From The White House to the red house

27391430571_c3a2c63c46_hLast week was a week of contrasts for me. On Tuesday I left Stockholm for New York City and the purpose of my trip was to attend a workshop at The White House in Washington DC. The workshop was on a topic very close to my heart: engaging participants as partners in research and it was organised jointly by the conference Stanford Medicine X and the Office of Science and Technology Policy at The White House. The intention from the organisers was to, by using design principles, 1) identify what’s working, 2) strengthen the community of innovators in the area, and 3) accelerate progress.

The amazing dr Larry Chu, anaesthesiologist at Stanford and executive director of the most patient-centered conference in the world, Stanford Medicine X.
The amazing dr Larry Chu, anaesthesiologist at Stanford and executive director of the most patient-centered conference in the world, Stanford Medicine X.

Exploring opportunities and challenges relating to engaging participants as partners in research is of course important. But I think there is also a bigger issue at play here, namely WHY we should engage participants as partners in research in the first place. In an article from 2015 called “We the scientists”: a Human Right to Citizen Science (Vayena E, Tasioulas J. “We the Scientists”: a Human Right to Citizen Science. Philos Technol. 2015;28(3):479-485. doi:10.1007/s13347-015-0204-0.) , authors Vayena and Tasioulas discuss the human right to science and connects it to article 27 of the 1948 Universal Declaration of Human Rights. Vayena and Tasioulas argue that participation in science should range from being a professional scientist to being a participant in a conventional clinical trial performed by professional scientists but also include more active participation in the form of e.g. individuals contributing data or observations, collaborating with researchers on funding research, setting the research agenda, and participants even taking the lead in initiating, designing and carrying out the research themselves.

And if a reference to the Declaration of Human Rights is not enough

Claudia Williams, Senior Health and Health IT advisor at The White House and co-convener of the workshop, with Nick Dawson, Executive Board Member, Stanford Medicine X.
Claudia Williams, Senior Health and Health IT advisor at The White House and co-convener of the workshop, with Nick Dawson, Executive Board Member, Stanford Medicine X.

to convince you, consider this: In the ‘dark ages’, before the Internet, knowledge was scarce. If you wanted to learn medicine, you had to go to university to study. Sure, you could pick up bits and pieces in books at the library but on the whole, (medical) knowledge was difficult to come by on your own. Times are very different now, we can all learn literally everything we want, using the tools and information available to us online. And in my opinion, it is a good thing that knowledge is democratised and available, it offers us plenty of opportunities but also a few significant challenges. One of the most exciting opportunities, and if you ask me, probably the best thing since sliced bread, is that we are now so many more people that can access the knowledge necessary to collaborate to solve the many remaining medical mysteries, like how to cure cystic fibrosis, cancer or genetic prion disease, or how to design better cardiac defibrillators or closed-loop-glucose-monitors-insulin-pumps or stoma bags and also how to enable us all to communicate across obstacles caused by injuries or diseases. Slightly more discouraging is that we are basically still doing research in the same old way as we did in the not-so-long-ago pre-internet days. Why are we doing that? Wouldn’t you say that it is an extreme waste of great minds with so much to give to NOT engage participants as partners? Who can be in a better position to help tease out which issues research should focus on than we, who are living with these diseases every hour of every day?

When I returned to Sweden, I went straight to our place in the Swedish countryside (see pic below), where my family owns a few houses right by a lake in the beautiful area of Bergslagen. The red house is my absolute favourite place in the whole world and as I was enjoying “fika” with my family, telling them about my travels, I was struck by the extreme contrast between The White House and the red house and that I am very fortunate to be able to experience such a wide range of environments. The work we all did at that workshop in The White House is a step in the right direction. My hope is that the work we started in The White House will lead to scientific progress so that many more of the Emilys, Hugos, Erins, Michaels, Danas, Sonias, Matts, Corries, Annes, Dougs, Jelicas, Cliftons, and Saras of the world can spend more time in their “red houses”. And I think it is possible, because these issues are too important not to deal with. These issues matter to people both in The White House and in the red house!

