|Year : 2020 | Volume
| Issue : 4 | Page : 148-152
Iontophoresis with Murivenna kwatha as an adjunctive therapy in the management of Vata kantaka (Plantar fasciitis): A case report
Akash Kumar Gupta1, Vyasadeva Mahanta2, Rahul Sherkhane3, Sanjay Kumar Gupta2
1 Ayurved Medical Officer, Ghunghchihai, Uttar Pradesh, India
2 Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi, India
3 Department of Shalya Tantra, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh, India
|Date of Submission||17-Jun-2020|
|Date of Acceptance||20-Jan-2021|
|Date of Web Publication||18-Mar-2021|
Dr. Vyasadeva Mahanta
All India Institute of Ayurveda, New Delhi
Source of Support: None, Conflict of Interest: None
Vata kantaka (~plantar fasciitis) is mentioned as one of Nanatmaja vatavyadhi (~disease caused by Vata dosha). It is manifested due to constant exposure on uneven surface or walking over an irregular surface for long period. Patients suffering from Vata kantaka usually complain of pain at the heel that gradually increases when a patient starts walking in the morning. One in ten people suffers from plantar fasciitis in their lifetime and conventional treatment has limitations in providing satisfactory relief. A 35-year-old male patient visited Asthi-sandhi-marma roga Outpatient Department with plantar fasciitis in left foot. Seven sittings of iontophoresis with Murivenna kwatha (~decoction of Murivenna formulation) were done on alternate day and rolling plantar exercise daily for 10 min. Satisfactory relief in pain score was found after the seventh sitting. Visual Analog Scale was reduced from 8 to 1 and Maryland foot score was increased from 45 to 96 by the end of the seventh sitting. No recurrence was reported during the follow-up of four months. Murivenna kwatha possesses Vatadosha (~functional units of body) pacifying properties, Shulahara (~analgesic), and Shophahara (~anti-inflammatory). Iontophoresis possibly enhances transdermal absorption of Murivenna kwatha. This iontophoresis in combination with Murivenna kwatha rendered significant relief from pain in the management of plantar fasciitis.
Keywords: Iontophoresis, Murivenna kwatha, plantar fasciitis, Vata kantaka
|How to cite this article:|
Gupta AK, Mahanta V, Sherkhane R, Gupta SK. Iontophoresis with Murivenna kwatha as an adjunctive therapy in the management of Vata kantaka (Plantar fasciitis): A case report. J Ayurveda Case Rep 2020;3:148-52
|How to cite this URL:|
Gupta AK, Mahanta V, Sherkhane R, Gupta SK. Iontophoresis with Murivenna kwatha as an adjunctive therapy in the management of Vata kantaka (Plantar fasciitis): A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2021 Apr 15];3:148-52. Available from: http://www.ayucare.org/text.asp?2020/3/4/148/311502
| Introduction|| |
Vata kantaka is a painful condition of the heel, which is manifested due to improper placement of foot on the ground or walking over an irregular surface for long period. Yogaratnakara has described Vata kantaka as Pada kantaka which is clinically characterized by pricking pain in Pada (~foot). In Vata kantaka, Prakupita vata (~aggravated Vata) is localized in the Khuddaka pradesha (~ankle joint). Sandhi pradesha (~joints) is the natural seat of Kapha dosha. Due to Dosha sansarga (~pathological bondage between two Doshas), Prakupita vata (~aggravated Vata) is mixed with Sthanika kapha (~localized Kapha) which produces Shula (~pain) and Stambha (~stiffness), especially in the morning hours. Acharya sushruta has mentioned Upakramas (~treatment modalities) such as Snehana (~unction), Upanaha (~poultice), Agnikarma (~therapeutic cauterization), and Bandhana (~bandaging) under context Vatavyadhi chikitsa to counter Prakupita vata when localized in Snayu and Sandhi pradesha. Swedana is specialized treatment modality recommended by Acahrya charaka to amenable vitiated Vata-kapha dosha.
Based on the similarities in signs and symptoms, Vata kantaka can be correlated with Plantar Fasciitis (PF) in modern parlance. It is an inflammatory condition. Inflammation of PF generally starts from plantar aponeurosis at the tuberosity of the calcaneum. In the current literature, it is described as plantar fasciosis or fasciopathy. Studies reported that degeneration and thickening of plantar fascia is more common than inflammatory changes. Overuse of foot may be a cause in its manifestation. One in ten people of 8 to 80 years suffers from PF in their lifetime. Severe pain is observed in the morning and reduces after involvement in some activities. Conservative treatments include rest, hot pack, ice pack, heel pads, night splints, plantar stretching, non-steroidal anti-inflammatory drugs, steroid injections, plasma rich-protein (PRP) injections, and plantar fasciotomy based on condition but have certain limitation.
