Vatarakta (Gout) is a disease explained in Ayurveda involving Vata Dosha imbalance affecting Rakta Dhatu. Raktadushti plays a crucial role in its pathogenesis. "Abhighataja Raktadushti" refers to a condition of vitiation of blood caused by injury or trauma leading to Utthana Vatarakta1. This can manifest as swelling, pain, and inflammation, particularly in the affected area. It's closely related to the concept of Vatarakta, where both Vata and Rakta are involved2. Cupping therapy has been a traditional practice dating back to ancient times. Cupping therapy is a therapeutic technique that utilizes a vaccum force created beneath a small vessel applied onto the skin’s surface. This approach focuses on blood and autologous healing substances in a specific area, stimulating metabolic activity, improving immune function, and stabilizing blood biochemistry3. Cupping is typically categorized into 2 primary procedures- wet and dry cupping. In both techniques, containers made from various materials are used to create a vaccum over a specific area of the skin. However, suction is applied in a wet cupping procedure to draw small quantities of blood and extracellular fluid from the body, typically after creating minor incisions or superficial skin abrasions, often in significantly smaller amounts than conventional bloodletting practices4. On the principal of vaccum, cupping methods are used for Raktamokshana karma. In this method the therapist puts special cups on the skin for few minutes to create suction. A 55 years old male patient visited OPD with the complaints of severe pain, numbness and swelling at left thigh region since 2 days associated with difficulty in walking. One day while working in the paddy field he met with a trauma, run over by a tractor front wheel on his left leg.

Introduction:

Ayurveda is an ancient medical and health care system which not only manages chronic diseases but maintain the health of the healthy human beings5. Vatarakta is a disease explained in Ayurveda involving Vata dosha imbalance affecting Rakta dhatu6.

Vatarakta is a chronic joint pain disease accompanied by pain, stiffness, swelling over joints which involve vitiated Vata dosha as well as Rakta dhatu7. Aggravated Vata is blocked by vitiated Rakta, which leads to further aggravation of Vata Dosha8. Vatarakta have two Avasthas i.e., Uttana and Gambhira. Uttana Vatarakta affects Twacha and Mamsa dhatu where as Gambhira affects Asthi, Majjadi Gambhira Dhatu9. 

Case Report-

A 55 years old male patient visited OPD with the complaints of severe pain, numbness and swelling at left thigh region since 2 days associated with generalized weakness, difficulty in walking & mild fever.

One day while working in the paddy field he met with a trauma, i.e run over by a tractor front wheel on his left leg. There was sudden onset of pain, swelling and the nature of pain was continuous.

The symptoms gets aggravated on prolonged standing and movement of limb.  He consulted to a local physician but the symptoms were not reduced so he visited to our clinic for further management. 

Clinical Findings

On general examination, the condition of the patient was found antalgic gait. He was not able to walk or stand for more than 5 minutes due to severe pain.

Investigations was done it revealed Hb-12.5g%, RBC count- 4.2 mil/cumm, TLC- 14000 cells/µL, ESR- 35mm/hour, Neutrophils- 80%, Lymphocytes-10%, Eosinophoils- 01%, Monocytes- 03%, Basophils- 02%, RBS- 85mg/dl.

The investigation report suggest the active infection & inflammation.

Past History – No history of DM, HTN, or any other systemic illness.

              H/o of Trauma by tractor

Patient had taken Analgesics, Anti inflammatory medications.

Family history – Not significant

General Examination

Built- Moderate

Nourishment – Moderate

Pulse- 80/min, regular

BP- 130/90 mmHg

Temperature - 98.4 F

Respiratory rate- 20 cycles/min

Height – 5.5ft

Weight – 68kg

Tongue- clear

Pallor- absent

Icterus/ Cyanosis/ Clubbing/ Lymphadenopathy –Absent

Edema- Present left thigh

Systemic examination

CVS - S1 S2 Normal

CNS - Concious, well oriented

RS – Normal vesicular breathing no added sounds

P/A – soft, No tenderness

Local Examination

Temperature- raised

Tenderness- present

Redness- present

Surface- smooth

Swelling-Present

Ashtavidha pariksha

Nadi- Vata-pitta

Mala- Samyak

Mutra- Daha

Jivha- Alpalipta

Shabda- Prakrut

Sparsha- Asahishnata

Druka- Prakrut

Akruti- Madhyama

Samprapti of Vatarakta10

Nidana- Abhighata

Vata prakopa–Rakta Dushti

Sthanasamshraya dosha in Uru pradesha- Twak, Rakta, Mamsa dhatu dushti

Uttana Vatarakta

Samprapti Ghatak

Dosha –Vata Rakta

Dushya- Twak, Rakta, Mamsa

Agni- Jatragni, Dhatwagni

Adhishtana- Twak, Mamsa

Srotas – Rasavaha & Raktavaha

Srotodushti prakara- Sangha, Vimarga gamana

Vyadhi swabhava- Chirakari

Sadhya- Kruchrasadhya

Materials & Methods

Intervention
1. Tab Amoxicillin clavulanic 625 mg 1 BD 5 days

2. Tab Aceclo- paracetamol + serratopeptidase

3. Tab Rabeprazol OD

Procedure – Cupping was conducted for 20 min for 2 sessions.

The first step includes primary suction. In this phase the specific point or area for cupping is selected and disinfected. A cup with suitable size is placed on the selected site and air is sucked inside the cup by manual suction. Then the cup is applied to the skin and left for a period of 3-5 min.

The second step is puncturing, on the skin using the needle.

The third step is about suction and bloodletting. The cup is placed on the skin using similar procedure for 3-5 min.

The fourth step includes the removal of the cup, followed by

Fifth step which inludes dressing the area11.

