Changes

B. Without using fire (niragni) in therapy  

B. Without using fire (niragni) in therapy  

====Inclusion of fire (sagni):====

====Inclusion of fire (sagni)====

There are thirteen methods of fomentation in which fire is used to induce sweating. [Cha.Sa.[[Sutra Sthana]] 14/39-40]. These methods utilize natural resources for fomentation making it relatively convenient and cost-effective. These can be used in healthcare practices with the same efficacy as of modern fomentation techniques.[table 1]

There are thirteen methods of fomentation in which fire is used to induce sweating. [Cha.Sa.[[Sutra Sthana]] 14/39-40]. These methods utilize natural resources for fomentation making it relatively convenient and cost-effective. These can be used in healthcare practices with the same efficacy as of modern fomentation techniques.[table 1]

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====Without using fire (niragni):====

====Without using fire (niragni)====

There are twelve methods to induce sweating without using fire as heating media. These methods are generally used to reduce [[kapha]] [[dosha]] and fats ([[meda dhatu]])by enhancing basic metabolism.[Su.Sa.Chikitsa Sthana 32/15]

There are twelve methods to induce sweating without using fire as heating media. These methods are generally used to reduce [[kapha]] [[dosha]] and fats ([[meda dhatu]])by enhancing basic metabolism.[Su.Sa.Chikitsa Sthana 32/15]

*Whole body(sarvanga): Indicated in generalized conditions [Cha.Sa.[[Sutra Sthana]] 14/66]

*Whole body(sarvanga): Indicated in generalized conditions [Cha.Sa.[[Sutra Sthana]] 14/66]

===Classification based on the medium of fomentation: ===  

===Classification based on the medium of fomentation ===  

*Heat bath/Radiant heat (tapa): This includes fomentation therapy in a chamber room (jentaka), fomentation using heat in a trench (karshu), fomentation in a chamber (kuti), fomentation in a pit (kupa), and fomentation using a heap of dung (holaka)  types.

*Heat bath/Radiant heat (tapa): This includes fomentation therapy in a chamber room (jentaka), fomentation using heat in a trench (karshu), fomentation in a chamber (kuti), fomentation in a pit (kupa), and fomentation using a heap of dung (holaka)  types.

*Bandage (upanaha)[Su.Sa.Chikitsa Sthana 32/3]<ref name=Susruta/>

*Bandage (upanaha)[Su.Sa.Chikitsa Sthana 32/3]<ref name=Susruta/>

===Classification based on the therapeutic purpose:===

===Classification based on the therapeutic purpose===

*For pacification (samshamana) of vitiated dosha

*For pacification (samshamana) of vitiated dosha

*For purification (samshodhana) of vitiated dosha[Dalhana on Su.Sa.Chikitsa Sthana 32/22]<ref name=Susruta/>

*For purification (samshodhana) of vitiated dosha[Dalhana on Su.Sa.Chikitsa Sthana 32/22]<ref name=Susruta/>

==Properties of the drug which impart fomentation:==

==Properties of the drug which impart fomentation==

The herbs used for fomentation therapy possess properties like hot potency,  penetrating, motile, unctuous, rough,  heavy and liquid.[Cha.Sa.[[Sutra Sthana]] 22/16]

The herbs used for fomentation therapy possess properties like hot potency,  penetrating, motile, unctuous, rough,  heavy and liquid.[Cha.Sa.[[Sutra Sthana]] 22/16]

==General indications of fomentation therapy:==

==General indications of fomentation therapy==

*Painful conditions: E.g.earache, headache, cervical pain, pain in foot, knee, thigh, calf, colicky pain etc.

*Painful conditions: E.g.earache, headache, cervical pain, pain in foot, knee, thigh, calf, colicky pain etc.

*As a prerequisite to [[panchakarma]] procedures[Cha.Sa.[[Sutra Sthana]] 14/24]

*As a prerequisite to [[panchakarma]] procedures[Cha.Sa.[[Sutra Sthana]] 14/24]

==Contraindications of fomentation therapy:==

==Contraindications of fomentation therapy==

*Conditions with predominance of [[pitta]] [[dosha]] in basic body constitution ([[Prakriti]]) and disease.  

*Conditions with predominance of [[pitta]] [[dosha]] in basic body constitution ([[Prakriti]]) and disease.  

