4 Building Credibility for Panchakarma
Building Credibility for Panchakarma Introduction
153
Application of Panchakarma
154
Bringing Credibility to Panchakarma
154
Lack of Evidence
155
Findings of a Survey on Panchakarma
155
Accreditation for Panchakarma Centres
156
Need of Guidelines for Ayurvedic Panchakarma Massage Parlours
156
Establishing a ‘Centre for Scientific Research in Panchakarma (CSRP)’
156
Example of a Research Study on Shirodhara
157
List of Instruments/Equipment required for research in Panchakarma
157
Conclusions and Recommendations
158
152 Status of Indian Medicine and Folk Healing
4 Building Credibility for Panchakarma
Introduction Panchakarma is one of the most trusted and widely used therapies practised in Ayurvedic hospitals and clinics all over India. It is considered a radical therapy, which reduces the chances of recurrence of disease. It is reported to be particularly beneficial for the maintenance of good health which accounts for the growing interest evinced by some sections of the public who are prepared to travel long distances to avail of authentic Panchakarma. The therapy comprises of five applications (pancha means five, and karma means therapeutic procedure) aimed at cleaning the disease-causing factors and hence rendering the body comparatively cleansed and ready to absorb different kinds of medication. They are Vamana (therapeutic emesis), Virechana (therapeutic purgation), Vasti (therapeutic enema), Nasya karma (nasal errhines) and Rakta mokshan (bloodletting). Tracing its origin to the classical textual triad of Ayurveda (Charaka, Sushruta and Vagbhata), Panchakarma has a history of many thousand years of uninterrupted practice. Being a part of samsodhana (correction through elimination) type of Ayurvedic therapeutics, it is considered superior to samsaman (correction through rebalance) therapy, because it aims at
eradicating the disease and minimizing the chances of recurrence.1 The main reason for which healthy patients visit AVS Kottakal and similar centres mainly in the South is to undergo seasonal detoxification of the body. In order to popularize Panchakarma, there is an increasing need to build substantial evidence to show its benefits. Several observational studies are required to collect evidence which justifies what today are just claims. The efficacy of Rasayana (rejuvenation) drugs need scientific endorsement. Unless evidence on the outcomes is documented, it would not be possible to rely only on claims or to motivate people to accept this therapy as treatment for medical conditions. Despite its popularity within the country, Panchkarma is underutilized at a global level as compared to Acupressure and Acupuncture therapies, which are available in abundance, particularly in the US. Only a few Panchakarma procedures that focus on de-stressing or relaxation, through whole body oil massage or a stream of medicated oil poured on the head (Shirodhara) have gained prominence. Panchakarma is not being practised like Chinese acupuncture, which is available with full certification of therapists and technicians not only of Chinese origin but belonging to different nationalities too.
1. This chapter was prepared with inputs from Dr. Sanjeev Rastogi, Associate Professor and Head, Department of Panchakarma, State Ayurvedic College & Hospital, Lucknow, Uttar Pradesh. Prof. R.H. Singh, Distinguished Professor, Faculty of Ayurveda, IMS, BHU, Varanasi was also consulted.
Building Credibility for Panchakarma  153
Application of Panchakarma Panchakarma is considered of particular importance in Ayurveda because it is considered a radical therapy, which nullifies the chances of recurrence of diseases. Panchakarma is beneficial for2 1.
Preventive, Promotive health purposes,
2.
Management of various systemic diseases viz., joint disorders, musculoskeletal, dermatological, neurological, psychiatric, geriatric, gynaecological disorders, respiratory disorders, etc.,
3.
The regimen is also widely prescribed in chronic incurable diseases for improving the quality of life.
Panchakarma has several sub-procedures3 which are generally being used for the following conditions: 1.
Preterm infants - Regular Snehana with til oil
2.
Rheumatoid Arthritis - Ruksha Udvartana, Saindhava Baluka Sweda, Vamana, Virachana, Vasti.
3.
Osteoarthritis - Patra pinda Sweda, Jaanu Vasti, Naadi Sweda
4.
Low back pain - Kanji Dhaara, Kati Vasti, Naadi Sweda
5.
Cervical spondylosis Greeva Vasti,
6.
Spondilytis - Patrapinda Sarwanga sweda
-
Shirodhara, Sweda,
7.
Hemiplegia - Sarwanga Sweda , Pinda Sweda, Vasti
8.
