Dr. Siddharth Kharkar

(Brand names in India: Syncapone, Entacom plus) How do Entacapone & Tolcapone act? Entcapone is a friend of levodopa. It prevents the breakdown of levodopa by inhibiting an enzyme called COMT. The name of the enzyme is not important, what is important is that entacapone protects levodopa. Therefore, it makes the levodopa stay longer in the blood. As a a result the effect of levodopa is increased, and more importantly – the effect of levodopa lasts for a longer time. Entacapone is a friend of Levodopa. It enables levodopa to work better and longer. Use/Advantages: It directly increases the effect of levodopa. In some patients, when Parkinson’s disease progresses, the effect of levodopa lasts for a shorter and shorter time. These patients may often say something like the following: Well, I agree that levodopa helps me. It perks me up, makes me want to walk, in fact, I can walk very, very well for the first 2 hours after taking levodopa. But, 2 hours later the effect goes away! And I am back to the stage where I was before taking levodopa. This roller-coaster ride continues throughout the day. – This is called “Predictable wearing OFF”. Entacapone is extremely helpful in this situation. Entacapone prevents levodopa from wearing-off early. Disadvantages: Rarely, it may cause mild liver side effects. This is not very common. The stronger brother – Tolcapone – is not available in India. Tolcapone is more effective than entacapone. But Tolcapone can result in serious liver injury, and therefore it’s use needs to be very closely monitored. Bottom-line: Who doesn’t need friends? Entacapone helps its buddy levodopa to keep acting longer. Doctors don’t use Entacapone much, because of the risk of liver injury. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Slowing progression (Click) Part 1: Exercise & Preventing Injuries Part 2: Medications Part 3: Traditional meds & Coffee Part 4: Stem Cell Therapy Important! Please note that the effect of these interventions is still under research. Do NOT take any medication without a prescription of a registered doctor. The medications we have for Parkinson’s disease are very effective in controlling the symptoms of Parkinson’s disease. But wouldn’t it be great to have some intervention that would slow the progression of Parkinson’s disease? Let me preface by saying that at the present time (as of November 2019), Stem Cells should NOT be used for the treatment of Parkinson’s disease, outside of carefully controlled research trials. They are not approved for this purpose yet, and the long term effects of such treatment are not known. Stem cells have fantastic potential. Neurodegenerative diseases like Parkinson’s disease, which are caused by loss of cells, may benefit the most with Parkinson’s Slow Progression – Stem Cell Therapy for Parkinson’s Disease. It is something that each patient with Parkinson’s disease can look at with hope. What are stem cells? Stem cells are special cells that can develop into many different cell types. Also, a single stem cell has the potential to divide many times and produce thousands and even millions of cells. A stem cell has the ability to produce many different kinds of cells. There lies the potential! Parkinson’s disease is caused by the gradual destruction of Dopamine-producing cells in the brain. If you had a cell that could form many millions of Dopamine-producing cells, perhaps you could use it to replace these dying cells! There are many technical difficulties involved, however: How do you get the Stem cells? How do you transport the stem cells to the substantia nigra (the part of the brain where they should be)? If you are using Pluripotent cells, how do you tell these cells to start producing dopamine? How do you make sure there are no undesirable cells mixed with the Dopamine cells? How do you make sure the Stem cells survive for a long, long time inside the brain? The networks in the brain are very complex. Scientists are still deciding where in the brain the stem cells should be implanted, and how to deliver them there. These technical difficulties and the possible risks associated with this therapy (see below) are the main hurdles in offering Parkinson’s Slow Progression – Stem Cell Therapy for Parkinson’s Disease and many other diseases such as Alzheimer’s in which there is a loss of cells. Where are stem cells obtained from? Let us talk about two types of Stem Cells, most relevant to Parkinson’s disease research:1. From Embryos or Aborted Fetus(es): These are called embryonic (or fetal) stem cells. These are the powerful kind of stem cells and are capable of tremendous division and differentiation. These cells are also very difficult to handle.2. From Adults: These have been removed mostly from 3 places: Bone marrow, Fat & Blood (including umbilical cord blood). Stem cells are even present in blood, especially in umbilical cord blood. Image from – National Institutes of Health, USA. These cells have obvious advantages: The ethical concerns are minimal, the supply is plentiful, and they are much easier to handle than Embryonic/Fetal stem cells. Also, when the stem cells are obtained from the patient himself, the risk of the body rejecting these cells is virtually zero.A problem with these (adult stem) cells is that are only multipotent: that is they can only produce particular kinds of other cells similar to themselves. For example, a stem cell from the bone marrow can usually produce only bone.But gradually scientists are learning how to manipulate these cells & make these cells Pluripotent: i.e. capable of differentiating into many different kinds of cells. For example, in the future, we might be able to manipulate a blood cell into having hair (see figure)! OR we could make a stem cell obtained from the bone marrow start producing Dopamine! Scientists are learning how to manipulate Stem cells with limited abilities to produce all-powerful “pluripotent” stem cells. Undoubtedly, this is the future – in the future, all stem cells will probably be derived from the patient’s own body and manipulated to produce Dopamine. But this is a very, very difficult science. At present, this manipulation has not been perfected, and so far, only Embryonic/Fetal stem cells have been researched for Parkinson’s disease. Why do scientists feel stem cells may be useful for Parkinson’s disease treatment? The thinking is straightforward: – Parkinson’s disease is caused by the death of Dopamine-Producing cells in the Substatia Nigra. – This produces a deficiency of Dopamine in the brain. – If you implant Stem cells here, and they start producing Dopamine… – The problem would be solved! But there are many hurdles. The most significant difficulties have been pointed out above. Because of these hurdles, experiments in human beings with stem cells have had mixed results. Have stem cells been tried for Parkinson’s disease treatment in Humans? Surprisingly, YES! Many times!! And the first such time was 30 years ago (in 1987)!!! A group of Swedish researchers at Lund University were the first to implant stem cells in patients with Parkinson’s disease. Fetal stem cells were surgically placed into the brain (more precisely, the putamen) of two patients with Parkinson’s disease, by doing open brain surgery. Both patients had very mild, barely detectable, improvement in their movements after the procedure. Lund University Hospital in Sweden Although this first study was not a roaring success, it demonstrated that such a procedure was possible and relatively free of short-term side-effects. The same researchers improved their surgical procedure and tried using the new method on two other patients with Parkinson’s disease… Success! Both these patients showed significant improvement in movement, and one of the patients was even able to stop taking levodopa! This spectacularly improved patient showed minimal signs of Parkinson’s disease even 10 years after the procedure! Many researchers after this time reported seeing modest improvements in their patients

Slowing progression (Click) Part 1: Exercise & Preventing Injuries Part 2: Medications Part 3: Traditional meds & Coffee Part 4: Stem Cell Therapy Important! Please note that the effect of these interventions is still under research. Do NOT take any medication without a prescription of a registered doctor. The Best Pain Medication for Parkinson’s Disease we have are very effective in controlling the symptoms of Parkinson’s disease. But wouldn’t it be great to have some intervention that would slow the progression of Parkinson’s disease? 1. Rasagiline/Selegiline: These work by suppressing an enzyme called “MAO-B” in the brain. There are two studies that suggest that these Best Pain Medication for Parkinson’s Disease may be neuroprotective, at least in the very early stages of Parkinson’s disease. However, many neurologists think these studies are not conclusive. Many neurologists feel this effect is minimal. Also, these medications have many possible side-effects, some of which are bothersome. I call these medications “The brothers Karamazov” – Just like them, these have significant flaws and probably belong to another era. Therefore, at this time, they are not used very commonly. Sometimes they are used in patients with very early Parkinson’s disease. Relevant studies: The DATATOP study (1989) The ADAGIO study (2008) 2. Vitamin D: It is critical to make sure your vitamin D levels are normal in Parkinson’s disease. Our skin produces Vitamin D when it is exposed to sunlight. At a fundamental level, this is because normal Vitamin D levels are required for strong bones. Parkinson’s disease patients are likely to fall, and a fracture of the hip or the spine can be extremely disabling. Therefore, make sure your Vitamin D levels are normal. If you tend to fall often, you should also do a test to check the density of your bones, called DEXA. If the density of your bones is low, you may require Best Pain Medication for Parkinson’s Disease (in addition to Vitamin D) to make them dense again. But, guess what, Vitamin D may actually help relieve Parkinson’s disease as well! People with low levels of Vitamin D may be at a higher risk for Parkinson’s disease (Knekt 2010). It may decrease inflammation and may be neuroprotective in Parkinson’s disease (Calvello 2017) In patients with Parkinson’s disease, Vitamin D may prevent falls, especially in younger patients (Hiller 2018). It does this by improving the postural corrections that prevent falls. Vitamin D may help to prevent falls. In patients with Parkinson’s, Vitamin D may prevent thinking and memory problems (Peterson 2013). Although the evidence for this part is weak: Some studies indicate that low levels of vitamin D can be associated with worse motor function/movements as well (Soliman 2019) Most tantalizingly, preliminary research indicates that Vitamin D supplements may slow the progression of Parkinson’s disease!=This effect may be more prominent for some patients than others, based on genetics (Suzuki 2013). Unfortunately, Vitamin D does not seem to have received the attention it deserves when it comes to the treatment of Parkinson’s disease. Thankfully, as demonstrated by the studies mentioned above, this is rapidly changing. This requires thorough research. But will the money to conduct research on a low-cost treatment be made available? Time will tell. At this point, it is not possible to recommend Vitamin D supplementation if your levels are normal. What is very easy to recommend is that most patients with Parkinson’s disease should have their Vitamin D levels measured. If low, you should certainly try to bring them back to normal. This can be done by taking Vitamin D supplements, by eating foods rich in vitamin D or by increasing exposure to sunlight. Check your Vitamin D level. If it is low, you may need to take Vitamin D supplements. If you start taking Vitamin D supplements, you should recheck your Vitamin D levels after a