Disabled children are of exceptional burden to the family and society.¹ Cerebral palsy (CP) is the most common motor disability in paediatric inhabitants affecting function and development.² It is the leading cause of chronic disability in children.¹ Unani System of Medicine (USM) has a separate branch of clinical specialization for the paediatrics age group known as Ilmul Aṭfāl. There is no single disease available in Unani classics texts, which can be correlated with cerebral palsy (CP) as it is a multifactorial disorder with complex clinical conditions. The terminology for CP in the classical Unani literature is Fālij-ī-Dimāgh. Some conditions that can be correlated with the symptoms of CP include insomnia, behaviour disorder due to weakness of the brain, convulsions, anxiety, depression, apoplexy, paralysis, muscular spasticity and stretching of muscles, facial palsy, tremors, and mental deficit. Injuries to the brain or associated structures, compression or dislocation of the spinal cord, as well as lingering effects of acute illnesses like meningitis, and any obstruction in the course of nerves are the causes of Fālij (paralysis).^3–5 Ibn Sīnā (980-1037 A.D) proposed that there are disturbances in the normal function of the body also include congenital causes, morbid cold dystemperament, trauma and injury. ⁶

The global incidence of CP is about 2.5 or 3 cases per 1000 live births.^1,7 CP incidence is estimated at around 3 cases per 1000 live births for India, nonetheless, the actual figure may be much higher being a developing country. The causes of CP may be foetal, natal, and environmental.¹ Children with CP are at a greater risk of these musculoskeletal anomalies deteriorating and progressing further as the disease progresses naturally. For these kids to receive successful therapy, a thorough is required.⁴

The aim in the management of moderate to severe CP children is to help the child acquire activity of daily life (ADL), improve quality of life and have a sense of belonging as a family member socially and emotionally. The latter is dependent on the child gaining improvement in cognitive functions, for which no recognized, established and accepted treatment exists.⁶ Up to this point, conventional medicine has not developed a treatment for underlying brain injury that is successful. The ideal paradigm for the medical treatment of children with CP throughout their lifespans to manage numerous related and secondary disorders is a multidisciplinary team approach.^1,9 There is currently no known cure for the disease, despite the best efforts of cutting-edge technology and highly expensive, intricate therapy.¹ Unani Medicine adopts a holistic approach to treating the patients keeping in mind the relation to daily routine and environment (physical as well as moral). The line of treatment available to treat cerebral palsy in USM is Ta‘dīl-i-Mizāj, Muqawwī-i-A‘ṣāb (nervine tonic), and Muqawwī-i-Dimāgh (brain tonic).⁶ Therefore, an effort was made to treat ⁵ years male child with quadriplegic spastic CP using a holistic approach with Unani treatment modalities including ‘Ilāj bi’l Tadbīr (Naṭūl, Dalk) and oral treatment. Anthropometric measurements, developmental milestones, and spasm analysis were used to evaluate the treatment's effectiveness.

Patient information and clinical history: A 5-year-old-male child with globally delayed milestones, contracture with marked spasticity in lower extremities and mental retardation and a known case of quadriplegic spastic cerebral palsy visited outpatient of Amrāḍ-i-Aṭfāl at A & U Tibbiya College. He was diagnosed as CP at the age of 2 years in an allopathic hospital with level 4 of the Gross Motor Function Classification System (GMFCS). He belonged to a middle-class Muslim family. The education of Father was 12^th standard who was currently working as a factory employee. The mother was educated till the 10^th standard and was a housewife.

The prenatal history of the child was uneventful. The mother's age was 21 years and had no specific history of disease or medication in the prenatal period. The birth history revealed that he was delivered on 21 July 2011, full term by lower segment cesarean section (LSCS). The indication for LSCS was mother had previous LSCS with a birth weight of 3 kg. The postnatal history revealed that the baby did not cry soon after birth. He was admitted and hospitalized for one week in Neonatal intensive care (NICU) for birth asphyxia, and convulsions. He developed jaundice on day 3. Parents revealed that there was a delay in the development of milestones and the child could not achieve normal growth and development. The mother reported that the child was not able to hold the neck properly; spasticity and involuntary movement were noticed at the age of 6 months. The child started sitting at the age of 15 months and standing with support at the age of 2 years. At 10 months of age, the child started using monosyllabic, aaa, baa, etc. Since then, the parents started treating the child but found no significant benefit. The child underwent physiotherapy. They approached us for further management at the age of 4 plus years. The history also revealed that for the last 4 years, the child did not have convulsions. The family history showed second-degree consanguinity in the parents with no other family history of any congenital anomalies. The immunization history of the child showed that all primary vaccination was received. The personal habit of the child was eating only semi-solid food as there was difficulty in swallowing and chewing the solid food. His appetite was poor according to his age and his sleep was disturbed (6–7 h/24 hours in 2-3 intervals). The stool was brownish yellow and the child had a history of constipation and passed stool once in 2 days.

