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== Vidhi Vimarsha (Applied Inferences) ==

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===Clinical administration of swedana===

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===Clinical administration of [[swedana]]===

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''Swedana'' should only be administered following a proper ''snehana'' (unless indicated otherwise). On application of unctuous substances like oil (''taila'') on various body parts, ''sweda'' forms an intervening viscous layer between the skin and the immediate environment prior to transdermal drug absorption. Thus the heat lost through sudation, along with large amounts of fluid and a marginal amount of Na+ and Cl- ions through radiation / conduction / convection / evaporation (which could potentially impair thermoregulation or cause hypothermia) does not happen too rapidly. Also, the procedure of ''swedana'' promotes the transdermal absorption of the ''sneha'' by inducing peripheral vasodilatation. However, environmental humidity and the duration of ''swedana'' procedure has to be strictly monitored, as exposure to small rise in temperature for a prolonged time can have a greater impact (more evaporation) than exposure to high temperature for a short time in a humid atmosphere<ref name="ref1">Cabanae, M., (2006), Journal of Applied Physiology, 100, Adjustable set point, 1338 – 1346.</ref>. Hence ''yathavath prayojithaihi'' has been written expressly to denote the optimal exposure to ''swedana''.

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''[[Swedana]]'' should only be administered following a proper ''[[snehana]]'' (unless indicated otherwise). On application of unctuous substances like oil (''taila'') on various body parts, ''sweda'' forms an intervening viscous layer between the skin and the immediate environment prior to transdermal drug absorption. Thus the heat lost through sudation, along with large amounts of fluid and a marginal amount of Na+ and Cl- ions through radiation / conduction / convection / evaporation (which could potentially impair thermoregulation or cause hypothermia) does not happen too rapidly. Also, the procedure of ''[[swedana]]'' promotes the transdermal absorption of the ''sneha'' by inducing peripheral vasodilatation. However, environmental humidity and the duration of ''[[swedana]]'' procedure has to be strictly monitored, as exposure to small rise in temperature for a prolonged time can have a greater impact (more evaporation) than exposure to high temperature for a short time in a humid atmosphere<ref name="ref1">Cabanae, M., (2006), Journal of Applied Physiology, 100, Adjustable set point, 1338 – 1346.</ref>. Hence ''yathavath prayojithaihi'' has been written expressly to denote the optimal exposure to ''swedana''.

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Proper application of ''snehana'' (''abhyanthara'' and ''bahya'') and ''swedana'' enhances gastro-intestinal motility. A study enumerates the instantaneous as well as prolonged benefits of continued ''swedana'', concluding that habitual use of ''swedana'' improves one’s heat tolerance capacity and physical endurance, while observing increased autonomic functions among patients due to intermittent purposeful heat stress.<ref>Sanjeev Rastogy & Francesco Chiappelli, (2013 April – June), AYU, 34(2): Heamodynamic effects of Sarvanga swedana (Ayurvedic passive heat therapy): a pilot observational study 154-159.</ref> There are numerous studies which claim that gastrointestinal motility disorders are caused due to decreased autonomic activity and its therapeutic increase, therefore helps cure motility disorders, thereby improving bowel-bladder functioning. [verse 3-5]

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Proper application of ''[[snehana]]'' (''abhyanthara'' and ''bahya'') and ''[[swedana]]'' enhances gastro-intestinal motility. A study enumerates the instantaneous as well as prolonged benefits of continued ''[[swedana]]'', concluding that habitual use of ''[[swedana]]'' improves one’s heat tolerance capacity and physical endurance, while observing increased autonomic functions among patients due to intermittent purposeful heat stress.<ref>Sanjeev Rastogy & Francesco Chiappelli, (2013 April – June), AYU, 34(2): Heamodynamic effects of Sarvanga swedana (Ayurvedic passive heat therapy): a pilot observational study 154-159.</ref> There are numerous studies which claim that gastrointestinal motility disorders are caused due to decreased autonomic activity and its therapeutic increase, therefore helps cure motility disorders, thereby improving bowel-bladder functioning. [verse 3-5]

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Environmental and age related factors also need to be considered for sudation. In extremely warm regions or during the peak of summer, there is remarkable body dehydration. And in an intensely humid climate or in an ill ventilated room where there is peripheral heat production from the body surface (and yet minimal evaporation), sudation has to be strictly monitored and precautionary procedures have to be well thought-out. Cold seasons are ideal for ''swedana'' procedures because body homeostasis favors or demands heat (evident from the behavioral response mechanisms adopted by each one of us in cold seasons). Among specific fomentation techniques, ''sarvangasweda'' is contraindicated in individuals at the extremes of age (i.e., infants and very elderly people) where there is ineffective thermoregulation, although ''ekanga'' and ''mridu sweda'' could be prescribed. [verse 6]

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Environmental and age related factors also need to be considered for sudation. In extremely warm regions or during the peak of summer, there is remarkable body dehydration. And in an intensely humid climate or in an ill ventilated room where there is peripheral heat production from the body surface (and yet minimal evaporation), sudation has to be strictly monitored and precautionary procedures have to be well thought-out. Cold seasons are ideal for ''[[swedana]]'' procedures because body homeostasis favors or demands heat (evident from the behavioral response mechanisms adopted by each one of us in cold seasons). Among specific fomentation techniques, ''sarvangasweda'' is contraindicated in individuals at the extremes of age (i.e., infants and very elderly people) where there is ineffective thermoregulation, although ''ekanga'' and ''mridu sweda'' could be prescribed. [verse 6]

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Health indicators such as serum electrolytes, blood urea, creatinine, mean acid base balance, serum and urine osmolarity, hemoglobin, hematocrit and vital signs should also be assessed before and after ''swedana''.

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Health indicators such as serum electrolytes, blood urea, creatinine, mean acid base balance, serum and urine osmolarity, hemoglobin, hematocrit and vital signs should also be assessed before and after ''[[swedana]]''.