few weeks to make sure they are normal/increasing. Relevant studies: Low vitamin D levels may place you at higher risk of Parkinson’s disease (Knekt 2010) Vitamin D may reduce inflammation and protect Dopamine-producing cells (Calvello 2017) Vitamin D may reduce falls (Hiller 2018) Vitamin D may help with balance – Study no.2 (Peterson 2013) Vitamin D may protect against thinking & memory problems associated with PD (Peterson 2013). Vitamin D may help both thinking and movement in Parkinsons disease (Soliman 2019) Vitamin D supplementation may slow progression of Parkinson’s disease (Suzuki 2013) 3. Vitamin E: Vitamin E is a strong antioxidant. Just like CoQ-10, the hope is that it will decrease damage to Dopamine-cells by harmful oxygen radicals. Almonds are a rich source of Vitamin E, an antioxidant. But the data seems to indicate otherwise. In fact, Vitamin E has been studied more thoroughly than CoQ-10. A large study published in the most respected journal in medicine (NEJM) strongly indicates that Vitamin E does not slow the progression of Parkinson’s disease (Shoulson 1993). However, in medical research, just one study, however significant and well designed is not considered to be the final word. Recently, there have been studies that indicate that Vitamin E may be slightly beneficial (Schirinzi 2019). However, these are smaller and less thorough than the NEJM study. Since the large NEJM study clearly concluded that Vitamin E is not beneficial, it is hardly prescribed by any doctor for Parkinson’s disease. Of note, Vitamin E is found in nuts including Almonds & Walnuts. Including a few nuts in your diet may not be a bad idea. If you have trouble swallowing, there is a risk of choking if you try to eat whole nuts. Instead, crush them into a powder or incorporate them in your smoothie. Relevant studies: Large multicentric study: Vitamin E is not helpful in Parkinson’s disease. Smaller questionnaire study published in a good journal (Zhang 2002) A very recent Italian study (Schirinzi 2019) 4. Statins (e.g. Atorvastatin): Statins are medications that are given to decrease “bad” cholesterol. Some examples of statins are Atorva-statin, Rosuva-statin, Simva-statin, Fluva-statin etc. Cholesterol lowering medications called Statins may affect the progression of Parkinson’s disease. Patients with Parkinson’s disease can

Slowing progression (Click)

Slowing progression (Click) Part 1: Exercise & Preventing Injuries Part 2: Medications Part 3: Traditional meds & Coffee Part 4: Stem Cell Therapy Important! Please note that the effect of these interventions is still under research. Do NOT take any medication without a prescription of a registered doctor. The medications we have for Parkinson’s disease are very effective in controlling the symptoms of Parkinson’s disease. But wouldn’t it be great to have some intervention that would slow the progression of Parkinson’s disease? The process of slowing down Parkinson’s disease by preventing further death of Dopamine-producing cells is called “Neuroprotection”. There are no approved medications for neuroprotection. However, there are many candidate drugs and many things you can try to slow down Parkinson’s disease. 1. Stay Active: Multiple studies have demonstrated that moderate levels of physical activity reduce the risk of Parkinson’s disease. The largest such study is a Swedish study that studied more than 43,000 patients over 12 years! (Yang 2015). Physical activity can improve many of the movement problems caused by Parkinson’s disease, especially balance (Dibble 2009). Also, physical activity can improve many other non-movement symptoms related to Parkinson’s disease, such as Thinking & Memory! (Tanaka 2008). Exercise slows down the progression of Parkinson’s disease. Although only a few studies have been listed here for reference, the evidence in support of exercise having a beneficial effect is extremely robust. Many prominent publications have highlighted physical activity as being an essential component of treatment in early Parkinson’s disease (Ahlskog 2011). Consider reading this article by Dr. Ahlskog in detail: Click here: Vigorous physical exercise may be neuroprotective (Alshkog 2011) Now that, hopefully, I have convinced you that physical exercise can benefit you tremendously, the next question is – what kind of exercise? I recommend that you exercise in two ways: Aerobic exercise – Walk for 30 minutes everyday. If possible, walk for 30-40 minutes every day and make it brisk. Vigorous exercise – or aerobic physical activity for 20-30 minutes that increases the heart rate and the need for oxygen – is thought to be more protective than light exercise.Therefore, brisk walking or a jog might be better than leisurely walking – Although both are infinitely more beneficial than doing nothing. Balance training – This is best learnt from a Physical therapist. Patients with Parkinson’s disease are at high risk for falls. They can fall because their feet get “stuck” to the ground. Also, Parkinson’s disease patients can fall because the normal postural reflexes that prevent falling are impaired. Balance training is a set of exercises that can help you maintain a better balance. Yoga can improve your balance & prevent falls. I will post a small video on balance training soon, but until that time you can meet your neighborhood physiotherapist to learn these exercises or follow the exercises posted on Mayo clinic’s website (click here) You may want to explore Yoga or Tai-Chi, many of the Yoga exercises emphasize balance. Remember: Only do the exercises you feel safe doing. Relevant studies: Physical exercise reduces risk of Parkinson’s disease (Yang 2015) Exercise improves balance in Parkinson’s disease patients (Dibble 2009). Exercise improves thinking in Parkinson’s disease patients (Tanaka 2008). Vigorous physical exercise may be neuroprotective (Alshkog 2011) Balance exercises : Mayo Clinic website. 