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| CASE REPORT |
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| Year : 2020 | Volume
: 8
| Issue : 4 | Page : 313-319 |
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Management of cauda equina syndrome by Ayurveda: A case study
Abhishek Bhattacharjee1, Seema Malakar2
1 Department of Panchakarma, College of Ayurveda, Shillong, Meghalaya, India
2 Ayurveda Hospital, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
| Date of Submission | 30-Aug-2020 |
| Date of Decision | 10-Dec-2020 |
| Date of Acceptance | 02-Jan-2021 |
| Date of Web Publication | 11-Feb-2021 |
Correspondence Address:
Dr. Abhishek Bhattacharjee
Department of Panchakarma, College of Ayurveda, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JISM.JISM_83_20
Cauda equina syndrome (CES) is a rare but potentially morbid condition which may cause permanent neurological disability in the form of motor and sensory dysfunctions of the lower extremities, impaired bladder, bowel, and sexual function. Different underlying pathological conditions may give rise to CES, of which a herniated lumbar intervertebral disc is the most common cause. In the present case study, a 62-year-old male patient who was diagnosed as a case of CES due to an extruded L4/L5 disc and refused to undergo surgery and wanted to go for Ayurveda treatment was admitted to the Panchakarma IPD, Ayurveda Hospital, NEIAH, Shillong. He was treated following the principles of Avarana Janya Vatavyadhi (diseases caused by Vata when vitiated due to obstruction in its normal flow) with oral medications and Panchakarma therapy. Improvement in the condition of the patient in terms of pain relief, bladder control, improvement of motor power, walking capacity, straight leg raising test (SLRT), etc. were observed after the completion of treatment and during the first follow-up after 1 month. Keywords: Avarana Janya Vatavyadhi, cauda equina syndrome, Panchakarma
How to cite this article:
Bhattacharjee A, Malakar S. Management of cauda equina syndrome by Ayurveda: A case study. J Indian Sys Medicine 2020;8:313-9 |
| Introduction | |  |
Cauda equina syndrome (CES) is a neurological condition in which injury to multiple lumbosacral nerve roots (poly radiculopathy) within the spinal canal distal to the termination of the spinal cord at L1-L2 takes place due to nerve compression or inflammation of the lower spinal cord.[1] Though it is a rare condition and is estimated to account for fewer than 1 in 2000 patients with severe low back pain,[2] when suspected it should be investigated properly as delayed diagnosis may lead to permanent neurological deficit. The commonest identified underlying pathology responsible in the causation of CES is a large lower lumber intervertebral herniated disc, prolapsed disc, or sequestration of an extruded disc. Less common causes are primary and metastatic tumors, spinal stenosis, hematoma formation, infection, and inflammatory and vascular pathologies, as a post-surgical complication, after manipulation, after chemonucleolysis, after spinal anesthesia, gunshot injury, etc.[3],[4] CES commonly presents with motor and sensory abnormalities affecting the lower limbs associated with bladder and bowel dysfunction.[5] Bilateral neurogenic sciatica, reduced perineal sensation, altered bladder function ultimately resulting into painless urinary retention, loss of anal tone, and sexual dysfunction are the five characteristic features most commonly seen in case of CES.[6] All the features may or may not be present in any individual patient. No specific symptom or sign or combination reliably diagnoses (or excludes) CES.[7] A clinical diagnosis of CES can be correctly done only if the lesion is severe enough to produce the characteristic neurological presentation and, in such cases, often the neurological deficits become irreversible.[8] So, for the confirmation of diagnosis in a suspected case of cauda equina compromise an urgent magnetic resonance imaging (MRI) has been recommended.[9] In a confirmed case of CES better outcome is expected if surgery is performed early[10] and in that case the chance of complication also gets reduced.[11] In many cases, good improvement could be seen in spite of delayed surgery, so even if surgery is performed late (commonly due to delayed diagnosis), significant improvement can still be expected.[12] Some case studies even show the possibilities of non-surgical management of CES.[13],[14],[15]
CES cannot be directly correlated with a single disease entity mentioned in Ayurvedic classics. Considering its stages and different presentations, some clinical similarity can be observed with Gridhrasi, Khanja, and Pangu. If we analyze the underlying pathology of the condition, then it is seen that Vata is the main Dosha involved. Among five types of Vata, Apana Vayu and Vyana Vayu seem to be mostly involved, considering the site of pathology and clinical manifestation. As in most of the conditions, the causative factor is a large herniated lumbar disc, a neoplastic lesion, or a hematoma compressing the cauda equina nerve roots interrupting the signal transmission, so it can be considered as Avarana (obstruction) in the Vata Vaha Srotas present in the Adho Nabhi (below umbilicus) area leading to mainly Apana Vayu and Vyana Vayu Dusti, resulting in sensory, motor, bladder, bowel, and sexual dysfunction.
