Clinical evaluation of effect of Jaloukavacharana(Leech therapy) in Knee Osteoarthritis

INTRODUCTION

Osteoarthritis in the knee begins with the gradual deterioration of cartilage. Without the protective cartilage, the bones begin to rub together, causing pain, loss of mobility, and deformity. Osteoarthritis is an important cause of disability and the second most common musculo-skeletal problem in the world (30%).¹ The majority of arthritis cases involving the knee are osteoarthritic cases. Causative factors include muscle weakness, obesity, heredity, joint injury or stress, constant exposure to the cold, and aging. Cartilage

in the knee begins to break down and leaves the bones of the knee rubbing against each other. Persons who work in a place that applies repetitive stress on the knees are at a high risk of developing this condition. Bone deformities increase the risk for osteoarthritis of the knee since the joints are already malformed and may contain defective cartilage. Treatment includes avoiding activities that make the pain worse; to reduce inflammation anti- inflammatory medications and physical therapy are advised. Topical creams and patches are also being used. Ayurveda identifies this clinical condition as Sandhigata Vata. ² The Lakshana are pain, swelling and stiffness. Raktamokshana³ is the therapy of bloodletting. Raktamokshana done with leech i. e jaloukavacharana, is said to have an analgesic and anti inflammatory effect. Hence the study was conducted to evaluate the effect of raktmokshana on pain, swelling and stiffness parameters of osteoarthritis subjects

MATERIALS AND METHODS

It was a single centre, observational clinical study with pre and post test assessment. The study protocol was approved by the Institutional Ethics Committee and clearance for the trial was taken. 40 patients diagnosed as Janusandhigatavata were selected incidentally from the Outpatient and Inpatient units of Shri Jayachamarajendra Institute of Indian Medicine, Bangalore. Irrespective of age, sex, religion, occupation and economic status, patients were selected for the present study

Inclusion Criteria:

1. The subjects coming under diagnostic criteria

2. Patients diagnosed as primary Knee Osteoarthritis (Sandhigata vata).

3. Patients fit for Jalukavacharana.

Exclusion Criteria:

1. Patients with secondary Knee Osteoarthritis.

2. Patients having other systemic disorders which may interfere with the course of the disease and its management.

3. Patients who are incapacitated, bedridden and confined to wheel chair.

Diagnostic Criteria:

Shoola, Shotha, Atopa, Vatapurnadhrutisparsha, Prasarana aakunchanayovedana⁴ (presence of pain, swelling, crepitus and stiffness), X-ray of Knee Joint AP and Lateral view were considered for diagnosis.

Intervention: Jaloukavacharana (leech therapy): Medicinal leeches were procured from Sri Raghavendra Enterprises, Breeders of laboratory animals, Bangalore. Required numbers of Leech were maintained in the 1000ml water in glass bottles. Holes of about 1mm diameter were drilled in the lid of glass bottles for free entry/exit of air. Bottles were maintained in the department of Shalyatantra OPD under room temperature. Water was replaced once in three days. After the completion of the study used Leech were discarded to the pond.

Materials used for leech therapy: Kidney tray, Haridra powder, Sarshapa powder, Rock salt, Laksha powder, water, Cotton swabs, cotton gauze, Cotton pads, Adhesive tapes, Gloves

Methodology of treatment: Patients were made to sit comfortably with the legs stretched. Procedure was explained to allay apprehension. The affected part was cleaned with the swab dipped in lukewarm water. Fresh Leech was taken from the bottle and placed in kidney tray containing clean potable water. Powders of Haridra and Sarshapa were sprinkled on the surface of water. Leech was left in the kidney tray for about 10 minutes to activate them as per the textual reference. Again the Leech was transferred to clean water in a kidney tray to remove the slimy and Haridra coating. Tender site was elicited by palpation and the Leech was applied on the site of maximum tenderness and immediately cotton gauze soaked in water was placed over the Leech to prevent migration of Leech to other area and also to create a favourable atmosphere to the Leech. The Leech was closed until it attaches itself to the tender site and starts sucking blood. The wet cotton gauze was partially removed to expose the mouthpart of the Leech. Rest of the part of the Leech was kept covered in the wet cotton gauze. During the blood sucking process, cold water was sprinkled over the gauze piece periodically till Leech gets detached from the site of its own.

