E-ISSN:2456-3110

Case Report

Rehabilitation

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 11 November
Publisherwww.maharshicharaka.in

Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha - A Clinical Management

Raghavi M1*, Gopalakrishna G2
DOI:10.21760/jaims.8.11.27

1* Raghavi M, Post Graduate Scholar, Department Of Kayachikitsa, Sri Sri College Of Ayurveda Science And Research, Bengaluru, Karnataka, India.

2 Gopalakrishna G, Professor HOD, Department of Kayachikitsa, Sri Sri College of Ayurveda Science and Research, Bengaluru, Karnataka, India.

Traumatic cerebral haemorrhage is an increasingly recognized complication of severe blunt head or neck trauma, more common with patient with motor vehicle accidents, which may lead to complete paralysis, paraplegia, hemiplegia or severe conditions end up with coma. In the present case history, a 43 year aged male patient was in coma stage after he met with RTA and he recovered back with right hemiplegia. So, he was brought for Rehabilitation through Ayurvedic lines of management. Hence for the same, assessments were done through CNS examinations and NIH scoring was adopted to compare the effect before and after the treatment. And specific treatment was planned which includes Panchakarma, diet regimen, Physiotherapy, Shamanoushadhis and was successfully treated with Ayurveda interventions with reference to Pakshavadha line of management as a rehabilitative management and significant results were obtained after 3 follow ups (total duration for 112 days).

Keywords: Hemiplegia, Pakshavadha, Panchakarma, Rehabilitation, Shamanoushadhis

Corresponding Author How to Cite this Article To Browse
Raghavi M, Post Graduate Scholar, Department Of Kayachikitsa, Sri Sri College Of Ayurveda Science And Research, Bengaluru, Karnataka, India.
Email: 		Raghavi M, Gopalakrishna G, Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha - A Clinical Management. J Ayu Int Med Sci. 2023;8(11):168-175.
Available From
https://jaims.in/jaims/article/view/2694

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-09-12 2024-09-18 2023-09-23 2023-09-28 2024-10-19
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 18.89%

© 2023by Raghavi M, Gopalakrishna Gand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

J Ayu Int Med Sci 2023;8(11)168
Raghavi M. et al. Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha

Introduction

Hemiplegia is a severe or complete loss of motor function of any one side of the body. It is generally caused due to intra cranial haemorrhage or ischemia (localized to cerebral hemisphere) where opposite side of the affected area the motor and sensory activity will be abnormal exhibiting the symptoms like loss of strength in upper and lower limbs with or without pain.[1] And the patient also may exhibit the symptoms like slurred or difficulty in speech. And the management of the condition will be through rehabilitative approach.

Pakshavadha (~stroke) according to Acharya Charaka exhibits Lakshanas (~signs and symptoms) like immobility and pain in half of the body along with slurred speech due to Vata Prakopa (~aggravated Vata) in half of the body resulting in constriction of Sira (~nerves) and Snayu (~includes connective tissue elements like tendons, ligaments or nerves etc).[2]

According to Acharya Sushrutha same Lakshanas (~signs and symptoms) are explained for Pakshaghata (~stroke) which is caused due to Rakta Dushti (~Rakta vitiation) and Vata Prakopa (~vitiated Vata).[3] Chikitsa (~treatment) of Pakshaghata / Pakshavadha (~hemip-legia) according to classical texts are mainly Brimhana (nourishing) which includes, Snehana (~unctiousness) Swedana (~fomentation) Vatanulomana (~alleviation of Vata) through Basti Chikitsa (~enema) and Mastishka Chikitsa (~applying various oils on head), Nasya (~nasal drops), Basti (~enema) and Vata Shamaka, Raka Prasadaka, Balya Gunayukta Shamana Oushadhas (~drugs which poses Vata alleviating action and are nourishing).[4]

Case History

A 43 year aged male patient with history of recovery from coma before 2 months approached to outpatient section of Kayachikitsa of Sri Sri College of Ayurveda science in Bengaluru with complaints of loss of strength in right upper and lower limbs and further detailed explanation are given in table no. 1

Diagnosis

On Physical Examination
Built - Poor

Nourishment - Poorly nourished
BP - 110/70mmhg
Pulse - 68bpm
Temperature - 97.8° F
RR - 22 cycles /minute
Height - 169cm
Weight - 53 kg
BMI - 18.6 kg/m2