| Case Presentation | | |
A 62-year-old male patient, resident of Shillong, came to Panchakarma OPD of Ayurveda Hospital, North Eastern Institute of Ayurveda and Homoeopathy (NEIAH), Shillong with the complaints of severe low back pain radiating to both lower extremities with heaviness and numbness for 4 days. There was mild weakness in both the legs, and patient was unable to walk without support. He added that in the last 2 days the pain and numbness was so severe that he could not even sleep for last two nights. According to the patient, the pain used to be worse when he sat or stood; on the contrary, lying down in supine position used to give him a bit relief. He also complained on and off urinary incontinence since last 2 days along with constipation. Patient was taking Tab. Diclofenac sodium 100 mg SOS since last 3 days and he was getting relief for 4–6 h after which pain again used to get aggravated. He had a long history of low back pain since about 15 years which got started after a fall during climbing stairs. He was a known case of hypertension and is on Amlodipin 5 mg daily morning. He had no other significant medical or surgical history apart from his chronic low back pain and hypertension.
On personal history, the patient worked as a police constable and after retirement was working as a shopkeeper. He was from lower-middle socio-economical class. His diet and sleep habit were irregular and he used to have constipation on and off. He was alcoholic since last 30 years and also had habit of smoking and chewing kowai (betel nut).
On physical examination, the patient was alert and oriented and his vital signs were stable. On palpation, he had tenderness over L4/L5, L5/S1 area of the low back, over the buttocks, and over the course of bilateral sciatic nerve. On examination, his straight leg raising test (SLRT) was 15° in the right leg and 30° in the left leg. Lasegue’s sign was positive in both sides. Motor strength in both lower extremities was decreased to four (4). Examination of the deep tendon reflexes showed normal knee jerk (patellar reflex) on the left, but knee jerk (patellar reflex) was diminished on the right. Ankle jerk (Achilles tendon reflex) was diminished bilaterally. Sensory function examination revealed hypoesthesia in the right foot, anterior aspect of right thigh, and in the perianal area.
MRI was advised to be done immediately which revealed multiple disc desiccations with a centrally extruded disc in the L4-L5 level with significant compression over the adjacent cauda equina nerve roots. Routine examination of blood and urine, fasting blood sugar, glycosylated hemoglobin, renal function test (RFT), and liver function test (LFT) was found within normal limits. Seeing the MRI report, patient was immediately referred to a neurosurgeon at North Eastern Indira Gandhi Regional Institute of Health and Medical Science (NEIGRIHMS), where his diagnosis was confirmed as CES and he was advised to undergo surgery within 2 days. He was also explained about the uncertain outcome of the surgery by the neurosurgeon. The patient and his relatives were unwilling to undergo surgery and wanted to take Ayurvedic treatment. Patient and his relatives were explained thoroughly about the condition, risk factors, and probable complications that may arise if patient does not undergo surgery. But they took decision to take Ayurvedic treatment, so the patient was admitted in the Panchakarma Male ward of Ayurveda Hospital, NEIAH, Shillong after taking proper written consent.
