INTRODUCTION:

Martial arts are codified systems of combat practices learnt for a variety

of reasons like self defense, competition, physical health and fitness. It helps in

of several Tamil martial art techniques – Varma Kalai, being a distinctive and
selective art form that takes a great amount of time, skill and patience to master.
The Tamil name ‘Varma Kalai’ means ‘The Art of Vital Points’.

HISTORY

According to the Hindu mythology, Lord Shiva taught this martial art to
his son, Lord Murugan. Further, Lord Murugan taught this art to sage
Agasthiya, who was the foremost of Siddhars during the time of Sangam
Literature. Agasthiya spread knowledge of this art form to the rest of the
Siddhars and it is evident from the presence of Agasthiyar’s shrines depicting
this art form in Kutralam (Panchayat town in Tirunelveli district, Tamilnadu)

The Tamil name ‘Varma Kalai’ means ‘The Art of Vital Points’. When triggered, these points
can disable, paralyze or even kill a person.

According to the Hindu mythology, Lord Shiva taught this martial art to
his son, Lord Murugan. Further, Lord Murugan taught this art to sage
Agasthiya, who was the foremost of Siddhars during the time of Sangam
Literature. Agasthiya spread knowledge of this art form to the rest of the
Siddhars and it is evident from the presence of Agasthiyar’s shrines depicting
this art form in Kutralam (Panchayat town in Tirunelveli district, Tamilnadu)

Kings of all four major Tamil dynasties – Chera, Chola, Pandya and Pallava –
patronized this art form to selected schools and they paid nivandhanams
(donations with high respect) for it. Varma Kalai is taught by teachers called
Aasan (Tamil – master) and grandmasters called Periyaasan.

AESTHETICS

Varma Kalai teachers are highly selective over their choice of students.
Besides the knowledge of this martial art form, they are required to have an
understanding of  Biology, Chemistry, Mathematics, Yoga, military tactics,
horsmanship, elephant riding, charioteering and Hindu philosophy (Saiva,
Vaisnava, Saktha, Koumara, Boutha, Samana) etc.

Varma Kalai martial artists are not allowed to teach the art to others until
they receive Deeksha (giving a mantra/ initiation) from the Aasan or Periyaasan.

TECHNIQUES

Varma Kalai is classified into 4 types:

Thodu Varmam – ‘Thodu’ means touch in Tamil. Around 96 vital points in the
body are triggered by touch. It is not fatal, but results in the disabling of the
victim’s body, organ movements and function.

Padu Varmam – It refers to the 12 vital points in the body, which when
triggered results in death or severe effects on the victim.

Thattu Varmam – This involves vital points that are held and used by the
master alone. It is kept confidential until the master passes on the knowledge to
the selected disciple.

Nooku Varmam / Meitheenda Kalai – As the name indicates, Tamil word

‘Nooku’ means look or contact. The Tamil word ‘Meitheenda’ means ‘without
touching’. The triggering of the vital points is done by focusing or concentrating
on the target. It takes several years of practice to become an expert in it.

In the human body there are 108 Varmams / Vital points.

 Also according to Siddha Medicines and their healing therapy on the
human body called Vaidhya murai, the vital points are explained as – 64 points
in Vadha Varmam, 24 points in Pitha Varmam, 6 points in Kaba Varmam, 6
points in Ul Varmam and 8 points in Thattu Varmam.

POPULARITY

The art was taught only to selected individuals, but due to strict
requirements for new students it never gained large numbers of adherents. Due
to its secretive nature, Varma Kalai was largely unknown even in India. The
release of a bi-lingual film, Indian, directed by Shankar, where Padmashri Dr.
Kamal Haasan etches the role of a Varma Kalai expert, enhanced the popularity
of this art form and generated a resurgence of interest in the art. Currently
Varma Kalai, is practiced in Tamilnadu and Kerala as part of other martial art
forms like Kalari (swords and sharp instruments are used) and Silambattam
(Bamboo cane is used).

SUMMARY:

varma adi recognizes 108 marmas (lethal varma points), 12 padu varnas
( death marmas) , 96 thodu varmas and about 350 therputic varma points within
our body. There are also counter marmas to heal trauma to the marmas.
varma also known as marma points which located at point of specific part of
body surface whereby application of pressureor insertion f needles will affect
the vital energy flow or prana (life) along a complex system of subtle channels
called Nadis. By using varying degrees of force to strike the body at different
vital points, can produce astounding results. when used in warfare by a skilled
combatant, these blows can causeinstant death, great pain, paralysis or infection
evendelayed death. the results vary according to the power and velocity used by
the combatant, subject to the training of the day as well.
common training in varma kalai:
1. Kai murai _ hand and finger methods
2. Seiyal murai – Application method
TRAINING IN LEVEL 1 : VARMA VARISAI (UNDERSTANDING)
Padu varmam – 12 with mudras ( varma techniques)
Adangal ( releasing of varmam/ revocery from unconscious) –actually have 56
adangal but reduced to 12
while the siddha’s have mentioned a lot about the beating, pushor touch
in the varmam to make a person incapacited. in real life a person may get
attacked accidentally in the vamam and incapacitated . Siddha’s have also
mentioned the ways to bring back such affected person to normal. this is called
marmathiravukol ( method to open varmam) ir adangal or key to bring back to
normal. a push, a touch or a beating in the relevant place, applying oils,
medicines, administering medicines brings back the affected person to normal.
this is possibleto all varmas.
Usually Guru will teach to student which consists of mel adangal (top),
naduvu adangal ( middle) and Kii adangal ( bottom)
TRAINING LEVEL 2 :PORMUGA VARMA VARISAI:
Padu varmam – 12 (deadly points) the meaning of padu is nothing but death.
Padu varmam are highly dangerous. these are located in the front part of the
body. a gentle touch or a pushin these places may result death. they are
thilarntha kaalam
natchathira kaalam
pidari kaalam
urakka kalam
sumei varmam
ner varmam
adappa kaalam
urumi kaalam
valia athisurukki
siriya athisurukki
kalladaikaalam
Por varmam – 24 (used in combat / self defence) varmam points are 36.
Amirthanila (nectar placement) this concept explains the effectiveness of attack
on varmam depends on the lunar movement. The varma points keeps moving
from toe to head and vice versa with the movementof moon. The movement
will be X shape. The vital varma pointsand the poison will travel in opposite
direction. Such effective points are known as the amirthanila.

