Dr. Siddharth Kharkar

DBS is the short form of “Deep Brain Stimulation”. DBS is one type of Parkinson’s Surgery. DBS works by passing a small current into the brain. This current is passed into only to a small part of the brain. The doctor selects one out of two brain parts (either the GPi or the STN). DBS works by changing the electrical currents in these areas. At present, we cannot mathematically calculate these changes. But, empirically (as-seen-with-our-own-eyes) – DBS improves Parkinson’s symptoms. Let us learn more about these topics: Table Of Contents What is Deep Brain Stimulation for Parkinson’s disease? How does Deep Brain Stimulation (DBS) work? What is the best theory for why DBS works? If the mechanism of DBS is not known, why should I consider it!? So, Should I get DBS surgery for Parkinson’s? Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar What is Deep Brain Stimulation for Parkinson’s disease? DBS is electrical stimulation of the brain by using a small machine. DBS can stimulate many brain areas. DBS is actually approved for many diseases. It is not just a “Parkinson’s surgery”. It can be used for epilepsy and other movement disorders as well. The basic setup is the same. The DBS battery is inserted below the chest skin. Two small wires from the battery go up to the head. The wires go through the skull. They are inserted into the desired area of the brain. A DBS system – The battery/pacemaker is placed below the skin in the chest. The wire going inside the brain is called an “electrode” For Parkinson’s disease: This target area of the brain is usually the “Subthalamic Nucleus (STN). In some patients, another area is chosen as the target. This other area is the Globus Pallidus interna (GPi). How is the target chosen? Read this article [Click here] DBS can dramatically improve Parkinson’s symptoms. There are many before-after videos available on the internet. For example, here is a video posted on youtube by the Neuromedical Center in USA. https://www.youtube.com/watch?v=wZZ4Vf3HinA How does Deep Brain Stimulation (DBS) work? No one completely understands how Deep Brain Stimulation (DBS) works. Doctors used to cut small parts of the brain to reduce Parkinson’s symptoms. This surgery is called a “tomy”, meaning “to cut”. For example, Thalamo-tomy, Pallido-tomy. A small electrical current is used to stop small bleeds during surgery. This is called “electrical cautery”. While doing this current, they noticed something odd. When they passed a current into certain brain parts, the Parkinson’s tremor disappeared! Would it be possible to continue the stimulation indefinitely? This question led to the design of the DBS electrical system around 2000. DBS was approved for widespread use in 2002. Reference: 1. “History & Future of Deep Brain Stimulation” Schwalb 2008: Fascinating article on how Deep Brain Stimulation for Parkinson’s was discovered (lots of pictures, free to read) DBS was invented by very, very smart and dedicated people. Ah Yes! So, it is one of those things where we don’t know how it works. But years of experience have shown us that it does. Like, complimenting your spouse… Many researchers believe DBS stimulates the target. Some believe DBS actually causes the target to stop working. The reality is complex, and as yet, out of reach. Each of these targets (for example the STN) contain many millions of little cells arranged in very intricate circuits. The circuits in each part of the brain are very complex. We don’t understand how they are affected by DBS. Probably, the DBS current stimulates some of these cells, while other cells stop working. Some circuits go into overdrive, while others shut down. This varying effect also varies according to the current characteristics, especially frequency. The net effect is, at present, impossible to calculate mathematically. Empirically though (with our own eyes), we see that when the stimulation is given at a high frequency – Parkinson’s symptoms decrease markedly. What is the best theory for why DBS works? Before starting, let me note that reading this part is not critical. It is very technical. As noted before, we don’t really understand how DBS works. But there are numerous complicated theories. Let us look at the simplest & most promising one, in relation to DBS of the most common target. The most common target is the Subthalamic Nucleus (STN). First, let’s see what causes Parkinson’s disease. Usually, Dopamine keeps the STN in check. When Dopamine decreases, the STN runs amok (becomes hyperactive). This causes problems with movement – especially slowness. We recognize these as “Parkinson’s disease”. STN: Without