Effect of Nadi Sweda on symptoms of Pain, Swelling and Stiffness in Knee...

[Full title: Effect of Nadi Sweda on symptoms of Pain, Swelling and Stiffness in Knee Osteoarthritis - An Open Labeled Single Arm Clinical Study]

[Find the meaning and references behind the names: Mahesh, Main, Guru]

ORIGINAL ARTICLE February 2023 Journal of Ayurveda and Integrated Medical Sciences | February 2023 | Vol. 8 | Issue 2 14 Effect of Nadi Sweda on symptoms of Pain, Swelling and Stiffness in Knee Osteoarthritis - An Open Labeled Single Arm Clinical Study Sandipkumar Baheti 1 , Mahesh S 2 1,2 Research officer, Central Ayurveda Research Institute, CCRAS, Patiala, Punjab, India. I NTRODUCTION Osteoarthritis is one of the leading causes of disability and is estimated that over 100 million people globally suffer from Osteoarthritis (OA) [1,2] It is reported that in India the prevalence of OA was found in between the range of 17 - 60 and 6% of this come under knee OA. The most common evident symptoms of knee OA are joint pain, stiffness and reduction in the function of the knee joint [3] The main aim of OA treatment is to reduce joint pain and stiffness, improve mobility and quality of Address for correspondence: Dr. Mahesh S Research officer, Central Ayurveda Research Institute, CCRAS, Patiala, Punjab, India. E-mail: maheshmtgavc@gmail.com Submission Date: 06/12/2022 Accepted Date: 14/01/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.2.3 life, slow down the progress of disease and optimize the functions of patients [4] To date, there are no disease-modifying treatments are available for OA in conventional medicine. Therefore, there is a need for alternative and well-tolerable supplementary treatment which has no drug interaction with conventional drugs for OA. As per the literature of Ayurveda Vata, Pitta and Shleshma are the primary and essential constitutional factors of the human organism. Ayurveda considers these three factors as the actual intrinsic factors whose imbalance causes or predisposes the various disease conditions. These factors are known as Doshas as they are susceptible to imbalance and vitiation. The imbalance of Tridoshas is the cause of diseases in the body [5] Vata Vyadhi denotes a group of special disease entities caused by the disturbance of Vayu for all practical purposes. Sandhigata Vata (osteoarthritis) is an example of Vata Vyadhi [6,7] The administration of Vatahara Dravyas ( drugs or processes which have opposite properties of Vata ) having properties like Snigdha (sliminess/unctuousness), Guru ( heaviness), Ushna A B S T R A C T Introduction: More than 100 million populations globally suffer from Osteoarthritis (OA) which is considered the leading cause of disability. The prevalence of OA knee in India is about 6% of total osteoarthritis. Therefore, there is a need for alternative and well-tolerable supplementary treatment which has no drug interaction with conventional drugs for OA Aim and objectives : To evaluate the effect of traditional sudation therapy ( Nadi Swedana) on pain, swelling and stiffness of patients with knee osteoarthritis Method: The study was conducted after getting approval from Institutional Ethical Committee and was registered to the Clinical Trials Registry of India (CTRI/2018/03/012636 19/03/2018). A total of 20 patients with knee joint osteoarthritis were treated for 6 weeks. Pre-test and the post-test outcome measure was recorded on subjective parameters and statistically analyzed Results: The applied score for pain, swelling and stiffness decreased significantly lower after the intervention (p<0.05). Conclusions : Traditional sudation therapy by Nadi Swedana was beneficial for patients with knee osteoarthritis Key words: Ayurveda, Swedana, osteoarthritis, sudation therapy, CAM

