“EFFICACY OF LASHUNA RASAYANA IN MANIBANDHA ...

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“EFFICACY OF LASHUNA RASAYANA IN MANIBANDHA

MARMABHIGHATA”

By

Dr. Manasa Rao B.A.M.S

Dissertation submitted to the Rajiv Gandhi University of Health Sciences

Karnataka, Bengaluru

In partial fulfillment of the requirement for the degree of

“AYURVEDA VACHASPATI”

DOCTOR OF MEDICINE (Ayu)

In

KAYACHIKITSA

GUIDE

DR. G. SHRINIVASA. ACHARYA M.D. (AYU)

Professor and HOD

Department of Post Graduate Studies in Kayachikitsa and Manasaroga

Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi.

DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA

SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF

AYURVEDA, KUTHPADY UDUPI

2017-2018

Scanned by CamScanner



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ABBREVIATIONS

A.H. - ASHTANGA HRIDAYAM

A.S - ASHTANGA SANGRAHA

A.T. - AFTER TREATMENT

B.P. - BHAVAPRAKASHA

B.R. - BHAISHAJYA RATNAVALI

BS.R. - BASAVARAJEEYAM

B.T. - BEFORE TREATMENT

C.S. - CHARAKA SAMHITA

M.N. - MADHAVA NIDANA

S.S. - SUSHRUTA SAMHITA

Y.R. - YOGARATNAKARA

XIII

LIST OF TABLES

S.No Tables Page No.

1. Samprapti ghataka of manibandha marmabhighata. 32

2. List of pathya of vatavyadhi / manibandha marmabhighata 41-43

3. List of apathya of vatavyadhi / manibandha marmabhighata 44

4. Showing responses 51

5. Distribution of the 15 patients according to their Age / gender 54

6. Distribution of the15 patients according to their Religion /

Marital status 55

7. Distribution of the15 patients according to their Profession /

Economic status 56

8. Diet and sleep of 15 patients 57

9. Day sleep and habit identified in 15patients 58

10. Family history of 15 patients 59

11. Distribution of 15 patients according to the initial recording of

Bodyweight and BMI 60

12. Distribution of 15 patients according to their prakriti 61

13. Distribution of 15 patients according to their Sara 62

14. Distribution of 15patients according to their Satva 63

15. Distribution of 12 patients according to their

Abhyavaranashakti 64

16. Distribution of 15 patients according to their Mode of onset 65

17. symptom supta of 15 patients 66

18. Effect of Lashuna rasayana on symptom severity of the illness 68

19. Effect of Lashuna rasayana on functional disability status 69

20. Effect of Lashuna rasayana on VAS pain score 70

21. Effect of Lashuna rasayana on VAS numbness score 71

22. Effect of Lashuna rasayana on hand grip strength 72

23. The overall effect of the Lashuna rasayana 73

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LIST OF GRAPHS &FIGURES

Sl.No Figures & Graphs Page. No

1. Distribution according to Age 54

2. Distribution according to Religion 54

3. Distribution according to Religion 55

4. Distribution as per Marital status 55

5. Distribution according to Profession 56

6. Distribution according to Socio economic status 56

7. Diet of 15 patients 57

8. Nature of sleep of 15patients 57

9. Day sleep identified in 15 patients 58

10. History of addiction in 15 patients 58

11. Family history in 15 patients 59

12. Distribution according to Bodyweight 60

13. BMI of 15 patients 60

14. Distribution of 15 patients according to their prakriti 61

15. Distribution according to Sara 62

16. Distribution according to Samhanana 62

17. Distribution according to Satva 63

18. Distribution as per Vyayama Shakti 63

19. Distribution as per Abhyavaranashakti 64

20. Distribution as per Jaranashakti 64

21. Distribution According to Mode of Onset 65

22. Symptom ruk in 15 patients 65

23. Symptom supta of 15 patients 66

24. Effect of Lashuna rasayana on symptom severity of the illness 68

25. Effect of Lashuna rasayana on functional disability status 69

26. Effect of Lashuna rasayana on VAS pain score 7

27. Effect of Lashuna rasayana on VAS numbness score 71

28. Effect of Lashuna rasayana on hand grip strength 72

29. The overall effect of the lashuna rasayana 73

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30. Lashuna 118

31. Lashuna Capsules 118

32. Lashuna Rasayana 118

33. Eranda Taila 118

34. Visual Anologue Scale 119

35. Hand Dynamometer 119

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ABSTRACT


MARMABHIGHATA”

Background

Manibandha marmabhighta is a multifactorial disease caused by

santarpana nidana as well as by physical strain .Hence it demands a drug

which pacifies vata dosha as well as clears margavarna where Lashuna

proves to be best. Hence this study is carried out.

Objectives

To assess Efficacy of a Lashuna rasayana on disease severity in patients

suffering from Manibandha marmabhighata / Carpal tunnel syndrome. (2) Effect on

functional disability in patients of Manibandha marmabhighata / Carpal tunnel

syndrome treated with Lashuna rasayana.

Method-

Design

Study type – Interventional; Allocation – Non randomized; Endpoint

classification - Efficacy study; Intervention Model - Single Group Assignment;

Masking - Open Label; Primary Purpose – Treatment.

II

Intervention

Day 1 - Oral administration of eranda taila in empty stomach, in a dose of 20

ml in the morning along with 100 ml of warm water as after drink;

Day 2 to 16 - Oral administration of Lashuna rasayana in a dose of 12 g in

empty stomach half an hour before breakfast along with 100 ml of milk as after drink;

Day 17 - Oral administration of eranda taila in empty stomach, in a dose of 20

ml in the morning along with 100 ml of warm water as after drink.

Results-

There was significant reduction in all the primary & secondary outcome

measures like symptom severity, functional status, VAS for pain, VAS for numbness

and hand grip. All these improvements when analyzed by the statistical tests of

significance proved highly significant results i.e. p <0.001.

INTERPRETATION & CONCLUSION: Lashuna rasayana is effective in both

clearing the co morbidity of margavarana as well as pacification of vitiated vata dosha

thus significantly reducing the signs and symptoms of Manibandha marmabhighata /

Carpal tunnel syndrome.

KEYWORDS: Manibandha marmabhighata, Lashuna rasayana, Carpal tunnel

syndrome

Introduction

Efficacy of lashuna rasayana in manibandha marmabhighata Page 1

INTRODUCTION


MARMABHIGHATA”

Vata vyadhi is considered as most virulent among the tridosha. Among the

diseases caused by vitiation of vata dosha, samanya & nanatmaja vyadhi presents with

distinct features. Literature quotes 80 types of nanatmaja vata vyadhi that is specified

as aavishkritatama vata vyadhi1. The description of some of these diseases is vivid in

the literature and elaboration of some is restricted to guidelines. In general, vata dosha

is diagnosed based on symptoms of aggravation of vata dosha and location of

affliction. Nakha Bheda, Paada Shola, Paada Supthi are just the examples.

Kuntata2 is a disorder characterised by the paralysis related to the activities of

hand. Scanning of literature explores the better explanation of the condition with due

consideration of abhighata nidana in Manibandha as Rujakara marma3.

Etiological factors of vata vyadhi such as strain caused due to exposure of

vyayama, abnormal positioning during different activities is worth considering. These

etiological factors have direct bearing on joints. To be more precise the excessive and

abnormal activities of involving the hand may affect the Manibandha marma.

Affection of Manibandha marma is the key pathology as per the understanding of

marmabhighata.

The Manibandha marmabhighata can happen for two reasons, they are the

internal factor & external factor4. External by the way of different activities related

to bahya abhighata involving the Manibandha. In contrast to santarpana nidana

causing excessive kapha & medas can lead to avarana vata vyadhi and can involve the

Introduction


Manibandha marma leading to margavaranajanya Manibandha marmabhighata similar

to the samprapti of urustamabha5.

Here the marga refers to vatavaha srotas. Manibandha marmabhighata is

caused either external factors or internal factors like santarpana nidana resulting in

vata vyadhi. Literature affirms the role of marmabhighata in causation of vatavyadhi.

Manibandha marmabhighata when it happens for above said reasons result in

manifestation of supta, ruja, vastushukairavakirna, shosha, parvashopha, kuntata.

These symptoms, comprising of Manibhandha marmabhighata; parallels with

symptom of carpal tunnel syndrome. The symptoms of Manibhandha marmabhighata

include suptata (paresthesia), ruja (pain) and kuntata (paralysis of the hand leading to

functional disability) .Thus these symptoms match with that Carpal tunnel syndrome.

Carpal tunnel syndrome may be caused due to obesity, trauma, pregnancy and

inflammation etc. These etiological factor either belonging to the category of

santarpana nidana or injury to wrist by physical activities. The pathology of

margavarana / abhighata in manibhandha is parallel to median nerve entrapment in

carpel tunnel. Surgical intervention in this syndrome will give good relief, whereas

conservative management have failed to overcome the disease as it gives just the

temporary relief. This syndrome is common in the working population related to the

increased use of activities of hand. Complications will leads to hindrance of routine

activity. A survey study revealed that 53 per 10,000 working adults have evidence of

Carpel Tunnel Syndrome6. These observations add to the seriousness of this

Manibandha marmabhighata or Carpel tunnel syndrome.

Manibandha marmabhighata and the resulting vatavyadhi is treated according to

the treatment of vatavyadhi by snehana, svedana, brimhana and rasayana. . Balanced

approach rectifying the kapha and medas and simultaneously normalizing the

Introduction


functions of the vatadosha is the sheet anchor of treating Manibandha marmabhighata

leading to kuntata. Needless to say Rasayana cikitsa has got an edge over any other

conservative management.

Also Lashuna rasayana is effective in both clearing the co morbidity of

margavarana as well as pacification of vitiated vata dosha thus proving its superiority

in the management of Manibandha marmabhighata.

Reviewing the clinical trials carried out in relation to the efficacy of Lashuna

rasayana carried out in different research institutions unravels the following truths.

In an Open idealistic clinical trial evaluating the effect of Lashuna rasayana in

Gradrasi / sciatica was conducted on 23 patients , where result showed patients had

90.58% relief from Stambha, 87.28% relief from Ruk,85.36% relief from Toda, 85.36

from Spandana, 100% relief from Aruchi, 147% relief from pain, 63% improvement

in neurological deficits, 50% improvement in functional ability, 68.61% relief from

functional disability, 117% improvement in active SLR test, 117% improvement in

passive SLR test, 38.81% improvement in walking for a distance of 30 feet, 18%

improvement in taking 10 sit ups, 32% relief in climbing 10 steps, 31.38%

improvement in floor hand distance.

In another Open Randomized Comparative Clinical Study on Lashuna

Rasayana and vaitarana Basti in gridhrasi on 40 patients was done. It was found that

75 % of patients had major improvement, 20 % had moderate improvement, 5 % had

mild improvement and none of the patients had the symptoms unchanged.

From the fore going it is clear that Manibandha marmabhighata is a multi-

factorial disease. Physical strain at the Manibandha marma or the santarpana nidana

leading to accumulation of kapha and medas at the Manibandha marma obstructing

the vatavaha srotas may precipitated the Manibandha marmabhighata and that mimics

Introduction


the clinical presentation of Carpal tunnel syndrome. Enough clinical study is carried

out on Lashuna rasayana on different diseases but no study is carried out on

Manibandha marmabhighata.

Pilot study has shown favorable response in patient suffering from

Manibandha marmabhighata treated with Lashuna rasayana. Hence this study is

intended to evaluate the therapeutic effect of Lashuna rasayana in patient suffering

from Manibandha marmabhighata / Carpel tunnel syndrome.

This dissertation consists of literary review drug review methods observation

results discussion and conclusion. Historical review, etiology, symptomatology,

diagnosis and treatment is the subject matter of chapter literary review. Details of the

Lashuna rasayana are given in the chapter of drug review. Complete details of the

design of the study are presented in the chapter entitled methods. The demographic

profile of the sample is elaborated in the observation chapter. The effect of treatment

with Lashuna rasayana with statistical analysis is recorded in the chapter of results.

Rationality of the treatment and the result obtained is discussed in the chapter of

discussion including mode of action. The conclusion obtained from this study is the

subject matter of the chapter conclusion.

Objectives


OBJECTIVES

Efficacy of Lashuna rasayana on disease severity in patients suffering from

Manibandha marmabhighata / Carpal tunnel syndrome.

Effect on functional disability in patients of Manibandha marmabhighata /

Carpal tunnel syndrome treated with Lashuna rasayana.

Historical Review


HISTORICAL REVIEW

Marma are the unique vital points in the body. Strong blow on these marma

can cause significant injury and may even prove fatal. Contrary to this a mild touch of

these vital points can cause healing. The whole practice of marma therapy is based on

this understanding. The knowledge of marma is essential for planning surgical

interventions. The seriousness of any trauma is judged by the involvement of marma.

The same marma knowledge is used in the martial arts to kill the opponent. Most

recently the same knowledge is utilized to treat certain diseases. To be clearer, the

knowledge of marma is traced back to Vedic literature and has progressed to the

present marma therapy practiced in the southern part of the India known by the name

Kalaripayattu. The full account of this history related to the marma and Manibandha

marma is elaborated below.

Vedic period (1500 BC)

The concept of marma is well documented in Vedic literature and mostly

related to the martial arts. From the citations in the Rig-Veda and others it is clear that

marma points in the body were well protected by wearing specific armors during the

wars. These amour was said to protect the vulnerable marma points in the body during

war injuries and thereby saving the life7. A citation in Rig-Veda says that

Vishwakarma sharpened the weapon Vajrayudha of lord Indra and by using this

weapon lord Indra attacked the marma point of the demon by name Vratra.8 Also in

Rig-Veda it is said that, best protection of the marma was achieved by chanting the

specific mantra (kavacha). Atharva Veda quotes the possibility of death due to injury

to the marma. The word kavacha is used referring the corselet or breast plate worn to

Historical Review


protect the marma during wars. It is worth mentioning about the surgical intervention

made by divine doctor’s Ashvini on Shayava at three locations of his body to make

him to move again9.

Also other than the weapons the fire was used as a great weapon to injure the

marma points during wars10

. Among the four sub veda, Dhanurveda deals with martial

arts. Much is discussed about the marma points in this literature.

Upanishad period:

Much information related to the anatomy of the marma is available in

Upanishad. The descriptions include description of vessels & blood circulation11

,

vascular injuries12

, Characteristics of sira and dhamani13

, anatomy and physiology of

hridaya14

, marma and kavacha15

, marma16

, dhamani17

. To be more specific elaboration

of marma is found in Garbhopanishad18

and Yogopanishad.

Epics period:

Citations of marma are found in Ramayana as well as Mahabharata. In a story

in Ramayana it is said that king Dasharatha shot an arrow accidentally on a marma

point of Shravana Kumara. He died due to this injury on his marma19

. Duryodhana

was said to have a vital marma point on his thigh and was revealed by lord Krishna to

Bheema during battle between Bheema and Duryodhana20

. Lord Krishna was shot

dead by a hunter Jara with an arrow injuring the marma point at his foot21

Historical Review


Samhita period:

Detailed description of the locations of marma, clinical illness when injured

and its management is detailed in the literatures of this period. Following details

substantiate the adequate description of marma in these literatures.

