E-ISSN:2456-3110

Case Report

Radial Nerve Palsy

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 10 OCTOBER
Publisherwww.maharshicharaka.in

Management of Radial Nerve Palsy w.s.r. to Ekangavata and Marmaghat - A Case Study

Kharat M1*, Antapurkar S2
DOI:10.21760/jaims.9.10.54

1* Manjushri Kharat, Assistant Professor, Department of Kayachikitsa, Dhaneshwari Ayurved College, Chh Sambhajinagar, Maharashtra, India.

2 Shital Antapurkar, Professor and Head, Department of Kayachikitsa, Dhaneshwari Ayurved College, Chh Sambhajinagar, Maharashtra, India.

Nervous disorders occurs due to imbalance of Vata Dosha. Acharyas considered nerve impulses to be kind of air travelling through the body. Vata Dosha is responsible for sensory & motor functions of body. In Ayurveda, various nervous disorders and their symptoms are not clumped under heading of single disease, rather they are described as types of Vata Vyadhi. Among nervous disorders, peripheral nerve injuries are most commonly encountered in day-to-day practice. One of the commonest peripheral nerves to be injured is Radial nerve. Radial nerve palsy is condition caused due to injury to radial nerve which leads to wrist drop and functional disabilities, In the present case scenario radial nerve is damaged due to compression of radial nerve as a result of prolonged pressure on arm and systemic condition like Diabetes. In the context of Ayurveda, the underlying cause of Radial nerve palsy is often attributed to aggravation of Vata Dosha. Acharya Charaka and Madhavkara mentioned features of Ekangavata characterized by localized paralysis or monoplegia. All etiological factors and manifestation of Ekangavata are quite resembling with radial nerve palsy. Hence, we can correlate Ekangavata with Radial nerve palsy. Another important etiological aspect regarding radial nerve palsy which needs to explore is Marmaghata. We have noticed that, in this case Bahavi Marma and Aani Marma are more prone for the injury, which might have led to the complaints of wrist drop and functional disabilities. we treated this case successfully with Upanah Swedan, Balya, Vatashamak and Pramehaghna Chikitsa.

Keywords: Radial Nerve Palsy, Diabetes, Ekangavata, Marmaghata, Upanah Swedan, Balya, Vatashamak Chikitsa, Splinting

Corresponding Author How to Cite this Article To Browse
Manjushri Kharat, Assistant Professor, Department of Kayachikitsa, Dhaneshwari Ayurved College, Chh Sambhajinagar, Maharashtra, India.
Email: 		Kharat M, Antapurkar S, Management of Radial Nerve Palsy w.s.r. to Ekangavata and Marmaghat - A Case Study. J Ayu Int Med Sci. 2024;9(10):324-330.
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https://jaims.in/jaims/article/view/3651

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-09-12 2024-09-23 2024-10-03 2024-10-12 2024-10-23
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 13.35

© 2024by Kharat M, Antapurkar Sand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Acharyas Charka stated that diseases are innumerable depending upon their distinctive features like signs & symptoms, etiology and site of origin.[1] In modern era, we came up with various disease presentations that are not actually described in Ayurvedic Samhita but we have to treat them according to predominance of Dosha and Dushya. Acharyas considered nerve impulses to be kind of air travelling through the body. Vata Dosha is responsible for sensory & motor functions of body. In Ayurveda, various nervous disorders and their symptoms are not clumped under heading of single disease, rather they are described as types of Vata Vyadhi.[2] Acharya Charaka described functions of Vata Dosha as ‘Vayu Tantra Yantradhara…’ which means Vata Dosha governs the nervous system and movement in the body, so that we can say that nerve disorders occur due to imbalance of Vata Dosha.[3] Among nervous disorders, peripheral nerve injuries are most commonly encountered in day-to-day practice. One of the commonest peripheral nerves to be injured is Radial nerve. Radial nerve is mixed type of nerve, i.e. it has both motor and sensory fibers but predominantly having motor component.[4] Radial nerve is commonly injured due to its superficial location, proximity to humerus shaft and long route. Radial nerve palsy is a condition that occurs due to damage to radial nerve. This condition leads to weakness or paralysis of the muscles controlled by the radial nerve in the arm and hand. Damage to radial nerve can be caused due to trauma, fracture or dislocation of humerus, gunshot wound, compression of radial nerve due to prolonged pressure on arm and systemic conditions like Diabetes.[5] Radial nerve palsy can be caused due to compression or damage to nerve at three different levels i.e., axilla, arm and elbow. Location of lesion is identified by clinical features and examination of muscle functions.

