Regain Control Over Movement

Understanding Parkinson's Disease in the Indian Context

Parkinson's Disease (PD)—a progressive neurodegenerative disorder causing tremor, stiffness, slowness, and balance problems—affects 1 in 500 Indians over 65. At Ajuda Hospitals, our Movement Disorder Clinic combines medication optimization, botulinum toxin therapy, and multidisciplinary rehabilitation to maximize function and independence.

PD results from dopamine-producing neuron loss in the substantia nigra. Symptoms emerge when 60-80% of dopamine is depleted. While incurable, treatment with levodopa and adjuncts provides excellent symptom control for years—the "honeymoon period." As disease advances, motor fluctuations and non-motor symptoms (dementia, psychosis) require complex management.

Indian patients face unique challenges: delayed diagnosis (tremor attributed to "old age"), limited access to physiotherapy in rural areas, and caregiver burden on joint families. We address these with telemedicine follow-up, home exercise programs, and caregiver education in Telugu, Hindi, Urdu, and English.

When to Consult Our Movement Disorder Specialists

Early diagnosis and treatment improve quality of life. Don't dismiss symptoms as "normal aging"—Parkinson's is treatable.

Our Diagnostic Approach

Clinical Diagnosis

UK Brain Bank Criteria: Bradykinesia (slowness) PLUS one of:

• Rest Tremor: 4-6 Hz, worse at rest, improves with action (e.g., pill-rolling).
• Rigidity: Increased muscle tone, "cogwheel" resistance to passive movement.
• Postural Instability: Impaired balance, falls (late feature).

Supporting Features: Asymmetric onset, response to levodopa, anosmia (loss of smell), REM sleep behavior disorder.

Differential Diagnosis

Rule out mimics:

• Essential Tremor: Action tremor (not rest), family history, alcohol-responsive.
• Atypical Parkinsonism: MSA (autonomic failure, cerebellar signs), PSP (falls, vertical gaze palsy), CBD (alien limb).
• Drug-Induced: Antipsychotics (haloperidol), metoclopramide, valproate—reversible if stopped.
• Vascular Parkinsonism: Lower-body predominant, MRI shows subcortical infarcts.

Neuroimaging

MRI Brain: Exclude stroke, tumor, hydrocephalus. Normal in PD (diagnosis is clinical). DaTscan: SPECT imaging of dopamine transporters; abnormal in PD vs essential tremor. Used when diagnosis uncertain.

Functional Assessment

UPDRS (Unified Parkinson's Disease Rating Scale): Quantifies motor and non-motor symptoms (0-199; higher = worse). Hoehn & Yahr Staging: 1 (unilateral) to 5 (wheelchair-bound). Falls Assessment: Timed Up-and-Go test; home safety evaluation by OT.

Treatment Pathways

Levodopa/Carbidopa Therapy

Gold Standard: Levodopa crosses blood-brain barrier, converts to dopamine. Carbidopa blocks peripheral conversion (reduces nausea).

Dosing: Start 100/25mg tid; titrate to symptom control (max ~1000mg levodopa/day). Take 30 min before meals (protein competes for absorption).

Response: 80-90% motor improvement in early disease. If no response, reconsider diagnosis.

Side Effects: Nausea (dose with domperidone initially), orthostatic hypotension, dyskinesia (late).

Dopamine Agonists

Options: Pramipexole, ropinirole stimulate dopamine receptors directly (don't require conversion).

Use: Younger patients (<65) to delay levodopa (postpone motor fluctuations). Monotherapy or levodopa adjunct.

Side Effects: Impulse control disorders (gambling, hypersexuality, compulsive shopping), daytime sleepiness, hallucinations (especially elderly), leg edema.

Monitoring: Screen for ICDs at every visit; reduce/stop if emerge.

MAO-B Inhibitors

Options: Rasagiline 1mg daily, selegiline 5mg bid. Mechanism: Block MAO-B enzyme that breaks down dopamine; extends duration. Benefit: Modest motor improvement; may delay levodopa need by months. Side Effects: Insomnia (take morning), orthostatic hypotension.

COMT Inhibitors

Entacapone 200mg with each levodopa dose; blocks peripheral dopamine breakdown, extends half-life. Use: When "wearing off" (symptoms return before next dose). Adds 1-2 hours ON time per dose. Side Effect: Orange urine (harmless), diarrhea (transient).

Amantadine

Dual Use: Mild anti-parkinsonian effect early; reduces dyskinesia later. Dose: 100mg bid-tid. Side Effects: Livedo reticularis (skin mottling), ankle edema, confusion (elderly).

Botulinum Toxin Injections

Indications:

• Cervical Dystonia: Involuntary neck turning/tilting.
• Blepharospasm: Involuntary eyelid closure.
• Limb Dystonia: Foot inversion, hand cramping.
• Sialorrhea: Drooling (inject parotid/submandibular glands).
• Tremor: Focal tremor (head, hand) unresponsive to meds.

Procedure: Inject overactive muscles; lasts 3-4 months. Repeat as needed.

Outcomes: 60-70% improvement in targeted symptom.

Physical & Occupational Therapy

Goals: Maintain mobility, prevent falls, preserve independence.

Interventions:

• Gait Training: Large-step practice, obstacle courses, dual-task training.
• Balance Exercises: Tai chi, tandem walking, perturbation training.
• LSVT LOUD: Voice therapy—increase volume to overcome hypophonia.
• LSVT BIG: Movement amplitude training—counteract small movements.
• ADL Strategies: Adaptive utensils, grab bars, shower chairs.

Dose: Intensive 4-8 weeks (3-5 sessions/week), then home maintenance program.

Speech & Swallow Therapy

For: Hypophonia (soft voice), dysarthria (slurred speech), dysphagia (swallowing difficulty—aspiration risk). Techniques: Lee Silverman Voice Treatment, chin-tuck swallow, diet modifications (thickened liquids).

What to Expect: Your Care Journey

First Visit (60 min)

History (onset, progression, symptoms), neurological exam (tremor, rigidity, bradykinesia, gait), UPDRS scoring. Start levodopa if diagnosis clear.

Week Follow-Up

Assess treatment response. If good improvement → confirm PD diagnosis. Titrate levodopa to optimal dose (balance efficacy vs side effects).

Month Visits

Monitor for motor fluctuations (wearing off, dyskinesia), non-motor symptoms (sleep, mood, cognition). Adjust medications; add COMT inhibitor or agonist if needed.

Annual Reviews

UPDRS scoring to track progression. Screen for dementia (MoCA test), depression (PHQ-9), orthostatic hypotension. Update PT/OT prescriptions. Discuss advanced therapies if severe fluctuations.

Advanced Disease (10+ years)

Complex regimen (5-6 drugs); consider DBS if severe OFF time/dyskinesia. Manage psychosis (quetiapine, pimavanserin), dementia (rivastigmine), dysautonomia (midodrine for BP). Caregiver respite planning.

Technology & Innovation

Levodopa-Carbidopa Intestinal Gel (LCIG)

For advanced PD with severe motor fluctuations unresponsive to oral therapy. Continuous levodopa infusion via PEG-J tube connected to portable pump.

Benefits: Stable dopamine levels; fewer OFF periods; reduced dyskinesia. Drawbacks: Surgical tube placement, device care, high cost (insurance authorization required).

Deep Brain Stimulation (DBS)

Candidates: Good levodopa response but intolerable fluctuations/dyskinesia; age <70; no significant dementia. Procedure: Electrodes implanted in subthalamic nucleus (STN) or globus pallidus interna (GPi); connected to battery in chest. Outcomes: 4-6 hour ON time increase; 50% dyskinesia reduction; 30-50% medication reduction. Risks: Surgical (hemorrhage 1-2%), hardware infection, speech/gait worsening (STN), battery replacement every 3-5 years.

Our neurosurgery team coordinates pre-operative evaluation (cognitive testing, MRI) and post-op programming.

Telemedicine Movement Disorder Clinic

• Monthly video consults for medication titration.
• Caregiver-assisted motor assessments via smartphone (UPDRS finger taps, gait).
• Remote adjustment of DBS settings (if implanted).
• Quarterly in-person visits for detailed exam and therapy renewals.

Preventing Complications

Falls: Leading cause of hospitalization in PD. Prevention: balance training, home modifications (remove rugs, install grab bars), walking aids, hip protectors.

Dementia: 30-40% develop PD dementia. Risk factors: older age, hallucinations, postural instability. Treatment: rivastigmine (cholinesterase inhibitor); avoid anticholinergics (worsen cognition).

Psychosis: Hallucinations (usually visual—"people/animals in room"), delusions (paranoia). Triggered by dopaminergic meds. Management: reduce agonists, quetiapine 25mg hs, pimavanserin if severe.

Aspiration Pneumonia: Dysphagia → food/liquid entering airway. Prevention: swallow evaluation, diet modifications, upright positioning during meals.

Orthostatic Hypotension: BP drop on standing → dizziness, falls. Management: salt, fluids, compression stockings, midodrine, fludrocortisone.

Why Ajuda for Movement Disorder Care?

Take the First Step

If new symptoms: Call 9010550550 for diagnostic evaluation. Early treatment improves quality of life.

If on medications but struggling: Request medication optimization visit. Fluctuations and dyskinesia are manageable with adjustments.

If advanced disease: Discuss LCIG or DBS candidacy. Advanced therapies restore function when meds alone are insufficient.

Ajuda Hospitals: Where movement disorders meet precision medicine, and every good day counts.