On admission, the patient was examined as per Ayurvedic perspective based on the principles of Rogi Pariksha (specialized patient examination criteria mentioned in Ayurveda), following the criteria of Dashavidha Pariksha (10-fold examination of the patient), Astavidha Pariksha (8-fold examination of the patient), Srota Pariksha (systemic examination) etc., and the disease was analyzed based on the principles of RogaPariksha or Pancha-Nidana (five criteria to analyze a disease condition mentioned in Ayurveda). On Dashavidha Pariksha, Prakriti (inherent nature of an individual) of the patient was found to be Vata-Pitta-predominant; Vata Dosha, especially Vyana and Apana Vayu, was vitiated. The status of Dhatu Sara (quality of the body tissues) of the patient was Avara/Hina (inferior), Samhanana (compactness of the body) was Madhyama (medium), Satva (mental state) was Hina/Avara, patient was found to be Avara Satmya, Pramana (measurements) of the different body parts was normal, Ahara-Shakti (digestion) of the patient was Madhyama, Vyama-Shakti (Physical power) of the patient was Hina, and Vayah (age) was 62 years. On Astavidha Pariksha (8-fold examination), Nadi (examination of pulse in Ayurveda) was Vata Pradhananadi, in Mutra Pariksha (urine examination as per Ayurveda) urinary incontinence was observed, Mala (stool) was Vaddha (constipated), Jihva (tongue) was Nirama (normal), Shabda (voice and other body sounds) was normal, Sparsha was Ruksha (dry), Drik (vision/eye) was normal, and Akriti (body structure) was Krisha (lean and thin).
The disease evaluation and analysis were done based on the criteria of Nidana Panchaka, and the following observations were recorded. Improper and irregular diet habit (Laghu, Ruksha, and Alpa Ahara), ethanol abuse (Madyapana), late night sleeping habit (Ratri Jagarana), abnormal posture (Utkatasana), standing for long time, injury due to fall (Abhighata), etc. was identified as probable Nidana (causative factor). Before developing all the features, the patient experienced numbness and pain in both legs and low backache with lower intensity, which can be considered as Purvarupa (prodromal features) of the disease. The presenting features suggest the condition as Vata-Vyadhi, and if we analyze from the understanding of modern system of medicine then it seems to be Avarana Janya Vata-Vyadhi. Lying down on bed in supine position, massage with warm oil, and hot fomentation used to give him comfort so can be considered as Upashaya (relieving factors); on the contrary, standing, walking, or bending forward caused more pain hence considered as Anupashaya (aggravating factors).
| Intervention | | |
In the beginning, the patient was advised Vrihat Vatchintamoni Ras,[16],[17]Agnitundi Vati,[18],[19]Trayodashanga Guggulu,[18],[20] andMaharasnadi Kwath[21],[22] for 8 days to achieve Ama Pachana, Agni Dipana, removal of the Avarana of Kapha, and for Srota Sodhana. After 8 days, Aswagandharista[22],[23] and capsule Maharajaprasarini (which contains 600 mg of 21 times Avartita Maharajaprasarini Taila[24]) were added for Vata Shamana and Dhatu Poshana. Eranda Taila[25] was advised at bed time for Vata Anulomana, which is an important treatment protocol for vitiated Apana Vayu.
Along with oral medication Dhanyamla dhara[26] to the low-back and lower extremities was advised for the first 3 days for the removal of Avarana of Kapha and for Srota Sodhana. After 3 days, Kativasti[27] with Mahavishagarbha Taila[28],[29] and gentle application of Mahavishagarbha Taila to the both legs followed by Nadiswedana[30] (using Dashamula, Eranda, Dhatura, and Nirgundi leaves) were continued for Vata-Kapha Shamana. From the first day, patient was advised Vaitarana Vasti[31] continuously for 8 days considering the Avaraka Dosha, i.e., Kapha followed by Matravasti[32] with Dhanvantaram Taila[33] for another 14 days for Vata Shamana and Dhatu Poshana. During the hospital stay, patient was in total bed rest and Amlodipin 5 mg was also continued. Patient was given nutritious diet containing egg, meat soup, fresh fruits and vegetables, milk, etc., as per the advice of dietician.
Patient was discharged on 24th day (from the day of hospital admission) with the following medications—VrihatVatchintamoniRas 125 mg daily morning in empty stomach, Trayodashanga Guggulu 500 mg 8 hourly after food, Mahavat Vidhwangsan Ras[34] 125 mg 8 hourly after food, Aswagandharista 20 mL 12 hourly with equal water after food, capsuleMaharajaprasarini[24] one capsule 12 hourly in empty stomach with warm water. Eranda Taila 10 mL was continued at bed time with 40 mL of Dashamula kwath.[35],[36]Mahavishagarbha Taila was advised for external application to the low back and the lower extremities. He was called for follow up after 1 month and was advised to report immediately if any problem arises in between [Table 1] and [Table 2].
