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→Premonitory signs of apasmara
=== Premonitory signs of apasmara ===
=== Premonitory signs of apasmara ===
The table 1 depicts the premonitory signs of apasmara described in the Ayurvedic texts. Each sign has a specific patho-physiology in terms of ''dosha'' and ''dushya'' behind its manifestation. The enlisted signs are the alerting signals or premonitory symptoms of apasmara before the onset of seizures. The probable system involved as per conventional medicine is also enlisted for every sign, so that it would be easier to consider the pathophysiological similarities and differences between the two medical streams.
The table 1 depicts the premonitory signs of apasmara described in the Ayurvedic texts. Each sign has a specific patho-physiology in terms of ''[[dosha]]'' and ''[[dushya]]'' behind its manifestation. The enlisted signs are the alerting signals or premonitory symptoms of apasmara before the onset of seizures. The probable system involved as per conventional medicine is also enlisted for every sign, so that it would be easier to consider the pathophysiological similarities and differences between the two medical streams.
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|-
|-
! Bhrūvyudāsa
! Bhrūvyudāsa
| abnormal / twitching of eyebrows || vata – rajas || majja || nervous system [NS]
| abnormal / twitching of eyebrows || [[vata]] – rajas || majja || nervous system [NS]
|-
|-
! Satatam akshi vaikrutam
! Satatam akshi vaikrutam
| constant abnormal/ irregular movements of eyes || vata – rajas || majja || NS
| constant abnormal/ irregular movements of eyes || [[vata]] – rajas || majja || NS
|-
|-
! Ashabda shravanam
! Ashabda shravanam
| auditory hallucinations || vata –rajas || manas || NS, psychiatric disorder
| auditory hallucinations || [[vata]] –rajas || [[manas]] || NS, psychiatric disorder
|-
|-
! Lala prastrava
! Lala prastrava
| excess secretion of saliva || kapha || rasa || NS, digestive system[DS]
| excess secretion of saliva || [[kapha]] || [[rasa]] || NS, digestive system[DS]
|-
|-
! Singhanaka prastrava
! Singhanaka prastrava
| excess nasal mucus discharge || kapha || rasa ||NS, respiratory system
| excess nasal mucus discharge || [[kapha]] || [[rasa]] ||NS, respiratory system
|-
|-
! Anannabhilashanam
! Anannabhilashanam
| lack of appetite || kapha- Pitta || rasa || DS, NS
| lack of appetite || [[kapha]]- [[Pitta]] || [[rasa]] || DS, NS
|-
|-
! Arochaka
! Arochaka
| aversion to food and drinks [anorexia] || Kapha –pitta –vata || rasa || DS, Psychiatric disorder
| aversion to food and drinks [anorexia] || [[Kapha]] –[[pitta]] –[[vata]] || [[rasa]] || DS, Psychiatric disorder
|-
|-
! Avipaka
! Avipaka
| indigestion || pitta || rasa || DS, NS
| indigestion || [[pitta]] || [[rasa]] || DS, NS
|-
|-
! Hridaya graham
! Hridaya graham
| heavyness of precordium/ congestion/ constriction in cardiac region || kapha, vata || mamsa,majja || NS, musculo skeletal system,
| heavyness of precordium/ congestion/ constriction in cardiac region || [[kapha]], [[vata]] || [[mamsa]],[[majja]] || NS, musculo skeletal system,
|-
|-
! Kukshe aatopa
! Kukshe aatopa
| puffiness/ swelling in the hypogastric region || vata, kapha || rasa, purisha, mutra || DS, urinary system
| puffiness/ swelling in the hypogastric region || [[vata]], [[kapha]] || [[rasa]], [[purisha]], [[mutra]] || DS, urinary system
|-
|-
! Daurbalyam
! Daurbalyam
| debility, loss of strength || kapha, vata || rasa, mamsa, majja || NS, musculoskeletal system
| debility, loss of strength || [[kapha]], [[vata]] || [[rasa]], [[mamsa]], [[majja]] || NS, musculoskeletal system
|-
|-
! Asthibheda
! Asthibheda
| splitting / breaking [pain] sensation in bones || vata || asthi, majja || skeletal system
| splitting / breaking [pain] sensation in bones || [[vata]] || [[asthi]], [[majja]] || skeletal system
