|
 
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| CASE REPORT |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 41-46 |
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Effectiveness of Varmam integration on the quality of pain management: A prospective observational case series
Nandhagopal Kannaiyan1, Rajalakshmi Shanmugavelan2, Arunachalam Krishna2, Radha Soundariya2, Samraj Karunanithi2, Vinod Nalupalil Purushothaman3
1 Technical Department, Central Council for Research in Siddha, Chennai, Tamil Nadu, India
2 Siddha Clinical Research Unit, Central Council for Research in Siddha, Tirupati, Andhra Pradesh, India
3 Siddha Central Research Institute, Central Council for Research in Siddha, Chennai, Tamil Nadu, India
| Date of Submission | 02-Feb-2023 |
| Date of Decision | 15-May-2023 |
| Date of Acceptance | 26-May-2023 |
| Date of Web Publication | 29-Aug-2023 |
Correspondence Address:
Nandhagopal Kannaiyan
Technical Department, Central Council for Research in Siddha, Chennai - 600 047, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jrsm.jrsm_2_23
Varmam is one of the noninvasive therapeutic procedures in the Siddha system of medicine, majorly practiced in ortho- and neuromuscular diseases. This observational case study was used to evaluate the effectiveness of Varmam integration with non-steroidal anti-inflammatory drugs improving the quality of life by reducing the pain. Fifteen participants of both sexes on different characteristic of pain such as sharp, hot, cold, and throbbing were participated in this semiexperimental study. Precisely targeted and commonly used pain-reducing Varmam points were manipulated for the patients based on the “Guidelines for practice of Siddha Varmam Therapy”. The different aspects and types of pain that patients experienced were measured with the help of Pain Quality Assessment Scale (PQAS) used before and after the Varmam application. PQAS can help to measure the type of pain such as sharp, hot, cold, dull, aching, radiating, throbbing, heavy, shooting, tender, tingling, and unpleasant categories. Findings showed that the scores of pain, quality of pain, and depth of the pain were significantly decreased, and quality of life was significantly increased. Varmam manipulation significantly decreased the severity of pain, such as aching pain, sharp pain, radiating pain, unpleasant pain, and dull types of pain, when compared with the pain with nature of tingling and throbbing, hot and cold cramping, and dull, heavy, and numb types of pain. The unique Siddha therapeutic procedure Varmam holds a considerable position in the management of pain with or without other supportive medications. Further heightened research can prove the hypothesis. Keywords: Pain, PQAS, Siddha, Varmam
How to cite this article:
Kannaiyan N, Shanmugavelan R, Krishna A, Soundariya R, Karunanithi S, Purushothaman VN. Effectiveness of Varmam integration on the quality of pain management: A prospective observational case series. J Res Siddha Med 2023;6:41-6 |
How to cite this URL:
Kannaiyan N, Shanmugavelan R, Krishna A, Soundariya R, Karunanithi S, Purushothaman VN. Effectiveness of Varmam integration on the quality of pain management: A prospective observational case series. J Res Siddha Med [serial online] 2023 [cited 2023 Oct 3];6:41-6. Available from: http://www.jrsm.in/text.asp?2023/6/1/41/384576 |
| Introduction | |  |
Pain, as defined by the International Association for the Study of Pain, is “a sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”[1] Pain is an enormous global health problem. Globally, 10% of the population was affected by pain, and pain prevalence was closer to 20%–25% in some countries and regions in the last decade (2010–2020). It has been estimated that one in five adults suffer from pain and that another 1 in 10 adults are diagnosed with chronic pain each year.[2],[3] Pain is a commonly reported medical problem with immense personal costs and a huge societal health care burden in developing countries such as India, which is already struggling with a growing disease burden and lack of quality health care resources.[4]
In 2004, the International Pain Society and Global Health Community concluded that “failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.”[3] However, because pain has always been regarded as a symptom, not a disease state, there has been an enormous gap between prevalence and treatment, and it remains largely undertreated.[2] A survey of pain conducted across eight major cities in India highlighted a high point prevalence (13%) of chronic pain, with 30% of the patients without treatment and 56% reporting unsatisfactory treatment. Pain in knees (32%), legs (28%), and joints (22%) was most prevalent. Majority (68%) of respondents were treated for pain with over-the-counter drugs, and most were taking non steroidal anti-inflammatory drugs (NSAIDs) (95%).[5] Acute pain, chronic pain, neuropathic pain, nociceptive pain, and radicular pain are the five most common types of pain.[6]
Varmam is an integral part of the ancient Siddha system of medicine.[7] It is very effective for the management of various diseases such as neurological disease, neuromuscular problems, migraine headaches, convulsions, arthritis, and spinal problems.[8] Also, the patients are under the treatment of biomedicine for some period; still, they are facing difficulties in their day-to-day life. Those patients are given an add-on external therapy of Varmam applications. The purpose of the current study was to provide a preliminary test of the validity of the effectiveness of Varmam integration in the management of pain qualities. We predicted that if the Pain Quality Assessment Scale (PQAS) items were valid for detecting treatment effects, significant pretreatment-to-posttreatment decreases in the descriptor ratings would be observed in patients with pain. The study also allowed us to determine the effectiveness of Varmam integrative management, Varmam and drug interactions, and the effectiveness of Varmam on the specific pain qualities.
| Materials and methods | | |
The study type used in this study was prospective case series. Fifteen participants were included with different types of pain.
