Kampavata/ Vepathu (Parkinson's disease)

Introduction

Parkinson's disease is a degenerative disorder. This is one of the most common extra-pyramidal crippling disease affecting the older adults. It is a syndrome consisting of classical triad of resting tremor, bradykinesia and rigidity7. This triad does not include the equally important gait and postural stability problems which also constitutes the syndrome. It is a disease of elderly and its prevalence increases from 1% in people over the age of 65 years to 5% in people over the age of 80 years and affects men and women equally8. The disease has insidious onset and is slowly progressive leading to severe morbidity in advanced age. A disease condition 'vepathu' described in Ayurveda may be correlated with Parkinson's disease. Generalized involuntary movements of all parts of the body or of the head only, is known as vepathu. It is caused by vitiated vata. So 'vatahara' treatment should be given to these patients.

Aetiology

Although aetiology of the disease is not well known but the following factors contribute in the pathogenesis of this disease

1. Genetic factors

2. Accelerated ageing

3. Environmental toxins (methyl-phenyl tetra hydro pyridine- MPTP) and other toxins (manganese, carbon monoxide and methanol)

4. Increased free radical and iron content in the Substantia Nigra

5. Drugs - Reserpine, Ethanol, Lithium, Diltiazem etc.

6. Neurodegenerative disorders such as multi system atrophy, Alzheimer's disease

7. Post infections (viral encephalitis etc.)

8. Brain tumor

9. Repeated head injury (as in boxing)

Pathogenesis

Parkinsonism is caused by degeneration of pigmented neurons (Dopaminergic neuron) in the zona compacta of substantia nigra, resulting decrease of dopamine levels in the brain which leads to motor dysfunctions viz. resting tremor, bradykinesia and rigidity.

Clinical features

1. Resting tremor

2. Bradykinesia

3. Rigidity

4. Stooped posture

5. Masked face

6. Pill rolling movements

7. Lack of postural adjustment

8. Festinating gait

9. Drooping of saliva due to infrequent swallowing movements

10. Monotonous soft voice

11. Absence of arm swing while walking

12. Aches and pain in body

Complications

1. Frequent falls

2. Incapacitation

3. Depressions and dementia

4. Postural hypotension

5. Urinary incontinence

6. Constipation

7. Aspiration

Investigations

There are no confirmatory tests available, diagnosis is commonly made on clinical grounds.The following investigations may help in the diagnosis.

1. CT Scan

2. MRI Scan

3. Positron-Emission Tomography (PET)

4. Levadopa drug challenge test

Differential Diagnosis

1. Drug induced Parkinson

2. Depression

3. Essential tremor

4. Normal pressure hydrocephalous

5. Cerebral hypoxia

6. Carbon monoxide poisoning

Management approaches

a. Preventive

1. Use shali (old rice), godhuma (wheat), citrus fruit, vegetable, nuts, milk and milk products, dadima (pomegranate), nimbu (lemon), mango, orange, guava, apple,peach, garlic, asafoetida, sprout etc.

2. Practice regular aerobic exercises

3. Take balance diet

4. Consume anti-psychotics or any other medication under close supervision of doctor

5. Be as active as possible

6. Avoid yava (barley), peas, puga (areca nut), jambu (jamun), excess protein diet, hot spicy food and incompatible food article.

b. Medical management

Line of treatment

1. Nidana parivarjana (avoidance of aetiological factors) - Modifiable causative

factors like environmental toxins, drugs, head injuries, infections should be avoided.

2. Shodhana chikitsa (Bio-cleansing therapies) followed by shamana chikitsa

(Palliative therapy) should be advocated.

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

• Maha narayana taila

• Kshrabala Taila

• Sahacharadi taila

• Dhanvantara taila

• Mahamasha taila

• Bala taila

• Ashvagandha taila

ii. Sarvanga sveda (Steam bath) / Patrapinda sveda for 3-7 days

iii. Matra Vasti with Sahacharadi taila 50 ml with Saindhava lavana (Q.S.) and Satapushpa (Q.S.) daily for 15-21 days

iv. Nasya karma/ Brinhna nasya with Purana ghrita (old Cow’s ghee)/ Narayana taila /Ksheera bala taila 8-8 drops in both nostrils for 7 days

v. Shirovasti with medicated oils (Ksheerabala taila, Mahamasha taila, Maha narayana taila, Brahmi taila daily 45 minutes for 7 days

vi. Shirodhara with medicated liquids (milk/water)/ oils (Ksheerabala taila, Mahamasha taila, Maha narayanaa taila, Brahmi taila) daily 45 minutes for 7 days.

3. Drug therapy

SINGLE MEDICINAL PLANTS

Drug	Dosage (per dose)	Vehicle	Duration
Ashvagandha (Withania somnifera Dunal)Powder	3-5 gm	Milk	15 days
Kappikacchu bija (Mucuna (pruriens Linn.) Powder/Paste	5-10 gm	After meal with milk	15 days
Parasika yavani /Khurasani Ajwain(Hyoscyamus niger L.)Powder	1-3 gm	Warm water	15 days
Bal! (Sida cordifolia Linn.)Root Powder	5 gm Milk	Milk	15 days
Rasona (Allium sativum Linn.) Ksheera paka	30-50ml	Water/ milk	15 days
Brahmi (Bacopa monnieri Linn.) svarasa	5-10 ml	Water	15 days

FORMULATIONS

Drug	Dosage (per dose)	Vehicle	Duration
Dashamula kvatha	10-20ml	Water	15 days
Brahmi vati	250-500mg	Water	15 days
Simhanada guggulu	1-1.5 gm	Warm water	15 days
Vatari guggulu	1-1.5 gm	Warm water	15 days
Koμncha beeja paka	5-10 gm	Milk/ water	15 days
Brahma rasayana	10 gm	milk	15 days
Balarishta	12-24 ml	Wate	15 days
Ashvagndharishta	12-24 ml	Water	15 days
Dashamularishta	12-24 ml	Water	15 days
Kshirabala taila	External use		15 days
Mahamasha taila	External use		15 days
Maha narayana taila	External use		15 days
Sahacharadi taila	External use		15 days
Brahmi taila	External use		15 days
Dhanvantara taila	External use		15 days
Chaturbhuja rasa	125-250 mg	Triphala kvatha/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.

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

1. Practice of Pranayama (Anuloma viloma, Nadi shuddhi, Bhramari) and meditation along with the practice of Yama and Niyama

2. Asanas to correct the postural imbalances, weight bearing postures to manage the tremors

3. Deep relaxation technique and Yoga Nidra

Counselling - Advice/ inform the patient to

1. The nature of illness

2. Maintain good physical and mental health

3. Practice exercise regularly

4. Be active

5. Take diet rich in fibers, antioxidants and vitamins

6. Limit protein intake

7. Limit intake of manganese and Vitamin B

8. Avoid stress and anxiety