Varmam Uses [PDF]

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INTRODUCTION: Martial arts are codified systems of combat practices learnt for a variety of reasons like self defense, competition, physical health and fitness. It helps in of several Tamil martial art techniques – Varma Kalai, being a distinctive and selective art form that takes a great amount of time, skill and patience to master. The Tamil name ‘Varma Kalai’ means ‘The Art of Vital Points’. HISTORY According to the Hindu mythology, Lord Shiva taught this martial art to his son, Lord Murugan. Further, Lord Murugan taught this art to sage Agasthiya, who was the foremost of Siddhars during the time of Sangam Literature. Agasthiya spread knowledge of this art form to the rest of the Siddhars and it is evident from the presence of Agasthiyar’s shrines depicting this art form in Kutralam (Panchayat town in Tirunelveli district, Tamilnadu)

The Tamil name ‘Varma Kalai’ means ‘The Art of Vital Points’. When triggered, these points can disable, paralyze or even kill a person.

According to the Hindu mythology, Lord Shiva taught this martial art to his son, Lord Murugan. Further, Lord Murugan taught this art to sage Agasthiya, who was the foremost of Siddhars during the time of Sangam Literature. Agasthiya spread knowledge of this art form to the rest of the

Siddhars and it is evident from the presence of Agasthiyar’s shrines depicting this art form in Kutralam (Panchayat town in Tirunelveli district, Tamilnadu) Kings of all four major Tamil dynasties – Chera, Chola, Pandya and Pallava – patronized this art form to selected schools and they paid nivandhanams (donations with high respect) for it. Varma Kalai is taught by teachers called Aasan (Tamil – master) and grandmasters called Periyaasan. AESTHETICS Varma Kalai teachers are highly selective over their choice of students. Besides the knowledge of this martial art form, they are required to have an understanding of  Biology, Chemistry, Mathematics, Yoga, military tactics, horsmanship, elephant riding, charioteering and Hindu philosophy (Saiva, Vaisnava, Saktha, Koumara, Boutha, Samana) etc. Varma Kalai martial artists are not allowed to teach the art to others until they receive Deeksha (giving a mantra/ initiation) from the Aasan or Periyaasan. TECHNIQUES Varma Kalai is classified into 4 types: Thodu Varmam – ‘Thodu’ means touch in Tamil. Around 96 vital points in the body are triggered by touch. It is not fatal, but results in the disabling of the victim’s body, organ movements and function. Padu Varmam – It refers to the 12 vital points in the body, which when triggered results in death or severe effects on the victim. Thattu Varmam – This involves vital points that are held and used by the master alone. It is kept confidential until the master passes on the knowledge to the selected disciple. Nooku Varmam / Meitheenda Kalai – As the name indicates, Tamil word ‘Nooku’ means look or contact. The Tamil word ‘Meitheenda’ means ‘without touching’. The triggering of the vital points is done by focusing or concentrating on the target. It takes several years of practice to become an expert in it. In the human body there are 108 Varmams / Vital points.

Also according to Siddha Medicines and their healing therapy on the human body called Vaidhya murai, the vital points are explained as – 64 points in Vadha Varmam, 24 points in Pitha Varmam, 6 points in Kaba Varmam, 6 points in Ul Varmam and 8 points in Thattu Varmam.

POPULARITY The art was taught only to selected individuals, but due to strict requirements for new students it never gained large numbers of adherents. Due to its secretive nature, Varma Kalai was largely unknown even in India. The release of a bi-lingual film, Indian, directed by Shankar, where Padmashri Dr. Kamal Haasan etches the role of a Varma Kalai expert, enhanced the popularity of this art form and generated a resurgence of interest in the art. Currently Varma Kalai, is practiced in Tamilnadu and Kerala as part of other martial art forms like Kalari (swords and sharp instruments are used) and Silambattam (Bamboo cane is used). SUMMARY: varma adi recognizes 108 marmas (lethal varma points), 12 padu varnas ( death marmas) , 96 thodu varmas and about 350 therputic varma points within our body. There are also counter marmas to heal trauma to the marmas. varma also known as marma points which located at point of specific part of body surface whereby application of pressureor insertion f needles will affect the vital energy flow or prana (life) along a complex system of subtle channels called Nadis. By using varying degrees of force to strike the body at different vital points, can produce astounding results. when used in warfare by a skilled combatant, these blows can causeinstant death, great pain, paralysis or infection evendelayed death. the results vary according to the power and velocity used by the combatant, subject to the training of the day as well. common training in varma kalai: 1. Kai murai _ hand and finger methods 2. Seiyal murai – Application method TRAINING IN LEVEL 1 : VARMA VARISAI (UNDERSTANDING)

Padu varmam – 12 with mudras ( varma techniques) Adangal ( releasing of varmam/ revocery from unconscious) –actually have 56 adangal but reduced to 12 while the siddha’s have mentioned a lot about the beating, pushor touch in the varmam to make a person incapacited. in real life a person may get attacked accidentally in the vamam and incapacitated . Siddha’s have also mentioned the ways to bring back such affected person to normal. this is called marmathiravukol ( method to open varmam) ir adangal or key to bring back to normal. a push, a touch or a beating in the relevant place, applying oils, medicines, administering medicines brings back the affected person to normal. this is possibleto all varmas. Usually Guru will teach to student which consists of mel adangal (top), naduvu adangal ( middle) and Kii adangal ( bottom) TRAINING LEVEL 2 :PORMUGA VARMA VARISAI: Padu varmam – 12 (deadly points) the meaning of padu is nothing but death. Padu varmam are highly dangerous. these are located in the front part of the body. a gentle touch or a pushin these places may result death. they are thilarntha kaalam natchathira kaalam pidari kaalam urakka kalam sumei varmam ner varmam adappa kaalam urumi kaalam valia athisurukki siriya athisurukki kalladaikaalam Por varmam – 24 (used in combat / self defence) varmam points are 36.

