Evaluation of Kukkutanda sweda with its twak in twodifferent modalities in Janusandhigata vata – A comparativeclinical study.

Introduction

Panchakarma is the specialized branch of Ayurveda which has got the importance in its own special way in preventive as well as curative aspects of the diseases. Along with the mainstream procedures like Vamana, Virechana, Basti, Nasya and Raktamokshana, the upakramas like Snehana and Swedana has also got its impact very strongly in treating the diseases. As said in treatises Swedana is considered one of the important aspects in shadvidha upakrama. According to the disease condition, numerous variety of Swedana can be adopted as Pradhana karma. Among them Upanaha and tapa sweda are the varieties mentioned by our Acharyas which is primely indicated in vataja, kaphaja disorders² . The Kukkutanda Sweda is one among the authenticated treatment modalities in Sandhigata Vata. Janu sandhi is the sthana of sleshaka kapha and vata dosha takes Ashraya in asthi sandhi, its prakopa causes the shoshana of kapha dosha thereby hampering gati. Sandhigata vata is a vataja disorder, disease wherein the sandhis are affected and manifested by features like vata purna driti sparsha, sandhi vedana, atopa and vedana during prasarana and akunchana³ .

These classical symptoms of sandhigatavata simulates to the Osteoarthritis (OA) which is one of Degenerative Joint Disease characterised by breakdown of joint cartilage & by focal loss of cartilage with evidence of accompanying periarticular bone response in the form of bony overgrowths called osteophytes, clinically presents as joint pain and crepitus in elderly age group. This is a non-inflammatory form of arthritis. According to WHO, Osteoarthritis is the 2nd commonest problem, suffered by 30% of world population. The major risk factors associated with OA are Old age, female sex, obesity, occupational knee bending making it an important cause of disability. There is no satisfactory, comprehensive & time bound treatment schedule for its management at present ^[4]. Since OA is the most disturbing joint disorder, a number of analgesics and anti-inflammatory drugs are available for its betterment. However, a permanent relief is not provided by any of these and the same is still under research.

According to Ayurveda, Sandhigata vata which affects the Asthi and sandhi can be included in madyamarogamarga vyadhi and the diseases affecting the Madhyama roga marga are either Kastasadya or Yapya. But previous researches showed very promising results in favour of Ayurvedic management in Sandhigata vata giving maximum extent of relief in the symptoms like pain, swelling and also considerable improvement in range of movement as well.

Kukkutanda Sweda is a Bahya Chikitsa wherein the researches showed considerable results in Sandhigata Vata and in this study Bandhana method of Upanaha Sweda was taken since Bandhana itself aids as upakrama for Vataja and vatakaphaja disorders. The objective of this study is to evaluate and compare the effect of kukkutanda sweda with its twak in two different modalities in Janusandhigata vata thereby helping achieve maximum treatment benefits with least cost and ingredients.

Materials and Methods

A total of 50 subjects were randomly selected from the OPD and IPD of SJIIM Hospital, Bangalore-09, with classical features of Janusandhigata vata, among which 25 patients were registered in group A, 5 patients dropped out in the middle, while 25 patients were registered in Group B, and 5 patients dropped out in the middle. The data of 10 patients who dropped out of the study have not been included here. Signed informed consent was obtained from all the participants.

Method of collection of data: 40 subjects who fulfil the inclusive criteria were selected randomly irrespective of sex, religion, occupation and economic status.

Diagnostic criteria:

The Diagnosis is based on these clinical features:

1. Sandhi shoola 2. Sandhi shotha 3. Sandhi atopa 4. Prasarana akunchanayo vedana 5. Tenderness in knee joint 

Inclusion Criteria:

1. Patients fulfilling the diagnostic criteria of janusandhigata vata.

2. Patients between age group of 40-70

3. Patients fit for sthanika swedana karma.

Exclusion Criteria:

1. Patients suffering from any systemic illnesses like rheumatic heart disease, rheumatoid arthritis and associated with bony deformities

2. Patients with obesity

Plan of Treatment:

40 Patients who fulfilled the inclusive criteria was randomly divided into 2 Groups A and Group B each consisting of 20 patients

Study duration:

14 days Follow up: 30th day Procedure of Kukkutanda Sweda Pottali Method: Group A

Poorva karma: Ingredients are: Ksheerabala taila 50ml-for abhyanga 4 Kukkutandas (eggs), Saindhavalavana 12gms, Ghrita 5ml, Cloth for preparing pottali (18×18 cms), small bowl, tying thread of 30 cms in length to tie a tuft. Spatula for stirring, water bath to heat, small towel & a chair.

