INTEGRATIVE APPROACH TO THE MANAGEMENT OF DIABETIC
NEUROPATHY USING MARMA CHIKITSAAND PANCHAKARMATHERAPIES
V S Charantimath1*, BharadwajT2, Sreyas Naik3, A V
Srinivasan4*
1Dean, Dept of Dravyaguna, 2Assistant Professor,
Department of Panchakarma, 3Internee, 4Chairman, Sri Paripoorna Sanathana
Ayurveda Medical College Hospital & Research Centre, Bangalore Rural,
Karnataka, India.
KEYWORDS:Diabetic neuropathy, Ayurveda, Marma
Chikitsa, Toronto Clinical Neuropathy Score.
ABSTRACT:
The National Centre
for Disease Control
(NCDC) has reported
that India has
6.51 crore Diabetes cases,
with projections reaching
10.9 crore by
2035. Diabetic neuropathy
is a prevalent complication
of long-standing Type
1 and Type
2 Diabetes mellitus,
affecting approximately 10.5% to 44.9% of individuals. With Diabetes
emerging as a global epidemic in both
developed and developing
nations, effective management
of its complications
is the need of the hour. Diabetic
neuropathy manifests as nerve damage, leading to symptoms such as hyperesthesia, paraesthesia,
pain, and sensory
loss. Despite advancements
in glycaemic control strategies,
conventional treatment remains
inadequate in addressing
neuropathic symptoms comprehensively. To
bridge this gap, a holistic
approach integrating
MarmaChikitsawith Panchakarma therapies was implemented at our centre, for the
management of Diabetic Neuropathy where-in
5 patients presented
with symptoms of
Diabetic neuropathy. This
integrative intervention yielded significant improvements, demonstrating the
efficacy of MarmaChikitsain
conjunction with Panchakarma therapies. Notably,
patients experienced faster and more effective
relief, as validated
by the Modified
Toronto Clinical Neuropathy Score (TCNS) assessment. These
findings highlight the potential of Ayurveda-based therapies in enhancing
neuropathic symptom management and underscore the necessity of adopting a
holistic framework for Diabetic care.
INTRODUCTION
The
National Centre for
Disease Control (NCDC) has
reported that India has 6.51 crore Diabetes cases, with
projections reaching 10.9
crore by 2035[1]. Diabetic neuropathy
is a significant
complication of Diabetes mellitus
(DM), affecting approximately
50% of individuals with
long-standing type 1 and type 2
Diabetes[2]. With Diabetes
now recognized as
a global epidemic, its
prevalence is rising
in both developed and developing nations. India reports
a notably higher prevalence of DM
(4.3%) compared to
Western countries
(1–2%)[3], accompanied by
an elevated complication rate.
In 2019, an
estimated 77 million individuals were diagnosed with
Diabetes.
However,
recent insights from
the Indian Council of
Medical Research (ICMR)
indicate a substantial
increase, with 101 million people currently living with
Diabetes and approximately
136 million in a
pre-Diabetic state. Alarmingly, 43.9
million[4]individuals
remain undiagnosed, emphasizing the urgent need
for intensive screening
and timely intervention.
Diabetic
neuropathy manifests as
nerve damage, leading to symptoms
such as hyperesthesia, paraesthesia, pain, and
sensory loss. Despite advancements in glycaemic control strategies,
conventional treatment remains inadequate in addressing neuropathic
symptoms comprehensively[5]. Diabetic
neuropathy is directly
associated with
hyperglycaemia, with its
presence, duration, and severity determining
the extent of
nerve damage[6]. Persistently
high blood glucose levels can impair nerve fibres throughout
the body, primarily
affecting the lower extremities,
particularly the legs
and feet. This condition manifests as Polyneuropathy,
Mono-Case Study neuropathy, Autonomic Neuropathy, Proximal Neuropathy, Focal
Neuropathy, And Numb Neuropathy,
each with distinct
clinical features. Common symptoms
include pain, numbness,
altered sensation, hypersensitivity, tingling, burning discomfort, and
progressive sensory deficits.
As the disease advances, pain
may diminish, leaving persistent sensory impairment in
the lower limbs.
