A A M J Anveshana Ayurveda Medical Journal

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A A M J Anveshana Ayurveda Medical Journal www.aamj.in ISSN: 2395-4159 Review Article Conceptual study of Aṁsa Marma w.s.r. to Avabāhuka - Frozen Shoulder and its management by Agnikarma Milind B.

1 A A M J Anveshana Ayurveda Medical Journal ISSN: Review Article Conceptual study of Aṁsa Marma w.s.r. to Avabāhuka - Frozen Shoulder and its management by Agnikarma Milind B. Nikumbh 1 Prāṇali Umakant Mangrule 2 Manisha K. Dawre 3 Sanjay T. Rathod 4 Kanchan P. Balpande 5 A b s t r a c t Ayurveda literally means traditional science of life. It believes in complete normal state of health. Acharya Sushruta defined Marmas as the vital points of body which have various fatal signs and symptoms on traumatic injury. These points should be protected from injury. There are 107 marmas on the human body surface. Firm union of Māṁsa, Sirā, Snāyu, Asthi and Sañdhi are called as Marma, which naturally and specifically form the seat of life. Knowledge of Marmas important during surgery. Aṁsa Marma is explained as Snāyu Marma and it is a type of Vaikalyakara Marma. Aṁsa Marma lies in between root of the arm and neck and joins the Aṁsapīṭha and Skañda together. An injury to Aṁsa Marma produces Stabdabāhutā i.e. stiffness in the upper extremity. Injury to the muscles and ligaments will produce deformity. In classical text of Ayurveda, it is co-related with Avabāhuka i.e. Frozen shoulder. In this condition Vāta is located in shoulder region, once vitiated, dries up the ligament of shoulder, constrict the Sirā present at shoulder joint and causes Avabāhuka. Now the available treatment in modern science is painkillers, corticosteroids, shoulder exercises etc. but it is expensive and chances of recurrence is inevitable. In Ayurveda various Para surgical procedures are mentioned for Vāta and Kapharoga, in which Agnikarma is one of them. It is advised in various musculoskeletal disorders. The properties of Agnikarama are Sūkṣma, Laghu, Tīkṣṇa and Uṣṇaguṇa, it acts on Vāta and Kapha Doṣa and reduces tenderness and stiffness. Keywords- Marma, Aṁsa Marma, Avabāhuka, Frozen shoulder, Agnikarma. 1 Professor & Head, 2 & 5 PG Scholar, 3 Associate Professor, 4 Assistant Professor, Department of Rachana Sharir, Government Ayurved College, Osmanabad, Maharashtra, CORRESPONDING AUTHOR Dr. Milind B. Nikumbh Professor & Head, Department of Rachana Sharir, Government Ayurved College, Osmanabad, Maharashtra, (India). drnikumbh@gmail.com sue1/aamj_1187_1191.pdf AAMJ / Vol. 3 / Issue 1 / January February 2017

INTRODUCTION The word Marma means vulnerable point, weak or sensitive part of body, vital structures in human body [i]. The total number of Marmas described in samhitas are 107 in number [ii].

