Health & Public Welfare

Management of Stroke through Virechana: An Ayurvedic Case Report

Management of Stroke through Virechana: A Case Report

Pakshaghata(Paralysis)is considered as Vatavyadhi and Mridu snigdha shodhana (Virechana) is the preferred treatment, which was adopted in this study.

Authors

  1. Adil Rais-Panchakarma Specialist, Lokbandhu Rajnarayan Combined Hospital, Lucknow, Uttar Pradesh
  2. Sangeeta R Tanwar-Department of Panchakarma, Shree Dhanwantari Ayurvedic medical College, Mathura, Uttar Pradesh
  3. Bhavana Prasher-Principal Scientist, CSIR–TRISUTRA Ayurgenomics Unit, CSIR-IGIB, New Delhi
  4.  Anup B Thakar-4Director, IPGT&RA, Gujarat Ayurved University, Jamnagar, Gujarat 

Key words : Pakshaghata, Stroke, Virechana

ABSTRACT

Stroke is a leading cause of adult neurological disability and represents an enormous health problem worldwide. It describes a clinical syndrome, which can be caused by a number of different pathologies, rather than a single disease. In Ayurveda, Pakshaghata can be compared to hemiplegia which is the presentation of stroke. In this study a case report of stroke is being presented. The patient was treated on the lines of Ayurvedic management involving Virechana as the chief treatment modality. On completion of Virechana karma, the case was subjected to one month of oral administration of Masha baladi kwatha, along with Sarvanga abhyanga and Vashpa swedana. The observations made after the treatment through assessment on various subjective and objective parameters were convincing and led to scope of further adjunction of other Panchakarma therapies after Virechana as the baseline therapy.

Introduction

Pakshaghata is a disabling Vata vyadhi and enlisted among the eighty Nanatmaja vata rogas.1 The term Pakshaghata is made up of two words; ‘Paksha’ i.e. either side of the body and ‘Aghata’ denotes a blow or a severe destruction caused which is due to the impairment of sensory and motor system and its controller i.e the brain.2 Hence, Pakshaghata is a condition which affects half part of the body. In classics it has been told that vitiated Vata due to intake of food items with Ruksha (~dry), Sheeta guna (~cold) and following a lifestyle that aggravates Vata, like Ratri jagarana (~night awakening), Shoka (~grief), Vega vidharana (~suppression of natural urges), Abhighata (~injury), Marmaghata (~injury of vital organs), Divaswapna (~day sleep), Krodha (~excessive anger), physical and mental stress etc. These factors may cause Sira vishoshana (~emaciation of vascular structures) and Snayu (~tendons or ligaments) and may lead to Toda (~pricking pain) and Sankocha (~restricted movements) affecting either of the halves of the body.3

Pakshaghata, occurs due to movement of vitiated Vata through various blood vessels traversing Urdhvagami, Adhogami and Tiryakgami (~upwards, downwards or in both directions) throughout the body.4 Sira (~vein) and Snayu (~nerve) which are responsible for coordinating motor movements causes vitiation of Vayu in half part of the body, may lead to loss of sensory and motor function. Prana vayu resides in the cephalic region, which is the place of all Indriyas.5 Hence, due to Vata prakopa (~vitiation of Vayu), functions in half part of the body get diminished, weakness in upper limb and lower limb, slurred speech6 and sometimes lost control over defecation and urination.

Considering the etymology, the term Pakshaghata can be compared with hemiplegia (paralysis of half body) where “Hemi” means ‘half’ and “Plegia” means ‘loss of function’ in Greek. Hence, word meaning appears as a loss of strength or voluntary movements on one of the sides. The common cause of hemiplegia is stroke7 which is of two types: hemorrhagic and infarctive. However; there may be other causes like tumor, a space occupying lesion, thrombus or an embolus etc.

Hemiplegia is one of the most common and challenging neurological conditions due to lack of a definite treatment modality and disability being produced for the rest of life, which may not be progressive but produces dependency on others for entire life. However; if the cause is not managed, the severity may be multiplied. Further; if subsequent attacks of stroke follow, which may also be life threatening. Many research works have been done for treatment and rehabilitation of such patients in Ayurveda and modern medical science but this still is a difficult task for the whole medical fraternity to come with some relief for the disability produced herein. A case is being reported here, wherein the cause of stroke was infarct and the Ayurvedic principle was applied and the observations made are presented and discussed.

