ISSN: 1391 - 0531
Sunday, October 15, 2006
Vol. 41 - No 20


By Smriti Daniel

Parkinson's disease does not have a cure. In the past, for those who contracted it, the years ahead seemed to hold only steady decline. More recently, however, a proactive, life-affirming approach has been adopted at the National Hospital's Movement Disorders Clinic. A team consisting of neurologists, neurosurgeons and therapists are battling the disease using cutting edge technology and simple techniques -so that victims of the condition may live a near normal life.

Parkinson's disease is one of the most common manifestations of a movement disorder, says Dr. Ranjini Gamage, Consultant Neurologist at the National Hospital. "A good 90 to 95% of the (movement disorder) patients belong to Parkinson's disease," she adds.

Electrodes inserted into the patient's brain allow the surgeon to monitor the brain and to locate the subthalamic nucleus

Dr. Gamage who sees her patients on Mondays at the Movement Disorders Clinic explains that it is the only one of its kind in Sri Lanka. Having opened two years ago the clinic treats about 1000 patients with Parkinson 's disease.

A monitor showing the pattern of electrical impulses in the brain as recorded by the electrodes.

Many who come there are unaware they have the disease. Dismissing it as the natural effect of aging, some leave it until the illness is in its last stages. At the onset of the disease, a patient will probably complain of tremors, rigidity and slowness in movement, (known as hypokinesia) warns Dr. Gamage. "When you have all three, then patients have difficulties in their day-to-day activities, like standing straight, turning, feeding or writing," she says. Poor balance and postural instability are common as is the difficulty in walking leading to a pattern of walking - known as the Parkinsonian gait.

Post-operative scan showing the correct placement of electrodes on both sides of the brain.

While it is most common amongst the elderly, the occasional young person has been known to fall victim to the disease. Genetic disorders, certain medications (such as those prescribed for schizophrenia), vascular disorders and other environmental factors have been known to trigger Parkinson's like symptoms. The actual disease is marked by the progressive deterioration of the nerve cells in the part of the brain known as the substantia nigra. Dopamine, which is one of the substances used by cells to transmit impulses, is normally produced in this area.

Naturally, the deterioration in the substantia nigra reduces the amount of dopamine being produced, which in turn leads to an imbalance between dopamine and other neurotransmitters such as acetylcholine. "As a net result of the chemical imbalance that occurs between the two neurotransmitters certain areas of the brain become hypo-active while others become hyper-active," reveals Dr. Gamage.

"Therefore the treatment of Parkinson's is directed towards increasing the dopamine levels in the brain or decreasing the acetylecholine levels," says Dr. Gamage adding that "this is done by giving various drugs." The aim is to balance the chemicals in the system, and the mainstay of treatment remains medical. "The clinic also screens Parkinson's patients for advanced management," says Dr. Gamage, explaining that this might involve the use of new drugs or advanced surgical techniques.

It must be understood that there is currently no cure for Parkinson's. The disease is both chronic and progressive, meaning that symptoms will continue and worsen over time. All treatment is geared simply towards retaining normal function for as long as possible.

Dr. Ranjini Gamage Saumya Ratnayake Sampath Abeywardana Nandana Welage Dr. Sunil Perera
The dedicated team

Surgery, in particular, is a possibility when the medication has ceased to have any effect. Dr. Gamage explains that this occurs over time as patients develop a tolerance - requiring more and more medication to control their symptoms. This stage is reached in 5 to 10 years time. "We do this (surgery) for patients who don't have any other hope," says Dr. Gamage, "because at this point the drugs have failed."

Dr. Sunil Perera, a neurosurgeon at the National Hospital says that there are essentially two options when it comes to surgery -Pallidotomy and Deep Brain Stimulation or DBS. Pallidotomy has been around for some time now, says Dr. Perera, explaining that the operation involves the precise destruction of a small area (the globus pallidus) in the deep part of the brain that causes symptoms. He warns that this is a one-time only procedure, as it destroys brain tissue irrevocably. Also, it can only be done on one side of the brain. In the end, it only offers relief from symptoms for 2 to 3 years, after which problems will return. Not surprisingly, Dr. Perera thinks that Pallidotomies will soon be a thing of the past.