Here is a link to information on the event on the website of Stanford MedicineX

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Eli Pollard, executive director of the World Parkinson Coalition and myself in front of the entrance to The West Wing
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In front of my favourite place on earth, our place in the Swedish countryside, where we spend as much of our free time as possible. The log house is painted in the red colour traditional to this area.

Neuroscience – theory and practice

My extra dopamine
My extra dopamine – on my left arm

I’m sure most of you have seen me write once or twice before that PD is a very complex disease, but it bears repeating:

PD is a very complex disease!

Let me explain to those of you lucky enough not to know first hand (or by proxy, like my husband and daughter do). If you’ve followed my work, you probably know about my complicated medication regimen, not unusually complicated if you have PD but very much key to my health and well-being. There are essentially four major types of PD meds: L-dopa (or levodopa), which goes into the brain and transforms into dopamine, the neurotransmitter that PD “steals” from us, dopamine agonists (or DA’s for short), which “imitates” some of the effects of dopamine in our brains, COMT inhibitors, which when taken simultaneously with L-dopa, lengthens the active period of the L-dopa, and MAO-B inhibitors, which helps to block the natural breakdown of dopamine in the brain. All of these act to increase the levels or effects of dopamine in our brains, which in turn restores some or even most of our normal patterns of movement as well as addresses, to a varying degree, the non-motor symptoms that comes with reduced levels of dopamine in the brain, such as for example depression, autonomic dysfunction, pain or sleep issues. My medication regimen consists of one of each of these types of PD meds, in different combinations throughout the day.

Neurotransmitters are chemicals that that help transmit signals in our brains, from one nerve call to another nerve cell, muscle cell or gland cell. There are plenty of different neurotransmitters, each with different chemical compositions, purposes and functions in our nervous systems. Dopamine is one of the most important for controlling our movements and is also involved in the reward system in our brains. Another important neurotransmitter is acetylcholine, which interestingly also is involved in our movement, it helps control our muscles. Acetylcholine also plays an important role in attention and motivation.

So why am I giving you a crash course in neuro science? Well, apart from the fact that the brain is the most sexy organ there is (look up the word “sapiosexual”), as a person with PD, my curiosity in neurotransmitters has very recently been key in my successfully managing an increasingly difficult disease.

During the last few years, I have been increasingly troubled by freezing-of-gait, my least favourite PD symptom. (For more info on freezing-of-gait, see: Bruised knees and bruised ego…Sara Riggare on ‘How Not To Fall’ and Parkinson’s never takes a day off). Imagine my delight when a study was published in The Lancet Neurology in January of this year titled: “Rivastigmine for gait stability in patients with Parkinson’s disease (ReSPonD): a randomised, double-blind, placebo-controlled, phase 2 trial“, and, being the engaged patient I am, I emailed my neurologist, attaching the article, asking him for a prescription. A few days later, I went to the pharmacy and picked up my new medication, Rivastigmine, which is an acetylcholinesterase inhibitor, meaning that it inhibits the enzymes responsible for the breakdown of the neurotransmitter acetylcholine in the brain, thereby increasing the levels of acetylcholine. The article argues that treatment with an acetylcholinesterase inhibitor could improve gait stability in people with Parkinson’s who have fallen during the last year.

During the following weeks I followed the scheme my neurologist had given me for introducing this new medication, while trying to find a constructive balance between objectively observing the potential effects and living life as usual.  After a rather terrifying experience when I went from 3 to 6 mg in my morning dose, I tapered it off again. The terrifying part meant that I found myself more or less unable to move, literally, a few hours after taking this higher dose. I felt almost like a statue and it would have been very interesting if I hadn’t felt so scared. I was very glad to get hold of my PD friend, who also is a neuroscientist at that time. He gave me a bit of a lecture about neurotransmitters and assured me that the effect was likely to wear off and my mobility return to normal (for a Parkie). Later that day, I could confirm his theory, at which point he was kind enough to point out to me that I couldn’t know for certain that the Rivastigmine was responsible for the effect I experienced unless I repeated the experiment. I haven’t. Yet.

