A Ayurvedic management of Pittavruta Vata w.s.r. to Cervical Myelopathy - A Case Study

P Sumayya

A Ayurvedic management of Pittavruta Vata w.s.r. to Cervical Myelopathy - A Case Study

Sumayya P.^1*

DOI:

^1* P Sumayya, Lecturer, Department of Samhita & Siddhanta, Himalaya Ayurvedic Medical College & Hospital, Palganj, Patna, Bihar, India.

Cervical myelopathy involves spinal cord dysfunction from compression in the neck. Patients report neurological symptoms such as pain and numbness in limbs, poor coordination, imbalance, and bladder problems. Owing to its mobility, the vertebral column of the neck is particularly prone to degenerative changes such as disc herniation, ligament hypertrophy or ossification, and osteophyte formation. Avarana is a unique concept in Ayurveda. Avarana is the route along which the pathogenesis of many diseases proceeds. It is one of the most complicated fundamental concepts to understand, teach and incorporate in clinical practice. There are so many conditions which mimic Avarana. It is either least observed, diagnosed or goes unidentified due to lack of skill. To understand and analyse the Avarana, meticulous knowledge of basic concept of Avarana is essential. Since Avarana comprises of many different clinical conditions, it is difficult to plan a general treatment schedule. Repeated Panchkarma and Rasayana therapies will help a lot in various types of Avarana management. Here we have to incorporate the concept of Avarana in treating cervical myelopathy for better results. Unravelling the spectrum of manifestations of Avarana will not only help to have a better understanding of the disease, but also enable the physician to have a differential diagnosis in each and every case he is going through. This article strives to put forward the correlation between treatment aspects of the cervical myelopathy and Pittavruta Vata.

Keywords: Cervical Myelopathy, Avarana, Pittavruta Vata, Panchakama, Rasayana

Corresponding Author	How to Cite this Article	To Browse
P Sumayya, Lecturer, Department of Samhita & Siddhanta, Himalaya Ayurvedic Medical College & Hospital, Palganj, Patna, Bihar, India. Email:	P Sumayya, A Ayurvedic management of Pittavruta Vata w.s.r. to Cervical Myelopathy - A Case Study. J Ayu Int Med Sci. 2022;7(9):176-180. Available From https://www.jaims.in/jaims/article/view/1968

Introduction

Cervical myelopathy is defined as a series of signs and symptoms that result in anatomical and physiological changes in the vertebral column, leading to spinal cord compression. The clinical symptoms are characterized by progressive deterioration of the spinal cord functions. In most cases, the natural progression occurs in bursts of exacerbation of symptoms followed by periods of stability.^[1]

The clinical symptoms rarely improve; however, there have been reports of cases in which this period of stability was not present, and the patient’s condition declined continuously and slowly. On the other hand, in a small number of cases, the progression may be acute and rapid. The cause is not well-defined, but it is known that changes in the bones, ligaments and discs act as a trigger for progressive spinal cord degeneration, which leads to direct compression often associated with circulatory damage.^[2]

The treasures of knowledge are often buried within very complicated conceptualizations. There are certain concepts in Ayurveda that can never be understood in their true sense. Avarana is such a concept that opens newer and newer areas of clinical interest when we go deeper and deeper into the matter. Unravelling the spectrum of manifestations of Avarana will not only help to have a better understanding of the disease but also enable the clinician to have a differential diagnosis in every case we are going through.^[3] This is because, in all the diseases involving Vata, Avarana is one of the differential diagnosis. Many questions arise among us when we go through our concepts but beyond any doubt that knowledge never create a problem provided it is used in the right way. Avarana is one of the most difficult concepts to understand, teach and incorporate in clinical practice. Acharya has elaborately explained different varieties of Avarana which is one of pathology in different diseases.

If, correctly observed and diagnosed the treatments will be quite effective. Sometimes it goes unidentified or mistaken as associative dosha in many conditions due to lack of observations and skills. But once identified it helps in designing the management protocol of a particular disease.

Case Report

A 58 years old male patient was consulted in Out-Patient Department of Charitable hospital Kottakkal, for complaint of gradually progressive weakness of both upper and lower limbs. He was not able to walk and hold things without the help of others and Numbness and tingling sensation were also present in both upper and lower limbs since 1 year.

