Vishwachi kc007 hyd

A Clinical Study in the management of Viswachi

With Sinduvaradi Yoga along with Ksheerabala

taila Nasyam

Thesis Submitted in Partial Fulfillment for the Degree of

Doctor of Medicine (AYURVEDA) in KAYA CHIKITSA

BY

Dr. G.LAVANYA

GUIDE:

Dr.Prakash chander (Ay) H.O.D Dept. of Kayachikitsa, P.G. Unit

POST GRADUATE DEPARTMENT OF KAYACHIKITSA Dr. B.R.K.R. GOVT. AYURVEDIC COLLEGE / HOSPITAL

HYDERABAD

Affiliated to Dr. N.T.R. University of Health Sciences Vijayawada, A.P.

2007

Dr. NTR UNIVERSITY OF HEALTH SCIENCES VIJAYAWADA, A.P.

Dr. NTR UNIVERSITY OF HEALTH SCIENCES

VIJAYAWADA, A.P. POST GRADUATE DEPARTMENT OF KAYA CHIKITSA Dr. B.R.K.R. GOVT. AYURVEDIC COLLEGE / HOSPITAL

HYDERABAD, A.P., INDIA 2007

Ayurmitra

Draft

CERTIFICATE

This is to certify that Dr.G.Lavanya final year Post

Graduate Scholar, Dept. of Kaya Chikitsa has submitted her dissertation work

entitled “A CLINICAL STUDY IN THE MANAGEMENT OF

VISWACHI WITH SINDUVARADI YOGAM ALONG WITH

KSHEERABALA TAILA NASYA” under our direct supervision.

We are satisfied with the work carried out by her and recommend the same for

the acceptance and approval of the adjudicators.

H.O.D. Dr. Prakash Chander, M.D. (Ay)

Professor Dept. of Kaya Chikitsa, P.G. Unit Dr. B.R.K.R. GOVT. Ayurvedic College / Hospital, Hyderabad.

Date:

Place:

Dr. NTR UNIVERSITY OF HEALTH SCIENCES VIJAYAWADA, A.P.

POST GRADUATE DEPARTMENT OF KAYA CHIKITSA Dr. B.R.K.R. G0VT. AYURVEDIC COLLEGE / HOSPITAL

HYDERABAD, A.P., INDIA 2007

CERTIFICATE

This is to certify that the present thesis of Dr.G.Lavanya, entitled by

“A clinical study in the management of Viswachi with Sinduvaradi yoga

along with Ksheera bala taila nasya” has been completed by the candidate

herself under our direct supervision. She has devoted the required time for the

purpose and her work has been checked periodically. This originality of the

work holds good of its kind to enlighten the branch of Kaya Chikitsa.

Guide:

Dr.Prakash chander M.D., H.O.D

Dept. of Kaya Chikitsa, P.G. Unit Dr. B.R.K.R. GOVT. Ayurvedic College / Hospital, Hyderabad.

Date: Place:

LIST OF ABBREVIATIONS

Ca.S - Caraka Samhitha

Su.S - Susruta Samhitha

As.Sa - Astanga Sangraha

As.Hr - Astanga Hrdaya

Ma.Ni - Madhava Nidana

Sa.S - Sarangadhara Samhitha

Bh.Pr - Bhava Prakasha

H.S - Haaritha Samhitha

C.D - Cakra Datta

Y.R - Yoga Ratnakara

B.R - Bhaisajya Ratnavali

D.G.V - Dravya Guna Vignanam

S.Y - Sahasrayogam

V.C - Vaidya Cintamani

S.K.D - Sabdakalpadrumam

S.E.D - Sanskrit English Dictionary

Su - Sutrasthana

Sa - Sareerasthana

Ni - Nidanasthana

Vi - Viamanasthana

Ci - Cikitsasthana

Ut - Uttaratantra

Mk - Madhyamakhanda

NPR - Numerical pain rating NSFT - Numericalscoringfunctionaltest

LIST OF TABLES

1. Table showing features of typical cervical vertebrae

2. Table showing origin, nervename, muscle name & action

3. Table showing nidanas explained in various classics

4. Table showing differentiating features of disorders of

urdhwa saakha

5. Table showing vitamin contents in cow’s milk

6. Table showing minerals contents of cow’s milk

7. Table showing the incidence of sex

8. Table showing the incidence of age

9. Table showing the incidence of religion

10. Table showing the incidence of occupation

11. Table showing the incidence of socio-economic status

12. Table showing the incidence of nature of work

13. Table showing the incidence of food habits

14. Table showing the incidence ofaddictions

15. Table showing the incidence of prakriti

16. Table showing the incidence of duration of illness

17. Table showing the incidence of duraion of pain

18. Table showing the incidence of side involved

19. Table showing the incidence of type of pain

20. Table showing the incidence of times of occurence

21. Table showing the incidence of intensity of pain

22. Table showing the incidence of bahu karma kshaya

23. Table showing the incidence of clinical features

24. Table showing the incidence of paraesthesia

25. Table showing the incidence of weakness

26. Table showing the results of intensity of pain after

treatment

27. Table showing the results of subjective symptoms

28. Table showing the results of scores of NPR & NSFT

29. Table showing the results of functional disability after

treatment

30. Table showing the statistical analysis of NPR & NSFT

31. Table showing the total outcome of the treatment

LIST OF ILLUSTRATIONS

1. Schematic representation of Viswachi samprapti

2. Schematic representation of Nasya karmukata

3. Images of anatomical structures involved in Viswachi

4. Images of pathology in cervical spondylosis

5. Images of drugs

6. Images of compound preparation

7. Graph showing incidence of sex

8. Graph showing incidence of age

9. Graph showing incidence of occupation

10. Graph showing incidence of nature of work

11. Graph showing incidence of type of pain

12. Graph showing incidence of clinical features

13. Graph showing NPR curve during treatment

14. Graph showing NSFT curve during treatment

15. Graph showing the pain relief

16. Graph showing the functional disability response to

treatment

17. Graph showing the total outcome of the treatment

ACKNOWLEDGEMENTS

I humbly owe every successful endeavour of my life to my beloved parents.

I utilize this prospect to express my unfathomable gratitude to the

persons who helped directly or indirectly; I would like to pick few names,

which doesnot mean that others are not remembered; human heart is not just

two pages of paper.

I express candid gratefulness with a deep admiration to my Guide

Dr.Prakash chander M.D., professor, H.O.D, Post Graduate Department of

Kayacikitsa, Dr.B.R.K.R Govt. Ayurvedic College/ Hospital, Erragadda,

Hyderabad for his able guidance, valuable support & affection. Iam

undoubtedly benefitted by his suggestions through out the period of my

P.G.studies.

I feel great pleasure to express my sincere gratitude to Dr.V.Vijaya

babu M.D., Reader, Post Graduate Department of Kayacikitsa, Dr.B.R.K.R

Govt.Ayurvedic College/ Hospital, Erragadda, Hyderabad for his thought

provoking lectures; had it not been for his valuable suggestions & constructive

criticisms this work would not have achieved its present form & standard.

I humbly express my heartfelt gratitude to Dr.M.Srinivasulu for his

diligent support & encouragement in the attempt of understanding concepts of

Ayurveda.

I am particularly indebted to Dr.G.Purushottamacharyulu M.D., for

his valuable advices and kind support in clarifying my doubts.

I thank Dr.M.L.Naidu, Dr.Bhaswanth Rao, Dr.S.Ramalingeswara

Rao Dr.K.Vijaya Lakshmi, for their co-operation during this work.

I acknowledge Dr.B.R.K.R Govt.AyurvedicCollege/Hospital Principal

Dr.Sadashiva Rao & Dr.L.R.K.Murthy Hospital Superintendent for

providing the necessary facilities during my study.

Dr.V.V.S.Rama Sastry, Dr.Chalapathi Rao, & Dr.Suresh Babu for

their valuable suggestions.

I gratefully acknowledge the contributions of all my teachers since

primary education that inspired, guided and nurtured my interest in acquiring

knowledge and scientific enquiry at various stages of my career.

Especially I thank Dr.P.Murali Krishna & Dr.A.R.V.Murthy of my

parent institution S.V.Ayurvedic College, Tirupati for their encouragement

through out my career.

I acknowledge the valuable support of my friends & colleagues

Dr.Ratnapriyadarshini, Dr.Neelayathachi, Dr.J.Sivanarayana, DrP.Himabindu,

Dr.Prasuna, Dr.K.Sireesha, Dr.Haritha, Dr.Binod, Vd.Pranita joshi & others

who helped me a lot in one way or the other in successful completion of this

task.

As a token of gratitude I acknowledge my beloved sisters G.S.Madhavi,

G.v.lakshmi & my brother G.S.Sanath for their attentive support and care in

every endeavour of mine.

I sincerely express my thanks to Swapna Bhupathi (M.P.T) & Amrutha

shah B.P.T for their timely co-operation and help extended in collecting the

books required.

I sincerely express my heart felt thanks to Mr.Sridhar for giving his

personal laptop, with out which the task of typing had been a challenge.

I acknowledge the staff of our college library, British library & I.M&H

library for their co-operation.

Lastly I thank all my patients, with out whom I could not have

completed my dissertation.

SOURCE ACKNOWLEDGEMENT

I sincerely express my gratitude to the authors of all the books and

articles which have been utilized by me, as the source of information, in this

dissertation work.

INTRODUCTION Pain is the most complicated area of human experience. Pain is derived

from the Greek poine (a tax) and the Latin poena (a punishment or reality). The

latter had both physical & mental implications in classical Latin.

The International Association for the study of pain defines pain as “an

unpleasant sensory & emotional experience associated with actual or potential

damage or described in terms of such damage.”

Pain is whatever the experiencing person says it is, and it exists

wherever he says it does”.

Pain, when it does occur, usually signals tissue disorder. Pain as a

symptom is often used by the physician in establishing the diagnosis. Several

diseases include pain as an important feature alerting the patient to take action.

One of such disease is Viswachi, affecting the upperlimbs. Great

mobility characterizes the upper extremity; they possess great range of

movement. They are also prey to many diseases & disorders. Present day

lifestyle has led to many diseases which though does not kill a person, but

hamper his day-to-day life

It seems totally unnecessary to champion the argument for the economic

importance of the hand when one considers the magnitude of person’s

economic limitations if hand function is impaired or lacking.

Aristotle contended that hand as “The organ of organs, the active

agent of the passive powers of the entire system.”

It has been estimated by research group that the hand performs

approximately thousand different functions in an ordinary day’s activity.

Quitner and Elvey postulated that mechanical tension upon neural

structures either distally (for instance at the wrist) or proximally(for instance

within the cervical spine), generates abnormal discharges within the nervous

system, and that such neural entrapment is the primary precipitating event in

the development of chronic upper limb pain.

Historically the relationship between diffused pains around the shoulder

girdle and cervical lesions has been recognized (Cyriax, 1969).

It is universally accepted that radicular symptoms in the arm usually

indicate nerve root entrapment secondary to a paracervical disc protusion or in

the older population to the foraminal bony hypertrophy. Nerve root pain may

be very distressing and is often compatible with manual or office work for a

variable period of time, depending upon the pathology.

The present study of viswachi is limited to the cervical spine lesions.

The degenerative diseases of the cervical spine, cervical spondylosis is

clinically correlated with Viswachi of vatavyadhi.

Cervical spondylosis is a chronic progressive degenerative disease. The

incidence of cervical spondylosis is becoming much more now a days because

of many reasons. It is occurring in more than 90% of adults over the age of 50

years and almost 100% by 70 years.

Cervical degenerative disorders lead to a wide spectrum of

presentations. Often a subtle mix of axial neck pain, radicular upper extremity

dysfunction and even myelopathic states exist. The most frequent reason for

seeking medical assistance is arm pain.

The treatment of cervical spondylosis is difficult and absolute cure of

this condition is impossible owing to the fact that the underlying structural

changes are irreversible and is part of the generalized ageing process. The

principle of treatment is therefore aimed at reducing the symptoms and

preventing the development of new ones and their complications.

Scope of present study includes the understanding of Viswachi disease

completely, with respect to cervical spondylosis and evolving an Ayurvedic

Compound which can manage the pain effectively along with delaying the

degenerative process in the cervical spine.

Vedana (pain) being the pratyatmika lingam (prime feature) ofViswachi

requires great attention. Ayurvedic texts have mentioned a lot of vedana

samaka dravyas from which Sinduvara (Vitex negundo), Suranjan (Colchicum

luteum), Parijatha (Nyctanthes arbortristis) are selected due to their potential

pain relieving property.

Apart from the oral administration of these drugs, Nasya karma is

considered for tarpana of uttamanga. Since this is purely vata disorder, tailam

being best vatasamaka dravya, Ksheera bala tailam is selected for nasya karma

which is mentioned in most of the authentic classics of Ayurveda.

This study has been taken up to make observation of these drugs, their

clinical efficacy and to put on record with statistical data.

This thesis contains two parts. First part includes Introduction, Review

of literature- Historical review, Sareera (both Ayurvedic & modern aspects),

Disease review (both Ayurvedic & modern aspects), and Drug review. Second

part includes the clinical study i.e Materials & methods, observation & results,

Discussion, Summary and Conclusion. Bibliography and Annexure containing

the case sheet & questionnaire mark the end of this sincere attempt done in

study of Viswachi.

HISTORICAL REVIEW

Mahabharat, one of the greatest epics of India, describes Ithihas

(history) as a destroyer of veil of Ignorance1. It would be profiting to study the

present in the light of past. So, review of references of disease Viswachi, from

the age old scriptures have been taken up.

There is no direct reference of term Viswachi in the Vedic literature.

Only indirect references are available, which indicate possible prevalence of

vata diseases during that period.

Vedic Period:

The term vata vyadhi was mentioned for the first time in Adharvaveda2.

Whereas the term vata has been used for wind in both Rigveda3 and

Adharvaveda4. Vata is also said as bhisak in Rigveda and A.V.S5.

In AdharvaVeda many synonyms were used for vata like maruta, vatajee

etc6. There is a hymn offering prayer to God of Vata (Marut-Storm Gods) to

protect the body & bear the limbs till old age.

Anatomical description of Bahu, hasta & amsa7 is seen in Vedic

literature. There are certain references from both Rigveda8& Adharvaveda9

quoting that there are certain diseases affecting the bahu, pani & anguli10, by

offering some prayers that parts will become disease free.

This denotes that, at that time though direct term viswachi was not

coined but the disease with same symptoms might have been present.

Upanishad Period:

The other literary works like Upanishads contain facts and concepts

related to medicine.

Chandogya & Brihadaranyaka has mentioned five types of vata,

whereas in the Agni Purana ten types of vata are described.

In Garuda Purana medicine is dealt in elaborate way and in nidana

vata vyadhi is dealt.

These are all the evidences which show occurance of viswachi, type of

vata vyadhi affecting upper limbs though unnamed at that times.

In some puranas (vahnipran’s ganabhednadhyaya) the word viswachi is

there but it is not applied as disease instead it is stated that viswachi was one of

the twelve apsaras in the court of Indra.

Samhita Period:

In the samhita period, Caraka Samhita has to be given credit of

describing vata in an explicit manner. Stating it to be shareera vayu, loka vayu

& again classifying it into five types allotting separate chapter named vata

kalakaleeyam, only for vata.

The pathological aspects are dealt in a separate chapter (28) of cikitsa

stana. Though the term viswachi is not seen in samhita but khalli is described.

There is mythological reference for the vyadhi affecting the upper limbs11. That

is while mentioning about miracles of Aswinis, the divine physicians, and the

stupefaction of arms of Indra has been quoted. Caraka has described ekanga

vata where shoola, toda, sankocha of either upper limb or lower limb is present.

In Bhela Samhita vata rogas are classified into two sarvanga & ekanga

rogas.

In Haritha Samhita “viswachi gridhrasi choktah khalli teevra

rujanvita” has been mentioned.

In the Susruta Samhita many important observations pertaining to

basics of vata are dealt. Vata vyadhi, first chapter of nidana sthana, explains

diseases specifically afflicting upper limbs. In those, viswachi is described for

the first time along with apabahukam and amsasosha.

In Astanga Hrdya & Sangraha, viswachi is explained in vata vyadhi

adhyaya.

Sarangdhara Samhitha is the samhita explaining viswachi as one of

the ashitivatajavikara i.e., as vatajananatmaja vyadhi for the first time.

Both Madhava Nidana & Bhavaprakasha have detailed explanation

of Viswachi, quoting “Bahvo Prasarana Akunchanadi Karma Ksyayakari”.

The later on evolved literature of ayurveda like Vangasena, Gadanigraha

all contain detailed description of Viswachi.

Dr. C. Dwarakanath in his book Introduction to KC quotes as follows

“Functions ascribed to sharira vayu, in the ancient medical classics are exactly

those which modern physiology ascribes to the nervous system”.

The historical aspect of the neurological aspects has been described

as follows:

Rufus of Ephesus, who flourished under the reign of Emperor Trozan,

was the first medical writer that adopted a global view of the function of

nervous system. Later on Galen, Vesalius made significant contributions.

Herophilus, Greek Physician and Anatomist in Egypt (335-280 B.C.)

was probably the first to differentiate between nerves, tendons and motor,

sensory nerves.

1621-1675 - Thomas Villis, English Physician and Anatomist, described the

spinal nerves.

1648-1730 - Joseph G. Duverney named the nerves which form the brachial

plexus in 1697. Before this nerves were designated by numbers.

1748-1791 - The developments in clinical neurophysiology are closely linked

to the discovery of electricity.

1783-1855 - Francois Magendie confirmed that the anterior roots of spinal

nerves are motor in function, posterior root stimulation elicited

pain.

1791 - Galvani, discovered nerves to be good conductors of electricity.

1806-1875 - Duchene was first to systematically study neuromuscular

diseases.

1817 - James Parkinson described a case whose clinical features suggest

cervical radiculopathy.

1836-1921 - Henric wilhelmgottfried waldeyer hartz proposed neuron theory.

1857-1952 - Charles Scott Sherington studied the distribution of ventral and

dorsal spinal nerve roots.

1873-1930 - Henry Verger devised classification of neuralgias in 1904.

1892 - Gowers described cases 0f cervical spondylosis under the

“vertebral exotoses.” Though lesions of cervical cord had been

diagnosed earlier, it was not until 1892 that the first successful

operation on the cervical spine was done by Horsley. (Taylor &

Collier 1901)

1926 - Elliot described after Gowers how spinal arthritis involving

cervical region might give rise to radicular symptoms through

narrowing of the intervetebral foramina.

1934 - Nachlas first drew attention to the fact that pain in the chest could

result from lesions involving the cervical spine

1936 - Hanflig discussed cervical spondylitis as a cause of pain in the

shoulder and arm referred to pain in the chest wall as an

associated symptom.

1943 - Semmes & Murphy discussed production of radicular symptoms

by acute protrusion of a cervical intervertebral disc.

1944 - Scoville reported 12 verified cases of ruptured cervical

intervertebral disc; they thought that the dorsal protrusion was

usually the result of trauma where as lateral protrusions were

result of degeneration and cause pain in the shoulders & upper

limbs resulting from root compression.

1944 - Seddon and his co-workers elucidated the nature of different

types of nerve injury.

1948 - Bull correlated the anatomy of joints of cervical spine with the

mode of production of the symptoms caused by their disease and

their abnormal radiological appearances.

1948 - Brain discussed importance of vascular factors as a cause of

disturbance in the function of the cervical cord below the site of

compression.

1950 - Acute traumatic disc herniation process was distinguished from

the chronic spondylotic process.

1951 - Frykholm published detailed study of patients with cervical root

compression along with comprehensive review of various aspects

of degeneration of intervertebral disc.

1954 - Pallis, Jones & Spillane stressed the fact that cervical spondylosis

was a common disease of elderly people.

1954 - O’connel distinguished three types of lesions occurring in

cervical spondylosis.

1963 - Fullerton and others shown that local ischaemia due to pressure is

one factor giving rise to signs and symptoms when peripheral

nerves or roots are compressed.

1965 – James found that in general the outcome in cervical spondylosis

was independent of age, sex, trauma, the extent of degenerative

changes and the clinical picture but did depend on duration of

symptoms & level of protein in C.S.F. He thought cervical

spondylosis could produce two types of changes in the spinal

cord: firstly an acute “exudative”, a revesible condition & a

second process of gradual loss of neural tissue with subsequent

demyelination & gliosis.

1974-1975 - Repeated prolonged pressure upon a nerve leads to ischaemia but

also to mechanical deformation of the myelinsheath with local

edema (rudge, Ochoa and gilliatt, neary and Eames).

1978 - Nakano comprehensively reviewed entrapment neuropathies.

1986 - The brachial plexus tension test (BPTT), devised by Elvey. It is

used particularly by physiotherapists with an interest in spinal

disorders.

1995 - Rowland described brachial plexus neuropathy disorder of

unknown cause that is characterized by sudden onset of severe

pain usually around the shoulder12.

REFERENCES:

1. Mahabharat, Adiparava, 1.27

2. Adharvaveda, 9-8-20


4. Rigveda, 2-33-13

5. A.V.S, 4-13-3


7. Adharvaveda, 2-13-2, 10-2-5

8. Rigveda, 10-163-2



11. History of Indian Medicine, P.V.Sharma

12. Medical Discoveries, Who & When By Schimdt.

SAREERA

Human body is divided into shadangas according to Ayurveda.1

Shadangas include Siras, madhyasareera, saakhas (4).2 Saakhas are urdhwa

saakha & adhosaakha. These are concerned with all the locomotor activities of

the body.

