Apabahuka kc001 kop


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Management of Apabahuka with ‘Laghumasha taila nasya’ and ‘Ekanga veera rasa’, Raviganesh.M, PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa.

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Apabahuka kc001 kop

  1. 1. BY Dr. Raviganesh. M B.A.M.S. (R.G.U.H.S, Bangalore) Dissertation submitted to Rajiv Gandhi University of Health sciences, Karnataka, Bangalore in partial fulfillment of the requirements for the degree of “Ayurveda Vachaspati” (M.D) in KAYACHIKITSAGUIDE Co-GUIDEProf. Pramod Kumar Mishra Dr. Banamali Das M.D. (Ayu),(RSU) M.D. (Ayu)Head of the Department Kayachikitsa Department of Roga Nidana and VikruthiVignana DEPARTMENT OF POSTGRADUATE STUYDIES IN KAYACHIKITSA A.L.N RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE, KOPPA-577126 CHICKMAGALUR DISTRICT, KARNATAKA, INDIA MARCH-2006
  2. 2. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Declaration I here by declare that this dissertation entitled Management of Apabahuka with ‘Laghumasha taila nasya’ and ‘Ekanga veera rasa’ is a bonafide and genuine research work carried out by me under the guidance of Dr.Pramod Kumar Mishra, Department of Post Graduate Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa. Date: Dr.Raviganesh.M Place: Koppa P.G.Scholar, Dept. of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  3. 3. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Certificate This is to certify that the dissertation entitled Management of Apabahuka with ‘Laghumasha taila nasya’ and ‘Ekanga veera rasa’ is a bonafide research work done by Dr. Raviganesh.M in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (M.D.) in Kayachikitsa, of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. Date: Guide: Prof.Pramod Kumar Mishra Place: Koppa M.D. (Ayu) (RSU) Head of the Department P.G. Studies in Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  4. 4. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Certificate This is to certify that the dissertation entitled Management of Apabahuka with ‘Laghumasha taila nasya’ and ‘Ekanga veera rasa’ is a bonafide research work done by Dr. Raviganesh.M in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (M.D.) in Kayachikitsa of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. Date: Place: Koppa Co-Guide: Dr.Banamali Das M.D. (Ayu) Department of Roga Nidana and Vikruti Vignana A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  5. 5. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Endorsement This is to certify that the dissertation entitled Management of Apabahuka with ‘Laghumasha taila nasya’ and ‘Ekanga veera rasa’ is a bonafide research work done by Dr. Raviganesh.M under the guidance of Prof. Pramod Kumar Mishra, Department of Post Graduate Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P.G. Centre, Koppa. Date: Dr.Jagadeesh Kunjal M.D. (Ayu) Place: Koppa Principal, A.L.N.Rao Memorial Ayurvedic Medical College, Koppa –577126, Dist: Chikmagalur
  6. 6. COPYRIGHT I here by declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate thisdissertation in print or electronic format for academic/research purpose.Date: Dr. Raviganesh.M P.G.Scholar,Place: Koppa Dept. of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126© Rajiv Gandhi University of Health Sciences, Karnataka
  7. 7. INDEX Page No. INRODUCTION 1-3Chapter - I OBJECTIVES 4Chapter - II REVIEW OF LITERATURE A) Disease review 5-57 Historical review 5 Nirukti 6 Rachana 7-16 Nidana 17-20 Samprapti 21-25 Poorvaroopa 26 Roopa 27-34 Upashaya, Anupashaya, Sadhyaasadyata 34 Upadrava 35 Sapeksha Nidana 36-37 Sadhyasadhyada 38 Chikitsa 39-54 Pathya apathya 55-57 B) Drug Review 58-69Chapter - III METHODOLOGY 70-88 A) Materials and Methods 70-76 B) Observations 77-88Chapter - IV RESULTS 89-110Chapter - V DISCUSSION 111-122Chapter - VI CONCLUSION 123 SUMMARY 124-125 REFERENCES BIBLIOGRAPHY ANNEXURES
  8. 8. TablesSl.No: List of Tables Page No: 1 Showing Muscles bringing about movements at the shoulder 14 joint. 2 Nidanas of Vatavyadhi and Vata prakopa vis-à-vis 17-19 Apabahuka. 3 Showing Sapeksha/ Vyavachedaka nidanas of Apabahuka. 37 4 Showing Nasya matra 45 5 Showing Patyaapatya. 56-57 6 Age wise distribution of 45 patients of Apabahuka. 77 7 Sex wise distribution of 45 patients of Apabahuka. 78 8 Religion wise distribution of 45 patients of Apabahuka. 79 9 Occupation wise distribution of 45 patients of Apabahuka. 80 10 Marital state wise distribution of 45 patients of Apabahuka. 81 11 Socio- economic status wise distribution of 45 patients of 82 Apabahuka. 12 Dietary pattern of 45 patients of Apabahuka. 83 13 Family history of 45 patients of Apabahuka. 84 14 General Nidana observed in 45 patients of Apabahuka. 85 15 Main symptoms observed in 45 patients of Apabahuka. 86 16 Associated symptoms observed in 45 patients of Apabahuka. 87 17 Sroto dusti lakshana observed in 45 patients of Apabahuka. 88 18 Effect of Shodhana on main symptoms of Apabahuka in 15 89 patients after treatment. 19 Effect of Shodhana on main symptoms of Apabahuka in 15 89 patients after follow up. 20 Effect of Shodhana on Associated symptoms of Apabahuka 90 in 15 patients after treatment. 21 Effect of Shodhana on Associated symptoms of Apabahuka 91 in 15 patients after follow up. 22 Effect of Shodhana on Sroto dusti lakshanas of Apabahuka 91 in 15 patients after treatment.
  9. 9. 23 Effect of Shodhana on Sroto dusti lakshanas of Apabahuka 92 in 15 patients after follow up.24 Effect of Shamana on main symptoms of Apabahuka in 15 93 patients after treatment.25 Effect of Shamana on main symptoms of Apabahuka in 15 93 patients after follow up.26 Effect of Shamana on Associated symptoms of Apabahuka 94 in 15 patients after treatment.27 Effect of Shamana on Associated symptoms of Apabahuka 95 in 15 patients after follow up.28 Effect of Shamana on Sroto dusti lakshanas of Apabahuka in 95 15 patients after treatment.29 Effect of Shamana on Sroto dusti lakshanas in 15 patients of 96 Apabahuka after follow up.30 Effect of Shodhanashamana on main symptoms in 15 patient 97 of Apabahuka after treatment.31 Effect of Shodhanashamana on main symptoms of 97 Apabahuka in 15 patients after follow up.32 Effect of Shodhanashamana on Associated symptoms of 98 Apabahuka in 15 patients after treatment.33 Effect of Shodhanashamana on Associated symptoms of 99 Apabahuka in 15 patients after follow up.34 Effect of Shodhanashamana on Sroto dusti lakshanas of 99 Apabahuka in 15 patients after treatment.35 Effect of Shodhanashamana on Sroto dusti lakshanas of 100 Apabahuka in 15 patients after follow up.36 Total effect of Shodhana therapy on 15 patients of 101 Apabahuka after treatment.37 Total effect of Shodhana therapy on 15 patients of 101 Apabahuka after follow up.38 Total effect of Shamana therapy on 15 patients of 102 Apabahuka after treatment.