Sandipkumar Baheti et al. Effect of Nadi Sweda in Knee Osteoarthritis ISSN: 2456-3110 ORIGINAL ARTICLE February 2023 Journal of Ayurveda and Integrated Medical Sciences | February 2023 | Vol. 8 | Issue 2 15 (hotness), Manda (mildness/slowness), Shlakshna, Mridu, Pichchila and Sthira Gunayukta) have seen advocated as specific treatment procedures for various for Vata disturbances. Among these procedures Snehana (therapeutic oleation), Swedana (sudation therapy) and Basti (therapeutic enema ) are the prime importance [8] Nadi Swedana is one type of Swedan Karma (sudation therapy) and is a popular and easy method of traditional sudation therapy. Nadi Swedana is a specialized traditional method type of Agnisveda ḥ in which sudation is done by giving steam for relieving pain, swelling and stiffness [9] A detailed description of Swedana is found in Ayurvedic literature and is used by Ayurvedic physicians in the management of Sandhigata Vata. However, we couldn’t find any report in the literature of research investigating the effect of Nadi Swedana on pain, swelling and stiffness in a patient with knee osteoarthritis. Therefore, the purpose of this observational study was to evaluate the effect on pain, swelling and stiffness of traditional Sudation therapy for the patient with knee osteoarthritis. M ATERIALS AND M ETHODS A total of 20 patients suffering from osteoarthritis of the knee joint, attending the OPD and IPD of the department of Kayachikitsa , Radhakishan Tonshniwal Ayurved College and Hospital, Akola, Maharashtra University of Health Science, Nashik, were enrolled irrespective of age, sex, religion, caste. The study was conducted after getting approval from Institutional Ethics Committee (letter no.266/18) and was registered in CTRI (CTRI/2018/03/012636 on 19/03/2018). Inclusion criteria ▪ Patients of the age group between 30 to 80 years. ▪ Clinically diagnosed with mild to moderate severity of symptoms of osteoarthritis (single or both knee joints) and confirmed by a radiologist or by an experienced Ayurvedic practitioner. Exclusion criteria ▪ Pain in the knee is caused by congenital dysplasia of the affected knee, rheumatoid arthritis, autoimmune diseases, malignancies, knee surgery or knee-arthroscopy ▪ Co-morbid conditions such as a history of Cardiac Arrhythmia, Acute Coronary Syndrome, Myocardial Infarction, Stroke or Severe Arrhythmia in the last 6 months. Study design: Single-arm study Duration of treatment: 6 weeks Intervention Nadi Swedana is a unique form of Swedana procedure where sweating is induced by passing steam over the body part by using a special instrument known as Nadi Swedana Yantra . Application of oil (sesame oil) to the body part that is to be subjected to sudation (sweating) treatment, followed by passing the steam to the same part with help of a tubular pipe is the procedure of Nadi Swedana . The steam is passed through a rubber tube fitted to the instrument and it is an easy method of applying heat to a localized part of a body. Dashmoola Kwath Choorna (mixture of 10 raw drugs) in Nadi Swedana Yantra along with a sufficient quantity of water (Table 2) During the study period all patients were given a placebo (capsule filled with starch powder) of 250 mg thrice daily. To compare the before and after effects of sudation therapy within the study group the paired ttest was done Table 1: Ingredients of Dasamoola Kwath Choorna with therapeutic actions [10,11] SN Drugs Botanical Name Therapeutic Actions 1. Shalaparni Desmodium gangeticum Anti-inflammatory, carminative 2. Prishniparni Uraria picta Anti-inflammatory, Antipyretic, carminative 3. Brihati Solanum indicum Anti-pyretic, Digestive, Diuretic 4. Kantakari Solanum surattense Anti-inflammatory, Digestive, Expectorant

Sandipkumar Baheti et al. Effect of Nadi Sweda in Knee Osteoarthritis ISSN: 2456-3110 ORIGINAL ARTICLE February 2023 Journal of Ayurveda and Integrated Medical Sciences | February 2023 | Vol. 8 | Issue 2 16 5. Gokshur Tribulus terrestris Analgesic, Diuretic, Carminative 6. Bilva Aegle marmelos Anti-diarrhoeal, Astringent, Digestive 7. Agnimanth Premna integrifolia Anti-inflammatory, Antipyretic, Analgesic 8. Syonaka Oroxylum indica Anti-inflammatory, Digestive, Anti-pyretic 9. Patala Stereospermu m suaveolens Anti-inflammatory, Antipyretic, Diuretic 10. Gambhari Gmelina arborea Anti-inflammatory, Analgesic, Carminative Assessment criteria 1. Pain: Subjective assessment was done as per the patient’s severity of pain. This was recorded according to Visual Analog Scale for assessment of Pain (Table 2). Table 2: Visual Analog Scale for assessment of Pain Score Grading of Pain 0 No Pain 1 Mild Pain that you are aware of but not bothered by. 2 Moderate Pain that you can tolerate without medication. 3 Moderate Pain that is discomforting and requires medication. 4-5 Severe Pain and the Patient began to feel anti-social. 6 Severe Pain 7-9 Intensely Severe Pain 10 Most Severe Pain. One may contemplate suicide over it. 2. Swelling: Assessment is done by measuring the circumference of the joint, before and after treatment at the fixed point over the joint in centimeters. 3. Stiffness: It was assessed as free movement against the normal range of movements (Table 3). Table 3: Scale for assessment of stiffness Complete free movement No stiffness ¾ free movements against that of the normal range of movement + stiffness ½ free movements against that of the normal range of movement ++ stiffness ¼ free movements against that of the normal range of movement +++ stiffness Difficulty with the complete range of movements ++++ stiffness Assessment of Clinical Parameters Detailed clinical observations were done every week for assessment of results. For final assessments, the clinical data were divided into four groups. 1. Complete Improvement: a) Complete or more than 75% relief or more. b) 75% or more relief in swelling. c) Decrease the angle of stiffness by 75% or more. 2. Marked Improvement: a) 50 to 75% subjective improvement in pain. (Pain scale-1) b) 50% or more relief in swelling. c) Decrease the angle of stiffness by 50% or more. 3. Moderate Improvement: a) 25 to 50% relief in pain. (Pain scale-2) b) 25% or more relief in swelling. c) Decrease the angle of stiffness by 25% or more. 4. Mild Improvement: a) Pain not relieved or only less than 25% (Pain scale-3 & 4) b) Less than 25% relief in swelling.

