For an improved quality of life
RUPA CHINAI
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Symptoms of Parkinson's Disease can be alleviated through surgery but the option may not be open to all patients.
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UMESH BAKSHI was only 40 when diagnosed with Parkinson's Disease, a brain disorder. British physician James Parkinson first described the symptoms of Parkinson's Disease in 1817.
Umesh initially experienced tremors in one leg. Over the course of three years, they became more pronounced till the jerky shaking engulfed his limbs and movement could not be coordinated. His walk was reduced to a shuffle and his speech became muffled. He was overcome by stiffness and rigidity of the limbs and trunk. He could not function without assistance.
Effects of medication
Umesh was prescribed a drug, generically known as levodopa. It was described as a "miracle drug" when introduced in the late 1960s. It claimed to offer Umesh a renewed quality of life by replenishing the brain's low production of dopamine — a chemical that helps brain cells control muscle activity. Although the drug cannot curb progression of the disease, it can stimulate temporary normalcy of limb movement for long stretches in a day.
As in the case of Umesh, most other patients found that their "honeymoon" with the drug lasted three to five years. Thereafter, the side effects become pronounced. It was found that, despite medication, the stretches of normalcy, described as "on effect", became shorter. Umesh found he needed ever increasing dosages to retain control of his limbs and reduce the "off effect", when he experienced an escalated manifestation of symptoms. This latter phase sees many patients suffering from hallucinations because of the drug.
At this stage of "dyskinesia" or excessive involuntary movement, caused by the lowered impact of the drug, patients experience loss of quality life and should consider the surgical option, says Paresh Doshi, functional neurosurgeon at Jaslok Hospital. Apart from Jaslok, other speciality centres for such surgery include All India Institute of Medical Sciences, Delhi and Sri Chitra Tirunal Institute, Thiruvananthapuram.
All patients may not be suitable candidates for surgery. At Jaslok, a team of "movement disorder" specialists makes this decision, said Dr. Doshi. Suitable patients are those who still respond to levodopa, hence surgery should not be so delayed that the situation is irreversible. Surgery, in combination with the drug, stretches the "on effect" to 85 per cent of the day when a person is in control of his movement. "The balance 15 per cent of the day will be `bad' but not as `bad' as in the past," Dr. Doshi explained.
Two options
Though surgery does not offer a cure and deterioration continues, it is found to support better control of movement — an 80 per cent improvement in quality of life and 50 per cent reduction in medication — Dr. Doshi clarified. Of the 75 patients operated since 1997 at Jaslok, 35 patients have now been followed for two years. Of these four are completely off medicines. These findings were published in 2004 as an abstract in Movement Disorders, an international journal of the Movement Disorders Society and in Neurology India (January 2003).
Surgery looks at two options. "Deep brain stimulation" sees the insertion of fine electrodes, connected to a pace maker, go deep into the brain through a small hole at the top of the head. The patient is under local anaesthesia and conscious right through the five hours procedure. The electrodes target the "sub thalamic nucleus", a group of cells that stimulate the symptoms of Parkinson's Disease and are reversibly inhibited by this method. The cost of surgery is Rs.1, 25,000 at Jaslok while the electrode costs $75,000 (Rs.3,75,000).
The second method of intervention is leasioning or burning of the sub thalamic nucleus through a heated electrode tip. This is an irreversible destruction of the cells with the use of an electrical current. This procedure costs Rs.75,000 at Jaslok.
Renewed flexibility
With both procedures the patient experiences alleviation of the symptoms of Parkinson's Disease. An instantaneous impact is seen on the operation table itself as patients experience a renewed flexibility of limbs and the loss of their rigidity and tremors.
The Lancet published the international evidence of improved performance of patients undergoing such procedures in January 1995, when it reported the seven-year follow-up study by Professor Alim-Louis Benabid of the Grenoble Institute in France.
Umesh sought the surgical option of deep brain stimulation when he was 50. He says the operation gave him 70 per cent improvement in quality of life, which has been maintained through yoga, nutrition and rest. He was lucky to have a supportive family, but, in the absence of insurance, more than Rs. 4,00,000 came out of their own pocket despite hospital concessions. Even then, he feels it was worth it because today he is independent enough to clamber aboard a bus and make his way around the city.
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