A Case Study on the Ayurvedic Managment of Spastic Cerebral Palsy Due to Birth Asphyxia

Background: Cerebral palsy is a disorder of motor control due to a static lesion of the developing brain. It was described almost 150 years ago. Global incidence of Cerebral Palsy is 2 to 2.5/1000 children but in Indian scenario, incidence is 03.8% of population. In India about twenty-five Lakh children are suffering from cerebral palsy. Most common type of cerebral palsy is spastic which cover 70% to 75% of overall. There is no exact correlation found for cerebral palsy in Ayurvedic literature but may be the result of Shiromarmabhighata (injury to brain) and can be considered as Vata Vikara or Vata Vyadhi (neurological disorders). Aim: To assess the effect of certain oral medication with Purvakarma (preparatory procedures) and Panchakarma procedures (Five-fold measures of Bio-cleansing) in the management of Cerebral Palsy (CP). Material and Method: In this case study, one case of Spastic cerebral palsy was registered and treated with multiple Ayurvedic treatment modalities. Total period of treatment was 93 days in which 5 days of Abhyanga (Massage) with Nadi swedana (steam kettle Sudation), 5 days of Abhyanga (Massage) with Shashti Shali Pinda Swedana (a type of Sudation) and then 7 days of Matra Vasti (Enema by Medicated oil in small dose) by Ksheera Bala Taila; this schedule of treatment was given three times with a gap of 14 days. Vacha mula (Root of Acorus calamus) and Samvardhana Ghrita was given as internal medication during the total course of treatment. Results were assessed by progress in delayed milestone, anthropometrical measurement, modified Ashworth scale, muscle power grading and Manual Ability Classification System (MACS) scale. Result: Treatment protocol of oral medication with Panchkarma delivered better result in CP patient, especially improving anthropometric data (weight, height, chest circumference), delaying milestone (walking and language), reducing spasticity and improved Quality of Life (QOL). Conclusion: Cerebral palsy is a disorder of motor function. The cause originates from the brain sometime during its developmental period. Internal medication along with Purvakarma (preparatory procedures) and Panchakarma (Five-fold measures of Bio-cleansing) give significant improvement in all the facets of spastic CP. DOI:10.18311/jnr/2019/23528


Introduction
CP is motor function disorder and first described by William Little (1810-1894) in the 1840s 1 . Most important cause of chronic disability in children is CP 2 and making them physically handicapped, mentally handicapped and socially detached 3 . Cerebral palsy is linked with convulsion, abnormalities in language, visualization and intelligence due to hypoxia in developing brain 4 , during prenatal, natal and postnatal period of life 5 . Global incidence of Cerebral Palsy is 2 to 2.5/1000 live births 6 but in India, incidence is 03.8% of the population 7 . Currently, in India about 2.5 million children are suffering from cerebral palsy 8 . The World Health Organization (WHO) estimates that, about 10 % of the overall population suffers from physical and mental disorder 9 . Indian data shows that 3.8% of the population suffers from various type of disability in India 10  physical handicapped children suffer from various type of cerebral palsy 11 . Motor disorders of CP are frequently associated with disorder of communication, behavior, sensation, perception and cognition. CP is divided into four types and most common type of cerebral palsy is spastic which cover 70% to 75% of overall cases 12 . Common causes of cerebral palsy are brain insult due to prematurity, birth asphyxia, hypoxic ischemic encephalopathy, meningitis and accidental head trauma. Modern medicine has no cure for any types or subtypes of cerebral palsy. Much newer advancement is being tried for treatment of cerebral palsy and associated features such as therapeutic hypothermia therapy 13 , Botulinum toxin injection 14 , Baclofen injection 15 , hyperbaric oxygen therapy 16 , selective dorsal rhizotomy 17 , neuroplasticity 18 and stem cell transplantation procedure.
There is no exact correlation found for CP in Ayurvedic literature. However, in view of the etiology and clinical feature, Cerebral Palsy may be the result of Shiromarmabhighata (injury to brain) and can be considered as Vata Vikara (neurological disorders) 19,20 . Various conditions like Phakka (nutritional disorder) 21 , Pangulya (locomotory disorders), Mukatva (Speech or language disorder), Jadatva (inability to do motor activities), Pakshaghata (hemiparesis), Ekangaroga (monoplegia) 22 Sarvangaroga (quadriplegia) 23 etc. exhibits signs and symptoms of Cerebral palsy where the main Dosha involved is Vata. Hence, CP should be treated on guideline of Vata Vikara or Vata Vyadhi (neurological disorders). In this case study, the effect of Ayurvedic therapy protocol for improving the condition of a spastic cerebral palsy patient was evaluated. The outcome of this clinical study will reveal further regarding the effect of these treatment modalities in the management of spastic cerebral palsy due to brain insult. Father has studied 10 th standard and currently working as a security guard, mother is house wife.

