Harnessing AI for Parkinson’s Research

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Harnessing AI for Parkinson’s Research

by Krishna Knabe,
January 14, 2019

Last week at the annual Consumer Electronics Show (CES), one of the big stories was health technologies. During CES, The Michael J. Fox Foundation (MJFF) and IBM announced a partnership using artificial intelligence (AI) to develop a model for Parkinson’s disease.

Though they are now gaining traction, artificial intelligence strategies, such as machine learning, have been a priority for MJFF for many years. In 2013, we launched a data challenge to spur ideas for Parkinson’s disease monitoring and treatment. The winners used machine learning and data collected from smartphones to improve communication between doctors and patients about symptoms. Since then, we have supported more research using artificial intelligence to analyze Parkinson’s data, including another data challenge in 2016 with partners at GE Healthcare.
Data is the key to this endeavor. You have to have a lot of comprehensive data from patients, collected using strict protocols, before you can apply machine learning or other types of artificial intelligence to it. MJFF has made a herculean effort over the last decade to collect this data in Parkinson’s, through the Parkinson’s Progression Markers Initiative, BioFIND, the LRRK2 Cohort Consortium and other MJFF-driven studies.

In an article in HealthLeaders, Mark Frasier, PhD, our senior vice president of research programs explains: “Today our challenge is to analyze this treasure-trove of complex imaging, clinical, and molecular data… AI and machine learning technologies can help scientists identify trends and models across Parkinson’s data. These frameworks can help researchers design more efficient and accurate clinical studies and drug trials, speeding discovery and bringing new personalized treatments to patient hands faster.”

The promise of artificial intelligence is that it can uncover fresh insights and trends in data that researchers might never find because they would not know to look for it or because the data analysis required is very complex. In our project with IBM, researchers will use our PPMI data to develop a model of the distinct stages of Parkinson’s. The next step will be to use that to develop a predictive model of how the disease might continue to progress. This understanding could improve patient care, but it will also help researchers understand what to expect during a clinical trial. When designing a trial, researchers want to make sure that patients are in the trial long enough to show a benefit. If they understand stages of progression, they can understand what is likely to happen over that span of time to patients on a placebo and, conversely, the benefit (in slowing or stopping progression) in patients taking a drug.

Our partnership with IBM Research Healthcare and Life Sciences is one of several designed to foster data analysis in Parkinson’s disease. Last year, we announced a partnership with Blackfynn to analyze data in PPMI using its data integration and analysis platform. And we are making our data sets available through our collaborations with AMP PD and BRAIN Commons. Important insights into Parkinson’s disease and how to treat it lie in the data we have collected, and we are doing everything possible to make sure they get found.

TAGS: Parkinson’s Data Challenge, Research News, Industry & Nonprofit Collaboration


Young Onset Story

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Kimberly Rogers

At 21, Kim started her career in education.

At 29, she became assistant principal.

At 31, Kim had her son and soon after experienced trouble walking.

At 34, she was diagnosed with Parkinson’s disease (PD).

“I woke up realizing that I have a child to live for and I have so much life left,” Kim said. “I can give up, but if it wasn’t for him I don’t know if I would be pushing through. I have a son, I have been through so much and there is no way I can give up.”

A wave of worsening symptoms, from difficulty washing her hair to not being able to move the entire left side of her body, made Kim go back to her doctor, who incorrectly diagnosed her with sciatica (nerve pain that radiates from the lower back).

“You definitely don’t have sciatica,” the doctor told Kim at her follow-up appointment. He asked if Parkinson’s ran in her family, completed some basic motor tests and then referred her to a neurologist. 

“You are one of the healthiest people I have ever seen in my life,” the first of three neurologists told Kim. Six months of extensive testing later, her third neurologist — a movement disorder specialist — administered an in-office motor test and immediately diagnosed her with Parkinson’s. Kim was a few days shy of her 34thbirthday.

With no family history, she told her doctors about a childhood experience where a tornado hit her elementary school, leaving nine children dead and injuring 17. Kim suffered from severe head trauma that day. Her doctors theorized that this brain injury could have caused her Parkinson’s, which may have stayed dormant until she had her son. After her diagnosis, a brain scan showed that one side of her brain had almost no dopamine and the other only had a little.

“Honestly, I was always a negative Nancy and it was even worse after I was diagnosed. I was full of fear and felt like my life was over,” Kim said. But Kim decided to begin thinking positively, for her son.

“Support groups did not help. People were negative and didn’t share my outlook. I started to connect with people on Facebook, looking for people who shared my new perspective.” Kim started a Facebook group for people living with PD.

