Cerebral Palsy in Ayurveda #Panchkarma In Cerebral Palsy

Cerebral Palsy in Ayurveda #Systematic_Review #Panchkarma In Cerebral Palsy #Ataxic_CP #Spastic_CP #Dyskinetic_CP #Udwartana #Abhyanga #Swedana #Basti #Nasya

1. Reg. No: RJ17D0105798 ISSN NO: 2582-0648
July to December 2021-Vol-16, Issue -2, (October, Addendum-3), Journal of Research in Indian Medicine PageNo.-15




Journal of Research in Indian Medicine
An Official Publication of Bureau for Health & Education Status Upliftment
(Constitutionally Entitled As Health-Education, Bureau)



Effect of Ayurvedic Panchkarma Therapy in management of Cerebral
Palsy-A Systemic Review

1
Dr. Vijay Kumar Pathak,
2
Dr. Mahapatra Arun Kumar &
3
Dr. Rajagopala S

1. MD Scholar, Dept. of Kaumarabhritya, All India Institute of Ayurveda, Sarita Vihar, Delhi
2. Assistant Professor, Dept. of Kaumarabhritya, All India Institute of Ayurveda, Sarita Vihar, Delhi
3. Associate Professor & HOD, Dept. of Kaumarabhritya, All India Institute of Ayurveda, Sarita Vihar,
Delhi

Email Id: [email protected]
Abstract
Cerebral palsy (CP) is a non-progressive, developmental, neuromotor disorder of cerebral origin,
resulting from brain injury that occurs before its development is complete. It is characterized by the
inability to normally control motor functions, which affect the child’s ability to explore, speak, learn,
and become independent. It is a common disorder with a prevalence of 2/1000 population.
Objective: To review existing reported human clinical trials of Panchkarma based treatment procedures
for the management of cerebral palsy. Design: Review of the database, with searches conducted in
PubMed, Google Scholar, and AYUSH Research Portal. Search terms included “Cerebral palsy,”
“Panchkarma,” “Ayurveda” articles dated between 2000-2020. Inclusion criteria were human trials with
a treatment arm that included “Panchkarma” based treatment procedures as a remedy for “cerebral
palsy” having minimum 06 participants. Intervention: Management with any regimen of
“Panchkarma”. Outcome measures: Number and results of studies identified in the review. Results:
Thirty-six articles were screened; Thirteen human trials met inclusion criteria. Ten studies used
Ashworth Scale to assess spasticity with different Panchkarma procedures in cerebral palsy reported
improvement in spasticity, and most commonly internal medication used in studies were in ghrita
dosage form. Udwartana (Dry powder massage), Abhyanga (Oil massage), Shashtika Shali Pinda
Sweda (A type of hot fomentation), Sarvanga Swedana (Fomentation), Salavana Upanaha (Poultice),
Matra Basti (Medicated oil enema), Anuvasana Basti (Medicated oil enema), Niruha Basti (Medicated
enema), and Parisheka (Pouring liquid medication) were the treatment procedures adopted in managing
cerebral palsy and these procedures have shown good result is spasticity. Whereas some procedures like
Nasya (Nasal medication), Shirodhara (Pouring medication over head), Shiroabhyanga (Head massage),
HEB JRIM

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Shiropichu (Medication-soaked cotton cloth on the head) are unexplored. Conditions like mental
retardation, ophthalmologic defects, hearing impairments, and speech and language disorders occurring
in CP are not addressed in these studies. Panchkarma interventions have shown good result in spastic
cerebral palsy whereas studies on other forms of cerebral palsy are lacking. There is need to conduct
future studies in other forms than spastic cerebral palsy like Atonic CP, Choreoathetoid CP, Dyskinetic
CP, Ataxic CP, Mixed Dystonic CP. This study attempts to aggregate all clinical studies on CP
published between 2000–2020 into a single study to find out what has been done and what is lacking in
previous clinical work, so that future study can be planned.
Key words: Cerebral palsy, Previous clinical work, Panchkarma, Ayurveda
Access this Article Online
Website:http://heb-nic.in/jrim
Received on 29/09/2021
Accepted on 22/10/2021 © HEB All rights reserved

