Ayurveda, yoga, and acupuncture therapies in alleviating the symptom score among patients with spinal cord injury – A systematic review

Background Spinal cord injury (SCI) is the leading cause of motor and sensory abnormalities due to damage caused to any part of the spinal cord resulting from trauma, disease, or degeneration. Most of the disability caused will be irreversible with various systemic manifestations. Hence, management of SCI focuses on minimising disability, diminishing limitations due to impairment, and improving quality of life, emotional, and psychological aspects. Aim This review is aimed at describing Ayurveda, Yoga, and Acupuncture therapies in the management of SCI as individual and integrated approaches for alleviating the symptom score in patients with SCI. Methods The data was collected from six databases, including PubMed Central, the Cochrane Library, Google Scholar, Scopus, MEDLINE, and Grey Literature. The subjects in these studies were between the ages group 21–70 years and had been previously diagnosed with SCI and its clinical presentation. The interventions used in the selected studies incorporate Ayurveda (medicinal system of longevity) herbal medications, Panchakarma (five methods) treatment, diet, and yoga (mind-body medicine) therapy. Full-text publications in English, and research designs such as randomised controlled trials, case studies, review articles and cohort studies were included. Letter to the editor, study protocol, animal trials, and in vitro studies were excluded. Results 216 records were identified using keywords such as spinal cord injury, Äyurveda, Acupuncture, païca karma, rehabilitation, and yoga. After applying inclusion and exclusion criteria, 28 articles were selected for synthesis, which contain 12 case studies, 12 literature review articles, 2 randomised controlled trials, 1 cohort study, and 1 meta-analysis. Conclusion The integration of Ayurveda management, including Panchakarmatherapy and Ayurveda medications, with other alternative therapies like Acupuncture, Yoga, and Rehabilitation improved muscle strength, quality of life, range of motion, and neuronal function, and reduced depression, stress, and pain with symptom scores.


Background
Spinal cord injury (SCI) is an immediate and devasting condition, that causes damage to the spinal cord resulting in necrosis which leads to loss of conduction of impulses from the brain to the periphery, with an incidence of 40e80 cases per million population, where 90% are due to traumatic etiology. The prevalence of acute traumatic SCI is estimated to be 236 per million in India [1]. The physical disability arises from the location in descending tract, where the connection between synaptic input and output is disorganized resulting from trauma, degeneration, or any disease (cancer) [2,3]. The impact of SCI on sensory, motor, and autonomic functions relies on the location and extent of damage and unfortunately, the adult central nervous system (CNS) is unable to allow considerable axon development and regeneration of lengthy fiber tracts, as well as the adult CNS's limited capability to replace neurons, this functional impairment is mostly irreversible [4,5]. The pathophysiology of SCI is considered to be biphasic. The mechanical force injures the spinal cord, resulting in primary damage. Edema, ischemia, inflammation, cytokine production, free radical damage, glial scar formation, apoptosis, and necrosis contributes to secondary injury [6]. People who have had a SCI are 2e5 times more likely to die prematurely than those who do not. The risk of death rises with the severity of the injury and is heavily impacted by the availability of prompt, high-quality medical care immediately, without delay. Axon regeneration and functional recovery following SCI are influenced by a variety of inherent and extrinsic variables. Individually targeted therapeutic techniques will not be enough for substantial functional restoration [7,8]. As a result, spinal cord injury rehabilitation is a multi-dimensional, complicated condition that will need a combination of treatment techniques [9]. The key objectives of SCI rehabilitation are to minimize disability, alleviate the limitation of the impairment, to improve the quality of life, emotional and psychological aspects.
Ayurveda is a holistic approach, which regards physical, mental, and spiritual entities for diagnosis and management. The universe, according to Ayurveda, is made up of pancha mahabhuta (five elemental combinations) including, Akash (Ether), Vayu (Air), Teja (Fire), Apa (Water), and Prithvi (Earth). At all scales of life and in both organic and inorganic entities, the five elements may be seen in the material universe [10]. In Ayurveda medicine, there are srotas (channels) that transport fluids, and these channels may be opened up with oil massage and svedana (fomentation) [11]. The disease is considered to be caused by unhealthy or clogged channels. The tridosha (three bodily humors) that governs all bodily processes and maintains physiological and psychological balance includes, Vata (space or air, symbolizes the nervous system), Pitta (fire, symbolizes enzymes), Kapha (earth and water, symbolizes mucus) [12]. A balanced condition of the tridoña brings equilibrium and health; an imbalance between the physical and mental dosha, whether it's a vriddhi (excess) or a kshaya (deficiency), emerges as a symptom or indication of sickness [13]. Improvements in SCI have been shown with Ayurveda comprehensive management, which includes a few rehabilitation techniques as well as oral Ayurveda medicines [14]. Hence in this review, various Ayurveda therapies and their impact on disabilities due to SCI are described.

