A Comprehensive Study On Marma Points.pdf

“A COMPREHENSIVE STUDY ON MARMA & A COMPREHENSIVE STUDY ON MARMA & ACUPUNCTURE POINTS AND EVALUATION OF THEIR THERAPEUTIC IMPORTANCE

ACUPUNCTURE POINTS AND EVALUATION OF THEIR THERAPEUTIC IMPORTANCE” BY

Dr. VIVEK.J. B.A.M.S

Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, for the partial fulfillment for the Degree Of MASTER OF SURGERY (Ayurveda Dhanvantari) In

SHALYA TANTRA Under the guidance of

Dr. VENKATESH.B.A B.S.A.M., B.A.M.S., M.D (SHALYA TANTRA)

Professor & HOD Department of Post Graduate Studies in Shalya Tantra Government Ayurveda Medical College, Bengaluru. Dr. VIVEK.J 2010 - 2011

DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA GOVERNMENT AYURVEDIC MEDICAL COLLEGE DHANWANTARI ROAD, BANGALORE – 560009 2010-2011

“A COMPREHENSIVE STUDY ON MARMA & ACUPUNCTURE POINTS AND EVALUATION OF THEIR THERAPEUTIC IMPORTANCE” BY

Dr. VIVEK.J.

B.A.M.S

Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, for the partial fulfillment for the Degree Of MASTER OF SURGERY (Ayurveda Dhanvantari) In

SHALYA TANTRA Under the guidance of

Dr.VENKATESH.B.A B.S.A.M., B.A.M.S., M.D (SHALYA TANTRA)

Professor & HOD Department of Post Graduate Studies in Shalya Tantra Government Ayurveda Medical College, Bengaluru. DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA GOVERNMENT AYURVEDIC MEDICAL COLLEGE DHANWANTARI ROAD, BANGALORE – 560009

2010-2011

Department of Post Graduate Studies in Shalya Tantra Government Ayurvedic Medical College Bangalore - 560009

CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A COMPREHENSIVE STUDY ON MARMA & ACUPUNCTURE POINTS AND EVALUATION OF THEIR THERAPEUTIC IMPORTANCE” is a bonafide research work done by

Dr. VIVEK.J in partial fulfilment of the requirement for the degree of M.S. (Ayurveda Dhanvantari).

Date:

Dr.VENKATESH.B.A. B.S.A.M., B.A.M.S., M.D (Shalya Tantra)

Professor & HOD Department of P.G. Studies in Shalya Tantra G.A.M.C., Bengaluru – 9.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A COMPREHENSIVE STUDY ON MARMA & ACUPUNCTURE POINTS AND EVALUATION OF THEIR THERAPEUTIC IMPORTANCE” is a bonafide and genuine

research

work

carried

out

by

me

under

the

guidance

of

Dr.Venkatesh.B.A, Professor & HOD, Dept of PG studies in Shalya Tantra, Government Ayurvedic Medical College, Bengaluru – 9.

Date: Place

Signature of the candidate Dr. Vivek.JB.A.M.S

Department of Post Graduate Studies in Shalya Tantra Government Ayurvedic Medical College Bangalore - 560009

ENDORSEMENT BY HOD, PRINCIPAL / HEAD OF THE INSTITUTION. This is to certify that the dissertation entitled “A COMPREHENSIVE STUDY ON MARMA & ACUPUNCTURE POINTS AND EVALUATION OF THEIR THERAPEUTIC IMPORTANCE” is a bonafide research work done by Dr. Vivek.J in partial fulfilment of the requirement for the degree of “AYURVEDA DHANVANTARI” – MS (Ayurveda) in Shalya Tantra under the guidance of

Dr.Venkatesh.B.A, Prof., Dept of PG studies in Shalya Tantra. I recommend this dissertation for the above degree to the University for Assessment and approval.

Dr. B. A. Venkatesh Prof. & Head of the Department, Department of P.G. Studies in Shalya Tantra, G.A.M.C Bengaluru – 9.

Date: Place:

Principal G.A.M.C Bengaluru – 9.

Date: Place:

COPYRIGHT DECLARATION BY THE CANDIDATE I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore, shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for Academic or Research purpose.

Date: Place:

Signature of the Candidate (Dr.Vivek.J)

© Rajiv Gandhi University of Health Sciences, Karnataka.

ACKNOWLEDGEMENT

I offer my prayers at the lotus feet of Lord Dhanvantari without whose grace this dissertation work would not have taken shape No work is a result of individual effort. It is contributory effort of many hearts, hands and heads. It gives me immense pleasure to offer my sincere thanks to all those who have rendered their wholehearted support, guidance and Co-operation in completing my thesis work. I find short of word to express my deepest gratitude & heartfelt thanks to my Guru, Guide Dr.Venkatesh.B.A, Prof. & HOD, Dept. of P.G. studies in Shalya Tantra, G. A. M. C Bengaluru for his critical suggestions, expert guidance the support extended by him in providing all the amenities needed to complete my work in time. I am very much thankful to Prof. Dr. R. Vijayasarathi, Prof. Dr. Ahalya, and Asst. Prof. Dr. Shridhar M.S, Asst. Prof. Dr. Narmada for their kind co-operation, encouragement & suggestions for my study. I am also thankful to Dr. Mangalagi.S.G, MD (Ayu) Principal, Govt Ayurvedic Medical College, Bangalore, for their timely help during the period of my study. I am grateful to Dr.Harish Babu, Naturopathy Physician, SJIIM Hospital, B’lore, Mr.Hifzulla a well known Acupuncturist, practising in Jaynagar & Mr.Sadhashiv Datar, Laser Acupuncturist, Holistic Health Care Centre, Malleshwaram, B’lore,for their support and guidance in carrying out this work.

My deep sense of gratification is for my parents – Sarvamangala, Late. Y.R.Jagadeesha, brother – Sudharshan, sister in law Roopa, who are the architects of my career to reach up to here. The culture, discipline and perseverance, which I could imbibe, are solely because of their painstaking, upbringing and strong moral support. My sincere thanks to the lecturers Dr. Shivu Arakeri, Dr. Shrinivas Masalekar & Dr. Durgesh.I am highly indebted to Dr.K.Ravishankar, for analysing the data obtained during my work & making a final picture out of the same. In my moment of happiness I am totally indebted to my wife Dr.Kavitha.C who has patiently borne with me ever since I joined P.G. studies till date. I am thankful to my sister in law, brother in law & parents–in-law who have been a source of encouragement. At this point, it would be ungrateful if I do not recall my classmates Dr.Divya Lakshmi, Dr. Jayanth, Dr. Jayashri Prasad, Dr. Prashanth Shetty.G, Dr.Lakshman Shivalli, Dr. Manjunath Joshi & Dr.Lokanath Avdhani who have been egging me on throughout the study with their valuable inputs I am thankful to my seniors Dr.Rajeshwari, Dr.Sweta, Dr.Veena, Dr.Abhinetri Dr.Ramya, Dr.Nadaf & Dr.Vishwanath Sharma for their timely advice. I am thankful to Dr. Poornima, Dr.Nazira, Dr.Reshma, Dr.Aditya, Dr.Durdundi, and Dr.Sushendra & Dr.Ravishankar for their support.

I am thankful to the librarians and staff of U.G & P.G libraries for providing the necessary books for this work. Lastly I am thankful to one and all who have directly or indirectly helped me in completing my work.

Date: Place:

(Dr.Vivek.J)

ABSTRACT

Janu Sandhigata Vata or Osteoarthritis of the knee is a major cause of disability among adults. No cure for osteoarthritis currently exists. Treatment focuses on managing the pain and dysfunction associated with the disease. Acupuncture is an effective treatment for management of pain and physical dysfunction associated with osteoarthritis of the knee. Since Janusandhigata Vata manifests in Janu Marma, Suchi Vyadha (an art of introducing delicate fine Suchi into different sensitive points in and around janu marma with in the radius of 3 angula) is done to stimulate janu marma & in turn to stimulate sandhi avayava’s present in it. So that it helps in relieving the pain & promotes sandhi poshana & thus helps in early repair of dhatu kshayata & restores normal joint integrity. OBJECTIVES OF THE STUDY ¾ To review the literature on concepts of Marma & Traditional Chinese Acupuncture Points. ¾ An attempt to establish the relevance of Marma Sthana with that of Acupuncture Points. ¾ To evaluate the Therapeutic Effect of Suchivyadha Chikitsa on Janu Marma in Janu Sandhigata Vata (Osteoarthritis of the Knee Joint). ¾ To evaluate the Therapeutic Effect of Acupuncture in the management of Janu Sandhigata Vata (Osteoarthritis of the Knee Joint). STUDY DESIGN A total number of 40 patients were selected randomly for the present clinical study. These 40 patients were divided into 2 groups. Group A & Group B, each consisting of

20 patients. Patients of Group A were treated daily by Suchivyadha on Janumarma for 12 sessions & for about 30 minute duration. And patients of group B were treated daily by Acupuncture on Acupuncture points for 12 sessions & for about 30 minute duration.

The improvements in the Subjective Parameters and Objective parameters were assessed by scoring method. The subjective criteria were scored in accordance with Index of severity of Osteoarthritis of the Knee by Lequesne et al & WOMAC. (Western Ontario & Mc Master Universities). Tenderness, Crepitus, Range of movement of Knee, Time taken to walk 50 metres of distance & Radiological changes are taken as objective parameters.

In Group A out of 20 patients 8 patients (40%) showed marked improvement, 6 patients (30%) showed moderate improvement & 6 patients (30%) showed mild improvement. In Group B out of 20 patients 10 patients (50%) showed marked improvement, 8 patients (40%) showed moderate improvement & 2 patients (10%) showed mild improvement.

Key Words: Sandhigata Vata, Suchi Vyadha, Acupuncture.

LIST OF TABLES

Table No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Contents Showing Shaka Marmas Showing Udara(Koshta ) Marmas Showing Uro Marmas Showing Prishta Marmas Showing Jatrurdhwa Marmas Showing Description of Marmas According to vaghbhata Acharya Showing Marmas in controversy on the basis of classification Showing prognostic classifications of Marmas based upon Trigunas & Panchamahabhutas. Showing Acupuncture points and meridians Showing Number of Sandhis according to different texts Showing the sites of different Sandhis Showing the muscles producing movements of the Knee joint Showing the Aharaja Nidana Showing the Viharaja Nidana Showing the Manasika Nidana Showing Anya Nidana Showing the roopa of Sandhigata Vata according to different texts Showing causes of Joint pain in patients with OA Showing the Kellgren- Lawrence Radiographic Grading Scale Showing the Chikitsa sutra of Sandhigata Vata according to different texts Showing Subjective and objective parameter Showing the sex distribution in both the groups Showing overall response based on Sex of the patient Showing the age distribution in both the groups Showing overall response based on age group. Showing the occupation of Patients in both the groups Showing overall response based on Occupation Showing the religion of the patients in both the groups Showing overall response based on Religion Showing the socio-economic status of the patients in both the groups. Showing overall response based on Socio-economic Status Showing the chronicity of the disease in both the groups Showing overall response based on Chronicity Showing the diet of the patients in both the groups Showing overall response based on Diet

Page no. 12 14 14 15 18 21 23 24 33 59 60 65 67 68 69 70 74 76 78 85 108 114 114 115 116 116 117 117 118 118 119 119 120 121 121

36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80

Showing the family history in both the groups Showing overall response based on Family History Showing the area involved in both the groups Showing overall response based on Area Showing overall response for the treatment Showing the effect on Pain during nocturnal bed rest. Showing the effect of pain after getting up Showing the effect on standing for 30 min Showing the effect on walking Showing the effect on Morning stiffness Showing the effect stiffness later in day. Showing effect on swelling in joint Showing effect on Maximum distance walked. Showing effect on walking aid requirement. Showing effect on able to climb up stairs. Showing effect on able to climb down stairs. Showing effect on able to squat. Showing effect on able to walk on uneven. Showing effect on Getting in/ out of car. Showing effect on putting on/ off socks. Showing effect on tenderness. Showing effect on crepetus. Showing effect on Measurement of Rt knee. Showing effect on Measurement of Lt knee. Showing effect on Movement of Rt knee. Showing effect on Movement of Lt knee. Showing effect on time taken to walk 50m distance. Showing effect on Radiological changes. Showing effect on pain during nocturnal bed rest. Showing effect on pain after getting up. Showing effect on pain on standing for 30min. Showing effect on walking. Showing effect on morning stiffness. Showing effect on stiffness later in day. Showing effect on swelling in joint. Showing effect on Maximum distance walked. Showing effect on walking aid requirement. Showing effect on Able to climb up stairs. Showing effect on Able to climb down stairs. Showing effect on squat. Showing effect on walk on uneven Showing effect on getting in/ out of car. Showing effect on putting on/ off socks. Showing effect on Tenderness Showing effect on Crepetus.

122 122 123 123 124 125 125 126 126 126 127 127 127 128 128 129 129 130 130 130 131 131 131 132 132 132 133 133 133 134 134 134 135 135 135 136 136 137 137 137 138 138 138 139 139

81 82 83 84 85 86 87

Showing effect on Measurement of Rt knee. Showing effect on Measurement of Lt knee. Showing effect on Range of movement of Rt knee. Showing effect on range of movement of Lt knee. Showing effect on time taken to walk 50m distance. Showing effect on radiological changes Showing Results on Comparison of Group A and Group B

139 140 140 140 141 141 142

LIST OF GRAPHS

Graph

Page Title

No.

No.

1

Showing sex distribution in both the groups.

103

2

Showing age distribution in both the groups

104

3

Showing occupation of the patients in both the groups

105

4

Showing religion of patients in both the groups

106

5

Showing socio-economic status in both the groups

107

6

Showing chronicity of the disease in both the groups

108

7

Showing diet of the patients in both the groups

109

8

Showing family history of patients

110

9

130

10

Showing means of Pain after getting up, pain on walking and morning stiffness in Group A Showing the means of swelling, tenderness and crepitus in group A

130

11

Showing means of Pain after getting up, pain on walking in Group B

131

12

Showing means of morning stiffness and stiffness later in day in Group B 131

13

Showing means of swelling, tenderness and Crepitus in Group B

131

LIST OF FIGURES

Sl.

Contents

No

Page No.

1

Marma on Anterior Surface

13

2

Marma on Posterior Surface

16

3

Marmas of Axilla & Elbow

18

4

Marmas of Ventral Surface of

20

Foot 5

Meridians & Acupuncture Points

32

6

Meridians of Lower Limb

33

7

Lung Meridian

33

8

Stomach Channel

34

9

Twenty Gunas & Relationship

44

With Yin & Yang 10

Anterior View of Marma &

49

Acupuncture Point 11

Posterior View of Marma &

50

Acupuncture Point 12

Lateral View of Marma & Acupuncture Point

51

CONTENTS SL. NO

CHAPTER

PAGE NO.

1

INTRODUCTION

2

REVIEW OF LITERATURE

a)

MARMA REVIEW

4-24

b)

REVIEW OF ACUPUNTURE

25-37

c)

COMPARISION OF ACUPUNTURE & AYURVEDA

1-3

38-52

d)

DISEASE REVIEW

53-80

e)

PROCEDUREREVIEW

81-85

f)

REVIEW OF ACUPUNCTURE NEEDLE

86-93

3

MATERIALS AND METHODS

94-102

4

OBSERVATIONS AND RESULTS

103-131

5

DISCUSSION

132-141

6

CONCLUSION

142-143

7

SUMMARY

144-145

8

REFERENCES AND BIBLIOGRAPHY

146-149

9

ANNEXURE

---

ABBEREVIATIONS

Ad: Arunadatta

AH: Ashtanga Hridaya

Api: Ayurvedic Pharmacoepia of India Apte: Sanskrit English AS: Ashtanga Sangraha

Dictionary by Apte

AV. Atharva Veda BH: Bhela Samhita

BP: Bhavaprakasha

Bpn: Bhavaprakasha Nighantu

BR: Bhaishajya Ratnavali

CA: Charaka Samhita CD: Chakradatta

Ch: Chikitsa Sthana

Cha: Chaurasia, Human Anatomy

Cak: Chakrapani

Dal: Dalhana

DVD: Davidson’s Internal Medicine

Gay: Gayadasa

GS: Gheranda Samhita

gud. Var: Guduchyadi Varga

HA: Harita Samhita

HM: Harsh Mohan’s pathology

HAR: Harrison’s Internal Medicine

har.Var: Haritakyadi Varga

Hem: Hemadri

Ka: Kalpa Sthana

Khi: Khila Sthana

KS: Kashyapa Samhita

MN: Madhava Nidana

Nad: Nadkarni’s Indian Materia Medica Ni: Nidana Sthana OA: Osteoarthritis

P.K: Poorva Khanda

pg.no. Page Number

Par: Paribhasha Prakarana

SH: Sharangdhara Samhita

Sha: Shareera Sthana

Si: Siddhi Sthana

SKD: Shabda Kalpa Druma

SMW: Monnier Williams Dictionary

SU: Sushrutha Samhita

Su: Sutra Sthana

Va. Vya.: Vata Vyadhi Chikitsa

VC: Vachaspatyam

vol: Volume

YR: Yogaratnakara

WD: Webers Medical Dictionary

Introduction  

 SECTION 1 INTRODUCTION Marma is one of the unique & important topics discussed in Ayurveda. It plays an important role in surgery. Hence it is rightly called as Shalya Vishayardha. The Marma Chikitsa has evolved as a special branch of treatment extensively practiced in most parts of Kerala. Many of the basic concepts of Marma in Ayurveda & Acupuncture point in Chinese system of medicine have a close relevancy. We get many references of major surgeries being carried out by Sushrutha in our classics by administering sura or madira. But it seems that there was some kind of Bandha or Pressure being applied over Marma Sthana which is a seat of prana to create anaesthetic or analgesic effect for performing surgeries. In present days we see same kind of analgesic or anaesthetic effect being done by acupuncturists for performing some minor surgeries & to treat many of chronic ailments. If we go back to the Indian medical classics, known as the Vedas, said to be written about 7000 years ago, we find "needle therapy" [Suchi karma] mentioned there. One volume of the Vedas, known as the “Suchi Veda”, translated as the "art of piercing with a needle" was written about 3000 years ago and deals entirely with acupuncture. Unfortunately this text is not available today. During ancient period, bamboo or wooden Suchi – needles were used for acupuncture. Sushrutha has mentioned the art of acupuncture under Vyadhana or Bhedhana Karma (Bhedhana means to pierce or to cut). During ancient time needles made up of wood were used, later on various metal needles were used for this purpose. Sushruta in Sharira sthana 8

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.  

 

 1 

Introduction  

‘Siravyadha’ has advised puncturing the channels (sira) by using needles, which are as small as ‘vrihi’ (vrihi is the outer cover of the rice grain which is pointed at both ends. The Indians have the knowledge of both body acupuncture and ear acupuncture. Thus in India, an entire system of treating every type of disease by the ear alone was [also] developed! Some scholars believe that acupuncture probably evolved in prehistoric times out of the modifications of the principles of Ayurveda near the snowy bleaks of the Himalayas, where no herbs were available. ... In fact, this knowledge has already got passed to the nearby countries around India mainly during ‘Buddha’ period and got stored as in cold storage. It is not a coincidence that almost all Buddhist countries have this knowledge and it is the Indian fortune that the origin of this knowledge [of acupuncture] is from India (But rather unfortunate that not many people in India know this and appreciate this fact as we sure have a 'tradition' of forgetting our traditions! and sciences be it mantric or Vedic. So a comprehensive study on classical concept of Marma & Traditional Chinese Acupuncture Point is carried out to evaluate its role in inducing analgesic effect. In this present study Suchi Vyadha & Acupuncture on two different groups are done over patients suffering from Janu Sandhigata Vata (Osteo Arthritis of Knee) to evaluate its Analgesic effect. Though the concept of Marma is well described in our classics, its importance in therapeutic aspect (other than Viddha Lakshana) is neither mentioned nor used. (I.e. Marma Sthana is not used to cure disease or to relieve pain). They only say that, Marma Sthana, a very vital point, should not be injured & should be kept intact even while doing surgeries. In this present study, a first of its kind, an attempt is made to A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.  

 

 2 

Introduction  

manipulate or stimulate Marma Sthana to obtain desired therapeutic effect. In coming days this idea may form basis in curing innumerable disease just by manipulating or stimulating Marma Sthana, which is a seat of prana or life. OBJECTIVES OF THE STUDY ¾ To review the literature on concepts of Marma & Traditional Chinese Acupuncture Points. ¾ An attempt to establish the relevance of Marma Sthana with that of Acupuncture Points. ¾ To evaluate the Therapeutic Effect of Suchivyadha Chikitsa on Janu Marma in Janu Sandhigata Vata (Osteoarthritis of the Knee Joint). ¾ To evaluate the Therapeutic Effect of Acupuncture in the management of Janu Sandhigata Vata (Osteoarthritis of the Knee Joint).

HYPOTHESIS: ¾ H0: there is no difference in efficacy of group A and group B treatments. ¾ H1: there is difference in efficacy of group A and group B treatments.

PREVIOUS WORK DONE   A Clinical Study on Siravyadhana (Acupuncture) & role of Acupuncture in Tamaka Shwasa (Bronchial Asthma).By, Dr. Shinde.J in 1997 from Dept. of Shalya, Govt. College, Nagpur.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.  

 

 3 

Review of Marma  

MARMA REVIEW Marma is not a new term as far as Indians are Concerned. It figures from Atharva vedic times to recent literature. The references of Marmas are also seen in the independent Tamil Medical Textual. If we go through the Sanskrit Lexicans namely Vachaspathya, Shabdha Kalpadrumam etc. we can see that the word Marma is used in three different meanings. They are; 1. Swarupa 2. Tatwa 3. Jeevasthana

As far as Ayurvedic literature is concerned the term Marma is used as Jeevasthana.  

HISTORICAL VIEW18(p.1‐2)  Marma science is part of Vedic science. Naturally it has influenced all other sciences which we find in Vedas like Yoga, Ayurveda, Dance, Music, Mantra, Marital arts, Astrology, Philosophy, Siddha system of medicine and sexology. Therefore we must study its historical background. The development of this science took place from Saraswati culture to the time period of Charaka, Sushruta, Ashtang hridaya and Ashtang sangraha and later on Buddha religion was responsible for its spread in the neighbouring Countries like China and Japan.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

4   

Review of Marma  

Marma in War The origin can be traced to Saraswati Culture or Indus Valley Civilization. It is known from various excavations at Harrappa and Mohen-jo-daro that people in this culture were using various types of weapons in war. In Vedic period also people were using different weapons like axes, spears, daggers, maces, bows and arrows. These were made of copper or bronze. For defensive purpose they were using body shields. Knowledge of Marma exists from very ancient time of Vedas, which dates back 4000 BC. The fist reference is found in Rig-Veda .There is reference of words like Varman and drapi, which is some kind of body armor or corselet to protect the body from the assault of enemy weapons. In AtharvaVeda also we find the reference of the term kavacha or corselet or breast-plate for the protection. In Mahabharata the great epic also we find many reference for Marma or Varman. ( Karnaparva 19.31, Shalyaparva 32.63 and 36.64, Dronaparva 125.17, Bhishmaparva 95.47, Virataparva 31.12 and 15). It is interesting that there are references of protective clothings of the Marmas of elephants and horses also. Arthashastra of Kautilya mentions the use of arrowheads made up of metal and some protective instruments against the injury to marmas. Marma and Marital arts Ahimsa or non-violence was taught by this religion. Monks were not allowed to use weapons even for their self-protection. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

5   

Review of Marma  

Milindapanha text, which is a dialogue between King Milinda and Monk Nagasena, explains that unarmed self defense was taught as a part of 19 arts. This science was essential when Buddha religion started spreading beyond the boundaries of India into neighboring countries like China, Indonesia and Thailand etc. This art became effective and popular because the monks were able to protect themselves against weapons. In the Hohan province of China a special monastery was built to accommodate monks travelling from India to China. This was built around 300 AD and was called Shaolian Temple which later on became famous place for teaching martial arts based on marma – or vital parts described in Ayurveda. This art was kept as secret for centuries, as it was taught only to certain disciples. As the monks started travelling to various countries like Japan, Indochina etc. This art also spread to these countries. It is therefore very certain that the Traditional Chinese Medicine had adopted this science from Ayurveda. Hence we do come across with various references in marital art like Karate. Marma and Yoga From the excavations done at the site of Mohen-jo-daro, we find some interesting figures which shows that the concept of marma was applied for enriching the Yoga practice. Marma and Sex It is evident in Siddha system, that science of vital points has been used to increase the vigour, strength for enjoyment. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

6   

Review of Marma  

Marma and Astrology Siddha system also refers to certain vital points and the effects of phases of moon and other planets on the human body. Nirukti: The word Marma comes from Sanskrit origin ‘mru’ or ‘marr’.”Marayate iti marma”, the Sanskrit phrase means likelihood of death after infliction to these places hence they are called Marma. The word Marma used with meanings as tender, secret or vital places. Word Meaning: Tatwam

– Shabdakalpadruma (Sdk)

“Mru + Mannin – Marma” ‘Ma’ – prana vayu ‘Re’ – seat of prana Marma – “mring” (marane) - (A. hri. Ad Commentary)3 M.Monier Williams in his Sanskrit English dictionary gives ten meanings for Marma they are – •

Martial sport.

•

Vulnerable point.

•

Any open, exposed, weak or sensitive part of the body.

•

Joint of a limb, any joint or articulation.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

7   

Review of Marma  

•

Core of anything.

•

Any vital member or organ.

