DISSERTATION SUBMITTED TO THE KERALA UNIVERSITY OF HEALTH SCIENCES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS

FOR THE AWARD OF THE DEGREE OF

DOCTOR OF MEDICINE (AYURVEDA)

In
PANCHAKARMA

By

PEEYUSH P KUMAR
Under the Supervision of

Dr. A.S. LILA B.Sc. MD (Ay)

Former Professor and HOD
Department of Panchakarma
GOVT. AYURVEDA COLLEGE
THIRUVANANTHAPURAM

DEPARTMENT OF PANCHAKARMA
GOVERNMENT AYURVEDA COLLEGE
THIRUVANANTHAPURAM
2017
 ABBREVIATIONS

Ayurveda
A.H : Ashtaanga Hrdayam
A.S : Ashtaanga Sangraham
Su. : Susruta Samhita
Ch. : Caraka Samhita
Kasyapa : Kaasyapa Samhita
Shaarngadhara : Shaarngadhara Samhita

Observation Analysis and Interpretation

ESR : Erythrocyte Sedimentation Rate
ODI : Oswestry Disability Index
RMDQ : Roland Moris Disability Questionnaire

Statistics
SD : Standard deviation
AVG : Average
AT : After treatment
BT : Before treatment
 EFFECT OF ROOKSHAVASTI IN KATIGRAHA
*Peeyush P Kumar
**Dr A.S.LILA MD (Ay)
Low back pain is the leading cause of activity limitation and work absence throughout
much of the world, imposing a high economic burden on individuals, families, communities,
industry, and governments. The lifetime prevalence of non-specific (common) low back pain is
estimated at 60% to 70% in industrialized countries. Rooksha vasti is a special vasti, which is
practiced in our institution. It is derived from the principle of Churna, Lekhana and Kshara
vasthis. Using vasti for rookshana gives another treatment option for physicians that can be
combined with external rookshana therapies. Rookshana therapy is the initial treatment done for
katigraha in our institution. Rookshana gives encouraging results in treatment of Katigraha.
Rooksha vasti gives immediate relief in symptoms of katigraha and also helps to achieve proper
rookshana needed in the initial stage of katigraha treatment. The objective of this study is to
scientifically prove the effect of Rooksha vasti and to evaluate its safety.

Study design is an interventional study with pre-post test without control group. 30 patients
of both sexes aged 20-60, satisfying the inclusion criteria, attending IPD of Govt. Ayurveda College
Panchakarma Hospital, Poojappura are selected as study population. Patients with complicated cases
of hypertension, diabetes mellitus, major liver and renal disorders, back pain associated with any
type of malignancy or neoplastic infiltration and those who are contraindicated for vasti are excluded
from the study.
.
The intervention is done for 7 days. The data for the study is collected using clinical research
pro-forma. After collecting the baseline data of the patients in the study group, anulomana is done
for one day to prepare the patient using Sindhuvaara Erandam 10-20 ml. Rookshavasti will be started
from second day onwards and it will be done for 7 consecutive days. Rookshavasti, which is being
practiced in our institution, is prepared using 3 prasrtas (300ml) of Gandharvahasthadi kashaya, 30
grams of vaiswanara churna for kalka, 30 ml. Madhu and 10 g of Saindhava. After Rookshavasti,
patient will receive the regular katigraha treatment protocol of our institution for the next two to
three weeks. The patients will be examined before and after Rooksha vasti. The results will be
assessed with regards to changes in the following outcome variables like pain, morning stiffness,
tenderness, functional assessment, lumbar flexion, Oswesry Disability Index, Roland Morris
Disability Questionnaire and laboratory investigation (ESR). Statistical analysis is done using Paired
t test for finding significant effect due to Rooksha vasti on study variables like Pain, morning
stiffness etc.

* MD Scholar, Dept of Panchakarma, Govt. Ayurveda College, Thiruvananthapuram.

** Professor and HOD, Dept of Panchakarma, Govt. Ayurveda College, Thiruvananthapuram
 CONTENTS Page No.

Introduction 1

Part I : Review of literature

Chapter 1 Rachana Saareera of Kati 5

Chapter 2 Anatomy of Low Back 6

Chapter 3 Disease Review 17

Chapter 4 Vasthi Review 52

Chapter 5 Rooksha vasti 86

Part II : Drug Review 88

Part III : Methodology 97

Part IV : Observation, Analysis and Interpretation 101

Part V : Discussion, Summary and Conclusions 138

References

Appendix
 Index of tables & Figures

INDEX OF TABLES

Table No Name of table Page No

2.1 Pathya Ahara in Katigraha 35
2.2 Apathya Ahara in Katigraha 37
2.4.1 Indication of Asthaapana vasthi 54
2.4.2 Contraindication of Asthaapana vasthi 56
2.4.3 Contraindication of Anuvasana 57
2.4.4 Measurement of Vasthinetra acc. to Charaka 59
2.4.5 Measurement of Vasthinetra acc. to Chakrapani 59
2.4.6 Measurement of Vasthinetra acc. to Vagbhata & Susruta 59
2.4.7 Quantity of vasthidravya according to Charaka & vagbhata 60
2.4.8 Quantity of vathidravya according to Susruta 60
2.4.9 Quantity of vathidravya as per Sarngadhara & Bhavaprakasha 61
2.4.10 Anuvasana Dosage as per to Sarngadhara & Bhavaprakasha 61
2.4.11 Anuvasana Dosage according to Kasyapa 62
2.4.12 Dosage of Asthaapana according to Charaka 67
2.4.13 Dosage of Asthaapana According to Susruta 67
2.4.14 Dvaadasa Prasrutha explained by Susruta 67
2.4.15 Dosage of Asthaapana According to Vangasena 68
2.4.16 Dosage of Asthaapana According to Vagbhata 68
2.4.17 Dosage of paadahina vasthi according to Vagbhata 69
2.4.18 Summary of digestion and absorption in the large intestine 81
4.1 Distribution of patients according to age 101
4.2 Distribution of patients according to sex 102
4.3 Distribution of patients according to religion 102
4.4 Distribution of patients according to economic status 102
4.5 Distribution of patients according to marital status 103
4.6 Distribution of patients according to education 103

i
 Index of tables & Figures

4.7 Distribution of patients according to occupation 104

4.8 Distribution of patients according to body weight 105
4.9 Distribution of patients based on bowel movement 105
4.10 Distribution according to low back pain chronicity 106
4.11 Distribution of patients according to Bala 106
4.12 Distribution of patients according to agni 107
4.13 Distribution of patients according to type of koshta 107
4.14 Distribution of patients according to Prakrithi 107
4.15 Distribution of patients according to Satwa 108
4.16 Distribution of patients according to Sathmya 108
4.17 Distribution of patients according to Samhanana 108
4.18 Distribution of patients according to Vaya 109
4.19 Retention time of Rookshavasthi 109
4.20 Number of Vega after Rookshavasthi 110
4.21 Complications after Rookshavasthi 110
4.22 Other observations in Rookshavasthi 111
4.23 Data related to safety of rookshavasthi 111
4.24 Effectiveness of treatment on pain 112
4.25 Effectiveness of treatment on pain - t test value 112
4.26 Effectiveness of treatment - Pain on lying 113
4.27 Effectiveness of treatment in Pain on lying - t test value 113
4.28 Effectiveness of treatment - Pain on Sitting 114
4.29 Effectiveness of treatment - Pain on Sitting - t test value 114
4.30 Effectiveness of treatment - Pain on Walking 115
4.31 Effectiveness of treatment - Pain on Walking - t test value 115
4.32 Effectiveness of treatment in Morning Stiffness 116
4.33 Effectiveness of treatment - Morning Stiffness - t test value 116
4.34 Effectiveness of treatment in Tenderness 117
4.35 Effectiveness of treatment - in Tenderness - t test value 117

ii
 Index of tables & Figures

4.36 Effectiveness of treatment in Functional Assessment 118

4.37 Effectiveness of treatment in Functional Assessment - t test 118
4.38 Effectiveness of treatment in reducing ESR 119
4.39 Effectiveness of treatment in reducing ESR - t test value 119
4.40 Effectiveness of treatment in Lumbar Flexion 119
4.41 Effectiveness of treatment in Lumbar Flexion - t test value 120
4.42 Effectiveness of treatment in Lateral Movement 120
4.43 Effectiveness of treatment in Lateral Movement - t test value 121
4.44 Effectiveness of treatment in ODI 121
4.45 Effectiveness of treatment in ODI - t test value 121
4.46 Effectiveness of treatment in RMDQ 122

INDEX OF FIGURES

Figure No. Description Page No.

1 Muscles of Back 10
2 Cross section of lumbar vertebrae 11
3 Posture Correction 39
4 Exercise For Katigraha 40
5 Arterial Supply of Large Intestine. 78

iii
 Index of graphs

INDEX OF GRAPHS

Graph Page
Name of graph
No No
1 Distribution of Patients according to Age 123
2 Distribution of patients according to gender 123
3 Distribution of patients according to religion 123
4 Distribution of patients according to Economical Status 124
5 Distribution of patients according to marital status 124
6 Distribution of patients according to education 124
7 Distribution of patients according to occupation 125
8 Distribution of patients according to body weight 125
9 Distribution of patients based on bowel movement 126
10 Distribution according to low back pain chronicity 126
11 Distribution of patients according to Bala 126
12 Distribution of patients according to Agni 127
13 Distribution of patients according to Koshta 127
14 Distribution of patients according to Prakriti 127
15 Distribution of patients according to Satwa 128
16 Distribution of patients according to Sathmya 128
17 Distribution of patients according to Samhanana 128
18 Distribution of patients according to Vaya 128
19 Retention time of Rookshavasthi 129
20 Number of vegas after Rookshavasthi 129
21 Data related to Complications after Rookshavasthi 129
22 Data related to Complications after Rookshavasthi 130
23 Effectiveness of treatment on pain 130
24 Effectiveness of treatment on pain - t test value 130
25 Effectiveness of treatment - Pain on lying 131
26 Effectiveness of treatment - Pain on lying - t test value 131

i
 Index of graphs

27 Effectiveness of treatment - Pain on Sitting 131

28 Effectiveness of treatment - Pain on Sitting - t test value 132
29 Effectiveness of treatment - Pain on Walking 132
30 Effectiveness of treatment - Pain on Walking - t test value 132
31 Effectiveness of treatment in Morning Stiffness 133
32 Effectiveness of treatment in Morning Stiffness - t test value 133
33 Effectiveness of treatment in Tenderness 133
34 Effectiveness of treatment in Tenderness - t test value 134
35 Effectiveness of treatment in Functional Assessment 134
36 Effectiveness of treatment in Functional Assessment - t test value 134
37 Average of ESR before and after treatment 135
38 ESR Mean value before and after treatment 135
39 Effectiveness of treatment in Lumbar Flexion 135
40 Effectiveness of treatment in Lumbar Flexion - t test value 136
41 Effectiveness of treatment in Lateral Movement 136
42 Effectiveness of treatment in Lateral Movement - t test value 136
43 Effectiveness of treatment in ODI Average 137
44 Effectiveness of treatment in ODI - t test value 137

INDEX OF DIAGRAM

Diagram Page
Name of diagram
No. No.
1 Schematic representation of sampraapti of Katigraha 29

ii
Introduction
 Introduction

INTRODUCTION

Ayurveda is the indigenous healthcare system of India, the origin of which

dates back to several thousand years. Ayurveda originated and developed as a sub part of
vedas, which are the basics of Indian philosophy. Ayurveda shows the healing wisdom of
the ancient India. In Vedic period, Ayurveda was mainly studied, preached and practiced
by eminent sages. Strong basic principles are the uniqueness of Ayurveda. The age old
Ayurvedic principles are still applicable in newly emerging diseases and it works well in
treating those diseases because of its fundamental integrity. During its developmental
period, new observations were added and theories were modified and fortified in the light
of logical reasoning by various Acharyaas.

There are two basic treatment streams in Ayurveda, which are shodhana
and shamana. Shodhana therapy ensures complete cure and prevents recurrence by
clearing the morbid factors from its root. There are five shodhana therapies described in
Ayurveda, which are collectively known as Panchakarma. Sodhana therapies work by
cleansing internal channels and disease producing dosha dooshya complex. This therapy
ensures proper transportation of nutrients to cells and clearing metabolic waste from
cells. Shodhana therapy is indicted for healthy and diseased persons.
Among the five cleansing therapies, vasthi is the most important
procedure as it has multidimensional application and properties. Vasthi is appraised as
ardha chikitsa1 by kayachikithsa acharyaas because it can be applied in all eight branches
of Ayurveda, it can be applied from birth to death and it conquers vata dosha. Vata dosha
is considered as the prime dosha which controls the other two doshas. To show the
supremacy of vata, it is said as the tantra yantra dhara. There are eighty diseases
mentioned by acharyaas, which are produced solely by vata dosha. The main feature of
vata roga is pain. Pain is the main factor which makes a patient to seek medical help.

Low back pain is one of such condition where pain and stiffness prevails
which limits the movements and daily activities of a person. This is the most common
disorder, which affects movement of leg especially in the prime productive period of life.
Symptoms of low back pain are put under the term katigraha in Ayurvedic literature.

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 Introduction

According to Ayurvedic perspective, Katigraha is caused by kevala vata or saama vata

with specific symptoms like pain and stiffness in low back area2.

Katigraha is not mentioned as a separate disease in brihathtrayees but

there are direct references seen in other texts, like Gadanigraha and Sarngadhara Samhita.
Sarngadhara giving more importance to katigraha included it under vata nanatmaja
4
vikara3. Katigraha is mentioned as a symptom produced by vatakopa in pakvashaya and
as an associated symptom of various conditions like gridhrasi, vatarakta, ashmari etc. As
pakvashaya is the main seat of vata dosha, the treatment procedure vasthi, which can deal
with vata dosha at its moolasthana become highly important.

Low back pain is one of the top 10 reasons, for which patients seek care
from a physician.5 In epidemiologic studies of different populations, the prevalence of
low back pain has varied from 7.6 to 37 percent. Peak prevalence is in the group between
45 and 60 years of age,6 although back pain is also reported by adolescents and by adults
of all ages. Annual direct cost of low back pain in Germany is: > euro 7000 per person.

Work absenteeism accounted for 75% of the total per-patient cost of low
back pain in Germany.7 Low Back Pain affects approximately 60-85% of adults during
some point in their lives. As of 2005, lower back pain ranks as number one cause of
disability in individuals under the age of 45.8 According to the journal of orthopaedics the
life time incidence of low back pain is 50%-70%

Rookshana therapy is the initial treatment done for katigraha in our

institution and the treatment for katigraha follows two protocols in our institution.
Rookshana gives encouraging results in treatment of Katigraha.

1. Kevala Vataja Katigraha

- Anulomana
- Deepana Pachana
- Rookshana - 3 to 5 days
- By Rooksha swedam or Rooksha vasthi or
- Both Rooksha sweda & Rooksha vasthi
- Abhyanga and swedam - 7 days

- Ptrapotala / Jambira Swedam - 7 days

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 Introduction

- Kativsthi or Katipichu - 7 days

- Kayaseka or Shastikapinda sweda - 7 days
2. Saama Katigraha

- Anulomana
- Deepana Pachana
- Rookshana - 5 to 7 days
By Rooksha swedam or Rooksha vasthi or
Both Rooksha sweda & Rooksha vasthi or
Dhanyamla dhara or Sankaraswedam
- Abhyanga and swedam - 7 days
- Ptrapotala Swedam - 7 days
- Kativsthi / Katipichu - 7 days
- Kayaseka / Shastikapinda sweda - 7 days

A general vatahara treatment line is followed in Katigraha but initial

rookshana plays an important role in the overall success of the treatment, especially in
saama vata katigraha. The initial rookshana helps in clearing aama. Treating aamavastha
with vasti gives another treatment option for physicians that can be combined with
external rookshana therapies.

Rookshavasthi with a slightly different preparation is used to bring down

temperature in fever by some practitioners in Kerala. So rookshavasthi is having a quick
action on aama, which can be very helpful in clinical practice. Therefore, the present
research work is planned to evaluate the effect of rookshavasthi in saama katigraha.

document the healing effect of rookshavasthi in Saama katigraha. Rookshavasthi is done

in almost all cases in our institution except in some vasthi anarha conditions. The lifestyle
of patients included in this study reveals that there are many factors which cannot be
avoided from day to day life, that causes the production of aama irrespective of economic
status, job type and activity level. Simple rookshana procedures like deepana, paachana
will take more time to produce niraamaavastha. Procedures like rooksha vasthi which
brings proper rookshana in a lesser time span are need of the hour because of the busy
lifestyle which leaves only a short time for people to address their health issues.

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 Introduction

There are many situations where application of rookshana will be difficult

as in an Ayurveda center for foreign patients. Most of the foreign national have sensitive
skin and they try to avoid dust. This becomes a real issue as the options for doing
rookshana with Churna pinda sweda or Udwartana are limited due to skin sensitivity and
internal deepana paachana will increase the duration of treatment. Rookshavasthi will be
a great choice in the above said situation which produces rookshana without much
difficulty to patient. The positive results from this study will be helpful for a large
number of Ayurvedic physicians in resort field to safely and confidently practice
Rooksha Vasti to deliver maximum health benefits to their patients.

This dissertation presented in the following order,

Introduction
Part I : Review of literature
Chapter 1 Rachana Saareera of Kati
Chapter 2 Anatomy of Low Back
Chapter 3 Disease Review
Chapter 4 Vasthi Review
Chapter 5 Rooksha vasti
Part II : Drug Review
Part III : Methodology
Part IV : Observation, Analysis and Interpretation
Part V : Discussion, Summary and Conclusions
References
Appendix

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 Part I
Review of Literature
 Review of Literature - Rachana Sarira of Kati

Chapter 1
RACHANA SHAREERA OF KATI
Knowledge of rachana and kriya in normalcy is the key to perfect diagnosis. In
katigraha, aggravated vata produce symptoms by lodging in kati pradesa. So for the better
understanding of this condition, a brief description of rachana saareera of kati is
mentioned below.
KATI AS A SANDHI
1
Ayurvedic anatomy classifies Kati under chala sandhi of thunnasevani type.
Sthira & Chala are the main classification of sandhis.2. This is subdivided into eight
groups, which are Kora, Ullookhala, Samudga, Pratara, Tunnasevani, Vayasatunda,
Mandala and Shankhavarta1

OTHER STRUCTURES IN SANDHI

Functional vata at Kati - Vyana Vata
Vyana controls all movements in our body as it is responsible for gati. Gayadasa
while commenting on Sushruta has mentioned that vyana it resides in the Sandhi3.
Functional kapha at Kati Shleshaka Kapha
Shleshaka Kapha resides in joints and it keeps the joint firmly united, protects
their articulation, and prevents their separation 4.
Kala at Kati
Shleshmadhara Kala is situated in all joints. The main function of sleshaka kapha
is lubrication. 5.
Snayu at Kati
There are nine hundred Snayus in body. Among that sixty are present in Kati.
Snayu helps in the rigidity of a joint and make it strong. 6
Peshi at Kati
Peshi helps in movement. No direct mentioning of pesi in kati is available.
Sanghata at kati
There is an asthi sanghata mentioned as trika. There are difference of opinion in
the exact location of trika. If trika is considered as shronikaanda bhaga (lumbosacral joint
and sacroiliac joint), kati pradesa contain asthisanghata. 7

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 Review of Literature - Anatomy of Low Back

Chapter 2

ANATOMY OF LOW BACK 1, 2

Structures in low back region

1. Bones
2. Muscles
3. Ligaments
4. Vascular Supply
5. Lymphatic Drainage
6. Nerve Supply

BONES IN LOW BACK REGION

LUMBAR VERTEBRAE 1

Characteristics of a Typical Lumbar Vertebra

A typical lumbar vertebra has the following characteristics

The body is large and kidney shaped.

The pedicles are strong and directed backward.
The laminae are thick.
The vertebral foramina are triangular.
The transverse processes are long and slender.
The spinous processes are short, flat, and quadrangular and project backward.
The articular surfaces of the superior articular processes face medially, and those
of the inferior articular processes face laterally.
There are three functional elements in each lumbar vertebra.
I. Anterior element - Vertebral body
II. The middle elements - consisting of Pedicles
III. Posterior elements - Laminae,
Articular process,
Spinous process,
Accessory process,
Transverse process and Mamillary process.

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 Review of Literature - Anatomy of Low Back

I - Anterior Element
Vertebral body is the essential part of vertebral column as it is the structure
which gives bulk and height. Vertebral body helps to bear compression loads applied on
vertebral column imparted by body weight or contraction of back muscles.
II - Middle Element
Pedicles are the connection between posterior and anterior element. Pedicles
serve as the transfer path of controlling force from posterior to anterior elements.
III - Posterior Elements
Posterior elements control the movements of vertebral column by regulating the
active and passive forces applied to vertebral column.
Lamina - Transmits the forces from spinous process and the inferior articular
processes to the pedicles. Thus they are susceptible to injuries such as
pars intra articular fractures.
Articular process - Acts as a locking mechanism that resists the forward sliding
and twisting of the vertebral bodies.
All other processes act as the site for attachment of muscles in vertebrae

JOINTS IN LUMBER VERTEBRAE

Three joint complexes are formed by articulation of lumbar vertebrae.
I - Joint between vertebral bodies with inter vertebral disc in between.
II & III - The two other joints are known as Zygophyseal or Apophyseal or Facet
joints. These are formed by the articulation of superior articular processes
of the vertebra and inferior articular process of the vertebra above.

I - Joint between Inter vertebral disc

Inter vertebral disc is the cushion between vertebrae which acts as a shock
absorber. Inter vertebral disc has three main components.
i) Nucleus pulposus
ii) Annulus fibrosis
iii) Vertebral end plates
i) Nucleus pulposus : Nucleus pulposus is the central gelatinous part of
disc. Nucleus consists of a matrix of proteoglycans that bind considerable amount
water.

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 Review of Literature - Anatomy of Low Back

ii) Annulus fibrosis : It is the structure which surrounds the nucleus pulposus. It
consists of concentric laminae of collagen fibres. In each lamina the fibres are
parallel and oriented 65 degrees from the vertical, but the direction of inclination
alternates in successive laminae. The inner fibres attached to the margins of the
vertebral end plates. The outer fibres are attached to the margins of the vertebral
bodies and constitute the ligamentous portion of the annulus fibrosus.
iii) Vertebral end plate : Is the cartilaginous substance which covers the
superior and inferior surface of each vertebral body within the area encircled by the
ring apophysis. The two end plates of each disc cover the nucleus pulposus as well
as the inner 2/3rd of the annular fibrosus. The main function of vertebral disc is to
separate the vertebral bodies so that movements may occur between the vertebral
bodies. The disc must be sufficiently compliant to allow movement but sufficiently
strong to with stand compression. Compression between vertebral bodies is
fundamentally resisted passively by the sheer bulk of the annulus fibrosus.

II - Zygophyseal or Apophyseal or Facet Joints

Facet joints are typical synovial joints with cartilage, capsule and synovial
membrane. The articular facets exhibit variations in both the shape of their articular
surface and general direction in which they face. This variation determines the extent
to which joints can prevent forward sheer translations between vertebral bodies and
axial rotations of the inter-body joint. These movements are resulted by the
impaction of interior articular process of the vertebra below. The only movement
permitted by the lumbar facet joints is sliding movement in a vertical direction,
which is executed during flexion and extension of the vertebral column.

2. MUSCLES IN LOW BACK REGION

Movements of vertebral column are directly controlled by muscles. In standing
posture almost all muscles are relaxed except a slight activity in psoas and
abdominus muscles.
a. The psoas major:
Origin - Transverse process of all lumbar vertebrae and from the sides of the
bodies and the intervening discs of T 12 to L 5 vertebrae.
Insertion - Lesser trochanter of the femur.

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 Review of Literature - Anatomy of Low Back

Course - It pass downwards and laterally at the margin of the brim of the pelvis,
narrowing down to a tendon which crosses the front of the hip
Action - The psoas major, together with iliacus, flexes the hip on the trunk, or,
alternatively, the trunk on the hips (e.g. in sitting up from the lying
position). Psoas exerts immense pressure on the vertebral disc on
contraction as in the exercise of the sit-ups.
b. Quadratus lumborum:
Origin - Transverse processes of L 1 L 4, the iliolumbar ligament, and
posterior third of the iliac crest.
Insertion - Inferior border of the 12th rib.
Action - Lateral flexion of vertebral column, Depression of thoracic rib cage,
elevation of the pelvis and fixation of 12th rib.
c. Intertransversarii Laterales
Origin - Transverse processes.
Insertion - Transverse processes.
Action - Lateral flexion of vertebral column, act synergistically with
Quadratus lumborum.
d. Interspinales
Interspinales are short muscles that connect the spinous process of adjacent lumbar
vertebrae. They probably serve a proprioceptive function.
e. Multifidus

the spine. It extends from each of the lumbar spinous process to caudal insertion on
mamillary process. The multifidus muscles help to take pressure off the vertebral
discs so that our body weight can be well distributed along the spine. Additionally,
the superficial muscle group keeps our spine straight while the deep muscle group
contributes significantly to the stability of our spine.
These two groups of multifidus muscles are recruited during many actions in our
daily living, which includes bending backward, sideways and even turning our body
to the sides. Studies have shown that the multifidus muscles get activated before any
action is carried out so to protect our spine from injury. Take for example when you
are about to carry an item or before moving your arm, the multifidus muscles will
start contracting prior to the actual movement of the body and the arm so as to
prepare the spine for the movement and prevent it from getting hurt.

