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CASE PRESENTATION ON APABAHUKA (FROZEN SHOULDER)

PANCHAKARMA TREATMENT OF APABAHUKA

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CASE PRESENTATION ON APABAHUKA (FROZEN SHOULDER)

  1. 1. CASE PRESENTATION PRESENTER BY DR. KAUSHAL SINHA PG SCHOLAR DEPARTMENT OF PANCHAKARMA SDM COLLEGE OF AYURVEDA AND HOSPITAL HASSAN
  2. 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. 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. 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. 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. 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. 7. FAMILY HISTORY No relevant family history contributing to the current condition of the patient. All members are said to be healthy.
  8. 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. 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. 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. 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. 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. 13. HIGHER MENTALACTIVITIES Consciousness Well conscious Orientation Well oriented to Person, place, time Memory Intact Speech Normal
  14. 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. 15. FOCUSED EXAMINATION OF RIGHT SHOULDER GATI (RANGE OF MOVEMENTS) : Shoulder joint - Flexion Extension Painful and restricted Abduction Adduction Internal rotation External rotation
  16. 16. INSPECTION  Swelling - Absent  Redness – Absent  Deformities – Absent PALPATION.  Tenderness – Present at Right scapular region  Temperature – Present at Right shoulder & elbow joint
  17. 17. SPECIAL MANEUVERS TO FIND LESION IN CERVICAL REGION:-  SPURLING TEST - POSITIVE ( RIGHT SIDE)  COMPRESSION TEST - POSITIVE ( RIGHT SIDE)
  18. 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. 19. APPLEY’S SCRATCH TEST
  20. 20. ARM DROP SIGN
  21. 21. EMPTY CAN TEST
  22. 22. INVESTIGATION  HB-12.2GM%  Total W.B.C count - 14500 cells/ cmm  E.S.R-18 mm/hour
  23. 23. OSTEOPHYTIC CHANGES
  24. 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. 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. 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. 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. 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. 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. 30. DIFFERENTIAL DIAGNOSIS
  31. 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. 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. 33. DIAGNOSIS APABAHUKA {FROZEN SHOULDER}
  34. 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. 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. 36. LAKSHANA’S  Apa means Vikruthi or Viyoga (Dysfuntion)  Bahupratispanditahara (limitations of ROM)  Sira Akunchana  Stambha (stiffness)
  37. 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. 38. TREATMENT PLAN
  39. 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. 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. 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. 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. 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. 44. RESULT
  45. 45. LAB INVESTIGATION
  46. 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. 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. 48. DISCUSSION
  49. 49. CHIKITSA SUTRA अिब हौ हहतां नथयां थनेहश्चोत्तरभस्ततकुः (A.H.CHI.15/44)
  50. 50. SNEHANA
  51. 51. CHIKITSA  BRUMHANA NASYA  BRUMHANA SNEHAPANA
  52. 52. CONCEPT OF BRIHMANANGA SHEHAPANA  ब्रुंहणो रस मध्याध्यै: स भक्तोऽल्पोऽस्योहहत: स च। (अ.ह्रर.सू.१६/२०)
  53. 53. sss NASYA
  54. 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. 55. BENEFITS OF NASYA तत्र यः स्नेहनार्थं शूधयशशरसां ग्रीि थकदधोरस ां च बलजनन िं दृन्ष्िप्रसादजननार्थं वा स्नेहो वविीयते (Su.chi.40/22)
  56. 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. 57. SWEDANA
  58. 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. 59. RUKSHA SWEDA  Administered in स म िथि of the disease  Valuka sweda  Choorna Pinda Sweda  Pariseka Sweda / Drava sweda  Upanaha Sweda(Ruksha)
  60. 60. SNIGDHA SWEDA Administered in ननर मिथि of the disease Jambeera pinda sweda Shastika shaali pinda sweda Arka patra sweda
  61. 61. ARKA PATRA SWEDA
  62. 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. 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. 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. 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. 66. CONCLUSION
  67. 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. 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. 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. 70. Thank you
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PANCHAKARMA TREATMENT OF APABAHUKA

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