•

Anything which requires to be kept concealed.

•

Secret in quality.

•

Hidden meaning.

•

Any secret or mystery

Definitions of Marmas: There are several classical Ayurvedic definitions of Marmas. From these we can see that Marmas are related to the energies of the body, mind, Prana and doshas. They are key connecting points to all aspects of our energies from the inner most consciousness to the outermost physical organs. ¾

Marmas are the sites where muscle, veins, ligaments, bones and joints meet together, though all these structures need not be present at each Marma. This explains Marmas as important connection centers or crossroads in the physical body. 1 (vÉÉ 6/15, pg. no. 371 pp. 734)

¾

Marmas are sites where important nerves come together along with related structures like muscles and tendons, a similar definition to that of Charaka. He says that sites which are painful, tender and show abnormal pulsation should also be considered as Marma or vital points regardless of their anatomical structure1. (zÉÉ.6/18)

¾ They are the seats of ‘life’ or Prana, means that any sensitive point on the body is a potential Marma1.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

8   

Review of Marma  

¾ Marmas are places where the three doshas (Vata, Pitta and Kapha) are present along with their subtle forms as Prana, Tejas and Ojas and the three gunas of sattva, rajas and tamas. This means that Marmas control not only the outward from of the doshas,but their inward essences or master forms as well (Prana, Tejas and Ojas) and also the mind (satva)1. ¾ Marmas are said to be supportive pillars of life, as any trauma to them leads to death or deformity. Hence they are called “Jeevanadhara”2. ¾ Any trauma to Marma, results in death or miseries equal to death1. ( vÉÉ. 6/40, pg. no. 376 pp. 734). ¾ Sushruta has mentioned Marma, as the seat of Prana, Tridoshas and Triguna. Well-being and illness of the body depends upon homeostasis of Tridoshas. So any injury to Marma causes derangement of all this factors. Sequels depend on the specific factors involved. Any injury to Marma, result in psychosomatic disturbances.1 ¾ According to Sushruta 4 types of siras carrying Vata, Pitta, Kapha and Rakta take part in the formation of Marma sthana, apart from the anatomical structures1. Composition of Marmas: Marmas are classified according to their dominant physical constituents as muscle, vessel, ligament, joint, or bone – based regions. Mamsa Marmas are related to muscle – based structures like fascia, serous membranes, sheaths and muscles. Sira Marmas – related to various vessels or channels supplying energy or fluids to the body, particularly the blood and lymphatic vessels, Sushruta explains four types of these vessels. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Review of Marma  

•

Vatavaha Sira

•

Pittavaha Sira

•

Kaphavaha Sira

•

Raktavaha Sira

Channels carrying the doshas are more energetic than anatomical in ones basis and so anatomical correlations are only general. Sushruta notes that no single vessel carries Vata, Pitta or Kapha alone.

ƒ

Snayu Marmas – related to the tissues and structures that bind the bones and muscles and aponeuroses.

ƒ

Asti Marmas – related to bony tissue, can be classified into bones proper, cartilages, teeth and nails.

ƒ

Sandhi Marmas – related to the joints, are important sensitive regions on the body for both Prana and the doshas. Joints are classified into movable, partially movable and non – movable. These can be complex or large Marmas.

The knowledge of Marma has got wide implication in the many fields of medical practice, but as today its traditional practices are limited and scattered in India. The knowledge of Marma can be classified in following fields: –

In martial art and warfare, in surgical importance

–

in the management of disease and in the diagnosis of illness, in medical importance

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As a surgeon, Acharya Sushruta stressed the importance of Marmas in surgical practice and stated in any surgical procedure knowledge of Marmas is as essential as the knowledge of the nerves, muscles, bones and blood vessels. Size of Marmas and individual Finger Unit (Anguli pramana): Marmas are located and measured in size in terms of ‘Anguli pramana’ or the ‘finger unit’ of the respective individual. To determine this follow these instructions: ƒ

Join both open palms at ulnar (little finger) side.

ƒ

Measure the width of both palms at metacarpo - phalangial joints (base of the fingers).

ƒ

Divide this by 8 (as this width is average for 8 fingers).

ƒ

This is individual finger unit. There are 107 Marmas in the human body Marmas are classified according to

regional, structural, prognostic, dimensional and numerical criteria. Sushruta and Vagbhata have a surgical approach. Sushruta and Vagbhata have detailed about 37 Marmas in the Shiras, whereas Charaka consider it as a single unit. Considering the importance of Basthi, Hridaya and Shiras, Charaka has emphatically mentioned about these 3 Marmas in the

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‘Trimarmeeya adhyaya’. Table No. 01: Showing Shaka Marmas:

Marma

Sthana

Ashraya

Anatomical synonym

Parinama/Viddha Lakshana

Pra man a

Sank hya

Talahrudaya

In the middle of palmar or plantar aspect in line of the middle toe

Mamsa

Palmar aponeurosis

Kalanthara pranaharaDeath due to severe pain

½

4

Kshipra

In b/n the thumb & index finger or in b/n big toe & 1st toe

Snayu

1st intermeta-tarsal ligament

Kalanthara pranaharaDeath due to convulsions

½

4

Kurcha

Two angulas above the Kshipra

Snayu

Tarsometatarsal & Intertarsal ligament

Vaikalyakara-Inability to move & rotate the foot &hand

4

4

Kurchasira

Below the Gulpha Sandhi (Ankle Joint)

Snayu

Lateral ligament of ankle

Rujakara-Causes Shopha & Ruja

1

4

Gulpha

At the junction of foot & calf

Sandhi

Ankle joint

Rujakara-Causes pain, stiffness & inability to perform activities

2

2

Manibandha

At the Junction of hand & forearm

Sandhi

Wrist joint

Rujakara-Causes pain, stiffness & inability to perform activities

2

2

Indravasti

Between the Janghas

Mamsa

Cubital fossa

Kalanthara pranaharaDeath due to severe loss of blood

½

4

Janu

At the joint of Uru & Jangha

Sandhi

Knee joint

Vaikalyakara-Produces Lamness

3

2

Koorparam

At the junction of upper arm & forearm

Sandhi

Elbow joint

VaikalyakaraDistortion of arm

3

2

Ani

Three angulas above on either side of Janu & Koorpara

Snayu

Biceps tendon

Vaikalyakara-Increased swelling & stiffness

½

4

Urvi

In the middle of the thigh & arm

Sira

Femoral vessels

Vaikalyakara-Causes Emaciation of leg due to Haemorrhage

1

4

Lohitaksha

At the root of thigh above the Urvi below the angle of groin

Sira

Femoral vessels

Vaikalyakara-Paralysis of extremity due to haemorrhage

½

4

Vitapa

Between the Scrotum & Groin

Snayu

Inguinal canal

Vaikalyakara-Causes Impotency

1

2

Kaksha

Between the axilla & collar bone

Snayu

Axilla

VaikalyakaraDistortion of the Upper

1

2

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Review of Marma   Limb

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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FIG.1 MARMAS OF ANTERIOR SURFACE

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Table No. 02: Showing Udara(Koshta ?) Marmas: Marma

Sthana

Guda

Attached to sthoolantra which expels flatus & faeces Located inside the true pelvis with one orifice pointed downwards In b/n the large intestine & stomach. Which is the seat of all siras

Vasti

Nabi

Anatomical structure involved Mamsa Anal canal, anus

Asraya

Snayu

Urinary bladder

Sira

Umbilicus

Parinama or Viddha Lakshana

Pram ana

Sank hya

Sadhyo pranaharaCauses immediate death or death with in seven days Sadhyo pranaharaCauses immediate death or death with in seven days Sadhyo pranaharaCauses immediate death or death with in seven days

4

1

4

1

4

1

Table No.03: Showing Uro Marmas: Marma

Sthana

Asraya

Hridaya

In b/n the Sira breasts, in b/n the uras & kosta & at Amasaya Dwaram Sthanarohit Two angula Mamsa a above the breast Sthanamoo la

Anatomical structure involved Heart

Lower portion of pectoralis major muscle

Two angula below the breast

Sira

Internal mammary vessels

Apasthamb Parshwabhaga of a Uras

Sira

Two bronchi

Sira

Lateral thoracic and sub scapular vessels

Apalapa

Below the Amsakoota, in b/n the prista vamsa & uras

Parinama or Viddha Lakshana

Pram ana

Sank hya

Sadhyo pranaharaCauses immediate death or death within seven days

4

1

Kalanthara pranahara-Causes death due to Raktha poorna kosta Kalanthara pranahara-Causes death due to Kapha poorna kosta Kalanthara pranahara-Causes death due to Rakta poorna kosta Kalanthara pranahara-Injury creates Raktapoorna kosta & death due to Rakta poornakostata transforming to pooyakosta

½

2

2

2

½

2

½

2

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Review of Marma  

Table No. 04: Showing Prishta Marmas:  

Marma

Sthana

Asray a

Katikatharu On either side of na Prista Vamsa & located on Sronikarna (Ear like bones of pelvis & above the buttocks) Kukundara Both sides of Kadeepradesha a hollow situated on both sides of prista vamsa & in the region slightly below the waist. On either sides of the vertebral column, on two meeting places out side the buttocks Nithamba Above the sronikarna on both sides of prista vamsa

Asthi

Anatomical Parinama/ structure Viddha Lakshana involved Sciatic Kalanthara notch pranahara-Death occurs due to severe Raktha Kshaya(Pandu)

Pra man a ½

San khy a 2

Sandh i

Ischial tuberosity

VaikalyakaraCauses loss of movement & loss of sensation in the lower part of the body

½

2

Asthi

Ala of ilium

½

2

&

Sira

Common iliac vessels

½

2

Bruhathi

On either side of the Vertebral column & in straight line with sthanamoola marma

Sira

½

2

Amsaphala ka

On either side of the Vertebral column at the Bahumoola

Asthi

VaikalyakaraCauses Bahu Swapa & Bahu Shosha

½

2

Amsa

On either side of the neck

Snayu

Subscapular and transverse cervical arteries Spine of scapul a Coraco and gleno humeral ligament, trapezius muscle

Kalanthara pranahara-Injury causes Adhakaya Shopha, debility & death Kalanthara pranahara-Death due to Raktapoorna kosta Kalanthara pranahara-Death due to severe Rakta Kshaya

Vaikalyakara-Loss of function of Bahu

½

2

Parsvasand hi

In b/n Jaghana Parshwa

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FIG.2 MARMAS OF POSTERIOR SURFACE   A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Review of Marma    

Table No. 05: Showing Jatrurdhwa Marmas: Marma

Neela

Manya

Mathruka

Krukatika

Sthana

Asraya

On either side of the Kanda Nalee near Hanu Pradesha On both side of Kandanalee near Hanu Pradesha On both side of Kandanalee in relation to Jihwa & Nasa At the Shirogreeva Sandhi

Anatomical structure involved Blood vessels of neck

Vaikalyakara-Causes Swara Vaikritha

Sira

Blood vessels of neck

Vaikalyakara-Loss Rasagrahana Shakthi

Sira

Sandhi

Sira

Vidhura

Below the back of the Snayu ears

Phana

On both sides of Sira Grhanamarga At the outer angle of the Sira eye, at the tail end of the eye brows & below the eye brows In the depression above Sandhi the eye brow

Apanga

Avartha

Shankha Uthkshepa m

Adjoining the ears Asthi located as forehead Above the shankha Snayu marma at the lower border of kesha

Sthapani

In b/n the eye brows

Sira

Sringataka

On the samagama sthana Sira of Jihwa, Akshi, Nasika, Karna & Talu

Seemantha

Five sutures Kapalasthi

Adhipathi

Inside the head on the Sandhi sira Sandhi pradesha

of Sandhi

Parinama or Viddha Lakshana

Pram ana

San khya

4

2

of

4

2

Blood vessels of neck

Sadhyo pranahara-Causes immediate death

4

8

Atlantooccipital articulaion Olfactory region of nose Olfactory nerves Zygomatictemporal vessels

Vaikalyakara-Loss of stability of sira (Head)

½

2

Vaikalyakara-Loss Hearing

of

½

2

Vaikalyakara-Loss sensation of smell Vaikalyakara-Causes blindness

of

½

2

½

2

½

2

½

2

½

2

½

1

4

4

4

5

½

1

Junction of Vaikalyakara-Causes frontal, molar blindness and sphenoid Temples Sadhya pranahara-Causes Immediate Death Temporal Vishalyaghna-Person can muscle and live with the Shalya intact fascia or when it falls after paka. But the removal of Shalya causes immediate death Nasal arch of Visalyaghna the frontal -dovein Cavernous Sadhya Pranahara-Causes and immediate death intercavernou s sinuses Cranial Kalanthara pranaharasutures Death due to Brama,Unmada & Manonasha Bregma Sadhya pranahara-Causes immediate death

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Review of Marma  

FIG.3 MARMAS OF AXILLA & ELBOW

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Review of Marma  

Table No. 06: Showing Description of Marmas According to vaghbhata Acharya:  

San khya

Name of the group Mamsa Marma

10

Asthi Marma

08

Snayu Marma

23

Dhamanee

09

Marma Sira Marma

37

Sandhi Marma

20

Marmas included in this group

Viddha Lakshana

Indravasthy, Sthanarohitha

Thalahrith, Continuous bleeding,blood resembles the water in which meat has been washed & more over the blood is thin, pandu, loss function of sense organs, causes immediate death Kateekataruna, Nithamba, Discharge of clear fluid mixed with Amsaphalaka, Shankha majja & associated with intermittent pain Koorcha, Koorchasira, Kshipra, Ayama, Akshepaka, Sthamba, Ani, Vasthi, Amsa, Apanga, severe pain and inability to ride, sit Utkshepa etc, distortions or even death Guda, Apasthamba, Vithura, The blood which is frothy and Sringataka warm flows out with sound & person become unconsious Urvi, Lohithaksha, Vidapa, Blood which is thick flows out Kakshadhara, Nabhi, Hrith continuous & in large quantity, Sthanamoola, Apalapa, Neela, which leads to Trit, Bhrama, Manya, Mathruka, Phana, Shwasa, Moha, Hidhma & even Sthapani, Parshwa Sandhi, death Brihathi Gulpha, Janu, Manibandha, The site of injury feels as though Koorpara, Krikatika, Kukundara, full of thorns, even after healing of Avatha, Seemantha, Adipa the wound there is shortening of arm, lameness decrease of strength & movement, emaciation of body and swelling of the joint

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FIG.4 MARMAS OF VENTRAL SURFACE OF FOOT

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Review of Marma  

Table No. 07: Showing Marmas in controversy on the basis of classification:  

Name of Marma

According to Vagbhata

According to Sushrutha

Guda

Dhamanee Marma

Mamsa Marma

Kakshadhara

Sira Marma

Snayu Marma

Vidhura

Dhamanee Marma

Snayu Marma

Vitapa

Sira Marma

Snayu Marma

Sringataka

Dhamanee Marma

Sira Marma

Apasthambha

Dhamanee Marma

Sira Marma

Apanga

Snayu Marma

Sira Marma

Susruthacharya has given much importance to the prognostic classification and has explained it on the basis of Panchamahabhutas. Predominance of all the five constituents - Mamsa, Asthi, Snayu, Sira and Sandhi – makes it a Sadyapranahara Marma, absence of one of them or presence in less proportion will make it naturally belong to other kinds in respective order - Kalantarapranahara, Visalyaghnam, Vaikalyakara and Rujakara marma.

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Review of Marma  

Table No. 08: Showing prognostic classifications of Marmas based upon Trigunas & Panchamahabhutas.1

Prognostic classification

No

Sadyapranah ara

19

Marmas Included

Trigunas

Nabhi, Shanka, Rajas Adhipathi, Apana, Satva Hridaya, Sringataka, Mathruka & vasthi

Bhutas

&   Agni

Prognosis/Viddha Lakshana Immediate death within 7 days. When injured there will be sudden Depletion of Agni Guna

Kalantarapra nahara

33

Apasthamba, Talahrith, Parshwa Sandhi, Kateeka Taruna, Seemantha, Sthanamoola, Indravasthy, Kshipra, Apalapa, Brihathi, Nithamba, Sthana Rohita

Rajas & Thamas

Agni + Death within 14 days of Jala injury. When injured there will be sudden Depletion of Agni Guna followed by gradual depletion of somaguna

Visalyaghna

03

Utkshepa, Sthapani

Rajas

Vayu

Vaikalyakara

44

Phana, Apanga, Thamas Vidura, Neela, Manya, Krikatika, Amsa, Amsaphala, Avartha, Vitapa, Urvi Kukundara, Janu, Lohithaksha, Ani, Kakshadhara, Koorcha & Koorpara

Soma

Koorchasira, Gulpha Manibandha

Agni + Vayu

Rujakara

08

Rajo & bahulya

Vayu escapes when shalya is removed and result in death. Vayu, Mamsa, Vasa, Majja & Masthulunga gets dried up, shwasa, kasa develops & destroys the life of person Sthirathvam & shaithyam of soma guna result in pranavalambanam and results in deformity. After injury here Soma Guna supports Prana by sheeta & sthira gunas

Any injury results in pain (Agni is Ashukari & Vayu produces pain)

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Classification of Marmas according to their viddha laxanas1: Marmas are also classified according to five types relative to their degree of vulnerability. 9 Sadya Pranahara – immediate death causing 9 Kalantara Pranahara – long term death causing 9 Vishalyaghna – fatal if pierced 9 Vaikalyakara – disability causing 9 Rujakara – pain causing Marmaviddha Lakshana1: •

Deha prasupti - giddiness

•

Guruta – heaviness of body

•

Sammoha - delirium

•

Sheeta kaamita – longing for cold items

•

Sweda - excessive sweting

•

Moorcha - unconcious

•

Vamana - vomitting

•

Shwasa – dyspnoea

(vÉÉ 7/47, pg. no. 323 pp. 965)

Samprapthi of marmabhigata: Marma abighata Vata prakopa Causes severe ruja Severe injury causes either deformity or death. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Chikitsa:

ƒ

Lakshanika chikitsa according to marma viddha lakshanas.

ƒ

Vata vyadhi chikitsa

ƒ

Judicial selection of Shasti upakrama, for vranopachara.

 

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Acupuncture (from Latin ‘Acus’ means ‘Needle’ & ‘Pungere’ means ‘To Prick’) refers to a technique of inserting and manipulating fine filiform needles into specific points on the body with the aim of relieving pain and for the therapeutic purposes. According to traditional Chinese acupuncture theory, these acupuncture points lies along the Meridians, which ‘Qi’, the vital energy flows.The earliest written record of acupuncture is the Chinese text Shiji (史記, English: Records of the Grand Historian) with elaboration of its history in the second century BC medical text Huangdi Neijing (黃帝內經, English: Yellow Emperor's Inner Canon). Different variations of acupuncture are practiced and taught throughout the world.

History Antiquity Acupuncture's origins in China are uncertain. One explanation is that some soldiers wounded in battle by arrows were cured of chronic afflictions that were otherwise untreated, and there are variations on this idea. In China, the practice of acupuncture can perhaps be traced as far back as the Stone Age, with the Bian shi, or sharpened stones. In 1963 a bian stone was found in Duolun County, Inner Mongolia, China pushing the origins of acupuncture into the Neolithic age. There are evidences of needles made of fish bone and stone found in Korea, dating approximately to 3000 BC. Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600-1100 BC) which suggest that acupuncture was practiced along with moxibustion. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Despite improvements in metallurgy over centuries, it was not until the 2nd century BC during the Han Dynasty that stone and bone needles were replaced with metal. The earliest records of acupuncture is in the Shiji (史記, in English, Records of the Grand Historian) with references in later medical texts that are equivocal, but could be interpreted as discussing acupuncture. The earliest Chinese medical text to describe acupuncture is the Huangdi Neijing, the legendary Yellow Emperor's Classic of Internal Medicine (History of Acupuncture) which was compiled around 305–204 B.C.  

The Huangdi Neijing does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The Mawangdui texts, which also date from the second century BC (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion but not acupuncture. However, by the second century BC, acupuncture replaced moxibustion as the primary treatment of systemic conditions.

In Europe, examinations of the 5,000-year-old mummified body of Ötzi the Iceman have identified 15 groups of tattoos on his body, some of which are located on what are now seen as contemporary acupuncture points. This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in Eurasia during the early Bronze Age.

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Middle history Around ninety works on acupuncture were written in China between the Han Dynasty and the Song Dynasty, and the Emperor Renzong of Song, in 1023, ordered the production of a bronze statuette depicting the meridians and acupuncture points then in use. However, after the end of the Song Dynasty, acupuncture and its practitioners began to be seen as a technical rather than scholarly profession. It became rarer in the succeeding centuries, supplanted by medications and became associated with the less prestigious practices of shamanism, midwifery and moxibustion. Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West. Jacob de Bondt, a Danish surgeon travelling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners. The first European text on acupuncture was written by Willem ten Rhijne, a Dutch physician who studied the practice for two years in Japan. It consisted of an essay in a 1683 medical text on arthritis; Europeans were also at the time becoming more interested in moxibustion, which ten Rhijne also wrote about. In 1757 the physician Xu Daqun described the further decline of acupuncture, saying it was a lost art, with few experts to instruct; its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes. In 1822, an edict from the Chinese Emperor banned the practice and teaching of acupuncture within the Imperial Academy of Medicine outright, as unfit for practice

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by gentlemen-scholars. At this point, acupuncture was still cited in Europe with both skepticism and praise, with little study and only a small amount of experimentation.

Modern era In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party's dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying that "Chinese medicine and pharmacology is a great treasure house and efforts should be made to explore them and raise them to a higher level."

Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anaesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.

The greatest exposure in the West came when New York Times reporter James Reston, who accompanied Nixon during the visit, received acupuncture in China for post-operative pain after undergoing an emergency appendectomy under standard anaesthesia. Reston was so impressed with the pain relief he experienced from the procedure that he wrote about acupuncture in The New York Times upon returning to A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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the United States. In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.

Traditional theory

Needles being inserted into a patient's skin.

Traditional Chinese medicine Traditional Chinese medicine (TCM) is based on a pre-scientific paradigm of medicine that developed over several thousand years and involves concepts that have no counterpart within contemporary medicine. In TCM, the body is treated as a whole that is composed of several "systems of function" known as the zang-fu (脏腑). These systems are named after specific organs, though the systems and organs are not directly associated. The zang systems are associated with the solid, yin organs such as the liver while the fu systems are associated with the hollow yang organs such as the intestines. Health is explained as a state of balance between the yin and yang, with disease ascribed to either of these forces being unbalanced, blocked or stagnant. The yang force is the immaterial qi, a concept that is roughly translated as "vital energy". The yin counterpart is Blood, which is linked to but not identical with physical blood, and capitalized to distinguish the two. TCM uses a variety of A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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interventions, including pressure, heat and acupuncture applied to the body's acupuncture points (in Chinese 穴 or xue meaning "cavities") to modify the activity of the zang-fu. Table No. 09: Showing Acupuncture points and meridians:   Flow of qi through the meridians

Zang-fu

Aspect

Hours

Lung

taiyin

0300-0500

Large Intestine yangming 0500-0700 Stomach

yangming 0700-0900

Spleen

taiyin

0900-1100

Heart

shaoyin

1100–1300

Small Intestine taiyang

1300–1500

Bladder

taiyang

1500–1700

Kidney

shaoyin

1700–1900

Pericardium

jueyin

1900–2100

San Jiao

shaoyang 2100–2300

Gallbladder

shaoyang 2300-0100

Liver

jueyin

0100-0300

Lung (repeats cycle) Classical texts describe most of the main acupuncture points as existing on the twelve main and two of eight extra meridians (also referred to as mai) for a total of fourteen "channels" through which qi and Blood flow. Other points not on the fourteen channels are also needled. Local pain is treated by needling the tender "ashi" points where qi or Blood is believed to have stagnated.

The zang-fu of the twelve main channels are Lung, Large Intestine, Stomach, Spleen, Heart, Small Intestine, Bladder, Kidney, Pericardium, Gall Bladder, Liver and the intangible San Jiao. The eight other pathways, referred to collectively as the qi jing ba mai, include the Luo Vessels, Divergents, Sinew Channels, ren mai and du mai A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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though only the latter two (corresponding to the anterior and posterior sagittal plane of the torso respectively) are needled. The remaining six qi jing ba mai are manipulated by needling points on the twelve main meridians.

Normally qi is described as flowing through each channel in a continuous circuit. In addition, each channel has a specific aspect and occupies two hours of the "Chinese clock".

The zang-fu are divided into yin and yang channels, with three of each type located on each limb. Qi is believed to move in a circuit through the body, travelling both superficially and deeply. The external pathways correspond to the acupuncture points shown on an acupuncture chart while the deep pathways correspond to where a channel enters the bodily cavity related to each organ.

The three yin channels of the hand (Lung, Pericardium, and Heart) begin on the chest and travel along the inner surface of the arm to the hand. The three yang channels of the hand (Large Intestine, San Jiao, and Small Intestine) begin on the hand and travel along the outer surface of the arm to the head. The three yin channels of the foot (Spleen, Liver, and Kidney) begin on the foot and travel along the inner surface of the leg to the chest or flank.

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FIG.5 MERIDIANS & ACUPUNCTURE POINTS OF UPPER LIMB A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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FIG.6 MERIDIANS & ACUPUNCTURE POINTS OF LOWER LIMB

FIG.7 LUNG MERIDIAN

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The three yang channels of the foot (Stomach, Gallbladder, and Urinary Bladder) begin on the face, in the region of the eye, and travel down the body and along the outer surface of the leg to the foot. Each channel is also associated with a yin or yang aspect, either "absolute" (jue-), "lesser" (shao-), "greater" (tai-) or "brightness" (ming).

