E-ISSN:2456-3110

Research Article

Frozen Shoulder

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 11 December
Publisherwww.maharshicharaka.in

Clinical study on the effectiveness of Vatagajankusha Rasa with Pippali Churna and Manjishta Kwatha as Anupana in Apabahuka (Frozen Shoulder)

Kamatagi M.1*, L. Jadhav L.2
DOI: http://dx.doi.org/10.21760/jaims.7.11.1

1* Muzammil Kamatagi, Post Graduate Scholar, Department of Kayachikitsa, Shri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

2 Lakshmiprasad L. Jadhav, Professor, Department of Kayachikitsa, Shri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

Apabahuka is a Vatavyadhi, localizing around the Amsapradesh and thereby causing of Amsa Bandha as well Aakuncana of Sira leading to symptoms like Bahupraspandita Hara. Amsashosha can be considered as the preliminary stage of the disease where loss or dryness of the Shleshakakapha from the shoulder joint occurs. In the next stage, due to the loss of Shleshakakapha symptoms like pain during movement, restricted movement are manifested. Vatagajankusha Rasa with Pippali Churna and Manjisthakwatha as Anupana is mentioned in the treatment of Apabahuka under the Vatavyadhichikitsa. The duration of intervention is 7 days as per the reference. Hence this study is intended to validate the same. Objective: Considering the prevalence, and lifestyle effect on patients, to evaluate the effectiveness of Vatagajankusa Rasa and Manjisthakashaya, Pippali Churna in Apabahuka. (Frozen Shoulder). Methodology: Among 34 registered subjects 28 completed the course of treatment. They were administered with Vatagajankusha Rasa (125mg) with Pippali Churna (3gm) and Manjishta Kwatha (15ml) as Anupana before food twice daily for a period of 7 days. For statistical analysis subjective and objective parameters were assessed by Wilcoxon signed rank, McNemar test and paired T test. Result: In the parameters of Apabahuka, the intervention was found to be statistically significant in relieving the assessment parameters like Amsa Sandhi Shoola, Bahupraspandita Hara (p < 0.005). In Objective parameters like ROM of Shoulder significant relief was observed after statistical analysis. Conclusion: Vatagajankusha Rasa with Pippali Churna and Manjishta Kwatha as Anupana is effective in the management of symptoms of Apabahuka.

Keywords: Apabahuka, Frozen Shoulder, Vatagajankusha Rasa, Pippali Churna, Manjishta Kwatha

Corresponding Author How to Cite this Article To Browse
Muzammil Kamatagi, Post Graduate Scholar, Department of Kayachikitsa, Shri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.
Email: 		Muzammil Kamatagi, Lakshmiprasad L. Jadhav, Clinical study on the effectiveness of Vatagajankusha Rasa with Pippali Churna and Manjishta Kwatha as Anupana in Apabahuka (Frozen Shoulder). J Ayu Int Med Sci. 2022;7(11):1-7.
Available From
https://www.jaims.in/jaims/article/view/2158

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-10-25 2022-10-27 2022-11-03 2022-11-10 2022-11-17
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 16%

© 2022by Muzammil Kamatagi, Lakshmiprasad L. Jadhavand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Apabahuka has two words. Apa means Viyoga[1] (dysfunction) & “Bahuka” means Bahu (shoulder).“Bahusthambo Apabahukaah”[2] which means stiffness in the shoulder joint. The management of ‘Bahusosha’[3] that resembles Apabahuka is explained under Bahushirshagata Vatachikitsa. Bahupraspanditha Hara is the cardinal feature of Apabahuka that occurs due to Siraaakunchana.[4] Frozen shoulder is defined as a clinical syndrome characterized by painful restriction of both active and passive shoulder movements due to causes within the shoulder joint or due to non-shoulder causes.

It’s causes are of two types, a) shoulder causes and b) non shoulder causes.