2. Prevent Injuries: This one should be obvious. All measures should be taken to prevent Parkinson’s disease patients from falling down and breaking bones. Using a cane can prevent falls. When it is hot outside, you wear a cap. When the ground is rough, you wear shoes. So if you are unsteady, you should use a cane, preferably one with multiple legs (picture below). There is no shame in using a cane, it should be as natural as wearing a cap in the hot sun. Physical exercise & balance training (see above) can help a lot in preventing falls. Patients with Parkinson’s disease should have their Vitamin D levels monitored. If they are at high risk for falls, the doctor will do a Bone density or DEXA test – these topics are covered in another article. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Parkinson’s disease may cause difficulty swallowing (Dysphagia). Food may go into the lungs – this is called Aspiration. The decrease in swallowing saliva may also cause drooling. These problems are particularly severe in a disease called Progressive Supranuclear Palsy (PSP). Although PSP is slightly different than Parkinson’s disease, all the information given here is helpful if you have PSP. Parkinson’s Problems discussed in this article 1. Swallowing difficulty (Dysphagia)2. Aspiration3. Drooling It is absolutely critical to recognize these problems. Aspiration in particular can cause a life-threatening bad lung infection (Aspiration Pneumonia). Although drooling is not life thereatening, some Parkinson’s patients report that drooling is one of their most inconvenient problems. Table Of Contents Is difficulty swallowing (Dysphagia) common in Parkinson’s disease? How does Parkinson’s cause Aspiration? Why does Parkinson’s disease cause Drooling? In Parkinson’s disease, how is swallowing difficulty (Dysphagia) & Aspiration treated? How is drooling in Parkinson’s disease treated? Summary Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar Is difficulty swallowing (Dysphagia) common in Parkinson’s disease? Yes. Many patients with Parkinson’s disease may complain of difficulty swallowing. The medical term for swallowing difficulty is “Dysphagia”. In milder cases, you may just have the feeling that food gets “stuck” in your throat. Some patients may report that they have a feeling of their “throat closing” when they try to swallow. In more severe cases, you may tend to choke on your food if you try to swallow it too quickly. How does Parkinson’s cause Aspiration? Our mouth connects to two pipes: The food-pipe (oesophagus) and the windpipe (trachea). When we are swallowing, the muscles in our throat move rapidly. They close the wind-pipe and make the food-pipe bigger, so that food goes into the food pipe. Swallowing food requires many muscles to move in a coordinated manner. These movements become slow in Parkinson’s disease – as a result, food may go into the wind-pipe instead and end up in the Lungs. Food going into the lungs is called “Aspiration”. The paths taken by air and food are different. Ideally, absolutely no food should go into the windpipe (trachea).Why do Parkinson’s patients cough while swallowing food? When a small particle of food goes into the wind-pipe, we gag & start coughing vigorously to throw the particles out. These are called the “Gag” and “Cough” reflexes. Food can go into the wrong pipe often in Parkinson’s patients (see above). Therefore they frequently cough while swallowing food. Gagging and coughing are protective responses to prevent food from going into the wind-pipe. These are “good” reflexes, which protect our lungs. But the condition becomes even more problematic in advanced Parkinson’s disease. In advanced Parkinson’s disease, there may be no coughing even when particles are entering the windpipe. This is dangerous! Thus, particles of food may repeatedly go into the lungs of Parkinson’s patients without them noticing it. This is called “Silent Aspiration”. Why does Parkinson’s disease cause Drooling? Saliva is produced by small glands around our mouth, called “Salivary glands”. Our salivary glands continuously produce saliva, even when we are not eating. It is a common misconception that Parkinson’s patients have drooling because they are producing too much saliva. In fact, multiple studies have shown that most Parkinson’s patients produce less saliva.  Our salivary glands continuously produce saliva, even when we are not eating. Normally, we automatically swallow this saliva, through small gulps that we don’t even notice. But in Parkinson’s disease, there is a marked decrease in all automatic movements, including automatic swallowing. Therefore, saliva accumulates in the mouth. When the mouth is full, it drips out. We call this “Drooling”. Let’s talk about treatment… In Parkinson’s disease, how is swallowing difficulty (Dysphagia) & Aspiration treated? If your Parkinson’s is causing dysphagia, the following things are helpful in preventing aspiration. A. Exercises to improve swallowing difficulty (dysphagia): A speech-swallow therapist evaluates how your muscles move while swallowing. They can teach you important exercises to improve swallowing difficulty (dysphagia) and prevent Aspiration. Click here for an excellent video by a speech & swallow therapist: https://www.youtube.com/watch?v=YBTIUE1oMEA Speech therapists specially trained in Parkinson’s can teach you exercises such as Expiratory Muscle Strength Training (EMST) or Lee Silverman Speech Therapy (LSVT) or LOUD therapy. These specialized training sessions are tremendously helpful in improving voice. But these exercises also make swallowing easier. Lee Silverman Speech Therapy – also called LSVT or LOUD therapy – can help you speak much more loudly and also decrease the risk of aspiration.B. Adequate treatment with levodopa: As described earlier, swallowing is a series of movements. These movements are slow if you have Parkinson’s disease. In many (but not all) patients Levodopa can make these movements rapid again. If your movement problems are adequately treated, then