Comprehensive Care Centre for Movement disorders

FacultyServices Projects PublicationsResearch Staff



INTRODUCTION

The Movement Disorders Section of the Neurology Department started its functions in July 1996. The Comprehensive Care Centre for Movement Disorders (CCCMD) at SCTIMST was established in 1998 in collaboration with the department of Neurosurgery, and is the first of its kind in India. The aim of the Centre is to provide the most advanced forms of medical and surgical treatment and ancillary services to patients afflicted with various movement disorders. The centre also trains senior residents in Neurology in the diagnosis and treatment of movement disorders, offers post-doctoral fellowship course (Click here for more details ) in Movement Disorders and PhD programs and conducts clinical, genetic and neurophysiological research. The faculty members are actively involved in several international collaborative and in house research projects funded by agencies including the NIH, INSERM, Dystonia Medical Research Foundation, Michael J Fox Foundation, Indian Council of Medical Research and the Department of Science and Technology, Government of India.

Sri. EK Nayanar, Chief Minister of Kerala, inaugurating the Comprehensive Care Center for Movement Disorders.
Sri. EK Nayanar, Chief Minister of Kerala, inaugurating the Comprehensive Care Center for Movement Disorders.
FACILITIES AND SERVICES
MOVEMENT DISORDERS CLINIC

Specialists trained in the state-of-the-art treatment of Parkinson’s disease and other movement disorders conduct the weekly movement disorder clinic. This clinic is dedicated to the follow up treatment of all cases of Movement Disorders referred to this centre and does not register new cases directly (New cases are registered in the general neurology outpatient clinic and will subsequently be transferred to Movement Disorder clinic for follow-up). The common movement disorders referred to this clinic include Parkinson’s disease (PD) (Click here for more details on Parkinson’s disease), other Parkinsonian syndromes, Tremor disorders, various forms of Dystonia (click here to know more about dystonia ), Tics, Chorea, Myoclonus etc. Patients with movement disorders who are not controlled with optimal medical therapy are selected for surgical treatment from the movement disorders clinic. The clinic also provides counselling, education and neuropsychological and psychiatric evaluation and support. Physiotherapists attached to the clinic provide guidance on exercise regimens, avoidance of falls, improvement of mobility, walking aids etc. The clinic has 1500 to 1800 annual patient visits. Awareness programs are organized periodically, for patients with Parkinson’s disease and other movement disorders to know more about their disease and the treatment options.

Awareness program conducted for patients with PD, in connection with the world Parkinson’s day 2015.
Awareness program conducted for patients with PD, in connection with the world Parkinson’s day 2015 .
BOTULINUM TOXIN CLINIC

Botulinum Toxin Injections are used for the treatment of a wide variety of movement disorders. The program offers freehand and EMG guided Botulinum toxin for all indications, through the clinic. The center has vast experience in Botulinum Toxin therapy and round 300-400 treatment sessions are conducted annually. (Click here to know more about Botulinum Toxin and its uses in movement disorders)

THE NON-INVASIVE BRAIN STIMULATION (NIBS) AND MOTOR PHYSIOLOGY LAB

The NIBS and motor physiology lab under the CCCMD performs various diagnostic tests as well as conducts research studies on the pathophysiology of Parkinson’s disease and other movement disorders. Electrophysiological studies for the diagnosis and analysis of tremor, myoclonus and dystonia are done in the lab. The lab is run by biomedical engineers who work under the supervision of the Movement Disorder Specialists. Transcranial magnetic stimulation studies for various research projects are performed using state of the art neuronavigation/ image guidance techniques

The Transcranial Magnetic Stimulator (TMS).
The Transcranial Magnetic Stimulator (TMS).
TMS being done on a subject
Transcranial magnetic stimulation study performed under image-guidance
The tremor analysis system
The tremor analysis system
MOVEMENT DISORDER SURGICAL PROGRAM

The CCCMD is the pioneer of Deep Brain Stimulation (DBS) surgery for Parkinson’s disease in India, with the first procedure of Globus Pallidus deep brain stimulation performed in August 1998. It is currently one among the leading centres in this field in the country. It was the first to introduce micro-electrode recording (MER) guided DBS surgery and use image guidance (Surgical Planning System and Neuronavigation systems) for Movement Disorder Surgery in India. DBS treatment is also offered to patients with intractable Tremor and Dystonia. (Click here to know more about DBS )

The centre was also the first to revive the modern MR-guided radiofrequency lesioning of Globus Pallidus for Parkinson’s disease in the country. A multidisciplinary dedicated team is involved in the systematic work up and post operative long term management of patients who undergo DBS. Until December 2015, the centre has performed over 350 surgeries for medically refractory Movement Disorders and the faculty have presented the results at several international meetings and published their experience in reputed international journals (Please see below, under “Selected Publications”).

