|Year : 2023 | Volume
| Issue : 2 | Page : 194-199
Traditional bonesetters clinics: Prospective trends and work assessment on 915 bonesetters operating in parts of Uttar Pradesh and Haryana, India
Nishit Palo1, Sidharth Singh Chandel2, Chhavi Malik3, Abhishek Shukla1, Govind Narayan Choudhary1, Veerendra Mannan1
1 Department of Orthopaedics, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India
2 Department of Orthopaedics, Saraswathi Institute of Medical Sciences, Hapur, Uttar Pradesh, India
3 Department of Emergency Medicine, PLCSUPVA, Rohtak, Haryana, India
|Date of Submission||30-Dec-2022|
|Date of Decision||19-Feb-2023|
|Date of Acceptance||27-Feb-2023|
|Date of Web Publication||3-May-2023|
Department of Orthopaedics, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: In India, majority patients with musculoskeletal injuries are attended by traditional medicine treatment provider. Bone setting services data from Subcontinent is not available. Methods: Prospective epidemiological study across 10 cities. Objective: To document bonesetter's spectrum of services and work-based information; radiological services use, treatment methods, treatment cost, treatment duration, referral timing, complication incidence and success rates. Results: Study encompasses 915 Traditional Bone Setters working over area of 6725 km2. Meerut houses most bonesetters (n=130); industry dominated by men (98.5%). 55% bonesetters are of 51-70 years. Overall experience 53.75 years. 9.50 % Bonesetters have radiograph machines. 55.95% practicing bonesetters are 3rd generation lineage. 32.67% bonesetters prescribe allopathic medications. For treatment, Males visit more (55%) followed by Females (25%) and Third gender (15%) patients. Patients age group 5-94 years. 22.4 patients visit each bonesetter daily. An average treatment lasts 4-5 sessions; treatment cost 300-400 Indian Rupees per sitting (3.60-4.80 USD). Patient report 2.75 days post injury & treatment lasts 14.5 days. 90% Bonesetters take time till 3rd bandage (9-10days) to decide on referral. Patient's satisfaction is 64% and 45% complication rates. Discussion: Traditional Bone Setters form largest specialised group offering services for musculoskeletal injuries in India; attracting 25-40 patients per practitioner daily. High complication and referral rates are worrisome. Conclusion: Clientele visiting bonesetters form major chunk of patients that should be treated by Orthopaedic Surgeons. Policies should be made to integrate bonesetters into structured health services; to benefit community at larger scale with fewer complications and man hours lost to work.
Keywords: Bonesetter, heritage, India, injury, manipulation, massage, rural, tradition
|How to cite this article:|
Palo N, Chandel SS, Malik C, Shukla A, Choudhary GN, Mannan V. Traditional bonesetters clinics: Prospective trends and work assessment on 915 bonesetters operating in parts of Uttar Pradesh and Haryana, India. J Orthop Dis Traumatol 2023;6:194-9
|How to cite this URL:|
Palo N, Chandel SS, Malik C, Shukla A, Choudhary GN, Mannan V. Traditional bonesetters clinics: Prospective trends and work assessment on 915 bonesetters operating in parts of Uttar Pradesh and Haryana, India. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:194-9. Available from: https://jodt.org/text.asp?2023/6/2/194/375544
| Introduction|| |
Traditional healers were practicing long before modern medicine was introduced to the developing world. In India and other developing countries, majority of patients needing orthopedic services are attended at various levels by health workers and traditional/alternate medicine treatment providers. It is estimated that India houses approximately 60,000 traditional bonesetter (TBS); many of whom do not have formal education or training in modern medicine but treat around 60% of bone-related trauma patients.
Majority of patients are located at the rural level and some patients in cities as well visit TBS initially due to various reasons such as word-of-mouth popularity, strong lineage, easy availability and accessibility, economical treatment, and fear of hospital. Some patients who visit hospitals initially; also, do visit these bonesetters later to avoid surgery or to save costs.
