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   Table of Contents     
CASE REPORT  
Year : 2022  |  Volume : 15  |  Issue : 2  |  Page : 168-172
Integrative approach improves fall risk and postural stability in spinocerebellar ataxia-2 – A case report


1 Department of Integrative Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Physiotherapy and Neurorehabilitation, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

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Date of Submission16-Mar-2022
Date of Decision19-Apr-2022
Date of Acceptance02-May-2022
Date of Web Publication5-Sep-2022
 

   Abstract 


Spinocerebellar ataxias (SCAs) comprise a large heterogeneous group of autosomal dominant cerebellar ataxias. Despite availability of various conventional treatments, reducing disability and improving the quality of life is a challenge in this condition. In the present case report, based on the clinical symptoms and site of pathology, an Ayurveda-based diagnosis of kaphavruta vayana and kaphavruta udana was considered. Therapeutic measures such as rookshana (drying therapy), vatahara (measures to pacifying vata), balya (strengthening), and brimhana (nourishing) regimens were adopted along with oral medications and specific yoga practices. The objective of the treatment was to improve stability, posture, and balance. After 10 weeks of integrative treatment, a demonstrable improvement was observed in scale for assessment and rating of ataxia Scale for the Assessment and Rating of Ataxia (SARA), fall risk, and limit of stability (using computerized dynamic posturography). Hence, an integrated Ayurveda and Yoga-based lifestyle regimen may serve as a useful adjuvant in improving fall risk and limit of stability in patients with SCAs.

Keywords: Fall risk, Panchakarma, postural stability, spinocerebellar ataxia, Vata Vyadhi

How to cite this article:
Kulamarva K, Chikkanna U, Ramakrishna KK, Bhargav H, Velayutham SG, Varambally S. Integrative approach improves fall risk and postural stability in spinocerebellar ataxia-2 – A case report. Int J Yoga 2022;15:168-72

How to cite this URL:
Kulamarva K, Chikkanna U, Ramakrishna KK, Bhargav H, Velayutham SG, Varambally S. Integrative approach improves fall risk and postural stability in spinocerebellar ataxia-2 – A case report. Int J Yoga [serial online] 2022 [cited 2022 Sep 27];15:168-72. Available from: https://www.ijoy.org.in/text.asp?2022/15/2/168/355602



   Introduction Top


Spinocerebellar ataxia (SCA) is a group of hereditary ataxias characterized by slowly progressive incoordination of gait often associated with poor coordination of hands, speech, and eye movements. The core pathology involved in SCA is progressive degeneration of the cerebellum. SCA is associated with recessive or dominant genetic inheritance with a global prevalence of 3 in 100,000.[1] Despite various treatment options available with conventional medicine, the search for effective disease-modifying therapies is still continuing.[2] Hence, there is a need to explore traditional systems of medicine for SCA. There are few case reports on Ayurveda management in SCA, but this is the first case report that reports satisfactory outcomes based on postural stability and fall risk indexes measured on dynamic posturography. The primary focus of the management was aimed to improve coordination. SCA can be considered under the preview of vatavyadhi (~ neurological disorders) in Ayurveda. Due to gait and speech disturbance, in this case, a diagnosis of kaphavruta vayana (~ movement disorders) and kahavruta udana (~ speech disorders) was considered.


   Patient Information Top


A 59-year-old male working as a supervisor in the fabric industry came to the Outpatient Department of Integrative Medicine, NIMHANS Hospital with complaints of difficulty in maintaining balance and swaying toward the right side when walking for the past 2 and ½ years. The patient had slurring of speech, sleep disturbance, tremors of both the hands, and difficulty in writing. He also reported an episode of fall. The patient is a known case of type 2 diabetes mellitus for the past 1 year, and a history revealed that he had rapid eye movement sleep behavior disorder. In 2019, the patient had consulted the Neurology Department, NIMHANS, and he was diagnosed with late-onset SCA-2/multiple system atrophy-cerebellar. Conservative treatment (tablet amantadine hydrochloride 100 mg twice daily and tablet clonazepam 0.25 mg once daily) was advised. The patient sought treatment through integrative medicine (Ayurveda and Yoga) approaches for improving his gait and balance.