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 Review of Literature - Anatomy of Low Back

FIGURE: 1 MUSCLES OF BACK

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 Review of Literature - Anatomy of Low Back

FIGURE: 2 CROSS SECTION OF LUMBAR VERTEBRAE

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 Review of Literature - Anatomy of Low Back

3. LIGAMENTS IN LOW BACK REGION

Following are the main ligaments in low back region.

i. Anterior longitudinal ligament

These are attached to the anterior surface of vertebrae. Anterior
longitudinal ligaments are broad and strong fibrous band. It has minimum width
at the level of inter vertebral disc and it contain tendons from crus of diaphragm.

ii. Posterior longitudinal ligament

Posterior longitudinal ligament runs posterior to the vertebral body. It
separates vertebral body from dural sac. It is loosely attached and has inter-
woven connection with disc. Posterior longitudinal ligament resists the
separation of posterior ends of vertebral bodies during flexion.

iii. Ligamentum flavum

Ligamentum flavum connects laminae and extends laterally to the
articular facet. Thickest part of ligamentum flavum is seen in lumbar region.
Ligamentum flavum helps in bringing spine to normal position after flexion and
protects disc from injury.

iv. Supraspinatum ligament

It joins the tips of the spinous processes of the vertebrae with aid of intra
spinous ligament.

v. Inter spinous ligament

It connects the adjoining spinous processes from their tips to roots.

vi. Inter transverse ligament

These are essentially membranes that extend between adjacent transverse
process. They constitute part of facial system that separates the muscles of the
ventral compartment from the posterior compartment.

vii. Ilio lumbar ligament

Bind Transverse process of L 5 to the Ileum. It resists forward sliding,
lateral bending and axial rotation of L 5 on sacrum.

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 Review of Literature - Anatomy of Low Back

4) VASCULAR SUPPLY OF LOW BACK REGION

Arteries:
Lumbar part of vertebral column and surrounding structures receive their arterial
supply from lumbar arteries.
Sacral region receive supply from from the iliolumbar and lateral sacral arteries,
branches of the internal iliac artery.

Veins:
Veins that drain structures of back form external and internal plexuses extending
along the vertebral column from skull to the coccyx. The external vertebral venous
plexus surrounds the vertebral column. The internal vertebral venous plexus lies within
the vertebral canal but outside the duramater of spinal cord.
The walls of these plexuses are thin and have incompetent valves or are valve
less. They communicate through the foramen magnum with the venous sinuses within
the skull. Free venous blood flow may therefore take place between the skull, the neck,
the thorax, the abdomen, the pelvis, and the vertebral plexuses, with the direction of
flow depending on the pressure differences that exist at any given time between the
regions.

5) LYMPHATIC DRAINAGE AT LUMBAR REGION

The deep lymph vessels follow the veins and drain into lateral aortic and sacral
nodes.
Vessels from the trunk above the iliac crests drain into the axillary nodes.
Vessels below the level of the iliac crests drain into the superficial inguinal
nodes.

6) NERVE SUPPLY OF LOW BACK REGION

Joints between the vertebral bodies are innervated by the small meningeal
branches of each spinal nerve. The nerve arises from the spinal nerve as it exits from the
intervertebral foramen. The nerve then re-enters the vertebral canal through the
intervertebral foramen and supplies the meninges, ligaments, and intervertebral discs.
Joints between the articular processes are innervated by the branches from the posterior
rami of the spinal nerves.

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 Review of Literature - Anatomy of Low Back

The skin and muscles of the back are supplied in a segmental manner by the
posterior rami of the 31 pairs of spinal nerves. The fourth and fifth lumbar nerves supply
the deep muscles of the back and do not supply the skin.

CURVATURES OF VERTEBRAL COLUMN

Curves in the Sagittal Plane

The vertebral column has a continuous anterior concavity in foetus. Functional
muscle development leads to the appearance of lumbosacral angle. The cervical part of
the vertebral column becomes concave posteriorly when the child becomes able to raise
head and keep it poised on the vertebral column. When the child begins to stand, the
lumbar part of the vertebral column becomes concave posteriorly. The development of
these secondary curves is largely caused by modification in the shape of the
intervertebral discs.
In an adult, the vertebral column exhibits the following regional curves;
Cervical - Posterior Concavity - Lordosis
Thoracic - Posterior convexity - Kyphosis
Lumbar - Posterior concavity - Lordosis
Sacral - Posterior convexity - Kyphosis

During the later months of pregnancy, with the increase in size and weight of the
foetus, women tend to increase the posterior lumbar concavity in an attempt to preserve
their centre of gravity. In older people, age related changes such as intervertebral disc
atrophy leads to broadening and loss of height of vertebral body. This results in gradual
return of the vertebral column to a continuous anterior concavity and progressive decline
in mobility of vertebral column especially at lumbar region.
Curves in the Coronal Plane
In late childhood, it is common to find the development of minor lateral curves
in the thoracic region of the vertebral column. This is usually caused by the predominant
use of one of the upper limbs. A right-handed person will often have a slight right-sided
thoracic convexity. Slight compensatory curves are always present above and below
such a curvature.

The lateral deviation of the vertebral column is termed as Scoliosis. Scoliosis is

commonly found in the thoracic region and usually caused by muscular or vertebral
defects. Scoliosis is often compensatory and may be caused by a short leg or hip disease.

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MOVEMENTS OF THE VERTEBRAL COLUMN

The degrees of movement between adjacent vertebrae are limited as the vertebrae
are held in position by strong ligaments. The following movements are possible in the
vertebral column.
Flexion
Extension
Lateral flexion
Axial Rotation, and
Circumduction.
Flexion and Extension
Flexion is the forward bending movement, and extension is the backward
movement. Flexion is produced by the rectus abdominis and the psoas muscles. Flexion
and extension are extensive in the cervical and lumbar regions but restricted in the
thoracic region. In flexion, anterior longitudinal ligaments are relaxed and the anterior
part of inter vertebral disc are compressed. Flexion is limited by the tension on posterior
longitudinal ligament, ligamentum flavum, posterior part of vertebral disc, inter and
supra spinous ligaments.
Extension is marked at cervical and lumbar regions and it is produced by the
postvertebral muscles. Extension is limited by bony impaction and ligament tension.
Bony impaction happens either by the spinous process impact against each other or by
the inferior articular process impacts against the laminae below. Ligaments limiting
extension on tension are anterior longitudinal ligament and anterior disc fibres.

Lateral flexion
Lateral flexion is the bending of the body to one or the other side. It is produced
by the postvertebral muscles, the quadratus lumborum, and the oblique muscles of the
anterolateral abdominal wall. It is extensive in the cervical and lumbar regions but
restricted in the thoracic region. Inter vertebral discs are compressed laterally, tensed
and lengthened contra laterally.

Axial Rotation
Rotation is a twisting of the vertebral column. It is produced by the rotatores
muscles and the oblique muscles of the anterolateral abdominal wall. Twisting of
vertebrae occurs relative to each other with a torsional deformation of disc. Oblique

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 Review of Literature - Anatomy of Low Back

abdominal muscles acting on the thorax makes the rotation possible and this movement
creates a screwing effect on the lumbar spine from L1 to the sacrum. Axial rotation is
resisted by impaction of zygapophyseal joints and by tension developed in the annulus
fibrosus.

Circumduction

Circumduction is a combination of all these movements.

DIURNAL CHANGES IN INTER VERTEBRAL DISC

Diurnal changes can affect the spinal stability and body height. These changes
are evident in cervical thoracic and lumbar regions of spine. Thoracic spine shows
curvature changes in response to diurnal changes and lumbar region show changes
without altering its curvature.
Dynamic movement of fluid in and out of inter vertebral disc and adjacent
vertebral body has been revealed by MRI studies. Inter vertebral discs are swollen with
water in the early morning hours which affects the functional movements during this
time. As the time passes, after several hours of normal activity, the disc loses 20% of
fluid content, which makes the functional movements easy.
Distribution of compressive load in spine is changed by the diurnal fluid loss in
disc. After losing fluid, the hydrostatic pressure in nucleus pulposus reduces and the
compression load is distributed to annulus fibroses and facet joints.

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 Review of Literature -Disease Review - Katigraha

Chapter 3

DISEASE REVIEW
HISTORICAL REVIEW

Historical review of helps to understand the importance given to the disease by

the developers of Ayurveda. Historical review of katigraha reveals its gradual upgrading
from a symptom to an independent disease. The historic review in this dissertation is
presented starting from Vedic period, covering Upanishad, Samhita and Samgraha
periods in order.

1. Vedic Period
Mobility is the essential quality required for survival in a challenging
environment. Diseases affecting mobility will reduce human capacity to search for food
and escape from threats, which were the basic needs for survival during the initial stages
of human race development. This is a humble attempt to collect data regarding katigraha
mentioned in Vedic literature.
In atharva veda, there are some descriptions about vatavyadhi with a specific
-lumbar spine. Spine is
termed ad and dorso-lumbar spine is termed as . The disease, which is
described in detail is Yakshma can affect any part of body including Sroni,
1,2,3
Prishta, Uru, Asthi, Majja etc. . Based on the above information, it can be
understood that diseased affecting low back area was evident in vedic period but the
term Katigraha is not mentioned directly.

2. Period of Upanishads and Puranas

In Upanishads and puranas, description of the functions and types of Vata, its
locations, qualities etc. are seen. There are references of sushumna nadi and its location.
Katigraha as such is not explained in Upanishads and puranas but the involvement of
vata in movement of body is mentioned. Same as in Vedas, Upanishads also mentioned
the term Anukam for spine.
Chala property of Vata and its association with body and movements are
4,5
mentioned in Chandokyopanishath . According Prashnopanishad, Sushumna is
mentioned as one of the 101 Nadis going upwards in body. It is also mentioned that
6
these nadis facilitate movement of udana vayu from foot to head.

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 Review of Literature -Disease Review - Katigraha

According to Brahmasootra, Vyana Vata is considered as the one which resides

7
in joints and which is responsible for the movements of the joints. A separate chapter
8
for vatavyadhi nidana is found in Garuda Purana.

3. Samhita Period
Caraka Samhita:
Classical description about vata dosha and vatavyadhi are seen in Charaka
Samhita. Charaka mentions Shula (pain) as a symptom of kupita vata. In Maharoga
adhyaaya of Sutrasthaana, while enumerating nanatmaja vata roga, symptoms of spinal
9
disease like prishtagraha, trikagraha, paadasula, supti are seen but the term katigraha is
not mentioned. In chikithsaasthana, vatavyadhi chapter covers the general line of
treatment of vata and also describes specific diseases caused by vata with its treatment.
References related to Katigraha in charaka samhita

Kati samgraha mentioned as a swedya vyadhi10

Prishta and Kati graha mentioned as symptoms of vrukkaja vidhradhi11
Kati shula mentioned as a symptom in Gridhrasi12
Excess use of pungent taste leads to Vata vikara in Prishta13
Kati and Prishta vedana in Vataja jwara14
Trika and Prishta roga as a symptom of Gudagatha Vata15
Trika Vedana as a symptom of Pakvashayagata Vata16
Kati Shula, Trika & Prushtha Shula lakshanas of Vataja Arshas17

Sushruta Samhita:
Being a salyatantra related work, Susruta Samhita gives an elaborated
description of rachana sareera. He has described the structure of Prishta along with
joints and bones in that area. While elaborating marmaghaatha lakshanas, it is
mentioned that trauma on Kukundara Marma leads to sensory and motor loss of lower
limbs and leads to disability (Vaikalya). Sushruta shows the importance of vata vyadhi
by allotting the first chapter of Nidana Sthana itself for Vatavyadhis. He described
conditions like Gridhrasi, Khanja, Pangu, etc. but references for Katigraha are not
found.
There are two main chapters for vata vyadhi chikitsa in Susruta Samhita. In the
chapter named Mahavatavyadhi Chikitsa, specific therapeutic measures to be adopted in
Gridhrasi, Vatarakta, Pakshaghata are described. The rehabilitation methods described

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 Review of Literature -Disease Review - Katigraha

for sandhimuktha and kanda bhagna can be applied in the form of traction and
manipulation in Katigraha cases caused by abhighata.

References related to Katigraha in Susruta Samhita

Trika Vedana mentioned as a symptom in Pakwashaya gata vata.18
Kati Shula is observed as a lakshana in
- Vataja arshas19,
- Vamkshanotha vidhradhi20,
- Bhagna, and in
- Seventh Sarpavisha vega21.
Bhela Samhita
Bhelaacharya classified Vata vyaadhi into two groups- Sarvanga and Ekanga
vata. All the pain dominating diseases of Kati and Prishta bhaga are mentioned in
Ekanga vata roga. He also mentions two types of Prishta diseases, Upakshari and
Kshari.
Acharya Bhela has described 45 kasherukas in the Prishta and 15 in Greeva.
Other general description about vata is almost same as in charaka Samhita. He has
mentioned Kati shula as a complication of diseases like vataja kasa. Mandagni and
margarodha of vata vata are the main cause of Kati shula. While describing the Yapana
basti he has mentioned it will relieve the pain at Kati.

Haarita Samhita
Harita while describing vatavyadhi- has allotted separate chapters for Aamavata
and Gridhrasi. He opines that Prushthastambha and Oorusthambha are disorders of
Vyana Vata.

Kashyapa Samhita:

In Kashyapa Samhita the general aspects of Vata and its nidana samprapthi of
vatavyadhi are discussed in Sutrasthana which is similar to Charaka views. According
Kasyapachaarya, Kati shoola is mentioned as one of the complication of dushprajata and
advised swedana as the treatment.
4. Sangraha period
Ashtangasamgraha and Hridaya:
A detailed description of vata with its all normal and abnormal factors is present
in Ashtangasamgraha. The views are almost same as that of Charaka and Susruta.

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Vridha vagbhata specifically mentioned the site of vata as adhonabhi, pakvasaya,

kati.. Vagbhata I give a detailed description of five varieties of vata in a more clinically
applicable way. The main impaired functions of katigraha like gati and prasarana are
found in the description of vyana vata. He mentions the circulation area of apana vata as
shroni.
References related to Katigraha in Ashtangasamgraha and Ashtangahridaya
In Ashtangasamgraha and Ashtangahridaya, kati shola is mentioned as a
symptom in pakvasaya gata vata kopa.22
Kati toda and Kati bheda are mentioned as poorva roopa of vata sonita.23
Sarvadhatu avruta vata produces pain in Prishta and Sroni.

Arunadatta:
In Sarvangasundara commentary on Ashtangahridaya, Arunadatta explains a
condition where pain occurs while raising leg straight and thereby restricting
movements of thigh. He quoted the cause for this condition as vatakopa in kandara. This
is an evident symptom associated with Gridhrasi.

Madhava Nidana
Madhavakara explains Vata Vyadhi in four chapters i.e., Vata Vyadhis,
Vatarakta, Oorusthambha and Aamavata. Description in madhavanidana is in line with
brihath trayees. Madhavakara explains in detail about shula. He mentions that vayu is
responsible for all type of shula. Prushtha shula and trika shula are mentioned in the
symptoms of vataja shula.
Madhavakara mentions that Prishta shula is caused by vata kapha.

References related to Katigraha in Madhava Nidana

Samgraha grahani24
Vataja arsas25
Vatanubandha rakta arsas26
Amavata 27
Anaha28

Gadanigraha:
Vaidya Shodhala giving importance to vatarogas, mentioned that vatavyadhi
leads to all other diseases. The description of katigraha as a separate disease is found
only in Gadanigraha. A detailed description about vyadhighatakas of katigraha is seen in

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 Review of Literature -Disease Review - Katigraha

vatarogadhikara under kayachikitsa khanda.29 However, it is to be noted that he has not

mentioned katigraga in nidanasthana. In Gadanigraha, treatment of Katigraha or
Katisthambha is elaborated in second chapter of Prayoga Khanda and nineteenth chapter
of Kayachikitsa Khanda.
He has specifically indicated Trayodashanga guggulu for Katigraha which is the
main internal drug prescribed for katigraha in our institution.
In Tailadhikara of Prayoga Khanda he gives the following preparations for katigraha.
30

31

Same as in brihath trayees, Gadanigraha also advise to look into rakta dushtihara
treatments if all other treatment modalities fail to give result.
Sarngadhara Samhita:
Description of katigraha as a separate disease is available in Sarngadhara
Samhita. Katigraha is included in vata nanatmaja vyadhi by sarngadharacharya.32
In deepika vyakhyana of Sarngadhara Samhita, Adamalla says that it is a vedana
visesha due to stambha. Sarngadhara explains various medicines for katishula and
katigraha. Erandasaptakam and rasna sapthakam are two well-known preparations
advised by Sarngadhara.

Bhava Prakasha

Bhavamisra gives a differet term Trikashula to mention the disords affecting kati
pradesha. He describes trika as the meeting point of two bons to Prishta vamsa.
Importance of rookshana therapy in katigraha can be seen in the description of
bhavamisra. He explained agni sveda and valuka sweda along with many drug
preparations like trayodasangaguggulu.

Yogaratnakara:

Yogaratnakara also included katishula in vata naanaathmaja rogas. He used

terms like kativata and katipida to denot disease of katipradesha. He has described the
usage of erandataila in katigraha, which is widely practiced in kerala irrespective of tha
ama nirama stage. He also mentioned special preparations like eranda beeja payasa and
modaka with taila, ghruta, ardraka rasa etc. for treating diseases affecting kati.

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 Review of Literature -Disease Review - Katigraha

KATIGRAHA
ETYMOLOGY

The explanation for which

33

-Churam-Atmam-Saka-
catch 34

On combining the above explanations, it shows that katigraha is a condition which leads
to the catching or stiffness of kati pradesa (low back region).

DEFINITION

produced by vata either shudha or with ama, causing ruja and stambha in kati by taking

35

SYNONYMS
The following terms are mentioned in classical texts to denote Katigraha.

Trika Graha
Kati Shoola
Trika Shoola
Kati Toda
Prishta Graha
Kati Stambha

NIDANA PANCHAKA OF KATIGRAHA

NIDANA OF KATIGRAHA
Understanding the nidana factors of a disease is very important as nidana
parivarjana, avoidance of etiological factor forms the first and foremost line of
treatment. Kaatigraha comes under the vatavyadhi spectrum and therefor vatavyadhi

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 Review of Literature -Disease Review - Katigraha

nidanas should be considered as the causative factor of katigraha. Nidana of vatavyadhi

are broadly classified in two by Caraka and Vagbhatachaarya, which are
1. Dhatukshaya and
2. Margavarodha 37

VATA KOPA NIDANA38

Vata kopa nidana mentioned in ashatanga hridaya are classified below
Ahara :
Thikta and Kashaya - Excessive intake of bitter and astringent food
Ushna food - Excessive hot foods
Alpa anna - Taking food in very less quantity
Rooksha anna - Dry foods i.e. fatless or deep fried
Pramita bhojana - Taking food long after the usual time
Vihara
Vega dhaarana - Suppression of natural urges
Vega udeerana - Forceful initiation of natural urges
Nisha jaagarana - Keeping awake at night
Athyuccha bhashana - Speaking loud for a long time
Vyaayaama - Excessive physical exercise
Maidhuna - Excessive sexual intercourse
Kaalaja
Greeshma - During summer
Vaya - In old age
Ahas - Towards the end of day
Ratri - Towards the end of night
Bhukta - Towards the end of Digestion
Manasika
Bheeta - Fear - Sudden fear or shock
Shoka - Grief
Chintha - Excessive thinking
Iatrogenic
Kriyaathiyoga - Excessive Sodhana proceures

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SAAMA NIRAAMA VATA39

The concept of saama niraama vata is considered here as the present study is
analyzing effect of rookshana in a vata predominant disease. Rookshana helps to clear of
aama and thereby produce srotosodhana and aid in treating maargaavarodha janya
vyadhi. The specific features of saama niraama vata are mentioned below. The presence
of saama vata lakshanas in a patient justifies the application of rookshana in katigraha.
Saama vata lakshana

Vibandha - Obstruction to mala and Mutra

Agni sada - Diminished function of Agni

Sthambha - Stiffness

Antra koojan - Increased bowel sounds

Vedana - Pain

Shopha - Swelling

Toda - Pricking pain

Rogavridhi in Snehaprayoga - Symptoms increases with snehadi kriya

Sooryodaya - Symptoms increases with sunrise
Meghavrita - Symptoms increases in cloudy season
Nishi - Symptoms increases at night
NIRAAMA VATA LAKSHANA

Vishada - Non slimy

Rooksha - Dry

Nirvibandha - No obstruction to mala and mootra

Alpa vedana - Less pain

Viparita gunai shanti - Symptoms reduce with the application of opposite

qualities, especially with unctuous quality application.

These characters were observed while selecting patients for this study.

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DETAILED NIDANA FACTORS OF VATAVYADHI

Specific food items which causes vatavyadhi 40

According to Susrutacharya and Ashtanga Sangraha, intake of
Aadhaki (Cajanus cajan),
Bisa (Nelumbuo nucifera),
Chanaka (Cicer arietinum),
Chirbhata (Cuccumus melo),
Harenu (Pisum sativum),
Jaambava (Eugenia jambolena),
Kalaya (Lathyrus sativus),
Kalinga (Holarrhena antidysenterica),
Kariya (Capparis decidua),
Koradusha (Paspalum scrobiculatum),
Masoora (Lens culinaris),
Mudga (Phaseolus mungo),
Nishpaava (Dolichos lablab),
Neevara (Hygroryza aristata),
Shaluka (Nelumbium speciosum),
Shushkashaaka (Dry vegetable),
Shyaamaka (Setaria italica),
Tinduka (Diospyros tomentosa),
Trunadhaanya (Grassy grain),
Tumba (Lagenaria valgaris),
Uddalaka (A variety of Paspalum scrobiculatum),
Varaka (Carthamus tinctorius) and
Viroodhaka (Germinated Seed) etc. in excessive quantity will lead to
vatavyadhi.

Specific viharas which cause vatavyadhi41

According to Ashtanga Sangraha, viharas like
Ashma bhramana (Whirling stone),

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 Review of Literature -Disease Review - Katigraha

Ashmachaalana (Shaking of stone),

Ashmavikshepa (Throwing of stone),
Ashmotkshepa (pulling down stone),
Divaasvapna (day sleep),
Dukhaasana (uncomfortable sitting),
Dukhashayya (uncomfortable sleeping),
Ghadhotsadana (strong rubbing),
Kashtabhramana (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),
Shilabhramana (Whirling of rock),
Shilachalana (Shaking of rock),
Shilavikshepa (Throwing of rock),
Shilotkshepa(Pulling down rock),
Bhaaraharana (Head loading) and
Vegadharana (Voluntary suppression of natural urges) will lead to
vatavyadhi.
Specific nidanas mentioned in Charaka Samhita
Atigamana (excessive walking)
Atipradhaavana (Excessive running)
Atiprajaagarana (Excessive awakening)
Ativyaayaama (Violent exercise)
Ativyavaaya (excessive sexual intercourse) are the main factor for
mechanical pain in low back region.

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Aama is mentioned as a causative factor for vatavyadhi in

bhaavaprakasha. 42 Description of saama vata lakshana and ama as nidana explained by
Bhavamisra illustrates the need of rookshana in katigraha.
SAMPRAPTHI
Samprapthi explains the course of progression of a disease from nidana factors.
, breaking the course of samprapthi is considered as chikitsa. So
understanding the factors involved in samprapthi of a disease has prime importance as it
is the base of treatment.

Samprapthi of Vatavyadhi According to Charaka Samhita

According to Carakaacharya, indulging in Vatakara aahara and vihaara leads to
vitiation of vata dosha. Vitiated vata settles in empty srotas (Rikta Srotas) and produce
43
disease related to that Srotas. While comm

Samprapthi of Vatavyadhi According to Vagbhata

Vagbhatacharya also follows the same samprapthi course as in charaka samhita.
He mentions dhaatu kshaya as the reason for sroto riktata. 44

Samprapthi of Vatavyadhi According to Gadanigraha

Sodalaachaarya explains the prime dosha involved in Katigraha as vata. The
condition can arise when the vitiated shudha or sama vayu takes its ashraya in the
katipradesha as kevala vataja or saama vata condition. To distinguish these two kevala
vataja and saama vata manifestations, he gives specific symptoms such as pain and
stiffness. In a vata predominant condition, shoola or pain will be the main complaint. In
saama Katigraha, stiffness will be the main disturbing factor for the patient.

Possibility of aama in Katgraha

Nidana factors mentioned in brihath trayees mainly focus on ahara and vihara
which will lead to vitiation of vata vitiation. Possibility of saama vata is not that evident
from the etiological factors in classical texts. Lifestyle in this era is highly favorable for
the production of aama. Late night food, frequent snacking, refrigerated sweetened soft
drinks, packaged virudha eatables etc account for the constant presence of aama in our

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 Review of Literature -Disease Review - Katigraha

body. This aama can produce srothorodha which in turn will produce disease. Action of
Saama vata should be equally considered in the samprapthi of vatavyadhi.

SAMPRATHI KHATAKAS OF KATIGRAHA

1. DOSHA
Vata - Vyana - Movement of patient is affected
- Samana - Account for ama and digestive issues
- Apana - Bowel irregularities seen in Katigraha
Kapha - - Kshaya leads to increased friction in joints

2. DUSHYA
Dhatu - Asthi - Pradhana Dhatu
- Rasa - Source of aama
- Maamsa
- Meda and
- Majja
Upadhatu - Snayu,
- Kandara, and
- Sira
3. UDBHAVA STHAANA
- Pakvaashaya - Pakvashaya is the main seat of vata

4. VYAKTHA STHAANA
- Kati pradesha - Katigraha manifest in Kati pradesha

5. SROTAS INVOLVED
- Asthivaha Srotas - Asthi is the main structure in Kati
- Purishavaha Srotas - Pakvashaya, the prime seat of vata is one of the
moolasthaana of purishavaha srotas
- Medovaha Srotas - Kati is is one of the moolasthaana of medovaha srotas
6. ROGA MAARGA
- Madhyama - Asthi and Sandhi comes under madhyama roga marga

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 Review of Literature -Disease Review - Katigraha

SAMPRATHI KHATAKAS OF KATIGRAHA

Chart no. 1 Schematic representation of sampraapti of Katigraha

NIDANA SEVA
Vatakopa nidana,
Aama nidaana,
Dhatukshayakara nidana

Sthaanasamsraya and
Dosha dooshya sammoorcchana in Kati

Kevala Vata Kopa Saama Vata Kopa

In Kati in Kati

Katigraha Katigraha

With vata predominant With aama lakshana

Symptoms

POORVARUPA
Poorva rupa or prodromal symptoms are the indicators of impending disease.
45
Purvarupa arise prior to the complete manifestation of a disease. Purvarupa occurs

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 Review of Literature -Disease Review - Katigraha

during the sthaanasamsra stage of shadkriyaakaala. Diagnosing a disease in the

poorvarupa stage is an important factor in the prognosis. Early detection will reduce
time, effort and will yield good treatment result.
Poorvarupa of vatavyadhi is an atypical entity among roganidana. In most of the
diseases, acharyas mention specific poorvarupas indicative of forthcoming disease
condition.
While elaborating nidana panchaka of vatavyadhi, acharya charaka states
avyaktha lakshanas (vauge or subclinical manifestation of symptoms) of vatavyadhi
46
should be considered as poorvarupa. Chakrapani clarifies the word avyakta as a few
mild symptoms occurring before manifestation of disease.
Vijayarakshita while commenting Madhava Nidana gives a better idea about
avyakta. He states that the symptoms are not exhibited clearly because of alpa nidana,
alpa lakshana and alpa aavarana of dosha.
As Katigraha is studied under vatavyadhi, vauge symptoms of back pain should
be considered as the poorvarupa.

