Pakshaghata (Hemiplegia)

Introduction

Hemiplegia is the commonest manifestation of a 'stroke' with neurological deficit affecting the face, limbs and trunk on one side or either side of the body. Impulses for voluntary movement are transmitted by the pyramidal tracts or upper motor neurons. Damage to these pyramidal tracts due to any lesion, trauma, ischemia or hemorrhage produces paralysis. In Ayurveda, it can be correlated with 'Pakshaghata'. When Vata getting aggravated, dries up the

Srotas and Snayu (tendons) of one side (half) of the body, makes the organ/ parts of that side incapable of functioning and loss of sensation.

Aetiology

1. Cerebro-vascular accidents (Stroke)

i. Cerebral hemorrhage

ii. Sub - arachnoid hemorrhage

iii. Cerebral thrombosis

iv. Internal carotid artery thrombosis or stenosis

v. Cerebral embolism

vi. Venous sinus thrombosis

2. Hypertensive encephalopathy

3. Cerebral tumors

4. Acute encephalitis

Pathogenesis

Damage to the pyramidal tracts produces impairment or loss of voluntary movement from interruption of the conduction of motor impulses.

Risk factors

1. Age

2. Sex

3. Hypertension

4. Diabetes mellitus

5. Smoking, Alcohol abuse

6. Obesity

7. Hyperlipidemia

Clinical features

1. Unilateral loss of voluntary power in the affected arm, leg and in the lower face

2. Clasp-knife type spasticity

3. Tongue is protruded towards the paralysed side (in facial palsy)

4. Upper limb flexed at the elbow and wrist forearm slightly pronated

5. Movement of the hand and fingers are more affected than those of upper arm

Investigation

1. Haemogram

2. Lipid profile

3. C T Scan /MRI

4. Doppler studies of the Neck

5. CSF examination

6. X - Ray Spine

7. ECG.

Management approaches

a. Prevention

1. Add masha (black gram), kulattha (horse gram), palandu(onion), rasona (garlic),

Shunthi/Ardraka (ginger), mulaka (radish), kushmanda (ash gourd), mudga (green

gram) in regular diet

2. Use fruits like dadima (pomegranate),Amra (mango), draksha (grape) etc.

3. Consume low fat and high fiber diet and Rasayana drugs

4. Control the treatable risk factors like diabetes mellitus, hypertension, heart diseases

5. Take neccessry treatment of hypertension (if any)

6. Control cholesterol level and weight

7. Practice regular exercises

8. Avoid excessive use of pungent, astringent and/ or salty, oily/ fatty food and

incompatible diet, chana (bengal gram), peas, barley etc.

9. Avoid excessive starvation, excess exercises, suppressing of natural urges and

awakening in the nights

10. Avoid alcohol consumption, smoking

11. Avoid discontinuation of any regular medication without medical advise

b. Medical management

Line of treatment (Charaka. Chikitsa sthana. 28/100)

1. Nidana parivarjana (avoidance of aetiological factors) - Management of treatable risk factors and diseases like hypertension, acute encephalitis, heart disease etc. and avoid trauma.

2. Samshodhana chikitsa - (Bio-cleansing therapies) followed by aamana chikitsa

(Palliative therapy) should be advocated.

i. Snehana (Oleation): massage with medicated oils such as

• Maha narayana taila

• Sahacharadi taila

• Dhanvantara taila

• Karpasasthyadi taila

• Prabhanjana vimardana taila

• Kshirabala taila

• Mahamsha taila

• Bala taila

ii. Svedana (Medicated fomentation)

•Shashtika shali panda sveda (made from shashtika shali(Navara Rice), Bala mula, Ashvagandha mula and milk)/Patra pind sweda for 7-14 days

• Sarvanga sveda for 7 - 14 days

iii. Virechana (Purgation) Decoction of the following is helpful with decoctions of (a) Draksha (Vitis vinifera) - 10 gm,

(b)Aragvadha Phala Majja(Cassia fistula Fruit Rind) - 10gm

(d) Katuki (Picrorhiza kurroa) - 5 gm along withEranda (Ricinus communis) taila – 1 teaspoon. Or Eranda taila(Caster oil) 10 - 20 ml with half glass of milk at nighti

iv. Vasti (medicated enema) • Matra vasti with Narayana taila 50 ml daily for 7 - 14 days

• Kashaya vasti for 15 days (Kala vasti krama) Eranda mula kvatha - 480 ml,Taila - 240 ml,Honey - 240 ml, Kalka - 30 gm,Saindhava lavana - 15 gm

• Kshira vasti 350 - 500 ml for 7 - 14 days

v. Nasya karma/ Brinhana nasya with Purana ghrita (old ghee) / Narayana taila /Ksheera bala taila 8-8 drops in both nostrils for 7 days

vi. Shirovasti with medicated oils (Narayana taila / Ksheera bala taila / Chandana bala lakshadi taila) daily 45 minutes for 7 days

vii. shirodhara with medicated liquids (Narayana taila / Ksheera bala taila / Chandana bala lakshadi taila / decoctions etc.) daily 45 minutes for 21 days

(above said formulations are common in practice but dose should be adjusted by the physician according to patient's condition).

