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Apabahuka kc014 udp

  1. 1. “A CLINICAL STUDY TO EVALUATE THE EFFECT OF UPANAHA AND SHAMANA CHIKITSA IN THE MANAGEMENT OF APABAHUKA” BY Ramesh.N. B.A.M.S. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. In partial fulfillment of the requirements for the degree of DOCTOR OF MEDICINE (M.D) In KAYACHIKITSA Under the Guidance of DR. G.SHRINIVASA ACHARYA., M.D. (AYU) Head of the department, P .G. Studies in Kaya Chikitsa Under the Co-Guidence of DR.SHRILATHA KAMATH.T., M.D.(AYU) Lecturer, P. G. Studies in Kaya Chikitsa DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574118 2006 -2007 I
  2. 2. Rajiv Gandhi University of Health Sciences DECLARATION BY THE CANDIDATE I hereby declare that this dissertation entitled “A Clinical Study to evaluatethe effect of Upanaha and Shamana Chikitsa in the Management of Apabahuka”is a bonafide and genuine research work carried out by me under the guidance ofDr.G.Shrinivasa Acharya.,M.D.(Ayu) and co-guidance of Dr.Shrilatha Kamath.T.,M.D.(Ayu). Signature of the CandidateDate: Ramesh.N. B.A.M.SPlace: Udupi. i
  3. 3. Rajiv Gandhi University of Health Sciences CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A Clinical Study to evaluatethe effect of Upanaha and Shamana Chikitsa in the Management of Apabahuka”is a bonafide research work done by Ramesh.N in partial fulfillment of therequirement for the degree of Doctor of Medicine M.D. (Ayu) in Kaya Chikitsa. Signature of the Guide: DR.G.SHRINIVASA ACHARYA., M.D. (AYU) Head of the Department , P.G. Studies in Kaya Chikitsa, S.D.M.C.A., Udupi. Date: Place: Udupi ii
  4. 4. Rajiv Gandhi University of Health Sciences ENDORSEMENT BY THE H.O.D, PRINCIPAL / HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A Clinical Study to evaluatethe effect of Upanaha and Shamana Chikitsa in the Management ofApabahuka”is a bonafide research work done by Ramesh.N in partial fulfillment ofthe requirement for the degree of Doctor of Medicine M.D. (Ayu) in KayaChikitsa.Signature of the H.O.D Signature of the PrincipalDr. G. Shrinivasa Acharya. Dr. U. N. Prasad. M.D. (Ayu) M.D. (Ayu)Head of the Department, Principal,P.G. Studies in Kayachikitsa. S.D.M.C.A. Udupi.S.D.M.C.A. Udupi.Date :Place: Udupi iii
  5. 5. COPYRIGHT Declaration by the candidate I hereby declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for academic/ research purpose. Signature of the Candidate RAMESH.N. B.A.M.S Date: Place: © Rajiv Gandhi University of Health Sciences, Karnataka iv
  6. 6. Acknowledgement ACKNOWLEDGEMENT I express gratitude beyond words to my guide Dr. G. Shrinivasa Acharya, Dept.of P.G.studies in Kayachikitsa, for his encouragement, wholehearted support and timelysuggestion. I wish to offer my sincere thanks to my co-guide Dr. Shrilatha Kamath .T, Dept.of P.G. studies in Kayachikitsa, for her valuable suggestions, encouragement and support. My gratitude to Dr.U.N.Prasad, Principal, and doctors of the P.G. facultyDr.K.R.Ramachandra, Dr.B.V.Prasanna, & Dr.Shrikanth.U, for their moral support andguidance. Highest respects to my parents, sister, brother and my uncle Dr. Prabhakar.S,who were been inspiration for me in all aspects of life. This thesis would have never attained its present form without the valuablesuggestions provided by Dr.Shreedhara Holla, Dr. Jonah, Dr.Lavanya, Dr. Veerkumar,Dr. Nagaraj, Dr.Prasanna Mogasale and Dr. Bairy.T.S I am grateful to the Hospital Superintendent, Dr.Y. N.Shetty, Dy. Superintendent,Dr. Deepak S. M. and Manager Mr. C. S. Hegade college Manager, Mr. Nagesh, libraryhead Mr. Harish Bhat & Digital library head Mr.Upendra kini for their timely help. It will not be out of the way to express my sole hearted thanks to my mostbeloved friends Dr.Kuldeep, Dr.Pradeep, Dr.Amit, Dr. Devanathan, Dr. Hari OmDr. Harish, Dr. Magan, Dr.Shobha, Dr.Deepti, Dr.Ranjit and Dr.Yoganarasimha, for thediscussions they extended to me during my project work. It will be unfair if I don’t remember to thank the service extended by Dr. Sarfaraz,for timely help and commitment shown. My sincere thanks goes to my beloved seniors Dr. Anilkumar, Dr. Madhusudanan,Dr. Vittal, Dr.Gajanan, Dr.Mithun, Dr.Pardhu and subordinates Dr.Thiru, Dr.Amruta,Dr.Waheeda, Dr.Anju , Dr.Abu, Dr.Shyam, Dr.Narayan, Dr.Pradeep , Dr.Jibi , Dr,Poonam , Dr.Sridhar and Dr. Anushree for their support provided throughout my studies.Place:Date: Dr.Ramesh. N Dept. of Kayachikitsa, S.D.M.C.A. Udupi. VI
  7. 7. Abstract ABSTRACT Apabahuka is a common condition which badly affects the routine domesticactivities of patients like combing; bathing etc. interference in occupation by the illness isequally true both in patients with sedentary office work as well as heavy field work. Inthe modern parlance the causes of restricted shoulder movement, stiffness and pain aremany and include conditions like rotator cuff disorders, adhesive capsulitis, osteoarthritis,etc. and these are further classified under the heading of shoulder pain or shoulderdisorders. The definite involvement of morbid vata dosa in the pathogenesis ofapabahuka may establish in distinct forms like kevala vata, dhatuksayaja vata andavaranaja vata. In accordance with this variant pathogenesis, much has to be explored inthe field of management of apabahuka. With less burden of cost, defining the mosteffective treatment of apabahuka is the need of the day. Hence this study is planned toascertain the therapeutic efficacy of Kolakulatthadi Upanaha and oral administration ofRaasna Guggulu in patients of apabahuka.Design: Single blind clinical study with a pre-test and post-test design.Source of the data: 21 patients of apabahuka who attended the O.P.D. and I.P.D. ofS.D.M. Ayurveda Hospital, Udupi, during the period November 2005 to August 2006.Intervention: Patients were subjected to 14 days course of Upanaha with Kolakulattadichoorna and oral medication of Raasna Guggulu for 28 days.Observations: Out of 21 patients of apabahuka studied in this work, 76 % belonged tothe age group of 41-60 years, 62% were males, 76% were Hindus, all were married, 36%were house wives, 43% had D.M. and 43%were of vataja prakruti.Results: Statistically significant improvement was observed in all the criteria ofassessment that included pain, stiffness, and range of shoulder movement.Conclusion: The combination of Kolakulattadi Upanaha and Raasna Guggulu orally istherapeutically effective in the patients suffering from apabahuka.Key words: Vatavyadhi, Apabahuka, Frozen Shoulder, Upanaha, etc. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. VII
  8. 8. Table of contents TABLE OF CONTENTSSection and Title: Page No.LIST OF TABLES IXLIST OF FIGURES XI INTRODUCTION 1-4 OBJECTIVES 5SECTION-I LITERARY REVIEW 6 Chapter-I Historical Review 7-8 Chapter-II Etymology of Apabahuka 9 Sandhi Shareera 10-15 Nidana 16-25 Samprapti 26-30 Poorvaroopa 31 Roopa 32-37 Upashaya and Anupashaya 38 Saapeksha Nidana 39-40 Saadyaasadyata 41 Chikitsa 42-46 Pathyapathya 47-48 Chapter-III Drug Review Upanaha 49-52 Kanji 52-53SECTION-II CLINICAL STUDY Material and Methods 56-64 Observations 65-86 Results 87-97SECTION-III DISCUSSION 98-110SECTION-IV CONCLUSION 111 SUMMARY 112-115BIBLIOGRAPHY 116-127ANNEXURE – PROFORMA 128-133 Dept. of Kayachikitsa, S.D.M.C.A. Udupi. VIII
  9. 9. List of tables LIST OF TABLESSerial No. Title of the table Page no. 1. Muscles responsible for the movements of the Shoulder Joint 15 2. Vatavyadhi Nidana 19 3. Differential diagnosis of Shoulder disorders 39 4. Pathya in Vata Vyadhi 46 5. Apathya in Vatha Vyadhi 47 6. Drugs in Kolakulattadi Choorna and Raasna Guggulu 53 7. Assessment of cardinal manifestation of apabahuka 58 8. Functional Assessment of Shoulder Joint 60 9. Distribution of 21 patients according to different age group 65 10. Distribution of 21 patients according to sex 66 11. Distribution of 21 patients according to the occupation 67 12. Distribution of 21 patients according to the religion 68 13. Distribution of 21 patients according to socio-economic status 69 14. Distribution of 21 patients according to marital status 70 15. Distribution of 21 patients according to the Education 71 16. Distribution of 21 patients according to addictions 72 17. Distribution of 21 patients according to the dietary habits 73 18. Distribution of 21 Patients according to Prakruti 74 19. Distribution of 21 Patients according to Sara 75 Dept. of Kayachikitsa, S.D.M.C.A. Udupi. IX
  10. 10. List of tables20. Distribution of 21 Patients according to Samhanana 7621. Distribution of 21 Patients according to Pramaana 7722. Distribution of 21 Patients according to Saatmya 7823. Distribution of 21 Patients according to Satwa 7924. Distribution of 21 patients according to Aahara 80 Abhyavaharana and Jarana Shakti25. Distribution According to Vyayama Shakti 8126. Distribution of 21 Patients according to Vaya 8227. Distribution of 21 Patients according to Chronicity 8328. Distribution of 21 Patients according to Joint involved 8429. Analysis of Movement affected in 21 cases of Apabahuka 8530. Effect on pain during and after the course of treatment 8631. Efficacy on Stiffness during and after the course of treatment 8732. Effect on Flexion during and after the treatment 8933. Efficacy on Abduction during and after the treatment 9034. Effect on Internal Rotation during and after the treatment 9235. Efficacy of treatment on External Rotation 9336. Effect of treatment on abduction against resistance 9537. Efficacy of treatment on Functional Ability 96 Dept. of Kayachikitsa, S.D.M.C.A. Udupi. X