Deep Brain Stimulation on the other hand is effective for far longer - even up to 12 years. Dr. Perera who was the first and only surgeon in the country to do so, conducted a DBS operation last year. Since then five such procedures have been undertaken with successful results. "This operation is unique to the country," he says, explaining that he travelled to several other countries to learn how it was done.

Experienced neurosurgeons from India were also brought down to work with the team in the initial stages. The operation is complicated and is moreover a team effort. "The neurosurgeon must work with a neurologist for it to be successful," says Dr. Perera, explaining that the patient remains conscious throughout the surgery, enabling the neurologist to determine whether there is a significant improvement or not.

The results are almost magical and can be seen at once, he says. In DBS, electrodes are placed in a small part of the brain called the subthalamic nucleus or globus pallidus. The electrodes are then connected by wires to a type of pacemaker device, called an impulse generator or IPG, which is implanted under the skin on the chest, below the collarbone. Once activated, the device sends continuous electrical pulses to the targets, blocking the impulses that cause tremors. It does not destroy brain tissue and has fewer risks than older, more destructive surgical methods, he explains.

However, it is expensive. The electrodes themselves can cost over a million rupees, which is to be expected as it is the most advanced surgery for Parkinson's in the world, says Dr. Gamage. The National Hospital is not equipped to handle a DBS operation, so they have been conducted in private hospitals such as the New Asiri Surgical Hospital.

In the meantime, the Movement Disorders Clinic continues to dispense medicine and advice every Monday to patients who come from all over the island. Part of the programme is several therapy sessions which are geared to help Parkinson's patients control their symptoms and make daily life easier.

Parkinson's patients are commonly affected with speech related difficulties, says speech and language therapist Saumya Ratnayake. Difficulty in producing sounds results in speech changes; words become slurred and the tone becomes monotonous. A loss of facial expression is characteristic of sufferers of Parkinson's disease and is known as "masking”. "They also have difficulty in swallowing," says Ms. Ratnayake, adding that memory problems compound the situation as patients are often literally at a loss for words.

To cope with this, she recommends patients do simple things, such as take deep breaths or change posture to make it easier to speak louder. Similar methods are employed by Sampath Abeyawardana who works as a physiotherapist at the clinic. He reveals that standing up, walking and even turning can become ordeals for Parkinson's patients. For instance, a patient might get frozen in one place and find himself unable to take a simple step forward. The solution is to take an extra large step, almost as if one were stepping over an obstacle. Other simple exercises increase muscle strength and flexibility and correspondingly decrease the chance of nasty falls.

Such techniques are designed to keep the patient mobile and independent for as long as possible, reveals occupational therapist Nandana Welage. During the half - hour sessions that the team conducts, patients and caregivers learn more about coping with the practical day to day aspects of the disease. It is easy for them to become depressed, says Mr. Welage, considering that the degenerative aspect of the disease seems to leave little room for hope.

However, moulding the environment to suit the patient helps considerably. Modifications to toilets, utensils and even pens can keep a patient self-reliant for much longer periods of time. For instance, cups can be made heavier and with larger handles, enabling someone with severe tremors to pick it up with ease. Such options provide a stronger sense of control when living with Parkinson's disease.

In the end, it is the emotions that need the most strengthening. Both patients and their families can end up battered by this ravaging disease. Depression, fear and anxiety, compounded by memory difficulties and in extreme cases dementia make for tough going….and it is perhaps in this part of the struggle that the Movement Disorders Clinic and its staff will make their presence most felt.


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Copyright 2006 Wijeya Newspapers Ltd.Colombo. Sri Lanka.