PANCHAKARMA TREATMENT OF APABAHUKA

1. CASE PRESENTATION
PRESENTER BY
DR. KAUSHAL SINHA
PG SCHOLAR
DEPARTMENT OF PANCHAKARMA
SDM COLLEGE OF AYURVEDA AND HOSPITAL
HASSAN

2. PATIENT DETAILS
Name : XXX
Age : 42 Yrs
Date of Admission : 11.07.2016
Ward No : SSW
Bed No : 174
Address : Shivmoga
 Occupation : LIC agent since 22 yrs
Religion : Hindu

3. CHIEF COMPLAINTS
Pain in nape of neck region radiating to Right hand till the finger
since 1 week.
Associated complaints: Numbness & weakness in right upper limb,
stiffness in arm.
Difficulty in performing routine works.

4. H/O PRESENT ILLNESS
 According to patient
Patient was said to be apparently healthy before 8 days. On 3 july
2016, he suffered from fever and pain in nape of neck radiating to
the right hand for which he consulted local clinic and took
medicine (Paracetamol) after which fever subsided .
 But neck pain still persisted. Pain was severe , agonizing , pricking
associated with numbness. He was unable to lift his right hand . He
consulted to a local hospital in shimoga but did not find any relief.
So he approached SDM hospital Hassan and was admitted on
11/7/16 for further management.

5. CHARACTERISTICS OF PAIN
Nature of pain : Pricking
Duration : Continuous
Severity : Severe & agonising
Radiation : From nape of neck to right upper hand
Aggravating factors : Activity
Relieving factors : Analgesics
Diurnal variation : More at night

6. H/O PAST ILLNESS
 MEDICAL HISTORY :- Patient experiences pain in right upper limb
once in 6 months since 3 years
Not a case of diabetes Mellitus/ Hypertensive, No history of any
accident or trauma
 SURGICAL HISTORY :-Nothing specific
PSYCHIATRIC HISTORY :- NAD
 TREATMENT HISTORY :- Pain used to get relieved by taking
analgesics
.

7. FAMILY HISTORY
No relevant family history contributing to the current condition of the
patient.
All members are said to be healthy.

8. PERSONAL HISTORY
 Diet -
 Break fast - Idli (5) – Sambhar, Coconut chatni, 1 Large mudde (Ragi ball) +
Rice (1 small bowl) with sambhar (occasionally).
 Lunch - No specific time, Sugarcane juice / Tender coconut / buttermilk
 Dinner – 1 Large mudde (ragi) with Sambhar, 2 chapati / Rice occasionally.
Curd + sugar before bed time
 Appetite - Good

9. Cont….
 Sleep : Disturbed due to pain
 Bowel habits : Twice in a day,
Habits :- 1 Beer once in 15 days or 1 month.
coffee / tea – 10-15 cups / day
Improper posture while watching TV and also
during sleep– uses 2-3 pillows.

10. PROFESSIONAL HISTORY
 Travel 100-150 km/day since 20 years.
 Working hours- 8am to 9 pm (12 hours)
 Travels in 2 wheeler in Rural area with speed of 50-60 km/hour
 Stress related work
 No proper food time

11. GENERAL EXAMINATION
Built Moderate
Pallor Absent
Icterus Absent
Cyanosis & Clubbing Absent
Lymphadenopathy Absent
Tongue coating Mild coated
Pulse rate 74/min
BP 130/90 mm Hg

12. SYSTEMIC EXAMINATION
 CVS - S1 S2 heard
 RS - NVBS , no added sounds
 P/A - No organomegaly and no tenderness
 CNS
Higher mental functions
Sensory system NAD clinically
Cranial nerves

13. HIGHER MENTALACTIVITIES
Consciousness Well conscious
Orientation Well oriented to Person, place, time
Memory Intact
Speech Normal

14. REVIEW OF SYSTEMS
 GENERAL CONDITION:-
 Weight: 68 kgs
 Height : 156 cm
 BMI: 27.98 kg/m2
 Recent weight changes-no
 Weakness:- Yes ( RIGHT UPPER LIMB )
 Fatigue:- Yes

15. FOCUSED EXAMINATION OF RIGHT
SHOULDER
GATI (RANGE OF MOVEMENTS) :
Shoulder joint - Flexion
Extension Painful and restricted
Abduction
Adduction
Internal rotation
External rotation

16. INSPECTION
 Swelling - Absent
 Redness – Absent
 Deformities – Absent
PALPATION.
 Tenderness – Present at Right scapular region
 Temperature – Present at Right shoulder & elbow joint

17. SPECIAL MANEUVERS
TO FIND LESION IN CERVICAL REGION:-
 SPURLING TEST - POSITIVE ( RIGHT SIDE)
 COMPRESSION TEST - POSITIVE ( RIGHT SIDE)

