Abstract
Stroke due to intracerebral hemorrhage is the most destructive subtype often causing disabilities in survivors. Early motor recovery, improving quality of life and improved social participation are the key aspects of stroke rehabilitation. Ayurveda describes stroke as Pakshaghata and categorized it as a Vata dominant disease.
This case reports the effect of Ayurveda and Sri Lankan traditional medicine in post stroke rehabilitation of a 60-year-old male, known case of diabetes and hypertension with recent left sided hemiplegia due to hemorrhage in the basal ganglia and hemorrhage in the lateral ventricle.
Following initial management at a modern facility for three weeks, the patient received Ayurveda and Sri Lankan traditional interventions for three months in addition to conventional treatment. Improvement was monitored using visual analogue scale, improvement in neurological and motor functions, clinical parameters, quality of life with stroke specific quality of life index, and life satisfaction questionnaire.
Significant improvement in motor functions, muscle tone, rigidity and hyperreflexia were observed. Patient's bladder-bowel control and functional abilities also improved leading to better quality of life. Better control of blood pressure and glucose levels was also observed indicating positive outcomes of integration of Ayurveda with conventional therapy in such cases. No adverse effects were observed during the observation period.
This case report suggests that Ayurveda and folklore medicine may play an important role in improving neuromuscular functions, quality of life and speedy rehabilitation of stroke patients.
Keywords: Traditional and complementary medicine, Cerebrovascular accident, Hemiplegia, Panchkarma, Pakshaghata, Ayurveda
1. Introduction
Stroke is an important global health issue, ranking as the second leading cause of mortality accounting 6.2 million deaths in 2019 [1]. The incidence of cerebrovascular accidents (CVA) increases with age making it a pressing health challenge in geriatric population. Among various subtypes of stroke, intracerebral hemorrhage (ICH) is the most destructive subtype with greater risk to life [2]. The prevalence of ICH is relatively high accounting for about 10 % of all strokes, with 35–40 % of mortality rate within the first month after onset. Incidence rates of ICH are exceptionally high amongst Asians and African-American individuals [3]. Following ICH, complications such as seizures, recurrent bleeding, edema with mass effect, hydrocephalus, venous thromboembolic events, and hypo/hypertension may further pose difficulty in recovery [4]. Rehabilitation is an important but challenging aspect in the management of stroke patients, that aims for early motor recovery, improving quality of life and enhance social participation [5].
According to Ayurveda, Hemiplegia is called Pakshavadha or Pakshaghata and is categorized under Vata Vyadhi (diseases arising due to derangement of Vata). Ayurvedic management of Pakshaghata includes Panchakarma (five treatments in Ayurveda for detoxification) management, and Sanshamana Chikitsa (palliative treatment) [6]. This case reports the effect of Ayurveda and Sri Lankan traditional medicine on post-stroke rehabilitation that may provide valuable insights for management strategies of stroke patients as well as for future research.
1.1. Patient information
Sixty-year-old male having 20 years history of hypertension (HTN) and type 2 diabetes mellitus (DM), approached for Ayurveda treatment for left sided hemiplegia. The patient developed these symptoms three weeks prior due to intracranial hemorrhage that was diagnosed and initially managed for three weeks at District teaching hospital. Patient approached for the Ayurveda treatment at clinical trial unit of faculty of Indigenous medicine, University of Colombo, in National Ayurveda Hospital, Colombo, Sri Lanka.
1.2. Clinical findings
Patient's Glasgow coma score (GCS) was 12/15, eye-opening was spontaneous, orientation and memory were good, the speech was slurred with normally reactive pupils bilaterally. Power grade on the affected side was 0/5 with hypertonia. Tendon reflexes (biceps, triceps, supinator, knee, and ankle) were brisk on the affected side with a positive Babinski sign and clonus in left lower limb. There was an in-situ urethral catheter. Sensation for touch (hot and cold) was intact in both the limbs with distal symmetric sensory polyneuropathy in the lower limbs. The patient also complained about excessive weakness, difficulty in swallowing, and headache.
1.3. Computerized Tomography (CT) findings
CT head showed intracerebral hemorrhage (ICH) in the basal ganglia and intraventricular hemorrhage (IVH) in the lateral ventricle (Fig. 1). According to Ayurveda, the condition was diagnosed as Vama Parshava Pakshaghata (Left sided CVA).
