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Category: Elders

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Buddhi Clinic: Leading the Way in Integrated Care for the Brain and Mind

In today’s fast-paced world, a large section of the population is denied the opportunity to manage chronic diseases through a wellness, holistic and healing-oriented approach.

Dr. Ennapadam S Krishnamoorthy

The burden of chronic disorders is largely attributed to the perils of modern medicine that prioritises cure through prescription drugs instead of focusing on the entire continuum of human healthcare engagement: rejuvenation, restoration and rehabilitation. The end result: an unhealthy ageing population.This is where India’s ancient and holistic Ayurvedic system as a viable form of alternative medicine comes in. It is about time medical practitioners harnessed the full potential of Ayurveda as it’s based on a strong foundation of scientific research, much like modern medicine’s tenets. 

In recent years, a growing body of research points to integrated medical treatments—a combination of complementary (alternative) and modern (allopathic) medicine—gaining popularity. While modern medicine’s thrust is on cure, integrative medicine focuses on disease prevention, comfort and care.

However, despite the marked shift in patients’ preference for alternative forms of healing, I observed a deficit of innovation in therapies that are based on integrative medicine. This is where Buddhi Clinic’s genesis and my entrepreneurial journey can be traced. 

I realised there was no other healthcare outfit in the world that provides a unique 360° evaluation of body, brain and mind through an integrated approach. At Buddhi, we take a holistic approach to diagnose a medical condition that combines the scientific rigour of modern medicine’s diagnosis and drug treatments with the therapeutic benefits of ancient healing traditions. 

In essence, my long-term vision for our healthcare startup that was founded as a project in 2009 and company in 2013, is to make complementary and alternative medicine (CAM) gain acceptance as mainstream therapies. From my experience, I realised this would be possible only by seamlessly integrating them with modern medicine. 

Let me tell you how this is done at Buddhi Clinic.

A Game-Changer in Brain and Mind Integrated Therapy

We are the pioneers and innovators of integrated care for the brain and mind. What sets Buddhi Clinic apart from the rest is that we don’t follow a cookie-cutter approach to diagnosis and treatment. Our raison d’être lies in being able to provide unique personalised treatment strategies for patients that is managed by interdisciplinary process-driven programmes. 

Since several neurological and mental health disorders and disability are longstanding issues, patients need continuous and comprehensive care. Thus, we strive to offer a better quality of daily life to our patients by curating a range of therapeutic solutions based on considerable clinical and empirical research, and our team’s extensive experience.

Buddhi Clinic’s focus is on neurology and mental health rehabilitation and therapy. We have also created a range of interventions for pain, mental health, lifestyle and disablement conditions. 

While our diagnostic approach and internal treatments are allopathic, we also rely on traditional healing therapies to restore the equilibrium of your brain and mind interface. Buddhi Clinic’s seamlessly integrated approach offers 14 non-pharmacological treatment modalities that are an amalgamation of modern science and ancient wisdom.

We offer treatment programmes for each condition customised for children, adults and the elderly. These include: Ayurveda, Acupuncture, Acupressure, Naturopathy- water, mud, aroma and magnet treatments; Reflexology and Yoga; and Rehabilitation therapies – speech, neurodevelopmental, physiotherapy and a range of specialized psychological therapies. We have also curated treatment combinations for Psychology – CBT, CRT, Behavioural, JPMR, ERP, EMDR; and Neuromodulation or brain stimulation (a full house of treatments). 

Empowering the Patient Based on the “McDonald’s Model”

One of the guiding principles behind founding Buddhi is respecting and understanding patient preferences and engaging patients in shared decision-making. Towards this end, we perceive our startup to be the McDonald’s of “Brain and Mind Care and Rehabilitation”. 

Similar to how a customer can curate his meal in a McDonald’s outlet, Buddhi Clinic, too, offers patients the choice to curate integrated treatment programmes tailored to their specific needs. This is called the “choice model” and is better suited for mild impairment and chronic or progressive health conditions. In such situations, we give patients the choice and flexibility to select a combination of modern and ancient interventions rather than rely on a single medical treatment, procedure and therapy. It is our belief that for best treatment outcomes, the patient should be in control of his own decisions regarding his healthcare options.

That said, our team also draws up a “prescription model” when the patient suffers from a chronic condition and requires continuous restoration and rehabilitation.

Crucially, at Buddhi Clinic, we adopt a holistic approach to healing our patients and focus on their overall wellness and recovery that goes beyond cure. We think different—not just about illness or disablement but also about ability and enablement. 

Research and Innovation Led Approach

Nothing fulfils me more than making sustained efforts to give our patients a better quality of life. Our patient-focused approach includes continuously monitoring their progress and offering them quality pre-treatment, mid-treatment and end-of-treatment assessments. 

Over the years, we have delivered quality healthcare to over 10,000 patients who have received an excess of 1,00,000 interventions. Our success stories that cover conditions such as autism, epilepsy, depression, Parkinson’s disease and dementia, among others, are documented as detailed case studies in ‘Buddhi Books’. The books are aimed at fostering the spirit of research and continuous learning to enable children, adults and elders achieve a better quality of daily life.

Buddhi Clinic also endeavors to offer innovative products and services to enhance the integrated approach to long-term brain and mind care. For instance, we use Transcranial Magnetic Stimulation (TMS) to treat neurological and psychiatric disorders. Transcranial Direct Current Stimulation (tDCS) and transcutaneous auricular Vagus Nerve Stimulation (taVNS) are also the Neuromodulation innovations we bring in. While the former two, rTMS and tDCS stimulate specific brain pathways for specific conditions and outcomes, the latter tAVNS stimulates the auricular (ear lobe) branch of the vagus nerve (ABVN), an easily accessible target that innervates the human autonomic nervous system. Like this, there are other innovations in the pipeline that we hope will lead to paradigm disruption in this space.

Building a Service-Oriented Approach

In order to create a healing environment based on holistic principles, we aim to continue to provide personalised and meaningful patient experiences at competitive rates. Since today’s patients have greater discernment, patient satisfaction is paramount to us. Our service-oriented approach helps us deliver, on an average, 10-20% more therapy to each paying client, apart from serving the disadvantaged at low cost or free of cost.

In the coming years, it is our goal to collaborate with doctors and diverse talents in the healthcare sector to serve populations beyond Chennai and India. Our objective is to demonstrate our capability as pioneers and leaders in integrated care with a brain and mind focus. 

One of my key learnings as a healthcare entrepreneur has been that it’s not enough to achieve a robust bottom line growth. It is equally important to sustain it by creating impact at scale through a committed patient-focused approach.

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Adults COVID-19 Elders Expert Blogs Featured

Did you know? COVID-19 vaccination can also be associated with unexplained neurological symptoms!

Recently Mrs. R aged about 55 years consulted us with a range of symptoms that closely followed the first dose of vaccination for Covid-19. They included

  • Pricking and pulling pain in the hands and feet
  • Pain in the neck and shoulders
  • Altered sensation in the soles, feels roughness in them.
  • Pulling pain in the back of the knees and legs
  • Palpitations on exertion.
  • Disturbed sleep

She had visited her family doctor and an orthopaedic surgeon and was diagnosed as having cervical and lumbar spondylosis and carpal tunnel syndrome. When it became apparent to us that her symptoms had followed vaccination, she having not considered this piece of information important in her earlier consultations, we proceeded to carry out our comprehensive 360* evaluation at Buddhi Clinic. Mrs. R met our team- physician, physical therapist, psychologist and electrophysiologist and was evaluated for a neuropathy as well as dysautonomia.

Lo and behold we discovered evidence of both a peripheral neuropathy (responsible for the pain in her hands and feet and altered sensation in her soles) as well as clinical autonomic dysfunction (Postural Orthostatic Tachycardia Syndrome being the diagnostic indicator) contributing to fatigue, palpitations and sleep dysfunction. There was also considerable health related anxiety about her new and unusual symptoms. A working diagnosis of “post vaccination neuropathy and clinical autonomic dysfunction” was made and Mrs. R inducted into our comprehensive care program. From a drug perspective we used pregabalin (a nerve membrane stabilising agent and weak anti-epileptic drug that helps with both neuropathy and dysautonomia), nortryptyline (a conventional antidepressant with anti-pain and anxiety relieving/ sleep promoting effects) and baclofen (for muscle spasm identified in clinical evaluation). 

