A case study on the Ayurvedic management

of cerebral palsy
Sagar Mahendrabhai Bhinde
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Abstract
Cerebral palsy (CP) is the leading cause of childhood disability affecting function and
development. CP is defined as a nonprogressive neuromotor disorder of cerebral origin. It
cannot be correlated with any single disease or condition in Ayurveda, as it is a multi-
factorial disease with clinical features of a wide variation. According to Vāgbhaṭa, it is
classified in the disease categories of sahaja (hereditary) and garbhaja (congenital) and
jātaja (psychosomatic) type of diseases. Of the many types and subtypes of CP, none has any
known “cure.” Here, an effort was made to treat a 3-year-old male child with spastic type of
CP using multiple Ayurveda treatment modalities. At the end of 94 days of treatment,
Pañcakarma procedures along with internal medication resulted in 10–15% improvement in
the overall effect of therapy.

KEY WORDS: Ayurvedic approach in cerebral palsy, Chaturbhadra Kalpa Basti,

Panchakarma in pediatric
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INTRODUCTION
Cerebral palsy (CP) is the leading cause of childhood disability affecting function and
development. CP is defined as a nonprogressive neuromotor disorder of cerebral origin.
Motor disorders of CP are often accompanied by disturbances of sensation, perception,
cognition, communication, and behavior. CP is classified into four types viz., spastic, ataxic,
dyskinetic, and mixed. Spastic CP accounts for a major portion of CP with incidence between
70% and 80%.[2]

The global prevalence of CP is 2:1000.[3] Of the many types and subtypes of CP, none has
any known “cure.” Autologous stem cell activation treatment to expand the blood vessels and
nourish the neurons, strengthening of body's immune system, stem cell transplantation
procedure, Botulinum toxin type A injection,[4] baclofen intrathecal injection,[5] selective
dorsal rhizotomy,[6] orthotic devices such as ankle-foot orthoses, hyperbaric oxygen
therapy,[7] neuroplasticity[8] are the newer advancements being tried out in the management
of CP.

Ayurveda has a separate branch of clinical specialization concerning child healthcare known
as Kaumārabhṛtya. There is no one to one correlation available in Ayurvedic classics with
CP, but there are many conditions and some causative factors linked to etiopathology for
such type of disease condition described in many chapters in different texts. Some conditions
which find an overlap of symptoms of CP include phakka (a kind of nutritional disorder),
pāṅgulya (locomotor disorders), mūkatva (dumbness), jaḍatva (mental disorders),
ekāṅgaroga (monoplegia), sarvāṅgaroga (quadriplegia), pakṣaghāta (hemiparesis),
pakṣavadha (hemiplegia) etc., under the group of vātavyādhi (neurological disorders).
Contributory factors like inappropriate ṛtu (ovulation cycle), kṣetra (uterus), ambu (amniotic
fluid and foetal nutrition) and bīja (sperm and ovum),[9] dauhṛdāvamanana[10] (neglect of
urges during dauhṛda stage of pregnant women), presence of garbhopaghātakarabhāva
(substances which can cause defects or death of fetus),[11] incompatible
garbhavṛddhikarabhāva (normal requisites for growth and development of fetus)[12] and
improper Garbhiṇīparicaryā (antenatal regimen) may have undesirable effects on the fetus
hampering its normal growth and development consequently leading to many diseases,
deformities, and even death. Considering all the above, we have formulated an Ayurvedic
therapy protocol to improve the condition of CP patients.

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CASE REPORT
Basic information of the patient

Age: 3 years

Sex: Male

Religion: Hindu

Socioeconomic status: Middle class.

Father has studied 8th standard and currently working as a salesman, mother has studied 10th
standard, and she is house wife.

Pradhānavedanāviseṣa (chief complaints)

Global delayed milestones and mental retardation (both since birth).