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Introduction
Cerebral palsy (CP) is a group of permanent disorders affecting the development of movement and
causing a limitation of activity. It is a static encephalopathy that may be defined as a non-progressive
disorder of posture and movement often associated with epilepsy and abnormalities in speech, vision
and intellect resulting from a defect or lesion of the developing brain.
[1]
Cerebral palsy is the most
prevalent cause of persisting motor function impairment
[23]
. In Ayurveda, there is no single condition /
disease which exactly show similarity with CP. Some conditions explained in Ayurveda, which have
shown some similarity with CP are, Phakka
[24]
(a kind of nutritional disorder), Pangulya
[25]
(locomotor
disorders), Mukatva
[25]
(dumbness), Ekanga roga
[25]
(monoplegia), Sarvanga roga
[25]
(quadriplegia),
and Pakshavadha
[25]
(hemiplegia) Vatavyadhi (neurological disorders)
[2]
. Cerebral palsy in Ayurveda
can be considered as Shiro-Marmabhigathaja Bala Vata Vyadhi. Causes of cerebral palsy can be
divided into Prenatal, Perinatal, Postnatal causes
[3]
.

Prenatal causes of cerebral palsy includes
Congenital brain malformations, Intrauterine infections, Chromosomal abnormalities etc. Peri-natal
factors are Hypoxic-ischemic insults, Kernicterus, Central nervous system (CNS) infections, Stroke etc.
Postnatal Causes includes Accidental and non-accidental trauma, CNS infections, Stroke, Anoxic
insults etc. Cerebral Palsy is broadly classified in five viz. Spastic, Ataxic, Dyskinetic, Hypotonic and
Mixed
[4]
. In Ayurveda inappropriate Ritu (Fertile period), Kshetra (Uterus), Ambu (Ahara rasa
nutrients) and Bija
[5]
(sperm and ovum), Dauhrida Avamanana
[6]
(negligence of urges during Dauhrida
stage of pregnant women), Garbhopaghatakarabhava
[7]
(Factor affecting in Antenatal period),
incompatible Garbha Vriddhikarabhava
[8]
(embryonic growth factors) and improper following of
Garbhini Paricharya
[9]
(Antenatal care) are attributed as Nidana (Etiology) for occurance of this
condition. In conventional system of medicine there is no definite cure to this condition which open
doors for Ayurveda to develop proper protocol for management of this disease on basis of its own
principle.

Materials and Methods
Review of the database, with searches conducted in PubMed, Google Scholar, and AYUSH Research
Portal. Search terms included “cerebral palsy,” “Panchkarma,” “Ayurveda”, and articles dated between
2000-2020. Inclusion criteria were human clinical trials with a treatment arm that included
“Panchkarma” based treatment procedures as a remedy for “cerebral palsy” having minimum of 06
participant.

Results
A total of 36 records were identified through database search. In addition, two records were identified
through sources outside of the core search through references of relevant article. A total of 13 records
were screened for eligibility that met inclusion criteria and were selected for the systematic
review. Figure further depicts the selection process of the studies.

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PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram of search
results from systematic review.

S.
No
.
Author Internal
medication
Panchkarma Design
of
study
Period Scale used Outcome
1 Aniket
Palande
[
16]

{2017}
Group A
Shishukalyan
Ghrita
[16]


No medication
in Group B and
Group C

Group A
Abhyanga and
Shashtishali
Pinda Sweda.

Group B
Abhyanga,
Shashtishali
Pinda Sweda and
Kala Basti –
(Anuvasana Basti
and Niruha
Basti)

Group C
Physiotherapy 90
days
A
random
ized
controll
ed
clinical
trial
90 days Modified
Ashworth
Scale for
spasticity
Group A shown statistically very
significant improvement in
Ashworth scale for spasticity in all
four limbs.

