A CLINICAL EVALUATION ON RUJAKARA MARMA WITH SPECIAL REFERENCE TO PAIN THRESHOLD

Abstract

Marmas are vulnerable spots, constituting the essential aspect of surgico-anatomical knowledge. While defining the type of marmas based on the effect or prognosis of the trauma, Acharya Sushruta has classified five types of marmas. Among them he has appreciated pain as a residual effect of trauma in Rujakara marma. This study was planned to analyze the tissues which were responsible for pain in Rujakara marma & to evaluate pain-threshold relation with this marma. The study involved 60 healthy individuals who volunteered. According to anatomical sites, in Group I was taken to evaluate pain threshold at 8 (Eight) Rujakara marmas (vital spots which have pain due to trauma) sites of body and In Group II the same 60 individuals were taken to measure pain threshold at sites other than Rujakara marmas. The results have shown that eight sites of Rujakara marma has different types of fibrous Scleratogenic tissues having high pain threshold noceceptive impulses, which might be the probable reason for Rujakara marmas to have a high pain-threshold in comparison to other sites of the body. [PUBLICATION ABSTRACT]

Headnote

ABSTRACT

Marmas are vulnerable spots, constituting the essential aspect of surgico-anatomical knowledge. While defining the type of marmas based on the effect or prognosis of the trauma, Acharya Sushruta has classified five types of marmas. Among them he has appreciated pain as a residual effect of trauma in Rujakara marma. This study was planned to analyze the tissues which were responsible for pain in Rujakara marma & to evaluate pain-threshold relation with this marma. The study involved 60 healthy individuals who volunteered. According to anatomical sites, in Group I was taken to evaluate pain threshold at 8 (Eight) Rujakara marmas (vital spots which have pain due to trauma) sites of body and In Group II the same 60 individuals were taken to measure pain threshold at sites other than Rujakara marmas. The results have shown that eight sites of Rujakara marma has different types of fibrous Scleratogenic tissues having high pain threshold noceceptive impulses, which might be the probable reason for Rujakara marmas to have a high pain-threshold in comparison to other sites of the body.

KEYWORDS: Ruja, Painthreshold, noceceptive impulse

INTRODUCTION

The Ayurvedic Science of Marma is itself a treatise on Surgico-anatomical learning. The concept of marma is a great contribution of Sushruta, who mentioned 107 vital points in various parts of the body, which should be carefully dealt with during surgery & should always be protected from injury, as the essence of life (prana) rest in them (Sushruta 200 B.C). Though general definition of Marma signifies that every marma is the confluence of five types of tissue, namely mamsa (muscle) Sira (vessels), Snayu (ligaments) Asthi (bone) & Sandhi (joints) (Charaka 200 B.C); but it is evident from the description of injuries that the traumatic effect or prognosis entirely depends on the predominance of the tissue type at the marma. Sushruta has classified Parinam prakar marmas (residual effect of trauma) into sadhyo pranhara (death on the spot after trauma) Kalantara pranhara,(death occuring after a short period post-trauma) Vishalyghana (death occuring after removal of foreign body from a traumatic wound) Vaikalyakara (there will be a stable deformity in the body structure post-trauma) & Rujakara. The vitiation of Rujakara marma creates only the feeling of pain and there is no condition of death or morbidity (Sushruta 200 B.C). There are eight points of Rujakara marma in the body out of which Gulfa (Ankle joint) and Manibandh (wrist joint) are sandhi & Kurchshira (brush like structure) are of Snayu predominance. The Rujakara marmas possess properties of Agni (Fire) & Vayu (Air) Mahabhutas both of which causes pain as a residual effect of trauma (Sushruta 200 B.C). The perception of pain due to trauma depends upon many factors like pain receptors in the skin (mechanical, Chemical & Thermal receptors) & rate of tissue damage (Snell S.Richard, 1992). The differentiation without discrimination was assessed on the basis of gradation of pain-threshold & in the present work this criterion was adopted for differentiating tissues at different anatomical sites to understand 'Rujakara marma' in a better way. Hence a study was planned to differentiate out the tissues responsible for Rujakara marma and to study the pain threshold at Rujakara marma sites & compare it with pain threshold in other body parts.

