Changes

''Bala'' of the individual has to be assessed through ''vyayama shakti'' (exercise capacity), which corresponds to the time taken for spending one’s ''ardha shakti'' (half strength). Based on the outcome of this assessment, ''pravara'' (maximum), ''avara'' (minimum) and ''madhyama'' (medium) ''bala'' have to be assessed. Based upon the results of these ''bala'' assessments, ''maha sweda'' (whole body sudation for an extended duration) and various minor/major ''sweda'' measures could be prescribed.

''Bala'' of the individual has to be assessed through ''vyayama shakti'' (exercise capacity), which corresponds to the time taken for spending one’s ''ardha shakti'' (half strength). Based on the outcome of this assessment, ''pravara'' (maximum), ''avara'' (minimum) and ''madhyama'' (medium) ''bala'' have to be assessed. Based upon the results of these ''bala'' assessments, ''maha sweda'' (whole body sudation for an extended duration) and various minor/major ''sweda'' measures could be prescribed.

Exercise intolerance has a significant impact on heat intolerance. People who exhibit exercise intolerance (like in the case of mitochondrial diseases, or in persons leading a sedentary lifestyle) may have autonomic dysfunction including vascular autonomia characterized by tachycardia, dizziness, changes in heart rate and blood pressure, heat intolerance and unusual sweating pattern. Also, deficiency in energy metabolism may cause exercise intolerance and reduced stamina. It is evident that exercise intolerance leads to heat intolerance and abnormal sweating pattern, making it difficult - and hazardous - to conduct ''swedana'' in those individuals. An interesting observation is that if an individual is acclimatized to hot environment, he gradually attains exercise tolerance by an increase in plasma and thereby increase in blood volume, increased venous return, increased cardiac output, sub maximal heart rate, sustained sweat response, earlier onset of sweat and increased capacity for evaporative cooling, decreased osmolality of sweat and electrolyte conservation and decreased likelihood for fatigue [4]. Contemporary science believes that heat has a beneficial effect (through thermotherapy, for instance) on pain relief. Effect of heat on pain is mediated by heat-sensitive channels. These channels respond to heat by increasing intracellular calcium (Ca). An increase in intracellular Ca generates action potentials that increase the stimulation of sensory nerves. These channels are a part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. These channels have certain characteristics in common, such as sensitivity to menthol, etc. Multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the purin pain receptors. These receptors, termed as P2X2 and P2Y2, are mediated pain receptors located in the peripheral small nerve endings. For peripheral pain, heat can directly inhibit pain. However when pain is originating from deeper tissues, heat stimulates peripheral pain receptors that can alter what can be termed as “gating” in the spinal cord and reduce the sensation of deep pain. Another effect of heat is its ability to increase circulation. These same TRPV1 and TRPV4 receptors, along with nociceptor, increase blood flow in response to heat. The initial response to heat is mediated through the sensory nerves that release substance P and calcitonin-related peptide to increase circulation. After approximately one minute, Nitric Oxide is produced in vasculature endothelial cells and is responsible for sustained response of circulation to heat. This increase in circulation is considered to be essential in tissue protection from heat and repair of damaged tissue. Thermotherapy is of two types: dry and moist. A study was conducted to assess the effect of moist and dry heat on delayed onset of muscle soreness. Moist heat not only had similar benefits as dry heat but in some cases was more beneficial, requiring only 25% of time for application as dry heat. This study was conducted on quadriceps muscles. The study also witnessed immediate (and maximum) reduction in pain on application of moist heat, since moist heat penetrates deeper tissues faster than dry heat. Also, dry heat draws out moisture from the areas of application leaving them dehydrated, unlike moist heat.  