Sandipkumar Baheti et al. Effect of Nadi Sweda in Knee Osteoarthritis ISSN: 2456-3110 ORIGINAL ARTICLE February 2023 Journal of Ayurveda and Integrated Medical Sciences | February 2023 | Vol. 8 | Issue 2 17 c) Decrease in the angle of stiffness by less than 25%. The purpose of the study was explained by physicians and oral informed consent was obtained from the study participants. Patient’s data were recorded in a case Performa including information on demographic variables of the patients such as age, gender, education, occupation and family monthly income etc. The patient’s symptoms of pain, swelling and stiffness were assessed clinically and documented. R ESULTS 70% of the patients in the study were from the age group of 41 - 60. Seventy percent of the patients enrolled in the study were married females, 75% with primary education, 50% were housewives and 85% of patients are from middle-class families (Table 4). 15% of the patients had a family history of OA and 85% had been diagnosed for OA more than one year. Among the study group, 50% of patients had left KOA (out of them 70% female) and 70% of the patients had taken conventional treatment. In the comparison of the “Pain, Swelling and Stiffness Score” of the patients in the group, the difference between pre-test and posttest score value was found to be statistically significant (p<0.05). Results after 6 weeks of given therapy 50% patient of the patients got moderate relief, 30% of the patient got marked relief and 20% of the patient got mild relief (Table 5). Table 4: Distribution of the patients according to their descriptive features. Study Group (n) % Age Group 31 to 40 02 10 41 to 50 08 40 51 to 60 06 30 61 to 70 01 05 70 to 80 03 15 Gender Female 14 70 Male 06 30 Marital Status Married 20 100 Unmarried 0 Occupation Housewife 10 50 Labour 08 40 Employee/Teac her 01 05 None/Retired 01 05 Income Status (Monthly Income) Lower (below 6000) 3 15 Middle (6001 to 15000) 17 85 High (above 15000) 0 0 Education Educated 15 75 Uneducated 05 25 Family history of OA Yes 05 25 No 15 75 Duration of Diagnosis < 1 Year 17 85 > 1 Year 03 15 Joint affected by OA Single 14 (Right KOA-4, Left KOA-10) 70 Both 06 30 History of previous medication Conventional only 14 70 Conventional & CAM 06 30 Table 4: Outcome of treated Patients (Assessment at baseline and after 6 weeks) Symptoms of OA Study Group X±SD Pain Pre test 3.1±0.718 Post test 1.9±0.641 t 7.712 Swelling Pre test 31.25±6.463 Post test 30.35±5.752 t 3.111

[Find the meaning and references behind the names: Dinesh Kumar, Sharma, Singh, Ram, Dave, Wang, Joshi, Harsh, Kumar, Dinesh, Ayu, Anjali, Baijnath, Pradeep, Kaur, Yildirim, Med, Prakashan, Prasad]

