Evaluation of Efficacy of Marma Therapy with Janu Basti in the Management of Janu Sandhigata Vata (Osteoarthritis of Knee)

Background: Janu Sandhigata Vata (Osteoarthritis of knee) is one of the most disabling musculoskeletal disorder. It is a type of Vata-vyadhi (Vata disorder), involving the Janu Sandhi (knee joint), whose symptoms include Shoola (pain), Shotha (swelling), Stabdhata (stiffness), and Atopa (crepitus). Ayurvedic texts recommend repeated use of Snehana (oleation) and Swedana (sudation) therapies for its management. In recent years, Marma Therapy has also been used for the management of various Vata disorders. Methodology: The present study explores the efficacy of Marma Therapy (on four Marma points of the legs, i.e. Kshipra, Gulpha, Indravasti and Janu) with Janu Basti (with Ksheerbala Taila) in the management of Janu Sandhigata Vata. The therapeutic procedure was administered for 9 days, with a followup of one month, when the patients did self-administration of Marma Therapy and massage at home. Twenty patients completed the study. Results: Significant improvement was observed in all the subjective parameters (Shoola, Shotha, Stabdhata, and Atopa) and objective parameters (WOMAC Index, Range of Motion, Walking Time) analyzed during the study. Mean values of all the parameters decreased continuously during the study period, including intervention time and follow-up. Verbal feedback taken about six months after the completion of the study period indicated almost complete relief for 4 patients (pursuing Marma Therapy regularly), and self-management by 10 others through regular Marma Therapy and massage. Conclusion: The present study illustrates the significant efficacy of the administered therapeutic intervention in the management of Janu Sandhigata Vata, both with regards to short-term relief, and long-term self-management.


Introduction
Osteoarthritis (OA) of knee is one of the most common and disabling musculoskeletal disorder, which is extremely common in the elderly population [1][2][3]. The symptoms of this disease include joint pain, joint stiffness, instability and loss of function, which have a severe impact on daily activities [3]. In the present times, the therapeutic interventions normally used for its treatment include the use of physiotherapy, weight control, different types of analgesics, intra-articular steroid injections, knee replacement surgery, etc. [1,2]. However, side-effect free, long-term management of this disease is still a challenge [1][2][3]. Given the severe disabling nature of this disease, there is definitely a need to look for safe and effective therapies for its management.
Janu Basti is a simple and effective Snehana (oleation) and Swedana (sudation) procedure of Ayurveda, which involves retaining warm medicated oil over the knee joint for sufficiently long duration [9][10][11]; the oleaginous properties of the oil, combined with its medicinal properties, as well as the sudation induced by the warm oil, can produce the desired therapeutic effect. Although it is a widely used practice in India, yet not many studies are available in the peer reviewed open literature that establish its quantitative efficacy in the management of Janu Sandhigata Vata.
Janu Sandhi (knee joint) is also a type of Vaikalyakara Marma (disabling Marma), and hence any injury to this part may lead to disability [12]. However, recent researches indicate that if any Marma point is inflamed or painful, then stimulating its nearby Marma points can help in alleviating this pain [13]. This Marma Therapy can be used to reduce the pain of nerves, muscles, ligaments, bones and joints [12]. Several scholars have reported the therapeutic benefits of Marma Therapy in treating various physical and mental disorders [12][13][14][15][16][17][18][19][20][21][22]. Schrott et al. (2016) [16] state that stimulation of Marma points can affect the functioning of the internal organs and mind-body coordination, resulting in healing with regards to improvement in eye-sight, digestive system, headaches, stress, etc. Marma Therapy can be used to detoxify, revitalize and provide strength to the body [16]. The knowledge of Marman is employed by the practitioners of Kalaripayat (ancient Indian Martial Art tradition of Kerala) as a health promoting technique [18,22]. Varmakkalai is an ancient therapeutic technique practiced in Tamil Nadu, that deals with the stimulation of Varmam (the vital spots of the body) for therapeutic benefits [22]. Marma points are stimulated during Abhyanga (massage), either by applying pressure in different ways, or through specific movement of hands or other body parts, for therapeutic benefits [14,20,21]. Joshi (2010) [12] has developed a simplified form of Marma Therapy (involving application of pressure on specific Marma points) and administered it to patients suffering from various diseases like cervical spondylosis, scoliosis, muscular dystrophy, paraplegia, prolapse inter vertebral disc, etc., with encouraging results.
Marmas are the seats of Prana; hence, Marma Therapy is an important method of regulating the flow of Prana [14]. Since Prana is connected to Vata Dosha, whose vitiation leads to the maximum types of diseases, hence Marma Therapy can be especially useful in treating the Vata disorders, which correspond to chronic degenerative diseases [14] like Janu Sandhigata Vata. Thus, Marma Therapy can be an effective approach for the management of Janu Sandhigata Vata. However, not much work is available in the peer reviewed open literature on the quantitative efficacy of Marma Therapy in the treatment of Janu Sandhigata Vata (OA of knee).
Looking at the effectiveness of these two therapeutic procedures, as well as the fact that both these therapeutic procedures are extremely cost effective, and can be easily done by the patients or their guardians, after simple training, at their home itself, a combined study of the effect of Marma Therapy with Janu Basti in the management of Janu Sandhigata Vata (OA of knee) was undertaken in the present study.

