An Introduction to Ayurvedic Marma Therapy

Introduction

Ayurveda is a medical system with a holistic orientation that originated in ancient India thousands of years ago. Though Ayurveda has ancient roots, it is practiced throughout the world today. The Ayurvedic view of the body includes unique concepts that integrate mind-body-spirit, and marma points are one such vehicle of integration. Marma points are vital energy points on the surface of the body that are connected to mind-body-spirit. As vital points, they can be used diagnostically and therapeutically to treat pain, balance emotions, and influence the nervous system, to name a few functions. Marmani is the plural term for energy points. Marma points represent in Ayurveda what acupuncture points represent in traditional Chinese medicine (TCM). Marma therapy involves the hands-on manual stimulation of energy points similar to acupressure in a noninvasive and nonpharmacological way.

History

The earliest textual reference to Marma points, from around 1000–700 B.C.E., comes from Charaka Samhita ¹ in which reference is made of marma as connected to vital organs. ¹ Sushruta Samhita, ² a compendium of surgical procedures written between 1000 and 600 B.C.E., mentions 107 marma points and describes them in detail along with their effects on prana and consciousness. Prana is the life-sustaining vital force or energy in Ayurveda. According to Sushruta, marma points are anatomical sites where muscles, veins, ligaments, bones, and joints are in confluence. Though Charaka and Sushruta, revered Ayurvedic physicians of their times, may have written their texts around the dates listed above, the actual source materials for these texts likely originated in earlier times and were passed down via oral tradition. A later text, Ashtanga Hridayam by Vagbhata, ³ written around 700 C.E., describes 108 marma points. Historically, marma points have also been used for dual purposes by targeting them for attack and protection in settings of martial arts traditions but also for therapeutic purposes to heal and recover from injuries. More recently in Ayurveda’s history, marma has been used primarily in the form of therapeutic touch at energy points during Ayurvedic oil massage as performed within the system of panchakarma detoxification techniques.

Significance of Marma Points

Although there are similarities between the marma points and the system of acupoints in TCM, both are thought to have evolved independently with their own cultural influences. ⁴ The spread of Buddhism from India to China resulted in exchanges between two cultures, and the two systems may have influenced each other. ⁵

Marmani (the pleural of marma in Sanskrit), as described by Sushruta, are points where vital energy, Prana, collects and flows through channels called nadis. Marmani are also connected with another type of channel called srotas. Whereas nadis are subtle energy channels and are not visible, srotas can be physical anatomical structures such as arteries, veins, bronchi, etc. ⁶ Marma points are connected to the seven chakras, energy centers, which are correlated to the nerve plexuses from a biomedical perspective. For example, the heart plexus, or chakra (Anahata) is the seat of love, compassion, and empathy, and bridges the chakras above and below and regulates prana and the upward-moving air element. ⁶

Sushruta’s main interest seemed to be dealing with battlefield injuries to these vital points and surgical considerations such as minimizing incisions at the site of vital marma points to preserve the body’s prana, or vital energy. These points are located through a measurement called anguli—the width of one’s middle finger, thus being different sizes on different body types. Sushruta Samhita discusses three types of treatment: 1.

Siravyadha is a type of massage with oils and herbalized pastes.

These were considered parasurgical procedures. With the foundation laid by Sushruta, practitioners and teachers in subsequent generations advanced the understanding of using marmani for therapeutic purposes through observation, clinical insight, and experimentation. ⁶ Gradually over time, these energy points became associated with various methods of stimulation for diagnostics and therapeutic effects with implications on health and healing.^6,7 When this evolution happened is unclear in the history of Ayurveda, as there are no texts available that discuss these as methods of treatment other than Sushruta Samhita. Experts mention that the art of stimulation of marmani for health benefits was taught in the traditional Vedic method of teacher-to-student through oral transmission (Guru-Shishya parampara), where teachers could select students with the right aptitude. ⁷ They also speculate that many ancient Vedic texts were lost during several invasions of India by foreign rulers, including texts on marma therapy, so the timeline of this evolution is not clear. ⁷ Recently, several books have been written in the modern age by the practitioners of this art for students of Ayurveda.^6–9

Marma as a Diagnostic Tool

Palpation of marma points can be used as a diagnostic tool. In this method, the clinician assesses tenderness or sensitivity. Marmani are connected to doshas (vital forces within the body), dhatus (body tissues), srotas (body channels), and organs. Sensitivity or tenderness of a marma point can indicate problems in the associated areas. For example, tenderness at Yakrut marma could be suggestive of liver dysfunction, and sensitivity at Pliha marma might signify a disturbance of the spleen. Vrukka in the lumbar area represents the kidneys, Skandhadhara on the chest for the lungs, and Hridayam at the center of the chest is tender when there are cardiac disorders. Sensitivity can alert a clinician to get adequate history to recommend further clinical studies if warranted.