Amirthanila (nectar placement) this concept explains the effectiveness of attack on varmam depends on the lunar movement. The varma points keeps moving from toe to head and vice versa with the movementof moon. The movement will be X shape. The vital varma pointsand the poison will travel in opposite direction. Such effective points are known as the amirthanila. THE VITAL SPOTS AND AYURVEDIC HISTORY AND PRINCIPLES

The earliest textual evidence of the concept of the vital spots dates from as early as the RgVeda (@ 1200 BCE) where the god Indra is recorded as defeating the demon Vrtra by attacking his vital spots (marman) with his vajra (Fedorova 1990). From this and numerous other scattered references to the vital spots in Vedic and epic sources, it is certain that India's early martial practitioners knew and practiced attacking or defending vital spots; however, we possess no martial texts from antiquity comparable to the Sanskrit medical texts in which a systematic knowledge of the vital spots is recorded. By the time that Susruta's classic Sanskrit medical text had been revised in the 2nd century A.D., 107 vital spots of the gross, external, physical body (sthula-sarira) had been identified and defined as an aid to surgical intervention: the areas where muscles, vessels, ligaments, bones, and joints meet together which by virture of their nature are specially the seats of life (Singhal and Guru 1973:132). Susruta knew the importance of avoiding vital spots in surgery, identified illnesses caused by direct and indirect injury to them, and diseases situated in them. He asserted that direct penetration of many vital spots was fatal, and classified these trauma as sadyah-pranahara (causing death within one day) or kalantara-pranahara (causing death within 14 days to one month). He also observed that death could be caused by extracting a foreign object from a wound to a vital spot (visalyaghna), that some wounds to the vital spots might result in maiming or deforming injuries (vaikalyakara), and other times penetration of vital spots only resulted in painful injuries (rujakar). Of the 107 vital spots he identified, Susruta listed 51 as leating either to immediate death, death within twenty-four hours, or one month. Limited emergency measures included surgical removal of the foreign body and amputation. Susruta

established a close connection between combat and medical intervention. Surgery was called salya, which referred to "foreign bodies of every kind...but...specifically...the arrow, which was the commonest and most dangerous foreign body causing wounds and requiring surgical treatment" (Kutumbiah 1974:144). Knowledge of the vital spots shares the general Ayurvedic principles that health is a state of humoral equilibrium. Susruta identified seven kinds of diseases, one of which was samghata-bala-pravrtta, "the traumatic type...caused by an external blow or...due to wrestling with an antagonist of superior strength" (Susruta, Suthrasthana XXIV, 6; Bhishagratna trans., 1963:230). All combat injuries fall into this class. Susruta related them to the primary humoral body by explaining that traumatic injuries enrage the wind humor in the area of injury. The first action of the attending physician should thus aim to calm the 'enraged wind humor (vayu). The legacy of identification, classification, and treatment of the vital spots established by Susruta, and in South India by Vagbhata, was a rational system based on humoral theory and therapeutic intervention applied to observations of wounds received in combat. It was certainly never a closed, secret tratition since its purpose was to save lives whenever possible. This medical tratition was eventually passed to martial specialists for whom the combat application (prayogam) of their specialized knowledge was just as important as medical intervention (cikits) VARMAM TREATMENT FOR MENTAL STRESS: In the modern world, peoples are very busy and moving with very many thoughts and too many targets to achieve for them in near future. Hence the multi-targeted people suffering from mental stress and emotional problems which disturb the equilibrium of the body. Like physical ailments, in probing and treating mental stress, one must keep in mind the chemistry of the brain which plays a major role in such diseases. It is well known that the wrong mental 215 thoughts may also results in physical illness. Besides the involvement of brain personality factors also lead to mental stress problems like depression, anxiety, over sensitiveness, fear, sadness, disappointment, too much stress and tension, lack of energy, excessive haste, anger and emotional outbursts.

‘kdkJ nrk;ik ahdhy; ke;jpuQ; nrgpf;f Ntz;lh kdkJ nrk;ikahdhy; thAit Aah;j;j Ntz;lh kdkJ nrk;ikahdhy; thrpia epWj;j Ntz;lh kdkJ nrk;ikahdhy; ke;jpuQ; nrk;ik ahNk’ mf];jpah; Qhdk;. If each and every person should have perfect mind setup, then we need not perform chatting of Mandiras, breathing exercises or Vasi yoga. Sound mind always results in sound body, as said by the great, Agasthiar Maamuni (Saint). Weak mind and negative thoughts are the fundamental reasons responsible for all the physical and mental ailments of the body. Also we should avoid alcohol and drugs which may trigger mental problems. MENTAL DEPRESSION: Depression is a medical condition that leads to intense of sadness or despair. There are two major types of depression. The first type is called ‘Reactive Depression” which is caused due to excessive conditional stress like sudden and shocking death of a loved one, unbearable financial loss or some other distributing event. The second type of depression is termed as ‘Endogenous” which emerge from within you, without any apparent external cause, usually resulted due to chemical change in the brain. It is a serious mental stress and needs medical counseling. Depression can occur at any stage and when it overpowered the body, many symptoms become apparent. Besides melancholy, certain physical problems like loss of energy, decrease in appetite, insomnia, constipation, headache, vague body pains, diminished interest in sex, intensive misery, negativity and self doubt, giddiness palpitations, dryness of the mouth and blurred version take place. Severe depression leads to feeling of total hopelessness, suicidal thoughts, loss of weight, withdrawal into self and non-responsiveness. The person suffering from depression has to be educated about the realities of life and the need for inculating positive 216 outlook. Varma therapy is useful in removing negative thoughts and building positive outlook, which is very essential to cure depression. ANXIETY: Anxiety is the integral part of our life. When it exceeds it becomes disorders of emotions and results mental stress. If the anxiety is caused by a

specific stress or any other problem, first remove that cause. Varma therapy, techniques of relaxation, meditation and yoga can relieve anxiety. Anxiety and panic attacks sometimes develop in relation to phobia which can be removed from mind through positive thoughts and counselling. CAUSES OF MENTAL STRESS Stress occurs all the time in most people’s lives. Too much stress seriously affect physical and mental well beings. When we encounter a stressful event, our bodies undergo a series of hormonal and biochemical changes that put us in alarm mode. Our heart rate increases, adrenatin rushes through our blood stream and our digestive and immune systems temporally shut down, if the stress we experience exhaustion and burn out. Common Signs of too much stress include Increased irritability Loss of concentration Rapid heart beat Heightened Sensitivity to criticism Indigestion Headache sleeplessness Early morning waking Drinking and smoking more Stiff neck or tight shoulders. Difficulty in making decision.