  10. 10. 39 Total effect of Shamana therapy on 15 patients of 102 Apabahuka after follow up. 40 Total effect of Shodhana shamana therapy on 15 patients of 103 Apabahuka after treatment. 41 Total effect of Shodhanashamana therapy on 15 patients of 104 Apabahuka after follow up Charts and GraphsSl.No: List of Charts Page No: 1 Schematic Representation of samprapti of Apabahuka. 24 2 Marmaabhigata Apabahuka Samprapti. 25 3 Nasya - Classification according to Charaka 44 4 Nasya -Classification according to Vagbata 44 5 Probable mode of action of Nasya. 53 List of Graphs 6 Age wise distribution of 45 patients of Apabahuka. 77 7 Sex wise distribution of 45 patients of Apabahuka. 78 8 Religion wise distribution of 45 patients of Apabahuka 79 9 Occupation wise distribution of 45 patients of Apabahuka 80 10 Marital state wise distribution of 45 patients of Apabahuka 81 11 Socio-economic status wise distribution of 45 patients of 82 Apabahuka 12 Dietary pattern of 45 patients of Apabahuka. 83 13 Family history of 45 patients of Apabahuka. 84 14 General nidana observed in 45 patients of Apabahuka. 85 15 Main symptoms observed in 45 patients of Apabahuka. 86 16 Associated symptoms observed in 45 patients of 87 Apabahuka 17 Sroto dusti lakshana observed in 45 patients of Apabahuka 88 18 Comparative effect of therapies on main symptoms of 105 Apabahuka after 30 days, of treatment
  11. 11. 19 Comparative effect of therapies on main symptoms of 105 Apabahuka after 30 days, after follow up.20 Comparative effect of therapies on Associated symptoms 106 of Apabahuka after 30 days, after treatment.21 Comparative effect of therapies on Associated symptoms 107 of Apabahuka after 30 days, after follow up.22 Comparative effect of therapies on Sroto dusti lakshana of 107 Apabahuka after 30 days, after therapy.23 Comparative effect of therapies on Sroto dusti lakshana of 108 Apabahuka after 30 days, after follow up24 Comparitive effect of overall therapies on Apabahuka after 108 treatment.25 Comparative effect of over all therapies on Apabahuka 109 after follow up
  12. 12. ABBREVIATIONSA.H.Chi. Astanga Hridaya Chikitsasthana.A.H.Ni. Astanga Hridaya Nidanasthana.A.H.Su Astanga Hridaya Suthrasthana.Amar. Amarakosha.A.N. Anjana Nidana.A.S.Su. Astanga Sangraha Sutrasthana.A.S.Chi. Astanga Sangraha Chikitsasthana.Ay.Ras. Ayurveda Rasashastra.B.N.R. Brhat Nigantu Ratnakara.B.P.N. Bhava prakasha Nigantu.Cha.Chi. Charaka Samhita Chikitsasthana.Cha.Ni. Charaka Samhita Nidanasthana.Cha.Su. Charaka Samhita Suthrasthana.Cha.Si Charaka Siddi.Chau. Ana. Chaurasia Anatomy.Hari. Harisson,s principle of Internal Medicine.Ma.Ni. Madhava Nidana.N.S. Nibandha Sangraha.P.V.S. P.V.Sharma.S.E.D. Sanskrit English Dictionary.S.K.D. Sanskrit Kannada Dictionary.S.E.D.M.W M Sanskrit English Dictionary Monier William.Su.Chi. Sushruta Samhita Nidanasthana.Su.Chi. Sushruta Samhita Chikisthana.Su.Su. Sushruta Samhita Suthrasthana.Su.Sha. Sushruta Samhita Shareerasthana.Su.U. Sushruta Samhita Uttaratantra.Tora Ana Tortora Anatomy and Physiology.V.S. Vangasena Samhita.Vach. Vachaspati.Y.R Yoga Ratnakara.
  13. 13. ABSTRACT Apabahuka is one of the vatavyadhi, which affects the normal function of theupper limb. Even though this disease it being a life threatening one, it hampers dailyactivity of the person. It is a neurological as well as musculo-skeletal disorder,cardinal features being restricted movements of the shoulder joints and shoola.Objectives: The objectives of the present study are- 1. Management of Apabahuka with the trial drugs- “Laghumasha taila and Ekanga veera rasa”. 2. To establish an effective treatment with the trial drugs for Apabahuka. 3. To asses the merits and demerits of the trials drugs. 4. To compare the efficacy of Laghumasha taila nasya & Ekanga veera rasa individually and in combined form. 5. Detailed study of the disease covering classical and modern literature. 6. Study of the trial drugs covering classical literature.Methodology: Total 45 patients who fulfilled the inclusion criteria was randomly selected forthe study. The patients were grouped in to three groups. Shodhana group – Laghu masha taila marsha nasya for 7 days. Shamana group – Ekanga veera rasa 125mg B.D after food with ushna jala. Shodhana Shamana group - Laghu masha taila marsha nasya for 7 days and Ekanga veera rasa 125 mg B.D after food with ushna jala.
  14. 14. Interpretation and results: At the end of treatment schedule of 30 days the results were collected and statistically analyzed. It was found that shodhana shamana group gave highly significant relief (p<0.001) in the management of Bahupraspandita hara and shoola. Shamana group provided moderate significant results and Shodhana group provided moderate significant result in Bahupraspandita hara and mild significant result in Shoola. Conclusion: Laghu masha taila have brihmana effect when used as marsha nasya brought out moderate significant result in Bahupraspanditahara and mild significant relief in Shoola. Ekanga veera rasa showed moderate significance in decreasing Shoola and Bahupraspandita hara but sustained relief was not seen. Combined therapy showed highly significant relief in Bahuprspanditahara and Shoola.
  15. 15. ACKNOWLEDGEMENT It is with the great pleasure I wish to express my profound gratitude to all those whohelped me to bringing out this dissertation. I am ever indebted to my parents whose blessing,encouragement, affection and moral support helped me to complete my work. I am ever grateful to Prof. Pramod Kumar Mishra. MD (Ayu), HOD, Dept. of KayaChikitsa, Postgraduate centre, A.L.N Rao Memorial Ayurvedic Medical College, Koppa. for hiscomplete guidance, meticulous supervision, motivation and constant support that he extendedthrough out the course of work. I am very thankful to Dr. Banamali Das MD (Ayu) for his constant supervision, valuableadvises, constructive discussions with out which my study would have been incomplete. I am grateful to Aroor Ramesh Rao, President, Aroor trust Koppa, for giving me a chanceto pursue my post-graduate studies in his esteemed institution. My enormous thanks to Dr. Jagadeesh Kunjal MD (Ayu), Principal, A.L.N RaoMemorial Ayurvedic Medical College, Koppa, for his help and support in completing this work. My sincere gratitude to Prof. D.S Lucas MD (Ayu), FRAS (Londan), FRAV (India), forhis motivational inspiration and support. I am awfully thanking Dr. P.K Narayana Sharma for his valuable suggestions during mysynopsis work. I show gratitude to Dr. T.K Mohanta MD (Ayu), Ph.D and Dr. Reshmi Rekha MishraMD (Ayu), Dr. C.B Singh. MD (Ayu) for their constant motivation during this work. My sincere thanks to Statistician, Dr. Shyamalan, Dr. Christy Thundiparambil forhelping me in the statistical analysis. My special thanks to Dr. Dinesh Kumar Mishra MD (Ayu) and Dr.Galib. MD (Ayu),Dept. of Rasa shastra and Bhaishajya Kalpana, for their factual support and co-operation inpreparation of medicine. I also take opportunity to thank Mr. Mathew and Mr. Nithyanand, Miss.Violet forassisting in the preparation of medicine. I am thanking Dr. Ramesh N.V. whose constant support was an asset for me in thecompletion of this work.
  16. 16. I am ever grateful to Dr. Sanjaya K.S. MD (Ayu), Dr. Pradeep H.R MD (Ayu),Dr. Sridhar.V. MD (Ayu), Dr. Radhakrishana, Botanist; for their constructive suggestions for thecompletion of this dissertation. I am great full to Dr. Rajesh Kumar MD (Ayu), Dr. Sathish Sringeri MD (Ayu), for theirkind support. My sincere gratitude to Dr. Ramohan, Dr.Lalitha Bhaskar and Dr. Abhinetri Hegdefor their priceless support throughout the clinical study. I am thankful to Miss. Amruta for helping in laboratory investigations. I am thankful toMrs. Triveni and Miss. Manjula, Librarian, for their support in the reference work. It is with immense amicability I express my gratitude to Dr. Sarat. K. Babu, Dr. JamesChacko, Dr. Partthasarathi, Dr.Ratheesh. P. Nair, Dr.Dayanand R.D, Dr. Guruprasad,Dr. Harihara Prasad. With amicable gratitude I thank Dr. Purushotham K.G and Dr. Harvin George. N forproviding me the technical support. I express my deep gratitude to my seniors Dr. Anil Varkey, Dr. Srinivas, Dr. PrasanthBhat, Dr. Pradeep K.V, Dr.Shivakumar, and Dr. Leeladhar. Dr. Rakesh, Dr. Indu, Dr. Clarencefor their support in every aspect of my work. I am also thankful to my colleagues Vijayendra, Prathibha, Pradeep, Kishore, Sanjeev,Prashanth, Pankaj, Binu, Roshy, Vishwanath, Kavitha, Suja. I am also thankful to Sandesh Shetty, Susheel Shetty, Raghuram for their moral support. I am thankful to all my junior PG scholars, House surgeons, and UG students who helpedme during this work. I will be grateful to all my patients with out whom achievement of this work would havebeen impractical. Finally thanks to all those people who helped me directly and indirectly to complete thisexposition. I dedicate this thesis with sweet memories, to my beloved mother Late. Mrs.Lalitha.Date :Place : Koppa. Dr. Raviganesh.M.