Charaka samhita (2nd century B.C):

In charaka samhita, the total number of marma in the body is accepted as 107.

Ample emphasis is given on three marma that include Shiras, hridaya and basti.

Exclusive chapters are allocated in the sutra sthana, chikitsa sthana and siddhi sthana.

The disease related these three marma locations with their treatment are discussed at

length. It is accepted that vata dosha predominated in the pathology of affliction of

marma and hence basti is regarded as best treatment in such situations. Also it is said

that injury to any marma can happen for internal and external causes22

. Vitiated dosha

afflicting the marma is accepted as internal cause of marma injury. External trauma is

regarded as external cause of injury of marma. It is crucial to note that vatavyadhi can

happen due to the injury to the internal marma. Also kapha and medas suppressing the

movement of vata leading the vatavyadhi is described as margavarana leading to

marma injury.

From the same concept to internal dosha causing the injury of the marma added with

margavarana due to kapha and medas; this present concept of Manibandha

marmabhighata is formulated.

Historical Review


Bhela Samhita

Harita Samhita

Sushruta samhita (2nd century AD):

Detailed description of 107 number of marma is described in the sushruta

samhita with the angle of surgical intervention. It is said that marma points should be

avoided during surgical intervention or utmost care should be taken lest the patient

may land in serious complications or lose his life. Injury to the marma and its clinical

implication is detailed at full length either is due to trauma or error in the surgical

intervention. Marma is defined as a vital point in the body structurally formed by the

combination of five structures of mamsa, sira ,snayu ,asthi sandhi and injury to this

may cause immediate death, late death, disability or severe pain. Marma is classified

differently on the basis of predominant composition of body elements, location in the

body, result of injury and also its size. The elaborate description of the treatment of

these marma is also given in the text23

.

Kashyapa samhita:

In the third chapter of sharira sthana along with the ten locations of prana the

major three marma are enlisted and named as maha marma24

.

Astanga sangraha and hridaya (6th century A.D.):

Detailed description of marma is given in both the texts in the sharira sthana.

Marma are described as in sushruta samhita giving importance to the external trauma

and the avoidance of marma points during the surgical intervention. Marma are

classified in accordance with their location, size, affect and composition. The full

account of the treatment of the same is available25, 26

.

Historical Review


Medieval period:

Most of the works in this period followed the description of marma as

described in the treatises of samhita period. However the books like chakradatta

yogaratnakara and sharangadhara have skipped the description of marma and injury to

marma.

Madhavakara (7th Century A.D.)

Citation of marma is limited to mentioning of involvement of marma in certain

diseases. Symptoms of injury to different types of marma are given in the chapter on

sadyovrana27

. Other than this, marma is mentioned in the samprapti of Dhatu gata

jvara, Chinna shvasa, Kaphaja unmada, Hridroga, Kshavathu, gara, Prognosis of

certain diseases is decided by the involvement or non-involvement of marma. The

examples include Vatarakta, Prameha pidaka, Shotha, Arbuda, Vrana, Visarpa,

Masurika, Balasa, Vidhradhi. Citation of 107 marma is made in the commentaries of

Madavanidana that include Madhukosha and Atanka darpana in the context of

Mutrakricchra28

.

Kalyanakaraka (9th

century AD)

The third chapter of Kalyanakaraka deals with the anatomy of human body. In

this chapter the total number of marma in the body is said as 10729

. Details of these is

not given in this chapter. But the full account in terms of location and symptoms of

injury of marma is given in the 20th

chapter. It is said that the manibhandha marma in

the hand matches with the gulpha marma of the leg and the injury to this marma

causes stabdhata, supti and ruk30

.

Historical Review


Bhavaprakasha: 16th Century A.D

In the first part of the purva khanda the third chapter is garbha prakarana. In

this chapter the detailed anatomy of the body is written. This description includes the

mentioning of the 107 marma in the body31

. The classification of the marma is made

as in sushruta samhita. Pair of manibhandha marma is listed as one among the 22

marma located in the arms. It is also said that the diseases involving the marma are

difficult to cure32

Modern period

Yogarathnakara (17 century AD)

The citation of marma is limited to the mentioning in samprapti and prognosis

of certain diseases like hridroga and vidradhi33

.

Bhaishajya rathnavali 18th

century AD

Details of the location of the marma, symptoms of injury and treatment of

marma injury are not included in the text. More to add until the medieval period the

clinical understanding of marma was restricted to injury to the marma, clinical

presentation of injury of marma and its treatment. Contrary to this in the modern

period the principle of treating different diseases by massaging and manipulating the

marma is developed.

Siddha system of medicine was developed in the southern part of the India.

Much importance was given to the knowledge of marma in the books on siddha

system of medicine. In the siddha medicine marma is known by the name varma. The

Vedic sage by name Agastya rishi is said as the founder of the siddha system of

medicine. In this system it is believed that in the disease states the energy is blocked

Historical Review


in specific marma. This can happen due to external trauma or internal factor of fear or

anger. It is conceptualized that the blockage of psychic energy in the marma locations.

This blockage of energy can be released by measures of mantra pranayama and

meditation. Also, injury to the marma is attributed to the astrological events. The

knowledge of marma was extended to the martial art where in knowledge of marma is

used for both defensive as well as offensive purposes. Martial art tradition of

Kalaripayattu34

is the example for this. Tamil tradition mentions 108 marma in the

body and the kalari tradition of Kerala considers 365 marma points. The relation

between the seven chakra in the body and marma is also elaborated in this science. 12

marma points are listed and the injury to this marma may lead to sudden death. It is

said that this martial art is founded by the sage Parasurama and this knowledge is said

to be derived from Dhanurveda (Science of War/Archery), Ayurveda, and Yoga35

.

Also massaging of the specific marma point is practiced to heal and cure a variety of

diseases.

Carpal tunnel syndrome:

During 1854 the first description of median nerve entrapment was recorded in

the history. A century later the term carpal tunnel syndrome came in to print. The

alternative diagnosis made for this disease included Acroparasthesia, motor branch of the

median nerve or the brachial plexus compression. The first description related to the

surgical intervention of CTS dates back to 193336. The first article on idiopathic CTS

was published during 194637. Tourniquet test was described for the diagnosis of carpal

tunnel syndrome during 1953 by Gilliatt and Wilson38

. During 1956,

electromyography was found to be effective in the diagnosis of CTS39

. From 1960

onwards the carpal tunnel syndrome became the common diagnosis.

Nirukti & Paribhasha


NIRUKTI & PARIBHASHA.

The word Manibandha marmabhighata has three component as manibandha,

marma and abhighata. For descriptive purposes these three are dealt separately.

Manibandha:

The Sanskrit word manibandha in masculine gender is formed by the

combination of two component terms of Mani and bandha with the addition of suffix

ghanj40

. Mani refers to the jewels41

. Bandha42

refers to the act of fastening or binding.

Put together, etymologically the fastening of the jewel is known as manibandha. This

implies, the wrist is the part where bracelets of precious stones are bound and hence

termed as manibandha.

The joint between the forearm and hand is called as manibandha 43

. It is

identified as the base of hand44

and is located in the proximal palm.45

Marma:

The Sanskrit word marma is derived from the root mrin maranae meaning to kill

/ death46

. Etymologically the word marma is translated as point that can kill. The word

marma is also derived in another way. Mah and ma are the component terms of

marma. The word maha connotes prana and the term ma means residence. Put

together the location of prana in the body is termed as marma.Marma refers to a body

location and injury to which tend to cause death47

In the Ayurveda literatures the

marma is defined as juncture of the body where two or more tissues of mamsa,sira

snayu ,asthi and sandhi48

The location in the body injury to which causes syandana

(pulsations) pidana (physical or mental distress) and ruk (pain) is also known as



marma. Or else the part of the body and the injury to which causes serious illness

similar to death is known by the term marma. The word marma also means hidden

secret.

Synonym: varma is the other name of marma in siddha system of medicine

Abhighata:

The Sanskrit word abhighata in masculine gender is derived from the Sanskrit

root “han” with the prefix “abhi”. The Sanskrit root “han” refers to the activity of

striking or attack. The prefix “abhi” implies severe intensity49

Thus etymologically

abhighata means severe attack and implies traumatic injuries.

By definition the traumatic injury caused by sticks50

or wild animals is called

as abhighata. It is worth mentioning here that in the context of marmabhighata the

word abhighata simply means injury and refers to both internal and external injury.

The injury caused by external factors like falling, weapons, wild animals or non-

human beings is known as abhighata. Also the injury of the marma caused by vitiated

dosha is considered as internal abhighata 52

Carpal tunnel syndrome:

The English word carpal is originated from Modern

Latin word carpus meaning wrist53

. Literally the word carpal is an adjective meaning

pertaining to the wrist. Artificial underground passage is known by the word tunnel.

Anatomically the word carpal tunnel refers to an osteofibrous canal situated in the

volar wrist. The median nerve passes through this canal. Group of symptoms which

consistently occur together is known by the word syndrome. Put together the



syndrome involving the carpal tunnel is known as carpal tunnel syndrome. By

definition compression of the median nerve within the carpal tunnel presenting with

characteristic clinical manifestation of numbness, paresthesia, and pain in the median

nerve distribution is termed as carpal tunnel syndrome.

Nidana


NIDANA

Paraesthesia54

and paralysis of the hand is the typical presentation of the

Manibandha marmabhighata. Hence this illness comes under the umbrella of

vatavyadhi. Hence all the nidana, purvarupa, rupa and samprapti of the Manibandha

marmabhighata is discussed under the pretext of vatavyadhi. Thus the etiological

factors of vatavyadhi are discussed as nidana of Manibandha marmabhighata. The

vatavyadhi in general or Manibandha marmabhighata in particular may happen due to

the apatarpana nidana or santarpana nidana. Apatarpana nidana are mostly the nidana

of vatavyadhi that directly causes the vitiation of vata dosha. Contrary to this the

santarpana nidana causes accumulation of the medas that obliterates the vatavaha

srotas causing the vatavyadhi. These two categories of etiological factors are

discussed separately.

Apatarpana nidana

Following are the apatarpana nidana segregated from the general etiology of

vatavyadhi. The same is categorized into dietary, behavioral, traumatic, psychological

factors and pre-existing illness for descriptive purposes55

.

Dietary factors: Excessive and habitual consumption of foods that are pungent ,bitter

or astringent in taste; Excessive and habitual intake of food articles having properties

like un-unctuousness or coldness; Excessive and habitual consumption of foods

having the property of lightness; the rice stored for long; recently harvested rice may

cause morbidity of vata dosha; Excessive and habitual consumption of specific cereals

and pulses that include Nishpava (Dolichos lablab Linn), Shyamaka (Echinochola

Nidana


frumentacea Linn), Mudga (- Phaseolus radiatus Linn), Masuri (Lens culinaris

Medic), Makushtaka (Phaseolus aconitifolius Jacq), Chanaka (Cicer arietinum Linn),

adaki (Cajanus cajan Mills), Kodrava (Paspalum scorbiculatum Linn) and Kalaya

(Lathyrus sativus Linn), Either excessive or much limited amount of food

consumption and starvation .

Behavioral factors

Excessive sexual indulgence; Excessive walking; Excessive physical exercise:

Exhaustion due to physical activities, Frequent traversing by leaps or jumps, Frequent

swimming, Frequent use of uncomfortable bed, Frequent use of uncomfortable seat,

Falling or racing while riding on an elephant, Falling or racing while riding on a

camel, Falling or racing while riding on a horse, Excessive physical activities,

Frequent staying awake at night, Day sleep, Exposing oneself to the easterly wind,

Exposure to snowy weather, Suppression of naturally manifesting urges like

defecation.

Psychological factors

Emotional disturbance of anxiety; Emotional disturbance of grief, Emotional

disturbance of anger, Emotional disturbance of fear& Emotional disturbance of sexual

love.

Traumatic factors

Trauma by different exogenous factors like beating with the stick & Injury to

the vital organs

Nidana


Iatrogenic factors

Excessive loss of dosha while undergoing shodhana treatment, Excessive loss

of dosha during the treatment of Vamanakarma, Excessive loss of dosha during the

treatment of Virechana karma.56

Preexisting illness

Depletion of body elements secondary to any illness, Excessive emaciation

due to any illness, Morbidity of ama leads to development of margavarana, Excessive

excretion of fecal matter during diseases states like atisara.57

Seasonal and environmental factors

Rainy season; winter season; unusual delay of digestion; late part of the night.

From the above the excessive physical strain involving the wrist joint has direct

bearing on the Manibandha marmabhighata. Different etiological factors related to

external traumatic injury have direct bearing on the Manibandha marmabhighata.

Santarpana nidana

Over nourishment predisposes to excessive accumulation of the medas which

in turn obstructs the vatavaha srotas and causes vatavyadhi58

. Following etiological

factors are worth mentioning59

.

Dietary factors

Excessive consumption of foods that is unctuous, sweet, slimy and heavy for

digestion; consumption of new cereals; intake of new alcoholic beverages,

consumption of meat of wet land and animals, excessive intake of sea foods, habitual

Nidana


consumption of dairy products, frequent consumption of molasses, excessive

consumption of foods prepared from cereal flour, consumption of foods that cause

accumulation of kapha in the body.

Behavioral factors

Lack of physical activity, day sleep, prolonged resting on comfortable chair or bed.

Psychological factors

Lack of mental activity .These factors increase kapha and medas predisposing

entrapment of vatavaha srotas causing vatavyadhi.

Etiology of carpal tunnel syndrome:

Carpal tunnel syndrome is considered as idiopathic. However any disease or

condition that generates pressure on the median nerve with in the anatomical structure

of carpal tunnel leads to carpal tunnel syndrome. The diseases that can predispose to

carpal tunnel syndrome include obesity, hypothyroidism, arthritis, diabetes and

trauma60

. Genetic factor also has some role in the causation of carpal tunnel

syndrome. The risk of carpal tunnel syndrome is said to increase with the

consumption of oral contraceptive pills. Even certain diseases at the wrist that

compress the carpal tunnel compromising the space with in the tunnel can cause the

carpal tunnel syndrome and is possible in conditions like lipoma, ganglion and

vascular malformation. Profession involving repetitive flexion and extension of the

wrist may precipitate carpal tunnel syndrome. Cumulative trauma on the wrist in the

form of repetitive movement and manipulating activities at the wrist that may be

possible in certain profession may increase the risk of Carpal tunnel syndrome.

Poorvaroopa


POORVAROOPA

In general in most of the vata vyadhi the development of the symptoms of the

disease in the milder form in the beginning of the illness is known as purvarupa61

.

This is also applicable in case of Manibandha marmabhighata. Initial development of

pain and numbness in the hand may be accepted as purvarupa of Manibandha

marmabhighata. With the pretext of carpal tunnel syndrome it may be further

specified as milder form of paresthesia involving thumb middle and radial half of ring

finger is the premonitory symptom of Manibandha marmabhighata.62

Roopa


ROOPA

Manibandha marma is enlisted as one among the 107 marma located in the

body. It is said that there are 11 marma in each arm. Among these manibandha marma

is located at the base of the hand. Following details give the full account of the

marma.