the movements of your swallowing muscles may also improve dramatically. The same medications that help your body move faster also help your speech and swallowing muscles to move faster. It is not just levodopa – any medication that improves your movements may improve dysphagia caused by Parkinson’s disease Proper movements of the lips, jaw, tongue and throat reduce difficulty swallowing & reduce the risk of aspiration. C. Follow these tips to decrease swallowing difficulty (dysphagia) & Aspiration risk: Although these tips are not a substitute for evaluation and training by a speech-swallow therapist, I think following these instructions will be very helpful for you. Try to avoid very hard foods: These are difficult to chew and grind. If you try to swallow larger chunks of food, you may find it difficult. For example, try to avoid hard fruits like green apples. How do you get your fibre then? Well, you can still eat these foods by putting them through an electric mixer first to make a smoothie! (Click here). Avoid hard to chew food items, like hard fruits. Put small portions of food in your mouth: This makes it easier for you to chew and grind them up adequately. Chew food adequately: If needed, you can count the number of times that you chew your food – Chew each piece of food that you put in your mouth at least 20

Diseases which look like Parkinson’s disease, but have additional features are called “Parkinson’s Plus” syndromes. You can read more about Parkinson’s Plus Syndromes here. Multiple System atrophy (MSA) is a Parkinson’s Plus syndrome. In MSA, a component of our nervous system called the “Autonomic Nervous System” is also affected. This causes problems in body functions such as urination, maintaining blood pressure & cardiac rhythm. Table Of Contents What does the Autonomic Nervous System do? Types of MSA What Causes Multiple System Atrophy (MSA)? What is the Treatment of Multiple System Atrophy (MSA)? Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar What does the Autonomic Nervous System do? The Autonomic Nervous System helps us do things that we don’t think about consciously. Thus, it helps us in: Preventing a drop in blood pressure when we stand up from a chair or bed. The Autonomic Nervous System helps us maintain our Blood Pressure. Maintaining heart rhythm Having an erection Sweating Passing urine and stool The following symptoms can be seen because of this system dysfunction: A sudden drop in blood pressure can cause sudden dizziness, blurred vision, or loss of consciousness if you stand up abruptly. In MSA, patients may feel lightheaded, have blurred visions, or experience loss of consciousness if they stand up suddenly. Heart rhythm problems (these are uncommon). Impotence Reduced sweating Loss of bladder or bowel control or severe constipation Occasionally, trouble breathing or stridor may be seen. This is a significant problem. Stridor needs to be detected and treated immediately, especially if it occurs in sleep. Types of MSA There are 2 types of MSA. The two types are MSA-P and MSA-C. Both types have the autonomic symptoms described above. Here are the other differences between the two: MSA-P MSA-C More common Less common The P stands for Parkinsonism The C stands for Cerebellum. This brain part helps with balance and coordination. The 4 cardinal features of Parkinsonism are seen. These are – slowness, tremor, stiffness & instability. Out of these, slowness (also called bradykinesia) is most common in MSA-P These patients appear uncoordinated and unsteady. This is called ATAXIA. When they are walking, they are unsteady. Therefore they may sway from side-to-side. Onlookers may mistakenly think that they are drunk. Coordination problems may make it difficult to drink water, write or button shirts. Swallowing trouble is common. Swallowing trouble appears a bit later. In the early stages, MSA-P is often misdiagnosed as Parkinson’s disease. In the early stages, MSA-C patients may have a lot of investigations. This is because many diseases can cause similar symptoms. Click here to know more [External link: Practical Neurology – Khemani 2013]. Later, the autonomic symptoms (described above) become easily noticeable. So, in later stages the diagnosis of MSA becomes easier. What Causes Multiple System Atrophy (MSA)? MSA is caused by the accumulation of the same waste material as in Parkinson’s disease (synuclein). We don’t know why the accumulation of synuclein causes Parkinson’s disease in some and Multiple System Atrophy in others. What is the Treatment of Multiple System Atrophy (MSA)? Like all Parkinson’s Plus syndromes, the mainstay treatment is Levodopa. As noted before, the patient’s response to Levodopa is unpredictable and sometimes may not be excellent. Just like all Parkinson’s Plus syndromes, and Parkinson’s disease itself, many MSA symptoms are treatable. For example: Drop in blood pressure: Maintaining a proper fluid balance and taking medications such as pyridostigmine, fludrocortisone, midodrine may be helpful. Heart rhythm problems: We can control these with medications. In rare cases, a pacemaker may be needed. Very rarely, a pacemaker may be needed to make sure the heart beats regularly. Impotence: There are many effective medications for impotence. Bladder & bowel control: A mixture of behavioural changes, physical supports (diapers), and medications are usually helpful. Stridor: Patients with stridor may need further evaluation with a sleep study. If there are severe breathing problems while sleeping, then a machine called CPAP can be used to keep the airway open. For critical problems, putting a small tube in the windpipe (tracheostomy) may be considered. Click here to know more about Stridor in MSA [External Link: Cortelli 2019 in the journal Neurology]. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