Ekadasa indriyas are explained in Ayurveda.3 Pancha karmendriyas are

a part of those eleven indriyas. Bahu is one of the panchakarmendriya. Its

functions are prasarana, akunchana, grahana & daana.4

Functional or physiological part in the body is carried out by the

tridoshas. Vata is the one which is responsible for every activity in the body.5

The term Vata is derived from the root Gati & Gandana, describing two

potential functions of vata. Gati indicates to move or cause movement. Where

as Gandana is knowledge. Vata in its prakritha avastha engazes all the eleven

indriyas in their normal function. It integrates all these indriyas and derives

specific work by co-ordination. 6

Out of panchavidha vatas 7 described, the vata that invades through out

the body being responsible for all the movements is Vyana vata.8 Movement is

specially attributed to this, though pranavata and udanavata control importanrt

vegetative functions of life.9

Functions of vyanavata are:

1. Gati- voluntary movements of skeletal muscles

2. Apakshepa- abduction

3. Utkshepa- throwing up

4. Unmesha- opening of eyelids

5. Nimesha- closing of eyelids

6. Rasavikshepa- circulation

7. Asrk sravana- circulation of blood

8. Sweda sravana- perspiration

This vata controls all the movements of the skeletal muscles.10

Qualities like Amurta 11, Anavastitha / chalatva 12, Swayambu 13,

Sukshma etc of vata indicate that the phenomenon of vata can be assumed as

phenomenon of nerve impulse. The vata or nerve impulse is conducted in

vatavaha srotases / nerve fibres and its sustained propagation is maintained by

the constituents of nerve fibres only.

According to function, there are two types of vatavaha srotases-

i. Chesta vaha srotas: to conduct motor function

ii. Sagna vaha srotas: to conduct sensory function

According to structure, these are again of two types-

i. Samvrita: well covered or concealed –myelinated fibres

ii. Asamvrita: not covered or open – non myelinated fibres.14

Since vata is amoorta (invisible), its chalanaswabhava is expressed by the

movements of the mamsapeshis, snayus, kandaras, asthi, and sandhi.

Movements are effected by the activation of muscles, which activate

through their nerve supply. The nerves which supply the skeletal musculature

take origin from the anterior horn cells of the spinal cord execute the functions

of vyanavata.15

Disease in most instances has a visible component and the study of morbid

anatomy has been the classic approach to its understanding.

The cervical spine is surely the most complicated articular system in the

body; there are 37 separate joints whose function is to carry out the myriad

movements of the head and neck in relation to the trunk, and subserve all

special sense organs.

The seven small cervical vertebrae with their ligamentous, capsular,

tendinous and muscle attachments appear poorly designed to protect their

contents, compared to skull above and the thorax below. The contents of this

anatomical cylinder interposed between skull and thorax include carotid and

vertebral arteries, the spinal cord, and all anterior and posterior nerve roots and,

in its uppermost portion, the brain stem.

Normally the neck moves over 600 times an hour, awake or asleep; no

other part of the musculoskeletal system in such constant motion. The cervical

spine is subject to stress and strain in ordinary everyday activities.

The cervical spine is a superb example of the biological principle of

adaptation of structure to function. It supplies support for the head, a flexible

and buffered tube for the transmission and protection of the upper spinal cord,

provision for the entry and exit of spinal nerves, and extremely serviceable

mobility.15

The posterior landmarks of the cervical spine include the occiput, the

inion, the superior nuchal line and the mastoid process.

Cervical vertebrae form the bony skeleton of the neck. These are

smallest of the 24 movable vertebrae, and bear less weight than do the

vertebrae inferior to them.

The cervical vertebrae as a whole are characterized by the fact that their

transverse processes contain a foramen, the transverse foramen. The bodies are

relatively delicate, their greatest diameter being the lateral one. The articular

process is short; the facets on the superior articular process face upward and

backward, those on the inferior articular process are forward and downward.

The first two cervical vertebrae are markedly different from the

remainder. The first cervical vertebra, known as Atlas, is especially

distinguished by the fact that it has no body but only an anterior arch. The

second cervical vertebrae or Axis is also peculiar in structure, as it bears

projecting up from its body a tooth like process, the dens. This process

articulates with the anterior arch of the Atlas, to which it firmly held by

ligaments in such a fashion that it acts as a pivot around which the atlas rotates.

1. Table showing features of typical cervical vertebrae (C3 –C7)16:

PART DISTINCTIVE CHARACTERSTICS

Body Small and wider from side to side than anteroposteriorly;

superior surface is concave and inferior surface is convex

Vertebral

foramen

Large and triangular

Transverse

process

Transverse foramina (foramina transversaria); small or absent in

C7; vertebral arteries are accompanying venous and sympathetic

plexus pass through foramina, except C7, which transmits only

small accessory vertebral veins; anterior & posterior tubercles.

Articular

processes

Superior facets directed superoposteriorly; inferior facets

inferoanteriorly; obliquely placed facets are most nearly

horizontal in this region.

Spinous

process

Short (C3-C5) and bifid (C3-C5); process of C6 is long but that of

C7 is longer (for this reason C7 is called Vertebra prominens.)

Blood supply of cervical vertebra: Vertebra and longitudinal muscles are

supplied by segmental arteries that give multiple branches. Other arteries are

deep cervical, occipital and transverse cervical arteries.

Nerve supply of cervical vertebra: Joints between vertebral bodies are

innervated by small meningeal branches of each spinal nerve as it exits the

foramina. Joints between articular processes are innervated by branches of

posterior rami of spinal nerve.

Joints of the cervical spine:

i. Joints of the vertebral bodies

ii. Joints of the vertebral arches

iii. Atlantoaxial joints

iv. Atlanto occipital joints

The joints of the vertebral bodies are secondary cartilaginous joints

designed for weight bearing and strength. The articulating surfaces of adjacent

vertebrae are connected by intervertebral discs and ligaments.

The discs are not solid lumps of inert gristle resembling rubberpads,

but living structures which flatten slightly during day and re-expand at

night17. The disc is a symphysis between each pair of vertebrae and with two

posterior facet joints, allows movement between vertebrae, acts as shock

absorbers, and their varying shapes produce the secondary curvatures of the

vertebral column.

Each intervetebral disc consists of:

i. The center is a semi-liquid, mucocartilagenous mass, the remnant of the

embryonic notochord, called the nucleus pulposus. It is a gelatinous

substance with high water content in which the collagen network is masked

by a rich layer of chondroitin sulphate. The collagen fibers form a fine

network resembling a porous system. It contains primarily type 2 collagen

which functions in resisting compression forces.

ii. The nucleus is maintained by a thick fibrous band called the annulus

fibrosus. It has a considerably denser and more regular collagenous pattern.

The fibrils are grouped in bundles of varying thickness that pass in a spiral

course from one vertebra to the next. It consists of water, proteoglycans and

type 1 collagen whose function is to resist tensile forces.

The intervertebral disc is further stabilized by the superior and inferior

cartilage end plates that fix the structure to the vertebral bodies above and

below.

Blood supply:

It is derived from the segmental vessels derived from the subclavian

artery. The nucleus pulposus is avascular throughout foetal and postnatal life,

but annulus receives a peripheral blood supply which gradually diminishes

during the first two decades until it is virtually avascular.

Innervation and nutrition of the disc:

Outer annulus is supplied by vertebral and sinu vertebral nerves. No

nerve supply in nucleus pulposus.

• Nutrition is by diffusion through central portion.

The joints of the vertebral arches are the zygapophysial joints. These

articulations are plane synovial joints between the superior & inferior articular

processes. Each joint is surrounded by a thin, loose articular capsule. Those in

the cervical region are especially thin & loose. These permit gliding

movements between the vertebrae. These are innervated by articular branches

that arise from the medial branches of the dorsal primary rami of spinal nerves.

The Atlanto occipital joint is between the Atlas and the occipital bone

of the skull. This is a synovial joint of condyloid type.

The Atlanto axial joint is between the Atlas & Axis. There are three

atlanto axial articulations. These are synovial joints with no intervertebral

discs. They are designed to give wider range of movement than in the rest of

the vertebral column.

Uncovertebral joints are between the uncinate processes of C3 through

C6 and the beveled surfaces of the vertebral bodies superior to them. The joints

are at the lateral and posterolateral margins of the intervertebral discs. These

joint like structures are covered with cartilage and contain a capsule filled with

fluid. These are the frequent sites of spur formation that may cause neck pain.

Ligaments: Ligamentous attachments of cervical spine are:

1. Anterior longitudinal ligament: The anterior longitudinal ligament runs

along the anterior and lateral surface of the vertebral bodies from sacrum

to C2 attached firmly to the vertebral bodies, but only loosely at the disc

area the ligament is compressed in flexion and is stretched in extension.

The ligament may become slack in neutral position of spine when the

normal height is reduced.

2. Posterior longitudinal ligment: This ligament runs within the vertebral

canal along the posterior surfaces of the vertebral bodies from C2 to

sacrum. It is stretched in flexion, slack in extension. This ligament is

firmly attached to the disc but loosely to the vertebral body surface. In the

cervical spine it is 3 to 5 fold thicker and more.

3. Ligamentum flavum: t is a thick, elastic ligament, which is located on

the posterior surface of vertebral canal. The fibres connect lamina of

adjacent vertebra which runs from C2 to sacrum. It gets stretched when

spine is in flexion and is under constant tension even when spine is in

neutral position.

4. Interspinous ligaments: This ligament varies from region to region. In

cervical region it connects and covers the margins of adjacent spinous

processes. The parallel fibres run diagonally and fill up the space between

the spinous process. The ligament is slack in extension and stretched in

forward flexion, when they resist the separation of spinous processes.

5. Supraspinous ligament: This ligament is cord like which connects the

tips of spinous processes from C7 to L3-L4. In cervical region it becomes

ligamentum nuchae. It is stretched in flexion and its fibres resist

separation of spinous process during forward flexion.

6. Intertransverse ligament: This ligment is paired and passes between the

transverse processes and attaches to deep muscles of back.This ligament is

alternatively stretched and compressed during lateral bending.

Nerve root exits:

The spinal cord passing through the vertebral column gives 31 pairs of

spinal nerves. Each spinal nerve is attached to the spinal cord by a dorsal root,

which is sensory and a ventral root which is motor. All the branches of a spinal

nerve contain both sensory & motor fibres.

At the C3-C4 level the anterior and posterior nerve root sites through the

dural sleeves are below the level of the intervertebral discs by approximately

4mm. This is as a consequence of the formation of nervous system, being

followed latter by rapid growth of the spine. With growth and extension of the

cervical spine, physiological traction is exerted on the cord and nerve roots and

the dural sleeve exit sites are at the level of vertebral bodies rather than at the

disc level; the root exit zone is generally below the level of the disc.

The anterior nerve root is normally situated low in the intervertebral

foramen and hence is very unlikely to be compressed. The posterior nerve root

is well protected from the point of any disc herniation.

There is normally a considerable individual disparity between the spinal

cord volume and space available in the bony canal. This seems a constitutional

or genetic, characteristic.

After mixed spinal nerve passes through the intervertebral foramen, it

divides into two branches, a dorsal branch that turns backward to supply

muscle and skin of the back. Ventral branch runs laterally and forward,

supplies the limbs and the anterolateral aspects of the trunk.

Except in the thoracic region, the ventral branches run close together

and exchange branches with each other, such an exchange being known as a

nerve plexus. The area of distribution of spinal nerve to skin is known as

dermatome. On the limbs the dermatomes bear no relation to the distribution of

various peripheral nerves.

The ventral rami of the upper four cervical nerves, unite to form the

cervical plexus; union of ventral rami of the lower four cervical nerves and the

greater part of the ventral ramus of the first thoracic nerve form brachial

plexus.

The muscles of head & neck receive innervation from C1 to C4 where as

the muscles of arm are supplied by C5, C6, C7, C8 & T1 nerve roots.

The following table shows the origin of nerve, name, muscle supplied &

action.18

2. Table showing, origin, nerve name, mucle name & action:

S. No

Origin Nerve Name Muscle Name Action

1. C2 , C3 Accesory/muscular Sternocleidomastoid Lateral flexion& rotation of head

2. C3,4 Accessory/muscular Trapezius Elevation of tip of shoulder

3. C3,4 Nerve to levator scapulae

Levator scapulae Elevation of scapula

4. C5 Dorsal scapular Rhomboidei(both) Retraction of scapula

5. C5,6 Nerve to subclavius Subclavius Depression of shoulder

6 C5,6 Axillary Deltoid,Teres minor Abduction & Ext.rot. of arm

7. C5,6 Upper subscapular Subscapularis Int.rot. of arm. 8. C5,6 Lower subscapular Teres major Extension &

int.rot.of arm 9. C5,6 Suprascapular Supraspinatus,Infraspinat

us Abduction & ext.rot.of arm

10. C5,6,7 Long thoracic Serratus anterior Upward rot. Of scapula

11. C5,6,7 Lateral pectoral Upper pectoralis major Adduction,flexion of arm

12. C8,T1 Medial pectoral Lower pectoralis major,Pectoralis minor

Adduction,extension of arm; depression of shoulder

13. C6,7,8 Thoraco dorsal Latissimusdorsi Extension,adduction of arm

14. C5-7 Musculocutaneous Biceps,Coracobrachialis,Brachialis

Flexion, adduction supination of forearm

15. C5-8 Radial Triceps, anconeus, extensors

Extension of forearm, adduction at wrist

16. C5-TI Median Flexors of forearm, 5 hand muscles

Pronation of forearm,flexion of wrist

17. C8-T1 Ulnar 11/2Flexors of forearm, skin of hand

Flexion of phalanges,adduction at wrist

Bio-Mechanics Of Cervical Spine From C4 To C7

• Biomechanics is study of mechanics in human body.

• It includes kinetics and kinematics.

Kinetics: Area of biomechanics concerned with forces producing motion or

maintaining equilibrium.

Kinematics: Area of biomechanics concerned with motion.

• Cervical spine is designed for large amount of motion.

• The motion of flexion, extension and lateral rotation are permitted in

cervical spine from C4-C7. Predominent translation at C2-C7 occurs in

sagital plane from C4 to C7.

Range of Motion and Muscles Acting:

Movement : Extension

Muscles : Longissimus Cervicis, Semispinalis Cervicis,

Splenius Cervicis.

Range of motion : 0’ to 30’

Movement : Flexion

Muscles : Scalene Muscles, Posterior Sternocleidomastoid

Range of Motion : 0’ to 35-45’

Movement : Lateral flexion

Muscles : Sternocleidomastoid, Splenius Cervicis, Scalenii,

Erector spine.

Range of motion : 20’ to45’

Movement : Rotation

Muscles : Splenius capitis, splenius cervicis on same side.

Sternocleidomastoid on opposite side.

Coupling characterstics: The coupling pattern in the lower spine is

important.

• The coupling is such that with lateral bending the spinous process goes

to the convexity of the curve.

• In lateral bending to left, the spinous process goes to the right and in

lateral bending to right the process goes to the left.

• This coupling phenomenon plays an important role in that some ratios of

axial rotation and lateral bending may result in a unilateral facet

dislocation.

Stability of cervical spine:

• Cervical region bears less weight and is generally more mobile.

• The loads imposed on cervical region vary with position of head and

body and are minimal in a well supported reclining body posture.

• In cervical region compressive forces are transmitted in three parallel

columns:

A single anterocentral column formed by veterbral bodies and discs

Two rod like posterolateral column composed of left and right

zygopophyseal joints.

Compressive forces are mainly transmitted through bodies and discs and

less than 1/3rd by posterolateral column.

• Compressive loads are low during erect stance, sitting posture and

during flexion and extension movements.

• Cervical motion segments exhibit stiffness in bending, axial rotation and

compression.C2 to C5 exhibit more stiffness in compression and

extension than C5 to T1.

• Head should be held in non rotated position during flexion, extension

activities to reduce the risk of injury. Joint capsules of cervical region

are lax and therefore provide fewer restrictions to motion.

Mobility of cervical spine:

• The motion of flexion, extension and rotation occur here.

• Lateral flexion below C2 is coupled due to articular facets.

• Flexion and extension occur between C4 and C 6.

• The height of disc plays role in determining the amount of motion of

spine.

• Large amount of motion occurs at each segment at younger age because

of large amount of water in disc.

• At older age disc appear ligamentous, dry and no evidence of nucleus

pulposus.

• Thus disc are more prone for protusion and degeneration.

• Highest occurs between C5 and C6 followed by C6 and C7, C4 and C5.

• A normal cervical spine shows anterior convexity that is a lordotic

curve.

• More degeneration occurs at C5 and C6 because of greater flexion and

extension movements at this region.

Factors affecting mobility and stability:

• Excessive extension is limited by passive tension in anterior longitudinal

ligament, spinous procces and anterior neck muscles.

• Forward flexion is limited by posterior longitudinal ligament,

ligamentum nuchae and flavum.

• Lateral flexion and posterior translation is limited by uncinate process. • Rotation and anterioposterior and lateral tilting are limited by fibres of

annulus fibrosis.19

References:

1. Su.Sa.5/3

2. Su.Sa.5/3

3. Su.Sa.1/8

4. As.Sa.Sa.5/58,59 & Bh.Pr.

5. Ca.Su.17/118

6. Ca.Su.12/8

7. Ca.Ci.28/5

8. Neurological concepts in Ayurveda- 4th chap ; pg no:99

9. Essentials of Basic Ayurvedic concepts- Dr.V.V.S.Sastry- 1st chap ; pg

no:17

10. Tridosha theory- Dr.V.V.S.Sastry

11. Ck on Ca.Su.12/20 & Su.Ni.1/7

12. Ck on Ca.Su.12/3

13. Su.Ni.1/5

14. Essentials of Basic Ayurvedic concepts- Dr.V.V.S.Sastry- 1st chap ; pg

No:10

15. Tridosha theory- Dr.V.V.S.Sastry

16. The clinical anatomy & management of cervical pain

17. Clinically oriented anatomy

18. Orthopaedic medicine-a practical approach

19. Gray’s anatomy

20. Role of physiotherapy in lower cervical spondylosis- project work

NIDANA Rogotpadaka hetu is called nidana.1 A particular factor capable of

producing a complete disease process in the body either immediately or after

certain period is termed nidana.2

Acharya Caraka described Trisutra i.e Hetu-Linga-Aushadi.3The sum

total of these three is Ayurveda. Where as Susruta stated nidana parivarjana as

one of the methods of treatment.4 These two statements denote the importance

of nidana in production as well as curative line of approach.

There are many and varied factors i.e both intrinsic (Nija) & extrinsic

(Agantuja) factors causing disease. The actual intrinsic factors which become

excited and imbalanced, either conferring a predisposition or actually causing

disease are, the Tridoshas.5These are susceptible to imbalance and vitiation.

There are no separate nidanas described for Viswachi. The general

nidanas of vatavyadhi and factors causing vataprakopa are applicable.

Acharya caraka explained vatavyadhi nidana in 28th chapter of cikitsa

sthana. Susruta explained vataprakopa nidana along with other dosaprakopa

hetus in sutrasthana.Similarly Vagbata explained vatasanchaya hetus in

sutrasthana and vataprakopa hetus in nidanasthana.

Basically nidanas are classified into sannikrista & viprakrista6 varieties.

Sannikrista nidana includes aharaja, viharaja, manisika, agantuja, anya factors.

In Vaidyacintamani viprakrista nidana for vatavyadhi is mentioned. It

states that “the person who steals the wealth of God or Brahman and who

deceives his master or who apposes his teacher will suffer from

vatavyadhi.”7

There is another description of horoscope status which predicts

occurrence of vatavyadhi. It is as follows

“If during birth Sun is in the Karkataka rasi & viewed by Saturn, then

the person will suffer from vatavyadhi.”8

Though so many factors are explained a few act as primary aetiological

factors causing the pathology where as others act as sahayaka nidanas.

Aharajahetus:

Gunas:

• Excessive intake of ruksha, laghu, seeta ahara increases the vata. As

samanyam is vriddhi karanam9, all these three factors are characters of vata

which get increased by excessive intake ruksha guna causes dhatukshaya

resulting in stamba, khatinyata of snayus and kandaras. Balanasa is noticed.

• Laghuguna causes sroto riktata and rukshatwa, excites vata results in

increased chalatwa.

• Seetaguna causes stamba opposing movement of any kind results in

stiffness10

Rasa:

• Kashaya, katu, tikta, rasas are vata kopaka rasas11.

• Katu rasa by its laghu and ruksha gunas vitiates vata causing piercing and

stabbing pain along with bala vighatam12.

• Tikta rasa by its laghu seta ruksha gunas leads to dhatu kshaya and vata

prakopa13.

• Kashaya rasa by its ruksha, visada, seeta, and vistambi gunas causes

soshana, stambana and srotorodha14.

• Khara guna causes lekhana results in dhatukshaya and vata prakopa15

• Excess sushka ahara sevana causes increased dryness in all the dhatus

resulting in kshaya of all the dhatus.

Sevana vidhi:

• Food taken following the matra, kala, Agni is digested and absorbed

properly, nourishes the body. Decreased quantity of food taken results in

improper nourishment of the dhatus resulting in dhatu kshaya. Abstinence

from food leads to lack of nourishment.

• Food taken in irregular fashion not following matra, kala, Agni leads to

improper paka of food, causing srotorodha and ultimately tridosha prakopa.

• Eating incompatable foods (viruddasana) affects Agni and malnourishment

of the dhatus. Vidahi bhojana vitiates rakta dhatu and is difficult to digest.

• The foods such as kalaya, chanaka etc comes under the vistambi, virudhaka

category. These are heavy to digest and cause stambana resulting in sroto

rodha, dosha prakopa and vyadhijanaka.

The materials required for incorporation into the structure of seat of vata

(mastishka and vatavahanadis) are produced in kosta by the in taken food. All

the improper sevana vidhis results in nutritional deficiencies.

Among all the nutrients B-complex, vitamins are very much essential for

the maintenance of normal health and activities of certain parts of the nervous

system. Thus improper sevana vidhi may result in neurological diseas16.

Viharajahetus:

• Primary one is ativyayama i.e excessive exercise which also includes

langhana (jumping), Plavana (swimming), dhavana (running), utkshepa,

vikshepa, bharaharana (lifting heavy weights), vichesta and atichesta.

• Due to excess of vyayama vata is vitiated along with pitta, rakta causing

srama, klama, dhatukshaya17. All these causes excessive strees and strain on

the spine. Ruksha, khara, laghu and visada gunas of vata increase.

• Dukhasayya and asana are specially described by Caraka. Improper posture

gives more and more pressure over the spine and disturbs the muscular

integrity provoking vata.

• The factors like gaja, turanga, ratha, pathadi charya and ati advagamana

also vitiates vata due to increased chalatwa causing excessive stress and

strain on the spine.

• Diwaswapna causes srotorodha excites kapha vata, leads to vataprakopa.18

• Ratrijagarana excites vata, pitta and kshaya of kapha. Rukshatwa is

increased.19

• Veganirodha and udirana both cause vata prakopa due to marga avarana.