History of Present Illness
A 5.0 years old male child brought by his parents to Kaumarbhritya OPD of Government Ayurvedic PG College Varanasi with above complaints. According to Patient baby was delivered by LSCS (lower segment cesarean section) prematurely, and suffered from Hypoxic Ischemic Encephalopathy (HIE) and neonatal jaundice. Spasticity and involuntary movement became noticeable after the age of 5 months and then parent started treatment by many allopathic doctors without any significant benefit. At the age of five years they approached us for further management.

History of Past
Hypoxic Ischemic Encephalopathy (HIE) grade-2 and neonatal jaundice.

Treatment History
Child was treated by many allopathic doctors and the treatment details are as mentioned below; 1. Anti-convulsant therapy for first 2 years (Phenobarbitone) 2. Tablet Baclofen for muscle relaxant.

Family history
Family history is not significant.

Birth History
At the time of delivery, age of mother was 21 years and has not suffered from any disease. According to patient, baby was delivered by LSCS and indication of LSCS was fetal distress. Baby did not cry after birth and weak cry start after 24 hrs. Baby was shifted to NICU (Neonatal intensive care unit) for proper care and management. Data of APGAR score and resuscitation measures taken was not available. Baby was delivered prematurely (34 weeks) and at the time of birth weight of baby was 1.6 kg (low birth weight).

Vaccination history
Proper for age.

Personal History
Patient was totally dependent for food intake and activity. Patient was eating only semi solid food due to lack of coordination in deglutition. Appetite of patient was very poor and frequently suffers from cough and cold. Sleep was disturbed, bed wetting (not achieved bladder control) and drooling from the mouth since birth.

Examination
Vitals of patient were normal. Examination of cardiovascular system, respiratory system and gastro intestinal system had not shown any abnormality.

Central Nervous System (CNS) Examination
• Patient was hypertonic (spasticity) and suffers from mild contractures at ankle and knee joint.
• Muscle power was in grade one.
• Cranial nerve examination-Not done (Due to handicapped physical and mental state of the patient. • Hyper-reflexia was present (Suggest upper motor neuron (UMN) injury which is main characteristic of cerebral palsy.

Investigations
CT scan and MRI were taken to identify anatomical abnormality in the region of brain. In this case impression of MRI is Spastic CP with sequels of HIE (Hypoxic ischemic encephalopathy).

Material and Method
In this case study one case of Spastic cerebral palsy was registered and treated with multiple Ayurvedic treatment modalities.

Criteria for Assessment
The assessment was done on the basis of improvement in delayed milestones, growth parameters, drooling Step -1 Oral medication (Total 93 days)

1.
Vacha-mula (Root of Acorus calamus) (Duration=93 days)  It was rubbed 40 times on a stone in 5 ml of cow's milk,  Half a piece of wet almond also rubs with Vacha Mula.  The product was mixed with 5 ml of honey and give orally to CP children.

Result
Three courses (sittings) of treatment were completed in 93 days. After that significant improvement was found in all milestones such as speech (grade-2 to grade-1), verbal (grade-2 to grade-1) and able to walk with support (grade-3 to grade-2) (Chart 1

Discussion
Cerebral palsy is a syndrome rather than single disease. Cerebral palsy mainly affects movement and posture which arise due to injury of fetal or infant brain 33 . The etiology of cerebral palsy can be thought of using the four P's: prematurity, prenatal, pen natal and postnatal. Birth asphyxia is cause of cerebral palsy in this case study and this is most common cause of cerebral palsy in another study also 34 Spastic CP is most common type and occurrence is about 70-75% of cases 35 . It is characterized by signs of upper motor neurons injury viz. hypertonia, spasticity exaggerated Deep Tendon Reflexes (DTR) and extensor plantar responses. Spastic cerebral palsy is of three types; quadriplegia, diplegia and hemiplegia. The studied case was spastic quadriplegia and it is secondary to hypoxic ischemic events.
There is no exact correlation found for cerebral palsy in Ayurvedic literature. However, in view of the etiology and clinical features, Cerebral palsy may be the result of Shiromarmabhighata (injury to brain) and can be considered as Vata dominant conditions or Vata Vyadhi (neurological disorders).
So the aim of treatment for CP was to pacify vitiated Vata dosha. In Ayurveda, Snehana (Oleation), Swedana (Sudation) and Vasti karma (Medicated enema) are main line of treatment for Vata Vikara or Vata related disorders (neurological disorders) 36 . In management of CP till now there is no successful treatment in modern pediatrics but in Ayurveda, by appropriate oral medication with Panchakarma procedures (Five-fold measures of Biocleansing) can be an effective method.

