Pakshaghata

Hemiplegia (paralysis or hemiparesis) is known as ‘pakshaghata’ or ‘pakshavadha’ in (Ayurveda). It is classified under 80 diseases due only to the vitiation of (vata dosha) (nanatmaja vata vyadhi). There is complete or partial paralysis of the arm, leg, and trunk on one side of the body. The most typical cause of hemiplegia is cerebrovascular stroke. A stroke affecting the corticospinal tract results in hemiplegia. Other causes are trauma, diabetes, infections affecting the nervous system, neoplasms, demyelination disorders, congenital disorders, multiple sclerosis, parasomnia etc. As per Ayurveda pathophysiology, the vitiated vata dosha afflicts half of the body by causing desiccation of nerves or blood vessels (sira) and muscles or tendons (snayu). It finally results in the signs and symptoms of pakshaghata. [Cha.Sa. Chikitsa Sthana 53-55] Rehabilitation is the primary treatment of hemiplegia to regain maximum function and quality of life. It includes both physical and occupational therapy. Ayurvedic management is vatahara (pacification of vata dosha) in nature. It can improve motor functions by vatanulomana (proper elimination of flatus, faeces, urine etc., by proper functioning of vayu) and balya (which provides strength) forms of medications.

Contributors

Section/Chapter/topic	Concepts & Contemporary Practices/Diseases/Pakshaghata
Authors	Adarsh P. M. 1, Deole Y.S. 2
Reviewer & Editor	Basisht G.3
Affiliations	1 Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India 2 Department of Kayachikitsa, G. J. Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India 3 Rheumatologist, Orlando, Florida, U.S.A.
Correspondence emails	dryogeshdeole@gmail.com, carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of publication:	October 10, 2023
DOI	In process

National Ayurveda Morbidity code: AAC-24

ICD code for: G81.90

Causes (hetu)

Aggravating factors of (vata dosha) lead to hemiplegia. These include following:

• Excessive intake of (tikta) (bitter), (katu) (pungent) and (kashaya) (astringent) tastes.

• Consuming insufficient quantity of food

• Excess intake of food items having dry quality.

• Late-time food consumption

• Suppression and provocation of natural urges.

• Avoidance of sleep at night

• Excess talking in a loud tone

• Excessive application of purificatory therapies

• Fear, grief, excessive thinking

• Excess exercise and sexual intercourse beyond one’s capacity. [A. Hri.Nidana Sthana 1/14-15]

• Injury to vital organs (marmaghata)

• Untreated chronic inflammations or infections

Clinical features

General clinical features

• Loss of motor function and pain on either side of the body (right or left)

• Slurring or loss of speech

• Contractions (spasticity) on the legs and hands on either side.

• Pricking pain or sharp pain in the body. [Cha.Sa. (Chikitsa Sthana) 28/53-55]

• Loss of activity (akarmanyata), and loss of sensation (achetana) of the affected side. [Su.Sa. Nidana Sthana 1/60-62]

Dosha specific clinical features

Dosha associated	Clinical features
(Pitta) associated condition	Burning sensation (daha) Increase in body temperature (santapa) Syncope (murcha)
Kapha associated condition	Coldness (shaitya) Swelling ((shotha)) Heaviness (gurutva)

                                                                                         [Ma.Ni.22/42]

Pathogenesis

The vata dosha is aggravated due to two possible pathologies:

1. Depletion of body constituents (dhatu kshaya)

2. Obstruction or covering of vata dosha by other dosha or body constituents (dhatu, mala)

These two causes provide a background for pathogenesis of vata dominant diseases.

The aggravated vata is lodged in vacant spaces or afflicted channels (sroto vaigunya). Due to obstruction in its path or impaired movement, vata dosha affects the indriya (sensory and motor organs) and leads to affliction of either side of the body. It also causes the desiccation of siras (nerves) and snayus (tendons), producing contractions of legs and hands on either side. [Cha.Sa. Chikitsa Sthana 28/43-45]

The different pathologies like arteriosclerosis, aneurysms, and plaque formation in cerebrovascular system need to be understood in this view. These pathologies result in cerebrovascular accident, causing hemiplegia or hemiparesis (pakshaghata). [A. Hri.Nidana Sthana 15/5-6]

Predisposing and contributing factors

• Food and regimen that aggravate vata dosha.

