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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 97-103

Effect of ayurveda treatment modalities in motor disabilities of children with cerebral palsy: A pilot clinical study


1 Department of Kaumarabhritya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India
2 Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India

Date of Submission28-Nov-2020
Date of Decision26-Apr-2021
Date of Acceptance16-Feb-2021
Date of Web Publication28-Jun-2021

Correspondence Address:
Dr. Shailaja Uppinakuduru
Department of Kaumarabhritya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan 573201, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jism.jism_112_20

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  Abstract 

Background: Cerebral Palsy (CP), is umbrella term which encompasses a broad spectrum of neurological impairments which requires multiple line of treatment. Ayurveda interventions for improving the motor disabilities can contribute in bringing out a better result in this condition. Objective: To evaluate the effect of Ayurveda treatment modalities in motor disabilities of children with cerebral palsy (CP). Materials and Methods: A single-centered, open-labeled, prospective, clinical trial was conducted at a tertiary care teaching hospital attached to Ayurveda Medical College located in district headquarters. Overall, 15 subjects affected with CP were administered with Ayurveda treatment modalities that are inclusive of Udwarthana (dry powder massage), Sarvanga Abhyanaga (oil massage), Sarvanga Parisheka (pouring of warm liquid over a desired body part), Shirodhara (pouring of warm liquid over the head), Upanaha (warm poultice), Matra Basti (medicated enema), and Karnapoorana (administering warm oil into the ear canals) for a period of 15 days. The subjects were assessed before and after treatment for spasticity, muscle power, and range of movements of joints. The data were collected by using a case report form designed for the study. Such collected data were tabulated and analyzed by using Statistical package for social sciences (SPSS, version 20) by using an appropriate statistical test. Results: The intervention was found to be effective in reducing spasticity as well as in improving the movement of joints at P < 0.05. Conclusion: Holistic Ayurveda treatment modalities can be beneficially implemented for treating spasticity in children with CP.

Keywords: Abhyanga, cerebral palsy, Matra Basti, motor disabilities, Upanaha, Ayurveda


How to cite this article:
Uppinakuduru S, Raj GA, Rao PN, Jyothsna M, Mallannavar V, Subrahmanya NK, Sagar K. Effect of ayurveda treatment modalities in motor disabilities of children with cerebral palsy: A pilot clinical study. J Indian Sys Medicine 2021;9:97-103

How to cite this URL:
Uppinakuduru S, Raj GA, Rao PN, Jyothsna M, Mallannavar V, Subrahmanya NK, Sagar K. Effect of ayurveda treatment modalities in motor disabilities of children with cerebral palsy: A pilot clinical study. J Indian Sys Medicine [serial online] 2021 [cited 2021 Oct 16];9:97-103. Available from: https://www.joinsysmed.com/text.asp?2021/9/2/97/319459




  Introduction Top


Cerebral palsy (CP) refers to a group of permanent disorders related to the development of movement and posture, causing activity limitation; these disorders are attributed to nonprogressive disturbances that occur in the developing fetal or infant brain.[1] CP is an umbrella term including spastic hemiplegia, spastic diplegia, spastic quadriplegia, ataxia, and dyskinesia.[2] The causes of CP are multifactorial, such as during the antenatal period, perinatal period, and the period of infancy.[3] Some of the causes, for example, are consanguinity, febrile illness to the mother during pregnancy, early rupture of membranes, prematurity, low birth weight, birth asphyxia, assisted delivery, bacterial meningitis during infancy etc. Spasticity is a motor disorder that is characterized by: (i) exaggerated tendon jerks (hyperreflexia) and (ii) increased muscle response to applied stretch, positively correlated with the lengthening rate (velocity-dependent hypertonia).[4] Spasticity occurs as a result of increased motor neuron excitability, increased intrinsic excitability, and absence of autogenic inhibition on gamma motor drive.[4] The incidence of CP in India is 3/1000 live births, among which 77.4% of the children are identified to be suffering with a spastic type of CP.[5]

CP can be considered as Shiromarmabhighataja Vatavyadhi, which may manifest itself in any of the following main clinical presentations: spastic monoplegia, spastic diplegia, spastic quadriplegia, hemiplegia, choreoathetoid, and ataxia, which are described under Vata Vyadhi in the texts.[6] The treatment of Shiromarmabhighata is carried out with oil massage, sudation, and warm poultice.[7] Previous studies have shown that dry powder massage, oil massage, warm poultice, pouring of warm liquid over a desired body part, pouring of warm liquid over the head, and medicated enema are effective in reducing spasticity, improving the muscle power, and improving the range of movement of joints when administered alone or in combination with a few among these.[8],[9],[10],[11],[12] By observing the several studies that have been conducted, it can be deduced that a single modality or fewer combinations of treatment(s) are not sufficient for treating diseases such as spastic CP. Hence, a treatment protocol was carved out from available literature and clinical experiences and previous research works. The current treatment protocol formulated was put in place to evaluate its effectiveness in motor disabilities of children with CP.