Inclusion criteria were as follows: participants having chief complaints of any type of chronic pain treated with NSAIDs, being between the age of 18 and 75 years. Participants were allowed to take their regular supplements such as calcium, multivitamins, and nervine tonics during the trial period.
Exclusion criteria were as follows: excluded the persons under the concomitant use of local anesthesia and sedative drugs for any other condition, participation in a clinical trial within the previous 30 days, and pregnancy.
Procedure and measures
Intense of pain and type of pain were measured using a PQAS questionnaire from all the participants.
Pain quality assessment scale
PQAS can help to measure the type of pain such as sharp, hot, cold, dull, aching, radiating, throbbing, heavy, shooting, tender, tingling, and unpleasant categories. It begins with an introduction that describes how people often experience pain sensations differently, and how pain unpleasantness differs from pain intensity. After the introduction, the PQAS asks respondents to rate the severity of each of 20 pain (quality and spatial) descriptor domains by using 0–10 numeric rating scales, in which 0 indicates “no pain” or “not (sensation/item)” and 10 indicates “the most (descriptor) pain sensation imaginable.” The PQAS also contains a temporal item that assesses the temporal pattern of pain. All study participants responded to the 20 PQAS descriptor items.
Intervention
Various Varmam points were manipulated for the relevant diseases and symptoms as per the ‘Guidelines for the Practice of Siddha Varmam Therapy,” as discussed in [Table 1].
Participants were included based on the eligibility criteria, and they were assigned to provide the PQAS for pretreatment assessment. Participants received Varmam intervention as per their symptoms at the start of the study. Time duration for each patient was assigned to do the Varmam manipulation every day as per the guidelines.
The PQAS items were administered to the study participants at baseline and end of the treatment. Informed consent was obtained from each participant before the study begins.
Data analysis
Here, our data are nonnormal, using nonparametric equivalent of paired t test. The Wilcoxon sign test is a statistical comparison of the average of two dependent samples. The Wilcoxon sign test works with metric (interval or ratio) data that are not multivariate normal or with ranked/ordinal data. Generally, the Wilcoxon sign test is the nonparametric alternative to the dependent samples t test. The Wilcoxon sign test tests the null hypothesis that the average signed rank of two dependent samples is zero.
- Null hypothesis: The average signed rank of two dependent samples is zero (i.e., there is no statistically significant difference in treatment effects of Varmam in both type of pain score and intense pain score [before vs. after])
- Alternate hypothesis: The average signed rank of two dependent samples is different from zero (i.e., there is a statistically significant difference in treatment effects of Varmam in both type of pain score and intense pain score [before vs. after])
Here, it is clear that we reject the null hypothesis and accept the alternate hypothesis. Hence, the average signed rank of the two dependent samples is different from zero (i.e., there is a statistically significant difference in treatment effects of Varmam on both type of pain score and intense pain score [before v/s after]).
| Results | | |
After the regular follow-up of all 15 participants, PQAS were recorded before and after Varmam intervention. In this PQAS assessment, type of pain and intensity of the pain were measured for the analysis. In the study, females were found affected more than males. A total of 67% were females and 33% were males, one-third were males and two-third were females, and 60% of participants were in the middle age group 41–60 years, and the age group between 20 and 40 years and above 60 years have 20% of participants for each. Details are given in [Table 2] and [Table 3].
In [Table 2], it was clear that 15 cases of type of pain were categorized into nine types. There should not satisfy normality assumption and the number of observations was very low, by using bootstrapping statistical procedure, the sample size may be resized and the same data set to creates many simulated samples. Using the simulated data analysis of testing, the statistically significant difference in type of pain was done.
From [Graph 1] and [Graph 2], it is clear that all 15 cases show improvement in treatments. Since there exists a statistically significant difference on both, type of pain score and intense pain score on treatment methods (before vs. after), testing there exists a statistically significant difference in type of pain. | Graph 1: Wilcoxon signed-rank test on type of pain score on pre- and posttreatments
Click here to view |
 | Graph 2: Wilcoxon signed-rank test on intense pain score on pre- and posttreatments
Click here to view |
From [Table 4], it was clear that there exists a statistically significant difference in Varmam treatment (before and after) for all types of pains. The Varmam intervention is decreased the intensity of pain and severity of pains, such as aching pain, sharp pain, radiating pain, unpleasant pain, and dull types of pain, when compared with the pain with nature of tingling and throbbing, hot and cold cramping, and dull, heavy, and numb types of pain. | Table 4: Hypothesis test summary-related-sample Wilcoxon signed-rank test
Click here to view |
| Discussion | | |
Varmam is a nonpharmacological, cost-effective, noninvasive, and pressure-manipulating method of treatment. Varmam was primarily developed for the emergency situations such as accidental injuries, animal attacks, and for war fields. So, these kinds of acute conditions were contentedly handled by the ancient Siddha practitioners. Any type of acute and emergency situation before starting any internal medicines Varmam application is advisable from the Siddha practitioners.