“We talk to each other online when we need support. When you share what is going on in your life and know someone else’s story, you quickly become friends. The socialization helped me to continue working out, too,” Kim said.

Kim finds solace in exercise. “My job is really stressful, so having that time to get some of the frustrations out is great,” she said. Kim’s 4:45 a.m. to 8 p.m. schedule forces her to constantly switch up her daily workouts. “I do everything from home — high intensity cardio, yoga, Pilates. Every time I finish a program I change it to something else.”

Exercise helped, but Kim’s medications were faltering. Her neurologist brought up deep brain stimulation (DBS), but the 36-year-old wasn’t ready for brain surgery. As a last effort before moving to DBS, the doctor tweaked Kim’s medications. She had to re-start her medication regimen all over, but it was worth it. After several weeks, her PD symptoms were unrecognizable. “I am on a patch and take twelve pills a day. For the most part I am doing really well and feel amazing.” Sleeping is now her biggest challenge.

A high-stress job, raising a son as a single mother and managing Parkinson’s in her 30’s all come with their own challenges and anxieties. Kim constantly tries natural treatments. In addition to working out, she uses essential oils and strongly believes in just spending time outside, doing things she loves. “When I leave work, I disconnect with school and connect with my son,” she said.

“I go through periods of meditation, depending on what is going on in my life. Right now, I am doing really well so it is not necessary,” Kim said.

Once Kim became part of the PD community, she looked for a local event she could become a part of — Moving Day Boca Raton. As soon as I was diagnosed I wanted to immediately get involved,” she said. Kim became team captain to team “Dope” Amines, raising $5,000 for Parkinson’s research her first year and $3,000 in 2017.

Kim hosts raffles and auctions to raise funds for her team. Last year, Kim asked for donations instead of birthday presents to raise funds for PD. Kim is already strategizing for Moving Day Boca Raton, which takes place November 4, 2018.

In terms of managing her Parkinson’s and Moving Day team, Kim said, “I am a go getter. I do the best I can.”

Find a Moving Day event near you at MovingDayWalk.org.

Parkinson’s Inosine Trial Ending Early

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Posted by

Rachel Dolhun, MD, December 10, 2018

Parkinson's Inosine Trial Ending Early

Researchers recently announced that SURE-PD3, a Phase III clinical trial evaluating the potential of inosine to slow Parkinson’s progression, will end earlier than planned. At a regularly scheduled meeting, the study’s Data and Safety Monitoring Board (DSMB), a group of independent experts, reviewed trial progress and available data. Based on the study’s primary measure and timeline, the board determined that SURE-PD3 would be unable to show that inosine slows Parkinson’s progression. While disappointing, this illustrates the importance of solid trial design and measurement tools and the value of research participation. Though the outcome is not what participants and researchers hoped for, there is still much to gain.

To learn more about this study, the use of inosine, and what this news means for people with Parkinson’s, we spoke with Michael Schwarzschild, MD, PhD, SURE-PD3’s principal investigator and scientific advisor to The Michael J. Fox Foundation (MJFF).

MJFF: What is the SURE-PD3 study?

Michael Schwarzschild (MS): SURE-PD3 (Study of Urate Elevation in Parkinson’s Disease) is a Phase III clinical trial to evaluate whether increasing levels of urate (a natural antioxidant) using inosine could slow disease progression in people recently diagnosed with Parkinson’s and not yet taking dopamine medication for symptoms.

The trial is randomized and placebo-controlled, meaning that roughly half of the participants are taking inosine capsules and the other half are taking placebo capsules, which are indistinguishable from inosine and contain an inactive substance. The study also is double-blind, meaning that neither study volunteers nor researchers know who is taking inosine and who is taking placebo.

The SURE-PD3 trial is being conducted at nearly 60 sites across the United States and is funded by the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (NINDS).”

MJFF: Why were you interested in studying inosine?

MS: Parkinson’s disease occurs and progresses because the cells in the brain that make dopamine and are essential for voluntary movements are damaged and lost. In laboratory studies, urate protects these brain cells. In epidemiological, or population, studies, researchers have found an association between higher levels of urate and a lower risk of Parkinson’s as well as slower disease progression in people with Parkinson’s.

Inosine is a precursor, or building block, to urate so it raises urate levels. Inosine has several attractive characteristics: it’s widely available over-the-counter in pill form and fairly inexpensive. It’s what’s known as a “repurposed” therapy — used for a different reason, in this case as a dietary supplement, and now being tested for safety and benefit in Parkinson’s.