A DAT scan or F-DOPA PET scan can be used for Parkinson’s diagnosis. But, Parkinson’s disease is primarily a clinical diagnosis. In other words, an evaluation of symptoms & examination by a doctor experienced in Parkinson’s disease is usually sufficient for diagnosis and treatment. Usually, your history a thorough examination is better than any testing for Parkinson’s disease. Let us know these symptoms & signs, and understand when a DAT scan or F-DOPA PET scan is needed. Table Of Contents Symptoms of Parkinson’s disease Other symptoms useful for Parkinson’s diagnosis Parkinson’s Misdiagnosis: Additional testing for Parkinson’s DAT Scan & F-DOPA PET scan Is a DAT scan or F-DOPA PET scan always needed? Bottom line: Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar Symptoms of Parkinson’s disease There are 4 main symptoms of Parkinson’s disease. At least one of these symptoms is present, and slowness is almost always present. Shaking = Tremor. This is the most easily recognized sign of Parkinson’s disease. Usually, the shaking only affects one hand or one leg in the early stages of the disease. The affected limb may shake both at rest, and while it is moving. Occasionally there might be shaking of the head. Shaking of hands is the most commonly recognized symptom of Parkinson’s disease. Slowness = Bradykinesia. The patient’s movements become slow. Sometimes only the movements of a particular hand/leg become slow. But usually, there is some slowness of movement of the entire body. This is best noticed while walking. Relatives will often say “Well, she was one of the fastest walkers in the family. Now she walks slowly so that she gets left behind when we are walking in a group. After every 10 feet or so we have to wait so that she can catch up with us. Perhaps it’s old age…?”. This isn’t old age – It is frequently Parkinson’s disease and the good news is that it is curable. Walking slowly could be a symptom of Parkinson’s disease. Stiffness = Rigidity. The patient’s body parts become stiff. This may be restricted to one hand so that, for the example, the patient has difficulty buttoning his shirt. A frequent complaint is that the patient is not able to reach the top of their head to comb or tie their hair. If a leg has become stiff, the patient may feel like he/she is dragging it while walking. Stiffness of the arms can make it difficult to comb hair, wear clothes or apply hair clips. Imbalance The person feels unsteady while walking, or even standing. Falling is uncommon in the early stages but may become more frequent later. Other symptoms useful for Parkinson’s diagnosis Now, in addition to these three main symptoms, the patient may also have other features which support the diagnosis of Parkinson’s disease. There are many problems with movement in Parkinson’s disease. Postural instability: Many doctors/guidelines consider this to be a core symptom of Parkinson’s disease. The patient is unstable while walking. Falls are not common in the early stages of Parkinson’s disease. But the patient may appear wobbly while taking turns, or if given a slight nudge in a crowded place. An expressionless face. Bending forwards while walking. Shuffling while walking. Freezing or getting stuck while walking. Decrease in dexterity, or fine motor skills such as drawing. Problems with thinking or memory (Dementia). Parkinson’s Misdiagnosis: These features are usually enough to make a clinical diagnosis of Parkinson’s disease. However, before the diagnosis can be made, two important things need to be ruled out: Parkinsons-Plus syndromes can cause symptoms just like Parkinson’s disease. Some medications can cause symptoms like Parkinson’s disease. These problems look like Parkinson’s disease, so they are called Parkinson’s disease Mimics. Parkinsons-Plus syndromes are diseases that appear to be just like Parkinson’s disease but are subtly different – e.g. in terms of eye movements, or early falls. These diseases have complicated names: Progressive Supranuclear Palsy (PSP), Multiple Systems Atrophy (MSA), Cortico-Basal Disease (CBD), etc…. These are further described here. Certain medications can cause symptoms, just like Parkinson’s disease! This is an absolutely essential and often overlooked part of treating the patient. Some patients don’t require more medications, they require less! Type of medication Examples 1. Many medications used for psychiatric problems such as schizophrenia Haloperidol, Risperdal, Olanzapine, Aripiprazole, Trifluoperazine, Amisulpuride and many more. Clozapine and low dose Quetiapine usually do not cause problems. 2. Some medications for mood and depression Fluphenazine, Tranycypormine, Lithium 3. Some anti-nausea / anti-vertigo medications Metoclopramide, Levosulpuride, High doses of domperidone about 30-40 mg/day, Flunarazine, rarely cinnarizine 4. Some heart and blood pressure medications Amiodarone, methly-dopa Besides these two mimics, there are 30+ mimics which may be mistaken for Parkinson’s disease. Additional testing for Parkinson’s Many doctors I know make a confirmatory diagnosis of Parkinson’s disease at this stage. If there are no red-flags, then a single office visit is usually enough to confirm the diagnosis. Some doctors, including myself, do request some simple investigations (see box below). These are done to rule out rare causes and Parkinson’s Mimics. Usually, these tests do not show an additional problem. Simple tests to detect Parkinson’s Mimics 1. MRI-Brain – with size measurements of brain parts called the midbrain and pons. I usually also request a unique picture called SWI, which shows iron inside the brain. 2. Blood tests: Complete blood count Liver function tests Renal function tests Thyroid hormone levels (TSH/T3/T4) Parathyroid hormone level Ceruloplasmin level & eye examination to look for a “ring of copper” Ferritin level HIV VDRL (Syphilis test) DAT Scan & F-DOPA PET scan Very rarely, the clinical diagnosis of a patient may be difficult. This can happen in two scenarios: Very early Parkinson’s disease with very subtle symptoms. When features of two different diseases are present – such as Parkinson’s disease and Essential tremor. The diagnosis of Parkinson’s disease is usually very straightforward. Sometimes, it can be difficult. In these cases, there are two options: Treat with levodopa: if the patient responds he/she probably has Parkinson’s disease. Do a DATscan or even better – a F-DOPA PET scan. The DAT scan & the F-DOPA PET

