Medicinal Plants Used for Treatment of Prevalent Diseases in Northern Pakistan of Western Himalayas

In this research study, we have scientifically assessed medicinal species and herbal preparations used by inhabitants of Northern Pakistan to treat joint pain, hypertension, skin diseases and glottis infections. The aim of the study is to document and highlight the ethnopharmacological significance and compare the uses of medicinal herbs for curing prevalent ailments in Northern Pakistan. Ethnomedicinal data were collected from 180 informants using semi-structured interviews and group meetings. A total of 80 plant species in 54 families were reported for the treatment of various health conditions. Heliotropium lasiocarpum, Geranium wallichianum, Parkinsonia aculeata, Rubia cordifolia and Salvadora persica were the favored plants for curing these diseases. Highest RFC was recorded for Neolitsea chinensis (0.956), Rubia cordifolia (0.928). The similarity of the informer’s knowledge about used medicines was found in Aesculus indica and Abies pindrow with high UV. Cuscuta reflexa and Lawsonia inermis had 98–99% fidelity level for management of joint pain, skin diseases, glottis infection and hypertension respectively. In Northern Pakistan, a rich diversity of medicinal plants was used in curing various diseases. The results of this study help us in screening of herbal plants for further phytochemical and pharmacological study which leads to discovery of natural drug and development with global interest for cure of various ailments.


Ethnobotany: concept and significance
Ethnomedicinal literature put emphasis on the relation between the indigenous communities and the usage of plants [1]. Plants are important for all biomes and the working of all social societies [2]. Traditional herbal drugs have been effective as a remedy for wide variety of diseases [3]. Traditional medicinal species and plant derivative treatments are extensively utilized in old medicinal systems worldwide, and the therapeutic use of plant species is becoming gradually popular in modern society as natural alternatives to synthetic medications [4]. Ethnomedicinal assessment of medicinal species is essential for preserving security and valuable for incipient plant medicines [5]. Many people of the rural areas retain indigenous knowledge of therapeutic plant species [6] and such plant material still exists because it is transferred from generation to generation [7]. Thus, the race of human generally relies on plant species and their needs are increasing with passage of time [8].

Medicinal plants used at global level
The usage of medicinal plant species is common, as they have little side effects, less price, easily accessible, consistent by numerous beliefs and traditional performs [9]. Native utilization of medicinal species becomes unavoidable in giving as a source of food and drugs for health care for the rural communities and low income class. The ethnic system of old herbal drugs rely on the utilization of medicinal flora by the people of native populations and has been experienced for spans [10]. These medicinal plants were commonly used by local inhabitants and were of great value so that lot of people was engaged in the trade of essential medicinal species throughout the world [11]. Medicinal herbs gained attention due to elevation in prices of allopathic drugs for the wellbeing, biomedical benefits and accessibility and maintenance of personal health, [12]. So, conservation and sustainability of traditional medicinal system is needed [13].
World Health Organization (WHO) stated that, in developing nations around 80% of the population of the world dependent on indigenous herbal drugs (THD) for treating various diseases. Internationally, 422,000 flowering species are stated [10]. Out of these, around 50,000 plant species are used as medicinal plants and only 5000 species have separated phytochemically to examine their active chemical compounds [14]. In developed nations, 25% of medications are based on plant species and their derivatives [14]. Consequently pharmaceutical companies have made a huge amount of clinical agents, still traditional knowledge of herbal medications and phytotherapies are running in different areas of the globe. The importance of the indigenous traditional medicinal system was highlighted by the WHO that the most of population the rural communities of the emerging states is still relies on the medications for healthcare [15].
Pakistan has about 6000 medicinal plant species out of which 600 are considered to be significant from medicinal point of view [16]. These medicinal herbs are recommended by the local healers, akhuns and hakims who give health care tips within the rural areas. Around 80% of the rural people of Pakistan depend on Unani medicinal system, derived from medicinal species directly or their products [17]. The rich biodiversity of Pakistan has nine major ecological amplitudes in which the areas of Northern Pakistan are blessed with a unique biodiversity [4]. Variety of economically essential medicinal plant species for indigenous communities is fairly rich in Northern Pakistan [18]. Therapeutic species have remained utilized as a base of herbal medicinal treatment since human civilization in these areas [19]. Because of diverse climatic conditions and unique phytogeography, the area has a high variety of aromatic and medicinal plant species [20]. People living in hilly areas of Pakistan utilized medicinal species for numerous diseases and they also reliant on herbal products for their shelter, fuel, food, health, and further needs [21].Field of ethnobotany has been presented currently in Pakistan in comparison to other nations however in the recent era much effort was performed in this research study by several scientists in various regions of country [17,19,[22][23][24][25][26][27][28][29][30][31][32][33]. Although, a lot of work has been done on medicinal species in several areas in Pakistan, yet, no study has been carried out on areas of Northern Pakistan in relation to special emphasis on hypertension diseases, skin infections, glottis problems and musculoskeletal disorders. Further, this is the first ever report on these prevalent disorders from Northern Pakistan.