THE VITAL SPOTS AND AYURVEDIC HISTORY AND PRINCIPLES

The earliest textual evidence of the concept of the vital spots dates from
as early as the RgVeda (@ 1200 BCE) where the god Indra is recorded as
defeating the demon Vrtra by attacking his vital spots (marman) with his vajra
(Fedorova 1990). From this and numerous other scattered references to the vital
spots in Vedic and epic sources, it is certain that India's early martial
practitioners knew and practiced attacking or defending vital spots; however,
we possess no martial texts from antiquity comparable to the Sanskrit medical
texts in which a systematic knowledge of the vital spots is recorded.

By the time that Susruta's classic Sanskrit medical text had been revised
in the 2nd century A.D., 107 vital spots of the gross, external, physical body
(sthula-sarira) had been identified and defined as an aid to surgical
intervention:

the areas where muscles, vessels, ligaments, bones, and joints meet
together which by virture of their nature are specially the seats of life (Singhal
and Guru 1973:132).

Susruta knew the importance of avoiding vital spots in surgery, identified

illnesses caused by direct and indirect injury to them, and diseases situated in
them. He asserted that direct penetration of many vital spots was fatal, and
classified these trauma as sadyah-pranahara (causing death within one day)
or kalantara-pranahara (causing death within 14 days to one month). He also
observed that death could be caused by extracting a foreign object from a
wound to a vital spot (visalyaghna), that some wounds to the vital spots might
result in maiming or deforming injuries (vaikalyakara), and other times
penetration of vital spots only resulted in painful injuries (rujakar). Of the 107
vital spots he identified, Susruta listed 51 as leating either to immediate death,
death within twenty-four hours, or one month. Limited emergency measures
included surgical removal of the foreign body and amputation. Susruta
established a close connection between combat and medical intervention.
Surgery was called salya, which referred to "foreign bodies of every
kind...but...specifically...the arrow, which was the commonest and most
dangerous foreign body causing wounds and requiring surgical treatment"
(Kutumbiah 1974:144).

Knowledge of the vital spots shares the general Ayurvedic principles that
health is a state of humoral equilibrium. Susruta identified seven kinds of
diseases, one of which was samghata-bala-pravrtta, "the traumatic
type...caused by an external blow or...due to wrestling with an antagonist of
superior strength" (Susruta, Suthrasthana XXIV, 6; Bhishagratna trans.,
1963:230). All combat injuries fall into this class. Susruta related them to the
primary humoral body by explaining that traumatic injuries enrage the wind
humor in the area of injury. The first action of the attending physician should
thus aim to calm the 'enraged wind humor (vayu).

The legacy of identification, classification, and treatment of the vital

spots established by Susruta, and in South India by Vagbhata, was a rational
system based on humoral theory and therapeutic intervention applied to
observations of wounds received in combat. It was certainly never a closed,
secret tratition since its purpose was to save lives whenever possible. This
medical tratition was eventually passed to martial specialists for whom the
combat application (prayogam) of their specialized knowledge was just as
important as medical intervention (cikits)

VARMAM TREATMENT FOR MENTAL STRESS:

In the modern world, peoples are very busy and moving with very many
thoughts and too many targets to achieve for them in near future. Hence the
multi-targeted people suffering from mental stress and emotional problems
which disturb the equilibrium of the body. Like physical ailments, in probing
and treating mental stress, one must keep in mind the chemistry of the brain
which plays a major role in such diseases. It is well known that the wrong
mental 215 thoughts may also results in physical illness. Besides the
involvement of brain personality factors also lead to mental stress problems like
depression, anxiety, over sensitiveness, fear, sadness, disappointment, too much
stress and tension, lack of energy, excessive haste, anger and emotional
outbursts.
 ‘kdkJ nrk;ik ahdhy; ke;jpuQ; nrgpf;f Ntz;lh
kdkJ nrk;ikahdhy; thAit Aah;j;j Ntz;lh
kdkJ nrk;ikahdhy; thrpia epWj;j Ntz;lh
kdkJ nrk;ikahdhy; ke;jpuQ; nrk;ik ahNk’
mf];jpah; Qhdk;.
If each and every person should have perfect mind setup, then we need
not perform chatting of Mandiras, breathing exercises or Vasi yoga. Sound
mind always results in sound body, as said by the great, Agasthiar Maamuni
(Saint). Weak mind and negative thoughts are the fundamental reasons
responsible for all the physical and mental ailments of the body. Also we should
avoid alcohol and drugs which may trigger mental problems.
MENTAL DEPRESSION:
Depression is a medical condition that leads to intense of sadness or
despair. There are two major types of depression. The first type is called
‘Reactive Depression” which is caused due to excessive conditional stress like
sudden and shocking death of a loved one, unbearable financial loss or some
other distributing event. The second type of depression is termed as
‘Endogenous” which emerge from within you, without any apparent external
cause, usually resulted due to chemical change in the brain. It is a serious
mental stress and needs medical counseling. Depression can occur at any stage
and when it overpowered the body, many symptoms become apparent. Besides
melancholy, certain physical problems like loss of energy, decrease in appetite,
insomnia, constipation, headache, vague body pains, diminished interest in sex,
intensive misery, negativity and self doubt, giddiness palpitations, dryness of
the mouth and blurred version take place. Severe depression leads to feeling of
total hopelessness, suicidal thoughts, loss of weight, withdrawal into self and
non-responsiveness. The person suffering from depression has to be educated
about the realities of life and the need for inculating positive 216 outlook.
Varma therapy is useful in removing negative thoughts and building positive
outlook, which is very essential to cure depression.
ANXIETY:
Anxiety is the integral part of our life. When it exceeds it becomes
disorders of emotions and results mental stress. If the anxiety is caused by a
specific stress or any other problem, first remove that cause. Varma therapy,
techniques of relaxation, meditation and yoga can relieve anxiety. Anxiety and
panic attacks sometimes develop in relation to phobia which can be removed
from mind through positive thoughts and counselling.
CAUSES OF MENTAL STRESS
Stress occurs all the time in most people’s lives. Too much stress
seriously affect physical and mental well beings. When we encounter a stressful
event, our bodies undergo a series of hormonal and biochemical changes that
put us in alarm mode. Our heart rate increases, adrenatin rushes through our
blood stream and our digestive and immune systems temporally shut down, if
the stress we experience exhaustion and burn out.
Common Signs of too much stress include
Increased irritability
Loss of concentration
Rapid heart beat
Heightened Sensitivity to criticism
Indigestion
Headache
sleeplessness
Early morning waking
Drinking and smoking more
Stiff neck or tight shoulders.
Difficulty in making decision.

