|
 
 |
| CASE REPORT |
|
| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 27-31 |
|
Effect of Panchakarma therapy in the management of congenital muscular dystrophy: A case report
Vijay Kumar Pathak1, Arun Kumar Mahapatra2, Prashant Kumar Gupta2, S Rajagopala2
1 Department of Kaumarabhritya, Mangalayatan Ayurveda Medical College and Research Centre, Mangalayatan University, Aligarh, Uttar Pradesh, India
2 All India Institute of Ayurveda, New Delhi, India
| Date of Submission | 08-Jun-2022 |
| Date of Acceptance | 09-Feb-2023 |
| Date of Web Publication | 21-Mar-2023 |
Correspondence Address:
Dr. Vijay Kumar Pathak
Department of Kaumarabhritya, Mangalayatan Ayurveda Medical College and Research Centre, Mangalayatan University, Aligarh - 202146, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jacr.jacr_49_22
Congenital Muscular Dystrophy (CMD) is a general term for a group of genetic muscle disorder that occurs at birth (congenital) or early infancy. Muscular dystrophies are characterized by weakness and degeneration of various voluntary muscles of the body. The severity, specific symptoms, and progression of these disorders vary greatly. A six and half-year-old female child was brought by her parents to the outpatient department (OPD) of Kaumarabhritya department, with the chief complaints of toe walking, unable to balance her body, tremors while standing, unable to stand from a sitting position without support, and unable to lift up both legs from the supine position. The patient visited the OPD with a diagnosis as CMD. After examination, internal medications: Bilwadi gutika, Ashwagandha churna, Pippali churna, Pravala bhasma, and Shirisharishta were prescribed along with Panchakarma procedures (~five therapeutic procedures) including Udwartana (~therapeutic massage using powders), Sarvanga abhyanga (~whole body oil massage), Swedana (~sudation therapy), Niruha basti (~therapeutic decoction enema), and Anuvasana basti (~therapeutic unctuous enema). After treatment, improvement in muscle power was seen. The total score of the Barthel index before the study was 70 and after the study was 95, which shows improvement in activity of daily life. Serum creatine phosphokinase and serum creatine kinase-MB values were insignificantly improved before and after treatment. Liver function test, kidney function test, and electrocardiogram before and after treatment were within normal limits, this shows the safety of the internal medication and Ayurvedic Panchakarma procedures. Improvement in the activity of daily life and muscle power seen in the present case gives hope, where there are still no satisfactory management options for patients with CMD are available.
Keywords: Abhyanga, Congenital muscular dystrophy, Panchakarma, Udwartana, Vasti
How to cite this article:
Pathak VK, Mahapatra AK, Gupta PK, Rajagopala S. Effect of Panchakarma therapy in the management of congenital muscular dystrophy: A case report. J Ayurveda Case Rep 2023;6:27-31 |
How to cite this URL:
Pathak VK, Mahapatra AK, Gupta PK, Rajagopala S. Effect of Panchakarma therapy in the management of congenital muscular dystrophy: A case report. J Ayurveda Case Rep [serial online] 2023 [cited 2023 May 30];6:27-31. Available from: http://www.ayucare.org/text.asp?2023/6/1/27/372250 |
| Introduction | |  |
Congenital Muscular Dystrophy (CMD) is one of the variants of muscle weakness disorders presenting early in life during infancy and soon after birth, most of these disorders are inherited and linked to specific genes.[1] The global prevalence of muscular dystrophy is 3.6 per 100,000 people.[2] CMDs are characterized by hypotonia, muscle weakness, and delays in achieving motor milestones.[3] There is no exact correlation for this disease in Ayurveda, however, it could be understood as Adibalapravrutta mamsadhatugata vatavyadhi (~hereditary anomalies affecting muscle tissues due to vitiated Vata).[4]
| Case Report | | |
A six and half-year-old female child was brought by her parents to the OPD of Kaumarabhritya department, with complaints of toe walking, having waddling gait, unable to balance her body, tremors while standing, unable to stand from sitting positing without support, and unable to lift up both legs from the supine position. The child was born with full-term, lower segment cesarean section (maternal indication due to cephalopelvic disproportion), and cried immediately after birth, with no perinatal complications. Family history reveals mother had hypothyroidism since 2015. She underwent surgery for intestinal obstruction in May 2020 and expired in September 2020 due to COVID-19 infection. The patient's three years younger sister is also experiencing the same problem as the patient have. Parents of the child noticed muscle weakness, and delay in sitting and standing at the 1st year of age, and visited the hospital in 2017, where after a thorough examination and muscle biopsy (August 29, 2017), the child was diagnosed with CMD (unclassifiable with available histochemical and immunohistochemical stains). The patient was also diagnosed with severe valvular pulmonary stenosis and mild pulmonary regurgitation. Cardiac catheterization with Tyshak balloon pulmonary dilation procedure was done successfully with no complication at the age of three years at the department of cardiology in a multispecialty modern hospital in New Delhi.
| Clinical Findings | | |
On examination, Nadi (~pulse) was 74/min, Mutra (~urine) frequency was 4–5 times in day and two times in night. Mala (~excreta) was Nirama (~formed stool), Shabda (~voice) was Spashta (~clear), Sparsha (~tactile examination) was Ushna (~warm touch), Jivha (~tongue) was Nirama (~clear), Drik (~eye and eyesight) was Samanya (~normal), and Akruti (~body stature) was Madhyama (~medium).
| Timeline | | |
The timeline of the case is depicted in [Table 1].
| Diagnostic Assessment | | |
Details of the motor system examination including deep tendon reflex[5] are depicted in [Table 2]. Barthel index,[6] muscle power grading with Medical Research Council scale (MRC scale),[7] Serum Creatine Phosphokinase (CPK), and Serum Creatine Kinase-MB (CK-MB) which are valuable noninvasive biomarker tools for monitoring disease progression and therapeutic response in muscle dystrophy was used as assessment tools before and after the treatment.[8] Liver Function Tests (LFT), Kidney Function Tests (KFT), and Electrocardiogram (ECG) were done before and after the treatment [Table 3]. The patient was admitted on March 22, 2022, and internal medications along with Panchakarma procedures (~five therapeutic procedures) were started.
| Therapeutic Interventions | | |
After the admission of the patient, two times daily doses of Bilwadi gutika (250 mg), Ashwagandha churna (2 g), Pippali churna (250 mg), Pravala bhasma (250 mg), and Shirisharishta (10 ml) were started. Udwartana (~therapeutic massage using powders) with Kolakulathadi churna, Sarvanga abhyanga (~oil application to the whole body) with Balashwagandhadi taila, and Sarvanga swedana (~whole body fomentation with medicated vapors) with Dashamoola kwatha and Yoga basti (~therapeutic enema) were used as Panchakarma procedures [Table 4].
| Follow-up and Outcome | | |
Effects of therapy were assessed considering changes in muscle power grading [Graph 1], Barthel index [Graph 2], Sr. CPK, and Sr. CK-MB [Table 3] before and after treatment. At discharge after 17 days, the child started balancing her body while standing and started lifting up her legs from the supine position. The improvement was seen in walking and climbing the stairs. Overall clinical improvement was noted in the child.
| Discussion | | |
Symptoms of CMD resemble Mamsa dhatu kshaya (~depletion of muscle tissues), Sphik griva shushyata (~muscle wasting in hip and neck region),[9] and Gatranam sadanam (~weakness of body).[10] Udwartana is useful in Sthirikaraṇaṃ anganam[11] (~brings stability to body organs) and it is Rukshana purvakarma (~preparatory procedure of desiccating therapy). Udwartana with Kolakulathadi churna[12] was selected for improving body balance while standing, and also as a preparatory procedure for Abhyanga (~therapeutic massage) and Swedana (~sudation therapy). Abhyanga with Balashwagandhadi taila[13] is used to improve muscle strength. It improves blood supply to the muscles, stimulates sensory nerve endings of the skin, and reduces muscle fatigue and pain.[14] Swedana is Sthambhagna (~removes stiffness), Gauravanigraha (~relief in heaviness), and Kapha-Vata nirodhaka.[15] Swedana with Dashamoola kwatha was selected for improving muscle spasm.[16] Sthiradi niruha basti was selected as it acts as Mamsabala pradaha (~enhances muscle power)[17] and the contents of Sthiradi niruha are having Hridya (~beneficial for the heart) properties.[18] Ashwagandha is having Balya (~strength) and Rasayana (~rejuvenating) properties,[19] Pippali is having Deepana (~enhancing metabolic fire), Vrishya (~aphrodisiac), and Rasayana (~rejuvenating) properties.[20] Pravala is also having Deepana, Vrishya, Balya properties along with Vishaghana (~anti-toxic) properties,[21] it is also beneficial in cardiac disorders.[22] Rasayana, Vrishya, and Balya qualities of these drugs help in the improvement of muscle strength.
Muscular dystrophies are typically associated with elevated Serum creatine kinase[23] (Sr. CPK and Sr. CK-MB). Higher values are associated with a greater burden on the kidneys, developing acute renal failure, severe electrolyte abnormalities, acid–base disturbances, and resulting in significant morbidity.[24] Excess of this act as endotoxin in the body and can be considered Visha in Ayurveda. Drugs such as Bilwadi gutika,[25] Pravala, and Shirisharishta[26] are used due to their Vishaghana property. In Ayurveda, various studies on muscular dystrophy used Vishaghana drugs, and clinical improvement was observed.[27]
Improvement in muscle power was observed in the present case infers improvement in activity of daily life. CPK and CK-MB values were insignificantly improved after the treatment [Table 3], and LFT, KFT, and ECG were within normal limits after treatment indicating the safety of the internal medication and Panchakarma procedures. At discharge after 17 days, the child started balancing their body while standing and started lifting up their legs from the supine position. This gives hope, where there are still no curative treatment options for patients with congenital muscular dystrophies,[28] Ayurveda treatment modalities can be explored for management.
| Conclusion | | |
Congenital muscular dystrophy can be managed on the basis of Ayurvedic management. Improvement in the activity of daily life and muscle power is seen in the present case. Randomized controlled trials can be done to further strengthen the evidence.
Declaration of patient consent
Authors certify that they have obtained the patient consent form, where the caregiver has given her consent for reporting the case along with the images and other clinical information in the journal. The caregiver understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Pasrija D, Tadi P. Congenital Muscular Dystrophy. StatPearls Treasure Island (FL): StatPearls Publishing; 2022.  |
| 2. | Salari N, Fatahi B, Valipour E, Kazeminia M, Fatahian R, Kiaei A, et al. Global prevalence of duchenne and becker muscular dystrophy: A systematic review and meta-analysis. J Orthop Surg Res 2022;17:96. |
| 3. | Claeys KG. Congenital myopathies: An update. Dev Med Child Neurol 2020;62:297-302. |
| 4. | Shastri A, editor. Vyadhi sammudeshiya. In: Sushruta Samhita of Sushruta Sutrasthana. Ch. 24., Ver. 5. Varanasi: Chaukhambha Sanskrit Sansthan; 2016. p. 130. |
| 5. | Walker HK. Deep tendon reflexes. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3 rd ed., Ch. 72. Boston: Butterworths; 1990. |
| 6. | Mahoney FI, Barthel DW. Functional evaluation: The Barthel index. Md State Med J 1965;14:61-5. |
| 7. | Naqvi U, Sherman AL. Muscle strength grading. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. |
| 8. | Burch PM, Pogoryelova O, Goldstein R, Bennett D, Guglieri M, Straub V, et al. Muscle-derived proteins as serum biomarkers for monitoring disease progression in three forms of muscular dystrophy. J Neuromuscul Dis 2015;2:241-55. |
| 9. | Shastri K, Chaturvedi G, editors. Kiyanta shiraseeya adhyaya. In: Charaka Samhita of Charaka Sutrasthana. Ch. 17., Ver. 65, Varanasi: Chaukhambha Bharti Academy; 2013. p. 348. |
| 10. | Shastri A, editor. Dosha-dhatu-mala-kshaya-vriddhi-vijnaniya. In: Sushruta Samhita of Sushruta, Sutrasthana. Ch. 15., Ver. 13, Varanasi: Chaukhambha Sanskrit Sansthan; 2016. p. 76. |
| 11. | Gupta KA, editor. Dinacharya adhyaya. In: Astanga Hridaya of Vaghbhat, Sutrasthana. Ch. 2., Ver. 15, Varanasi: Chaukhambha Prakashan; 2019. p. 26. |
| 12. | Shastri K, Chaturvedi G, editors. Sutrasthana. In: Charaka Samhita of Charaka. Ch. 3., Ver. 18, Varanasi: Chaukhambha Bharti Academy; 2013. p. 62. |
| 13. | Nishteswar K, Vidyanath R, editors. Tailaprakarana. In: Sahasrayogam by Anonymous. Varanasi: Chowkhamba Sanskrit Series Office; 2014. p. 117. |
| 14. | Nunes GS, Bender PU, de Menezes FS, Yamashitafuji I, Vargas VZ, Wageck B. Massage therapy decreases pain and perceived fatigue after long-distance Ironman triathlon: A randomised trial. J Physiother 2016;62:83-7. |
| 15. | Shastri K, Chaturvedi G, editors. Sutrasthana, swedadhyaya. In: Charaka Samhita of Charaka. Ch. 14., Ver. 13. Varanasi: Chaukhambha Bharti Academy; 2014. p. 283. |
| 16. | Shastri A, editor. Sutrasthana, dravya-sangrahaniya. In: Sushruta Samhita of Sushruta. Ch. 38., Ver. 71-2. Varanasi: Chaukhambha Sanskrit Sansthan; 2016. p. 189. |
| 17. | Shastri K, Chaturvedi G, editors. Siddhisthana, bastisutriyam siddhi. In: Charaka Samhita of Charaka. Ch. 3., Ver. 36-7, Varanasi: Chaukhambha Bharti Academy; 2015. p. 999. |
| 18. | Sharma PV, editor. Priyanighantu, Haritakayadivarga. Ch. 1., Ver. 46-7. Varanasi: Chaukhamba Prakashan; 2018. p. 16. |
| 19. | Sitaram B, editor. Poorvkhanda guduchyadi varga. In: Bhavaprakasha by Bhavamisra. Part I. Sec. 1. Ch. 6., Ver. 189-90. Varanasi: Chaukhambha Orientalia; 2020. p. 278. |
| 20. | Sitaram B, editor. Poorvkhanda haritakyadi varga. In: Bhavaprakasha by Bhavamisra. Part I. Sec. 1. Ch. 6., Ver. 53-8, Varanasi: Chaukhambha Orientalia; 2020. p. 137-8. |
| 21. | Mishra SN, Bhaisajaya ratnavali of Kaviraj Govind das sen. Sodhan Maran Gunadi Prakaran. Ch. 3, Ver. 3/153-156. Varanasi: Chaukambha Subharati Prakashan; 2019. p. 53. |
| 22. | Shree Baidyanath Bhawan Limited. Prakarana 2. In: Ayurved Saar-Sangrah, Sodhan-Maran Prakarana. Allahabad: Shree Baidyanath Bhawan Limited; 2015. p. 140. |
| 23. | Rocha CT, Hoffman EP. Limb-girdle and congenital muscular dystrophies: Current diagnostics, management, and emerging technologies. Curr Neurol Neurosci Rep 2010;10:267-76. |
| 24. | Luckoor P, Salehi M, Kunadu A. Exceptionally high creatine kinase (CK) levels in multicausal and complicated rhabdomyolysis: A case report. Am J Case Rep 2017;18:746-9. |
| 25. | Gupta KA, editor. Uttarsthana, Sarpavishapratishedh. In: Astanga Hridaya of Vaghbhata. Ch. 36., Ver. 84-5. Varanasi: Chaukhamba Prakashan; 2019. p. 799. |
| 26. | Mishra SN, editor. Visharogadhikara. In: Bhaisajaya Ratnavali of Kaviraj Govind Das Sen. Ch. 72., Ver. 71-3. Varanasi: Chaukambha Subharati Prakashan; 2014. p. 1106. |
| 27. | Pathak VK, Mahapatra AK, Rajagopala S. Ayurveda interventions in the management of Duchenne muscular dystrophy – A review. Ann Ayurvedic Med 2022;11:243-55. |
| 28. | Kirschner J. Congenital muscular dystrophies. Handb Clin Neurol 2013;113:1377-85. |
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for