Case report

A 32 years old male patient, presented with the complaints of weakness and impaired movements in right upper and lower limb, slurred speech, facial weakness and impaired memory since four months. The onset of disease was sudden due to accidental slip from bike and reported unconsciousness for ten days along with fracture of left fibula. He was catheterized for improper evacuation of urine for about one and half month. Speech was almost absent, however; patient was able to speak a few simple words and his own name on prompting. At the time of admission, patient was conscious with normal vitals.

Patient had cerebrovascular accident (CVA) involving left side of brain in October, 2015. There was a history of trauma due to fall from bike, which resulted in the fracture of left fibula. No history of hypertension, diabetes or any other long term disease was found. No history of fever, seizures was found. Patient was admitted to intensive care unit, immediately after the episode of paralytic attack. He was discharged after ten days when regained consciousness, able to recognize relatives, mute, movements impaired in both upper and lower limb of right side. No relevant family history of hypertension or diabetes was reported by the patient’s relatives. Normal bowel and bladder habits were reported, however; he was catheterized since four months as he was bed ridden due to the disability produced after stroke. Appetite of the patient was moderate. No history of smoking, alcohol or any other addiction was found. Patient was taking Ecosprin 75 mg twice daily since four months as advised at allopathic hospital on discharge.

Examination

Respiratory and cardiovascular system examinations showed normal findings. On CNS examination; patient was conscious with altered orientation about time and space (had to take help of relatives to answer in yes or no through gestures) and impaired speech. Memory was impaired but was able to recall some past incidences when helped by relatives. Facial nerve weakness with deviation of face towards left side and involvement of spinal accessory nerve with weakness of right shoulder was observed. Muscle bulk was marginally reduced on right side, with reduced muscle power (Grade 0) and increased tone on right side. All the deep tendon reflexes were exaggerated (Grade 4) on right side, plantar response was extensor on right side with ankle clonus positive.

Investigations

Routine blood and urine investigations were within normal physiological limits. The MRI of brain (27-10-2015) showed subacute infarct in left fronto-temporo-parietal lobar regions and basal ganglia with mass effect and occlusion of left MCA in M1 segment. 2D Echo was normal, lupus anticoagulant was negative. The CT brain findings (28-03-2016) were suggestive changes of ongoing gliosis involving cortex and sub-cortical white matter of left fronto-parieto-temporal region and left ganglio-capsular region associated with focal parenchymal volume loss and tiny lacunar infarct is noted in mid brain.

Treatment protocol

Patient was admitted in the Panchakarma IPD on 1st March, 2016. Assessment was done on subjective and objective parameters using suitable assessment scales. Routine biochemical investigations were carried out before and after the treatment. The treatment regimen planned for the patient was Virechana karma (Table 1) followed by internal administration of Masha baladi kwatha.8 (Table 2) To proceed with Virechana karma, patient was examined for Bala (~strength), Agni (~digestive capacity) and Koshtha (~bowel habits). After assessment of these parameters, patient was advised to take Dhanyaka–shunthi siddhajala (~water processed with one part of Dhanyaka and Shunthi and sixteen parts of potable water) as Deepana (~digestives) and Pachana (~appetizers) for three days.

Table. 1: Clinical intervention

Sr. No. Intervention Medicine Duration
1 Deepana pachana Medicated water with Dhanyaka (Coriandrum sativum L.) 1st to 3rd day
and Shunthi (Zingiber officinale Rosc.)
2 Snehapana Goghrita 4th to 7th day
3 Abhyanga Bala taila 8th to 10th  day
4 Vashpa swedana Steam prepared from Dashamoola decoction
5 Virechana 60 ml Eranda (Ricinus communis Linn.) taila with 180 ml 11th day
Triphala kwatha
6 Samsarjana krama Peya,  Vilepi,  Kruta,  Akruta  yusha,  Mamsarasa  as  per 12th to16th day
Madhyama shuddhi
7 Sarvanga abhyanga Bala taila Next one month
8 Vashpa swedana Decoction prepared from Dashamoola
9 Shamana drug 100ml/ day Masha baladi kwatha along with 250 mg each
of Shuddha hingu and Saindhava lavana

