Role of Panchakarma in the management of Parkinson’s Disease : A Case Study

[Find the meaning and references behind the names: Long]

CASE REPORT Sept-Oct 2020 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2020 | Vol. 5 | Issue 5 548 Role of Panchakarma in the management of Parkinson’s Disease : A Case Study Amulya G V 1 , Ananta S Desai 2 , Shaila Borannavar 3 1 Post Graduate Scholar, 2 Head of Department, 3 Professor, Department of Post Graduate Studies in Panchakarma, Government Ayurveda Medical College, Dhanvantari Road, Bengaluru, Karnataka, INDIA. I NTRODUCTION Idiopathic Parkinson’s Disease is the most common akinetic rigid syndrome. Parkinson’s Disease (PD) is more common in older people. It affects 1% of adults over the age of 60 years, with increasing frequency in Address for correspondence: Dr. Amulya G V Post Graduate Scholar, Department of Post Graduate Studies in Panchakarma, Government Ayurveda Medical College, Dhanvantari Road, Bengaluru, Karnataka, INDIA. E-mail: amulya.gv 2019@gmail.com Submission Date: 13/09/2020 Accepted Date: 28/09/2020 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 older age. Both sexes - male and female are affected equally [1] The major clinical abnormalities are tremor, rigidity, bradykinesia/akinesia, and postural disturbances. Pill-rolling tremor, Lead-pipe rigidity, Cog-wheel rigidity, mask-like face, festinating gait, are the distinct features of PD. Micrographia, hypophonic and monotonous voice, increased salivation, seborrhoea are commonly seen. Postural instability and gait difficulty are major problems in PD. Glabellar tap is often positive [1] Rapid, repetitive and alternating movements are performed slowly and clumsily. Retropulsion is exhibited in Pull test. There is pronounced kyphosis. Non-motor symptoms like depression, anxiety, and insomnia can affect the quality of life of patients with PD. Constipation is a common and frequent complaint in patients with PD. The pathology involves degeneration of the nigrostriatal tract. The degenerating neurons contain A B S T R A C T Idiopathic Parkinson’s Disease is the most common akinetic rigid syndrome. Parkinson’s Disease (PD) is more common in older people. Postural instability and gait difficulty are major problems in PD. Nonmotor symptoms like depression, anxiety and insomnia can affect the quality of life of patients with PD. Long term use of Anti- Parkinson’s drugs, has been known to have adverse side effects like, dry mouth, hallucinations, confusion, anorexia, nausea and diarrhea. An attempt is made here, to reduce the dose of allopathic medicines, manage their side effects, and improve the quality of life with Panchakarma procedures in a 58 year old male who was diagnosed with PD. The patient was examined on the basis of Hoehn and Yahr Scale and was found to be in stage 3 of PD. The patient exhibited symptoms like Vaak-Swara Graha (difficulty in speech) and Gati Sanga (difficulty in walking) , which are the Lakshanas of Kaphavrita Udana Vata and Kaphavrita Vyana Vata respectively. Hence, the treatment was aimed at removing Kapha Avarana initially. Next procedure was aimed at Brihmana and pacifying Vata. The doses of allopathic medicines were tapered gradually. The patient was again examined on the basis of Hoehn and Yahr Scale and was found to be in stage 2.5 of PD. Repeated administration of the therapies, either same or different, based on the Avastha of the Vyadhi is advisable. Counselling the patient and modifying their home and workplace such that they can carry out their activities of daily living with ease, have to be given due importance. Key words: Parkinson’s Disease, Shashtika Shali Pinda Sweda, Kaphavrita Vyana Vata, Kaphavrita Udana Vata, Kapikachu.

[Find the meaning and references behind the names: Rasa, Shakti]