These are the almost always adisease causing factors in all diseases.

• Ativyavaya can also be included under ativyayama but here along with

vitiation of vata and pitta, dhatukshaya that to sukra kshaya occurs. This

causes sandhi saitilya, rukshata and dourbalya20.

• Atichankramana leads to pain in both lower limbs, angamarda, amsabhitapa

which are resultanat of vata prakopa21.Laghu guna, rukshaguna vriddhi

occurs.

• Excessive dosha srava or rakta srava from the body leads to dhatukshaya

resulting in vata prakopa by increasing visada, laghu, and ruksha gunas in

the body.

• Occupational factors causing vata prakopa also comes under this category.

Manasika hetus:

Susruta defined swastha as one with healthy mind and body .22 The

manasika factors also influence the health of an individual.

Chinta, soka, bhaya, krodha are due to rajasa guna, where as vata is also

rajo guna pradhana.23 Thus all these aggrevate vata. These factors also cause

nidra viparyaya leading to vata pitta prakopa along with kapha kshaya.

Agantuka hetus:

This includes abhighata i.e. patana, bhanga, where injury to the organs

leads to diseased states. Marmas are 107 in number. They are vital points of

prana in the body. Marmaghata results in diseased conditions depending on the

type and the site of the marma.

Kalaja hetus:

In the classics swabhavika vata prakopa is described in certain periods

of time in a day and a year, they are ahoratri, bhuktante, vruddha vayah,

greeshma and sisira and varsha ritus.24 During these times vata prakopa occurs

naturally without any reason.

All the factors which excite vata i.e. inducing the rukshatwa, laghutwa,

seetatwa, dharunatwa, kharatwa, visadatwa and sushiratwa in the body, are vata

vyadhi nidanas.25 In the Viswachi disease, the viharaja hetus are pradhana

factors and the aharaja and manasika factors are vyanjaka nidanas.

Thus all the described nidanas increases rukshadi gunas resulting in

decreased snehadi properties essential for proper vata function is the ultimate

result.

3. Table showing nidanas explained in various classics:

Nidana C.Samhita S.Samhita A.Sangraha A.Hrdya B.Prakash C.Karika

1.Ahara

a.Rasa

Kashaya - + - + + +

Tikta - + - + + +

katu - + - + + +

b.Guna

Ruksha + + + + + +

Laghu + + + + + +

Sushka + + + + + +

Khara + + + + + +

c.Veerya

Seeta + + + + + +

d.Sevanavidhi

Alpanna + + - + - -

Pramitasana - - - + - +

Adhyasna - + + - - -

Ajeernasana + + - - - -

Viruddhasana + + + + + +

Vistambi - - + + - -

Virudhaka - + + - - -

Ama + - - - - -

Anasana + + - - - -

Vishamasana - + - - - -

Abhishyandi + + + + + +

Upaclinna + + - - - -

2.Vihara

Ativyayama + + + + - +

Ativyavaya + + - + - -

Vishamopachara + + + + + -

Langhana + + + - - -

Plavana + + - - - -

Dhavana - + + - - -

Pratarana - + + - - +

Diwaswapna + + - - - -

Ratri jagarana - + + - + +

Dukhasayyasana + - - - - -

Veganirodha + + + + + +

Bharavahana - + - - - -

Vichesta + - + + - -

Gajaturagapada

ati charya

+ + + + - -

Dosha

srava/kshaya

+ + + + + +

3.Agantuja

Abhigata + + + - + +

Marmaghata + - - - - -

4.Manasika

Chinta + + + + + +

Bhaya - - - - + +

Shoka + + - + - -

Krodha + + - - - -

5.Kalaja

Ahoratri + + + + + +

Bhuktante + - + - - -

Vruddhavayah + + + + + +

Greeshma + - - - - -

Sisira + + + - - -

Varsha + + + + + +

References:

1) Madhukosa on panchalakshana nidana

2) Ma.Ni.1/4

3) Ca.Su.1/29

4) Su.Ut.1st chapter

5) Introduction to KC 4th chapter/20th page

6) Madukosha- Harischandra in upakalpaneeya chap

7) Vaidya cintamani-vatavyadhi chap.1st sloka

8) Vaidya cintamani-vatavyadhi chap.5th sloka

9) Ca.Su. 1/45

10) As.Su.9/19

11) Ca.Su.1/66

12) Ca.Su.26/40

13) Ca.Su.26/40

14) Ca.Su.26/40

15) As.Su.1/18 Hemadri teeka

16) Essentials of basic ayurvedic concepts-Dr.V.V.S.Sastry-1st chap/18th page

17) Ca.Su.7/33

18) Ca.Su.21/50

19) Su.Sa.4/48

20) Ca.Ni.6/8-9

21) Ca.Vi.3/12

22) Su.Su.15

23) Su.Sa.1/40

24) Su.Su.21/19

25) Introduction to K.C 8th chap; pg 1

SAMPRAPTI

The process of manifestation of disease by morbid doshas which are

circulating all over the body is known as samprapti.1

In otherwords it briefly the course of development of disease right from

the vitiation of doshas to affliction of different parts of the body. Ultimately

resulting in either structural or functional changes in the part.

Acharya Susruta, vagbhata, Madhavakara described Viswachi as “ the disease

in which the enranged vata affecting the kandara which run to the tips of finger

from behind the roots of the upper arm, making them incapable and depriving

them of their power of flexion & extension.2

Dalhana while commenting upon the above verses of Susruta stated that

talakandara means internal kandara and bahu prista denotes the external

kandara. And further he mentions that both the arms may also be affected

sometimes.

Arundatta commenting upon Astanga Hrdya considers kandara as the

site of snayusanghata and extended upto the dorsal side of the arm. These

kandaras when affected by vitiated vata, forsakes the activity of the arm.

Samprapti of any Vata vyadhi occurs as follows:

“ Due to the naidanik factors, vata prakopa occurs and it moves all over

the body and where, it comes in contact with snehadirahita rikta srotases it

fills them up producing either sarvanga or ekanga vyadhi.”3

In Viswachi disease, the prakupita vata while moving all over the body

settles in the greeva making it the adhistana. As the khavaigunya is in griva,

vata fills those srotases doing soshana of the sleshaka sleshma of grivakaseruka

sandhis along with the grivakaseruka vikara.This inturn leads to dusti of

kandara of bahu manifesting the symptoms of Viswachi i.e radiating pain all

along the arm & weakened or loss of movements of the arm.

Samprapti of Viswachi involves two major steps-

i. Vitiation of vata

ii. Kandara dusti

Caraka explained two ways for vataprakopa, causing disease. They are

i. Dhatu kshaya

ii. Margavarodha

“Dhatukshayat iti sara kshayam “cakrapani on Ca.Ci.28/58

Cakrapani states that in this context Sara has to be understood as the innerpart

of kapala & kshaya as the decreased snehadi qualities or change in

composition, as a very minute change can upset the equilibrium.4

Nidanas explained in earlier chapter leads to increased ruksha, khara &

visada gunas of vata resulting in dhatukshaya i.e reduction in snehadi gunas to

large extent and further vitiating already prakupita vata.

Margavarodha may be to kapha, ama etc. three doshas spread all over

the body, amongst them vatadosha is sukshma having property of prerakatwa.

Thus it being sukshma, when in vitiated stage reaches everywhere in the body

stimulate pitta & kapha dosha.These pitta & kapha then obstruct the flow of

vata thus vitiating it more & more.5

Obsruction to the flow / movement of vata blocks the transmission, thus

excites vata, causing diseases.6 As explained in the nidana chapter few factors

such as abhigata etc cause margavarodha resulting in disease.

Thus the prakupita vata due to its rookshadi gunas does soshana of the

sleshaka sleshma of griva kaseruka sandhis. Stanasamsraya of vata occurs at

griva.

In samprapti of a disease, the sthana has a special importance because

the dosha ultimately settles in the vaigunya sthana & treatment is directed

against correction in such sthana dusti.7

Enraged vata not only dries up the sleshakasleshma but also causes

vikriti in griva kaserukas. This depends on the strength and type of nidana.

Kaseruka vikriti can be understood as follows: Vata & asthi share

asrayee and asraya relation respectively.8Even though the basic rule is that the

materials which cause increase of asraya should also effect the increase of

asrayee and the materials that cause decrease of asraya cause decrease of

asrayee, the reverse is true in case of vata & asthi. A material which causes

increase of asthi will produce decrease of vata & viceversa. Thus creating

imbalance in the relationship between the asraya & asrayee.9

Thus kaseruka vikriti along with soshana of sleshaka sleshma causes

dusti of bahu kandara which precipitates Viswachi vyadhi.

Schematic representation of Viswachi samprapti:

Nidanas

Dhatukshaya Margavarodha

Vataprakopa

Stanasamraya at griva

Sleshakasleshma Soshana & Kaseruka vikriti

Bahu Kandaradusti

Viswachi

Samprapti ghatakas:

i. Dosha : Vata; Vyana Vata

ii. Dushya : Kandara

iii. Srotas : Chestavaha (Srotases Conducting Both Drishya &

Adhrihya Movements; Manas & Buddhi Considered

As Moolas.)10

iv. Srotodushti : Sanga

v. Adhistana : Greeva

vi. Vyaktasthana : Bahu

vii. Rogamarga : Madhyama

viii. Vyadhisvabhava : Chirakari

Samprapti through various types:

i. Sankhya : One

ii. Vikalpa : Ruksha, Khara, Laghu, Visada Gunas of Prakupita Vata

iii. Pradhanya : Vata (vyana vata )

iv. Bala : Krichra Sadhya

v. Kala : Vata Prakopaka Kala.

As the Scope of this study includes understanding Viswachi with

respect to Cervical Spondylosis, an explicit explanation of the

morbid condition follows:

AETIO-PATHOGENESIS Predisposing factors:

• Poor posture associated with anxiety and habit.

• Occupational stress eg: typist, coal miners, drivers…. Etc.

• Body type: Thick necks [dowgers hump] and long backs are prone for

spondylosis.11

The aetiology of cervical spine pathology is thought to include

progressive degeneration, trauma and aberrant neurological reflex pattern

(Mootz, 1995).In addition to degenerative changes that occur with the ageing

process, it has been speculated that frank trauma such as injury from a whiplash

mechanism or microtrauma produced by faulty sleeping posture and other

habitual positions that produce repetitive strain can cause the pathology.

The vulnerability of the neck is created by the 3.5-5.5 kg head sitting

on top of the cervical spine with its multitude of joints, 50 pairs of muscle and

a complex ligamentous/ capsular network. From this perspective we have a ball

(the head), a flexible chain (the neck) and a rigid base (the upper back). It is not

surprising that this structure is subject to degenerative & subluxation

syndromes accompanied by soft tissue damage.

A) The process and mechanics of spinal degeneration:

• Single most important cause for the cervical spine disease is degeneration.

Degenerative disease of the cervical spine is an extremely common clinical

problem. The pathological changes in the conditions of cervical disc

degeneration, degenerative arthritis of cervical spine and herniation of

cervical disc are quite similar, differing only in degree. It is the generalized

disease process affecting the entire cervical spine and related to chronic disc

degeneration. It occurs in more than 90% of adults over the age of 50 yrs

and almost 100% by 70 yrs.

• The intrinsic factors that make the healthy spine a comparatively stable and

mobile mechanical unit are vested in the elastic properties of some

structures of the spine. Forces acting on the typical cervical motion segment

include the axial pressure of the head on the nuclei pulposi and the tension

exerted by ligaments holding each segment together, thus forming an

intrinsic equilibrium. Relatively little muscular force is required from the

contractile elements to maintain erect posture when this intrinsic

equilibrium is preserved. Degeneration of the cervical disc represents

premature ageing of this particular tissue.12

• It is characterized by dehydration, fissuring, annular disruption and

osteophytosis.

• Rapid depolymerization of the acid mucopolysaccharide and dehydration of

the nucleus pulposus of the disc, converts this normally gel like substance

into a thinned fibrous scar tissue that can no longer function as an adequate

shock absorber.

• The tension within the disc is maintained by fluid imbibition at the cellular

level. If imbibition fails for any reason the pressure within the disc falls, the

disc collapses, increased movement occurs between the adjacent vertebrae,

the annulus fibrosus is exposed to increased stress and this is accompanied

by vague pain.

• Advancing degeneration of the nucleus pulposus and annulus fibrosis

means lessening of the mechanical efficiency of the disc to act as shock

absorber or insulator between two vertebral bodies.

• Subsequently tears in the posterolateral region of the annulus occur.13

• When the intervertebral disc degenerates, the intrinsic balance mechanism

is disrupted with reduced turgidity, as nucleus pulposus looses its

hydrophilic properties, segmental instability occurs because the inelastic

ligaments cannot shorten to compensate for the loss of disc height. The

resultant increase in muscle activity required to stqbilize the degenerating

spine leads to the familiar-pain-spasm-cycle.

• With the collapse of the disc space, the axis of motion shifts posteriorly to

the apophyseal joints. These joints cannot withstand the stress and

deteriorative changes soon follow to alter the smooth contour of the

apophyseal joints.

• The longitudinal ligaments degenerate and form bony spurs at their

insertion into the vertebral body.

• Hall (1965) reviewed the pattern of degeneration of the cervical spine. In

early stages he noted cavities at the lateral margin of the annular fibres of

the intervertebral disc that spread from oneside to other with accompanying

loss of disc height and ligamentous laxity. In the final stage, the

intrevertebral distance is greatly reduced and the bone structure becomes

distorted by osteophyte formation that results in stabilization of the excess

mobility allowed by intersegmental ligaments.

• Following the initial stage of dysfunction, loss of the intrinsic equilibrium

creates an unstable phase of kinesiopathology during which subluxation

occurs.In the final stage, stabilization occurs, when motion in the

zygapophysial joints and disc becomes restricted by osteophytic

proliferation: this stage is characterised by cartilage degeneration, loss of

disc substance, soft tissue fibrosis, and the formation of osteophytes

(anterior margin) of involved vertebrae.

• The converging of the cervical disc space may result in buckling of the

ligamentum flavum, with further narrowing of the spinal canal.

• Segmental injury will result in hypertrophic formation of osteophytes by the

uncovertebral joint of Lushchka and the facet joints. These prominent spurs

will compress both the neural foramina and the spinal canal.

• In the cervical spine the joints of Lushchka aiso exhibit degenerative

changes, with the joint between the bodies of vertebrae altered from a

fibrocartilagenous amphiarthrosis to a ball i.e. sockets shaped dysarthrosis

(Hall, 1965).

• When a disc protrusion becomes symptomatic, there has usually been a long

period of silent degenerative change, first with fissure formation. If there

are multiple fissures, a loose fragment will develop and this causes a major

alteration in the disc mechanics. Under relatively small loads, the fragment

will be displaced posteriorly, tearing the inner annulus and causing a

protrusion. If the fragment displaces further the whole thickness of the

annulus gives way and the fragment is extruded as a herniation.14

B) The mechanics of cervical spine injury:

• In general, spinal injuries are classified according to the mechanism of

injury. Hyperflexion most commonly result from blows to the back of the

head & forceful deceralations as in motor vehicle accidents (MVA) whereas

hyperextension injuries likely to occur from a blow to forehead or from

whiplash injury.

• Displaced fragments can produce cord injury in otherwise stable (structure)

segments.

• Cervical disc herniation occurs across a broad spread of age ranges from 20

to 60 yrs, being most common in individuals in their 30’s.

• Herniation after the age of 30 is unlikely to occur since the gelatinous

nucleus pulposus has been replaced by fibrocartilage.

• The male to female ratio is approximately 1.4 to 1.Cervical disc herniations

are less common than lumbar disc herniations and linked risk factors

include smoking, diving and lifting heavy objects.

• The most common levels of involvement are C6 to C7 (60%) & C5 to C6

(30%).

• Cervical disc herniations are often referred to according to their

consistency, being soft, when gelatinous nucleus pulposus extrudes and are

unassociated with posterior osteophytes.

• So called hard herniations are fibrocartilagenous annular bulges which

occur in tandem with posterior osteophytes.

• Lateral herniations are less common due to relative anatomical barrier of the

uncovertebral joints and tend to select a single nerve root producing features

consistent with lower motor neuron involvement.

• Almost 50% of posterior herniations are intraligamentous lying between

deep and superficial layers of the ligament.

• Two main types of disc protrusions occur. They are-

1. Nuclear herniation

2. Annular protrusion

Nuclear Herniation: In this a circumscribed mass is formed by the extension

of the nuclear material through a tear of the annulus fibrosis as a result of the

strain put upon it by excessive movements of the neck. Thus it is traumatic and

is the type of lesion commonly encountered in young people.

Annular Protrusion: This occurs usually in the middle aged and elderly

persons. During the ageing process the disc becomes dehydrated & looses its

elasticity. As a result of this it collapses and the annulus bulges in all the

directions, which may be

A. Central

B. Lateral

C. Dorsal

D. Ventral

E. Combination of any these

Depending on the direction of protrusion signs & symptoms occur.

1. Dorsolateral: protrusion which does not invade the invertebral foramen but

may compress the intrameningeal nerve roots against the vertebral lamina.

2. Intraforaminal: Protrusion which comes from the uncinate part of the disc

and compress the radicular nerve against the articular process. In this case

the compressing agent may be the usual spur formation from the disc.

Above said changes cause the nerve root compression along with the root

sleeve fibrosis. The sleeves become thickened and adhesions form between

the nerve filaments, with fibrosis of the arachnoid membrane.

C) Athletic injuries:

Injuries to cervical spine include those from athletic activities such as

football, soccer, skiing etc. The mechanical vulnerability of the head neck

coupling increases the risk of severe disruption of the motion segments.

Bony elements, ligaments, discs and muscular supporting structures as well

as neurovascular structures can be affected.

D) Occupational and life style factors:

A variety of occupational risk factors have been suggested for degenerative

and mechanical disorders of the neck. The introduction of modern

technology has resulted in monotonous tasks that impose static and

repetitive loads. These tasks affect the joints and muscles which, inturn can

contribute to subluxation & degenerative syndromes. Consequently, a

relationship has been found between times spent working with office

machines, including visual display units and the occurrence of

musculoskeletal symptoms. Other factors contributing to these disorders are

mental strain, lack of situational control and low job satisfaction.15

E) Congenital narrowed spinal canal since birth.

F) Compression due to neuroma, lymphoma, extradural tumour or

metastases:

With any duration of compression the blood supply to the nerve is

compromised, changes in the spinal cord and nerves due to insufficient

blood supply result in tingling later numbness and weakness appear in the

territory of the affected nerve.

These degenerative changes occurring in the spine, the protruded disc or the

osteophytes formed reduce the spinalcanal sagittal diameter lead to nerve

root compression or and cord compression. It is thought that disc releases

inflammatory mediators causing abnormality in the function of a

compressed root. This is time dependent, and although the disc may

continue to compromise the nerveroot, the inflammation can resolve and the

symptoms settle.

A large disc protrusion which compresses the nerve root will cause

increased intra radicular venous pressure. This reduces the blood flow and

impairs the arterial supply to the root. There will be nerve root edema

as extra vascular fluid collects in the root, and nerve function is then

impaired.16

REFERENCES:

1 As.Hr.Ni.1st chap

2 Su.Ni.1/35

3 Ca.Ci.28/18

4 Basic concepts of essentials of ayurveda 1st chap page 21

5 Ca.Ci.28/60

6 Ck on Ca.ci.28/58

7 Thesis “ A clinical trial of parijatha in Grdhrasi “ chap 20, page 30

8 As.Hr.Su.11/26,27

9 Basic concepts of essentials of ayurveda 1st chap, page 8

10 Basic concepts of essentials of ayurveda 8th chap, page 200

11 Role of physiotherapy in lower cervical spondylosis- project work

12 The clinical anatomy & management of cervical pain-vol 3

13 Fundamentals of orthopaedics- Gartland

14 The spine and medical negligence- R.W.porter

15 The clinical anatomy & management of cervical pain-vol 3

16 Orthopaedic medicine-a practical approach

POORVA ROOPA Poorva roopa marks the beginning of the disease. After doshas gets

excited and spread to other parts of the body i.e stana samsraya, occurs, then

poorva roopa is manifested.1

Certain features that develop before the complete clinical features

develop are called prodromal symptoms.

In Vata vyadhi poorva roopa is stated as “avyaktam lakshanam

tesham poorva rupamiti smritam”2

Avyaktam means incomplete in symptoms due to slightness. In this

disease there is no poorva ropa different from roopa, but only in latent form.

So, one may not appreciate them. Roopa slightly manifested before the

appearance of disease is poorva roopa.3

In this context of Visvaci pain and other symptoms in milder form

(alpatwa) can be taken as poorvaroopa.

References:

1 Ca.Ni 1/8

2 Ca.Ci.28/ 19

3 Ck on Ca. Ci.28/19

ROOPA

Roopa is manifestation of signs &symptoms.1 It is the vyakta

avastha.2During this stage dosha dushya samoorchana gets completed.3This

leads to manifestation of all lakshanas including pratyatmika lakshana, based

on which the disease is diagnosed.4

In description of Viswachi Susruta mentioned bahu karma kshaya as the

only symptom.5Vagbata quoted bahu chestapaharana as the lakshana 6 where as

Madhavakara also described bahu karma kshaya as the only symptom.7

While commenting on the verses of Acharyas, various commentators

have described in the following way: Dalhana opines that this disease

resembles Grdhrasi affects one arm or sometimes both the arms.8The other

commentators like Gayadasa, Vijayarakshita and Arunadatta stressed the point

of occurrence of pain as the cardinal feature in this disease.9

They have also concluded that whenever there is severe pain in Visvaci

& Grdhrasi they should be termed as “Khalli”. For all practical pueposes, in

nidana and cikitsa the diseases are to be considered as separate entities except

in the above said references of “Haritha samhita”.10 The poorva acharyas also

have dealt them separately.

The word Viswachi is derived from two words: Visva + anc

Visva means entire / whole / all pervading

Anc means turned to / directed towards / to move / wander about

Thus Viswachi literally means spread through out i.e.pain through

out or whole of the upperlimb.11

Viswachi is vedana pradhanaja vyadhi. Here stanika lakshanas are

exhibited rather than sarva daihika lakshanas. Classics described Pain as of

radiating nature in viswachi.