Group B shown statistically very
significant improvement in
Ashworth scale for spasticity in Left
upper and lower limbs; while it
shows statistically significant result
in Ashworth scale for spasticity in
Right upper and lower limbs.

Group C which is control group has
shown very significant result in
Ashworth scale for spasticity in
bilateral lower limbs; while it shows
statistically significant improvement
in Ashworth scale for spasticity in
bilateral upper limbs. In intergroup
comparison Group A is statistically
significant over Group C in
Ashworth scale for spasticity in right
upper limb.
Records identified through database
searching (n=36)



Additional records identified through
other sources (n=2)
Records after duplicates removed
(n=27)
Records screened (n=27)
Full text articles assessed for eligibility
(n=13)
Studies included in qualitative
synthesis (n=13)
Records excluded (n=14)
Full text article excluded
(n=0)

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2 Apexa
G.
Vyas
[11]

{2013}
Samvardhana
Ghrita
[35]

Group A
(Abhyanga,
Shashtika Shali
Pinda Sweda and
Samvardhana
Ghrita internally)

Group B
(Samvardhana
Ghrita internally)
Open
labeled
double
arm
clinical
trial
35 days Motor
milestones and
GMFCS level
for motor
function level.
In this study, both groups A and B
have shown better results in
improving the disease condition.
More prominent outcome is
observed in group A in improving
the motor system components,
thereby leading to a more effective
protocol of combined treatment.
3 Arun
Raj
GR
[20]

{2018}
No internal
medication

Group A:
Abyanga,
Parishek, and
Salavana
Upanaha.


Group B:
Abyanga, and
Salavana
Upanaha.
Single
centere
d, open
labeled,
double
arm,
prospec
tive
clinical
trial
90 days Modified
Ashworth
Scale for
Spasticity
Overall it can be concluded that both
Parisheka and Salavana Upanaha
Sweda when applied for 90 days
helps in reducing spasticity. More
reduction in spasticity was observed
in Upanaha along with Parisheka
group, highlighting the effectiveness
of Parisheka compared to Upanaha
only group

4 Gavali
Kishor
[1
7]

{2016}
Group A
No internal
medication

Group B
Samwardhan
Ghrita
[35]

Group A-
Physiotherapy
treatment

Group B-
Physiotherapy +
Abhyanga,
Shashtika Shali
Pinda Sweda,
and Hapushadi
Yapana Basti
Open
labeled
double
arm
clinical
trial
3
months
Modified
Ashworth
Scale

MRC Power
scaling
The results of both the groups were
most of the time gained the
statistically significance proving
physiotherapy as the standard
management of the Cerebral palsy.
However in most places group B was
present with maximum improvement
and some highly significant results
then group A. Hence proving the
efficacy of Ayurvedic modalities to
be new way of better management in
the field of Cerebral palsy.
5 Kurubar
A
Deepti
[2
1]

{2014}
No internal
medication
Group A:
Matra Basti

Group B:
Sarvanga
Abhyanga, and
Nadi Sweda
A
random
ized
compar
ative
clinical
study
15 days Modified
Ashworth
Scale, Muscle
Stretch
Reflexes,
Goniometry,
Gross Motor
Classification
Matra Basti (enema) is more
effective in treating the spasticity of
cerebral palsy as compared to
Abhyanga (massage) and Sweda,
whereas Abhyanga (massage) and
Sweda (sudation) is effective in
treating fine motor functions
6 Palak
Purohit
[
15]

{2017}
Medhya
Churna
[15]

Udvartana,
Abhyanga and
Shashtika Shali
Pinda Sweda
Single
arm
clinical
trial
86 days CDC grading
for motor
milestones.
Ashworth
scale For
Spasticity.
MRC Scale
For Muscle
Power. ADL
scale and
MACS
(Manual
Ability
Classification
System)
Significant result was observed in
head holding, Sitting, language,
Personal, social and fine motor
milestone. In anthropometrical
measurement significant result
shown in Weight, CC, MAC Rt.,
MAC Lt., MTC Rt., MTC Lt., and
Length parameter.