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''Bala'' (physical fitness) of the individual has to be assessed through ''vyayama shakti'' (exercise capacity), which corresponds to the time taken for spending one’s ''ardha shakti'' (half strength). Based on the outcome of this assessment, ''pravara'' (maximum), ''avara'' (minimum) and ''madhyama'' (medium) ''bala'' have to be assessed. Based upon the results of these ''bala'' assessments, ''maha sweda'' (whole body sudation for an extended duration) and various minor/major ''sweda'' measures could be prescribed.

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''Bala'' (physical fitness) of the individual has to be assessed through ''[[vyayama]] shakti'' (exercise capacity), which corresponds to the time taken for spending one’s ''ardha shakti'' (half strength). Based on the outcome of this assessment, ''pravara'' (maximum), ''avara'' (minimum) and ''madhyama'' (medium) ''bala'' have to be assessed. Based upon the results of these ''bala'' assessments, ''maha sweda'' (whole body sudation for an extended duration) and various minor/major ''sweda'' measures could be prescribed.

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Exercise intolerance has a significant impact on heat intolerance. People who exhibit exercise intolerance (like in the case of mitochondrial diseases, or in persons leading a sedentary lifestyle) may have autonomic dysfunction including vascular autonomia characterized by tachycardia, dizziness, changes in heart rate and blood pressure, heat intolerance and unusual sweating pattern. Also, deficiency in energy metabolism may cause exercise intolerance and reduced stamina. It is evident that exercise intolerance leads to heat intolerance and abnormal sweating pattern, making it difficult - and hazardous- to conduct ''swedana'' in those individuals. An interesting observation is that if an individual is acclimatized to hot environment, he gradually attains exercise tolerance by an increase in plasma and thereby increase in blood volume, increased venous return, increased cardiac output, sub maximal heart rate, sustained sweat response, earlier onset of sweat and increased capacity for evaporative cooling, decreased osmolality of sweat and electrolyte conservation and decreased likelihood for fatigue<ref>Kondo, N., et. al, (2009), Global Environmental research, Thermoregulatory adaptations in Humans and its modifying factors, 13 (1), 35 - 41.- online research</ref>

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Exercise intolerance has a significant impact on heat intolerance. People who exhibit exercise intolerance (like in the case of mitochondrial diseases, or in persons leading a sedentary lifestyle) may have autonomic dysfunction including vascular autonomia characterized by tachycardia, dizziness, changes in heart rate and blood pressure, heat intolerance and unusual sweating pattern. Also, deficiency in energy metabolism may cause exercise intolerance and reduced stamina. It is evident that exercise intolerance leads to heat intolerance and abnormal sweating pattern, making it difficult - and hazardous- to conduct ''[[swedana]]'' in those individuals. An interesting observation is that if an individual is acclimatized to hot environment, he gradually attains exercise tolerance by an increase in plasma and thereby increase in blood volume, increased venous return, increased cardiac output, sub maximal heart rate, sustained sweat response, earlier onset of sweat and increased capacity for evaporative cooling, decreased osmolality of sweat and electrolyte conservation and decreased likelihood for fatigue<ref>Kondo, N., et. al, (2009), Global Environmental research, Thermoregulatory adaptations in Humans and its modifying factors, 13 (1), 35 - 41.- online research</ref>

Contemporary science believes that heat has a beneficial effect (through thermotherapy, for instance) on pain relief. Effect of heat on pain is mediated by heat-sensitive channels. These channels respond to heat by increasing intracellular calcium (Ca). An increase in intracellular Ca generates action potentials that increase the stimulation of sensory nerves. These channels are a part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. These channels have certain characteristics in common, such as sensitivity to menthol, etc. Multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the purin pain receptors. These receptors, termed as P2X2 and P2Y2, are mediated pain receptors located in the peripheral small nerve endings. For peripheral pain, heat can directly inhibit pain. However when pain is originating from deeper tissues, heat stimulates peripheral pain receptors that can alter what can be termed as “gating” in the spinal cord and reduce the sensation of deep pain. Another effect of heat is its ability to increase circulation. These same TRPV1 and TRPV4 receptors, along with nociceptor, increase blood flow in response to heat. The initial response to heat is mediated through the sensory nerves that release substance P and calcitonin-related peptide to increase circulation. After approximately one minute, Nitric Oxide is produced in vasculature endothelial cells and is responsible for sustained response of circulation to heat. This increase in circulation is considered to be essential in tissue protection from heat and repair of damaged tissue. Thermotherapy is of two types: dry and moist. A study was conducted to assess the effect of moist and dry heat on delayed onset of muscle soreness. Moist heat not only had similar benefits as dry heat but in some cases was more beneficial, requiring only 25% of time for application as dry heat. This study was conducted on quadriceps muscles. The study also witnessed immediate (and maximum) reduction in pain on application of moist heat, since moist heat penetrates deeper tissues faster than dry heat. Also, dry heat draws out moisture from the areas of application leaving them dehydrated, unlike moist heat.

