Management of Pakshaghat (Stroke) Using Panchakarma Therapies: A Case Report & Review

Introduction

India is a developing country that faces the dual burden of communicable disease and non-communicable disease. Among non-communicable diseases, stroke is one of the leading causes of death and disability. The estimated adjusted prevalence rates of stroke are 84-262/100,000 in rural areas and 334-424/100,000 in urban areas. The incidence rate is 119-145/100,000 based on recent population-based studies in India.¹ Stroke increases the economic burden on family members due to death or permanent disability of the affected person. Common symptoms include numbness or weakness in the face, arm, or leg, especially on one side of the body, difficulty in speaking, problems with walking or coordination. It may be correlated to Pakshaghat, mentioned in Vata Vyadhi in Ayurvedic Samhita, having symptoms like loss of function of right or left part of the body, pain and aphasia.² While there is no specific treatment indicated in biomedicine, stroke can be managed with specific Panchakarma therapies, which have shown significant results.

Case Presentation

A male patient aged 41 years visited the OPD of Panchakarma, on 14/11/18 (OPD No. 7914112018) presenting with complaints of weakness and rigidity on right upper and lower limbs, difficulty in walking and slurred speech for the past 1.5 years. After clinical examination, the subject initially presented with a Saama condition.

However, upon conducting Asthavidha Pariksha, the patient was found to have Kaphavritta Jivha. After a ten-fold examination, the subject was recommended to receive Vatakapha Prakriti (physical constitution), Madhyama Samhanana (medium body constitution), Madhyam Sara (medium purest body tissue), Avara Vyayam Shakti (lowest ability to perform physical activities), Madhyama Abhyavarana, and Jaranashakti (middle dietary intake and digestive power). It was noted that the patient had Rasavaha and Mansavaha Srotodushti (Vitiation in micro-channels associated to circulatory sys tem and muscle tissues). Examining additional micro channels using Srotasa Pariksha indicated that the other Srotasas were in normal condition.

Ashtavidha Pariksha

Nadi Pariksha revealed a Vata-Kapha predominant, slow, and weak pulse. Mala and Mootra Pariksha indicated Vata-Kapha imbalance and Kapha dominance, respectively, with hard, dry stool and cloudy, odorous urine. Jivha and Drik Pariksha further confirmed Kapha dominance through a coated tongue and dull, watery eyes. Slurred speech (Shabda Pariksha) and cold, rough skin (Sparsha Pariksha) pointed to Vata Kapha imbalance. Akriti Pariksha showed a medium build with a tendency toward obesity, suggesting Kapha dominance. The patient initially presented with a Saama condition (presence of toxins). Srotasa Pariksha revealed Rasavaha and Mansavaha Srotodushti, indicating disturbances in circulatory and muscular channels. Additionally, Avarana (obstruction) was noted in Prana Vata and Vyana Vata pathways, reflecting impaired circulation and neuromuscular activity.

History of Present Illness

The subject suddenly lost consciousness on August 4, 2017, and was subsequently admitted to the ICU of an allopathic hospital for emergency management. Upon regaining consciousness, he was found to have paralysis on the right side of his body. He reportedly took allopathic medication continuously for 1.5 years but experienced no significant improvement in the right sided body movements, weakness, or walking ability.

Clinical Findings Summary

Systemic Examination:

• Pulse: 78 bpm

• Blood Pressure: 130/80 mmHg

• Respiratory System: Bilateral air entry clear

• Cardiovascular: S1 and S2 audible, no added sounds

• Abdomen: Soft, non-tender, no organomegaly; scaphoid shape

Neurological Examination:

• General Appearance: Alert, anxious, mild slurred speech, right-sided facial asymmetry

• Cranial Nerves:

• CN I-II: Normal
• CN III, IV, VI: Normal pupils and eye movements
• CN V: Decreased right facial sensation
• CN VII: Right-sided facial droop, incomplete eye closure
• CN VIII: Normal hearing
• CN IX, X: Mild dysphagia, slightly diminished right gag reflex
• CN XI: Weak right shoulder shrug
• CN XII: Tongue deviates slightly right

• Motor System: 

• Normal muscle bulk
• Right-sided spasticity, exaggerated reflexes, positive Babinski
• Power: Right UL 1/5, LL 3/5 o Gait: Hemiplegic

• Sensory System:

• Decreased pain, temperature, proprioception on right
• Impaired two-point discrimination and graphesthesia

• Coordination: 

• Mild right dysmetria, impaired heel-shin test, unable to walk unaided o No cerebellar signs
• No cerebellar signs or

