E-ISSN:2456-3110

Case Report

Frozen Shoulder

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 8 AUGUST
Publisherwww.maharshicharaka.in

Efficacy of Marma Chikitsa and Shoulder Exercises in the management of Avabahuka (Frozen Shoulder) - A Case Study

Chaudhari P1*, Marwaha R2, Bhalerao N3, SD Panda4
DOI:10.21760/jaims.9.8.41

1* Pranali Chaudhari, Post Graduate Scholar, Dept of Rachna Sharir, Pt Khushilal Sharma Govt Ayurveda College, Bhopal, Madhya Pradesh, India.

2 Rita Marwaha, Professor and HOD, Dept of Rachna Sharir, Pt Khushilal Sharma Govt Ayurveda College, Bhopal, Madhya Pradesh, India.

3 Nisha Bhalerao, Associate Professor, Dept of Rachna Sharir, Pt Khushilal Sharma Govt Ayurveda College, Bhopal, Madhya Pradesh, India.

4 SD Panda, Assistant Professor, Dept of Rachna Sharir, Pt Khushilal Sharma Govt Ayurveda College, Bhopal, Madhya Pradesh, India.

Avabahuka is one among the 80 Vatavyaadhis mentioned in Samhitas. The disease known as Avabahuka is characterized by Dushita Vata Dosha, which is localized in the Ansa Pradesha and results in shoulder dysfunction as well as Akunchan of Sira at this site. It is correlated with Adhesive Capsulitis that is Frozen Shoulder. The prevalence of frozen shoulder is 3% to 5% in general population and upto 20% in those with diabetes. Allopathy medicines have limitations giving short term relief in pain and surgeries which carries risk. Marma therapy being a non pharmaceutical technique is a hidden treasure of Ayurveda. It is ancient Neuromodulation therapy which offers deep sense of relief in pain and stiffness of muscles. A 32 year aged women who has already diagnosed with frozen shoulder since 3 years approached to Pt. Khushilal Sharma Ayurveda Hospital and was treated with Marma Chikitsa and Shoulder Exercises. The treatment was continued for 15 days in which day wise improvement was analyzed. The range of movements improved from 30° to 120° for abduction, 105° to 160° for flexion, 35° to 45° for extension and 55° to 65° for external rotation. Pain is assessed using VAS score which also improved after the treatment. Thus, Marma therapy and Shoulder exercises gives highly remarkable relief in both range of movement as well as pain in Avabahuka. Nonetheless, a large-scale population study was recommended.

Keywords: Avabahuka, Frozen Shoulder, Marma Chikitsa, Shoulder Exercises

Corresponding Author How to Cite this Article To Browse
Pranali Chaudhari, Post Graduate Scholar, Dept of Rachna Sharir, Pt Khushilal Sharma Govt Ayurveda College, Bhopal, Madhya Pradesh, India.
Email: 		Chaudhari P, Marwaha R, Bhalerao N, SD Panda, Efficacy of Marma Chikitsa and Shoulder Exercises in the management of Avabahuka (Frozen Shoulder) - A Case Study. J Ayu Int Med Sci. 2024;9(8):268-273.
Available From
https://jaims.in/jaims/article/view/3745

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-07-13 2024-07-23 2024-08-03 2024-08-13 2024-08-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 13.32

© 2024by Chaudhari P, Marwaha R, Bhalerao N, SD Pandaand 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].

J Ayu Int Med Sci 2024;9(8)268
Pranali C et al. Efficacy of Marma Chikitsa and Shoulder Exercises

Introduction

Ayurveda, A natural System of Medicine, is an ancient health science devoted to the cure on human sufferings and to the care of human health. In the vast science of the knowledge of Ayurveda, Marma is one of the hidden science. Marma Sthana are points where the Siras (veins) Snayu (ligament), Mamsa (muscles), Asthi (bones) & Sandhi (Joints) meet. Marma therapy involves subtle and sometimes more profound touch on Marma Sthana. The touch has the power to greatly rejuvenate and heal. If these Marma points are injured or damaged, there could be severe consequences, while proper stimulation of these points can treat many physical and mental ailments.

