When 64-year-old MBK Nair first noticed a subtle tremor in his right hand in 2020, he brushed it off as fatigue or muscle weakness, assuming that could be a sign of aging. A retired electrical engineer from Bengaluru, he experienced other symptoms after a few months and the tremors worsened.
A few tests later, Nair was diagnosed with Parkinson’s disease (PD), a progressive neurological disorder that affects movement apart from cognitive and emotional function. Though initially he managed it with medication, the relief was temporary. However, everything changed for the better early this year, after he underwent magnetic resonance-guided focused ultrasound (MRgFUS), a cutting edge procedure. Within days of the non-invasive treatment, the tremors that had dominated his life for years were nearly gone.
Nair’s case is one of many that demonstrate how advanced procedures are offering renewed hope to millions of Parkinson’s patients. Despite the challenges, evolving technologies like focused ultrasound and deep brain stimulation are transforming management strategies and improving quality of life.
Once mostly associated with older adults, PD is now alarmingly affecting younger populations in India, which now reports between 15 and 43 PD cases per one lakh people. Data from the National Institute of Mental Health and Neurosciences (NIMHANS) reveals that nearly 40-45% of Indian patients aged between 22-49 years experience the symptoms, which is nearly 10 years earlier than the global average.
A recent study published in the British Medical Journal projects that the global Parkinson’s population will reach 25.2 million by 2050, up by over 112% from 2021. South Asia, particularly India, is expected to account for nearly 6.8 million of these cases. The prevalence has been estimated at 267 cases per one lakh people worldwide.
Invisible onset
PD is the world’s second most prevalent neurodegenerative disorder after Alzheimer’s. The World Health Organization warns that neurodegenerative diseases, including Parkinson’s and Alzheimer’s, could surpass cancer as the second leading cause of death globally by 2040.
The disease results from the gradual loss of dopamine-producing neurons in the brain. Dopamine is a chemical messenger essential for smooth and coordinated muscle movements. When dopamine levels drop, motor functions become impaired, leading to a range of uncontrollable symptoms. Parkinson’s typically strikes people over 60, though younger cases (below 50) are also reported. Men are more likely to develop the condition than women.
Some key symptoms of PD include tremors, especially in hands, arms, or legs, bradykinesia (slowness of movement), muscle rigidity, and shuffling gait. The disease is characterised primarily by motor symptoms like TRAP - tremors, rigidity, akinesia, and postural instability (difficulty to maintain balance). Non-motor symptoms such as depression and anxiety, sleep disturbances, cognitive impairment, constipation, and loss of smell (anosmia) are also seen in some patients.
People ideally should watch out for are persistent hand tremors, stiffness or reduced arm swing on one side, slowness in daily activities, difficulty with balance or small handwriting, and soft or slurred speech, said Dr Sowmya M, senior consultant of Neurology at Aster RV Hospital, Bengaluru.
“The earliest signs are often so subtle that they go unnoticed or are mistaken for signs of aging or stress. Tremors are the hallmark symptom, typically starting on one side of the body, mostly in a hand or finger while at rest. Non-motor symptoms can appear years before motor symptoms begin. In such cases, people should always consult neurologists as symptoms like anxiety, loss of sense of smell, sleep disturbances, and even subtle cognitive decline are not always linked to Parkinson’s by non-specialist physicians and it delays the diagnosis,” Dr Sowmya said.
Clinical diagnosis
Diagnosing Parkinson’s is largely clinical as no blood test or scan can confirm it with certainty. A neurologist typically evaluates a combination of symptoms, medical history, and physical examinations. Imaging tools like MRI or CT scans are used to rule out other conditions, while a specialised nuclear imaging scan, known as DaTscan, can visualise dopamine activity in the brain.
“Diagnosis of Parkinson’s disease is primarily based on signs and symptoms, typically motor-related, identified through neurological examination. Medical imaging techniques like positron emission tomography can support the diagnosis,” Dr Lulup Kumar Sahoo, professor in the Neuro Medicine department of IMS and SUM Hospital, Bhubaneswar said. Treatment begins with medications to increase dopamine levels. Patients generally respond well to dopamine supplementation, commonly known as Syndopa. Though many patients benefit from Syndopa, its effects tend to last for only a short period. Levodopa, often combined with Carbidopa, is also a commonly used drug. It helps replenish dopamine and improves muscle control, though its long-term use can lead to side effects such as dyskinesia.
New hope
Two major breakthroughs in Parkinson’s treatment have emerged in recent years - magnetic resonance-guided focused ultrasound (MRgFUS) and deep brain stimulation (DBS).
Focused ultrasound is a non-invasive technique that uses sound waves, guided by MRI, to target and destroy tiny areas of brain tissue responsible for tremors, without impacting surrounding healthy tissues. It does not require anaesthesia, surgery, or recovery time.
“A great alternative to traditional brain surgery, focused ultrasound can be beneficial for patients who haven’t responded well to medication or prefer non-invasive procedures. Patients come in shaking and walk out with steady hands after the procedure. The treatment requires no surgical incisions or implants, and the mild transient numbness is resolved within days,” said Dr Sunil Patra, senior neurosurgeon at Manipal Hospitals, Bhubaneswar.