Mechanism of Marma Points

According to Ayurveda, stimulation of marmani is thought to affect the doshas (internal forces). Doshas are defined by a specific combination of the five elements—Earth, Water, Fire, Air, and Space (from grossest to subtlest). Vata is defined by the combination of space and air and is the force of movement. Pitta is defined by the combination of fire and water and is the force of transformation. Kapha is defined by Earth and Water and is the stabilizing force of structure. In addition to affecting the doshas, which regulate functions of body, mind, and consciousness, marma therapy is understood by traditional practitioners as a way to regulate underactive, stagnant, or overactive prana, or energy flow, which is thought to cause specific symptoms. Marmani also affect the subtle energies of the doshas: prana (subtle energy of Vata), tejas (subtle energy of Pitta), and ojas (subtle essence of Kapha).

Although not visible to the naked eye anatomically or microscopically, marma points may be connected to the fascia. There is limited understanding of marma points from a biomedical perspective, but Ayurvedically they affect the tissues and organs that are connected to the srotas (energy channels). ⁶ Research on connective tissue and fascia suggests possible correlations with marmani, as fascia is closely connected to the HPA (hypothalamus and pituitary axis) and neuroendocrine system and forms a pathway for relaxation response mediated by these mechanisms ¹⁰ Since marma points are connected to fascia, effects mediated by these systems can be achieved by stimulation of marma points.

There are similarities between marmani and acupoints, with approximately 75 energy points that are common to both systems with the same point location. ⁶ Another explanation for how marma points work can be the correlation with acupressure. Touching the skin with varying degrees of pressure can cause various sensations and physiological effects on the points, resulting in activation of the HPA (hypothalamic pituitary axis), parasympathetic system, and neuroendocrine system. This leads to the relaxation response, creating more endorphin and serotonin production. According to Gate Control Theory, through acupressure, continuous impulses shut the neural gates and block the brain’s perception of pain while activating the HPA axis. ¹¹

Available research on the mechanism of acupuncture may shed some light on how marmani work. It should be distinguished that marma therapy is a noninvasive treatment while acupuncture is invasive, and the use of essential oils, herbal oils or pastes used topically on the skin in marma therapy can add another layer of complexity in this understanding. There are numerous studies that show acupuncture works through several mechanisms as outlined below. A systematic analysis of several studies implied that some of the meridians on which acupoints are located had lower impedance ¹² (decreased resistance to electrical flow) or increased electrical conductance ¹⁰ compared to other structures. Nuclear tracers injected along meridians have been shown in human subjects to migrate along the meridians, but not in non-meridian points. ¹³ Some acupoints have a high concentration of mast cells compared to sham points, and needling promotes analgesia by the release of histamine via degranulation.^14,15 Analgesia is also achieved through activation of neuroendocrine system, release of neuropeptides, endorphins, serotonin, norepinephrine, endogenous opioids, and endocannabinoids.^14,16 Acupuncture also causes muscle relaxation and treats insomnia via activation of the parasympathetic system, ¹⁷ and anti-inflammatory effects via modulation of the HPA axis, inhibition of cyclooxygenase, and production of PGE₂. ¹⁴ These are some examples of possible mechanisms of acupuncture to suggest that there might be an overlap of mechanisms with the marmani. Future research in this regard is needed to understand the function and mechanism of marma points.

Therapeutic Uses of Marma Points

Various methods and techniques of treating marmani have been described for therapeutic benefit. ⁶ These are shown in Table 1.

OPEN IN VIEWER

Table 1.

Methods of Treating Marmani

Method	Technique	Description
Oleation	Massage with herbal oil	Apply herbal oil to marmani directly with fingertips; oil type is based on individual’s constitution (prakruti) and doshic imbalance (vikruti).
Sweat or heat therapy	Steam bath or direct application	Involves use of heat via steam or medicated steam infused with herbs or essential oils are used.
Deep massage	Kneading of deeper tissues including fascia underlying marma points.	Can be done with or without oil. Generally recommended for individuals of kapha constitution who tend to have more subcutaneous fat, compared with others. This helps release deeply held emotions.
Deep, dry pressure	Sometimes using a blunt instrument	This is not as deep as above and sometimes involves a blunt instrument made from wood or various metals to apply pressure. The blunt instrument can also be used to apply heat.
Binding and holding	Applying steady pressure with hands	This involves applying firm, steady pressure for a few minutes.
Application of paste	Herbal paste made from leaves, roots and barks applied over marmani	Herbs are selected based on the condition and the constitution of the individual.
Application of heat	Heat is applied to marmani with heated turmeric root, or a blunt rod held close to the skin.	Comparably, in TCM this is done with moxibustion, burning the Artemisia vulgaris herb close to the skin at specific acupoints or directly on the skin.
Needling	Fine needles are inserted in this technique into the marma points subcutaneously	This did not become popular in Ayurveda due to its invasive nature.
Irritation/Friction	A rough surface such as a brush or stone is rubbed on the marma points	This stimulates the flow of prana (vitality).
Rakta moksha (blood purification)	Blood is removed from marma points using traditional tools (similar to venesection tools) or may be done using jaluka (leeches).	Therapeutic bloodletting to improve circulation, sometimes performed during the Ayurvedic cleansing protocol (called panchakarma).

