Changes

=== ''Vidhi Vimarsha'' ===

=== ''Vidhi Vimarsha'' ===

''Swedana'' should only be administered following a proper ''snehana'' (unless indicated otherwise). On application of unctuous substances like ''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>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''.

''Swedana'' should only be administered following a proper ''snehana'' (unless indicated otherwise). On application of unctuous substances like ''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''.

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]

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]

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.  

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.  

''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) 1) Reduced heart rate at a fixed work rate 2) Expanded plasma volume 3) lower core temperature at an equivalent workload 3) Superior Na and Cl reabsorption from sweat, and an elevated sweat secretion. [8] [verse 13]

''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  

#lower core temperature at an equivalent workload, and

#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]

It is very essential to differentiate heat exhaustion from heat stroke. 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. [[Charaka 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 [9] [verse 14-15]

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. [[Charaka 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]

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 [[Charaka Samhita]]. [10]

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 [[Charaka Samhita]]. <ref name="ref2" />

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. [11]

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 [12]

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>

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.  

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.  

*Whiplash and other musculoskeletal types of neck pain, shoulder pain, such as rotator cuff injuries.  

*Whiplash and other musculoskeletal types of neck pain, shoulder pain, such as rotator cuff injuries.  

*Decreased range-of-motion like in frozen shoulder, other types of joint pain, including many forms of arm pain (e.g., tennis elbow), leg pain (e.g., restless leg syndrome), knee pain (e.g., injured anterior cruciate ligament), foot pain (e.g., plantar fasciitis), tendonitis, bursitis, sprain, costochondritis, abdominal and pelvic pain, and fibromyalgia,  

*Decreased range-of-motion like in frozen shoulder, other types of joint pain, including many forms of arm pain (e.g., tennis elbow), leg pain (e.g., restless leg syndrome), knee pain (e.g., injured anterior cruciate ligament), foot pain (e.g., plantar fasciitis), tendonitis, bursitis, sprain, costochondritis, abdominal and pelvic pain, and fibromyalgia,  

*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. [13] [verse 20-24]

*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]

''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. [14]

''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'' ====

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

Take cotton cloth of one square meter size and divide it into four equal square pieces. Place four square pieces of cloth (each four inch) at the center of each cloth. Put equal portion of prepared drug into four pieces. Hold the cloth by the four corners and make the drug into a bolus. Hold tightly at the junction. Leave the larger end of the cloth and fold the other three corners by inserting into the center. Using the large flap of cloth surround the folded ones neatly and tightly so that it is sufficient to hold. Tie the twine at the junction of handle and bolus. Wind this tightly with the free end of the twine and fasten the knot.  

Take cotton cloth of one square meter size and divide it into four equal square pieces. Place four square pieces of cloth (each four inch) at the center of each cloth. Put equal portion of prepared drug into four pieces. Hold the cloth by the four corners and make the drug into a bolus. Hold tightly at the junction. Leave the larger end of the cloth and fold the other three corners by inserting into the center. Using the large flap of cloth surround the folded ones neatly and tightly so that it is sufficient to hold. Tie the twine at the junction of handle and bolus. Wind this tightly with the free end of the twine and fasten the knot.  

''Kizhi'' once prepared is used upto a maximum of 3 days.  

''Kizhi'' once prepared is used upto a maximum of three days.  

===== Preparation of the patient =====

===== Preparation of the patient =====

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

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 ''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.

#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.15

#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>

Another study reported that infrared radiation application was more effective than hot water fomentation in minimizing the level of pain among patients with osteoarthritis of the knee 15.

 

Another study reported that infrared radiation application was more effective than hot water fomentation in minimizing the level of pain among patients with osteoarthritis of the knee <ref name="ref3">.

===== ''Pizhicchil'' =====

===== ''Pizhicchil'' =====