HEALTH PROBLEMS LINKED TO STRESS are

Heart attack Hypertension Stroke

Cancer Diabetes Obesity Eating disorders Ulcers Irritable bowel syndrome Memory loss Infertility Auto immune disease Insomnia The causes of stress are highly individual. It depends on your personality, general outlook on life, problem solving abilities, and social support system. Exercises, humour, play, music, prayer, meditation and relaxation will reduce your stress in your life and will balance your mind to maintain well being status. LOCATION OF MIND Mind can activate the functions of brain and body pituitary glands and other endocrine systems. It can enlarge the ‘Puththi’ (vision over the world) which inturn enlarge the ‘Siddhi’ (rational desire) which can enlarge the Angaram (rational knowledge-wisdom). There is a three school of thoughts among siddhars regarding the location of mind 1) Located in brain 2) located in Nabi 3) Located in spiritual heart at chest. Though after brain death, the body is functioning. This feature suggest that the mind is not situated in the brain and it may be located in the spiritual heart of the spiritual body. Research should be attempted regarding the location of the mind of the human body. But no doubt, the mind is in the body.

VARMA TREATMENT FOR MENTAL STRESS: Counseling on mind and positive thoughts, when accompanied with Varma points manipulation techniques play vital role in bringing down the mental stress through change of life pattern towards peaceful sound health and mind. 7 persons (three women at the age of 24, 42 and 19 and men at the age of

52, 37 and 28) are treated for their mental stress problems. The 218 following Varma points were manipulated to relieve mental stress related to emotions and mental imbalance. Kondaikolli - To correct the chemistry of cerebrospinal fluids of the brain and mind in the spiritual heart. Patchi nema varmam- To enhance the spiritual condition of the mind and body and to activate functions of the body and mind. Patchi Varmam - To reduce the mental stress and cool down the anxiety and enhance the positive thoughts through divine power-Varma energy (ieVasi) into the body. Thilartha Kaalam - To activate mind, decision making, intellect, and rational thoughts, (Manam, Puththi, Siddhi and Angaram) Vettrilai Kaalam - Located three finger right side of Patchi Nema Varmam. To regulate the divine power into the mind and body (Vasi) to accomplish or carried out all functions smoothly, because of the relief in mental stress and mental calmness will be attained. Aakirana Kuruthu - Located on the tip of nose. To normalize Vatham, Pitham and Kuttri Kaalam Khapam. To coordinate the parts of body according to the thoughts of mind. To maintain well being status. Adappa Kaalam - To attain the spiritual power and relieve bad evil thoughts from the mind through the activation of mind, lungs and liver. Soozhiaadi Varmam - To enhance the spiritual energy in the body and mind and connect the energy system between head and the trunk of the body. Saramudichu - To regulate Saram (important energy circulation in the body) so as to reach good conditions of mind and body. Kilimega Varmam - To treat mental hysteria, calm down mind by inducing perfect respiration and relieve mental stress. Kaiperuviral - To regulate ‘Vasi’, an energy system running through out the body Nagakkan Varmam is the Varma energy, without this, proper function of human body is not possible. Nattel and Ner Enai - Simulataneous lifting of these Varma points bring out good Varmangal functioning of the Dhasavayus in the body and perfect

functioning of idakalai, pingalai and suzhumunai nadis. This varma manipulation is performed to relieve mental stress and body stress 219 so as to reach the proper function of mind and body. Your positive thoughts and memory power will be increased. The above varmam therapy is capable of enhance the body functions, relax the mind, activate the correct circulation of cerebral spinal fluids, energy (Varma energy) and blood in the brain and body. The varma therapy bring out proper function of endocrine and exocrine system of the body and regulate ‘vasi’ (varma energy), Saram (energy emerging after passing all six chakaras and enter into the brain) and Pranan (energy bearing or energized blood with oxygen flowing through out the body in each cells and tissues of the body). Three day treatment was given once in two days. First day treatments was given along with the above Varmam points, through the special method of Kaipagam and Seipagam, Sarakkayan (problems in the flow of saram) Vasikkayam (hurdles in Vasi energy circulations) and Pranakkayam through Dhasanadi thattal (To solve problems pertaining to Prana energy circulation) were also performed to relieve the problems / set right their circulation in the body. This helps to reach well being status in mind and body. Varmam therapy works well in alleviating the mental stress among the people. EFFECTIVENESS OF VARMAM MANAGEMENT OF OSTEOARTHRITIS

THERAPY

FOR

THE

 Osteoarthritis (OA) is a type of joint disease that results from breakdown of joint cartilage and underlying bone. Osteoarthritis is the most common form of arthritis with disease of the knee and hip affecting about 3.8% of people as of 2010.Among those over 60 years old, about 10% of males and 18% of females are affected.  It is the cause of about 2% of years lived with disability. In Australia, about 1.9 million people are affected, and in the United States, 30 to 52.5 million people are affected.  It becomes more common in both sexes as people become older. Osteoarthritis in the knee begins with the gradual deterioration of cartilage. Without the protective cartilage, the bones begin to rub together, causing pain, loss of mobility, and deformity.6 It affects approximately 16 million people. The majority of arthritis cases involving the knee are osteoarthritic cases.

It is not always certain why arthritis of the knee develops. Most physicians believe that it is a combination of factors that can include muscle weakness, obesity, heredity, joint injury or stress, constant exposure to the cold, and aging. Cartilage in the knee begins to break down and leaves the bones of the knee rubbing against each other as you walk. Persons who work in a place that applies repetitive stress on the knees are at a high risk of developing this condition. Bone deformities increase the risk for osteoarthritis of the knee since the joints are already malformed and may contain defective cartilage. Having gout, rheumatoid arthritis, Paget's disease of bone or septic arthritis can increase your risk of developing osteoarthritis. Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include: Pain, Tenderness, Stiffness, Loss of flexibility, Grating sensation, Bone spurs.  In Siddha the symptoms of Osteoarthritis is similar to Azhal keel vaayu. The complete remedy of these diseases is still not available in modern medicine. The drugs used mainly are analgesic, anti-inflammatory and steroids, which can’t spell out the disease but are only symptomatic, on the other hand furious side effect like Gastritis, Ulceration of mucosal layer of stomach, heart burn and Vomiting are added as the unwanted results. Varmam also called as marmam, indicates the therapeutic stimulation of specific points in which pranic energy is found concentrated. Varmam therapy which is drugless, non invasive, cost effective, simple therapy is very effective for the management of osteoarthritis. Varmam is a specialized field of Siddha pertained to cure neurological weakness, neuromuscular problems, migraine headaches, convulsions, arthritis, spinal problems, muscle wasting and to wail intense pain. The therapy time is less and when properly complied to, gives long lasting results. Hence an attempt has been done to prove the efficacy of Varmam therapy for the management of osteoarthritis. MATERIALS AND METHODS:   Patients with Clinically diagnosed primary osteoarthritis of knee joint who are willing to undergo the varma treatment were selected and asked to visit OPD of Ayush wellness clinic for 48 days of Varmam therapy point stimulation. Totally 30 Patients with different age group, gender, and socioeconomic status were randomly selected, on the basis of following criteria.