ROOPA
Roopa or the manifestation of actual disease happens in vyakti avastha of
kriyakala. Disease will be clearly recognizable with almost all signs and symptoms. In
Katigraha the main features appearing will be pain of varied intensity and type along
with stiffness of katipradesha. In roopavastha due to pain and stiffness, the day today
activities of patient will be affected and they seek medical help. So the cardinal features
of Katigrahas as per Ayurvedic classical texts are Shoola and Graha

Shoola / Ruja : In gadanigraha, pain is mentioned as the prime symptom of.

e the characteristics of pain in katigraha.
In a typical case, pain is confined to the katipradesha or the Lumbo sacral and sacroiliac
region only.
Graha : In graha, the movements like flexion, extension, lateral flexion and rotation at
the Lumbo-sacral region are hampered either completely or partially. The degree of
affection varies depending on the presentation of etiological factors, such as the site of
the structures injured and the extent of injury and duration.

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Tenderness : Apart from these two classical symptoms, tenderness can be elicited in
conditions when there is severe pain. It can be elicited by pressing the thumb along the
whole length of the spinal column.
UPASHAYA AND ANUPASHAYA
Upashaya and anupashaya or trial and error method is having a strong
role in treatment of conditions especially with the presence of aama. Upashaya is the use
of oushadha, ahara and vihara which aid in positive result i.e. which are opposite to
qualities of disease. Anupashaya are the measures which will increase the disease if
applied. Usually in clinical practice, upashayanupashaya is applied to determine the apt
time for introduction of snehaprayoga after rookshana.
Upashaya and anupashaya for katigraha can be detected from the nidana factors.

SADHYAASADHYATA
Before commencing treatment, it is essential to know the

between curable and incurable diseases and initiate treatment in time with the full
knowledge about the various aspects of chikitsa will certainly accomplish his object of
curing the disease. 47
Prognosis depends upon the strength of vyadhi ghatakas like chronicity,
severity of symptoms, intensity nidana factors, extent of deformities etc. Prognosis of
Katigraha is not mentioned separately. It can be understood from the general
sadhyaasaadhyatha mentioned for vatavyadhi. Vatavyadhi is classified under mahagada,
which indicates the kricchra saadhyata or asaadhyata of vatarogas. In conditions where
samprapthi ghatakas are weak and patient is balavan and in youvana stage, then the
disease can be cured easily otherwise generally vatarogas are very difficult to cure 48, 49
Fatal features appear in vatavyadhi: According to Susruthaachaarya, if a
vataroga patients develop complications like
Shoona (oedema/inflammation)
Suptatvaca (Tactile senselessness),
Bhagna (fracture),
Kampa (tremors)
Aadhmaana (distension of abdomen with tenderness) and
Pain in internal organs, then he does not survive 99

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CHIKITSA OF KATIGRAHA
Katigraha is the condition where kupita vata from pakvashaya get localized in
katipradesha, afflicting asthi dhatu and vitiating snayu and kantaras. The main outcome
of this samprapthi is shola and graha in Katipradesha.
There is a set protocol for treating katigraha in our institution, which will be
dealt later. It is not possible to stick to a pre prepared treatment plan as Ayurveda
advocates for personalized treatment considering dasavidha pariksha factors.

rookshana is applied even to kevala vataja katigraha patients. Mild rookshana is done by
anulomana, deepana pachana, vyayama, atapa along with rooksha sweda or
rookshavasthi. Moderate to heavy rookshana is done done by anulomana, deepana
pachana, vyayama, atapa, lepana, rooksha sweda and rookshavasthi. After getting
niraamaavastha, a general vatahara treatment is applied.

Various components in Katigraha chikitsa are listed as below

1. Rookshana - Dehydration therapy
2. Sneha - Oleation therapy
3. Sveda - Sudation therapy
4. Virechana - Therapeutic Purgation
5. Vasthi - Medicated Enema
6. Shamana - Pacification therapy
7. Ahara - Diet regimen
8. Vihara - Lifestyle modification
9. Rasayana - Rejuvenation therapy

ROOKSHANA
Rookshana therapies are the initial set of treatments. It is done by applying
different lankhana methods like deepanam, paachanam, upavaasam, vyayama etc. which
is suitable for the patient. In patients with prominent aama lakshanas, more vigorous
rookshana is applied by combination of above said procedures along with Rooksha
sveda and / or Rooksha vasthi. Rookshana is done till patient gets samyak langhana
lakshanas and when the lab investigation like ESR and CRP values comes to normal
range. 50

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SNEHANA:
Is applied both externally in the form of Abhyanga, Dhara, Avagaha, Parisheka,
Kativasthi etc and internally as sodhananga or shamananga snehapana. Sushrutacharya
states that Sneha applied externally will reach the Majja Dhatu in 900 Matrakalas. 51
Both internal and external application of sneha requires an aama free body.
Ghritapana and taila pana can be adopted in katigraha but tailapana should be preferred
to ghritapana as taila is the paramaushadha for vata. Also some conditions like
krurakoshtata are often seen in Katigraha patients, which is a clear indication for the
application of taila.

SWEDANA:
Sudation should follow proper snehana to dislodge leena doshas and facilitate its
transportation to koshta. It is done in the form of different types of pinda swedas,
parisheka sveda, avagaha sveda, nadi sweda etc. Svedana can be done locally also.
Sveda also helps in relieving stambha, which is one of the main difficulties faced by
katigraha patients.

VIRECHANA:
Virechana52 with eranda taila is usually applied in katigraha. Virechana
stimulates parasympathetic nervous system and there by helps in relieving muscle
spasm. Eranda taila is the only oil which can be applied in aama condition. A
virechanam with Sindhuvara erandam in Katigraha is a custom among Ayurveda
physicians.
VriddhaVagbhata specifies that Virecana must be employed in Vata disorders
53
that are not subsided by Snehana and Swedana. Sneha Virecana brigs sroto shodhana
54
and quickly relieves vata vitiation.

VASTI:
Vasthi is the prime treatment modality in katigraha. Vasthi directly enters
pakvashaya, which is the main seat of vata, and pacify vata at its moolasthana. It is
55
considered as ardha chikithsa and even poorna chikithsa by kayachikithsa authorities.
Susruthachaarya mentions that all disorders of vata either sarvanga or ekanga can be
corrected by vasthi. Vangasena in Bastikarmaadhikara has quoted Vaitarana Basti,

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which is useful in KatiShula, Uru Shula, Prushta Shula, Shotha, and other Vataja
disorders. As vata control everything in body, the process which control vata has a high
position among other procedures.

SHAMANA:
Shamana chikithsa is done with the application of internal medicines. The main
formulations used in our institution are
1. Gandharvahasthadi Kashayam
2. Trayodashanga Guggulu
3. Magarasnadi Kashayam
4. Punarnavadi Kashayam
5. Chandraprabha vati
6. Rasna Saptakam Kashayam
7. Rasna Panchakam Kashayam
8. Brihat vata chinthamani rasa etc.
Taila and Ghrita yogas used in treating Katigraha
1. Rasona Taila (Cakradatta)
2. Narayana Taila (Cakradatta)
3. Mahanarayana Taila
4. Vajigandhadi Taila (Yogaratnakara)
5. Masha Taila (Cakradatta)
6. Swadanstradi Taila (Vangasena)
7. Vishagarbha Taila (Vaidya Chintamani)
8. Shatavari Taila (Sharngadhara Samhita)
9. Nakula Taila (Bhaishajya Ratnavali)
10. Vidarigandhadi Ghrita (Sushruta)
11. Bhadradharvadi Sneha (Sushruta)
12. Ashwagandhadi Ghrita (Sushruta)
13. Chagalyadi Ghrita (Sharngadhara Samhita)
14. Panchatikta Ghrita (Yogaratnakara)
15. Rasnadi Ghrita (Rasaratna samucchayam)
AHARA
Pathya and Apathya of Katigraha as elaborated in Yogaratnaakara and in
Basavarajeeyam. 56, 57

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PATHYA AHARA
Table No: 2.1 Pathya Ahara in Katigraha

Ahaara Yoga Ratnakara Bhaishajya Ratnavali

Rasa Lavana

Godhuma Godhuma
Shooka Dhanya Varga
Raktashali Puraana Dhaanya
Masha Masha
Shami Dhanya Varga
Kulatha Kulatha

Kukkuta

Tittiri

Maamsa Varga Barhi

Chataka

Jaangala maamsa

Shaileendhra
Parvata
Nakra
Matsya Varga
Gagrara
Khudisha
Jhasha
Patola
Kooshmanda
Kaaravellaka
Shigru
Shaakha Varga
Moolaka
Vaartaaka
Soorana
Tarkkari
Vaastuka

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Dadima
Parooshaka
Phala Varga
Badara
Draksha
Ghruta
Dugdha
Gorasa Varga: Kilaata
Dadhi
Koorcika

Sneha Varga Taila

Lashuna Bruhati
Tamboola Kasamarda,
Kataka
Punarnava

Anya Dravya Vatsaka

Mundi
Dunduka
Matsyandika
Mishi
Jeeraka

Vaastuka

APATHYA AHARA
Table No: 2.2 Apathya Ahara in Katigraha

Ahaara Yoga Ratnakara Bhaishajya Ratnavali

Kashaaya

Rasa Tikta

Katu
Guru anna
Anna Anashana
Abhishayandi

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Tataaka,

Jala Varga Tatinijala Sheetaambu

Dushta Jala

Shookadhanya Varga Navadhaanya

Mudga Mudgaka

Nivara Nishapava

Shameedhanya Kuruvinda Sarshapa

Kalaaya

Chanaka

Alaabu Shakala,

Ervaaru, Kanda,

Shakha Varga Bimba Trapu

Koshataki Kareera

Kareera

Kshaudra Mrinali

Anya Dravyas Nimba Sharasinimba

Tikta

VIHARA

Pathya viharas in Katigraha are

Abhyanga
Svedana - Steam bath
Ushnodaka Snana
Mardana
Veshtana
Yoga

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Vyayama
Lifestyle modifications should be done based on the nidana factors observed in
patient. Occupational environment and work related postures are the main factors which
should be corrected to manage katigraha effectively. Posture correction is one of the
main vihara which should be corrected in order to reduce recurrence of katigraha. There
are some effective yogasana and exercise methods which are helpful in relieving back
pain.

POSTURE CORRECTION

SITTING
Seat should be of knee height or slightly less than knee height.
There should be back support at least for lumbar region.
Spine should be erect while sitting
Do not sit for more than 30 minutes continuously.
Change sitting position every 15 minutes.

STANDING
Avoid asymmetrical standing (Standing on one leg)
Keep knees relaxed on comfortably straight position.

LYING
Lie on lateral side
Do not lie on your ventral surface
Be careful while getting up from bed.

WORKING
Do not carry weight asymmetrically
Avoid high heel shoes.
Avoid forward bending
Use better lifting techniques

WORK OUT
Do not make swift and vigorous movements
Cardio exercises are safe in Katigraha
Crunches and sit ups should be avoided

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Figure: 3 - Posture Corrections 58

YOGA AND EXERCISE FOR KATIGRAHA

YOGA FOR KATIGRAHA

Yoga poses helps in controlled stretching of muscles and stimulates
internal organs. Yoga poses can be practices during treatment for better result. Forward
bending poses are usually avoided in back pain conditions.
Best yoga procedures to reduce back pain are
Bhujangaasana
Merudandaasana
Salabhaasana
Savasana etc.

EXERCISE FOR KATIGRAHA

Exercise helps to strengthen paravertebral muscles and there by helps in

proper spine alignment. Some useful exercises are mentioned below.

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Figure: 4 - Exercise For Katigraha 59

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LOW BACK ACHE

Low back pain is the leading cause of activity limitation and work absence
throughout much of the world, imposing a high economic burden on individuals,
families, communities, industry, and governments. The lifetime prevalence of non-
specific (common) low back pain is estimated at 60% to 70% in industrialized countries
(one-year prevalence 15% to 45%, adult incidence 5% per year). Prevalence increases
and peaks between the ages of 35 and 55, although back pain is also reported by
adolescents and by adults of all ages. 60
In the United Kingdom, low back pain was identified as the most common cause
61
of disability in young adults, with more than 100 million workdays lost per year. It is
often ignored till it becomes a chronic disability. Pain may be the manifestation of an
underlying pathology.

CAUSES OF LOW BACK PAIN 62

Lower back pain can be caused by a variety of problems with any parts of the
complex, interconnected network of spinal muscles, nerves, bones, discs or tendons in the
lumbar spine. Typical sources of low back pain include:

The large nerve roots in the low back that go to the legs may be irritated
The smaller nerves that supply the low back may be irritated
The large paired lower back muscles (erector spinae) may be strained
The bones, ligaments or joints may be damaged
An intervertebral disc may be degenerating

An irritation or problem with any of these structures can cause lower back pain
and/or pain that radiate or which is referred to other parts of the body. While lower back pain
is extremely common, the symptoms and severity of lower back pain vary greatly. A
simple lower back muscle strain might be excruciating enough to make the person seek
medical help, while a degenerating disc might cause only mild, intermittent discomfort.

There are several symptoms that are fairly consistent for people with lower back pain
or neck pain from degenerative disc disease, including:

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Pain that is usually related to activity and will flare up at times but then return to a
low-grade pain level, or the pain will go away entirely
The amount of chronic pain - referred to as the patient's baseline level of pain - is
quite variable between individuals and can range from almost no pain or just a
nagging level of irritation, to severe and disabling pain
Severe episodes of back or neck pain that will generally last from a few days to a few
months before returning to the individual's baseline level of chronic pain
Chronic pain that is completely disabling from degenerative disc disease does happen
in some cases, but is relatively rare
Activities that involve bending, lifting, and twisting will usually make the patient's
pain worse
Certain positions will usually make the pain worse. For example, for lumbar
degenerative disc pain, the pain is generally made worse with sitting, since in the
seated position the lumbosacral discs are loaded three times more than standing
Walking, and even running, may actually feel better than prolonged sitting or
standing
Patients will generally feel better if they can change positions frequently
Patients with lumbar Degenerative Disc Diseases will generally feel better lying in a
reclining position (such as with legs propped up in a recliner), or lying down with a
pillow under the knees, since these positions relieve stress on the lumbar disc space.

COMMON CAUSES OF LUMBAR BACKACHE 62

1. Lumbar strain,

2. Nerve irritation,

3. Lumbar radiculopathy,

4. Bony encroachment,

5. Conditions of the bone and joints and

6. Other causes

Lumbar strain (acute, chronic)

A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of
the low back. The stretching incident results in microscopic tears of varying degrees in

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these tissues. Lumbar strain is considered one of the most common causes of low
back pain. The injury can occur because of overuse, improper use, or trauma. Soft-tissue
injury is commonly classified as "acute" if it has been present for days to weeks. If the
strain lasts longer than three months, it is referred to as "chronic."
Lumbar strain most often occurs in people in their forties, but it can happen at
any age. The condition is characterized by localized discomfort in the low back area
with onset after an event that mechanically stressed the lumbar tissues. The severity of
the injury ranges from mild to severe, depending on the degree of strain and resulting
spasm of the muscle ranges from mild to severe, depending on the degree of strain and
resulting spasm of the muscles of the low back. The diagnosis of lumbar strain is based
on the history of injury, the location of the pain, and exclusion of nervous system injury.
The treatment of lumbar strain consists of resting the back, medications to
relieve pain and muscle spasm, local heat applications, massage, and eventual (after the
acute episode resolves) reconditioning exercises to strengthen the low back and
abdominal muscles. Long periods of inactivity in bed are no longer recommended, as
this treatment may actually slow recovery. Spinal manipulation for periods of up to one
month has been found to be helpful in some patients who do not have signs of nerve
irritation. Future injury is avoided by using back-protection techniques during activities
and support devices as needed at home or work.

Nerve irritation:
The nerves of the lumbar spine can be irritated by mechanical pressure
(impingement) by bone or other tissues, or from disease, anywhere along their paths -
from their roots at the spinal cord to the skin surface. These conditions include lumbar
disc disease (radiculopathy), bony encroachment, and inflammation of the nerves caused
by a viral infection (shingles).

Lumbar radiculopathy:
Lumbar radiculopathy is nerve irritation that is caused by damage to the discs
between the vertebrae. Damage to the disc occurs because of degeneration of the outer
ring of the disc, traumatic injury, or both. As a result, the central softer portion of the
disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or
its nerves as they exit the bony spinal column. This rupture is what causes the
commonly recognized "sciatica" pain of a herniated disc that shoots from the low back

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and buttock down the leg. Sciatica can be preceded by a history of localized low-back
aching or it can follow a "popping" sensation and be accompanied by numbness and
tingling.
The pain commonly increases with movements at the waist and can increase
with coughing or sneezing. In more severe instances, sciatica can be accompanied
by incontinence of the bladder and/or bowels. The sciatica of lumbar radiculopathy
typically affects only one side of the body, such as the left side or right side, and not
both. Lumbar radiculopathy is suspected based on the above symptoms. Increased
radiating pain when the lower extremity is lifted supports the diagnosis. Nerve testing
(EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities
can be used to detect nerve irritation. The actual disc herniation can be detected with
imaging tests, such as CAT or MRI scanning. Treatment of lumbar radiculopathy ranges
from medical management to surgery. Medical management includes patient education,
medications to relieve pain and muscle spasms, cortisone injection around the spinal
cord (epidural injection), physical therapy, and rest.
With unrelenting pain, severe impairment of function, or incontinence (which
can indicate spinal cord irritation), surgery may be necessary. The operation performed
depends on the overall status of the spine and the age and health of the patient.
Procedures include removal of the herniated disc with laminotomy (a small hole in the
bone of the lumbar spine surrounding the spinal cord), laminectomy (removal of the
bony wall), by needle technique (percutaneous discectomy), disc-dissolving procedures
(chemonucleolysis), and others.

Bony encroachment:
Any condition that results in movement or growth of the vertebrae of the lumbar
spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes
of bony encroachment of the spinal nerves include narrowing
of, spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis
(compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the
spinal canal). Spinal-nerve compression in these conditions can lead to sciatica pain that
radiates down the lower extremities. Spinal stenosis can cause lower-extremity pains
that worsen with walking and are relieved by resting (mimicking the pains of poor
circulation).

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Treatment of these afflictions varies, depending on their severity, and ranges

from rest and exercises to epidural cortisone injections and surgical decompression by
removing the bone that is compressing the nervous tissue Bone and joint conditions:
Bone and joint conditions that lead to low back pain include those existing from birth
(congenital), those that result from wear and tear (degenerative) or injury, and those that
are due to inflammation of the joints (arthritis).

Conditions of the bone and joints:

Congenital bone conditions:
Congenital causes of low back pain include scoliosis and spina bifida. Scoliosis
is a lateral curvature of the spine that can be caused when one lower extremity is shorter
than the other (functional scoliosis) or because of an abnormal architecture of the spine
(structural scoliosis). Children who are significantly affected by structural scoliosis may
require treatment with bracing and/or surgery to the spine. Adults infrequently are
treated surgically but often benefit by support bracing. Spina bifida is a birth defect in
the bony vertebral arch over the spinal canal, often with absence of the spinous process.
This birth defect most commonly affects the lowest lumbar vertebra and the top of the
sacrum
Occasionally, there are abnormal tufts of hair on the skin of the involved area.
Spina bifida can be a minor bony abnormality without symptoms. However, the
condition can also be accompanied by serious nervous abnormalities of the lower
extremities.

Degenerative bone and joint conditions:

With age the water and protein content of the body's cartilage changes. This
change results in weaker, thinner, and more fragile cartilage. Because both the discs and
the joints that stack the vertebrae (facet joints) are partly composed of cartilage, these
areas are subject to degenerative changes over time. Degeneration of the disc is called
spondylosis. Spondylosis can be noted on X-rays of the spine as a narrowing of the
normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that
predisposes the disc to herniation and localized lumbar pain ("lumbago") in older
patients.
Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of
localized lumbar pain that can be detected with plain X-ray testing. These causes of

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degenerative back pain are usually treated conservatively with intermittent heat, rest,
rehabilitative exercises, and medications to relieve pain, muscle spasm, and
inflammation.

Injury to the bones and joints:

Fractures of the lumbar spine and sacrum bone most commonly affect elderly
people with osteoporosis, especially those who have taken long-term cortisone
medication. For these individuals, occasionally even minimal stresses on the spine (such
as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can
collapse (vertebral compression fracture). The fracture causes an immediate onset of
severe localized pain that can radiate around the waist in a band-like fashion and is
made intensely worse with body motions. This pain generally does not radiate down the
lower extremities. Vertebral fractures in younger patients occur only after severe
trauma, such as from motor-vehicle accidents or a convulsive seizure.
In both younger and older patients, vertebral fractures take weeks to heal with
rest and pain relievers. Compression fractures of vertebrae associated
with osteoporosis can also be treated with a procedure called vertebroplasty or
kyphoplasty, which can help to reduce pain. In this procedure, a balloon is inflated in the
compressed vertebra, often returning some of its lost height. Subsequently, a "cement"
(methymethacrylate) is injected into the balloon and remains to retain the structure and
height of the body of the vertebra. Pain is relieved as the height of the collapsed vertebra
is restored.

Arthritis:
The spondyloarthropathies are inflammatory types of arthritis that can affect the
lower back and sacroiliac joints. Examples of spondyloarthropathies include reactive
arthritis (Reiter's disease), ankylosing spondylitis, psoriatic arthritis, and the arthritis
of inflammatory bowel disease. Each of these diseases can lead to low back pain and
stiffness, which is typically worse in the morning. These conditions usually begin in the
second and third decades of life. They are treated with medications directed toward
decreasing the inflammation.

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OTHER CAUSES OF LOWER BACK PAIN 62

Other causes of low back pain include
Kidney problems,
Pregnancy,
Ovary problems, and
Tumors.

Kidney problems
Kidney infections, stones, and traumatic bleeding of the kidney are frequently
associated with low back pain. Diagnosis can involve urine analysis, ultrasound, or other
imaging studies of the abdomen.

Pregnancy
Pregnancy commonly leads to low back pain by mechanically stressing the
lumbar spine (changing the normal lumbar curvature) and by the positioning of the baby
inside of the abdomen. Additionally, the effects of the female hormone estrogen and the
ligament-loosening hormone relaxin may contribute to loosening of the ligaments and
structures of the back. Pelvic-tilt exercises and stretches are often recommended for
relieving this pain. Women are also recommended to maintain physical conditioning
during pregnancy according to their doctors' advice. Natural labor can also cause low
back pain.

Ovary problems
Ovarian cysts, uterine fibroids, and endometriosis may also cause low back pain.
Precise diagnosis can require gynaecologic examination and testing.

Tumors
Low back pain can be caused by tumors, either benign or malignant, that
originate in the bone of the spine or pelvis and spinal cord (primary tumors) and those
which originate elsewhere and spread to these areas (metastatic tumors). Symptoms
range from localized pain to radiating severe pain and loss of nerve and muscle function

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(even incontinence of urine and stool) depending on whether or not the tumors affect the
nervous tissue.
Tumors of these areas are detected using imaging tests, such as plain X-rays, nuclear
bone scanning, CAT and MRI scanning.

UNCOMMON CAUSES OF LOW BACK PAIN 62

Uncommon causes of low back pain include
1. Paget's disease of bone,
2. Bleeding or infection in the pelvis,
3. Infection of the cartilage and/or bone of the spine,
4. Aneurysm of the aorta, and
5. Shingles.

Paget's disease of bone

Paget's disease of the bone is a condition of unknown cause in which the bone
formation is out of synchrony with normal bone remodelling. This condition results in
abnormally weakened bone and deformity and can cause localized bone pain, though it
often causes no symptoms. Paget's disease is more common in people over the age of
50. Heredity and certain unusual virus infections have been suggested as causes.
Thickening of involved bony areas of the lumbar spine can cause the radiating lower
extremity pain of sciatica
Paget's disease can be diagnosed on plain X-rays. However, a bone biopsy is
occasionally necessary to ensure the accuracy of the diagnosis. Bone scanning is helpful
to determine the extent of the disease, which can involve more than one bone area. A
blood test, alkaline phosphatase, is useful for diagnosis and monitoring response to
therapy. Treatment options include aspirin, other anti-inflammatory medicines, pain
medications, and medications that slow the rate of bone turnover.

Bleeding or infection in the pelvis

Bleeding in the pelvis is rare without significant trauma and is usually seen in
patients who are taking blood-thinning medications, such as warfarin. In these patients,
a rapid-onset sciatica pain can be a sign of bleeding in the back of the pelvis and
abdomen that is compressing the spinal nerves as they exit to the lower extremities.
Infection of the pelvis is infrequent but can be a complication of conditions such

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as diverticulosis, Crohn's disease, ulcerative colitis, pelvic inflammatory disease with

infection of the Fallopian tubes or uterus, and even appendicitis. Pelvic infection is a
serious complication of these conditions and is often associated with fever, lowering
of blood pressure, and a life-threatening state.

Infection of the cartilage and/or bone of the spine

Infection of the discs (septic discitis) and bone (osteomyelitis) is extremely rare.
These conditions lead to localized pain associated with fever. The bacteria found when
these tissues are tested with laboratory cultures include Staphylococcus
aureus and Mycobacterium tuberculosis. TB infection in the spine is called Pott's
disease.