Objectives
This study has been planned with the objective to document the folkloric knowledge of commonly used therapeutic species from different regions of Northern Pakistan, to save the medicinal knowledge. The current work focused to quantitatively calculate consensus of plants usage for treatment of diseases. This study also aims to form a baseline data for future comprehensive research on bioactive constituents.

Study sites
The Northern part of Pakistan in Western Himalayas is situated among world's largest peaks and high heaps i.e., Himalaya ranges, Alai Ranges, Karakorum, Kunlun, Tien Shan and Hindu Kush [34]. The Himalaya ranges have of world largest peak i.e. Mount Everest and K2 present in this range and the lesser Himalayas Mountains are located on 2000-3000 m elevation. Its topography diverges from desiccated rocky areas in north to forest and green plains in the south. Northern part of Pakistan has rich floral variety particularly of therapeutic plant species [35]. The areas included in the research work were Bannu, Swat, Mahnshera, Dir, Abbottabad, Naran, Khaghan, Hazara division, and other tribal areas of northern parts ( Figure 1). It is located at 72°35-to 73°31-east latitude and 33°50-to 34°23north latitudes. It shares border with FATA (Federal Administered Tribal Areas) in the Western South part, in Northern side Azad Jammu and Kashmir, Gilgit Baltistan in north east while the Punjab in south east. Northern areas of Pakistan are home of the largest peaks these covers 72,496 km 2 . Mean lowest temperature in January was documented to be 1.7°C, while average highest temperature to be 32.41°C in June. These Northern areas have also very severe winter with heavy rainfall [33]. The chief tribes of the area are Marwat, Shinwari, Afridi, Mohmand, Abbassies, Tareen, Khattak, Mashwani, Jadoon, Tanolis, Awans, Yusufzai, Sardars, Qureshis and Orakzai [30]. Majority of people speaks Pushto other local languages are Potohari, Gujrati and Hindko.

Ethnobotanical data collection
This work was mainly focused on communities exploiting conventional plant resources for treatment of hypertension, glottis disorders, skin infection, joint pain and throat diseases. The people living in Northern Pakistan have information on the usage of natural resources. The field work was performed for 6 months (from March to September, 2016). Semi-structured interviews were taken from 180 informants having traditional curing methods against variety of ailments after receiving their prior consent. The data about medicinal uses of these plants was collected from local informers and healers and medicinal practionists. Questionnaire forms was comprised of two sections; first section involves the demographic information of participants and the other section contains data about plants vernacular name, part used and mode of administration used against these diseases. Further evaluation of data obtained during field study was done by using quantitative indices.

Plant collection and preservation
The medicinal plants exploited for different ailments in the Northern Pakistan were first collected and vouchers were constituted for identification at Herbarium of Quaid -i-Azam University Islamabad Pakistan (ISL). Correct scientific families and names were confirmed by database of KEW medicinal plant name services (mpns: http://www.kew.org/mpns) and flora of Pakistan [36]. Each plant sample contains vital parts such as stems, seeds, roots, bark, fruits, flowers and leaves, whole plants was generally collected for small herbaceous plant specimen.

Use value citations (UV)
UV was assessed by means of standard procedure of [24].
"u" denoted the total respondent citing different usages of a medicinal species. Use value is usually larger at close to (1) incase numeral of usage is higher and UV of plant noticeably lowers if it is close to (0). Use values do not deliver data for only one or numerous uses of plants.