MATERIALS

The research work was conducted on 60 healthy individuals selected from Indira Gandhi Girls Hostel, P.G.Hostel of State Ayurvedic College, Lucknow. Some of the observations have been made by the researcher itself at the neighbourhood. All the 60 healthy individuals were taken in two groups:

Group I-Measurement of Pain threshold at site of Rujakara marma sthana

Group II- Measurement of Pain threashold 5 cms proximal to the site of Rujakara marma sthana

For this study a Proforma was prepared. The information regarding name, age, sex and occupation were noted down. The blood pressure, temperature, respiratory rate & pulse rate were also recorded. For the purpose of measuring pain threshold following instruments were used: Sphygmomanometer, Specially designed blunt conical wooden object, Scale, Stethoscope, Watch. (River.J, 1999).

METHOD

Measuring of Pain Threshold:

The subjects were asked to sit on a chair in erect posture placing forearm in supinated position on a table. A specially designed blunt conical wooden object with cuffof sphygmomanometer was kept on the site of Rujakara marma i.e. at the wrist joint (for manibandh marma) & just medial to the tubercle of scaphoid at the palmar surface (for kurchashira marma) (Solanki J.C.1982). Thereafter, cuffwas wrapped & air was gradually pumped to produce, pressure pain. As soon as the subject complained the pain, the pressure necessary to produce that degree of pain was recorded in terms of mm Hg. These readings were utilized as the parameter of painthreshold. For the measurement of pain threshold in lower extremities the wooden conical object was placed on Ankle joint (For Gulfa marma) & at the cross of line drawn horizontally on the planter surface by joining the medial conversity of medial cuniform bone and base of the 5th metatarsal bone and vertically following the junction of 1st and 2nd toe (For Kurcha Shira marma) (Solanki J.C.1982). For accuracy three readings were taken at the same place at a 10 min interval. For comparative studies, measurement of pain threshold was done on other body parts i.e. 5 cm proximal to Rujakara marma site. Average of all these readings of pain-threshold and observations were statistically calculated.

RESULTS

Table-1 indicates that the average pain threshold at Manibandha (wrist joint) was 190.36 mm Hg with a SD of ± 56.40 and 124.22 mm Hg with a SD of ± 46.60 was found at a site, 5 cm proximal from Manibandha Marma (wrist joint). Comparative assessment was statistically significant with 't' value of 18.52 and p value < 0.001. The average of pain threshold at Gulfa (ankle joint) was 151.71 mm Hg with a S.D. of ± 52.07 and for sites other than Gulfa (ankle joint) i.e., 5 cm proximal to the Gulfa Marma (ankle joint) was lower with a mean value 118.25 mm Hg with a S.D of ± 49.60. The difference observed was highly significant, with 't' value being 13.30 and p value <0.001. The mean value of pain threshold was 130.27 mm Hg with a S.D. of ± 48.48 and for site other than Kurchshira Marma of Upper extremity while it was 91.78 mm Hg with a S.D. of ± 45.68 for the other sites on the palm i.e. 5 cm distal from the Kurchashira Marma of Upper extremity. The comparative assessment shows the 't' value being - 7.149 and p value < 0.001, which is highly significant. The mean value of pain threshold at Kurchshira Marma of lower extremity was 170.65 mm Hg with a S.D. of ± 68.88 and other site on planter surface 5 cm distol to Kurchshira Marma of lower extremity while it was 120.95 mm Hg with a S.D. of ± 60.18. The comparative assessment shows the value were statistical significant with a 't' value of 9.685 and p value < 0.001. In Table-2 the mean value of pain threshold at Rujakara marma site was 136.02 mm Hg with S.D. of ± 46.23. The mean value of pain threshold of control group of Rujakara marma was 128.88 mm Hg with S.D of ± 48.85. So it was observed that the average pain - threshold of control site of Rujakara marma was lower than the average pain threshold at Rujakara marma sites. The comparison between the two groups is highly significant with a 't' value of 4.237 and p value < 0.001. The mean value of pain threshold at Rujakara marma site was 136.02 mm Hg with S.D. of ± 46.23. The mean value of pain threshold of control group of Rujakara marma was 128.88 mm Hg with S.D ± 48.85. So it was observed that the average pain - threshold of control site of Rujakara marma was lower than the average pain threshold at Rujakara marma sites. The comparison between the two groups is highly significant with a 't' value of 4.237 and p value <0.001.

