|Year : 2022 | Volume
| Issue : 3 | Page : 116-121
Effect of Ayurvedic interventions as add-on therapy in Huntington's disease: A case report
B Malavika, HP Savitha
Department of Manovigyana Evum Manasa Roga, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India
|Date of Submission||17-Sep-2021|
|Date of Acceptance||22-Aug-2022|
|Date of Web Publication||03-Oct-2022|
Dr. B Malavika
Department of Manovigyana Evum Manasa Roga, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan - 573 201, Karnataka
Source of Support: None, Conflict of Interest: None
Huntington's disease (HD) is a rare autosomal dominant neurodegenerative disorder. It is caused due to trinucleotide cytosine-adenine-guanine (CAG) repeat expansion on chromosome 4. The greater the CAG repeat size, the earlier the onset of the disease. It is characterized by motor, cognitive, and psychiatric symptoms. The onset of Juvenile HD occurs before the age of 21 and is rarer compared to adult-onset HD. A 30-year-old female, diagnosed with HD by molecular genetic analysis and magnetic resonance imaging, presented to Ayurveda hospital with chief complaints of abnormal involuntary movements in both the limbs bilaterally, difficulty in walking without support, difficulty in speech, swallowing, episodes of anger outbursts, and hard stools. The Ayurvedic treatment protocol was planned with a course of Nasya (~medication through nasal route), Basti (~medicated enema), and Abhyanga (~therapeutic oleation). Shashtika Shali Pinda Sweda (~sudation by application of poultice with rice), Shiropichu (~therapeutic procedure of placing tampon with oil over head region), and Karnapurana (~filling of ear with medicated liquid) along with internal medications which had Balya (~strength promoting), Brimhana (~restorative measures), Agni balavardhana (~enhancing digestive fire), Rechana (~cleansing), Rasayana (~rejuvenation therapy), and Vatahara (~Vata pacifying) actions were also adopted. By the completion of treatment, improvement was noticed in terms of reduced involuntary movements, better balance while standing, and reduced frequency of falls. Assessment by Abnormal Involuntary Movements Scale showed a reduction from score 30 to 18 after treatment, inferring that Ayurvedic therapies can help in betterment of patients affected with HD.
Keywords: Abhyanga, Basti, Nasya, Shashtika shali pinda sweda, Shiropichu
|How to cite this article:|
Malavika B, Savitha H P. Effect of Ayurvedic interventions as add-on therapy in Huntington's disease: A case report. J Ayurveda Case Rep 2022;5:116-21
|How to cite this URL:|
Malavika B, Savitha H P. Effect of Ayurvedic interventions as add-on therapy in Huntington's disease: A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2023 Jan 27];5:116-21. Available from: http://www.ayucare.org/text.asp?2022/5/3/116/357789
| Introduction|| |
Huntington's disease (HD) is a neurodegenerative disorder caused by an abnormal version of Huntington gene. A normal Huntington gene has 10–35 repeats of Cytosine-Adenine-Guanine (CAG) nucleotide triplets. It encodes for the amino acid glutamine. In HD, there is more than 36 CAG repeats. This leads to an abnormally long polyglutamine, and it alters the structure of Huntington protein. This causes uncontrolled dance-like movements, known as Huntington's chorea. The overall prevalence of HD in Asia is 0.40/100,000. Approximately 10% of the cases of HD have an age at onset younger than 21.
In HD, a phenomenon called genetic anticipation is observed, in which the signs and symptoms of the condition tend to appear at an earlier age as the disorder is passed from one generation to the next. It is found that paternally transmitted repeats are subjected to a larger increase are seen predominantly in paternal transmissions, and it is mostly found to be inherited from affected fathers.
The description of Tandava Roga as explained in Ayurveda is a pathological condition presenting with violent and frantic gesticulations, which are involuntary and pathological in nature and is caused due to vitiation of Vata dosha. The presentation of HD in this case can be correlated to Tandava Roga. Brimhana, Rechana, and Agni balavardhana are the line of treatment for Tandava roga.
| Patient Information|| |
A 30-year-old married unemployed female presented to Ayurveda hospital, with chief complaints of progressive increase of involuntary movements in bilateral upper and lower limbs, loss of balance while walking, and inability to stand up without support for the last three years, associated with difficult and slurred speech for the past three to four years along with difficulty in swallowing and hard stools for the past two years.