Methodology
To evaluate the efficacy of Marma Therapy with Janu Basti in the management of Janu Sandhigata Vata (Osteoarthritis of knee).

Study Design
Single group experimental study with pre-testposttest research design was adopted.

Description of Variables
The Independent Variables of this study are Marma Therapy and Janu Basti, which have been described below in Section -Intervention. The Dependent Variables of this study are as follows: 1. Subjective Parameters These include Sandhi Shoola (joint pain), Sandhi Shotha (joint swelling), Sandhi Stabdhata (joint stiffness), and Atopa / Sandhisphutana (crepitus), which were analyzed through pre-defined assessment criteria and grading (Table 1).

WOMAC Index (Modified -CRD Pune Version)
The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis (OA) Index was developed to assess pain, stiffness, and physical function in patients of knee and / or hip OA [23,24]. The WOMAC consists of 24 items, rated on a five point Likert scale, and divided into 3 sub-scales [23,24]:  [23,25]. This scale is successfully used in many researches for the assessment of OA of knee [23,25]. WOMAC Index (Modified -CRD Pune Version) has been used in this study for the assessment of OA of knee.

Range of Motion (ROM)by Goniometer
Range of Motion (ROM) of the knee joint was measured by a Goniometer to quantitatively assess the movement of the knee joint.

Walking Time
Walking Time was assessed by asking the patient to walk 21 m distance, and noting the time taken for the same; two such readings were recorded, and the average of the two was taken as the final value. The Walking Time was assessed both before the starting of intervention and after the completion of intervention, as well as at the time of each follow-up.

Selection of Patients
This study was conducted to be an open trial, with single group experimental design. Patients were selected through purposive sampling from the Out Patient Section of the Department of Ayurveda and Holistic Health, Dev Sanskriti Vishwavidyalaya, Haridwar, between May 2018 to May 2019. Screening of 53 patients was done, out of which 21 patients fulfilled the inclusion criteria and joined the study; one patient left in between, so total 20 patients completed the study.
The clinical history of all the patients was taken, and they went through routine hematological examination (Hemoglobin, TLC, DLC, ESR), biological investigations like serum calcium, serum uric acid, serum cholesterol, fasting blood sugar and urine analysis -routine and microscopic -to exclude any other pathology. The diagnosis was confirmed by Xray examination of involved joint.
Informed consent was obtained from all the patients before the start of the therapy. The authors have maintained necessary ethical standards while conducting the research.

Intervention
A total of 20 patients suffering from Janu Sandhigata Vata (Osteoarthritis of knee) were administered the treatment. The treatment involved administration of Marma Therapy and Janu Basti on the affected knee joint. The details of the administered treatment are as follows.