  11. 11. List of figures LIST OF FIGURESSerial No. Title of the Figures Page no. 1. Distribution of 21 patients according to different age group 65 2. Distribution of 21 patients according to sex 66 3. Distribution of 21 patients according to the occupation 67 4. Distribution of 21 patients according to the religion 68 5. Distribution of 21 patients according to socio-economic status 69 6. Distribution of 21 patients according to marital status 70 7. Distribution of 21 patients according to the Education 71 8. Distribution of 21 patients according to addictions 72 9. Distribution of 21 patients according to the dietary habits 73 10. Distribution of 21 Patients according to Prakruti 74 11. Distribution of 21 Patients according to Sara 75 12. Distribution of 21 patients according to Samhanana 76 13. Distribution of 21 Patients according to Pramaana 77 14. Distribution of 21 Patients according to Saatmya 78 15. Distribution of 21 Patients according to Satwa 79 16. Distribution of 21 patients according to Aahara 80 Abhyavaharana and Jarana Shakti 17. Distribution of 21 patients according to Vyayama Shakti 81 18. Distribution of 21 Patients according to Vaya 82 19. Distribution of 21 Patients according to Chronicity 83 Dept. of Kayachikitsa, S.D.M.C.A. Udupi. XI
  12. 12. List of figures20. Distribution of 21 Patients according to Joint involved 8421. Analysis of Movement affected in 21 cases of Apabahuka 8522. Effect on pain during and after the course of treatment 8623. Effect on Pain 8624. Effect on Stiffness during the course of treatment 8825. Effect on Stiffness 8826. Effect on Flexion during the course of treatment 8927. Effect on Flexion 9028. Effect on Abduction during the treatment 9129. Effect on Abduction 9130. Effect on Internal Rotation during the course of treatment 9231. Effect on Internal Rotation 9332. Effect on External Rotation during the course of treatment 9433. Effect on External Rotation 9434. Effect on abduction against resistance during treatment 9535. Effect on abduction against resistance 9536. Effect on Functional Ability 96 Dept. of Kayachikitsa, S.D.M.C.A. Udupi. XII
  13. 13. Introduction INTRODUCTION Aches and Pains in muscles and joints surface at all ages, though the causes maydiffer. These are more during the later years of life but common tendency with mostpeople is to ignore and quite often to brush them aside as minor problems. It is only whenthese minor problems become major, people realizes the importance of addressing andattending to these health issues. In the process of evolution from quadrupeds to bipeds, the forelimbs developedinto upper limbs. In quadrupeds they serve the purpose of weight bearing and attack. Inbipeds their responsibility are mainly to concentrate on sub serving fine functions,holding an object, attack & defence. Because of varied causes joints may get affected easily & leads to pain,inflammation and decrease in range of motion. It may prove to be severe and may evencripple. It may interfere with routine activities and difficulty in living a healthy, normaland peaceful life. Paradoxically, shoulder joint which privileged as the most mobile joint in thebody has its nemesis because of this very advantage. Its mobility makes it veryvulnerable to problems which ultimately affects on its movements. Compromisedshoulder movement due to pain, stiffness, or weakness can cause substantial disabilityand affect a person’s ability to carry out daily activities like eating, dressing, personalhygiene and work. The shoulder is notorious for undergoing stiffness, not only followingits own pathology, but also following the pathology situated centrifugally as in cervicalspondylosis and in pathology of sternoclavicular joints etc. It is important to make an accurate diagnosis of the cause for shoulder pain, sothat appropriate treatment can be directed. Some common causes includes : Rotator cufftendinopathy , Impingement , Subacromial bursitis , Rotator cuff tears , Frozen shoulder ,Osteo arthritis , Acromio clavicular disease , Infection, Labral or Bicepetal tendon tears,Shoulder instability and Dislocation. Among these the four most common causes ofshoulder pain and disability in primary care are rotator cuff disorders, glenohumeraldisorders, acromioclavicular joint disease, and referred pain form other structures. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 1
  14. 14. Introduction Self reported prevalence of shoulder pain is estimated to be between 16 % and 26%. It is the third most common cause of musculoskeletal consultation in primary care,and approximately 1% of adults consult a general practitioner with new shoulder painannually. 5% of consecutive new patients attend a shoulder clinic for the complaint ofGlenohumeral disorders like Frozen Shoulder. The estimated prevalence is 11-30% indiabetic patients and 2-10% in non-diabetics. It is more common in women between theages of 40-70. It occurs equally in the right and left shoulders, and it makes no differenceof dominant hand. About 10 % of people with this condition will get a frozen shoulder onthe other side within five years. The clinical manifestations like decreased range of movements, stiffness, andpainful shoulder characterize the illness apabahuka though sparse literature is availableabout the illness it is regarded as one among the 80 vata vikara. Morbidity of vata dosa isinvariable in the pathogenesis of apabahuka in general, and at times morbid kapha dosatakes the leading the major role targeting the structures like sira, snayu and kandaraaround the shoulder. In the realm of conventional medicine this illness is managed by analgesics,physiotherapy, oral corticosteroids, intra articular corticosteroid injections, capsulardistention, manipulation under anesthesia and arthroscopic capsular release. Among theseoral medications like analgesics, corticosteroids, etc. are less effective in relievingshoulder pain. Being a vatavyadhi, the general principles of treatment of vatavyadhi is alsoapplicable to apabahuka. Shodhana and Shamana treatment that include Antaparimarjanaas well as Bahiparimarjana Chikitsa form the sheet anchor of treatment of apabahuka.Nasya and Raktamoksana are the choice of shodhana procedures effective in apabahuka.Effective list of shamana procedures include Baktokthara Snehapana, Swedana LikeUpanaha, Abhyanga and various herbal or herbomineral compounds. Randomized clinical trials in regards to the effective management of apabahuka indifferent postgraduate and research institute can be simply numbered. Following is thedetails of the same. In a single blind clinical study patients suffering from Apabahuka were subjectedto Nasya Karma by Kaarpaasasyadi Taila for seven days. This study recorded satisfactory Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 2
  15. 15. Introductionimprovement in the range of shoulder movement; contrary to this remission of the painwas recorded to a lesser extent.180 In another clinical study the patients suffering from apabahuka were randomlycategorized into group A and group B. The patients in the group A received Mahamashataila Abhyanga and Eranda Patra Pinda Sweda for seven days followed by oralmedication with Prasarinyadi Kashaya in a dose 30 ml twice daily for 2 weeks. Thepatients in the group were subjected to Karpasasyadi Taila Nasya, Mahamasha TailaAbhyanga and Eranda Patra Pinda Sweda for seven days followed by oral medicationwith Prasarinyadi Kashaya, in doses of 30 ml twice daily for 2 weeks. The studyconcluded that Nasya Karma and Brimhana line of treatment is very effective in themanagement of apabahuka.181 Yet another single blind clinical study was carried out evaluating the therapeuticeffect of conventional medication as well as Rehabilitation therapy in 20 patientssuffering from Abhigatha janya Apabahuka. The patients were randomly grouped intocontrol and test group. The patients in the control group received oral medication ofdhanvantary kasaya. The patients in the test group were treated with Jambeera PindaSweda, Shoulder Exercises and oral medication with Dhanwantari Kashaya as well asRaasna Erandadi Kashaya. The treatment was found to be safe, and better response inrelation to range of shoulder movement as well as pain reduction was recorded in testgroup.182 This review of clinical study reveals meager effect in terms of relief in Pain andstiffness, increase in range of shoulder movement; also the therapies are less costeffective. Plenty of effective therapies of apabahuka are elaborated in the literatures ofayurveda, and very few of them are subjected to randomized clinical trials. Many moretherapies like Ruksha Sweda, Raktamoksana, Baktottara Snehapana etc are unearthed.Hence there is a definite need to work on different therapeutic modalities in an attempt toabate the agonies of apabahuka. Loss of Bahu Praspandana, Stambha and Sula at the shoulder joint are the cardinalmanifestation of apabahuka. Swedana treatment is proved to be efficacious in reliving thepainful conditions. Further, Upanaha Sweda is an ideal option to treat localized illnesslike apabahuka. On the other hand, the therapeutic efficacy of raasna and Guggulu as Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 3
