Introduction

Kalari marmachikilsa (KMC) is an indigenous medical practice with origins in ancient India. It is a treatment method employing the knowledge of marmas which are vital energy points in the human body containing life force called prana (Acharya, 2014; Mishra and Shrivastava, 2022; Parashar and Shinde, 2023; Singh and Sabharwal, 2023; Tekam et al. 2023). According to KMC, the human body houses 108 marma points through which energy is channelled (Godbole et al. 2017). Obstructing this energy flow could result in health complications or fatality in the individual (Palazhy, 2021). The treatment method of KMC involves careful manipulation of such energy points by applying external pressure to heal and rejuvenate the body (Bhandare and Mhatre, 2021; Prabhu and Tantry, 2021). To stimulate marma points, practitioners utilize treatment techniques such as massages, herbal wraps, herbal poultices, and scrubs (Vinodan and Meera, 2018). Furthermore, the medicines used for KMC are largely prepared in the treatment centre utilising local herbs and medicinal plants (Abraham, 2009; Palazhy, 2021). Like many other non-codified healing traditions, KMC procedures are comprised of non-invasive and natural treatment methods. These unique practices of KMC distinguish it from other biomedical treatment systems. The KMC treatment is particularly effective for ortho-related ailments because it originated traditionally as a specialised treatment method for sport-related injuries sustained in an Indian martial art called, Kalarippayattu (Girija, 2022).

Kalarippayattu is often coupled with KMC and it is speculated to be one of the oldest martial arts in the world (Gulia and Dhauta, 2019; Meera and Vinodan, 2019; Tarun and Therattil, 2022; VM, 2023). It incorporates dance-like postures and movements aiming to enhance the endurance and flexibility of the body (Sreenath (2017)). This training helps to master both offensive and defensive techniques for armed and unarmed combat. Integrating the knowledge of marmas for combat purposes to incapacitate opponents makes Kalarippayattu stand out from other martial arts (Wu and Wang, 2023). Historically, knowledge of marma points (Bhishagratna, 1907) was used to treat injuries sustained in the war field or during combat and thus, KMC became an integral part of this martial art. The knowledge of KMC is taught orally to trusted candidates in the advanced stages of Kalarippayattu training. Hence even in contemporary times, there are limited healthcare providers (HCPs) of KMC.

KMC is part of a larger network of non-codified treatment options (Unnikrishnan, 2004). Contemporary research and practice encourage the coexistence and collaboration of multiple medical knowledge systems thereby providing an opportunity for patients to choose from different medical practices (Muyskens, 2024; Tilburt and Miller, 2007). Despite rampant technological advancements across medical fields, KMC remains a treatment availed by people, especially around the southern Indian state of Kerala. Even in the modern era with diverse treatment options, KMC is preferred by sectors of the population. Hence, this research investigates the perception of HCPs and Kalari marmachikilsa patients (KMPs) availing KMC to access this treatment method’s relevance, benefits and uniqueness. Results from this study contribute to establishing the reliability of KMC from the perspective of the respondents. Furthermore, this study provides insights into levels of patient satisfaction, the scope of treatment for various ailments and attempts to revive KMC as a viable alternate treatment method.

Method

Research design

This study uses a mixed-method approach by incorporating both qualitative and quantitative methodologies to understand the perception of HCPs and the KMPs being treated using KMC. A concurrent triangulation design was employed in the study to capitalise on the strengths of both qualitative and quantitative methodologies. To give them equal weightage, both types of data are gathered and analysed simultaneously in this framework (Hanson et al. 2005). The design was chosen to holistically comprehend the respondents’ perception of KMC’s treatment modality.

Quantitative methodologies are employed to elicit quantifiable aspects of KMC such as information about the treatment centres, procedures followed, the number of KMPs treated and their gender distribution. It also obtains information on predominant diseases for which treatment is availed, their cure rate and the satisfaction rate of the KMPs. Apart from providing basic knowledge about this treatment method and the functioning of treatment centres, the data collected provides insights into the perception of KMC within the studied demographic. Conversely, the qualitative dimension of the study elicits the respondents’ subjective explanations for the quantifiable data collected. This dual approach synergising quantitative and qualitative data enables the study to arrive at findings that are systematically validated and subjectively grounded in the experiences of the demographic. A mixed method design was chosen to deductively arrive at culturally enriching and novel findings on KMC.