This comes at a cost, as the patients lose important time postinjury, thereby hampering overall functional recovery and clinical outcomes. From this pool of treated patients, some patients are referred to the hospital after 3–4 sittings if desirable results are not found. These patients present with either major complications, or with missed or neglected injuries needing specialized orthopedic surgeries.
These patients not only the patient lose man-hours to work but also have limited clinical recovery ultimately. If caught and treated early, the majority of such patients can get back preinjury level. Published data about the bone setting services in India are not available, although the practice is very rampant and aggressively working at root levels in the subcontinent and other developing countries. Gathering and assessing data will help identify and treat early those patients who have serious bone and joint pathologies but at initially reach to and are treated by the bonesetters. This is also important to assess the lacunas and determine intervention point where professional health-care providers can get involved to ultimately improve patient treatment success rates and overall clinical output.
The purpose of this study is threefold; first, this study documents bonesetter and alternative medicine providers spectrum of services and work-based information; second, to assesses relevant parameters such as average cost per sitting, treatment duration, timing of referral to doctors, complication incidence, and success rates; and third, to understand the load that these bonesetters treat and evaluate whether working with bonesetters in a synergistic way or integrating them into the main health-care system as allied unit would ultimately help patients with musculoskeletal injuries.
| Methods|| |
It is a prospective questionnaire-based epidemiological study from January 2021 to July 2022. On TBS across 10 cities, principal investigators interviewed TBS in person with a questionnaire comprising 14 questions; interviews were recorded in their native dialect and later transcribed into English.
The data were analyzed using a constant comparative method which included several iterations to refine common themes and determine counterfactual and specific focal points from each interview. The regions surveyed in Uttar Pradesh and Haryana were Noida, Greater Noida, Bulandshahr, Ghaziabad, Modinagar, Meerut, Panipat, Sonipat, Jhajjar, and Rohtak.
Data were tabulated, and results were documented. Parameters assessed were spectrum of injuries treated, radiological services access and use, treatment methods, follow-up routine, complication rate, success rate, average treatment cost, and patient compliance modes.
Questionnaire: Comprising 14 standard questions for all bonesetter personnel:
- What is your educational qualification?
- Any other family member in the same profession?
- How many years of practice?
- Number of patients seen per day?
- Range of injuries covered?
- Type of paste, ointment applied with choice of splintage?
- Various anatomical parts treated per day distribution?
- Timing of patient's presentation postinjury?
- What is your duration and schedule of treatment?
- During treatment when is the patient referred elsewhere; any injuries not treated?
- Range of complications encountered with incidence rate?
- What is the average procedure cost and success rate?
- How do you evaluate the patient for injuries and fractures?
- Any use of radiograph? Allopathic medications?
Data were tabulated using standard MS Office Tools (Microsoft Office 365 Apps – Word, PowerPoint, and Excel). The data were analyzed descriptively and organized in tables and graphs. Standard deviation, mean, and range were calculated for continuous variables. Statistical analyses were performed using SPSS 13.0. (SPSS Inc., Chicago, IL, USA).
| Results|| |
The study encompasses data on 915 TBS working over a vast area of 6725 km2; spread over 10 cities, 8 districts, and 2 states (Uttar Pradesh and Haryana) in India [Figure 1].
The highest number of bonesetters practice in Meerut (n = 130), followed by Bulandshahr (n = 110) and Jhajjar and Panipat (n = 100) [Table 1]. The bonesetter industry is dominated by men (98.5%, n = 901), with the majority being in the 51–70 years age group (55%, n = 503). There are few female bonesetters (1.5%, n = 14) in active practice in Haryana [Figure 2]. About 55.95% (512/915) of practicing bonesetters are third generation in their lineage.
|Table 1: Bone setters Variables (City-Wise): Experience, Radiograph use and Spectrum of Injuries treated.|
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Bonesetters possessed a work experience of 53.75 years (mean), with Rohtak city in Haryana having the most experience of 68 years (mean). About 9.50% (87/915) bonesetters had in-house radiograph machine to facilitate their emergency radiograph needs and 32.18% (28/87) had hired a professional radiographer [Table 1]. Average charges per radiographic view were 100 Indian rupees (1.20 USD).