FIG.8 STOMACH CHANNEL

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A standard teaching text comments on the nature and relationship of meridians (or channels) and the Zang Fu organs:

The theory of the channels is interrelated with the theory of the Organs. Traditionally, the internal Organs have never been regarded as independent anatomical entities. Rather, attention has cantered upon the functional and pathological interrelationships between the channel network and the Organs. So close is this identification that each of the twelve traditional Primary channels bears the name of one or another of the vital Organs. In the clinic, the entire framework of diagnostics, therapeutics and point selection is based upon the theoretical framework of the channels. "It is because of the twelve Primary channels that people live, that disease is formed, that people are treated and disease arises." [(Spiritual Axis, chapter 12)]. From the beginning, however, we should recognize that, like other aspects of traditional medicine, channel theory reflects the limitations in the level of scientific development at the time of its formation, and is therefore tainted with the philosophical idealism and metaphysics of its day. That which has continuing clinical value needs to be reexamined through practice and research to determine its true nature.

The meridians are part of the controversy in the efforts to reconcile acupuncture with conventional medicine. The National Institutes of Health 1997 consensus development statement on acupuncture stated that acupuncture points, Qi, the meridian system and related theories play an important role in the use of acupuncture, but are difficult to relate to a contemporary understanding of the body. Chinese medicine forbade dissection, and as a result the understanding of how the body functioned was based on a system that related to the world around the body rather than its internal structures. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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The 365 "divisions" of the body were based on the number of days in a year, and the twelve meridians proposed in the TCM system are thought to be based on the twelve major rivers that run through China. However, these ancient traditions of Qi and meridians have no counterpart in modern studies of chemistry, biology and physics and to date scientists have been unable to find evidence that supports their existence.

Traditional diagnosis The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation. •

Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.

•

Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.

•

Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.

•

Palpation includes feeling the body for tender "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions Cun, Guan, Chi (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers).

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Other forms of acupuncture employ additional diagnostic techniques. In many forms of classical Chinese acupuncture, as well as Japanese acupuncture, palpation of the muscles and the hara (abdomen) are central to diagnosis.

Traditional Chinese medicine perspective Although TCM is based on the treatment of "patterns of disharmony" rather than biomedical diagnoses, practitioners familiar with both systems have commented on relationships between the two. A given TCM pattern of disharmony may be reflected in a certain range of biomedical diagnoses: thus, the pattern called Deficiency of Spleen Qi could manifest as chronic fatigue, diarrhea or uterine prolapse. Likewise, a population of patients with a given biomedical diagnosis may have varying TCM patterns. These observations are encapsulated in the TCM aphorism "One disease, many patterns; one pattern, many diseases". (Kaptchuk, 1982)

Classically, in clinical practice, acupuncture treatment is typically highly individualized and based on philosophical constructs as well as subjective and intuitive impressions, and not on controlled scientific research.

(WWW.Wikepedia.Com)

 

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Comparison of Ayurveda and Traditional Chinese Medicine Sankhya & TCM Comparison ` Unity ` A comparison of TCM and Sankhya philosophy reveals many inherent similarities. ` In both traditions, as well as in modern science, similar principles have emerged through the process of intuitive insight, observation of nature, developing hypotheses. ` At the heart of both traditions is a sense of cosmic unity as the source from which all creations arises. This termed Wu or Tao in TCM, and is comparable to two concepts in Sankhya philosophy: Avyakta (the unmanifest) and Purusha, the conscious principle that springs forth from Avyakta. These are eternal, unbounded in space and time, and are essence of oneness. They are without attributes and beyond name, form and differentiation.

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` Duality: ` In both TCM & Sankhya the first step of manifestation of the fundamental wholeness or unity is duality. ` In TCM the unity expresses as Yin and Yang, which arise together and are eternally and co-equally paired in every aspect of creation. Together they are the Supreme Ultimate, Tai Ji. Yin and Yang co-exist;one cannot exist without

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the other. They constitute a dynamic whole that is inter-transforming and inter-consuming. ` The Sankhya model is significantly different. While the fundamental wholeness, the un manifest Avyakta appears to differentiate as Purusha and Prakruti, Purusha is primary and Prakruti cannot exist without Purusha, while Purusha can exist without Prakruti. ` Another subtle difference is that, like yin in TCM, Prakruti is considered feminine, while Yang & Purusha are masculine; but yin is viewed as essentially passive. ` Like Yin & Yang, Purusha & Prakruti are dynamic but they are not intertransforming; that is they do not convert in to one another. ` Qualities: ` IN contrast to the duality model of Yin/Yang, Prakruti first expresses itself as three: the three gunas: Sattva, Rajas, Tamas. All of the creations are imbued with three qualities, which can be compared with the qualities and characteristics of Yin & Yang. ` Rajas have the active of Yang, while Sattva and Tamas possess the passive qualities of Yin. ` Sattva & rajas are yang in terms of being light while Tamas is Yin being darkness. ` Rajas is a bridge between sattva & Tamas, while there is no third entity between yin and yand which mediates between them. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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` While Sattva, Rajas, and Tamas are considered to be maha gunas, Ayurveda also recognizes twenty gunas (10 pairs of opposites) that are directly parallel to the commonly accepted qualities of Yin and Yang in TCM. ` E.g. Vata dosha is cold, light, mobile, clear, subtle, rough and dry> Pitta dosha is hot, sharp, light, liquid, oily, and spreading. Kapha dosha is heavy, dull, cold, dense, stable, cloudy, soft, gross, smooth and oily. ` Therefore, Vata and Pitta are predominantly yang in nature, while Kapha is yin.

FIG.9 GUNAS & THEIR RELATIONSHIP WITH YIN/YANG

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Qi and Prana: ` Qi and Prana are virtually equivalent. Both represent energy, the vital life force responsible for the animation of every organism and the life of everything in the universe. Without them, life cannot exist and death is inevitable. ` Qi is generated from the movement of unity into duality. ` Prana is the energy that flows through creation from Prakruti to Mahad to Buddhi, to Ahankara and lastly in to three gunas, in to the organic and inorganic universe.

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` Within the body, both flow through the subtle energy pathways termed meridians in TCM and Nadis in Ayurveda. ` Ayurveda considers prana not only as energy but also as the flow of intelligence and awareness. Prana also exists in conjunction ojas, and tejas forming a trinity within the microcosm of the body and universe. In the body prana is cellular awareness, tejas is cellular digestion and intelligence and ojas is equated with cellular immunity. ` The TCM equivalent is Qi (energy) corresponds to Prana, Shen (spirit) with tejas and Jing (essence) with ojas. They are called the three treasures. ` TCM also emphasizes the functional relationship of qi and blood. Qi is yang in nature and blood is yin. Blood is viewed as mother of qi because of its nourishing nature. Qi is called commander of blood, because it is thought to lead blood through the channels. ` In Ayurveda, blood is called rakta and it is intimately associated with prana in manner similar to qi and blood, traditionaly expressed as prana raktanu dhavati, prana moves with the blood.

The Five Elements: ` Essential to both TCM and Ayurveda are the five elements or organizing principles that support life when in balance and create disease when imbalanced.

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` The five elements do not overlap precisely. Fire, Earth and Water are common to both systems while the remaining two elements differ. Sankhya system includes Space & Air while TCM has Wood and Metal. ` The difference is not great as metal has many attributes similar to air and vata dosha and wood shares common attributes with fire and pitta dosha, because it carries the hidden potential of fire within. ` Space from the sankhya system does not have a direct correspondence in TCM but it is implied there as the space within which the other elements exist and interact. ` In TCM the elements nourish and regulate each other in a cyclical manner. ` In contrast, the Ayurvedic five elements arise from a linear, hierarchical progression where one element generates the next in natural order. ` Perhaps the greatest difference is the role the five elements play in each system. ` In TCM, the structural progression from Tao or Wu through Yin and Yang stops with the five elements. ` In Ayurveda, the five elements are not the end point, but from their combination emerge three doshas, the cornerstone of its conceptual framework. ` Thus In Ayurveda the five elements are not given the same importance as in TCM, as three doshas play more prominent role in Ayurveda. ` Space and Air form Vata dosha, Fire and Water form pitta dosha and water and Earth constitute kapha dosha. These three doshas are governing factors for diagnosis and treatment. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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` Just as the TCM five elements have a “controlling cycle” that maintains selfregulating balance, the three doshas continuously adjust and re-adjust to maintain equilibrium. ` In both systems, when an element or dosha becomes excessive or deficient, balance is disrupted leading to specific symptomatology and pathology.

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Individual Constitution: ` De is the Chinese term for individual constitution, which is typically expressed in terms of five elements. A person may be predominantly fire, manifesting as energetic, robust, hot tempered, while a person with predominantly earth will be good natured, jovial, grounded, stable and possibly stubborn. ` These constitutional types are discussed in modern interpretations of TCM but are not mentioned in the ancient texts. ` In Ayurveda, an individual’s constitution is predominantly vata, pitta, kapha or combination of three doshas. ` In Ayurveda, the prakruti is considered to have, in addition to basic physical, doshic combination, a karmic and genetic component and a mental component ` In addition vikruti also plays an important part in individual’s unique composition. ` In TCM, health is the balance of yin and yang in the body. From energetic view point, health is an abundance of qi that flows smoothly throughout the network of meridians and related organs. Reflecting the intricate relation of microcosm and macrocosm, health is viewed as harmony between the inner and outer world, and between the individual and nature. ` Disease is disruption of balance between yin, yang and qi ` When doshas, dhatus and malas are in proper functional relationship, along with a balance on the cellular level of ojas, tejas and prana, there is perfect A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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balance of body, senses, mind and consciousness, resulting in clarity, happiness, joy, peace and love. ` Disease or at least less than perfect health arises when this balance is not maintained or disturbed due to external forces.

Comparison between Nadis & Meridians ` Both nadis and meridians are subtle, refined pathways of intelligence and energy, while srotasmi are more physical and functional entities. ` Nadis and meridians form an interconnected network;srotamsi do not. ` Meridians are classified according to location and function, while the nadis are not. ` Meridians are accessible on the exterior surface of the body, while nadis and srotasmi are internal pathways that do not surface, though they can be influenced from the surface by such means as electrical stimulation, Laser, or accupressure. ` Unlike meridians, nadis and srotamsi cannot be mapped on the exterior surface of the body. ` Interestingly both systems recognize 14 major channels. ` Meridians are closely linked to their associated organs, while srotamsi are more closely related to tissues and functions. ` Meridians are delineated by accupoints that trace the flow of energy in a continuum from the first point on the meridian to the last. The energy flows in sequence from first meridian to the last and the cycle continues. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Typical similarities between Acupuncture points and Marma Marmas are also called as Adankals, pressure-points, reflex points, and vital points. Marmas are hundreds of areas on the surface of the body that nadis (pranic channels, carriers of prana or bio-energy) join to organs and nonadjacent areas. Marma points are important pressure points on the body, much like the acupuncture points of Traditional. One finds the first reference to them in the Atharva Veda and they are elaborately dealt with by Sushruta. Like the Chinese acupuncture points, Marma points are measured by the finger units (Anguli) relative to each individual. Their size is measured by finger inches and their location determined by them." Siravedhana” (Acupuncture) and Marma Chikitsa (Acupressure) were very prevalent and highly accepted therapies during RgVeda and AtharvaVeda and flourished during Samhita period. It is amazing to read the details of treatment which Sushruta described in the Sushruta Samhita...Chinese literature of Acupuncture when decoded answers to it. In fact 24 channels (meridians) of Chinese Acupuncture are nothing else than Sushruta’s 24 Dhamanis while points on channels are 700 Siras of Sushruta...

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Comparison of TCM & Ayurveda  

FIG.10.Anterior View Of Marma & Acupuncture Point

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Fig.11 Posterior View of Marma & Acupuncture Points.

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Comparison of TCM & Ayurveda  

Fig.12 Lateral View of Marma & Acupuncture Points

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Conclusion ` In conclusion, Ayurveda and TCM show striking similarities in philosophy, inclusion of five element model, related concept of both health and disease. Both reflect a holistic approach involving mind, body and spirit. Despite their differences, each system presents an integral philosophical and medical model clearly demonstrating the connection between health’s and living in balance, in harmony with nature. ` Most notably both traditions utilize the energy points as doorways to maintain health and harmony. ` Marma is both structural & functional unit, where as acupuncture point is only functional. ` In one Marma Sthana there may be more than 2 or 3 acupuncture points of different meridian.

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Disease Review

Janu Sandhigata Vata Janu: Utpatti: The word Janu is derived from root “jan”4(p.451) means knee Nirukti: “F eÉÇbÉrÉÉåÈ qɱ pÉÉaÉÈ”4(p.531) means that which joins the Uru and Jangha is known as Janu The word “Sandhigata Vata” comprises of three words, viz. Sandhi, Gata and Vata. Sandhi - Sandhi is a word of masculine gender. Sandhi is derived from root “dha” which when prefixed by “sam” and suffixed by “ki” gives rise to word Sandhi4(p.240). Dictionary meaning: Union, junction, combination, a joint. Gata - Gata word exists in all the three genders and it is derived from “Gam” dhathu and “Ktin” pratyaya. “aÉdcÉÌiÉ eÉlÉÉÌiÉ rÉiÉåÌiÉ uÉÉ”4(p.298)

- That which has went or

reached. Vata : - Vata is a word of masculine gender. The word is coined from “Vaa” dhathu and “Ktin” pratyaya. Vata is derived from “uÉÉ aÉÌiÉ aÉlkÉlÉrÉÉåÈ”4(p.325) i.e. gamanamovement, to move and gandhana – pressure. Meaning: Vata means wind/air, one of the three humours of the body. Thus, collectively the Janu Sandhigatavata means the disease resulting from the settling of vitiated Vata dosha in Janu Sandhi (Knee joint). The word “Osteoarthritis” is a combination of three words. Osteon”, “arthron” and “itis” respectively means bone, joint and inflammation. The word mening is “inflammation to the bony joint”.

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Sandhigata Vata Sandhigata Vata is one among the Vata vyadhis which is described as a separate clinical entity. It falls under various gatavata vyadhis caused by localization of kupita Vata dosha in the asthi sandhis. HISTORICAL REVIEW OF SANDHIGATA VATA: VEDIC PERIOD: Earliest available record regarding the disease and its treatment is in Vedas. In Atharva Veda 6th chapter we can find a quotation which describes a disease of sandhis “Destroy every balasa, which is seated in the limbs and in the joints, the in-dwelling one, which loosens the bones and the joints and afflicts the heart”. A.v.6/14/1 SAMHITA PERIODS: Charaka Samhita: Description of Sandhigata Vata as a separate clinical entity is available in Vata vyadhi Chikista Adhyaya of Chikitsa Sthana. However Charaka has not mentioned any specific line of treatment for this condition.2(chi.ch.28.sl37) Sushrutha samhita: Signs and symptoms have beeen described in Nidana sthana and separate line of Chikitsa has been explained in Chikitsa sthana.1(ni.ch.1.sl.28) Harita Samhita: Though no separate description of the disease is available line of treatment has been explained under Vata Vyadhi Chikitsa.

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Disease Review

Ashtanga Sangraha and Ashtanga Hridaya: Both the books have followed Charaka while describing the lakshana of Sandhigata

Vata

and

Sushruta’s

version

while

describing

the

chikitsa

aspect.3(ni.ch.15.sl.12) Madhava Nidana: Signs and symptoms have been explained under Vatavyadhi chikitsa and for the first time he has added Atopa as a symptom.10(ni.ch.22.sl.21) Chakradatta and Bhaishajya Ratnavali: Both these books have explained the line of treatment under Vata vyadhi chikitsa which is akin to Sushruta’s description.5(ch.22.sl.9) Bhavaprakasha and Yogaratnakara: The description is same as in Sushrutha Samhita, both in Nidana as well as chikitsa aspects.7(ch.23.sl.258-259) Sandhi Shareera: Here an attempt has been made to collect all the scattered references pertaining to functional anatomy of Sandhis as described in Ayurvedic literatures under various circumstances. Dalhana commenting on sandhis opines it as “Asthi sandhi”1(sha.ch.5.sl.28) Table.No.10: Showing Number of Sandhis according to different texts: Text Name

CA.

SU.

A.S.

A.H.

KS.

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Disease Review

No. of Sandhis

200

210

210

210

381

Classification of Sandhis:1(sha.ch.5.sl.24.p.366) Based on mobility Sushrutha has classified Sandhis broadly into 9 Chestavanta Sandhi 9 Sthira Sandhi The sandhis in shakha, hanu and kati are included under Chestavanta Sandhis, which may be alpa chesta or bahu chesta; the remaining Sandhis are included under Sthira Sandhis. Table No: 11 showing the sites of different Sandhis1(sha.ch.5.sl.27) Sl.

1

2

3

Name Sandhis

of Type and site

These are freely movable joints, Kora anguli (interphalangeal joints), (resembles a bud) manibandha (wrist), gulpha (ankle), janu (knee) and kurpara {Hinge joint} (elbow) come under this variety This type of sandhi performs wide range of actions (bahu Ulukhala chesta), seen in kaksha (shoulder), vankshana (Ball and socket ) ( hip) and danta (alveolar sockets and teeth) This variety has only slight movements (alpa chesta), Amsapeetha (sternoclavicular), Samudga (lid and box Guda (sacrococcygeal), Shape) bhaga (symphysis pubis) and nitamba (lumbosacral)

4

Pratara (floating)

This type of joint is formed by bones having symmetrical surface.These joints are slightly movable, Greeva and prishta sandhis (intervertebral joints) come under this variety

5

Tunnasevani (sutural joints)

In this variety the connection between the bone and the joint is in zigzag fashion. It is seen in Shira, kati & kapala. This is included under sthira type of joints

6

Vayasatunda

It resembles beak of crow. Hanusandhi is an example for this type of joint

7

Mandala (rounded)

It is circular in shape and made up of Tarunastis. Kantha (tracheal rings) comes under this type of joint

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Disease Review

8

Sankhaavarta (Conch shaped)

Present in Shrothra (cochlea )

Mere union of two or more Asthis is not sufficient to form a Sandhi. It requires other sturcures like Snayu, Kandara, pesi etc which connect the Asthis to one another and give strength to the Sandhi. Asthi: Asthi is the main component of a Sandhi. Dharana is the prime function of Asthi.1(su.ch.11.sl.4). Asthi is the ashraya dhatu for Vata dosha, as a rule the vriddha dosha causes vriddhi of the ashraya dhatu, unlike others Vata vruddhi causes Asthi kshaya and Vata kshaya causes Asthi vriddhi.1(su.ch.11.sl.26-28) Vyana Vata: - Vyana Vata is responsible for all types of motor functions, namely prasarana, akunchana, vinamana, unnamana and tiryag. It resides in all types of Sandhis and hridaya and is responsible for movement of rasa etc dhatus.1(ni.ch.1.sl.13) Janu sandhi is kora variety of Sandhi. It is made up of ¾ 1 Janu kapalikasthi (kapala type of asthi) upper part of 2 Janghasthis ¾ lower part of 1 Urunalakasthi

Snayu and Kandara: Snayus are the structures which bind the Asthi, Mamsa and Medas together. Pratanani variety of Snayu is present in Sandhis and the large numbers of Snayus which bind sandhis tightly are responsible for bearing the body weight. There are 10 Snayus in Janu sandhi. Kandara is a varity of Snayu which is round or cylindrical in shape. It is responsible for prasarana and akunchana of bodily parts.

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Shleshmadhara kala:

Kala is a structure located in between dhatu and ashaya.

Kala contains kleda and it is described as dhatu rasa vishesha by Vagbhata. Sleshmadhara kala is fourth Kala which resides in all the joints. Joints function properly by the support of kapha as wheel moves on well by lubricating the axis. It is responsible for proper alignment and movements of all joints. Shleshaka kapha: Shleshaka kapha is situated in all sandhis. It binds the joints firmly, protects their articulaton and opposes their seperation and disunion. Peshi: Peshi imparts strength to the different structures of the body like Sira, Snayu, Asthi parva and Sandhis by enveloping them. Five Peshsi are present in janu sandhi. Siras and Dhamanis: The Kaphavaha siras carrying prakrita Kapha, maintains the sandhi, ensures its sthirata, increases its bala etc. One of the functions of Vatavaha siras is pancha cheshta such as Prasarna, Akunchana etc. the Raktavaha siras does dhatu purana brings about sthirata and does poshana. Asthi is one of the dhatus; hence these functions are applicable for Asthi dhatu poshana also. The Sparshavaha dhamanis are spread in the upward direction and these have the function of carrying the sparsha jnana. The sparsha may be sukhakara or dukhakara. Janu Sandhi is considered as a Sandhi marma and grouped under Vaikalyakara marma, injuries to this leads to khanjata (limping). Measurement of Janu: Lenghth 3 angulas and circumference 16 angulas Knee Joint The knee joint is the largest and the most complex joint of the body. The complexity is the result of fusion of three joints in one. It is formed by fusion of the A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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lateral femorotibial, medial femorotibial, and femoropatellar joints. It is a compound synovial joint, incorporating two condylar joints between the condyles of the femur and tibia, and one saddle joint between the femur and the patella. Articular surfaces: The knee joint is formed by (1) The condyles of the femur, (2) The condyles of tibia; and (3) The patella. The femoral condyles articulate with the tibial condyles below and behind, and with the patella in front. Fibrous (Articular) capsule: The fibrous capsule is very thin, and is deficient anteriorly, where it is replaced by the quadriceps femoris, the patella and the ligamentum patellae. Ligaments: The knee joint is supported by seven ligaments. They are (1) Ligamentum Patellae, (2) Tibial Collateral Ligament, (3) Fibular Collateral Ligament, (4) Oblique Popliteal ligament, (5) Arcuate Popliteal Ligament, (6) Anterior Cruciate Ligament, (7) Posterior Cruciate Ligament. Menisci (Semilunar Cartilage): The menisci are two fibrocartilaginous discs. They are shaped like crescents. They are (1) Medial meniscus, (2) Lateral meniscus. Functions of Menisci: (1) They help to make the articular surfaces more congregate. (2) The menisci serve as shock absorbers. (3) They help to lubricate the joint cavity

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(4) Because of their nerve supply; they also have a sensory function. They give rise to proprioceptive impulses.

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Table No. 12 showing the muscles producing movements of the Knee joint

Sl. No.

1

Movement

Flexion

Principle

Accessory

Muscles

Muscles

Biceps Semitendinosus

femoris, Gracilis, Sartorius

Semimembranosus

Popliteus, Gastrocnemius

Quadriceps femoris

Tensor fascia latae

2

Extension

3

Medial Popliteus, Semitendinosus rotation of Semimembranosus flexed leg

4

Lateral rotation of Biceps femoris flexed leg

Sartorius, Gracilis

Blood Supply: ¾ Five genicular branches of the popliteal artery. ¾ The descending genicular branch of the femoral artery. ¾ The descending branch of the lateral circumflex femoral artery. ¾ Recurrent branches of the anterior tibial artery. ¾ The circumflex fibular branch of the post-tibial artery. Nerve Supply: Femoral nerve: - Through its branches to the vasti, especially the vastus medialis. Sciatic nerve: - Through the genicular branches of the tibial and common peronial Nerve. Obturator nerve:-Through its posterior division

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Synovial fluid: The surfaces of articular cartilage are separated by a space filled with synovial fluid, a viscous liquid that lubricates the joint. Synovial fluid is as ultra filtrate of plasma into which synovial cells secrete hyaluronan and proteoglycans. NIDANA

Nidana can be classified under various headings with different views. Among them one classification is Sannikrishta and Viprakrishta Karana. Here, with the complimentary references the Nidanas of Sandhigatavata is classified on this basis.

Sannikrishta

Hetu:

Ativyayama,

Abhighata,

Marmaghata,

Bharaharana,

Sheeghrayana, Pradhavana, Atisankshobha.

Viprakrushta Hetu: ™ Rasa – Kashaya, Katu, Tikta ™ Guna – Rooksha, Sheeta, Laghu ™ Dravya – Mudga, Koradusha, Nivara, Shyamaka, Uddalaka, Masura, Kalaya,

Adaki, Harenu, Shushkashaka, Vallura, Varaka. ™ Aharakrama – Alpahara, Vishamashana, Adhyashana, Pramitashana ™ Manasika – Chinta, Shoka, Krodha, Bhaya ™ Viharaja – Atijagarana, Vishamopacara, Ativyavaya, Shrama, Divaswapna,

Vegasandharana, Atyucchabhashana, Dhatu Kshaya.

The nidanas of Vatavyadhi/ Vata prakopaka karanas are listed under the following headings 1. Aharaja, 2.Viharaja, 3.Manasika, 4.Anya. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No. 13 showing the Aharaja Nidana:

Sl.