I went back to 3 mg per day and over the last few weeks, I have found myself really struggling with moving and walking. I usually say that living with PD takes an olympic gold in stubbornness, but over these last few weeks, it has been much tougher than I probably have been prepared to admit to myself. Thinking back, I have not been able to do much more than doing my daily dose of exercise, working, falling asleep on the couch, watching TV and then going to bed. And with PD, you can’t really be sure what’s wrong until you’ve done a fair amount of troubleshooting:

First, observation: “Hmmm, I don’t feel well today… my whole body is heavy, my back hurts, my hands move slowly… even more slowly than usual…. I wonder what’s wrong…?”.

Then, hypothesis testing: “Am I coming down with something…? Do I have a pinched nerve in my back or lumbago….? Or did I forget to take my meds….? Have I been stressing too much… or sleeping badly….? Or…., the worst fear: is my PD suddenly progressing faster…?”

This kind of troubleshooting takes some time, as you can imagine… But I am very happy to tell you that I feel much better today! So, what is different today? I’ll tell you: My neuroscientist friend with PD told me that our movements are really controlled by the balance between dopamine and acetylcholine (this is of course an extremely simplified explanation) and in simple terms: the Rivastigmine was likely to somewhat cancel out the effect of my dopamine enhancing medication. When this crucial piece of information had reached its way into my brain, I formed a new hypothesis which I tested this morning: this morning, I took more L-dopa than I usually do and what a success it was! It was such a relief to be able to move effortlessly again (well, effortless by PD standards anyway…)! My family and colleagues will tell you that I have been smiling the entire day from the pure joy of moving!

This approach enables me to keep living as well as I can with this very complex disease!

45 and counting

stock-photo-14302068-45th-birthday-candlesIt was my birthday last Friday, on the 19th of February. This year I turned 45 and was honoured, grateful and very happy for all the birthday greetings that came flooding in from all corners of the world via Facebook. On days like that I really love social media. I had a very good day with productive work meetings and a very nice “fika” (one of the most important Swedish words and concepts, if you don’t know what it means, check out Wikipedia) with my colleagues and a “kladdkaka” baked by my daughter and her friend. The evening was spent at a bowling alley with family and friends. On the whole a very nice birthday!

When I was in my early teens, like all teenagers, I thought people in their 40s were ancient. Strangely enough, having reached that age myself, I still feel sort of young. But I guess it is just another piece of evidence that Einstein was right: time is relative.

Honestly though, living to see 45 is not really impressive these days, when the average life span for women in Sweden now being 84 years. What impresses me however, is how my body still keeps hanging in there.

I’ve had Parkinson for over 30 years now, and I have been told that I make it look so easy. I am actually not sure if “making Parkinson look easy” is doing myself or the Parkinson community any favours but I am not doing it on purpose. Because I can assure you that it is not easy, managing Parkinson takes a lot of hard work. And I have come to realise that all the medicines  I take, see pic below,  are not enough.

My meds for one day.

My pills for one day. The first column is my early morning dose, the second is for late morning, the third is afternoon, the fourth is early evening and the last column is for late evening.

The longer I have Parkinson, the more convinced I am of how essential it is to stay physically and mentally active. The mentally active part has not been a problem so far, I love challenging my mind in discussions, riddles and puzzles. I also love knitting, which is said to be good for your brain and even decrease the risk for dementia.

Staying physically active with a difficult disease like Parkinson is however very challenging. Ever since I couldn’t keep up with my mother and brother when we went cross-country skiing up north when I was a teenager, I have been struggling to keep physically active. None of us had any idea then that my inability to keep up was caused by a neurodegenerative disease and I was perceived as “lazy”. I didn’t know what was wrong but it was very frustrating when my body didn’t work and I cried a lot when I couldn’t keep up.

