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Comparative management study of Pakshaghata with                Mashadi Yoga                                       By     ...
D.G.M.AYURVEDIC MEDICAL COLLEGEPOST GRADUATE STUDIES AND RESEARCH CENTER                               GADAG, 582103   Thi...
J.S.V.V. SAMSTHE’S                  D.G.M.AYURVEDIC MEDICAL COLLEGEPOST GRADUATE STUDIES AND RESEARCH CENTER              ...
Declaration by the candidateI here by declare that this dissertation / thesis entitled “Comparativemanagement Study of Pak...
Copy right          Declaration by the candidateI here by declare that the Rajiv Gandhi University of Health Sciences, Kar...
Acknowledgement        Any research is not an individual effort. It is a contributory effort of many hearts, handsand head...
Contents of   “Comparative management study of Pakshaghata with Mashadi Yoga”                                        By   ...
Tables of“Comparative management study of Pakshaghata with Mashadi Yoga”Sl                                  Content       ...
Figures and Photos of    “Comparative management study of Pakshaghata with Mashadi Yoga”Sl.                               ...
ABBREVATIONS                                            UsedA.H        ASHTANGA HRIDAYA                        D.N      DH...
Abstract    Abstract of “Comparative management Study of Pakshaghata with Mashadi Yoga”Key words: Pakshaghata, Paksha, Aka...
CHAPTER -1                                                           INTRODUCTION        Pakshaghata is one among the Vata...
Condition similar to Pakshaaghaata in modern medical science is the Hemiplegia. similarto Pakshaghata Hemiplegia also caus...
arm and leg on one side of the body. It is the most frequent distribution of paralysis in humanbeings. Hemiplegia is cause...
out using this principle of Charka at various research institutes, we have evolved adifferent pattern of treatment which f...
CHAPTER 2                        OBJECTIVES OF THE STUDY       Pakshaghata is a ‘Vata vyadhi’14. Then why this problem has...
only in business and carrier but also in day to day communication. The increaseddemand of hard workers is evident by numbe...
data, the same combination is mentioned by saharngadhara in the management ofPakshaghata .Here Mashadi Yoga Kwatha for ora...
Chakradatta17 said to be time tested. This Mashadi Yoga contains mainly Vatashamaka dravays. Vata dosha is the main culpri...
CHAPTER -3                              REVIEW OF LITERATUREHISTORICAL REVIEWVEDIC KALA (PRE-SAMHITA PERIOD)       Which h...
been given as Pakshavadha28 “Swedanam Sneha Samyuktam PakshaghateVirechanam” is the line of treatment given by            ...
Pakshaghata has been given in 15th chapter of Nidana Sthana The treatment has beenhighlighted in Chikitsa Sthana 23rd chap...
CHAKRADATTA 34:       Majority portion of this Grantha deals with the treatment of various diseases.Vatavyadhi Chikitsa ha...
Chikitsa. Some drug formulations have also been indicated for Pakshaghata. In othertreatises i.e. Kalyaanakaaraka of Ugrad...
Review of PakshaghataEtymology:        In Sanskrit language each word is considered to be Shakti Swarupa and behind thewor...
description of Pakshaghata. We can conclude doubtlessly from the foregoing description thatword “Paksha” depicts one side ...
CLASSIFICATION OF PAKSHAGHATA:        While describing the prognosis of Pakshaaghaata, Aacharya Sushruta has classifiedthe...
regarded as the aetiological factors of Pakshaghata as well. Though the causativefactors remain same in all vatavyadhis, d...
-Excess intake of ahara having katu, tikta and kashaya rasa causes vitiation of vata.48-Excessive ingestion of Katu rasa c...
Ativyavaya causes shukra dhatu kshaya and this leads to kshaya of all dhatus according to thetheory of PraTilaoma Kshaya. ...
-Injury to lohitaksha marma causes loss of blood and leads to Pakshaghata. Injury to                                      ...
Nidanarthakar Diseases provoking vata:        Disease, which acts, as the causative factor for other disease is knownas Ni...
Hypertension       –    Initiates    and   accelerates   the     cerebral   atherosclerotic     disease,probably by degene...
Undetermined origin of ParalysisCauses of Lacunar infarction: -     Hypertension     Atherosclerosis     Diabetes     ...
 With hemorrhagic infarction, arterial or venous.     With       inflammatory     disease   of   arteries    and    vein...
 Physical inactivity – A sedentary lifestyle.     Excessive alcohol intake.     Illegal drug use: Intravenous drug abus...
manifestation of the disease. Purvarupa of Pakshaghata is                    not     described in any text.Pakshaghata bei...
insufficiency, those involving the brainstem as vertebro– basilar insufficiency. In carotidartery disease the transient wa...
of stroke can occur anywhere in the brain and consequences range from minimal disability toparalysis or death. Ischemic st...
cerebral arteries. The most frequent sides are in the ICA at the carotid sinus, in the cervicalpart of the vertebral arter...
aneurysm formation - mycotic aneurysm. Fat embolism may occur as the result of fatglobules being set free into the circula...
When neurons are rendered ischemic, a number of biochemical changes occurs whichpotentiate and enhance cell death: K+ move...
segmental lipohyalinosis can also cause bleeding into the brain. The degree of damage willdepend on the location, rapidity...
vata vyadhi, (4) Shosha Pradhana vata vyadhi and (5) Stambha Pradhana vata vyadhi.     Pakshaghata is included mainly unde...
81of Buddhi, Hridaya, Indriya and Chitta.             . All types of movements occur due to properfunctioning    of Karmen...
Hemiplegia with sensory loss on opposite side is seen in MCA occlusion. Sensory lossis also encountered in PCA occlusion, ...
the symptoms of Ekanga roga. Ruja means pain and any kind of pain is always associatedwith vayu. ‘Santat Ruk’ has been men...
Shaitya/ Shoth/ Guruta:          These are the kaphanubandhit symptoms of Pakshaghata. Acharya Sushruta says thatwhen viti...
Determination of the side of hemiplegia in an unconscious patient –     Away from the paralysed side – A transient conjuga...
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Comparative management study of Pakshaghata with Mashadi Yoga By ISHWAR Y PATIL, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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  1. 1. Comparative management study of Pakshaghata with Mashadi Yoga By ISHWAR Y PATIL Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P. (German) M.A., [Ph.D] (Jyotish) Department of KayachikitsaPost Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2007-2010
  2. 2. D.G.M.AYURVEDIC MEDICAL COLLEGEPOST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582103 This is to certify that the dissertation “Comparative management study of Pakshaghata with Mashadi Yoga” is a bonafide research work done by ISHWAR Y PATIL in partial fulfillment of the requirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka. Date: Guide Place: Prof. Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish) Professor in Kayachikitsa DGMAMC, PGS&RC, Gadag
  3. 3. J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGEPOST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103Endorsement by the H.O.D, principal/ head of the institution This is to certify that the dissertation entitled “Comparative management study of Pakshaghata with Mashadi Yoga” is a bonafide research work done by ISHWAR Y PATIL under the guidance of Prof. Dr. Shiva Rama Prasad Kethamakka, M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish), Professor in Kayachikitsa in partial fulfillment of the requirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under RajeevnGandhi University of Health Sciences, Bangalore,Karnataka. . Professor & HOD (Dr. G. B. Patil) Dept. of Kayachikitsa Principal, PGS&RC DGM Ayurvedic Medical College, Date: Gadag Place: Gadag Date: Place:
  4. 4. Declaration by the candidateI here by declare that this dissertation / thesis entitled “Comparativemanagement Study of Pakshaghata with Mashadi Yoga” is a bonafideand genuine research Work carried out by me under the guidance ofProf. Dr. Shiva Rama PrasadKethamakka, M.D. (Ayu) (Osm) M.A.(Jyotish), [Ph.D (Jyotish)], Professor inKayachikitsa, DGMAMC,PGS&RC, Gadag.DatePlace ISHWAR Y PATIL
  5. 5. Copy right Declaration by the candidateI here by declare that the Rajiv Gandhi University of Health Sciences, Karnatakashall have the rights to preserve, use and disseminate this dissertation/ thesis inprint or electronic format for the academic / research purpose.DatePlace ISHWAR Y PATIL© Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. Acknowledgement Any research is not an individual effort. It is a contributory effort of many hearts, handsand heads. I am very much thankful to the subjects of this study. I am extremely happy to expressmy deepest sense of gratitude to my beloved and respected guide Prof. and H.O.D. Dr. K. ShivaRama Prasad, M.D. C.O.P. (German) M.A. [Ph.D.] for his guidance and timely help. I am sincerely grateful to Dr. G. B. Patil, Principal, for his encouragement and providingall necessary facilities for this research work. I express my gratitude to Dr. V. V. Varadacharyuluformer Professor and H.O.D for his advice and encouragement in every step of this work. I extend my gratitude to Dr. R.V.Shettar,Dr Varadacharylu Dr. G. Purushottamacharyulu,Dr.P.Shivaramudu, Dr.Suresh Babu, Dr.Madhav Diggavi, Dr.M.C.Patil, Dr.G.S.Hiremath,Dr.G.Danappagoudar.Dr.S.N.Belawadi,Dr.Nidugundi,Dr.Samudri,Dr.Kuber sanq Dr.Mulgund.Dr. J. Mitti, Dr. Mulki Patil,Dr.Yasmin,Dr Ashok Patil,Dr.Swami,Dr.Veena. Kori, Dr Suvarna,Dr Shakuntala Garawad and Dr Aihole. I express my immense gratitude to my statistician Nandakumar, Tippanagoudar (Lab), V.B.Mundinamani (librarian) and Shyavi and Kerur for facilitating me books for my thesis. My deep senses of gratification to my inspirations of this study are my parentsYallanagouda.B.Patil. and Tungabai.Y .Patil and grand parents Bhimanagoda, Rangavva andYallappa,Bhimavva. I express my deepest sense of gratitude to My uncle L.M.Handi andLalitha.M. Handi. and my brothers family Siddu Patil , Nilamma Patil And Chinmay Patil Iexpress my heartfelt gratitude to my brothers ,Siddalingeshwar , Dr Parashuram andSomashekhar for constant help and encouragement to move ahead. I take this moment to expressmy thanks to all my Post gratude colleagues, Dr. V S Kanthi, Dr.Bodake, Dr. Praveen Naik ,DrShakuntala ,Dr Sanathkumar,Dr shabareesh, Dr Rajesh ,Dr Jayashankar, Dr Deepak, Dr C CHiremath, Dr Bupesh, Dr Ashaa , Dr Sevanthika , Dr Palled, Dr Gorpade, Dr Jadhav, Dr DeepaDr Ashok M.G. Dr. Shivaleela, Dr. Kamalakshi, Dr. Sulochana, Dr.Vijayalakshmi, Dr. Sanjeev,Dr.Neeraj, Dr. Veena. Jigalur,Dr P V Joshi , Dr. Adarsha, Dr. Nataraja, Dr. Uday, Dr Shailej, Mr.Shakti Dr. Ravi , Late Dr. Shivakumar ,Dr Bhagesh ,Dr Vijayamahantesh, Dr Babasaheb ,Drbarawal ,Dr surej ,Dr joshi Dr Anish , Dr Das ,Dr Renukraj Dr Sangamesh ,Dr Vijay Chavadi,Sanjeev Raddi, Dr Satish ,Dr Raghava Dr Anitha ,Dr Prajwal, Dr Harshavardhan Dr AnilManaguli ,Dr Kashinath,Dr Nagaraj sajjan ,Dr gurubasavraj, all GAMC Bangalore friends , JNVAlamatti friends,AOL friends. Last but not least I express my deepest thankfulness whose names are not taken here buthelped me a lot along with my kith and kilns to my family members. ISHWAR Y PATIL