Location type

Manibandha marma is considered as sakthi marma, as is related to the

extremities. Among the extremities also, manibandha marma is located in the arms at

the joint between the forearm and hand63

.

Dimension type: 2 angula is the dimension of manibandha marma.64

Component type: Structurally the manibandha marma is considered as sandhi

marma 65

since it formed by the joint between the fore arm and hand.

Illness type: Pain is the major clinical manifestation due to the manibandha

marmabhighata hence is noted as rujakara marma66

.

Based on these specifications the following symptoms occur in manibandha

marmabhighata.

Supti

The morbid vata dosha by virtue of its lightness as well as instability causes

lack of sensation in different body parts and is known as supti. The effected part

becomes numb, senseless and fails to carry out its motor activity. Person fails to

appreciate the pain when the affected part is injured by nails and others. More to add,

Roopa


the person fails to experience the very existence of the affected part. In regards to the

Manibandha marmabhighata supti involves the hand67

.

Ruk

The symptom of continuous and uninterrupted pain which is of either

moderate or severe intensity is known as ruk. Manibandha marma belongs to the

category of rujakara marma and pain in the hands is the leading symptom.

Vastushukairavakirna:

The subjunctive symptom as if the body part is afflicted with awn of grains is

the symptom of vastushukairavakirna. To be clearer, the feeling of pins and needles is

refered by this work vastushukairavakirna. This is the typical symptom of any sandhi

marma68

. As the manibandha marma is the sandhi marma sensation of pins and

needles involving the hand is a clinical presentation.

Shosha: The symptom shosha refers to either dehydration or diminution of different

body parts. Dehydration of the body fluids is said by the term shosha69

. Dryness and

lightness are two properties of the vata dosha that are responsible for the occurrence

of the symptom shosha. To quote an example, reduced bulk of the muscle in different

parts of the body or emaciation of the whole body is referred as shosha. The atrophy

of the muscles of the hand is typical of manibandha marmabhighata.

Parvashopha : Swelling around the finger joints is the symptom of sandhi marma70

Kuntata : Paralysis of the hand.

Roopa


Carpal tunnel syndrome

Numbness and tingling, pain, weakness as well as dysautonomia form the

complete list of symptoms of carpal tunnel syndrome.

Numbness and tingling

This is the most common symptom of carpal tunnel syndrome. Frequently the

patient may complain that their hands fall asleep or at times the thing held in the

affected fingers without their noticing. Some patients may complain of loss of grip.

Few other patients may complain that frequently thing drop from their hands without

their notice.

Pain: Numbness of the hand is usually associated with an aching pain sensation

distributed in the ventral part of the wrist. This pain may exhibit radiation from the

wrist distally to the palm and fingers. Even the pain may extend proximally from the

wrist along the ventral forearm.

Weakness: Reduction of the power in the hand can occur in considerable number of

patients. This may lead to clumsiness in the precision of the grip involving the thumb.

Autonomic symptoms: Median nerve carries autonomous nerves fibers to the hand

hence some autonomic symptoms are seen in patients suffering from carpal tunnel

syndrome. Feeling of tightness or swelling distributed in the hands is the presentation

of autonomic presentation. At times even variation in temperature of the hands either

being cold or hot all the time may be felt in the affected hand. Some patient may even

have sensitivity to changes in temperatures. Patients hand may turn pale on exposure

to cold.

Roopa


Onset and course: gradual or insidious onset of symptoms is typical of Carpal tunnel

syndrome. Usually the symptoms are intermittent rather continuous. The activities

listed in the aggravating factors may initiate the symptoms of Carpal tunnel

syndrome.

Aggravating factors: The most common specific activities that may trigger the

symptoms of Carpal tunnel syndrome include driving the vehicles, reading the

newspaper, knitting the woolen coat, painting any art. Symptom may even become

worse at night hours and may make the patient to wake up.

Relieving factors: Usually the symptoms of Carpal tunnel syndrome get reduced by

shaking the hand/wrist71

.

Laterality: Carpal tunnel syndrome may be unilateral but is usually bilateral. Also it

is noted that it is the dominant hand that affected first than the non-dominant hand.

More to add the symptoms are comparatively severe in dominant hand.

Symptom distribution: Symptoms are limited to the area or sensory distribution of

the median nerve that includes palmar aspect of the first to the fourth fingers and the

distal palm. It should be remembered that if the numbness is predominantly

experienced in fifth finger or extending to the thenar eminence or dorsum of the hand

then is not suggestive of Carpal tunnel syndrome. Contrary to this a significant

number of patients are not able to clearly explain the distribution of numbness.

Roopa


Physical examination findings: Sensory examination motor examination and special

test helps in the confirmation of the diagnosis of Carpal tunnel syndrome.

Sensory examination: Different modalities of sensory abnormalities are noticed in

the palmar aspect of thumb index and middle fingers and radial one half of the index

finger. Also the tow point discrimination is most sensitive in clinching the diagnosis.

The pin prick test is equally sensitive72

.

Motor examination

Wasting as well as weakness of the hand muscles innervated by the median

nerve is characteristic73

. The muscles affected include First and second lumbricals,

Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis.

Special tests

The special tests that are helpful in the confirmation of the diagnosis of Carpal

tunnel syndrome are Hoffmann tinel sign, phalen sign, carpal compression test

palpatory diagnosis and square wrist sign.

Hoffmann tinel sign74

: A gentle tap is made on median nerve at the region of carpal

tunnel of the wrist. This elicits tingling sensation in the distribution of median nerve.

Though this test is commonly done it is considered as less sensitive test.

Phalen sign75

: The wrist is held in fully flexed position for a minimum of 60 seconds.

This activity triggers tingling in the median nerve distribution. This is the positive

phalen sign. Tingling sensation in the distribution of the median nerve may be

Roopa


induced by holding the wrist in fully extended position for not less than 60 seconds.

This is known as reverse phalen sign. Though these tests are very specific but are

found to be low sensitive.

Carpal compression test: Firm pressure is applied on the carpal tunnel by applying

the thumb and is maintained for 30 seconds. This will trigger the symptoms of carpal

tunnel syndrome76

. This test is found to be sensitive by 89 to 96 %.

Palpatory diagnosis: This test is carried out by examining the soft tissues overlying

the median nerve at the wrist for any mechanical restriction77

.

Square wrist sign. The thickness and the width of the wrist is measured and its ratio

is calculated. If the ratio is greater than 0.7 then is positive for carpal tunnel

syndrome78

.

Investigations

Nerve-conduction studies are highly sensitive detecting the median nerve

damage. Muscle activity may be studied by electromyography.

Bheda


BHEDA

From the foregoing chapters it is clear that Manibandha marmabhighata

belongs to the category of nanatmaja vata vyadhi. Hence the etiopathogenesis of vata

vyadhi also holds well in Manibandha marmabhighata. Vatavyadhi is categorized into

two on the basis of basic causes of vatavyadhi as dhatu kshayaja vata vyadhi as well

as margavaranja vata vyadhi79

.The same is applicable to Manibandha marmabhighata.

Margavaranja marmabhighata

In general the accumulation of the medas in the body leads to the pathology of

avarana. In the context of Urustambha it is said that excessive accumulation of the

medas in the thigh region obliterates the channels that carry vata dosha and the patient

suffers from urustambha. Identical to this the accumulation of medas in the

manibandha can obliterate the vatavaha sira which is on among the content of marma

in general; can precipitate the clinical presentation of Manibandha marmabhighata.

Dhatu kshayaja marmabhighata

Dhatu in the context of vatavyadhi refers to snayu upadhatu. The degeneration

of this is termed as dhatu kshaya in general. Among the different nidana of vata

vyadhi excessive physical strain involving wrist precipitates the depletion of the

snayu with in the wrist joint this will lead to the manibandha marmabhighata.

Samprapthi


SAMPRAPTHI

Vitiated vata dosha afflicting the sira and snayu at the manibandha marma

leads to the clinical manifestation of the Manibandha marmabhighata. The following

paragraphs will give the full account of different samprapti ghataka involved in the


Dosha: Vata dosha is invariably involved in the samprapti of Manibandha

marmabhighata. Manibandha marma belongs to the category of rujakara marma and

raja is the major symptoms of morbid vata dosha. More to add the symptoms of Supti,

Ruk, Vastushukairavakirna, Shosha and Kuntata of Manibandha marmabhighata all

are caused by vata dosha. On the other hand when the santarpana nidana is

precipitating the margavarana leading to the marmabhighata, the santarpana nidana

causes accumulation of kapha and medas in the body. In this pathology kapha dosha

may be involved in the causation of margavarana.

Dhatu: Mamsa is a component of any marma including the manibandha marma hence

its rationale to consider the mamsa dhatu in the pathogenesis of Manibandha

marmabhighata. Moreover, the symptom of shosha of manibandha marmabhighata is

pathognomonic of mamsa dhatu80

. Considering the etiopathogenesis of santarpana

nidana and the involvement of medas in the causation of margavarana reveals the

medas as a samprapti ghataka of Manibandha marmabhighata.

Upadhatu: Snayu is an invariable component of any marma including manibandha

marma. Localized or generalized paralysis in the body is attributed to snayu gata

vata81

. Considering the symptom of kuntata presenting with paralysis of the hand the

Samprapthi


morbid involvement snayu upadhatu in the samprapti of manibandha marmabhighata

is justified.

Mala: No specific mala is involved in the samprapti of Manibandha marmabhighata

Manas: No symptom of Manibandha marmabhighata indicates the involvement of

manas.

Indriya: Vata dosha is instrumental in the activities of indriya including the

sparshanendriya82

. Sensation is the function of sparshanendriya. Sensation of pins

and needles as well as numbness of the hand indicates the affliction of the

sparshanendriya.

Srotas: Sensation and motor activity in the body is said to be mediated through the

vatavaha sira83

and vatavaha dhamani84

. Sira and dhamani and snayu are component

of any marma and so also the manibandha marma. Loss of sensation is

pathognomonic of affliction of vatavaha dhamani. In contrast to this the paralysis of

the hand is indicative of affliction of vatavaha sira. Again in case of the santarpana

nidana the rasavaha srotas as well as medovaha srotas is invariably involved.

Srotodushti prakara: Motor activity is the function of vatavaha sira. This function is

greatly affected in the symptom of kuntata. Thus the sanga of the vatavaha sira is

justified. On the other hand different modality of sensation is the function of vatavaha

dhamani. The numbness in Manibandha marmabhighata is indicates sanga of

vatavaha dhamani. More to add sanga of the rasavaha srotas as well as medovaha

Samprapthi


srotas is instrumental in morbid increase of medodhatu that obstructs the vatavaha

dhamani and sira.

Agni: Pathological state of Agni is unrelated in the samprapti of the manibandha

marmabhighata caused by the nidana. Contrary to this dhatvagnimandya is evident in

santarpana nidana. The impairment of rasa dhatvagni facilitates excessive production

of medodhatu from the rasa dhatu.

Ama: When the manibandha marmabhighata is caused by indulgence of etiology of

vata vyadhi, ama is not involved in the pathogenesis. On the contrary rasa dhatu gata

ama is argued in the samprapti of santarpana nidana. The excessive intake of unctuous

and sweet foods causes abnormal accumulation of kapha and medas in the initial rasa

dhatu. This morbid accumulation of medas in the rasa dhatu is termed as amarasa85

.

This eventually causes over weight and obesity. Again thus produced medas is

responsible for the entrapment of the vatavaha dhamani and sira at the manibandha.

Udbhava sthana: Vata dosha is exclusively involved in the samprapti of Manibandha

marmabhighata of the type caused by nidana. Hence the pakvashaya86

as the origin of

the illness is justified. Contrary to this kapha and medas are additional in the

samprapti of Manibandha marmabhighata due to margavarana. Hence amashaya87

and

pakvashaya together is accepted as origin of the illness.

Dosha sanchara sthana: Over stain of the wrist during different activities

predisposes to vitiation of vata dosha and causes Manibandha marmabhighata. In this

samprapti the symptoms are distributed in the wrist as well as hand and are the

sanchara sthana of the dosha. On the other hand in the santarpana nidana, kapha and

Samprapthi


medas circulate all over the body presenting with overweight and obesity indicating

the whole body as the sanchara sthana of the dosha. It is same morbid medas at the

wrist predisposes to Manibandha marmabhighata.

Vyakta sthana: Numbness pain and paralysis related to the wrist and hand are the

cardinal manifestation of the Manibandha marmabhighata. Based on this it can be said

that manibandha sandhi and pani as the vyakta sthana of the manibandha

marmabhighata.

Rogamarga: Involvement of manibandha sandhi and marma justifies the madhyama

roga marga 88

of the illness.

Vyadhi svabhava: It is said that any disease involving the marma / madhyama roga

marga is difficult to cure. Accordingly any marmabhighata is described as

“krichratama vyadhi”89

i.e. the illness is treatable only by energetic and meticulous

planning.

Samprapthi


Table:1 Samprapti ghataka of manibandha marmabhighata.

Sl no Category Details (Margavaranja)

1 Dosha Vata (kapha)

2 Dhatu Mamsa (medas)

3 Upadhatu Snayu

4 Mala Nothing significant

5 Mansa Nothing significant

6 Indriya Sparshanendriya

7 Srotas

Vatavaha dhamani, vatavaha sira,

rasavaha srotas, medovaha srotas.

8 Sroto dushti prakara sanga

9 Agni (rasa dhatvagni mandya)

10 ama (amarasa)

11 Udbhava sthana Pakvashaya (ama pakvashaya)

12 Dosha sanchara sthana Manibandha, pani (sarvasharira)

13 Vyakti sthana Manibandha, hasta

14 Rogamarga madhyama

15 Vyadhi svabhava krichratama

Samprapthi


Pathophysiology of carpal tunnel syndrome.

Carpal tunnel syndrome happens due to the entrapment of the median nerve90

.

This happens with in the rigid confines of the carpal tunnel. To begin with, there

exists high carpal tunnel pressure. This increased pressure obstructs the venous out

flow. Obstructed venous outflow in term increases the back pressure and development

of edema. This edema within the Carpal tunnel ultimately leads to ischemia of the

nerve. This ischemia initiates the median nerve damage. Initially due to the

entrapment the median nerve undergoes demyelination. This is followed by axonal

degeneration. In this pathophysiology the sensory nerve fibers are affected first. This

is followed by affliction of motor nerve fibers91

. More to add the autonomous fibers

with in the median nerve also get affected.

