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Introduction

Pain or shoola, these are the terms that are used to explain the physical discomfort one feels in any kind of situation but this term is not used just to explain the physical discomfort felt by a person but is used to explain even when a person is in some kind of emotional distress or mental discomfort and this feeling of discomfort or distress affects the mental and physical health of a  person, their speed of recovery from the injury or so and their overall immunity as well, this connection is not direct and somewhat difficult to decode but the pain is an extensive topic that needs to be looked into depth to be understood completely, that is why a complete chapter in Madhav nidana has been dedicated to helping understand the concept of pain in extreme detail and solution can be found for the same.

The first step to understanding anything to understand is to know its definition, so, how is the term “pain” described in the texts and by the IASP(International Association for the Study of Pain), is as follows-“An Unpleasant sensory and emotional experience associated with, actual or potential tissue damage”. Pain is always an individual experience that a person experiences and understands in the journey of life and when we are to understand the definition and its meaning it comes as it can be a physical experience as well as a psychological experience and is always associated with the actual or potential tissue damage, this is the word to word meaning of the definition. Now, if we look at the definition provided by the Acharyas is as follows- “shoolanikhatvedvdnajanakatvaccha” This is a Sanskrit verse taken from Sushruta Samhita uttartantra chapter 42, which gives us the meaning of the term “shoola” which is, that “when a person feels a piercing feeling which is similar to drilling a screw into the body of a person then this piercing feeling is named as shoola.” Now, here we get to understand exactly what feeling is called the shoola, which on experiencing and on being explained to the Vaidya the person can understand that the person is in pain.

Normally, this pain can occur in any part of the body, it does not have a specific place of its own but it depends on the causative factor on which place will the pain manifest, also, pain or shoola is a symptom of a disorder as well as it is also a disorder o its own that can be manifested by the causes of it’s own, so this can be of both the types. Let us understand how is this a disorder on its own.

Shoola- an independent disorder

As earlier the meaning of the term shoola has been explained, here we will try to understand what are the causes that can lead to shoola, what is its pathogenesis (Samprapti), it’s types and how can it be treated.

1. Causes of shoola(nidana)-

This is well known that vata is the dosha that is responsible for all the kinds of pain(shoola) a person experiences as vata is the only component that has the property for motion and it is what is responsible for any kind of sensation felt as it is what controls the nadivaha strotas, so this can be understood that the dosha that is predominantly involved in shoola is the vata dosha and thus the causes includes all the factors that are responsible for the aggravating vata along with some other factors as well, these are as follows-

Vega dharan- this one cause is responsible for aggravation of vata very dominantly as when the body does not excrete the waste on time, then the Apan Vayu is disturbed and this disturbed Apan Vayu then takes the opposite path from the normal i.e. it attains a pratiloma gati and this pratiloma gati then leads to disturbing of other vayu gatis as well and when such a dushit vayu finds khavaigunya it can lead to shoola.

 Ati-bhojana, ajirna, adhyashan- all three factors are related to the digestive system and all of them grossly act in a very similar fashion, as, if the digestion is not proper then what can happen? The first thing that happens is the agni dushti, and this agni dushti will lead to agni mandhya, which will make the stomach unable to digest the incoming food properly once this happens, the next thing to come line is that what is responsible for the agni to have adequate power? Again it’s vayu, the samana vayu is responsible for the proper functioning of the vayu and when this vayu is disturbed and agni doesn’t work properly then the food remains stagnant in the stomach that may lead to conditions like gas and stomach ache and this way these causes are responsible for the shoola as well, even Acharya Sushruta and Acharya Charak mentions that the places of Gulma in the abdomen are the main points for shoola as well.