SURE-PD3 built on The MJFF-funded Phase II SURE-PD trial, which demonstrated that inosine was safe, tolerable and raised urate levels in the blood and spinal fluid.

Listen to Dr. Schwarzschild discuss inosine in a podcast.

MJFF: Tell us about the design of SURE-PD3. How do you measure disease progression?

MS: SURE-PD3 enrolled 298 people who were recently diagnosed with Parkinson’s (an average of one year prior), had lower blood urate levels and had low levels of dopamine brain cells on DaT scan, a specialized brain imaging study that looks at the dopamine brain chemical system. An interesting feature of SURE-PD3 is that it is one of the first studies to use DaT scan as an “enrichment tool,” a way to ensure that the trial only enrolled people with Parkinson’s symptoms who have dopamine brain cell loss.

Through a process similar to flipping a coin, we randomly assigned half the volunteers to take inosine and the other half to take placebo. Every three months, we checked blood urate levels and, if necessary, adjusted an individual’s inosine dose to keep their urate within the range that appeared optimal in the Phase II inosine study. SURE-PD3 is unique in that instead of examining a specific dose (or doses) of inosine, we adjusted each participant’s inosine dose to target a specific urate level. Each participant was instructed to take an individualized daily dose for up to 24 months.

To monitor progression, we assessed Movement Disorder Society Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) scores, a measure of movement and non-movement symptoms and ability to do daily activities, every three months. The plan was to evaluate each participant’s MDS-UPDRS score at every visit for two years.

MJFF: What other data do you collect in SURE-PD3?

MS: As I mentioned, the main goal of the study was to examine the change in MDS-UPDRS scores over time to see whether raising urate levels with inosine could slow Parkinson’s progression.

But we are collecting a large amount of additional data on other Parkinson’s features that are not captured by the MDS-UPDRS. And we also are conducting several sub-studies, most of which are funded by The Michael J. Fox Foundation. This rich and varied information on a group of people who are recently diagnosed will increase our understanding of Parkinson’s, regardless of SURE-PD3’s final results. The sub-studies include:

  • DaT scan imaging at enrollment and within three months of inosine or placebo discontinuation to see how the brain changes in early stages of disease, as well as whether inosine modifies those changes, 
  • Measures of blood plasma and genetic markers as well as whole genome sequencing to identify factors that might modify the risk of Parkinson’s or its rate of progression, and 
  • Use of technology, such as smartphone apps and surveys to measure and track symptoms remotely and more continuously.

Upon study completion, participants have the opportunity to enroll in the AT-HOME PD study, which aims to learn more about how telehealth could optimize research by tracking participants in their natural home environment and decreasing trial costs.

MJFF: Why is SURE-PD3 ending early?

MS: We recently determined that, based on the trial’s design and the main measure we’re using to track disease progression (MDS-UPDRS score change over two years), we won’t be able to show that inosine slows Parkinson’s progression. So, it doesn’t make sense to continue inosine treatment for the originally planned two years.

We obviously didn’t know this at the outset of the trial. When you begin a trial, you “make a bet” on the best way to support your idea. Our hope was that inosine could slow Parkinson’s progression and we thought we could show that by measuring MDS-UPDRS scores over two years.

Our Data and Safety Monitoring Board (DSMB) — an independent group of scientific experts and a patient advocate that regularly evaluates study safety and performance — concluded, at their most recent review, that we were not likely to show that inosine slows Parkinson’s progression. The DSMB therefore recommended that we stop the study early. Importantly, the DSMB did not note any significant safety concerns.

MJFF: What happens now?

MS: We’ve been working with each study site and each participant to systematically end the trial in a way that maximizes what we can learn from SURE-PD3 and its sub-studies for the benefit of the Parkinson’s community.

Because there were no significant safety concerns prompting early closure, we’re asking participants to remain in the study but change the timeline of their participation. At their next regularly scheduled visit, participants will discontinue taking their study drug (inosine or placebo). Within the following three months, we’ll perform a final safety evaluation and a second DaT scan.

Once all participants have completed the study, we will analyze and report the data. We expect to report results of SURE-PD3 and its sub-studies by the end of 2019.

MJFF: What is the future of inosine research?

MS: It’s hard to say right now. When we have the results of SURE-PD3 next year, it may be easier to express an opinion on whether additional research is worth pursuing.