• Excess use of amla (sour substances) and lavana (salt)

• Increased serum cholesterol levels

• Uncontrolled hypertension and diabetes mellitus

• Improper management of infections and inflammation (ama sandharana)

• Unhealthy sleeping habits

• Stress, emotional disturbances, and obstruction of natural urges.

• Consumption of cold food and beverages.

Clinical diagnosis

• Review of past medical history

• Neurological examination.

• Imaging technique ( computerized tomography scan & magnetic resonance imaging )

• electroencephalogram

• Blood tests (complete blood count, Erythrocyte sedimentation rate, hemoglobin level, platelet count etc.)[D1]

• Based on clinical features of disease in Ayurveda as mentioned earlier

Biomarkers for diagnosis and assessment of efficacy

Diffusion tensor imaging (DTI), diffusion-weighted imaging (DWI), T1-weighted MRI, T2 weighted MRI are biomarkers used to measure the structure or injury, whereas Electroencephalography (EEG), functional magnetic resonance imaging (fMRI), Magnetoencephalography (MEG), Positron emission tomography (PET), Transcranial magnetic stimulation (TMS) etc. are biomarkers used to measure the function.

Prognosis

                         Table 2: Prognosis

Clinical feature	Prognosis
Association of kapha and pitta dosha	Easily curable (sadhya)
Caused by vata dosha only (kevalavata)	Most difficult to cure (krichrasadhyatama)
Developed by depletion at tissue level (dhatukshaya kruta)	Treatable but not curable (asadhya)
Vedanarahita (absence of pain)	Pariharya (untreatable)
In bala (children), vridha (old age), garbhini (pregnant women), sutika(puerperal women), kshina (exhausted), asruksrutha (developed by hemorrhage)	Pariharya (untreatable)

[Ma. Ni 22/43]

Management

Stagewise management of disease

Ⅰ. Acute condition

Treatment of acute ischemic stroke (AIS) consists of a multidisciplinary approach. Early detection and early intervention can reduce the severity of neural damage. Therapies to arrest intracerebral hemorrhage and reversal of anticoagulation shall be initiated as early as possible. Neurological Institutes of Health stroke scale and several other scales are used to assess stroke severity. Arterial occlusion evaluation scale can be used to measure the degree of occlusion of large blood vessels. Neuro imaging using non contrast CT can be done. Non contrast CT scan can be used to find the Alberta Stroke Program Early CT Score (ASPECTS) which is designed to assess the severity of infarct in middle cerebral artery. CT angiography can also provide useful information about large vessel occlusion.

Revascularization and limitation of neuronal injury are the next steps in acute ischemic stroke management. IV thrombolysis is used for the removal of clots, and endovascular therapy is used for revascularization. Supplementation of oxygen is required if oxygen saturation drops down to 94%. Current AHA/ASA guidelines recommends permissive hypertension with a blood pressure goal of less than or equal to 220/120mg Hg for the first 24-48 hours, until or unless acute interventions such as intravascular tissue plasminogen activator administration or endovascular interventions are administered. Anti-hypertensives should be administered only beyond this level to prevent hemorrhage. Glycemic control must be at 140-180 mg/dl and monitored frequently to avoid hypoglycemia, which may worsen the outcomes. Managing cerebral edema associated with large infarcts in the middle cerebral and internal carotid arteries is very important as it can enhance neurologic deterioration. Decompressive hemicraniectomy must be done to manage raised intracranial pressure.

Early rehabilitation is also thought to have better outcomes in stroke patients. The etiology of stroke must be understood to take steps for secondary prevention. Antiplatelet therapy is a well-known and established way to prevent stroke and transient ischemic attacks. Statins, the drugs for dyslipidemia, are also used to seize the atherosclerotic progress.

An observational study prospectively comparing outcomes in 2 cohorts of AIS patients treated with whole-system classical Ayurveda (n = 13) or conservative (nonthrombolytic, noninterventional) western biomedicine (n = 20) has shown similarity in safety profiles of classical Ayurveda and conservative western biomedicine in AIS.