Ati- parishram (excessive working)- when a person works excessively, then the person feels exhausted and pain in their whole body, this can be understood as follows, that when a person works excessively like lifting some thing heavy, standing work for a long time, writing for a long time or any such work then leads to pain as, the pressure that in put in all these works in a bit different, now, if we are to say that the person lifted something heavy that was not meant for them to lift, now the person basically put much more pressure on his legs, hands, chest and eventually heart as this will increase their blood demand and to fulfill that the heart has to pump blood faster and when this happens the vayu that is responsible for this one act is the vyan vayu and it’s stana is the whole body as this vayu basically keeps on circulating in the whole body and once or twice it is not an issue but if the person is doing the same regularly then the vyan vayu doesn’t get enough time to transport adequate amount of nutrients to each part of the body and even the vayu because of not able to work properly will be imbalanced and then this imbalanced vayu leads to pain in whole of the body, but if the pain is only in upper or lower limbs, then the concept of kha vaigunya works in a similar way that the dhatus of that part is not adequately strong and the dushta vayu leads to shoola in that Kha Vaigunya, it is bit similar to concept of strained us less that are the reason for the pain in that specific part of the body or the reduction in bone density etc.

Pishtamya food and dry meat (Shuska mamsa)- The consumption of the kinds of food mentioned like dry meat (Shuska mamsa) can lead to an increase in properties like rukshta and all in the body of a person which will then lead to them increasing the dryness in the body which will lead to aggravation of vata in overall body and thus may cause pain.

Pathogenesis of Shoola:

After understanding the causes of shoola in all its complex now we are to see the pathogenesis or the Samprapti of the shoola. Shoola or pain is a feeling, it does not have any kind of physical manifestations, so when there is no physical manifestation of pain and is just a feeling, then this feeling is related to the nervous system as that is the sole system that is responsible for transferring of different signals throughout the body, this nervous system is called nadivaha strotas in Ayurved and again is governed by vata mainly. So now, one point is much clearer why is vata the main cause behind the shoola.

The pathogenesis is explained by Kaviraja Gana Nath Senaji as follows-

When in the Nadivaha strotasa, (Sangyavaha strotas are the nervous system) there is any kind of irritation and that specific kind of irritation is the cause of pain, and each type of pain has a predominance of vata dosha.

We have seen and understood the predominance of vata in the shoola very clearly, now, the pathogenesis here is explained in short and mainly focuses on irritation of the nerves that leads to pain. If we see the mechanism of pain in modern science then also, we observe that the pain is due to stimulation or dysfunction of the nervous system only, the same is explained by Acharya here.This way the pathogenesis of the shoola has been explained.

Types of shoola:

Shoola has been described to be of Eight  types, which are-

vataj, pittaj, kaphaj, vata-pittaj, pitta-kaphaj, vata-kaphaj, sannipataj, aamaj.

All the causes and symptoms are similar to the aggravating factors of the doshas, also, this is to be noted that these types are because even after the dominance of vata, the dosha that is acting along with vata is the determining factor for the types of shoola and that determines the type of treatment to be provided.

Management of shola:

Shoola, as we have seen can be a disorder on its own, now, we need to see the solutions that are provided by Ayurveda in the field, and many solutions Ayurved provides for the relief from pain. The important thing to understand here is that the solutions here are not necessarily pain killers, these drugs do not act as pain killers, but they are pain relievers that help in keeping the pain at bay and help in recovering the body fast and well. For understanding the management and treatment protocol well, we need to understand the underlying concept of it well.  As was stated in the causes, how the causes are leading to disturbance of different types of vayu ad leading to different types of pain, then now we will see what Vayu leads to what type of pain, if the pain is generalized, i.e. if the person feels the pain throughout the body, then the vayu responsible for pain is vyana vayu; for headache prana vayu and the vyan vayu are responsible; while for abdominal pain saman and apana vayu are responsible, for chest pain, prana vayu, and vyana vayu along with the udana vayu is responsible.

