Ayurveda research in Hypothyroidism, P

vyayam in hypothyroidism
nasya in hypothyroidism
niragni swedan in hypothyroidism

1. “EVALUATION OF THE EFFECTS OF NIRAGNI SWEDAN, NASYA AND VISHWADI KASHAYAM IN COMPARISION TO THYROXINE SODIUM IN THE MANAGEMENT OF HYPOTHYROIDISM” SCHOLAR Dr. SHALU JAIN GUIDE CO-GUIDES Dr. UMESH SHUKLA Dr. KAMINI SONI Dr. PREETI CHATURVEDI Dr. BABITA DASH Dr. VINOD KOTHARI DEPARTMENT OF PANCHAKARMA PT. KHUSHILAL SHARMA GOVT. (AUTO.) AYURVEDA COLLEGE & INSTITUTE BHOPAL (M.P.)  

2. Introduction Inadequate production of thyroid hormone is considered as hypothyroidism , which is characterized by slower metabolic rate, weight gain, fatigue, constipation, hair fall, forgetfulness, sleepiness, dry and coarse skin, menstrual irregularities etc. Most common disorder of thyroid gland Commonest endocrine disorder. Very commonly observed clinical entity.

3. In Ayurveda classics, there is no direct mention about how to understand the pathogenesis of hypothyroidism, however, certain pathogenic phenomenon that includes Kaphavarit-Vata , Kapha-Medo-Avrita Vata , Galgand in Urdhvjatrugat Rogas , Dhatvagnimandhya Janya Vikriti appear to be pathological entities that paves the way to understand the disease manifestation. Niragni Swedan is indicated in Kaph- Meda - Avrita Vata . Niragni Swedan , although 10 of types,in present study opted in the form of Vyayam . Vyayam is belived to do kindling of Agni and increases basal metabolic rate which is found to be decreased in case of Hypothyroidism.

4. Thyroid gland is situated in supraclavicular region ( Urdhvajatrugata Sthana ) ,which is a Kaphsthana . Nasya is considered as the most specific procedure for disease of head and neck region. As in Ayurveda nose is considered as the door of head, and the suitable route for drug administration in Urdhvajatugata Rogas . Vishwadi Kashayam is indicated in Kapha Dosha and Agnimandhya but it also have Lekhan , Agnideepan , Shrotoshodhan and Medhya properties to deal with Medodushti , Agnimandhya , Avrit-Vata . Hence was selected for oral use. Thus, the combination of above three regimen has been planned to evaluate its effect in the management of hypothyroidism.

5. Need of study Global incidence of Hypothyroidism is rising rapidly and it is posing major health challenges in both developing as well as developed world. The prevalence of hypothyroidism is high, affecting approximately one in 10 adults in population and more prevalent among the females, with male to female ratio being 1:6 It is found to be 10.95% in adult urban population with significantly female number outweighing the males i.e. 15.86% in females and 5.02% in males. The prevalence of primary Hypothyroidism is high accounting for over 95% of total Hypothyroidism patients. Central Hypothyroidism of pituitary origin, occurrence rate is even lower i.e. 1 from 1000 cases.

6. Hypothyroidism influences the standard of life of individuals. Inspite of many progresses the modern management of hypothyroidism remains disappointing. The only treatment available is synthetic thyroid hormone which patient has to take lifelong and has certain side effects causes cardiac arrhythmia, palpitation, muscle cramp, weakness, restlessness, osteoporosis etc.

7. Looking into the pathogenesis and complications of hypothyroidism, it requires a systemic and radical therapy for which ayurveda may provide a ray of hope through Panchakarma , which is believed to facilitate to regulate metabolism and better improvement in quality of life of affected person. Some of the scientific works also have been done by using Ayurveda regimen. However the specific line of treatment, comprising of Niragni Swedan and Nasya along with Vishwadi Kashyam needs to be studied and verified to generate the scientific evidence. Hence the present study has been planned.