Amulya G V et al. Role of Panchakarma in the management of Parkinson’s Disease : A Case Study ISSN: 2456-3110 CASE REPORT Sept-Oct 2020 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2020 | Vol. 5 | Issue 5 549 Lewy bodies which are highly sensitive markers for PD. Depletion of dopaminergic neurons of the substantia nigra results in the reduction of striatal dopamine. The etiology remains unknown, though environmental factors have been implicated. In modern science, levodopa preparations, anticholinergics, dopamine agonists, apomorphine, amantadine, COMT inhibitors, MAO-B inhibitors are used in treating PD, with levodopa-carbidopa being the most effective combination. However, long term use of any of these classes of medicines, has been known to have adverse side effects like, dry mouth, hallucinations, confusion, anorexia, nausea, and diarrhea. Hence, an attempt is made here, to reduce the dose of allopathic medicines, manage their side effects, and improve the quality of life with Panchakarma procedures in a 58 year old male who was diagnosed with PD. C ASE R EPORT A male patient aged 58 years, a K/C/O type 2 diabetes since 15 years was apparently normal 4 years back. He noticed slowness in walking, with his neck tilted to the left. He also noticed jerking of the neck while sitting. A month later, he went to an Ayurveda therapy center where he was given Sarvanga Abhyanga twice weekly, for 4 weeks. With this, the jerking of the neck was completely relieved. After a month, he noticed mild difficulty in performing fine movements like buttoning and wearing shoes. His movements were slow especially while drinking with his right hand; while praying, his hands tend to come down. Left hand appeared to be normal. He had complained to his wife that he was finding it difficult to speak. His wife had also noticed a change in his gait and different movement of the right hand. She also said that his handwriting had become illegible, which the patient denied. Two months later, on consulting an allopathic physician, he was diagnosed with Parkinson’s Disease and was prescribed with trihexyphenidyl (2 mg) one tablet, twice daily. With this, his symptoms were reduced to a certain extent. Two months later, his symptoms worsened and he found himself taking longer time to get up from sitting and to start walking. On consulting the physician again, he was prescribed baclofen 25 mg one tablet, twice daily and the dose of trihexyphenidyl was increased to three times a day. With these, the symptoms were manageable to a certain extent but over a period of 6 months, the patient observed change in his mood and was not very enthusiastic in carrying out his daily activities like he used to. On further consultation with the physician, escitalopram 20 mg one tablet, once daily was prescribed and the dose of trihexyphenidyl was increased to 2 tablets, three times a day. With these medications, his mood improved but the other symptoms persisted. He also developed difficulty in passing stools and complained of excessive dryness of the mouth. With these complaints, the patient got admitted to SJIIM on 09/01/2020 for better management of the condition. C LINICAL F INDINGS On Examination Patient was Vata-Kapha Prakriti with Dushta Vata- Kapha involved, Sthana Samsraya in Sarvanga ; having Madhyama Saara (moderate body tissue), Madhyama Samhanana (moderately built), Madhyama Pramana (normal body proportion), Madhura Rasa Saatmya (habitual to Madhura Rasa ), Madhyama Satva (moderate mental strength), Avara Vyayamashakti (poorly capable of carrying out physical activities), Avara Abhyavaharana Shakti (poor food intake), Avara Jarana Shakti (poor digestion capacity). Systemic Examination The patient was conscious, well oriented to time, place and person. Complete neurological examination was performed, which showed speech disturbance, while other aspects were normal. On motor system examination, the attitude of upper limbs was found to be semi-flexed at elbows and that of lower limbs was found to be mildly bent knees. Mild nuchal rigidity was present. Upper and lower limbs were mildly hypertonic. Hand grip and finger tap were normal. The patient was able to walk on heels and toes. Romberg’s sign was positive On examination of the gait, step length was found to be medium. Heel strike was absent, right arm swing

[Find the meaning and references behind the names: Sara, Ama]