Iontophoresis is a noninvasive method used to increase transdermal drug absorption by using electric current. It uses weak galvanic current in water to deliver a chemical drug through the skin. In this process, electric current flows through the circuit and it helps to move away of medication from the electrodes and causing its penetration through the skin to reach up to the desired site. Electro-osmosis is another mechanism accepted as a mode of drug absorption. It is a well-categorized method for transdermal drug delivery on active transportation within the electric field. The dominant forces of this transport are electro-migration and electro-osmosis, which are measured units of chemical flux (commonly in μmol/cm2/h). Murivenna oil is an Ayurvedic formulation, routinely used in Vrana (~ulcer), Sandhi shopha (~inflamed joints), Abhighatajanya shopha (~inflammation due to trauma), Asthi bhagna (~bone fracture), and Sandhi chyuti (~dislocation of bones). The contents of Murivenna oil were converted into Kwatha and used as liquid media in iontophoresis. This study aimed to see the effect of Murivenna kwatha used along with iontophoresis as adjunct therapy in relieving pain and stiffness in plantar fasciitis.
| Case Report|| |
A 35-year-old male, non-diabetic, normotensive patient, a mechanical engineer by profession, with a history of playing badminton daily for 3–4 h visited Asthi-sandhi-marma roga Outpatient Department with the complaint of pain at left heel for five years.
Patient reported pain in the morning hours exacerbating with walking. There was no history of any kind of trauma. He consulted at sports injury unit in a tertiary care hospital and took treatment for three years. After that, he again consulted at an allopathic hospital and took treatment for two more years. He was managed with steroid injections and PRP injections but did not get satisfactory relief. Further, he was advised for surgery. On general examination, the patient was hemodynamically stable (pulse rate = 70/min regular with normal volume and blood pressure – 110/70 mmHg in sitting position). On local examination, limited range of left ankle joint movement in passive dorsiflexion was observed. Extension of the first metatarsophalangeal joint produced pain along the course of plantar aponeurosis. Severe tenderness elicited at medial aspect of the left heel at the level of calcaneal tuberosity.
Diagnostic focus and assessment
As per the Visual Analog Scale (VAS), the pain was scored to 8 and Maryland Foot Score (MFS) was 45 marks. X-ray of the left foot revealed the presence of calcaneal spur and no signs of calcaneal fracture were found. Based on these findings, the condition was diagnosed as plantar fasciitis/Vata kantaka and planned to manage by iontophoresis with Murivenna kwatha.
Therapeutic focus and assessment
After obtaining written informed consent, the patient was advised for iontophoresis with Murivenna kwatha [Table 1]. Coarsely powdered material of one part of each herbs and one-sixth part of Shatavari was taken and a Kalka (~paste) of all the ingredients was made by using mixer. The Kwatha was prepared from Kalka by adding eight times water and boiled to reduce up to one-fourth and filtered to obtain fresh Murivenna kwatha. No oral medications or other therapies were administrated during the treatment period. Freshly prepared Murivenna kwatha (250 ml) was filled in both iontophoresis chambers and the patient was advised to keep his both feet separately in each of the chambers. A weak galvanic current was applied through the iontophoresis machine in anode mode starting from 0.00 mAmp and gradually increased up to 15.0 mAmp. At this point, he felt a maximum tingling sensation in the foot region and current of 15.0 mAmp was allowed to flow for 20 min. Thereafter, 15.0 mAmp current was allowed to flow in the cathode mode for 20 min for the same foot [Figure 1] and [Figure 2]. Similar such seven sittings on alternate day were given. During the procedure, gold ring was removed and all wires and foot plates were checked. During the course of treatment, he was advised to avoid work that increases more foot pressure. He further advised to perform rolling plantar exercise daily for 10 min at morning and evening before starting to walk. Placing a tennis ball on the ground and gently rolling it under foot for 10 min can help loosen up the plantar fascia, making it much less likely to become irritated.
| Timeline|| |
Timeline for drug treatment is placed at [Table 2].
| Follow-up and outcomes|| |
Significant reduction in the severity of pain was observed after the third sitting and the pain was almost relieved by the seventh sitting. The pain on VAS was reduced from 8 to 1 and MFS was increased from 45 to 96 at the end of the seventh sitting [Graph 1]. No tenderness at medial aspect of the left heel was complained by the patient. After treatment, the patient was followed for four months. No signs and symptoms of PF were reported even after four months of follow-up.