History of present illness showed sudden onset of anger outbursts and scholastic backwardness 11 years back, which later progressed to mild jerky movements of both feet and arms chronologically. Within a year, involuntary shoulder jerks were noticed, which extended to lower limbs also. The disease progressed to difficulty in balancing while walking due to chorea in the next four years. Gradual loss of weight was also observed. A molecular genetic analysis showed an expanded CAG repeat of 73 which diagnosed the condition as HD. Family history suggests paternal grandfather suffering from HD with onset of symptoms at the age of 55 years. Five out of ten of his children were affected with the pathogen, which was diagnosed by molecular genetic analysis carried out by a conventional physician. Her father was diagnosed with HD with a CAG repeat size of 42 and had the onset of symptoms at the age of 40 years. She was under amantadine 100 mg, revocon 25 mg, B-complex, Vitamin E1, and livogen, which were continued in the same dose during the course of treatment.
| Clinical findings|| |
On examination, parakinesia was absent, tongue protrusion was not maintained, and milkmaid's grip was noticed. Mild facial chorea was present. On cranial nerve examination, slow saccades and broken pursuits were noted. Power of limbs was 5/5. Motor reflexes were normal. Respiratory and cardiovascular system examination showed normal findings. Abnormal involuntary movements scale (AIMS) score was 30.
| Diagnostic assessment|| |
Magnetic Resonance Imaging (MRI) brain conducted in 2017 showed moderate generalized volume loss in bilateral cerebral, cerebellar hemispheres and brainstem along with diffuse volume loss in bilateral caudate nuclei and putamina, with resultant boxing of frontal horns of bilateral lateral ventricles. On molecular genetic analysis, the CAG repeat size was 73.
| Timeline and therapeutic intervention|| |
The timeline of internal and external medication is described in [Figure 1] and [Table 1].
|Figure 1: Panchakarma therapies. *Honey (100 ml), Saindhava lavana (10 g), Kalyanaka Ghrita (100 ml), Shatapushpa, Ashwagandha and Bala Churna (10 g each), and Mustadi Raja Yapana Ksheerapaka (350 ml)|
Click here to view
| Follow-up and outcomes|| |
There was a significant reduction in the involuntary movements in terms of its frequency of occurrence. Better balance while standing was observed. She was able to stand up without support from sitting position. Reduced frequency of falls and an improvement in gait were observed. AIMS was applied before, during, and after treatment [Table 2]. Internal medications were prescribed for a duration of two more months at the time of discharge.
| Discussion|| |
The differential diagnosis was done with Apasmara (~epilepsy), Apatanaka (~spasmodic contractions/convulsions of body), and Akshepaka (~clonic convulsion) because all the conditions have exaggerated motor presentations. In Apasmara, there are Hasta vikshepana (~jerking of hand) and Pada vikshepana (~sudden movements of hands and legs), which occur during the episodes associated with loss of consciousness. In Apatanaka, there are convulsive movements that lead to difficulty in breathing and unconsciousness. In Akshepaka, repeated or episodic convulsive movements are observed. In Tandava Roga, there is continued difficulty in holding objects, difficulty to feed oneself, dancing-like movements of upper and lower limbs, and facial grimaces. These exaggerated movements are absent during sleep that were observed in this case. Episodic nature of the disease, difficulty in breathing, and unconsciousness were absent in this case, which enforced the diagnosis of Tandava roga.
The causes and symptoms of Tandava roga are related to Vata vruddhi (~increase of Vata) and Majja dhatukshaya (~depletion of bone marrow). Exaggerated movements of upper and lower limbs, difficulty in production of speech, and constipation are caused due to an imbalance in Vata. Majja dhatukshaya is evident through the MRI findings of generalized volume loss in bilateral cerebral and cerebellar hemispheres and brainstem along with diffuse volume loss in bilateral caudate nuclei and putamina.
Considering the above discussion, this case presents with Dhatukshayajanya (~due to depletion of Dhatu) Samprapti (~pathogenesis). Incorporating this with the treatment plan mentioned for Tandava roga, Balya, Brimhana, Agni balavardhana, Rechana, Rasayana, and Vatahara therapies were adopted.
Sarvanga abhyanga (~synchronized whole body massage with medicated oil) and Shashtika shali pinda sweda were the external therapies given for the first five days. Skin contains melanocytes which have similar origin to neurons. The neurological system is closely related to the skin. The stimulation of the skin by these methods also lead to dilation of the arterioles, which increases the circulation and helps in better absorption of the drugs through skin. Skin is also the abode of Vata. Thus, these therapies can help in this case as it is a neurodegenerative condition, and they are Vatahara. Sarvanga abhyanga is a form of Bahya snehana (~external oleation). Sarvanga abhyanga with Ksheerabala taila is Brimhana jivana (~to give life) and has Rasayana effects. Ksheerabala taila contains Ksheera (~milk), Bala (Sida cordifolia L.), and Tila taila (~sesame oil). Ksheera is Vatahara, Jeevaniya, Brimhana, and Balya. Bala is effective in neurological disorders and has anxiolytic activity., It is Vatahara, Balya, and Brimhana. Tila taila is the best among the Taila varga (~group of oil) and is Vatahara.
In Vata-predominant conditions, Svedana (~sudation) is to be done with Snigdha (~unctuous) drugs. Thus, Shashtika shali pinda sweda was adopted which is a type of Snigdha sankara sweda (~bolus fomentation with fire) that comes under Sagni Sweda., It nourishes the muscles and helps in improvement of movements.
The energy centers in the human body are known as Chakras. The position of Chakras are also the abode of different types of Vata. Muladhara chakra and Swadhisthana chakra are closely related to Apana vayu, Manipura chakra with Samana vayu, Anahata chakra with Prana vayu, and Vishudha chakra with Udana vayu. Application of Ghrita on Shat chakras stimulate these centers and pacifies Vata, which is the Dosha to be dealt with in this condition.
Basti is considered as Ardha chikitsa (~half the treatment) and is the best therapy for Vata disorders. The gut–brain axis explains how the absorption of Basti from the gut influences the brain. Due to time constrains, Kala Basti was planned with Niruha (~nonoily enema) and Anuvasana Basti (~oily enema) given at different timings in the same day. Yapana basti administered in this case contained Shatapushpa (Anethum sowa Roxb.), Bala, and Ashwagandha (Withania somnifera [L.] Dunal) as Kalka (~paste) and Kalyanaka Ghrita as Sneha. Shatapushpa contains flavonoids which have antioxidant activity., This can reduce the oxidative stress, which is present in HD. Mustadi raja yapana kashaya was used along with honey and Saindhava lavana. Yapana Basti helps rejuvenate the nerve cells. The administered Niruha basti was retained for 10–12 min. Anuvasana basti was given with Kalyanaka ghrita, which was retained for around 2 h in the first 2 days and later extended to 12 h. Kalyanaka ghrita mitigates Vata and functions as Brimhana, Balya, and Rasayana., It increases Medha and Buddhi (~intelligence). Kalyanaka ghrita contains polyphenols, which has antioxidant activity. These polyphenols are converted into neuroprotector compounds through gut bacterial metabolism. They are found to have neuroprotective effects in neurodegenerative diseases. Kalyanaka ghrita also crosses the blood–brain barrier effectively as it is lipid based, thus aiding better action on the higher centers of the brain.
The skin over the scalp is thin and has rich blood supply that aids in better transdermal absorption. In Shiropichu, the drug is kept in the scalp without shaving for 1 h. Here, the drug used is Kalyanaka ghrita, which is lipophilic and hence shows better penetration through the scalp. It can also cross the blood–brain barrier and provide action on higher centers of the brain. As head is considered as a seat of Vata, Snehana therapy specific to head can act as Vatahara.
Nose is the gateway to the head. Drugs given through the nasal route helps in direct absorption of the molecules through trigeminal and olfactory pathways, thus facilitating direct entry to the brain. Nasya acts on higher centers of brain controlling different neurological functions. Marsha nasya with Kalyanaka ghrita (12 drops each) was given for 5 days. Later, it was given as Pratimarsha nasya with two drops in each nostril. Pratimarsha nasya is indicated for daily use in all seasons with minimal complications. As the drug used is lipid based, it can cross the blood–brain barrier effectively and act on higher centers and controls Vata by providing neuroprotective activity, Nasya and Shiropichu acted on the derailed Vata dosha and helped in the cognitive and behavioral symptoms of the disease.
Karna poorana has positive effects on vestibulocochlear nerve, which is responsible for balance. Ksheerabala taila provides Balya, Brimhaniya, and Vatahara action and is effective in neurological disorders.,, Thus, Karna poorana helped in improving the balance in this condition.
Ashwagandha-bala Ksheerapaka (50 ml) was given twice daily before food. Ashwagandha is neuroprotective, antioxidant and also has cognition-promoting effect., The active constituent of Ashwagandha has antistress activity. Bala is found effective in neurological disorders and has antioxidant activity. The ethanol extracts of Bala have antistress activity. Flavonoids present in Bala and their glycosides exert anxiolytic and sedative effects on the central nervous system. Ksheerapaka contains medicines processed with milk. Milk contains phospholipids which have emulsifying properties. Thus, it can be used as a delivery system, and it helps in better absorption of the medicine. Thus, Ashwagandha bala Ksheerapaka helped in the cognitive symptoms of the disease and helps in reducing anxiety.
Ashwagandharishta was given twice daily at a dose of 15 ml with equal quantity of water. It improves memory, is indicated in emaciation and increases Agni. It has antioxidant effect.
Gandharvahastadi eranda taila 10 ml was given at 5 pm with warm milk for 5 days. It contains Eranda taila, which is Vatahara, and has Rechana action thus helping in relief from constipation and improvement of Agni.
The treatments given showed a positive impact on reducing involuntary movements and overall well-being. AIMS with score 30 during admission reduced to 23 during treatment and 18 after treatment. The follow-up assessment was done over telephonic conversation with the patient's attender after 1 month which revealed about fever and infection which prevented them from physical follow-up. The subject maintained a better state of well-being after the discharge, and the oral medications were continued. The subject was advised inpatient Panchakarma therapies every 6 months to prevent the progress of the disease.
| Conclusion|| |
HD is a neurodegenerative condition caused due to vitiation of Vata. A treatment protocol with Balya, Brimhana, Agni balavardhana, Rechana, Rasayana, and Vatahara actions was selected. The treatment incorporated a combination therapy of Abhyanga, Shashtika shali pinda sweda, Nasya, Basti, Shiropichu, Karnapoorana, and internal medications. The patient was using conventional medicines as prescribed by her physician during the treatment period. The Ayurveda drugs along with the prescription drugs did not developed any new reactions. Considering these, it can be inferred that the treatment proved to be beneficial in reducing neurological symptoms of HD. Thus, the adaption of Panchakarma therapies once in six months may help in delaying the progress of HD.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gardiner SL, van Belzen MJ, Boogaard MW, van Roon-Mom WM, Rozing MP, van Hemert AM, et al.
Huntingtin gene repeat size variations affect risk of lifetime depression. Transl Psychiatry 2017;7:1277.
Ho LW, Carmichael J, Swartz J, Wyttenbach A, Rankin J, Rubinsztein DC. The molecular biology of Huntington's disease. Psychol Med 2001;31:3-14.
Myers RH. Huntington's disease genetics. NeuroRx 2004;1:255-62.
Gundamaraju R, Vemuri R. Huntington's disease: A perplexing neurological disease. Afr J Neurol Sci 2014;33:107-16.
Xu M, Wu ZY. Huntington disease in Asia. Chin Med J (Engl) 2015;128:1815-9.
Ranen NG, Stine OC, Abbott MH, Sherr M, Codori AM, Franz ML, et al.
Anticipation and instability of IT-15 (CAG) n repeats in parent-offspring pairs with Huntington disease. Am J Hum Genet 1995;57:593-602.
Wheeler VC, Persichetti F, McNeil SM, Mysore JS, Mysore SS, MacDonald ME, et al.
Factors associated with HD CAG repeat instability in Huntington disease. J Med Genet 2007;44:695-701.
Sharma S, editor. Sarngadhara Samhita with Subodhim Hindi Commentary. Parishishta. 7th
ed., Ch. 1, Ver. 12. Varanasi: Chaukambha Amarbharti Prakashana; 1988. p. 487.
Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale. Hosp Community Psychiatry 1988;39:1172-7.
Sharma PV, editor. Charaka Samhita, Chikitsa Sthana; Apasmarachikitsa Adhyaya. Ch. 10, Ver. 6-7. Varanasi: Chaukhamba Orientalia; 2016. p. 213.
Sharma R, Bhagvandas V, editors. Charaka Samhita Revised by Dridhabala, Siddhi Sthana; Trimarmiyasiddhi Adhyaya. 2nd
ed., Ch. 9, Ver. 12-15. Varanasi: Chaukhambha Sanskrit Sansthana; 2005. p. 334.
Sharma PV, editor. Charaka Samhita, Sutra Sthana; Vatakalakaliya Adhyaya. Ch. 12, Ver. 8. Varanasi: Chaukhamba Orientalia; 2016. p. 63.
Acharya YT, editor. Charaka Samhita of Charaka, Chikitsa Sthana. Ch. 28, Ver. 59. Varanasi: Choukhamba Surbharati Prakashan; 2017. p. 619.
Yaar M, Park HY. Melanocytes: A window into the nervous system. J Invest Dermatol 2012;132:835-45.
Ansel JC, Armstrong CA, Song I, Quinlan KL, Olerud JE, Caughman SW, et al.
Interactions of the skin and nervous system. J Investig Dermatol Symp Proc 1997;2:23-6.
Shailaja U, Rao PN, Girish KJ, Arun Raj GR. Clinical study on the efficacy of Rajayapana Basti and Baladi Yoga in motor disabilities of cerebral palsy in children. Ayu 2014;35:294-9.
] [Full text]
Murthy SK, editor. Ashtanga Hridayam of Vagbhata, Sutra sthana; Doshabhediya Adhyaya. 4th
ed., Ch. 12, Ver. 1. Varanasi: Chaukhamba Press; 1999. p. 166.
Murthy SK, editor. Ashtanga Hridayam of Vagbhata, Sutra Sthana; Snehavidhi Adhyaya. 4th
ed., Ch. 16, Ver. 15. Varanasi: Chaukhamba Press; 1999. p. 211.
Acharya JT, editor. Charaka Samhita, Sutrasa Sthana; Vatashonitachikitsa Adhyaya. 4th
ed., Ch. 22, Ver. 4. Varanasi: Chaukhamba Orientalia; 1994.
Sharma PV, editor. Ashtanga Hridaya of Vagbhata, Sutra Sthana; Dravadravyavijnaniya Adhyaya. 10th
ed., Ch. 5, Ver. 21-22. Varanasi: Chaukhamba Orientalia; 2011. p. 95.
Galal A, Raman V, Khan IA. Sida cordifolia
, a traditional herb in modern perspective – A review. Curr Tradit Med 2015;1:5-17.
Sumanth M, Mustafa SS. Antistress, adoptogenic activity of Sida cordifolia
roots in mice. Indian J Pharm Sci 2009;71:323-4.
] [Full text]
Sitaram B, translator. Bhavaprakasa of Bhavamisra. Vol. 1. Varanasi: Chaukhambha Orientalia; 2006. p. 265-6.
Shastry SP, editor. Maharshi Susruthapraneetha Susrutha Samhita. Sutra Sthana; Dravadravyavidhim Adhyayam. 2nd
ed., Ch. 45, Ver. 130. Varanasi: Chaukhamba Surbharati Prakashan; 1985. p. 144.
Acharya JT, editor. Charaka Samhita, Sutra Sthana; Swedadhyaya. 4th
ed., Ch. 14, Ver. 8. Varanasi: Chaukhamba Orientalia; 1994. p. 88.
Acharya JT, editor. Charaka Samhita, Sutra Sthana; Swedadhyaya. 4th
ed., Ch. 14, Ver. 39. Varanasi: Chaukhamba Orientalia; 1994. p. 90.
Acharya JT, editor. Charaka Samhita, Sutra Sthana; Swedadhyaya. 4th
ed., Ch. 14, Ver. 41. Varanasi: Chaukhamba Orientalia; 1994. p. 90.
Wajpeyi SM. Role of Ayurveda in the management of Guillain-Barré syndrome. Int J Ayurvedic Med 2018;9:288-92.
Sweta KM, Awasthi HH, Godbole A, Prajapati S. Physio-anatomical resemblance of inferior hypogastric plexus with Muladhara chakra
: A cadaveric study. Ayu 2017;38:7-9.
] [Full text]
Sharma PV, editor. Ashtanga Hridaya of Vagbhata, Sutrasthana; Bastividhi Adhyaya. 10th
ed., Ch. 19, Ver. 87. Varanasi: Chaukhamba Orientalia; 2011. p. 275.
Foster JA, McVey Neufeld KA. Gut-brain axis: How the microbiome influences anxiety and depression. Trends Neurosci 2013;36:305-12.
Asutkar R, Kadu A, Kharat R, Deogade M. Physico-chemical and phytochemical analysis of Shatapushpa (Anethum Sowa Linn) – A Madhura Prabhava drug delineated in Madhura Skandha of Charaka's materia medica. J Indian Syst Med 2017;5:61.
Pei R, Liu X, Bolling B. Flavonoids and gut health. Curr Opin Biotechnol 2020;61:153-9.
Browne SE, Ferrante RJ, Beal MF. Oxidative stress in Huntington's disease. Brain Pathol 1999;9:147-63.
Ramana GV, Yadav B, Gupta HK, Sahoo S, Chaudhary S, Khanduri S, et al.
Clinical evaluation of Kalyanaka Ghrita in the management of cognitive deficit in children. J Res Ayurvedic Sci 2019;3:85-90.
Sharma PV, editor. Ashtanga Hridaya of Vagbhata, Uttara Sthana; Unmadapratishedh Adhyaya. 10th
ed., Ch. 6, Ver. 26. Varanasi: Chaukhamba Orientalia; 2011. p. 799.
Rajput P, Mamidi P. An open label pilot study of Kalyanaka Ghrita in the management of obsessive-compulsive disorder. Psychiatry Behav Sci 2018;8:118.
Reddy VP, Aryal P, Robinson S, Rafiu R, Obrenovich M, Perry G. Polyphenols in Alzheimer's disease and in the gut-brain axis. Microorganisms 2020;8:199.
Ogiso T, Shiraki T, Okajima K, Tanino T, Iwaki M, Wada T. Transfollicular drug delivery: Penetration of drugs through human scalp skin and comparison of penetration between scalp and abdominal skins in vitro
. J Drug Target 2002;10:369-78.
Singh VV, Rai VS. A systematical review of traditional Ayurvedic and morden medical perspectives on Ghrita (clarified butter): A boon or bane. Tradit Med Res 2019;4:293.
Joshi KL, editor. Atharvaveda, Dashamakhanda, Brahmaprakashana Sookta. 1st
ed., Ch. 2, Ver. 26. Varanasi: Chaukhambha Orientalia; 2000. p. 284.
Sangeeta HJ, Toshikhane HD. A critical evaluation of the concept of “Nasa Hi Shiraso Dwaram” (Nasal Route Entry for the Cranial Cavity). Pac J Sci Technol 2009;10:338-41.
Erdő F, Bors LA, Farkas D, Bajza Á Gizurarson S. Evaluation of intranasal delivery route of drug administration for brain targeting. Brain Res Bull 2018;143:155-70.
Acharya JT, editor. Charaka Samhita, Siddhi Sthana; Trimarmiyasiddhi Adhyaya. 4th
ed., Ch. 9, Ver. 117. Varanasi: Chaukhamba Orientalia; 1994. p. 875.
Chaturvedi G, editor. Charaka Samhita by Agnivesha, Sidhhi Sthana. Vol. 2. Ch. 9, Ver. 117. Varanasi: Choukhamba Bharta Academy; 2013. p. 1073.
Acharya JT, editor. Charaka Samhita, Chikitsa Sthana; Vatashonita Chikitsa Adhyaya. 4th
ed., Ch. 29, Ver. 120. Varanasi: Chaukhamba Orientalia; 1994. p. 632.
Gupta GL, Rana AC. Withania somnifera
(Ashwagandha): A review. Pharmacogn Rev 2007;1:129.
Zahiruddin S, Basist P, Parveen A, Parveen R, Khan W, Gaurav, et al.
Ashwagandha in brain disorders: A review of recent developments. J Ethnopharmacol 2020;257:112876.
Kaur P, Mathur S, Sharma M, Tiwari M, Srivastava KK, Chandra R. A biologically active constituent of Withania somnifera
(ashwagandha) with antistress activity. Indian J Clin Biochem 2001;16:195-8.
Contarini G, Povolo M. Phospholipids in milk fat: Composition, biological and technological significance, and analytical strategies. Int J Mol Sci 2013;14:2808-31.
Mahadik KR, Gopu CL, Gilda SS, Paradkar AR. Comparative evaluation of antioxidant potential of Ashwagandha arishta and self-generated alcoholic preparation of Withania somnifera
Dunal. Planta Med 2008;74:288.
Shastri SP, editor. Maharshi Susruthapraneetha Susrutha Samhita, Sutra Sthana; Dravadravyavidhim Adhyayam. 2nd
ed., Ch. 45, Ver. 114. Varanasi: Chaukhamba Surbharati Prakashan; 1985. p. 144.
[Table 1], [Table 2]