Ayurvedic management of Vascular Parkinsonism: A Case Report

[Find the meaning and references behind the names: Anand, Giri, Main, Sali]

CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 343 Ayurvedic management of Vascular Parkinsonism: A Case Report Nanditha N 1 , PKV Anand 2 , PV Giri 3 1 Post Graduate Scholar, Department of Kayachikitsa, Vaidyaratnam Ayurveda College, Ollur, Thrissur, Kerala, India. 2 Associate professor, Department of Panchakarma, Vaidyaratnam Ayurveda College, Ollur, Thrissur, Kerala, India. 3 Professor, Department of Kayachikitsa, Vaidyaratnam Ayurveda College, Ollur, Thrissur, Kerala, India. I NTRODUCTION Parkinsonism is a broad term referring to various neurodegenerative diseases that manifest with motor symptoms such as bradykinesia with rigidity and / or tremor. Parkinson’s disease accounts for 80% of cases, while the reminder comprises a collection of other neurodegenerative disorders with similar motor symptoms. Secondary parkinsonism can be associated with stroke, drugs, tumor, infections, or exposure to Address for correspondence: Dr. Nanditha N Post Graduate Scholar, Department of Kayachikitsa, Vaidyaratnam Ayurveda College, Ollur, Thrissur, Kerala, India. E-mail: vnnanditha@gmail.com Submission Date: 12/10/2024 Accepted Date: 25/11/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.11.51 toxins such as carbon dioxide and manganese [1] Vascular parkinsonism (VP) is a distinct clinicopathological entity from Idiopathic Parkinson’s disease, that is presumably caused by cerebrovascular disease. It accounts for 4.4%-12% of all cases of parkinsonism [2] VP is characterized by predominant lower body parkinsonism, postural instability, shuffling or freezing gait, absence of rest tremors, absence or poor response to dopamine, and presence of corticospinal tract signs [2] The main pathological lesions that underlie VP include lacunes, subcortical white matter lesions and, rarely, territorial infarcts [3] MRI of the brain is a useful morphological test to evaluate vascular lesions. The presentation of the disease is comparable to Kampavatha with Pakshakhatha . Among Vataja Nanatmaja Vyadhi Caraka as mentioned Kampavata , while other Acharyas explain the same as Vepathu. Madhava Nidana explained as Vepathu is characterized by Sarvanga Kampa and Shiro Kampa [4] In Basavarajeeyam , the symptoms of Kampavata offer A B S T R A C T Introduction: Vascular parkinsonism (VP) is a distinct clinicopathological entity from idiopathic Parkinson’s disease, which is presumably caused by cerebrovascular disease. It is characterized by predominant lower body parkinsonism, postural instability, shuffling or freezing gait, absence of rest tremors, absence or poor response to dopamine, and the presence of corticospinal tract signs. Methodology: A 62-year-old male patient was admitted to the Panchakarma IPD of VAC, Ollur complaining of tremors in the hands (left > right), weakness in the left hand, slowness in activities and speech, memory loss, swaying while walking, and pain over the left shoulder joint for the past 10 months. On examination, extrapyramidal signs were positive. He underwent a treatment protocol for Vatavyadhi , including Udvarthanam, Dhanyamladhara , Sirodhara, Vasthi, and Shastika Sali Pinda Sweda , along with Samanoushadis , for a period of 26 days, which yielded better results in the condition. Result: patient assessment was conducted using the Modified Hoehn and Yahr scale, Schwab and England ADL scale, and PDQ-39 scale on the 1 st and 26 th days. After the treatment, there was a notable amelioration of symptoms, a reduction in disability, and an enhancement in overall quality of life. Key words: Vascular parkinsonism, Kampavatha, Quality of life, Case report.