  17. 17. Introduction INTRODUCTION The entire vedic tradition is composed of highly spiritual wisdom and pureknowledge revealed through the hearts of enlightened Rishis. It is not a creation madeby man but rather unfolded in the hearts of meditative minds. This ancient wisdomcame from the caves and mountains of India where the Sages and Seers had theirashrams and disciples. The knowledge of Ayurveda has been passed down to us in sootras or smallphrases and the wisdom they contain is to be unlocked by the enquiring mind. Theknowledge contained in it deals with the nature, scope and purpose of life. It embracesboth the meta-physical and physical, health and disease, happiness and sorrow, painand pleasure. It defines life as the expression of cosmic consciousness as exemplifiedby the entire sphere of creation. Stated simply, the purpose of life is to know or realizethe creator and to express this divinity in one’s daily life. “Change is constant” this is a confirmed principle of life from timeimmemorial and noted social economists have clarified the fact that rate of changeaccelerated much faster in the past 50 years compared to last 2,000 to 3,000 years.The change has resulted in an acute social upheaval all around the world, ultimatelyresulting in the present day’s reality of globalization. As a result there has been adrastic economic industrial revolution that has caused unprecedented life stylechanges which society has not been able to confront to with ease. In Ayurveda, we deal with diseases and their treatments and give importanceto the preventive aspects. It is obtained by attaining the equilibrium of doshas and anyviolence of this hampers the healthy state. Page : 1
  18. 18. Introduction Dosha, Dhatu and Mala are considered as the responsible factors for thenormal maintenance of health. When these factors derange, they produce severaltypes of diseases in the body. Among the above, these tridoshas play an important roleas they are prime factors to be involved in the either stages i.e., Swastha andAswastha of the body. These tridoshas vitiate in different ways, under differentpathological conditions of the body and manifest several diseases. Vata is a doshawhich also helps the other two doshas for the manifestation of different vikaras. Asvata plays a pivotal role in the maintenance of equilibrium, it is considered to besuperlative to the other doshas. Generally, in the body vata is considered as a chief factor for physiologicalmaintenance. So factors provoking it results in instantaneous manifestation ofdiseases, which can prove even fatal. There fore vataja nanatmaja vyadhis haveutmost importance than the vyadhis produced by other two doshas. Contradictoryapproaches to pacify this vitiated state have to be resorted to maintain the equilibrium. In the modern point of view under vata vyadhi, the diseases involvingneurological, musculo-skeletal, psychosomatic and gastro-intestinal system disordercan be considered. It indicates the wide-ranging involvement of vata in varioussystems of body. Economy of country relies on its work force. Apabahuka is one of suchdisease which hampers the day to day activity of an individual. The fact that Vatavyadhi is one amongst the asta-maha gada makes it self-explanatory regarding theconsequences caused by Apabahuka. Even though a definite factor responsible for themanifestation of this disease is not mentioned, however a set of etiological factors canbe interpreted. On analyzing etio-pathology, it may be interpreted that the diseaseApabahuka manifest due to the dhatu kshaya as well as samsrusta dosha. Page : 2
  19. 19. Introduction Apabahuka is considered as a disease that affects usually the amsa sandhi andis produced by the vata dosha. Even though the term Apabahuka is not mentioned inthe nanatmaja vata vyadhi, Acharya Susruta and others have considered Apabahuka asa vata vyadhi. In Madhava nidana two conditions of the disease has been mentioned –Amsa shosha and Apabahuka. Amsa shosha can be considered as the preliminarystage of the disease where loss or dryness of Sleshaka kapha from amsa sandhioccurs. In the next stage i.e., Apabahuka, due to the loss of shleshaka kaphasymptoms like shoola during movement, restricted movement etc are manifested.While commenting on these in Madhukosha teeka it is mentioned that Amsa shosha isproduced by dhatu kshaya i.e., sudha vata janya and Apabahuka is vata kapha janya. Considering these facts an attempt is made to study the disease Apabahuka indetail and to counter act the disease process by adopting suitable therapies. Vata vyadhis can be relived by therapies like Abhayanga, Swedana, Snehapana, Nasya karma, Vasti karma and shamana oushadhis like vata shamaka oushadhisevana. In the present study nasya karma with Laghu masha taila and shamanaoushadhi Ekanga veera rasa are advised to the patients of Apabahuka, comprising ofthree different groups. In the first group i.e., Shodhana group, Laghu masha tailanasya, is advised in the form of marsha nasya. In the second group i.e., shamanaoushadhi group, Ekanga veera rasa 125 mg b.d is advised which contains vata kaphashamaka and nadi balya karaka dravyas. And in the third group i.e shodana shamanagroup, both Laghu masha taila nasya and Ekanga veera rasa is advised. Page : 3
  20. 20. Objectives OBJECTIVESThe objectives of the present study are-1. Management of Apabahuka with the trial drugs- “Laghumasha taila and Ekanga veera rasa”.2. To establish an effective treatment with the trial drugs for Apabahuka.3. To asses the merits and demerits of the trials drugs.4. To compare the efficacy of Laghumasha taila nasya & Ekanga veera rasa individually and in combined form.5. Detailed study of the disease covering classical and modern literature.6. Study of the trial drugs covering classical literature.Hypothesis:1. Null hypothesis - Laghumasha taila nasya and Ekangaveera rasa individually or in combinations does not have any effect on Apabahuka.2. Alternate hypothesis - Laghumasha taila nasya and Ekangaveera rasa administered individually and in combined form in cases of Apabahuka has Apabahukahara property. Page : 4
  21. 21. Disease Review DISEASE REVIEWHISTORICAL REVIEW:The Vedas: In the Vedas the references related to vata vyadhi are not found. YajurvedaRudra sookta mentions about Dasha vatas. These are prana, vyana, udana, samana,apana, naaga, krakara, kurma,devadatta and dananjaya. The word Apabahukadenoting a disorder is never found in the elaborate text of Vedas.Samhita: Samhita that are adjunct to the Vedas are the key source of every existingprinciples of Ayurveda. Out of which Charaka samhita considered to be epitome ofknowledge. In Charaka samhita there is no direct reference regarding the diseaseApabahuka. But he gives the reference regarding the disease Bahushosha in sutrasthana.1In Sushruta samhita samprapti, lakshana and chikitsa has been discussed in detail.In Astanga sangraha a complete description regarding the disease has been dealt.In Anjana nidana explanation regarding Apabahuka has been givenTransitional period: Many commentators like Arunadatta, Dalhana, Hemadri have tried to analyzeApabahuka.Compilation period: Madava nidana, Yogaratnakara, Vangasena samhita explained Apabahuka inVata vyadhi chapter. Madavakara was the first to differentiate Apabahuka fromAmsashosha. Other authors like Bhavamishra, Sarangadara have discussedApabahuka. Page : 5
  22. 22. Disease ReviewThe modern period: The recent text like Gadanigraha, Brihatnigantu ratnakara, Nidana saraexplained Apabahuka.NIRUKTI AND PARIBHASHA:Before proceeding to Apabahuka it is better to deal with the nirukti and paribhasha ofVata vyadhi as it is one of the vata vyadhi - “Vikrita vata janito asadharana vyadhi vata vyadhi2”Extra- ordinary disease resulting from vikrita vata is known as vata vyadhi.Apabahuka comprises of two words Apa and Bahuka.APA means a) Viyoga, vikratou3 Viyogaou means dysfunction, separation4 b) Upasarga vishesha, Bhramsa, Vairoopyam, Tyaga iti durgadasa c) Apakristarthah, viyoga, viparyaya, vikruti, chourya iti medini5 d) Bhramsa apa shabdasyat, that is dislocation6Ava used as alternate for Apa in some texts gives the following meaning. a) ‘Ava’ as a prefix to verbs and verbal norms that express of, away or down.7 Thus in the present context the Ava or ‘Apa’ can be taken as deterioration or dysfunction.The word Bahuka means, a) Bahuka - Muscular gender b) Bahu - Bahu prabahu cha koorparasya urdhwadha bhagou iti (Vishnupurana) Page : 6
  23. 23. Disease ReviewThus Apabahuka can be defined as, i) Bahustambho Apabahuka8 ii) Bad arm, stiffness in the arm joint7 To summarize the above discussion and considering the relevant clinicalfeature, the term Avabahuka or Apabahuka would mean "dysfunction of bahu(stiffness or disability in the arm) i.e, bahu praspanditahara.AMSA SANDHI SHAREERA VIVECHANA: This is a major joint of upper limb. This is one type of chala9 and ulookhalasandhi.10 This is formed by the combination of pragandasthi, akshakasthi andamsaphalakasthi.Pratanavat types of snayus cover this sandhi11 Shleshmadhara kala is presents in this joint and secretes Shleshaka kapha.12This acts as lubricant and helps in protection and movement of the sandhi.13Amsamarma is present near this sandhi. A brief explanation of it can be done asfollows. The word Amsa denotes a specific area of the shoulder. The Amsa marma issituated within the line of the area joining head (murdha), neck (greeva) and the arm(bahu). This is a Snayu marma measuring to a length of half fingers width (1 cm) 14 This Marma is located on the Amsa that is formed by the union of Amsapeetha (glenoid) and the Skanda (acromio clavicular joint). The physical matrix that are present in Amsa marma are mamsa, sira, snayu,sandhi and asthi.15 But it is a Snayu marma.16 As it is one of Vaikalyakara marma, any trauma to this will produce disabilityor deformity of the shoulder joint.17 Page : 7