Exercise intolerance has a significant impact on heat intolerance. People who exhibit exercise intolerance (like in the case of mitochondrial diseases, or in persons leading a sedentary lifestyle) may have autonomic dysfunction including vascular autonomia characterized by tachycardia, dizziness, changes in heart rate and blood pressure, heat intolerance and unusual sweating pattern. Also, deficiency in energy metabolism may cause exercise intolerance and reduced stamina. It is evident that exercise intolerance leads to heat intolerance and abnormal sweating pattern, making it difficult - and hazardous- to conduct ''swedana'' in those individuals. An interesting observation is that if an individual is acclimatized to hot environment, he gradually attains exercise tolerance by an increase in plasma and thereby increase in blood volume, increased venous return, increased cardiac output, sub maximal heart rate, sustained sweat response, earlier onset of sweat and increased capacity for evaporative cooling, decreased osmolality of sweat and electrolyte conservation and decreased likelihood for fatigue [4].  

 

Contemporary science believes that heat has a beneficial effect (through thermotherapy, for instance) on pain relief. Effect of heat on pain is mediated by heat-sensitive channels. These channels respond to heat by increasing intracellular calcium (Ca). An increase in intracellular Ca generates action potentials that increase the stimulation of sensory nerves. These channels are a part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. These channels have certain characteristics in common, such as sensitivity to menthol, etc. Multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the purin pain receptors. These receptors, termed as P2X2 and P2Y2, are mediated pain receptors located in the peripheral small nerve endings. For peripheral pain, heat can directly inhibit pain. However when pain is originating from deeper tissues, heat stimulates peripheral pain receptors that can alter what can be termed as “gating” in the spinal cord and reduce the sensation of deep pain. Another effect of heat is its ability to increase circulation. These same TRPV1 and TRPV4 receptors, along with nociceptor, increase blood flow in response to heat. The initial response to heat is mediated through the sensory nerves that release substance P and calcitonin-related peptide to increase circulation. After approximately one minute, Nitric Oxide is produced in vasculature endothelial cells and is responsible for sustained response of circulation to heat. This increase in circulation is considered to be essential in tissue protection from heat and repair of damaged tissue. Thermotherapy is of two types: dry and moist. A study was conducted to assess the effect of moist and dry heat on delayed onset of muscle soreness. Moist heat not only had similar benefits as dry heat but in some cases was more beneficial, requiring only 25% of time for application as dry heat. This study was conducted on quadriceps muscles. The study also witnessed immediate (and maximum) reduction in pain on application of moist heat, since moist heat penetrates deeper tissues faster than dry heat. Also, dry heat draws out moisture from the areas of application leaving them dehydrated, unlike moist heat.  

 

Heat therapy shows best results in increasing extensibility of collagen tissues, decreasing joint stiffness, relieving muscle spasm, reducing pain, inflammation, and edema. It also helps in post acute phase of healing and increasing blood flow. Examples of applications of dry heat in contemporary medicine include  diathermy, ultra sound, and heat packs, while examples of moist heat include hydrocololator heat packs (1650F), heat regulated hydrotherapy (1050 F) (basically for 5-20 mins).5

Heat therapy shows best results in increasing extensibility of collagen tissues, decreasing joint stiffness, relieving muscle spasm, reducing pain, inflammation, and edema. It also helps in post acute phase of healing and increasing blood flow. Examples of applications of dry heat in contemporary medicine include  diathermy, ultra sound, and heat packs, while examples of moist heat include hydrocololator heat packs (1650F), heat regulated hydrotherapy (1050 F) (basically for 5-20 mins).5

Practically, ''valuka sweda'' may be considered to be an extreme form of ''ruksha sweda'' and taila droni as an ultimate form of snigdha sweda. Patrapotala sweda, jambheera pinda sweda etc are na atisnigdharuksha (neither too unctuous nor too dry) in nature. From this, a spectrum of swedana techniques could be formulated starting from valuka sweda (sudation using sand as driest form) and ending in taila droni (dipping in warm oil as most unctuous form). The complete sequence of techniques would imply valuka sweda at one end of the spectrum, followed by thusha sweda, kareesha sweda, pinyakasweda, dhanyamla dhara, churnapindasweda, jambheera panda sweda, patrapotala sweda, anda sweda, shashtika pinda sweda, sarvanga dhara and eventually ending with taila droni. [verse 7-8]