Nidana

CA SU AS AH MN BP YR

1

Rooksha Bhojana

+

+

+

+

+

+

+

2

Laghu Bhojana

+

+

+

-

+

+

+

3

Sheetanna

+

+

+

-

+

-

+

4

Alpa Bhojana

+

-

-

+

+

-

+

5

Abhojana

+

+

-

-

+

+

+

6

Pramita Bhojana

-

-

+

+

-

-

-

7

Vishama Bhojana

-

+

-

-

-

-

-

8

Ama

+

-

-

-

+

+

+

9

Adhyashana

-

+

-

-

-

-

-

10

Vishtambhi Ahara

-

-

+

-

-

-

-

11

Viruddha Ahara

-

-

+

-

-

-

-

12

Shushka shaka

-

+

-

-

-

-

-

13

Trushitashana

-

-

+

-

-

-

-

14

Kshudhitambupana

-

-

+

-

-

-

-

15

Tikta-Katu-Kashaya rasa

-

+

+

+

-

+

-

-

+

-

-

-

-

-

-

-

+

-

-

-

-

No

Vallura-varaka-uddalaka-koradusha16

shyamaka-nivara-mudga-masuraadhaki-harenu-kalaya-nishpava Katruna-dhanya-kalaya-chanaka-

17

karira-tumba-kalinga-chirbhita-bisashaluka-jambu-tinduka

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Table No. 14 showing the Viharaja Nidana:

Sl. No Nidana

CA SU AS AH MN BP YR

1

Ati vyayama

+

+

+

+

+

+

+

2

Ati prajagara

+

+

+

+

+

+

+

3

Atyadhva

+

+

+

-

+

-

+

4

Ati vyavaya

+

+

+

+

+

+

+

5

Gaja-ashva-ushtra-sheeghrayana +

+

+

-

+

-

+

6

Vegadharana

+

+

+

+

+

+

+

7

Abhighata

+

+

+

-

+

+

+

8

Dukha shayya

+

-

-

-

+

-

+

9

Dukha asana

+

-

-

-

+

-

+

10

Plavana

+

+

-

-

+

-

+

11

Prapatana

+

+

-

-

+

-

+

12

Pradhavana

-

+

-

-

-

-

-

13

Bharaharana

-

+

-

-

-

-

-

14

Vega udheerana

-

-

+

+

-

-

-

15

Atyuccha bhashana

-

-

-

+

-

-

-

16

Prapeedana

-

+

-

-

-

-

-

17

Pratarana

-

+

-

+

-

-

-

18

Divaswapna

+

-

-

-

+

-

+

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Manasika Nidana: Psychological factors like Chinta, Shoka, Bhaya, Krodha etc are the aggravating factors of Vata. As Vata is the controller of the manas, any affliction to Manas disturbes the Vata dosha.

Table No. 15 showing the Manasika Nidana Sl. No

Nidana

CA

SU

AS

AH

MN

BP

YR

1

Chinta

+

-

-

+

+

+

+

2

Shoka

+

-

+

+

+

+

+

3

Bhaya

+

-

+

-

+

+

+

4

Krodha

+

-

-

-

+

-

+

Anya Nidana: Panchakarma apacharas like Atidoshasravana, Atiraktamokshana, Atiyoga

of

langhana,

Apatamsana

etc

and

Dhatukshayakarabhavas

like

Rogakarshana, Gadakrita atimamsakshaya etc vitiate Vata. Dhatukshaya is an important vitiating factor of Vata dosha. Table No. 16 showing Anya Nidana:1(su.ch.1.sl.12) 1 Vishama upachara

+

-

-

-

+

-

+

2 Kriyatiyoga

-

-

+

+

+

-

-

3 Ati asruka mokshana

+

-

-

-

+

+

+

Sthoulya is another causative factor for Vata prakopa. The Medaavarana of Vata is the mechanism causing inter-relationship between Sthoulya and vata vyadhis. All types of avaranas are also important vitiating factors of Vata. Vardhakya avastha is dominate by Vata, during this period, Dhatukshaya occurs which causes Vata prakopa.

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Living in Jangaladesha is another cause of Vata prakopa.1(su.ch.1.sl.22) Vata gets vitiated in the end of day and night. Vata prakriti persons are more susceptible to Vata vikaras. Persons who are Rooksha-kashaya-katu-tikta satmya are also more susceptible to Vata vikaras. OSTEOARTHRITIS EPIDEMOLOGY AND RISK FACTORS: 13(p.2036)

Osteoarthritis is the most common joint disease of humans. Among elderly, knee OA is the leading cause of chronic disability in developed countries. ƒ

Age and Sex: Age is the most powerful risk factor for OA. Women are at high risk than men in developing OA. Radiographic evidence of knee OA, and especially symptomatic knee OA, is more common in woman than in men. In a radiographic survey of women <45 years, only 2% had OA; between the ages of 45 and 64 years, however, the prevalence was 30%, and for those > 65 years it was 68%. In males, the figures were similar, but somewhat lower, in the older age groups.

ƒ

Hereditory Factor: The relation of heredity to OA is less ambiguous. Thus, the mother and sister of a woman with distal interphalageal (DIP) jointa OA (Heberden’s nodes) are, respectively, two to three times as likely to exhibit OA in these joints as the mother and sister of unaffected woman.

ƒ

Race Factor: Racial difference exists in both the prevalence of OA and the pattern of joint involvement. OA is more frequent in Native Americans than in whites. The Chinese in Hong Kong have a lower incidence of hip OA than

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in whites. Interphalangeal joint OA and especially hip OA are much less common in South African blacks than in whites in the same population. Whether these differences are genetic or due to differences in joint usage related to life style or occupation is unknown. ƒ

Trauma: Major trauma and repetitive joint use are important risk factors for OA. Anterior Cruciate ligament insufficiency or meniscus damage may lead to knee OA. Although damage to the articular cartilage may occur at the time of injury or subsequently, with use of affected joint, even normal cartilage will degenerate if the joint is unstable.

ƒ

Occupation: Men whose jobs required knee bending and at least moderate physical demands had a higher rate of radiographic evidence of knee OA, and more severe radiographic changes, than men whose jobs required neither.

ƒ

Obesity: Obesity is risk factor for both knee OA and hand OA. For those in the highest quintile for body mass index at base line examination, the relative risk for developing knee OA in the ensuing 36 years was 1.5 for men and 2.1 for women. For severe knee OA, the relative risk rose to 1.9 for men and 3.9 for women, suggesting that obesity plays an even larger role in the etiology of the most serious cases of knee OA.

OA is classified as primary and secondary based on causes. Primary OA is the term used when the disorder arises from unknown or hereditary causes. Secondary OA describes cases in which direct causes for the disorder are known. Classification based on causes.13(p.2037)

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A) Localised OA (Hands, Knee, Hip, Spine), and other single sites, e.g. glenohumoral, acromioclavicular, tibiotalar, sacroiliac, temporomandibular. B) Generalized which includes 3 or more of the areas listed above.

II. Secondary: 1) Trauma: a) Acute, b) Chronic (occupational, sports) 2) Congenital or developmental: (Congenital hip dislocation, slipped epiphysis, Valgus/varus deformity, epiphysial dysplacia etc.) 3) Metabolic: Ochronosis, Hemochromatosis, Wilson’s disease, Gauchres’ disease 4) Endocrine: Acromegaly, Hyperthyroidism, Diabetic mellitus, Obesity, Hypothyroidism 5) Neuropathic: Charcot joints 6) Calcium deposit diseases: Calcium phosphate dehydrate deposition POORVA ROOPA: Avyakta or alpa lakshanas manifesting before the disease is considered as poorva roopa In Vata vyadhi1(ni.ch.1). So symptoms such as mild shula, shotha etc manifesting prior to the rupa can be considered as poorvaroopa in Sandhigata Vata. ROOPA Tabel No. 17: showing the roopa of Sandhigata Vata according to different texts: Sl.

Roopa/Lakshana

C.S. S.S. A.S. A.H. M.N B.P Y.R

1

Shula

-

+

-

-

+

+

+

2

Vata poorna druti sparsha

+

-

+

+

-

-

-

3

Shopha

-

+

-

-

-

+

+

+

-

+

+

-

-

-

No.

4

Prasarana Akunchanayoho savedana pravrutti

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5

Hanti sandhin

-

+

-

-

+

+

+

6

Atopa

-

-

-

-

+

-

-

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•

SHULA: Prakupita Vata dosha is responsible for all types of shula and there cannot be any shula without the involvement of Vata. Asthi toda (breaking or tearing type of pain) is one of the main symptoms of Asthi kshaya.

•

SHOTHA/ SHOPHA: Except Madhavakara all other acharyas have described shotha/shopha as one of the main feature of Sandhigata Vata. Charaka has explained that the shotha seen in Sandhigata Vata resembles an air filled bag; this opinion is accepted by both the Vagbhatas. Though Sushruta has explained Shopha as one of the features of Sandhigata Vata unlike Charaka he has not specified the type of Shopha.

•

PRASARANA AKUNCHANAYOHO SAVEDANA PRAVRUTTI: It means painful joint movements. It can be felt as difficulty in normal joint movement or the pain felt on initial movements after long period of inactivity can be compared to this which is due to the stambha or stiffness caused due to inactivity.

•

HANTI SANDHIN: This can be compared to restricted joint movement and it was first explained by Sushrutha. Different commentators have explained this as follows:a) Dalhana: Explains this as absence of prasarana and akunchana of the Sandhi i.e. absence of normal range of movement of the joint (flexion and extension). b) Gayadasa: Explains this as inability of the joint to move which is similar to Dalhanas explanation.

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c) Sandhi Vishlesha and Stambha: In Madhukosha vyakhya on Madhava Nidhana, Hanti Sandhi has been explained as Sandhi vishlesha (weakness of joint) or Stambha (stiffness or loss of function) of the joint. •

ATOPA: Only Madhavakara has explained this feature. It has replaced the Shopa form Sushruta’s version. No specific commentary is available for this word. Charaka while explaining the trividha pareeksha, states that Sandhi sphutana in the anguli parva (interphalangeal joints) should be examined under Pratyaksha pariksa.

CLINICAL FEATURES OF OSTEOARTHRITIS: The joint pain of OA is often described as a deep ache localized to the involved joint. Typically, it is aggravated by joint use and relieved by rest but, as the disease progresses, it may become persistent. Nocturnal pain interfering with sleep is seen particularly in advanced OA of hip and may be enervating. Stiffness of the involved joint after a period of inactivity (e.g. a night’s sleep or automobile ride) may be prominent but usually lasts<20 minutes. Systemic manifestations are not a feature of primary OA. Because articular cartilage is anueral, the joint pain in OA must arise from other structures.13(p.2039) Table No. 18 showing causes of Joint pain in patients with OA

Sl. No

Source of pain

Mechanism

1

Synovium

Inflammation

2

Subchondral bone

Medullary hypertension, micro fracture

3

Osteophytes

Stretching of periosteal nerve endings

4

Ligaments

Stretch

5

Capsule

Inflammation, distention

6

Muscle

Spasm

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Clinical Signs of OA: 9 Restricted movement (capsular thickening, blocking by osteophytes) 9 Palpable, sometimes audible, coarse crepitus (rough articular surface) 9 Bone swelling (osteophytes) around joint margins 9 Deformity, usually without instability 9 Joint-line or periarticular tenderness 9 Muscle weakness, wasting 9 No or only mild synovitis (effusion, increased warmth)13(p.1098) KNEE OSTEOARTHRITIS:11(p.1098)

OA of knee may involve the medial or lateral femorotibial compartment and/or the patellofemoral compartment. Trauma is a more important risk factor in men and may result in unilateral OA. Most Knee OA particularly in women is bilateral and symmetrical. OA pain is usually localized to the anterior or medial aspect of the knee and upper tibia. Patello-femoral pain is usually worse going up and down stairs or inclines.11(p.2040-2041) Local examination findings may include:11(p.1099)

o A varus, less commonly valgus, and/or fixed flexion deformity o Joint line and/or periarticular tenderness o Weakness and wasting of quadriceps muscle o Restricted flexion/extension with coarse crepitus A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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o Bony swelling around knee joint o Jerky asymmetric “antalgic” gait—less weight bearing on the painful side

The American College of Rheumatology has established clinical criteria for diagnosing primary osteoarthritis of the knees as follows:14(p.796)

Knee pain and; •

At least three of the following 6 criteria: 50 years of age or older, stiffness lasting less than 30 minutes, crepitus, bony tenderness, bony enlargement, no warmth to the touch

Laboratory and Radiographic findings:13(p.2040)

The diagnosis of OA is usually based on clinical and radiographic features. In the early stages, the radiograph may be normal but joint space narrowing becomes evident as articular cartilage is lost. Other characteristic findings include subchondral bone sclerosis, subchondral cysts, and osteophytosis. A change in the contour of the joint, due to bony remodeling, and subluxation may be seen.

No laboratory studies are diagnostic of OA. Because primary OA is not systemic, the erythrocyte sedimentation rate, serum chemistry determinations, blood counts, and urinalysis are normal. Synovial fluid reveals mild leukocytosis (<2000 WBC per micro liter), with predominance of mononuclear cells.

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Table No. 19 showing the Kellgren- Lawrence Radiographic Grading Scale14(p.796)

Of Osteoarthritis of Tibio-Femoral Joint:

Grade of the Osteoarthritis

Description

0

No radiographic findings of Osteoarthritis

1

Minute osteophytes of doubtful clinical significance

2

Definite osteophytes with unimpaired joint space

3

Definite osteophytes with moderate joint space narrowing

4

Definite osteophytes with severe joint space narrowing and subchondral sclerosis

UPASHAYA AND ANUPASHAYA: Upashaya is judicious use of drugs, diet and practices (vihara) which results in relief of symptoms. Upashaya is antagonistic to the cause of disease and to the disease itself and anupashaya is that which aggravates the symptoms. No specific Upashaya has been described for Sandhigata Vata in the classics. The general Upashaya and Anupashay of Vata vyadhis can be considered here. Tailabhyanga is an upashaya in Sandhigata Vata. The snigdha, guru and ushna gunas of taila counters the ruksha, laghu and sheeta guna of Vata. Indulgence in laghu, ruksha ahara, and ati vyayama etc viharas can be considered as aupashaya in Vata vyadhis. Sadhyasadhyatva: Sandhigata Vata is one of the kevala Vata vyadhis. Vata vyadhi is one among the Mahagadas, which are considered as difficult to treat right from the beginning stage of the disease. Sandhigata Vata usually occurs in old age due to dhatu kshaya as old age is dominated by Vata. Moreover Sandhigata Vata belongs to A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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madhyama rogamarga vyadhis. Diseases situated in marmas and madhyama rogamaraga are kashta sadhya vyadhis. Diseases involving the gambheera dhatus are yapya vyadhis and in Sandhigata Vata asthi dhatu is involved which is a gambheera dhatu. Considering all the above points Sandhigata Vata can be grouped under yapya vyadhi,s which need regular and long term treatment.1(ni.ch.1.sl.8) SAMPRAPTI It is very important to know the Samprapti or pathology before starting the treatment. From the onset of Dosha-Dushya Dushti, till the evolution of the Vyadhi various stages can be seen. Samprapti explains such series of pathological stages involved. As no special Samprapti has been explained for Sandhigata Vata the Samanya Samprapti of Vatavyadhi can be considered as the Samprapti of Sandhigata Vata. According to Acharya Charaka and Vagbahta, dhatu kshaya is the main cause for Vata prakopa.This balavan (prakupita) Vata circulates through the empty channels in the body (rikta srotas), fills them and produces sarvanga and ekanga rogas (systemic and localized diseases). Chakrapani commenting on the word riktani states that riktani means tuchyani (snehadi gunashunyani) i.e channels or srotasas devoid of nutrients. Avarana of this prakupita Vata by other doshas is the other reason for the Vata prakopa in the absence of dhatu kshaya resulting in disease.6(ni.ch.15.sl.6) That is, the above said Ahara vihara induces reduction of Snehabhava and simultaneously produces Vatakopa due to the dhatu kshaya. Reduction of Shleshaka kapha occurs and this allows the settling of vitiated Vata (vyana vata) in the joints thereby gradually resulting in the manifestation of Sandhigata Vata. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Concept of Gatavata As the disease belongs to Gatavata group of Vata vyadhis, it will be relevant to discuss the concept of Gatavata here. While mentioning Gatavata, acharyas have mentioned the gatatva of dhatu, upadhatu, ashaya, avayava etc.160 The various terminologies used to denote this Gatavata are gate, sthithe, avasthite, ashrite, prapte, etc. These all terminologies can imply two important factors – A) related to the gati of the vitiated Vata and B) related to the occupation of a particular site. Three main factors involving in the production of Sandhigata Vata are – ¾ Kopa of vyana vata, which normally controls all the movements of the body. ¾ Kshaya of shleshaka kapha, which normally aligns the joints and maintains its compactness. ¾ Deterioration of Shleshmadhara kala, which lubricates the joints.

Samprapti ghatakas 01. Dosha

–

Vata – Vyana vata vridhi, and Kapha – Shleshaka kapha kshaya

02. Dushya

–

Asthi, Majja, Peshi, Snayu, Shleshmadhara kala

03. Srotas

–

Asthivaha, Medovaha, Majjavaha, Mamsavaha

04. Agni

–

Jatharagni, Asthidhatwagni,

05. Ama

–

Jatharagni mandyajanya, Asthidhatwagni mandyajanya,

06. Udbhava

–

07. Rogamarga

– Madhyama

Pakwashaya

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Disease Review

08. Adhisthana

–

Sandhi

Pathogenesis of Osteoarthritis:11(p.1097)

A variety of mechanical, metabolic, genetic or constitutional insults may damage a synovial joint and trigger the need for a repair. Most often the insult remains unclear (‘primary OA’) but sometimes there is an obvious cause such as trauma or ligament ruptures (secondary OA). All the joint tissues (cartilage, bone, synovium, capsule, ligament, muscle) depend on each other for health and function. Insult to any one of the tissue impacts on the others, resulting in a common OA phenotype affecting the whole joint. OA process involves dynamic new tissue production and remodeling of joint shape. Often the slow but efficient OA process compensates for the insults, resulting in an anatomically altered but pain-free functioning joint (‘compensated’ OA). Sometimes, however, because of either overwhelming or chronic insult or an inherently poor repair response, it fails; resulting in progressive tissue damage, more frequent association with symptoms, and presentation as ‘joint failure’. Pathological changes: 13(p.833)

Articular cartilages: The regressive changes are most marked in the weight bearing regions of the articular cartilages. Initially, there is loss of cartilaginous matrix (proteoglycans) resulting in progressive loss of normal chondrocytes, and at other places, proliferation of chondrocytes forming clusters. Further progression of the process causes loosening, flanking and fissuring of the articular cartilage resulting in

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Disease Review

breaking off of pieces of cartilage exposing subchondral bone. Radiologically, this progressive loss of cartilage is apparent as narrowed joint space.

1) Bone: The denued subchondral bone appears like polished ivory. There is death of superficial osteocytes and increased osteoclastic activity causing rarefaction, imcrocyst formation and occasionally micro fractures of subadjucent bone. These changes result in remodel ling of bone and changes in the shape of joint surface leading to flattening and mushroom-like appearance of the articular end of the bone. The margins of the joints respond to cartilage damage by osteophytes or spur formation. These are cartilaginous outgrowths at the joint margins which later get ossified. Osteophytes give the appearance of lipping of the affected joint. Loosened and fragmented osteophytes may form free ‘joint mice’ or loose bodies. 2) Synovium: Initially, there are no pathological changes in the synovium but in advanced cases there is low-grade chronic synovitis and villous hypertrophy. There may be some amount of synovial effusion associated with chronic synovitis.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Disease Review

SAMPRAPTI OF JANU SANDHIGATA VATA

Viharaja Nidana

Vardhakya Aharaja Nidana

Reduced Poshana of Rasadhi Dhatus

Asthi Dhatu & Other Dhatu Kshaya

Damage to Shleshmadhara kala

Reduction of Snehanamsha

Vata Prakopa

Shithilata of Snayu, Sira, Kandara, Peshi

Shleshaka Kapha Kshaya

Khavaigunyata of Janu Sandhi

Sthana Samshraya of Kupita Vata

Janu SandhigataVata

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Disease Review

CHIKITSA

The treatment of the disease is nothing but the breaking-up of the Samprapti. Charaka has not mentioned any special line of treatment for Sandhigata Vata, but has mentioned bahya and abhyantara snehana as the treatment for Asthi and Majjagata Vata which can be adopted in Sandhigata Vata also. Later authors have mentioned specific line of treatment for Sandhigata Vata with minor changes which is listed below.

Tabel No. 20 showing the Chikitsa sutra of Sandhigata Vata according to different texts

Sl. No

Chikitsa

CA

SU

1

Snehana

-

+

2 3 4 5 6 7 8

Upanaha Agni karma Bandhana Svedana Raktavsechana Pradeha Mardhana

-

+ + + +

-

A.S

+ + + + + + +

A.H

C.D

B.P

Y.R

B.R

+

+

+

-

+

+ -

+ + + +

+ + -

+ + +

+ + + +

“xlÉåWûÉåmÉlÉÉWûÉÎalÉMüqÉïoÉlkÉlÉÉålqÉSïlÉÉÌlÉ cÉ | xlÉÉrÉÑxÉlkrÉÎxjÉxÉÇmÉëÉmiÉå MÑürrÉÉï²ÉrÉÉuÉiÉÎlSìiÉÈ ||”2(chi.ch.4.sl.8.p.480) Dalhana commenting on the word snehana explains that here snehana means both bahya and abhyantara types of snehana should be considered. Further he

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80

Disease Review

explains atandrita as analasa i.e. continuous, means the treatment should be done regularly for long duration. Vridddha Vagbhata has laid stress on abhyanga. Raktavasechana is indicated in case of tvak swapana, and it should be followed by pradeha with tila, lavana and agara dhuma. Bhavaprakasha has mentioned one yoga for Sandhigata Vata: Indravaruni mula, magadhi and guda when consumed in a dose of 1 karsha cures Sandhigata Vata. PATHYA1(ch.23.sl.597) Ahara 1. Rasas

: - Madhura-Amla-Lavana

2. Shukadhanya

: - Nava godhuma, Nava shali, Rakta shali, Shashtika shali.

3. Shimbi varg a

: - Nava tila, Masha, Kulattha.

4. Shaka varga

: - Patola, shigru, vartaka, lashuna.

5. Mamsa varga

: - Ushtra, Go, Varaha, Mahisha, Bheka, Nakula, Chataka, Kukkuta, Tittira, Kurma.

6. Jala varga

: - Ushnajala, Shrithasheetajala, Narikelajala.

7. Dugdhavarga

: - Go, Aja, Dadhi, Ghritha, Kilata, Kurchika.

8. Mutravarga

: - Gomutra.

9. Madyavarga

: - Dhanyamla, Sura.

10. Snehavarga

: - Tilaja, Ghrita, Vasa, Majja.

Vihara Veshtana, Trasana, Mardana, Snana, Bhushayya, etc. APATHYA Ahara 1. Rasa

: - Katu, Tikta, Kashaya.

2. Shimbivarga

: - Rajamasha, Nishpava, Mudga, Kalaya.

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Disease Review

3. Shukavarga

: - Truna, Kangu, Koradusha, Neevara, Syamaka.

4. Phalavarga

: - Jambu, Udumbura, Kramuka, Tinduka.

5. Mamsavarga

: - Sushka mamsa, Kapota, Paravata.

6. Jalavarga

: - Sheeta jala.

7. Ksheeravarga

: - Gardabha.

Vihara 1. Manasika

: - Chinta, Shoka, Bhaya.

2. Shareerika

: - Jagarana, Shrama, Vyayama, Vyavaya, Chankramana, Vegadharana etc.

