Apomorphine Therapy

Myths and Truth About Nanavathi Hospital Parkinson Injection Video

December 19, 2023By 0 comment

A Video about Parkinson’s disease patient being treated with apomorphine injections at Nanavathi Hospital , Mumbai became an social media craze in early 2019  (well known as Nanavati hospital Parkinson injection ).  The video shows an dramatic improvement, which has made everyone to think that this is a cure for Parkinson’s disease.   Thousands of Parkinson’s disease patients / caregivers thronged hospitals to find out about this therapy.   Even medical fraternity were perplexed about this, and what was being conveyed.    As a medical fraternity, we do know that till now there is NO CURE for parkinson’s disease currently.   There are good treatments available for Parkinson’s disease including medications, injections and surgeries.   Apomorphine is usually used as treatment option in moderately advanced Parkinson’s disease.  The video shows basically an improvement seen after the injections, which could be similar to levodopa tablets or DBS.  What it missed out on telling was this response would last only for about 60-90 minutes and this is only an symptomatic therapy.

As this video is popping up seasonally, this section would give an idea about Apomorphine and remove the myths around it.

Nanavati Hospital Parkinson Injection Video showing dramatic improvement

Dr Prashanth LK responding to Nanavathi Parkinson Injection Video

Facts about Apomorphine Injection Therapy for Parkinson Disease

FAQ about apomorphine injections

What is Apomorphine?

Apomorphine is a medication which is classified under “Dopamine Agonists”.  This means it works towards increasing dopamine levels in the brain. Other medications under this category include Pramipexole, Ropinirole,etc.

Is Apomorphine similar to Morphine and causes addiction?

Apomorphine is derived from Morphine (Apo means “from”). It is produced by combining Morphine with acids like Hydrochloric acid at high temperatures. By this process, Morphine loses all its properties and a complete new chemical is formed. The chemical name of apomorphine is (C17H17NO2) and is significantly similar to Dopamine.

When was Apomorphine discovered? What are the conditions where Apomorphine is used?

Apomorphine was discovered in 1845. Since then it has been used in various medical conditions like :

i. Vomit inducing agent in poisoning patients,

ii. Sleep inducing agent,

iii. Anesthesia,

iv. De-addiction purposes

v. Respiratory distress disorders

vi. Sexual dysfunction

vii. Movement Disorders (Parkinson’sDisease)

How does apomorphine help in Parkinson’s disease?

In Parkinson’s disease patients, there is reduction of the brain chemical – Dopamine. Apomorphine increases the levels of dopamine and hence improvement in Parkinson’s symptoms.

Since when Apomorphine is used in management of Parkinson’s Disease?

The first use of Apomorphine for Parkinson’s disease is around 1935. Since then it has been used in various studies. Its utilization was not prominent in early years due to nausea/ vomiting issues. With introduction of domperidone to reduce the side effects of Apomorphine, in 1970’s apomorphine utilization has dramatically increased and since last 20 years it is one of the options for advanced therapies for Parkinson’s Disease along with Deep Brain Stimulation (DBS) surgery and Levodopa-Carbidopa Intestinal gel (LCIG).

What are the different formulations, in which Apomorphine is available currently?

Apomorphine is primarily marketed in the form of Injections. However, tablet formulations are also available. There are research studies going on for newer delivery methods with better patient adaptation

What is the advantage of Apomorphine injections as compared to oral levodopa tablets used for Parkinson’s Disease?

We all know that as Parkinson’s disease progress, the duration of benefits of oral levodopa tablets start reducing and people will also start to have erratic responses. Sometimes the oral medications does not work or take too long to work as they are not absorbed properly in our gut (Stomach, duodenum). This is due the changes happening in our gut due to progression of Parkinson’s disease. Apomorphine, which is taken in injection formulation, bypassess the stomach absorption and hence its limitations. This bypassing helps to overcome the limitation of medications and gives quick and predictable benefits.

What are Apomorphine Rescue Injections? How long does it take to work and last for?

Apomorphine rescue injections are “emergency injections” which can be carried by patients in their pockets like “Insulin Injection pens”. If at any time, any Parkinson’s disease patient develops severe slowness, he can take subcutaneous injections similar to insulin injections. This apomorphine injection usually starts working within 5-10 minutes and gives quick and predictable relief. This whole beneficial effect lasts for about 60-90 minutes, helping people to tide over acute worsening. Hence called Rescue injections.

What is Apomorphine Pump Therapy?

In advanced Parkinson’s disease, people who are in need of taking medications very frequently and limited by benefits of oral therapy (like ON-OFF phenomenon, dyskinesia) are suggested for advanced Parkinson’s disease therapies. Apomorphine pump therapy is an advanced Parkinson’s disease therapy. It involves slow release of apomorphine throughout the day and hence providing stable, predictable benefits. It is somewhat similar to Insulin Pump therapy used by diabetes patients.

Are Apomorphine Pump therapy available in India?

Yes, currently two different generations of Apomorphine pumps are available in India. These products are in use in India since 2019.  These are supplied by – Rusan Pharamceuticals and Ever Pharma (Celera India)

Can anyone with Parkinson’s Disease take Apomorphine?

Apomorphine is used in specific stages of Parkinson’s disease to get desired benefits and improve quality of life. Your treating doctor would be able to tell whether you would benefit from Apomorphine therapy.

In the initial phase Apomorphine is used to assess whether the givenParkinson’s disease / Parkinsonism patient would be having benefits with levodopa therapy. This is called the “Apomorphine ResponseTest (ART)”.

In mid-phase of Parkinson’s disease, Apomorphine is used as emergency medications to give quick benefits when certain dosages of levodopa are not working due to various causes. This is called as “Rescue Therapy”

In moderately advanced Parkinson’s Disease, Apomorphine is used in continuous injections in the form of “ApomorphinePumpTherapy ” to over come motor fluctuations (ON – OFF phenomenon) and Dyskinesias.

