In spite of very advanced researches in Science, Pain still remains the major cause of disability affecting the large number of population in the world. An integrated approach towards Pain Management should possibly answer the grief involved in treating this Symptom of varying degrees. Even Ministry of AYUSH, India has stressed upon this alarming topic and professed its theme as “Pain Management through Ayurveda” for Second National Ayurveda Day.
In this article, review of the classical text with special references to pain, and its management through Ayurvedic procedures such as Snehan, Swedan, Agnikarma, Jalaukaavcharan, Vedhankarma, Lepankarma &amp; Bastikarma has been discussed in context to their utility in Pain management. Similarly, The role of Madhur-Amla-Lavan Rasa Aushadhi in Pain management due to Dhatukshayjanya Vataprakopa in view of G-PCR bio-signalling of taste and Pain modulation is also incorporated to explain role of palliative medicines

Kulkarni, Anjna

P. Dwivedi, Amar

Pathrikar, Anaya

English

International Journal of Research in AYUSH and Pharmaceutical Sciences (IJRAPS)

ISSN: 2456-9909 (Online)   International Journal of Research in AYUSH and Pharmaceutical Sciences   Website: http://ijraps.in  168     Review Article     REVIEW OF CONCEPT OF PAIN MANAGEMENT IN AYURVEDA Amar P. Dwivedi1*, Anaya Pathrikar2, Anjna Kulkarni3 *1Professor, Shalyatantra Department, D.Y.Patil College of Ayurveda, Navi Mumbai. 2Ph.D. Scholar, Tilak Maharashtra Vidyapeeth, Pune, Maharashtra.  3Ph.D. Scholar, School of Ayurveda, D.Y.Patil University, Navi Mumbai.  Keywords: Pain management, Shool, Vedana, Snehan-Swedan, Lepa, Basti, Agnikarma.         ABSTRACT  In spite of very advanced researches in Science, Pain still remains the major cause of disability affecting the large number of population in the world. An integrated approach towards Pain Management should possibly answer the grief involved in treating this Symptom of varying degrees. Even Ministry of AYUSH, India has stressed upon this alarming topic and professed its theme as “Pain Management through Ayurveda” for Second National Ayurveda Day.  In this article, review of the classical text with special references to pain, and its management through Ayurvedic procedures such as Snehan, Swedan, Agnikarma, Jalaukaavcharan, Vedhankarma, Lepankarma & Bastikarma has been discussed in context to their utility in Pain management. Similarly, The role of Madhur-Amla-Lavan Rasa Aushadhi in Pain management due to Dhatukshayjanya Vataprakopa in view of G-PCR bio-signalling of taste and Pain modulation is also incorporated to explain role of palliative medicines.  INTRODUCTIONPain is a symptom of mental and physical hurt or disease. The International Association for the Study of Pain defines pain as- ‘An Unpleasant sensory and emotional experience arising from actual or potential tissue damage.1 In Ayurvedic classical text Sushrut Samhita we found terms such as Shool, Ruja, Vedana and Ruk revealing condition of Pain. Similarly, in Charak Samhita Angmardprashaman (10 drugs used in treatment of Body ache), Shoolprashaman & Vednasthapak Mahakashaya is mentioned.2,3 This article elaborates various treatment modalities mentioned in Ayurveda in context to pain management such as Snehan (Oleation), Swedan (Fomentation), Agnikarma (Heat burn Therapy), Jalaukaavcharan (Leech therapy), Vedhankarma (needle puncturing), Lepa (medicated paste), Bastikarma (enema) is discussed. This article will be useful for the research scholars who are exploring the role of Ayurveda in the pain management.    