HEALTH PROBLEMS LINKED TO STRESS are

Heart attack
Hypertension
Stroke
Cancer
Diabetes
Obesity
Eating disorders
Ulcers
Irritable bowel syndrome
Memory loss
Infertility
Auto immune disease
Insomnia
The causes of stress are highly individual. It depends on your personality,
general outlook on life, problem solving abilities, and social support system.
Exercises, humour, play, music, prayer, meditation and relaxation will reduce
your stress in your life and will balance your mind to maintain well being status.
LOCATION OF MIND
Mind can activate the functions of brain and body pituitary glands and
other endocrine systems. It can enlarge the ‘Puththi’ (vision over the world)
which inturn enlarge the ‘Siddhi’ (rational desire) which can enlarge the
Angaram (rational knowledge-wisdom). There is a three school of thoughts
among siddhars regarding the location of mind 1) Located in brain 2) located in
Nabi 3) Located in spiritual heart at chest. Though after brain death, the body is
functioning. This feature suggest that the mind is not situated in the brain and it
may be located in the spiritual heart of the spiritual body. Research should be
attempted regarding the location of the mind of the human body. But no doubt,
the mind is in the body.

VARMA TREATMENT FOR MENTAL STRESS:

Counseling on mind and positive thoughts, when accompanied with
Varma points manipulation techniques play vital role in bringing down the
mental stress through change of life pattern towards peaceful sound health and
mind. 7 persons (three women at the age of 24, 42 and 19 and men at the age of
52, 37 and 28) are treated for their mental stress problems. The 218 following
Varma points were manipulated to relieve mental stress related to emotions and
mental imbalance.
Kondaikolli - To correct the chemistry of cerebrospinal fluids of the
brain and mind in the spiritual heart.
Patchi nema varmam- To enhance the spiritual condition of the mind and
body and to activate functions of the body and mind.
Patchi Varmam - To reduce the mental stress and cool down the anxiety
and enhance the positive thoughts through divine power-Varma energy (ie-
Vasi) into the body.
Thilartha Kaalam - To activate mind, decision making, intellect, and
rational thoughts, (Manam, Puththi, Siddhi and Angaram)
Vettrilai Kaalam - Located three finger right side of Patchi Nema
Varmam. To regulate the divine power into the mind and body (Vasi) to
accomplish or carried out all functions smoothly, because of the relief in mental
stress and mental calmness will be attained.
Aakirana Kuruthu - Located on the tip of nose. To normalize Vatham,
Pitham and Kuttri Kaalam Khapam. To coordinate the parts of body according
to the thoughts of mind. To maintain well being status.
Adappa Kaalam - To attain the spiritual power and relieve bad evil
thoughts from the mind through the activation of mind, lungs and liver.
Soozhiaadi Varmam - To enhance the spiritual energy in the body and
mind and connect the energy system between head and the trunk of the body.
Saramudichu - To regulate Saram (important energy circulation in the
body) so as to reach good conditions of mind and body.
Kilimega Varmam - To treat mental hysteria, calm down mind by
inducing perfect respiration and relieve mental stress.
Kaiperuviral - To regulate ‘Vasi’, an energy system running through out
the body Nagakkan Varmam is the Varma energy, without this, proper function
of human body is not possible.
Nattel and Ner Enai - Simulataneous lifting of these Varma points bring
out good Varmangal functioning of the Dhasavayus in the body and perfect
functioning of idakalai, pingalai and suzhumunai nadis. This varma
manipulation is performed to relieve mental stress and body stress 219 so as to
reach the proper function of mind and body. Your positive thoughts and
memory power will be increased.
The above varmam therapy is capable of enhance the body functions,
relax the mind, activate the correct circulation of cerebral spinal fluids, energy
(Varma energy) and blood in the brain and body. The varma therapy bring out
proper function of endocrine and exocrine system of the body and regulate
‘vasi’ (varma energy), Saram (energy emerging after passing all six chakaras
and enter into the brain) and Pranan (energy bearing or energized blood with
oxygen flowing through out the body in each cells and tissues of the body).
Three day treatment was given once in two days. First day treatments was given
along with the above Varmam points, through the special method of Kaipagam
and Seipagam, Sarakkayan (problems in the flow of saram) Vasikkayam
(hurdles in Vasi energy circulations) and Pranakkayam through Dhasanadi
thattal (To solve problems pertaining to Prana energy circulation) were also
performed to relieve the problems / set right their circulation in the body. This
helps to reach well being status in mind and body. Varmam therapy works well
in alleviating the mental stress among the people.

EFFECTIVENESS OF VARMAM THERAPY FOR THE

MANAGEMENT OF OSTEOARTHRITIS

 Osteoarthritis (OA) is a type of joint disease that results from breakdown

of joint cartilage and underlying bone. Osteoarthritis is the most common form
of arthritis with disease of the knee and hip affecting about 3.8% of people as of
2010.Among those over 60 years old, about 10% of males and 18% of females
are affected.  It is the cause of about 2% of years lived with disability. In
Australia, about 1.9 million people are affected, and in the United States, 30 to
52.5 million people are affected. 

It becomes more common in both sexes as people become older.

Osteoarthritis in the knee begins with the gradual deterioration of cartilage.
Without the protective cartilage, the bones begin to rub together, causing pain,
loss of mobility, and deformity.6 It affects approximately 16 million people. The
majority of arthritis cases involving the knee are osteoarthritic cases.
 It is not always certain why arthritis of the knee develops. Most
physicians believe that it is a combination of factors that can include muscle
weakness, obesity, heredity, joint injury or stress, constant exposure to the cold,
and aging. Cartilage in the knee begins to break down and leaves the bones of
the knee rubbing against each other as you walk. Persons who work in a place
that applies repetitive stress on the knees are at a high risk of developing this
condition.
Bone deformities increase the risk for osteoarthritis of the knee since the
joints are already malformed and may contain defective cartilage. Having gout,
rheumatoid arthritis, Paget's disease of bone or septic arthritis can increase your
risk of developing osteoarthritis. Osteoarthritis symptoms often develop slowly
and worsen over time. Signs and symptoms of osteoarthritis include: Pain,
Tenderness, Stiffness, Loss of flexibility, Grating sensation, Bone spurs. 
In Siddha the symptoms of Osteoarthritis is similar to Azhal keel vaayu.
The complete remedy of these diseases is still not available in modern medicine.
The drugs used mainly are analgesic, anti-inflammatory and steroids, which
can’t spell out the disease but are only symptomatic, on the other hand furious
side effect like Gastritis, Ulceration of mucosal layer of stomach, heart burn and
Vomiting are added as the unwanted results.
Varmam also called as marmam, indicates the therapeutic stimulation of
specific points in which pranic energy is found concentrated. Varmam therapy
which is drugless, non invasive, cost effective, simple therapy is very effective
for the management of osteoarthritis. Varmam is a specialized field of Siddha
pertained to cure neurological weakness, neuromuscular problems, migraine
headaches, convulsions, arthritis, spinal problems, muscle wasting and to wail
intense pain. The therapy time is less and when properly complied to, gives long
lasting results.
Hence an attempt has been done to prove the efficacy of Varmam therapy
for the management of osteoarthritis.

