herbal protocols for acute and chronic pain...• marma therapy internal treatments • dosage forms...

HERBAL PROTOCOLS FOR ACUTE

AND CHRONIC

PAINS. Prasad Vinjamury

Outline

Pain in AyurvedaDefinition

Causes

Pathomechanisms

Treatment of Pain in Ayurveda

Internal and External treatments

Ayurvedic Herbal Treatments

Single herbs

Herbal Formulations

Patent Herbals

Pain in Ayurveda -Etymology

• “vedana” from “vid” dhatu• Knowledge, perception, feeling, sensation, pain

• “anukula vedana” = pleasant perception/sensation - happiness

• “pratikula vedana” = unpleasant perception/sensation - pain

Manifestation of Pain (vedana jnana) • Pain occurs when the object comes in contact with • the skin (physical pain) - cutaneous mechanism• manas (emotional pain)

• Pain may occur as• A disease• Prodromal symptoms• Complication of a disease

• Asha S Raj & Sara Monsy Oommen: Concept Of Pain In Ayurveda – A Review. International Ayurvedic Medical Journal {online} 2018 {cited October, 2018} Available from: http://www.iamj.in/posts/images/upload/2355_2363.pdf

• S, Mahesh & Wele, Asmita & Patgiri, B & Pórszász, Róbert. (2019). REVIEW OF PAIN: AN AYURVEDIC APPROACH. International Research Journal of Pharmacy. 10. 20-34. 10.7897/2230-8407.1009256.

Anatomical substratum of Pain

• “mano-indriya-indriyartha sannikarsha”• Combination of mind, sense organ and stimulus for perception.

(Sattwa and Sareera –substrata for pain)

• Exceptions (Pain not perceived)– • Hair• Vellus hair (peach fuzz or tiny hair on the body)• Tips of nails• Excreta (mala)• Ingested food (anna)• Excretory fluids/ discharges (drava)

Etiology of Pain

All causes for diseases are

causes of pain –

No independent

cause

Asatmendriyartha samyoga

PrajnaparadhaParinama

Common Causes

Pathomechanism of Pain

• “Vata” – the main culprit• No pain without the involvement of vata (Susruta)• Pain (shoola) occurs only because of “vitiated vata”

• Vata imbalance caused by

Obstruction of vata (avarana)

Depletion of dhatu

Types of Pain• Depends upon • Vata’s association with other dosha imbalances – • pitta (burning type pain) • kapha (cold/stiffness type pain)

• Nanatmaja vyadhis• Vata (e.g., Gridhrasi, Angabheda, Janubheda, Siro ruk, Udavarta, etc.)• Pitta (e.g., Daha, Carmadalana, Angadaha, twak daha, etc.)

• Vata +Blood (rakta)• Peeda (uneasiness and restlessness) – Sharangadhara

• Location of Vata• Body parts: Koshta (parswa soola); Pakwashaya (Soola, trika vedana), Asthi (Bheda on

asthi-parva, sandhi shoola, etc.)• Srotas: Pranavaha srotas (sa shoola uchvasam); Rasavaha srotas (Angamarda-body

pains)

Prognosis • Sadhya and Asadhyata depends upon

the type of pain,

understand the srotas

involved, location of

disease, status of disease,

dosha involvement

AYURVEDIC TREATMENTS

INTERNALINTERNAL

EXTERNAL

EXTERNAL

CLEANSING

CLEANSING

DIET & LIFESTYL

E

DIET & LIFESTYL

E

Treatment of Pain

External Treatments

• Abhyanga• Swedana• Upanaha (poultice)• Agni karma• Kshara karma• Blood letting with leeches• Marma therapy

Internal Treatments

• Dosage forms with Single herbs

• Dosage forms with polyherbals• Pills, Powders• Oils, ghees• Decoctions • Alcohol based preps (Asava-

arishta), herbo-minerals, etc• Panchakarma

Treatment Principle: Balance “vata”and increase the pain threshold of the individual