THE CONCEPT OF PAIN IN AYURVEDA In Ayurvedic texts, various terms such as, Ruk, Ruja, Vedana & Shool are commonly used for pain, however, ‘Shool’ is more appropriate term amongst all, stating the definition of Shool as experience similar to driving a nail into the body of the person.4 Further, it has been elaborated that out of Tridoshas, vitiated ‘Vata’ is the main causative factor responsible for all painful conditions.5 This vitiation of Vata occurs in two ways, viz. Dhatukshya janya Vata prakop and Margavarodh janya Vata prakop.6 Similarly, ‘Ruksha’ and ‘Chala’ Gunas (characters) of Vata are mainly involved in the manifestation of pain. Classification of Pain as mentioned in Ayurveda, specifically discusses the types of Shool implying colic. As per Sushrut Samhita, Shool is classified into 13 types as per the location of visceral organs. As per Doshas, Shool is classified into 16 types in Madhavnidan (8 types as per Doshas + 8 types of Parinaam shool as per Doshas), 8 types in Yogratnakar & 4 types in Kashyap Samhita.7,8,9,10  Amar P. Dwivedi et al. Review of Concept of Pain Management in Ayurveda  IJRAPS | October 2017 | Vol 1 | Issue 4  169 MODALITIES FOR MANAGEMENT OF PAIN Snehan Karma: Snehan (oleation) is dmentioned as Purvakarma and practiced before all Panchkarma procedures. Due to Sneh (oleation) VataDosha gets pacified. Bahya Snehan or Abhyanga is application of oil on the skin which is again divided into SarvangaSnehan (whole body massage) or SthanikSnehan (application of oil locally to the affected part like Janubasti, Katibasti or Manyabasti etc  As per the modern perspective, the Neuro-hormonal effects of Bahya Snehan has been established, stating that massage increases levels of Dopamine, increases availability of serotonin, may elevate epinephrine (adrenaline) and release of endorphins. (Research conducted at TOUCH Research Institute at the University of Miami). All these neuro-hormones alter brain chemistry which in turn reduces response to pain sensation.11 Swedan Karma: Swedan (hot fomentation) is also the Poorvakarma to Panchkarma which helps in inducing sweating to the patient. The role of Swedan can be explained with Transient Receptor Potential Channels which are mainly found in nociceptive neurons of peripheral nervous system. Role of Swedan in management of pain can be explained through TRPV1 channels which are responsible for perception of heat and pain. 12,13 Agnikarma Therapy: Agnikarma (Heat burn Therapy) is one of the para surgical procedure described for the pain management. Agnikarma helps in relieving pain in painful conditions specially Musculoskeletal pain such as heel pain, Osteoarthritis, Frozen shoulder etc. Agnikarma, leads to pacification of Vata & KaphaDosha, thereby reducing pain. Similarly, Agnikarma pacifies Manda Dhatvagni and facilitates Amapachan and increases the Dhatvagni, thereby, metabolite toxins are removed. Thus, pain caused by the accumulation of metabolic waste products in the tissues is immediately relieved after Agnikarma Therapy. 14 Raktamokshan by Jalauka: Jalaukaavcharan (Leech therapy) involves application of Jalauka (Leeches) for removal of vitiated blood at the site of pain.15 It is proved by various researches that the sensory stimulus caused by the pain and burning sensation of the leech bite can alleviate the symptoms of the patient through the “gate theory”. The main components of Medicinal Leech saliva is Hirudin which inhibits blood coagulation by binding to thrombin, Bdelins acts as anti-inflammatory and inhibits trypsin, Eglins acts as anti-inflammatory and inhibit activity of cathepsin G, Carboxy-peptidase A inhibitors increases the inflow of blood at the bite site, Histamine like substance, acetylcholine acts as vasodilator and Anesthetic substance which causes anesthesia at the bite site. 16,17 Viddhan karma: Vedhan karma is one of the eight Shastrakarma (surgical measures) mentioned in Sushrut Samhita.18 In Viddha karma the points are pierced with special hollow needles which leads to painful mechanical stimulus which causes release of endorphins thereby, causing immediate pain relief.  