vaitaranabast amavata pk021_gdg

EVALUATION OF THE EFFICACY OF VAITARANABASTI IN AMAVATA - AN OBSERVATIONAL STUDY

By

Dr. DEVENDRAPPA. F. BUDI.

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI M.D.

In PANCHAKARMA Under the Guidance of

Dr. P.Shivaramudu, M.D. (Ayu), M.A. (SAN), M.A (PSY)

Professor, Post Graduate Department of Panchakarma.

And co-Guidance of

Dr. Santosh. N. Belavadi, M.D. (Ayu)

Lecturer, Post Graduate Department of Panchakarma.

DEPARTMENT OF PANCHAKARMA POST GRADUATE STUDIES AND RESEARCH CENTER

SHRI.D.G.MELMALAGI AYURVEDIC MEDICAL COLLEGE GADAG -582103

2007

EVALUATION OF THE EFFICACY OF VAITARANABASTI

IN AMAVATA - AN OBSERVATIONAL STUDY By

Dr. DEVENDRAPPA. F. BUDI.

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka.

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI (M.D)

In PANCHAKARMA Under the Guidance of

Dr. P. Shivaramudu, M.D. (Ayu), M.A. (SAN), M.A (PSY)

Professor, Post Graduate Department of Panchakarma. And co-Guidance of

Dr. Santosh. N. Belavadi,

M.D. (Ayu)

Lecturer, Post Graduate Department of Panchakarma.

DEPARTMENT OF PANCHAKARMA

POST GRADUATE STUDIES AND RESEARCH CENTER SHRI.D.G.MELMALAGI AYURVEDIC MEDICAL COLLEGE

GADAG -582103 2007

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

DECLARATION BY THE CANDIDATE

Hereby declare that this dissertation / thesis entitled “Evaluation of the Efficacy

of Vaitaranabasti in Amavata – An observational study” is a bonafide and genuine

research work carried out by me under the guidance of Dr. P. Shivaramudu, M.D.

(Ayu), M.A. (SAN), M.A. (PSY), Professor, Post-graduate department of Panchakarma

and co-guidance of Dr. Santosh.N.Belavadi, M.D. (Ayu) Lecturer, Post graduate

department of Panchakarma.

Date: Signature of the Candidate

Place:

(Dr. Devendrappa. F. Budi)

SHRI D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG.

POST GRADUATE DEPARTMENT OF PANCHAKARMA

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “Evaluation of the Efficacy

of Vaitaranabasti in Amavata – An observational study” is a bonafide research work

done by Dr. Devendrappa. F. Budi in partial fulfillment of the requirement for the

degree of Ayurveda Vachaspathi. M.D. (Panchakarma).

Date: Signature of the Guide

Place: Gadag. Dr. P. Shivaramudu M.D. (Ayu), M.A. (SAN), M.A (PSY)

Professor, Post Graduate Department of Panchakarma. Shri D. G. Melmalagi Ayurvedic Medical College,

Gadag – 582103.

SHRI D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG.

POST GRADUATE DEPARTMENT OF PANCHAKARMA

CERTIFICATE BY THE CO-GUIDE

This is to certify that the dissertation entitled is “Evaluation of the

Efficacy of Vaitaranabasti in Amavata – An observational study” a bonafide research

work done by Dr. Devendrappa. F. Budi in partial fulfillment of the requirement for the

degree of Ayurveda Vachaspathi. M.D. (Panchakarma).

Date: Signature of the Co-Guide Place: Gadag. Dr. Sontosh. N. Belavadi, M.D. (Ayu).

Lecturer, Post graduate department of Panchakarma. Shri D. G. Melmalagi Ayurvedic Medical College,

Gadag – 582103.

SHRI D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG. POST GRADUATE DEPARTMENT OF PANCHAKARMA

ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION

This is to certify that the dissertation entitled “Evaluation of the

Efficacy of Vaitaranabasti in Amavata – An observational study” is a

bonafide research work done by Devendrappa. F. Budi under the guidance of

Dr.P.Shivaramudu, M.D. (Ayu), Professor, Postgraduate department of Panchakarma

and co-guidance of Dr. Sontosh. N. Belawadi, M.D. (Ayu), Lecturer Post graduate

department of Panchakarma.

Dr.G.Purushottamacharylu, M.D. (Ayu) Dr. G. B. Patil.

Professor & HOD Post graduate department Principal

Of Panchakarma. Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103.

COPYRIGHT

Declaration by the candidate

I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka

shall have the rights to preserve, use and disseminate this dissertation / thesis in print

or electronic format for academic / research purpose.

Date: Signature of the candidate

Place:

Dr. Devendrappa. F. Budi

© Rajiv Gandhi University of Health Sciences, Karnataka.

Acknowledgement

Any research is never an individual effort. It is contributory effort of many hearts,

hands and heads. It gives me inexpressible pleasure to offer my sincere thanks to all those

who have rendered their wholehearted support, guidance and Co-operation in completing

my thesis work.

I express my deep sense of gratitude to their great holiness of Shree

Gonibasaveswara and Shree Bidarallyamm for their divine blessings.

My deep sense of gratification is due for my father Dr.Fakkirappa. M. Budi and

my Mother Smt. Neelamma, who are the architects of my career, culture and discipline,

which I could imbibe, are solely because of their pains taking, upbringing and strong

moral support.

I express my obligation to Shri.H.Beerappa and Smt.Pushpa, Mantesh,

Harshavardhana, Yashoda, Shri.Dayanadappa and Smt.Prema, Guramma, Arunkumar

and Gurunatha, Shri.Ningappa and smt Annalakshi, Savita, Shreekant and Shashikanta,

Shri.H.Basavarajappa and smt Shoba, Komalakrisha, Nivedita and Ravichandra for their

valuable support.

I express my obligation to my honorable H.O.D, Dr. G. Purushothamacharyulu

M.D. (Ayu), H.O.D., P.G. Department of Panchakarma, P.G.S&R, D.G.M.A.M.C, Gadag

for his critical suggestions and expert guidance for the completion of this work.

I am extremely happy to express my deepest sense of gratitude to my beloved

Guide Dr.P.Shivaramudu.MD(Ayu),M.A.(SAN),MA(PSY), Professor, P.G. Department

of Panchakrma, P.G.S & RC, D.G.M.A.M.C, Gadag whose sympathetic, scholarly

suggestions and guidance at every step have inspired me not only to accomplish this work

but in all aspects.

I express gratitude to my Co-Guide Santhosh. N. Belavadi MD (Ayu), Lecturer,

P.G. Department of Panchakarma, P.G.S & RC, D.G.M.A.M.C, Gadag for his constant

supervision, guidance encouragement and wholehearted support during my research

study.

I express my deep gratitude to Dr .G.B Patil, Principal, D.G.M.A.M.C, Gadag, for

his encouragement as well as providing all necessary facilities for this research work.

I express my sincere gratitude to Dr. Sureshbabo. MD (Ayu) Professor, P.G.

Department of Panchakarma, P.G.S & RC, D.G.M.A.M.C, Gadag. Dr. Sahidhar.H.

Doddamani. MD (Ayu) Lecturer, for their sincere advices and assistance. Dr.C.V.Rajshekar.

MD (Ayu) Lecturer P.G. Department of Panchakarma, for their sincere advices and

assistance. Dr.P. Yasmin, MD (Ayu) Lecturer P.G. Department of Panchakarma, for their

sincere advices and assistance.

I take this opportunity to thank HOD’s of other departments

Dr.M.C.Patil MD (Ayu), Dr.Varadhacharyulu MD (Ayu), and Dr.G.V.Mulgund MD (Ayu) for their

inspiration and valuable suggestions.

I am grateful to all the PG teachers Dr.K.S.R.PrasadMD.(AYU), Dr.R.Y.Shetter

MD(AYU), Dr.A.Samudri.MD(Ayu), Dr.Girish.Danappagouder,MD(Ayu), Dr.Jagadeesh.

G.Mitti.MD.(AYU), Dr.Kuber.SankMD.(AYU), Dr.Dilipkumar.B,MD(Ayu), Dr.Shashidhar

NidagundiMD.(AYU)), and other PG Staff. For their valuable suggestions.

I extend my immense gratitude to Dr.G.S.Hiremath, Dr.S.A.Patil, Dr.U.V.Purad,

Dr.B.G.Swami, Dr.Paraddi, Dr.Sajjana, and Dr.Shankaragouda, Dr.G. Yarageri,

Dr.S.H.Radder, Dr.Mulkipatil and Tippanagouder (Lab technician) and other teaching

staff who helped during my study.