Study strategy and design
This study was conducted and reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The data was collected from 5 databases including PubMed Central, Cochrane Library, Google Scholar, Scopus, MEDLINE, and Grey literature using keywords Spinal cord injury, Ayurveda, panchakarma, and rehabilitation from 2003 to 2021. Full-text publications in English, and research design such as randomized controlled trials, case studies, review articles, and cohort studies were included. Letter to editor and study protocol were excluded. Studies with animal trials and studies carried out in vitro were not included. After applying inclusion and exclusion criteria 28 studies were selected for review.

Study population and intervention
The studies selected contained a population between 21 and 70 years of age, who were diagnosed previously with SCI and other systemic manifestations of SCI. All the study subjects were found to have normal higher mental functions. Studies with Ayurveda management for SCI and its manifestations were included. The interventions used in the selected studies incorporate, Ayurveda herbal medications, Panchakarma treatment, diet, and yoga therapy. This is shown in Fig. 1.

Outcome measures
General examination, a systemic examination was assessed for recording the symptom score, Visual analogue scale, Oswestry Low Back Pain Scale, and Neck disability score were assessed for pain and degree of disability, X-ray, and MRI were assessed for noting the structural changes before and after the intervention.

Results
In this review, 216 records were identified using the keywords Spinal cord injury, Ayurveda, panchakarma and rehabilitation. After applying inclusion and exclusion criteria and excluding the duplicate records (n ¼ 21), 62 articles were selected of which 16 animal studies, 7 non-English studies, and 11 in-vitro studies were excluded and final synthesis was done for 28 eligible articles (Fig. 1). The articles selected for review include Ayurveda management (Ayurveda herbal medications, Panca karma treatment,  Pharmacological activities include anti-inflammatory, analgesic, antioxidant, and immune-stimulant properties. All of the treatments performed in this case were targeted at decreasing pain, stiffness, improving muscular power, strengthening spinal muscles, and correcting the curvature of the spine.

Not Applicable
Withania somnifera roots Roots of W. somnifera exhibit great potential as a safe and effective neuroprotectant. It might be a good neuroprotective treatment for Alzheimer's, Parkinson's, anxiety, stress, cognitive, and other nervous system problems. So far, no harmful or adverse effects have been recorded for this medication. 9 Not Applicable Shasthikashali Pinda Sweda Pinda Shashtikashali Sweda is an Ayurveda therapy that aids in improving tissue strength, immunity, and nutrition, preventing degeneration and inflammation, and treating pain and swelling associated with Arthritis, Neuromuscular and Musculoskeletal diseases 10 Neck Disability Index; Subjective Parameters; X-ray cervical spines Group A-Panchtikta Ghrita Matra Vasti; group B-Panchtikta Ghrita Marsha Nasya.
Due to the short timeframe of the intervention and research, there was no major improvement in radiological results in the cervical X-ray spines. Both groups showed a significantly improvement in decreasing cervical spondylosis symptoms and minimizing the neck disability score. It was also statistically proven that Nasya with Panchtikta Ghrita is more effective than Matra Vasti with Panchtikta Ghrita when comparing the two groups. This therapy did not achieve total function independence in the instance, but it did significantly reduce dependency, as seen by the improved MBI score. 16 Not Applicable Acupuncture Acupuncture was used as part of an extensive treatment plan in the majority of the trials. Manual acupuncture stimulation and electrical stimulation produced equal results in terms of the proportion of individuals whose symptoms improved, according to subgroup analyses. Diet), Acupuncture and Yoga therapy for SCI and its systemic manifestations which contains 12 case studies, 12 literature review articles, 2 randomised controlled trials, 1 cohort study, and 1 metaanalysis. In Table 1 the article details along with the source and keywords and the design of the study are explained and in Table 2 intervention used, parameters assessed, and the conclusion is explained. The whole SCI and intervention for SCI manifestations are also reviewed in detail.