The description of pain given in this context in contemporary medicine

suits exactly to the description given in our classics. It is as follows-

Pain is described as severe and sharp usually follows a radiating pattern from

the shoulder to the arm and frequently into the forearm to the fingers.

Pain often has a neuritic quality – described as throbbing, burning,

stabbing, electric shock like& aching. Sometimes it is cramping paraesthesia

often felt in the fingers. These descriptions of pain are available in our classics

as vyadha, bhedana etc. Weakness& occasional tenderness occurs.

The pratyatmika lakshana of Viswachi is radiating pain from the bahu

prishta to the hasta talam & pratianguli.14In fact, this typical pain readily

gives the diagnosis.

Bahu karma kshaya is emphasized as pratyatmika lakshana by Susruta.

Prasarana, akunchana, grahana, & daana are bahu karmas.Kshaya literally

means loss/diminished/decreased/weaken. In this context diminished or

weakened movements of the arm is appropriate.

As Viswachi is described similar to Grdhrasi of lower limbs, 15 the

lakshanas described in Gridhrasi can also be considered in Viswachi. Thus

along with vedana, bahu karma kshaya other signs & symptoms of Viswachi

can be considered as follows-

1. Stambha : There is a feeling of tightness or rigidity throughout the upper

limb. This is also manifested by way of restricted movements.

2. Ruk : Ruk is nothing but ruja /vedana /shoola i.e. pain. It is different

from the pain which has been described as the cardinal feature of Viswachi i.e.

radiating pain. But ruk is dull aching pain of continous nature. It is felt

throughout the hand and is not localized to one portion. It is muscular in origin

result of stambha. Ruksha & sheeta gunas are responsible for it.

3. Toda : Toda is nothing but pricking type or lacerating type of pain felt

in some region or felt at the intervals especially when Viswachi vedana is

intense. This can be considered as pins& needles type of paraesthesia.

4. Spandana : Along with pains of various types there is many times a

sensation of something pulsating or throbbing. This is due to muscular

twitching. This may be in any region of the upper limb, can also alternate with

the stambha, ruk, toda.

After the classical description of lakshanas of Viswachi, the contemporary explanation of the Clinical features are as follows:

The development during adult life of chronic disc protrusions, combined

with osteophyte formation on the vertebral bodies and soft tissue changes in the

paravertebral tissue frequently cause compression of the cervical cord and or

roots.This slowly progressive degenerative process is known as cervical

spondylosis and become increasingly common with age.

Spondylotic changes affect almost all individuals with advancing age,

but in many remain only as an asymptomatic radiological finding.Spondylotic

changes are most common in the mid to lower cervical cord, with the maximal

frequency and severity of involvement at C5/6 level.14

Generally pain, paraesthesia, weakness, muscle spasm and limitation

of movement are symptoms observed.

Pain is dull, aching, superimposed by sharp stabbing pain and from time

to time as cramp type throbbing. It is initially intermittent but later constant.

Pain is worse and can get altered with sleep.

Paraesthesia is pins and needle type with altered sensation in the area

supplied by an impinged nerve root.

Pressure applied on nerve root causes weakness.Postural muscles like

flexors of upper cervical spine and extensors of lower spine and side flexors are

often weak.

Neck movements are bilaterally limited.During acute episode of pain

one side is more affected than other.Upper cervical spine flexion is more

affected than extension of lower spine.15

These above said symptoms can be broadly classified into following

groups:

1. Cervical radiculopathy

2. Cervical myelopathy

3. Occipital headache

4. Pain in the neck

5. Vertebrobasilar syndrome

Cervical radicuopathy can be grouped under three headings basing on

the cause of compression i.e.acute disc protrusion or the secondary

degenerative changes of the cervical spine.

1. Acute radiculopathy-I

2. Acute radiculopathy-II

3. Chronic radiculopathy

The chronic variety is the continuation of acute variety without

remission of symptoms but leaving some permanent sensory disturbances.

The symptoms are extensive topographically i.e. pain & sensory loss in

the appropriate dermatome along with segmental weakness, wasting, and reflex

loss affecting the relevant myotome. The manifestations depending on the

nerve root involved are as follows16:

C1 – C3:

• It is rare condition.

• Motor supply to number of neck muscles is interrupted but is not usually

clinically apparent.

• Sensory loss is found over the back (C2) and side (C3) of the neck.

C4:

• It is also a rare condition.

• There is sensory loss in a cape distribution between the side of the neck

and the top of shoulder.

• Unilateral lesions cause weakness of Rhomboids.

A C2, C3, & C4 root palsy weakens scapular elevation. The muscles of the arm are supplied by the C5, C6, C7, C8,& T1 nerve roots.

C5:

• Disc lesions are fairly common.

• Pain in the neck, shoulder, lateral arm to elbow.

• Pins & needles are usually absent; if present, extends from the outer

surface of the shoulder down into the lateral arm and forearm.

• Weak Deltoid, Supraspinatus -- resisted abduction

• Weak Biceps -- resisted elbow flexion

• Weak Infraspinatus – resisted lateral rotation

• Biceps jerk – absent/sluggish

• Brachioradialis jerk – absent/sluggish/inverted.

C6:


• Pain in the neck, lateral arm to thumb & index finger.

• Pins & needles in the thumb &index finger.

• Weak Extensor carpi radialis – resisted wrist flexion

• Weak Brachialis & Biceps – resisted elbow flexion

• Weak Subscapularis – resisted medial rotation.

• Biceps jerk – sluggish/absent.

C7 :

• Disc lesions extremely common, probably 90% of cervical disc lesions

causing a root palsy at the sixth level compresses the seventh root.

• Pain in the lateral arm to middle, index & ring fingers.

• Pins & needles in the index, middle, & ring fingers, and a strip in the

middle of the hand both on the palmar & dorsal surface.

• Weak Latissimus dorsi – resisted arm adduction.

• Weak Triceps – resisted elbow extension.

• Weak common flexor muscles – resisted wrist flexion.

• Triceps jerk – rarely affected

C8:


• Pain in the medial forearm and hand; occasionally it can also be in

lower scapular area and back or innerside of the arm & forearm.

• Pins & needles in middle, ring & little fingers.

• Weak thumb adduction

• Weak thumb extension.

• Weak ulnar deviation.

• Weak adduction of the index finger.

T1 :

• An electric shock like sensation elicited by neck flexion and radiating

down the spine from the neck (Lhermitte’s symptom).

• This usually indicates cervical or upper thoracic (T1 – T2) spinal cord

involvement.17

True radicular pain is often severe and may be present nocturnally.

Recumbency may not relieve the pain. Symptoms are activity dependant and

posture dependant, their longevity determined by the nature of the causation of

spinal pathology.

Cord compression: Main initial symptoms are dysaesthesia in the hands,

weakness & clumsiness of the hands & spastic weakness of the lowerlimbs.

The clinical course of the myelopathy is usually progressive, leading to

complete disability over period of weeks to months.

Deep aching pain of the extremity, broad based gait, loss of balance, loss of

hand dexterity and general muscle wasting are found in patients with advanced

myelopathy.

Impotence is not uncommon in these patients.

Occipital headache: Headache is due to upper cervical pathology. It may be

presenting symptom in few people. Usually, the headache is worse in the

morning and improves throughout the day. It is commonly located in the

occipital region and radiates toward the frontal area.

Pain in the neck: Neck ache is due to mid cervical pathology. Acute disc

protrusion is likely to be associated with severe pain, muscular spasm and

rigidity of neck muscles. In chronic cervical spondylosis pain is usually

comparatively mild and tends to be more severe in the morning.

Vertebro basilar ischaemia: Often rotation to one or other side or extension of

the neck and, less frequently flexion may precipitate a brief attack of giddiness

or a drop attack. Probably pressure on the vertebral arteries with consequent

impairment of the blood supply of the hind brain.18

References:

1) Ma.Ni.1/7

2) Su.Ni 21

3) Su.Su.24

4) Ca.Ni 1/9

5) Su.Ni.1/75

6) As.Hr.15/44

7) Ma.Ni.22/57

8) Dalhana on Su.Ni.1/75

9) Ma.Ni.22/57

10) Ha.sam.

11) Sanskrit to English dictionary

12) Su.Ni.1/75

13) Su.Ni.1/74

14) Lange’s current diagnosis & treatment in orthopaedics

15) Role of physiotherapy in lower cervical spondylosis-Project work

16) Brain’s neurology

17) Cyriax’s illustrated manual

18) Golwalla medicine

.

EXAMINATION

The need for a detailed history and a comprehensive musculoskeletal

examination that includes the cervico dorsal spine is paramount in the

assessment of all upper limb disorders.

Assessment of function is a particularly important aspect of the

examination. Topographically, function of one part of the limb, for instance the

hand, can only be evaluated if the rest of the limb, the axial skeleton and the

contralateral limb are examined.1

Examination of neck: The neck can move in all directions, but for

examination purpose they are reduced to six primary ranges. If these prove full

and painless, the lesion must be sought else where.

• First active movements are assessed, starting with extension.

• Next passive movements, starting with extension.

• For the passive side flexions, care must be taken to limit the movement

to the neck by counter pressure to the thorax; otherwise trunk

movements will complicate the clinical picture.

• When the passive rotations are tested, rotation of the patient’s trunk is

precluded by the exaaminer’s elbows, one placed in front of the shoulder

and the other behind, against the opposite scapula.

• Passive flexion is normally omitted as any disc lesion may be

exacerbated.

• Next, the six resisted movements are tested.

• In particular, the arm is examined for weakness to establish any

neurological deficit.

• The provocative test of combined passive extension & ipsilateral

rotation is highly sensitive for the detection of nerve root irritation /

compression at the intervertebral foramen; an increase in this manoevre

indicates neural compression.

• Root signs are looked for in logical order, working down the arm.

• Along with active shoulder movements all the resisted movement of the

arm is to be examined primarily to check weakness caused by nerveroot

pressure.

• If weakness is found, the good side is compared. But pain on resisted

movements suggests a lesion of the appropriate contractile structure. 2

Functional assessment is done by performing a series of functional

tests or movements to determine the functional capacity keeping in mind the

patient’s age and health.These tests include activities of daily living.3

Special Tests: Special tests for neurological symptoms performed on cervical

spine, almost exclusively, by physiotherapists, they are

1. Foraminal compression (spurling’s) test

2. Distraction test

3. Upper limb tension test

4. Shoulder abduction test

1. Foraminal compression test (spurling tests):

In this test the patient bends or side flexes the head to the unaffected

side first and then to the affected side.The examiner carefully presses straight

down on head.

Result: The test is positive if patient complains of pain radiating into arm when

head is compressed towards the affected side, indicating pressure on the nerve

root.

2. Distraction test:

In this test, the examiner places one hand under patients chin and other

hand around the occiput, and then slowly lifts the patient’s head in effect of

applying traction to the cervical spine.

Result: The test is positive if the pain is decreased or relieved when the head is

lifted or distracted, indicating of nerve root pressure, that has relieved.

3. Upperlimb tension tests (ULTT):

The tests of neural tension proposed for the upper limb have been

developed much more recently than those used for the lower limb and trunk.

These are equivalent to the straight leg raise (SLR) test in the lumbar spine.

Indications:

• Routine for any upper quadrant symptoms ie, cervical spine, arms, thoracic

spine.

• For any patient indicating that a similar functional position produces their

symptoms.

Tests for assessing neurodynamics:

ULTT 1 – Median Nerve

ULTT2a – Modified Median Nerve

ULTT2b – Radial Nerve

ULTT 3 – Ulnar Nerve.

The test is positive if

• Reproduce local and referred symptoms

• Restriction of movement which is assymetrical and can be altered by

changing a remote component of the test that implicates neural structure.

• The test is significant if

• Reproduces symptoms

• There is asymmetrical restriction of movement that relates to symptoms

• There is diffirent symptoms response from either normal or the other

side. 4

4. Shoulder abduction (relief test):

This test is used for C5-C6 nerve root involvement.The patient is in

sitting or lying position, the examiner passively or the patient actively elevates

the arm through abduction, so that hand or forearm rests on top of head.

Result: The test is positive if pain decreases because of abduction of arm. This

is because of lengthening of neurological pathway and decreases the pressure

on lower nerve roots

Indications: Extra dural compression problem such as herniated disc, epidural

vein compression usually in C4-C5 area.

References:

1. WRULD-recognition & management

2. Cyriax’s illustrated manual

3. Orthopaedic physical assessment-Magee

4. Mobilisation of nervous system- Butler

INVESTIGATIONS

1.Blood tests : Complete blood picture ; E.S.R

: Blood sugar levels

: Serum proteins

: C R P; C- reactive proteins

2. X-rays : Spinal – cervical spine – A.P ; Lateral views

3. Imaging : M.R.I – Excellent for cord, root lesions

: CT- For bony lesions

: CT with contrast, intra thecal – for root, cord lesions

: Myelography – if MRI not possible

4. Electrodiagnostic : Nerve conduction studies

5. Isotopescans : Bone (metastases), infective lesions( gallium)

6. C.S.F : Presence of infection / inflammation ; demyelination

The specific diagnostic tools are

I.Conventional Radiography :

• Degenerative changes are graphically depicted, such as loss in disc height,

osteophytes and displacement.

• Loss in vertical height is assessed by comparision with adjacent discs.

Normally disc height is less at C6-C7 and C7-T1 as the transition is made to

the thoracic spine.

• Bony outgrowhs from vertebral bodies occur initially at the insertion of the

anterior longitudinal ligament.

• Loss of lordosis occur commonly from the segment above degenerative disc

changes have occurred, due to segmental extension as the uncovertebral

joints approximate.

• This has a limited role in detection of herniation.

• Canal size can be estimated on the lateral view from the point of posterior

mid vertebral body to the adjacent spinolaminar line and normally is around

17mm in AP diameter.

• A measurement less than 13mm suggests stenosis with cord impingement

and less than 10mm impingement will invariably be present.Average

spinalcord size from C1 to C7 averages 10mm.

• Degenerative changes affect almost al individuals with advancing age, but

in many remain as only an asymptomatic radiological finding.

II.Computed tomography :

• Axial images use ful in depiction of osteophytes and the resultant canal

stenosis.

• CT features of degenerative cervical spine includes osteophytes, sclerosis,

endplate irregularities, vaccum phenomenon, calcification and disc bulging.

• Anterior osteophytes displace or impress on the adjacent retropharyngeal

wall.

• Posterior osteophytes extend into in the central canal and may be seen

contacting & deforming the adjacent cord.

• Sclerosis occupies the subendplate and may be interspersed with focal

radiolucencies.

• Calcification with in the annulus is usually focal and near the circumference

of the disc, while nuclear calcifications are placed more internally.

• Bulging discs, unlike lumbar spine are uncommon and are recognized by a

broad based soft tissue convexity extending less than 2mm beyond the

adjacent posterior vertebral bodies.

• Disc herniation features as a broad based soft tissue density contigous with

the posterior disc margin and distortion of the ventral surface of the thecal

sac.

• CT (intrathecal) i.e. CTM particularly useful for demonstrating

impingement upon the exiting root with a failure for the axillary sleeve to

fill with contrast.

III. Magnetic resonance imaging :

• In comparision with CT in lateral & central canal pathology MRI sensitivity

is at least 90% in comparision to 75%-80% for CT.

• In general T1 and T2 axial & saggital views are acquired.T1 images are

most useful for delineating vertebral body marrow & spinal cord outlines.

• Posterior cord impingement from thickened ligamentum flavum is best seen

on mid saggital images.

• It is the most sensitive imaging modality in depicting cervical disc

herniation and neural compression.It is the best method for evaluating the

patient with radiculopathy or myelopathy.

• MRI features of cervical disc herniation include extension of nuclear

material beyond the posterior margin of the vertebral body seen on T1

which on saggital images has been referred o as the “squeezed tooth paste

sign”.

• Radiculopathy is best evaluated by oblique projections to demonstrate the

intervertebral foramen and its contents and their relationship to any disc

material or bony element.

Reference:

1. Clinical neurology- II edition

VYAVACHEDAKA NIDANA

To diagnose i.e to determine & establish a disease that diseased

condition should be differentiated from taking consideration of similar other

disorders. This is differential diagnosis or sapeksha nidana, which is a very

important area of disease diagnosis. As each and every step reflects ultimately

in the treatment. The disorders are differentiated from one another basing on

pratyatmika lakshana i.e. cardinal features.

In this context of Viswachi, all the disorders of the upper limbs i.e.

urdhwasaakha are to be considered. They are

1. Apabahuka

2. Bahusosha

3. Ekangavata

Cardinal feature of Apabahuka is bahu praspandanahara1 i.e. movements

of the arm are restricted. Dushyas are siras; their sankocha at amsa sandhi

(adhistana) is cause for apabahuka. Though pain is present it is not of radiating

type& that too next to movement restriction.

In Amsasosha, wasting of muscles is cardinal feature. This is identified

as a separate entity by Madhavakara. 2 Where as Bahososha can be later stage

of both Apabahuka & Visvaci, so it does not need any differentiation.

In Ekangavata shoola & toda may be present along with sankocha of

either one arm or one leg.3 Dushyas are siras & snayus. There is complete loss

of movements of arm due to lesion in the brain.

Type of pain, adhistana of dosha dushya samoorchana and the degree of

movement restriction/ loss are the differentiating features of the disorders of upper

limbs, all the disorders are of vataja nanatmaja variety but separating themselves.

Table showing differentiating features of disorders of urdhwa saakha:

S.no Disease Nidan Dushya Adhistana Typeof

Pain

Bahukarma Amsa Sosha Pathology

1. Viswachi Vata kara Kandara Griva Radiating Weakness &

restriction of

movements

In later stage Spinal nerveroot

involvement

2. Apabahuka Vata kara Sira Amsa sandhi Locally Restriction of

movements

In later stage musculo skeletal

involvement

3. Bahu Sosha Vata kara Sandhi Amsa sandhi Absent Severe

restriction

Cardinal

feature

Wasting as a

result of

preceding

disease

4. Ekangavata Vata kara Sira, snayu Mastishka Maybe

locally

Complete loss In later stage Uppermotor

neuron lesion

References:

1.Su.Ni.1/82

2.Ma.Ni.22/64 3.Ca.Ci.28/54.

UPADRAVA & ARISTA LAKSHANA

Upadrava is defined as disorder which associates afterwards with the

disease originated earlier and having the same root cause. It is secondary

disease or complication, which signifies prognosis of the disease.1As such

Viswachi upadravas are not mentioned. It is one of the vataja nanatmaja

vyadhi. Vata vyadhi is one among asta mahagadas as explained by both Caraka 2 & Susruta3. Mahagada, greatness is due to fatal and incurable nature, these are

difficult to treat by their very nature. Susruta specified upadravas for

vatavyadhi as sotha, suptatwacha, bhagna, kampa, admana and ruja.4 Where as

Madhavakara gives description of the upadravas of vata vyadhi as visarpa,

daha, ruk, moorcha, aruchi, agnimandhya and pakshavadha. One with ksheena

bala mamsa & above upadravas is sure to die.5

In Viswachi, wasting of the muscles and permanent disability of the arm

can be the complications i.e upadravas. Aristalakshana: Arista is defined as Niyata marana kyapaka lingam i.e ominous

symptoms that indicate death.6Extensive description of aristas i.e definite &

indefinite and external & internal is seen in both Susruta samhita 7& Caraka

samhita. But Haritha samhita explained shoola, suptatwacha, bhagna, admana,

ruja and finally death as the arista for vatavyadhi.8 But in the case of Viswachi

worst crippling disorders may occur but not death.

References:

1. Su.Su.33 / 3

2. Ca.In.9 / 8-9

3. Su.Su.33/4

4. Su.Su.33/7

5. Ma.Ni.22/74

6. Madhukosa commentary

7. Su.Su.30

8. H.S.Dvi.4chap/5

SADHYASADHYATA Classification of disease as curable & incurable to accomplish the

objective of treatment is prognosis.1After the diagnosis and before starting the

treatment it becomes essential to know the prognosis of disease.

The sadhyasadhyata of Viswachi is not mentioned anywhere in the

classics. Even the recent scholars of Ayurveda have not mentioned about its

prognosis.

Vata vyadhi in general prognosis is discussed in few classics. As

Viswachi is a vata vyadhi which is a mahagada, when associated with bala

mamsa kshaya inspite of treatment, will not yield good results.

Caraka while explaining vatavyadhi cikitsa explains prognosis. Vata

vyadhi after lapse of one year becomes krichra sadhya or asadhya. Disorders

due to vata afflicting the deeper tissues (gambhira) are curable with difficulty

or they are incurable. They should be treated if they are new, free from

complication and in strong patients.2 Gambhira means being seated in deeper

tissues, while few take it as chronic.3Susruta describes that if vatavyadhi is

associated with sonata, sputa, twacha, mlana, kampa, admana, rujarti then it is

asadhya.4

Yogaratnakara mentions vata vyadhi as asadhya and in few occasions it

may be cured due to God’s grace.5 In Madhava nidana it is mentioned that if

patient is strong enough and with out upadrava then it is sadhya.6

Sadhyasadhyata can also be assessed by considering hetu, poorvarupa,

rupa, dosha & dushya etc.Thus Viswachi in the initial stages will become

sadhya and after certain period of time it will be krichra sadhya or asadhya.

References:

1. Ca.Su.10/7-8

2. Ca.Ci.28/74

3. Cakrapani on Ca.Ci.28/74

4. Su.Su.33/4

5. Y.R.546

6. Ma.Ni.22 / 74

CIKITSA

The term cikitsa is derived from the root “Kit rogapanayane” 1 which

means to adopt measures calculated to the removal of the factors of disease.

Cikitsa aims, not only at the radical removal of the causative factors of

the disease, but also at the restoration of the doshic equilibrium.2

Acharya Susruta advised three major approaches in the management of

vata vyadhi.3 they are

• 1.Treatment of kevala vata

• 2.Treatment of doshayukta (samshrusta) vata

• 3.Treatment of avruta vata

In all the classics general line of treatment is mentioned with regards to

stanta, vriddhi & kshaya of vata. Caraka further classified specific therapies

depending on the loctaion & dushya.