Diabetic
neuropathy can also
contribute to muscle weakness,
gait disturbances, hammertoe deformities, and midfoot
collapse, increasing susceptibility to unnoticed injuries. Without appropriate management,
infection may spread
to the bone, necessitating limb
amputation[7]. Therefore,
routine sensory examinations
and foot care
education are crucial for
neuropathic patients to
mitigate complications.
Moreover,
autonomic neuropathy presents multisystem challenges, including
orthostatic hypotension, delayed gastric
emptying, nausea, odynophagia,
and sexual dysfunction, while paradoxically
inducing hypoglycaemia unawareness[8], complicating efforts
to achieve optimal
glycaemic control. Despite advancements
in glycaemic control strategies, conventional treatment
remains inadequate in addressing neuropathic symptoms
comprehensively.[3]Given these complexities, an integrative approach
encompassing both conventional
and holistic interventions is essential in Diabetic care.
Diabetes and Prameha: Diabetes can
beviewed under the
Ayurvedic descriptions of
Prameha, Prameha, one among
the Astamahagadas[9](eight dreadful disorders) in Ayurveda, is
extensively discussed by Acharyas.
It is described as a
Kulaja Vikara(hereditary disease),
exhibiting Apatyasamkramatva(transmission to offspring) and Anusangi(chronic and
recurring nature). The pathogenesis of Pramehafollows a Tridosharabhadatvapattern, with
all three doshasinvolved in
its progression. Over
time, it becomes KalantarenaAsadhya[10](incurable at
advanced stages).
The
condition leads to Dhatu
Shaitilya(tissue laxity),
particularly affecting Medo Dhatu,
due to an increase
in Bahu Drava Kapha,
which results in Dusya Kleda Mutra
Utpatti[11](formation of morbid
elements in urine). Ayurvedicliterature categorizes Pramehabased on therapeutic
approaches, distinguishing Sthula Balavan
Pramehi(obese and strong
Diabetic patients) and
Krusha Durbala Pramehi(lean
and weak Diabetic patients). The
treatment protocol varies
accordingly, emphasizing Samshodhana(purification therapies)
for the former and Shamana[12](palliative therapies)
for the latter.
Diabetic
Neuropathy (DN) is
considered as an Upadrava(complication) of Madhumeha,
necessitating analysis through
Vikara Prakriti(disease nature), Samuthana Vishesha(etiological specificity), and Adhisthana(primary pathological site).
The neuropathic manifestation in
Diabetes aligns with
its parent disease in
terms of pathology, exhibiting Dhatukshaya(tissue depletion)
in certain cases
and Avarana(obstructive
pathology) in others.
The management of DN,
therefore, requires a
tailored Ayurvedic approach, integrating therapies based on its underlying
pathophysiology.
Marma chikitsa: Marma philosophy is
one such imperative
and unique principle of Ayurveda.
In Ayurvedicsamhitas, science of
Marmawas limited to
the war science
and Marma points were mainly
considered as only
fatal points i.e., trauma
to them leads
to debility or
even death as these
are seat of Prana(life
energy), but in present
era, stimulation of
these Marmaby means of Abhyanga(massage), Mardana(Acupressure),
Aromatherapy, Pranichealing, Herbs (Lepa),Raktamokshana(bloodletting) and Agni
karma(heat application) is utilised
to treat certain
conditions. Marmachikitsa, a
therapy practiced by
few practitioners to
stimulate these Marmapoints
directly by applying
pressure, vibrating tendons, pinching
or application of
hot and cold pastes, oils and
ointment on Marmadepending on the type of Marmahad
emerged as new
dimension in
non-pharmacological treatment of Ayurveda.The concept of Marmahas its
root in Vedasand from Vedic era to till date, it is still surviving due to its
importance for human life.
Ayurveda considers that
there are 107 Marma
points[13]in the body
that must be
protected. Marmascience was basically
considered as war science
in which the
knowledge of Marmaswas very crucial
because the protection
of these parts
of the body is mandatory for
survival. These body regions are considered as the seat of Prana (life energy).