8. Aim and objectives To evaluate the efficacy of treatment regimen comprising of Niragni Swedan ( Vyayam ) , Nasya ( Katutumbi Tail) and Vishwadi Kashayam on the patients of Hypothyroidism. To compare the efficacy of treatment regimen comprising of Niragni Swedan ( Vyayam ), Nasya ( Katutumbi Tail) and Vishwadi Kashyam with that of Thyroxin Sodium on the patients of Hypothyroidism

9. Review of literature All the literature related to Niragni Swedan , Nasya and the concept of Urdhvjatrugat Sthan Vikar , Kapha-Avritta - Vata and Dhatvaagnimand-Janya vikar by which hypothyroidism is correlated to be identical disease condition find place in classics, are being explored and all the details of literary review. At the same time modern literature including recent advances in the field are also being reviewed.  

10. previous research works done Pandya- Tridosha vis-à-vis endocrine gland -1966. Trivedi (MS) A.U.- evaluation of Kshargutika in the cases of hypothyroidism L-1907 Govt. Akhandanand college & hospital 1992 Lineswala Gaurang - A clinical study on the role of Vamana and Shamana in the management of Kaphaja Galaganda w.s.r . to hypothyroidism. – 2002 Jamnagar Gupta Chanchal- comparative study of pippali prayoga and Shodhan-Poorvaka Shamana Chikitsa in the management of Dhatvagni-Vikrati (hypothyroidism). -2003 Jamnagar.

11. Kankaran Komal -clinical evaluation of kanchanara guggul and pippali Vardhman rasayan in the management of hypothyroidism-2003 NIA. Rajasthan University. Sherekar Dipali -A Clinical study on Vamana karma in the management of Hypothyroidism-An Ayurvedic approach-2008 GAMC Blore , R.G.U.H.S. Mali Anjali -The effect of Vamanottara Virechana Karma followed by Vardhamana Pippali Rasayana in the management of Hypo- thyroidism -2012 Jamnagar. Bansal Roli - Effect of Vamana Karma in the Management of Hypothyroidism - 2013 Jamnagar.

12. Patariya Pratiksha – A clinical study on the role of vaman and virechan in the management of hypothyroidism with punarnava guggulu -2014 Jamnagar P.Murali Krishna– A clinical study on combined effect of vamankarm and Gomutra Haritaki in the Management of Hypothyroidism 2015 Sri. Dharmsthalamanjunatheshwar college of Ayurveda and Hospital, Hassan Singh Karishma Mahi Pal Singh- A Comparative Clinical Study Of Virechana And Triphladya Guggulu Along With Punarnavadi Kashaya In The Management Of Hypothyroidism -2017 Jamnagar Sahu Sarita – evaluation of the effect of Udvartana of Basti Karma along with Varun Twaka Kashayam , in comparison to Thyroxin Sodium- 2020 Bhopal

13. Disease Review Hypothyroidism is a clinical syndrome resulting from a deficiency of thyroid hormones. It results in a generalized slowing of metabolic processes. The clinical manifestation of hypothyroidism, depending upon the age at onset of disorder, are divided into 2 forms 1. CRETINISM : It is the development of severe hypothyroidism during infancy and childhood, results in marked slowing of growth and development with serious permanent consequences including mental retardation. 2. ADULT HYPOTHYROIDISM: causes a generalized decrease in metabolism MYXOEDEMA is the severely advanced adult hypothyroidism.

14. Classification of hypothyroidism PRIMARY HYPOTHYROIDISM Subclinical hypothyroidism Overt hypothyroidism CENTRAL HYPOTHYROIDISM Secondary hypothyroidism Tertiary hypothyroidism

15. PRIMARY HYPOTHYROIDISM There are two degrees of primary hypothyroidism: SUBCLINICAL HYPOTHYROIDISM: defined as a high serum TSH concentration in the presence of normal serum T 4 and T 3 concentrations. Other terms for this condition are mild hypothyroidism, preclinical hypothyroidism, and decreased thyroid reserve. OVERT HYPOTHYROIDISM : defined as a high TSH concentration in the presence of a low serum T 4 concentration.