Ⅱ.Chronic condition

Multidisciplinary rehabilitation and the drugs for secondary prevention come under the management of post-stroke patients. Physiotherapy, modified constraint-induced movement therapy, and the use of various assistive devices such as brace chains. Wheelchairs and walkers are advised for the improvement of motor function, cognition, speech, and quality of life. Mental imagery and electrical stimulation for the movement of muscles are also combined with the above. Ayurvedic management can be done at this stage. A systemic approach in the management of pakshaghata is explained in classical textbooks. [Cha.Sa. Chikitsa Sthana 28/100] [Su.Sa. Chikitsa Sthana 5/19] [A.Hri. Chikitsa Sthana 21/44]

Principles of management

The principles of management of pakshaghata consist of

• Vata shamana (pacification of vata dosha) by snehana (therapeutic oleation) and swedana (therapeutic sudation)

• Vatanulomana (proper functioning of vayu) by mridu samshodhana (Therapeutic purgation using drugs with mild potency) or avarana dosha shamana (pacification of dosha causing occlusion) by snigdha virechana (therapeutic purgation using unctuous drugs)

• Balya (strengthening) and regenerative therapies (rasayana) by therapeutic enemas.

Therapies advised in pakshaghata

1) Snehana (therapeutic oleation):

Snehana is administered externally as well as internally. Internal can be used for shamana (pacification) and shodhana (purification) purpose,whereas external application is used only for shamana (pacification) purpose. Shirobasti (keeping oil on head) and abhyanga (therapeutic massage) are the most commonly used external unctuous therapies in pakshaghata. Abhyanga with anu taila is considered best. [Su.Sa. Chikitsa Sthana 5/19]

2)Swedana (therapeutic sudation):

Swedana can be used for pacification and purification purpose. Salvana upanaha sweda (poultice) and bashpa sweda are commonly advised in pakshaghata.

3)Virechana (therapeutic purgation):

Virechana is the principal purificatory procedure mentioned in pakshaghata management. Virechana with unctuous drug is especially mentioned in classics because vata shamana (pacification of vata dosha) and vatanulomana (proper functioning of vayu).

4)Anuvasana basti (therapeutic unctuous enema):

Anuvasana with bala taila is indicated in pakshaghata. Anuvasana basti can pacify vata dosha to rejuvenate the tissues may be helpful.

5)Asthapana basti (therapeutic decoction enema):

Asthapana basti can be administered when shodhana (purification) is required prior to vata shamana (pacification of vata dosha).

[Su.Sa. Chikitsa Sthana 5/19]

6)Nasya (nasal medication): Ksheera bala taila avartita, Dhanwantara taila avartita are used for nasal administration. Nasya provides effect on the space occupying lesion. Research is required to generate evidence on the same.

Currently used important herbal formulations

Decoctions:

Dhanadanayanadi Kashaya [Sahasrayoga 1/58], Prasarinyadi Kashaya [Sahasrayoga 1/59(1)], Sahacharadi Kashaya [Sahasrayoga 1/59(2)], Rasonadi kwatha [Sahasrayoga 1/59(3)] Gandharvahastadi kwatha [Sahasrayoga 1/59(4)], Maharasnadi kwatha [Sahasrayoga 1/60], Balasahacharadi Kashaya. [Sahasrayoga 1/54]

Churnas/Herbal powder mixtures

Saraswata churna[Sahasrayoga 4/72], Kolakulatthadi churna [(external application)[Ca.Sa. Sutra Sthana 3/18]

Tablets

Yogaraja guggulu [Sahasrayoga 8/3], Mahayogaraja guggulu [Sharngadhara Samhita. Madhyama khanda 7/56-59], Simhanada guggulu [Bhaishajya ratnavali ,amavata adhikara 130-135]

Ghee/Oil

Kalyanaka ghrita [Sahasrayoga 2/81], Mahakalyanaka ghrita [Sahasrayoga 2/82], Saraswata ghrita [Sahasrayoga 2/92], Sarvamayantaka ghrita [Sahasrayoga 2/97], Dhanwantara taila [Sahasrayoga 3/109], Narayana taila [Bhaishajya Ratnavali Vatavyadhi 140-150], Mahanarayana taila [Bhaishajya Ratnavali. Vatavyadhi. 151-162], Ksheerabala taila [Sahasrayoga 3/110], Prabhanjana vimardana taila [Sahasrayoga 3/7], Bala-aswagandhadi taila [Sahasrayoga 13/117], Sahacharadi taila [Sahasrayoga 3/131], Bala taila [Sahasrayoga 3/68], Prasarini taila [Sahasrayoga 3/69], Erandataila [Ca.Sa. Sutra Sthana 13/12(1)], Gandharvahastadi erandataila [Sahasrayoga 1/59(4)].

