The purview of Parkinsonism in Ayurveda

REVIEW ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 249 The purview of Parkinsonism in Ayurveda Dr. Shereen Sreenivas 1 , Dr. Muralidhara 2 , Dr. Sindhura A. S. 3 1 Post Graduate Scholar, 2 Professor, 3 Lecturer, Department of Kayachikitsa, Sri Kalabyraveshwara Swamy Ayurvedic Medical Coleege Hospital & Research Centre, Bengaluru, Karnataka, INDIA. I NTRODUCTION Parkinsonism is a clinical syndrome that consists of four cardinal signs: Tremor, Rigidity, Akinesia and Postural disturbances (TRAP) [1] It is also called as the Shaking Palsy or Paralysis agitans. Parkinson’s disease is a common cause of the TRAP syndrome, but there are numerous other causes which can be considered as the differential diagnosis. Parkinson’s disease Address for correspondence: Dr. Shereen Sreenivas Post Graduate Scholar, Department of Kayachikitsa, Sri Kalabyraveshwaraswamy Ayurvedic Medical College, Hospital and Research Centre, Bengaluru, Karnataka, INDIA. E-mail: shereensreenivas@gmail.com Submission Date: 17/09/2019 Accepted Date: 22/10/2019 Access this article online Quick Response Code Website: www.jaims.in Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CCby-NC-SA accounts for 80% of Parkinsonism. Parkinson’s disease specifically refers to patients who have Parkinsonism, without any atypical features and who have essentially normal MRI that excludes other causes for their Parkinsonian symptoms. The main difference between the two is the effect of levadopa drug in Parkinson’s disease and not the other. Parkinson disease, which is the second most common neurodegenerative disorder after Alzheimer disease, occurs in approximately 1 in 1000 in the general population and in 1% of persons older than 65 years. Men are affected slightly more often than women (3 : 2) and it is attributed to be because of a sex gene named SRY found only in males and produced by Substantia Nigra, the brain region affected by Parkinson’s [2] It is suspected that the SRY gene serves as a protective agent. Many of the features of Parkinson disease are due to loss of dopamine in the Neostriatum (especially the putamen) secondary to loss of pigmented A B S T R A C T Parkinsonism is a clinical syndrome in which the Parkinson’s disease accounts for 80% of involvement. Parkinson’s disease specifically refers to patients who have Parkinsonism, without any atypical features and who have essentially normal MRI that excludes other causes for their Parkinsonian symptoms.The main difference between the two are the effect of levadopa drug in Parkinson’s disease and not the other. Parkinson’s disease, which is the second most common neurodegenerative disorder after Alzheimer disease, occurs in approximately 1 in 1000 in the general population and in 1% of persons older than 65 years. Men are affected slightly more often than women (3:2). The cause of Parkinson’s disease is believed to be a variable combination of poorly understood genetic and environmental factors. Hence treatment is often aimed at prevention of further complications and preserving the condition using general measures, drug therapy and surgery. In Ayurveda , giving importance to prevention of further derangement, Lakshanika Chikitsa is often attributed to the different stages of the disease. Parkinson’s disease is generally understood as Kampavata in Ayurveda . But the development of the disease can be understood under various concepts of Bahukampavata, Snayugatavata, Kaphavruta Vyanavata and Kampavata . As Parkinsonism is widely treated with better efficacy in Ayurveda, hence it is the need of the hour to understand it in all its aspects with its relevant treatment.Hence the main aim of this article is to understand these varied concepts in possible correlation with the Parkinson’s disease. Key words: Parkinsonism, Baahukampavata, Snayugatavata, Kaphavruta Vyanavata, Kampavata.

