JR.A.S. Vol. XXX, No.2, April- June ·09 pp. 57-70

A PRELIMINARY STUDY ON EVALUATION OFCLINICAL EFFECT OFAGNlKARMA CHIKITSA

ON PARSNISULA (PLANTAR FASCITIS)

G. Kusuma', A. Mitral, V. C. Deepl, P. Madhavi Kutty', P.K.S. Nair',V. A. Prabhakaran- and N. Jaya'

(Received on 18-01-2006)

Females of late 30 S commonlysuffer with a clinical condition calledParsnisula. In this condition the patientexperiences severe pain under the heel(parsni). The characteristic feature ofparsnisula is pain which will getincreased during walking or standingfrom sitting posture. After few steps thepain will get reduced.

Not much description is available inclassical literature of Ayurvedaregarding Parsnisula. It can becompared with plantarfascitis of modernmedicine based on the symptomatology.

Modern practitioners usuallyprescribe NSAID s and protect heel bya resilient cushion on an insole. If painis not relieved then local injection of

hydrocortisone into the tender area isthe alternate.

Whereas in Ayurv edic system ofmedicine Agnikarma-an Ayurvedic para-surgical procedure has been indicatedand practiced in this condition byancient physicians of Ayurveda sincecenturies.

In support of this, a preliminarystudy has been carried out by CentralResearch Institute, Cher uth uruthy.Keral a and 30 patients in total haveaccepted the trial procedure andAgnikarma therapy was performed overthe affected heel. On the basis ofclinical improvement by symptomaticobservation encouraging results wereobtained by the study.

1. Research officer (Ayurveda), 2. Asst. Director (Ayurveda), 3. Asst. DirectorIncharge. P.O.-Cheruthruthy, via shora nur, Thrissur Dist. Kerala

57

G. Kusuma, A. Mitra et a/.

Introduction

Parsnisula is a common clinicalcondition found especially among femalesin late 30's, In this condition .the patientexperiences unbearable pain under theparsni (heel) (S,Sa,SI19) particularly duringwalking or standing from sitting posturewhen the weight of the body is carried bythe heel and quite common during earlymorning after getting up from bed,

Not much description is available inclassical literature of Ayurveda regardingParsnisula. As Vata is mainly responsiblefor pain in the body, so Parsnisula can beconsidered as a Vata predominant disorderwhere characteristic pain is the cardinalsymptom.

Parsnisula of Ayurveda can becompared with plantar fascitis of modernmedicine. Plantar fascitis is a commoncause of heel pain in adults. It is otherwisepopularly known as Policeman's heel ortender heel pad and is characterized by painbeneath the hind part ofthe heel (anteriorpart of the calcaneus) (Fig. I0 & Fig.ll)on standing or walking from sitting posture.The cause may be a small tear in theattachment of plantar fascia to the os-calcis(Fig.9).Non specific infection fromnon specific urethritis or from specificgonococcal infection may also develop inthis condition. Sometimes a bony spur atthe attachment of the plantar fascia maybe the cause. This mayor may not be thecause of pain. The site of the tenderness isthe tough fibro-fatty tissue beneath the

prominent weight bearing part of thecalcaneus. In most cases mild inflammationof uncertain origin will be there but in somecases the lesion is only a simple contusion,Pain beneath the heel extending mediallyand into the sole on standing or walking isthe only symptom. The disability issometimes severe, On examination thereis well marked local tenderness over thesite of attachment of the plantar fascia tothe calcaneus on firm palpation over theheel pad. The site of tenderness is fartherforward than it is in tender heel pad,Radiographs usually do not show anyabnormality. There is a tendency to slowspontaneous improvement. Recovery maybe hastened by providing a sponge-rubberheel cushion on an insole and by localinjection of hydrocortisone or by a courseof short-wave diathermy to the tender area,

Central Research Institute (tv.).

Cheruthuruthy is a reputed Institute o. thearea and popularly known as Institute ofexcellence in Panchakarma whereinPanchakarma procedures are practicedregularly with good results, Patientssuffering with Parsnisula visit to O,P,Dof this Institute very frequently,Agnikarma (a Para-surgical procedure)has been indicated and practiced inParsnisul a by ancient physicians ofAyurveda since centuries, This has drawnour attention towards the disease and madeus to carry out a pilot study of 6 weekstreatment with Agnikarma over 36selected patients at O,P.D level.