16. Central hypothyroidism It is rare and is caused due to failure of TSH and TRH production due to disease of anterior pituitary ( SECONDARY HYPOTHYROIDISM ) or hypothalamus ( TERTIARY HYPOTHYROIDISM)

17. Clinical manifestation Early symptoms of hypothyroidism are nonspecific and insidious in onset. A generalized slowing of metabolic processes can lead to abnormalities such as fatigue, slow movement and slow speech, cold intolerance, constipation, weight gain, stiffness and cramping of muscles and Bradycardia . Accumulation of matrix glycosaminoglycans in the interstitial spaces of many tissues can lead to coarse hair and skin, expressionless facies , periorbital puffiness, enlargement of the tongue, and hoarseness

18. Ayurvedic view Although, after mere knowledge of disorder pertaining the thyroid gland from view of modern system of medicines, we can’t directly correlate in Ayurveda as a whole disease yet signs and symptoms which we approach in day-to-day clinical practice can be seen in Ayurvedic texts in different manners. Certain pathogenic phenomenon that includes Kaphavarit-Vata , Kapha-Medo-Avrita Vata , Galgand in Urdhvjatrugat Rogas , Dhatvagnimandhya Janya Vikrati appear to have pathological significance in disease manifestation.

19.   S.N.   Clinical manifestation of Hypothyroidism Lakshanas of Kaphavrit Saman and Udan   Ca.Ch.28/226-227   Su.Ni.1/37   A.H.Ni.16/48   1.     Dry skin, loss of sweating     Aswednam + - + 2.   Loss of appetite Mandagni + - + 3.     Hoarseness of voice     Vakswargriha + - + 4.   Weakness Daurbalya + - + 5.   Loss of appetite Aruchi + - + 6.   Weight gain Gurugatrtvam + - + Hypothyroidism vis-a-vis Avaran

20.   S.N. Cinical manifestation of Hypothyroidism   Lakshnas   Involved Dhatu 1. Loss of appetite, Aruchi   2. 3. Heaviness in body Somnolence Gaurava Tandra   RASA Ca.Su.28/9-10 4. Generalized ache Angamarda   5. Anaemia Panduroga   6. Loss of libido Klaibya   7. Indigestion Agnimandhya   1. Wt. gain Sthaulya MEDA 2. Sleepiness Nidraadhikya Ca.Su.28/15 3. Drowsiness Tandra Ca.Su.21/3 4. Breathlessness Swasa Ca.Ni.4/47 5. Edema Sopha Su.Sa.9/12       Su.Su.15/19 Hypothyroidism and involved Dhatu- Rasa & Medas

21. S.N Clinical manifestation of Hypothyroidism Lakshanas Involved dosha 1. Cold intolerence Saityam Kapha vata vriddha hinapitta (Ca.su.17/56) 2. Weight gain Gauravam - 3. Loss of appetite Mandagni , Asradha - 4. Anaemia Nakha dinam shuklatvam - 5. Dry and coarse skin Gatra parusyam - 7. Constipation Malsanga Vata vruddhi (Ca.Su.11/6) 8. Weakness Bala bhransha , Bala Hani Vata vruddhi,Pitta kshaya (Su.Su.15/18) 9. Depression Avsad Kapha vruddhi (Su.Su.15/18) 10. Somnolence Tandra - 11. Excessive sleep Atinidrata Kapha vruddhi ( AH.Su.11/7) 12. Laziness Alasya - 13. Breathlessness Shwash - Hypothyroidism and involved Dosha

22. S.N. Clinical manifestation of Hypothyroidism Ama lakshanas (A.H.13/23- 24) 1. General Weakness Balbhransha 2. Heaviness in the body, swollen, puffyy oedematous look of face, weight gain Gaurav 3. Laziness Alasya 4. Indigestion Apakti 5. Constipation Malsanga 6. Loss of appetite Aruchi 7. Tiredness Klama Symptoms of Ama in Hypothyroidism

23. Samprapti ghatak Dosha Kapha vriddhi associated with pitta dushti and margavaranjanya vatvriddhi Dushya All dhatus mainly rasa and meda dhatu Srotas Rasvaha , Medovaha predominantly Srotodushti Sanga , vimarggaman Agni Jathragnimandhya , dhatvagnimandhya Adhisthan Gala pradesh Udbhavsthan Aamashaya Vyakta sthan Sarvang Roga marga Bahya and aabhyantar Vyadhi swabhav Chirkari