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Heat therapy shows best results in increasing extensibility of collagen tissues, decreasing joint stiffness, relieving muscle spasm, reducing pain, inflammation, and edema. It also helps in post acute phase of healing and increasing blood flow. Examples of applications of dry heat in contemporary medicine include diathermy, ultra sound, and heat packs, while examples of moist heat include hydrocololator heat packs (1650F), heat regulated hydrotherapy (1050 F) (basically for 5-20 mins).<ref>Aroun Prasath, R., (2014), Journal of Science, Volume 4, Issue 1, A comparative study to assess the effectiveness of Infrared radiation and hot water fomentation on pain among patients with osteoarthritis of Knee, 1-3.</ref>

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Practically, ''valuka sweda'' may be considered to be an extreme form of ''ruksha sweda'' and taila droni as an ultimate form of ''snigdha sweda''. ''Patrapotala sweda, jambheera pinda sweda'' etc are ''na atisnigdharuksha'' (neither too unctuous nor too dry) in nature. From this, a spectrum of ''swedana'' techniques could be formulated starting from ''valuka sweda'' (sudation using sand as driest form) and ending in ''taila droni'' (dipping in warm oil as most unctuous form). The complete sequence of techniques would imply ''valuka sweda'' at one end of the spectrum, followed by ''thusha sweda, kareesha sweda, pinyakasweda, dhanyamla dhara, churnapindasweda, jambheera panda sweda, patrapotala sweda, anda sweda, shashtika pinda sweda, sarvanga dhara'' and eventually ending with ''taila droni''. [verse 7-8]

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Practically, ''valuka sweda'' may be considered to be an extreme form of ''ruksha sweda'' and taila droni as an ultimate form of ''snigdha sweda''. ''Patrapotala sweda, jambheera pinda sweda'' etc are ''na atisnigdharuksha'' (neither too unctuous nor too dry) in nature. From this, a spectrum of ''[[swedana]]'' techniques could be formulated starting from ''valuka sweda'' (sudation using sand as driest form) and ending in ''taila droni'' (dipping in warm oil as most unctuous form). The complete sequence of techniques would imply ''valuka sweda'' at one end of the spectrum, followed by ''thusha sweda, kareesha sweda, pinyakasweda, dhanyamla dhara, churnapindasweda, jambheera panda sweda, patrapotala sweda, anda sweda, shashtika pinda sweda, sarvanga dhara'' and eventually ending with ''taila droni''. [verse 7-8]

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In general practice, early degenerative conditions such as pre-senile dementia, demyelinating poly neuropathy of adolescence or adulthood such as CIDP, and post-infective (febrile) neurological disorders such as GBS present themselves as ''amashayagata vata samprapthi lakshanas'' (signs of ''vata'' vitiated in ''amashaya'') and therapeutic ''swedana'' measures such as ''rukshana'' (dry fomentation techniques) are found to be very effective in the initial stages of these conditions. Metabolic disorders of the aged, such as vascular dementia, and various rheumatological disorders resemble ''pakwashayagata kapha lakshanas'' and the treatment may be initiated with ''snigdha sweda''. [verse 9]

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In general practice, early degenerative conditions such as pre-senile dementia, demyelinating poly neuropathy of adolescence or adulthood such as CIDP, and post-infective (febrile) neurological disorders such as GBS present themselves as ''amashayagata vata samprapthi lakshanas'' (signs of ''[[vata]]'' vitiated in ''amashaya'') and therapeutic ''[[swedana]]'' measures such as ''[[rukshana]]'' (dry fomentation techniques) are found to be very effective in the initial stages of these conditions. Metabolic disorders of the aged, such as vascular dementia, and various rheumatological disorders resemble ''pakwashayagata kapha lakshanas'' and the treatment may be initiated with ''snigdha sweda''. [verse 9]

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For some of the disorders mentioned above that are ''sweda sadhya, mridu sweda'' alone should be performed. If the disease is ''sweda asadhya'', it’s better to avoid administering ''swedana'' to these areas. This indicates that utmost care has to be taken when it comes to applying fomentation to vital areas as well as fomenting the whole body. Various ''acharyas'' suggest using ''dravyas'', or medicated formulations, to shield or protect vital organs from any adverse affects of ''swedana''. ''Gangadhara'' recommends the use of ''sheeta veerya dravyas'', in this context, while administering ''mridu sweda'' to these vital parts, and Chakrapani also advises the use of these ''dravyas'' as protective measures of those parts while performing ''swedana''. It is well established that hyperthermia in testicular region adversely affects spermatogenesis and virility of semen, in turn hampering fertility.

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For some of the disorders mentioned above that are ''sweda sadhya, mridu sweda'' alone should be performed. If the disease is ''sweda asadhya'', it’s better to avoid administering ''[[swedana]]'' to these areas. This indicates that utmost care has to be taken when it comes to applying fomentation to vital areas as well as fomenting the whole body. Various ''acharyas'' suggest using ''dravyas'', or medicated formulations, to shield or protect vital organs from any adverse affects of ''[[swedana]]''. ''Gangadhara'' recommends the use of ''sheeta veerya dravyas'', in this context, while administering ''mridu sweda'' to these vital parts, and Chakrapani also advises the use of these ''dravyas'' as protective measures of those parts while performing ''[[swedana]]''. It is well established that hyperthermia in testicular region adversely affects spermatogenesis and virility of semen, in turn hampering fertility.

A sudden increase in body temperature produces a corresponding increase in cutaneous vascular conductance. This is followed by an increase in systemic conductance which produces alterations in cardiac output (decrease in central venous pressure and increase in cardiac output thereby increased left ventricular ejection fraction), oxygen consumption and water loss. Heart rate increases.

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There is a significant hemodynamic change at the beginning of ''swedana'' like significant cardiovascular stress which causes an increase in blood pressure (systolic and diastolic) and pulse rate. Whole body fomentation is therefore contraindicated in elderly and those with cardiomyopathy, congestive heart disease, bundle branch block, anemia, MI, hyperthyroidism etc.<ref> Sanjeev Rastogy & Francesco Chiappelli, (2013 April – June), AYU,34(2): Hemodynamic effects of Sarvanga swedana ( Ayurvedic passive heat therapy): a pilot observational study 154-159.</ref> Extra caution needs to be exercised when it comes to administering ''swedana'' procedure to patients with heart conditions .

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There is a significant hemodynamic change at the beginning of ''[[swedana]]'' like significant cardiovascular stress which causes an increase in blood pressure (systolic and diastolic) and pulse rate. Whole body fomentation is therefore contraindicated in elderly and those with cardiomyopathy, congestive heart disease, bundle branch block, anemia, MI, hyperthyroidism etc.<ref> Sanjeev Rastogy & Francesco Chiappelli, (2013 April – June), AYU,34(2): Hemodynamic effects of Sarvanga swedana ( Ayurvedic passive heat therapy): a pilot observational study 154-159.</ref> Extra caution needs to be exercised when it comes to administering ''[[swedana]]'' procedure to patients with heart conditions .