Participants

The study was conducted in Kerala, the southwestern state in India with an area of 38,863 km2 (10.1632° N, 76.6413° E) and a population of 3,33,87677 (Kadakkadan and Subheesh 2011). A total of 30 KMC centres were chosen randomly from the available list of accessible centres in the 14 districts of Kerala state. From each centre, data were collected from two categories of respondents—HCPs and KMPs. Altogether, the study involved the participation of 180 respondents. Among these, 30 individuals were HCPs with one each from each centre. HCPs were selected using purposive sampling, and a minimum of 10 years of experience in practising KMC was set as an inclusion criterion. Additionally, five KMPs each from each centre amounting to a total of 150 respondents were selected. A convenience sampling method was used to select the respondents based on their availability and willingness to take part in the study. All the HCPs who participated in the study were male with an average age of 53.37 (SD = ± 10.226). Among the 150 KMPs, 62.0 percent were male with an average age of 44.9 (SD = ± 11.358) and 38.0 percent were female with an average age of 42.46 (SD = ± 9.573).

Demographic details of the respondents

Table 1 shows the frequency distribution of demographic details of the sample population. Among the HCPs, about 50 percent were qualified above the higher secondary level and 40 percent had completed higher secondary education. About 93.3 percent HCPs were self-employed and 6.7 percent were employed in the private sector. Meanwhile, 51.4 percent of KMPs were graduates and 34.7 percent completed higher secondary level schooling. It can also be observed that 45.3 percent of KMPs were employed in private/government sector, 25.3 percent were self-employed, and 29.3 percent were unemployed.

Table 1 Demographic characteristics of the respondents in the study.
Full size table

Instruments

Two separate semi-structured questionnaires were devised to elicit responses from HCPs and KMPs. Questions on sociodemographic details were the same for both questionnaires. The second set of questions for HCPs focused on information related to their knowledge about KMC, attitude towards treatment, experience, and practices followed. However, the second set of questions for the KMPs was based on their experiences with treatment in the healthcare facility, the cost incurred, and the quality of treatment provided by the HCPs. The questionnaire also examined their levels of satisfaction with the facility and providers. Two five-point Likert scales and one 10-point rating scale were used to assess attitudes, satisfaction, and experience of HCPs and KMPs respectively. With respect to the Likert scale, respondents were required to rate each question either on a scale of 1 (Extremely Unsatisfied) to 5 (Extremely Satisfied) or on another scale of 1 (Very Good) to 5 (Very Poor). The endpoints of the 10-point rating scale were 1 being ‘very unlikely’ and 10 being ‘very likely’.

Procedures

The primary foci in project planning were on tool development, finalising sample size, deciding study setting, obtaining ethical clearance for data collection and pretesting the questionnaires. The two semi-structured questionnaires specific to the sample group were formulated based on the literature review and study objectives. Employing stratified random sampling, 7 districts of Kerala state were selected thereby representing 50 percent of the districts in the selected state. The 30 KMC centres selected were distributed among the seven districts concurrent to the proportion of the number of centres present in each district. After obtaining ethical clearance for data collection from the home institute, a pretest was conducted in May 2023. The pretest helped to revise the questionnaires and obtain appropriate information in the ensuing data collection.

With the finalised questionnaires, all the respondents were interviewed face-to-face in the respective healthcare facilities at their convenience. One of the authors conducted all interviews privately while ensuring participants’ privacy. During the process, the researcher assumed the role of an active listener and collected relevant information employing non-suggestive questions. The author attempted to reduce any interviewer bias and elicit honest opinions from the participants. All the respondents chose to communicate in the vernacular language (Malayalam) for their interviews. As the data involves a qualitative component, the responses were tape-recorded with their consent. Before conducting the interviews, written informed consent was obtained from all the respondents of the study. Data collection was carried out from May to July 2023 and the data were stored digitally after removing identifiers to maintain confidentiality. In the spirit of self-reflexivity, the authors acknowledge their positionality as researchers originating from the state of Kerala and their familiarity with the language and culture of the state. We acknowledge that our positionality might have influenced the study’s findings to some extent.