24. NidanaSevana KaphaPrakop Jatharagnimandya AamaUtpatti Rasa Dhatvagnimandya MedaDhatvagnimandya MalarupKaphaVriddhi Srotorodh, Margavrodha KaphavruttaVata Kaphavrutta Saman Vata Kaphavrutta Udaan Vata KaphaVataVriddaHina Pitta Cold intolerance, weightgain, anaemia, loss of appetite, dry and coarse skin Loss of appetite, heaviness of body, lethargy,somnolence, anaemia, infertility sluggishness,sleepiness,Tiredness, weight gain due to meda dhatu vriddhi Cold intolerance, weight gain,oedema, generalized ache Dry and coarse skin, loss of sweating, loss of appetite Clinical Manifestation of Hypothyroidism Loss of appetite, Hoarseness of voice, weakness Ras SrotoDushti Probable samprapti

25. Clinical Study For the clinical study on Hypothyroidism 40 patients, fulfilling the criteria of diagnosis selected, irrespective of their religion, caste, sex and socioeconomic status from OPD & IPD of Pt. Khushilal Sharma Govt. Autonomous Ayurveda College & Institute, Bhopal ( M.P. ) being registered. The Drug required for the Clinical study has been procured and prepared in the department of Rasa Shastra and Bhaishajya Kalpana of Pt. Khushilal Sharma Govt. Autonomous Ayurvedic College and Institute, Bhopal M.P. The patients are being registered based on a detailed proforma comprising of all clinical signs and symptoms of Hypothyroidism and modern investigation as advised in the criteria designed.

26. Grouping Group A ( N=20 ) Niragni Swedan ( Vyayam ) and Katutumbi Taila . Nasya along with Vishwadi Kashayam Group B ( N=20 ) Thyroxin sodium Dose- calculated as per guidelines Study duration- 45 days Follow up – 15 days

27. Diagnostic Criteria The diagnosis of the Hypothyroidism is made on the basis clinical signs and symptoms. (Harrison’s principle of internal medicine 19 th edition) Laboratory investigation- Serum TSH Serum T 3 Serum T 4

28. Inclusion criteria Newly diagnosed cases of Hypothyroidism. Patients age- above 21- 45 years. Patients those fit for Nasya & Niragni Sweda Based on thyroid profile elevated level of serum TSH level or low level of serum T3 &T4. However, the cases, where T3 and T4 levels are within normal range and TSH level is high (TSH value >5.0mIU/ml) Patients those have given written consent to participate in the study.  

29. Exclusion criteria All complicated cases of Hypothyroidism, myxedema, severe mental illness, thyroid cancer etc and other disease associated with endocrine imbalance. Patients having chronic systemic illness. Congenital hypothyroidism Pregnant women and Lactating Mother. Patients having undergone thyroid surgery

30. Criteria for assessment SUBJECTIVE PARAMETERS Weight gain Excessive Sleep Muscle ache Oedema Dry and coarse skin Constipation Tiredness Hair fall OBJECTIVE PARAMETERS BMI BIOCHEMICAL PARAMETERS S.TSH S.T3 S.T4

31. Grading system sahu sarita et.al Parameters Criteria Grading 1. BMI Between 18.5 to 24.9 25to29.9 1 30 to34.9 2 Above 35 3 2. Excessive sleep 6-7 hrs/ day 8 hrs/ day 1 10 hrs/ day 2 More than 10hrs/ day 3

32. Parameters Criteria Grade 3. Muscle cramp Not present Once in a week 1 Twice /thrice in aweek 2 Continuously present 3 4. Oedema No oedema Oedema on lower/ upper extremities 1 Oedema on upper and lower extremities 2 5. Dry and coarse skin No dryness Dryness after bath only 1 Dryness whole day but relieved by oil application 2 Dryness whole day and not relieved by oil application 3

33. Parameters Criteria Grading 6. Constipation No constipation Motion once in a day w/o complete evacuation 1 Motion once in two days 2 Motion once in more than two days with hard stool 3 7. Tiredness Absent tiredness Pt. like to stand in comparison to walk 1 Pt. like to sit in comparison to walk 2 Pt. like to lie in comparison to sit 3 8. Hair fall Absent Hair fall on washing 1 Hair fall on combing 2 Hair fall on stretching 3

