Pain management: Hands-on therapies in Ayurveda...Ayurvedic external treatment is effective for pain-relief in chronic low back pain Kumar S,et.al. J Alter Comp Med2017;23(2):109 –115

Dr. Priyanka IngleBAMS, MS, PhD, MWC, AD

NAMA 2020, Boone NC

Pain management: Hands-on therapies in Ayurveda

4/25/2020 All Rights Reserved | Restricted Permission 1

Outline

• Pain

• Panch karma• Case study

• Agni karma • Case study

• Recent advancements in Ayurveda pain research


Pain: Chronic


Interplay of Doshas Dosha Sanchaya Prakopa Prashamana

Vata Rukshadi + SheetaDry, etc + Cold

Rukshadi + UshnaDry, etc + Hot

Snighdhadi + UshnaSlimy, etc+ Hot

Pitta Tikshnadi + Sheeta Sharp, etc + Cold

Tikshnadi + Ushna Sharp, etc + Hot

Mandadi + Sheeta Slow/mild, etc + Cold

Kapha Snighdhadi + Sheeta Slimy, etc+ Cold




Interplay of Doshas Dosha Sanchaya Prakopa Prashamana

Vata Rukshadi + SheetaDry, etc + Cold



Pitta Tikshnadi + Sheeta Sharp, etc + Cold

Tikshnadi + Ushna Sharp, etc + Hot

Mandadi + Sheeta Slow/mild, etc + Cold

Kapha Snighdhadi + Sheeta Slimy, etc+ Cold





Panchakarma

Panchakarma


Nasya

Elimination of toxins through

the nose

Rakta Mokshana

Detoxification of the blood

Basti

Enema

Vamana

Emesis

Virechana

Purgation

Snehana Oleation

Swedana Fomentation

PK: who may take it

4/25/2020All Rights Reserved | Restricted Permission

8

NasyaElimination of toxins

through the noseHead and neck related

Vata related diseases

Pitta related

diseases

Kapha related

diseases

VamanaTherapeutic vomiting or

emesisRecent fever, diarrhea,

hemorrhagic diseases, skin disorders, asthma, head and neck

diseases

VirechanaPurgation

Jaundice, ascites, hemorrhoids, gout, constipation, toxicity, old

fever, skin diseases

BastiEnema (Decoction- Niruha) (Oil-

Anuvasan) Vitiated Vata, muscle, bone, sarvanga

disorders

Rakta Mokshana detoxification of the blood

Pitta- Kapha- Rakta, related

PK: who may NOT take it


Vamana• Pregnancy• Vata vyadhi, Ajirna• Hungry, melancholic, weak, ruksha• Hemorrhoids• Ascites

Virechana• Pregnancy• Vata vyadhi, Ajirna• New fever, mandagni, hemorrhage • Who has taken asthanapana basti • Krura kostha

Basti• Signs of snehan++++• Too weak, aam++• Who have taken vamana, virechana• Asthma, Cough, Prameha• Hemorrhoids

Nasya• +++ consumption of water, alcohol,

toxin, sneha • Donated blood, underwent shodhana• Cold, cough, breathlessness • After parturition • Cloudy day

Case study # 1• Patient: XXX male, 36 years old

• Complaints: • ++ back pain – on and off• Pain aggravates on physical stress, low back pain starts by prolong standing

• Investigations (MRI) suggests : Annular tear, posterior bulge L5-S1

• No leg pain/ claudication/bladder- bowel disturbance/ hypothyroidism

• Assessment: • Pain scale – between 8-9 on scale of 10• Weight ++• Anorexia • Tongue – Saam


Approach• Guggulu use

• Aligning the agni and bala

• Asthi and Majja

• Simhanad guggulu

• Aarogyavardhini

• Guduchi, musta, shunthi

• Jalaukavarcharan – Leech therapy

• Kati basti


Outcome • Assessment after 5 weeks of treatment:

• Pain scale – between 3-4 on scale of 10• No morning stiffness• Low back pain- almost complete relief• No pain while traveling

Conclusion• Comprehensive approach of dosha and dhatu- complemented with

shodhana and shaman, could prove more effective in pain control



Agnikarma

What is Agni karma?


• Agni (fire) and karma (procedure): A procedure done by Agni for treating a disease

• Sushruta mentions Agni karma as supreme in all the para surgical procedures

• The procedure primarily involves a topical application of controlled heated rod of specific qualities to treat various kind of diseases and or disorders

• Classification of Agni karma:Dravyas used Location of the

site Nature of disease Type of akriti

(shape/image)Dhatus to be

cauterized

Snigdha Ruksha

At the siteDistal to site

e.g.: Sinus fistula, in-ano

Circle, disc, line, etc

Skin, vessel, muscle, joint, etc.

