Comparison of the Efficacy of Choorna Pinda Sweda and Parisheka Sweda with Bruhat Panchamoola Choorna in the Management of Manyastambha W.S.R Torticollis - A Clinical Randomized Study

Introduction

In today’s fast-paced world, most people lead busy and stressful lives. The modern lifestyle has disrupted various biochemical balances in the body. Career advancement often demands long hours of sitting and working under pressure, along with continuous exposure to repeated stress. These factors contribute to the development of cervical disorders due to the pressure and tension on the spine.¹

Manyastambha is described under Vataja nanatmaja vyadhi, and occurs in Manya pradesha.² Pratyatma laxanas are Stambha and Ruk. Asamstana, Divyaswapna, and Urdhva Nirikshana are the Nidanas.³

Torticollis is a condition characterized by an abnormal, asymmetrical head and neck position, caused by various underlying factors. It involves involuntary tonic contractions or intermittent spasms of neck muscles. This is a common condition, with estimates suggesting that up to 90% of people will experience at least one episode of torticollis during their lifetime. The female to male predilection ratio is 2:1 and is noted in less than 4% of newborns. Symptoms may begin at any age ranging between 20 and 60 years, with typical occurrence in 30 to 50 years age group. Its intensity ranges from mild to severe.⁴ In contemporary science, it is usually managed conservatively with stretching exercises, use of neck brace, and inj. Botulium toxin, providing temporarily relief. However, this line of treatment without long-term relief results in patient dissatisfaction.⁵ In Manyastamba, Vata gets Avruta by Kapha, leading to Stamba and Ruk. There are numerous references to Ruksha sweda, which is considered highly effective in Kaphavruta vata conditions. Therefore, the objective of this study was to assess the efficacy of Choorna pinda sweda in comparison to Parisheka sweda in the management of Manyastambha.

Materials and Methods

Trial design

The present study was a single-blind, randomized, comparative clinical study. The study was approved by the Institutional Ethical Committee (IEC), SVM Ayurvedic Medical College, Ilkal, Karnataka. Written consent from the participants was obtained in the consent form approved by the institutional ethics committee, provided in the local language prior to the initiation of screening procedures.

Participants criteria

Inclusion criteria

The diagnosis was made based on the symptoms like Ruk (Pain) and Stamba (Stiffness). Patients aged between 16 and 60 years, of both the genders were included in the study. Only the patients fit for Swedana karma were considered.

Exclusion criteria

Patients diagnosed with congenital torticollis, pregnancy, traumatic injuries to the cervical region, patients suffering from any systemic disorders, malignancy of spine, tuberculosis of spine, cervical myelopathy were excluded.

Settings and locations for data collection

A minimum of 40 patients, suffering from symptoms of Manyastambha and fulfilling the above mentioned criteria were randomly selected from the IPD and OPD of S.V.M Ayurvedic Medical College’s RPK Ayurvedic Hospital, Ilkal. These patients were randomly allocated to Group A and Group B, with 20 patients in each group.

Interventions

Patients allotted to Group A received Parisheka sweda for a duration of seven days, while the patients in Group B received Choorna pinda sweda for the same duration.

Group A: Parisheka sweda

Purva karma: Fresh Bruhath panchamoola kwatha was prepared daily. Patient preparation was carried out accordingly. After completing their morning routine, the patient was instructed to lie in prone position.

Pradhana karma: Sukhoshna kwatha (maintained at approximately 42°C to 45°C) was filled in a Kindi patra (mug). The Kwatha was poured continuously over the Manya pradesha from a height of approximately 12 Angula (about 9 inches) without any interruption. The Kwatha was reheated and reused and the procedure was continued for 30 minutes.

Paschat karma: The area was then cleaned with cotton. The patient was advised to rest for 15 minutes, followed by warm water bath. The patients were advised to consume Laghu (light), Ushna (hot) and Anabhishyandi ahara (food which does not causes obstruction to the channels after digestion).⁶ The procedure of Parisheka sweda is shown in Figure 1.

Group B: Choorna pinda sweda

Poorva karma: About 200 g of fine Bruhath panchamoola choorna was tied into one Pottali, and was used for Choorna pinda sweda. Then it was warmed in a clean pan on a uniform flame. After the morning routine, the patient was asked to sit on a knee height stool.

Pradhana karma: Once the temperature of the Pottali was confirmed to be in the range of 42°C to 45°C by testing it on the dorsum of the therapist’s hand, it was gently applied over the Manya pradesha. Only gentle pressing with the Pottali was done, without any massaging or kneading. The Pottali was reheated as needed to maintain uniform temperature throughout the procedure, which was carried out for 30 minutes.⁷

Paschat karma: The patient was allowed to rest for a brief period, followed by implementation of Parihara vishaya of Swedana karma. Figure 2 shows the procedure of Choorna pinda sweda.