dopamine keep it under control, that pink little thing runs amok. What happens when you put a wire into the STN and pass a high-frequency current through it? If you pass high-frequency electrical current into the STN, it cannot keep doing what it is doing. The fast electrical buzz causes it to go into “overload”. The part being stimulated (e.g. the STN) stops working. Gatekeepers in the brain (e.g. a part called the Thalamus) prevent the high-frequency electrical current from spreading to the rest of the brain. Thus, the rest of the brain keeps functioning well. The other theories are a variation on this theme. Click here for a short table about these proposed mechanisms. Some DBS effects cannot be explained by this theory. Many symptoms including tremor and slowness decrease with high-frequency stimulation. But some symptoms like Freezing decrease with low-frequency electrical stimulation. Why? We don’t know. Therefore, there is a lot more to discover. If the mechanism of DBS is not known, why should I consider it!? Because it works. Because it is quite safe. There are many things for which we don’t understand the exact reason. For example, we are still finding out more about the myriad benefits of exercise. For example – How does exercise improve Mood? We don’t understand that too well. But it is easy to grasp that exercise is good for you. This what-you-see-is-true evidence is called “Empiric Evidence”. Exercise, even in short bursts, has

Normal functioning of the brain Our brain is divided up into many different parts. These different brain parts have varied functions. For example: The brain parts in the front do most of the thinking. The brain parts behind the ears store memories. The brain parts just above the ears help us to move our hands and legs. The brain parts at the very back help us to see things. And so on… These parts communicate with each other using minute electrical currents. This electricity is strictly regulated. Our hand only moves when we want it to move. We remember something only when it is relevant, or we try to remember it. We see something only when our eyes send a electrical current to the brain parts in the back. Thus, usually these things happen for a reason. Patients with seizures can get olfactory (smell) hallucinations. What causes a seizure? A seizure is caused by a sudden uncontrolled surge of electricity in the brain. If wires connecting two brain parts are not properly connected, electricity in that area can become un-regulated. This may occasionally cause cause a sudden surges of electricity. Frequently, this electrical surge is suppressed by our brain. But sometimes, this local electrical surge becomes uncontrollable. It may spread to other areas of the brain, like an electrical storm. A seizure is like an electrical storm inside our head. When the electrical storm involves different brain parts, you experience symptoms related to that brain part. For example: If the electrical surge involves the brain part behind the ears, you may get a sudden surge of memories. If it involves the brain part above the ears, your hand may cramp up or start shaking If it involves the back of the brain, you may see things and so on… If the electrical storm spreads over the entire brain, your entire body shakes violently and you lose consciousness. At this stage, the electrical storm is called a “Generalized convulsion” or “Generalized Tonic-Clonic seizure”. When the electrical storm spreads over the entire brain, the entire body may start shaking. What happens during a seizure? The symptoms during a seizure depend on which brain part is involved. A few examples are given above. Our brain produces ALL our experiences. Therefore, you can get any kind of experience during a seizure. But some parts of the brain have seizures more frequently than others. Therefore, some symptoms are more common during seizures. Each part of our brain has a specific, unique function. Common symptoms which happen during a seizure A bad odor. It may be disgusting (for example of garbage) or sickeningly sweet. A bad taste. A metallic taste, or a bitter taste is very common. Some patients report tasting blood. Extreme fear or anxiety. A Deja-Vu feeling: An intense feeling of “This has happened to me before”. Difficulty in talking or understanding other people. Visual hallucinations: Seeing things that are not really in front of you. Tingling or numbness in the face, arm or legs Cramping or shaking of a hand, leg or the entire body. Involuntarily passing urine or stool. Blanking out and staring off into space As noted, any experience can happen with a seizure. Here are some experiences/symptoms