HypertensionShirodhara
9.
Anxiety- Shirodhara
10. DepressionShirodhara
Sarwanga
Nasya,
Sweda
,
Dhumapana,
11. Psoriasis – Vamana, Virechana Bringing Credibility to Panchakarma Years ago only skilled people performed the therapies under the supervision of an expert. This has changed and now the technicians use a range of practices of different duration, using herbs, steam and massage in differing proportion. Owing to the absence of standardization of Panchakarma procedures, patients face a dilemma about what to expect. While specific protocols for each procedure have been recounted in the ancient texts, the management is quite subjective and at times haphazard. This limits the use of these procedures to a limited segment of societythose who are unaware of the details of the therapies but who have innate faith in its goodness. Lack of Standard Operating Procedures (SOPs) is the biggest gap that prevents further growth and dissemination of the benefits of Panchakarma and remarks like “Dirty”, “Unhygienic” and “Inefficiently managed” are often heard, except when practised at selected centres. Recognizing the utilization and potential of Panchakarma, the Central Council for Research in Ayurvedic Sciences (CCRAS)
2. Guidelines on Basic Training and Safety in Panchakarma, CCRAS, New Delhi, 2008. 3. Snehana ( oil application), Swedana (steam application) and regional adaptations of these procedures to suit local site and disease like: Kati Vasti (hot medicated oil irrigation upon low back), Greeva Vasti (hot medicated oil irrigation upon back of neck) , Janu Vasti (hot medicated oil application upon knee joints) and Patrapinda Sweda (heat application through a bolus of herbs roasted in medicated oil). Shirodhara is another allied procedure where a medicated liquid preparation (oil or decoction) is poured upon forehead in the form of a regulated stream.
154 Status of Indian Medicine and Folk Healing
drafted guidelines for basic training and safety in administering Panchakarma. These guidelines were finalized in a national workshop after inviting subject experts and incorporating their suggestions.4 These guidelines remain available but are hardly applied in the Panchakarma clinics either in the public or private sector. Lack of Evidence There is scanty evidence proving the effectiveness and safety of Panchakarma while treating various clinical conditions. Its effectiveness has been poorly evaluated. Both in terms of primary and secondary outcomes and treatment endpoints, there are no prescribed procedural standards. In a literary search made at PubMed and Google Scholar, besides individual case reports, case series, and some pilot trials, it was not possible to locate studies that identified patient perceptions about the effects of Panchakarma therapy.
procedural explanations to the patients but owing to their limited experience and over enthusiasm, there is a possibility of over-projection of expected benefits. •
The non-involvement of senior consultants in the process of explaining the processes to the patients was seen as a deficiency.
•
The delay caused by the “waiting for turn” syndrome was a major component of the total time consumed, leading to a poor resource-patient ratio at some centres.
•
The scope of reducing the patient’s hospital stay without compromising on the services had not been addressed.
•
There was gross inadequacy of privacy for women which ultimately affected their receptivity to undergoing treatment. It was found that if patients do not feel comfortable during the process of preparation or during the actual treatment they remain under stress which impacts outcomes negatively on outcomes.
•
An evaluation of the patient’s perception of his experiences and expectations would help identify the gaps that lie between the “perceived” and the “practised” standard of Panchakarma procedures.
•
Cancelling or refusing Panchakarma services due to breakdown of equipment or its non-availability affects the professional reputation of the Panchakarma centres. A thorough record-keeping of the equipment and the regular supply of all consumables are both necessary to improve efficacy.
Findings of a Survey on Panchakarma A questionnaire based survey was conducted at the State Ayurvedic College and Hospital, Lucknow, Uttar Pradesh to identify the perceived efficacy, safety and standard of service delivery of Panchakarma.5 This hospital is one of the largest secondary care Ayurvedic hospitals in the northern region of India. The hospital has a fully functional Panchakarma unit with approximately 22,000–26,000 treatment enrollments in a year. The findings of this report points to many gaps that need to be filled: •
Trainees (who are the ones who generally administer the procedures) tend to offer
4. Guidelines on Basic Training and Safety in Panchakarma, CCRAS, New Delhi, 2008. 5. Sanjeev Rastogi. Effectiveness, safety, and standard of service delivery: A patient-based survey at a Panchakarma therapy unit in a secondary care Ayurvedic hospital. J Ayurveda Integr Med 2011; 2:197-204.