34. Overall Assessment Criteria   Total effect of the therapies will be graded as follows: Complete remission 100% relief Marked improvement 75% to < 100% relief Moderate improvement 50% to < 75% relief Mild improvement 25% to < 50% relief No improvement < 25% relief

35. TREATMENT REGIMEN Procedure Duration Drug DOSE TIME Nasya 1-21 Days (7 Days + 1day Rest +7 Days + 1day Rest +5days Nasya ) Katutumbi Tail 6 drop in each nostril Purvahn Kaal Niragni Swedan 1-21 Days Vyayam Till Balardh Vyayam Lakshan appear Purvahn Kaal Shaman Drug 1-45 Days Vishwaadi Kashayam 40 ml. Twice a day

36. DRUG REVIEW VISHWADI KASHAYAM (SAHASRA YOG KASHAY KALPANA -499) S. No. Drug Latin Name Family         1. Vishwa Aconitum hetrophyllum Ranunculaceae 2. Abhya Terminalia chebula Combretaceae 3. Guduchi Tinospora cordifolia Meninspermaceae 4. Shunthi Zingiber officnales Zingiberaceae 5. Chavya Piper retrofractum Piperceae 6. Chitrak Plumbego zeylanica Piperceae 7. Pippalimool Piper longum Piperceae 8 Pippali Piper longum Piperceae 9. Marich Piper nigrum Piperceae 10. Tejpatra Cinnamon zelanicum lauraceae 11. Twak Cinnamon zelanicum lauraceae

37. KATUTUMBI TAIL (GADNIGRAH 4 TH KHAND CHAPTER-VERSE 72-73S) S. No. Drug Latin Name Family         1. Vidang Embelia ribes Myrsinaceae 2. Vacha Acorus calamus Araceae 3. Rasna Pluchia lanceolata Compositae 4. Shunthi Zingiber officnales Zingiberacae 5. Ikshvaku Lagenaria siceraria Cucurbitacae 6. Devdaru Cedrus deodara Pinaceae 7. Sarshap Brassica campestris Cruciferae

38. Null Hypothesis Group A ( Niragni swedan , Nasya and Vishwadi kashayam ) and Group B ( Thyroxin Sodium ) are equally effective in the management of Hypothyroidism. hypothesis Alternate Hypothesis 1. Group A is more effective than Group B in the management of Hypothyroidism. 2. Group B is more effective than Group A in the management of Hypothyroidism.

39. Statisticle analysis The observation will be recorded and presented in tabulation form and result will be analyzed statistically by applying appropriate statistical test.   expected outcome It is expected that at the end of the study we would be able to demonstrate the effects of Niragni swedan , Nasya and Vishwadi kashayam in the management of hypothyroidism. It is further expected that this study would be able to provide comparative efficacy between the trialed treatment is that.

40. ETHICAL CONSIDERATION study was approved by institutional ethical Committee. Informed Conscent An informed written consent in language suitable to the patients was obtained from all enrolled subjects.  

41. OBSERVATIONS AND RESULTS DEMOGRAPHIC DATA EFFECT OF THERAPY

42. Demographic Data In this study, majority of patients (52.5%)belonged to the age group between21-30 years. People in this age group are busy and stressed out about making a good living, despite the fact that this is the time in life when a person wishes to enjoy himself to the fullest and can’t following Dincharya , Rutucharya etc . while engaging in either of these activities may lead to vitiation of doshas may become more vulnerable to Agni derangement. Age wise distribution

43. Gender wise distribution It is supported by prevalence of disease i.e.; male female ratio 1:6. Hypothyroidism is most common in females. Qiu Y, Hu Y, Xing Z, et al. reported that the females using contraceptive for more than 10 years have significant association with developing Hypothyroidism.

44. Religion wise distribution Nothing can be inferred from this observation because it may be an outcome of demographic considerations as the study area is a Hindu-dominated area.

45. Marital status wise distribution Hypothyroidism in married patients may be brought on by lack of exercise, family responsibilities, and various types of stress. American Thyroid Association claims that, hypothyroidism incidence is most common after pregnancy and postpartum this could be reason why marital status slaved and association with the disease.

