Introduction

Imagine if any portion or part of our body becomes frozen/stiff and encountered with extreme pain then how would you feel…??? You will probably become irritable, impatient, short tempered and finally depressed thus ruining one’s self peace. Pain is an irksome experience, whether acute or chronic, it makes our life difficult. So one such condition is frozen shoulder that makes our lifestyle harsh. Our shoulder joint consists of three bones namely humerus (upper arm bone), clavicle (collarbone) and scapula (shoulder blade) and important structures like rotator cuff, bursa , labrum and capsule. Normally capsule of shoulder joint is elastic and allows great range of motion but inflammation, fibrosis, scarring and contraction of the capsule may cause restriction of movement and this condition is baptized as frozen shoulder. Frozen shoulder is sometimes also known as adhesive capsulitis, or painful stiff shoulder.

What is frozen shoulder

Frozen shoulder is composed of two words frozen + shoulder. Frozen rendered immobile and shoulder means the upper joint of a person's arms . So a constant pain, stiffness and progressive loss of shoulder motion is termed as frozen shoulder. It affects both active and passive movements of shoulder joint whether it is flexion, extension, abduction, adduction, external rotation, internal rotation.

So lets do some exercise to scrutinize are you a patient of frozen shoulder or not…???

1. Abduction: “ Move your arms away from midline of your body ”.
2. Adduction: “ Swing your arms towards midline of your body ”.
3. Flexion: “ Raise your arms anteriorly in front of your eyes and now above the head ”.
4. Extension: “Just opposite to flexion move your arms posteriorly ”.
5. External Rotation: ” Make a shape of letter “ L” by your arm and forearm and move it sidewards ”.
6. Internal Rotation: “Please put your hands on the back of your spine ”.

If you are unable to perform these movements then you conceivably might be a sufferer of frozen shoulder.

Causes of frozen shoulder

The specific cause of frozen shoulder is not yet detected. However this condition may be induced due to certain risk factors such as:

• Diseases: People suffering from stroke, diabetes mellitus, heart diseases, lung diseases, connective tissue diseases, shoulder conditions like calcific tendonitis, rotator cuff tear, thyroid problems may be overactive thyroid (hyperthyroidism) or an underactive thyroid (hypothyroidism), breast cancer, immobility, seizures, accidents, shoulder injury or surgery, rheumatoid arthritis, autoimmune diseases, cervical disc diseases of neck etc.
• Aging influence: The people belonging to 4th or 5th decade are more susceptible for this disease especially women as these people are more prone for fall, decrease in bones strength & density, loss of calcium & minerals, injuries and immunosenescence.
• Immobilization: Any previous injury or surgery, after surgery idleness or repose stage may cause inefficiency to move the shoulder joint which may also become a leading cause of frozen shoulder.
• Trauma: A mild trauma to the shoulder also act as a trigger for frozen shoulder

Symptoms:

Symptoms occurs slowly, without any hurry i.e leisurely and in three phases. These phases are named according to the symptoms that developed gradually. So these phases are pain or freezing stage, stiffness or frozen stage and lastly resolution or thawing stage.

• 1st stage: Pain or freezing stage: It is the the initial stage of adhesive capsulitis, in this pain is the cardinal factor which may get enhanced with any movement of limb or soma It may get worse at night or in cold weather and may lasts for several weeks to months.
• 2nd stage: Stiffness or frozen stage: It is the succeeding stage of shoulder contracture as the name suggests, in this range of motion of the shoulder joint is limited i.e the shoulder gets stiffed or frozen.The most astonishing feature of this phase is that pain is self resolving in nature while period of this stage may lasts up to 1 year.
• 3rd stage: Resolution or thawing stage: It is the ultimate stage of the frozen shoulder which apprise that the range of glenohumeral joint begin to improve over time. This process will take time, sometime several years and may lasts up to 3 years.

Treatment

In modern sciences anti-inflammatory medicines, physical therapy, injections and manipulation under anesthesia (hydrodilatation) was performed. If these non operative methods fails then surgery is executed.

If you have tried all these treatments and it hasn’t resulted in a positive outcome then the best job is to move on to another therapy especially to Marma therapy/treatment which is also designated as “Mother of all healing therapies” because one sitting of marma therapy can really bring marked relief. Many people have tried this therapy and got relieved from painful & stiff shoulder in a very short span of time.