She started also on our comprehensive care (non-drug therapy) program with our Mobility & CAM labs. The mobility lab team delivered manual and electrotherapy treatments for pain/ dysasthesia and a comprehensive exercise therapy program for dysautonomia. The CAM lab team delivered focal abhyangam with Sahachadhari thailam and kizhi together with acupressure, reflexology and mud therapy sessions. 

After 15 hours of each treatment paradigm Mrs. R was reviewed in our case conference, with the following outcomes. 

Mobility Lab:

  • Muscle spasm and pain in the neck and shoulders has reduced completely – the Visual Analogue Scale scores were- Pre therapy-8, Mid therapy-4, End therapy-0
  • Mild pain in the right brachioradialis continues with a Visual Analogue Scale Score of 2
  • Altered sensation in the hands and feet has reduced by 50% but tends to fluctuate, being present on and off
  • Grip, grasp and fine motor skills are improving

CAM Lab: 

  • Pricking and pulling pain in the legs improved
  • Her metabolism improved and she perceives overall wellness in her daily functions
  • Sleeps 5 hours fitfully but would like that to return to her customary 7 hours  
  • The self-application (assisted by family) of lepam (herbal paste) in both palms and soles is helping her; when her night time symptoms are bothersome she has learnt to apply ice packs to the dysasthetic areas and is able to sleep
  • Abnormal sensation in palms continues to fluctuate

Summary:

A vaccination is nothing but a minor and contained infection inducer, designed to help people develop immunity. Not just COVID-19 vaccination, but all vaccinations can induce some adverse effects, unexplained neurological and neuropsychiatric symptoms not being uncommon. The temporal relationship between the de novo symptoms that Mrs. R developed, detailed by our comprehensive evaluation and targeted testing, confirmed for us new onset peripheral neuropathy and dysautonomia. As is our practice in Buddhi Clinic we combined modern drug treatment with the wisdom of convention (physiotherapy) and ancient traditions (Ayurveda and Naturopathy) to give Mrs. R much needed relief. Mrs. R continues in a step down program combining weekly clinic visits with our “Do it Yourself” (DIY) Buddhi kits and is on the pathway towards complete recovery. She discovered Buddhi Clinic and in her we have evolved the pathway to helping people with post-vaccination neurological symptoms. 

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Adolescents Adults Children Elders Featured Patient Stories

A traditional touch alongside an allopath

#Trimedtherapy.com our #innovative #healthcare #enterprise featured in the #start-up files of the Times of India recently- a story by Pushpa Narayan.

After practicing medicine for seven years in India, London returned neuropsychiatrist Dr Ennapadam S Krishnamoorthy understood that while Indians had total trust in modern medicine their heart was often in traditional systems. If an Ayurvedic medicine would work or if a series of yoga sessions seemed to help, they would rather go for that. Like most allopaths, Dr Krishnamoorthy , was initially dismissive but soon realized that he should investigate the science behind “alternative medicine.”

After some years of diligent research and efforts, he launched a small clinic called Trimed, as a pilot, near his house in Sri Nagar Colony in 2009. With seed money from family and friends, Trimed sought to weave allopathy with Ayurveda, yoga, naturopathy and Pilates.

The first task for the integrated medical therapy centre was drawing up treatment protocols that integrate diverse genre whose practitioners have typically worked in silos – with each being mostly dismissive of the other. “In most such integrated centers, we realized that treatment was mostly left to patients’ choice. Many times patients aren’t guided through choices. Ours was a clinic and we decided that treatment protocols will be decided by the doctor,” said Dr Krishnamoorthy , one of the founders of Trimed. For nearly 40 conditions including pain, disability and mental health issues the team has standardized treatment practices.

Patients coming to Trimed meet an allopathic practitioner first, but they are also evaluated by at least four other specialists including a physiotherapist, naturopath, Ayurveda practitioner and a psychologist. The specialists then discuss the treatment plan for each case sheet.”Sometimes treatment plans take more than two hours to formulate,” said Dr Rema Raghu, an epidemiologist/ lifestyle physician, who is one of the core members. The aim is to bridge the limitations of allopathy with the wisdom in traditional medicine. “We made a conscious choice that all medicines prescribed will be only allopathic. Massages and therapy from other traditional streams are integrated with modern medicine. But with every case it is important to offer holistic care,” she adds.

The cloud-based electronic medical records of each patient stored at the hospital showed substantial progress in most patients. For instance, a 92-year-old a wheelchair bound patient walked out of the hospital after 15 days of intensive therapy and young IT professional was taken off the bench and put on projects after he was able to control mood disorders. Soon, Trimed, with its mobile therapy unit -an ambulance converted to therapy centre -extended services to home-care. “When people come to us they realize that almost everyone in the family needs holistic medical management,” said Gayathri Krishnamoorthy, a core administrator at Trimed. The centre, which was exclusively for medical management, is now expanding to offer rejuvenation therapy.

The company received funding of $300,000 from an Indian businessman living abroad. It is planning to start another centre in Coimbatore. “When I first heard about it I was impressed about the holistic approach concept. In fact some members in my family tried and benefited from it. I don’t think such centres should mushroom all over, but I certainly believe they have a place,” said A Vellayan, executive chairman, Murugappa Group, who has invested in his individual capacity.

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Adults Elders Featured Patient Stories

Food for the ageing brain…

The prevention of dementia assumes great significance, especially as we exist in an era of chronic and lifestyle diseases. Indeed, the role of hypertension, obesity, lipidemias (high cholesterol) and diabetes (the HOLD construct) as causative factors of chronic and lifestyle diseases including dementia has assumed great significance in the last decade. The American Dietetic Association has opined that food and nutrition play an important role in maintaining one’s health. It is also well known that sub-clinical deficiency in essential nutrients and nutrition-related disorders can lead to loss of memory and other cognitive functions.

Poor performance in memory tests has been shown to be associated with low levels of a range of nutritional factors:

  • Vit B12 (with elevated homocysteine)
  • plasma lycopene
  • a-carotene, total carotene, b-carotene
  • b-cryptoxanthin
  • a-tocopherol etc. 

Supplementation: 

There is growing evidence that vitamin supplementation has a significant role to play in lowering the risk of dementia. Evidence for vit C, E, B12 and folic acid being given, as supplementation in higher doses, is particularly strong. However, the benefit seems most when supplementation is introduced in people who need it (with low vitamin levels) than in those who do not. These findings and allied research have also resulted in the US FDA recommending folic acid fortification of foods for the elderly, for example flour and bread. It is important to remember that high vitamin levels due to inappropriate supplementation can also be problematic and the taking of supplements should therefore be done with medical supervision.

Diet:

There is mounting evidence that the Mediterranean diet, which includes a high consumption of olive oil and fish — and hence elevated intakes of monounsaturated fatty acids and v–3 polyunsaturated fatty acids — is protective against age-related cognitive decline. This maybe partly due to the antioxidant compounds in olive oil (tocopherols and polyphenols) and in part to the role of fatty acids in maintaining the structural integrity of nerve membranes. 

Red Wine:

There is no doubt that red wine consumed in moderation has been shown to be beneficial to health and well-being; reducing bad cholesterol, preventing blood clots and protecting the heart. In part this has been attributed to the constituents of red wine, which include procyanidins, a class of flavonoids found in plants, fruits and cocoa beans.

Plant Formulations:

It has long been known that certain plant formulations have pro-cognitive properties and may enhance memory function. Many of these are the subject of active research today, Brahmi (Bacopa Monnieri), Tulsi (Basil), Ashwagandha (Withania Somnifera) for example. Curcumin, an active ingredient of turmeric, is also the subject of worldwide research. Among the fruits the pomegranate and walnut are thought to have pro-cognitive properties. While a variety of plants and plant formulations are under study, the jury is still out with regard to their specific benefits. The evidence for over-the-counter plant formulations is, therefore, not yet existent, notwithstanding their many claims.