Marma Therapy
The Marma Therapy administered in the present study for the management of Janu Sandhigata Vata included stimulation of four Marma points, i.e. Kshipra, Gulpha, Indravasti and Janu, whose location is depicted in Figs. 1(a) and 1(b). The method of Marma Therapy adopted in the present study is described below [12,13]. The rhythm of applying and releasing pressure was kept similar to the rhythm of the heartbeat (normal heart-beat rate is 72 times per min, i.e. 0.8 second for each heart-beat). Pressure was applied at the Marma point for 0.8 second with the help of tips of fingers and thumb of the hand and then released, and this cycle was maintained.
The rate of applying pressure, i.e. the number of times, was similar to the respiratory rate -16 to 18 times per minute. Each Marma point was pressed for 18 to 20 times. Thus, one session of Marma Therapy took about 5 minutes, and three such sessions were administered during the day. After giving pressure, the site was rubbed gently to avoid the creation of a mark at the site. The method of identifying the Marma points and applying pressure on them was taught to the patients also, so that they could do Marma Therapy on their own, at home, during the follow-up period of the study.

Janu Basti
In Janu Basti, warm medicated oil (Ksheerbala Taila) was retained over the anterior portion of the painful knee joint (at supine position) [9] for 35 to 40 minutes.
Pre-Procedure After releasing natural urges (urine and stool), patient was made to lie down on massage table in supine position, and expose the knee area properly.
Main-Procedure Dough of split black gram (without skin) powder (250gm) [9] was prepared with sufficient quantity of water. This dough was stuck over the affected knee joint to form a leak-proof frame of two inches height and five inches diameter around the patellar surface of the knee, in order to retain the medicated oil. The medicated oil used in the present study was Ksheerbala oil (250ml to 300ml, for each knee, for three days). After making sure that there is no leakage from the walls of the frame, warm Ksheerbala oil (that was warmed in a hot water bath) was gradually filled in this frame with the help of a small piece of cotton of one inch thickness; the top level of oil was kept about 1 inch above the skin surface [9]. It was made sure that the temperature of oil was bearable for the patient. In order to maintain the temperature of the oil, small amount of cooled oil was taken out after every 5 to 7 minutes with a piece of cotton, was warmed, and again filled back in the frame.
Post-Procedure After completing the therapy, the entire oil was taken out from the frame with the help of a cotton piece, collected in a separate vessel for using over the next two days of therapy. The frame of black gram was also removed. Next, light massage of the affected joint was done for five minutes. After that medicated steam (generated from the decoction of Dashamoola) was applied on the affected knee joint for 5 to 10 minutes.
Local application of medicated steam (Nadi Sweda) Janu Basti was followed by local application of medicated steam (Nadi Sweda) [9] on the affected knee joint for 5 to 10 minutes. The Nadi Sweda instrument consists of an electric pressure cooker, with a rubber pipe (about 5 feet long) attached to its nozzle, through which the steam flows out [9]. While administering the medicated steam, the tip of the pipe is to be kept at a distance of about 1.5 to 2 feet from the target region (affected knee joint in the present case), and rotated continuously so that the steam does not cause burning. A bundle of 500 gm medicinal herbs (Dashamoola was used in the present study) and water were kept in the pressure cooker to generate medicated steam [9]. Dashamoola is a mixture of ten medicinal herbs, i.e. Desmodium gangeticum, Uraria picta, Solanum indicum, Solanum xanthocarpum, Tribulus terrestris, Aegle marmelos, Clerodendrum phlomidis, Gmelina arborea, Oroxylum indicum, Stereospermum suaveolens [26].
So, the total time duration of therapy, including Marma Therapy and Janu Basti, was 65 to 75 minutes per day, and this intervention was given for 9 days.
After that there was a follow-up time period of one month, in which two follow-ups were taken: -1st Follow up: After 2 weeks of completion of treatment -2nd Follow up: After 4 weeks of completion of treatment -During follow-up time period, patient had to daily do the following things, on their own, at home; -Massage of the affected knee with Ksheerbala Taila, followed by plain water hot fomentation -Three sessions of Marma Therapy, wherein each session included applying pressure on each of the four Marma points, 18 to 20 times.

