Ayurveda Research on Agnikarma in Osteoarthritis of Knee Joint

Abstract

In Ayurveda, treatment with intentional therapeutic heat burns is called Agnikarma (thermal cauterization), which is one of the para-surgical procedures. It is also called Dahan Karma (thermal cauterization). Various painful conditions like joint pain, sciatica, tendinopathies, headache, abdominal cramps/discomfort, and few convulsive disorders like epilepsy, schizophrenia, psycho-somatic disorders, and some skin diseases can be treated with this intentional heat burn therapy. Agnikarma has widely been used in clinical practice since time immemorial and is said to have immediate and long-lasting relief, as mentioned in the Indian traditional therapy. This para-surgical procedure is practiced in all teaching institutes of Ayurveda in India, and many researchers are publishing the research work done on Agnikarma in musculo-skeletal disorders. In this chapter, the concept of Agnikarma along with a brief procedure and published evidence-based research studies on osteoarthritis (OA) of the knee joint treated with Agnikarma are critically analyzed. This chapter contributes the knowledge of the Indian traditional para-surgical procedure in musculoskeletal disorders in general and OA knee joint in particular.

1. Introduction

According to Sushruta, Agnikarma (intentional therapeutic heat burns) is a superior Anu-shastra Karma (para-surgical procedure), and in patients treated with the Agnikarma (cauterization) procedure, the disease usually did not recur [1]. Depending on the disease, different materials heated at different temperatures are used for Agnikarma; that is, depending upon the disease and its predominant doshas (body humors), different materials and temperatures are selected for the treatment; for example, in the case of Agnikarma on the skin, less hot shalakas (probes) are used [2, 3].

Snigdha Agnikarma is cauterization with the help of heated liquids, semi-liquids, or fats, while Ruksha Agnikarma is cauterization with the help of heated metal [4]. Local Agnikarma (sthanika) is done at the disease site, such as skin disorders, and distant Agnikarma (sthanantriya) is done away from the actual diseased area.

Four kinds of shape of the Agnikarma are described in Ayurveda classics: Valay – circular, Bindu – dotted with a pointed object, Vilekha – linear, and Pratisarana –produced by the rubbing of a heated object upon the site up to the desired extent (Acharya Sushruta) [5]. Three additional shapes of Agnikarma are: Ardhachandra – semilunar or crescent shaped, Swastika – cross shaped, and Ashtapada – having eight arms or limbs (Acharya Vagbhata) [6].

According to the depth and tissue involved, four kinds of Agnikarma are Twak Dagdha, Mamsa Dagdha, Sira snayu Dagdha, and Sandhi Asthi Dagdha [7].

1.1 Indications of Agnikarma

A number of diseases and conditions belonging to the musculo-skeletal system, eyes, ENT, hernias, sciatica, elephantiasis, hemorrhoids, sinuses and fistulae, headache, and benign neoplasms have been explained in texts where Agnikarma is indicated as a therapeutic measure [8].

The above statement is based on the indications mentioned in the Ayurveda text, that is, in Sushruta Samhita. On the basis of this concept, some clinical trials are conducted in Ayurveda research institutes and published in the PubMed indexed journals. The clinical pieces of evidence in the context of Agnikarma in the management of musculo-skeletal disorders are Tennis elbow [9], lumbar spondylosis [10], osteoarthritis of the knee joint [11, 12], sciatica [13, 14], migraine [15], and benign growths like warts [16, 17].

The clinical pieces of evidence in the context of Agnikarma in musculo-skeletal disorders with doi numbers are review articles [18, 19], trigger finger [20], calcaneal spur [21], de Quervain’s tenosynovitis [22], plantar fasciitis [23], cervical erosion [24], gynecomastia [25], and mucocele [26].

The clinical pieces of evidences other than PubMed-indexed journals in the context of Agnikarma in the management of musculo-skeletal disorders are corn [27, 28], direct inguinal hernia [29], osteoarthritis of the knee joint [30, 31], cervical spondylosis [32, 33], planter fasciitis (calcaneum spur) [34, 35], and sciatica [36].

1.2 Contra-indications of Agnikarma

It should not be done in Pitta Prakriti (Pitta-dominating body constitution), Bhinna kosthas (abdominal perforations), Dourbalya (general debility), Vriddha (old age), Baala (children), Bheeru (fearful or bogey man), a person afflicted with a large number of Vrana (multiple wounds), Antah shonita (internal hemorrhage) [37], and a person who is unfit for svedana (unfit for hot fomentation) (Anuddhrita Shalya) [38]. According to Acharya Charaka, Agnikarma should not be done in the vrana of snayu (tendon or ligament injuries), marma (vital parts), Netra (eyes), kushtha (leprosy), and vrana with visha and Shalya (wounds with poison or retained foreign body) [39].