Lifestyle & Attitude:

The jury is still out as to whether it is the aforementioned constituent factors that render protection, or indeed whether the overall Mediterranean lifestyle — physical activity, healthy food, abundant sunshine, meals eaten at a leisurely pace with plenty of socialisation — is responsible for the health, well being and good levels of memory/ cognitive function in that population. For example, therefore, red wine consumed in moderate quantities may be good for you, but only when it’s accompanied by such a “healthy” lifestyle & attitude.

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Adolescents Adults Children Depression Dystonia Elders Expert Blogs Featured Obsessive Compulsive Disorder

Stimulation for the brain!

What is deep brain stimulation?

Our brain is a wonderful organ. Designed by the chief architect, this is the most complex CPU ever built. Like our computer’s CPU, this CPU in our body can also be thought of a bundle of electrical wires criss-crossing in a highly complex fashion. Every once in a while, there can be something that happens to cause some malfunction in this circuit. DBS can be thought of as an operation to set right this malfunction by inserting a pacemaker into the brain.

Miss J, a 22 year old girl had been diagnosed with a brain tumour as a child and had undergone radiation for that. While the tumour was successfully treated, this radiation to the brain had a nasty side-effect. Some of the circuitry in her midbrain had been altered, leaving her with a permanent tremor in the right hand and leg.

She was suffering silently for more than 10 years, not knowing that this problem has a solution in the form of DBS! While the damage to the brain that is an inevitable consequence of radiation cant be undone, by placing a pacemaker into the brain, the imbalance in her movement circuitry could be modulated.

The result is almost instantaneous since the operation is done with the patient awake in the operating room. Once the electrode reaches the correct area in the brain and electrical current is sent through it, the tremor reduces immediately and her slow movements become rapid.

DBS is helpful in a wide variety of conditions apart from tremors. It is very useful to improve the symptoms of Parkinson’s disease, Dystonia, drug resistant Epilepsy, Obsessive compulsive disorder, major depression and Chronic Pain syndromes.

The deep area in the brain which is stimulated varies according to the condition treated. However, in all conditions the patient is awake during surgery and is being tested with stimulation and a wide variety of observations are done as and when surgery is in progress. Therefore, the success of surgery involves the active co-operation of the patient.

Before surgery is considered, all patients undergo a detailed assessment to look for factors in favour and against surgery.

Each patient and family are thoroughly counselled about what to expect before, during and after surgery. After successful surgery, they need to be followed up for programming sessions where the stimulator is turned on and tuned in order to achieve the best clinical benefit with the least side-effects.

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Adolescents Adults Children COVID-19 Elders Epilepsy & Seizures Expert Blogs Featured

Managing epilepsy during COVID-19

Epilepsy is the most common serious neurological disease affecting over 50 million people worldwide and an estimated 5 million plus people in India.

People with epilepsy have recurrent, unprovoked seizures and these have to be differentiated from provoked seizures that follow a tumour, stroke, infection, inflammation, metabolic disease (like very low or very high blood sugar) and so on. A seizure is an electrical storm in the brain; a short circuit in the brain’s normal electrochemical activity.

World Epilepsy Day or Purple Day just passed us on 26th March. In this time of COVID let’s ask ourselves what the implications are for people with epilepsy. Here are some common FAQs.

Can COVID-19 cause epilepsy?

According to the International League Against Epilepsy, there is no direct evidence that the coronavirus infection can directly cause epilepsy. However, like all infections that can cause high fever, breathing difficulties and other problems with normal functioning, being infected can result in a person who is susceptible to epilepsy, suffer breakthrough episodes.

Does epilepsy or its treatment make one more susceptible to COVID-19?

At present there is no information to suggest that either epilepsy or epilepsy treatment (anti-epileptic drugs, most commonly) will in any way make a person susceptible to COVID-19. Indeed, there is no suggestion that people with epilepsy have any special immune vulnerability either. However, the stress a pandemic of this nature can induce in people, the sleep deprivation and attendant lifestyle changes, can all make a person already vulnerable to seizures, express them more frequently.

What should I do if I have a seizure in this time of COVID-19?

If one has never had a seizure before in their lives, it is obviously imperative that they consult a neurologist, urgently and undergo relevant investigations as advised. As most routine clinics are cancelled, the emergency room of a hospital may be a better point of access at this time. However, for people with pre-existent epilepsy, a single seizure is no reason for panic. Call your usual doctor and discuss what you can do to manage your epilepsy better; follow your doctors advice.

Avoid visiting clinics and hospitals for single breakthrough seizures unless you feel it is absolutely necessary. However, if seizures cluster together, or indeed a person suffers continuous seizures with no recovery of consciousness in-between, what is called “status epilepticus”, it must be treated as an emergency.

What precautions should a person with epilepsy take at this time?

People with epilepsy are advised to stock up adequately on their anti-epileptic drugs, as even missing a single dose can cause a breakthrough seizure for some. Compliance with drug treatment is extremely important for people with epilepsy. Stress is inevitable and managing it with meditation, yoga, a healthy diet and lifestyle are all possible. Many good online tutorials exist on all the above. If one is very stressed out an online consultation with a psychiatrist or psychologist can be helpful. Sleep deprivation is another risk factor for people with epilepsy; adequate rest and sleep are therefore very important. Sleep can be disturbed due to stress or indeed due to excessive exposure to digital media — televisions, computers, tablets and smartphones.

Good sleep hygiene: making oneself clean and comfortable before going to bed, making the temperature and lighting in the room ambient and suitable to the extent possible, putting way all digital media and retiring to bed with either a book or gentle instrumental music (if one must have a distraction) are all encouraged.

Are there special precautions?

Unless one is a healthcare worker or otherwise at high risk of exposure, no special precautions are recommended. If a person with epilepsy belongs to this category, they are encouraged to speak with their usual doctor about drug prophylaxis and other precautions. For all other people with epilepsy, the principles of social distancing, avoiding unnecessary contact with people outside one’s immediate family, or indeed taking due care around anyone who is symptomatic of COVID, is adequate.

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Buddhi Stories Dementia & Memory Loss Elders Featured Memory Problems Patient Stories

Jayaram – The Decline

Jayaram – The Decline
Jayaram – The Decline

Biography

It was six years into retirement, in 2009 when the early signs of mental illness surfaced in a subtle manner in Mr. Jayaram. Where had he kept the house keys? How could he forget to buy the cooking oil from the shop round the corner? He had never missed even one of ten items for routine household purchase that his wife verbally listed to him and so she spared herself the trouble of writing it down. Jayaram brushed aside his occasional memory lapses, and went on to read the day’s news, reclining comfortably in his planter cane-and-wood ‘easy chair’, while his wife brought him fresh south Indian filter coffee, even as the television audio sounded the Suprabhatham, the gentle daily chant to wake up the Lord of the Seven Hills.

The wife began to register concern as the memory lapses occurred more frequently. Jayaram appeared agitated at times as if he was experiencing an inner turmoil. Soon he showed signs of social withdrawal.

Exploring the Condition

When the family physician was approached for a routine check up of his hypertensive and diabetic status, for which he was on regular medication for several years, the wife shared her concerns with the doctor. A specialist consultation was advised, but at the very heel of the neurological consultation, Jayaram had lost his way home along his oft trodden path and had to be escorted to his house by tense family members and neighbours. A repeat of this behaviour resulted in GPS tagging and going out on his own became a taboo. A diagnosis of Alzheimer’s Disease was made and T2 Hyperintensities (with his history of long-term diabetes and hypertension) on MRI brain suggested an added vascular element to the dementia.

Following a successful career in a position of authority in Central Government, Jayaram had returned to his hometown near Chennai with his wife to settle to a peaceful retired life. His son and daughter having been married a couple of years earlier, had settled abroad with their respective families. They visited the parents once a year. Jayaram and his wife travelled to USA to be with the children and grandchildren for a few months, as was the practice with many Indian parents with children abroad. Life seemed to offer the best of both worlds. However, this state of well-being was not to last forever.