When we analyze the data, we’ll look at all the measures in SURE-PD3 and its sub-studies — not just MDS-UPDRS — for any hint of benefit with inosine. Given what the DSMB has already seen when reviewing changes in MDS-UPDRS scores, we likely will not see improvement on movement symptoms. But perhaps we could see positive change on cognition, mood, or quality of life, or in a sub-population of people with Parkinson’s. If we do, this may warrant further study. Conversely, if the results for other measures are consistent with the interim analysis, then inosine likely would not merit any more research for its potential to slow disease progression.

MJFF: How do studies like SURE-PD3 advance our understanding, even when their outcome isn’t as anticipated?

MS: When a study ends early and you don’t get the results you hoped for, it’s certainly disappointing. But once you get over that initial disappointment, you can see there’s still a lot to learn. No matter the results of SURE-PD3, urate remains a clue in Parkinson’s. Laboratory and population studies show that urate is linked to Parkinson’s. The results from SURE-PD3 may still help us learn more about the role of urate in Parkinson’s and new ways to target the disease. And if inosine isn’t the way to slow disease progression, that’s beneficial too. It helps us close one door so we can now walk through another, and each door we try gets us closer to our goal.

The time, effort and information that research participants volunteer is extremely valuable. Even when results are negative, there are still successes. Every bit of data we gather contributes to and broadens our understanding so that we can ask smarter questions about the causes of Parkinson’s, pick better candidates to test against those causes and design better trials to test those candidates.

MJFF: What does this mean for people with Parkinson’s who are thinking about taking inosine?

MS: Unfortunately, SURE-PD3 did not show that raising urate levels with inosine can slow Parkinson’s in the way we thought it might.

Because inosine is widely available over-the-counter, inexpensive and relatively safe, many people wonder about taking the supplement despite the lack of scientific evidence. (Don’t confuse “relatively safe” with lack of side effects; inosine can cause kidney stones, gout and possibly other harmful conditions.) I do not recommend that my Parkinson’s patients take unproven candidate protectants such as inosine to slow progression (unless, of course, they are enrolled in a clinical trial testing the therapy). If you are considering taking inosine or any other over-the-counter supplement, make sure you talk with your physician about the pros and cons and how it may fit in your regimen.

What’s the future for us

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I have been diagnosed with Parkinson’s Disease 8 years ago when I’m 38 years old. At first 2 years I did not take it seriously but as the time goes by little by little I feel the symptoms and it’s very progressive. 

What is Parkinson’s Disease

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Parkinson’s disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing (“dopaminergic”) neurons in a specific area of the brain called substantia nigra.

Symptoms generally develop slowly over years. The progression of symptoms is often a bit different from one person to another due to the diversity of the disease. People with PD may experience:

Tremor, mainly at rest and described as pill rolling tremor in hands. Other forms of tremor are possible
Bradykinesia
Limb rigidity
Gait and balance problems
The cause remains largely unknown. Although there is no cure, treatment options vary and include medications and surgery. While Parkinson’s itself is not fatal, disease complications can be serious. The Centers for Disease Control and Prevention (CDC) rated complications from PD as the 14th cause of death in the United States.

The first step to living well with Parkinson’s disease is to understand the disease and the progression:

It is possible to have a good to great quality of life with PD. Working with your doctor and following recommended therapies are essential in successfully treating symptoms by using dopaminergic medications. People with PD need this medication because they have low levels or are missing dopamine in the brain, mainly due to impairment of neurons in the substantia nigra.

It is important to understand that people with PD first start experiencing symptoms later in the course of the disease because a significant amount of the substantia nigra neurons have already been lost or impaired. Lewy bodies (accumulation of abnormal alpha-synuclein) are found in substantia nigra neurons of PD patients.

Scientists are exploring ways to identify biomarkers for PD that can lead to earlier diagnosis and more tailored treatments to slow down the disease process. Currently, all therapies used for PD improve symptoms without slowing or halting the disease progression.

In addition to movement-related (“motor”) symptoms, Parkinson’s symptoms may be unrelated to movement (“non-motor”).People with PD are often more impacted by their non-motor symptoms than motor symptoms. Examples of non-motor symptoms include: apathy, depression, constipation, sleep behavior disorders, loss of sense of smell and cognitive impairment.

In idiopathic Parkinson’s disease, progression tends to be slow and variable. Doctors often use the Hoehn and Yahr scale to gauge the progression of the disease over the years. The scale was originally implemented in 1967 and it included stages zero to five, where zero is no signs of Parkinson’s and five is advanced PD. It was later changed to become the modified Hoehn and Yahr scale.

Page reviewed by Dr. Ahmad Elkouzi, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.