46. Education wise distribution Understanding its prevention and control measures is greatly aided by education. This generally shows that the educated class is more aware hence are more likely to undergo diagnostic and treatment procedures to overcome it. A larger sample size is needed in order to correlate education with the occurrence of disease.

47. Occupation wise distribution this high incidence may be due to their sedentary life style, which results in less energy expenditure than uptake. Housewives are confined to their homes; technology has lightened the load of household chores, however since it was not a survey study which in large scale may prove the above observation.

48. Socioeconomic status wise distribution Due to their lofty aspirations and the current competitive environment, people in upper middle class are more vulnerable to stress. They lead a life in which making money is their only priority. This group of people also exhibits negligence in healthy lifestyle which can contribute to the development of the disease hypothyroidism.

49. Habitat wise distribution This may be due to the reason that the present study was undertaken in urban area. Usually, urban people are having sedentary lifestyle, inconsistent dietary pattern; consume junk food etc.

50. Family History wise distribution The well-documented genetic risk factors for autoimmune hypothyroidism are HLA-DR polymorphisms.Despite the fact the sample size is too small to draw any firm conclusions. To determine whether hypothyroidism runs in families or not, more research is required.

51. Diet pattern This can be because of the Hindu community consumes primarily vegetarian food.

52. Appetite wise distribution maximum no of patients (52 %) had good appetite, followed by 35% had moderate appetite and only 13%% had poor appetite.

53. Bowel wise distribution 67% of the patients in this series had regular bowel habits. However 33%of the patients had irregular bowel habit.

54. Stress wise distribution 52% of patients had stressful life and remaining had no stress in life.

55. Kostha wise distribution in the present study, 70% patients had Madhyama Kostha followed by 23% had Krura Kostha and 7% had Mrudu Kostha .

56. Prakruti wise distribution The Kaphaj-Vataj Prakruti persons are more likely to develop hypothyroidism. It might be caused by a similar Dosha to the pathophysiology of Hypothyroidism. To determine which Prakruti is more prone to the disease's development, a sizable sample size is necessary.

57. Vyayam Shakti wise distribution This observation supports the nature of the disease which makes lethargy and fatigueto the person to avoid exercise. Additionally, the majority of study participants were overweight, and it was discovered that these patients had less ability to exercise. Hypothyroid individuals' ability to exercise is further limited by lower cardiac output and stroke volume, as well as by diminished muscular strength and increased muscle fatigue.

58. Agni wise distribution maximum (62%) patients were possessing Mandagni followed by 30% patients were possessing Vishamagni .

59. Distribution of 40 patients according to BMI Medodhatvagnimandya resulting in Sama Medo Dhatu Vriddhi leading to Sthaulyata . It is however yet to be seen whether inactivity and weight gain influence to hypothyroidism or vice-versa. These findings suggest that the Dushti of Meda Dhatu in hypothyroid patients.

60. Symptoms wise distribution

61. in the present study Tiredness was present in 82.5% patients followed by muscle cramp 77.5% in patients. Constipation was found in 67.5% patients,weight gain was found in 62.5% patients whilehair fall was observed in 50% patients, generalized ache & pain was observed in 47.5% patients. Menstrual irregularity was found in 30% patients, Dry skin was found in 25% patients while edema was observed in 25% patients and the excessive sleep was observed in 17.5% patients.  

62. Effect of Therapies

63. Effect of Therapies on Constipation Constipation Mean Mean difference % Relief SD SE P value & W value BT AT Group A 1.000 0.2000 0.8000 80% 0.5231 0.1170 P <0.0001 ES W=120.00 Group B 1.150 0.7500 0.4000 34% 0.5982 0.1138 P =0.0156 S w=28.000 Mann Whitney test p =0.0211, U =124.50, Cosidered significant

64. Effect of Therapies on Excessive Sleep Excessive sleep   Mean Mean difference % Relief SD SE P value & W value BT AT Group A 0.5500 0.05000 0.5000 90% 0.6882 01539 P =0.0078 VS W=36.000 Group B 0.6500 0.4500 0.2000 30.7% 0.4104 0.09177 P=0.1250 NS W=10.000 Mann Whitney test p =0.0686, U -147.000, not quite significant