Inclusion Criteria: 1. 2.

Patients of both sex between the age group 30 to 60yrs. Patients with the signs and symptoms of Primary osteoarthritis of knee joint. Exclusion Criteria:

1. 2. 3. 4. 5. 6.

Patients below age 30yrs and above 60yrs of either sex. Secondary Osteoarthritis of knee joint. Rheumatoid arthritis & Gouty arthritis. Pregnant women. Patients having other Systemic disorder. Patients having severe osteoarthritic changes. Methods: Stimulation of varma points for 48 days. Varma Points:

1. 2. 3. 4. 5. 6. 7. 8.

Chippi Varmam: Situated 6 finger breaths below Saramudichu, 3 finger breaths lateral on either side. Uppukuttri Varmam: Situated 3 finger breaths above posterior aspect of the heel. Kuthikaal Varmam: Situated 7 finger breaths above posterior aspect of the heel. Viruthi kaalam: Situated between big toe and adjacent in its dorsal aspect. Komberi kaalam: Situated 8 finger breaths above medial malleolus. Naai thalai Varmam: Situated 3 finger breaths below knee joint. Kaal moottu Varmam: Situated in centre of the popliteal fossa. Veeradangal: Situated 4 finger breaths above kaal moottu Varmam. Each varma point will be stimulated with pressure mentioned in text and may vary according to patients pirakuruthi (body constitution).  Assessment Criteria: The symptoms of Osteoarthritis of knee joint and joint activity were taken for the assessment results of Varmam therapy. Following parameters were taken in account.

Grading of assessment criteria: A. Severity of pain (VAS scale): Severity of pain can be assessed by the following Visual Analogue Scale. 

FIG. 1: SEVERITY OF PAIN Tenderness: TABLE 1: ASSESSMENT CRITERIA FOR TENDERNESS  S.no

Grading of Tenderness

Score

1

No pain on pressure

0

2

Tenderness with no physical response

1

3

Tenderness with grimace, wince, and/or flinch

2

4

Tenderness with withdrawal (positive jump sign)

3

5

Non-noxious stimuli (e.g., superficial palpation, gentle percussion) 4 results in patient withdrawal or patient refusal to be palpated due to pain

 

Swelling: TABLE 2: ASSESSMENT CRITERIA FOR SWELLING  S.no

Grading of Tenderness

Score

1

No Swelling

0

2

Swelling may not be apparent on casual inspection, 1 but recognizable to an experienced examiner

3

Swelling obvious even on casual observation

2

4

Markedly abnormal swelling

3

5

Swelling to a maximally abnormal degree

4

Range of Motion (R.O.M.) (By Goniometer): Assessed on following grading system. TABLE 3: ASSESSMENT CRITERIA FOR RANGE OF MOTION S.no

Grading of Tenderness

Score

1

0-130 degree

0

2

129-90 degree

1

3

89-60 degree

2

4

59-30 degree

3

5

30-0 degree

4

RESULTS: TABLE 4: OVERALL EFFECT ON THE ASSESSMENT CRITERIA Assessment S Criteria’s

Before therapy

Varma

(n=30) Mean ±S D

After therapy

Varma T- value

Pvalue

(n=28) Mean ± S D

1

Severity of pain (VAS 3.63 ±1.42 scale )

1.8±0.66

6.36

P=1

2

Tenderness

2.46±0.86

1.16±0.59

6.75

P=1

3

Swelling

2.73±0.69

1.25±0.75

6.43

P=1

4

Range of motion 2.68±0.86 1.28±0.58 7.31 The results were significant (p=1) with respect to the assessment criteria

P=1

DISCUSSION:  Maximum patients 43.33 % were found in age groups of 51 to 60 years followed by 40 % patients from 41 to 50 years of age group and 16.66% patients from 31 to 40 yrs. This study shows that this disease is more prevalent in age group 51 to 60 years. Vatham is predominant in this age group; This supports the literature about risk factor of OA. (Harrison’s internal medicine 17th edition 2008) In the study females were found affected more than male. 60% were females and 40% were males. The disease osteoarthritis is itself more common in women. Osteoarthritis seems to run in families, and there appears in particular to be a genetic link among women. After menopause, when women’s estrogen levels go down, they lose that protection and may have a higher risk of developing osteoarthritis even if they are on hormone-replacement

therapy (HRT). Statistics show that more women than men are obese or severely obese, and obesity plays a major role in osteoarthritis.13 This has been reflected in the study also. 95% of cases were non-vegetarian. The general population status is reflected in the study population and no specific inference could be made with respect to the study. After 48 days of treatment of Varma therapy the results showed clinical improvement which is evident from the assessment parameters (P =1). The results regarding pain, stiffness, swelling and range of movements were really encouraging. Varmam therapy relieves pain effectively may look like a magic. But in true it was built on a basic human anatomy and scientific manipulation techniques written mostly by Siddhars. In Siddha theory diseases are caused by the derangements of three humors. The derangement of Vatham is responsible for pain. Varmam is one among the Siddha therapies by which the pain is managed by stimulating Varma points. The Varma energy pathway can be correlated scientifically with the physiological analgesic pathway (Brain opiate system) and the reviews by which the release of neuromodulators such as Endorphins, Enkephalins and dynorphins are recorded under massage or touch therapy. Osteoarthritis is the cause of about 2% of years lived with disability, since only anti-inflammatory, analgesics cannot control the disease, certain non pharmacological therapies such as Varmam plays a crucial role for the management of Osteoarthritis. In some cases drugs mentioned for Azhal Keel Vaayu such as Amukkara Chooranam, Arumuga Chendooram, Sangu Parpam and external applications such as Pinda thylam, Vatha kesari thylam can also be administered along with Varmam therapy.  Varma treatment regime has been very effective for the management of Osteoarthritis. Treatment with Varmam application alone can be tried in near future to substantiate the effect of Varmam on pain management of osteoarthritis. s