What is an Apomorphine Response Test(ART)?

Apomorphine Response test or ART is a test to see whether your clinical symptoms improve with Apomorphine. This is done as an elective procedure, where in certain blood tests are done prior to testing. You would also be given “domperidone” tablets to reduce the side effects of Apomorphine. During ART, you would be asked to come in the morning without taking any levodopa and you would be assessed by giving different dosages of Apomorphine injections (usually ranging from 1mg to 6mg). The whole process may last from 90mins to 4-5 hours depending on response and side effects. Your treating doctor/team, will explain about this in detail. If there is a good response to ART, then you can be recommended for rescue therapy OR pump therapy as required.

What is Apomorphine Pump Therapy?

Apomorphine Pump therapy involves slow and continuous release of Apomorphine using a small pump, which can be carried in the pocket or sling bag or belt attachment. The continuous slow release of Apomorphine gives a predictable response throughout the day.

This takes away the side effects of excess medications and has the ease of quick adjustments. Usually pump therapy is given for about 10-16 hrs in a waking day period. However, in some cases night time use is also recommended.

What are the advantages of Apomorphine pump therapy in Parkinson’s Disease?

The advantages of Apomorphine pump therapy include:

i. It gives predictable responses

ii. Dosages can be easily modified as required

iii. No upfront cost like in DBS or LCIG gel therapies

iv. It is also used in patients in whom DBS is contraindicated and has shown good consistent benefits.

v. It has beneficial effects on cognitive function and can be used in people who are having mild to moderate cognitive impairment (where DBS is contraindicated)

vi. It is used in patients with resistant axial symptoms (Camptocormia – bending spine posture) with good benefits.

vii. It is also used in patients in whom DBS effects are reducing over the period of time to give add on benefits.

viii. It can be used for resistant Restless legs syndrome

What are the disadvantages of Apomorphine Pump Therapy?

The disadvantages of Apomorphine are similar to that of Levodopa, Pramipexole, Ropinirole etc. Specific disadvantage of Apomorphine pump therapy include:

i. It has to be managed on a daily basis to start and stop. Some patients may require assistance for the same.

ii. Some people are scared of needle pricks, which is a hurdle for utilization.

iii. Some people feel it is clumsy to carry.

iv. Skin injection sites small nodules are formed. Albeit they are temporary and non-concerning, rarely they can get infected causing problems.

v. Some people continue to have disturbing side effects of nausea, vomiting, drowsiness, blood pressure fluctuations in spite of domperidone.

Most of the dropouts in Apomorphine pump therapy have been noted in the first few months due to adaptation required. However once accepted, people have been using it over many years, with consistent benefits.

Are there any studies Indian / International on benefits of Apomorphine therapies?

Apomorphine therapy has been well accepted therapy for Parkinson’s disease for the last 30+ years. This is categorized under advanced therapies for Parkinson’s disease along with DBS and LCIG. There have been many publications on benefits and long term outcomes of Apomorphine therapy from various countries including India. There are guidelines published by International Movement Disorders groups on who should use apomorphine therapies.

Is Apomorphine injections / therapy available everywhere across India?

Theoretically Apomorphine should be available everywhere across India easily. However as this is an advanced therapy and used in a certain set of Parkinson’s Disease, the ease of access is limited to these advanced movement disorders centers in India. Usually you would be guided on how to procure after therapy initiation. Most of the time they are delivered to each patient on a requirement basis, without any major logistical issues. Even during COVID times, the logistics were maintained and even dispatched to patients who were struck abroad due to lockdown.

Where should I contact for Apomorphine pump therapy?

Your treating doctor will be able to guide you to the nearest Parkinson’s Disease center, who specialize in apomorphine therapies. Please speak to your treating Neurologist / Movement Disorders Specialist for further details.

Resources and Further reading

1. Prashanth LK, Jaychandran R, Seetharam R, Iyer RB. Apomorphine: The Initial Indian Experience in Relation to Response Tests and Pumps. Ann Indian Acad Neurol. 2020 Jan-Feb;23(1):20-24. doi: 10.4103/aian.AIAN_428_19. Epub 2019 Dec 19. PMID: 32055117; PMCID: PMC7001430.

2. Kukkle PL, Garg D, Merello M. Continuous Subcutaneous Infusion Delivery of Apomorphine in Parkinson’s Disease: A Systematic Review. Mov Disord Clin Pract. 2023 Jun 26;10(9):1253-1267. doi: 10.1002/mdc3.13810. PMID: 37772305; PMCID: PMC10525070.

3. Metta V, Borgohain R, L Kukkle P, Mridula R, Agarwal P, Kishore A, Goyal V, Chaudhuri R. Subcutaneous apomorphine in advanced Parkinson’s disease and its use in Indian population. Ann Mov Disord 2020;3:145-55

4. Trenkwalder C, Chaudhuri KR, García Ruiz PJ, LeWitt P, Katzenschlager R, Sixel-Döring F, Henriksen T, Sesar Á, Poewe W; Expert Consensus Group for Use of Apomorphine in Parkinson’s Disease, Baker M, Ceballos-Baumann A, Deuschl G, Drapier S, Ebersbach G, Evans A, Fernandez H, Isaacson S, van Laar T, Lees A, Lewis S, Martínez Castrillo JC, Martinez-Martin P, Odin P, O’Sullivan J, Tagaris G, Wenzel K. Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson’s disease–Clinical practice recommendations. Parkinsonism Relat Disord. 2015 Sep;21(9):1023-30. doi: 10.1016/j.parkreldis.2015.06.012. Epub 2015 Jun 17. PMID: 26189414.