MATERIALS AND METHODS:

 
Patients with Clinically diagnosed primary osteoarthritis of knee joint
who are willing to undergo the varma treatment were selected and asked to visit
OPD of Ayush wellness clinic for 48 days of Varmam therapy point
stimulation. Totally 30 Patients with different age group, gender, and socio-
economic status were randomly selected, on the basis of following criteria.
 Inclusion Criteria:

1. Patients of both sex between the age group 30 to 60yrs.

2. Patients with the signs and symptoms of Primary osteoarthritis of knee
joint.

Exclusion Criteria:

1. Patients below age 30yrs and above 60yrs of either sex.

2. Secondary Osteoarthritis of knee joint.
3. Rheumatoid arthritis & Gouty arthritis.
4. Pregnant women.
5. Patients having other Systemic disorder.
6. Patients having severe osteoarthritic changes.

Methods: Stimulation of varma points for 48 days.

Varma Points:

1. Chippi Varmam: Situated 6 finger breaths below Saramudichu, 3 finger

breaths lateral on either side.
2. Uppukuttri Varmam: Situated 3 finger breaths above posterior aspect of
the heel.
3. Kuthikaal Varmam: Situated 7 finger breaths above posterior aspect of
the heel.
4. Viruthi kaalam: Situated between big toe and adjacent in its dorsal
aspect.
5. Komberi kaalam: Situated 8 finger breaths above medial malleolus.
6. Naai thalai Varmam: Situated 3 finger breaths below knee joint.
7. Kaal moottu Varmam: Situated in centre of the popliteal fossa.
8. Veeradangal: Situated 4 finger breaths above kaal moottu Varmam.
Each varma point will be stimulated with pressure mentioned in text and may
vary according to patients pirakuruthi (body constitution). 
Assessment Criteria: The symptoms of Osteoarthritis of knee joint and joint
activity were taken for the assessment results of Varmam therapy. Following
parameters were taken in account.
Grading of assessment criteria: A. Severity of pain (VAS scale): Severity of
pain can be assessed by the following Visual Analogue Scale. 

FIG. 1: SEVERITY OF PAIN

Tenderness:
TABLE 1: ASSESSMENT CRITERIA FOR TENDERNESS 
S.no Grading of Tenderness Score
1 No pain on pressure 0
2 Tenderness with no physical response 1
3 Tenderness with grimace, wince, and/or flinch 2
4 Tenderness with withdrawal (positive jump sign) 3
Non-noxious stimuli (e.g., superficial palpation, gentle percussion)
5 4
results in patient withdrawal or patient refusal to be palpated due to pain
 
Swelling:
TABLE 2: ASSESSMENT CRITERIA FOR SWELLING 
S.no Grading of Tenderness Score
1 No Swelling 0
Swelling may not be apparent on casual inspection,
2 1
but recognizable to an experienced examiner
3 Swelling obvious even on casual observation 2
4 Markedly abnormal swelling 3
5 Swelling to a maximally abnormal degree 4

Range of Motion (R.O.M.) (By Goniometer): Assessed on following grading

system.

TABLE 3: ASSESSMENT CRITERIA FOR RANGE OF MOTION

S.no Grading of Tenderness Score
 1 0-130 degree 0
2 129-90 degree 1
3 89-60 degree 2
4 59-30 degree 3
5 30-0 degree 4

RESULTS:
TABLE 4: OVERALL EFFECT ON THE ASSESSMENT CRITERIA
After Varma
Before Varma
Assessment therapy
therapy P-
S T- value
value
Criteria’s (n=28) Mean ± S
(n=30) Mean ±S D
D
Severity of pain (VAS
1 3.63 ±1.42 1.8±0.66 6.36 P=1
scale )
2 Tenderness 2.46±0.86 1.16±0.59 6.75 P=1
3 Swelling 2.73±0.69 1.25±0.75 6.43 P=1
4 Range of motion 2.68±0.86 1.28±0.58 7.31 P=1
The results were significant (p=1) with respect to the assessment criteria

DISCUSSION: 
Maximum patients 43.33 % were found in age groups of 51 to 60 years
followed by 40 % patients from 41 to 50 years of age group and 16.66%
patients from 31 to 40 yrs. This study shows that this disease is more prevalent
in age group 51 to 60 years. Vatham is predominant in this age group; This
supports the literature about risk factor of OA. (Harrison’s internal medicine
17th edition 2008)

In the study females were found affected more than male. 60% were
females and 40% were males. The disease osteoarthritis is itself more common
in women. Osteoarthritis seems to run in families, and there appears in
particular to be a genetic link among women. After menopause, when women’s
estrogen levels go down, they lose that protection and may have a higher risk of
developing osteoarthritis even if they are on hormone-replacement
therapy (HRT). Statistics show that more women than men are obese or
severely obese, and obesity plays a major role in osteoarthritis.13 This has been
reflected in the study also. 95% of cases were non-vegetarian. The general
population status is reflected in the study population and no specific inference
could be made with respect to the study.

After 48 days of treatment of Varma therapy the results showed clinical

improvement which is evident from the assessment parameters (P =1). The
results regarding pain, stiffness, swelling and range of movements were really
encouraging. Varmam therapy relieves pain effectively may look like a magic.
But in true it was built on a basic human anatomy and scientific manipulation
techniques written mostly by Siddhars.

In Siddha theory diseases are caused by the derangements of three

humors. The derangement of Vatham is responsible for pain. Varmam is one
among the Siddha therapies by which the pain is managed by stimulating Varma
points. The Varma energy pathway can be correlated scientifically with the
physiological analgesic pathway (Brain opiate system) and the reviews by
which the release of neuromodulators such as Endorphins, Enkephalins and
dynorphins are recorded under massage or touch therapy.

