|Year : 2014 | Volume
| Issue : 4 | Page : 462-466
Management of spastic cerebral palsy through multiple Ayurveda treatment modalities
Sagar M Bhinde1, Kalpana S Patel2, Virendra Kumar Kori2, S Rajagopala2
1 Department of Kaumarbhritya, GJ Patel Institute of Ayurvedic Studies and Research, New Vallabha Vidyanagar, Anand, India
2 Department of Kaumarbhritya, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India
|Date of Web Publication||18-Jun-2015|
Sagar M Bhinde
C-10, Ayurveda Staff Quarter, GJ Patel Institute of Ayurvedic Studies and Research, New VV Nagar, Anand - 388 121, Gujarat
Source of Support: IPGT and RA, Gujarat Ayurved University, Conflict of Interest: None
Clinical trial registration CTRI/2011/11/002157 [Registered on: 22/11/2011]
| Abstract|| |
Background: Cerebral palsy (CP) is a leading cause of childhood disability affecting function and development. The global incidence of CP is 2:1000. It has been reported that children with CP and their caretaker have impaired health-related quality of life (QOL). Of the many types and subtypes of CP, none has any known cure. For a detailed description of the disease CP, though, there is no one to one correlation in Ayurvedic classics; it can be taken as Vata Vyadhi as far as its etiology and symptomatology are concerned. Aim: To assess the effect of certain Panchakarma procedures in the management of CP. Materials and Methods: Total 8 patients were registered and treated with 5 days of Udvartana, 5 days of Abhyanga followed by Sarvanga Swedana and then 8 days of Yoga Basti. The same course of treatment has been repeated for 3 times with an interval of 14 days. Ashtanga Ghrita was given during whole procedures as internal medication. Results of treatment were assessed with anthropometrical measurement, developmental milestone, Modified Ashworth Scale, spasm scale, reflex scale, and muscle power grading. Result: This Ayurvedic management shows good result in CP patients, especially by improving growth (height, weight, chest circumference) and development (head holding and sitting), reducing spasticity of left upper limb and muscle spasm. Conclusion: Multisystem approach is needed to improve the condition of the patient. Panchakarma along with internal medication should be given to improve all the facets of spastic CP. Yoga Basti acts by their own mode of action and can be used freely for such disease conditions.
Keywords: Cerebral palsy, Panchakarma in pediatrics, Yoga Basti
|How to cite this article:|
Bhinde SM, Patel KS, Kori VK, Rajagopala S. Management of spastic cerebral palsy through multiple Ayurveda treatment modalities. AYU 2014;35:462-6
|How to cite this URL:|
Bhinde SM, Patel KS, Kori VK, Rajagopala S. Management of spastic cerebral palsy through multiple Ayurveda treatment modalities. AYU [serial online] 2014 [cited 2020 Apr 2];35:462-6. Available from: http://www.ayujournal.org/text.asp?2014/35/4/462/159044
| Introduction|| |
Disabled children are of great concern to the family as well as the society. Cerebral palsy (CP) is the leading cause of chronic disability in children,  making them physically and mentally handicapped and socially apart. The worldwide incidence of CP is approximately 2.5 cases per 1000 live births.  For India, it is estimated around 3 cases per 1000 live births, but being a developing country the actual figure may be much higher. Among all the types of CP, spastic CP is the most common type, occurring in 70-80% of all cases.
Cerebral palsy is an umbrella term encompassing a group of nonprogressive, noncontagious condition that causes motor impairment by abnormalities in movement, posture, and tone.  It can be caused by any of prenatal, natal, and postnatal factors and eventual pathology is any type of injury to the developing brain.
No effective treatment for the underlying brain damage has been formulated till today. All the sophisticated technology and highly expensive and complicated therapies of the medical research field have failed to find out a definite cure for the disease.
There is no exact correlation found for CP in Ayurvedic literature. While observing the etiology and clinical features, the predominance of Vata is obvious and put this disease entity nearer to Vata dominant conditions or Vata Vyadhi. While considering pathophysiology and management of Spastic CP it can be taken as Avarana Janya Vata Vyadhi (Kaphavrita Vata).