*Weak, extremely emaciated, immune-compromised and unconscious persons[Cha.Sa.[[Sutra Sthana]] 14/16-19]

*Weak, extremely emaciated, immune-compromised and unconscious persons[Cha.Sa.[[Sutra Sthana]] 14/16-19]

==General instructions during fomentation therapy:==

==General instructions during fomentation therapy==

*Exposure to direct wind shall be avoided during fomentation therapy.  

*Exposure to direct wind shall be avoided during fomentation therapy.  

*If the fomentation is performed for purification treatments (shodhana), it must be done after proper internal and external oleation ([[snehana]]).

*If the fomentation is performed for purification treatments (shodhana), it must be done after proper internal and external oleation ([[snehana]]).

*After fomentation the person should take rest by covering the body with a blanket. Warm water shall be used for bath after fomentation treatment.  

*After fomentation the person should take rest by covering the body with a blanket. Warm water shall be used for bath after fomentation treatment.  

==Assessment of effect of fomentation therapy:==

==Assessment of effect of fomentation therapy==

===Features of optimal fomentation:===

===Features of optimal fomentation:===

The signs of optimal fomentation are relief from cold, pain, stiffness, heaviness; and disease pacification.[Cha.Sa.[[Sutra Sthana]] 14/12]

The signs of optimal fomentation are relief from cold, pain, stiffness, heaviness; and disease pacification.[Cha.Sa.[[Sutra Sthana]] 14/12]

===Features of inadequate fomentation:===

===Features of inadequate fomentation===

The features of inadequate fomentation include persistent feeling of heaviness, stiffness, pain, and associated complaints.

The features of inadequate fomentation include persistent feeling of heaviness, stiffness, pain, and associated complaints.

===Features of excessive fomentation:===

===Features of excessive fomentation===

Excess fomentation leads to vitiation of [[pitta]] [[dosha]], unconsciousness, giddiness, excessive thirst, burning sensation, weakness of body, eruptions in the body parts, pain in joints, and increased body temperature. [Cha.Sa.[[Sutra Sthana]] 14/14] [A.H. Sutra Sthana 17/16]

Excess fomentation leads to vitiation of [[pitta]] [[dosha]], unconsciousness, giddiness, excessive thirst, burning sensation, weakness of body, eruptions in the body parts, pain in joints, and increased body temperature. [Cha.Sa.[[Sutra Sthana]] 14/14] [A.H. Sutra Sthana 17/16]

In the diseases caused by the suppression of natural urges, swedana is indicated to relieve the obstruction of [[vata]].  It is an important treatment in the initial stage of fever [Cha.Sa.[[Chikitsa Sthana]] 3/142], accumulation of metabolic wastes (ama condition) [Cha.Sa.[[Vimana Sthana]] 2/13],piles (arsha) [Cha.Sa.[[Chikitsa Sthana]] 14/250] and hemiplegia (pakshaghata). [Cha.Sa.[[Chikitsa Sthana]] 28/100]  

In the diseases caused by the suppression of natural urges, swedana is indicated to relieve the obstruction of [[vata]].  It is an important treatment in the initial stage of fever [Cha.Sa.[[Chikitsa Sthana]] 3/142], accumulation of metabolic wastes (ama condition) [Cha.Sa.[[Vimana Sthana]] 2/13],piles (arsha) [Cha.Sa.[[Chikitsa Sthana]] 14/250] and hemiplegia (pakshaghata). [Cha.Sa.[[Chikitsa Sthana]] 28/100]  

==[[Dosha]] specific action of fomentation methods:==  

==[[Dosha]] specific action of fomentation methods==  

*Heat bath/Radiant heat (tapa) and vapors or steam (bashpa sweda): Mitigate [[kapha]]

*Heat bath/Radiant heat (tapa) and vapors or steam (bashpa sweda): Mitigate [[kapha]]

*Sweda without using fire (niragni sweda):  Mitigates [[vata]] associated with [[kapha]] and adipose tissue ([[meda dhatu]])[Su.Sa.Chikitsa Sthana 32/14-15]<ref name=Susruta/>

*Sweda without using fire (niragni sweda):  Mitigates [[vata]] associated with [[kapha]] and adipose tissue ([[meda dhatu]])[Su.Sa.Chikitsa Sthana 32/14-15]<ref name=Susruta/>

==Contemporary approach:==

==Contemporary approach==

   

   

In fomentation therapy (swedana), the body is exposed to varying intensities and qualities of heat which results in sweating. Nowadays different heating techniques are used as a therapeutic measure. This includes diathermy, infra-red, ultraviolet, ultrasound, wax bath, heat pads, hot water bags etc. Sauna bath is practiced in many parts of the world as a method for fomentation.   