Shoulder causes: Problems directly related to shoulder joint which can give rise to frozen shoulder are tendinitis of rotator cuff, bicipital tendinitis, fracture and dislocations around the shoulder.[5]

Non Shoulder Causes: problems not related to shoulder joint like diabetes, cardiovascular diseases with referred pain to the shoulder which keeps the joint immobile, a complication of Colle’s fracture can lead to frozen shoulder. The reason could be prolonged immobilisation of the shoulder joint due to referred pain.

There are three classical stages in frozen shoulder:[6] Stage of pain, Stage of stiffness, Stage of recovery.

Management of Apabahuka needs Vatashamana, Dipana-Pachana and Shulaprashamana. Vatagajankusha Rasa is a combination of Vyosha, Rasa Bhasma, Vatsanabha, Karkatasringi, Haritaki of which Shunti, Maricha, Pippali act as Deepana, Pachana. Vatsanabha has the property of Vikasi, Vyavayi, Yogavahi, helping in easy absorption. Haritaki, Agnimantha, Karkatashringi act as Deepana, Kaphanissaraka, Vatashamaka. Rasa Bhasmas are Balya, Rasayana and Tridoshashamaka. So Vatagajankusha Rasa with Pippali Churna and Manjishta Kwatha as Anupana has been taken for the clinical study.[7]

Methodology

Source of data: Subjects of Apabahuka will be selected from Out Patient

and In Patient Department of Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan.

Methods of collection of data

A. Screening: A screening form was prepared with all aspects of history, signs and symptoms of Apabahuka.

B. Diagnostic criteria: Diagnosis will be made on the basis of Samanya Lakshana of Apabahuka viz. Bahupraspandahara, Amsa Sandhi Shoola and symptoms of frozen shoulder.

C. Inclusion criteria

1. Subjects who are willing to participate and sign the informed consent form

2. Subjects of either gender

3. Subjects aged between 40-70 years

4. Diabetic Patient with sugar level control

D. Exclusion criteria

1. Subjects presenting with fracture or dislocation of shoulder joint

2. Uncontrolled Diabetes Mellitus and Hypertension

3. Any other systemic disorder

4. Pregnant and lactating women

E. Laboratory investigations: X- Ray Shoulder joint - Anterio-posterior/ lateral view - to rule out fracture.

Study design: An open label, single arm clinical study on Apabahuka (frozen shoulder) (n=30) selected using the convenience (non-random) sampling technique with pre and post design conducted in tertiary Ayurveda hospital attached to the Ayurveda medical college located in district headquarters in southern India.

Intervention

Medicines: Vatagajankusha Rasa Tablet (125mg), 30 minutes before food with Anupana, 15ml Manjishta Kwatha and 3gm Pippali Churna twice daily for 7 days.

Assessment Criteria: Subjective and objective parameters were assessed using Constant Murley Score.

a. Pain : ( Max 15 Points)


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b. Activities of daily living : ( Max 20 Points)

  • Sleep
  • Normal daily living
  • Normal recreation activity
  • Hand comfort

c. Movement : (Max 40 Points)

  • Flexion
  • Abduction
  • External rotation
  • Internal rotation

d. Strength: (Max 25 Points)

Statistical Methods: Data was collected using case report form (CRF) designed by incorporating all aspects (Ayurveda & modern medicine) for the study. Such collected data was tabulated and analysed using SPSS (Statistical package for social sciences) version 23 by using appropriate statistical test. Demographic data and other relevant information were analysed with descriptive statistics. Continuous data was expressed in mean +/- standard deviation, and nominal and ordinal data was expressed in percentage. Nominal & ordinal data were analysed using non parametric tests like, Wilcoxon’s signed rank test, McNemar test. Continuous data was analysed using parametric test like, paired t as and when required. The changes (one tailed) with p value<0.05 were considered as statistically significant.