| Result | | |
After the completion of treatment at hospital, significant improvement was observed in the patient’s condition. Pain was relieved by about 60%. Numbness was felt occasionally. Patient could stand and walk for about 5–10 min without much difficulty, but walking more than 10 min or climbing stairs was still difficult and trying to do so was aggravating the pain. There was still subjective feeling of weakness in the lower extremities, although the muscle power in both the legs was normal. In SLRT, patient was able to raise his right leg up to 45° and left leg about 60°. The bladder control was better and there was no complaint of constipation.[37][38][39][40][41][42]
On the first follow-up after 1 month, better improvement was observed in terms of pain, numbness, and weakness in the lower extremities. Pain was relieved by about 80%, numbness was occasionally present but was not causing much discomfort. He could walk better. There was no complaint regarding the bowel and bladder function and during SLRT, he could raise the right leg up to 50° and left leg up to 80° [Table 3] and [Table 4].
| Discussion | | |
This case study shows a possibility of managing CES conservatively through Ayurvedic approach in patients in whom surgery is not possible. In this case of CES, the degenerated extruded L4-L5 disc caused compression over the cauda equine nerve roots resulting in the development of all the signs and symptoms which indicate the suppression of Vata functions like difficulty in walking due to motor weakness (motor function) and pain in the legs, reduced sensory perception, bladder incontinence, constipation (Apana Dusti), etc. In contrast, some abnormal Kapha symptoms like heaviness (Gaurava), numbness (Supti), etc. in the legs were also observed, which suggests Avarana of Kapha over Vata, specially Apana Vayu and Vyana Vayu. From the understanding of the underlying pathology (from the perspective of modern medical science) in this condition, it can be understood that the extruded disc caused obstruction (Sanga/Srota Avarodha) to the Vata Vaha Srotas present in the spinal cord and the lower extremities resulting in obstruction to the circulation of Vata causing Vata vitiation leading to development of the signs and symptoms.
Considering the condition as Marga Avarodha Janya Vata Vyadhi, the treatment was planned. So, in the beginning for the treatment of Avaraka (obstructing) Kapha Dosha, the drugs which possess Ruksha Guna (roughness), Ushna Guna (hotness), Tikshna Guna (sharpness), and Sukshma Guna (penetrating) having predominantly Tikta (bitter) and Katu (pungent) Rasa with Agni Dipana (stimulating digestion and metabolism), Amapachana (capable of digesting Ama), and Srota Sodhana (capable of cleansing the channels) properties were selected. Later, the treatment of Avrita (obstructed) Vata Dosha was given more importance using drugs having Ushna Guna (hotness), Guru Guna (heaviness), Snigdha Guna (unctuousness) and which are having Bringhana (nourishing), Dhatu Poshana (nourishing the tissues) and Vata Anulomana (capable of facilitating the downward flow of Vata) properties.
In the beginning of Panchakarma therapy, Dhanyamla Dhara was administered as Vahih Parimarjana Chikitsa (external cleansing procedure) and Vaitarana Vasti as Antah Parimarjana Chikitsa (internal cleansing procedure) for the Avaraka Kapha Dosha. Both of these therapies are Kapha Vatahara, Vivandhaghna (removes obstruction), Srotosodhana (clear channels), Ama Hara, Agni Dipana, and Vataanulomana in nature, so they treat the Avaraka Kapha Dosha without further increasing the Avrita Vata Dosha. After that Kati Vasti with Mahavishagarbha Taila followed by Nadi Swedana were given considering Kati (Lumbosacral region) as the main Adhisthana (site) of the disease and this might have helped in Samprapti Vighatana (disintegration of pathogenesis)of the disease. Matra Vasti was given after Vaitarana Vasti, as Sneha Vasti has been considered as the best therapeutic modality for Vata Dosha, especially in case of Adhonabhigata Vatavikara (diseases occurring below umbilicus due to Vata vitiation).