Building Credibility for Panchakarma 155
Panchakarma Protocols at AVS Kottakal The PI found that the AVS Kottakal Branch Hospital at Karkardooma, Delhi follows a check-list which is pasted on the door of each Panchakarma cubicle which ensures that individual procedures are taken up in sequence and continue like clock-work. This calls for laying down Standard Operating Procedures (SOPs) and introducing an accreditation system for each clinic whether in the government or private sector. Accreditation for Panchakarma Centres The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has brought AYUSH hospitals and wellness centers under its ambit. It has issued detailed guidelines on services to be maintained by AYUSH hospitals aspiring for certification. There is a need to introduce a Central Scheme to support the acquisition of NABH Certification by State Government Ayurvedic Hospitals. The condition of the Panchakarma units in the Government hospitals in most places is poor. The PI found a low level of hygiene and general upkeep in most government-run facilities in almost all States. With the exception of a few privately-run nursing homes, the standards even in private clinics were rudimentary Despite all these shortcomings, Panchakarma units are doing brisk business in many hospitals and centres and have a substantial turnover of patients. Seeing the large number of waiting patients, it is necessary to lay down basic conditions that must be fulfilled to receive accreditation. Need of Guidelines for Ayurvedic Panchakarma Massage Parlours There has been a phenomenal increase in the demand for specific Panchakarma
156  Status of Indian Medicine and Folk Healing
procedures to enhance beauty and provide relaxation. Most five star hotels and highend tourist resorts provide Panchakarma limited to massage and Shirodhara. Since the name of Ayurveda is being used, there should be a requirement for such procedures to be performed only by qualified staff. Panchakarma which calls for massaging, fomentation, steam bath, etc. need to follow certain precautions, keeping in mind factors such as age, time of day, etc. If Panchakarma is followed by swimming or preceded by a full meal it may have some associated risks. The association of the name of Ayurveda or Panchakarma will fall into disrepute if care is not taken. Hence there is a need to involve the Tourism Departments of the states through the Ministry of Tourism to bringing uniformity in the use of massages and other techniques which purport to be a part of Ayurveda. If they are merely offering massage services, it needs no intervention but the use of the term Ayurvedic massage or Panchakarma should have some attendant requirements that need not have to be fulfilled. Establishing a ‘Centre for Scientific Research in Panchakarma (CSRP)’ While commendable efforts have been made to research different aspects of Panchakarma, unfortunately, according to many Ayurveda teachers that the PI interacted with, the research has been poorly designed, poorly executed and the main focus has been on subjective clinical observation. The statistical tools employed to evaluate such studies are generally inappropriate. A fundamental reason for this is that research is being done primarily by postgraduate students as a part of their dissertation. A separate centre for quality research in specialized fields is required where the scientific validation of various Panchakarma procedures can be undertaken
based on the clinical application of different procedures for specific indications. Such a research centre needs to be equipped with a team which includes Panchakarma experts as well as experts from biochemistry, physiology and radiology. A Panchakarma research centre would generate data on a range of benefits that are observed scientifically which alone can justify the claims about Panchakarma. Example of a Research Study on Shirodhara “Ayurveda definitely has new ideas for health promotion and prevention of diseases,” says Kazuo Uebaba, Associate Superintendent of the International Traditional Medicine Research Center of Toyama prefecture, International Health Comple, Japan. His study is titled `Usage of Modern Technology for the Scientific Study of Ayurveda’ on Shirodhara (oil dripping treatment on the forehead). According to him, Shirodhara is one of the characteristic healing techniques in Ayurveda prescribed for headache, insomnia, anxiety, neurosis, hypertension and several kinds of psychosis. Dr. Kazuo and his team6 developed a healing robot to conduct Shirodhara in a standardized manner. “The healing robot will conduct Shirodhara in a computerized reproducible manner. This helps in studying the mechanism of the treatment. It was found that physiological changes during Shirodhara were related to psychological experiences such as anxiety and Altered State of Consciousness (ASC) or
anxiolysis. This was assessed by a psychometric method. The study also discussed the clinical utility and validity of Shirodhara. Factors such as oil flow rate, oil temperature, dripping speed, dripping pattern and kind of oil and its effect on the treatment of stress, headache, insomnia, eye disease and facial wrinkles were also studied. All patients tolerated the treatment well without any adverse events. Such studies can be undertaken in India in collaboration with the National Brain Research Centre (NBRC), Manesar, Haryana (Deemed University under Department of Biotechnology, Govt. of India)7 among other tertiary level Institutions. List of Instruments/Equipment required for research in Panchakarma The PI had requested Dr. Sanjeev Rastogi8 and Dr. Rama Jayasundar9 to prepare a list of equipments that would be needed to conduct tests and evaluation. Professor R.H. Singh, Distinguished Professor, Department of Kayachikitsa, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi while appreciating the lists provided by the two experts, suggested the necessity of using investigative equipment for two different purposes: 1.