Regarding eyes, the scientific community is interested in knowing more about the side effects of transpupillary thermotherapy (TTT). A study conducted on normal mouse retina reveals that retinas treated with a power of 70 mW exhibited progressive retinal damage that was almost exclusively restricted to the photo-receptors. In those cases, early damage to the outer segments of the photo-receptors was seen one day after the thermotherapy and saw degeneration of outer nuclear layer after five days. At the same time, an accumulation of pigmented cells, presumably of macrophages, was seen in the sub-retinal space. No apparent damage was seen in the RPE or choroid. Today, researchers are considering the importance of using sub-threshold effects while applying TTT to patients with neurovascular age-related macular degeneration.<ref>A.P. Kvanta, P. Algvere Department of Ophthalmology, St Erik's Eye Hospital, Stockholm, Sweden, Effect of Transpupillary Thermotherapy (TTT).</ref> [verse 10] These practices are very common nowadays except for the usage of wheat balls. When lotus petals are unavailable, rose flower petals are substituted these days. Even cotton balls soaked in cold water, bandaged with cloth are commonly used to protect eyes while sudation. [verse 11]

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The ''sarvanga abhyanga'' (whole body) fomentation technique should be administered for approximately 8-10 mins, in suitable humid conditions, and until the patient sweats profusely. ''Ekanga sweda'', when administered for 5-20 minutes, helps provide relief to patients showing symptoms of joint stiffness, restricted movements and acute pain.

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''Swedana'' procedures are recommended for a specific duration and not for prolonged periods of time. How do we know when to stop it? Repeated thermal stress elicits adaptations evident within the neural networks and integrating regulatory systems that appear as morphological changes (sweat gland hypertrophy) and may be expressed as adjustments within effector processes altered vasomotor or sudomotor sensitivities. The most common functional effect of heat acclimation is a change in the effector activation being shifted downwards. One can also observe effector adaptations evident from changes in the gain of the effector response. Thus, for a given thermal stimulus acclimatized individuals frequently display an increased effector sensitivity such as greater sweating response for an equivalent change in body temperature. Phenotypic adaptation evident after sufficient fomentation (continuum model, not with respect to time):

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''[[Swedana]]'' procedures are recommended for a specific duration and not for prolonged periods of time. How do we know when to stop it? Repeated thermal stress elicits adaptations evident within the neural networks and integrating regulatory systems that appear as morphological changes (sweat gland hypertrophy) and may be expressed as adjustments within effector processes altered vasomotor or sudomotor sensitivities. The most common functional effect of heat acclimation is a change in the effector activation being shifted downwards. One can also observe effector adaptations evident from changes in the gain of the effector response. Thus, for a given thermal stimulus acclimatized individuals frequently display an increased effector sensitivity such as greater sweating response for an equivalent change in body temperature. Phenotypic adaptation evident after sufficient fomentation (continuum model, not with respect to time):

#Reduced heart rate at a fixed work rate

#Expanded plasma volume

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#Superior Na and Cl reabsorption from sweat, and an elevated sweat secretion. <ref name="ref2">Kondo, N., et. al, (2009), Global Environmental research, Thermoregulatory adaptations in Humans and its modifying factors, 13 (1), 35 - 41.</ref> [verse 13]

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It is very essential to differentiate heat exhaustion from heatstroke. Both come under the concept of ''atiswinna'' (over sudation). But from the treatment advised for ''atiswinna'', we may infer it as heat exhaustion. Contemporary science advises fluid replacement therapy for heat exhaustion whereas rapid aggressive cooling techniques are prescribed for heat stroke. [[Charak Samhita]] advises treatment procedures that include ''greeshma ritucharya'' along with ''madhura, ~~snigddha~~, seethala prayogas'' as ''ahara'' & ''vihara''. Symptoms of heat exhaustion include normal to slightly elevated core temperature (39 – 40°C), fatigue or malaise, orthostatic hypotension, tachycardia, clinical signs of dehydration, nausea, vomiting, and diarrhea (due to splanchnic and renal vasoconstriction). Similarly, Symptoms of heat stroke include elevated core temperature (usually greater than 40.5°C), vague symptom of weakness, nausea, vomiting, headache, CNS symptoms including confusion, ataxia, coma, seizures, delirium, hot, dry skin, hyperdynamic cardiovascular systems (high central venous pressure [CVP], low systemic vascular resistance [SVR], tachycardia), elevated hepatic transaminases (usually in the tens of thousands range), coagulopathy, rhabdomyolysis, and renal failure <ref name="ref1" /> [verse 14-15]

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It is very essential to differentiate heat exhaustion from heatstroke. Both come under the concept of ''atiswinna'' (over sudation). But from the treatment advised for ''atiswinna'', we may infer it as heat exhaustion. Contemporary science advises fluid replacement therapy for heat exhaustion whereas rapid aggressive cooling techniques are prescribed for heat stroke. [[Charak Samhita]] advises treatment procedures that include ''greeshma ritucharya'' along with ''madhura, snigdha, seethala prayogas'' as ''ahara'' & ''vihara''. Symptoms of heat exhaustion include normal to slightly elevated core temperature (39 – 40°C), fatigue or malaise, orthostatic hypotension, tachycardia, clinical signs of dehydration, nausea, vomiting, and diarrhea (due to splanchnic and renal vasoconstriction). Similarly, Symptoms of heat stroke include elevated core temperature (usually greater than 40.5°C), vague symptom of weakness, nausea, vomiting, headache, CNS symptoms including confusion, ataxia, coma, seizures, delirium, hot, dry skin, hyperdynamic cardiovascular systems (high central venous pressure [CVP], low systemic vascular resistance [SVR], tachycardia), elevated hepatic transaminases (usually in the tens of thousands range), coagulopathy, rhabdomyolysis, and renal failure <ref name="ref1" /> [verse 14-15]