5. Jenner P, Katzenschlager R. Apomorphine – pharmacological properties and clinical trials in Parkinson’s disease. Parkinsonism Relat Disord. 2016 Dec;33 Suppl 1:S13-S21. doi: 10.1016/j.parkreldis.2016.12.003. Epub 2016 Dec 13. PMID: 27979722.

6. Todorova A, Ray Chaudhuri K. Subcutaneous apomorphine and non-motor symptoms in Parkinson’s disease. Parkinsonism Relat Disord. 2013 Dec;19(12):1073-8. doi: 10.1016/j.parkreldis.2013.08.012. Epub 2013 Aug 29. PMID: 24051336.

7. Dafsari HS, Martinez-Martin P, Rizos A, Trost M, Dos Santos Ghilardi MG, Reddy P, Sauerbier A, Petry-Schmelzer JN, Kramberger M, Borgemeester RWK, Barbe MT, Ashkan K, Silverdale M, Evans J, Odin P, Fonoff ET, Fink GR, Henriksen T, Ebersbach G, Pirtošek Z, Visser- Vandewalle V, Antonini A, Timmermann L, Ray Chaudhuri K; EUROPAR and the International Parkinson and Movement Disorders Society Non- Motor Parkinson’s Disease Study Group. EuroInf 2: Subthalamic stimulation, apomorphine, and levodopa infusion in Parkinson’s disease. Mov Disord. 2019 Mar;34(3):353-365. doi: 10.1002/mds.27626. Epub 2019 Feb 4. PMID: 30719763.

8. Fernández-Pajarín G, Sesar Á, Ares B, Castro A. Evaluating the Efficacy of Nocturnal Continuous Subcutaneous Apomorphine Infusion in Sleep Disorders in Advanced Parkinson’s Disease: The APO-NIGHT Study. J Parkinsons Dis. 2016 Oct 19;6(4):787-792. doi: 10.3233/JPD-160886. PMID: 27662329.

9. Sesar Á, Fernández-Pajarín G, Ares B, Rivas MT, Castro A. Continuous subcutaneous apomorphine infusion in advanced Parkinson’s disease: 10-year experience with 230 patients. J Neurol. 2017 May;264(5):946-954. doi: 10.1007/s00415-017-8477-0. Epub 2017 Mar 31. PMID: 28364292.

10. Borgemeester RWK, van Laar T. Continuous subcutaneous apomorphine infusion in Parkinson’s disease patients with cognitive dysfunction: A retrospective long-term follow-up study. Parkinsonism Relat Disord. 2017 Dec;45:33-38. doi: 10.1016/j.parkreldis.2017.09.025. Epub 2017 Sep 29. PMID: 29032012.

11. Sesar Á, Fernández-Pajarín G, Ares B, Relova JL, Arán E, Rivas MT, Gelabert-González M, Castro A. Continuous subcutaneous apomorphine in advanced Parkinson’s disease patients treated with deep brain stimulation. J Neurol. 2019 Mar;266(3):659-666. doi: 10.1007/s00415-019-09184-5. Epub 2019 Jan 7. PMID: 30617907.

12. Menšíková K, Kaiserová M, Vaštík M, Nevrlý M, Kurčová S, Kaňovský P, Colosimo C. The long-term effect of continuous subcutaneous apomorphine infusions on camptocormia in Parkinson’s disease. Parkinsonism Relat Disord. 2020 Jun;75:14-16. doi: 10.1016/j.parkreldis.2020.05.015. Epub 2020 May 12. PMID: 32442812

Overall this Nanavati Hospital Parkinson injection video has been impressive in creating awareness about treatment options for people with Parkinson’s disease.   Many people have equated Nanavati Hospital Parkinson injection video to be synonymous with cure for Parkinson’s disease, which is a misinterpretation of the video circulated, leading to lot of myths associated around this therapy.  We hope our blog on Nanavati hospital Parkinson injection video gives an open insight into the indications, uses and limitations of this therapy and breaks down into some of the myths which are being interpreted from this video.

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Awareness

Navigating Choices: Factors Influencing Deep Brain Stimulation (DBS) Surgery Decisions in Developing Countries – India

December 17, 2023By 0 comment

What factors contribute to the significant difference in the rate of Deep Brain Stimulation (DBS) surgery for Parkinson’s Disease (PD) between developed and developing countries?  What influences the decision of patients with PD in the developing world to opt for or against Deep Brain Stimulation (DBS) surgery? What are the primary barriers hindering a larger proportion of eligible PD patients in the developing world from undergoing Deep Brain Stimulation (DBS) surgery?  These questions have been addressed in a recently published medical paper from India in the medical journal – Movement Disorders in Clinical Practice.   Let’s see what we as a general population can understand from this article.

Deep Brain Stimulation (DBS) Surgery for Parkinson’s Disease – The Developing World’s (India) Perspective:

  • Study focused on patients with Parkinson’s disease (PD) and motor complications in developing countries (India) spanned over 5 year period (2016-2020) involving 1017 Parkinson’s Disease patients.
  • Among 1017 Parkinson’s Disease people, 223 patients met the medical criteria for consideration of Deep Brain Stimulation (DBS) surgery.
  • Among 223 medically indicated for DBS surgery, Only 35% (78 patients) patients opted for DBS surgery.
  • Among these 78 Patients who opted for surgery, 37 patients were found to be unfit for DBS surgery during the Pre-operative workup and only 41 patients finally underwent DBS Surgery.
  • So in brief, in 1017 patients with Parkinson’s Disease, roughly 22% met the clinical criteria for DBS surgery.  From the whole cohort, 7% opted for DBS surgery and among them, only about 4% were deemed fit and underwent the procedure.

Let’s see what factor played a role in decision making for Deep Brain stimulation Surgery in these patients in India.

Characteristics of Patients Opting for DBS Surgery:

Demographics:

  • Older age: Patients choosing DBS were generally older.
  • Higher socioeconomic status: Those opting for surgery had a higher socioeconomic status.