  Materials and Methods Top


Objective

To evaluate the effect of Ayurveda treatment modalities in motor disabilities of children with CP.

Research Design

A single-centered, open-labeled, prospective clinical trial was conducted at a tertiary care teaching hospital attached to Ayurveda Medical College located in district headquarters of Southern India.

Source of Data

Patients were selected successively from the outpatient department of Kaumarabhritya, a tertiary care teaching hospital attached to Ayurveda Medical College located in district headquarters. The study protocol and related documents were reviewed and approved by the Institutional Ethics Committee of the study center (SDM/IEC/121/2020), and the study was conducted in accordance with the WHO’s Good Clinical Practice Guidelines. The trial has been registered in the Clinical Trial Registry of India (CTRI/2020/10/028205).

Method of Collection of Data

Patients who fulfilled the criteria for diagnosis and inclusion were selected for the study.

Screening of Patients

The patients were screened from OPD/IPD regarding the diagnostic/inclusion/exclusion criteria mentioned earlier.

Diagnostic Criteria

  • Children with spasticity in one or all limbs with failure of coordination in spontaneous movements


  • Children with significant delayed milestones


  • Children presenting with exaggerated deep tendon reflexes and increased muscle tone as well as excessive extensor tone


  • Inclusion Criteria

    • 1) Children in the age group of 2 to 10 years of both gender


    • 2) Children whose parents are willing to sign the informed assent form


    • 3) If participant has a history of epilepsy, which is well controlled by medication


    Exclusion Criteria

    • 1) Mixed variety of CP


    • 2) Children with infectious diseases such as tuberculosis and meningitis


    • 3) Children with poor controlled epilepsy, recurrent status epilepticus, intractable seizures, complex seizures, juvenile diabetes mellitus, and severe cognitive impairment


    • 4) Children with severe motor handicap and deformities from long-standing spasticity


    • 5) Children with CP with congenital malformations, other systemic illness such as congenital heart disease, and nephrotic syndrome will be excluded from the study.


    • Study duration: 15 days


    • Sample size: 15


    • Intervention plan: Detailed in [Table 1] and [Table 2]


    • Laboratory investigations: Complete blood count
    Table 1: Intervention plan

    Click here to view
    Table 2: Intervention plan

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      Assessment Criteria Top


    The assessment of subjects was done before and after 15 days of intervention. However, the following laboratory investigations (complete blood count) were performed only before the treatment:

    • 1) Goniometer[13]
      • Shoulder – Flexion: 0–180


      • Extension: 0–40


      • Abduction: 0–180


      • Internal rotation: 0–80


      • External rotation: 0–90


      • Elbow – Flexion: 0–150


      • Wrist – Flexion: 0–60


      • Extension: 0–60


      • Radial deviation: 0–20


      • Ulnar deviation: 0–30


      • Hip – Flexion: 0–100


      • Extension: 0–30


      • Abduction: 0–40


      • Adduction: 0–20


      • Internal rotation: 0–40


      • External rotation: 0–50


      • Knee – Flexion: 0–150


      • Ankle – Plantar flexion: 0–40


      • Dorsiflexion: 0–20


    • 2) Power of the limbs[14]

      • 0: Complete paralysis


      • 1: Flicker of contraction


      • 2: Movement if gravity excluded


      • 3: Movement against gravity


      • 4: Moderate power against resistance


      • 5: Normal power


    • 3) Modified Ashworth scale for spasticity[15]

      • a. 0: No increase in muscle tone


      • b. 1: Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension


      • c. 1+: Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the range of motion


      • d. 2: More marked increase in muscle tone through most of the range of motion, but affected part(s) easily moved


      • e. 3: Considerable increase in muscle tone, passive movement difficult


      • f. 4: Affected part(s) rigid in flexion or extension




    Statistical Analysis

    • ➢ Data were collected by using a case report form designed by incorporating all aspects (Ayurveda and Modern) for the study. Such collected data were tabulated and analyzed by using SPSS Version 20 by using appropriate statistical tests. Demographic data and other relevant information were analyzed with descriptive statistics. Continuous data were expressed in mean ± standard deviation, and nominal and ordinal data were expressed in percentage.


    • ➢ Friedman test is used to analyze the significance of change in subjective parameters.


    • ➢ Paired t-test is done for objective parameters.


