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{{#seo:
|title=Pakshaghata
|titlemode=append
|keywords=Pakshaghata, hemiplegia, Charak samhita, carakasamhitaonline, Indian System of Medicine, Ayurveda, treatment of hemiplegia
|description=The conditon in which ama alomg with vitiated vata effects the joints
|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg
|image_alt=carak samhita
|type=article
}}
{{Infobox
|title = Contributors
|label1 = Section/Chapter/topic
|data1 = Concepts & Contemporary Practices/[[Diseases]]/[[Pakshaghata]]
|label2 = Authors
|data2 = Adarsh P. M. <sup>1</sup>, Deole Y.S. <sup>2</sup>
|label3 = Reviewer & Editor
|data3 = Basisht G.<sup>3</sup>
|label4 = Affiliations
|data4 = <sup>1</sup> [[Charak Samhita Research, Training and Development Centre]], I.T.R.A., Jamnagar, India
<sup>2</sup> Department of Kayachikitsa, G. J. Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India
<sup>3</sup> Rheumatologist, Orlando, Florida, U.S.A.
|label6 = Correspondence emails
|data6 =dryogeshdeole@gmail.com, carakasamhita@gmail.com
|label7 = Publisher
|data7 = [[Charak Samhita Research, Training and Development Centre]], I.T.R.A., Jamnagar, India
|label8 = Date of publication:
|data8 =October 10, 2023
|label9 = DOI
|data9 = In process
<p style='text-align:justify;'>}}Hemiplegia (paralysis or hemiparesis) is known as ‘pakshaghata’ or ‘pakshavadha’ in ([[Ayurveda]]). It is classified under 80 diseases due to the vitiation of ([[vata dosha]]) (nanatmaja [[Vatavyadhi Chikitsa|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 [[Vata dosha|vata]]<nowiki/>nulomana (proper elimination of flatus, faeces, urine etc., by proper functioning of [[vayu]] and balya (which provides strength) forms of medications.
'''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]<ref name=":0">Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy; 2000.</ref>
*Injury to vital organs ([[marma]]<nowiki/>ghata)
*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]<ref name=":1">Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>
===Dosha specific clinical features===
{| class="wikitable"
|'''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]<ref name=":2">Madhavakara. Madhava Nidanam (Roga vinischaya). Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007</ref>
==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|vata]] dosha by other [[dosha]] or body constituents ([[dhatu]], [[mala]])
These two causes provide a background for pathogenesis of [[Vata dosha|vata]] dominant diseases.
The aggravated [[Vata dosha|vata]] is lodged in vacant spaces or afflicted channels ([[Sroto Vimana|sroto]] vaigunya). Due to obstruction in its path or impaired movement, [[Vata dosha|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|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]<ref name=":0" />
==== Predisposing and contributing factors====
*Food and regimen that aggravate [[Vata dosha|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'''
{| class="wikitable"
|'''Clinical feature'''
|''' Prognosis'''
|-
|Association of [[Kapha dosha|kapha]] and [[Pitta dosha|pitta]] dosha
|Easily curable (sadhya)
|-
|Caused by [[Vata dosha|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 Paricharya|sutika]](puerperal women), kshina (exhausted),
asruksrutha (developed by hemorrhage)
|Pariharya (untreatable)
|}
[Ma. Ni 22/43]<ref name=":2" />
==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 . [D1] 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.<ref>Franziska Herpich, Fred Rincon. Management of Acute Ischemic Stroke. Crit Med. 2020 Nov; 48(11): 1654–1663. doi: 10.1097/CCM.0000000000004597 PMCID: PMC7540624 PMID: 32947473.</ref>
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.<ref>J Aarthi Harini, Avineet Luthra, Shrey Madeka,et al. Ayurvedic Treatment of Acute Ischemic Stroke: A Prospective Observational Study. Glob Adv Health Med. 2019; 8: 2164956119849396. PMCID: PMC7540624 PMID: 32947473.</ref>
'''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|Chikitsa]] Sthana 28/100] [Su.Sa. Chikitsa Sthana 5/19]<ref name=":1" /> [A.Hri. Chikitsa Sthana 21/44]<ref name=":0" />
===Principles of management===
The principles of management of pakshaghata consist of
*[[Vata dosha|Vata]] [[shamana]] (pacification of [[vata dosha]]) by [[Snehana (unction therapy)|snehana]] (therapeutic oleation) and [[swedana]] (therapeutic sudation)
*Vatanulomana (proper functioning of [[Vayu mahabhuta|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:ok===
'''1) [[Snehana (unction therapy)|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 [[Snehadhyaya|sneha]] in pakshaghata. [[Abhyanga]] with anu taila is considered best. [Su.Sa. Chikitsa Sthana 5/19]<ref name=":1" />
'''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 dosha|vata]] [[shamana]] (pacification of [[vata dosha]]) and [[Vata dosha|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 dosha|vata]] shamana (pacification of [[vata dosha]]).