Type of patients at high risk of suffering from untoward reactions during fomentation include athletes exercising strenuously in hot climates, elderly patients (because of decreased efficacy of thermoregulation, comorbid illness or medications, lack of fans or air conditioning, inappropriate dress), infants and small children (because of high ratio of surface area to weight, inability to control fluid intake), patients with cardiac ailments or those taking beta-blockers (because of inability to increase cardiac output sufficiently for vasodilation) Patients who are dehydrated because of poor fluid intake, gastroenteritis, or diuretic use (dehydration increases demand on ATPase pumps, which contribute 25-45% of basal metabolic rate.), patients prone to higher endogenous heat production, patients taking medications that inhibit sweat production or increase heat production (eg, anticholinergics, antidepressants, antihistamines, neuroleptics, zonisamide, sympathomimetics, lithium, alpha- and beta-blockers), and patients taking medications that cause dehydration (eg, diuretics, alcohol). This coincides with most of the contraindications mentioned in [[Charak Samhita]]. <ref name="ref2" />

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In demyelinating neuropathy or in other demyelinating as well as in diabetic neuropathy conditions or in severe DM without neuropathy, ''swedana'' should not be practiced. Hypothermia in demyelinating disorders is a common manifestation. In some patients, core temperature drop to 33 – 34°C has been noted. If the temperature decreases to (or less than) 33°C, severe lethargy, muscle stiffness, rigid limbs, a confused state of mind or even mutism might develop. These patients show full symptomatic clinical recovery on passive “rewarming” at 35 – 36°C. As the temperature rises to more than 36.5°C the symptoms become adverse. Hence there is always a requirement to maintain the core temperature between 33 – 36°C. ''Swedana'' thus always poses a risk to such patients. <ref>Sullivan, F., Hutchinson, M., Bahandeka, S., Moore, R. E.,(1987), Journal of neurology, neurosurgery and psychiatry, Chronic hypothermia in multiple sclerosis, 50: 813 – 815 & Online article, By Picture: Inside the Brain, A “reasonable lesion”: Causes and effects of demyelinating diseases.) </ref>

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In demyelinating neuropathy or in other demyelinating as well as in diabetic neuropathy conditions or in severe DM without neuropathy, ''[[swedana]]'' should not be practiced. Hypothermia in demyelinating disorders is a common manifestation. In some patients, core temperature drop to 33 – 34°C has been noted. If the temperature decreases to (or less than) 33°C, severe lethargy, muscle stiffness, rigid limbs, a confused state of mind or even mutism might develop. These patients show full symptomatic clinical recovery on passive “rewarming” at 35 – 36°C. As the temperature rises to more than 36.5°C the symptoms become adverse. Hence there is always a requirement to maintain the core temperature between 33 – 36°C. ''[[Swedana]]'' thus always poses a risk to such patients. <ref>Sullivan, F., Hutchinson, M., Bahandeka, S., Moore, R. E.,(1987), Journal of neurology, neurosurgery and psychiatry, Chronic hypothermia in multiple sclerosis, 50: 813 – 815 & Online article, By Picture: Inside the Brain, A “reasonable lesion”: Causes and effects of demyelinating diseases.) </ref>

In diabetes mellitus & diabetic polyneuropathy, there is impaired distal thermoregulation, distal sudomotor & micro vascular dysfunction. The nerve fibres that play an important role in thermoregulation are the earliest nerve fibres affected in polyneuropathy. Neuronal activity is highly temperature sensitive and causes neuropathic pain. Many studies have pointed out that there is an increased peripheral insulin resistance associated with hyperthermia. Starved off glucose cells turn to lipids as a source of energy in a diabetic patient. Hyperthermia promotes further lipolysis which hampers the condition <ref>Seward, B. Rutkove et. al, (2009 April), PMC, Diabetis care, 32 (4), Impaired Distal Thermal regulations in Diabetes and diabetic polyneuropathy, 671 – 676. & Sullivan, F., Hutchinson, M., Bahandeka, S., Moore, R. E.,(1987), Journal of neurology, neurosurgery and psychiatry, Chronic hypothermia in multiple sclerosis, 50: 813 – 815.</ref>

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In patients with hypothyroidism who are undergoing thyroxin supplementation, there is a chance of development of an increased basal metabolic rate that stimulates increased heat production. The same is the condition with persons suffering from hyperthyroidism.

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Hence ''swedana'' is contraindicated in both of these conditions. [verse 14-15]

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Hence ''[[swedana]]'' is contraindicated in both of these conditions. [verse 14-15]

Thermotherapy can be used to treat a number of painful conditions. A number of studies with thermotherapy conducted worldwide has shown significant results in a wide range of disease conditions. These include:

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*Other chronic pain disorders, including lupus and myofascial pain syndrome, asthma, reduction of joint contractures. Other conditions that may be treated with heat include back sprain, degenerative disc disease, sciatica and scoliosis, as these conditions are usually associated with muscle spasm. <ref name="ref2" /> [verse 20-24]

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''Swedana'' accounts for a major part of Ayurvedic [[Panchakarma]] therapy. It is considered an essential preparatory procedure before bio-cleansing. It is normally done after internal or external oleation. ''Swedana'' liquefies and separates the vitiated body humors adhered to the tissues and facilitates their flow to the elementary tract for easy evacuation from the body. In Ayurvedic practise majority of ''swedana'' (sudation) procedures are done in the form of ''kizhi / pindasveda'' (sudation using bolus). The commonly practiced few are detailed below with its preparation, application indication etc. <ref>Manoj Kumar (Editor) et.al, Practical Guide to Panchkarma, Published by Dept. of Kayachikitsa, VPSV [[Ayurveda]] College, Kottakkal. 2006</ref>