Preparation of the Pottali: The contents of all the eggs with the powdered shell are taken into a bowl. To this 5ml ghritha &12gms saindhava lavana is added. The entire mixture is stirred well and made to reach a semi-solid consistency over a boiling water bath (indirect heat). The scrambled and processed eggs are poured on a cloth and tied into a pottali and kept ready for use.

Preparation of Patient: Patient to be treated with Kukkutanda sweda should be made to sit in a comfortable position and then the janu sandhi should be given a sthanika abhyanga with Ksheerabala taila for 5min.

Pradhana karma: After abhyanga, the pottali is dipped in Ksheerabala taila being heated on a water bath and gently rubbed in a circular manner over Janu sandhi region with intermittent dipping in warm Ksheerabala taila until samyak swinna lakshanas occurs.

Paschaat Karma: After swedana the part is wiped with a towel dipped in warm water and the wetness is gently wiped off with dry cloth. Food should be Laghu Paki and it should be served Hot and fresh. Abhishyandhi Ahara like Dadhi was avoided.

Bandhana Method: Group-B Ingredients are: Ksheerabala taila 50mlfor Abhyanga, 4 Kukkutandas (eggs), Saindhavalavana12gms, Ghrita5ml, Erandapatra, Coracloth (50×25 cms), Frying pan, small bowl, spatula, & chair

Preparation for Bandana dravya: The contents of all the eggs with the shell are taken in a bowl. To this 5ml ghritha & 12gms saindhava is added. The entire mixture is stirred well, this mixture is poured over a heated frying pan and it should be in a low flame, when it becomes like flake (omelet) kept over erandapatra & ready for use. The thickness is around 1-1.5 cm

Preparation of Patient: Same as Group A

Pradhana karma: After abhyanga, the prepared warm Bandhana dravya applied over Janusandhi region considering tolerable heat capacity of the patient then covered with eranda patra and tied using cora cloth.

Paschat Karma: Advice the patient to remove the Bandhana dravya after 12 hours. Later the part was washed with warm water and patted dry. Rest of the regimens same as Group A.

Assessment criteria: Subjective parameters and objective parameters were used to assess the clinical response in both the groups. The patients were assessed on 1st day (before starting the treatment) and 15th day (after completion of treatment)

Criteria for Assessment of Total Response of the Treatment: For the total Assessment of results the above all Parameters were considered before and after trial and results were obtained.

Marked improvement - relief of >61%

Moderate improvement - 41 to 60% relief

Mild improvement - 21% to 40% of relief

No Change - 0-20% relief

Observations

In present study, 12.5% patients were from age group 41-50, 32.5% were from 51-60 age group, 37.5% were from 61-70 age group, 17.5% were from 71-80 age group. Majority of the patients (57.5%) were females and (42.7%) were males. Majority of the females (45%) were in post-menopausal and 12.5% of the patients were Pre-menopausal stage. 27.5% of the patients suffered from Unilateral OA and while 72.5% of them suffered from bilateral OA. 17 patients (42.5%) had history of 1- 2 years of illness, 9 patients (22.5%) had history of <1 year, 14 patients (35%) had >2 years of history of illness, while no patients were newly diagnosed. Majority of the Patients indulged in Vataprakopakara Aharas like Rookshaahara(85%), Sheetaahara(25%), Abhojana(7.5%), Alpaahara(2.5%) and Viharas like, AtiVyayama (57.5%), AtiChesta (12.5%), Vega Sandharana (27.5%), while 27.5% of the patients were habituated to Divaswapna. Sandhi Shula was present in all the patients, in 90 % of the patients SandhiShotha was observed, while Sandhigraha was observed in 22.5% and Prasaranaakunchanayo savedana was observed in 92.5 % of the patients, all the patients had Atopa and 82.5% patients were having Sparshaasahishnuta.

Results

Subjective parameters:

Janu shoola: The test revealed that extent of relief obtained was same in both groups on Janu Shula after the two different treatment regimens; was statistically highly significant. This indicates the procedural effect on janu shula where in the immobilization of the part plays an important role in reducing the pain of the patients.

Janu shotha: Here in this study though the test revealed highly significant relief on janu shotha in Group B i.e Bandhana method has given better results when compared with Group A(Pottali Method); was statistically significant at p value<0.001.

Janu Atopa: The Test does not reveal any statistical significance for the criteria Atopa in both the groups as well as in between the groups. This may be due to the fact that atopa ie Crepitus is manifested mainly due to structural damage of the articular cartilage and it is difficult to manage the structural damage. But clinically there is improvement in the patient i.e. from audible crepitus to palpable crepitus.

Tenderness: In this study the test revealed that extent of relief obtained was same in both groups on the factor tenderness; was statistically highly significant.