Disease Duration and Motor Complications:

  • Longer duration of PD: Patients choosing DBS had PD for a longer period.
  • Longer duration of motor fluctuations: Opted-for surgery patients experienced motor fluctuations for an extended time.

Motor Symptoms:

  • More severe motor disability in the OFF state: Severity of motor disability was higher in surgery-opting patients when not on medication.
  • More severe freezing of gait in the OFF state: Patients choosing DBS experienced more severe freezing of gait without medication.

Psychiatric and Cognitive Symptoms:

  • History of hallucinations and psychotic symptoms: Opted-for surgery patients had a higher incidence of these symptoms.
  • Higher burden of cognitive symptoms: Prevalence of cognitive dysfunction was higher in surgery-opting patients.

Correlation Between Socioeconomic Status and Surgical Decisions:

  • Correlation found between higher socioeconomic status and the willingness to undergo DBS surgery.
  • Almost 40% of patients opting for medical management cited financial constraints.

Barriers to DBS Surgery:

Reasons for Not Undergoing Surgery:

  • Financial constraints: 39.3% cited financial limitations.
  • Concerns about risks and complications: 13.1% were hesitant due to surgical concerns.
  • Lack of conviction about benefits: 9% were not convinced about expected benefits.
  • Inadequate family support: 6.9% lacked sufficient family support.

Consideration for Future DBS Surgery:

  • 31.7% of patients opting for medical management kept DBS as an option for future consideration.

Comparison with Western Populations:

  • Difference in DBS surgery rates between Western and developing countries.
  • In India, limited access, insurance coverage, and socioeconomic factors contribute to the low rate (35%).
  • Western countries, with comprehensive health coverage, may have higher rates, but concerns about efficacy and safety still influence decisions.

Conclusion:

  • Understanding the complex interplay of socioeconomic, medical, and personal factors crucial for making informed decisions about Deep Brain Stimulation (DBS) surgery in developing countries.
  • Financial constraints, limited insurance, and familial support emerged as significant barriers.
  • Future research and policy considerations should address these barriers to ensure equitable access to DBS surgery in developing regions.
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Awareness

Empowering Well-being: Daily Routine for Parkinson Disease

November 26, 2023By 0 comment

Incorporating a well-rounded daily routine for Parkinson Disease is crucial for well-being. Tailoring activities to address specific needs can enhance overall health and quality of life. Let’s explore daily recommendations under six key areas.

Aerobic Activities:

In the pursuit of holistic well-being, aerobic activities emerge as a cornerstone for seniors and individuals navigating Parkinson’s disease. These activities not only foster physical health but also contribute significantly to mental and emotional resilience.  Aerobic exercises, known for their rhythmic and continuous nature, are pivotal for enhancing cardiovascular health. For seniors and Parkinson’s patients, engaging in these activities promotes increased blood circulation, oxygenation, and overall endurance. This, in turn, contributes to improved energy levels and cognitive function.

Tailoring exercises to individual needs is crucial. Low-impact activities such as walking, swimming, and stationary cycling are excellent choices. These exercises are gentle on joints, reducing the risk of injuries. Aim for at least 30 minutes of moderate-intensity aerobic activity most days of the week.

Research suggests that aerobic exercises can have positive effects on motor functions and cognitive performance in individuals with Parkinson’s disease. These activities may help manage symptoms, enhance balance, and promote a sense of well-being.

Tailor activities to individual fitness levels and modify them as needed. Incorporating warm-up and cool-down sessions is crucial to prevent injuries.  The key lies in creating a personalized and sustainable aerobic exercise plan that aligns with individual capabilities and preferences. By embracing the power of movement, individuals can unlock a pathway to enhanced vitality, both physically and mentally.

#AerobicHealth #SeniorFitness

Meditation:

In the realm of holistic well-being, meditation stands as a profound practice with the potential to enhance the lives of seniors and individuals grappling with Parkinson’s disease. Beyond its calming effects, meditation contributes significantly to mental clarity, emotional resilience, and overall quality of life.

Various meditation techniques cater to different preferences. Pranayama, Mindfulness meditation, guided visualization, and loving-kindness meditation are popular choices.  Studies suggest that regular meditation can positively impact cognitive function, potentially slowing the cognitive decline associated with aging. For Parkinson’s patients, meditation may provide cognitive support, aiding in concentration and mental clarity.

Establishing a Meditation Routine:

Begin with short sessions and gradually extend the duration as comfort grows. Integrating meditation into daily life can be as simple as finding a quiet space, focusing on breath, and embracing the present moment. Consistency is key to reaping the full benefits.  Participating in group meditation sessions fosters a sense of community and shared purpose. For seniors and those managing Parkinson’s, this communal aspect of meditation provides an avenue for shared experiences and emotional support.

In the pursuit of well-being, meditation emerges as a transformative practice for seniors and individuals navigating Parkinson’s disease. By embracing moments of stillness, individuals can discover a profound source of mental and emotional strength. Whether practiced individually or in a group setting, meditation unveils a pathway to serenity, empowering individuals to navigate life’s challenges with grace.

#MindfulnessForSeniors #ParkinsonsWellness

Strength and Balance Training:

In the journey towards holistic well-being, the significance of strength and balance training cannot be overstated for seniors and those managing Parkinson’s disease. These targeted exercises not only enhance physical resilience but also contribute to improved mobility, reduced fall risks, and an overall sense of empowerment.

Crafting a personalized strength and balance training routine is essential. Include exercises that focus on major muscle groups, such as squats, lunges, and leg lifts. For Parkinson’s patients, incorporating exercises that enhance core strength can contribute to improved stability.  Consider low-impact options for those with mobility concerns. Water aerobics, tai chi, and yoga are excellent choices that provide a gentle yet effective approach to building strength and improving balance.  Participating in group strength and balance classes not only adds a social component but also provides a supportive environment.

