Role of Ayurveda in the Management of Guillain-Barré Syndrome Case Study

Guillain-Barré syndrome (GBS) is a peripheral neuropathy with acute onset, and characterized by rapidly developing motor weakness. It is autoimmune in nature and triggered by a preceding infection. A 48 years old female patient was brought with complaints of paralysis of all the four limbs (quadriplegia), back pain and pain in the right lower limb since one month. She was previously treated in tertiary care hospital with IV Immunoglobulin and plasmapheresis but showed no improvement. So she admitted and treated in Mahatma Gandhi Ayurved College Hospital & Research Centre, Salod (H) Wardha on 21.06.2018. In Ayurveda , there is no direct description of this disease but this condition can be correlated with Sarvanga vata (vata affecting all parts of the body), hence she was treated following principles of Vatavyadhi chikitsa which include Abhyanga (Oleation therapy) , Swedana (Fomentation), Matrabasti (enema with medicated oil), Nasya (Nasal medicated oil administration) and various herbomineral formulations for 51 days. Along with this physiotherapy and Trans Electrical Nerve Stimulation was also applied. Significant results were observed in the form of improvement in the muscle power from zero to four for all the four limbs with improvement in her general condition as well as daily activities


Introduction
Guillain Barré syndrome (GBS) is an acute, frequently severe, and fulminant polyradiculoneuropathy that is autoimmune in nature. It occurs year-round at a rate of between 1 and 4 cases per 100,000 annually; in the United States, ~5000-6000 cases occur per year. Males are at slightly higher risk for GBS than females. GBS manifests as a rapidly evolving are flexic motor paralysis with or without sensory disturbance. The usual pattern is an ascending paralysis that may be first noticed as rubbery legs. Weakness typically evolves over hours to a few days and is frequently accompanied by tingling dysesthesias in the extremities. The legs are usually more affected than the arms, and facial diparesis is present in 50% of affected individuals. Pain in the neck, shoulder, back or diffusely over the spine is also common in the early stages of GBS, occurring in ~50% of patients. Approximately 70% of cases of GBS occur 1-3 weeks after an acute infectious process, usually respiratory or gastrointestinal (1).
Treatment of GBS according to Modern Medicine includes Intravenous Immunoglobulin and Plasma pheresis which both are expensive (2).Hence there is need of cost effective treatment, which improves the Quality of Life in the patients having no side effects.
In Ayurveda no such disease is described but on the basis of symptoms this condition can be correlated with Sarvanga vata that is vata affecting all parts of the body. It is described in snayugata dushta vata lakshana by A charya Charak in V atavyadhi chikitsa adhyaya. In Vatavyadhi predominance of vata dosha is present hence the principles of V atavyadhi chikitsa can be used in treating this condition (3). It includes Snehana (oleation therapy), Swedana (fomentation), Shashtika shali pinda sweda (4). (sudation using a shashtika rice cooked in milk and Balakwath), Basti (Medicated enema), Nasya (administration of medicated oil in nostrils) and use of vatahar formulations.

Case Report
A 48 years old female patient (OPD No-1806210096-21/06/18) was brought with complaints of paralysis of all the four limbs (quadriplegia). She also had complaints of back pain and pain in the right lower limb since one month. She had increase frequency of micturition. She was a known case of hypertension and was taking treatment for the same regularly since 3 years. She was also taking medicines for Diabetes mellitus since one month.

Past history
Patient was alright before one month. She had fever and loose motion and took medicines for the same from family physician for 3-4 days. Later on she started feeling weakness in both lower limbs. The weakness progressed into both upper limbs as well. The intensity of the weakness gradually increased. After 2-3 days she seeked advice of a medical specialist and hence went a tertiary care unit. Meanwhile she also developed difficulty in breathing. There she was investigated for Electromyelogram (EMG), Nerve Conduction Velocity (NCV) and MRI. She also underwent blood and other

Examination of patient on admission-Ashtavidhapariksha
The patient's pulse was vatakapha predominant and tongue was saam (coated). She had sthula akruti (obese) having weight 78kg. She was catheterized with No. 16 Foley's catheter.

General examination
The general condition of patient was moderate, she was afebrile with pulse rate 110/min, Blood pressure 130/80 mm Hg and respiratory rate 18/min. Her chest movements were normal and equal on both sides.