DISCUSSION

Based on the result of vitiation of marma sites, the marmas are divided into 5 types in which the Rujakara marma belongs to least morbidity (Sushruta, 200 B.C). Ruja (pain) is a expression of body related to damage of tissue. This is a psychosomatic phenomenon which is different in every individual (www.iasppain. org), which has been made the criteria in this study to differentiate one site of tissue to another site of tissue. This phenomenon has been used as a basic tool by school of Sushruta to classify Marmas (vital spot) on the basis of result of the traumatic effect. All the tissues such as Mansa (Muscle) Sira (vessels) Snayu (ligament) Asthi (bone) Sandhi (joints) carry noceceptor a biological sensor which is related to noxious stimuli which is cast by mechanical (direct trauma) biological irritation & thermal The nonceceptive receptors are specialized nerve endings in skin and deep tissues and unlike other sensory receptors they are activated at high threshold by a range of potentially damaging stimuli (Grey's, 1980). This reveals that school of sushruta has concerned nonceceptive pain as a criterion for Rajukar marma. There are eight Rajukar marmas being comparatively high nonceceptive pain-threshold which also indicates that it belongs to sclerotogenous pain rather dermatogenic pain. The sclerotogenic pain pattern is selective of ligament, tendon, disc, periosteum & apophysial joint (Grey's 1980) the anatomical places of Rujakara marma carry one or more than one type of sclerotogenous tissue like manibandh (wrist joint) and gulfa (ankle joint) carry abundant ligaments and kurch shira consists largely tendons and all these have sclerogenatic pain receptors having high pain threshold. (Snell S Richard 1992). This discussion lead to Sushruta's observation in the form of Rujakara marma that the vital parts are precisely of sclerotogenous type of nonceceptive pain receptor, bearing high threshold as compared to other places where tendon, ligament & other fibrous structures are lesser in quantum. The Group II are largely consisting of muscle & vascular tissue which are definitely having lesser pain-threshold as compared to Group I.

CONCLUSION

The classified Rujakara marmas according to school of Sushruta anatomically placed at eight sites carrying different fibrous sclerotogenic tissues, have comparatively high threshold of noceceptive impulse. This observation further draws the attention to the subject of inquiry that whyManibandha (wrist) has the highest pain threshold than Kurchashira of upper extremity. This study opens the gate of further research to prove these specific observations made in present study.

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Cite this article:

Benjwal S (2013), A CLINICAL EVALUATION ON RUJAKARA MARMA WITH SPECIAL REFERENCE TO PAIN THRESHOLD, Global J Res. Med. Plants & Indigen. Med., Volume 2(4): 254-258

References

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Grey Henery (1980) Grey's Anatomy by Peter L Williams and Roger Warwick 36th edition, Churchill Livingstone, Published by Jarrold and Sons Ltd.

Snell.S.Richard (1992) Clinical Anatomy for Medical student 4th edition Chapter-9, page- 487-495.

Solanki J.C, A Study on Rujakara marma with Special Reference ot their anatomical & surgical significance. Thesis M.D Lucknow University, 1982.

Source: //www..iasp-pain.org/. Basic concept of Pain physiology.

Sushruta (200 B.C.) Sushruta Samhita hindi commentary by Ghanekar B.G.(1999), 14th edition, published by Mehar Chand Luxmi Chand Publication, Chapter-6th page-184-189.

River J (1999) Adolescence pain measurement, pain threshold. Journal of paediatrics 75(4):244-248

Source of Support: Nil

Conflict of Interest: None Declared