Clinical features of Radial nerve palsy depend on location of radial nerve injury[6]

1. Low lesions [damage to radial nerve at elbow]: Finger, wrist and thumb extensions are lost causing wrist drop.
2. High lesions [damage to radial nerve at arm]: Autonomous zone sensation is lost. Brachioradialis and supinator muscle power is lost. Finger, wrist and thumb extensions are lost causing wrist drop.

3. Very high lesions [damage to radial nerve at axilla]: Triceps is paralyzed causing loss of active elbow extension.

In the context of Ayurveda, the underlying cause of Radial nerve palsy is often attributed to aggravation of Vata Dosha. Vata-Dosha is controller of motor activity and speech. Vata in normal state is responsible for movement, activities and life support. Hence, Vata derangement always involves some weakness or some sort of neurological deficit. Acharya Charaka mentioned ‘Nanatmaj Vatvyadhi’ which are caused due to vitiation of only Vata Dosha. Pakshaghata is one of Nanatmaj Vatvyadhi. In context of Pakshaghata, Acharya Charaka and Madhavkara mentioned features of Ekangaroga characterized by localized paralysis or monoplegia.

Symptoms and etiology of Ekangavata are as follows:

Acharyas Charaka described etiological factors which are responsible for aggravation of Vata Dosha such as, sleeping over uneven bed & sitting in odd postures [Dukhashayyashana], trauma [Abhighata] and injuries to vital body parts [Marmaghata].[7] Aggravated Vata seizes power of half of the body i.e., on either right or left, also leads to weakness or loss of strength in affected limb which ultimately is responsible for loss of mobility and function of limb [Akarmanya]. Loss of sensation in affected limb [Vichetan] and is also characterized by atrophy of muscles [Sira-Snayu-Vishoshya] and piercing pain in affected limb.[8] All the above said etiological factors and manifestation of Ekangavata are quite resembling with radial nerve palsy. Hence, we can correlate Ekangavata with Radial nerve palsy. Another important etiological aspect regarding radial nerve palsy which needs to explore is Marmaghata. Marma are vital points on the body where muscles, veins, arteries, tendon, bones and joint meet. Marma is a place where Prana is said to be situated.[9] According to Ayurveda, Kakshadhara, Lohitaksha, Bahavi, Aani and Kurpara Marma are the five Marma that are located along the route of radial nerve from its origin. These Marmas are Vaikalyakar Marma. All these Marma when subjected to any form of injury or trauma leads to deformity. In the present case study of Radial nerve palsy, depending upon the clinical presentation it can be infer that, the patient may have compression type of damage to radial nerve at mid forearm.


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Hence, Bahavi Marma and Aani Marma are more prone for the injury, which might have led to the complaints of wrist drop and functional disabilities.

Case Presentation

Patient’s Demographic and Chief Complaints

A male patient of 35 yrs old, working as LIC agent with known history of Diabetes and Chronic Alcoholic, presented to Kaychikitsa OPD of Dhaneshwari Ayurved Hospital, Georai Tanda, Chhatrapati Sambhajinagar, on 17th January 2024 with complaints of:

1. Inability to extent wrist & fingers of right hand and wrist
2. Numbness & tingling at right forearm and dorsal aspect of index finger and
3. Inability in picking up
4. Loss of sensation at dorsum of lateral side of
5. Pain at right forearm on and

Duration: Since 15 days.

History of present illness

Patient was apparently normal before 15 days. There was sudden onset of symptoms. Patient reported history of heavy alcohol consumption and falling asleep putting his body weight over the right arm for prolonged period in alcohol intoxicated state, on 31st of December 2023. Next morning patient was unable to extent his right hand and fingers against gravity and right wrist drop along with severe tingling and numbness at hand and forearm. Also, there was total loss of gripping power. Patient was not able to lift an object like writing pen. Patient reported to have aggravation of tingling and pain on vigorous movements of hand. On the other hand, there was relief in tingling and numbness on supporting wrist joint. Patient consulted at Neurology department of Government Medical College, Chh. Sambhajinagar, where he got diagnosed as a case of Radial Nerve Palsy. Physician advised him for nerve conduction study, where conduction defect was noted. They advised to keep blood sugar levels in check and physiotherapy, patient did physiotherapy for a week but failed to continue the same. Patient’s symptoms got worsened day-by-day causing increased tingling and numbness for which he presented at OPD of Dhaneshwari Ayurved Hospital and Research Institute, Chh. Sambhajinagar.