Table 1: Clinical events and timeline

Date and DurationClinical Events
3/2/22   4/2/22 - 7/2/22 8/2/22 - 17/3/22 18/4/22- 23/7/22    23/7/22Patient met with an RTA and was taken to nearby PHC in unconscious state, after first aid they referred the patient to higher neurological department. And there he was declared as stage of COMA.He was on NT tube and catheterisation, and 7th February he got eye opening response with blurred vision.Considering the improvement, he was shifted to general hospital as he was out of danger.Gradually he gained his sensorium and noticed loss of strength in right upper and lower limbs. And right ulna and radius fracture was corrected through internal fixation.Patient could move his right lower limbs with restricted right arm movement.For further better rehabilitation improvement he came to SSCASR

Negative History

No h/o Seizures, Not a known case of HTN

Complaints

Patient complaints of reduced strength in right upper and lower limb associated with stiffness since 6 months. Patient complaints of pain in right scapular region and arm since 2 months. Patient also complaints of slurred speech since 1 month.

Central Nervous System

Patients higher mention functions were intact at the time of examination with reduced muscular strength, muscular tone and abnormal reflexes in right upper and lower limbs which the detailed findings are mentioned in table no. 2, 3, 4.

Table 2: Higher mental function examination.

Higher Functions
GaitSpeechMental Statusa)        HMFb)       MMSERight leg circumduction gaitMildly affected (slurred speech) Intact, well oriented30/30
Cranial Nerve Examination
Olfactory nerve (CN1)Opticnerve (CN2)Occulomotor (CN3)Trochlear (CN4)Trigeminal (CN5)Abducent (CN6)Facial (CN7) Vestibulocochlear (CN8) Glossopharyngeal (CN9)Vagus (CN10)Hypoglossal (CN12)Intact
Affected Cranial NerveRightLeft
Accessory nerve (CN11)a)        Shoulder shruggingWithout resistanceWith resistanceb)       Head turnWithout resistanceWith resistance  Slightly possibleNot possible Slightly possiblenot possible  PossiblePossible PossiblePossible



J Ayu Int Med Sci 2023;8(11)169
Raghavi M. et al. Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha

Table 3: Motor system examination

Muscle ToneLeftRight
Upper LimbLower LimbNormalNormalRigidity PresentRigidity Present
Muscle Strength
Upper LimbLower Limb5/55/52/53/5
Muscle Girth
Mid Thigh CircumferenceMid Calf CircumferenceMid Arm Circumference54cm41cm25.3 Cm54 Cm41 Cm24.9 Cm
Involuntary Muscle MovementsNilNil
Muscle Reflex
a)        Superficial ReflexBabinski’s Reflexb)       Deep Tendon ReflexesBicepsBrachioradialisTricepsKnee JerkAnkle Jerk Normal NormalNormalNormalNormalNormal Positive DiminishedDiminishedDiminishedExaggeratedExaggerated
Examination for Involvement of Meninges
§   Neck Rigidity (Nuchal Rigidity) - Nil§   Kerning’s Sign - Nil§   Brudzinski’s Sign - Nil

Table 4: Sensory system examination

Sensory ExaminationLeft Upper LimbRight Upper LimbLeft Lower LimbRight Lower Limb
a.        Light touchb.        Sharp touchc.        Pain sensationd.        temperaturee.        Proprioception    f.         Stereognosisg.        Graphasthesiah.        2-point discriminationNormalNormalNormalNormalNormal    NormalNormalNormalNormalPresent (not precise) NormalNormalPresent (not precise) NormalPresent in thumb and index finger and absent in othersAbsentAbsentAbsentAbsentNormalNormalNormalNormalNormal-NormalNormal NormalNormalNormalNormalPresent (not precise)Present (not precise)NormalPresent (not precise) NormalPresent in big toe and 2nd phalanx and absent in othersAbsentAbsentAbsentAbsent
Romberg’s signFinger to nose testRapid alternative movementTandem walkingHeel to Shin testNegativeCan’t do it with right handCan’t do it with right handCan’t performRight heel falls to side of the shin of left leg as it descents down.