In fomentation therapy (swedana), the body is exposed to varying intensities and qualities of heat which results in sweating. Nowadays different heating techniques are used as a therapeutic measure. This includes diathermy, infra-red, ultraviolet, ultrasound, wax bath, heat pads, hot water bags etc. Sauna bath is practiced in many parts of the world as a method for fomentation.   

   

   

==Physiology of sweating:==

==Physiology of sweating==

   

   

Among the three main types of sweat glands, eccrine sweat glands are distributed over a much larger body surface area and they are mainly responsible for thermoregulation. These glands get stimulated by thermal heat and also by emotional stress. When the body is exposed to hot conditions or by exercises a redistribution of heat from the core to periphery happens through an increase in blood flow in the periphery (skin). This thermophysiological change stimulates the sweat gland. The increase in body temperature is sensed by central and skin thermoreceptors. The preoptic area of hypothalamus process this information and triggers the sudomotor response. Sympathetic cholinergic stimulation mediates thermal sweating. The release of acetylcholine from nonmyelinated class C sympathetic postganglionic fibers binds to muscarinic receptors on the sweat gland, stimulating sweat production. The clear cells present in the secretory coil of eccrine gland produce an isotonic fluid. It moves to the resorptive duct which traverses the dermis. The sodium and chloride ions get reabsorbed in this stage. The resultant hypotonic fluid is released on to the skin surface as sweat. Due to a decline in non-thermal feedback to the brain on termination of activity or hot conditions, sweat rate drops and the surface sweat gets evaporated quickly.<ref>Baker LB. Physiology of sweat gland function: The roles of sweating and sweat composition in human health. Temperature (Austin). 2019;6(3):211-259. Published 2019 Jul 17. doi:10.1080/23328940.2019.1632145</ref>  <ref name=glandtoskin>Gerrett N, Griggs K, Redortier B, Voelcker T, Kondo N, Havenith G. Sweat from gland to skin surface: production, transport, and skin absorption. J Appl Physiol (1985). 2018;125(2):459-469. doi:10.1152/japplphysiol.00872.2017</ref>

Among the three main types of sweat glands, eccrine sweat glands are distributed over a much larger body surface area and they are mainly responsible for thermoregulation. These glands get stimulated by thermal heat and also by emotional stress. When the body is exposed to hot conditions or by exercises a redistribution of heat from the core to periphery happens through an increase in blood flow in the periphery (skin). This thermophysiological change stimulates the sweat gland. The increase in body temperature is sensed by central and skin thermoreceptors. The preoptic area of hypothalamus process this information and triggers the sudomotor response. Sympathetic cholinergic stimulation mediates thermal sweating. The release of acetylcholine from nonmyelinated class C sympathetic postganglionic fibers binds to muscarinic receptors on the sweat gland, stimulating sweat production. The clear cells present in the secretory coil of eccrine gland produce an isotonic fluid. It moves to the resorptive duct which traverses the dermis. The sodium and chloride ions get reabsorbed in this stage. The resultant hypotonic fluid is released on to the skin surface as sweat. Due to a decline in non-thermal feedback to the brain on termination of activity or hot conditions, sweat rate drops and the surface sweat gets evaporated quickly.<ref>Baker LB. Physiology of sweat gland function: The roles of sweating and sweat composition in human health. Temperature (Austin). 2019;6(3):211-259. Published 2019 Jul 17. doi:10.1080/23328940.2019.1632145</ref>  <ref name=glandtoskin>Gerrett N, Griggs K, Redortier B, Voelcker T, Kondo N, Havenith G. Sweat from gland to skin surface: production, transport, and skin absorption. J Appl Physiol (1985). 2018;125(2):459-469. doi:10.1152/japplphysiol.00872.2017</ref>

==Effect of sweating on body fluid dynamics:==

==Effect of sweating on body fluid dynamics==

   

   

Heat stress results in sweating. Sweating causes water loss which leads to a reduction in water volume and electrolyte content in the body. The osmolarity of body fluids increases due to sweating. Sweat is hypotonic in body fluid. In a study conducted on six healthy men, a reduction of 4.1% in body weight was reported when subjected to dehydration through thermal means (sauna) and through exercise. The extracellular fluid loss was found to be more after thermal heat stress when compared to exercise dehydration. Loss of sodium chloride was more during thermal dehydration while potassium loss was more through exercise.<ref>KOZLOWSKI S, SALTIN B. EFFECT OF SWEAT LOSS ON BODY FLUIDS. J Appl Physiol. 1964;19:1119-1124. doi:10.1152/jappl.1964.19.6.1119</ref>  