In early 2015, Jayaram’s condition took a marked downhill course. He developed global insomnia, decreasing appetite, weight loss, and refusal to extend his cooperation in simple activities of daily living, leaving the wife, the principal caregiver, in a desperate state and with increasing inability to cope with the situation. She was in a near ‘burn-out’ phase and that is what  brought her to the doors of TriMed-Neurokrish. He was bed bound, with double incontinence, expressive aphasia (inability to express language through speech or writing), and probable unexpressed pain and discomfort, resultant behavioural and psychological dysfunction. He became stubborn, refusing to follow any instruction. However, formal psychological testing revealed that he had retained several of his cognitive abilities. Repeated and staggered assessments had to be carried out, deriving maximum diagnostic leads during the lucid phases of orientation and patient co-operation.

Our Healing Approach

From the start, the patient management by our team had to be home-care based, since transporting him to the clinic would prove to be a great ordeal all round and would cause exacerbation of behavioural symptoms. A global assessment of the patient was the first step. Jayaram was clearly heading towards Stage 3 Dementia, in the absence of stimulation and positive hand-holding.

The patient was already on multiple drugs for Dementia, Behavioural and Psychological Symptoms of Dememtia (BPSD) and comorbid conditions, prescribed by his regular Neurologist and Diabetologist  over the years. He was on Escitalopam 10 mg – 0-0-1 (a mood elevator), along with Tab.Donamem 10 mg – 0-0-1  (a combination drug of Donapezil and Memantine and specific for dementia), Tab.Oleanz 2.5 mg – 0-0-1, Olanzipine (an antipsychotic), Tab.Ativan 1 mg – 1/2-0-1, Lorazepam (for a tranquillising effect) and follow up with a Diabetologist and General Physician, who had prescribed regular Tab.Glyciphage 1-0-1, Tab.Telista (Telmisartan) 40mg – 1-0-0,  Tab.Ecosprin 150 mg – 0-0-1 and Tab.Tonact TG (Atorvastatin)  0-0-1 towards control of diabetes and hypertension and blood thinning and cholesterol-lowering  actions,  respectively.

The team decision was to cash in on the patient’s cognitive reserve after reshuffling the regular medicine regimen and introducing add-on medication to tame the BPS.  In short, the focus was on pharmacotherapy to control the BPS, and cognitive therapy to encourage re-establishing basal activities of daily living to start with. He was treated with Dicorate ER 1 g a day and Tab. Escitalopam 10 mg was stepped up to 1-0-1, in addition to Donamem and his other regular medication. The physiotherapist encouraged gait training in a graded manner till the patient was able to walk around the house with support. With this the BPSD symptoms decreased. Remission or reduction of BPSD is known to produce remarkable improvement in the functional and even cognitive  abilities of the patient, which it did in the case of Jayaram. He became more responsive in interpersonal relations, responded to questions, showed some improvement in memory in terms of alphabets, numbers and was able to indulge in meaningful physical activities like throwing a ball.

Glycemic control was one of the foremost challenges at this point, with an erratic dietary pattern, at the patient’s bidding, often ending with poor intake followed by binging on carbohydrates and sweets of his preference. His regular diabetologist reviewed his diabetic status. Jayaam needed a short period of hospitalization as his blood sugar levels were high. On Tab.Galvus Met 50/500 – 1-0-1  and Tab.Diamicron 80 mg 1/2-0-0, the most recent prescription, good control of blood sugar levels and  hypertension was established. A lipids review showed a high level of triglycerides and cholesterol. With titration of the drug dosage during his period in hospital, his medication was lowered subsequently to Escitalopram  10 mg – 0-0-1 and Tab.Dicorate to 750 mg – 0-0-1, and the significant control of the BPS remained. However, the occasional lack of overnight sleep would bring on the screaming, which started as a whimper, built up to a crescendo, staying high-pitched for prolonged stretches into the morning hours.

Meanwhile Jayaram developed an intermittent headache, which he indicated by constantly holding his head with his hands, and tucked between his folded knees. As BPS can increase with pain or other discomfort, a detailed investigation for headache was done and diagnosed to be an exacerbation of the migraine which was recorded in his past history. He was treated with Tab.Sibelium 5 mg, 1 at bedtime which effectively controlled the headache.

Initial hand-holding of the spouse to reduce caregiver fatigue and hopelessness was an essential part of the treatment plan, as much to safeguard her health status as to encourage her active participation in the management of the patient. She had meanwhile learnt to cope with his illness, having reached the acceptance stage. However, episodic exacerbation of caregiver distress was inevitable in spite of formal caregivers employed.

“Initial hand-holding of the spouse to reduce caregiver fatigue and hopelessness was an essential part of the treatment plan…”

Dementia

Behavioral and Psychological Symptoms of Dementia (BPSD), represent a heterogeneous group of non-cognitive symptoms and behaviors which occur in subjects with dementia. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. BPSD constitute a major component of the dementia syndrome irrespective of its subtype and it has been estimated that it affects up to 90% of all dementia subjects over the course of their illness (Lyketsos, 2015). BPSD is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD.

BPSD also have a profound physical and psychological impact on both the formal and informal caregivers. A considerable part of caregiver distress relates directly to the manifestation of BPSD. Caregiver burden refers to the presence of problems, difficulties or adverse events which affect the life of significant other(s) of the patient (Platt, S., 1985). It is the extent to which caregivers perceive their emotional, physical health, social life, and financial status to be affected as a result of caregiving (Zarit et al., 1986). A qualitative quote from an Indian study reflects the Indian ethos and culture of caring for a near relative:  ‘‘Why are you using the word ‘Burden’? My father is not a burden to me. It is my duty to care for my parent and doing so makes me a little tired but gives me great satisfaction.”  (R.D. Pattanayak, 2010). Regarding BPSD, these symptoms are stressful for the co-resident caregivers, who lack support and guidance from the health care delivery system which service is poor in developing nations (Shaji K.S., 2009). Prince observes “Our findings underline the global impact of caring for a person with dementia and support the need for scaling up carer support, education and training.. Carer benefits, disability benefits for people with dementia and respite care should all be considered” (Prince, M., 2012).

References

  • Helen C. Kales , Laura N. Gitlin, Constantine G. Lyketsos Assessment and management of behavioral and psychological symptoms of dementia, State of the Art Review BMJ 2015;350:h369
  • Platt, S., 1985. Measuring the burden of psychiatric illness on the family: an evaluation of some rating scales. Psychol. Med. 15, 383–393. Zarit, S.H., Todd, P.A., Zarit, J.M., 1986. Subjective burden of husbands and wives as caregivers: a longitudinal study. Gerontologist 26, 260–270
  • R.D. Pattanayak , R. Jena , M. Tripathi , S.K. Khandelwal ,  Asian Journal of Psychiatry 3 (2010) 112–116 Shaji, K.S., George, R.K., Prince, M.J., Jacob, K.S., 2009. Behavioral symptoms and caregiver burden in dementia. Indian J. Psychiatry 51, 45–49.
  • Prince M., Brodaty H., Uwakwe R., Acosta D., Ferri C.P., Guerra M., Huang Y., Jacob K.S., Llibre Rodriguez J.J., Salas A., Sosa A.L., Williams J.D., Jotheeswaran A.T.,Liu Z. Strain and its correlates among carers of people with dementia in low-income and middle-income countries. A 10/66 Dementia Research Group population-based survey Int J Geriatr Psychiatry. 2012 Jul;27(7):670-82.

Looking Ahead

The merciless progression of the degenerative process cannot be halted or reversed at this stage of medical knowledge. However, reducing the BPSD significantly, encouraging some physical and mental activity in the patient and allowing some calm to prevail is in itself noteworthy.

The spouse’s understanding has changed from vacillating between anger, fear and panic, to one of acceptance and the need for pursuing individual activities to the extent possible within the circumstances. She is in better control of her emotions. She is aware that with progression of the degenerative process, the cognitive, language and motor decline will be steep and that the character of the BPS often can change from one of positive symptoms of aggression, night-wandering to a predomi-nant negative symptom cluster, characterized by apathy. She is thankful for being able to give some quality of life to her husband, and to have achieved some peace of mind and calm, having reposed faith in the treating team and managing reasonably with formal caregivers to share the work.She shudders at the thought of the day’s prior to TriMed-Neurokrish intervention when each day was a nightmare. Knowl-edge is power, and with it, if you have extended your resources-physical, mental, emotional, financial to the utmost, you know you have done your best.