Vartamānavyādhivṛtta (history of present illnesses)

Patient was delivered by lower segment cesarean section (LSCS) prematurely and did not cry
soon after birth and also suffered from septicemia, convulsions, and jaundice. Due to all these
clinical complications, the child could not achieve normal growth and development.
Spasticity and involuntary movement became apparent after the age of 5 months and since
then the parents started treating the child going to many doctors without any significant
benefit. They approached us for further management.

Pūrvavyādhivṛtta (history of past illness)

Septicemia, convulsions, jaundice

Cikitsā Vṛttānta (treatment history)

The child was being given tablet baclofen (as a muscle relaxant). He was undergoing
physiotherapy and also had undergone treatment by botox injection (to reduce contractures).

Kulaja Vṛttānta (family history)

No family history and consanguinity found.

Birth history

Antenatal: Mother (25 years) was suffering from hyperthyroidism and mental stress during
pregnancy and taking tablet thyroxin regularly.

Natal: Preterm (32 weeks) LSCS (due to oligohydramnios and primiparity of mother) was
done. Baby did not cry soon after birth. Birth weight was 1.6 kg (very low birth weight).

Postnatal history

Birth asphyxia, neonatal sepsis, pathological jaundice.

Viruddhābhisamskṛti (history of immunization)

Proper for age.

Vaiyaktika Vṛttānta (personal history)

Āharaja

Patient was totally dependent for food intake, and was eating only semi solid food due to lack
of coordination in deglutition. Appetite was poor. Diet was dominant in madhura rasa (sweet
diet).

Vihāraja

Nature of activity was always assisted (due to severe spastic quadriplegia). Sleep was
disturbed (2–3 h/day, 6–7 h/night). Bed wetting (had not achieved bladder control) and
drooling from the mouth was there since birth.

Examination

Vitals were normal. Cardiovascular system, respiratory system and per abdomen
examinations had shown no deformity. Prakṛti (constitution) was Vātādhikakapha.

Aṣṭavidhaparīkṣā

Nāḍi (pulse) was vātādhikatridoṣaja. There was no complaint with regard to Mūtra (urine).
Frequency and color were normal. Mala (stool) was constipated and passes with a foul smell
and dark color, once in 2–3 dayṣ Bowel control was not yet achieved (which should have
been achieved by 1.5 years of age). Jihvā (Tongue) was sāma (coated suggestive of improper
digestion). Śabda (speech) was not learnt (monosyllables should have been learnt by 9
months of age). Sparśa (touch) was hard and dry (due to hypertonia and spasticity). Dṛk
(eyes) showed squint in right eye (divergent and the concomitant type of squint). Akṛti
(appearance) was lean (due to malnourishment).

Central nervous system examination

Patient was diagnosed to have the hypertonia (spasticity) and contractures at ankle and knee
joint. Muscle power could not be elicited because patient was unable to follow the command.
Sensory system was intact, and no abnormality found. Cranial nerve examination could not
be done because of severely handicapped physical and mental state of the patient.
Hyperreflexia was present, suggestive of upper motor neuron disease (which is the hallmark
of CP). Babinski sign was up going (positive). Meningeal signs were not present.

Differential diagnosis

Spastic CP, demyelinating (degenerative) disease of central nervous system (CNS), sequel of
postnatal hypoxia.

Diagnosis was confirmed by modern pediatrician

“Severe quadriplegic spastic CP” as a sequel of postnatal hypoxia [Table 1].

Table 1
Probable pathophysiology and its management

Treatment protocol

Total duration

Ninety four days as given below: Five days Udvartana followed by 5 days massage with
sudation followed by 12 days Caturbhadra Kalpa Basti. Three such courses were done with
the interval of 14 days.

Udvartana

With barley powder and horse gram powder for 20 min (5 days).

Abhyaṅga

With Balataila[13] for 20 min followed by sudation[14] for 20 min (5 days).