Fig. 1.
ICH was seen at the right lateral ganglion, internal capsule and blood density were noted in the right basal ganglion and right lateral ventricle.
1.4. Prognosis
40 % stroke survivors are left with some degree of functional impairment [7]. Intracranial hemorrhage has the highest mortality rate presented with all other stroke subtypes [8]. Patients with IVH had poor outcomes. Cohort studies have reported that patients with IVH are nearly three times more likely to die than those without IVH [9].
Details of the recorded clinical observations are presented in Table 1.
Table 1.
Changes in neurological and motor function parameters from Day 1–90.
| Parameter | Day 1 | Day 15 | Day 30 | Day 60 | Day 90 |
| Visual Analogue Scale | |||||
| Loss of locomotion | 10 | 8 | 4 | 2 | 1 |
| Numbness | 7 | 5 | 3 | 2 | 2 |
| Slurred speech | 8 | 5 | 1 | 1 | 1 |
| Incontinence/retention of urine | 8 | 7 | 2 | 1 | 1 |
| Incontinence/retention of motion | 8 | 7 | 2 | 1 | 1 |
| Facial palsy | 6 | 4 | 1 | 1 | 1 |
| Motor function | |||||
| Spasticity | 5 | 4 | 3 | 2 | 1 |
| Power | 0 | +2 | +3 | +4 | +5 |
| Tone | Hyper | Hyper | Improved hyper | Normal | Normal |
| Spasm | No | No | No | No | No |
| Reflex | Hyper | Hyper | Normal | Normal | Normal |
| Wasting | None | None | None | None | None |
| Plantar reflex | Extensor | Extensor | Flexor | Flexor | Flexor |
| Clonus | Present | Reduced but present | Absent | Absent | Absent |
(Note: VAS scale range 10-1: 10-Negative and 1-Positive, Spasticity grades: 1-No increase muscle tone, 2- Slight increase muscle tone when joint is moved in flexion and extension, 3-Marked increased muscle tone but joint easily flexed, 4-Considerable increase in muscle tone and passive movements difficult, 5-Rigid in flexion or extension, Power grades: 0-Nil, 1-Flicker of movement, 2-Movement with gravity eliminated, 3-Movement against gravity, 4-Movement against minimal resistance, 5-Movement against maximum resistance).
1.5. Timeline
The patient had Ayurvedic treatment for three months. The timeline of the treatment is given in Table 2.
Table 2.
Timeline of the health events and treatment.
| Health Event | Timeline |
|---|---|
| Episode of left sided hemiplegia, CT of the brain detected ICH and IVH | 2021 April 28 to May 03 |
| Managed at District hospital | |
| Managed at District rehabilitation hospital | 2021 May 04 to May 16 |
| Approached for Ayurveda treatment | 2021 May 17 |
| Assessment and examination done. The treatment regime first started | 2021 May 18 |
| Assessment on first follow-up and treatment regime two started | 2021 June 01 |
| Assessment on second follow-up and treatment regime three started. Follow-up CT of the brain was advised | 2021 June 15 |
| Assessment on third follow-up and fourth treatment regime started | 2021 July 15 |
| Assessment on fourth follow-up and fifth treatment regime started | 2021 August 15 |
1.6. Therapeutic intervention
The patient was managed on the line of treatment of Vata Vyadhi (diseases due to derangement of Vata) Treatment plan included oral medications, Panchakarma procedures, dietary modifications, and passive and active movements of the affected side for 90 days. Some of the formulations used for the treatment are used in Sri Lankan folklore practice [[10], [11], [12]]. Details of the interventions are presented in Table 3.
Table 3.
