fbpx

Tag: Diabetes

Categories
Adults Buddhi Stories Epilepsy & Seizures Featured Memory Problems Patient Stories

Joseph – His Unedited Life

Joseph – His Unedited Life
Joseph – His Unedited Life

Biography

Equipped with a Masters in Political Science, a supportive wife and 2 young children and a video-editing job in a reputed TV channel, which he carried out with a natural flair, Joseph had his stars to thank for a comfortable and fulfilling life. He had always been hardworking, an amiable companion at work, a good husband and a loving father. It was not just the sudden onset of seizures that disrupted his life flow, but the inability to work, the prominent cluster of neurobehavioural symptoms, the agitation, the paranoia, which mounted within a few weeks of the seizure onset. Back at work after recovery from the subacute phase, he could not perform. To make matters worse, the software of the editing platform had been updated with a newer version, during the period of his absence!

When Joseph presented to us over three years back with a cluster of seizure episodes, delirium and subsequent neurobehavioral symptoms, one needed to step back and view the sequence of events that led to this acute/subacute symptom complex that altered the course of his life so dramatically. The hospital which had received Joseph as an emergency had done well to manage the acute phase of the illness. The patient was diabetic and on oral medication with moderate control of blood sugar levels. Other laboratory parameters were within the normal range. The MRI showed bilateral hippocampal atrophy and the EEG recorded bilateral epileptiform dysfunction. A course of IV methylprednisolone brought about some control of the acute phase of the illness.

Exploring the Condition

However, Joseph continued to have seizures, poor recent memory, mood swings, irritability and aggression. He was unable to return to work both due to cognitive deficits which acted as impairment to his job performance and also due to poor social tolerance, to interact with team members. This came to the notice of the TV channel in which he was Senior Video Editor and the managerial staff of the channel took it upon themselves to support and take an active role in the neurorehabilitation  process of the patient. It was then that they stumbled upon Neurokrish – The Neuropsychiatry Center where they met Dr. Ennapadam S Krishnamoorthy. After a detailed interdisciplinary evaluation of his clinical profile, a discussion was held with the family and employer’s Chief Medical Officer on Joseph’s protracted cognitive and neurobehavioural sequelae and its impact – personal, familial and occupational. Concerned that their key employee should continue to work with them, the employer readily offered to support his care in all possible ways. The family too was committed to helping him get back on his feet.

Most importantly, the doctor was the purveyor of good news – that recovery from the ravages of a significant brain inflammation was possible, with medication, prolonged therapy and  psychosocial support. “Patience and gentle persuasion are the key” he said, in a convincing voice, persuading and encouraging patient, family and employers, through the long dreary days and months of targeted therapy.

Understanding Joseph

The enormity of the challenge of comprehensive neurorehabilitation for Joseph descended on us, fully, only when the clinical psychologist along with some other TriMed-Neurokrish team members, tried to unravel from basic literature, the complex demands on the video editor of a TV channel. With this background knowledge the cognitive retraining and cognitive behaviour therapy interventions could be individualized more effectively. A brief account of the video editor’s role would not be out of place here.

Video Editing

Although video editing may be considered a creative act, it requires working through a well-established, predictable set of steps. The first step is the importing and ingesting phase, followed by rough edits to the footage, dragging clips into the timeline, synchronizing the audio track and then fine-tuning the clips. Once the structure is set at this level, some additional post-production steps are required, namely, adding transitions between clips and various kinds of video filters, which change the visual quality of one or more clips to impact on the tone and texture of a piece. Titles are added and finally the color grading is done. In short, TV video editing calls for thematic conceptualization and sequencing in a timeline as executive function, with clarity of online working memory, pattern recognition and creative abilities, visual and auditory sensitivity, coupled with addressing the emotional element of a broadcast, team work and alert, timely delivery of the end product. This end product must capture the main features of the program, have a flow and continuity and appeal to the viewer expectations to create an overall impact!

Our Healing Approach

We came to the diagnosis that his symptoms were provoked by an underlying antibody syndrome – Autoimmune Limbic Encephalitis (LE). Detailed assessment for a possible malignancy was carried out, to rule out Paraneoplastic Limbic Encephalitis A second course of IV methyl prednisolone (the first having been given during admission in the acute phase), intensive cognitive rehabilitation and stress management was the doctor’s well considered management schedule, along with the other integrative therapies .Other medication included Levetiracetam for seizures, Donepezil for memory, Clobazam (for seizures and anxiety), Piracetam and Gingko Biloba (cognitive enhancers). He was under regular antidiabetic medication with his Diabetologist who also saw him through an unexplained acute skin reaction together with a dermatologist.