  16. 16. IntroductionVata Shamana and Sula Harana is unequivocal. Thus, hypothetically the combination oflocal treatment of Upanaha Sweda and oral medication with Raasna Guggulu must be themost effective treatment in apabahuka. With this rationality the present work entitled “Aclinical study to evaluate the effect of Upanaha and Shamana Chikitsa in the managementof Apabahuka” is planned. This dissertation is a sincere effort to study the Nidana Pancaka as well asChikitsa of apabahuka with special reference to the therapeutic efficacy of KolakulatthadiUpanaha and Raasna Guggulu. This dissertation consists of: Conceptual Study. Clinical Study. Discussion. Conclusion and Summary. Conceptual study comprises of three chapters. The first chapter begins with thehistorical review of Apabahuka. There after the definition, etymological derivation,anatomical understanding of shoulder joint in ayurvedic and modern perspective, nidanapanchankas, modern perpetuation of the disease apabahuka, chikitsa and pathyapathya inthe second chapter. Description of Upanaha in general and the detail of drugs mentionedin Kolakulattadi choorna and Raasnadi Guggulu are mentioned in the third chapter ofdrug review. Clinical study starts with the materials and methods of the present work withcomplete description of the assessment criteria and descriptive statistical analysis of thesample taken for the study is methodically elaborated. Finally observations, results andtheir statistical analysis are presented in order along with tables and graphs. Discussion includes the critical conceptual analysis, observation and resultsobtained in the present study. The whole thesis work is summarized with conclusive points under the headingsof Conclusion and Summary. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 4
  17. 17. Objectives OBJECTIVES OF STUDY1. To make a comprehensive literary study on Apabahuka.2. To evaluate the combined effect of Upanaha by Kolakulattadi Choorna and Raasna Guggulu in the management of Apabahuka. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 5
  18. 18. Conceptual Study AYURVEDIC REVIEW The word Vatavyadhi is composed of two words Vata and Vyadhi. In general allthe three dosha are ubiquitously distributed in the whole body.1 Among the three primeimportance is being given to the vata dosa by virtue of its ability to independently moveanywhere and every where with in the body.2 Vata dosa is regarded as most active as wellas powerful. Few of the citations from the literature states - Vayu is life and vitality;Vayu is the supporter of all embodied beings; Vayu is all pervasive, and vayu is reputedas the controller of everything in the universe.3 All these portrayal of vata dosa justify itsprime role in the physiology. Vata dosa also takes the leading role in the pathogenesis ofany disease as the other two dosa, being stagnant rely upon the vata dosa for theirmobilization.4 Adding to the preeminence of the vata dosa, when morbid it can precipitate80 different variety of vata vyadhi.5 The term Vyadhi refers to abnormal state of an individual in which both the bodyand the mind are subjected to pain and misery. The term vatavyadhi is self explanatoryand refers to morbid state of vata dosa afflicting distinct dhatu leading to occurrence ofseveral sufferings; either in the whole body or a part of it. The unique illness, brought outby the morbid vata dosa through the specific process of Dosa Dushya Sammurchana iscalled as vata vyadhi.6 To be more precise the specific diseases caused due to theinvariable involvement of the morbid vata dosa is termed as Nanatmaja Vata Vyadhi.This distinctive nature of pathology of vata vyadhi7 differentiates it from the otherSamanyaja Vata Vyadhi. Based on the unique features of clinical presentations, theNanatmaja disease of Vata dosa may be classified under the following principal headings: Akarmyata Pradhana Vata Vyadhi – e.g. Pakshaghata , Ekanga Vata. Sula Pradhana Vata Vyadhi – e.g. Grudrasi. Shosha Pradhana Vata Vyadhi – e.g. Amsa Shosha , Bahu Shosha. Sthamba Pradhana Vata Vyadhi – e.g. Apabahuka. So to say the Apabahuka belongs to the category of Nanatmaja Vata Vyadhi andis characterized by Sula and Stabdhata of the shoulder joint. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 6
  19. 19. Historical review HISTORICAL REVIEW Vatavyadhi refers to the group of diseases characterized by invariableinvolvement of morbid vata dosa. The disease apabahuka is enlisted with in this group of80. Under the title historical review an attempt is made to explore the available literatureabout vatavyadhi as well as apabahuka from the period of veda till date.Veda Kala: A description about Tridhatu is available in Vedas referring to Vata – Pitta –Kapha. In Atharvaveda the term “Vatikrit” or “Vatikar” is used to indicate Vatavyadhi.8The detail description about the locations, properties and functions of Vata has beengiven, in Chandogya Upanishad. In Purana the terminology is same as used in Veda’s. In Visnu Purana there is adescription of Laghu, Shita and Ruksha’s properties as that of Vata Dosha. Importance isgiven to the Vayu as an emaciating factor of the body.Citation about the apabahuka or its clinical presentation is negative in literatures of vedicperiod.Samhita Kala: Detail description about Vata is explained mainly in Sutrasthana and ChikitsaSthana of Charaka Samhita.9, 10 Among the eighty different nanatmaja vata vyadhi listedin the sutrasthana the citation of bahu shosha11 is worth mentioning even though the wordapabahuka is missing. Further the treatment of Bahu Shirsa Gata vata is elaborated in thechikitsa sthana.12 The analysis of the literature reveals that the term apabahuka is coined insushruta samhita13 for the first time. In the nidana sthana the samprapti, and rupa ofapabahuka are elaborated. Rakta Mokshana and Rooksha Sweda are cited as treatment ofchoice for apabahuka.14 Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 7
  20. 20. Historical review In the Astanga Hridaya15 and Astanga sangraha16 the description of Vatavyadhi inthe Nidanasthana is identical. Both texts have elaborated the full account of the illnessApabahuka.17, 18 General descriptions about Vata vyadhi is explained by Kashyapa, 19Bela, 20 Haritha21 but none mentioned the name of apabahuka in their respective treatises.Medieval Period:The Vataja and Kaphaja Classification of apabahuka are mentioned by madhukosha.22Apabahuka is mentioned as one among the eighty types of vata nanatmaja vikaras byboth Sharangadhara and Bhavamishra. 23, 24Arunadutta and Dalhana, both have commented on samprapti, lakshana and treatment ofapabahuka in their works.25, 26Description of Apabahuka is also found in the books like Kalyanakaraka, 27 Vangasena,28 and Basavarajeeyam.29 Vangasena and other recent texts like Nidana Sara haveconsidered Vedhana as the major symptom of apabahuka.Different formulations are claimed to be effective in the management of Apabahuka ascited in Chakradatta30 and Baishajya ratnavali.31. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 8
  21. 21. Derivation and Definition DERIVATION AND DEFINITIONVyutpatthi & Nirukti:Apabahuka comprises of two words ‘apa’ and ‘bahuka’. 32The word ‘apa’ having the following meanings: Viyoga, Vikratou which means dysfunction or separation. Bhramsa, vairoopyam, tyaga, Apakarshitah, viyoga, viparyaya, vikriti – meaning displacement, disfigurement, abnormal separation. Bhramsa apa shabdasyat - means dislocation.The word ‘bahuka’ is the second part of the compound word apabahuka and implies thefollowing meaning: Bahu – meaning upper limb and is one among Shadanga.33 The Sanskrit literatures means the word apabahuka as bad, stiffness and musclespasm in the arm.34 The prefix ava is used as an alternative to apa of apabahuka. Theprefix ava has the similar meanings of apa also. In toto – the prefix ava or apa refers todeterioration or dysfunction.Paribhasha of Apabahuka: 35 Apabahuka is a disease characterized by morbid vata dosa localizing around theamsa pradesa and there by causing soshana of amsa bandha as well as akuncana of sira atthis site leads to bahupraspanda hara. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 9
  22. 22. Sandhi Shareera RACHANA SHAREERA The word sandhi means union of any two separate anatomical structures.36 In thepresent context the word sandhi refers to the asthi sandhi alone. There are 200 snadhi inthe body. 37, 38 These are surrounded by the sira and snayu which makes this sandhi morestable and aid in their functioning.39 Sandhi are responsible for all the movements thatinclude akunchana, prasarana, utkshepa and apakshepa.40 Sandhi is the normal abodeShleshaka Kapha which by way of lubrication eases the proper functioning of sandhi.41Defination of Sandhi: According to Vacaspatyam, the word sandhi is derived from the root ‘Dha’which when prefixed by sam and suffixed by ki gives rise to the word sandhi whichmeans the joint or union. This also means junction, combination and the connection.Classification of sandhi :42A wide description regarding the sandhi has been given by Sushrutha dalhana opines thatthe word Sandhi refers to Asthisandhi. The Classification of the Sandhi is as follows:Susrutha has mainly classified the sandhi into two.1. Cestavanta: This type of sandhi allows free mobility and is further subdivided into. a) Bahucesta: With free movements - present in extremities. b) Alpacesta: With comparatively less movement - present in prsta vamsa.2. Sthira: The immovable sandhi is known as Sthira sandhi.Based on the shape of the joints, it is classified into 8 types: 43 1. Kora sandhi: This is freely movable sandhi seen in Manibandha, Gulpha,kurpara, Janu. 2. Udukhala sandhi: These types of sandhi perform wide range of actions andare situated in kaksa and vanksana. This type of sandhi is also found in the teeth butwithout movements. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 10