  24. 24. Disease ReviewANATOMY OF THE SHOULDER JOINT: 18, 19This is a synovial joint of the ball and socket variety.Articular surface - The joint is formed by articulation of the scapula and the head ofthe humerus. Therefore, it is also known as the gleno humeral articulation. Structurally it is a weak joint because the glenoid cavity is too small andshallow to hold the head of the humerus in the place. (The head is four times the sizeof glenoid cavity). However, this arrangement permits great mobility. Stability of thejoint is maintained by the following factors. 1) The coracoacromial arch or secondary socket for the head of the humerus. 2) The musculotendinous cuff of the shoulder. 3) The glenoid labrum helps in deepening the glenoid fossa. Stability is also provided by the muscles attaching the humerus to the pectoral girdle, the long head of the biceps, the long head of the triceps and atmospheric pressure.Ligaments of the Joint: 1) The Capsular Ligament - It is very loose and permits free movements. It isleast supported inferiorly where dislocations are common. Such a dislocation maydamage the closely related axillary nerve. Medially the capsule is attached to the scapula beyond the supraglenoidtubercle and the margins of the labrum. Laterally, it is attached to the anatomicalneck of the humerus with the following exceptions. Inferiorly the attachment extendsdown to the surgical neck. Superiorly it is deficient for passage of the tendon of thelong head of the biceps brachii. The joint cavity communicates with subscapularbursa, with the synovial sheath for the tendon of the long head of the biceps brachii, Page : 8
  25. 25. Disease Reviewand after with the infraspinatus bursa. Anteriorly, the capsule is reinforced by 3supplemental bands called the superior, middle and inferior glenohumeral ligaments.An extension of this membrane forms a tubular sheath for the tendon of the long headof the biceps.The coracohumeral ligament - it extends from the root of the coracoid process to theneck of the humerus opposite the greater tubercle. It gives strength to the capsule.Transverse humeral ligament - It bridges the upper part of the bicipital groove of thehumerus (between the greater and lesser tubercle). The tendon of the long head of thebiceps brachii passes deep to the ligament.The Glenoidal labrum - It is a fibrocartilaginous rim which covers the margins of theglenoid cavity, thus increasing the depth of the cavity.Bursae related to the shoulder joint: 1) The subacromial (subdeltoid) bursa 2) The subscapularis bursa, communicates with the joint cavity. 3) The infraspinatus bursa, may communicate with the joint cavity 4) Several other bursae related to the coraco brachialis, teres major, long head of the triceps, latissimus dorsi, and the coracoid process are present.Relations: • Superiorily - coracoacromial arch, subacromial bursa, supraspinatus and deltoid. • Inferiorly - long head of the triceps • Anteriorly - subscapularis, coracobrachialis, short head of biceps and deltoid. Page : 9
  26. 26. Disease Review • Posteriorily - Infraspinatus, teres minor and deltoid, within the joint - tendon of the long head of the biceps brachii.Blood Supply: • Anterior circumflex humeral artery • Posterior circumflex humeral artery • Suprascapular artery • Subscapular arteryNerve Supply: • Axillary nerve • Musculocutaneous nerve • Suprascapular nerveMovements at the Shoulder Joint: The shoulder joint enjoys great freedom of mobility at the cost of stability.There is no other joint in the body which is more mobile than the shoulder. This widerange of mobility is due to laxity of its fibrous capsule, and the large size of the headof the humerus as compared with the shallow glenoid cavity. The range ofmovements is further increased by concurrent movements of the shoulder girdle. Movements of the shoulder joint are considered in relation to the scapularather than in relation to the sagittal and coronal planes. When the arm is by the side(in the resting position) the glenoid cavity faces almost equally forwards and laterallyand the head of the humerus faces medially and backwards Keeping these directionsin mind, the movements are analysed as follows. Page : 10
  27. 27. Disease Review1) Flexion and extension - During flexion the arm moves forwards and medially and during extension, the arm moves backwards and laterally. These flexion and extension take place in a plane parallel to the surface of the glenoid cavity.2) Abduction and adduction takes place at right angles to the plane of flexion and extension (i.e., approximately midway between the sagittal and coronal planes). In abduction, the arm moves anterolaterally away from the trunk. This movement is in the same plane as that of the body of the scapula.3) Medial and lateral rotation is best demonstrated with a midflexed elbow. In this position, the hand is moved medially in medial rotation, and laterally in lateral rotation of the shoulder joint.4) Circumduction is a combination of different movements as a result of which the hand moves along a circle. The range of any movement depends on the availability of an area of free articular surface on the head of the humerus. It may be noted that the articular area on the head of the humerus is four times larger than that of the glenoid cavity.Muscles Producing Movements:1) Flexion is brought about- a) Mainly by the clavicular part of the pectoralis major, the anterior fibres of the deltoid, and the coracobrachialis and b) Is assessed by the short head of the biceps. A fully extended arm is Chiefly flexed by the sternocostal part of the pectoralis major.2) Extension a) In the resting position extension is brought about by the posterior fibres of the deltoid and by the teres major. Page : 11
  28. 28. Disease Review b) A fully flexed arm is brought back to the plane of the body by the latissimus dorsi and sternocostal part of the pectoralis major.3) Abduction of the arm is brought about by the deltoid, the supraspinatus, theserratus anterior and the upper and lower fibres of the trapezius. In the initial stagesof abduction the deltoid exerts an upward pull on the head of the humerus. This iscounteracted by a downward pull produced by the subscapularis, the infraspinatus andthe teres minor (thus avoiding upward displacement of the humerus). Thus the deltoid and these three muscles constitute a couple which permitstrue abduction in the plane of the body of the scapula. The supraspinatus assists inbringing about and maintaining the movement, but its precise role is controversial.The serratus anterior and the trapezius increase the range of abduction considerablyby rotating the scapula so that the glenoid cavity faces upwards.4) Abduction is brought about; a) Mainly by the pectoralis major and the latissimus dorsi (b) Is assisted by the teres major, the coracobrachialis, the short head of the biceps and the long head of the triceps.5) Medial rotation is produced by the pectoralis major, the anterior fibres of thedeltoid, the latissimus dorsi and the teres major; when the arm is by the side, themovement is also assisted by the subscapularis.6) Lateral rotation is produced by the posterior fibres of the deltoid, theinfraspinatusand the teres minor. Page : 12
  29. 29. Disease ReviewAnalysis of Abduction at the Shoulder - Abduction at the shoulder occurs through 180degrees. The movement takes place partly at the shoulder joint and partly at theshoulder girdle (forward rotation of scapula around the chest wall). The humerus andscapula move in the ratio of 2:1 throughout abduction, for every 15 degrees ofelevation, 10 degrees occur at the shoulder joint and 5 degrees are due to movementof the scapula. Rotation of the scapula is facilitated by movements at thesternoclavicular and acromioclavicular joint. The articular surface of the head of the humerus permits abduction of the armonly upto 90 degrees. At the limit of this movement, there is lateral rotation of thehumerus and the head of the bone comes to lie deep to the coraco-acromial arch.Abduction is initiated by the supraspinatus, but the deltoid is the main abductor. Thescapula is rotated by combined action of the trapezius and serratus anterior.THE BRACHIAL PLEXUS:18The plexus consists of roots, trunks, divisions and cords. a) Roots: These are constituted by the anterior primary rami of spinal nerves (5, 6, 7, 8) and T1 with contributions from the anterior rami of C4 and T2. The origin of the plexus may shift by one segment upward or downward, resulting in a prefixed or postfixed plexus respectively. In a prefixed plexus the contribution by C4 is large and that form T2 is often absent. In a postfixed plexus the contribution by T1 is large, T2 is always present, C4 is absent, and C5 is reduced in size. The roots join to form trunks as follows. Page : 13
  30. 30. Disease ReviewTable No: 1Showing muscles bringing about movements at the shoulder joint: Movements Main muscles Accessory muscles Flexion Clavicular head of the Coracobrachialis, pectoralis major, Anterior Short head of biceps, fibres of deltoid Sternocostal head of the pectoralis major Extension Posterior fibers of deltoid, Teres major, Latissimus dorsi Long head of triceps Adduction Pectoralis major, Teres major, Latissimus dorsi Coracobrachialis, Short head of biceps, Long head of triceps Abduction Deltoid, Supraspinatus Serratus anterior, Upper and lower fibres of trapezius Medial rotation Pectoralis major, Anterior Subscapularis fibres of deltoid Latissimus dorsi Teres Major Lateral rotation Posterior fibres of deltoid Infraspinatus Teres minor Page : 14
  31. 31. Disease Review2) Trunks Roots C5 and C6 join to form the upper trunk Root C7 forms the middle trunk Roots C8 and T1 join to form the lower trunk3) Divisions of the trunks : Each trunk divides into ventral and dorsal divisions (whichultimately supply the anterior and posterior aspects of the limb). These divisions jointo form cords as follows.Cord: i) The lateral cord is formed by the union of the ventral divisions of the upper and middle trunks ii) The medial cord is formed by the ventral division of the lower trunk iii) The posterior cord is formed by union of the dorsal divisions of all the three trunks.Branches of the Plexus for the Upper LimbThe root value of each branch is given in bracketsa) Branches of the roots i) Nerve to serratus anterior (long thoracic nerve) (C5,6,7) ii) Nerve to rhomboids (Dorsal scapular nerve) (C5)b) Branches of the trunks, these arise only from the upper trunk which gives 2 branches i) Suprascapular nerve (C5,6) ii) Nerve to subclavius (C5,6)c) Branches of the Cords - Branches of Lateral cord i) Lateral pectoral (C5,6,7) ii) Musculocutaneous (C5,6,7) Page : 15
  32. 32. Disease Review iii) Lateral root of median (C5,6,7)Branches of medial cord i) Medial pectoral (C8,T1) ii) Medial cutaneous nerve of arm (C8,T1) iii) Medial cutaneous nerve of fore arm (C8,T1) iv) Ulnar (C7 & T1 v) Medial root of median (C8, T1)Branches of Posterior Cord i) Upper subscapular (C5, 6) ii) Nerve to latissimus dorsi (thoracodorsal) (C6,7,8) iii) Lower subscapular (C5, 6) iv) Axillary (circumflex) (C5, 6) v) Radial (C5, 6, 7, 8, T1) In addition to the branches of brachial plexus, the upper limb is also supplied,near the trunk, by the supraclavicular branches of the cervical plexus and by theintercostobrachial branch of the second intercostal nerve. Sympathetic nerves aredistributed through the brachial plexus. The arrangement of the various nerves in theaxilla will be studied with the relations of the axillary artery. Page : 16
  33. 33. Disease Review NIDANA The factor, which is responsible for the causation of disease, is nidana20.Proper awareness about the factors responsible for the disease becomes very helpfulin determining the line of treatment, prognosis and diagnosis. Even though a specific bahya hetu(external cause) have not been mentionedfor Apabahuka, however the general factors told for vata prakopa have to be analyzedand elicited.In case of Apabahuka hetu may be classified into two groups; Bahya hetu – causing injury to the marma or the region surrounding that. Abhyantara hetu – indulging in vata prakopaka nidanas leading to vitiation of vata in that region. This may be again of bahya abhigataja(External cause) which manifest vyadhi or disease first and the other is dosha prakopajanya(Samshraya) which in turn leads to karmahani of bahu.Table No: 2Showing nidanas of vatavyadhi and vata prakopa vis-a-vis apabahuka:Nidanas CS21 Su.S22 AS23 AH24 MN25Aharaja(food)Rasa- Katu - + + + - Tikta - + + + - Kashaya - + + + - Page : 17
  34. 34. Disease ReviewGuna- Laghu + + + - + Ruksha + + + + + Sheeta + + + - +Dravya -Adhaki - + + - - Chanaka - - + - - Kalaya - + - - - Masura - + + - - Mudga - + + - - Nishpava - + + - - Shuskashaka - + - - - Tinduka - - + - -Matra- Abhojana + + - - + Alpashana - + + + - Vishamashana - + + - +Viharaja (external) Atiplavana + + - - + Atiprapatana - + - - - Atiprapidana - + - - - Ativichestitam + - - - + Ativyayama + + + + + Kriyatiyoga + - + + +Mityayoga-Asama Chalana - - + - - Balavat Vigraha - + + - - Page : 18
  35. 35. Disease Review Bhara harana - + + + - Dukhasana + - - - + Vegadharana + + + + +Kalaja- Aparatra - - + + -Agantuja-Abhighataja + - - - + Marmaghata + - - - +Amongst these, aharaja and viharaja responsible for the manifestation of Apabahukaare elicited as –Aharaja : Katu, tikta, kashaya rasas, laghu sukshma, sheeta guna causes vitiation of vata.Viharaja: These either directly or indirectly causes abhigata to the marma present in theamsa desha resulting in Apabahuka.Vyayama: Those exercises directly or indirectly influencing the shoulder or amsa deshashould be considered here.Plavana: Results in vata kopa due to over exertion in sandhi.Bharavahana: Carrying heavy loads over shoulder will cause vata prakopa and deformity inthe joint capsule. This leads to disease formation.Balawat Vigraha: Wrestling with a person who is more powerful will cause agahata toamsapradesha and vataparkopa takes place. This manifests the disease. Page : 19
  36. 36. Disease ReviewDukha Shayya: Improper posture that gives more and more pressure over the amsasandhi willdisturb the muscular integrity and provokes vata. This manifests the disease. Otherviharaja nidana told in vatavyadhi context may influence the condition by provocatingvatadosha. To summarize, the above said nidanas mentioned under vihara especiallyinvolving amsa sandhi and marmabhighata to amsa leads to the development ofApabahuka. Page : 20
  37. 37. Disease Review SAMPRAPTI The word samprapti refers to the cumulative events involved right from thetime inception to the time of complete manifestation of disease26.The diseaseApabahuka is considered as a type of vata vyadhi. The term vata vyadhi is specific forthe disease like “Vikrutha vata janito asadharana vyadhih” means the very specificdiseases produced only by vikruta vata2. Regarding the vitiation of vata, it is told thatvata can either be aggravated by dhatu kshaya or by avarana.“Vayuh dhatukshayat kopo margasya avaranena cha” Sushruta has mentioned three pathological conditions of vata i.e kevala vata,doshayukta vata and avrita vata27.Kevala vata (Shuddha vata): Kevala vata means shuddha vata or dosha asamsristavata i.e pathological state of vata without association of other dosha. The etiologicalfactors of vata are depletion in nature here, due to that decrease in body tissues occur;resulting in the increase in akasha (vacuum) and to fill the vacuum, vata is increasedleading to its prakopa. In such condition, hetu are of vata, symptoms are of vata andupasya and anupasaya are also of vata.Doshayukta vata: It refers to the samsarga or sannipata with other doshas, which isdifferent from avarana. In this condition clinical manifestation of vata as well as ofthe associated dosha as anubandha may be there. In that case, generally vata is theprimary dosha, which dominates the hetu, symptoms and treatment of other dosha. Page : 21
  38. 38. Disease ReviewAvrita vata: Avarana means to mask or to cover or to obstruct. Gati is the uniquefeature of vata. Whenever the gati of vata is obstructed due to avarana then itsvitiation occurs. This has been the central idea of avrita vata. Avarana of vata is a distinctive pathological condition, where obstruction to itsgati occurs due to the etiological factors other than its own, leading to its prakoparesulting into various avarana type of vata vyadhis. The dosha, dhatu, mala, anna andama can cause the avarana of vata. Even any sub type of vata may cause avarana ofeach other i.e anyonya avarana. The symptoms manifested in avrita vata arecomprised of disturbed function of vata, the obstructing factor as well as theobstructed vata. According to Astanga sangraha, the symptoms are produced based onthe principles of rupahani, rupavriddhi and anyakarma, which depend upon theintensity of the obstruction i.e partial or complete, functional or organic. Thesymptomatology also depends upon the place wherever dosha dushya sammurchanahas taken place28. In case of Apabahuka, either way of vitiation of vata can be considered. Thenidanas like ruksha, laghu etc and atibharavahana etc cause vitation of vata directly.In another way, kapha prakopaka nidanas like taking of atisnigdha, atiguru etc dravyacause increase of vikruta kapha which produce kaphavrita-vata condition. In bothways, vikruta vata dosha gets accumulated in the srotas and manifests the symptomslike stabdha poorna kosthata. In the prakopa avasta, the vata produces symptoms likekostha toda and sancharana and the prasara avasta symptoms like atopa also mayproduce. But Ashukaritva being one among the symptoms of vata, the symptoms Page : 22
  39. 39. Disease Reviewproduced by it is very quick in onset and hence the dosha kriyakalas of the vyadhi areill defined and cannot be observed properly. Stana samsraya avasta of the vyadhi occurs with the localization of aggravatedvata in the specific dhatu i.e dosha dushya sammurachana, which occurs in thespecific organ of the body where kha vaigunya previously has taken place by thespecific part of nidanas simultaneously with the dosha vikruti. Shiro marma is considered as the uttamanga and is mentioned as seat or moolaof all indriyas. Shiro marma performs all types of chesta in the presence of normalvata because; among the three doshas only vata helps for all the varieties of chesta.Charaka samhita has mentioned that29 when shiro marma gets affected, it producessymptom like chestahani. In this case, sthana samsraya of the dosha can be taken asin siro pradesha. Usually in sthana samsraya avasta, poorvaroopa of vyadhi aremanifested. As Apabahuka is considered as a vata vyadhi and vata having ashukari gunathe poorvaroopas like bahupraspanditahara and shoola may manifest mildly or aretotally absent. But the above symptoms are clearly manifested in the vyaktha avasthaor in roopa avastha of the vyadhis in the vyakta sthana i.e in the amsa pradesha. Inthis stage the amsa pradesha gets affected by aggravated vata for which Amsashoshaoccurs in the initial stage by the decrease of shleshaka kapha and further leading tomanifestations of Apabahuka by the symptoms like bahupraspanditahara and shoola.There fore Madhava nidana, Madhukosha commentary has mentioned that amsashosha and Apabahuka are the two stages of the vyadhi30. Page : 23
  40. 40. Disease ReviewMarma abhighata: Morbid vyana vata in other way may cause abhyantara marmabhighata or anyexternal trauma to amsapradesha may cause bahya marmbhighata to the amsa marmapresent in amsadesha. Because this is a snayu16 and vaikalyakara marma,17 byafflicting snayu will manifest bahupraspanditahara. Even in modern medical science, the partial loss of blood supply in the area ofinsertion of tendons or some idiopathic cause, can produce localized degeneration ofthe collagen. This induces autoimmune response and cause tear or distortion oftendinous sheaths and ligaments. This obliterates the integral stability of the joint andresults in restricted movement with painful and stiffened joint.31Chart No.1Schematic Representation of Samprapti of Apabahuka: Nidana sevana Ahara Vihara Swabhavika(old age) Provocation of vyana vata Adhisthana in amsadesha Shleshaka kapha shosha Amsa shosha Sira akuncha Bahu chesta hara APABAHUKA Page : 24
  41. 41. Disease ReviewChart No: 2.Marmabhighata Apabahuka samprapti : Marmabhighata(amsa) Abhyantara marmabhighata Bahya marmabhighata Amsa marmabhighata Affliction to mamsa, sira, snayu, asthi, Provocation of vata Bahu chesta hara APABAHUKA SAMPRAPTI GHATAKA Dosha - Vata (vyana vata) Kapha (sleshaka) Dushya - Mamsa, meda, sira, snayu, kandara, Srotas - Mamsavaha, medovaha, astivaha, majjavaha. Srotodustiprakara - Sanga Rogamarga - Madhyama Adhisthana - Amsadesha Vyaktasthana - Bahu Vyadhi swabhava - Chirakari Page : 25
  42. 42. Disease Review POORVA ROOPA Before the actual onset of disease, some symptoms develop and they giveclues about the forth coming disease. Such symptoms are called prodromal symptomsor poorva roopa. Pathological process of every disease starts before the clinicalmanifestations of a disease. Due to the on going pathological process certain featureswill develop, though a complete clinical picture is not manifested In Ayurveda, these lakshanas were considered as poorva roopa32. In thepresent context the poorva roopa of Apabahuka which is a vata vyadhi may be“Avyaktam laxanam tesham poorvaroopamiti smrutam” 33. In case of vata vyadhi the phase of poorva roopa will be in latent forms. So thepatient will not appreciate them. Here in Apabahuka some of the minor symptoms likeslight difficulty in the movement of shoulder joint and slight pain may be felt. Page : 26
  43. 43. Disease Review ROOPA The fifth stage of kriya kala is the vyakta stage, where the vaguely appearedsigns and symptoms of the disease seen in poorva roopa or 4th stage will be exhibitedin a fully manifested form and this particular stage is called roopa.34 Here in this stage, the dosa-dooshaya sammoorchana gets completed with themanifestation of all the lakshanas of vyadhi including the the pratyatma linga, whichare essential for the diagnosis of the disease. As the name itself indicates, in “Apabahuka,” the term itself is selfexplanatory. Mainly it gives rise to local symptoms as - • Bahupraspandita harana35 • Shoola36 • Amsashoshana37Bahupraspandita hara:The term bahupraspandita hara has three words. • Bahu – upper limb, • Praspandana – praspandana shareerasya chalanam idam vyanasya karmam.38 Means movement or chalana, considered to be a normal function of vyana vata.Dalhana commenting on this says that praspandana means chesta/ movement39. ● Hara –loss of /impaired/ difficulty. Thus, in the present context bahupraspanditahara may be taken as difficulty in the movement or impairment or loss of movementof upper limb. As told in the samprapti, the dusta vyana vata in amsa sandhi causessiraakunchana resulting in loss of movement of the particular limb, which may be Page : 27
  44. 44. Disease Reviewcomplete or partial. Thus the movements of shoulder joints like abduction, rotation,elevation etc are affected. The degree of affection varies depending on thepresentation of etiological factors, such as the site of the structures injured and theextent of injury and duration. Thus, this is one of the most important symptomsamongst the other lakshanas and the patient is compelled to approach the doctor.Shoola or Vedana: Shoola is one among the symptom in Apabahuka. In Anjana nidana it is toldthat “Amoola eka bahoschet vyathasyath apabahukaha” 40 The Amsa marma being a snayu marma, when it is injured or get afflicted byvata will produce shoola, because Shoola is one of the symptoms of snayu gata vata41. Recent Ayurvedic text like Chikitsa sara sangraha clearly mentions aboutVedana42, as a predominant lakshana of Apabahuka, along with other lakshanas. It isto be noted that vata is responsible for the production of pain43. Thus, pain isconsidered as a prominent symptom in this thesis.Amsa shosha: Amsa shosha means drying up of the kapha in amsa pradesha or atrophycaused by lack of nutrition. From the reference given by the Acharya Susruta, 37 it canbe interpreted that Amsa shosha also occurs as a lakshana of Apabahuka. This can beconsidered as muscle wasting around the joint due to lack of nourishment and disuseatrophy. It can also be interpreted from the reference by Sushruta that Amsa shoshacan lead to Apabahuka. Page : 28
  45. 45. Disease Review In the context of akshi roga samprapti, Sushruta mentions that sleshma doesthe bandhana of sira, kandara and medas of kalakasti and any derangement ofshleshma leads to the pathological state through the medium of siras44 This provesthat shleshma is responsible for structural stability of sira, kandara and medas and notthe amsa sandhi alone. So in this case, drying up of kapha leads to the akunchana ofsira resulting in Apabahuka. In the context of marma, it is told that four types of siras are present aroundmarma region that nourishes snayu, asti, marma and sandhi in total. So akunchuna ofsira results due to lack of nourishment to the snayu, asti, marma present in the sandhileading to shosha of amsa pradesha45.There are some clinical conditions of modern science, which may be compared withthat of Apabahuka. These may be categorized as follows. i) Periarthritis or frozen shoulder or adhesive capsulitis.46 ii) Incomplete rupture of supraspinatus tendon46 iii) Lesions of the rotatory cuff 46 iv) Sub acromial or subdeltoid bursitis 46 v) Sub coracoid bursitis 46 vi) Painful shoulder 46 vii) Bicipital tendinitis 46 viii) Osteo arthritis of shoulder joint 47 ix) Brachial plexes neuropathies 48i) Periarthitis or frozen shoulder or adhesive capsulitis - This is a descriptive termused to indicate a clinical syndrome where in the patient has a restricted range ofactive and passive glenohumeral motion. Page : 29
  46. 46. Disease Review Simmonds report on the tight inelastic tissues around the shoulder joint. Theybelieved that the pathological changes in frozen shoulder were due to degenerationand focal necrosis of the supraspinous tendon. With revascularization, the tendonpathology could resolve. With in-adequate vascular response, the tendons wouldcontinue to degenerate, developing tears of varying size, or a secondary bicepstendinitis could develop. In this condition, pain and stiffness of the shoulder joint are the cardinalsymptom leading to inability or loss of function of affected upper limb. This may beachieved by 3 phases. i) Painful phase ii) Stiffening phase iii Thawn / Resolving Phase The patient gives a history of having noticed a slight painful catch in theregion of the shoulder and upper arm for several months. Gradually becoming awareof the inability to perform certain tasks, because of stiffness of the arm. Night pain,often awakening him after he has fallen asleep, is a common complaint. Frequently itradiates down the arm to the hand without being localized to any nerve distribution.Stiffness of the shoulder increases until all movements are lost. Bridgman identified an increased incidence of frozen shoulder in patients withDiabetes mellitus. Those patients who were insulin dependent were particularlypredisposed. Page : 30
  47. 47. Disease ReviewIncomplete rupture of supraspinatous tendon- It is a common sequel to tendinitis though often not diagnosed. Pain iscomplained of over the shoulder. Tenderness is present over the insertion of thetendon.Lesions of the Rotatory Cuff: The rotatory cuff consists of the common tendinous insertion of supraspinatus,infraspinatus and teres minor muscles, as well as the subscapularis tendon. Thesetendons form a continuous fibrous sheath, which is intimately adherent to theunderlying shoulder capsule when the shoulder is moved from the anatomical positionof full elevation or abduction. The rotator cuff comes in contact with the undersurface of the coracoacromial ligament and is subjected to mechanical irritation anddegenerative changes occurs. With sufficient degeneration, bursitis may develop inthe intervening subacromial bursa. This separates the under surface of the acromionand coracoacromial ligament from the rotator cuff. With changes in the tendon,deposition of calcium occurs in the worn and degenerative tendon, as well as in thesubacromial bursa. In the absence of pre-existing symptomatology, patient may note thespontaneous acute onset of severe unrelieving pain in the shoulder and in the region ofgreater tuberosity. The onset may occur after unusual vigorous exercises or sportactivities in the patient over thirty five years. Any motion of the shoulder causes pain.Plain X-ray may show a calcium deposit in the acromial bursa or supraspinatoustendon. Page : 31
  48. 48. Disease ReviewSubdeltoid or Subacromial bursitis: Pain in the shoulder on abduction and internal rotation of the humerus- severeat night, and tender points in the shoulder is usually felt near the insertion of thedeltoid muscle, rather than in the joint itself, although it may radiate wide. Usually there is point tenderness on the greater tuberosity, which disappearsunder the acromion on abduction (Dawbamis sign). This tenderness may be absent orit may be wide spread over the deltoid region. In some cases, the patient gives a history of an injury to the shoulder. Thisusually takes the form of a fall on the outstretched arm or stabbed shoulder. When thepain follows, an injury there is usually an interval of few days before it manifestsSubcoracoid Bursitis: This is situated between the tip of the coracoid process and the capsule of theshoulder joint. It extends upto and even over the lesser tuberosity of the humerus.Normally, the humerus and the coracoid are closely applied to each other, the tip ofthe latter resting against or being opposite to the lesser tuberosity of thehumerus. Itfollows that, though this bursa is not particularly exposed to external violence, it is yetdistinctly liable to suffer derangement through irritation from the pressures of thelesser tuberosity against the coracoid when the arm is used at great deal. The patient complains of pain in the region of the coracoid and there isdefinite tenderness over the interval between two bones. Chronic cases on whichadhesions are present have marked limitations of lateral rotation and abduction. Page : 32
  49. 49. Disease ReviewPainful Shoulder: Spontaneous pain or pains after minor strains of the shoulder are extensivelycommon after the age of 35 years. The most common lesion responsible for shoulderpain in this age group is that of rotator cuff, bicipital tendinitis or subacromial bursitis.Bicipital tendinitis: Shoulder symptoms resembling supraspinatous tendinitis may be due to abicipital tendon, which has become irritated, and inflammed in its groove and longpassage through the shoulder joint. The symptoms are quite similar, butdifferentiation may be made based on pain and tenderness extending further distal tothe bicipital groove.Osteo Arthritis of Shoulder Joint: Repeated slight trauma or one major injury is an important etiological factor.Men after 50 are the usual victims. Large joints like knee, shoulder are affected.Morning stiffness, which gradually progress after continued use of the limb owing toincreased synovial secretion, is pathognom.On Examination i) Limitation of movements ii) Radiological imaging shows diminished joint space with osteophytesThe loss of mobility results from- i) Articular cartilage destruction with marked loss of joint space ii) Muscle spasm and contractures with fibrosis of overlying fascia and their musculo tendinous junction. Page : 33
  50. 50. Disease ReviewBrachial Plexus Neuropathy: Although the entity of Brachial plexus neuropathy is idiopathic, it presentswith the symptoms of pain that comes with no apparent reason. The location of paincan vary but usually involves the shoulder. The pain is followed in days or weeks byloss of motor function in the limb.To summarize Considering the cardinal features of Apabahuka and the features of aboveconditions, Apabahuka may be compared to the above said conditions. UPASHAYA AND ANUPASHAYA In the process of investigating a disease, occasionally upashaya andanupashaya method i.e., therapeutic trials with certain diet, drugs and viharas are alsoconsidered as a diagnostic tool in some cases.49, 50 In case of Apabahuka, use of shoulder joint during physical work provokes theproblem.On the other hand hot fomentation and rest gives relief. So the factorsaggravating vata are said to be Anuupashaya and pacifying factors of vata areUpashaya. Page : 34
  51. 51. Disease Review UPADRAVA The occurrence of another disorder on the wake of a primary disease is termedas upadrava.51 Sushruta has described upadravas of Mahagadas including vatavyadhis.They are Pranakshaya, Mamsakshaya, Jwara, Atisara, Murcha, Trisna, Hikka, Chardiand Swasa.52 He further specifies the upadravas for vatavyadhis as Shosha, Kampa,Supta twacha, Adhmana, Bhanga and Antah ruja.53According to Dalhana. ‘Pranakshaya’ means ‘Utsahakshaya’, mamsakshaya meansUpachayakshaya, Supta tvacha means ‘Badhira twacha’ Bhanga meansVedanatrutitam and Antah ruja means Gambhira vedana.Among various musculo-skeletal disorders of the shoulder joint explained earlier andeven Brachial plexus neuropathies, if left untreated may result into local muscularatrophy. This may cause permanent disability of that particular arm. Page : 35
  52. 52. Disease Review SAPEKSHA NIDANA There are many diseases having close resemblance. After the completemanifestation of disease, it should be differentiated from its allied one. This is beingdone based on the cardinal features of the disease. In the present context, same thingis discussed. Apabahuka is to be differentiated from the following disease conditions thataffect the upper limb. • Vishwachi • Amsa shosha • Ekanga vataVishwachi: In this context our Acharya mentions that the pain which is present at the 54posterior aspect of the arm radiates to the dorsal aspect of the fingers . In case ofApabahuka, clinical features like difficulty in the movement and pain in shoulderjoints are observed.Amsa shosha: This being mentioned as a separate entity by Madhavakara30, it should bedifferentiated from Apabahuka. The cardinal feature of this disease is wasting ofmuscles. However, in case of Apabahuka, other symptoms like difficulty in movementand pain are the predominating features. Page : 36
  53. 53. Disease ReviewEkanga vata; This disease affects the whole upper limb and features like loss of function(akarmanya) and sensory loss (vichetana) are observed here. Where as in Apabahukasymptoms like difficulty in movement and pain occurs only in the amsa prdesha.Table No: 3.Showing Sapeksha / vyavachedaka nidana of Apabahuka: Apabahuka Vishwachi Amsashosha Ekangavata A. Nidana Vatakara Vatakara Vatakara Vatakara B. Adhisthana Amsasandhi Bahu Amsasandhi Murdha C. Laxanas • Bahupraspa Bahu Amsashosha Akarmanya ndahara karma and kshaya vichetana • Shoola Radiates Absent Absent present in from tala to amsa sandhi bahupristha • Amsashosha _ Cardinal _ present feature D. Dosha Vatakaphaja Vataja Vataja Vataja or or vataja pitta / kapha anubandha Page : 37
  54. 54. Disease Review SADHYASADHYATAAfter the diagnosis and before starting the treatment it becomes essential to know theprognosis of a disease.55 Next few paragraphs will explain about the sadhyasadhyataof Apabahuka. The sadhyasahdyata of Apabahuka is not mentioned anywhere in the classics.Even the recent scholars of Ayurveda have not mentioned about its prognosis. Buthowever, following points are necessary to be considered while dealing withprognosis of Apabahuka. As Apabahuka is considered as Vatavyadhi which is a ‘Maharoga’ inspite ofeffective treatment, will not yield good results, when it is associated withbalamamsakshaya56 Yogaratnakara says that vatavyadhi is sadhya, if it is of recent onset and if thepatient has good bala.57 In Madhava nidana, it is said that if patient is strong andwithout any complications then the patient should be treated, as it is sadhya forchikitsa.58 Sushruta59 and Madhavakara60 say that shuddha vataja roga is Krichrasadhya,Dhathukshayaja is asadhya and samsargaja is sadhya. Bhava prakasha61 andVagbhata62 opines the same. Even while explaining vatavyadhi chikitsa Charakacharya has mentioned thatall the vatavyadhi after lapse of one year becomes Krichrasadhya or Asadhya.63 Sadhyasadhyata can also be assessed by considering hetu, poorvaroopa, roopa,dosha, dushya etc.64 Thus Apabahuka in the initial stage will become sadhya and isKrichrasadhya or Asadhya after certain Page : 38
  55. 55. Disease Review CHIKITSA After the diagnosis of a disease, the next step will be its management. In thepresent chapter, the management of Apabahuka is discussed. The general line of treatment mentioned for vatavyadhi in Ayurvedic classicsinclude Snehana (both internal and external), Swedana, mrudusamshodhana, basti,sirobasti Nasya, etc.65 Charaka further says that depending on the location and dushya (tissueelement vitiated by vata) each patient should be given specific therapies.66 Nasyakarma has been mentioned by Vagbhata in jatroordhva vatavikaras.Three major approaches are made in the management of vatavyadhi.67 1. Treatment of Kevala vata 2. Treatment of Samsrusta vata 3. Treatment of Avruta vataAyurvedic classics explain the chikitsa of Apabahuka as follows. 1. Nasya and uttarabhaktika Snehapana are useful in the management of Apabahuka.68 2. Astanga Sangraha mentions Navana Nasya and sneha pana for Apabahuka.69 3. Sushrutacharya advice vatavyadhi chikitsa for Apabahuka, except siravyadha.70 4. Chikitsa sara sangraha advice Nasya, Uttara bhaktika Snehapana and Sweda for the treatment of Apabahuka.71 5. Brumhana nasya indicated in Apabahuka by Vagbhata7 Page : 39
  56. 56. Disease Review By considering the above references, following can be said as the line oftreatment of Apabahuka. 1. Nidana parivarjana 2. Abhyanga. 3. Swedana 4. Uttarabhaktika snehapana 5. Nasyakarma 6. Shamanoushadhi.Abhyanga Anointing oil on the body is abhyanga. This abhyanga brings about thefollowing qualities. “It prevents old age, removes pain in the body and gives pusthi tothe body.”73 The virya of the drug used for abhyanga gets digested with the help ofsthanika bhrajakagni and enters in to the srotus and starts its action.74 Taila used for abhyanga after entering in to the body nourishes the bodytissues, gives strength and increases agni.75 Massage profoundly influences the entire nervous system and by mechanicalmeans affects all the tissues of the body. The effects of massage upon the nerves maybe either stimulating, promoting activity of the muscles, vessels and glands governedby them or sedative producing relief of pain and of nervous irritability. Massagepromotes nutrition of nerves by its beneficial effects upon digestion and circulation. The influence of massage on the circulation is very helpful in eliminating painafter injuries. Page : 40
  57. 57. Disease ReviewSwedana: Stambha Gourava Sheetaghnum swedanum swedakarakam.76 This isdefined as the process, which brings about swedana or perspiration in the body. Itdoes the dilation of the vessels thus improving blood circulation. Hence, it is verymuch beneficial in conditions where Shoola, Stambha and Sankocha are present. In the context of vatavyadhi sweda karma like pinda sweda, nadisweda,avagaha sweda are mentioned which alleviate vatadosha. It also helps to relieveStambha (Stiffness), Gourava (heaviness) and Sheeta (cold).Uttarabhaktika Snehapana:In the classics, Abhyantara Snehapana is divided into 3 types.77 1. Shamana 2. Shodhana 3. Brumhana Shamana and shodhana are used in case when we need palliation andalliviation of the morbid doshas from the body respectively. Brumhana is the one, which is done or used for the nourishment. In the presentcontext of Apabahuka, the vitiated vata due to its rookshadi qualities does theshoshana of shleshaka kapha that is present in the amsasandhi. To subside thisrooksha quality and to normalize the shleshaka kapha qualities, brihmana snehapanais advisable. Brumhana type of snehapana is adviced prior, middle and after theintake of food, as explained by Hemadri.78 Page : 41
  58. 58. Disease Review Uttarabhaktika snehapana i.e., snehapana done after intake of food is useful inthe disorders of vyanavata.79 Uttarabhaktika snehapana indicated in Apabahukafulfills the need of treatment required in case of vynavata disorder and also acts asBrumhana. Here alpa matra of snehapana should be used. Sneha used here should beTaila, because taila is best amongst snehas in vatavyadhi.80NASYA KARMA The administration of either medicine (drug) or medicated oil through the noseis known as Nasya Karma. 81 Navana, Nastakarma are the words used for Nasya karma. This is useful inShiroshunyata. It gives strength to neck, shoulders, chest and increases vision.82 ThusNasya is useful in Apabahuka. By studying our classics, it is observed that Nasya Karma is adviced tomaintain the health in healthy persons and to alleviate the diseases. This chapterdescribes Nirukthi, Paribhasha, Classification, Dosage, Indications, and method ofNasya karma, Samyak laxana, Vyapat and its chikitsa.Vyutpatti Nirukti and paribhasha: The word Nasya Karma is composed of two words Nasya and Karma.Nasya: ‘ Nas’ is substituted for Nasa when it is followed by the suffix ‘Yath’. Nasika + Yath = Nasadeshancha Nasikaayai hitam – Nasya Page : 42
  59. 59. Disease Review In Vachaspathyam the word, ‘Nasya’ has been defined as the one, which isadministered through the nose. Chakrapani explains that “Nastha Prachardanam iti Shirovirechanam.”Considering the above definitions, Nasya can be defined as that which is administeredthrough nose by using the medicines to alleviate Jatrurdhva Vikaras in particular.Synonyms of Nasya: Shirovirechana, Shirovireka, Murdhavireka, Navana, Nastha karma, nasthametc.Karma: The action done by Kartru according to his will is known as karma.The treatment of diseases done with Nasya is called Nasya Karma where Karma isused in the meaning of chikitsa.Classification of Nasya Karma: Depending on the forms of medicine used, the mode of action of drugs and thequantity of medicine used, Nasya is classified as follows.Classification according to its matra: 831. Marsha2. Pratimarsha Page : 43
  60. 60. Disease Review Chart No:3 Nasya - Classification according to Charaka: 84 Nasya Nasya Navana Avapeeda Dhmapana Dhooma PratimarshaSnehana Shodhana Proyogika Virechanika Snaihika Shodhana Stambhana Snaihika Virechana Chart No:4 Nasya -Classification according to Vagbhata: 85 Nasya Virechana Bruhmana Shamana Page : 44
  61. 61. Disease ReviewNasya Matra: The unit of Nasya is the quantity of medicine that dribbles down when the firsttwo digits of index finger are dipped in to the medicine and taken out which is calleda “Bindu” (drop).86Table No: 4 Maximum Moderate MinimumFor snehas 10 8 6(Bramhana)For kwatha, 8 6 4Swarasa etc.According to Sushruta:Snehanasya 64 32 16(Bramhana) (32+32) (16+16) (8+8)Shirovirechana 8 6 4Marshanasya Or 10 drops 8 drops 6 dropsSnehanasyaOther forms ofMedication like 8 6 4Kwatha, Swarasa Page : 45
  62. 62. Disease Review Pradhamana nasya, which will be in powder (churna) form, is administeredwith the help of a hollow tube of 6 Angulas in length having openings at both ends.The powder is filled in to it and blown in to the nostrils of the patient till the powderreaches his throat.87Kala for Nasya Vidhi: 88 Vataja disorders- Afternoon Pittaja disorders- Noon Kaphaja disorders – Fore noon Swastha, - cold seasons- Noon Sharat rutu and Vasanta rutu- Fore noon Greeshma rutu – Afternoon Rainy season- bright sunlight For persons undergoing Panchakarma, it should be done after basti. NasyaKarma is contraindicated during cloudy weather irrespective of season.Navana nasya: 89 Sneha dravyas are mainly used. It acts as Brumhana. It is of two type- snehanaand shodana.Avapeedana nasya: 90 Nasya performed by squeezing a wet drug is avapeedana. This may beShodhana or Sthambhana depending on the drug used. Page : 46
  63. 63. Disease ReviewDhmapana: 91 A form of nasya where in medicated powders are blown in to the nostrilsthrough a hollow tube. This is virechana nasya.Dhooma nasya: 92 Medicated fumes are inhaled through nostrils and exhaled from the mouth.This may be vairechanika or snehika.Pratimarsha nasya: 93 When the nasya dravya is used with minimum quantity (2 bindus), it is calledPratimarsha. Usually sneha dravyas are used. This is different from marsha nasyawhere in the quantity used will be 6, 8, 12 bindus.Navana nasya: Navana type of nasya which is done with Taila acts as Brumhana nasya whichis useful in case of Apabahuka. The same is explained in the forthcoming paragraphs.Method of Nasya Karma: Nasya Karma can be explained in the following three headings as told in theclassics.Poorva Karma: 94 This encompasses the following points like Oushadhi sangraha, Nasya yantra,Atura vaya, Kala, Atura siddhata etc. Patient is instructed not to suppress the naturalurges and go through the normal routines. Before taking Nasya Karma he should nothave any food. Then, patient is taken to a comfortable room, which is without dust,extreme breeze and sunlight. Bahyasnehana in the form of mrudu Abhyanga is done Page : 47
  64. 64. Disease Reviewto shiras first and then over gala, kapola, lalata and karna. After snehana, mildswedana is done to the part of the body above the shoulders. Care of the eyes shouldbe taken with closing the patient’s eyes with a band of cloth.Pradhana Karma: 95 Once the poorva karma is over, the patient is made to lie down on the table inthe supine position with legs slightly raised. Eyes should be covered with a cloth.With the help of the tepid medicine, panitapa sweda is done to the parts of the bodyabove the shoulder excluding the patient’s eyes. The head of the patient is then highlyraised and medicine is poured in each nostril one after the other. The other nostrilshould be closed while administering the medicine in one nostril. The medicineshould be slowly instilled in an uninterrupted manner called “Avicchinna dhara”. Thepatient is advised to inhale the medicine slowly and forcefully. The same procedure isrepeated in either of the nostrils. Care should be taken not to shake the head duringthe procedure. Tapasweda can be repeated conveniently. After the administration of the medicine, patient is adviced strictly not toswallow the medicine but should spit it out. The spitting can be done till the smell andtaste of the medicine disappears from the throat. Then, the patient is allowed to relaxin the same posture for 100 matra kala. (30-32 sec) without going to sleep.Paschat Karma: 96 Pradhana karma is followed by dhoomapana, gandoosha and kavala graha.The patient is adviced to follow certain rules and regimen. Page : 48
  65. 65. Disease ReviewSamyak yoga laxanas: 97 The symptoms like Shirolaghava, Sukhaswapna, Prabhodhana, Vikaropashamana, indriya prasannata, manah prasannata and srotovishuddi indicate samyaknasya laxanas.Ayoga laxanas: 98 The medicine administered in insufficient quantity produces kandu, gouravata,vikara anupashamana and indriya rukshata which are heena yoga laxana.Atiyoga laxanas: 99 Kaphasrava from nose, shirogouravata, indriyavibhrama are atiyoga laxana.When ayoga laxanas are observed, samyak nasya karma should be done. In atiyoga,ruksha chikitsa should be done.Nasya vyapat chikitsa100Nasya vyapats are of 2 types. 1. Doshotkleshaja 2. Doshakshayaja The following complications arise when nasya is done in anarhas, jalapeeta,ajeerna, bhaktabhukta and in durdina. Kaphaja vikara will manifest and these shouldbe treated with kaphahara chikitsa. Rukshajanya vikaras that manifest in Krisha,virikta, vyayama klanta, garbhini and trishnartha are treated with snehana andBrumhana chikitsa. Nasya karma done in Shokabhitapta, Madhyapeeta and Jwara rogi, lead totimira roga. This should be treated with rooksha, sheetala lepa, anjana and Page : 49