Cognitive Retraining (CRT) sessions were focused on improvement of sustained attention and memory enhancement. Tasks followed were the cancelling of digits for attention and verbal games, reading and visual memory games. He was able to recall from a small paragraph initially, to quarter of a page at mid therapy and half a page of details by the end of ten sessions of CRT.

Cognitive Behaviour Therapy (CBT) was given for his neurobehavioural symptoms. Family counseling, worksite review, and introduction of Joseph’s family members as his treatment monitors were other focused methods to enhance patient motivation and to see him progressively attain his premorbid state at home, in the community and at his workplace 

Our Ayurveda Consultant prescribed Shirodhara, the calming effect of which has been elaborated in the ancient texts. We have observed remarkable improvement in some of our patients with neurobehavioural problems who have undergone this procedure and we saw it succeed once again in Joseph.

Within a three month period of therapy, with the overall feeling of well being and improvement in his cognitive ability, that glimpse of hope of recovery sparked off definite positive trend in his attitude, with less agitation and irritation, a more focused goal to help himself and to take maximum advantage of the therapies and counseling offered to him by the TriMed-Neurokrish team. From this point the improvement in his condition was by leaps and bounds and there was no looking back.

Our Integrative Medical Therapy

  • Shirodhara is a classical and well-established procedure, as described in the ancient Ayurvedic treatises, of slowly and steadily dripping medicated oil or other liquids onto the forehead. Shira – head, is the ‘Seat of the Mind’ and Dhara signifies flow – a constant flow of the medicated, warm liquid – oil, milk,  buttermilk or coconut water onto the forehead of the subject, lying supine on the Ayurvedic massage table in the yogic Shavasana posture of complete relaxation of body and mind.
  • The liquid is gently poured, in a constant stream, ‘the size of the little finger’ from a height of 8-10cms from a special vessel, (protecting the eyes), onto the centre of the  forehead for a minimum duration of 30 minutes and a maximum of 60 minutes. The liquid is allowed to flow down the scalp and is collected from the table, warmed and reused during the procedure. Shirodhara may be repeated 2-3 times with an interval of 7, 14 or 21 days, depending on the severity of the disease/disorder.
  • The constant flow of fluid stimulating the Sthapani Marma (this ‘vital spot’ being one of the 37 vital spots of the head, the whole body consisting of 107 such spots) indirectly stimulates the pituitary gland, at which brain level (Sthapani), the liquid flow occurs. The Ayurvedic texts mention the master gland and other endocrine glands and their function and clearly outline the calming neurobehavioural benefits of the procedure. The centre of the forehead, which was evolution-wise related to the third eye, is also connected atavistically to the pineal gland. This spot is known as Agnya Chakra, one of the vital energy centres in the yogic tradition. Focusing on Agnya Chakra with closed eyes during meditation leads to psychosomatic harmony.
  • As the oil drips on the Agnya Chakra, the authors propose, that the meditation-like effect is a consequence of stillness of mind leading to adaptive response to the basal stress. Shirodhara is popularized today by the modern health spas as a sure way to ‘rejuvenation and stress relief’! However, the ancient texts lay emphasis on its role in neurological and psychological disorders, headache and insomnia, and mention other indications and contraindications.

References

  1. Vaghbatta. Shirodhara Ashtanga Hridaya, Sutra Sasthana, Chapter 22
  2. GS Lavekar, TV Menon,  Bharthi, A Practical Handbook of  Panchakarma Procedures (2009)  Central Council for Research in Ayurveda and Siddha, Dept. of AYUSH, Ministry of Health and Family Welfare GoI, New Delhi
  3. Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1;  9 : 457–463
  4. Kalpana D. Dhuri, Prashant V. Bodhe,  Ashok  B. Vaidya . Shirodhara: A Psycho-physiological Profile in Healthy Volunteers J Ayurveda Integr Med. 2013 Jan-Mar; 4(1): 40–44.

Our Neuropsychiatry Focus

Autoimmune Limbic Encephalitis is a rare disorder, characterised by the subacute onset of seizures, short-term memory loss, and psychiatric and behavioural symptoms. This type of limbic encephalitis is associated with Voltage-Gated Potassium Channel (VGKC) or N-methyl-D-aspartate receptor (NMDAR) antibodies.