History of past illness

Patient is recently diagnosed Type 2 Diabetes mellitus [2 months before] for which he is taking Tab.Gemer 1 [Glimepiride 1 mg & metformin 500 mg] 1 B.D. Patient is chronic alcoholic over 10 yrs. He has history of excessive alcohol intake on daily basis, with no periods of absolute abstinence. No known case of Hypertension / Bronchial Asthama / Rhumatoid Arthritis / Major illness. No history of any surgery reported. No history of any trauma reported.

Vitals and Systemic Examinations

Bp - 130/80; Pulse rate - 90/min; Temp - 97.4℉; CNS - conscious & oriented; RS - Clinically NAD; CVS - Sinus rhythm.

Physical Examination

Radial nerve supplies to triceps, extensors of wrist, fingers and thumb, supinator and brachioradialis. Examination of muscle function is also useful in localizing lesions of radial nerve. Following examinations are done for muscle supplied by radial nerve to access its strength and functions.

SNExamination Rt. ArmObservationsGradation of Muscle Power.
1.Wrist extensionInability in lifting Rt. wrist joint against gravity causing wrist drop.0/5
2.Finger extensionInability in lifting Rt. hand fingers against gravity.1/5
3.Gripping strengthInability in picking up objects with Rt. thumb & index finger.0/5
4.Forearm supinationPresent5/5
5.Elbow extensionPresent5/5
6.Brachioradialis reflexAbsent2/5
7.Tingling & PainAt right forearm and dorsal aspect of index finger and thumb.8/10 (Visual Analog Scale with 0 as minimum and 10 as maximum)
8.SensationLoss of sensation over dorsum of lateral side of hand.Absent

Diagnosis:

Above said physical examination and clinical features of patient confirmed the diagnosis of High radial nerve palsy [Saturday nerve palsy].


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It occurs due to compression of radial nerve against humerus around radial groove till it pierces septum.

Investigations and lab work

18th January 2024 [Pre-treatment]

Complete blood count:- HB- 15.9,RBC-5.1O/Mill/cu/mm, WBC- 6220/cu/mm, Platelet- 195/cu/mm, Blood sugar fasting - 234 mg/dl, Blood sugar postprandial - 298 mg/dl, Urine analysis - sugar ++++, Liver function test - WNL

29th January 2024 [Second visit]:

Blood sugar fasting - 140 mg/dl, Blood sugar postprandial - 162 mg/dl, Urine analysis - WNL

Treatment Approach:

Integrated treatment approach was used in this case of Radial nerve palsy. Considering the patient’s Bala and the Vata Pradhanya, it was decided to avoid Shodhan and implement Shaman regime, as Shodhan may further lead to vitiation of Vata Dosha.

The Shaman treatment incorporated following external procedures and medicines.

1. Upanah Swedan: Upanah is application of warm paste of Vataghna Dyavya with Lavana, Sneha, Takra or Ksheer over affected body part and bandaging it with cloth.[10] In this patient, Godhumadi Upanah was used.[11]

2. Balya: Ashwagandha and Bramhi were the drug of choice considering their Vatshamak and proven action on CNS.

3. Pramehaghna Drugs: Chandraprabhavati and Nisha Amalaki Churna, these two drugs were used to have a control on the blood sugar levels and also to combat the complications, of Diabetes Mellitus Type 2.

4. Anupan: Lukewarm water was commonly used as Anupana throughout the course of

5. Rasayan Chikitsa: Rasayan Chikitsa was added at a stage when most of the symptoms were relived in order to facilitate the faster recovery. For this purpose, Amruta Ghanavati was used.

6. Splinting: Adequate support in the form of splint was advised in order to prevent further consequences like muscular atrophy, contracture and to protect the affected muscles and

Treatment Details

DateTreatmentDoseDuration
17/01/2024
[First visit]		1. Godhumadi Upanah Sweden6 hours a day15 days
2. Ashwagandha-Vati750 mg BD15 days
3. Bramhi Vati500 mg BD15 days
4. Chandraprabhavati500 mg BD15 days
5. Nisha-Aamalki Churna5gm BD15 days
29/01/2024
[Second visit]		1. Godhumadi Upanah Swedan6 hours a day8 days
2. Ashwagandha-Vati750 mg BD15 days
3. Chandraprabha-Vati500 mg BD15 days
4. Nisha-Aamalki Choorna5 gm BD15 days
5. Amruta Ghan-Vati5oo mg15 days