Relative frequency of citation (RFC)
The computation of RFC was done by using formula: The number of respondents stated by "Fc" that specified about therapeutic use related to herbal medicinal plants whereas "N" stands for numeral total value related to the respondents [37][38][39].

Family importance value (FIV)
FIV of the plant species being evaluated by using formula as under [40].
where "Fc" is the numeral value of respondents stating the use of the family and N denotes to the total numeral value of respondents contributing in the research work.

Fidelity level (FL)
FL is measured by following formula: where "Np" is the numeral value of participants who defined medicinal plants as a remedy for particular ailments while "N" is the total number of informants [41].

Socio-demographic profile of informants
Demographic information of the participants was taken from semi structured questionnaires. A total of 180 respondents were questioned in this field survey. Of the 180 informants, 113 were Indigenous people and the rest (67) were local health practitioners, rest of all information is stated in ( Table 1).

Medicinal plant diversity
Present research stated 80 medicinal plants used to treat some prevalent diseases in Northern Pakistan ( Table 2). These medicinal plants were distributed in 54 families. They show diversity in growth and presented by all growth forms with high proportion of herbs (54%), shrubs (30%) and trees (16%) ( Table 3). The main cause for herbs dominancy in the research area may be the easily accessibility resultant from bulk growing in wild area. The native respondent described that most of the hakims and healers commonly use herbs for treatment of ailments because of their easy attainability and availability.
The recorded medicinal species and medicinal uses along with local name, part used, preparations and mode of utilization had been documented in Table 2. The plant family that have higher number of medicinal specie was Lamiaceae (7 species) followed by (4 species) of Papaveraceae, (3 species) of Malvaceae, Apiaceae, Asteraceae and Brassicaceae, (2 species) Acanthaceae, Pinaceae, Myrtaceae, Rubiaceae, Lythraceae, Plantaginaceae, Cactaceae and Capparaceae, (1 species) Ranunculaceae, Berberidaceae, Saxifragaceae, Umbelliferae, Moraceae, Papilionaceae, Poaceae, Oleaceae, Fabaceae, Salvadoraceae, Solanaceae, Rutaceae, Meliaceae and rest of the families presented one medicinal plant ( Figure 1). Lamiaceae documented higher diversity of medicinal species followed by Asteraceae and Solanaceae; Lamiaceae also indicated greater diversity of medicinal flora plants [42]. Lamiaceae a diverse family with mostly herbaceous plants producing volatile aroma over all aerial parts, has been described as dominant plant family by [43]. In ethnobotanical studies of lesser Himalayas the high percentage of medicinal plants in the families' Papaveraceae, Moraceae and Fabaceae has previously been stated by [44].

Plant parts used as a medicine
In this ethnobotanical study, the part of plant most frequently utilized is was leaves (41%), and seeds and roots (10%) ( Table 4). Leaves were used as main part of plant, it has been stated within different ethnomedicinal research of Thailand, India, Bangladesh, Colombia, Pakistan, and China [45][46][47][48][49][50][51]. Leaves are the dominantly used plant part because it is easily attainable plant part and requires small effort to collect as compared to other plant parts [43]. Moreover, other important fact of leave utilization is important for conservation and maintenances of plant because collection of other plant parts and roots may kill the plant or endangered the specie [52]. Bulk use of whole plant, fruits, seeds, roots and bark in herbal medicinal preparations may results in decreasing population of plants in nature [53].
In earlier described studies from various parts of the Pakistan whole plant, flower and fruit therapy is very common and it is present among the top of the plant parts usage [54]. Rhizomes, roots and fleshy parts of the plant species have a high amount of bio-active compounds [55].

Types of herbal preparations
Medicinal species utilized and administrated in herbal medicines in numerous forms in the area. The common preparation methods were categorized into decoction (33%), powder (14%), paste and extracts (11%), infusion (1o%). Juice (5%), tea (7%), poultice (3%), raw (2%) and Oil and cooked (2%) ( Table 5). There are several routes of administration, such as, topical use and oral ingestion for the treatment of different diseases ( Table 2). Local traditional healers use ingestion to cure most diseases, but topical use is an important route of intake to cure diseases such as skin disorders, glottis diseases, joint pain, hypertension, wounds, and body pain, weakness and poisonous bites [54]. The particular parts of plants and definite quantity of dosages taken for ailments control mainly depends on patients physical health [35].Some individuals use, orange peel, sugar, lemon, banana pulp, tobacco leaf, black pepper and camphor, as adjuvant with various diluents.
Large number of the plant drugs (74%) was made from fresh part of plants neither the dry parts of plants. In this study it was observed that there are ambiguities in taking exact quantities of medicines between the respondents due to variation of person's experiences and difference in ethnical information of the respondents.