Significant results in MRC scale for
muscle power for all four limbs and
in Ashworth scale for spasticity
Lower limbs and upper limbs has
shown significant result.

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7 Rahul
Ghuse
[14
]

{2016}
Medhya
Churna
[14]

Udvartana,
Abhyanga, and
Yoga Basti
Single
arm
clinical
trial
86 days Grading for
motor
milestones,
Ashworth
Scale to assess
spasticity,
Muscle Power
grading,
Manual
Ability
Classification
System
(MACS), and
Activities of
Daily Living
score (ADL)
Study showed significant results in
the head holding, sitting, standing,
fine motor, personal and social
parameters. Muscle power and
MACS, parameters showed
significant result.
8 Sagar
M.
Bhinde
[1
0]

{2014}
Ashtanga
Ghrita
[34]

Udvartana,
Abhyanga,
Sarvanga
Swedana and
Yoga Basti.
Single
arm
clinical
trial
82 days Modified As
hworth Scale,
spasm scale,
reflex scale,
and muscle
power
grading.
Significant results in developmental
milestone parameters like head
holding, sitting. In anthropometrical
measurement length, weight, chest
circumference. In motor system
component left upper limb spasticity
and all four limb spasm
9 Satyawa
ti
Rathia
[1
3]

{2015}
Samvardhana
Ghita
[35]

Udvartana,
Abhyanga,
Nadi Sweda and
Yoga Basti
Open
labeled
double
arm,
clinical
trial
86 days Ashworth
Scale to assess
spasticity
Muscle Power
grading
Manual
Ability
Classification
System
(MACS)
Gross Motor
Functions
Classification
System
(GMFCS)
Activities of
Daily Living
score (ADL)
In this study improvement was found
in length (0.12%), weight (1.75%),
Chest circumference (0.27) and Mid
thigh circumference (0.35) and in
development milestone
improvement was found in neck
holding (8.33%), sitting (8.33%),
standing (6.66%), Fine motor (7.7%)
language (14.48%), personal and
social milestones (17.29%) and
gross motor classification system
(GMFCS) (11.42%).

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10 Shailaja
U.
[12]

{2013}
Baladi Yoga
[12]

in treated group

Godhuma
Choorna
[12]
in
control group
Treated (RB)
group
Sarvanga
Abhyanga,
Shastika Shali
Pinda Swedan
and Mustadi
Rajayapana
Basti

Control group
Sarvanga
Abhyanga and
Shastika Shali
Pinda Sweda
Open
labelled
random
ized,
controll
ed
clinical
trial
68 days On the basis
of milestone
Gross motor
Fine motor
Language
Performance
Overall improvement of Treated
(RB) group
Gross motor, Fine motor, Language,
Performance Respectively 19.11%,
15.29%, 11.72%, 11.11%

Overall improvement of control
group
Gross motor, Fine motor, Language,
Performance Respectively 2.8%,
2.4%, 1.5%, 3%
11 Shailaja
U
[18]

{2013}
Group A
Samvardhana
ghrita
[35]


Group B
No internal
medication
Group A
No Panchkarma

Group B
Abhyanga, Nadi
Sweda, and
Matra Basti
Open
labelled
double
arm
clinical
trial
48 days On the basis
of milestone
Gross motor
Fine motor
Language
Performance
Group A and B shown
improvements in language and
performance (61.11%, 46.15%),
speech (66.66%, 56.25%) and
performance of skill (57.89%,
76.45%), in fine motor functions
such as puts small object in a
container (58.88%, 66.66%), throws
ball in all direction (38.23%,
60.00%), uses thumb and index
finger (34.21%, 68.75%), retain 2
one inch cube in fist (34.21%,
55.58%), folds paper inserts into
envelope (66.66%, 38.88%), in gross
motor functions such as in crawling
(31.85%, 48.00%), sitting (55.55%,
57.89%), standing (36.36%,
61.90%), walking (34.61%, 44.00%)
and claps hands (44.44%, 63.41%)
respectively
12 Sumeet
Goel
[22]


