Janu Avagaha Instrument

Osteoarthritis (OA) of knee joint is the most common type of arthritis with a prevalence of 22% to 39% in India. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion.

Presently used NSAIDs, alternative anti-inflammatory medications and Intra-articular Injections of Glucocorticoids and Hyaluronic acid are although effective in reducing pain, but for short duration with substantial and frequent side effects. Since OA is a mechanically driven disease, the mainstay of treatment involves altering loading across the painful joint and improving the function of joint protectors, so they can better distribute load across the joint by adjunctive role of pharmacotherapy along with mainstay non-pharmacological measures. Improving the strength and conditioning of muscles that bridge the joint, to optimize their function.

Ayurvedic therapies or procedures performed locally on the joint can play an adjuvant role in strengthening the joint protectors and as a result in management of osteoarthritis.

Janu Basti, one of most common Ayurvedic treatment advocated in the management of this disease, is a procedure in which comfortably hot medicated oil is kept over the anterior area of knee joint for a certain period of time with the help of a cap like hollow structure constructed with dough prepared of wheat flour, covers only limited anterior surface of the effected knee joint, leaving behind the most important popliteal fossa, lateral and medial aspect of the joint. The efficacy of the procedure may be increased if the complete joint is dipped in the oil like in Ayurvedic procedure known as sthanik Avagaha (Complete dipping of the part of body in medicated oils/decoctions for a certain period of time so as to give fomentation to that body part). So, there was a need to modify the procedure or instruments to gain maximum benefits.

Since past many years, medical science is continuously searching for the successful and sustained treatment of OA of knee, a non-fatal disease which is making the life miserable for millions of patients. The World health Organization (WHO) in last decade has put their eyes on Complementary and Alternative Medicines (CAM) like Ayurveda for the solution. Many research papers published in peer reviewed International Medical Journals have also accepted the role of Ayurveda in the management of OA of Knee.

With increasing demand of Ayurveda in the scientific community and rapid globalization, there is an urgent need to update Ayurveda using latest technologies and without leaving the base of strong concepts of treatment.

With the same intention and understanding his responsibilities, Dr Animesh Mohan, who is pursuing his specialization {MD(Ay)} in the branch-Panchakarma from prestigious SDM College of Ayurveda and Hospital, Hassan, Karnataka started working in this area. Primarily, he listed out the areas where modification by up gradation can be carried out and then based upon the number of patients, need in today's world and available options, he prioritized them all. The first disease which was selected was OA of Knee, or Janu Sandhigata Vata in Ayurvedic terminology. As a solution for the same, he invented a therapy and a instrument to execute it, namely “Janu Avagaha Instrument.

In this modification focus was laid down mainly on:

1. Designing an instrument to perform this new treatment procedure – Janu Avagaha (Therapeutic fomentation of full Knee joint and associated musculature using medicated oils).

2. Through this treatment, increasing the surface area of contact of oil used for janu basti. (Fomentation of knee by oil pooling technique) to gain maximum therapeutic benefits in the patients of OA of Knee.

3. Making the procedure easy and convenient for administration so that it can be performed even by non-skilled masseurs or for self-use by the patient.

4. Facility within the instrument for continuous monitoring and maintaining the temperature within standard limit (41 ± 2°C) that too with avoiding repeated changing of oil.

5. Minimizing the quantity of medicated oil required as much as possible.

6. Cushioned thigh rest inclined at an angle such that when patient keeps the knee joint on it for the treatment, the knee joint will automatically come into "Position of Ease" or optimal position for whole duration of the therapy to further enhance the benefits.

7. Adjustable upper slits for fitting easily on every patient with different size of thigh and leg comfortably.

8. Performing the procedure without harming the comfort of the patient during the procedure.

9. Material used for making the instrument is handy, not easily breakable i.e. stainless steel.

10. This instrument and the procedure don't require use of electricity or any power source to operate, so that it can be performed even to the patients of remote or inaccessible areas.