65. Effect of Therapies on Tiredness Tiredness Mean Mean difference % Relief SD SE P value & W value BT AT Group A 1.850 0.8000 1.050 56.7% 0.8256 0.1846 P =0.0001 W=105 ES Group B 1.800 1.150 0.6000 33.3% 0.6806 0.1522 P =0.0020 W=55.000 VS Mann Whitney test U=145.00, p =0.1179, Insignificant

66. Effect of Therapies on Hair Fall Hair Fall Mean Mean difference % Relief SD SE P value & W value BT AT Group A 1.750 0.900 0.8500 48.5% 0.6708 0.1500 P=0.0001 W=105.00 ES Group B 1.600 1.100 0.5000 31.2% 0.6882 0.1539 P=0.0078 W=36.000 VS Mann Whitney test U=146, p=0.1080,Consider Insignificant

67. Effect of Therapies onDry Skin Dry Skin Mean Mean difference % Relief SD SE P value & W value BT AT Group A 1.250 0.200 1.050 84% 0.9987 0.2233 P=0.0005 W=78.000 ES Group B 0.800 0.400 0.400 50% 0.5982 0.1338 P=0.0156 W=28.000 S Mann Whitney test U= 127.000, p=0.0328 Considered Significant

68. Effect of Therapies on Muscle Ache Muscle Ache Mean Mean difference % Relief SD SE P value & W value BT AT Group A 1.550 0.7000 0.8500 54.8% 0.5871 0.1313 P<0.0001 ES Group B 1.100 0.4000 0.7000 63.6% 0.6569 0.1469 P=0.0005 W =78.000 ES Mann Whitney test U =165.000, p=0.2882, Insignificant

69. Effect of Therapies on Edema Edema Mean Mean difference % Relief SD SE P value & W value BT AT Group A 0.4000 0.1500 0.2500 75% 0.4702 0.1051 P=0.0313 W=21.000 S Group B 0.2500 0.1000 0.1500 60% 0.3663 0.08192 P=0.2500 w = 6.000 NS Mann Whitney test U =170, p =0.2701, Insignificant

70. BMI Mean Mean difference SD SE t-value P value & W value BT AT Group A 27.840 26.770 1.070 1.140 0.2549 4.198 P=0.0005 ES Group B 25.210 24.900 0.3100 0.8220 0.1838 1.687 P=0.1080 NS Unpaired t test p= 0.0205, t= 2.418, considered significant Effect of Therapies on BMI

71. S.TSH Mean Mean difference SD SE t-value P value & W value BT AT Group A 10.292 5.812 4.480 5.328 1.192 3.759 p=0.0013 VS Group B 8.626 4.495 4.131 2.975 0.6653 6.208 p<0.0001 ES Unpaired t test p= 0.7995, t= 0.2557, considered Insignificant Effect of Therapies on Serum TSH

72. Overall assessment of Therapy   Total Effect Group A Group B No. of patient % No. of patient % Complete remission (100%relief) Marked improvement (>75% to <100%relief) Moderate improvement (>50% to75%relief) 10 50 04 20 Mild improvement (25% to 50% relief) 09 45 16 80 No improvement (<25%relief) 01 5

73. DISCUSSION

74. Probable mode of action of NiragniSwedan ( Vyayam ) The reason for selecting Niragni Swedan in hypothyroidism, because it is specifically indicated in the management of KaphaMedaAvrittaVata is found to be involved in the pathogenesis Vyayam is a type of Niragni Swedan and is included in type of langhan also. They do langhan by production of sweat. NiragniSwedana ( Vyayam ) liquifies Sama Kapha and Meda which comes throughout microchannels of the body. Kleda is the Mala of Meda Dhatu . Swedana Karma helps in flushing the vitiated Meda or Kleda which is present in inter or intra cellular place in the form of excess body weight.