{2018}
Group A
Ashtang
Ghrita
[34]


Group B
No internal
medication
Group A
Abhyanga,
Shashtika Shali
Pinda Sweda,
Matra Basti

Group B
Physiotherapy
3
months
Modified
Ashworth
Scale
In intergroup comparison, Group A
has shown significant gain in
Ashworth scale of spasticity of Right
upper limb over group B, whereas no
significant gain was seen in Group A
over Group B Ashworth scale of
spasticity in Left upper limb and
right and left lower limbs.
13 Upasana
Sonker
[1
9]

{2020}
Balapanchamri
ta Yoga
[47]

Udwaratan,
Sarvanga
Abhyanga,
Nadi Sweda, and
Matra Basti

A
single
arm
prospec
tive
clinical
trial
81 days Modified
Ashworth
Scale
Gross Motor
Functional
Manual Scale
Quality of Life
The overall comparative clinical
improvement in the present study
have shown 19.99% on Modified
Ashworth scale, 19.08% on Gross
Motor Function Manual Scale and
9.47% on Quality of life scale.

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Discussion
Panchakarma is made of two words ‘Pancha’ means ‘five’ and ‘Karma’ means ‘procedure’. It involve
Vamana, Virechana, Nasya, Basti, and Raktamokshana. While performing procedure it consist of three
phases: Poorva Karma, Pradhana Karma and Paschat Karma. Udwartana
[26]
is the Rookshana
Poorvakarma, it help in reduction of vitiated Kapha by its dryness-inducing and blockage-removing
properties. Once Aavarana is removed, vitiated Vata can be pacified by further treatment. The effect of
Udwartan in reducing psychophysical parameters such as weight, BMI, WHR and serum lipid values
and other scales like stress inventory, quality of life and sleep are also seen
[37][38]
. Udwartan can
help in normalizing lipid profile also in reduction of weight; BMI, body circumference and skin fold
thikness in case of dyslipidemia
[39]
. Most of the clinical trial have used Udwartan in management of
CP
[10][13][14][15][19]
. Abhyanga
[27]
(Massage) comes under Poorvkarma, it improves blood supply to
muscles, stimulates sensory nerve endings of the skin, reduces muscular fatigue and pain
[43]
and stifness.
Study shows that massage therapy attenuates impairment of upper extremity endothelial function
resulting from lower extremity exertion-induced muscle injury
[40]
, it has also been shown to be effective
for decreasing neuropathic pain in some people with spinal cord injury
[41]
, and can effectively reduce
the spasticity
[42]
. Abhyanga (massage) is useful in reducing subjective stress
[36]
. Here all studies have
included Abhyanga as a therapeutic procedure in Cerebral palsy. Swedana
[28]
is Sthambhagna
(Reducing spasticity), Gauravnigrah (Reducing heaviness in body), and Kapha-Vata nirodhaka.
Swedana drugs by Ushna and Tikshnaguna are capable of penetrating the microcirculatory channels
(Srotas) where they activate the sweat glands to produce mores heat. Swedana Karma hastens this
process by increasing the permeability of capillary and bringing the morbidities into an extracellular
fluid by dilating and clearing the channels of the body
[44]
. Thus it helps in removing obstructions from
channels and stiffness of the joints is relieved. A study shows significant increase in blood pressure and
pulse rate immediately after the completion of Sarvanga Swedana therapy
[45]
. Different forms of
Swedana used in CP is Shashtika Shali Pinda Sweda
[11][12][15][16][17][22]
, Nadi Sweda
[21][19][18][13]
, Sarvanga
Swedana
[10]
, Salavana Upanaha
[20]
and Parisheka
[20]
. Basti is best treatment
[29]
for Vata Dosha, it may
act over the receptors of the ENS (Enteric Nervous System) to stimulate the CNS (Central Nervous
System) causing secretion of required