Dr. Shereen Sreenivas et al. The purview of Parkinsonism in Ayurveda ISSN: 2456-3110 REVIEW ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 250 dopaminergic neurons in the Substantia Nigra cells of the midbrain. Approximately 60% of these dopaminergic neurons will have degenerated before clinical features of the disease develop. Parkinsonism basically is of two types - Primary and Secondary. Primary Parkinsonism consists of Sporadic and Genetic. Sporadic is also called as Idiopathic and it usually occurs in late middle age and its incidence increases with age. Genetic involvement is often attributed to mutations in at least six genes, including alpha-synuclein, uchL 1, LRRK 2, parkin, PINK 1, and DJ- 1, are linked to Parkinson's disease [3] The younger the age of onset, the more likely the genetic involvement. Atypical Parkinsonism is also called as Parkinsonism Plus Syndrome. These include Dementia with Lewy Bodies, Progressive Supranuclear Palsy, Multiple system atrophy and Corticobasal syndrome. Atypical Parkinsonian disorders are progressive diseases that present with some of the signs and symptoms of Parkinson's disease, but that generally do not respond well to drug treatment with levodopa. Atypical Parkinsonian disorders are not currently thought to be genetic. Most cases arise from unknown causes, though some may be associated with long-term drug exposure or trauma. Secondary Parkinsonism (environmental etiology) include Drug induced (antipsychotics, reserpine, tetrabenazine), Infections (post encephalitic), Toxins (dieldrin, Carbon disulphide), Heavy metal (mercury, manganese), Head Trauma, Brain tumors and Liver failure. Clinical Features The main features are the TRAP as mentioned above. Other Motor features include micrographia, hypomimia, reduced eye blink, hypophonia, dysphagia and freezing. The cardinal features are; Resting Tremors which are 4-6 cycles per second, pill rolling in nature, disappears on voluntary movement and sleep. Rigidity is the increased muscle tone, on examination by passive movements. Cogwheel rigidity and leadpipe rigidity are the two types identified with Parkinson's disease. Leadpipe rigidity is sustained resistance to passive movement throughout the whole range of motion, with no fluctuations. Cogwheel rigidity is the jerky resistance to passive movement as muscles tense and relax. Bradykinesia are the Slowness of movement with progressive loss of speed. Difficulty with planning, initiation and execution of movements Postural Disturbances include Stooped posture, Universal flexion, Shuffling gait and Freezing phenomenon. The other non-motor symptoms include the neuropsychiatric symptoms like depression, anxiety disorders, apathy, the autonomic disturbances like Urinary dysfunction, constipation, the sensory symptoms like Pain, Restless syndrome, Olfactory dysfunction, the sleep disturbances like excessive day time drowsiness, changes in REM cycle and the cognitive impairmentlike dementia in 80% of pts after 20 years of disease. Investigations include [4] CT, MRI, PET and Transcranial Ultrasound to rule out other causes and to confirm the diagnosis. There are various criteria’s and staging mentioned for different aspects of Parkinson’s. Staging is usually done using Modified Hoehn and Yahr staging 5 .Complications include Frequent falls, Incapacitation, Depression and dementia, Postural hypotension, Urinary incontinence, Constipation, Aspiration. Treatment in Allopathic system of medicine is three fold: General measures includes physiotherapy, speech therapy and diet control. Drug therapy using drugs like levadopa, amantidine, bromocriptine, pramipexole, ropinerole, selegiline and benztropine. Surgery includes deep brain stimulation, thalamotomy, pallidotomy and neural transplantation. Ayurvedic understanding of Parkinsonism The pathogenesis of neurological diseases involves the concept of Dhatukshaya and Avarana. [6] Considering the Lakshanas exhibited in Parkinson’s disease, in Ayurveda, we can consider Baahukampa

