A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo...

[Full title: A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo (PC-BPPV) with special reference to Bhrama - A Case Report]

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

CASE REPORT Nov-Dec 2020 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2020 | Vol. 5 | Issue 6 356 A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo (PC-BPPV) with special reference to Bhrama - A Case Report Karthik M. 1 , Ahalya S. 2 1 Post Graduate Scholar, Department of PG Studies in Shalakya Tantra, 2 Principal, Government Ayurveda Medical College, Bengaluru, Karnataka, INDIA. I NTRODUCTION Vertigo is a symptom in diseases like Meniere's disease, Labyrinthitis, Hemiplegia, Multiple sclerosis etc. and also an independent entity as Benign Paroxysmal Positional Vertigo (BPPV). It is estimated that more than 25% of patients who present to the general practitioner with vertigo suffer from BPPV [1] Address for correspondence: Dr. Karthik M. Post Graduate Scholar, Department of PG Studies in Shalakya Tantra, Government Ayurveda Medical College, Bengaluru, Karnataka, INDIA. E-mail: mkarthikm 008@gmail.com Submission Date: 19/11/2020 Accepted Date: 23/12/2020 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 The onset is usually in the fourth or fifth decade of life and affects females more than males. The pathogenesis involves otoconia which gets displaced from utricle and get deposited in the cupula of posterior semicircular canal. Vertigo spell usually lasts for seconds and not more than a minute. However patients usually complain longer subjective feeling of dizziness. The diagnosis is made by Dix-Hallpike test and the treatment consists of repositioning maneuvers like Epley's maneuver and Semont maneuver. There is no role of oral medicines in the conventional medicine. Though BPPV is not a life threatening condition, the quality of life in patients is compromised. In general, Bhrama is the nearest correlation to vertigo in Ayurveda classics. Bhrama is a Vataja Nanatmaja Vyadhi [2] which means it is caused by Vatadosha alone. There is also a reference that it's a disease caused by the confluence of Rajas , Pitta and Vata. [3] Apart from giving Bhrama , the status of a A B S T R A C T Introduction : This is a case report of 45 year old male who stepped into our OPD with complaints of dizziness during walking and heaviness of head since 7 months. The subject was not a known case of hypertension, diabetes mellitus, stroke or any cardiac problems. The Pure Tone Eudiometry results showed bilateral mild sensory neural hearing loss. But the subject had no symptoms of Tinnitus to be included in the vicinity of Meniere's disease. The Dix-Hallpike test was positive for left ear and confirmed the diagnosis as left posterior canal Benign Paroxysmal Positional Vertigo (PC-BPPV) Materials and Methods: The subject who approached Shalakya Tantra OPD of GAMC, with symptoms of dizziness, was systematically reviewed and intervention was planned for Doshic components involved in Bhrama Results: The subject showed considerable improvement subjectively as shown by Dizziness Handicap Inventory (DHI) score Discussion: The repositional maneuvers prescribed in the BPPV, though effective in most of the cases, recurrence is noted in one third of the patients. This study sheds light on holistic treatments like Shirodhara told in the Ayurveda classics that could be integrated with the maneuvers thereby improving the quality of life with no potential risk of side effects Key words: Posterior canal Benign Paroxysmal Positional Vertigo (PC-BPPV), Bhrama, Shirodhara.