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

Nanditha N. et al. Ayurvedic management of Vascular Parkinsonism ISSN: 2456-3110 CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 344 a diagnostic hint for Parkinson's disease, which is characterized by symptoms such as Karapadatale Kampa, Deha Bhramana, Mathiksheena and Nidrabhanga. [5] In this instance, the patient had took medications for 1 month for addressing Parkinsonian symptoms. Despite the administration of this medication, the patient continued to experience challenges in performing routine daily activities. While admitted to Vaidyaratnam Ayurveda college hospital (VACH), ayurvedic treatment was initiated with a primary focus on restoring the balance of disturbed doshas, ama Pachana, Agnideepana, Vathanulomanana, Srothoshodana, Brahmana, Balya and Dhathusatmyakara Chikitsa . The goal of these interventions is to enhance the patient's quality of life and mitigate the progression of the disease. C ASE R EPORT A 62-year-old male patient was admitted to VAC Hospital on May 2, 2024. He had been on allopathic medication for hypertension and dyslipidemia for the past 2 years and had a history of ischemic stroke in July 2022. He complained of tremors in his hands (left > right), weakness in the left hand, slowness in activities and speech, memory loss, swaying while walking, pain over the left shoulder joint, and irregular and constipated bowel movements. The complaints had started gradually 10 months ago, initially as weakness in the left upper limb and fine tremors in the left hand. After a few weeks, tremors also developed in his right hand. The tremor was most noticeable during activities like wearing shirts, buttoning shirts, and wearing a dhoti. The tremors were more evident when the patient became anxious. Gradually, he began to experience slowness in his movements and speech, swaying while walking, and slurring and monotony in his speech, which became more pronounced over the past 4 months. During this period, family members also noticed recent memory loss. He also complained of left shoulder joint pain, which followed a road traffic accident (RTA) in February 2023. He underwent Ayurvedic inpatient management for 14 days but did not experience any relief. In March 2024, he consulted an allopathic doctor for the aforementioned complaints, was diagnosed with Parkinsonism, and was advised to take internal medications. However, even after 1 month, the patient did not feel any improvement and consulted the same doctor again. He was advised to take T. Syndopa 110 mg for 2 weeks, but the patient discontinued the medication after 2 days due to dizziness he experienced after taking it. Psychosocial history Mood and emotion: anxiety present Cognitive function Memory: recent memory impaired Attention, executive function, language: present Psychiatric history - no pre-existing psychiatric conditions, such as bipolar disorders, schizophrenia, or past episodes of major depressive disorders. Psychosocial functioning - Social withdrawal is present (withdrawal from social interactions) Socioeconomic status - lower-middle-class family [6] Family history Father had similar complaints (tremors in hands, slowness of activities, and difficulty in walking) Personal history He had a mixed diet, preferably take cold water. Bowel was Irregular and constipated, 1 time / 3-4 days, for last 4 months mostly once in a week. Micturition was normal and sleep was sound. Treatment history T. Atorvastatin 1-0-0, T. Cilovin ½-0-0, T. Ecosprin 75/20 mg 1-0-0 Clinical Findings General examination The patient was lean in built, moderately nourished with a height of 157.5, weight of 46 kg and BMI of 18.5 kg/m 2 . The patient was anxious, had a stooped posture, festinant gait with reduced arm swing.

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

Nanditha N. et al. Ayurvedic management of Vascular Parkinsonism ISSN: 2456-3110 CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 345 Physical examination Head and neck: stooped head, a subtle flattening of the left nasolabial fold, and angle of mouth had slightly deviated to the right side. Systemic examination On systemic examination nervous system and locomotor system are affected. Nervous system examination: Higher mental function - patient was right handed person with slightly slurred speech, oriented to time, place and person; patient displayed symptoms of anxiety, accompanied by intact immediate and remote memory and, while recent memory showed impairment. Cranial nerve examination - On examination of the facial nerve, there was subtle flattening of the left nasolabial fold, with the angle of the mouth slightly deviated to the right side. The wrinkles on the forehead were present, and the patient could distinguish all tastes. Motor system examination - Tone was hypertonic, bilateral rigidity of muscle was evident in both upper and lower limb (Lt> rt) with a preserved muscle power on right upper limb and both the lower limbs, while the power was only 4+ in left upper limb. Muscle bulk was symmetrical in both side in upper and lower limb, although there was a reduction in hand grip on left side. Superficial and deep reflexes within the normal limits. Sensory system examination - revealed no abnormalities. Cerebellar signs - Ataxia, hypotonia, and nystagmus were absent. The patient had intentional tremors, and buttoning and the finger-to-nose test were possible, although accompanied by slowness and tremors. During tandem walking swaying was observed. Rhomberg’s sign yielded a positive result. Extrapyramidal sign including bradykinesia, muscular rigidity, festinating gait, glabellar tap and monotony in speech were present. On examination, the patient showed difficulty with finger tapping and opening and closing the fist due to bradykinesia. While assessing the tremor, the patient exhibited postural and akinetic tremors. Upon assessing rigidity, the patient was able to rotate his wrist and passively flex and extend the elbow. Locomotor symptoms The affected area is the left shoulder joint. On inspection, symmetry was maintained, the position of the scapula was symmetrical on both sides, there was no muscle wasting or winging of the scapula, and swelling was absent. On palpation, grade 1 tenderness over left shoulder joint and muscle spasm over left shoulder joint. Examination of range of movements and special test were done (table 1 & 2 respectively) Table 1: Examination of range of movements Movements Range of movements Rt Lt Flexion 140° 50° Extension 45° 25° Adduction 30° 20° Abduction 150° 40° External rotation (modified) 70° Can’t elicited due to pain Internal rotation (modified) 60° Table 2: Special test of shoulder Right shoulder Left shoulder Painful arc test Negative Positive at 60° Drop arm test Negative Positive Empty can test Negative Positive Hawkins Kennedy test Negative Can’t elicited due to pain Neer test Negative Can’t elicited due to pain Diagnostic Assessment MRI Brain (24/04/24) revealed mild age-appropriate generalized involutional and few chronic small vessel ischemic changes. No acute infarct or bleed seen. MRI Brain (11/07/22) during the admission of stroke revealed chronic infarcts noted in the periventricular