I am greatly thankful to my friend Dr.Vanishree and friends, Deepamol.K.and

Mr.Santosh. B. Hugar, BE (Civil) for their valuable support.

I would like to express my sincere thanks to Librarian Shri.V.M.Mundinamani,

and Asst Librarian Shri.S.B.Sureban and Shri Shavi for providing valuable books in time

throughout the study.

I take this moment to express my thanks to all my Departmental Friends Dr.

Subin, Dr. Febin, Dr. Satheesh, Dr. Santosh, Dr.Varsha Dr. Shaila, Dr.Mahantesh

Hugar, Dr. Chandramouli, Dr. Jayaraj, Dr. Kendadmath, Dr. Hakkandi, Dr. Ashwin,

Dr.lingaraddy, Dr.Vijay, Dr.Manjunath Akki, Dr. Sibu , Dr.Payappagouder, Dr.prasanna,

Dr. Madhushree, Dr.Nataraj, Dr. Udayaganesh, Dr adarsh, Dr,Mukta, Dr.Shailej.

Dr.Deepak. Dr.Jayashankar, Dr, Rajesh, Dr.Sabareesh, Dr.Sanath.

I take this moment to express my thanks to all my Post Graduate friends

Dr.Channaverswami, Dr.Krishna, Dr.Gavi, and Dr.Sarvi. Dr.Kalmath, Dr.Ashok,

Dr.Kendadmath, Dr.Sajjanar, Dr. Basavaraj Ganti, Dr.Pradeep, Dr.Venkareddy, ,

Dr.Sunita, Dr.Bingi, Dr.Ratan, Dr.Uday, Dr.Hugar, , Dr.Ashwini, , Dr.Shalini, Dr.

Shivaleela,Dr.Kataraki, Dr,Kattimani, Dr. Sulochana, Dr.Jayashree Dr.Anita, and other

post graduate scholar for their support.

I am very much thankful to Smt. P. K. Belavadi, Mr. M. M. Joshi, Mr. Shankar,

Mr. Biradar, Mr. Dasar and Smt. Sarangamath and Mr. Kulakarani.

Last but not least, I thank to the patients who are pillars of my research work.I

express my thanks to all the persons who have helped me directly & indirectly with

apologies for my ability to identify them individually.

Dr. Devendrappa. F. Budi.

Abstract: In Ayurveda chikitsa is broadly classified into two parts shodhana and shamana. Here

also shodhana occupies first place. Among five shodhana procedures Vasti is one among

them and it has been called as Ardhachikhtsa.

Amavatat is commonest among chronic inflammatory joint diseases in which joints

become swollen, painful, and stiff. It is a debilitating disease in view of its chronicity and

complications. Therefore, it has taken the foremost place among the joint disorders.

The crippling nature, repetitive attacks and chronic course of Amavata, forced the

scientific world to conduct extensive studies on Amavata. Unfortunately the man has not

succeeded in eradicating this diseases and find to come out with successful therapeutic

measures that can cure the patient completely.

So the disease drawing attention for the consideration of research firstly due to

gravity of the problem secondary due to lack of suitable medicines and society of present

era are looking for the successful management of Amavata. So the present study is

entitled “EVALUATION OF THE EFFICACY OF VAITARANA BASTI IN

AMAVATA” – An observational study is undertaken.

The objectives of the study are 1). To Evaluate of the effect of Bastikarma in

Amavata. Anad 2).To Evaluate of the efficacy of Vaitaranabasti in Amavata.

The aim of this study was to find out the effect of Vaitaranabasti in the management

of Amavata. The study is a prospective observational clinical trail in a single group of 30

patients, where all the patients received Vaitaranabasti for 8 days and a parihara kala

(follow up) of 16 days is given.

Subjective parameters i.e. Bahusandhishoola, Bahusandhishota, Stabdhata and

Spershasahishnuta are the chief complaints of Amavata and objective parameters are

Hb%, ESR, CRP, RA, NRS(Assessment of pain),VAS(Assessment of pain), RAI,

EAMRAI, GDA, AIMS, Physical Disability, Walking Time, Grip Strength, Range of

Movements, DAS criteria, Ayurvedic health assessment, Assessments are done before

and after the treatment.

Among 30 patients, 13 (43.33%) patients were shown good response i.e. above 75% in

signs and symptoms, 17 (56.66%) patients responded moderately i.e. 50-75% in signs and

symptoms. all the subjective and objective parameters showed highly significant.

Amavata is a Kapkavata vyadhi affecting people in the Madhyama avasta. The

disease is obtained by the involvement of Ama and Vata, characterized by Ruja and

Shotha in Sandhi sthanas. Therefore, the agents/therapies of Amapachana, Lekhana,

Vatanulomana etc, and properties should be used in this disease. So Patyadichurana is

used for Deepanapachana, Sadyovirechana (Eranda taila) imparts Agnideepana,

Vatanulomana and opens up the srotas in the shareera facilitating more nourishment and

free movement of Vata dosha followed by Vaitaranabasti. Vaitaranabasti. is prime

treatment for Amavata in turn plays vital role in correcting pathology of the disease and

gives remarkable results.

This results in the relief of symptomatology of the disease, by acting locally and

systematically. The ingredients of the Vaitaranabasti are having the quality of deepana,

pachana gunas, which dairectly influences the koshtagni and dhatwagni, which inturn

leads to pachana of already existing ama and obstructs the further production of ama.

And it is also having vatanulomana and vata shlesmahara properties. There by, it is an

ideal treatment of choice in Amavata.

Key words: - Patyadi choorna, Eranda tail-Sadyovirechana, Amavata, Rheumatoid

Arthritis, Vaitaranabasti.

TABLE OF CONTENTS

Chapters Page No

1. Introduction 01 - 04

2. Objectives 07 - 07

3. Review of Literature 08 - 63

4. Methodology 64 - 76

5. Observations and Results 77 - 105

6. Discussion 106 - 128

7. Conclusion 129 - 130

8. Summary 131 - 132

9. Bibliography 133 - 147

10. Annexure

List of Tables

Table No Page No

1. Showing Amavata Nidana according to various Acharyas 29

2. Showing the similarity between Amavata and Rheumatoid Arthritis 34

3 Showing lakshans According to different Ayurvedic classics 36

4 Showing the Sthananusara Laxana 37

5 Showing various Upakramas have been prescribed by different 44

Acharyas for the treatment of Amavata:

6. Showing extra articular features of RA 53

7. Showing differential diagnosis regarding with Amavata 55

8 Showing the Composition and Properties of Patyadi Churna 63

9. Showing the Quantitative assessment of pain 70

10. Showing the Ayurvedic Health Assessment (AHA): 72

11. Showing the Arthritis Impact Measurement Scale (AIMS) 73

12. Showing Physical Disability 74

13. Showing distribution of patients by age groups 77

14. Showing distribution of patients by Sex 78

15. Showing distribution of patients by Socioeconomic Status 79

16. Showing distribution of patients by Dietary habits 80

17. Showing distribution of patients by Treatment history 81

18. Showing distribution of patients by Koshta 82

19. Showing distribution of patients by Jataragni 83

20. Showing distribution of patients by Vyasana 84

21. Showing distribution of patients by Dehaprakruti 85

22. Showing distribution of patients by Occupational Status 86

23. Showing distribution of patients by Religion 87

24. Showing distribution of patients by RA factor 88

25. Showing distribution of patients by CRP Titer 89

26. Showing distribution of patients by Bahusandhishoola

Response to the treatment 90

27. Showing distribution of patients by Bahusandhishota


28. Showing distribution of patients by Bahusandhigraha


29. Showing distribution of patients by Sparshasahishnuta


30. Showing distribution of patients by walking time


31. Showing distribution of patients by Grip Strength


32. Showing distribution of patients by Range of movements’


33. Showing distribution of patients by DAS criteria


34. Showing the overall effect of treatment 98

35. Showing the Data related to the response of Treatment to

Subjective parameters 99


objective parameters 100







40. Showing the statistical analysis of Subjective and

Objective parameters 104

41. Showing the mean % improvement of Subjective and

Objective parameters 105

List of Graphs

1. Showing distribution of patients by age groups 77

2. Showing distribution of patients by Sex 78

3. Showing distribution of patients by Socioeconomic Status 79

4. Showing distribution of patients by Dietary habits 80

5. Showing distribution of patients by Treatment history 81

6. Showing distribution of patients by Koshta 82

7. Showing distribution of patients by Jataragni 83

8. Showing distribution of patients by Vyasana 84

9. Showing distribution of patients by Dehaprakruti 85

10. Showing distribution of patients by Occupational Status 86

11. Showing distribution of patients by Religion 87

12. Showing distribution of patients by RA factor 88

13. Showing distribution of patients by CRP Titer

14. Showing distribution of patients by Bahusandhishoola


15. Showing distribution of patients by Bahusandhishota


16. Showing distribution of patients by Bahusandhigraha


17. Showing distribution of patients by Sparshasahishnuta


18. Showing distribution of patients by walking time


19. Showing distribution of patients by Grip Strength


20. Showing distribution of patients by Range of movements’


21. Showing distribution of patients by DAS criteria


22. Showing the overall effect of treatment

List of flow chart 1. Flow chart showing Samprapti of Amavata 31

2. Flow chart showing pathogenesis of RA 51

Introduction

Introduction

Ayurveda assigns of locomotor and associated motor functions to the five

karmendriaas ex: Vak, Pani, Payu, Pada and Upasta. Vata is the driving force to perform

