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Introduction

Avabahuka is one such disease that hampers the day-today activity of an individual. Avabahuka is a disease characterized by morbid Vata Dosha localizing around the Ansa Pradesha (Shoulder joint) and thereby causing Soshana (Atrophy) of Ansa Bandha (ligaments of shoulder joint) as well as Akunchana (contraction) of Sira (vessels) at this site1. Acharya Vagbhata mentioned that morbid Vata Dosha in Ansa Moola causing Shira Sankocha and Bahupraspandithara which means impaired movement of upper limb, Acharya Bhavaprakasha and Vangasena mentioned Ansabandhan Shosha and Vedana (pain) in Ansa Pradesha in Avabahuka. 

Nidana (Hetu): Nidana In, classics, the causative factors for Avabahuka are not mentioned separately. Only the aggravated Vayu is considered as the prime factor. In regard to causative factors of Vata Vyadhi, only Acharya Charaka, Bhavprakasha, have explained in detail, while in Sushruta Samhita, Ashtanga Samgraha, Ashtanga Hridya etc. the causes of Vata Vyadhi have not been clearly described.

In case of Avabahuka, Hetu (causes) may be classified into two groups;

1. Bahya Hetu:  Causing injury to the vital parts of the body (Marma) or the region surrounding the Ansa Sandhi, which is also known as Bahya Abhighata.
2. Abhyantra Hetu: Indulging in the etiological factors that aggravate Vata leading to the vitiation of Vata in that region and is also known as Dosha Prakopajanya, which in turn leads to Karmahani (loss of function) of Bahu. The Nidanas are given below:

1. Aharaja Rasa:  Katu, Tikta, Kashaya Rasa Guna- Laghu, Ruksha and Sheeta Guna Dravya- Adhki, Chanaka, Kalaya, Masura, Mudga, Nishpava, Shushkashaka, Tinduka Matra- Abhojana, Alpashana, Vishamashana Cause vitiation of Vata.

b) Viharaja: The exercises directly or indirectly influencing the shoulder or Amsa Desha should be considered here Vyayama, Plavana, Bharavahana, Balawat Vigraha, Dukha Shayya.

Roopa: Roopa in case of Avabahuka, Sthanika Lakshana (local symptoms) takes important place as compared to Sarvadaihika Lakshana.

The cardinal features of Avabahuka are as follows.

• Bahu praspanditahara

• Ansabandhana Shosha

• Shoola

In Ayurveda, there is no direct correlation of any disease with frozen shoulder but some symptoms of Avabahuka resemble the symptoms of frozen shoulder.

Samprapti (aetiology)2, 3, :

Samanya Samprapti in case of Avabahuka, two ways of vitiation of Vata can be considered.  The etiological factors like Ruksha, Laghu, Atibharavahana and the like causes vitiation of Vata directly. In another way, Kapha Prakopaka Nidanas like Atisthirta, Atiguru Dravya and so on cause an increase in the Vikruta Kapha, which produces the Kaphavrita Vata condition3. In both ways, the Vikruta Vata Dosha gets accumulated in the Srotas and manifests symptoms of Avabahuka.

Vishistha Samprapti: In case of Avabahuka, the examination of the etiological factor reveals the underlying predominance of Ativyayama and Abhighata causes Vata Dushti. The Vata vitiated here is Vyana. According to Acharya Charaka and Acharya Sushruta, Vyana Vata is continuously circulating in the entire body and hence its location is body as a whole. Also, Acharya has mentioned its functions like motion, extension and movements of the body parts but because of excess walking, exercise, improper activities, taking food which is incompatible and dry, aggravates Vyana Vayu. Khavaigunya gets generated in Ansa Sandhi because of Nidana Sevana related to Ansa Pradesha and therefore Vyana Vayu of shoulder joint gets aggravated. Morbid Vyana Vata and the excess use of the shoulder joint like Plavana, Balwat Vigraha types of Nidana also causes Marmabhighata and Abhighata in Shleshama Dhara Kala. Marmabhighata is one of the causes of Shotha and Shotha leads to thinning of Sira. Because of this, there is block of nutrients to affected Dhatu of shoulder joint and thus leads to Bahupraspandithara. In another way, Kapha Prakopaka Nidana like Atisthirta, Atiguru Guna of Kapha Dosha and so on cause an increase in the Vikruta Kapha, which produces Kaphavruta-Vata condition and this will lead to heaviness all over the body, pain in all joints and loss of mobility.