Aneurysm of the aorta

In the elderly, atherosclerosis can cause weakening of the wall of the large
arterial blood vessel (aorta) in the abdomen. This weakening can lead to aneurysm of the
aorta wall. While most aneurysms cause no symptoms, some cause a pulsating low back
pain. Aneurysms of certain size, especially when enlarging over time, can require
surgical repair with a grafting procedure to repair the abnormal portion of the artery.

Shingles (herpes zoster)

Is an acute infection of the nerves that supply sensation to the skin, generally at
one or several spinal levels and on one side of the body (right or left). Patients
with shingles usually have had chickenpox earlier in life. The herpes virus that
causes chickenpox is believed to exist in a dormant state within the spinal nerve roots
long after the chickenpox resolves. In people with shingles, this virus reactivates to
cause infection along the sensory nerve, leading to nerve pain and usually an outbreak of
shingles (tiny blisters on the same side of the body and at the same nerve level). The
back pain in patients with shingles of the lumbar area can precede the skin rash by days.
Successive crops of tiny blisters can appear for several days and clear with crusty
inflammation in one to two weeks. Patients occasionally are left with a more chronic
nerve pain (post herpetic neuralgia).
Summary of causes of low back ache
A. Low back ache due to Spinal conditions
B. Low back ache due to Non-spinal conditions

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Low back ache due to Spinal origin is again classified into congenital and acquired.
Low back ache due to Congenital Spinal conditions
a) Spondylolisthesis
b) Spina bifida
c) Hemi vertebrae
Low back ache due to Acquired Spinal conditions
a) Infections
b) Inflammation
c) Metabolic
d) Neoplastic
e) Traumatic
f) Iatrogenic
g) Degenerative
h) Osteoarthritis
i) Spondylolisthesis
j) Prolapsed Intervertebral disc

RISK FACTORS FOR LOW BACK PAIN 62

Risk factors for low back pain include
Athletic activity,
Heavy lifting,
Throwing,
Moving luggage,
Traumatic injury,
Kidney infection,
Pregnancy,
Osteoporosis, and
Aging.

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DIAGNOSIS OF LOW BACK PAIN 62

The diagnosis of low back pain involves a review of the history of the illness and
underlying medical conditions as well as a physical examination. It is essential that a
complete story of the back pain be reviewed including injury history, aggravating and
alleviating conditions, associated symptoms (fever, numbness, tingling, incontinence,
etc.), as well as the duration and progression of symptoms. Aside from routine abdomen
and extremity evaluations, rectal and pelvic examinations may eventually be required as
well. Further tests for diagnosis of low back pain can be required including blood and
urine tests, plain film X-ray tests, CAT scanning, MRI scanning, bone scanning, and
tests of the nerves such as electromyograms (EMG) and nerve conduction velocities
(NCV)
Prognosis of low back pain
The outlook for low back pain absolutely depends on its precise cause. A
generally heal entirely with minimal treatment. On the othe
re irritating the spinal cord can require significant surgical repair
and the outlook depends on the surgical result. Long-term optimal results often
involve exercise rehabilitation programs that can involve physical therapists.

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VASTHI

NIRUKTHI

Word Vasthi has its origin from root

1
. Word
vasthi has been used with different meanings such as the one which covers urine, the

drug. The word vasthi can be used as male or female gender according to situation. 1

DEFINITION 2

A. As the procedure is done with processed urinary bladder (vasthi) of

animals, it is called vasthi2.
B. The procedure gets the same name as per adhaaraadheya bhava.
C. As the medicine introduced in the form of enema through rectum reaches
Vasthi, area of urinary bladder first, the procedure is named as vasthi.
D. Vasthi is defined in Charaka Samhita as the procedure in which the
medicine entering into umbilical region, Kati and kukshi churns up mala
and doshas, spreads its effect allover body and easily comes out with
morbid dosha and faecal matter.

IMPORTANCE OF VASTHI
A. Ardha chikitsa Sampoorna Chikithsa3
Charaka Samhita and Vagbhataachaarya consider Vasthi as Ardha
chikitsa. Vasthi is the prime treatment for vata dosha, which is
responsible for the movement and localization (vikshepa and samhara)
of faecal matter (vit), kapha, pitta and other malas. Vasthi is even
considered as Sampoorna chikitsa due to the above said qualities of
vasthi
B. Effective in all conditions 4

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Vasthi is useful in conditions arising due to anomalies in Vata, Pitta,

Kapha, Raktha, Samsarga and Sannipatha Susruthaacharya also

C. Quick action5
One of the important quality of vasthi is its ability to produce sudden
effects like shodhana and tarpana without any adverse effects.
D. Amrutham 6

wide application in infants and aged

TYPES OF VASTHI

Vasthi is classified in three broad varieties:

I. Asthaapana (Decoction Enema)

II. Anuvasana (Unctuous Enema) and

III. Uttaravasthi (Vaginal or ureteric enema)

Susruthaacharya included Uttaravasthi in Anuvasana vasthi 7

Asthapana vasthi 8

Asththaapana vasthi gets the name from the specific functions such as

Nirooha is another name given or decoction enema as it is explained to have

unimaginable actions. Nirooha can be modified to suite a variety of disease conditions
by altering vasthi dravya combination. Some of the actions produced by nirooha are
uthklesana, samshodhana, samshamana, lekhana, brimhana, vajeekarana etc. One of
the popular nirooha variant is maadhutailika, which has got many varieties like
yaapana, yuktharatha, sidhavasthi, doshahara vasthi etc.

Anuvasana Vasthi 9

It is also known as Snehavasthi or snaihika vasthi as only lipid base

medicine is used in this type of enema. Anuvasana vasthi gets the name as it does not
produce any ill effects even if retained in body for one day. Based on the quantity

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used, Chakrapaani and Dalhanaachaarya classified anuvasana into three, which are
Sneha vasthi, anuvasana vasthi and maatraavasthi.

Table No. 2.4.1 Indication of Asthaapana vasthi 10

ASTHAAPANA YOGYA AH/AS 10 CH 11 SU 12

Gulma + +
Anaha +
Khuda + + +
Pleeha + +
Shudhathisaara + + +
Shoola + +
Jeernajwara +
Prathishyaaya + +
Shukra graha + +
Anila graha + + +
Malagraha + + +
Mootra graha + + +
Vardhma + + +
Asmari + +
Rajonaasha +
Rajakshaya +
Daaruna anilaamaya +
Sarvaanga roga + + +
Ekaanga roga + +
Kukshi roga +
Bala, Varna, Maamsa kshaya +
Shukra kshaya + +
Aadhmaana + + +
Udaavartha, Aanaaha, Supthi, +
Krimikoshta +
Parvabheda +

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Hridroga +
Bhagandara +
Unmaada +
Sirashoola + + +
Hrithsoola, Paarswasoola +

Katishoola - Graha +
Prishtasoola +
Vepathu +
Akshepaka +
Anga gourava +
Athilaaghava + + +
Sphik Uru Janu Jangha soola +
Bahu Paani Prapada Anguli
+
Nakha soola
Yoni shoola + +
Sthana, Parva asthi Shoola +
Shosha +
Sthambha +
All vata roga explained in
+
maharogaadhyaaya
Aantrakoojana +
Parikarthika +
Jwara + +
Thimira + +
Arditha +
Manya graha + +
Hanu graha +
Mooda garbha + +
Mootra krichra +

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Table No. 2.4.2 Contraindication of Asthaapana vasthi

ANASTAAPYA CH 14 SU. 15 AS 13 VYAAPATH

Athisnighdha + + Dushyodara
Snehapeetha + Moorcha
Ajeerni + + Swayathu
Urakshatha + + + Ashu pida of deha
Brisham krisha + + + Make more krisha
Amaathisaara + +
Vamimaan + + +
Urdhwa gamana of
Prasaktanishtiva, Hikka + +
nirooha
Swasa, Kasa, + + +
Prameha,Arsa, Kushta + + + Roga vruddhi
Adhmaana + +
Alpa varcha +
Shoona paayu +
Krithaahaara +
Badhodara + +
Mrityu by Bhrisatara
Chidrodara + +
aadhmaana
Udakodara + +
Garbha vyaapath, Aama
In Garbhini before Seven
+ + garbha paata leads to
months
daaruna roga
Alpaagni, Uthklishta
+ + + Theevra arochaka
dosha
Yaana Klaanatha + Aashu Deha shoshana
Athi durbala + +
As the person cannot
Kshudaartha +
tolerate oushadhabala,
Thrushnaartha + +
Praanoparodha happens
Shramaartha +
Bhukthabhakta + + Vishtmbha of mala, asthi
Udakapeeta + + and anna causes mrithyu

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Vamita, Virikta + + Kshatha kshara iva daaha

Vivrita urdhwa srotas
Krita Nasya Karma + +
causes aasya vibhramsa
Urdhva upaplavana of
Krudha, Bheeta +
vasthi
Vyapath due to
Mattha, Moorchitha + +
chittopaghaata

Alasaka +
Aamadosha + Aamadoshothpatti
Pandu +
Arochaka +
Unmada +
Shoka +
Sthoulya +
Baala +
Vridha +

Indication of Anuvasana vasthi 12

All persons indicated for aasthaapana are arha for anuvasana, especially
persons with athi agni, who are rooksha, and kevala vata rogi are indicated for
anuvasana

Table No. 2.4.3 Contraindication of Anuvasana

ANANUUVASYA CH 14 SU 15 AH 13 VYAPATH

Naasthaapya + + +

Navajwara +

Pandu + + +
Doshothklesha causes udara
Kamala + +

Prameha + +

Niranna + + Urdwagamana

Prathisyaya +

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Pleehodara + + +
Prabhuta dosha vrudhi
Kaphodara + + +

Urusthambha + +

Athisaara + +
Prabhuta dosha vrudhi
Vishapeeta + +
Kaphaja
+ +
abhishyanda
Gurukoshta + +

Sleepada + +

Galaganda + +

Apachi + +

Durbala +
Manda tara agni
Mandaagni +

Arochaka + Reduces annagridhi

Abhishyanda, adhmana and
Arsha + + pranahimsa due to
apratyaagamana
Krimikoshta + + Prabhuta doshavrudhi

Prameha + +
Rogavrudhi
Kushta + +

Sthoulya + +

Vasthi netra 16

Vasthi netra should be made of metals like swarna, rajata, tamra, iron,
brass. Acharya also mention the following materials for making vasthi netra like bone,
wood, bamboo reed, ivory, horn and gems. Vasthi netra should be straight, in the shape
of gopccha with a gutika mukha (rounded tip). It should be made with three Karnikas
(rings). Presently Plastic vasthi netra with classically mentioned features are used.

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Table No. 2.4.4 Measurement of Vasthinetra According to Charaka 17

Age Length in Angula Diameter

6 years 6 Mudga
12 years 8
20 years 12 Karkandhu

2.4.5 Measurement of Vasthinetra According to Chakrapani 17

Age Length in Angula Diameter
6 years 6 Mudga
6 to 12 years Increase 1/3 angula per year
12 years 8
12 to 20 years Increase 1/2 angula per year
20 years 12 Karkandhu

2.4.6 Measurement of Vasthinetra According to Vagbhata and Susruta

According to Vagbhata 18 According to Susruta 19

Distance of
Diameter Gutika
Length Length Diameter of Karnika
Age of internal Age mukha
Angula Angula Putaka end from tip in
canal end
angula

Up to
<1 Vana
5 1 6 Kanishtanguli Mudga 1.5
Year mugda
Year
1
6 Mugda
Year
7 8
7 Masha 8 Anamikanguli Masha 2
Years Years
12
8 Kalaya
Years
16 Klinna 16
9 10 Madhyanguli Kalaya 2.5
Years kalaya Years
20 25
12 Karkandu 12 Kanishtanguli Karkandu 3
Years Years

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Vrana vasthi netra by Susruta:

Length - 8 Angula
Paasage allowing - Mudga

Vasthi Putaka 20

Bladder of aged ox, buffalo, deer, goat etc. is used as vasthi putaka. If these are
not available, skin of thigh, neck of plava, leather or vastra smeared with
madhucchishta can be used. The vasthi obtained should be soft, clean, and firm,
without vessels or foul smell. It should be processed in kashayarasa drugs and tanned
to red color. Presently polyethylene bags above 100 microns thickness and rexin
material are widely used as vasthiputaka.

DOSAGE OF ASTHAAPANA

Table No. 2.4.7 Quantity of vasthidravya acc. to Charaka 21 and vagbhata 22

Age Dose in Pala

1 Year 2

12 Years 12

16 Years 20

18 70 Years 24

Above 70 Years 20

Table No. 2.4.8 Quantity of vathidravya according to Susruta 23

Age Dose in Prasrta

1 Year 2

8 Years 4

16 Years 8

25 70 Years 12

Above 70 Years 8

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Table No. 2.4.9 Quantity of vathidravya as per Sarngadhara & Bhavaprakasha21

Maatra Quantity In Palam

Pravara 1 ¼ Prastham 20 Palam

Madhyama 1 Prastham 16 Palam

Heena 3 Kudavam 12 Palam

According to kasyapa, the dose can be increased or decreased based on vaya,

bala, roga, and rogi. Kasyapa gives a dosage pattern for Snehavasthi based on age and
advised to take three times of snehavasthi dose for Nirooha. 26

In this study, dosage of vasthi dravya is 300 ml. which is lesser than the heena
maatra mentioned by Sarngadhara and Bhaavaprakasha. This quantity has been in
practice for many years in our hospital. The quantity is minimized to reduce
complications and as the aim of rookshavasthi is rookshana not shodhana.

Dosage of Anuvasana

According to Charakacharya, 1/4th quantity of niroohavasthi is taken for

snehavasthi. As nirooha vasthi dose is described based on age, quantity of sneha vasthi
also can be calculated by multiplying the nirooha quantity of a specific age with 0.25.

Table No. 2.4.10 Anuvasana Dosage as per to Sarngadhara and

Bhavaprakasha

Quantity of Snehavasthi dravya as per Sarngadhara and Bhavaprakasha 27,28

Maatra In Palam Name by Gayadasa

Pravara 6 Palam Snehavasthi

Madhyama 3 Palam Anuvasana

Heena 1.5 Palam Matravasthi

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Table No. 2.4.11 Anuvasana Dosage according to Kasyapa

Age Dose
3 Years 3 Karsham
4 Years 1 Palam
6 Years 1 Prasrtam
12 Years 2 Prasrtam
16 Years 4 Prasrtam
Vardhakya Decrease Gradually

VASTHI PROCEDURE 29

In charaka Samhita, it is mentioned to consider factors like dosha, oushadha,

desa, kala, satmya, satva, vaya, bala etc.

Anuvasana vidhi

Before administering asthaapana, the person is made snigdha with anuvasana.

According to charaka, in a course of panchakarma, anuvasana is to be started

on the ninth day after purgation. Ashtanga hridaya and susrutha advise to start
anuvasana on 8th day after virechana.

In Gridhrasi chikithsa, it is mentioned that vasthi is given before urdhva and

adha sudhi will be useless like giving ahuthi in ash.

Vrinda madhava and vangasena have advised to give either kshara vasthi or
vaitharana vasthi in virechana anarhaas having malasanchaya before anuvasana vasthi.

It should be given in day time only especially in hemantha sisira and

vasantha. If given at night, it causes dosha uthklesha.

Anuvasana is given at night if: 30

- A samyak niroohitha rogi has agnibala and vatha vridhi.
- If pitta lakshanas like daaha are seen in ushnakaala
- Kevala vata rogi and teevra vaata rogaarditha
- Dry body
- Minimal vitiation of pitta and kapha
- In sarath greeshma varsha

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Poorva karma of Anuvasana

After abhyanga, ushnodaka snana and mangala karma, drava pradhna ushna
lakhu anna with a little bit of sneha is given in a quantity of 1/4 th less than usual meal.
Charaka contra indicates snigdha anna to avoid vata and agni dushti due to application
of sneha in urdhva and adha maarga.

According to susruta, Rooksha anna causes bala varna haani and vishtambha.
Athi snigdha anna causes mada murcha agnisada and hrillasa. There should be maamsa
rasa, ksheera, yoosha according to vyadhi or saathmya. After eating the person should
walk (classical recommendation is to walk 100 steps) and should attend to urges. If
dravaamsa is less in food or urges are not attended, it causes vyaapath by aavarana of
sneha with anna, purisha or mutra.

h indicates that vasthi should be administered soon after food. Dalhana

mentions that if anuvasana is delayed, food will enter vidagdhaavastha and will
produce Jwaram.

Shayana vidhi 31

Lie on a cot with height upto knee, in left lateral position, in a room devoid of
breeze.
With head towards east and foot end of cot raised slightly
Keep body straight and fold left arm and keep under head.
Extend left leg and flex right.
In this position, guda valis on left side disappears and vasthi dravya easily
enters guda.
Anuvasana Preparation 32, 33

Preparation of vastidravya

Generally, taila in chikkana or madhyama paka prepared with amla and

vatahara dravya are used for anuvasana. Charakaachaarya advises to avoid aama taila
for vasthi as it cause abhishyanda of guda.

Chakrapani quotes that majja should not be used for anuvasana but charaka and
susruta indicated majja in anuuvasana for different conditions.

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Susruta advise to add saindhava and satahva as prakshepa dravya in anuvasana

just before administration. Sarngadhara mentioned the quantity of prakshepa dravya to
be added in anuvasana as 1 Masha for 1 Pala of sneha.

In Swastha, Vilwa taila, Jeevaniya taila and Phala taila are indicated in vata,
pitta and kapha dosha respectively.

Preparation of vasthiyantra for administration

Required amount of sneha is filled in putaka (Glycerin syringe in case of

Matravasthi). Place Vasthinetra inside putaka, hold netra and a part of putaka together
with left hand and with right hand, carefully tuck in the remaining portion of putaka by
removing air from putaka. Plug cotton in netra mukha and tie the putaka to the
karnikas at base of netra.

Administration of Anuvasana

Putaka should be held in right hand, hold Vasthinetra with left thumb and
middle finger and close Vasthinetra opening with index finger. Smear oil or ghee on
anal opening and on nozzle for lubrication. Insert nozzle straight and parallel to
vertebral column till karnika.

Putaka is pressed by holding the netra with left thumb and index finger and
pressure is given with right hand so that the dravya will enter in a steady manner and
the squeezing should be completed in 30 minutes. A little dravya is left behind to
prevent entry of air. Remove netra slowly after administration. If patient gets natural
urges during administration, the nozzle is removed and patient is allowed to attend
urges and remaining drug is administered afterwards

Paschat Karma

Patient should lie on his back with a pillow under head for 100 matra. Legs
should be flexed and extended three times. Palm sole and buttocks should be beaten
thrice gently with palm. Foot end of cot is raised three times. Heels and buttocks are
is stroked with his own heel. All these
measures help to retain vasthidravya.

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Samyak yoga and athiyoga 34

Are same as snehapana

Samyak yoga 35

Dravya comes out after some time with vit, mutra, vata without any difficulties.
Budhi indriya prasadam
Rakthadi dhathu prasadam
Proper vega and sleep
Lakhutva and bala

Ayogya lakshanas 36

Udara prishta parswa adha sariira vedana

Roukshya and kharatva of body
Mala mutra anila sanga

Athiyoga 37

Hrillasa
Klama
Murcha
Moha
Sada
Daha
Pravahika

Pratyaagamana kaalam 37

Anuvasana usually comes out after three yama. If it comes out suddenly after
pranidhana, another vasthi with a less amount should be administered.

Vasthi comes out immediately in cases of

Atyushna, theekshna guru dravyam

Vataprapeedanam
Excess prakshepa dravya
Sa vaata pranidhaanam

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Paschath karmam 38

Light food is given in the evening if the patient has agni deepthi. Wait for one
ahoratra if dravya does not come out. After one ahoratra, phalavarthi or theekshna
nirooha is applied to evacuate sneha. No food is given till the elimination of sneha.
The condition needs no medical intervention if the non-elimination is due to roukshya
of koshta and no upadrava like jaadya are present.

Hot water boiled with shunti and dhanyaka can be given on next morning for
complete digestion of remnant snehaand to mitigate vata kapha. Luke warm water is
given in pittapradhana condition and peya is avoided during anuvasana as it causes
abhishyanda. Considering agnibala, another anuvasana can be given on third or fifth
day. It can be given daily to patients with agnideepthi, roukshya, vataroga, udavarta,
vataprakopa, vyayaamanitya.

Sneha is absorbed quickly in these patients like water absorbed by sand. In

other patients, sneha takes three days to get absorbed. Like this, three to five
anuvasana can be given till samyak snigdha lakshana are observed. Susruta advise to
give six, seven or nine vasthis continuously as required and then a nirooha for
shodhana is applied. Even after snehavasthi, if patient is asnigdha, snehana nirooha is
given.

ASTHAAPANA VIDHI 39

Asthaapana is done on third or fifth day of anuvasana. The starting day is

planned by selecting a shuklapaksha. The patient who has attended his natural urges
properly after jeernaajirna vichinthanam should perform mangala karmas as per vidhi.
After abhyanga and sweda, when the patient is na athi bubhukshita (not too hungry)
and when madhyahna is just started (around 10.00 am), the doctor should administer a
suitable vasthi after consulting and in the presence of vasthivisaaradaas. 145

DOSAGE OF ASTHAAPANA

24 pala is the standard maximum dose for nirooha vasthi. There are many
explanations available in different samhitas regarding dosage of different ingredients
in a vasthi preparation.

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Table no. 2.4.12 Dosage of Asthaapana according to Charaka 40

Kvatha 5 Prassruta 10 Palam

Vata 3 Prassruta 1/4 6 Palam

Sneham Pitta 2 Prassruta 1/6 4 Palam

Kapha 1 ½ Prassruta 1/8 3 Palam

Chakrapani states that makshika, lavana and kalkka should be added in a quantity
considering dosha dushya and prakruthi of patient.
Jathukarna mentioned the quantity of kalkka as 2 palam in all vasthis.
According to Hareetha, Saindhava should be 1 Karsham and makshikam 2 palam.
Table no. 2.4.13 Dosage of Asthaapana According to Susruta 41

Kvatha 4 Prasruta 8 Pala

Vata 1/4th of total quantity 6 Pala

Svastha 1/5th of total quantity 4 ¾ Pala

Sneham
Pitta 1/6th of total quantity 4 Pala

Kapha 1/8th of total quantity 3 Pala

Kalka 1/8th of total quantity 3 Pala

Other ingredients As per Vaidya yukthi

Table no. 2.4.14 Dvaadasa Prasrutha explained by Susruta

INGREDIENT QUANTITY

Saindhavam 1 Karsham

Madhu 2 Prasrutham

Kalka 1 Prasrutham

Sneham 3 Prasrutham

Kvatham 4 Prasrutham

Avapam 2 Prasrutham

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Table no. 2.4.15 Dosage of Asthaapana According to Vangasena 42

INGREDIENT VATA PITTA KAPHA

Madhu 3 4 6

Sneha 6 4 3

Kalkka 2 2 2

Kvatha 10 10 10

Avapa 3 4 3

TOTAL 24 Pala 24 Pala 24 Pala

Table no. 2.4.16 Dosage of Asthaapana According to Vagbhata 43

INGREDIENT QUANTITY

20 Pala drug + 8 madana phalam + 16 times water boil

Kvatha
and reduce to 1/4th

Sneha Vata 1/4th of Kvatha

Pitta and Svastha 1/6th of Kvatha

Kapha 1/8th of Kvatha

Kalkkam 1/8th of Kvatha

Guda 1 Pala

Madhu According to Yukthi

Saindhava According to Yukthi

Avaapa According to Yukthi

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Table no. 2.4.17 Dosage of paadahina vasthi according to Vagbhata

INGREDIENT QUANTITY

Makshikam 3 Pala

Lavanam ½ Karsham

Sneha 3 Pala

Kalkkam 2 Pala

Kvatham / Dravyam 10 Pala

Most of the acharyas mentioned madanaphala as one of the ingredients in all

nirooha to be used in kalkka or kvatha.

Vasthi samyojana vidhi 44

Nirooha is prepared in a special way by adding and triturating ingredients in

the following order.

Step 1 Makshika and lavana mixed well

Step 2 Add sneha and mix thoroughly

Step 3 Kalkkam add little by little and mix well

Step 4 Kvatham add little by little and mix well

According to Charaka and Vagbhata manthana with khaja should be done finally and
the mixture is made warm by placing it on hot water bath.

According to Susrutha 45
Take Saindhava in the mixing vessel, madhu is added to it and mixed with
'tala'. Dalhana clarifies the word tala as hastatnla (palm). Manthana is continued with
addition of sneha slowly. Madansphala kalka and other finely grinded kalka are added
according to dosha. Dalhana clarifies here that both Madanaphala and other dravyas
together should constitute the quantity of kalka. The mixture is then put into a deep
vessel and churned with khaja. Dalhana refers khaja to panchangula hasta (fist) or
manthana (chumer). This indicates that churning can be done even with hands. Thus,

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any method that can lead to the production of a semisolid mixture can be followed.
Mamsarasa, ksheera, mootra, amla dravya etc. are added according to doshavastha.
Properly filtered kvatha is added in the end. Dalhana quotes tantrantara directing
to mix with the palm.
A Properly mixed vasthi will be homogenous. The ingredients like kalkka,
sneha and kvatha will not separate after samyojana in a properly mixed vasti.
Separation of ingredients leads to dosha prakopa.
Dalhana narrates that improperly mixed vasthi will show demarcation between
different ingredients and it will neither stick nor wash off from hand.
Indu says that hot water bath is used for heating to avoid vidaaha of vasthi
dravya.

According to Kasyapa 46

Kasyapaachaarya gives reason for the special vasthi mixing order. He mentions
that madhu is added first as it is mangalya. Lavana is added next to remove the
paicchilya, bahalatva and Kashayatva of madhu. Lavana breaks the sanghata by its
taikshnyatva. Taila is added after lavana to get a proper mixture. Adding kalkka next
produce quick samsarjana and kvatha makes sama roopata (uniform mixture).
Prakshepas are added at the end. Adding mootra will impart Patutva and veeryavriddhi
to the nirooha.

