895

Journal of Parkinson’s Disease 14 (2024) 895–898
DOI 10.3233/JPD-240011
IOS Press

Short Communication

Feasibility of Somato-Cognitive
Coordination Therapy Using Virtual Realityfor Patients with Advanced Severe
Parkinson’s Disease
Masahiko Haraa,b,∗ , Yuichiro Murakawaa , Tomomi Wagatsumaa , Keito Shinmotoa
and Masatake Tamakia
a Department of Neurology and Clinical Rehabilitation, mediVR Rehabilitation Center, Toyonaka, Japanb Centre for Community-Based Healthcare Research and Education, Shimane University Faculty of Medicine,
Izumo, Japan

Accepted 18 March 2024
Pre-press 11 April 2024Published 4 June 2024

Abstract. This feasibility study enrolled 20 patients with advanced severe Parkinson’s disease (PD) to evaluate somatocognitive coordination therapy (SCCT) using virtual reality. Focusing on the safety and tolerability of SCCT, 17 patients(76 ± 9 years old and 64.7% male) completed the 3-month trial. Key observations included absence of adverse eventsand tolerability of the participants to SCCT despite initial apprehensions and minor adjustments in medication. Physicalfunctions showed no significant deterioration, suggesting the safety of SCCT. In conclusion, SCCT emerges as feasible andwell-tolerated intervention in advanced severe PD, requiring further research to assess its therapeutic efficacy.
Keywords: Virtual reality, Parkinson’s disease, motor coordination

INTRODUCTION
Advanced severe Parkinson’s disease (PD), classified as Hoehn–Yahr severity classification (H&Y)
stage IV or V disease, is debilitating [1, 2]. Various treatment options are available for severe PD;
however, managing symptoms in the advanced stages
remains a significant challenge [3, 4]. Recent technological advancements have led to the exploration of∗ Correspondence to: Masahiko Hara, MD, PhD, Departmentof Neurology and Clinical Rehabilitation, mediVR Rehabilitation
Center, Ryokuchi Station Building 3F, Terauchi 2-chome 4-1, Toyonaka, 561-0872, Japan. Tel.: +81 6 6151 4008; Fax: +81 6 7635
9728; E-mail: hara@medivr.jp; ORCID 0000-0002-0631-1534.

additional rehabilitation approaches, including virtual reality (VR) [5–7]. In this evolving field of
VR rehabilitation, we developed a novel intervention approach, named somato-cognitive coordination
therapy (SCCT), to facilitate motor coordination byfocusing on the involuntary movement of joints otherthan those intended to be mobilized [8–11].
METHODS
Study population and design
We preliminary conducted the single-arm, multicenter, prospective feasibility study enrolling 20

ISSN 1877-7171 © 2024 – The authors. Published by IOS Press. This is an Open Access article distributed under the termsof the Creative Commons Attribution License (CC BY 4.0).

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patients with advanced severe PD at three nursing
homes. The eligibility criteria were patients for whomboth pharmacological treatments and standard rehabilitation activities can only maintain their current
physical functions at best in the past 3 months. Exclusions were based on unsuitability for VR therapy
including severe mental disorders, as determined bythe attending physician. The objective of the study
was to evaluate the feasibility of the SCCT approachin this patient population. The primary endpoints
were set as the safety and tolerability of SCCT. We
have defined “safety” as the absence of adverse eventsdirectly related to the SCCT sessions and “tolerability” as the ability of participants to complete theprescribed therapy sessions without discontinuation
due to discomfort or other VR-related problems. We
also evaluated the Timed Up and Go (TUG) testfor gait [12], the Simple Test for Evaluating Hand
Function (STEF) for hand function [13], Movement
Disorder Society-unified Parkinson’s disease rating
scale (MDS-UPDRS) Part 3, and functional independence measure (FIM) as secondary endpoints [1–3].
The purpose of including these secondary measures
was not primarily to assess therapeutic efficacy but toensure that the SCCT did not have detrimental effects
on physical functions. The study protocol compliedwith the principles of the Declaration of Helsinki
and was approved by the Central Institutional Ethics
Committee of the Japan Society of Clinical Research(UMIN CTR: UMIN000041770). Written informed
consent was obtained from all participants.
Protocol of therapy
We used a commercially available VR device(mediVR KAGURA, mediVR, Inc., Toyonaka,Japan) specialized for SCCT backed by 18 patented
technologies [8–11]. In an immersive VR environment deliberately designed without body avatars(Fig. 1a, b), we specifically focused on joint movements outside the intended action, which we termed
as articular linkage (AL). This unique VR setting
prominently reveals or provokes AL, allowing us
to observe the entangled somato-cognitive action
network (SCAN) [14]. We conceptualized this entanglement of SCAN, akin to a marionette puppet’s
strings becoming tangled, rendering it unable to move
one part of its body independently as illustrated inFig. 1c and 1d. This is a unique perspective that
our team has developed [8–11], offering a novel lensthrough which to view and address the complexities
of motor coordination in PD. SCCT was conducted