The incidence of pain with various diagnoses was reported in Siddha Clinical Research Unit, Tirupati, justified that 33% males and 67% females. Fifteen patients are treated with Varmam therapy. A PQAS and hypothesis test summary-related-sample Wilcoxon signed-rank test[9] were helpful in ruling out the results. Of 15 patients, 13 patients showed good relief from pain, found brisk walk, flexibility in bending forward, reduced pain around the affected region, and tenderness also reduced, two patients showed mild relief with slight decrease in pain and tenderness. After 28 days of treatment with Varmam therapy, the results showed clinical improvement, which is evident from the assessment parameters (Sig < 0.001). The results regarding pain, stiffness, swelling, and range of movements were really encouraging. Varmam therapy has a significant effect on different types of pain and intensity of pain.
In Siddha theory, diseases are caused by the derangements of three vital forces in the body called humors (Vali-Air, Azhal- Fire, and Aiyam- Water).[10] The derangement of Vali is responsible for pain, Varmam intervention helps to regulate the deranged vital forces. The Varmam 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.
Certain nonpharmacological therapies such as Varmam plays a crucial role in the management of pain.[11]Varmam treatment is helpful for patients who no longer respond to NSAIDs and in those for whom NSAIDs are contraindicated. Intervention with Varmam therapy in early stages of painful diseases may prevent the development of deformities and surgical intervention.[12] The Varmam therapy has decreased the pain, and disability score in Kumbavatham (adhesive capsulitis) external therapy has changed their quality of life significantly in 28 days.[13] However, because pain is associated with a variety of pain sensations, the effects of Varmam treatments on different sensations could go undetected if specific pain qualities are not assessed. Responsively, the PQAS items and scales may support effective Varmam treatment, these measures may be a considerable choice of Varmam point for the specific type of pain and intensity.
| Conclusion | | |
The Varmam manipulation significantly reduced the severity of pains precisely in the acute and chronic pains in muscular or in bone and joint, such as aching pain, sharp pain, radiating pain, unpleasant pain, and dull types of pain, when compared with dermatome level pain with nature of tingling and throbbing, hot and cold cramping, and numb types of pain. This was clearly proved through the PQAS scale of analysis and with the results of PQAS, Varmam treatment will be an add-on therapy in some kinds of pain and standalone therapy in other types of pain. Hence, it could be concluded that the unique Siddha therapeutic procedure Varmam holds a considerable position in the management of pain with or without other supportive medications. On the various types of pain, Varmam manipulation significantly decreased the severity of pains, such as aching pain, sharp pain, radiating pain, unpleasant pain, and dull types of pain, when compared with the pain with nature of tingling and throbbing, hot and cold cramping, and dull, heavy, and numb types of pain. Hence, it could be concluded that the unique Siddha therapeutic procedure Varmam holds a considerable position in the management of pain with or without other supportive medications.
Limitations
- a. This paper does not focus on a particular disease or Varma points.
- b. This is to assess the quality and intensity of pain and its prognosis with various types of Varma points given as per the Guidelines.[7]
- c. Also, we assessed the efficacy of Varmam on various types of pain management as per PQAS worksheet.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Terminology. International Association for the Study of Pain. Available from: https://www.iasp-pain.org/resources/terminology/#pain. [Last accessed on 29 Sep 2021].  |
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| 3. | Jackson T Anesthesiologists VS-AS of, 2014 undefined. The Global Burden. Available from: https://www.asahq.org/~/media/sites/gho/gho-newlsetterarticles/jackson_stabile_mcqueen_june2014.pdf. [Last accessed on 29 Sep 2021]. |
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| 10. | Karunanithi S, Nandhagopal K, Vinod NP, Sathyarajeswaran P, Kanakavalli K Survival analysis based on the Siddha body constitution of asymptomatic SARS-CoV-2 patients under integrative management of hydroxychloroquine (HCQ) and KabaSuraKudineer (KSK): A retrospective cross-sectional case series from Tirupati. Curr Tradit Med 2021;7:66-72. |
| 11. | Janani L, Manickavasagam R Effectiveness of Varmam therapy for the management of osteoarthritis. Int J Pharm Sci Res 2017;8:5286-90. |
| 12. | Meena R, Natarajan S, Anbarasi C, Muralidass SD Effect of Varmam therapy in Santhuvatham (Osteo arthritis–knee joint)—A single case study. Int J Pharm Pharm Sci 2017;9:284-7. |
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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