History: Patient had suffered from intermittent neck stiffness and neck pain since 6 years. The patient also reported intermittent numbness and pain over the past 2 years which radiated to bilateral lower limbs. One year back the patient had fall on ground, after the fall he was presented with weakness of both upper and lower limbs associated with incontinence of bowel. At that time, he lost all sensations on his body. The patient had undergone neurologic and orthopaedic consultations in a tertiary care hospital and conservative and surgical management was recommended. Cervical orthosis was given for immobilisation& bladder was catheterised. After 2 weeks of admission he could move his both lower limbs though weak also he could feel sensations but the weakness existed as he was unable to stand without support and hold things. He could wipe his face but eating, bathing toileting, transfers all need assistance. Then he was admitted here for better management.

Personal history

Appetite - Increased
Bowel - Regular
Micturition - Regular (4-5times /day)
Sleep - Disturbed due to abnormal sensation
Habit - Alcohol 2 times in a week, Cigarette smoking (10-15 per day)
Diet - Mixed

Physical Examination

H/O HTN, DM

BP - 140/90 mm of Hg

PR - 78 / min

Central nervous system

Higher functions - Consciousness: fully conscious to time place and person.

Memory Intact Behaviour Friendly Orientation fully oriented to time, place and person.

Cranial nerves

Optic nerve

Visual acuity - difficulty in distant reading

Accessory nerve

Shrugging the shoulder-not possible against resistance
Neck movement-not possible against resistance

Motor System

Muscle bulk: Atrophy of muscles of hand-myelopathic hand

Muscle tone: Hypertonic

Muscle power	Rt	Lt
Elbow; Flexion	3/5	3/5
Extension	3/5	3/5
Wrist; Flexion	3/5	3/5
Extension	3/5	3/5
Knee ; Flexion	2/5	2/5
Extension	2/5	2/5
Ankle; Dorsiflexion	2/5	2/5
Plantar flexion	2/5	2/5

Co-ordination

Upper limb - finger nose test - not able to perform

Lower limb - knee heel test - not able to perform

Involuntary movements - absent

Reflex	Rt	Lt
Biceps jerk	+++	+++
Triceps jerk	+++	+++
Knee jerk	+++	+++
Clonus	Absent

Babinski reflex - present

Locomotor System

Range of movements of all joints - Restricted.

Spine examination

Range of movements - Cervical spine possible but with difficulty

Others not possible

Ashta Sthana Pareeksha

Nadi - 80/min
Mutra - Sadharanam

Mala - Sadharanam
Jihwa - Sadharanam
Sabdha - Aspashtam
Sparsa - Ushnam
Druk - Aspashtam
Aakruti - Madhyama

MRI

Degenerative disc disease with osteophytic disc bulge

Reduction in disc height, spinal canal narrowing at multiple levels

Myelopathy at C3-C5 level

Nidana	Viruddhahara, Vishamasana, Atichankramana Seela, Abhighata, Madyapana.
Poorvaroopa	Pain on Greeva, Bhrama, Karapada Daha
Roopa	Balakshaya of Sarvanga, Aswapnata, Bhrama

Vyadhi Nirnayam

Asthivaha Strotas - Asthi-Sandhi Soola, Balakshaya
Majjavaha Strotas - Aswapna, Stabdhata, Asthiruja, Asthi Saushirya

Astimajjagata Vata: The Samprapti we assessed was due to the above Nidana Ghataka occurs in Asti Majjagata Srotas initiate the Saushirya and Mruduta of Asti and this leads to the Purana of that Rikta Srotas with Vayu results in Astimajja Gata Vata. In this case Asti and Majja are affected.

That is the provisional diagnosis at that time was Astimajjagata Vata.

Treatment

Vatasamana - Snehana, Swedana, Vasti

Asthiposhaka Dravya - Internally

Rooksha Swedam - Choorna Pinda Swedam

Snigdha Swedam - Pizhichil

According to Charaka treatment of Asthimajjagata Vata is Bahya Abhyantara Sneha. In this condition as per the Asthivaha Strotas & Vayu Vrudhi, Snehan, Swedana, Basti Chikitsa & Abhyantar Asthiposhak & Vata Shaman Chikitsa were given. So, we have given the first treatment as Rooksha Sweda to reduce the spasticity of the muscles for 3 days with Kottamchukkadi Choornam

and Vata Shamana Kashya was given internally. After that pizhichil was started as Snigdha Swedam. At that time patient felt severe burning sensation in his body and his sweat and appetite was also increased and he couldn’t sleep at night due to this burning sensation. Then we have suspect an Avarana behind this because the symptoms of Pitta Avrana Vata was present clearly in this condition.