Discussion
This systematic review was undertaken to provide the evidence base for recommendations of alternative therapies in the management of pain in SCI patients. The up-regulation of specific inflammatory molecules following damage, which leads to gliosis, is one of the longer reaction times to get recovered completely from SCI. Modern medicine uses a variety of surgical techniques, stem Not Applicable Abhyanga and Oral medications Guggul and kutki are two herbs that are used to purify the bones and are particularly effective in curing kapha doña in the asthi dhatu. Vata pacification can be achieved by abhyanga, or self-massage with sesame oil, and Dashamularishta. 18 Not Applicable Ayurveda oral medications Rasayana herbs are well-known for their tissue-protecting properties. Curcumin has been shown to increase hippocampus neurogenesis in both children and adults, as well as a biological process that may improve brain plasticity and repair. The contractility of cardiomyocytes generated from embryonic stem cells was improved after treatment with herbal extract. The action of Dhanvantar Kashaya (a decoction of herbs with regeneration properties) on Wharton jelly mesenchymal stem cells has been observed (WJMSCs). The decoction enhanced the rate of proliferation, reduced turnover time, and postponed senescence. 19 Not Applicable Asana, Dhyana, Pranayama Yoga lowers salivary cortisol, blood glucose, blood pressure, plasma rennin, and urine nor-epinephrine and epinephrine levels throughout a 24-h period. Atherosclerosis is reversed, myocardial ischemia is reduced, and left ventricular hypertrophy is reduced as a result of these causes.In patients with chronic obstructive lung disease, yoga treatment reduces dyspnea-related discomfort and improves functional performance. Yoga can help with depression by increasing serotonin levels while decreasing monamine oxidase, an enzyme that breaks down neurotransmitters and cortisol. 20 Not RMT may increase VC and maximal respiratory pressures (MIP and MEP) for people with cervical SCI. However, the effect size for all three outcomes was small and there was no evidence of carryover beyond the training period. Some evidence shows that inspiratory muscle training could improve respiratory function and decrease dyspnoea.