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''[[Swedana]]'' accounts for a major part of Ayurvedic [[Panchakarma]] therapy. It is considered an essential preparatory procedure before bio-cleansing. It is normally done after internal or external oleation. ''[[Swedana]]'' liquefies and separates the vitiated body humors adhered to the tissues and facilitates their flow to the elementary tract for easy evacuation from the body. In Ayurvedic practise majority of ''[[swedana]]'' (sudation) procedures are done in the form of ''kizhi / pindasveda'' (sudation using bolus). The commonly practiced few are detailed below with its preparation, application indication etc. <ref>Manoj Kumar (Editor) et.al, Practical Guide to Panchkarma, Published by Dept. of Kayachikitsa, VPSV [[Ayurveda]] College, Kottakkal. 2006</ref>

=== ''Kizhi / Pinda / Pottali'' ===

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==== ''Dosha''-specific indications of ''kizhi'' ====

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*''Kizhi'' is primarily administered in ''kapha-vata'' or isolated ''vata'' disorders.

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*''Kizhi'' is primarily administered in ''[[kapha]]-[[vata]]'' or isolated ''[[vata]]'' disorders.

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*Specific types / modifications of ''kizhi'' are administered in ''pitta / rakta'' disorders

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*Specific types / modifications of ''kizhi'' are administered in ''[[pitta]] / [[rakta]]'' disorders

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=== ''Prakriti'' & season specific indications of ''kizhi'' ===

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=== ''[[Prakriti]]'' & season specific indications of ''kizhi'' ===

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*''Kizhi'' can be safely employed in ''kapha'' and ''vata''-predominant ''prakriti''

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*''Kizhi'' can be safely employed in ''[[kapha]]'' and ''[[vata]]''-predominant ''[[prakriti]]''

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*''Pitta''-predominant individuals should take specific precautions.

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*''[[Pitta]]''-predominant individuals should take specific precautions.

*Ideal seasons for ''kizhi'' are winter, spring and rainy seasons.

*Special care should be taken in summer and autumn seasons

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==== Procedure ====

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Heat the ''pottali'' by dipping in the liquid medium. Heat it on a gentle fire and apply it as mentioned earlier in seven postures; 5-10 minutes in each posture. The duration of the procedure depends on the condition of patient. Do gentle massage all over the body and advise the patient to take rest it bed, in a non-windy room, cover the body with a thick blanket. After taking rest for about one hour, take bath in hot water. Water boiled with ''dhatri'' (Indian gooseberry) can be used for washing the head and that with ''vata'' alleviating leaves for body. Then apply ''rasanadi churna'' on vertex. Advice the patient to take hot ''peya'' (rice soup).

+

Heat the ''pottali'' by dipping in the liquid medium. Heat it on a gentle fire and apply it as mentioned earlier in seven postures; 5-10 minutes in each posture. The duration of the procedure depends on the condition of patient. Do gentle massage all over the body and advise the patient to take rest it bed, in a non-windy room, cover the body with a thick blanket. After taking rest for about one hour, take bath in hot water. Water boiled with ''dhatri'' (Indian gooseberry) can be used for washing the head and that with ''[[vata]]'' alleviating leaves for body. Then apply ''rasanadi churna'' on vertex. Advice the patient to take hot ''peya'' (rice soup).

==== Indications ====

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{| class="wikitable"

|-

−

| ''Dosha''

+

| ''[[Dosha]]''

−

| Alleviates ''vata'' as well as ''vata-kapha''

+

| Alleviates ''[[vata]]'' as well as ''[[vata]]-[[kapha]]''

|-

−

| ''Prakriti''

+

| ''[[Prakriti]]''

−

| Suitable to ''vata'', ''kapha'', ''vata-kapha'' and ''tridosha'' constitutions

+

| Suitable to ''[[vata]]'', ''[[kapha]]'', ''[[vata]]-[[kapha]]'' and ''tridosha'' constitutions

|-

| Diseases

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{| class="wikitable"

|-

−

| ''Dosha''

+

| ''[[Dosha]]''

−

| Alleviates ''vata-kapha''

+

| Alleviates ''[[vata]]-[[kapha]]''

|-

−

| ''Prakriti''

+

| ''[[Prakriti]]''

−

| Suitable to ''vata'',''kapha'', ''vata-kapha'', & ''tridosha'' constitutions

+

| Suitable to ''[[vata]]'',''[[kapha]]'', ''[[vata]]-[[kapha]]'', & ''tridosha'' constitutions

|-

| Diseases

−

| Joint diseases, specifically those that are traumatic in origin; lower back ache, ''kapha''dominant sciatica, frozen shoulder, stiff neck, rheumatic arthritis

+

| Joint diseases, specifically those that are traumatic in origin; lower back ache, ''[[kapha]]''dominant sciatica, frozen shoulder, stiff neck, rheumatic arthritis

|-

|}

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=== ''Churna pinda sweda'' (Sudation using bolus made of herbal powders) ===

−

''Churna pinda sweda'' is a ''rukshana'' (de-oleation) procedure practiced in ''vata-kapha'' conditions. Generally, it is done without adding oil. Internal oleation is not done as preparatory procedure of ''churna pinda sweda''

+

''Churna pinda sweda'' is a ''[[rukshana]]'' (de-oleation) procedure practiced in ''[[vata]]-[[kapha]]'' conditions. Generally, it is done without adding oil. Internal oleation is not done as preparatory procedure of ''churna pinda sweda''

==== Material required ====

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{| class="wikitable"

|-

−

| ''Dosha''

+

| ''[[Dosha]]''

−

| Alleviates ''kapha'' as well as ''kapha'' dominant ''vata''. Contraindicated in isolated ''vata'' vitiation

+

| Alleviates ''[[kapha]]'' as well as ''[[kapha]]'' dominant ''[[vata]]''. Contraindicated in isolated ''[[vata]]'' vitiation

|-

−

| ''Prakriti''

+

| ''[[Prakriti]]''

−

| Suitable to ''kapha'', ''vata-kapha'' and ''tridosha'' constitutions. Contraindicated in asthenic persons

+

| Suitable to ''[[kapha]]'', ''[[vata]]-[[kapha]]'' and ''tridosha'' constitutions. Contraindicated in asthenic persons

|-

| Disease

−

| Joint problems of ''kapha'' predominance, associated with ''ama'', acute lumbago & sciatica, neurological disorders suspected of association with ''kapha'', early stages of demyelination, GBS,rheumatoid arthritis, etc.