Samanya cikitsa includes bahya, abyantara sneha; sweda ;vasti ;snehika

nasya ; sirovasti ;virechana; dhooma; gandusha ; etc.4

Above said line of treatment can be classified basing on the cause of

disease origin. It is as follows

1. In dhatu kshaya origin:

Deepana, pachana, vastikarma, nasya, dhara, sirovasti, etc.Methods

correct the Agni & normalizes the vitiated vata.

2. In margavarodha origin:

Seka, abhyanga with chaturvidha sneha, sweda, vasti, nasya etc. where

treatment should alleviate the cause.5

To treat diseases of vata, there are three routes of approach:

1. Through the place where the neurons are exposed to the external

environment i.e. olfactory epithelium.To stimulate or tickle this mucous

membrane is nasyakarma

2. Through the region of nutritional support: pakwashaya, purishadhana.

Virechana, vastikarma are the methods to alter the interior environment of

this region so that proper digestion & absorbtion occurs so as to adjust the

nutritional status of the nervous system.

3. Through the skin: which has common source of origin with the nervous

system. Sneha (abhyanga) & sweda kriyas are the methods to be adopted.6

Ayurvedic classics explain the cikitsa of visvaci as follows:

1. Caraka advised nasyam for diseases affecting bahu & siras along with

uttarabhaktika snehapana.7

2. Susruta advised siravyadhana (venesection) in the affected parts along with

vatavyadhi samanya cikitsa.8 And also mentioned vamanam & nasyam in

diseases of skanda, vaksha and manya.8a

3. Vagbhata & others advised nasya and uttarabhaktika snehapana .9

4. Sarangadhara advised gunjadi lepam external application.10

From the above all statements, line of treatment of visvaci can be evolved as:

1. Abhyanga

2. Sweda

3. Uttarabhaktika snehapana

4. Nasya karma

5. Shamanoshadhi

6. Nidana parivarjana.

Abhyanga:

Annoiting the oil on the body is abhyanga. This process brings about

following qualities, “it prevents old age, removes pain in the body and gives

strength to the body.11

Susruta has mentioned that it is the veeryam of the externally applied

medicine that enters the endings of dhamanis of twacha.In the twacha bhrajaka

pitta acts and thus it enters into the srotas and starts it action.12

Sukoshna oil is used for abhyanga. The effect of heat apart from

vasodialation enhances the properties of oils, especially permeability.

Analgesic action (reduction in the thermal gradient) is the result of optimal

heating.13

Abhyanga reduces stress as it releases endorphins; the natural pain

killers. Abhyanga has profound influence on the entire nervous system and by

mechanical means effects all the body tissues.

Oils & fats used for the abhyanga are emollients and are smooth muscle

relaxants.They increase vascularity and reduce rigidity. They protect the skin

and are highly piercable. They also stimulate nerves.

Uttarabhaktika Snehapana:

As in Viswachi the rookshadi gunas of vata does the soshana of sleshaka

sleshma and inturn kandara dusti, snehapana is best suitable. It subsides all the

increased rookshadi gunas, thus attaining vata samana.

Snehapana done after intake of food is uttarabhaktika snehapana. It is

useful in disorders of vyanavata.14

As in visawchi vyanavata is the dosha, uttarabhaktika snehapana is best

suitable.Taila is preferred when compared to other snehas as it is best

vatasamaka.

Nasya Karma:

Nasyam is explained in detailed in the forth coming pages.

Shamanoushadi:

Basically vatavyadhis are difficult to manage. So, along with stanika

cikitsa, internal administration of shamanoushadhis is essential.

1. Ajamodadi churnam15

2. Lasuna pakam16

3. Maharasnadi kashaya17

4. Masha tailam18

5. Rasnaputika tailam19

6. Prasarini tailam20

Nidana parivarjana:

Importance of nidana has already been explained. Susruta has given great

importance by stating “nidana parivarjana” as the essence of treatment.21So, all

the nidanas explained in the previous chapter should be curtailed.

NASYA KARMA “Nasayama bhavam nasyam”

Nasya is a term to be applied generally for medicines administered through the

nasal passages.22 Nasya also means beneficial to nose.

Many classifications of nasya are described in classics basing on dravya

used, karmukata etc. Navana, Avapida, Dhmapana, Dhumanasya &

Pratimarsha are described by Caraka.Navana nasya is a type of nasya, which is

generally a sneha nasya and is known as nasya in general. It acts as brmhana,

virechanika, and samana depending on the drug used.23

Navana type of nasya is indicated in Viswachi. The procedure of nasya karma

is classified into three headings:

1. Poorva karma

2. Pradhana karma

3. Paschat karma

Poorva karma: Be fore giving nasya prior arrangement of materials and

equipments were made in a special room free from atmospheric effects like

direct blow of air, and dust.

i) Nasya asana : A cot for lying purpose

ii) Nasya aushadi : Ksheerabala 101 Avartita Tailam

iii) Nasya yantra : Dropper Was Used

Besides this spitting measures pot, bowl, napkin & cotton were kept ready.

Selection of patients:

Patients were selected according to indication and contraindication of

nasya described in classics.

Preparation of patients:

• Patient after attending nature calls.

• Completed routine activities like tooth brushing, bath etc.

• After these when patient is ready, he is made to lie down on a nasya table.

• Mrdu abhyanga was done on scalp, forehead, face & neck for few minutes.

• Mrdu swedana done for elimination & liquefaction of dosha. Tapa sweda

was given on sira, mukhabhaga, Nasa, manyapradesha, greeva, kanta

pradesha.For this purpose cloth dipped in hot water is used.

• Care of the eyes should be taken by closing the patient’s eyes with a band

of cloth.

Pradhana karma:

• Patient is made to lie down in supine position on nasya table with legs

slightly raised.

• Sira (head) should not be excessively flexed or extended.

• Snehana nasya matra pravara is 10 drops, madhyama is 8 drops and avara is

6 drops.

• After keeping the head in proper position i.e. extending to 45degrees and

covering the eyes with clean cotton cloth, raise the tip of patient’s nose with

left thumb and medicine is instilled with righ hand.

• Medicine should be instilled in an uninterrupted manner called “avicchinna

dhara”. The other nostril should be closed while administering medicine in

one nostril.

• Medicine should neither be very hot or cold.

• Patient is advised to inhale the medicine slowly and forcefully.

• Care should be taken not to shake the head during the procedure.

• Since nasyakarma is an invasive technique proper care was taken, hand

gloves were used, and instruments were sterilized properly.

Paschat karma:

• After administration of medicine patient is advised not to swallow the

medicine but should spit it out.

• Patient made to lie in supine position for a time interval consumable for

counting numbers upto 100. Feet, shoulders, palms & ears were massaged.

• Adviced to avoid speech, laughter, anger.

• Dhumapana, kavalagraha & gandushadharana is done.

Advised to take warm & light diet and avoid dust, smoke, bright

sunlight, hot bath, day sleeping, traveling, alcohol, doshaprakopaka ahara.

NASYA KARMA KARMUKATA:

Nasyakarma is especially indicated in urdhwajatrugata vikaras. It has

special action in that region.

As acharya Vagbhata has stated “Nasa hi siraso dwaram” i.e. nose is the

nearest & easiest entry for conveying the medicines to cranial cavity. He is first

person to narrate the mode of action of drugs by nasyakarma. The drugs

administered will reach the shringataka marma and spread through the

openings of eyes, ears & throat etc and to the head.

Acharya Susruta stated shringataka marma as a sira marma situated at

the site of the union of siras supplying to nose, ear, eye, tongue.

Indu, commentator on Astanga sangraha stated shringataka as the inner

side of the middle part of the head (siraso antarmadhya).

Acharya Caraka while explaining indications of nasya in siddhi stana

emphasized that, the nasya drug will act through absorbtion by shringataka

marma. After the absorbtion of drug, it acts on the diseasea of amsa, skanda &

greeva.Then it takes out the doshas like munjadi shikavat.24

Probable mode of action of nasya karma on the lines of modern science

can be as follows:

Only region of the body through which neurons are directly exposed to

external environment is nose. Olfactory receptors extend through about 20

olfactory foramina in the cibriform plate of the ethmoid bone. Nasya dravya

may stimulate the olfactory neurons which may have effect on the regions

through which the impulse travels.

The nasya dravya acts on or through two regions:

1. The area through which the dravya is travelling.

2. The area to which the dravya is absorbed.25

The given nasya dravya have momentary retention in nasopharynx and

suction causes oozing of drug into the sinuses. These sites are rich in blood

vessels entering the brain and meninges through the exiting foramens in the

bones. Therefore there are better chances of drug transportation in this path.

As nose is highly vascular structure and its mucous membrane provides

good absorbing surface. Hence, siddhasneha on their administration spread

along the nasal membrane. Active principles along with sneha get absorbed

inside the olfactory nourishment to nasal structures and other shirogata organs.

The network of nasal blood vessels and lymph vessels has many

communications with those of subdural and subarachnoid spaces. Veins of the

nasal cavity form a close cavernous plexus beneath the mucous membrane.

Arterio venous communication is present. Some ethmoidal arteries, end in

ophalmic veins, few communicate with veins on the orbital surface of the

frontal lobe of the brain, through the foramina in the cibriform plate of the

ethmoid bone. The nasya dravya might be getting absorbed through the blood

circulation of the nasal mucosa into the cavernous sinuses.

Blood brain barrier is highly permeable for lipid substances. So, the

siddhasneha particles can pass easily the blood brain barrier and exert their

actions. The ksheerabala 101 avartita tailam provides nourishment to the

nervous system and helps in removing the irritation. On its administration, it

reaches to different shirogata indriya to cause vatashamana and brmhana.

To conclude, the given nasya dravya get absorbed into the blood

circulation reaches the brain and acts. Its action can be expected by the

stimulation of the olfactory nerve or by its absorption into the C.S.F.

Schematic representation of Nasya Karmukhata:

Dissertation works done till now in Viswachi includes the following:

1. 1984 - Study on systemic effect of Vasti in Viswachi, Pakshaghata,

Grdhrasi- I.P.G.T.- Jamnagar

2. 1996 - Rajata sindhoora nirmana evam prabhavatmaka adhyayan Grdhrasi

evam Viswachi rog ke paripeksh me. N.A.C- Jaipur

3. 1998 – Viswachi management w.s.r to nasya cikitsa- Pune

4. 2004 - Clinical study in the effect of Mahamasha taila nasya karma in

Viswachi- Udipi.

5. 2005 - Study of Viharaja hetus & lakshanas of Viswachi vyadhi- Pune

Nasya Dravya

Absorbed Into

C.S.F

Absorbs into General blood Circulation or

thru venous drainage

Stimulates Olfactory

Nerves

Cavernous Sinus

Olfactory Pathway

1. Nourishes the nerves 2. Stimulates the hypothalamus

pituitary axis.

Crosses BBB

References:

1. Introduction to K.C- 2nd chap; pg no: 6

2. Ca.Su.9/5

3. Su.Su.5/29

4. Su.Ci.4/22

5. Essentials of Basic Ayurvedic concepts 1st chap; pg no: 21

6. Essetials of Basics Ayurvedic concepts 1st chap; pg no: 21

7. Ca.Ci.28/97

8. Su.Ci.5/23

9. Su.Ci.4/17

10. Sa.Ut.Kh.11/201-2

11. As.Hr.Su.2/8

12. Su.Sa.9/9- Dalhana

13. Vaidyam jrnl- KAPL

14. As.Hr.Su.13/39

15. Sa.Ma.Kh.6/118

16. V.C.vatavyadhi adhyaya

17. Y.R / S.Y.3rd chap; pg no: 34

18. C.D / V.C / Y.R vatavyadhi adhyaya

19. C.D /V.C / Bh.Pr. vatavyadhi adhyaya

20. V.C vol.I vatavyadhi adhyaya /Bh.Pr.vol II vatayadhi cikitsa

21. Su.Ut.1

22. Su.Ci.40/21

23. Ca.Si.9/8

24. As.Hr.su.20/1

25. Kaya cikitsa-IV Vol. 7th chap; pg no: 850

PATHYAPATHYA

Cikitsa of a vyadhi not only includes giving aushadha but also advising

and administering pathya ahara and vihara. They play a major role in treatment

of a disease radically. In the classics almost for all diseases pathya apathya are

mentioned may not be in a elaborate manner but in a nutshell.

Pathya is patho anapetham….. i.e. conducive to the patha (srotas) of

the body.1 Those ahara and vihara which when taken in an appropriate time

with proper proportions becomes beneficial to the body by correcting the

imbalance or morbid condition of doshas & dhatus in the body.Contrary to the

above statement is apathya. Non conducive ahara & vihara, which may

aggravate the morbidity, still more.

Upasaya and anupasaya can be considered as a part of pathya and

apathya respectively. Nidanas are apathya for any disease.2 Upasaya is

administration of drug, diet and behavior which are contrary to aetiology and

disease or which produce effects contrary to them. It is used as a diagnostic

tool in some cases. As far as Viswachi disease is concerned, there is no

particular description of upasaya & anupasaya. But according to Caraka,

naidanik factors are considered as anupasaya. To summarize all factors that

aggrevate vata are anupasaya and that pacifies vata are upasaya.

In Viswachi, pain aggravates while working with the affected arm and

during night times where as abhyanga and swedana locally will reduce the

pain. So, they can be considered as upasaya and anupasaya.

After compiling all the pathya apathya of vata vyadhi’s from amost all

classics, they are found to be described as follows:

4. Table showing pathya apathya in Viswachi:

S.no: Dravya Pathya Apathya

1. Samanya Santarpana, brmhana, swadamla

lavana rasa, snigdha, ushna sama

shana

Anashana, viruddhasana,

kashaya, katu, tikta, ruksha rasa.

2. Anna

varga

Purana shali, shastika, godhuma,

masha, kuluttha, patola, shigru,

vartaka, lasuna, prasarini,

gokshura, shuklakshi, paribhadra,

naveena tila, moolaka.

Canaka, kalaya, neevara

koradushaka syamaka, curna,

trinadhanya, raja

masha,kuruvindamukha,

mudga, yava, bimbi, nishpava

beeja, mrnala,udumbara.

3. Mamsa

varga

Vasa majja: gramya- gomamsa,

ushtra, asva, vrishaba; anupa-

mahisha,gaja, hamsa; cataka,

kukkuta, matsya- nakra, silindra,

kurma.

-

4. Phala

varga

Dadima, pakva talam,

parushaka,jambeera, badara,

draksha,naranga, tintidiphala

Jambu, kareera,kaseruka,

kramuka,shaluka,tinduka,

talaphala asthi majja,bala talam

5. Drava

varga

Ksheera, gojala, eranda tailam,

dhanyamla,kilata, dadhikurchika,

payahpeti, sarpi, taila, sura.

Seethambu, kshoudra, rasabha

payah, tataka saritha ambu,

pradushta salilam.

6. Vihara Abhyanga,mardana,vasti,snehana,s

avagahana,samvaha, Vatavarjana, u

agnikarma, bhusayya, snana,

sana, tailadroni, Sirovasti,

sayanam, nasyam. Yogasana:

Sashankasana,vajrasana etc.

Isometric strengthening

excercises

Cinta, prajagarana, vega

dharana, chardi, srama,

vyayama, vyavaya, hasthi asva

yana, cankramana.

References:

1. As.sa.su.

2. As.Sa.Ni.1

3. V.C.vatavyadhi adhyaya.

DRUG REVIEW

Pain is the characterstic feature of Viswachi vyadhi. Vata is the main

factor causing pain.1 so, all vataharas, vedanastapana, rujahara, angamarda

prashamanas, shoola haras were screened and three drugs were selected. They

are

1. Sinduvara – Vitex negundo

2. Suranjan – Colchicum luteum

3. Parijatha – Nyctanthes arbortris.

• Sinduvara has vatahara, sothagna properties.

• Suranjan is widely used in Unani medicines variedly.To evaluate its utility

in vatavyadhi this drug has been taken up.

• Where as parijatha is specially advocated by Cakrapani in grdhrasi, which is

similar to viswachi. It is having vatakshayapaha, vedanastapana,

sandhivatagna properties which emphasize its action in viswachi vata.

For nasya karma ksheera bala tailam was used. It is made up of three

ingredients. They are

1. Bala moolam

2. Tila tailam

3. Go ksheeram

SINDUVARA

Botanical Name : Vitex negundo

Family : Verbenaceae

Vernacular names:

Telugu : Vavili

Hindi : Samhaliu

Tamil : Nochchi

Bengali : Nishinda

English : Five leaved chaste, Indian privet

Synonyms: Nirgundi, Suvaha, Sinduka, Sinduvaraka, Surasa, Svetapuspa,

Nilamanjari, Vanaja, Bhutakesi.

Classical categorization:

Caraka : Vishagna, Krimigna

Susruta : Surasadi

Vagbata : Surasadi

Introduction:

Vishnudharmasutra quotes Nirgundi (61\3).

Brihat trayi have described this plant with the synonyms sinduvara and

nirgundi for most of the times. In two contexts Susruta mentioned sita sinduvar

(white variety) indicating existence of two varieties of nirgundi.The synonym

Sephalika is quoted twice by Susruta(S.S.su.8\15,18) and once by

Vagbata(A.H.ut9\15).Caraka did not mention the above two synonyms.

It is generally believed that Sinduvara and Nirgundi are the two different

species of Vitex bearing white, blue flowers respectively.1

Nirgundi is described as Analgesic, Diuertic, & Emmanagogue in

“indigenous drugs of India”. Flemming (Asiatic research vol.2) reported its

anti-inflammatory properties.2

Botanical description:

It is small tree or shrub.Branchlets and underside of leaves are

pubiscent. Leaves tri or pentafoliate, leaflets lanceolate entireor crenate,

glabrate, and dark above and pale beneath.

Flowering& fruiting between March-August.

Major Chemical Constituents:

Phenol, dulcitol, alkaloidvitricine,β sitoserol, Camphene,α β pinenes,

Angioside, acecubin, casticin, artemisin, orientin, etc.

Properties:

Rasa : Tikta, Kashaya, Katu

Guna : Laghu, Ruksha

Veerya : Ushna

Vipaka : Katu

Karma : Vatakaphahara, Caksusya, Kesya, Krimighna,

Vranaropana, Smritida.

Indications : Soola, Sotha, Amamaruta, Krimi, Gridrasi.

Parts used : Leaves, Root, Seeds

“Sinduvara dalam jantu vatasleshmaharam laghu.”3

Research:

1. Analgesic affect of extract is reported (Srivastava &Sisodia, 1970)

2. The ethylacetate extract at a dose of 50 mg\kg orally produce definite anti-

inflammatory effect against carrageenin, 5ht&bradykinin induced edema.

(Ccrimh, 1977-78)

3. 50 gms of coarse leaf powder was boiled in 800ml of distilled water till the

volume is reduced to 100ml and was filtered through a thick cloth After

cooling 1,5ml of total watery extract was administered to albino rats which

were induced with arthritis by using formaldehyde. Significant antiarthritic

activity is shown by nirgundi. (Singh&Chaturvedi)4

4. Pe extract of dried leaves shown analgesic, anticonvulsant and sedative

hypnotic activities when tested in Swiss mice of either sex. (Ind,

J.Pharmaceutic.sci.1997).

5. Plant powder used as antiinflammatory &antiarthritic (kakrani&saluja,

1994)

References:

1. Dravyaguna vignan- Dr.J.L.N.Sastry—vol-2

2. Chopra’s, Indigenous drugs of India— II edition

3. Bhavaprakasham

4. Wealth of India—vol2-page no: 307,

.

SURANJAN

Botanical Name : Colchicum Luteum Baker

Family : Liliaceae

Vernacular Names:

Sanskrit : Hiranya Tuttha

Unani : Allahlah, Qalb-al-arz

Hindi : Haran Tutiya, Suranjana

English : Golden Collyrium, Kashmir Hermodactys,

Colchicum1

It is a medicine of great repute in Afghanistan and Northern India

Introduction

It is a perennial herb having underground tuber and yellow flowers. It

grows at 4000-7000 ft. in western Himalayas and in outskirts of forests

extending from the munee hills to Kashmir and chamba. 2a.

It is of two varieties : 1. Sweet – Suranjan – I – Shirin

2. Bitter – Suranjan – I – Talkh

Suranjan is not described in samhithas and nighantus. It is incorporated

in recently written books like dravyaguna vignan by Nishteshwar, J.L.N.Sastry.

The corms and seeds of c.autumnale linn are official in British

pharmacopia. C.luteum is a good subtitute for c.autumnale and is official in the

Indian pharmacopia.3

Period of occurance: Plant occurs from December to march, flowering

june to july.

Cultivation:

For raising plants, seeds are sown under cover in beds or boxes from

May onwards and lightly covered with soil. Seeds sometimes take a long time

to germinate. Seedlings when one year old are transplanted three feet apart in

the field. Collection of corms may start when the plants are two year old.

Collected during June, July in the Kashmir valley.

The corms of colchicum luteum are occasionally adulterated with corms

of sweet variety and another plant viz. Narcissus tazetta.

Procedure & time of collection:

The corms are dug out and separated from the shriveled remains of the

flowerstalk and the adhering soil. Tied in a piece of cloth & dipped for a short

while in boilng water and dried. Thisprevents the loss of colchicines during

boiling. Corms are collected after the leaves have dried down.


Colchicine, luteidine, luteicine, luteine, collutine etc.

The chief alkaloid colchicine, C22 H25 O6 N, occur in the form of

yellow flakes, crystals or as a whitish yellow amorphous powder. When taken

in large doses cause intestinal pain, diorrhea and vomitings.

Colchicine is an analgesic, whose peculiarly specific action is still

mystifying.4

Indian colchicum corms contain abundant starch and the alkaloid

colchicine (0.21-0.25% of dried corm)2b.

Seeds and roots both of bitter variety contain alkaloid colchicine in

fairly large proportions. Sweet variety also contains traces of alkaloid which

has been found to be physiologically inactive.5

Properties:

Rasa : Tikta, katu


Veerya : Ushna

Vipaka : Katu

Karma : Kapha vata hara, Raktashodaka; anti-imflammatory

(muhallil-e-waram), laxative(mulaiyyin), dieurtic

(mudirr-e-baul).

Indications : Gridhrasi, vatarakta, sandhigata vata, amavata.