AYURVEDIC HERBAL

TREATMENTSAN EVIDENCE BASED REVIEW

List of Single Herbs included in studies – Selected listSanskrit Names Botanical Names Common Names

Shallaki Boswellia serrata Indian Frankincense

Nisha (Haridra) Curcuma longa Turmeric

Ashwagandha Withania somnifera Indian ginseng (winter cherry)

Pushkaramoola Inula racemose Indian Elecampane

Guduchi Tinospora cordifolia Heart-leaved moonseed

Guggulu Commiphora mukul/wightii Mukul myrrh tree

Eranda Ricinus communis Castor

Nirgundi Vitex negundo Chinese chaste tree

Bala Sida cordifolia Country mallow

Rasna Pluchea lanceolata Galangal

Compound Herbal Formulations – Selected List

Name of the Formula Dosage forms

Maharasnadi Kwatham Decoction

Dashamula Kwatham Decoction

Yogaraja / Kaisora Guggulu Pills

Vatari Guggulu Pills

Guggulutiktaka ghrita Ghee

(Maha) Narayana Oil Oil

Amalakyadi Powder Powder

Clinical evaluation of Vatari guggulu, Maharasnadi kwatha and Narayan taila in the management of

osteoarthritis kneeMangal A, Shubhasree MN, Devi P, et al. J Ayurveda Integr Med. 2017;8(3):200–204.

doi:10.1016/j.jaim.2017.02.001

• Maharasnadi Kw (20 ml bid)+ Vatari Guggulu (500mg bid)+ Ext appln of Narayana tailam. – Pragmatic trial for 12 weeks.

Patent Herbal Formulations for Knee OA

Name of the Formula Ingredients in the Patent Formula

TLPL/AY/03/2008(Nipanikar et al 2013)

Boswellia, Guggulu, Ashwagandha, Nirgundi, Eranda, Parijata, Shunthi

SGC(G)(Chopra et al 2013)

Sunthi + Guduchi + Amalaki (± Guggulu)

Nartana (Modak &Barde 2017)

Guduchi, Ashwagandha, Gokshura, Boswellia, Shunthi

Ayurartis (Mundhe et al 2019)

Guggulu, Ashwagandha, Shallaki, Musta, Prasarini, Nirgundi, Kutaja, Chochini, Punarnava, Gokhshuru, Ajamoda, Bala, Ajwain, Methi

Ariflex (AHPL/AYTAB/0313)(Nipanikar et al 2020)

Boswellia, Guggulu, Rasna, Ashwagandha, Nirgundi, Guduchi, Eranda, Shunthi

Additional Studies on Herbal Formulations

Additional studies on Ayurvedic herbals

Herbal effects on Pain in Animal Models

Herb Common name

Disease tested Pharmacological effects

Saptaparni

Blackboard tree

Sciatic neuropathy Increased nociceptive thresholdReduced total calcium and inflammatory cytokines (from nerve damage)

Udumbara

Cluster Fig Diabetic Neuropathy Increase in antioxidant enzyme levelsDecrease in nitrite levelsDecrease malondialdehyde levels

Nisha (Haridra)

Turmeric Osteoarthritis Increased nociceptive thresholdIncreased weight bearing

Ashwashila

Rheumatoid arthritis Increased nociceptive thresholdDecrease in paw and ankle edemaDecrease in RA associated cartilage and bone deformation

Jyotishmati

Intellect Tree

General pain and inflammation model

Increased nociceptive threshold25% decrease in paw edema

Pain Conditions Investigated

OSTEOARTHRITIS (SANDHI VATA) OF THE KNEE JOINT

RHEUMATOID ARTHRITIS

LOW BACK PAIN MIGRAINE HEADACHE

FIBROMYALGIA

Summary• “Pain” has an elaborate description in Ayurveda• Causes, pathogenesis, types of pain, and nature of pain according to its location

•Many ayurvedic correlations to many biomedical “pain” conditions are available

• Treatment of pain is comprehensive – includes internal and external approaches

• Herbal approaches could be single (individual herbs), or formulations that are either classical or patented

• Research evidence indicates - positive outcomes with herbal approaches specifically, in Osteoarthritis (Sandhivata), Rheumatoid Arthritis (Amavata), Low back pain (Kati shoola), Migraine Headaches (Sirashoola), Fibromyalgia (Sarvanga vedana).