Thus, a properly mixed vasthi produce vishyandana of kapha, vata and pitta in
the srotas and expels from body. Changing the mixing order leads to the formation of a
heterogeneous mixture which is devoid of guna and unable to perform its karma. So,
the order of mixing plays a vital role in the action of nirooha vasthi.

Kasyapa advise to maintain the ratio between different ingredients by altering

the total quantity. Various factors like snigdhata, rookshata, sita ushna can be adjusted
with yukthi by changing ingredients.

Nirooha Pranidhaanam 47

Procedure of nirooha vasthi is same as anuvasanam. The process differs at

paschatkarma. After nirooha, taadana and other procedures to prevent immediate
elimination of vasthi are avoided as the we are expecting the vasthi dravya to expel
from body with in a muhoortha. After introducing nirooha, patient is made to lie in

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supine position with a pillow under head. The patient can lie on bed till he/she get
evacuation reflux or according to vagbhata he / she should be in uthkutakasana ie
squatting position after 30 muhoortha for facilitating bowel movement.

If vasthi does not expel with in one muhoortha, another theekshna vasthi
should be given immediately or phala varthi should be inserted.

Kasyapa mentions the following period

Mridu vasthi retained for 100 matra

Theekshna vasthi retained for less than 100 matra
Yaana vasthi - retained for more than 100 matra

A second, third or fourth putaka can be given on the same day till samyak
nirooha lakshanas are obtained. Vagbhata and susruta support the use of fourth vasthi
but charaka opines that only three vasthis can be done like this.

Charaka explains that the first vasthi eliminates vata, second pitta and third
vasthi eliminates kapha and there is no need of fourth putaka s it will lead to sareera
himsa.

The present study follows the clinical practice at Panchakarma department of

Government Ayurveda College Trivandrum. So dviputaka or triputaka are not applied
as here the aim of vasthi is not shodhana.

SAMYAK, ATI AND AYOGA LAKSHANAS

Samyak yoga lakshanas 48

Expulsion of Vit-Mutra-Vata-Pitta-Kapha-Vata in order

Proper taste and digestion
Lakhuthva of ashayam
Roga samanam
Phena sankha sphatika varna of excreted material
Softness of body
Vaishadyam
Indriyaprasannatha
Prakruthishtata

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Ayoga lakshanas 48

Sira, hridaya, guda, vasthi, sepha ruk

Sopham
Prthishyayam
Vikarthika
Hrillasam
Vata & mutra sanga or alpa pravruthi
Swaasa
Mutra krichra
Aruchi
Jaadyam

Athiyoga lakshanam 48

Same as athiviriktha lakshanas according to brihath trayees

Excessive flow of Kapha, Pitta and Rakta like maamsadhaavana tulya jalam
Hikka, kampa, trishna, glani
Gaatra peeda, Tama, Klma
Nidraanaasa
Pralaapa

Paschaath karma 49

On observing samyak niroohita lakshana, the patient is made to take bath in

warm water and eat food with tanu jangala maamsarasam. This pschaathkarma brings
the chala dosha sesha to swsthaana and any vikaara arise will subside.
According to dosha,
for Vata Maamsarasa
Pitta Ksheera
Kapha Yoosha should be given.
Anupana to attain vata kapha samana should be dhanya naagara siddha ushnodakam.

According to condition, an anuvasana is done on same day or next day.

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CLASSIFICATION OF VASTHI ACCORDING TO NUMBER 50, 51

Sankhyaabhedena 3 types - Karma vasthi, Kala vasthi and Yoga vasthi

KARMA VASTHI

According to Charaka :
Total 30 vasthis - 18 Anuvasana and
- 12 Nirooha
According to Kasyapa :
Total 30 vasthis - 24 Anuvasana
- 6 Nirooha
Sequence of application of Karma vasthi
2 Anuvasana + 12 Nirooha + 12 Anuvasana + 4 Anuvasana
Karma vasthi is done in chronic diseases and mainly vata rogas

KAALA VASTHI

According to Chakrapani :
Total 15 vasthis - 9 Anuvasana and
- 6 Nirooha
According to Charaka :
Total 16 vasthis - 10 Anuvasana
- 6 Nirooha
Kaala vasthi is done in madhyabala patients and in Paithika rogas

YOGA VASTHI

All achaaryaas mention total number of yogavasthi as eight.

Total 8 vasthis - 5 Anuvasana and
- 3 Nirooha
Sequence of application of Karma vasthi
1 Anuvasana + 3 Nirooha + 3 Anuvasana + 1 Anuvasana

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UTTARAVASTHI

Uttaravasthi is done through uttaramaarga, which is the urethral canal in males

and urethral or vaginal canal in females. As the scope of uttaravasthi is limited in
producing rookshana, detailed description is avoided in this dissertation.

GENERAL CONSIDERATION IN VASTHI KARMA

1. A minimum of seven days gap should be there for doing nirooha after
virechana. Virechana produce soonyatva, nirooha right after virechana will
increase soonyathva. 52, 53
2. Rookshadi guna of Vashti dravya should be opposite to rogi and roga guna.
That is in ushnaadhikya seetala Vashti is administered and in Snigdhaadhikya,
rooksha Vashti should be applied. 54
3. Sodhana vasthi are contraindicated in kshataksheena, durbala, moorchita and in
sarvadhaathu kshayaartha rogi. 55
4. Snehavasthi or nirooha done alone for more than the stipulated number.
Excessive snehavasthi produce agnimaandhya due to kaphothklesha. Excess
nirooha produce vatakopa due to athisodhana. Application of vasthi can be
designed to mitigate three doshas by doing nirooha after getting samyak
anuvaasitha lakshana, and doing anuvasana after getting proper srothoshodhana
by nirooha.
5. According to chakrapani, madhu, ghrita, ksheera, taila, mootra, dhanyamla,
lavana are used as prakshepa dravya to attain specific action. Madhu, ghrita
and ksheera are used in paithika condition. Taila and lavana in vata. Taila,
mootra and dhanyamla in kaphaja condition. 56
6. In prabala and chira diseases, theekshna vasthi are indicated. In achira and
mridu rogas, mridu vasthi are indicated.
7. Mridu vasthi indicated for baala and vridha. Theekshna vasthi affects their bala
and ayu. Lavana is avoided in vasthi preparation for baala.
8. Theekshna vasthi should be used to evacuate a stagnant mridu vasthi. Karshana
produced by theekshna vasthi should be treated with svadudravyayuktha
vasthi.57
9. Immediate evacuation of vasthi is seen
-If done while the patient is feeling natural urges like pureesha, muthra, vata.
-In severe vataprakopa

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-Weakness of anal sphincter

-Increased quantity of vasthi dravya
-Vasthi given with excessive temperature or theekshna. 58
MODE OF ACTION
Ayurvedic view
According to Charaka, vasthi enters nabhi, kati parsva kukshi pradesa,
churns out faeces and accumulated doshas, imparts snehana to sareera and
expels with purisha and dosha. Vata dosha which normally get vitiated in its
sthana that is adhonabhi is the main dosha which is cleared out by vasthi. So in
normal condition vasthi will reach up to nabhi only. 59
Vasthi mitigate vata by clearing srotas with sneha vasthi and imparting
sneha with anuvasana. Acharyas compared this karmukata to nourishing a tree
by watering at its moola.
Chakrapani quoting Parasara, says that guda is the moola of body and
blood vessels present in guda nourish the whole body.
Vagbhata and Charaka gives the example of cutting roots of a tree to
destroy its leaves, fruits, flowers etc. to explain the effect of vasthi. Vasthi
cleanse vata dosha from its root that is moolasthana and there by destroy all
vataja vikaras. 60
Vasthi cures disease of all body parts even though it is applied on vasthi
by its virya, like the sun drying up water from earth even though it is situated
away.
Susrutha states that vasthi spreads through srothas by apana vayu like
water spreads from the root to top. This action will happen even if vasthi is
evacuated quickly. Dalhana makes it clear that the factor being delivered by
vasthi is snehadi guna which is carried by respective vatas to respective body
parts.
Chakrapani mentions that veerya is the prime quality of vasthi, which
enables vasthi to give quick results and quick spreading which expels doshas
within a day.
Like a cloth dipped in water containing kusumbha, it absorbs only the
colour of kusumbha and leaves the water behind when squeezed. Like that
vasthi removes only mala without harming the body. 61

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According to Kasyapa, action of anuvasana is compared to cleaning air

by water. Arunadatha emphases the shodhana action of anuvasana by giving
example of ksheera.

MODE OF ACTION OF VASTHI MODERN VIEW

Before going to the probable mode of action explained in terms of
anatomy and physiology, a brief review of relevant anatomy and physiology of
large intestine is described below.
Anatomy of Large Intestine 62, 63
LARGE INTESTINE
The large intestine is subdivided into:
Caecum with the appendix vermiformis;
Ascending colon (12 20 cm);
Hepatic flexure;
Transverse colon (45 cm);
Splenic flexure;
Descending colon (22 30 cm);
Sigmoid colon (12 75 cm, average 37 cm);
Rectum (12 cm) and
Anal canal (4 cm).
The large bowel may vary considerably in length in different subjects; the average is
approximately 5 feet (1.5 m).
THE RECTUM
The rectum is 5 inches (12 cm) in length. It commences anterior to the third
segment of the sacrum and ends at the level of the apex of the prostate or at the lower
quarter of the vagina, where it leads into the anal canal. The rectum is straight in lower
mammals (hence its name) but is curved in man to fit into the sacral hollow. Moreover,
it presents a series of three lateral inflexions, capped by the valves of Houston,
projecting left, right and left from above downwards.
Relations
The main relations of the rectum are important as they must be visualized in
carrying out a rectal examination.
Posteriorly: Sacrum and coccyx and the middle sacral artery, which are separated
from it by extraperitoneal connective tissue containing the rectal vessels and

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lymphatics. The lower sacral nerves, emerging from the anterior sacral foramina, may
be involved by growth spreading posteriorly from the rectum, resulting in severe
sciatic pain.
Anteriorly: The upper two-thirds of the rectum are covered by peritoneum and relate
to coils of small intestine which lie in pouch of Douglas between the rectum and the
bladder or the uterus. In front of the lower one-third lie the prostate, bladder base and
seminal vesicles in the male, or the vagina in the female.
THE ANAL CANAL
The anal canal is 1.5 inches (4 cm) long and is directed downwards and
backwards from the rectum to end at the anal orifice.
Peculiarities of anal canal
1. The lower half is lined by squamous epithelium and the upper half by
columnar epithelium.
2. The blood supply of the upper half of the anal canal is from the superior
rectal vessels, whereas that of the lower half is the blood supply of the
surrounding anal skin, the inferior rectal vessels, which derive from the
internal pudendal, and ultimately the internal iliac vessels. The two venous
systems communicate and therefore form one of the anastomoses between
the portal and systemic circulations.
3. The lymphatics above this mucocutaneous junction drain along the superior
rectal vessels to the lumbar nodes whereas, below this line, drainage is to
the inguinal nodes.
4. The nerve supply to the upper anal canal is via the autonomic plexuses, the
lower part is supplied by the somatic inferior rectal nerve, a terminal branch
of the pudendal nerve. The lower canal is therefore sensitive to the prick of
a hypodermic needle, whereas injection of an internal hemorrhoid with
sclerosant fluid, by passing a needle through the mucosa of the upper part
of the canal, is painless.
THE ANAL SPHINCTER
The internal anal sphincter, of involuntary muscle continues above with the
circular muscle coat of the rectum. The external anal sphincter, of voluntary muscle
surrounds the internal sphincter and which extends further downwards and curves
medially to occupy a position below and slightly lateral to the lower rounded edge of
the internal sphincter, close to the skin of the anal orifice.

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Arterial supply of the intestine

The alimentary tract develops from the fore-, mid- and hind-gut; the arterial
supply to each is discrete, although anastomosing with its neighbour. The fore-gut
comprises stomach and duodenum as far as the entry of the bile duct and is supplied by
branches of the coeliac axis which arises from the aorta at T12 vertebral level. The
mid-gut extends from mid-duodenum to the distal transverse colon and is supplied by
the superior mesenteric artery arising from the aorta at L1. The hind-gut receives its
supply from the inferior mesenteric artery arising from the aorta at L3.
Each branch of the superior and inferior mesenteric artery anastomoses with its
neighbour above and below so that there is, in fact, a continuous vascular arcade along
the whole length of the gastrointestinal canal.
Figure 5: Arterial Supply of Large Intestine.

The superior and inferior mesenteric arteries and their branches.

Lymph drainage of the intestine

The arrangement of lymph nodes is relatively uniform throughout the small and
large intestine. Numerous small nodes lying near, or even on, the bowel wall drain to
intermediately placed and rather larger nodes along the vessels in the mesentery or
mesocolon and thence to clumps of nodes situated near the origins of the superior and
inferior mesenteric arteries. From these, efferent vessels link up to drain into the
cisterna chyli.

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The structure of the alimentary canal

The alimentary canal is made up of mucosa demarcated by the muscularis
mucosae from the submucosa, the muscle coat and the serosa - the last being absent
where the gut is extra peritoneal.
The mucosa of the large intestine is lined almost entirely by mucus secreting
goblet cells; there are no villi. The muscle coat of the alimentary tract is made up of an
inner circular layer and an outer longitudinal layer. In the upper two-thirds of the
oesophagus and at the anal margin this muscle is voluntary; elsewhere it is
involuntary.
The stomach wall is reinforced by an innermost oblique coat of muscle and the
colon is characterized by the condensation of its longitudinal layer into three taeniae
coli. The autonomic nerve plexuses of Meissner and Auerbach lie respectively in the
submucosal layer and between the circular and longitudinal muscle coats.

PHYSIOLOGY OF LARGE INTESTINE 64

Functions of large intestine
Absorption of water, ions and vitamins
Breakdown of amino acids
Production of vitamin K and B
Feces formation
Defecation
Absorption of water in colon
Colon has a very high absorptive capacity. It can absorb more than 90% of
water entering from small intestine. Trans mucosal osmotic pressure gradient is the
basis of water absorption in colon. The term standing gradient osmosis is used to
denote the reabsorption of water against the osmotic gradient in intestines. A
hypertonic fluid will create an osmotic pressure that pushes water into the intercellular
spaces, which will move to basement membrane and will enter the capillaries.
Absorption of ions in colon
Colon absorbs sodium and chloride ions in exchange of bicarbonate and
potassium ions.
Bacteria in Large intestine

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An extensive number and variety of bacteria are found colonized in colon. This
large bacterial mass is capable of producing various chemical reaction in large
intestine. These bacteria degrade contents of colon into short chain fatty acids, which
lower the pH and produce gases like carbon dioxide, hydrogen and methane. These
bacteria also produce a wide range of enzymes.
Digestion in Large intestine
Movements of colon begin when substance pass the ileocecal sphincter. Since
chime moves through the small intestine at a fairly constant rate, the time require for a
meal to pass into the colon is determined by gastric emptying time. As food passes
through the ileocecal sphincter, it fills the caecum and accumulates in the ascending
colon.
Haustral churning is a characteristic movement of the large intestine. In this
process, the haustra remains relaxed and distended while they fill up. When the
distension reaches a certain point, the walls contract and squeeze the contents into the
next haustrum. Peristalsis also occurs, although at a slower rate (3-12 contractions per
minute) than in other portions of the gastro intestinal tract. A final type of movement is
mass peristalsis, a strong peristaltic wave that begins at about the middle of the
transverse colon and quickly drives the colonic contents into the rectum.

Food in the stomach initiates this gastro colic reflex in the colon. Thus mass
peristalsis ally takes place three or four times a day, during or immediately after a
meal.

Chemical Digestion
This is the last stage of digestion occurs in the colon through the activity of
bacteria, which live in the lumen. Mucus is secreted by the glands of the large
intestine, but no enzymes are secreted. Chyme is prepared for elimination by the action
of bacteria, which ferment any remaining carbohydrates and release hydrogen, carbon
dioxide, and methane gas. These gases contribute to flatus in the colon. Bacteria also
convert remaining proteins to amino acids and break down the amino acids into
simpler substances, indole, skatole, hydrogen sulphide and fatty acids.

Some of the indole and skatole is carried off in the faeces and contributes to its
odour. The rest are absorbed and transported to the liver, where they are converted to
less toxic compounds and excreted in the urine, bacteria also decompose bilirubin to

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simpler pigments, which give faces their brown colour. Several vitamins needed for
normal metabolism and absorbed in the colon, including some B vitamins and vitamin
K, which are bacterial products.

Absorption and faces formation

After 3-10 hours, the chyme remaining in the large intestine become solid or
semi-solid as a result of water absorption and it is termed as faeces. Chemically, faeces
consist of water, inorganic salts sloughed of epithelial cells from the mucosa of the
gastro-intestinal tract, bacteria, products of bacterial decomposition, and undigested
food material.

Table No. 2.4.18 Summary of digestion and absorption in the large intestine
Structure Action Function
- Lubricates colon and protects mucosa,
- Maintains water balance,
Mucus secretion,
- Solidifies faeces,
Mucosa Absorbs water and other
- Absorption of vitamins, electrolytes
soluble compounds
-Transport toxic substances to liver for
detoxification.
- Breaks down undigested carbohydrates,
proteins and amino acids into products
that
can be expelled through faeces or
Lumen Bacterial activity absorbed
and detoxified by liver.
- Certain B vitamins and vitamin K are
synthesized.

Haustral churning Contents moved from haustrum to

haustrum by muscular contractions.

Peristalsis Contents moved along the length of the

colon by contractions of circular and
longitudinal muscles.
Muscularis
Mass peristalsis Contents forced into sigmoid colon and
rectum by strong peristaltic waves.

Defecation Faeces eliminated by contractions in the

sigmoid colon and rectum.

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The total volume of mucous in colon is estimated approximately 3 ml, spread

over a total surface area of approximately 300 cm 2. The pH of mucous layer is around
7.5 with a little buffering capacity.

ENEMA
Administration of a medicament in liquid form into the rectum is called enema.
The main medical usages of enemas are:
As a bowel stimulant.
To relieve constipation and fecal impaction
Cleansing the lower bowel prior to a medical or surgical procedure.
As a drug delivery root.

Cleansing the lower bowel

Solutions such as soap water, warm water, glycerin, olive oil, turpentine
etc. are used to cleanse the colon and to relieve fecal impaction. The quantity of fluid
administered is around 600 ml in adult. It produces distension and lubrication of colon.
When used as evacuant, enemas are hypertonic, to cause an outward flow of water
from the body into distal portion of the digestive system and thus promote defecation.

Colonic irrigation

Colonic irrigation or colon hydrotherapy is a large enema which cleanses

the whole colon. Colon cleansing is a preventive medicine procedure by which
parasites and other wastes are removed from the colon to prevent other health
problems. It was in vogue for hygienic purposes at the beginning of the 20th century
and remains popular as an alternative therapy in many parts of the world. Hydro colon
therapy practitioners believe that it can be a safe and valuable tool for eliminating
toxins from the body and restoring normal muscular activity in the colon.

Benefits of colon cleansing

Digested and undigested food particles enter colon after getting all nutrients
absorbed in small intestine. So colon contents are mainly dead cells, microbes and
other harmful bi-products. Colon absorbs mainly water and electrolytes. After water
absorption, the left over waste should be eliminated on a daily basis. If the elimination
is nor proper, then the contents starts putifying nd will lead to increase in microbes.

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The unhealthy microbes produce endo and exo toxins which will make colon filled
with toxins. Colon cleansing helps to remove these wastes and toxins from the body
before autointoxication takes place.

Enema as a drug delivery root

Colon is the site where local and systemic drug delivery are possible. Drug
administration through colon is done in conditions where targeted drug delivery is
needed. Drugs applied in colon are absorbed passively by paracellular or transcellular
route. Lipophilic drugs are absorbed through transcellular route and hydrophilic drugs
take the paracellular route through the tight junction between cells. Several anti-
angiogenic agents can be safely administered via a gentle enema. Medicines for
cancer, arthritis and age related macular degeneration are often given as enema.

Enteric nervous system

Enteric nervous system is defined as the system of neurons and their

supporting cells that is present in the wall of the gastrointestinal tract. There are about
100,0000,000 neurons in the ENS (more than that in the spinal cord). This system is
responsible for all the complex characters of the bowel like propulsive peristaltic
movement and various movements that result in mixing. The ENS also regulates the
intestinal blood supply and mucosal epithelial water and electrolyte transport. There is
also probably complex interplay between the ENS and the immune system. Structure,
function and development of enteric nervous system (ENS)

Enteric nervous system is an extensive division of the autonomic nervous

system, which spread over the entire gastro intestinal tract. In this system, different
types of enteric neurons with the help of different neuro transmitters, innervate
different types of target cells in the gut. Chemicals that act as neurotransmitters in the
central nervous system are also found in the ENS. The ENS mediates motility of
reflexes and plays a major role in controlling water and electrolyte balance by the
mucous epithelium and also regulates intestinal blood supply.

There are two major functional components in ENS, which are myenteric plexus
(aurbach) and Submucosal plexus.

1. Auerbach's plexus (Myenteric plexus)

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muscle in the gastrointestinal tract and provides motor innervations to both layers and
secretory and motor innervations to the mucosa.
2. Submucous plexus

Lies in the sub mucus coat of the intestine and contains ganglia, from which
nerve fibres pass into the muscularis mucosa and to the mucus membrane.

Enteric pacemakers

Nerve impulse is carried to smooth muscle of intestinal tract through a

specialized cell called interstitial cells of cajal. The interstitial cells of cajal acts as the
intrinsic pacemaker of intestinal tract.

Enteric neurotransmitters

There are about 30 identified neurotransmitters in enteric nervous system. One

of the main neurotransmitter found in enteric nervous system is Serotonin. The
enterochromaffin cells in gastro intestinal mucosa are rich in serotonin.
Enterochromaffin cells are mechanosensitive and may mediate peristaltic reflux.

PROBABLE MODE OF ACTION OF VASTHI

Considering the factors described above, following could be the probable mode
of action of enema.

1. Local effects

Osmotic changes:

The hypertonic vasthi dravya may drain water from colon cells. As water absorption is
the main physiological function of colon, this outward movement of solvent from cells is a
notable process.

Pressure effect:

The fairly large quantity of vasthi dravya introduced into the rectum may stimulate
peristalsis. Thus enema helps to expels toxins along with contents in colon. Baro receptors in
colon get stimulated during vasthi may help in sending afferent signals and may act as a
therapy for activating hypothalamo pituitary adrenal axis and autonomous nervous system.

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Immune response:

Immune system may be stimulated by cleansing the colon, as the colon is

richly endowed with elements of mucosal immune system.

2. Systemic Effects

Action on ionic balance

The colonic mucosa facilitates the movement of water, ions and small molecules
between the lumen and plasma. Unlike small intestine, large intestine mucosa has tightness
and ion selectivity, which may help in flushing off of ions by altering the ionic character of
vasthi dravya. By altering ionic balance with vasthi, the generated electrical potential might
help in healing process

Action on chemical environment of body

Hypertonic vasthi reduces the level of pyruvic acid level. This decline in
pyruvic acid level increases vitamin B1 level in body, which is a prime factor for
maintaining healthy neurons.
Action on bacterial flora
Colon cleansing eliminates accumulated toxins and thereby provide a clean
environment for development of good bacteria in colon.
Action on Nervous system
Vasthi act by stimulating enteric nervous system with the chemical nature or
with the pressure effect.

nces pass through

the walls into the ilium; such incompetence may permit the enema fluid to reach the

same, if the valve dilates, there is a good chance of the medicines moving quickly
towards the duodenum. They can also reach the stomach and mouth. This can read
along with hrithprapthi and urdwagamana of vasthi vyapath.

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Chapter 5
ROOKSHA VASTHI

Vasthi with Gandharvahasthadi Kashayam, Vaiswanara churnam, madhu and

saindhavam is a moditied form of niroohavasthi. Vasthi modification can be seen in
classics where achaaryas try different vasthi yogas by adding or deleting ingredients.
Some popular vasthi modifications are given below.

Description of vasthi without the essential ingredient Madhu is seen in

panchathikthaka vasthi which is indicated in prameha abhishyanda and kushta1.
Ksheera vasthi is done without the essential ingredient Kalkka.2 Jeevaniya nirooha
vasthi is done without Saindhava.27 Kshara vasthi and lekhana vasthi are done without
taila. From these examples, it is evident that changing ingredients of vasthi to suit
specific condition or to produce a specific effect was in practice since the samhita
period.

Vasthi with ushnajala is explained in Charaka samhita Sidhisthaanam, where it

is done with Madhu, ghrita, ushnajala and satahva kalkkam.

Chakrapani while commenting on the context of adding ushnajala in vasthi,

quotes the opinion of some acharyaas about choorna vasthi. In choorna vasthi, drugs for
vasthi are administered in powder form and it is mixed in water at the time of
administration.

Rookshavasthi is similer to choorna vasthi, where vaiswanara churna is mixed

with decoction. Eminent physicians have formulated different rookshavasthis to suit
different conditions. Rookshavasthi with Amrithotharam kashayam and vaiswanara
churna or shaddharana churna is used in chronic and high fever which gives quickly
bring down temperature. Rookshavasthi with Gandharvahasthadi kashayam and
avipathy churnam is practiced in treatment of udavartha.

This special vasthi is successfully practiced in our institution for many years to
produce aama paachana and for proper rookshana. There were some previous studies
which analyzed the effect of vasthi with Guloochyadi kashayam and vaiswanara

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churnam by Dr. Shita (in 2012 - Dept. of Panchakarma, Ayurveda college Trivandrum)
and another study by Dr. Vijaya (in 2008 - Dept. of Panchakarma, Ayurveda college
Trivandrum) with amritadi kashayam and vaiswanara churnam. Both these studies

the scientific base for Rookshavasthi with Madhu and Saindhava and to assess its
efficacy.
There was a focal group response data collected by Dr. Vijaya in 2008 which
shows the opinion of experts about Rookshavasthi. The data from Dr. Vijayas
dissertation work is summarized below.
90% of experts agreed with the name Rookshavasthi.
60% had the opinion that the dose should be of paadamatram (300ml).
75% had the opinion that it can be included under niroohavasthi.
60% opined that it should be done for 7 days.
30% suggested adding Madhu and Saindhava to the vasthi
Adding Madhu and Saindhava will make it more rooksha which will give
quick aama paachana and thereby reducing the treatment duration
cosiderably
80% opined that this yoga will reduce aama and vedana.
Most of the members suggested doing only Swedana as poorvakarma

The present study is a further step to these previous works to assess the effect of
rookshavasthi with Madhu and Saindhava. The kvatha used is gandharvahasthadi
kashayam which is indicated for pavanashanti, vahnibala and malashodhana. These
symptoms were prevalent in majority of katigraha patients who were enrolled in this
study.