27
Oswestry Low Back Pain Scale. Dashamoola Nirgundi kwath Nadisweda followed by Majja basti The shukra, rasa, shleshma, meda, and majja are all enhanced by majja. It helps with neurological diseases, muscle and tissue numbness, back and lumber stiffness, and all vitiated vata-related ailments. Snehana svedana improves blood circulation and reduces spasms and stiffness in the local area. Majjabasti nourishes the saptadhatu and strengthens the muscles, therefore relieving pain and providing symptomatic relief to the patient. 28 American Spinal Injury Association grade A -ASIA A Not Applicable From pooled data from prospective trials and observational series, the total rate of conversion of ASIA grade A SCIs is 28.1 percent and looks to be higher.
cell implantation therapy, and other medicinal therapies, however, they are all limited [15]. Treatment of secondary damage with Ayurveda intervention may aid in healing from SCI and its presentation [16]. Ayurveda medications like ras€ ayana herbs are wellknown for their tissue-protecting properties. Curcumin has been shown to increase hippocampus neurogenesis in both children and adults, as well as a biological process that may improve brain plasticity and repair. The contractility of cardiomyocytes generated from embryonic stem cells was improved after treatment with the herbal extract. The action of dhanvantari kashaya (a decoction of herbs with regeneration properties) on Wharton jelly mesenchymal stem cells has been observed (WJMSCs). The decoction enhanced the rate of proliferation, reduced turnover time, and postponed senescence [17,18]. The pharmacological effects of these medications include anti-inflammatory, analgesic, antioxidant, and immune-stimulant properties. All of the treatments performed in this case were targeted at decreasing pain, and stiffness, improving muscular power, strengthening spinal muscles, and correcting the curvature of the spine [19].
Panchakarma has many therapeutic advantages, including cleansing, better circulation, and pain reduction. Panchakarma's effectiveness has also been demonstrated in the treatment of painrelated illnesses. It relieves tension, relaxes the body, lowers pain, and provides a soothing effect while improving circulation [20,21]. The shukra (reproductive fluid or semen) rasa (plasma or lymph fluid) çleçma (mucus), meda (fat), and majja (bone marrow) are all enhanced by majja basti (therapeutic enema) [22]. It helps with neurological diseases, muscle and tissue numbness, back and lumber stiffness, and all vitiated Vata -related ailments. Snehana svedana (heat therapy after oil or lubricant application) improves blood circulation and reduces spasms and stiffness in the local area. Majja basti nourishes the saptadhatu and strengthens the muscles, therefore relieving pain and providing symptomatic relief to the patient.
Vasti is the best treatment for vitiated Vatadosha. Yapana vasti can support life and promote longevity. Abhyaìga and svedana are considered as external therapeutic procedures that mitigate vitiated Vatadosha. The immense number of nerves which are located in the enteric nervous system can be nourished easily and quickly due to the Sadyaobalajanana and Rasayana effect of Vasti and Abhyanga [23].
Yoga is gaining popularity in modern medicine for its ability to improve health and well-being, and it has been studied in a range of clinical groups for both acute and chronic illnesses. Yoga is a safe and supportive mindebody practice that may simultaneously attenuate some of the negative psychological impacts of SCI and is beneficial as a stand-alone treatment or as adjuvant therapy in the treatment of a range of chronic illnesses in randomised controlled trials [24,25]. When people with post-stroke hemiparesis participated in a 10-week yoga study, their depression levels improved clinically when compared to others who did not participate. Thus, Yoga Practice results in increased mindfulness from preintervention to postintervention, with an increased capacity to observe and not react to immediate physical and emotional experiences [26]. Yoga benefit patients by boosting their strength, removing toxins, cleansing circulation channels, and making the body and mind steadier and more focused.
Acupuncture and rehabilitation training was shown to be more beneficial than rehabilitation training alone at reducing postvoid residual (PVR) urine volume for chronic urinary retention (CUR) due to SCI.
Ayurveda management can successfully address critical diseases like SCI-induced paraplegia by enhancing the patient's quality of life. Monocarboxylic acid transporters, which are active during Abhyanga and Vasti, aid in the transfer of lactate, pyruvate, and ketone bodies across biological membranes and aid in neuroprotection, resulting in better recovery of neuronal function after SCI [27]. Hence, from this review, it is evident that Ayurveda management integrated with conventional intervention is proven to be beneficial for patients with SCI and its manifestations.

Conclusion
In this study, 28 articles were reviewed, in which, the integration of Ayurveda management including panch karma therapy and Ayurveda medications along with conventional management showed improvement in muscle strength, Quality of life, range of motion and neuronal function and reduced depression, stress, and pain. The Ayurveda treatments when administered with yoga and acupuncture, help in better recovery in symptom score, and pain through improving local blood circulation, strengthening local tissues, and preserving nerve degeneration.

Funding
The research has been self-funded.

Declaration of competing interest
There is no potential conflict of interest during the review.