ROLE OF VARMAM MANAGEMENT

THERAPY

IN

KUMBAVATHAM

Siddha system is originated in southern part of India, which is one of the ancient traditional systems of medicine. This system has its own unique

methodology of treatment for various ailments. Varmam is one among such therapies used to treat multiple ailments, especially related to musculoskeletal and neurological deficits. This helps the suffering community either acting by locally or regulating the three humors, i.e., Vali, Azhal, and Iyam. Varmam therapy can also be used along with internal medications and external applications as well. Varmam is the points wherever the energy (pranan) is stored, and when particular area or organ is affected, the energy will spread to that area and make that organ function effectively. This treatment methodology is taught by the guru-disciple method (Gurukulam). The guru who teaches varmam is called as “Varmani or Asan.” According to Siddha principles, the movements of the body are mainly controlled by Vali. Hence, the varmam points were also classified as Vali, Azhal, and Iyam varmam points. Kumbavatham (periarthritis or adhesive capsulitis) is a common cause of shoulder pain and disability. In Siddha text Yugi Vaithya Chinthamani, it was mentioned as pain in the shoulder and upper limb, pricking pain in the cheek and jaw region, and inability in flexion and extension.Adhesive capsulitis is characterized by pain, stiffness, and limited function of the glenohumeral joint , which adversely affects the entire upper extremity. Patients typically describe onset of shoulder pain followed by a loss of motion [4], and the most common limitations in range of motion are flexion, abduction, and external rotation. Approximately 70% of frozen shoulder patients were women [5]; however, males with frozen shoulder were at greater risk for longer recovery and greater disability. METHODS Study design and subjects This pilot study was done in 17 participants (single group) who visited the outpatient department of Siddha Regional Research Institute (CCRS), Puducherry. The study was conducted for a period of 2 weeks. Both inclusion and exclusion criteria for the patients were mentioned below. Inclusion criteria 1. Age between 35 and 65 years 2. With or without diabetic 3. Unilateral or bilateral involvement 4. Both sexes. Exclusion criteria

1. Age below 35 and above 65 years 2. Traumatic history 3. Fracture within the glenohumeral joint 4. Other type of systemic involvement such as gouty, rheumatoid arthritis, SLE, and psoriatic arthritis 5. Attended varmam therapy Therapeutic schedule The following varmam points were stimulated 1 time/day for 5 days. The pressure is mentioned in varmam literatures. Varmam points [6-10] • Mozhi piralgai (Sondhari varmam - midpoint of interdigital cleft between middle and ring finger). • Kavuli kaalam (webspace (dorsal side) between the thumb and index finger PI.L3 . UIh-3). • Chavvu varmam (Mundaga varmam- six fingerbreadth above from midpoint of the elbow joint (anterior side) A.L.UIa-60). • Enthi kaalam (one fingerbreadth anterior to midpoint of the axilla. Am.L4.UIS-8). • Piratharai (near to armpit in posterior side Pm.L3.UIS-8). • Kakkatai Kaalam (midway between the neck and head of arms, four fingers above from midline of the clavicle). • Kaiketti varmam (two fingerbreadth below from medial angle of the scapula, P.L3.T5 ). Assessment tools Shoulder pain and disability index (SPADI) [11,12]. Procedure Patients with kumbavatham (periarthritis) who were fulfilling both the inclusion and exclusion criteria and volunteered to participate in this study were assessed through SPADI index, and the data were recorded. Patients were asked to visit outpatient department (OPD) for consecutive five sittings of varmam therapy. They were also treated with regular OPD medications both internal and external (medicated oils). Before the treatment, the disability scale is recorded by SPADI, and all the movements with angle were recorded clinically. After five sittings of varmam therapy, the patient was examined for prognosis. RESULTS AND DISCUSSION

Before initiating the treatment, both pain and disability in doing regular household works were scored based on patient words. After varmam therapy, improvements were noted again from the words of patients. Range of movements was also assessed both before and after varmam therapy. Before varmam therapy, the pain and disability score were averagely more than 70%. However, after five sittings of varmam therapy, it was averagely reduced to 30%. The quality of life was also improved well after 5 days of treatment. During the full course, no complaints about adverse effect or non-responsiveness were reported. CONCLUSION From this study, it was observed that the varmam therapy has decreased the pain and disability score in kumbavatham patients. VARMAM THERAPY SARAM (VITAL ENERGY) CIRCULATION 5 The term “Saram” indicates the places where vital energy or the life energy exists. It also indicates the directions of flow of vital energy. The vital energy or the life energy is also called “Vaasi”. The function of saram can be understood only through its circulation which is the basic of Varmam. The vital energy called vaasi is derived from our act of breathing and it moves from one Varmam point to another through specific channels and forms a chain of circuits in the body cells and offers an environment for the body cells to function smoothly. VARMAM THERAPY: Varmam therapy is the therapeutic manipulation of Varmam points in which the pranic energy remains concentrated. Manipulation over these points with a particular force for the specified time will release the pranic energy from these points and bring relief to the affected individual by regulating the flow of pranic energy which is obstructed due to assault on specific points (Varmam points) or due to other causes. The basic principle is to normalize the flow of Varmam energy. The methods of Varmam treatment being practised today can be classified as follows: 1. Energy based treatment

2. Vital air based treatment 3. Nervous system based treatment 4. Bone based treatment 5. Muscle based treatment 6. Internal organ based treatment The above said treatment procedures are appropriately chosen and carried out by well-trained and experienced Varmam experts by appropriate hand/digit usage. CLASSIFICATIONS OF VARMAM 5 Varmam therapy is classified as follows. i)

Noi Nilai conditions)

ii) Kaaya conditions)

Nilai

Maruthuvam

(Treatment

in

diseased

Maruthuvam

(Treatment

in

traumatic

In general, Varmam therapy includes: (ii) (iii) (iv)