Categories
Buddhi Stories Depression Elders Featured Patient Stories Traumatic Brain Injury

Varadarajan – Spiritual Odyssey

Varadarajan – Spiritual Odyssey
Varadarajan – Spiritual Odyssey

Varadarajan was on a pilgrimage to Badrinath in the company of extended family members in late 2010. Little did he imagine that he would be the victim of a fall, which proved disastrous and would alter the course of his life so abruptly. The initial 3-4 months of dramatic progress in his health condition reached a plateau, with minimal further improvement. It was at this point of standstill that the helplessness and hopelessness of a dependent status descended on him. The loss of self-esteem and of self-confidence built up, till the depression peaked in early 2013. All this in spite of a supportive family.

Biography

Mr. Varadarajan an engineering graduate, worked in a company for a few years before he decided to establish his own business. This he pursued in a committed manner and with enterprise, travelled a great deal on business, kept his family comfortable, educated his two children well, arranged & conducted his daughter’s marriage, an important milestone for any middle aged Indian couple. The daughter is settled abroad and visits with family every year. The trip to Badrinath, fulfilled Varadarajan’s religious inclinations as much as his urge to travel and seek adventure in the ‘mountainous Himalayan escape’!

Of Holy Shrines and Landslides The organised Char Dham pilgrimage is to the holy shrines of Lord Vishnu, Siva, Gangotri and Yamunotri, dotting the celestial Himalayan heights of Uttarakhand. The shrines are open to devotees in May and closed in early October, with the onset of the heavy snowfall. Roadblocks occur due to landslides, especially during the monsoon months of July-August, when the south-westerly winds bring with it rain, which lashes in all her fury on the slopes of the mountain ranges. Thousands of pilgrims may be stranded for a few days to a week for the roads to be cleared following a landslide. Natural disasters caused by the landslides and flash floods (the latter as in 2012 which claimed many lives) are no deterrent to the pilgrims, and year after year over 20 million pilgrims visit these holy temples in groups. The Border Road Organisation, Uttarakhand Government and the Badrinath-Kedarnath Temple Committee have their hands full during the pilgrimage season, not only to cater to basic amenities, which are sparse, but also to ensure the safety of vehicles on the winding, hazardous roads leading to the shrines. The Army is called upon to help in clearing heavy roadblocks and emergency helicopter service has to be sometimes deployed for medical emergencies and in disaster situations. The State Disaster Response Force has been established following the flash floods in 2013, to regulate the flow of pilgrims and towards better preparedness in the face of natural or man-made disaster situations. All these arrangements fall short of ideal organization, which the sheer enormity of the pilgrim population defeats.

The bus with the pilgrims had wound its way through the mountainous terrain until the driver was alerted of landslides ahead, and he knew by force of habit that he must halt the vehicle and warn the passengers to stay put. They had reached Pandukeshwar, a small town, 1829 metres above sea level, which lies about 20 km from the Vishnu temple at Badrinath. The bus crew took control of the situation, which was familiar to them, and made sure that there was no sign of panic among the busload of devotees. Their common mission was to reach Badrinath and that they would.

Exploring the Condition

Peace and calm prevailed and the long wait for the onward journey was taken as the ‘Will of God’. It was in the late evening that Varadarajan having just stepped out of the bus, perhaps to answer the call of nature, slipped on the slope, which sent him hurtling down 40 feet to land on his forehead. The bus crew and a few passengers rushed to the rescue. The wound was sutured and other first aid measures employed by the special team of healthcare providers. There was no immediate sequelae of loss of consciousness or seizures.

Varadarajan, within a few hours of the event, showed the foreboding signs of irritability and restlessness, pacing the floor of the shelter, becoming disoriented at times. He was transferred to the primary health centre at Joshi matt the following morning. In the next 3 days he progressed to semi-coma and was slipping into coma, and required specialized care. He was air-lifted by the Army helicopter and admitted to the ICU of a premier hospital in Dehradun, (the capital of Uttarakhand) which offered Neurosurgery as a superspeciality. The MRI reported ‘Subarachnoid haemorrhage and Subdural haematoma, with contusion on the right side’. His progress was monitored closely to minimize secondary brain injury following Traumatic Brain Injury (TBI), and the condition was managed conservatively with the patient on heavy medication. He regained consciousness after 21 days, was disoriented initially and did not recognize his immediate family members, who had rushed down on receiving the news. At discharge he was able to sit up, was on oral feeds and was continent and off the Foley’s catheter.

Back in Chennai, followed by a neurologist, and on home care, in familiar surroundings, stimulated by the presence of family and friends and with minimum therapies, the patient made slow progress. Over a few months, his memory improved, and he recovered his gross cognitive ability and other faculties, including to some extent language and writing skills. There was a residual right-sided weakness, but the patient could walk with a little support. He had impaired hearing in the right ear. Repeat MRI confirmed resolution of the blood clots over large brain areas, which correlated with return of efficient brain functioning. 

Traumatic Brain Injury

  1. Moderate to severe Traumatic Brain Injury (TBI) is a major Public Health concern in India, as  it is globally. 1.5 to 2 million persons are injured and 1 million succumb to death every year in India due to accidents. A comprehensive report in 2002 of the Dept. of Epidemiology, WHO Collaborating Centre for Injury Prevention and Safety Promotion, Rehabilitation, Policies and Programmes, at NIMHANS, Bangalore, India, headed by Prof. Gururaj, states that road traffic injuries are the leading cause (60%) of TBIs, followed by falls (20%-25%) and violence (10%). Since then, road traffic accidents have increased exponentially, and with an ageing population, falls in the elderly must add significantly to that category as well.
  2. Of all TBIs, 63% affect persons aged 15 to 64 and these represent the primary working population. These persons often have severe problems resuming a productive life and maintaining satisfactory interpersonal relations, despite the significant physical recovery within the first 6 months of injury. Depression can occur at any stage following an acquired brain injury, from the acute hospital stage to many years later. Post-injury depression may range from mild, (where a person may still be able to function in day to day life, but generally feel ‘low’), to severe depression and debilitation. Like in other forms of depression, the mood may be of sadness, despair, flat emotional reaction, increased frustration, irritability and anger. The thinking pattern may include a sense of hopelessness, pessimistic beliefs, and behaviour patterns may be of reduced attention to physical appearance, social withdrawal, loss of motivation to participate in activities the subject enjoyed premorbidly, accompanied by  fatigue, sleep disturbances and poor appetite. There may be inability to return to previous employment and the subject may become dependent and progressively isolated, with a gradual decline in ability to perform everyday tasks and progressive disability to cope with everyday stressors. Most of the patients with these disturbances are unable to identify the cause of their inner mental state or report their social functioning accurately and the family may be at an equal loss to fathom the reason. Researchers have consistently suggested that the psychosocial problems associated with TBI may be the major challenge facing rehabilitation. This is where a specialist integrative therapy team can step in to achieve what seems impossible, patiently holding the hands of the patient and family members, guiding them through the assessments followed by the therapies in a graded manner and coaxing stepwise positive advancement in the patient’s condition. This is the ‘Art of Medicine’.
  3. Recognition of pituitary hormonal insufficiencies after head injury and Aneurysmal Subarachnoid Hemorrhage (SAH) may be important, especially given that hypopituitarism-related neurobehavioral problems are typically alleviated by hormone replacement.
  • Gururaj G. Epidemiology of Traumatic Brain Injuries: Indian scenario. Neurol Res. 2002  Jan;24(1):24-8.
  • Rafael Gomez-Hernandez, Jeffrey E. Max, Todd Kosier, BS, Sergio Paradiso, Sergio Paradiso, Robert G. Robinson, Social Impairment and Depression After Traumatic Brain Injury Archives of Physical Medicine Rehabilitation 1997; 78: 1321-1326
  • Daniel F.Kelly, Irene T, Gaw Gonzalo, Pejman Cohan, Nancy Berman, Ronald Werdloff,  Christina Wang Hypopituatarism Following Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: a preliminary report J Neurosurg; 93: 743–752, 2000

The Prolonged, Gloomy, Negative Phase

The rehabilitation progress seemed to have reached a plateau within the next few months . The realization of the problems related to recovery from TBI dawned on Mr. Varadarajan. He was no longer the independent, vigorous, frequent-traveller, successful businessman, to whom the whole family looked up and others marveled. He was dependent, even for some physical help, could no longer travel alone on business, and with the financial stress and poor back up of human resource for his private enterprise, he was in the verge of closing down his business, which he had nurtured with a certain nonchalant air of confidence through these years. Life seemed to be slipping away from his control, and he was home bound, sleeping much of the time, with poor appetite, poor socializing and full of all the negative thoughts which sheer hopelessness can bring with it.

