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Table of Contents
ORIGINAL ARTICLES
Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 146-150

Evaluation of efficacy of Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita in lumbar disc degeneration induced Gridhrasi (sciatica): A clinical study


1 Department of Panchakarma, All India Institute of Ayurveda, New Delhi, India
2 Department of Kaumarabhritya, Rajasthan Ayurveda University, Jodhpur, Rajasthan, India

Date of Submission30-Oct-2019
Date of Decision14-Nov-2019
Date of Acceptance28-Nov-2019
Date of Web Publication24-Jan-2020

Correspondence Address:
Dr. Jitender Kumar
Department of Panchakarma, All India Institute of Ayurveda, Gautampuri, Sarita Vihar, New Delhi 110076.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_49_19

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  Abstract 

Context: Gridhrasi has been mentioned under the spectrum of Vatavyadhi in Ayurveda texts. The clinical presentation in Gridhrasi is very similar to sciatica. Lumbar disc degeneration is one of the common causes of sciatica. Aim: This clinical study was carried out to judge the effectiveness of Brimhana Ksheera Basti (medicated enema) with Guggulu Tiktaka Ghrita in lumbar disc degeneration induced Gridhrasi (sciatica). Settings and Design: This was an open-labeled single arm interventional clinical study. Materials and Methods: Fifteen diagnosed cases of lumbar disc degeneration induced sciatica were registered from the outpatient and inpatient departments of All India Institute of Ayurveda, New Delhi, India, and Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita was administered followed by oral administration of Ashwagandha and Shatavari Choorna. Statistical Analysis: The data were statistically analyzed using paired t test. Results: Highly significant (P < 0.001) result was found in all the assessment parameters, namely pain, stiffness, and straight leg raise. Conclusion: Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita followed by oral administration of Ashwagandha and Shatavari Choorna is an effective treatment method for reliable and successful management of Gridhrasi (sciatica) induced by lumbar disc degeneration.

Keywords: Gridhrasi, Guggulu, lumbar disc degeneration, sciatica


How to cite this article:
Kumar J, Bhatted SK, Dharmarajan P, Kumar A. Evaluation of efficacy of Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita in lumbar disc degeneration induced Gridhrasi (sciatica): A clinical study. J Indian Sys Medicine 2019;7:146-50

How to cite this URL:
Kumar J, Bhatted SK, Dharmarajan P, Kumar A. Evaluation of efficacy of Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita in lumbar disc degeneration induced Gridhrasi (sciatica): A clinical study. J Indian Sys Medicine [serial online] 2019 [cited 2020 Sep 26];7:146-50. Available from: http://www.joinsysmed.com/text.asp?2019/7/3/146/276734




  Key message: Top


There are some cases that do not want to go for contemporary treatment or want to be advised with some expensive treatment. In these cases and also for regular cases, Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita can be a good solution for the management of cases of Gridhrasi (sciatica) induced by lumbar disc degeneration.


  Introduction Top


Intense pain radiating from the gluteal region down the posterolateral leg to the foot more or less following the distribution of the sciatic nerve is known as sciatica, which is commonly caused by nerve root compression or irritation. This has been found that sciatica occurs in 1%–10% of the population, most commonly in the age-group of 25–45 years. Several low back conditions can cause sciatica, lumbar disc degeneration is one of them. Prevalence of disc-related sciatica in the general population is estimated as 2.2% annually.[1] In Ayurveda, sciatica can be correlated with Gridhrasi because of similarity in their clinical presentation. The common symptoms of Gridhrasi are Ruk (pain) that starts from Sphik (buttock) and then radiates to Kati (lower back), Prishtha (back), Uru (thigh), Janu (knee), Jangha (calf) and Pada (foot) along with Stambha (stiffness), Toda (pricking pain), and Spandana (twitching), and if the ailment is caused by aggravated Vata and if associated with Kapha then the patient has Tandra (drowsiness), Gaurava (heaviness), and Aruchi (anorexia) also.[2] The intervertebral discs lie between adjacent vertebrae. They are made up of fibrocartilaginous tissue and form a fibrocartilaginous joint between each vertebrae. Intervertebral disc can be correlated to Tarunasthi mentioned in Ayurveda texts. This indicates the involvement of (bones and joints)in the causation of Gridhrasi along with Vata Dosha. In Ayurveda, Tikta Dravya Siddha Ksheera, Ghrita is advised to administer as Basti (rectal administration) in Asthi Vikara. Guggulu Tiktaka Ghrita chiefly contains Tikta Rasa Dravya and has been mentioned especially in Asthi-Sandhigata Vata Vikara. So an attempt was made to evaluate the effectiveness of Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita followed by oral administration of Ashwagandha and Shatavari Choorna in lumbar disc degeneration–induced Gridhrasi (sciatica).