Osteoarthritis is the cause of about 2% of years lived with disability,

since only anti-inflammatory, analgesics cannot control the disease, certain non
pharmacological therapies such as Varmam plays a crucial role for the
management of Osteoarthritis. In some cases drugs mentioned for Azhal Keel
Vaayu such as Amukkara Chooranam, Arumuga Chendooram, Sangu Parpam
and external applications such as Pinda thylam, Vatha kesari thylam can also be
administered along with Varmam therapy.
 Varma treatment regime has been very effective for the management of
Osteoarthritis. Treatment with Varmam application alone can be tried in near
future to substantiate the effect of Varmam on pain management of
osteoarthritis.
s
ROLE OF VARMAM THERAPY IN KUMBAVATHAM
MANAGEMENT

Siddha system is originated in southern part of India, which is one of the

ancient traditional systems of medicine. This system has its own unique
methodology of treatment for various ailments. Varmam is one among such
therapies used to treat multiple ailments, especially related to musculoskeletal
and neurological deficits. This helps the suffering community either acting by
locally or regulating the three humors, i.e., Vali, Azhal, and Iyam. Varmam
therapy can also be used along with internal medications and external
applications as well. Varmam is the points wherever the energy (pranan) is
stored, and when particular area or organ is affected, the energy will spread to
that area and make that organ function effectively. This treatment methodology
is taught by the guru-disciple method (Gurukulam). The guru who teaches
varmam is called as “Varmani or Asan.” According to Siddha principles, the
movements of the body are mainly controlled by Vali. Hence, the varmam
points were also classified as Vali, Azhal, and Iyam varmam points.
Kumbavatham (periarthritis or adhesive capsulitis) is a common cause of
shoulder pain and disability. In Siddha text Yugi Vaithya Chinthamani, it was
mentioned as pain in the shoulder and upper limb, pricking pain in the cheek
and jaw region, and inability in flexion and extension.Adhesive capsulitis is
characterized by pain, stiffness, and limited function of the glenohumeral joint ,
which adversely affects the entire upper extremity. Patients typically describe
onset of shoulder pain followed by a loss of motion [4], and the most common
limitations in range of motion are flexion, abduction, and external rotation.
Approximately 70% of frozen shoulder patients were women [5]; however,
males with frozen shoulder were at greater risk for longer recovery and greater
disability.
METHODS
Study design and subjects This pilot study was done in 17 participants
(single group) who visited the outpatient department of Siddha Regional
Research Institute (CCRS), Puducherry. The study was conducted for a period
of 2 weeks. Both inclusion and exclusion criteria for the patients were
mentioned below.
Inclusion criteria
1. Age between 35 and 65 years 2. With or without diabetic 3. Unilateral
or bilateral involvement 4. Both sexes.
Exclusion criteria
 1. Age below 35 and above 65 years 2. Traumatic history 3. Fracture
within the glenohumeral joint 4. Other type of systemic involvement such as
gouty, rheumatoid arthritis, SLE, and psoriatic arthritis 5. Attended varmam
therapy
Therapeutic schedule
The following varmam points were stimulated 1 time/day for 5 days. The
pressure is mentioned in varmam literatures. Varmam points [6-10]
• Mozhi piralgai (Sondhari varmam - midpoint of interdigital cleft
between middle and ring finger). • Kavuli kaalam (webspace (dorsal side)
between the thumb and index finger PI.L3 . UIh-3).
• Chavvu varmam (Mundaga varmam- six fingerbreadth above from
midpoint of the elbow joint (anterior side) A.L.UIa-60).
• Enthi kaalam (one fingerbreadth anterior to midpoint of the axilla.
Am.L4.UIS-8).
• Piratharai (near to armpit in posterior side Pm.L3.UIS-8).
• Kakkatai Kaalam (midway between the neck and head of arms, four
fingers above from midline of the clavicle).
• Kaiketti varmam (two fingerbreadth below from medial angle of the
scapula, P.L3.T5 ).
Assessment tools
Shoulder pain and disability index (SPADI) [11,12].
Procedure
Patients with kumbavatham (periarthritis) who were fulfilling both the
inclusion and exclusion criteria and volunteered to participate in this study were
assessed through SPADI index, and the data were recorded. Patients were asked
to visit outpatient department (OPD) for consecutive five sittings of varmam
therapy. They were also treated with regular OPD medications both internal and
external (medicated oils). Before the treatment, the disability scale is recorded
by SPADI, and all the movements with angle were recorded clinically. After
five sittings of varmam therapy, the patient was examined for prognosis.
RESULTS AND DISCUSSION
 Before initiating the treatment, both pain and disability in doing regular
household works were scored based on patient words. After varmam therapy,
improvements were noted again from the words of patients. Range of
movements was also assessed both before and after varmam therapy.
Before varmam therapy, the pain and disability score were averagely
more than 70%. However, after five sittings of varmam therapy, it was
averagely reduced to 30%. The quality of life was also improved well after 5
days of treatment. During the full course, no complaints about adverse effect or
non-responsiveness were reported.
CONCLUSION
From this study, it was observed that the varmam therapy has decreased
the pain and disability score in kumbavatham patients.
VARMAM THERAPY
SARAM (VITAL ENERGY) CIRCULATION 5 The term “Saram”
indicates the places where vital energy or the life energy exists. It also indicates
the directions of flow of vital energy. The vital energy or the life energy is also
called “Vaasi”. The function of saram can be understood only through its
circulation which is the basic of Varmam.
The vital energy called vaasi is derived from our act of breathing and it
moves from one Varmam point to another through specific channels and forms
a chain of circuits in the body cells and offers an environment for the body cells
to function smoothly.
VARMAM THERAPY:
Varmam therapy is the therapeutic manipulation of Varmam points in
which the pranic energy remains concentrated. Manipulation over these points
with a particular force for the specified time will release the pranic energy from
these points and bring relief to the affected individual by regulating the flow of
pranic energy which is obstructed due to assault on specific points (Varmam
points) or due to other causes.
The basic principle is to normalize the flow of Varmam energy. The
methods of Varmam treatment being practised today can be classified as
follows:
1. Energy based treatment
 2. Vital air based treatment
3. Nervous system based treatment
4. Bone based treatment
5. Muscle based treatment
6. Internal organ based treatment
The above said treatment procedures are appropriately chosen and carried
out by well-trained and experienced Varmam experts by appropriate hand/digit
usage.
CLASSIFICATIONS OF VARMAM
5 Varmam therapy is classified as follows.
i) Noi Nilai Maruthuvam (Treatment in diseased
conditions)
ii) Kaaya Nilai Maruthuvam (Treatment in traumatic
conditions)
In general, Varmam therapy includes:
(ii) The location of Varmam points
(iii) Observation of the signs and symptoms of Varmam assault.
(iv) Application of techniques for releasing affected Varmam
(Ilakku Murai).
(v) Manipulation over the vital emergency Varmam points,
(Adankal) if the patient is unconscious
(vi) Use of medications such as nasal drops (Naciyam) and ear
drops
(vii) (vi) Treatment with herbal medicines and dietary regimen.
The points where life energy resides and flows through, in the human
body are known as Varmam. Varmam also means points where breathing
energy resides in the body (Vaakata Nithanam: Verse 31). Varmam are
scattered over various parts of body in nerves, nerve joints, bones, muscles,
ligaments and inner organs.
CLASSIFICATION OF VARMAM POINTS
 4 Two major classifications with respect to Varmam points mentioned in
Siddha literature are:
• Padu Varmam-12
• Thodu Varmam- 96
which have been well established and are widely in use. However, it is
observed that thousands of Varmam points are mentioned in several literatures
Varmam can also be classified as the following:
Padu Varmam Major points (12)
Thodu Varmam Minor points (96)
Thattu Varmam Activating the Varmam point by tapping/slapping (8)
Pakka Varmam Proximally located Varmam points
Inai Varmam Paired Varmam points
Naal Varmam/ Natchathira Varmam Varmam points related to 27 Stars
Ellidai Varmam Points located in between the joints