Amulya G V et al. Role of Panchakarma in the management of Parkinson’s Disease : A Case Study ISSN: 2456-3110 CASE REPORT Sept-Oct 2020 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2020 | Vol. 5 | Issue 5 550 was absent with a mild stooped posture. The patient could turn with no loss of balance and had mild shuffling gait. The patient was examined on the basis of Hoehn and Yahr Scale and was found to be in stage 3 of PD. Table 1: Hoehn and Yahr Scale Stage 0 No signs of disease Stage 1 Symptoms on one side only (unilateral) Stage 1.5 Symptoms unilateral and also involving the neck and spine Stage 2 Symptoms on both sides but no impairment of balance Stage 2.5 Mild symptoms on both sides, with recovery when the ‘pull’ test is given Stage 3 Balance impairment, mild to moderate disease, physically independent Stage 4 Severe disability, but still able to walk or stand unassisted Stage 5 Needing a wheelchair or bedridden unless assisted Laboratory investigations MRI brain done 4 years ago was found to be normal. Diagnosis By relevant history and clinical examination, the case was diagnosed as Parkinson’s Disease Treatment principle 1. Pachana-Deepana, Rukshana 2. Snehana 3. Swedana 4. Brihmana 5. Rasayana Table 2: Therapeutic Interventions Date Principle Procedure 09/01/2020 - 11/01/2020 Rukshana Sarvanga Dhara with Dhanyamla Pachana- Deepana Vaishwanara Churna 5 g-0-5 g B/F 12/01/2020 - 21/01/2020 Snehana Sarvanga Abhyanga with Balaashwagandha Taila Swedana, Brihmana Shashtika Shali Pinda Sweda Brihmana Matra Basti with Mahamasha Taila - 50 ml 22/01/2020 - 28/01/2020 Snehana Sarvanga Abhyanga with Balaashwagandha Taila Swedana, Brihmana Shashtika Shali Pinda Sweda 29/01/2020 - 04/02/2020 Brihmana Nasya with Ksheerabala Taila (6 drops into each nostril) Advice on discharge 1) Amalaki Rasayana - 0 - 0 - 1 tsp A/F with warm milk 2) Kapikachu Churna - ½tsp - ½tsp - ½tsp A/F mixed with ghee 3) Avipattikara Churna 0 - 0 - ½ tsp B/F with warm water 4) Abhyanga with Dhanvantaram Taila 5) Shiropichu with Ksheerabala Taila DISCUSSION Though Kampavata has been explained to be having symptoms like Karapadatale Kampe , Nidrabhanga , and Ksheenamati, in the book Basavarajeeyam, [2] it depicts only Vataja Lakshanas . Here, along with the above symptoms, the patient also exhibited symptoms like Vaak-Swara Graha (difficulty in speech) and Gati Sanga (difficulty in walking) , which are the Lakshanas of Kaphavrita Udana Vata [3] and Kaphavrita Vyana Vata respectively [4] Hence, the treatment was aimed at removing Kapha Avarana initially. For this, Dhanyamla [5] Dhara was administered. Along with this, Vaishwanara Churna was administered orally and Yava [6] ( Hordeum vulgare ) was advised as diet as it is Agni Vardhaka (increases digestive fire), Sara (increases intestinal motility), and Purisha Jananiya (promotes stool bulk). Ama Harana (removal of undigested material) and Agni Deepana (increase in digestive fire) were observed on the 4 th day. Next procedure was aimed at Brihmana and pacifying Vata . Hence, Sarvanga

[Find the meaning and references behind the names: Sri, Sharma, Low, Deep, Nil, Med, Prakashan]

