There are 424.9 million adults estimated to currently have diabetes globally.[1] Diabetic patients have an inherent risk of foot problems. Globally every 30 seconds, a major amputation occurs; 85% of which are preceded by trivial foot lesions.[2] In Ayurvedic literature, it is explained that Pidakas are formed in Adhoshaka in patients with Prameha due to the weakness of Rasayanis of lower limbs.[3] Such Pidakas if neglected over a period of time, without treatment will undergo Paaka and form a Vrana. Acharya Sushruta has described Shashti Upakramas (60 modalities) for the successful management of Vranas. Among them this article highlights the use of Shodhana, Kshara Varma, Chedana, Ropana and Bandhana Upakramas in the management of Diabetic Foot Ulcer/ Madhumehajanya Dushtavrana and also the need of Shastrakarma (surgical intervention) at the right time. In this study, Triphala Kashaya Avagaha and Pratisaraneeya kshara Karma for Vranashodhana, Chedana Karma followed by Ropana with Jatyaditaila was carried out. The course of treatment carried out brought about Dushtavranaavastha to Shuddhavranaavastha

Dr. Madhuri G. Hegde

Dr. Shailaja S. V.

English

Journal of Ayurveda and Integrated Medical Sciences (JAIMS)

                                                      CASE REPORT Nov-Dec 2019  Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec  2019 | Vol. 4 | Issue 6 280  Ayurvedic management of Diabetic Foot Ulcer - A Case Study Dr. Madhuri G. Hegde1, Dr. Shailaja S. V.2 1Post Graduate Scholar, 2Professor, Dept. of Shalyatantra, Sri Kalabyraveshwaraswamy Ayurvedic Medical College, Hospital and Research Center, Bengaluru, Karnataka, INDIA.                     INTRODUCTION Diabetic foot is one of the most feared complications since it carries propensity to reach the proportions of a diabetic foot attack, which is described as a point beyond which it is irreversible, the point of overwhelming necrosis. Diabetic foot is characterized by a classical triad of neuropathy, ischemia and infection; glucose laden tissue is quite vulnerable for infection and thus ulcer is formed.[4] Diabetic foot infection needs prompt attention, accurate diagnostic Address for correspondence:  Dr. Madhuri G. Hegde Post Graduate Scholar, Dept. of Shalyatantra, Sri Kalabyraveshwaraswamy Ayurvedic Medical College, Hospital and Research Center, Bengaluru, Karnataka, INDIA. E-mail: hegdemadhuri22@gmail.com  Submission Date: 18/11/2019 Accepted Date: 19/12/2019 Access this article online Quick Response Code Website: www.jaims.in  Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA evaluation and suitable therapeutic strategies (medical and surgical). The treatment includes Glycemic control, antimicrobial administration, wound care management, surgical interventions in the form of wound debridement/ amputations or specialized therapies such as Negative Pressure Wound Therapy and Skin Grafting. In Ayurveda classics, Acharyas describe Pramehajanya Upadravas which mostly occur in lower limbs due to Dourbalya of Rasayanis. Acharya Charaka enlists Upadravas due to Prameha among which Pootimamsa (gangrenous) is one of them.[5] Acharya Sushruta, in the context of Prameha Pidaka which is also a Prameha Upadrava describes the Avasthika Chikitsa of Prameha Pidakas which includes Shastrapranidhana and Vranakriyopaseva for Vranas formed preceded by Paaka.[6] Further Acharya Sushruta describes Shashti Upakramas for the management of Vrana, among which few modalities were selected to treat a case of Diabetic foot ulcer. To treat any case of Vrana, Sthanika Shodhana and Ropana plays a very important role. In this study with A B S T R A C T  There are 424.9 million adults estimated to currently have diabetes globally.[1] Diabetic patients have an inherent risk of foot problems. Globally every 30 seconds, a major amputation occurs; 85% of which are preceded by trivial foot lesions.