Effective combine Siddha external therapy of Ottradam and Thokkanam in management of Kumbavatham

Dr. R. Srikajan^1*, Dr. S. Anpuchselvi², Dr. T. Shyama ³

1-Senior Registrar, 2- Senior Lecturer Gr.I, Unit of Siddha Medicine, University of Jaffna, Sri Lanka, 3- Director, Siddha Teaching Hospital, Kaithady, Sri Lanka.

*-Corresponding Author

Abstract

Introduction:Kumbavatham (periarthritis or adhesive capsulitis) is a common cause of shoulder pain and disability. In Siddha text Yugi Vaithya Chinthamani, it was mentioned as pain in the shoulder and upper limb, pricking pain in the cheek and jaw region, and inability in flexion and extension [2].Adhesive capsulitis is characterized by pain, stiffness, and limited function of the glenohumeral joint [3], which adversely affects the entire upper extremity. Patients typically describe onset of shoulder pain followed by a loss of motion [4], and the most common limitations in range of motion are flexion, abduction, and external rotation. Approximately 70% of frozen shoulder patients were women [5]; however, males with frozen shoulder were at greater risk for longer recovery and greater disability [3,5]. The aim of the present study was to evaluate the effect of Ottradam on kumbavatham management. The result of the present study may help in the betterment of disease management. Methods:Case study;A 58 years married male from Jaffna presented with pain and restricted abduction, adduction, external rotation and flexion of right shoulder both in active and passive movements for 2 months. He was diagnosed to be adhesive capsulitis which is equated to Kumbavatham. He was treated with Siddha external therapeutic procedure, Ottradam with amanakku ilai. After the treatment period of 15 days, the patient was followed for 6 months. The effect of external therapy on kumbavatham was assessed in accordance with shoulder pain and disability index. Result and Conclusion:The result of the current study concludes that the varmam therapy might be useful in the management of kumbavatham diseases and thus improves the quality of life of the patients. There were no adverse reactions/events observed during the course of treatment. The combination therapy has provided the reduction in pain and restricted movements which was measured using goniometer and SPADI index.

Keywords:Kumbavatham, Adhesive capsulitis, Ottradam, Thokkanam, SPADI index, Siddha medical system.

Introduction

Adhesive capsulitis is also known as frozen shoulder or painful stiff shoulder or peri-arthritis often has a prolonged course of treatment for two to three years. It is a condition characterized by functional restriction of both active and passive shoulder motion[1].The diagnostic criteria are shoulder pain for at least one month, inability to lie on the affected shoulder, stiffness and restricted shoulder movements which may cause pronounced sleep disturbances. Frozen shoulder condition is most common in the fifth and sixth decades of life. The peak age is in the mid-50s. Onset before the age of 40 is rare. Women are more often affected than men [2]. The chances for non-dominant shoulder to get affected is slightly higher. This is prevalent in patients with uncontrollable diabetes [3]. Usually, it has a prolonged course of treatment. The conventional treatment available are use of NSAID, intra-articular steroids, physiotherapy, acupressure and yoga [4]. Although pain is relieved by NSAIDs, the recovery from this condition is prolonged. Moreover, NSAIDs may cause side effects. Though there are various treatment options for this condition, there is no decisive treatment established yet. The painful functional deficit in this condition also decreases the quality of life. This condition is analogous to Kumbavatham, one of the types of 80 Vatha diseases mentioned in the textbook Yugi Vaidhya Chindhamani. Kumbavatham is a disease characterized by pain in shoulders and upper limbs with difficulty in abduction and adduction of shoulders, burning sensation in cheeks and eyes, giddiness, fever, pain below the umbilicus, inflammation below the tongue etc. [5], Thokkanam and Ottradam therapy in Siddha system of medicine is found to be effective in musculoskeletal disorders. The therapy time is less and if given regularly it gives long lasting results. Thokkanam is one of the 32 external therapies in Siddha system of medicine. Herein we report this case study of a patient diagnosed with kumbavatham and successfully treated with Siddha ottradam therapy and Thokkanam therapy.

Patient InformationA 58 years married male from Jaffna, who is a working as manager in private sector, presented with pain and restricted abduction, adduction, external rotation and flexion of right shoulder both in active and passive movements for 2 months. he was a non-vegetarian by diet taking chicken, fish very frequently. His sleep was disturbed due to pain, the bladder and bowel habits were normal. he hails from a middle income group family. There was no traumatic history. History revealed pain in right shoulder with restricted abduction and external rotation for 4 months. The x-ray of right shoulder taken 4 months back revealed no fracture or rotator cuff tear. The joint space in right shoulder was reduced. he had undergone physiotherapy for the pain and restricted shoulder movements 2 months back which resulted in reduction of pain and stiffness in right shoulder. But the symptoms reappeared after a week. Due to unsatisfactory result with recent treatment, the patient reported to the Ward 2, Siddha teaching Hospital, Kaithady, Jaffna, Sri Lanka.