Objective Parameters:

Range of movements: The test revealed that extent of relief obtained was same in both groups on Range of Movements after the two different treatment regimens; was statistically highly significant. I.e. the range of movements are improved in both the groups equally

Walking time(in seconds): The test revealed that extent of relief obtained was same in both Groups on Walking time after the two different treatment regimen and after follow up; was statistically highly significant at P≤0.001.

In Group A out of 20 patients 2 patients (10%) & in Group B 10 patients (50%) showed marked improvement. In Group A 6 patients (30%), Group B 8 patients (40%) showed moderate improvement. Group A 12 patients (60%), Group B 2 patients (10%) showed mild improvement.

By looking into the above results it can be concluded that the results in Group B (Bandhana method) is better than Group A (Pottali method) in Janusandhigata Vata in the factor like janu shopha. Though there is no difference in many of the criterias in between the group statistically, there is clinical significance as well as advantage in using Bandhana method in Janusandhigata vata.

Discussion

Janusandhigata vata is a degenerative disease where vatadosha prakopa is more dominant hence more snigdhata of the joints is needed. To lubricate and nourish the joints kukkutanda sweda is given for 14 days. The drug ksheerabala taila used for abhyanga having the properties like snigdha helps to pacifies vata dosha. The abhyanga performed before Swedana, creates the pressure gradient necessary for the absorption of the sneha amsha and by stimulating the sensory nerve endings it relaxes the muscles & its related structures⁵ . Here the Hilton’s Law can be applied in understanding the action of abhyanga, which says that the nerve which supplies a joint also supplies group of muscles acting over those joints, along with the skin covering that area. Usually in joint disorders there is a contraction of the nerve reflex to fix the joint in a comfortable position. This also causes a referred pain over the skin in that area covered. Therefore Abhyanga relaxes the muscle acting on the joint.

The contents of Kukkutandasweda are kukkutanda (egg), Grutha, Saindava and kukkutanda twak. All the contents of the yoga are having Vata-Kaphahara properties which are useful in Janusandhigata vata.

The egg with the shell, the shell membranes, the yolk & the egg white contains highly nutritive substances like, glucosamine, chondroitin sulphate, hyaluronic acid, ovotransferrin, desmosine and isodesmosine, Iysyl oxidase, lysozyme and the unique combination of 113 amino acids with many mineral supplements. Glucosamine is beneficial to sufferers of osteoarthritis pain. It is a major component of joint cartilage which helps in preventing degeneration of cartilage and also in joint space reduction. As we grow older, our body loses the capacity to make enough glucosamine, so the cartilage in our weight-bearing joints, then hardens and forms bone spurs, causing pain, deformed joints and limited joint movement. Chondroitin sulphate is claimed to maintain the structure, function of cartilage (referred to as chondro protection), pain relief of osteoarthritic joints and anti-inflammatory activity. The topical application or injection chondroitin sulphates to protect joint cells, reduce aseptic inflammation. Hyaluronic acid is effective for pain relief, for the risk of adhesion and contractures of joints. The injection of same is useful for the treatment of osteoarthritis, and rheumatoid arthritis⁶ .

Ghruta used in kukkutanda sweda having snigdha guna helps to pacify vatapitta dosha and saindhava is having sukshma guna which helps to take the veerya of the drug to the sukshma vaha strotas. The physiologic effects of temperature occur at the site of the application of the heat & in distant tissues. Locally there is an increased blood flow with associated capillary dilation & increased capillary permeability. Initial tissue metabolism increases & there may be changes in the pain threshold. Distant changes include reflex vasodilatation, reduction of muscle spasm due to skeletal muscle relaxation.

In the present study two method of kukkutanda sweda tried bandhana method is given better than pottali method, in bandhana heat is constantly maintained for more time in side, where as the pottali is heated by dipping in oil and rubbing heat is not uniform.

Conclusion

The disease Janusandhigata vata and osteoarthritis are similar in their etiology, sign and symptoms. Sandhigata Vata is a type of Vata vyadhi commonly associated with the vardhakya and dhatu kshaya is a prominent feature in its manifestation. The Doshas involved in this disease are mainly Vyanavata and Sleshaka Kapha. Old age, female sex, obesity and repeated trauma are the main risk factors for Osteoarthritis of Knee joint. Occupational, improper postures, sitting on irregular surfaces are the precipitating factors in the pathogenesis of Janusandhigata vata. Kukkutanda is having vatahara & kaphahara properties. Both Pottali & Bandhana method of kukkutandasweda showed significant results in all the parameters. No complications of Kukkutanda sweda were observed in this study. Clinically, Group B showed more significant results when compared to group A. The cases of Janusandhigata vata (Osteo arthritis) mild to moderate in intensity can be well managed with the treatments employed in the present study. Degenerative joint changes being progressive and irreversible, treatment is aimed at the relief of the symptoms and to check the disease process & to induce regeneration if possible.