Strength and balance training stand as pillars of physical well-being, offering seniors and individuals with Parkinson’s disease the tools to navigate daily life with confidence. By incorporating these exercises into a regular routine, individuals can not only enhance their physical capabilities but also cultivate a sense of empowerment and resilience.

#StrengthTraining #BalanceForSeniors #ParkinsonsWellness #SuryaNamsakara

Stretching Exercises:

In the pursuit of comprehensive well-being, the often-overlooked practice of stretching exercises plays a pivotal role for seniors and individuals managing Parkinson’s disease. Beyond enhancing flexibility, these exercises contribute to improved joint health, increased range of motion, and a heightened sense of physical comfort.

Emphasize gentle, gradual stretches, especially for seniors or those with limited mobility. Focus on major muscle groups such as the neck, shoulders, back, and legs. Incorporate both static and dynamic stretching techniques for a well-rounded approach.  Individualized stretching routines are key. Consider specific needs, such as addressing areas of discomfort or focusing on enhancing flexibility in particular joints. Seek guidance from healthcare professionals for personalized recommendations.

Stretching exercises offer a gateway to improved flexibility, joint health, and overall physical comfort for seniors and those with Parkinson’s disease.  Incorporating this daily routine for Parkinson Disease makes a dramatic change into the overall outcome of the disorder.

#FlexibilityRoutine #StretchingForSeniors #ParkinsonsWellness

Engaging Activities: 

In the pursuit of holistic well-being, engaging activities, such as gardening and participating in small chores, emerge as invaluable tools for seniors and individuals navigating Parkinson’s disease. Beyond providing a sense of purpose, these activities contribute to physical activity, mental stimulation, and an overall enhancement of daily life.

Gardening is a multifaceted activity that not only encourages physical movement but also provides exposure to nature, promoting mental well-being. Planting, weeding, and tending to a garden offer low-impact exercises that contribute to overall mobility.

Participating in everyday chores, even on a smaller scale, can be a form of functional exercise. Folding laundry, light cleaning, or organizing spaces contribute to physical activity and help maintain motor skills.

The goal is to create activities that are enjoyable, achievable, and aligned with personal interests.  or seniors and individuals with Parkinson’s, these activities infuse daily life with purpose, physical activity, and mental stimulation. By embracing active joy, individuals can cultivate a fulfilling and vibrant daily routine.

#EngagingActivities #ActiveLiving #ParkinsonsWellness # Daily Routine for Parkinson Disease

Social Activities:

In the realm of holistic well-being, the value of social activities and group events cannot be overstated for seniors and individuals managing Parkinson’s disease. Beyond mere socialization, these activities foster a sense of belonging, emotional support, and contribute to an enriched quality of life.  Engaging in group events provides a structured avenue to combat loneliness, fostering connections and meaningful relationships.  Sharing experiences, laughter, and camaraderie during group events create a positive atmosphere that helps alleviate stress and boost mood.  Engaging in conversations, playing games, or participating in group activities can help maintain mental sharpness, benefiting both seniors and individuals with Parkinson’s.

Group events offer a platform to celebrate milestones, whether personal or collective. Recognizing achievements, birthdays, or special occasions within a supportive community enhances a sense of joy and accomplishment.  Incorporating intergenerational activities can be especially enriching. Seniors and Parkinson’s patients benefit from the energy and perspectives of younger generations, creating a dynamic and inclusive social environment.

Social activities and group events are not mere pastimes—they are essential threads in the fabric of well-being. For seniors and individuals with Parkinson’s, these activities weave a tapestry of connection, support, and joy. By actively participating in social events, individuals can foster a community that uplifts and enhances the overall quality of life.

#SocialWellness #CommunityConnection #ParkinsonsSupport # Daily Routine for Parkinson Disease

To reap the full spectrum of benefits, strive to dedicate at least 30 minutes to each event, engaging in activities at least three days a week. This commitment ensures a consistent and impactful embrace of social well-being, promoting a fulfilling and vibrant lifestyle. By weaving the tapestry of connection and shared moments, we cultivate resilience, joy, and a community that uplifts us on this journey of well-being – Incorporate a healthy daily routine for Parkinson disease.

#SocialWellness #CommunityConnection #ParkinsonsSupport

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Deep Brain Stimulation

Understanding the Process of Deep Brain Stimulation (DBS) Surgery

November 1, 2021By 0 comment
Pathyway for a Deep Brain Stimulation (DBS) Surgery

When we decide or think to undergo Deep Brain Stimulation (DBS) surgery for Parkinson’s disease, the most common thought comes is HOW IS THE SURGERY DONE?. There are various steps before the surgery and you would have gone through these process like Levodopa challenge, cogntive assessment, decision making ability, speaking to people who have underwent surgery. BUT, still the question of how the surgery is done remains an intriguing enigma. In this blog we go through the process of SURGICAL DAY EVENTS along with the video and images to give an insight to all the people to understand the same. A brief visual overview of the events can be found on youtube : https://youtu.be/4QAugdLKYjg (This video link is available for above 18+ years only due to the descriptive videos)

One Day Prior to DBS Surgery

Most of the people planned for Deep Brain Stimulation (DBS) surgery are admitted a day prior to the surgery. Usually this day Patient and family gets settled after hospital admission process are finished. No medication changes are done on that day (If any changes are usually done atleast a week before – either stopping or adding). Surgical site preparation instructions are given by the surgeon (like head shaving / Part preparation etc). You would have your usual meal and medications before going to sleep.

