E-ISSN:2456-3110

Case Report

Atypical Parkinsonism

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 11
Publisherwww.maharshicharaka.in

An Ayurvedic Approach in Improving the Quality of Life in Atypical Parkinsonism - A Case Report

Sasidharan AT1*, Dileep KS2, PV Giri3
DOI:10.21760/jaims.9.11.40

1* Athira T Sasidharan, Post Graduate Scholar, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Thaikattussery Ollur, Thrissur, Kerala, India.

2 Dileep KS, Associate Professor, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Thaikattussery Ollur, Thrissur, Kerala, India.

3 PV Giri, Professor, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Thaikattussery Ollur, Thrissur, Kerala, India.

Atypical parkinsonism is another form of parkinsonism, which is having a more widespread pathology than seen in Parkinson’s disease. A group of neurodegenerative conditions including Multiple system atrophy (MSA), Progressive supranuclear palsy (PSP), and Corticobasal syndrome (CBS) constitute this form of parkinsonism. Due to the widespread pathology including degeneration of striatum, globus pallidus, cerebellum, and brainstem, as well as the SNc, the clinical features tend to resemble to that of Parkinson’s disease, but different manifestations are seen. Early involvement of speech and gait, absence of rest tremor, lack of motor asymmetry are the clinical presentations seen in patients with atypical parkinsonism. Additionally, poor or no response to levodopa, and a more aggressive clinical course also differs it from Parkinson’s disease. Initially, the diagnosis is difficult, but as the disease progress, a clear diagnosis can be obtained. A 64-year-old male patient was admitted to Kayachikitsa IPD complaining of difficulty in walking, slowness of activities, whole body numbness, tremor of hands and chronic constipation. On examination, extrapyramidal signs were positive, sensory system was not much affected, hyperreflexia and decreased muscle bulk was noted. Unified MSA rating scale was used to assess the change in quality of life before and after treatment. Vatavyadhi and Gulma Chikitsa was adopted. Procedures such as Churnapinda Sweda, Sirodhara, Vasti, Nasya were done. Walking and tremor of hands improved significantly. Mild decrease in whole body numbness, overall increase in body strength were obtained.

Keywords: Atypical Parkinsonism, Vatavyadhi, Kampavata

Corresponding Author How to Cite this Article To Browse
Athira T Sasidharan, Post Graduate Scholar, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Thaikattussery Ollur, Thrissur, Kerala, India.
Email: 		Sasidharan AT, Dileep KS, PV Giri, An Ayurvedic Approach in Improving the Quality of Life in Atypical Parkinsonism - A Case Report. J Ayu Int Med Sci. 2024;9(11):283-289.
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https://jaims.in/jaims/article/view/3808

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-10-12 2024-10-22 2024-11-02 2024-11-12 2024-11-23
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© 2024by Sasidharan AT, Dileep KS, PV Giriand 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].

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Athira TS et al. An Ayurvedic Approach in Improving the Quality of Life

Introduction

Parkinsonism is a movement disorder that is neurodegenerative in nature and causes significant morbidity in old age.[1] Among the different forms of Parkinsonism, Parkinson’s disease is the most commonly seen one. The features include bradykinesia, tremor and rigidity.[2] The global burden of Parkinson’s disease accounts for approximately 5 million people worldwide. The hallmark pathological feature of Parkinson’s disease is degeneration of dopaminergic neurons in substantia nigra and presence of Lewy bodies in cell bodies.[3] Atypical parkinsonism is one of the different forms of parkinsonism which differs from Parkinson’s disease by its widespread pathology involving substantia nigra, globus pallidus, brainstem and cerebellum.[3] It and involves multiple system atrophy, corticobasal syndrome and progressive supranuclear palsy.[4] The early diagnosis of atypical parkinsonism is difficult, and definitive pathology of the disease is being researched.[5] The clinical features include early falls, absence of rest tremor, speech difficulty, poor or no response to levodopa. Since neuroimaging of dopamine system shows striatal dopamine depletion in both atypical and Parkinson’s disease, it is seldom not confirmatory for diagnosing atypical parkinsonism. Further, contrast metabolic imaging of basal ganglia or thalamus network shows decreased activity pattern in globus pallidus and increased activity in thalamus, which is opposite in case of Parkinson’s disease.[3] In Multiple system atrophy (MSA), there are cerebellar, autonomic and parkinsonian features, with either parkinsonian or cerebellar features predominating.[6] In Ayurveda, the symptoms can be compared to that of Kampavata. Kampavata is a Vatika Nanatmaja Vyadhi according to Acharya Charaka, and has been described in Basavarajeeya.[7] The condition can be managed by Vatavyadhi Chikitsa. Brimhana therapy can be administered considering the Dhatukshaya nature of the disease. Along with Brimhana, specific treatment aiming at Kampa can also aid in the better management of the condition.

Case Report

64-year-old male patient complaints of difficulty in walking after getting up from resting position, tremor of hands, whole body numbness,

slowness of activities, constipated bowel and tendency to fall on standing for some time and the symptoms worsened since past 5 months.

Patient History

64-year-old hypertensive, cardiac patient, with a long history of smoking and chronic constipation complaints of difficulty in walking after getting up from resting position for 5 months. Patient has a long history of neck and low back pain and managed the condition overtime by taking painkillers without medical advice. Apart from these symptoms, patient noticed slight difficulty in walking with tendency to fall, which rapidly progressed within the past 5 months into a short-stepping gait with tendency to deviate to sides while walking along with whole body numbness. He started experiencing abnormal leg movements which are jerking in nature before one and a half months, which worsened during the course of the disease, and for 1 month he requires another person’s support for walking.

He went for allopathic consultation after a feeling of weakness of left half of body 3 months before, and was referred to neurology department after imaging studies revealed occurrence of CVA. He was prescribed with Syndopa in addition to regular cardiac medicines. Later, his already existing abdominal complaints including constipation, gastric irritation became so severe that he was prescribed with more medicaments including those for anxiety. He also started noticing slowness of activities, difficulty in buttoning of shirt, generalized debility, tendency to fall or need to sit on standing for some time and urinary incontinence. Before 1 week, patient started developing tremor of hands and he then decided to take Ayurvedic IP treatment for better management of the condition.

Treatment History

Patient was on Syndopa 100 mg twice daily after food, Omeprezole 20 mg twice daily before food, Clopidogrel 75 mg once daily after food, Amixide H one tablet once daily after food for anxiety, Clonam 0.25 mg once daily after food for anxiety.

Systemic Examination

Examination of Central Nervous System

Patient was of moderate built with BMI of 27.1 kg/m2, cooperative, anxious, neat and tidy in appearance.


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He was oriented to time, place, person with intact memory. Speech was fluent with slight slurring and monotonous in nature. Speech comprehension in intact and there is no dysarthria or aphasia. All cranial nerves were found to be intact on examination. The muscle bulk on upper limb 10 cm above olecranon process was 27 cm on right side and 25 cm on left side; and 10 cm below olecranon process was 24 cm on right side and 23 cm on left side.

On lower limb, the muscle bulk at 18 cm above patella was 36 cm on right side and 38 cm on left side; and at 10 cm below tibial tuberosity, it was 24 cm on right side and 25 cm on left side. Both upper and lower limbs were hypertonic in nature. The muscle power was normal at upper limbs and in lower limb, the power was 4/5. Plantar reflex was positive and all deep reflexes were exaggerated (+++).

Finger nose test was possible, there was no dysdiadochokinesia, buttoning and straight-line walking were difficult, tandem walking and knee-heel test was not possible, Romberg’s test was positive. Nystagmus and ataxia of gait was absent. Postural tremor was present, and gait was short stepping in nature with reduced arm swing.

The sensory system was intact on examination. Signs of extrapyramidal lesion observed were bradykinesia, tremor of hands, Festinant gait, slight monotonous speech, slightly manifested muscular rigidity, and positive glabellar tap.

Ayurvedic Parameters Examination

  • The Sarira Prakriti of patient is Vata-Kapha and was analysed using TNMC Prakriti
  • Doshas vitiated are Vyana Vayu, Samana Vayu, Apana Vayu, Sadhaka Pitta, Pachakapitta, Avalambhaka Kapha and Tarpaka Kapha.
  • Dhatu involved are Rasa, Rakta, Mamsa, Medas and Asthi
  • Upadathu involved is Snayu
  • Sara is Madhyamam
  • Satwam is Avaram
  • Samhananam - Madhyamam
  • Vyayama Sakthi - Avaram
  • Satmyam - Sarvarasa
  • Pramanam - Madhyamam
  • Ahara Sakthi: Abhyavaharana Sakthi - Avaram, Jarana Sakthi - Avaram
  • Vaya - Vardhakya
  • Kalam: Kshanadi - Greeshmam, Vyadhyavastha - Navam
  • Desam: Bhoomi - Sadharanam, Deham - Sarvadeham
  • Rogamargam - Madhyamam
  • Srotas affected - Rasavaha, Raktavaha, Mamsavaha, Medovaha, Asthivaha, Annavaha, Purishavaha
  • Nidanas are Ruksha Asatmya Ahara, Chronic smoking, Prolonged use of antacids and painkillers
  • Poorvaroopam - Avyaktam
  • Roopam - Tremor of hands, jerking movements of lower limbs, slowness of activities, difficulty in walking, numbness of whole body, constipation, urinary incontinence
  • Upasaya - Ushna Laghu Ahara, mild exercises
  • Anupasayam - Ruksha Seta Asatmya Ahara, heavy works and exercises, cold applications
  • Samprapti: Nidana - Vata Prakopa, Rasa Rakta Dushti - Sthanasamsraya in Snayu, Grahani - manifestation of Roopas

Diagnostic Assessment

From the clinical presentations and poor response to levodopa, and after careful examination, diagnosis was reached. Unified MSA rating scale was used to assess the quality of life of the patient before and after treatment.[8] Diagnosis was concluded as Atypical parkinsonism (Kampavata) (Multiple system atrophy)

Therapeutic Intervention

The treatment was mainly focussed on to improve the quality of life of the patient, considering the rapid progressive nature of the disease. Vatavyadhi Chikitsa, mainly Dhatukshayajanya Vyadhi Chikitsa was adopted. Brimhana was the prime objective along with management of tremor and associated conditions. The internal medicines given are included in table 1 and external therapies given are included in table 2.


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Table 1: Internal medicines

DateMedicineDoseTime
04/04/241.  Gandharvahasthadi Kashaya15 ml Kashaya with 45 ml luke warm water6am, before food
2.  Gandharvahastha Eranda Tailam10 ml with Kashaya6 am, before food
3.  Vaiswanara Churnam1 teaspoon with hot water12 pm, Before food
4.  Ashtavargam Kashayam15 ml Kashaya with 45 ml luke warm water6pm, before food
5.  Dhanwantaram tab0-0-1With Kashaya
6.  Balarishtam + Aswagandharishtam30 ml -0-30 mlAfter food
08/04/247.  Kapikachu Churnam with Aswagandha Churnam5 gm each with milkBed time
8.  Suntibaladi Churnam2 teaspoon Churna in 2 litres of waterFrequently
14/04/241.  Gandharvahasthadi Kashayam15 ml Kashaya with 45 ml lukewarm water6 am, Before food
2.  Rasonadi KashayamAs Ksheera Kashayam8 pm
3.  Vaiswanara Churnam1 teaspoon with hot water12 pm, Before food
4.  Balarishtam + Aswagandharishtam30 ml-0-30 mlAfter food
5.  Aswagandha Churnam + Kapikachu Churnam1 teaspoon each with milkBed time
6.  Suntibaladi Churnam2 teaspoon Churna with 2 litres of water as ToyamFrequently

Table 2: External therapies

DateMedicineProcedureOutcome
04/04/24 to 08/04/24Internal medicine
1.  Gandharvahasthadi Kashayam
2.  Ashtavargam Kashayam
3.  Dhanwantaram tablet
4.  Vaiswanara Churnam
5.  Gandharvahastha Eranda Tailam
External treatment medicines
1.  Kolakulathadi Churnam
2.  Dhanyamlam		Churna Pinda Sweda with Kolakulathadi Churna in Dhanyamlam steamPatient felt easiness of joints, slight improvement (subjective) in walking
09/04/24 to 11/04/24Internal medicines
Additionally, Kapickachu Churna and Aswagandha Churna in milk and Suntibaladi Toya given with previous internal medicines
External treatment medicines
1.  Kolakulathadi Churnam
2.  Karpasastyadi Tailam Mashasaindhava Tailam		Churna Pinda Sweda in Karpasastyadi and Mashasaindhava Tailam.Whole body numbness reduced; tremor of hands reduced.
09/04/24 to 15/04/24Internal medicines
Same as before
External treatment medicines
1.  Pippalyadi Anuvasana Tailam		Matravasthi with Pippalyadi Anuvasana Tailam - 100 mlPatient had urge for defaecation, however, consistency of bowel and satisfaction on proper evacuation was irregular
10/04/24 to 23/04/24Internal medicines
Same as before and was revised on 14/04/24 by adding Rasonadi Ksheera Kashaya instead of Ashtavargam Kashayam
External therapy medicines
1.  Dhanwantaram Tailam		Dhanwantaram Tailam Pichu on lower abdomen and pelvic regionUrinary incontinence reduced significantly and frequency of toilet visits for urination also reduced.
14/04/24 to 18/04/24Internal medicines
Same as before
External treatment medicines
1.  Ksheeram
2.  Karpasastyadi Tailam
3.  Mashasaindhava Tailam		Ksheeradhoomam with face massage with Karpasastyadi Tailam and Mashasaindhava TailamNo significant change in symptoms

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DateMedicineProcedureOutcome
16/04/24Internal medicines
Same as before
External treatment medicines
1.  Erandamoola Kwatham - 800 ml
2.  Saindhavam - 15 gm
3.  Satapushpa Kalkam - 20 gm
4.  Makshikam - 100 ml		Kashaya VastiPatient complained of abdominal distension and constipation in between treatment and thus Kashaya Vasti was given. Vasti Dravya passed within 5 minutes and abdominal distension was relieved. However, constipation persisted next day also.
17/04/24 to 23/04/24Internal medicines
Same as before
External therapy medicines
1.  Dhanwantaram 101 Avarthi Tailam		Pratimarsha Nasya with Dhanwantaram 101 Avarthi Tailam, 2 drops each nostril in morningTremor of hands was almost negligible and patient felt an increase in overall strength of body.
19/04/24 to 23/04/24Internal medicines
Same as before
External therapy medicines
1.  Bala Aswagandhadi Tailam		Sirodhara with Bala Aswagandhadi TailamTremor of hands was almost negligible and patient felt an increase in overall strength of body. The abnormal jerking movements of lower limbs showed slight improvement and thus patient had much easiness while getting up from sitting position and on walking.
21/04/24Internal medicines
Same as before
External therapy medicines
1.  Sukumara Ghritam		Musthadi Rajayapana VastiConstipation persisted in the following days also.
23/04/24Discharged

Results

Patient Perspective

From patient’s perspective, there was improvement in walking as he required support to walk before and after treatment, he was able to walk on his own. Hand tremor got cured completely. Bowel remained unsatisfactory. Whole body numbness was also reduced to some extent. Urinary urgency and incontinence were significantly reduced. After 3 weeks of follow-up, patient reported satisfactory bowel, occasional gastric irritation, reduced whole body numbness.

Analysis using unified MSA rating scale.

The score reduced from 43 to 26 after treatment. The table showing the score is given below.

Table 3: Unified MSA rating scale

Before treatmentAfter treatment
Part 1 - Historical review2013
Part 2 - Motor examination scale1910
Part 3 - Autonomic examinationPresent - urinary incontinence, mild orthostatic hypotension
Part 4 - Global disability scale43

Discussion

Atypical parkinsonism, although not as common as Parkinson’s disease, is a debilitating disorder due to its rapid progress. The symptoms of atypical parkinsonism can be seen in the features of Kampavata. The treatment mainly focusses on improving the quality of life by reducing tremor, improving motor activities and speech difficulties. The treatment in this case is staged as Vata Anulomana, Agni Sameekarana initially, along with specifically managing Kampa, walking difficulty, followed by Brimhana measures. Internally, Gandharvahasthadi Kashaya along with Gandharva Eranda Tailam, Vaiswanara Churnam, Dhanwantaram tablet, Ashtavargam Kashaya, Balarishta, Aswagandharishta, Kapikachu Churna, Aswagandha Churna, Shuntibaladi Churna and Rasonadi Kashaya are given. The drugs of Gandharvahasthadi Kashaya are of hot potency, is carminative and has purgative effect. Gandharva Eranda Taila has antioxidant, and purgative property. Vaiswanara Churna which is mentioned in Gulma Chikitsa is an excellent yoga that increases digestive power by its Agni Deepana property. Ashtavargam Kashaya has anti-inflammatory and analgesic properties.[9]


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Balarishta is mentioned in Vatavyadhi Chikitsa and acts as a general nerve tonic for pacifying the aggravated Vata. Aswagandharishta also acts as a nervine tonic. Kapikachu Churna is beneficial for managing tremor as it is a richest source of levodopa. Aswagandha Churna has anti-stress, anti-inflammatory and neuroprotective properties.[10]

Suntibaladi Churna is proven for its effect on numbness. Externally, Churna Pinda Sweda with Kolakulathadi Churna in Dhanyamla was done first. It helps in managing the initial Avarana and ama condition and thus bringing lightness to Sarira. Later, Churna Pinda Sweda with Karpasastyadi and Mashasaindhava Taila was done.

Karpasastyadi Taila is beneficial for all Vata Rogas and is Brimhana in nature. Mashasaindhava Taila is indicated for Sankuchita Anga in Vatavyadhi chikitsa. These bring about laxity to joints and improve motor activities.

Matravasti with Pippalyadi Anuvasana Taila will pacify Vata Dosha and provides strength to Sareera. Considering the bowel of the patient and abdominal distension, Pippalyadi Anuvasana Vasti is a good choice. Dhanwantara Taila Pichu on Adhonabhi is used to manage urinary incontinence as it strengthens and nourishes the detrusor muscle.[11]

Nasya with Dhanwantaram 101 Avarti Taila helps to improve the symptoms by its Vatahara and Balya properties.[12] Sirodhara with Bala Aswagandhadi Taila is also Brimhana in nature. At the time of discharge, patient was advised to follow Pathya including Laghu Ahara and walking.

Conclusion

The incorporation of Ayurvedic treatment modalities along with modern medication demonstrated a notable difference in improving the quality of life in atypical parkinsonism symptoms.

However, continuous intake of internal medicines and periodical Ayurvedic external therapies are required to sustain the effect and prevent the progress of the disease. Further exploration in the field of atypical parkinsonism is required in Ayurveda as there is no definitive way of management of atypical parkinsonism.

Patient Consent

Patient consent form had obtained.

References

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2. Shrimanker I, Tadi P, Schoo C, Sánchez-Manso JC. Parkinsonism. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Nov 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK542224/

3. Loscalzo J, Kasper DL, Longo DL, Fauci AS, Hauser SL, Jameson JL. Harrison’s Principles of Internal Medicine. 21st ed. Vol. 2. New York: McGraw Hill Medical; 2024. 3386–3400.

4. Stamelou M, Hoeglinger GU. Atypical parkinsonism: an update. Curr Opin Neurol. 2013 Aug;26(4):401–5.

5. McFarland NR. Diagnostic Approach to Atypical Parkinsonian Syndromes. Contin Lifelong Learn Neurol. 2016 Aug;22(4 Movement Disorders):1117–42.

6. Colledge NR, Walker BR, Ralston SH. Davidson’s Principles & Practice of Medicine. 21st ed. China: Churchill Livingstone; 2010. 1198 p.

7. Chaangani SG, Sharma. Basavarajeeya. 2005th ed. Delhi: Chaukhamba Samskrita Pradhishtan; 2005. 101 p.

8. Krismer F, Seppi K, Tison F, Sampaio C, Zangerl A, Peralta C, et al. The Unified Multiple System Atrophy Rating Scale: Intrarater reliability. Mov Disord. 2012 Nov;27(13):1683–5.

9. P A, Acharya S. A comparative clinical study on the effect of Ashtavargam Kashaya and Gandharvahastadi Kashaya in the management of Katigraha w.s.r. to lumbar spondylosis. Int Ayurvedic Med J. 2020 Jul 30;4:2375–81.

10. Verma J, Mangal G, Garg DrG. Parkinson’s Disease: Treatment approach through Ayurveda (based on previous studies and PubMed articles). Int Ayurvedic Med J. 2019 Jun 10;6:454.


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11. Fathima PV, MJ G. A clinical evaluation of Dhanwantaram Taila Matra Vasti and Kanchanara Guggulu in the management of Vatashtila (benign prostatic hyperplasia). Int Ayurvedic Med J. 2022 Sep 14; (September 2022).

12. Pai AS, Borannavar S, Desai AS. An integrated approach through Panchakarma in the management of trigeminal neuralgia w.s.r Anantavata. Ayushdhara. 2024 Jul 5;11(January-February 2024).

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