1.3 Suitable time or Ritu (Season) for Agnikarma

Agnikarma can be done during all the seasons except Grishma (summer) and Sharad (extreme winters) [40]. It is because in Sharad, there is vitiation of Pitta and Agnikarma also aggravates Pitta, and it may lead to further Pitta vitiation. During Grishma season, there is increase in environmental temperature and Bala (vital force) of the patient remains weak. Even in these seasons, in emergent conditions that are amenable only to Agnikarma, it may be used after taking appropriate counter-measures to protect the patients from the complications.

1.4 Methodology of Agnikarma

1.4.1 Pre-operative measures

The collection of instruments, other required articles, and assistance should be ready. Diet: All the required Agnikarma should be done after feeding the patient with Pichhila diet (slimy diet/curd rice).

Examination, investigations, and other precautions: Before going for any surgical or para-surgical procedure, a complete assessment should be carried out regarding all the factors, such as routine blood investigations like CBC, blood sugar, etc. Tetanus prophylaxis is given. Patient’s Bala (strength), Marmasthana (vital parts), Roga, and Ritu (season) should be properly assessed. Only after that Agnikarma should be done [41]. After confirmation of the site of Agnikarma, it is marked (maximum tenderness). The selected site is cleaned with Triphala kwath or normal saline (in any condition, spirit should not be applied). The area is covered with a sterile holed towel.

1.4.2 Main procedure

After completion of the assessment of the patient and making final diagnosis, Agnikarma should be done with a suitable instrument according to the Dosha (body humor) and Dhatu (body tissue) involved and on the site mentioned for the disease until the Samyaka Dagdha lakshanas are produced. Depending on the nature of the disease, the predominance of the Dosha, and its site, 10–12 heat burns are made with appropriate Shalakas (probes). According to the disease, superficial burns, that is, ‘Twaka dagda’, are done for the disease receding superficially, and deep heat burns, that is, Mamsa Dagda, are done for deep-seated diseases. During the procedure, the patient may feel pain, so he or she should be taken in confidence and assistance may be required to hold him or her so that the procedure can be performed appropriately. During and after Agnikarma, aloe vera pulp should be applied to minimize the burning sensation.

1.4.3 Post-operative Measures

After completion of Agnikarma, the part where Agnikarma has been done should be anointed with Madhu (honey) and Ghrita (clarified butter) for Ropana (healing) of Dagdha Vrana (burn wound). Wound should not be made wet to prevent the wound infection.

1.5 Probable complications

1. Heena Dagdha: If the Shalaka is not properly heated, it will produce this type of Dagdha.

2. Ati-Dagdha: This complication is produced due to transfer of more heat from the red-hot Shalaka to the diseased part.

3. Marmaghata: Due to the fear of burn, the patient may go in vasovagal shock. Emergency treatment should be given to the patient.

4. Daha (burning): More or less burning pain is experienced by each and every patient undergoing Agnikarma Chikitsa. This may be treated by Avachurna (dusting) of Yashtimadhu powder or Lepa of Ghritkumari Swarasa.

5. Shopha (odema): Inflammation is one of the complications; it should be treated accordingly with shothahar (anti-inflammatory drugs).

6. Dushta Vranata: Infection at the burn site is one of the complications, which should be treated accordingly as a superficial burn.

2. Evidence-based research studies

The research studies carried out by researchers of Ayurveda with the help of different sources of Agnikarma in the management of OA knee joint has been summarized with a brief methodology and results citing the references of published research studies for further details.

Pragnesh D. Pandya had conducted a study on 18 patients of Sandhigata Vata (osteoarthritis) of knee joint with the aim to evaluate the role of Agnikarma and internal Ayurveda medicine in the management of OA knee joint [42]. Selected patients were divided into 3 groups. In group A (n = 6), patients were treated with Binduvata Agnikarma by boiling Ghrita (clarified butter) after local anesthesia (2% lignocaine) in the respective knee joint one time. In group B (n = 6), patients were treated by Vata Vidhvansadi Yoga followed by Shuddha Guggulu Vati as internal medicines for 12 weeks. In group C (n = 6), patients were treated with both the therapies, that is, Agnikarma locally and drugs internally. Those patients who were in group A and B were observed with equally benefited patients who were treated locally as well as with internal medicines, that is, patients in group C, showed comparatively better results than group A and B. The study concluded that Agnikarma offers a better and competent solution in the management of Sandhigata Vata (OA of knee joint).