1. भारत में मिर्गी की सर्जरी क्यों की जाती है? कुछ लोगों को दौरे पड़ते हैं. दिमाग में बिजली अनियंत्रित होने के कारण ऐसा होता है. इस स्थिति को “मिर्गी” कहते हैं. दवाइयां लेने के बाद करीब 80% मरीज़ों में दौरे पड़ने बंद हो जाते हैं. लेकिन, 20% लोगों को 2 या अधिक दवाएं लेने के बाद भी दौरे पड़ते रहते हैं. इन मरीज़ों को “चिकित्सकीय रूप से प्रतिरोधी (रेझिस्टंट) मिर्गी” होती है. दौरे रोकने के लिए उन्हें भारत में मिर्गी की सर्जरी करने की ज़रूरत होती है. 2. क्या भारत में मिर्गी की सर्जरी की जाती है? हां. भारत में भी सभी प्रकार की मिर्गी की सर्जरी की जा सकती है. अमरिका में मिर्गी की सर्जरी बहुत ही सामान्य है. बड़े अस्पतालों में (जैसे कि, यूसीएसएफ, जहां मैंने पढ़ाई की है) हर हफ्ते करीब 2-3 मिर्गी की सर्जरी की जाती है. भारत में, मिर्गी की सर्जरी बहुत ही कम पैमाने पर की जाती है. इसका कारण है: –     मरीज़ों और डॉक्टरों को इसकी जानकारी नहीं है. –     मिर्गी की सर्जरी करने के लिए बहुत कम प्रशिक्षित डॉक्टर है. –     इसका खर्च –     जटिलताओं (कॉम्प्लीकेशन्स) का डर –     लेकिन सबसे ज़रूरी बात, बहुत से भारतीयों की यह दुखद, निराशाजनक और पूरी तरह से गलत धारणा है कि मिर्गी को नियंत्रित नहीं किया सकता. मिर्गी की सर्जरी कितने प्रकार से की जाती है? भारत में मिर्गी सर्जरी कई प्रकार से की जाती है. रिसेक्टिव (खराब हिस्सा निकालने की सर्जरी): यह सबसे बढ़िया प्रकार की मिर्गी की सर्जरी है. दिमाग में दौरा पैदा करनेवाले खराब हिस्से को निकाल दिया जाता है. इससे दौरे पड़ने बंद हो जाते है. वेगस नर्व स्टिम्युलेशन (VNS): कुछ मामलों में, रिसेक्टिव (निकालने की) सर्जरी मुश्किल होती है. अगर खराब हिस्सा बहुत बड़ा हो, या फिर दिमाग के महत्वपूर्ण हिस्सों के पास हो तो ऐसा हो सकता है. ऐसे मामलो में, वेगस नर्व स्टिम्युलेशन (VNS) सर्जरी की जाती है. इस सर्जरी के लिए ज़्यादा समय नहीं लगता है. छाती पर त्वचा के नीचे एक छोटी-सी बैटरी बिठा दी जाती है. गर्दन की त्वचा के नीचे की एक नस एक पतली तार से जोड़ दी जाती है. VNS उपकरण दिमाग में बिजली की छोटी धाराएं छोड़ता है जिससे दौरे रुक जाते हैं. दूसरी सर्जरियां: खास परिस्थितियों में दूसरी सर्जरियां की जाती है. उदाहरण के लिए, मरीज़ अगर VNS का खर्च नहीं उठा सकता तो VNS की बजाय कॉर्पस कॉलोस्टॉमी की जा सकती है. 3. भारत में मिर्गी की सर्जरी से पहले कौन-कौन–से टेस्ट करने की ज़रूरत होती है? किसी भी मिर्गी की सर्जरी से पहले किए जानेवाले सामान्य टेस्ट्स की सूची नीचे दी गई है. 1.   हमारे मरीज़ की मिर्गी किस प्रकार की है और उसे किस प्रकार के दौरे पड़ते हैं? 2.   कौन-से हिस्से की वजह से दौरे पड़ रहे हैं? 3.   क्या इसे सुरक्षित तरीके से निकाला जा सकता हैं? 4.   सफलता की संभावना कितनी है? 5.   क्या दूसरी सर्जरियां की जा सकती है?  हम इन टेस्ट्स से जुड़े सवालों के जवाब देने की कोशिश करते हैं: कुछ मरीज़ों के मामले में, इन सवालों के जवाब देने के लिए ज़्यादा टेस्ट्स करने की ज़रूरत होती है. ज़्यादातर मरीज़ों में, इन टेस्ट्स की ज़रूरत नहीं होती है. बहुत ही कम मामलो में, इन टेस्ट्स के बाद भी खराब हिस्सा कहां है यह पता नहीं चलता है. ऐसे समय, हमें सीधे दिमाग से ईईजी रिकॉर्ड़ करने की ज़रूरत होती है. दिमाग में पतले तार डालकर ऐसा किया जाता है. इस प्रक्रिया को स्टीरियो-ईईजी कहा जाता है. 4. वीड़ियो ईईजी मॉनिटरिंग (मिर्गी की मॉनिटरिंग) में कौन-सी बाते शामिल है? लगातार ईईजी मॉनिटरिंग करने के लिए मरीज़ को भर्ती किया जाता है. इस दौरान, हम दवाओं की मात्रा कम कर सकते हैं जिससे रोगी को दौरे पड़ने शुरू होते हैं. हम हर प्रकार में से करीब 2 दौरे रिकॉर्ड़ करने कि कोशिश करते हैं. उदाहरण के लिए, रोगी को एक दौरा पड़ता है जिससे वह गिर जाता है, और दूसरा दौरा पड़ता है जिससे वह होठों को चटकाता है, तो हम 2+2 = 4 दौरे रिकॉर्ड़ करते हैं. यदि आपको बार-बार दौरे पड़ते है, तो मिर्गी की मॉनिटरिंग में सिर्फ 1-2 दिन लग सकते हैं. दूसरे लोगों में, 7 या उससे ज़्यादा दिन लग सकते हैं. 5. भारत में मिर्गी की सर्जरी कितने हद तक सफल होती है? भारत में मिर्गी की सर्जरी की सफलता बहुत ही उच्च होती है, लेकिन 100% नहीं. सफलता दर मिर्गी के प्रकार और मिर्गी की सर्जरी के प्रकार पर निर्भर करता है.उदाहरण के लिए: ·       रिसेक्टिव सर्जरी की सफलता दर 80% से ज़्यादा हो सकती है. ·       दूसरे सर्जरियों की सफलता दर कम होती है, लेकिन सामान्यत: बहुत अच्छी होती है. ·       VNS के बाद, ज़्यादातर मरीज़ों के दौरों में 50% या उससे ज़्यादा की कमी आ जाती है. खासकर, ऐसे दौरे बड़े पैमाने पर कम हो जाते हैं, जिसमें मरीज़ गिर जाते हैं और खुद को चोट पहुंचाते हैं. सर्जरी से पहले किए जानेवाले टेस्ट्स करने के बाद सफलता की दर के बारे में आपके साथ बात की जाएगी. 6. क्या मिर्गी की सर्जरी के बाद मुझे दवाएं लेने की ज़रूरत नहीं पड़ेगी? मिर्गी की सर्जरी का लक्ष्य है दौरों को रोकना. भारत में मिर्गी की सर्जरी के बाद लगभग 50% मरीज़ अपनी दवाएं लेना बंद कर पाने में सक्षम होते हैं. लेकिन, दूसरे मरीजों को अपनी दवाएं लेते रहने की ज़रूरत होती है. कुछ मरीज़ अपनी दवाओं की मात्रा कम कर पाने में सक्षम हो पाते हैं. 7. संभावित जटिलताएं (कॉम्प्लीकेशन्स) कौन-सी हो सकती है? किसी भी सर्जरी में एनेस्थीसिया और संक्रमण (इन्फेक्शन) से संबंधित कुछ जोखिम हो सकते हैं. रिसेक्टिव सर्जरी में, आसपास के हिस्सों को नुकसान पहुंचने का डर लगा रहता है. यह इस बात पर निर्भर करता है कि खराब हिस्सा असल में कहां पर है. यदि खराब हिस्सा दिमाग के महत्वपूर्ण हिस्सों के पास हो (उदा. बोलने का और स्मृति का क्षेत्र) तो सर्जरी बहुत ही सावधानी से करने की ज़रूरत होती है. खुशी की बात है, कि रिसेक्शन के बाद दौरे रुकने से बहुत से लोगों में सोचने की और स्मृति की शक्ति में सुधार होता है. यह इसलिए, क्योंकि दिमाग के स्वस्थ हिस्से अच्छी तरह से काम कर रहे होते हैं. सर्जरी से पहले किए जानेवाले टेस्ट्स