Effect of Oral Medication
In the form of oral medication Samvardhana Ghrita and Vacha-mula (Root of Acorus calamus) was given for 93 days continuously.

• Vacha Mula (Roots of Acorus calamus)
Many studies have claimed that the Vacha-mula (roots of Acorus calamus) helps in subsiding neurological symptoms of brain 38 -40 and also have positive effects on memory disorder 41 . Root of Vacha is very effective in improving grasping power, speech performance (language milestones) 42 and learning performance, by decrease brain lipid peroxide content 43 . Use of Ayurvedic medicine with honey enhances the potency and decreases its bitterness; thereby increasing its palatability 44 .

• Effect of Purva-karma (Preparatory Procedures)
In total duration of treatment, Purva-karma (preparatory procedures) was done in three sitting with 14 days interval after each sitting.

• Sarvanga snehana / abhyanga (Whole Body
Massage) Abhyanga (body massage) by oil provides nourishment due to its Snigdh, Mridu and Picchila Guna (Oily, soft and sticky quality). Vayu resides in Sparshnendriya which is situated in tvacha (skin). Abhyanga (Massage) on skin directly works on Vata to shift to normalcy. Bala Taila and Mahanarayan tail both have Vata shamak (suppress Vata) property. When Snehana (Oleation) and Swedana (Sudation) are done together then Dosha deflect from Shakha (peripheral system comprising blood, tissues, skin and Rasa (plasma) to Koshta (hollow organs and cavities of body or complete digestive system) and then Koshta dosha managed by Vasti karma (Medicated Enema). When Vata comes to normalcy then delayed milestones will shift to normal state 45 . Abhyanga (Oleation) manages hypertonic condition, improves muscle bulk and power in Cerebral palsy 46 .

• Effect of Pradhan Karma (Main Procedures)
During total duration of treatment Matra-vasti (Medicated oil enema in small dose) was done in all three sitting and 7 days in each sitting.

• Matra-Vasti (Oil Enema in Small Dose)
Vasti is most important Pradhan-karma to manage the Vata Dosha in treatment of Cerebral palsy. Short chain fatty acids of medicated oil reaches rectum, colon and direct diffusion property from epithelial cells to blood capillary where it shows generalized effect 48 . Vasti is restricted till the crawling age but Anuvasana vasti (oil enema) can be given from early infancy. Matra-vasti is having Balya (strengthening), Brimhana (nourishing) and Vatarogahara property. Matra-vasti provides nourishment to deeper tissues 49 . Ksheera Bala Taila vasti mainly improves motor functions such as sitting, standing, crawling and walking in cerebral palsy patients. Fine and gross motor functions of cerebral palsy were improved by Vasti karma. Matra-Vasti found beneficial in spastic diplegia 50 .

Total Effect of Therapy
Total effect was found near 15-20% improvement and this improvement helps the patient to improve QOL. Previously it was believed that neurons do not repair after any injury, but the new concept of neuroplasticity has mentioned that CNS have the ability to repair their neurons by axonal budding to take over the function of injured neurons. This improvement in cerebral palsy patients also supports the new concept of neuroplasticity.

Conclusion
Cerebral palsy is a multi-factorial disease. Ayurveda consider cerebral palsy as Vata-Vikara or Vata-Vyadhi (neurological disorders), occurring as a result of Shiromarmabhighata (injury to brain). The preferred treatment protocol is effective in reliving the symptoms of cerebral palsy patient. Combination of oral medication (Vacha mula and Samvardhana Ghrita) Purva-Karma (Abhyanga by equal amount Bala Taila and Mahanarayan along with Nadi Swedana & Shashti Shali Pinda Swedana) and Pradhan-Karma (Ksheera Bala Taila Matra-vasti) was very effective for spastic cerebral palsy due to birth asphyxia.