Wednesday, November 13, 2013


An Ayurvedic protocol for the management of Cerebral Palsy
A developmental disorder is impairment in the normal development of motor or cognitive skills which occur at some stage in a child’s development, often retarding the development. These may include psychological or physical disorders. According to the Developmental Disabilities Act, section 102(8), "the term 'developmental disability' means a severe, chronic disability of an individual 5 years of age or older that attributable to a mental or physical impairment or both, manifested before the individual attains age 22 and is likely to continue indefinitely resulting in substantial functional limitations in three or more of the following areas of major life activity viz. Self-care, Receptive and expressive language, Learning, Mobility, Self-direction, Capacity for independent living, and Economic self-sufficiency.
The worldwide prevalence of such disabilities scores as high as 10% (UN report) while in India, this figure stands at an alarming 40-70 million persons, with nearly 150 million children affected (CRIN). With the intense untoward outcome that such a condition imposes on the physical existence itself of an individual, it is an area of utmost concern among all the existing systems of medicine, Ayurveda, being no exception to this.
Amid the motor developmental disorders, the most common are the neuro-developmental disorders, which manifest as an outcome of the failure in the proper functional expression of a motor unit. Clinically, such neuro-developmental disorders present in three varied forms, viz. Atonicity (loose child/floppy baby), Hypertonicity (tight child), and Child With movement disorders (athetoid,epilepsy,myoclonic etc.). This functional blockade can be understood under the terminology of Dhatukshaya (tissue loss/underdevelopment) in Ayurveda, setting the stage for Vata prakopa. The vitiated Vayu finds a harbor in the Sira, Medas, Snayu and Mamsa resulting in the clinical manifestation of the motor developmental disorder in either of three forms listed earlier.
Cerebral Palsy
Cerebral Palsy or Little’s Disease is the commonest identified cause of childhood disability. It presents as a static encephalopathy and is studied to be prevalent among 1.5-2.5 per 1000 live births, its etiology being:Prenatal: Anoxia due to interference with placental circulation, Eclampsia/pre eclampsia etc; Natal: Anoxia during birth process, Asphyxia due to blockage of respiratory passage etc; or Post natal: Kernicterus, Trauma, etc., precipitating either a Diffuse cortical and scattered focal atrophy, or a Cystic softening of brain in small or large areas, or Hypoplasia of the midbrain or cerebellum, or normal gross appearance with loss of cortical neuronal cells on microscopy; clinically interpreted as Periventricular leucomalacia (Spastic Diplegia), Periventriculat leucomalacea, multicystic encephalomalacia, (Spastic Quadriplegia), Stroke (in utero /neonatal).

An Ayurvedic overview of Cerebral Palsy

Cerebral Palsy (CP) is accommodated under the category of hypertonic developmental disorder. Hypertonicity in CP may be a spasticity, rigidity or contractures identified as Kubjata, Kunitwa and Stabdhata in Ayurveda. The Doshic analysis here reveals the vitiation of Vata and Kapha presenting as Sangam (obstruction), Sadam (reduced function) and Vartam (hardening), being a hyper expression of the former, and the latter imparting Sthairyam (hardening) and Chirakaaritwa (make it chronic). Thus, it can be concluded that spasticity is Vata predominant Kapha Vatika manifestation. The Dooshya here, as previously mentioned, involves Sira, Medas, Snayu and Mamsa. Snayu, is a much debated still most applied terminology in Ayurvedic literature. The classical description of Snayu describing it to be a thread like structure, quite numerous in number, distributed all over the body and its pathological lesions creating maximum harmful effects including convulsive disorders and tetanic postures with marked spasticity, yields the anatomical identification of Snayu as the Nerve tissue. Stabdhata etc, being the Hypertonicity, thus are due to a neurological lesion.