58

A PRELIMINARY STUDY ON .. ,.

Material and Methods

I. Selection of Patients

Those Patients were selected fromOPD who have suffered from Parsnisula(with special reference to Plantar fascitis)having less than 2 years of history with allcardinal features irrespective of age, sex,religion and occupation etc.

1.1 Inclusion criteria

* Age between 12-60 years.Patients of either sex,With less than 2 years of history,With all cardinal features of the disease(i.e , Tenderness, Pain, localizedswelling, Pain increased duringwalking from sitting posture/rest)

1.2 Exclusion criteria

***

* Any con com itant serious disorder ofthe liver, kidneys, lungs, eye and/ormulti-systemic involvement, i.e.Diabetes mellitus, Chronic Renalfailure, Bronchial asthma etc.

* Any other drug treatment beingreceived simultaneously that influencedthe positive study outcome.

* Without clear signs and symptoms,

* Other related cases like fracture ordiseases of Calcaneum (Osteomyelitisor tumor or Paget's disease) ,arthritisof the subtaloidjoint, Calcaneum Spur,Tendo Achilis bursitis, retrocalcaneumbursitis, Apophysis of the Calcaneum

(Sever's disease) and rupture andparatendinitis of the tendo Achilis,infracalcaneum bursitis, Rheumatism,local Cellulitis etc. Ski graphic viewswere taken for exclusion from thestudy.

* Age below 12 years and above 60years.

1.3 Number of Patients36 (Thirty Six)

1.4 Duration of therapy (Agnikarm«i6 weeks

2. Agnikarma Chikitsa is the methodof producing Samyak Dagdh aVrana at diseased part of the patient.It is a therapeutic burn, Th isUpakrama (method of treatment) isdivided into three parts (S,Su.5/4)i.e. Purvakarma (pre-operativepreparation), Pr adhan akarma(Operation proper) andPasc atkarma (post-operativemanagement). Disease produced byVata and Kaph a dosa may betreated successfully by this methodof treatment.

2.1 Purvakarm a (Pre-operativeproced ure/preparotions)

Collection of the materials required

for the Agnikarma therapy forms the

prime pre-reqisite. PanchalohaShalaka, Patra of Ghritakumari

(Aloe vera) and mixture of Ghrita

S9

G. Kusuma, A. Mitra et al.

and Madhu is kept ready prior to theactual procedure.

Localized anti-septic dressing(ASD) of affected part of the patientwas done every time before principalprocedure. Patients were allowed totake langhu ahara (light food) 30minutes before the actual procedureto avoid fasting condition andassociated weakness.

2.2.Pradltallak(lrmaprocedure)

(Principal

After anti septic dressing (ASD), theproper procedure i.e.AgnikarmaCikitsa was done with Shalaka madeup of Panchaloha (Gupta P. D.,)1993) as panchaloha Shalaka is saidto be ideal produce SamyakDagdha Vrana (S.Su.12/8).Panchaloha Shalaka was kept onfire and heated red hot and appliedover the affected area or diseasedpart i.e. hee I frequently to produceSamyak Dagdha Vrana along with theapplication of the pulp ofGhritakumari (Aloe vera) inbetween to prevent burns if excessheat is applied and to reducedagdhaVedana(burning pain). The type ofAgnikarma adopted isTwakdagdha S.Su.1217) and is doneinBindu Akriti or dot pattern(S.Su.12/II). This method of AgnikarmaChikitsa is result oriented having nocomplication and easy to carry out.

The total procedure may becontinued for maximum 15 minutesand the sittings of Agnikarma Chikitsavaries depending on the severity andchronicity of the disease andpatient's condition. Agnikarma wasdone in 6 sittings. I sitting per weeki.e.6 sittings in 6 weeks.

2.3. Paschatkarma (Post-operativeprocedure)

As per guidelines of Susruta(S.Su.12/13), mixture ofGhritaandMadhu (may be due to its soothingeffect) is anointed over the heel afterthe principal procedure.

2.3. Assessment criteria for evaluation

The results were on beforetreatment, 14u1 day, 28th day and aftertreatment (42nd Day). The fourcardinal signs & symptoms weretaken for assessment Iike Pain inmorning, tenderness of heel, typicalpain increased when standing/walking/ running after getting upfrom sitting posture and localizedswelling. The clinical improvementof disease condition was evaluatedon the basis of signs and symptomsby means of arbitral)' scoring index,where 04 indicated severe and 03indicated marked or fair, 02 indicatedmoderate, 0 I for mild or poor and 0

60

A PRELIMINARY STUDY ON. .....

for nil or none. The results wereevaluated before treatment, 14thday,28th day, and after treatment (42nd

Day).