3. Drug Therapy - All therapeutic measures may be started after crossing the acute phase of attack.

SINGLE MEDICINAL PLANTS

Drug	Dosage (per dose)	Vehicle	Duration
Ashvagandha (Withania somnifera Dunal) Powder	3-5 gm	Milk	15 days
Brahmi (Bacopa monnieri Linn.) svarasa	5-10 ml	Water	15 days
Rasona (Allium sativum Linn.) kshira paka	5-10 ml	Water/ milk	15 days
Eranda (Ricinus communis Linn.) taila	5-10 ml	Milk	3 days

FORMULATIONS

Drug	Dosage (per dose)	Vehicle	Duration
Gandharva hastadi kvatha	10-20 ml	Water	15 days
Sahacharadi kvatha	10-20 ml	Water	15 days
Maharasnadi kvatha	10-20 ml	Water	15 days
Brahmi vati	125-250mg	Water	15 days
Manasa mitra vataka	125 mg	Rasnasaptaka kvatha	15 days
Vatari guggulu	1-1.5 gm	Warm water	15 days
Trayodashanga guggulu	1-1.5 gm	Warm water	15 days
Balarishta	10-20 ml	Water	15 days
Ashvagandharishta	15-30 ml	Water	15 days
Hingutriguna taila	5 ml	Lukewarm water	15 days
Chandana bala lakshadi taila	external use		15 days
Kshirabala taila	external use		15 days
Mahamasha taila	external use		15 days
Maha narayana taila	external use		15 days
Narayana taila	external use		15 days
Sahacharadi taila	external use		15 days
Dhanvantara taila	external use		15 days
Karpasasthyadi taila	external use		15 days
Prabhanjana vimardana Taila	external use		15 days
Vatagajankusha rasa	125-250 mg	Honey	15 days
Vatakul!ntaka rasa	125-250 mg	Honey	15 days
Rasaraja rasa	65 - 125 mg	Honey	15 days
Yogendra rasa	125-250 mg	Rasona svarasa and honey	15 days
Brihatvata chintamaanii rasa	125-250 mg	Honey	15 days
Ekangavira rasa	125-250 mg	Honey	15 days

Initially 2 times in a day after meal for 15 days followed by condition of patient and physician's direction.

NOTE: Out of the drugs mentioned above any one of the drug or in the combination may be prescribed by the physician.The duration of the treatment may vary from patient to patient. Physician should decide the dosage (per dose) and duration of the therapy based on the clinical findings and response to therapy.

Names of the medicines ending with the word Rasa may be taken with caution and of slandered manufacturing quality under the guidance of qualified Ayurveda physician only as they contain mercury and may not be free from side effects

c. Yogic practices - The following yogic practices are beneficial in Hemiplegia; however, these should be performed only under the guidance of qualified Yoga therapist.Duration should also be decided by the Yoga therapist.

1. Practice of Pranayama (Anuloma Viloma, Nadi shodhana, Bhramari and meditation alongwith the practice of Yama and Niyama

2. Deep relaxation technique, Yoga nidra

3. Asanas to correct the postural imbalances

Counselling - Advise the patient to -

1. Be active and optimum use of affected part

2. Grasp the spastic arm at wrist with unaffected arm and push it above head regularly (10-15 times at each time) for atleast 3-4 times a day

3. Continue exercises as suggested by the physiotherapist

4. To increase the practice of exercise gradually

5. Take balanced diet

6. Maintain healthy body weight

7. Limit salt intake and fat in diet

8. Control of hypertension and diabetes mellitus

9. Check lipid profile periodically

10. Avoid over exertion

11. Avoid smoking and alcohol consumption

Indications for referral

1. Further deterioration

2. Patient with head injury and requires surgical intervention.

3. Not responding to medication

The other neurological conditions like monoplegia (paralysis of one limb), paraplegia(paralysis of both lower limbs) and quadriplegia (paralysis of all four limbs) are also to be managed in the similar manner.

Reference

AYURVEDIC MANAGEMENT OF SELECT GERIATRIC DISEASE CONDITIONS

CENTRAL COUNCIL FOR RESEARCH IN AYURVEDA AND SIDDHA

Department of AYUSH, Ministry of Health & Family Welfare

Government of India, New Delhi - 110 058 2011