Caturbhadra Kalpa Basti[15] has been clearly indicated as free from complications. This
protocol of Basti administration includes, four Sneha Bastis to start with, followed by four
āsthāpana Basti and four Anuvāsana Bastis.

Anuvāsana Basti

Thirty milliliter; lukewarm Balataila.

Āsthapana Basti

One hundred and twenty milliliter; as per the classical reference of Madhutailika Basti.[16]

Internal medicine

Aṣṭāṅgaghṛta, throughout treatment schedule, except the days on which Basti was given.

 Anupāna for internal medicine: Lukewarm water

 Dosage: 2.5 g once/day.[17]

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DISCUSSION
Parameters of growth, goniometric evolution to assess the range of motion (ROM), ashwarth
scale to assess spasticity, spasm scale to assess intensity of spasm and manual ability
classification system to assess the function of upper limb were taken as assessment criteria to
observe the effect of therapy.

Refer Chart 1: Here, improvement in growth might has been achieved by nourishment of
Rasādi dhātus. Aṣṭāṅgaghṛta causes bṛmhaṇa (nourishing action) due to its snigdha
(unctuous) and guru (heavy) qualities, udvartana helps opening up the minute channels and
hence may have improved blood and lymphatic circulation. Massage provides nourishment
due to its snigdha, mṛdu (soft), picchila (sticky) qualities. Sudation causes excretion of waste
metabolites through diaphoresis. Snigdha Basti (anuvāsana with balataila) is said to have
bṛmhaṇa effect. Height might have increased due to decrease in joint contractures.

Chart 1
Effect of therapy

Elbow and knee flexion improved by 10° and ankle plantar flexion decreased by 10°. This
effect might have been achieved due to localized vātaśamana by sudation and systemic
vātaśamana by Basti. Tightness of Achilles tendon was reduced and due to that only the
ankle joint shows improvement in goniometric evaluation.
Spasticity is characterized by increased resistance by passive stretch, velocity dependent and
asymmetric about joints (i.e., greater in flexor muscle at the elbow and the extensor muscle at
the knee).[18] This may happen due to āvaraṇa of vāta, wherein, due to āvaraṇa, vāyu
cannot perform its normal function, that is, normal movement of joints
(pravartakaceṣṭanam). Ashwarth scale shows 20% improvement in spasticity because
initially udvartana would have helped in a reduction of vitiated kapha by its dryness-
inducing and blockage-removing properties. Once āvaraṇa is removed, vitiated vāta can be
pacified by further treatment. Vāyu resides in sparśanendriya which is located in the skin.
Massage is said to be as tvachya (good for the skin). Hence, massage might have directly
worked on vāta to bring it back to normalcy. Basti acts on CNS by stimulating enteric
nervous system (ENS), there are many evidences linking CNS and ENS.

Spasm scale shows 25% improvement, due to śamana of vātaguṇas which are cala and śīta
due to the action of aṣṭāṅgaghṛta, massage with balataila, sudation, and mṛduśodhana
Āsthāpana Basti.

Manual ability classification system shows 20% improvement due to a reduction in spasticity
and improvement in ROM.

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CONCLUSION
In this patient, the overall effect was found near 10–15%. As this disorder is incurable, this
percentage of improvement also helps the patient to improve the quality-of-life (QOL).
Treatment of this kind of condition is important and in that, if we are able to make small
improvements in an earlier age, then it will reflect as a major benefit in later age in the form
of developing skills. Previously, it was believed that neurons do not repair or rejuvenate after
any injury, but the new concept of neuroplasticity says that CNS have the ability to repair
their neurons by axonal sprouting to take over the function of damaged neurons.[19] This
improvement in patients also supports the concept of Neuroplasticity. Going by the results of
this case study, we can conclude that Ayurvedic Pañcakarma therapy along with appropriate
internal medication can do a lot for the improvement in QOL.

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Footnotes
Source of Support: IPGT and RA Hospital, Jamnagar.