Few Ayurveda experts are practicing a modified Agnikarma procedure named- Viddhagni, by clubbing Agnikarma & Vedhan karma together. However, there is no validated document available to prove its supremacy over the conventional Agnikarma therapy.  Lepan chikitsa: This is application of medicated paste over the painful body parts. Sushruta has described Lepan in Twakgatvata, Mansagata Vata and in management of pain due to Vranshopha. 19,20 The mechanism of action of lepan can be explained with the Mechanism of transduction of cold thermoreceptors as for example Menthol sensation is perceived via TRPM8 channel; whereas role of Pradeha can be explained with TRPV1 channels and furthermore certain Warm receptors also being sensitive to painful stimuli function as nociceptors.21,22,23 Basti chikitsa: In Bastikarma, the medicinal dravyas are administered into the rectum of the patient. Since, every Pain is attributed to vitiated Vata Dosha and in order to correct this imbalance Basti is the main (prim) treatment modality amongst the Panchkarma therapies.24 It is hypothesized that Basti karma has a feature to regulate sympathetic activity, thereby, balancing the autonomic nervous system. Hypothalamus-Pituitary-Adrenal axis (HPA) gets activated with the visceral afferent stimulation, involving the release of neurotransmitters from adrenal gland called cortisol, a neuroendocrine hormone, acts as a potent anti-inflammatory systemically. 25,26,27 Palliative treatment (Shaman Chikitsa) in the management of pain  The main objective of palliative treatment is to correct the vitiated Vata Dosha. Further, to resolve this Vata imbalance and pain Madhur, Amla & Lavan Rasa (taste) herbs are prescribed.28 This concept can be better understood through the knowledge of receptors on cells that mediate Taste & Pain both. G-Protein Coupled Receptors are dynamic machines for signaling Pain.29 These same group of receptors (T1R2 & T1R3 receptors) are responsible for perception of Sweet taste (Madhur IJRAPS, 2017:1(4):168-171  Website: http://ijraps.in  170 Rasa) thereby, making us understand the role of Madhur Rasa in resolution of pain. As regards, Lavan (Salty taste - ENaC Receptors) & Amla (Sour taste - Two TRP channels – PKD2L1, which are also present in pain fibres responding to chemical stimuli like Capsaicin & menthol) use ion channels-proteins that form a channel through which specific inorganic ions can diffuse. Changes in cellular ion concentrations could then be detected and transmitted to the nervous system. However, Dr. Charles Zuker, meanwhile, states that current ion channel theory is not correct and GPCRs could also be involved in these perception modalities. In a nutshell, the role of GPCR in mediation of pain and mediation of taste thereby, explaining the role of Madhur, Amla and Lavan Rasa in the Pain management.30,31,32,33 DISCUSSION This article is explores the concept of Pain in classical texts of Ayurveda mitigating by modern perspective. The treatment modalities such as Snehan karma, Swedan karma, Agnikarma, Raktamokshan by Jalauka, Lepan chikitsa, Bastikarma are discussed followed by brief recitation of palliative medicine i.e. Shaman chikitsa. Sensitization of pain and process of inflammation are mediated by G-Protein Coupled Receptors (GPCRs). Ligands (biomolecule) attach to the GPCRs and cause conformation of GPCRs results in transmission of signals to the nucleus, thus, controls the functions of the cell. The Dhatukshaya janya Vataprakopa leads to abnormal signal initiation gives rise to defect in GPCRs in turn, leading to over signaling within the cell. This over signaling causes inflammation within the cell. Margaavrodh that is defect in transmission of signals via GPCRs causes less perception of signals by the cell thereby, disrupting cell functioning leading to accumulation of metabolite toxins within the cell again leading to inflammation.  