    Observations

    In the present study, 15 subjects diagnosed with spastic CP were enrolled. One subject was younger than three years, seven subjects were in the age group of three years to four years, five subjects were in the age group of five years to seven years, and two subjects were in the age group of seven years to 10 years. Overall, 12 subjects were male and three subjects were female. One subject was hemiplegic, five subjects were diplegic, and nine subjects were quadriplegic. Two subjects were born out of consanguineous marriage, five subjects were from a nuclear family, and 10 subjects were from a joint family. Two subjects had a history of fetal distress, eight subjects had a history of prematurity, two subjects had a history of birth trauma, one subject had the required neonatal resuscitation, four subjects did not have any significant history, seven subjects were born out of normal vaginal delivery, two subjects were born out of forceps-assisted vaginal delivery, one subject had vacuum-assisted vaginal delivery, five subjects were born out of lower segment Caesarean section, four subjects did not cry immediately after birth, three subjects had a history of convulsion, one subject had a history of respiratory distress syndrome, one subject had a history of neonatal jaundice, and six subjects did have significant neonatal complications.

    Out of the 100 joints that were assessed, 12 joints had grade 1 spasticity, 25 joints had grade 1+ spasticity, 32 joints had grade 2 spasticity, 25 joints had grade 3 spasticity, and six joints had grade 4 spasticity on Ashworth spasticity scale. Out of the 100 joints that were assessed for muscle power, eight joints showed the power of grade 1, 45 joints had the power of grade 2, 40 joints had the power of grade 3, and seven joints showed the power of grade 4. Out of the 29 knee joints that were assessed, seven joints had goniometric measurements between 140° and 150°, six joints had from 151° to 160°, eight joints had from 161° to 170°, and eight joints from 171° to 180°. Out of the 29 ankle joints that were assessed, nine joints had a 100° to 110° angle, nine joints had a 111° to 120° angle, seven joints showed a 121° to 130° angle, and four joints showed a 131° to 140° angle. Out of the 18 joints that were assessed, nine joints had a 140° to 150° angle, one joint showed a 151° to 160° angle, five joints showed a 161° to 170° angle, and three joints showed a 171° to 180° angle. Out of the 17 wrist joints that were assessed, two joints showed a 120° to 140° angle, one joint showed a 150° to 160° angle, and 14 joints showed a 160° to 180° angle.


      Results Top


    The effect of intervention on the Ashworth spasticity scale of knee joints is detailed in [Table 3]. When Freidman test was applied, there was found to be a statistically significant reduction in the level of spasticity in 15 right knee joints with χ2 =15,000, P < 0.05. There was also found to be a statistically significant reduction in the level of spasticity in 14 left knee joints with χ2 = 13,000, P < 0.05. The effect of intervention on the Ashworth spasticity scale of ankle joints is detailed in [Table 4]. When Freidman test was applied, there was no statistically significant reduction in the level of spasticity in 15 right ankle joints with χ2 =3.571, P = 0.059. There was a statistically significant reduction in the level of spasticity of 14 left ankle joints with χ2 = 5.000, P < 0.05. The effect of intervention on the Ashworth spasticity scale of elbow joints is detailed in [Table 5]. When Freidman test was applied, there was a statistically significant reduction in the level of spasticity in 11 right elbow joints with χ2 =7.000, P < 0.05. There was a statistically significant reduction in the level of spasticity in 10 left elbow joints with χ2 = 8.000, P < 0.05. The effect of intervention on the Ashworth spasticity scale of elbow joints is detailed in [Table 6]. When Freidman test was applied, there was a statistically significant reduction in the level of spasticity in 11 right wrist joints with χ2 =7.000, P <0.05. There was a statistically significant reduction in the level of spasticity of 10 left wrist joints with χ2 = 6.000, P < 0.05. The effect of intervention on the muscle power of right knee joints is detailed in [Table 7]. When Freidman test was applied, it was found that there was no statistically significant improvement in the muscle power of all the joints with p-value >0.05. The effect of intervention on the goniometric measurement of the knee joints is detailed in [Table 8]. When paired ‘t’ test was applied on the goniometric measurements of the given sample, it was found to be statistically significant at all joints with p-value <0.05, except the left wrist joint with p-value >0.05.
    Table 3: Effect of intervention on Ashworth spasticity scale of knee joints

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    Table 4: Effect of intervention on Ashworth spasticity scale of ankle joints

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    Table 5: Effect of intervention on Ashworth spasticity scale of elbow joints

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    Table 6: Effect of intervention on Ashworth spasticity scale of wrist joints

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    Table 7: Effect of intervention on muscle power of right knee joint

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    Table 8: Effect of intervention on goniometric measurement of the knee joint

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      Discussion Top


    Udwarthana was done to create mild Rukshana (dryness) in the body due to its Sukshma Guna (fineness), so as to increase the uptake of Sneha (oily substance). Its dryness-inducing and blockage-removing properties help in the reduction of vitiated Kapha. In chronic diseases such as CP, there will be increased Aavarana (blockage) and once the same is removed, the vitiated Vata can be pacified by further treatment.[16] It also opens the minute channels and improves blood as well as lymphatic circulation.