Outcomes

The outcomes were measured using subjective parameters. Pain intensity was assessed using the Numerical Pain Rating Scale, as described in Hutchinson’s Clinical Methods. Stiffness was graded on a scale from Grade 0 to Grade 4, and the range of neck movement was measured using a goniometer. Readings were recorded in degrees. Observations were noted at the baseline (0^th day), and subsequently on 8^th, 15^th, and 22^nd days after the treatment.

Sample size and randomization

A two-sided test was planned with a level of significance set at 5% and a power of 80% to detect significant differences. A total sample size of 40 subjects was calculated to detect an effect size of 0.47. This yielded a statistical power of 80.76%. After accounting for dropouts, 40 patients remained and were divided into two groups (n=20 per group) using simple random sampling via the lottery method.

Statistical methods

Intra-group comparisons were conducted for quantitative parameters using paired t test, and the inter-group comparisons were performed using unpaired t test.

Hypothesis testing was performed for each parameter, and results were interpreted accordingly. The level of significance was maintained at 0.05. Appropriate summary statistics, including mean, SD, and t-values were calculated. To compare outcomes between Group A and Group B, unpaired t-test was used.

Blinding

Evaluator-blinded data collection was maintained throughout the study. The outcome variables related to the interventions were documented and statistical analysis was also performed in a blinded manner.

Results

Demographic detail and baseline data

All the demographic and baseline data of the participants were evaluated, and the results indicated no significant difference between Group A and Group B in terms of patients’ age, gender, marital status, religion, education, socio-economic status, inhabitance, diet, Koshta, Prakurti, disease duration and history of other illnesses. No patient underwent concomitant treatments during the study period.

Outcomes and estimation

Unpaired t-test was used to compare outcomes between Group A and Group B. As observed in Table 1, the P value for the parameter ‘range of movements’ is less than 0.05. Therefore, we conclude that there is a statistically significant difference between Group A and Group B in the management of Manyastambha. F

urthermore, the average percentage of improvement in Group B was 79.32%, which is notable higher than the 59.22% observed in Group A. This suggests that intervention in Group B was more effective than that in Group A.

Discussion

Parisheka sweda and Choorna pinda sweda are forms of Bahirparimarjana chikitsa. The direct reference explaining its mode of action is found in Susrutha Samhitha. Out of the four obliquely traversing Dhamanis, each undergoes multiple divisions - hundreds and thousands of times, becoming innumerable. They cover the body forming a network, bound and pervaded. Their openings are attached to hair follicles that carry sweat and replenish Rasa internally and externally. It is through these pathways that the Veerya of Parisheka, Sankara sweda enter the body, after being transformed in skin.

Probable mode of action of Parisheka sweda

Parisheka is a type of Rooksha sweda that helps relieve Ruk, Stambha, and other symptoms associated with Vata, and softens the body parts. It is a variety of Drava Sweda, effective in reducing Stambha. Vyan vata, Shleshaka kapha, Amarasa, Mamsa, Meda are mainly responsible for Stambha. Ushna guna of Kwatha parisheka alleviates Stambha. Additionally, Ushna guna of Swedana facilitates Srotoshuddhi and Amapachana, thereby reducing stiffness.⁸

Probable action of Choorna pinda

Choorna pinda is a type of Rooksha sankara sweda. The drug with its Ushna and Teekshna guna helps dissolve Kapha in a Ghratitha stage that is firmly adhered to the channels. Furthermore, it relieves Kapha avarana by liquefying it. Swedana induces vasodilation, facilitating drug absorption into body and exert therapeutic effects.⁹

Conclusion

The following conclusions can be drawn based on the research undertaken on Swedana karma at R.P. Karadi Ayurvedic Hospital, Ilkal. The diseases Manyastambha and torticollis show similarity in their signs and symptoms. Manyastambha is one of the Vataja Nanatmaja vyadhis. The dosha entities involved in this disease are Vyanavata and Sleshmaka Kapha. In the initial stages, Vata avarana by Kapha is observed, leading to Stambatwa, Gaurava, and Ruk. Occupational strain, improper cervical postures, and sleeping or sitting on irregular surfaces are identified as the precipitating factors in the pathogenesis of Manyastambha.

The condition appears more prevalent in males and in the age group of 31-50 years, although this may be influenced by the small sample size. In cases of Manyastambha, drugs possessing Avarana hara and Vata hara properties should be administered. Considering this, Parisheka and Choorna pinda swedas were administered in this study. No complications related to Swedana were observed. Clinically, upon comparing overall responses, Group B i.e. Choorna pinda sweda showed the most favourable response (79.62%).

Informed consent

Informed consent was obtained from all patients included in this study

Conflict to interest

The authors declare that they have no known competing f inancial interests or personal relationships that could have appeared to influence the work reported in this paper.