Management of OA: The American Rheumatism Association (ARA) has issued pharmacologic guidelines for treatment of OA of the hip and knee. (1) Arthrocentesis with corticosteroid injection can be used only for knee OA if effusion is present. (2) Acetaminophen can be administered, up to 4 g/d. This is the preferred initial treatment to be given to patients with OA. (3) Topical anti-inflammatory medications or capsaicin can be administered only for knee OA. (4) Low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) (i.e., analgesic doses) or nonacetylated salicylates may be indicated. (5) Administration of full-dose NSAIDs with misoprostol, if risk factors for upper gastrointestinal bleeding are present. (6) Narcotic analgesic use may be indicated in cases of severe pain. Surgical interventions for OA of the knee: •

Arthroscopic lavage - Using a saline lavage to wash out the joint

•

Joint realignment (realignment osteotomy)

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

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Disease Review •

Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion

•

Joint replacement (arthroplasty)

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83

Suchi vyadha chikitsa  

SUCHI VYADHA HISTORICAL REVIEW If we go back to the Indian medical classics, known as the Vedas, said to be written about 7000 years ago, we find "needle therapy" [Suchi karma] mentioned there. One volume of the Vedas, known as the “Suchi Veda”, translated as the "art of piercing with a needle" was written about 3000 years ago and deals entirely with acupuncture. Unfortunately this text is not available today18(p.11). During ancient period, bamboo or wooden Suchi – needles were used for acupuncture. Sushrutha has mentioned the art of acupuncture under Vyadhana or Bhedhana Karma (Bhedhana means to pierce or to cut). During ancient time needles made up of wood were used, later on various metal needles were used for this purpose. Sushruta in Sharira sthana 8 ‘Siravyadha’ has advised puncturing the channels (sira) by using needles, which are as small as ‘vrihi’ (vrihi is the outer cover of the rice grain which is pointed at both ends. The Indians have both body acupuncture and ear acupuncture. Thus in India, an entire system of treating every type of disease by the ear alone was [also] developed! Some scholars believe that acupuncture probably evolved in prehistoric times out of the modifications of the principles of Ayurveda near the snowy bleaks of the Himalayas, where no herbs were available. ... In fact, this knowledge has already got passed to the nearby countries around India mainly during ‘Buddha’ period and got stored as in cold storage. It is not a coincidence that almost all Buddhist countries have this knowledge and it is the Indian fortune that the origin of this knowledge [of acupuncture] is from India (But rather unfortunate that not many people in India know this and appreciate this fact as we sure have a 'tradition' of forgetting our traditions! and sciences be it mantric or Vedic. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

 

81 

Suchi vyadha chikitsa  

PROCEDURE Suchi Vyadha is an art of Introducing delicate fine Suchi (Fine Needles) into different sensitive points to stimulate the particular area to get the desired therapeutic effect. In this clinical study we have used a fine silver headed acupuncture needle for suchi vyadha. Suchi vyadha is done in and around janu marma with radius of 3 angula to stimulate janu marma & in turn to stimulate Sandhi Avayava’s present in it, so that it helps in relieving the pain & promotes Sandhi poshana & thus helps in early repair of Dhatu Kshayata & restores normal joint integrity. Back Ground: As such there is no direct reference presently available in our classics for suchi vyadha chikitsa. Acupuncture has great role in pain management & it is world widely accepted as an alternate system of treatment for pain management. In acupuncture they puncture on an acupuncture point & stimulate the same to cure many diseases. With the same principle we have tried to stimulate janu marma to manage janu sandhigata vata. In fact the concept of Marma is well described in our classics, but its importance in therapeutic aspect (other than Viddha Lakshana) is never mentioned & ever used (i.e. Marma Sthana is not used to cure disease or to relieve pain). They only say that, Marma Sthana which is a very vital point should not be injured & should be kept intact even while doing surgeries. In this present study to first of its kind an attempt is made to manipulate or stimulate Marma Sthana to obtain desired therapeutic effect. In coming days this idea may form basis in curing innumerable disease just by manipulating or stimulating Marma Sthana, which is a seat of prana or life.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

 

82 

Suchi vyadha chikitsa  

In this present study patient with jaanusandhi vikara is considered and Suchi Vyadha is done with suchi on jaanu marma to relieve from jaanu shoola and other associated symptoms. Though there is no direct reference for Vyadhana karma on Marma Sthana & Suchi Vyadha Chikitsa (for Analgesic purpose) in our classics, with some of the following cross references this treatment procedure is carried out. iɤÉÌrÉiuÉÉ ¤ÉÑUåhÉÉ…¡Çû MåüuÉsÉÉÌlÉsÉmÉÏÌQûiÉqÉç | iÉ§É mÉëSåWû S±ÉŠ ÌmÉ¹Ç aÉÑgeÉÉTüsÉæÈ M×üiÉqÉç || iÉålÉÉmÉoÉÉWÒûeÉÉ mÉÏQûÉ ÌuÉμÉÉcÉÏ aÉ×kÉëxÉÏ iÉjÉÉ | AlrÉÉÅÌmÉ uÉÉiÉeÉÉ mÉÏQûÉ mÉëzÉqÉÇ rÉÉÌiÉ uÉåaÉiÉÈ ||

3  

(Uk ch.11 sl.102) 

Diseases which is purely of vataja in origin like apabhahuka, vishvaachi, grudrasi etc, in it first pricking with needle should be done, then followed by lepa with gunja phala is applied. This type of treatment gives immediate relief. With this reference we can consider that puncturing or suchi vedha can be done.  mɤqÉhÉÉÇ xÉSlÉå xÉÔcrÉÉ UÉåqÉMÔümÉÉlÉç ÌuÉMÑüûrÉåiÉç |

2  

(UT ch.9 sl.18) 

In pakshmashata they say that first the site should be pricked with needle then other line of treatment is adopted. Even in nilika, vyanga, keshashaata kuttana karma (pricking) with kurcha is mentioned. kÉlÉÑuÉï¢üÉ ÌWûiÉÉ qÉqÉïTüsÉMüÉåzÉÉåSUÉåmÉËU | CirÉåiÉÉÎx§ÉÌuÉkÉÉÈ xÉÔcÉÏxiÉϤhÉÉaÉëÉ xÉÑxÉqÉÉÌWûiÉÉ ||1  (su.ch.25.sl.23)    A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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83 

Suchi vyadha chikitsa  

The above shloka says suturing in marmasthana, vrashanakosha, udara is done by using curved needle (Dhanurvakra). With this we can come to conclusion that when suturing itself is allowed on marmasthana, why not it be punctured. With the above references we can come to conclusion that directly or indirectly suchi vyadha or puncturing can be done. More over it is a controlled way of introducing delicate fine suchi to marma and does not creates any injury or viddha. In marma viddha lakshana they say death occurs due to blood loss, since there is no blood loss or injury in this procedure, this may be carried out. This only activates the doshas present in the marma and brings them into harmony through a controlled way of pricking and does not create any injury or abhighata to marma.

Shastra Karma उ पा य़पा यसी यैंयले यू छानकु टनम ् । छे यं भे यं यधो म थो महो दाह

त बया ॥

(अ. .सू.२६/२८) Above shloka says Vyadhana karma is one among shastra karma, literally it means puncturing, puncturing on sira for bloodletting is mentioned in our classics, but puncturing needle for analgesic effect is not mentioned it is a new approach to do suchi vyadha on janu marma to manage signs & symptoms of janu sandhigata vata.                 

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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84 

Suchi vyadha chikitsa  

Suchika Bharana Rasa रसग धकनाग च वषं ःथावरज गमम ् । मा ःयवाराहमायूर छाग प ै

भावयेत ् ॥

सूिचकाभरणो नाम भैरवेण ूक िततः ।

सूिचकामेण दात यः स नपातकुला तकः ॥ (भै.र. वर.िच.५/६४२-६४३) With fine suchi, suchika bharana rasa, is put into circulation through suchi vyadha on Bramha Randra. With this we can say that concept of suchi vyadha was known to our ancients.  

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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85 

Needle review  

HISTORY OF ACUPUNCTURE - NEEDLE The earliest acupuncture implements were sharp pieces of bone or flint in the shape of arrowheads called Bian stones. Their use was limited because of their size and shape and they were used to scratch or prick acupuncture points. Later, sharp pieces of pottery were used for this purpose. As time went on, the Chinese refined this process eventually using needles to stimulate acupuncture points. Early acupuncture needles were made from bamboo and bone and as they were rather thick, their insertion was painful. In spite of there being no knowledge of sterilization before the 19th century, it is surprising to note that infection rarely occurred with acupuncture. This is because acupuncture stimulates the immune system enhancing the body's protective mechanisms. With the advent of the Iron Age and the Bronze Age the next type of needles to be developed were metal needles. As the art of metallurgy progressed, different types of needles were made. Early needles were made from iron, copper, bronze, silver and gold. At the time when the "Neiching" was written, there were nine different types of acupuncture needles in use. These were similar to present day needles. Very thin, fine needles were used for routine treatment. Arrowhead needles were used to prick the points. Blunt and round needles were used for acupressure. Scalpels like needles were used for cutting open boils and abscesses. Larger and heavier needles were available for insertion into joints and when the acupuncture points lay deep below the skin, longer needles were used. Small thumbtacks shaped needles were used for insertion at ear acupuncture points when prolonged stimulation was required. Three-sided needles were used to bleed the A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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86 

Needle review  

patient in cases of coma and high fever. The drawing of a few drops of blood from certain acupuncture points can bring down high fever, stop convulsions and restore consciousness in a matter of minutes without any other treatment. Finally there were the plum blossom needles also called the seven star needles which were used to tap the skin over acupuncture points. This was mainly used to treat skin diseases, children, old people and patients who were afraid of needles. These needles were in widespread use for thousands of years until the early years of the 20th century, when the invention of stainless steel revolutionized the art of Some acupuncturists claim that needles made from silver or gold have special therapeutic properties. Needles made from silver and gold are expensive and so are often re sharpened, straightened and reused. Unfortunately, the process of re sharpening needles is laborious and time consuming and it is rarely possible to get as sharp a point on these needles as on a stainless steel needle. In my experience needles made from stainless steel are as effective in therapy as needles made from any other material. Needles made from two metals act as a thermocouple, and generate a small electric current. So the handles of some acupuncture needles are made from metals like copper, silver and gold with the needle itself being made from stainless steel. Needle handles made with copper and silver get oxidized during use and storage, which reduces their electrical conductivity making them unsuitable for electrical stimulation. An average acupuncture needle is slightly thicker than a human hair and its insertion is virtually painless. Many potential patients are dissuaded from trying acupuncture by the pictures they see of acupuncture where long, thick needles are inserted into the A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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87 

Needle review  

patient. This has given rise to the misconception that acupuncture is painful. This misconception also arises from the belief that acupuncture needles are similar to injection needles. There are several fundamental differences between acupuncture needles and hypodermic needles used for giving an injection. Normal acupuncture needles are so thin that they cannot be seen in a picture or on television. The needles used for demonstration are far thicker than those used for acupuncture. As you would appreciate, a silver needle slightly thicker than a human hair is hard to see. An acupuncture needle is very thin, ranging from 0.16 mm to 0.38 mm in thickness, while injection needles range from 0.6 mm to 2 mm (in blood transfusion needles). The tip of an acupuncture needle is conical in shape, which allows it to penetrate the tissues separating the fibres of the muscle as it enters, without causing damage. Similarly on removing the needle the separated fibres close smoothly around the needle, preventing bleeding. A hypodermic needle in contrast, has a sharp edge and its insertion cuts out a small cylinder of flesh as it enters. This fact is used for carrying out a needle biopsy to diagnose cancer. A hypodermic needle also has a hole through which a liquid is forced while giving the injection. Once the medicine is injected it forces the cylinder of flesh, into the place where the injection is given releasing painful substances called prostaglandins. The forcing of the medicine into a closed space also causes pain.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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88 

Needle review  

In acupuncture, no fluid is injected into the body and as the needle does not have a cavity in the middle; it is much thinner than a hypodermic needle. The sensation felt when an acupuncture needle is inserted is very different from the sensation felt when a hypodermic needle is used. In contrast to an injection, an acupuncture needle produces its effect by altering the energy flow inside the human body. Acupuncture needles come in various sizes and thicknesses ranging from two millimetres to ten centimetres in length. The handles are one to three centimetres long. The longest needles are used on fat people in areas where there is thick muscle and a lot of fat, like the buttocks and hips. On the forehead hands and face, only the tip of the needle is inserted. The depth of insertion of the needle varies from one millimetre to about ten centimetres depending on the depth of the acupuncture point to be treated.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

 

89 

Needle review  

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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90 

Needle review  

The Acupuncture Needles:16(p.35-40) In ancient China, nine different types of needles were used for acupuncture. Although they were called needles, some of them were really in the form of small lances, while others had a small cutting edge. One type of needle had a ball point and was used for micro massage (acu-massage) at the acupuncture point. The following is a description of the types of needles in common use today. a) The filiform needles The filiform needle comprises a handle or holder, and a shaft. The handle may be made of copper, bronze, aluminium, silver or stainless steel. Plastic handled disposable acupuncture needles are also now available. The shaft nowadays is always manufactured from stainless steel (astematic steel).

The length of these needles (i.e. the length of the shaft) varies from 0.5 inch to 8 inches or more. The calibre (diameter) may range from gauge 26 to 34. The following table shows the standard sizes available: Length Inches (cuns)

0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Millimetres

15

25

40

50

65

75

90

4.5

5.0

6.0

100 115 125 150

Diameter Standard Wire Gauge No. Millimetres

26

28

30

32

34

0.45

0.38

0.32

0.26

0.22

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91 

Needle review  

For general use the 1.0 inch or 1.5 inch long, No.28 or 30 needles are preferred. Gauge No. 30 (i.e. the thinner needles) are particularly recommended for points in the eye region, in children and for conditions where minimum stimulation is needed. The longer needles are used for areas where the muscular mass is thick. E.g. Huantiao (G.B.30) and in puncturing-through technique, where the needle is directed from one point through to another. The thicker needles, Gauge No.26 & 28 are used in regions where relatively stronger stimulation is required.

b) The embedding needles Also called the press needle and implanted needle, they come in several shapes, depending on their use.

i) The thumbtack type: this looks like a small thumbtack. The body of the needle is in the form of a small circle about 3mm in diameter and its tip stands out at right angles to the circle. It penetrates to a depth of 2-3 mm. It is used more commonly in ear acupuncture. ii) The ‘fish tail’ type: This is similar to the thumbtack type, except that its shaft lies at the same plane as its body. This needle is used on certain body acupuncture points for continuous stimulation. It is inserted horizontally under the skin, and then fixed with adhesive tape. Both these types of needles are indicated in chronic conditions like bronchial asthma, epilepsy & in painful condition like migraine. They may be kept in place A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Needle review  

for up to seven days & are therefore, useful in providing mild stimulation of an acupuncture point between treatment sessions. In warm weather it is advisable to change the needle in about half this time. iii) The spherical press needle (ball bearing type): This may also be used for the same purpose. This is becoming more popular nowadays, as it is safer because there is no chance of damage to cartilage and infection of the ear. It consists of a tiny stainless steel ball which is fixed on the skin at acupuncture point with adhesive porous tape. iv) The muscle embedding needle: these are slightly longer than the fish tail type and are used to allay very intractable painful conditions like phantom limb pain and the pain of secondary cancer. The muscle embedding needle is left in situ at local painful points in the muscle (Ah-Shi point) for a few days. c) The “Plum Blossom” needle This is known as the “Five Star” or “Seven Star” needle. It is made up of 5 or 7 short filiform needles attached to a holder at the end of long handle. The plum blossom needle is used to tap on the skin along a channel or at specific points. It is indicated in children, in weak patients, in skin diseases and in those who dislike puncturing.

d) The three-edged (or prismatic) needle This has a triangular point and is used to bleed certain areas in skin disorders, arthritis & in acute emergencies. (In modern acupuncture a syringe & an intravenous needle are used for the same purpose). A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

 

93 

Materials & Method  

SECTION 3 MATERIALS AND METHODS OBJECTIVES OF THE STUDY ¾ To review the literature on concepts of Marma & Traditional Chinese Acupuncture Points. ¾ An attempt to establish the relevance of Marma Sthana with that of Acupuncture Points. ¾ To evaluate the Therapeutic Effect of Suchivyadha Chikitsa on Janu Marma in Janu Sandhigata Vata. (Osteoathritis of the Knee Joint) ¾ To evaluate the Therapeutic Effect of Acupuncture in the management of Janu Sandhigata Vata. (Osteoathritis of the Knee Joint) 2. SOURCE OF DATA Patients of Janu Sandhigata Vata who fulfiled the inclusion criteria were randomly selected from outpatient & in patient Department of PG Studies in shalyatantra, SJIIM Hospital.

3. SELECTION CRITERIA ¾ Diagnostic Criteria Patients with classical signs & symptoms of Janusandhigata vata supplemented with that of Osteoarthritis of Knee Joint like 1. Pain & restricted movement of the knee joint. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

94

Materials & Method  

2. Presence of crepitus 3. Tenderness 4. Presence of swelling 5. Radiological evidence of OA of knee 6. Janu Sandhi kriya kshamath in varying degree

3.1 Inclusion Criteria 1.

Patients fulfilling the diagnostic criteria in the age group between 40 to 75 years are selected for the present study.

3.2 Exclusion Criteria 1. Patients having Janusandhi shoola due to trauma, fracture & dislocation. 2. Patients suffering from Rheumatoid Arthritis, Gouty Arthritis, Psoriatic Arthritis & other inflammatory disease. 3. Patients suffering from tuberculosis & other infectious & malignant disease.

4. STUDY DESIGN A total number of 40 patients were selected randomly for the present clinical study. These 40 patients were divided into 2 groups. Group A & Group B, each consisting of 20 patients. ¾ Group A Patients of this group were treated daily by Suchivyadha on Janumarma for 12 sessions & for about 30 minute duration. ¾ Group B Patients of this group were treated daily by Acupuncture on Acupuncture points for 12 sessions & for about 30 minute duration. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

Dept. of PG Studies in Shalyatantra, GAMC, Bangalore.

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Materials & Method  

4. MATERIALS REQUIRED FOR THE STUDY ¾ Cotton Swab ¾ Tankana Jala ¾ Sterile, Packed Acupuncture Needle ¾ Kidney Trey ¾ Goniometry ¾ Measuring Tape ¾ Stop Clock ¾ Gas Stove ¾ Lighter 5. METHODOLOGY OF STUDY The patients who fulfilled the inclusion criteria were evaluated for both subjective & objective parameters. ¾ Measurement of Knee joint: Circumference of the knee joint was measured with the help of measuring tape in the following manner: The patient was asked to lie in relaxed supine position, breathe easily and not to hold the knees tight. Both knees were exposed. The circumferences of both the knees were measured just above the Patella. GONIOMETRIC MEASUREMENT The patient was first educated about the examination and was asked to lie in supine position with both the legs flat on the table exposing the legs as far as possible. While examining the female patients help of fellow female scholars was sought. The fulcrum of the Goniometre was aligned with the lateral A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Materials & Method  

epicondyle of the femur. The stationary arm was placed in line with the greater trochanter and midline of the femur. The moving arm was placed in line with the lateral malleolus and midline of fibula. Then the patient was asked to bend the knee as far as they can. The angle created was noted and recorded. STUDY DESIGN Group-A Patient was made to sit comfortably on a chair, with the affected knee well exposed. As a aseptic precaution the part was cleaned with tankana jala. Then Suchi Vyadha was done on Janu Marma with delicate fine sterile sookshma suchi on the following points for about 30 minutes.

Specific Points for Suchi Vyadha on Janu Marma ¾ Suchi Vyadha on most tender points, in & around the Janu Marma is done. ¾ One needle just above the superior border of the patella on the medial side is punctured for about 1 cm depth. ¾ Just above the superior border of the patella on the lateral aspect of knee is punctured for about 1 cm depth. ¾ One Centimeter below the apex of the patella a needle is punctured perpendicularly up to 2 cm depth. ¾ Vyadhana on either end of the joint crease is done.

Group-B Patient was made to sit comfortably on a chair, with the affected knee well exposed. As a aseptic precaution the part was cleaned with tankana jala. Then the Acupuncture was done with sterile Acupuncture needle on the following Acupuncture points for about 30 minutes. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Materials & Method  

Acupuncture Points for Osteoarthritis of Knee 1. Baihui (Du.20) This point is a meeting point of a hundred points & controls all other points & channels in the body. Location: Draw a straight line from the tip of the ear lobe to the apex of the auricle & extend this line upwards on the scalp till it intersects the midline, the point lies at this intersection.

II LOCAL POINTS 2. Ah-Shi Points-Most tender points Ah-Shi in Chinese means “Oh Yes”, this being the verbal action of the patient, when tender points are palpated. 2 to 3 maximum tender points in & around the knee joint are punctured. 3. Heding (Ex.31) On the mid point of the upper border of the patella. Puncture-0.5 cun perpendicularly. 4. Xiyan (Ex.32) In the depression on the medial side of the ligamentum patellae. Puncture-0.5 cun perpendicularly. 5. Dubi (St.35) The point on the lateral side of the ligamentum patellae. Puncture-0.5 cun obliquely & medially. 6. Weizhong (UB.40) At the mid point of the popliteal transverse crease. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Materials & Method  

Puncture-0.5 to 1 cun perpendicularly. 5. ASSESSMENT CRITERIA ¾ The improvements in the Subjective Parameters and Objective parameters were assessed by scoring method. The subjective criteria (Table no.21) were scored in accordance with Index of severity of Osteoarthritis of the Knee by Lequesne et al & WOMAC. (Western Ontario & Mc Master Universities) ¾ The patients were assessed on 1st, 6th & 12th day of treatment.

Table No. 21 showing Subjective and objective parameters Sl. No

PARAMETER

FINDINGS

PONITS

PAIN OR DISCOMFORT 1

pain or discomfort during nocturnal bed rest

none only on movement or in certain positions without movement

2

duration of morning < 1 minute stiffness or pain after getting up > 1 minute but < 15 minutes > 15 minutes

3

4

5

remaining standing for 30 minutes increases pain pain on walking

pain or discomfort after getting up from sitting without use of arms

no

0 1 2 0 1 2 0

yes

1

none

0

only after walking some distance after initial ambulation and increasingly with continued ambulation no

1 2

0

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Materials & Method  

yes

1

WALKED MAXIMUM DISTANCE 6

maximum distance walked

unlimited > 1 kilometer but limited about 1 kilometer (about 15 minutes) about 500 - 900 meters (about 8-15 minutes) from 300 - 500 meters from 100 - 300 meters < 100 meters

7

walking aids required

None 1 walking stick or crutch 2 walking sticks or crutches

0 1 2 3 4 5 6 0 1 2

ACTIVITIES OF DAILY LIVING 8

able to climb up a standard flight of stairs

easily with mild difficulty with moderate difficulty with marked difficulty impossible

9

able to climb down a standard flight of stairs

easily with mild difficulty with moderate difficulty with marked difficulty impossible

10

able to squat or bend at the knee

easily with mild difficulty

0 0.5 1.0 1.5 2.0 0 0.5 1.0 1.5 2.0 0 0.5

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Materials & Method  

with moderate difficulty with marked difficulty impossible 11

able to walk on uneven ground

easily with mild difficulty with moderate difficulty with marked difficulty impossible

12

Getting in or out of car

easily with mild difficulty with moderate difficulty with marked difficulty impossible

13

Putting on or taking off easily socks with mild difficulty with moderate difficulty with marked difficulty impossible

14

Tenderness

OBJECTIVE PARAMETER No tenderness Patients complains of pain

15

Crepitus

Patients complains of pain and winces Patients complains of pain and withdraws the joint No crepitus

1.0 1.5 2.0 0 0.5 1.0 1.5 2.0 0 0.5 1.0 1.5 2.0 0 0.5 1.0 1.5 2.0

0 1 2 3 0

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Palpable crepitus Audible crepitus 16

Measurement of Right knee joint

1 2

Just above the patella over the middle of the patella Just below the patella

Measurement of Left knee joint

Just above the patella over the middle of the patella Just below the patella

17

Range of Movement

Right Knee joint(Flexion) Left Knee joint(Flexion)

18

Time taken to walk 50 metres distance on even ground

In seconds with the help of a stop clock

FOLLOW UP PERIOD Š After the treatment schedule, patient was advised to visit OPD once in 20 days for a follow up period of 2 months for any recurrence or otherwise. Š Criteria for assessment of total response of the treatment The sum points of all the parameters of assessment before and after the treatment were taken into consideration to assess the total effect of the treatment as follows:1. Marked Improvement

- Relief of 60-80%

2. Moderate Improvement - 30 to 60% relief 3. Mild Improvement

- < 30% of relief

4.

- 0% relief

No Change

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Observations & Results

SECTION 4 OBSERVATIONS A total of 40 patients were registered for the present study.

20 patients were

registered in group A & 20 patients were registered in Group B. All the patients were examined before and after the treatment according to the case sheet format given in the appendix. Changes in both the subjective and objective parameters were recorded. The data recorded are presented here under the following heading:– I. Demographic data II. Data related to the disease III. Data related to over all response to the treatment DEMOGRAPHIC DATA Table No 22: Showing Sex distribution in both the groups. Groups Group A Group B Total

Male 12 12 24

% 60% 60% 60%

Female 8 8 16

% 40% 40% 40%

Graph No.1: Showing Sex distribution in both the groups.

In this study it is observed that in Group A, 12 (60%) were male and 8 (40%) were female. In Group B, 12 (60%) were male and 8 (40%) were female. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.23: Showing overall response based on Sex of the patient

Group Group A Group B

Sex

Marked

%

Moderate

%

Mild

%

No Change

%

Male Female Male

4 4 6 4

20 20 30 20

3 3 5 3

15 15 25 15

5 1 1 1

25 5 5 5

0 0 0 0

0 0 0 0

Female

Table No.24: Showing Age distribution in both groups. Age Groups in years 41- 45 46- 50 51- 55 56- 60 61- 65 65- 70 71- 75

Group A

%

Group B

%

Total

%

1 2 3 6 4 2 2

5% 10% 15% 30% 20% 10% 10%

3 2 1 8 3 2 1

15% 10% 5% 40% 15% 10% 5%

4 4 4 14 7 4 3

10% 10% 10% 35% 17.5% 10% 7.5%

Graph No.2: Showing Age distribution in both groups.

In the present study it is observed that in Group A 1patient in 41 to 45 years age group, 2 in 46 to 50 years, 3 in 51- 55 years, 6 in 56- 60 years, 4 in 61- 65 years, 2 in 65- 70 years and 2 in 71- 75 years age group. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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In Group B 3 patients 41 to 45 years age group, 2 in 46 to 50 years, 1 in 5155 years, 8 in 56- 60 years, 3 in 61- 65 years, 2 in 65- 70 years and 1 patient in 71- 75 years age group. Table No.25: showing overall response based on age group.

Group Age group Marked

%

Moderate

%

Mild

41 - 45 46 - 50 51 - 55 56 - 60 61 - 65 66 - 70 71 - 75 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65 66 - 70 71 - 75

5 5 5 15 5 5 0 5 5 5 20 5 5 5

0 0 2 3 1 0 0 1 1 0 3 2 1 0

0 0 10 15 5 0 0 5 5 0 15 10 5 0

0 1 0 0 2 1 2 1 0 0 1 0 0 0

Group A

Group B

1 1 1 3 1 1 0 1 1 1 4 1 1 1

No % change 0 0 0 5 0 0 0 0 0 0 0 0 10 0 0 5 0 0 10 0 0 5 0 0 0 0 0 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 %

Table No.26: Showing Occupation of the patients in both groups. Occupation Business Official Housewife Labour

Group A 7 5 8 0

% 35% 25% 40% 0%

Group B 2 6 5 7

% 10% 30% 25% 35%

Total 9 11 13 7

% 22.5% 27.5% 32.5% 17.5%

Graph No.3: Showing Occupation of the patients in both groups.

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Observations & Results

Above table and graph suggests in Group A, 7 patients of Business class, 5 in Official class, 8 were housewives, none of them were labour class. In Group B 2 patients in Business class, 6 each in official, 5 were housewives and 7 were in labour class. Table No. 27: showing overall response based on Occupation

Group

Group A

Group B

Occupation

Marked

%

Moderate

%

Mild

%

No Change

%

Business Official Housewife Labour Business

3 4 1 0 1 2 3 4

15 20 5 0 5 10 15 20

3 3 0 0 0 3 3 2

15 15 0 0 0 15 15 10

1 1 4 0 1 0 0 1

5 5 20 0 5 0 0 5

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

Official Housewife Labour

Table No.28: Showing Religion of patients in both groups. Religion Hindu Muslim Christian

Group A 19 1 0

% 95% 5% 0%

Group B 19 1 0

% 95% 5% 0%

Total 38 2 0

% 95% 5% 0%

Graph No.4: Showing Religion of patients in both groups.

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It is seen that 19 in Group A and Group B were Hindu, 1 each in both groups were Muslim.

Table No.29: showing overall response based on Religion

Group Group A Group B

Religion

Marked

%

Moderate

%

Mild

%

No Change

%

Hindu Muslim Hindu

8 0 9 1

40 0 45 5

6 0 8 0

30 0 40 0

5 1 2 0

25 5 10 0

0 0 0 0

0 0 0 0

Muslim

Table No.30: Showing SE Status of patient in both groups.

SE Status L.C M.C U.C

Group A 4 10 6

% 20% 50% 30%

Group B 5 10 5

% 25% 50% 25%

Total 9 10 11

% 22.5% 50% 27.5%

Graph No.5: Showing SE Status of patient in both groups.

It is seen that in Group A 4 patient in LC, 10 in MC, 6 in LC. In Group B 5 patients in LC, 10 were in MC, 5 were in UC.

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Table No.31: showing overall response based on Socio-economic Status

Group Group A Group B

Socio-economic Status

Marked

%

Moderate

%

Mild

%

No Change

%

3 3 2 2 5 3

15 15 10 10 25 15

0 6 0 2 4 2

0 30 0 10 20 10

1 1 4 1 1 0

5 5 20 5 5 0

0 0 0 0 0 0

0 0 0 0 0 0

Lower class Middle class Upper class Lower class Middle class Upper class

Table No.32: Showing Chronicity of the disease in patients.

Chronicity <1yr 1y - 2y 2y - 3y >3y

Group A 10 8 2 0

% 50% 40% 10% 0%

Group B 10 5 5 0

% 50% 25% 25% 0%

Total 20 13 7 0

% 50% 32.5% 17.5% 0%

Graph No.6: Showing Chronicity of the disease in patients.

Above data shows in Group A 10 patients had history of disease below 1 year, 8 had 1y – 2y history, 2 had 2y- 3y history, no one had more than 3 years history. In

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Observations & Results

Group B 10 had within 1 year, 5 had 1y- 2y history, 5 had 2y- 3y history and no one had more than 3 years history. Table No. 33: showing overall response based on Chronicity

Group

Group A

Group B

Marked

%

Moderate

%

Mild

%

No Change

%

< 1 year

5

25

4

20

1

5

0

0

1–2 years

3

15

2

10

3

15

0

0

2-3 years > 3 years

0 0

0

0

0

0 0

0

2 0

10 0

0 0

0 0

< 1 year

6

30

3

15

1

5

0

0

1–2 years 2-3 years > 3 years

1 3 0

5

3 2 0

15 10 0

1 0 0

5

0 0 0

0

Chronicity

15 0

0 0

0

0

Table No.34: Showing diet of patients of both groups. Diet Group A % Vegetarian 12 60% Mixed 8 40%

Group B % 10 50% 10 50%

Total 22 18

% 55% 45%

Graph No.7: Showing diet of patients of both groups.

It is observed that in Group A 12 were of vegetarian diet and 8 of mixed. In Group B 10 each were of vegetarian diet and mixed. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.35: showing overall response based on Diet

Group Group A Group B

Diet

Marked

%

Moderate

%

Mild

%

No Change

%

Vegetarian Mixed Vegetarian

4 4 6 4

20 20 30 20

3 3 5 3

15 15 25 15

5 1 1 1

25 5 5 5

0 0 0 0

0 0 0 0

Mixed

Table No.36: Showing Family history of patients. Family History +ve -ve

Group A 8 12

% 40% 60%

Group B 6 14

% 30% 70%

Total 14 26

% 35% 65%

Graph No.8: Showing Family history of patients.

Family history shows positive in 8 and 6 patients in Group A and Group B respectively, negative in 12 and 14 patients in Group A and Group B respectively.

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Table No.37: showing overall response based on Family History Family History

Group

Positive Negative Positive

Group A Group B

Negative

Marked

%

Moderate

%

Mild

%

No Change

%

2 6 3 7

10 30 15 35

1 5 3 5

5 25 15 25

5 1 2 0

25 5 10 0

0 0 0 0

0 0 0 0

Table No.38: Showing the area involved in disease in patients of both groups. Area Right Knee Left Knee Both Knees

Group A 5 6 9

% 25% 30% 45%

Group B 6 5 9

% 30% 25% 45%

Total 11 11 18

% 27.5% 27.5% 45%

It is observed that 5 and 6 patients had involvement of right knee in Group A and B respectively, 6 and 5 patients had involvement of left knee in Group A and B respectively, 9 each had both knee involvement in Group A and B.

Table No.39: showing overall response based on Area

Group Group A Group B

Area

Marked

%

Moderate

%

Mild

%

No Change

%

Right Knee Left Knee Both Knees Right Knee

3 2 1 3 2 1

15 10 5 15 10 5

0 3 3 3 2 3

0 15 15 15 10 15

0 1 1 4 1 1

0 5 5 20 5 5

0 0 0 0 0 0

0 0 0 0 0 0

Left Knee Both Knee

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The sum points of all the parameters of assessment before and after the treatment were taken into consideration to assess the total effect of the treatment as follows:1. Marked improvement

relief of >60%

2. Moderate improvement

30 to 60% relief

3. Mild improvement

less than 30% of relief

4. No Change

0% relief

Table No.40: showing overall response for the treatment

Group

Marked improvement No. of % patients

Group A Group B

Response Moderate Mild improvement improvement No. of No. of % % patients patients

No Change No. of patients

%

8

40

6

30

6

30

0

0

10

50

8

40

2

10

0

0

In Group A out of 20 patients 8 patients (40%) showed marked improvement, 6 patients (30%) showed moderate improvement & 6 patients (30%) showed mild improvement. In Group B out of 20 patients 10 patients (50%) showed marked improvement, 8 patients (40%) showed moderate improvement & 2 patients (10%) showed mild improvement.

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RESULTS

STATISTICAL ANALYSIS: Paired t test is applied for Group A and Group B for analyzing the individual efficacy of treatment. Student t test is applied to compare efficacy of the two treatment plans. Following results are obtained by statistical analysis.

Results in Group A: Table No.41: Showing effect on Pain during nocturnal bed rest. Day

Mean

SD

SE

t Value

df

P Value

6th

0.8

0.4104

0.0918

8.718

19

P<0.001

12th

1.45

0.5104

0.1141

12.704

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.42: Showing effect on pain after getting up. Day

Mean

SD

SE

t Value

df

P Value

6th

0.5

0.5130

0.1147

4.359

19

P<0.001

12th

1.35

0.4894

0.1094

12.337

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.43: Showing effect on standing for 30 min. Day

Mean

SD

SE

t Value

df

P Value

6th

0.2

0.4104

0.0918

2.179

19

P<0.05

12th

0.65

0.4894

0.1094

5.940

19

P<0.001

Test is significant on 6th day assessment with P value of P<0.05 and highly significant on 12th day assessments with P value of P<0.001

Table No.44: Showing effect on walking. Day

Mean

SD

SE

t Value

df

P Value

6th

0.95

0.2236

0.05

19.0

19

P<0.001

12th

1.65

0.4894

0.1094

15.079

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.45: Showing effect on Morning stiffness. Day

Mean

SD

SE

t Value

df

P Value

6th

0.7

0.4702

0.1051

6.658

19

P<0.001

12th

1.55

0.6048

0.1352

11.461

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.46: Showing effect on stiffness later in day. Day

Mean

SD

SE

t Value

df

P Value

6th

1.05

0.6048

0.1352

7.764

19

P<0.001

12th

1.75

0.9105

0.2036

8.596

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.47: Showing effect on swelling in joint. Day

Mean

SD

SE

t Value

df

P Value

6th

0.65

0.5871

0.1313

4.951

19

P<0.001

12th

1.4

0.9947

0.2224

6.194

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.48: Showing effect on Maximum distance walked. Day

Mean

SD

SE

t Value

df

P Value

6th

1.9

0.3078

0.0688

27.606

19

P<0.001

12th

3.65

0.9881

0.2209

16.520

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.49: Showing effect on walking aid requirement. Day

Mean

SD

SE

t Value

df

P Value

6th

0.15

0.3663

0.819

1.831

19

P>0.05

12th

0.45

0.5104

0.1141

3.943

19

P<0.001

Test is significant on 6th day assessment with P value of P<0.05 and highly significant on 12th day assessments with P value of P<0.001

Table No.50: Showing effect on able to climb up stairs. Day

Mean

SD

SE

t Value

df

P Value

6th

0.6750

0.2447

0.0547

12.337

19

P<0.001

12th

1.25

0.2565

0.0574

21.794

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.51: Showing effect on able to climb down stairs. Day

Mean

SD

SE

t Value

df

P Value

6th

0.7

0.2513

0.0562

12.457

19

P<0.001

12th

1.375

0.5350

0.1196

11.495

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.52: Showing effect on able to squat. Day

Mean

SD

SE

t Value

df

P Value

6th

0.8

0.2513

0.0562

14.236

19

P<0.001

12th

1.25

0.3804

0.0851

14.694

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.53: Showing effect on able to walk on uneven. Day

Mean

SD

SE

t Value

df

P Value

6th

0.9250

0.52

0.1163

7.955

19

P<0.001

12th

1.55

0.6669

0.1491

10.394

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.54: Showing effect on Getting in/ out of car. Day

Mean

SD

SE

t Value

df

P Value

6th

0.4375

0.25

0.0625

7.0

15

P<0.001

12th

0.9375

0.5439

0.1360

6.895

15

P<0.001

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Test is highly significant on 6th and 12th day assessments with P value of P<0.001 Table No.55: Showing effect on putting on/ off socks. Day

Mean

SD

SE

t Value

df

P Value

6th

0.6389

0.2304

0.0543

11.762

17

P<0.001

12th

1.1111

0.3660

0.0863

12.878

17

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.56: Showing effect on tenderness. Day

Mean

SD

SE

t Value

df

P Value

6th

1.3

0.0402

1.051

12.365

19

P<0.001

12th

2.25

0.5501

0.1230

18.291

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.57: Showing effect on crepetus. Day

Mean

SD

SE

t Value

df

P Value

6th

0.35

0.4894

0.1094

3.199

19

P<0.01

12th

0.9

0.6407

0.1433

6.282

19

P<0.001

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Observations & Results

Test is highly significant on 6th and 12th day assessments with P value of P<0.01 and P<0.001respectively.

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Table No.58: Showing effect on Measurement of Rt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

0.3571

0.4127

0.1103

3.238

13

P<0.001

12th

1.0

0.6504

0.1738

5.752

13

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.59: Showing effect on Measurement of Lt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

1.0

0.8756

0.2189

4.568

15

P<0.001

12th

1.6875

1.4009

0.3502

4.818

15

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.60: Showing effect on Movement of Rt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

1.0

0.3922

0.1048

9.539

13

P<0.001

12th

2.0

0.8771

0.2344

8.532

13

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.61: Showing effect on Movement of Lt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

1.1875

0.4031

0.1008

11.783

15

P<0.001

12th

1.9375

0.6801

1.17

11.396

15

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.62: Showing effect on time taken to walk 50m distance. Day

Mean

SD

SE

t Value

df

P Value

6th

1.25

0.4443

0.0993

12.583

19

P<0.001

12th

2.05

0.6863

0.1535

13.358

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.63: Showing effect on Radiological changes. Day

Mean

SD

SE

t Value

df

P Value

6th

-

-

-

-

-

-

12th

0.65

0.2236

0.05

1.0

19

P>0.05

Test is insignificant on 12th day assessments with P value of P>0.05

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This implies there is no much change I the radiological findings in Group A by 12 days. Results of Group B: Table No.64: Showing effect on pain during nocturnal bed rest. Day

Mean

SD

SE

t Value

df

P Value

6th

0.95

0.2236

0.05

19.0

19

P<0.001

12th

1.6

0.5026

0.1126

14.236

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.65: Showing effect on pain after getting up. Day

Mean

SD

SE

t Value

df

P Value

6th

0.7

0.4702

0.1051

6.658

19

P<0.001

12th

1.45

0.5104

0.1141

12.704

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.66: Showing effect on pain on standing for 30min. Day

Mean

SD

SE

t Value

df

P Value

6th

0.4

0.5026

0.1124

3.559

19

P<0.01

12th

0.7

0.4702

0.1051

6.658

19

P<0.001

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Test is highly significant on 6th and 12th day assessments with P value of P<0.01 and P<0.001respectively. Table No.67: Showing effect on walking. Day

Mean

SD

SE

t Value

df

P Value

6th

1.0

-

-

-

-

-

12th

1.7

0.4702

0.1051

16.170

19

P<0.001

Test is highly significant on 12th day assessments with P value of P<0.001

Table No.68: Showing effect on morning stiffness. Day

Mean

SD

SE

t Value

df

P Value

6th

0.7

0.4702

0.1051

6.658

19

P<0.001

12th

1.45

0.7592

0.1698

8.542

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.69: Showing effect on stiffness later in day. Day

Mean

SD

SE

t Value

df

P Value

6th

1.1

0.7182

0.1606

6.85

19

P<0.001

12th

1.8

0.8944

0.2

9.0

19

P<0.001

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Observations & Results

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

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Table No.70: Showing effect on swelling in joint. Day

Mean

SD

SE

t Value

df

P Value

6th

0.75

0.6387

0.1128

5.252

19

P<0.001

12th

1.45

1.09

0.2458

5.9

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.71: Showing effect on Maximum distance walked. Day

Mean

SD

SE

t Value

df

P Value

6th

1.95

0.2236

0.05

39.0

19

P<0.001

12th

3.95

0.6863

0.1535

25.738

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.72: Showing effect on walking aid requirement. Day

Mean

SD

SE

t Value

df

P Value

6th

0.25

0.443

0.0993

2.517

19

P<0.05

12th

0.4

0.5026

0.1124

3.559

19

P<0.001

Test is significant on 6th day assessment with P value of P<0.05 and highly significant on12th day assessment with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.73: Showing effect on Able to climb up stairs. Day

Mean

SD

SE

t Value

df

P Value

6th

0.65

0.2351

0.0526

12.365

19

P<0.001

12th

1.275

0.2552

0.0571

22.342

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.74: Showing effect on Able to climb down stairs. Day

Mean

SD

SE

t Value

df

P Value

6th

0.65

0.2351

0.0526

12.365

19

P<0.001

12th

1.275

0.4993

0.1117

11.419

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.75: Showing effect on squat. Day

Mean

SD

SE

t Value

df

P Value

6th

0.75

0.3035

0.0679

11.052

19

P<0.001

12th

1.2

0.3403

0.0761

15.771

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

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Observations & Results

Table No.76: Showing effect on walk on uneven Day

Mean

SD

SE

t Value

df

P Value

6th

0.85

0.3663

0.819

10.376

19

P<0.001

12th

1.4

0.4472

0.01

14.0

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.77: Showing effect on getting in/ out of car. Day

Mean

SD

SE

t Value

df

P Value

6th

0.5357

0.2373

0.0634

8.446

13

P<0.001

12th

1.0

0.3922

0.1048

9.539

13

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.78: Showing effect on putting on/ off socks. Day

Mean

SD

SE

t Value

df

P Value

6th

0.625

0.2236

0.0559

11.180

15

P<0.001

12th

0.9688

0.4270

0.1067

9.076

15

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.79: Showing effect on Tenderness Day

Mean

SD

SE

t Value

df

P Value

6th

1.25

0.5501

0.1230

10.162

19

P<0.001

12th

2.25

0.5501

0.1230

18.291

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.80: Showing effect on Crepitus. Day

Mean

SD

SE

t Value

df

P Value

6th

0.6

0.5026

0.1124

5.339

19

P<0.001

12th

1.15

0.5871

0.1313

8.759

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.81: Showing effect on Measurement of Rt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

0.5667

0.5936

0.1533

3.697

14

P<0.01

12th

1.3

1.0316

0.2664

4.880

14

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.01 and P<0.001respectively. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.82: Showing effect on Measurement of Lt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

0.8571

0.9693

0.2591

3.309

13

P<0.01

12th

1.5357

1.4473

0.3868

3.970

13

P<0.01

Test is highly significant on 6th and 12th day assessments with P value of P<0.01

Table No.83: Showing effect on Range of movement of Rt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

1.1333

0.5164

0.1333

8.5

14

P<0.001

12th

2.0667

0.7988

0.2063

10.02

14

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.84: Showing effect on range of movement of Lt knee. Day

Mean

SD

SE

t Value

df

P Value

6th

1.2857

0.4688

0.1253

10.262

13

P<0.001

12th

2.2143

0.5789

0.1547

14.311

13

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001 A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Table No.85: Showing effect on time taken to walk 50m distance. Day

Mean

SD

SE

t Value

df

P Value

6th

1.1

0.3078

0.0688

15.983

19

P<0.001

12th

2.0

0.4588

0.1026

19.494

19

P<0.001

Test is highly significant on 6th and 12th day assessments with P value of P<0.001

Table No.86: Showing effect on radiological changes. Day

Mean

SD

SE

t Value

df

P Value

6th

-

-

-

-

-

-

12th

0.15

0.3663

0.0819

1.831

19

P>0.05

Test is insignificant on 12th day assessments with P value of P>0.05 This implies there is no much change I the radiological findings in Group B by 12 days.

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Observations & Results

Results on Comparison of Group A and Group B:

Table No.87: Showing Results on Comparison of Group A and Group B:

Parameter

Mean

SE

t Value

df

difference

P Value

1. Pain during nocturnal bed rest

0.15

0.16

0.9365

38

P>0.05

2. Pain after getting up

0.1

0.158

0.6324

38

P>0.05

3. Pain on standing for 30 min

0.05

0.152

0.3295

38

P>0.05

4. Pain on walking

0.05

0.152

0.3295

38

P>0.05

5. Morning stiffness

0.1

0.217

0.4607

38

P>0.05

6. Stiffness later in day

0.05

0.285

0.1752

38

P>0.05

7. Swelling in joint

0.05

0.33

0.1515

38

P>0.05

8. Max distance walked

0.3

0.269

1.1152

38

P>0.05

9. Walking aid required

0.05

0.16

0.3122

38

P>0.05

10. Able to climb up stairs

0.025

0.128

0.1959

38

P>0.05

11. Able to climb down stairs

0.1

0.164

0.6111

38

P>0.05

12. Able to squat

0.05

0.114

0.4380

38

P>0.05

13. Able to walk on uneven

0.15

0.18

0.8354

38

P>0.05

14. Getting in/ out of car

0.0625

0.175

0.3562

28

P>0.05

15. Putting on/ off socks

0.1423

0.136

1.0465

32

P>0.05

0

0.174

0

38

-

17. Crepitus

0.25

0.194

1.2866

38

P>0.05

18. Rt knee measurement

0.3

0.323

0.9288

27

P>0.05

19. Lt knee measurement

0.1518

0.521

0.2916

28

P>0.05

20. Range of Rt knee movements

0.0667

0.311

0.2143

27

P>0.05

21. Range of Lt knee movements

0.2768

0.232

1.1909

28

P>0.05

22. Time taken to walk 50m distance

0.05

0.185

0.2709

38

P>0.05

23. Radiological changes

0.1

0.096

1.0421

38

P>0.05

16. Tenderness

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Above table suggests that for parameter Tenderness difference of mean is 0. This implies test is insignificant. Both treatments are equal in the parameter Tenderness. In all other 22 parameter test shows insignificance with P value of >0.05 This implies in all parameters both treatments are statistically equal in efficacy. Graph No.9: Showing means of Pain after getting up, pain on walking and Morning stiffness in Group A 1.8 1.65 1.55

1.6 1.4

1.35 pain after getting  up

1.2 1 0.8 0.6 0.4

0.95

pain on walking

0.7 morning stiffness

0.5

0.2 0 6th day

12th day

Graph No.10: Showing the means of swelling, tenderness and Crepitus in Group A 2.5 2.25 2 1.5 1.3 1 0.5

1.4

swelling tenderness

0.9

crepetus

0.65 0.35

0 6th day

12th day

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Graph No.11: Showing means of Pain after getting up, pain on walking in Group B

Graph No.12: Showing means of morning stiffness and stiffness later in day in Group B

Graph No.13: Showing the means of swelling, tenderness and crepetus in Group B

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Discussion

DISCUSSION

As the name suggests, Sandhigata Vata is one of the nanatmaja Vata Vyadhi affecting the joints of the body. It is explained under the various gata Vata vyadhis. Here the kupita Vata gets localized in Sandhis leading to the manifestation of disease. Asthi dhatu is the ashraya sthana of Vata dosha, and Vata vruddhi results in Asthi kshaya. In Sandhigata Vata both these features can be seen. In modern system of medicine, it is grouped under Rheumatology. OA is a slowly progressive degenerative disease of joints which shows a strong association with aging and is a major cause of pain and disability in the elderly. Risk factors outlined for OA varies with joint sites. OA of the knee joints is the most common form of OA; hence the present study was designed on management of Janu Sandhigata Vata (OA of Knee Joint).

SHAREERA: Though the words sound different, there is not much difference in the description of joint anatomy in Ayurvedic and modern systems of medicine. Sandhi is not a single structure rather it is an organ. Different structures like Snayu, Kandara, Siras, Peshi etc. support the stability of the Sandhi. Large numbers of Snayus which bind Sandhis tightly are responsible for bearing the body weight. Functions of the Peshis and Snayus are identical to that of the muscles and ligaments related to the joints. Shleshmadharakala situated in the joints supported by Shleshaka Kapha helps in lubrication. Functions of the Shleshmadhara kala and Shleshaka Kapha described in Ayurveda can be co-related to the Synovial membrane and Synovial fluid situated in Synovial joint which lubricates the joint, a nutrient carrier to the cartilage, disc, and A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Discussion

helps in keeping the joint firmly united. The Marmas are considered as the point of union of nerves, vessels and muscular system, which are vital in the structure and functioning status of the joints. Knee works as a hinge joint, but the articulation is more complex than other hinge joints which is supported by seven major ligaments, flexor and extensor muscles. NIDANA AND SAMPRAPTI: No specific nidana for Sandhigata Vata has been described in the Ayurvedic classics, hence general nidanas of Vata vyadhis are considered here. Consumption of rooksha ahara, laghu ahara, alpa bhojana, and abhojana are considered as Vata prakopaka karanas. Above type of food habit deprives a person of nutrients which are essential for the replacement of worn-out tissues and maintenance of normal physiological activities. Sushruta opines that in vardhakya the poshaka Rasa Dhatu supports the Rasadhi Dahtus in such a way as to sustain the life, but fails to correct the Dhatu kshaya occuring due to the old age. The Dhatu kshaya supplemented by the Vatakara ahara leads to Vata prakopa. Various physical activities such as Bharaharana, pradhavana, adhwa, ati yana, vishamasana, abhighata are important viharaja nidanas of Sandhigata Vata. Repetitive movements may lead to excessive strain leading to erosion and joint damage. Major trauma and repetitive joint use are important risk factors for OA. Obesity is one of the major risk factors for knee OA. In sthoulya, ati matra medo vruddhi hampers the poshana of the rest of the dhatus, leading to Dhatu kshaya. In this case Asthi dhatu kshaya leading to Vata prakopa and more weight on knee joints, resulting in joint damage.

