Impact of Consistent and Standardized Administration of Peyadi Samsarjana Krama in Post-Vamana-Virechana (Dietary Regimens Post Emesis and Purgation Therapies) Protocols: A Quasi-Randomized Control Trial

The term “Panchakarma” denotes a set of five therapeutic procedures within Ayurveda, specifically aimed at internally purifying the body by expelling accumulated morbid Dosha through the most accessible route. According to Ayurveda principles, maintaining health involves achieving a balance of Dosha, Dhatu, Jatharagni and ensuring the elimination of Mala through defecation.¹

The term “Samsarjana Krama” is derived from three distinct words. “Sam” is a prefix meaning “best” or “proper,” and “Sarjana” signifies upgrading or increasing. “Krama” denotes a series, proceeding, course, order or step. According to M. Monier Willums’ dictionary, “Samyak” translates to proper or in a good way and “Krama” denotes order. Consequently, Samsarjana Krama can be understood as a series of dietary practices aimed at enhancement or an ordered approach to dietary increase. It’s noteworthy that the classical Ayurveda texts don’t explicitly mention the term “Samsarjana.” The term is introduced by Chakrapani, a commentator, in his commentary on Charaka Samhita.²

Since Acharya has not provided a specific definition for Samsarjana Krama, it can be briefly described as a set of strict and well-defined post-Shodhana dietary regimens intended for individuals to restore disturbed Agni (digestive power) to normalcy, Snehapana (oral intake of ghee) and Langhana (emaciating therapies).³ Ayurvedic texts outline various methods of Samsarjana Krama, including Peyadi Samsarjana Krama,⁴ Tarpanadi Samsarjana Krama,⁵ and Rasa Samsarjana Krama.⁶

The Jatharagni plays a crucial role in sustaining Oja and life and any disturbance in it can lead to the onset of diseases. Following Panchakarma, particularly Vamana and Virechana, the Jatharagni becomes disrupted and weakened, potentially causing a decline in the patient’s strength. It is not advisable to immediately resume a regular diet during this diminished state of Jatharagni post-Samshodhana. Instead, a specific dietary regimen known as Samsarjana Krama is implemented. This involves a gradual reintroduction of food, progressing from light (Laghu) to heavy (Guru) Ahara in accordance with Shudhi. This step-by- step approach aims to enhance Jatharagni (digestive power), provide systematic nourishment to the patient and facilitate adaptability across all systems of the body. If the patient fails to adhere to proper precautions and a regulated diet, it can result in various complications. To prevent these complications following Samshodhana Krama, the Samsarjana Krama is crucial and advantageous. Acharya Charaka emphasizes the significance of Agni in Samsarjana Krama with an analogy: Just as a small fire when kindled gradually, with substances Like dry grass and cow dung, becomes robust and stable, similarly, in the case of Jatharagni after Vamana Krama and Virechana Krama, the Peyadi Krama enables Jatharagni to efficiently digest all kinds of food.⁷

Samsarjana Krama and Krama should not be equated, as Krama refers to any procedure, while Krama denotes a specific numbering sequence that must be adhered to. Peya, a more liquid substance with lower carbohydrate content, is easily digestible. In contrast, Vilepi, a semi-solid preparation, has a thicker consistency and includes rice particles, resulting in higher carbohydrate content. Mudga yusha, a green gram soup, is prepared in the Akrita form without the addition of salt and Ghrita, while in the Krita form, salt and Ghrita are included, providing simple plant proteins.

Mamsarasa, a mutton soup, is prepared in the Akrita form for simpler proteins, while the Krita Mamsarasa contains complex proteins such as animal proteins and fats. Rasa Samsarjana Krama is typically employed following Peyadi Samsarjana Krama. Tarpanadi Krama is used for the Tarpana of the patient, aiming to nourish the Dhatu of the Samshodhita Purusha (an individual who has undergone Vamana and Virechana).^4,5