METHODS OF STIMULATION OF VARMAM POINTS

In Varma Maruthuvam, there are 3 specific techniques which can
stimulate the Varmam points and adangal points (points where the pranic
energy remains in abundance).
1. Massage (Thadaval) For stimulating the Varmam points massaging
technique can be used. There are different types of massaging techniques. (E.g.
clockwise, anticlockwise rotatory movements with fingers, stretching the
fingers from one Varmam point to the other points or regions of the body. By
using varma thadaval (massaging), we can alleviate the problems arising due to
¼ mathirai visai (pressure).
2. Tapping (Thattal) In this technique, to stimulate Varmam points and
adangal points, we can use both hands and feet. While using the hand, we can
use palmar or dorsal sides of hands. In case of doing with foot, dorsal aspect is
preferred. It is most often used in adangal techniques. Tapping can be done with
mild, moderate and strong pressure. According to the need, tapping can be done
1, 3 or 5 times. By using Varma tapping we can alleviate the problems arising
due to ½ mathirai visai.
3. Pressing (Amartthal) It is the technique of giving a specific pressure.
The pressure can be given with fingers (or small objects like tamarind seed) on
Varmam points, for alleviating the problems which arise due to 1 mathirai visai.
DURATION OF PRESSURE
The time taken for giving pressure on a Varmam point is termed as
‘’Kaala Kanakku’’ which differs from point to point and it is generally taken as
½, 1, 2, 3 minutes.
Term Duration Description
Uthamam ½ minute The best effect is obtained with this duration of
manipulation Mathimam 1 minute Less effective than Uthamam
Athamam 2 minutes Less effective than Mathimam
Athamaathamam 3 minutes Least effective Pressure can be given
continuously for a specific time or intermittently according to necessity.
If given intermittently maintain a gap of 10 seconds in between two
successive manipulations.

The praanan (life energy) resides abundantly in adangal points. So, the
duration of pressure needed to stimulate the adangal points is less compared to
the duration of pressure required to stimulate other Varmam points.
DISORDERS THAT ARE COMMONLY TREATED WITH VARMAM
THERAPY
The following table shows the disorders that are commonly treated with
Varmam therapy in India.
Thandaga vatham Lumbar Spondylosis
Cegana vatham Cervical Spondylosis
Azhal keel vayu Osteoarthritis
 Kumba vatham Adhesive Capsulitis
Pakka vatham Stroke
Nadukku vatham Parkinson’s Disease
Malakkattu Constipation
Valippu Epilepsy
Madhumegm Diabetes
Adhikuruthi azhutham Hypertension
Thalai nokkadu Migraine headache
Peenisam Sinusitis
VARMAM THERAPY IN MALAYSIA
As Varmam therapy is a new modality introduced in the public hospitals
in Malaysia, a set of criteria was determined during the development of this
guideline to standardise the indications of referral, method of stimulation of
Varmam points, treatment criteria and regime of treatment. This standardisation
is aimed to ensure the safety of service as well as patients and to assess efficacy
of the treatment. The set of criteria could be considered for revision in the future
depending on the effectiveness of the service.
TREATMENT CRITERIA
i. Method Of Stimulation Of Varmam Points
Only the technique by massaging (Thadaval) and pressing
(Amartthal) is allowed as a method of stimulation of Varmam
points within the public hospitals in Malaysia.

ii. Age Limit For the time being, only adult patients of age 18 years
and above, will be eligible to be referred for Varmam therapy.
GENERAL CONDITION OF PATIENTS REFERRED FOR VARMAM
THERAPY
Patients referred for Varmam therapy should be:
1. Clinically stable (normal vital signs, no acute illness diagnosed
at the time of referral or treatment)
2. Not chronically bed ridden
 3. Able to understand and follow instructions
INDICATIONS FOR REFERRAL
As Varmam therapy is a new modality introduced within the existent
Traditional and Complementary modalities in the public hospitals in
Malaysia, the following chronic disorders have been carefully identified
as suitable for the initial phase of this service.
• Cervical spondylosis
• Lumbar spondylosis • Osteoarthritis (Knee)
• Adhesive capsulitis (Frozen shoulder)
Other indications of referral could be considered from case to case basis
(determined by Orthopaedic and Rehabilitation Medicine Department)
after obtaining written approval from the Traditional and Complementary
Division, Ministry of Health Malaysia.

TECHNIQUE AND METHOD OF STIMULATION OF VARMAM POINTS

CERVICAL SPONDYLOSIS Cervical spondylosis is a disorder in
which there is wearing on the cartilage (disks) and bones of the neck (cervical
vertebrae). It is a common cause of chronic neck pain. The following 10
Varmam points are stimulated to achieve a therapeutic effect in the treatment of
patients diagnosed with Cervical Spondylosis.