Practically, ''valuka sweda'' may be considered to be an extreme form of ''ruksha sweda'' and taila droni as an ultimate form of ''snigdha sweda''. ''Patrapotala sweda, jambheera pinda sweda'' etc are ''na atisnigdharuksha'' (neither too unctuous nor too dry) in nature. From this, a spectrum of ''swedana'' techniques could be formulated starting from ''valuka sweda'' (sudation using sand as driest form) and ending in ''taila droni'' (dipping in warm oil as most unctuous form). The complete sequence of techniques would imply ''valuka sweda'' at one end of the spectrum, followed by ''thusha sweda, kareesha sweda, pinyakasweda, dhanyamla dhara, churnapindasweda, jambheera panda sweda, patrapotala sweda, anda sweda, shashtika pinda sweda, sarvanga dhara'' and eventually ending with ''taila droni''. [verse 7-8]

In general practice, early degenerative lesions such as pre-senile dementia, demyelinating poly neuropathy of adolescence or adulthood such as CIDP, and post-infective (febrile) neurological disorders such as GBS present themselves as amashayagata vata samprapthi lakshanas (signs of vata vitiated in amashaya) and therapeutic swedana measures such as rukshana (dry fomentation techniques) are found to be very effective in the initial stages of these conditions. Metabolic disorders of the aged, such as vascular dementia, and various rheumatological disorders resemble pakwashayagata kapha lakshanas and the treatment may be initiated with snigdha sweda. [verse 9]

 

For some of the disorders mentioned above that are sweda sadhya, mridu sweda alone should be performed. If the disease is sweda asadhya, it’s better to avoid administering swedana to these areas. This indicates that utmost care has to be taken when it comes to applying fomentation to vital areas as well as fomenting the whole body. Various acharyas suggest using dravyas, or medicated formulations, to shield or protect vital organs from any adverse affects of swedana. Gangadhara recommends the use of sheeta veerya dravyas, in this context, while administering mridu sweda to these vital parts, and Chakrapani also advises the use of these dravyas as protective measures of those parts while performing swedana. It is well established that hyperthermia in testicular region adversely affects spermatogenesis and virility of semen, in turn hampering fertility.

In general practice, early degenerative lesions such as pre-senile dementia, demyelinating poly neuropathy of adolescence or adulthood such as CIDP, and post-infective (febrile) neurological disorders such as GBS present themselves as ''amashayagata vata samprapthi lakshanas'' (signs of ''vata'' vitiated in ''amashaya'') and therapeutic ''swedana'' measures such as ''rukshana'' (dry fomentation techniques) are found to be very effective in the initial stages of these conditions. Metabolic disorders of the aged, such as vascular dementia, and various rheumatological disorders resemble ''pakwashayagata kapha lakshanas'' and the treatment may be initiated with ''snigdha sweda''. [verse 9]

A sudden increase in body temperature produces a corresponding increase in cutaneous vascular conductance. This is followed by an increase in systemic conductance which produces alterations in cardiac output (decrease in central venous pressure and increase in cardiac output thereby increased left ventricular ejection fraction), oxygen consumption and water loss. Heart rate increases. There is significant hemodynamic change at the beginning of swedana like significant cardio vascular stress which causes an increase in blood pressure (systolic and diastolic) and pulse rate. Whole body fomentation is therefore contraindicated in elderly and those with cardiomyopathy, congestive heart disease, bundle branch block, anaemia, MI, hyperthyroidism etc.[6]Extra caution needs to be exercised when it comes to administering swedana procedure to patients with heart conditions .