Analysis

The responses were analysed separately as quantitative and qualitative data sets. Descriptive statistics for quantitative data were processed using SPSS v27 software, and qualitative data were thematically analysed. The verbatim of the open-ended questions (qualitative) was transcribed and translated into English. The transcripts were read multiple times to identify themes that are repeatedly observed in the data set. Iterative comparison was employed to carefully study the data to identify representative passages and significant themes. Themes identified were categorised, coded and interpreted using ATLAS.ti software. The analysed quantitative and qualitative data were compiled to consolidate the findings.

Result

KMC as a treatment modality

All the HCPs predominantly provided treatment for ailments like sports injuries, spondylosis (a form of degenerative disorder of the spine (Prescher, 1998)), back pain, orthopaedic and muscle injuries and tissue-related problems. In addition, 60 percent of HCPs provided treatment for neurological ailments. The KMPs who participated in the study were undergoing treatment for joint pain (36 percent), general body wellness (16.7 percent), back pain (14.7 percent), spondylosis (12.6 percent), muscle-related ailments (8.7 percent), neurological issues (5.3 percent), sports injuries (3.3 percent), and other ortho related ailments (2.7 percent). The treatment procedures of KMC consist of oil massages, bone setting, herbal poultices and wraps, and other lifestyle modifications. Through these procedures, KMC aims to rejuvenate the body and stimulate particular marma points associated with the ailments thereby treating the underlying cause of illness. This argument is supported by the responses of a HCP and KMP given below:

'Mostly, external treatment like massages, bone setting, herbal poultices etc. are provided for our patients.' (HCP 9)

'I was happy when I was told to eat nutritious food and take rest while undergoing herbal poultice massage twice a week. I did not have to take any medicines.' (KMP 80)

Many HCPs did not find the need for in-patient service and 66.7 percent of the centres only had outpatient services. Whereas 33.3 percent of centres offered both outpatient and inpatient services. Concerning the gender distribution of KMPs, as many as 33.3 percent of the HCPs responded that they receive an equal number of male and female KMPs. However, 43.3 percent expressed that male KMPs were higher (55 percent to 70 percent of male KMPs), and 23.7 percent stated that the number of female KMPs was higher (55 percent to 60 percent of female KMPs).

A natural treatment method

KMC employs the use of various herbs and medicinal plants in their treatment procedures thereby making it a natural treatment option. As many as 80.7 percent KMPs preferred this treatment method because of the sustainable values inherent in KMC. The comments from respondents affirm this argument.

'I came to this centre because no chemicals are used for treatment here, and that is something difficult to find nowadays in any treatment method.' (KMP 117)

As many as 60 percent of HCPs mentioned that the average duration of treatment for one episode ranged from one to three weeks. Also, 99.3 percent of KMPs chose KMC only for particular ailments such as orthopaedic and neuromuscular ailments and general rejuvenation therapy.

Trust in KMC

All HCPs and KMPs exhibit a high degree of trust in the treatment method. The oldest KMC centres in the study to which the HCPs were affiliated date back to 1930 and the latest one was established in 2014 (Median: 1991). While all KMC centres provide both preventive and curative treatments, there are specific ailments that this treatment method specialises in. HCPs conduct a preliminary screening of KMPs to assess the treatability of the ailments presented. The HCPs’ positive perception of KMC was reflected in the reported cure rate of KMPs. All HCPs report that the cure rate for this treatment was above 70 percent, and among them, 50 percent stated it was 90 percent or above and 43.3 percent responded it was between 80–89 percent. Following are the verbatims from respondents elaborating on their trust in this treatment method:

'People who know about this method understand its true potential. All the patients coming to the centre are either through references from previous patients or from relevant sources. The centre always had patients and never had to advertise to get patients. This demonstrates the people’s perception about this treatment.; (HCP 10)

'In this treatment method, I know what is going to happen and can trust the medic.' (KMP 83)