Table 2: Ingredients and properties of Masha baladi kwatha

Sr. Dravya Latin name Guna- Dharma Pharmacological properties
No.
1 Masha Phaseolus Madhura, Guru snigdha, Ushna virya, Madhura Aphrodisiac, carminative,
Mungo (L.) vipaka, Vatashamaka, Pittakaphakara, Vataghna, diuretic, laxative, nervine
Vedanasthapana, Nadibalya, Sramsara, Tarpana, tonic
Brumhana, Shukrala, Balya
2 Bala Sida cordifolia Madhura,  Guru  snigdha  pichchila,  Vatapitta Aphrodisiac, emollient,
Linn. shamaka, Balya, Brimhana, Ojovardhaka, nervine and cardiac tonic,
Anulomana, Snehana, Raktapitta shamaka, diuretic
Mutrala, Rasayana Vatasanshamana,
3 Eranda mula Ricinus Madhura,  Katu,  Kashaya,  Guru  snigdha, Nervine, useful in joints and
communis Tikshna, Sukshma, Ushna virya, Kapha muscular disorders
Linn. vata  shamaka,  Vedana  sthapana,  Sotha  hara,
Angamarda prasamana, Deepana, Bhedana,
4 Kapikacchu Mucuna Madhura, Tikta, Guru snigdha, Ushna virya, Aphrodisiac
prurita (L.) DC Vatashamaka, Kaphapitta vardhaka, Vrushya,
Brumhana, Balya
 

After assessment of Agni; Snehapana (~internal administration with Goghrita) was planned that was given once daily to the patient before 6.30 AM and continued till the appearance of Samyak snigdha lakshana (~symptoms indicating the end point to cease snehapana). It took five days to observe these features. Dose of Goghrita was increased daily observing the digestive capacity of the patient. Goghrita was administered in a dose of 30 ml, 60 ml, 90 ml and 150 ml for four days. The symptoms include Srotovishuddhi (~clarity of channels), Indriyasamprasadanam (~clarity of sensory perception), Laghutwam (~feeling of lightness), Anamayatwam (~general well-being) and Malasnigdhata (~unctuous stools).9 One of the specific features of saturation of internal oleation is body resisting more Ghrita intake by producing nausea or vomiting on trying to take Ghrita in increased dose.10 Internal oleation was followed by Abhyanga (~external application of oil over whole body in a definite pattern) and Vashpa swedana (~sudation in a steam chamber) for three days. Patient was advised to take diet like Mudgayusha and fruit juice like orange or pomegranate once a day for three days.

At the end of this, drugs for Virechana were administered. The drug used for Virechana was 60 ml castor oil 180 ml Triphala kwatha.11 The drug was administered at about 10 AM after Abhyanga and Swedana, taking into consideration of the vital parameters of the patient like pulse, respiratory rate and blood pressure. Patient was under observation for the whole day and was advised to consume about 50 ml warm water every 15 to 20 minutes to assist easy purgation. End point of Virechana is indicated by the presence of Kapha (~mucus) in the stools (Laingiki shuddhi), then efforts were made to cease the Vegas by administration of cold water instead of warm water to the patient. If at this stage, warm water is continued it may lead to Atiyoga (~more frequency of stools) which might lead to dehydration, sometimes even producing hypovolemic shock.

Samsarjana krama (~dietary regimen) is the specific diet advised after Shodhana as per the number of Vegas present. The diet comprises of Peya (~watery rice gruel) for two times, followed by Vilepi (~semi liquid rice preparation) two times, then Mudga yusha (~soup prepared from green gram) once without and then Yusha processed with Ghrita. The last two food items in the series were Mamsarasa (~soup prepared from meat). After completion of this specific diet regimen, patient was advised to take normal diet.

After Virechana karma, patient was advised to take Masha baladi kwatha in a dose of 100 ml prepared from crude drugs (Table 3) for one month twice daily with fine powders of Saindhava lavana and Shuddha hingu in dose of 250 mg each. Patient was also advised Sarvanga abhyanga (~whole body oleation) with Bala taila and Vashpa swedana (~steam fomentation) prepared with decoction of Dashamoola for one month.