  Materials and methods Top


A total of 15 patients were registered for the study from the outpatient and inpatient department of All India Institute of Ayurveda, New Delhi, India, who were diagnosed with lumbosacral disc degeneration–induced sciatica. The study was approved by the institutional ethics committee (vide letter no. IECAIIA/2017/PG-21 dated August 12, 2017) and registered under CTRI (Clinical Trials Registry, India) and the registration number of the trial was CTRI/2017/11/010659. Informed consent was obtained from the patients before starting the intervention.

Inclusion Criteria

  • Age-group 25–65 years of either gender


  • Clinical presentation of Gridhrasi


  • Positive straight leg raise (SLR) test


  • Chronicity of disease <5 years


  • Diagnosed cases of lumbar disc degenerative disease


  • Exclusion Criteria

  • Any traumatic conditions of spine and hip


  • Rheumatoid arthritis and gout


  • Pregnancy and lactation


  • Other systemic disorders


  • Contraindications for Basti


  • Diagnostic Criteria

  • Clinical examination


  • Low back pain radiating to foot


  • Positive SLR test


  • Positive Bragard’s sign


  • Radiological evidences, namely MRI/X-ray of lumbar spine to assess the degenerative changes in the lumbar spine


  • Investigations

    Following investigations were carried out before starting the treatment to exclude any other pathology related to the exclusion criteria.

  • Hemoglobin


  • Total leukocyte count


  • Differential leukocyte count


  • Erythrocyte sedimentation rate


  • Routine urine examination


  • Treatment

    The treatment is described in [Table 1].
    Table 1: Drug and dose schedule of treatment

    Click here to view


    Study Duration

    The study lasted 45 days followed by 15 days of follow-up period.

    Methods

    Poorva karma

  • Preparation of Ksheera Basti: First, Madhu (honey) was taken in which Saindhava Lavana (rock salt) was added and triturated thoroughly with the help of a wooden churner, then Guggulu Tiktaka Ghrita was warmed and added slowly. Once the ghee was mixed, proportionately Kalka made of Shatapushpa Choorna (along with warm water) was added and mixture was again triturated thoroughly. In the next step, plain Ksheera (milk) was made lukewarm and added. All the ingredients were thoroughly mixed, and a colloidal solution was prepared.


  • Preparation of patients: The patients were advised to be empty stomach, after confirming digestion of previously taken food and before developing hunger, they were given Sarvanga Abhyanga with lukewarm Tila Taila, followed by Vashpa Svedana with Dashamoola Kwatha.


  • Pradhana karma

    The patients were asked to lie on the Droni in Vama Parshwa (left lateral position with right leg flexed). After lubricating the anal ridge and tip of rubber catheter, one-fourth of the catheter was inserted into the anal canal and lukewarm Basti Dravya was administered slowly with the help of enema can. Enema can was held high to prevent any obstruction. Catheter was removed with little Basti Dravya remaining in the rubber tube of enema can. Extreme care was taken to avoid the Basti Vyapada.

    Pashchata karma

    The patients were asked to lie in supine position and to defecate on developing urge. After evacuation of Basti, they were advised to take hot water bath and light meal.

    Rasayana dravya

    After the completion of Basti Karma, Ashwagandha Choorna and Shatavari Choorna were given in the dose of 3g twice a day, before food, with warm milk for 15 days.