The location of Varmam points Observation of the signs and symptoms of Varmam assault. Application of techniques for releasing affected Varmam (Ilakku Murai). (v) Manipulation over the vital emergency Varmam points, (Adankal) if the patient is unconscious (vi) Use of medications such as nasal drops (Naciyam) and ear drops (vii) (vi) Treatment with herbal medicines and dietary regimen. The points where life energy resides and flows through, in the human body are known as Varmam. Varmam also means points where breathing energy resides in the body (Vaakata Nithanam: Verse 31). Varmam are scattered over various parts of body in nerves, nerve joints, bones, muscles, ligaments and inner organs. CLASSIFICATION OF VARMAM POINTS

4 Two major classifications with respect to Varmam points mentioned in Siddha literature are: • Padu Varmam-12 • Thodu Varmam- 96 which have been well established and are widely in use. However, it is observed that thousands of Varmam points are mentioned in several literatures Varmam can also be classified as the following: Padu Varmam Major points (12) Thodu Varmam Minor points (96) Thattu Varmam Activating the Varmam point by tapping/slapping (8) Pakka Varmam Proximally located Varmam points Inai Varmam Paired Varmam points Naal Varmam/ Natchathira Varmam Varmam points related to 27 Stars Ellidai Varmam Points located in between the joints

METHODS OF STIMULATION OF VARMAM POINTS In Varma Maruthuvam, there are 3 specific techniques which can stimulate the Varmam points and adangal points (points where the pranic energy remains in abundance). 1. Massage (Thadaval) For stimulating the Varmam points massaging technique can be used. There are different types of massaging techniques. (E.g. clockwise, anticlockwise rotatory movements with fingers, stretching the fingers from one Varmam point to the other points or regions of the body. By using varma thadaval (massaging), we can alleviate the problems arising due to ¼ mathirai visai (pressure). 2. Tapping (Thattal) In this technique, to stimulate Varmam points and adangal points, we can use both hands and feet. While using the hand, we can use palmar or dorsal sides of hands. In case of doing with foot, dorsal aspect is

preferred. It is most often used in adangal techniques. Tapping can be done with mild, moderate and strong pressure. According to the need, tapping can be done 1, 3 or 5 times. By using Varma tapping we can alleviate the problems arising due to ½ mathirai visai. 3. Pressing (Amartthal) It is the technique of giving a specific pressure. The pressure can be given with fingers (or small objects like tamarind seed) on Varmam points, for alleviating the problems which arise due to 1 mathirai visai. DURATION OF PRESSURE The time taken for giving pressure on a Varmam point is termed as ‘’Kaala Kanakku’’ which differs from point to point and it is generally taken as ½, 1, 2, 3 minutes. Term Duration Description Uthamam ½ minute The best effect is obtained with this duration of manipulation Mathimam 1 minute Less effective than Uthamam Athamam 2 minutes Less effective than Mathimam Athamaathamam 3 minutes Least effective Pressure can be given continuously for a specific time or intermittently according to necessity. If given intermittently maintain a gap of 10 seconds in between two successive manipulations.

The praanan (life energy) resides abundantly in adangal points. So, the duration of pressure needed to stimulate the adangal points is less compared to the duration of pressure required to stimulate other Varmam points. DISORDERS THAT ARE COMMONLY TREATED WITH VARMAM THERAPY The following table shows the disorders that are commonly treated with Varmam therapy in India. Thandaga vatham Lumbar Spondylosis Cegana vatham Cervical Spondylosis Azhal keel vayu Osteoarthritis

Kumba vatham Adhesive Capsulitis Pakka vatham Stroke Nadukku vatham Parkinson’s Disease Malakkattu Constipation Valippu Epilepsy Madhumegm Diabetes Adhikuruthi azhutham Hypertension Thalai nokkadu Migraine headache Peenisam Sinusitis VARMAM THERAPY IN MALAYSIA As Varmam therapy is a new modality introduced in the public hospitals in Malaysia, a set of criteria was determined during the development of this guideline to standardise the indications of referral, method of stimulation of Varmam points, treatment criteria and regime of treatment. This standardisation is aimed to ensure the safety of service as well as patients and to assess efficacy of the treatment. The set of criteria could be considered for revision in the future depending on the effectiveness of the service. TREATMENT CRITERIA i.

Method Of Stimulation Of Varmam Points Only the technique by massaging (Thadaval) and pressing (Amartthal) is allowed as a method of stimulation of Varmam points within the public hospitals in Malaysia.

ii.

Age Limit For the time being, only adult patients of age 18 years and above, will be eligible to be referred for Varmam therapy.

GENERAL CONDITION OF PATIENTS REFERRED FOR VARMAM THERAPY Patients referred for Varmam therapy should be: 1. Clinically stable (normal vital signs, no acute illness diagnosed at the time of referral or treatment) 2. Not chronically bed ridden

3. Able to understand and follow instructions INDICATIONS FOR REFERRAL As Varmam therapy is a new modality introduced within the existent Traditional and Complementary modalities in the public hospitals in Malaysia, the following chronic disorders have been carefully identified as suitable for the initial phase of this service. • Cervical spondylosis • Lumbar spondylosis • Osteoarthritis (Knee) • Adhesive capsulitis (Frozen shoulder) Other indications of referral could be considered from case to case basis (determined by Orthopaedic and Rehabilitation Medicine Department) after obtaining written approval from the Traditional and Complementary Division, Ministry of Health Malaysia.

TECHNIQUE AND METHOD OF STIMULATION OF VARMAM POINTS CERVICAL SPONDYLOSIS Cervical spondylosis is a disorder in which there is wearing on the cartilage (disks) and bones of the neck (cervical vertebrae). It is a common cause of chronic neck pain. The following 10 Varmam points are stimulated to achieve a therapeutic effect in the treatment of patients diagnosed with Cervical Spondylosis.

MUDICCHU VARMAM Location: Prominence corresponding to C7 vertebra Technique: i.

ii. iii.