Dr. Shereen Sreenivas et al. The purview of Parkinsonism in Ayurveda ISSN: 2456-3110 REVIEW ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 251 Vata, [7] Snayugata Vata, [8] Kaphavrutavyana Vata [9] and Kampavata [10] under the banner of Parkinson’s disease. Baahukampavata is mentioned in Basavarajeeyam as the tremors in one side of the arm, affecting the activities of the body and that which gives rise to various kinds of discomfort during the day and night. This can be correlated to the initial stages of Parkinson’s disease where there is unilateral involvement along with axial involvement. Snayugata Vata is defined in Bhava Prakasha as, When the deranged Vatadosha is situated in the tendons, there may be Soola, Akshepaka, Kampa, Stambha, Anilaodbhava (cramps, convulsions, tremors and muscular rigidity). To rectify this condition, Swedana, Upanaha, Agnikarma and Bandhana are suggested. This can be compared to the stages of development of the disease where there is bilateral involvement with recovery on Pull test. This verse could be interpreted as 1 or 2 sided as the treatment is not intended for Bahudoshaavasta . Kaphavruta Vyanavata explained in Caraka Samhita is understood as, if Vyanavayu is occluded by Kapha , then there will be heaviness all over the body, pain in all the joints and bones, and restricted movements or excessive loss of morbidity. This can be understood with reference to the pathology in Allopathic science. The prime pathology occurring in Parkinson’s disease is that the substantia nigra pars compacta cells begin to die. These cells produce dopamine, which is a hormone and a neurotransmitter (chemical released by neurons to send signals to other cells). Dopamine brings about the movement, helps in memory, sleep, mood, pleasurable reward, behavior and cognition. The dopamine depletion blocks autoinhibition of acetylcholine release through muscarinic autoreceptores, leading to excessive acetylcholine release which eventually prunes spines of the indirectpathway projection neurons of the striatum and thus interrupts information transfer from motor command centers in the cerebral cortex [11] In short, decrease in dopamine leads to an increase in acetylcholine i.e. they are inversely proportional in nature. Breakdown of acetylcholine-dopamine balance hampers proper functioning of the cortico-basal gangliathalamocortical loop circuits. Acetylcholine is the neurotransmitter responsible for the muscles to contract, activates pain responses, regulates endocrine and REM sleep. Hence when the acetylcholine is increased, it leads to bradykinesia, rigidity, postural disturbances and tremors which are also explained by the Acharya as Gatisanga and Adhika Gatisanga : where there is obtruction to the normal function of Vata . This can be understood as bradykinesia, rigidity, postural disturbances and Adhika : increased activity such as tremors can be considered here. This can be understood under the concept of Avarana where there is hindrance to the path of Vyanavata by the Kapha leading to Avarana . Dopamine molecule is too polar to cross the blood brain barrier. Hence the treatment in such conditions is L-Dopa, a precursor of Dopamine which can enter the blood brain barrier effectively. Even in Ayurveda, Avaranahara Chikitsa is done initially with Kapikachu being the main drug of choice. Kampavata is defined in Basavarajeeyam and this can be understood as the complete manifestation of the disease with the patient being bedridden or wheelchair bound and is physically dependant. Nidana (Causative Factors) The primary and secondary Parkinson’s disease can be understood from the aspect of Swatantra and Paratantra Vyadhis . The causes of primary Parkinson’s disease can be understood as Swatantra or Anubandhya Vyadhi though the causes state idiopathic. The Secondary Parkinson’s disease which is caused due to secondary factors can be considered as Paratantra or Anubandha Vyadhis as the treatment involves treating the primary cause and not the secondary manifestations. Chikitsa (Treatment aspects) The main aim of any Chikitsa is to improve the “Quality of life” of an individual. WHO has defined “Quality of life” as “a broad ranging concept affected