Dr Sahoo said MRgFUS uses over 1,000 beams of focused ultrasound energy directed at a precise point in the brain, typically the thalamus, which is involved in motor control. Guided in real time by high-resolution MRI imaging, the treatment raises the temperature of the targeted tissue to a point where it is thermally ablated, disrupting the abnormal brain circuits causing tremors.
“The entire process is performed without scalpels, anaesthesia, or hospitalisation. Patients remain awake and responsive, allowing physicians to evaluate the effects in real time. Most patients experience immediate and significant reduction in tremor, immediately after the procedure. It, however, costs around `25 lakh, almost double the cost of DBS,” he added.
DBS, on the other hand, involves implanting electrodes into specific brain regions such as the subthalamic nucleus or globus pallidus, guided by MRI. These electrodes deliver controlled electrical pulses that modulate abnormal brain activity. DBS can significantly reduce tremors, stiffness, and medication dependence.
“In DBS surgery or brain pacemaker surgery, small burrholes (keyhole) are made in the skull and electrodes are placed deep inside the brain under stereotactic guidance. These electrodes will be connected to a battery placed in the subcutaneous pouch in the upper chest. Based on the patient’s symptomatic profile, the electrodes can be activated by switching on the battery with specified current. The electrodes will stimulate the desired neurons and give symptomatic relief,” Dr T P Jeyaselva Senthilkumar, senior consultant neurosurgeon, SRM Global Hospitals, Chennai.
“It is a one-day procedure and requires the patient to stay at the hospital for five days for observation and wound healing. The programming of the impulse generator battery will begin after two weeks, once the patient is stable. It is another one-day procedure,” added Dr Asha Kishore, director of the Parkinson’s and Movement Disorders Centre at Aster Kerala Cluster.
Senthilkumar added that to be eligible for DBS, the patient should have been responsive to oral medications.
The total cost can range from Rs 15.5 lakh to Rs 20 lakh, based on model of implant used.
MRgFUS is incisionless
MRI helps pinpoint the exact location within the brain where the ultrasound beams will be focused
High-intensity ultrasound waves are directed at the target area, generating heat to precisely ablate (destroy) targeted tissue
MRI provides continuous monitoring during the procedure, allowing for adjustments and ensuring accuracy
Unlike traditional surgery, MRgFUS is incisionless, minimising risks associated with surgery and recovery
It reduces tremors and dyskinesia
By reducing motor symptoms, MRgFUS can lead to improved daily function and overall quality of life
DBS or MRgFUS
The key difference between DBS and focused ultrasound is that the former is a reversible procedure. “It does not involve ablating or destroying any brain structures, whereas the focused ultrasound does result in ablation,” said Dr Hema Krishna P, consultant of Neurology, Parkinson’s and Movement Disorders at Aster Whitefield Hospital, Bengaluru.
“Additionally, the parameters in DBS can be fine-tuned based on the patient’s symptoms during follow-up visits. If symptoms worsen over time, we can adjust the voltage settings in DBS. It has been approved for treating patients with symptoms affecting both sides of the body while focused ultrasound is approved only for patients whose symptoms are primarily restricted to one side of the body,” Dr Hema said.
Although DBS is still evolving, Dr Aakash Agrawal, consultant neurologist at Manipal Hospitals, said it is already solving decades old problems of PD patients with the help of external batteries and a few months of smart programming by the treating neurologist. These batteries can last somewhere between three to four years to a decade depending upon the type of device the patient opts for (non-rechargeable and rechargeable). “Newer technology now allows the device to auto-detect any abnormal signals within the brain and change stimulation settings accordingly,” he said.
Deep Brain Stimulation
DBS is a surgical procedure where electrodes are implanted in specific areas of the brain to deliver electrical impulses, used to treat certain neurological conditions. These impulses help regulate abnormal brain activity that causes symptoms like tremors, stiffness, and slow movement, especially in conditions like Parkinson’s disease
Thin wires with electrodes are surgically implanted into targeted areas of the brain
A battery-powered device, placed under the skin, usually in the chest, sends electrical pulses through the electrodes
The electrical impulses modulate brain activity and help reduce or control the symptoms
A good candidate for DBS should have been undergoing treatment for more than four years
Can PD be prevented?
While Parkinson’s cannot yet be prevented, several lifestyle habits can be given up to lower risk. Regular physical exercise, especially aerobic activity, has shown strong neuroprotective effects. Diets rich in antioxidants, such as the Mediterranean diets, will help protect brain cells from oxidative stress. Green tea, caffeine, and omega-3 fatty acids have been associated with reduced risk in some studies.
While the exact cause remains unclear, Parkinson’s is believed to be triggered by a combination of genetic and environmental factors. Researchers are exploring stem cell therapies, gene editing technologies, and neuroprotective drugs that could slow or even halt the progression of the disease. Artificial intelligence and wearable sensors are also revolutionising how Parkinson’s is tracked and managed at home.
Dr Patra said certain habits, including regular exercise, healthy diet, avoiding toxins by limiting exposure to pesticides and industrial chemicals, and cognitive engagements like mental stimulation may help delay neurological declines and lower the risk of PD.
(With inputs from Anna Jose @ Kochi, Sinduja Jane @ Chennai)