[Find the meaning and references behind the names: Luke, Sara, Long, Mala, Rasa, Sakthi, Rupa, Kalam]

Nanditha N. et al. Ayurvedic management of Vascular Parkinsonism ISSN: 2456-3110 CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 346 white matter. Multiple discrete scattered T 2 / FLAIR hyperintensities noted involving the deep white matter and pons without any evidence of diffusion restriction suggestive of small vessel ischemic changes. Age related atrophy and right maxillary sinusitis. According to Zijlmans’ diagnostic criteria [2] (criteria for the clinical diagnosis of vascular parkinsonism) the patient was diagnosed with vascular parkinsonism with insidious onset. Ayurvedic diagnostic parameters ▪ Prakrithi - Kapha Vatha [7] ▪ Dosha vitiated - Vyana Vatha, Samana Vatha, Apana Vatha, Udana Vatha, Prana Vatha, Pachaka Pitha, Sadhaka Pitha, Sleshaka Kapha ▪ Dhathu - Rasa, Raktha, Medas, Majja ▪ Upadhathu - Snayu, Sira ▪ Mala - Purisha ▪ Sara - Madhyamam ▪ Satwam - Avaram ▪ Samhananam - Madhyamam ▪ Satmyam - Sarvarasa Satmya ▪ Pramanam - Madhyamam ▪ Aharasakthi - Abhyavaharana Sakthi - Avaram ▪ Jaranasakthi - Avaram ▪ Vaya - Vardhakya ▪ Kalam - Kshanadi - Greeshmam ▪ Vyadhi Avastha - Navam ▪ Desam - Bhoomi - Sadaranam ▪ Deham - Sarvadehikam ▪ Rogamargam - Madhyamam ▪ Srothas affected - Rasavaha, Rakthavha, Medovaha, Majjavaha, Annavaha, Pureeshavaha Nidana Panchaka The exact causative factors for this disease were unknown, the most probable predisposing factors in the patient include Seethajalapana, Kshutvegadharana, anxiety and Jara. Poorvaroopa was Avyaktha, while the Roopa exhibits tremors in his hands (left > right), weakness in the left hand, slowness in activities and speech, memory loss, swaying while walking, pain over the left shoulder joint, and irregular and constipated bowel movements. Samprapti refers to the complete procedure of disease manifestation. Kampa is specifically mentioned under Vataja Nanatmaja Vikara . Therefore, the Samprapti of Kampavata is not mentioned separately. The general Samprapti of Vatavyadhi can be considered as the Samprapti of Kampavata. The patient had a long history of Agnimandya, which increased the likelihood of ama formation in the body, leading to the formation of Sanga at the Srotas. Additionally, the patient continued to be exposed to the aforementioned Nidanas , which could have caused Vata Prakopa . This, in turn, resulted in Dhatvavishamya (Rasa, Raktha, Medas, Majja), ultimately leading to Dhatukshaya. The Dhatukshaya further aggravated Vata, causing Sthanasamsraya in the Snayu, Sira, and Siromarma , which led to the manifestation of symptoms in the patient. The case was diagnosed as Vascular parkinsonism with insidious onset. In Ayurveda, the diagnosis was identified as Kampavatha with Pakshakhatha. Diagnosis Kampavatha with Pakshaghata (Vascular parkinsonism with insidious onset) Therapeutic Intervention Treatment is mainly concentrated on improving the quality of life of the patient by reducing the clinical symptoms. Detailed descriptions of internal medicine and external procedures administered are provided in Tables 3 and 4 Table 3: Internal medicine Date Medicine Dose Anupana Time 02/05/24- 27/05/24 Padoladi Kashayam 15 ml + 45 ml luke - Twice daily, before food