OBJECTIVES: As
prevalence of Diabetic
Neuropathy is increasing necessitating
holistic approach in treatment we
tried evaluating the
clinical efficacy of Marmachikitsa–an unexplored area
with conditional Treatment as
Usual (TAU).Materials and Methods. This
study presents a
case series of
five in-patients diagnosed
with Diabetic Neuropathy,
treated at Sri Paripoorna Sanathana Ayurveda Medical College,
Hospital & Research
Centre. Patients were
selected randomly after assessing
fitness for Marma Chikitsaand Panchakarmatherapies, and
analyzed for overall treatment outcomes.
A cross-sectional analysis
was conducted by reviewing
all sections of
patient case sheets, systematically tabulating
observations and comparing them
with standardized assessment
scales used during evaluation. The
case series included
four male and
one female patient, aged
between 40–65 years.
Sampling was based on
disease presentation, with
symptom patterns carefully documented and
analyzed to determine specific
etiological correlations. Treatment
interventions, including Panchakarma
and Marma Chikitsa, were administered and
outcomes were assessed. The
results were critically
examined to evaluate the
mode of action
of these therapies
in alleviating Neuropathic symptoms.
This case series provides valuable insights into the
variability of Diabetic Neuropathy and underscores the therapeutic
potential of Marma Chikitsaand Panchakarmaas effective and
holistic interventions. The findings
highlight the efficacy
of these Ayurvedic approaches in
addressing Neuropathic complications, contributing to
the development of
integrated treatment protocols for Diabetes care.
The patients were subjected to Marmatherapy
consisting of activating
the Marma points along with Sarvanga
Marmamassage and a set of Panchakarmatherapies which
were apt for
the condition of
the patient with special
respect to doshaand avasthaof
condition. Marmatherapy consists of
activation of Marmasthat enhances
functioning of pancreas
and points on which
stimulating alleviates Diabetic Neuropathic pain. i.e., Hrudayam
Marma[16]/ Urumikalam Varma[17](four finger breadth superior to umbilicus in
the midline of the body), Nabhi marma.[18]Unthiverma[19]/ (points
lies in the
umbilicus), Amsamarma[20]/Puyaverma[21](point lies
at the superior end
of the shoulder
joint), Lohitakshamarma[22]/Kai
Puja poruthuvarmam[23],
Bahwimarma[24]/ Mundagavarmam[25](this
relieves pain of
neuropathy of upper extremities),
Puratharaivisainarambu-varmam[26](3
angula proximal to Manibandhamarma point
lies on lateral
epicondyle of humerus
helps in paresthesia and numbness),/ Kurparamarma[27]/
Kaimuttu Varma[28](point lies on the
olecranon fossa of
humerus, helps in
itching sensation numbness paresthesia), Ani marma[29]/
Naithalaivarmam[30](point located at
anterior tibial tuberosity,
helps in neuropathic pain),
Urvimarma[31]/
Amaivermam[32](point located at anterior midpoint of leg).
After Marma point
stimulation Sarvangamarmamassage
was being conducted
and patient were coupled with
therapies like Parisheka, shastikashali pindaswedana, Takradhara,
Pichu, Padabhyanga, Dhanyamladhara, Padavagaha, Siravyadhanaetc.
A Sign Test
was applied to
evaluate the directional change
in symptoms before
and after treatment. Statistically
significant improvement (p =
0.0312) was observed in foot pain, numbness, tingling, and weakness,
with all five
patients showing
symptomatic relief in
these domains. No
significant change was observed
in ataxia and
upper limb symptoms. This
results add statistical
validity to our clinical outcomes.
DISCUSSIONDiabetic
Neuropathy presents a
complex spectrum of clinical
manifestations that aid
in determining appropriate interventions. Diabetic Neuropathy is
understood in Ayurveda as Madhumehajanya
Vatavyadhi, manifests in
clinical patterns such as
pain, numbness, and
paresthesia, reflecting vitiation of Vataand Kaphadoshas. Recognizing the
specific type and
severity of neuropathic involvement
is essential for
determining appropriate
therapeutic interventions and
improving patient outcomes.
The pathology initiates
with an Avarana-janya(obstructive) condition, progressing through Srotorodha(channel
obstruction) and ultimately leading to Dhatu Kshaya(tissue degeneration). The
vitiation of Kapha, Pitta,
Medas, Rakta, andMamsainduces Avarana ofVata, resulting in
either Chestahani(loss of function)
or Vimarga Gamana of Vata[34](abnormal
movement), which clinically
manifests as motor and sensory dysfunction.
