CLINICAL APPROACH TO PAIN MANAGEMENT BY AYURVEDA

VAIDYA ANIRUDDHA SHREEDHAR KULKARNI, B.A.M.S.

SHREE ATMARAJ AYURVEDEEYA CHIKITSALAYA, GANESH MARG, SHANIWAR PETH, MIRAJ. 416410 PHONE 0233 2222402 CELL 9422407049 EMAIL askulkarni2@gmail.com WEBSITE www.ayusampada.co.in

INTRODUCTION
Health is the main aspect in leading happy, calm and fulfilling life. As told in Vedas, good health is a must to achieve knowledge, indulge in wealth creation and reproductive activities and lastly, to attain salvation. Ayurveda advocates a complete equilibrium in body, mind, senses and soul for good health. Vata, Pitta and Kapha doshas (humors) alongwith dhatus and malas, are the functioning components of body. When they are in equilibrium, health prevails, while their inequilibrium creates disease. Many physical and psychological factors are constantly affecting the health. By virtue of that, disease process initiates in the body demonstrating various symptoms. The two most frustrating and debilitating conditions are, fever and pain. Ayurveda has given due importance to both these conditions. Many times, these symptoms are interrelated or coexist simultaneously. Pain is a cardinal symptom attributed to Vata humor or dosha. Increased or aggravated vata definitely generates pain according to pathophysiology. Vata disorders are seen arising out of three main mechanisms 1. When the momentum of vata is obstructed, vata gets vitiated. 2. When the body elements are depleted, vata fills the vacant space and gets vitiated. 3. Momentum of vata is obstructed by its subtypes or dhatus or malas. Obstructed vata moves in reverse direction, but, obstructed again and gets enveloped. This process is known as avarana and is also responsible for vitiation of vata. As we all know, vata is in constant momentum and circulates throughout the body. So, the location, time and character of pain vary according to affected body element or organ or mind.

PAIN DEFINITION AND SCOPE

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The concept of Total pain encompasses the multidimensional factors that contribute to the patients experience of pain. It may include all of the following: Intellectual Pain, Emotional Pain, Interpersonal Pain, Financial Pain, Spiritual Pain, Bureaucratic Pain, and Physical Pain. The patients experience of pain is expressed within the context of the illness, and the personal, emotional, social, cultural, and spiritual orientation of the individual. 1

Pain is what the patient says it is, and exists whenever the patient says it does.

ASSESSMENT OF PAIN
Pain assessment is the most important part of pain management. Any pain complaint that has an impact on physical function or quality of life should be recognized as a significant problem. Unfortunately, there are no biological markers of pain. The most accurate and reliable evidence for the existence and intensity of pain is the patients description. HISTORY A detailed history of pain and associated complaints should be noted carefully. The following questions should be asked and evaluation is done. 1. When the pain started? Between 2-6 am/pm vata Between 6-10 am/pm - kapha Between 10-2 am/pm pitta

2. What events or illness coincided with the onset? Trauma, excessive rains, travelling, mental shock vata Immobilization/lack of activities, excessive cold, build up of impurities (Ama) kapha Fever, excessive heat, anger, working in heat pitta

3. Where does it hurt? (Location) From head to chest kapha and prana vayu From chest to umbilicus pitta and samana vayu From umbilicus to feet vata and apana vayu

4. How does it feel? (Character) Dull ache, pins and needles, deep, occasional kapha Burning, shooting, electric like, squeezing pitta Discomfort, sharp, stabbing, throbbing, surface, constant - vata

5. What are the aggravating and relieving influences? (Upashaya-Anupashaya) Movement, consumption of foods with pungent, bitter and astringent tastes, cold, varsha ritu(rainy season) aggravation of vata Rest, consumption of sweet, sour and salty foods, hot fomentation relieving of vata Consumption of sour, salty and pungent foods, hot weather, sharad ritu ( Mid-october) aggravation of pitta Consumption of sweet, bitter and astringent foods, cold application relieving of pitta Lack of movements, consumption of sweet, sour and salty foods, cold, vasant ritu (spring season) aggravation of kapha Movements, consumption of pungent, bitter and astringent tastes, hot relieving of kapha 2