    The massaging helps in passive stretching of the muscle, activation of the golgi tendon organ, which results in the transmission of impulses to the spinal cord. From the spinal cord, the impulses are transmitted to a higher center. The inhibitory association neurons of the higher center send the impulses to relax the muscles. This golgi tendon organ-mediated relaxation of muscle fibers can be stretched without producing any further damage, and also it is useful in the development of proper flexibility. The abhyanga done in a specific direction causes the absorption of medicated oil into the sweat glands and sebaceous glands and results in faster absorption through the stratum corneum.[17] Here, Abhyanga with TilaTaila (seasum oil) is administered to induce Dardhyata (compact) to the body. There is a reduction of Prakupitha (vitiated) Vata Kapha, as Tila Taila is of Ushna Virya (hot potency), Snigdha Guna (unctuous property).

    Parisheka is a form of Swedana and it does Sthambhaghnata (reduces stiffness), thus it clears the Srothosanga (blockage of minute channels). As there is a pouring of liquid that is of a higher temperature than the body temperature, it causes an increase in the local blood circulation and thus clears the channels and performs better absorption. The increased blood supply will result in increased oxygen supply to the target organ, resulting in better relaxation of the muscle. Gouravaghnata (reduces heaviness), when Parisheka is done, increases sweating, thereby removing the impurities of the body, stimulating the nerve endings, and relaxing the muscle. Parisheka stretches the connective tissue and adhesions, thereby decreasing stiffness, increasing the tissue temperature and blood flow of the particular part of the body, and resulting in increased nerve conduction velocity, thereby improving the active flexion and extension function of the muscle.[18],[19] Here, Dashamula Kashaya is used since it has both Vata Kaphahara qualities; due to its Ushna Teekshna (penetrating) Guna, it has the ability to enter the Sukshma Srotas. It helps in muscle relaxation.

    Shirodhara is the continuous pouring of liquid over the Shiras; this helps in the relaxation of nerve fibers that are involved in the continuous contraction of the myofibrils, thereby relaxing the affected part of the body. The effect of Shirodhara is enhanced by the hollow sinuses in the frontal region.[20] The Shirodhara will decrease the beta waves, increase the alpha rhythm, and increase in the right–left coherence.[21] Here, the beta waves represent the anxiety dominant activity with a frequency of 12–35 Hz. The alpha waves represent a very relaxed state with a frequency of 8–12 Hz, thereby relaxing the muscles all over the body.

    Upanaha involves tying the heated medicated paste over the affected part and leaving it for a period of time; it stimulates the nerve fibers, golgi tendon apparatus and improves the relaxation of the muscle.[22] The tying may also help in reducing the space in between the myofibrils, which reduces the deposition of collagen tissue and reduces the formation of early contractures and fibrosis.

    Matra Basti is a type of Sneha Basti (oil enema) in which medicated oil is given in a small dose, and it can be given daily with no risk.[12]Matra Basti (oil enema in small dose) is said to be Balya (strengthening), Brimhana (nourishing), and Vatarogahara (eliminates neurological disorders). Pakwashaya (large intestine) is the Moola Sthana (main seat) of Vata Dosha. Basti, by its action on the Moola Sthana, gets control on Vata all over the body. The rectum has a rich blood and lymph supply; drugs can cross the rectal mucosa like any other lipid membrane; and on entering the general circulation, Basti acts on the whole body. Basti may block neuromuscular transmission by binding to receptor sites on motor or sympathetic nerve terminals, entering the nerve terminals, and probably inhibiting the release of acetylcholine. Matra Basti provides more nourishment to deeper Dhatu’s (tissues). Basti improves fine motor functions, general motor functions such as crawling, sitting, standing, walking, and clasping hands in patients with CP. When compared with internal medicines, Basti has improved fine and gross motor functions in CP cases.

    Improvement in the neuronal synapses, protection of the neurons from injury, and the regeneration/ adaptogenic nature of the drugs help in the reduction of spasticity. Hence, from the earlier discussion, it is clear that spasticity cannot be cured completely but reduction can be attained, thereby improving the normal range of movement of the joints, which, in turn, results in the attainment of normal routine activities. Repeated treatment has to be administered to achieve improvement and at a younger age itself, which shows the importance of early intervention in neurodevelopmental disorders. In the present study, a reduction in spasticity along with improved movement of joints was observed.


      Conclusion Top


    The response to the treatment depends on the type of CP and the extent of injury to the developing brain: the lesser the injury, the better the response. In the present study, improvement has been observed in the movement of joints along with a reduction in spasticity. From this study, it can be concluded that a single modality of treatment is not sufficient to treat CP, so the approach should be holistic.

    Financial Support and Sponsorship

    Nil.

    Conflicts of Interest

    There are no conflicts of interest.



     
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        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



     

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