Causative factors like inappropriate Ritu (ovulation period-menstruation period), Kshetra (uterus), Ambu (nutrition) and Bija (sperm and ovum),  Dauhrid Avamanana (negligence of urges during Dauhrid-stage of pregnant women), presence of Garbhopaghatkarbhavas (food and regimen of pregnant lady which cause fetal anomalies),  incompatible Garbha Vriddhikara Bhava (factors responsible for fetal growth),  and improper following of Garbhini Paricharya may have undesirable effect on the fetus in utero.  Moreover Akala Pravahana (inappropriate force) during labor, Shiromarmabhighata (head injury), defect in Prana Pratyagamana (neonatal resuscitation) process, Ulbaka (a type of disease), Nabhi Nadi Vikara (diseases of umbilical cord), Graha Roga (infectious diseases), improper Shishu Paricharya, etc., may play role as causative factor, during and after birth. These hamper normal growth and development of the child and cause many diseases, deformities, and even death.
In the previous research works, it is proved that internal medication along with Panchakarma procedures is more effective in comparison with only oral medications.  Hence, in the present study, Panchakarma procedures like Udvartana, Abhyanga, Swedana, and Yoga Basti are taken along with internal medication (Ashtanga Ghrita) were undertaken to evaluate the effect of multiple Ayurveda treatment modalities in the management of spastic type of CP.
| Materials and Methods|| |
Selection of patients
Prediagnosed cases of spastic CP, attending IPD of Kaumarbhritya Department, IPGT, and RA Hospital, Jamnagar were registered, after taking informed consent from parents/guardian, for the present clinical trial. The study was approved by Institutional Ethics Committee (PGT/7-A/Ethics/2010-11/1858; Dated 1.9.10).
- Children with spastic CP of 3-10 years of both sex
- Children with developmental disability of both physical and mental (delayed milestones).
- Children with major congenital disorders and with other types of CP like hypotonic, dyskinetic and athetoid
- Children with other diseases such as diabetes, acute infection, etc.
Dose of Ashtanga Ghrita was determined by using the reference of Sharngdhara Samhita after converting the ancient unit of measurement, that is, Masha into grams. Aushadha Kala was morning and Anupana (adjuvant) was Koshna Jala (luke warm water). Ashtanga Ghrita or 58 days along with the procedures, except the days in which Basti was given.
- Udvartana : With lukewarm Yava and Kullattha Churna (20 min) for 5 days
- Abhyanga : With lukewarm Bala Taila (20 min) followed by Sarvanga Nadi Sweda (20 min) for 5 days
- Yoga Basti for 8 days, in which 1 Anuvasana Basti in beginning and then 3 set of Anuvasana and Asthapana Basti followed by 1 Anuvasana Basti at last were given. Anuvasana Basti was given with Bala Taila and Madhutailika Basti was given as Asthapana Basti. The dose  of Basti Dravya for Aasthapana Basti are depicted in [Table 1]. Anuvasana was given Ό of the quantity of Aasthapana Basti.
Such three courses were repeated with the interval of 14 days between each course. Total duration of the treatment is 82 days. Test drugs were procured from the Pharmacy, Gujarat Ayurved University, Jamnagar.
Criteria for assessment
Anthropometrical measurement, developmental milestone, Modified Ashworth Scale (MAS),  spasm scale to assess intensity of spasm, manual ability classification system (MACS),  reflex scale to assess deep tendon reflex, and muscle power grading  were taken as assessment criteria to observe the effect of therapy.
Assessment of total effect of therapy
Maximum Improvement: >75% improvement.
Moderate Improvement: >50-75% improvement.
Mild Improvement: >25-50% improvement.
No Improvement: ≤25% improvement.
Statistical analysis was done by using student paired t-test.
| Observations and Results|| |
Total 8 patients were registered in this study and 2 were dropped out, 6 patients completed the course of treatment. Out of 8 patients, 6 were quadriplegic and 2 were hemiplegic.
Effect of therapy on developmental milestone
It shows significant results (P < 0.05) in assessment parameters of head holding and sitting, while the rest of all parameters have shown insignificant (P > 0.05) results [Table 2].
Effect of therapy on anthropometrical measurement
It shows the significant result (P < 0.05) in anthropometrical parameters, that is, length, weight, and chest circumference; whereas head circumference and mid-arm circumference have shown insignificant results [Table 3].
