|
 
 |
| CASE REPORT |
|
| Year : 2015 | Volume
: 35
| Issue : 1 | Page : 52-57 |
|
An ayurvedic approach in the management of Guillain-Barre syndrome: A case study
Amit Nakanekar, Sunanda Bhople, Harshad Gulhane, Suraj Rathod, Jayant Gulhane, Pravin Bonde
Department of Kayachikitsa, Government Ayurved College, Nagpur, Maharashtra, India
| Date of Web Publication | 18-Sep-2015 |
Correspondence Address:
Amit Nakanekar
Department of Kayachikitsa, Government Ayurved College, Nagpur, Maharashtra
India
 Source of Support: Nil., Conflict of Interest: None  | Check |
DOI: 10.4103/0257-7941.164540
Guillain-Barre syndrome is an acute, frequently severe and fulminant polyradiculopathy that is autoimmune in nature. Guillain Barre syndrome is a rare disorder that causes immune systems to attack peripheral nervous system (PNS). A 46 year old male patient, presenting with sudden onset, complete paralysis of all four limbs (quadriplegia), unable to walk, stand, sit, difficulty in deglutition (dysphagia) and dysarthia, was having foley’s catheter and Ryle’s Tube brought by relative to Out Door Patient Department (OPD) of Government Ayurvedic Hospital, Nagpur; He was provisionally diagnosed as subacute sensory motor paraplegia. Previously patient admitted and treated in Government Medical College (GMC) Nagpur but did not show any sign of improvement so patient was admitted and treated with Ayurvedic treatment for about 50 days. As per Ayurvedic classics, this condition can be correlated with sarvāṅgagatavātavyādhi (~vāta disorder affecting all parts of the body), which is apatarpaṇa in nature (~diseases with deprived nourishment of body tissue) preceded by jvara (~(H/O fever before onset of GBS). Hence, the principle of treatment is santarpaṇa cikitsā (~nourishing treatment). Santarpaṇa (~nourishing treatment) includes bahyopakramas (~nourishing external treatment modalities), such as abhyaṅga (~oleation therapy) and ṣaṣṭikaśālipiṇḍasveda (~sudation using of hot and processed ṣaṣṭika rice), karmabasti (~medicated enema) śirodhārā (gentle pouring of medicated liquid over forehead) and jvaraghna cikitsā (~treatment of fever) using various Ayurvedic herbomineral compounds. Remarkable results were observed in the form of improvement in the muscle power from zero to five of all four limbs with improvement in speech. There was no difficulty post treatment in deglutition, sitting, standing and walking; and now patient has near to normal movements. Keywords: Abhyaṇga, GBS, Karma Basti, ṣaṣṭikashali Pinda Sveda, Śhirodhārā
How to cite this article:
Nakanekar A, Bhople S, Gulhane H, Rathod S, Gulhane J, Bonde P. An ayurvedic approach in the management of Guillain-Barre syndrome: A case study. Ancient Sci Life 2015;35:52-7 |
| Introduction | |  |
Guillain-Barre syndrome is an acute, frequently severe and fulminant polyradiculopathy that is autoimmune in nature. Guillain Barre syndrome is a rare disorder that causes the immune system to attack the peripheral nervous system (PNS).[1] As per Ayurvedic classics, this condition can be correlated with Sarvāṇgagatavātavyādhi (~Vāta disorder affecting all parts of the body).[2]
Guillain-Barre syndrome is a rapidly evolving areflexic motor paralysis with or without sensory disturbances. The usual pattern is an ascending paralysis that may be first noticed as rubbery legs. Weakness typically evolves over hours to a few days and is frequently accompanied by tingling dysesthesias in the extremities. The legs are usually more affected than the arms and facial diparesis is present in 50% of affected individuals. The disease is usually triggered by an infection. Intubation, plasmapheresis, intravenous immunoglobulin and glucocorticoids are lines of treatment adopted by biomedicine practitioners.[3]
As per Ayurvedic classics, this condition is correlated with sarvāṅgagatavātavyādhi[4] (~vāta affecting all parts of the body), which is apatarpaṇa in nature (~diseases which are associated with deprived growth of body tissue). Hence, the choice of treatment is santarpaṇa cikitsā[5] (~nourishing treatment). Santarpaṇa bahyopakramas (~nourishing external treatment modalities) such as candanabalalākṣādi tailam[6] abhyaṅga (~oleation therapy) and ṣaṣṭikaśālipiṇḍa sveda[7] (~application of processed rice) were administered along with karma basti[8] (~pittaghna drugs processed in kṣīra), śirodhārā (gentle pouring of medicated liquid over forehead), and bṛhatvātachitamani kalpa whose main ingredients include bṛhatavātachitamani,[9] guḍūci (Tinospora cordifolia) sattva, rajatabhasma[10] and sūtaśekhara rasa.[11]
| Case Report | | |
A 46 year old male patient,(OPD No-21036-11/12/13) presented with complete paralysis of all four limbs (quadriplegia). There was inability to walk, stand, sit, difficulty in deglutition (dysphagia) and dysarthia, since 1 month. He had Folley's catheter and Ryle's Tube at the time of presenting at the OPD. He was treated for subacute sensory motor paraplegia (Suspected GBS) in the Government Medical Hospital Nagpur and the symptoms had not shown any improvement and hence his condition was deteriorating.