Observation & Results

1. Demographic data

1.1. Age & sex ratio

Total 36 patients were selected forthis present study where 30 patientshave completed the 28 days trial. Allpatients were female (J 00 %) andno male patients have been seen.Most of patients (J 4 cases) werebelongs to middle age group (31-40years) in the pre-menopausal age(fig. J).

1.2 Religion wise classification

From the present study it is observedthat 76.6 % patients belong to Hinducommunity and 23.4% patients arefrom Muslim community (fig.2).

2. Symptomatological assessment

The signs and symptoms wereassessed by the scoring index on 0day, J 4th day, 28th day and 42nd day

12-20 Years51-60 Years 0% 21-30 Years

13'Y<~20%

41-50 Years20"/0

31-40 Years47%

Fig 1: Age- Sex ratio of trial cases ofParsnisula

of treatment. Pain in rest andmorning had been reducedsignificantly after treatment (p<0.00 I) when compared with 0 dayvalue (Table-I,fig.3). One of themost common objective criteria of(plantar fascitis) is tenderness of

heel. It was also scored oy armtraryindex and treated patients have gothighly signification response (p<0.001) when compared with thevalue of before treatment(Table-IIfigA). It is also observed that treatedpatients have got good responsefrom typical pain increased whenwalking/ running after sitting orresting posture. Treated patientshave got significant response (p <0.001) when compared with 0 day

Value (Table-III, fig 5). Treatedpatients also have got very goodresponse from local swelling oredema (p<O.O1) when compared witho day value (Table-Iv, fig.5 & 6).

Christian0%

Muslim Others

23~-:.:77%

Fig 2: Religion wise demographic data ofParsnisulu cases

61

G. Kusuma, A. Mitra et al.

Table I : Clinical improvement of tenderness of heel in Parsnisula cases

o day 7th day 14th day 21st day

1.03 ± 0.148*2.57 ± 0.160 1.83 ± 0.128* 0.5 ± 0.142*

* p<O.OOI, values are mean ± SEM, where n =30

3.5

2.5

1.5

0.5

3 287

2

-2.13

-"

It';1.5

-~-

0.63-

Io day 7th day 14th day 21st day

Fig 3 : Clinical improvement of Local 12ed-pain in heel of Parsnisula cases

3

2572.5 -I·,

- ~-.,,~

E

-

1.03- I!l

0.5--

I ~Ii!!

"'";w

2

1.5

0.5

oo day 14th day 28th day 42nd day

Fig 4 : Clinical improvement of tenderness of heel in Parsnisula cases

62

A PRELIMINARY STUDY ON.....

Table III : Clinical improvement of typical pain in standing/walking just aftersitting or laying in Parsnisula cases

o day 14thday 21st day

2.1± 0.140 1.37 ± 0.l39* 0.90 ± 0.129* 0.40 ± 0.132*

* p<O.OO1, values are mean ± SEM, where n =30

2.5

2

1.5

0.5

o

2.1

0.26 ± 0.095*

14th day

09

0.4

Do day 14th day 28th day 42nd day

Fig 5 : Clinical improvement of typical pain in standing/walking just aftersitting or laying in Parsnisula cases

o day

Table IV : Clinical improvement of localized swelling in heel of Parsnisula cases

14thday 21st day

0.47 ± 0.120 0.13 ± 0.079* 0.10 ± 0.073*

* p<O.OO1, values are mean ± SEM, where n =30

0.50.45

0.40.35

0.3

0.25

0.2

0.15

0.1

0.05o

0.47--

113--

0.26--- tA 0.11

0.1- I~

- Io day 28th day 42nd day

Fig 6 : Clinical improvement of localized swelling in heel of Parsnisula cases

63

G. Kusuma, A. Mitra et al.

3 ~Pain

3.5

2.5

~ Typical painduring walking

.....~....Local swelling

___ Tenderness2

1.5

0.5

o14thday

o day 28thday

42ndday

Fig 7 : Global assessment on symptomatic in improvement in Parsnisula cases

1614

'" 12.•...cCoI 10.•...C'iI

Q., 8'-<:> 6QZ 4

20

---

--

-I---

I---

I--- -

Fair Response PoorResponse

GoodResponse

No Response

Result of the study

Fig 8: Individual assessment as per subjective scoring of Parsnisula cases

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A PRELIMINARY STUDY ON .....