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[Find the meaning and references behind the names: Guna, Hindu, Sun, Rasa, Unterberger]

Karthik M. et al. A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo (PC-BPPV) ISSN: 2456-3110 CASE REPORT Nov-Dec 2020 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2020 | Vol. 5 | Issue 6 357 Vyadhi , it is widely mentioned as a symptom in many Pittaja diseases. In the present case, the treatment protocol is planned based on Gunas of the Bhrama . O BJECTIVES 1 To understand Posterior canal Benign Paroxysmal Positional Vertigo (PC-BPPV) under the umbrella of Bhrama . 2 To study the effect of Shirodhara in Posterior canal Benign Paroxysmal Positional Vertigo (PC- BPPV). M ATERIALS AND M ETHODS Case report Basic information of the patient Age: 45 years Sex: Male Religion: Hindu Occupation: Salesman Socioeconomic status: Middle class Chief complaints Dizziness within few steps of walk associated with heaviness of head since 7 months. History of present illness The patient was apparently normal 7 months ago. One day, he experienced dizziness while walking and sat for sometime after which he experienced heaviness of head. Thereafter, the patient started experiencing dizziness followed by heaviness of head almost every day which was slightly relieved after a nap. The patient approached an ENT surgeon for the same and was asked to do a Pure tone audiometry (PTA). PTA report revealed as bilateral mild sensori-neural hearing loss. The patient was provisionally diagnosed as having bilateral Meniere's disease and given Vertin 48 mg, 1 tablet O.D for 2 weeks. The patient did not find any relief and approached Shalakya Tantra OPD of GAMC Bengaluru. History of past illness No past history of seizures, stroke, cardiac problems or any other systemic abnormalities. Personal history a) Aharaja : Diet is predominantly with Katu- Madhura Rasa (spicy & sweet diet) b) Viharaja : The patient being a salesman, spends most of his day walking under the sun. Examination 1 Prakriti (Constitution): Pitta-Vataja Prakriti 2 Vitals were normal. 3 Respiratory system, Cardiovascular system and per abdomen had shown no abnormality. 4 Central nervous system: Romberg's test: Negative 5 Ophthalmic examination: No abnormality detected 6 ENT examination A. i) Right ear: Tympanic membrane: Intact External Auditory canal: Clear ii) Left ear: Tympanic membrane: Intact External Auditory canal: Clear B. Tests of hearing i) Rinne’stest: Right ear - Rinne’spositive, Left ear - Rinne’s positive ii) Weber ’s test: No lateralization iii) Pure Tone Audiometry: Right ear-33.3 dB HL, Left ear- 31.6 dB HL. Tests for Balance a) Unterberger's stepping test: no vestibular pathology. b) Dix-Hallpike test: Positive for left ear. c) Supine roll test: Negative for both ears. Diagnosis Left ear posterior canal Benign Paroxysmal Positional Vertigo (PC-BPPV).