Heat stress results in sweating. Sweating causes water loss which leads to a reduction in water volume and electrolyte content in the body. The osmolarity of body fluids increases due to sweating. Sweat is hypotonic in body fluid. In a study conducted on six healthy men, a reduction of 4.1% in body weight was reported when subjected to dehydration through thermal means (sauna) and through exercise. The extracellular fluid loss was found to be more after thermal heat stress when compared to exercise dehydration. Loss of sodium chloride was more during thermal dehydration while potassium loss was more through exercise.<ref>KOZLOWSKI S, SALTIN B. EFFECT OF SWEAT LOSS ON BODY FLUIDS. J Appl Physiol. 1964;19:1119-1124. doi:10.1152/jappl.1964.19.6.1119</ref>  

Another study conducted in 10 volunteers who exercised in the heat for 90-110 minutes reported decreased plasma volume by 9.4% compared with the pre-exposure value. The body is compensating for the reduction in central circulating blood volume, due to hypovolemia as a result of dehydration or due to dilation of peripheral vasculature, through the body’s ability to mobilize water from extravascular to intravascular space. During dehydration higher water loss is reported from extra cellular fluid space than from intracellular fluid. Sodium and Chlorine are the main electrolytes found to be excreted during thermal dehydration. These are the main electrolytes in extra cellular fluid.<ref>Nose H, Mack GW, Shi XR, Nadel ER. Shift in body fluid compartments after dehydration in humans. J Appl Physiol (1985). 1988;65(1):318-324. doi:10.1152/jappl.1988.65.1.318</ref>  

Another study conducted in 10 volunteers who exercised in the heat for 90-110 minutes reported decreased plasma volume by 9.4% compared with the pre-exposure value. The body is compensating for the reduction in central circulating blood volume, due to hypovolemia as a result of dehydration or due to dilation of peripheral vasculature, through the body’s ability to mobilize water from extravascular to intravascular space. During dehydration higher water loss is reported from extra cellular fluid space than from intracellular fluid. Sodium and Chlorine are the main electrolytes found to be excreted during thermal dehydration. These are the main electrolytes in extra cellular fluid.<ref>Nose H, Mack GW, Shi XR, Nadel ER. Shift in body fluid compartments after dehydration in humans. J Appl Physiol (1985). 1988;65(1):318-324. doi:10.1152/jappl.1988.65.1.318</ref>  

==Therapeutic use:==

==Therapeutic use==

   

   

The main physiological function of sweating is thermoregulation. While sweating the heat is transferred from body to the water present on the skin's surface.<ref name=glandtoskin/>

The main physiological function of sweating is thermoregulation. While sweating the heat is transferred from body to the water present on the skin's surface.<ref name=glandtoskin/>

===Removal of toxins:===

===Removal of toxins===

Some studies report the chemicals, persistent organic pollutants, heavy metals, bisphenol A etc. in sweat. Their concentration is also reported to be higher in sweat than in blood or urine. This suggests the possible action of skin as an excretory organ for body toxins. Further studies are required to prove this activity of the skin.<ref name=glandtoskin/>

Some studies report the chemicals, persistent organic pollutants, heavy metals, bisphenol A etc. in sweat. Their concentration is also reported to be higher in sweat than in blood or urine. This suggests the possible action of skin as an excretory organ for body toxins. Further studies are required to prove this activity of the skin.<ref name=glandtoskin/>

Cardiovascular diseases: In a cohort study it is reported that repeated heat stress therapy results in a reduction of cardiovascular risks.<ref name=PHcentralbloodV/>

Cardiovascular diseases: In a cohort study it is reported that repeated heat stress therapy results in a reduction of cardiovascular risks.<ref name=PHcentralbloodV/>

==Current clinical practices: ==

==Current clinical practices ==

In current clinical practice, fomentation therapy is done through three different forms:

In current clinical practice, fomentation therapy is done through three different forms:

The affected body parts are immersed in warm decoctions or oils

The affected body parts are immersed in warm decoctions or oils

==Mode of action of induced sweating:==

==Mode of action of induced sweating==

   

   