Avaleha

Kalyana leha [Bhaishajya ratnavali. Swarabheda rogadhikara. 27-29]

Ksheerapaka

Lasuna ksheerapaka [Ca.Sa. Chikitsa Sthana 5/94-95], Prasarinyadi ksheera Kashaya [Sahasrayoga 1/59(1)], Masha athmagupthadi ksheera (nasapana) [Chakradatta. Vatavyadi 27], mashabaladi kwatha [Bhaishajya Ratnavali. Vatavyadhi adhikara 62-63]

Research on Ayurvedic formulations

In a study involving 40 patients afflicted with post stroke aphasia, kalyana leha is found more effective than speech therapy on auditory and verbal comprehension as well as naming.

Research on Ayurvedic treatments

A comparative clinical study was conducted among 31 patients of pakshaghata between virechana group and koshtha shuddhi group. Both of these groups have shown marked to moderate improvements in patients with a better percentage wise improvement in the virechana group.

A comparative study was done between snehayuktha virechana (therapeutic unctuous purgation) followed by shamana (pacification therapy) using ekangaveer rasa and shamana alone. Using Ekangaveer rasa among 30 patients of pakshaghata, it is evident that virechana followed by shamana is far more effective than shamana only in all aspects.

A comparative clinical trial for comparing the effect of kala basti and virechana in pakshaghata was conducted in 25 patients. Kala basti group has shown better improvement in outcomes compared to the virechana group.

In a clinical study involving 10 patients of pakshaghata, the treatments like abhyanga, sarvanga shashtikashali pinda sweda and rajayapana basti were administered consecutively. It has shown significant improvement in slurred speech, spasticity of upper limb, spasticity of lower limb, pain and lose of movement.

In a comparative clinical study conducted among 40 patients, kalabasti with dasamoola kashaya, yavanyadi kalka, and sahacharadi taila has shown better improvement both in subjective and objective parameters as compared to the group of nasya (nasal medication) with karpasasthyadi taila and group with shamana (pacification) drugs only.

Case reports

1. A case study of 63 years old male patient who has weakness on his left side of body and unable to walk was published. His diagnosis was haemorrhagic stroke presenting with left sided hemiplegia with acute intraparenchymal haemorrhage in C.T. brain. The Ayurvedic diagnosis of pakshaghata was made and managed with treatment principle which is mentioned by Acharya Charak.  Snehana, swedana and mridu virechana along with panchakarma procedures like shirodhara, shiropichu and basti for 21 days. Samshamana aushadhis (oral medicines) and physiotherapy were adopted at various stages of the diseases. Maximum improvement was noticed in upper and lower extremity functions at the end of the treatment. Patient showed remarkable recovery in speech ability and mobility.

2. In a case report of a 77-year-old male patient with complaints of sudden weakness in right side of the body including face, inability to stand, walk, slurring of speech in the past 2 days. The main treatments given are dhanyamladhara, abhyanga, shashtika shali pinda sweda, matra basti, nasya, tailadhara along with shamana aushadhis in the above-mentioned order. The patients’ muscle power, tone, strength improved greatly and deep tendon reflexes regained the normal status. Patient was able to walk without any support at the end of treatment.

3.  A case on management of stroke of a male patient aged 40 years with chief complaints of loss of function of the left upper & lower limb is reported. He was a diagnosed case of stroke based on clinical presentation and computerized tomography scan. Ayurveda medications were found to be effective in providing relief in chief complaints with improvement of overall health of the patient. Treatment protocol was snehana, swedana, mridu virechana, basti karma, murdhni taila (shirodhara) along with internal medication which is mentioned by Acharya Sushruta.