The presentation of symptoms varies according to
Anubandha(associated doshainvolvement), necessitating distinct therapeutic
approaches.•Kaphanubandha
Vata[35]often presents with
dull pain (Shoola), numbness
(Supti), and progressive muscle
wasting (Shosha).•Pittanubandha
Vata[36]is marked by
burning pain (Daha), sharp
pricking sensations (Toda),
and variable intensity of Shoola.The pins-and-needles sensation
can primarily be attributed to Vatadominance. The
treatment protocol for Diabetic
neuropathy follows a structuredapproach:1.Dosha-DushyaIdentification-Understanding
pathological involvement based on symptomatology.2.AgniCorrection-Since Diabetic
neuropathy presents with Bahu Dosha Avastha(multiple dosha involvement),
stabilizing metabolic fire is imperative.3.Dosha-Specifictreatment-Intervention
targeting the dominant vitiated dosha to restore
balance.4.DhatuRestoration-Rejuvenative therapies aimed at strengthening the
weakened tissues.Known that Prameha and its Upadrava (complications)
areAnusangi Vyadhi(chronic conditions with continuous affliction),
achieving Dosha-DhatuSamya(equilibrium) is
a prolonged process
requiring sustained
medical care. In
cases of Diabetic Neuropathy marked
by burning sensation
and associated symptoms,
Pittavruta Vata Chikitsashould be prioritized
following Dosha Shamana
measures. Therapies that enhance Bala(strength) must
be administered, alongside
Rakta prasadana Oushadhis(blood-purifying medications), Ojakshaya Chikitsa(therapy addressing
depleted Ojas),and Rasayana Prayoga(rejuvenation therapy)
tailored to patient needs.
This
integrative Ayurvedicapproach
offers a comprehensive and
structured intervention for Diabetic Neuropathy,
addressing both symptomatic relief and long-term tissue
restoration
Here is the
discussion about mode
of action of Ayurveda modalities.
Parisheka:
One such procedure
which has the advantage of
producing Snehanaand Swedanasimultaneously[37]. It is categorised under
Snigdhaswednaa orDravaswedana. It helps
enhancing local blood circulation, eases
stress and tension, reduces pain via continuous warm
liquid flow. [38]
Shastikashalipindaswedana: Though
it is a Swedanaprocedure it
has a Brimhana guna. It is
Tridoshaghna sheeta, Guru, Snigdha performed
as Ekanga or Sarvangawith the bolus
of Shali andBalamoola kwatha[39].
It also enhances
nerve conduction and
sensory-motor recovery, promotes
anti-inflammatory and pain relief
effects mitigating stiffness
and heaviness.[40]
Virechana:
Indicated in Kevala pitta
conditions along with
kaphanubandhapittaand Pittasthanagatakapha conditions[41]. Virechana helps as
aeustress inducing agent which
triggers neuro endocrine
responses. The neuro hormonal
modulation likely supports reductions in inflammation, blood pressure and
stress.[42]
Kala
Basti: According to
Acharya Kashyapa Kalabastiis
indicated in
Pittanubandhavata.[43]Tailaand Kashayaare
readily absorbed by
rectal mucosa as it
bypasses first pass
metabolism. It also
demonstrates analgesic and anti-inflammatory properties that decrease swelling and neuralgia.[44]
Raktamokshana: By Raktamokshanaall Raktajadisorders will
be cured from root. Hence Siravyadhais considered as Ardhachikitsain
Shalyatantra. Siravyadhaalso have robust
analgesic effect in
pain caused by Vata-kaphaconditions.[45]
where
vapours obtained by
boiling liquid in
a vessel through a pipe.
Continuous Bashpaswedanashows systemic
hemodynamic improvement and
autonomic regulation and supports nervous system balance.[46
Takradhara: Takra isMadhura andTeekshna
withSheetaveeryahence it alleviates Vataand burning pittamanifestation in neuropathy.[47]Along
with improvement in symptoms,
quality of life
also increases.