At this juncture, Varadarajan’s son’s marriage was fixed and the wife was forced to take up single-handedly, the elaborate arrangements and formalities which go with an arranged south Indian marriage. The daughter, who arrived early from abroad for her brother’s marriage, was alarmed at the father’s state of health, with weight loss, socially withdrawn, curled up in bed and sleeping long hours and finding it difficult to participate spiritedly in the wedding activities, which was very unlike the father she knew. She realised that something had to be done to pull him out of this state and to instill in him some positive energy. It was at this point that she came across information of the novel and holistic TriMed-Neurokrish approach to healthcare and decided to pursue it.

Our Healing Approach

After putting the marriage celebrations behind her, Varadarajan’s daughter arrived at the Trimed-Neurokrish reception counter and made enquiries and met Dr. E. S. Krishnamoorthy. She knew right away that that ray of hope to give her father some quality of life lay in this setting. She did not delay by even a day to arrive with her father to initiate the comprehensive assessment, integrated therapy and counselling offered here.

The Neuropsychiatric diagnosis was Post-Traumatic Brain Injury Depression, and Gait Disability. The residual neurological deficit was minimal on clinical examination, with some gait dysfunction and right sided weakness. Blood examination was unremarkable except for D3 deficit. A careful endocrinal screening was done to rule out neurobehavioural problems secondary to hypopituitarism, which can occur in TBI with subarachnoid haemorrhage.

Varadarajan’s blood pressure was under control on regular medication with Amlodipine taken twice daily. He was also on regular Phenytoin Sodium twice daily, Clinidipine for heart function, started on admission soon after the TBI and these continued. Other medication introduced at Trimed-Neurokrish included antioxidants, piracetam, ginseng (all for brain health), pregabalin (for anxiety and seizure prophylaxis) once a day, Donepezil (for memory) and Paroxetine (for mood). Vitamin D3 and B12 supplementation was initiated as well. 

On neuropsychological evaluation, deficits in certain subtler areas of cognition were noted, which could hinder efficient performance. When questioned, Varadarajan said he felt hopeless, worthless, and had a sense of guilt for not being able to support his family. Cognitive Behaviour Therapy for depression and Cognitive Retraining were introduced and continued for over months, with a definite positive trend in his outlook. Family counseling and psychoeducation added to the improvement. The physiotherapist noted severe hamstring spasm, with restricted SLR bilaterally – basic exercises to make the limbs more flexible were given with Yoga and mud therapy. His gait disabilities were addressed specifically and over time he began to ambulate with greater ease. Yoga therapy helped his posture and balance, apart from reducing anxiety. Ayurvedic medicated oil massage for muscle spasm and joint flexibility, Shirodhara for cognition and mood and sessions of acupuncture were all spread over 3 months. Patient and family members were extremely pleased with the personal participation in the recovery process, the positive waves from the team enhancing the results of the long term therapies.

The focus of the TriMed-Neurokrish challenge was not just to improve the physical independent activity  of the patient, but to modify behaviour (with the negative feelings of hopelessness and helplessness of the patient, leading to severe depression), to positive waves in slow but sure stages through cognitive behaviour therapy for the patient and through family counseling. Gaining the trust of the patient and family as the first step made them go along with the therapies with a sense of total dynamic participation in the process of rehabilitation and it even became a ‘fun game’ as marked improvement was noted. Recognising the patient’s often warped ‘thoughts and beliefs’, the altered life situations and the loss of self-esteem that contribute to the maladaptive and social withdrawal behaviours and the immediate triggers that set it off, are part of the sensitive professional assessments. These can be remedied by cognitive behaviour therapy, (when followed with diligence), towards placing the patient back in his original zone of comfort and self confidence in the home and in the community. A supportive network in this process includes health care providers, family, old friends, new friends, and persons who have had similar experiences.

The yoga sessions, massages, and other integrative therapies reinforce the wellness of the person through their general and specific actions, ensure continuity with the treatment team, and motivate the patient and family to participate willingly in the path to patient recovery.

“She knew right away that that ray of hope to give her father some quality of life lay in this setting.”

Looking Ahead

Over months, Varadarajan has made a steady recovery. His cognitive difficulties have largely remitted, his walking has improved, so much so, that he now does 5 kms on his own and walks his dog as well; his mood has improved, anxiety reduced and confidence levels have been boosted considerably. He is attending to his business again and has started to strike new deals, possibly saving his factory from closure; he is even planning a visit to the USA to spend time with his daughter, rekindling too an old desire for travel. Mr. Varadarajan continues to attend his medical reviews and booster therapy sessions regularly as scheduled and is gregarious in his interactions with the treating team, often sharing a hearty laugh.

For us, Varadarajan and scores of courageous patients like him, are our true inspiration. His family are beside themselves with joy to have him well and truly back in their midst, for his has truly been “A Himalayan Odyssey”. The Longman’s Dictionary of Contemporary English which defines the word ‘odyssey’ (with its roots in the Homer’s epic poem by that name)  “as a series of experiences that teach you something about yourself or about life – a spiritual odyssey”, suits the theme of this TriMed-Neurokrish story best.

Categories
Buddhi Stories Dementia Elders Featured Patient Stories

Bharadwaj – The Resurrection

Bharadwaj – The Resurrection
Bharadwaj – The Resurrection

Biography

Bharadwaj at 74 years was alert, active, enjoyed life as a whole and the company of his son, daughter, their spouses and their children. Born into an illustrious industrial house of Madras, he pursued his engineering studies abroad and came back to join, along with his 3 brothers, the industry founded by his father. In contrast to Jayaraman our other patient with dementia, here was Bharadwaj, with a huge extended family, all living close by, with him and his wife living with the son’s family, with a doting daughter and family next door. Socializing within this inner group, with true camaraderie and meeting over a meal on the multiple Indian festive occasions with exchange of gifts, and taking turns in singing south Indian classical music compositions solo or in groups was the traditional practice, a form of partial community living which could curb individuality, but did have its benefits for extended families that kept in close touch. There was  support through thick and thin from extended family, close family ties among large extended families being common till 3-4 decades ago. The advantages of such mutual support is slowly being eroded as families scatter and few of the younger generation, who migrate to greener pastures in the quest of employment and upward mobility, are left behind.

Exploring the Condition

Bharadwaj’s loss of cognitive ability was subtle and demonstrated itself as changes in mood and behavior. His family noticed several changes in him over time; he became progressively withdrawn socially, spoke very little, stopped watching TV or reading the newspaper. In stages, fatigued, depressed and lacking motivation, he confined himself to bed, and with less physical activity, he became a near recluse in the midst of the over-reaching social interaction around him. More worryingly, for the family, the gregarious family man became paranoid and prone to spells of aggression, a change that was both frightening and distressing. No amount of coaxing and cajoling from his son, daughter and other close family members could shake his resolve to slowly fade away. It is in this mood that he was brought to TriMed-Neurokrish, stubborn as a mule and refusing to co-operate for the comprehensive assessment and showing resistance to undergo therapy.

Bharadwaj was not diabetic or hypertensive. His lab reports were unremarkable. He had followed the middle path in his lifestyle, well-disciplined, with no excesses, and no smoking or drinking. He was, however, addicted to south Indian classical music, and would venture into complex pre-composed music, and sing along with his daughter in a state of joy and sheer abandon as the melody flowed in an unfettered cascade. Where had that music gone?