  7. 7. Contents of “Comparative management study of Pakshaghata with Mashadi Yoga” By ISHWAR.Y.PATILChapter Content Page No. 01 Introduction 1 to 4 02 Objectives 5 to 8 03 Literary Review 9 to 70 04 Materials and Methods 71 to 77 05 Results 78 to 107 06 Discussion 108 to 120 07 Conclusion 121 to 123 08 Summary 124 to 126 09 Bibliographic reference 1 to 8 10 Annexure -1 Master charts 1 to 18 11 Annexure -2 Case sheet 1 to 8 “Comparative Management study of Pakshaghata with Mashadi Yoga” 1
  8. 8. Tables of“Comparative management study of Pakshaghata with Mashadi Yoga”Sl Content PageNo. no.1 Guna Vachaka aetiological factors vitiating vata 172 Trauma (Abhighata) Provoking vata 193 Psychic factors vitiating vata 204 Rupa according to various acharya 335 Composition of Trial drug 576 Grade of tendon reflexes 767 The Medical Research Council Scale for grading muscle function 768 Showing the distribution of patient’s according to age groups 789 Showing the distribution of patients according to Gender 7910 Showing distribution of patients by Religion 8011 Showing distribution of patients by Occupation 8112 Showing distribution of patients by Economic Status 8213 Showing distribution of patients Type of diet 8414 Showing distribution of patients Overall response 8515 Showing distribution of patients by Agni 8616 Showing distribution of patients by Nidana (Ahara) 8717 Showing distribution of patients by Nidana (Vihara) 8818 Showing distribution of patients by Manasika Hetu 8919 Showing distribution of patients by Emotional Status 9020 Showing distribution of patients by Presenting Complaints 9121 Showing distribution of patients by Associated Complaints 9322 Showing distribution of patients by Presenting Complaint 9423 Showing distribution of patients by Facial Nerve Examination 9524 Showing distribution of patients by Motor System Examination 9725 Showing distribution of patients by Reflex 9826 Showing distribution of patients by Upper Motor Neuron Examination 10027 Showing distribution of patients by Lower Motor Neuron Examination 10128 Showing distribution of patients by Results : Subjective Criteria 10329 Showing distribution of patients by Results : Objective Criteria 10330 Comparative Study of Group A and Group B after treatment 10431 Comparative Study of Group A and Group B After follow up 10532 Shows analysis for Before Treatment and After treatment 10633 Shows Analyses for Before Treatment and After Treatment 106 “Comparative Management study of Pakshaghata with Mashadi Yoga” 2
  9. 9. Figures and Photos of “Comparative management study of Pakshaghata with Mashadi Yoga”Sl. Content Pageno. no.1 Showing distribution of patients by age 792 Showing distribution of patients by gender 803 Showing distribution of patients by religion 814 Showing distribution of patients by occupation 825 Showing distribution of patients by Economic status 836 Showing distribution of patients by type of diet 847 Showing distribution of patients by Overall response 858 Showing distribution of patients by Agni 869 Showing distribution of patients by Nidana (Ahara) 8710 Showing distribution of patients by Nidana (Vihara) 8811 Showing distribution of patients by Manasika Hetu 8912 Showing distribution of patients by Emotional Status 9113 Showing distribution of patients by Presenting Complaints 9214 Showing distribution of patients by Presenting Complaints 9315 Showing distribution of patients by Presenting Complaints 9516 Showing distribution of patients by Facial Nerve Examination 9617 Showing distribution of patients by Motor System Examination 9818 Showing distribution of patients by Reflex 9919 Showing distribution of patients by Upper Motor Neuron Examination 10120 Showing distribution of patients by Lower Motor Neuron Examination 102 “Comparative Management study of Pakshaghata with Mashadi Yoga” 3
  10. 10. ABBREVATIONS UsedA.H ASHTANGA HRIDAYA D.N DHANVANTARI NIGHANTUA.S. ASHTANGA SAMGRAHA Y.R YOGA RATNAKARACha. S CHARAKA SAMHITA MCA MIDDLE CEREBRAL ARTERYSU.S SUSHRUTA SAMHITA PCA POSTERIOR CEREBRAL ARTERYBha. BHAVA PRAKASHA C.V.A CEREBRO VASCULAR ACCIDENTPraHa. S HARITA SAMHITA HTN HYPERTENSIONKaa. S KASHYAPA SAMHITA L.M.N LOWER MOTOR NEURONEC .D CHAKRADATTA T.I.A TRANSIENT ISCHEMIC ATTACKSh.s SHARANGADHARA SAMHITA U.M.N UPPER MOTAR NEURONVs.S VANGASENA SAMHITA I.C.H INTRA CEREBRAL HEMORRHAGES..St .M SHABDASTOMA MAHANIDHI S.A.H. SUB ARACHNOID HEMORRHAGEB .R BAISHAJYA RATNAVALI CSF CEREBRO SPINAL FLUIDM.N MADHAVA NIDANA B.T BEFORE TREATMENTK .N KAIDEVA NIGHANTU A.T AFTER TREATMENTR.N RAJA NIGHANTU A.F AFTER FALLOW UP “Comparative Management study of Pakshaghata with Mashadi Yoga” 4
  11. 11. Abstract Abstract of “Comparative management Study of Pakshaghata with Mashadi Yoga”Key words: Pakshaghata, Paksha, Akarmanyatha, Chesta Nivritti, Ruja, Sankocha, Shosha,Sandhibhandha, Vakstambha , CVA, Paralysis Pakshaghata is one of the Central nervous system diseases, considered as Vata Vyadhi inAyurveda occurs mainly due to vitiation of Vata. The present study objectives are to evaluate theefficacy of Mashadi yoga in Pakshaghata. A simple random sampling technique with Double blidclinical trial is adopted here. Pakshaghata express the important signs as the ShareeraAkarmanyata, Chesta Nivritti, Hasta Pada Ruja, Hasta Pada Sankocha, Sira Snyu Shosha,Sandhibandha Vimokshana and Vakstambha either to Right or Left Side of the body. The Mode of onset is understood as sudden or gradual with the association ofHypertension or Diabetes. Loss of functions of limbs - with or without involvement of face isobserved here. It affects either left half or Right half or both sides even. It may include face sometimes and may not. Pakshaghata is etiology of vataja ahara and vihara as aggravates Vata andimpair the functions of Pitta and Kapha simultaneously. The manifestation of condition may besudden or gradual with the involvement of central nervous system. It may be of lower motorneuron or upper motor neuron according to contemporary understanding. The condition is causedcommonly by high blood pressure there by increasing intracranial pressure will lead to rupture ofvessels intern causing the thrombus. The areas in the brain which affected by thrombus will startdegenerate. The parts and function of the body which are connected to the particular part will behampered or lost. Mashadi Yoga is mainly related to pacify the Vata as Vata is the main cause ofPakshaghata. All ingredients of Mashadi Yoga are Vatashamaka. Masha is Mamsaprasadaka,Atmagupta is vrishya, Rasna is best vatahara, Bala Rejuvinates all body parts Urubuka is bestvatanulomaka ,Rohisha is vedanastapaka and mutrala, Ashwagandha is nervine tonic .The Samedrugs is used for both groups to prepare the kwath for oral administration and Nasya taila forinternal administration From the analyses except Stroke Recovery Score Card, Barthel indexand Grip test all other parameters shows highly significant as P <0.05. The Subjective parametersshow high significance with Mashadi yoga in both groups. Among subjective and objectiveparameters, the objective parameter Stroke Recovery Score Card, the Barthel Index and GripTest shows non-significant. The Subjective parameter Akarmanyata, Chesta Nivritti, Ruja Sankocha, Shosha,Sandhibhandha and vakstambha showed highly Significant in the both Group after fallow up inthis study. Thus it is fair to conclude that the Mashadi Yoga is effective in Pakshaghata. “Comparative Management study of Pakshaghata with Mashadi Yoga” 1
  12. 12. CHAPTER -1 INTRODUCTION Pakshaghata is one among the Vata nanatmaja vikara1 . Pakshaghata is a most distressingdisease among Vatavyadhi. It is mentioned to be very difficult to cure due to its deep seatednature. A variety of pathological processes of Vata are described by the Ayurvedic classics to beresponsible for the manifestation of Pakshaaghaata. The pathological phenomena of Vata playingcentral role in the manifestation of Pakshaghata are Shuddha Vata Prakopa, Anyadosha SamsristaVata Prakopa and Dhatu kshayajanya Vata Prakopa “Comparative Management study of Pakshaghata with Mashadi Yoga” 1
  13. 13. Condition similar to Pakshaaghaata in modern medical science is the Hemiplegia. similarto Pakshaghata Hemiplegia also caused by a wide spectrum of disease processes like vasculardisorders, infective disorders of brain tissue, tumors, trauma etc. among these vascular disorder ofthe brain referred to as cerebrovascular accident (CAV) or stroke is the commonest cause ofhemiplegia2 . It is the 3rd leading cause of death in the developing country. Stroke is not a diseasein itself but is heterogeneous group of disorders. Hemiplegia is one of the most frequentclinical presentations of stroke (CVA)3. Though the Hemiplegia/stroke related mortality issteadily declining in the west, it has been rising in India. This is due to the fact that the lifeexpectancy has increased and urbanization has changed the life style. This changing life style leads to vitiation of vata, chief among Tridosha and dynamicentity of life and locomotion. One of the conditions is stated as a consequence of vitiated Vata isPakshaghata (Hemiplegia). Pakshaghata 4 has been enlisted amongst the eighty types ofNanatmaja Vata Vyadhies and is considered to be prominent of all Vata vyadhies. This disease has been described in almost all Ayurvedic literature under Vatavyadhi. Pakshaghata may be defined as loss of voluntary functions of one side of the body.Charaka – the foundation stone of Chikitsa describes Pakshavadha5 (Pakshaghata) by saying thatmorbid vata beholds either side of body, dries up sira and snayu of that part rendering it deadand producing cheshta-nivritti along with ruja and vakstambha. Acharya Sushruta6 has describedthis ailment more precisely. He has considered pathological involvement of the joints of one halfof the body along with sensory loss of affected part in Pakshaghata. Ardit described by AcharyaCharaka includes in Paralysis of all parts of one side of the body (including face),i.e., complete hemiplegia. The pittanubandhita and kaphanubandhita lakshanas ofPakshaghata have been mentioned in Mdhava Nidana7 . The description of Pakshaghata can be interpreted with Hemiplegia. Modern medicalscience attributes this condition as damage to brain or CNS 8 structures caused byabnormalities of the blood supply. Hemiplegia is defined as paralysis of musculature of the face, “Comparative Management study of Pakshaghata with Mashadi Yoga” 2