In 21st century, All people became busy in day to day life and not taking care of their health which causes varieties of diseases. Avabahuka is one of the diseases which hampers the function of upper limb. It commonly occurs in people of age between 40-70years. In classical Ayurveda texts, Avabahuka is explained under Vatavyadis. It is mentioned in Ayurveda - Sushruta Samhita, Charak Samhita, Ashtanga Hridaya etc. It is formed with two words Ava+Bahuk. Bahuk, which means arm or forearm, and Ava, which denotes Vikriti, or Dysfunction, together signify Dysfunction of Bahu. According to Acharya Sushruta, when Vata Dosha gets vitiated at Amsa Sandhi, it leads to constriction of vessels. This condition is known as Avabahuka. It is evident from clinical features such as Sandhi Shoola, Sandhigraha, and Bahupraspanda Haratvam from that vitiation of Vata and Kapha is predominant. Vitiated Vyan Vayu is a prime cause which affects the Sirabandhana of shoulder joint and dried it which causes restricted movement of shoulder joint. Avabahuka in Modern terms can be compared with Adhesive Capsulitis commonly known as Frozen Shoulder. It is characterised by stiffness and pain in the shoulder region along with restriction of movements of arms. Treatment of frozen shoulder includes analgesics (Pain relievers NSAIDS) and steroid injections, Hydrodilatation, Shoulder manipulation and Surgery[1] which carries risks such as chances of bleeding problems, Heart problems, Nerve Injury, Fracture, and Muscle failure and need for revision surgery. Exercises and Routine stretching are useful in both short term and long term for reducing pain and increasing range of motion in frozen shoulder.

Exercises helps in strengthening and lengthening the shoulder muscle and relieve pain. Marma Chikitsa is economical, easily acceptable, pain relieving and with almost no side effects if done properly.

Case Report

It is a single case study. A 32 year aged women who has already diagnosed with frozen shoulder since 3 years approached to Pt. Khushilal Sharma Ayurveda Hospital. She was having the following complaints - Difficulty in movement of right shoulder joint since 3 years, pain in right shoulder joint (radiating to right arm sometimes) since 3 years and stiffness in right shoulder joint since 2 years. She was taking Pain Relievers and Anti-inflammatory medicines for pain management.

History of Past Illness

Patient does not have any surgical or trauma history regarding right shoulder. There is no history of any comorbidity.

Family History

There is no family history of any musculoskeletal disease.

Personal History

  • Appetite: Normal
  • Bowel: Sometimes constipation
  • Sleep: disturbed due to pain
  • Micturition: Normal

Treatment history

History of taking Pain Relievers and Anti-inflammatory medicines.

Physical Examination

  • Body weight: 64 kg
  • Heart rate: 88/min
  • Respiration rate: 22/min
  • Blood pressure: 110/80 mm hg
  • Cardiovascular system: Normal
  • Respiratory system: Clear
  • Central Nervous System: consciousness, attention, orientation
  • Prakriti: Vata-Kaphaj

J Ayu Int Med Sci 2024;9(8)269
Pranali C et al. Efficacy of Marma Chikitsa and Shoulder Exercises

Shoulder Joint Examination

Examination of right side shoulder

Pain: VAS Score for pain was 8(grade 4)

Range of movement: Restricted (30°abduction, 105° flexion, 35°extension and 55°external rotation)

Stiffness: Relieved by oral medicine (grade 3)

Tenderness: On pressing pain appears on face of the patient (grade 2)

Sleep: 3-6 hours due to pain (grade 2)

Investigation

X-Ray of right shoulder was normal.

CBC, ESR and RBS are within normal limits.

Treatment Protocol

Patient was subjected to Marma Chikitsa and shoulder exercises for 15 days twice daily. This study includes stimulation of 9 Marma points that are Kshipra, Talahryday, Kurpar, Ani, Urvi, Kakshadhara, Amsa, Amsaphalak and Brhati. These are stimulated 15-18 times in one sitting.[2]

Shoulder exercises that are included in this study are Pendulum Exercise, Shoulder elevation, Shoulder wheel exercise, Pulley exercise and Finger ladder Exercise.