6. What investigations have been done? 7. What treatments have been tried? 8. Past medical and surgical history is important to identify existing disease and previous experience with pain and analgesic use. PHYSICAL ASSESSMENT PRAKRUTI (CONSTITUTION) Prakruti or physical and mental constitution of the patient should be evaluated. According to Panchabhautik chikitsa, the main period in determination of constitution is its second month of fetal development. According to ayurveda, all the parts of the body are derived from blood. Blood is instrumental in formation and nourishment of all body organs. Development of rakta dhatu (blood) takes place in second month of pregnancy. The blood is ideally neutral in nature. If development of blood takes place in winter, constitution is sama (normal); if in rainy season, constitution is amla (acidic) and if in summer, constitution is kshara (alkaline). Blood is responsible for normal sensory and motor nerve transmissions. Pain is closely related with the condition of blood. That is why; bloodletting (Raktmokshana) is useful in instant relief from pain and inflammation. DARSHAN (INSPECTION) Carefully observe the location of pain. The non-verbal (i.e. infants and children), non-cognizant persons (i.e. the cognitively impaired) should be evaluated by inspection. For these populations, behavioral observations that are validated by family and caregivers are the primary source of information for a pain assessment. Body language should also be observed: facial expressions, verbalizations, behavior during activity, movements and gestures. Along with pain, redness, edema etc. should be noted. SPARSHAN (PALPATION) Palpation at the site of the pain should be of four types hardness or softness, tenderness, hot or cold and percussion in cases of edema. Hardness is commonly found in vata-kapha dominance. Softness is perceived in vata-pitta dominance. The degree of tenderness gives us an idea of underlying dosha prevalence. Slight (kapha), medium (vata) and acute (pitta) tenderness should be understood.

CLASSIFICATION OF PAIN
After assessment of pain, classification should be taken into account. It helps in determining the priorities in management plan. It is also helpful in evaluation of prognosis of the disease. ASHUKARI (visarp, anta vidradhi) CHIRAKARI (sandhishoola, vatarakta) EKANGA(affecting a single site or organ)- SARVANGA(affecting entire body or multiple organs/systems) UTTANA (superficial) - GAMBHIRA(deep)

ACCORDING TO DOSHA DOMINANACE vataj, pittaj, kaphaj, vatakaphaj, vatapittaj and sannipatik ACCORDING TO ORGAN- skin, stomach, bones, joints etc.

MODREN ASPECT Pain is classified by mode of origin and transmission to aid in choosing a management plan for pain relief. Nociceptive pain is due to the stimulation of nerve fibers that transmit signals in a normal way from nerve endings to brain centers. Somatic pain pain originating from muscle, soft tissue or bone. It is usually well localized and described as deep, aching, or boring. It may be worse with movement. Some examples are bone metastases, osteoarthritis, and muscle/tissue damage. Visceral pain pain originating from internal organs or viscera surrounding them. It is usually less well localized and can be referred; often described as deep aching, cramping, or squeezing. Some examples are bowel obstruction, brain tumor, and appendicitis. Neuropathic pain is the abnormal sustained stimulation of the nerve fibers that transmit signals from the nerve ending to brain center and/or from a dysfunction in the central nervous system. It can be dysesthetic pain described as burning, electrical sensations or pins and needles and/or lancinating pain described as stabbing, shooting, or hot poker. Some examples are post-herpetic neuralgia, spinal cord compression, diabetic neuropathy, phantom limb, or central pain from a stroke.

PRINCIPLES OF MANAGEMENT OF PAIN

Pain is the most frustrating and debilitating symptom. It affects the lifestyle of a person. So, analgesics or pain killers are sold over the counter in vast volumes. Pain in acute or chronic stage, demands relief and patients are willing to do anything for it. As Vata dosha is the main force in creation of pain, basic management revolves around purification and pacification of it. Panchabhautik chikitsa, a therapy pioneered and developed by late vaidyaraj A.W.Datarshastri, believes in systematic and methodical approach to management plan. HETU NISCHITI (DETERMINATION OF CAUSATIVE FACTOR) The major causative factors or any internal situation which is responsible for creating disease should be first examined and decided. PATHOGENESIS (SAMPRAPTI) Understanding the samprapti or disease process is the next thing to look at. How the causative factors have affected in development of three basic mechanisms of vata disorders, should be analyzed. The obstruction of the momentum of vata is usually due to consumption of oversaturation factors, which include heavy foods, cold, obesity, day sleep etc. which produce abnormal increase in the properties of Prithvi and Aap mahabhutas or Kapha dosha. Here, treatment with opposite properties is recommended.

Vata which gets vitiated due to depletion of dhatus, is usually due to consumption of degenerative factors such as undernourishment, exertion, insomnia etc. which abnormally increases the properties of Teja, Vayu and Akasha mahabhutas. Here, treatment with opposite properties is recommended.

Avaran or envelopment of vata should be understood with their typical presentations and the momentum should be restored. SHODHANA CHIKITSA (PURIFICATION METHODS) These include snehana (oleation), swedana (sudation), virechana(forced catharsis), raktmokshana (bloodletting) and basti (medicated enemas), which is the foremost treatment. Agnikarma (cauterization) is also useful in many conditions. SHAMAN CHIKITSA (PACIFICATION METHODS) The main pacifying drug for vata is oil. So, according to condition of the patient, different kind of medicated oils and ghees should be used. The internal and external medications must contain heavy, unctuous, stable, hot and bulky properties. VIHARA CHIKITSA (NON PHARMACOLOGICAL MANAGEMENT) The main aspects of vihara chikitsa are - DIET, BEHAVIOR, EXERCISE, and PSYCHOLOGICAL ADVICE. It should be carefully prescribed, so, the patient can practically observe it. In chronic pain, patients lose enthusiasm in following the medical advice. The education of the patient, his family members and caretakers plays an important role in achieving control over pain.