The administration of Peyadi Samsarjana Krama involves a meticulous balance of herbal ingredients, each selected for its specific therapeutic properties. These components synergistically aim to optimize digestive functions, enhance metabolic processes and promote overall rejuvenation following the cleansing procedures of Vamana (therapeutic emesis) and Virechana (therapeutic purgation). To advance our understanding of the therapeutic efficacy of Peyadi Samsarjana Krama in post Vamana–Virechana protocols, a Quasi-Randomized Control Trial has been designed. This study seeks to investigate the impact of a standardized and regular serving size of Peyadi Samsarjana Krama on key health parameters, including digestive function, metabolic balance and overall well-being. The trial aims to provide valuable insights into the potential benefits of consistent dosing, offering a foundation for refining Ayurvedic post-detoxification practices and enhancing the holistic care of individuals undergoing these traditional therapies. Through a rigorous and scientific approach, this research endeavours to contribute to the evidence-based integration of Ayurvedic principles into contemporary healthcare practices.

The research took place at KLE Ayurveda Hospital and Medical Research Centre in Shahapur, Belagavi district of Karnataka, utilizing a Quasi Randomized Control Trial design. A sample of 240 individuals, aged 18 to 50, who were apparently healthy or ill and undergoing Vamana/Virechana with Madhyama Shudhi, was randomly chosen. Subsequently, the 240 subjects were split into two groups based on interventions. Both the Control Group (Group 1), receiving a regular serving size of Peyadi samsarjana krama and the Study Group (Group 2), receiving a standardized serving size of Peyadi samsarjana krama, Consisting of 120 subjects each. The randomization process was carried out using a computer-generated randomization method (Table 1).

Standardized Samsarjana Krama diet was derived after a rigorous and meticulous assessment carried out on 81 subjects by following steps;

The subjects were served the Samsarjana Krama diet as per regular serving size which is followed or practiced at KLE Ayurveda Hospital Belagavi as below;

Here 400 mL of peya is served to the subject or the patient who underwent Samshodhana Krama as per his proper hunger. The time of consumption of peya is noted and later observed for the next hunger time. During this hunger subject or patient should exhibit the Jeernahara Lakshana (digestion) and this was recorded in hours and minutes.

Twelve-hour dose or serving size was calculated on the lines of Sneha Pana dose fixation which is as follows;

This 1600 mL was served to him/her for consumption as per hunger in divided doses either 2 or more servings and this 1600 mL of Peya is the fixed maximum dose for that particular subject/ patient. He/she should not exceed this quantity which is fixed for him during that period.

The same calculation pattern was followed to all remaining Samsarjana Krama diets like Vilepi, Akrita Yusha, Krita Yusha, Akrita Soya Yusha, krita Soya Yusha.

For standardization of dose in Pravara, Madhyama and Avara Deha Pramana subjects as per agni was calculated as follows.

81 subjects enrolled in the study, in different Deha Pramana groups. Standardized quantity of peya to be supplied to particular dehapramana was calculated by following method. Summation of quantity calculated for all the members of particular dehapramana and particular agni divided by number of subjects in that particular Deha Pramana with agni.

Ex. Suppose 6 Pravara Dehapramana subjects with samagni had consumed the following quantities of peya as 1200 mL, 1250 mL, 1300 mL, 1400 mL, 1500 mL and 1600 mL. The standardized dose of Samsarjana Krama is calculated by summation of the quantity of peya consumed will be 8250 mL which divided by 6 (subjects/ patients) and the answer will be 1375 mL.

In the same manner standardized dose of remaining Samsarjana diets like vilepi, akruta and kruta yusha, akruta and kruta soya yusha for different deha pramana were calculated. These standardized doses were given to post vamana/virechana in group 2 i.e. study group.

Following classical Vamana and Virechana Krama, participants in control or group 1 received the customary portion of Samsarjana Krama, a practice conducted at KLE Ayurveda Hospital Shahapur Belagavi for duration of 5 days with 8 anna kala. The preparation method adhered to classical procedures. Meanwhile, participants in the study or group 2 received a standardized serving size of Samsarjana Krama based on the specified inclusion criteria. In both groups, subjective assessment parameters including headache, food cravings, giddiness and lethargy, as well as objective parameters such as fasting blood sugar, postprandial blood sugar and random blood sugar, were evaluated on the first day of the Samsarjana Krama regimen.