Investigations

Table 5: Lab investigation impressions

Normal ImpressionAbnormal Impression
7/2/22: MRI of cervical spine and bracheal plexus.4/2/22: CT brain plain: acute EDH measuring 18mm along right anterior temporal lobe convexity. Cortical contusion in left temporal lobe fracture of lateral wall of right orbit, zygomatic arch, walls of right maxillary sinus and squamous part of right temporal bone.7/2/22: MRI (brain) F/s/o DAI & right anterior temporal convexity SDH, clavicle fractures and scalp swelling.17/6/22: MRI brain: multiple sites of blooming on SWI noted involving the brain stem (rostral midbrain), bilateral cerebral peduncles. Right side of body of corpus callosum and frontal subcortical white matter - s/o haemorrhagic diffuse axonal injury (DAI) grade III.Extra axial T2 hyperintensity noted in close proximity to the left transverse sinus as described above? Collection suggested CEMRI for further characterisation.Area of gliosis noted in left inferior temporal region with abnormal susceptibility-sequel of prior insult. Micro angiopathic changes noted. No acute infarcts.

NIH Scoring (National Institutes of Health Stroke scale)

Table 6: NIH stroke SCORE assessment

SNNIH score featuresScore
1.2.3.4.5.6.7.8.9.10.11.Level of consciousnessLOC questions (month and age)LOC questions (eye movement and grip test)Best gazeInstructions (visual)Instructions (facial palsy)Instructions (motor leg)Limb ataxiaInstructions (sensory)Instruction (best language)Instruction (extinction and in tension)11010111121

NIH scoring was adopted to assess the changes in the patient before and after the treatment

Which includes certain parameters (table no. 6). It is an 11 item neurological examination stroke scale used to evaluate the cerebral infarction of the levels of consciousness, language, neglect, visual-field loss, extra ocular movements, motor strength, ataxia, dysarthria, and sensory loss.

Treatment Protocol

Patient was treated with Shirodhara (~scalp treatment) with Brahmi Taila and Himasagara Taila, Kala Basti(~enema) with Anuvasana Dravya(~ oil enema) as Ashwagandha Ghrita and Niruha Basti (~decoction Basti) Dravya as Erandamoola Niruha Basti, Stanika Abhyanga with Prasarini Taila and Ashwagandha Bala Lakshadi Taila to right half of the body which was followed by Stanika Nadi Sweda, and throughout the hospital stay patient was on physiotherapy. Detailed treatment timeline and protocol is mentioned in the table below.

Table 7: Timeline of the treatment during hospital stay.

DurationPanchakarma TreatmentsMedications Used
Day 1 - Day 201.        Shirodhara  2.        Kala Basti 1)       Brahmi Taila + Himasagara Taila2)       A) Anuvasana Basti (Ashwagandha Ghrita) = 75mlB) Niruha Basti = Erandamoola Niruha BastiIngredients:Madhu - 50 mlSaindhava Lavana - 1 pinchAshwagandha Ghrita - 75 mlShatapushpa Kalka - 15gramsErandamoola Kashaya - 450 ml
Day 1 - Day 20Yoga (Pranayama)Anuloma and Viloma (5 time for each side of the nostril)
Day 4 - Day 9PhysiotherapyRange of movement exercises
Day 5 - Day 20Stanika Abhyanga + Stanika Nadi Sweda (right half of the body)Prasarini Taila + Ashwagandha Bala Lakshadi Taila

Shamanoushada

Based on Rogi Bala (~patients strength) and Lakshana (~signs and symptoms) exhibited nerve strengthening and stabilizing logic was applied and was advised with tablet Nural, capsule Ksheerabala 101 DS, Tablet Prolong was given till hospital stay and was advised with separate list of Shamanoushadhis as discharge medications for 1 month and after that 2 follow ups were done after every 15 days.

Table 8: Oral medications during hospital stay

SNYogasDosageDurationTiming
1.T. Nural1TIDAfter food
2.C. Ksheerabala 101 DS1TIDBefore food
3.T. Prolong1HSAt bed time

J Ayu Int Med Sci 2023;8(11)170
Raghavi M. et al. Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha

And the patient was advised to continue the existing allopathic medications

Existing Medications

1. Tab. Folitrax 10mg (Once in week)
2. Tab. Folic Acid 5mg (Once in a week)
3. Tab. MCQS 200mg (0-0-1) (Rheumatoid Arthritis)
4. Tab. Shelcal 500 Mg (0-1-0)
5. Tab. Retoz 60mg SOS for Pain
6. Cap. Evion LC 0-1-0

Discharge Medications and Follow Ups.