He was brought by his relatives to Govt. Ayurvedic Hospital, Nagpur. Patient was admitted in Indoor Patient Department (IPD) (IPDNo 4885-11/12/2013). He did not have any history of Diabetes, Hypertension, Asthma, Tuberculosis, or any major surgical procedure. He had history of occasional consumption of alcohol. No history of any specific medication or drug abuse.
| Past History | | |
Patient was healthy a month before presentation but had fever for which he had taken medications from a local doctor and even then the fever did not subside. He developed gradual weakness in both lower limbs with ascending progression to upper limb. For these complaints he again took treatment from another private practitioner. Even so, he did not get relief and was transferred to GMC Nagpur.
He was investigated at GMC Nagpur, electromyelogram and Nerve conduction velocity (EMG NCV) and other investigations were done and he diagnosed with GBS on 04/12/2013.
Treatment received by patient in govt. medical college (over a seven day period) included dosage of Ceftriaxone (1gm BD), Metronidazole (500mg TD), Cefotaxim (1 gm TDS), Pregabalin (75 mg) with methyl cobalamine and Vitamin B complex.
| Examination on Admission | | |
General examination
The Patient was afebrile and his pulse was 110/min, Blood pressure 130/80 mm Hg. He appeared pale and he had moderate weight (59 kg).
Physical examination
There was diffuse weakness of all four extremities, distal greater than proximal and involving the lower limbs more than the upper limbs. Muscle tone was decreased and vibratory sensation was diminished in the distal lower extremities. Muscle stretch reflexes were absent.
Systemic examination
In the systemic examination, findings of respiratory and cardiovascular system were within the normal limits. Abdomen was mildly distended, non-tender, and bowel sounds were present. Patient was conscious and well oriented and pupillary reaction to light was normal.
- DTR
Ankle- absent Knee- absent Biceps- absent Triceps- absent
Superficial Planter Reflexes-absent. - Muscle power grade: On admission
Aṣṭavidhaparīkṣā
The patient's pulse was vātapitta predominant, tongue was sāma (coated), was of madhyamākṛti (medium built) had difficulty in speaking (bulbar speech). Malabaddhatā (constipation) was also present. He was catheterized and input output chart was maintained.
Vikṛtasrotas parīkṣaṇa
Māṃsavahasrotovikṛti was presented as ubhayahastapāda daurbalya (weakness over all four limbs). While majjāvahasrotas showed quadriplegia, sakaṣṭagilana (dysphagia) sakaṣṭashabdoccāraṇa (dysarthriya).
Investigations
Routine studies of blood and urine were within normal limits.
CT-Scan of brain was normal. MRI LS Spine-was within normal limits.
EMG-NCV showed sub-acute demyelinating sensory motor polyneuropathy involving both upper and lower limbs and distal and proximal segment was affected.
This EMG-NCV was done in Govt. Medical Hospital Nagpur; directing the diagnosis towards GBS. There are different causes for acute polyneuropathy based on the following differential diagnosis table. Other causes were ruled out and the case was diagnosed as Gullian Barre Syndrome [Table 1]. | Table 1: Confirmation of Guillain barre syndrome to rule out possible differential diagnoses
Click here to view |
Ayurveda treatment
After confirming presence of intestinal motility basti started.
