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Introduction

Marma science is one of the hidden sciences of Ayurveda which was practiced in Vedic era. Marma are the vital points of the body described in Ayurveda that, when injured, may lead to pain, disability, or even death depending upon the type of Marma involved. There are 107 Marma points in the body, and have been elaborately described in Sushrut Samhita.1An anatomical place where muscles, veins, ligaments, bones, and joints connect is known as a Marma point.1These are vitally significant locations known as the “seats of life” (Prana - the vital life force).2  Marma science is an ancient art of healing based on re-energizing vital points in the body for revamping the Prana which is hidden status as Gupta Vidya (occult science). After stimulating the Marma points, many transformations in the body's biochemistry might occur, resulting in a revolutionary chemical change in one's make-up. Stimulation of these inner pharmacy pathways causes the body to produce therapeutic neuro-chemicals which allow the body and mind to heal. In recent years, the applied aspect of this concept, i.e., Marma chikitsa/ therapy, is drawing attention and gaining popularity as these vital sites are being directly utilized by Ayurvedic physicians to obtain therapeutic goals by controlled physical stimulus on them. The controlled stimulation of each Marma is different from other and is done by using hands only. The basic logic behind the use of these Marma regions rest on the theory of Panchamahabuta and Triguna, the fundamental constituents of all physical forms. It is hypothesized that Marma has holistic effect as their stimulation directly affect Prana (life force) which in turn influence all the three doshas, nadis, and chakras bringing homeostasis and subsidence of ailments.3,4 Testing of this hypothesis in different ailments is yet to be done. Although, a few studies have been conducted, clinical data regarding efficacy of this therapy is very sparse and hence, its application in different diseases remained unexplored till date. The human body experiences continuous degenerative changes with age. The degeneration is very commonly observed, especially in the inter-vertebral discs in between the cervical vertebrae at higher ages. The slowly but gradually degenerating discs often irritate the nerve roots. This may develop symptoms in the extremity to which the irritated nerve is supplying. This leads to the start of problematic symptoms in the neck region. Neck pain is the worst amongst them. Neck stiffening & inability to perform movements are the other complications and the associated disease is the Sandhigata vata (cervical spondylosis), for which there is as yet no permanent cure available in the modern system of medicine. This disease can, however be effectively managed through the Ayurvedic system. This roga can be managed by using the Marma Chikitsa of Ayurveda.

2. CASE DESCRIPTION

2.1 Patient information: The patient was 60 years old female, business woman by occupation consulted in outpatient department of ITRA hospital, Jamnagar. She had a well-built physique, with a height of 165 cms and weight 70 kg.

2.2 Present medical history: During data collection for an ongoing research study with registration no - CTRI/2021/04/032983 in the Department of Shalya Tantra, ITRA, Jamnagar (India) the patient was enrolled, she had complain of pain and stiffness in Cervical region for one year and pain radiating to right upper limb for six months. Occasionally during the night and early morning she had felt tingling and numbness in both hands. She had a headache once in a week and sometimes felt vertigo. Before two months back, she had a painful neck movement. She had diagnosed as a case of cervical spondylosis. She had consulted neurological and orthopedic doctors in Jamnagar and surgical intervention was advised, which the patient refused. She had advised to take analgesics and anti-inflammatory medications for pain management by a previous consultant.

2.3 Past medical history: She had known case of hypertension and taking Tab. Telmisartan –H 50mg once in morning since last two years. She had no any history of diabetes mellitus, thyroid problems, tuberculosis or any serious illness.

2.4 Past surgical history: She had done TAH (Total abdominal hysterectomy) in 1990. She had operated for Carpal tunnel syndrome in both hands in 2010-11.

2.5 Family history: There was no family history of hypertension or any other hereditary or congenital diseases.

2.6 On physical examination: On physical examination, the general condition of the patient was good, her pulse was 82/min, regular; BP was 130/80 mm of Hg; the respiratory rate was 18/min regular and the patient was afebrile. The tongue was clean, the voice was clear, the bladder habits were normal and the bowel constipated sometimes. She had Vata-Kapha Prakriti with Madhya Vayah (Medium age), Madhyama Sara (medium purity of body tissue), Madhyama Satva (Medium mental strength), Madhyama Satmya (homologation), Sama Pramana (equal body proportions), Avara Vyayama Shakti (least physical endurance), Madhyama Ahara Shakti (medium food activity and digestive power). The patient had a normal gait. The active movement of the range of the cervical spine was restricted. Pain aggravated on the movement of the neck. On examination, tenderness was found. over C3, C4, C5, C6, and C7 vertebras. All cranial nerves were well intact.

2.7 Investigation: There was no significant finding on lab investigations. X-ray of Cervical spine (AP & Lateral view) that was done on (19/03/2021), suggested Grade 1 anterolisthesis of C3 over C4 vertebra; changes of cervical spondylosis in form of reduced inter vertebral disc spaces, anterior and posterior osteophyte from C4 to C7 level.