  23. 23. Sandhi Shareera 3. Samudga: The Amsapitha, Guda, Bhaga and Nitamba sandhi constitutesamudga. This is partially movable sandhi. 4. Pratara sandhi: The joint formed by Asthi having symmetrical surface iscalled as pratara sandhi. This type of sandhi is found in Griva and prsthavamsa. It isslightly movable. 5. Tunna sevani sandhi: In this type of sandhi, two Asthi are connected witheach other by teeth like structures and is seen in sira kapala and kati kapala. 6. Vayasa tunda Sandhi: It resembles beak of a crow in shape. 7. Mandala sandhi: It is circular shaped sandhi made up of tarunasthi. Itencircles kantha nadi, Hrdaya, etc. 8. Sankhavarta: It has the shape of sankha and is present in srotra and srngataka. Shoulder joint is known as Kaksha sandhi or Amsa sandhi which comes undercatagory of Bahu Chesta sandhi and samudga sandhi. The kapha dosa present aslubrication with in the sandhi aids in the movements like prasarana, akunchan. Dryness ofthe kapha or decrease in the quantity of kapha leads to impaired range of movements. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 11
  24. 24. Sandhi ShareeraANATOMY OF SHOULDER JOINT: 44 Joints are the articulations or structural connecting arrangements between two ormore bones. Based on Structure and its function it is classified mainly into three types:1. Fibrous Joints: The articular surfaces of the bones forming the joints are connected by fibrous tissue.2. Cartilaginous Joints: The articulating bones are intervened by cartilage and this cartilage unites the bones.3. Synovial Joints: These joints have a wide range of movement.Characteristic Features of Synovial Joints:• It is surrounded by an articular capsule which consists of outer fibrous capsule and inner synovial membrane. This synovial membrane forms a cavity filled with synovial fluid.• Synovial membrane lines whole of interior of joint except the cartilage covered ends of articulating bones. It secretes a viscid glary fluid termed Synovial fluid or’ Synovia’ which act as lubricant and also provides nourishment of articular cartilage. It removes the particulate matter and transference to cells of deeper zone and also the absorption of cartilaginous debris formed as a result of wear and tear.SHOULDER JOINT: Plate No. I - pic.1, 2, 3 It is an articulation between humerus and scapula and also known as Gleno- Humeral joint. It is a Synovial type of Joint in which Ball and Socket of Polyaxial sub type. The articulation of humeral head with the glenoid cavity of Scapula forms the joint. The synovial membrane of the shoulder joint lines the inner surface of the fibrous capsule and protrudes through the opening in front of capsule to communicate with subscapsular bursa and sometimes with infraspinatus bursa behind the capsule. It invests the tendon of long head of Biceps as tubular sheath which is reflected back to transverse ligament and also to floor of inter tubercular sulcus. This sheath glides to Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 12
  25. 25. Sandhi Shareera and also with tendon of long head when abduction and adduction of shoulder takes places.Accessory Ligaments: • Coracohumeral ligament. • Transverse humeral ligament. • Glenohumeral ligaments.Muscles surrounding the joint: • Above – Tendon of supraspinatus. • Behind – Infraspinatus and Teres minor. • In front – Subscapularis.Relations of the Joint: • In front: Subscapularis, Coracobrachialis, short head of Biceps and Deltoid. • Behind: Infraspinatus, Teres minor and Deltoid. • Above: Coracoacromial arch, subacromial bursa, Supraspinatus and Deltoid. • Below: Long head of Triceps separated by Axillary nerve and posterior circumflex humeral vessels. • Within the Joint: Tendon of long head of Biceps.Arterial Supply of the Joint: • Anterior and posterior circumflex humeral artery. • Suprascapular artery. • Subscapular artery.Nerve Supply of the Joint: • Axillary nerve. • Musculocutaneous nerve. • Suprascapular nerve. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 13
  26. 26. Sandhi ShareeraJoints at Shoulder Region: 1. Acromioclavicular Joint. 2. Coracoclavicular Joint.Bursae related to the Joint: • Subacromial b/w Supraspinatus and coracoacromial arch and does not communicate with the shoulder joint. It forms a socket for the lateral rotation of humerus when overhead elevation of the arm occurs. • Subscapular b/w fibrous capsule and subscapularies muscle and communicates with the shoulder. • Other bursae do not communicate with the joint and related to surrounding structures.Movements of the Shoulder Joint: • Flexion and Extension. • Abduction and Adduction. • Medial and Lateral rotation. • Circumdiction.Stability of the Shoulder Joint: Bony configuration (shallow glenoid cavity) and lean loose and lax texture of thefibrous capsule make the joint less stable for the sake of mobility. Still some factors playan important role for maintaining stability: 1. Tension of upper part of fibrous capsule, coracohumeral ligament and supra- spinatus muscles- prevent downward displacement of humerus. 2. Glenoidal labrum – It deepens the glenoid cavity and, thereby, prevents skidding. 3. Musculotendinous cuff (formed by four muscles Subscapularis, Supraspinatus, Infraspinatus and Teres minor). 4. Coracoacromial arch and long head of Biceps: prevent upward displacement of head of humerus. 5. Teres major and long head of Triceps: play some role in supporting the lower weakest part during movement of abduction. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 14
  27. 27. Sandhi ShareeraTable No. 1 Muscles responsible for the movements of the Shoulder JointMuscles responsible for the movements of the Shoulder Joint 45Movements Muscles actingForward Deltoid ( anterior fibres )Flexion Pectoralis Major ( Clavicular fibres ) Coraco brachialis Biceps( When strong contraction requires)Extension Deltoid ( Posterior fibres ) ,Teres Major and Teres Minor Pectoralis Major ( Sternocoastal fibres) &Latissimus dorsii Long head of tricepsHorizontal Pectoralis majoradduction Deltoid ( anterior fibres )Horizontal Deltoid ( Posterior fibres)abduction Teres Major and Teres Minor InfraspinatusAbduction Deltoid, Supraspinatus and Infra spinatus Subscapularis , Teres minor and Long head of biceps.Adduction Pectoralis major, Latissimus dorsi, Teres major and SubscapularisInter / Medial Pectoralis major, Latissimus dorsi , Teres major and SubscapularisrotationLateral/ Infraspinatus , Deltoid posterior fibres and Teres minor.Externalrotation Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 15
  28. 28. Nidana NIDANA 46,47,48 The word Nidana is derived from the Sanskrit Dhatu ‘Ni’ which means todetermine. This word refers to etiology of the illness in particular. The first and theforemost line of treatment is to avoid etiological factors.49 Hence Nidana plays an utmostimportance in the perspective of the treatment. Nidana is classified into two types asSamanya Nidana and Vishesha Nidana. The Nidana are not uniform for all the diseases.While in some of the diseases both Samanya and Vishesha Nidana is explained while infew others Vishesha Nidana is mentioned. The description of Nidana is restricted toSamanya Nidana alone in regards to many other diseases. The specific Nidana of Apabahuka is not separately enlisted. The involvement ofVata is invariable in apabahuka and as it is a vataja nanatmaja vikara, the nidana ofVatavyadhi in general is also being considered as the nidana of Apabahuka. All thenidanas are subdivided into aharaja, viharaja, agantuja, manasika etc.Aharaja: The Nidana in the form of Aharaja or faulty diet is included under this groupand this can be divided into 8 subgroups as follows:i. Dravyataha: All the food articles responsible for Vata Prakopa have been includedunder this group.ii. Gunataha: The quality of food articles like Ruksha, Shita etc. that lead to thePrakopa of Vata have been included under this group.iii. Rasataha: Excessive use of certain rasa which leads to the prakopa of Vata has beenincluded in this group.iv. Karmataha: Vata prakopa can occur due to excessive use of Vishthambhi foodarticle and those are included under this heading.v. Viryataha: Shita Virya Yukta Ahara may cause the Prakopa of Vata.vi. Matrataha: Taking food in Alpamatra, Atimatra etc. comes under this heading. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 16
  29. 29. Nidanavii. Kalataha: The Vata Prakopa occurs at the end of ahara jeerna kala and in varsha rutuwhich is included here.viii. Mithyopayogatah: Violating the rules of ahara sevana can lead to vata prakopa.B) Viharaja: The Nidana in the form of Vihara or factors related to the habit andbehavior of the patient is considered here.Any of the following two can cause vataprakopa and leads to disease.(1) Mithyaprayogataha: The faulty habits or the improper use of Sharira that may lead tothe Prakopa of Vayu is included under this heading.(2) Atiyogataha: The excessive use of the Karmendriya can cause vata prakopa.C) Agantuja: Vata prakopa which occurs due to external factors like trauma, etc. isincluded under this heading.D) Manasika: The Manasika Nidana like Chinta, Bhaya, Shoka etc. are also responsiblefor Vata Prakopa.E) Anya Heuja: All the other Nidanas except above are included under this heading.Vishista Nidana: One of the Nidana that has been mentioned for the causation of the Vatavyadhi isMarmabhighata. Charaka and Sushrutha have identified 107 Marma in the body, whereSushrutha has elaborated all the types. While going through the Lakshana mentioned forthe Marmabhighata, it is said that the Amsa Marmabhighata, where the bahu lose itsfunction and becomes stiff which mimics the Rupa of the disease Apabahuka.50 Hence itcan be considered as one of the specific Nidana for this illness. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 17