18.  TO LOCATE LESIONS AT ROTATOR CUFF:-
 APPLEY’S SCRATCH TEST :- POSITIVE ( RIGHT SIDE)
 DROPARM SIGN :- POSITIVE ( RIGHT SIDE)
 EMPTY CAN TEST :- POSITIVE ( RIGHT SIDE)

19. APPLEY’S SCRATCH TEST

20. ARM DROP SIGN

21. EMPTY CAN TEST

22. INVESTIGATION
 HB-12.2GM%
 Total W.B.C count -
14500 cells/ cmm
 E.S.R-18 mm/hour

23. OSTEOPHYTIC CHANGES

24. ASHTAVIDHA PAREEKSHA
 Nadi : Vatakapha
 Mutra : D/ N – 3 / 2 times
 Mala : Twice in a day
 Jivha : Aliptha
 Shabda : Prakrita
 Sparsha : Ushna sparsa in affected sandhi
 Druk : Prakrita
 Akriti : Madhyama

25. DASHAVIDHA PAREEKSHA
1) Prakruti - Vata-kapha
2) Vikruti -
Hetu - Ahara –Vatakara,kaphakara
Vihara - Atiyana (daily travel)
Manasika - Chinta
Dosha - Vata-kapha
Dushya - Rasa, asthi,rakta, mamsa ,snayu
Desha - Sadharana
Kala - Visarga
Bala - Madhayama

26. CONTD…….
3) Sara - Madyama
4) Samhanana - Madyama
5) Pramana - 68 kgs
6) Satva - Madyama
7) Saatmya - Nitya dahi sevana (kaphakara ahara)
8) Ahara shakti - Madyama
9) Vyayama shakti -Madyama
10) vaya - Madyama

27. NIDANA PANCHAKA
• NIDANA - Akala bhojana, Nitya Dadhi sevana,atiyana
• POORVARUPA- Shrama, Pain in right shoulder
• RUPA - Pain in nape of neck radiating to right upper
limb associated with numbness & weakness in
right upper limb, stiffness in right arm
• UPASHAYA - Oushadha

28. SAMPRAPTI
NIDANA
APABAHUKA
Bahupraspandana hara
Shoshana of Sleshaka Kapha, Mamsa, Sira,
Snayu & Kandara
Sthanasamsraya in Amsa
Vata prakopa
Vatakara
Kaphakara
Adhishthana in
Amsapradesha
Kapha Prakopa
Kaphavruta Vyana in
Sandhi
Sira Sankocha

29. SAMPRAPTI GHATAKA
Dosha : Vyana Vata, Shleshaka Kapha.
Dushya : Sira, Snayu, Mamsa, Kandara, Asthi.
Srotas : Mamsavaha, Asthivaha.
Sroto Dushti : Sanga, Vimargagamana
Roga Marga : Madhyama.
Udbhava Sthana : Pakwashaya.
Vyakta Sthana : Bahu.
Adhisthana : Amsa Pradesha.
Vyadhi Swabhava : Chirakari.

30. DIFFERENTIAL DIAGNOSIS

31. DIFFERENTIAL
DIAGNOSIS
INCLUSION CRITERIA EXCLUSION CRITERIA
1. एक ांग रोग हस्तं वा तोदशूलकृ त् पादं सङ्कोचयत्येकं हस्तं
(Voluntary activity affected
part is impaired or lost)
2. विश्ि ची
 बाह्यो: कर्म क्षयकरी तलं प्रत्यङ्गुलीनां या
कण्डरा बाहुपृष्ठतः
3. अांश शोष
दौबमल्य in अंससन्धि र्ांस क्षय , र्ांस शोष
4. अपब हुक अांसमूलस्थितो ि युुः
ससर ुः सङ्कोच्य तत्रग ुः
ब हुप्रथपस्दितहरां with
shoola and sthambha

32. DIFFERENTIAL
DIAGNOSIS
INCLUSION CRITERIA EXCLUSION CRITERIA
1.BURSITIS Joint tenderness. Pain during
movement
Pinching pain, redness
2.TENDENITIS Pain in shoulder and arm
stiffness
Loss of morbidity,
strength in the affected arm
3.ROTATOR CUFF
INJURY
Pain in shoulder, Joint
stiffness, muscle weakness
Loss of muscle, nerve
injury
4.CERVICAL
SPONDYLOSIS
Pain in neck and
shoulder,weakness in the right
upper arm
Neurological dysfunction
5.FROZEN SHOULDER Stiffness, pain and limited
range of movements.
Pain in shoulder during
movement.
Pain usually worsens at night.