Therapeutic interventions given during treatment period.
| Treatment Regimen | Duration | Drug | Dose and frequency | Time of Administration | Route of Administration |
|---|---|---|---|---|---|
| One | Day 1–15 | Denibabebatuadi decoction with Seetharama Vati | 60ml and 250 mg respectively twice a day | 6.00 a.m. | Oral |
| Mathabruhatidalu Anupanaya with Buddharaja Kalka | 60ml and 500mg respectively twice a day | 8.00 a.m. | Oral | ||
| Brihatvata Chintamani Rasa | 125mg twice a day | 8.00 a.m. | Oral | ||
| Vataviduranga Taila | 30 ml once a day | 10.00 a.m. | Topical application on affected side | ||
| Two | Day 16–30 | Dashamoola Bala Eranda decoction | 60 ml twice a day | 6.00 a.m. | Oral |
| Mathabruhathidalu Anupanaya with Buddharaja Kalka | 60ml and 500mg respectively twice a day | 8.00 a.m. | Oral | ||
| Yogaraja Guggulu | 500mg twice a day | 8.00 a.m. | Oral | ||
| Dashamoola Niruha Basti with Anuvasana Basti with Narayana Taila | 500 ml and 60 ml respectively once daily for 16 days | 11.30a.m and 1.30 p.m. | Per rectal | ||
| Vataviduranga Taila with Narayana Taila | 30 ml once day | 10.00 a.m. | Topical application | ||
| Three | Day 31–45 | Rasnavishwavidangadi decoction | 60 ml twice a day | 6.00 a.m. | Oral |
| Mathabruhathidalu Anupanaya | 60 ml twice a day | 8.00 a.m. | Oral | ||
| Yogaraja Guggulu | 500 mg twice a day | 8.00 a.m. | Oral | ||
| Narayana Taila with Mahamasha Taila | 30 ml once a day | 10.00am | Topical application | ||
| Four | Day 46–60 | Ashwagandhabalathisruadi decoction 120ml | 60 ml twice a day | 6.00 a.m. | Oral |
| Mathabruhathidalu Anupanaya | 60 ml twice a day | 8.00 a.m. | Oral | ||
| Yogaraja Guggulu | 500 mg twice a day | 8.00 a.m. | Oral | ||
| Mahamasha Taila with Ashwagandha Taila | 30 ml once a day | 10.00a.m. | Topical application | ||
| Five | Day 61–90 | Mashabaladi decoction | 60 ml twice a day | 6.00 a.m. | Oral |
| Yogaraja Guggulu | 500 mg twice a day | 8.00 a.m. | Oral | ||
| Ashwagandha Taila | 30 ml once a day | 10.00 a.m. | Topical application |
Note: Decoction and Dalu Anupana were prepared by the patient (see ). Raw herbs for the preparation of decoction were purchased from the market along with other medicines).
1.7. Mathabruhatidalu Anupanaya and method of preparation
Traditional physicians in Sri Lanka use Mathabruhatidalu Anupanaya in the early stage of Pakshaghata which is believed to purify the vitiated Dosha in the Srotasa (circulatory channels). The ingredients of the formula are presented in Annexure Table 1. Additionally, Buddharaja Kalka (paste prepared from the herbs) (Annexure Table-2) is consumed with Mathabruhatidalu Anupanaya to achieve better therapeutic benefits. For preparation of Mathabruhatidalu Anupanaya the ingredients are tied in cotton cloth Potalis and are steamed till the aroma of herbs is felt, then the Potalis are squeezed to extract the juice. The extracted juice is mixed with 2.5 ml bee's honey, 1.5 g of sugar, 1.25 ml of Tila Taila, and 500mg of Buddharaja Kalka. Total 120 ml of the drug was prepared which is consumed in the dose of 60 ml twice a day [13]. The details of other medications are provided in the annexure.
1.8. Basti protocol
Kaala Basti (course of sixteen therapeutic enema) was employed using Dashamoola Niruha Basti (therapeutic decoction enema) and Narayana Taila Anuvasana Basti (a form of unctuous enema) (with 5g of Shatahva (Anethum graveolens L.) paste. Niruha Basti (600ml) was given before the meals, whereas Anuvasana Basti (60ml) was given after the meals. Whole body Abhyanga (therapeutic oil massage) and Svedana (sudation therapy) by Dashamoola Nadi Svedana were done for 16 days.
1.9. Follow-up and outcomes
The patient was followed up and observed for the treatment outcomes over a period of three months. During this period, the treatment was well tolerated, with no adverse reactions observed.
1.10. Observation of quality of life (QoL)
QoL was assessed using the five-point graded scale of Stroke-specific quality of life index (SS-QOL) [14] and the six-point graded life satisfaction questionnaire (LISAT-11) [15].