[2] In Ayurvedic literature, it is explained that Pidakas are formed in Adhoshaka in patients with Prameha due to the weakness of Rasayanis of lower limbs.[3] Such Pidakas if neglected over a period of time, without treatment will undergo Paaka and form a Vrana. Acharya Sushruta has described Shashti Upakramas (60 modalities) for the successful management of Vranas. Among them this article highlights the use of Shodhana, Kshara Varma, Chedana, Ropana and Bandhana Upakramas in the management of Diabetic Foot Ulcer/ Madhumehajanya Dushtavrana and also the need of Shastrakarma (surgical intervention) at the right time. In this study, Triphala Kashaya Avagaha and Pratisaraneeya kshara Karma for Vranashodhana, Chedana Karma followed by Ropana with Jatyaditaila was carried out. The course of treatment carried out brought about Dushtavranaavastha to Shuddhavranaavastha.  Key words: Prameha, Diabetic foot ulcer, Shodhana, Chedana, Kshara, Ropana. Dr. Madhuri G. Hegde et al. Ayurvedic management of Diabetic Foot Ulcer - A Case Study ISSN: 2456-3110                                                            CASE REPORT Nov-Dec 2019  Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec  2019 | Vol. 4 | Issue 6 281  classical symptoms of Dushtavrana like Durgandha and Picchilasrava, Triphala Kashaya was chosen for Shodhana[7] in the form of Avagaha followed by Pratisaraneeya Kshara Karma for further Shodhana of Dushodhya Vrana.[8] Kotha or Pootimamsata which was noted during the pathological process of the Vrana in this case was treated with Chedana Karma[9]followed by Ropana with Jatyadi Taila[10] and Bandhana.  CASE REPORT A 75 year old male patient visited Shalyatantra OPD of SKAMCH & RC, Bengaluru presented with complaints of wound in the plantar aspect of right foot with pain and mild pus discharge since 3days. He also complained of generalized weakness along with increased frequency of micturition since 10days. H/O present illness  Patient was apparently healthy 10 days ago. Gradually he developed  painful swelling in the plantar aspect of right foot along with generalized weakness and increased frequency of micturition. He neglected this condition.  After a week  the swelling in right foot spontaneously opened with pus discharge causing a painful ulcer in the plantar aspect of right foot which extended upto the dorsal aspect of great toe. Patient  experiences pricking type of pain which is continuous. Pain gets aggravated while walking and during night time. Patient approached S.K.A.M.C.H &   RC, Bengaluru for   the same. Purva Vyadhi Vruttanta  K/C/O Type II Diabetes Mellitus since 8 years and is on regular medication.  Not K/C/O HTN/Thyroid disorders/other systemic disorders. Koutumbika Vruttanta  All family members are said to be healthy. Vayaktika Vruttanta  Diet  - Mixed, Atimadhura, snigdha, mamsaahaara  Appetite - Reduced  Sleep - 5-6 hours, disturbed due to pain,      Diwaswapna ~1hour  Micturition - 7-8times during day and 3-4times during night  Bowel - Regular, once in a day.   Habits - Smoking; about 1 packet of beedi/ day, for 45years. (stopped since 5 years)   - Tea 3-4times a day. Rogi Pareeksha General examination  Temp - 98.6°F  Pulse - 74 bpm  B.P. - 130/80 mm of Hg  Respiration - 18 cycles / min  Height - 177 cm  Weight - 70kg  BMI - 24.22  Gait - Normal Systemic examination  Cardiovascular system examination - S1 S2 heard, no added sounds.  Respiratory system examination - Normal vesicular breathing sound heard, no added sounds.  Per Abdomen examination - Soft, non-tender.  