RESEARCH ACTIVITIES

The CCCMD is involved in various research projects addressing the patho-physiology of Parkinson’s disease and other movement disorders using techniques like image-guided Transcranial magnetic stimulation and functional magnetic Resonance Imaging (fMRI), genetics of Parkinson’s disease and other movement disorders, molecular basis of brain cell death in Parkinson’s disease, efficacy and long term stability of various surgical treatments for Parkinson’s disease and non-motor, neuropsychological and Quality of life issues in Parkinson’s disease. The centre has participated in several international clinical trials testing new drugs for Parkinson’s disease and dystonia. Many of the medical research projects are undertaken with international collaboration. In addition, CCCMD is also involved in biomedical technology and medical device development, collaborating with the Biomedical Technology Wing of the institute and other national research centers. CCCMD has won research grants from international and national funding agencies like the Dystonia Medical Research Foundation, Michael J Fox Foundation, Indian Council of Medical Research and the Department of Science and Technology, Government of India.

PERMANENT FACULTY AND STAFF
Movement Disorder Specialists
Stereotactic and Functional Neurosurgeons
Psychologist / Medical- Social Worker

Sri. S. Gangadhara Sarma. MA, PGDip
            Phone: +91-471-2524262(office),
            +91-9387774689 (cell phone)
            E-mail: mov@sctimst.ac.in

INFORMATION FOR PUBLIC
Movement Disorders Specialty Clinic (Monday: 10AM – 1.30 PM)

New patients (not registered in Sree Chitra Institute before) with movement disorders can register and consult the movement disorder specialists (Dr. Asha Kishore and her team) directly in the General Neurology OP on Wednesdays (Registration time: 8.00AM- 12.00PM). Appointment has to be fixed in advance and the patients are directed to contact 0471-2524262 / 09387774689, for appointment. Further follow-up will be in the Movement Disorders Clinic on all Mondays. The appointments for follow-up visits are taken at each visit, from the hospital’s Medical Records Division.

Botulinum Toxin Injection Clinic (Saturdays: 9AM-12PM)

Botulinum Toxin Injections are used for the treatment of focal and segmental dystonia (‘dystonia’ is a condition characterized by abnormal, often ‘twisted’ posturing, sometimes accompanied by jerking movements of any of the parts of the body, like neck hands etc, multiple parts or the whole body) as well as other conditions like hemi-facial spasm (involuntary contraction of muscles of face, causing intermittent, forceful closure of one eye, often accompanied by deviation of face) and post-stroke spasticity (stiffness of muscles occurring in a limb, paralysed by stroke). The involved muscles are identified and injected using special equipments including Electromyogram (EMG). A single session gives relief of symptoms (generally varying from 50% to 100%, depending on the condition and the muscles involved) for around 3-4 months and regular re-injections are required for sustained benefit. The injection is relatively safe. The faculty has vast experience and conduct around 300-400 sessions annually. Patients requiring treatment are selected by the Movement Disorder specialists from their Neurology out patient clinic.

EMG machine for accurate identification of muscles for Botulinum Toxin injection
EMG machine for accurate identification of muscles for Botulinum Toxin injection
Botulinum toxin injection for neck dystonia
Botulinum toxin injection for neck dystonia
Movement Disorder Surgeries

The patients referred for DBS surgery have to be evaluated in the clinic in detail for fitness for the procedure as all the patients with Parkinson’s disease and other movement disorders do not require / do not benefit from DBS. A preliminary evaluation for surgery is done including screening for heart diseases, Diabetes, High BP and any other important medical conditions. A detailed evaluation for mood, behavior, intellectual and memory disorders will be done before selection for surgery. Patients and their families will be counseled both by doctors as well as the medical social worker on the potential benefits and side effects of surgery. (Click here to know more about Deep Brain Stimulation )