Clinical FindingThe patient complained of difficulty in wearing shirt, combing hair, taking things from shelves above his height, unable to take hand at back. The pain was worse at night and aggravated while lying on right side. The clinical findings like pain score, Range of movements and Siddha assessment envagai thervu-1. Naadi (pulse) 2. Sparisam (palpation) 3. Naa (tongue examination) 4. Niram (colour of the body) 5. Mozhi (speech) 6. Vizhi (eye examination) 7. Malam (stool examination) 8. Moothiram (urine examination) were recorded. The vital signs were normal.

Diagnostic assessmentThe pain was assessed by Visual Analogue Scale and the shoulder movements were assessed using goniometer in sitting position. SPADI form was used for recording the pain and disability [6]. The pain score in SPADI was found to be 37/50 at the time of initial assessment. The shoulder movements were assessed and were recorded in Table 3. The assessments were done weekly once. Clinical examination revealed no weakness of muscles around the shoulder and upper limbs. The naadi was found to be vatha pitham and the neikkuri pattern (Oil in urine sign) was “aravena neendathu” ie, snake pattern. With the above symptoms he was diagnosed to be affected by Kumbavatham (Adhesive capsulitis) with predominant vatha humour.

Informed consentWritten informed consent was obtained from the patient. The patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Clinical study

Study design:

Study type :An open clinical trail

Study place :OPD and IPD of Siddha Teaching Hospital, Kaithady, Jaffna, Sri Lanka.

Study period :03 Months

Sample size :01 patient

Subject Selection:Patient reporting with symptoms of Kumbavaathamwill be subjected to screening using screening proforma then they will be involved for the trial by fulfilling the inclusion criteria.

Tests and Assessments:

A. Clinical assessment

B. Siddha system examination

A. Clinical Assessment

Pain and stiffness in Shoulder joint, With or without radiation of pain to upper arm, Exacerbation of pain on movements, Restricted movements [abduction and external rotation]

B. Siddha parameters:

Naadi, Sparisam, Naa, Niram, Mozhi, Vizhi, Malam, Moothiram

a. Neikkurib. NeerKuri:

Study enrollment:

Patient reporting at the OPD with the clinical symptoms of KUMBAVATHAM will be examined clinically for enrolling in the study based on the research criteria. The patients who were enrolled would be informed about the study, trial drug, possible outcomes and the objectives of the study in the language and terms understandable to them and informed consent would be obtained in writing from them in the consent form. Complete clinical history, complaints and duration, examination findings and laboratory investigations would be recorded in the prescribed Proforma.

Screening case sheet will be used for recording the patient history, clinical examination of symptoms, signs and laboratory Investigation. Patients will be advised to take the trial drug and to follow the appropriate dietary advice.

Adverse effect/serious effect management

In this study, no adverse reactions were observed during the course of treatment.

Outcome:

Shoulder improvement assessed by following assessment:

Shoulder Pain and Disability Index (SPADI)

Source:

Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991 Dec;4(4):143-9.

The Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that consists of two dimensions, one for pain and the other for functional activities. The pain dimension consists of five questions regarding the severity of an individual's pain. Functional activities are assessed with eight questions designed to measure the degree of difficulty an individual has with various activities of daily living that require upper-extremity use. The SPADI takes 5 to 10 minutes for a patient to complete and is the only reliable and valid region-specific measure for the shoulder.

Scoring instructions

To answer the questions, patients place a mark on a 10cm visual analogue scale for each question. Verbal anchors for the pain dimension are ‘no pain at all’ and ‘worst pain imaginable’, and those for the functional activities are ‘no difficulty’ and ‘so difficult it required help’. The scores from both dimensions are averaged to derive a total score.

Interpretation of scores

Total pain score: / 50 x 100 = % (Note: If a person does not answer all questions divide by the total possible score, e.g. if 1 question missed divide by 40) Total disability score: / 80 x 100 = % (Note: If a person does not answer all questions divide by the total possible score, e.g. if 1 question missed divide by 70) Total Spade score: / 130 x 100 = % (Note: If a person does not answer all questions divide by the total possible score, e.g. if 1 question missed divide by 120)The means of the two subscales are averaged to produce a total score ranging from 0 (best) to 100 (worst).Minimum Detectable Change (90% confidence) = 13 point (Change less than this may be attributable to measurement error) Circle the number that best describes your experience where: 0 = no difficulty and 10 = so difficult it requires help.

