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 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.