Ayurvedic formulations such as Angamarda, Shool Prashaman and Vednasthapak Mahakashaya are mentioned in Charak Samhita. The Angamarda Mahakashaya can be prescribed for Angamarda (body ache) in both Dhatukshaya and Margavrodhjanya vataprakop. Shoolprashamiya Mahakashay has Ushan property, hence, useful abdominal colic; whereas, Vednasthapak Mahakashaya has Kashaya Rasa and Sheeta virya can be used effectively in pain management due to traumatic conditions.  Further, medicines like Ajmodadichurna, Shankhvati, Rasonadivati, Agnitundivati, Hingvadi churna etc. are used in Udarshool and formulations of Guggul, Shallaki, Dashmool, Shuntthi, Haridra, Ashwagandha, Rasna, Rakta Chandan, Aam Vateshwar – Vatachintramani Rasa  are used effectively in other  painful condition with varied prognosis.    REFERENCES  1. https://en.wikipedia.org/wiki/International_Association_for_the_Study_of_Pain  [Last accessed on 14/02/2018] 2. Charaka, Katidhadhaypurushiyaam shaarir. In : Vaidyamanorama Hindi Commentary, Acharya Vidyadhar Shukla, Prof.Ravi Dutt Tripathi, Caraka Samhita Purvaardha sharirsthan, 2nd ed. Varanasi : Chaukhamba Sanskrit Pratishthan ; 2007. p.691,1:92. 3. Charaka, Shadvirechanshatashritiya adhyay. In : Vaidyamanorama Hindi Commentary, Acharya Vidyadhar Shukla, Prof.Ravi Dutt Tripathi, Caraka Samhita Purvarardha Sutrasthana, 2nd ed. Varanasi : Chaukhamba Sanskrit Pratishthan ; 2007. p. 77, 4:44,45,47. 4. Susruta, Gulmapratishedh.In : Prof. K.R.Srikantha Murthy, Susruta Samhita uttarardha,2nd ed. Varanasi : Chaukhamba Orientalia ; 2005.p.271,42:81 5. Sushruta, Aampakwaaishaniya adhyay. In : Prof. K.R.Srikantha Murthy, Susruta Samhita Sutrasthanam, 2nd ed. Varanasi : Chaukhamba Orientalia ; 2005.p.125,17:7 6. Charaka, Vatvyadhichikitsaadhyay. In : Vaidyamanorama Hindi Commentary, Acharya Vidyadhar Shukla, Prof.Ravi Dutt Tripathi, Caraka Samhita Uttarardha, 2nd ed. Varanasi : Chaukhamba Sanskrit Pratishthan ; 2007. p. 699,28:59. 7. Susruta, Gulmapratishedh.In : Prof. K.R.Srikantha Murthy, Susruta Samhita uttarardha,2nd ed. Varanasi : Chaukhamba Orientalia ; 2005.p.276-279, 42:117-141. 8. Mahamatishrimadhavkar, Shool parinaamshool annadravshool shoolnidana. In : Shri.Pandit Brahmashankar Shastri Bhishakratna, Madhavnidanam. Varanasi : Chaukhamba Sanskrit Sansthan; 2012. p. 180,26:1 9. Yogratnakar, Shoolnidan. In : Vaidya Shrilaxmipatishastri, Yogratnakar uttarardha, 8th ed. Varanasi : Chaukhamba Sanskrit Sansthan ; 2004. p.5 10. Vriddha Jivaka, Shoolchikitsa adhyay, In : Pandit Hemraj Sharma, Kashyap samhita Khilsthana, 1st ed., Varanasi : Chaukhamba Sanskrit Sansthan ; 2010. p.345,18:4 Amar P. Dwivedi et al. Review of Concept of Pain Management in Ayurveda  IJRAPS | October 2017 | Vol 1 | Issue 4  171 11. https://www.britannica.com/science/thermoreception[Last accessed on 25/01/2018] 12. Charaka, Kalpanasiddhi adhyay. 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Varanasi : Chaukhamba Sanskrit Pratishthan ; 2007. p. 883,1:40 28. https://www.researchgate.net/publication/282324532_Understanding_The_Mode_Of_Action_Of_Bastikarma_Medicated_Enema [Last accessed on 25/01/2018] 29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263906/ [Last accessed on 25/01/2018] 30. Vagbhata, Aayushkamiya adhyay, In : Prof.K.R.Srikantha Murthy, Ashtang Hridayam sutrasthanam, 1st ed. Varanasi : Chowkhamba Krishnadas Academy ; 2007.p.10,1:15  Cite this article as:  Amar P. Dwivedi, Anaya Pathrikar, Anjna Kulkarni. Review of Concept of Pain Management in Ayurveda. International Journal of Research in AYUSH and Pharmaceutical Sciences, 2017;1(4):168-171. Source of support: Nil, Conflict of interest: None Declared  *Address for correspondence Dr. Amar P. Dwivedi  Professor, Shalyatantra Department, D.Y.Patil College of Ayurveda , Nerul, Navi Mumbai Mobile-9022325666, Email: dramar.sarc@gmail.com 

REVIEW OF CONCEPT OF PAIN MANAGEMENT IN AYURVEDA

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REVIEW OF CONCEPT OF PAIN MANAGEMENT IN AYURVEDA

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