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Conditions we treat
Movement Disorders Clinic
Botulinum Toxin Clinic
Deep Brain Stimulation (DBS) and Neuromodulation:
Electrophysiology (Tremor/ Myoclonus/ Dystonia)
Autonomic Function Lab
Gait and Balance Assessment
Gait and Balance Rehabilita/on
Neuropsychology
Speech and Swallowing Therapy
What is Parkinson’s disease?
Parkinson's disease is the second most common neurodegenerative disorder after Alzheimer's disease. It is mostly a disease of old age, affecting people above 50 years. About 5% develop young-onset Parkinson's disease before the age of 40 years. Parkinson’s disease is caused due to degeneration of cells in a region of the brain known as substanEa nigra, which produces a chemical called dopamine. Reduced dopamine in the brain produces the clinical manifestaEons of Parkinson's disease. Common symptoms are slowness in activities, stiffness, and tremors. As the disease progresses, walking and balance are also affected.
What causes Parkinson's disease:
In most cases, the cause for Parkinson's disease is not known and hence it is called idiopathic Parkinson's disease. Several factors appear to play a role in the development of Parkinson's disease, including genes and environmental triggers. Toxins like pesticides, illicit drugs (MPTP), and head trauma can increase the risk of developing Parkinson's disease. In about 5-10 % of cases, a genetic problem can be identified.
What are the symptoms of Parkinson's disease?
Symptoms of Parkinson's disease can be divided in motor and non-motor symptoms.
Motor symptoms
Slowness: In patients with Parkinson’s disease, the movements become slow, and it takes more time to finish a task. Slowness can affect one side of the body more than the other. Walking also becomes slow in more advanced stages.
stiffness: stiffness can start in any limb but eventually affects the whole of the body. Parkinson’s disease commonly presents as shoulder stiffness and is often misdiagnosed as frozen shoulder. stiffness as a symptom can be very disabling.
Tremor: Tremor in Parkinson’s disease usually start in one limb and eventually affects other limbs and both sides of the body. The tremor is classically present at rest and reduces with limb movement.
Walking and balance problem: Parkinson’s disease patients walk slowing with small steps. In more advanced stages shuffling develops, which is dragging of the feet without lifting them fully off the ground. Freezing while walking may develop in some patients in which the steps become smaller and smaller till walking stops. Freezing can happen any time during walking but is more common at turns and while walking through narrow passages like through a door. Balance can also be affected resulting in falls.
Speech: Parkinson's disease paEents have a low volume and monotonous (flat) speech. As the speech is soft, it is often hard to for the caregivers to understand.
Non-motor symptoms
Constipation: Constipation is a common symptom in Parkinson's disease and can be seen many years before the diagnosis of Parkinson’s disease is made. Constipation can also be a side effect of some medications used in the treatment of Parkinson’s disease.
Sleep problems: Patients with Parkinson's disease can have sleep initiation (difficulty in falling asleep) or sleep maintenance (difficulty in staying asleep) problems. At times sleep is disturbed because of stiffness in body or increased frequency of urination at night (nocturia) resulting in frequent awakenings. REM sleep behavior disorder (RBD) is a common symptom of Parkinson's disease. It may start many years before the diagnosis of Parkinson's disease is made. In this disorder, the patient speaks and moves in dreams, sometimes causing injury to self or bed partner.
Autonomic dysfunc/on: Autonomic dysfunction is common in advanced Parkinson's disease but sometimes can be seen even in the early stages. Patients feel dizzy or light-headed while standing due to a drop in blood pressure. This can result in a fall. Bladder symptoms like urgency and incontinence are common. Episodes of profuse sweating can be very inconvenient and embarrassing.
Cognition: Cognition is usually preserved till late in Parkinson's disease. When cognition is affected patients may have difficulty in remembering new things, difficulty in multitasking, planning and navigation. Visual hallucination are common in Parkinson's disease dementia and can be very disabling.
Mood and behavior: Mood changes are commonly seen in Parkinson's disease, even in the early stages. Depression is very common, and early identification and treatment can significantly improve the quality of life. Some patients may develop mania or bipolar disorder. Delusions can be present in patients with Parkinson's disease dementia. Impulse control disorders like compulsive eating, shopping, and hoarding can be a side effect of drugs used in the treatment of Parkinson's disease.
How is Parkinson’s disease treated?
There are many effective oral medications for the treatment of Parkinson’s disease. In mild and young cases dopamine agonists are usually prescribed. The most effective medication in the treatment of Parkinson’s disease is Levodopa. Levodopa is converted to dopamine (chemical deficient in Parkinson’s disease brain) after it enters the brain. Levodopa improves most of the symptoms of Parkinson’s disease including tremor, stiffness, slowness and walking difficulty. It has to be taken empty stomach, multiple times a day. Non-motor symptoms like constipation, sleep problems, REM sleep behavior disorder, orthostatic intolerance and cognitive decline can be treated with medications and lifestyle changes. Surgical options are available for advanced cases or when symptoms are not well controlled with oral medications.
Is there a surgical treatment for Parkinson’s disease?
Deep brain stimulation (DBS) is the surgical procedure for treating Parkinson’s disease. DBS is considered in Parkinson’s disease when symptoms are not adequately controlled with medications. As the disease progresses, patients develop unpredictable OFF periods and dyskinesia (involuntary dance-like movements). after a certain stage, oral medications may not be effective in controlling these symptoms. DBS is an effective surgical option in these patients and symptoms of tremor, stiffness, and slowness are well controlled after the surgery. As medications are reduced post-surgery, dyskinesias also improve.
Before the surgery, a movement disorders specialist conducts an extensive assessment including evaluation of medications, symptoms, and response to oral Levodopa. A detailed evaluation of cognition by a neuropsychologist is also done.
