 which reduced to 0.05±0.05 after treatment, giving a relief of 95.24%, which is statistically significant with p<0.001.
No apparent change was observed in the X-ray examination before and after the treatment.

Verbal Feedback after Six Months of Completion of the Study Period
Verbal feedback taken from patients about six months after the completion of the study period indicated that 4 patients still had almost complete relief (who had chronicity of less than 3 years) and were pursuing Marma Therapy regularly, while 10 others were able to self manage the disease through regular Marma Therapy and massage (who had chronicity of 3 to 10 years).

Discussion
The aim of the present study was to evaluate the efficacy of Marma Therapy with Janu Basti (with Ksheerbala Taila) in the management of Janu Sandhigata Vata (Osteoarthritis of knee).
According to Ayurveda, a healthy human body is supposed to have a relatively stable equilibrium (congenial homeostasis) of Dosha (psychobiological rhythm -Vata, Pitta, Kapha), Dhatu (body tissues) and Mala (excreta) [4]. Imbalance in this equilibrium leads to disease, and the aim of the therapy is to restore this balance [4].
Among the Tri-Doshas (i.e. Vata, Pitta and Kapha), Vata is of primary importance as it regulates the movement of the other two Doshas, Dhatus and Malas all over the body, mainly because of its Chala Guna (moving property) [4]. When Vata gets aggravated, either due to Vata Vardhaka Ahara (Vata aggravating diet), or Vihara (lifestyle), or Manasika Nidanas, or a combination of these causative factors, it gets firmly embedded in the Khavaigunya Yukta Srotas (micro-channels that have weak or defective space that can serve as a location for the starting of some pathology) associated with specific parts of the body, and impairs the functions of those body parts, causing the disease [4]. If this body part is Janu Sandhi, then the disease is termed as Janu Sandhigata Vata [1,3,4].
Vata has Ashraya-Ashrayi Sambandha (relationship) with Asthi Dhatu; this means that Vata takes shelter in Asthi [4]. In case of Janu Sandhi, if Vata is aggravated then because of its dry nature, it leads to a reduction of the Snehansha (Shleshma / Snigdhata) (unctuousness) from there; because of the decrease in Sneha, Khavaigunya (weak or defective space that can serve as a location for the starting of some pathology) occurs in Asthi and Sandhi, leading to the production of Sandhigata Vata there [4].
In this procedure, warm oil is retained for sufficiently long duration (approximately 35 to 40 minutes) over the affected body part [9]; as a result, the Veerya (active principle) of the oil is absorbed by the Loma Koopa (openings situated over the skin), which in turn undergoes Paka (metabolism) with the help of Bhrajaka Pitta situated in Twacha (skin) [4]. As the oil used in Janu Basti is opposite to the nature of Vata (has Vata pacifying properties), therefore, when it is absorbed by the skin and goes to Dhatus, it helps to rectify the disease present at that site.
In this disease, the glue that binds the cells of the cartilage, is disrupted, leading to cartilage damage at the affected site; oil, due to its properties like Tikshna (sharp) and Sukshma (minute), penetrates the cartilage, and helps in binding together the cartilage cells through its Snigdha (unctuous) and Guru (heavy/thick) properties -this property of oil is termed as Sandhaniya [27]. Also, since Snehana has properties similar to those of Kapha, it helps in bringing back Sthanika Kapha (Shleshaka) to normalcy, which further contributes to the management of this disease [4].

Mode of action of Nadi Sweda
Janu Basti was followed by Nadi Sweda over the Janu Sandhi, with Dashamoola Kwatha (local application of medicated steam generated from the decoction of Dashamoola). Swedana is Agni Deepaka (enhances the digestive fire), Srotoshuddhikara (cleans the subtle micro-channels), Sandhicheshtakara (improves joint movement), and Kaphavatanirodhaka (pacifies Kapha and Vata Doshas) [27]. Swedana supports the activation of local metabolic process, causes an increase in the local blood flow, and hence leads to an increase in the absorption of Sneha (oil) through the skin [3,4]. Sandhigata Vata is characterized by Sanga type of Srotodushti; Swedana relieves this Sanga, leading to the pacification of Sandhigata Vata [3,4,27]. Swedana produces sweating, and reduces stiffness and heaviness in the body [27,32].

Mode of action of Marma Therapy
The Marma Therapy administered in the present study for the management of Janu Sandhigata Vata included stimulation of four Marma points, i.e. Kshipra, Gulpha, Indravasti and Janu, by applying pressure on these locations. The mode of action of Marma Therapy may be understood through various ancient and modern concepts as follows.
According to the scriptures, 'Havya Vaha' and 'Kavya Vaha' Tadit Shakti (bio-electric power), resides in the Marma locations [33]. The positive electricity named 'Havya Vaha' resides in the Marmas of the head and the torso, while the negative electricity named 'Kavya Vaha' resides in the Marmas of the hands and legs [33]. Imbalance of the Havya Vaha and Kavya Vaha Tadit Shakti residing in the Marma points results in the occurrence of disease and weakness [33]. In order to provide relief from this suffering by regaining this balance, the ancient sages invented Yogasanas (Yogic postures) [33]. The stretching, vibration, rhythmic movement and pressure caused by Yogasanas have a direct influence on the Marma points, which play an important role in their refinement, stability and nourishment [12][13][14]33]; subsequently, the functioning of the respective organs with which the specific Marmas are associated, also gets affected leading to therapeutic benefits [12]. For example, the four Marma points used in the present study are stimulated during Vajrasana and Supta Vajrasana, which are useful for knee pain/ strengthening of knee in a healthy person [13]; this indicates the effectiveness of the stimulation of these Marma points in knee disorders.
Marmas are connected to the Nadis (subtle nervous system) and Chakras (subtle energy centers) of the subtle body [14]. The Chakras can be considered to correspond to seven main Marmas or Pranic centers, which provide energy to all other Marmas [14,17]. Through stimulation of Marma points, the flow of Prana through the Chakras can be stimulated, thus activating them, and resulting in the awakening of subtle dormant areas in the brain, that leads to the experiencing of higher realms of consciousness, which are normally inaccessible [34]; this, in turn, can lead to better control over the mind-body network including the autonomic nervous system and various organs, resulting in an overall healing effect [14].
Marmas are related to the three Doshas (Vata, Pitta and Kapha). Acharya Charaka has assigned great importance to the Trimarmas, i.e. Basti, Hridaya and Shirah [5]; these three main Marmas seem to have a direct relationship with the three Doshas, that are known to primarily reside in the same regions, i.e. Vata in the lower abdomen (site of Basti Marma), Pitta in the heart region (site of Hridaya Marma) and Kapha in the head area (site of Shirah Marma) [16]. According to Acharya Sushruta [Sushruta Sharira 6/35] [4], Marmas are the locations having the presence of the three Doshas (Vata, Pitta, Kapha), as well as their subtle forms, i.e. Prana, Tejas, Ojas, and also the three Gunas, i.e. Sattva, Rajas and Tamas [14]. Thus, the stimulation of Marmas may be correlated with the balance of the three Doshas and their subtle forms (Prana, Tejas, Ojas), as well as the three Gunas, which includes Sattva (mind) [14]. Ojas signifies the immunity power; by properly balancing it through the appropriate stimulation of Marmas, the immune system may be strengthened, as well as it can cause rejuvenating effect [14]. Through the connection with the Sattva Guna (mind), the proper stimulation of Marmas can provide relief in stress [14].
As Marmas are the seats of Prana, the vital life force that governs the