Parts Used : Corm, the drug suranjan is yellow or black in

colour. The corm are some what conical, ovoid or

elongated. They are translucent or opaque. The flat

surface has a longitudinal groove. Fresh corms

measure 15-20mm in diameter.

Corm has bitter taste, carminative, laxative, lessens inflammation, pain; applied

to oil piles to lessen pain, heal wounds, useful in headache, gout and

rheumatism.

Research:

1. Colchicine (500μGms) inhibited catecholamine secretion evoked by acetyl

choline but not of that induced by excess potassium in perfused rabbit renal

glands (Brit. J. Pharmacol. 1972, 45, 129).

2. Colchicine (33mg/kg, p.o.) suppressed development of Carrageenin induced

edema in rat (J.Pharmacol. Exp. Ther. 1975, 194, 154).

3. Colchicine inhibited phyto hemaglutinin induced agglutination of ascitic

hepatoma cells from mice (chem.abstr. 1981, 75, 73329k).

References:

1. Dravyaguna vignan – Vol.2 Dr.J.L.N. Sastry

2. Chopras, Indigenious Drugs of India II Edition

3. Wealth of India Vol.2 Page No. 307

4. Pharmacology, Beckham pg no:258

5. Materia Medica Vol.1 Nadkarni

PARIJATA

Botanical Name : Nyctanthus arbortristis linn

Family : Nyctanthaceae (Oleaceae)

Vernacular Names:

Telugu : Parijathamu, pagadamalli, swetasarasa

Tamil : Majjapu

Hindi : Harsingar, parja

English : Night jasmine, Coral jasmine, Tree of sorrow,

Weeping nyctanthes.

Synonyms : Sephalika; Prajaktah, harasingara pushpa,

nalakumkumako, raga pushpa, karapatraka.

Introduction: It is a small tree growing upto 100 mts distributed throughout India,

cultivated in gardens. Sephalika is described by susruta and vagbata. Its leaves

are described among the anusastras. Sephali is the synonym of blue variety of

nirgundi also.1


Leaves contain tanic acid, methyl salicylate, an amorphous glycoside

1%, mannitol 1.3%, an amorphous resin 1.2% and trace of volatile oil. β

Sitoserol, flavanoglycosides, astragalin, nicotiflorin. Also contain ascorbic acid

and carotene. This ascorbic acid increases on frying leaves in oil.2.

Properties:

Rasa : Tikta, Katu


Veerya : Ushna

Vipaka : Katu

Karma : Kapha vata hara, vedana stapana

Indications : Gridrasi, ama vata, sandhi vata.

Parts Used : Leaves and stem bark.

“Katu tiktha rasam patram jwara vata haram smrutam”

Leaves are bitter, acrid, thermogenic, antibacterial, anodyne, laxative, anti

inflammatory and tonic. They are useful in vitiated conditions of kapha and

vata, obstinate sciatica, inflammations.

Research:

1. The water soluble portion of alcoholic extract of leaves showed significant

anti inflammatory activity against acute sub-acute and chronic models of

inflammations in rats (Saxena etal, 1984).

References:

1. Dravya guna vignan vol.2 Dr.J.L.N.Sastry

2. Wealth of India vol.2

BALA

Botanical Name : Sida cordifolia linn

Family : Malvaceae

Vernacular Names:

Telugu : Chittamutti, Muttavapulagam

Tamil : Paniyar Tuttul

Hindi : Khirainti, Bariyara

English : Country mallow

Synonyms : Vatya, vatyalika, vatyapushpi, vatyayani,

bhadroudani

Classical Categorization:

Caraka : Balya, Brmhaniya, Prjasthapana, Madhuraskanda

Susruta – Vatasamsamana

Introduction:

In the Vedic literature Bala is described as rasayana, vishagna, balya and

pramehagna (pai.sam. 19/39/1-13; Atha.pa.5/1/14)

Different Varieties:

Bhava misra mentioned four varieties viz

1. Bala – S. cordifolia

2. Atibala – A. indicum

3. Nagabala – S.veronicaefolia

4. Mahabala – S.rhombifolia

Botanical Description:

A small downy erect herb or shrub, 1.5 mts in height with long branches

sometimes rooting at nodes. Distribited in tropical and sub-tropical regions of

both hemispheres.


Ephedrine, Hypaphorine, Vasicinone, Vascicine, Vasicinol, Choline,

Betaine, Phytoserol, Asparagin, Potassium nitrate etc.1.

Properties:

Rasa : Madhura

Guna : Laghu, snigda, picchila

Veerya : Sita

Vipaka : Madhura

Karma : Vata pitta hara, balya, brmhana, vrsya, rasayana,

sameerasra pittasra kshatanashanam.

Indications : Vata vyadhi, rakta pitta, prameha, kshaya

Parts Used : Root

The bark of the root with sesame oil and milk is very much efficacious

in curing cases of facial paralysis and sciatica when caused by inflammation of

nerves concerned (koman; Ind.med.gazette.aug.1921)2.

References:

1. Dravya guna vignana vol.2 Dr.J.L.N.Sastry

2. Indian Medicinal Plants vol.3 Keerthikar & Basu

GOKSHEERAM (Cow’s Milk) In Ayurveda ksheeram is described as one of the best wholesome foods.

It is extensively used as pathyahara in many diseases, and also used for

purifying so many herbal drugs & minerals. Caraka described “ksheeram

jeevaneeyanam sreshtam” (ca.su.25th chap).

Susruta described “Jeevaneyam thadha vata pittagnam param

smrutham” (su.su.25th chap). Bhavamisra included cow’s milk in “Dugda

varga”.

Latin Name : Lactus

English : Milk

Hindi : Doodh

Telugu : Palu

Sanskrit : Dugda, Ksheeram, Payah, Stanyam, Peeyusha etc.

Source : Mammary glands of female, cows, she goats, ewes,

she asses, mares etc.

Properties:

Rasa : Madhura

Guna : Guru, snigda, mrudu, picchila

Veerya : Sita

Vipaka : Madhura

Characters:

Cow’s milk is an opaque white or yellowish white emulsive faintly alkaline

fluid, a little more viscous than water, it is one with higher fat content having a

lower specific gravity(1.027-1.034).1.

Constituents:

Milk contains all the elements necessary for the growth and nutrition of

bones, nerves muscles and other tissues. It is rich in proteins, fats,

carbohydrates, vitamins, and minerals. One pint (600ml) of milk supplies 7/8th

of the calcium, 1/3rd of riboflavin, over 1/4th of the proteins and just less than

1/5th of vit.A requirements of a moderately active man for one day.

100ml of cow’s milk contain

Calories : 67 kcal/281 kJ

Protein : 3.2 g – casein, lactalbumin, lactoglobulin

Fat : 4.1g – 2/3rd saturated, 1/3rd unsaturated

Carbohydrate : 4.4g – Lactose

Sugar : 4.5

Salts : 0.5 – Calcium phosphate large proportion

Total solids : 12.0

Water : 88

5. Table showing Vitamin Contents in the Cow’s milk:

S.no Vitamin Content

1. Vitamin A 45µg

2. Vitamin B1 0.04mg

3. Riboflavin 0.17mg

4. Nicotinic acid 0.1mg

5. Vitamin C 1 mg

6. Vitamin D 0.1mg

7. Vitamin E 0.1mg

6. Table showing Mineral Content in Cow’s milk:2

S.no Mineral Content

1. Calcium 122

2. Phosphorus 92

3. Iron 0.1

4. Sodium 50

5. Potassium 160

Action:

Milk is generally considered cooling nutritive, strengthening and

vitalizing also demulsent and emollient, cardio tonic, promotes memory.

It is sadyah shukrakaram, jeevanam, brmhanam, balyam medhyam

vajeekaram vayasthapanam ayushyam sandhikari rasayanam. It cures

aggrevation of vayu and rakta pitta. Improves milk production and ojas

in the body. It causes slight kleda in dosha dathu and malavaha

srothasas. It is useful in jeerna jwara, mental diseases, sosha, moorcha,

bhrama, grahani, panduroga, daha, trit, shoola, shrama etc.3.

References:

1. Materia medica vol.2 Nadkarni

2. Clinical dietics and nutrition 4th edition – F.P.Anitha and Philip

Abraham – Chap.40 Pg. No. 201

3. Bhava prakasam – Dugda varga

TILA TAILAM (Sesamum Oil)

“Snehanam Sneha Vishyanda Mardava kleda karakam” sneha has

both jangama and oudbidha origin. Tailam is one among chathurvidha snehas.

In Ayurveda tailam indicates tila tailam unless otherwise stated. Tila taila is

extracted from tila. It is the best choice in taila prepartions because of its

specific characterstics. It is moderately unsaturated oil having anti-oxidant

property and has anti-arthrogenic effect.

Botanical Name : Sesamum indicum linn

Family : Pedaliaceae

Vernacular Names:

Telugu : Nuvvu

Tamil : Ellu

Hindi : Til

Sanskrit : Tila, Snehaphala

English : Sesamum seeds, Gingely

Synonyms : Tilaha, pavitra, hemadhanya, etc.1.

Introduction:

It is an annual herb growing upto one meter bearing white or pink

coloured flowers. It is mainly cultivated in the temperate regions of India.

Three varieties are described, they are black, white, red or brown.

“Krishnaha sreshtatamastheshu shukralo madhyamo sitaha”.2

The black variety is the most common and yields best quality of oil and

are also best suited for the medicinal purposes. White variety is richer in oil.

Classical Categorization:

Caraka – Svedopaga, Pureeshavirajaneeya


Neutral lipids, glycolipids, phospholipids, sesamose, sesamolin,

sesamolinol(anti-oxidants,hepatoprotectives) Sesamol, pinoresinol(anti-

carcinogenic)

Seeds contain fixed oil – 50-60p.c

Oil contains 70p.c of liquid fats consisting of the glycerides of oleic and

linoleic acids and 12-14p.c of solid fats, stearin, palmitin and myristin, a

crystalline substance sesamine (lignin, anti-oxidant and anti-microbial) and a

phenol compound sesamol.

Properties of Tila Taila:

Rasa : Madhura, kasaya, tikta

Guna : Guru, snigdha, tikshna, vyavayi, sukshma, visada,

agneyam.

Veerya : Ushna

Vipaka : Madhura

Karma : Vata kapha hara, tvatchya, balya, kesya, sukrala pittalam

Indications : Vata roga, grahani, Agni mandya, yoni roga.

Parts Used : Seeds, oil

Tila taila is used in vasti kriya, sneha pana, nasya karma, karnapoorana, seka,

and abhyanga.

After extracting oil from the seeds the remnant (khali) is given to cattle as feed.

Description of the Taila:

Appearance : Pale yellow in color

Consistency : Liquid at ordinary temperature, merely a trace of

stearine is deposited on standing.

Taste & Smell : Not unpleasant

Composition of Tila Taila :

Saturated Fatty Acids: Palmitic Acid – 9.1%

Stearic acid – 4.3%

Arachidic acid – 0.8%

Unsaturated Fatty acids: Oleic acid – 45.4%

Linoleic acid – 40.4%.2

It is slightly soluble in alcohol, its physical constants are

1. Refractive index - 1.47 – 1.476

2. Acid value not more than - 2

3. Iodine value - 103 – 116

4. Saponification value - 188 – 195

5. Unsaponiable matter not more than - 1.5

These values can be used to identify and determine the purity and quality of

the sesame oil. The lignins present inhibit premature ageing process and have

rejuvenative action. This may be the rationale behind the usage of sesame oil in

panchakarma. Further, sesame contains a lot of calium. It is said that a cup

of sesame contains three times calcium in comparision with milk. The

presence of calcium with precursor of its fixing agent vit.D in sesame and

sesame oil makes them the ideal supplements for the integrity of bones and

related tissues. When we correlate with the ayurvedic notion that vata is

based on asthi, sesame oil is most ideal drug (paramaushadam) for vata

sounds reasonable.3.

References:

1. Dravya guna vignan vol.2 Dr.J.L.N.Sastry

2. Thesis of Dr. V.A.Naidu – Clinical study of effect of KB Capsules with

rasanakwadam on greevagata sandhigatavatam

3. KAPL Vaidyam Journal – Paper of Dr.Jolly

MATERIALS & METHODS

Aim of Study:

Viswachi is a vedanapradhana vatavyadhi. The aim of study includes-

1. To search for an efficient vedanahara (pain killing) drug

2. To observe the action of nasya in arresting/delaying the process of

degeneration in the cervical spine.

Clinical study comprises of-

1. Materials & Methods

2. Observation & results.

Materials & Methods: - Materials required for the present study are

(i) Sinduvaradi yogam

This compound conistsof three drugs. They are

a. Sinduvara

b. Suranjan

c. Parijatha

Description of the Individual Drugs is dealt in drug review.

Fresh nirgundi leaves were collected cleansed and shade dried, then

powdered.Suranjan corms were purchased from market and were powdered.

These two powders were mixed in equal quantities and made bhavana with

Parijatha patra kwatha. This kwatha is prepared according to the classical

description.

After the bhavana, the obtained medicine was filled in 500mg capsules.

Capsulation increases palatability, enhances shelf life. Whole process was done

under strict aseptic conditions.

(ii) Ekotthara sathavarthitha ksheerabala tailam

Fats & oils come under the group of lipids; they are energy reservoirs

and hence have metabolic value. Aavarthana process is employed for preparing

fortified medicaments.

Ksheerabala tailam 101 avarthitha contains

1. Ksheeram

2. Bala moolam

3. Tila tailam. 1

Method of Preparation:

After preparing balamoolakwatham i,e., by boiling 16 pala of

powdered balamoola with one drona of water, reducing it to 1/4th part, add one

prastha ksheeram, one prastha tila tailam and balamoolakalka made by

grinding with ksheeram. Process according to taila paka vidhi.2 Processing of

oil is carried out repeatedly till the formulation of desired quantity is obtained.3

Following are confirmative tests for completion of sneha paka:

1. Sneha kalka becomes wicklike, when rolled between two fingers

2. There should not be any sound when sneha kalka is sprinkled over fire.

3. Foam is observed when taila paka completes

4. Specific color, odour, taste of ingredients become marked when sneha paka

is over.4

Percentage variation in moisture is one of the parameters in fat and oil

preparations and this is detected by the end point of evaporation, which is

referred to as paka. There are three types of acceptable endpoints. For

mucosal absorption early endpoint(mrudupaka) with a higher moisture

percentage is indicated.

The obtained product is filtered and the filtrate is again subjected to

above process. Completion of one cycle is considered as one avarthana. In

this manner repeating the process for 101 times, makes the ksheerabala 101

avarthitha taila.

Significance of Avarthanam:

• Parameters like specific gravity, saponification value, iodine value, acid

value, peroxide value, are usually evaluated for assessing the activity of fats

or oils.

• After the process of avarthana, there was marked raise in saponification

value, moderate decline in specific gravity, significant loss of moisture is

noted. Anti-inflammatory activity gets enhanced by repeated

fortification process.

• Freund’s adjuvant arthritis test suggested that the possibility to enhance

effect efficacy of ksheerabala tailam by subjecting it to aavarthana.5.

• This specific oil has been used in several cases of ardhitha vata, gridrasi,

both internally and externally. It is found to be very efficacious in curing

those diseases when they are due to inflammation of nerves. (Indian Drug

report, Madras), (Indian Materia Medica).

Selection of patients:

Patients for the present study, suffering with Viswachi were selected

from the OPD of Post graduate Department of Kayacikitsa Dr.B.R.K.R Govt

Ayurvedic Hospital, Hyd (A.P)

Inclusion Criteria:-

- Patients of either sex between the age group of 30 to 70 yrs were selected.

- Patients with signs & symptoms of viswachi were selected.

- Patients suitable for nasyakarma were selected.

Exclusion Criteria:-

- Patients suffering with Diabetes mellitus were excluded from the study.

- Patients with the history of trauma to that arm were excluded from the

study.

- Patients with major systemic disorders like malignancies, hyperthyroidism

etc, that interfere with the course of treatment were excluded from the

study.

Diagnostic criteria:-

- Patients with pain predominance along with weakness on resisted

movements of the arm were selected.

Investigations:-

1. X-ray Cervical Spine – AP View & Lateral view

2. Complete blood pressure & ESR

3. Routine Urine Examination

Research Design-

Study : Open trial

Sample size : 33

Duration of study : 30 days

Trial drug –

1. Oral drug : Sinduvaradi yogam 500mg cap 2 TID

2. Nasya karma : Ksheerabala 101 avartitha tailam (6 drops in

each nostril) for 7 days.

Review : Once in every 10 days

During the period of treatment patient was strictly advised to avoid the

following:

1. Heavy exercises

2. Use of two wheeler vehicles

3. Use of pillows

4. Use of coldwater for bath

5. Lifting heavy weights

6. Weight bearing on the head

7. Sudden jerky movements of the neck & body

8. Heavy work done with the affected arm.

The clinical study records were maintained as follows:

1. Onset conditions

2. Sex distribution of the disease

3. Economic status & incidence of disease

4. Relation to the nature of work

5. Relation to the occupation & disease

6. Prakriti relation to disease

7. Predominant clinical features and their incidence

8. Results of treatment.

Assessment Criteria:-

Subjective symptoms like pain & weakness of movements were considered.

1. Pain : For the assessment of pain Numerical pain rating scale was adopted.

This scale was used to capture the patient’s level of current, best & worst levels

of pain using an 11 point scale ranging from 0 to 10.

0 : No pain

1 & 2 : Pain ignored if involved in any activity

3 & 4 : Pain (dull) constantly

5 & 6 : Pain hampering daily activities

7 & 8 : Pain disturbing sleep.

9 & 10 : Worst pain imaginable

2. Functional capacity: Functional capacity of arm of a Viswachi affected

patient was assessed basing on a questionnaire. This questionnaire was

prepared by taking the help of Neck disability index & Shoulder pain disability

index of American Physiotherapy Association. This questionnaire named

Numerical scoring functional test (NSFT) consists of 10 questions, whose

answers were graded as

0 : Able to do without difficulty

1 : Able to do with difficulty

2 : Able to do with great difficulty

3 : Requires help

3. Sensory symptoms (paraesthesia): These were assessed by giving grading

as follows

0 : Absence of paraesthesia

1 : On & off present; can be ignored

2 : Causing discomfort

3 : Hampering activities

4. Weakness: This was assessed basing on

0 : Absence of weakness

1 : Mild weakness

2 : Moderate weakness

3 : Severe weakness

5. Decreased Range of motion: Only either normal or decreased range of

motion was assessed. No further details were taken.

0 : Normal range of motion

1 : Decreased range of motion

6. Occipital headache: Presence or absence was only considered

0 : Absence of O.headache

1 : Presence of O.headache

7. Wasting of limbs: Presence or absence was only considered

0 : Absence of wasting

1 : Presence of wasting

8. Tenderness: Presence or absence was only considered

0 : Absence

1 : Presence

9. Giddiness: Presence or absence was only considered

0 : Absence

1 : Present

These numbering as grades were given for statistical purpose. Data was

collected on every visit i.e. 10th, 20th, 30th day. Every patient data has been

documented in a special case sheet prepared exclusively for Viswachi patients.

After the data collection, it was subjected to statistical analysis by calculating

the Mean, Standard deviation, Standard error & “t” value. Paired t test was

used to calculate “t” value. Basing on this “t” p value is determined.

Then the results were assessed basing on the above values.

Classification of results: The results may be grouped as

1. Complete relief : where 100% relief has been noted

2. Partial relief : a. Marked relief: upto 75% and above

b. Moderate relief: relief above 50% but below 75%

c. Mild relief: relief more than 25% but below 50%

d. No relief: with out relief or marginal improvement

References:

1. Sahasra yogam – taila prakaranam – Page no. 75, sloka 10-15

2. Sharangadhara samhitha

3. KAPL Journal vaidyam – Paper of Dr.C.D.Krishna kumar i.e.,

pharmacological and clinical aspects of external application of fats and oils

in therapy.

4. Text book of Baishajya kalpana (Indian Pharmaceutics) – Dr. Shobha G.

Hiremath, Chap. 22

5. KAPL Journal vaidyam – Paper by Dr. B.Ravishankar , shukla V.J. and

others on pharmacological studies on medicated oil and ghee – In that study

on avarthitha KB tailam by Krishna Murthy, Ravi shankar etal 2002.

IMAGES OF ANATOMICAL STRUCTURES INVOLVED IN VISWACHI

24

IMAGES OF PATHOLOGY IN CERVICAL SPONDYLOSIS

25

IMAGES OF COMPOUND PREPARATION

Sinduvara Leaf Powder Suranjan Corm Powder Triturated Powder Sinduvaradi Yogam(Capsules)

Ekottara Satavartita Ksheerabala Tailam

26

IMAGES OF DRUGS

Suranjan Sinduvara

Parijatha Suranjan

Tila Tilatailam Balamulam

27

OBSERVATION AND RESULTS

In the present study 40 cases were registered out of which there were 7

dropouts during various stages of clinical study. In 33 patients clinical study

was completed. The observations made during the study are as follows:

1. Table showing the incidence of sex:-

S.no Sex No. of patients Percentage

1. Male 13 39.3

2. Female 20 60.6

Total 33 100%

The sex incidence of patients of viswachi in the present study shows that

the female patients were more with 20(60.6%) when compared to more patients

of 13 (39.3%).

2. Table showing the incidence of Age:-

S.no Age No. of patients Percentage

1. 30-40 11 33.3%

2. 40-50 11 33.3%

3. 50-60 8 24%

4. 60-70 3 9%

Total 33 100%

The study revealed a maximum number of patients between the age

group of 30-40 & 40-50 years 11 (33.3%) in each group, 8 patients between

50-60 years (24%), 3 patients between 20-30 years (9%) & 3 patients between

60-70 years (9%). This shows that the degenerative changes occurrence starts

from the third decade of life.

3. Table showing the incidence of religion:-

S.no Religion No. of patients Percentage

1. Hindu 29 87.8

2. Muslim 4 12.1

Total 33 100%

In the present study 29 (87.8%) were Hindus and 4 (12.1%) were Muslims.

