“The measure of who we are is what we do with what we have” – Vince Lombardi
The measuring of Parkinson’s is complicated. There is such enormous variability between individual cases that the task of assessing people is very difficult.
The primary method that is used in clinics around the world is the Unified Parkinson’s Disease Rating Scale (or UPDRS). It is by no means perfect, and recently (in the wake of several unsuccessful clinical trials) there has been heated debate as to whether it is really up to the task.
Does it accurately reflect the condition? Does it really capture the lived experience? Can it pick up subtle changes associated with potentially disease modifying therapies in clinical trials? Or is it simply a “we’ve always done it this way” kind of tool?
In today’s post, we will look at what the UPDRS is, discuss some of the criticisms associated with it, and consider what solutions to those issues could look like.
This is Andy Grove and his story is rather remarkable.
Born in 1936 to a Jewish family in Budapest, he managed to survive the Nazis, and then fleed Hungary when Soviet tanks started rolling in. Arriving in the US with absolutely nothing, he taught himself English, before going to City College of New York and later the University of California (Berkeley) where he received a PhD in chemical engineering.
And that was just the start of his amazing tale.
After completing his PhD (and publishing a textbook on semiconductors), Grove joined the seminal Silicon Valley company – Fairchild Semiconductor – in 1963. He worked his way up from researcher to assistant director of development, before becoming the first person that Robert Noyce and Gordon Moore (of Moore’s Law fame) hired after they departed Fairchild to start their own little company in 1968.
The name of that company was Intel.
Grove also worked his way up the ladder at Intel – from director of engineering to CEO – and he is credited with transforming the company from a struggling memory chip maker into the processor powerhouse it is today. He was Time’s ‘Man of the Year’ in 1997 and he was a widely revered figure in Silicon valley.
But the path to success was not easy.
Having survived prostate cancer in 1995, Grove was diagnosed with Parkinson’s in 2000. Viewing the situation as a problem solving exercise, he poured tens of millions of his own money into researching Parkinson’s.
Andy & Michael J Fox. Source: MJFF
But coming from the world of ‘Moore’s Law’, Grove became frustrated by a.) the slow speed of progress in the world of biomedical research and b.) the tools used to assess it.
In particular, he disliked the UPDRS, which he referred to as a “piece of crap” (Source – you should read the linked article).
What is the UPDRS?
Recent analysis of blood samples collected during the Phase II clinical trial of Exenatide in Parkinson’s has uncovered a very interesting finding that could have major implications for not only Parkinson’s, but for many different neurological conditions.
Exenatide is a treatment that helps to control glucose levels in people with diabetes. More recently, however, it has been suggested that this drug may also have beneficial effects in Parkinson’s. A collection of clinical trials in Parkinson’s are currently unway to test this idea.
The researchers who conducted a Phase II clinical trial of Exenatide in Parkinson’s have analysed ‘exosomes‘ collected from the blood of participants, and they found something rather remarkable.
In today’s post we will discuss what exosomes are, what the researchers found, and why their discovery could have major implications for all of neurological research.
This week, however, researchers involved in the study reported yet another really interesting finding from the trial. And this one could have profound consequences for how we study not only Parkinson’s, but many other neurological conditions.
What did they find?
Last week this report was published:
Title: Utility of Neuronal-Derived Exosomes to Examine Molecular Mechanisms That Affect Motor Function in Patients With Parkinson Disease: A Secondary Analysis of the Exenatide-PD Trial.
Authors: Athauda D, Gulyani S, Karnati H, Li Y, Tweedie D, Mustapic M, Chawla S, Chowdhury K, Skene SS, Greig NH, Kapogiannis D, Foltynie T.
Journal: JAMA Neurol. 2019 Jan 14. doi: 10.1001/jamaneurol.2018.4304. [Epub ahead of print]
In the Exenatide Phase II clinical trial, 60 people with moderate Parkinson’s were randomly assigned to receive either 2mg of Exenatide or placebo once weekly for 48 weeks followed by a 12-week washout (no treatment) period. The results suggested a stablisation of motor features over the 48 weeks of the study in the treated group (while the condition in the placebo group continued to progress).
During the study (which was conducted between June 2014 – June 2016), blood samples were collected at each assessement.
From those blood samples, serum was collected and analysed.
Remind me again, what is serum?
An important aspect of developing new potentially ‘curative’ treatments for Parkinson’s is our ability to accurately test and evaluate them. Our methods of assessing Parkinson’s at the moment are basic at best (UPDRS and brain imaging), and if we do not improve our ability to measure Parkinson’s, many of those novel treatments will fail clinical testing and forever remain just “potentially” curative.
Researchers from Madrid (Spain) and the Massachusetts Institute of Technology have developed new technology that could aid in better measuring and monitoring of Parkinson’s over time.
And it is as easy as typing on your keyboard or sending a text message.
In today’s post, we will look at how the monitoring of typing could provide a useful ‘real world’ method of assessing people with Parkinson’s over time.
Measuring stuff. Source: Medium
When we think about new technology for the monitoring of Parkinson’s, we all too often think of a device that is strapped on to the body in order to measure tremor or speed of movement (Click here to read a previous post on wearable tech).
Or perhaps a smart phone app that has simple tests on it that individuals can use to assess themselves over time (Click here to read a previous post on this topic).
One of the issues with these approaches, however, is ‘adherence‘ – these devices require effort from the individual being assessed (they have to strap on the motion sensing device or remember to complete the task on the smart phone). And after the first week or so of using the device or the app, the novelty wears off and recordings may be less frequent.
Many of these methods are also slightly ‘unnatural‘, and they may deviate the individual from their normal way of life. For example, wearable tech is amazing, but the individual may find it uncomfortable to wear all the time or may alter aspects of their behaviour to better suit the wearing of the device.
A better approach would be to have methods of monitoring that require no effort from the individual. Tools that silently and seamlessly slip into the background of their lives and monitor continuously – the individual completely forgets about them, which provides a more unbiased assessment.
We have previously discussed some examples of more ‘real world/natural’ approaches (such as smart pills – Click here to read that post – and also with regards to sleep monitoring – Click here to read that post), and today we will explore another example: keyboard stroke monitoring.
What is keyboard stroke monitoring?
Regular readers will be aware that here at the SoPD, we are on a mission to change the way we clinically test drugs (Click here for the most recent rant on this topic).
We have a lot of interesting drugs waiting in the pipeline to be clinically tested and an eager (read: desperate) population of individuals affected by Parkinson’s, but we are missing one critical part of the equation: better tools of assessment.
How can we determine whether a drug is actually working or not? And how can we better monitor people over time on said drug?
Our current methods assessing individuals with Parkinson’s rely heavily on clinical rating scales and brain imaging. These are basic tools at best, conducted episodically (annually in general, or once every 2-6 months during a clinical trial), and provide little in the way of useful objective data (on an individual basis).
In today’s post, we will look at a single aspect of Parkinson’s – sleep – and try to nut-out a better/more informative method of assessing it over time.
The Bluesky project. Source: Mirror
Last week tech industry giants Pfizer and IBM made an big announcement.
It was news that I have been quietly waiting to hear for some time.
It related to their “BlueSky Project” – a collaboration between the two companies to provide better methods of assessment/monitoring of Parkinson’s.
The two companies announced that they are now ready to start accepting the first participants for a new clinical trial.
And it is a really intriguing study for one simple reason:
The entire trial will take place inside one house.
There has been a lot of discussion on this site (and elsewhere on the web) regarding the need for more objective systems of measuring Parkinson’s – particularly in the setting of clinical trials.
Yes, subjective reports of patient experience are important, but they can easily be biased by ‘placebo responses’.
Thus, measures that are beyond the clinical trial participants conscious control – and focused on biological outcomes – are needed.
In today’s post, we will consider one possible approach: Smart pills. We will discuss what they are, how they work, and how they could be applied to Parkinson’s research.
In order to encourage a growing discussion regarding objective measures of Parkinson’s (and to follow up on previous rants – Click here and here for examples), I have decided to regularly (once a month) highlight new technologies that could provide the sort of unbiased methods of data collection that are required for assessing whether a treatment is having an impact on Parkinson’s.
Today, we will look at smart pills.
What is a smart pill?
This is one of those posts (read: rants) where I want to put an idea out into the ether for someone to chew on. It starts with a very simple question:
Why is ‘the drug’ the focus of a clinical trial?
If our goal is to find beneficial therapies for people with Parkinson’s, then the way we currently clinically test drugs is utterly nonsensical.
And if we do not change our “we’ve always done it this way” mindset, then we are simply going to repeat the mistakes of the past. Others are changing, so why aren’t we?
In today’s post, we will consider one possible alternative approach.
Why is ‘the drug‘ the focus of a clinical trial?
The way we clinically test drugs makes absolutely no sense when you actually stop and think about it.
Other medical disciplines (such as oncology) have woken up to this fact, and it is time for the field of Parkinson’s research to do this same.
Let me explain: