A RANDOMIZED COMPARATIVE STUDY TO EVALUATE THE AUGMENTATIVE EFFECT OF MARMA CHIKITSA IN LUMBAR SPONDYLOSIS (KATIGRAHA)
Introduction
In recent years the applied aspect of Marma Chikitsa, is drawing attention and gaining popularity, as these sites are being directly utilized by Ayurvedic physicians to obtain therapeutic goals by controlled physical stimulus on them. CCRAS, Govt. of India, has published a book “Marma Chikitsa-Basic Tenets in Ayurveda and therapeutic approach†edition 2020. Manipulation of Marma is non-surgical, non- pharmacological technique and cost effective. Katigraha is a Vataja vyadhi with Kapha-anubandha which produces symptoms like pain and stiffness of Kati. In Samhitas scattered references of Katigraha, it is said that Kati is sthana of Vata, and Pakwashayagata prakupita vata produces various symptoms, one among which is Katigraha . Katigraha in aged people is mostly considered as Apatarpana janya vikara . Katigraha is mentioned as separate disease in Gada nigraha, Vata rogadhikara. The sthamba produced in the Kati will hamper the gati of Vayu resulting in Kha vaigunya and all these in total result in pain and stiffness of lower back region. Saranghadra also mentioned it as one of the Vataja nanatmaja vyadhi.
वायॠकटयाशà¥à¤°à¥€à¤¤à¤¾: शà¥à¤¦à¥à¤§ सामो वा जनयेतॠरà¥à¤œà¤® कटिगà¥à¤°à¤¹ स विनà¥à¤œà¥‡à¤¯ पंगà¥: सकà¥à¤¥à¤¿ दà¥à¤µà¤¯à¤¾à¤¶à¥à¤°à¥€à¤¤à¤¾ (gada nigraha; vatarogadhikara 19/60) The symptoms of Katigraha can be correlated with Lumbar spondylosis. Low back pain with stiffness is the main cardinal symptom in Lumbar spondylosis. This cardinal symptom is comparable with the ‘Graha’ condition mentioned in Ayurveda classics. The lumbosacral part of the spine is comparable with the ‘Kati’ mentioned in Ayurvedic texts. Hence, Lumbar spondylosis in contemporary medical science can be correlated with the Katigraha (one of the eighty Nanatmaja Vata Vikar) mentioned in Charak Samhita. Lumbar spondylosis is a degenerative disorder of the lumbar spine characterized clinically by an insidious onset of pain and stiffness and radiologically by osteophyte formation. Cause- Bad posture and chronic back strain are the most common cause Pathology-Primarily, degeneration begins in the inter-vertebral joints. This is followed by a reduction in the disc space and marginal osteophyte formation. Degenerative changes develop in the posterior facet joints. Osteophytes around the inter-vertebral foramen may encroach upon the nerve root canal and thus interfere with the functioning of the emerging nerve. Clinical features: Symptoms begin as low backache, initially worst during activity, but later present almost all the time. There may be a feeling of ’a catch’ while getting up from a sitting position, which improves as one walks a few steps. Pain may radiate down the limb up to the calf (sciatica) because of irritation of one of the nerve root. There may be complaints of transient numbness and paresthesia in the dermatome of a nerve root, commonly on the lateral side of the leg or foot (L4 -L5, S1 roots). Lumbar Spondylosis occurs in 6-10% of general population.
LACUNAE IN EXISTING KNOWLEDGE
There is case study available but there is no RCT which suggest the efficacy of manipulation of Marma in Lumbar spondylosis.
PREVIOUS STUDY DONE
1. A CONCEPTUAL ANALYSIS OF MARMA CHIKITSA IN GRIDHRASI This review article suggests that by the use of appropriate pressure over the Marma points, these vital and powerful points can be stimulated leading to biochemical changes in brain as well as in the body, resulting in suppression of the symptoms like pain, stiffness, numbness etc.
2. MARMA CHIKITSA AND AGNIKARMA IN KATIGRAHA – A CASE STUDY The result of the case study shows that Marma chikitsa along with Shamana chikitsa has improved the Oswestry low back disability score, VAS and tenderness assessment score in the patients of Katigraha.
3. MARMA THERAPY IN KATISHOOLA [Lumbago]. A non-invasive healing therapy A review article based on Marma therapy on Katishoola in International Ayurvedic medical journal
4. COMPARATIVE CLINICAL STUDY ON EFFICACY OF MARMACHIKITSA AND STIMULATION OF MARMA BY TENS
5. MARMA CHIKITSA IN THE MANAGEMENT OF GRIDHRASI W.S.R. TO SCIATICA- A case report The result of the study showed that there is improvement in stambha, toda, ruja, Straight leg raising test and Braggards test in Gridhrasi or Sciatica after the treatment.
6. CONCEPT OF MARMA THERAPY IN MANAGEMENT OF PAIN
RESEARCH QUESTION
Is combined therapy of manipulation of prishta sakthigata Marma with oral medicine for 14 days is more effective than oral medicine alone in improving the symptoms of Lumbar spondylosis [Katigraha]?
HYPOTHESIS
Null hypothesis: There is no difference in efficacy between combined therapy of manipulation of Marma with oral medicine and oral medicine alone in the management of Lumbar spondylosis (Katigraha). Alternative hypothesis: The combined therapy of manipulation of Marma with oral medicine is more effective than oral medicine alone in the management of Lumbar spondylosis (Katigraha).
AIM and OBJECTIVES:
AIM To determine the difference between the efficacy of combined therapy of manipulation of Marma with oral medicine and oral medicine alone in the management of Lumbar spondylosis. OBJECTIVES: 1] To determine the difference between the efficacy of combined therapy of manipulation of Marma with oral medicine and oral medicine alone in the movements (flexion, extension, lateral flexion, rotation) of the lumbar region. 2] To determine the difference between the efficacy of combined therapy of manipulation of Marma with oral medicine and oral medicine alone in Oswestry low back disability index score.
LITERATURE REVIEW
The science of Marma known as Marma Vaigunyam is a dynamic part, especially described in Sushrut Samhita and other Ayurvedic classics. Acharya Sushrut has described 107 Marmas and classified them into various types based on location, involved structure and effect of injury. According to Acharya Sushrut Marma comprises of Jala, Vayu, Tej, Satva, Raja, Tama, and jivatma. Brihatrayi has explained about the Marma and their impact on body but noteworthy description of Marma is found in Pratyek- Marmanirdesham shariram adhyay of Sharirasthanam in Sushrut samhita. Achaya Charak has mentioned 107 numbers of Marma but discussed only Trimarma namely Hridya, Shir, and Basti. Vagbhata also mentioned about 107 Marmas in the Sareera sthana 6 th chapter and classified them into 6 according to Dhatubheda.
ANATOMICAL STRUCTURE OF MARMA AREAS
S.no | Marma | Type | Anatomical Structure | 1. | NITAMBHA | Asthi Marma Kalantara Pranahra Marma 1/2 A | Ilium bone, Sacrum bone, Sacroiliac joint, Ant. And posterior, Sacroiliac ligaments. Sacral plexus of nerves, Psoas major and liac muscles. | 2 | KUKUNDARA | Sandhi Marma Vaikalyakara Marma 1/2 A | Ilium bone, Ischium bone[no joint structure] . Inferior gluteal artery and vein. Inferior pudendal artery and vein. Sciatic nerve . Gluteal maximus and Levator ani muscles. | 3 | JANU | Sandhi Marma Vaikalyakara 3 A | Knee joint. Posterior cruciate ligament, Oblique posterior ligament. Plantaris and Gastrocenemus muscles. Popliteal artery and vein. Femur tibia and Patella bones. Medial popliteal nerve. | 4. | GULPHA | Sandi Marma Rujakara Marma 2A | Superficial Peroneal Nerve Extensor retinaculum Deep Peroneal nerve Extensor digitorum longus Extensor hallucis longus Tibialis anterior artery Anterior tibial artery Peroneal retinaculum on lateral side of ankle. Peroneus tertius muscle | 5. | KSHIPRA | Snayu Marma Kalantara Pranahara Marma 1/2 A | Combined Tendon of Adductor hallucis and Flexor and hallucis brevis. Transverse metatarsal ligament. Bifurcation of the first dorsal metatarsal artery of plantar arch. Lateral dorsal artery. Superficial stratum of digital slip of plantar aponeurosis. Bifurcation of the first common digital nerve. Plantar digital nerves of first cleft. Bifurcation of the medial terminal branch of deep peroneal nerve. Lumbricals.