  14. 14. arm and leg on one side of the body. It is the most frequent distribution of paralysis in humanbeings. Hemiplegia is caused by a variety of clinical conditions like CVD9, trauma, braintumor and abscess, syphilis, meningitis, etc., but CVD exceeds all others in frequency. Pakshaghata presents itself as a functional disability more than an organic fault. Itproduces a very miserable, dependent and prolonged crippled life with constantmental trauma. If he or she is the only earning member, the family has to face endless problems.Due to this, patient goes in extreme state of depression and frustration. In such a disease if anyhelp is extended to the sufferer, it will be a great advantage to the patient, a good credit to thephysician and in turn to the science itself. With advent of modern drugs, the pattern of disease has grossly changed, where the drugsonly assuage the symptoms temporarily and the underlying pathology goes on progressively toworsen the condition. Though ample research is being carried out for alleviating the disease andnew avenues are being explored for treating early ischemic injury by thrombolytic10 agents,Neuro protectants, anti oxidants, etc. Followed by physical rehabilitation, physiotherapyetc., yet the disease have not been dominated and remain incurable. To add it up, the adverse effects pose distant threat to the well- being. Therefore, theAyurvedic therapeutics has attracted considerable glamour for providing safe and effectiveremedies. Numerous researches have been done time and again to reprove the worth of thesemedicaments. Yet there is a necessity for perusing further research to find out some safe,effective and cheap remedy Taking all the above points into consideration, its poor prognosis andnature of inertia, the disease was selected, to find a measure that could help in restoring quality inlife of paralyzed patients. Ayurveda has broadly clarified treatment into three parts, i.e., Nidanaparivarjana, Shodhana and Shaman chikitsa. Many therapeutic principles have beenrecommended in Ayurvedic classics for the treatment11 of Pakshaghata. Acharya Charaka hasadvised time of treatment for Pakshaghata. Although a number of projects have been carried “Comparative Management study of Pakshaghata with Mashadi Yoga” 3
  15. 15. out using this principle of Charka at various research institutes, we have evolved adifferent pattern of treatment which falls under the principles boundaries of Charaka inwhich shodhan and Shaman principles are also involved. A sincere effort has been made toevaluate the combined effect of Shodhana and Shaman therapies12 and only Shamana therapyexplained for the management of Pakshaghata.Stroke – Incidence, Prevalance and mortality rate in India 13 It has been noted that stroke incidence may vary considerably from country to country.The prevalence of stroke in India was estimated as 203 per 100,000 populations above 20 years,amounting to a total of about 1 million cases. The male to female ratio was 1.7. Around 12% ofall stroke occurred in population below 40 years. The estimation of stroke mortality was seriouslylimited by the method of classification of cause of death in the country. The best estimate derivedwas 102,000 deaths; which represented 1.2 % of total deaths in the countryResearches on Pakshaghata (1) Evaluation of classical line of treatment in Pakshaghata,by Chidanad, P.G. Thesis ,1992, Mysore. (2) Evaluation of the Comparative efficacy of shodhana and shamana in the management of the Pakshaghata with special reference to ischemic strokes, by U V Purad , P G Thesis , 2001 , Gadag (3) Management of Pakshaghata-A observational study, by Chandrakala S ,P.G. Thesis, 2002,Mysore. (4) A clinical study on Pakshaghata (Hemiplegia), by Sudhir Raj N, P.G. Thesis, 2003, Bijapur. (5) A-Comparative study of effect of samshodhana and samshaman in Pakshaghata, by Devgirikar v p, P.G. Thesis, 2004, Udupi. “Comparative Management study of Pakshaghata with Mashadi Yoga” 4
  16. 16. CHAPTER 2 OBJECTIVES OF THE STUDY Pakshaghata is a ‘Vata vyadhi’14. Then why this problem has been selected forResearch work? There are certain specific reasons behind the selection of problem. Inrecent era everybody wants to succeed in his /her field and to go ahead than others. Soit becomes necessary that each and everyone should have some extra qualities whichmake his personality different to others. Success depends on individual’s workingefficiency, knowledge and personality. Thus personality plays an important role toachieve goals and to place one on the top in the society. A good personality helps not “Comparative Management study of Pakshaghata with Mashadi Yoga” 5
  17. 17. only in business and carrier but also in day to day communication. The increaseddemand of hard workers is evident by number of jobs and interviews and is in greatdemand in public. Factories are better run by the numbers of laborers .In the presentstudy of Pakshaghata patients are disabled form working .Because of loss of functionsof hand and leg .this dreadful disease make person to inactive and burden for thefamily members to carry out his daily regimens. Despite of its prevalence and its high cost management as well as disability,Pakshaghata has been paid proper attention and functioning for Stroke research inscandalously. In spite of advance of modern medicine and neuro imaging it issurprised to note that there is no standard medical treatment of strokes so far. It isreported that with present status of treatment the effect of infarction or hemorrhagecan not be reserved The dead neurons can not be visualized and the degree ofimprovement is commonly observed is to be attributed up to some extent, to therecovery of damage but viable cells of the periphery to infarction. The use of thrombolytics, anticoagulants and vasodilators are found to beineffective and does not increase blood flow through the damaged area .There is nodrug which improves series of mental functions particularly higher cortical functionssuch as learning ability, memory ability to think, consciousness etc. vascular surgerycan alter the progress of stroke, but a very few patients are fit for surgery and theefforts put the high financial burden. Ayurveda is gaining a global popularity for the effective ,majority of thetreatment in Pakshaghata because almost all patients become victims of physicaldisability after the latest treatment of modern medicine , therefore patients are alsopreferring to go to ayurvedic treatment after the acute phase of stroke. Mashadi Yoga is classical herbal combination which is mentioned in Chakra “Comparative Management study of Pakshaghata with Mashadi Yoga” 6
  18. 18. data, the same combination is mentioned by saharngadhara in the management ofPakshaghata .Here Mashadi Yoga Kwatha for oral administration and Mashadi YogaTaila for Nasya karma is administered to evaluate the efficacy of Mashadi YogaKwatha and Taila as comparative management of study of Pakshaghata with MashadiYoga. Therefore, there is a need for proper understanding of such problems of thesociety through Ayurvedic perspectives and to find some effective steps ofmanagement. The present research work has been planned with following aims andobjectives.Aims and objectives of the study:1. To study the disease Pakshaghata with its etiopathology and symptomatology toAyurvedic as Well as modern literature.2. To asses the efficacy of Mashadi Yoga 15 Kwatha (Oral) in the management of Pakshaghata. 163. To asses the efficacy of Mashadi Yoga Taila (Nasya) in the management ofPakshaghata.4. To evaluate the comparative efficacy of Mashadi Yoga kwatha and MashadiYoga Taila in the management of Pakshaghata.5 To study about Ayurvedic approach in the field of Vata Vyadhi.Reasons to Choose Following Therapies for Present Study: Ayurveda believes that the management of Vata vyadhi, which are givingagony to body and Manas, disability of functioning, burden for family members fordaily regimens. Considering these factors present study is undertaken to minimize theDisability, which is the typical nature of this disease. Here an attempt is estimated tomake the sufferer free from clinical symptom. Mashadi Yoga mentioned in “Comparative Management study of Pakshaghata with Mashadi Yoga” 7
  19. 19. Chakradatta17 said to be time tested. This Mashadi Yoga contains mainly Vatashamaka dravays. Vata dosha is the main culprit to cause Pakshaghata, so MashadiYoga Kwatha is administered orally Sharangadhara18 advocates the similarcombination with slight modification in the ingredients for Nasya karma so itsefficacy on Oral use Nasya karma effect is compared. In Chakradatta, Mashadi Yoga is advised for Oral administration. This isgiven in the form of Kwatha which is having eranda as one of the ingredient whichwill have the effect of virechana karma as the chikitsa sutra of Pakshaghata is“Snehanam swedanam Pakshaghate virechanam”19 . This line of treatment iseffortlessly followed. In Sharangadhara samhita the same combination of drugs are used for Nasyakarma in the management of Pakshaghata. As the Pakshaghata is considered under thecerebro-vascular accidents (CVA,) the pathology lies in the brain the medication hasto be reached at same site, so “nasa hi shiraso dwaram”20 the Nasya karma willdefinitely useful in the management of Pakshaghata.Research question: Whether Mashadi Yoga Kwatha administered orally is effective or MashadiYoga Taila in Nasya karma is effective .The same can be interpreted as whethervirechana is effective or shirovirechana is effective in the management ofPakshaghata.Hypothesis:(1) Oral administration of Mashadi Yoga Kwatha will act as Vatahara andVirechaka21.(2) Mashadi Yoga Taila for Nasya karma will act as Shirovirechaka. “Comparative Management study of Pakshaghata with Mashadi Yoga” 8
  20. 20. CHAPTER -3 REVIEW OF LITERATUREHISTORICAL REVIEWVEDIC KALA (PRE-SAMHITA PERIOD) Which have been claimed as ‘Vatakritasya Bheshaja’23 and ‘Vatakrita Nasani’respectively Blumefield interprets the word Vatakrita as the disorder caused by Vata.The words Pakshaghata and Pakshavadha are not mentioned in Vedas butAngabheda24 mentioned in Atharvaveda and Pangu25 mentioned in Rigveda indicatesthe knowledge regarding the Pakshaghata related diseases in that era.SAMHITA KALA: Detailed description regarding Pakshaghata has been mentioned by theAcharya in the Samhita Granthas.CHARAKA SAMHITA: Pakshavadha and Pakshagraha are considered among the ailments ofMadhyama Roga Marga, i.e., Marm-Asthi-Sandhi Marga26 Pakshavadha has beenlisted under eighty Nanatmaja Vata Vikaaras27 Detailed description of the disease has “Comparative Management study of Pakshaghata with Mashadi Yoga” 9
  21. 21. been given as Pakshavadha28 “Swedanam Sneha Samyuktam PakshaghateVirechanam” is the line of treatment given by Acharya Charaka. Jejjata (9thCen.) clarifies this by saying that Swedana and Virechana should be administeredalong with Sneha. Gangadhara (19th Cen.) comments that Snehayukta Swedana andSnehayukta Virechana should be given in Pakshaghata.BHELA SAMHITA AND HARITA SAMHITA: A brief description on Pakshaghata29 is available in both these Samhita. 20thChapter of third Sthana of Harita Samhita deals with Pakshaghata related diseasesnamely Ekanga Vata and Ekanga Pakshaghata.SUSHRUTA SAMHITA 30: In the first chapter of Nidana Sthana aetiopathogenesis, clinical features andprognosis of Pakshaghata have been described. The role of Urdhvagami, Adhogami,and Tiryaga Dhamanis in the pathogenesis of Pakshaghata has been shown. LakshanaAnyatara Pakshahanana, Sandhi Bandhana Vimoksha has been added here. Treatmentof Pakshaghata has been described in Maha Vata Vyadhi Adhyaya of Chikitsa Sthana(Su. Chi. 5/19). Sushruta has highlighted Vata Vyadhi among Ashta Mahagada in Su.Su. 33. Commentator Dalhana interprets Akarmanyata as Ishatkarma kshayamam -partial loss of function, where patient is unable to maintain stance and tends to fall.He interprets Achetana as Alpachetana, referring to partial loss of sensation.SANGRAHA KALA:ASHTANG SANGRAHA AND ASHTANG HRIDAYA 31: Similar description of Pakshaghata is found in both these Samhita. In AstangaSamgraha, the general Nidana of Vata Vyadhi, signs, symptoms and prognosis of “Comparative Management study of Pakshaghata with Mashadi Yoga” 10
  22. 22. Pakshaghata has been given in 15th chapter of Nidana Sthana The treatment has beenhighlighted in Chikitsa Sthana 23rd chapter. In Astanga Hridaya, Pakshaghata has been described in 15th chapter of NidanaSthana and 21st chapter of Chikitsa Sthana. The term Anyatara Paksha Nasha hasbeen used here and interpreter Arundatta (11th Cen.) interprets word Anyatara as rightor left side of the body. Line of treatment is same as that given by Charaka with theonly difference that Sneha is mentioned instead of Swedana.KASHYAPA SAMHITA32: Pakshaghata has been listed among 80 types of Nanatmaja Vata Vyadhi in thisSamhita (K.S. Su. 27-28). It is also included in the list of persons fit for Swedana(K.S. Su. 23-22). More details of Pakshaghata are not found in the available edition ofthis Samhita.MADHAV NIDANA 33: Madhava Nidana is considered to be the most authentic text of diagnosticvalue. Pakshaghata has been described in detail here. General description of causativefactors, pathogenesis, signs and symptoms of all Vata Vyadhi is found in 22ndchapter. In addition to the general symptoms of Pakshaghata, Pitta and KaphaAnubandha Lakshana have also been described. Interpreter Vijaya Rakshita (14thCen.) has differentiated Pakshaghata from Adaranga Vata by giving illustration of‘Ardhanarishwaravat’ to the former and ‘Narsimhavat’ to the later.NYAYA CHANDRIKA:The Lakshana “Sandhibandha Vimoksham” has been interpreted by Gayadas as“Sandhibandhan Kaphasanhitabhih Dhamanibhih Kritan Mokshayan PakshaghatamKuryat.” “Comparative Management study of Pakshaghata with Mashadi Yoga” 11
  23. 23. CHAKRADATTA 34: Majority portion of this Grantha deals with the treatment of various diseases.Vatavyadhi Chikitsa has been described in details in 22nd chapter. Some formulationshave been indicated for the treatment of Pakshaghata and amongst them one has beenselected for the present study.VANGASENA SAMHITA 35: The 24th i.e., Vatavyadhi adhikara, chapter deals with the pathogenesis,prognosis, symptomatology of Pakshaghata. Prognosis is described in detail. Sneha,Swedana, Virechana is the line of treatment given here. Basti described forAkshepaka has been described to be administered in Aksheena patient ofPakshaghata.SHARANGADHARA SAMHITA36: In this Samhita, very little description is found regarding the disease.Pakshaghata has been enumerated among the 80-Vaatik Nanatmaja disorders (Sh.S.Pu. 7/107). Some formulations of Pakshaghata have been mentioned in Sh. M. 2/92;and Sh. M. 2/142.BHAVAPRAKASH 37: Following the footprints of Madhavakara, detailed description bas beenpresented in B.P. M. 24/205-207, 262,263.YOGRATNAKARA38: Description similar to that of Madhava Nidana is found in the VatavyadhiNidana chapter. Formulations of Pakshaghata are also indicated.BHAISHAJYA RATNAVALI 39: This text deals mainly the only the treatment of various diseases. DetailedChikitsa of Vatavyadhi has been described in the 26th chapter named as Vata Vyadhi “Comparative Management study of Pakshaghata with Mashadi Yoga” 12
  24. 24. Chikitsa. Some drug formulations have also been indicated for Pakshaghata. In othertreatises i.e. Kalyaanakaaraka of Ugradityacharya (9th Cent.), Chikitsakalika byTisatacharya (10th Cent.), Shodhal’s Gada Nigraha (12th Cent.), Rasa RatnaSamuchhaya 21st chap. (13th Cent.) etc., a synoptic description is found as presentedin the earlier classics.HISTORY OF CEREBROVASCULAR ACCIDENT: Hippocrates, the father of medicine, first recognized stroke over 2,400 yearsago. At this time stroke was called apoplexy, which means "struck down by violence"in Greek. This was due to the fact that a person developed sudden paralysis andchange in well-being. Physicians had little knowledge of the anatomy and function ofthe brain, the cause of stroke, or how to treat it. It was not Untill the mid-1600s that Jacob Wepfer found that patients whodied with apoplexy had bleeding in the brain. He also discovered that a blockage inone of the brains blood vessels could cause apoplexy. Medical science continued to study the cause, symptoms, and treatment ofapoplexy and, finally, in 1928, apoplexy was divided into categories based on thecause of the blood vessel problem. This led to the terms stroke or "cerebral vascularaccident (CVA)." Stroke is now often referred to as a "brain attack" to denote the factthat it is caused by a lack of blood supply to the brain, very much like a "heart attack"is caused by a lack of blood supply to the heart. The term brain attack also conveys amore urgent call for immediate action and emergency treatment by the general public.Today, there is a wealth of information available on the cause, prevention, risk, andtreatment of stroke. Even then much less is known about the treatment of the stroke,there is no any satisfactory and widely acceptable measure for the stroke. “Comparative Management study of Pakshaghata with Mashadi Yoga” 13
  25. 25. Review of PakshaghataEtymology: In Sanskrit language each word is considered to be Shakti Swarupa and behind theword its meaning invariably entangles. The word Pakshaghata also bears a meaning that ishallmark of the disease itself, as explained hereby. This word is composed of two pada i.e.‘Paksha’ and ‘Aghata’40 detailed meaning of which are as under.Paksha:It is of masculine gender and its various meaning is as follows in different texts.• Dehangama – Shabdakalpadrum41• Parshwa - Vachaspatyama• Dehardha - Vachaspatyama• Dehangabheda - Vachaspatyama• Paksha Sharirardham – Dalhana• Paksha Ardha Narishwaravat – Vijayarakshita• The flank or side or the half of anything - Monier Williams Acharya Charaka has used the Pada ‘Paksha’ in different contexts. It has been usedfor describing 15 days, feather of bird and one side of the body. Acharya Sushruta has used this ‘Pada’ while describing the disease Pakshaghata.Dalhana has commented on this by rightly saying it as Paksham Sharirardham. Ashtanga Samgraha and Ashtanga Hridaya42 have also used this pada whiledescribing the disease Pakshaghata, the meaning of Paksha being taken as one side of thebody. Madhava Nidana has also incorporated the pada Paksha in Pakshaghata.Vijayarakshita the commentator of Madhava Nidana explains it as Ardhanarishwaravat givinga clear idea about terminology used. In contemporary literature like Sharangadhara Samhita, Bhava Prakasha andYogaratnakara43 the word Paksha has been used with meaning of half of the body during the “Comparative Management study of Pakshaghata with Mashadi Yoga” 14
  26. 26. description of Pakshaghata. We can conclude doubtlessly from the foregoing description thatword “Paksha” depicts one side of the body.Ghata: It is of masculine gender and is derived as below:An + Han + GhanHan + Vich + Bhave + Layut (Halayudh Kosha) The suffix ghata of the word Pakshaghata has also been used in terms likeMutraghata, Marmaghata, etc. The word Aghata bears same meaning as Ghata. Its variousmeanings are as follows -Vadha44 - ShabdakalpadrumMarane - VachaspatyamKilling, Blow,Injury – Monier WilliamsTerm Pakshavadha is also used as a synonym of Pakshaghata.So, we will have a brief view of word Vadha. It is of masculine gender and is derived asfollows –Hananam iti, Han + Ap, Vadhadesha. Its various meanings are as follows:Prana Viyoga Phalaka Vyapar – Shabdakalpadruma Killing, Destruction - Monier WilliamsDestruction, Blow - V. S. ApteThus, the etymology of Pakshaghata goes like this –  Pakshashaya Dehardhashaya ghatam vinashanam yasmat yatrava  Pakshashaya aghataha iti pakshaghataha  Pakshashaya ghataha iti pakshaghata  Pakshashaya vadhaha iti pakshavadhaFrom all the above description we can draw the bottom line that the meaning of wordPakshaghata is loss of function of one half of the body and its modern homologue isHemiplegia “Comparative Management study of Pakshaghata with Mashadi Yoga” 15
  27. 27. CLASSIFICATION OF PAKSHAGHATA: While describing the prognosis of Pakshaaghaata, Aacharya Sushruta has classifiedthe disease in three types as per their aetiopathogenesis. The three types of Pakshaaghaata areas follows  Shuddha Vataja Pakshaaghaata:- The Pakshaaghaata where the Vata is aggravated on account of its own Nidana  Anyadosha Samsrista Pakshaaghaata: - Where the Vata associated with other Dosha to manifest the disease.  Kshaya Hetuja Pakshaaghaata: - Where the Vata is aggravated as a consequence of Dhatu Kshaya.  Aachaarya Sushruta has used the terms Samanwita, Samsrista, Anwita, Samyukta etc as synonym of Aavarana45 in the context of description of  Aavarana. So here the term Anyadosha Samsrista can be understood as Anyadosha Aavrita, as there are only three routes for the aggravation of Vata.NIDANA The word Nidana46 carries two meanings in Ayurvedic classics, viz - causativefactors and diagnosis. The former one will be discussed here. Acharya Charakadefines Nidana as under – Nidana is defined as the factors, which cause the disease. Treatment becomes easierby knowing the causative factors of a disease. In this light it has been clearly stated that‘Nidana Parivarjanam’ is one type of Chikitsa. According to Ayurveda, considerationof aetiological factors is important for the diagnosis, prognosis and line of treatment. With the review of Ayurvedic literature it is evident that no specificaetiological factor has been described separately for Pakshaghata. Disorders of Vata,including Pakshaghata have been classified as Nanatmaja Vata Vyadhis, so all thefactors vitiating vata in the body are likely to be the root cause of Pakshaghata. Hence, thegeneral causative factors of vata vyadhi or factors vitiating vata dosha in the body may be “Comparative Management study of Pakshaghata with Mashadi Yoga” 16
  28. 28. regarded as the aetiological factors of Pakshaghata as well. Though the causativefactors remain same in all vatavyadhis, different forms appear like Pakshaghata,Gridhrasi, etc. This is because of the Samprapti vishesha of vitiated vata. The Nidana of Vatavyadhi and Vata prakopa given in Ayurvedic texts have been classified here under eightmain headings, which are tabulated below.GUNA VACHAK AETIOLOGICAL FACTORS VITIATING Vata Table no. 1Sl .no Aetiological Ch. Su. A.S A.H Bh.P M.N Sh C.D Y.R Factors1 Ruksha + + + + + + + + +2 Sheeta + + + - + + + - -3 Laghu + + - - + + + - -4 Katu - + + - + - - + +5 Tikta - + + + + - - + +6 Kashaya - + + + + - - + +7 Daruna + - - - - - - - -8 Khara + - - - - - - - -9 Vishada + - - - - - - - -Guna Vachaka aetiological factors vitiating vata: The qualities of vata as described in Ayurvedic texts are ruksha,laghu, sheeta, khara, sukshma, chala47. According to the principles of Ayurveda, samanya isthe cause of increase and vishesha is the cause of decrease of all things at all time. . Henceexcess intake of the above gunayukta ahara causes rukshata, laghuta, shitalta, darunta,kharata in the body and when body gets affected by these gunas, vayu makes its place inthe body and eventually it becomes aggravated.-Vata vyadhies are compared to the diseases of nervous system. The nerve cells are coveredby myelin sheath, which is chiefly made up of fat. It gives nourishment to the nerve fibres.This fat can be taken as snigdha substance.- By excess intake of ruksha gunahara, the nourishing material of nerve will be decreased andthis will cause dhatukshaya, which in turn leads to vata prakopa and Pakshaghata. “Comparative Management study of Pakshaghata with Mashadi Yoga” 17
  29. 29. -Excess intake of ahara having katu, tikta and kashaya rasa causes vitiation of vata.48-Excessive ingestion of Katu rasa causes Bala Kshaya, Bhrama and on account of havingvayu and agni mahabhuta in preponderance, it generates various kinds of vata disorders inthe legs, arms, sides and back along with giddiness, pain etc. In Pakshaghata also leg, arm andsometimes face of one side of the body is affected by Vata.- Tiktarasa when taken in excess causes shosha of Rasa, Rakta, Mansa, Meda, Asthi andMajjadhatu and produces many vata disorders by virtue of ruksha, khara and vishadaguna 49-Kashaya rasa is khara, vishada and ruksha. Its atiyoga causes various Vata disorderslike Pakshavadha, Ardita, etc.Nutritional aetiological factors provoking vata:-Anashana or Alpashana reduces bala, varna, upachaya, veerya; impairs eight sara,sharir, mana, buddhi, indriyas and is cause of eighty types of vata vyadhies. 50-Atimatra bhojan leads to vitiation of all three doshas. These doshas reside in the kukshi andproduce various disorders. Amongst them vitiated vata produces shira sankuchan, stambha.-Abhojana, ajeerna bhojana, atibhojana, vishamashana leads to angnimandya. This impairsthe production of rasadhatu and thus results in kshaya of subsequently produced dhatus.This dhatukshaya causes vata prokopa.-Ama is produced by ajeernashana and adhyashana .This ama dosha obstructs thepath of vayu (margavarana) which results in vitiation of vata 51-Kordusha, Shyamaka, Nivara, etc., being kudhanya vargadravyas, vitiates vata by theirruksha guna and katu vipaka. Bidal varga dravyas like Mudga, Masura, Makushtha, Chanaka,Kalaya etc. vitiates vata by their Kashaya rasa, katu vipaka and shita guna. These dietaryhabits, from the nutrition point of view, are less nourishing, making body weak and thenervous system more irritable and produce various nervous disorders.Karma Vachaka etiological factors vitiating vata:-Excessive sexual indulgence makes the body ruksha 52 and this is the cause of vata prakopa. “Comparative Management study of Pakshaghata with Mashadi Yoga” 18
  30. 30. Ativyavaya causes shukra dhatu kshaya and this leads to kshaya of all dhatus according to thetheory of PraTilaoma Kshaya. This dhatu kshaya results in vata prakopa. Charaka mentionsbalanasha, ekanga and sarvanga roga, manoavasada, etc., vitiates Doshas due to ativyavayaand indirectly pointes towards Pakshaghata. Acharya Sushruta hasclearly mentionedexcessive sexual indulgence as the direct cause of Pakshaghata. 53-Atijagaran / Ratrijagaran increase the ruksha guna in the body and there by vitiates vata.Charaka mentions that keeping awake at night diminishes rasa dhatu and viscosity ofbody fluid.-Divasvapna causes aruchi, avipaka, agninasha, etc. 54 this leads to ama production and resultsin avaranjanya vata prokopa.-Ativyayama causes dhatukshaya and this leads to vitiation of vata. The maindamaging effect of such exertion is on the pranavaha and mamsavaha srotas givingrise to may disorders.-Suppression of natural urges produces the symptoms of excitation of vata byvitiating it for example, suppressing the urge of Apana vayu cause many vatajanyadiseases. 55Trauma (Abhighata) Provoking vata: Table No.2Sl .no Aetiological Ch. Su. A.S A.H Bh.P M.N Sh C.D Y.R Factors1 Abhighata + + + - + + + - -2 Marmaghata + - - - - + - - -3 Balvad Vigraha - + + - - - - - -4 Prapatana + + - - + + - - -5 Prapeedana - + - - - - - - -6 Vikshepa - - + - - - - - --Acharya Chakrapani says that Abhighata can be of two types – Doshabhighata andMarmabhighata. Head is considered as a vital part (marma), the seat of Indirya and Prana56 Shiromarmaghata causes diseases like Ardita, Manyastambha, Mukta, Cheshta-Nasha 57.Which are seen in Pakshaghata? “Comparative Management study of Pakshaghata with Mashadi Yoga” 19
  31. 31. -Injury to lohitaksha marma causes loss of blood and leads to Pakshaghata. Injury to 58kakshadharamarma also causes Pakshaghata . Abhighata, balvad vigraha, prapatan,prapidan, etc. cause achaya purvak vata prakopa.Psychic factors vitiating vata: Table No. 3Sl .no Aetiological Ch. Su. A.S A.H Bh.P M.N Sh C.D Y.R Factors1 Chinta + - - + + + + + +2 Shoka + - + + + + + + +3 Krodha + - - - - - - - -4 Bhaya + - - + + - + + -5 Kama + - - - + - + - -6 Apravritta - - + + - - - - - vegadharana7 Utkranta - + - - - - - - --Emotional stress of mind, i.e., kama, krodha, bhaya, chinta, etc., are likely totrigger the psycho-physiological mechanism liberating neuro humors and hormones inthe body which may have direct bearing with the excitation of Vata and production of severalpsychosomatic disorders. Vata is predominant in rajo guna Psychic causes, which arepredominant of rajo guna, will vitiate vata and in turn cause vata vyadhi.-Mana is Ubhayendria. Both the sensory and motor functions are governed bymana. Abnormality in mana causes disturbance in sensory and motor function and causesPakshaghata.-In a person suffering from chinta, shoka, etc., the matra yukta pathya ahara is also notdigested properly leading to ama formation and agnimandya. This can lead tomargavarodh janya Pakshaghata.Season and time provoking vata: The cyclic effect of season, time, day-night, temperature produce a rhythmic effect onHuman body. The doshas of the body are also affected. Grishma, Varsha, Shishirseasons; Bhuktante, Jeernante, end of day and night are the kala for vitiation of vata. “Comparative Management study of Pakshaghata with Mashadi Yoga” 20
  32. 32. Nidanarthakar Diseases provoking vata: Disease, which acts, as the causative factor for other disease is knownas Nindanarthakarroga. Dhatuskhaya, Ama, Rogatikarshana, etc., comes under thiscategory because they vitiate vata and causes various vata disorders. Ama causesmargavaranjanya vataprakopa. Ama when combines with vata (vata sanshrishta ama)leads to many vata vyadhies .59Improper treatment induced vata prakopa: Vitiation of vata due to improper management may be treated as a complication oftherapies. Excessive use of Panchakarma, Rakta Mokshana, etc. causes excessive lossof body elements, malas which leads to riktata of srotasa and in turn provokes vata. AcharyaCharaka quotes that vata gets vitiated either by dhatukshaya or margavarana. 60We cansee that all the above said factors vitiate vataeither by causing dhakushaya or by obstructing the normal gati of vata.ETIOLOGY The World Health Organization (WHO) defines stroke as “Rapidlydeveloping clinical symptoms and/or signs of focal and at times global, loss of cerebralfunction with symptoms lasting more than 24 hours. Hemiplegia is a classical sign of stroke.THE ETIOLOGICAL FACTORS OF STROKE:I. CAUSES OF ISCHEMIC STROKE (IS): IS results from several etiological factors out of which three arepredominant: Thrombosis, embolism and lacunars disease.Causes of Atherosclerotic (Thrombotic) Stroke 61 – Atherosclerosis a progressive pathological state where blood vesselsdevelop fibroproliferative, fatty lesions that express as occlusive plaques is thevascular disease that contributes most frequently to thrombosis. Ischemic stroke resultingfrom thrombosis are often classified as having atherothrombotic. This is predisposed by “Comparative Management study of Pakshaghata with Mashadi Yoga” 21
  33. 33. Hypertension – Initiates and accelerates the cerebral atherosclerotic disease,probably by degeneration of the small vessel wall. Hyperlipidemia/obesity – Affects thelarge vessels. Intimal thickening by deposition of cholesterol and often bycalcification and ulceration leading to breaching of internal elastic lamina.Diabetes – Hastens the atherosclerotic process in both large and small arteries.Myxodema – Also found to be a cause.Smoking – Aggravates the process by decreasing HDL cholesterol and reducing cerebralblood flow.Causes of Cerebral Embolism Embolism of an intracranial artery is a complication of many disorders, which allowthrombi or other material such as cholesterol, air or fat to enter the circulation in such a waythat it reaches the brain. Causes are:-Cardiac Origin 62 :  Atrial fibrillation and other arrhythmias (with rheumatic, atherosclerotic, hypertensive, congenital or syphilitic heart disease).  Myocardial infarction with mural thrombus.  Acute and subacute bacterial endocarditits.  Heart disease without arrhythmia or mural thrombus (mitral stenosis, myocarditis.  Complications of cardiac surgery.  Valve prostheses.  Non-bacterial thrombotic (Marantic) endocardial vegetations.  Prolapsed mitral valve.  Paradoxical embolism with congenital heart disease.   Trichinosis.Non Cardiac Origin 63  Atherosclerosis of aorta and carotid arteries (mural thrombus, atheromatus material).  From sites of cerebral artery thrombosis (basilovertebral, middle cerebral)  Thrombosis in pulmonary veins.  Fat, tumor or air.  Complications of neck and thoracic surgery. “Comparative Management study of Pakshaghata with Mashadi Yoga” 22
  34. 34. Undetermined origin of ParalysisCauses of Lacunar infarction: -  Hypertension  Atherosclerosis  Diabetes  Small-vessel diseases such as infectious or non-infectious arteritis.Cryptogenic causes: Moyamoya disease, Fibromuscular dysplasia, Binswanger’s subcorticalarteriosclerotic encephalopathy, leuko-araiosis, Winiwarter-Buerger disease and AorticArch syndrome (Non inflammatory).Other Unusual causes: Vasculopathies resulting from drug abuse and oral contraceptive pills,congophilic angiopathy, cerebral malaria, Homocystinuria-vasculitis, Arteritis (Syphilitic,tuberculous, rheumatic, Takaysu’s disease, collagen disease, etc.), Migraine/vasospasm,Arterial hypotension and anoxic encephalopathy, cerebral thrombophlebitis,Dissecting aortic aneurysm, Demyelinating conditions–Multiple sclerosis andencephalomyelitis, Ergotism, diphtheria, Hypercoaguable states (i.e. defects in thefibrinolytic system) such as ProteinC & S deficiency, resistance to activated proteinC & antithrombin III deficiency.II. CAUSES OF INTRACRANIAL HAEMORRHAGE 64  Primary (hypertensive) intracerebral haemorrhage.  Ruptured saccular aneurysm.  Ruptured arteriovenous mal formation.  Undetermined causes (normal B.P., no aneurysm or AVM)  Trauma including post traumatic delayed apoplexy.  Hemorrhagic disorders: Leukemia, aplastic anemia, sickle cell disease, polycythemia vera, thrombocytopenic purpura, liver disease, complication of anticoagulant therapy, hyperfibrinolysis, hypofibrinogenemia, haemophilia, Christmas disease, Hyperviscocity syndrome.  Hemorrhage into primary and secondary brain tumors.  Septic embolism, mycotic aneurysm. “Comparative Management study of Pakshaghata with Mashadi Yoga” 23
  35. 35.  With hemorrhagic infarction, arterial or venous.  With inflammatory disease of arteries and veins (Polyarteritis, lupus erythematosus).  With arterial amyloidosis.  Miscellaneous rare types: After vasopressor drugs, upon exertion, during arteriography, during painful urologic examination, as a late complication of early life carotid occlusion, complication of carotid-cavernous AV fistula, anoxemia, migraine, teratomatous malformations, Herps simplex encephalitis, Acute necrotizing hemorrhagic encephalopathy.RISK FACTORS OF STROKE65 The American Stroke Association has identified several factors that increase the riskof stroke. The more risk factors a person has, the greater the chance that he will have a stroke.Medical conditions that increase stroke risk 66:-  Transient ischemic attacks (TIAS): TIAS are “mini strokes’. They are strong  Predictors of stroke. A person who’s had one or more TIAS is almost 10 times More likely to have a stroke than someone of the same age and sex who hasn’t.  High blood pressure: Hypertension is one of the leading risks of stroke. The effective treatment of high blood pressure is key reason for the accelerated decline in the death rates of stroke.  Diabetes mellitus: Diabetes is an independent risk factor for stroke.  Heart disease: People with heart disease have more than twice the risk of stroke as Those whose hearts work normally. Atrial fibrillation in particular raises the risk For stroke. Recent MI is also a major cause of death among stroke survivors.  Carotid artery disease: Atherosclerosis of carotid artery can lead to stroke. Carotid Bruit is an indication for carotid artery disease.  High Red blood cell count: A moderate or marked increase in the red blood cell count is a risk factor for stroke. The reason is that more RBCs thicken the blood and make clots more likely.Controllable risk factors and life style choices:-  Smoking: Recent studies have shown cigarette smoking to be an important risk factor for stroke.  Obesity, elevated cholesterol and elevated lipids. “Comparative Management study of Pakshaghata with Mashadi Yoga” 24
  36. 36.  Physical inactivity – A sedentary lifestyle.  Excessive alcohol intake.  Illegal drug use: Intravenous drug abuse carries a high risk of stroke from cerebral emboli.  Oral contraceptive pills: It increases the risk of venous thromboembolism.Uncontrollable Risk factors:-  Increasing age: Stroke is more common in people over 60.  Sex: Latest data show that, over all, the incidence and prevalence of stroke are about equal for men & women. However, at all age, more women than men die of stroke.  Heredity and Race: The chance of stroke is greater in people who have a family history of stroke. African – Americans and Hispanic Americans are at higher risk than white Americans. This may be due in part to hypertension and dietary differences.Other factors:  Season & Climate: Stroke deaths occur more often during periods of extremely hot or cold temperatures.  Socioeconomic factors: There’s some evidence that people of lower income and educational levels have a higher risk for stroke.  Vit. B deficiency increases stroke risk.  Air pollution may increase stroke risk (Oct. 2003 – Journal of American Heart Association)  Sleeping for more than eight hours at night, snoring and daytime drowsiness is associated with an increased risk for stroke. (Feb. 2001, American stroke Association’s 26th International stroke conference).  Low potassium intake may increase risk for stroke. (Aug. 13, 2002 – Journal of American Academy of Neurology).PURVARUPA According to Ayurveda clinical features of a disease are divided into twoparts – Purvarupa and Rupa. Before full-fledged manifestation of disease, thesymptoms which are developed in the initial stage with the localization of doshas in aparticular area of the body are called Purvarupa. These symptoms are exhibited during thesthanasanshraya avastha of shatkriyakala of the disease 67 Termination of the disease atthis stage may save the patient from the damage, which may be done by the complete “Comparative Management study of Pakshaghata with Mashadi Yoga” 25
  37. 37. manifestation of the disease. Purvarupa of Pakshaghata is not described in any text.Pakshaghata being a vata vyadhi;purvarupa of vata vyadhi can be taken as that ofPakshaghata. Acharya Charaka68 mentions Avyakta Lakshana as the purvarupa of any vata vyadhi.Acharya Chakrapani has interpreted the term ‘Avyakta’ as the rupa presented in lesser degree.Vijayarakshita gives very clear meaning of the term Avyakta. According to him thesymptoms that are not manifested clearly are Purvarupa and these are due to: - Less severe causative factors - Very less or mild symptoms - Less Avarana of Doshas (M.N. 1/5-6, Madhu.) Vijayrakshita has designated AvyaktaLakshanas under vishishta purvaurpas . Thus 69general symptoms of vata vyadhi , viz., Sankocha, Romaharsha, Pralapa, etc., if occur inmild form can be taken as purvarupa. Loss of voluntary movements of the limbs is thecardinal feature of Pakshaghata. Hence weakness in limbs may be considered asPurvarupa of Pakshaghata. The symptoms of Kaphanubandha and PittanubandhaPakshaghata if occur in mild form before the stroke may be considered asvishishta purvarupa of Pakshaghata.PRODROMAL SYMPTOMS 70CEREBRAL THROMBOSIS – Premonitory symptoms are common and exist for hours,days or months before the onset of paralysis. They are given name as TIA.Transient cerebral Ischemic attacks:- Since the aim of treatment in CVD71 is the prevention of a majorstroke, the management of the TIA72 may be considered first. TIA is theepisodes indicating ischemia of some part of cerebral hemisphere or the brain stem. They aredefined as episodes of temporary and focal cerebral dysfunction of vascular origin leaving nopersistent neurological deficit and lasting less than 24 hours. Attacks indicatingischemia in the distribution of one carotid artery are often referred to as episodes of carotid “Comparative Management study of Pakshaghata with Mashadi Yoga” 26
  38. 38. insufficiency, those involving the brainstem as vertebro– basilar insufficiency. In carotidartery disease the transient warning attacks consist of monocular blindness, hemiplegia, hemianesthesia, disturbances of speech and language, confusion, etc. In vertebro-basilar systemthe prodromata take the form of episodes of dizziness, diplopia, numbness, andimpaired vision in one or both visual fields, dysarthria.CEREBRAL EMBOLISM: Premonitory symptoms are absent in this type of CVA. Onset is instantaneous,hemiplegia developing in few seconds or minutes. However cases of less sudden onset,resembling that of ‘Stroke-in evolution’, have been described. A convulsion mayoccur at onset and there is sometimes headache.CEREBRAL HAEMORRHAGE: The onset is usually sudden like a bolt from blue without any prodromal symptoms.But the patient may be known to be hypertensive and there may have been premonitorysymptoms such as transitory speech disturbances or attacks of weakness of a limb.Severe headache, vomiting, loss of consciousness and convulsions are accompanied at theonset.Intracranial Aneurysms 73 May produce symptoms by compressing the structures in their vicinicty. Patientsmay suffer from recurrent headaches, typical migraine, convulsions, TIAs. SAHfrom a cerebral angioma may occur without previous warning but is more oftenpreceded by symptoms and signs of the cerebral lesion.PATHOPHYSIOLOGY OF HEMILEGIA / PARALYSIS 74 There are two major categories of brain damage in stroke – Ischemia andHemorrhage, which result in the destruction of brain tissue via abnormalities in the brain’sblood supply. Ischemic stroke is a consequence of a lack of blood flow where brain tissue isstarved of oxygen and vital nutrients. Hemorrhagic stroke is the rupture of a blood vessel andthe subsequent release of blood into the extravasuclar space with in the cranium. Either kind “Comparative Management study of Pakshaghata with Mashadi Yoga” 27
  39. 39. of stroke can occur anywhere in the brain and consequences range from minimal disability toparalysis or death. Ischemic stroke account for 80-86% of all stroke whereas hemorrhagicstroke accounts for 14-20%.ISCHEMIA: Ischemia can be further subdivided into three different mechanisms:thrombosis, embolism and decreased systemic perfusion.Thrombosis: Thrombosis refers to an obstruction of blood flow due to a localized occlusiveprocess within one or more blood vessels. The lumen of the vessel is narrowed or occluded byan alteration in the vessel wall or by superimposed clot formation. The commonest type ofvascular pathology is atherosclerosis in which fibrous and muscular tissues overgrow in thesub intima, and fatty materials form plaques that can encroach on the lumen. Next, plateletsadhere to the plaque crevices and form clumps that serve as nidi for the deposition of fibrin,thrombin and clot. Atherosclerosis affects chiefly the larger extracranial and intracranialvessels.-Occasionally clot forms within the lumen because of primary hematologicalproblems.-In hypertensive patients, increased arterial tension leads to hypertrophy of themedia of small arteries and arterioles and deposition of fibrinoid material into the vessel wall,sometimes with atherosclerosis, is seen.-Lacunar infarcts are among the commonest cerebrovascular lesions. When small arteries orarterioles already thickened as a result of hypertension are occluded by thrombus or embolusfrom larger atherosclerotic vessels, this may cause areas of micro infarction, whichultimately lead to small slit-like cavities known as lacunes. Some affected vesselsshow lipohyalinosis. In sever hypertension multiple lacunes may be found in putamen,pons, thalamus, internal capsule, etc. There is tendency for Atheromatous plaques to form at branching and curves of the “Comparative Management study of Pakshaghata with Mashadi Yoga” 28
  40. 40. cerebral arteries. The most frequent sides are in the ICA at the carotid sinus, in the cervicalpart of the vertebral arteries and at their junction to form the basilar at the main bifurcation ofthe MCA, in the PCA as they wind around the midbrain, and in the ACA as they curve overcorpus callosum.Embolism75: An embolus is a foreign body that is transported from one part of the circulatorysystem to another where it becomes impacted. The process is known as embolism.Approximately 99% of all emboli are pieces of a dislodged thrombus, hence thecommon term thrombo embolism. Other forms of emboli are fat, air, tumor, bone marrow,atheromatous material and clumps of bacteria. Embolic material typically originates in theheart (valves, endocardium, atrial or ventricular clots or tumors), major arteries (eg-aorta,carotid, vertebral) or systemic vein. In contrast to thrombosis, embolic luminalblockage is not due to localized process originating within the blocked vessel. Brainembolism is essentially a manifestation of heart disease. Any region of the brain may beaffected; the territory of the MCA, particularly the upper division is most frequently involved.The arteries of the left side of the brain are embolized more often than those of right, chieflythe MCA. Large embolic masses can block large vessels (sometimes the carotids in the neck);white tiny fragments may reach vessels as smaller 0.2 mm in diameter. The embolic materialmay remain arrested and plug the lumen solidly but in many cases it breaks up into fragments,which enter smaller vessels and disappear completely. Because of the rapidity with whichembolic occlusion develops, there is not much time for collateral influx to becomeestablished. Following impaction of an embolus, a thrombus usually forms in the vessel andmay spread distally or less frequently proximally and the area of brain deprived of bloodsupply is infracted. If an embolus impacts and then moves on, arterial blood may then enterthe infarcted area. Thus embolism is the commonest cause of hemorrhagic infarction. Whenthe embolus is infected, meningitis or cerebral abscess may develop, or when the infection isof low virulence, embolism may be followed by infective softening of the vessel wall and “Comparative Management study of Pakshaghata with Mashadi Yoga” 29
  41. 41. aneurysm formation - mycotic aneurysm. Fat embolism may occur as the result of fatglobules being set free into the circulation after the fracture of one of the long bones, passingthrough the pulmonary circulation and so reaching the brain. In an embolism, gas bubblesmay appear in the arterial circulation of the CNS in Caisson disease or air can enter thecirculation accidentally during cardiac surgery, venous catheterization etc.Decreased systemic Perfusion: In this circumstance, diminished flow to brain tissue is due to low systemic perfusionpressure. The most common causes are cardiac pump failure and systemichypotension. In such cases, the lack of perfusion is more generalized than in localizedthrombosis or embolism and affects the brain diffusely and bilaterally. Poor perfusion is mostcritical in border zone or so-called watershed regions at the periphery of the major vascular-supply territories. Asymmetrical effects can result from preexisting vascular tensions,causing an uneven under perfusion.Local brain effects of Ischemia by all three above mentioned mechanism:- When blood flow to a brain region is reduced, survival of the at-risk tissue usuallydepends on the duration of compromised blood flow and the availability of collateralcirculation to the cells. Generally, the sooner circulation is restored to occluded neural tissue;the more likely ischemic damage can be reserved. Prolonged vascular blockage results inirreversible ischemic damage and cell death, an event termed infarction. Surrounding the core of infracted neural tissue is a region with reduced,but not entirely blocked, cerebral blood flow (CBF). This marginally profuse area is calledthe ischemic penumbra. Infracted neural tissue is characterized by local CBF below 10mL/100 g/min (normal CBF is approx. 50 mL/100 g/min.), where as CBF in the Penumbra ispresumed to be 10-20 mL/100 g/min. Scientists believe that infracted tissue cannot besaved but that the ischemic penumbra represents potentially reversibly damagedneural tissue. “Comparative Management study of Pakshaghata with Mashadi Yoga” 30
  42. 42. When neurons are rendered ischemic, a number of biochemical changes occurs whichpotentiate and enhance cell death: K+ moves across the cell membranes into the extra cellularspace and Ca ++ moves into the cell which ultimately leads to mitochondrial failure.Decreased O2 availability leads to production of oxygen free radicals, which causesperoxidation of fatty acid and severely damages the cell function. With decreasedoxygen availabity, anaerobic glycolysis leads to an accumulation of lactic acid and a decreasein pH. The resulting acidosis also greatly impairs cell metabolic functions. In regions ofischemia, concentrations of excitatory neurotransmitters especially glutamate isincreased which causes vulnerable neurons to receive toxic exposure to glutamateand there by increasing the likelihood of cell death. Glutamate entry opens membranes andincreases Na + & Ca ++ influx into cells. Large influxes of Na+ are followed by entry ofchloride ions and water, causing cell swelling and oedema. In chronic phase, glial scarsform and macrophages gradually ingest the necrotic tissue debris, within the infarct leading toshrinkage of the volume of the infracted tissue or a frank cavity. These afore mentioned local metabolic changes cause a self-perpetuatingcycle of changes that lead to increasing neuronal damage and cell death.INTRACRANIAL HAEMORRHAGE 76: This is the third most frequent cause of stroke. There are four varieties of intracranialhemorrhage – extradural, subdural, subarachnoid and intracerebral. The first two areinvariably traumatic.Intracerebral Haemorrhage – The term intracerebral hemorrhage describes bleeding directly into thebrain substance. The commonest cause of intracerebral arterial hemorrhage is rupture of anatheromatous artery in a hypertensive individual. Hypertension causes medialhypertrophy in small arteries and arterioles, which leads to degeneration of media andproduces a thickened but brittle vessel. Bleeding diatheses, vascular malformations, ruptureof saccular aneurysm and vasculopathies such as amyloid degeneration or “Comparative Management study of Pakshaghata with Mashadi Yoga” 31
  43. 43. segmental lipohyalinosis can also cause bleeding into the brain. The degree of damage willdepend on the location, rapidity, volume and pressure of the bleeding. The extravasations form a roughly circular or oval mass, which disrupts the tissueand grows in volume as the bleeding continues. Adjacent brain tissue is displaced andcompressed. Intracerebral hemorrhages are at first soft and dissect along whitematter fiber tracts. When bleeding dissects into the ventricles or onto the surface of thebrain, blood is introduced into the cerebrospinal fluid. The blood clots andsolidifies, causing swelling of adjacent brain tissues. Later the clot is absorbed, and isreplaced by a neuroglial scar or by a cavity containing yellow serous fluid. During absorptionof the clot, gliosis occurs in the wall of the cavity with phagocytosis of destroyed neuraltissue by compound granular corpuscles. Hemorrhage may be described as massive, small, slit and petechial. Massive refers tohemorrhages several centimeters in diameter; small applies to that 1 to 2 cmin diameter. Slit refers to hypertensive hemorrhage, which lies subcortically atthe junction of white and gray matter, and petechial are pinpoint hemorrhages.Subarachnoid hemorrhage: Here blood leaks out of the vascular bed onto the brain’s surface and is disseminatedquickly via the spinal fluid pathway into the spaces around the brain. The commonest causeis a ruptured aneurysm, which releases blood rapidly at systemic blood pressure;suddenly increasing intracranial pressure, where as bleeding from other causes isusually lower and at lower pressures.RUPA77When the disease is fully established there is full clinical manifestation, this is called Rupa ofthe disease . The characteristic symptoms and signs appear clearly in the fifthkriyakala, i.e., vyakti avastha of the disease. All eighty types of vata vyadhies have beenclassified under five main headings by some eminent scholars of Ayurveda, viz. (1)Akarmanyata Pradhana vata vyadhi, (2) Kampa Pradhan vata vyadhi, (3) Shoola Pradhana “Comparative Management study of Pakshaghata with Mashadi Yoga” 32
  44. 44. vata vyadhi, (4) Shosha Pradhana vata vyadhi and (5) Stambha Pradhana vata vyadhi. Pakshaghata is included mainly under the Akarmanyata Pradhana vata vyadhi because its cardinal feature is Cheshta Nivritti (Loss of voluntary functions of one side of the body). Though vata is dominant in this disease, the association of pitta and kapha also found. Various symptoms of Pakshaghata according to different Acharyas are tabulated below:- Rupa (Symptoms) According to various Acharyas: Table No. 4Sl Symptoms Ch. Su. A.H M.N Bh.P BS Y.R VR1 Akarmanyata /Chesta nivritti + + + + + + + -2 Paksha Hanana + + + + + + -3 Vichetana /Achetana - + + + + + + -4 Paksha Vimoksh - + - - - - - -5 Sandhi Bandhan Vimoksh - + + + + + + -6 Ruja + - - - - - - -7 Vakstambh + - - - - - - -8 Hasta Pada Sankoch + - - - - - - -9 Toda + - - - - - - -10 Shoola + - - - - - - -11 Patyasan - + - - - - -12 Kampa - - - - - - - +13 Daha/ Santap/ Murcha - - - + + + + -14 Shaitya/ Shotha/ Guruta - - - + + + + - Cheshta Nivritti / Sharirardha Akarmanyata: Loss of motor activity is known as cheshta nivritti. It is hallmark in the diagnosis of Pakshaghata. Exaggerated vata travels through the Urdhva, Adhaha and Tiryag dhamanis performing vishosh of sira and snayu, loosening their grip and thus leading to vaam or dakshinpaksha hanana.78 . Acharya Dalhana interprets ‘Akarmanyata’ as ‘Ishatkarmakshamam’ i.e. Partial loss of function of half of the body. He says that when there is Akarmanyata patient tends to fall. Vijayrakshita specifies ‘Ardh’ as Ardhanarishwarvat, affection of one side of the body; ‘Paksha’ as ‘Bahu, Kaksh, Parshvadi Parts’, Anyatra as left of right half; and Akarmanya as Ishatche 79 shtakshamaha. Arundatta while commenting gives the meaning of Akarmanya as less strength to perform the activities. 80.This cardinal feature is produced mainly due to vitiation of Prana and Vyana Vayu. The main seat of Prana vayu is Mastishka and is the controller “Comparative Management study of Pakshaghata with Mashadi Yoga” 33