[Su.Sa. Chikitsa Sthana 5/19]<ref name=":1" />
'''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===
'''[[Kashaya|Decoctions:]]'''
Dhanadanayanadi [[Kashaya]] [Sahasrayoga 1/58]<ref name=":3">Dr.K.Nishteswar,Dr.R.Vidyanath. Sahasrayogam.3rd ed. Varanasi: Chowkhamba Krishnadas academy;2011</ref>, Prasarinyadi Kashaya [Sahasrayoga 1/59(1)]<ref name=":3" />, Sahacharadi Kashaya [Sahasrayoga 1/59(2)]<ref name=":3" />, Rasonadi kwatha [Sahasrayoga 1/59(3)]<ref name=":3" /> Gandharvahastadi kwatha [Sahasrayoga 1/59(4)]<ref name=":3" />, Maharasnadi kwatha [Sahasrayoga 1/60]<ref name=":3" />, Balasahacharadi Kashaya. [Sahasrayoga 1/54]<ref name=":3" />
'''Churnas/Herbal powder mixtures'''
Saraswata churna[Sahasrayoga 4/72]<ref name=":3" />, Kolakulatthadi churna [(external application)[Ca.Sa. [[Sutra Sthana]] 3/18]
'''Tablets'''
Yogaraja guggulu [Sahasrayoga 8/3]<ref name=":3" />, Mahayogaraja guggulu [Sharngadhara Samhita. Madhyama khanda 7/56-59]<ref>Sarngadhara.Sarngadhara Samhita.Translated from Sanskrit by K.R Srikantha murthy.Varanasi.Chaukhambha orientalia;2009</ref>, Simhanada guggulu [Bhaishajya ratnavali ,amavata adhikara 130-135]<ref name=":4">Govindadasa.Bhaishajya ratnavali.Hindi commentary by Ambikadattasastri.Edited by Brahmashankar mishra.Varanasi:Chaukhambha prakashan;2011</ref>
'''Ghee/Oil'''
Kalyanaka ghrita [Sahasrayoga 2/81]<ref name=":3" />, Mahakalyanaka ghrita [Sahasrayoga 2/82]<ref name=":3" />, Saraswata ghrita [Sahasrayoga 2/92]<ref name=":3" />, Sarvamayantaka ghrita [Sahasrayoga 2/97]<ref name=":3" />, Dhanwantara taila [Sahasrayoga 3/109]<ref name=":3" />, Narayana taila [Bhaishajya Ratnavali Vatavyadhi 140-150]<ref name=":4" />, Mahanarayana taila [Bhaishajya Ratnavali. Vatavyadhi. 151-162], Ksheerabala taila [Sahasrayoga 3/110]<ref name=":3" />, Prabhanjana vimardana taila [Sahasrayoga 3/7]<ref name=":3" />, Bala-aswagandhadi taila [Sahasrayoga 13/117]<ref name=":3" />, Sahacharadi taila [Sahasrayoga 3/131]<ref name=":3" />, Bala taila [Sahasrayoga 3/68]<ref name=":3" />, Prasarini taila [Sahasrayoga 3/69]<ref name=":3" />, Erandataila [Ca.Sa. [[Sutra Sthana]] 13/12(1)], Gandharvahastadi erandataila [Sahasrayoga 1/59(4)]<ref name=":3" />.