Systemic examination
In the systemic examination, findings of respiratory and cardiovascular system were within normal limits. Abdomen was mildly distended, nontender and bowel sounds were present. Patient was conscious, well oriented with time and place and responding well to commands. Pupillary reaction to light was normal. Examination of cranial nerves was normal. Muscle atrophy was absent. Muscle fasciculations and irritability absent. Involuntary movements were absent. Muscle tone -All four limbs flaccid.  (areflexia)  Clonus -absent  Co-ordination -can't be elicited.

Investigations
Routine investigations of blood, urine, liver function, renal functions, serum electrolytes, CPK were within normal limits.
CT-Scan of brain and MRI lumbar spine was normal.
Electromyogram and Nerve Conduction Velocity showed symmetrical sensory motor axonal polyradiculoneuropathy affecting both UL & LL.

Result and Observations
Improvement in Symptoms Before and After Treatment was noted. Patient admitted on 21.06.2018. Above treatment was started and continued for 51 days. Patient was assessed weekly and improvement was noted as following.

Discussion
GBS is an Autoimmune Disease. In modern medicine pathogenesis in the demyelinating forms of GBS, the basis for flaccid paralysis and sensory disturbance is conduction block. This finding, demonstrable electrophysiologically, implies that the axonal connections remain intact. Hence, recovery can take place rapidly as remyelination occurs. In severe cases of demyelinating GBS, secondary axonal degeneration usually occurs; its extent can be estimated electrophysiologically.
More secondary axonal degeneration correlates with a slower rate of recovery and a greater degree of residual disability. When a severe primary axonal pattern is encountered electrophysiologically, the implication is that axons have degenerated and become disconnected from their targets, specifically the neuromuscular junctions, and must therefore regenerate for recovery to take place. In motor axonal cases in which recovery is rapid, the lesion is thought to be localized to preterminal motor branches, allowing regeneration and reinnervation to take place quickly. Alternatively, in mild cases, collateral sprouting and reinnervation from surviving motor axons near the neuromuscular junction may begin to reestablish physiologic continuity with muscle cells over a period of several months (7).
There is no direct reference of GBS in A yurveda classics but according to its clinical features, and involvement of the doshas and dushyas it can be correlated with Sarvanga V atvvyadhi. The 'Vaat' is described as "Vaa Gati Gandhanayoh" wherein 'Gati' represents 'Motor function and 'Gandhana' represents International Journal of Ayurvedic Medicine, 2018, 9(4), 288-292 ISSN: 0976-5921 'Sensory function. Samprapti of this mainly involves predominance of V aat Dosha, as entire Nervous System is under the Control of V ata it is mainly responsible for all movements in the body. Hence, correction of V ata is very important in treatment of GB syndrome. Hence this case of GB syndrome was treated by using V atavyadhi chikitsa sutra.The main chikitsa of Vatavyadhi includes bahya Snehana, Swedana, Basti and Vatahar chikitsa using various herbomineral formulations (8).
For A bhyanga Ashwagandha bala taila was used. It alleviates vatadosha, it is pushtikara (strength promoter) and Jarahar (prevents aging). Considering the vitiation of vata doṣha and dhatukshaya Vatahar and balya taila was selected and movements were performed in anuloma gati which reduces its chalaguna (property to move) causing inability to transmit nerve impulses (9).
Shashtika shali pinda Sweda helps in nourishment of muscles and in improvement of the movements. It is a type of Brimhana Sweda (nourishment) having Vatahara (vata alleviating) and Balya (Strength promoter) property. Its ingredients like milk and Shashtika Shali nourishes and gives strength to muscle tissues. Bala and A shwagandha gives nourishment to nervous tissues. During application of taila the heat is generated which causes vasodialation, because of which the blood circulation improves causing removal of waste products. Improvement in blood circulation helps in nutrition of muscle tissues. It decreases stiffness of muscles and increases strength and flexibility of muscles which helps in improving movements (10). Skin i.e. Sparshanendriya is considered as the site of Vata. Hence Shashtika shali pinda sweda when applied directly on the skin lead to the correction of the deranged V ata, which helps in correction of the impaired functions (11). Shashtika shali pinda sweda (fomentation using Shashtikashali rice cooked in milk processed with Bala (Sida cordifolia Linn.) and Ashwagandha (Withania somnifera Linn.) was used. All ingredients of the pindasweda, ksheer (milk), Shashtika shali and Balamula have santarpana qualities (Antioxidantant and nourishing) and is indicated for balya (strenghthening), brimhana (nourishing) of dhatus with alleviation of vata . Shashtika shali helps in opening up of blocks in nerve conduction and facilitates remyelination of nerves which helps in transmitting nerve impulses (12,13).