in 20-min sessions, three times a week for 3 months,
focusing on reducing AL during tasks. In SCCT sessions, a key feature was having patients alternate
reaching tasks between the left and right hands while
in a seated position [8–11] (Supplementary Video1). Patients performed reaching tasks toward staticor falling targets in VR space. Therapist adjustments
personalized the tasks to each patient’s ability, withsuccessful interactions confirmed by multisensory
biofeedback: visual (text), auditory (sound), and tactile (vibration). Sessions focused exclusively on thesealternating reaching tasks. This approach aimed tosimulate the shifting of body weight experienced during walking, thus potentially enhancing gait abilities
in our theory. Additionally, by ensuring trunk stability, we hypothesized an improvement in upper limb
functionality without the need for task-oriented training. This method reflects our strategic approach tosimultaneously address gait and upper limb functions in advanced PD patients [8–11]. During thestudy period, attending physicians were requested tominimize any adjustments to medications.

RESULTS
Seventeen of 20 patients completed the 3-monthtrial successfully. One participant dropped out owing
to relocation, and two could not continue the trial
owing to health complications, specifically the common cold and bacterial pneumonia. The mean age was
76 ± 9 years, 11 (64.7%) were male, and the average duration from diagnosis to study enrolment was
11 ± 6 years. Thirteen patients (76.5%) had H&Y
stage IV, whereas four (23.5%) had stage V disease. Despite initial apprehensions, all participating
patients adapted well to the VR tool with no dropouts
due to tolerance issues. In addition, no adverse events,
such as VR-induced sickness or falls, occurred during the study period. Regarding secondary endpoints,
pre- and post-trial evaluations were possible for 15
using the TUG test (Fig. 1e and Supplementary Video2) and 14 using STEF (Fig. 1f and Supplementary
Video 3). For the TUG test, participants who wereunable to walk, even with the use of assistive devices
such as walkers, were excluded (n = 2) from this portion of the assessment. About the STEF, the inability
to complete the transfer of any object was considered a test failure (n = 3). All measurements weretaken under consistent conditions at the same location and time slot during a presumed best-on time,using the same walking aid. Although we could notM. Hara et al. / SCCT with VR for Severe PD

897

Fig. 1. mediVR KAGURA-Guided Somato-Cognitive Coordination Therapy. The patient treatment scene (a) and an image displayed ona device (b). Schematic illustrations of healthy reaching motion (c) and the entangled somato-cognitive action network in a patient (d).
After 3 months, there were no significant deteriorations in the Timed Up & Go (TUG) test scores (e), the simple test for evaluating handfunction (STEF) score (f), Movement Disorder Society-unified Parkinson’s disease rating scale (MDS-UPDRS) Part 3 (g), and functional
independence measure (FIM) (h). Permission was granted by the patient.

make any reliable statements about the effectiveness in this small feasibility study without a control
group, there were no significant deteriorations in secondary endpoints. As for the medication status, there
were minor adjustments in drug dosages but wasno significant difference in levodopa equivalent dosefrom 512 ± 238 mg at baseline and 518 ± 243 mg at
3 months (p = 0.543). We also observed no deterioration in the MDS-UPDRS Part 3 (36.5 ± 20.3 vs.
39.4 ± 19.5, p = 0.217) (Fig. 1g) and the FIM scores(69.2 ± 26.3 vs. 73.2 ± 26.5, p = 0.199) (Fig. 1h).

itations, such as the small sample size and lack of
a control group. In addition, secondary endpoints
did not show significant deterioration, emphasizing
the safety of the SCCT. The statistical improvements
observed in the TUG and STEF scores seem to be
driven by partial data points (Fig. 1e, f), raisingconcerns that these may be the result of statisticalanomalies or potentially attributable to a placebo
effect. We speculated that minor adjustments in medication dosages did not significantly impact the overall
treatment regimen.

DISCUSSION

Conclusion

Key observations from our study included thesafety and tolerability of the participants to VRguided SCCT. Despite initial apprehensions, allpatients expressed enjoyment and willingness to continue post-session resulting in study completion in 17
patients. The absence of adverse events, such as VRinduced sickness or falls, further supports the safetyof SCCT. This aspect is particularly important given
the vulnerability of the study population for whommanaging symptoms remains a significant challenge[1–3]. The primary focus on feasibility, rather thanefficacy, is crucial given the study’s design and lim-SCCT appears to be a feasible and well-tolerated
intervention for advanced severe PD, warranting further research with larger sample sizes and control
groups to evaluate its therapeutic efficacy.
ACKNOWLEDGMENTS
The authors have no acknowledgments to report.
FUNDING
The authors have no funding to report.