|-
|-
! Angamarda
! Angamarda
| generalized bodyache/ twisting/churning pain in body || vata || mamsa, majja || musculo-skeletal system, NS
| generalized bodyache/ twisting/churning pain in body || [[vata]] || [[mamsa]], [[majja]] || musculo-skeletal system, NS
|-
|-
! Moha
! Moha
| confused state of mind [leading to lack of knowledge] || vata, kapha, Tama || rasa, majja || NS, psychiatric disorder
| confused state of mind [leading to lack of knowledge] || [[vata]], [[kapha]], Tama || [[rasa]], [[majja]] || NS, psychiatric disorder
|-
|-
! Tamas darshanam
! Tamas darshanam
| black outs / temporary loss of vision without alteration in consciousness || pitta, vata || rasa- rakta-majja || cardio-vascular/ cerebro vascular system, NS
| black outs / temporary loss of vision without alteration in consciousness || [[pitta]], [[vata]] || [[rasa]]- [[rakta]]-[[majja]] || cardio-vascular/ cerebro vascular system, NS
|-
|-
! Murchcha
! Murchcha
| syncope / a fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood || pitta, kapha || rasa, rakta, majja || cardio-vascular/ cerebro vascular system, NS
| syncope / a fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood || [[pitta]], [[kapha]] || [[rasa]], [[rakta]], [[majja]] || cardio-vascular/ cerebro vascular system, NS
|-
|-
! Abhikshnam Bhrama
! Abhikshnam Bhrama
| frequent vertigo/ dizziness || pitta, vata, rajas || rasa, rakta, rajas || cardio-vascular/ cerebro vascular system, NS, psychiatric disorder
| frequent vertigo/ dizziness || [[pitta]], [[vata]], rajas || [[rasa]], [[rakta]], rajas || cardio-vascular/ cerebro vascular system, NS, psychiatric disorder
|-
|-
! Swapne cha || ! colspan="4" | In dreams
! Swapne cha || ! colspan="4" | In dreams
|-
|-
! Mada
! Mada
| slight intoxication, becoming out of senses showing uncanny or abnormal behaviour || rowspan="6" | vata, rajas, kapha || rasa, rakta, manas || rowspan="6" | Cardio-vascular/ Cerebro vascular system, NS, psychiatric disorder
| slight intoxication, becoming out of senses showing uncanny or abnormal behaviour || rowspan="6" | [[vata]], rajas, [[kapha]] || [[rasa]], [[rakta]], [[manas]] || rowspan="6" | Cardio-vascular/ Cerebro vascular system, NS, psychiatric disorder
|-
|-
! Nartana
! Nartana
| dancing || majja
| dancing || [[majja]]
|-
|-
! Vyadhana
! Vyadhana
| needling like sensation || majja
| needling like sensation || [[majja]]
|-
|-
! Vyathana
! Vyathana
| pain || majja
| pain || [[majja]]
|-
|-
! Vepana
! Vepana
| tremors || majja
| tremors || [[majja]]
|-
|-
! Patanadini
! Patanadini
| falling etc. || rasa-rakta,
| falling etc. || [[rasa]]-[[rakta]],
majja
majja
|-
|-
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The abovementioned pre-clinical features are observed in the fourth stage of ''shatkriyakala'' (pathogenesis). These may be considered as aura in apasmara patients. These are important in view of prevention of apasmara progression to epileptic seizure. In conventional medicine text books, some of the above signs like auditory and visual hallucinations are referred. These signs need to be searched upon for their prevalence, categorization as per ''dosha'' dominance, involvement of ''dosha'' attributes in order to establish precise guidelines for early prevention and management of disease.
The abovementioned pre-clinical features are observed in the fourth stage of ''shatkriyakala'' (pathogenesis). These may be considered as aura in apasmara patients. These are important in view of prevention of apasmara progression to epileptic seizure. In conventional medicine text books, some of the above signs like auditory and visual hallucinations are referred. These signs need to be searched upon for their prevalence, categorization as per ''[[dosha]]'' dominance, involvement of ''[[dosha]]'' attributes in order to establish precise guidelines for early prevention and management of disease.
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Table 2: Differentiation between types of apasmara
Table 2: Differentiation between types of apasmara
Su: As described by Sushruta in Sushruta Samhita AH: As described in Ashtang Hridaya
Su: As described by Sushruta in Sushruta Samhita AH: As described in Ashtang Hridaya
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The specific features of all the four types of apasmara are described in Table 2. ''Vata'' type of apasmara manifests itself with repeated seizures of short duration and increased frequency of attacks. The speed, severity and abnormality of movements are more in this case. This is due to ''chala'' (movable), ''laghu'' (light), and ''sukshma'' (minute) attributes of ''vata dosha''. ''Vata'' is the initiator of all activities including those of the body and the mind. The regulation and coordination of the sequence of sense and locomotor organs – mind-intellect-soul for attainment of knowledge is performed by ''vata''. ''Prana vata, udana vata'' and ''vyana vata'' are involved in the pathophysiology of apasmara. The clinical manifestation of ''vataja'' apasmara may be due to repeated, excess, hyposynchronous discharges in neurons of the central nervous system. Transient hypoxia leading to dysregulation of brain functioning, and neurological diseases similar to epilepsy syndromes can be categorized under this type of apasmara.
The specific features of all the four types of apasmara are described in Table 2. ''[[Vata]]'' type of apasmara manifests itself with repeated seizures of short duration and increased frequency of attacks. The speed, severity and abnormality of movements are more in this case. This is due to ''chala'' (movable), ''laghu'' (light), and ''sukshma'' (minute) attributes of ''[[vata dosha]]''. ''[[Vata]]'' is the initiator of all activities including those of the body and the mind. The regulation and coordination of the sequence of sense and locomotor organs – mind-intellect-soul for attainment of knowledge is performed by ''[[vata]]''. ''Prana vata, udana vata'' and ''vyana vata'' are involved in the pathophysiology of apasmara. The clinical manifestation of ''vataja'' apasmara may be due to repeated, excess, hyposynchronous discharges in neurons of the central nervous system. Transient hypoxia leading to dysregulation of brain functioning, and neurological diseases similar to epilepsy syndromes can be categorized under this type of apasmara.
In ''pitta apasmara'', the frequency, duration of paroxysms will be comparatively less than those observed in ''vata'' type. The ''ushna'' (hot) and ''tikshna'' (acrid) attributes of ''pitta'' are responsible for the pathology of paroxysms. ''Sadhaka pitta'' located at the heart and the functions responsible for accomplishment of activities are responsible for this apasmara. ''Tamahpravesha'' is a sign primarily of ''pitta''-dominance in which metabolism or transformation at the cellular level might be an underlying pathology. Derangement of ''sadhaka pitta'' implies the decrement or depletion in psychological performance in apasmara patients. Since ''pitta'' is responsible for all metabolic activities, the derangement of metabolism at the cellular level is an important pathological factor and the enzymatic pathways might be held responsible. The types of epileptic syndromes originating due to metabolic disorders like hepatic encephalopathy can be categorized under this type. Changes in body temperature, excess thirst, and perspiration are specific differentiating features of ''pitta apasmara''. The cerebral conditions due to derangement of metabolisms can be enlisted here.
In ''[[pitta]] apasmara'', the frequency, duration of paroxysms will be comparatively less than those observed in ''[[vata]]'' type. The ''ushna'' (hot) and ''tikshna'' (acrid) attributes of ''[[pitta]]'' are responsible for the pathology of paroxysms. ''Sadhaka pitta'' located at the heart and the functions responsible for accomplishment of activities are responsible for this apasmara. ''Tamahpravesha'' is a sign primarily of ''[[pitta]]''-dominance in which metabolism or transformation at the cellular level might be an underlying pathology. Derangement of ''sadhaka pitta'' implies the decrement or depletion in psychological performance in apasmara patients. Since ''[[pitta]]'' is responsible for all metabolic activities, the derangement of metabolism at the cellular level is an important pathological factor and the enzymatic pathways might be held responsible. The types of epileptic syndromes originating due to metabolic disorders like hepatic encephalopathy can be categorized under this type. Changes in body temperature, excess thirst, and perspiration are specific differentiating features of ''[[pitta]] apasmara''. The cerebral conditions due to derangement of metabolisms can be enlisted here.
In cases of ''kaphaja apasmara'', the ''sthira'' (stable), ''manda'' (slow), and ''snigdha'' (unctuous) attributes of ''kapha'' are responsible for delayed onset, prolonged duration as well as minimal frequency of paroxysms in apasmara. Excessive sleep and hypothermia specifically suggest ''kaphaja apasmara''. Hypoperfusion and hypovolemic conditions leading to cerebral dysfunction can be considered as attributes of ''kaphaja apasmara''.
In cases of ''kaphaja apasmara'', the ''sthira'' (stable), ''manda'' (slow), and ''snigdha'' (unctuous) attributes of ''[[kapha]]'' are responsible for delayed onset, prolonged duration as well as minimal frequency of paroxysms in apasmara. Excessive sleep and hypothermia specifically suggest ''kaphaja apasmara''. Hypoperfusion and hypovolemic conditions leading to cerebral dysfunction can be considered as attributes of ''kaphaja apasmara''.
Finally, the ''sannipatika'' type of apasmara presents itself with complex mixed features due to overlapping of all ''doshas''. The prognosis is poor leading to incurability of disease. This might be a mixed presentation of neuronal, endocrinal, circulatory and metabolic pathways.
Finally, the ''sannipatika'' type of apasmara presents itself with complex mixed features due to overlapping of all ''[[dosha]]s''. The prognosis is poor leading to incurability of disease. This might be a mixed presentation of neuronal, endocrinal, circulatory and metabolic pathways.
While considering the clinical pictures of a disease, the attributes of ''doshas'' responsible for variation in pathologies at somatic and psychological level should be emphasized. Important mechanisms of loss of consciousness and abnormal movements at the somatic level, and impairment of intelligence and memory at psycho-pathological levels needs to be focused. The epigenetic patterns related to particular signs and symptoms originated from ''doshic'' pathologies can be researched to reveal new treatment methods and management aspects. The genetic constitution of a person plays a significant role in making him prone to developing certain type of disorders. Therefore, as discussed above for ''vata apasmara'' can become more apparent after taking ''vata''-aggravating diet and lifestyle in ''vata prakriti'' individuals that can get alleviated by using ''vata shamana'' (i.e., ''vata''-pacifying) diet and lifestyle. Furthermore, if anti-epileptic drugs are used more judiciously depending upon the ''dosha'' and ''prakriti''-specific diagnosis, then the treatment regimen can be made much more precise leading to beneficial results in patients. As discussed in the section of predisposing factors, the preventive lifestyle and dietary regimens can be designed to prevent incidence of epilepsy, reduce the dose of drugs with supportive diet and lifestyle therapy and prevent further progression of disease. Therefore, training of epileptics regarding causative and avoidable factors is of utmost importance. The epigenetic variations in epileptics due to enlisted causative agents should be studied as a part of genomic and proteomic research.
While considering the clinical pictures of a disease, the attributes of ''[[dosha]]s'' responsible for variation in pathologies at somatic and psychological level should be emphasized. Important mechanisms of loss of consciousness and abnormal movements at the somatic level, and impairment of intelligence and memory at psycho-pathological levels needs to be focused. The epigenetic patterns related to particular signs and symptoms originated from ''doshic'' pathologies can be researched to reveal new treatment methods and management aspects. The genetic constitution of a person plays a significant role in making him prone to developing certain type of disorders. Therefore, as discussed above for ''[[vata]] apasmara'' can become more apparent after taking ''[[vata]]''-aggravating diet and lifestyle in ''[[vata]] [[prakriti]]'' individuals that can get alleviated by using ''[[vata]] shamana'' (i.e., ''[[vata]]''-pacifying) diet and lifestyle. Furthermore, if anti-epileptic drugs are used more judiciously depending upon the ''[[dosha]]'' and ''[[prakriti]]''-specific diagnosis, then the treatment regimen can be made much more precise leading to beneficial results in patients. As discussed in the section of predisposing factors, the preventive lifestyle and dietary regimens can be designed to prevent incidence of epilepsy, reduce the dose of drugs with supportive diet and lifestyle therapy and prevent further progression of disease. Therefore, training of epileptics regarding causative and avoidable factors is of utmost importance. The epigenetic variations in epileptics due to enlisted causative agents should be studied as a part of genomic and proteomic research.
=== Differential diagnosis of apasmara ===
=== Differential diagnosis of apasmara ===