Central nervous system examination - Higher mental functions, Sensory, Motor, reflexes and Coordination intact. Vrana Pareeksha  Vrana Varna - Krishna, Peeta  Vrana Gandha - Amanojnagandha  Vrana Vedana - Toda, Bheda  Vrana Akriti  - Vikruta, ativivruta Dr. Madhuri G. Hegde et al. AISSN: 2456-3110                       Journal of Ayurveda and Integ  Vrana Srava - PicchilapuyasravExamination of ulcer  On inspection  Size : ~10cm in length, 5cm in width,1 Shape:  Irregular shape  Number : 1  Position : Plantar aspect of right foupto      great toe on dorsal aspect.  Edge : Punched out edge  Floor : Pale with slough and necrotic tgreat toe and midsole.  Discharge : Purulent  Surrounding area : Oedematous wdiscolouration  On palpation : o Tenderness : present o Edge and margin : Punched ouinduration Investigation RBS - 552mg/dl Serum creatinine - 1.07mg/dl HbA1c - 16.9% Urine protein - Present (traces) Urine sugar - Present (4+) Right Lower Limb Arterial Doppler suggediffuse atherosclerotic in right lower liDiffuse subcutaneous edema in right lregion. MATERIAL AND METHODS Preparation of Triphala Qwatha Sufficient quantity of Triphala Qwatha taken and added with 8 parts of water. Ireduced to 1/4th  and filtered using a cleawas used lukewarm for Avagaha. yurvedic management of Diabetic Foot Ulce                                      CASE REPOrated Medical Sciences | Nov - Dec  2019 | Vol. 4a  cm in depth ot extending issue around ith blackish t edge, No stive of Mild mb arteries. eg and foot Churna was t was boiled, n cloth. This Preparation of Apamarga MThe Panchangas of the dwhich was burnt with calcand then ash was allowed collected and mixed withstirred well, and kept unmixture was filtered for 2discarded. The filtrate wasreduced to half which is cais continuous stirred formixture.  Later it is kepcontinuously stirred till it bKshara was collected with and preserved in airtight glTreatment Vrana Kriyopaseva  Triphala Kashaya ShoAvagaha for 15-20 minu Jatyadi Taila Pichu daily Swasthika Bandhana[11Anushastra Karma  On 12th day slough in noted for which Pratwas done using ApamaShastra Karma  Kotha (Gangrene) of Riby Chedhana Karma ofanaesthesia with preopChikiVranaKriyopasevaKashayaTailaBandhanaAnushaPranidhKsKar - A Case Study RT Nov-Dec 2019  | Issue 6 282 ridu Kshara ried Apamarga was taken ium carbonate into ashes, to cool. The whole ash was  six times of water and disturbed overnight. This 1 times and residue was  heated on low flame till it lled Ksharajala. Ksharajala  making a homogenous t on the low flame and ecame a thick paste. Later little amount of Ksharajala ass container.  dhana in the form of tes daily for 15 days.  for 45 days. ] Karma for 45 days. the floor of the ulcer was isaraneeya Kshara Karma rga Kshara for one sitting. ght great toe was followed  Right great toe under Local erative and postoperative tsastra anahara rmaShastraPranidhanaChedhanaDr. Madhuri G. Hegde et al. AISSN: 2456-3110                       Journal of Ayurveda and Integ antibiotic cover and analgesicsmanagement. Medications  Capsule Grab 1-0-1 A/F.  Capsule Viscovas 1-0-1 A/F.  Inj. Wosulin 30/70 according to slidingOBSERVATIONS AND RESULTS DISCUSSION Dushtavrana is a DeerghakaalanubandVrana, but any Vrana though Achirakrecent origin) is a Dushtavrana if it has Lakshanas of Dushtavrana. Though the hrecent origin in this case, it had Tridoshas like Toda (pricking pain), Bhpain), Krishna Varna (blackish), Peetayellow), Paaka (suppuration), Amanojnasmell), Ativivruta (extensive), Sthooloshedge) and Pichilapuyasrava (pus discmaking it a Dushtavrana. Triphala KashayFig 1: Dushta Vrana Day 1Fig 2: Dushta Vra1Fig 3: After kashaya shodhana Day 14Fig 4: Ulcer with Day 15Fig 5: Kshara karma Day 16 Fig 6: Post kskarma Dayyurvedic management of Diabetic Foot Ulce                                      CASE REPOrated Medical Sciences | Nov - Dec  2019 | Vol. 4 for pain  scale.  