    Assessment Criteria

    The assessment parameters used in the study are present in [Table 2].
    Table 2: Assessment parameters

    Click here to view


    Assessment of Effect of Therapy

    Assessment was carried out two times, one before the treatment and second after the end of follow-up period. Percentage improvement in each parameter was assessed using the following formula:

    [INLINE 1]

    BT = before treatment; AT = After treatment


      Observations Top


    The maximum number of patients were females (73.33%), having chronicity between 4 and 5 years (46.66%), patients were having bilateral sciatica (73.33%), involvement of L5-S1 area (73.33%), having pain as chief complaint (100%) followed by stiffness (40%), pain aggravated by standing (40.0%), Hindu (80.0%), married (86.66%), uneducated (26.66%), middle-class category socioeconomic status (60.0%), housewives (66.66%), vegetarian (53.33%), having Asamyaka Nidra (disturbed sleep) (60.00%), Krura Koshtha (53.33%), and Vishama Agni (53.3%).

    The maximum patients were of Vata-Pittaja Prakruti (66.66%), Madhyama Sara (60.00%), Avara Samhanana (40.00%), normal and overweight as per body mass index (46.66% each), Pravara Satmya (60.00%), Pravara Satva (53.33%), Madhyama and Pravara Jarana Shakti (40.00% each), Madhyama Abhyavarana Shakti (46.66%), and age between 25 and 34 years (40.0%).


      Results Top


    The results obtained were highly significant (P < 0.0001) with percentage relief obtained was 55.17% improvement in pain (Ruk), 70.86% improvement in stiffness (Stambha), 100% improvement in fasciculation (Spandana), 68.06% improvement in lumbar spine mobility, and 54.71% improvement in SLR test with 44.44% improvement in low back outcome score (LBOS) and 66.29% improvement in maine–seattle back questionnaire (MSBQ) [Table 3].
    Table 3: Effect of therapy on all assessment parameters

    Click here to view



      Discussion Top


    Discussion on Disease

    Sciatica has been a well-known condition in today’s life. It is the pain that radiates from the buttock downward along the course of the sciatic nerve associated with symptoms such as tingling sensation and numbness. Although sciatica has several causes, compression of lumbosacral nerve root caused by degeneration of intervertebral discs in the lumbosacral spine is the principal cause. For degenerative conditions of the lumbar, spine magnetic resonance imaging (MRI) is the final verdict after a trial of conservative treatment. It also helps in differential diagnosis. Pfirmann et al.[6] introduced MR classification of intervertebral disc degeneration, dividing them into five grades as per height and signal intensity. On the basis of the clinical findings, sciatica is similar to Gridhrasi mentioned in the Ayurvedic texts. There is involvement of Vata Dosha and Asthi-Majja Vaha Srotas in Gridhrasi.

    Discussion on Procedure

    In Chakradutta, Bhavaprakasha, and Vangasena Samhita, Shodhana was advised before administration of Basti. Before doing any Shodhana, Deepana-Pachana has to be carried out. Deepana-Pachana increases the Agni and transforms the morbid Doshas from unformed state to formed state so that they can be mobilized and removed by Shodhana. Mridu Samshodhana has also been mentioned in the line of treatment of Vata by Acharya Charaka. So after performing Deepana–Pachana, Koshtha Shuddhi was carried out for the purpose of Mridu Samshodhana followed by Basti administration.

    When Vata gets exceedingly aggravated there is no remedy other than Basti for its alleviation. It is a well-known fact that rectum has rich blood and lymph supply. So drugs can cross the rectal mucosa like other lipid membrane. In Basti Karma, a homogenous emulsion of honey, Saindhava (rock salt), Sneha Dravya (medicated oil or ghee), Kalka (paste of herbal drugs), and decoction blended in remarkable combination after proper churning (break the large- and middle-chain fatty acid to small-chain fatty acids) is administered, which encourages absorption better then a single drug per rectum. Basti may produce neuromuscular remodeling, pain modulation by influencing enteric nervous system and thereby central nervous system. Tikta Dravya Siddha Ksheera, Ghrita Basti is especially advised in Asthi Vikara by Acharya Charaka. The Basti that has Ksheera or milk as the main ingredient is known as Ksheera Basti. Ksheera Basti contains hypoosmotic solution, which results in the nourishment of Sapta Dhatu after absorption in the blood.