After application Leech detached on its own within 45 – 60 minutes. Immediately after the detachment of the Leech, it was collected in the kidney tray. The wound site was left to bleed for about 15 minutes, after which the wound site was dressed with Laksha and Haridrachoorna. A cotton pad was kept over the wound site with the help of adhesive tape in order to hold the oozing blood. In the meanwhile, the detached Leech was made to vomit by applying the Haridrachoorna to the mouth of the Leech repeatedly till it vomited completely. Later the Leech was kept in the Haridra jala for 5 minutes after ensuring complete vomiting, which was confirmed by its free movement (to and fro) in search of food and then transferred to the glass bottle. The bottle was labeled with the name of the patient and date of application of Leech. The same Leech was used to the same patient during successive sittings.

Treatment schedule: Single Leech was applied to the affected JanuSandhi once in a week for three consecutive sittings with a gap of 7 days i.e. on 0th, 7th and 14th day and changes in the parameters were recorded.

Assessment: Pain (Shoola), swelling (Shotha) and stiffness (Prasarana aakunchanayo vedana) were assessed before, during and after the intervention. Pain and swelling responses were assigned a score between 0 (None) to 4 (Extreme). Whereas for stiffness goniometry was done where grading was done as 00 – 450(0), 450 – 900 (1), 900 – 1350 (2) and >1350 (3).

Follow up period: A period of 2 months, after the study was fixed for follow-up. The patients were advised to inform if any marked changes manifest during this period and the same was recorded in the proforma.

Observations and Results

In the present study, maximum numbers of patients were of age Group 41-50 years (50.0%) followed by 30-40 years age Group (37.5 %). Majority of the patients were of female (75%). In this study it was observed that majority of the patients were housewives i.e. 18 (45%) followed by officials 10(25%). Patients from urban area were more i.e., 27 (67.5%). It was found that 31 patients had the chronicity up to 1yr, followed by 9 patients had chronicity 1- 3yrs.

Pain: Data related to assessment of response

Comparison between baseline scores and scores on 21st day the changes were highly significant on Pain, Stiffness whereas in case of Stiffness the change was statistically significant.

After the completion of treatment, it was observed that, 21 cases (52.5%) reported to have relieved from all the three symptoms, 9 cases (22.5%) reported to have relieved from symptoms with respect to pain and degree of flexion, 6 cases (15%) were relieved of only one symptom and 4 cases (10%) showed no response to the treatment.

DISCUSSION

Sandhigata vata, a vatavyadhi5 is a major problem and large number of population suffers from this malady. The present way of lifestyle has greater impact in this disease manifestation. Raktamokshana, considered as Shodhanaprakara according to Dalhana, is the best line of treatment in managing the vyadhis with involvement of rakta. This procedure is mentioned separately under the context of shashti upakramas⁶ , which can be employed in many occasions depending on the conditions. Whenever immediate relief from pain and swelling is to be achieved, Raktamokshana appears to be one of the lines of treatment. When vatavyadhi does not subside by conventional therapy, the condition must be suspected as raktadushti janya vyadhi and should be treated accordingly.⁷

Leeches are widely used in various conditions, specifically in conditions where there is predominance of pain and swelling either in acute or chronic conditions. It is a painless procedure as leeches secrete anesthetic material through the saliva during the sucking.

Vatavyadhis are generally caused due to vata vruddhi. Raktamokshana in general is contra indicated in vata vyadhi. Even then leech therapy was preferred as this therapy relieves margavarna (occlusion of channels) which is an event in the etiopathogenesis of sanadhigata vata. Hirudin secreted by leeches help improve microcirculation and results in release of tension. Anti-inflammatory and anesthetic substance present in the secretion of leech reduces pain, thereby enabling improvement in flexion and extension of joint. In this trial the reduction in the pain, stiffness and swelling justify the role of jaloukacharana in sandhigatavata.

CONCLUSION

Efficacy of Jalaukavacharana deduced hypothetically in managing Sandhigata vata with presenting symptoms Shoola, shotha and prasaranakunchana vedana by the literatures available proved positive in the clinical trial as the results obtained are clinically and statistically significant.