Around 50 ml of indirectly heated candanabalalākṣāditailam[6] was applied in anuloma gati (downward) for 15 min (bāhya snehan) and nāḍīsvedana by nirguṇḍī (vitex nigundo) and dashamūla siddha kvātha (decoction) for a period of 15 minutes. 15 g of bala mūla (root of Sida cordifolia) 15 g of aśvagandhā (Withania somnifera) cūrṇa and 15 g śatāvarī (Asparagus racemosus) was processed with 500 ml of kṣīra (milk) wherein milk was boiled to reduce the quantity to half with 25 g of ṣaṣṭikaśāli (processed ṣaṣṭika rice) was cooked very soft and made like paste with above filtrate of kṣīra. This paste was applied with gentle circular movements for 20 min in anuloma gati. Patient was treated for a total of 36 days.[7] Śirodhārā was done using tila tailam (lukewarm sesame oil) for a period of 15-20 min for 16 days.[12] Kṣīra processed with pittahara dravya in the form of basti was used and tila taila basti (sesame oil enema) was given on alternate days.[8] Basti was administered between from 18th Dec 2013 to 20th Jan 2014. (Graph of basti retention time can be seen in [Figure 1]). [Figure 1] shows that basti retention time increased gradually after starting the treatment and with the improvement in basti retesion time clinical condition also improved. Bṛhatvātachitamani kalpa which is composed of bṛhatvātachitamani,[9] 1 g; guḍūci (Tinospora cordifolia) sattva, 30 g; rajata bhasma[10] 5 g and sūtaśekhara rasa[11] 30 tab each of 250 mg powdered together and divided into 60 divided doses BD was given as internal medicine.
| Result | | |
As Ayurvedic treatment progressed, the patient got beneficial effects. On admission patient was unable to walk, sit without support, wasn't able to speak or swallow and there was incontinence of urine [Table 2].
After treatment with various pancakarma procedures such as snehana[13] (using candanbalalākṣādi tailam), svedana (nāḍī sveda, Initially for three days followed by piṇḍasveda), basti, śirodhārā, balya cikitsā (~Nourishing treatment) and administration of a formulation containing svarṇa (Gold) bhasma, bṛhatvātacintāmaṇi and sūtaśekhara rasa helped improve the symptoms of patient [Table 3] and [Table 4].
| Discussion | | |
Pathophysiology
In the demyelinating forms of GBS, the basis for flaccid paralysis and sensory disturbance is conduction block. This finding, demonstrable electrophysiologically, implies that the axonal connections remain intact. Hence, recovery can take place rapidly as remyelination occurs. In severe cases of demyelinating GBS, secondary axonal degeneration usually occurs; its extent can also be estimated electrophysiologically. More secondary axonal degeneration correlates with a slower rate of recovery and a greater degree of residual disability. When a severe primary axonal pattern is encountered electrophysiologically, the implication is that axons have degenerated and become disconnected from their targets, specifically the neuromuscular junctions, and must therefore regenerate for recovery to take place. In motor axonal cases in which recovery is rapid, the lesion is thought to be localized to preterminal motor branches, allowing regeneration and reinnervation to take place quickly. Alternatively, in mild cases, collateral sprouting and reinnervation from surviving motor axons near the neuromuscular junction may begin to reestablish physiological continuity with muscle cells over a period of several months.[14]
In GBS there is ascending paralysis, weakness beginning in the feet and hand and migrating towards the trunk, this was considered as māṃsa, rakta and majjā dhātu duṣṭi along with vāta, majjādharakāla and pittadharakāla involvement. Hence while treating this patient, we decided to use pittadharakāla-majjādharakāla sahacharya.[15] Constipation of patient is indication that Anuloma gati of vāta is affected. Nourishment of nerves is also important. Considering all the above facts we decided to use sūtaśekhararasa, guḍūci satva and brihatvātacintāmaṇi. Guḍūci acts on majjā and jvara. It is also antiflamatory, antioxidant.[15],[16],[17]
Massage with aśvagandhā, balā, śatāvarī piṇḍasveda (rice processed with milk and withania somnifera asparagus racemosus, sida cordifolia) was performed. All ingredients of the piṇḍasveda, kṣīra (milk), ṣaṣṭikaśāli and balamūla possess santarpaṇa qualities (Antioxidantant nourishing) with prithvi and ap-mahabhutas (subtle elements of earth and water, which are nourishing in nature) and is indicated for balya, brimhana (nourishing), strengthening dhātus (building blocks) and vāta pacification. Abhyaṇga, mitigates vātadoṣa, it is puṣṭikara (promotes strength) and it is Jarahar (prevents aging). Abhyaṇga using candanbalalākṣādi tailam and ABS ṣaṣṭikaśālipiṇḍasveda were performed in anuloma gati because the doṣa involved is vāta and the disease is caused due to the reduction in its calaguṇa causing inability to transmit nerve impulses. Considering the doṣa and dhātu involvement vātaniyantraṇa and balya treatments were selected and movements were performed in anuloma gati. ṣaṣṭhiśāli facilitates opening up of blocks in nerve conduction and facilitates remyelination of nerves; thereby helps transmit nerve impulses with minimum amount of stimulus for muscularcontractions.
Basti (~medicated enema) is an effective treatment for vāta. It also brings about anulomana of vāta. When we use this route of administration we can facilitate rapid absorption action of medicated oils and decoctions for vāta disorders. The patient came with history of jvara which was pittapradhāna. Hence we have used this route of administration for vātaghna and pittaghna medicines i.e. pittaghnagaṇasiddhakṣīrabasti. We were expecting action of drugs on majjādharakāla through pittadharakāla.
We know that GBS is autoimmune in nature which means that there is hypersensitivity of immune system. There are two major phenomenon in the pathogenesis of Auto-immune disorders.
- Mistaken judgement about body tissue
- Attack of immune system on the body tissues to destroy them.[18]
Mistaken judgement about body tissue occurs by the virtue of śīghra guṇa. While explaining vāta prakṛti Caraka states that by virtue of this śīghra guṇa we can found alpa smṛti (~lesser rememberance) and śīghra grāhitā (~Early identification) in persons. Alpa smṛti when occurs at the level of WBC their recognition of body tissues is disturbed. Hence treatment which reduces this śīghraguṇa vāta is also very important while treating autoimmune disorders.[19]
Attack of immune system- while describing pitta prakṛti lakṣaṇa Caraka[19] has mentioned that tīkṣṇa guṇa of pitta is responsible for tīkṣṇāgni and tīkṣṇaparākrama (~Increased appetite and increased tendency to fight). When we correlate this effect of tīkṣṇa guṇa with respect to immune system, increase in tikṣṇaguṇa causes destruction of external pathogen. Tīkṣṇaguṇa of pitta along with śīghra guṇa of vāta at immune system level bring about misjudgement and hypersensitivity and causes destruction of the body tissue and we can postulate that this is how autoimmune disorders occur.
Hence consideration of tīkṣṇa guṇa of pitta and its treatment is very important while treating various autoimmune disorders. Caraka has also stated importance of kṣīra in the treatment of vatpittaja jvara. Hence pittaghna dravya siddha kṣīra basti is used. Treatment of vāta can be used while treating various auto immune disorders. In short, vāta pittaghna cikitsā is important in treatment of autoimmune disorders. Various vāta-pittaghna dravyas can be used according to sāmatā or nirāmatā in the treatment of autoimmune disorders. Considering all this pittaghna gaṇa sidhha kṣīra (Milk processed with herbs of pittaghnagaṇa) was used for basti.[8] Sūtaśekhara rasa is a drug which classically acts on pitta while guḍūci and raupya bhasma acts on majjādhara kāla. Ayurvedic concept of pittadhara kāla - majjādhara kāla sāhacarya also shows resembalance with molecular mimicry theory for C. Jejuni and nerve involvement in GBS pathology.[20] Considering all this sūtaśekhara rasa was given along with guḍūci and raupya bhasma and brihatvatcintāmaṇi.
According to biomedicine, patients with GBS achieve full functional recovery within several months to year.[21] In this patient recovery was seen in one and half months, which is suggestive of quicker beneficial effects of Ayurvedic treatment [Table 5]. | Table 5: Summary of Nerve conduction velocities before and after treatment. Report shows modest improvement compared with previous study
Click here to view |
| Conclusion | | |
This case study not only gives us confidence and better understanding for treating such cases in Ayurvedic hospital but also leads in the direction of further clinical trials to establish cost effective Ayurvedic therapy. As immunoglobin treatment is a costly alternative, cost effectiveness of the ayurvedic treatment seems promising.
This case study also confirms that Ayurvedic kriyā and Ayurvedic diagnosis is very important in terms of doṣa, sthāna (~status) and udgama (~etiology). Pittadharakāla-majjādharakāla relation and clinical understanding of basic concepts of guṇa in treatment of anukta vyādhi form the important bridge between modern diagnostic methods and Ayurvedic treatment of GBS.
Acknowledgment
Authors are thankful to Dr. Mukund Baheti, DM Neurologist, for helping to understand Electromyography and Nerve Conduction Velocity.
| References | | |
| 1. | Longo DL, Fauci AS, Kasper DL, Jameson JL, Hauser SL, Loscalzo J. Harrison's Principle of Internal Medicine. Vol. 2. New York, NY: McGraw Hill; 2010. p. 3473.  |
| 2. | Mahadevan L, Srividya S, Jeyalakshmi B. Dr. L. Mahadevan's Guide to Ayurvedic Clinical Practise Neurology. Vol. 2. Kanyakumari, Tamil Nadu, India: Sarada Mahadeva Iyer Ayurvedic Educational and Charitable Trust Derisanamscope; 2011. p. 300-1. |
| 3. | Longo DL, Fauci AS, Kasper DL, Jameson JL, Hauser SL, Loscalzo J. Harrison's Principle of Internal Medicine. Vol. 2. New York, NY: Mc Graw Hill; 2010. p. 3473. |
| 4. | Tripathi R. Charak Samhita of Charaka, Chikitsasthan, Vatvyadhi Chikitsa. Varanasi: Chaukhamba Sanskrit Series; 2009. p. 691. |
| 5. | Tripathi R. Charak Samhita of Charaka, Chikitsasthan, Vatvyadhi Chikitsa. Varanasi: Chaukhamba Sanskrit Series 2009. p. 701. |
| 6. | Mishra SN. Bhaishajya Ratnavali of Govindadas Sen, Jwaraadhikar. Varanasi: Chaukhamba Sanskrit Series; 2007. p. 218. |
| 7. | Kasture HS. Aayurvediya Panchkarmavidnyan of Haridas S Kasture, Sweda Vidnaniya. Nagpur: Baidyanath Aayurved Bhavan Publication; 7 th ed. p. 168. |
| 8. | Tripathi R. Charak Samhita of Charaka, Siddhisthan Bastisidhi. Varanasi: Chaukhamba Sanskrit Series; 2009. p. 966. |
| 9. | Mishra SN. Bhaishajya Ratnavali of Govindadas Sen Vatvyadhirogaadhikar. Varanasi: Chaukhamba Sanskrit series; 2007. p. 530. |
| 10. | Bhisagratna and Brahmasankar Sastri Yogratnakar - Dhatuprakaran (Rajat Bhasma) Shlok 1. Varanasi: Chaukhamba Sanskrit Series; 2010. p. 130. |
| 11. | Bhisagratna and Brahmasankar Sastri Yogratnakar - Amlapitta Chikitsa Shlok 1-5. Varanasi: Chaukhamba Sanskrit Series; 2010. p. 244. |
| 12. | Mishra SN. Bhaishajya Ratnavali of Govindadas Sen, Shodhan Maran gunadi prakaran. Chapter 3 verse 206-207. Varanasi: Chaukhamba Sanskrit Series Reprint; 2007. p. 60. |
| 13. | Kasture HS. Aayurvediya Panchkarmavidnyan of Haridas S Kasture, Sneha Vidnaniya. Chapter 2. 7 th ed. Nagpur, India: Baidyanath Aayurved Bhavan Publication; 2006. p. 118. |
| 14. | Longo DL, Fauci AS, Kasper DL, Jameson JL, Hauser SL, Loscalzo J. Harrison's Principle of Internal Medicine. Vol II, Part 17, Chapter 385. Entitled "GBS". New York, NY: McGraw Hill; 2010. p. 3476. |
| 15. | Shastri A. Sushrut Samhita of Sushruta Sharir Sthan, Garbhavyakaran. Chapter 4, Verse 16. Dalhan Commentary Chaukhamba Sanskrit Series. Varanasi: 2007. p. 59. |
| 16. | Singh SS, Pandey SC, Srivastav S. Chemical and medicinal properties of tinospora cordifolia. Indian J Pharmacol 2003;35:83-91.  |
| 17. | Krishna KL, Bhatt J, Patel J. Guduchi (Tinospora cordifolia): Biological and medicinal properties, a review. Internet J Altern Med 2009;6:10-5. |
| 18. | Harsh Mohan, Pathology Quick Review. Chapter 4. Entitled Immunopathology Including Amyloidosis. New Delhi: Jaypee Brothers, Medical Publishers; p. 48. |
| 19. | Joshi YG. Charak Samhita of Charaka, Vimansthan Rogbhishakjitiyaviman. Chapter 8, Verse 97-98. Pune: Vaidya Mitra Publications; 2003. p. 599. |
| 20. | Longo DL, Fauci AS, Kasper DL, Jameson JL, Hauser SL, Loscalzo J. Harrison's Principle of Internal Medicine. Volume II, Part 17, Chapter 385. Entitled "GBS". New York, NY: McGraw Hill; p. 3477. |
| 21. | Devasagayam TP, Tilak JC, Boloor KK, Sane KS, Ghaskadbi SS, Lele RD. Free radicals and antioxidant in human health: Current status and further prospects. J Assoc Physicians India 2004;52:794-804. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|
Search Pubmed for