Treatment continued…20 days

1. Sarivadyasava12 3 tsf tid Before food

2.  Kaishora Guggulu13 1 Tab tid After food

3. Shatadhouta Ghruta14 for external application

Results

Loss of blood along with vasodilation tends to increase the parasympathetic activity and relaxes the muscles after cupping method. Furthermore, the loss of blood increases the quality of the remaining blood that improves pain symptoms by producing endogenous opiod in the brain. 

 It has been claimed that cupping therapy tends to drain excess fluids and toxins, loosen adhesions and revitalize connective tissue, increase blood flow to skin and muscles, stimulate the peripheral nervous system, and modulates the immune system. 

Discussion:

"Abhighatja Raktadushti" refers to a condition of vitiation of blood caused by injury or trauma. This can manifest as swelling, pain, and inflammation, particularly in the affected area. It's closely related to the concept of Vatarakta, where Vata dosha and Rakta dhatu are majorly involved. Aggravated Rakta quickly obstructs the path of already aggravated Vata. On obstruction in the route of Vata its Gatis obstructed leads to further aggravation.

In Uttana Vatarakta the Sthanasamshraya of dosha takes place in Uru pradesh leading to Twak, Rakta, Mamsa dhatu dushti. Sarivadyasava indicated in Vatarakta, as the dravya possess Raktaprasadana properties does Rakta dhatu shamana.

 Triphala guggulu indicated in Vrana and Shota Adhikara, it decreases the swelling, pain and excessive secretions. The Dravyas possess the wound healing properties and decreases the inflammation. 

Shatadhouta Ghrita possess Go- Ghrita as base having Shita quality, Vata-pitta prashamana decreases the local inflammatory conditions. Due to its Dahashamaka properties it reduces, burning sensation and produces cooling effect. Also it reduces the local rise of temperature.

The Rakta dhatu is most important base supported to the body. Hence, it should be preserved with efforts since the existence of life itself rests on it15. 

Raktamokshana is a type of parasurgical procedure included under Shodhana Chikitsa. It is a process of bloodletting for the therapeutic purpose, removing the vitiated Dosha from the body. Acharya Sushruta had given much importance to Rakta dhatu and considered it as fourth Dosha. Raktamokshana was done through cupping procedure where the vitiated Rakta dhatu is removed using the suitable size cups on local area16.

Cupping therapy helps to improve microcirculation, promoting capillary endothelial cell repair, accelerating granulation and angiogenesis in the regional tissues, thus helps in normalize the patient's functional state and progressive muscle relaxation.17

Cupping therapy is an ancient method of treatment that has been used in the treatment of a broad range of conditions.18

Conclusion:

In the cupped region, blood vessels are dilated by the action of certain vasodilators such as adenosine, noradrenaline and histamine, there is an increase in the circulation of blood this allows the immediate elimination of trapped toxins in the tissues, hence the patient feels better.19

There are three primary hypotheses and theories may clarify how pain reduction occurs. These consist of “Pain-Gate Theory”, “Diffuse Noxious Inhibitory Controls” and Reflex Zone Theory”.

Pain-Gate Theory

One of the most significant theories regarding pain reduction is proposed by Melzack and Wall (1965). They suggested that both thin and large nerve fibers transmit pain signals from the injury site to two areas in the dorsal horn of the spinal cord. In this process, transmission cells carry the pain signals to the brain while inhibitory interneurons block the activity of the transmission cells. Activity from both thin and large diameter fibers stimulates the transmission cells. The activation of thin fibers hinders the function of the inhibitory cells (which tends to permit the transmission cells to be active), whereas the stimulation of large fibers activates the inhibitory cells (which tends to decrease the activity of the transmission cells). Therefore, increased activity from large fibers results in a diminished perception of pain.

Cupping therapy might reduce pain through its antinociceptive properties & by creating a counter-irritation effect. Nevertheless, it is still uncertain how significantly cupping triggers these mecha-nisms. It is thought that cupping activates pain receptors, resulting in a higher frequency of nerve impulses, which ultimately facilitates the closure of pain gates & leads to decrease in pain sensations.

Diffuse Noxious Inhibitory Controls

DNIC signifies inhibition of activity in convergent or wide dynamic range-type nociceptive spinal neurons triggered by a second, spatially remote, noxious stimulus. This phenomenon is thought to underlie the principle of counter-irritation to reduce pain. In this context, “one pain mitigates another”, or “pain suppresses pain”. Most of the research related to this theory has focused on idiopathic pain conditions such as such as irritable bowel syndrome, temporomandibular disorders, fibromyalgia and tension- type headache, which have demonstrated positive responses to cupping therapy. Localized injury to the skin and small blood vessels caused by cupping can trigger a nociceptive response that stimulates diffuse noxious inhibitory controls (DNICs). Cupping therapy might alleviate pain through nerves that respond to mechanical stimuli. This mechanism resembles that of acupuncture as it activates A and C nerve fibers associated with the DNIC system, a pain modulation pathway often referred to as the ‘pain inhibits pain’ phenomenon.

Reflex Zone Theory

A suction stimulation is applied to the affected area, allowing red blood cells from the blood vessels to move into the surrounding tissues without damaging the capillary vessels. This process is referred to as dry diapedesis. Extravasated blood cells are either digested or cleared away by connective tissue. This occurs when the affected region receives an increased blood supply, leading to an activation of biological processes in the treated area, specifically in the disturbed reflex zone.

In cupping therapy, when an affected organ transmits a signal to the skin via the autonomic nerves, the skin reacts by becoming sensitive and sore accompanied by swelling. When cups are placed on the skin, the skin’s receptors are triggered. This whole procedure leads to an increase in blood circulation and blood flow to both the skin and the internal organs through neural pathways20.

Before treatment

After treatment

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