+

| Joint problems of ''[[kapha]]'' predominance, associated with ''ama'', acute lumbago & sciatica, neurological disorders suspected of association with ''[[kapha]]'', early stages of demyelination, GBS, rheumatoid arthritis, etc.

|-

|}

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=== ''Shashtika pinda sweda'' (sudation using bolus made of ''shashtika'' rice) ===

−

It is a variety of ''pindasweda'' in which ''shashtika, shali'' (a special variety of rice with medicinal value which is cropped in just 60 days) processed in ''kwatha'' (decoction) and milk is used for ''swedana''. It is well known in Kerala as ''nhavara kizhi''. As it provides ''swedana'' (sudation), ''snehana'' (oleation) and ''brimhana'' (anabolic quality) simultaneously it is widely used in ''vata'' vitiated conditions. As it possesses inherent cool property and it is also advised moderately vitiated ''pitta''.

+

It is a variety of ''pindasweda'' in which ''shashtika, shali'' (a special variety of rice with medicinal value which is cropped in just 60 days) processed in ''kwatha'' (decoction) and milk is used for ''[[swedana]]''. It is well known in Kerala as ''nhavara kizhi''. As it provides ''[[swedana]]'' (sudation), ''[[snehana]]'' (oleation) and ''[[brimhana]]'' (anabolic quality) simultaneously it is widely used in ''[[vata]]'' vitiated conditions. As it possesses inherent cool property and it is also advised moderately vitiated ''[[pitta]]''.

==== Materials required ====

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{| class="wikitable"

|-

−

| ''Dosha''

+

| ''[[Dosha]]''

−

| Alleviates ''vata'' as well as ''vata-pitta'', but contraindicated in isolated ''kapha'' and ''ama'' associated conditions

+

| Alleviates ''[[vata]]'' as well as ''[[vata]]-[[pitta]]'', but contraindicated in isolated ''[[kapha]]'' and ''[[ama]]'' associated conditions

|-

−

| ''Prakriti''

+

| ''[[Prakriti]]''

−

| Suitable for ''vata'', ''vata-pitta'' and ''tridoshi'' constitutions, but need to be avoided in obese persons

+

| Suitable for ''[[vata]]'', ''[[vata]]-[[pitta]]'' and ''tridoshi'' constitutions, but need to be avoided in obese persons

|-

| Diseases

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=== ''Ksheera dhuma'' (fomentation by steam of medicated milk) ===

−

''Ksheera dhuma'' is a popular ''nadisweda'' that is therapeutically very effective in the case of facial palsy. ''Ksheera dhuma'' is a modified ''swedana'' procedure. It is found to be effective especially in diseases pertaining to ''udradhavanga'' (upper part of body specifically head and neck region).

+

''Ksheera dhuma'' is a popular ''nadisweda'' that is therapeutically very effective in the case of facial palsy. ''Ksheera dhuma'' is a modified ''[[swedana]]'' procedure. It is found to be effective especially in diseases pertaining to ''udradhavanga'' (upper part of body specifically head and neck region).

==== Materials required ====

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=== Avagaha (sitz bath) ===

−

''Avagaha'' is a commonly used ''swedana'' which is a variant of ''drava sweda''. Here the patient is made to sit in a tub filled with decoction, ''dhaayaamla'', oil etc. It is found to be very effective in correcting vitiated ''apana vayu''.

+

''Avagaha'' is a commonly used ''[[swedana]]'' which is a variant of ''drava sweda''. Here the patient is made to sit in a tub filled with decoction, ''dhaayaamla'', oil etc. It is found to be very effective in correcting vitiated ''apana vayu''.

==== Materials required ====

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Water as required

−

Drugs: ''~~vatahara~~'' leaves like ''eranda, karanja, tulasi, vasha, arka, vaataghni'', etc. Instead of these, ''dashamoola'' can be used as per the condition.

+

Drugs: ''[[vata]]hara'' leaves like ''eranda, karanja, tulasi, vasha, arka, vaataghni'', etc. Instead of these, ''dashamoola'' can be used as per the condition.

Preparation of medicated water:

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Thirteen types of ''agnisweda'' mentioned in [[Charak Samhita]] are based on four principles of heat transfer, namely, conduction, convection, radiation, and evaporation. Conduction is the transfer of heat between two surfaces that are in direct contact with each other and depends on the temperature gradient between body & surface, the total body surface area, velocity of the cutaneous blood flow & thickness of subcutaneous insulating tissue. Examples of ''agnisweda'' that leverage conduction include ''sankara, prastara, parisheka, avagaha,'' and ''ashmaghna''.

−

Convection is the transfer of heat between two surfaces without direct contact through the medium of air. Examples of ''swedana'' techniques leveraging convection are ''naadi, jenthaka, karshu, kuti, bhu, kumbhi'' and ''koopa''.

+

Convection is the transfer of heat between two surfaces without direct contact through the medium of air. Examples of ''[[swedana]]'' techniques leveraging convection are ''naadi, jenthaka, karshu, kuti, bhu, kumbhi'' and ''koopa''.