Marma Chikitsa in Apabahuka: A Case Presentation

The Natural Force within each of us is the greatest Healer of a disease Hippocrates

A female aged 50 years, non-hypertensive with no thyroid problems and without any history of injury or trauma presented with the following symptoms :

1. Dakshina Amsa Sandhi vedana (Pain in Right Shoulder)
2. Amsa Sandhi Graham (Stiffness of Shoulder)
3. Restricted Range of Movement (R.O.M) - Since Past 4 months she was having these complains…

Our examination

Abduction, Circumduction (movement of shoulder in a circular motion) and Flexion of the shoulder joint was difficult. She was unable to lift her arms more than 90 degrees and had extreme pain in doing so. The patient was even unable to comb her hairs. Stiffness was present in the Deltoid and Supraspinatus muscle (reason for painful abduction), and also in Long head of Biceps brachii (causing difficulty in flexion). There was moderate loss of external rotation of the shoulder. Tenderness was elicited: In Supraglenoid tubercle – 7, Coracoid process - 6 and near Acromioclavicular region- 5 on Visual Analogue scale of 0-10 where 0 meant no pain and 10 as maximum pain possible. While examining for the R.O.M, coarse crepitations and mild swelling were felt in the regions of supraglenoid tubercle & Coracoid process (probably due to the stiffness of the Supraspinatus & Long head of Biceps brachii muscles pulling the Acromio Clavicular joint). She was not able to move the right forearm behind the back due to pain and stiffness in the shoulder joint. She was asked to get an Xray done of the affected limb and the X-Ray was normal in appearance.

• Aggravating factor: Movements of Abduction, flexion and external rotation
• Relieving factor: When the patient slept on the unaffected side she felt better.

Provisional Diagnosis: Apabahuka/ Idiopathic Frozen shoulder (Primary Adhesive capsulitis of shoulder)

Plan of treatment:

• Immediate: Marma Therapy
• Oral Medications: Arogyavardhini Vati & Yograj Guggulu for 2 weeks
• Follow Up after 2 months for re-evaluation.

Marma Therapy

Marmas manipulated were

1. Amsa
2. Kakshadhara
3. Kurpara
4. Kshipra

Each Marmas were stimulated 20 times in the same rhythm where we inhale and exhale by digital pressure and asked to follow it up twice a day for two weeks.

• The Patient Pre Marma Therapy
  *Note the expression of Pain on <90°

• Same patient Five minutes Post Marma Therapy
  *Note the increase in degree of Abduction to 120° and also with highly reduced Pain.

Observation:

The patient showed immediate improvement in flexion, abduction of shoulder after Marma Therapy. Abduction improved by nearly 30 degrees and flexion by 25-30 degrees. The stiffness had reduced considerably up to 80% and the pain around 85% after one week. She was advised to follow Marma Therapy along with medications until the next follow up after two weeks. The patient was totally asymptomatic and was happily attending her daily routines, without any hindrance caused by her earlier affected shoulder after two weeks. And now after 2 months since the case she has not complained of any pain or restriction of movement in her right shoulder. After Two weeks on follow up she can raise the arms fully and with a smile now.

Discussion:

The Shoulder Joint in Ayurveda has been described as a type of chala1 and ulookhala sandhi2 which is formed by the combination of pragandasthi (Humerus), akshakasthi(Clavicle) and amsaphalakasthi (Scapula). Pratanavat snayu covers this sandhi3 while Shleshmadhara kala is presents in this joint and secretes Shleshmaka kapha4. This acts as lubricant and helps in protection and movement of the sandhi5 . Amsa marma which is a snayu marma measuring half finger width6 is present near this Sandhi.

Avabahuka is a disease characterized by morbid vata dosha localized around the amsa pradesha (shoulder region) therefore causing soshana of amsa bandha as well as akunchana (constriction) of sira which site leads to bahupraspandahara. In Allopathic science also for idiopathic Frozen Shoulder one of the probable mechanism of its occurrence is inadequate blood flow to shoulder joint7

The term Avabahuka was first coined by Acharya Sushruta⁸ where he has described Samprapti (Pathogenesis) and Rupa (Symptom) of Avabahuka. Both Ashtang Hridaya and Ashtang Samgraha have elaborated the full account of Avabahuka^9,10. It is mentioned as one among the eighty types of vata nanat maja vikaras by both Sharangadhara and Bhavamishra^11,12. Arunadutta and Dalhana, both have commented on samprapti, lakshana and treatment of Avabahuka in their works^13,14. In Madhava nidana two conditions of the disease has been mentioned¹⁵ – Amsa shosha and Avabahuka. Amsa shosha can be considered as the preliminary stage of the disease where loss or dryness of Sleshmaka kapha from amsa sandhi occurs. In the next stage i.e., Avabahuka, due to the loss of shleshmaka kapha symptoms like shoola during movement, restricted movement etc are manifested.

The basis of Marma Science is 107 vital points¹⁶ in the body, which are located in anatomically defined sites viz. nerves, nerve roots, bones, muscles, ligaments, vessels and internal organs¹⁷ well described by Acharya Sushruta. They have been further classified by him on the basis of anatomical location, type of tissue, size and the effects they produce on injury. Marma Points are said to be a link between the Manovaha Srotas and the Majja Vaha Srotas.