By considering the positive changes in the patient by the end of treatment course in hospital patient was advised to discharge with same set of medicines which were given during hospital stay with altered dose for 1 month and then was followed by 2 follow ups in each 15 days. And details of the medicines are mentioned in the table no.8. So, the total duration of the treatment was for 112 days.

SNShamana YogasDay 20 - Day 50Day 51 - Day 81Day 82 - Day 112
1.T. Nural 1 TID A/F+1 BID A/F-
2.C. Ksheerabala 101 DS 1TID B/F+1 BID A/F-
3.T. Prolong 1 HS++-
4.    Amalaki Churna - 30 gms+Guduchichurna - 30 gms+Musta Churna - 30 gms 1 Tsf BID A/F-    +    1 TSF at bed time A/F   
5.Balarishta 10 ml BID A/F--+
6.T. Livon 1 BID A/F--+
7.T. Jointapp 1 BID A/F--+
8.T. Neo joint CQ 1 HS--+
9.T. Shankha Vati 1 TID B/F--+
10.C. Coligo 1 TID SOS--+

Result

There was a significant improvement in gait of the patient compared to the initial days (right circumduction gait) to almost normal gait without imbalance by the end of the treatment that is on Day 112.

Table 9: End Point Results

Muscle ReflexRTLT
Babinskis reflexBiceps reflexBrachio-radialisTricepsKnee jerkankle jerkAnkle jerkNegativeDiminishedNormalDiminishedNormalNormalNormalNormalNormalNormalNormalNormal
Muscle StrengthRTLT
Upper limb3/55/5
Lower limb5/55/5
Sensory ExaminationRight Upper LimbRight Lower Limb
a. Light touchb. Sharp touchc. Paind. Temperaturee. Proprioceptionf. Stereognosisg. Graphasthesiah. 2 point discriminationNormalPresentNormalPresent in thumb and index finger absent in other fingersAbsentAbsentNPresentNNPresentAbsentAbsentAbsent

Other improvements include increased grades in muscle strength and tone of the

muscles in right upper and lower limbs and the details are given in table 9 and table 10.

Table 10: NIH SCORE comparison before and after treatment

SNNIH score featuresScore BTScore AT
1.2. 3. 4.5.6.7.8.9.10.11.Level of consciousnessLOC questions (month and age)LOC questions (eye movement and grip test)Best gazeInstructions (visual)Instructions (facial palsy)Instructions (motor leg)Limb ataxiaInstructions (sensory)Instruction (best language)Instruction (extinction and intension)110 10111121000 00011000

Discussion

Haemorrhagic stroke is a condition which includes symptoms such as loss of strength and if not treated in right approach can lead to coma or patient can be in the stage of coma soon after the head injury and could recover back but with partial loss of sensory or motor activities. Which depends on location of the haemorrhage and extent of gliotic changes in the cerebral hemisphere. Here in the present case initially patient was in stage of coma (without rapid eye movement) which after hospitalisation, gradually he came out of stage of COMA. And now he came to our hospital with concerned to loss of strength in right upper and lower limbs which we can compare to Pakshavadha/Pakshaghata in Ayurveda and Vata Vyadhi Chikitsa Sutra[5] (~Vata type of disease and treatment) was adopted. Main aim of the treatment for the present case was achieved through Brimhana (~nourishing), Rakta Prasadana (~blood circulation), and Balya (~strengthening), Vata Pradhana Tridosha Shamaka Dravyas (~drugs processing Vata and other Dosha alleviating properties).