−

Radiation is the difference in temperature between the body surface and objects in the environment. It decides the rate of cooling. Examples of ''swedana'' techniques that use radiation for heat transfer include ''jenthaka, karshu, kuti, bhu, kumbhi, holaka'' and ''koopa''.

+

Radiation is the difference in temperature between the body surface and objects in the environment. It decides the rate of cooling. Examples of ''[[swedana]]'' techniques that use radiation for heat transfer include ''jenthaka, karshu, kuti, bhu, kumbhi, holaka'' and ''koopa''.

Finally, evaporation involves the transfer of heat as vapor from the surface. Adequate humidity minimizes evaporative loss.

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A study2 has been conducted regarding ''sarvanga sweda''. It mentioned the hemodynamic effects of ''sarvanga sweda''. The remarkable points from this study are:

−

#Significant rise in the blood pressure (systolic & diastolic) was observed immediately after ''sarvanga swedana'' (found to reach near base levels after five minutes rest). Hence five minutes is the minimal period for which the patient should be kept in a supine posture, preferably at the same place. A continued ''~~sarvangaswedana~~'' therapy was noted to cause a significant decrease in pulse rate & systolic BP compared to the base levels observed at the beginning of the procedure.

+

#Significant rise in the blood pressure (systolic & diastolic) was observed immediately after ''sarvanga [[swedana]]'' (found to reach near base levels after five minutes rest). Hence five minutes is the minimal period for which the patient should be kept in a supine posture, preferably at the same place. A continued ''sarvanga [[swedana]]'' therapy was noted to cause a significant decrease in pulse rate & systolic BP compared to the base levels observed at the beginning of the procedure.

#The study recommended lying or supine posture during the procedure as opposed to sitting posture with head tilted downwards with cold draping over the head, since heat stress is supposed to cause a reduction in central venous pressure and a shift in blood volume from splanchnic to cutaneous area. Hence supine posture is considered ideal. Maximum time should be 8 – 10 minutes.<ref name="ref3">Aroun Prasath, R., (2014), Journal of Science, Volume 4, Issue 1, A comparative study to assess the effectiveness of Infrared radiation and hot water fomentation on pain among patients with osteoarthritis of Knee, 1-3.</ref>

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=== ''Pizhicchil'' ===

−

''Pizhiccil'' is a process that includes both ''snehana'' and ''swedana''. In this warmed ''taila dhaara'' is done along with simple massage. It can be included under ''drava sweda''.

+

''Pizhiccil'' is a process that includes both ''[[snehana]]'' and ''[[swedana]]''. In this warmed ''taila dhaara'' is done along with simple massage. It can be included under ''drava sweda''.

==== Materials required (for 7 days) ====

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Meanwhile gently massage the part following the path of stream. The process is done in seven postures, about 5-10 minutes in each posture. Collect the ''taila'' in the ''droni'' and heat it again. (This ''taila'' is used for three days and the rest half is used for another three days. On the final day supernatant ''taila'' of both halves is taken and ''pizhiccil'' is done with it. Everyday the ''taila'' has to be boiled after the process, so as to evaporate the water content.)

−

After completing the procedure wipe off the ''taila'' with a clean towel. Do gentle massage with fresh ''taila''. Give ''gandharvhasthadi kwatha''. Take rest for about one hour covered with blanket. Then take bath with hot water. Water boiled with ''~~vatahara~~'' leaves can be used for body and that with ''amalaki'' for head. Apply ''raasnadi churna'' on vertex after bath and allow to take light food when hungry.

+

After completing the procedure wipe off the ''taila'' with a clean towel. Do gentle massage with fresh ''taila''. Give ''gandharvhasthadi kwatha''. Take rest for about one hour covered with blanket. Then take bath with hot water. Water boiled with ''[[vata]]hara'' leaves can be used for body and that with ''amalaki'' for head. Apply ''raasnadi churna'' on vertex after bath and allow to take light food when hungry.

−

Usually, ''mridu shodhana'' is done following the whole process to eliminate the ''utklishta dosha'' (aggravated ''dosha'').

+

Usually, ''mridu [[shodhana]]'' is done following the whole process to eliminate the ''utklishta [[dosha]]'' (aggravated ''[[dosha]]'').

Temperature of ''taila'' should be checked each time, to avoid burning of skin.

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=== ''Dhanyamla dhara'' ===

−

''Dhanyamla dhara'' is another type of ''parisheka''. The word ''dhanyamla'' means that which is fermented from ''dhanya''. In this procedure ''dhara'' is performed using ''dhanyamla''. This procedure is a type of ''rukshana karma'' also it comes under ''dravasweda''.

+

''Dhanyamla dhara'' is another type of ''parisheka''. The word ''dhanyamla'' means that which is fermented from ''dhanya''. In this procedure ''dhara'' is performed using ''dhanyamla''. This procedure is a type of ''[[rukshana]] karma'' also it comes under ''dravasweda''.

==== Materials required ====

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Normal thermoregulation in a human body consists of an important voluntary regulating mechanism termed as behavioral control wherein the person adopts various postures (fetal posture), food habits (like alcohol derivatives), exclusive clothings (woolen sweaters) or passively attains certain emotional states (like anger, fear which stimulates sympathetic nervous system with release of epinephrine & norepinephrine that increases BMR which in turn increases heat production) which significantly modulates the core temperature as a response to changing environmental conditions. Thus ''niragnisweda'' corresponds to adaptive mechanisms of human beings.

−

After proper ''swedana'' person is equally exhausted as after doing moderate to severe exercise (increased sweating, fatigue etc). Hence if a person indulges in ''vyayama'' after ''swedana'' it results in ''atiswedana'' or ''ativyayama''.

+

After proper ''[[swedana]]'' person is equally exhausted as after doing moderate to severe exercise (increased sweating, fatigue etc). Hence if a person indulges in ''[[vyayama]]'' after ''[[swedana]]'' it results in ''atiswedana'' or ''ativyayama''.

</div>

+

== References ==

Eganeesh

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