Duration of study:15 days

Follow-up:7th day

SNMarma pointStimulation TimeFrequencyDuration
1.Kshipra0.8sec15-18timesTwice daily
2.Talahryday0.8sec15-18timesTwice daily
3.Kurpar0.8sec15-18timesTwice daily
4.Ani0.8sec15-18timesTwice daily
5.Urvi0.8sec15-18timesTwice daily
6.Kakshadhara0.8sec15-18timesTwice daily
7.Amsa0.8sec15-18timesTwice daily
8.Amsaphalak0.8sec15-18timesTwice daily
9.Brhati0.8sec15-18timesTwice daily

A steady and moderate pressure will be applied slowly and gently pressure will be increased gradually depending upon pressure strength.

Shoulder exercises are following:[3,4]

SNName of ExerciseExercise repetitionsDuration
1.Pendulum Exercise10 repetitionsTwice daily
2.Shoulder elevationHold for 5 sec. Repeat 10 timesTwice daily
3.Shoulder wheel exercise10 repetitionsTwice daily
4.Pulley exercise10 repetitionsTwice daily
5.Finger ladder Exercise10 repetitionsTwice daily

jaims_3745_01.JPG
Figure 1: Pendulum Exercise

jaims_3745_02.JPG
Figure 2: Shoulder Elevation Exercise

jaims_3745_03.JPG
Figure 3: Shoulder Wheel Exercise


J Ayu Int Med Sci 2024;9(8)270
Pranali C et al. Efficacy of Marma Chikitsa and Shoulder Exercises

jaims_3745_04.JPG
Figure 4: Pulley Exercise

jaims_3745_05.JPG
Figure 5: Finger Ladder Exercise

Assessment Criteria

The assessment of the effect of treatment will be based on subjective and objective parameters of disease. This will be recorded before and after treatment. The symptoms will be graded on the basis of the scoring system to be adopted as below[5]

Pain

SNPainGrade
1.VAS range in between 0-20
2.VAS range in between 2-41
3.VAS range in between 4-62
4.VAS range in between 6-83
5.VAS range in between 8-104

Stiffness

SNStiffnessGrade
1.No Stiffness0
2.Stiffness, no medication1
3.Stiffness, relieved by external application2
4.Stiffness, relieved by oral medication3
5.Stiffness not responded by medicines4

Flexion

SNFlexionGrade
1.161°- 180°0
2.121°- 160°1
3.81°- 120°2
4.41°- 80°3
5.0°- 40°4

Extension

SNExtensionGrade
1.41°- 60°0
2.31°- 40°1
3.21°- 30°2
4.11°- 20°3
5.0°- 10°4

External Rotation

SNExternal RotationGrade
1.81°- 90°0
2.61°- 80°1
3.41°- 60°2
4.21°- 40°3
5.0°- 20°4

Abduction

SNAbductionGrade
1.161° - 180°0
2.121° - 160°1
3.81°- 120°2
4.41°- 80°3
5.0°- 40°4

Tenderness

SNTendernessGrade
1.On pressing patient does not feel any pain0
2.On pressing patient feels pain, but no sign on face (wincing)1
3.On pressing pain appear on face of patient (wincing)2
4.Wincing of the face and withdrawal of the affected part on pressure3
5.Patient does not allow to touch4

J Ayu Int Med Sci 2024;9(8)271
Pranali C et al. Efficacy of Marma Chikitsa and Shoulder Exercises

Sleep

SNSleepGrade
1.More than 8 hours0
2.6-8 hours1
3.3-6 hours2
4.Less than 3 hours3
5.No sleep4

Observation

Diagnostic criteriaBefore treatmentAfter treatment
PainVAS Score 8 (grade 4)VAS Score 0 (grade 0)
StiffnessStiffness, relived by oral medication (Grade 3)No Stiffness (Grade 0)
Flexion105°160°
Extension35°45°
External rotation55°65°
Abduction30°120°
TendernessOn pressing pain appears on face of patient (Grade 2)On pressing patient does not feel any pain (Grade 0)
Sleep3-6 hours (Grade 2)6-8 hours (Grade 1)

