|Year : 2019 | Volume
| Issue : 1 | Page : 1-8
The chronicles of modern movement disorders in India
Prashanth L Kukkle1, Hee Kyung Park2, Mona T Obaid3, Shinshuki Fujioka4
1 Center for Parkinson’s Disease and Movement Disorders, Institute of Neurosciences, Vikram Hospital, Bangalore, Karnataka, India
2 Center for Parkinson’s Disease and Movement Disorders, Institute of Neurosciences, Vikram Hospital, Bangalore, Karnataka, India, Department of Neurology, Ewha Womans University Medical Center, Seoul, South Korea
3 Center for Parkinson’s Disease and Movement Disorders, Institute of Neurosciences, Vikram Hospital, Bangalore, Karnataka, India, Director Movement Disorders Program, Neurology Department, National Neuroscience Institute , King Fahad Medical City, Riyadh, Saudi Arabia
4 Center for Parkinson’s Disease and Movement Disorders, Institute of Neurosciences, Vikram Hospital, Bangalore, Karnataka, India, Department of Neurology, Fukuoka University, Fukuoka, Japan
|Date of Web Publication||17-Apr-2019|
Dr. Prashanth L Kukkle
Center for Parkinson’s Disease and Movement Disorders, Vikram Hospital, Bengaluru, Karnataka, India.
Source of Support: None, Conflict of Interest: None
Movement Disorders are currently growing to be one of the major subspecialties of neurology worldwide, primarily by developments of research and therapeutics in this field. As any specialty grows, it leads to the formation of its society and the publication of journal to disseminate the knowledge. The International Parkinson’s Disease and Movement Disorders Society (IPMDS, formerly known as Movement Disorders Society) played its role with inception since 1980s. Further development of Movement Disorders subspecialty leads each region and country to have their own national societies and publications. Similarly, the seeds of Movement Disorders were sown in India in mid-1980s but it took a major stride in last few years with the formation of Movement Disorders Society of India (MDSI) in 2014 and following this, it is now at the crux of starting its journal—Annals of Movement Disorders (AOMD). This would be a right time to look back into the history of Indian Neurology with specific reference to the Movement Disorders and pen down these chronicles since the inception of modern neurology in India. The current chronicles of Indian Movement Disorders is penned based on personal interviews with various senior Movement Disorder specialists of India. However, it should also be remembered that many of the chronicles are limited by the memories of people and their biases with whom the interviews are conducted.
Keywords: History, India, leadership program, movement disorders, LEAP MDS
|How to cite this article:|
Kukkle PL, Park HK, Obaid MT, Fujioka S. The chronicles of modern movement disorders in India. Ann Mov Disord 2019;2:1-8
|How to cite this URL:|
Kukkle PL, Park HK, Obaid MT, Fujioka S. The chronicles of modern movement disorders in India. Ann Mov Disord [serial online] 2019 [cited 2019 Jul 22];2:1-8. Available from: http://www.aomd.in/text.asp?2019/2/1/1/256491
The advent of modern neurology as a specialty in India, began in mid-1950s and early 1960s with the establishment of neurology as a “Department” by the pioneers of Indian neurology, Prof. Eddie Barucha, Prof. Baldev Singh, Prof. Noshir Hormusjee Wadia, and Prof. Arjundas G.