Procedure of Godhumadi Upanah Swedan:

Ingredients:

1. Godhum Churna - 50 gms
2. Teela Kalka - 50 gms
3. Rasna Choorna - 20 gms
4. Ashwagandha Churna - 20 gms
5. Godugdha - 150 ml
6. Teela Taila - 20 ml
7. Saidhav Lavana - 10 gms
8. Eranda Patra
9. Bandage
10. Cardboard

Poorvakarma: Upanah Nirman

Godhum Churna, Teela Kalka, Rasna and Ashwagandha Churna are mixed with Godugdha. This mixture is heated on low flame till you get soft textured paste. Saindhava Lavana and Tila Taila are added to mixture at end.

Temperature of Upnah Dravya: 38-40°C.

Pradhankarma: Snehana is done with warm Bala Taila over affected Rt. forearm in gentle way, as too much pressure can irritate radial nerve. Warm paste of Upanah Dravya was applied over Rt. forearm, wrist and hand in opposite direction of hair-follicles. Uniform thick layer of 2cm is formed, it is then covered with Erandapatra. After that for splinting purpose we have used cardboard of forearm length to keep hand in supine position with wrist in slightly extended position to prevent wrist drop. Bandage was tied along the length of forearm, wrist and hand.

Pashchyat Karma: Patient was asked to keep Uapanah in position for 6 hours. After six hours, paste was removed with lukewarm water and finally Abhyanga was done with lukewarm Bala Taila.


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Results and Observations

ExaminationObservationsGrade
BeforeAfterBeforeAfter
Wrist extensionInability in lifting Rt. wrist joint against gravity causing wrist drop.Wrist extension present0/55/5
Finger extensionInability in lifting Rt.hand fingers joint against gravityFinger extension present1/55/5
Gripping strengthInability in picking up writing pen with Rt. Thumb & index fingerAble to pick up pen with Rt. thumb &index finger0/55/5
Tingling & PainAt right forearm and dorsal aspect of index finger and thumb--Present [8/10]Absent
SensationLoss of sensation over dorsum of lateral side of handPatient can feel pain on pricking with penAbsentPresent

jaims_3651_01.JPG
First visit 17 Jan 2024

jaims_3651_02.JPG
Godhumadi Upanah Bandahan

jaims_3651_03.JPG
Post treatment 15th feb 2024

Discussion

Mode of action of Upanah Swedan

Upanah Swedan is type of Ekang Swedan where only a part of body is subjected to Swedan Karma. in this case of radial nerve palsy only Rt. Hand is affected so Upanah Swedan is ideal for Swedan purpose. During the process of Upanah Swedan, we have applied warm paste of various Vataghna and Balya Dravya along with Saindhava over affected part and covered it with Eranda Patra, to ensure continuous fomentation for at least 6-7 hours.

Upanah Swedan causes dilatation of capillaries thus increases circulation at affected area which in turn enhances absorption of Upanaha Dravya and Sneha.[12] Ushna Guna of Swedan Karma also stimulate muscle and nerves, which promotes its renovation. Swedan Karma helps to relax muscle, reduces pain and stiffness at affected site. This is particularly helpful in radial nerve palsy condition caused due to compression of nerve. In short, Upanah Swedan promotes blood circulation, reduces inflammation of nerve and muscles and also facilitates the expected effect of the medicines.

Splinting: In modern medicine splinting is a common treatment approach for radial nerve palsy. In present case scenario, while applying Upanah, we have used cardboard for splinting purpose. Splinting can help to maintain proper positioning of wrist, hand and fingers as well as provide support and protection to the affected muscles and joint. Splinting is done in such a way that, wrist is kept in slightly extended position and fingers in functional position; this can help to prevent the development of contractures and promote functional use of hand.[13]

Mode of action of Ashwagandha Vati

Ashwagandha is having Balya, Rasayan, Vataghna properties.[14] Ashwagandha provides strength to nerves and muscles by pacifying Vata Dosha and reducing inflammatory conditions of nerves. It is beneficial in restoring functions of nerves.

Mode of action of Bramhi Vati

Bramhi Vati was used in present scenario for its Balya, Tridoshshamak and Pramehahara properties.[15] Acharya Charaka included Bramhi in Balya Varga. It is primarily known for its cognitive, neuroprotective and anti-inflammatory effect.


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In radial nerve palsy we have noted that patient is having compression of radial nerve leading to impaired nerve conduction resulting in paralysis, numbness in affected area. One of the pathophysiological findings noted in radial nerve palsy is disruption of myelin sheath which is responsible for insulating nerve conduction, Re-myelination of affected nerve fiber is crucial for recovery process.