Dhiraj D. Chandasna had done further study on 21 patients of Sandhigata Vata (OA of knee joint) [43]. All 21 patients were divided in 3 groups. In group A (n = 7), patients were treated with Binduvata Agnikarma by boiling Ghrita (clarified butter) after local anesthesia on the affected knee joint one time. In group B (n = 7), patients were treated with Vata Vidhvansadi Yoga followed by Shuddha Guggulu Vati as internal medicines for one month. In group C (n = 7), patients were treated with both the therapies, that is, Agnikarma locally and drugs internally. 100% relief in all the symptoms was found in 4 patients out of 7 in group A, 1 patient out of 7 in group B, and all 7 patients in group C. Those patients who were in group C showed comparatively better relief among the 3 groups. The study concluded that Agnikarma is effective in the management of Sandhigata Vata (osteoarthritis).

Nilesh G. Jethava reported a study on 28 patients of Janu Sandhigata Vata to evaluate the efficacy of Agnikarma with Rajata and Loha Shalaka in the management of Janu Sandhigata Vata (OA of knee joint) [44]. A study was carried out in two groups, in which patients of group A received Agnikarma treatment with Rajata Shalaka and patients of group B received Agnikarma treatment with Loha Shalaka once a week for 4 weeks. Both groups showed statistically insignificant difference in the result. Loha Shalaka showed better result for pain relief compared to Rajata Shalaka. The study has proven the efficacy of Agnikarma in Janu Sandhigata Vata (OA of knee joint) for pain management.

Sucheta Ray conducted RCT on Agnikarma with two different Shalakas in OA of knee joint [45]. A total of 30 patients were divided into two groups: Rajat Shalaka and Tamra Shalaka. Assessment was done after the follow-up on 7^th and 14^th days. In patients treated with Rajat Shalaka, complete remission was seen in 3 patients (20%), remarkable improvement in 6 patients (40%), and moderate improvement in 6 patients (40%). In patients treated with Tamra Shalaka, complete remission was seen in 2 patients (13.33%), remarkable improvement in 4 patients (26.66%), and moderate improvement in 9 patients (60%). Results in both groups were statistically highly significant with p value of ≤0.0001. The study showed that Agnikarma with Rajata Shalaka was more effective than Tamra Shalaka in relieving the pain, tenderness, and other signs and symptoms of Janu Sandhigata Vata (OA of knee joint).

Aneesh Sharma carried out RCT on Agnikarma and Panchatikta Guggulu in the management of Sandhivata (OA of knee joint) [11]. A total 33 patients with Janugata Sandhivata were divided into 2 groups; in group A (n = 18), Agnikarma was done with Panchadhatu Shalaka once every week for one month, while in group B (n = 15), Agnikarma was done along with Panchatikta Guggulu given orally for one month.

Sandhishula (pain), Sparshaasahyata (tenderness), Sandhisphutana (crepitus), and Sandhigraha (stiffness) were weekly assessed by subjective gradation, and a range of movement (ROM) was recorded in research proforma. In Sandhishula, 86% relief was seen in group A, whereas 77.78% relief was seen in group B. Sparshaasahyata was reduced by 69% in group A, while 87.78% in Group B. Nearly 39% improvement was seen in Sandhisphutana in Group A, while 46.67% in Group B. In Sandhigraha, 63% relief was obtained in each of the groups. The patients got relief from the pain after first sitting of Agnikarma in both the groups. The relief was sustained for more than 3 months in most of the patients, as noted during follow-up. There was no significant difference in radiological findings before and after treatment in both the groups.

Mohasin Kadegaon et al. conducted a clinical study on 30 patients of Sandhigata Vata with special reference to Janu Sandhi (OA of knee joint) [46]. The aim of the study was to evaluate the efficacy of Agnikarma and Svedana in the management of OA of the knee joint. All the selected patients were equally divided into 2 groups. In group A (n = 15), patients were treated with Agnikarma in the affected knee joint in a single sitting by Lohadhatu Shalaka, and in group B (n = 15), patients were treated with Dashamula Nadisveda for 7 days. Follow-up was done on 7^th and 14^th days. Agnikarma with Lohashalaka is more effective in the management of Vedana and Stambha, whereas Dashamula Nadisveda is more effective in treating Sandhisotha. The overall result of improvement seen in group A was 74.62%, while in group B it was 70.19%. The study showed better and quick result in Agnikarma with Lohashalaka as compared to Dashamula Nadisveda (OA of knee joint).

Parth Pandya et al. did further study on 30 patients with Janu Sandhigata Vata (OA of knee joint) [47]. In group A (n = 15), patients were treated with Agnikarma by Panchadhatu Shalaka once a week for one month. In group B (n = 15), patients were treated with Agnikarma by Panchadhatu Shalaka along with Panchatikta Guggulu orally for one month. There was not much difference in the percentage of improvement in both groups. However, the combined effect of Agnikarma and oral Panchatikta Guggulu showed better results in reference to relief in the complaints of joint pain, joint stiffness, and crepitus.