 

Regarding eyes, the scientific community is interested in knowing more about the side effects of transpupillary thermotherapy (TTT). A study conducted on normal mouse retina reveals that retinas  treated with a power of 70 mW exhibited progressive retinal damage that was almost exclusively restricted to the photoreceptors. In those cases, early damage to the outer segments of the photoreceptors was seen one day after the thermotherapy and saw degeneration of outer nuclear layer after five days. At the same time, an accumulation of pigmented cells, presumably of macrophages, was seen in the subretinal space. No apparent damage was seen in the RPE or choroid. Today, researchers are considering the importance of using sub-threshold effects while applying TTT to patients with neurovascular age-related macular degeneration. [7] [verse 10] These practises are very common nowadays except for the usage of wheat balls.  When lotus petals are unavailable, rose flower petals are substituted these days. Even cotton balls soaked in cold water, bandaged with cloth are commonly used to protect eyes while sudation. [verse 11]

For some of the disorders mentioned above that are ''sweda sadhya, mridu sweda'' alone should be performed. If the disease is ''sweda asadhya'', it’s better to avoid administering ''swedana'' to these areas. This indicates that utmost care has to be taken when it comes to applying fomentation to vital areas as well as fomenting the whole body. Various ''acharyas'' suggest using ''dravyas'', or medicated formulations, to shield or protect vital organs from any adverse affects of ''swedana''. ''Gangadhara'' recommends the use of ''sheeta veerya dravyas'', in this context, while administering ''mridu sweda'' to these vital parts, and Chakrapani also advises the use of these ''dravyas'' as protective measures of those parts while performing ''swedana''. It is well established that hyperthermia in testicular region adversely affects spermatogenesis and virility of semen, in turn hampering fertility.

The sarvanga abhyanga (whole body) fomentation technique should be administered for approximately 8-10 mins, in suitable humid conditions, and until the patient sweats profusely. Ekanga sweda, when administered for 5-20 minutes, helps provide relief to patients showing symptoms of joint stiffness, restricted movements and acute pain.  

 

Swedana procedures are recommended for a specific duration and not for prolonged periods of time. How do we know when to stop it? Repeated thermal stress elicits adaptations evident within the neural networks and integrating regulatory systems that appear as morphological changes (sweat gland hypertrophy) and may be expressed as adjustments within effector processes altered vasomotor or sudomotor sensitivities. The most common functional effect of heat acclimation is a change in the effector activation being shifted downwards. One can also observe effector adaptations evident from changes in the gain of the effector response. Thus, for a given thermal stimulus acclimatized individuals frequently display an increased effector sensitivity such as greater sweating response for an equivalent change in body temperature. Phenotypic adaptation evident after sufficient fomentation (continuum model, not with respect to time) 1) Reduced heart rate at a fixed work rate 2) Expanded plasma volume 3) lower core temperature at an equivalent workload 3) Superior Na and Cl reabsorption from sweat, and an elevated sweat secretion. [8] [verse 13]

A sudden increase in body temperature produces a corresponding increase in cutaneous vascular conductance. This is followed by an increase in systemic conductance which produces alterations in cardiac output (decrease in central venous pressure and increase in cardiac output thereby increased left ventricular ejection fraction), oxygen consumption and water loss. Heart rate increases.  

It is very essential to differentiate heat exhaustion from heat stroke. Both come under the concept of atiswinna (over sudation). But from the treatment advised for atiswinna, we may infer it as heat exhaustion. Contemporary science advises fluid replacement therapy for heat exhaustion whereas rapid aggressive cooling techniques are prescribed for heat stroke. Charaka Samhita advises treatment procedures that include greeshma rithcharya along with madhura, snigddha, seethala prayogas as ahara & vihara. Symptoms of heat exhaustion include normal to slightly elevated core temperature (39 – 40oC), fatigue or malaise, orthostatic hypotension, tachycardia, clinical signs of dehydration, nausea, vomiting, and diarrhea (due to splanchnic and renal vasoconstriction). Similarly, Symptoms of heat stroke include elevated core temperature (usually greater than 40.5°C), vague symptom of weakness, nausea, vomiting, headache, CNS symptoms including confusion, ataxia, coma, seizures, delirium, hot, dry skin, hyperdynamic cardiovascular systems (high central venous pressure [CVP], low systemic vascular resistance [SVR], tachycardia), elevated hepatic transaminases (usually in the tens of thousands range), coagulopathy, rhabdomyolysis, and renal failure [9] [verse 14-15]

