Comparative Study of Cold And Neutral Enema on Autonomic Variables in Healthy Volunteers

INTRODUCTION

Enema is the introduction of quantity of water into the colon. It is colon irrigation where water is made to flow in without pressure.[1]In Naturopathy, enema is given at the beginning of the treatment as a detoxifying method. Naturopathy is a nonpharmacological system of healing, based on the recognition of natural ability to resist disease, inherent mechanism of recovery and selfregulation or vital curative force within the body. [2]It is an art and science of healthy living based on morbid matter of theory and the concept of vitality.Hydrotherapy as a part of Naturopathic medicine aims to integrate scientific knowledge with traditional healing practice where Enema or Rectal irrigation involves “cleaning out” the lower part of the bowel using water with irrigation equipment.[3] Usually the rectal part is flushed using enema catheter which is inserted after applying the lubricating jel to the anal sphincters[4] According to Dr. Henry Lindlar colons are the store house of morbidity in our body. Proper diet along with enema are the most efficient means for cleansing the colons and bring about health. It is the aid for healing crisis of the body. The plain water introduction into the colon is not only for the purpose of evacuation of bowels, but also for reducing body temperature in cases of fever and general promotion of health.[5]Ancient Indian texts on yoga like Hata-yoga pradeepika describes enema as basti. Basti literally refers to urinary bladder of the animal, i.e. during ancient times the urinary bladder of animal was used to administer the basti. [6] The Gheranda Samhitha, mentions enema as Vasti. It is one of the six purifying procedures (shat karmas), supposed to give the effect of cleansing (shodhana). The process is aimed at cleaning the lower intestines and the colon, removing toxins and cooling the body. [7] In Ayurveda system of medicine basti is given with preparation of medicated decoctions or oils or with plane water to cure disorders related to Vata-vyadhis. According to Acharya Charaka half of diseases of the human body can be cured just by giving basti as it is also mentioned as Chikitsardha.[8] At present enema or rectal irrigation is used for the administration of a substance in liquid form into the rectum. Enema are majorly used to aid evacuation of the bowel and to administer medicines. [9] Enema is a primary procedure practiced in every Naturopathy as well as Ayurveda hospitals. Conventional form of medicine use enema to administer medications also.[10] Being a common practice as a preventive and remedial process there is no evidence-based studies conducted on effect of enema. So, this study is conducted to evaluate the effect of cold and neutral enema on autonomic variables of healthy volunteers.

2. MATERIALS AND METHODS:

2.1 Setting: The study was conducted at the Department of Hydrotherapy, in an inpatient set up of yoga and naturopathy hospital.

2.2 Inclusion criteria:

• The subjects were found to be healthy based on routine medical examination conducted by a primary care physician.

• Age ranging between 17 and 26 years.

• Those who have given written informed consent.

2.3 Exclusion criteria:

• Any health disorders

• Those who were taking medication which could influence autonomic function eg, phenylpropanolamine as a common cold remedy.

• Females during Menstrual cycle.

• Those who were consuming alcohol and nicotine except caffeine.

2.4 Ethics Statement: Prior to study, approval was obtained from Institutional Ethical Committee.

2.5 Study Participants: The subjects were randomly recruited from a residential college. An informed consent was obtained from every participant after an appraisal about the study protocol. Out of 100 Subjects, 60 eligible subjects were considered based on inclusion and exclusion criteria and were randomly allocated into two groups using computer generated random number table. Group 1(n=30) received cold enema and group 2(n=30) received neutral enema. Assessments were done before 5 minutes and immediately after 5 minutes of the intervention.

2.6.Intervention: A rectal irrigation is a hydrotherapy modality, where the subject was asked to lie with minimal dress on Sims’s position with knees drawn up towards the chest..¹ For Group 1, enema apparatus was filled with cold water and for group2, enema apparatus was filled with neutral water. The quantity of water used was 1 to 1.5 liters (2-3 pints) anda single use catheter was used. The treatment room was maintained at a constant room temperature, so that the external temperature does not have an influence on the water temperature. The testing and intervention environment were carefully controlled to reduce all kinds of environmental and physical factors that may cause a fluctuation in blood pressure, such as maintaining room temperature.