KMPs’ satisfaction with the treatment

KMPs’ satisfaction was evaluated using a 5-point Likert scale (1 being ‘Extremely Unsatisfied’ and 5 being ‘Extremely Satisfied’) on eight aspects of the treatment. The descriptive statistics of the assessment revealed an overall mean score of 4.522 (SD = 0.392). Satisfaction with the process of making an appointment for consultation had the highest mean score of 4.75, followed closely by the HCP’s expertise in diagnosing (4.73) and the professionalism of the HCP (4.72). Similarly, KMPs expressed high satisfaction with other aspects of KMC such as care provided by the HCP (mean score—4.60), the expertise of the HCP in treatment (mean score—4.43), the cure process after treatment (mean score—4.37), overall satisfaction with the treatment method (mean score—4.33) and rehabilitation after treatment (mean score—4.25). The Cronbach’s alpha coefficient for the scale was 0.855, indicating a high level of internal consistency. Satisfaction with treatment drew many KMPs to the centres, and on average, they received 37.1 male and 30.5 female KMPs in a month. These aspects cumulatively contributed to forming a positive perception of HCPs and all KMPs expressed that they are satisfied with the treatment.

Perceived side effects of KMC

As many as 80.7 percent believed this treatment had no side effects, while 19.3 percent were uncertain about the existence of side effects. HCPs responses validated this belief and this contributed to better satisfaction with the treatment among the respondents. The following quotes show the perception of respondents on side effects:

'There are no harmful side effects for this treatment. The worst that can happen is that it may not completely cure the illness… that may be due to some other body condition.” (HCP 29)

'I have not heard of any side effects of this treatment.' (KMP 84)

Affordability

As many as 70 percent of HCPs reported that the minimum per day cost ranged from 350 to 500 Indian Rupees (approximately 4 to 6 US dollars) depending upon the treatment they provide. The overall cost of the treatment was affordable to the KMPs, and it was revealed from their verbatims.

'Compared with other treatment methods, KMC is not expensive.' (HCP 13)

'I have tried other treatment options for my shoulder dislocation, and the medics suggested surgical intervention which would cost a lot more than the current treatment.' (KMP 43)

Religious influence and KMC

The responses from HCPs and KMPs elicited dichotomous views on the influence of Hindu religion on KMC. The vast majority of 86.7 percent of HCPs stated that religious beliefs were intertwined with the treatment practice, whereas 13.3 percent HCPs opposed this belief. KMC is closely linked to the Indian martial art form of Kalarippayattu and is considered the appropriate treatment method for those injured in the practice of martial arts. The following response from a HCP elaborates on the influence of religion on Kalarippayattu and KMC:

'Kalarippayattu has religious beliefs in it, if you see a kalari you will understand that. We all learn kalarippayattu first and then chikilsa (KMC), so we cannot say chikilsa is not religious, there will always be those beliefs within us.' (HCP 30)

The responses opposing religious influence were rooted in the conviction that faith-associated rituals or practices in the healing process may not always be attributed as religious. The following are some of the responses subscribing to this view:

'There are certain religious rituals followed in kalarippayattu, but that is not the case for marmachikilsa. This is a treatment like any other.' (HCP 28)

'As a patient, I was never told to follow any religious ritual while undergoing treatment.' (KMP 60)

'It is with faith we do all things. If I do not believe in a treatment method, I will not resort to it and it may not be effective too. I am not sure if this can be termed religious.' (KMP 70)

Need for reviving KMC

The one notable criticism of KMC that 65 percent of the HCPs expressed was that the treatment method of KMC is neglected in contemporary times and needs revival. They observed that institutionalized support for establishing KMC as an alternate medical practice with commonly established treatment procedures is lacking. Below are some comments from HCPs:

'…lack of institutionalized support restricts the growth of this traditional practice.' (HCP 16)

'I believe that there should be more coordination among practitioners. For a treatment method to flourish, practitioners should work together to provide quality treatment for the patients. They should not work as individual units.' (HCP 24)

Another observation from the responses collected highlighted the lack of documentation of this knowledge system. Books or articles on various aspects of KMC treatment are limited in the available literature as most of the treatment procedures are not standardized. The responses of HCPs state that knowledge of KMC is orally imparted and experientially acquired. The following are some of the HCPs thoughts on documentation of KMC:

'…At present, there are not many texts specifically for KMC. I strongly believe it should be documented and preserved for future generations. Otherwise, it will affect the quality of this treatment method.' (HCP 17)