2 INTRODUCTION The word Marma means vulnerable point, weak or sensitive part of body, vital structures in human body [i]. The total number of Marmas described in samhitas are 107 in number [ii]. Marmas are situated in various regions of body. If any injury to Marma points that leads to deformity of the structures produces the severe pain, loss of movements and sometimes death occurs. [iii] Every Marma holds its own clinical importance and significant scientific values. The meeting point of Māṁsa, Sirā, Snāyu, Asthi, Sañdhi and Prāṇa are called as Marma [iv]. Pṟuṣṭha marma(vital points on the back) are 14 in number, Aṁsa marma is one of them. Aṁsa Marma is situated in between neck and arms on the trapezius muscle. Injury to Aṁsa marma causes Stabdhabāhuta i.e Avabāhuka [v]. In this the rupture of ligaments and muscles of shoulder joint leads to disability of Aṁsasañdhi (Shoulder joint) and Bāhu(Arm). In Avabāhuka Vātadoṣa increases and constricts the Sirā and ligament present at shoulder joint and there is wasting of the shoulder i.e Aṁsaśōṣa [vi] (atrophy of shoulder joint). The present day world is full of stress and strain, this has leads to many diseases which through do not kill a person but hampers the day to day activities. The symptoms like Śūla (pain) during movements, restricted movements. In modern science it is called as Frozen Shoulder (Adhesive capsulitis). [vii] In this disorder there is stiffness, pain in shoulder, shoulder movements become difficult and painful. In modern science this pain and inflammation can be controlled by analgesics and NSAIDS. It causes various side effects and high economical cost. In Ayurveda various parasurgical procedures are mentioned for Avabāhuka, in which Agnikarma(Cauterization) is one of them. Agnikarma has been designed to relieve various muscular joint disorder. It is highly potential procedure then the Bheshaja(medicines) Shastra(Surgery) and Kṣārakarma [viii] (caustic alkali substances). The properties of Agnikarma are Sūkṣma(finest), Laghu(Light), Tīkṣṇa (sharp)and Uṣṇa(hot) guṇa [viii]. It affects Kapha and Vāta Doṣa and reduces pain and tenderness in shoulder region. [viii] It helps to remove Strotosañga and Āvaraṇa by these Guṇas. Due to this increased metabolism which normalize the blood circulation, thus resulting in reduction in pain intensity, rise in temperature induces relaxation of muscles and hence muscle spasm and pain get reduced. Hence this study is aimed to analyze the anatomical structures of Aṁsa Marma and its Vidhalakṣaṇa(Injury effect) and role of Aagnikarma in Avabāhuka. AIMS & OBJECTIVES Conceptual study of Aṁsa Marma w.s.r to Avabāhuka (Frozen shoulder) and its management by Agnikarma. Objectives- 1) To study the anatomical position of Aṁsa Marma. 2) To study the underlying structures of Aṁsa Marma. 3) To study the Stabdabāhutā (Avabāhuka) on modern parameter. 4) To study how Agnikarma effects on Avabāhuka. MATERIALS & METHODS Material 1) Ayurvedic literature related to Aṁsa Marma studied from Brihat-trayee. 2) Modern literature related to shoulder region. 3) Modern literature related to frozen shoulder. Methodology: Literary study Aṁsa Marma It is situated between the root of the arm on one side and neck on other side [ix]. This ties the shoulder and Aṁsa pīṭha together. Formed by union of Aṁsa Pīṭha (glenoid cavity) and the Skañda (acromioclavicular joint). Name Number 02 Site Type (According to Rachana) Type (According to Aghataja Pariṇāma) Type (According to Parimāṇa) Aṁsa Marma Between neck and arm Snāyu Vaikalyakara ½ Añgula Structures related to Aṁsamarma [xiv,xvi] 1 Māṁsa(Muscles) 2 3 Sirā( Blood vessels) Snāyu (Ligaments) Pectoralis major,lattisimusdorsi, Deltoid, Bicep brachii, Coracobrachialis, Teres major and minor, Supra and infra spinatus, Subscapularis. Anterior and posterior circumflex humoral artery, Subscapular artery, Internal thoracic artery, Thoraco acromial artery. Capsular ligament, Interclavicular ligament, Coracoclavicular ligament, Glenoidal AAMJ / Vol. 3 / Issue 1 / January February