Nowadays I am almost painfully aware of the importance of exercise.  If for some reason, be it a bad cold, travelling or a busy schedule, I am unable to get my dose of treadmill walking, I know it will take a lot of work to make up for it. Parkinson is also a very unpredictable disease, some days, with no apparent explanation, nothing works and I spend the day moving very slowly and trying to find a comfortable way of sitting or lying down. Fortunately days like that are few and far apart… for now.

This is why I am so very grateful that my body still responds well to me constantly pushing it. Pushing towards and beyond what I thought possible… over and over again.

It takes a lot of really hard work to make Parkinson look this good!

Photo from my presentation at the half-time review of my doctoral studies, taken by Hiba Mualla.
Photo from my presentation at the half-time review of my doctoral studies on 5th June 2015, taken by Hiba Mualla.

For whose sake is research done – really?

openness-research300 I owe a lot to research. Thanks to an immense number of dedicated researchers, I have access to reasonably effective treatments for my Parkinson with (so far) manageable side effects. And of course we need more research, in all diseases and on all levels of health and healthcare.

But, is the current process for how research is being undertaken ideal to achieve the best results? I think improvements are urgently needed and here’s why:

I don’t doubt for a second that researchers are dedicating all that time for all the right reasons: they want to help people and improve health and healthcare. But what does the system look like? Well, if you’re a researcher, or even just a doctoral student like me, you know very well that your work is rated to a large extent based on publications. And of course, that would be all good and well, assuming that scientific journals make sure that they assess that submitted articles address research important to patients. To my knowledge, to date, only the British Medical Journal actively asks researchers to what extent patient input has influenced the research reported in the submitted article (as described in this article about their strategy for patient partnership).

I was very happy to read about the Australian government’s proposed changes to the process of research funding earlier this year (link here), where they suggest more emphasis on “engagement” and “impact” over publications. As far as I know, the details of the proposed changes are not clear yet, but I am carefully optimistic.

Most research being done to date, is primarily done for the sake of research, secondarily for the sake of healthcare, and thirdly, if at all, for the sake of individual patients. This is a result of the very complex weave that makes up the current research process. And I am not saying that good or even great research cannot come from the current research process. I am however convinced that we would all benefit from a complementary research paradigm, taking the individual patient as its starting point.

Research being done for the sake of research may be good, but it’s not enough!

 

 

BEAT Parkinson – på svenska

2015-11-21 10.01.35-2Under en helg i november 2015 var Stockholm platsen för ett nytt (för Sverige) och innovativt initiativ för träning för Parkinson. Narva boxningsklubb hade tillsammans med Parkinson Stockholm och mig bjudit in den portugisiska sjukgymnasten/fysioterapeuten Josefa Domingos för att erbjuda boxarna på Narva utbildning om Parkinsons sjukdom och dessutom prova-på träning för Parkinson Stockholms medlemmar. Det var en succé, som filmen nedan visar.

Nu letar vi efter sätt att kunna erbjuda regelbundna träningspass speciellt för personer med Parkinson, genom sponsring eller andra sätt. Om du har något förslag, kontakta mig via: contact@riggare.se.

BEAT Parkinson – in English

2015-11-21 10.01.35-2On a weekend in November 2015, Stockholm was the scene for the start of a novel (for Sweden) concept for training for Parkinson’s: boxing training! The boxing club Narva had taken the initiative together with the Parkinson’s association of Stockholm and me to invite the Portuguese physical therapist Josefa Domingos to offer the boxers at Narva boxing club education in Parkinson’s disease and also offer trial sessions of boxing training to the members of Parkinson Stockholm. It was a huge success, see the film below.

We are now looking for ways to offer regular training sessions specialising in Parkinson through sponsorships or other means. If you have ideas or suggestions, please email me at contact@riggare.se.