  45. 45. 81of Buddhi, Hridaya, Indriya and Chitta. . All types of movements occur due to properfunctioning of Karmendriyas, which are governed by Pranavayu. Hence, inPakshaghata, the abnormality in the motor function (cheshta nivritti) is due toimpaired function of Prana vayu. The Vyana vayu controls the circulation of Rasa and Rakta and is also responsiblefor various types of movements, viz., Gati, Prasarana, Akunchana, etc. In abnormality ofVyana vayu, various movements of the body are either diminished or lost completely. Henceby the vitiation of Prana and Vyana vayu, loss of voluntary functions of one side of the bodytakes place. Akarmanyata may be attributed to shosh of nerves due raised levels of ruksha,shita, kahar gunas of Prana vayu and a fall in the levels of chala guna of vyan vayu. Pittavrittavyana leads to cheshta sanga 82. Udanavritta vyana leads to cheshta hani . Pittavritta vyanaresults in gatravikshepasanga. Kaphavritta vyana leads to gatisanga 83.Ardhakaya Vichetana / Sharirardha Achetana 84-85: Chetana means sensation or consciousness and achetana means loss of sensation orconsciousness. The term achetana has been used by Sushruta Acharya and vichetana byVagbhata. Acharya Dalhana interprets the word achetana as alpachetana – partial diminutionof sensation. He further says that the presence of this feature raises the mortality. . Gayadasinterprets it to be complete loss of chetana. Todara explains vichetana as Ishadsparshavignana, i.e., less sensation. Another commentator Chandra interprets it asvigata sangya which means loss of consciousness. Vijayarakshita’s opinion onvichetana is partial diminution of sensation, where tactile, etc. sensory functions aremaintained to some extent.By the sannikarsha of atma, mana, indriya and their artha,gyana or perception of sense is produced. (Ch. Su. 8/12). Hence when there is alteration inthis pathway or in mastishka – center of jnanendriyas, sensory impairment is produced.Achetana/Vichetana is caused by vitiation of Prana and Vyana vayu. Sensation is the functionof jnanendriya and vitiation of Prana vayu leads to Pancha jnanendriya 86Upaghata Vitiation of Vyana vayu leads to Anga suptata (loss of tactile sensation) . “Comparative Management study of Pakshaghata with Mashadi Yoga” 34
  46. 46. Hemiplegia with sensory loss on opposite side is seen in MCA occlusion. Sensory lossis also encountered in PCA occlusion, thalamic hemorrhage, etc.Sandhi Bandhana Vimoksha: Sushruta and Vagbhata have described this symptom. Sandhibandhanavimokshameans losseness/laxation of joints. As per the description given by Sushruta, when vitiatedvayu travels through Urdhavagami, Adhogami and Tiryagadhamanies, it loosens thesandhibandhana. Gayadas interprets word dhamani as snayu. Sandhibandhan is made up ofsnayu and shleshaka kapha in particular . Vimoksha is vishishtamoksha, i.e., laxation ofsnayu. Vimoksha means shlathikarana (Hemadri) or vimochayan (Dalhan), i.e.,sublaxation or dislocation of joints on the affected side. This may be due to fallin the level of snigdha guna of kapha due to rise in the ruksha guna of vata. In Modernscience, sublaxation of shoulder is described as a complication of stroke.Vakstambha: This symptom is mentioned by Acharya Charaka only in reference to Pakshaghata.Vak means speech and stambha means to stop, to arrest, to cease, etc. Henceobstruction in speech or loss of speech is vakstambha. Four types of deformities of speechhave been described in classics, viz. Mukatva, Gadagadatva, Minminatva and Vaksanga.According to the samprapti, anyone can occur. Vakstambha results due to vitiation of Pranaand Udana vayu. Vakpravritti is one of the important functions of Udanavayu. Due toabnormality of Udanavayu patient may suffer from this complaint. Kaphavritta Udana resultsin vakgraha. Usually the abnormality is present in the Indriyayatana where the vak indriyamoola is present. If the Pranavayu, which controls all the indriyas, is affected,then vakstambha may occur. According to site of the lesion in brain various disorders ofspeech and language like dysarrthria, aphasia, etc. occur.Ruja:- It is an associated symptom of Pakshaghata which is found on the affected side of thebody. Acharya Charaka mentions ruja as a symptom of Pakshaghata and toda and shoola as “Comparative Management study of Pakshaghata with Mashadi Yoga” 35
  47. 47. the symptoms of Ekanga roga. Ruja means pain and any kind of pain is always associatedwith vayu. ‘Santat Ruk’ has been mentioned as a symptom in Asthi-Majjagatavata inPakshaghata there is involvement of snayu and sira. When vayu gets aggravated insnayu, shoola is produced and when vayu gets aggravated in sira, manda ruja is 87produced Pittavritta Prana vayu also results in ruja Pain present is said to be a goodprognostic sign. While describing the prognosis of Pakshaghata it has been mentionedthat the patient should not be taken for the treatment if there is no pain. Pain isfound in RSDS (reflex sympathetic dystrophy syndrome), occurring as acomplication of stroke.Sira Snayu Vishosha: Acharya Charaka and Vagbhata have mentioned this symptom.Chakrapanidatt differentiates Ekangaroga and Pakshaghata and includes this symptomunder Ekanga roga, where as Vagbhata considers them as same. When sira and snayu areaffected by vitiated vayu, due to increased level of shita and rukshaguna of vayu, vishoshaof siraand snayu takes place and this results in kshaya. Sirasnayuvishosha represents itselfas stambha (rigidity), hasta pada sankocha (contraction), vakrata, etc.Daha/ Santapa/ Murcha: These are the pittanubandhit lakshanas of Pakshaghata. Acharya Charaka has statedthat though vata vyadhies are vata dominant diseases, still they are accompanied by theassociation of Pitta and Kapha 88. Acharya Sushruta has clearly stated that when vitiatedvata comes in association with pittadha, santap and murcha are produced89 Bhavaprakash states that ‘Daho Bahya’ and ‘Santapa Abhyantarah’. According toDalhana, daha, santap, etc. are produced due to increase in the level of ushana guna of pitta.In pittavritta saman vayu, daha is found.90. In pittavritta Vyana vayu daha is produced all overthe body, i.e., internal as well as external. Prana vayu when obstructed by pitta, Murcha isproduced. “Comparative Management study of Pakshaghata with Mashadi Yoga” 36
  48. 48. Shaitya/ Shoth/ Guruta: These are the kaphanubandhit symptoms of Pakshaghata. Acharya Sushruta says thatwhen vitiated vayu comes in contact with kapha, shaitya, shoth and guruta are produced.Both vayu and kapha have shita guna. So when both come in contact, the level of shita gunais increased and shaitya is manifested. Vitiation of vyana vayu results in shopha Gaurava is aproperty of kapha.Kampa: It is a vata nanatmajvikar due to elevation of Chala guna in chief and alsoan associant of snayu prapta vata There is physiological kshaya of shukra in old agepersons leading to Rasakshaya and vata prokopa, which manifests as kampa Inlesions of mid brain and thalamus, tremor, ataxia, and/or choreoathetoid movementsare encountered.SYMPTOMATOLOGY The common mode of expression of CVD is the stroke, defined as a sudden non-conclusive, focal neurological deficit. Hemiplegia stands as a classical sign of CVD in whichparalysis occurs of one side of the body affecting both arm and leg andsometimes face. Hemiplegia is most commonly seen in damage to the UMN above the levelof the foramen magnum. A discrete lesion of the spinal cord in the uppercervical region may produce hemiplegia but this is rare.CLINICAL FEATURES OF HEMIPLEGIA 1. STAGE OF ONSET :- If the responsible cerebral lesion is acute the paralysis is at first flaccid (Shockeffect). In complete hemiplegia the arm is affected more than the leg and thedistal movements suffer more than proximal ones. The lower face is more affected than theupper. The trunks muscular are weakened on the affected side but the ocular muscles andthose of mastication escape, as they have dual innervations from bothhemispheres. “Comparative Management study of Pakshaghata with Mashadi Yoga” 37
  49. 49. Determination of the side of hemiplegia in an unconscious patient – Away from the paralysed side – A transient conjugate deviation of the head and eyestowards the unparalysed side may be observed for a few days. On the hemiplegia side –  Check puffs out during respiration.  Nasolabial fold obliterated.  Corneal reflex diminished  Pain stimulation less effective  More absolute flaccidity of limbs (dropping test)  Paralysed leg extended and assumes position of external rotation while healthy one tends to be semi flexed.  Pupil large on the side of hemorrhage. Eyelid release test: Eye-lid slides down slowly after both the eyelids are pulled upand released simultaneously.  Temperature of paralysed side usually higher.In conscious patients – (On affected side)  Weakness of closure of the eyes and the orbicularis muscle  Weakness of the lower face when the patient is asked to show teeth with flattening of the nasolabial fold and the base of the tongue may be higher.  In slighter cases- weakness of dorsiflexion of the wrist and clumsiness of the fine finger movements with the thumb-finger test, weakness of the extensors of the fingers and elbow joint, and in the leg there is inability to dorsiflex the affected foot as powerfully as that on the unaffected side, with weakness of the flexors of the knee and hip.  The tendon reflexes may be abolished for some hours.2. Stage of Recovery (Residual Hemiplegia) :-In chronic progressive lesion and in stage of recovery of acute lesions there is:  Spasticity making its appearance of “Clasp-Knife” variety. Hence the tendon reflexes return, become greatly exaggerated and may be accompanied by clonus.  The abdominal and cremasteric reflexes on the affected side remain absent and the plantar response is clearly extensor. “Comparative Management study of Pakshaghata with Mashadi Yoga” 38

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