Amulya G V et al. Role of Panchakarma in the management of Parkinson’s Disease : A Case Study ISSN: 2456-3110 CASE REPORT Sept-Oct 2020 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2020 | Vol. 5 | Issue 5 551 Abhyanga followed by Shashtika Shali Pinda Sweda and Matra Basti with Mahamasha Taila was administered for the next 10 days. With this, the patient found slight relief from tremors and there was slight improvement in speech. For the next 7 days, only Abhyanga and Shashtika Shali Pinda Sweda were carried out. Ksheerabala Taila in the form of Nasya was administered during the last 7 days of his stay at the hospital and this brought 30% improvement in his gait. The doses of allopathic medicines were tapered gradually. The patient was again examined on the basis of Hoehn and Yahr Scale and was found to be in stage 2.5 of PD. On discharge, Amalaki Rasayana [7] was prescribed to prevent further progress of the disease. Along with this, Kapikachu [8] (Mucuna pruriens) Churna was prescribed as its seeds are known to have Levodopa. Avipattikara Churna was advised to aid Vatanuloma and prevent constipation. Abhyanga with Dhanvantaram Taila was advised as it would help in pacifying Vata, and Shiropichu with Ksheerabala Taila was advised as Brihmana and to help combat depression. Though the symptoms were reduced to a certain extent, the fear of relapse would always remain. Hence, repeated administration of the therapies, either same or different, based on the Avastha of the Vyadhi is advisable. Apart from the treatment, different occupational therapies like handwriting aids, computer modifications, etc. have to be given importance. The stiffness and slowness of movement require graded exercises - walking, fixed-bicycle or fixed-wheel exercises and deep breathing [1] At home, grooming aids, eating and dinnerware adaptations, use of low-level visual cues to prevent gait freezing, and modification in toilet and bathroom will aid the patient in carrying out their activities of daily living independently. CONCLUSION The physician should aim at making the life of the patient better from all approaches. Counseling the patient and modifying their home and workplace such that they can carry out their activities of daily living with ease, have to be given due importance. REFERENCES 1 Munjal, Y., 2015. API Textbook of Medicine. 10 th ed. Mumbai: Jaypee Brothers Medical Publishers (P) Ltd., pp.1987-1989. 2 Vaidyavarashree Basavaraj. Basavarajeeyam, Sri Govardhana Sharma, editor. 1 st ed. Vatavyadhi Nidana Lakshana Chikitsa, Chapter 6. Nagpur: Gorakshana Yantralaya Publication; 1978 p. 100-101 3 Sharma RK, Vaidya Bhagavan Dash. editors. Agnivesha, Charaka Samhita; English Translation. Chikitsa Sthana. Vol V. Chapter 28. 224. Varanasi. ChaukhambaPrakashan. 2013. p. 81. 4 Sharma RK, Vaidya Bhagavan Dash. editors. Agnivesha, Charaka Samhita; English Translation. Chikitsa Sthana. Vol V. Chapter 28. 228. Varanasi. Chaukhamba Prakashan. 2013. p. 82. 5 Sharma RK, Vaidya Bhagavan Dash. editors. Agnivesha, Charaka Samhita; English Translation. Vimana Sthana. Vol I. Chapter 8. 140. Varanasi. Chaukhamba Prakashan. 2013. p. 296. 6 Prof. Krushnachandra Chunekar, Bhavprakash Nighantu, Chaukhambha Bharati Academy, Varanasi, Reprint 2013, Dhanyavarga, 9/27-30, Pg. No.- 628 7 Sharma RK, Vaidya Bhagavan Dash. editors. Agnivesha, Charaka Samhita; English Translation. Chikitsa Sthana. Vol III. Chapter 1. 75. Varanasi. Chaukhamba Prakashan. 2013. p. 22. 8 DR.J.L.N.Sastry; Dravyaguna Vijnana Foreword by Prof K.C.Chunekar volume II; Chaukhambha Orientalia, Varanasi, 2012;176 ******************************* How to cite this article: Amulya G V, Ananta S Desai, Shaila Borannavar. Role of Panchakarma in the management of Par kinson’s Disease : A Case Study . J Ayurveda Integr Med Sci 2020;5:548-551. Source of Support: Nil, Conflict of Interest: None declared.

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Lakshana, Yava, Vata, Dhara, Sara, Snehana, Nasya, Matra-basti, Rasayana, Rukshana, Sthanasamshraya, Agnivardhaka, Charakasamhita, Dhanyamla, Brihmana, Mucuna pruriens, Madhyamasatva, Kampavata, Nausea, Gait, Confusion, Stiffness, Depression, Anxiety, Constipation, Anorexia, Insomnia, Diarrhea, Allopathic medicine, Dry mouth, Quality of life, Deep breathing, Environmental factor, Rapid movement, Long-term use, Case report, Amalaki Rasayana, Swedana, Neurological examination, Hand Grip, Therapeutic intervention, Systemic examination, Avipattikara churna, Parkinson's disease, Rigidity, Glabellar tap, Bradykinesia, Akinesia, Ksheerabala taila, Vata-Kapha Prakriti, Panchakarma procedure, Ksheenamati, Substantia nigra, Sarvanga Abhyanga, Mahamasha taila, Agni Deepana, Basavarajeeyam, Avara Jarana Shakti, Activities of Daily Living, Shashtika Shali Pinda Sweda, Madhyama Pramana, Treatment principle, Madhyama samhanana, MRI brain, Pachana-Deepana, Motor system examination, Adverse side effects, Levodopa, Shiropichu, Kyphosis, Postural instability, Bhavprakash Nighantu, Gait improvement, Kapha Avarana, Non-motor symptoms, Gati sanga, Lewy bodies, Hoehn and Yahr Scale, Dopamine Agonist, Clinical abnormalities, Relapse, Amantadine, Tremor, Dopaminergic neuron, Heel strike, Seborrhoea, Shuffling gait, Striatal dopamine, MAO-B inhibitor, COMT inhibitor, Hallucination, Apomorphine, Visual cue, Fine movements, Anticholinergic, Speech disturbance, Step length.