Implication of Ayurveda in the Management of Apasmara (Epilepsy) – Case Study
Epilepsy affects 1% of the world’s population a most common serious disorder of the brain, greatly impacting on the quality of life of affected individuals. In Ayurveda, the similar presentation is named as Apasmara has been explained with its aetiology, diagnosis and management. Imbalance in the three Doshas Vata, Pitta, Kapha singly or all of them together can cause Apasmara. Those aggravated Doshas get accumulated in Hridya and produce the features based upon Doshika predominance which cause illusion of the mind and visual hallucination and seizures (tonic spasms and clonic jerks) often it is presented with outwarding tongue, deviation of eyes, dribbling of saliva with froth, tonic and clonic movements of limbs. Even though medical world claims of the advancements in the management of Apasmara drugs don’t work as they expect. The present Anti-epileptic drugs medication has so many drawbacks like adverse drug interaction and teratogenicity, cognitive impairment to an extent is also seen in some patients with epilepsy. An 18-year male patient arrived to the OPD and complained of seizure attack from last 6 years. The patient sought out ayurvedic treatment because he had tried numerous allopathic treatments but did not get significant result. With the Ayurvedic treatment, remarkable changes in the symptoms of Epilepsy were seen.
Introduction
Apasmara is explained as Mahagada [1], Acharya Charaka explained Apasmara as Apagama (loss) of Smriti (memory) associated with Bibhatsta Chesta (Irrelevant behavior) due to derangement of Dhi (thinking capacity) and Satva (mental strength) [2]. Acharya Madhav described as a loss of Smriti characterized by Tamah Pravesh (feeling of aura) that happens spontaneously [3]. In Apasmara can be correlated with epilepsy in modern medicine.
The word epilepsy is derived from Greek word “Epilepsia” which means to “seiz” or to be overwhelmed by surprise. Epilepsy is a chronic disorder characterized by recurrent seizures, which may vary from a brief lapse of attention or muscle jerks and prolonged convulsions [4]. The seizures are caused by sudden, usually, brief, excessive electrical discharges in a group of brain cells (neurons) [5]. In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions and behavior or sometimes convulsions, muscle spasms and loss of consciousness. Anything that disturbs the normal pattern of neuron activity from illness or brain damage to abnormal brain development can lead to seizures. A measurement of electrical activity in the brain with EEG as well as MRI or CT scan is the common diagnostic test for Epilepsy [6].
Antiepileptic medications suppress the seizure but do not cure the underlying conditions. They also have side effects, contraindications and occasionally require lifelong use. Although the strong tranquillizers and sedatives used in modern therapy are effective, they have negative effects on mind, therefore it is important to look for safe treatments those not only relieves the symptoms but also the underlying cause. Acharya Charaka has mentioned purification therapy as Vamana (therapeutic controlled emesis), Virechana (therapeutic controlled purgation) and Basti (medicated enema) along with palliative therapy as a line of treatment of Apasmara [7].
Case Details
Patient’s Profile
- Name- xxxx
- Age- 18 year
- Sex-Male
- Religion-Hindu
- Socio Economic Status -Middle class
- Occupation- Student
- Father-Job in government sector
- Mother- Housewife
- OPD No-677/5228
- IPD No- PW 4/15 Chief Complaints: Loss of consciousness, Jerky movements, Tachypnea, Fatigue after seizure attack since 6 years.
History of Present Illness
An 18 Year old male Patient came to OPD of Panchakarma Reg no. 677/5228 Rishikul Ayurvedic hospital, Haridwar with a complaint of epileptic seizures, fatigue, and forgetfulness since 6 years. Past history revealed that he got injury in head at the age of 12 years then he suddenly felt jerk at night for around 5-8 minutes for which he got admitted in hospital and started with antiepileptic drugs. Instead of taking medicines he has seizure 6-8 episodes per week. Antiepileptic medicines were administered till 18 years of age then they came to Rishikul Ayurvedic Hospital, Haridwar for further management.
Family History
- Paternal -Grandmother suffered from same problem
- Maternal- Mother suffering from same problem Developmental History
- All milestones attained at appropriate time.
Immunization History • Given as per Schedule
Treatment History • Patient took allopathic treatment from Himalayan hospital jolly grant, Dehradun for 4 years (Table 1).
| Dose | Timing | |
|---|---|---|
| Tab sodium valproate + valproic acid | 200 mg | BD |
| Tab clonazepam | 0.25 mg | OD |
| Tab calcium + VitD3 | 500mg | OD |
Table 1: Medication took by patient.
Personal History
- Diet-Vegetarian
- Appetite-Good
- Bowel-Clear, once/day
- Micturition-Normal,4-5 time/day
- Sleep-Sound
General Examination
Vital signs
- HR-72/min
- PR-70/min
- RR-18/min
- BP-110/80mmHg Systemic Examination
- Respiratory system: Chest bilateral symmetrical, no added sound, chest sound clear
- Cardiovascular system: S1, S2 heard normal no murmurs
- Per abdomen: Soft, no any prominent veins, no any organomegaly Central Nervous System Examination
- Appearance-Alert, active
- Behavior- Cooperative well mannered
- Hallucination-No hallucination during seizure episodes
- Intelligence – Normal
- Consciousness-Conscious
- Memory -Intact
- Orientation – Well oriented to place, person, time
- Speech-Slow speech
- Cranial nerves – All cranial nerves are intact
- Cerebellar sign-NIL
- Signs of meningeal irritation- NIL
- Coordination: Normal
- Sensation: Normal
- Gait: Normal
- Muscle power: 5/5 in all four limbs
- Muscle Tone: Normotonic
Ashta Vidha Pariksha
- Nadi -72/Min
- Mala -Samyak
- Mutra- Samyak
- Jihwa -Saam (Lipta)
- Shabda-Anushnashita
- Druk-Samyak
- Akruti -Madhyama
Investigation
- Investigation shows normal hematological and biochemical reports.
- The EEG Showed evidence of generalized tonic clonic epilepsy.
Assessment Criteria
Subjective: For Subjective Assessment four symptoms will be kept as parameter [9].
Severity of attack
Grade 0-Nothing Grade 1-Multi focal clonic tremors Grade 2-Generalized tonic tremors Grade3-Frothing+tongue biting
Frequency of Convulsions
Grade 0-No convulsions Grade 1-1 episode/30 days Grade 2-1 episode /15 days Grade3-1 or more episodes/day
Duration of Convulsion Attack
Grade 0-No convulsions Grade 1-30 sec-1min Grade 2-1 min-5min Grade3->5 min
Ictal Features
Grade0-No any features Grade 1-Headache Grade 2-Headache+drowsiness/delirium Grade3-Paresis and other complaints
Objective
• Lab investigation: EEG
Diagnostic Criteria
- According to the international league against epilepsy [8]:
- At least two unprovoked seizures occurring >24 hours apart
- One unprovoked seizure and probability of further seizure like the general recurrence risk after two unprovoked seizures, occurring over the next 10 years.
- Diagnosis of an epilepsy syndrome.
Treatment Plan
Panchakarma was planned for this patient after assessing strength, Prakriti, Agni etc. for better and further management. He had advised to come OPD weekly for regular follow up. After 20 days of oral medicine. He admitted in IPD of Panchakarma for further management.
1st Sitting In first sitting internal medicine is given to patient for 20 days. Duration of treatment for first sitting 20 days.
Internal Medications (Table 2)
| S.No | Drug/Formulation | Dose |
|---|---|---|
| 1 | Manas Mitra Vatak | 2BD |
| 2 | Bhrami Vati Swarna Yukta | 2BD |
| 3 | Saraswatarishta | 20 ml BD |
Table 2: Medication given in first sitting.
2nd Sitting Patient is admitted to IPD and panchakarma treatment is planned. Firstly, Deepana Pachana is done followed by Sarvanga Abhyanga along with Nasya then after 7 days Shirodhara is done for 14 days. Total duration of treatment in second sitting is 26 days (Table 3).
| S.No. | Treatment | Drug Used | Duration |
|---|---|---|---|
| 1 | Deepan Pachana | Panchakola Churna 3 gm BD | 5 days |
| 2 | Sarvanga Abhyanga | Ksheera Bala Taila for Abhyanga | 7 days |
| 3 | Nasya | Anu Taila for Nasya | |
| 4 | Shirodhara | Ksheera Bala Taila | 14 days |
Table 3: Medication and treatment given in second sitting.
3rd Sitting In third sitting Nasya is done along with Shirodhara for 14 days total duration of treatment in third sitting is 14 days (Table 4).
| S.No. | Treatment | Drug Used | Duration |
|---|---|---|---|
| 1 | Nasya | Kalyanaka Ghrita | 7 days |
| 2 | Shirodhara | Ksheerabala Taila | 14 days |
Table 4: Medication given in third sitting.
Total duration of treatment is 60 days. Follow up done after 1 month of treatment.
Result and Discussion
Effect of Panchakarma therapy and Ayurvedic medicine on symptoms of Epilepsy (Table 4).
| S.No | Assessment Criteria | Bt | At 1st Sitting | At 2nd Sitting | At 3rd Sitting |
|---|---|---|---|---|---|
| 1 | Severity of attack | 2 | 2 | 2 | 1 |
| 2 | Frequency of convulsion | 3 | 2 | 1 | 1 |
| 3 | Duration of attack | 3 | 2 | 2 | 1 |
| 4 | Ictal features | 2 | 2 | 1 | 0 |
In above case patient got marked improvement from symptoms of Apasmara (Epilepsy) after Panchakarma in severity of attack, frequency of attack, duration of attack and post ictal features. Panchakarma treatment is the specialization of Ayurveda. Deepana and Pachana control the formation of Ama in the initial stage, which is very crucial for preventing the manifestation of the diseases. Acharya Charaka has mentioned Shodhana as a line of treatment so Nasya, Abhyanga and Shirodhara has been chosen and they showed good results.
Mode of Action of Kalyanaka Ghrita Nasya
Among all Snighdha Dravya Ghrita is considered as best in Ayurveda. It is one of Nitya Sevan [10] (can be consumed daily) mentioned in Ayurveda. Acharya Charaka and Acharya Vagbhata have explained Kalyanaka Ghrita in Apasmara Chikitsa which contains 28 ingredients. Medicine instilled through NASA reaches Sringataka Marma and distributes all over the brain opening vessels of eyes, ear, throat etc. Nasal route is easily accessible, convenient and reliable with a porous endothelial membrane and a highly vascularized epithelium that provides a rapid absorption of compounds into the systemic circulation, avoiding the hepatic first pass elimination. Blood brain barrier (BBB) has a lipophilic molecular structure, as Ghrita contains DHA, an omega 3 long chain polyunsaturated fatty acid, which are high concentration in brain cells too. Ghee is known to have antioxidant property which acts upon the degenerative brain cells and repair them.
Mode of action of Shirodhara with Ksheerabala Taila
Shirodhara is a type of Murdhini Taila where pressure and vibration are created over the forehead and this vibration is amplified by hollow sinus present in the frontal bone. The vibration then transmitted inwards through the fluid medium of the cerebrospinal fluid (CSF) and thus this vibration along with little temperature may activate the function of thalamus and basal forebrain which then brings the amount of serotonin and catecholamine to the normal stage inducing the sleep. Due to continuous and rhythmically pouring of Taila Dhara also lead to state of concentration and enhance the release of serotonin and produces chemical substance like acetylcholine. Ksheerabala Taila is being utilized as a Rasayana drug in Ayurveda Treatment. The continuous administrations of this formulation prevent the release of abrupt electrical discharge and improve the physical and mental condition of the patients. It has profound soothing and relaxing effect on mind.
Conclusion
Epilepsy is a clinical syndrome affecting central nervous system. It influences the physical, psychological, familial and occupational life of a person. In this case study treatment was planned on the basis of treatment of Apasmara which are mentioned in classics. Now Patient feels better, comfortable at his work, the frequency of seizure attack is reduced and patient is under follow up.
References
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Agnivesha (2015) Charaka Samhita. In: Acharya T, et al. (Eds.), Ayurveda Deepika Commentary of Chakrapani. Chikitisa Sthana, Chapter 10, verse 68, Chaukhambha Orientalia, Varanasi, India, pp: 477.
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Agnivesha (2015) Charaka Samhita. In: Acharya T, et al. (Eds.), Ayurveda Deepika Commentary of Chakrapani. Nidana Sthana, Chapter 8, verse 5, Chaukhambha Orientalia, Varanasi, pp: 226.
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Upadhyaya Y (2002) Madhav Nidan, Madhukosha Tika, Apasmara Nidana 21, verse 1. Sanskrit Sansthana, Varanasi, India, pp: 45.
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Epilepsy F (2023) It’s Time to Take Action Together. Epilepsy Foundation, USA.
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Sibat HF (2011) Novel treatment of epilepsy. Neurology Intech publishers 201: 69-72.
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Misra UK, Kalita J (2009) Clinical Electroencephalography. 1st (Edn.), chapter 17, Elsevier publishers, pp: 371-373.
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Ibidem1; 10/16:474p.
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Kamath SA, Shan SN, Nadkar MY (1944) API Textbook of medicine, 11th (Edn.), 2(21): 1900.
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ILAE (2023) Research. The International League Against Epilepsy, TX, USA.
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Agnivesha (2015) Charaka Samhita, Ayurveda Deepika Commentary of Chakrapani. In: Acharya T, et al. (Eds.), Sutra Sthana, Chapter 5, verse -12, Chaukhambha Orientalia, Varanasi, India, pp: 38.
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