Therapeutic equipment to assess the efficacy of different treatment procedures such as standard Droni, Shiridhara equipment, Nasya equipment, standard Vasti instrument, standard Vaman chair, standard Shirovasti set, etc.
6. Uebaba K, Xu FH, Tagawa M, Asakura R, Itou T, Tatsuse T, Taguchi Y, Ogawa H, Shimabayashi M, Hisajima T. Using a healing robot for the scientific study of shirodhara. Altered states of consciousness and decreased anxiety through Indian dripping oil treatments. IEEE Eng Med Biol Mag. 2005 Mar-Apr;24(2):69-78. 7. Inputs provided by Dr. Sathya N. Dornala, Ph.D. (Panchakarma), Senior Medical Officer, East Delhi Municipal Corporation, New Delhi. 8. Associate Professor, Department of Panchakarma, State Ayurvedic College, Lucknow 9. Associate Professor, Department of Nuclear Magnetic Resonance (NMR), AIIMS, New Delhi
Building Credibility for Panchakarma 157
2.
Equipment to assess the mechanism of the effect of different procedures to see how they act.
He drew a distinction between efficacy studies and studies on the mechanism of action. He felt that sophisticated procedures and equipment were required for the mechanism of action studies and advised that the current focus should be on efficacy studies which would demonstrate prima facie the therapeutic effect of the treatment which may help to standardize the procedures. For this, simpler devices could be fabricated by individual investigators and therapists. In view of this he felt that we may not need an isotopic tracer studies or even the detailed molecular studies straightaway. In view of this the exhaustive lists of equipment suggested by Dr.Sanjeev Rastogi and Dr. Rama Jayasunder have not been referred in this chapter but the material is available with the PI. Conclusion and Recommendations Effectiveness Studies There is a need to build up substantial evidence to show the benefits of Panchakarma as a therapeutic intervention. Several observational studies are required to collect evidence which justifies what today are mere claims. The efficacy of Rasayana (rejuvenation) drugs need scientific endorsement and by simultaneously setting up two similar groups of patients - one which undergoes Panchakarma and another which does not, outcomes can be registered in comparative terms. Unless such evidence is documented following a strict protocol and the research has independent co-researchers on the team, the outcomes even if they are very positive may not be trusted. Evaluation Studies on Patient Responses There
is
scanty
evidence
proving
158 Status of Indian Medicine and Folk Healing
the
effectiveness and safety of Panchakarma while treating various clinical conditions. Both in terms of primary and secondary outcomes and treatment endpoints, there are no prescribed process standards. Therefore there is a need to also evaluate the patient’s perception of his experiences and expectations which would help identify the gaps between the “perceived” and the “practised” standard of Panchakarma procedures at different facilities. Establishing a ‘Centre for Scientific Research in Panchakarma In the long term there is a need to plan for a Centre where the related validation studies can be undertaken or alternatively to fund research which can be undertaken in leading medical research institutes which can permit the use of their equipment to test the change in markers and physical parameters of the patient as a sequel to undergoing different procedures. A group of scientists from Ayurveda as well as related modern medicine research fields including biophysicists needs to be set up to agree on measurement devices and markers that can evaluate different parameters to establish the efficacy of each intervention separately. Most of the Sub procedures of Panchakarma seem to be a part of physical medicine as seen from a contemporary perspective. As a quick measure, a Panchakarma unit should be started at the All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai or collaborative studies can be undertaken with AIIPMR which would be a simple way of determining the effectiveness of Panchakarma procedures. There is likely to be no resistance as that Institute is generally interested in any procedure that helps rehabilitation of patients. There is no doubt that Panchakarma has a strength in the areas of restoration and rehabilitation. AIIPMR receives the kind
each procedure which can be seen by the patient also. Alternately the CCRAS guidelines should be officially notified for adoption after being examined for general application.