Clinical findings: All the activities were assisted. Drooling from the mouth was present. The Mizāj of the child was Bārid wa Yābis. General examination showed lean and thin build, mild pallor, hair blackish brown skin wheatish and dry, tongue coated, and a convergent squint in both eyes. The hearing BERA screening showed 35db, indicating normal hearing. The speech was alerted and was able to say only bisyllabic babbling was present. He was conscious but not alert and the behaviour was hostile. Vitals were normal. The systematic included cardiovascular, respiratory and per abdomen examinations no abnormality was detected.

Diagnostic assessment: The diagnostic assessment included anthropometrical measurement, developmental milestones, spasm scale, reflex scale, and muscle power grading.

Diagnosis: The diagnosis was confirmed as Quadriplegic spastic CP as a sequel of postnatal hypoxia.

CP is classified into four types viz., spastic, ataxic, dyskinetic, and mixed. Dyskinetic CP includes athetosis and dystonia (4%-7%), whereas ataxic CP and hypotonic CP constitute 4%-6% and 2%, respectively.⁷ Spastic CP is the most commonest type, among all the types of CP, occurring in 70–80% of all cases.¹ Spastic CP is further sub-classified into hemiplegia (38% of all spastic CP cases), diplegia (37%), and quadriplegia (24%). Multiple epidemiological studies report that half of the children who develop CP were born at term without any identified risk factor.⁷

Cerebral palsy (CP) as it is a multifactorial disorder with complex clinical conditions therefore, there is no single disease available in Unani classic texts, which can be correlated. However, some causative factors are linked to its aetiology and pathology is described in many chapters of Unani classical texts and can be correlated with the symptoms of CP that include Sahar (insomnia), Ru‘unat (behaviour disorder due to weakness of the brain), Jumūd (obstruction produced in the brain resulting in stoppage of sensory function and body movements), Ṣar‘ Dimāghī (convulsions), Junūn wa Sabat (anxiety, depression, violent behaviour), Ḍu‘f-i-Dimāgh (weakness of brain), Abūblaqsiyā (apoplexy), Fālij (Paralysis), Tashannuj Īdhā’ī (muscular spasm), Tamaddud (spasticity and stretching of muscles), Laqwa (facial palsy), Ri‘sha (tremors) Khadar (numbness), Ḥawal (squint), Tashnak (weakness/sub-acute inflammation in brain especially in children), Ḥumq (imbalance in routine work and social behaviour), and Ikhtilāṭ al-‘Aql (mental deficit) or Fālij-ī-Dimāgh. According to USM, injuries to these structures, compression or dislocation of the spinal cord, as well as lingering effects of acute illnesses like meningitis and Insidād-i-Aw‘iya/Sudda (any obstruction) in the course of nerves caused by Balgham Ghalīẓ (phlegmatic humour in the brain or neurons), are the causes of Fālij (paralysis).^3,4 Imtilā’ī Balgham first manifest in the region of the Baṭn-i-Dimāgh (brain's ventricles), where it abruptly dissolves. From there, Balgham falls to either the left or right side of the body, depending on which side is weaker.⁵ Ibn Sīnā (980-1037 A.D) proposed that there are disturbances in the normal function of the body in Humuq whereas impairment of thought is found in Ikhtilāl-i-Aql. Ikhtilāl-i-Aql is a condition of the mid-brain, the probable causes include Asbāb-i-Khilqī (congenital causes), Sū’-i-Mizāj Bārid (morbid cold distemperament) and trauma and injury.⁶