 

Type of patients at high risk of suffering from untoward reactions during fomentation include athletes exercising strenuously in hot climates, elderly patients (because of decreased efficacy of thermoregulation, comorbid illness or medications, lack of fans or air conditioning, inappropriate dress), infants and small children (because of high ratio of surface area to weight, inability to control fluid intake), patients with cardiac ailments or those taking beta-blockers (because of inability to increase cardiac output sufficiently for vasodilation) Patients who are dehydrated because of poor fluid intake, gastroenteritis, or diuretic use (dehydration increases demand on ATPase pumps, which contribute 25-45% of basal metabolic rate.), patients prone to higher endogenous heat production, patients taking medications that inhibit sweat production or increase heat production (eg, anticholinergics, antidepressants, antihistamines, neuroleptics, zonisamide, sympathomimetics, lithium, alpha- and beta-blockers), and patients taking medications that cause dehydration (eg, diuretics, alcohol). This coincides with most of the contraindications mentioned in Charaka Samhitha. [10]

There is significant hemodynamic change at the beginning of ''swedana'' like significant cardiovascular stress which causes an increase in blood pressure (systolic and diastolic) and pulse rate. Whole body fomentation is therefore contraindicated in elderly and those with cardiomyopathy, congestive heart disease, bundle branch block, anemia, MI, hyperthyroidism etc.[6]Extra caution needs to be exercised when it comes to administering ''swedana'' procedure to patients with heart conditions .

In demyelinating neuropathy or in other demyelinating as well as in diabetic neuropathy conditions or in severe DM without neuropathy, swedana should not be practiced. Hypothermia in demyelinating disorders is a common manifestation. In some patients, core temperature drop to 33 – 34 oC has been noted. If the temperature decreases to (or less than) 33 oC, severe lethargy, muscle stiffness, rigid limbs, a confused state of mind or even mutism might develop. These patients show full symptomatic clinical recovery on passive “rewarming” at 35 – 36 oC. As the temperature rises to more than 36.5oC the symptoms become adverse. Hence there is always a requirement to maintain the core temperature between 33 – 36oC. Swedana thus always poses a risk to such patients. [11]

 

In diabetes mellitus & diabetic polyneuropathy, there is impaired distal thermoregulation, distal sudomotor & micro vascular dysfunction. The nerve fibres that play an important role in thermoregulation are the earliest nerve fibres affected in polyneuropathy. Neuronal activity is highly temperature sensitive and causes neuropathic pain. Many studies have pointed out that there is an increased peripheral insulin resistance associated with hyperthermia. Starved off glucose cells turn to lipids as a source of energy in a diabetic patient. Hyperthermia promotes further lipolysis which hampers the condition [12]

Regarding eyes, the scientific community is interested in knowing more about the side effects of transpupillary thermotherapy (TTT). A study conducted on normal mouse retina reveals that retinas  treated with a power of 70 mW exhibited progressive retinal damage that was almost exclusively restricted to the photo-receptors. In those cases, early damage to the outer segments of the photo-receptors was seen one day after the thermotherapy and saw degeneration of outer nuclear layer after five days. At the same time, an accumulation of pigmented cells, presumably of macrophages, was seen in the sub-retinal space. No apparent damage was seen in the RPE or choroid. Today, researchers are considering the importance of using sub-threshold effects while applying TTT to patients with neurovascular age-related macular degeneration. [7] [verse 10] These practices are very common nowadays except for the usage of wheat balls.  When lotus petals are unavailable, rose flower petals are substituted these days. Even cotton balls soaked in cold water, bandaged with cloth are commonly used to protect eyes while sudation. [verse 11]