Dr. Shereen Sreenivas et al. The purview of Parkinsonism in Ayurveda ISSN: 2456-3110 REVIEW ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 252 in a complex way by the person’s physical health, psychological state, personal beliefs, social relationships and their relationship to salient featureas of their environment” [12] In a patient of Parkinson’s disease, the Sickness Impact Profile (SIP) and the Short-Form Health status survey (SF-36) are the most popular. Subjective factors in QoL in PD patients include perception of symptoms, level of fitness, self-image, satisfaction with family life, work, the economic situation, the interaction with other people, social support, and life in general. The objective factors include the clinical picture of disease, social status, social and living conditions and the number and intensity of social contacts. The scales used to assess the QoL in PD include either subjective or objective indicators, or both. Depending on the Avastha of the disease and the cause involved, Dhatushayajanya or Avaranachikitsa can be undertaken. Nirupahata Vatavyadhi Chikitsa explains that if the disease is of Asamsrishta or Dhatukshayajanya or Anavrita origin, the treatment includes [13] Snehana, Swedana, Anuvasanavasti, Nasya and Tarpanaahara. Snehana can be Bahya or Abhyantara . Snehana acts as Vishyandana, Mardavakara and Kleda Karaka . Also it is Vatahara in action. Swedana does Sthambanigraha, Srotoshuddhi, Gowravagna and Vatashamana. Vasti helps in Vatashamana, Agnivardhana, Manabuddhiindriyaprasadana, Ashayalaghutwa, Ruchikara and prakrutisthapan. Nasya Karma removes the accumulated Dosha. Tarpanaahara becomes beneficial due to the Dhatukshayaavastha in the body as Brahmana is the treatment of choice here. Repeated Snehana and Swedana should be done by which the Koshta becomes Mrudu and Vatavyadhis cannot recur. If the Doshas don’t subide then Mridusnigdha Virechana should be done by Snehapana with Tilwaka or Satalaghrita/ Taila with milk. Virechana is done for Arhas where there is Pitta and Kapha Pitta involvement in the body. If the patient is too weak for Virechana then Niruhabasti should be done. Niruhabasti is done to remove Tridoshas especially Vata. It also provides Balavriddhi, Agnidipana, Rogashamana, removal of Vit, Mala and Samiranatva. In all conditions, Nasya and Dhoomapana should be given. The aim of Avarana Chikitsa [14] is to treat the patient with Anabhisyandi to clear the Snigdha Srotas, If Vayu is Rudha or blocked then Vatanumola which is not antagonistic to Pitta and Kapha should be done. Yapanabasti along with Anuvasanabasti . If the patient is strong, the Mriduvirechana is also explained. Usage of Rasayanas has been indicated. The Shamanoushadis to be used also depend on the Avasta of the patient. Understanding the necessity of Dopamine in this condition gives Kapikachu , the most natural levodopa-containing drug, as the prime drug of choice in Parkinson’s disease Kapikachu - The Natural Levodopa Kapikachu ( Mucuna pruriens ) is the drug of choice in Parkinson’s disease because of its natural Levadopa content. It is included under Balya and Madhuraskanda in Charaka Samhita . The seeds are the main source as they contain up to 7% levodopa. It is also an aphrodisiac as it causes a rise in testosterone levels, increased muscle mass and strength, and also improves coordination and attention. Extract of Mucuna seed powder contains large amounts of levodopa and a little serotonin and nicotine along with other ingredients that are only partially known. In the treatment of Parkinson’s disease, such extracts seem to be more effective and less toxic than the synthetic preparations [15] Mucuna increases the adaptation and regeneration of tissues in general and has been shown to increase growth hormone [16] It has an anabolic effect and increases muscle mass; it also has antioxidant properties and favors the protective functions of the liver [17] Mucuna contains prurienine which increases intestinal peristalsis and is a good remedy for constipation, so prevalent in Parkinson’s disease patients. It usually enhances motility and gastric emptying. Mucuna pruriens, which contains natural levodopa and is tolerated better than the synthetic version [18]