  • The emphasis in the management of autoimmune LE is on its timely recognition, in order to rule out malignancy and to initiate treatment early. This potentially life-threatening disease responds well to immunomodulatory therapy.
  • The diagnosis of Paraneoplastic Limbic Encephalitis (PLE) is difficult because clinical markers are often absent and the LE symptoms usually precede the diagnosis of cancer or may mimic other complications. The clinical diagnosis of PLE requires :
    • a compatible clinical picture;
    • an interval of <4 years between the development of neurological symptoms and tumour diagnosis;
    • exclusion of other neuro-oncological complications.

References

  1. M.J. Thieben, ; Lennon, V.A.  Boeve B.F.  Aksamit A.J.,Keegan M,  Vernino S. Potentially reversible autoimmune limbic encephalitis with neuronal potassium  antibody Neurology April 2004;62:1177–1182
  2. Guetekin SH, Rosenfeld MR, Voltz R, Eichen J, Posner JB, Dalmau J Paraneoplastic limbic encephalitis: neurological symptoms, immunological findings and tumour association in 50 patients. Brain. 2000 Jul;123 ( Pt 7):1481-94

Looking Ahead

At work a change in the software platform used, resulted in Joseph’s problems being magnified. No longer could he work on the auto-pilot, with skills learnt over two decades suddenly becoming obsolete. Supported by the three legged stool, his family, his employer and our therapeutic team, all working in tandem, he has managed to overcome these many hurdles. Apart from therapy and rehabilitation, he has benefitted too from a second course of intravenous steroids. Titrating his drug prescription, avoiding drugs that have unacceptable side effects and responding to his changing situation have all been necessary.

Two years on, the transformation of Joseph is remarkable. He is seizure free, composed, communicates clearly and well, manages well at work having learnt to use the new software platform, and enjoys a close trusting relationship with his family. He still has some residual memory and cognitive dysfunction and attends our centre for periodic cognitive retraining sessions. This father of two, the sole breadwinner of a young family, has managed to retain his job, thanks to the therapeutic alliance between his family, employer and our treating team. Indeed, his employer’s corporate social responsibility in walking the distance with Joseph deserves special commendation. This editor’s life continues unedited, thanks to the science of modern medicine, the wisdom in our ancient medical systems and the goodness that continues to exist in our society.

Categories
Adults Bipolar Disorder Elders Expert Blogs

From Elusive Cure to Enabling Comfort

We must consider quality of life and wellness as treatment outcomes and ask ourselves whether the treatment we opt for will help us achieve these outcomes.