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

Nanditha N. et al. Ayurvedic management of Vascular Parkinsonism ISSN: 2456-3110 CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 347 warm water 02/05/24 -27/05/24 Varuni Tailam 10 drops With milk Twice daily, after food 02/05/24 -15/05/24 Vaiswanara Choornam 1 tsp With hot water Twice daily, before food 02/05/24 -27/05/24 Mandoora Vatakam 1 tab Twice daily, after food Table 4: External treatment Date Procedure Medicine / remarks 03/05/24 – 06/05/24 Udvarthanam Kolakulathadi Choornam 07/05/24 – 13/05/24 Dhanyamladhara Lightness of the body, rigidity of upper limb slightly reduced. 12/05, 16/05, 18/05 Yapana vasthi Masha Atmaguptadi 14/05/24 – 20/05/24 Abyangam and Sirodhara Maha Masha Tailam 21/05/24- 27/05/24 Shastikashali Pinda Sweda Mahamasha Tailam 21/05, 23/5, 25/05 Matravasthi Pippalyadi Anuvasana Tailam R ESULTS Patient assessment was conducted using Modified Hoen and Yahe scale, [8] Schwab and England scale, [9] and PDQ 39 (Parkinson’s disease quality of life questionnaire) [10] Assessments were done on 03/05/2024 and 26/05/2024 (before treatment and after treatment) Assessment tool Pre-treatment Post treatment Modified Hoen and Yahe scale Score 2.5 Score 2 Schwab and England scale 80% 90% PDQ 39 Mobility 35% 20% Activity of daily living 37.5% 20.83% Emotional well being 20.83% 16.66% Stigma 43.75% 18.75% Social support 0% 0% Cognition 12.5% 12.5% Communication 33.33% 8.3% Bodily discomfort 33.33% 8.3% PDQ 39 SI 28.84% 15.38% DISCUSSION As the aging process progresses, there is a significant and exponential increase in Vata dosha . As a result, the elderly are at a higher risk of developing Vatavyadhi . The main contributing factors to Vatavyadhi are Dhatukshaya (tissue depletion) and Margavarana (obstruction of channels). In Basavarajeeyam, Kampavata presents with symptoms such as Karapadatale Kampe, Deha Brahmana, Nidrabhanga, and Mathiksheena , all of which are consistent with classical Vataja Lakshanas . In this case instead of Avarana, Dhathukshaya was the major cause for Vatha vitiation. In the pathophysiology of Vascular parkinsonism, the disease is presumably caused by cerebrovascular disease. In Ayurveda Grandas, Virechana is regarded as the primary treatment protocol for Pakshaghata . Based on this principle, internal medications are recommended for the patient. Padoladi Kashayam is Vatanulomana, Amapachanam, and Agni Vardhanam . Most of the drugs in the stipulated Yoga are having Tiktha and Kashaya Rasa, Tiktha Rasa works on Amasaya and helps in Amapachana , finally improve Agni and helps in Srothosudhi [11] Vaiswanara Choorna corrects Apanavayu by the Anulomana effect of Hareethaki , which is in higher quantity. The Apanavayu correction in turn corrects the Samana Vayu , which in turn

[Find the meaning and references behind the names: Shri, Shree, Murthy, Kumar, Ann, Jun, Guru, Med]