Page 87
 Part II
Drug Review
 Drug Review

DRUG REVIEW

Oushadhas used in this study are

For Anulomanam
1. Gandharvahasthadi Erandam

For Rookshavasthi

1. Saindhavam
2. Madhu
3. Vaiswanara Churnam
4. Gandharvahasthadi Kashayam

GANDHARVAHASTHADI ERANDAM1

INGREDIENTS
SNEHAM

1 Eranda tailam Castor oil

DRAVA DRVYAM

1 Ksheeram

2 Decoction of

Gandharvahastha Root of castor Ricinus communis

Yava Barley Hordeum vulgare

Nagara Ginger Zingiber officinalis

KALKKAM

1 Gandharvahastha Ricinus communis

2 Nagara Zingiber officinalis

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 Drug Review

INDICATIONS

Alpagni Pleeha

Vishamagni Gumla

Alakshmighna Udaavartha

Kanthikara Sopha

Balya Udara

Brimhana Arsas

Vayasthaapana Medaroga

Vridhi Yoniroga

Vidradhi Mahavatavyadhi

ROOKSHA VASTHI

INGREDIENTS

I. Saindhava - 12 g
II. Madhu - 30 ml
III. Churna - 30 g
IV. Kvatham - 300 ml

I. SAINDHAVAM 4
Saindhava lavana or rock salt is considered best among all salts. Its qualities,
usage and health benefits are quite different from regular salt.
English name
Rock salt
Himalayan salt.
Synonyms:
Sheetashiva (because it is coolant in nature),
Sindhuja (because it is found in Sindh region of Punjab),
Naadeya (because it is found in the banks of rivers),
Manimantha

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 Drug Review

Available in two varieties

Shweta Saindhava (white in colour)
Rakta Saindhava (Red in colour)
Chemical composition
Sodium chloride (NaCl) is the major ingredient making up to 98 %.
Molecular weight is 58.44 gm. It also contains 21 essential and 30 non-essential
minerals such as Iodine, Lithium, Magnesium, Phosphorus, Potassium, Chromium,
Manganese, Iron, Zinc, Strontium, etc.

Pharmacodynamics

Rasa - Lavana, Madhura

Guna - Snigdha, Sukshma and Thikshna
Veerya - Sita
Vipaka - Madhura

Effect on Tridosha

Saindhava is Thridoshaghna

Pharmacological Action

Rochana - Improves taste

Dipana - Improves digestion strength
Vrushya - Acts as aphrodisiac in small dose
Chakshushya - Good for eyes, helps to relieve infection
Aviidahi - Does not cause burning sensation.
Hrudya - Good for heart
Hikkanashana - Useful in hiccups

As per Charaka, saindhava can be taken daily in food.5 (Pathya)

Probable role in enema

Makes the enema drug hypertonic
Maintain alkaline pH (acid base balance) of vasthidravya
Act as an irritant which helps in proper elimination of vasthidravya

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 Drug Review

II. MADHU 6

Latin name
Mal depuratum
Chemical composition
Honey is a watery solution of dextrose and laevulose two invert sugars in
nearly equal proportion. These are simple sugars which can enter directly to blood
without conversion by invertase enzyme. On an average, honey contain the following
Moisture - 17.2%
Fructose - 38.5 %
Glucose - 31.28 %
Sucrose - 1.31 %
Disaccharides - 7.32 %
Higher sugars - 2.7 %
Gluconic acid - 0.43 %
Glucono lactone - 0.14 %
Ash - 0.17 %
Nitrogen - 0.041 %
Formic acid - 0.08 %
Pharmacodynamics
Rasa - Madhura, Kashaya
Guna - Rooksha, Guru, Sita
Veerya - Sita
Vipaka - Katu

Effect on Tridosha

Madhu is Kapha Pittaharam

Pharmacological Action
Sandhanam,
Chedanam,
Lekhanam,
Dipanam

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 Drug Review

Madhu is Yogavahi and sookshma marganusari i.e. honey possess catalytic

property and the property to penetrate into the minute channels of body. Honey is an
inevitable content of niroohavasthi. In nirooha the drugs are expelled before getting
paaka so heating honey in the vasthi dravya does not elicit its toxic character.
Honey contains hydrocarbon and cerotic acid. Hydrocarbons and cerotic acid
combine with K + ion to form and emulsifying agent. Honey often contains
polyphenol, which can act as antihistamine. Antioxidants in honey help in reducing
the damage done to the colon in colitis. Being a nutrition medium, honey may be
effective in increasing the populations of prebiotic bacteria in the gut, which may
help strengthen the immune system and prevent colon cancer.
Hygroscopic character of honey speeds up healing process by increasing
growth of healing tissues. Honey has antibacterial properties because of its acidic
nature and enzymatic production of hydrogen peroxide.

III. CHOORNAM

Vaiswanara Churnam (30 g.) is used as Kalkam in rookshavasthi

VAISHVANARA CHOORNAM 7

Ingredients:

1. Manimantha Saindhava lavana Rock salt 1 Part

2. Yavani Trachyspermum ammi 2 Parts
3. Ajamoda Trachyspermum roxburghianum 3 Parts
4. Kana Pipper longum 4 Parts
5. Nagara Zingiber officinalis 5 Parts
6. Haritaki Terminalia chebula 15 Parts

This is described in Ashtanga Hridaya Gulma chikitsa. It is famous for its

anulomana and agni deepana properties. Hareetaki included in this yoga as its half
part. Since hareetaki is kaphavatahara, deepani and vayasthapani, the choorna also
gets all theekshna and ushna guna, hence enhances the bio availability of the drug. It
is given along with the hot water as anupana.

1. MANIMANTHA - Explained earlier

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 Drug Review

2. YAVANI
Botanical name : Tachyspermum ammi (Linn.)
Family : Umbelliferae
Synonyms : Deepyaka, Yamini, Yaviniki
English name :
Malayalam name : Omam
Part used : Fruit
Pharmacodynamics
Rasa : Katu, tikta
Guna : Laghu, ruksha, tikshna
Veerya : Ushna
Vipaka : Katu
Karma : Kapha Vatahara, Anulomana.
Decpana, Pachana, Krimighna, Rucya
3. DEEPYAKA
Botanical name : Apium leptophyllum (Pers.)
Family : Umbelliferae
Synonyms : Ajamoda
English name : Ajowan
Malayalam name : Ayamodakam
Part used : Fruit
Pharmacodynamics
Rasa : Katu, tiktha
Guna : Laghu, Ruksha
Veerya : Ushna
Vipaka : Katu
Karma : Kapha Vatahara, Deepana, Ruchikrit, Krimijit
Indication : Gulma, aruchi, adhmana, hikka, krimiroga, chardi 8

4. KANA
Botanical name : Piper longum Linn.
Family : Piperaceae
Synonyms : Magadhi, krishna, upakulya, vaidehi
English name : Indian long pepper

Page 93
 Drug Review

Malayalam name : Tippali

Part used : Dried spike
Pharmacodynamics
Rasa : Katu
Guna : Lakhu, Snigdha
Veerya : Ushna
Vipaka : Madhuram
Karma : Vata Kaphahara, Pittakara,
Deepana, Vrishya,
Rasayana, Rochana
Indication : Swasa, Kasa, Udara, Jwara,
Kushta, Prameha, Gulma
Arsha, Pleeha, Shoola,
Aamamaarutha 8
5. NAGARA
Botanical name : Zingiber officinale Rosc.
Family : Zingiberaceae
Synonyms : Sunti, Viswabheshajam, Mahoushadham
English name : Dry ginger
Malayalam name : Chukku
Part used : Rhizome
Pharmacodynamics
Rasa : Kadu
Guna : Laghu, snigdha, tikshna Ushna
Virya : Ushna
Vipaka : Madhura
Karma : Vata Kaphaharam, Pittakaram
Deepana, Vrishya, Grahi,
Hridya, Vibandhanut,
Ruchyam, Pachanam, Swaryam
Indication : Shopha, Shoola, Aruchi, Adhmana
Vatodara, Badhodara, Arsha
Hridroga, Shleepada, Vami
Kasa, Swasa Hikka8

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 Drug Review

6. HARITAKI
Botanical name : Terminalia chebula
Family : Combretaceae
Synonyms : Vijaya, Abhaya, Pathya, Jaya, Rohini
Putana, Chetaki
English name : Chebulic myrobalan
Malayalam name : Kadukka
Part used : Fruit
Pharmacodynamics
Rasa : Pancharasa except lavana
Guna : Laghu, Ruksha, Saram
Virya : Ushna
Vipaka : Madhura
Karma : Kapha Vataharam, Chakshushyam
Deepana, Medhya, Vayasthapana,
Pachanam
Indication : Shopha, Sroto vibandha, Urusthambha
Kushta, Praseka, Gulma, Arsha
Hridroga, Pleeha Kamala, Vami
Kasa, Swasa, Hikka, Anaha, Gara, Udara8

IV. DRAVA DRAVYAM / KVATHAM

Gandharvahasthadi Kashayam (300 ml.) will be used as dravadravyam

GANDHARVAHASTHADI KASHAYAM2

Ingredients
The decoction is prepared by following herbs in equal parts. Preparation method
follows classical kwatha nirmana procedure.
Gandharvahasta Ricinus communis
Chirabilva Holoptelea integrifolia
Hutasha Plumbago zeylanica
Vishwa Zingiber officinalis
Pathya Terminalia chebula

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 Drug Review

Punarnava Boerhaavia diffusa

Yavasa Alhagi pseudalhagi
Bhumitaala Phyllanthus niruri
Anupana
Saindhava - Rock salt
Gudam - Jaggery
Indication
Vatanulomanam - Helps in downward movement of vata
Agnidipthi - Increases digestive fire
Ruchikaram - Relieves anorexia
Malasodhanakaram - Mild purgative
Dosage
60 ml 0 60 ml before food with one pinch Saindhava and 5 g. Jaggery
Table showing Pharmacodynamics of ingredients of Gandharvahasthadi Kashayam
Drug Rasa Guna Virya Vipaka Karma

Guru, Vrsya, Vatahara,

Gandharvahasta Madhura Ushna Madhura
Snigdha Amapachana

Tikta, Laghu, Anti-inflammatory

Chirabilva Ushna Katu
Kasaya Rooksa
Laghu, Carminative,
Hutasha Katu Rooksa, Ushna Katu Anti-inflammatory,
Tiksna Anti-arthritic
Vishwa
Explained earlier
Pathya
Madhura,
Ruksa, Vatasleshmahara,
Punarnava Tikta, Ushna Madhura
Laghu. Mutrala, Sothahara,
Kasaya
Madura, Anti-inflammatory,
Guru,
Yavasa Tikta, Seeta Madura Diuretic,
Snigdha
Kasaya Expectorant
Cooling,
Bhumitaala Madhura Guru Sita Madhura
Demulcent

Page 96
 Part III
Methodology
 Methodology

METHODOLOGY

Research is defined as scientific and diligent study, investigation or experimentation

in order to establish facts and analyze their significance. Research is done for establishing
new facts, discarding the old or modifying them. Research helps to validate old principles
with fresh proofs. The methodology of this study is described below.

Collection of drugs
The drugs for this study were purchased from pharmacy of panchakarma hospital at
Poojappura. Prepared yoga of Gandharvahasthadi erandam of vaidyaratnam oushadhasala
was used for all subjects. For rookshavasthi, Gandharvahasthadi kashaya sookshma
choornam of Everest pharmacy was used for all subjects. Prepared vaiswanara churnam
from Oushadhi was used for all subjects. Good quality Honey and saindhava was
purchased from pharmacy of panchakarma hospital at Poojappura.

Preparation of Gandharvahasthadi kashayam

15 gms of Gandharvahasthadi kashaya sookshma choornam was mixed with 400 ml
water and boiled for 5 minutes and stained. 300 ml from this prepared decoction was used
in rookshavasthi.

Preparation of Rookshavasthi
In a clean mortar, 30 ml. madhu and 12 g. saindhava were added first and ground
with a pestle. 30 gm. Vaisvanara churnam is added little by little to this mixture and finally
300 ml of Gandharvahasthadi kashayam is added in a thin stream while continuing the
grounding process till complete mixing of the ingredients. Then the mixture was filtered
through a clean made lukewarm by keeping it over steam. The temperature of vasthidravya
was maintained at 99o F to 100o F. Then the mixture is churned with a churner and filled
into a clean and sterile thick plastic cover and Vasti netra is tied and plugged with cotton.

Page 97
 Methodology

OBJECTIVE
1. Observe the changes in signs and symptoms of Katigraha produced by the
administration of Rooksha Vasti.
2. 2. To assess the safety of Rooksha Vasti

HYPOTHESIS
Null Hypothesis
Rooksha Vasti is not effective in reducing the signs and symptoms of Katigraha.
Alternate Hypothesis
Rooksha Vasti is effective in reducing the signs and symptoms of Katigraha

MATERIALS AND METHODOLOGY

Literary review
A detailed review of subject matter will be collected from all relevant Ayurvedic
classical texts, journals, contemporary texts and from internet.
Clinical Study
1. Study design
Interventional study - Pre-Post test, without control group.
2. Study setting
Panchakarma Department IP of Government Ayurveda College
Panchakarma Hospital, Poojappura, Thiruvananthapuram
3. Study population
Patients of both sexes aged 20-60, with signs and symptoms of Katigraha as
identified by Oswestry Disability Index for Low Back Pain from the OPD and IPD
of Government Ayurveda College Panchakarma Hospital, Poojappura,
Thiruvananthapuram
4. Inclusion criteria
Patients with signs and symptoms of katigraha
Patients of both sexes

Page 98
 Methodology

Patients who falls in severe and moderate categories as per Oswestry

Disability Index for Low Back Pain
Patients aged 20 - 60
Patients with written consent
5. Exclusion criteria
Back pain associated with any type of malignancy or neoplastic infiltration.
Patients with complicated cases of hypertension and diabetes mellitus
Patients with major liver and renal disorders
Patients contra-indicated for vasti as per Ayurvedic classical text books as in
arsas, durbalagni, garbhini, kusta, udara and unmada.
6. Sample size
30 Cases
7. Sampling technique
Purposive consecutive cases satisfying sample size
8. Study Duration
- Intervention - 7 days
- Observation till discharge of patient.
9. Data collection
The data for the study will be collected by using clinical case pro-forma,
interview, observations, and laboratory investigations.
10. Study tool
Clinical Case pro-forma
Symptom score sheet
Visual analogue scale
Haematological investigation (ESR & CRP)
Function assessment questionnaire (ODI & RMDQ)
11. Procedure
Patients will be selected according to inclusion and exclusion criteria.

Page 99
 Methodology

investigations (ESR & CRP) before commencement of treatment. After collecting

the baseline data of the patients in the study group,

Preparation of patient
Anulomana will be done with 5 to 10 ml. Gandharvahasthadi erandam on the first
day.
Rooksha Vasti
Rookshavasti will be started from second day onwards and it will be done for 7
consecutive days.
Route of administration - Anal Route

Time of administration - Between 9.30 am-11am, when patient is not having

much appetite.
Mode of administration -
Patient is asked to take very light food in early morning before 8 am. Just before the
administration of Vasti, local Swedana will be done with hot water bag over kati, udara,
paarsva pradesha. Patient is asked to lie on a droni in left lateral position. His left lower
limb is extended and right lower limb is flexed at knee and hip. A small amount of oil is
smeared over the tip of Vasti netra as well as the anus of the patient for lubrication.
Wearing the hand gloves the rectal examination is carried out. Vasti netra is then gently
introduced into the anus and the putaka is pressed slowly and steadily to push the Vasti
dravya into the rectum in one attempt. Vasti netra is withdrawn with a little amount of
medicament remained in the putaka to avoid the entry of air. After administering the Vasti
patient is asked to lie in prone position up to getting defecation urge. Patient is asked to
take bath with lukewarm water and also for taking the food and advised to take rest. The
same process will be adopted for seven days.
The results will be assessed with regards to improvements in clinical findings.
Patient will be monitored daily to note down subjective and objective changes during the
course of Rooksha Vasti.
After the rookshana therapy, patient will receive the regular katigraha treatment
protocol of our institution for the next two to five weeks.

Page 100
 Part IV
Observation, Analysis
&Interpretation
 Observation, Analysis & Interpretation

OBSERVATION, ANALYSIS AND INTERPRETATION

After screening about 58 katigraha patients who were admitted in IPD of

Poojappura Panchakarma Hospital, 30 patients who meet the exclusion inclusion criteria
were selected for this study. 30 subjects were screened in such a way to get 15 male and
15 female patients with majority in their fifties and thirties.
All patients were examined before and after rookshavasthi. Examination
details were noted down in case sheet, the format of which is given in annexure. To assess
the overall effect of treatment protocol of katigraha, a final assessment was done on the
day of discharge from hospital.
The data collected are presented here under the following headings.
A. Socio demographic data
B. Data related to clinical status of the patient
C. Data related to Rookshavasthi
D. Data related to treatment response

A. SOCIO DEMOGRAPHIC DATA

(1) Distribution according to Age

Table No. 4.1 : Distribution of patients according to age

Age in Years Count Percent

51 TO 60 13 43.33
41 TO 50 6 20
31 TO 40 7 23.33
21 TO 30 4 13.33

Out of the total thirty patients, 43.33% belonged to the age group of 51 - 60 years,
20% belonged to 41 TO 50 years age group, 23.33 % belonged to 31 TO 40 years age
group and 13.33% belonged to 21 - 30 years age group.

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 Observation, Analysis & Interpretation

(2) Distribution according to sex

Table No. 4.2 : Distribution of patients according to sex

Sex Count Percent

Male 15 50

Female 15 50

Among the 30 patients 50% patients were male, 50% patients were female.

(3) Distribution according to religion

Table No. 4.3 : Distribution of patients according to religion

Religion Count Percent

Hindu 26 87

Muslim 3 10

Christian 1 3

Among the 30 patients 87% of the total patients were Hindus, 10 % were Muslim,
3% were Christians.

(4) Distribution according to Economical Status

Table No. 4.4 : Distribution of patients according to economic status

Economic status Count Percent

Middle class 26 87

Upper Middle class 3 10

Rich 1 3

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 Observation, Analysis & Interpretation

Among the 30 patients participated in the study, 87% of the total patients belong to
middle class family, 10 % were in upper middle class status and 3% in rich economic
status.

(5) Distribution according to marital status

Table No. 4.5 : Distribution of patients according to marital status

Marital status Count Percent

Married 27 93

Single 3 7

Among the thirty patients 93% were married and 7% were unmarried.

(6) Distribution according to education

Table No. 4.6 : Distribution of patients according to education

Education Count Percent

PG 3 10

Graduate 17 54

Secondary
7 23
education

Primary education 3 13

Out of thirty patients, 13% were having primary education, 23 % underwent

secondary education, 54 % were graduates and 10 % were postgraduates.

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 Observation, Analysis & Interpretation

(7) Distribution according to occupation

Table No. 4.7 : Distribution of patients according to occupation

Occupation Count Percent

Office 11 37

House wife 6 20

Driver 3 10

Teacher 2 7

Retired 1 3

Conductor 1 3

Police 1 3

Mason 1 3

Nurse 1 3

Electrician 1 3

Medical rep. 1 3

Student 1 3

Out of the thirty patients 37 % were doing office jobs, 20 % were house wife, 10 %
were drivers, 7% were teachers and 3 % of Retired , Conductor, Police, Mason, Nurse
Electrician, Medical representative and Student.

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 Observation, Analysis & Interpretation

B. DATA RELATED TO CLINICAL STATUS OF THE PATIENT

(1) Distribution of patients according to body weight

Table No. 4.8 Distribution of patients according to body weight

Body Weight in Kilogram Count Percent

61-70 19 63.3

71-80 7 23.3

81 - 90 4 13.3

Out of thirty patients, 19 were having body weight between 61 to 70, 7 patients
were in 71 to 80 group and four patients were above 81 Kg. Increase in body weight puts
more stress on low back leading to back pain.

(2) Distribution of patients based on bowel movement

Table No. 4.9 Distribution of patients based on bowel movement

Bowel Movement Count Percent

Loose bowels 0 0

Normal 7 23

Hard fecal matter 11 37

Constipated 4 13

Irregular 8 27

Out of thirty patients, 37% were having difficulty in bowel evacuation due to hard
bowel, 27 % had irregular bowel movement, 23 % were having normal bowel movement
and 13% were constipated.

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 Observation, Analysis & Interpretation

(3) Distribution of patients according to low back pain chronicity

Table 4.10 Distribution according to low back pain chronicity

Low back pain chronicity Count Percent

Less than 1 Month 1 3

1 month to 6 months 14 47

7 months to 1 Year 10 33

1 Year to 2 Years 2 7

More than 2 Years 3 10

Out of thirty patients, 47% had 1 to 6 months chronicity; 33% had 7 moths to 1
year chronicity; 10 % had back pain for more than 2 years, 7% had 1 year to 2 years
chronicity and 3 % had back pain duration less than 1 month.

(4) Distribution of patients according to Bala

Table No. 4.11 Distribution of patients according to Bala

Bala Count Percentage

Pravara 5 10.0

Madhyama 24 75.0

Avara 1 15.0

Out of the 30 patients, 10 % of the total patients had pravara bala, 75 % had
madhyama bala and 15 % had avara bala.

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 Observation, Analysis & Interpretation

(5) Distribution of patients according to Agni

Table No. 4.12 Distribution of patients according to agni

Anala Count Percent

Vishamagni 9 30

Teekshnagni 2 7

Mandagni 19 63

Out of the thirty patients selected for the study, 30 % had vishamagni, 7 % had
teekshnagni and 63% had mandagni.

(6) Distribution of patients according to type of Koshta

Table No. 4.13 Distribution of patients according to type of koshta

Type of koshta Count Percent
Mridu koshta 4 13

Madhyama koshta 22 73

Kroora koshta 4 13

Out of the thirty patients selected for the study, 13 % of the total patients were
mridu koshta, 73 % madhyama koshta and 13 % of the total patients were with kroora
koshta.

(7) Distribution of patients according to Prakrithi

Table No. 4.14 Distribution of patients according to Prakrithi

Prakrithi Count Percent
Vatha pitha prakrithi 6 20
Pitha kapha prakrithi 12 40
Vatha kapha prakrithi 12 40

Among 30 patients 20 % were vatha pitha prakrithi, 40 % were pitha kapha

prakrithi and 40 % had vatha kapha prakrithi.

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 Observation, Analysis & Interpretation

(8) Distribution of patients according to Satwa

Table No. 4.15 : Distribution of patients according to Satwa

Satwa Count Percent

Pravara 4 13

Madhyama 19 63

Avara 7 23

Out of the thirty patients selected for the study, 13 % had pravara satwa, 63 % had
madhyama satwa and 23 % had avara satwa.

(9) Distribution of patients according to Sathmya

Table No. 4.16 Distribution of patients according to Sathmya

Sathmya Count Percent
Madhura 10 33
Amla 16 53
Lavana 20 67
Katu 25 83
Thiktha 2 7
Kasaya 2 7

Out of the thirty patients selected for the study, 33 % are madhura satmya, 53 %
are amla satmya, 67 % are lavana rasa satmya, 83 % are katu rasa satmya, 7 % are thiktha
rasa satmya and 7 % are kasaya rasa satmya.

(10) Distribution of patients according to Samhanana

Table No. 4.17 Distribution of patients according to Samhanana

Samhanana Count Percent

Pravara 1 3

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 Observation, Analysis & Interpretation

Madhyama 29 97

Avara 0 0

Out of the thirty patients selected for the study, 97 % of the total were having
madhyama Samhanana and rest 3 % were having Pravara Samhanana.
(11) Distribution of patients according to Vaya

Table No. 4.18 Distribution of patients according to Vaya

Vayas Count Percent

Youvana 2 7

Madhyama 28 93

Vardhakya 0 0

Out of the thirty patients selected for the study, 7 % of the patients were under
Youvana category and the rest 93 % fall in Madhyama category. Vardhakya category was
excluded from this study.

3. DATA RELATED TO ROOKSHAVASTHI

(a) Data related to Retention time of Rookshavasthi

Table No. 4.19 Retention time of Rookshavasthi

Time Count Percentage

Less than 5 minutes 10 33

Less than 10 minutes 16 50

Less than 15 minutes 3 14

More than 15 minutes 1 3

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 Observation, Analysis & Interpretation

The retention time of rookshavasthi was in with in standard range for all patients.
The maximum retention time observed was 20 minutes. The minimum retention time
observed was 1 minute. 50 % of the patients got evacuation reflux within 10 minutes after
doing rookshavasthi.

(b) Data related to Number of Vega after Rookshavasthi

Table No. 4.20 Number of Vega after Rookshavasthi

Vega Count Percentage

1 8 27
2 12 40
3 6 20
4 3 10
5 1 3

40% of the patients had 2 vegas after rookshavasthi, 27 % of the patients had 1
vega and 20 % of the patients had 3 vegas after rookshavasthi. 3% patients had 5 vegas
and 10% had 4 vegas after rookshavasthi.

(c) Data related to Complications after Rookshavasthi

Table No. 4.21 Complications after Rookshavasthi

Complication seen Count Percentage

Pain in Abdomen 4 13
Tiredness 1 3
Bloating 2 7
No issues 23 77

without any discomfort. 13% had pain in abdomen, 7 % had bloating and pain in chest due
to bloating. 3% had tiredness after rookshavasthi.

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 Observation, Analysis & Interpretation

(d) Other observations

Table No. 4.22 Other observations in Rookshavasthi

Observation Count Percentage

Burning sensation in 4 13.33
rectum

Agnideepti Count Percentage

No change 0 0

Slight increase in appetite 10 33

Moderate increase in
20 67
appetite

Out of 30 patients who underwent snehapana therapy, 67 % reported that their

appetite have improved considerably. 33% of total patients said they are feeling an
improvement in appetite but not to the extent they expected.