Mode of Action

Shirodhara was adopted for Shiro Marma Chikitsa for Vata-Pitta Shamana and Medya action by Brahmi Taila which is Medya Dravya[6] also told for Medya and Jarturdva Roga Chikitsa, and Himasagara Taila is having key ingredients such as Shatavari (Asparagus racemosus), Vidari [Pureria tuberosa (Roxb.ex Wild)], Kushmanda [Benincasa hispida (Thunb.)Cogn.], Dhatri [Emblica officinalis Gaertn.], Shalmali [Bombax ceiba] is Vata Pitta Shamaka and is indicated for Shiro Abhghata which does Rakta Prasadana and Vata Hara and is Medya.[7]

Karma Basti was given as Brimhana Basti with Ashwagandha Ghrita (~ghee based medicine) as Anuvasana


J Ayu Int Med Sci 2023;8(11)171
Raghavi M. et al. Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha

which is having Guna-Karma (~properties) such as Brimhana (~nourishing therapy), Rasayana (~rejuvination therapy), Balya (~strengthening) properties and Erandamoola Niruha Basti is classically indicated for Vata Vyadhi (~diseases of Vata).[8]

Stanika Abhyanga was adopted for Snehanarta (~Oleation) with Prasarini Taila which is having properties of Vata-Shamaka, Rakta Prasadaka properties and Ashwagandha Bala Lakshadi Taila in which the ingredients possess properties as Balya Brimhana, and Vata Shamaka and helps in clearing the occurred pathology.[9]

Shamana Oushadhis

Tab. Nural which is having ingredients like Brihat Vata Chintamani, Rajata Bhasma, Maharasnadi Kwatha, Dashamoola Kwatha, Ashwagandha, Eranda, Kapikachchu, Rasona, Guggulu, Trikatu. Accountably they exhibit functions such Deepana, Pachana. Brihat Vata Chintamani does Vata Shamana and strengthens nervous system. Pravala Bhasma is claimed to have properties of Balya and Dhatu Prasadana (~promoting tissue promoting action) and it has got nano particles of calcium, gold does regulating presynaptic plasticity in nerve cells.[10]

Tab. Prolong is a curcumin extract which has got apoptotic activity[11] can stop the gliotic changes in the brain. And is also mentioned as Shirovirechanopaga by Acharya Vagbhata

Cap. Ksheerabala 101 DS - Based on studies it is claimed to have neuroprotective action, Bala is the main ingredient in the Yoga and it is indicated for Vata Vyadhi.[12]

Amalaka Churna - As the basic pathology involved in this case is hemorrhage, there will be Rakta Dhatu Kshaya and so, as Amalaka [Emblica officinalis Gaertn.] is having Amla Rasa Pradhana (~predominant sour taste) and Rasayana Dravya (~rejuvinator) it does Swayoni Vardhana and helps in Dhatu Poshana (~tissue nourishment) and Balavardhana.[13]

Guduchi Churna - Based on studies it is claimed to be an anti-inflammatory and immune-modulator drug[14] even in classical texts also properties of Guduchi [Tinospora cordifolia] is mentioned as Tridosha Shamaka (~alleviates Tri Doshas), Rasayana is also a Balya Dravya.

Musta Churna - Musta Churna [Cyperus rotundus

Linn.] is told as Deepana, Pachana (~digestive stimulants) and Rakta Dushti Hara by Acharya Charaka[15] And based on studies it is claimed to have properties like anti-inflammatory action.[1]

Balarishta - The key ingredients of the yoga are Bala [Sida cordifolia Linn.], Ashwagandha [Withania somnifera(L.)] which are mainly Vata Hara (~alleviates Vata) is directly indicated for Vata Vyadhi (~diseases of Vata. It promotes Balya action through its Brimhana (~nourishing) action and enhances muscular activities. And classically told as Bala, Pushti and Agni Vardhana (~enhances strength, vigour, and digestive capacity).[16]

Livon tablet - Livon contains key ingredients such as Katuki [Picrorhiza kurroa], Bhumyamalaki [Phyllanthus niruri Linn.], Patola [Trichosanthum diocius], Punarnava [Boerhavia diffusa (BD) Linn.], Chitraka [Plumbago zeylanica Linn.] which in this case helps in Agni Vardhana (~digestive enhancer), Pitta Rechana, Patola helps in Rakta Prasadana and hence it may act in liver protection.

1. Jointapp, T. Neo joint CQ (Cizzus quadrangularis) was given as calcium supplement as the patient was also had fractures.
2. Shankha Vati, C. Coligo was given during follow for other digestion related complaints.