Assessment criteria

Patient was assessed on several parameters for psychological and physical functioning on the basis of European Stroke Scale.12 Maximum score 100 indicates normalcy of health, minimum score 0 is indicative of maximum hampering of physical and mental status after stroke. Similar scale provided by National Institute of Health Stroke Scale (NIHSS)13 with maximum score of disability as 34 and minimum score 0 pointing to normal status of health. The degree of disability or dependence was assessed by incorporating Modified Rankin Scale.14,15 Motor Grading Scale was used to assess muscle power.16

Outcome

Patient passed stool for eighteen times (18) throughout the day, which was initially semi solid in consistency, while later on most of the times watery in appearance. After Virechana, patient was properly oriented, no incidence of weakness or any other untoward effects of therapy were noticed. Appetite of the patient was good after Virechana. This was a case of Madhyama shuddhi (~average purification) on the basis of number of Vegas (~bowel frequency) so the Samsarjana krama planned after the Pradhana karma (~main procedure) was of average purification i.e. for five days.

There was considerable improvement noticed in comprehension (50%), speech (50%), facial weakness (25%), arm movement (25%) raising and stretching, leg maintaining position (25%), leg flexing movement (25%), gait and stance (40%) after irechana and Shamana drug consumption.

The dependency of patient decided by Modified Rankin Scale also showed lesser personal dependency and an improvement by 16.66%. The average muscle power assessed by Motor Grading Scale showed a net improvement of 20% after completion of the treatment protocol.

On the basis of NIH Stroke Scale, language change of 33% was noticed after the treatment. There were certain parameters wherein no significant change was detected after treatment, like strength of fingers, movement of wrist and dorsiflexion of ankle joint and toes movement in lower limb.

The overall improvement in European Stroke Scale was noticed from 45 to 59 (Table 3) and reduction in NIH Stroke Scale was observed from 13 to 8. (Table 4) Modified Rankin Scale showed a reduction of 1 from 5 to 4 owing to lesser dependency for routine activities. (Table 5) Motor Grading Scale also confirmed improvement in the muscular strength tested against resistance of the examiner. (Table 5) There was no change noticed in deep tendon reflexes.17 (Table 6) The biochemical markers (blood sugar level, hemoglobin, serum proteins etc.) were within normal limits before and after the treatment. (Table 7)

Discussion

Pakshaghata is considered as Vatavyadhi and Mridu snigdha shodhana (Virechana) is the preferred treatment, which was adopted in this study.18 Acharya Charaka has also mentioned Mridu shodhana in the treatment of Margavarana.19 Hence, certain features wherein involvement of other Doshas like Pitta and Kapha are seen along with Vata (as main Dosha) are supposed to respond well to Shodhana therapy. Acharya Madhavakara has mentioned Samsarga of Pitta and Kapha in Pakshaghata.20 Secondly Vata prakopa may be either due to Dhatukshaya or Margavarana. Hence, Deepana pachana was done with water processed in by Shunthi (Zingiber officinale Rosc.) and Dhanyaka (Coriandrum sativum L.) to remove the Avarana and augment Agni prior to Virechana karma so as to increase its effectiveness. Acharya Charaka mentioned Snehana, Swedana followed by Snigdha virechana as specific choice of treatment for Pakshaghata.21

Table 3: Assessment as per European Stroke Scale

Sr. Parameter BT AT FU
No.
1 Level of consciousness 10 10 10
2 Comprehension 4 8 8
3 Speech 2 4 6
4 Visual field 8 8 8
5 Gaze 8 8 8
6 Facial movement 6 6 8
7 Arm  (ability  to  maintain 1 2 2
outstretched position)
8 Arm (raising) 1 1 2
9 Fingers 0 0 0
10 Extension of wrist 0 0 0
11 Leg (maintain position) 1 2 2
12 Leg (flexing) 2 3 3
13 Dorsiflexion of foot 0 0 0
14 Gait 2 2 6
Total Score 45 54 59