  30. 30. Nidana The following are considered as the vishista nidana as these are directly or indirectlycause detrimental effect on amsapradesha.Abhighata: Any direct or indirect trauma that causes injury to the amsapradesha oramsamarma will change the structural integrity and can cause kriyahani of bahu.Vyayama: Those exercises which directly or indirectly influence the shoulder joint areto be considered here. Vyayama in excess or violent exercises related with bahuprovocates vata, producing shoshana and sankocha of the sira and ultimately causesdysfunction of the joint.Plavana: This if done in excess will be a cause of over exertion to the sandhi causingvataprakopa and then manifesting the disease apabahuka.Bharavahana: Carrying heavy loads over shoulder will cause deformity in the jointcapsule which further leads to disease.Balatwat Vigraha: Wrestling with a person who is stronger will cause aghata toamsapradesha and vataprakopa can takes place.Dhukka Shayya: An improper posture that gives more pressure over the amsasandhiwill disturb the muscular integrity and can vitiate vata. This leads to the disease. Other than the above mentioned Ashma or Kasta bhramana / Vikshepa / Chalana /Utkshepa / Atikaracapakarshana/ Atiprapidana etc. factors also causes vata prakopa andleads to sthana samshraya in amsa sandhi manifesting Apabahuka. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 18
  31. 31. NidanaNidana are classified in following three categories to explain the mechanism of the Vata 51, 52, 53Prakopana.1. Swanidanajanya like Ativyayama, Ati chesta, Ati Plavana, Abhigata, etc.2. Dhatukshayajanya like atiraktasravana, Vyadhijanya dhatu karshana etc.3. Margavaranajanya like obstruction for rasa , rakta marga sanchalana etc.All the above three pathologies lead to Prakopana of Vata and Vatavyadhi which willmanifest as following:1. Kevala Vata vyadhi.2. Samsargaja Vata vyadhi.3. Avarana Vata vyadhi.Apabahuka can present either as Kevala Vataja or Avaranssaja depending on thecausative factors. The samanya Vaata Vyadhi nidhana are as listed below in the table no.2.Table No. 2: Vatavyadhi NidanaCauses Ca Su A.S A.H B.PI Dravyatah (Substantial) - + - - -Aadhaki (Cajanus cajan)Bisa (Nelumbuo nucifera) - + + - -Chanaka (Cicer arietinum) - - + - -Chirbhata (Cuccumus melo) - - + - -Harenu (Pisum sativum) - + - - -Jaambava (Eugenia jambolena) - - + - -Kalaya (Lathyrus sativus) - + + - -Kalinga (Holarrhena antidysenterica) - - + - - Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 19
  32. 32. NidanaKariya (Cappaaris deciduas) - - + - -Koradusha (Paspalum scrobiculatum) - + - - -Masoora (Lens culinaris) - + - - -Mudga (Phaseolus mungo) - + - - -Nishpaava (Hygroryza aristata) - + - - -Neevara (Hygroryza aristata) - + - - -Saluka (Nelumbium speciosum) - - + - -Sushkasaaka (Dry vegetable) - + - - -Syaamaka (Setaria italica) - + - - -Tinduka (Diospyros tomentosa) - - + - -Trunadhaanya (Grassy grain) - - + - -Tumba (Lagenana valgaris) - - + - -Uddalaka (variety of Paspalum scrobiculatum) - + - - -Varaka (Carthamus tinctorius) - + - - -Viroodhaka (Germianated Seed) - - + - -II.Gunatah + + + + +Rukshaanna (ununctous diet)Laghvanna (light diet) - + + - -Gurva anna (heavy diet) - - + + -Seetaanna (cold diet) + - + - -III.Rasatah - + + + +Kashaayaanna (astringent taste)Katvanna (acidic taste) - + + + +Tiktaanna (Bitter taste) - + + + + Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 20
  33. 33. NidanaIV.Karmatah - - + - -Vishtambhi (constipative diet)V. Veeryatah - - + - -Seeta (cold)VI.Maatratah + + - - +Abhojana (fasting)Alpaasana (dieting) + - + + -Vishmaasana (Taking unequal food) - + - - -VII. Kaalatah - + - - -Adhyasana (eating before digestion of previousmeal)Jeernanta (After digestion) - + + + +Pramitasana (Taking food in improper time) - - + + +(B) Vihaaraja (Behaviour):1.Mithyayogatah - - + - -Asmabhramana (Whirling stone)Asmachalana (Shaking of stone) - - + - -Asmavikshepa (Throwing of stone) - - + - -Asmotkshepa (pulling down stone) - - + - -Balavat vigraha (wrestling ) - + + - -Damyagaja nigraha (subduing unteameable - - + - -elephant) cow and horseDivaasvapna (day sleep) + + - - -Dukhaasana (uncomfortable sitting) + - - - -Dukhasayya (uncomfortable sleeping) + - - - -Ghadhotsadana (strong rubbing) - - + - - Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 21
  34. 34. NidanaKashtabhramana (whirling of wood) - - + - -Kashtachalana (shaking of wood) - - + - -Kashta vikshepa (throwing of wood) - - + - -Kashtotkshepa (pulling down wood) - - + - -Lohabhramana (whirling of metal) - - + - -Lohachalana (shaking of metal) - - + - -Lohavikshepa (Throwing of metal) - - + - -Lohotkshepa (pulling down metal) - - + - -Paragatana (strike with others) - - + - -Shilabhtamana (Whirling of rock) - - + - -Shilachalan (Shaking of rock) - - + - -Shilavikshepa (Throwing of rock) - - + - -Shilotkshepa (Pulling down rock) - - + - -Bhaaraharana (Head loading) - + + - -Vegadharana (suppression of natural urges) + + + + +Vegodeerana (Forceful drive of natural urges) - - + + -Vishamopachara (Abnormal gestures) + - - - -2. Atiyogatah + - + - -Atigamana (excessive walking)Atihaasya (Loud laughing) - + + + -Atijrumbha (Loud yawning) - + - - -Atikharacapakarshana (Violent stretching of the - - + + -bow)Atilanghana (Leaping over ditch) + + + - -Atiplavana (Excessive bounding) + + - - -Atiprabhashana (Countinous talking) - - + + -Atipradhavana (Excessive running) + + - - - Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 22
  35. 35. NidanaAtiprajagarana (Excessive awakening) + + + + +Atiprapatana (Leaping from height) - + - - -Atiprapidana (Violent pressing blow) - + - - -Atipratarana (Excessive swimming) - + + - -Atiraktamokshana (Excssive Blood letting) - - - - +Atisrama (Over exertion) - - - - +AtiSthaana (Standing for a long period) - + - - -Ativyaayaama (Violent exercise) + + + + +Ativyavaaya (excessive sexual intercourse) + + + + +Atiadhyayana (excessive study) - + + - -Adyasana (sitting for a long period) - + - - -Atyuccabhaashana (speaking loudly) - - - + -Gajaticarya (excessive riding on elephant) - - + + -Kriyaatiyoga (excessive purification therapy) - - + + +Padaticarya (walking long distances) - + - - -Rathaaticarya (excessive riding on chariot) - + - - -Turangaticarya (excessive riding on horse) - + - - -(C) Aagantuja (External factors):Abhighaata (trauma) + - - - -Gaja, Ushtra, Ashvasighrayanapatamsana + - - - -(Falling from speedy, running elephant, cameland horse)(D) Manasika (Mental factors):Bhaya (fear) + - + + +Cinta (worry) + - + - - Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 23
  36. 36. NidanaKrodha (Anger) + - - - -Mada (Intoxication) - - - - +Soka (Grief) + - + + +Utkant’ha (Anxiety) - - + - -(E) Kalaja (Seasonal factors):Abhra (cloudy season) - + - - -Aparaahnna (evening) - + + + +Apararatra ( the end of the night) - - + + -Greeshma (summer season) - - + - -Pravaata (windy day) - + + - -Sisira (winter day) - - - - +Sheetakaala (early winter) - + - - +Varsha (rainy season) - + + - +(F) Anya Hetuja (Miscellaneous causes):Aama (undigested article) + - - - -AsRukshaya (loss of blood) + + + - -Dhatukshaya (loss of body elements) + - - - -Doshakshaya (depletion of Dosha) + - - - -Rogatikarshana (emaciation due to disease) + - - - -Gadakruta mamskshaya (wasting due to - - - - +disease) Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 24
  37. 37. NidanaEtiological factors that produce Shoulder Girdle Problems: 54 Because of varied causes, joints may get affected easily & leads to pain,inflammation and decrease in range of movements. It may prove to be severe and mayeven cripple. It may interfere with routine activities and difficulty in living a healthy,normal and peaceful life. Only some of the predisposing factors are explained in case ofshoulder disorders. But no definite cause can however be elicited. If the joint for longerperiods, due to any cause, is immobile may cause the shoulder problem. Usually Middleaged and elderly persons are more affected. Incidence of shoulder problems in Diabetesmellitus is more compare to the other diseases. Trauma to the shoulder or other parts ofthe upper extremity always leads to shoulder problems. Sometimes the surgeries aroundthe shoulder joint are also one of the causes for shoulder pain. Shoulder pain is an extremely common complaint, because of its varied causes, itis important to make an accurate diagnosis of the cause for pain, so that appropriatetreatment can be directed. some common causes includes : Rotator cuff tendinopathy ,Impingement , Subacromial bursitis , Rotator cuff tears , Frozen Shoulder , OsteoArthritis , Acromio clavicular disease , Infection and labral or bicepetal tendon tears,Shoulder Instability and Dislocation. Among these the four most common causes of shoulder pain and disability inprimary care are rotator cuff disorders, glenohumeral disorders, acromioclavicular jointdisease, and referred pain form other structures like in Hyperthyroidism , Chronicbronchitis , Emphysems , Cardiac problems. Some times intracranial pathologies likehemiplegia, cerebral hemorrhage will have a higher risk of producing shoulder problems. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 25