4. Table showing incidence of occupation:-

S.no Occupation No. of patients Percentage

1. Physical worker 12 36.3

2. House wife 8 24.2

3. Retired Employee 2 6.06

4. Software

Professionals

5 15.1

5. Clerk 3 9.0

6. Tailor 1 3.0

7. Cook 1 3.0

8. Lecturer 1 3.0

Total 33 100%

Out of 33 patients, 12 (36.3%) were physical workers including coolies,

maidservants. Construction workers etc; 8 (24.2%) were house wives doing all

sort of household work, 5 (15.1%) were software professionals involved with

computer work, 3 (9%) were clerks doing deskwork, 2 (6.06%) were retired

employee, 1 tailor, 1 cook & 1 lecturer.

5. Table showing the incidence of socio-economic status:-

S.no Socio-economic status No. of patients Percentage

1. Lower class 9 27.2

2. Middle class 13 39.3

3. UpperMiddleclass 11 33.3

4. Higher class 0 0

Total 33 100%

The categorization of socio-economic status was based on the

occupation & annual income. Study revealed that majority of patients belong to

middle class 13 (39.2%), 11 (33.3%) to upper middle class and 9 (27.2%)

belong to poor class.

6. Table showing incidence of nature of work:-

S.no Nature of work No. of patients Percentage

1. Hard work 13 39.3

2. Sedantary work 9 27.2

3. Moderate work 11 33.3

Total 33 100%

Nature of work is based on work taken up by individual with their upper

limbs. Hard work is done by physical workers. Moderate work done by house

wives & sedentary work by all the employees including clerks,software

professionals, lecturer, statistician.In the present study 13 patients (39.3%)

were doing hardwork, 9 (27.2%) were doing sedentary work, 11 (33.3%) were

doing moderate work.

7. Table showing the incidence of Food habit:-

S.no Food habit No. of patients Percentage

1. Mixed 23 69.6%

2. Vegetarian 10 30.3%

Total 33 100%

A total of 69.6% were on mixed diet and 30.3% were on vegetarian diet.

8. Table showing the incidence of Addictions:-

S.no Addictions No. of patients Percentage

1. Alcohol 11 33.3%

2. Smoking 3 9%

3. Betel nut chewing 6 18.1%

4. Nil 13 39.3%

Total 33 100%

In the present study out of 33 patients, 13 patients (39.3%) were not

having any addictions whereas 11 patients (33.3%) were addicted to alcohol; 3

patients (9%) to smoking, 6 patients (18.1%) to betelnut chewing.

9. Table showing the incidence of Prakriti:-

S.no Prakriti No. of patients Percentage

1. Vata 3 9.09

2. Pitta 2 6.06

3. Vatapitta 12 36.3

4. Vatakapha 8 24.2

5. Pittakapha 8 24.2

Total 33 100% In the present study 3(9.09%) were vata prakriti, 2 (6.06%) were pitta

prakriti, 12 (36.3%) patients were of vatapitta prakriti; 8 (24.2%) were of

vatakapha prakriti & 8 (24.2%) were of pittakapha prakriti.

10. Table showing incidence of duration of Illness:-

S.no Duration of illness No. of patients Percentage

1. Within 6 months 3 9

2. 6 months to 1 year 15 45.4

3. 1 year to 2 year 5 15.1

4. More than 2 years 10 30.3%

Total 33 100%

Maximum number of patients were suffering from months to 1 year

(45.4%), 30.3% were suffering from more than 2 years, 15.1% were suffering

from 1 year to 2 years, 9% within 6 months period.

11. Table showing incidence of duration of pain:-

S.no Duration of pain No. of patients Percentage

1. Wholeday 19 57.5

2. Half day 12 36.3

3. Few hours 2 6

Total 33 100%

Out of 33 patients, 19 (57.5%) were having pain whole of the day, 12

(36.3%) were having pain half of the day. Only 2 (6%) were having few hours

of pain

12. Table showing the incidence of side involved:-

S.no Side Involved No. of patients Percentage

1. Right 27 81.8

2. Left 6 18.1

Total 33 100%

Maximum number of patients (81.8%) had right limb involvement,

18.1% had left limb involved.

13. Table showing the incidence of Type of Pain:-

S.no Side Involved No. of patients Percentage

1. Toda 9 27.2

2. Ruja 9 27.2

3. Vyadha 10 30.3

4. Bhedana 3 9

5. Stambha 2 6

Total 33 100%

In the present study 9 (27.2%) had toda, 9 patients (27.2%) had ruja, 10

patients (33.3%) had vyadha, 3 patients (9%) had vedana, 2 patients (6%) had

stambha.

14. Table showing the incidence Times of occurance of Pain:-

S.no Times of occurance No. of patients Percentage

1. Nights 22 66.6

2. Whole day 4 12.1

3. Morning after getting up

from bed

4 12.1

4. Evening 3 9

Total 33 100%

Maximum number of patients 22(66.6%) had pain occurance in night, 4

(12.1%) whole day, 12.1% after getting up from bed, 9% in the evening.

15. Table showing the incidence of pain:-

S.no pain No. of patients Percentage

1. Mild 4 12.1

2. Moderate 12 36.3

3. Severe 17 51.5

Total 33 100%

Out of 33 patients all had pain as predominant feature; 17 (51.5) had

severe pain, 12 (36.3%) had moderate pain, only 4(12.1) had mild pain.

16. Table showing the incidence of functional disability (bahu karma

kshaya):-

S.no Functional disability No. of patients Percentage

1. Mild 6 18.1

2. Moderate 27 81.8

3. Severe 0 0

Total 33 100%

In this present study all the 33 patients had bahu karma kshaya out of

which 27 (81.8) had moderate disability where as 6 (18.8) had mild disability.

No one had severe disability.

17. Table showing the incidence of clinical features:-

S.no Clinical features No. of patients Percentage

1. Paraesthesia 24 72.7

2. Weakness 27 81.8

3. Decreased R.O.M 21 63.6

4. Tenderness 20 60.6

5. Occipital headache 11 33.3

6. Giddiness 2 6

7. Wasting 0 0

Out of 33 patients, 24(72.7%) had paraesthesia, 27 (81.8%) had

weakness, 21(63.6) had decrased R.O.M, 11 (33.3) had occipital headache and

5(15.1%) had giddiness and 20 (60.6%) had tenderness. No one had wasting as

a clinical feature

18. Table showing incidence of paraesthesia occurance:-

S.no Paraesthesia No. of patients Percentage

1. Absent 9 27.2

2. Present but ignored in activity 14 42.4

3. Causing discomfort 10 30.3

4. Hampering activities 0 0

Total 33 100%

Out of 33 patients, 10 (30.3%) had paraesthesia causing discomfort, 14

(42.4%) had paraesthesia which can be ignored involved in activity, 9(27.2%)

never had paraesthesia. No one had paraesthesia hampering activities.

19. Table showing the incidence of weakness:-

S.no: Weakness No: of patients Percentage

1. No weakness 6 18.1

2. Mild weakness 14 42.4

3. Moderate weakness 12 36.3

4. Severe weakness 1 3

Total 33 100

In this study out of 33, 27 patients had weakness. In those 14(42.4%)

had mild weakness, 12 (36.3%) had moderate weakness, 1 (3%) had severe

weakness.

RESULTS

After collecting the data, it is subjected to statistical analysis for the sake

of assessment. The subjective parameters includes the clinical features where

as the Numerical pain Rating scale & Numerical score of functional test were

considered as the objective parameter. The following tables show the scores

obtained before and after treatment revealing the Percentage of relief from the

treatment done.

1. Table showing the results of intensity of pain after treatment:

S.no: Intensity of pain No: of patients

Percentage

1. No pain 11 33.3

2. Mid pain 22 66.6

3. Moderate pain 0 0

4. Severe pain 0 0

Pain was observed in all the 33 patients, 11 (33.3%) patients reported no

pain,

Where as 22(66.6) patients reported mild pain after treatment.

2. Table showing results of subjective symptoms:

S.no: Symptom B.T.Score A.T.Score % of relief

1. Paraesthesia 34 10 70.5

2. Weakness 41 15 63.4

3. D.R.O.M 21 6 71.4

4. Tenderness 20 5 75

5. Oc.headache 11 4 63.6

6. Wasting 0 0 0

7. Gidiness 5 2 60

In the subjective symptoms like paraesthesia 70.5% relief is noticed,

weakness 63.4% relief, deranged R.O.M 71.4% relief, occipital headache

63.6% relief, tenderness is relieved 75% & giddiness got relief.

3. Table showing the scores of N.P.R & N.S.F.T before & after treatment:- N.P.R N.S.F.T S.no:

B.T(x) A.T(x`) x-x`

% Of

change B.T(x) A.T(x`) x-x`

% Of

change

1. 8 0 8 100 15 3 12 80

2. 8 1 7 87 13 3 10 76

3. 8 0 8 100 15 4 11 73

4. 6 1 5 83 14 7 7 50

5. 8 1 7 87 12 4 8 66

6. 8 2 6 75 15 10 5 33

7. 7 1 6 85 18 8 10 55

8. 8 1 7 87 11 2 9 81

9. 8 1 7 87 17 8 9 52

10. 6 1 5 83 12 6 6 50

11. 7 2 5 71 12 6 6 50

12. 8 3 5 62 18 12 6 50

13. 8 3 5 62 15 10 5 33

14. 6 1 5 83 20 10 10 50

15. 4 0 4 100 13 4 9 69

16. 6 1 5 83 15 3 12 80

17. 5 1 4 80 13 4 9 69

18. 5 0 5 100 19 10 9 47

19. 6 0 6 100 13 3 10 76

20. 4 1 3 75 8 3 5 62

21. 4 0 4 100 10 7 3 30

22. 5 0 5 100 9 0 9 100

23. 5 1 4 80 11 3 8 72

24. 8 1 7 87 18 6 12 66

25. 7 1 6 85 16 8 8 50

26. 8 2 6 75 15 3 12 80

27. 6 0 6 100 18 2 16 88

28. 4 0 4 100 10 2 8 80

29. 8 1 7 87 16 7 9 56

30. 7 1 6 85 12 6 6 50

31. 6 1 5 83 10 3 7 70

32. 8 0 8 100 12 2 10 83

33. 6 0 6 100 8 2 6 75

The N.P.R & N.S.F.T scores showed a marked change after treatment,

% of change reports major relief of pain & disability.

4. Table showing results of Functional disability after treatment:-

S.no: Functional

disablity

No: of patients Percentage

1. No disability 1 3

2. Mild disability 27 81.8

3. Moderate

disability

5 15.1

4. Severe disability 0 0

All the 33 patients had functional disability (bah karma kshaya),

27(81.8%) patients reported mild disability, 5(15.1%) patients still have

moderate disability & only 1(3%) patient had no disability after treatment.

5. Table showing the statistical analysis of N.P.R & N.F.T.S scores:-

Mean S.no: Parameter

A.T(X) B.T(X`)

% 0f

relief

X-

X`

S.D S.E t p

1. N.P.R 6.54 0.88 86.5 5.66 5.8 1.01 5.5 <0.001

2. N.S.F.T 13.7 5.18 62.3 8.54 8.93 1.57 5.43 <0.001

Mean N.P.R is 5.66, N.S.F.T is 8.54 & percentage of relief is 86.5 &

62.3 in both scales respectively. The “p” value is highly significant in both

scores.

6. Table showing the total outcome of the treatment:-

S.no: Result No: of patients Percentage

1. Marked relief 13 39.3

2. Moderate relief 20 60.6

3. Mild relief 0 0

4. No relief 0 0

Total outcome of the treatment shows marked relief in 13 (39.3%)

patients and moderate relief in 20 (60.6%) patients.

Chart No.1 showing The Incidence of Sex

Male39%

Female61%

Male

Female

11 118

302468

1012

No.of Patients

Charts No.2 Showing the Incidence of Age

60-70y50-60y40-50y30-40y

128

53 2 1 1 10

2

4

6

8

10

12

No.of patients

Occupation

Chart No.3 Showing Incidence of Occupation: Lecturer

Cook

Tailor

RetiredemployeeClerk

SoftwareprofessionalHouse w ife

Physicalworker

Chart No. 4 Showing Incidence of Nature of Work:

Sedentary work27%

Moderate work33% Hard work

40%

Hard work

SedentaryworkModeratework

9

910

3

2

0 2 4 6 8 10No.of Patients

Type

of p

ain

Chart No.5 Showing Incidence of Type of Pain:

TodaRujaVyadhaBhedanaStamba

27 24 21 2011

05

0

5

10

15

20

25

30

No.of Patients

Clinical Features

Chart No. 6 Showing Incidence of Clinical Features:

Giddiness

Wasting

Occ.headacheTenderness

DeranegdR.O.Mparaesthesi

Chart No.7 Showing N.P.R.Curve During Treatment:

0123456789

10

Day 0 Day 10 Day 20 Day 30Mean of NPR

Table No.8 Showing NSFT Curve During Treatment:

0

5

10

15

20

25

30

Day 0 Day 10 Day 20 Day 30

Mean of NSFT

0

10

20

30

40

50

B.T scores A.T Scores

Chart No.9 Showing the Results of Subjective Parameters:

Weakness Paraesthesia Deranged ROM Tenderness Occ Headache Giddiness Wasting

04

12

17

11

22

0 00

5

10

15

20

25

Before treatment After treatment

Chart no:10 Showing the Pain Relief :

No PainMild ModerateSevere

0

5

10

15

20

25

30

Before treatment After treatment

chart no:11 showing functional disability response to treatment

no disability

mild

moderate

severe

0

10

20

30

40

chart no:12 Total Result of Treatment

No relief

Mild relief

Moderate relief

Maked relief

chart no:12 showing total outcome of trial

no relief mild relief moderate relief marked relief

DISCUSSION Ayurveda, being an acient medical science, is formulated on the

scientific parameters available in those times. Research is the only way

available to re-establish old facts through modern methodology. It is not only

useful to expand the area of knowledge, but can also help to develop and

advance in new directions.

An open trial was done on “A Clinical Study In The Management Of

Viswachi With Sinduvaradiyogam Along With Ksheerabala Tailam

Nasyam”

Viswachi is a pain predominant disease. Pain in Viswachi is caused by

partial damage to nerve membranes, which become sensitive to mechanical &

chemical stimuli. Such de-afferentiation pain may either be of burning,

superficial (dysaesthetic) type or of stabbing character. So, evolving a potent

vedanahara yogam is very needful in the management of Viswachi.

All Ayurvedic classics included Nasya in the management of

vatavyadhis. Bahu having its moolam in the griva gets affected in Viswachi.

Thus, nasya becomes the line of treatment in this disease.

Discussion on Inclusion & Exclusion criteria:

As Viswachi occurs in both sexes without bias, both gender were

selected for the study. As the diseases like Diabetes mellitus & other major

systemic disorders like hypothyroidism, malignancies, tuberculosis line of

treatment should differ from the present study so, they were excluded. Trauma

being common reason, in majority requires surgery. So, patients with history of

trauma are excluded.

Discussion on Diagnostic & assessment criteria:

Describing and quantifying pain can be confusing. The perception of

pain and pain complaint are not necessarily synonymous.

As the key goals of pain management programme are reduction of

incapacity and an increase in physical function to the maximum achievable. As

a declared outcome it becomes incumbent upon the clinician to monitor &

measure the level of function and disability. So, the NPR & NSFT were taken

as assessment criteriae.

Discussion on observations:

In the present study, all the patients were selected from OPD of G.A.C;

HYD. 33 cases were included for the clinical study out of 40 as 7 were

dropouts.

Sex : In this study 20(60.6%) females & 13(39.3%) males were registered.

Prevalence is more in the female sex.

Age: Maximum numbers 22(66.6%) of patients were between 30-50 yrs of age

group. This shows that majorly disease occurs in the working age group people.

Then more number 8 (24.6%) patients were observed in 50-60 yrs, as it is the

Vata period prone to degeneration.

Religion: Most of the patients were Hindus(87.8%).

Education: Literates were outnumbering the illiterates in the study. Though it

does not directly relate to the disease but have an indirect influence. This aspect

reflects on the occupation, socio-economic status of the individual.

Diet: Out of 33, 23 patients were on mixed diet. No significant relation is

found bet ween diet & disease. Probably this factor will be secondary in

causing disease.

Addictions: 13patients were with out any sort of addictions (alcohol, smoking

and betelnut) where as the remaining 20 patients had addictions. No significant

relevance to disease is found in this observation.

Prakriti: Observations on 33 patient’s prakriti revealed maximum occurrence

of disease in vata related prakriti i.e vata(9%), vatapitta(36.3%), vatakapha

(24.2%). This signifies the occurrence of vata disorders more dominantly in

vata related prakriti persons.

Occupation: This is the key factor in this disease.

Out of 33 patients, 12(36.3%) were physical workers, 8(24.2%) were

employees (desk workers), 8(24.2%) were house wives remaining

miscellaneous. The physical workers were also majorly skilled workers

involved in some fine work.Basing on occupation nature of work was assessed

that is

Moderate : work involving more effort of upper limbs

Hard : maximum extent effort of upperlimbs

Sedantary : continous sitting posture along with effort of upperlimbs

In this category 13 patients were doing hard work, 11 were doing

moderate work and 9 patients were sedanary workers. This signifies that any

kind of work with maximum effort on upperlimbs is disease causing. These

observations signifies Viswachi occurrence due to occupation or work related

early degenerative changes in the cervical spine.

Socio-economic status: Maimum 13 patients were from middle class, 11 from

uppermiddle class and 9 from lower class. No one was from higher class as the

study was conducted in Govt hospital. This category observations show

occurrence of Viswachi in almost all the strata of society wherever there is

more usage of upperlimbs either for hard or fine work.

Duration of illness: Out of 33 patients, 15(45.4%) were suffering since

6months to 1year; 10(30.3%) patients were suffering more than 2yrs; the rest

were between 6months & 6months to 2 yr. This signifies chronic nature of the

disease. The patients from the group of 6 months & 6months to 1yr had marked

relief where as the chronic patients showed moderate relief.

Duration of pain: Maximum 19(54.5%) patients had pain 24 hrs. This

category indicates intensity of pain. After treatment it was observed that

duration of pain reduced in all though it varied individually. Only few had

absence of pain.

Site involvement: Maximum 27 patients had right limb involvement. This

signifies the vulnerability of the more used limb to disease.

Type of pain: In 33 patients’ toda(27.2%), ruja(27.2%), vyadha(30.3%),

bhedana(9%), stambha(6%) types of vedana were observed. All these

descriptions of pain are of neuralgic variety, indicating neurological

involvement.

Distribution of pain: This observation was made in accordance to description

of Viswachi in classics (Talam pratiangulinam………). Typical pain

distribution follows a dermatomal & myotomal pattern, characteristic feature

observed in all 33 patients. 17 patients had pain in C4, C5, C6 segments. 6

patients had pain in C2, C3 segments. 4 patients had pain in C3, C4, C5, C6

segments. Majority of segments involved were C4, C5, and C6. After treatment

it was observed that pain persisted in C6, C5 segments majorly.

Times of occurrence: Increased pain was observed in nights & evenings in

majority of patients. This can be attributed to vataprakopa.

Clinical features: Though many clinical features are described all were not

observed in all the 33 patients. Pain, dysfunction, paraesthesia, weakness,

deranged R.O.M, tenderness were the predominant features observed. Occipital

headache & giddiness were observed only in few patients.

Sensory symptoms: Out of 33 patients 18 had pins & needles and only 6

patients had numbness. These were typically distributed in dermatomal pattern.

C8,T1 were the major segments involved in pins & needles. Majority got

relieved after treatment. A few had persisted paraesthesia with decreased

segmental involvement. T1 segment was noticed in most of the persistent

patients.

Paraesthesia was observed in intensity fashion also. 9 out of 33 patients had

no paraesthesia. Out of 24(72.7%) no one had paraesthesia hamering daily

activities. 14 & 10 patients had pins & needles which can be ignored and

causing discomfort respectively. This denotes the degree of sensory

involvement in the disease.

Weakness: Another major symptom manifested. It denotes motor component

of the disease. 27(81.8%) patients complained weakness, out of which

14(42.4%) had mild weakness, 12 (36.3%)had moderate weakness and only 1

patient had severe weakness. This signifies the chronicity & the progress of the

disease. More is the weakness more is the functional disability. As in the nerve

function and nutrition increases the compression on the nerves increases

disturbance linearly. Weakness is the symptom that persists even after pain

reduces.

Radiological findings of all the 33 patients did not show degenerative changes.

26 patients were with osteophytic changes, reduced disc heights. One patient

was with disc herniation. But clinical features in all the patients were not

correlative to the radiological findings.

This observation denotes occurance of Viswachi also due to repetitive strain or

as an occupational disorder (WRULD). In many persistently painful conditions,

especially those arising from musculoskeletal system, the precise diagnosis of a

causal pathology may be very difficult or even impossible. Patients may report

extreme pain &.weakness of muscle action, with little actual identifiable

pathology. Pain free subjects may demonstrate evidence of considerable

abnormality but have excellent measurable function. (Price & Harkins, 1992)

Discussion on results:

Subjective symptoms were graded and the scores obtained showed % of

relief as follows: 75% relief was observed in tenderness, 71.4% of relief in

decreased R.O.M i.e movements improved; 70.5% relief was observed in

paraesthesia, 63.4% relief was observed in weakness, 63.6% relief in occipital

headache & 60% relief in giddiness. No one was with wasting as a symptom.

These numerical data signifies the moderate relief shown by the oral medicine

& nasya in the subjective symptom in Viswachi vata.

Pain measurement is difficult & confusing. Numerical pain rating scale

was adopted to avoid confusion. All the 33 patients’ pain was rated numerically

on first day, 10th day, 20th day and 30th day. The mean NPR for all the 33

patients before treatment was 6.54, where as the mean on 10th day was 4, on

20th day was 2.21 and after treatment was 0.88. This showed how pain

gradually came down during treatment period. These patients were again

classified into having mild, moderate, severe pain. 17 patients were with severe

pain before treatment. Results showed that 11 patients were with no pain, 22

with mild pain; no one was with severe pain. The mean difference of NPR

value between before and after treatment was 5.66 ± 5.8. 86.5% of relief was

noted with a‘t’ value of 5.5 and ‘p’ value(< 0.001)obtained was highly

significant. This signifies the vedanahara property of the Sinduvaradi yogam

along with nasyam.