    Discussion on Drug

    Guggulu Tiktaka Ghrita contains predominantly Tikta Rasa and Ushna Virya drugs. Being composed of Akasha and Vayu Mahabhuta, Tikta Rasa helps in the preservation of the normal health of Asthi Dhatu. It also increases the Dhatvagni (metabolic stage), which in turn helps in proper nutrition of all the Dhatus. Owing to the Snigdha and Ushna Guna, Guggulu Tiktaka Ghrita helps in the pacification of aggravated Vata. Pharmacologically, Guggulu has anti-inflammatory, immunomodulatory, and anti-lipidemic properties. In short, Asthi Dhatu and Majja Dhatu may get proper nourishment due to Ksheera Basti with Guggulu Tiktaka Ghrita. To maintain the optimum quantity and quality of Dhatu, Rasayana Dravyas (such as Ashwagandha and Shatavari) were administered. Ashwagandha is having Tikta, Katu and Madhura Rasa, Balya, and Brimhaniya nature, indicated in Kshaya. Withaferin A and withanolide D are two main withanolides that are responsible for much of the pharmacological activity of Ashwagandha. Ashwagandha also has anti-inflammatory and antioxidant effect.[7]Shatavari has Tikta and Madhura Rasa. It is Balya by nature. Anti-inflammatory activity may be attributed to flavonoids and polyphenols.[8]


      Conclusion Top


    Sciatica, which is well explained in modern medicine, can be well equated with disease Gridhrasi described in Ayurveda classics based on the clinical manifestation. Lumbar disc degeneration–induced sciatica is one of the common presentations seen nowadays. Statistically significant improvement was noticed among all the assessment parameters by using Guggulu Tiktaka Ghrita as Brimhana Ksheera Basti followed by oral administration of Ashwagandha Choorna and Shatavari Choorna. From the outcomes, which we had got in the aforementioned clinical trial, we can conclude that it was not wrong to mention that Brimhana Ksheera Basti with Guggulu Tiktaka Ghrita may be a sensible choice of treatment for the management of lumbar disc degeneration–induced .

    Financial support and sponsorship

    This study was supported by the Ministry of Ayush, All India Institute of Ayurveda, New Delhi, India.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Younes M, Béjia I, Aguir Z, Letaief M, Hassen-Zrour S, Touzi M, et al. Prevalence and risk factors of disk-related sciatica in an urban population in Tunisia. Joint Bone Spine 2006;73:538-42.  Back to cited text no. 1
        
    2.
    Trikamji Y, editor. Chikitsasthana; chapter 28, verse no. 56. In: Charakasamhita of Agnivesha with Commentary of Chakrapanidatta. Varanasi, India: Chaukhamba Surbharati Prakashan; 2016. p. 619.  Back to cited text no. 2
        
    3.
    Harishastri P, editor. Chikitsa sthana; chapter 21, verse no. 57. In: Ashtanga Hridayam of Vagbhatta. Reprint edition. Varanasi, India: Chowkhambha Surbharati Prakashan; 2017. p. 726.  Back to cited text no. 3
        
    4.
    Greenough CG, Fraser RD. Assessment of outcome in patients with low-back pain. Spine (Phila Pa 1976) 1992;17:36-41.  Back to cited text no. 4
        
    5.
    Atlas SJ, Deyo RA, van den Ancker M, Singer DE, Keller RB, Patrick DL. The Maine-Seattle Back Questionnaire: A 12-item disability questionnaire for evaluating patients with lumbar sciatica or stenosis: Results of a derivation and validation cohort analysis. Spine (Phila Pa 1976) 2003;28:1869-76.  Back to cited text no. 5
        
    6.
    Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976) 2001;26:1873-8.  Back to cited text no. 6
        
    7.
    Bulusu S, commentator. Guduchyadi varga, 6, verse no. 190. In: Bhavaprakasha of Bhavamishra. Vol. 1. Reprint edition. Varanasi, India: Chaukhamba Orientalia; 2015. p. 278.  Back to cited text no. 7
        
    8.
    Singh A, Sinha B. Pharmacological significance of Shatavari: The queen of herbs. Int J Phytomed 2014;6:477-88.  Back to cited text no. 8
        



     
     
        Tables

      [Table 1], [Table 2], [Table 3]



     

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