(e) Data related to safety of rookshavasthi

Table No. 4.23 Data related to safety of rookshavasthi

Agnideepti Count Percentage

Unmanageable
0 0
complications

No major complications were seen during the vasthi course. Minor complications
occur were easily manageable.

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 Observation, Analysis & Interpretation

4. DATA RELATED TO RESPONSE OF TREATMENT

(A) Effectiveness of treatment on pain

Table No. 4.24: Effectiveness of treatment on pain

PAIN
Before After
Count Percentage Count Percentage
Treatment Treatment
SEVERE 30 100 SEVERE 2 6.666667
MODERATE 0 0 MODERATE 22 73.33333
MILD 0 0 MILD 6 20
NIL 0 0 NIL 0 0

All patients enrolled in this study were having severe pain which was measured by
visual analogue scale. After Rookshavasthi, only 7% of total patients had severe pain,
73.3 % had moderate pain and 20% had mild pain. Complete remission was not seen in
any patients.

Table No. 4.25: Effectiveness of treatment on pain - t test value

Pain Mean Median SD Paired t Test

Before 8.2 8 0.48

P value is <0.001
After 4.9 5 1.53

The mean score of pain before treatment and after treatment are 8.2 and 4.9 with a
standard deviation of 0.48 and 1.53 respectively. Paired t test was done to compare the
values obtained before treatment and after treatment. The P value obtained is <0.001,
which indicate that the treatment is significant at 0.01 level.

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 Observation, Analysis & Interpretation

(B) Effectiveness of treatment - Pain on lying

Table No. 4.26: Effectiveness of treatment - Pain on lying

PAIN ON LYING
Before After
Count Percentage Count Percentage
Treatment Treatment
0 0 0 0
SEVERE SEVERE
14 47 2 7
MODERATE MODERATE
16 53 21 70
MILD MILD
0 0 7 23
NIL NIL

Before treatment, moderate pain on lying was found in 47% of the total patients
and 53% had mild pain which was measured by scoring table. After Rookshavasthi, only
7% of total patients had severe pain, 70 % were having mild pain and 23 % had no pain on
lying.

Table No. 4.27: Effectiveness of treatment in Pain on lying - t test value

Pain Mean Median SD Paired t Test

Before 1.46 1 0.50 t = 7.077 with 29

degrees of P value is <0.001
After 0.83 1 0.53 freedom.

The mean score of pain on lying before treatment and after treatment are 1.46 and
0.83 with a standard deviation of 0.50 and 0.53 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was <0.001, which indicate that the treatment is significant at 0.001 level.

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 Observation, Analysis & Interpretation

(C) Effectiveness of treatment - Pain on Sitting

Table No. 4.28: Effectiveness of treatment - Pain on Sitting

PAIN ON SITTING
Before After
Count Percentage Count Percentage
Treatment Treatment
10 33 0 0
SEVERE SEVERE
18 60 12 40
MODERATE MODERATE
2 7 18 60
MILD MILD
0 0 7 23
NIL NIL

Before treatment, severe pain on sitting was found in 33% of the total patients, 60
% had moderate pain and 7% had mild pain on sitting which was measured by scoring
table. After Rookshavasthi no patients complained about severe pain on sitting, majority
of the patients (60%) were having mild pain, 40% had moderate pain and 23% had no pain
while sitting.

Table No. 4.29: Effectiveness of treatment - Pain on Sitting - t test value

Pain on Paired t Test

Mean Median SD
Sitting
Before 2.27 2 0.58 t = 6.595 with 29
degrees of P value is <0.001
After 1.67 2 0.66 freedom.

The mean score of pain on sitting before treatment and after treatment are 2.27 and
1.67 with a standard deviation of 0.58 and 0.66 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was <0.001, which indicate that the treatment is significant at 0.001 level.

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 Observation, Analysis & Interpretation

(D) Effectiveness of treatment - Pain on Walking

Table No. 4.30: Effectiveness of treatment - Pain on Walking

PAIN ON WALKING
Before After
Count Percentage Count Percentage
Treatment Treatment
1 3 0 0
SEVERE SEVERE

MODERATE 3 10 MODERATE 1 3

MILD 26 87 MILD 19 63

0 0 10 33
NIL NIL

Before treatment, severe pain on walking was found in 3% of the total patients, 10
% had moderate pain and 87% had mild pain on walking, which was measured by scoring
table. After Rookshavasthi no patients complained about severe pain on walking.
Majority of the patients (63%) were having mild pain, 3% had moderate pain and 33% had
no pain while walking.

Table No. 4.31: Effectiveness of treatment - Pain on Walking - t test value

Pain on Paired t Test

Mean Median SD
walking
Before 1.17 1 0.46 t = 5.037 with 29
degrees of P value is <0.001
After 0.70 1 0.54 freedom.

The mean score of pain on walking before treatment and after treatment are 1.17
and 0.07 with a standard deviation of 0.46 and 0.54 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was <0.001, which indicate that the treatment is significant at 0.001 level.

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 Observation, Analysis & Interpretation

(E) Effectiveness of treatment in Morning Stiffness

Table No. 4.32: Effectiveness of treatment in Morning Stiffness

MORNING STIFFNESS
Before After
Count Percentage Count Percentage
Treatment Treatment
0 0 12 40
MILD MILD
21 70 14 47
MODERATE MODERATE
8 27 4 13
SEVERE SEVERE
VERY 1 3 VERY 0 0
SEVERE SEVERE

Before treatment, very severe morning stiffness was found in 3% of the total
patients, 27 % had severe morning stiffness, 70 % had moderate morning stiffness and no
one had mild Morning Stiffness. After Rookshavasthi no patients complained about very
severe morning stiffness, 47 % had moderate morning stiffness and 40 % had mild
morning stiffness. 13 % of patients had severe morning stiffness even after treatment.

Table No. 4.33: Effectiveness of treatment - Morning Stiffness - t test value

Morning Paired t Test

Mean Median SD
Stiffness

Before 2.33 2 0.55 t = 6.595 with 29

degrees of P value is <0.001
After 1.73 2 0.69 freedom.

The mean score of Morning Stiffness before treatment and after treatment are 2.33
and 1.73 with a standard deviation of 0.55 and 0.69 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was <0.001, which indicate that the treatment is significant at 0.001 level.

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 Observation, Analysis & Interpretation

(F) Effectiveness of treatment in Tenderness

Table No. 4.34: Effectiveness of treatment in Tenderness

Tenderness
Before After
Count Percentage Count Percentage
Treatment Treatment
5 17 8 27
GRADE 0 GRADE 0
23 77 22 73
GRADE 1 GRADE 1
2 7 0 0
GRADE 2 GRADE 2
0 0 0 0
GRADE 3 GRADE 3
0 0 0 0
GRADE 4 GRADE 4

Before treatment, no patients were having Grad-4 or Grade-3 tenderness. 7% were

having Grade-2 tenderness. 77% had Grade-1 tenderness and 17% had no tenderness
(Grade-0). After Rookshavasthi, number patients with Grade-2 tenderness become zero.
73% had grade-1 tenderness and 27% had no tenderness after treatment.

Table No. 4.35: Effectiveness of treatment - in Tenderness - t test value

Tenderness Mean Median SD Paired t Test

Before 0.90 1 0.48 t = 1.980 with 29

degrees of P value is 0.0573
After 0.73 1 0.45 freedom.

The mean score of Tenderness before treatment and after treatment are 0.90 and
0.73 with a standard deviation of 0.48 and 0.45 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was 0.057, which is considered not quite significant.

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 Observation, Analysis & Interpretation

(G) Effectiveness of treatment in Functional Assessment

Table No. 4.36: Effectiveness of treatment in Functional Assessment

Functional Assessment
Before After
Count Percentage Count Percentage
Treatment Treatment
0 0 0 0
GRADE 0 GRADE 0
0 0 0 0
GRADE 1 GRADE 1
14 47 19 63
GRADE 2 GRADE 2
10 33 7 23
GRADE 3 GRADE 3
6 20 4 13
GRADE 4 GRADE 4

Functional assessment before treatment revealed the following data. No patients

were having a Grade-0 or Grade-1 functional capacity. 47% fall under Grade-2 functional
capacity and 33% fall under Grade-3 functional assessment group. Functions were
severely affected in 20% of patients who came under Grade-4. After rookshavasthi,
percentage of patients in Grade 4 has reduced to 13% and Grade 3 to 23%. The reduction
in higher grades was reflected in Grade 2, which became 63%.

Table No. 4.37: Effectiveness of treatment in Functional Assessment - t test value

Functional Paired t Test

Mean Median SD
Assessment

Before 2.69 3 0.76 t = 2.703 with 28

degrees of P value is 0.0116
After 2.50 2 0.73 freedom.

The mean score of functional assessment before treatment and after treatment are
2.69 and 2.50 with a standard deviation of 0.76 and 0.73 respectively. Paired t test was
done to compare the values obtained before treatment and after treatment. The P value
obtained was 0.0116, which indicate that the treatment is significant at the level of 0.01

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 Observation, Analysis & Interpretation

(H) Effectiveness of treatment in reducing ESR

Table No. 4.38: Effectiveness of treatment in reducing ESR

ESR AVERAGE

Before Treatment After Treatment

22.26 mm in 1st Hour 15.4 mm in 1st Hour

Average value of ESR before rookshavasthi was 22.26 and after treatment were 15.4.

Table No. 4.39: Effectiveness of treatment in reducing ESR - t test value

Pain Mean Median SD Paired t Test

Before 20.5 10 20.18 t = 4.034 with 29

degrees of P value is 0.0004
After 14.4 9.5 13.05 freedom.

The mean score of ESR before treatment and after treatment are 20.5 and 14.4 with
a standard deviation of 20.18 and 13.05 respectively. Paired t test was done to compare the
values obtained before treatment and after treatment. The P value obtained was 0.0004,
which indicate that the treatment is significant at the level of 0.001.

(I) Effectiveness of treatment in Lumbar Flexion

Table No. 4.40: Effectiveness of treatment in Lumbar Flexion

Lumbar Flexion

Before After
Count Percentage Count Percentage
Treatment Treatment
0 0 0 0
GRADE 0 GRADE 0
0 0 7 23
GRADE 1 GRADE 1
24 80 19 63
GRADE 2 GRADE 2

6 20 4 13
GRADE 3 GRADE 3

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 Observation, Analysis & Interpretation

Before treatment, 80 % of the total patients were in Grade 2 and 20 % patients

were in Grade 3 in terms of Lumbar flexion. No patients were in Grade 1 and grade 0.
After Rookshavasthi 23% of total patients came under Grade 1, 63% came under Grade 2
and 13% were in Grade 3.

Table No. 4.41: Effectiveness of treatment - Lumbar Flexion - t test value

Pain Mean Median SD Paired t Test

Before 2.2 2 0.41 t = 3.525 with 29

degrees of P value is 0.0014
After 1.9 2 0.61 freedom.

The mean score of lumbar flexion before treatment and after treatment are 2.2 and
1.9 with a standard deviation of 0.41 and 0.61 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was <0.0014, which indicate that the treatment is significant at 0.001 level.

(J) Effectiveness of treatment in Lateral Movement

Table No. 4.42: Effectiveness of treatment in Lateral Movement

LATERAL MOVEMENT
Before After
Count Percentage Count Percentage
Treatment Treatment
0 0 3 10
GRADE 0 GRADE 0
10 33 12 40
GRADE 1 GRADE 1
20 67 15 50
GRADE 2 GRADE 2

0 0 0 0
GRADE 3 GRADE 3

Among 30 patients 67% had Grade 2 lateral movement and 33% had Grade 1
Lateral movement. No one was with Grade 3 and Grade 0 lateral movement. After

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 Observation, Analysis & Interpretation

Rookshavasthi, 50% came under Grade 2 and 40% came under Grade 1 lateral movement.
10 % became Grade-0 after the treatment.

Table No. 4.43: Effectiveness of treatment in Lateral Movement - t test value

Lateral Paired t Test
Mean Median SD
Movement
Before 1.67 2 0.48 t = 3.247 with 29
degrees of P value is 0.0029
After 1.40 1.5 0.67
freedom.

The mean score of lateral movement before treatment and after treatment are 1.67
and 1.40 with a standard deviation of 0.48 and 0.67 respectively. Paired t test was done to
compare the values obtained before treatment and after treatment. The P value obtained
was 0.0029, which indicate that the treatment is significant at 0.01 level.

(K) Effectiveness of treatment in ODI

Table No. 4.44: Effectiveness of treatment in ODI

ODI AVERAGE
Before Treatment After Treatment
70 53

Average value of ODI before rookshavasthi was 70 and after treatment was 53.

Table No. 4.45: Effectiveness of treatment in ODI - t test value

ODI Mean Median SD Paired t Test

Before 70 70 5.81 t = 29.440 with 29

degrees of P value is < 0.001
After 53 51 7.6 freedom.

The mean score of ODI before treatment and after treatment are 70 and 53 with a
standard deviation of 5.81 and 7.6 respectively. Paired t test was done with the raw data to
compare the values obtained before treatment and after treatment. The P value obtained
was 0.001, which indicate that the treatment is significant at the level of 0.001.

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 Observation, Analysis & Interpretation

(L) Effectiveness of treatment in RMDQ

Table No. 4.46: Effectiveness of treatment in RMDQ
RMDQ BT RMDQ AT IMPROVEMENT IN %
21 11 47.6
16 8 50
20 8 60
22 11 50
17 8 52.9
23 11 52.2
20 11 45
20 9 55
21 7 66.7
15 5 66.7
21 8 61.9
16 7 56.3
21 12 42.9
21 11 47.62
14 9 35.7
20 12 40
16 10 37.5
24 14 41.67
22 8 63.6
20 9 55
20 9 55
21 9 57.14
24 10 58.3
16 7 56.3
20 8 60
22 10 54.5
18 9 50
18 8 55.56
16 9 43.8
18 10 44.4

RMDQ average before and after treatment was 19.4 and 9.2 respectively.

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 Observation, Analysis & Interpretation

Graph No. 1 Distribution of Patients according to Age

21 TO 30

31 TO 40

41 TO 50

51 TO 60

0 10 20 30 40 50

Graph No. 2 Distribution of patients according to gender

50 50
Male Female

Graph No. 3 Distribution of patients according to religion

Christian 3

Muslim 10

Hindu 87

0 20 40 60 80 100
 Observation, Analysis & Interpretation

Graph No. 4 Distribution of patients according to Economical Status

Rich 3

Upper Middle class 10

Middle Class 87

0 20 40 60 80 100

Graph No. 5 Distribution of patients according to marital status

Married

Single

Graph No. 6 Distribution according to education

13% 10%

P.G
23%
Graduate
Secondary
54%
Primary
 Observation, Analysis & Interpretation

Graph No. 7 Distribution of patients according to occupation

Student

Medical rep.

Electritian

Nurse

Mason

Police

Conductor

Retired

Teacher

Driver

House wife

Office

0 5 10 15 20 25 30 35 40

Graph No. 8 Distribution of patients according to body weight

70 63.3
60
50
40
30 23.3
20 13.3
10
0
0 7 11
 Observation, Analysis & Interpretation

Graph No. 9 Distribution of patients based on bowel movement

Irregular Normal
27% 23%

Constipated Hard
13% 37%

Graph 10 Distribution according to low back pain chronicity

More than 2 Years 10

1 Year to 2 Years 7

7 months to 1 Year 33

1 month to 6 months 47

Less than 1 Month 3

Graph No. 11 Distribution of patients according to Bala

Avara
3% Pravara
17%

Madhyama
80%
 Observation, Analysis & Interpretation

Graph No. 12 Distribution of patients according to Agni

Vishamagni
30%

Mandagni
63%
Teekshnagni
7%

Graph No. 13 Distribution of patients according to Koshta

Kroora koshta Mridu koshta

13% 13%

Madhyama
koshta
74%

Graph No. 14 Distribution of patients according to Prakriti

VP
20%
VK
40%

PK
40%
 Observation, Analysis & Interpretation

Graph No. 15 : Distribution of patients according to Satwa

Avara Pravara
23% 14%

Madhyama
63%

Graph No. 16 : Distribution of patients according to Sathmya

Kasaya

Thiktha
Katu
Lavana
Amla

Madhura

0 20 40 60 80 100

Graph No. 17 & 18 : Distribution of patients according to:

Graph No. 17 Samhanana Graph No. 18 Vaya

Pravara Youvan
3% a
7%

Madhya Madhya
ma ma
97% 93%
 Observation, Analysis & Interpretation

Graph No. 19 Retention time of Rookshavasthi

60

50

40

30

20

10

0
< 5 mins < 10 mins < 15 mins > 15 mins

Graph No. 20: Number of vegas after Rookshavasthi

45 40
40
35
30 27
25 20
20
15 10
10
3
5
0
1 Vega 2 Vegas 3 Vegas 4 Vegas 5 Vegas

Graph No. 21: Data related to Complications after Rookshavasthi

90
80 77

70
60
50
40
30
20 13
10 7
3
0
Pain in Abdomen Tiredness Bloating No issues
 Observation, Analysis & Interpretation

Graph No. 22: Data related to Complications after Rookshavasthi

70 67
60
50
40 33
30
20
10
0
0
No change Slight increase in appetite Moderate increase in
appetite

Graph No. 23: Effectiveness of treatment on pain

100 80
80 60
60
40
40
20 20
0 0

Graph No. 24: Effectiveness of treatment on pain - Mean of Values

PAIN AT 4.933333333

PAIN BT 8.2

0 1 2 3 4 5 6 7 8 9
 Observation, Analysis & Interpretation

Graph No. 25: Effectiveness of treatment - Pain on lying

20 70
60
15 50
40
10 30
5 20
10
0 0

Graph No. 26: Effectiveness of treatment - Pain on lying - Mean of Values

PAIN AT 0.83

PAIN BT 1.47

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60

Graph No. 27: Effectiveness of treatment - Pain on Sitting

70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
 Observation, Analysis & Interpretation

Graph No. 28: Effectiveness of treatment - Pain on Sitting - Mean of Values

PAIN AT 1.67

PAIN BT 2.27

0.00 0.50 1.00 1.50 2.00 2.50

Graph No. 29: Effectiveness of treatment - Pain on Walking

90 70
80 60
70
50
60
50 40
40 30
30
20
20
10 10
0 0
GRADE GRADE GRADE GRADE GRADE GRADE GRADE GRADE
0 1 2 3 0 1 2 3

Graph No. 30: Effectiveness of treatment - Pain on Walking - Mean of Values

PAIN AT 0.70

PAIN BT
1.17
0.00
0.50
1.00
1.50
 Observation, Analysis & Interpretation

Graph No. 31: Effectiveness of treatment in Morning Stiffness

70 50
60 40
50
40 30
30 20
20
10 10
0 0

Graph No. 32: Effectiveness of treatment in Morning Stiffness - Mean of Values

1.73
PAIN AT

2.33
PAIN BT

0.00 0.50 1.00 1.50 2.00 2.50

Graph No. 33: Effectiveness of treatment in Tenderness

90 80
80 70
70 60
60
50
50
40
40
30
30
20 20
10 10
0 0
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
 Observation, Analysis & Interpretation

Graph No. 34: Effectiveness of treatment in Tenderness - Mean of Values

0.73
TENDERNESS AT

0.90
TENDERNESS BT

0.00 0.20 0.40 0.60 0.80 1.00

Graph No. 35: Effectiveness of treatment in Functional Assessment

50 70
60
40
50
30 40
20 30
20
10
10
0 0
Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade
0 1 2 3 4 0 1 2 3 4

Graph No. 36: Effectiveness of treatment in Functional Assessment - Mean Values

Fn. Assessment AT

Fn. Assessment BT

2.400 2.450 2.500 2.550 2.600 2.650 2.700 2.750

 Observation, Analysis & Interpretation

Graph No. 37: Average of ESR before and after treatment

25
22.26

20

15.4
15

10

0
ESR AVG BT ESR AVG AT

Graph No. 38: ESR Mean value before and after treatment

ESR AT 14.4

ESR BT 20.5

0.0 5.0 10.0 15.0 20.0 25.0

Graph No. 39: Effectiveness of treatment in Lumbar Flexion

80
80 70 63
70 60
60 50
50
40
40
30 23
30 20
20 13
20
10 0 0 10 0
0 0
Grade Grade Grade Grade Grade Grade Grade Grade
0 1 2 3 0 1 2 3
 Observation, Analysis & Interpretation

Graph No. 40: Effectiveness of treatment in Lumbar Flexion - Mean Values

LUMBAR FLEXION AT

LUMBAR FLEXION BT

1.75 1.8 1.85 1.9 1.95 2 2.05 2.1 2.15 2.2 2.25

Graph No. 41: Effectiveness of treatment in Lateral Movement

70 60

60 50
50
40
40
30
30
20
20

10 10

0 0
Grade 0 Grade 1 Grade 2 Grade 3 Grade 0 Grade 1 Grade 2 Grade 3

Graph No. 42: Effectiveness of treatment in Lateral Movement - Mean Values

LAT. MOVEMENT AT

LAT. MOVEMENT BT

1.25 1.30 1.35 1.40 1.45 1.50 1.55 1.60 1.65 1.70
 Observation, Analysis & Interpretation

Graph No. 43: Effectiveness of treatment in ODI Average

80
70
70
60 53
50
40
30
20
10
0
ODI AVG. BT ODI AVG. AT

Graph No. 44: Effectiveness of treatment in ODI Mean Values

ODI AT 53

ODI BT 70

0 10 20 30 40 50 60 70 80
 Part V
Discussion, Summary
and
Conclusion
 Discussion

DISCUSSION

Rational interpretation of data obtained from the clinical study is done in this
part. Discussion forms the base for conclusion. The discussion part in the present dissertation
is divided into the following parts-

Discussion on conceptual study

Discussion on clinical study
1. Discussion on demographic data
2. Discussion on clinical status of the patients
3. Discussion on response of treatment

Discussion on Conceptual Study

Low back pain is the leading cause of activity limitation and work absence
throughout much of the world, imposing a high economic burden on individuals, families,
communities, industry, and governments. The lifetime prevalence of non-specific (common)
low back pain is estimated at 60% to 70% in industrialized countries (one-year prevalence
15% to 45%, adult incidence 5% per year). Prevalence increases and peaks between the ages
of 35 and 55, although back pain is also reported by adolescents and by adults of all ages. In
the United Kingdom, low back pain was identified as the most common cause of disability in
young adults, with more than 100 million workdays lost per year. 2
Katigraha as the name indicates is characterized by restricted movement of kati
associated with pain. In Brihat trayis, Katigraha is considered as an associated symptom of
various conditions like Gridhrasi. Vatarakta etc. A general vatahara treatment line is followed
in Katigraha but initial rookshana plays an important role in the overall success of the
treatment especially in vata kaphaja katigraha. The initial rookshana also helps in clearing
aama. Treating aamavastha with vasti gives another treatment option for physicians that can
be combined with external rookshana therapies.
The lifestyle of patients included in this study reveals that there are many factors
which cannot be avoided from day to day life that causes the production of aama irrespective
of economic status, job type and activity level. Simple rookshana procedures like deepana,

Page 138
 Discussion

paachana will take more time to produce niraamaavastha. As a result of busy lifestyle, people

vasthi which brings proper rookshana in a lesser time span are need of the hour.

Discussion on clinical study

A. Discussion on demographic data

(1) Age

Out of the total thirty patients, 43.33% belonged to the age group of 51 - 60 years,
20% belonged to 41 TO 50 years age group, 23.33 % belonged to 31 TO 40 years age group
and 13.33% belonged to 21 - 30 years age group. Age group data of patients shows that
katigraha is predominant in peoples at their 3rd, 4th and 5th decades of life are more prone to
this disease. Most of the patients were at their fifties.

(2) Sex

Among the 30 patients 50% patients were male, 50% patients were female.
Katigraha affects both males and females are affected with katigraha because of change in
lifestyle and increased usage of motor cycle.

(3) Religion

Among the 30 patients 87 % were Hindus, 10 % were Muslim and 3 % were

Christians. This is due to their increased proportion in the society, as no linkage of religion
with this disease is established.

(4) Economical Status

Among the 30 patients participated in the study, 26 % belonged to middle class, 10%
belong to upper middle class and 3 % were from Rich socio economic status. Increases in
socio economic status directly influence the onset of many lifestyle diseases. Office job
which leads to continuous sitting predisposes the occurrence of katigraha. All most all
patients in this study were doing either physical exertion or continuous sitting which may
have accelerated the onset of Katigraha.

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 Discussion

(5) Marital status

93% of the patients in the present study were married. Patients who seek medical
help for katigraha are usually above 30 years. And by this age most of the people get married
(6) Education
Majority of the patients were graduates which constitutes about 54 %. 23 percent
were having secondary education and 13 % had primary education. 10% of the patients were
postgraduates. Educated population is aware about the severity of back pain and sought
medical help on time. There no relation with education level and disease.
(7) Occupation
37 % of total patients were having office jobs which may have a direct effect on their
health condition. Majority were working in air-conditioned office where they were forced to
sit continuously for long hour due to work load. 20 % were house wives who did improper
weight lifting many times which might have led to the manifestation of katigraha. 10% of
patients were drivers who are aware about the ill effects of continuous sitting but most of
them are unable to change profession due to personal problems. 7% of patients were teachers
who used to take more than three four periods per day and had to stand and talk loud for
about 45 minutes continuously which may lead to vatavridhi and pain. 3% of patients were in
professions like police, conductor, mason, electrician, nurse medical representative and
student who were working in an environment which may predispose the onset of low back
pain. Most of the patients were using motor cycle at some point of their daily life which
might have a strong relation with their current health condition.

B. Discussion on clinical status of the patient

(1) Body weight
Most of the patients in this study were having fairly nourished body. Some patients were
overweight which may lead to low back pain. About 36 % patients were having pot belly
which might have put extra stress on spine because of the forward pressure leading to back
pain. Almost all patients were not concerned about what they eat and gained weight due to
frequent snacking habit. This habit might have led to the production of aama.