Agnikarma eligibility


• The patient with pitta prakriti• Hemorrhage • Diarrhea• Retaining foreign body• Debilitated

• Children• Old age• People afraid of procedure• Having multiple wounds already • Unable to perspire

Advised to avoid Agnikarma

• Local involvement of Vata and Kapha doshas • Hemarrhoids • Tumors• Fistula Sinus Cyst Carbuncles • Sciatica • Disorders of Sira, Snayu, Asthi and also in Sandhigata Vata Prakopa

Agni karma – Viddhagni • Ancient Treatment modality, practiced in India for thousand of years

• Sushruta Samhita: defines Shalyatantra as “YANTRA SASHTRA KSHARA AGNI PRANIDHANAM”

• Performed using • metallic instrument called Agnikarma Shalaka or • specialized Agnikarma Unit (Thermal Microcautery Unit)


Case study # 2• Patient: XYZ female, 51 years old

• Complaints: Frozen shoulder (left); restricted joint movements- last 6 months

• No H/O trauma, injury, fall, DM, HT

• No swelling, or any report on inflammation

• Assessment: • Typical frozen shoulder, pain scale 7, side movement up to 40

degree• Pain scale 8 if any further or backward movement


Approach• Viddhagni/ Thermal micro cautery

• Done on 4 most painful positions of movement • Sideway lifting of arm• Rolling it behind towards neck for combing• Backward movement to hook up bra• Pulling zip of dress

• 5 sittings every 3 days along with diet and exercise

• 3 sets of vedhan/ cautery with 6 needles low intensity 3 rounds each sitting

• No additional intervention


Outcome • With each sitting ROM increased Pain scale score dropped by 3

points to be bearable

• In 15 days significant decrease in pain and normalization of ROM

• Capable to do day to day activities

Conclusion• Viddhagni provides effective and fast pain relief for pain associated

with frozen shoulder


Case study # 3


• Patient: ABC female, 45 years old

• Complaints: Early morning heel pain (severe) – early morning – since 4 months

• No H/O trauma, injury, fall, DM, HT

• No swelling, or any report on inflammation

• Assessment: • Pain scale 9• Increased pain after walking, or standing for a long time

Approach• Viddhagni/ Thermal micro cautery

• Done on 3 most painful points of pain on heel

• 4 sittings each every week days along with diet and exercise

• 3 sets of vedhan/ cautery with 6 needles low intensity 3 rounds each sitting

• No additional intervention


Outcome • Pain scale score reduced from 9 to 0 in 4 weeks

• After 4 weeks, follow up on 6th week – patient had no pain while walking or standing

• Started walking as exercise again

Conclusion• Viddhagni provides effective and fast pain relief for pain associated

with Heel pain



Clinical research and studies

Clinical studies


Study Objective Results Conclusion Reference

Agnikarma

Agnikarma and Pathyadi decoction for Ardhavabhedaka (migraine)

N=15,Agnikarma temporal side of face (dot) 1 time/week+Pathyadi 40 ml twice a day (30 days)

Significant relief (P < 0.001) in headache, photophobia and phonophobia; statistically significant (P < 0.05) relief in vomiting, nausea and vertigo

Agnikarma + Pathyadi decoction: effective line of treatment to manage migraine

Kanakhara B, Ayu. 2018; 39(1):56–61

Siravedha and Agnikarma in management of Gridhrasi (sciatica)

Agnikarma (at LS spine & Achilles tendon region-Panchadhatu Shalaka) (n=19)Siravedha (from four Angulas below Knee joint) (n=11)

After Agnikarma: 68.42% (marked improvement) 21.05% (complete relief) In Siravedha: 72.73% (mod. Improvement) 27.27%(marked improvement)

Agnikarma exhibited better effect than Siravedha in mngt of Gridhrasi

Kumar J, Ayu. 2014; 35(3): 270–276

Combination

KAFA trial Additive Complex Ayurvedic Treatment in Fibromyalgia Syndrome Compared to Conventional StandardCare Alone

Fibromyalgia Impact Questionnaire (FIQ) score, Spielberger StateTrait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS) – no difference

Ayurvedic therapy is non-inferior to conventional treatment in patients with severe FMS

Kessler C,et.al. Evi Based CAM 2013; :751403

Clinical studies


Study Objective Results Conclusion Reference

Snehana

Effectiveness of Ayurvedic Massage (Sahacharadi Taila) in Patients With Chronic Low Back Pain

change of mean pain (VAS) from baseline to week 4

N=64;Mean back pain (week 2) significantly reduced from 53.4 ± 18.5 to 21.6 ± 18.2 (massage group) and from 55.3 ± 12.9 to 41.8 ± 19.8 (standard thermal therapy group) (p< 0.001)

Ayurvedic external treatment is effective for pain-relief in chronic low back pain

Kumar S,et.al. J Alter Comp Med2017;23(2):109 –115

Vatari guggulu, Maharasnadi kwatha & Narayan taila in the mgmt of OA knee

gentle massage for 15 min daily up to 12 weeks on affected knee joint pain assessed on VAS and WOMAC

N=142; VAS, WOMAC score and clinical symptoms were reduced significantly from baseline to end of the treatment (P < 0.001).