Fig 9 : Showing Plantar fascia

Fig 10 : Showing most common site (Ieteral view) of in Parsnisula

Painoftenhere

Lateral Side

Medial Side

() Plantar Fascia

Fig 11: Showing most common site (Inferior-superior view) of pain in Parsnisula

65

G. Kusuma, A. Mitra et a/.

DiscussionPlantar fascitis is an inflammation of

the plantar fascia. "Plantar" means thebottom of the foot; "fascia" is a type ofconnective tissue, and "it is" means"inflammation".

Pain in the heel may be subdivided into3 types.

(a) Pain within the heel

(b) Pain behind the heel

(c) Pain beneath the heel

In conditions like fracture or diseaseof the calcaneus (osteomyelitis or tumoror Paget's disease) and arthritis of thesubtaloidjoint there will be pain within theheel and in tendo Achilis Bursitis,retrocalcaneum bursitis, apophysitis of thecalcaneum (Sever's disease) and ruptureand paratendinitis of the tendo achillis painwill be behind the heel.

Whereas in infra-calcaneum bursitisand plantar fascitis (Policeman's heel) painwill be beneath the heel.

Sometimes parsnisula is wronglycorrelated with Calcaneal spur. Calcanealspur is a bony projection forwards fromundersurface of the calcaneal tuberosityand is usually revealed in X-Ray. It's nothingbut ossification of the plantar fascia at itscalcaneal end. This has very littlesignificance so far as the pain in the heel isconcerned. That means if a patientcomplains of pain in the heel and on X-Ray one can find the presence of

calcanean spur, the clinician cannot inferthat the calcanean spur is the cause of pain.Very often inflammation of the soft tissueor a bursa beneath the spur gives rise topam.

Heel spurs are soft, bendable depositsof calcium that are the result of tension andinflammation in the Plantar fasciaattachment to the heel. The plantar fasciaencapsulates muscles in the sole of thefoot. It supports the arch of the foot byacting as a bowstring to connect the ball ofthe foot to the heel. When walking and atthe moment the heel of the trailing legbegins to lift off the ground, the plantarfascia endures tension that is approximatelytwo times body weight. This moment of

maximum tension is increased and"sharpened" (it increases suddenly) ifthereis lack of flexibi Iity in the calf muscles. Apercentage increase in body weight causesthe same percentage increase in tension inthe fascia. Due to the repetitive nature ofwalking, plantar fascitis may be a repetitivestress disorder (RSD). Moreover, the lesionaffects the soft tissues at the site ofattachment of the plantar aponeurosis tothe inferior aspect of the tuberosity of thecalcaneus.

From this present study it has beenobserved thatParsnisula or Plantar fascitisis commonly seen in female subjectsspecifically in pre-menopausal age (3 1-40yrs.).Plantar fascitis is a common causeof heel pain in adults. The pain is usuallycaused by collagen degeneration at the

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A PRELIMINARY STUDY ON .....

caused by collagen degeneration at theorigin of the plantar fascia at the medialtubercle of the calcaneus. Thisdegeneration is similar to the chronicnecrosis oftendonosis, which features lossof collagen continuity, increases in groundsubstance (matrix of connective tissue) andvascularity and the presence of fibroblastsrather than the inflammatory cells usuallyseen with the acute inflammation oftendonitis.

Conclusion

Agnikarma Chikitsa as heat therapyis practiced inparsnisula since ancient eraby Ayurvedic scholarsParsnisula is mostlysimi lar to the conditions of plantar fascitisas per clinical features. The classical signof Plantar fascitis or Parsnisula is that theworst pain occurs with the first few stepsin the morning. Patients often notice painat the beginning of activity that lessens orresolves as they warm up. The pain mayalso occur with prolonged standing and issometimes accompanied by stiffness andtenderness by examination associated withslight swell ing ofhee!' In the present studyit was seen that female were mostlyaffected those who were belongs to pre-menopausal may due to sudden weight gainand less movement or activities. From thisstudy it was observed that all patients havegot highly significant clinical improvementon the basis of subjective scoring and it maybe concluded that Agnikarma is the rightsolution for the treatment of Parsnisula. Itis also revealed from this study that 15

is also revealed from this study that 15patients have got excellent response, 11patients have got fair response whereas 4patients have got no response on the basisof individual assessment of symptoms.Moreover. it is also very much costeffective and cost benefited treatment andno adjuvant therapy or drugs required.