Pathya Apathya

Patient was advised to eliminate brinjal, pulses, potatoes and sprouted legumes as regular diet as they cause further Vata Prakopa. And patients was given with Pongal, Purana Shali (old rice), Jeera Rasam, green leafy vegetables, Mudga Yusha, Yavagu, Chapati and well boiled vegetables (all freshly prepared) milk with sugar candy at night, 1 tsp of ghee daily, during hospital stay and was advised to continue the same even after discharge with Mamsa Rasa. Meditation and Anuloma and Viloma was advised as Pathya Vihara and 20 minutes of dhyana was also advised.

Conclusion

Ayurveda line of management depends upon the extent of gliotic changes that have happened in the brain tissues, Rogi Bala and chronicity of the disease with respect to Hemiplegia. So, here through a well understood case history, involved Dushti and based on Vata Vyadhi line of management, treatments


J Ayu Int Med Sci 2023;8(11)172
Raghavi M. et al. Role of Ayurveda in rehabilitation of Abhighataja Pakshavadha

were planned and successful outcome was established. Through this it can be inferred that it is possible to treat case of hemiplegia in Ayurveda and rehabilitation can be established with our line of management.

Patients consent was taken before taking the case for article writing.

References

1. Harrison's Principles of Internal Medicine. 19th ed. Volume 2, Chapter 446. New York: McGraw-Hill Education; 2015. p. 2559-2770.

2. Acharya JT. Charaka Samhita Sutra Sthana. Varanasi: Chaukhamba Krishnadas Academy; 2016. Sutra 20/11. p. 300.

3. Acharya JT, Acharya NM. Sushruta Samhita Sutra Sthana. Varanasi: Chaukhambha Surbharati Prakashan; 2011. Sutra 14/30. p. 65.


4. Acharya JT. Charaka Samhita Sutra Sthana. Varanasi: Chaukhamba Krishnadas Academy; 2016. Sutra 11/45. p. 178.

5. Acharya JT. Charaka Samhita Sutra Sthana. Varanasi: Chaukhamba Krishnadas Academy; 2016. Sutra 11/45. p. 179.

6. Acharya JT, Acharya NM. Sushruta Samhita Chikitsa Sthana. Varanasi: Chaukhambha Surbharati Prakashan; 2011. Sthana 5/19. p. 428.

7. Mishra S (Prof), Govindadas Sen KS (Kaviraj). Baishajya Ratnavali. Varanasi: Chaukhamba Surabharathi Prakashan; 2009. p. 516-526.

8. Ayurveda Sara Sangraha (Hindi). Shri Baidyanath Ayurved Bhavan Pvt Ltd; 2014. p. 647-657.

9. Vaidyanath R, Nishteshwar K, Acharya Sharangadhara. Sharangadhara Samhita. Varanasi: Chaukhambha Surbharati Prakashan; 2021. p. 119-123.

10. Ghoshan V, Mundugaru R, Prakash N, Bhat S, Basavaiah R. Evaluation of neuro-protective activity of Brihat Vata Chintamani Rasa. JPHYTO. 2015;4(4):207-211.

11. Park SI, Lee EH, Kim SR, Jang YP. Anti-apoptotic

effects of Curcuma longa L. extract and its curcuminoids against blue light-induced cytotoxicity in A2E-laden
human retinal pigment epithelial cells. J Pharm Pharmacol. 2017 Mar;69(3):334-340.

12. Rejitha S, Prathibha P, Madambath I. The Ayurvedic drug Ksheerabala (101) ameliorates alcohol-induced neurotoxicity by down-regulating the expression of transcription factor (NFkB) in rat brain. Ayu. 2015 Jul-Sep;36(3):323-328.

13. Sharma S. Ashtanga Sangraha with Sasilekha commentary of Indu. 2nd ed. Varanasi: Chaukambha Sanskrit Series Office; 2008. p. 144.

14. Dhanwantari Nighantu by J.K. Ojha, U.P. Mishra. Edition: 2004. Varanasi: Chaukhambha Subharati Prakashana; p. 25-26.

15. Nagaranjan M, Kuruvilla GR, Kumar KS, Venkatasubramanian P. Pharmacology of Ativisha, Musta and their substitutes. J Ayurveda Integr Med. 2015 Apr-Jun;6(2):121-133.

16. Mishra S (Prof), Govindadas Sen KS (Kaviraj). Baishajya Ratnavali. Varanasi: Chaukhamba Surabharathi Prakashan; 2009. p. 569-572.


J Ayu Int Med Sci 2023;8(11)173