Use of phototherapies
This ethnobotanical survey showed indigenous people utilized therapeutic plant species most often for the cure of hypertension (20 reports) followed by cough (14 reports), skin problem (11 reports), rheumatism (10 reports). This survey specified fact that indigenous communities used medicinal plants frequently exploited in skin diseases, respiratory disorders, cough, throat infections, joint pain and hypertension specified that the plant of this zone have versatile medicinal usages against disease [56].The other noticeable diseases were throat infections (10 reports), wound healing (7 reports), Sore throat (5 reports), joint pain (4 reports), skin burn (3 reports). Though, skin problems were followed by pimples and swelling of body (2 reports) and boils and body pain (1 report) ( Tables 2 and 6). Recent studies shown that maximum of local populations were dependent on a diversity of native plant species to treat several diseases as the modern health services were out of reached. It was noticed in throughout the field study that old information of indigenous therapeutic species is about to vanishing upcoming age groups belonging to research region. This is because of absence of attention by modern cultures, as they thought herbal medicines are less useful in comparison to allopathic medicines. Despite the fact when these elder persons die than these conventional medicinal practices might be quickly disappeared [57].

Relative frequency of citation
For examining the ethnobotanical knowledge quantitative analysis was recorded in this study. Most stated plant species identified by a large number of respondents for medicinal purposes. Maximum RFC was documented for Neolitsea chinensis (0.956), Rubia cordifolia (0.928), Parkinsonia aculeate (0.906) and Tagetes erecta (0.850) ( Table 2). These findings are related to the fact that a large number of respondents cited the plant species and RFC directly related to the number of  (2) the comparatively high price of synthetic drugs and non-approach to the systems of medicine [41].

Use value of medicinal plants
Mostly local health practitioners in study area used these species to cure diseases from other communities. The current research showed that the use value varies from 0.094 to 0.006 ( Table 2). Plant species recorded with high use values were Aesculus indica, Abies pindrow, Opuntia dillenii, Nepeta praetervisa, Begonia reniformis and Berberis lyceum. These plants were commonly found in people's homes, the decoction, tea, extract made from leaves was found very effective in hypertension, joint pain and glottis infection. Thus it should be recommended that medicinal plants have maximum UV values, would be further studied for phytochemical and pharmacological evaluation for developing medicinal system of herbal drugs [58]. Neolitsea chinensis (Use value 0.006) revealed least UVs because they were not abundant in the research area. Used value was less in some conditions due to the lower information of the informants about the medicinal plants, that may be of exotic source [59].

Fidelity level (FL)
To find the plant that is most chosen by the respondents for the cure of specific disease is fidelity level. FL in the present study varied from 50 to 99%. Cuscutareflexa (99%), Lawsonia inermis (98%), Daphne mucronata (96%),
High FL values of medicinal plant shows the selection of plant by respondents to cure particular disease [60,61]. These plants might be confirmed as significant medicinal species by further evaluation and assessment by pharmaceutical, phytochemical and biological actions [62]. The species with least FL cannot be ignored as it causes the next generation to control the risk of gradually decreasing medicinal knowledge [63].

Conclusion
The ethnobotanical data revealed that the conventional knowledge of therapeutic plants in the Northern Pakistan is mostly sustained by elders, and this knowledge was transferred from their forefathers. This study revealed that the most frequently exploited plants were present in Lamiaceae and Papaveraceae, The common method of utilization was decoction. Numerical indices of FC, UV, RFC, FL, and FIV reveal that a greater variety of medicinal species is still utilized between the native inhabitants as treatment of various ailments in the study site. Particularly, this ethnobotanical study suggested that the studied species of far-off valley should be further assessed for appropriate research and pharmacological activities to validate their present traditional usage that may help as the primary means to produce plant-derived prescriptions. Future study on the security and usefulness of medicinal herbs, along with ecological and traditional management works, which are required intended for the maintainable development of herbal drugs in the Northern Pakistan.