Observations and Results

Results of showing the effect of therapy on Amsa Sandhi Shoola

Amsasandhishoola BT AT N P Value Remarks
Present Absent Present Absent
Right BT-AT 16 12 2 14 28 .000 S
Left BT-AT 12 16 2 10 28 .002 S

BT - Before Treatment, AT - After Treatment, N - Number

Results of showing the effect of therapy on Bahupraspandita Hara

Bahupraspanda Hara BT AT N P Value Remarks
Present Absent Present Absent
 Right BT-AT 12 16 1 11 28 .001 S
 Left BT-AT 8 20 2 6 28 .031 S

BT - Before Treatment, AT - After Treatment, N - Number

Results of showing the effect of therapy on Shoulder Abduction

Shoulder Abduction Negative ranks Positive ranks Ties Total Z –value P - value Remarks
N MR SR N MR SR
BT-AT RIGHT 14 7.50 105.00 0 .00 .00 14 28 -3.742 .000 S
BT-AT LEFT 10 5.50 55.00 0 .00 .00 18 28 -3.162 .002 S

MR - Mean Rank, SR - Sum of Ranks, N = Number

Results of showing the effect of therapy on Shoulder Flexion

Shoulder flexion Negative ranks Positive ranks Ties Total Z -value P - value Remarks
N MR SR N MR SR
BT-AT RIGHT 16 8.50 136.00 0 .00 .00 12 28 -4.000 .000 S
BT-AT LEFT 11 6.00 66.00 0 .00 .00 17 28 -3.317 .001 S

MR - Mean Rank, SR - Sum of Ranks, N = Number

Results of showing the effect of therapy on Shoulder Internal Rotation

Shoulder internal rotation Negative ranks Positive ranks Ties Total Z -value P - value Remarks
N MR > SR N MR SR
BT-AT RIGHT 15 8.00 120.00 0 .00 .00 13 28 -3.873 .000 S
BT-AT LEFT 13 7.00 91.00 0 .00 .00 15 28 -3.606 .000 S

MR - Mean Rank, SR - Sum of Ranks, N = Number

Results of showing the effect of therapy on Shoulder external rotation

Shoulder external rotation Negative ranks Positive ranks Ties Total Z -value P - value Remarks
N MR SR N MR SR
Bt-at right 8 4.50 36.00 0 .00 .00 20 28 -2.828 .005 S
Bt-at left 5 3.00 15.00 0 .00 .00 23 28 2.236 .025 S

MR - Mean Rank, SR - Sum of Ranks, N = Number

Results of showing the effect of Constant murley score

Constant Murley Score Paired Differences T value DF P value
Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference
Lower Upper
BT-AT -12.60714 7.72365 1.45963 -15.60206 -9.61222 -8.637 27 .000

Discussion

The condition in which the aggravated Vata in the Amshapradesha dries up the Snayu of shoulder joints leading to Amsasosa; later, Dosha does the


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Aakunchana of the Sira of Amsadesha that condition is called as Apabahuka.[8] Bahupraspanditha Hara is the cardinal feature of Apabahuka that occurs due to Siraaakunchana.[9]

Frozen shoulder is a painful condition presents with Restriction or pain, or both, on shoulder elevation and external rotation. It progresses in three phases, first phase is characterized by increasing pain during movement, without significant loss of motion, typically lasts 2-9 months. In phase two, lasting 4-12 months, the shoulder ROM become progressively limited, pain occurs mostly at end range. last stage can last up to 4 years and consists of resolution with persisting pain[10]

Effect on Amsa Sandhi Shoola

Statistically significant improvement was noticed in Amsa Sandhi Shoola in 28 subjects. McNemar’s test (P value <0.05) showed improvements in mean after treatment.

Remission of pain was recorded during follow up. Before the treatment the initial mean pain score was 3.8572 and which came down to 0.8572 after treatment. The observation shows the pain decreased in intensity in a week. This remission of the symptom after the treatment, is statistically significant (P<0.05).

Amsashoola is manifested as a result of Nidanas like Atibhara Vahana, Vishamacheshta leading Vataprakopa in Amsapradesha, leading to Shoola. Karkatasringi in Vatagajankusha Rasa is Vatashamakadravya. In previous studies on Pistacia integerrima (Karkatashringi) isolated from the pisatacia integerrima bark, demonstrated marked muscle relaxant effects in various animal-based models.[11] The muscle relaxant potential of pistagremic acid was performed in many muscle relaxant paradigms including the rotarod test, the traction test, the inclined plane model and the climbing test.

