Suggested Supplements - Triphala, Haritaki, Amalaki, Vibhitaki, Dashmoola, Rasna, Arjuna, Turmeric, Jaggery, Hing, Cumin Powder, Castor oil, Ginger Powder, Flax powder, Sesame oil, Sheila Bala Thailam, Bala Thailam, Himalayan salt, Rosemary, lemon balm, Peppermint oil, Frankincense oil, Myrrh oil, Olive oil, Camphor  

Namaste, everyone. Welcome to another Athreya herbs practitioner podcast which is done for our community of Ayurvedic practitioners. In these podcasts, our group of Ayurvedic practitioners brings in different cases from our community. We discuss these cases and see what can improve our critical thinking (Pareeksha) and clinical skills (Chikitsa). These are the two things that we will learn. 

 

October 15, 2021 |  42 minutes, 50 seconds
By Vaidya. Jay Parla. 

Vaidya- We're back today with Lisa Jacoby on our podcast. Lisa, is Jacoby still your surname, or has it changed?  

Lisa - It'll be Lisa Flynn. However, I haven't done that legally yet. 

Vaidya - Thank you for correcting me. We know her as Lisa; she recently got married and entered into Grihastra ashrama. We are fortunate to have Lisa on the podcast again with an interesting case in which we all have to think about what can be done. Such a case is what Lisa has today. You may present your case after the chant. Om Namami Dhanwantrayam Aadi Devam, Surasura Vanditham Pada Padmam, Loke Jara Rugbhay Mrityu Nashakam, Datharam Eesham Vividhaushadhinam.Om Shanti Shanti Shanti Hari Om. May Dhanvantari guide us in this clinical case discussion. Thank you. Lisa, please present your case to all of us. 

Lisa - Dhanyavadah (Thank you), Vaidya Jay. The patient is a 49-year-old male who visited me on December 28 with Malabadata and secondary Abhigata. On January 3, I spoke with him and learned that he had a coccyx and sacrum injury, possibly a fracture caused by a snowboarding accident. He lives in Jackson Hole, Wyoming. It was an early season up there, the rocks aren't covered, and there's no base yet. He was snowboarding on snow that looked like powder. He was snowboarding when he hit a rock, his snowboard skidded, and he flew up and landed directly on his coccyx. He was able to snowboard down the mountain before being taken to the clinic. There they checked him, gave painkillers, and sent him to the emergency room for an X-ray. He decided to go home because there wasn't much they could do at the hospital for that kind of injury. There was pain, swelling, and bruising, and lots of sensitivity in that region. I talked to him after one week of his accident, and he had discontinued his pain medicines. He was in pain and complained of numbness around the buttocks and some areas of the lower back. He took many NSAIDs, such as ibuprofen 800 mg, and then reverted to taking a lot of CBD and THC to get some relief. He stopped taking hydrocodone or narcotics pain relievers because he didn't want to be constipated and have the GI issues that come with it. Ayurveda can help in this situation. He was also given a stool softener, which didn't work well a week after the injury. He'd sit on the toilet for a while, but it took time.  He continued to eat small meals but could not go to the bathroom, he became constipated, but the urination was regular. When I spoke with him, his pain level was a 7 out of 10, with an 8 and a half being the worst. You can tell that he has a high pain tolerance level when you see the photographs of the injury. The swelling grew slightly and moved up to the spine, the lower back, and there's a purple line between both buttocks, and the spine is also purple. The swelling grew slightly and moved up to the spine, the lower back, and there's a purple line between both buttocks, and the spine is also purple. There was also a line right across the lower back changing every day. It wasn't radiating down the legs, and he could walk without pain, but every movement had to be slow. He couldn't stand for long and began to have cramps in his lower leg calves, which were not severe but indicated something was going on there. Other areas of his body were compensating for this injury.  The only position that allowed him to be comfortable was laying down on both sides of his body. When it came to rest, he was up every 2-3hours. He could not sleep longer 2-3hours. He's able to sit on his knees but couldn't go into a full Child's Pose. His hips, knees, ankles could rotate well, which means good mobility in all of his joints. He was certain that he had no further injuries other than a possible coccyx or sacral fracture, but he still wanted to wait to get an X-ray. In terms of past medical history, he’s a healthy 49-year-old guy who practices yoga, is an active bike rider and is a surfer. In 2014, he underwent shoulder replacement surgery. He is a healthy guy with no pharmaceutical medications, a normal diet, and has no medication allergies. Currently, he’s taking ibuprofen 800 milligrams, has begun drinking smooth move tea, which is a laxative, and he had taken Duralax as well. He was taking these three things with the stool softener and still had no movement since the injury. He had discomforts, and the lower abdomen was distended, causing further issues on the lower back. There is no libido. Except for hypercholesterolemia on his father's side, he has no significant family history. Additional information about the patient: he works as a DJ and does events for weddings as a hobby. He got into stocks and trading for fun since the Coronavirus started. He doesn't have a set bedtime routine because of his work, but he gets up at 7 a.m, follows a yoga regimen, and is an avid meditator. He has been eating plant-based for a few years, but recently he has been craving a lot of meat and eating some local elk meat. He craves fatty foods and sugars since the injury. When I looked at his tongue, it had a swollen appearance, was pale pink, had some teeth marks along the side, and possibly some Alma on the back, but not a significant amount of Alma. His voice is normal, a little high-pitched but also low; it's difficult to tell. He is soft-spoken and patient. When I touched his skin, it was soft and cool. Vision is normal. He is thin and has medium-sized muscles. He gave me all the information in one conversation. Before the initial intake, I advised him to do Vatahara Vihara because it was a lower back injury, and he was also constipated. First, I advised him to see a doctor and get an X-ray Because I wanted to make sure there's no spinal injury. When the swelling goes down, an injury can appear as he gains more mobility, causing long-term damage, something we don't want.

Vaidya -  Did he get an X-ray, Lisa?

Lisa - He hasn't yet. I did speak with him today, and he said he would get an X-ray done on Monday. I told him that Monday would be too late.

Vaidya -  You told us the history and the sequelae of events that happened. The case is an Abhigataja, which is a Sanskrit term for an injury-induced health issue. The Sheeta Guna is present as the accident occurred in a cold climate, and the patient moving at a rapid speed refers to Chala Guna. The Vata-dosha increases after an injury because it is an abnormal movement basically towards our body. Sheeta Guna is naturally there because of the cold. Chala Guna is present because of the movement. Because of height and the fall, Vata got dispersed from the Apana, its primary location. This injury would have scattered the Vata, and the Sukshma quality of Vata would have increased. The pictures of the injury that you sent seemed extensive. There were purple, blue, and red patches below the lumbar spine that covered most of the left buttock, thigh region, and a bit towards the Ischial tuberosity. The injury disperses the Vata that moved the Ashti, Majja, Mamsa, Rasa, and Rakta, bringing them to a standstill.  Vagbhata says in one of his references that where pitta is Pangu (lame), Kapha is handicapped or lame. Pangavo Mala Dhatavah means Dhatus is stagnant and cannot do anything because Vayu and Vata can move and do what they do. It's a classic example of how Vata got scattered from its location, and the dhatus functioning in that area, including Mala, came to a standstill. This is a beautiful way of correlating physiology to pathogenesis, and our practitioners and listeners have to correlate with it.  Vata that has Sukshma, Laghu, Chala, and Sheeta quality has increased. As Lisa suggested, imaging or at least an X-ray is required to rule out fractures, in addition to the MRI or CT scan. When I looked at the image of the patient that Lisa sent, I noticed that there is no significant swelling, though there may be swelling in the area where he landed. There is also no pooling of fluids in the thigh region or in the legs, which is a good sign because the fluids will stop moving if the injury is severe. Blood vessels or veins could have been injured or ruptured, but this has not occurred.   The most common symptom of lower motor neuron injury is the control of bowel and urine.  The area is controlled by the spinal nerve sacral three and sacral four nerve roots come down the coccyx and innervate the entire pelvic floor, according to Davidson's and Harrison's book of intro medicine. From an Ayurvedic perspective, the pelvic floor regulates Apana and Viana Vata. Viana Vata moves the area, while Apana Vata controls the sphincters. The anal sphincters, the urinary sphincter, and in women opening the uterus, the internal and external OS. These are all controlled by the spinal nerves coming from the nerve roots, sacral three and four, the coccyx branches, and all the branches come down through the lower end of the spine and innervate all this area. We need to think about is the structure involved in the injury. This is an Abhgata, and if it's not appropriately assessed, the person may take a long time to recover, or the person may have permanent deficits. That’s why Lisa said she doesn't want him to wait longer and asked him to do the imaging. I want Lisa to take my advice and ask him to have an X-ray or imaging done as we are not able to see if there is any bone injury because he is somewhere remote from our location. It's better to take the help of something developed by technology to know if there is an injury. If you send him to an X-ray facility and the injury comes out to be extensive, they would appreciate your clinical intelligence. After all, you did not neglect the injury, where the most common complication, such as constipation, is occurring. In modern comparison, the neurogenic bowel is caused by either stroke or trauma. Diseases involving demyelination, Guillain-Barre syndrome, and ASL are examples of conditions in which people cannot control their bowel movements. He's taking three softeners, and it's still not working, which means the problem isn't the formation of the bowel. It's the regulation of the aperture, the anal canal, as well as the anal sphincter, which aren't working. He has to sit squatting on the toilet and use his abdominal muscles to force the bowel to come through. When we go for a bowel movement, the nerve tells anal muscles to expand and open to defecate everything, but that is not happening in this case. I highly suspect that he is going through a neurogenic bowel.  Lisa, you suggested that he should take some of the Herbs. Could you please repeat your suggestion?

Lisa - I will work for sure, but before I go any further, I'd like to state that he is a good friend of mine who I've known for quite some time and that I need to be more strict with my friends than my clients. Thank you for reiterating that I can't help you until you get the CT, MRI, or X-ray done. I knew he didn't live near a grocery store, so I recommended Triphala, a simple formula of three fruits: Vibhitaki, Amalaki, and Haritaki. I knew Haritaki would get things starting to move down and help Apana Vata.  I also wanted to encourage him to improve the quality of his food. Instead of the Sheeta Laghu/ guru and all of that, I was in Sukshma. I wanted Ushna Laghu, Snigdha Laghu, and warm home-cooked meals that are easy to digest. I wanted him to start the day with warm water and advised him to avoid anything that would aggravate his condition, such as ice foods or cold drinks and ice creams, because he was constantly craving them. I gave him Triphala, which he happened to have, as he received it a few days later.  I also sent Dashmoola (10 roots) that he hasn't received yet. He would make a healing dose by combining Dashmoola, Rasna, Nirgundi, Arjuna, Turmeric, and fresh Ginger. 

Vaidya - I like the analogy you're using, that with Sheeta, you need to do Viparita Guna, that is Ushna. The Ahara is Ushna, Snigdha, and the guru, as you suggested. Food like this helps in reducing Vata. Triphala is a safe option because we can make the mistake of thinking, "Oh, I need to push with something strong, like Katuki, the Sonamukhi (Senna), or Cascara sagrada." These can cause more harm to this person because the problem is not with the peristalsis but with the spinal nerve. If we continue to increase peristalsis by using strong Rechana and Bhedana dravyas, it can weaken the Pakvashaya and cause spasms and pain throughout the entire colon. You made a Jeanine choice of using Triphala. We can help the nerve injury or trauma that has traveled from Ashti to Majja Dhatu externally by sitting on the hot water bottle with the sesame or castor oil being applied to the lower spine, the central cleft from where the sacrum and the coccyx extend and sit on a hot water bottle.

Lisa - Sit on the hot water bottle?

Vaidya - Yes, sit on the hot water bottle while applying the oil to the affected area.

Lisa - I did recommend the sesame and castor oil on the belly.

Vaidya - Ensure he's not putting any pressure, and it's malleable on his buttocks where he's resting his injured area. I am saying this because we work in modern hospital settings in India, I've seen what happens when people fall from trees or electrical poles while working on them, and their bladder control is lost. When we do this, the spinal nerves and the muscles will start relaxing. There is a chance that he will urge to use the bathroom or improve the opening of the sphincter. The second thing we can do is something simple like Upanaha, which is a warm herbal poultice.  Ask him to mix 4 teaspoons of flax powder or meal with one and a half teaspoons of garlic powder, a quarter teaspoon of hing or a teaspoon of cumin powder, a tablespoon of jaggery or muscovado sugar or Terminator sugar, a little castor oil, and pour hot water in it. This paste is applied right from the sacral where the two dimples, two points, Kukundara Marma. There is a Marma called Kukundara Marma. Pack this paste from the kukundara marma down to the sacrum and the anal sphincter, then have him lie facing down and use the hot water bottle to ferment or warm it up again. If he has somebody to help, shape the warm mixture into a triangle from the two dimples, either side of the posterior superior iliac spines to the entire sacrum and coccyx, and place the hot water bottle on it. These two external treatments with Snigdha, Ushna, Guru, Manda, Sulakshana,  Kira qualities will gradually push the scattered Vata towards its original location. If the X-ray shows no sacral fractures or if the coccyx is slightly displaced. The coccyx is a cartilaginous bone that extends from the tip of the sacrum and has 3 or 4 annual rings through which nerves pass towards the rectal area. It is not a problem if this coccyx is quilted or ripped off from its original position. A fracture is the only thing to be concerned about. The coccyx does not fracture due to cartilage; it is the sacrum that tends to crack. If there is no fracture, you can ask him to do Matra Basti. Matra Basti means using oil. He can either use sesame oil, or  Sheela Bala Thailam, or Bala Thailam. Warm-up 50 ml of these oils and combine half a teaspoon to three-quarters of a teaspoon of Himalayan salt. Himalayan salt is mixed with this oil to create a homogeneous mixture. Get a syringe and a tube from Amazon, and perform the enema at night. He should take this enema with warm oil before going to sleep. You're doing the external treatment of Upanaha Sweda and Sneha Sweda. Internally you're doing Sneha (oil enema). Matra Basti, unlike any other type of Basti, is simple to perform and tolerate. All of these supplements are given from the surrounding area. Lisa recommended Dashamoola kashayam because it reduces swelling and is beneficial for Apana Vata and bone healing. We can provide Dashmoola kashayam with ginger, Nirgundi rasna, and a little turmeric. These are useful for relieving pain and reducing Vata's Sukshma Guna. I would also recommend giving him Guggulu as well. Yograj Guggulu combined with Lakshadi Guggulu is beneficial for bone injuries. If they do not have Lakshadi Guggulu, Yograj Guggulu and Kaishore Guggulu can be combined and given. Kaishore Guggulu can be taken 2 in the morning, 2 at noon, and 2 at night, while Yograj Guggulu 2 in the morning and 2 at night. If you do these types of Guggulu preparations, then the healing will be faster. The ability of Guggulu to deliver other Herbs into a deeper space is documented in the classical textbooks. You can use this general formula to heal the injured area. Give him as much bone broth as possible. He eats elk meat, so if you can find some bones and make mamsa or majja rasa for him to drink daily, all of this should gradually help him. As you mentioned, Lisa, the most important thing is to get the imaging done to determine the extent of the injury.

Lisa -  You took my mind into another area. I was also thinking about Basti (enema) and Dashmoola kashayam. When working with this client from afar, I have to keep in mind that he lives alone and does not have a caregiver. He goes to the grocery store to get the grocery stuff to make rice porridge, soups, etc. He already has some essential oils to rub and was able to get the Triphala. What do you do when you get to the point of this frustration? He has the manas vikruti of giving up.

Vaidya - Good point. As a healer, you must hold their hands and guide them through these situations. The responsibility of an Ayurvedic practitioner quadruples when a person is alone and has no caregiver. The four limbs of therapeutics are Vaidya (Healer), Rogi (Diseased person), Upastha (Caregiver), and Aushada (Medicine). If the caregiver is not present, it becomes a tripod rather than a table. If the patient is incapable of doing things, then even one leg of the tripod is also gone, and the therapy will become impossible to complete. This is why you need to walk him through, encourage him, and you need to do this today. We'll create a daily schedule for him. Today, you'll give him bone soup and do the enema tonight, or you can make Dashamoola tea in the morning and bone soup at night. You can help him by motivating him to keep track of his therapeutic progress. Another point that interests me is that if he can find rosemary or lemon balm nearby, he can use it in the area where the pain or injury is. If he cannot locate these items, he can use essential oils such as frankincense, myrrh, or even stronger oils such as peppermint, etc.

Lisa - Camphor?

Vaidya - Yes

Lisa - At that time also I was thinking about the quality that you need to favor. If you have olive oil, warm it and apply a small amount to the injured area.

Vaidya - Ask him to heat the olive oil, add some Garlic to it, allow it to become golden brown, and then remove the Garlic. This mixture is enough to drive the Vata out.

Lisa - With that, a little Pranayama. I learned the Kumbhaka pranayama, which involves inhaling for 5 counts, holding your breath for 5 counts, and exhaling for 5 counts. When we were texting, he mentioned he was frustrated and couldn't do anything today, and Pranayama helped him that day.

Vaidya - Encourage him to do Mula Bandha along with Pranayama. Most of our practitioners know a type of exercise known as Kegel exercise; encourage him to do this for better nerve control towards the muscles. Mula bandha is performed by slowly inhaling, constricting, holding the anal muscles, and then exhaling and releasing the anal sphincter. Ultimately he has to learn to communicate with the anal region through his nerves.

Lisa - Like feedback?

Vaidya - Yes, Like feedback.

Lisa - He can do 10 sets of those exercises. Another thing I want everyone to hear, which I thought was excellent, is listening to your SCU lectures. Medicine be thy food and food be thy medicine and rasa the taste is sweet, sour, and salty.

Vaidya - I liked how you first told him what to eat. Food is something that one can control. You made him eat something warm, moist, and oily, including a little bit of healthy sweet. For a sweet taste, use jaggery, muscovado sugar, or something similar, Himalayan salt for a salty flavor, and lemon or rhubarb for a sour flavor. If he can get a clover nearby, that will be awesome.

Lisa - I have such a great story about clover. I harvested a whole bush of clover. It is beneficial for health.

Vaidya - Yes. After he is done with the imaging, give us feedback on how we discussed in this podcast helped him. We will be looking forward to that feedback. Thank you for coming back on our podcast with this case. These injuries occur during the winter season, and Ayurvedic practitioners must be good at the clinical skill of knowing what we should and should not attempt and when to refer the patient to the appropriate care. This is important for developing the Ayurvedic profession in this country, and this case is one example of that. Thank you very much.

Lisa - Dhanyavadhah, Namaste.

Vaidya - Dhanyavadhah, Namaskaram.