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Discussion

LAKSHANAS: Sandhi shula, Sandhi shotha, prasarana akunchanayoho savedana pravrutti and atopa are the important clinical features of Sandhigata Vata. This is similar to the general clinical features of OA viz. joint swelling, marginal tenderness, Painful and restricted joint movement associated with joint stiffness and crepitus. CHIKITSA: Janu Sandhi Gata Vata or Osteoarthritis of the knee is a major cause of disability among adults. No cure for osteoarthritis currently exists. Treatment focuses on managing the pain and dysfunction associated with the disease. Acupuncture is an effective treatment for management of pain and physical dysfunction associated with osteoarthritis of the knee. Since Janusandhigata Vata manifests in Janu Marma, Suchi Veda (an art of introducing delicate fine Suchi into different sensitive points in and around janu marma with in the radius of 3 angula) is done to stimulate janu marma & in turn to stimulate sandhi avayava’s present in it, so that it helps in relieving the pain & promotes sandhi poshana & thus helps in early repair of dhatu kshayata & restores normal joint integrity.                 CLINICAL STUDY: This is a controlled clinical study conducted on Janu Sandhigata Vata with special reference to OA of knee joint. After registering the patients who fulfil the inclusion criteria, they were randomly allotted into two groups. Patients of group A were

treated daily by Suchiveda on Janumarma for 12 sessions & for about 30 minute duration. And Patients of group B were treated daily by Acupuncture on Acupuncture points for 12 sessions & for about 30 minute duration. A total of 40 patients were registered for the study. Patients under Group A: 20 Completed treatments : 20

Patients under Group B: 20 Completed treatments : 20

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Dropout

:0

Dropout

:0

OBSERVATIONS: The data available from the observations made during the study are discussed here Age: In this study the upper age limit was restricted to 75 years with equal distribution of patients in all the age groups. Patients after 75 may not tolerate Suchi Veda Chikitsa hence age restriction was done up to 75 yrs. In the present study it is observed that in Group A 1(5%) patient in 41 to 45 years age group, 2 (10%) in 46 to 50 years, 3 (15%) in 51- 55 years, 6 (30%) in 56- 60 years, 4(20%) in 61- 65 years, 2(10%) in 65- 70 years and 2(10%) in 71- 75 years age group. In Group B 3(15%) patients 41 to 45 years age group, 2(10%) in 46 to 50 years, 1(5%) in 51- 55 years, 8(40%) in 56- 60 years, 3(15%) in 61- 65 years, 2(10%) in 65- 70 years and 1(5%) patient in 71- 75 years age group. With this above data we can say that after 40 yrs of age people are more prone to Osteoarthritis of the knee & OA of knee is a major cause of disability among adults. Sex: In this study it is observed that in Group A, 12 (60%) were male and 8 (40%) were female. In Group B, 12 (60%) were male and 8 (40%) were female. But generally Female sex is a risk factor for Knee OA, and Radiographic evidence of knee OA and especially symptomatic knee OA is more common in women than in men. Here the male patient’s ratio is more, it may be accidental & because the sample size is less we cannot take it as authenticated. Larger sample study says female ratio is more in OA of knee. Occupation: In group A house wife are more affected (40%), where as in group B both officials & laborers are more affected (30% & 35%). May be house wises are nearing their menopausal age they are more affected.

The previous report by

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135

Discussion

Husskison and Dudley – 1978 – says that Osteoarthritis is more common in menopause women with the ratio of female to male 2:1. People who do more physical labor, which involves long hours of working in fields, lifting weights, standing for long hours and traveling are more affected with OA. Knee joint is a weight bearing joint, hence the constant standing, walking long distances, lifting weights etc activities exerts stress on the joints and accelerates the process of degeneration. However the sample size is very small to arrive at any conclusion about the relation between OA and Occupation. Religion: In this present study it is seen that 95% in Group A and Group B were Hindus, 5% each in both groups were Muslim. With this can say that, in our hospital majority of the patients who come for Ayurvedic treatment are Hindus & OA manifests in later age of life irrespective of caste & religion & there is no significant relationship between disease manifestation & religion. Socio-economic Status: It is seen that in Group A 20% of patients were from Lower Class, 50% from Middle Class, 30% from Upper Class. In Group B 25% of patients were from Lower Class, 50% were from Middle Class, 25% were from Upper Class. With this we can say that most of the people who come to Govt. Hospital for treatment are from Lower & Middle Class people. And OA affects irrespective of Socioeconomic status of people. Chronicity of the Disease: In Group A 50% of patients had history of disease below 1 year, 40% had 1y – 2y history, 10% had 2y- 3y history, and no one had more than 3 years history. In Group B 50% had within 1 year, 25% had 1y- 2y history, 25% had 2y- 3y history and no one had more than 3 years history. Majority of patients are from 1yr chronicity, this shows that now a day’s people are very much aware about their A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Discussion

problems & they are health conscious & they want to get rid of their problem as early as possible, and hence they seek medical advice at the earliest. Food Habit: It is observed that in Group A 60% of patients were vegetarian and 40% of patients were mixed diet. And In Group B 50% each were of vegetarian diet and mixed. This does not seem to have any important role to play as far as Sandhivata is concerned. Family History: It is positive in 40% and 30% patients in Group A and Group B respectively, negative in 60% and 70% patients in Group A and Group B respectively. Number of Knees affected: 50% patients each were affected with bilateral and unilateral knee OA. Majority of the patients with unilateral OA showed marked improvement. The response was better in Group B than in Group A. This shows that unilateral OA responds to the treatment better than bilateral OA. In chronic conditions with bilateral OA the damage done to the joint is more and it is difficult to repair the damage.

RESULTS: Subjective parameters: I.

PAIN OR DISCOMFORT:

Marked relief was observed in pain or discomfort during nocturnal bed rest. In Group A 70% of patient got relief & were as in Group B 90% of patients got relief. Pain after getting up from sitting position: In Group A 65% improvement was found in pain after getting up, where as in Group B there was 75% relief. Increase in pain after remaining standing for 30 minutes: In group A the mean score before treatment was 0.95, which was reduced to 0.30 after the treatment, with a reduction of 65% of pain which was significant. In group B the A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Discussion

mean score before the treatment was also 0.8, but it reduced to 0.1 after the treatment, with a reduction of 70% of pain which was highly significant. This shows that the pain reduced better in the patients of group B than in the patients of group A. Pain on walking: In group A there was 70% relief in pain, where as in group B there was 90% relief in pain. This shows that Group B is much better in pain management because of its universally accepted accurate acupuncture points which has been in practiced since thousands of years & some of acupuncture points helps in Motor Recovery. Stiffness: There was 45% & 65% relief in morning stiffness & stiffness later in the day in Group A & in Group B there was 55% & 75% relief respectively. Once the pain is reduced the muscles around the joint relaxes & in turn helps in reduction of stiffness. Swelling in the Joint: In Group A there was 40% relief in the swelling, where as in Group B there was 50% relief. With this we can say that acupuncture or suchi veda is much better in pain management.

II.

MAXIMUM DISTANCE WALKED:

There was significant improvement in quality of walking in both the groups. In Group A 20% & in Group B 40% patients were able to walk UN limited distance, 45% each in both the groups able to walk more than 1 kilometre & 35% & 15% were able to walk about 1kilometre. It’s natural that when pain & stiffness is reduced patients were comfortable in walking after treatment.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Discussion

In Group A & Group B there was 45% & 40% improvements was seen in using walking aids respectively. Improvement is less when compared to other parameter because, patient uses walking aids only in severe OA when there is disturbance in joint anatomy, both these treatments to far extent is good at giving relief in sign & symptoms rather than reversing the degeneration. III.

ACITIVITIES OF DAILY LIVING:

There was significant difference in Climbing up & climbing down standard flight of stairs after treatment in Group A & Group B, but when compared to Group A, Group B was little better because acupuncture is good at motor function recovery. In Group A & Group B flexibility of the knee improved significantly & reduction in pain while squatting was noticed. In both the Group there was 75% improvement in pain on walking on uneven surface. This shows that both the treatment are significant in improving the joint stability. In Group A there was 68.75% & 71.5% & in Group B 85.68% & 81.25% improvement in Getting in or out of car & putting or taking of socks respectively. Overall better improvements were observed in activities of daily living in patients of group B than in group A. Since in Group A the points used are only local the effect is less, where as in Group B i.e. in acupuncture both local & distal points are used which has a Analgesic, Homeostatic (regulatory) & Motor recovery action.

IV.

OBJECTIVE PARAMETERS:

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Discussion

There was 65% relief in tenderness in Group A & 85% relief in Group B, this shows that Acupuncture is having good Analgesic action, hence WHO recommends acupuncture for pain management. Exact sensitive points for stimulation on janu marma (which is 3 angula pramana) should be identified for obtaining better analgesic action. There was 60% relief in crepitus in Group A & 70% relief in Group B. This shows that the treatment increased localized blood circulation which in turn helped in nourishing shleshaka kapha & cartilage. There was considerable reduction in measurement of knee in Group B when compared Group A was observed; this is because of anti inflammatory action of acupuncture treatment. In Group A there was 57.12% & 50% & in Group B 73.26% & 71.42% improvement in Range of Movement in right knee & left knee was found respectively. In Group A & Group B there was only 1 & 3 patients respectively showed very slight change in X-ray after treatment. In remaining 36 patients it was unchanged. This shows that in both groups X-ray changes was in significant. So probably more number of treatment sittings are necessary to repair the worn-out cartilage and articular surfaces to get significant changes with respect to Joint space, Osteophytes and other radiological features.

PROBABLE MODE OF ACTION OF SUCHI VEDA

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Discussion

Suchi veda stimulates janu marma & in turn it stimulates Sandhi Avayava’s present in it & helps in relieving the pain. It also promotes sandhi poshana & thus helps in early repair of Dhatu Kshayata & restores normal joint integrity. When suchi veda is done it increases the sthanika agni, it improves the blood local blood circulation & helps in cartilage regeneration & in turn reduces pain. In janu Sandhi gata vata there will be vata vriddhi, in turn there will be increase in sheeta guna, which causes stiffness of the joint, when suchi veda is done it increases ushmata & subsides sheeta guna & thus helps in relieving signs & symptoms of janu Sandhi gata vata. Suchi veda activates the doshas present in the janu marma and brings them into harmony through a controlled way of pricking & subsides signs & symptoms of janu Sandhi gata vata.

PROBABLE MODE OF ACTION OF ACUPUNCTURE Acupuncture is thought to relieve pain through the gate-control mechanism or through the release of neurochemicals. Pomeranz and Berman describe the possible neural mechanisms of acupuncture analgesia as follows: small diameter muscle afferents are stimulated, sending impulses to the spinal cord, which then activates 3 centers (spinal cord, midbrain, and pituitary) to release neurochemicals (endorphins and monoamines) that block pain messages. They discuss 17 different lines of research in support of endorphins being involved in acupuncture pain relief. While acknowledging that there is some debate, Pomeranz and German conclude that the evidence supporting the endorphin hypothesis is overpowering. The authors assert on A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Discussion

the basis of supporting evidence from several studies, that midbrain monoamines (serotonin and nor epinephrine) are also involved in acupuncture analgesia; however, the role of the pituitary is less clear.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Conclusion

CONCLUSION After systematic clinical trials, based on the observations, results & discussions following conclusions are drawn. 9 Sandhigata Vata is a type of Vata vyadhi commonly associated with the vardhakya and dhatu kshaya is a prominent feature in its manifestation. 9 Janu Sandhigata Vata or Osteoarthritis of the knee is a major cause of disability among adults. 9 Old age, female sex, obesity and repeated trauma are the main risk factors for Osteoarthritis of Knee joint. 9 No cure for osteoarthritis currently exists. Treatment focuses on managing the pain and dysfunction associated with the disease. 9 Treatment responses of all subjective & objective parameters were highly significant in both the groups. However Group B showed good improvements when compared to Group A. 9 Both Suchi Vyadha Chikitsa & Acupuncture is cost effective & ecofriendly. 9 Suchi Vyadha Chikitsa & Acupuncture treatments are simple technique that can be useful as a nondrug method of pain control. 9 The better response for Acupuncture is due to use of both local & distal points in treating OA & its exact location of Acupuncture Points. 9 Acupuncture & Suchi Vyadha is an effective treatment for management of pain and physical dysfunction associated with osteoarthritis of the knee. 9 No complications were observed during the study. A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Conclusion

Suggestion for further research: ¾ To Study on Meridians (Channels) in Traditional Chinese Medicine & Srotos in Ayurveda. ¾ To Study the Analgesic effect of Suchi Vyadha on Gridrasi & other vata vyadhis.

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Summary

SUMMARY

This dissertation entitled “A Comprehensive Study on Marma & Acupuncture Points and Evaluation of their Therapeutic Importance comprises of

six parts viz. Introduction, Literary review, Materials and Methods, Discussion, Conclusion and Summary. I. INTRODUCTION: The introduction gives a brief account of need and scope for the study and the rationality behind selecting the procedure and objectives of the study. II. REVIEW OF LITERATURE: Literary review is subdivided into 4 chapters namely Review of Marma, Review of Acupuncture, Disease review and Acupuncture needle review. Review of Marma: In this chapter the historical aspect, vyutpatti, nirukti, classification of Marma, composition of Marma, its anguli pramana & its viddha lakshana have been explained. Review of Acupuncture: This section deals with History, Traditional theory, Acupunture points & meridians & Chinese traditional diagnosis. Comparison of Ayurveda & Acupuncture: This chapter deals with comparison of basic principles of Ayurveda & Traditional Chinese Medicine, like Shrushti Utpatti Krama, Pancha Mahabhoota theory, Prana & Qi, Prakrithi & De, Nadi & Meridian And Marma & Acupuncture Points. Disease review: Under this heading the vytpatti, nirukti of the Janu Sandhigat Vata, functional anatomy of Janu sandhi, Nidana panchaka of Janu Sandhigata Vata with

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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Summary

treatment along with modern aspects of Knee joint and Osteoarthritis are described in brief. Procedure Review: In this chapter history of suchi vyadha, suchi vyadha procedure & suchi vyadha for different purpose is mentioned. Acupuncture needle review: History, different type of acupuncture needle, its length & diameter is explained in this chapter. III. MATERIALS AND METHOD: The second part of the study begins with Materials and Methods, where in description regarding the aims and the objectives, criteria of selection of patients, details of inclusion and exclusion criteria, diagnostic and assessment criteria for assessing the effects of the therapies and actual course of the trial have been explained. IV. OBSERVATIONS AND RESULTS: Thereafter general observations of the 40 patients of Janu Sandhigata Vata studied are presented in tabular form along with brief description of each finding and graphs. In the end the results along with statistical analysis of the results obtained are depicted. V. DISCUSSION: This section contains discussion about review of literature, materials & methods, observations & results & mode of action of procedure. VI. CONCLUSION: This section deals with the conclusions regarding the whole study & recommendations for further study. VII. SUMMARY: This is the gist of all the sections of this dissertation work.

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                                                                                                                                               Bibliography 

BIBLIOGRAPHY 1. Acharya Susrutha. Susrutha Samhita- Nibandhasamgraha of Dalhanacharya, Nyayacandrika Panjika of Sri Gayadasacarya, edited by Vaidya Yadavji Trikamji Acharya, Narayan Ramacarya Kavyatirtha. Varanasi: Chaukhambha Krishnadas Academy; reprint 2004. pp.734.

2. Agnivesha. Charaka Samhita - Revised by Charaka and Dridhabala with Ayurveda Deepika commentary of Chakrapani Datta. 3rd ed. Bombay: Nirnaya Sagar Press; 1941.pp.738.

3. Vagbhata Acharya. Ashtanga Hridaya- Sarvangasundara of Arunadatta, Ayurvedarasayana of Hemadri, collated by Dr. Anna Moreswar Kunte and Krishna Ramachandra Shastri Navre, edited by Pt. Bhishagacharya Harishastri Paradkar Vaidya. Varanasi: Krishnadas Academy; 2001. pp.965  

4. Raja

Radhakantha.

Shabdhakalpadruma-

Shri

varadaprasadvasu,

Shri

Haricharanavasu, 3rd ed. New Delhi: Naga Publishers; 2006. pp 937.

5. Chakrapani. Chakradatta – translated by Pandit Jaganatha Sharma Bajpeyee. Mumbai: Shri venkateshwara press; 4th ed. 2006. pp.

6. Vrddha Vagbhata. Ashtanga Samgraha- Sasilekha by Indu, prologue in Sanskrit and English by Prof.Jyotir Mitra. Varanasi: Chaukhambha Sanskrit Series Office; 1998. pp.965.

7. Sri Brahmasankara Misra, Sri Rupalalaji Vaisya. Bhavaprakasa of Sribhava Misra

including

Nighantu

portion-edited with the Vidyotini Hindi

Commentary. 11th ed. 2004. Varanasi: Chaukhambha publications; 1992. pp.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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8. Yogaratnakara– ‘Vidyotini’ Hindi commentary by Vaidya Lakshmipati Shastri. Edited by Bhishagratna Bramhananda Shastri. 7th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1999. pp.

9. Sharangadhara Acharya. Sharangadhara Samhita– Deepika of Adhamalla and Gudhartha Deepika of Kashirama. Varanasi: Krishnadas Academy; reprint 2000. pp.

10. Madhavakara. Madhava Nidana– Madhukosha by Vijayarakshita and Srikanthadatta, extracts from Atankadarpana by Vachaspati Vaidya. Varanasi: Chaukambha Orientalia; 6th ed. 2001. pp.  

11. Nicholas A Boon, Nicki R , Brain R Walker, John AA Hunter, Editors, Davidson’s Principle & Practice of Medicine – 20th ed. CHURCHILL LIVINGSTONE: ELSEVIER L; 2006, International Edition.  

12. Churasia B.D. Human Anatomy Regional & Applied – reprint 2000. New Delhi: CPB Publishers & Distributors; 2000.  

13. Dennis L.Kasper,et al,J.Larry Jameson, Editors, Harrison’s Principles of Internal Medicine – New Delhi: McGraw – Hill, Medical Publishing Division; 2005, volume-2.  

14. Kijowski et al. American Journal of Rheumatology: 187-September-2006.

15. Dr.David Frawley, Dr. Subhash Ranade, Dr. Avinash Lele. Ayurveda & Marma Therapy.1st ed Delhi: Choukhamba Sanskrit pratistana; 2003. pp.259.  

16. Anton Jayasuriya. Clinical Acupunture-Revised edition 2002, reprint edition:2007, Published by Kuldeep Jain, for B.Jain Publishers (P) Ltd.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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17. Prof J.N Mishra. Marma and Its Management. 1st ed. Varanasi: Choukamba Orientalia; 2005. pp. 254.  

18. Dr.David Frawley, Dr. Subhash Ranade, Dr. Avinash Lele. Secrets of Marma.1st ed, reprint;2005, Delhi: Choukhamba Sanskrit pratistana; pp.115.  

19. Frank Ros. The lost secrets of Ayurvedic Accupunture. 1st ed. Delhi: Jainendra Prakash Jain at shri Jainendra Press; 1995. pp.203.  

20. Alexander Macdonald. Acupunture: From ancient art to modern medicine. 1st ed. Great Britain:Guernsey Press Co. Ltd; 1982.pp.184.

21. Monier – Williams. A Sanskrit English dictionary M. Monier – Williams.Collected ed. Delhi: Motilal Banarsidass Publishers Private Limited; 2002.

22. R.C.G.Russell, Norman S. Williams and Christopher J.K. Bulstrode. Bailey and Love’s Short Practice of Surgery- International student’s edition. 24th ed. 2004.pp.1348.

23. John Ebnezar. Text book of Orthopedics, Delhi: Jaypee brother’s medical publishers (P) Ltd; 3rd ed. 2006.pp.478. 24. Ronald McRae. Clinical Orthopedic examination. Newyork: Churchil Livingstone; 5th ed. 2004.pp. 318. 25. Hand book of pain management-G.P. Dureja.1sted. Delhi: Elsevier publication; 2004.pp.338. 26. Richard L Drake, Wayne Vogl, Adam W N Mitchell. Gray’s anatomy for students- New York: Elsevier Churchill Livingstone; 2005. pp. 1578.

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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27. Pamela k Levangie, Cynthia C Norkin. Joint structure & function – A Comprehensive Analysis, Newdelhi: Jaypee Publication; 4th ed. 2006. pp. 588.

28. Jayanth Joshi, Prakash kothwal. Essentials of Orthopaedics and Applied Physiotherapy. New Delhi: Elsevier publication; reprint 2008. pp. 592.

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Websites •

http://www.emedicinehealth.com/articles

•

http://www.drgraceliu.com

•

http://www.pubmedcentral.nih.

•

http://www.osteoarhtritis.about.com

•

http://en.wikipedia.org/

A Comprehensive Study on Marma & Acupuncture Points And Evaluation of their Therapeutic Importance.

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INFORMED CONSENT FORM

I ..................………………... here by willingly agree to participate in this clinical study. I affirm that there has been no compulsion or monetary inducement in my agreeing to be volunteer for this study, which I do on my free will. I have been explained the general purpose of the experiment. I am convinced that it is for my benefit & for the benefit of science and mankind. I understand that the risk involved is very less. I agree to undergo following investigations.

1. Radiological examination 2. Blood investigations

I also agree to remain under observation for 2 months period. I can apt out the study at any time.

Signature of the investigator

Signature of the Guide

Signature of the Volunteer

DEPARTMENT OF P.G. STUDIES IN SHALYATANTRA. GOVERNMENT AYURVEDIC MEDICAL COLLEGE, BANGALORE-560009 PROFORMA OF CASE SHEET FOR JANU SANDHIGATA VATA GROUP- A/GROUP- B PART – I ADMISSION FORM PG Scholar: - DR.VIVEK.J Guide: - DR.VENKATESH.B.A 1. Name of the patient

:

Reg. No:

2. Father’s / Husband’s Name

:

OPD No:

3. Age

:

IPD No:

4. Sex

:

8. Address

M

F

Bed No:

: _____________________________ Phone No: _____________________________ Email ID: _____________________________

9. Educational Status: - Illiterate/ Read and Write/ Graduate/ Post Graduate 10. Occupation: - Desk work/ Field work/ Physical labor/ House wife/others Indicate Nature of work: 11. Socio-economic status: - P/LM/UM/R 12. Religion: - Hindu/Muslim/Christian/Others 13. Marital status: - Unmarried/Married/Widow/Widower/Divorcee 14. Date of Initiation

:

15. Date of Completion

:

16. Result

:

PART II/CASE RECORD 1. CHIEF COMPLAINTS:Sl.

Chief complaints

Duration

After Treatment

No JanuSandhi shotha/ 1

Vatapoorna druti sparsha (Swelling) Prasarana Akunchanayoho

2

Savedana Pravrutthi (Pain on extension & flexion) Sandhigraha (Joint Stiffness)

3

-

Morning stiffness (0 - 30 minutes)

4

Stiffness after disuse

Limitation of joint movement

5

Shoola (Tenderness)

6

Atopa (Crepitation)

NATURE

Pricking

Aching

Generalized

Tearing

OF

PAIN: ROUTINE ACTIVITIES AFFECTED:

2. HISTORY OF PRESENT ILLNESS:

3. HISTORY OF PAST ILLNESS:

Yes

No

Burning

4. TREATMENT

Modern Medicine Ayurvedic Medicine/Therapy

HISTORY:

Other Systems Relief with previous treatment 5. FAMILY HISTORY:

OA

Partial / No relief

Other Joint disorder

RA

6. PERSONAL HISTORY: 1. Ahara:

Veg

2. Agni:

Manda

3. Koshta;

Non Veg

Teekshna

Madhya

Vishama

Mrudu

4. Nidra:

Sukha

5. Vyasana:

Smoking

Alpa

Sama

Krura

Ati

Tobacco

Vishama

Alcohol

Others

None

7. OBSTETRIC HISTORY:

GYNAECOLOGICAL HISTORY:

M.C._____ Days R/IR: Menarche _____ yrs

Dysmenorrhoea/Leucorrhoea/Metrorrhagia/Menorrhagia

PARIKSHA VIDHI/EXAMINATION 1. VITAL SIGNS: Weight in Kgs

Pulse rate per minute

Height in Cms

Respiration per Minute

Temperature in Degree Celsius

Blood Pressure in mm Hg

2. ASHTA STHANA PAREEKSHA Nadi: -

/min, regular/irregular

Jihva: - Alipta/Ishat Lipta/Lipta Mala: - Badda/Abadda, Sama/Nirama ____ Times/Day Mutra: - Prakruta/Vikruta ____ Times/Day Shabda: - Prakruta/Vikruta Sparsha: -Mrudu/Khara Druk: - Prakruta/Kunchita Akruti: - Sthula/Madhyama/Heena 3. Atura Bhoomi Desha Pareeksha Jangala

Jangala Jata

Anupa

Vardhita

Sadharana

Anupa

Jangala Vyadhita

Sadharana

Anupa Sadharana

4. Atura Deha Desha Pareeksha: DASHAVIDHA PAREEKSHA 1 2 3 4 5 6 7

8

9

PRAKRUTI SARATAHA SAMHANANA TAHA SAATMYATA HA PRAMANATA HA SATVATAHA AHAARA SHAKTITAH A VYAYAMA SHAKTITAH A VAYATAHA

Shareera Manasika Pravara

Avara

Ekarasa Divasvapna

Madhyama samhata Sarvarasa Vyayama

Sama

Heena

Adhika

Pravara

Madhyama

Avara

Pravara

Madhyama

Avara

Pravara

Madhyama

Bala

Yuva

Susamhata Rasa Vihara

Madhyama

Asamhata Vyamishra

Avara Vriddha

4. SROTO PAREEKSHA: RASAVAHA SROTAS;-

ASTHIVAHA SROTAS: -

MEDOVAHA SROTAS:-

OTHER SROTAS:-

6. SYSTEMIC EXAMINATION: C.V.S: -

R.S.: -

G.I.T.: -

NERVOUS SYSTEM: -

7. SPECIAL EXAMINATION OF JOINTS A. Darshana Pareeksha:

1) Joint

Right Knee

Present

Absent

Present

Absent

Swelling: Left Knee

2) Deformity:

Present

Absent

3) Joint Movement:

4) Muscle Wasting:

Completely Restricted

Partially restricted

Passive Completely Restricted

Partially restricted

Active

Present

Absent

B. Sparshana (Palpation)

1. Local Temperature

Raised

Not raised

2. Tenderness

Grading

3. Crepitus:

Heard

0

1

2

Felt

3

None

5. Measurement: Circumference of

Right Knee

Knee Joint Left Knee

8. Range of Movement (Goniometric Measurement)

Normal

Before

After

Reading

Treatment

Treatment

ROMExtension of

120-0 degree

Knee ROM-Flexion

0-130 degree

of Knee

Hb%

Total Count (WBC)

6. Lab Investigations:

ESR

/1st Hr.

