Role of Patrapinda Sweda and Matrabasti in management of Katishoola (Low back pain)- A case study

Low back pain (LBP) is the most common chronic musculoskeletal disorder. It has symptoms like pain, swelling, stiffness or limited range of motion and these symptoms lie very close to the entity Katigraha & Katishoola in Ayurveda which is coming under Vatavyadhi (diseases of Nervous system and musculoskeletal system). The Contemporary management has little


Introduction
University Ayurvedic college Hospital, Rajkot, for treatment of her lower back pain., who presented with complaints of Pain, swelling in low back since 1years. Sometime it worsens after daily routine activity. On examination, mild Swelling, Tenderness were present in lumbar region and showing painful movements with SLR 60 Degree. She had no history of trauma and her symptoms were increased gradually.
Motor and sensory functions were normal in right and left legs and both deep and superficial reflexes were also normal. All details of the patient including present history, past history, treatment history, dietary habits, lifestyle, and addictions were recorded before the treatment. Necessary examinations and X-rays in lumbo-sacral region were done and finding was recorded. Visual analogue Scale was assessed for pain and WOMAC Scale was assessed for pain, Stiffness and physical function of the Low back.Patient was kept on a normal diet without any specific restrictions and was advised not to lift any weight. The patient was treated with Ayurvedic treatment regimens for 14 days. Details are as below.

Dashavidha pariksha(~Ten-fold examination)
Prakruti was Vatakaphaj, Sara was Madhyam, Samhanana was Madhyam, Pramana was Madhyam, Satmya was sarvaras, Satva was Madhyama, Aharashakti was hina, jaranashakti was hina, Vy a y a m s h a k t i w a s M a d h y a m a , v a y a w a s Madhyamavastha.
• Purvarupa: The occurrence of symptoms at minimal severity was the Purvarupa for vatavyadhi. So, here in the context of katishoola the occasional occurrence of back pain, stiffness was the Purvarupa. [5] • Rupa: The excited vata spreads to the katipradesha i.e., the snayu, peshi, asthi of katipradesha occasionally causing pain, stiffness at the katipradesha and restricted range of movement of kati. [6] • Samprapti: The vitiated doshas get residence at the afflicted places in the body. The various Vatakara Nidana specially those giving on due strain to the katipradesha produces srotovigunata in the channels. The vitiated vatadosha undergoes localization at the site of kha-vaigunya. The dosha vitiates the dushya (asthi, snayu, peshi, majja) by confining itself to the katipradesha.Theresfore symptoms of pain and stiffness are occurring in a mild form distinctive of poorvaroopa of vatavyadhii.e.katishoola. [7] • Vyaktaavastha:The dosha vitiates the dushya (asthi, snayu, peshi, majja) by confining itself to the katipradesha and manifest as a disease. This stage is marked by thepresence of pain, stiffness and restricted range of movement. [8] • Bhedavastha: As the negligence continues the disease proceeds into more severe forms due to extensive dhatukshaya. It finally attains asadhyata in this stage. This stage can make the condition worse by manifestation of degenerative changes in the dushyaas (asthi) which are irreversible. [9]

Investigations
Haemoglobin was 14.2 %, White blood count was 9500 Cells/Cu mm, ESR was 15 -mm in 1hr, Blood urea nitrogen was 9.89mg/dl, Serum Creatinine was 0.82 mg/dl, uric acid was 6.11 mg/dl, and calcium was 9.67 mg/dl. Other blood investigations like RA, ASO, CRP were done to rule out other disease conditions.
Diagnosis based on the sign and symptom, VAS score, WOMAC scale, X-ray and blood investigation.

Materials and Methods
Snehana and swedana are the main line of treatment in vatavyadhi, and in katishoola vata is the prime factor for pain. So treatment planned was Snehana (oleation)in the form of Abhayangha(massage) externally and internally Matrabasti (Oil enema). And Patrapindasweda as swedana was planned for the case. Assessment of condition of the patient before and after treatment was done based on Subjective parameters (pain, stiffness, swelling) and Objective parameter (Visual analogue scale and WOMAC )scale for pain and physical activity grading, to evaluate efficacy of the treatment. Based on the assessment parameters, significant improvement was seen in the subjective symptoms and pain scale after the completion of a schedule of 14 days of treatment and follow up after 1 month. The physical activity grading also improved significantly.

Treatment Protocol
Snehana and Swedana are the main treatment planned for this case. Snehana as Abhyanga with Ksheerabala taila , swedana with Patrapinda sweda for 7 days. Abhyantara Snehana Matrabasti-Administration of Medicated oil through the rectal route . In this case study, ksheerabala taila was used for Matrabasti for 7 days.Treatment done for a total period of 14 days. The ingredients of above-mentioned medications are given below in the tables.

Oil was prepared with the above ingredients for external and internal application
Subjective and Objective assessment was done before treatment and after treatment.

Before Treatment
After Treatment -Vas scale Vi s u a l a n a l o g u e s c a l e ( c o n s o l i d a t e d ) represented in line diagram shows improvement Sum and average of WOMAC grading before and after treatment are calculated and compared.

Follow up period -1month
Treatment was administered as per the prescribed schedule.

Discussion
As Vata is the most important factor causing Katishoola(Low back pain) and Snehana-Swedana is the first line of treatment of Vatadosha.And as in this case degenerative changes were observed.The Abhyanga carried out before the swedana are likely to correct the imbalances of Vatadosha. [11] In addition to this, the sudation procedure helps in rectifying the morbid doshaas well.ThePatrapinda sweda is very much efficacious in such clinical conditions. [12] It Alleviates the pain and swelling.So,Abhyanga with the Ksheerbala Tail, Patrapinda Sweda followed by Matrabasti with ksheerbala Tail was effective and markedly improved in the sign and symptoms of Katishoola(Low back pain).

Conclusion
Abhyantara and bahyasnehana and swedana-Patrapindasweda is highly effective in Low back pain. This case showed significant improvement in symptomsimmediatelyafterthetreatment. After follow up no reoccurrence of symptom was noted.This indicates that Snehana and swedana both have a long way of action in the effective management in Lowback pain. But a longer duration study with a large sample size must be done to get more accurate conclusions. On the basis of this single case study, it can be concluded that panchakarma procedures like patrapinda sweda and Matrabasti had been effective in the management of the Low back pain. Pain VAS SCALE 2 0 5