MUDICCHU VARMAM
Location: Prominence corresponding to C7 vertebra
Technique:
i. Place the middle three fingers over the prominence. Give
pressure in a clockwise rotation for three times then stretch the
fingers manipulate up to the right shoulder
ii. Follow the same technique in the opposite side
iii. Manipulate in a clockwise and anticlockwise rotation 3 times
each and then stretch downwards along the spine up to the T6
KAKKATAI KAALAM
 Location: Supra clavicular fossa on both sides

Technique:
i. Fix the middle three fingers on the supraclavicular fossa
from the posterior aspect of the patient
ii. Press and release
KAICHULUKI VARMAM
Location: From mudicchu varmam point location, move four fingers
downwards and three fingerbreadths laterally on both sides of the spinal column
Technique: Fix the middle of the thumb on both sides; press and release.
CHIPI VARMAM:
Location: Two fingerbreadths downward from the kaichulukki varmam point
Technique: Fix the tip of the three middle fingers; move fingers up and down
whilst giving pressure
SAVVU VARMAM
Location: Four fingerbreadths distal from the shoulder joint on the medial side
of the upper arm
Technique: Fix the middle of the thumb (palmar aspect); press and release
KAVULI KALAM
Location: Web area in between the thumb and the index fingers
Technique: Fix the tip of the three fingers; press in a pumping motion 3 times or
so
MANIBANDHA VARMAM
Location: Middle of the wrist joint (ventral aspect)
Technique: Fix the middle of the thumb (palmar aspect) and give moderate
pressure 3 times (Simultaneously the patient is asked to move his/her neck
laterally to the respective treatment side)
SOODOTHARI VARMAM
Location: Four fingerbreadths above the manibandha varmam (radial aspect of
the forearm)
Technique: Fix the middle of the thumb (palmar aspect); press and release
MELMANNAI VARMAM
Location: Upper end of the calf muscle (posterior aspect)
Technique: Fix the middle finger at the point and press (Simultaneously the
patient is asked to flex and extend the neck)
KEELH MANNAI VARMAM
Location: Lower end of the calf muscle (posterior aspect)
Technique: Fix the middle finger and then press (Simultaneously the patient is
asked to flex and extend the neck)
LUMBAR SPONDYLOSIS
“Spondylosis of the lumbar spine” means degenerative changes such as
osteoarthritis of the vertebral joints and degenerating intervertebral discs
(degenerative disc disease) in the low back. The following 10 Varmam points
are stimulated to achieve a therapeutic effect in the treatment of patients
diagnosed with Lumbar Spondylosis.
MANIPOORAGA ADANGAL
Location: Five fingerbreadths below the umbilicus
Technique: Fix the tip of the middle three fingers transversely on the point;
gently press and lift upwards
KOMBERI KALAM
Location: Eight fingers above the medial malleolus
Technique: Place the tips of the middle three fingers over the point. Press three
times (in a pumping motion) towards medial border of tibia
KEELH MANNAI VARMAM
Location: Lower end of the calf muscle (posterior aspect)
Technique: Fix the middle finger and press
KUTHIKAL VARMAM
Location: Seven fingerbreadths above the heel (posterior aspect)
Technique: Place the tips of the middle three fingers over the point; press three
times
KANPUGAICHAL VARMAM
Location: One fingerbreadth below the lateral malleolus
Technique: Place the tips of the three fingers of hand above the malleolus and
glide downwards around the malleolus pressing the exact point
KALKULASU VARMAM
Location: Anterior part of junction of foot and leg
Technique: Place the central part of the thumb at the point described; press and
release three times
SEVIKUTRI KALAM
Location: Fossa behind the ear lobe
Technique: Fix the central part of the middle finger; apply gentle upward
pressure to the point (simultaneously on both sides)
NANGANAPOOTU
Location: Sacral Groove, Three Fingerbreadths From The Lumbosacral Joint
(Lateral Aspect)
Technique: Place The Middle Part Of The Thumb At The Point Described;
i. Provide 3 Rounds Of External Rotation At The Sacral Groove
ii. ii. Glide Laterally To Reach Anterior Superior Iliac Spine
iii. iii. Finally Give Clockwise Rotation Using 3 Fingers On Anterior
Superior Iliac Spine

POOVADANGAL
Location: Near the ischial tuberosity
Technique: Press with the center portion of the thumb over the point on both
sides. Sustain the pressure on the point for 10 seconds. Afterwards press thundu
varmam, mel mannai, keel mannai and uppu kutri.
PULIMUTHADANGAL
Location: Just above the nail of the big toe
Technique: Fix the central portion of the thumb and apply deep pressure
Adhesive capsulitis is a musculoskeletal condition that has a disabling
capability. It is diagnosed by numerous physical characteristics including a
thickening of the synovial capsule, adhesions within the sub-acromial or sub-
deltoid bursa, adhesions to the biceps tendon, and/or obliteration of the axillary
fold secondary to adhesions. This condition remains an enigmatic shoulder
disorder that causes pain and restricted ROM at the glenohumeral joint. The
following 8 Varmam points are stimulated to achieve a therapeutic effect in the
treatment of patients diagnosed with Adhesive Capsulitis or commonly referred
to as Frozen Shoulder.
MUDICHCHU
Location: Prominence corresponding to C7 vertebra
Technique: i. Place the middle three fingers over the prominence. Give pressure
in a clockwise rotation for three times then stretch the fingers up to the right
shoulder ii. Follow the same technique in the opposite side iii. Manipulate in a
clockwise and anticlockwise rotation 3 times each and then stretch downwards
along the spine up to the T6
KAAKKATTAI
Location: Supra clavicular fossa on both sides
Technique: i. Fix the middle three fingers on the supraclavicular fossa from the
posterior aspect of the patient ii. Press and release
ENTHI KALAM
Location: Anterior axillary fold
Technique: Fix the tip of the middle three fingers; press and release