 So, for proper treatment, it is extremely important to understand the following things-

• to understand, the site of pain
• to find the underlying cause of pain
• to understand the nature of pain
• to understand the doshas involved in the pain
• knowledge of proper and appropriate methods to treat the pain

After, understanding the following things, then the treatment should be done with an appropriate method the following is explained below-

1. Medicinal drugs- Some extremely effective medicinal drugs and formulations are explained in the texts that can help with the pain to a great extent, one of such groups being the Vednasthapaka Dravya that are explained by Acharya Charak. Acharya charak has mentioned the Vednasthapaka Maha Kashaya in the 4th  chapter of the Charak Samhita sutrasthana and the drugs that are mentioned are as follows- 1. Shala; 2. Kayaphala; kadamba; padmak; tumba; mocharasa; Shirish; vanjula; aelua; Ashoka, these 10 drugs are mentioned that are helpful in vednasthapana as is explained in the chart below-

 Table no.1  Showing vednasthapana drugs and its properties:

Panchakarma in Shool:

2. Snehana-   Snehana is one of those methods used for pain reduction in which the whole body is thoroughly and methodically massaged to balance out the doshas with the attempt to reduce the pain, for example, if the patient is suffering from muscle-related pain (mamsa dhatu) now, such a pain could be due to over exertion and in such types of pain snehana is the best method to be used for relaxation where the oil is used to massage the part properly that leads to relaxation of the muscle and thus it being free from pain. This method uses different pressure points to provide relaxation to the body, this is a treatment process that can be integrated with the Marma Chikitsa to provide the best possible treatment.

 3. Swedana- Swedana is the treatment procedure in which the whole body or a local part is provided relief with sudation, through sudation the heat is integrated inside the body relaxes the muscles, and balances the doshas, especially vata, as has been mentioned earlier, vata is the main dosha involved in the pathogenesis of pain this also leads to vasodilation that helps in better blood circulation to the targeted area which also helps in better relief in pain. This way swedana helps in the treatment of shola.

 4.  Basti –   Basti is a part of panchakarma, panchakarma, which is a collective name for the 5 main procedures used in the management of doshas and thus diseases. The five procedures that come under panchakarma are- Vaman, Virechan, Basti, Nasya and Raktamokshan. Which basti is described as the best treatment for vata dosha, which makes it an ideal procedure to be used for the treatment of shoola. The way basti works is that when the drugs are administered through the rectal path, the blood vessels in that area are stimulated which leads to absorption of the nutritive factors from the medicine used which later on circulates in the whole body through the bloodstream and these medicinal properties then leads to balancing of doshas in the body through their action after which then the shoola subsides, now, this mode of action is true but still if the pain is localized then also through the same mode of action the doshas in that place will be focused and treated upon.

5. Shirodhara- Shirodhara is a process in which oil is dropped with a specified pressure and height on the forehead of the patient, now, this process is used for disorders that are related to the brain or hair or so, even in mental disorders this process is very useful, but how is this process useful in the treatment of pain? As we have seen earlier pain does not necessarily have a physical representation an d many a times there are cases like where the pain persists but it does not have any reason but is a stimulation of brain, for example phantom limb pain, in this type of pain the patient may feel pain even if there is not any source to it like even after limb is amputees even after that the patient may feel the pain, in such cases  brain acts in an overactive manner and during that period it is important to provide calmness  the brain so that it can go back in its normal form of working, for which reason ashirodhara is one of the best procedures to go on with, as the oil is poured on a specific temperature from a specific height on a specific point on the forehead, which is the point just above the sthapni marma at the position of the penial gland which is the gland responsible for maintenance of circadian cycles etc and this is also the position of the agya chakra or the third eye, which is extremely important for the proper and balanced functioning of the body, these chakras re made up of numerous plexus present at the site in the body which on simulation helps in balancing the functioning of the body in a such better manner. This is how Shirodhara helps in relaxing the brain setting its functions back to normal levels and helping in enduring and reducing the pain of the patient.