BT -Before treatment; AT -After treatment; FU -Follow up

Table 4: Assessment according to NIH Stroke Scale

Sr. Parameter BT AT FU
No.
1 Level of consciousness 0 0 0
2 Asked month and age 2 2 2
3 Asked to open and close eyes then 0 0 0
to grip and release non paretic hand
4 Gaze 0 0 0
5 Visual field 0 0 0
6 Facial palsy 1 1 0
7 Motor arm 3 3 2
8 Motor leg 4 3 3
9 Limb ataxia 0 0 0
10 Sensory 0 0 0
11 Language 2 2 1
12 Dysarthria 2 2 1
13 Extinction and inattention 0 0 0
Total Score 13 11 8

Table 5: Assessment as per Modified Rankin Scale and Motor Grading

Parameters BT AT FU
Modified Rankin Scale 5 4 4
Motor grading 1 1 2
Table 6: Deep tendon reflexes before and after
treatment
Sr. Reflexes Right Left
No. BT   AT BT AT
1 Biceps 4 4 2 2
2 Triceps 4 4 2 2
3 Supinator 4 4 2 2
4 Knee 4 4 2 2
5 Ankle 4 4 2 2
BT -Before treatment; AT -After treatment;
4 = Exaggerated; 2 = Normal
Table 7: Laboratory investigations
Sr. Test BT AS AT
No.
1 Fasting  blood glucose 139 133 99
(mg/dl)
2 E.S.R. (mm/1st hr.) 51 79 66
3 Hemoglobin (gm%) 13.9 13.5 13.6
4 Total protein (gm%) 7.5 7.34 7.1
5 Serum albumin (gm%) 4.69 4.6 4.1
6 Serum gobulin (gm%) 2.81 2.74 2.1
7 A/G Ratio (%) 1.67 1.68 1.95
BT -Before treatment; AS – After Snehapana;
AT – After treatment

In Pakshaghata, aggravated Vata results in Sira-snayu shosha. This Shosha (~emaciation or under nourishment) of Sira and Snayu may be due to reduced oxygen and nourishment possibly because of restricted blood supply, which is the main cause of ischemic stroke that can result in an infarction, if blood supply is not restored within a short period of time. Virechana, by virtue of its Srotoshuddhi property, checks Sanga (~obstructive) type of Srotodushti encountered in Pakshaghata and may improve blood circulation. As Pakshaghata is described under Vatavyadhi; Snehavirechana was selected not to aggravate the Vata dosha. Besides, Eranda taila is said to be best in pacifying Vata and Kapha dosha22 and Taila due to its Snigdha, Ushna, Guru guna pacifies Ruksha, Sheeta and Laghu characteristics of Vayu. Castor oil, itself is non-irritant but when ingested, it is hydrolyzed in the intestine by pancreatic lipase to glycerol and ricinolic acid. Ricinolic acid acts as an irritant and produces purgation. The active component of castor oil, ricin oleic acid, is a selective agonist of EP3 and EP4 receptors and that the pharmacological effects of castor oil are mediated by activation of EP3 receptors on smooth-muscle cells which in turn activate intestinal cells and subsequently its motility.23 Laxatives produce myoelectric alterations in intestinal smooth muscle and induce accumulation of fluid in the intestinal lumen; these effects cause rapid transit of material through the bowel.24

Acharya Sushruta has stated use of Eranda taila with Triphala kwatha in a ratio of one to three parts to induce mild Virechana especially in children, old age, and those lacking muscular strength.25 Acharya Charaka has also mentioned use of Eranda taila along with Triphala kwatha specifically for Pakshavadha and other Vata disorders.26 Triphala has been mentioned as one of the drugs, which promote the act of purgation of other drugs.27 This was the reason for the use of Triphala kwatha along with Eranda taila. Besides Eranda taila, if taken as a single medicine is unpalatable for most of the patients and may sometimes induces vomiting.