It was the gentle persuasion of the daughter and daughter-in-law on the one hand, and the professional prowess of the TriMed-Neurokrish team on the other, that saw the thawing of Bharadwaj‘s adamant early phase, and he entered the phase of acceptance of the assessment and integrated therapy, though rather grudgingly to start with. A diagnosis of Dementia, stage 2 was made, knocking threateningly at the doors of stage 3 if not intensively managed. His behavioural manifestations were those of apathy, irritability and aggression on the Neuropsychiatric Inventory (NPI).

Our Healing Approach

Bharadwaj was already on Admenta (memantine) and Cognix (piracetam) along with a mood elevator prescribed by a Neurology Consultant, who had seen him in early 2015. We added a small dose of an antipsychotic, Olanzapine. With strengthening of the lower limbs and gait training, Bharadwaj became less dependent as he walked with minimal support, and his low back pain, and body pain, which he had brought upon himself with poor physical activity, was under control. Abhyanga (Ayurvedic whole-body warm, herbal oil massage), Shirodhara (Ayurvedic therapy that involves gentle pouring of liquids over the forehead) and Acupressure ran parallel, as part of the intensive therapy. Reflexology was also introduced. It was a slow and tedious process that shook off the negative apathetic behaviour and veered Bharadwaj toward a more positive behaviour.

Reflexology

Reflexology is an ancient traditional massage form, involving particular areas of feet, hands and ears which are believed to represent specific human internal organs and body systems. These areas have been mapped elaborately especially to guide foot reflexology. The skilled massage can achieve positive changes in the function of these organs and systems and is also effective in neck, upper back, lower back, painful disorders of the spine, and knee pain. In the book “Relieving Pain At Home” authored by William H. Fitzgerald (1917), an ENT specialist, he observes “Humanity is awakening to the fact that sickness, in a large percentage of cases, is an error of body and mind”, echoing the modern concept of body-mind link in many chronic medical conditions. Reflexology as a discipline shares the common belief of the ancient therapies, in that of opening of any block in the energy channels of the body.

Our Focus

Cognitive retraining is a therapeutic strategy that seeks to improve or restore a specific person’s skills in the areas of paying attention, remembering, organizing, reasoning and understanding, problem-solving, decision making, and higher level cognitive abilities. The primary aim of this therapy is to train the patient to overcome the cognitive difficulties that interfere with day to day activity, towards gaining independence in activity.

Retraining usually begins with simpler cognitive skills like attention, short term memory and information processing and then proceeds to more complex skills like problem solving, and executive function. Each identified lost skill is retrained using graded practice of activities. Cognitive retraining involves repetitive practice that focuses on the skills of interest. Repetition is essential for the newly retrained skills to become automatic. Cognitive retraining requires a quiet room without distractions and the patient must be able to relax to receive optimum benefit from the retraining.

References

Alex Bahar-Fuchs A, Clare L, Wood  B Cognitive Training and Cognitive Rehabilitation for persons with mild to moderate dementia of the Alzheimer’s or vascular type: a review Alzheimers Res Ther. (2013) 5 (4): 35

Malhotra S,. Bhatia MS, Rajender G, Sharma V, Singh TB Current Update on Cognitive retraining in Neuropsychiatric disorders Review Article Delhi Psychiatry Journal (Oct. 2009) 12 ( 2 ): 213-218.

Looking Ahead

At the 6 month follow up, Bharadwaj is well overall, except for the occasional disturbances at night.

  • Aricep (donepezil) 10mg – 1-0-0
  • Admenta (memantine) 10mg – 0-0-2
  • Cognix Plus (piracetam + gingko biloba) 1-0-1
  • A to Z  1-0-0
  • Supracal A (calcium + D3) 1-0-0
  • Epitril 0.5 mg (clonazepam) was prescribed SOS at bedtime

He continues his therapies once a week. Bharadwaj walks with a little support within the house, is more independent in his self care, but needs help with soaping himself, and toweling after a bath. He socializes with immediate family members and language is more fluent and the content shows improvement. The lyrics of familiar songs are well recalled and musically expressed, as they go with the melody and the beat. Being able to sing puts him in a mood of elation. Perhaps most striking, he has islands of great clarity in thought and expression now. Recently, while watching a cricket match (another of his erstwhile passions) on the television, he regaled his family to their delight with comparisons, about the innings being played and another famous one from cricketing history. The family is pleased to see Bharadwaj enjoy some quality of life and never miss the once a week therapies.

Categories
Buddhi Stories Elders Epilepsy & Seizures Featured Patient Stories Stroke & Cardiovascular Diseases

Devi – The Iron Lady

Traumatic Brain Injury Dialogue- Buddhi Clinic
Traumatic Brain Injury Dialogue- Buddhi Clinic

It was the harvest festival of South India, Pongal – the day of Thanksgiving to the Sun God – the beginning of the new Tamil month, Thai, and as the popular saying goes, “Thai brings in its wake, new hope and cheer”. The house had to be decorated with flowers and the pot of rice with all its special ingredients had to be allowed to boil over, symbolic of plenty, peace and prosperity. Families would gather to celebrate the joyous occasion together. The festivities would continue over 4 days – cattle pampered with special food, decked with bells, cowrie shells and flower garlands and rejoicing covered every aspect of agricultural life. Urbanisation had not taken away from marking this day of festivity every year, when man, beast, the sun and rain gods and the earth, all came together to celebrate the yield of man’s toil, in the form of nature’s harvest bounty. It was a celebration of life and all living things in an environment of harmony, peace and goodwill to all.

Biography

January 14th, 2015, 6 am on Pongal day and the 80 year old lady Mrs. Devi was already up, bathed and dressed in the exquisite new Kanchipuram sari gifted to her by her family for the festive occasion. The gift was also to mark a warm home-coming, after three months of grappling with the acute phase and serious sequelae of a cerebrovascular event she had miraculously conquered. The spirit of Pongal which signifies the unity of all living things on the face of the earth and the five elements, seemed to echo the principles of Yoga, acupuncture, Ayurvedic massage and other forms of traditional Medicine of the East, which follow the tenet that the body heals itself. Mrs. Devi had undergone these alternative therapies in the subacute and rehabilitation phase of the stroke.

Was Devi slowly reclaiming her original, premorbid personality, which many could have envied?  She had been active and on her toes from dawn to dusk, warm in her relationship with the members of her family and friends alike, a good wife, a loving mother, a doting grandmother and  a charming and gracious host. As a homemaker, home and hearth were always her priority, but it was the joy of giving of her best that made her unique! The grandchildren swore that only grandma could make such exotic ‘meen kozhumbu’ (fish curry). The daughters’- in – law sharpened their culinary skills, with Devi overseeing the making of the new recipe, or produced the most intricate rangoli designs on the floor in their courtyard, with her active participation, or just tucked the children in bed before going out for a function with their respective husbands, with the assurance that Devi was there to keep a watchful eye on them, even through their deep slumber.

Exploring the Condition

Mrs Devi, a known hypertensive on regular antihypertensive medication for 6 years, (Tab Telma 40 mg. 1-0-0 and Tab. Tazloc 20mg.-0-0-1), had  an episode of seizure followed by difficulty in speaking and  weakness of the right upper and lower limbs in mid October 2014, when she was admitted to a leading hospital in Chennai.

Frisium (Clobazam) and Dicorate (Divalproex Sodium) tablets were added to her drug regimen as anticonvulsant therapy. A diagnosis of left middle cerebral artery (MCA) infarct was made, confirmed by CT scan and routine stroke management initiated. All seemed well till 3rd November, when she developed acute breathlessness and emergency tracheostomy was performed, following which she was on ventilator support for a period of ten days. On inpatient treatment, she recovered, was able to talk normally, walk, and attend to her activities of daily living with partial support.

A second episode of seizure and loss of consciousness occurred, The repeat MR imaging revealed bilateral subarachnoid haemorrhage, with oedema and mass effect. There was a 50-60% block of the right internal carotid artery and a small berry aneurysm of the left middle cerebral artery. After a stormy period in ICU, she slipped into deep coma. The hospital indicated to the family that continued intensive care while required, did not guarantee a good prognosis.

At this point, she was transferred at the family’s initiative to Trimed-Neurokrish care in our partner hospital. At the time of take over, Devi was barely conscious, had the tracheostomy tube, feeding tube and catheter in place, was severely paralysed on the left side, with not even a flicker of muscle contraction and had excessive throat secretions and severe chest congestion.