Conflict of Interest: None declared.

Cerebral Palsy
Cerebral palsy (CP) is a disorder that affects muscle tone, movement, and motor skills (the
ability to move in a coordinated and purposeful way). Cerebral palsy is caused by damage to
the motor control centers of the developing brain and can occur during pregnancy, during
childbirth, or after birth up to about age three. About 2% of all cerebral palsy cases are
believed to be due to a genetic cause. Cerebral palsy is not an infectious disease and is not
contagious. Most cases are diagnosed at a young age rather than during adolescence or
adulthood.

There is no cure for CP, but treatment, therapy, special equipment, and, in some cases,
surgery can help a child who is living with the condition.

Cerebral palsy is one of the most common congenital (existing before birth or at birth)
disorders of childhood.

The three types of CP are:

1. Spastic cerebral palsy — causes stiffness and movement difficulties

2. Athetoid cerebral palsy — leads to involuntary and uncontrolled movements
3. Ataxic cerebral palsy — causes a disturbed sense of balance and depth perception

Cerebral palsy affects muscle control and coordination, so even simple movements like
standing still are difficult. Other vital functions that also involve motor skills and muscles
such as breathing, bladder and bowel control, eating, and learning may also be affected when
a child has CP. Cerebral palsy does not get worse over time.

Kids with CP have varying degrees of physical disability. Some have only mild impairment,
while others are severely affected. This depends on the extent of the damage to the brain. For
example, brain damage can be very limited, affecting only the part of the brain that controls
walking, or can be much more extensive, affecting muscle control of the entire body.

The brain damage that causes CP can also affect other brain functions, and can lead to other
medical issues. Associated medical problems may include visual impairment or blindness,
hearing loss, food aspiration (the sucking of food or fluid into the lungs), gastroesophageal
reflux (spitting up), speech problems, drooling, tooth decay, sleep disorders, osteoporosis
(weak, brittle bones), and behavior problems.

Seizures, speech and communication problems and mental retardation are more common
among kids with the most severe forms of CP. Many have problems that may require ongoing
therapy and devices such as braces or wheelchairs.

Causes

The exact causes of most cases of CP are unknown, but many are the result of problems
during pregnancy in which the brain is either damaged or doesn’t develop normally. This can
be due to infections, maternal health problems, a genetic disorder, or something else that
interferes with normal brain development. Problems during labor and delivery can cause CP
in some cases.

Premature babies particularly those who weigh less than 1,500 grams (3.3 pounds) have a
higher risk of CP than babies that are carried full-term, as are other low birth weight babies
and multiple births, such as twins and triplets.
Brain damage in infancy or early childhood can also lead to CP. A baby or toddler might
suffer this damage because of lead poisoning, bacterial meningitis, malnutrition, being shaken
as an infant (shaken baby syndrome), or being in a car accident while not properly restrained.

Symptoms

Signs and symptoms can vary greatly. Movement and coordination problems associated with
cerebral palsy may include:

 Variations in muscle tone, such as being either too stiff or too floppy
 Stiff muscles and exaggerated reflexes (spasticity)
 Stiff muscles with normal reflexes (rigidity)
 Lack of muscle coordination (ataxia)
 Tremors or involuntary movements
 Slow, writhing movements (athetosis)
 Delays in reaching motor skills milestones, such as pushing up on arms, sitting up
alone or crawling
 Favoring one side of the body, such as reaching with only one hand or dragging a leg
while crawling
 Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with
knees crossing or a wide gait
 Excessive drooling or problems with swallowing
 Difficulty with sucking or eating
 Delays in speech development or difficulty speaking
 Difficulty with precise motions, such as picking up a crayon or spoon

The disability associated with cerebral palsy may be limited primarily to one limb or one side
of the body, or it may affect the whole body. The brain disorder causing cerebral palsy
doesn’t change with time, so the symptoms usually don’t worsen with age, although the
shortening of muscles and muscle rigidity may worsen if not treated aggressively.