Outcome:

Very good – 76-100% reduction of SPADI Score

Good – 51-75% reduction in SPADI Score

Moderate – 26-50% reduction in SPADI Score

Mild –0-25% SPADI Score

Therapeutic intervention

1. Therapeutic purgation To normalize the vitiated vatha humour, therapeutic purgation was started. Virechanapoopathi maathirai 42 mg X 3 (3 tablet) was chosen for therapeutic purgation[7]. The pill was powdered, mixed with Lemon Juice and was given to the patient at 5 am in a single dose. Hot water was administered every 15 min. The purgation started at 5.45 am. The patient had nausea and passed loose stools 5 times since morning. The purgation subsided in the afternoon. he was given a glass of milk porridge. The diet he took on the day of purgation was Rasam & Rice in the afternoon and 5 String Hoppers for dinner. On the day of purgation therapy, no blood investigations or therapy was done. From the next day, blood investigations and the assessment of pain, shoulder movements with the aid of goniometer and SPADI scoring was done.

2. Ottradam and Thokkanam therapy The treatment package of amanakku Ilai ottradam was started. The treatment for kumbavatham was done with amanakku ilai ottradam was done daily morning at 10 am. The details of the Aamanakku ilai Ottradam[9] are shown in Table 1. Duration of treatment session: 15 min; Posture: Sitting; Time of treatment: Half an hour after a meal; Technique: Pressing (Amarthal); 10 sec gap between each manipulation. The patient was advised to take bath in hot water after the treatment.

TABLE 1 Tamil name, botanical name and quantity of ingredients used in the preparation of Aamanakku Ilai Ottradam

Preparation of Aamanakku Ilai OttradamThe leaves of aamanakku (Ricinus communis) is fried with castor oil and made into a pouch like kizhi, then fomented in the affected area.

3. Concomitant medicationNo any internal medicines.

4. Pathiyam (Diet)The pathiyam (treatment diet) mentioned for vatha diseases was adhered during the treatment period. The diet free from sweet, sour taste, tubers, food with cold potency were avoided. Bengal gram, string hoppers and primarily rice-based food prepared with vegetables, curry leaves, etc, were provided. Moreover sprouts, green leafy vegetables, butter milk and milk were also served during the treatment period.

Follow up and outcomeAfter the treatment of 15 days, the intensity of the pain was reduced. The pain scoring in SPADI score was reduced from 37/50 to 22/50. The disability was reduced from 66/80 to 38/80. The range of movements improved well allowing him to perform his daily activities with ease. The vitals and routine blood investigations were normal. The timeline of the clinical findings and details of range of motion of shoulder are portrayed in Table 2.

TABLE 2:Clinical Findings

TABLE 3:Measurement of Shoulder Movement with Goniometer and SPADI Score Before and After the Treatment

Discussion

Use of NSAIDs are the mainstay of treatment for pain. The range of motion of affected joints are in general improved with physiotherapy and exercises. Due to the panic of side effects and the expensive treatment, patients are marching towards traditional medicine. Here the patient was treated on the line of management of vatha diseases mentioned in Siddha literatures. The vatha humour was aggravated in the patient which was evident from the naadi (pulse) and neikkuri (oil on urine sign). To pacify the vitiated vatha, purgation was given and consequently the Ottradam and Thokkanam therapy was started [10]. The Ottradam therapy is effective in pain management. Previously the effect of ottradam therapy in osteoarthritis, periarthritis were reported. The exact mechanism of action is still unexplored. The mechanism of action of massage technique (Thokkanam) was already established. There are 9 types of Thokkanam described in Siddha system of medicine and appropriate techniques are adopted according to the disease condition [11]. Hypothetically after Thokkanam, the level of amino acid tryptophan increases which in turn increases the production of neurotransmitter serotonin. Thokkanam helps to dilute the toxins and expels them via lymphatic drainage [12]. The patient was advised to avoid tubers, sour taste.

ConclusionThe combination therapy of ottradam and Thokkanam has provided the reduction in pain and restricted movements which was measured using goniometer and SPADI index. There is reduction in SPADI score with the treatment package. The treatment is effective as there are minimal chances for adverse reactions. The strict adherence to the Siddha line of treatment and diet also have contributed to the ease of pain. The findings in this single case study have given strong hope for management of Kumbavatham through non-pharmacological therapies. However randomized controlled clinical trials with large sample size are warranted to substantiate the results.

Reference

1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg 2011;20:322e5.

2. Connolly J, Regen E, Evans OA. The management of painful stiff shoulder. Clin Orthop 1972;84:97e103.

3. Balci Nilu fer, Kemal Balci Mustafa, Tuzu ne Serdar. Shoulder adhesive capsulitis and shoulder range of motion in type II diabetes mellitus: association with diabetic complications. J Diabet Complicat 1999;13:135e40.

4. Vas J, Ortega C, Olmo V, Perez-Fernandez F, Hernandez L, Medina I, et al. Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial. Rheumatology 2008;47: 887e93.