Five-Channel Micro-electrode Recording (MER) guided Deep Brain Stimulation surgery for Parkinson's disease being performed in SCTIMST, for a patient with Parkinson’s disease.
Five-Channel Micro-electrode Recording (MER) guided Deep Brain Stimulation surgery for Parkinson’s disease being performed in SCTIMST, for a patient with Parkinson’s disease.
ACADEMIC PROGRAMS
PhD Program and Post-Doctoral Fellowship Program

Dr. Asha Kishore is a recognized guide for PhD program in clinical/ basic science aspects of Movement Disorders. The Center is recognized by the institute to offer 1 year post doctoral fellowship (PDF) in Movement disorders, to Neurologists. Applications are called for in August-September every year and the course commences on the 1st of January next year. (Click here to know more about the PDF Program)

RESEARCH PROJECTS

The CCCMD is actively involved in several international and national collaborative and in-house research projects pertaining to the clinical, genetic and neurophysiological aspects of Parkinson’s disease and other movement disorders. Research projects undertaken by CCCMD has been funded by international and national funding agencies like the NIH, Dystonia Medical Research Foundation, Michael J Fox Foundation, Indian Council of Medical Research and the Department of Science and Technology, Government of India.

Ongoing Projects in 2016:

  1. Deciphering the genetic architecture of LRRK2 gene for Parkinson’s disease in Indian population (Funded by the Michael J Fox Foundation, USA)
  2. Encoding of interhemispheric interactions in mirror dystonia: a window to the physiology of dystonia (Funded by the Dystonia Medical Research Foundation).
  3. Effect of Yoga on motor cortex plasticity, motor learning and motor deficits of Parkinson’s disease (Funded by the Department of Science and Technology, Government of India)
  4. Cerebellar control of synaptic depotentiation at the primary motor cortex and implications for levodopa induced dyskinesias.
  5. Resting state connectivity between the basal ganglia and cerebellum in health and Parkinson’s disease: a combined functional magnetic resonance and diffusion tensor imaging study.
  6. Study of factors that promote aggregation of alpha synuclein and their influence on the clearance mechanisms: relevance to sporadic Parkinson's disease.
  7. Long-term follow-up of mild Cognitive Impairment in Parkinson’s disease
  8. Effect of Subthalamic Nucleus-Deep Brain Stimulation surgery on impulsivity in Parkinson’s Disease.
  9. Contribution of DRD3 genetic polymorphisms to impulsivity in Parkinson’s disease patients.
  10. Non-motor symptoms and non-motor fluctuations in Parkinson’s disease- prevalence and effects of Deep Brain Stimulation
SELECTED RESEARCH PUBLICATIONS
  1. Kishore A, Ashok Kumar Sreelatha A, Sturm M, von-Zweydorf F et al Understanding the role of genetic variability in LRRK2 in Indian population. Mov Disord. 2018 Nov 28. doi: 10.1002/mds.27558. [Epub ahead of print]. PMID: 30485545
  2. Rajan R, Krishnan S, Sarma G, Sarma SP, Kishore A. Dopamine Receptor D3 rs6280 is Associated with Aberrant Decision-Making in Parkinson's Disease. Mov Disord Clin Pract. 2018 Jul 19;5(4):413-416. doi: 10.1002/mdc3.12631. eCollection 2018 Jul-Aug. PMID: 30363458
  3. Krishnan S, Pisharady KK, Divya KP, Shetty K, Kishore A. Deep brain stimulation for movement disorders. Neurol India. 2018 Mar-Apr;66(Supplement):S90-S101. doi: 10.4103/0028-3886.226438. PMID: 29503331