In patients with hypothyroidism who are undergoing thyroxin supplementation, there is a chance of development of an increased basal metabolic rate that stimulates increased heat production. The same is the condition with persons suffering from hyperthyroidism. Hence swedana is contraindicated in both of these conditions. [verse 14-15]

 

Thermotherapy can be used to treat a number of painful conditions. A number of studies with thermotherapy conducted worldwide has shown significant results in a wide range of disease conditions. These include:  

The ''sarvanga abhyanga'' (whole body) fomentation technique should be administered for approximately 8-10 mins, in suitable humid conditions, and until the patient sweats profusely. ''Ekanga sweda'', when administered for 5-20 minutes, helps provide relief to patients showing symptoms of joint stiffness, restricted movements and acute pain.  

-(Chronic) muscle spasms in the form of persistent and often painful tension and shortness in a muscle or group of muscles that cannot be released voluntarily.  

 

-Types of arthritis that may benefit from thermotherapy include: Subacute or chronic inflammatory conditions, osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, reiter's syndrome, and sources of back pain such as a herniated disc.   

''Swedana'' procedures are recommended for a specific duration and not for prolonged periods of time. How do we know when to stop it? Repeated thermal stress elicits adaptations evident within the neural networks and integrating regulatory systems that appear as morphological changes (sweat gland hypertrophy) and may be expressed as adjustments within effector processes altered vasomotor or sudomotor sensitivities. The most common functional effect of heat acclimation is a change in the effector activation being shifted downwards. One can also observe effector adaptations evident from changes in the gain of the effector response. Thus, for a given thermal stimulus acclimatized individuals frequently display an increased effector sensitivity such as greater sweating response for an equivalent change in body temperature. Phenotypic adaptation evident after sufficient fomentation (continuum model, not with respect to time) 1) Reduced heart rate at a fixed work rate 2) Expanded plasma volume 3) lower core temperature at an equivalent workload 3) Superior Na and Cl reabsorption from sweat, and an elevated sweat secretion. [8] [verse 13]

-Whiplash and other musculoskeletal types of neck pain, shoulder pain, such as rotator cuff injuries.  

 

-Decreased range-of-motion like in frozen shoulder, other types of joint pain, including many forms of arm pain (e.g., tennis elbow), leg pain (e.g., restless leg syndrome), knee pain (e.g., injured anterior cruciate ligament), foot pain (e.g., plantar fasciitis), tendonitis, bursitis, sprain, costochondritis, abdominal and pelvic pain, and fibromyalgia,  

It is very essential to differentiate heat exhaustion from heat stroke. Both come under the concept of ''atiswinna'' (over sudation). But from the treatment advised for ''atiswinna'', we may infer it as heat exhaustion. Contemporary science advises fluid replacement therapy for heat exhaustion whereas rapid aggressive cooling techniques are prescribed for heat stroke. [[Charaka Samhita]] advises treatment procedures that include ''greeshma ritucharya'' along with ''madhura, snigddha, seethala prayogas'' as ''ahara'' & '''vihara'''. Symptoms of heat exhaustion include normal to slightly elevated core temperature (39 – 40°C), fatigue or malaise, orthostatic hypotension, tachycardia, clinical signs of dehydration, nausea, vomiting, and diarrhea (due to splanchnic and renal vasoconstriction). Similarly, Symptoms of heat stroke include elevated core temperature (usually greater than 40.5°C), vague symptom of weakness, nausea, vomiting, headache, CNS symptoms including confusion, ataxia, coma, seizures, delirium, hot, dry skin, hyperdynamic cardiovascular systems (high central venous pressure [CVP], low systemic vascular resistance [SVR], tachycardia), elevated hepatic transaminases (usually in the tens of thousands range), coagulopathy, rhabdomyolysis, and renal failure [9] [verse 14-15]