About 67.33% (616/915) bonesetters apply ayurvedic preparations for patients' symptomatic relief and 32.67% (299/915) prescribe allopathic medications [Table 1].
Approximately 20,285 per day are treated by bonesetters in our study area. Gender distribution for outdoor patients was males (55%) followed by females (25%) and third gender (15%) patients [Figure 3]. Patients belonged to the 5–94 years age group, with the maximum number of patients seen in the 46–60 years age group. Each bonesetter treats 22.4 (mean) patients per day, with the highest number of patients seen in Panipat city (90 [max] and 32 [mean]) [Table 2].
|Table 2: Clinical Parameters (City-Wise): OPD, Referral Timing, Patient Satisfaction & Complication Rates.|
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Variety of ailments treated ranges from ligament tears (sprain) to fractures, dislocations, and muscle strain/cramps [Table 1]. Treatment is offered in 3-day sessions; repeated as per requirement. Spine ailments were treated mostly followed joints and lower limb issues [Figure 4]. Average treatment lasted 4–5 sessions/bandaging, i.e. 14.5 days (mean) with the highest duration of 21 days seen in Haryana (Jhajjar, Sonipat, and Panipat). The average treatment cost per sitting was 300–400 Indian rupees (3.60–4.80 USD); this included the material cost.
Patients presented at 2.75 days (mean) postinjury; it is an important criterion as this factor determines ultimate clinical recovery and patient satisfaction directly [Table 2]. Overall Patient's satisfaction was 64% (mean), with 75% (highest) in Panipat and Meerut [Table 2]. The authors observed high complication rates of 45%. Persistent swelling, followed by stiffness and persistent abnormal movements at injury site was the usual presentation.[Figure 5].
| Discussion|| |
TBS are one the largest specialized groups offering services for bone and muscle injuries in India. Literature suggests the skill development and extension of bone setting services to humans were made after obtaining success in treatment of domestic cattle and other animals., A TBS is a lay practitioner of joint manipulation. He or she is a practitioner who takes up the practice of healing without having had any formal training in accepted medical procedures.
TBS practice is connected deep into roots of Indian Heritage. Clientele visiting them for their services form a major chunk of the potential pool of patients that can be treated by orthopedic surgeons. Bonesetters are more common in rural parts and areas with low socioeconomic status, easily approachable, and often have a good local reputation,; thereby attracting more than 25–40 patients per practitioner per day. On average, there each city houses 70–80 such bonesetters. This accounts for around 2400 patients in a city with bone and muscular injuries per day, which is a significant number compared to a regular medical school's outpatient department patient visitor tally of 100/day (approximately).
Moreover, data from Western developing countries estimate that up to 85% of patients with fractures present first to TBS before reporting to the hospital; thus, this mode of care delivery cannot be ignored. These services offered by this specialized group are known by various names such as “Puttur Kattu” in Chennai, Andhra Pradesh, and Karnataka; “Seko” in Odisha; Bengal or “Pahalwan” in Delhi, Uttar Pradesh, Punjab, and Rajasthan; and “Vaidya” in Haryana. Some of these centers are specialized with in-house radiograph machines to facilitate the demand for initial radiographs. Lineage of many dates to hundreds of years into history. In the present time to modernize the practice and to make use of the huge patient bank in the future; kins of these service providers undergo programed medical school training to continue the practice in more organized way with seniors continuing their traditional treatment in backdrop as usual.