Age group of 18 to 50 years of both sexes.
Subjects undergoing classical Vamana/Virechana (Madhyama Shuddhi).

Sadyo Vamana/Sadyo Virechana.
Subjects with Vaman/Virechana Vyapat (complications).
Subjects with Diabetes mellitus.
Known cases of food incompatibilities.

It is an Interventional Randomized Controlled trail where Control group of subjects will be served the regular size of Samsarjana Krama for 5 days with 8 anna kala (food servings). Which inturn consists of Peya-2, Vilepi-2, Akruta mudga yusha-1, Kruta mudga yusha-1, Soya yusha-1, Soya yusha-1 serving. Quantity at Servings are Peya 400 mL, Vilepi 250 g, Mudga yusha 200 mL, Soya yusha-200 mL. Trial group subjects will be served as the standardized serving size.

Subjects will be categorised on the bases of Deha Pramana (body frame) into Pravara, Madhyama and Avara. Inturn these categories will be sub divided on the basis of Agni i.e Samagni, Teekshnagi, Mandagni. In total subjects will be categorised into 9 factors as shown in Tables 1 and 2.

Deha pramana or Body Frame assessment was assessed by height, weight and BMI of the subjects and the Methodology used for standardization of samsarjana krama is followed as per the method used by sandeepsagare, et al.⁸

All the preparations used in Samsarjana Krama were prepared as per the preparation methods explained in the classics and served to the subjects.

Stratified sampling with optimum allocation of the different structure of the body Study

This is the sample size reducing 20% attrition and 95% confidence level

Between the groups assessment of non-parametric variables like headache etc. will be through the chi-square test and within group assessment will be through Mac-nimar test. Parametric variables like blood glucose estimation will be assessed through repeated measure ANOVA. All tests will be considered statistically significant at p<0.05.

Assessment parameters are the different untoward effects frequently encountered during conventional Samsarjana Krama practice were;

Subjective Parameters:

Head ache
Hunger
Giddiness
Lethargy
Objective Parameters
FBS, PPBS and RBS on Day of Vamana and Virechana.

Table 3 illustrates the distribution of subjects in two groups: Regular Serving Size and Standardized Serving Size, based on Ahara–Vihara of Samsarjana Krama

Table 4 presents a visual representation of the occurrence of headaches in the morning and evening for individuals consuming regular and standard serving sizes of Samsarjana Krama on different days.

Table 5 depicts the occurrence of morning hunger in individuals following both regular and standard serving sizes of Samsarjana Krama across different days.

Table 6 depicts the morning giddiness experienced by individuals following both regular and standard serving sizes of Samsarjana Krama on different days.

Table 7 demonstrates the occurrence of morning lethargy among individuals following the regular and standard serving sizes of Samsarjana Krama across different days.

Table 8 illustrates the outcomes of a Generalized Linear Model, specifically examining the impact of Standardized Serving size compared to Regular Serving on blood glucose levels.

As per Acharya Chakrapani, not only Vamana and Virechana, but also other Panchakarma techniques like Basti, Nasya and Raktamokshana are recommended for Shodhana purposes. However, in a busy lifestyle, it becomes challenging to consecutively undergo all these therapies. If an individual undergoes Shodhana procedures once a year, it can lead to overall health benefits throughout the entire year.

According to our investigation, both groups exhibited subjective symptoms such as headache, hunger, giddiness and lethargy. In the first group, 58% experienced headaches on the morning of the first day, while in the second group, 93-96% reported an absence of headaches at both time points. Severe cravings were observed in more than 45.4% of the first group in the morning on days 1 and 5 and over 47.1% in the evening, whereas over 90% of the second group had no complaints. Mild giddiness was reported by 44.5% in the first group during the morning and 43.7% experienced it in the evening. In the second group, no participants reported giddiness in either the morning or evening on all days. On the morning of days 1 and 4 in the first group, 44.5% were free from lethargy, while in the second group, over 91.7% were not lethargic on all 5 days. In the evening of day 5, 47.9% in the first group experienced lethargy, whereas in the second group, 73.6% to 96.7% were free from lethargy on all 5 days. The results were statistically significant. Fasting Blood Sugar (FBS) and Random Blood Sugar (RBS) levels were higher in the Standardized Serving Size group (B=1.44) compared to the Regular Serving Size and this difference was significantly higher (B=4.37, p<0.05) in the Standardized Serving Size group.