The initial work on Movement Disorders was carried out by Prof. N. H. Wadia (neurologist) [Figure 1] and Prof. Darab K. Dastur (neuropathologist) [Figure 2]. The combination of an astute neurologist and neuropathologist led to best of the Indian contributions to world literature. This was the time, wherein in addition to their contribution to other neurology specialties, work on Movement Disorders started to appear. Among them was the first case recognition of Wilson’s disease in the late 1950s, which presented clinically in the form of myoclonus in addition to other symptoms (Personal Communication by Prof. Kalyan Bhattacharya about the contributions of Dr. Wadia, Dr. Dastur, and Dr. Manghani). This later led to seminal articles on Wilson’s disease published in the journal “Neurology.”, This also paved the way for recognition of Wilson’s disease in India, and currently, India is one of the hot spots for Wilson’s disease treatment and research with major Wilson’s disease clinics running across the country. The most important contribution to Movement Disorders by Prof. N. H. Wadia was the article entitled “A new form of heredo-familial spinocerebellar degeneration with slow eye movements (nine families),” published in 1971 Brain Journal, wherein his astute clinical skills showed the autosomal-dominant ataxia with saccadic abnormality, which is currently well known as spinocerebellar ataxia type-2 (SCA-2). He not only established the clinical features but later along with his German colleagues, he documented that the degeneration of neurons in the paramedian pontine reticular formation was responsible for the slow eye movements. During this time, “Infantile Tremor Syndrome”—a unique syndrome mainly noted in India—was described by Prof. Dikshit A. K. in 1957, which is considered to be due to vitamin B12 deficiency., The other important contributions during these time were unusual forms of Parkinsonism More Details because of chronic manganese intoxication of miners of Madhya Pradesh and reversible parkinsonism after inhaled organophosphate pesticides. Albeit the Modern Movement Disorders in India started with the establishment of neurology departments by the pioneers of Indian Neurology. It would be worth to remember the contribution of Indian biochemists, who had revealed that the seeds of Mucuna pruriens (used in the treatment of tremors in ancient India and in current Ayurvedic therapy) contained levodopa in 1937. It was shown only between 1970s and 1990s that M. pruriens was twice as effective as the same amount of synthetic levodopa, suggesting that it contained other unidentified ingredients.,,
With such a great foundation in the initial years by the pioneers of Indian neurology, the Movement Disorders started to grow further with inputs from the next generation neurologists. Prof. Bhim Sen Singhal [Figure 3], has been the pioneer in this period with his great clinical and organizational skills. Prof. Singhal is credited with the description of “megalencephalic leukodystrophy,” a disorder primarily noted in Aggarwal community of India characterized by large head, seizures, and cerebellar ataxia., Prof. Singhal went on to establish the “Parkinson Disease and Movement Disorders Society of India (PDMDS)” in 2001 and also is the patron of the MDSI. Currently, PDMDS has several outreach centers across India, with primary objective to improve the quality of life of people with movement disorders and to disseminate public awareness. During the same time, Dr. Zaheer Ahmed Sayeed sowed the seeds of Movement Disorders in Chennai, along with his contributions to dopamine receptor blockers in control of chorea.
The seeds sown by early pioneers led to the sprouting of Movement Disorders in 1980s. This was an era when specialized training in Movement Disorders began and this led to the starting of Movement Disorders clinics. The first Movement Disorders clinic was started by Dr. Rajashekar Nair in 1983 at the Government Medical College Hospital, Trivandrum, Kerala. During this time, Prof. Madhuri Behari [Figure 4] did her 1-year training with Prof. C. D. Marsden at the iconic Queen’s Square and returned back to India to initiate the Movement Disorders clinic at All India Institute of Medical sciences (AIIMS), New Delhi, India. The well-known “Wilson’s Disease Clinic” of National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, was established by Prof. H. Sathyanarayan Swamy during this tenure, and its torch has been successfully carried forward by Prof. A. B. Taly and Prof. Sanjib Sinha.
The boom of Movement Disorders as a subspecialty started with the current leaders having done their training under the Masters of Movement Disorders across the globe. That includes Prof. Mohit Bhatt (Vancouver, Prof. Donald B. Calne and Queens Square, Prof. Marsden C. D.), Prof Uday Muthane (New York, Prof. Stanley Fahn), Prof. Kalyan B. Bhattacharya (Queens Square, Prof. Marsden C. D.) (Prof. Bhattacharya was later appointed as visiting professor in Movement Disorders to King’s College, London in 2012) [Figure 5], Dr. Prof. Asha Kishore (Vancouver, Prof. Donad B. Calne), Prof. Charulatha Sankhla (Houston, Prof. Joseph Jankovic), Prof. S. K. Das (Calgary), and Prof. Pramod Kumar Pal (Vancouver, Prof. Donad B Calne and Toronto, Prof. Robert Chen). Prof. Rupam Borgohain requires a special reference for his efforts and work to establish a well-rounded Movement Disorders clinic in Nizams Institute of Medical Sciences (NIMS), Hyderabad, Telangana, in the 1990s. Dr. Uday Muthane along with Dr. Yasha Muthane (neuropathology) brought the Movement Disorders subspecialty into NIMHANS.