Dr. Shereen Sreenivas et al. The purview of Parkinsonism in Ayurveda ISSN: 2456-3110 REVIEW ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 253 The other formulations include Dhanwantaram Kashayam due to its Vatanuloma, Brahmana, Nadi Kshobhahara properties, Ashtavargam Kashayam for its Vatakapha Shamana, Avarana Vatahara, Srotoshodana and Lekhana properties, Pancasakara Curna for its Vatanulomana, Vatakaphahara, Sulahara properties, Gorochanadi Gutika for its Tridoshagna, Prananulomana, Srotoshodana and Sukshma Srotogami properties, Shiva Gutika for its Tridoshahara, Prabhava of Rasayana and Dhatuvriddhikara properties, Mahayogaraja Guggulu for its Yogavahitwa, Dhatuposhaka and Nadibalya properties, Trayodasanga Guggulu for its Dhatubalya, Vatahara and Pushtikara properties, Balarishta for its Balya, Brahmana and Dipana properties, Ashwagandhaarishta for its Balya , Dhatuposhana and Rasayana properties, Mahanarayana Taila for its Vatashamana, Sulahara and Balya properties and Dhanwantaramtaila for its Vatanuloma, Angamarda Prashamana, Balya and Brahmana properties. Rasayana which can be administered in Parkinson’s disease include Ashwagandhadhi Lehya, Brahma Rasayana, Chyavanaprasha, Dasamula Haritakilehya, Narasimha Rasayana, Nayopayam Lehya etc. DISCUSSION Due to any of the Nidana mentioned for Vatavyadhi , the Prakupitavata leads to Dhatukshaya and manifests as Ekabahukampa which is often seen during the initial onset of Parkinson’s disease. This can be understood as Nidana lead to Vataprakopa which accumulate in Rikta Srotas leading to the Lakshanautpatti of Baahukampavata. Considering the Lakshanas of Snayugatavata , the probable Samprapti leading to Parkinson’s disease would be that the Nidana lead to Vataprakopa which then moves to the Snayusthana up bringing the Lakshana Utpatti of Snayugatavata . Avarana of Vyanavata by Kapha can be considered for the later stages where in there is marked postural instability along with weakness of body. Here, the Nidana assimilate to bring about Vataprakopa leading to Udhirana of Pitta and Kapha to various Sthanas . This leads to the formation Avarana of Vyanavata by Kapha. This later leads to the Rasadhidhatu Shoshana and manifests as Kaphavruta Vyanavata. The complete manifestation of Parkinson’s disease is characterized by resting tremors along with being bed ridden or wheel chair bound. The Kampavata Lakshanas like Kampa all over the body leading to restless nights and making the person emaciated can be considered as the complete manifestation for Parkinson’s disease. Nidana leads to the Dhatukshaya Avastha wherein there is Vataprakopa. The Vriddhi involved here is that of Vyanavata. This circulates through Rasayanis leading to the manifestation of Kampavata. CONCLUSION Since the definite cause of Parkinson’s disease is unknown, the treatment is often aimed at preventing further deterioration. In Ayurveda , the Lakshanika Chikitsa is usually adopted with respect to that of Parkinson’s disease. Hence the relevant diagnosis, wherever possible should be made and the Oushadi and procedures which help in the same should be adopted, keeping in mind our limitations. REFERENCES 1 Nancy E. Lane Thomas J. Schnitzer, Goldman: Cecil Medicine, 23 rd ed.Copyright © 2007 Saunders, An Imprint of Elsevier,Vol 2, Chapter 409, pg 2454-2461 2 Czech DP*, Lee J*, Correia J, Loke H, Möller E, Harley VR (2014) Transient neuroprotection by SRY upregulation in dopamine cells following injury in males. Endocrinology . Apr 7 [Epub] PMID: 24708242 (joint first author) 3 Cookson MR. Parkinsonism due to mutations in PINK 1, parkin, and DJ-1 and oxidative stress and mitochondrial pathways. Cold Spring HarbPerspect Med. 2012;2(9):a 009415. Published 2012 Sep 1. doi:10.1101/cshperspect.a 009415 4 Nancy E. Lane Thomas J. Schnitzer, LGoldman: Cecil Medicine, 23 rd. Copyright © 2007 Saunders, An Imprint of Elsevier,Vol 2, Chapter 409, pg 2455