All doctors and possibly all patients should know what can mimic Parkinson’s disease. There are more than 30+ diseases that produce similar similar symptoms. These mimics may cause Parkinson’s misdiagnosis. For example, hypothyroidism also produces slowness of movements. Therefore hypothyroidism can be misdiagnosed as Parkinson’s disease. The treatment is different for each of these conditions. Misdiagnosis may lead to ineffective treatment. A DAT scan (or F-DOPA PET scan) of the brain can confirm the diagnosis. 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. Come, let’s learn together about diseases that can be very similar in presentation to Parkinson’s disease. Table Of Contents What can mimic Parkinson’s Disease? The most important Parkinson’s Mimic: Drug-Induced Parkinsonism Parkinson’s Plus Syndromes Mimics caused by brain destruction Completely Unrelated Mimics Which test can be done when the diagnosis is in doubt? Bottom-line: Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar What can mimic Parkinson’s Disease? Before we proceed, let’s take a minute to understand some basic stuff. Here is a collection of 4 extremely important movement problems. 4 movement problems = “Parkinson-ism” 1. Slowness (Bradykinesia, Hypokinesia or Akinesia)2. Uncontrolled shaking (tremor)3. Stiffness (rigidity)4. Unsteadiness & shuffling gait. This group of problems is collectively called “Parkinsonism”. Parkinsonism means “like those produced by Parkinson’s disease”. Many diseases produce Parkinsonism. Of course, the most common one is Parkinson’s disease itself! But, other diseases can mimic Parkinson’s disease by producing similar symptoms. These are called the “Parkinson’s Mimics”. Let us talk about these Parkinson’s Mimics under 4 headings. Mimics of Parkinson’s Disease 1. Drug-induced Parkinsonism 2. Parkinson’s Plus Syndromes 3. Mimics caused by brain destruction 4. Completely unrelated Mimics The most important Parkinson’s Mimic: Drug-Induced Parkinsonism Certain medications can reduce the activity of Dopamine inside the brain. These medications produce symptoms very similar to Parkinson’s disease. Tremor is usually not seen, but some people can even have tremor! So, drug-induced movement problems can be tough to distinguish from Parkinson’s Disease. This is the most important cause underlying Parkinson’s Misdiagnosis, by far. The most important thing is carefully telling the doctor which medications you took recently. Unfortunately, some medications can cause Parkinsonism (Symptoms like Parkinson’s disease). If you are on any of these medications, your symptoms may be a side-effect of these medications. Type of medication Examples 1. Many medications used for psychiatric problems such as schizophrenia Haloperidol, Risperdal, Olanzapine, Aripiprazole, Trifluoperazine, Amisulpuride and many more. Clozapine and low dose Quetiapine usually do not cause problems. 2. Some medications for mood and depression Fluphenazine, Tranycypromine, Lithium 3. Some anti-nausea / anti-vertigo medications Metoclopramide, Levosulpiride, High doses of domperidone (30–40 mg/day), Flunarizine, rarely Cinnarizine 4. Some heart and blood pressure medications Amiodarone, Methyldopa Parkinson’s Plus Syndromes You could think of these as the “evil sisters” of Parkinson’s disease. These diseases can mimic Parkinson’s disease very closely. Misdiagnosis is very common in the early stages of these diseases. They have the exact symptoms of Parkinson’s disease. But they also produce additional symptoms such as falling backwards. So, they are called “Parkinson’s Plus syndromes”. “Parkinson’s Plus Syndromes” are the evil sisters of Parkinson’s disease. For example, in one such condition called PSP, the person has trouble moving his eyes. He/She can look from side-to-side but has difficulty looking up or down. Here is a video of a patient with PSP. This video has been posted on youtube by Dr Dusan Pavlovic. This patient has trouble looking upwards. He can look downwards, but there is a slight difficulty in doing that as well. https://www.youtube.com/watch?v=LU7TC0wufhg When present, difficulty in looking downwards is highly suggestive of PSP. Parkinson’s plus syndromes are the diseases that mimic Parkinson’s disease most closely. Misdiagnosis is very, very common. Parkinson’s Plus syndromes are often mistaken for Parkinson’s disease in the early stages. As they progress and additional symptoms build-up, they are correctly diagnosed. A table of such diseases is given below. You can read more in this article: What are the Parkinson’s Plus Syndromes? Parkinson’s Plus Syndrome Additional Features 1. Dementia with Lewy Bodies (DLB) DLB is the most similar to Parkinson’s disease. But patients with DLB also have: Visual hallucinations Fluctuating confusion Dream enactment [Click here for the NIH webpage] 2. Multiple Systems Atrophy (MSA) There is dysfunction of the “Autonomic Nervous System”. This part helps our brain to manage automatic actions like passing urine and sweating. So, MSA patients can have: Drop in blood pressure on standing Heart rate abnormalities Loss of urinary control Impotence Sweating problems etc… 3. Progressive Supranuclear Palsy (PSP) PSP patients have: Trouble moving eyes, especially looking upwards & downwards Frequent falls, mostly backward 4. Corticobasal Degeneration (CBD) CBD is a rare disease. The person forgets how to use a hand That arm/hand may have jerks It may twist into unnatural postures 5. Many kinds of Dementia Dementia is a term for “losing memory”. Many causes of Dementia also produce Parkinson’s symptoms. These include: Alzheimer’s disease Fronto-temporal dementia Dementia with Lewy bodies (DLB) Luckily, decreased Dopamine activity is the main problem in all these diseases. So, the treatment of these Parkinson’s Plus Syndromes is similar to Parkinson’s disease. Mimics caused by brain destruction Most of these diseases are due to damage caused by various chemicals. This process also destroys brain cells which produce Dopamine. This can create a condition very similar to Parkinson’s disease. Name of the disease Caused by 1. Wilson’s disease Excessive copper in the brain 2. Neuronal Brain Iron Accumulation (NBIA) Excessive iron in the brain 3. Fahr’s disease Excessive calcium in the brain 4. Toxins Examples: Carbon monoxide poisoning Methanol poisoning Exposure to industrial chemicals such as solvents, petroleum waste & insecticides 5. Lack of oxygen or blood supply Multiple strokes Brain damage due to drowning or a cardiac arrest 6. Infections HIV –