Quality of life is a relatively novel concept that dominates both medical science and health policy today and is widely accepted as the best indicator of outcome of treatment. The focus among practitioners of modern medicine, and indeed, in social consciousness, however, remains firmly on the elusive concept of “cure.” The adage among medical practitioners of yore: “to cure sometimes, control often; but comfort always,” hints at the importance of life quality, one that is forgotten, however, in the quest for miracle cures.That the majority of chronic conditions defy cure is something doctors know, but often choose to be agnostic of. Thus apart from infections, inflammations, metabolic disturbances and transient visitations of their ilk, that respond well to drugs designed to terminate them; and indeed abnormalities of structure (organs that have lost structural integrity) that are amenable to surgical intervention, the vast majority of medical conditions while potentially controllable, are not curable. Diabetes, hypertension, high cholesterol levels, ischaemic heart disease, stroke, epilepsy, dementia and a host of other conditions while “treatable” and/or “modifiable” (relief from clinical symptoms and attendant complications) are not “curable.” The promise of a “cure” for many chronic diseases thus remains wishful; that rainbow with its elusive pot of gold, at the end of the dark, illness cloud.There is no doubt we are living longer as a society, and this longevity is attributable, in great part, to advances in modern medicine; cardiac bypass procedures, joint replacements, organ transplants and such like. There is ample evidence to support our collective social longevity, the average Indian lifespan having increased by over a third, since the time of independence, the increase being greater in “advanced” societies like Japan. However, whether such longevity leads automatically to enhanced quality of life remains a conjecture. For example, the follow-up data after a cardiac bypass surgery, arguably the best known lifespan enhancing procedure, shows in many studies high rates of depression and cognitive dysfunction (memory and higher order brain function problems) 5-10 years after the procedure. It would be fallacious to blame the bypass procedure for these complications in the brain and mind; after all, had the person with ischaemic heart disease lived long enough, without the procedure, he might have developed these anyway. However, in evaluating the overall “success” of such procedures or advocating their widespread application through policy implementation, these factors must be considered carefully. In this instance, the question that begs our attention is: “while the procedure enhances lifespan, does it enhance the quality of life?” And if it does not for a select group, who constitutes the group? Why not for it? When does it enhance the quality of life, and when doesn’t it? What determines the outcome in a given individual? Where and how is this outcome determined? These questions need clear answers and we do not always have them.It is striking how both modern medicine and society are obsessed with the concept of “cure,” the quest for magic pills (or, indeed, magic procedures) that will help achieve the longevity goal, being never ending. The energy, enterprise and expense invested in this quest, by affected individuals, their families, and governments are, unfortunately, not always rewarded with a good quality of life after the procedure. Our obsession with “cure” probably comes from two very different directions. The first is idealistic; the tantalising possibility that we will, through advancements in science and technology, “fix” the vast majority of problems concerning the human body. When mankind has learnt to fly, build tunnels through mountains and under the sea, and transport itself into space at will, this aspiration of curing chronic diseases and enhancing longevity does not really seem that distant a frontier.The second, however, probably has more sinister origins that merit careful consideration. The business of curative medicine is enormously lucrative and demands the constant creation of markets that will utilise the goods and services it develops. What could interest the human race more than the possibility of a cure for illness and life-enhancement (with or without quality)? A degree of scepticism of novel, potentially curative treatments is, therefore, warranted in the modern social context, and we must examine carefully whether the promise of “a magic cure” for any chronic condition guarantees alongside an improvement in the quality of life. Thus, while we share a collective belief that people not only live longer due to advances in medical science but also live well, the presumption of a better quality of life, is sadly, in many instances, just that — a presumption!Scientifically viewed, the proof that many modern medical treatments enhance the life quality remains tenuous, to say the least. At a recent lecture in VHS, Chennai, Shah Ebrahim, Professor at the London School of Hygiene and Tropical Medicine and Chair of the South Asian Chronic Diseases Network, a renowned international expert on chronic disease epidemiology, rued our societal predilection for magic bullets (The Hindu, January 9, 2010). Talking about the “polypill” — a combination of aspirin (blood thinner), a Statin (to lower cholesterol levels), and antihypertensive agents (to lower blood pressure) — that is intended to enhance cardiovascular health, he pointed out that simple health promotion measures such as changing over to rock salt from processed salt (high in sodium) and using soya oil as opposed to palm oil (which strangely attracts a lower tax probably due to anomalies in trade policy) were just as likely to improve cardiovascular health. These are far cheaper for governments to implement, and relevant to developing nations.Prescribing the widespread use of the polypill for the middle-aged, as opposed to implementing these simple public health interventions through changes in policy, both health and trade, will be deleterious in many ways, he opined. It will be costly to the nation and poorly sustainable, will have low penetration in society and perhaps, most importantly, take away the responsibility for our health from us, placing it firmly in the hands of the pharmaceutical industry. Further, the former approach, of making people assume responsibility for their lifestyle and diet, alongside the implementation of a complementary government lead policy, is far more likely to enhance other desirable health behaviours in society and, indeed, global health outcomes.Why do we then as a society look to the “polypill” with such enthusiasm or consider it with such seriousness? The answer probably lies in our preference for “cure” as opposed to comfort and life quality. Happily for us, improved quality of life and “wellness,” a concept that has traditionally dominated eastern thought and traditional medical systems, is today receiving much global attention. Wellness encompasses both physical and mental well-being, the latter being a dynamic state of optimal functioning referring to the individual’s ability to develop his or her potential, work productively, build strong and positive relationships with others and contribute to the community. We must recognise that the prevention and management of diabetes extend far beyond the popular notion of blood sugar control; that cardiac health cannot be achieved merely by unblocking blood vessels and enhancing circulation through a stent or bypass; and indeed that the drugs for dementia available today do not even guarantee slowing of disease progression, let alone cure or reversal.Given this scenario, we as a nation and society must consider quality of life and wellness as treatment outcomes, quite seriously, and ask ourselves whether the treatments we are considering, however technologically advanced and seductive, will likely help us achieve these outcomes. We would also do well to examine closely the role of traditional and indigenous medical systems that have for centuries retained this focus on wellness and life quality through health promotion, prevention of illness, care and comfort for those affected with chronic illness; not merely curative treatments.

BUDDHI CLINIC PRIVATE LIMITED © 2023 All rights reserved​

POWERED BY BLUSTREAM

Book An Appointment

Appointments
at Buddhi Clinic

We'll ask for some basic information to assess your care needs.