The Diagnosis

The first stroke was an infarct, due to lack of blood supply to a well – defined vascular territory of the brain, the first indicator of a cerebrovascular deficit.  The second stroke was the result of a bleed from the berry aneurysm into the subarachnoid space. Was there a minor re-bleed resulting in the first respiratory distress event, or was it caused purely by aspiration, and secondary chest congestion and infection? Initially, the tracheostomy tube was blocked requiring constant attention and had to be replaced by a metal tube, and this was electively removed after a few months of stabilization of the patient’s condition by the ENT surgeon.

Saccular Cerebral Aneurysms, also known as Berry Aneurysms, are intracranial aneurysms with a rounded appearance and account for the majority of intracranial aneurysms. They are also the most common cause of non-traumatic Subarachnoid Haemorrhage (SAH). SAH  accounts for 3% of all strokes, and 50% are fatal

Sudlow and Warlow, 19971

Of those who survive, “All in all, only a small minority of all patients with SAH have a truly good outcome.”

Johnston 19982

Aneurysmal Subarachnoid Haemorrhage (aSAH): The prevalence of intracranial aneurysms from various parts of India varies from 0.75 to 10.3%, with higher numbers of cases being diagnosed due to increasing age of the population and improvements in imaging techniques. Surgical clipping of aneurysm is not much resorted to in India

Koshy 20103

Un-ruptured aneurysms are asymptomatic making it difficult to identify the patients with un-ruptured aneurysms and prevent subarachnoid haemorrhage

Shingare 20114

There is familial predisposition to SAH, with 5-20% having a positive family history. Hypertension, excessive alcohol consumption and smoking are the other risk factors. Though a very severe headache of sudden onset is the typical history, as in the case of  Devi, seizure may mark the onset, with loss of consciousness initially and in an obtunded state over several days. The risk of rebleeding gradually decrease between 1-6 months. MRA is a feasible tool for detecting aneurysms.

1 Sudlow CL, Warlow CP. Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. Stroke 1997; 28: 491–9.

Our Healing Approach

After the TriMed-Neurokrish comprehensive assessment, overseen by our neurologist and rehabilitation physician, supported by our chest and ENT physician, we optimised all Devi’s medication including broad spectrum antibiotics, bronchodilators and nebulisation, and the patient’s condition stabilized. We introduced moderate dose intravenous steroids to kick start brain function. We also started to deliver to her, on the bedside, an integrative therapy program. She was discharged after an ENT opinion was obtained on the tracheostomy status and the cardiologist opinion. She continued therapy at home.

The patient was readmitted 3 weeks later into the ICU with acute symptoms following a probable aspiration. Endotracheal secretion culture and sensitivity was positive for Klebsiella pneumoniae and Pseudomonas aeroginosa, and treated with the antibiotic of choice.  Suction of the lung secretions and chest physiotherapy was part of the intensive treatment of this second episode of acute respiratory distress. This was followed by stepping up the alternative therapies and the patient’s recovery has been on a remarkable upward curve.

Our Focus:

Devi had undergone Yoga, Ayurvedic massage, acupuncture, acupressure, reflexology and other forms of traditional Medicine of the East over the subacute and rehabilitation phase of the stroke. All these forms of what is globally termed Complementary and Alternative Medicine (CAM) sets its strong belief in the body healing itself, empowered by the energy centres in the body and the flow of this energy through specific channels. Any block in the energy flow causes ill health. Traditional knowledge-based interventions released these blocks, to pave the way to recovery. The TriMed-Neurokrish technique is to encourage the CAM procedures of the trained team, to complement the astute Allopathic diagnosis and management, cognitive therapies and counseling. It allows patient participation in his/her own healthcare, along with family members, who witness the palpable improvement in the patient’s health condition.

A little detail of the yoga breathing patterns and exercises that benefitted Devi and its rationale in yogic terms, will not be out of place in its elaboration here.

Yoga asanas involve movements (bending, stretching, rotating), that stimulate ‘injured’ parts of the body by increasing the blood supply, followed by phases of total relaxation, Savasana, between movement phases. In the case of Devi, our Naturopathy & Yoga doctor believed that the group of asanas that stretch and strengthen the thoracic cage muscles, to encourage full excursion of the chest wall in efficacious breathing would benefit her most as therapy and eliminate her acute respiratory episodes. Considering her age and health state, the therapist chose to put her on a simple but an intensive asana regimen which he stepped up in a graded manner. Padahasthasana involves a set of asanas with stretching and touching toes standing and in a seated position, with outstretched lower limbs. Thadasana is standing upright ‘like a mountain’, stretching backward and bending forward to touch toes on the same side. Trikonasana: standing and bending diagonally to touch toes on the opposite side; repeating stretches in the seated position – Paschimottanasanas – seated and bending forward to touch toes; also bending diagonally to touch toes on opposite feet, alternately. Rhythmic abdominal breathing accompanies these movements, with the  inhalation phase accompanying the stretch and exhalation phase, the bending.

Breath is the essence of Prana – the ‘life force’. Pranayama, alternative nostril breathing in Padmasana meditative seated posture, seeks to harness this prana. By focusing the mind totally on the rhythmic breathing, the body channels are opened, allowing energy to flow freely and connect with the life force. In modern scientific terms, the role of the autonomic nervous system in this breathing pattern has been recognized, with increase in sympathetic inputs. As a result, concentration and clarity of thought develops. Prana provides the strength, power and vitality required to carry out higher level activity. Attentive awareness of the breath can gently lead the aspirant to the art of meditation.

Chinmudra is hand gesture with opposition of the thumb and index finger bilaterally and the other fingers are outstretched and facing upwards. Chinmudra in yogic meditative posture enhances Ekagrhachittam – one-pointed concentration of the mind during meditation. When the finger touches the thumb a circuit is established, which allows the energy that would normally dissipate into the environment, to travel back into the body. When the fingers and hands are placed on the knees, in the meditative seated posture, the knees are sensitized, creating another pranic circuit that maintains and redirects prana within the body. As the palms face upwards in Chinmudra, the chest and heart area are opened up as well.

Why this thumb and index finger alignment in yoga gesture, towards deep concentration? It makes us look for a link with theories regarding the evolution and attributes of thumb opposition in the early homo sapien, employment of toys which encourage a pincer grip for toddlers in the Montessori system of child education, the Neuroscience concept in modern Medicine of the homunculus, where the cortical motor (and sensory) representation of the thumb is enormous, with the index finger next in line, the maximum use of the index finger for serious Braille reading.

“It is specifically the opposition between the thumb and index finger that has made it possible to execute the extremely refined movements that have produced the whole of human culture — from architecture to writing, from music to painting, and all the technology that enriches our lives.”

Looking Ahead

With the last admission for the aspiration pneumonia, Devi had left behind the roller coaster ride through various catastrophic health events. She was alert and poised to instruct her daughters-in-law on making the rice dish to perfection and all the other delicacies for lunch, when the whole family would feast together. Till the previous year, she had led the women of her household by nonchalantly tossing in hand-measured quantities of ingredients with the flourish of the seasoned cook that she was. This year she had to be content with gesturing the instructions with her hands, with the occasional word thrown in. She knew that the cashew-nut jar was on the topmost shelf, out of reach of the children, the jaggery in the jar could not be adequate and more had to be purchased from the corner store. All these minor details of the kitchen front, her culinary skills her motivation and leadership quality returned and she was to participate in yet another family Pongal festivity.

The family members felt that the level of recovery was well beyond all expectations and recollected their shocked state and hopelessness when they saw their dear one being wheeled into the hospital in an obtunded state for the second time in a month. The TriMed-Neurokrish team gave of their best, with total co-operation from the family. But it was the Iron Lady, the patient herself, with her ekagrhachittam or single –pointed intent, focus and willpower that saw her in this recovered state, with some residual visual deficit, a more subdued, rasping voice due to left laryngeal nerve palsy, mild gait disability, but with a mind to overcome even these residual problems or accept the  discomfort they posed, with cheer, to lead from the front once again, as was her nature.

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