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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 28-33

Management of Frozen Shoulder in Diabetics through Panchakarma


Dept. of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India

Date of Web Publication7-Jul-2022

Correspondence Address:
R T Sangeeta
Dept. of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-0593.350096

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  Abstract 


Diabetes is having a steep rise in prevalence and is on the way to take shape of a global epidemic, mostly associated with improper diet and lifestyle. Musculoskeletal problems are common in diabetics but are not so well- known as compared to other complications of the disease. Frozen Shoulder, one such musculoskeletal problem, is estimated to affect diabetic patients five times more as compared to non-diabetics, resulting in pain and limited range of movement and is compared to Apabahuka in Ayurveda. Conventional treatment modalities like analgesics, NSAIDs, steroids and surgery etc have certain limitations. Hence, alternatives are being searched from other systems of medicines. A 64 years old female patient, presented with pain and restricted movements of left shoulder joint; was treated with Udvartana followed by local Swedana with Jambeera pinda and Panchatikta panchaprasritika vasti for five five days. After completion of therapy, pain was subsided and satisfactory improvement was found in the shoulder joint movements. Panchakarma in the form of Basti regimen and external therapies is surely a result oriented therapy in the management of Diabetes and such complications like Frozen shoulder. Panchakarma in the form of external therapies and Vasti regimen is a result oriented therapy in the management of Frozen Shoulder and also effective in Diabetes.

Keywords: Apabahuka, Case report, Diabetes, Frozen shoulder, Panchakarma, Udvartana, Vasti


How to cite this article:
Sangeeta R T, Adil R, Anup B T. Management of Frozen Shoulder in Diabetics through Panchakarma. J Ayurveda Case Rep 2018;1:28-33

How to cite this URL:
Sangeeta R T, Adil R, Anup B T. Management of Frozen Shoulder in Diabetics through Panchakarma. J Ayurveda Case Rep [serial online] 2018 [cited 2022 Dec 9];1:28-33. Available from: http://www.ayucare.org/text.asp?2018/1/1/28/350096



Introduction: Diabetes has emerged as one of the most common non-communicable diseases globally and it is threatening to be the most challenging health problem of this century. Complications from diabetes, such as coronary artery disease and peripheral vascular disease, diabetic neuropathy, diabetic nephropathy etc are resulting in increasing disability, reduced life expectancy and enormous health cost for every society.

Among them muscle cramps, muscle infarction, neuropathic joints, carpel tunnel syndrome, tenosynovitis, diffuse idiopathic skeletal hyperostosis, dupuytren’s contracture and adhesive capsulitis are commonly seen. Among these, Adhesive Capsulitis of Shoulder also known as Frozen Shoulder is the most common manifestation, that affects diabetic patients five times more as compared to non-diabetics.[1] Hence, high blood sugar is a big risk factor for the development of frozen shoulder. Studies reported increased prevalence of frozen shoulder in diabetic patients (26.25%), comparatively more in non dominant shoulders of females with type II DM.[2]

Primary pathology in frozen shoulder is within the glenohumeral joint capsule which becomes adherent to the humerus head, resulting in pain and limited range of movements. Pain mostly worsens at night and there is progressive loss of passive range of movement (PROM) and active range of movement (AROM). It predominantly occurs unilaterally but both shoulders may get affected in about 10-20% of cases.[3] Other Risk factors include female sex, older age, shoulder trauma, surgery, parkinsons disease,[4] increased body mass index, cardiovascular and thyroid disorders etc.[5],[6],[7],[8],[9] Clinically, frozen shoulder develops in three symptom- related phases; first one is freezing or painful phase characterized by insidious onset of pain, which gradually increases in intensity with gradual PROM & AROM. It lasts for few weeks to nine months followed by frozen or adhesive phase of about four to nine months and finally thawing or recovery phase in which resolution starts with the gradual returning of shoulder joint to almost normalcy in six to twenty four or more months.