Organising your own “health management system”

Personal View published in BMJ (http://www.bmj.com/content/351/bmj.h6318): “Patients organise and train doctors to provide better care” by Sara Riggare and Kenton Unruh.

During the last few years, I have been thinking a lot about healthcare, which could be seen as strange, since I actually don’t use a lot of healthcare. If you’ve ever seen me present at a conference or watched a video of me, you have probably seen my “picture-with-all-the-dots”, so you know that I see my neurologist only one hour per year. And I am actually quite a healthy person, apart from the fact that I have an incurable progressive neurological disease, so I don’t go to other physicians a lot either. All in all, on an average year, I probably spend 2-3 hours in a doctor’s or nurse’s office for my own health.

So why am I spending so much time thinking about healthcare, what the current problems are and how to make it better? Well, the main reason is probably that I want to improve the system for my own sake, so that when I need more help, the right help is available. But I am also doing what I do because I believe that I have a responsibility to contribute in the best way I can to making the world a better place and it seems that this is an area where my efforts seem to have a good effect.

My work these last few years has given me the pleasure of meeting a lot of fantastic people, people who, like me, are living with substantial health challenges. And I have realised that all of us have one thing in common: instead of adhering to “the system’s” idea of the best way to organise healthcare for our particular disease or condition, we have all taken things into our own hands and organise our own “health management  system”. This often include aspects that is not always considered part of the healthcare system.

The organisation of what you need to manage your health in the best way is also the theme of a recent Personal View that was published in the British Medical Journal, written by Kenton Unruh and myself. In the article we describe the work we both do to make sure we get the care we need for our Parkinson’s disease. The main points of the article are:

  • Assemble the best team – we have both identified and assembled the clinical expertise we need to ensure access to the support we need in managing our complex needs.
  • Manage information efficiently – we gather information prior to visits using a single page colour-coded summary of current medication regimen, clinical status and questions and/or a prototype of a smartphone app.
  • Evidence or opinion? – to ensure optimal decision making, we ask our clinicians to indicate if the information they provide is based on scientific evidence or general clinical practise.
  • Coordination between visits – we acknowledge that we have the biggest interest and the best possibility to be in possession of the full picture of our health and therefore take it upon ourselves to be the carrier of information between visits and clinicians.

We are aware that we are taking on tasks that could be considered to be the work of the healthcare system. However, we find that our approach enables us to optimise the outcomes of our healthcare interactions and also to use our own time more efficiently.

Let’s help ourselves by working together to improve healthcare systems: patients, clinicians and healthcare organisations!

The Burden of Tracking

"The quantified self Counting every moment" - The Economist
Image copied from the article “The quantified self Counting every moment”, published in The Economist March 3rd 2012 (http://www.economist.com/node/21548493)

I have called myself a self-tracker since the first time I heard the word. The concept of using technology to collect data about myself and then analysing that data to better understand different aspects of myself and my surroundings has always resonated strongly with me, both as an engineer and as a researcher.

My self-tracking practises have been very useful for exploring how to best manage my Parkinson’s medication and also for other aspects of this challenging disease.

But I don’t track every day. I do however collect data almost every day, mainly relating to my physical activity (steps) and sleep. I don’t consider that tracking though. I consider self-tracking to be a process, and I often use the PDSA-cycle (plan, do, study, act) to explain it, and if not all the steps are addressed, it is not self-tracking.

For self-tracking, I specify the steps as goal-setting, data collection and analysis, reflection, and decision-making and, in my opinion, it is essential that we interact with our data, put our data into a context and reflect on what it means. That is when the magic happens!

When I first learnt about the Quantified Self movement and presented at the first QSEU conference in Amsterdam in November 2011, I thought it was all about the technology, about the gadgets. With time, I have realised that it is not, technology is important, but as a tool, not as the goal itself.

The goal is to use your own data to answer your own questions. 

The collection of data can be facilitated by the use of technology but it is not necessary.