The most common practice involves marma therapy massage in the context of panchakarma detoxification and cleansing procedures. Others perform marma therapy with gentle pressure with essential oils.^6,9 Dr. Vasant Lad is the first Ayurvedic doctor in modern times who developed a specific way of using marma stimulation as a standalone treatment modality similar to acupressure. Some Ayurvedic practitioners, including the authors, have been practicing it as a standalone modality with gentle acupressure using essential oils for various conditions, including anxiety, headaches, migraines, low back pain, bowel spasms in inflammatory bowel disease and irritable bowel syndrome, and sinus congestion, among others.

Clinical Studies on Marma Therapy

Clinical studies on marma techniques are limited and include both randomized and nonrandomized studies. One study targeted the parasympathetic nervous system to achieve improvements in anxiety and depression. A prospective crossover study including 24 healthy female students showed a statistically significant increase in parasympathetic activity with improved scores in anxiety measured by STAI (State-Trait Anxiety Inventory), liveliness, depression, and boredom as measured by VAS (Visual Analog Scale) in those receiving marma massage compared to sham/control at 15 minutes after receiving the treatment. Blood pressures did not show improvement in 15 minutes after treatment. ¹⁸

The remaining studies were conducted on musculoskeletal disorders. One study was done on acute stroke patients to improve mobility. In a nonrandomized study including 30 patients who suffered acute stroke comparing usual rehabilitation plus marma therapy to a control group that received rehabilitation alone found no significant improvement in the motricity index (a measure of strength of the involved lower extremity) between the two groups at the end of 12 weeks. ¹⁹ This was a feasibility study, and the authors estimated that a sample size of 172 would be needed to evaluate a significant improvement in the motricity index.

Other studies used a TENS (transcutaneous electrical nerve stimulation) unit in addition to marma point massage for stimulation. In an Randomized Controlled Trial (RCT) with 40 patients with low back pain diagnosed with lumbar spondylosis, marma massage was compared to stimulation with a TENS unit of the same marma points. The group that received therapy with TENS units showed significant improvement in all assessment scores, including the Oswestry Low Back Disability Assessment, at the end of 14 days. The massage group also showed significant improvements in some of the scores. The two groups were not compared with each other. ²⁰ In a nonrandomized study including 40 subjects with cervical spondylosis, marma massage was also compared to stimulation of the same marmani with a TENS unit. Both groups received treatment for 7 days. At the end of 14 days, the TENS group showed statistically significant improvement in all assessment scores (before and after). The massage group showed significant improvement in some scores. When both groups were compared, the TENS group had significantly reduced pain, stiffness, and neck disability index and improvement in neck flexibility, compared to the massage group. ²¹

Another study used digital pressure instead of massage of marma points for frozen shoulder. A prospective cohort study of 30 patients with frozen shoulders received marma treatment with digital pressure twice daily for 1 month. There were statistically significant improvements in pain, range of motion, and joint stiffness at the end of the study period. ²²

A study in cancer survivors included marma therapy in addition to nutrition, lifestyle, and yoga practices. This feasibility study showed that cancer patients were able to self-treat marma points after instruction. ²³

Conclusions

Marma therapy has been practiced for several millennia as part of Ayurveda. Marma treatment is similar to stimulating acupoints in acupuncture, but in a noninvasive way similar to acupressure. Although the biomedical mechanism is not yet known, Ayurveda asserts that marma treatment exerts its influence through effects on tri-doshas, body channels (srotas, nadis), and prana.

There are several techniques of stimulation to achieve healing. While not considered as mainstream as acupuncture in the West, its practice is growing among a small number of both Ayurvedic and integrative health practitioners, using it as a stand-alone treatment for balancing the doshas from an Ayurvedic perspective and reducing symptoms of various illnesses. There is currently no data on how many practitioners are using this as a stand-alone therapy. Clinical studies of marma are limited. There is a need for well-designed studies to understand its efficacy so that it can be incorporated into the tool kit of an integrative health practitioner consistent with evidence.

It is important to emphasize, however, that marma therapy evolved as part of a larger, traditional, whole-health system of Ayurveda. Using marma therapy as an adjunctive treatment as part of this system may be essential to promote the whole health of a person, rather than merely alleviating symptoms. However, marma therapy, done alone, as in the practice of acupuncture/acupressure, may help one to alleviate symptoms and suffering in the short term while embarking on a longer journey of comprehensive lifestyle changes based on Ayurvedic principles.