'When we check other treatment disciplines, their whole system relies on texts and books. This is not the case with KMC, there are not many texts on this treatment procedure.' (HCP 19)

It was observed from the responses that there was a definitive need for literature development specific to KMC and its various treatment modalities. The respondents have stated that limited studies in this field affect the overall perception of KMC as a treatment practice. This point repeatedly appeared in the responses and a few of them are given below:

'Modern medicine is flourishing due to the numerous research studies that happen each day in the scientific field. The same should happen with KMC establish it as a scientific treatment method.' (HCP 23)

'Studies can give scientific evidence to show the effectiveness and benefits of this treatment method. I think such studies are less compared with other treatment methods.' (KMP 28)

Awareness of KMC

As many as 55.4 percent of the respondents became aware of this treatment method through family members, friends, relatives, or coworkers. Among them, 32.6 percent of the respondents had past experience of this treatment method and 12 percent of respondents preferred KMC for its affordability, novelty and rejuvenation therapy. Even though awareness of KMC is created through word-of-mouth, the data collected reveals that before opting for this treatment method the majority of KMPs had tried other treatment options. As many as 56.7 percent of the KMPs had resorted to allopathic medicine, 7.3 percent had tried homoeopathic treatment, 8 percent had tried multiple treatment methods, and 2 percent had opted for Ayurveda. Only 26 percent preferred KMC as their first choice for treatment. Both HCPs and KMPs emphasized the need to create awareness of KMC as an alternate treatment method. Given below is a response from a respondent iterating the need to create awareness of KMC:

'I feel like there is a general lack of awareness about the treatment among this generation. It may be because people are moving away and following modern medicine for all health-related issues.' (KMP 34)

Discussion

This study examines the perception of KMC from the standpoint of HCPs and KMPs. While prior studies have explored various dimensions of KMC, a study based on perception is a novel contribution to the existing literature on KMC. The present study confirms the argument purported by previous studies that KMC is traditionally male-centred (Mandakathingal, 2020). All HCPs who participated in the present study were male. The HCPs gain expertise in practical and technical know-how of KMC procedures with hands-on training in the KMC centre (Zarrilli, 1998, p. 154). The majority of HCPs were formally educated and had qualified higher secondary degree or above. In KMC, training and experience are valued over formal education. KMC is also faced with a shortage of authorized institutions offering a standardized certifiable course on the treatment procedures (Vinodan and Meera, 2023). It was also noticed that KMPs seeking KMC treatment had completed higher secondary education or held higher educational degrees indicating that this treatment is accepted by educated individuals. High self-employment among HCPs indicates lack of employment prospects in public and private domains. Though the sample demography is not representative of Kerala’s population, the specific findings obtained from the responses help this study understand HCPs’ and KMPs’ broader perception of KMC.

Consistent with the findings of previous studies, this study iterates that this treatment is largely provided for orthopaedic ailments (Dhiman and Srikanth, 2020; Vinodan and Meera, 2018, 2023). Most of the procedures in this treatment method are non-invasive. Prior studies have cited the treatment modality as a unique feature of KMC (Harishbhai and Kumar, 2019; Joshi et al. 2020; Nirmal, 2022). The study also finds that male and female KMPs avail KMC despite the percentage of male KMPs being relatively higher. Signifying that the number of female KMPs availing the treatment is increasing, a recent study details KMC’s benefits for female KMPs in eliminating fatty deposits and maintaining vitality (Vinodan and Meera, 2023). Further studies are necessary to determine the effect of HCP’s gender on the gender distributions of KMPs availing treatment in that centre.

Multiple factors influence the duration and cost of treatment such as the particular ailment that KMPs are treated for, the duration of the health problem, and the immunity level of KMPs. Despite the relatively longer treatment duration of KMC, this study reaffirms that KMC is a cost-effective treatment method. Past studies also echo this finding that KMC is cost-effective (Deshpande et al. 2020; Saini et al. 2020). Studies also show that accessibility and convenience to healthcare services can have a higher impact on patient satisfaction (Ganasegeran et al. 2015). The cost-effectiveness of procedures makes this treatment a viable option for common people. The study infers that higher patient satisfaction can be attributed to the greater confidence in HCPs in the treatment method. Taking all these factors into account, KMC creates a positive perception among respondents.