The assessment was done on day 1, day 15, day 30, day 60, and day 90. Improvement was observed across all the domains (Table 5).
Assessment using the SS-QOL scale revealed progressive and clinically significant improvements across multiple functional and psychosocial domains over the 90-day intervention period. The total score improved from 96/390 (24.6 %) on Day 1–334/390 (85.6 %) on Day 90, reflecting an overall improvement of 61 %. Upper extremity function showed significant recovery, improving from 9/45 at baseline to 40/45 (68.8 %). The energy domain improved markedly from 4/20 to 20/20, reflecting a complete restoration (80 %). Similarly, improvements were seen in personality (from 4/20 to 18/20; 70 %), language (from 7/35 to 30/35; 65.7 %), and mood (from 8/40 to 34/40; 65 %). Cognitive improvements were evident in the thinking domain, which rose from 5/20 to 18/20 (65 %), while functional recovery in work/productivity increased from 3/15 to 13/15 (66.6 %).
Scores on the LISAT-11 also demonstrated consistent improvement across nearly all domains of life satisfaction. The total score increased from 11/66 at baseline to 51/66 at Day 90, indicating a 60 % improvement in overall life satisfaction. Prominent improvements were observed in self-care management from 1/6 to 6/6 (83 %), psychological situation from 1/6 to 6/6 (83 %), partner relationships, family life, and Physical health each improved by 66.6 %, leisure situation, contact with friends, and sexual life each improved by 50 %.
1.11. CT imaging
CT imaging were performed on day 1 and day 45 by the radiologists. Reported findings of both the CT scan are given in Fig. 1, Fig. 2.
Fig. 2.
After 45 days, no acute intracerebral hemorrhage was seen and resolved right thalamic intracerebral hemorrhage, and hypodensity was seen in right Thalamus.
1.12. Hematological parameters and blood pressure
During the initial observation, systolic and diastolic blood pressure was 160/100 mmHg that came down to 140/90 mmHg after three months of treatment. Similarly, fasting blood sugar recorded during initial assessment was 220 mg/dl which showed noticeable reduction to 126mg/dl after three months. It is important to mention that during the treatment period, patient was advised to continue his antihypertensive and anti-diabetic medications which he was taking earlier. With the addition of Ayurvedic treatment better control of blood pressure and blood sugar levels were observed.
2. Discussion
The ultimate goal of rehabilitation in hemorrhagic stroke is to reduce the disability, regain independence and improve the quality of life [16]. In the present case, after management of acute stage for twenty-one days with allopathic treatment, a combination of Basti (therapeutic enema), combination of Ayurveda and Sri Lankan folklore oral medications along with dietary modifications was given to the patient for a period of three months. Dietary recommendations included the intake of light, easily digestible foods when hungry, while avoiding stale, fried, packaged, and dairy-dominant items.
Significant gradual improvement in motor functions was seen during the period of observation. Improvement in muscle tone, rigidity and hyperreflexia was seen that suggests better muscular strength and control which is beneficial for early rehabilitation in a case of stroke. Additionally, bladder-bowel control and functional abilities of the patient improved, and patient was able to carry out his routine physical activities with less difficulty. Moreover, quality of life was improved by more than sixty percent and was present across all domains of SS-QOLS (Table 5). An initial average quality of life score of 24.6 % improved significantly to 85.6 % over the course of treatment, reflecting a substantial reduction in patient dependency from a severely dependent to a moderately dependent functional state [17]. Ayurvedic treatment also lead to better control of blood pressure and glucose which connotes the better outcomes of integration of Ayurveda with conventional therapy in such cases.
According to Ayurveda, Pakshaghata (hemiplegia) is a Vata dominant condition with involvement of Kapha & Pitta, its treatment principles revolve around restoring the balance of Vata Dosha. Abhyanga (therapeutic oil massage), Svedana (sudation therapy) and Basti (therapeutic enema) are the prime beneficial Ayurvedic therapeutic procedures to control the vitiated Vata. In this case, Shodhana (treatment modality based on the principle of removal of vitiated Dosha) and Shamana Basti along with internal medication mainly focusing on the Vata were employed. Most ingredients of Niruha Basti (therapeutic decoction enema) possess Shodana (bio-purificatory) properties, aiding in the elimination of accumulated Dosha (morbid bio-elements). In contrast, the components of Anuvasana Basti (unctuous enema) primarily exhibit Shamana (pacifying) properties, helping to soothe aggravated Vata. [18]. In this case, average retention time of Shodhana and Shamana Basti was 37 minutes and 413 minutes (Table 4), respectively, which implies that the Shodhana Basti largely helped in evacuating the rectum and colon, whereas Anuvasana Basti was retained for significant duration, getting in the systemic circulation and producing generalized therapeutic effect. The beneficial effects of Basti treatment has been reported in improving the motor functions, early recovery as well as in improving quality of life of such cases [19,20].