Pittavaruta Vata

In Pittavruta Vata there will be Dravatmaka Vrudhi of Pitta occurs. It hampers the function of Vata causes the symptoms like Daha, Trushna, Shola, Bhrama, Ushnai Vidhaha, Sheetakamita.^[4] These were present in this patient at that time. Then treatment was given according to this condition.

Medicine	Dose	Duration
1. Punarnnavadi Kashayam	60 ml Bd	10 days
2. Kaisora Guggulu	1-0-1	20 days
3. Ksheera Kashaya Pana (Bala, Sahachara, Eranda, Devadaru)	1 glass Bd	20 days
4. Ksheerabala (101 A)	10 drops with Kashayam	5 days
5. Chandraprabha Gulika	1-0-1	20 days
6. Trivrit Leham	1 tsp Bt	5 days
7. Dhanwantharam Kashayam	60 ml Bd	10 days
8. Dasamoola Ksheera Dhara	QS	7 days
9. Abhyanga with Pinda Thailam	QS	7 days
10. Shastika Pinda Sweda - Karppasasthyadi Tailam and Pinda Tailam	QS	7 days

Discussion

In classics, some of the application of Vyatyasa Chilitsa are clearly described in different diseases like Arsha, Grahani, Hikka, Kasa, Vatavyadhi etc.

Pittavruta Vata is a type of Anyonyavarana, in which obstruction of Vayu Marga by Pitta Dosha takes place. Treatment of this Avarana is Sheeta and Ushna Chikitsa, it is adopted as alternative form or repeated form.

These alternative treatments do not increase the Pitta and Vayu simultaneously. Sheeta Chikitsa suppresses the increased Pitta and similarly Ushna Chikitsa decreases the Vata alone.

These Vyatyasa Chikitsa removes the obstruction and helps in normal movement of Vata. So, we can select these types of treatment in Avarana according to the condition.

These treatments were also mentioned by Acharya for Pitta Avruta Vāta

Yapana Vasti
Ksheera Vasti
Virechana
Ksheerapana - Bala, Panchamula
Sechana - Ksheera (Madhuyashti, Bala, Panchamula), cold water

In this case we got an idea only by Upashaya Anupashaya. As per Acharyas among the identification of Avarana pathology is the Upashyas and Anupashaya.

In this condition the patient get Vidaha by Vata Upashamana and shows Shita Kamita (desire for cold things) which is Upashaya of Pitta.

In Pittavruta Vata there will be Shula, Daha, Trushna, Bhrama, Tama Laxanas. By seeing Shula if one given the Vatahara treatment like Ushna Amla Lavana (which are antagonistic to Pitta) may worsen the condition.

So, here to pacify the dominant Lakṣana of Vata, Pittahara Chikitsa should be undertaken because the basic pathology is due to the increased Pitta.

Conclusion

Concept of Avarana can incorporate in every disease. We must assess each patient differently. Categorise the diseases into Gatavata, Avarana Vata, Ama Vata, Anubandha Doshas etc. in every case comes to us.

Avarana is a clinical condition where the dynamic equilibrium of Vata is lost, either due to the impact of other Doshas or due to untoward movement of any type of Vata. The Avarana is least observed diagnosed or goes unidentified due to lack of skills. To understand and analyse Avarana meticulous knowledge of Ayurveda is essential. If we can trace out the exact Avruta Dosha and the Aavaraka factor, it becomes easier to treat the case and the results become more encouraging.

Reference

1. Hochman M, Tuli S. Cervical Spondylotic Myelopathy: A Review. The Internet Journal of Neurology. 2004;4(1).

2. Emery SE. Cervical Spondylotic Myelopathy: Diagnosis and Treatment. J Am Acad Orthop Surg. 2001;9(6):376-88.

3. Abhilash, Lakshmi. Avarana. 1st ed.: Arya Vaidya Sala Kottakkal; 2012

4. Vagbhat, Astanga Hridhaya Samhita Vol- 2, Nidansthana, Vatashonita Nidana Adhyaya, 16/50, Edited by Prof. K R Srikantha Murthy, 4th edition, Chaukhambha Orientalia, Varanasi, 2000, p.168

5. Agnivesha, Charaka Samhita, Vol-5, Chikitsasthan, Vatavyadhi Chikitsa Adhyaya, 28/199-202, Edited by R K Sharma and Bhagwan Das, Reprint edition, Chaukhambha Sanskrit Series Office, Varanasi. 2005, p.73

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-08-29	2022-08-31	2022-09-07	2022-09-14	2022-09-21
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	17%

Case Report

Cervical Myelopathy

Journal of Ayurveda and Integrated Medical Sciences