The MOTIVE-PSP Initiative (Progressive Supranuclear Palsy)

Overview

Progressive Supranuclear Palsy (PSP) is a rapidly progressive neurodegenerative disease characterized by falls and oculomotor disturbances. Several clinical trials are currently evaluating the efficacy of new pharmacological compounds in slowing disease progression. Yet, both early diagnosis and evaluation of disease progression remain challenging. Study aims include verifying if specific motor, cognitive, language, cerebrospinal fluid and imaging assessments represent reliable biomarkers of PSP diagnosis, phenotypization and progression over 1-year follow up. Motor evaluation will include recordings from wearable sensors. Expected results include 1) improvement of PSP diagnosis and phenotypization; 2)improvement of evaluation of disease progression in the context of clinical trial; 3)enhancement of strategies to prevent falls and fractures in such patients leading, in turn, to significant cost savings for the National Health System.

Hyphotesis and Significance: 1)Cross-sectional phase:verify if specific motor, cognitive, language, cerebrospinal fluid (CSF) and imaging assessments represent reliable biomarkers of diagnosis in PSP in the earliest stages of disease compared to Parkinson's disease (PD) and healthy controls (HC) and are able characterize the different PSP clinical phenotype 2)12-month longitudinal phase:verify if specific motor, cognitive, language, CSF and imaging assessments represent reliable biomarkers of disease progression also according to the clinical phenotype Preliminary Data: Cross-sectional data suggest that current motor, cognitive, language and imaging assessments may be useful in supporting the diagnosis of PSP compared to PD and HC, but not in characterizing the PSP clinical phenotypes. No robust data on wearable sensors and CSF biomarkers is available. Longitudinal data on such biomarkers are lacking. As for cognition, preliminary data suggest that the Repeatable Battery for the assessment of neuropsychological status (RBANS) may evaluate cognitive trajectories in PSP with Richardson's syndrome. Specific Aim 1: Determine the feasibility, validity and reliability of application of digital biomarkers in PSP. Specifically if clinic-based wearable sensors and smartphone-based remote assessments can (1) support early clinical diagnosis and phenotyping of PSP patients compared to PD and HC and (2) evaluate disease trajectories in the whole cohort of PSP patients and discrete phenotypes compared to standard rating scales. For both points the hypothesis is that both clinic-based and smartphone-based wearable sensors outperform standard rating scales. Specific aim 2: Verify if cognitive, language and behavioral testing can (1) support early clinical diagnosis and phenotyping of PSP patients compared to PD and HC and (2) evaluate disease trajectories in the whole cohort of PSP patients and discrete phenotypes. For point (1) the hypothesis is that cognitive, language and behavioral testing support early diagnosis and phenotyping in the earliest stages compared to PD and HC. For point (2) the hypothesis is that cognitive, language and behavioral testing are able to evaluate disease progression in the whole cohort of PSP patients and discrete phenotypes. Specific aim 3: Verify if single parameter and multiparameter magnetic resonance imaging (MRI) imaging assessments can (1) support early clinical diagnosis and phenotyping of PSP patients compared to PD and HC and (2) evaluate disease trajectories in the whole cohort of PSP patients and discrete phenotypes. Experimental design aim 1 includes a cross-sectional phase with enrollment of 3 groups of subjects (PSP, PD and HC). During the baseline evaluation each enrolled subject will perform:1) a clinic-based standardized protocol for assessment of gait with wearable inertial sensors to specifically monitor quality of gait and balance using a wide range of measures from the upper and lower body (APDM Mobility Lab system) ;2) home-based monitoring with smartphone of inertial measurement (balance and gait task) and voice recorded with microphone for at least 5 days;3) standard clinical rating scales including the PSP rating scale, the Natural History and Neuroprotection in Parkinson Plus Syndromes, Movement Disorder Society Unified Parkinson's disease rating scale part III, Falls diary to be filled during the 5-day home based monitoring. Caregivers will be asked to actively support patients for the home- smartphone-based digital biomarkers measurements. Furthermore, at baseline only PSP patients will be asked to perform lumbar puncture to collect CSF and measure total-tau, phosphorylated tau, Beta-amyloid 42, neurofilament light and heavy chain. A 12-month longitudinal phase will follow only for PSP patients. During both cross-sectional and longitudinal phases (every 3 months), only patients enrolled at Unit 1 will also perform a gait analysis assessment with a traditional opto-kinematic, hospital-based gait analysis system (Qualisys®, Sandvälen, Sweden). Experimental design aim 2 includes a cross-sectional phase with enrollment of 3 groups of subjects (PSP, PD and HC). During the baseline evaluation each enrolled subject will perform:1) the RBANS; 2)standard cognitive assessment currently used by part of the research team to evaluate cognitive abilities in PSP patients as detailed elsewhere; 3) functional autonomy will be evaluated with the Instrumental Activities of Daily Life, while depression and apathy with the Beck Depression Inventory II and Apathy Evaluation Scale, respectively; 4) other neuropsychiatric symptoms will be explored with the Neuropsychiatric Inventory; 5) language abilities will be explored with the Screening for Aphasia in NeuroDegeneration (SAND) battery. A 12-month longitudinal phase will follow only for PSP patients. Experimental design aim 3 includes a cross-sectional phase with enrollment of 3 groups of subjects (PSP, PD and HC). During the baseline evaluation each enrolled subject will undergo a multimodal 3T MRI. The MRI protocol will include conventional sequences for morphometric measures (ie, the superior cerebellar peduncles, the middle cerebellar peduncles, the MR Parkinsonism index, the midbrain-pons area ratio; a 3D Spoiled Gradient Recalled Echo (SPGR) and a 3D-GRE multi-echo susceptibility weighted (SWAN) images to obtain quantitative susceptibility mapping and ROI based measures in substantia nigra, basal ganglia thalamus, red nucleus and fronto-parietal cortex, a resting state functional MRI and an Arterial Spin Labeling sequence. A 12-month longitudinal phase will follow only for PSP patients. Both single parameter and multiparameter (morphometric, iron based, functional, and perfusion) MRI approaches will be applied to validate the usefulness of imaging assessments in predicting both early PSP diagnosis and phenotyping as well as disease progression.