As Pratiloma gati of Prana vayu takes place in the pathogenesis of Pakshaghata; Virechana is one of the best remedy for Vatanulomana.28 Hence, Virechana plays a key role in providing Anuloma gati (~downward movement) to Pranavayu, pacify the vitiation of Rakta dosha and thereby its Updhatus kandara and Sira, thus producing significant effects in Pakshaghata. Vitiation of Prana vayu is the main cause in the pathogenesis of Pakshaghata, which is the controller of all senses. Virechana increases the strength of sensory and motor modalities and thereby checks their impairment encountered in disease.29

Mastishka (~brain) is the Indriya adhisthana,30 Mastishka majja resides in Majjadhara kala, which is analogous to Pittadhara kala.31 In Pittadhara kala vikriti, Virechana is the best Shodhana chikitsa. Hence, Virechana may also act on Majjadhara kala vikriti simultaneously. Majjavaha srotodushti takes place in Pakshaghata and in order to combat the morbidity related to Majja; timely Shuddhi has been mentioned.27

Functions of Manasa are also affected in this case, which included impaired memory and intelligence and Virechana is said to bring Buddhi shuddhi and Prasadana (~clarity of mind and improved intellect).32 Virechana also has a decompressive effect over the system.33 It releases the pressure from lower abdominal cavity, thus releasing pressure in other cavities of the body as well; which results in a lowering of intracranial pressure thus producing better functioning of brain.

Sira-snayu shosha is one of the important symptoms of Pakshaghata. Involvement of Sira and Kandara being Upadhatu of Rakta shows the involvement of Rakta dhatu also and Virechana is an important remedy to pacify such disorders.34 Rakta dushti produces excess Pitta, being Mala of Rakta,35 Virechana is best to pacify Pittaja disorders.

Abhyanga of complete body with Bala taila was done to enhance general strength and sturdiness by promoting muscular health,8 which tend to drop their strength due the cumulative effect of stroke. Swedana was done to pacify the Vata dosha remaining after removal of Avarana and to enhance nourishment to the dried Sira-snayu involved in the pathogenesis.

Masha baladi kwatha described in Chakradatta for the management of Vata disorders36 possess Brimhana (~anabolic), Balya (~strengthening muscular tissue), Rasayana (~promoting longevity), Ojovardhaka (~improving immunity and vital strength), Vata kapha shamaka (~alleviates vata and kapha doshas) and nervine tonic properties. Individual ingredients of Masha baladi kwatha have been reported to have varied pharmacological properties.37 Saindhava lavana and Shuddha hingu due to their Sukshma and Tikshna properties make the drug more effective and more penetrative. By these cumulative effects the drug augmented the effects produced by Virechana in Pakshaghata.

The result of Virechana was more prominent on improving higher functions like speech, language, comprehension, dysarthria and facial weakness probably due to its specific action on subsiding Vata, improving brain function (~Majja dhatu) and having a subsidiary effect on Pitta and Rakta.

This was seen as the scoring clearly shows an upsurge in the improvement seen in various parameters like

arm and leg strength, gait and stance after Virechana. (Table 8) The results in follow-up, which was assessed after completion of Samsarjana krama showed an upward trend in scores, indicating positive effect of the drugs and other treatment procedures including Abhyanga, Swedana.

Table 8: Changes in gait and stance

Parameters BT AT
Stance Inability to stand Limited speed &
distance
Gait Inability to walk Limited speed &
distance

BT -Before treatment; AT – After treatment

There were certain parameters wherein no significant improvement was seen like the strength of fingers and of the distal structures like wrist and ankle region. These were the areas, which were maximally affected with disease and finest coordinated movements. To procure better results in these finer areas controlled by deeper structures in brain, other Panchakarma therapies like Basti and Nasya should also be inculcated to enhance the effect of Virechana.

Conclusion

The results in this case were encouraging to prove Virechana as the prime treatment in stroke. Improvement was seen in various parameters assessing speech, language, higher functions like comprehension immediately after Virechana, while the improvement was increased after Abhyanga, Swedana and Shamana especially in the muscular strength of arms and legs thus causing a better movement and producing lower dependency and subsequently improve the lifestyle. The results could be further improved if other Panchakarma treatment modalities acting over higher psychological functions like Basti and Nasya could be involved in the treatment protocol after Virechana. To explore further possibilities, adjuvant studies need to be conducted with Virechana as the baseline therapy and give way to more concrete conclusions in stroke patients.


Source of support None.

Conflict of interest None.


References

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SOURCE: : Management of Stroke through Virechana-Journal of Ayurveda Case Reports -Journal of Ayurveda Case Reports Volume 2 Issue 2 April-June 2019

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