  38. 38. Samprapti SAMPRAPTI55 The whole pathophysiology that takes place in the body beginning from the HethuSevana upto the Vyadhi Utpatthi is known as Samprapti. Jati and Agati are its synonyms.Samanya Samprapti: 56 Etiological factors leads to the morbidity of vata dosa. This morbid vata dosa inturn fills the riktata of the srotas. This unique pathology may involve the whole body or apart of it, thus establishing as vata vyadhi. Here, the lack of normal qualities of srotas likesneha is referred by the name riktata. This is the samanya samprapti of vatavaydhi andholds good even for apabahuka. Indulgence of various etiological factors mentioned in the table no.1 leads to theaccumulation of the vata dosha in the amsapradesha and cause the shoshana of theamsabandhan or siraakunchana, which in turn leads to manifestation of kevala vatajaapabahuka.57 Further kshaya of the dhatu causes the prakopa of the vata and then leads tothe amsa shosha.58 This unique pathology is described as dhatukshayaja apabahuka.Some times due to Kaphakara nidana, the kapha gets aggravated in the sandhi whichimpedes the chala guna of the vata leading to the occurance of apabahuka. This distinctpathology is refered as kaphavruta vatajanya apabahuka.59Samprapti ghataka:Dosha: Sula and sosha at the shoulder joint in patients suffering from apabahuka indicatesthe morbidity of vyana vayu. This is true in case of dhatukshayaja and swanidanajaapabahuka Kapha Dosha plays a vital role in case of Margavarodhaja apabahuka. Thispathogenesis leads to the development of Kaphavruta Apabahuaka / Kaphaja apabahuk.Impairement of Bahupraspanda is one of the cardinal features in apabahuka and thisaffects Utkshepana, Apakshepana, Prasarana and Akunchana etc activities of the shoulderjoint. These are the activities that are attributed to Vyana Vayu.60 Hence it is evident that Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 26
  39. 39. Sampraptiout of five types of Vata, morbid Vyana Vayu is the primary cause of the disease inkevala and swanidanajanya apabahuka.Dushya:The amsa sandhi is the union of Asthi, Sira, Snayu and Mamsa. In Apabauka, sira,snayu, kandara get affected initially and then the asthi , mamsa dhatu. Mulasthana ofMamsa is Snayu and is an Upadhatu of Meda.61 Sira and Kandara are the upadhatu ofRakta Dhatu which are responsible for akunchana and prasarana. 62 Thus Meda and Raktadhatu are also involved in the apabahuka. As the prakopana of vata and avarana of vatainterfere with the rasa dhatu, it is also considered as the dushya in the initial or later stageof the disease apabhuka respectively in the form of amsa sosha. The concept of ashraya-ashrayee sambandha between asthi and vayu is evident in the long run of the disease.Thus shula and Atopa are also common in the later stage of the disease apabahuka.63Srotas: 64 The symptoms enlisted above to determine the Dhatu involvement are alsosuggestive of involvement of respective Srotas. Thus the involvement of Raktavaha,Mamsavaha, Medovaha as well as Asthivaha Srotas is contended in this disease andRasavaha Srotas is associated with Mamsa Shosha in the Chronic Stage of disease.Sroto dusti: Morbid vata dosa tend to localize in the amsa pradesha due obstruction in itscourse manifesting as apabahuka. This implies the sanga as the srotodusti in apablahuka. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 27
  40. 40. SampraptiUdbhava Sthana: 65 The invariable involvement of Vata Dosha in the pathogenesis of Apabahukareveals that the disease originates from the Pakvashaya in the kevala and dhatukshayajaapabahuka and Amashaya in the avaranaja type of apabahuka.Sancharasthana:Distribution of symptoms like pain in the Shoulder and restricted movements of theshoulder indicates the upper half of the body, Sira, kandara and Snayu of the Amsapradesha as the Samcara Sthana of the Vitiated vata dosha.Adhistana:The vitiated Vyana Vayu in the kevala vataja, dhatukshayaja apabahuka and Kapha in theavaranajanya apabahuka getting localized in the amsapradesha produces the pratyatmalakshanas like bahupraspandana hara etc. Hence amsapradesha is considered as theAdhishthana for this disease.Vyaktha:The pratyatma lakshana of the disease is bahupraspanda hara in bahu and amsa pradesha.Rogamarga:The involvement of rasa ,raktha, mamsa dhatu and sira, snayu , kandara , sandhi areevident to say the role of bahya and madhyama rogamargas in the disease apabahuka. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 28
  41. 41. SampraptiSamprapti Chart of Apabahuka Nidana Vaatakara Kaphakara Swanidana Dhatukshaya Kapha prakopa Vyadhikrutha Rooksha ahara vihara Adhistana in Amsa Pradesha Rasarakta kshya Ati vyayama vyavaya Abhigata Kaphavrutha vyaana in sandhi Vaata Prakopa Sira sankocha Apabahuka Sthana samshraya in Amsa Pradsha Shoshana of Shleshaka kapha Mamsa Sira Snaayu Kandara Asthi Bahupraspanda Mamsa kshaya Sira akunchana Asthidhatu kshaya hara Bahupraspanda With Sira With out Apabahuka Amsa shosha hara akunchan Sira akunchan Apabahuka Apabahuka Sandhigata vata Adhesive Wasting Tears//Ruptures O.A Sh.jt. with Capsulitis disorders Tendinopathy or without Sprains restricted Bursitis movements Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 29
  42. 42. Samprapti In modern parlance the symptomatology depends upon the cause as well as thepathology.66 Tears in the rotator cuff after trauma is the cause for the pain but differs inAcromioclavicular disease, bursitis, tendinopathy where inflammation is the cause for thepain in the shoulder. The pathology in referred pain is differing according to the cause.The cause for the glenohumeral disorders are either due to degenerative changes or lackof synovial fluid, adhesions etc. The etiology of frozen shoulder remains unclear. The disease process particularlyaffects the anterosuperior joint capsule and the coracohumeral ligament. Arthroscopyshows a small joint with loss of the axillary fold and tight anterior capsule, mild ormoderate synovitis and no adhesions. Disagreement prevails about whether theunderlying pathological process is an inflammatory condition, a fibrosing condition, oreven an algoneurodystrophic process. Evidence shows a synovial inflammation with subsequent reactive capsularfibrosis. A dense matrix of type I and type III collagen is laid down by fibroblasts andmyofibroblasts in the joint capsule. Subsequently, this tissue contracts. Increased growth factors, cytokines and expression of matrix metalloproteinasesin capsular biopsy specimens obtained from patients with primary and secondary frozenshoulder indicate that these are involved in the inflammatory and fibrotic cascades seenin frozen shoulder. Cytokines and growth factors are involved in the initiation andtermination of repair processes in musculoskeletal tissues through regulating fibroblasts,and the remodeling process is controlled by matrix metalloproteinases and theirinhibitors. An association between frozen shoulder and Dupuytren’s disease has beenidentified, and this may be related to matrix metalloproteinase inhibitors. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 30
  43. 43. Poorva roopa 67 POORVA ROOPA Poorva rupa are indicators of impending diseases. They occur prior to completemanifestation of disease to suggest the forthcoming illness. In parlance with theShadkriyakala this stage denotes the Sthanasamshraya Avastha. No specific Poorva rupa of Vatavyadhi has been given in literatures of ayurveda,but it is clearly mentioned that the Avyakta Laksana are the Poorva rupa of Vatavyadhi.68While commenting upon this word, Chakrapani mentions that Avyakta means Alpa orIshat Vyakta.69 Vijayarakshita gives a clear meaning of the term Avyakta, as thesymptoms that are not clearly exhibited.70 So in Apabahuka also Poorva rupa can betaken as minor symptoms of disease produced before the actual manifestation of thisdisease like vague shoulder pain, mild stiffness in the upper extremities, mild restrictedmovements and similar other symptoms of Apabahuka in its minimal severity may beconsidered as Poorva rupa. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 31
  44. 44. Roopa ROOPA During the stage of fifth Kriyakala or the Vyakta Avastha of the Shad kriyakala,characteristic signs and symptoms of the disease gets manifest and can be recognizedclearly. This unique stage is known as the Roopa. Sushruta narrating about the disease Apabahuka mentions that the vitiated Vatacauses the shoshana of amsa bandhana and sankocha of Sira & Kandara of the Amsapradesha leads to sthamba & Bahu Praspandana hara.71 Other scholars like Vagbhata,72Madhavakara,73 Bhavaprakasha,74 Kalyanakaraka,75 have also shared the same opinions.Recent texts like Vangasena76 & Nidana Sara mentioned about savedana or Vyadha as apredominant lakshana of Apabahuka. Dalhana opines that the Amsa means Bahu Shira, Amsa pradesha means aroundthe bahu shira, and Amsa bandanam means the Shleshaka Kapha which resides in thejoints.77 Nyaya Chandrika quoted that Vayu in this context means Dhatu kshayajanya vayuwhich further causes the shoshana of amsabandana & Sira, Snayu of the amsa pradesha isconsidered as amsabandana.78Madhukosha mentioned apabahuka as of two types: Vataja and Kaphaja.79Considering all the above lakshanas, apabahuka can be categorized as a sthanika vikararather than sarvadaihika vikara and its cardinal features are as below: 1. Bahupraspandihara. 2. Amsabandhana Shosha. 3. Sira Akunchana / Sthamba. 4. Shoola. The word Bahupraspandahara has three terms: Bahu, Praspandana & Hara where theword bahu having different meanings like urdhva shaka i.e. whole upper limb, shoulder80and also only arm. The word Praspandana means chalana or movement which is Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 32