hi (chronic) aaleena (of most of the istory was of Lakshanas of eda (cutting varna (pale gandha (foul ta (punched harge) thus a comprising of Haritaki, Amalaki and VibDoshaghna, Vranya, Shoththus chosen for Vrana Shodhaving properties like Shoand Tridoshghnata helped debride the necrotic tissueDuring the course of illnesKotha-Pooti Bhava[14] (GangChedhana Karma[15] was dfor gangrene. Further forTaila was used whose moShothahara, Ropana and VeCONCLUSION Diabetic patients have aproblems. Diabetic foot presentation, thus has tunder good glycemic conhighlighting the importancethe right time so as to avoiwith local management ofof management of Pramena Day slough hara  17Fig 7: Gangrenous right great toe Day 24Fig 9: Shuddha Vrana Day 40Fig 11: Ruhyamana vrana Day 45r - A Case Study RT Nov-Dec 2019  | Issue 6 283  heetaki has properties like ahara and Krimihara and hana.[12] Further Kshara[13] dhana, Lekhana, Shoshana to mobilise slough and also  from the floor of the ulcer. s the right toe underwent renous changes) for which one as was the indication  Vranaropanartha, Jatyadi st of the ingredients have danasthapana properties. n inherent risk of foot is a challenging clinical o be treated accordingly trol. The study aimed at  of surgical intervention at d complete limb loss along  the wound. Thus principle ha Pidaka stagewise was Fig 8: Post Chedhana karma Day 35  Fig 10: Ruhyamana vrana Day 45Fig 12: Ruhyamana vrana Day 45Dr. Madhuri G. Hegde et al. Ayurvedic management of Diabetic Foot Ulcer - A Case Study ISSN: 2456-3110                                                            CASE REPORT Nov-Dec 2019  Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec  2019 | Vol. 4 | Issue 6 284  adopted in this case as Vranakriyopaseva and Shastrapranidhana and treated successfully. REFERENCES 1. IDF Diabetes Atlas. Seventh Edition. 2015. Available at: http://www.idf.org/idf-diabetes-atlas-seventh-edition. Accessed on: 29th Mar., 2017.  2. Pendsey S. Contemporary management of diabetic foot. New Delhi: Jaypee Brothers Medical Publishers (P) ltd; 2014. 3. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Chikitsasthana 12/8, Pp 824. 4. Somen Das, A manual on Clinical Surgery, SD Kolkata, 9th Edition, Chapter 4, Pp 650, Pg 70. 5. Acharya Agnivesha, Charaka Samhita, revised by Charaka & Dridabala, Ayurveda Dipika commentary of Chakrapanidatta, Edited by Yadavji Trikamji Acharya; Varanasi: Chaukhambha Prakashana; Reprint 2013; Nidanasthana 4/48-49, Pp 738. 6. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Chikitsasthana12/4, Pp 824. 7. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Chikitsasthana 1/53-54, Pp 824. 8. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Chikitsasthana 1/88, Pp 824. 9. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Sutrasthana25/4, Pp 824. 10. Acharya Sharangadhara, Sharangadhara Samhita; with Dipika Hindi Commentary by Dr. Brahmanand Tripathi; Varanasi: Chaukhamba Surbharti Prakashan; Reprint 2010; Madhyamakhanda 9/168-171, Pp488. 11. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Sutrasthana18/18, Pp 824. 12. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Sutrasthana 46/143-199-200, Pp 824. 13. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Sutrasthana11/5, Pp 824. 14. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Sutrasthana 25/4, Pp 824. 15. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandha sangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2013; Chikitsasthana 1/34, Pp 824.   *******************************  How to cite this article: Dr. Madhuri G. Hegde, Dr. Shailaja S. V., Ayurvedic management of Diabetic Foot Ulcer - A Case Study. J Ayurveda Integr Med Sci 2019;6:280-284.  Source of Support: Nil, Conflict of Interest: None declared. 

Ayurvedic management of Diabetic Foot Ulcer - A Case Study

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Ayurvedic management of Diabetic Foot Ulcer - A Case Study

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