In 2011, I was very optimistic, we probably all were: the emerging technologies would be able to help us better manage our diseases in ways we couldn’t even begin to imagine. I still think we have a lot to gain from using more technology in chronic disease management, but I am significantly less optimistic.

Self-tracking is really hard! 

Firstly, it is very difficult to ask the right questions, like: What do I want to achieve? How can I even measure that? What kind of data do I need? How can I collect it? And how to analyse? and last but not least: What on earth do these results mean? Different questions and approaches are likely to require very different tools, knowledge and skills.

Secondly, it is very, very difficult to design and develop tools for self-tracking that are accurate enough to give correct and valid results but at the same time versatile enough to enable the users to explore their own questions, and not only the ones that healthcare or the device manufacturers thought were the relevant and important ones.

And, finally, self-tracking takes time. A lot of time. And if you are already spending a significant amount of your time on managing different aspects of your disease, maybe you just don’t want to add more chores. In my case for example, I take six different prescription medications, five times per day, in three different combinations, with   four different time intervals. These pills need to be organised, distributed, restocked etc and this takes time. In order to stay as well as I can for as long as I can, I also need to make sure I get enough exercise, which of course also takes time. To add more tasks, like self-tracking, would mean less time with my family.

Self-tracking has to be worth the effort. And to me, most of the time, it is not. I track when I have a good reason, for example when I want to find the best timings for a new medication dose or if I want to investigate a suspected new symptom.

You’ve probably heard the expression: “burden of disease”, frequently used in Public Health as a measure of the impact of health problems, to for example a country or a region. Carl R May, Victor Montori and Frances Mair have proposed the expression “burden of treatment” as a measure of the work we patients have to do to care for ourselves, for example managing treatments and doctor’s visits, lifestyle changes etc.

When discussing the future of healthcare, it is very often predicted that patients will collect a lot of data on their own devices. But will we? Will the effort of tracking pay off in the form of actual health improvements?

I would like to suggest that we start talking about

“the burden of tracking”.

Perspectives?

images-5Most people would probably agree that being diagnosed with Parkinson’s disease (PD) at age 32 would be a hard blow.

It was.

I usually describe it as “it felt like I fell down into a black hole”. Stephen Hawking would probably have a lot to say about my complete disregard for the laws and theories that govern space and black holes but what does he know about hard blows anyway… oh, right, he probably knows enough…

Anyway, I digress… I did get a really hard kick from life on that day in June of 2003, when a neurologist told me that I have PD.

Earlier that same year, life brought me something else. The most beautiful baby ever born. My husband’s colleague said: “She looks very much like her father but she’s still very cute”.

This means that at the time for my diagnosis, Frida was four months old. It also means that black hole or not, I couldn’t stay there. I had something more important to do than feeling sorry for myself. Slowly, very slowly (Parkies are very rarely anything but slow, unless there’s chocolate to be had…), I crawled back up into the light and started rebuilding myself and my new perspective on life.

It was not easy. It still isn’t.

Every day I fight PD and the increasing number of symptoms it brings me. If I would only get out of bed on the days I feel well, you wouldn’t see me many days of the month. But you know what? There are billions of people struggling on this planet, we all struggle. Sure, there are plenty of days when I think that I deserve an Olympic gold medal in stubbornness, and that’s only for getting to work.

I would never have wished for having PD, but it has brought me so many good things where the most important is all my wonderful friends all over the world, both fellow parkies and others.

PD is tough, really tough. Every day I fight, together with millions of fellow parkies all over the world. We fight increasing disability in the form of slowness, pain, sleeplessness, bruises from falling and much more.

Malcolm Gladwell writes that you have to spend approximately 10,000 hours to become an expert in something. I have spend much more than that to actively fight PD and I am proud of what I have achieved. I am definitely not saying that I am better than anyone else at battling PD but I am definitely an expert at fighting my PD. I am proud to be a “super patient”.

But this doesn’t make me special. I am only doing what I think I need to do to make the best of the hand I am dealt.

No one ever said life is fair.