33. DIAGNOSIS
APABAHUKA
{FROZEN SHOULDER}

34. Apabahuka
 One among vataja nanatmaja vyadhi
 Acharya Susruta, Vagbhata - Avabahuka a Vata Vyadhi.
 Not explained by Charaka , but word Bahu sosha had been used
instead.
 Avabahuka - Shleshaka Kapha Sosha + Shoola during movement,
restricted movement etc.
 Madhokosha :- two types( V and VK)

35. Definition
 Apabahuka is a disease characterized by morbid vata dosa localizing
around the amsa pradesa and there by causing soshana of amsa
bandha as well as akuncana of sira at this site leads to
bahupraspanda hara

36. LAKSHANA’S
 Apa means Vikruthi or Viyoga (Dysfuntion)
 Bahupratispanditahara (limitations of ROM)
 Sira Akunchana
 Stambha (stiffness)

37. FROZEN SHOULDER
Also known as adhesive capsulitis
Characterized by Stiffness, pain and limited range of movements.
Pain usually worsens at night.
Frozen shoulder occurs in about 2% of the general population.
It most commonly affects people between the ages of 40 and 60, and
occurs in women more often than men.

38. TREATMENT PLAN

39. TREATMENT ON 12 July 2016 (First day)
1- Sarvanga udwartana + parisheka with dhanyamla + dashmula kwatha
2- Nasya with K.B taila 101- 8-8 drops each nostrils.
3- Upanaha at Right upper arm with kolakulathadi churna + saindhava +
godhuma + karpasasthyadi taila
4- Shiropichu with Bramhi ghrita
5. V.M vati 2-2-2 (A/F)

40. On 13 July 2016 (Second day)
1- Sarvanga Udwartana + Parisheka
2- Nasya.
3- Upanaha same 1,2,3,4,5was the same
4- Shiropichu
5. V.M vati
Cap. Flexofen MR 1-0-1 (A/F)

41. On 14 JULY 2016 TO 15 JULY 2016
(3RD DAY TO 4TH DAY)
1- Sarvanga udwartana + parisheka
2- Nasya
3- Upanaha 1,2,3,4,5,6was the same
4- Shiropichu
5. V.M. vati
6- Cap. Flexofen MR

42. ON 16 JULY 2016 TO 18 JULY 2016
( 5TH DAY TO 7TH DAY)
 Sarwanga Abhyanga with Mahanarayana taila + Jambeera pinda sweda
 Sthanika Arka Patra sweda in upper limb
2.Nasya with K.B. taila 101
3.Upanaha Treatment was the same
4- Shiropichu
5- V.M. vati
6- Cap. Flexofen MR

43. 19 JULY 2016 TO 22 JULY 2016
(11TH DAYS)
1. Sarwanga Abhyanga with M.N. taila + SSPS ( sasthika shali pinda sweda )
2.Nasya with K.B. taila 101
3.Upanaha Treatment was the same
4- Shiropichu
5- Cap. Flexofen MR
6. V.M vati
7. Sthanika arka patra sweda

44. RESULT

45. LAB INVESTIGATION

46. RANGE OF MOVEMENT:
JOINT FLEXION EXTENSION ABDUCTION ADDUCTION
RIGHT
SHOULDER
JOINT (0)
BT 60 30 30 35
AT 80 50 40 50
JOINT INTERNAL
ROTATION
EXTERNAL
ROTATION
RIGHT
SHOULDER JOINT
BT 20 20
AT 30 40
7/31/2016
47

47. DISCHARGE MEDICATION
ON 23 JULY 2016
 Cap. Flexofen MR 1-0-1 (A/F)
 Cap. Cervilon 1-0-1 (A/F)
 Ksheerbala 101 2-2-2 drops each nostrils
 Shirupichu with kalyanaka ghrita
 Kalyanaka Ghrita 2tsp-0-0 after food with milk
 Kolakulathadi churna-200gm + karpasthayadi taila + hot water in greeva lepa
Review after 2 month

48. DISCUSSION

49. CHIKITSA SUTRA
अिब हौ हहतां नथयां थनेहश्चोत्तरभस्ततकुः
(A.H.CHI.15/44)

50. SNEHANA

51. CHIKITSA
 BRUMHANA NASYA
 BRUMHANA SNEHAPANA

52. CONCEPT OF BRIHMANANGA
SHEHAPANA
 ब्रुंहणो रस मध्याध्यै: स भक्तोऽल्पोऽस्योहहत: स च।
(अ.ह्रर.सू.१६/२०)

53. sss
NASYA

54. BRIHMANA NASYA
 Its is a type of navana nasya in which medicated oil or ghee is used.
 Its also called Sneha nasya
 Nasya karma is one of the major Brimhana and Shodhana Modality
specially indicated for vitiated dosha and the diseases situated in
jatru urdhwa pradesha, as nasa is told as dwara for shiras which is a
uttamanga and considered as moola of human body.
 As the word sneha sugests, snehana nasya gives strength to all the
dhatu and is used as dhatuposhaka.