Limitations of this Review

• Reviewed only those published and available in English language

• Exclusively looked at herbal approaches only.

• Comprehensive holistic approach is recommended and is tested as well.

Conclusion

• Limited number of studies are available

• A small number of pain conditions were investigated

• Small sample sizes

•Non-randomized samples

• Overall, rigorous good quality trials are required

• However, historically, ayurvedic herbs and formulations are used along with other therapies, diet and lifestyle and therefore, testing only herbs and herbal formulations as stand alone therapies may not be appropriate.

Case- Study – Acute Low Back Pain• A 53 year old Caucasian woman teacher presented with acute low back pain. She

described the pain as sudden in onset that started while waking up from bed 10 days ago. She rated the severity at 8-9 out of 10 on a verbal rating scale (VRS) and describe it as excruciating and pounding. Any activity especially sitting and lying worsened her pain and standing or NSAIDs reduced the pain temporarily. She was overly worried that her activities of daily living are very much affected as the pain interfered with her normal daily life including her job. Pain radiating to left thigh and present most of the time.

• Her treatment history included pain killers (including narcotics), physical therapy and modified lifestyle since the pain started. Diagnostic imaging – MRI nothing significant

• Past Medical History – Nothing significant. No history of hypertension, diabetes or any major illnesses. Attained menopause 3 years ago. No known allergies

• Family History: No major illnesses that run in the family.

Case- Study – LBP (Cont’d)• Psychosocial History:

• Moderately built teacher, married, physically active.

• Non-smoker, social drinker, and no history of use of recreational drugs.

• Non-vegetarian, but did eat fruits and vegetables regularly. (balanced), but did eat vata increasing foods – raw salads, cold drinks, hummus, grilled and dry food now and then

• General Examination:

• 53 year old female visibly in pain, but cooperative and alert. No pallor.

Case –Study: Examination• Ashta Sthana Pareeksha: • Nadi – Vata 3, Pitta 2, Kapha1; • Jihwa: Purple tongue body with thick white coating• Malam – Incomplete bowels, occasionally hard• Mutram – Normal frequency and color• Akriti – Moderately built, visibly in pain• Sparsha – Pain on tenderness. Skin smooth and no visible marks• Sabda – Voice was clear and coherent. No hearing abnormality was detected or reported. • Drik – No visual abnormality was detected and reported

• Straight leg raising test – negative; Deep tendon reflexes- Normal; No sensory or motor deficits. Local tenderness – 3 to 4.

Case –Study: Diagnosis and Treatment• Diagnosis: Kati Shoola with Gridhrasi

• Line of Treatment: Shamana chikitsa focusing on anti-vata diet, lifestyle, and herbs

• Treatment:• Sahacharadi Kwatham Tablet: 2 tablets twice a day with warm water on empty stomach

at 6 AM and 6 PM• Add 10 drops of Ksheerabala tailam (101 times) to warm water and drink along with the

tablet• Dasamula Haritaki Lehyam – 2 teaspoonful with warm water at bed time.• External Application – Mahanarayana plus Dhanwantaram plus Karpuradi tailam

combination

• Kati Basti – 7 treatments• Diet – Anti-vata diet

• Lifestyle – Anti-vata

Case –Study: Outcomes

After 4 weeks pain reduced to 3-4 and the patient resumed all her

activities.

Pain still present when she lies down and cannot

lie down on the left side as the pain wakes her up. Has

stopped using pain-killers ever since she

started ayurvedic approach

After 6 weeks: Pain reduced to 2-4 and is

pretty much able to do all her activities. Able to stand

and teach

After 8 weeks: Pain reduced to almost

negligible except on pressing locally and moving quickly could re-create the

pain.

After 12 weeks: Is happy and is just coming for avoiding recurrence.

THANK YOUPrasad@scuhs.edu