6. Agni karma- Agni karma, is the process in which some type of heat stimulation is passed into the body which helps in the reduction of pain, agnikarma is one of those procedures that help directly in the reduction of pain and that too immediately. Its mode of action is somewhat difficult to understand this is a procedure in which the body is given a strong stimulation so this is a process that can work in two different ways, one is psychological while the other is physiological. These two are explained below as follows-

Psychological mode of action of Agni karma-

  According to modern research and their results, Agni karma is said to be working of the theory called “gatekeeping theory” This theory states that “when a non-painful stimulus is given to the body in the place of the painful sensation that is being transferred by the body, then the painful stimuli is blocked and the brain does not receive that stimulus and thus the person is relieved from pain” this theory works just the same as the name suggests, a gate is being closed and the stimulus is not allowed to be passed from that specific gate which is the pain stimuli not being able to be passed from one point from another and being blocked. This is how the psychological mode of action of Agni karma is explained.

Physiological mode of action of Agni karma- The psychological mode of action of Agni karma is explained based on the following principle, “ body is a good conductor of both the heat and electricity and when this heat is transmitted in the body, the body absorbs this heat as the body is good in the absorption of heat now, when this heat is absorbed they can penetrate and reach upto 2-3 inches deep in the muscular tissues and ligaments, this heat energy that penetrated will then lead to the dilation of vessels, leading to better blood circulation, thus promoting better healing. When the mode of action of Agni karma is to be understood using the Ayurvedic point of view, it is explained as, when the heat is transmitted in the body, then this will lead to a reduction of vata and kapha doshas which will lead to the dissolution of strotorodha, this stororodha was the one that leads to vataj dushti and thus the vata is released, the rasa rakta samvahan is increased, this betterment will lead to a balancing of doshas, now, even after this the dhatavagni needs to be balanced which will also be balanced as the part of the process, and in this way, the shoola will be treated successfully. The Agni karma is most effective in the following types of painful conditions- musculoskeletal pain; neurological pain; arthritic problems etc.

This way the treatment procedures for the pain or shoola as is given by the Ayurved is explained and it can be easily observed that the texts provide so many treatment options for pain that are being faced by the patients, from the most basic form of a tablet to various panchakarma procedures have been seen that can be useful in the treatment of pain and even the emergency conditions regarding pain can also be managed with the use of Agni karma and raktamokshan procedures. So, this way, Ayurveda provides pain management to patients.

Discussion

Shoola, as we have seen in detail in the above sections is a type of symptom as well as can be a completely independent disorder as well and we have seen pain as well which is explained in detail and as we see the two, the treatment protocols that are proposed by the two parties are very different from each other whose origin comes from the point where the pathogenesis for the occurrence of pain is given the principle used by the two pathies are different so the focus during the treatment is also different which leads to the difference in the treatment protocols advised by the two pathies can be observed. To point out some of the most important principles used in pain management in Ayurveda are the doshas and their predominance, the main cause of pain, the dietary and behavioral habits and how they affect the pain of the patient, the emotional and mental state of the patient, the cause may be visible or invisible. All these factors are kept in mind and during the treatment, all the factors are taken into consideration. While, when we look at allopathy, the principles used for treatment are, determining the physical cause of pain, and identifying the mechanism of pain, pt. should be encouraged to endure some amount of pain. While giving the medicine a fixed analgesic ladder that is given by WHO( World Health Organization) is to be followed that goes as follows- 1. Non-opioid analgesic + adjuvant, if the pain persists, then 2. Opioid for mild/moderate pain + non-opioid + adjuvant what is needed and what not should be decided by the doctor accordingly, even after this pain persists then the dose is to be increased for the opioid .these steps are decided for all while Ayurveda provides the freedom to design the treatment plan according to the patient.

Conclusion

After evaluating the concept of shoola from different perspectives, it can be observed that Ayurveda also provides a good number of options for pain management that are both feasible and fast acting or as there is needed, in the pain related disorder as well as emergency conditions the procedures and drugs are available in Ayurveda to tackle the condition and manage it properly. Also. Ayurveda gives various options for treatment for the patients.  Ayurveda offers the patient a wider range of therapy like Basti, Nasya, Shirodhara,  Snehan, swedan and has fewer adverse effects.