55. BENEFITS OF NASYA
तत्र यः स्नेहनार्थं शूधयशशरसां ग्रीि थकदधोरस ां च
बलजनन िं दृन्ष्िप्रसादजननार्थं वा स्नेहो वविीयते
(Su.chi.40/22)

56. WHY TO USE BRUMHANA NASYA AND
SNEHAPANA IN APABAHUKA
 Apabahuka is a disease caused by kupita vata dosha, localizing around the
amsa pradesha causing the shoshana of amsa sandhi.
 There by leading to akunchana of sira at that site and giving rise to
bahupraspandaharatwam which means restricted movement of bahu.
 Vyanavata and siras are responsible for all types of motor functions namely
prasarana, aakunchana, vinamana.
 The kapha present as lubricating material within the sandhi aids in the
movements such as prasarana, aakunchana etc.
 Shoshana of kapha or kshaya in the quantity of kapha leads to impaired range
of movements.
 In Apabahuka Vatahara and Brimhana Dravyas are useful in the form of Nasya
and Snehapana. As aushadha kala of Vyana and Udanavata is adhobhakta,
Uttarabhaktika Snehapana is useful.

57. SWEDANA

58. Sweda
RUKSHA SWEDA IN
SAMAVASTHA. EG:-
PARISHEKA
SNIGDHA RUKSHA
SWEDA IN NIRAM
AVASTH. EG :-
PATRA PINDA
SWEDA
SNIGDHA SWEDA IF
PRAVRUDDHA AND
DHATU KSHAYA. EG:-
SHASTIKA SHAALI
PINDA SWEDA
WHICH SWEDA……?

59. RUKSHA SWEDA
 Administered in स म िथि of the disease
 Valuka sweda
 Choorna Pinda Sweda
 Pariseka Sweda / Drava sweda
 Upanaha Sweda(Ruksha)

60. SNIGDHA SWEDA
Administered in ननर मिथि of the disease
Jambeera pinda sweda
Shastika shaali pinda sweda
Arka patra sweda

61. ARKA PATRA SWEDA

62. PHYSICAL EXERCISE
Specific exercises will help restore motion.
These may be under the supervision of a physical therapist
or via a home program.
Therapy includes stretching or range of motion exercises
for the shoulder.
Sometimes heat is used to help loosen the shoulder up
before the stretching exercises

63. EXTERNAL ROTATION — PASSIVE
STRETCH.
 Stand in a doorway and bend
your affected arm 90 degrees
to reach the doorjamb. Keep
your hand in place and rotate
your body as shown in the
illustration. Hold for 30
seconds. Relax and repeat.

64. FORWARD FLEXION — SUPINE
POSITION
 Lie on your back with your
legs straight. Use your
unaffected arm to lift your
affected arm overhead until
you feel a gentle stretch. Hold
for 15 seconds and slowly
lower to start position. Relax
and repeat

65. CROSS OVER ARM STRETCH.
 Gently pull one arm across
your chest just below your
chin as far as possible without
causing pain. Hold for 30
seconds. Relax and repeat

66. CONCLUSION

67.  Avabahuka is one of the most common problems which effect mostly in
middle age group of patients
 Bharavahana, atiyana, rooksha, alpa ahara and vegadharana, ativyayama
are the most common causes for the manifestation of disease Apabahuka.
 Vyana vayu prakopa is the prime pathology of Apabahuka. This can
happen either due to dhatuksaya or kapha avarana (vata dosha encircled
with kapha).
 Brumhana Nasya and Uttarabhaktika Snehapana can be practiced safely .
Nasyakarma and Uttarabhaktika Snehapana are effective in eliminating
vyadhi.

68. विक रन म कु शलो न स्जह्रीय त् कि चन
न हह सिवविक र ण ां न मतोऽस्थत ध्रुि स्थिनतुः
स एि कु वपतो िोषुः समुत्ि नविशेषतुः
थि न दतरगतश्चैि जनयत्य मय न् बहून्
तथम द्विक रप्रकृ तीरधधष्ठ न दतर णण च|
समुत्ि नविशेष ांश्च बुद््ि कमव सम चरेत्
यो ह्येतस्त्त्रतयां ज्ञ त्ि कम वण्य रभते सभषक्
ज्ञ नपूिं यि दय यां स कमवसु न मुह्यनत
(CHA.SU.18/47)
 If a physician not able to name a disease, he should not feel ashamed because it
is not always possible to name (sarvaikara ) all type of disease in difinite terms.
 When dosha is aggravated,it may cause manifold disease depending upon
(samutthana )various etiological factors and sthana site of its manifestation.
.

69.  Hence the physician should start treatment after considering
vikarprakruti intimate cause for disaese location and etiological
factors.
 The physician who follows the above mentioned factors after
having the knowladge for the therapeutic properties will never fail in
his his attempt to cure the disease

70. Thank you