Babu, Boni, Dr Hrishikesh Kumar, Institute of Neurosciences Kolkata
Getting to grips with Babu's medical mystery by analysing his footprints....
Each morning, the round meeting gathers doctors from across the hospital to brainstorm challenging cases. The meeting closes with all standing for the institute’s Hippocratic oath blasting over the tannoy
Hypocratic oath - I will apply for the benefit of the sick all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well science and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say, “I know not”, nor will I fail to call on my colleagues when the skills of another are needed for a patient’s recovery.
Hannah - One of the cases presented was this boy.
Mohammed - My name is Mohammed Islam
Hannah - How old are you?
Mohammed - 12 years.
Hannah - How do you feel?
Interpreter - He says he’s having a tremendous back pain that is causing his gait difficulty. He’s unable to walk properly. He’s unable to get up when he sits down. That's the main problem when he’s sitting, he’s unable to get up or when he’s walking, he’s having the back pain.
Hannah - To find out why Mohammed Islam who’s also affectionately called (Babu) for short is experiencing these symptoms, I met with his attending doctor.
Kumar - I'm Hrishikesh Kumar head of neurology in Institute of Neurosciences Kolkata. Babu is a 12 years old male and he’s following me definitely for the last 2 years.
A very strange case because he came with sudden onset: difficulty in walking and pain all over body. So, when you have such a case, you think of spinal cord disease because both limbs are not working properly. But when we examined the patient, the patient has a lot of symptoms but no sign. That means, while he was lying down, he could move his leg. So, quite intriguing. We did all the investigations that included MRI, blood test and they all were normal. We gave some medicine and they're very non-specific for pain and inflammatory, and he responded in a few days time. we were very happy that we missed some diagnosis but he is alright. A few months later, he came with similar problem and he has strange difficulty in walking. But what I noticed that when you give him a small push, he could maintain himself very well. He could maintain the balance.
Hannah - So, Babu went to visit Bonashee. She’s a research assistant at the Neuroscience Institute Kolkata who’s working on movement disorders.
Bonashee - Now, I'm just asking him to walk in support of the both hands and then I’ll ask him to walk on the GAITRite.
Hannah - And the GAITRite is a mat that's probably about 6 inches long and it’s got many sensors in it that can pick up the movements and the pressure that's being applied as the patient walks.
Bonashee - I'm asking him to walk on this GAITRite and he has to walk middle of this because these are sensors. So whenever he will be walking on this mat, his foot impressions will be recorded on the GAITRite machine so that we can record it and assess it.
Hannah - How many sensors are there within this 6-meter mat?
Bonashee - There are millions of sensors in the mat. So wherever he keeps his foot, the foot impression is captured. All the foot pressure, the length, the stride length, the step time – everything is captured from this GAITRite machine to the computer.
Female - 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17...
Hannah - And with a bit of encouragement, Babu is able to walk across the centre mat and his footprints and the gait will have been measured whilst he’s walking.
Bonashee - These are the temporal and spatial temporal parameters. Those are getting recorded from the foot impressions of this young boy.
Hannah - What will that information help to tell us?
Bonashee - This information, whenever he comes the next time, we can compare the foot faults and we can see what's the difference with the medication and we can say whether it is a psychogenic or something else.
Hannah - I went back to speak with Dr. Hrishikesh Kumar to find out what this gait walking test revealed about Babu
Kumar - You can call it magic carpet. This is about 20 feet long and 3 feet wide. It has thousands of sensors embedded in it. so, when a person walks on that, all the gait parameters, they're transmitted to the computer so you can see that recorded the speed gait, recorded the stride length – at what force the patient had put his one foot on the mat. The different parameters is a little technical like swing time, single support time. that means how long the right foot is on the ground. Double support time – how long both feet are on the ground. So, there are at least 20 parameters we can measure by that mat. This has been used in only 3 centres in India and a few centres all over the world. It can be used as walkway as a biomarker for different diseases.
What we are doing, is when we know that diagnosis of Parkinson's disease or when we know the diagnosis of say, stroke, we ask the patient to walk on that. We’re collecting a huge number of data on the mat. We are seeing a very clear pattern that Parkinson’s disease, they have different pattern. Those having only stroke, they have a different pattern. Another thing known as hydrocephalus – there's water in the brain – they also have walking difficulty and they have a different pattern. We can fix a pattern for each diagnosis. And then if we don't know the diagnosis, we ask the patient to walk on that and at least with the software, this can give the hint that it’s Parkinson’s disease or vascular parkinsonism or hydrocephalus and likewise.
For Babu, we asked him to walk on that because all the diseases, what we talked were Parkinson’s disease, vascular Parkinsonism, spinal cord, myelopathy. They should have a constant pattern when they walk. In his case, what we saw, that he had walking difficulty but the pattern kept on changing. That was in favour of an non-organic – that means psychogenic disorder rather than organic disorder because any organic disorder, the pattern will remain same in all the walks.
In Babus case, it was different every time. so, that was the clue that he has psychogenic walking disorder rather than true walking disorder. That gave us an idea that something is wrong not physically – psychologically. So, we discussed the case with our psychiatrist.
Hannah - And so, Babu, his family and myself took a lift down to another ward since the doctors weren’t sure if Babus symptoms were due to inflammation around his spinal cord or if it was an emotional reaction to stress. A psychiatric assessment was required.
P. Kumar - My name is Dr. Praveen Kumar. I'm a consultant child and adolescent psychiatrist.
Hannah - And you just spent the last hour speaking with Mohammed Islam and his nickname is Babu's family. And then also spending half an hour chatting with Babu himself. What did you find out during that consultation?
P. Kumar - First session, like I just tried to establish a rapport with the child. Okay, this is a case which is referred from a neurologist. They have investigated further on neurological diseases and they are suspecting there is some psychological component maybe associated with this child. I thought during the first session, okay, I’ll be just establishing a rapport with the child. That means, just as you saw, like I asked about his positive things – what he likes to do or we talked about the activities he’s good at.
Hannah - And you mentioned sports and then he got really stuck into some mathematical calculations that you laid out for him.
P. Kumar - He said like he’s good at math, he’s good at sports. Then when we appreciated him, he said that, “I got some certificate for some running race” in his school. So, this is the behaviour establish, a rapport with the child. Then you're going into deep and explore there. He shows other issues.
Hannah - During the meeting today with all the doctors, so this case was brought up that doctors needed to discuss in order to try and find out what the problem was, one of Babu’s possible diagnosis could’ve been Munchausen’s disease by proxy. Can you tell us a little bit about what that is and how you can diagnose it if it is the case for Babu?
P. Kumar - Munchausen syndrome is symptoms a child will present with some physical symptoms for which there are no physiological cause or no physical cause. When the child is doing these symptoms consciously then you say it’s a Munchausen syndrome. Sometimes child may present with certain physical symptoms although child is not doing it voluntarily, these symptoms are created by the caregiver.
Hannah - So, maybe that the caregiver whether it’s the brother or the father or the parents are stressed and then it’s manifesting itself within Babu.
P. Kumar - Yeah, but we have to explore it. it’s not clear like is it a Munchausen syndrome. Actually, in children, we say it’s a kind of dissociation disorder, dissociation.
Hannah - And I left Dr. Praveen Kumar to answer his phone.