2.8. Treatment plan

The patient was subjected to the controlled physical stimulation of below mentioned Marma after informed written consent on the same day. Each Marma was stimulated for 20-25 times in one sitting per day and pressure applied should be optimal with contact time of one cardiac cycle constituted by 0.8 seconds for two weeks empty stomach in the morning. The rhythm of stimulation is same as the rhythm of our respiration i.e. approx. 18 times per minute. Start pressing the Marma in the upper extremities from centre to periphery and for male start from the right side but here the patient was female we started the stimulation of Marma from the left side of the body.

After thorough instructions about self-Marma stimulation, she was trained for it and told to continue the therapy once in a day.

Observation                 

The assessment was done on the bases of improvement in symptoms and range of movements along with NDI score [Table.2] On 1st consultation, Visual analogue Scale (VAS) score was 6, stiffness was present while given 1st sitting of Marma stimulation pain VAS score was 2 and stiffness was relieved immediately. After given continuous 14 days sitting of Marma stimulation active range of motion which was measured by Goniometer and NDI score, before and after treatment given in Table.2 There was significant improvement was seen.

VAS-Visual analogue Scale, Hb-Haemoglobin, ROM-Range of Movements, TC-Total count, DC-Differential count, ESR-Erythrocyte Sedimentation Rate, RBS-Random Blood Sugar, NDI score – Neck Disability Index Score

Discussion

All Marmas are present in bilateral upper and lower limbs. The classical texts of Ayurveda instruct to prevent the Marma or vital points from being injured. But, in the current era, these Marma are physically stimulated in controlled way to treat diseases. In this case, bilateral upper extremities Marmas – Krikatika, Ansa, Urvi, Ani, Kurpar, Kshipra & Talahridya (only in leftside) stimulation was given to the patient whom was suffering from cervical spondylosis with bilateral CMC (Carpometacarpal joint) arthritis. With her consent, this therapy was given once a day for 14 days.  The above-mentioned Marmas was identified and pressed in the both hand along the thumb & finger and was pressed in a controlled way, 20 to 25 times in coherence with breathing. These Marmas can also be pressed by the therapy receiver itself with the help of index finger and thumb of the other hand after through instruction. Thus, this therapy was also taught to the patient and regular follow-up was done with the ongoing therapy. During the first day of therapy, the patient felt slight bearable pain on the Marma area. She was over-cautious while going through the therapy. On the first day there was reduction in pain and stiffness immediately after the therapy. However, on the second day, the pre-therapy pain & stiffness was lower than the previous day which motivated the researcher to continue the therapy. After seven days, pain (VAS-1) significantly decreased; stiffness totally relieved; ROM of neck joint improved; occasionally tingling and numbness at night, no headache and vertigo was found. After fourteen days, painless (VAS-0) normal flexion, extension, lateral flexion achieves and except rotation towards left; no tingling and numbness was seen. From the first day of the therapy, till the last date, she did not have any problem in her neck along with its movements. The patient is still practicing self-Marma therapy and her neck pain and ROM is within normal range till the day of reporting this case report. This finding reinforces the hypothesis that Marma regions of the body are the vital regions having multimodal and multi-dimensional effects due to their influence on Prana and hence, on Tridsoha and Triguna which perhaps brings harmony between the systems of the body.6

Patient perspective on treatment received

On the first screening day for the study, I was not aware of Marma therapy in the management of Cervical spondylosis for which I had taken different kind of treatment previously but I didn’t get any relief from it. So, I became bit tensed about my disease. But the investigator and his team counseled me well enough and they advised me to consult in Asthi Sandhi & Marma OPD. After thoroughly screening by the consultant and his team after which they demonstrated the Marma therapy on me. The therapy was comfortable, and I felt slight bearable pain at that point which subsided as the therapy was finished and to my surprise, my neck pain lowered, neck stiffness relieved immediately after first sitting which motivated me to go for the therapy. I start coming to the Marma department daily to get the therapy and to learn the therapy which continued for 14 days. I had no complaints either during the therapy or post-therapy. I was happy to see that the readings of my neck pain and range of motion gradually came to normal limits. Right now, I am having normal range of motion without pain. Thanks to the investigator and his team for all efforts and teaching me the therapy which was extremely easy to learn and1 apply.

Conclusion

Marma therapy was found to have immediate effect in pain and stiffness and good long-term effect in normalizing pain, resulted in total reduction of pain as well as stiffness over the affected area to good extent. Also, the patient was able to carry on with her day to day work and lifestyle with precautions advised. Thus, a further large-scale study is needed to analyze the effect of Marma therapy in cervical spondylosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the Director, ITRA, Jamnagar.

Conflicts of interest

There are no conflicts of interest.

Disclaimer: All Ayurvedic therapies provided aim towards improving the quality of life of the patient and does not advocate medical diagnosis or claim cure of disorders.