of patients that would benefit from such treatment. The Institute comes under the Ministry of Health/Directorate General of Health Services. Research Study on Shirodhara shows the way A study which has been referred to in the main Chapter had described the efficacy of Shirodhara when it is undertaken in a standardized reproducible manner, which helps in studying the mechanism of treatment. This study can be a model for similar studies to be undertaken on the efficacy of Shirodhara. Studies can also be undertaken in collaboration with the National Brain Research Centre (NBRC), Manesar, Haryana (Deemed University under Department of Biotechnology, Government of India) if Department of AYUSH approaches them and also funds the project. Evaluation of Panchakarma
Functional
aspects
of
Research has shown that trainees (who are the ones who generally undertake the procedures) tend to offer procedural explanations to the patients but owing to their limited experience and over enthusiasm, there a possibility of over-projection of expected benefits. The non-involvement of senior consultants in the process of explaining the processes to the patients has been viewed as a deficiency. Hence the following recommendations are made: i.
The delay caused by “waiting for turn” should be reduced without compromising on the quality of services. The model followed by AVS Kottakal and some other centers could become the benchmark for the duration of procedures as well as essential equipment and consumables that would need to be used. AVS Kottakal has checklists for
ii.
Privacy for women should be assured as it affects their receptivity to undergoing treatment.
iii.
Patients need to feel comfortable during the process of preparation and during the actual treatment. Uncertainty leads to stress which impacts negatively on the outcomes.
iv.
Cancelling or refusing Panchakarma services due to breakdown of equipment or absenteeism of staff should be monitored to bring in more professionalism. A thorough recordkeeping of the equipment and regular supply of all consumables is necessary to improve efficiency.
Standard Operating Procedures Accreditation for Panchakarma Centres
and
Standard Operating Procedures (SOPs) for Panchakarma needs to be introduced for all centers whether in the government or private sector. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has brought AYUSH hospitals and wellness centers under its ambit. It has issued detailed guidelines on services to be maintained by AYUSH hospitals aspiring for certification. There is a need to introduce a Central Scheme to support the acquisition of NABH Certification by all State Government Ayurvedic Hospitals which provide Panchakarma treatment. It is also necessary to encourage reputed Panchakarma centres in the private sector to acquire accreditation as there is a low level of hygiene and general upkeep in many facilities. With the exception of a few privately
Building Credibility for Panchakarma 159
run nursing homes, the standards are rudimentary. Hence accreditation will provide minimum benchmarks for hygiene and give users the confidence about the standards and services offered at the facility. Department of AYUSH could also give a bridge loan to selected private facilities to get NABH accreditation on the condition that they treat an agreed number of referred cases sent by Government facilities. Need of Guidelines for Ayurvedic Panchakarma Massage Parlours There has been a phenomenal increase in the demand for specific Panchakarma procedures to enhance beauty and provide relaxation. Most five star hotels and high-end tourist resorts provide some form of Panchakarma limited to massage and Shirodhara. Since the name of Ayurveda is being used, there should be a requirement for such procedures to be performed only by qualified staff. Care has to be taken that the fair name of Ayurveda or Panchakarma does not fall into disrepute. By involving the Tourism Departments of the states through the Ministry of Tourism it would be possible to bring uniformity in the services provided, when the service is claimed to be a part of Ayurveda. If they are
160  Status of Indian Medicine and Folk Healing
merely offering massage services, it needs no intervention. However, the use of the term Ayurvedic massage or Panchakarma should have attendant requirements that have to be fulfilled on the lines of the green leaf strategy of Kerala State. Promotion of Panchakarma on the lines of Chinese Acupuncture Despite its popularity, Panchkarma is underutilized at a global level as compared to Acupressure and Acupuncture. Clinics for such procedures are available in abundance, particularly in the US. Chinese acupuncture is also available with full certification of therapists and technicians. In the US such staff is not only of Chinese origin but can belong to any nationality. There is a need to gain a similar foothold for Panchakarma services by offering courses for students in the US, leading to the grant of a licence. Initially, such courses can be started with the approval of any US State authority which is prepared to allow such courses to be run in that State. Ayurveda and Panchakarma do not need endorsement from the US. However that is one of the most effective ways of marketing authentic and effective Panchakarma services. The recommendation should be seen in that spirit.