The spasm scale improved by 30%, and the manual ability categorization system improved by 30% as a result of decreased spasticity and increased ROM. Figure 2 depicts the child's improvement after he was able to stand without assistance. With the holistic and individualized approach with Unani medicine adapted to treat CP in children, the effect might have been achieved due to the localized application of Muḥallil-i-Auram Harr oils through Dalk Layyin. The line of treatment available to treat cerebral palsy in USM is Ta‘dīl-i-Mizāj, Tanqiya’-i-Dimāgh (cleansing of morbid matter/humour from the brain), Istifrägh-i-Mawäd (removal of morbid matter), Muqawwī-i-A‘ṣāb, and Muqawwī-i-Dimāgh.⁶ CP is incurable. However, improvement in quality of life and prevention of spasms and contractures is required. CP treatment needs long follow-ups. Sixty-day treatment included Habb Ayarij followed by Sharbat Ustukhuddus orally. Sharbat Ustukhuddus with Inkabab of Muḥallil-i-Auram medicine was given 10 min for 5 days. After 5 days of Inkabab, Naṭūl with Roghan Babunna followed by Dalk Layyin was advised regularly till improvement in symptoms.¹⁰ Dalk Layyin with Härr Mizäj (hot temperament) oils have Muhallil (anti-inflammatory) and Muqawwī-i-A‘ṣāb, actions are recommended to dissolve the causative matter and potentiate the nerves.¹¹

The delayed development of gross and fine motor functions could be related to an issue with the brain's normal function. As a result of Muqawwi-i-A‘sab wa Dimāgh properties of Unani medicine, increase brain function and are recommended to obtain results in developmental diseases. Here, improvement in growth has been achieved by Ta’dil-i-Mizāj and Tanqiya’-i-Dimāgh with Habb Ayarij and Sharbat Ustukhuddus. The ethnomedicinal properties of L. steochas include Muhallil (anti-inflammatory), Mundij (concoctive), Muqawwi (tonic), Mulattif, Munaqqi-i-Dimāgh (cleansing of the brain), Muqawwi-i-A‘sab, Munawwim (sedative), Mushil-i-Balgham (phlegm purgative), Mushil-i-Sawdā’ (Black bile purgative), Muharrik-i-A‘sab (nervine stimulant), Mufarrih Qalb (exhilarant), Muqawwi-i-Badn (general tonic), Kasir-i-Riyah (carminative), Dafi-i-Tashannuj (antispasmodic), Muqawwi-i-Qalb (cardiotonic), Musakkin-i-A‘sab (nervine analgesic), and Muqawwi-i-Mi‘da (Stomachic).¹² Lavender has a long history of medicinal use and possesses anti-depressive, neuroprotective, antioxidant, anticonvulsant, sedative, anxiolytic, and calming properties. Some medieval physicians including Ibn Sīnā and Rāzī recommended lavender for the treatment of epilepsy and migraine. Lavender is also thought to be helpful in the treatment of pain and tremors.

Linalool, which is found in lavender, inhibits acetylcholine release and modifies ion channel activity at the neuromuscular junction. The effects of lavender on motor activity and their link to dopaminergic neurotransmission were investigated, and it was shown that intraperitoneal administration of lavender greatly boosted rotarod activity and improved dopamine receptors subtype D3 in mouse olfactory bulbs. The cholinergic system is thought to have a role in lavender's analgesic, antianxiety, anti-depressive, and anticonvulsant properties. It has been claimed that certain medicinal herbs have good impacts on cognition.¹³

Habb Ayarij is useful in chronic headaches, melancholy, paralysis, facial palsy, epilepsy and other diseases of the brain. Cleans the brain from toxic substances as it possesses Mukrij’-Akhlat Salasa wa Ghaliz property of the brain and stomach.¹⁴

Muqawwī-i-Dimāgh wa A‘ṣāb drugs such as Majun Falasfa, Khamira Marwareed and Khameera Gauzaban are used for toning up the brain, nerves and heart and to improve its faculties as they possess Muqawwī-i-Qalb wa Dimāgh properties.¹⁴ Muqawwī drug such as Majun Falasfa strengthens organs of the body for their optimal functions.¹⁵