hormones or other chemicals
[46]
, different forms of Basti used in
CP is Matra Basti
[22][21][19][18]
, Yoga Basti
[10][13][14]
, Yapana Basti
[17]
Mustadi Rajayapana
[12]
. Kala
Basti
[16]
. Physiotherapy
[22][17][16]
is also used in CP. As a internal medication, Ghrita
[10][11][13][16][17][18][22]

preparation is dominating in these studies, reason might be using ghrita more lipophilic the drug is, the
more likely it is to cross the blood-brain barrier
[31][32][33]
due to lypophilic nature of ghrita it help drugs
in crossing blood brain barrier. Formulations having Medhya (Nootropic) ingredients is used in CP as
a internal medication. Children with CP are more likely to have associated conditions including mental
retardation (52%), ophthalmologic defects (38%), hearing impairments (12%), and speech and language
disorders (38%)
[30]
. Here studies taken motor functions, spasticity for assessment criteria, but ayurvedic
Panchkarma can also be used for mental retardation, ophthalmologic defects, hearing impairments, and

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speech and language disorders occurring in CP. The reviewed studies are showing good result in
reduction of spasticity mainly targeting spastic CP, studies in other forms of cerebral palsy are
unavailable, so Ayurvedic intervention should also be evaluated in other forms of CP. There are no
studies where Rasaushadhi is used as a internal medication, so future studies can be planned with using
Rasaushadhi. Udwartana, Abhyanga, Shashtika Shali Pinda Sweda, Sarvanga Swedana, Salavana
Upanaha, Matra Basti, Anuvasana Basti, Niruha Basti, Parisheka are explored for the treatment in CP
and these procedures are showing good result is spasticity, where as some procedures like Nasya,
Sirodhara, Siroabhyanga, Siropichu are still unexplored. CP in Ayurveda is considered as a
Siromarmabhigatjanya Baal Vaat Vyadhi, stimulation of Marma point can lead to better results during
Abhyanga.

Conclusion
The disease cerebral palsy described in conventional system of medicine has no exact correlation in
Ayurveda. Based on signs and symptoms of this disease, it resembles vitiation of Vata dosha originating
from Siro marma (Brain) and producing its symptoms in whole body. Different Ayurvedic physicians
classify this disease based on their own yukti (understanding), but all agree with the fact as this is a
disorder of vitiated Vata dosha or Vata-predominant condition. This is a life long disease and having
no treatment in conventional system. All the above studies have shown effectiveness of Ayurvedic
Panchkarma based procedures in relieving the signs and symptoms and reducing the disabilities in
children with CP. There is no adverse effect of internal medication as well as Panchkarma procedure
is reported in above studies which depict safety of management protocol. Early intervention with
Ayurvedic Panchkarma based procedures in the management of CP can produce better outcome, results
of ayurvedic management depend upon the age of patient at the time of intervention. There is a need of
standardising treatment protocol of CP in Ayurveda, which is cost effective, easily available, producing
good results. In the above studies many permutation and combination of Panchkarma procedures were
tried and almost all are showing more or less similar results, in majority of studies use of Udwartana,
Sarvanga Abhyanga, Sarvanga Swedana, and Basti along with internal medication are seen and these
combinations have shown good response, the protocol of management of CP is cost effective, easy to
prepare, easy to administer, easily available, producing good result, and Indian parents are much aware
of this procedures, currently in many ayurvedic hospital this protocol is followed so this can be
considered as a holistic management protocol of CP in Ayurveda. There is no study on CP other than
spactic one, so there is a need to conduct more clinical trials in other type of CP. Conditions like mental
retardation, ophthalmologic defects, hearing impairments, and speech and language disorders occurring
in CP are not addressed in these studies so more study is needed for efficacy of Ayurveda treatment.
Some Panchkarma procedures are not explored in CP such as Nasya (Nasal medication), Shirodhara
(Pouring medication over head), Shiroabhyanga (Head massage), Shiropichu so there is need to explore
these procedures as these directly act on siro marma (Brain). It can be concluded that medicine along

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with Panchkarma procedure having better effect then internal medicine alone. Where there is no
treatment of this condition in conventional system, Ayurveda can fill this gap.

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