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M. Hara et al. / SCCT with VR for Severe PD

CONFLICT OF INTEREST
Masahiko Hara and Masatake Tamaki are directorsof mediVR, Inc. and hold private equity. Yuichiro
Murakawa, Tomomi Wagatsuma, and Keito Shinmoto are full-time employees of mediVR, Inc.
Otherwise, the authors have no conflict of interest
to report.

[6]

[7]

[8]

DATA AVAILABILITY[9]

The data supporting the findings of this study areavailable from the corresponding author upon reasonable request.

[10]

SUPPLEMENTARY MATERIAL[11]

The supplementary material is available in theelectronic version of this article: https://dx.doi.org/
10.3233/JPD-240011.

[12]

REFERENCES
[13]
[1]

[2]
[3]

[4]

[5]

Shulman LM, Gruber-Baldini AL, Anderson KE, Vaughan
CG, Reich SG, Fishman PS, Weiner WJ (2008) The evolution of disability in Parkinson disease. Mov Disord 23,790-796.
Gilbert R, Khemani P (2022) Treatment of advanced Parkinson’s disease. J Geriatr Psychiatry Neurol 35, 12-23.
Fox SH, Katzenschlager R, Lim SY, Barton B, de Bie
RMA, Seppi K, Coelho M, Sampaio C; Movement Disorder Society Evidence-Based Medicine Committee (2018)
International Parkinson and movement disorder society
evidence-based medicine review: Update on treatments forthe motor symptoms of Parkinson’s disease. Mov Disord 33,1248-1266.
Schrag A, Hommel ALAJ, Lorenzl S, Meissner WG, Odin P,Coelho M, Bloem BR, Dodel R; CLaSP consortium (2020)
The late stage of Parkinson’s -results of a large multinational
study on motor and non-motor complications. Parkinsonism
Relat Disord 75, 91-96.
Canning CG, Allen NE, Nackaerts E, Paul SS, Nieuwboer A,Gilat M (2020) Virtual reality in research and rehabilitationof gait and balance in Parkinson disease. Nat Rev Neurol 16,409-425.

[14]

Sarasso E, Gardoni A, Tettamanti A, Agosta F, Filippi
M, Corbetta D (2022) Virtual reality balance training toimprove balance and mobility in Parkinson’s disease: A systematic review and meta-analysis. J Neurol 269, 1873-1888.
Ortelli P, Ferrazzoli D, Bera R, Caremani L, Giladi N,Maestri R, Frazzitta G (2018) Effectiveness of a goal-based
intensive rehabilitation in Parkinsonian patients in advanced
stages of disease. J Parkinsons Dis 8, 113-119.
Takimoto K, Omon K, Murakawa Y, Ishikawa H (2021)
Case of cerebellar ataxia successfully treated by virtual
reality-guided rehabilitation. BMJ Case Rep 14, e242287.
Michibata A, Haraguchi M, Murakawa Y, Ishikawa H(2022) Electrical stimulation and virtual reality-guided balance training for managing paraplegia and trunk dysfunction
due to spinal cord infarction. BMJ Case Rep 15, e244091.
Omon K, Hara M, Ishikawa H (2019) Virtual reality-guided
dual-task body trunk balance training in a sitting position
improved walking ability without improving leg strength.
Prog Rehabil Med 4, 20190011.
Yamaguchi T, Miwa T, Tamura K, Inoue F, Umezawa N,
Maetani T, Hara M, Kanemaru SI (2022) Temporal virtual reality-guided, dual-task, body trunk-balance training
in a sitting position improved persistent postural-perceptual
dizziness: Proof of concept. J Neuroeng Rehabil 19, 92.
Mollinedo I, Ma Cancela J (2021) Evaluation of the psychometric properties and clinical applications of the Timed
Up and Go test in Parkinson disease: A systematic review.
J Exerc Rehabil 16, 302-312.
Irie K, Iseki H, Okamoto S, Okamoto K, Nishimura S,
Kagechika K (2019) Development of the modified simple
test for evaluating hand function (modified STEF): Construct, reliability, validity, and responsiveness. J Hand Ther32, 388-394.
Gordon EM, Chauvin RJ, Van AN, Rajesh A, Nielsen A,Newbold DJ, Lynch CJ, Seider NA, Krimmel SR, Scheidter
KM, Monk J, Miller RL, Metoki A, Montez DF, Zheng A,Elbau I, Madison T, Nishino T, Myers MJ, Kaplan S, Badke
D’Andrea C, Demeter DV, Feigelis M, Ramirez JSB, Xu T,Barch DM, Smyser CD, Rogers CE, Zimmermann J, Botteron KN, Pruett JR, Willie JT, Brunner P, Shimony JS, KayBP, Marek S, Norris SA, Gratton C, Sylvester CM, PowerJD, Liston C, Greene DJ, Roland JL, Petersen SE, RaichleME, Laumann TO, Fair DA, Dosenbach NUF (2023) A
somato-cognitive action network alternates with effector
regions in motor cortex. Nature 617, 351-359.