Temperature of water used for cold and neutral enema

• Cold enema: 18o c to 20oc (Group 1)

• Neutral enema: 35oc to 37oc (Group 2)¹

2.7.Outcome measures: The outcome measures were Heart Rate & Heart Rate Variability, Respiratory Rate, Blood Pressure, Body Temperature and Pulse Rate. The measurements were taken immediately after 5 minutes of the intervention in lying position.

2.7.1 Assessments:

a. Heart Rate & Heart Rate Variability: A 4-channel polygraph (Recorders of Medicare Systems, Chandigarh, India) was used to record the electrocardiogram (EKG), respiration. EKG was recorded using standard limb lead I configuration. The EKG was digitized at a sampling rate of 1024 Hz. The data recorded was visually inspected off-line and only noise free data was included for analysis using the HRV analysis software.

b. Respiratory Rate: Respiration was recorded using a volumetric pressure transducer fixed around the trunk about 8 cm below the lower costal margin as the subject sits erect. Thisstethograph consists of airbag, strap and connecting tubes. The airbag is positioned on subject’s chest and open-ended tube is connected to pressure differential sensor tubing, which in turn is connected to a logbook data logger attached to a computer. Care is taken to adjust the strap such that full inhalation is not restricted. Breath rate will be calculated in cycles per minute (cpm) by counting the breath cycles in 60 second epochs, continuously.

c. Blood Pressure: The blood pressure was recorded with a sphygmomanometer by auscultation over the right brachial artery.

d. Body Temperature: The contactless thermometer has used as a standard tool to measure the temperature. The body temperature was recorded with a thermometer by placing 1inch away from the forehead of the subject.

e. Pulse Rate: Radial artery pulse was measured by placing index and middle fingers on the radial artery of subject’s left-hand wrist, by using a wrist watch and will count the pulse rate for 60 seconds.

3. STATISTICAL ANALYSIS:

Statistical analysis was done using Statistical Package for Social Sciences (SPSS) (Version 20.0). Data was checked for normal distribution using Kolmogorov-Smirnov test and analyzed by using t tests. P value less than 0.05 was accepted as an indicator for significance.

4. RESULTS

Results for the post data inbetween the group with independent t test showed a significant change in Heart rate {Group 1-75.370(9.399), Group 2- 81.844 (7.877); (p=0.005*)}. However, there was no significant changes in Mean RR, RMSSD, NN50, pNN50, VLF, LF, HF, LF/HF, Systolic BP, Diastolic BP, Pulse Rate, Respiration.

The dependant t test within the groups showed a significant increase in Body Temperature in both the groups. The increase in body temperature after the Cold enema was, Pre temperature: 34.417(0.406) and Post temperature: 34.603(0.436). The increase in body temperature in Neutral enema was Pre temperature: 34.487 (0.4175) and Post temperature: 34.695 (0.408).

5. DISCUSSION:

The main aim of this study was to compare theeffect of cold enema and neutral enema on HRV, RR, SBP, DBP, TEMP, and PR in normal healthy individuals. All the 60 subjects underwent the intervention for the duration of 2 to 5 minutes. Rectal irrigation was safely completed in all subjects. There were no adverse effects reported during or after the intervention. In Pre and Post study, there were no dropouts reported. Dependent T test within the group shows significant change in the body temperature in group 1 and 2. Independent T test for Post data in between the groups shows significant difference in heart rate. Other parameters were insignificant.