Effect of therapy on motor system components
It shows significant results (P < 0.05) in Left upper limb spasticity and all four limb spasm. Insignificant improvements were found in muscle power, spasticity grading (MAS) in rest of group of muscles, reflex scale, and MACS [Table 4].
| Discussion|| |
Delayed development of gross and fine motor function may be due to a problem in normal function of Vata (Pravartaka Cheshtanamucchavchanam). Hence, to achieve results in developmental disorders, function of Vata (normal physiology) should come to normal. Here, Ashtanga Ghrita might have worked on central nervous system (CNS) by crossing BBB (Blood Brain Barrier-Majja Dhara Kala) because of its lipophylic property, thus stimulating higher mental functions (Medha, Smriti and Buddhi). Udvartana had given a well platform for further procedures like Abhyanga, Swedana and Basti by removing Avarana and Srotorodha.  Abhyanga and Swedana caused Dosha Gati from Shakha to Koshtha, which helped in removing vitiated Dosha through Basti. Finally, Basti helped to accomplish the effect of Shodhana. Thus by the combined effect of total therapeutic measures, Avarana was removed, Mastulunga Majja got nourishment, Vata came to normalcy, and hence the proper development of milestones were achieved.
Language is more of the function of Udana Vayu (Vaka Pravrutti Prayatnorja), which is normally situated at Uraha Pradesha, insignificant result in this study suggests that Basti along with other Panchakarma procedures do not show complete correction in the function of vitiated Udana Vayu within study period. As this disease entity comes under Asadhya Vyadhi, the study period may not be enough to show the effect on language. Individualistic Dosha oriented practices like Aushadha Grahana Kala (Sayam Bhojana Pashchat for Udana Vayu),  Swasthana Dosha Chikitsa, etc., might give better results in this aspect.
Personal and social development is more of the function of Prana Vaya (Buddhi, Indriya, Chittadhruka). Insignificant result in this milestone suggests that the treatment protocol did not show effect to the persistent damaged Murdha. This milestone starts to develop in early infantile age, so the correction of this milestone requires early and prolonged intervention.
Growth is achieved by nourishment of Rasadi Dhatus. Here Ashtanga Ghrita might cause Brumhana by Snigdha (unctuous) and Guru Guna (quality), Udvartana opened the minutes channels and improved blood and lymphatic circulation, Abhyanga provided nourishment by its property like Snigdha, Mridu, Bahala, Pichchhila which are told as properties of Brimhana Dravya. Swedana caused excretion of Mala (waste metabolites). Snigdha Basti (Anuvasana with Bala Taila) is told to have Brumhana effect. 
Spasticity is characterized by increased resistance by passive stretch, velocity dependent, and asymmetric about joints (i.e. greater in flexor muscle at the elbow and the extensor muscle at the knee).  This may happen due to Avarana of Vata, wherein, due to Avarana, Vayu cannot perform its normal function, that is, normal movement of joints (Pravartaka Cheshtanam). Initially, Udvartana helped in reduction of vitiated Avarita Kapha by its Ruksha and Srotoshodhana property. Once Avarana is removed, the aim of treatment is to pacify vitiated Vata. Vayu resides in Sparshnendriya, which is located in Tvacha, Abhyanaga is quoted as Tvachya, so Abhyanga might work directly on Vata to bring it back to normalcy. Basti acts on CNS by stimulating ENS (enteric nervous system). 
Spasm was reduced significantly, which may be due to Shamana of Vata Guna like Chala and Shita by virtue of Ashtanga Ghrita, Abhyanga with Bala Taila, Bashpa Sweda, and Mrudu Shodhana Aasthapana Basti.
Total effect of therapy
In majority of patients, total effect was found near 10-15%. As this disorder is incurable, this percentage of improvement also helps the patient to improve QOL. Treatment of this kind of condition is just like a pyramid, if we are able to make small improvement in an earlier age than it will reflect its major benefit in later age in the form of developing skills.
Previously it was believed that neurons do not repair or rejuvenate after any injury, but the new concept of neuroplasticity says that CNS have the ability to repair their neurons by axonal sprouting to take over the function of damaged neurons.  This improvement in patients also supports the concept of Neuroplasticity.
Hence, it is quite irrational to say "no improvement" (<25%) by following standard criteria for assessing the total effect of therapy.
| Conclusion|| |
The selected Ayurvedic treatment modality is effective in relieving the signs and symptoms and thus reducing the disability in children with Spastic CP. Available research data and references are not enough to explain the mode of action of Ashtanga Ghrita in precise way. Panchakarma with Yoga Basti are effective in improving growth (height, weight, CC) and development (head holding and sitting), reducing spasticity of left upper limb, and spasm in patients.
| References|| |
Datta AK, Sachdeva A, editor. Kuban, Leviton and Rosenbaum. Advances in Pediatrics. 1 st
ed. New Delhi Jaypee Publication; 2007. p. 623.