Place the middle three fingers over the prominence. Give pressure in a clockwise rotation for three times then stretch the fingers manipulate up to the right shoulder Follow the same technique in the opposite side Manipulate in a clockwise and anticlockwise rotation 3 times each and then stretch downwards along the spine up to the T6

KAKKATAI KAALAM

Location: Supra clavicular fossa on both sides Technique: i. Fix the middle three fingers on the supraclavicular fossa from the posterior aspect of the patient ii. Press and release KAICHULUKI VARMAM Location: From mudicchu varmam point location, move four fingers downwards and three fingerbreadths laterally on both sides of the spinal column Technique: Fix the middle of the thumb on both sides; press and release. CHIPI VARMAM: Location: Two fingerbreadths downward from the kaichulukki varmam point Technique: Fix the tip of the three middle fingers; move fingers up and down whilst giving pressure SAVVU VARMAM Location: Four fingerbreadths distal from the shoulder joint on the medial side of the upper arm Technique: Fix the middle of the thumb (palmar aspect); press and release KAVULI KALAM Location: Web area in between the thumb and the index fingers Technique: Fix the tip of the three fingers; press in a pumping motion 3 times or so MANIBANDHA VARMAM Location: Middle of the wrist joint (ventral aspect) Technique: Fix the middle of the thumb (palmar aspect) and give moderate pressure 3 times (Simultaneously the patient is asked to move his/her neck laterally to the respective treatment side) SOODOTHARI VARMAM

Location: Four fingerbreadths above the manibandha varmam (radial aspect of the forearm) Technique: Fix the middle of the thumb (palmar aspect); press and release MELMANNAI VARMAM Location: Upper end of the calf muscle (posterior aspect) Technique: Fix the middle finger at the point and press (Simultaneously the patient is asked to flex and extend the neck) KEELH MANNAI VARMAM Location: Lower end of the calf muscle (posterior aspect) Technique: Fix the middle finger and then press (Simultaneously the patient is asked to flex and extend the neck) LUMBAR SPONDYLOSIS “Spondylosis of the lumbar spine” means degenerative changes such as osteoarthritis of the vertebral joints and degenerating intervertebral discs (degenerative disc disease) in the low back. The following 10 Varmam points are stimulated to achieve a therapeutic effect in the treatment of patients diagnosed with Lumbar Spondylosis. MANIPOORAGA ADANGAL Location: Five fingerbreadths below the umbilicus Technique: Fix the tip of the middle three fingers transversely on the point; gently press and lift upwards KOMBERI KALAM Location: Eight fingers above the medial malleolus Technique: Place the tips of the middle three fingers over the point. Press three times (in a pumping motion) towards medial border of tibia KEELH MANNAI VARMAM Location: Lower end of the calf muscle (posterior aspect) Technique: Fix the middle finger and press KUTHIKAL VARMAM

Location: Seven fingerbreadths above the heel (posterior aspect) Technique: Place the tips of the middle three fingers over the point; press three times KANPUGAICHAL VARMAM Location: One fingerbreadth below the lateral malleolus Technique: Place the tips of the three fingers of hand above the malleolus and glide downwards around the malleolus pressing the exact point KALKULASU VARMAM Location: Anterior part of junction of foot and leg Technique: Place the central part of the thumb at the point described; press and release three times SEVIKUTRI KALAM Location: Fossa behind the ear lobe Technique: Fix the central part of the middle finger; apply gentle upward pressure to the point (simultaneously on both sides) NANGANAPOOTU Location: Sacral Groove, Three Fingerbreadths From The Lumbosacral Joint (Lateral Aspect) Technique: Place The Middle Part Of The Thumb At The Point Described; i. ii. iii.

Provide 3 Rounds Of External Rotation At The Sacral Groove ii. Glide Laterally To Reach Anterior Superior Iliac Spine iii. Finally Give Clockwise Rotation Using 3 Fingers On Anterior Superior Iliac Spine

POOVADANGAL Location: Near the ischial tuberosity Technique: Press with the center portion of the thumb over the point on both sides. Sustain the pressure on the point for 10 seconds. Afterwards press thundu varmam, mel mannai, keel mannai and uppu kutri.

PULIMUTHADANGAL Location: Just above the nail of the big toe Technique: Fix the central portion of the thumb and apply deep pressure Adhesive capsulitis is a musculoskeletal condition that has a disabling capability. It is diagnosed by numerous physical characteristics including a thickening of the synovial capsule, adhesions within the sub-acromial or subdeltoid bursa, adhesions to the biceps tendon, and/or obliteration of the axillary fold secondary to adhesions. This condition remains an enigmatic shoulder disorder that causes pain and restricted ROM at the glenohumeral joint. The following 8 Varmam points are stimulated to achieve a therapeutic effect in the treatment of patients diagnosed with Adhesive Capsulitis or commonly referred to as Frozen Shoulder. MUDICHCHU Location: Prominence corresponding to C7 vertebra Technique: i. Place the middle three fingers over the prominence. Give pressure in a clockwise rotation for three times then stretch the fingers up to the right shoulder ii. Follow the same technique in the opposite side iii. Manipulate in a clockwise and anticlockwise rotation 3 times each and then stretch downwards along the spine up to the T6 KAAKKATTAI Location: Supra clavicular fossa on both sides Technique: i. Fix the middle three fingers on the supraclavicular fossa from the posterior aspect of the patient ii. Press and release ENTHI KALAM Location: Anterior axillary fold Technique: Fix the tip of the middle three fingers; press and release

PIRATHARAI Location: Posterior axillary fold Technique: Place the tip of the middle three fingers; press and release

KAIKOOTTU Location: Center of the axilla Technique: Place the tip of the middle finger; press and release SOODOTHARI Location: Four fingerbreadths above the manibandha varmam (radial aspect of the forearm) Technique: Fix the middle of the thumb (palmar aspect); press and release MANJADI Location: Near the junction of the index finger and thumb; along the upper part (base) of index finger (just below kavuli) Technique: Place the central portion of the thumb; press upwards MANIBANDHA VARMAM Location: Middle of the wrist joint (ventral aspect) Technique: Fix the middle of the thumb (palmar aspect) and give moderate pressure 3 times (Simultaneously the patient is asked to move his/her neck laterally, on the respective treatment side) OSTEOARTHRITIS (KNEE) Osteoarthritis (OA) is a progressive joint disease due to failure in repair of joint damage. This may arise as a result of biomechanical, biochemical and/or genetic factors. The process may involve one or multiple joints. The following 5 Varmam points are stimulated to achieve a therapeutic effect in the treatment of patients diagnosed with Osteoarthritis of the knee. PANCHAMUGA VARMAM Location: Around the patella Technique: Place the tips of the thumbs along the upper border of the patella and glide over the borders and end at lower border MOOTTU VARMAM Location: Centre of popliteal fossa Technique: Place the tips of the middle three fingers over the point; press three times (in pumping motion)