75. Niragni Swedan ( Vyayam ) helps in Vishyandan (liquefaction), Doshpaka , Srotomukh Shodhan and Vayu Nigrah because of its Vata-Kaphahar property. Vyayam rises the metabolic rate in the body, dilates the capillaries and increased circulation leads to more elimination of waste product in the form of Sweda by sweating. Due to rising temperature to all parts of the body the triglycerides present in the subcutaneous tissue will breakdown in the fatty acid. These fatty acids are carried out to the liver due to the vasodilatation and convert in to bile. In this treatment less caloric diet is supplied along with brisk walk the body leads more oxygen to meet the same in the absence of carbohydrate and increased metabolic rate due to heat. fat is utilized for the purpose of energy production which deposited in the form of Meda .

76. Probable mode of action of Nasya Hypothyroidism is Kapha predominant disease condition; hence the drugs which are having Kaphashamaka properties such as Ushna , Teekshna Guna should be used in curing the disease. KatutumbiTaila have Ushna , Teekshna and Kaphashamaka properties. The Sthana of the thyroid gland being Urdhwajatru , which is a Kaphasthana , hence the management of hypothyroidism is by Katutumbi Tail Nasya may be a better option. As in ayurveda, Nasa is the only gate way of Sirah . Hence nose is the suitable route for drug administration in case of Urdhva-Jatrugata disease.

77. With the help of previous pharmacological research, we found that all the herbs evaluated here act on hypothalamus and pituitary gland directly or indirectly and stimulate the thyroid gland by Nasya action i.e.; peripheral olfactory nerve, which acts as chemo receptors are stimulated by Nasya Dravya which stimulates the olfactory bulb. This further stimulates higher centers of hypothalamus and pituitary, thus having the effect on endocrine system secreting the normal secretion of thyroid hormones. Katutumbi Tail reaches the brain and acts on important centers controlling endocrine functions and thus having systemic effects.

78. Drugs in the form of lipid soluble have greater affinity for passive absorption through the nasal mucosa, also be enhanced by local massage and fomentation. Facilitates by the structure of facial nerve, communicate intra cranial circulation. Urdhvang Abhyanga and Swedan and Paschat Karma helps to drain out the excess Kleda formation. Most of the herbs, used in the preparation of Katutumbi Tail , evaluated above have their action upon thyroid gland. Katutumbi Taila Nasya only provides relief in various symptoms but also directly alters the secretions of different hormones involved in pathogenesis of the disease.

79. Probable mode of action of VishwadiKasayam The management of Hypothyroidism primarily focused on to remove the Avaran , Srotoshodhan and increase the Dhatwagni . Drugs under Vishwadi Kashayam ( Vidang , Vacha , Rasna , Shunthi , Marich , Pippali , Saindhav Lavan , Yavkshar , Chitrak , Devdaru Katutumbi , Katu Tail ) having Ushna Virya , Tridoshhar and Vedanasthapak , Deepan, Anuloman , Shothagn , Lekhan , Medhya , Srotoshodhan properties balance the vitiated Doshas in this disease. Vishwadi Kashayam indicated in Agnimandya , thus prevents the jathragni-mandyajanya vikar followed by Dhatvagnimandyajanya vikar .  

80. CONCLUSION

81. An analysis various data and its results drawn therein following conclusions are placed as under: Hypothyroidism is the most common form of thyroid disorders and commonly encountered problem in clinical practice, it is also the commonest endocrine disorder worldwide and India too. In Ayurveda although there is no specific terminology or clinical entity described as such, probably because the disease is biochemically diagnosed and not just only on the basis of symptomatology. In the present study, in group A Complete and Marked improvement was not found in any of patients, Moderate improvement was found in 50% patients and Mild improvement was recorded in 45% patients.

82. In the present study, in group B Complete and Marked improvement was not found in any of the patients, 20% patients had shown Moderate improvement and 80% patients reported with mild improvement. Ayurvedic treatment regimen comprising of Niragni Swedan , Nasya and Vishwadi Kashayam provided statistically significant results on clinical signs and symptoms and Serum TSH of the patient suffering from the Hypothyroidism. On comparing Ayurvedic treatment regimen ( Niragni Swedan , Nasya and Vishwadi Kashayam ) to that of Standard control (Thyroxin sodium), By observing and analyzing the data statistically, it was found that the group A was more effective in Subjective parameters and both groups are equally effective in Thyroid profile.