Upadrava


UPADRAVA

In regards to the marma in general, it is said that either permanent

disability or death is the complication of marmabhighata. To be more precise; it is

said that in case of poor management or sever injury of the rujakara marma eventually

leads to permanent disability92

. From these descriptions it is clear that permanent

disability is the complication of manibandha marmabhighata. The permanent

disability in relation to the manibandha marmabhighata is described as kuntata or

paralysis. Hence the kuntata or paralysis of the hand is accepted as complication of

manibandha marmabhighata. Paralysis, complete loss of sensation and atrophy of

muscles is regarded as complications of vatavyadhi in general. By implication

paralysis of the hand, loss of sensation of the hand and atrophy of the hand muscles is

the complications of manibandha marmabhighata

Complications of carpal tunnel syndrome: Timely and meticulous treatment is

essential in case of carpal tunnel syndrome lest it will lead to permanent irreversible

damage to the median nerve. This will result in decrease in hand function, atrophy of

thenar muscle and disability of hand.

Sadya-Asadyata


SADYA-ASADYATA

Multiple factors determine the prognosis of the Manibandha marmabhighata.

Following factors are worth considering in the context of sadhya asadhyata of


Morbidity of vata dosha.

Vatadosha is the most important and virulent dosha present in the body.

Among the dosha vata is considered as svatantra dosha or independent dosha. Pitta

and kapha are capable of moving when mobilized by the vata dosha. Vata is circulates

in the whole body and hence causes severe diseases. Morbidity of vata dosha is hence

treated as most difficult among the vitiation of three dosha. Manibandha

marmabhighata causes vata vyadhi hence is difficult to cure.

Avarana vyadhi.

In general diseases caused by the avarana is said to be difficult to cure.

Santarpana nidana causes accumulation of medas in the wrist. This entrapts the

vatavaha srotas manifesting as avarana eventually leading to manibandha

marmabhighata. Needless to say, the manibandha marmabhighata manifesting as a

sequel of avarana is difficult to cure.

Marmagata vyadhi.

By all means the diseases related to the marma are difficult to cure. Even

minor injury to any marma should be considered seriously and it should be

meticulously treated with priority. Any error in the treatment may either lead to

permanent disability or death. Usually the rujakara marma proves causing permanent

Sadya-Asadyata


disability if not fatal. It is said that since the mamsa, sira, snayu, asthi and sandhi are

collectively present the injury to the marma is always serious93

. Physiologically the

prana exist in the marma and hence injury to any marma should be considered as

serious injury. The characters of agni and vayu predominate in the rujakara marma

including manibandha marmabhighata94

. This unique combination tends to cause

permanent disability of kuntata or paralysis of hand.

Madhyama roga marga vyadhi.

Involvement of manibandha sandhi and marma substantiates the Manibandha

marmabhighata as sandhi and marma gata vyadhi. Hence is enlisted as one among the

madhyama roga marga. In general it is said that any disease involving the madhyama

roga marga is difficult cure, so also the Manibandha marmabhighata.

Prognosis of carpal tunnel syndrome.

Usually the Carpal tunnel syndrome is progressive over time. Symptoms may

fluctuate from week to week. In a long run it may lead to permanent median nerve

damage. Conservative management works well in significant number of cases.

Surgical correction gives prompt relief and prevents the permanent damage. However

recurrence is possible when treated conservatively and also after surgical intervention.

When the Carpal tunnel syndrome is secondary to some preexisting illness like

diabetes or wrist fracture then the prognosis is poor. Patients with negative nerve

conduction study reports have good prognosis.

Chikitsa


CHIKITSA

Internal or external injury can cause affliction of marma. Vitiated dosha

afflicting the marma forms the pathophysiology of internal doshaja marmabhighata.

Manibandha marmabhighata of to internal injury type, caused by affliction with

doshaja marmabhighata leading to vatavyadhi is the subject matter of this chapter.

Again the santarpana nidana causing accumulation of medas at the wrist; which in

turn, obliterating the vatavaha srotas is the unique pathology of doshaja manibandha

marmabhighata. Thus clearing the effects of santarpana nidana and rectifying the

resulting vatavyadhi forms the crux of the treatment of Manibandha marmabhighata.

With this pretext following line of treatment of doshaja Manibandha marmabhighata

is discussed95

.

Srotas Shodhana: In general shodhana is contraindicated in vatavyadhi. But if the

vatavyadhi is associated with other dosha or else the pathology of avarana is involved

then the shodhana should be planned at the outset. In this regard it is said that by

mistake if the snehana and other treatment of vata dosha is initiated at outset the

symptoms are likely to be worsened96

. Hence shodhana is indicated. Santarpana

nidana leading excess of medas accumulated in the manibandha is the unique

pathology of manibandha marmabhighata hence shodhana is ideal at the outset. Since

the pathology of medas is ubiquitously spread in the body sequential administration of

dipana pachana, snehapana, snigdha sveda, virechana karma and samsarjana krama

should be adapted. This will clear the medas accumulation in the wrist clearing the

avarana of vatavaha srotas.

Chikitsa


Anabhishyandi sneha: Since kapha and medas is instrumental in initiating the

pathology of vata dosha both factors should be give equal importance while planning

snehana chikitsa as part and parcel of shodhana chikitsa. Snehapana is essential

prerequisite to achieve shodhana treatment and at the same time snehapana tend to

worsen the kapha and medas which is the initial pathology. Thus considering this the

anabhishyandi sneha is advised97

in the treatment of avarana. The ghee processed with

drugs that alleviate kapha and medas like pippali and guggulu should be prescribed to

the patient. In this regard guggulu tikta is an ideal medication for ensuring the sneha

effect prior to the shodhana in patients suffering from manibandha marmabhighata.

Mridu sramsana: Shodhana may worsen the vitiation of the vata dosha. Hence when

the patient physically strong and fit for shodhana treatment; mild shodhana in the

form of mridu sramsana should be adapted. Such balanced treatment clears the kapha

and medas and at the same time do not increase the virulence of vata dosha.

Sneha virechana: Virechana is ideal shodhana in accumulation of medas causing

avarana. At the same time resulting morbidity of vata dosha should be considered and

is made possible by adapting the sneha virechana. Virechana medicines in the sneha

form serve the purpose of sneha virechana. Thus oral administration of Eranda taila98

is an ideal prescription to accomplish sneha virechana.

Kapha pitta aviruddha chikitsa: At every stage of the treatment one should

remember that the vatavyadhi manifestation of Manibandha marmabhighata is

associated with morbidity of kapha and medas. Hence treatment of vata vyadhi that

does not worsen the kapha and medas should be judiciously planned.

Chikitsa


Vatanulomana chikitsa: All measure of vata shamana like snigdha sveda should be

planned following shodhana chikitsa. Also one should plan with such measures that

do not worsen the kapha and medas.

Yapana basti: In general yapana basti is indicated in all vata vyadhi caused by

avarana. This yapana basti has the duel effect of shodhana as well as brimhana effect.

Shodhana effect is ideal to negate the effect of kapha and medas and the brimhana

effect negates the influence morbid vata dosha.

Rasayana: Rasayana chikitsa is always effective in avarana vata vyadhi. The

rasayana that are effective in avarana vatavyadhi include Shilajatu loha rasayana,

Bhargavaprokta rasayana, Guggulu rasayana with the anupana of milk and Haritaki

rasayana. Lashuna rasayana is worth mentioning in this regard. The Lashuna rasayana

is indicated both in dhatu kshayaja as well as avarana vatavyadhi99

. Lashuna rasayana

would be an ideal prescription in avarana manibandha marmabhighata.

Vyatyaasaat ushna anushna krama: Alternative employment of heat and cold

measures are is the balanced approach of treating the avarana vatavyadhi. This

implies the rukshana treatment of kapha and medas is followed by snehana chikitsa of

vata dosha should be adapted treating both the medas as well as morbid vata dosha.

Haritaki or yava is advisable in the form of rukshana chikitsa for about a week

followed by next one week medication with bala taila is suitable in avarana vata. Such

an alternative approach of treatment is justified in Manibandha marmabhighata.

Chikitsa


Bahiparimarjana chikitsa: Snigdha sveda is advisable in general in patients

suffering from vatavyadhi. This is also true in cases of Manibandha marmabhighata.

Also kapha and medas is involved in the avarana spearheading the samprapti of

Manibandha marmabhighata; ruksha sveda may be preferred in comparison to snigdha

sveda. Since part affected is hand different forms of ekanga sveda is most suitable.

Svedana may be done by adapting nadi sveda or avagaha sveda limited to the hand.

Even upanaha sveda is effective in avarana Manibandha marmabhighata. Sveda is

effective in relieving the pain and swelling and hence the pain of Manibandha

marmabhighata is best treated by ruksha or upanaha sveda.

Patya-Apatya


PATYA-APATYA

Manibandha marmabhighata is accepted as vata vyadhi. Thus all the pathya

and apathya related to the vata vyadhi is relevant and hence is listed below. However

it should be remembered that the do’s and don’ts of santarpana nidana that cause

avarana Manibandha marmabhighata will differ. Hence a while planning the pathya

and apathya in patients with Manibandha marmabhighata; a balance should be

achieved between the pathya - apathya of vata vyadhi as well as santarpana vyadhi100,

101,102.103.

Table:2 list of pathya of vatavyadhi / Manibandha marmabhighata

Category List of do’s

properties Madhura / Sweet taste, amla /sour taste, lavana / salty taste, snigdha

/unctuousness, ushna /hot.

cereals Godhuma /Wheat, shashtika shali / rice that matures 60 days, rakta

shali /red rice, cereal grains that older than an year.

pulses Kulattha /horse gram, masha / black gram, tila / sesame seed .

vegetables Patola / snake gourd, shigru / Drumstick, vartaku /Solanum

melongena Linn, lashuna / garlic, tambula / betel leaf.

fruits Dadima / Pomegranate, pakvatala / fruit Palmyra Palm, rasala /

Mangifera indica, parushaka / Griwia asiatica linn, jambira /

lemon, badara / Zizyphus sativus, draksha / grapes, naranga /

orange, tintidika / Rhus parviflora Roxb.

meat Gramya mamsa / Meat or Domesticated animals like go /cow,

ashvatara / mule, ushtra / camel, ashva / horse, rasabha / donkey,

Patya-Apatya


chaga / goat (Úeie}); anupa mamsa / meat of animals inhabiting

marshy land like kola /pig, mahisha / buffalo, nyangu / antelope,

khangi / rhinoceros, gaja / elephant; audaka mamsa /meat of

acquatic animals like hamsa /swan, kadamba / duck; bileshaya

mamsa / meat of animals which live burrows in earth like bheka /

frog, godha / Iguana iguana, nakula / mongoose, shvavida /

porcupine; jangala mamsa /meat of animals dwelling in dry land

like tree cataka / sparrow, kukkuta / hen, tittiri / partridge bird, barhi

/ peacock, shilindhra /

clown knifefish, nakra / crocodile, gargara /Gagora catfish, kavayi

/ Cojus Cobojus -a fish with numerous small spines in the back,

jhallisha / Clupea Alosa – a kind of fish, kurma / tortoise,

shishumara / aligator, timingila / whale, rohita fish, madguru /

kind of sheatfish - Silurus pelorius, shringi / a species of fish, varmi

/ a species of fish, kulisha / a species of fish, jhasha / a species of

large fish .

milk Kshara / Milk, kilata / curdled milk, dadhikurchika / preparation

made out from boiling curd and milk in equal quantity, payapeti /

coconut milk.

Edible oil Sarpi / Ghee, tila taila / sesame oil, vasa / muscle fat, majja /

marrow fat, eranda taila / castor oil.

Shugar cane Matsyandika / Coarse or unrefined sugar .

urine gomutra / cow's urine .

dish Kulattha yusha / Dal soup prepared from horse gram, rasa / meat

soup.

Patya-Apatya


Alcoholic

beverages

Sura / Alcoholic preparation made by fermenting a mixture of

water, flour of rice, dhanyamla / Alcoholic beverage prepared by

fermenting water in which grains and pulse are slightly cooked or

merely washed .

activities Abhyanga / Oil massage, mardana / oil massage followed by

massage across the muscle, sveda / sudation, samvahana / soft

compression of the legs, snigdoshna anulepana / anlointig the body

with unctuous warm applications, sukhoshna parisheka / luke warm

shower, the application of saffron, Agura, Patra, Kushtha,

Ela, Tagara, guru aurnika pravarana / wearing of thick woollen

garments, guru Karpasa pravarana / wearing of thick cotton

garments, guru kausheya pravarana / wearing of thick silken

garments, guru rauma pravarana / wearing of thick fur coat, nivata

garbha griha / living in a warm inner chamber which is not exposed

to the wind, mridvi shayya / soft bed, sgni santapa / heat from fire,

brahmacharya / abstinence from sexual act .

Patya-Apatya


Table:3 list of apathya of vatavyadhi / manibandha marmabhighata

Category List of don’ts

properties Kashaya / bitter taste, katu / pungent taste, tikta / bitter taste.

cereals Nivara / a type of paddy, kangu / Foxtail millet / Setaria italic,

koradusha / Paspalum scorbiculatum Linn, shyamaka /

Indian barnyard millet, trina dhanya / different millets, yava / barley.

pulses Canaka / chickpea, kalaya / pea, rajamasha / Vigna unguiculata.

mudga /green gram, shimbi / legumes, nishpava / lablab bean.

vegetables Karira / Capparis deciduas, mrinala / edible root of lotus, shaluka /

tubors of Nelumbium speciosum Willd, katillaka / Momordica

charantia Linn, patra bhava shakha / leafy vegetables, kasheru /

Scirpus kysoor Roxb.

fruits Jambu / Syzygium cuminii, kramuka / areca nut, talaphala asthi

majja / Palmyra Palm seed, tinduka / Diospyros tomentosa Roxb,

balatala / tender palmyra palm udumbara / cluster fig tree [Ficus

Glomerata .

Milk Rasabha paya / Donkey’s milk.

sugarcane Kshaudra / honey .

water Tadaga / pond water, saridambu / river water, shitambu / cold water..

dish Shushka palala / dried meat .

Eating

habit

Anashana / Fasting, viruddhashana / consumption of combination of

foods that are derogatory to health.

activities Prajagara / keeping awake at night, vegadharana / Suppressing the

naturally manifesting urges, sharama / physical exertion, vyavaya /

sexual intercourse, hastyashvayana / riding on elephant, horse,

chankramana / excessive walking, prolonged resting on bed,

Mental

state

Chinta / Mental tension .

Drug Review


DRUG REVIEW

In the present study on efficacy of Lashuna rasayana104

in Manibandha

marmabhighata; the patient is initially treated with eranda taila for koshta shodhana

followed by administration of lashuna rasayana. The dravya guna of both lashuna and

eranda is given in this chapter.

LASHUNA 105

Lashuna is the only one content of the lashuna rasayana. For the purpose of

rasayana the garlic was administered in the freeze dried form filled in 500 mg capsule.

The full account of the dravya guna of the lashuna is given below.

Latin Name - Allium sativum.

Family Name – Liliacehe

Synonyms - Rasona, Yavanesta.

Vernacular Names

English : Garlic.

Hindi : Lahsun.

Kannada : Balluci.

Malayalam : Vellulli, Nelluthulli.

Properties

Rasa - Katu prdhana amla varjita sadrasa.

Guna - Snigdha, Tiksna, Picchila, Guru, Sara.