Bramhi, because of its anti-diabetic properties along with marked neuroprotective action & significant anti-inflammatory effect, have given a very prompt relief from the signs and symptoms.

Mode of action of Chandraprabha Vati

Diabetes can significantly increase the risk of radial nerve palsy. As Chronic high blood sugar level can lead to nerve damage, causing numbness tingling and weakness. In present case scenario we have used Chandraprabha Vati and Nisha-Amalaki Churna as Pramehaghna Chikitsa

Conclusion

Prognosis of radial nerve palsy is governed by the underlying cause and the extent of nerve damage. In this case, patient was diagnosed with Radial night palsy. In Radial night palsy there is compression of nerve due to prolonged pressure causing loss of function. If timely and adequately treated, Radial night palsy patient usually recovers within few weeks to few months. Delayed recovery causes lot of consequences such as muscular atrophy, joint stiffness, contractures and functional disability.

It is important for individuals with radial nerve palsy to receive appropriate, adequate and timely medical treatment for speedy recovery and to minimize potential consequences. With integrated treatment approach which includes Upanah Swedan with splinting and Shaman Chikitsa, patient recovered within 15 days of treatment.

Patient is able to use his hand and wrist effectively; he can now perform fine activities like writing & grasping objects. Radial nerve palsy can be debilitating and impact the individual’s quality of life, if delayed recovery happens. Ayurvedic treatment approach plays major role by regaining patient’s functional abilities, avoids consequences and also ensures speedy recovery.

References

1. Acharya Vidhyadhar Shukla, Ravi Dutt Tripathi: Charak samhita of Agnivesha, elaborated by Charaka and Redacted by Drudhabala, volume I, Edited with Vaidyamanorama hindi commentary, Chaukhamba pblication, Reprint :2022, Adhyay- 20, Shloka-3.
2. S.Byadgi, A.K.Pandey: A text book of Kaychikitsa, Volume III, Reprint edition,2022,Chokhamba Publication, Chapter -1,Page no-2.
3. Acharya Vidhyadhar Shukla, Prof.Ravi Dutt Tripathi:Charaksamhita of Agnivesha, Elaborated by Charaka and Redacted by Drudhabala, volume I, Edited with Vaidyamanorama hindi commentary, Chaukhamba pblication, Reprint :2022,Adhyay- 12,Shloka-7.
4. Kaushik Banerjee: Essential Handbook of Practical Orthopaedic Examination, Academic Publishers, First Edition, Chapter 18-Peripheral nerve Injuries, Page no.59.
5. Manish Kumar Varshney: Practical Orthopedic Examination made easy, Jaypee Brothers, Second Edition2012, Chapter 7-Wrist and Hand, Page no-294-95.
6. Kaushik Banerjee: Essential Handbook of Practical Orthopaedic Examination, Academic Publishers, First Edition, Chapter 18-Peripheral nerve Injuries, Page no.60.
7. S.Byadgi, A.K.Pandey: A Text book of Kaychikitsa, Volume III Reprint edition, 2022, Chokhamba publication, Chapter -2, Page no-42-43.
8. Kaviraja Ambikadutta Shastri:Susruta Samhita of Maharshi Sushruta edited with Ayurveda-Tattva - Sandipika ,Sushrut Sharir Sthana, Adhyaya -6,Shloka7
9. Mannoj K. Shamkuwar: Panchakarma Sangraha, Chaukhamba publication, Third Edition 2022, Swedan-page no.120-121.
10. Evaluation effect of Godhumadi Upanaha sweda in Niramaja Katigraha: Taran kumar, Rajashekhar Sanapeti, June 2017: International journal of research in Ayurveda and Pharmacy8(2):139-141 DOI:10.7897/2277-4343.08299:
11. Vasant C.Patil : Text book of Panchakarma, Chaukhamba Publication, Reprint 2022,Chapter 3- Svedana,page no.196.


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12. Kaushik Banerjee: Essential Handbook of Practical Orthopaedic Examination, Academic Publishers, First Edition, Page no.
13. Prakash L. Hegde, Harini A: A Text Book of Dravyaguna Vijnana, Chukhamba Publication, Second Edition 2021, Page no-82,83.
14. Prakash L. Hegde, Harini A: A Text Book of Dravyaguna Vijnana, Chukhamba Publication, Second Edition 2021, Page no-161,162,165.


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