On the Day of DBS Surgery

Your day begins around 6 to 7am in the morning, when the treating nurse checks and provides instructions. You would not be given any Parkinson’s disease medications (unless specifically indicated by the doctor) or food (you will be fasting overnight till the surgery is finished). You can take your other medications like for blood pressure etc. These would have been instructed to you a day before itself by the treating team and the Neuroanesthetist. Once your pre-surgical instructions are carried out by the nursing team (like part preparation, supervising medications), you would be shifted for the Frame fixation. From this point onwards your surgical day starts. We will go through them as step by step below.

Step-1 : Frame Fixation

Frame fixation for Deep brain stimulation surgery.
DBS Frame being fixed by Dr. Kiran Khanapure and Dr. Harish PN

You would be taken for Frame fixation, where in a box type frame is fixed on your head with local anesthesia. This box will act like a landmarks for various brain structures. (In simple way it like graph computation using X, Y and Z co-ordinates to locate different brain structure)

Step – 2 : Imaging of the Brain with Frame

Imaging following frame fixations for Deep brain stimulation (DBS) surgery
DBS Patient undergoing CT Brain after Frame being fixed

Following the fixation of the frame, you will undergo imaging (Commonly CT Brain is done. MRI can also be done). This will help to get the images of brain with the frame, which will act as anchor points to locate different distances in the brain.

Step – 3 : Planning of the Surgical co-ordinates

Planning process on the Stealth station for Deep brain stimulation (DBS) surgery
DBS plan on a stealth station

Once the imaging is done, you are shifted to the operating theatre room. Here you would be set in a comfortable position (so that you can stay like that for next few hours). In the mean time, the treating team will merge your images on a specialized software. From this software, they will choose the brain target (in PD mostly it would be subthalamic nucleus. Some time GPI is considered) and would be able to get co-ordinates based upon there distances from the frame anchor points. This will act as X, Y, Z co-ordinates of a 3d graph to target the brain.

Step – 4 : Positioning, Burr hole

Dr. Kiran Khanapure and Dr. Harish PN in DBS surgical process
Dr. Kiran Khanapure and Dr. Harish PN in the surgical process

Once the planning and co-ordinates for the surgery are finalized. The surgical team will set up a frame at the operating table. With this frame, then can mark the distances the electrodes to travel to reach the intended location. You would be awake or mildly sedated during this whole process. Once the frame is fixed a small hole is done in the skull (a size of a 25 paisa coin) to target one side of the brain. Later similar process with another hole is done to target other brain site. Once this is done, the scene is set up for assessment and target finalization.

Step – 5 : Microeletrode Recording

Microelectrode recording of subthalamic nucleus during Deep brain stimulation (DBS) surgery
Microelectrode recordings (Source : https://www.ijnonline.org/)

Once the burr hole is done a microdrive is fixed and fine recording electrodes are pushed in the planned trajectory. Each part of the brain has different electrical activity pattern and based upon which we can assume where the electrodes are going get placed. This is a method of re-affirmation of Imaging planning done previously and gives an confirmation of right position. Based upon these recordings the position of electorde is considered.

Step – 6 : Macro Stimulation and Clinical assessment

Clinical assessment during the DBS surgery
Clinical assessment. Source : www.news-medical.net

Once the microelectrode recordings are done, then the most important clinical assessment will start. In this step, small currents are given in the intended target region and clinical assessment for benefits would be done. This is point where patient has to be very alert and respond to various questions and tasks given by Dr. Prashanth LK. The benefits of stimulation and at voltages sides effects / excess effects are noted and recorded. This clinical assessment gives an final confirmation of the electrode placements.

Step – 7 : Electrode fixation

X-ray fluroscopy to look in the electrode positioning during fixation
X-Ray imaging during the process of electrode fixation

Following the electrode placement, it is fixed to the position and locked by a cap.

Step – 8 : Repeat procedure for the second site

After the electrode placement on one side, Step 4,5,6,7 are repeated on opposite side to fix the second electrode.

Step – 9 : Check Imaging

Check CT brain re-merged with the software to cross check the electrode trajectories
CT imaging showing Reconfirmation of trajectories after the electrodes are fixed

Once both the electrodes are fixed, a check imaging is done preferabbly and then these images are merged with the actual intended trajectories. The goal is to cross confirm the initial planned trajectories with the final fixed trajectories.

Step – 10 : Battery Placement

Image showing the location of battery placement in DBS patients
IPG (Battery) placement below the collar bone. Source : www.researchgate.net

Following the check imaging, now you would be planned for battery placement. This point onwards you would be in general anaesthesia and deep sleep. A small pocket is made in your chest, just below the collar bone. After this an tunnel is created from the battery area to the head (Near the burr holes) just beneath the skin and both the parts are connected by the wire. Once all the electrical systems are connected, they are checked for integrity of the circuit, before closing the surgical sites. With this the surgical process is finished.

Step – 11 : Immediate Post Surgical care

Once the surgical process is finished you are weaned from the anesthesia and then shifted to the ICU. You would be awake (probably exahusted /sleepy). No oral feeds are given for another few hours at the discretion of the anesthesia team. Following that your regular Parkinson’s disease and other medications are started. You would be in the Intensive care unit overnight. There would some pain at the surgical wound points, but usually less as you would be given pain killer.

Step – 12 : Point to Remember

Please remember, surgical process is to fix the DBS stimulation system in the brain. The system is not yet assessed and started. It would be done subsequently at a later date. The whole surgical process lasts for 8-10 hours. In some patients the process may be staggered on different days, based upon the comfort levels of the patient and the surgical teams. There would be some deviations based upon each case to case basis, which would be discussed with the patient and family before and during the procedure (if required)

Day After the DBS Surgery

The next day following the Deep Brain Stimulation (DBS) surgery, you would be assessed. Most of the people would be back to normal status, with possible some sense of improvements, due to microlesional benefits. If you are deemed fit, then you would shifted to the ward, where you would stay for next few days.

Your whole stay in the hospital will last between 5-7 days on average.

Post Discharge

Post discharge, you would be guided on dates for surgical suture removals and planning for DBS programming.