Random Blood Sugar

Mg/dl

9. RADIOLOGICAL EXAMINATION OF KNEE JOINTS (Antero- posterior/ Lateral View) Reduced

Unaltered

2 Subchondral bony sclerosis

Present

Absent

3 Formation of osteophytes

Present

Absent

4 Periarticular ossicles

Present

Absent

1

Joint space

5 Others

CHIKITSA VIDHI Group A Patients of this group were treated daily by Suchivyadha on Janumarma for 12 sessions & for about 30 minute duration. Group B Patients of this group were treated daily with Acupuncture on Acupuncture points for 12 sessions & for about 30 minute duration.

ASSESSMENT CRITERIA:I. SUBJECTIVE PARAMETRERS: I 1 2

9 10

Pain Morning Stiffness Stiffness later in the day Remaining standing for 30minutes Pain on walking Pain or Discomfort after getting up from sitting without use of arms Maximum distance Walked Walking aids required Able to climb up flights of stairs Able to climb down flight of stairs Able to squat or bend at Knee

11

Able to walk on uneven surface

12

Swelling in the joint

13

Getting in or out of car

14

Putting on or taking off socks

3 4 5 6 7 8

II

III

IV

V

II. OBJECTIVE PARATERS: I 1

Tenderness

2

Crepitus

3

Measurement of knee at fixed points

4

5 6

II

III

IV

V

Rt. Knee Lt. Knee

Range of Movement (Knee flexion) (Goniometric Measurement) Time taken to walk 50 Meters distance Radiological treatment

Changes

After

INVESTGATOR’S NOTE:Signature of Investigator

Signature of the Guide

Clinical Observations in Suchi Veda Chikitsa (Group‐A)

Sl.No. NAME 1 2 4 5 6 8 11 13 14 15 16 18 19 20 3 7 9 10 12 17

Kulvanthkaur Ramesh Murthy Narayana Shetty Manjiththaya R.V Indira Jayamma Nagaraj Vasudeu Sakamma Shashikala Prasanna Abdul Khader Srivatsa Kempachari Ratnamma Narasimha Murthy Madhu Nagratnamma Sarvamangala

OP/IP NO. OP.13825 IP.815 IP.533 OP.32508 OP.19593 OP.34370 IP.595 OP.13819 OP.14090 OP.25461 OP.30811 OP.32510 OP.21610 OP.22121 OP.15167 OP.31621 OP.40780 OP.40865 OP.12168 OP.30940

AGE  56 48 60 60 66 55 52 60 58 65 61 59 55 45 65 68 46 74 73 63

SEX F M M M M F F M M F F M M M M F M M F F

OCCUPATION HOUSE WIFE BUISNESSMAN BUISNESSMAN BUISNESSMAN OFFICIAL HOUSE WIFE HOUSE WIFE OFFICIAL OFFICIAL HOUSE WIFE HOUSE WIFE OFFICIAL BUISNESSMAN BUISNESSMAN BUISNESSMAN HOUSE WIFE BUISNESSMAN OFFICIAL HOUSE WIFE HOUSE WIFE

RELIGION HINDU HINDU HINDU HINDU HINDU HINDU HINDU HINDU HINDU HINDU HINDU HINDU MUSLIM HINDU HINDU HINDU HINDU HINDU HINDU HINDU

CHRONICITY  12 10 18 6 36 6 18 30 12 24 12 6 24 20 24 24 12 12 24 6

DIET VEG MIXED MIXED VEG VEG VEG MIXED VEG MIXED MIXED VEG VEG MIXED VEG VEG MIXED VEG MIXED VEG VEG

FAMILY HISTORY POSITIVE NEGATIVE NEGATIVE POSITIVE POSITIVE POSITIVE NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE POSITIVE POSITIVE

Pain  Pain  Pain on  Pain on  Morning  Stiffness  Swelling  Maximu Walking  Able to  Able to  Able to  Able to walk  Getting in  Putting on  Tendern Crepitus BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 SE DATE OF COM DATE OF COMP JOINT AFFECTED MC 4/28/2010 5/9/2010 LEFT KNEE 5/12/2010 BOTH KNEE LC 5/1/2010 6/15/2010 RIGHT KNEE MC 6/4/2010 6/19/2010 RIGHT KNEE MC 6/8/2010 UC 6/12/2010 6/23/2010 RIGHT KNEE MC 8/2/2010 8/13/2010 BOTH KNEE MC 8/20/2010 8/31/2010 BOTH KNEE UC 9/4/2010 9/15/2010 LEFT KNEE UC 9/10/2010 9/21/2010 BOTH KNEE LC 9/10/2010 9/21/2010 LEFT KNEE LC 9/15/2010 9/26/2010 RIGHT KNEE UC 10/2/2010 10/13/2010 BOTH KNEE LC 10/4/2010 10/15/2010 LEFT KNEE 10/17/2010 LEFT KNEE UC 10/6/2010 5/21/2010 BOTH KNEE MC 5/10/2010 UC 7/15/2010 7/26/2010 BOTH KNEE MC 8/10/2010 8/21/2010 LEFT KNEE MC 8/16/2010 8/27/2010 BOTH KNEE MC 9/1/2010 9/12/2010 BOTH KNEE MC 9/18/2010 9/29/2010 RIGHT KNEE

2 2 2 1 1 2 1 2 2 2 2 2 1 1 2 2 2 2 2 2

1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1

2 1 2 1 1 2 1 1 1 2 2 2 2 2 2 2 2 2 2 2

1 0 1 1 0 1 1 0 1 1 1 2 1 1 2 2 2 2 2 2

0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1

1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1

0 1 0 0 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1

2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 2 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1

3 3 3 0 2 3 2 2 3 3 3 1 2 2 1 1 1 3 3 1

2 2 2 0 1 2 1 1 2 2 2 1 1 1 1 1 1 2 2 1

1 1 1 0 0 1 1 0 1 1 1 0 0 0 0 0 0 2 1 0

3 3 2 0 1 2 1 2 3 3 2 1 3 3 2 2 2 2 2 2

1 1 1 0 0 1 1 1 2 1 1 1 2 1 1 1 1 1 1 1

0 1 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 1 0

3 3 3 1 0 3 1 0 2 3 3 2 1 3 2 0 2 2 0 2

2 2 2 1 0 2 1 0 1 1 2 1 1 2 1 0 1 1 0 2

1 0 1 0 0 1 0 0 0 0 1 0 0 0 1 0 1 1 0 1

6 6 6 3 3 6 3 3 6 6 6 4 5 5 5 5 5 5 3 5

4 4 4 1 1 4 1 2 4 4 4 2 3 3 3 3 3 3 2 3

1 2 1 0 0 1 0 1 2 1 1 0 1 1 2 2 2 2 1 2

1 1 1 1 0 1 0 0 1 1 1 1 0 0 1 1 0 1 0 1

1 0 0 1 0 0 0 0 1 1 1 1 0 0 1 1 0 1 0 1

0 2 1 0.5 2 1 0 2 1 0 2 1 0.5 2 1 0 2 1 0 2 1 0.5 2 1 0 2 1 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 2 1 0.5 2 1.5 1 2 1 0 1.5 1 0 1 0.5 0.5 1.5 0.5 0 1 0.5 0 1 0.5 0 2 1.5 0 2 1 0.5 2 1 0 2 1 0 2 1 0.5 2 1 0 2 1 0 2 1 0.5 2 1.5 1 2 1 0 1 0.5 0 1 0.5 0 1.5 0.5 0 1.5 1 0 1 0.5 0 2 1.5 0 1.5 1 0 1 0.5 0 2 1.5 1 2 1.5 1 2 1 0 2 1 1 2 1.5 1 2 1 0 2 1 0 2 1.5 1 2 1.5 1 1.5 1 1 2 1.5 1 2 1 0 2 1 0 2 1.5 1 1.5 1 0.5 2 1.5 1 2 1.5 1 2 1.5 1 1.5 1

0.5 0 0.5 0 0 0.5 0 1 0.5 0.5 0.5 0 0.5 0.5 1 1 1 1 1 1

1.5 1.5 1.5 1 1 1.5 1.5 1 1.5 1.5 1.5 1 2 2 0.5 0.5 1.5 0.5 1.5 1.5

0.5 1 0.5 0.5 0.5 0.5 0.5 0.5 1 0.5 0.5 0.5 1 1 0.5 0.5 1 0.5 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0.5 0.5 0 0 0.5 0 0.5 0.5

1 1.5 ‐ 1 1.5 ‐ 1 0.5 1.5 1 ‐ 1.5 ‐ 1 1 1 2 1 1.5 2

0.5 1 ‐ 0.5 1 ‐ 0.5 0 1 0.5 ‐ 0.5 ‐ 0.5 1 1 1.5 1 1 1.5

0 0 ‐ 0 0 ‐ 0 0 0 0 ‐ 0 ‐ 0 1 1 1 1 0 1

1 1.5 ‐ 0.5 1 1.5 0.5 0.5 1.5 1 1.5 1 ‐ 1.5 2 2 2 2 1 2

0.5 0.5 ‐ 0 0.5 1 0 0 0.5 0.5 1 0.5 ‐ 0.5 1.5 1.5 1 1.5 0.5 1

0 0 ‐ 0 0 0 0 0 0 0 0 0 ‐ 0 1 1 0.5 1 0 0.5

3 2 3 3 2 3 2 2 2 3 3 2 2 2 3 3 3 3 3 3

1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2

0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 1 1 1

2 1 2 1 1 2 1 2 1 2 2 1 1 1 2 2 2 2 1 2

1 1 1 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 2

Measurement of Rt  BT 6 12

Measurement of  Range of  Range of  Time taken  Radiologi Over All Relief t lk 50 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12

1 ‐ ‐ ‐ 55‐3 52‐0 50‐0 ‐ ‐ ‐ 0 36.5‐3 36‐2 35‐1 37‐3 36.5‐2 36‐1 3 2 0 0 33‐3 32‐1 31‐0 ‐ ‐ ‐ 2 1 0 0 30‐Mar 29‐Jan 29‐Jan ‐ ‐ ‐ 2 1 0 0 32‐3 32‐3 32‐3 ‐ ‐ ‐ 3 1 0 0 32‐3 31.5‐2 31‐Jan 33‐3 32‐1 31‐0 3 2 0 0 37‐3 36‐1 35‐0 37‐3 37‐3 36‐1 2 2 1 1 ‐ ‐ ‐ 45‐3 45‐3 45‐3 ‐ ‐ ‐ 0 36.5‐3 36‐2 35‐1 37‐3 36.5‐2 36‐1 3 2 0 1 ‐ ‐ 55‐3 52‐0 50‐0 ‐ ‐ ‐ 0 32‐3 31.5‐2 31‐Jan 33‐3 32‐1 31‐0 3 2 0 0 40‐3 40‐3 39‐1 41‐3 40‐1 39‐2 2 1 0 0 ‐ ‐ ‐ 37‐3 36‐1 36‐1 ‐ ‐ ‐ 0 ‐ ‐ ‐ 48‐3 47‐1 46‐0 ‐ ‐ ‐ 2 35‐3 35‐3 34‐1 36‐3 35‐1 35‐1 3 2 2 2 35‐3 35‐3 35‐3 36‐3 35‐1 35‐1 3 2 2 2 ‐ ‐ ‐ 38‐3 37‐1 37‐1 ‐ ‐ ‐ 2 35‐3 35‐3 34‐1 36‐3 35‐1 35‐1 3 2 2 0 40‐3 40‐3 40‐3 40‐3 40‐3 39‐1 3 2 1 2 35‐3 35‐3 34‐1 ‐ ‐ ‐ 3 2 2

3 3 ‐ ‐ ‐ 3 2 2 3 3 3 2 2 2 3 3 2 3 3 ‐

2 1 ‐ ‐ ‐ 1 1 1 1 2 2 1 1 1 2 2 1 2 2 ‐

1 0 ‐ ‐ ‐ 0 0 0 0 1 1 0 0 0 2 2 1 2 1 ‐

2 3 2 2 3 2 3 2 3 2 2 2 2 2 3 3 3 3 3 3

1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 1 2 0 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

13 Para‐ MOD Imp 16 Para‐ Mar Imp 11 Para‐ Mod Imp 17 Para‐ Mar Imp 17 Para‐ Mar Imp 13 Para‐ MOD Imp 17 Para‐ Mar Imp 12 Para‐ MOD Imp 16 Para‐ Mar Imp 14 Para‐ Mar Imp 12 Para‐ MOD Imp 19 Para‐ Mar Imp 13 Para‐ MOD Imp 16 Para‐ Mar Imp 4 Para‐ Mild Imp 4 Para‐ Mild Imp 2 Para‐ Mild Imp 2 Para‐ Mild Imp 4 Para‐ Mild Imp 2 Para‐ Mild Imp

Abbreviations‐ OP‐ Out‐patient IP‐In‐patient M‐Male F‐Female M.C‐Middle class L.C‐ Lower class U.C‐ Upper class Veg‐Vegetarian D.o.Com‐Date of commencement D.o.comp‐Date of completion BT‐ Before treatment

Clinical Observation in Accupuncture Treatment (Group‐B)

Sl.No

NAME

Pain 

OP/IP No.

AGE SEX

OCCUPATION RELIGIO CHRONICITY   DIET N IN MONTHS

FAMILY  HISTORY

SE

DO  COM

Pain 

Pain on  Pain on  Morning  Stiffness  Swelling  Maximu Walking 

Able to 

Able to 

Able to 

Able to 

Getting in  Putting on  Tendern Crepitus

DO COMP

JOINT                     BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12 AFFECTED

1 2 3 4 5 6 7 8 9 10 11 12 13

Honne Gowda Bachchappa Venkataramana Narasimha Shanthi Rajeshwari Leena Saroja Devi Kumuda Shantala Devi Shahida Bhanu Ranganath Srinivas

2772 IP.224 IP.241 6616 IP.635 IP.596 12170 IP.146 12161 14096 21507 2771 25478

43 74 65 66 56 58 42 54 56 41 48 48 65

M M M M F F F F F F F M M

Labourer Labourer Labourer Official House Wife House Wife House Wife Official House Wife Official House Wife Labourer Labourer

Hindu Hindu Hindu Hindu Hindu Hindu Hindu Hindu Hindu Hindu Muslim Hindu Hindu

12 36 6 24 12 36 6 12 18 6 24 18 36

Mixed Mixed Mixed Veg Veg Mixed Veg Veg Veg Mixed Mixed Mixed Veg

Positive Negative Negative Negative Negative Negative Positive Negative Negative Positive Positive Negative Negative

LC LC LC UC MC MC UC MC MC UC MC LC MC

4/26/2010 4/30/2010 5/6/2010 5/6/2010 5/19/2010 5/21/2010 6/5/2010 6/11/2010 6/14/2010 7/19/2010 7/23/2010 8/2/2010 8/10/2010

4/7/2010 5/11/2010 5/17/2010 5/17/2010 5/30/2010 6/1/2010 6/16/2010 6/22/2010 6/25/2010 7/30/2010 8/3/2010 8/13/2010 8/21/2010

Rt Knee Lt Knee Lt Knee Lt Knee Lt Knee Both Rt Knee Both Lt Knee Both Rt Knee Both Both

2 1 2 2 2 1 2 2 1 2 1 2 2

1 0 1 1 1 0 1 1 0 1 0 1 1

0 0 0 0 0 0 1 0 0 0 0 0 0

2 2 2 1 2 1 2 1 2 1 1 1 2

1 1 1 0 1 1 2 0 1 0 1 0 2

0 0 0 0 0 0 1 0 0 0 0 0 1

1 1 1 0 1 1 1 0 1 1 1 0 1

0 1 0 0 0 1 1 0 1 0 0 0 1

0 0 0 0 0 0 1 0 0 0 0 0 0

2 2 2 1 2 2 2 1 2 2 2 1 2

1 1 1 0 1 1 1 0 1 1 1 0 1

0 0 0 0 0 0 1 0 0 0 0 0 0

3 2 1 2 3 2 1 2 2 3 0 2 0

2 1 1 1 2 1 1 1 1 2 0 1 0

1 0 0 0 1 1 0 0 0 1 0 0 0

2 3 1 2 3 1 2 2 3 3 0 2 1

1 1 1 1 1 1 1 1 1 1 0 1 1

1 0 0 0 0 0 0 0 0 1 0 0 0

3 1 0 0 3 1 2 3 3 3 1 0 2

2 0 0 0 2 1 1 1 1 2 1 0 1

1 0 0 0 1 0 1 0 0 0 0 0 0

6 5 5 3 6 3 5 4 5 6 3 4 4

4 3 3 2 4 1 3 2 3 4 1 2 2

1 1 1 0 1 0 2 0 1 2 0 0 0

1 0 1 0 1 0 1 0 0 1 1 0 1

0 0 1 0 0 0 1 0 0 0 1 0 1

0 2 1 0.5 2 1 0 2 1 0 1.5 1 0 1 0.5 0 2 1.5 0 2 1 0.5 2 1 0 1.5 1.5 0 1 0.5 0 2 1.5 1 1 0.5 0 2 1 0.5 2 1 0 2 1 0 1.5 1 0 1 0.5 0.5 1.5 0.5 1 2 1.5 1 2 1.5 1 1.5 1 0 1 0.5 0 1 0.5 0 1.5 0.5 0 1.5 1 0 1 0.5 0 2 1.5 0 2 1 0.5 2 1 0 2 1 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1.5 0.5 0 1 0.5 0 1 0.5 0 1.5 0.5

0.5 0.5 1 0 0.5 0 1 0.5 0.5 0.5 0 0.5 0

1.5 2 1.5 1 1.5 1.5 1.5 1 2 1.5 1 1 1

0.5 1 0.5 0.5 0.5 0.5 1 0.5 1 1 0.5 0.5 0.5

0 0.5 0 0 0 0 0.5 0 0.5 0 0 0 0

14 15 16 17

P.M.Kannan Jayaram Krishna Murthy Mallikarjun Swamy

25466 IP.944 12171 30825

60 61 60 66

M M M M

Official Labourer Businessman Official

Hindu Hindu Hindu Hindu

30 12 24 30

Veg Mixed Mixed Veg

Positive Negative Negative Negative

UC LC MC UC

8/11/2010 8/30/2010 9/1/2010 9/13/2010

8/22/2010 9/10/2010 9/12/2010 9/24/2010

Both Both Rt Knee Both

2 2 2 2

1 1 1 1

1 0 0 0

2 2 2 2

2 1 1 2

1 0 0 1

1 1 1 1

1 0 1 1

1 0 0 0

2 2 2 2

1 1 1 1

1 0 0 0

1 3 2 1

1 2 1 0

0 1 0 0

2 2 3 1

1 1 1 0

0 1 0 0

2 3 0 2

1 2 0 1

1 1 0 0

5 6 5 4

3 4 3 2

2 1 1 0

1 1 1 1

1 0 1 0

1 2 1.5 0 2 1 1 1.5 1 0 1 0.5

1 0.5 1 0

0.5 1.5 2 1

0.5 0.5 1 0.5

0 1 1 0 ‐ ‐ 0.5 ‐ ‐ 0 1.5 0.5

18 19 20

Sheela Devi K.Madhu Narayan Rao

31623 30946 32501

57 60 60

F M M

Official Labourer Businessman

Hindu Hindu Hindu

6 12 12

Veg Mixed Veg

Positive Negative Negative

MC MC MC

9/13/2010 9/17/2010 9/20/2010

9/24/2010 9/28/2010 31‐09‐2010

Both Rt Knee Rt Knee

1 1 0 2 1 0 1 0 0

Abbreviations‐ OP‐ Out‐patient IP‐In‐patient M‐Male F‐Female M.C‐Middle class L.C‐ Lower class U.C‐ Upper class Veg‐Vegetarian D.o.Com‐Date of commencement D.o.comp‐Date of completion BT‐ Before treatment

1 0 0 2 1 0 2 1 0

1 0 0 1 0 0 0 0 0

1 0 0 2 1 0 2 1 0

0 0 0 3 2 1 2 1 0

2 1 0 2 1 1 3 1 0

3 2 0 0 0 0 2 1 0

4 2 0 6 4 1 5 3 1

1 0.5 0 0

2 1 0 2 2 1.5 1 2 1 0.5 0 2 1 0.5 0 1.5

1 1 1.5 0.5

‐ ‐ ‐ 0.5 1 1 2 1 1 1.5 1 ‐ 1.5

‐ ‐ ‐ 0 0.5 0.5 1.5 0.5 0.5 1 0.5 ‐ 0.5

‐ ‐ ‐ 0 0 0 1 0 0 0 0 ‐ 0

‐ ‐ ‐ 0.5 1 0.5 2 0.5 1.5 1.5 0.5 ‐ 1

‐ ‐ ‐ 0 0.5 0 1 0 0.5 0.5 0 ‐ 0.5

1 2 1.5 ‐ 1.5 1 ‐ 1.5 1 0 1 0.5

Measurement of Rt  BT 6 12

Measurement of  Range of  Range of  Time taken  Radiolog M t t lk 50 BT 6 12 BT 6 12 BT 6 12 BT 6 12 BT 6 12

‐ ‐ ‐ 0 0 0 0.5 0 0 0 0 ‐ 0

3 2 3 2 3 2 3 2 2 2 3 2 2

1 1 1 2 1 1 2 1 1 1 1 1 1

0 0 0 1 0 0 1 0 0 0 0 0 0

2 1 2 2 2 1 2 2 1 1 1 2 1

1 1 1 1 1 1 2 1 0 1 0 1 1

0 33‐3 32‐1 31‐0 ‐ ‐ 0 ‐ ‐ ‐ 37‐3 36‐1 0 ‐ ‐ ‐ 34‐3 34‐3 1 ‐ ‐ ‐ 45‐3 45‐3 1 ‐ ‐ ‐ 55‐3 52‐0 0 37‐3 36‐1 35‐0 37‐3 37‐3 2 35‐3 35‐3 34‐1 ‐ ‐ 1 46‐3 45‐1 44‐0 46‐3 44‐0 0 ‐ ‐ ‐ 48‐3 47‐1 0 36.5‐3 36‐2 35‐1 37‐3 36.5‐2 0 30‐Mar 29‐Jan 29‐Jan ‐ ‐ 1 39‐3 39‐3 39‐3 39‐3 39‐3 0 39‐3 38.5‐2 38‐1 38‐3 38.5‐3

2 ‐ ‐ ‐ ‐ 2 3 3 ‐ 3 2 3 2

1 ‐ ‐ ‐ ‐ 2 2 1 ‐ 2 1 1 1

0 ‐ ‐ ‐ ‐ 1 2 0 ‐ 0 0 0 0

‐ 2 3 2 3 2 ‐ 3 2 3 ‐ 3 2

‐ 1 2 1 2 1 ‐ 1 1 1 ‐ 1 1

‐ 0 1 0 1 0 ‐ 0 0 0 ‐ 0 0

2 2 2 2 2 3 3 2 2 3 2 2 2

1 1 1 1 1 1 2 1 1 1 1 1 1

0 0 0 0 0 0 2 0 0 0 0 0 0

3 3 3 3 3 3 3 3 3 3 3 3 3

3 3 3 3 3 3 3 3 3 3 3 3 3

2 3 3 3 3 3 3 3 3 2 3 3 2

1 0 1 0

3 3 2 2

2 1 1 1

1 0 0 0

2 2 1 1

2 1 0 1

2 0 0 0

35‐3 32‐3 35‐3 40‐3

3 3 2 2

2 2 1 1

2 0 1 0

3 3 ‐ 2

2 2 ‐ 1

2 1 ‐ 0

3 2 2 2

2 1 1 1

2 0 0 0

3 3 3 3

3 3 3 3

3 3 3 3

2 1 0 2 1 0 1 1 0

50‐3 34‐3 40‐3

0 0 0 1 0.5 0 1 0.5 0 1.5 0.5 0.5 1.5 0.5 0 1 0.5 0 0.5 0 0 0 0 0 2 1 0.5 2 1 0 1 0.5 0 1.5 0.5 0 1 0.5 0 1.5 0.5 0 0 0 0 1.5 1 0 1 0.5 0 2 1.5 0.5 2 1 0.5 1 0.5 0 1 0.5 0

2 1 0 3 1 0 2 1 0

‐ 36‐1 34‐3 45‐3 50‐0 36‐1 ‐ 43‐0 46‐0 36‐1 ‐ 38‐1 38.5‐ 3 35‐3 34‐1 36‐3 35‐1 35‐1 31.5‐2 31‐Jan 33‐3 32‐1 31‐0 35‐3 35‐3 ‐ ‐ ‐ 40‐3 39‐1 41‐3 40‐1 39‐0 48‐0 34‐3 39‐1

46‐0 34‐3 38‐0

50‐3 48‐0 47‐0 3 1 0 ‐ ‐ ‐ 2 1 0 ‐ ‐ ‐ 2 1 0

3 1 0 ‐ ‐ ‐ ‐ ‐ ‐

2 1 0 2 1 0 2 1 0

3 3 3 3 3 3 3 3 3

Over all relief

12 para‐ MOD Imp 13 para ‐Mar Imp 12 para ‐MOD Imp 13 para ‐MOD Imp 13 para ‐MOD Imp 17 para ‐Mar Imp 2 para ‐Mild Imp 18 para‐Mar Imp 16 para‐Mar Imp 15 para‐Mar Imp 17 para‐Mar Imp 13 para‐MOD Imp 18 para‐Mar Imp 4 para‐ Mild Imp 12 para‐MOD Imp 11 para‐ Mod Imp 20 para‐Mar Imp 19 para‐Mar Imp 13 para‐MOD Imp 15 para‐Mar Imp

   

ACUPUNTURE TREATMENT                            

   

 

SUCHI VYADHA CHIKITSA