Management of Cerebral Palsy
Management of such disabilities require a multidisciplinary approach, Cerebral Palsy being no exception to this. Thus management of Cerebral Palsy demands like, Symptomatic treatment, Procedure Based Therapies of Ayurveda, Rasayana chikitsa, Medhyam, balya, Kapha Vata haram, Physiotherapy, Occupational therapy, Educational intervention, Orthopaedic support, Surgery if needed and Social interventions.
Laying down the Ayurvedic principle for the management of CP, bearing in mind that the condition is a Vata predominant Vata Kapha manifestation both Snehana (unctuating) and Rukshana (dry/coarse) therapies ought to be incorporated to pacify them respectively. The statement may seem to be controversial theoretically as Rukshana and Snehana may deteriorate the condition by stimulating further vitiation of Vata and Kapha correspondingly. So, these therapies have to be applied alternatively with keen monitoring to aptly decide the shift in therapy.  However, Swedana (fomentation), being a common treatment for both Kapha and Vata, yields promising results. The practical efficacy of Sodhana (purificatory) therapy is questionable as it is impossible to eliminate doshas (humors) in the above discussed Ayurvedic pathogenesis of CP. Hence, Samana (palliative) plays the pivotal role, with the prime concern being set for Brimhana (nourishing), Medhya and Rasayana ().  In the nutshell, the Ayurvedic protocol for the management of CP includes:
o  Rukshana: Udwarthanam /Dhanyamla parisheka/ Utkharshanam/Danyamla potali
o  Snehanam: Snehapaanam/ Abhyangam / Matravasthy / Pizhichil /Pichu /Sirovasthy
o  Swedanam: Abhyangam/Pizhichil / Nalee swedam / Pindaswedam/Avagaham 
o  Brimhanam: Snehanam/Balaaksheerapakam/Abhyangam, Shashtika Sali Pinda Sweda
o  Medhyam  and Rasayanam: Guluchee , Nagabala , Brahmee , Sankha pushpee
o  Symptomatic Management.
A protocol developed on these hypothetical principles is being subject to practice in the Kaumarabhriya OPD of VPSV Ayurveda College, Kottakkal. The 31 days protocol includes alternate application of Snehana and Rukshana in various forms, throughout the day, each for three days consecutively. For Rukshana, different modes applied include: Madhoodaka panam (6 am); Udwarthanam/KK/ etc (8 am) ; Pradhamanam (3 pm); Rukshathalam (4 pm). Snehana is applied in following forms: Abhyanga/pizhichil etc. (8 am); Matra vasti (8 am) ; Pratimarsa nasya (3 pm); Siro pichu (4 pm) ; Snehapanam (4.30 pm)
Based on the analysis of the gross motor functions on Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R), usually it is required for the patient to undergo multiple courses of this therapeutic protocol. The result, as observed in practice, generally include:
1.      Achievement of a new motor milestone or improvement in an existing one, within a period of 3 months after a course of treatment
2.      A positive improvement in spasticity as measured on Modifies Ashworth scale for hypertonia

The promising results obtained with this protocol in CP provoked the thought for its scientific analysis in terms of Modern principles of physiology and pathology. As previously discussed, the neuro-developmental disorders are a manifestation of the malfunctioning of the motor unit. The functional capability of such an inactive nerve can be achieved either by stimulating the Sensory end (sensory nerve), the effector end (motor nerve), or both (mixed nerve).  Unfortunately, though, the property of nervous tissue adaptability hurdles the constant application of a uniform stimulus as quite soon the nervous tissue gets adapted and stops responding to the applied stimulus. To overcome this hurdle, the altering short term application of various stimuli can safely be adopted. In the literature regarding the conventional therapy for CP also the principle of management of such motor developmental disorders by application of altering stimulus to the inactive areas of the brain to stimulate their normal functioning thereby enhancing the motor skills is quite apparent. This may be achieved by drugs, external therapies (medical/para medical) or behavioral trainings ensuring the exposure of the tissue to varying stimuli. This concept forms the basis of adoption of the Ayurvedic protocol for the management of Cerebral Palsy as discussed here.
To conclude, Ayurveda has in store immense hopes to promise a better quality of life to children with developmental disorders. The success of the treatment lies in precise diagnosis in Ayurvedic terminology of tridoshas which directs to the planning of a sharp treatment principle. Cerebral Palsy, the commonest cause of developmental disability, can theoretically be interpreted as a Vata pradhana Kapha Vata condition, clinically responding astoundingly to the alternate application of various Snigdha-Ruksha therapies. The protocol discussed in this piece of literature is in practice in our OPD with absolute physician and patient satisfaction and so can safely be recommended in the cases of Cerebral Palsy.