Clinical findings and diagnostic assessment

Clinical findings

The patient was conscious and oriented. Gait examination revealed intermittent swaying toward the right side and reduced arm swing on the right side. Cranial nerve examination showed slow movement of the tongue, suggesting the involvement of hypoglossal nerve. The speech was dysarthric (poor pronunciation of words and change in rhythm), and hypermetric saccades with reduced blink rate were observed on ocular examination. Muscle bulk, tone, and power were within normal limits for all four limbs. The patient was unable to perform tandem walking and Romberg's sign was positive. Among the tests for coordination, the patient was not able to perform finger–nose test, knee–heel–shin test, and had dysdiadochokinesia. Sensory examination for pain, pressure, vibration, position, and discriminative sensation was found to be normal, and the plantar response was equivocal. Dynamic posturography suggested fall risk and postural instability [Figure 1], [Figure 2], [Figure 3].
Figure 1: Fall risk test progress report

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Figure 2: Postural stability progress report

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Figure 3: Limits of stability progress report

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Ayurveda perspective

Prakruthi (Ayurveda-based physical and mental constitution) of the patient was of kapha-vata type. Other Ayurveda clinical parameters were as follows: (1) digestive fire (agni) – irregular (vishamagni); (2) body symmetry (pramana), nourishment, and constitution of tissues (SARA) – medium (madhyama); (3) Satmya (suitability of the body and daily routine), sattva (mental strength), and samhanana (built) – medium (madhyama); (4) physical endurance capacity (vyayamashakti) – Avara (low); and (5) Aharashakti (food intake) and jaraanshakti (digestive power) – medium (madhyama). Predominant dosha involved was vata (attribute related to movement) associated with kapha (attribute related to body integrity). Dhatu (tissue elements) involved were rasa (fluid tissue of the body) and majja dhatu (mastishka majja/brain tissue).

Ayurveda-based pathophysiological understanding and diagnosis

Gadgadatwa (slurred speech), anidra (insomnia) and kampa (tremors), Gatisanga (restriction of movement/difficulty in walking) and adhoshakha guruta (heaviness of lower limbs) suggested impaired functions of vyana (~ Motor functions) and udana (~ Speech) vata. Symptoms such as Vak swara graha (impaired speech), Dhourbalya (weakness), Guru gatrata (heaviness of body), and Gatisanga (restriction of movement/difficulty in walking) are observed in kaphavruta vayana and kaphavruta udana. Hence, based on the clinical symptoms and site of pathology, the diagnosis of kaphavruta vayana and kahavruta udana was considered. As the diseases involved Marma (Brain) and chronicity was more than 1 year, it was considered under Yapya Vyadhi (A condition which can be managed through Palliative care).

Treatment plan

The management was aimed at improving the coordination and balance. Initially, Rookshana (measures which induce dryness in the body) to remove avarana (blockage of movement of vata by kapha) followed by vatahara (measures which pacifying vata imbalance), Balya (strengthening), and Brimhana (nourishing) along with oral medications and yoga practices specifically, to improve stability, posture, and balance, were adopted. The details of the ayurvedic medications and Panchakarma measures and the yoga module are summarized in [Table 1] and [Table 2].
Table 1: Disease course, management, and outcomes

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Table 2: Yoga module

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Outcome measures and assessment time points

SARA (scale for the assessment and rating of ataxia), functional ambulatory performance, and dynamic posturography were assessed at the baseline, end of the treatment, and on follow-up after 1 month of discharge. The patient started noticing an improvement in clinical symptoms pertaining to his gait and speech from the 2nd week of treatment. The SARA score improved from moderate disability to mild disability at discharge. Functional ambulatory performance score, however, decreased during discharge from 81 to 70, although it improved to 73 during follow-up. A significant improvement in fall risk, overall stability index, and limits of stability was noticed from baseline to discharge using computerized dynamic posturography. The improvement in overall stability index was maintained during follow-up after 1 month. The details of changes in outcome measures are summarized in [Table 3].
Table 3: Details of changes in outcome measures

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   Discussion Top


Currently available treatments for SCA-2 are supportive in nature as there is no known therapy to delay or halt the progression of the disease. Neither exercise nor physical therapy has been shown to stem the progression of incoordination or muscle weakness.[3] The management of SCA-2 in Ayurveda is based on vatavyadhi chikitsa (treatment of diseases caused predominantly due to vata dosha).[4] Classical texts of Ayurveda provide a detailed description of various vatavyadhis and their management. Based on the clinical presentation, vatavyadhi line of treatment was followed for Ayurveda and yoga intervention in the present case.