that occur with seizures, but less commonly. Less common symptoms during a seizure Extreme anger Extreme happiness or sadness A feeling of floating away from your body and looking towards it from above (Autoscopy) A feeling of being one with nature, or with the surroundings (Depersonalization) Sudden nausea or urge to vomit Sudden urge to urinate Dizziness Hearing strange sounds such as ringing bells or people talking Repetitive eye blinking In addition to these symptoms that happen during a seizure, there may be some complications due to a seizure: You may bite your tongue. In generalized convulsions (see above), some people may dislocate their shoulder. In generalized convulsions,  some people may get other injuries – such as bruises or head injuries. After a seizure, you may have trouble speaking, using a body part or thinking for some time. You may bite your tongue during a seizure. Warning signs of a seizure (Aura) An Aura is the beginning of a seizure. Many patients interpret this as a warning sign of a seizure. Auras are usually seen with Focal seizures (see below) When the seizure is small, it produces minimal symptoms. It may produce a bad smell, or some memories, or some problems with eyesight. Later, when the seizure spreads over the entire brain, the patient gets a big seizure. For example, a patient may smell something bad, and then get a large seizure with violent shaking of the entire body. An aura is a small seizure that produces subtle symptoms. When this keeps happening repeatedly the patient recognizes that the bad smell is a warning. This warning is called an “Aura”. Auras in Primary Generalized Seizures: Primary generalized seizures (see below) usually don’t produce an aura. The occur without warning. This is because they occur over the entire brain at once. However, newer research has show that even in these kind of seizures, some patients get a warning. This warning is felt before the big seizure. How this happens is not known. Auras also occur in primary generalized seizures, but they may be difficut to describe. Types of seizures There are two main types of seizures. Focal seizures and Primary Generalized seizures. Focal seizures: Partial seizures start in one part of the brain’s surface. Sometimes, a focal seizure may not spread and produce limited symptoms. At other times,  it may then spread to the entire brain and produce dramatic symptoms. Generalized seizures & Focal seizuresPrimary Generalized seizures: Generalized seizures start all over the brain, at once. It is unclear where they start from. Many researchers believe that they start deep within the brain. These deep-seated brain parts are called the “Basal-Ganglia” & “Thalamus”. These seizures had different names earlier. For example, focal seizures used to be called “Partial seizures”. Even more confusingly, each one of

The meaning of the medical term Bradykinesia is “slowness of movement”. He/she has Bradykinesia means that the person walks, talks, eats and even blinks slowly (see video below). If a person does not move at all, it is called “Akinesia”. The most common cause of Bradykinesia (meaning slowness of movement) & Akinesia is Parkinson’s disease. Doctors test for bradykinesia by asking the patient to do various tasks. These tests include tapping fingers rapidly. The treatment for bradykinesia depends on the cause. A medication called levodopa can reduce bradykinesia in Parkinson’s disease. Hello! I am Dr Siddharth Kharkar, a Neurologist in Thane, India and a Neurologist in Mumbai, India. I provide Parkinson’s treatment in India and am an Epilepsy specialist in India. I provide Epilepsy surgery in India at Mumbai & Parkinson’s surgery in India. Let us know more: Table Of Contents Bradykinesia Meaning & difference between bradykinesia, Hypokinesia & Akinesia What does bradykinesia feel like? How do doctors test for bradykinesia? What are the 8 causes of bradykinesia? Can Bradykinesia be reversed? In summary: Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar Bradykinesia Meaning & difference between bradykinesia, Hypokinesia & Akinesia These words are from the Greek language. Bradykinesia: Brady means slow. Kinesia means movement. So Bradykinesia means “slow movements”. Here is a video of  a bradykinetic patient, being examined by Dr. Niall Turbidy from the University of Dublin. Most importantly, notice how the lady’s is walking slower than usual. This is called Bradykinesia. https://www.youtube.com/watch?v=kXMydlXQYpY&t=16sHypokinesia: Hypo means little or reduced. When a patient does not move much, he/she is said to have hypokinesia. Akinesia: A means absent. Akinesia means loss of some or all