The effect of cold enema and neutral enema are employed clinically for different health conditions. Cold enema may be usefully employed in the cases of feeble patients as a preparation for surgical operation. Warm enema may be usefully employed as a means of introducing water into the system in case of any surgical operations in the stomach, hemorrhage from stomach and typhoid fever.¹¹ The cold enema was employed by the De Hahn’s in Germany in 1737 in the treatment of fevers, which also encourages the action of the liver and kidneys, and especially in cleansing the alimentary canal. The cold water enema energizes the muscles and nerves of the intestine which is most effectual as a means of relieving constipation through its tonic effects upon the structures of the rectum and mucous membrane. The hot enema may be used with great benefit for its relaxing effect upon involuntary muscular tissue, in cases of hepatic or biliary colic.¹² Enema helps in the absorption from the intestine much more rapidly than from the stomach. So, colon irrigation is done with nutritive food substances as well as rectal drug administration.¹³ The common natural ingredients used in enemas are aloe, coffee, garlic and milk thistle. Other types of enemas include the ones made with mineral water, Epsom salt, glycerin, vinegar, bark of the marula tree, fruit of the Cucumis africanus, various wild herbs, industrial thinner, turpentine, undiluted dettol, ginger, pepper or soap.¹⁴ So, keeping all these advantages of enema, the two temperatures are studied to find out the difference in their action .We could find many studies which were conducted for colon irrigation rather than rectal irrigation. In 1932 Bastedo noted positive effects of colonics on the blood supply and tone of the colon. He publishes in JAMA, offering his viewpoint on therapeutic application of colonic irrigations: “When one sees the dirty gray, brown or blackish sheets, strings and rolled up wormlike masses of tough mucus with a rotten or dead-fish odor that are obtained by colon irrigations, one does not wonder that these patients feel ill and that they obtain relief and show improvement as the result of the irrigation”. [15] Friedenwald and Morrison identify a number of situations in which colonic irrigations appear to have some efficacy, including “cleansing the colon mucous membrane of abnormal mucus, infection, debris and foreign bodies”.¹⁶

In our study it was observed that the individuals who underwent rectal irrigation felt relaxation with better evacuation. Mechanical distension of the rectal wall is the ideal mechanism for inducing high amplitude propagating contractions and was able to ensure effective aboral transport of the rectal contents. Modern trans anal irrigation techniques make it possible to bring adequate volumes of water to the more proximal colonic tracts distending those sections.¹⁷ Hence, the subsequent evacuation is not simply the result of the action of the water by itself, but also of induced propulsive motility.

The HRV analysis is used as an indicator of beatto-beat changes in the heart rate. Reduced HRV has been associated with negative consequences to health, particularly related to stressful events and negative emotions.¹⁸ Our results showed no such negative emotions when compared with the both cold and neutral groups.

There was a significant reduction in Heart rate, and Temperature with significant p values suggesting parasympathetic dominance followed by a single session of rectal irrigation. In this context, tone specifically refers to continual nature of baseline parasympathetic action that vagus nerve exerts. While baseline vagal input is constant ,the degree of atiulation it exerts is regulated by sympathetic and parasympathetic nervous system of ANS.¹⁹ Vagal dominance is typically considered in context of heart function but also has utility in assessing emotional regulation and other processes that alter, or by altered changes and modifications in parasympathetic activity. Enemas typically stimulate only the end part of the colon, and are not intended to cleanse the entire colon as is a colonic irrigation. Vagal activity results in various effects including vasodilatation/ vasoconstriction of vessels, heart rate reduction, and glandular activity of heart, lungs and digestive tract as well as control of gastrointestinal sensitivity, motility and inflammation.²⁰ On a contrary, it is not unusual to find that, even after a single rectal irrigation session, the patient starts to improve, achieving evacuation that is satisfactory both in terms of completeness and frequency. We can, however, speculate that this gradual, light methodical lavage, which can be taken for few minutes and repeated, can actually free up a part of large intestine by releasing faecal residues that were present for some time, stuck to the intestinal walls, obstructing the transport, causing irritation and colon dysfunction. In summary, regular use of rectal cleaning techniques can be an effective, in individuals with cardiovascular disorder and in Pyrexia.²¹ Thus, findings of this study demonstrate improvement of vagal tone with parasympathetic dominance and lowering of myocardial workload followed by a short-term practice of rectal irrigation. But there were no significant changes observed in autonomic variables.

6. CONCLUSION

Here we conclude that depending upon the results there is no significant difference found on autonomic variables in healthy volunteers when cold and neutral enemas are given. So, the study concludes that cold and neutral enema can be replaced to each other, as there is no difference found.