Page 140
 Discussion

(2) Bowel movement

Out of 30 patients enrolled, 37% were having hard fecal matter with tendency to become
constipated. 27 % were having irregular bowel movement with most of them having sticky
and foul smelling fecal matter indicative of aama. 23 % were having regular bowel
movement. Most of the people with hard fecal matter and constipated bowel were having
severe pain in low back.
(2) Chronicity
80% of patients had chronicity of 1 year. With chronicity the nature of disease may
change to vata predominant state where applying rookshana may worsen the condition. This
study intends to assess the rookshana therapy, which should be done in the initial stages of a
disease where presence of aama is evident. Chronicity also affects the recovery and response
to the treatment. Less chronic cases showed good response to the treatment
(3) Bala
Majority of the patients i.e. 75% were having madhyama bala. This may be a
reflection of the general status of the patients who were attending our institution.
(4) Agni
63% of the total subjects observed were having mandagni and 30% were having
vishamagni. All diseases are produces by mandagni. Agnimandya can be the cause for aama.
(5) Koshta
Most of the patients (80%) were having madhyama kostha. There were 13 % of
mridu and krura koshta persons. Type of koshta does not seem to have much effect on
katigraha.
(6) Prakrithi
Among 30 patients enrolled, 40 % were vata kapha and another 40% were pitta kapha

body more prone to aamaja vikaras. Due to the presence of kapha prakriti factors in the study
subjects, it was easy to manage katigraha which is a vata spectrum disease. As katigraha
mainly occurs due to lifestyle or work related stress on spine, prakriti factors might have only
a small role in production of disease.

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 Discussion

c) Satva
Among the thirty patients, 63% were having Madhyama satva. Being Madhyama
satva may give somewhat actual examination reading like that of pain etc. A pravara satva
person may mask their pain and behave normal an avara satva person may exaggerate their
symptoms and may affect the scoring.
b) Sathmya
No persons enrolled in the study were ekarasa satmya. Dvirasa and trirasa satmya
patients were more. No one was sarvarasa satmya. Considering the rasas differently, 83 % of
the patients uses more katu rasa and 67% patients were lavana rasa satmaya. Katu rasa seva
can quickly provoke vata and it can accelerate the course of disease. Excessive usage lava
may lead to fluid retention. 53 % patients were amla satmya and 33 % were madhura rasa
satmya. Usage of madhura amla lava will lead to formation of kapha and excessive kapha
bhavas will lead to agnimandya and aama formation.
b) Samhanana
97 % of the total study population was having Madhyama samhanana and 3 % was
having pravara samhanana. Persons with avara samhanana were excluded from the study as
the main aim of study was to assess the effect of rookshana produced by rookshavasthi.
Pravara and Madhyama samhanana persons will be taking good amount of food which may
lead to the presence of aama in their body. Katigraha can be more prevalent in pravara and
Madhyama samhanana persons due to mechanical stress on spine by body weight. Katigraha
in avara samhanana persons who were admitted in our institution were mostly due to inter
vertebral disc prolapse. IVDP cases were not included in this study as it is a structural
abnormality.
c) Vaya
Patients in Vardhakya stage were excluded from this study as their body will be vata
predominant and rookshana may worsen pain. 93% of the patients were in Madhyama vaya.
And 7 % were in Youvana stage. As Madhyama vaya people are living in high stress due to
work and family chances for vata derangement are more in their body. Most of the
Madhyama vaya people enrolled in the study were having busy work sessions which made
them to take irregular meals and snack items in between which might have led to the
presence of aama in their body.

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 Discussion

C. DISCUSSION ON DATA RELATED TO ROOKSHAVASTHI

(1) Retention time of Rookshavasthi

Rookshavasthi is can be classified under nirooha vasthi so the standard retention time
was taken as 1 muhoortha (45 minutes), which is the maximum retention time mentioned for
nirooha vasthi in classical Ayurveda texts. The expulsion of rookshavasthi occurred within
10 minutes for half of the patients enrolled in this study. Only one person took about 20
minutes for bowel evacuation after vasthi. 33 % of patients got evacuation reflux within 5
minutes and the minimum retention time observed was 1 minute. The same person, whose
retention time was 1 minute, was able to retend vasthi for more than 5 minutes from the very
next day onwards.

(2) Number of Vega after Rookshavasthi

The yoga ayoga lakshanas of nirooha vasthi is determined like that of virechana. The
intention of Rookshavasthi is not shodhana. The amount of vasthi dravya used is also very
less to stimulate large intestine in producing multiple evacuation reflexes. So the vega seen in
rookshavasthi need not to be same as that seen in nirooha.

The maximum number of vegas observed after rookshavasthi was 5, which was seen
in a mridukoshta patient for two days only. The same patient got only 2 vegas for the next
two days and afterwards he got only one vega after rookshavasthi.

20 % of the patients had 3 vegas after rookshavasthi. In this group, 5 patients had two
vegas right after rookshavasthi and one vega after eating food.

40% of the patients had 2 vegas after rookshavasthi. In 5 patients among this group,
one vega happened just after rookshavasthi and the next vega was after around 40 minutes to
60 minutes when they were resting after lunch. 27% of patients had only one vega after
rookshavasthi. Pain relief was more in patients who had 2 and 3 vegas after rookshavasthi.

Number of vegas in rookshavasthi might be due to the irritation caused by the

hypertonic solution and the anulomana nature of gandharvahasthadi kashayam which is the

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 Discussion

dravadravya in this rookshavasthi. Previous studies done on rookshavasthi used only

dravadravya and churna. in this study, Saindhava and honey are added, which makes it more
rooksha.

(3) Complications after Rookshavasthi

without any discomfort. This might be due to less quantity of vasthi dravya and as it does not
produce shodhana.
Pain in abdomen was observed in 13 % subjects. Pain in abdomen started in 3 patients
immediately after bowel evacuation and in 1 patient while taking bath after bowel
evacuation. The patients who felt pain in abdomen took too much time in toilet and bath
room, which might be the reason for this complication. The pain subsided after eating food.
One patient was not feeling hungry after rookshavasthi and waited for the appearance
of appetite. After 20 minutes the patient felt tiredness and giddiness. He was advised to take
food suddenly and the tiredness reduced quickly.
Two female patients felt severe bloating and pain in chest while lying after eating
food. On enquiry it was revealed that one patient took food which was not hot and the other
patient took chickpea curry with rice. Both of them were advised to keep hot water bag on
stomach and one dose of 30 ml Abhayarishtam mixed with 2 Dhanwantharam tablet was
given. The symptoms subsided within 30 minutes.

(3) Other observations about Rookshavasthi

Burning sensation in Rectum
13% of patients complained about burning sensation in rectum towards the end of
rookshavasthi course. The discomfort was noted by three patients after 5 th day of
rookshavasthi and one patient noticed this discomfort on 7th day. This burning sensation
should be an indicative of rookshatva of vasthidravya which may cause mucosal irritation on
mucosa of rectum. The patients were advised to take plenty of water and the amount of
Saindhava and honey was reduced as a precaution. These measures helped to reduce burning
sensation. The burning sensation completely disappeared after 4 days in 2 patients and after
days in 2 patients.

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 Discussion

Agni Deepthi

Improvement in appetite was seen in all patients. 33 % of 33% of total

patients said they are feeling an improvement in appetite but not to the extent they expected.
Deepana paachana medicines were continued for these patients during the next 7 days of
regular treatment. 67% patients had a moderate increase in appetite which was increased
during the next phase of regular treatment.

Safety of rookshavasthi
The complications seen in rookshavasthi were easily manageable. Most of the
complications aroused due to delay in taking food. After taking food the discomforts reduced
and disappeared within 30 minutes. So with this data it can be substantiated that
rookshavasthi can be practiced beautifully without any complications if the patient takes a
quick shower after bowel evacuation and eat warm food immediately after bath

4. Discussion on response of treatment

Response of treatment on Pain
On individual assessment of all cases, there was good relief of symptoms. After
rookshavasthi, there was a considerable reduction in severity of pain. Highly significant
improvement in pain scoring was seen after rookshavasthi except in 6% chronic cases. 73 %
of total patients got their pain reduced to moderate level. Percentage of severe pain has come
down to 6.66 from 100. Thus we can infer that Rookshavasthi is very effective in reducing
the pain in saama katigraha patients.
Pain on lying, Sitting and walking
Pain on lying was completely relieved in 23% of patients and the pain become mild in
70 % of patients. 47% of patients had moderate pain before treatment ant it came down to
7%. Pain on Sitting and Walking had reduces significantly after the treatment course. This
data proves efficacy of rookshavasthi in relieving pain in saama stage of katigraha. In
statistical analysis, reduction in pain was highly significant at 0.001 level.
Morning Stiffness
Very severe morning stiffness, seen in 3% of total patients has reduced considerably
to no patients with very severe morning stiffness. 70% of moderate morning stiffness has

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 Discussion

changed to 47% and 27% of severe morning stiffness has changed to 13%. Morning stiffness
of 40 % patients becomes mild after rookshavasthi. This data supports the action of
rookshavasthi in morning stiffness.
Tenderness
Very slight changes were observed in terms of tenderness. Grade 2 tenderness
became) 0 % from 7% and Grade 1 tenderness became 73% from 77%. Statistical analysis of
this data showed no significance. From this information we can infer that rookshavasthi has
no significant action on tenderness.
Functional assessment
Majority of the patients came under Grade 2 functional assessment score before and
after rookshavasthi. Grade 3 and grade 4 patients got some improvement in function and the
values improved to 23% from 33% in Grade 3 and 13 % from 20 % in Grade 4. Statistical
analysis showed significance at the level of 0.01 for functional assessment scoring. With this
data we can infer that rookshavasthi helps to improve functionality by reducing pain
intensity.
ESR
ESR has been taken as an indicator of aama in a previous study done by Dr. Sunil
John in Ayurveda College Trivandrum. Rookshavasthi considerably reduces ESR from an
average of 22.26 to 15.4. This data substantiate the action of rookshavasthi in alleviating
aama.
Lumbar flexion and Lateral movement
Both lumbar flexion and lateral movement has considerably improved after
rookshavasthi. The restriction in movement was due to pain and the improvement must be
due to the overall reduction in pain. The values obtained after treatment shows significance at
0.001 level.
ODI
Disability index has improved after rooksha vasthi. The values were significant at
0.001 level. ODI also measures categories which will improve when pain is reduced. As pain
was reduced considerably after rookshavasthi, ODI score also improved. Some of the
questions in ODI were not answerable as the patient has more treatment left and they are still
admitted in hospital.

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 Discussion

RMDQ
RMDQ average before treatment was 19.4 and after treatment was 9.2. RMDQ value
showed an average improvement of 52% after Rookshavasthi. Most of the improvement
areas were related to pain and as pain was reduced by rookshavasthi, it reflected in the
overall score of RMDQ.

PROBABLE MODE OF ACTION IN KATIGRAHA

Rookshavasthi acts as a samana procedure rather than a shodhana procedure. The

procedure was started with anulomana by giving Gandharvahasthadi erandam. Eranda tailam
in small doses acts as aamapaachana and it has mild vedana shamana property. The prior
anulomana may aid in the safe and effective administration of rookshavasthi.

The drugs used in rookshavasthi are potentially agnideepana in nature. This property
may be the reason for increase agni in patients. The extra ingredients used in this
rookshavasthi are honey and Saindhava which makes the vasthi combination more similar to
nirooha vasthi and also these ingredients will make it more rooksha. This increased rooksha
nature may increase the aama paachana process and thereby accelerating the aamapachana
process.

The Saindhava in vasthi makes it hypertonic which helps in draining fluid from cells.
Draining excess fluid from cells account for general dryness in whole body which indicates
rookshana. Dryness of body is usually considered as an indicator of rookshata.

Vaisvanara churna in the vasthi may account for deepana pachana and vata shamana
nature of the combination. Internal administration of vaiswanara choorna is seen to reduce
erythrocyte sedimentation rate. The same effect was seen with anal route administration also.

Bowel evacuation happens in rookshavasthi may help in vatanulomana and thereby

reduce pain.

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 Discussion

SUMMARY

Th f Rookshavasthi in Katigraha
the effect of Rookshavasthi with Gandhavarhasthadi kashayam, Vaiswanara churnam,
Saindhava and Honey in reducing signs and symptoms of saama katigraha.

This dissertation is presented in the following order. Introduction, Review of

Literature, Review of disease, Review of Vasthi, Drug review, Methodology, Observation
Analysis and Interpretation, Discussion Summary and Conclusion. The literary work related
to the topic covers both Ayurvedic and modern aspects.

The dissertation starts with an introduction to Katigraha, Low back pain, its
epidemiology, importance of rookshana in treatment and the relevance of the present study.
The first part covers literary review, which consists of five sections. First section
deals with the rachana saareera of kati. Second section deals with the anatomical aspects of
low back region. The 3rd section elaborates the disease, etiology, pathogenesis, prognosis,
preventive measures and treatment of katigraha and its modern counterpart. The 4 th section
deals with the literature about vasthi, arha and anarha according to different acharyaas, matra
of vasthi dravya, types of vathi, yoga, ayoga and athiyoga lakshanas etc. 5 th chapter deals
with rookshavasthi
The second part of this dissertation covers the Drug review elaborating
pharmacodynamics of each ingredient in rookshavasthi and other drugs used in this study
.
The third part of this dissertation deals with methodology. Detailed description of
assessment criteria used in this study are included in this section. Katigraha patients, getting
admitted in the IPD of Government Ayurveda College Panchakarma Hospital,
Thiruvananthapuram were screened and selected as per inclusion criteria. Total 30 patients
were included in the study. Detailed history of the patient along with assessment of clinical
symptoms and required biochemical parameters were noted and recorded in the specific
format. Patients were given a mild anulomana with 10 - 20 ml gandharvahasthadi tailam on
the first day. Rookshavasthi was started from the second day onwards and continued for 7

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 Discussion

days. Assessment was done on the first day and on the 9th day. Patients were subjected to the
usual katigraha treatment protocol after rookshavasthi course.
The fourth part deals with Observation analysis and Interpretation of data. The
observed values are presented with graphs and tables in this section. Distribution of patients
according to demographic data, clinical condition of the patient and the data related to
response to treatment are elaborated under this section. The results obtained were statistically
analyzed and tables and graphs were drawn using the data. The significance of the
effectiveness of treatment was assessed by paired t test.
Fifth part deals with discussion. The whole work is elaborately discussed along with
the proper reasoning to draw some fruitful conclusions regarding this topic. A brief account
of the summary and conclusions in the study were also given in the fourth part. A clinical
proforma for the present study was designed considering the review of literature and is
attached as annexure. In the last part, various aspects of the study has been discussed and
finally, conclusion was drawn that Rookshavasthi is effective in reducing symptoms of
katigraha and it is safe to practice without any major complications.

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 Discussion

CONCLUSION

Katigraha became prevalent in Laghu trayee period as the description is more in these
newer classical texts.

Katigraha can be an associated symptom of some conditions as described in

Ayurvedic classical texts.

Rooksha vasthi can be safely and effectively practiced to produce proper rookshana in
conditions with pain.
Rookshavasthi was effective in reducing pain related symptoms of saama katigraha in
the patients of 20-60 yrs age group and was statistically significant.
Subjective parameters like pain and functional assessment was significantly improved
after the treatment.

Effectiveness in reducing tenderness was not statistically significant.

The sroto shodhana and vatanulomana property of ingredients in rookshavasthi helps

relieve pain.
Deepana property of drugs in rookshavasthi helps to increase agni, which prevents
formation of aama.
The intervention had not produced any adverse effect

LIMITATIONS
A general conclusion about rookshana cannot be drawn as the study focused only
katigraha.
Symptom score criteria should be updated with more scoring options that suit
katigraha.
Aamatva was assessed with classical symptoms told for saama vata. These data
should have included in the assessment criteria.

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 Discussion

Base line study with only one group.

Duration of study was limited.

complete rest during the treatment. Rest also will have a considerable effect on
reduction in pain.

RECOMMENDATIONS
Same study with data collection done at the time discharge and after a follow-up
period can be done to get the effect of Ayurvedic treatment in Katigraha.
Rookshavasthi with different dravadryavyas can be performed and observed
Rookshavasthi with altered dose can be done to assess the appearance of rookshana.
A black box design study of rookshavasthi, Rooksha sweda, internal medicines and
Sopha hara Lepana can be done to find out the efficacy in reducing aama in various
conditions.
Case series on rookshana therapy can be done to find out average time needed to
produce rookshana and thereby challenge the present standard duration of 7 days.
Study in a big sample size is to be done.
Advanced investigating procedures can be employed for assessment.

Page 151
Reference
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Appendix
 Appendix

ANNEXURE 1

CLINICAL CASE PROFORMA

Title of the study : EFFECT OF ROOKSHAVASTHI IN KATIGRAHA

Name of the Researcher : Peeyush P Kumar, Dept. of Panchakarma,
Govt. Ayurveda College, Thiruvananthapuram.

1. Particulars of the patient

Name : OPD No :
Age : IPD No :
Sex : DOA :
Religion : DOD :
Economic status : Education : UE/P/S/G/PG
Marital Status : Occupation :
Address :
2. Presenting complaints with duration:

3. History of present illness:

a) Age of onset
b) Development pattern
c) Aggravating factors
d) Relieving factors
4. History of past illness:

5. Treatment history:

6. Family history: Relevant (yes/no)

7. Personal history:

Dietary habits : Bladder :

Appetite : Bowel :
Sleep : Exercise :
Allergy : Addiction :
 Appendix

8. Menstrual history

9. General Examination:
Built : Well/Moderate/Poor
Nourishment : Good/Moderate/Poor
Height : cm
Weight : Kg
Skin rashes : Present/Absent
Edema : Present/Absent
Gait :
Cyanosis : Present/Absent
10. Vital data:
Temperature : ºC
Pulse : /min
Respiratory Rate : /min
Blood Pressure : mm of Hg
11. Systemic Examination

Locomotory system
Pain : Mild/Moderate/Severe
Swelling : Mild/Moderate/Severe
Overlying skin : Normal/Redness/ Discoloration
Tenderness : Present/Absent
Morning stiffness: Mild/Moderate/Severe/Very Severe
Crepitus : Present/Absent
Deformity : Present/Absent
Muscle : Wasting present /absent
Nervous System
Higher Mental Function Normal/Abnormal
Sensory/Motor deficit P/A
Cranial nerve Normal/Abnormal
Cardiovascular System
Pulse rate
Pulse rhythm Regular/Irregular
Heart rate
 Appendix

Respiratory System
Respiratory rate
Cough P/A
Dyspnoea P/A
Gastro-intestinal System-
Appetite Good/Poor
Position of Umbilicus Centrally/Ecentrally
Superficial veins & artery Visible /Invisible
Abdominal Pain P/A
Constipation P/A
Any mass/ Lump P/A
Hemorrhoids P/A
12. Range of movements:
Lumbar spine :
Flexion :
Extension :
Lateral bending :
13. Lab Investigations
ESR :
CRP :
14. Ashta Sthana Pareeksha
1. Nadi : 2. Mootram :
3. Malam : 4. Jihwa :
5. Shabda : 6. Sparsha :
7. Druk : 8. Akruthi :
15. Dasa vidha pareeksha:
Dooshyam : Dosham - Desham: Deham-
Dhathu - Bhumi-Jangala/Anupa/Sadharana
Balam: P / M / A Kalam:
Analam: V/T/M Prakruthi: VP / PK / VK / Sama
Vayas: Y/M/V Satwam: P / M / A
Sathmyam: M / A / L / K / T / KS
Aharam : Abhyavaharanashakthi - P/ M / A, Jaranashakthi - P / M / A
 Appendix

16. Diagnosis

17. Treatment

18. Assessment

VARIABLES BEFORE TREATMENT AFTER TREATMENT

Pain

Pain on rest lying

Pain on rest sitting

Pain on movement walk

Morning stiffness

Tenderness

Functional assessment

ESR

Lumbar flexion

Lateral movements

ODI

RMDQ

Signature of Guide :

Signature of Investigator :
 Appendix

ANNEXURE 2

ASSESSMENT CRITERIA SCORING

1. Pain Visual analogue scale

0 1 2 3 4 5 6 7 8 9 10

Nil =0
Mild =1-3
Moderate = 4 - 6
Severe =7 10
2. Morning stiffness
Mild = < 1 hour
Moderate = - 1-2 hours
Severe = 2-3 hours
Very severe = > 3 hours
3. Functional assessment

Grade 1 = Completely able to perform usual activities of daily living.

Grade 2 = Able to perform usual self-care and vocational activities, but limited in
non-vocational activities.
Grade 3 = Able to perform usual self-care activities, but limited in vocational and
non-vocational activities
Grade 4 = Limited ability to perform usual self-care, vocational, and non-
vocational Activities
4. Lab investigations
Erythrocyte sedimentation rate (ESR)
C Reactive Protein (CRP)
5. Pain on rest (On lying)
Grade 0 - No complaint
Grade 1 - Reveals on enquiry (mild)
Grade 2 - Complaints frequently when moves joints (moderate)
Grade 3 - continues pain (Severe)
 Appendix

6. Pain on rest (On sitting)

Grade 0 - No complaint
Grade 1 - Reveals on enquiry (mild)
Grade 2 - Complaints frequently when moves joints (moderate)
Grade 3 - continues pain (Severe)
7. Pain on movement (on walk)
Grade 0 - No complaint
Grade 1 - Able to walk more than 10 mtrs
Grade 2 - Able to walk only Up to 5 mtrs
Grade 3 - Cannot walk due to pain
8. Tenderness
Grade 0 - No tenderness
Grade 1 - Pain on touch
Grade 2 - Pain on touch and winces
Grade 3 - Withdraws the part
Grade 4 - Not allow to touch the part
9. Lumbar flexion
Grade 0 - Able to touch the ground
Grade 1 able to go up to ankle
Grade 2 able to go just below knee
Grade 3 Not up to knee
10. Lateral movement
Grade 0 Able to go below knee without difficulty
Grade 1 - Able to go below knee with pain
Grade 2 Cannot go below knee
Grade 3 No movement
11. Oswestry Disability Questionnaire for Low Back Pain

Section 1 Pain intensity

I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
 Appendix

The pain is very severe at the moment

The pain is the worst imaginable at the moment
Section 2 Personal care (washing, dressing etc)
I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but manage most of my personal care
I need help every day in most aspects of self-care
I do not get dressed, I wash with difficulty and stay in bed
Section 3 Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain
Pain prevents me from lifting heavy weights off the floor, but I can manage if they
are conveniently placed e.g. on a table
Pain prevents me from lifting heavy weights, but I can manage light to medium
weights if they are conveniently positioned
I can lift very light weights
I cannot lift or carry anything at all
Section 4 Walking
Pain does not prevent me walking any distance
Pain prevents me from walking more than 1 mile
Pain prevents me from walking more than ½ mile
Pain prevents me from walking more than 100 yards
I can only walk using a stick or crutches
I am in bed most of the time
Section 5 Sitting
I can sit in any chair as long as I like
I can only sit in my favorite chair as long as I like
Pain prevents me sitting more than one hour
Pain prevents me from sitting more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting at all
Section 6 Standing
I can stand as long as I want without extra pain
I can stand as long as I want but it gives me extra pain
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than 30 minutes
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
Section 7 Sleeping
My sleep is never disturbed by pain
My sleep is occasionally disturbed by pain
Because of pain I have less than 6 hours sleep
Because of pain I have less than 4 hours sleep
 Appendix

Because of pain I have less than 2 hours sleep

Pain prevents me from sleeping at all
Section 8 Sex life (if applicable)
My sex life is normal and causes no extra pain
My sex life is normal but causes some extra pain
My sex life is nearly normal but is very painful
My sex life is severely restricted by pain
My sex life is nearly absent because of pain
Pain prevents any sex life at all
Section 9 Social life
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more
energetic interests e.g., sport
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain
Section 10 Travelling
I can travel anywhere without pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys over two hours
Pain restricts me to journeys of less than one hour
Pain restricts me to short necessary journeys under 30 minutes
Pain prevents me from travelling except to receive treatment

Interpretation of ODI scores

The patient can cope with most living activities. Usually no

0% to 20%: minimal
treatment is indicated apart from advice on lifting sitting
disability:
and exercise.
The patient experiences more pain and difficulty with
sitting, lifting and standing. Travel and social life are more
21%-40%: moderate difficult and they may be disabled from work. Personal
disability: care, sexual activity and sleeping are not grossly affected
and the patient can usually be managed by conservative
means.
Pain remains the main problem in this group but activities
41%-60%: severe
of daily living are affected. These patients require a detailed
disability:
investigation.
Back pain impinges on all aspects of the patient's life.
61%-80%: crippled:
Positive intervention is required.
These patients are either bed-bound or exaggerating their
81%-100%:
symptoms.
 Appendix

12. The Roland-Morris Low Back Pain and Disability Questionnaire

I stay at home most of the time because of my back.
I change position frequently to try to get my back comfortable.
I walk more slowly than usual because of my back.
Because of my back, I am not doing any jobs that I usually do around the house.
Because of my back, I use a handrail to get upstairs.
Because of my back, I lie down to rest more often.
Because of my back, I have to hold on to something to get out of an easy chair.
Because of my back, I try to get other people to do things for me.
I get dressed more slowly than usual because of my back.
I only stand up for short periods of time because of my back.
Because of my back, I try not to bend or kneel down.
I find it difficult to get out of a chair because of my back.
My back is painful almost all of the time.
I find it difficult to turn over in bed because of my back.
My appetite is not very good because of my back.
I have trouble putting on my sock (or stockings) because of the pain in my back.
I can only walk short distances because of my back pain.
I sleep less well because of my back.
Because of my back pain, I get dressed with the help of someone else.
I sit down for most of the day because of my back.
I avoid heavy jobs around the house because of my back.
Because of back pain, I am more irritable and bad tempered with people than usual.
Because of my back, I go upstairs more slowly than usual.
I stay in bed most of the time because of my back.
Interpretation
The patient is instructed to put a mark next to each appropriate statement.
The total numbers of marked statements are added. Clinical improvement over time
can be graded based on the analysis of questionnaire scores. For example, at the

her score was 2 (10 points of improvement), then improvement is 83% (10 /12 x
100).