Table −5.
Improvement in Stroke-specific quality of life scale and life satisfaction questionnaire over a 90 day treatment period.
| Parameter |
Number of items |
Day 1 |
Day 15 |
Day 30 |
Day 60 |
Day 90 |
Improvement % |
|---|---|---|---|---|---|---|---|
| Stroke-specific quality of life scale (SS-QOL) | |||||||
| Energy (4) | 4 | 4/20 | 8/20 | 12/20 | 16/20 | 20/20 | 80 |
| Family roles (8) | 8 | 8/40 | 18/40 | 20/40 | 26/40 | 30/40 | 55 |
| Language | 7 | 7/35 | 16/35 | 22/35 | 24/35 | 30/35 | 65.7 |
| Mobility | 12 | 12/60 | 30/60 | 36/60 | 42/60 | 50/60 | 63.3 |
| Mood | 8 | 8/40 | 20/40 | 24/40 | 28/40 | 34/40 | 65 |
| Personality | 4 | 4/20 | 8/20 | 12/20 | 16/20 | 18/20 | 70 |
| Self-care | 8 | 9/40 | 20/40 | 24/40 | 28/40 | 35/40 | 65 |
| Social roles | 7 | 7/35 | 16/35 | 22/35 | 24/35 | 26/35 | 54 |
| Thinking | 4 | 5/20 | 8/20 | 14/20 | 16/20 | 18/20 | 65 |
| Upper extremity function | 9 | 9/45 | 22/45 | 28/45 | 34/45 | 40/45 | 68.8 |
| Vision | 4 | 20/20 | 20/20 | 20/20 | 20/20 | 20/20 | 0 |
| Work or productivity | 3 | 3/15 | 4/15 | 8/15 | 10/15 | 13/15 | 66.6 |
| Total | 78 | 96/390 | 190/390 | 242/390 | 284/390 | 334/390 | 61 |
| Percentage (%) | 24.6 | 48.7 | 62.1 | 72.8 | 85.6 | ||
| Life satisfaction questionnaire (LISAT-11) | |||||||
| Life as a whole | 1/6 | 2/6 | 3/6 | 4/6 | 5/6 | 66.6 | |
| Vocational situation | 1/6 | 1/6 | 1/6 | 2/6 | 3/6 | 33.3 | |
| Financial situation | 1/6 | 1/6 | 1/6 | 2/6 | 4/6 | 50 | |
| Leisure situation | 1/6 | 1/6 | 2/6 | 3/6 | 4/6 | 50 | |
| Contact with friends | 1/6 | 1/6 | 2/6 | 3/6 | 4/6 | 50 | |
| Sexual life | 1/6 | 1/6 | 2/6 | 3/6 | 4/6 | 50 | |
| Self-care management | 1/6 | 2/6 | 3/6 | 4/6 | 6/6 | 83 | |
| Family life | 1/6 | 1/6 | 2/6 | 3/6 | 5/6 | 66.6 | |
| Partner relationships | 1/6 | 2/6 | 3/6 | 4/6 | 5/6 | 66.6 | |
| Physical health | 1/6 | 2/6 | 3/6 | 4/6 | 5/6 | 66.6 | |
| Psychological situation | 1/6 | 2/6 | 3/6 | 5/6 | 6/6 | 83 | |
| Total | 11/66 | 15/66 | 21/66 | 34/66 | 51/66 | 60 | |
Responses of LISAT-11 are marked as 1-Very dissatisfying, 2-Dissatisfying, 3-Rather dissatisfying, 4-Rather satisfying, 5-Satisfying, 6-Very satisfying.
Table 4.