KOMBERI KALAM Location: Eight fingerbreadths above the medial malleolus Technique: Place the tips of the middle three fingers over the point; press three times (in a pumping motion) towards medial border of tibia KAAL SANNI ADANGAL Location: At the junction of big and second toe Technique: Place the tip of the index finger; press and release ULLANKAAL VELLAI VARMAM Location: At the junction of big and second toe in plantar region Technique: Place the tip of the thumb; press and release. STANDARD OPERATING PROCEDURE TREATMENT REGIME Patients should be given adequate information to enable them to make an informed decision about the type, duration and frequency of the care that they will receive. The therapist must always examine and treat the patient, whether female or male, with a chaperon being physically present in the consultation room, with visual and aural contact throughout the treatment session. The following table describes the treatment regime for each condition or disorder. As Varmam therapy is tailored based on the individual patient’s response to treatment, the following treatment regimes were adopted for standardization of treatment sessions based on the common practices of Varmam therapy in India. Osteoarthritis of the knee 21 Once in 3 days 15 min 10th session max 36 sessions Lumbar spondylosis 16 Once in 2 days 20 min 8th session max 24 sessions Cervical spondylosis 12 Once in 2 days 15 min 6th session max.18 sessions Adhesive capsulitis 12 Once in 2 days 15 min 6th session max.18 sessions The above recommended regime may be reduced or increased based on the practitioners’ assessment of the patient to the prescribed treatment or up to the point that the patients’ symptoms are relieved, whichever is earlier. MONITORING AND FOLLOW UP

The patient’s response to care should be monitored at each follow-up visit and through periodic reassessments. For the purpose of assessing the efficacy of treatment, every patient should be given a 2 weeks’ appointment upon the completion of treatment and reassessment of treatment response is recommended at the following interval of 6 weeks, 3 months and 6 months after completion of treatment. The frequency of reassessment depends on the patient’s response. For instance, a patient who is responding as expected could be reassessed less frequent than someone who is responding slowly. Re-injury, exacerbation of symptoms, or new symptoms (especially neurologic) may necessitate immediate reassessment. SAFETY ISSUES PRECAUTIONS Practitioners should exercise caution when treating certain groups of patients – especially those with the following conditions; 1. Neurologic symptoms 2. Recent infection or surgery 3. Any conditions listed as contraindications, as stated below CONTRAINDICATIONS With thorough assessment, multiple caution-indicating risk factors in a patient may be considered as contraindication to the desired treatment modality. Thus, the decision to administer treatment or not should be made after careful consideration of the risk factor(s) present. Pregnancy ii. Mental/Psychological disorders iii. Chronic bed ridden iv. Unconscious with severe head injuries v. Loss of protective sensation vi. Bleeding disorders • Suspected bleeding disorder or clotting abnormalities (e.g. thrombocytopenia, hemophilia or any bleeding tendencies) • On anticoagulant pharmacotherapy vii. Confirmation or presence of any clinical evidence to suggest active infection e.g.: • Pyrexia • Sepsis • Meningitis

viii. Confirmation or presence of any clinical evidence to suggest potentially serious pathological condition e.g.: • Periosteal or intramuscular haematoma or abscess • Fracture & dislocation • Popliteal Aneurysm • Baker’s Cyst • Deep vein thrombosis • Peripheral arterial disease • Disc prolapse/prolapsed intervertebral disc/disc herniation • Local infections (such as suppurative arthritis, septic arthritis, osteomyelitis, bony tuberculosis) • Open wounds, skin derangement, recent surgery ix. Confirmation or presence of any clinical evidence to suggest potentially serious systemic condition e.g.: • Severe Osteoporosis • Compromised bone or joint stability especially in metastatic disease • Aneurysm involving a major blood vessel. • Acute cauda equina syndrome • Connective tissue diseases ADVERSE EVENTS Varmam therapy is regarded as a relatively safe procedure. However, the following side effects have been observed. Mild, transient adverse events • Local discomfort • Lethargy • Nausea • Pins and needles Unpleasant reactions There are some hazardous points which carry high risk particularly with unskilled and inexperienced practitioners

Fainting (Vasovagal Syncope) Fainting is a serious adverse event that may occur during Varmam Therapy. Hence, educating the patient about the Varmam Therapy and its procedures before initiating Varmam Therapy is of utmost importance. It is advisable to perform Varmam Therapy in a lying position with care and gentleness for the first-time patients and utmost care should be given while performing Varmam Therapy in the neck region. Fainting episode is often associated with the feeling of discomfort, weakness, and vertigo. Patients may also complain of palpitations, nausea and rarely chest discomfort. Forceful manipulation in Varmam therapy may cause chillness over extremities, dip in blood pressure, and unconsciousness. If alarming symptoms appear, keep the patient in lying position in the table with head down and leg upside. Usually symptoms disappear. In severe cases, assess whether the patient is stable or unstable and then first aid should be given. If the patient is stable the following Varmam points may be stimulated i. ii.

Kavuli kalam Located in the web area in between the thumb and the index finger Pulimuthadangal Located just above the nail of the big toe Pain

Usually pain will not be felt in the Varmam points manipulated during Varmam therapy. Forceful stimulation of Varmam points may induce pain at those particular point and its associated areas. Appropriate application of technique and giving optimal pressure to the Varmam points will not produce pain. Internal Organ Injuries Normally Varmam therapy will not harm any organ. However wrong and forceful manipulation may injure any organ. SERIOUS ADVERSE EVENTS Serious complications are very rare, and it would seem unlikely that the adverse occurrences have been solely attributable to the therapeutic intervention. Unpleasant conditions or accidents that result from manipulative therapy can be presented by careful appraisal of the patient’s history and examination findings. Information must be sought about coexisting diseases and the use of any medication, including long‐term use of steroids and anticoagulant therapy. A detailed and meticulous examination must be carried out. The use of appropriate

techniques is essential, and the practitioner must avoid techniques known to be potentially hazardous.