The combination effective and safe in controlling pain

Mangal A, et.al. JAIM 2017; 8: 200-204

Virechana

Analysis of Virechana karma with Danti avaleha: A retrospective study

Compilation and analysis of 27 case reports of virechana for various ailments

Details on snehena, virechana and its possible complications are mentioned

Depending on kostha- the matra and type of virechana can be decided

Chaganti S, et al. JAIM 2015; 6:300-4

Other studies • A comparative study of Dashamoola Taila Matra Basti and Tila Taila Matra

Basti in Kashtartava (dysmenorrhea) Ayu. 2010; 31(3): 305–310 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221063/)

• Management of tennis elbow by Agnikarma. Mahanta V, et.al. JAIM 2013; 4 (1): 45-47 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667434/)

• Efficacy of Agnikarma Over the Padakanistakam (Little Toe) and Katibasti in Gridhrasi: A Comparative Study. Bali Y, et.al. Int J Ayurveda Res. 2010; 1(4): 223–230 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3059445/)

• Role of Agnikarma in Sandhigata Vata (osteoarthritis of knee joint). Jethava N, et.al. Ayu. 2015; 36(1): 23–28 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4687233/)

• Clinical study of Agnikarma and Panchatikta Guggulu in the management of Sandhivata (osteoartheritis of knee joint). Sharma A, et.al. Ayu. 2016; 37(1): 38–44 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541466/)

• Clinical Trials of Treatment of Acute Facial Paralysis With Pain by Blood-Letting Plus Acupuncture in Patients (https://pubmed.ncbi.nlm.nih.gov/26054203/?from_term=pain+blood+letting&from_pos=5)

• Bloodletting From the Ankle Vein to Treat Sciatic Pain (https://pubmed.ncbi.nlm.nih.gov/24702699/?from_term=pain+blood+letting&from_pos=4)

• Clinical Observation of Blood-Letting to Reduce Pressure Plus Electroacupuncture for Acute Scapulohumeral Periarthritis (https://pubmed.ncbi.nlm.nih.gov/29231387/?from_term=pain+blood+letting&from_pos=3)


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221063/








https://pubmed.ncbi.nlm.nih.gov/26054203/?from_term=pain+blood+letting&from_pos=5






Summary • Apart from herbal approaches- other physical manipulative

approaches could be effective in pain control, possibly are imperative as well

• One must consider the eligibility criteria before employing any

type of physical manipulative approach as well as the regulatory framework before adapting them

• Hands-on training for skill development can foster the success

• Patient safety must always be the prime focus 4/25/2020 All Rights Reserved | Restricted Permission 27

Special thanks to


Vd. Prashant Waghmare Pancha karma expert

Shree Punarvasu Aryurveda,Navi Mumbai

Vd. Uday KulkarniAgni karma expert

Arogyadham,Thane, Mumbai

References1. Dwivedi AP, et.al. AGNIKARMA: A Reference Manual for Ayurvedic Physicians – Information Directly

Extracted from Approximately 3000 Years Old Literature. Ayurvedic, 2(2); Nov 2015: 19-28

2. Shukla R, et.al. AGNIKARMA: A BLESSING FOR PAIN MANAGEMENT. EUROPEAN JOURNAL OF PHARMACEUTICAL AND MEDICAL RESEARCH, 6(1); 2019: 235-238

3. Jadhav DK, et.al. Agnikarma in Ayurved: An Overview. International Journal of Science and Healthcare Research, 3(1); 2018: 39-44

4. Kumar VA. THE CONCEPT OF AGNI KARMA IN AYURVEDA AND ITS IMPORTANCE IN CURRENT AYURVEDIC SURGICAL PRACTICE. International Journal of Applied Ayurved Research, 1(7): 2014.


Thank you!


Back up slides


Ayurvedic perspective

VATA

PITTA

KA

PH

A

Pain


• http://www.elynsgroup.com/journal/article/basti-medicated-enemata


Additional questions

• Do you think physical manipulative methods are best used singularly or in combination with herbal interventions?

• What are the challenges that a practitioner in USA can face with these methods- are these relevant to us here?

• How can one ensure “safety” of patient and practitioner both during these procedures?

• How important or crucial it is to get training on these methods?


Documents

Pain management: Hands-on therapies in Ayurveda...Ayurvedic external treatment is effective for pain-relief in chronic low back pain Kumar S,et.al. J Alter Comp Med2017;23(2):109 –115