Marie-Laure Welter, scientific director of the Movement and Gait Laboratory and co-director of the Brain e-Novation Laboratory in the Brain and Spine Institute, outlines the importance of new technologies to treat Parkinson’s disease.
The Brain and Spine Institute (ICM) is an international-level research center on diseases of the nervous system (neurology and psychiatry) bringing patients, doctors, and researchers together in the same place to foster the development of innovative preventive, diagnostic or therapeutic products and procedures. In recent years, new technologies applied to health have been viewed as promising and emerging opportunities to treat patients with diseases of the nervous system such as Parkinson’s disease.
These neurodegenerative diseases represent a major challenge, as recent data estimated that 165 million Europeans are likely to experience a brain-related illness during their lifetime, which represents a staggering cost of €1.5m per minute to the economy.
Commercial digital gaming applied in a non-leisure context is a potential revolutionary way of rehabilitating people with neurological disorders. However, due to important differences between these commercial tools and specialists’ proceedings, such approaches may not be adapted to the disabilities of the patient at an individual level, and they therefore need to be validated for such use.
Dementia and falls: two major health problems in the elderly
With the aging of the population, two major health problems have emerged over the last three decades: dementia and falls. Dementia and falls have been linked to increased morbidity and mortality with poor quality of life and social exclusion, and they also present a high healthcare cost. An estimated 50 million people are living with dementia worldwide, with most suffering from Alzheimer’s disease, and yet it has been reported that only 20-50% of people have been diagnosed.
Falls represent the first cause of death linked to disabilities in people over 75 years old. In 60% of falls, a neurological disorder is present. Parkinson’s disease (PD) represents the most frequent motor disorder in this population with 6.3-10 million people worldwide. Both Alzheimer’s and Parkinson’s are neurodegenerative diseases with no treatment available that can cure the diseases or halt their progression, or, moreover, to significantly improve cognitive deficit or falls. Worryingly, the number of people with these diseases is estimated to double by 2030.
Gait disorders, falls and Parkinson’s disease and rehabilitation strategies
The causes of gait disorders and falls in Parkinson’s disease are not fully understood. From a neuropathological point of view, Parkinson’s disease is first related to the loss of neurons that produce dopamine within deep brain structures. This leads to the occurrence of classical motor signs with tremor, rigidity and slowness of the movement (or akinesia). These motor signs are improved by the intake of dopamine using medical drug treatments. Gait and balance disorders with falls appear later in the course of the disease. These signs have been linked to additional brain lesions or dysfunctions within frontal cortical and brainstem regions, and are resistant to dopaminergic drugs or other medications, as well as to surgery.
Rehabilitation programmes targeting gait and balance are widely used in clinical practice to maximise functionality through movement rehabilitation. In the past 20 years, a growing number of methods employing physical work have been proposed in PD. The primary goal of the current rehabilitation programme for PD is to enable motor function by utilising general exercise regimes, including exercises for cardiovascular fitness, strength, range of motion, posture, gait, co-ordination and balance; or specialised behavioural strategies to teach subjects compensations. For example, external cues, with auditory, visual or tactile stimulus, are used to elicit larger steps, faster walking speeds and to improve posture. Subjects are also instructed to focus their attention on key aspects of movement to replace automaticity.
A large number of physiotherapy techniques have been proposed and have also been shown to improve motor performance and quality of life in PD patients with no significant differences between these various strategies. However, to be effective, rehabilitation necessitates that the individual engages in repetitive, intensive and salient task practice. An important aspect of rehabilitation training is that a patient has opportunities to meaningfully interact with objects in the environment and to receive salient and positive feedback about their performance to enhance the rehabilitation experience. The patient’s level of engagement or motivation is also an integral element for learning to occur through neuroplastic mechanisms. Such a combination of key elements for effective rehabilitation strategies are integrated in more complex programmes using dance or martial arts, with significant benefits recently reported in PD patients.
Finally, nearly all types of rehabilitation methods are beneficial for PD, provided that they are tailored to the needs of the patient and are also maintained over time. The advent of new technologies, such as virtual reality, provides the opportunity to mix together each of the key features to guarantee the best efficacy of a treatment in a individually adapted, motivating and engaging manner. Virtual reality coupled with treadmill walking or cycling has produced benefits for PD patients with regard to their gait, and has also been shown to reduced falls. Gaming with virtual reality therefore represents an amusing and enjoyable approach to treat patients, with the possibility to be executed at home and on demand.
Gaming to rehabilitate PD patients
A few commercial games have been tested in small cohorts of PD patients using Xbox KinectTM or WiiTM with interesting results. However, on average, commercial games are too difficult for PD patients, leading to a lack of motivation, negative emotions and disappointment.
To fill in the gaps between available commercial games and PD disability, and to promote rehabilitation using such an approach, we have built a customised videogame designed to treat gait disorders and falls in PD. The game was designed using a multidisciplinary approach with physiotherapists, neurologists and engineers within the Brain e-Novation laboratory at the Brain and Spine Institute (Paris, France).
The game is called ‘ToapRun’, and was displayed on a screen with the patient being placed in front of it. To play, by using the Kinect motion sensor, the patient has to perform high amplitude and fast movements of all four limbs to induce movements of the avatar (a small animal), around three different environments (a garden, a mine cart and a surfboard on a lake), with auditory (rhythmic music) and visual cueing (pieces to catch).
To validate this new therapeutic tool, we have or plan to perform three different clinical research programmes. First, we examined the feasibility and acceptability of our videogame training in a pilot study of 10 PD patients with an advanced form of the disease with resistant gait disorders and falls. The patients performed 18 training sessions at the institute, with two-to-three sessions per week. The difficulty of the game was progressively increased over time, as was the duration (from 15 to 42 minutes between the first and last session) and number of movements (from 210 to 930). The motor disability was assessed before and after videogame training sessions in the Gait and Movement Laboratory. Our videogame was well accepted by our patients, with seven of them finding the game ‘amusing’. Patients also performed well on the game, with an overall success rate of 94%. We also observed a significant improvement in gait disorders, with increased step length and gait velocity, and a disappearance of falls in seven patients. These first results suggest that our game is feasible and adapted for PD suffering from resistant gait disorders and falls.
The next steps are:
- To validate the efficacy of rehabilitation training with the ‘Toap Run’ videogame at home in a controlled study with 50 PD patients who suffer from gait disorders and falls;
- To assess its medico-economic impact; and
- Finally, we also aim to understand how such training would contribute to brain plasticity and promote brain repair, as suggested in animal models of PD, using precise neuroimaging techniques.
These new technologies open up new ways of considering the therapeutic possibilities in these neurodegenerative diseases, provided that they are properly validated in patients. This fits into the context of personalised medicine, in relation to the patient’s own difficulties and their ability to treat themselves. The application to other pathologies for which physical activity contributes to improving health, or even survival, such as cancer, is now under consideration.
Marie-Laure Welter
Clinical Director
Neurophysiology Department
Professor
Medical Faculty
Rouen University
Neurologist, Neurophysiologist, Movement Disorders and Parkinson’s Disease specialist
Marie-Laure Welter
Scientific Director
Gait and Movement Laboratory
Co-director
Brain e-Novation Laboratory
Brain and Spine Institute
Paris