Sign and symptoms of frozen shoulder have resemblance with Apabahuka described in Ayurveda, which is a condition of deranged Vata and Kapha.[10] Hence Vata kapha pacifying management was planned in the present case study.

Though it is a self limiting condition, but recovery process is quite slow, which hampers daily routine of patients leading to frustration at times. Modern science uses treatment options like Analgesics, Non Steroidal Anti-inflammatory Drugs, Steroids, Physiotherapy & Surgery etc in the management which are not satisfactory and are known to develop adverse effects too. Hence, alternatives are being searched from other systems of medicines. In this attempt, a patient presenting with symptoms of frozen shoulder was managed with Ayurveda principles.

Case report: A 64 years aged female patient, visited OPD of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar with complaints of pain, stiffness and restricted movements at left shoulder joint since 8 months. The pain was dull initially, gradually increased in severity, specially exacerbating at night (around 2 or 3 am). Pain usually was aggravating with movements of shoulder and was being relieved after intake of analgesics or with hot fomentation. Gradually the condition was worsened and the majority of shoulder joint movements were restricted. Routine activities including combing hair, bathing etc badly affected.

Patient had regular bowel and bladder habits. Appetite was slightly reduced and sleep was altered due to shoulder pain and stiffness. Detailed examination following Ashta vidha and Dasha vidha pareeksha was done.[11],[12]

The patient was a known diabetic, hypertensive and was on anti-hypertensive drugs (Amlodipine 5 mg + Atenolol 50 mg once daily, Losartan 50 mg twice daily), hypoglycemic drugs (Glimepiride twice daily) and analgesics (Tramadol SOS). Besides medicines, patient also attended physiotherapy sessions for six months.

Blood pressure (138/86 mm of Hg), pulse (80/min) and respiratory rate (22/min) were within the physiological limits. Respiratory system examination revealed bilateral adequate air entry with no added sounds. Cardio vascular system revealed normal audible S1, S2. Abdomen was soft with no tenderness, no organomegaly or no lump. All the movements at left shoulder joint were limited both actively and passively.

Investigations: Routine haematological, urine and biochemical investigations were carried out to exclude other pathology and to know the underlying cause, which were within normal limits except blood sugar level i.e. fasting & post prandial blood sugar levels were 232 mg/dl and 189 mg/dl respectively. Radiograph of left shoulder joint (AP view) showed normal study.

Treatment protocol: After assessing the Dosha (Vata- kapha), Aushadha (Tikta, Ushna, Teekshana), Desha (Jangala), Kala (Sheeta), Satmya (Madhyama), Satva (Madhyama), Agni (Manda), Vaya (old age) and Bala (Madhyama),[13] local Udvartana was done for five days, which was followed by Jambeera Pinda Sweda along with Panchatikta panchaprasritika vasti for the next five days.[14] Patient was advised to take lukewarm water during the procedure. Total duration of the study was 10 days. No oral drugs were administered during this study period, while conventional anti-hypertensive and anti-diabetic drugs taking earlier were continued. Brief details of drugs used in the treatment are mentioned at [Table 1].
Table 1: Treatment Protocol

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Assessment criteria: Visual Analogue Scale (VAS), Stiffness, Range of movements using Goniometer and Blood sugar were assessed before and after treatment [Figure 1] and [Table 2].
Figure 1: Visual Analogue Scale

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Table 2: Gradation of Stiffness

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Observations and Results: Satisfactory improvement in overall functional status after ten days treatment was observed. No analgesics were needed by the patient during the treatment period and one month of follow up. No untoward effects were noticed during the whole procedure. Pain and stiffness were relieved completely by the end of treatment [Table 3] with significant improvement in the range of shoulder movements [Figure 1] and [Table 4]. FBS and PPBS came down to 168 mg/dl and 93 mg/dl from 232 mg/dl and 189 mg/ dl respectively. No aggravation in pain or stiffness was reported by the patient during follow up period of about one month after completion of therapy.
Figure 1: Improvement of the shoulder movements before and after therapy

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Table 3: Effect of therapy on VAS, Stiffness and Weight