In Sushrut Samhita Siravedha, Agnikarma and Kshara karma have been discussed. In these treatments certain points have been correlated with certain internal organs and doshas. Taking these references into account, Marma therapy has been developing. Marma Therapy is the art of treating these 107 very special vital points on the human body and re channelise the Prana ( Vital force in the body). "A Marma point is the junction between physiology and consciousness," says Ed Danaher, Director of the PanchaKarma department at the Ayurvedic Institute in Albuquerque, New Mexico. Touching a marma point changes the body’s biochemistry and can unfold radical, alchemical change in one’s makeup. Stimulation of these inner pharmacy pathways signals the body to produce exactly what it needs, including hormones and neurochemicals that heal the body, mind and consciousness says Dr. Vasant Lad¹⁸ . The important point to remember here is that through treating their respective marmas, we can treat the nadis, elements, sense and motor organs, and other factors associated with the chakras¹⁹ or vital energy centres.

The art and technique of stimulation varies for each of the marma. Care has to be taken for adequate pressure application only to avoid complications. Identification of each marma is also very important for optimum results of the therapy and initially should be done under expert guidance only.

The Marmas are stimulated 2-4 times a day. Each marma is stimulated for 20-25 times in one sitting. The rhythm of stimulation is same as the rhythm of our respiration i.e approx 18 times per minute. It can be done both in sitting and supine posture, however for optimum results various asanas and postures have been described in various texts. In our clinical practice we find great results in the reduction of pain and also improvement of range of motion and gait of patient by this method. Our most important observation is that in many cases it gives immediate pain relief which so far has been thought to be a lacuna in Ayurveda. This beautiful science has the potential to take care of patients of Primary Adhesive capsulitis by this non invasive technique . This case leaves room for further research of large sample data with wider population distribution.

References

1. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, Varanasi P.o 1139, 2003 Sharir Sthan, 5/24-25
2. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, Varanasi P.o 1139, 2003 Sharir Sthan, 5/27
3. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, Varanasi P.o 1139, 2003 Sharir Sthan,.5/31
4. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, Varanasi P.o 1139, 2003 Sharir Sthan, 4/14
5. Vagbhata Acharya, Astanga Hrudaya, Pandit. Bhisagacharya Hari Shastri paradkar vaidya, Nirnay Sagar Press, 2002, Varanasi A.H.Su.12/18
6. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, Varanasi P.o 1139, 2003 Sharir Sthan, 6/26
7. Susruta, Susruta Samhita, Acharya Jadavji Trikamji, Chaukhambha Orientalia 2003 Varanasi. Pp824, Page no.269
8. Vagbhata Acharya, Astanga Hrudaya, Pandit. Bhisagacharya Hari Shastri paradkar vaidya, Nirnay Sagar Press, 2002, Varanasi, Pp-956, Page no.534
9. Vagbhata, Astanga Sangraha, Pandit Nanda Kishore Sharma, Krishnadas Academy, 2002, Varanasi, Pp-436, Page no.398
10. Sharangadhara, Sharangadhara Samhita, Vaidya Sagar Pandit Parasurama sastri, Chaukhambha Orientalia, 2002, Varanasi, Pp 398, Page no103
11. Bhava Mishra, Bhava Prakasha Nighantu, Dr. G.S.Pandey, Chaukhambha Bharati Academy, 2004, Varanasi, Pp-984, Page No.226
12. Aruna Dutta, Ashtanga Hrudaya, Pandit. Bhisagacharya Hari Shastri paradkar vaidya, Nirnay Sagar Press, 2002, Varanasi, Pp-956, Page no.534
13. Dalhana, Susruta Samhita, Acharya Jadavji Trikamji, Chaukhambha Orientalia 2003 Varanasi. Pp824, Page no.268,
14. Madhava Kara, Madhava Nidanam, Prof. K.R. Srikanta Moorthy, Chaukhambha Orientalia, 1993, Varanasi, Pp-329, Page no.404
15. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, VaranasiP.o 1139, 2003 Sharir Sthan, 5/3
16. Sushrut Samhita, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit bhavan, VaranasiP.o 1139, 2003 Sharir Sthan, 5/16
17. Marma Points of Ayurveda by Dr Vasant Lad http://www.narayana-publishers.com/Marma-Points-of-Ayurveda/Vasant-Lad/b 9673/partner/leseprobe)
18. Ayurveda and Marma therapy by Dr David Frawley, Dr Subhash Ranade and Dr Avinash Lele. Lotus Press, PO Box 325, Twin Lakes, WI 53181. ©2003