3 4 Asthi(Bones) 5 Sañdhi(Joints) 6 Bursa 7 Nerves Avabāhuka- labrum, Coracohumoral ligament. Humerus, Clavicle and Scapula Sternoclavicular, Acromioclavicular joint. Subacromial bursa, Subscapularis bursa, Infraspinatus bursa Axillary nerve, Musculocutaneous nerve, Suprascapular nerve, Nerve to subclavius. the four tendons which form expansion and blend with the capsule of the shoulder joint. This is known as Rotator cuff [vii]. The tendon of the supraspinatus superiorly, tendon of the infraspinatus and teres minor posteriorly and tendon of the subscapularis anteriorly take part in rotator cuff. [vii] When injury to this cuff leads to frozen shoulder. Causes- 1) Injury to vital parts of body. 2) Activities like weight lifting, swimming, fall on outstretched hand. 3) Improper posture. 4) Due to shoulder injury, surgery, diabetes, rotator cuff injury. Avabāhuka is a disease characterized by morbid Vāta Doṣa localizing around the Aṁsa Pradēśa (Shoulder region) and thereby causing Śōṣaṇa (Atropy) of Aṁsa Bandha as well as Akunchana of Sirā at this site leads to Bāhu praspandana. [x] In avabāhuka Ślēṣaka Kapha Śōṣa occurs and Śūla(Pain) during movements and restricted movements [xi]. The structure related to shoulder region are the most exposed area to common injuries. The activities like weight lifting, swimming, cricket playing, and fall on out stretched arm, causes the rupture of ligaments and muscles of shoulder joint leads to disability of Aṁsa Sañdhi(Shoulder joint) and Bāhu(Hand).There is symptoms like Aṁsa Śōṣa [xii]. Aṁsaśōṣa(wasting of the shoulder) can be considered as preliminary stage of this disease. The stiffness to the joint is contributed by kaphadoṣa. [xiii] Saṁprāprti Ghaṭaka of Avabāhuka Doṣa Dūṣya Srotas Stroto Duṣṭi Roga Mārga Udbhava Sthāna Vyakta Sthāna Adhiṣṭāna Frozen Shoulder Vyānavāyu, Ślēṣakakapha Sirā, Snāyu, Māṁsa, Kandara, Asthi Srotas Māṁsavaha, Asthivaha, Medovaha Sañga, Vimārgagamana Madhyama Pakwāśaya Bāhu Aṁsapradēśa It is also known as Periarthritis or Adhesive Capsulitis [vii]. There is capsule of connective tissue in shoulder joint. This capsule gives a protective cover to the bones, ligaments, and tendons of the shoulder joint. In frozen shoulder this capsule thickens due to inflammation and tighten around the affected shoulder joint [xv]. This thickening and tightening of capsule causes restriction of movements and pain. The capsule of the shoulder joint is reinforced by Symptoms- 1) Pain around shoulder joint. 2) Pain radiates along the outer side of the arm and back and forearm. 3) Night pain. 4) Stiffness in shoulder region due to contracture of shoulder ligaments, which decreases the volume of the capsule, thus limiting range of motion. Stages of frozen shoulder Three stages of frozen shoulder have been described in the modern literature [vii] : 1) Painful phase - The duration and severity is variable, and last for 2 to 9 months. The nature of pain is gradual onset, diffuses at first time, difficult on movements, then continues over a period of weeks to months and becomes worse at night. 2) Stiffening phase (frozen)- The first stage is followed by progressive loss of motion, which can be last for 4 to 12 months. It is longest out of three stages. The pain becomes dull with occasional sharp when extreme movements. 3) Thawing phase The range of motion in your shoulder begins to improve. Gradual reduction of stiffness to almost normal movements of the joint. Agnikarma Agnikarma is a thermal Para surgical procedure in which Agni is used for intentional burning as therapeutic purpose. It is indicated for various Vāta and Kapha disorders [viii]. It is also useful in painful condition of musculoskeletal disorder. Aṁsa Marma is a Snāyu Marma and Avabāhuka is a Snāyugata vāta, Acharya Sushruta has adviced Agnikarma for disorder of Snāyu (ligaments and tendon), Asthi(bones), Sañdhi(joints) etc. [vi] Agnikarma AAMJ / Vol. 3 / Issue 1 / January February