5. Kuppuswamy Mudhaliyar KN, editor. Siddha maruthuvam (Podhu). 6th ed. Chennai: Department of Indian Medicine and Homoeopathy; 2004. p. 583. & 1998. p. 39e40.

6. Williams Jr JW, Holleman Jr DR, Simel DL. Measuring shoulder function with the shoulder pain and disability index. J Rheumatol 1995;22(4):727e32.

7. IMPCOPS, siddha marunthugalin seimurai,17th edition.india maruthuvargal kootaravu marundhu seinilayam mattrum pandagasaalai,2018.p.318.

8. Murugesa mudhaliyar K. S.,Gunapadam part 1 Mooligai,2th ed. Chennai : Department of Indian Medicine and Homoeopathy; 1951. p. 72,73.

9. Amirthalingam Pillai TS, editor. Agathiyar nayana vidhi. 1st ed., vol. 9. Tamilnadu Siddha Medicinal Board, Directorate of Indian System of Medicine; 1976. Chennai.

10. Sambasivampillai T. V, Introduction to siddha medicine, published by Directorate of Indian medicine and Homeopathy Chennai -600 106, 1st edition page:1-5

11. Kandasamypillai, History of siddha medicine, published by Dept of Indian medicine, 2nd edition-1998 Page :1-6

12. Subramaniyan V. ,Siddha maruthuvam part -4 vaathamthodarbananoigal, published by Tamil valarchikalagam, Chennai palgalai kazhagam,Chennai-600 005 2nd edition 2006

13. Chidambarathanupillai, Siddha system of diseases, Siddha medicine literature research center E-32 Anna nagar (E) Madras-600102 1-4

14. Shanmugavelu H.P.I.M ,Principles of diagnosis in Siddha, Dept of Indian medicine and Homeopathy Chennai 600106 First edition :2009 page:

15. Prema MD(S), A gasthiyar mani 4000 ennumvaithiyasinthamanivenpaa Thamarai noolagam,7 NGO coleney Vadapalani, Chennai 26, march 1996 page: 5

16. Ramachandran, Yoogi muni vaidhiyachindamani Thamarainoolagam ,7- NGO colony,Chennai2013.

17. Lois Solomon, David war wick, Selvadurainayaram ,System of orthopaedics and fractures,9th edition -2010 published by: Hodder, Arnold, Animprint, of Hodder education Hachette Uk company,338 Eustanroad, London. Page:351,352.

18. Waynevogi, Adam W.M. Mitchel Grayes anatomy for students 2nd edition Page 668,669,670,671.

19. Ryan, Brown H, Mins Lowe CJ the pathology associated with primary (idiopathic) shoulder a systemic review, BMC musculo skeletal disorder-2016 Aug15,17(1):340 (medicine)

20. Ozaki, Nakagawav, Sakurai .G, etal Recalcitrant chronic adhesive capsulitis the shoulder Role of contracture of the coraco humeral ligament and rotator interval in pathogenesis and treatment. Bone joint surg aAM.1989 Dec 71 (10), 1511-5(medicine)

21. Nerviaser A S,Hannafin JA, Adhesive capsulitis of the shoulder A review of current treatment AMJ sports med.2010 Jan 28(Medicine)

22. Biomarker in synovial fluid suggest chronic inflammation is present =kim y skim Jm,leeyg, hongok, KwonHs; Intercellular adhesion molecule -1 (icam-1,CD 54) is increased in adhesive capsulitis. Bone joint surgery Am 2013 feb 2015(4);e 181 - 8(medicine)

23. HSUJE, Anak We Ze OA,, Warrender WJ, Abbound JA. current review of adhesive capsulitis. J Shoulder elbow surgery 2011 Apr.2o(3):502 -14(medicine)

24. Sureshwar Pandey, Anilkumar Pandey clinical orthopaedic diagnosis, Jaypee brothers medical publishers 3rd edition -2009 pg no 114,122,123

25. Textbookn of orthopaedic and Trauma Jaypee brothers’ medical publishers First edition :1991 pg no 311

26. Churchill living stone Out line of orthopaedics,13th edition -2001 Harcourt publishers limited pg no:166

27. Owen Epsten G. Davidperkin, Johncookson, lans. Walt, Roby Rakhit Andrew Robins, clinical examinations 4thedition,Reprinted 2009, British library cataloguing in publication

28. Ramadass V., M.Sneha, M.Kannan, European Journal of Molecular & Clinical Medicine ISSN 2515-8260 Volume 10, Issue 06, 2023 1172

29. Shyfa. C, Jaison. N.P., Clinical study of Siddha drug for “Kumbavaatham”(Periarthritis), International journal of current research in chemistry and pharmaceutical sciences, Volume 6, Issue 6 – 2019, 6(6): 4 -13 www.ijcrcps.com