  45. 45. Roopaconsidered as samanya karma of Vyana vata.81 Dalhana comments that praspandanameans chesta or movement and chesta to akunchana, prasaranadi karma.82 This karma ismaintained by vyanavata in the limbs.83 The word Hara means impaired / loss / difficult.Thus in the present context Bahupraspandahara may be taken up as difficulty in themovement or impaired or loss of movement of upper limb and the function of the sandhilike the Utkshepana, Prasarana, and Akuncana will be affected in Apabahuka. The word Amsa is having different meanings like Skanda, 84 Marma85 & Bahushira.86The word amsabandhana considered as amsagatashleshma87 or sira present around theamsapradesha. The shoshana of these considered as amsabandhana shosa88 which is amajor lakshana of apabahuka. Sira are the upadhatu of raktha dhatu and forms Snayu by combining with snehamsaof medas. These are also responsible for the akunchana and prasarana of the sandhi. Theword akunchana means sankocha.89 So sankochana of the siras around the amsa sandhileads to bahupraspandahara. The word sthamba means nishkriya90 or nischala , sankocha which is the main featureof apabahuka. Sandhi is considered as the junction between the asthi or the junction of sira, snayu,mamsa91 with or without asthi. Sandhi is considered as the sthana of shleshaka kapha.The prakopana of the Vayu get located in the amsa pradesha causing shoshana of thekapha92 and leads to bahupraspandahara. Due to ati nidana sevana it enters either in snayuor asthi and causes shoola and sankocha. If neglected it leads to atopa in furtherprogression of the disease due to asthikshaya due to Ashraya-Ashrayee siddanta betweenvata and asthi. To sum up, due to the specific Nidana there will be vitiation of Vyana Vayu. ThisVitiated Vyana Vayu originating from the Pakvashaya circulates in the upper extremitiesand gets accumulated in the Amsa Sandhi & Bahu. Here the Vyana Vayu afflicts the Sira,Kandara, Snayu, Rakta, Mamsa, Meda and Asthi Dhatu involving the respective Srotasand produces the Shoola in the Amsa & Bahu Pradesha with bahupraspandahara. In Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 33
  46. 46. Roopaaddition to this, in later stage of the disease involvement of Rasa dhatu leads to MamsaShoshana around the Amsa Pradesha. Compromised shoulder movement due to pain, stiffness, or weakness can causesubstantial disability and affect a person’s ability to carry out daily activities like eating,dressing, personal hygiene and other works. The four most common causes of shoulder pain and disability in primary care arerotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease, andreferred pain.93, 94Rotator cuff disorders: It includes rotator cuff tendinoathy, impingement, subacromial bursitis,rotatorcuff tears. Plate no I pic.4 The incidence of age is between 35-75 years. Rotator cuff tendinopathy is the most common cause of shoulder pain. Anoccupational history may reveal heavy lifting or repetitive movements, especially aboveshoulder level. Although related to activity. It often occurs in the non-dominant arm andin non-manual workers. Evidence suggests genetic susceptibility in some families.Wasting may be present on examination; active and resisted movements are painful andmay be partially restricted, whereas passive movements are full, albeit painful. Althougha painful arc is neither specific nor sensitive as a clinical sign, its presence reinforces thediagnosis of a rotator cuff disorder. A rotator cuff tear is usually strongly indicated by the history: traumatic in youngpeople and atraumatic in elderly people related to attrition from bony spurs on theundersurface of the acromion or intrinsic degeneration of the cuff. Partial tears may bedifficult to differentiate from rotator cuff tendinopathy on examination; weakness inresisted movement may occur in either condition. Several studies have suggested that nocorrelation exist b/w symptoms and loss of function in the presence of full thicknesssupraspinatus tears that tears of the lower rotator cuff may lead to inability to rotatebeyond 20 º and that partial and full thickness tears are commonly found during imagingof asymptomatic people. The “drop arm test” may be used to detect a larger or completetear. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 34
  47. 47. Roopa1. Glenohumeral disorders : It includes Frozen Shoulder or Adhesive Capsulitis and Osteoarthritis. Plate No.I Pic.No.6 The incidence of age in former is 40-65yrs in later ≥ 60yrs.These two are often preceded by a history of non-adhesive capsulitis symptoms, are characterized by deep joint pain, and restrict activities such as putting on a jacket due to impaired external rotation. Adhesive Capsulitis is more common in people with diabetes and may also occur after prolonged immobilization. Plate No. I Pic.No.5 The term “frozenshoulder” was first introduced by Codman in 1934. The three hallmarks of this disease are insidious shoulder stiffness, severe global pain even at night and near complete loss of passive and active external and internal rotation of the shoulder joint. In 1872, the same condition had already been labeled as “peri-arthritis” by Duplay. In 1945, Naviesar coied the term Adhesive Capsulitis. Although still in use, this more recent term is unfortunate since, although a frozen shoulder is associated with synovitis and capsule contracture, it is not associated with capsular adhesions.95 It present usually in the sixth decade of life, and onset before the age of 40 is very uncommon. The peak age is 56, and the condition occurs slightly more often in women than men. In 6-17 % of patients, the other shoulder becomes affected, usually within five years, and after the first has resolved. The non-dominant shoulder is slightly more likely to be affected. A patient with frozen shoulder traditionally progresses through three overlapping phases. Painful freezing phase: The duration of this phase continues up to 2-6 months. Pain and Stiffness around the shoulder with no history of injury. A nagging constant pain is worse at night and increases by sleeping towards the affected side. This phase shows little response to NSAID’s. Adhesive Phase: It occurs at 4-12 months.The pain gradually subsides but stiffness remains. Pain is apparent only at the extremes of movement. Gross reduction of glenohumeral movements, with near total obliteration of external rotation. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 35
  48. 48. RoopaResolution Phase: Takes 12-42 months. Follows the adhesive phase withspontaneous improvement in the range of movement. Mean duration fromonset offrozen shoulder to the greatest resolution is over 30 months. When examining any joint, it is useful to apply the well known axiom of the lateAlan Apley, a popular orthopaedic speaker and teacher: “Look,Feel,Move.” On inspection, the arm is held by the side in adduction and internal rotation, Milddisuse atrophy of the deltoid and supraspinatus may be present. On Palpation, there is diffuse tenderness over the glenohumeral joint, and thisextends to the trapezius and interscapular area owing to attempted splinting of thepainful shoulder. On Moving the joint in true frozen shoulder there is almost complete loss ofexternal rotation.This is the pathognomonic sign of a frozen shoulder. Confirmingthat external rotation is impossible with active and passive movementsis important.For example, if external rotation was easily possible with the help of he doctor, wewould consider the diagnosis of a large rotator cuff tear, which would requirecompletely different management. In frozen shoulder, all other movements of thejoint are reduced, and if movement occurs this usually come from the thoracoscapularjoint.Secondary Frozen Shoulder: Frozen shoulder can be a primary or idiopathic problem or it may be associatedwith another systemic illness. By far the most common association of a secondaryfrozen shoulder is diabetes mellitus and incidence rate reported to be 10-36% whichis similar in type 1 type 2. Unfortunately, frozen shoulder in diabetes is often moresevere and is more resistant to treatment. Much more rarely, secondary frozen shoulder may be associated with conditionssuch as Dupuytren’s disease in the hand, because of the contracting shoulder tissueitself respresents a form of fibromatiosis. Hyperthyroidism, Hypothyroidism andhypoadrenalism also associated with frozen shoulder. Additional associations include Parkinson’s disease, Cardiac disease, pulmonarydisease and Stroke. Although the pathological condition here may be different from Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 36