|Figure 5: Prof. Niall Quinn, Prof. Kailash Bhatia, Prof. C. D. Marsden, and Prof. Kalyan B. Bhattacharya|
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Their critical works included demonstration of differences in melanized nigral neurons from Indian and western population, Niemann–Pick type C and GM1 gangliosidosis presenting as dystonic phenotypes with Gaucher-like foam cells, and the founder gene effects of Huntington’s disease in the Indian population. Prof. S. K. Das contributed on the epidemiology of various movement disorders. The other important contribution of Indian literature has been on SCA-12. Except for the initial description of SCA-12 in 1999, most of the publications for SCA-12 has been from India.,,, The interesting fact has been that almost all of these patients belong to Agarwal community and have origins of ancestry from a small town called Agroha (Haryana, India), suggesting a founder mutation. The other person who has always been away from the limelight is Prof. Gurusidheswar Wali. Prof. Wali is the person who has carried out tremendous research and publications in Movement Disorders by staying in a tier-II city of India. He described a novel gene (EKD2 on chromosome 16) for paroxymal kinesegeneic dyskinesia along with researchers from Queen’s Square., He has also contributed toward the interesting “Uner Tan syndrome” variants from Indian subcontinent and the rare “sepiapterin reductase deficiency syndrome.” Other major contributions include Prof. Kalyan Bhattacharya, from Kolkata, who has contributed to various aspects of Movement Disorders,,,, including rare presentations. Prof. Pramod Pal, from NIMHANS, has worked significantly in the field of ataxia, in addition to other movement disorders publications.,, Prof. Asha Kishore, from Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) Trivandrum, Kerala, has worked significantly on understanding the cerebellum and its connection’s role in dyskinesia., In addition, works from different researchers from various parts of India have flowed in either as case reports or primary research. It would be difficult to acknowledge each of them for their contributions to the medical literature.
In 1990s, as the interest in Movement Disorders started to grow, this paved a logical pathway for spreading the awareness of Movement Disorders in India. The first Movement Disorders workshop was held at New Delhi by Prof. Behari in 1991. This was also the time when botulinum toxin started to come to the Indian Market and the pharmaceutical industries were looking for people to spread the awareness of botulinum usages and indications [Figure 6]. Prof. Mohit Bhatt aptly puts it as the best symbiotic environment, wherein the need of specialists of Movement Disorders to spread the awareness of Movement Disorders across India was aptly coupled with the need to spread the usage of botulinum toxin [Figure 7]. The stage was rightly set for the takeoff of Movement Disorders, and Prof. Marsden’s visit to India in January 1995 for the teaching program in Mumbai was the trigger point, followed by Prof. Stanley Fahn (Bangalore, Prof. Uday Muthane), and Prof. Donad B. Calne (Kerala, Prof. Asha Kishore) who gave the requisite impetus to the society. These were soon followed by Movement Disorders meet by Prof. K. K. Sinha and Ambar Chakraborthy in 1996, and by Prof. Kalyan Bhattacharya, which led to the exposure of Indian community to leaders in International Movement disorders such as Mark Hallet, K. Ray Chaudhari, Philip Thompson, Angelo Antonioni, Per Odin, and Heinz Reichmann.
|Figure 6: Prof. Rupam Borgohain conducting one of botulinum workshops in 1990s|
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|Figure 7: Prof. Mohit Bhatt and Prof. Uday Muthane during the Movement Disorders meets in 1990s|
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With the advent of twenty-first century, the leaders in Movement Disorders started to emerge. This was also the point wherein surgical therapy, especially deep brain stimulation, came to India. The first case being performed by Prof. Paresh Doshi in Mumbai, followed by various centers across India. At this point, a brief retrospective look into the early neurosurgeons who introduced lesioning for Movement Disorders has to be remembered, which was rooted from bold pioneer in 1940s such as Prof. Chintan Nambiar, followed by refining the procedure by others in 1950s and 1960s. Probably among the various neurosurgeons, the name of Prof. R. M. Varma stands out for his novel approach for the percutaneous chemothalamotomy for patients with tremors. This procedure is also known as “Varma’s technique”—a minimally invasive procedure, conducted under X-ray guidance as an outpatient procedure, with dramatic outcomes. Around the same time, Prof. B. Ramamurthi and Prof. V. Balasubramaniam used to perform stereotactic thalamotomies and chemopallidectomy by using the balloon cannula technique of Cooper.
The twenty-first century led to growth of both, the Indian trained and grown Movement Disorders specialists and the specialists returning from abroad. Special references should include Prof. Vinay Goyal of AIIMS, Dr. Sumith Singh, and Prof. U. Meenakshisundaram. Dr. Muthane, who was mentored by Prof. Fahn, wanted to start the Aspen-like Movement Disorders course in India and was successfully able to initiate the same with annual courses. Soon various others courses were conducted across India, including that of “Movement Disorders Update” (2004, Chennai), RAM-MOVE (2005, Chennai), teaching course for Movement Disorders (2010, Bangalore), and Institute of Neurosciences Kolkatta Movement Disorders Update (2012, Kolkata). This was also the time when the second generation of Movement Disorders specialists started to make their foray into the scenario—Dr. Pettarusp Wadia and Dr. Prashanth L. K. (Toronto, Prof. Anthony Lang and Prof. Elena Moro), Dr. Hrishikesh Kumar (London, Ontario, Prof. Mandar Jog), Dr. Sanjiv C. C. (Vancouver, Prof. Donad Calne), Dr. Sujit Ovallath and Dr. Pankaj Agarwal (Vancouver), Dr. Sanjay Pandey (National Institute of Health, Mark Hallet), Dr. Ravi Yadav (NIMHANS, India), and Dr. Rukmini Mridula (NIMS, Hyderabad). Fellowship courses for Movement Disorders were started at SCTIMST and NIMHANS.
The boom of movement disorders in the beginning of twenty-first century in India paved a way for better collaborative research programs at National and International levels. Some of the works to quote are development of Global Assessment Scale for Wilson’s disease (GAS-WD) by Prof. Mohit Bhatt, genetics of Parkinson’s disease at SCTIMST under Prof. Asha Kishore, Autonomic Lab works with grants from Wellcome Trust by Prof. Uday Muthane, and human motor physiology including transcranial magnetic stimulation by Prof. Pramod Kumar Pal at NIMHANS. This was also the critical time, when new molecule trials started to happen in India. Among these, the safinamide study (Study 016 and Study 018) carries a significant importance. This was the first trial published in a major disease from outside of America and Europe. It was also the first new molecule for Parkinson’s disease approved in 10 years by the US Food and Drug Administration and European Medical Agency worldwide. Prof. Rupam Borgohain was the lead investigator for this multicenter study and most of the subjects recruited for the study were from Indian centers, in addition to USA, Italy, Romania, Switzerland, and others., The zenith was the formation of Parkinson Research Alliance of India (PRAI) under the stewardship of Prof. Kapil D. Sethi in 2006–07. The primary goal was to bring more research and innovative treatments to India. There have been various projects carried out under the banner of PRAI. Currently, Genetics of Parkinson’s in India–Young Onset Parkinson’s Disease India (GOPI-YOPD) is the major collaborative genetic project going on with the group, with lead investigators being Dr. Prashanth L. K. (PRAI) and Dr. V. L. Ramprasad (MedGenome). The PRAI is currently guided by Prof. Rupam Borgohain.
The time was ripe, wherein Movement Disorders, needed to grow beyond a subsection of Indian academy of neurology. In 2012–13, Prof. Pramod Kumar Pal, along with all the Movement Disorders specialists, at that juncture came with the idea of initiating the MDSI [Figure 8] and the same was officially formulated in April 2014 with 20 founding members (Drs. B. S. Singhal, Madhuri Behari, S. K. Das, Kalyan Bhattacharya, Mohit Bhatt, Uday Muthane, Asha Kishore, Rupam Borgohain, Bhaskar Ghosh, Pramod Pal, Charulatha Sankhla, Vinay Goyal, U. Meenakshisundaram, Pettarusp Wadia, Hrishikesh Kumar, Prashanth L. K., Sujit Ovallath, Ravi Yadav, Rukmini Mridula, and Netravathi). Prof. Madhuri Behari was the first president and Prof. Pramod Kumar Pal was the secretary to lead the society during the initial formation years. Following Dr. Madhuri Behari, Prof. S. K. Das (2016–17), Prof. Uday Muthane (2017–18), and Prof. Kalyan Bhattacharya (2018–19) were the presidents of the society. Soon the MDSI was recognized as an affiliate member of IPMDS. The first Movement Disorders Society of India Conference (MDSICON) was successfully held in 2016 at Chennai under the stewardship of Prof. U. Meenakshisundaram [Figure 9]. Following this, the subsequent MDSICONs were held at Bangalore (2017) and Hyderabad (2018). The MDSI is now at the verge of launching its official journal, “Annals of Movement Disorders” in 2018 [Figure 10].
|Figure 8: Prof. Pramod Pal with Dr. Prashanth L. K. getting the signatures for the formation of the MDSI society by the founding members in 2014|
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|Figure 9: Faculty at the first MDSICON 2016|
Left to right: Top row: Drs. Yasha Muthane, Mohit Bhatt, Wali G. M., Sujit Ovallath, Vinay Goyal, Z. K. Wszolek, Anthony Lang, Kailash Bhatia, Madhuri Behari, Pramod Pal, Uday Muthane, Kalyan Bhattacharya, and Mark Hallet
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The chronicles of Indian movement disorders will not be complete without references of those, who went abroad to create a niche for themselves in the international arena and were able to guide the Indian community. The foremost among them will be Prof. Kapil D. Sethi. He finished his medical school from Christian Medical College, Ludhiana, and residency from Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, and went on to become the director of Movement Disorders at Georgia Health Sciences University, Augusta, USA [Figure 11]. In addition to his leadership roles in steering the International Movement Disorders Society, he was also the pioneer in initiating the PRAI, the research wing. Prof. Kailash Bhatia (Queen’s Square, London, UK) who completed his medical and neurology training from Mumbai went on to become the current leader in International Movement Disorders [Figure 11]. He is the face in most of the Movement Disorders conferences in India and has been the guiding light for the society and the young Movement Disorders specialists to take up the challenges. In addition, numerous other people have made a place for themselves that include Prof. Kallol Ray Chaudhuri (United Kingdom), Prof. Mandar Jog (Canada), Prof. Shilpa Chitnis (USA), and Prof. Neil Mahant (Australia).
It would be worthwhile to note that many more Movement Disorders specialists have started to take up the baton in India after their formal trainings, and it would be difficult to compile all the names in this script. Currently, the Movement Disorders in India is on a steady ship with the guidance of MDSI under Prof. U. Meenakshisundaram and PRAI under Prof. Rupam Borgohain. The second generation of Movement Disorders specialists are getting mentored under their guidance to create a better awareness and research opportunities in the field.
| Acknowledgments|| |
This project has been the brainchild of leadership program – Asia Oceanic subsection (LEAP-AOS) 2017 with the guidance of LEAP faculty (Prof. Cynthia Comella, Prof. Shilpa Chitnis, and Prof. Carolyn Sue) and LEAP coordinators (Heather Vitale and Anette Scott). This historical article was done with major contributions from personal interviews with various faculties and requires specific acknowledgements of Prof. B. S. Singhal, Prof. Kapil Sethi, Prof. Madhuri Behari, Prof. Kalyan Bhattacharya, Prof. Shymal Das, Prof. Uday Muthane, Prof. Wali G. M., Prof. Mohit Bhatt, Prof. Yasha Muthane, Prof. Rupam Borgohain, Prof. Pramod Pal, Prof. Charulatha Sankhla, Prof. Vinay Goyal, and Prof. U. Meenakshisundaram.
| Financial support and sponsorship|| |
| Conflicts of interest|| |
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]