Discussion

Avabahuka is one of the most common diseases which hampers daily activities. Morbid Vata Dosha is a characteristic of the disease Avabahuka, which is seen in the Amsa Pradesh. It thereby causes Shoshana of Amsa Bandha and Akunchana of Sira at this site that leads to Bahupraspandahara. Clinically, Avabahuka is correlated with Adhesive Capsulitis - Frozen shoulder. The three main hallmarks of frozen shoulder are gradual, excruciating discomfort (even at night), Stiffness and almost complete loss of movement of the shoulder. It is widespread disease which causes considerable morbidity. Even after treating this ailment for more than a century, the definition, pathophysiology, diagnosis, and most effective treatment remain mostly uncertain.

Here, In this study Combined treatment of Marma Chikitsa and Shoulder Exercises which are explained under physiotherapy are administered to patient for 15 days and the results obtained are much significant. The above mentioned outcomes were evaluated using VAS scale for subjective criteria that is pain. The objective criteria such as stiffness and difficulty in movement is evaluated by using Goniometer.

Probable Mode of Action of Marma Chikitsa

Marma Chikitsa is the art of treating specific vital points on the human body where Prana resides. It is greatest healing secret of Ayurveda. It can be used to relieve obstructed energy, detoxify, strengthen, and restore the body. It can also be used for relaxation and rejuvenation. Marma therapy is a crucial approach to addressing Prana, the energy that controls all of our bodily functions. Prana in turn is connected to Vata Dosha which therefore is the most significant humour in the pathogenesis and management of illness. Marma therapy is ancient neuromodulation therapy. Certain chemicals and neurotransmitters, such as endorphins are released in response to pressure or stimulation applied to specific Marma points, which further convey nerve impulses to the brain, generating the desired impact. Marma Chikitsa can be likely explained as Gate control theory.

Probable Mode of Action of Shoulder Exercises

Therapeutic exercise is the sequential, organized performance of physical exercises meant to give a patient the tools to avoid impairment, enhance, or restore physical function, lower risk factors associated with health issues, and maximize entire state of health. Self-stretching (also referred to as flexibility exercises or active stretching) improves muscle strength and flexibility. Pendulum exercise helps to relieve pain through gentle traction and oscillating movements and provide early motion of joint structures and synovialfluid. Shoulder wheel exercise and Finger ladder exercise can provide the patient with objective reinforcement and, therefore motivation for performingshoulderROM. Exercises that manipulates or mobilizes the joints are manual techniques specifically applied to joint structures which are used to stretch capsular restrictions or reposition a subluxed or dislocatedjoint.[6,7]

Conclusion

This case report reveals a significant improvement in symptoms like stiffness, pain, and limited mobility. Hence, if done appropriately, Marma Chikitsa and Shoulder exercises can be used combinedly as an alternative for managing Avabahuka. This treatment modality is safe and effective without any adverse effects. Stimulating Marma points reveal latent ability to treat Avabahuka with hopeful outcomes.


J Ayu Int Med Sci 2024;9(8)272
Pranali C et al. Efficacy of Marma Chikitsa and Shoulder Exercises

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695331/
2. Joshi SK. Marma Science and Principles of Marma Therapy. 1st ed. Delhi: Vani Publications; 2010. ISBN: 8189221-64-7. p. 46
3. Textbook of Orthopedics by John Ebnezar 4th edition Page no 273
4. European Journal of Biomedical and Pharmaceutical sciences, EJBPS, 2018, Volume 5, Issue 12,22-27
5. Mavani Shrija, A comparative clinical study to evaluate role of Nasya and Physiotherapy in the management of Avabahuka W.S.R to Frozen shoulder, IPGT Jamnagar 2018
6. Kaltenborn, FM: The Kaltenborn Method of Examination and Treatment, Vol 1: The Extremities, ed 5. Olaf Norlis Bokhandel, Oslo, 1999.
7. Maitland, GD: Vertebral Manipulation (ed 5). Butterworth,London,1986.


J Ayu Int Med Sci 2024;9(8)273