Carpel tunnel syndrome treatment in Ayurveda

In October 2016 one of my acquaintance in New Delhi was calling me for his superior, who was an advocate in supreme court. This Keralite lady in her fifties, was asking for medical advise for her pain in right hand. She said the pain started nearly 2 months back, specifically 3-4 days after an attack of epidemic fever in Delhi. Most probably that must be chikungunya, which had an episode of spread at that time there. Right from its beginning the pain was so intense that she cannot hold the pen even to put a signature. The pain was present throughout the day & night without any change in intensity by change of position or time. In spite of having painkillers (NSAIDS) and sleeping pills at night, she wakes up due to pain after a short spell of sleep. 

While asked about treatment history, she said that she went to allopathy hospital on the next day itself, at first to an orthopedist. He went for X-rays and blood tests & assured her that in a week things will be better and advised some pain killers. Even after next visit and two more subsequent visits and some more investigations and physiotherapy, the response was negligible. She then visited an Ayurvedic practitioner with good Keralite Ayurvedic practice and followed his prescription perfectly.  His recomendations included Prasaranyadi Kashayam, Gulguluthikthakam Ghritham, Parinathakeri Ksheeradi thailam etc., which was a standard prescription for almost all upper limb manifestations of rheumatic origin. She was not satisfied with the response even after 2-3 weeks of this treatment. That is how she searched for other options and called me. 

She was quiet clear in her communication and I was convinced about her opinions on her degree of pain and the details associated. Yet I was interested to find out why the illness slipped out of the hands of two experts attended earlier.  I found both of them had attended her well and there was less chances of a lapse in diagnosis.  Still I asked her the details of pain again. 

 

 I decided to go for finding signs of Mamsadhatu involvement. The location was not really recognizable as she was describing it all over the left hand. So to exclude each one I went on asking the movement of each joints and the changes in pain during movements. When she went to its details, I understood that she was able to have full range of movements in shoulder and elbow. When she is trying to lift even a pen with  pronated and half flexed elbow, she has pain in the flexor compartments and tight feel at the wrist. The pain is extreme and feels like the hand has gone suddenly weak. With any other movements at the wrist the pain extends further down to the palm and fingers in extreme degrees. Even though I could not find any evidence to exclude mamsadhatu, I narrowed down the possibility to the involvement of muscle compartments, fascia tightness, or any other kind of ligament involvement. Any signs to relate to a local inflammation or other kinds of internal joint involvement were not seen. The pain relating to Mamsadhatu is described in texts as Mushtidanda hatopama - as if received punches or hit with sticks.  As this typical feature was not presented, 

The nature of pain she was describing is like a kind of pressurizing and excruciating type pain from which I could not make out something. Still I assumed it as a kind of high degree Angamardam & Vyadha types. If it is the former, the involvement of Mamsadhatu and Medodhatu are expected as they present the unique pain as if beaten by fist or a staff (Mushti danda hatopama type pain). From that I excluded joint inflamations, instead doubted the possibility of pain due to muscle fatigue, consequent to the fever. Jwaram is a disease of Rasadhatu, which is presented well in the skin. The skin and Mamsadhatu are having product-source relation (Mamsad vasa twacha shad cha). So there is a possibility that the if the pain is originating from Mamsadhatu, it is a sequel to the fever. 

Even when specifically asked she was not mentioning any numbness or loss of sensation, not even in palms or fingers. She did not have any swellings and it was not pale or reddish. Whenever I repeatedly asked the timings of the pain, she was repeating that it is through out day and night, never goes off, does not reduce or increase, but on keeping certain hand positions she  cannot hold that position even for some time. The timing of pain which was thorough out  and constant was pointing to the involvement of Asthi-Majjadhatu, which will have Santhatharuk. Since it is combined with weakness at conspicuously at some positions it shows a relations to joints and movements. It matches to some extent as Majja is responsible for the integrity of joints. Next immediate possibility to consider was the Upadhatu involvement. As Snayu was the one responsible for locomotor functions, its involvement is to be identified. Snayu is clinically referred for both nerves and ligaments. Since there was no numbness or tingling sensation, the urge to consider entrapment was not strong. More over she had symptoms in the forearm mainly rather than in the palm.  This made Carpel tunnel involvement a distant possibility, where the symptoms are always prominent distal to the entrapped location. The weakness could also be due to nerve entrapment or due to degree of pain. The cause of pain can be due to the nerve entrapment or a neuritis. 






Here both these were possible. After the strong fever episode, there is definitely a chance of sequels. The heat of fever will have an impact on all dhatus.  One or many of the organs at any location is sure to suffer unless intervened during the fever attack. Viral fevers, Chikun gunea etc are some examples were it is visha krimija and has affinity to joints. In her case, the joints appears to have spared, but the ligaments, specifically the ones which make carpel tunnel is affected. The ligament substance underwent an inflammation during or after fever. The heat has melt the structure like a rubber band. When it subsided, its length and elasticity has been greatly reduced, making the canal narrower and the structures inside to suffer mechanical pressure issues that generate pain. The next chance is for an inflammation of median or ulnar nerve. There was no evidence of active inflammation either for nerves or ligaments by way of local tenderness or swellings. Hence I concluded the diagnosis as Vata located in Snayu of the wrist joint making pain and incidental weakness. 



"Snava Sandhi Siraaprapthe sneha daha upanahanam" is the line of treatment mentioned for Sthanagata vatavyadhi. From the empirical knowledge and practical convenience I opted Upanahana swedanam. So I prescribed Kolakulathadi choornam, common salt, sesame oil and curd to mix them all together and make a paste. This paste is for placing a poultice at the wrist joint and bandaged well. This is to be placed for 12 hours and then removed. The hand is then washed. I instructed this treatment to be continued for 7 days every evening 6pm to 6 am and to report me after one week.  I asked her not to take any internal medication either Ayurveda or english. 


Next day by noon I received a phone call from her again, expressing extreme happiness and surprise. She was telling that the pain is completely relieved and no weakness was felt.  Still I asked her to continue with the poultice further.  After a week, she called again thanking me that the pain did not reappear at all.  I asked her to stop any further treatments 

I invite the attention of the readers to the deductive reasoning which helped to isolate and limit the cause to the single event of a snayu sankocha at a specific location, which is sequel to a aaganthu jwaram. The earlier doctors who attended did the right thing of expecting the frequently presented upperlimb presentations relating to the way symptoms manifested. The awareness of recent outbreak of viral fever and by analyzing the cause of Anupasayam by treatments of 2 earlier doctors and re-reading of anatomy of the region helped me to arrive at a conclusion, even though the symptoms presented misleadingly.