Veerya - Ushna.

Drug Review


Vipaka - Katu.

DoshaKarma- Kaphavatashamaka.

Rogaghnakarma-Brmhana, vrsya, pacana, saraka, bhagnasandhaanaya, kanthya

raktavardaka, balya, varnya, medya, netrahita, rasayana, hridya, jirnajvaraghna,

Kuksisulaghna, vibandha, gulmaghna, rucikara, kasaghna, sothaghna, kustaghna,

dipana, krimighna, svasaghna, kaphanisaraka.

Constituents–volatile oil containing Allyldisulphide and Diallyldisulphide. It also

contain Allin, Allicin, Mucilage and Albumin.

Substituents and adultrents-

Bulbs of Allium ampeloprasm Linn. Which is large in size and have two to four

cloves are considered as a good substitute for medical use in some parts of northern

India. A single clove variety of Allium sativum is grown in Rajastan for medicine

use.

ERANDA TAILA- This was administered for kosta shodhana before and after

treatment in the dose of 20 ml.

Eranda106

Latin name : RicinusCommunis Linn.

Family name : Euphorbiaceae.

Synonyms : Gandharvahasta, Panchaangula,vatari.

Drug Review


Vernacular Names

English : Castor Oil plant.

Hindi : Eranda, Rendee, andu.

Kannada : Haralu.

Malayalam : Avanakku, Abanakka.

Pharmacodynamics

Rasa : Madhura, Katu, Kashaya.

Guna : sukshma, Snigdha and Tiksna.

Veerya : Ushna.

Vipaka: Madhura.

DoshaKarma:kaphavatasamaka.

Rogaghnakarma- Shulagna, sothaghna, katisulagna, bastirogahara, sirasulahara,

udararogahara, jvaraghna, svasghna, kasaghna, Kusthaghna, amavatahara, saumya,

samsrana, stanyajanana, dahasamaka, vrsya, bhedani, svedopaga,

angamardaprasamana, adhobhagahara, snehana, vedanasthapana, krmighna.

Chemical Constituents: The alkaloids, fixed oil, glycerides, recinole acid etc.

Methodology


METHODOLOGY

Objective of Study-

Efficacy of a Lashuna rasayana on disease severity in patients suffering from

Manibhandha marmabhighata / Carpal tunnel syndrome.

Effect on functional disability in patients of Manibhandha marmabhighata /

Carpal tunnel syndrome treated with lashuna rasayana.

MATERIALS AND METHODS -

Source of data:

15 patients diagnosed as manibandha marmabhighata / carpel tunnel syndrome

were taken for study from OPD and IPD of Sri Dharmasthala Manjunatheshwara

Ayurveda Hospital, Kuthpady, 574118. The freeze dried powder of lashuna is

obtained in the 500 mg capsule from the Sri Dharmasthala Manjunatheshwara

Ayurveda Pharmacy.

Method of collection of data:

A specific proforma was prepared incorporating all points of history taking,

physical signs, and symptoms as mentioned in Ayurveda as well as bio medicine.

DESIGN OF THE STUDY:

Study Type : Interventional

Actual Enrollment : 15 participants

Allocation : Non-Randomized

Endpoint Classification : Efficacy Study

Intervention Model : Single Group Assignment

Masking : Open Label

Primary Purpose : Treatment

Study Start Date : October 2017

Study Completion Date : February 2018

Methodology


The patients were selected irrespective of gender, cast, race, religion, based on

the diagnostic inclusion and exclusion criteria. All the parameter of signs, symptoms

is scored as enlisted in the assessment criteria and the result obtained was statistically

analyzed by the paired t test.

Diagnostics Criteria:

Signs and symptoms Manibandha marmabhighata / Carpal tunnel syndrome

(paresthesia in the distribution of median nerve distal to wrist, weak hand grip,

wasting of muscles at the thenar eminence and positive tinels and phalen sign).

Inclusion Criteria:

Subjects with a clinical diagnosis of Manibandha marmabhighata / Carpal

tunnel syndrome.

Subjects must be between 16 to 70 years of age (both ages inclusive).

Subjects of both genders.

Having signed a written informed consent form.

Exclusion Criteria:

Patients with uncontrolled Diabetes Mellitus & Hypertension.

Patients with Fracture of wrist.

Subjects with history of excessive menstruation.

Patients who are pregnant by patient report or intending to become pregnant

during the study.

Patients that have been previously diagnosed with cervical radiculopathy.

ASSESSMENT CRITERIA

Primary outcome measures

Questionnaire of Levine et al for Clinical Assessment of Carpal Tunnel

Syndrome [Time Frame: Baseline, day 17]

Secondary outcome measures:

Change in Grip strength (Dynamometer) [Time Frame: Baseline, day 17]

Change in Visual Analog Scale for pain [Time Frame: Baseline, day 17]

Methodology


Participants Assessment of numbness Over Time by the method of visual

analog scale (VAS) ranging from 0 (best) to 10 (worst) cm

[Time Frame: Baseline, day 17]

Intervention:

Koshta shodhana on Day 1 : Oral administration of eranda taila in empty

stomach, in a dose of 20 ml in the morning

along with 100 ml of warm water as after

drink.

Lashuna Rasayana on Day 2

to 16

: Oral administration of lashuna rasayana in a

dose of 12 g in empty stomach half an hour

before breakfast along with 100 ml of milk107

as after drink.

Pitta virechana108

on Day 17 : Oral administration of eranda taila in empty


along with 100 ml of warm water as after drink

Follow up duration: 30 days

Total duration of study: 47days.

Clinical Assessment of Carpal Tunnel Syndrome (Levine et al)

A self-administered questionnaire can be used to assess the severity of

symptoms and functional impairment in patients with the carpal tunnel syndrome.

This can be used over time to monitor the effect of therapeutic interventions on the

course of the disease.

Parts to questionnaire:

(1) Symptoms severity scale

(2) Functional status scale

Symptom Severity Scale- over the past 2 weeks

(1) Severity of pain at night

(2) Waking up from pain

(3) Pain during daytime

(4) Frequency of daytime pain

Methodology


(5) Duration of daytime pain

(6) Numbness

(7) Weakness

(8) Tingling sensation

(9) Loss of sensation or tingling at night

(10) Being wakened by numbness or tingling

(11) Difficult grasping each item is graded from 1 (normal) to 5 (very abnormal)

Symptom severity score = SUM (points for all 11 questions)

Functional Status Scale Activities:

(1) Writing

(2) Buttoning of clothes

(3) Holding a book while reading

(4) Gripping of a telephone handle

(5) Opening of jars

(6) Household chores

(7) Carrying of grocery bags

(8) Bathing and dressing

Table 4 showing responses:

Response Points

No difficulty 1

Mild difficulty 2

Moderate difficulty 3

Severe difficulty 4

Cannot do at all due to hand or wrist symptoms 5

FUNCTIONAL STATUS SCORE = sum (points for all 8 activities)

Interpretation:

Minimum functional severity scale: 11

Maximum functional severity scale: 55

Minimum functional status scale: 8

Maximum functional status scale: 40

The lower the score in each scale, the better the patient's status.

Methodology


Change in grip strength (dynamometer)

Hand Dynamometer used here was measuring isometric grip force from 0-

130 kg. It was handy and reliable. It was made of plastic material. Patient had to

squeeze the hand dynamometer with maximum isometric efforts.

Visual analog scale for pain / numbness

It is a continuous scale comprising a horizontal visual analog scale 0- 10

readings. Lesser the reading by patient less is the pain where as more the reading

more is the pain.

Results


EFFECT OF TREATMENT

15 Patients suffering from manibandha marmabhighata were diagnosed and

screened under strict diagnostic, inclusion and exclusion criteria and were registered

for the study. These patients were invited to participate in the study after signing a

detailed informed consent prior to beginning of the study. These subjects were given

koshta shodhana on the day one of the intervention with oral administration of eranda

taila in empty stomach, in a dose of 20 ml in the morning along with 100 ml of warm

water as after drink. From day 2 to 16 patients were given lashuna rasayana in a dose

of 12 g in empty stomach half an hour before breakfast along with 100 ml of milk as

after drink. On the 17 the day pitta virechana was done by oral administration of

eranda taila in empty stomach, in a dose of 20 ml in the morning along with 100 ml of

warm water as after drink. All 15 patients completed the full treatment course

comfortably with no any adverse manifestations. Results of the intervention were

assessed by the following outcome measures and same is elaborated in this chapter.


Symptom severity.

Functional disability status.


Pain .

Numbness.

Grip strength (Dynamometer).

Overall effect.

Results


Effect of Lashuna rasayana on symptom severity of the illness

By adapting the Questionnaire of Levine et al for Clinical Assessment of

Carpal Tunnel Syndrome, the symptom severity of the manibandha marmabhighata /

carpal tunnel syndrome was assessed. The mean score of severity before the

intervention was 44.467 (±SE 1.546) that came down to 31.800 (±SE1.303) following

medication with lashuna rasayana. Thus a reduction into the severity score of 12.667

was recorded in this study. Also the improvement was statistically significant when

analyzed by the Wilcoxon Signed Rank Test with p <0.001. Full account the

statistical analysis is shown in the table18. .

Table 18: Effect of Lashuna rasayana on symptom severity of the illness

Outcome

(score

range)

Data Mean ±SD ±SE Median Min max

Mean

BT-

AT

P

value*

Severity

(11-55)

BT 44.467 5.986 1.546 43.000 35.000 57.000 12.667 <0.001

AT 31.800 5.046 1.303 31.000 25.000 41.000

* Wilcoxon Signed Rank Test

Graph.24 Effect of Lashuna rasayana on symptom severity of the illness

0

5

10

15

20

25

30

35

40

45

Severity

44.467

31.8

BT

AT

Results


Effect of Lashuna rasayana on functional disability status

The functional disability status of the patients suffering from manibandha

marmabhighata / carpal tunnel syndrome was assessed by adapting the Questionnaire

of Levine et al for Clinical Assessment of Carpal Tunnel Syndrome. At the baseline

the mean score of functional disability status was 34.600 (0.616) that came down to

25.333 (0.715) following lashuna rasayana thus recording an improvement by 9.267 is

functional disability status score. Again when analyzed by the statistical test of

significance, this improvement was highly significant with p <0.001. Details of the

statistical analysis is depicted in the table 19.

Table 19: Effect of Lashuna rasayana on functional disability status

Outcome

(score

range)


Mean

BT-

AT

P

value*

Functional

status (8-

40)

BT 34.600 2.384 0.616 35.000 30.000 38.000

9.267 <0.001 AT 25.333 2.769 0.715 26.000 20.000 30.000


Graph.25 Effect of Lashuna rasayana on functional disability status

0

5

10

15

20

25

30

35

Functional status

34.6

25.333

BT

AT

Results


Effect of Lashuna rasayana on VAS pain score:

The visual analogue scale VAS of 0 to 10 was used to assess the intensity of

pain in the hand. Higher values represented the worse pain in hand. The mean VAS

pain score in 15 patients at base line was 8.133 that came down to 4.0 following the

medication. Thus an improvement of 4.333 in the mean Vas pain score was recorded.

By the method of Wilcoxon Signed Rank test when the improvement was analyzed it

was found to be statistically highly significant with P<0.001. Details of the statistical

analysis are given in the table 20.

Table 20: Effect of Lashuna rasayana on VAS pain score

Outcome

(unit/range) Data Mean ±SD ±SE Median Min max

Mean

BT-

AT

P

value*

PAIN

(0-10)

BT 8.133 2.56

0 0.661 8.000 3.000 14.000

4.133 <0.001

AT 4.000 1.41

4 0.365 4.000 1.0000 7.000

* Wilcoxon Signed Rank test

Graph.26 Effect of Lashuna rasayana on VAS pain score

0

2

4

6

8

10

VAS Pain

8.133

4 BT

AT

Results


Effect of Lashuna rasayana on VAS numbness score:

For assessing the severity of subjective symptom of numbness of the hand the

visual analogue scale - VAS of 0 to 10 was used in patients suffering from

manibandha marmabhighata / carpal tunnel syndrome. Higher the VAS score the

worst is the symptom numbness. The initial VAS score was 8.133 before beginning

the lashuna rasayana. After the intervention the numbness recorded was 4.133 thus

showing a decrease in severity of numbness VAS score of 4. Further by adapting the

Wilcoxon signed rank test, the improvement recorded by medication was found to be

statistically significant with P value <0.001. All statistical analysis is displayed in the

table 21.

Table 21: Effect of Lashuna rasayana on VAS numbness score:

Outcome

(Score

range)


Mean

BT-

AT

P

value*

Numbness

(0-10)

BT 8.133 2.532 0.654 8.000 6.000 15.000 4 <0.001

AT 4.133 1.457 0.376 4.000 2.000 7.000


Graph.27: Effect of Lashuna rasayana on VAS numbness score:

0

2

4

6

8

10

Numbness

8.133

4.133 BT

AT

Results


Effect of Lashuna rasayana on hand grip strength.

The hand grip strength of the patients suffering from manibandha

marmabhighata / carpal tunnel syndrome was measured by using the dynamometer.

At baseline the mean hand grip strength was 5.600 Kg. After the lashuna rasayana this

improved to 12.133 Kg. Thus an improvement of 6.53 Kg in the hand grip strength

was recorded in the study. Analysis of the statistical significance was done by

adapting the paired t test, it showed that the improvement in the hand grip strength

was statistically significant with p value of <0.001.

Table 22: Effect of Lashuna rasayana on hand grip strength

Outcome

(unit) Data Mean ±SD ±SE Median Min max

Mean

BT-

AT

P

value*

Hand

grip (Kg)

BT 5.600 3.291 0.376 4.000 0.000 12.000 6.53 <0.001

AT 12.133 4.673 1.207 6.000 4.000 23.000

* Paired t-Test

Graph.28 : Effect of Lashuna rasayana on hand grip strength

0

2

4

6

8

10

12

14

Hand grip

5.6

12.133

BT

AT

Results


THE OVERALL AFFECT OF THE LASHUNA RASAYANA:

The overall effect of the lashuna rasayana in patients suffering from the

doshaja manibandha marmabhighata / carpal tunnel syndrome was assessed by

percentage of improvement in the summation of symptom scores of severity of

illness, functional status, pain, and numbness. Complete remission of the illness was

recorded in none. The study revealed that 13.33 % of patients had moderate remission

and 80 % of patients have recorded average remission. Also 6.66 % of patients

showed poor remission. The details of the same is given in the table 23.