Sandipkumar Baheti et al. Effect of Nadi Sweda in Knee Osteoarthritis ISSN: 2456-3110 ORIGINAL ARTICLE February 2023 Journal of Ayurveda and Integrated Medical Sciences | February 2023 | Vol. 8 | Issue 2 18 Stiffness Pre test 1.65±0.671 Post test 0.75±0.639 t 6.282 Study Group n % % Result of the treatment Complete 00 Marked 06 30 Moderate 10 50 Mild 04 20 DISCUSSION Literature review revealed no studies investigating the effects of Nadi Swedana (sudation therapy) on pain, stiffness and swelling of patients with knee OA. Nadi Swedana is a traditional and popular method used in this research had a heat transfer effect on the applied area. It was reported that heat application decreased pain and disability of patients with Knee Osteoarthritis [12] Blood flow, capillary permeability, nerve conduction and collagen extensibility increase through vasodilation as a result of heat treatment and it may reduce pain and stiffness [13] The analgesic effect of Dasamoola drugs is already proven [11] Nadi Swedana (sudation) seems to be a traditional Vata Shamaka procedure. Snehana (oleation) and Swedana (sudation) are opposite properties of Vata , viz., Sheeta (coldness), Ruksha (dryness) etc. with this mechanism Nadi Swedana produces relief in all sorts of Vata Vyadhi. L IMITATION This study has a single arm and lacks a comparator arm with a small sample size. In this study, there is a lacuna regarding Standard Operating Process (SOP) for the intervention of Nadi Swedana , another limitation of the study is that pain and stiffness assessment was not evaluated as per WOMAC CONCLUSION In fact, it is concluded that sudation therapy is the application of steam on the affected part has the potential to reduce the symptom of pain, stiffness and swelling due to the effect of heat. Nadi Swedna seems to be a traditional Vata Shamaka procedure. Nadi Swedana can be used as a supportive treatment in OA patients. Further clinical trials with a large sample size and longer follow up are warranted. REFERENCES 1 Kaur R, Ghosh A, Singh A. Prevalence of knee osteoarthritis and its determinants in 30-60 years old women of Gurdaspur, Punjab. Int J Med Sci Public Health . 2018; 7(10): 825-830. doi:10.5455/ijmsph.2018.0516207062018 2 Chintala Srilekha, Dr. Challa Pradeep Kumar. The study on prevalence and management of osteoarthritis in South India. Int J Orthop Sci 2019;5(4):112-117. DOI: 10.22271/ortho.2019.v 5.i 4 c.1656 3 Yildirim N, Filiz Ulusoy M, Bodur H. The effect of heat application on pain, stiffness, physical function and quality of life in patients with knee osteoarthritis. J Clin Nurs. 2010;19(7-8):1113-1120. doi:10.1111/j.1365- 2702.2009.03070.x 4 Wang C. Complementary and Alternative Medicine and Osteoarthritis. Int J Integr Med. 2013;1:13. doi:10.5772/56431 5 Vagbhata, Ashtanga Hridaya, Suta Sthana, 1 st Edition, Varanasi, Chaukhamba Surbharati Prakashan, 2016; 204. 6 Joshi A, Mehta CS, Dave AR, Shukla V D. Clinical effect of Nirgundi Patra pinda sweda and Ashwagandhadi Guggulu Yoga in the management of Sandhigata Vata (Osteoarthritis). AYU,2011;32:207-12. 7 Prasad Anjali Baijnath et al. Ayurvedic approach in the management of sandhigatavata: A critical review. Int. J. Res. Ayurveda Pharm. 2018;9(2):12-17 http://dx.doi.org/10.7897/2277-4343.09227 8 Ram Harsh Singh, concept of Vayu in relation to Vatavyadhi with special reference to role of swedana therapy in management, selected research papers on safety and efficacy of panchkarma publish by CCRAS, New Delhi Page No. 156-166. 9 Vagbhata, Ashtanga Hridaya, Suta Sthana,1 st Edition, Varanasi, Chaukhamba Surbharati Prakashan, 2016; 273. 10 K. Sharma and Dinesh Kumar Singh, A Scientific study on the role of Snehana, Swedana and Rasnadi Guggulu in

[Find the meaning and references behind the names: Zahoor, Lee, Vikas, Ahmad, Khan, Ravi, Shin, Mushtaq, Monika, Shekhar, Zafer, Nil, Lim]

Sandipkumar Baheti et al. Effect of Nadi Sweda in Knee Osteoarthritis ISSN: 2456-3110 ORIGINAL ARTICLE February 2023 Journal of Ayurveda and Integrated Medical Sciences | February 2023 | Vol. 8 | Issue 2 19 the management of Sandhigatavata (Osteoarthritis). JRAS.2003; Xxiv(3-4):88-103 11 Ravi Shekhar Singh, Mushtaq Ahmad, Zahoor Ahmad Wafai, Zafer Yab Khan, Monika Sharma, Vikas Seth. Analgesic Effects of Dashamula, an Ayurvedic Preparation, versus Diclofenac Sodium in Animal Models,2012;6(3):547-550 12 Mahesh S. et al. Review of Pain: An Ayurvedic approach. Int. Res. J. Pharm. 2019;10(9):24-34 13 Lim KO, Lee DY, Shin WS. The effects of a warm whirlpool bath on pain and stiffness of patients with chronic stroke induced knee osteoarthritis. J Phys Ther Sci. 2013;25(7):873-875. ******************************* How to cite this article: Sandipkumar Baheti, Mahesh S. Effect of Nadi Sweda on symptoms of Pain, Swelling and Stiffness in Knee Osteoarthritis - An Open Labeled Single Arm Clinical Study. J Ayurveda Integr Med Sci 2023;02:14-19. http://dx.doi.org/10.21760/jaims.8.2.3 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2023 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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