|Year : 2020 | Volume
| Issue : 1 | Page : 30-34
Management of diabetic peripheral neuropathy through Ayurveda
S Krishna Rao1, S Indu1, P P Pradeep Kumar2, Parvathy G Nair2, P Radhakrishnan2
1 Central Ayurveda Research Institute for Hepatobiliary Disorders, Bhubaneswar, Odisha, India
2 National Ayurveda Research Institute for Panchakarma, Thrissur, Kerala, India
|Date of Submission||11-Oct-2018|
|Date of Acceptance||08-May-2020|
|Date of Web Publication||14-Jul-2020|
Dr. S Krishna Rao
Central Ayurveda Research Institute for Hepatobiliary Disorders, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Diabetic neuropathies are one among the complications of diabetes. Over a period of time, the nerves of diabetes get affected, especially the peripheral nerves leading to Diabetic Peripheral Neuropathy (DPN). A 67-year-old male diabetic who was diagnosed with DPN was treated with a combination of Ayurvedic oral medication and external therapies. Considering the treatment protocol of Prameha upadrava and Vatavyadhi chikitsa, internally, Balaguduchi ksheera kashaya, Ksheerabala 101 Capsule, and Nishamalaki churna were used during the course of treatment. External therapies including Udvartana, Abhyanga, Patrapotala sveda, and Ksheera vasthi were done for a duration of 22 days. Assessment of the patient was done before and after treatment using the Diabetic Neuropathy Symptom Score, Michigan Neuropathy Screening Instrument, and Toronto Clinical Scoring System. Significant improvement was seen in all the scores after the treatment. This case study shows that DPN can be successfully managed by Ayurvedic treatment.
Keywords: Abhyanga, diabetic neuropathy, Prameha, Udvartana, Vatavyadhi
|How to cite this article:|
Rao S K, Indu S, Kumar P P, Nair PG, Radhakrishnan P. Management of diabetic peripheral neuropathy through Ayurveda. J Ayurveda Case Rep 2020;3:30-4
|How to cite this URL:|
Rao S K, Indu S, Kumar P P, Nair PG, Radhakrishnan P. Management of diabetic peripheral neuropathy through Ayurveda. J Ayurveda Case Rep [serial online] 2020 [cited 2021 Oct 27];3:30-4. Available from: http://www.ayucare.org/text.asp?2020/3/1/30/289373
| Introduction|| |
Diabetic Peripheral Neuropathy (DPN) is the most common complication of Diabetes Mellitus (DM) with a lifetime prevalence of about 50%. DPN considerably reduces the quality of life, causes disability due to foot ulceration and gait disturbances, and significantly increases the cost associated with diabetic care. Unavailability of satisfactory treatment in the conventional system leads to disease progression that can lead to neuropathic deformity and nontraumatic amputation. The symptomatology corresponding to the clinical presentation of DPN is scattered in Purvarupa (~premonitory symptoms), Lakshana (~ symptoms) and Upadrava (~complications) of Prameha, and Vatavyadhi. It can be compared under the broad head of Prameha janya upadrava as it manifests secondary to DM. It can be treated in dual line of treatment directed at the main disease Prameha and its complications. A patient with DPN was treated successfully as an inpatient with Ayurvedic oral medications and external therapies. This article highlights the potential of Ayurveda in the management of sensory and motor symptoms of DPN in a case where satisfactory treatment modalities are available in conventional medical system. The case highlights the importance of the stage-wise selection of drugs and external therapies as per the pathogenesis of the disease.
| Case Report|| |
A 67-year-old Indian, married, non-smoking, non-alcoholic male patient with a history of DM for 10 years with a positive family history for DM visited the outpatient department with the complaints of gradually progressive numbness in both the legs from the ankle to the tip of the fingers (right > left), intermittent burning sensation of both the soles (right > left) for three months along with unsteady gait, and feeling of walking on sponge. He was on insulin (10 units) for the past one year. He also had pain on flexion and extension of the right knee joint for three months. He was admitted to the IPD on May 31, 2018, for management. The history of symptomatology was suggestive of DPN [Table 1].
On examination of the sensory system, a reduced sensation in both the upper and lower limbs in a glove and stocking pattern was found. The foot appeared normal with unsteadiness of gait, reduced pinprick sensation, weakness, and reduced lower-limb deep tendon reflexes (knee jerk and ankle jerk). The vibration sensation was also found to be diminished in both the lower limbs. Baseline hematological investigations was done on May 31, 2018, which revealed HbA1c: 8.9%, hemoglobin: 13.7 gm%, total leukocyte count: 5,700 cells/cu mm, total red blood cell: 4.8 million/cu mm, neutrophils: 53%, lymphocytes: 33%, eosinophils: 13%, monocytes: 01%, platelet count: 2.39 lakh/cu mm, erythrocyte sedimentation rate: 30 mm/h, and serum uric acid: 4.9 mg/dl.
The patient was of Vridhavastha (~old age) and of Vata kapha prakruti (~constipation) with Vata as the Vikrita dosha (~Vata being predominately vitiated). The patient was of Asthi medosara (~the essence of tissues) with a moderate Samhanana (~body compactness), Pramana (~anthropometric measures), Satmya (~accustomed things), Satva (~tolerance level), Ahara shakti (~digestive power), and Avara vyayama shakti (~less exercise tolerance).
Magnetic resonance imaging report
Magnetic Resonance Imaging (MRI) report (dated May 14, 2018) suggests the central area of altered signal intensity of cervical cord and lower medulla, which may suggest syringobulbomyelia; posterocentral disc bulge at C4–C5, C5–C6, and C6–C7 disc with thecal sac compression and hypertrophy of posterior longitudinal ligament at C3–C7 level with compression of the thecal sac; and diffuse posterocentral disc bulges at L4–L5 and L5–S1 disc with thecal sac and bilateral neural foramina compression.
Diagnosis and assessment
Based on the history, physical examination, and clinical findings, the case was diagnosed as Stage 2 DPN (painless type) with partial sensory loss based on the diagnostic criteria of stages of DPN. In ayurvedic parlance, it was diagnosed as Prameha upadrava with the manifestation of Supti (~numbness) and Daha (~burning sensation).
| Treatment Protocol|| |
Considering the Nirama avastha (~unassociated Ama), chronicity of the disease, and Krurakosta (~constipated bowel), Balaguduchi ksheera kashaya and Ksheerabala 101 Capsule were selected for internal medication. Nishamalaki churna was included for controlling Prameha. Eranda taila and Hinguvachadi churna were used during treatment to manage constipation and loss of appetite, respectively[Table 1] and [Table 2]. Udvartana with Triphala churna,Abhyanga with Vatasini taila,Patrapotala sveda with Vatasini taila, and Ksheeravasthi were done in the patient [Table 3]. Allopathic medication (insulin injection), which the patient was taking for glycemic control, was continued during the treatment period. Assessment of the patient was done before and after treatment using the Diabetic Neuropathy Symptom Score (DNS) [Table 4], Michigan Neuropathy Screening Instrument (MNSI) [Table 5], and Toronto Clinical Scoring System (TCSS) [Table 6].
| Followup and Outcome|| |
Improvement was found in DNS, MNSI, and TCSS scores before and after the treatment [Table 7]. Complete recovery was seen in ataxia, pinprick sensation, numbness, tingling sensation, and weakness. All the deep tendon reflexes (knee and ankle jerk) were found to be normal after the treatment. Temperature and light touch sensation showed marked improvement. General improvement was noted in quality of life as reported by the patient. Investigations on June 1, 2019, showed postprandial blood sugar: 326 mg%, total cholesterol: 220 mg%, and serum triglycerides: 160 mg%. The postevaluation on June 11, 2018, showed fasting blood sugar: 148 mg% and postprandial blood sugar: 306 mg%.
| Discussion|| |
In Ayurvedic classics, no direct reference is available with respect to DPN. Acharya Charaka mentions that when a physician is unable to make a diagnosis or naming a disease, he needs to consider Samuthana vishesha (~causative factor of the disease), Adhisthana (~the site of disease manifestation), and Vikara prakruti (~the nature of disease). DPN is considered as an Upadrava of Prameha and should be understood based on the Dosha predominance. As per Ayurveda, DPN being a progressive complication phase of diabetes can be understood as Vata pitta predominant stage of Prameha happening due to excessive loss of the Soumya dhatus as Prabhuta avila mutrata (~excessive turbid urination) causing pathological brittleness in the body leading to myelin sheath degeneration of the nerves. Furthermore, seven years of self-medication without proper supervision was a possible contributing factor. The symptoms are predominant in the peripheries due to Rasayani daurbalya (~weakness of channels of circulation) as mentioned by Acharya Sushruta.
According to Ayurveda, every illness is unique due to the involvement of Visesha samprapti (~specific pathogenesis). In this case, the patient is elderly having DM for 10 years and the symptoms of DPN for the past three years. DM in Ayurveda is considered to be Prameha, which is one among the Astamahagadas (~eight dreadful diseases), and Vridhavastha (~old age) further aggravates the pathogenesis leading to the predominance of Vata and Pitta in the pathogeneses. Based on the symptomatology of the patient, Vata shamana chikitsa is adopted. Snehana (~oleation), Svedana (~sudation), and Sneha virechana is the line of treatment of Nirama vatavyadhi as told in Charaka samhita. However, Prameha being a Sveda anarha (~disease not suitable for sudation), only controlled sudation in the form of Patrapotala sveda was done in this case following Udvartana for the initial Langhana in the form of Rukshana and Abhyanga for external Snehana.
Udvartana with Triphala churna
In the pathogenesis of Prameha, it is mentioned that due to the Bahu drava sleshma (~excess moisture content), the Sthirata (~compactness) of the muscles of the body is lost. As Udvartana is a procedure that decreases Kapha, liquefaction of Medas imparts Sthirata to the body and helps in Tvak prasadana (~stimulates the skin by increasing the peripheral circulation), which was preferred. In this case, Udvartana is aimed at providing the initial Langhana and sensitization of the skin by increasing the circulation. Triphala churna is a polyherbal Ayurvedic medicine consisting of three fruits, namely Amalaki (Emblica officinalis Gaertn.), Bibhitaki (Terminalia bellerica [Gaertn.] Roxb.), and Haritaki (Terminalia chebula Retz.). Triphala churna helps in reducing the Tvakgata kleda, Meda, Meha, etc., and is a proven Rasayana dravya.
Abhyanga with Vatasini taila
After the initial Rookshana by Udvartana, Abhyanga is done with Vatasini taila [Table 8] which is Vatahara and also indicated in Prameha. The process of Abhyanga alleviates Vata and improves the sensory perception of the skin as Vayu dominates the tactile sensory organ located in the skin.
It is a type of Ushma sveda, where leaves with Vatahara property such as Eranda (Ricinus communis L.), Arka (Calotropis gigantea L.), Shigru (Moringa oleifera Lam.), Chincha (Tamarindus indica L.), and Nirgundi (Vitex negundo L.) are processed in a special manner and made into Pottalis (bolus). It is Vata kapha hara by nature and helps in relieving the movement difficulties associated with knee joint and associated joint pain.
As the patient was elderly and debilitated with Krurakosta, Ksheera kashaya was selected which suits the condition.Balaguduchi ksheera kashaya mentioned in Supthi vata chikitsa was thus selected as it suits the disease and stage of the disease. Bala (Sida cordifolia L.) is of Madhura rasa, Ushna veerya, and Vatahara in nature, whereas Guduchi (Tinospora cordifolia [Willd.] Miers) is of Tikta rasa and reduces the glycemic level. As the patient developed constipation in between, Sneha virechana (~oleaginous therapeutic purgation) was given with castor oil with milk at bedtime. Ksheera vasthi was administered in between with honey, Bala ksheera kashaya, Guggulu tiktaka ghrita, and Dhanwanthara taila.Ksheerabala is considered as one among the best Vatapitta samana taila, a prime rejuvenator, and stimulates the sense organs (~Indriya prasadana). It relieves burning sensation and facilitates the sensory perception by sense organs that are hampered in DPN. The combination of Nisha (Curcuma longa L.) and Amalaki (Emblica officinalis Gaertn.) is mentioned by Acharya as Agrya aushadas (~best medicines) of Prameha.
| Conclusion|| |
The combined Ayurvedic treatment protocol of oral drugs and external therapies were found to be effective in the management of sensory as well as motor symptoms of DPN. Concomitant use of Ayurvedic treatments and internal medications can be effective in the treatment of DPN; further use of suitable Rasayana drugs may arrest the disease progression also.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was financially supported by the National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, Thrissur, Kerala - 679 531, India.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Juster-Switlyk K, Smith AG. Updates in diabetic peripheral neuropathy. F1000Res. 2016;5:F1000 Faculty Rev-738. Published 2016 Apr 25. doi:10.12688/f1000research.7898.1
Sharma RK, Dash B, editors. Charaka Samhita of Agnivesha, Nidana Sthana. Ch. 4, Ver. 47. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 65.
Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, et al
. Diabetic neuropathies: A statement by the American diabetes association. Diabetes Care 2005;28:956-62.
Namboodiri DS. Chikitsa Manjari, Vatavyadhi. Ver. 219, 8th
ed. Mullakkal: Vidyarambham Publications; 2008. p. 402.
Murthy SK, editor. Astagahridaya of Vagbhatta, Chikitsa Sthana. Ch. 22, Ver. 45-46. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 521.
Murthy SK, editor, Astagahridaya of Vagbhatta, Utharasthana; Ch. 40, Ver. 12-13. 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2003.
Murthy SK, editor, Astagahridaya of Vagbhatta, Sutra Sthana. Ch. 5, Ver. 45-46. 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 67.
Murthy SK, editor. Astagahridaya of Vagbhatta, Chikitsa Sthana. Ch. 14, Ver. 31-33. 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 406.
Murthy SK, editor. Astagahridaya of Vagbhatta, Sutra Sthana. Ch. 6, Ver. 159, 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 105.
Murthy SK, editor. Astagahridaya of Vagbhatta, Sutra Sthana. Ch. 2, Ver. 8-9, 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 24.
Krishnanvaidyar KV, Gopalapillai S. Sahasrayogam, Tailayoga, 26th
ed. Mullakkal: Vidyarambam publications; 2006. p. 308-9.
Murthy SK, editor. Astagahridaya of Vagbhatta, Kalpa Sthana. Ch. 4, Ver. 21, 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 562.
Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP. Symptom scoring systems to diagnose distal polyneuropathy in diabetes: The Diabetic Neuropathy Symptom score. Diabet Med 2002;19:962-5.
Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N, Greene DA. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabetes Care 1994;17:1281-9.
Perkins BA, Olaleye D, Zinman B, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care 2001;24:250-6.
Sharma RK, Dash B, editors. Charaka Samhita of Agnivesha, Sutra Sthana. Ch. 16. Varanasi: Chaukhamba Surbharati Prakasan; 2002. p. 345.
Murthy SK, editor. Astagahridaya of Vagbhatta, Nidana Sthana. Vatarakta Chikitsa. Ch. 10, Ver. 7. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 93.
Dalhana A. Commentary Nibandha Sangraha on Susruta Samhita of Sushruta, Chikitsa sthana; Prameha Chikitsa. Varanasi: Chaukhamba Surabhi Prakasan; 2013. p. 455.
Murthy SK, editor. Astagahridaya of Vagbhatta, Sutra Sthana. Ch. 13, Ver. 1-3, 5th
ed. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 182.
Murthy SK, editor. Astagahridaya of Vagbhatta, Sutra Sthana; Dinacharya Adhyaya. Ch. 2, Ver. 15. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 25.
Murthy SK, editor. Astanga Samgraha of Vagbhatta, Sutra Sthana. Ch. 26, Ver. 13, 6th
ed. Varanasi: Chaukhamba Orientalia; 2002. p. 455.
Paradkarvaidya BH, editor. Commentary sarvangasundara of arunadutta and Ayurveda rasayana of hemadri on astanga hridayam of Vagbhatta, Chikitsa sthana, Jwara chikitsa. Ch. 1, Ver. 105-107, 5th
ed. Varanasi: Chaukhamba Krishnadas Academy; 2006. p. 565.
Patel MB, Mishra S. Hypoglycemic activity of alkaloidal fraction of Tinospora cordifolia. Phytomedicine 2011;18:1045-52.
Murthy SK, editor. Astagahridaya of Vagbhatta, Chikitsa Sthana; Vatavyadhi chikitsa. Ch. 21, Ver. 58-61. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 508.
Murthy SK, editor. Astagahridaya of Vagbhatta, Sarira Sthana; Garbhavyapad Sarira; Ch. 2, Ver. 47-52. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 388.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]