DMD in ayurveda

Annals of Ayurvedic Medicine Vol-11 Issue-1 Jul.-Sep., 2022 243
Review Article
Ayurveda interventions in the management of Duchenne Muscular
Dystrophy – A Review
Vijay Kumar Pathak, Arun Kumar Mahapatra , Rajagopala S.
Dept. of Kaumarabhritya, All India Institute of Ayurveda, Sarita Vihar, Delhi.
Corresponding Author’s Email: rpvvvijay@gmail.com
Date of Submission: 4 Sep 2021 || Date of Acceptance: 26 Jun 2022
Abstract
Duchenne Muscular Dystrophy (DMD) is a heterogeneous group of inherited disorders caused due to mutation in the gene
for the protein dystrophin, located on the short arm of the X chromosome in the Xp21 region. It is characterized by proximal
muscle weakness, calf hypertrophy, frequently developing contractures, and loss of walking by the 2nd
decade. Patients are
predisposed to severe, fatal pulmonary infections and lose their lives due to dysfunction of muscles involving the respiratory
system. The incidence is 1 in 5000 live boys. Objective: To review existing human case reports and clinical trials for
treating Duchenne muscular dystrophy through the Panchakarma interventions. Design: The literature research comprised
an electronic database from January 2000 to April 2021. The study included MEDLINE, PubMed, The Cochrane Library,
Google scholar, Ayush research portal and DHARA database. Search terms were used “Duchenne muscular dystrophy”,
“Ayurveda”, “Panchakarma”, “DMD” No limits were used. The search strategy was adapted for each database as necessary.
Only trials on humans were included in the patient review. The study applied inclusion criteria while screening the records.
Intervention: Treatment with any regimen of “Panchakarma”. Outcome measures: Number and results of studies identified
in the review. Results: Seventeen articles were screened; Eight human trials met inclusion criteria. Ayurvedic Panchakarma
based procedures effectively relieve the signs and symptoms and reduce the CPK level in children with DMD. There are only
few studies published inAyurveda in the management of DMD. The Conventional System of medicine andAyurveda System
of medicine are at the same level in the case of DMD for therapeutic purposes as there is no permanent cure for this disease
in both systems. Acombined approach should be made to manage this disease with the conventional method of medicine and
Ayurveda. The integrative approach could open new hope for patients of DMD, and it is a need of time.
Key words: Duchenne Muscular Dystrophy, Dystrophin, Panchakarma, Ayurveda, Serum CPK
How to Cite This Article:
Pathak VK, Mahapatra AK, Rajagopala S., Ayurveda interventions in the management of Duchenne Muscular Dystrophy –
A Review, Annals Ayurvedic Med. 2022;11(3) 243-255, 10.5455/AAM 119753
Introduction
Duchenne Muscular Dystrophy (DMD) is an X linked
disorder that results in a progressive decline in muscle
function and, when left untreated, leads to loss of
ambulation (LoA) by age 10–12 years. Death occurs from
cardiac or respiratory failure by approximately 18-25
years of age[1]
. Mutations causing DMD disrupt the
dystrophin messenger RNA (mRNA) reading frame and
prevent the production of functional dystrophin[2]
.
Dystrophin protein loss leads to susceptibility to repeated
cycles of necrosis and regeneration as well as diminished
regenerative muscle capacity, resulting in fat and
connective tissue replacement[4]
. Behavioural studies have
shown that DMD boys have a cognitive impairment and
a lower IQ (average 85)[37]
. DMD is the most common
form of muscular dystrophy, with an incidence of about
1 in 5000 live boys[3]
. There is no exact co-relation of
this disease in Ayurveda. This disease in Ayurveda is
classified as Aadibalapravrita (Inherited diseases),
Shukra-shonita dosha[8]
(Gametes), Bijabhagavayay
dushtijanya[9]
Vyadhi (Genetic disorder), and takes
Sthanasamshraya[10]
(Situated) primarily in Mamsa Dhatu
(Muscle tissue), vitiation of Vata leads to Mamsa-
dhatvagni[11]
and Medodhatvagni[11]
impairment which in
turn forms dysfunctional Mamsa Dhatu and accumulation

of abnormal tissue Meda Dhatu (Adipose tissue) in place
of Mamsa Dhatu. This dysfunctional Mamsa Dhatu is
unable to perform Prakrita Karma[12]
of Mamsa Dhatu
that is Sharira Pushti[12]
, Meda Dhatu Pushti[12]
, and shows
symptoms of Mamsa Dhatu Kshaya[5][6[7]
(Decreased
muscle tissue) Gatranam Sadanam[6]
(paresthesia),
Dhamni shaithilya[6]
(Loose and flabby arteries), Aksha
glani [7]
(debility of the sense organs), Sandhi Vedana[7]
(pain in the joints), Sphik Griva Shushyata[5]
(Muscle
wasting in hip and cervical region). Impaired
Dhatwagni[14]
(Metabolic enzymes) causes the improper
formation of Uttarottara Dhatu[15]
(Subsequent dhatu
formation). This also leads to the formation of Ama[16]
(Undigested metabolic product), Sanga Srotodushti[13]
and
Vimarga Gamana[13]
of Vata and consequently depletion
of Mamsa Dhatu and progressive wasting and necrosis
of the affected muscle fibres takes place. Based upon the
end result of DMD, it can be categorized under the
Paurasadini Jaataharini[36]
(in which the affected child
dies before 16 years of age). In the modern system of
medicine, there is no permanent cure for this disease, and
currently, steroids are prescribed. This opens the door
for Ayurveda to develop a proper protocol for managing
this disease based on its principle. In this scenario,
standardized management protocol based on the
Ayurvedic principle is the need of the hour.
Methods
Eligibility criteria: Case report, Case series, Randomized
Controlled Trials (RCTs), Non-Randomized Controlled
Clinical Trials (CCTs) were eligible. No language
restrictions were applied.
Types of participants: Studies on paediatric population
(Below 18 years) with DMD diagnosed as per diagnostic
criteria were eligible.
Type of interventions : Interventions were included in
the study explicitly mentioned ayurvedic intervention in
the respective publication.
Control : Studies comparing ayurvedic interventions to
usual care or any active control intervention were eligible.
Studies comparing different ayurvedic interventions were
also eligible.
Types of outcome measures : For inclusion, studies had
to assess at least one important patient-centred outcome
measure of DMD, i.e., serumCPK level, physical function
as assessed by muscle power, generic health-related
quality of life.
Search methods: The literature research comprised an
electronic database from period January 2000 to April
2021. The research comprised MEDLINE, PubMed, The
Cochrane library, Google scholar, Ayush research portal
and DHARA database.
Search term were used “Duchenne muscular dystrophy”,
“Ayurveda”, “Panchakarma”, “DMD” No limits were
used. The search strategy was adapted for each database
as necessary. Only trials on humans were included in the
present review.
Research studies identified during the literature search
were reviewed by authors independently. Eligible articles
were read in full to analyze whether they met the eligibility
criteria.
Data extraction and management: Two authors
independently extracted data on study design,
intervention, outcome and results using a prior developed
data extraction form.
Result
A total of 14 records were returned from the
comprehensive database search. In addition, three
documents were identified through sources outside of the
core search through general Google searching. Atotal of
8 records were screened for eligibility that met inclusion
criteria and was selected for the systematic review. The
figure further depicts the selection process of the studies.
Pathak V.K. et.al. : Ayurveda interventions in the management of Duchenne....

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram of
search results from a systematic review.
Figure 1
Table showing studies included in qualitative synthesis after using PRISMA guideline

Discussion
In DMD patients, CPK is highly elevated compared to
the normal range, which has diagnostic value[73]
. Higher
CPK values are associated with greater burden on the
kidneys, developing acute renal failure, severe electrolyte
abnormalities, acid base disturbances and resulting in
significant morbidity[74]
, excess of CPK act as endotoxin
in the body and can be considered as Visha in Ayurveda.
A total of eight studies were reviewed and reduction in
serum CPK by 56.81%[23]
, 97.15%[20]
, 36.36%[25]
,
95.53%[22]
, 72.05%[21]
, 97.47%[24]
, respectively were
observed in these studies. In two of the studies[19][18]
assessment of serum CPK was not done. Minimum
duration for study duration reported as 25 days[19]
,and

maximum study duration was 2 years[21]
. Seven studies
were case reports and one was a single arm clinical study
with 30 participants. Oral medication used in studies
having action mainly as Rasayana (rejuvenator and anti-
ageing), Balya- Daurbalyahara (strength promoting),
Vatahara (pacifying aggravated Vata Dosha),
Snayudaurbalya-nashaka (providing strength to tendons,
muscles), Deepana,-Pachana (digestion improvement),
Hridya (Cardioprotective), Shoolanashaka (pain reliver),
Medhya (nootropics), Swasha-kasa nashaka (drugs
improving breathing difficulties) and Vishaghna
(removes/decreases endotoxins) Table 2, depicts actions
of drugs. In two studies[18][19]
no internal medication was
used. One study[20]
shown 5 years long follow up of DMD
patient, where patient mother taught about the
Panchakarma procedure and was asked to follow the
treatment and repeat the cycle every year till child gets
fully benefitted, at the age of 19 years patient was fully
independent. Relapse of disease not described in above
studies (Table 1).

Term Panchakarma is made of two words ‘Pancha’means
‘five’ and ‘Karma’ means ‘procedure’. It involves
Vamana, Virechana, Nasya, Basti, and Raktamokshana.
While performing procedure it consists of three phases:
Poorva Karma, Pradhana Karma and Paschat Karma.
Udwartana[17]
is the Rookshana Poorvakarma, it helps in
reduction of vitiated Kapha by its dryness-inducing and
blockage-removing properties. Once Aavarana[30]
is
removed, vitiated Vata can be pacified by further
treatment. Most of the clinical trials have used Udwartana
in the management of DMD[18][21][23][25]
. Udwartana can
help in normalizing lipid profile also in reduction of
weight; BMI, body circumference and skin fold thikness
in case of dyslipidemia[26]
. Abhyanga[27]
(Massage) comes
under Poorvakarma it improves blood supply to muscles,
stimulates sensory nerve endings of the skin, reduces
muscular fatigue and pain[28]
and stiffness. Abhyanga
massage is useful in reducing subjective stress[29]
.Here
all studies have included Abhyanga as a therapeutic
procedure in DMD. Swedana[31]
is Sthambhagna,
Gauravanigraha, and Kapha-Vata nirodhaka. Swedana
drugs by Ushna and Tikshnaguna are capable of
penetrating the microcirculatory channels (Srotas) where
they activate the sweat glands to produce more heat. Only
pinda and dhara form of Swedana Shashtika Shali Pinda
Sweda[18][19][20][21][22][23][25]
, Taila dhara[21]
, Dhanyamla
sarvanga dhara[18]
is used in DMD. Basti is best
treatment[32]
for Vata Dosha, it having Vayah Sthapana
Guna[34]
(checks aging process), Shishuvriddha Yunah[34]
(Benificial for children, adults and old aged patient), Bala
pradaha[34]
(Gives strength) Rasayana (rejuvenating)
property, the immensely number of nerves which located
in enteric nerves system (ENS) can get nourished directly
by using Basti with Rasayana, Balya, Vatahara guna. So,
using Basti in DMD, muscles get proper nourishment and
muscle weakness can be decreased[33]
different form of
Basti used in DMD is Matra Basti[24][18]
, Yoga Basti[20][21]
,
Yapana Basti[21]
, Kala Basti[22][24]
, Mamsa Rasa Basti[25]
,
Anuvasana Sneha Basti[23]
, Tiktakshira basti[20]
, Majja
basti[20]
, Dashamooladi Niruha basti[24]
, Balamooladi
basti[19]
. Virechana is Malapaham[35]
(help in
detoxification) which lead to better absorption of drugs,
Jwalanasya diptm[35]
(correct Agni)
Balavarnaprasadanam[35]
(improve strength and
complexion). Virechana[23]
is also used in DMD, using
Balya, Rasayana drugs as internal administration after
virechana in DMD can be beneficial in order to correct
Mamsa-Medo dhatwagni Mandya and can help in
formation of more Mamsa dhatu (Muscle tissue). Nasya[20]
is also used in DMD, it is said to be entry point of brain