• Autonomic:

• Mild hypertension, no bladder/bowel issues

Physical & Panchakarma Fitness:

• No congenital deformities or spinal abnormalities

• Vitals stable for Swedana Karma

• Rectal tone normal for Basti

• Sensory nerves: Normal across all modalities

• Motor nerves: Normal nutrition, decreased tone, brisk knee jerk (++), no primitive reflexes

Imaging and Diagnosis:

• MRI Brain: Acute bilateral medial medullary infarct

• CT Angiography: Right vertebral artery stenosis

Therapeutic Interventions with Timeline

Treatment protocol

Firstly, the patient was explained about the Panchakarma therapy and its necessity for the treatment. A detailed description of Panchakarma therapy and palliative medicine is provided in Tables 1, 2 and 3. Table 4 shows the grading criteria, Table 5 presents the assessment parameters and timeline, and Table 6 displays the before treatment (BT) and after-treatment (AT) results.

The patient underwent a 16-day course of Mushtadi Yapana Basti, with Pratyagamana Kāla (retention time) progressively varying between 20 to 45 minutes. Initially, retention time increased from 20 minutes on Day 1 to a peak of 45 minutes on Days 8, 12, and 16, indicating improved tolerance and therapeutic response over the treatment period.

*Rasa Aushadhi was discontinued after 30 days. A 10 day gap was given, after which all Rasa Aushadi were reintroduced during the treatmentx

The patient's progress was assessed using a symptom grading scale across key neurological and functional domains:

• Muscle Power was evaluated on a 0-5 scale (0 = complete paralysis; 5 = normal power).
• Reflexes were graded from 0-5, ranging from absent reflexes (0) to sustained clonus (5).
• Walking Capacity was scored from 0-3, with 0 indicating inability to walk and 3 representing normal walking ability
• Standing from Sitting was assessed on a 0-3 scale, from requiring firm support (1) to standing independently (3).
• Speech was graded from 0-4, capturing progression from aphasia (0) to normal speech (4).

Outcomes

The subject had been experiencing weakness and rigidity in the right upper and lower limbs, difficulty in walking, and slurred speech for the past 1.5 years. According to the assessment parameters, the subject’s muscle power was 2/5 at the time of admission and improved to 4/5 post-treatment. The knee jerk reflex was 3/5 at admission and improved to 4/5 post-treatment. Walking capacity was initially 1/5 and improved to 2/5, while the ability to stand from a sitting position also improved from 1/5 to 2/5.

Following Ayurveda interventions and Panchakarma modalities, the patient showed improvement in muscle power in the right upper and lower limbs, increased walking time and capacity, reduced heaviness in the affected area, and was able to walk approximately 20 30 minutes without support. There was improvement from slurred speech to the ability to speak in 1-3 sentences. Overall, the patient demonstrated significant improvement following the treatment. Notably, there was enhanced muscle strength, improved reflexes, and reduced muscle tone. However, certain signs and symptoms remained unchanged, including persistent fatigue, occasional muscle spasms, and slight numbness in the affected limb. Despite these residual effects, the patient reported improved overall functionality and a better quality of life, indicating a positive response to the treatment.

Discussion

The subject had a history of smoking, which is a well established risk factor for stroke.³ There are two main types of cerebrovascular accidents (strokes): ischemic brain damage and the intracranial hemorrhage.⁴ Pakshaghat has been mentioned as Vata Vyadhi in different Samhitas, and the line of treatment is Swedana and Snigdha Virechana.² In the present case, the stroke was due to ischemic brain damage, and vitiation of Vata Dosha was identified as the primary cause for paralysis. Therefore the prime concern was Vata-Shamana.

Justification for Kala Basti course

Kala Basti is a specific type of Basti (enema) therapy that is indicated for Vata-dominated conditions, such as Pakshaghat (stroke). The patient's symptoms, such as weakness, stiffness, and difficulty walking, are indicative of Vata imbalance. Kala Basti helps to balance Vata Dosha, nourish the nervous system, and promote muscle strength and tone.

Justification for repeated frequency of Kala Basti

The patient's condition required repeated treatment sessions to achieve optimal results. Kala Basti is typically given in a course of 8-10 sessions, administered every other day. This frequency allows for consistent and sustained improvement in the patient's symptoms.