| Conclusion | | |
Based on the clinical features and the underlying pathology, the present case of CES has been considered as Avarana Janya Vatavyadhi and the treatment principle of the same was also followed which has shown appreciating result. This was a single case study so that the effectiveness of this treatment protocol cannot be claimed in CES but it may be tried as an alternative way for the management of CES in patients for whom surgery cannot be advised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Panos G, Watson DC, Karydis I, Velissaris D, Andreou M, Karamouzos V, et al. Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: A case report and review of the literature. J Med Case Rep 2016;10:165.  |
| 2. | Tait MJ, Chelvarajah R, Garvan N, Bavetta S Spontaneous hemorrhage of a spinal ependymoma: A rare cause of acute cauda equina syndrome: A case report. Spine (Phila Pa 1976) 2004;29:E502-5. |
| 3. | Fraser S, Roberts L, Murphy E Cauda equine syndrome: A literature review of its definition and clinical presentation. Arch Phys Med Rehabil 2009:90:1964-8. |
| 4. | Gardner A, Gardner E, Morley E Cauda equine syndrome: A review of the current clinical and medico-legal position. Eur Spine J 2011;20:690-7. doi:10.1007/s00586-010-1668-3 |
| 5. | Woodfield J, Hoeritzauer I, Jamjoom AAB, Pronin S, Srikandarajah N, Poon M, et al; British Neurosurgical Trainee Research Collaborative (BNTRC). Understanding cauda equina syndrome: Protocol for a UK multicentre prospective observational cohort study. BMJ Open 2018;8:e025230. |
| 6. | Todd NV, Dickson RA Standard of care in cauda equine syndrome. Br J Neuros2016;30:518-22. |
| 7. | Balasubramanian K, Kalsi P, Greenough CG, Seetharam MPK . Reliability of clinical assessment in diagnosing cauda equine syndrome. Br J Neuro Surg 2010;24:383-6. https://doi.org/10.3109/02688697.2010.505987 |
| 8. | Domen PM, Hofman PA, van Santbrink H, Weber WE Predictive value of clinical characteristics in patients with suspected cauda equina syndrome. Eur J Neurol 2009;16:416-9. |
| 9. | Bell DA, Collie D, Statham PF Cauda equina syndrome: What is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 2007;21:201-3. |
| 10. | Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber A, Kostuik J, et al. Cauda equine syndrome secondary to lumber disc herniation: A meta-analysis of surgical outcomes. Spine 2000:25:1515-22. |
| 11. | DeLong WB, Polissar NL, Neradilek MB, Laam LA Does early surgical decompression in cauda equina syndrome improve bladder outcome?: Comments on a recent study by Srikandarajah et al. Spine (Phila Pa 1976) 2016;41:1772-5. |
| 12. | Aly TA, AboRamadan MO Efficacy of delayed decompression of lumber disc herniation causing cauda equine syndrome. Orthopedics 2014;35:e153-6. https://doi.org/10.3928/01477447-20140124-18 |
| 13. | Park JW, Hur JW, Lee JB, Park J-Y. Non-surgical treatment for cauda equina syndrome after lumbar epidural block. Asian J Pain 2017;3:36-8. |
| 14. | Khurana R, Arora SK, Hemal A, Arorab S. Successful non-operative management of cauda equine syndrome in a case of thalassemia major. Pediat Hematol Oncol J 2016;1:41-2. http://dx.doi.org/10.1016/j.phoj.2016.07.004 |
| 15. | Grammaticos P, Papadopoulos N, Tarazi L, Katsarkas D Cauda equina syndrome. An emergency, some unexpected severe symptoms and conservative treatment. Hell J Nucl Med 2016;19:277-80. |
| 16. | Pathak R Ayurved Sara Sangraha. Allahabad: Shri BaidyanathAyurved Bhavan; 2006. p. 346. |
| 17. | Mahadevan L Dr L Mahadevan’s guide to Ayurvedic Clinical Practice (vol-1). 2nd ed. Tamilnadu: Publisher Dr Y Mahadeva Iyer’s Sri Sarada Ayurvedic Hospital; 2012. p. 355. |
| 18. | Pathak R Ayurved Sara Sangraha. Allahabad: Shri BaidyanathAyurved Bhavan; 2006. p. 516. |
| 19. | Mahadevan L Dr L Mahadevan’s guide to Ayurvedic Clinical Practice (vol-1). 2nd ed. Tamilnadu: Publisher Dr Y Mahadeva Iyer’s Sri Sarada Ayurvedic Hospital; 2012. p. 354. |
| 20. | Sharma PV, editor. Chakradatta (Sanskrit text with English translation). Varanasi: Chaukhamba Orientalia; 2013. p. 192. |
| 21. | Pathak R Ayurved Sara Sangraha. Allahabad: Shri BaidyanathAyurved Bhavan; 2006. p. 714. |
| 22. | Mahadevan L Dr L Mahadevan’s guide to Ayurvedic Clinical Practice (vol-1). 2nd ed. Tamilnadu: Publisher Dr Y Mahadeva Iyer’s Sri Sarada Ayurvedic Hospital; 2012. p. 349. |
| 23. | Pathak R Ayurved Sara Sangraha. Shri BaidyanathAyurved Bhavan, Allahabad. 2006. p. 631. |
| 24. | Sharma PV, editor. Chakradatta (Sanskrit text with English translation). Varanasi: Chaukhamba Orientalia; 2013. pp. 209-13. |
| 25. | Tripathi B, editor. Astangahridayam of SrimadVagbhata. Delhi: Chaukhamba Sanskrit Pratisthan; Reprint edition 2009. p. 77. |
| 26. | Jain A A text book of panchakarma. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2019. pp. 167-8. |
| 27. | Jain A A text book of panchakarma. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2019. pp. 171-3. |
| 28. | Mahadevan L Dr L Mahadevan’s guide to Ayurvedic Clinical Practice (vol-1). 2nd ed. Tamilnadu: Publisher Dr Y Mahadeva Iyer’s Sri Sarada Ayurvedic Hospital; 2012. p. 341. |
| 29. | Pathak R Ayurved Sara Sangraha. Allahabad: Shri BaidyanathAyurved Bhavan; 2006. p. 692. |
| 30. | Kar PK Principles and practice of panchakarma. 1st ed. Hoogly, West Bengal: Sunita Biswas for Chhonya; 2012. pp. 233-5. |
| 31. | Dvivedi R, editor. Chakradatta of Chakrapanidatta with vaidyaprabha Hindi Commentary. Varanasi: Chaukhamba Publication; 2002. p. 455. |
| 32. | Kasture HS Ayurvediya Panchakarma Vigyan (hindi). Allahabad, UP: Shree BaidyanathAyurved Bhawan; Reprint edition 2019. pp. 396-7. |
| 33. | Panditrav DB, editor. Sahasra Yoga (Hindi—Anuvad). New Delhi: Central Council for Research in Ayurvedic Science; 2003. pp. 260-1. |
| 34. | Pathak R Ayurved Sara Sangraha. Allahabad: Shri BaidyanathAyurved Bhavan; 2006. p. 349. |
| 35. | Pathak R Ayurved Sarsangraha. Allahabad, UP: Shri BaidyanathAyurved Bhavan; 2006. pp. 708-9. |
| 36. | Nistheswar K, Vidyanath R, editors. Sahasrayogam. Varanasi: Choukhamba Sanskrit Series; 2008. p. 384. |
| 37. | Ranasinghe RLDS, Ediriweera ERHSS A pharmacological appraisal of dhanyamla. Int Ayurvedic Med J 2015;3:778-97. |
| 38. | Aswani PS, Ratha KK, Dighe DP, Rao MM, Vijayan R . Vaitarana Vasti—A conceptual study. Res J Pharmacol Pharmacodyn 2018;10:45-50. |
| 39. | Sharma AK, Gupta OP A clinical study on kativasti and yogasana in the management of katishoola with special reference to low backache. Int Ayurvedic Med J 2017;1:564-73. |
| 40. | Dvivedi AK, Sharma AK Clinical evaluation of the efficacy of a herbal preparation and kativasti in the management of Gridhrasirogawsr to sciatica. Int Ayurvedic Med J 2015;3: 22-37. |
| 41. | Jacob S, Anandaraman PV, Namboothiri P, Prathibha CK. A clinical study to evaluate the effect of churnapindasweda with nadisweda in manyastambha. Ayurpharm Int J Ayur Alli Sci 2017;6:1-7. |
| 42. | Tripathy R, Namboothiri P, Otta SP Open level comparative clinical trial of dvipanchamooladi and kheerabalatailamatravasti in the management of low back ache. Int J Ayurveda Pharma Res 2016;4:19-26. |
[Table 1], [Table 2], [Table 3], [Table 4]
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