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Study Centre- PG Dept. of Rachana Sharir and Kayachikitsa, OPD & IPD, Hospital of CBPACS Sample size - 70 (35 in each group) n=Z^2×p×(1-p)/d^2 Z=standard normal variable (1.96) P=prevalence 10% (.1) d=error=10%=.1 n=1.96^2 ×.1 ×.9 /.1^2 =35 Duration of study – 12 months
STUDY PLAN ï¬ Total 70 patients of Lumbar spondylosis will be registered in the study from the OPD/IPD of hospital CBPACS after informed consent and will be divided into two groups (group A&B) each having 35 patients. ï¬ Detailed history, signs and symptoms and examination of a range of motion of lumbar region will be carried out of all the patients. All the patients of group A (OPD patients) will be treated with oral medicine of Ayurveda, Trayodashanga guggulu 500 mg/2 tab BD (Bhaishajya ratnavali, vatavyadhyahikara 98-101) with Rasnasaptaka kwatha (oral) 50ml BD )(Sharngandhara Samhita ,kwathadi kalpana 86-87) and all the patients of group B (IPD patients) will be treated with stimulation of following Marma (five in number) along with oral medicines of group A. ï¬ Marma points to be taken - 1) Nitamba 2)Kukkundara 3)Janu 4)Gulpha 5)Kshipra 18 After general Examination, based on the book (Marma Chikitsa Basic Tenets in Ayurveda and Therapeutic Approaches) all the Marma sites will be identified and manipulated on an empty stomach or after three hours of meals, by applying gentle pressure with the thumb and supported by hand, 18 times on each Marma site, in coherence with breathing. Manipulation of Marma will be done for 14 days. Drugs used- Rasnasaptaka kwata and Trayodashanga uggulu. All the drugs will be provided from the Hospital pharmacy or any other GMP certified pharmacy. Preparation of Rasnasaptaka kwath - The patient will prepare the decoction of the powder as follows. One and a half tablespoons full of ingredients are added with 200ml of pure water and boiled under medium flame and reduced upto one-fourth (50ml) and filter the decoction (kashaya). Dosage of Medicine Kwath - 50ml oral B.D twice a day, morning and evening half an hour before food for 2 weeks. Trayodasanga guggulu- 500 mg/ 2 tablet twice a day with Kwath for 2 weeks All seventy patients will be assessed on the following parameters before and after treatment.
ASSESSMENT OF PATIENTS BEFORE AND AFTER TREATMENT Sl.No | Assessment criteria | Before treatment | After treatment | Follow up | | | | 1st day | 7th day . | 14th day | 21st day | 1. | Lumbar (ROM)
| | | | | | 2. | Back pain (VAS scale)
| | | | | | 3. | Oswestry low back disability index
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Follow up will be done on 21st day i.e. after completing 14 days of treatment.
INCLUSION CRITERIA 1) Patients irrespective of sex, presenting with signs and symptoms of Lumbar Spondylosis. 2) Patient having findings of Lumbar spondylosis in plain lumbar X-Ray ( AP and Lat.) 3) Subjects of the age group 20 to 60 years will be registered in both groups. 4) Patients fit for stimulation of Marma.
EXCLUSION CRITERIA 1) Post- traumatic patients having a history of fractures and dislocation of the lumbar and lower back region. 2) Patients having Lumbar deformities, Postural defects and Uncontrolled Diabetes, Hypertension, Malignancy and Hepatitis. Major systemic disorders, Neurodegenerative conditions of the spine (e.g. TB, malignancy) All the above collected data along with the Demographic data will be filled in the case report proforma. STATISTICAL DESIGN To assess the intervention’s effectiveness, a comprehensible statistical analysis will be conducted to compare outcomes between two groups. After completion of clinical trial in both outpatient and inpatient settings, the collected data will be statistically analysed. Subjective parameters will be expressed as frequencies and percentages, while objective measure will be presented as means and standard deviations. Group comparisons will be made using an unpaired t -test to ensure reliable and interpretable results.
EXPECTED OUTCOME OF STUDY This study will give the evidence based applied aspect of Marma in Lumbar spondylosis. We may come out withmore effective treatment for Lumbar spondylosis. |