The surgery of DBS is done in two stages. In the first stage, the electrodes are inserted in the brain under stereotactic guidance. During this part of the surgery, the patient is awake. In the second stage, the impulse generator (IPG) or the pacemaker is placed under the skin of the chest. The brain electrodes are then connected to the pacemaker with connecting wires tunneled beneath the skin. The second stage of surgery is done under general anesthesia.
The programming of the impulse generator (IPG) is done after the surgery. It may take a few days to weeks to reach the optimal setting, as the current increase has to be done slowly to allow the brain to adapt. The programming of the IPG is done by a movement disorders specialist as an outpatient procedure.
What is dystonia?
Dystonia is involuntary muscle contractions causing abnormal posturing of body parts. It can affect any part of body including eyes (forceful eye closure), jaw, neck, arms, legs, and trunk.
Common presentation of dystonia are:
Blepharospasm: Blepharospasm is forceful closure of both the eyes. In the initial stage, it may present as excessive blinking. Forceful eye closure can lead to functional blindness, making activities like reading and driving difficult. Oral medications are of limited use. Botulinum toxin in eyelids can improve the symptoms.
Cervical dystonia: Abnormal twisting movements of the neck is known as torticollis or cervical dystonia. It is one of the most common types of dystonia manifesting in middle age. Neck tremors can be an associated feature. Treatment of choice for cervical dystonia is botulinum toxin injections.
Writer's cramp: Writer’s cramp is usually seen in people who write a lot. In this condition, the activity of writing causes abnormal posturing of hand or arm. Using a thick pen can improve writing in some patients. Botulinum toxin is the first line of therapy.
What causes dystonia?
In some cases dystonia is caused because of an abnormal gene. In others it can be due to a birth injury, infection or stroke. Dystonia occur in patients doing repetitive activities like writing (writers cramp), playing a musical instrument (musicians dystonia) and typing. In some cases the cause for dystonia can't be ascertained even after extensive investigations.
How is dystonia treated?
Anticholinergics drugs are the most commonly used oral therapy for treating dystonia. Other medications that are used are Baclofen, Clonazepam and Tetrabenazine. A few childhood onset dystonia cases respond very well to a medication called Levodopa.
Botulinum toxin is used in the treatment of focal or segmental dystonia. A small amount of this toxin is injected into the selected muscles using a fine needle. Side effects are minimal as the action is local. The effect lasts for 3-4 months. Deep brain stimulation (DBS) is a surgical procedure offered to selected patients with generalized dystonia.
What is ataxia?
Ataxias are a group of disorder that affects balance, coordination, and speech. Common symptoms include loss of balance, falls, change in speech, tremor, and difficulty with fine motor activities. Balance can be affected by diseases of the brain (cerebellum), vision, inner ear, and peripheral nerves.
What are the causes for ataxia?
Common causes for ataxia are:
What are the treatments options available for ataxia?
Treatment of ataxia depends upon the cause. In few cases of ataxia it is possible to improve the symptoms by treating the underlying cause like in episodic ataxia and ataxia with Vit E deficiency. There are a few oral medications that can be tried for improving the symptoms in cases where a treatable cause cannot be identified.
Non-pharmacological therapies like balance rehabilitation, biofeedback techniques, and non-invasive brain stimulation (transcranial direct current stimulation) are useful in improving the symptoms of ataxia.
What is essential tremor?
Essential tremor is the most common movement disorder. It usually presents with shaking of hands. Other body parts like head, vocal cords, and legs can be affected. The tremors are more prominent while doing activities like eating, drinking and writing. Many patients with Essential tremor have a relative with the same disorder. Age of onset has a bimodal distribution with a peak in the 2nd-3rd decade and the second peak in the 7th-8th decade. Sometimes it can be confused with Parkinson's disease, but they are different conditions with different treatment.
What treatment options are available for essential tremor?
Oral medications are the first line therapy for essential tremor. Commonly used medications are beta-blockers like propranolol and anti-epileptic medications like topiramate, gabapentin and primidone. For patients who do not respond to oral medications or for those who can’t tolerate the oral medications, botulinum toxin injections can be used. Botulinum toxin is injected with a fine needle into the muscles showing tremor activity.
Deep brain stimulation (DBS) is a surgical procedure for treating essential tremor. Deep brain stimulation surgery is done in two stages. In the first stage, the electrodes are inserted in the brain under stereotactic guidance. During this part of the surgery, the patient is awake. In the second stage, the impulse generator (IPG) or the pacemaker is placed under the skin of the chest. The brain electrodes are then connected to the pacemaker with connecting wires tunneled beneath the skin. The second stage of surgery is done under general anesthesia. The programming of the pacemaker is done aYer the surgery.
Which conditions can be treated with botulinum toxin injections?
How does botulinum toxin work?
Botulinum toxin injections can help an overactive muscle relax by blocking a neurotransmitter (acetylcholine) that is involved in muscle contraction. The effect of botulinum toxin starts in 4-5 days and peaks at 3-4 weeks. The effect is temporary and wears off in about 3-4 months.
How is botulinum toxin administered?
Botulinum toxin is injected into a muscle using a thin needle. Electromyography (EMG) is sometimes used to localize a muscle. Patient discomfort is usually mild in most cases. This is done as an outpatient procedure.
Can Botulinum toxin treat tremor?
Botulinum toxin is used in the treatment of tremors affecting the jaw, head, arms, and legs. It can be used in the treatment of Essential tremor, Parkinson's disease tremor, and dystonic tremor. The effect of injections last for 3-4 months. This therapy is usually offered to patients with tremor refractory to oral medications or when oral medications are not tolerated due to undesirable side effects.