normal activities of karmendrias. Pitta performs its functions through substantive and

metabolic power which is the cause of bio chemical energies, and kapha through the

nourishing and preserving powers which protect the human organism.

Dharma, Artha, Kaama are three important factors to be fulfilled by a person during

his life aiming, to attain ultimate goal of everybody i.e. ‘MOKSHA’ (Salvation). Human

being knowingly or unknowingly struggles to finish them at their ability. But Arogya

(health) is essential to achieve them. This wealth one has to protect at any cost.

‘Sheeryate Anena Iti Shareeram’ indicates that, the body gets affected (destructed) during

various activities of routine life. Hence there is always fear of getting imbalance both

structurally and functionally. But as the daily balanced diet with proper following up of

Dinacharya, Ruthucharya etc. one can get corrected without his knowledge. This

phenomenon has certain limitation. Living in the external atmosphere the changes in the

form of Heena, mithya and Atiyoga with respect to Kala-Artha-Karma forces him to

detritions in the fundamental units of the body called as Doshas-Dathus and Malas. As

they get self corrected, person meantime commits mistakes known as Prajnaparadha

results in the form of disease manifestation.

In the present competent and tense world, people are so much busy that they

cannot follow Swasthavrittha and Sadurittha. So cannot rectify the imbalance in their

body or totally ignores till he becomes unable to perform his routine work properly. They

are not taking sufficient rest in time. Even they cannot have their food in appropriate and

fixed time. Food may not be having rich properly of Rasa, Guna etc. Use of packed food

and freezed items are also seen widely. Changing world made the people may not give

chance to practice proper exercises like walking etc. More number of vehicles, factories,

oil refineries, overcrowds etc. makes pollution of air, water etc. In simpler words man in

the name of modernization looses his natural power of immunity and depends on several

artificial methods for everything. Thus becomes focus of diseases easily.

Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational Study

1

Introduction

Amavata is such a disorder where etiology points out commitment of Viruddha ahara

and Viruddha chesta. It is a troublesome disorder, manifests for a long time, leads to

complications and unless treated early and perfectly it makes oneself to confine to bed.

It Affects many facets of patients life, for example his family, occupational and

community relationships. It affect not only the social and economical position of

individual and his family but it leads to the draining of national resource due to the work

hours lost, resulting in diminished production.

It is a multifactorial disease, if not treated in early stage, a structural deformity is

developed and the life of the patient is ruined. The disease is progressive in nature with

prognosis of the disease is bad and leads to joint deformities. Rheumatoid Arthritis occurs

throughout the world and in all ethnic groups. The prevalence is highest in Indians. In

Caucasians it is around 1-1.5% with a female: male ratio 3:1.1The onset of Rheumatoid

Arthritis may occur at any time of the life approximately 70% of RA occurs between the

third to fifth decades.2

The crippling nature, repetitive attacks and chronic course of Amavata, forced the

scientific world to conduct extensive studies on Amavata. Unfortunately the man has not

succeeded in eradicating this diseases and find to come out with successful therapeutic

measures that can cure the patient completely. In Ayurveda also many scientific studies

were carried out in different centers.

In recent years an intense study of different conditions primarily involving the

musculoskeletal structures (Rheumatology) has been made and it revealed that

inflammatory or digestive changes occur in diseases like Rheumatoid Arthritis. Diseases

of connective tissue are responsible for much temporary or permanent disablement.

Despite the awareness of the diseases, responsible explanation for the cause and

source of Rheumatoid Arthritis are still obscure in modern science. Hence no rational

curative measures are known.

Anti-inflammatory Analgesics and diseases modifying Anti Rheumatic drugs are the

drugs of choice in contemporary system of medicine. Unfortunately all the analgesics are

liable to give many side effects particularly by repeated and prolonged use.


2

Introduction

Ayurveda, the age old Indian System of Medicine, advocates a reliable management

of diseases with the consideration to protect the normal health while treating the diseases

with highly efficacious and easily and easily available drugs based on humeral theory.

Ayurvedic approach to diseases Amavata is to re establish the body structure and to

balance the vitiated doshas. Alleviation of Vata dosha has special importance in the

management. Langhana, Swedana, Deepana, Rechana, Snehapana and Basti are the

therapeutic measures are advocated.

Till now more than 100 research works have been carried out at various Ayurvedic

Institutions and about 25 Research works have been carried out in P.G. Institutes. This

large number itself suggests its large occurrence and faith of patients in Ayurvedic

Management.

• In 2003, Deepak S.M. worked on “ A comparative study of Eranda paka and

Ajamodadichurna in the management of Amavata”

• In 2003, Riti shah Worked on “ Clinical assesement of the role of Kamsa

hareetaki and Virechana in the management of Amavata”

• In 2004, Veerakumar studied on “Comparative study of Shamana and

shodana chikitsa in Amavata.

• In 2004, Gururaj worked on “A stydy on Indravalli W.S.R.T.its effect on

Amavata”

• In 2005, P. Koteshra stydied on Preparation, Physico chemical Analysis of

Hinguleshwara rasa and its clinical Efficacy on Amavata W.S.R.T.

Rheumatoid Arthritis”

• In 2005, Veena kori studied on “Evaluation of efficacy of Shunti and

Gokshura in Amavata (Rheumatoid Arthritis) –A comparative clinical study.

• In 2006, Prathima adiga worked on “A study on effect of Bandhadi yoga in

the management of Amavata (Rheumatoid Arthritis).

• In 2006, Praddep Agnihotri worked on “Preparation and Analytical study of

Shri siddha daradamruta Rasa and its clinical effect in Amavata”

• In 2007, Suresh hakkandi worked on “A Comparative Study of Virechana

karma and Basti karma in Amavata W.S.R.T. Rheumatoid Arthritis.

• Etc…


3

Introduction

So the disease drawing attention for the consideration of research firstly due to

gravity of the problem secondary due to lack of suitable medicines and society of

present era are looking for the successful management of Amavata. So the present

study is entitled “EVALUATION OF THE EFFICACY OF VAITARANA BASTI IN

AMAVATA” – An observational study is undertaken.

.


4

Objectives

Objectives:

• In today’s era the people want to leave a luxurious, due to sedentary life style with

improper dieting habits occurrence of Amavata on large scale is one of the

outcomes of this modification.

• It is commonest among chronic inflammatory joint diseases in which joints

become swollen, painful, and stiff. It is a debilitating disease in view of its

chronicity and complications. Therefore, it has taken the foremost place among

the joint disorders.

• It continues to pose challenge to physician due to severe morbidity and crippling

nature and claiming the maximum loss of human power making it a biggest world

wide burning problem irrespective of races.

• It is equated with Rheumatoid Arthritis, an inflammatory Auto-immune disorder.

The lives of more than one million people are physically impaired due to

Rheumatic disorders and one fifth of these are severely disabled.

• Anti-inflammatory Analgesics and diseases modifying Anti Rheumatic drugs are

the drugs of choice in contemporary system of medicine. Unfortunately all the

analgesics are liable to give many side effects particularly by repeated and

prolonged use.

• By seeing the above said hazards because of the disease and the complications

arising from the drugs used in contramprary medicine, it seems to be good to look

at the Ayurvedic remedies.