Nanditha N. et al. Ayurvedic management of Vascular Parkinsonism ISSN: 2456-3110 CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 348 improves the digestive fire of the patient. The Deepana effect of the yoga again improves the Agni of the patient [12] Varuni Tailam is the yoga explained in Sarngadhra Samhitha , it only possess 2 ingredients, Indravaruni also called bitter fruit (which is Thiktha Pradhana ) and Tilataila Nitya Anulomana is recommended for this kind of patients because abnormal protein accumulation and aggravation is one of the strong causative factors for the pathology of this neurogenerative disorder. As Vasular parkinsonism is a neurodegenerative disease and its pathology starts in the brain, the medicine has to act on the brain cells. According to Ashtangam Hridayam , Thiktha Rasa has Medhya property (improves intellect) and also has the potency to act on Majja Dhatu (marrow element), whereas according to Chakrapani, brain is considered as the Majja Dhatu of Siras ( Masthulunga majja ). Udvarthanam has Sthairyakara property which enhances the motor functions. Dhanyamladhara is a procedure explained in renowned treatise of traditional kerala ayurveda, Chikitsa Manjari which recommends Dhanyamladhara as first line of therapy in Pakshakhatha , advised in done in Vathavyadhi associated with Ama, Pitha and Kapha. [13] Being a Vatavyadhi, Vasti has got the prime role. The main aim of Niruhavasti is to impart Dosha Samanatva . Mashaatmagupthadi Yapana Vasthi was selected. Masha Atmaguptadi Kashaya is specifically indicated for Kampavata in Chakradatta . Sirodhara and abhyanga were done with maha Mashatailam , which is indicated for Hasthakampa, Sirakampa , and specifically indicated for Urdhajatrugadas. Shirodhara is a type of Murdhani Taila and it is found to have an anxiolytic and tranquilizing effects resulting into a kind of relaxation response. It calms down the hyper action of vitiated Vyana Vata and Sirodhara shows significant result in the Kampa [14] Shastikasalipinda Sweda is Snigdha,Guru, Seetha and Brihmana. Matravasti with Pippalyadi Anuvasana Tailam helps to relieve the Rookshatha of Koshta and helps in Malapravrithi. CONCLUSION The incorporation of Ayurvedic treatment procedures demonstrated a notable amelioration of symptoms, reduction in disability and an enhancement in the overall quality of life. Quality of life scale PDQ-39 SI score was improved from 28.84% to 15.38%. REFERENCES 1 Jameson J, Fauci A, Kasper D, Hauser S, Longo D, Loscalzo J. Harrison’s Principles of Internal Medicine. 20 th ed. Vol. 1. New York: McGraw Hill Medical Publishing Division; 2018. p. 3120 – 3132. 2 Udagedara TB, Dhananjalee Alahakoon AM, Goonaratna IK. Vascular Parkinsonism: A review on management updates. Ann Indian Acad Neurol. 2019;22(1):17 – 20. 3 Korczyn AD. Vascular parkinsonism: Characteristics, pathogenesis, and treatment. Nat Rev Neurol. 2015 Jun;11(6):319 – 26. 4 Srikantha Murthy KR. Madhava Nidanam (Roga Vinshaya) of Madhavakara. 2016 ed. Varanasi: Chaukhambha Orientalia; p. 88. 5 Krishnamurthy MS. Basavarajeeyam: A Reputed Text of Ayurvedic Therapeutics and Pharmaceutics Codified by Vaidya Shree Basavaraja. 1 st ed. Vol. Chapter 6. Varanasi: Chaukhambha Orientalia; 2014. p. 148. 6 Modified Kuppuswamy socioeconomic scale 2023: Stratification and updates. ResearchGate [Internet]. 2024 Oct 22 [cited 2024 Nov 27]; Available from: https://www.researchgate.net/publication/375145135 _Modified_Kuppuswamy_socioeconomic_scale_2023_ stratification_and_updates 7 MA, SK B. Development of a clinically useful tool for Prakriti assessment. Int J Ayurvedic Med. 2021 Sep 29;12(3):599 – 609. 8 Hoehn and Yahr Scale. Physiopedia [Internet]. [cited 2024 Nov 28]. Available from: https://www.physiopedia.com/Hoehn_and_Yahr_Scale 9 Veterans Affairs. VA.gov [Internet]. [cited 2024 Nov 28]. Available from: https://www.parkinsons.va.gov/resources/se.asp 10 Final PDQ- 39 English UK SAMPLE. Parkinson’s UK [Internet]. [cited 2024 Nov 28]. Available from: https://www.parkinsons.org.uk/sites/default/files/202 0-12/Final%20 PDQ-39_English_UK_SAMPLE.pdf 11 Kumar S, NK, CRK. A study on the efficacy of Patoladi Kashaya and Karanjadi Lepa in Vicharchika W.S.R. to eczema. AYUSHDHARA [Internet]. 2016 [cited 2024 Nov

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Nanditha N. et al. Ayurvedic management of Vascular Parkinsonism ISSN: 2456-3110 CASE REPORT November 2024 Journal of Ayurveda and Integrated Medical Sciences | November 2024 | Vol. 9 | Issue 11 349 28]; Available from: https://ayushdhara.in/index .php/ayushdhara/article/view/118 12 Research Paper. JETIR 2303774. JETIR [Internet]. [cited 2024 Nov 28]. Available from: https://www.jetir.org /papers/JETIR 2303774.pdf 13 Jose JV, M ST, K AV. Management of rigidity dominant Parkinson’s disease through Ayurvedic protocol. Int J Ayurveda Pharma Res. 2024 May 4;57 – 64. 14 Kumar MP. A review of the role of Panchakarma in Parkinson’s disease ******************************* How to cite this article: Nanditha N, PKV Anand, PV Giri. Ayurvedic management of Vascular Parkinsonism: A Case Report. J Ayurveda Integr Med Sci 2024;11:343- 349. http://dx.doi.org/10.21760/jaims.9.11.51 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2024 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 (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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