The whole write up can be viewed as short 3 minute video on Youtube https://youtu.be/4QAugdLKYjg

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Awareness

A Sneak Peak into Gastrointestinal (GUT) Conundrum of Parkinson Disease

April 14, 2021By 0 comment

The understanding of Parkinson’s disease has been dramatically changing over the years. The gastrointestinal symptoms of Parkinson disease are well recognized and keeps on adding up to the number of symptoms of Non Motor Symptoms (NMS). Even further the question of whether Parkinson’s disease arises from Gut perse has become a promienent question among the scientists across the world. The has given raise to concept of GUT-BRAIN axis and further postulation of Gut first and Brain first theories. In this blog, we are trying to highlight the awareness about various gastrointestinal symptoms noted in patient with Parkinson’s disease.

The Gastrointestinal symptoms in Parkinson disease is one of the common NMS in PD, even early in the disease course. Several factors such as loss of dopaminergic activity, presence of Lewy bodies, gut exposure to neurotoxins, gut dysbiosis, cytokine-induced toxicity, inflammation-derived oxidative damage and aging have been associated with the pathogenesis and progression of PD although robust evidence is lacking.

Gastrointestinal Symptoms of in Parkinson Disease

The symptoms of Gut in Parkinson’s disease can be noted all the way from the mouth and salivary glands. the following list helps to understand the possible symptoms which could be associated with Parkinson’s disease.

Salivary Glands symptoms

  • Reduced Saliva Production
  • Low swallowing frequency leading to drooling

Mouth related symptoms

  • Pooling of saliva and problems with movements needed to brush teeth can cause dental dysfunction
  • Jaw tremors related discomfort

Pharynx related symptoms

  • Oropharyngeal dysphagia increases risk of aspiration

Oesohagus related symptoms

  • Slow esophageal transit
  • Segmental esophageal spasm
  • Spontaneous contractions of proximal esophagus
  • Air trapping
  • Aperistalsis
  • Gastro-esophageal influx

Stomach symptoms

  • Impaired gastric emptying causes nausea
  • Bloating
  • Early satiety and weight loss

Small Intestine symptoms

  • Dilatation leading to bloating sensation

Colon symptoms

  • Colonic dysmotility
  • Constipation
  • Megacolon
  • Volvulus
  • Bowel perforation

Rectum symptoms

  • Anorectal dysfunction leads to difficulty with defecation

Management of Gastrointestinal symptoms in Parkinson disease

There are various symptomatic options for various GI related symptoms. The same has been highlighted in this article image.

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Elephant in the Room – Astonishing Parkinson’s disease Beyond Tremors

April 3, 2021By 0 comment
The Elephant in the Room art by Banksy at Barely legal exhibition in 2006

The expression “Elephant in the room” is an metaphorical idiom used to describe something which everyone knows, but no one wants to mention or discuss it for various reasons. The above image is a part of “controversial art” by famous British artist Banksy. This art named “Elephant in the room” was featured as a part of US exhibition – “Barely legal” in 2006. It had it’s own set of controversies. However, the primary objective of this art was to highlight that billions of people lived below the poverty line. This art perse was a metaphor to speaking about elephant in the room and controversies there off.

Parkinson’s Disease is well known disorder where in people know issues about tremors, slowness, stiffness and walking related issues. However, there are many more other issues, which is well know to the patients, caregivers, and doctors, but most of the time, these symptoms are either brushed under the carpet or not enquired upon at consultation. Currently these features are becoming more important in the management of Parkinson’s Disease and more efforts are being put into the assessment and treatment of these issues. These are broadly classified under the category of Non Motor Symptoms (NMS) under the management of Parkinson’s Disease. However, these for all of us is the Elephant in the room which needs to be more outspoken and appropriate management needs to be done.

The International Parkinson Disease and Movement disorders society (IPMDS), has come up with exclusive scales on non motor symptoms to address this concern of elephant in the room.

“Elephant in the Room” – Parkinson’s Disease

The Motor and the Non Motor symptoms of Parkinson’s disease.
Image source: Parkinsonnsw

There are various symptoms which qualify for elephant in the room for Parkinson’s disease and prominent among them are

  • Mood : All Parkinson’s disease patients might have some form of mood/behavioral changes, which is mostly under reported and only symptoms which become much bothersome are spoken about. Depression is one of the well know and needs to be tackled properly.
  • Sleep : Sleep disturbances are common and sometimes predate the onset of motor symptoms by many years. These symptoms might include vivid dreams, nightmares, shouting/yelling/enacting in dreams (aka RBD), restless leg syndrome (RLS).
  • Bladder issues : Urinary urgency, increased frequency, night time increased urinary frequency/volume are common bladder issues noted.
  • Constipation : Constipation is probably one of well accepted and acknowledged symptom, which is noted well before the onset of motor symptoms
  • Sexual dysfunction : Probably this is one of the least discussed non motor symptom, and mostly not addressed. The issue has to be discussed promptly by the patient or the doctor as its fairly treatable symptom
  • Excessive sweating / drooling / skin oilyness : These changes are noted in patients with Parkinson’s disease and skin changes can be noted.
  • Postural dizziness / fatigue : Patients with Parkinson’s disease tend to have

In the subsequent weeks, we will try to bring out exclusive write ups, including their symptoms, management, both on video and web write up. Effort will be put to get Kannada language audio/video files for the patients and care givers. Keep a lookout on the facebook page and youtube channel.

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Parkinson’s Disease challenge and advise collage from Doctors across India

August 15, 2020By 0 comment
https://youtu.be/F3XH503h9I0

#PDchallenge was initiated on July 22nd 2020 on the occasion of World Brain Day to create awareness about Parkinson’s Disease. The challenge included, showing various activities with a theme to win over Parkinson’s Disease. It included videos of patients, caregivers, friends, relatives, movement disorder specialists, neurologists, neurosurgeons, therapists, researchers from across the globe.