Patient satisfaction is a vital component in the healthcare field as it is linked directly to the retention of KMPs, the quality of the healthcare facility and the efficacy of the treatment (Hooker et al. 2019; Ng and Luk, 2019). HCPs who participated in the study state that all KMPs are very satisfied with the treatment provided. The same was echoed in the responses given by KMPs. They stated that they were satisfied with various aspects of treatment such as HCPs’ professionalism, the treatment process, cure rate, care received, rehabilitation and the quality of treatment. This study translates positive patient experiences of a traditional medical system into terms (such as patient satisfaction) understood in different science, knowledge, and healthcare domains, notably the biomedical. Moreover, it does this without measuring the indigenous medical system against incompatible biomedical criteria as the metrics of perception and patient satisfaction can be applied to any healthcare system. Supporting previous studies (Tiwari et al. 2021; Wu and Wang, 2023), this study finds that KMC uses a natural way of treatment. This, in turn, was found to increase the trust that KMPs had in this treatment method. This study finds that the treatment resulted in no known adverse side effects in KMPs. Earlier studies also reinforced that this treatment method if done by an experienced practitioner had zero known adverse side effects (Tiwari et al. 2021). Unlike their predecessors these findings are rooted in patient and practitioner perspectives and affirm KMC’s potential to act as an effective alternative or complementary healing practice.

Many HCPs expressed that Kalarippayattu and KMC share the same religious context citing the intertwining of KMC with the Indian martial art of Kalarippayattu in myths and oral tales (Luijendijk, 2008). HCPs also state that KMC might have some religious practices as faith-based rituals are followed by practitioners of Kalarippayattu (Pati, 2010). Reiterating the importance of faith as the underlying aspect of healing (Menon, 2019), the majority of the HCPs who participated in the study expressed their faith in particular religions. However, the study finds that religious rituals or customs are not part of KMC treatment procedures. KMPs support this finding by acknowledging that they were not asked to partake in any religious ritual during the treatment. Practices followed in KMC are solely for KMPs’ health benefit.

The year of establishment of KMC centres attests to the practical experience of centres that participated in the study. Decades-long healthcare provided by these centres testifies to their credibility and the consistent treatment quality delivered by HCPs serving in the centre. The study finds that there exists a positive perception of KMC as its centres rely on word-of-mouth publicity from satisfied KMPs. Although the expertise of HCPs and the experience of KMPs demonstrate a better perception of KMC, the study identifies a lack of awareness among people on KMC. The study also found that the qualitative and quantitative results were in agreement in all aspects. Concurrent with the data analysed, the study predominantly presents positive perceptions of participants on KMC. There might be a few reasons for the existing pattern of the lack of negative responses among the participants on KMC. All the participants selected were patients availing treatment from KMC centres. As mentioned in the result, the majority of them opted for KMC due to their own experience or recommendation from satisfied patients. Similarly, a preliminary screening of patients is conducted by HCPs prior to treating them. This screening is to exclude patients/conditions that are beyond KMC’s range of treatments. KMC largely treats ortho-related issues. The specialized treatment offers an improved cure rate thereby instilling trust in the treatment method of KMC. These factors could have resulted in the lack of critical observation among the participants. Further studies involving patients who discontinued the KMC treatment would shed light on the potential deficits of this treatment method.

Conclusion

This novel study examining practitioner and patient perceptions of the Kalari marmachikilsa health system found largely positive responses, indicating the ability of Kalari marmachikilsa to cure specific ailments. The study revealed the acceptability, affordability and credibility of this treatment method. Irrespective of all the positive factors that this treatment method offers, this study finds that Kalari marmachikilsa lacks institutionalized support. The extensive growth of this treatment practice is impeded due to the lack of research and development facilities. Consequently, this has resulted in the practice of non-standardized treatment procedures across centres. This study also demonstrates one way to measure and communicate patient perspectives of traditional treatments in a manner that can be understood by proponents of any medical system. A comprehensive study to revive this traditional treatment method is imperative to institutionalize kalari marmachikilsa as an alternate or complementary healing system.