Efficacy of Āyurvedic treatment using Pañcakarma combined with balance exercises for disability and balance in progressive supranuclear palsy
A 55-year old lady already diagnosed with PSP presented at the Department of Pañcakarma in March 2012, with the chief complaints of inability to walk, falling over backward, memory loss (Smṛtikṣaya) and increased episodes of spontaneous laughing. Patient started complaining of memory loss since 2001 with minor incidents like: forgetting her keys, forgetting to mix salt in food etc., The memory loss gradually increased and by September 2010, she was not able to remember her signature. She also had complaints of falls along with balance and gait difficulties (Gati saṅga) since 2003. The problem persisted and the patient was referred to a neurologist where diagnosis of PSP was established. Past medical history included hypothyroidism and hypertension. Family history was not significant.\nOn observation, face was expressionless and mask-like. Patient had poor balance with the tendency to fall over backwards. On sitting, trunk deviation was seen towards right. She was able to walk only with support and gait was slow and wide based. Dysarthria (Vāk graha) was present but most of the words were comprehensible. Horizontal saccades were slow but vertical saccades were more affected. Downward gaze was hampered severely []. Neck rigidity was observed during extension. She used to fall abruptly on the chair while sitting down and was unable to get up from the chair without support. Postural stability was severely impaired with patient requiring assistance to stand still. Average sleep was less than 5 hours per day and patient complained of difficulty both in falling asleep and remaining asleep (Nidrā nāśa). Ocular examination revealed loss of upward and downward gaze. Blinking was severely affected with blink rate of less than one per minute. Patient was able to read, however the vision was blurred. Patient was assessed for cognitive impairment using Mini Mental Status Examination (MMSE) which showed mild deterioration of cognitive functions. Her ability to write was severely affected. Magnetic Resonance Imaging (MRI) revealed midbrain, frontal and cerebellar atrophy.\nAssessing subject on Āyurvedic parameters revealed her to be of Vāta-pittaja prakrti with madhyama samhanana (medium build) and normal Jatharāgni (appetite). History given by attendant was indicative of her anxious nature (Ati cintan) with habit of late night sleep (Rātri jāgarana). The symptoms observed like memory loss (Smritikshaya), spontaneous episodes of laughing and history as mentioned above were suggestive of Mano vāha as well as Rasa vāha srotas involvement.[]\nFor assessing disability, progressive supranuclear palsy rating scale (PSPRS) was used. It comprises of 28 items in six categories: daily activities (by history), behaviour, bulbar, ocular motor, limb motor and gait/midline. Scores range from 0 to 100. Inter-rater reliability is good, with intra-class correlation coefficient for the overall scale of 0.86 (95% CI 0.65-0.98).[] Balance was assessed by using Tetrax Interactive Balance System (IBS) posturography. It measures the anteroposterior and mediolateral sway of the patient under eight conditions (facing forwards eyes open, eyes closed; standing on foam with eyes open, eyes closed, stable standing eyes closed head rotated to right, left, back and forwards).\nAfter taking informed consent of the patient the treatment was started with Virecana karma (purgation). The classical process of Virecana was completed in 15 days. The allopathic treatment being taken by her then was stopped on the day of purgation and was restarted afterwards. From 16th day onwards, Mātrā basti, Śirobasti, and palliative treatment were started. Mātrā basti was given on alternate days for consecutive 3 months, while Śirobasti was given in two courses of three sittings each. Each session of Śirobasti comprises of 7 days. Between two sessions of Śirobasti, a compulsory break of seven days was given []. The palliative treatment was started in accordance with the treatment for Vāta vyādhi as described in classics and rejuvenation therapy[] []. Additional balance exercises were given to the patients under the supervision of physiotherapists[] [].