PAIN DOMINANT DISEASE CONDITIONS AND THEIR TREATMENT

The treatment of any disease is based on clinical assessment of the patient. The diseases mentioned below are the ones who present themselves frequently to ayurvedic physicians. The drugs mentioned here are the most useful in arresting the pain. Many drug names may sound unfamiliar, but, they are from PANCHABHAUTIK CHIKITSA method. Their detailed description is available in the literature regarding PANCHABHAUTIK CHIKITSA. AJIRNA (INDIGESTION) HARALU, LAGHUSUTASHEKHAR, SHANKH BHASMA, VARANGAK KSHAR, VIDANGA POWDER KUKSHISHOOLA (PAIN IN FLANKS) HINGWASHTAKA CHURNA, KUSHTH POWDER, NAGARADI DECOCTION HRITSHOOLA (ANGINA CHEST PAIN) MRIGASHRINGA BHASMA, VARANGAK KSHAR, GOKSHURADI GUGGUL, ARJUNARISHTA, PRABHAKAR TABLET UDAVARTA (INVERTED VATA) HARALU, GOKSHURADI GUGGUL, PHALATRIKADI GUGGUL, VARANGAK KSHAR, CHINCHALAVAN OIL KRUMI (WORM INFESTATION) CHATURTHAKA YOGA, ARGAVDHAKAPILA TABLET, VIDANGA POWDER, VIDANGARISHTA GULMA (ABDOMINAL LUMP) PHALATRIKADI GUGGUL, AROGYAVARDHINI, CHATURTHAKA YOGA, VARANGAK KSHAR, TALISADI POWDER, PANCHASAKAR POWDER, CHINCHALAVAN OIL SHIROROGA (HEADACHE) PATHYADI YOGA, LAXMINARAYAN RASA, TRIBHUVANKIRTI, MAHASUDARSHAN POWDER, SOOTASHEKHARA, PANCHAKASHAY YOGA 5

VIDRADHI (INTERNAL AND EXTERNAL ABSCESSES) SHOBHANJAN, TRIPHALA GUGGUL, PATOLADI GUGGUL, GANDHAKA RASAYAN, RAJANI YOGA, JINGI SHARADI GUDAGAT VYADHI (ANORECTAL DISEASES) TRIPHALA GUGGUL, SHATATAL YOGA, PHALATRIKADI GUGGUL, LAGHUSOOTSHEKHAR, VIDANGA POWDER, AVIPATTIKAR POWDER ASHMARI (RENAL AND BILIARY CALCULI) ELADI YOGA, CHANDRAPRABHA, GOKSHURADI GUGGUL, HARALU, VARANGAK KSHAR, VARUNADI DECOCTION STREE ROGA (GYNECOLOGICAL DISORDERS) CHANDRAPRABHA, GOKSHURADI GUGGUL, DASHAMULARISHTA, VARANGAK KSHAR, JINGI SHARADI, KALINGAKADI YOGA BALA ROGA (PEDIATRIC DISORDERS) CHATURTHAK YOGA, VIDANGA POWDER, TAMRA BHASMA, PARIPATHADI DECOCTION, KUMARIA ASAV NO-3, VIDANGARISHTA, SHANKHA BHASMA SANDHIGAT VATA (ARTHRITIS) GOKSHURADI GUGGUL, CHANDRAPRABHA, TRIPHALA GUGGUL, CHATURTHAK YOGA, PANCHAKASHYA YOGA, KUSHTH POWDER, PADMAK KITTA YOGA, KINAHI, SHOBHANJAN, VATAGAJANKUSH VISARP (ERYSIPELAS-HERPES) RAJANI YOGA, JINGI SHARADI, SITOPALADI POWDER, PUNARNAVADI GUGGUL, SOOTASHEKHAR, PRAWAL BHASMA, GIRIJ VRANASHOTHA (INFLAMMATION) PATOLADI GUGGUL, SOOTASHEKHAR, TRIPHALA GUGGUL, RAJANI YOGA ANTRAPUCHHA DAHA (APPENDICITIS) SHOBHANJAN, TRIPHALA GUGGUL, PATOLADI YOGA, RAJANI YOGA, JINGI SHARADI, GANDHAK RASAYAN DUSHTARBUDA (MALIGNANT CONDITIONS) KUNAKHI GUGGUL, CHOPCHINYADI POWDER, SUVARNA BHASMA, HIRAK BHASMA, GOKSHURADI GUGGUL, AROGYAVARDHINI VATARAKTA (GOUT) PATOLADI YOGA, VARANGAK KSHAR, TRIPHALA GUGGUL, YOGARAJ GUGGUL, EKANGAVEER, VATVIDHWANSA, SHOBHANJAN, CHATURTHAK YOGA

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