| Discussion|| |
Vata kantaka is illustrated as Nanatmaja vatavyadhi. Vata dosha prokopa due to repeated Aaghata (~micro-trauma) plays prime role in producing Ruja (~pain) in Vata kantaka. The continuous microtrauma and traction forces on the plantar fascia are thought to be a cause of heel spurs at anterior medial edge of calcaneal tuberosity, but it does not give rise to pain. When pain is present at the heel region, it may be due to plantar fasciitis/fasciosis but not due to the spur. Hence, in some cases, usually, spur is found in foot radiograph, but radiography has limited value in the diagnosis of plantar fasciitis. Considering Dosha ashraya-ashrayibhava (~reciprocal relationship between Dosha, Dhatu, and Mala), it can be understood that Gulpha sandhi is a seat of Kapha dosha. In a clinical presentation, Kapha samsrishta (~pathological bondage Kapha with other Dosha) is observed and severity of pain is more at early morning and after getting up from the bed. According to Ayurveda classics, early morning is of Kapha kala (~time of aggravation of Kapha). The Upakarma having the property of Ushnata (~hot property) is capable to neutralize the vitiated Vata-kapha dosha. Drava sweda is a unique concept in Ayurveda to pacify the vitiated Vata-kapha dosha. In this study, the technique of iontophoresis was simulated as the concept of Swedana and Murivenna kwatha was used as media.
Iontophoresis works in principle to flow ions diffusively in an aqueous medium driven by an applied electric field and converts the high-frequency alternating current to low-frequency smooth direct current and was applied directly on the plantar surface of the foot to enhance the absorption of therapeutic properties. Therefore, therapeutically, electromotive drug administration process delivers medicinal properties of Murivenna kwatha through the skin. In this method, medication or bioactive agents are transdermally absorbed by repulsive electromotive forces through the skin. Most of the contents of Murivenna kwatha possess Ushna veerya (~hot potency) and Katu vipaka (~pungent metabolic effect). Ushna veerya pacifies Vata dosha and Katurasa, Katuvipaka helps to pacify Vikrita kapha (~vitiated Kapha) due to its opposite quality. Thus, Murivenna kwatha provides relief from Ruja and Stambha (~morning stiffness) by controlling aggravated Vata and Kapha. Karanja (Pongamia pinnata [L.] Pierre) is a widely used plant in Ayurveda for the ailments of Arsha (~piles), Krimi (~worms), Shotha (~inflammation), and Kushta (~skin disorders). It exhibits anti-inflammatory activity on different phases of inflammation without producing side effects and used as wound-healing and pain-relieving herb. Tambula (Piper betle L.) possess α-pinene and germacerene-D compounds and these compounds act as analgesic and anti-inflammatory. Fresh juice of Palandu (Allium cepa L.) has reported to possess potent analgesic and anti-inflammatory properties. Paribhadra (Erythrina variegate Linn.) has mentioned as Shothahara and methanolic extract of its leaf has shown analgesic activity. Kumari (Aloe vera Linn.) has reported to act as anti-inflammatory agent. Shatavari (Asparagus racemosus Willd.) is one of the well-known drugs used to prevent aging and used as anti-inflammatory. Tandulodaka (Oryza sativa L.) possesses different antioxidants which synergistically act as anti-inflammatory and helps in reducing inflammation. Thus possibly, the constituents of all these drugs penetrate through the intact skin of sole through the iontophoresis process and reach to plantar fascia. Although plantar fascia has limited blood perfusion, iontophoresis might help to improve blood circulation. The adequate Shothahara (~anti-inflammatory response) and Rasayana (~anti-aging) effect of Murivenna kwatha might have helped to subside the inflammatory process and initiates healing process of plantar fascia injury. Active stretching of plantar fascia by rolling ball under the foot with moderate pressure for 10 min at morning and evening helps to relieve pain by stretching and relaxing plantar fascia. No special precaution was required to do this procedure. No adverse effect was noted during the entire treatment.
| Conclusion|| |
Heel pain due to plantar fasciitis is a common foot problem. In Ayurveda perspective, it can be correlated with Vata kantaka. In this case, the patient responded better after seven sittings of iontophoresis with Murivenna kwatha and no signs and symptoms of plantar fasciitis were noticed after four months of follow-up period. Its sustainable effect can be evaluated in larger sample size to establish a better option for the management of plantar fasciitis.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]