4 helps to reduce Śōtha (edema) and Śūla(pain), by virtue of its opposite qualities such as Uṣṇa(hot), Tīkṣṇa(sharp), Sūkṣma(finest), and Āśukāri(quick acting). Mode of action- By uṣṇa(hot), sūkṣma(finest), laghu(light), tīkṣṇa(sharp) and Āśukāriguṇa of agni, it activates dhātwāgni, it digests āma and achieves nirāmāvastha and pacifies Vāta and Kapha Doṣa. [vi] Pain receptors are located in the skin and motor end plates of the muscles. These pain receptors are stimulated by application of heat by Agnikarma. Pain and stiffness in Avabāhuka is decreased. Points of Agni karma and settings - Most tender point of the shoulder joint. Supero-posterior and lateral aspects including deltoid insertion area of shoulder joint in three settings in a week with panch - dhatushalaka. Effects of Agni karma- Increases metabolism. Increases blood circulation. Decreases pain. Exiting and stimulating nerve. Relaxation of muscles. Decreases joint stiffness and inflammation. DISCUSSION As per Rachana Aṁsa Marma is a Snāyu Marma and according to Viddha lakṣaṇa it is Vaikalyakara Marma. The Snāyu Marma Viddha lakṣaṇa are Stambha, excessive Ruja in Snāyus, Vaikalyatha in Añga etc. Injury to Aṁsa Marma produces disability of shoulder joint. Aṁsa Marma that includes the structures related to the shoulder region are most exposed to common injuries. It is a Snāyu Marma, and Snāyus observed in relation to Marmas are Capsular ligament, Interclavicular ligament, Coracoclavicular ligament, Glenoidal labrum, Coracohumoral ligament. An injury to these ligaments leads to disability of Aṁsa Sañdhi. The capsule of the shoulder joint is reinforced by the four tendons which form expansion and blend with the capsule of the shoulder joint. This is known as Rotator cuff. The tendon of the supraspinatus superiorly, tendon of the infraspinatus and teres minor posteriorly and tendon of the subscapularis anteriorly take part in rotator cuff. When injury to this cuff leads to frozen shoulder. An injury to Aṁsa Marma leads to damage of axillary nerve, anterior and posterior circumflex humoral artery, subscapular artery leads to disability of arm. That injury causes rupture of ligaments and muscles of shoulder region leads to dysfunction of Aṁsa Sañdhi and Bāhu stabdhata. The Vāta Doṣa located in upper limb causes a condition called Avabāhuka. By constricting the Sirā i.e blood vessels, nerves, and tendons leading to symptoms like pain, numbness, restricted movements etc. In frozen shoulder capsule thickens due to inflammation around the shoulder joint. This causes pain, stiffness, and restricted movements. Agnikarma is a thermal Para surgical procedure. By the action of Agnikarma pacifies the Vāta and Kapha Doṣa, increases blood circulation, decreases pain. It also decreases stiffness and inflammation. CONCLUSION From above discussion, I conclude that the Aṁsa Marma is a Snāyu Marma. It is present between neck and arm region. The Snāyu present at these regions are Capsular ligament, Interclavicular ligament, Coracoclavicular ligament, Glenoidal labrum, Coracohumoral ligament. Injury to these ligaments can lead to disability of shoulder joint. Viddha lakṣaṇa of Aṁsa Marma are Stambha, excessive Ruja, which can be compared with sign and symptoms of frozen shoulder. In frozen shoulder inflammation, tightness and radiating pain is present around the shoulder joint. Anikarma is a Para surgical procedure which is commonly used in Vāta and Kapha Doṣa. Uṣṇa, Tīkṣṇa, Sūkṣma and Laghu Guṇa of Agnikarma can reduces the stiffness and tenderness present at the shoulder region. ΛΛΛΛ AAMJ / Vol. 3 / Issue 1 / January February