'''Avaleha'''
Kalyana leha [Bhaishajya ratnavali. Swarabheda rogadhikara. 27-29]<ref name=":4" />
'''Ksheerapaka'''
Lasuna ksheerapaka [Ca.Sa. [[Chikitsa Sthana]] 5/94-95], Prasarinyadi ksheera Kashaya [Sahasrayoga 1/59(1)]<ref name=":3" />, Masha athmagupthadi ksheera (nasapana) [Chakradatta. Vatavyadi 27]<ref>Chakrapanidatta. Chakradatta. Edited and translated by Priya vrat sharma.Varanasi:Chaukhambha orientalia.2007</ref>, mashabaladi kwatha [Bhaishajya Ratnavali. Vatavyadhi adhikara 62-63]<ref name=":4" />
==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.<ref>Priyanka Patel (2017): A randomized controlled clinical trial on kalyana leha in the management of post stroke aphasia. Department of Kayachiktsa, Parul Institute of Ayurved, Limda.</ref>
==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.<ref>Pandya Asutosh (2003): A comparative study of Virechana Karma and Sramsana in the management of Pakshaghata.Department of Panchakarma, ITRA, Jamnagar.</ref>
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.<ref>Tripti Lokesh (2013): A comparative study of virechana (snehayukta virechana) & shamana chikitsa in pakshaghata. Department of panchakarma, Govt.Akhandanand Ayurveda college, Ahmedabad.</ref>
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.<ref>Vimal M Vekariya (2008): comparative study of virechana karma and kala basti in the management of pakshaghata. Department of Panchakarma, ITRA, Jamnagar.</ref>
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 improvements in vakstambha, padasankocha, hastakankocha, shula and Cheshta nivritti.<ref>Manasa T. V, Kiran M. Goud, Lolashri S. J. (2019). A clinical study to evaluate the efficacy of rajayapana basti in pakshaghata. IAMJ: Volume 7, Issue 3, March - 2019 (www.iamj.in).</ref>
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.<ref>Dr. Sayeda Nikhat Inamdar, Dr. Prashanth A S, Dr. Rahul kumar. Clinical evaluation of basti and nasya in pakshaghata (hemiplegia). PIJAR/July-August-17/volume 1/Issue-6, ISSN:2456:4354
</ref>
==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 (unction therapy)|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.<ref>Mohan, V., B, D., & Deva, S. (2021). Ayurvedic Management of Pakshaghata (Left Hemiplegia) – A Case study. International Journal of Ayurvedic Medicine, 12(3), 733–741. <nowiki>https://doi.org/10.47552/ijam.v12i3.1954</nowiki></ref>
'''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.<ref>Karthikeya Prasad, Manjusri. (2022). Pakshaghata – A case study. International Journal of Pharmaceutical Research and Applications. Volume 7, Issue 6 Nov-Dec 2022, pp: 687-690 www.ijprajournal.com ISSN: 2456-4494.</ref>
'''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 repored. He was a diagnosed case of stroke based on clinical presentation and brain computed tomography-scan. In the case, [[Ayurveda]] medications were found to be effective in providing relief in chief complaint with improvement of overall health of the patient. Treatment protocol was [[Snehana (unction therapy)|snehana]], [[swedana]], mridu [[virechana]], [[basti]] karma, murdhni taila ([[shirodhara]]) along with internal medication which is mentioned by Acharya Sushruta.<ref>Santhosh kumar Bhatted, Uttamram Yadav. (2020). Treatment Protocol of Stroke (Pakshaghata) Through Ayurveda Medicine -A Case Study. International Journal of Health Sciences and Research. Vol.10; Issue: 1; January 2020 Website: www.ijhsr.org Case Study ISSN: 2249-9571.</ref>
<references/>