-Other chronic pain disorders, including lupus and myofascial pain syndrome, asthma, reduction of joint contractures. Other conditions that may be treated with heat include back sprain, degenerative disc disease, sciatica and scoliosis, as these conditions are usually associated with muscle spasm. [13] [verse 20-24]

 

Swedana accounts for a major part of Ayurvedic panchakarma therapy. It is considered an essential preparatory procedure before bio-cleansing. It is normally done after internal or external oleation. Swedana liquefies and separates the vitiated body humors adhered to the tissues and fascilitates their flow to the elementary tract for easy evacuation from the body. In Ayurvedic practise majority of swedana (sudation) procedures are done in the form of kizhi / pindasveda (sudation using bolus).  The commonly practised few are detailed below with its preparation, application indication etc. [14]

Type of patients at high risk of suffering from untoward reactions during fomentation include athletes exercising strenuously in hot climates, elderly patients (because of decreased efficacy of thermoregulation, comorbid illness or medications, lack of fans or air conditioning, inappropriate dress), infants and small children (because of high ratio of surface area to weight, inability to control fluid intake), patients with cardiac ailments or those taking beta-blockers (because of inability to increase cardiac output sufficiently for vasodilation) Patients who are dehydrated because of poor fluid intake, gastroenteritis, or diuretic use (dehydration increases demand on ATPase pumps, which contribute 25-45% of basal metabolic rate.), patients prone to higher endogenous heat production, patients taking medications that inhibit sweat production or increase heat production (eg, anticholinergics, antidepressants, antihistamines, neuroleptics, zonisamide, sympathomimetics, lithium, alpha- and beta-blockers), and patients taking medications that cause dehydration (eg, diuretics, alcohol). This coincides with most of the contraindications mentioned in [[Charaka Samhita]]. [10]

Kizhi / Pinda / Pottali

 

These words mean bolus. Fresh herbs / powders / fruits / cereals etc are used to make bolus of different varieties. This bolus is heated and used to induce sweating. Before coming to the procedural details, the preparation of a kizhi should be generally understood.

In demyelinating neuropathy or in other demyelinating as well as in diabetic neuropathy conditions or in severe DM without neuropathy, ''swedana'' should not be practiced. Hypothermia in demyelinating disorders is a common manifestation. In some patients, core temperature drop to 33 – 34°C has been noted. If the temperature decreases to (or less than) 33°C, severe lethargy, muscle stiffness, rigid limbs, a confused state of mind or even mutism might develop. These patients show full symptomatic clinical recovery on passive “rewarming” at 35 – 36°C. As the temperature rises to more than 36.5°C the symptoms become adverse. Hence there is always a requirement to maintain the core temperature between 33 – 36°C. ''Swedana'' thus always poses a risk to such patients. [11]

Preparation of Kizhi

 

Take cotton cloth of one square meter size and divide it into four equal square pieces. Place 4 square pieces of cloth (each four inch) at the center of each cloth. Put equal portion of prepared drug into four pieces. Hold the cloth by the four corners and make the drug into a bolus. Hold tightly at the junction. Leave the larger end of the cloth and fold the other three corners by inserting into the center. Using the large flap of cloth surround the folded ones neatly and tightly so that it is sufficient to hold. Tie the twine at the junction of handle and bolus. Wind this tightly with the free end of the twine and fasten the knot. Kizhi once prepared is used upto a maximum of 3 days.  

In diabetes mellitus & diabetic polyneuropathy, there is impaired distal thermoregulation, distal sudomotor & micro vascular dysfunction. The nerve fibres that play an important role in thermoregulation are the earliest nerve fibres affected in polyneuropathy. Neuronal activity is highly temperature sensitive and causes neuropathic pain. Many studies have pointed out that there is an increased peripheral insulin resistance associated with hyperthermia. Starved off glucose cells turn to lipids as a source of energy in a diabetic patient. Hyperthermia promotes further lipolysis which hampers the condition [12]

Preparation of the patient:

 

In patients with hypothyroidism who are undergoing thyroxin supplementation, there is a chance of development of an increased basal metabolic rate that stimulates increased heat production. The same is the condition with persons suffering from hyperthyroidism.  