  49. 49. Roopa idiopathic frozen shoulder. Clearly, in the case of stroke, shoulder stiffness may be simply the result of muscle spasticity in the shoulder region. Frozen shoulder has also been reported subsequent to non-shoulder surgical procedures, such as cardiac surgery, Cardiac Catheterization through the brachial artery, neurosurgery, and radical neck dissection.Laboratory investigations & Radiology in frozen shoulder: There are few specific laboratory tests or radiological markers for frozen shoulder,and the diagnosis is essentially clinical. Immunological studies such as Human LeucocyteAntigen B27, C reactive protein and Erythrocyte Sedimentation Rate are all normal andwould be measured only to exclude other conditions. When plain radiographs of thefrozen shoulder are taken they may well be reported a normal, although they may showperiarticular osteopenia as a result of disuse. Contrast technetium-99m diphosphonate bone scan shows an increased uptake on theaffected side in compared with the opposite side or in normal shoulder. Arthrography shows characteristic finding of limitation of capacity of the shoulderjoint about 5-10 ml compared with 25-30ml in the normal joint and a small or non-existent dependent axillary fold. Magnetic resonance imaging may show a slight thickening in the joint capsule andthe coracohumeral ligament.2. Acromioclavicular disease : Plate No.I Pic.No.7 It is usually seen in between teenage to 50 yrs. It usually secondary to trauma orosteoarthritis; dramatic joint dislocation can occur after injury. Pain, tenderness andoccasionally swelling are localized to this joint and there is restriction of passive,horizontal adduction i.e. flexion of the shoulder, with the elbow extended, across thebody. Acromioclavicular osteoarthritis may also cause subacromial impingement.3. Referred Pain : Referred Pain is commonly seen in many disorders like neck pain, myocardialischemia, referred diaphragmatic pain, Polymyalgia rheumatica, Malignancy of apicallungs etc. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 37
  50. 50. Upashayaanupashaya UPASHAYA and ANUPASHAYA Upashaya is an important diagnostic tool especially when all other methods fail todiagnose the disease. Upashaya is rightly called as exploratory therapy. Administration ofthe medicines when produces a negative effect or aggravates the illness is known asAnupashaya.96 The abhyanga on the shoulder may cause subsidence of the symptoms orotherwise. If the symptoms subside that indicates the kevala vataja apabahuka. Contraryto this if the symptoms aggravate on application of oil it is indicative kaphavarana janyaapabahuka.UPADRAVA: During the chronic course the apabahuka it may lead to the atrophy musclesaround the shoulder joint and is referred as amsashosha. 97 98Arista Lakshana: Appearance of complications like Shuna, Suptatvaca, Bhagna, Kampa, andAdhmana is indicative of fatal termination in patients suffering from vata vyadhi ingeneral. This aristha laksana seems to be less relevant in so far the apabahuka isconcerned. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 38
  51. 51. Saapeksha Nidana SAAPEKSHA NIDANA Diagnosis can successfully be made by thoroughly observing the patient forclinical manifestations of the disease and analyzing the symptoms to determine thevitiation of Dosha, involvement of Dhatu, affliction of Srotas, as well as other events ofSamprapti. Diagnosis of Apabahuka can be ascertained easily by typical clinicalpresentation of loss of Bahupraspanda with shoola and sthamba. These cardinalmanifestations reveal the vitiation of Vata and at times the Kapha Dosha. ThoughApabahuka is characterized by restricted movements of the shoulder joint, stiffness andpain, it may be a difficult task to differentiate it with the similar conditions likeAmsashosha, Vishwachi and Ekanga Vata. Even then the differentiation between these disorders can be made easily byanalyzing the site of the disease, course of pain, character of pain, severity, associatedphenomena and functional disability in patients. Vishwachi closely resembles with Apabahuka. The illness may be distinguishedby the typical presentation of radiating pain starting from upper arm to forearm and palm.The pain is also sharp, severe, lightning and intermittent. It is distributed from the back ofthe neck to fingers. Contrary to this the pain in apabahuka does not radiate. The pain ismore or less constant and dull aching in character and is restricted to the amsa pradesha. Amsa Shosha is next to vishwaci and can be differentiated by the presence ofmamsa kshaya or shosha in amsa pradesha. Pain is not the diagnostic criteria in amsashosha but mandatory in Apabahuka and vishwachi.99 Ekanga Vata characterized by weakness in the affected upper limb and thevoluntary activity of the affected part is impaired or lost.100 This may be even associatedwith pain and stiffness. Impairment of voluntary activity differenctiates ekangavata fromthe other conditions that include visvaci, amsa shosha and apabahuka. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 39
  52. 52. Saapeksha NidanaTable No. 3: Differential diagnosis of Shoulder disorders Differential diagnosis of Shoulder disorders :101 Rotator cuff Frozen Cervical Spondylosis lesion ShoulderHistory 30 – 50 years > 40 years > 50 years Inc.pain after Insidious onset Acute or chronic eccentric load Func.restrictionsObservation Nr. Bone & Soft Nr. Bone & Soft With min. Cervical & Spine tissues outlines. tissues outlines move. or torticollis.Palpation Tender at the site Capsule strech Tenderness over appropriate of rotator cuff causes painful vertebrae or fascet.Active Move. Restricted Abd. & Restricted ROM Limited ROM with Pain. Rotation.Crepitus shoulder hiking may be present.Passive Move. Pain if Limited ROM of Limited ROM and symptoms impingement all. Predominant may be eccerbated. occurs. with external rot.Resisted Pain & Weakness Normal when Nr. Except if nerve rootIsometric on abd. and lat. arm by side compressed myotome mayMove rotation. be effected.Special Tests Drop arm +ve None Spurlings test +ve Distraction Empty cantest +ve test +ve Sh.Abd.Test +veSens. Funct. Not affected Not affected Dermatomes may affectedReflexes Not affected Not affected AffectedDiagnostic Radiography - Radiograph -ve Radiography showsImaging acromial spurring Arthroscopy - narrowing of space and and MRI. dic. Capsularsize presence of osteophytes Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 40
  53. 53. Saadhyaasadhya SADHYA ASADHYA It is essential to know the Sadhyasadhyata of a disease before the starting oftreatment. Caraka says, “A physician who can distinguish between curable and incurablediseases and initiate treatment in time with the full knowledge about the various aspectsof the therapeutics can certainly accomplish his/her object of curing the disease.102 Sushruta considered the Vatavyadhi as Mahagada and Vagbhata as Maharoga.Most of the Acharya’s agreed that Vatavyadhi’s are difficult to cure.103 Also, it is saidthat if patient is having balamamsakshaya and with complications then the patient shouldnot be treated, as it is asadhya for chikitsa.104 Based on the type of the vata roga, sushrutaand madhavakara says that samsargaja vata roga is sadhya, Kevala vataja roga iskrichrasadhya, and Dhatukshayaja vataja vikara is asadhya.105 Based on the duration,charaka says that all the vatavyadhi’s after lapse of one year becomes Krichrasdhya orAsadhya.106 Based on the sthana, if the disease is of sandhi and marma adhistana, then itis considered as yapya.107 The specific prognosis has not been mentioned for Apabahuka. Therefore thegeneral prognosis for Vatavyadhi may be taken as the prognosis for Apabahuka. ThusApabahuka in the initial stage will become sadhya and Krichrasadhya or Asadhya aftercertain time or period. Apabahuka with Balamamsa Shosha may or may not be curedeven after careful treatment. But if this condition occurs in strong person, of recent originand without any associated diseases, then it is curable. Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 41
  54. 54. Chikitsa CHIKITSA As the pathology involves multiple factors, the effective treatment of Apabahukacannot be unified. Vitiated Vata that originates from the Pakvashaya afflicts the Sira,Kandara initially and Asthi and Mamsa dhatu in later stage of the disease. Hence theprocedures should be mainly aimed at the rectification of the imbalance of the VataDosha in the Kevala Vataja, datukshayaja apabahuka and kapha dosha in avaranajanyaapabahuka. The treatment is classified mainly into two types viz: santarpana andapatarpana.108 In Apabahuka either procedure are indicated based on the cause of thedisease. Raktamokshana is the choice of treatment but contraindicated in 109dhatukshayajanya apabahuka. As a rule, when all the other treatment modalities of vatavyadhi fails to cure the disease then Raktamokshana should be performed as a last resortexcept in dhatukshayajanya apabahuka.110 Gayadasa considered sandhi as a kapha sthanaand advised the rooksha chikitsa in the form of rooksha nasya and sweda..This type ofapatarpana treatment is helpful only in avaranajanya apabahuka. In kevala vataja andDhatukshayaja apabahuka, the samanya Vataja chikitsa like snehana, Swedana,Abhyanga, Basti, etc. are the choice of treatment.111 The details of these procedures areas follows:1. Snehana: Snehana therapy is used as Bahya and Abhyamtara. In case of kevala andDhatukshayaja Apabahuka, bahya Snehana may be performed in the form Abhyanga,Parisheka etc. Brimhana sneha internally can also be given as abhyantara sneha.112 Thisprocedure can facilitates remission of the apabahuka.2. Swedana: The cardinal symptom of Apabahuka is Stambha in the Bahu and Shulaaround the amsapradesha. The therapeutic effect of Svedana like Sthambhaghna,Gauravaghna and Shitaghna helps to counteract the pratyatma lakshanas of apabahuka.113Ekanga sweda like Upanaha, Pinda, etc. are beneficial in case of apabahuka.3. Virecana: Mrudu Virecana is advised in Vatavyadhi114 and also in Apabahuka. It is tobe performed in the form of anuloma which may not lead to the Riktata of the Dept. of Kayachikitsa, S.D.M.C.A. Udupi. 42