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Karthik M. et al. A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo (PC-BPPV) ISSN: 2456-3110 CASE REPORT Nov-Dec 2020 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2020 | Vol. 5 | Issue 6 358 Treatment adopted Phase 1.1. Chitrakadi vati 1-1-1 before food for 3 days. (from 02/11/2019 to 04/11/2019). 1.2. Sadhyo Virechana with Trivrt Lehya 20 gms was given on 06/11/2019 Phase 2:1. Shirodhara with Yashtimadhutaila for 7 days (08/11/2019 to 14/11/2019). 2.2. Vidaryadi Leha 0- 0-1 tsp with Milk at bed time of 45 days. Assessment criteria Subjective criteria Dizziness Handicap Inventory (DHI) [4] questionnaire score - before and after treatment R ESULTS 1 The DHI score showed Moderate Handicap (score- 46) before phase 1 of the treatment. There was no change in DHI score after phase 1 of the treatment. 2 After Shirodhara , the DHI score showed Mild Handicap (score-30). DISCUSSION In this clinical trial, the treatment protocol was planned based on the Doshic components involved in Bhrama i .e., Vata, Pitta and Rajas. Vata and Pitta are Shareeraja Doshas and Rajas is a Manodosha . The common factor involved in all the three Doshas is Laghuguna (lightness). Therefore the medicines selected were Brimhana Dravyas which counter acts Laghu Guna . Although BPPV and Meniere's disease can exist together in an individual; the present case is purely a case of left posterior canal BPPV since there was never a complaint of tinnitus in the patient. After phase 1 of the treatment, there was no hint of improvement in the patient. But during phase 2 of the treatment, on 6 th day, the patient felt relief in the symptoms and there were no symptoms of heaviness of head. After completion of 7 days of Shirodhara in phase 2, the patient experienced considerable relief in the symptoms. Shirodhara , one of the four Murdhnitaila , though not indicated for Bhrama in the Ayurveda classics, is selected in the present study based on its hypothetical relation with the Rajas Dosha of the mind. In Shirodhara , medicated oil is poured in forehead at optimum temperature for 45 minutes. The oil thus dripping for a stipulated period will be absorbed through Seemantha Marma (Anterior fontanellae) and other channels in head into the diploic veins and intracranial venous veins. Any injury to this Seemantha marma is known to provokemental diseases caused by rajas like Bhaya (fear), Chittanasha (mental retardation),and Unmada (Insanity) indicating the relationship between the Rajas and Seemantha Marma . Hence the medicines which are Vata-Pittahara and the procedure Shirodhara which acts on Rajas Dosha of mind are selected for Bhrama . Apart from this, for subjective assessment of the patient, Dizziness Handicap Inventory questionnaire is selected, which incorporates functional (F), emotional (E) and physical (P) impacts on disability caused by vertigo. This again, gives a hint that vertigo is not purely a somatic disease, but also includes mental factors as told in the Ayurveda classics. CONCLUSION In patients of posterior canal BPPV, repositional maneuvers like Epley maneuvers have been found to be effective in 90% of the cases, though the condition recurs in around one third of cases. The maneuver aims to move the particles (otoconia) from cupula of posterior semicircular canal which cause symptoms such as vertigo, and reposition them to where they do not cause these problems. Surgery is advised as a last option only in severe and persistent cases which fail repositional maneuvers. Along with these maneuvers, the holistic approach in the form of Virechana can be integrated as the primary line of treatment in BPPV, which removes the Pitta Dosha from the body, followed by the procedure of Shirodhara , which negotiates with the mind thereby improving the quality of life in the debilitating disorders like BPPV and any other disorders involving vertigo.

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[Find the meaning and references behind the names: Mohan, Nil, Med]

Karthik M. et al. A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo (PC-BPPV) ISSN: 2456-3110 CASE REPORT Nov-Dec 2020 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2020 | Vol. 5 | Issue 6 359 REFERENCES 1 Mohan Bansal. (2013). Diseases of ear, nose and throat. New Delhi, India: Jaypee Brothers Medical Publishers (P)Ltd: page 237. 2 Yadavaji Trikamji Acharya, editor. (Reprint Edition: 2011). Charaka Samhita of Agnivesha, Sutrasthana; Vataja Nanatmaja vikaras: Chapter 20, Verse 11. Varanasi: Chaukhambha Orientalia: Page 113. 3 K. R. Srikanta Murthy, English translator. (Reprint Edition: 2011). Madhava Nidanam of Madhavakara, Chapter 17, Verse 19/1. Varanasi: Chaukhambha Orientalia: Page 63. 4 Jacobson GP, Newman CW(1990). The development of the Dizziness Handicap Inventory, Arch Otolaryngol Head Neck Surg, 116: 424-427. ******************************* How to cite this article: Karthik M., Ahalya S. A Role of Shirodhara in Posterior Canal Benign Paroxysmal Positional Vertigo (PC-BPPV) with special reference to Bhrama - A Case Report. J Ayurveda Integr Med Sci 2020;6:356-359. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2020 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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Shirodhara, Bhrama, Quality of life, Chitrakadi Vati, Vataja Nanatmaja Vyadhi, Government Ayurveda medical college, Vata-pittahara, Meniere's disease, Tympanic Membrane, Laghuguna, External auditory canal, Pure tone audiometry, Benign paroxysmal positional vertigo, Sadhyo Virechana, Ayurveda Classic, Brimhana Dravya.