Matricaria chamomilla (Chamomile) is beneficial in reducing spasms as it possesses antioxidant, anti-inflammatory, relaxant, antispasmodic, and analgesic activities. Chamomile's apigenin ingredient decreases the impact of hormones on the body and mind as well as excitation neurotransmitters, therefore relaxing the overactive sympathetic nervous system. It influences the activity of dopamine and serotonin. Furthermore, suppressing the COX enzyme lowers pain feeling and the immune system's inflammatory response. Its essential oil also contains antispasmodic and calming properties, making it useful for symptom relief. Because CNS stimulating molecule is a nerve relaxant, it is also beneficial for stress and anxiety reduction as Apigenin, Luteolin, Glycine, and flavonoid. Enhancers have been reported to be usually safe.^16,17

Chamomile's potent bioactive plant metabolite, a flavonoid, stimulates the CNS. Apigenin and Luteolin, two bioactive compounds, operate as antianxiety and pain relievers by binding to benzodiazepine receptors.¹⁸ Chamazulene, which is contained in chamomile extract, has been linked to anti-inflammatory properties. Both matricine and (-)-alpha-bisabolol have anti-inflammatory and analgesic properties. (-)-alpha-bisabolol, spiroethers, and apigenin have spasmolytic properties.¹⁹

Melia Azedarach L. leaves were beneficial to reduce spasms as they possess ethnomedicinal properties including Muhallil-i-auram, Muqawwi-i-alm, Mulayin, and Duf-i-Huma properties.²⁰ It contains bioactive molecules flavonoids, acids, steroids, terpenoids, alkaloids, anthraquinones, saponins, and tannins. Terpenoids and limonoids found in the leaves include l-Cinnamoyl-3-acetyl-11-hydroxy meliacarpin, l-Deacetyl salannin, -Pinene, -Pinene, Terpinene, Terpineol, Kaempferol-3-O--rutinoside, Kaempferol-3-L-rhamno-D-glucoside, and Rutin.²¹ Further it is also proven pharmacologically as an antioxidant, anti-inflammatory, analgesic, muscular relaxant, antispasmodic, and analgesic activities.^21,22

Dalk and Naṭūl provide nourishment as musculoskeletal cells can sense incoming mechanical signals using a diverse group of transmembrane mechanosensitive proteins (mechanosensory). Mechanical stimulation of the mechanosensory translates the mechanical signal into a biochemical signal (biochemical coupling), which activates intracellular signalling cascades and results in mechanical stimulus activation. As a result of the mechanical stimulus, the atrophied muscles regain strength.²³

To the best of our knowledge, this is the first case report on CP and holistic approach including ‘Ilāj bi’l Tadbīr and internal Unani medications to improve all the facets of spastic CP. It is important to recognize that while cerebral palsy (CP) remains an incurable condition, Unani Medicine has shown promise in alleviating some of its symptoms and improving the quality of life (QOL) for affected individuals. It's crucial to understand that treating a condition like CP, particularly in children, holds significant value. Even modest advancements in their condition at an early age can translate into substantial benefits as they grow, aiding in skill development and overall well-being. Thus, the implementation of Unani treatment modalities, including oral medications and 'Ilāj bi’l Tadbīr,' is a step toward enhancing the daily lives of children whose activities are hindered by CP-related impairments.

This observed improvement aligns with the concept of neuroplasticity, demonstrating the capacity of the nervous system to adapt and reorganize. Based on the findings of this case study, it is reasonable to infer that Unani Medicine, in combination with 'Ilāj bi’l Tadbīr,' offers a potential avenue for enhancing the lives of children with CP. While CP remains a challenging condition, this holistic approach offers hope and an opportunity for enhanced QOL and functional outcomes in affected children. The limitations are it was a single case study, so it is difficult to apply such a study to most patients, and it seems that there are limitations in interpreting the results of this study. Furthermore, Phase II and Phase III randomized controlled trials are recommended in large sample sizes. Further, the pharmacodynamics and pharmacokinetics of medicinal plants and the mechanism of action of Dalk and Naṭūl are suggested.

It is important to recognize that while cerebral palsy (CP) remains incurable, Unani Medicine has shown promise in improving the quality of life (QOL) and alleviating some CP symptoms. This case, with a 30% overall improvement, highlights the value of early intervention, especially in children, as even modest progress can significantly impact their development and well-being. Unani treatments, including oral medications and 'Ilāj bi’l Tadbīr,' offer hope for enhancing the lives of CP-affected children. This observed improvement aligns with neuroplasticity principles, showcasing the nervous system's adaptability. Further research is needed to fully harness Unani Medicine's potential in CP management.