Retention time of Basti.
| Basti Type | Retention time in minutes (Mean ± SD) | Minimum retention time in minutes | Maximum retention time in minutes | Retention time Range in minutes |
|---|---|---|---|---|
| Narayana Taila Anuvasana Basti | 413.00 ± 128.8 | 295 | 720 | 425 |
| Dashamoola Niruha Basti | 37.00 ± 11.58 | 15 | 47 | 32 |
Drugs that were used internally are also having targeted action primarily on deranged Vata, majority of the drugs were having Deepana (improving the digestive fire), Ama Pachana (digestion of harmful metabolic residues), Srotoshodhana (circulatory channel purification) and Vata pacifying properties. Mathabruhatidalu Anupana also known as Dalu Beheth is used in combination with Buddharaja Kalka for the treatment of Pakshaghata (hemiplegia). This combination is believed to uniquely act on three Marma (three vital organs viz. heart, brain and genitourinary system). Seetarama Vati and Deniba Debatu decoction are also commonly used by Sri Lankan traditional healers for Pakshaghata management. These medications help to pacify vitiated Vata and Kapha. Moreover, Seetarama Vati having Vata pacifying properties due to their Ushna and Tikshna properties may help to relieve the symptoms [21]. Brihatvata Chintamani Rasa is a herbo-mineral Rasayana drug used in Ayurveda practice for Vata related disorders which has the evidence of its neuroprotective and antioxidant activity. Kashaya (decoctions) used during the treatment period contain ingredients like Dashamoola, Ashwagandha, Bala, Eranda, etc. which are having Brimhana (nourishing) and Vata pacifying properties. These drugs have antioxidant, anti-inflammatory, neuroprotective, cognition improving actions [22]. Ashwagandha has been reported to have neuroprotective and cognition improvement effect due to its ability to prevent oxidative damage induced apoptosis [23,24].
Oils used for the Abhyanga (therapeutic massage) in this case are primarily Vata pacifying and provide nourishment and strength to the tissue. Abhyanga followed by Svedana are helpful in improving the rigidity and regaining the motor functions of the affected parts. Probably, medicated oils used in Abhyanga improved the neuromuscular stimulation of the hypertonic and paresthesia affected muscles and helped in regaining the power, improving the range of motion, maintaining the balance and ambulation [25].
3. Conclusion
Overall, the combination of Ayurvedic and Sri Lankan folklore medication has shown significant effect in rehabilitation of a case of hemorrhagic stroke. Possibly improvement in neuromuscular functions and quality of life was the outcome of combination of Ayurvedic Panchakarma procedures and internal medication. It is important to mention that during the treatment period no adverse effects were observed which suggests the safety aspect of the treatment modalities employed in the present case. However, as these observations are collected from a single case and hence, they need to be studied further with positive control arm in larger number of subjects to make further inferences of the treatment. A systematic series of case reports, incorporating plausible biological mechanisms and comparative analysis with cases not managed through Ayurveda or Sri Lankan traditional medicine, could provide valuable insights into the therapeutic potential of these interventions.
Informed consent
Patient gave the informed consent for the treatment as well as publication of the treatment outcomes.
Patient perspective
The patient was satisfied with the Ayurveda treatment protocol. Patient believes that with this treatment regimens recovery of the patient was fast. He also reported improvement in energy levels and was satisfied with the results.
Author Contribution
AMHS: Conceptualization, Methodology, Software, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. UMGD: Conceptualization, Methodology, Formal analysis, Writing – original draft. PKP: Conceptualization, Methodology, Formal analysis, Writing – review & editing, Visualization. AU: Conceptualization, Methodology, Software, Formal analysis, Writing – review & editing, Visualization. AKS.: Conceptualization, Methodology.
Data availability statement
Data that support the findings of this study are available from the corresponding author upon reasonable request.
Declaration of generative AI in scientific writing
No data and part of manuscript has been generated from any of the generative AI tools.
Funding sources
None.
Declaration of competing interest
The authors declare that they have no competing financial interests or personal relationships that could have influenced the work presented in this paper. Although one of the authors (PKP) is a member of J-AIM Editorial Board, he was not involved in peer review process and editorial decisions related to this paper
Acknowledgment
We thank the patient and the patient's family for permitting us to publish the article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data that support the findings of this study are available from the corresponding author upon reasonable request.