 

Hence ''swedana'' is contraindicated in both of these conditions. [verse 14-15]

 

Thermotherapy can be used to treat a number of painful conditions. A number of studies with thermotherapy conducted worldwide has shown significant results in a wide range of disease conditions. These include:  

*(Chronic) muscle spasms in the form of persistent and often painful tension and shortness in a muscle or group of muscles that cannot be released voluntarily.  

*Types of arthritis that may benefit from thermotherapy include: Subacute or chronic inflammatory conditions, osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, reiter's syndrome, and sources of back pain such as a herniated disc.   

*Whiplash and other musculoskeletal types of neck pain, shoulder pain, such as rotator cuff injuries.  

*Decreased range-of-motion like in frozen shoulder, other types of joint pain, including many forms of arm pain (e.g., tennis elbow), leg pain (e.g., restless leg syndrome), knee pain (e.g., injured anterior cruciate ligament), foot pain (e.g., plantar fasciitis), tendonitis, bursitis, sprain, costochondritis, abdominal and pelvic pain, and fibromyalgia,  

*Other chronic pain disorders, including lupus and myofascial pain syndrome, asthma, reduction of joint contractures. Other conditions that may be treated with heat include back sprain, degenerative disc disease, sciatica and scoliosis, as these conditions are usually associated with muscle spasm. [13] [verse 20-24]

 

''Swedana'' accounts for a major part of Ayurvedic [[Panchakarma]] therapy. It is considered an essential preparatory procedure before bio-cleansing. It is normally done after internal or external oleation. ''Swedana'' liquefies and separates the vitiated body humors adhered to the tissues and facilitates their flow to the elementary tract for easy evacuation from the body. In Ayurvedic practise majority of ''swedana'' (sudation) procedures are done in the form of ''kizhi / pindasveda'' (sudation using bolus).  The commonly practiced few are detailed below with its preparation, application indication etc. [14]

 

==== ''Kizhi / Pinda / Pottali'' ====

 

These words mean bolus. Fresh herbs / powders / fruits / cereals etc are used to make bolus of different varieties. This bolus is heated and used to induce sweating. Before coming to the procedural details, the preparation of a ''kizhi'' should be generally understood.

 

===== Preparation of ''Kizhi'' =====

 

Take cotton cloth of one square meter size and divide it into four equal square pieces. Place four square pieces of cloth (each four inch) at the center of each cloth. Put equal portion of prepared drug into four pieces. Hold the cloth by the four corners and make the drug into a bolus. Hold tightly at the junction. Leave the larger end of the cloth and fold the other three corners by inserting into the center. Using the large flap of cloth surround the folded ones neatly and tightly so that it is sufficient to hold. Tie the twine at the junction of handle and bolus. Wind this tightly with the free end of the twine and fasten the knot.  

 

''Kizhi'' once prepared is used upto a maximum of 3 days.  

 

===== Preparation of the patient =====

 

Medicated oil massage is done before pindasweda. Oil is specially applied over the vertex, ears and the feet. The patient is comfortably placed on the droni (special wooden cot for administering treatment). Normally pindasweda is done in seven positions. These are sitting, supine, left lateral, again supine, right lateral, again supine and lastly sitting.

Medicated oil massage is done before pindasweda. Oil is specially applied over the vertex, ears and the feet. The patient is comfortably placed on the droni (special wooden cot for administering treatment). Normally pindasweda is done in seven positions. These are sitting, supine, left lateral, again supine, right lateral, again supine and lastly sitting.

Application of kizhi:

Application of kizhi: