by Dr Slavka Ulikova
Current treatment of Parkinson’s disease includes symptom treatment and nothing to counter neurodegeneration. Traditionally in routine clinical care the severity of movement symptoms are assessed by the clinical impression and patient self-reporting of symptoms, which have well-known limitations including: no assessment during daily living activities, poor compliance with medications, inadequate reporting of symptoms, no or poor quality controlled data and inter-rater variability.
Availability of objective measurement may help to identify poorly controlled patients by detecting unreported symptoms, provide information useful for clinical evaluation, help with therapeutic decision-making, and subsequently support improved patient outcomes. The Parkinson’s Kinetigraph (PKG) is a wrist worn device, which can provide reproducible and independent measurement of both bradykinesia and dyskinesia over a period of wear in the home environment during the activities of daily living.
The aim of this quality improvement project was to assess impact of PKG testing on assessment and management of selected PD patient and to see whether this process ultimately improves patient outcome.
This study involved 29 patients (12 men and 17 women). All patients completed baseline Parkinson’s disease Quality of Life Questionnaire (PDQ-8) before start of the PKG testing.
- Daily medication dose was quantified through Levodopa equivalent daily dose (LEDD).
- All patients had Parkinson’s Kinetigraph device fitted for six days.
- Single PKG report was issued and analysed. Analysis of the report included bradykinesia and dyskinesia score and also fluctuations and dyskinesia score (FDS) compared to the control.
- Treatment adjustment was made as per PKG report and change of dose was quantified through Levodopa equivalent daily dose (LEDD).
Effect of therapeutic intervention was assessed 3 months after medication changes through PDQ-8 questionnaire.
PDQ-8 evaluation showed that 38% of patients improved, 14% stayed unchanged, and 48% deteriorated. Overall there were no significant changes in Pre and Post PDQ-8 values. Detected bradykinesia was managed by increment in Levodopa. PDQ-8 showed upward trend (improvement) with the Levodopa increment, with few exceptions.
Recognition of symptoms from wearable sensors as PKG have its limitations, for example: difficulty to detect if slowness of movement represent bradykinesia, or if it is the result of fatigue or other factors e.g. slow walking due to fear of falling. This also applies for dyskinesia, where some repetitive movement activities e.g. colouring can be reported as dyskinesia.
Trials have demonstrated that, non-motor burden may have a greater impact on overall quality of life than the motor symptoms in later disease. As PKG only capture motor component of the disease, it will not reflect the overall clinical picture and this motor centric approach may be counterproductive to the fundamental holistic approach that is necessary in managing complex PD patients.
PDQ-8 is valid tool used for assessing quality of life of PD patients performed as a self-assessment, which can be influenced by many subjective factors.
Conclusions and recommendations
- The study showed that PKG monitoring mainly helped us to detect untreated bradykinesia. However, targeted medication increments to treat PKG indicated bradykinesia alone and too aggressive changes may not result in positive patient experience as reflected in results from PDQ-8.
- Patients find device very useful, liked, easy to use, medication reminder was very popular feature and they had desire to discuss results further.
- Although PKG may help to identify clinically unrecognized motor fluctuations this is not a substitute for thorough clinical assessment with good history taking and examination.
- Current PKG algorithm needs improvement to determine specially dyskinesia and tremor severity of PD patients, possibly use of GPS to differentiate bradykinesia from normal mobility with stationary mortar activities.
- Wider data related to clinical use of PKG is necessary to assess the relationship of PKG motor findings to actual patients experience and gather the evidence of best way of managing abnormalities detected from PKG test.
- We also feel more work is necessary to identify specific patients group that may benefit from PKG testing. Until such time clinicians should be more cautious in directly transferring PKG finding in to medication interventions.
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