inAyurveda, cognitive impairment associated with DMD
can be managed by using Nasya. There was no adverse
effect of internal medication as well as Panchakarma
procedure is reported in above studies.
Schematic representation of possible action of Ayurveda interventions in DMD
(Figure : 2)
In DMD there is disbalance in formation and destruction
of muscle tissue (Mamsa Dhatu), Increased destruction
leads to clinical sign and symptom of DMD. The vitiated
Vata and Kapha dosha in DMD patients blocks the
Mamsvavaha Srotas (Channels) and prevents the
formation of Prakrita Mamsa Dhatu (Healthy muscle
tissues), these vitiated Doshas i.e., Vaikruta Dosha in
turn produces contracture, spasticity in tendons, muscles,
and cartilages. Udwartana helps in removing the blockage
and help in reducing contracture and spasticity. Abhyanga
and Swedana bring mriduta (Softness) in local applied
area, promotes muscle movement, increase muscle power
and help in mobilization of joints. Basti act on Vatasthana
and pacifies vitiated Vata dosha which is responsible for
deranged Mamsa dhatwagni and helps in formation of
more healthy muscle tissue (Mamsa Dhatu). Virechana
removes toxins from body and bring Jatharagni to normal
functioning state, Jatharagni is responsible for
functioning of all seven Dhatwagni.
Lacuna
There are only few published studies available in
Ayurveda for the management of DMD, most of them
are Case Reports, there is no Randomised Controlled
Clinical Trial (RCT) available on DMD inAyurveda, and
also no study published with large number of subjects
too. There is a need to conduct more clinical trials in
Ayurveda on the management of DMD in robust manner.
In above studies (Table 1) only Serum CPK, Muscle
power, Activity of daily life is used for therapeutic
assessment, where in DMD heart and diaphragm become
necrotic[71]
, so serumCK-MB (Creatine kinase-MB), ECG
(electrocardiogram), spirometry evaluation can also be
used in assessment parameters. Some boys with DMD
having non progressing cognitive dysfunction, with
deficits in verbal, short-term, and working memory[72]
,
assessment of cognition can also be done.
Conclusion
The disease DMD described in conventional system of
medicine having no exact correlation in Ayurveda text,
based on sign and symptom of this disease it is classified
as Aadibalapravrita Sukrashonitadosha

Bijbhagavayavadushtijanya Vyadhi, it also resembles as
Paurasadini Jaataharini. This is a genetic disease and
having no treatment in conventional system. Articles in
table shows effectiveness of Ayurvedic Panchakarma
based procedures in relieving the signs and symptoms
and reducing the CPK in children with DMD.
Conventional System of medicine and Ayurveda System
of medicine both are at same level in case of DMD for
therapeutic purpose as there is no permanent cure to this
disease in both systems. Hence, combined approach
should be done for management of this disease with
conventional system of medicine andAyurveda and such
integrative approach could open new hope for patient of
DMD and it is a need of time.
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Report. Am J Case Rep. 2017;18:746-749.
Published 2017 Jul 4. doi:10.12659/ajcr.905089.
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Source of Support : Nil
Conflict of Interest : None

DMD in ayurveda

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DMD in ayurveda