Sushruta, Sushruta Samhita, Sharira Sthana, Shukrashonita Shuddhi Sharira, 2/33, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Sanskrit Sansthana, Varanasi, 2009; 348.
Agnivesha, Charaka, Dridhabala, Charaka Samhita, Sharira Sthana, Mahatigarbhavkranti, 4/17, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Prakashana, Varanasi, 2009; 320.
Ibidem, Charaka Samhita, Sharira Sthana, Mahatigarbhavkranti, 4/18; 320.
Ibidem, Charaka Samhita, Sharira Sthana, Mahatigarbhavkranti, 4/27; 321.
Ibidem, Charaka Samhita, Sharira Sthana, Jatisutriya Sharira, 8/22; 344.
Dodge NN. Cerebral palsy: Medical aspects. Pediatr Clin North Am 2008;55:1189-207, ix.
Vyas A, Kori VK, Rajagopala S, Patel KS. Etiopathological study on cerebral palsy and its management by Shashtika Shali Pinda Sweda and Samvardhana Ghrita. Ayu 2013;34:56-62.
Sharangadhara, Sharangdhara Samhita, Purva Khanda, 6/14-17, edited by Murthy KR, 5 th
ed. Chaukhambha Orientalia, Varanasi, 2003; 29.
Vagbhata, Ashtanga Hridaya, Uttara Tantra, Balopcharaniya 1/43-44, edited by Tripathi B, reprint ed. Chaukhamba Sanskrita Pratishthan, Delhi, 2007; 884.
Sharangadhara, Sharangdhara Samhita, Uttarakhanda, 6/28-30, edited by Murthy KR, 5 th
ed. Chaukhambha Orientalia, Varanasi, 2003; 219.
Agnivesha, Charaka, Dridhabala, Charaka Samhita, Siddhi Sthana, Bastisutriya Siddhi, 3/31-32, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Prakashana, Varanasi, 2009; 695.
Sushruta, Sushruta Samhita, Chikitsa Sthana, Netrabasti Pramana Pravibhaga, 35/18, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Sanskrit Sansthana, Varanasi, 2009; 526.
Carnahan KD, Arner M, Hägglund G. Association between gross motor function (GMFCS) and manual ability (MACS) in children with cerebral palsy. A population-based study of 359 children. BMC Musculoskelet Disord 2007;8:50.
Santosh K. Pediatric Clinical Examination. 2 nd
ed. Hyderabad: Paras Medical Publisher; 2010. p. 232.
Sushruta, Sushruta Samhita, Chikitsa Sthana, Anagat Badhapratishedha, 24/51-52, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Sanskrit Sansthana, Varanasi, 2009; 489.
Vagbhata, Ashtanga Hridaya, Sutra Sthana, Doshabhediya, 12/5, edited by Tripathi B, reprint ed. Chaukhamba Sanskrita Pratishthan, Delhi, 2007; 171.
Agnivesha, Charaka, Dridhabala, Charaka Samhita, Chikitsa Sthana, Yonivyapada 30/299, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Prakashana, Varanasi, 2009; 646.
Vagbhata, Ashtanga Hridaya, Sutra Sthana, Doshabhediya, 12/4, edited by Tripathi B, reprint ed. Chaukhamba Sanskrita Pratishthan, Delhi, 2007; 171.
Agnivesha, Charaka, Dridhabala, Charaka Samhita, Sutra Sthana, Langhana Brimhaniya, 22/14, edited by Yadavji Trikamji Acharya, reprint ed. Chaukhamba Prakashana, Varanasi, 2009; 120.
Ibidem, Charaka Samhita, Siddhi Sthana, Snehavyapatti Siddhi, 4/54;701.
Shukla G, Pandey S, Thakar A. Pharmacodynemic understanding of Basti - A contemporary approach. Int J Pharm Biol Arch 2012;3:893-96.
Trojan S, Pokorný J. Theoretical aspects of neuroplasticity. Physiol Res 1999;48:87-97.
[Table 1], [Table 2], [Table 3], [Table 4]