Pain is always associated with dysfunction. The functional disability

was assessed basing on a questionnaire (NSFT) and the scores obtained were

subjected to statistical analysis. The mean NSFTscore before treatment was

13.54, on 10th day it was 10.4, on 20th day it came down to 7.3 and on the 3oth

day it was 5.18. This signifies reduction of functional disability. These patients

were again divided into patients having mild, moderate, severe disability. After

treatment one patient was without disability, 27 were with mild disability and 5

were with moderate disability. The mean difference of NSFT scores before and

after treatment was 8.54± 8. 93.63.6% of relief was noted with a‘t’ value was

5.3 with a significant ‘p’ value(<0.001). This suggests marked improvement.

The overall outcome of the trial was assessed by considering the result

of subjective parameters, NPR & NSFT scores. This showed that in 13 patients

(39.3%) marked relief was noticed. In 20 patients (60.6%) moderate relief was

observed.

This signifies the effect of Sinduvaradi yogam along with ksheerabala

taila nasya in the management of Viswachi.

Limitations of the study:

Sampling method was incidental & the sample size was very small. So,

limited size and time period have a limitation on the study.

For the diagnosis as well as assessment the help of advanced techniques

like CT, MRI, and NCV studies would have been better selected to prove the

treatment results in more scientific way. So, it is difficult to generalize the

results to give definite conclusions.

Probable mode of action:

This clinical trial includes both oral medicine & nasya karma.

Explaining mode of action of a compound only basing on the clinical trial is

difficult.Action can only be assumed.

Synergistic action of the individual entities might be exhibited by the

compound. The oral medicine- Sinduvaradi yogam under taken for the present

study contains Nirgundi, suranjan & Parijatha. All these three have both

Classical & scientific references for their anti-inflammatory (sotha hara) and

analgesic (vedanastapana) activities. Thus the compound can be expected to

have the same action.

To understand pharmacological action knowledge of pathophysiology is

necessary. It is as follows : the noxious stimuli (inflammatory mediators

released by protruded disc material) received by the nociceptors in the tissues is

converted into energy which is carried along the different sized nerve fibers at

varying speed to dorsal horn of the spinal cord and then to the brain. At any

level of transmission pain may be modulated.

The compound Sinduvaradi yogam will be acting along the nociceptor

pathways, acting against the pathological process producing pain at the

periphery to modulation of the response at the cerebral level.

For Nasya karma ksheera bala 101 tailam was taken. This is a siddha

sneha having brmhana karma, nourishes the nerves sick due to compression.

The contents of the tailam are best vatasamaka and brmhanakara dravyas. They

have good amount of calcium, useful in bone metabolism.

The nasya karma karmakata was explained earlier in the cikitsa chapter.

The nasya dravya either stimulates hypothalamic-pituitary axis or nourishes the

nerves by entering the brain tissue in different channels. Also it might be

stimulating the production of endogenous painkillers Enkephalins,

Endorphins & Dynorphins that are manufactured in the gray matter of the

brain and present in the dorsal horn.

Thus the action can be summarized as:

1. Oral medicine- acting on the effect i.e pain

2. Nasya dravya- acting on the cause i.e degeneration primarily.

Scope for further study:

2. Trial in a large sample to generalize the outcome.

3. Cross over double blind studies using a placebo or standard drug in

evaluating analgesics.

4. Adopting parameters like patient specific functional scale(PSFS) & global

rate of change(GRC)

5. Extensive scientific study of pharmacodynamic properties of nasya dravya

along with pharmacokinetics to establish mode of action of nasya.

SUMMARY In Toto, the work done on the viswachi disease in evaluating the effect

of sinduvaradi yogam along with ksheerabala tailam (101 avartitha) nasya can

be summarized as follows:

Viswachi is a vataja nantmaja, vedana pradhana vyadhi. Classics

described very less about Viswachi. But however this is a major disorder of

upperlimb that hampers the normal routine life. Radiating pain is the

pratyatmika lakshana of this disease. As pain follows dysfunction, this results

in impairment of activities affecting the individual economy inturn society

economy.

The present life style is causing early degenerative changes which are

crippling not only the individual but also society.

In the present study after a brief introduction about the topic, review of

literature was done. This review starts from the historical aspects of both the

ayurvedic & modern perspective. This chapter signifies the developmental

facts of the disease awareness both socially & scientifically.

In the chapter Shareera, vata, the casuative factor has been described

along with cervical spine & its constituents. The biomechanics of cervical

spine especially related to upperlimbs is also included.

In the disease desription no where separate viswachi nidana, poorvarupa,

samprapti, upasaya, sadhyasadhya are available. So, generally vatavyadhi

nidana etc. are adopted for viswachi. In this chapter both ayurvedic & modern

explanations regarding disease are compiled in a explicit manner along with

description of myotomal & dermatomal distribution of pain & paraesthesia.

Treatment of viswachi includes abyanga, sweda, uttarbhaktika

snehapana, nasya etc. which are vatahara & brmhaneeya in nature. Present

study includes Nasyakarma along with shamanoushadi as they are effective &

beneficial for the degenerative condition taken up in the study.

Apart from the procedure of nasya & nasya karmukhata explanation, a

detailed description of examination of the patient including special tests like

ULTT etc. performed by physiotherapists are also mentioned. These provide

more accurate diagnosis of specific nerve root involvement.

Review of literature ends with description of pharmacological &

therapeutic description of the drugs selected. Sinduvara, suranjan, parijatha

were selected for the present clinical trial.

The second part of the work is dedicated to the clinical trial evaluating

the efficacy of nasya with ksheerabala (101) taila & sinduvaradi yogam in

viswachi. It includes inclusion, exclusion, diagnostic & assessment criteriae

along with research design in materials & methods.

Present study is an open trial done on 33 patients of viswachi for a

period of 30 days in each patient. Patients were selected incidentally basing on

the diagnostic criteria. All patients were given nasya for 7 days along with oral

medicine for a period of 30 days. The observations of the study included

demographic data, disease specific data i.e., pain, and sensory symptoms

affected segments etc. NPR & NSFT scores were observed all through the

duration of the treatment.

Assessment was made for every 10 days. The effect of treatment was

assessed after 30 days. Variables were subjected to statistical analysis and

reported. It is observed that oral medicine along with ksheerabala tailam nasya

was very efficacious in relieving pain & other symptoms. It also showed

efficacy in improving the functional ability of the affected arm. Nasya had

highly significant action in patients of full blown degenerative changes,

whereas the oral medicine alone showed significant result in patients of

repetitive strain injury & occupational disease. Further studies & extended

clinical trials are required to assess the mode of action of the drug.

This work on viswachi was done basing on scientific lines & results

were appreciating. But still more scientific work is to be done to generalize the

outcome.

CONCLUSION 1. Viswachi is a disorder affecting upperlimbs. It is identified by radiating

pain all through the limb & dysfunction of that limb.

2. Viswachi is a neurological disorder occurring commonly due to cervical

spine lesions.

3. Disease is gaining importance due to its crippling nature.

4. Prevalence of the disease viswachi is more in the age group of 30-50 yrs.

5. Occupations involving the upperlimbs usage continuously are resulting in

increased disease precipitation/prevalence.

6. More women are suffering than men.

7. More deskworkers are prone to the disease.

8. Clinical features are not always correlative to radiological findings.

9. Sinduvaradi yogam along with nasyakarma showed marked relief in the

blownup degenerative conditions.

10. Amsasosha can be considered as next stage of viswachi.

BIBLIOGRAPHY 1. Carakasamhita : Agnivesa revised by caraka & dhrdabala with the

ayurveda deepika commentary of chakrapani datta edited by V.D.Yadavji

Trikamji acharya- 5th edition-published by Chowkambha Sanskrit

Samsthan, Varanasi( 2001)

2. Carakasamhita : English translation-editor, translator Priyavat

Sharma- vol II&vol IV-published by chowkambha Orientalia (1983)

3. Caraka samhita : Satyanarayana shastri with vidyotini Hindi

commentary edited by bramhasankara misra-18th edition- published

byChaukambha Bharati Academy (1992)

4. Bhelasamhita : Edited by Venkata Subrahmanya Sastry, published by

Central council for research in Indian medicine and Homeopathy, New

Delhi (1977)

5. Bhava prakasa : Bhavamisra edited with vidyotini Hindi

commentary by Bramhasankara misra-1st edition- published

byChaukambha orientalia (1980)

6. Cakradatta : Cakrapanidatta with Bhavarthasandeepani commentary

by Jagadeswar Prasad Tripathi-edition- Chaukambha Sanskrit Series

publications (1961).

7. BhavaPrakasaNighantu:CommentarybyDr.K.C.Chunekar-Editedby

G.S.Pandey, 5th edition Chowkhamba Sanskrit Sansthan, Varanasi.(1979)

8. Introduction to Kayacikitsa: C.Dwarakanatha - 3rd edition

published by Chowkambha Orientalia, Varanasi. (1996)

9. Abhinavam shareeram : Damodar Sharma Gaur-in Sanskrit- 1st

edition-published by Shri Baidyanath Ayurved Bhawan Pvt Ltd.(1974)

10. Sachitra Hindi pratyaksa Sharira: Gananathsen- - part I- 5th edition-

published by Chaukambha Sanskrit series office, Varanasi (1978)

11. Bhaisajya Ratnavali : Govindadasa- with vidhyotini hindi

commentary by Ambika Datta Shastri- 18th edition- published by

Chowkambha Sanskrit samsthana, Varanasi.(2005)

12. Haaritha samhita : Haaritha-– Srivenkateswara press, Bombay.(1931)

13. Vaidyacintamani (Telugu): Indrakanti vallabhacharya- published by

Dachepalli Kistaiah & Sons, Secunderabad (1955)

14. Dravyaguna Vignan : J.L.N.Sastry-Vol II-2d edition-

Chowkambha Orientalia Publishers. (2005)

15. Indian medicinal plants: Kirtikar & Basu- -2nd edition- published by

Lalitmohan basu, Allahabad, India (1975)

16. Indian Materia & Medica: K.M.Nadkarni- vol II- 3rd revised & enlarged

edition- Popular prakasham private ltd.

17. Madhava nidanam:Madhavakara with Madhukosa (vyakhya)

commentary by Vijayrakshita & Srikantadatta with the ‘vidyotini’ hindi

commentary & notes by Sri Sridarshana Sastri-17th edition-published by

Chaukambha Sanskrit sansthan, varanasi(1988).

18. History of Indian Medicine: Editor P.V.Sharma published by the Indian

National Science Academy (1992)

19. Sahasrayogam : Hindi Translation Dr.Ramnivas sarma-1st edition-

Dakshina prakasham publications.

20. Pancha karma therapy: Prof. R.H. Singh - 1st edition - Published by

Chowkambha Sanskrit series office, Varanasi (1992)

21. Shabdakalpadrum:Raja Radhakanta deva- -published byChaukambha

Sanskrit series office, Varanasi (1961)

22. Chopra’s, Indigenous drugs of India: Col.Sir R.N.Chopra &

I.C.Chopra, K.C.Handa, C.D.Kapur- II edition-published by U.N.Dhur &

Sons private limited

23. Sarangadhar samhita: Sarangadhara - subodhini hindi commentary,

Lakshmi notes and appendices commentary by Prayoga data sarma-6th

edition- published by Chaukambha amarabharati prakasham, Varanasi

(1981)

24. A Sanskrit English dictionary: Sir Monier Monier Williams- 1st edition-

published by Oxford University Press, London (1956)

25. Gadanigraham : Sodhala- with vidyotini Hindi commentary by

Indradu Tripathi- publication of Chowkambha Sanskrit Series, Varanasi

(1968)

26. A text book of Bhaisajya kalpana: Dr. Shobha G. Hiremath- (Indian

pharmaceutics)-1st edition- Published by IBH prakasana, Bangalore

(2000).

27. Essentials of Basic Ayurvedic Concepts: Dr.V.V.S.Sastry - published by

publication division of post graduation and research centre Shree

D.G.MulMalay Ayurvedic Medical College, Gadag, India.(1999).

28. Tridosha theory : Dr.V.V.S.Sastry- Supplement to Ayurvedic seminar-

XIV-Aryavaidya sala, Kottakal (1977)

29. Susruta Samhita: Susruta - Nibandha Sangraha commentary of

Dalhanacharya,Nyayachandrika panjika of Gayadasa on Nidanasthana

edited by V.D.Yadavji Trikamji Acharya- 7th edition- published by

Chowkambha Orientalia, Varanasi (2002)

30. Susruta Samhita: Edited with ayurveda tatva sandeepika by Kaviraja

ambika datta sastry part-1 15th edition Chowkambha Sanskrit samsthan

Varanasi (2002)

31. Susruta samhita:(Text, English translation, notes appendices & index) -

translator prof K.R.Srikantha Murthy-1st edition- published by

Chaukambha orientalia (2000)

32. Susrutasamhita: (English translation) translated by Kaviraj kunjalal

Bhishagratna- vol II- third edition- published by Chaukambha Sanskrit

series office, Varanasi (1981)

33. Astanga Hrdayam:Vagbhata with vidyotini Hindi commentary by

kaviraja atrideva gupta edited by Vd.Yadunandana upadhyaya-14th edition

published byChaukambha Sanskrit sansthan, Varanasi (2003)

34. Astangasangraha: Commentary by Lalchandra sastry vaidya – 1st edition

Baidyanath ayurved bhavan Pvt. Ltd.

35. Astanga Hrdyam (English):Translated by Prof. K.R.Srikantha Murthy

V. Edition - published by Krishnadas academy, Varanasi (2003)

36. Astanga sangraha (English): Translated by prof. K.R.Srikantha murthy-

4th edition- published byChaukambha orientalia, Varanasi, (2001)

37. Indian medicinal plants:Vaidyaratnam P.S.Varier’s Aryavaidyasala,

Kottakkal- Orientlongman limited (1995)

38. Yogaratnakaram: Vd. Lakshmipati sastry- With Vidyotini Hindi

commentary editor Bramhasankar sastry-Chowkambha Sanskrit Series,

Varanasi (2002)

39. Neurology in ayurveda (understanding vata): Dr.U.Govind raju &

Dr.V.N.K.Usha- Chowkamba orientalia.

40. Vaidyam : Journal of K.A.P.L vol.IV Issue I Jan-Mar.2006

41. The wealth of India : (A dictionary of Indian Raw materials & Industrial

products) - published by the publications & information directorate, New

Delhi.

42. Golwalla- Medicine for students: Aspi.F.Golwalla & Shahrukh A.– 20th

edition published by Dr.A.F.Golwalla, Mumbai (1951)

43. Brain’s diseases of the Nervous system: Edited by Micheal Donaghy-

11th edition- published by Oxford university press (2001)

44. Clinical Neurology: C.David Marsden & Timothy Fowler- II edition.

45. Clinical Dietics & Nutrition: F.P.Anita & Philip Abraham-– IV edition-

publications-Oxford University press. (2006)

46. Clinical Orthopaedics:Gregory S.McDowell & Frank P.Cammisa- -

edited by Edward v.craig-published by Lippincott Williams & Wilkins

(1999)

47. Harrison’sprinciples of internal medicine: Harrison- 6th editionVol-I-

editors Dennis Kasper.L, Engine Braunwaldchal- McGraw Hill medical

publishing division. (2005)

48. Lange current diagnosis & treatment in orthopaedics: Harry

B.Skinner- 2nd edition- McGrawHill medical publishing division.(2000)

49. Gray’s Anatomy : Henry Gray - 36th edition- edited by R.Warwick and

P.L.Williams Edinburg- published by Longman group.(1980)

50. An introduction to neuropathology: Hume Adams etal- - 2nd edition –

Churchill living stone (1994)

51. Functional anatomy of the LIMBS and BACK: Hollinshead and

Jenkins-- 5thedition- Published by W.B.Saunders Company Philadelphia

(1981)

52. Cyriax’s illustrated manual of orthopaedic medicine: J.H.Cyriax &

P.J.Cyriax- II edition- Butterworth Heinmann (1993)

53. Medical discoveries by who & when: J.E.Schmidt

54. Fundamentals of Orthopaedics: John J.Gartland, M.D- - 3rd edition -

Published by W.B.Saunders company London (1979)

55. Outline of Orthopaedics: John Crawford Adams & David l.Hamblen- -

13th edition-published by Churchill Livingstone Edinburgh (2001)

56. Journal of orthopaedics & sports physical therapy: Vol.35, no:12

publication of the American physical therapy Association.

57. Clinically oriented Anatomy: Keith L. Moore, Arthur F. Dalley- - 4th

edition- Published by Lippin cott Williams & Wilkins Company. (1999)

58. Lange current medical diagnosis & treatment: Edited by Lawrence

m.tierney- 45thedition-Mcgrawhill medical publishing division-(2006)

59. Adams and victor’s manual of neurology: Maurice victor & Anan H.

Popper- 7th edition- Mc Graw hill publishing division.

60. Work related upper limb disorders- recognition & management:

Michael A.Hutson- Butterwprth Heinmann(1997)

61. Orthopaedic medicine, a practical approach: Monica kesson, Elaine

Atkins- - 2nd edition- Elsevier (2005)

62. Key topics in neurology: P&M Smith- - Bios scientific publishers ltd

(1998)

63. Pain management-An interdisciplinary approach:Chris j.main, chris c.

spanswick- Churchill livingstone (2000)

64. Principles of neurology: Raymond D.Adams, Maurice victor, Allan

H.ropper- 6th edition- published by Mcgraw hill -company(1997)

65. Orthopaedic physical therapy: Robert A. Donatelli & Michael j.

Wooden- 3rd edition- published by Churchill Livingstone.

66. The Spine And Medical Negligence R.W.Porter- - Bios scientific

publisher ltd. (1998)

67. The clinical anatomy & management of (backpain series) -cervical

spine pain- vol.3-edited by CGR Cules & K.P.Singer- published by

Butterworth Heinmann-(1998)

68. Pharmacology & pharmacotherapeutics: R.S.satoskar- Popular

prakashan ltd (2001)

69. The Hand as a mirror of Systematic disease: Theodre. J.Berry, M.D-. -

Davis Company, publishers. (1963)

70. Orthopaedics and fractures: T.Duckworthy- 3rd edition- Blackwell

science ltd. (1995)

71. Clinical neurophysiology: U.K.Misra & J. Kalita- 1st edition - Published

by Elsevier, New Delhi (2005)

72. A history of neurology: Walter Riese- M.D publications.

73. Pocket Companion to Neurology in Clinical practice: Walter G.

Bradley- 3rd edition- Butterworth Heinnmann- (2002)

Dr.B.R.K.R. Govt. Ayurvedic College, Hyderabad.

P.G.Dept. of Kaya Cikitsa.

Special Case Sheet for Viswachi

Name : Occupation :

Age : Economic status :

Sex : IP/OP No :

Religion : D.O.Initial Medication :

Address : D.O.Completion :

Phone No :

INFORMED CONSENT

I am ...………………………………………. exercising my free

will to participate in above study as a subject. I have been informed to my

satisfaction, by attending physicians, the of purpose of clinical evaluation and

the nature of drug treatment.

I am also aware of my right to opt out of the treatment schedule

at any time during the course of the treatment.

Signature of the patient

1. Chief complaints with duration:

2. Associated complaints :

3. History of present illness :

4. Past history : Trauma / HTN/ DM

H/o I.M.interventions

5. Family history :

6. Personal history :

Diet :

Appetite :

Micturition :

Bowels :

Sleep :

Addictions :

Nature of work :

7. Asta Sthana Pariksha:

Nādi : Sabda :

Mutram : Sparsha :

Malam : Drik :

Jihwa : Akriti :

8. Dasavidha pariksha:

Prakriti : Sātmyam :

Vikriti : Pramana :

Sāra : Āhara Sakti :

Samhanana : Vyayama Sakti :

Satwam : Vayah :

9. Physical Examination:

A. General :

B. Local:

I. Pain : a) Onset :

b) Site :

c) Duration :

d) Radiation :

e) Type :

1. Sphurana 5. Toda

2. Stambha 6. Vedana

3. Vyadha 7. Bhedana

4. Dāha 8. Ruja

f) Intensity:

1. Mild

2. Moderate

3. Severe

g) Times of occurrence:

h) N.P.R score:

II. Tenderness

III. Range of movements:

Flexion: Extension:

Rotation: Abduction:

Abduction: Circumduction:

IV. Motor Examination: RUL LUL

a. Power:

b. Tone:

c. Nutrition:

d. Reflexes:

V. Sensation: RUL LUL

Hypoaesthesia:

Hyperaesthesia:

Paraesthesia :

10. NSFT Score (BT):

11. Investigations:

i) X-ray cervical spine :

AP view :

Lateral view :

ii) X-ray shoulder :

iii) Others :

12. Panchalakshana Nidana:

a. Nidana:

b. Poorva rupa:

c. Rupam:

d. Upasaya:

e. Anupasaya:

13. Cikitsa:

Trial drug:

a) Nasyakarma with Ksheerabala-101 Tailam for 1 wk

Date Time of

Administration

Dosage Results Complications

b) Oral drug: Sinduvaradi yogam (Parijata patra kwatha

bhavita Sinduvara and Suranjan churna).

Dose: 500 mg cap 2 tid

AFTER TREATMENT ASSESMENT

CRITERIAE

BEFORE

TREATMENT 10 days 20 days 30 days

1.N.P.R

2.N.S.FT

3.Paraesthesia

4.Weakness

5.Dec. R.O.M

6.Oc.H.ache

7.Tenderness

8.Wasting

9.Giddiness

c) Assessment Rating Curve:

0

3

6

9

12

15

18

21

24

27

30

1st day 10th day 20th day 30th day

nprnsft

14. Result: 1. Marked Relief

2. Moderate Relief

3. Mild Relief

4. No Relief

Signature of P.G. Scholar

Signature of Co-guide Signature of Guide

QUESTIONNAIRE OF NSFT

1. Can you wash your hair?

2. Can you wash your back?

3. Can you put on your pants / socks on & off?

4 Can you roll chapathies?

5. Can you place an object high on shelf?

6. Can you lift heavy weights?

7. Can you push an object with the involved arm?

8. Can you drive your vehicle?

9. Can you work as much as you want?

10. Can you concentrate fully when you want?

Score:

“0”: able to do with out difficulty “1”: able to do with minimum difficulty “2”: able to do with maximum difficulty “3”: very difficult to do, requires help

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