A raise in the external environment temperature leads to the vasodilation of cutaneous blood vessels. This increases the cutaneous microvascular blood flow. The systemic conductance is also increased. To maintain homeostasis, the cardiac output increases. As a result, the cardiovascular system gets stimulated, which in turn may stimulate the entire body metabolism. An improvement of endothelial function and reduction in arterial stiffness may also happen as a result of sweating. Sweating reduces the core body temperature. Anti-oxidant capacity might get also improved. It may also improve the lung's vital capacity and thereby aids in micro ventilation. The above data shows the action of induced sweating on different systems however, more studies are required to find out the exact mode of action.<ref name=PHcentralbloodV/>

A raise in the external environment temperature leads to the vasodilation of cutaneous blood vessels. This increases the cutaneous microvascular blood flow. The systemic conductance is also increased. To maintain homeostasis, the cardiac output increases. As a result, the cardiovascular system gets stimulated, which in turn may stimulate the entire body metabolism. An improvement of endothelial function and reduction in arterial stiffness may also happen as a result of sweating. Sweating reduces the core body temperature. Anti-oxidant capacity might get also improved. It may also improve the lung's vital capacity and thereby aids in micro ventilation. The above data shows the action of induced sweating on different systems however, more studies are required to find out the exact mode of action.<ref name=PHcentralbloodV/>

==Current researches:==

==Current researches==

Whole body fomentation therapy results in cardiovascular stress. There will be increase in cutaneous vascular conductance followed by increase in systemic conductance. But the homeostasis will be maintained by decreased conductance at noncutaneous bed and increased cardiac output. It might be due to this increased cardiac output and by the redistribution of blood from central to peripheral circulation, a reduction in central venous pressure occurs during the onset of passive heating. In certain studies, it is noted that passive heating significantly raises the left ventricular ejection fraction.<ref name=PHcentralbloodV/>  In an observational study on whole body steam fomentation (sarvangabashpa sweda), significant increase in pulse rate and blood pressure was recorded immediately after the completion of the therapy. This raised blood pressure and pulse rate were transient as it came back to normal after five minutes of therapy.<ref>Sanjeev R, Francesco C.Hemodynamic effects of Sarvanga Swedana (Ayurvedic passive heat therapy): A pilot observational study.Ayu. 2013 Apr;34(2):154-9. doi: 10.4103/0974-8520.119669.</ref>

Whole body fomentation therapy results in cardiovascular stress. There will be increase in cutaneous vascular conductance followed by increase in systemic conductance. But the homeostasis will be maintained by decreased conductance at noncutaneous bed and increased cardiac output. It might be due to this increased cardiac output and by the redistribution of blood from central to peripheral circulation, a reduction in central venous pressure occurs during the onset of passive heating. In certain studies, it is noted that passive heating significantly raises the left ventricular ejection fraction.<ref name=PHcentralbloodV/>  In an observational study on whole body steam fomentation (sarvangabashpa sweda), significant increase in pulse rate and blood pressure was recorded immediately after the completion of the therapy. This raised blood pressure and pulse rate were transient as it came back to normal after five minutes of therapy.<ref>Sanjeev R, Francesco C.Hemodynamic effects of Sarvanga Swedana (Ayurvedic passive heat therapy): A pilot observational study.Ayu. 2013 Apr;34(2):154-9. doi: 10.4103/0974-8520.119669.</ref>

===Effect of fomentation through tube (nadi sweda):===

===Effect of fomentation through tube (nadi sweda)===

   

   

Fomentation through a tube (nadi sweda) and simultaneous passive stretching have shown a beneficial effect in knee joint contractures due to rheumatoid arthritis.<ref>Patel MM, Patel MV, Gupta SN, Patel KB. Effect of Nadisvedana with simultaneous passive stretching on correction of sandhijadya. J Ayurveda Integr Med. 2018;9(1):61‐63. doi:10.1016/j.jaim.2017.07.002</ref> Local hyperthermia improves blood circulation and local blood tissue metabolism. It also helps in reducing inflammation by lowering various inflammatory mediators.

Fomentation through a tube (nadi sweda) and simultaneous passive stretching have shown a beneficial effect in knee joint contractures due to rheumatoid arthritis.<ref>Patel MM, Patel MV, Gupta SN, Patel KB. Effect of Nadisvedana with simultaneous passive stretching on correction of sandhijadya. J Ayurveda Integr Med. 2018;9(1):61‐63. doi:10.1016/j.jaim.2017.07.002</ref> Local hyperthermia improves blood circulation and local blood tissue metabolism. It also helps in reducing inflammation by lowering various inflammatory mediators.