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Introduction

Ahara, Nidra and Brahmacharya are the Trayopsthambha metioned in Ayurved classics. Nidra i.e., sleep is one amongst them [1]. Sleep is a state of reduced mental and physical activity, in which consciousness is altered, and sensory activity is inhibited to a certain extent. During sleep, there is a decrease in muscle activity, and interactions with the surrounding environment are significantly reduced. While sleep is different from wakefulness in terms of the ability to react to stimuli, it still involves active brain patterns, making it more reactive than a coma or disorders of consciousness[2]. Nidra is the harmonious feature gifted by nature to the mankind which is an essential phenomenon for maintenance and restoration of both body and mind. In Charaka Samhita, Acharya Charaka has highlighted the importance of Samyaka Nidra that it leads to happiness, fertility, good memory and longevity of life [3]. The importance of sleep is well accepted by modern science also. Sleep is a physiological phenomenon which contributes in conservation of energy, restoration of tissues and growth, thermoregulation, regulation of emotions, neural maturation, memory and learning. It runs according to the biological clock mandatory for the wellbeing of human life’s rhythm. Sleep disorders are commonly under diagnosed and are significant source of concern in the geriatric population. Compared to younger adults, the prevalence of insomnia is higher in middle and older adults and increases with age [4]. Up to 50% of older adults report insomnia symptoms; however, this does not mean that insomnia is a normal part of aging. Sleep onset or initial insomnia is manifested by difficulty falling asleep that occurs at the start of the sleep period [5]. Sleep maintenance or middle insomnia involves multiple and prolonged awakenings during the night [6]. Late insomnia or early-morning awakenings is waking up early on mornings and being unable to return to sleep [7]. Older adults tend to have more challenges with sleep maintenance compared to younger adults, which results in reductions in total sleep time and sleep efficiency [8]. Several other factors are also involved in the disturbed sleep which includes no work after retirement, personal health problems and emotional trauma like death of spouse or family member, various medications. The current prevalence of insomnia is estimated approximately 6%.[9]. Antidepressant dependence is a state of adaptation caused by regularly taking a medication. Someone who is dependent on Antidepressants may experience unpleasant symptoms after abrupt discontinuation or reduction of use leading to serious side effects particularly in elderly patients. Taking all the above points about the use of allopathic medicines, their dependency and side effects, a thought was in mind to overcome insomnia and further to avoid side effects and dependency of allopathic medicine. In Sushrut Samhita the use of Murdhni Tail is mentioned very well in the disorders related to Murdhi (head) [10]. Shirodhara is one of the types of Murdhni Tail mentioned by Vagbhata.

OBJECTIVES

1) To study the effect of Shirodhara with Bramhi Tail in the patients with Nidranasha.

2) To study an Ayurvedic literature about Nidra and Nidranash.

3) To study a deTailed literature about insomnia through modern text.

4) To explore the knowledge of Murdhni Tail in the Ayurvedic text.

5) To evaluate the effect of Shirodhara in the symptoms of Nidranasha in older patients

MATRIALS AND METHODS

Selection of Sample: The patients of age above 60 years and visiting the OPD with the complaints of disturbed sleep (Nidranash) were selected irrespective of sex, religion, region, economic status and educational status.

Shirodhara:

Definition: Shirodhara is a procedure of continuous pouring of a liquid on the forehead of scalp of head. The liquid used can be Tail (seasum oil), Takra (butter milk), Kshira (milk), Kwatha (various medicated decoctions) etc. Nidranash being a Vataja Nanatmaja Vikara (Ch. Su. 20/11) [11] and Vatapradhanta in old age.[12] medicated Tail with Bramhi herb (Bacopa monniera) was used for the purpose of Shirodhara

Size of Sample: 10 patients

Selection of Drug for Shirodhara: A lukewarm Bramhi Tail.

Time duration of the procedure: 30 min

Time of the procedure: 6-7 pm

Duration of the setting :10consecutive days

Place of study:Ojas Ayurved Panchakarma Centre, Nagpur

Procedure: The patients coming to the OPD were asked to sit relax for 10 minutes. Their pulse, BP were monitored on each day of Shirodhara. The patients were asked to lie down in supine position on the Shirodhara table. A roller bandage was applied just above the eyebrows to avoid the spilling of the oil in the eye. A wet cotton piece was also applied on each eyelid to protect the eye from oil. Then the medicated oil with Bramhi was poured in the container use for Shirodhara and a continuous Dhara (flow) has been done over forehead for about 30 minutes duration. The flow was maintained throughout the procedure so as the temperature of the Bramhi Tail. After Dhara patients were asked to wash the eyes with lukewarm water and advised not to expose to wind, sunlight and dust and advised to take bath after an hour with lukewarm water. Patients were also advised to avoid the excessive use of mobile, television, reading throughout the setting of Shirodhara.

CRITERIA OF DIAGNOSIS

Patients having complaints of insomnia (Nidranash) such as

1) Difficulty falling sleep (Anidra)

2) Trouble staying asleep (Alpanidra)

3) Waking up before anticipated wake time

4) Headach (Shirahshool)

5) Fatigue (Angamarda)

6) Worry / Anxiety (Manastap)

7) Lack of drive

8) Mood disturbance

9) Behavioural disturbances etc

CRITERIA FOR SELECTION

1) All the patients above 60 years of age complaining about insomnia and other complains discussed above were selected.

2) Patients with controlled hypertention were selected for the study

3) Patients on antidepressant medicines were also selected.

4) All the patients willing to participate in study were selected.

CRITERIA FOR EXCLUSION

1) Patients below 60 years of age.

2) Patients not willing for trial.

3) Patients leaving the treatment in between were excluded from the study.

CRITERIA OF ASSESSMENT

In this study, the symptoms like sleeplessness, Shirahshool (headach), Angamarda (fatigue), after awakening symptoms, anxiety and nightmares are graded from 0 to 3 grading from no symptoms at all to the pick of it with a total score range from 0 to 18. Then their statuses of severity were noted before starting the treatment and are termed as before treatment values (BT). After administration of Shirodhara for 10 days all these parameters were noted and the scorings are termed as after treatment values AT. The scoring pattern for the assessment of symptomatic relief in insomnia is given below.

A) Sleeplessness

1) Sound sleep                                                                                                                        0

2) Patient gets sleep at night or awakens early in the morning                       1

3) Sleep disturbs at midnight due to any reason and does not                        2

  get sleep afterwards

4) Doesn’t get sleep at all                                                                                                  3

B) Shirahshoola

1) No symptoms                                                                                                                    0

2) Mild degree (Occasionally complaints)                                                                  1

3) Moderate degree (once or twice in 2 – 3 days)                                                    2

4) Severe degree (daily complaints)                                                                             3

C) Angamarda

1) No symptoms                                                                                                                    0

2) Mild degree (Occasionally complaints)                                                                  1

3) Moderate degree (once or twice in 2 – 3 days)                                                    2

4) Severe degree (daily complaints)                                                                             3

D) After Awakening symptoms

1) Fresh (Sukhavabodhana)                                                                                             0

2) Sleepy or fatigued                                                                                                           1

3) Poor concentration                                                                                                        2

4) Tense, irritable                                                                                                                  3

E) Anxiety

1) Not present                                                                                                                        0

2) Mild: seems anxious, tense posture                                                                        1

3) Moderate: clearly very tense, fearful expression                                               2

4) Severe: continually agitated, pacing                                                                       3

F) Nightmares

1) No symptoms                                                                                                                    0

2) Mild degree (Occasionally complaints)                                                                  1

3) Moderate degree (once or twice in 2 – 3 days)                                                    2

4) Severe degree (daily complaints)                                                                             3

Discussion

In this study patient suffering from Insomnia had average of 63.84% of relief, the percentage reliefs in each symptom taken for the study is as mentioned in Table-3. Out of the 10 patients selected for the study 40% were of age group 60 to 65 years and 30-30 % patients were between 65 to 70 and 70 to 75 age group respectively (Table-1). 60% patients of this series were female and 40 % were male (Table-2).

The data was assessed as percentage of relief as below. The sleeplessness symptom had the percentage relief of 72.22 in all 10 patients, Shirahshoola and Angamarda got 50% relief. 70.59 %, 62.50% and 77.78 % reliefs were observed in the after awakening symptoms, anxiety and nightmares respectively (Table-3)

Conclusion

In Sushrut Samhita the use of Murdhni Tail is mentioned very well in the disorders related to Murdhi (head). Shirodhara is one of the types of Murdhni Tail. Sushruta highlighted its importance in the Tarpan of Prana (nourishment of Prana Vayu in the brain) [13]. It is noted that the continuous use of Shirodhara over a certain period of time dilates the blood vessels supplying to the brain (circle of Willis) leading to calmness of mind and sound sleep by increasing the perfusion of oxygen to brain tissues.

While doing the Shirodhara procedure the redness in the eyes of the patient is observed which might indicates the increased blood flow through the blood vessels. In Sushrut Samhita the Nidranash or Anidra is supposed to be caused by the vitiation of Vata and Pitta Dosha [14] predominantly Vata. Shirodhara alleviates vitiated Vata and Pitta [15]. In elderly patients’ vitiation Vata is there. By Tarpan action vitiation of Vata might be restored to normal condition. In Charak Samhita the Nidranasha is considered as the Nanatmaj Vikara of Vata Dosha and there is not best drug than Tail to alleviate the vitiated Vata Dosha [16]. Thus, Shirodhara reduces the vitiation of Vata reducing the resulting phenomenon i.e., Nidranasha. There was no any side effect which was observed in the administration of Shirodhara neither the dependency of it has been noted. It is very obvious from this study that Ayurvedic concept of management of Insomnia plays major role in present era to serve mankind. It will be of interest to compare the treatment like this with standard established having large number of samples.