According to Ayurvedic classical literatures, comprehensive management of Osteoarthritis of knee or Janu Sandhigata Vata in Ayurvedic terminology includes a judicious combination of the Abhyantara Chikitsa (treatment involving the internal addministration of drugs) and Bahya Chikitsa (treatment involving external application of drugs) like Janu Basti.

As Janu basti is the procedure that does both Snehana (Oleation therapy) and Svedana (therapeutically induced perspiration), treat the disease by braking the pathology chain has been already proved effective by many clinical trials. But it was focusing only on limited part of "Anterior extensor group" of Joint protection mechanism. Others muscle group need to be given more concern to enhance its activity for early recovery.

A new therapy "Janu Avagaha" was thus planned and for its execution an instrument was required. Several models were made and changed around

12 times to meet the following practical challenges that were faced on performing it :

1. Large size of the instrument.

2. Huge amount of oil required to completely cover the knee.

3. Facility to maintain the temperature of oil or re-heat it.

4. Easy collection of oil preventing any wastage for reusing it.

5. Maintaining the comfort of the patient for whole course of treatment.

6. Continuous monitoring of temperature.

All these issues were solved by changing the design, material used and installing other accessory equipment. The final design was tested on the patients in the pilot study and after getting good results, a request was submitted for clinical trial to the research committee of the institution. Clinical trial was performed in a comparative study with classically used procedure after clearance from Institutional Ethics Committee (IEC) and registration in Clinical Trials Registry – India (CTRI).

Now this instrument and treatment procedure is very commonly used for the management of patient suffering with OA of Knee and approaching SDM Ayurveda Hospital, Hassan, Karnataka and giving significant and sustained results.

Application

This innovation is highly useful in treatment of patients of Osteoarthritis of Knee, particularly Grade-I to Grade-III. Especially in the large percentage of sub threshold population that is Grade-I or borderline OA it can not only give symptomatic relief but can also check the further progression of disease.

It can be very easily used at Ayurveda treatment or Panchakarma centers all over India or any foreign country without any difficulty on regular basis. As it don't require any skills or training, it can also be used by the patients for self-use.

From Jan 2018, this instrument is being used on the patients of Osteoarthritis of Knee as a pilot study.

After getting clearance from the Institutional Ethical Committee (IEC) and Research committee of the Institution, and registration in Clinical Trials Registry – India (CTRI), Clinical trial in controlled environment was started on the Outdoor and Indoor patients of SDM Ayurveda Hospital, Hassan, Karnataka.

After getting significant results on assessing these patients on various subjective and objective parameters, also proven by application of statistics, this treatment procedure has been widely accepted by many departments of SDM Ayurveda Hospital. Since then daily it is been practiced on several patients approaching the hospital for management of Osteoarthritis of Knee.

The instrument requires one time product cost of Rs 1,500/instrument. Which can be used for years together by putting different medicated oils, decoctions or even plain hot water as per the availability or requirement of the disease. Not any servicing is required other than cleaning the tubes for preventing any blockage and proper functioning once after every 20-25 use by opening the service window provided at the bottom of the instrument. As the body is made up of stainless steel, there are minimal chances of any damage due to falling of instrument or improper use. Then also if required, repairing cost will be within 500 rupees.

Already the market size for this instrument is very big with 28.7% prevalence rate of OA Knee in India. With increasing awareness towards avoiding excessive use of pain-killers and use of Ayurveda treatment for non-communicable diseases, demand is continuously going to increase in coming years.

As this therapy is easy to use, scientifically proven effective by clinical trial and can be practiced on daily basis, it will be widely accepted by about 8 lakhs of Ayurveda doctors in India and abroad at their centers. Because it don't require any training or skill for practice, patients can also purchase it for self-use.

The light weight and hard stainless steel body make it convenient for transportation at low cost. Being the first and the only one supplying this product.