  4. Popa T, Hubsch C, James P, Richard A, Russo M, Pradeep S, Krishan S, Roze E, Meunier S, Kishore A. Abnormal cerebellar processing of the neck proprioceptive information drives dysfunctions in cervical dystonia. Sci Rep. 2018 Feb 2;8(1):2263. doi: 10.1038/s41598-018-20510-1. Pubmed Link: https://www.ncbi.nlm.nih.gov/pubmed/29396401
  5. Caligiore D, Pezzulo G, Baldassarre G, Bostan AC, Strick PL, Doya K, Helmich RC, Dirkx M, Houk J, Jörntell H, Lago-Rodriguez A, Galea JM, Miall RC, Popa T, Kishore A, Verschure PF, Zucca R, Herreros I. Consensus Paper: Towards a Systems-Level View of Cerebellar Function: the Interplay Between Cerebellum, Basal Ganglia, and Cortex. Cerebellum. 2017 Feb;16(1):203-229. doi: 10.1007/s12311-016-0763-3.
  6. Krishnan S, Pisharady KK. Surgical treatment of levodopa-induced dyskinesia in Parkinson’s disease. Ann Indian Acad Neurol 2017;20:199-206.
  7. Nandakumar S, Vijayan B, Kishore A, Thekkuveettil A. Autophagy enhancement is rendered ineffective in presence of α-synuclein in melanoma cells. J Cell Commun Signal. 2017 Jul 26. doi: 10.1007/s12079-017-0402-x. [Epub ahead of print]
  8. Rajan R, Popa T, Quartarone A, Ghilardi MF, Kishore A. Cortical plasticity and levodopa-induced dyskinesias in Parkinson's disease: Connecting the dots in a multicomponent network. Clin Neurophysiol. 2017 Jun;128(6):992-999.
  9. Kishore A, James P, Krishnan S, Yahia-Cherif L, Meunier S, Popa T. Motor cortex plasticity can indicate vulnerability to motor fluctuation and high L-DOPA need in drug-naïve Parkinson's disease. Parkinsonism Relat Disord. 2017 Feb;35:55-62.
  10. Mandali A, Chakravarthy VS, Rajan R, Sarma S, Kishore A. Electrode position and current amplitude modulate impulsivity after subthalamic stimulation in Parkinson’s disease - A computational study. Front Physiol. 2016 Nov 29;7:585. e-Collection 2016.
  11. Krishnamoorthy S, Rajan R, Banerjee M, Kumar H, Sarma G, Krishnan S, Sarma S, Kishore A. Dopamine D3 receptor Ser9Gly variant is associated with impulse control disorders in Parkinson's disease patients. Parkinsonism Relat Disord. 2016 Jun 15. pii: S1353-8020(16)30217-6. doi: 10.1016/j.parkreldis.2016.06.005
  12. Rajan R, Krishnan S, Kesavapisharady K, Kishore A. Malignant subthalamic nucleus deep brain stimulation withdrawal syndrome in Parkinson’s disease. Movement Disorders Clinical Practice 2016. Published online in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/mdc3.12271
  13. Krishnan S, Prasad S, Pisharady KK, Sarma G, Sarma SP, Kishore A, The decade after subthalamic stimulation in advanced Parkinson's disease: A balancing act., Neurol India. , 2016, 64(1):81-9, http://www.ncbi.nlm.nih.gov/pubmed/26754997
  14. Krishnan S, Justus S, Meluveettil R, Menon RN, Sarma SP, Kishore A., Validity of Montreal Cognitive Assessment in Non-English speaking patients with Parkinson's disease., Neurol India. , 2015, 63(1):63-7., http://www.ncbi.nlm.nih.gov/pubmed/25751471
  15. Kishore A, Popa T. Cerebellum in levodopa-induced dyskinesias: the unusual suspect in the motor network. Front Neurol. 2014 ; 18;5:157
  16. Kishore A, Popa T, James P, Yahia-Cherif L, Backer F, Varughese Chacko L, Govind P, Pradeep S, Meunier S. Age-related decline in the responsiveness of motor cortex to plastic forces reverses with levodopa or cerebellar stimulation. Neurobiol Aging. 2014;35:2541-51.
  17. Kishore A, Meunier S, Popa T. Cerebellar influence on motor cortex plasticity: behavioral implications for Parkinson's disease. Front Neurol. 2014; 6;5:68.
  18. Syambabu Chandran, Syam Krishnan, Gangadhara Sarma S, Sankara Sarma P, Asha Kishore., Gender influence on selection and outcome of deep brain stimulation for Parkinson's disease., Ann Indian Acad Neurol, 2014, 17:66-70., http://www.ncbi.nlm.nih.gov/pubmed/24753663
  19. Kishore A, Popa T, Balachandran A, Chandran S, Pradeep S, Backer F, Krishnan S, Meunier S, Cerebellar sensory processing alterations impact motor cortical plasticity in Parkinson's disease: clues from dyskinetic patients., Cereb Cortex., 2014, 24(8):2055-67, http://www.ncbi.nlm.nih.gov/pubmed/23535177
  20. Hubsch C, Roze E, Popa T, Russo M, Balachandran A, Pradeep S, Mueller F, Brochard V, Quartarone A, Degos B, Vidailhet M, Kishore A, Meunier S. Defective cerebellar control of cortical plasticity in writer's cramp. Brain. 2013 Jul;136(Pt 7):2050-62. doi: 10.1093/brain/awt147
  21. Sarathchandran S, Soman S, Sarma SG, Krishnan S, Kishore A., Impulse control disorders in Indian patients with Parkinson?s disease., Mov Disord, 2013, 28: 1901-1902., http://www.ncbi.nlm.nih.gov/pubmed/23801595
  22. Kishore, Asha; Popa, Traian; Velayudhan, Balu; Joseph, Thomas; Balachandran, Ammu; Meunier, Sabine, Acute dopamine boost has a negative effect on plasticity of the primary motor cortex in advanced Parkinson's disease., Brain, 2012, http://www.ncbi.nlm.nih.gov/pubmed/22609619
  23. Popa, T; Velayudhan, B; Hubsch, C; Pradeep, S; Roze, E; Vidailhet, M; Meunier, S; Kishore, A, Cerebellar Processing of Sensory Inputs Primes Motor Cortex Plasticity., Cereb Cortex, 2012, , http://www.ncbi.nlm.nih.gov/pubmed/22351647
  24. Krishnan, Syam; Sarma, Gangadhara; Sarma, Sankara; Kishore, Asha, Do nonmotor symptoms in Parkinson's disease differ from normal aging?, Mov Disord, 2011, 26; 2110-3, http://www.ncbi.nlm.nih.gov/pubmed/21661056
  25. Kishore, Asha; Joseph, Thomas; Velayudhan, Balu; Popa, Traian; Meunier, Sabine, Early, severe and bilateral loss of LTP and LTD-like plasticity in motor cortex (M1) in de novo Parkinson's disease., Clin Neurophysiol, 2011, , http://www.ncbi.nlm.nih.gov/pubmed/21945457
  26. Kishore A, Rao R, Krishnan S et al., Long term stability of effects of subthalamic stimulation in Parkinson?s disease: Indian experience., Mov Disord. , 2010, 25:2438-44., http://www.ncbi.nlm.nih.gov/pubmed/20976738
  27. Gupta, Deepak; Saini, Jitender; Kesavadas, Chandrasekharan; Sarma, P Sankara; Kishore, Asha, Utility of susceptibility-weighted MRI in differentiating Parkinson's disease and atypical parkinsonism., Neuroradiology, 2010, 52; 1087-94, http://www.ncbi.nlm.nih.gov/pubmed/20358367
  28. Divatia, Ruchir; Khan, Firosh; Kishore, Asha, Co-occurrence of radiological features of progressive supranuclear palsy and corticobasal degeneration., Neurol India, 2007, 55; 75-7, http://www.ncbi.nlm.nih.gov/pubmed/17272907
  29. Krishnan, Syam; Mathuranath, P S; Sarma, Sankara; Kishore, Asha, Neuropsychological functions in progressive supranuclear palsy, multiple system atrophy and Parkinson's disease., Neurol India, 2006, 54; 268-72, http://www.ncbi.nlm.nih.gov/pubmed/16936386
  30. Madegowda, R H; Kishore, A; Anand, A, Mutational screening of the parkin gene among South Indians with early onset Parkinson's disease., J Neurol Neurosurg Psychiatry, 2005, 76; 1588-90, http://www.ncbi.nlm.nih.gov/pubmed/16227559
  31. Panikar, D; Kishore, A, Deep brain stimulation for Parkinson's disease., Neurol India, 2003, 51; 167-75, http://www.ncbi.nlm.nih.gov/pubmed/14570997
  32. Kishore, A; Panikar, D; Balakrishnan, S; Joseph, S; Sarma, S, Evidence of functional somatotopy in GPi from results of pallidotomy., Brain, 2000, 123 Pt 12; 2491-500, http://www.ncbi.nlm.nih.gov/pubmed/11099450