Basti (medicated enema) is an effective treatment for vata. It also brings about anulomana ( Downward movement) of vata. Matrabasti is a type of abhyantar snehana which helps in pacifying Vatadosha. Ashwagandha taila matrabasti 50ml was given for 15 days. This route of administration of medication also facilitates its rapid absorption. A shwagandha is balya, rasayana and gives strength to nerves . Nasya is the route of administration of drugs through nose as it reaches to the brain and eliminates the morbid doshas responsible for producing the vyadhi (14).
Nasya is indicated in all Urdhvajatrugata vikara (diseases of upper part). Diseases of spinal cords and roots can be considered under Urdhvajatrugata vikara. Nasya can be given in neurological disorder in which muscle wasting and muscular weakness is present.
Ksheerabala taila is used in this case which rapidly get absorbed and causes bruhana and helps in alleviation of vatadosha in urdhvajatrugata part (15).
Capsule Palsineuron contains Mahavatavidhwansa, Samirpannaga, Ekangvir rasa, Khursani Ova (Hyoscyamus niger Linn.), Lajjalu (Mimosa pudica Linn.) manufactured by SG Phyto Pharma Pvt. Ltd., Kolhapur. It manily works on neuromuscular disorders. Mahavatvidhwansa improves metabolic processes in CNS and PNS, activates neuromuscular communication, Sameerpannag improves tissue oxidation and regulates blood supply in affected areas, Ekangveer Ras promotes healing of damaged nerves and blood vessels, Sootshekhar Rasa provides nutritional support for faster healing of damaged tissues. Lajjalu has regenerative effect on neuro-lesions. Khurasani Owa checks neuro-irritation. Due to properties of these ingredients it is indicated in cases of neuro-muscular disorders of CNS and PNS, hemiplegia, general paralysis, facial paralysis, hand shoulder syndrome, convulsions, whole body stiffness, sciatica, nerve injury, neuralgia (nerve pain), cramps in calf, myalgia (muscle pain), Migraine and other neurodegenerative disorders (17,18,19).
Guduchi (Tinospora cordifolia (Willd) Miers ex Hook. F. & Thoms) and A shwagandha (Withania somnifera Linn.) both have balya and Rasayana properties which helps in strengthening and promoting bulk of muscle tissue. It has immunomodulatary action, which helps in correcting immune dysfunction of the body and helps in reducing stress (20,21) . Physiotherapies like passive exercises, passive assisted exercises and resistive exercises were started when patient was in complete bedridden condition. Later on strengthening exercises for quadriceps, hamstrings, deltoid and biceps muscles along with calf muscle stretching exercises were given. After gaining muscle strength of lower limbs and when patient started to stand with support, co-ordination exercises, knee balancing and ankle balancing exercises started. Studies have shown that physical fitness can positively influence not only outcomes such as mobility and fatigue levels in GBS patients (GBSPs) but also mental functioning (22,23). Along with this Electrical nerve stimulation for lower back, upper and lower limb was started which helps in reducing pain (24).
Significant results were observed in the form of improvement in the muscle power.The muscle power was zero in all four extremities at the time of admission which improved to four after treatment with improvement in general condition of patient. According

Sadhana Misar Wajpeyi, Role of Ayurveda in the Management of Guillain-Barré Syndrome
ISSN: 0976-5921 to modern medicine, it takes several months to year in patients of GBS to achieve full functional recovery (25). In this patient recovery was seen in one and half months, which suggests the rapid recovery due to favorable effects of management of principles given in Ayurveda.

Conclusion
Guillain Barre syndrome can be compared with Sarvanga Vatavyadhi. From this case study it can be concluded that GB syndrome can be effectively treated with using V atavyadhi chikitsa sutra like A bhyanga, Shashtika shali pinda sweda, Basti, Nasya and various herbomineral formulations like Brihatavatachintamani rasa, Ekangvir rasa, Guduchi and Ashwagandha. Physiotherapy and Trans Electrical Nerve Stimulation also have prime role in improving condition GB syndrome patient. All this treatment is cost effective and having minimum or no side effects and if given adjuvant to Modern medicine showed rapid improvement. This is a single case study so to prove effectiveness of chikitsa principles it should be conducted on large sample size for long duration of time.