Table 23: The overall affect of the lashuna rasayana:

Extent of Change Change category No of patients % of patients

100 % Improvement Complete remission 0 0

Improvement from 76 to 99 % Best remission 0 0

Improvement from 51 to 75 % Moderate remission 2 13.33%

Improvement from 26 to 50 % Average remission 12 80%

Improvement from 1 to 25 % Poor remission 1 6.66%

Worsening Worsening 0 0

Graph.29: The overall affect of the lashuna rasayana:

0

10

20

30

40

50

60

70

80

Overall effect

0 0

13.33

80

6.66 0

Complete

Best

Moderate

Average

Poor

Worsening

Discussion


DISCUSSION

Hand is prehensile, multi fingered appendage located at end of forearm in

humans. It plays an important function in body language and sign language. Ten

digits of two hands and twelve phalanges of four fingers have given rise to systems

and calculation techniques. Wrist joint support movements of hand and forearm

.sports and manual works involve complicated and coordinated activities of hand and

wrist joint. It is second most active joint after ankle joint. This joint is affected in the

doshaja Manibandha marmabhighata / Carpal tunnel syndrome.

The perceptions of marma are discussed with two distinct perspectives in the

literature. External trauma and internal injury due to morbid dosha may present with

clinical condition of marmabhighata. The surgical school of thought has described the

marma with more emphasis on traumatic injury and surgical intervention. On the

other hand the same topic is marma is elaborated in the medical school of thought

with the objective of diagnosing internal injury due to morbid dosha and conservative

medical management. This is also true in relation to Manibandha marmabhighata. The

description of marmabhighata comes under the topic of possible external injuries. In

the medical school of thought marmabhighata is mostly cited in under the umbrella

term of nanatmaja vata vyadhi.

Vata vyadhi is considered as most virulent among the tridosha. Among the

diseases caused by vitiation of vata dosha, samanya & nanatmaja vyadhi presents with

distinct features. Literature quotes 80 types of nanatmaja vata vyadhi that is specified

as aavishkritatama vata vyadhi. The description of some of these diseases is vivid in

the literature and elaboration of some is restricted to guidelines. In general vata dosha

Discussion


is diagnosed based on symptoms of aggravation of vata dosha and location of

affliction. Nakha bheda, Paada shola, Paada supthi are just the examples.

Kuntata is a disorder characterised by the paralysis related to the activities of

hand. Scanning of literature explores the better explanation of the condition with due

consideration of abhighata nidana in manibandha as rujakara marma.

Etiological factors of vata vyadhi such as strain caused due to exposure of

vyayama, abnormal positioning during different activities is worth considering. These

etiological factors have direct bearing on joints. To be more precise the excessive and

abnormal activities of involving the hand may affect the manibandha marma.

Affection of manibandha marma is the key pathology as per the understanding of

marmabhighata.

The Manibandha marmabhighata can happen for two reasons, they are the

internal factor & external factor. External by the way of different activities related

to bahya abhighata involving the manibandha. In contrast to santarpana nidhana

causing excessive kapha & medas can lead to avarana vata vyadhi and can involve the

manibhandha marma leading to margavaranajanya Manibandha marmabhighata

similar to the samprapti of urustamabha. Here the marga refers to vatavaha srotas.

Manibandha marmabhighata is caused either external factors or internal factors like

santarpana nidana resulting in vata vyadhi. Literature affirms the role of

marmabhighata in causation of vatavyadhi.

Manibandha marmabhighata when it happens for above said reasons result in

manifestation of supta, ruja, kuntata, vastushukairavakirna,shosha,parvashopha.These

symptoms, comprising of Manibandha marmabhighata; parallels with symptom of

Carpal tunnel syndrome. The symptoms of Manibandha marmabhighata include

Discussion


suptata (paresthesia), ruja (pain) and kuntata (paralysis of the hand leading to

functional disability) .Thus these symptoms match with that Carpal tunnel syndrome.

Carpal tunnel syndrome may be caused due to obesity, trauma, pregnancy and

inflammation etc.These etiological factor either belonging to the category of

santarpana nidana or injury to wrist by physical activities. The pathology of

margavarana / abhighata in manibandha is parallel to median nerve entrapment in

carpal tunnel.

Manibandha marmabhighata and the resulting vatavyadhi is treated according

to the treatment of vatavyadhi by snehana, svedana, brimhana and rasayana. Balanced

approach rectifying the kapha and medas and simultaneously normalizing the

functions of the vatadosha is the sheet anchor of treating Manibandha marmabhighata

leading to kuntata.

Needless to say rasayana cikitsa has got an edge over any other conservative

management. Also Lashuna rasayana is effective in both clearing the co morbidity of

margavarana as well as pacification of vitiated vata dosha thus proving its superiority

in the management of Manibandha marmabhighata. Pilot study has shown favorable

response in patient suffering from Manibandha marmabhighata treated with Lashuna

rasayana. Hence this study is intended to evaluate the therapeutic effect of Lashuna

rasayana in patient suffering from Manibhandha marmabhighata / Carpal tunnel

syndrome.

Review of literature

Marma are the unique vital points in the body. Strong blow on these marma

can cause significant injury and may even prove fatal. Contrary to this a mild touch of

these vital points can cause healing. The whole practice of marma therapy is based on

Discussion


this understanding. The knowledge of marma is essential for planning surgical

interventions. The seriousness of any trauma is judged by the involvement of marma.

The same marma knowledge is used in the martial arts to kill the opponent. Most

recently the same knowledge is utilized to treat certain diseases. To be clearer, the

knowledge of marma is traced back to Vedic literature and has progressed to the

present marma therapy practiced in the southern part of the India known by the name

Kalaripayattu.

Nirukti and paribhasha-

The word Manibandha marmabhighata has three component as manibhandha

marma and abhighata.The Sanskrit word manibandha in masculine gender is formed

by the combination of two component terms of Mani and bandha with the addition of

suffix ghanj. Mani refers to the jewels. Bandha refers to the act of fastening or

binding. Put together, etymologically the fastening of the jewel is known as

manibhandha. The joint between the forearm and hand is called as manibandha. It is

identified as the base of hand and is located proximal to the palm. Marma refers to a

body location and injury to which tend to cause death. The Sanskrit word abhighata in

masculine gender is derived from the Sanskrit root “han” with the prefix “abhi”. The

Sanskrit root “han” refers to the activity of striking or attack. Again this injury may be

due to external trauma or internal injury caused by morbid dosha. In short, internal or

external injury to the vital organ of wrist is known as manibandha marmabhighata.

NIDANA

Manibandhamarmaghata happens due to santarpananidana and

apatarpananidana. . Therefore considering the nidana, maximum patients suffering

Discussion


from the apatarpananidana were witnessed in this study. About 80% of the patients

belonged to this category. This may be due to injury or professional causes. Patient in

the study, were found with excessive usage of hands in their activities may be the

involving the house hold activities like lifting heavy materials ,washing cloths etc..

Professionally tailors and bankers were found to be the culprits of this disease.

Considering the santarpananidana only 20% of patients were found who were obese,

as carpal tunnel syndrome occurs due to fat deposition in the wrist around the carpal

bone hence compressing the median nerve which passes within it.

ROOPA

Manibandha marmabhighata will present with symptoms like suptata, ruk,

Vastushukairavakirna, shosha, parvashopa, all the patients in the present study had

pain and numbness in their thumb, forefinger, middle finger and radial half of ring

finger which signifies the median nerve entrapment. In physical examination sensory,

motor deficits and the specific tests like Hoffmann tinel sign, Phalen sign were

present in the patient.

SAMPRAPTHI

Vitiated vatadosha afflicting the sira and snayu at the manibandha marma

leads to the clinical manifestation of the manibandha marmabhighata. The

pathophysiology of the disease goes in two modes according to the nidana. Injury to

any marma can happen due to santarpana or aptarpananidana. Santarpananidana

results into fat accumulation around the surface of wrist, thus causing compression to

the carpal tunnel eventually leading to entrapment of median nerve. Apatarpana

factors are any kind of injury or professional cause i.e. over usage of hands, example-

Discussion


tailors, typists, etc. Exposure to the different nidana like physical activities and

external traumatic factors mentioned in vatavyadhi, leads to vitiation of vatadosha in

the effected part leading to symptoms like supta, ruk, kuntata, shosha,

vastuhukaivakirna and parvashopha leading to Manibandha marmabhighata.

Considering the santarpana nidana, exposure of santarpana nidana in terms of

ahara and vihara, leads to increase kapha and medas obstructing the marga leading to

aggravation of vata causing the Manibandha marmabhighata. The pathophysiology

may be different in two case but it has a common culprit, the vatadosha leading to

Manibandha marmabhighata at the end.

UPADRAVA

The morbid event developed by the manifestation of main disease after its

genesis is upadrava. It is the complication of the disease seen after the fully

manifested disease. Hence considering the manibandha marmabhighata where

“kuntata” is seen as the upadrava. Kuntata is defined as “karasyaakarmanyavat” ie

functional loss of the hand. In parallel science we can consider it functional loss in the

activities due to immense pain or paresthesia leading to disability of hand and atrophy

of thenar eminence seen in carpal tunnel syndrome.

CHIKITSA

Literature specifies various kinds of treatment mentioned in vata roga. Though

samprapti is different for the mode of causation of disease according to the factors but

at the end it is vatadosha that is to be controlled and pacified. Hence demand of such a

drug is necessary which will not only pacify vata but also does the samprapthi

vighatana of the both samprapti and there by curing the disease. The pathology may

be further complicated by the margavarana at the manibandha by the kapha and

Discussion


medas that causes pain, numbness etc. Balanced approach rectifying the kapha and

medas and simultaneously normalizing the functions of the vatadosha is the sheet

anchor of treating manibandha marmabhighata leading to kuntata. Needless to say

rasayana cikitsa has got an edge over any conservative management. Also lashuna

rasayana is effective in both clearing the co morbidity of margavarana as well as

pacification of vitiated vatadosha thus proving its superiority in the management of

margavaranja manibandha marmabhighata as well as the one caused by external

factor.

Pathya – Apathya.

Manibandha marmabhighata is a vatavyadhi .hence pataypathya of vatavyadhi

is to be followed. Literature specifies dietetic, lifestyle rules and regimens, which on

following brings the morbid vatadosha to the normalcy.

In case of Vatavyadhi, Vatashamaka Ahara Vihara has been given

importance. In general, Mamsarasa, Paya, Madhura, Amla, Lavana Rasa yuktadravya,

and Brimhana have been advised. Hence one has to balance the food according to the

causation of disease. If the pathology is margavarana then one has to avoid the

santarpana ahara vihara along with vatashamaka drugs so that the dosha is maintained

in their normalcy.

Carpal tunnel syndrome.

Manibandha marmabhighata is compared to that of carpal tunnel syndrome. It

is caused by entrapment of median nerve within the carpal tunnel either due to injury

or by the fat deposition around the wrist compressing the median nerve within the

carpal tunnel. It presents with with typical symptoms, paresthesia of thumb,

Discussion


forefingers, middle finger and radial half of ring finger, atrophy of thenar eminence

etc.. causing the sensory and the motor deficits. The definite diagnostic signs are the

tinel’s sign and phalen’s sign. The treatment among the modern medicine is limited

just to steroids and painkillers. If not controlled by both of these surgery is the

ultimate option without the assurance of its cure.

Drug Review

Lashuna rasayana is chosen as the drug as it is a best drug of choice for both

the pathologies. It is said to be best in the vataroga as well as in clearing the

margavarana. Hence this drug is taken for the study and administered in avara dose

.The freeze dry powder of this drug was used in capsules containing 500mg each as it

is more palatable than the crude drug. 12 g was given for total of 15 days with prior

koshta shodhana with eranda taila .Eranda is said to be best in vata roga as well as

clearing the margavarana. At the end pitta virechana was done due to the usual

tendency of aggravation of pitta dosha and is achieved by oral administration of

eranda taila.

Methodology

As discussed in chikitsa, Lashuna rasayana is used to treat patient suffering

from manibandha marmabhighata / carpal tunnel syndrome. An open label, single

arm, non randomized efficacy study was planned to evaluate the therapeutic effect of

Lashuna rasayana. The patients were selected with no any restriction of gender and

cast for the study by strict screening as per the diagnostic, inclusion and exclusion

criteria.

Discussion


Signs and symptoms of manibandha marmabhighata / carpal tunnel syndrome

(paresthesia in the distribution of median nerve distal to wrist, weak hand grip,

wasting of muscles at the thenar eminence and positive tinels and phalen sign) is

taken as diagnostic criteria. Patients of both genders between the age group of 16 to

70 years of age were included in the study. Also the patients with uncontrolled

Diabetes Mellitus, uncontrolled hypertension, fracture of wrist, history of excessive

menstruation, pregnant / lactating females and patients with cervical radiculopathy

were excluded from the study. 15 participants who have signed a written informed

consent form were registered in the study.

The participants included in the study received koshta shodhana on the day

one of the treatment as shodhana is mandatory prior to any rasayana treatment. For

this purpose Eranda taila was orally administered in a dose of 20 ml in the morning

along with 100 ml of warm water as after drink. Lashuna rasayana was administered

on Day 2 to 16 in a dose of 12 g in empty stomach half an hour before breakfast along

with 100 ml of milk as after drink. This was followed by Pitta virechana on Day 17 in

the form of oral administration of Eranda taila in empty stomach, in a dose of 20 ml in

the morning along with 100 ml of warm water as after drink. It is said that Lashuna

rasayana tend to cause accumulation of the pitta dosha hence to clear the

accumulation of pitta dosha pitta virechana is planned by the end of Lashuna

rasayana. For recording the results the patients are assessed by way of primary and

secondary out come measures at base line and 17th

day.

Observation

Out of 15 patients included in the study 6.66% of patient belonged to age

group of 16-30 years .33.33% belonged to 31-50 years and 60% belonged to 51-70

Discussion


years. Patients are more in age group of 51-70 years as these set of patients are more

exposed to the trauma and professional wear and tear. Patients within the age group of

31-50 were the second highest ones as they were next to the maximum exposed ones.

Maximum of patients were females comprising total of 86.66%. Most of the

females are engaged in house hold activities which involves maximum usage of

hands. For example cleaning utensils, cooking, washing clothes etc. Probably this has

accounted for the higher incidence of the illness in the present sample. 86.66% of the

patients were of Hindu religion in this study. This only represent the dominance of

Hindu population in and around Udupi, from where this sample is taken. As such the

Hindu religion has nothing to do with the causation of the illness.

As the study was carried out in adults excluding children and seniors, 93.3%

of the patients were married and only 6.66% were widowed in the present study.

Out of the 15 patients, 66.66% were housewives and 20% were working as

tailors. These people use their wrist extensively in the professional activities and

hence have bearing in the causation of illness Manibandha marmabhighata / Carpal

tunnel syndrome.

Majority of the patient belonged to middle class family as these people do

enough physical activities for their lively hood tend to suffer from Manibandha

marmabhighata in comparison to the people of higher class who lead a leisurely life.

The participants of the study are selected from the costal belt, and hence a

maximum of 73.33% patients had mixed diet and they mostly consume sea food.

Excessive consumption of such foods may predispose to overweight and obesity. This

in turn may contribute to the etiopathogenesis of manibandha marmabhighata. This

fact should be considered when planning pathya-apathya in such patients.

Discussion


Disturbed sleep was recorded in 75% of the patients in this study. Partially the

disturbance is due to the discomfort in the hand related to the Manibandha

marmabhighata / carpal tunnel syndrome.

In most of the other patient the exact cause of the disturbed sleep could not be

confirmed. 80% of patients had the habit of sleeping in the afternoon. This is obvious

as majority housewives were involved in the study who would be tired at the noon

due to household work.

An enquiry about the habit revealed that all patients had the habit of taking

tea or coffee. Around 13.33% of the patients were addicted to tobacco chewing or

smoking cigarettes.

20% of the patient had a family history of Carpal tunnel syndrome. This is

because 3 patients had family history of obesity. Other 80% did not have family

history of carpal tunnel.

Out of 15 patients 46.66% of the patients belonged to each of vata pitta and

kapha vata prakriti. 6.66% belonged to pitta kapha prakriti. 80 % of the patients had

madhyama sara. 40% of the patients showed madhyama samhanaana. A majority of

66.66% had madhyama satva. Madhyama type of vyayama shakthi was recorded in

46.66% of patients. 73.33% of the patients had madhyama abhyavaharana shakthi

Majority of 80% patients of the study had madhyama jaranashakthi followed by

another 13.33% with the avara jaranashakthi.

Out of the 15 patients, 73.33 % of patients had gradual onset of symptoms as

against 26.66% of patients complained of sudden onset of illness. The symptom of

ruk / pain, supti / numbness and kuntata / reduced hand grip was recorded in all the 15

patients of manibandha marmabhighata / carpal tunnel syndrome. In 80 % of patients

the over strain of the wrist during different professional or house hold activity is

Discussion


recognized as major cause of illness in the form of bahya abhighata. No such cause

could be recorded in 20 % of patients pointing towards the internal injury as the cause

of Manibandha marmabhighata / carpal tunnel syndrome.

RESULTS

The mean score of severity before the intervention was 44.467 (±SE 1.546)

that came down to 31.800 (±SE1.303) following medication with Lashuna rasayana.

Thus a reduction into the severity score of 12.667 was recorded in this study. At the

baseline the mean score of functional disability status was 34.600 (0.616) that came

down to 25.333 (0.715) following Lashuna rasayana thus recording an improvement

by 9.267 is functional disability status score. The visual analogue scale VAS of 0 to

10 was used to assess the intensity of pain in the hand. Higher values represented the

worse pain in hand. The mean VAS pain score in 15 patients at base line was 8.133

that came down to 4.0 following the medication. Thus an improvement of 4.333 in the

mean Vas pain score was recorded. The initial VAS score was 8.133 (±SE 0.654)

before beginning the Lashuna rasayana. After the intervention the numbness recorded

was 4.133 (±SE 0.376) thus showing a decrease in severity of numbness VAS score of

4. At baseline the mean hand grip strength was 5.600 Kg. After the Lashuna rasayana

this improved to 12.133 Kg. Thus an improvement of 6.53 Kg in the hand grip

strength was recorded in the study. All these changes following medication with

Lashuna rasayana was subjected to Wilcoxon Signed Rank Test or Paired t-Test

depending upon the type of variables and the improvement observed was found to be

statistically highly significant with P value <0.001. Thus it can be said that the

Discussion


improvement observed is definitely because of the Lashuna rasayana and not due to

chance factor or sampling variability.

Excessive physical activities involving the wrist will have direct bearing on

the manibandha marma. Marmabhighata being one of the important etiologies of

vatavyadhi, the injury to the manibandha marma is clinically important for the same.

Pain stinging muscles atrophy and paralysis related to the hand are the symptoms of

Manibandha marmabhighata. Considering these symptoms this illness of Manibandha

marmabhighata is paralleled to Carpal tunnel syndrome of biomedicine. Again the

clinical presentation of manibandha marmabhighata is attributed to the morbidity of

vata dosha. Lashuna rasayana is indicated both dhatu kshayaja and margavarana

vatavyadhi.

In the present study significant reduction in the severity of symptoms of pain

numbness and paralysis is recorded proving the definite amelioration of the vata

dosha. Again it is observed that almost all the symptoms have shown partial

remission. None of the symptoms have completely cleared in this study. By

implication, definitely this treatment is effective but some more medication is

required for the complete amelioration of the illness. In general the Lashuna rasayana

dosage is fixed to 16 or 30 days. Selection of other Lashuna rasayana schedules

consisting of more prolonged medication may show complete remission of the illness.

Or else shamana medication is continued for about 30 days followed by planning the

second course of the Lashuna rasayana may prove more beneficial. Needless to say

this study will open scope for newer clinical studies in treatment of Manibandha

marmabhighata with different dosage schedule and there by proving its efficacy

against surgical interventions.

Discussion


In regards to the etiopathogenesis of Carpal tunnel syndrome it is said that the

entrapment of the nerve causes local ischemia and inflammation of the injured median

nerve at the location of the carpal tunnel. Thus developed local ischemia eventuates

degeneration of the nerves related to the median nerve. This degeneration of the

median nerve causes clinical symptoms like Numbness, tingling, pain, weakness as

well as dysautonomia related to palmar aspect of the first to the fourth fingers and the

distal palm. It is interesting to note that the studies have proved the improvement of

circulation and reversal of ischemia of the entrapped nerves by the administration of

the garlic. Thus the Lashuna rasayana is effective in ensuring the reversal in the

pathology of nerve ischemia and thus proves effective in the management of


Though this clinical study involved larger doses of Lashuna rasayana, all 15

patients tolerated the medicine very well with no any adverse reactions. Presence of

morbidity of pitta or pitta prakriti is contraindication of the administration of Lashuna

rasayana. No patients were excluded in the study on the basis of prakriti. Patients

having pitta dosha involved in the prakriti also treated with Lashuna rasayana.

The pitta virechana was done by the completion of the course of rasayana.

However even the patients with pitta dosha in their prakriti showed no symptoms of

pitta morbidly. Hence it can be said that this medication very effective and also

equally safe.

In short, marmabhighata is looked differently in surgical and medical schools

of thought. Surgical school of thought describes the marmabhighata with the

rationality of external injury and surgical interventions. Medical school of thought

emphasized the internal injury causing marmabhighata and medical management of

the same. Thus the marmabhighata is regarded as an important etiology of vata

Discussion


vyadhi. Manibandha marmabhighata presents with features of affliction of sandhi

marma in general and manibandha marma in particular. Supti / numbness, Ruk / pain,

Vastushukairavakirna / stinging, Shosha / muscle atrophy, Parvashopha / swelling of

the finger joints and Kuntata / paralysis of the hand are the symptoms of manibandha

marmabhighata. Shodhana, shaman, brimhana and rasayana form the principle of

treatment of vata vyadhi and is planned with the due consideration of associated

dosha and involvement of avarana in the pathogenesis. Lashuna rasayana is effective

in both margavaranaja as well as dhatu kshayaja vata vyadhi. With this understanding

the study is planned to evaluate the effect of Lashuna rasayana in patients suffering

from Manibandha marmabhighata. The study proved favorable response to this

conservative management with near complete remission of the clinical symptoms.

Also the medication is equally safe with no any adverse effects even in patients

having pitta involved in the prakriti. Thus the study also gives more scope for further

clinical studies in patients suffering from Manibandha marmabhighata. More clinical

studies may be planned with different dosage schedule of Lashuna rasayana to

establish more evidences to this conservative management of Manibandha

marmabhighata.

Conclusion


CONCLUSION

15 patients diagnosed as Manibandha marmabhighata / Carpal tunnel syndrome

were treated with oral administration of Lashuna rasayana in a dose of 12 g for fifteen

days. Following conclusions are drawn from the study.

Manibandha marmabhighata is a vataja nanatmaja vyadhi; margavaranja and

dhatu kshayaja are the clinical variants; supti, ruk, shosha and kuntata or hand

are the symptoms; matches with Carpal tunnel syndrome; Lashuna rasayana is

a treatment option.

Statistically significant reduction was recorded in the mean severity score of

carpal tunnel syndrome by 12.667 from the initial score of 44.467.

The reduction in the mean score of functional disability by 9.267 from the

baseline value of 34.600 is statistically significant.

The mean VAS pain score at base line was 8.133 that came down to 4.0

following the medication and is statistically significant.

The reduction in the mean VAS score for numbness to 4 from the base line

value of 8.133 is statistically significant.

At baseline the mean hand grip strength was 5.600 Kg. that improved to

12.133 Kg and is statistically significant.

12 patients had average improvement, 2 patients had moderate improvement

and in 1 patient there was no improvement.

Summary


SUMMARY

Marmabhighata is looked differently in surgical and medical schools of

thought. Surgical school of thought describes the marmabhighata with the rationality

of external injury and surgical interventions. Medical school of thought emphasized

the internal injury causing marmabhighata and medial management of the same. Thus

the marmabhighata is regarded as an important etiology of vata vyadhi. Manibandha

marmabhighata presents with features of affliction of sandhi marma in general and

manibandha marma in particular. Supti / numbness, Ruk / pain, Vastushukairavakirna

/ tinging, Shosha / muscle atrophy, Parvashopha / swelling of the finger joints and

Kuntata / paralysis of the hand are the symptoms of Manibandha marmabhighata.

These clinical symptoms also tally the manifestations of Carpal tunnel syndrome.

Shodhana, shamana ,brimhana and rasayana form the principle of treatment of vata

vyadhi and is planned with the due consideration of associated dosha and involvement

of avarana in the pathogenesis. Lashuna rasayana is effective in both margavaranaja

as well as dhatu kshayaja vata vyadhi. With this understanding the study is planned to

evaluate the effect of Lashuna rasayana in patients suffering from Manibandha

marmabhighata.

OBJECTIVES OF THE STUDY-

Efficacy of a Lashuna rasayana on disease severity in patients suffering from

Manibandha marmabhighata / Carpal tunnel syndrome

Effect on functional disability in patients of Manibhandha marmabhighata /

Carpal tunnel syndrome treated with Lashuna rasayana.

Summary


MATERIALS AND METHODS –

Source of data -15 patients diagnosed as Manibandha marmabhighata / Carpal tunnel

syndrome were taken for study from OPD and IPD of Sri Dharmasthala

Manjunatheshwara Ayurveda Hospital, Kuthpady, 574118. The freeze dried powder

of lashuna is obtained in the 500 mg capsule from the Sri Dharmasthala

Manjunatheshwara Ayurveda Pharmacy.

Method of collection of data- A specific proforma was prepared incorporating all

points of history taking, physical signs, and symptoms as mentioned in Ayurveda as

well as bio medicine.

Design of the study-

Study Type : Interventional

Actual Enrollment : 15 participants

Allocation : Non-Randomized

Endpoint Classification : Efficacy Study

Intervention Model : Single Group Assignment

Masking : Open Label

Primary Purpose : Treatment

Study Start Date : October 2017

Study Completion Date : February 2018

The patients were selected irrespective of gender, cast, race, religion, based

on the diagnostic inclusion and exclusion criteria. All the parameter of signs,

symptoms is scored as enlisted in the assessment criteria and the result obtained was

statistically analyzed by the paired t test.

Summary


Diagnostic criteria-Signs and symptoms Manibandha marmabhighata / carpal tunnel

syndrome (paresthesia in the distribution of median nerve distal to wrist, weak hand

grip, wasting of muscles at the thenar eminence and positive tinels and phalen sign)

Inclusion Criteria-

Subjects with a clinical diagnosis of Manibandha marmabhighata / Carpal

tunnel syndrome.

Subjects must be between 16 to 70 years of age (both ages inclusive).

Subjects of both genders.

Having signed a written informed consent form,

Exclusion Criteria-

Patients with uncontrolled Diabetes Mellitus & Hypertension.

Patients with Fracture of wrist.

Subjects with history of excessive menstruation.

Patients who are pregnant by patient report or intending to become pregnant

during the study.

Patients that have been previously diagnosed with cervical radiculopathy,

Outcome measures-


Questionnaire of Levine et al for Clinical Assessment of Carpal Tunnel

Syndrome [Time Frame: Baseline, day 17].

Summary



Change in Grip strength (Dynamometer) [Time Frame: Baseline, day 17].

Change in Visual Analog Scale for pain [Time Frame: Baseline, day 17].

Participants Assessment of numbness Over Time by the method of visual

analog scale (VAS) ranging from 0 (best) to 10 (worst) cm

[Time Frame: Baseline, day 17]

Intervention:

Koshtashodhana on Day 1 : Oral administration of Eranda taila in empty


along with 100 ml of warm water as after drink

LashunaRasayana on Day 2

to 16

: Oral administration of Lashuna rasayana in a

dose of 12 g in empty stomach half an hour

before breakfast along with 100 ml of milk as

after drink.

Pitta virechana on Day 17

:Oral administration of Eranda taila in empty


along with 100 ml of warm water as after drink.

Follow up duration: 30 days

Total duration of study: 47days.

Summary


Observation & Results

Among the 15 patients, maximum number of patients, 6.66 % were between

the age group of 16 -30 years followed by the age group of 31 to 50 years i.e. 33.33

%. 60% patient belonged to age group of 51-70years. 86.66% were females followed

13.33 % of males. A maximum of 86.66% of the patients were belonging to the Hindu

religion. In contrast to this 13.33% of the patients were of Christian community.

93.33%% were married. 6.66% were widow. 66.66% of patients were house wives by

profession. The remaining 13.33% of the patients were engaged in business.20% were

employees. 60% belonged to the category of middle class. 20% of patients were in the

category of upper middle socio economic status and other20% of patients were of

upper socioeconomic status. Only 26.66% of the patients were restricted to vegetarian

diet, and the remaining 73.33% of the patients had the dietary habit of taking mixed

diet. 80% of the patients had sound sleep. Remaining20% of the patients complained

of disturbed sleep for different reasons. Erroneous habit of day sleep was identified in

80% of the patients among the 15 patient. Remaining 20 %of the patients were not

resorting to the day sleep. Only 13.33% of the patients had the addiction of

consuming tobacco. 100% of the patients had the habit of taking coffee or tea

regularly. Remaining 86.66% of patients admitted that they had no any addictions.

20% of the patients gave the family history of Carpal tunnel syndrome, while the rest

80% didn’t have any history. 60% had their body weight between 40 to 60 kg.

6.66%of the patients had their body weight more than 91 kg. 13.33% of the patient

had their body weight between 71-80kgand 20% between 61-70 kg. 66.66 % of

patients had BMI between 20-24.4. 26.66% had BMI between 25-29.9 where as 6.66

% of the patients had BMI between 30-34.9. 46.66% each showed vata pitta prakriti

and vatakapha prakriti and 6.66% showed pitta kapha prakriti. 80 % had madhyama

Summary


sara, 20 % of the patients belonged to Avara sara. 46.66 % had madhyama type of

samhanana, about 46.66 % patients had avarasamhanana and 13.33% had pravara

samhanana. 66.66 % patients had madhyama satva, 26.66 % had avara satva where as

6.66% of the patients belonged to the category of pravara satva. 41.66 % had

madhyama vyayamashakti and 58.33% had avaravyayama. 26.66 % had

avaravyayamashakti and in comparison to this, 73.33 % had

madhyamaabhyavaranashakti. 80 % of the total number had madhyamajaranashakti,

contrary to this, 13.33 % of the patients had avarajarana Shakti and 6.66% had

pravarajaranashakthi.,73.33% had the progressive onset of the Manibandha

marmabhighata. 26.66% had sudden onset. 1oo% of the patients gave the data of

presence of ruja, and supta. Out of 15 patients in the study 80% are suffering from

Manibandha marmabhighata due to apatarpana and the other 20% due to

santarpananidana.

Effect of Lashuna rasayana in Manibandha marmabhighata.

The mean score of severity before the intervention was 44.467 (±SE 1.546)

that came down to 31.800 (±SE1.303) following medication with Lashuna rasayana.

Thus a reduction into the severity score of 12.667 was recorded in this study. Also the

improvement was statistically significant when analyzed by the Wilcoxon Signed

Rank Test with p <0.001. At the baseline the mean score of functional disability status

was 34.600 (0.616) that came down to 25.333 (0.715) following Lashuna rasayana

thus recording an improvement by 9.267 is functional disability status score. Again

when analyzed by the statistical test of significance, this improvement was highly

significant with p <0.001. The mean VAS pain score in 15 patients at base line was

8.133 that came down to 4.0 following the medication. Thus an improvement of 4.333

Summary


in the mean VAS pain score was recorded. The initial VAS score was 8.133 (±SE

0.654) before beginning the Lashuna rasayana. After the intervention the numbness

recorded was 4.133 (±SE 0.376) thus showing a decrease in severity of numbness

VAS score of 4. Also the improvement was statistically significant when analyzed by

the Wilcoxon Signed Rank Test with p <0.001. At baseline the mean hand grip

strength was 5.600 Kg. After the Lashuna rasayana this improved to 12.133 Kg. Thus

an improvement of 6.53 Kg in the hand grip strength was recorded in the study.

Analysis of the statistical significance was done by adapting the paired t test, it

showed that the improvement in the hand grip strength was statistically significant

with p value of <0.001. The study revealed that 13.33 % of patients had moderate

remission and 80 % of patients have recorded average remission. Also 6.66 % of

patients showed poor remission.

CONCLUSION

The study proved favorable response to the conservative management of

Manibandha marmabhighata with Lashuna rasayana administered in a dose of 12 g

OD for 15 days and recorded a statistically significant, near complete remission of the

clinical symptoms. Also the medication is equally safe with no any adverse effects

even in patients having pitta involved in the prakriti.

References

Efficacy of lashuna rasayana in manibandha marmabhighata. Page 97

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Series Office;4rd



Series Office; 3rd

edition 2012.pp935.p928

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¢£ÁAPÀ:

¸ÀÞ¼À :

ªÀåQÛAiÀÄ ºÀ¸ÁÛPÀëgÀªÉÊzÀågÀ ºÀ¸ÁÛPÀëgÀ

PATIENT CONSENT FORM

I ………………………….. aged…………….. years R/O………………………….. is

exercising my free power of choice, hereby give my consent to be included as a trial subject in

the clinical research subject “ EFFICACY OF LASHUNA RASAYANA IN SUBJECTS

WITH CARPAL TUNNEL SYNDROME(MANIBHANDHA MARMABHIGHATA”. I

understand that I may be treated with drug for the disease with which I am suffering. I have

been informed to my satisfaction the aim, objective of the clinical trial, ingredients of the trial

drug treatment and follow up including laboratory investigations to monitor and safeguard my

body functions as and when required. I am also aware of the right to opt out of the trial at any

time during the course of my treatment. I will not make any compensatory claim for any

hazardous effects on me during the treatment.

Date…………… Patient’s signature

Patient has signed the declaration and has given consent.

Signature of research scholar

107

SHRI DHARMASTALA MANJUNATHESHWARA COLEGE OF

AYURVEDA AND HOSPITAL, UDUPI

DEPARTMENT OF POST GRADUATE STUDIES IN

KAYA CHIKITSA AND MANASA ROGA

CASE PROFORMA FOR MANIBHANDHA MARMABHIGHATA

Patient Inclusion/Exclusion Form Case Number ( )

Name: Age: yrs

Sex: M/F

Address:

Sl Patient details Criteria Eligible Not

Eligible

01 Signed informed consent Required

02 Symtoms:

Pain at wrist:

Paresthesia of thumb

Paresthesia of forefinger:

No

Site right wrist left wrist

All

03 Major criteria

a)Tinel/ signYes / No

b) Phalen signYes / No

04 Fracture of wristYes / No No

04 Cervical RadiculopathyYes / No No

05 H/O of excessive menstruation Yes / No No

06 Uncontorolleddiabetismellitus/hypertensionYes

/ No

No

07 Pregnant Yes / No No

08 Planning to conceive in 6 months Yes / No No

09 Lactating Yes / No No

12 Duration: Years < 10

years

13 Age: Years >16-

70Yrs

ACCEPTED REJECTED

108

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£À£ÀßvÀÈ¦ÛUÉvÀPÀÌAvÉ £À£ÀUÉ «ªÀj¸À®ànÖzÉ.F ªÀÄÆ®PÀ F AiÉÆÃd£ÉAiÀÄ°èM¼À¥ÀqÀ®Ä £Á£ÀÄ ¸ÀªÀÄäw

¸ÀÆa¸ÀÄwÛzÉÝÃ£É. £Á£ÀÄ AiÀiÁªÀÅzÉÃPÁgÀtªÀ£ÀÄßPÉÆqÀzÉÃ F AiÉÆÃd£É¬ÄAzÀAiÀiÁªÀÅzÉÃ ¸ÀAzÀ¨sÀðzÀ°è »AzÉ

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¢£ÁAPÀ:

¸ÀÞ¼À :

ªÀåQÛAiÀÄ ºÀ¸ÁÛPÀëgÀªÉÊzÀågÀ ºÀ¸ÁÛPÀëgÀ

PATIENT CONSENT FORM

I ………………………….. aged…………….. years R/O………………………….. is

exercising my free power of choice, hereby give my consent to be included as a trial

subject in the clinical research subject “ EFFICACY OF LASHUNA RASAYANA

IN SUBJECTS WITH CARPAL TUNNEL SYNDROME(MANIBHANDHA

MARMABHIGHATA”. I understand that I may be treated with drug for the disease

with which I am suffering. I have been informed to my satisfaction the aim, objective

of the clinical trial, ingredients of the trial drug treatment and follow up including

laboratory investigations to monitor and safeguard my body functions as and when

required. I am also aware of the right to opt out of the trial at any time during the

course of my treatment. I will not make any compensatory claim for any hazardous

effects on me during the treatment.

Date…………… Patient’s signature

Patient has signed the declaration and has given consent.

Signature of research scholar

109

SDM COLEGE OF AYURVEDA AND HOSPITAL, UDUPI

DEPARTMENT OF POST GRADUATE STUDIES IN KAYA CHIKITSA

RESEARCH PROFORMA FOR THE STUDY ON

CARPAL TUNNEL SYNDROME (MANIBHANDHA MARMABHIGHATA)

A STUDY EVALUATING THE EFFICACY OF LASHUNA RASAYANA IN

SUBJECTS WITH CARPAL TUNNEL SYNDROME (MANIBHANDHA

MARMABHIGHATA)

GUIDE: Dr. G. SHRINIVASA ACHARYA,

Investigator- Dr. Manasa Rao

CASE SHEET

I.PATIENT PROFORMA

Sl.no Date: DOA: DOD:

OPD No: IPD No: Bed No:

Name: Age:yrs Gender: M□/F□

Religion: H□ /M□/C□ /Others□ Education:IL□/P□/HS□/JC□/GR□/PG□

Marital status: M□ /UM□ /D□/W□ Social Status: UC□ /UMC□ /MC□ /LMC□

/LC□

Desha:

Jn/An/Sd

Occupation: Postal address:

Contact No:

Email ID:

II. PRADHANA VEDANA -

Sl.no Pradhanavedana Duration Site

1 Pain

2 Tingling sensation

3 Numbness

4 Weak grip

5 Wasting of thenar

eminance

6 Decreased sensation

110

Assessment of severity

BT AT

symptom severity

scale

functional severity

scale

VISUAL ANALOGUS SCALE FOR PAIN/NUMBNESS:

DYNAMOMETER READING:

Right Left

Dynamometer reading

IV. History of past Illness-

Fracture of wrist Cervical radiculopathy

V .Treatment taken so far:

System Variety Duration Effect

Ayurveda Shodhana/shaman

Allopathy Oral/parental/applicatio

n

Other

111

VI. Family history:

VII. Personal History

1) Ahara

a) Appetite G/M/P

b) Diet Nature: Veg /Mix/ Non-veg

c) Break Fast

d)Mid Morning

e) Lunch

f) Snacks in Evening

g) Habits Samshana / Vishamashana / Adhyashana / Anashan /

Pramitashan

h) Fruits Regular/ Occasional

i) Rasapradhana M / A / L / K / T / KS / SR

k)Any special allergy of

particular rasa/food:

l) Supplementary Diet tea / coffee / milk / cold drinks

m) Water Intake Every morning/ during or After Lunch/ Dinner

Day + Night – It’s Total

n) Cold Beverages Regular / Occasional

o) Butter milk/Curds Regular / Occasional

p) Junk Foods Regular/ Occasional

2)Vihar

a) Exercise Regular/ Irregular/ Occasional/

Only retinue Work

Type ofexercise for

_____

mins

b)Vishrama Proper/ Less/ Excessive

c) Nidra

Sound /

Disturbed/Delayed/Staying

Asleep

FAMILY

MEMBERS

AGE

(in year)

HEALTH

STATUS

LIVE /DEAD History of Carpal

tunnel syndrome

Father

Mother

Siblings

Wife

Son

Daughter

Others

112

Day_____ hours / Night ______ hours

If disturbed reason:

Mental strain: Y/N ; If yes, since_______

d) Mental activity

Occupational stress: Yes/No

Reliving factors:

Aggravating factors:

Day / years of exposure:

d) Recreation TV / Indoor games / outdoor games / Outing /

others

e) Sexual intercourse Frequency

f) Bowels Regular /irregular /formed / unformed

/constipated frequency

g)Micturation Regular/ irregular/ Dysuria / Polyuria / Oliguria

Frequency _________ times/day

Frequency _________ times/night

h)Snana Regular/ irregular

k)Addictions: Duration Continued/Occasional/

Regular

Stopped/ reduced

Smoking

Alcohol

Tobacco

Snuff

Others

VIIIOccupational History –

Type of profession Sedentary /Involves physical strain /Involves mental strain

Since _______ day /

years

Shift of work – Day/ Night Day – Night hrs

Utilization of hand: Yes/No Hours of work:

113

IX. Gynecological history

Menarche: Bleeding days: Menopause:

Menstrual cycle:Regular□ / Irregular□ Obstretic history: P__G__L__D__A__

Menorrhagia□/Metrorrhagia□/Dysmenorrhoea□/Leucorrhoea□

History of contraception: Present □/ Absent□ Temporary : Mechanical □/

Chemical □/Oral □/Local□ / I.U.C.D□ Permanent : Tubectomy□/

Hysterectomy

X. Vital signs

Pulse :_____ per min B.P :__________mm of Hg Temperature : ______F

Heart rate :_______ per

min

Respiratory rate : ______

per min

X.Dashavidha pareeksha

Prakrithi V/P/K/VP/PK/VK/ Sama

Vikriti V / P / K

Satva P / M / A

Sara P / M / A

Samhanana P / M / A

Pramana P / M / A Height__ cms Wt____ Kg

Satmya P / M / A

Vyayamashakthi Purvakalina : P/M /A

Adyatana: P/M/A

Aharashakthi

Abhyavarnashakthi Purvakalina : P/M /A

Adyatana: P/M/A

JaranaShakthi Purvakalina : P/M/A

Adyatana:P/M/A

Vaya Bala/Madhyama / Vriddha

X.Astasthana pareeksha

Nadi

Mala

Mootra

114

Jihwa

Shabda

Sparsha

Drik

Akriti

XI. General Physical examination.

Built & nourishment: well

/mod /poor.

Pallor: P / A Cyanosis: P /

A

Icterus: P / A

Lymphadenopathy: P/A Edema: present/absent; pitting /non pitting ;

Region:

Ht: _____c.m Wt: _____ kg BMI:____kg/m2

Deformities: Tempreure: Throat: Thyroid: Normal /

abnormal

XII. Systemic Examination-

System Findings

Integumentary

Respiratory

Cardiovascular

Per abdomen

Urogenital

Musculo skeletal

Examination of hand-

INSPECTION:

RIGHT LEFT

Drooping of wrist

Wasting of thenar

eminance

Swelling

Inflamation

115

PALPATION-

RIGHT LEFT

Tenderness

Temperature

Tenal sign

Phelen sign

Pressure provocation test

Range of movement-

RIGHT LEFT

Pronation

Supination

Flexion

Extension

Rotation

Abduction

Routine Hematological Investigation.

Results LFT LIPID

PROFILE OTHERS

XIV. Nidanapanchaka:

1.Nidana –

2.Poorvaroopa-

3.Roopa-

4.Upasaya-

5.Anupasaya-

4) SAMPRAPTI GHATAKA

Nidana :

Dosha :

Dushya :

Srotas :

Srotodusti:

Ama :

Udbhavasthana :

116

Sancharasthana:

Vyaktasthana :

Rogamarga :

5) VYADHI VINISCHAYA:

6) SADHYASADHYATA:

7) UPADRAVA:

XV. CHIKITSA:

Koshtha Shodhana on day 1: Oral administration of Eranda taila in empty

stomach, in a dose of 20 ml in the morning along with 100ml warm water as after

drink.

Lashuna rasayana on day 2 to day 16: Oral administration of 12 g of Lashuna

rasayana with 100ml of milk in empty stomach, about half an hour before

breakfast.

Pitta virechana on day 17: oral administration of Eranda taila in empty stomach, in

a dose of 20 ml in the morning along with 100ml of warm water as after drink.

Diet &regimen :

Avoid hot oily spicy food

Rest

Adverse effect during treatment – yes/no

FOLLOW UP INTERVEIW:

XVI. ASSESSMENT CRITERIA:

Primary

outcome

B.T A.T Secondary outcome B.T. A.T

Symptom severity

score

Change Grip in strength

(Dynamometer)

Functional status

score

Change in visual analog

scale for pain

Change in visual analog

scale for numbess

117

VISUAL ANALOGUS SCALE;

Parameters Before treatment After treatment

Pain

Numbness

Adverse effect during treatment: yes/no

If yes:

Signature of the Guide Signature of the Scholar

Pictures

Efficacy of lashuna rasayana in manibandha marmabhighata

118

Figure No. 30 LASHUNA Figure No. 31 LASHUNA CAPSULES

Figure No. 32 LASHUNA RASAYANA Figure No. 33 ERANDA TAILA

Pictures

Efficacy of lashuna rasayana in manibandha marmabhighata

119

Figure No. 34. Visual Analogue Scale

Figure No. 35. Hand Dynamometer

“EFFICACY OF LASHUNA RASAYANA IN MANIBANDHA ...

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