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Updated: Dec 27, 2025

Dynamic Digital Biomarkers of Motor and Cognitive Function in Parkinson's Disease
Published on: July 24, 2019
Disease modification and biomarker development in Parkinson disease: Revision or reconstruction?
Alberto J Espay1, Lorraine V Kalia2, Ziv Gan-Or2
1From the Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Edmond J. Safra Program in Parkinson's Disease (L.V.K.), Krembil Research Institute, Toronto Western Hospital, Ontario, Canada; Department of Neurology and Neurosurgery (Z.G.-O.), Montreal Neurological Institute, and Department of Human Genetics (Z.G.-O.), McGill University, Montreal, Quebec, Canada; Department of Clinical Neurosciences (C.H.W.-G.), John van Geest Centre for Brain Repair, University of Cambridge, UK; Division of Medical Oncology and Hematology (P.L.B.), Princess Margaret Cancer Centre, University Health Network, and Department of Medicine (P.L.B.), University of Toronto, Ontario, Canada; Departments of Medicine (S.M.R.), Pediatrics (S.M.R.), Cell Developmental and Integrative Biology (S.M.R.), and Neurology (D.G.S.), University of Alabama at Birmingham; Department of Clinical and Experimental Medicine (F.M.), University of Messina, Italy; Institute of Molecular and Clinical Sciences (F.M.), St George's University of London, UK; Edmond J. Safra Program in Parkinson's Disease (A.F., A.P.S., A.E.L.), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University of Toronto; Krembil Research Institute (A.F., A.P.S., A.E.L.); Tomorrow Edition (B.S.), Toronto, Ontario, Canada; Consultorio y Laboratorio de Neurogenética (M.A.K.), Centro Universitario de Neurología "José María Ramos Mejía" y División Neurología, Hospital JM Ramos Mejía, Facultad de Medicina, UBA; Programa de Medicina de Precision y Genomica Clinica (M.A.K.), Instituto de Investigaciones en Medicina Traslacional, Facultad de Ciencias Biomédicas, Universidad Austral-CONICET, Buenos Aires, Argentina; Clinical Genomics Program (M.J.F.), Norman Fixel Institute for Neurological Diseases, McKnight Brain Institute, University of Florida Clinical and Translational Science Institute, Gainesville; Clinical Trials Statistical & Data Management Center (C.S.C.), University of Iowa College of Public Health, Iowa City; Department of Neurology (M.A.S.), Massachusetts General Hospital, Boston; Michael J. Fox Foundation for Parkinson's Research (T.S.), New York City, NY; Department of Neurology (R.B.P.), Montreal General Hospital, Quebec; Research Imaging Centre (A.P.S.), Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Ontario, Canada; Laboratory of Neurogenetics (A.B.S.), National Institute on Aging, NIH, Bethesda, MD; Department of Clinical Neurosciences (R.A.B.), John van Geest Centre for Brain Repair, WT-MRC Cambridge Stem Cell Institute, University of Cambridge, UK; Clinical Trials Coordination Center (K.K.), University of Rochester Medical Center, NY; Department of Neurology and Neuroscience (C.W.O.), Mount Sinai School of Medicine, New York, NY; Clintrex LLC (C.W.O.), Sarasota, FL; Division of Neurosurgery (A.L.), Krembil Neuroscience Institute, Toronto Western Hospital, Ontario, Canada; Department of Neurological Sciences (J.H.K.), Rush University Medical Center, Chicago, IL; Coeruleus Clinical Sciences (J.M.C.), Woodbridge, CT; and Center for Neurodegenerative Science (P.B.), Van Andel Institute, Grand Rapids, MI. alberto.espay@uc.edu.
Abstract:
A fundamental question in advancing Parkinson disease (PD) research is whether it represents one disorder or many. Does each genetic PD inform a common pathobiology or represent a unique entity? Do the similarities between genetic and idiopathic forms of PD outweigh the differences? If aggregates of α-synuclein in Lewy bodies and Lewy neurites are present in most (α-synucleinopathies), are they also etiopathogenically significant in each (α-synuclein pathogenesis)? Does it matter that postmortem studies in PD have demonstrated that mixed protein-aggregate pathology is the rule and pure α-synucleinopathy the exception? Should we continue to pursue convergent biomarkers that are representative of the diverse whole of PD or subtype-specific, divergent biomarkers, present in some but absent in most? Have clinical trials that failed to demonstrate efficacy of putative disease-modifying interventions been true failures (shortcomings of the hypotheses, which should be rejected) or false failures (shortcomings of the trials; hypotheses should be preserved)? Each of these questions reflects a nosologic struggle between the lumper's clinicopathologic model that embraces heterogeneity of one disease and the splitter's focus on a pathobiology-specific set of diseases. Most important, even if PD is not a single disorder, can advances in biomarkers and disease modification be revised to concentrate on pathologic commonalities in large, clinically defined populations? Or should our efforts be reconstructed to focus on smaller subgroups of patients, distinguished by well-defined molecular characteristics, regardless of their phenotypic classification? Will our clinical trial constructs be revised to target larger and earlier, possibly even prodromal, cohorts? Or should our trials efforts be reconstructed to target smaller but molecularly defined presymptomatic or postsymptomatic cohorts? At the Krembil Knowledge Gaps in Parkinson's Disease Symposium, the tentative answers to these questions were discussed, informed by the failures and successes of the fields of breast cancer and cystic fibrosis.
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