Dr Dinesh.K.S;MD(Ay.);Asst.Professor,V.P.S.V.Ayurveda College, Kottakkal,, +919447698085

Man is a social animal; because he transfers emotions, uses language and communicate each other. He has several other skills to make fit himself in to the society. This is attained by proper neuronal formation and maturation which starts from the intra uterine environment and completes with the help of the environment proper outside the womb. This is the essence of pervasive development, and the disorder of the above said physiology is called pervasive developmental disorder [PDD]. The best known PDD is Autism.  This may be the reason why the doctors are speculating their role in the autism management as it has a physical basis. Autism was previously a symptom in adult schizophrenia1. In this condition there is marked and sustained impairment in social interaction, deviance in communication, and restricted or stereotyped patterns of behavior and interest. Abnormalities in functioning in each of these areas must be present by age 3 years. Approximately 70 percent of individuals with autistic disorder function at the mentally retarded level, and mental retardation is the most common comorbid diagnosis2. Humanity is now astonishing with the rising scene of autism features among the children. Obviously the disease is a stroke to the family as well as to the society.  The curative management of the condition is still a mirage because the cause of the disease is still unknown. However the management teams like religious persons, traditional healers and ayurvedic hospitals are mushrooming with golden blind offers to exploit the helplessness and hopes of the suffering family members. Even the visual media is now a day identifying this trend and trying to highlight Ayurveda as a ridicule method to treat autism.  So it is the responsibility of scientific Ayurveda people to publish and highlight the real thrust areas of Ayurveda in autism management. Following are some of the areas where Ayurveda has a pronounced role in the autism management according to the limited experience of author.
Neuronal Migration problems and autism
                                                                                                                                Neuronal migration disorder refers to a heterogenous group of disorders that, it is supposed, share the same etiopathological mechanism: a variable degree of disruption in the migration of neuroblasts during neurogenesis3. The recent autopsy studies are revealing the the children with PDD has migrational defects4. So the PDD has to be considered as the garbha vikritis caused by the deficient quality of gametes[sukla and artava], defective uterine environment, time of conception, diet and activities of mother5. The features of PDD will be expressed as, defective pravritti of vayu[sanga] in the areas of budhi and mana[praana and udaana]. Language developemental problems, sterotypies, defective socializations are example of it6. Sometimes in PDD the vata vitiated[vriddhi] lakshanas in the pakwasaya, siraa and snaayu will be expressed as walking difficulties, microcephaly, loss of bladder control etc7. This clearly indicates the srotorodha is in the brain itself so as to produce a bipolar feature of vayu viz  atipravritti and sanga. So the medhya with ushna teekshna drugs and budhi prabodhaka procedures [gomutra preperations and pradhamana ] along with tiktapaachana drugs mainly with guloochee is showing some hopes to alleviate the symptoms. Here we have to exploit the neuronal plasticity, the wonderful capacity of neurons to mould and rewire according to the inputs from the sensory organs and proprioceptive stimulus. Ayurveda is a science with good treasure of procedures which promotes the neuronal growth by the mechanism of neuronal plasticity. Udwarthana, abhyanga, some vastis are such examples. These procedures can be effectively implemented aiming the management of migration issues.
Gut problems in autism &deficiencies
Usual gut problems of autistic children are some specific allergies especially to gluten and casein. Frequent spells of either diarrhea or constipation is usual among these children.  All these issues are invariably featuring similarity to either aama/ajeerna or doosheevisha concept in ayurveda. The amaasayastha or pakwasayastha dosheevisha lakshanas are more prominent in this context. The kaalasaakadi kashaya, villwadi gulika, hinguvachaadi churnam, doosheevisharigulika are the chief agents which acts powerfully to manage these problems. But interesting point is that management of food allergies is finally reaching to the good management of hyperactive symptoms associated with autistic children. This is due to the fact that both faculties [gut and mind] are the functions of rasadhatu.  The references of enterocolonic encephalopathy theory have to be read in connection with this similarity.
The management of deficiencies has been started since 1960 for the autism treatment plan. Vitamin B6, magnesium,zinc are the usual supplements of foods which gives positive results in speech,attention,irritability and learning skills8. These are all indicative of an inherent agnimandya of autistic babies either at the level of koshta or at the level of dhatuparinaama.
Toxins in autism
Several endotoxins and exotoxins are hypothesized to have a prominent role in the etiogenesis of autism diseases. Endotoxins are chiefly by several infections9, intermediary metabolic substances like ammonia, lactate, pyruvate, endomorphin10 etc. Exotoxins are chiefly by heavy metals, food addictives, drugs, pesticides etc11. Here the endotoxins are to be treated as dhatugata aama and doosheevisha and should be treated accordingly. Exotoxins are the real vishaas and heavy metals and all vishahara chikitsas are inevitable in most of the cases. Heavy metals such as mercury from several vaccines and fishes have been chiefly blamed in the causation of autism disorders12. Current chelation therapy in biomedicine is one such an effort in this regard. The patoladi ganam, aragwadhadi ganam are the chief agents which we are utilizing for this aspect in autism management.
Hyperactivity and autism
 Poor affect modulation and the display of emotions inappropriate to a given social situation are common. Some individuals may show sudden mood changes, and laugh, cry, or giggle to themselves for no apparent reason.  The controlling and stimulating power of the vayu on mind is getting totally underdeveloped here to produce almost similar features of vata paittika unmada. Interestingly all those children are showing other paittika symptoms like diarrhea, self injurious behavior, head banging etc..Maximum other co morbidities like fragile X syndrome[FRAXA],tuberous sclerosis are mostly seen with this prominent symptom of hyperactivity in autism.  So the management protocol should be directed towards these co morbidities. Snehapaana with kaaraskara ghrita[Indicated in vatasonita chikitsa by sahasrayoga] usually alleviate hyperactivity in tuberous sclerosis and FRAXA. The typical  vatapittika unmaada hara chikitsas like seka with himasagaram tailam, yashti madhu+gudoochee kwatha, rajanyaadi churna, sirolepam giving positive changes.  Sleep issues are also getting relieved by this management scheme.
Autism spectrum disorders(ASDs)
                Rett’s syndrome, Asperger syndrome, childhood disintegrative disorder(CDD) and pervasive developmental disorder not otherwise specified are the ASDs. Of these exposure to asperger syndrome is less to the author where as PDD –NOS is the mostly encountered case. Rett’s syndrome and CDD are the diseases in which the doshas in the rasadhatu makes its manifestation both in somatic and psychic areas prominently. The samprapti finally progress to the further dhatus and upadhatus to create the symptoms like, vasti vikaras, dourbalyam, kampam, akshepakam, apasmaaram etc.
General informations and conclusions13
Research based acceptable methods, principles, techniques and rationale are the only applicable interventions allowed ethically in autistic children. Ayurveda is not one among them at present. The accepted interventions are Applied Behaviour Analysis(ABA), the TEACCH approach[Treatment and Education of Autism and related Communication Handicapped Children], Lovaas and discrete trial teaching, augmentative and alternative communication,Higaashi daily life therapy,  sensory integration therapy are few of them.  A multidisciplinary team and transdisciplinary team is inevitable to manage those children and that team should inevitably consist of an experienced Ayurveda specialist. If it is a classical case of autism best approach is multidisciplinary and if it is co morbidity along with other multiple problems transdisciplinary approach is best.