Initially, Udhwartana (powder massage) was administered with Kolakulatthadi churna to remove Kapha avarana (impedance to movement of vata by kapha). It also helps in bringing stability to the body.[5] The patient reported reduction in heaviness of lower limbs after the treatment. Post-Udvartana, Shashtikashalipinda sweda, and Mustadi yapana basti with shuddha bala taila Anuvasana (oil enema) were administered to mitigate vata dosha and to restore the strength of lower limbs. Studies on Shashtikashali pinda sweda in various neurological conditions suggest an improvement in motor deficits and activities of daily living and have nourishing effects on muscles and peripheral nerves.[6] Local heat application improves muscle excitability, improves hemodynamics, and enhances parasympathetic activity. Further therapeutic massage improves motor control and performance in the balance parameters.[7] Basti is considered the best treatment for Vata Vyadhi.[8] It helps in achieving Sroto shodhana (clearing the channels) and Vatanulomana (downward regulation of vata). Studies on basti suggest an improvement in activities of daily living,[9] enhanced vagal activity, and changes in gut microbiome post-Basti chikitsa.[10] Nasya karma is exclusively indicated in diseases involving head and neck and nose is said to be the gateway of the brain. Nourishing oil administered through the nose may improve brain functioning.[11]

SARA scoring showed a significant improvement after treatment, but slight worsening was observed during the first follow-up. Whereas there was deterioration in the functional ambulatory scale posttreatment, the scores improved during the first follow-up. Worsening in SARA score during the first follow-up was mainly due to slight deterioration in speech and Heel-shin slide domines. In general, patients recover very slowly during the basti parihara kala (postbasti recovery period), which might be the reason for delayed improvements. Similar delayed responses are also noticed in most of the neurological disorders in routine clinical practice. The yoga intervention may have led to an improvement in proprioceptive and interoceptive awareness with reduction in anxiety. This may be the reason for reduction in fall risk, enhancement in stability index after treatment. On follow-up during the postrecovery period, significant improvements were noted in both these parameters. Considering the progressive nature of the disorder, the patient may require continued long-term follow-up with a regular application of suggested yoga- and Ayurveda-related regimens for further improvement and to delay the progression of the disease.


   Conclusion Top


Integrative approach of treatment combining Ayurveda and yoga therapies along with conventional modalities of treatment can produce a synergistic effect in SCA. A long-term integrative Ayurveda and yoga-based lifestyle regimen can be particularly useful in improving postural stability and fall risk in patients with chronic neurological disorders like SCA-2. This should be explored further through systematic trials.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Velázquez-Pérez LC, Rodríguez-Labrada R, Fernandez-Ruiz J. Spinocerebellar ataxia type 2: Clinicogenetic aspects, mechanistic insights, and management approaches. Front Neurol 2017;8:472.  Back to cited text no. 1
    
2.
Brooker SM, Edamakanti CR, Akasha SM, Kuo SH, Opal P. Spinocerebellar ataxia clinical trials: Opportunities and challenges. Ann Clin Transl Neurol 2021;8:1543-56.  Back to cited text no. 2
    
3.
Pulst SM. Spinocerebellar ataxia type 2. In: Adam MP, Ardinger HH, Pagon RA, Wallace SE, Bean LJ, Mirzaa G, et al., editors. GeneReviews®. Seattle (WA): University of Washington, Seattle; 1993. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1275/. [Last accessed on 2021 Nov 06].  Back to cited text no. 3
    
4.
Vatavyadhi Chikitsa. Available from: https://www.carakasamhitaonline.com/index.php?title=Vatavyadhi_Chikitsa. [Last accessed on 2022 Jan 25].  Back to cited text no. 4
    
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Bhat A, Geetha Kumari S. Role of Udvartana, a diurnal Ayurveda practice in the prevention and management of diabetes mellitus. Int J Curr Res Physiol Pharmacol (IJCRPP) 2019;3:12-3.  Back to cited text no. 5
    
6.
Vyas AG, Kori VK, Rajagopala S, Patel KS. Etiopathological study on cerebral palsy and its management by Shashtika Shali Pinda Sweda and Samvardhana Ghrita. Ayu 2013;34:56-62.  Back to cited text no. 6
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7.
Sriranjini SJ, Pal PK, Devidas KV, Ganpathy S. Improvement of balance in progressive degenerative cerebellar ataxias after Ayurvedic therapy: A preliminary report. Neurol India 2009;57:166-71.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Basti (Therapeutic enema). Available from: https://www.carakasamhitaonline.com/index.php?title=Basti. [Last accessed on 2022 Jan 25].  Back to cited text no. 8
    
9.
Shailaja U, Rao PN, Girish KJ, Arun Raj GR. Clinical study on the efficacy of Rajayapana Basti and Baladi Yoga in motor disabilities of cerebral palsy in children. Ayu 2014;35:294-9.  Back to cited text no. 9
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10.
Rawat N, Roushan R. A critical appraisal on the mechanism of action of Basti procedure of Ayurveda in perspective of modern physiology. Int J Res Ayurveda Pharm 2020;11:154-8.  Back to cited text no. 10
    
11.
Ramteke RS, Patil PD, Thakar AB. Efficacy of Nasya (nasal medication) in coma: A case study. Anc Sci Life 2016;35:232-5.  Back to cited text no. 11
    

Top
Correspondence Address:
Umesh Chikkanna
Department of Integrative Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoy.ijoy_49_22

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