Anju Lata et al. carried out RCT on a comparative study of conductive and direct method of Agnikarma with Tamra Shalaka in Sandhigatvata [48]. A total of 60 patients with OA of knee joint were divided into two groups. In the conductive method (n = 30) and direct method (n = 30) of Agnikarma with Tamra Shalaka at an average temperature of 150°C and 50°C, respectively, it was found that the pain, tenderness, and swelling were significantly reduced after treatment by both methods with a p-value less than 0.05. But in the direct method, more effective and satisfactory result was found than in the conductive, which method might be due to a high temperature of about 150°C. The study concluded that Agnikarma shows good results in pain relief when the temperature of the Shalaka is 150°C and more in conditions like osteoarthritis of knee joint.

Ruchi Pandey carried out an RCT to evaluate the effect of Agnikarma along with Panchatikta Guggulu in the management of Janu Sandhigata Vata (osteoarthritis of knee joint) [49]. In group A (n = 21), 4 sittings of Agnikarma were done with Panchadhatu Shalaka. In group B (n = 20), 4 sittings of Agnikarma were done with Panchadhatu Shalaka along with Panchatikta Guggulu orally for one month. Significant relief was observed in both groups in all subjective parameters. Clinically and percentage wise, group B showed better results. The study concluded that Agnikarma alone has a definite role in reducing the knee joint pain and tenderness, but the addition of Panchatikta Guggulu showed convincing results in stiffness, swelling, and range of movement of knee joint. The author also demonstrated a video of Agnikarma for the same study [50].

Shubham Puri conducted a study on Agnikarma and indigenous drugs in the management of Janu Sandhigata Vata w.s.r. to OA of knee joint [51]. In this study, in group A, 15 patients received oral indigenous drugs, while in group B, 15 patients received Agnikarma with Rajat Shalaka. Agnikarma was done in four sittings with a weekly interval. The group of patients who received Agnikarma showed better results as compared with the orally treated group of patients. In terms of the two parameters of pain and range of movements, Agnikarma-treated patients showed very good result as compared to patients treated with oral medications. The study concluded that Agnikarma was found to be very effective in the management of Janu Sandhigata Vata (OA knee joint).

Syyed MJ carried out RCT on Agnikarma in 60 patients of Janu Sandhigata Vata w.s.r to OA of knee joint [52]. Patients were randomly allocated to receive either conservative medicine or Agnikarma for a period of 15 days. Clinical efficacy was evaluated on 7^th and 14^th days on the basis of cardinal symptoms with a visual analogue scale. Treatment with Agnikarma produced a significant drop in the severity of pain (p < 0.001). Radiological assessment, however, did not show any significant changes in both the groups.

Lobo SJ did a comparative clinical trial on 60 patients with Janu Sandhigata Vata (OA of knee joint) [53]. The aim of the study was to evaluate the effect of Agnikarma (therapeutic heat burn) by Suvarna Shalaka (rod made of gold) and Panchadhatu Shalaka (rod made up of five metals). All patients were divided into two groups. In group A (n = 30), patients were treated by Agnikarma with Suvarna Shalaka, and in group B (n = 30), patients were treated by Agnikarma with Panchadhatu Shalaka once a week for four weeks. All patients were followed up after 15^th and 30^th days. The statistical analysis showed that Agnikarma by Suvarna Shalaka was statistically more significant in reduction of pain, tenderness, crepitus, swelling, angle of flexion, and extension compared to Agnikarma by Panchadhatu Shalaka. Thus, the study concluded that Suvarna Shalaka Agnikarma is found more beneficial than Agnikarma using Panchadhatu Shalaka in prime symptoms of Janu Sandhigata Vata (OA of knee joint).

Raut SR conducted a case-based study on pain management by the conductive method of Agnikarma with Suvarna Shalaka in Janu Sandhigata Vata [54] in three sittings. On every 7^th day, it was observed that the response of the patient was good to conductive Agnikarma therapy. The pain is reduced in VAS from 7/10 to 0/10. ROM flexion improved from 110 to 135 with no burn marks.

3. Conclusions

Thus, in conclusion, Agnikarma is practiced in India with positive outcomes in the management of OA as a conservative measure, and its effects are sustained for up to 6 months. This procedure needs further evaluation with other parameters like inflammatory markers in a scientific way in more number of cases. Data on more number of cases with specific parameters and multicentric trial are needed for the exact mode of action and scientific validation.

Acknowledgments

The author thanks Prof. Dr. Anup Thakar, Director, ITRA, Jamnagar, Gujarat, India, for providing all facilities at the department for continuous research studies on para-surgical procedures.

Conflict of interest

None declared.