Other neurological problems

Brain abnormalities associated with cerebral palsy also may contribute to other neurological
problems. People with cerebral palsy may also have:

 Difficulty with vision and hearing

 Intellectual disabilities
 Seizures
 Abnormal touch or pain perceptions
 Oral diseases
 Mental health (psychiatric) conditions
 Urinary incontinence

Diagnosis

CP may be diagnosed very early in an infant known to be at risk for developing the condition
because of premature birth or other health problems. Doctors, such as pediatricians and
developmental and neurological specialists, usually follow these kids closely from birth so
that they can identify and address any developmental delays or problems with muscle
function that might indicate CP.

In a baby carried to term with no other obvious risk factors for CP, it may be difficult to
diagnose the disorder in the first year of life. Often doctors aren’t able to diagnose CP until
they see a delay in normal developmental milestones (such as reaching for toys by 4 months
or sitting up by 7 months), which can be a sign of CP.

Abnormal muscle tone, poorly coordinated movements, and the persistence of infant reflexes
beyond the age at which they are expected to disappear also can be signs. If these
developmental milestones are only mildly delayed, the diagnosis of CP may not be made
until the child is a toddler.

Once diagnosed with cerebral palsy, further diagnostic tests are optional. Neuroimaging with
CT or MRI is warranted when the cause of cerebral palsy has not been established. MRI is
preferred over CT due to diagnostic yield and safety. When abnormal, the neuroimaging
study can suggest the timing of the initial damage.

If the child has seizures, an electroencephalogram (EEG) will be done to determine if he or

she has epilepsy, which often occurs in people with cerebral palsy.

Complications

Muscle weakness, muscle spasticity and coordination problems can contribute to a number of
complications either during childhood or later during adulthood, including:

 Contracture – Contracture is the shortening of muscle tissue due to severe tightening

of the muscle (spasticity) – Contracture can inhibit bone growth, cause bones to bend,
and result in joint deformities, dislocation or partial dislocation.
 Malnutrition – Swallowing or feeding problems can make it difficult for someone
who has cerebral palsy, particularly an infant, to get enough nutrition. This may cause
impaired growth and weaker bones. Your child may need a feeding tube for adequate
nutrition.
 Mental health conditions – People with cerebral palsy may have mental health
(psychiatric) conditions, such as depression. Social isolation and the challenges of
coping with disabilities can contribute to depression.
 Lung disease – People with cerebral palsy may develop lung disease and breathing
disorders.
 Neurological conditions – People with cerebral palsy may be more likely to develop
movement disorders or worsened neurological symptoms over time.
 Osteoarthritis – Pressure on joints or abnormal alignment of joints from muscle
spasticity may result in the early development of painful degenerative bone disease
(osteoarthritis).

Ayurveda Management

Management of cerebral palsy always remained a quest for the physicians all over the world.
Even with introduction of newer and better possible ways to improve the functions of the
child so that the quality of life is improved but still is a challenge for them.
Cerebral palsy cannot be correlated with any single disease or condition mentioned in
Ayurveda, as it is a multi-factorial disease. Classical signs and symptoms of CP will fit into
criteria of Vata vyadhi (Vata predominant disease). Hence Vata vyadhi chikitsa will prove
beneficial.

Overall goal of treatment is to help the individual with cerebral palsy reach his or her greatest
potential physically, mentally, and socially. It is to improve the quality of life by establishing
optimal independence.

Treatment at CHARAKA for CP involves intensive Panchakarma therapy program along

with researched oral medicines. Therapies like Abhyanga swedam, Nasyam, Pichu,
Shirodhara, Pizhichil, Navara or mamsakizhi, Vasti are done based on the presentation.
Duration of therapy could range from 3 weeks to 5 weeks.

Repetition of therapies in small courses either individual or in combination intermittently will

yield great benefit and stands as long term support for CP child