Samprapti Ghataka: The factors involved in the pathogenesis of the disease are known as Samprapti Ghatakas. The main Samprapti Ghatakas involved in the diseases are described here:

Dosha: Vyana Vayu, Shleshaka Kapha

Dushya: Sira, Snayu, Mamsa, Kandra, Asthi

Srotas: Mamsavaha, Asthivaha

Sroto Dushti: Sanga, Vimargagamnama

Udbhava Sthana: Pakwashya

Vyakta Sthana: Bahu

Adhishthana: Ansa Pradesha

Vyadhi Swabhava: Chirkari

Chikitsa5: Acharya Charaka in Chikitsa 28 and Acharya Sushruta in Chikitsa 4 has mentioned the prime Chikitsa Sidhanta is Nidana Parivarjana and here complete rest is required if the condition is much severe. Avabahuka being a Vata Vyadhi, general Vata Upakrama is advisable for Vata Shamnama. Snehanam, Swedanam, Abhyangam, Upanaha, Upveshtanam, Unmardanam, Peedanam, Samvahanam, Parisheka, Avagahana, different types of Lepas etc. all which pacifies the Dosha and corrects the Gati of Vata are mentioned as the treatment principle of Vata. All these are applicable to the disease of Avabahuka.

Case Study: In current study 45 years male approached to our OPD with complaints of difficulty in movement of Right shoulder. Patient has history of lifting of heavy weight before 15 days and since then he started above complaints. Patient has taken some conservative treatment from outside in form of Analgesic and antacid. But no relief was observed. On clinical examination it was observed that patient having general condition Fair.  No history of any major medical illness, Patient was not having any medication. Systemic examination No abnormality was found.

Local examination: No localised tenderness was present. Movement of right shoulder forward and backward movement was obstructed and painful beyond 15 degrees. Abduction of Right shoulder joint not moving beyond 10 degrees. It was painful after forceful movement. Patient was diagnosed as Avbahuk on right side.

Treatment planned

Cauterization with Electrocautery as Agnikarma

Period: once a week for 3 weeks

Agnikarma Procedures by Electrocautery method Samyak dagdha Lakshan.

Agnikarma Procedures: Procedure of Agnikarma The procedure performed in three stages as Purva Karma, Pradhana Karma, and Paschata Karma mentioned by Acharya Sushruta. Purva Karma Snigdha Picchila Annapana (rice and curd) was given prior to the procedure6. The site of Agnikarma was washed with Triphala Kwatha and wiped with dry sterilized gauze and covered with a hole sheet. Electrocautery was prepared (All connections attached. cautery probe is clean and sterile. A cautery probe with rounded ball like tip was used). Madhu & Ghrita are kept ready for dressing.

Pradhana Karma: Supine position was adopted as it is comfortable to the patient. Irrespective of a specific site, Agnikarma was done at maximum tender site affected. Agnikarma in the form of samyak twak dagdha (therapeutic superficial skin burn) as done by making a Binduvat dahana vishesa (single dot at maximum tender site) with dahanopakarana7 i.e., electrocautery with spherical head. Appropriate precaution was taken not to produce asamyak dagdha vrana (neither superficial nor too deep burn). After Agnikarma, fresh Ghritakumari pulp was applied on Dagdha to relieve burning pain.

Paschat Karma8: After wiping of Ghritakumari pulp, honey and ghee was applied on Dagdha Vrana. Patient was observed for 30 min after procedure and advised Pathya. Pathya as mentioned in Sushruta Samhita Patient was advised to apply the paste of Madhu & Ghrita bed time. Pathya for both Groups Vata vardhak ahara-vihar (diet and activities which aggravate vata dosha) was also restricted during the treatment and follow-up period.

Sr. no.   SamyakDagdha Symptoms   Yes/ No

                 and Diseases

1. Twak    1. shabdapraadurbhav

                    2. durgandhata

                    3. Twaksankoch

Confirmation of Vvyadhimukti by Agnikarma –

1) V.A.S.: Visual Analog Scale was used for assessment of pain

2) Goniometry was done to assess the range of motion

It was observed that movement of Right shoulder was increased with regular treatment. Patient did not have complete relief from disease but considerable improvement was observed. Pain during movement of right shoulder was decreased considerably. After 3 weeks of treatment considerable improvement in movement i.e Flexion, Extension and Internal rotation of Right shoulder was observed.

Discussion

In current study Agnikarma was done by using electrocautery which is readily available in operation theatre. Intensity of electrocautery was kept at 1 and was placed at coagulation was used for Agnikarma. Electrocautery generated heat energy and forming effect of Agnikarma on skin.

All signs of Twakgat agnidagdh was obtained due to Agnikarma with electrocautery. Effect of Agnikarma was helpful in reducing pain in right shoulder. Vata is mainly responsible for pain, Ushna and Tikshna properties of Agnikarma helps in reducing vitiated Vata. Also, it creates localised counter irritation and helps in reducing pain due to frozen joint and rotation of joint gets easier. Once localised stambha of joint gets converted into mobilisation it helps in further pain free movement of joint. Thus, it helps in reducing overall symptoms of Avbahuaka and helps in treatment of disease.

Conclusion

Agnikarma with electrocautery was helpful in management of symptoms of Avbahuaka. Also, process was easy and handy.

Samyak dagdha effect can be achieved by Agnikarma by electrocautery in Agnikarma sadhya vyadhi.