Precautions
Patient was advised to avoid exposure to cold air or wind, immediately after taking the therapy. During the course of treatment, patient was advised to take proper rest, avoid too much walking and climbing the stairs, lifting heavy objects, etc.

Dietary recommendations
Patient was advised to take warm, fresh and easily digestible food items; especially green vegetables, green gram pulse, porridge, boiled sprouts, over-night soaked dry fruits, fenugreek, seasonal fruits, etc. Also, patient was advised to avoid heavy to digest food items like black gram pulse, beans, cauliflower, peas, okra, pumpkin, potato, polished rice, as well as cold, sour, oily, spicy food items.

Assessment Criteria and Grading
To assess the effect of therapy, the criteria given in Table 1 were followed. Grading was assigned to the criteria depending on their severity. From the time the therapy was started, required objective tests and assessments were done on day 0 (i.e. before starting the therapy), immediately after the completion of 9 days of therapy, after 2 weeks of completion of therapy, and after 4 weeks of completion of therapy. At the time of second follow-up, X-ray of the involved knee joint/s was done once again.

Statistical Analysis
For statistical analysis, the mean, percentage variation, standard deviation, standard error, t and p values were calculated by using t-test.  26.64% had chronicity in between 3 -5 years, 9.99% had chronicity of more than 7 years, and 6.66% had chronicity of less than one year Overall Effect on the Assessment Criteria Table 2 lists the overall effect of the therapy on all the assessment criteria of the present study, except Walking Time; for all these parameters, n = 30, i.e. the number of affected knees that were treated in the present study. For half of the patients, both the knees were affected, while only one knee was affected for the other half. Since, for the patients whose both the knees were affected, it was possible that a particular patient experienced different level of therapeutic effect in different knees, hence the parameters given in Table 2 were measured separately for both the knees, and as a result n = 30 for these parameters, i.e. the total number of knees treated in this study. It can be seen from Table 3 that the mean score of Walking Time was 1.05±0.09 before treatment, which reduced to 0.05±0.05 after treatment, giving a relief of 95.24%, which is statistically significant with p<0.001.
No apparent change was observed in the X-ray examination before and after the treatment.

Verbal Feedback after Six Months of Completion of the Study Period
Verbal feedback taken from patients about six months after the completion of the study period indicated that 4 patients still had almost complete relief (who had chronicity of less than 3 years) and were pursuing Marma Therapy regularly, while 10 others were able to self manage the disease through regular Marma Therapy and massage (who had chronicity of 3 to 10 years).