Padabhyanga: It
has an important
role in Diabetic peripheral neuropathy as
it pacifies Vata-pittaconditions. Massage
enhances the cutaneous
nerve activation which promotes
neuroplasticity, increased ankle
ROM leads to better plantar sensation.[48]
Sthanikapichu: Pichu soaked in Pitta vatahara kashayas
orTailascalms neuropathic pain.
Anti-inflammatory and analgesic effects are appreciated due to enhanced
microcirculation and transdermal absorption. [49
Dhanyamladhara: It
is a type
of Kayasekaincluded under Dravaswedanaone of the Sandhanakalpanaused specially in Kapha anubandhavatarogas. Dhanyais
Dahanashaka.[50]Dhanyamla
dharaenhances nerve
conduction and sensory
functions through improved neurovascular support.[51]
Marma therapy: Varma
kalaiis a way
of applying pressure to specific
vital points of the body. These vital points
are used for
self-defence and healing. Varma points are gateways to access
the body's inherent self-healing mechanism as Verma points relate to functions
of organs. They
regulate the flow
of vital energy, enzymes and
toxins. Marma therapy aligns the
three Doshas vaata pitta and
Kaphawhich are present
in these points in
their subtlest forms.
Probable mode of action
of Marmacan be analysed
under neuro endocrine system
influence and gate
control theory. Marmatherapy may stimulate the
release of
neurotransmitters and hormones
like endorphins, which can
alter pain perception and
promote relaxation. Pressure or
stimulation of specific Marma points, can
transmit signals to the brain,
influencing various bodily functions.
Marmatherapy might also work by influencing the "gate
control theory" of
pain, which proposes
that the brain can
modulate pain signals
by stimulating specific
Marmapoints; the theory
suggests that the brain
can alter its
interpretation of pain
sensations, potentially leading to pain reduction.
The
current intervention has
yielded clinically significant results
in all the
subjects based on
the assessment done before
and after treatment
on the subjective parameters of
Foot pain, Numbness, Tingling, weakness,
Ataxia and Upper
limb symptoms as per modified
Toronto Clinical Neuropathy Score.
With all these
modes of actions
discussed and the results
achieved it can
be concluded that Panchakarmatherapies coupled
with Marma chikitsaoffers apt
and adequate treatment
modality for Diabetic
Neuropathy.
CONCLUSION:
Diabetic
neuropathy occurs in
almost every third Diabetic.
Even though wide
range of drugs
are empirically used to control pain in Diabetic neuropathy these drugs
sometimes reduce the
presenting symptoms but cannot prevent a progression of disease Thus there
remains a need
for a therapy
which would also slow
down disease progression
and improve quality of
life. 52 Marwa
Chikitsa has demonstrated substantial efficacy
in the management
of Diabetic Neuropathy. The results
of this study
indicate both statistically and
clinically significant improvements
in Neuropathic symptoms following
intervention. These findings
underscore the therapeutic potential of Marna Chikitsa as
a viable integrative
approach, offering promising outcomes in enhancing
neurological function and overall
patient well-being. Further research is
warranted to expand
the scope of application and
optimize treatment protocols
within Ayurvedic clinical practice.
Conclusion and Scope for Further Study: This study
highlights the efficacy
of MarmaChikitsaand Panchakarmain
the management of Diabetic Neuropathy, demonstrating
significant clinical and
statistical improvements in
symptom relief While the
findings provide valuable
insights, the sample
size of five patients limits broader generalization.
To further validate
these results, large-scale studies employing
the same parameters
should be conducted,
incorporating a greater number of patients over a
longer duration. Comparative
analysis with standard pharmacological treatments would
help establish the relative efficacy and integration potential of Ayurvedic
interventions in Diabetic
care. These future studies
will contribute to
the refinement of holistic treatment
protocols, enhancing evidence-based Ayurvedic
practice for Diabetic
Neuropathy management
Declaration of patient consent: Authors certify that
they have obtained patient consent
form, where the patient
has given his
consent for reporting the case along with the images and other
clinical information in
the journal. The
patient understands that his
name and initials
will not be published
and due efforts
will be made
to conceal his identity, but anonymity cannot be guaranteed.
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