Manjisthakashaya helps in pacifying the Vriddhavata due to its Ushnavirya and Madhura Rasa. Pippali, Manjishta, Vatsanabha have Shoolahara activity due to glycosides, alkanoids and other bio active compounds present in them and help in reducing the pain.[12]

Effect on Bahupraspandita Hara

Statistically significant improvement was noticed

in Bahupraspandita Hara in 28 subjects after treatment. McNemar’s test (P value <0.05) showed improvements in mean after treatment.

Bahupraspandita Hara is a major symptom in Apabahuka where active movements are restricted because of Pain and stiffness of the shoulder joint. Significant result was observed with degree of active movements after the treatment. Range of shoulder flexion showed an improvement following treatment. Mean range of flexion movement was 8.6071 degree before treatment and which improved to 9.5715 degrees after treatment. Increase in the range of flexion by about 39 degrees was found to be statistically highly significant (P<0.0001) as assessed by McNemar’s test. Mean range of abduction movement was 89.048 degrees before treatment and which increased to 124.286 degrees after treatment. Increase in the range of flexion by about 40 degrees was found to be statistically highly significant (P<0.0001). The mean range of internal rotation was 19.048 degrees before treatment and which increased to 40.952 degrees after treatment.

Increase in the range of flexion by about 22 degrees was found to be statistically highly significant (P<0.0001). Mean range of external rotation movement was 17.143 degrees before treatment and which increased to 56.190 degrees after treatment. Increase in the range of external rotation by about 40 degrees was found to be statistically highly significant (P<0.0001) as assessed by paired t test. Range of abduction against resistance of 1 kg was 38.810 degrees before treatment and which increased to 53.300 degrees after treatment. increase in the range of abduction against resistance of 1kg was by about 16.5 degrees was found to be statistically highly significant (P=0.002) It is interesting to quote the significant improve in the Functional ability of the shoulder joint which was assessed according to the parameters of Constant and Murely.

Before treatment the mean score was 31.619 improved to 60.952 with the difference in mean score of 29.333 which was statistically highly significant where P<0.001 as assessed by paired‘t’ test.

In this study maximum numbers of subjects were diabetic, and also were involved the strenuous exercise, Bahupraspandita Hara (stiffness)


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develops. The wounded muscle which has increased glucose uptake is infiltrated with a large number of inflammatory cells. Macrophages which are the predominant inflammatory cells in wounded muscle can increase glucose oxidation by epididymal fat pads,[13] also previous studies revealed positive association between high AGE’s levels and declined decreased muscle properties (strength, power and mass) and increased physical frailty, thus restriction of movements develops.

Manjishta Kashaya acts as Sothahara (anti- inflammatory), because of the presence of Rubimallin. This reduces the inflammation and prevents the further glucose deposition over the injured muscle and enhancing the healing process by improving the circulation.

Ingredients of Vatagajankusha Rasa like Rasasindhura, Lohabhasma, Swarna Makshika, Gandhaka, Vatsanabha, Tankana, Trikatu with the Bhavana of Nirgundi and Mundi Swarasa makes the drug more potent against Vata and Kapha disorders.

Vatsnabha is Vata Hara and Rujapaha. Its Vikasi, Vyavayi, Yogvahiguna makes it easy to reach the cellular level thus improving the circulation and reducing inflammation.

Shudha Haratala, Shunti, Pippali act as Vatashamaka, due to its Ushnavirya and Snigdha Guna, might have improved Snigdhaguna inducing the lubrication and ease for range of movements, reducing Bahupraspandita Hara.

Discussion on mode of action of drug

Vatagajankusha Rasa is a combination of Rasa Aushadhis like Rasa Sindhura, Lohabhasma, Swarnamakshikabhasma, Gandhaka, Haratala, Tankana and Dravyas like Haritaki, Karkatasringi, Vatsanabha, Shunti, Pippali, Agnimantha with Bhavana in Nirgundiswarasa and Mundi Swarasa.