Causes of Parknson’s

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Parkinson’s disease (PD) is an extremely diverse disorder. While no two people experience Parkinson’s the same way, there are some commonalities. Parkinson’s affects about one million people in the United States and ten million worldwide. The main finding in brains of people with PD is loss of dopaminergic neurons in the area of the brain known as thesubstantia nigra.

10 Early Signs of Parkinson’s Disease

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It can be hard to tell if you or a loved one has Parkinson’s disease (PD).

Below are 10 signs that you might have the disease. No single one of these signs means that you should worry, but if you have more than one sign you should consider making an appointment to talk to your doctor.

Tremor

Have you noticed a slight shaking or tremor in your finger, thumb, hand or chin? A tremor while at rest is a common early sign of Parkinson’s disease.

What is normal?
Shaking can be normal after lots of exercise, if you are stressed or if you have been injured. Shaking could also be caused by a medicine you take.

Small Handwriting

Has your handwriting gotten much smaller than it was in the past? You may notice the way you write words on a page has changed, such as letter sizes are smaller and the words are crowded together. A change in handwriting may be a sign of Parkinson’s disease called micrographia.

What is normal?
Sometimes writing can change as you get older, if you have stiff hands or fingers or poor vision.

Loss of Smell

Have you noticed you no longer smell certain foods very well? If you seem to have more trouble smelling foods like bananas, dill pickles or licorice, you should ask your doctor about Parkinson’s.

What is normal?
Your sense of smell can be changed by a cold, flu or a stuffy nose, but it should come back when you are better.

Trouble Sleeping

Do you thrash around in bed or act out dreams when you are deeply asleep? Sometimes, your spouse will notice or will want to move to another bed. Sudden movements during sleep may be a sign of Parkinson’s disease.

What is normal?
It is normal for everyone to have a night when they ‘toss and turn’ instead of sleeping. Similarly, quick jerks of the body when initiation sleep or when in lighter sleep are common and often normal.

Trouble Moving or Walking

Do you feel stiff in your body, arms or legs? Have others noticed that your arms don’t swing like they used to when you walk? Sometimes stiffness goes away as you move. If it does not, it can be a sign of Parkinson’s disease. An early sign might be stiffness or pain in your shoulder or hips. People sometimes say their feet seem “stuck to the floor.”

What is normal?
If you have injured your arm or shoulder, you may not be able to use it as well until it is healed, or another illness like arthritis might cause the same symptom.

Constipation

Do you have trouble moving your bowels without straining every day? Straining to move your bowels can be an early sign of Parkinson’s disease and you should talk to your doctor.

What is normal?
If you do not have enough water or fiber in your diet, it can cause problems in the bathroom. Also, some medicines, especially those used for pain, will cause constipation. If there is no other reason such as diet or medicine that would cause you to have trouble moving your bowels, you should speak with your doctor.

A Soft or Low Voice

Have other people told you that your voice is very soft or that you sound hoarse? If there has been a change in your voice you should see your doctor about whether it could be Parkinson’s disease. Sometimes you might think other people are losing their hearing, when really you are speaking more softly.

What is normal?
A chest cold or other virus can cause your voice to sound different, but you should go back to sounding the same when you get over your cough or cold.

Masked Face

Have you been told that you have a serious, depressed or mad look on your face, even when you are not in a bad mood? This is often called facial masking. If so, you should ask your doctor about Parkinson’s disease.

What is normal?
Some medicines can cause you to have the same type of serious or staring look, but you would go back to the way you were after you stopped the medication.

Dizziness or Fainting

Do you notice that you often feel dizzy when you stand up out of a chair? Feeling dizzy or fainting can be a sign of low blood pressure and can be linked to Parkinson’s disease (PD).

What is normal?
Everyone has had a time when they stood up and felt dizzy, but if it happens on a regular basis you should see your doctor.

Stooping or Hunching Over

Are you not standing up as straight as you used to? If you or your family or friends notice that you seem to be stooping, leaning or slouching when you stand, it could be a sign of Parkinson’s disease (PD).

What is normal?
If you have pain from an injury or if you are sick, it might cause you to stand crookedly. Also, a problem with your bones can make you hunch over.

What can you do if you have PD?

Work with your doctor to create a plan to stay healthy. This might include the following:
A referral to a neurologist, a doctor who specializes in the brain
Care from an occupational therapist, physical therapist or speech therapist
Meeting with a medical social worker to talk about how Parkinson’s will affect your life
Start a regular exercise program to delay further symptoms.
Talk with family and friends who can provide you with the support you need.
For more information, visit our Treatment page.

Watch and share this public service announcement featuring U.S. Senator Cory Booker that discusses the early warning signs of Parkinson’s disease.

Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.