The majority of bonesetters (55%) are third generation in this trade, indicating strong hereditary skills passage and old history of skilled professionals. Treatment forms offered by the bonesetters range from massage and manipulation to reduction maneuvers and splintage with a variety of ointments and pastes containing herbal ingredients to apply locally. Inventory for “lape or pastes” is mostly natural, commonly available, warm in nature; cheap to procure such as camphor, turmeric, lime, or herbs such as Ashwagandha, Bilva, Kutki, Hadjod, Punarnava Guggulu, and oil preparations; supported by crepe bandage, bamboo sticks, and muslin cloth. Majority of these are skin irritants leading to skin blisters, skin peeling, and skin hardness. Many bonesetters use “Roti” cooked on one side and uncooked on one, to wrap around injured part. Condition of the Roti at subsequent sitting guides them about diagnosis and recovery. Some of the established centers in Kalupada, Kulailo, Athagad can attract 200–300 patients per day with various bone and muscle injuries.
Bonesetters have few set practices, if they have >10% lack of confidence in a particular case, they allow patients to take a second opinion or refer them to hospitals. However, treated patients were referred elsewhere only after 3rd bandage (9–10 days after injury – 90% bonesetters), if they do not find reasonable recovery or before if patients choose so. Vice versa is also true; patients visiting hospitals initially also land up to bonesetters subsequently to escape surgeries or professional treatment costs.
Bonesetters believe that patients who smoke or consume alcohol and who have diabetes, hypertension, or liver issues pose a big challenge, wounds take a longer time to heal and have a poor prognosis compared to healthy counterparts. They often face bias from the modern medical community but believe if people are patient and gave natural remedies, they would be surprised by quality of favorable results.
Bonesetters believe in a sense of bias from the modern medical community; but still, feel the need to collaborate and learn to enhance their treatment success rates. This includes moving with time by incorporating radiographs and allopathic medications in their daily practice. On the other hand, health workers, mainly the orthopedic professionals in developing continents, face challenges while treating patients complicated by bonesetters., High complication rates could be because they lack basic knowledge of anatomy, physiology, imaging, and principles of infection prevention and control practices. Western literature reports similar complications as encountered in our scenario such as gangrene, nonunion, joint stiffness, and limb infections in patient treated by TBS.,
Presently constitution of India considers bonesetter services and allied practices as quackery with well-defined Indian Penal Code (IPC) sections. Section 54 of the National Medical Commission Act, outlines punishment for quackery as imprisonment extending up to 1 year or a fine up to ₹5 lakh or both. One thousand eight hundred sixty IPC punishes quacks under Section 120B (criminal conspiracy), Section 420 (cheating), and Section 416 (impersonation).
However, it is important to understand their perspective as the practice is widely prevalent with good share of musculoskeletal injuries patients visiting the bonesetters daily. Unfortunately, treated patients are referred late; only after developing complications. Thus, medical institutions should educate, train, or ally with such experienced but not formally trained traditional bone setting providers to identify and treat such patients early; this will help reduce morbidity and patient dissatisfaction, thereby improving overall quality of orthopedic services.
| Conclusion|| |
Bonesetter's network is extensive and deeply anchored into our health-care system. Orthopedic surgeons and health-care associations should conduct CME, training workshops, personal interaction, and road shows to spread awareness about first aid, emergency splinting, and safe conservative orthopedic procedures.
Their spectrum of services includes sprains and dislocation in the spine and extremities; they avoid treating fractures. The treatment lasts 10–14 days in 3-day courses repeated as desired. Patient undergoing treatment is referred around 9th day, have high complication rate and cost per sitting is in tune of 3.60–4.80 USD.
Bonesetter's availability, accessibility, cost-effective treatment, and word-of-mouth popularity are strong point favoring rampant use of services by local community. It is wise to utilize these strong points to ensure safe orthopedic treatment in the community. Few strategies to initiate cooperation from them and reducing complications are by teaching them basics of wound care, injured limb evaluation, principles of fracture immobilization and techniques and indicators of fracture.
A sense of compassion and brotherhood will surely boost their confidence. With this gesture, it is possible that medical practitioners may get early referral from them for patients with fractures or patients whom they feel are beyond their scope of services. Catching these patients early are the prime point of interest for orthopedic surgeons. This symbiont way should help improve the quality of care for orthopedic services in the community with fewer complications across developing nations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]