Dr. Shereen Sreenivas et al. The purview of Parkinsonism in Ayurveda ISSN: 2456-3110 REVIEW ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 254 5 https://parkinsons-info.weebly.com/updrs.html 6 Agnivesha, Charaka Samhitta, Ayurveda Dipika commentary by Chakrapani Dutta, chaukamba orientalia, reprint 2014, chapter 28, vatavyadhichikitsa, sloka 59, pg 738, pg 619 7 Basavaraja, Basavarajeeyam, chaukamba samskrita pratishtana, reprint 2005, chapter 6, pg 423, pg 101 8 Bhavamishra, Bhava Prakasha, commentary by Dr.Bulusu Sitaram, Chaukamba Orientalia, Reprint 2014, vol 2, chapter 24, sloka 258, pg 770, pg 295 9 Agnivesha, Charaka Samhitta,Ayurveda Dipika commentary by Chakrapani Dutta, chaukamba orientalia, reprint 2014, chapter 28, vatavyadhichikitsa, sloka 229, pg 738, pg 626 10 Bhavamishra, Bhava Prakasha, commentary by Dr.Bulusu Sitaram, Chaukamba Orientalia, Reprint 2014, vol 2, chapter 24, sloka 258, pg 770, pg 294 11 https://www.ncbi.nlm.nih.gov/pubmed/20590830 12 Opara JA, Brola W, Leonardi M, Błaszczyk B. Quality of life in Parkinson's disease. J Med Life. 2012;5(4):375– 381 13 Agnivesha, Charaka Samhitta, Ayurveda Dipika commentary by Chakrapani Dutta, chaukamba orientalia, reprint 2014, chapter 28, vatavyadhichikitsa, sloka 75-77, pg 738, pg 620 14 Agnivesha, Charaka Samhitta, Ayurveda Dipika commentary by Chakrapani Dutta, chaukamba orientalia, reprint 2014, chapter 28, vatavyadhi chikitsa, sloka 238-245, pg 738, pg 627 15 Katzenschlager R et al. Mucuna pruriens in Parkinson's disease: A double blind clinical and pharmacological study. Journal of Neurology, Neurosurgery, and Psychiatry. 2004;75:1677 16 Alleman RJ Jr et al. A blend of chlorophytum borivilianum and velvet bean increases serum growth hormone in exercise-trained men. Nutrition and Metabolic Insights. 2011;4:55-63 17 Obogwu MB, Akindele AJ, Adeyemi OO. Hepatoprotective and in vivo antioxidant activities of the hydroethanolic leaf extract of mucunapruriens (Fabaceae) in antitubercular drugs and alcohol models. Chinese Journal of Natural Medicines. 2014;12:273-283 18 Vaidya AB et al. Treatment of Parkinson's disease with the cowhage plant-mucunapruriens Bak. Neurology India. 1978;26:171-176 ******************************* How to cite this article: Dr. Shereen Sreenivas, Dr. Muralidhara, Dr. Sindhura A. S. The purview of Parkinsonism in Ayurveda. J Ayurveda Integr Med Sci 2019;5:249-254. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2019 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Ayurveda, Avarana, Rasayana, Bhavaprakasha, Trap, Dhatukshaya, Vataprakopa, Nasyakarman, Vatavyadhichikitsa, Mucuna pruriens, Kampavata, Velvet bean, Differential diagnosis, Original work, Journal of Ayurveda, Conflict of interest, Quality of life, Objective factor, Sleep disturbance, Parkinson's disease, Rigidity, Neurodegenerative disorder, Bradykinesia, Akinesia, Substantia nigra, Parkinsonism, Snayugata vata, Drug therapy, Ayurveda Dipika commentary, Kapikachu, Snayugatavata, Deep brain stimulation, Cardinal feature, Non-motor symptoms, Antitubercular drugs, Neuropsychiatric symptoms, L-dopa, Alzheimer Disease, Swatantra Vyadhi, Paratantra Vyadhi, Drug induced, Chakrapani Dutta, Sickness Impact Profile, Olfactory dysfunction, Tremor, Resting tremor, Dopaminergic neuron, General Measures, Lakshanika chikitsa, Open access article, Creative Commons Attribution, Acetylcholine release, Atypical features, SRY gene, Creative Commons Attribution License, Shaking palsy.