Discussion
The aim of the present study was to evaluate the efficacy of Marma Therapy with Janu Basti (with Ksheerbala Taila) in the management of Janu Sandhigata Vata (Osteoarthritis of knee).
According to Ayurveda, a healthy human body is supposed to have a relatively stable equilibrium (congenial homeostasis) of Dosha (psychobiological rhythm -Vata, Pitta, Kapha), Dhatu (body tissues) and Mala (excreta) [4]. Imbalance in this equilibrium leads to disease, and the aim of the therapy is to restore this balance [4].
Among the Tri-Doshas (i.e. Vata, Pitta and Kapha), Vata is of primary importance as it regulates the movement of the other two Doshas, Dhatus and Malas all over the body, mainly because of its Chala Guna (moving property) [4]. When Vata gets aggravated, either due to Vata Vardhaka Ahara (Vata aggravating diet), or Vihara (lifestyle), or Manasika Nidanas, or a combination of these causative factors, it gets firmly embedded in the Khavaigunya Yukta Srotas (micro-channels that have weak or defective space that can serve as a location for the starting of some pathology) associated with specific parts of the body, and impairs the functions of those body parts, causing the disease [4]. If this body part is Janu Sandhi, then the disease is termed as Janu Sandhigata Vata [1,3,4].
Vata has Ashraya-Ashrayi Sambandha (relationship) with Asthi Dhatu; this means that Vata takes shelter in Asthi [4]. In case of Janu Sandhi, if Vata is aggravated then because of its dry nature, it leads to a reduction of the Snehansha (Shleshma / Snigdhata) (unctuousness) from there; because of the decrease in Sneha, Khavaigunya (weak or defective space that can serve as a location for the starting of some pathology) occurs in Asthi and Sandhi, leading to the production of Sandhigata Vata there [4].
In this procedure, warm oil is retained for sufficiently long duration (approximately 35 to 40 minutes) over the affected body part [9]; as a result, the Veerya (active principle) of the oil is absorbed by the Loma Koopa (openings situated over the skin), which in turn undergoes Paka (metabolism) with the help of Bhrajaka Pitta situated in Twacha (skin) [4]. As the oil used in Janu Basti is opposite to the nature of Vata (has Vata pacifying properties), therefore, when it is absorbed by the skin and goes to Dhatus, it helps to rectify the disease present at that site.
In this disease, the glue that binds the cells of the cartilage, is disrupted, leading to cartilage damage at the affected site; oil, due to its properties like Tikshna (sharp) and Sukshma (minute), penetrates the cartilage, and helps in binding together the cartilage cells through its Snigdha (unctuous) and Guru (heavy/thick) properties -this property of oil is termed as Sandhaniya [27]. Also, since Snehana has properties similar to those of Kapha, it helps in bringing back Sthanika Kapha (Shleshaka) to normalcy, which further contributes to the management of this disease [4].

Mode of action of Nadi Sweda
Janu Basti was followed by Nadi Sweda over the Janu Sandhi, with Dashamoola Kwatha (local application of medicated steam generated from the decoction of Dashamoola). Swedana is Agni Deepaka (enhances the digestive fire), Srotoshuddhikara (cleans the subtle micro-channels), Sandhicheshtakara (improves joint movement), and Kaphavatanirodhaka (pacifies Kapha and Vata Doshas) [27]. Swedana supports the activation of local metabolic process, causes an increase in the local blood flow, and hence leads to an increase in the absorption of Sneha (oil) through the skin [3,4]. Sandhigata Vata is characterized by Sanga type of Srotodushti; Swedana relieves this Sanga, leading to the pacification of Sandhigata Vata [3,4,27]. Swedana produces sweating, and reduces stiffness and heaviness in the body [27,32].