5 REFERENCES i. Dr. BhaskarGovindGhanekar, SushrutSamhita (Sharirsthana),chapter 6,Reprint, 1986,Meharchand Lachhmandas Publication, Page no.196. ii. Dr. DenkarGovindThate, SushrutSamhita,(Sharirsthana),Chapter 6, First edition 1994,Chaukhambha Orientalia, Page no.129. iii. Dr. Anantram Sharma, SushrutSamhita, vol. 2 (Sharirsthana), Chapter 6, Reprint 2012,Chaukhambhasurbhartiprakashan, Varanasi, Page no.96. iv. Acharya Priyavata Sharma, Sushrutsamhita,(Sharirsthana), (NibandhaSangrahatika by Dalhanacharya), Chapter 6, Eighth edition 2005, ChaukhambhaOrientalia, Page no.374. v. KavirajAmbikadattaShastri, SushrutSamhita,(Ayurvedtatvasandeepikatika), (sharirsthana), Chapter 6, Chaukhabha Sanskrit Sansthan, page no:57. vi. KavirajAtridevGupt, AshtangSangraha, (Sutra sthana), Chapter 40, Reprint 2005, ChaukhambhaKrishnadasa Academy, Varanasi, Pagr no: 258. vii. KavirajAtridevGupt, AshtangSangraha, (Sutra sthana), Chapter 40, Reprint 2005, ChaukhambhaKrishnadasa Academy, Varanasi, Pagr no: 258. viii. Kaviraj Dr. Ambikadattashastri, SushrutSamhita, ( Sutrasthana), (Ayurvedtatvasandeepikatika), Chapter 12, Chaukhabha Sanskrit Sansthan, Varanasi, page no:38. ix. Dr. Shri BhaskarGovindjiGhanekar, Sushrutsamhita, (Atridevtika), (Sharirsthana), Chapter 6, MootilalBanarasidaas,Delhi, Page no.327. x. Dr.BrahmanandTripathi, AshtangHridayam, Sharirsthana, Chapter no 4, Reprint, 2011,Chaukhamba Sanskrit Prakashana, Page no.392. xi. Ayurvedacharya Shri YadunandanaUpadhaya, MadhavNidanam, (first part), (Madhukoshatika), Thirtyoneth edition, Chaukhambha Sanskrit Bhawan, page no:490. xii. KavirajAmbikadattaShastri, SushrutSamhita,(Ayurvedtatvasandeepikatika), (Nidansthana), Chapter 1,Chaukhabha Sanskrit Sansthan, page no:235. xiii. Acharya Priyavata Sharma, Sushrutsamhita,(Nidansthana), (NibandhaSangrahatika by Dalhanacharya), Eighth edition 2005, Chapter 1,ChaukhambhaOrientalia, Page no.269. xiv. B. D. Chaurasia s Human Anatomy, Vol 1,Reprint,2004, CBC Publication,New Delhi, Page no.53. xv. Richard. S. Snell, clinical Anatomy, Published by, Lippincott Williams&Wilikins Ninth Edition, Chapter no.9, Page no 351. xvi. Cunningham s Manual Of Practical Anatomy, Vol 1,Published by, Oxford Medical Publication.page no:45 Source of Support: Nil. Conflict of Interest: None declared How to cite this article: Milind et.al,. : Conceptual study of Aṁsa Marma w.s.r. to Avabāhuka - Frozen Shoulder and its management by Agnikarma. AAMJ 2017; 1: ΛΛΛΛ AAMJ / Vol. 3 / Issue 1 / January February

World Journal of Pharmaceutical Research SJIF Impact Factor 7.523

World Journal of Pharmaceutical Research SJIF Impact Factor 7.523 SJIF Impact Factor 7.523 Volume 6, Issue 3, 911-915. Research Article ISSN 2277 7105 THE STUDY OF EFFECT OF AGNIKARMA IN THE MANAGEMENT OF CALCANEAL SPUR-A CLINICAL STUDY Bhandare Madhuri Vitthalrao* 1,