PIRATHARAI
Location: Posterior axillary fold
Technique: Place the tip of the middle three fingers; press and release
KAIKOOTTU
Location: Center of the axilla
Technique: Place the tip of the middle finger; press and release
SOODOTHARI
Location: Four fingerbreadths above the manibandha varmam (radial aspect of
the forearm)
Technique: Fix the middle of the thumb (palmar aspect); press and release
MANJADI
Location: Near the junction of the index finger and thumb; along the upper part
(base) of index finger (just below kavuli)
Technique: Place the central portion of the thumb; press upwards
MANIBANDHA VARMAM
Location: Middle of the wrist joint (ventral aspect)
Technique: Fix the middle of the thumb (palmar aspect) and give moderate
pressure 3 times (Simultaneously the patient is asked to move his/her neck
laterally, on the respective treatment side)
OSTEOARTHRITIS (KNEE) Osteoarthritis (OA) is a progressive joint disease
due to failure in repair of joint damage. This may arise as a result of
biomechanical, biochemical and/or genetic factors. The process may involve
one or multiple joints. The following 5 Varmam points are stimulated to achieve
a therapeutic effect in the treatment of patients diagnosed with Osteoarthritis of
the knee.
PANCHAMUGA VARMAM
Location: Around the patella
Technique: Place the tips of the thumbs along the upper border of the patella
and glide over the borders and end at lower border
MOOTTU VARMAM
Location: Centre of popliteal fossa
Technique: Place the tips of the middle three fingers over the point; press three
times (in pumping motion)
KOMBERI KALAM
Location: Eight fingerbreadths above the medial malleolus
Technique: Place the tips of the middle three fingers over the point; press three
times (in a pumping motion) towards medial border of tibia
KAAL SANNI ADANGAL
Location: At the junction of big and second toe
Technique: Place the tip of the index finger; press and release
ULLANKAAL VELLAI VARMAM
Location: At the junction of big and second toe in plantar region
Technique: Place the tip of the thumb; press and release.
STANDARD OPERATING PROCEDURE
TREATMENT REGIME
Patients should be given adequate information to enable them to make an
informed decision about the type, duration and frequency of the care that they
will receive. The therapist must always examine and treat the patient, whether
female or male, with a chaperon being physically present in the consultation
room, with visual and aural contact throughout the treatment session. The
following table describes the treatment regime for each condition or disorder.
As Varmam therapy is tailored based on the individual patient’s response to
treatment, the following treatment regimes were adopted for standardization of
treatment sessions based on the common practices of Varmam therapy in India.
Osteoarthritis of the knee 21 Once in 3 days 15 min 10th session max 36
sessions
Lumbar spondylosis 16 Once in 2 days 20 min 8th session max 24 sessions
Cervical spondylosis 12 Once in 2 days 15 min 6th session max.18 sessions
Adhesive capsulitis 12 Once in 2 days 15 min 6th session max.18 sessions
The above recommended regime may be reduced or increased based on the
practitioners’ assessment of the patient to the prescribed treatment or up to the
point that the patients’ symptoms are relieved, whichever is earlier.
MONITORING AND FOLLOW UP
 The patient’s response to care should be monitored at each follow-up visit
and through periodic reassessments. For the purpose of assessing the efficacy of
treatment, every patient should be given a 2 weeks’ appointment upon the
completion of treatment and reassessment of treatment response is
recommended at the following interval of 6 weeks, 3 months and 6 months after
completion of treatment. The frequency of reassessment depends on the
patient’s response. For instance, a patient who is responding as expected could
be reassessed less frequent than someone who is responding slowly. Re-injury,
exacerbation of symptoms, or new symptoms (especially neurologic) may
necessitate immediate reassessment.
SAFETY ISSUES
PRECAUTIONS
Practitioners should exercise caution when treating certain groups of
patients – especially those with the following conditions;
1. Neurologic symptoms
2. Recent infection or surgery
3. Any conditions listed as contraindications, as stated below
CONTRAINDICATIONS
With thorough assessment, multiple caution-indicating risk factors in a
patient may be considered as contraindication to the desired treatment modality.
Thus, the decision to administer treatment or not should be made after careful
consideration of the risk factor(s) present.
Pregnancy
ii. Mental/Psychological disorders
iii. Chronic bed ridden
iv. Unconscious with severe head injuries
v. Loss of protective sensation
vi. Bleeding disorders
• Suspected bleeding disorder or clotting abnormalities (e.g.
thrombocytopenia, hemophilia or any bleeding tendencies)
• On anticoagulant pharmacotherapy
vii. Confirmation or presence of any clinical evidence to suggest
active infection e.g.: • Pyrexia • Sepsis • Meningitis
 viii. Confirmation or presence of any clinical evidence to suggest
potentially serious pathological condition e.g.:
• Periosteal or intramuscular haematoma or abscess
• Fracture & dislocation
• Popliteal Aneurysm
• Baker’s Cyst
• Deep vein thrombosis
• Peripheral arterial disease
• Disc prolapse/prolapsed intervertebral disc/disc herniation
• Local infections (such as suppurative arthritis, septic arthritis,
osteomyelitis, bony tuberculosis)
• Open wounds, skin derangement, recent surgery
ix. Confirmation or presence of any clinical evidence to suggest
potentially serious systemic condition e.g.:
• Severe Osteoporosis
• Compromised bone or joint stability especially in metastatic
disease
• Aneurysm involving a major blood vessel.
• Acute cauda equina syndrome
• Connective tissue diseases
ADVERSE EVENTS
Varmam therapy is regarded as a relatively safe procedure. However, the
following side effects have been observed.
Mild, transient adverse events
• Local discomfort
• Lethargy
• Nausea
• Pins and needles
Unpleasant reactions
There are some hazardous points which carry high risk particularly with
unskilled and inexperienced practitioners
Fainting (Vasovagal Syncope)
Fainting is a serious adverse event that may occur during Varmam
Therapy. Hence, educating the patient about the Varmam Therapy and its
procedures before initiating Varmam Therapy is of utmost importance. It is
advisable to perform Varmam Therapy in a lying position with care and
gentleness for the first-time patients and utmost care should be given while
performing Varmam Therapy in the neck region. Fainting episode is often
associated with the feeling of discomfort, weakness, and vertigo. Patients may
also complain of palpitations, nausea and rarely chest discomfort. Forceful
manipulation in Varmam therapy may cause chillness over extremities, dip in
blood pressure, and unconsciousness. If alarming symptoms appear, keep the
patient in lying position in the table with head down and leg upside. Usually
symptoms disappear. In severe cases, assess whether the patient is stable or
unstable and then first aid should be given.
If the patient is stable the following Varmam points may be stimulated
i. Kavuli kalam Located in the web area in between the thumb and
the index finger
ii. Pulimuthadangal Located just above the nail of the big toe Pain

Usually pain will not be felt in the Varmam points manipulated during Varmam
therapy. Forceful stimulation of Varmam points may induce pain at those
particular point and its associated areas. Appropriate application of technique
and giving optimal pressure to the Varmam points will not produce pain.
Internal Organ Injuries Normally Varmam therapy will not harm any organ.
However wrong and forceful manipulation may injure any organ.
SERIOUS ADVERSE EVENTS
Serious complications are very rare, and it would seem unlikely that the
adverse occurrences have been solely attributable to the therapeutic
intervention. Unpleasant conditions or accidents that result from manipulative
therapy can be presented by careful appraisal of the patient’s history and
examination findings.
Information must be sought about coexisting diseases and the use of any
medication, including long‐term use of steroids and anticoagulant therapy. A
detailed and meticulous examination must be carried out. The use of appropriate
techniques is essential, and the practitioner must avoid techniques known to be
potentially hazardous.