Mode of action of Marma Therapy
The Marma Therapy administered in the present study for the management of Janu Sandhigata Vata included stimulation of four Marma points, i.e. Kshipra, Gulpha, Indravasti and Janu, by applying pressure on these locations. The mode of action of Marma Therapy may be understood through various ancient and modern concepts as follows.
According to the scriptures, 'Havya Vaha' and 'Kavya Vaha' Tadit Shakti (bio-electric power), resides in the Marma locations [33]. The positive electricity named 'Havya Vaha' resides in the Marmas of the head and the torso, while the negative electricity named 'Kavya Vaha' resides in the Marmas of the hands and legs [33]. Imbalance of the Havya Vaha and Kavya Vaha Tadit Shakti residing in the Marma points results in the occurrence of disease and weakness [33]. In order to provide relief from this suffering by regaining this balance, the ancient sages invented Yogasanas (Yogic postures) [33]. The stretching, vibration, rhythmic movement and pressure caused by Yogasanas have a direct influence on the Marma points, which play an important role in their refinement, stability and nourishment [12][13][14]33]; subsequently, the functioning of the respective organs with which the specific Marmas are associated, also gets affected leading to therapeutic benefits [12]. For example, the four Marma points used in the present study are stimulated during Vajrasana and Supta Vajrasana, which are useful for knee pain/ strengthening of knee in a healthy person [13]; this indicates the effectiveness of the stimulation of these Marma points in knee disorders.
Marmas are connected to the Nadis (subtle nervous system) and Chakras (subtle energy centers) of the subtle body [14]. The Chakras can be considered to correspond to seven main Marmas or Pranic centers, which provide energy to all other Marmas [14,17]. Through stimulation of Marma points, the flow of Prana through the Chakras can be stimulated, thus activating them, and resulting in the awakening of subtle dormant areas in the brain, that leads to the experiencing of higher realms of consciousness, which are normally inaccessible [34]; this, in turn, can lead to better control over the mind-body network including the autonomic nervous system and various organs, resulting in an overall healing effect [14].
Marmas are related to the three Doshas (Vata, Pitta and Kapha). Acharya Charaka has assigned great importance to the Trimarmas, i.e. Basti, Hridaya and Shirah [5]; these three main Marmas seem to have a direct relationship with the three Doshas, that are known to primarily reside in the same regions, i.e. Vata in the lower abdomen (site of Basti Marma), Pitta in the heart region (site of Hridaya Marma) and Kapha in the head area (site of Shirah Marma) [16]. According to Acharya Sushruta [Sushruta Sharira 6/35] [4], Marmas are the locations having the presence of the three Doshas (Vata, Pitta, Kapha), as well as their subtle forms, i.e. Prana, Tejas, Ojas, and also the three Gunas, i.e. Sattva, Rajas and Tamas [14]. Thus, the stimulation of Marmas may be correlated with the balance of the three Doshas and their subtle forms (Prana, Tejas, Ojas), as well as the three Gunas, which includes Sattva (mind) [14]. Ojas signifies the immunity power; by properly balancing it through the appropriate stimulation of Marmas, the immune system may be strengthened, as well as it can cause rejuvenating effect [14]. Through the connection with the Sattva Guna (mind), the proper stimulation of Marmas can provide relief in stress [14].
As Marmas are the seats of Prana, the vital life force that governs the physical and subtle processes of the body, therefore, through the stimulation of Marmas, the flow of Prana in different body parts can be modulated in such a way that it can be used to remove blockages, and decrease or enhance the physical and subtle energy currents within the body, resulting in the corresponding healing effect [14]. Since Prana is connected to Vata Dosha, hence Marma Therapy can be especially useful in treating the Vata disorders [14]. Out of the five forms of Vata Dosha, Vyana Vayu, that is associated with the skin, as well as the movement and circulation of the Prana, can be most closely linked to the Marmas [14]. Thus, stimulation of the Marmas can balance the Vyana Vayu and Vata Dosha, resulting in the corresponding healing effect in diseases like Janu Sandhigata Vata.

Effect of Therapy on Cardinal Symptoms
In the present study, 66.77% relief was observed in Sandhi Shoola (p<0.001) ( Table 2). Vata Prakopa (vitiation) was the primary reason for pain, and hence the best treatment was to pacify the Prakupita Vata. The properties of Ksheerbala Taila, such as Snigdha and Guru Guna, and Ushna Veerya are opposite to the properties of Vata [4,28,29]; it must have helped in subsiding the Shoola. Since the stimulation of the Marmas can balance the Vyana Vayu and Vata Dosha (Kshipra and Gulpha Marma have been correlated with Vata) [14], hence this must have contributed to reducing the Shoola.
There was a relief of 81.22% in Sandhi Shotha (swelling) (p<0.001) ( Table 2). When Prakupita Vata gets localized in the Asthi Sandhi, it produces Srotorodha (obstruction of the micro-channels) due to Vata Sanga; consequently it produces Shotha [3,4]. The Ushnata applied by the Janu Basti procedure, and the Ushna Veerya of the oil used, do the Paka (metabolism) of the Dushyas present there, and hence Shotha gets reduced [4]. Since, the stimulation of Marmas can pacify the Prakupita Vata (Kshipra and Gulpha Marma have been correlated with Vata), and also modulate the flow of Prana in such a way that it can be used to remove blockages [14], it must have contributed to the reduction of Shotha. Kshipra, Gulpha and Janu Marmas have been correlated with Kapha, and, Janu Marma has been correlated with Udakavaha Srotas [14]; therefore, the stimulation of these Marmas may balance the functioning of Kapha and Udakavaha Srotas, causing reduction of Shotha.
There was a relief of 80.42% in Sandhi Stabdhata (p<0.001) ( Table 2). When the disease is aggravated, the vitiated Vata might produce Stambha (stiffness) due to its Ruksha (dry) and Sheeta (cold) Guna, leading to the restriction in movement [3]. Swedana leads to an increase in the Dhatvagni at the level of joints, and hence improves joint activity (Sushruta Chikitsa Sthana 32/22) [3,4]. The stiffness, i.e. restriction in the joint movement, may also be attributed to the blockage in the movement of Prana at that location; since Marma Therapy reinstates the proper flow of Prana, it must have contributed to the removal of blockages [14], resulting in the reduction of Stabdhata. Indravasti and Janu Marma have been correlated with Pitta; Gulpha Marma has been correlated with Vata and Asthivaha srotas; and, Kshipra Marma has been correlated with Pranavaha and Rasavaha Srotansi [14]; therefore, the stimulation of these Marmas may help to increase Dhatvagni at the level of joints, remove blockage in the flow of Prana at that location, resulting in reduction of Stabdhata. This observation is further supported by the fact that while administering Marma Therapy, several patients reported that they felt immediate relief in stiffness.
There was a relief of 32.79% in Sandhi Atopa (p<0.001) ( Table 2). Atopa is caused because of Vata Vriddhi (increase) and Sthanika Kapha Kshaya (depletion of local Kapha). This symptom is due to Srotoriktata (empty space in micro-channels) present at Sandhi; Swedana removes Srotoriktata and regulates the Vata Dosha, thus resulting in relief in Atopa [3]. Snehana provides Vrinhana (nourishing / rejuvenating) effect, which helps in mitigating Sthanika Kapha Kshaya [4]. Since Janu Basti provides both Snehana and Swedana, hence it must have helped in reducing the Atopa. Since the stimulation of the Marmas can balance the Vata Dosha [14], as well as modulate the proper flow of Prana, hence it must have contributed to the mitigation of the Srotoriktata that was present at Sandhi, with the corresponding reduction in Atopa. Kshipra and Gulpha Marma have been correlated with Vata and Kapha, and, Janu Marma has been correlated with Kapha [14]; therefore, the stimulation of these Marmas may balance Vata and Kapha Doshas, resulting in relief in Atopa. Gulpha Marma has been correlated with Medovaha Srotas, With regards to the knee joint flexion (ROM), 44.43% relief was observed in the same (p<0.001) ( Table 2). Movement of the knee joint was restricted because of Sanga type of Sroto Dushti, as well as Sheeta Guna of Vata, which causes Stambha (stiffness) [3]. Swedana removed Stambha and Sheetata, and induced sweating; consequently, better movement of the joint was achieved (Charak Sutra 22/11) [3,5]. The restriction in the joint movement may also be attributed to the blockage in the movement of Prana at that location. Indravasti and Janu Marmas have been correlated with Pitta [14]; therefore, the stimulation of these Marmas may help to increase Dhatvagni at the level of joints, remove blockage in the flow of Prana at that location, resulting in better ROM.
On examining the Walking Time, 95.24% improvement was observed (p<0.001) ( Table 3). Due to pain and stiffness in the knee joint, the patients had difficulty in walking. As the pain and stiffness reduced, difficulty in walking also reduced.
The WOMAC Index (Modified -CRD Pune Version), which is suitable for Indian-Asian use [23,25], was used in this study to assess the pain, stiffness, and physical function in the patients. There was 69.73% improvement in the WOMAC score (p<0.001) ( Table 2). Since the therapeutic intervention reduced the pain and stiffness, and improved the physical function of the knee joint, hence the WOMAC score also reduced, illustrating the effectiveness of the therapeutic procedure.
It can be seen from Table 4 and Figure 2, that there was a continuous decrease in the mean values of all the subjective and objective parameters, with the duration of intervention. During the first 9 days of the therapy, both Marma Therapy and Janu Basti were being administered to the patients at the Department of Ayurveda and Holistic Health; hence, the results indicate the significant efficacy of the therapeutic procedure in providing relief in the symptoms of Janu Sandhigata Vata.
During the subsequent follow-up period of four weeks, the patients had to daily do the following things, on their own, at home -massage of the affected knee with Ksheerbala Taila, followed by plain water hot fomentation, and, three sessions of Marma Therapy; hence, the results indicate that after the short-term initial therapeutic intervention, the patients attained the capability of long term selfmanagement of the disease at home through regular practice of Marma Therapy and massage. This further indicates the efficacy of Marma Therapy in the management of symptoms of Janu Sandhigata Vata.
Verbal feedback taken from patients about six months after the completion of the study period indicated that 4 patients still had almost complete relief (who had chronicity of less than 3 years) and were pursuing Marma Therapy regularly, while 10 others were able to self manage the disease through regular Marma Therapy and massage (who had chronicity of 3 to 10 years). This further indicates the efficacy of Marma Therapy in the long-term selfmanagement of Janu Sandhigata Vata.
Thus, the results illustrate the promise that the present therapeutic intervention holds in providing the ability to the patients for long-term selfmanagement of this disease, after short-term initial therapeutic intervention under the supervision of a medical practitioner.

Conclusion
The present study was done to evaluate the efficacy of Marma Therapy with Janu Basti (with Ksheerbala Taila) in the management of Janu Sandhigata Vata (Osteoarthritis of knee). The therapeutic procedure involved administration of Marma Therapy on four Marma points of the legs, i.e. Kshipra, Gulpha, Indravasti and Janu, three times during the day, and, Janu Basti with Ksheerbala Taila, followed by Nadi Sweda of Dashamoola Kwath. The total time duration of therapy was 65 to 75 minutes per day, and this intervention was given for 9 days. After that there was a followup time period of one month, during which the patient had to daily do the massage of the affected knee with Ksheerbala Taila, followed by plain water hot fomentation, as well as three sessions of Marma Therapy, wherein each session included applying pressure on each of the four Marma points, 16 to 20 times. Twenty patients completed the study, which involved the treatment of 30 knees.
With regards to the management of the symptoms of Janu Sandhigata Vata, Significant improvement was observed in the subjective parameters (Sandhi Shoola, Sandhi Shotha, Sandhi Stabdhata, and Sandhi Atopa) and objective parameters (WOMAC Index, ROM, Walking Time) analyzed during the study. After the completion of the study, there was 66.77% relief in Sandhi Shoola (pain) (p<0.001), 81.22% relief in Sandhi Shotha (swelling) (p<0.001), 80.42% relief in Sandhi Stabdhata (Akunchana Prasaranajanya Vedana / stiffness) (p<0.001), 32.79% relief in Sandhi Atopa (crepitus) (p<0.001), 44.43% relief in knee joint flexion (Range of Motion -ROM) (p<0.001), 95.24% improvement in Walking Time (p<0.001), and 69.73% improvement in the WOMAC score (p<0.001). Both during the initial therapeutic intervention of nine days, as well as the followup time of one month, there was continuous decrease in the mean values of all the subjective and objective parameters with the duration of intervention, indicating the efficacy of the therapeutic procedure. This also indicated that after the short-term initial therapeutic intervention, the patients attained the capability of long term self-management of the disease at home through regular practice of Marma Therapy and massage.
Verbal feedback taken from patients about six months after the completion of the study period indicated that 4 patients still had almost complete relief (who had chronicity of less than 3 years) and were pursuing Marma Therapy regularly, while 10 others were able to self manage the disease through regular Marma Therapy and massage (who had chronicity of 3 to 10 years). These observations indicate the specific efficacy of Marma Therapy in the long-term self-management of Janu Sandhigata Vata.
Thus, the present study illustrates the significant efficacy of the administered therapeutic intervention in the management of Janu Sandhigata Vata, both with regards to short-term relief, and long-term selfmanagement.

Compliance with ethical standards
Informed consent was obtained from the patients before the start of the therapy.

Conflict of interest
The authors declare that they have no conflict of interest.