Organization of multi didisciplinary model of service delivery(source Orelove and Sobsey 1987)

A transdisciplinary team should have one or two persons as primary facilitators of the services and other team members acts as consultants.
1.       Kuhn R; tr. Cahn CH. Eugen Bleuler's concepts of psychopathology. Hist Psychiatry. 2004;15(3):361–6.
2.       Benjamin J Sadock; Virginia Alcott Sadock; Pedro Ruiz; Kaplan and Sadock’s comprehensive text book of psychiatry.
3.        Sarnat, Harvey (1992). Cerebral dysgenesis, embryology and clinical expression. New York, US: Oxford University Press. ISBN 0-19-506442-9
4.       Schmitz C, Rezaie P. The neuropathology of autism: where do we stand? Neuropathol Appl Neurobiol. 2008;34(1):4–11.
5.       Charakasamhita,sareerasthaana,atulyagotreeyam sareeram.
6.       Ashtanga samgraha,sutrastaana,doshabhedeeya.
7.       Ashtangahridaya, Nidanastaana,vatavyaadhi.
8.       DSE(ASD)Therapeutics; rehabilitation council of india;Kanishka publishers.
9.       .Libbey JE, Sweeten TL, McMahon WM, Fujinami RS. Autistic disorder and viral infections. J Neurovirol. 2005;11(1):1–10.
10.    Ng F, Berk M, Dean O, Bush AI. Oxidative stress in psychiatric disorders: evidence base and therapeutic implications. Int J Neuropsychopharmacol. 2008;11(6):851–76.
11.    Rutter M. Incidence of autism spectrum disorders: changes over time and their meaning. Acta Paediatr. 2005;94(1):2–15.
12.    Austin D. An epidemiological analysis of the 'autism as mercury poisoning' hypothesis. Int J Risk Saf Med. 2008;20(3):135–42
13.   DSE(ASD)Therapeutics; rehabilitation council of india;Kanishka publishers.