According to research conducted by Yemalwad et al., (2023),⁹ a critical aspect of Ayurveda treatments lies in Panchakarma, a therapeutic approach aimed at preventing and treating diseases while preserving overall health. This therapy, deemed valuable for its effectiveness, encompasses five procedures serving various purposes. Among these, Virechana and Vamana Karma stand out as significant therapeutic measures within the Panchakarma system. Specifically designed for addressing imbalances in Kapha and Pitta doshas, these therapies utilize drugs with Tikshna, Sukshma and Ushna properties, effectively balancing and eliminating morbid Pitta, Kapha and Vata doshas. Moreover, they aid in the removal of toxins from the body. Virechana and Vamana Karma are instrumental in managing a range of diseases classified under the umbrella of Shodhana Chikitsa.

Dr. Rajendra Garg et al.¹⁰ The Jatharagni is the source of life and Oja and when it is vitiated, ailments arise. Jatharagni becomes diminished after Vamana and Virechana, in such a state of reduced Jatharagni, regular food is difficult to digest, hence it is not advised to resume it right after Samshodhana. In this scenario, a unique food plan known as Samsarjana Krama-which translates to a suitable sequence of Peya-Vilepi-Krita-akrita Yusha–Krita-akrita Mamsarasa are followed after the administration of Vamana Karma or Virechana Karma.

After Samyak Shudhi (proper purification), Samsarjana Krama can commence on the same day. Depending upon Pradhana, Madhyama and Avar Shuddhi (purification). Annakala are mentioned i.e., in Pradhana Shuddhi 3 Annakala for 7 days, in Madhyama Shuddhi 2 Annakala for 5 days and in Heena Shuddhi 1 Annakala for 3 days of Peya, Vilepi, Akrutakruta Yusha, Akrukruta Mamsa Rasa are been given.¹¹

Every Samshodhita Purusha must practice Samsarjana Krama, as it will helps to assist in conquering the Dosha-Dhatukshaya and restoring the strength of Jatharagni, which has been weakened by the purifying process. By setting up such plans, the diet consisting of all the tastes can be served through meals and Dosha becomes normal. It also normalizes the Jatharagni and Vayu, provides nutrition and helps to normalize the body tissues, which are weakened due to Samshodhana.¹²

Samsarjana Krama is a sequential dietary regimen administered following Vamana and Virechana Karma (therapeutic emesis and purgation), aimed at enhancing Jatharagni, i.e., the digestive power of the body. It is essential for individuals undergoing Samshodhana (purificatory) procedures and plays a crucial role in regulating weakened Jatharagni caused by the purification process. The advantages of Samsarjana Krama include normalizing Jatharagni and Vayu, offering nourishment and restoring weakened body tissues resulting from Samshodhana. The standardized serving size of Samsarjana Krama is one of the unique methods of serving the diet, which maintains the Fasting Blood Sugar (FBS) and Random Blood Sugar (RBS) levels higher than the regular serving group. This method reduces subjective symptoms like headache, cravings for food, giddiness and lethargy, so this standardized dose of Samsarjana Krama based on body frame and Agni can be adopted in post-Vamana/ Virechana procedures.

The present study unveiled a better trend for standardized servings over regular practice, this trend can be still streamlined through in-depth work analysis of individual preparations and newer biochemical analysis.

We would like to thank, Dr. J. B. Prasad, Department of Biostatistics, KAHER’s J. N. Medical College, Belagavi. Dr. Pradeep Grampurohit, Dr Rudramma Hiremath and Dr. Ajit Lingayat, KAHER’s Shri. B. M. Kankanawadi Ayurved Mahavidyalaya, Shahapur, Belagavi.