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Table 4: Effect of Therapy on Range of Movement

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Discussion: Most of the complications of DM usually intervene with various functions of visceral organs. But, excess sugar in the blood stream seems to cause other problems also like musculoskeletal complications, out of which Frozen Shoulder is most common. Glucose molecules can adhere to collagen and make it sticky. Collagen is a major building block in the ligaments that holds the bones together in a joint. In Diabetics, this adhesion due to extra sugar molecules in blood stream can contribute to abnormal deposits of collagen in the cartilage and tendons of the shoulder, which causes stiffness of the affected shoulder and restricts its movements.[15]

In addition, poor perfusion leads to abnormal collagen repair and degenerative changes. The theory is that platelet derived growth factor is released from abnormal or ischemic blood vessels, which will then act as a stimulus to local myofibroblast proliferation.[16]

The pathology of frozen shoulder includes a chronic inflammatory response with fibroblastic proliferation, which may be immuno-modulated. Characteristically, pain precedes stiffness in frozen shoulder, which suggests an evolution from inflammation to fibrosis. These clinical and macroscopic features support the pathological findings of both inflammation and fibrosis. [17] That is why Udvartana was planned to reduce inflammation followed by Jambeera pinda sweda to act on fibrosis owing to its Snigdha, Amla and Ushna guna. Moreover, Swedana enhances local microcirculation, by increasing the blood circulation rate of peripheral arterioles, delivering higher level of oxygen and nutrients to the injured cells.

Prameha has been mentioned as Santarpanottha vyadhi and Virukshana kriya, Udvartana has been indicated in its management.[18],[19] So due to Rukshana kriya, excess Kleda in Pramehi may get absorbed due to opposite Guna. This may also cause reduction in viscosity due to increased sugar molecules attached to collagen. Thus, this could be helpful in reducing pain, stiffness and improving the range of shoulder movements.

Apabahuka is having Vata kapha dosha dominancy,[20] after mobilization of dried Kapha and Shoshana of Kleda by Udvartana; dominancy of Vata dosha remains to be dealt with. Besides this, chronicity of the disease also leads to Vata prakopa up to some extent, for which Jambeera pinda sweda was applied, which is supposed to pacify Vata dosha due to its Amla, Lavana, Snigdha and Ushna guna.

Though Vasti is not a choice of treatment for Prameha; Asthapana vasti can be administered.[21] However, Panchatikta pancha prasritika vasti finds a special mention for Prameha.[22]

The Rasa panchaka of the ingredients of Vasti possess mainly Snigdha, Ushna guna, Ushna virya and Kapha vataghna effects,[23] which would be helpful in pacifying the Vata kapha dosha involved in the Samprapti of Apabahuka. Besides this, Tikta rasa is supposed to have direct effect on Asthi dhatu.[24]

Pharmacological properties of Vasti drugs exhibit Hypoglycaemic, Hypotensive, Anti-inflammatory, Analgesic, Diuretic, Immuno-stimulant and Anti- oxidative effects [Table 5]. Hence, the hypoglycemic effect found after Vasti regimen in the biochemical reports and the analgesic effect may be attributed to these properties of drugs.
Table 5: Pharmacological properties of ingredients of Panchatikta Panchaprasritika Vasti

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Conclusion: Though, Frozen Shoulder is a self limiting disease, Ayurvedic treatment modalities can shorten the recovery time. Rukshana kriya like Udvartana followed by Jambeera pinda sweda can be helpful in reducing pain, stiffness and improving the range of shoulder movement in frozen shoulder. Panchatikta panchaprasritika vasti is effective in reducing the blood sugar level and improving the quality of life of diabetics. Thus, Udvartana followed by Jambeera pinda sweda along with Panchatikta panchaprasritika vasti is found effective in the management of frozen shoulder associated with diabetes. To further establish this treatment protocol in frozen shoulder, a study involving larger sample size is needed.

Source of support: Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar 361008, Gujarat, India

Conflicts of interest: None declared



 
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