Vatsnabha is Kaphavata Hara and Rujapaha. It’s Vikasi, Vyavayi, Yogvahiguna makes it easy to reach the cellular level.Pippali, Maricha, Shunti are Shoolaprashamanadravyas. Karkatasringi, Haritaki, Agnimantha work as Vatashamaka. Nirgundi, Agnimantha, Lauhabhasma, Shudhagandhaka and Tankanabhasma act as Shothahara. Shunti acts as Srotoshodhaka and Raktaprasadaka. Pippali, Manjishta, Vatsanabha have analgesic activity due to glycosides, alkanoids and other bio active compounds present in them and helps in reducing the pain.[14]

Rasaushadi in the Vatagajaankusa Rasa has to undergo Marana, after that Rasa Bhasmas become more potent and fine particles. Due to which absorbtion into the body gets rapid, with the Manjishta Kashaya as catalyst for circulation and nourishment to the injured muscle. Rasa Aushadis penetrate the intestinal barrier by endocytosis, phagocytosis or persorption and transit to the blood stream, reducing the further cell injury process and providing proper circulation for healing by reducing the inflammation.[15]

Shudhaharatala, Shunti, Pippali act as Vatashamaka, due to its Ushnavirya and Snigdha Guna, might have improved Snigdhaguna inducing the lubrication and ease for range of movements, reducing Bahupraspandita Hara.

Conclusion

Vatagajankusha Rasa contains the main ingredients like Rasa Sindhura, Lohabhasma, Swarnamakshikabhasma, Shunthi, Pippali, Vatsanabha and hence acts on Vata and Kapha Dosha which shows its action on both variants of Apabahuka.

Vatagajankusha Rasa with Pippali Churna and Manjishta Kwatha as Anupana showed marked effect on the signs and symptoms of Apabahuka - Amsa Sandhi Shoola, Bahupraspanditha Hara.

Range of movements of Shoulder joint showed significant improvement after treatment. Vatagajankusha Rasa orally in the dose of 125 mg twice daily with Pippali Churna (3gm) and Manjishta Kwatha (15ml) as Anupana for 7 days is effective in Apabahuka.

Reference

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3. M. Monier William a Sanskrit English Dictionary National Banarasidas Publishers Pvt Ltd. New Delhi, 1st edition 2002. P-728


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4. Bhishagacharya Harishastriparadkarvaidya, Astanga Hridayam of Vagbhata with Arunadutta & Hemadri commentaries 8th edition published by Chaukambha orientalia 2007 p-534.

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8. Sushruta, Dalhana, Gayadas, Sthana-Nidanasthana, Chapter-1, Verse-82, In: Acharya Y T, Susruta Samhita, Reprint Edition. Varanasi: Choukambha Orientalia 2003, Page no.428

9. Vagbhata, Ashtanga Hrudaya, Sarvanasundara of Arunadatta, Sthana- Nidansthana, Chapter-15, Verse-43, Hari Sadashiva shastri Paradakara Bhishagacharya, Ashtanga Hridaya, Reprint Edition, Varanasi, Chaukambha Surbharati Prakashana, 2002, p.530.

10. Wolf EM, Cox WK. The external rotation test in the diagnosis of adhesive capsulitis. Orthopedics 2010;33. doi:10.3928/01477447-20100329-11. pmid:20506951

11. Uddin G, Rauf A, Al-Othman MA, Collina S, Arfan M, Ali G, et al. Pistagremic acid, a glucosidase inhibitor from Pistacia integerrima. Fitoterapia 2012;83:1648–52.

12. Chaudhary, Anand & Meena, Vandana. (2015). Manjistha (Rubia Cordifolia)- A helping herb in cure of acne. Journal of Ayurveda & Holistic Medicine. III. 11-17.

13. Shearer JD, Amaral JF, Caldwell MD. Glucose metabolism of injured skeletal muscle: the contribution of inflammatory cells. Circ Shock. 1988 Jul;25(3):131-8. PMID: 3168170.

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15. C.B. Jha, B.Bhattacharya, K.K. Narang, Bhasmas as natural nanaorobots: the bio relevant metal complex. J. Tradt Nat Med; 1(1): 2-9


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