movements. For example, loss of blinking or normal arm swinging while walking. Bradykinesia, Hypokinesia and Akinesia have slightly different meanings. But since they are similar, many doctors use only one word in their note. The most popular word is “Bradykinesia”. So when doctors write the word Bradykinesia (meaning simply “slowness of movement”), they indicate that the patient has all 3 symptoms described above. Some doctors may prefer to write “Akinesia” or “Akinetic syndrome” instead. Reference / Extra reading: 1. Marsden’s textbook of Movement disordersThis is the “bible” of movement disorder specialists. Although possibly too complex for individual patients, Chapter 3 and Section 3 in the book beautifully describe the terms discussed here. 2. The terminology of Akinesia, Bradykinesia & Hypokinesia – Schidler 2017 This paper describes how the meaning and usage of these terms has evolved. A fascinating read, but very detailed. Bradykinesia versus Dyskinesia Even though they sound similar, bradykinesia and dyskinesia have very different meanings. Dys means “bad”. Dyskinesia means excessive “bad” movements. Usually, these bad movements are jerky dance-like movements of the limbs. Treatment with certain medications like levodopa can cause Dyskinesias of the limbs. Some psychiatric medications can cause excessive facial movements, called “Tardive dyskinesia”. What does bradykinesia feel like? You may have the following symptoms of Bradykinesia. You may yourself notice these Bradykinesia symptoms. Sometimes, it is your friends who might bring your slowness of movement to your attention. In the morning, when you are trying to stand up from the bed and walk, your feel might feel stuck to the ground. It may take longer to take a bath and get dressed. Doing fine tasks like buttoning of shirts and writing may be difficult. Doing any movement may need you to make an extra mental effort. You may get left behind when walking in a group. Your spouse may complain of you taking too long to get ready. Patients with Parkinson’s disease can get “left behind” when walking in a group, because they walk slowly. It is easy to attribute bradykinesia to ageing. This is a mistake. Early evaluation by a doctor is critical. A doctor can confirm bradykinesia, and treat it in time. How do doctors test for bradykinesia? Tests for bradykinesia do not need special instruments. The doctor will ask you to perform certain tasks. Some of these are: Some doctors may prefer to write “Akinesia” or “Akinetic syndrome” instead. Tests for Bradykinesia Tapping your fingers together as fast as you can Opening and closing your fist rapidly Turning your palm up and down – like flipping a pancake – as fast as you can Tapping your toes or heel on the floor – as fast as you can During this time, the doctor notices: How long it takes for you get started How fast you are able to do the movement Whether the movements become smaller after a few seconds…. and so on…. Here is an excellent video of Dr. Kathleen Poston from Stanford University demonstrating the tests done for bradykinesia. https://www.youtube.com/watch?v=cxHpFWKIfGw&t=100s If you take a long time to start moving, the doctor may suspect Akinesia. If you have slow movements, the doctor may suspect bradykinesia…. As noted before, your doctor may write a single phrase (for example “akinetic syndrome”) to describe all these symptoms. Reference / Extra reading: 1. Neupsykey – Approach to the hypokinetic patient.A detailed description of what doctors check in a hypokinetic/bradykinetic patient. I think, now we know the answer to the question: What is Bradykinesia? Let us look to an even more important question: What causes Bradykinesia? What are the 8 causes of bradykinesia? Parkinson’s disease is the most common cause of Bradykinesia. Bradykinesia meaning simply, slowness of movement, may also be due to other causes. Some patients who walk slowly may not have “true”-bradykinesia at all! They may be walking slowly because they are afraid of falling down. This “cautious gait” is due to a problem in the balance system of the body. Thus, it is very important for the doctor to confirm that you have “true”-bradykinesia. Even if you do have truly slow movements, you may not have Parkinson’s disease. There are 4 main features of Parkinson’s disease. Most patients with Parkinson’s disease will have two or more of these symptoms: 4 Cardinal signs of Parkinson’s disease Slowness (Bradykinesia, Hypokinesia or Akinesia) Uncontrolled shaking (tremor) Stiffness (rigidity) Unsteadiness Other than these 4 symptoms, patents with Parkinson’s disease have other symptoms too. There are many problems