Justification for selection of Shashtika Shali Pinda Sweda

Shashtika Shali Pinda Sweda is a type of Snigdha Sweda (oil-based fomentation) that is specifically indicated for Vata-dominated conditions. The use of Shali (rice) in the Sweda helps to nourish and strengthen the muscles and nervous system. Pinda Sweda (bolus fomentation) helps relax muscles, improve circulation, and reduce stiffness. Shashtika Shali Pinda Sweda was chosen over other Snigdha Sweda due to specific benefits in addressing the patient's Vata-dominated symptoms.

Yogaraja Guggulu is indicated in the management of Vata Vyadhi (neurological and musculoskeletal disorder). Dashmoola Kwath possesses analgesic, anti-inflammatory, and anti-platelet properties, and thus is recommended for Pakshaghat.⁵ Ashwagandha also has Rasayan Guna, Balya, and Vata-Kapha Shamak properties.^6,7 Nagaradhya Churna is a combination of Shunthi and Kupilu. Shunthi is Pachana, Kapha & Vatahar, and also possess Shoola and Shothahar properties. Kupilu possesses analgesic, anti-inflammatory and antioxidant properties. Ashwagandharist has Balya properties.^8,9,10 Dashmoolarista is indicated in Vata-Vyadhi, Shoola, Kshaya, Mandagni and Dhatukshaya conditions.¹¹ Ekangaveera Ras is Vata-Kapha Shamaka and Shrotoshodhaka. Rasrajeshwar Ras contains ingredients such as Rasraj Ras, Kuchla, Aswagandha, Rassindoor, and Guggulu.^11,12 It possesses Balya and Vata Shamaka properties and is indicated in Pakshaghat, particularly beneficial in Vatika disorders. Triphala Churna is known for its diverse effects, including appetite stimulation, reduction of hyper acidity, antioxidant, anti-inflammatory, immunomodulating, antibacterial, antimutagenic and adaptogenic properties.¹³

Snehana and Swedana are the first line of treatment in Vata-Vyadhi. Shalishastika Pinda Swedana, a type of Pinda-Sweda mentioned in the Charak Samhita, is beneficial in Vata Vyadhi.¹⁴ It helps strengthen weakened muscles. Shali Pinda Shastika Sweda is a part of Snigdha Sankar Sweda. It reduces stiffness because of the massage and heat applied in the affected region. The muscles gain strength from the nutrients absorbed through the Shastika Shali. As the sweat pores open, metabolic waste is eliminated. Improved blood flow further facilitates relaxation and enhances the range of motion.¹⁵

Basti is considered the most effective treatment modality for managing Vata-Vyadhi.¹⁶ Mushtadi Rajyapana Basti is one of the important treatment modalities used to pacify vitiated Vata, possessing Balya, Sanjeevani, Vrisya and Shoolanasana properties.¹⁷ For enhancing strength, Vrishya (fertility), and Jeevana Shakti (vigour or quality life), Mushtadi Yapana Basti is recommended. It helps relieve discomfort in the calf and thigh region, and is beneficial in Vatarakta (a variety of rheumatic spectrum diseases), Katishoola (low back soreness), and Sopha (inflammation or pseudohypertrophy). It possesses Rasayana characteristics. With its ability to remove obstructions, purify channels, and deplete Dhatus owing to its Brumhana nature, it can disrupt the aetiology of the illness. The majority of muscle, bone, and bone marrow disorders can be managed with Mushtadi Yapana Basti.¹⁸

Nasya is also mentioned in Vata-Vyadhi, Ksheerabaladi Taila, and is used to treat arthritis, central nervous system disorders and insomnia.¹⁹ Nasya with Kshirabala Taila helps in the elimination of Vata- Kapha Dosha and clears obstruction in the channels to pacify vitiated Vata.²⁰

Conclusion

• Pakshaghat has multiple etiological factors; in this case, the primary cause was a stroke (acute bilateral medial medullary infarct).
• The Ayurvedic treatment protocol employed in this case resulted in significant improvement and proved highly beneficial for the condition.
• Although this is a single case study, it highlights considerable potential for further research in this area.
• Larger group studies are necessary to establish standardized treatment protocols.

Conflict of Interest

None

Financial Support

None

Informed Consent

Informed consent was taken from patient.

Patient Perspective

"I am really happy with the progress I've made since the beginning of treatment. The special Ayurvedic massage has helped me feel stronger and enabled me to do things on my own. I can now perform tasks with much ease and confidence. I am experiencing fewer muscle spasms and less pain, which has resulted in better sleep and increased energy. I am grateful to my healthcare team for their kindness and expertise.

Acknowledgements

The Authors would like to thank the subject for giving his consent to participate in this case study and for his kind cooperation during the treatment period.