The following collage video shows the various Movement Disorders specialists, Neurologists, Neurosurgeons, researchers taking part in the #PDchallenge, released on August 15, 2020. This matches with the essence of ‘Mile Sur Mera Tumhara‘ theme of Unity in diversity theme song launched on August 15th 1988.

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World Brain Day – #PDchallenge

July 22, 2020By 0 comment

#PDchallenge

Lets Shake the Parkinson’s Disease

World Brain Day 2020

#Parkinsons

Every year July 22nd is commemorated as WORLD BRAIN DAY.  Annually one disorder will be highlighted to increase the awareness of the disorder.  World Brain Day 2020 is dedicated to raising awareness for Parkinson’s Disease, a neurodegenerative brain disorder affecting more than 70 lakh people of all ages worldwide.   This year, World Federation of Neurology and International Parkinson and Movement Disorder Society have joined together to end #parkinsons.

In this context, here in India, we are doing an active Parkinson’s Disease awareness campaign in the form of #PDchallenge.  The challenge is open to all patients, caregivers, friends, health care workers and everyone across.  The primary goal is to create awareness about Parkinson’s Disease.  Please do a brief video about your active movements or agility and challenge your family members, friends, colleagues to show their agility. Come lets create awareness about Parkinson’s disease and remove the myths about it.  Let’s create awareness by challenging our friends and relatives

10 things about Parkinson’s Disease for this World Brain Day:

  1. Parkinson’s Disease is neurodegenerative disease affecting the brain
  2. More than 70 Lakh people of all age groups affected by Parkinson’s Disease Worldwide.
  3. Parkinson’s Disease classically causes Slowness, Stiffness, Tremors and Balance problems.
  4. Mood changes, Anxiety, Depression, reduced smelling ability, Sleep disturbances, Urinary issues, Constipation, can also be affected.
  5. The Scare of the name “PARKINSON’S DISEASE”, make many people to loose hope in life.
  6. Parkinson’s disease is treatable
  7. People affected with Parkinson’s disease can lead a near normal quality of life.
  8. Good treatment options are available including mediations, injections and surgeries.  
  9. Active life style and Exercises form the most important part of management of Parkinson’s Disease.
  10. Come on the World Brain Day, “Lets Shake the Parkinson’s”
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Dance for PDnews

Dance for Parkinson’s Disease – Learn Online

July 20, 2020By 0 comment

The COVID-19 breakout has lead to a significant limitations in mobility of people across the world. This is primary concern for People with Parkinson disease and Parkinsonism disorders. In these disorders people need to do workouts on daily basis to have a good quality of life. Many people require supervised care and some require a group to motivate the exercise schedules. This has been significantly hindered by the current #pandemic outbreak and #Lockdown. To over come this modern day problem, people have adapted and improvised to bridge the current issues. In this context “Hirshikesh’s Center for Contemporary Dance” in Pune, has been successfully working on online dance programs for Parkinson’s Disease and Parkinsonism Disorder patients. The dance program for Parkinson’s disease facilitators integrate movement from Indian classical and modern dance, and choreographic repertory. This initiative has been helping many Parkinson’s Disease people from across India.

Difficulties with gait and balance are common among individuals with Parkinson disease (PD), contributing to an increased incidence of falls. Gait changes include slowness of walking with short, shuffling steps and a flexed posture, and may also include festination and/or freezing of gait. Aspects of walking that appear to be particularly impaired include dual tasking, turning and walking backward

Given the potential benefits of exercise for those with PD, recommendations have been made regarding key components of an exercise program designed for those with PD. The recommendations include four key areas: 1) cueing strategies to improve gait, 2) cognitive movement strategies to improve transfers, 3) exercises to improve balance, and 4) training of joint mobility and muscle power to improve physical capacity. Emerging evidence also suggests that aerobic training, such as walking on a treadmill, may result in improved quality of life, reduced disease severity as reflected by lowering of UPDRS-III scores, and improved aerobic capacity

Dance as a group-based treatment for Parkinson’s disease (PD) incorporates physical exercise, cognitive tasks, sensory experience (music), emotional expression, and social interaction. As such a multidimensional activity, dance has the potential to address many of the challenges faced by patients. Indeed, in addition to significant motor and cognitive impairment, patients are troubled by mood changes and social isolation. Therefore, dance may highly impact the quality of life in patients with PD.

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Parkinsons diseaseAwareness

Destination Unknown – My Journey with Parkinson’s – An Autobiography by Rajeev K Gupta

June 12, 2020By 0 comment
Destination Unknown – My Journey with Parkinson’s

Destination Unknown – My Journey with Parkinson’s, is an autobiography of Mr. Rajeev K Gupta, who is diagnosed with Young Onset Parkinson’s Disease.   The book fills a long overdue void about personal experiences about Parkinson’s Disease, especially from Indian Context.  It goes through the various phases from, ‘Overcoming the Shock’ attached with diagnosis of Parkinson’s disease in a young active professional life.  The story leads on to explain the “Million Dollar Decision” on how and when to reveal the diagnosis to the family members and on professional front.  It also gives insights about how to cope with the diagnosis, adapt and overcome, to win over this ‘Mental Game’.  Mr. Gupta, further goes into the depth of various treatments he received, their benefits / limitations.  Later, he continues on his decision on ‘Deep Brain Stimulation’ surgery and his whole experience from the point of considering it to the post-surgery outcomes.   The book also gives a Q&A section, which will be helpful for all Parkinson’s disease patients, to understand about Parkinson’s disease and its treatment.  Overall, a must read for every Young Onset Parkinson’s Disease Patients and their families.   The Book is currently available on various online sellers including Amazon, Kobo, Google Play books and on publishers site (Notion Press).

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