The probable mode of action ofAgnikarma Chiki ts a is by doingAgnikarma the Agni from the stove/gasflames is taken by Shalaka and it becomesred hot. Then thisAgni(heat) is transferredfrom the Shalaka to the Dushya-Dhatu(skin). The time taken for this transfer ofheat is two to three seconds. The Dhatu-Agni in the skin becomes Utkl esita(activated) and the disease producing Dosabecomes neutral byDosha-pachana acnonof the Utklesita Dhatu-Agni.

So it can be concluded that localdisorders produced by Vata dosha orKapha dosha are beneficially treated bythis result oriented method of AgnikarmaChikitsa.

Acknowledgement

Authors are grateful to the Director,CCRAS, New Delhi for providingnecessary facilities and his continuoussupport & encouragement for innovativeresearch. Authors are also thankful to Adm.Officer & all staff of this institute and thepatients who have cooperated through outthe study period.

67

G. Kusuma, A. Mitra at a/.

D. Singh et al.

D.Ojha

M. Wolgin et al.

M. Powell et al.

MS Mizel et al.

E. C. Huskission & Hart. F. Dubly

S. Das

B. K. Mahajan

Astangahri day

1997

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A PRELIMINARY STUDY ON .....

GuptaP. D. 1993 Agnik arma Chikitsa- TechnologicalInnovations Regarding AgnikarmaSalaka, Samyak Dagdha Vrana andUseful Method of Agnikarma Chikitsa,l.R.A.S. Vol. XIV, No.3-4, pp. 125-136,Sept-Dec. 1993.

Susruta Samhita 2004 Translated by K. R. Srikantha Murthy,2nd edition, Chaukhambha Orientalia,Varanasi, Sutra Sthana 5th and 12thChapter.

~I;C,< ~ (Plantar Fascitis) 1R 31P"1Cf)q ~ - ~'fHPll @Of Cf) ~ rf> ftrf¢ct1c6h, ~ C5T

1f\t""Q jCf)"1 ~ ~~ 3T~

~. ~, ~. fl1:5rr, cfr. xt. ~, 1fi. l1tJ)fq ~R:<, 1fi. cfJ. "Cfff. -;::n<R,

cfr. ~. Wi Icp'F"I ~ ~. \jJ<IT

LITfWf ~ "CfCP ~ ~ Rlfmffll 3TCR~ t vfr ~ ~ ~ ~~ ~ ~ gl'"lcllc1) iiffiC'll3lT -B ~ \JlTffi t I ~ 3lCR~ em ~ cfJ ~e5C'l'"l "lIT~ ~ m -B \JXlro ~.~ -B ii5fl\'H men t I cgt9 ~ ~

cfi ~ Gcf Q)1l m \JlTffi t I

~ ~ ~1I'bI'j -q ~ ~ Cf>T~ \i~~ ~ f?tC'idl I ~~cm-"C'1T~ ~ ~ ~ WR=?f ~ ~I~'< cbffiR:fi (PlantarFascitis) xl gc;RT CfR ~ ~ I

69

G. Kusuma, A. Mitra et at.

~ ~ flIJiI;;q("j: NSAID's cpr f.1c{~I'1 qmf t Jftx ~ emC"Ii?tC"llq'1~ (Resillient cushionjvl ~e:rr~ t I Gcf Cf)ll m m tR

~'RlenlR:'<fl'1 (Hydrocortisone) cfi x~ ~~~1'1 -gr fclenC'G t I

~ ~ cfi ~Fchctil ~ l) ~fT.1en4 (~ fI~~I~en ~) em~ ~ ~ ~ -9" ~ ~ l) \3q~'PI cpr ~ ~ ~ I

~ ~ il, ~ ~ 3l~ $rs;~~ ~ ~ (~,ih>g'Q~,~, ~ il f$<:n lTm 3m- ~ ,<lfTltll· ~ ~ WafUT ~ emtell enl '< fclRrr I ~ tR tR ~ fT.1en4 em f$<:n 7fm 3TR ~ 3lUfl.T'1" il"C'1T~ -Q-afUT&RT ~fchcticB)~ XJ'tlR cfi ~ tR 3f1ctilf@en qRul(J"I ~

~I

70