Introduction

Ano-rectal disorders refer to the illness of the anal canal and rectum. Fissure in ano, fistula in ano and haemorrhoids are among the most common ano-rectal conditions. In these cases, symptoms like pain, itching, burning, bleeding and swelling can significantly affect a patient's lifestyle.

Ano-rectal symptoms and complaints are common and may be caused by a wide spectrum of conditions. The history, as well as the physical examination, can distinguish anal pain due to haemorrhoids, fissure or abscess.

The anal canal is the most terminal part of the lower gastrointestinal tract, which lies between the anal verge in the perineum below and the rectum is the lower 10 to 15 cm of the large intestine four to eight anal glands drain into the crypts of Morgagni at the level of the dentate line. The dentate line also delineates where sensory nerve fibres end. Above (proximal to) the dentate line, the rectum is supplied by stretch nerve fibres but not pain nerve fibres. Conversely, below the dentate line, there is extreme sensitivity, and the perianal area is one of the more sensitive areas of the body. The evacuation of bowel contents depends on action by the muscles of both the involuntary internal sphincter and the voluntary external sphincter

Although the most common ano-rectal disorders are not considered life-threatening, they can negatively impact a patient's activities of daily living and quality of life.

Ano-rectal diseases require long term conservative treatment and also surgical intervention (Foxx-Orenstein, Umar, & Crowell, 2014). Due to this patients are suffering from long term problems. For this purpose, certain measures are required to solve the problems of patients.

In Today’s Era, for pain management in post-operative cases of ano-rectal diseases, yoga plays an important role in pain management. Yoga is a way of living that aims towards a healthy mind in a healthy body. Ashwini mudra is a tantric practice used to generate and move prana (life force energy) upward along the spine, via the main energy channel of the subtle body known as sushumna nadi.

The practice involves contracting the anal sphincter in a rhythmic way, thereby generating and containing intense energy within the lower body before pumping it upwards (Ashwini Mudra, 2020). Yoga is a way of living that aims towards a healthy mind in a healthy body (The Essence of Yoga, 2020).

Sushruta and Vagbhata have described that the total length of Guda is 4½ Angula only. Vagbhata had also told measurement of Guda as Atmapanitala (palm of hand) (Choudhary, 2018). Therefore present study will be conducted to evaluate the effect of Ashwini mudra in post operated cases of common ano-rectal diseases.

Methodology

Trial design

Observational study

Study setting

Diagnosed Patients will be selected from Shalyatantra OPD & IPD of M.G.A.C.H. and R.C. Wardha. Figure 1 as shows,

Inclusion Criteria

1. Post-operative cases of ano-rectal diseases of haemorrhoids, Fissure in ano and Fistula in ano.

2. Age group from 18 to 70 yrs of either sex.

3. Irrespective of economic status, religion and caste.

Exclusion Criterion

1. Other than post-operative Ano-rectal cases except for Haemorrhoids, Fissure in ano, Fistula in ano.

Criteria for discontinuing or modifying allocated interventions

Patients will be withdrawal from intervention if any harmful incidence, any problem will occur; a patient will be offered treatment free of cost till the disease subsided.

Follow up period after treatment.

20^th day after treatment.

Primary Outcomes

To study the effect of Ashwini Mudra on pain in post-operative ano-rectal cases.

Secondary Outcomes

To study the effect of Ashwini Mudra on bleeding in post-operative ano-rectal cases.

Statistical analysis

Statistical analysis will be done on the basis of observations.

Time duration till follow up

All the subjects will call for follow on the 2^nd, 4^th, 6^th & 10^th Day. Assessment in follow up will be on the basis of pain and bleeding.

Time schedule of enrolment, interventions

Post-operative cases of common Ano-rectal diseases. Ano-rectal diseases includes-

• Haemorrhoids

• Fissure in ano

• Fistula in ano

Interventions

• Explanation to a patient about Ashwini Mudra

• Assessment of the effect of Ashwini Mudra in post-operative cases with a hot sitz bath.

• Statistical analysis from data collection.

Groups - 2

Groups each with a minimum15 of patients fulfilling the inclusion criteria will be selected for this study. Table 1 as shows,

Group A

Patients will be advised to do Ashwini mudra with a hot Sitz bath daily for 10 minutes twice a day.

Group B

Patients will be advised to do a hot sitz bath for 10 minutes twice a day.

Post-operative medicinal treatment will be the same in both groups.

Recruitment

A patient will be recruited by a single-arm study

Implementation

Principal invigilator will register the subject.

Data collection methods

Randomized

Assessment criteria

Pain

Pain will be assessed according to the standard modality of assessment of pain through a visual analog scale.

Description of VAS: Figure 2 can be categorized and graded as below-

(a) Very happy no pain = 0 grade

(b) Hurts a just little bit =2 grade

(c) Hurts a little more=4 grade

(d) Hurts even more=6 grade

(e) Hurts a whole lot=8 grade

(f) Hurts as much as you can imagine (don’t have to be crying to feel this much pain) =10grade

Bleeding

Bleeding will be assessed on the basis of the presence or absence of per rectal bleeding before or after defecation. Figure 3 and Table 2 as shows,

Data management

The principal investigator will do the coding of data.

Ethics and dissemination

Permission for research has been taken from Institutional Ethical Committee.

Consent or assent

Written informed consent will be obtained from the patient.

Dissemination policy

For future research, results will be disseminated, and research will be published in a reputed journal.

Informed consent materials

All the research related document and consent form will be given to the patients.

Expected Results and Discussion

In yoga, many modalities have been given, but according to reference, it is found that Ashwini Mudra is one of among yoga which is helpful in pain management. (Joshi, Veettil, & Deshpande, 2020) The practice of Ashwini Mudra provides strength to the puboanalis and puborectalis muscles of the pelvic floor (Geoffrion et al., 2009). Therefore the present study is conducted to evaluate the effect of Ashwini mudra in post operated cases of common ano-rectal diseases. As in most of the postoperative cases, non-steroid anti-inflammatory drugs (NSAID) are prescribed, and it causes peptic ulcer and other complications in patients; therefore, to avoid such complications we need treatment which can be easily practiced and is non-invasive. Discussions will be carried out on the basis of the effect of this yogic exercise with the help of different parameters.

Conclusion

After completion of this intervention, it can be expected that Ashwini mudra with a hot sitz bath is more helpful comparing to the hot sitz bath in treating post-operative cases of ano rectal disease. Thus, by virtue of this research work, conclusions will be drawn whether this improved modality is a better modality for the post-operative pain management of ano rectal disease.

Ethical clearance

Taken from Institutional Ethical committee.

Conflict of Interest

The authors declare that they have no conflict of interest for this study.

Funding Support

The authors declare that they have no funding support for this study.