• Many theories and practical approaches have been tried to get a better answer for

solving this problem. But being a Yapya Vyadhi it reappears and gives long

standing sufferings. However, improper follow up, faulty dieting, irregular

exercises, poor economic status excessive work load, improper life style and

mental stress play vital role in the failure. Anyhow, keeping all these in mind, an

effort has been done to find out and analyze in this study in the guidelines

explained in Ayurvedic classics.

• The Panchakarma therapy is an integral part of Ayurveda many diseases

according to Ayurveda are direct result of Srotavarodha particularly due to the

Agnimandya and Ama.3 The management of Amavata, Ayurveda gives


5

Objectives

importance to shodhana karma. Among shodhana Virechana and Basti karma

have got its vital role in treatment and preventing the disease.4 Shodhana karma

helps to eradicate the cause of the disease and as such the disorders treated with

shodhana do not reoccur.5

• So considering this aspect in the present study an attempt is made to find suitable

remedy for Amavata as mentioned specially by Chakradatta,6 i.e. Vaitaranabasti is

taken and hypothetically the following objectives are evalued

1. Evaluation of the effect of Bastikarma in Amavata.

2. Evaluation of the efficacy of Vaitaranabasti in Amavata.

1. Evaluation of the effect of Bastikarma in Amavata:

• ‘Vata’ is responsible for smooth functioning of the different systems in the body.

Pitta-Kapha Doshas, as well as the Dhatus and Malas are handicapped

Without the support of Vata and cannot work independently. Just like wind

carries the clouds (in the sky), the Vata helps other Doshas and Dushyas during

various activities of routine life.

• In Amavata ‘Ama’ is produced by agnimandya of both Jatharagni and

Dhatwagnis. It is the main causative factor. Ama and vata vitiated simultaneously

and disease is manifested mainly in joints of hasta, pada, sira, trika, gulpha, janu

and uru. The main symptoms produced are Angamarda Aruchi, Trishna, Alasya,

Gouravam, jwara, Apaka and Shotha.

• So this derangement of the vata may be corrected by this vasti, as vasti is the

prime and important treatment modality for vata. So it may helps to avoid the

complications. Basti is said to be ideal as it pacifies both ama and vata.

• The symptoms of avarana vata are seen in the joints, the main seat of vata is

pakwashaya, and hence the eliminative therapy is directed to pakwashaya. After

the administration of basti, the basti is retained only for limited period in the

pakwashaya even then it can be assumed from the effects produced that, and the

essentials are absorbed in the system


6

Objectives

2. Evaluation of the efficacy of Vaitaranabasti in Amavata:

• The shodana therapy is must to treat the disease Amavata, among the shodana bsti

is said to be ideal as it pacifies both ama and vata.

• Chakrapani has appreciated the role of ksharabasti has got its importance in the

treatment of Amavata.

• The explanation of Vaitaranabasti follows the ksharabasti with most of the same

ingredients but with reduced quantity, which can be tolerated when compare to the

ksharabasti.

• Vaitaranabasti is indicated in Amavata as well as in Shula.

• The ingredients of Vaitaranabasti are cheap and easily available

• The symptoms of avarana vata are seen in the joints, the main seat of vata is

pakwashaya, and hence the eliminative therapy is directed to pakwashaya. After

the administration of basti, the basti is retained only for limited period in the

pakwashaya even then it can be assumed from the effects produced that, and the

essentials are absorbed in the system

• The ingredients of the Vaitaranabasti are having the quality of deepana, pachana

gunas, which dairectly influences the koshtagni and dhatwagni, which inturn leads

to pachana of already existing ama and checks the further production of ama. And it

is also having vatanulomana and vata shlesmahara properties.

• After administration of basti it reaches the various parts of the body like sandhisand

even to the minute channels by its suksma guna and liquefies the ama and kapha

which was present in various forms. Liquification is caused by ushna, teekshana

and lekhana gunas which inturn decreases the srothoabhishyandhana meanwhile

usna and snigdhata guna of the content pacifies the vata. Gomutra, which is the

chief content, is helpful to reduce the shotha and ruja as it is mainly indicated in

ama.


7

Historical Review

Review of literature:

Historical review of vasti

1) Veda kala:

Direct reference of Vasti karma will not be found in Veda, but explanation of

Vasti is their as “Vishitam te Vastibilam” 7

2) Purana kala

Vasti is indicated as the principal remedy in the problem of increase of

Vatadosha in Agnipurana.8 Different Snehas has told to use for Vasti according to

season9

3) Samhita kala

Most of the Ayurvedic classical text have given much importance to Vasti karma,

that’s why we found separate Adhyayas for explaining Vasti karma and while dealing the

treatment of each disease we will find the elaborate version of Vasti Dravya and

preparation.

Vasti review of Samhita can be studied by referring Charaka samhita, Susruta

samhita, Astanga sangraha and Astanga hridaya.

Charaka samhita

Charaka has explained definition of Vasti, Types of Vasti, preparation of Vasti,

Procedure of Vasti, Karmukata of Vasti, Vasti Vyapat its Chikitsa, Vasti dravyas etc.10

Sushruta samhita

Sushruta widely explained definition of Vasti, Types of Vasti, preparation of

Vasti, Procedure of Vasti, Karmukata of Vasti, Vasti Vyapat its Chikitsa, Vasti dravyas

etc in his Chikitsa sthana.11

Vagbhata

Both in Astanga sangraha 12 and Hridaya 13 elobarate description of Vasti have

been told in Sutrasthana and regarding Vasti Dravya we will find in Kalpasthana.14, 15


8

Historical Review

Kashyapa Samhita:

In Kashyapa Samhita, Basti has been explained in detail in Siddhisthana and

Kalpasthana.16

Bhela Samhita:

In Bhela Samhita, description of Basti is available in four chapters of

Siddhisthana namely Bastimatriya Siddhi, Upakalpa Siddhi, Phalamatra Siddhi and

Dosha Vyapadika Basti Siddhi.17

Harita Samhita:

In this text, only 3rd chapter of Sutrasthana deals with Basti.18

Chakradatta:

In this text, two chapters named Anuvasanadhikara and Niruhadhikara are dealt

with Anuvasana and Niruha Basti respectively. 19

Vangasena:

In Chikitsa Sarasangraha, Vangasena has devoted “Basti Karmadhikara” chapter

for description of Basti.

Sharangadhara Samhita:

Three chapters of Uttarakhanda namely Basti Kalpana Vidhi, Niruha Basti

Kalpana Vidhi and Uttara Basti Kalpana Vidhi described various aspects of Anuvasana

Basti, Niruha Basti and Uttara Basti respectively.20, 21, 22

Bhavaprakasha:

In this 5th chapter of Purvakhanda has been contributed to the description of

Basti. Vrana Basti – this type of Basti has been explained in this Grantha.23

Kalyanakaraka: In this text, Basti is described in Vatarogadhikara only.

Todarananda: In this text, Basti is described in the chapter Basti Vidhi.

Historical review of Amavata

An off shoot of Atharva and Rigveda, this science of medicine is without

beginning, but Ayurveda saw throughout many people, who organized it into beautifully


9

Historical Review

woven treatises, incorporating newer diseases and their treatment, which cropped up

during their times. It is evident in the Samhitas that the most prevalent and deadly

diseases have been devoted separate chapters were included as secondary diseases under

the major category.

Vedic period (5000 BC to 1000 BC):

Clear cut explanations of Amavata are not available in Vedic Samhitas, but

disease caused by Kapha have been more or less described under the major heading

Balasa, but the diseases of joints are not included here. Sayana has quoted few references

indicating arthritic syndromes, such as-

Rapasi: 24 Disease arising due to sin (Rigveda) characterized by pain in multiple joints

also referred to as Papa. Yakshma and treatment with Jala, Vayu Yava, and Kushta have

been indicated.

Jayanya25: This disease is said to affect the bones cervical vertebrae and arise from

women through Sanga. Whether the disease refers to rheumatoid arthritis is still not clear.

Grahi26: (Rigveda and Atharvaveda): This has been described as the disease of joints but

characteristic features have not been clearly mentioned. Treatment of this disease with

Dashavruksha has been mentioned.

Vatikrut27: This disease has been described as a serious ailment caused by Vata and

treatment with Pippali and Vishanashaka has been mentioned.

Sandhivikruti28: (Atharvaveda): This disorder is caused by Sleshma and can be treated

with prayers.

Samhita period (1000 BC TO 600 AD):

Charaka Samhita: Charaka has described in detail Ama and Ama Pradoshaja

Vikara and their treatment with Langhana and Ullekhana.29

Charaka had described treatment for Amavata while dealing with Avarana

Chikitsa in Vatavyadhi, 30 which indicate Pramehahara and Medohara Vidhi. Amavata

finds a mention in the list of therapeutic indication of Kamsa Hareetaki 31 in Shwayathu

Chikitsa and Vishaladi Phanda in Pandu Chikitsa. 32


10

Historical Review

The treatment of Ama in Grahani Chikitsa by Charaka 33 is similar to the

description of Amavata Chikitsa by Bhava Mishra i.e. Langhana, Pachana and oral

administration of Panchakola Phanta34 same is the case with Amavata Chikitsa of

Chakrapani in Chakradatta 35

Sushruta Samhita: The description of Amavata in Sushruta Samhita is conspicuous by

its absence.

Bhela Samhita: The tenth chapter in Sutra Sthana deals with Ama Pradosha. This

description has some resemblance with that of Amavata.

Harita Samhita: A complete chapter on Amavata finds a mention in Harita Samhita.36

The classification of Amavata is quite unique and not followed by any of the later works

in this field.

Anjana Nidana: This work is claimed to be written by Acharya Agnivesha, contains

detailed description about etiology, premonitory symptoms, clinical manifestations and

complications.

Sangraha Kala (600AD-1600AD):

Astanga Sangraha and Astanga Hridaya have ignored the disease though the word

Amavata is included in the therapeutic index of compounds Vatsakadi Yoga 37 and

Vyoshadi yoga.38

Madhava Nidana: 39 Madhavakara stated this disease as a separate entity and has dealt

separate chapter.

Chakradutta: Chakrapanidutta is the first to described the treatment for Amavata. 40

Vangasena 41 followed Madhava with little additions yoga in the treatment aspect.

Works like Bhava Prakasha, 42 Yogaratnakara 43 and Bhaishajya Ratnavali 44 have only

corroborated the descriptions with additional principles of treatment.

Adhunika Kala (1600AD onwards):

Mahopadhyaya Acharya Gananathsen has coined the term Rasavata for Amavata.

In yoga shastra the practice of shushka basti for improving the jataragni and

treating Amavata has been mentioned.45

Y.N.Upadhyaya (1955) has correlated the disease with rheumatoid arthritis. Later

research workers have agreed with Y.N.Upadhyaya.


11

Historical Review

Review of Rheumatoid Arthritis 46

First Century AD: The Rheumatoid/rheumatology is derived from the root

‘Rheuma’, which refers to a substance that flows and probably was derived from phlegm,

an ancient primary humor, which was believed to originate from brain and flow to

various parts of the body causing ailments.

1642 A.D.: The word rheumatism is introduced into the literature by the French

physician Dr.G.Baillou who emphasized that arthritis could be a systemic disorder.

1800 A.D.: Landre Baervier a physician from Salta Petruver in Paris seemed to have

described the disease for the first time he called it Gartte Asthanique Primitive.

1857 A.D.: Sir Garrod proposed the name Rheumatoid Arthritis, Bannatyne also in 1959

published his pathological observations on the disease but he could differentiate it from

Osteoarthritis only in his later edition.

1928 A.D.: The American committee for the control of rheumatism is established in U.S.

by Dr.R.Pemberton, renamed American Association for the study and control of

rheumatic disease (1934), then American Rheumatism Association (1937) and finally

American college of Rheumatology (ACR) (1988).

1940 A.D.: The terms Rheumatology and Rheumatologist are first coined by Drs.

Hollander and Comroe respectively.

1948 A.D.: Roses identified some criteria for diagnosis of Rheumatoid Arthritis.

1958 A.D.: American Rheumatic Association suggested uniform criteria for diagnosis.

1987 A.D.: The criteria were revised.

In the beginning it was thought to be an infective condition especially in early 20th

century. French scientists thought it to be due to tuberculosis.

Hench and Kendell introduced steroids in the management of rheumatoid arthritis

described pediatric onset, juvenile Rheumatoid Arthritis. in 1896. Later Felty A.R.

described Felty’s syndrome.

Recent advancement in immunology has opened new vistas in the management of

Rheumatoid Arthritis. Unfortunately till date the etiology of Rheumatoid Arthritis is

unknown the pathogenesis is speculative, the treatment is only palliative and there is no

cure to this disease.


12

Historical Review


13

Basti karma

Basti karma

Vyutpatti

“Vasti” the word derived from the root “Vas” with the suffix of Prattyaya

“Tich”.

Nirukti and Paribhasha

1. Using Ajadi Vasti Putaka for the use of giveing Aoushadha is called

Vasti47

2. Due to giving medicine by Vasti Putaka is called Vasti.48, 49, 50

3. Due to administering medicine in to Gudamarga with Vasti is called

Vasti.51

4. Which is Sadhyakarma with Mootradhara Putaka is Vasti.52

5. The karma while moveing in Nabhi, Kati, Parshwa, Shroni churns up the

stool including all the other doshas located their, and appropriately

eliminates them with easy after doing Snehana of body is called Vasti 53

Vasti Karmukhata

Vasti is one of the best Chikitsa in Panchakarma, its action will not be

restricted to only Pakwashaya Shodhana where as it acts all over the body. By

mixing different drugs it acts as Shodhana, Shamana, Lekhana, Brouhana,

Vajikarana, Vayasthapana etc.54 So Vasti can be used in any type. Now its mode

of action will be explained as follows.

Just as the cloth absorbs only colour from the solution of Kusumbha and

other coloring substances, so also the Vasti expels out from the body only the

doshas, which have been maid moist.55, 56

The body is sustained by Vayu because of its ability to cause detachment

of any adhesion. Vayu alone or along with other doshas get aggravated in its own

habitat. Vasti by its Shodhana action causes downward movement of that Vayu

along with Pitta, Kapha and feces. Because of allivetion of this Vayu, all the

diseases pervading the whole body get alleviated.57

Chakrapani comments over above point and says, science Vasti causes

alleviation of basic Vayu located in Pakwashaya other connected Vayus else

where in the body gets automatically alleviated. This holds good similar

destruction of a tree by cutting its root. This explains the cure of all the diseases

of the body by simply correcting the Vayu located in its basic habitat ie colon.


13

Basti karma

In Charaka siddhi Vasti is described to draw out all doshas from the foot

to the head by its Virya.

Medicine injected through rectum remains in the intestines in the region of

the pelvis and below the umbilical region. The potency Vasti dravya spreasds all

over the organism from the Pakwashaya just as the potency of the water poured at

the root of the tree tends to permeate the whole tree through its minutest cells and

fibers. The liquid part of Vasti is emitted out through the rectum either by it self

or with feocal matter etc. But its potency acts over whole organism through the

intervention of Apana and other Vayus. The potency of the Vasti dravya in the

Pakwashaya acts on the while organisam from top to toe, like the sun in the haven

acting on the humidity of the earth below. Vasti if applied correctly tends to

eliminate completely from the system all the doshas accumulated in the region of

the back, waist and abdomen. 58, 59, 60

Importance of Basti karma

Vata is the Neta 61 of all Dosas, it is considered as Ishvara 62 and it is the

causative factor for all trimargaja rogas.63, 64 For this type of Vata Vasti is the best

amoung other Karmas.This Vasti is considered as Ardha chikitsa because of

disease produced by Vata are 80 in number.65

Vasti can be utilized in Bala, Vridha, Krasha, Sthoola, Kshina dhatu

person, and in Sthree.66 In the Snehadi karma Basti is chief, because of having

Shodhana effect, Shamana effect, Sangrahana effect, Vajikarana effect, Brohana

effect etc. 67

Vasti is beneficial if it is used with different drugs in Vata, Pitta, Kapha,

Samsargaja and Sannipataja disorders.68, 69

Vasti is Amruta samana in Shishu and Ashishu, 70 when Vasti is used in

combination of Niruha and Anuvasana it eradicates all type of diseases.71

Main specialty of Vasti is first it do the Utkleshana of doshas than

Shodhana of doshas and lastly Shamana of doshas.72, 73, 74

It is the only one Karma which we found to be given continuously for 324

days, if Vasti is taken for such days person neither become old nor sick, lives for

thousand years with keen sense organs, devoid of sins shining like gods, like a

stallion in matters of sex, like a elephant in strength with steady mind, sense

organs and digestive activity.75

Vasti if appropriately administered keeping in view the strength of patient

doshas involved in the causation of disease, nature of disease of disease, physical


14

Basti karma

constitution of patient and properties of different groups of drugs prescribed for

different diseases cures these ailments.76

No other therapeutic measures other than Vasti cleanses the body quickly

and easily, causes depletion and nourishment instantaneously and is free from any

adverse effect.77

Vasti is useful in Pangu, Urustambhs, Bhagna etc.78

Virechana and Vamana therapy no doubt causes elimination of doshas but

it involves intake of recipe ingredients of which are pungent, sharp, hot etc.Those

ingredients causes’ unpleasantness eruption nausea cardiac discomfort and pain in

the gastrointestinal tract.79

Infants have immature tissue and less of strength, there is diminution and

reduction in strength in old people. For both these category Virechana and

Vamana therapy is contraindicated. Asthapana type of Vasti can however be

given for elimination of doshas and nourishment of body. Vasti therapy

instantaneously promotes strength, complexion, sense of exhilaration and

tenderness as well as unctuousness of body. 80

Basti Effect:

(1) Promotive aspects

• Sustains Age.

• Provides better life, improves strength, digestive power, voice and

complexion.

• Perform all functions

• Provide firmness

• Corpulence quality.

• Lightness in viscera / systems because removes morbid matter from all

over the body.

• Restores normalcy.

• Increases Relish

(2) Curative aspect

• Relieves Stiffness

• Relieves contractions and adhesions.

• Effective in paralytic conditions

• Effective in dislocation and fracture conditions


15

Basti karma

• Effective in Those conditions where vata aggravated in Shakha /

extremities.

• Relieves pain

• Effective in disorders of GI tract

• Effective in diseases of Shakha and Kostha.

• Effective in diseases of vital parts, upper extremities localized or general

parts.

• Beneficial to debilated and weak persons.

• Arrest premature old age and the progress of white hair.

(3) Preventive aspects

• Beneficial in constipation.

• Effective to purify various systems of the body.

(4) Effect on dhatu:

• Increases the quantity and quality of sperm

• Effective to restore the normal functions of blood and other dhatus.

• It provides strength by increasing muscle power.

• Beneficial as geriatrics

5) Effect on Brain and Psychology

• Improves intellectual power

• Provides clarity of mind

• Improves clarity of sense organs

• Induces sound sleep

• Lightness

• Exhilaration

• Invigorates eyesight

• Spright lightness of mind

(6) Effective at any age and in any season

• Basti is non antagonistic to healthy, diseased and old persons

• Applicable in all seasons

• Basti can be administered in child and older person too, because it is free

from complications.


16

Basti karma

Types of Basti

Two types of basti • Niruha basti, Auvasana basti 81

• Niruha basti, Snehika basti 82

• Shita basti, Sukhoshna basti 83

Three types of basti

• Asthapana basti, Auvasana basti, Uttara basti. 84, 85, 86

• Utkleshana basti, Shodhana basti, Shamana basti 87, 88, 89, 90

• Karma basti, Kala basti, Yoga vasti.91, 92, 93

• Vatahara basti, Pittahara basti, Kaphahara basti.94

• Sneha basti, Anuvasana basti, Matra basti.95

• Teekshna basti, Mrudu basti, Sadharana basti.96

• Kaphavatahara basti, Kaphapittahara basti, Pittaraktahara basti.97

Four types of basti

• Asthapana basti, Auvasana basti, Uttara basti Matra basti.98

• Pakvashayagata basti, Shiro basti, Kati basti, Vrana basti.

Five types of Madhutailika basti

1) Madhutailika basti 99

2) Youktaratha basti 100

3) Doshahara basti 101

4) Siddha basti 102

5) Mustadiyapana basti.103

Six types of Vasti [On the Basis of Rasa predominance in the Basti Dravya]

1) Madhura Rasa Skandha Dravya Basti

2) Amla Rasa Skandha Dravya Basti

3) Lavana Rasa Skandha Dravya Basti

4) Katu Rasa Skandha Dravya Basti

5) Tikta Rasa Skandha Dravya Basti

6) Kasaya Rasa Skandha Dravya Basti

Eight types of basti 104

1) Chatuprasruyika basti

2) Panchaprasruyika basti

3) Shatprasruyika basti

4) Saptaprasruyika basti


17

Basti karma

5) Astaprasruyika basti

6) Navaprasruyika basti

7) Ekadasa Prasrta Basti

8) Dwadashaprasruyika basti.

Ten types of Vasti [On the Basis of chief drug]

1) Ksira Basti

2) Mamsa Rasa Basti

3) Gomutra Basti

4) Rakta Basti

5) Kshara Basti

6) Dadhimastu Basti

7) Amlakamji Basti

8) Prasanna Krta Basti

9) Sura Krta Basti

10) Asava Krta Basti

Fifteen types of basti

1) Vatahara basti

2) Pittahara basti

3) Kaphahara basti

4) Raktahara basti

5) Kaphavatahara basti

6) Kaphapittahara basti

7) Pittaraktahara basti

8) Pittavatahara basti

9) Pittaraktahara basti

10) Raktakaphahara basti

11) Raktavatahara basti

12) Vatapittakaphahara basti

13) Vatapittaraktahara basti

14) Kaphapittaraktahara basti

15) Vatapittakapharaktahara basti


18

Basti karma

Brief introduction about some important Vasti

a. Niruha Basti (Evacuative or Un-unctuous Enema):

In Niruha Basti, Kashaya (decoction) is the predominant content. With

the Kashaya, Madhu, Saindhava, Sneha and Kalka are the ingredients

commonly used. Its synonyms are Asthapana Basti, Kashaya Basti etc.

The Basti, which eliminates the vitiated Dosha from the body and

increase the strength of the body because of its potency, is called Niruha

Basti. 105

Because of this enema stabilizes the age (Vaya), stabilizes the normal

functions of Dosha and Dhatu and stabilizes Deha i.e. strength of the body, is

called Asthapana Basti .106

Depending upon drugs and preparations used in Basti it may be

classified as follows: 107

Madhutailaika Basti

Yuktaratha Basti

Yapana Basti

Siddha Basti

b. Anuvasana Basti (Unctuous Enema):

In this type of Basti only Sneha is used. According to the quantity of

oil given, it is subdivide as follows:

The Sneha Basti which will not cause any harm even if it is retained

for one day and can be administered after taking food, therefore it is called

Anuvasana Basti

Sneha Basti 1/4th to the quantity of Niruha i.e. 6 Pala (298ml).

Anuvasana Basti The quantity of Sneha is half of the Sneha Basti i.e.

3 Pala (144ml).

Matra Basti This is the minimum quantity of Sneha Basti (½ of

Anuvasana Basti) i.e. 1½ Pala (72ml). 108, 109,110


19

Basti karma

B) Anatomical Classification:

It depends upon the part of the body used for the administration of Basti.

Internal application:

• Pakvashayagata Basti

• Uttara Basti

a. Garbhashayagata Basti

b. Mutrashayagata Basti

External application:

Vranagata Basti Kati Basti

Shiro Basti Netra Basti

C) According to the number of Basti to be used:

Karma Basti - 30 Basti - 12 Niruha & 18 Anuvasna Basti

Kala Basti - 16 Basti - 6 Niruha & 10 Anuvasana Basti

Yoga Basti - 8 Basti - 3 Niruha & 5 Anuvasana Basti

In the above types fixed sequence of Niruha and Anuvasana Basti is

followed.

Rectal Administration:

Substances may be introduced into the rectum for exciting evacuation or

for medication, which later may be intended for effect in three different

locations.

• For effects on the contents of the colon for which the term "endocolonic

might be suggested to differentiate it from,

• Effect to be exerted on the tissue of the colon, for which the term

encolonic might be a suitable designation and

• For administration by the way rectal medication intended for systemic

action for which the term diacolonic might be employed.

• Before one resorts to rectal administration it is a good rule to make a

digital examination of the rectum.


20

Basti karma

• Rectum distended with fecal matter should be cleaned out by an evacuate

enema before it is given the task of receiving medication.

• Rectal injections, also known as enemas, clysters or Lavements may be

large or small.

Why rectal administration?

1. When it is desired to spare the stomach and intestine from the action of the

drug or to protect the drug from the action of the digestive ferments.

2. With children, who will not take disagreeable tasting medicaments, or

with the insane, which refuse to swallow, rectal administration may

become an important recourse.

3. Such a bitter substance as strychnine can best be given to children in

suppository form provided this method of administration is carried out

gently, skillfully and tactfully.

Enemas:

Rectal injections, also known as enemas, clysters or lavements, maybe

"large" or "small". An enema of less than half a liter might be considered a

small enema and of more than half a liter is a large enema.

1. When a rectal enema is given by means of a syringe with a short tip, it is

deposited just within the sphincter of the anus, a portion of the rectum that

is normally very intolerant of sudden distention. It is indeed this

irritability, which is responsible for the prompt evacuation of any fecal

matter that arrives in this part of the bowel. For this reason, even a small

quantity of fluid, when given rapidly, tends to cause evacuation.

2. When, on the other hand, the enema is administered very slowly, it

suppresses evacuation reflex and reaches to the upper part of the colon

which is not only more retentive but also more absorptive than the rectum.

3. After the drug once passes the anal sphincter, will pass easily up to the

sigmoid and descending colon, across and down to the caecum regardless

of the position of the body of the patient.

Cool large enemas are believed to excite the gallbladder for

contraction and are advocated in the treatment of catarrhal jaundice.

Irritation of the colon is a long established form of treatment for the

various types of jaundice. Garbat and Jacobi offer an experimental

demonstration of the possible efficacy of this treatment. They found that

within a period of from three or twelve minutes after the instillation of


21

Basti karma

various solutions high into the rectum a flow of bile was obtained from the

duodenal tube that would continue for from eighteen to sixty minutes

without any interruption.

Hence, the introduction of various solutions into the upper part of the

rectum produces drainage into the duodenum of bile that comes directly

from the liver and without contraction of the gallbladder.

(A) Evacuate enemas:

1. Evacuate enemas in increasing order to potency, should be repeated every

three or four hours, care being taken not to over distend the colon, until

success is secured or the uselessness of the procedure becomes evident.

2. Whether large or small, hot or cold, simple or medicated enemas should be

employed to secure evacuation in any one case depends on the conditions

present.

3. If the rectum merely is to be emptied of feces, 0.5-liter enema given

rapidly with the patient in the sitting posture suffices. If, on the other hand

the most thorough possible cleansing of the bowel is aimed at (colonic

flushing), the largest possible quantity of warm water from 1 to 2 liters is

slowly introduced with the patient recumbent in the lateral or Sims

position ; or, better still in the knee-chest position.

4. On the other hand, a small (0.25 liter), cool enema rather quickly injected

into the bowel, to stimulate it to evacuation, maybe considered one of the

least objectionable procedures, even when employed quite habitually.

(B) Oil enemas:

Though oil enemas are essentially evacuant enemas, they are given with

the technique of the retention enema, because they are to be retained for

many hours, usually over night.

Indications:

1. To soften feces, in constipation characterized by the formation of hard

scybala and in that due to partial obstruction of the colon.

2. For evacuate action, in so-called spastic constipation, in pelvirectal

constipation and in any other form of constipation and in which oral

administration of cathartics is contraindicated by gastric disturbance.

3. for soothing action, in excessive irritability of the colon and rectum, in

colitis and in proctitis.


22

Basti karma

4. It has been suggested that oil enemas might inhibit absorption of toxic

products. That the oil has the power of removing substances soluble in it is

shown by the fact that it is passed dark yellow or olive green and of

offensive odour.There is no definite knowledge, however, of the degree to

which this property might be of clinical value.

Rules:

1. The oil must be pure and free from rancidity. This is more important than

that it come from a certain source. (Thus poppy seed oil, oil of sesame or

cottonseed oil, when pure, is just as good for this purpose as olive oil).

2. The oil should be placed in a basin of hot water until it has acquired blood

heat (100 F).

3. The oil enema is given at bedtime, unless it produces discomfort and

interferes with sleep. In such case it may be taken early in the morning,

and the patient may lie in bed for three or four hours after ward.

4. The patient should understand that, unless the oil remains in the intestine

for several hours at lest satisfactory results cannot be expected. The total

quantity to be injected depends, therefore, on the patient's ability to retain

it.

5. This is so variable that no definite quantity can be stated. The principle to

be followed is to have the patient gradually increase the amount injected at

successive times until a satisfactory amount can be introduced and

retained.

(C) Retention enemas:

Technique:

It is well to precede a retention enema by a cleansing enema, so as to

unload the lower part of the bowel of fecal matter that may be contained in

it, thereby lessening distention and favoring retention.

1. The smaller in bulk the enema the better it is retained.

2. Still, to be retained, it must also be quite devoid of irritating properties.

3. The retention of an irritative substance may be favored by making its

solution as nearly isotonic as possible, and by using colloidal fluid, such as

starch water as diluents.

4. If the fluid is introduced very slowly and steadily, the rectum does not

become as readily aware of the distention and retains a quantity of fluid

that would otherwise be expelled.


23

Basti karma

5. Giving the enema at body temperature favors retention, as extremes of

temperature excite peristalsis.

6. The patient should assume the recumbent position for at least an hour after

the injection, and should be instructed to resist any inclination to

evacuation as much as possible.

(D) "Nutrient" enemas:

Why? The attempt has been made to maintain nutrition by rectal feeding

when it is impossible or undesirable to introduce food into the stomach, or when it

cannot be retained. But the colon has hardly any digestive power and it absorptive

capacity even for water-soluble substances of large molecular size is very poor

and nil for fat.

Rules:

1. Not more than three nutrient enemas should be given in the twenty - four

hours, at about eight hour intervals. The amount should at first not exceed

150 cc., to be gradually increased to 300 when given as ordinary enemas,

though when given by proctoclysis the quantity may reach 1 liter.

2. After each administration the patient should keep as quite as possible for

at least two hours and suppress any desire to evacuate the bowel.

3. In point of fact patients who need nutrient enemas should be kept in bed

continuously; at rest in bed lessen the consumption of calories by at least

25 per cent.

4. A daily cleansing enema is advisable. This should precede the nutrient

enema by about an hour.

(E) Medicated enemas:

Medicated enemas are given by the technique of retention enemas. They

may be employed, as previously stated, for endocolonic, encolonic or diacolonic

action.

Oil may be used as a vehicle for diacolonic administration of oil-soluble

volatile bodies. On the basis of extensive experience by Gwathmey.

Thus from above description we can easily understand the role of madhu,

saindhav and sneha in each basti. Above description resembles to the Ayurvedic

description of basti karma up to maximum extent. Though modern science

developed other advanced routes for the drug administration so now days they are

not using this route but they cant deny the importance of this route


24

Amavata

Disease Review

Amaravata describes a wide range of joint disease manifestations.

Amavata is mainly caused by two factors ama and vata.

Etymology of Amavata

1. ‘Amena samhita vata Amavata’. The virulent Ama circulates in the whole

body propelled by the vitiated vata dashas producing block in the body

channels that stations itself in the sandhi giving rise to Amavata.111

2. The combinations of ‘Ama’ and vata form Amavata. It shows the

Pridomminance of Ama & vata in the samprapti of Amavata. 112

3. Ajeerna produce ‘Ama’ & along with vata it produce Amavata.113

Definition

‘Ama’ is produced by agnimandya of both Jatharagni and Dhatwagnis.

Even though ama is a cause for various diseases, in Amavata it is the main

causative factor. Ama and vata vitiated simultaneously and disease is manifested

mainly in joints of hasta, pada, sira, trika, gulpha, janu and uru. The main

symptioms produced are Angamarda Aruchi, Trishna, Alasya, Gouravam, Apaka

& Shotha 114

Role of Ama in Amavata

The main causative factor for the manifestation of Amavata is Ama. So it

is necessary to know about the Ama in detail.

Etymology of Ama

1. The unprocessed or undigested food partical is Ama. 115 2. Ama means, “Which is subject of digestion”.116

Definition of Ama

1. The first Rasa dhatu, which has been inadequately digested due to the

weakness of digestive fire and accumulating in the stomach in the

abnormal state, is know as Ama 117, 118

2. The undigested Adya Ahara dhatu is Ama.119

3. The food material which will not undergone vipaka, leads to Durgandha,

which is large in quantity, which is picchila & which leads to Gatra

Sadana is called Ama.

4. Due to impairment of digestive fire the undigested remained food material

is ‘Ama’.


25

Amavata

5. Apakva Anna Rasa is Ama & some other considers the accumulation of

mala as Ama & still other opines the first stage of vitiation of dosa as

Ama.

On the basis of the for going, Ama may be classifieds as below

I) Ama produced due to hypo functioning of Agni i.e

1) Ama due to Jatharagni Mandya.

2) Ama due to Dhatvagni Mandya.

3) Ama due to Bhutvagni Mandya.

II) Ama produced irrespective of the action of Agni

1) Accumulation of mala.

2) Ama due to interaction & virulently vitiated dosas

3) First phase of dosic vitiation.

Vata in Amavata

Voluntary & involuntary functions are all under the control of Vaya. In

Amavata the normal function of Vata is disturbed. It produces stabdhata &

sandhigraha leading to the restricted movements of joints & it will become the

responsible for crippling effect seen in the patients. This shows that predominance

of vata dosa in the pathogenisis of Amavata.

Now let us carry a brief description of vata dosa. The word vata derived

from “Va gati gandhanyoh” it means to move, to make known, and to enthuse.120

It has got the other synonyms like Anila, Maruta, Pavana etc. 121

Gunas of Vata

Ruksha, Seeta, Laghu, Sukshma, Chala, Visada, Parusha & Khara 122, 123

Functions of Normal Vata

Vaya sustains the body with expiration, inspiration, enthusiasm, movement of

various parts. Kneenees (sharpness) of sense perception, initiation of the natural

urges and many other functions.124

1. Tantrayanradhara

2. Cheshta Pravartaka

3. Mano Niyanta & Praneta

4. Sharvendriya Uttyojaka

5. Sharvendriya Artha Abhivodha

6. Sharva sharira dhatu Vyuhakara

7. Sharira Sandhanakar

8. Vak pravartaka


26

Amavata

9. Sabdasparsa Prakrti

10. Srota sparsana mula

11. Harsha utsahayoni

12. Agni samirana

13. Mala ksepta

14. Grabhakrti Karta

15. Ayusha Anuvratti 125

Importance of Vata

Pitta, Kapha, Dhatu & Mala are movementless, unless they are brought to

the proper place by vata to carry out their functions. Thus Vayu makes the

functions of all the tissues of body 126

Symptoms produced due to Ama

1. Srotordha

2. Balabramasa

3. Gaurava

4. Anila Mudhata

5. Alasya

6. Apaki

7. Nisthivana

8. Mala sanga

9. Aruchi

10. Klama

11. Vit, Mutra, Nakha, Dhatu, Chakshu Pitata/Raktata/Krishnata

12. Prusthtasthi, Katisandhi Ruk

13. Siroruk

14. Nidra

15. Mukhavairasya

16. Jvara

17. Atisara

18. Romaharsa.

Symptoms of Vataprakopa 127

1. Parava Samkocha

2. Stambha

3. Asthi Paravabheda

4. Lomaharsa, Pralapa, Hasta-Pristha-siro-graha


27

Amavata

5. Khanjata-Pangulya

6. Kubjata

7. Sosha

8. Anidra

9. Grabha-sukra-Rajonasa

10. Spandana

11. Gatra Suptata

12. Sira, Nasa, Akshi, Jatru, Grivahanunam-Bheda ,Toda-Arti

13. Akshepa

14. Moha

15. Ayasa

Nidana of Amavata

Nidana is defined as the factors which deranges the dynamic state of

doshic equilibrium provokes the disease is known as Nindan. This Nidana

helps us to decide the line of treatment as well as prognosis of the disease.

Amavata Ninda is of multifaceted various Acharya’s mentioned their

different views for the productions of Ama in Amavata.

Madhavakarhas128 delt the separate Nidana as

1. Viruddha Ahara (Incompatible food)

2. Viruddha Chestha (Incompatible food)

3. Mandagni (Hypofunctiony of agni)

4. Nischala (Lack of exercise)

5. Snigdha Ahara followed by immediate exercise.

Besides these intakes of Kanda, mula and sakha and excessive exertion are

itiological factors opeined by Harita 129

In Anjana Nidana which vititate vata, pitta and kapha are considered under

Nidana.130

These all above Nindan can be included under two heading

1). Unwholesome diet & 2).Erroneous habits.

Unwholesome diet means “which aggravates the body humors but not

expel them out of the body”.131 Charaka has mentioned 18 types of

unwholesome diet (Viruddha Ahara) 132 some of the virudha Ahara are as

follows

1. Milk along kulatha,

2. Panase fruit with matsya


28

Amavata

3. Mixtures of equal quantities of honey & ghee.

4. Boiled curd 133

Erroneous habits (Viruddha chesta) mainly included alternate use of cold

and heat, suppression of natural urges, sleeping daytime, walking at night, over

indulgence in work.

Table No 1,: Amavata Nidana according to various Acharyas.

Sr Nidana M.N. H.S. A.N.

i. Viruddha ahara + - -

ii. Guru ahara - + -

iii. Tarpite kandashakastu - + -

iv. Mandagni + + -

v. Viruddha cheshta + - -

vi. Avyayama + -

vii. Snigdha bhuktavato hiannam vyayama + - -

viii. Swa prakopnaiha :

Vatadosha

Pittadosha

Kaphadosha

- - +

ix. Vyavayina - + -

Samprapti of Amavata 134

The impairment of Agni will produce the condition of Ama. Mainly

Agnimandya initially affects digestion followed by metabolism. Hence in this

state of Agni, the Rasadhatu is not formed up to the standard level & it is

considered as Ama. This ‘Ama’ along with Vyana Vayu and also by virtue of its

Vishakari guna it quickly moves to all kapha sthanas, through Hridaya and

Dhamanes. This Vidhagada Ama, in kapha sthana is further contaminated by

dosas and assumes different colours, because of the Atipichhilata.

If Ama gets obstructed in to channels and promotes further vitiation of

vata dosha, this morbid Ama circulates ubiquitously in the body propelled by

vitiated vata with predilection for shesma sthana. On the dhamanies with the other

dosas it facilitates sroto abhisyanda and srotorodha causing sthanasmsraya

manifested stabdhata (stiffness), sandhisula (joint-pain), sandhishotha (swelling),


29

Amavata

Anga marda(body ache) Apaka(indigestion), Jwara (fever), Anga gourava

(heaviness of body), Alasya(laoghess) etc symptoms of Amavata.

According to the commentators on Madhava Nidana the Samprapti of

Amavata can be summarized accourding to Shatkriyakal

Sanchaya & Prakopa: When a person is exposed to aetiological factors like

Viruddha Ahara, does vyayama after intake of snigdha ahara, Chinta, Krodha etc.,

Agnimandya is there leading to Tridoshadushti and Amotpatti in the Sanchaya

and Prakopavastha.

Prasara: With the help of Vata (Biophysical mechanism), this Ama gets Prasara

to shleshma sthana producing mild sandhishoola etc. along with Ama symptoms.

Then Ama gets interacted with Tridosha and further modified (Vidagdha) to great

extent and yagapatakupitavanta of Ama and Vata takes place via Rasavaha srotasa

(Dhamani).

Sthana Sanshraya: This prasarita Ama, which viscid, unctuous and guru endures

Sthana Sanshraya in Hridaya, Trika Sandhi and Sarvanga (Srotoabhishyanda)

leading to Dosha-dushya Sammurchchana. Primarily the disease is not manifested

completely, so only initial mild symptoms like Aruchi, Apaka etc. are observed

which can be considered as purva rupa of the disease Amavata.

Vyakti: As it reaches vyakti stage most of the symptoms of Amavata are

manifested like Vrishchika dashavata vedana, stabdhata etc. In Adibala Pravrita

cases (Karmajanya, Mata-pita apcharajanya etc.) Khavaigunya is already there

and with the minor nidana sevana disease in manifested.

Bheda: In chronic stage or if the disease is left untreated it reaches bhedavastha-

producing updrava like Sankocha, Khanjata etc.

The Samprapti Ghatakas, which are involved on the Amavata, are as follows.

1. Dosha-Tridosha mainly vata(vyana, samana, Apana) and kapha ( Kledaka,

Bodhaka, slemaka)

2. Dhatu -Rasa, Mamasa. Asthi, Majja.

3. Upadhatu -Snayu and Kandara.

4. Srotases -Annavaha, Rasavaha, Asthivaha, Majjavaha.

5. Srotodusti -Sanga, Vimaragagmana.

6. Udbharasthana- Amashya (Ama), Pakvasaya (vata).

7. Adhisthana -whole body

8. Vyaktasthana -Sandhi

9. Avayava -Sandhi.


30

Amavata

10. Vyadhiswabhava -Mainly Ashukar.

11. Sanchara Sthana -Hridya, Dhamani.

12. Roga Marga -Madhyama roga marga

13. Agni -Jataragni Mandya, Dhatwagni Mandya.

FLOW CHART-1

SAMPRAPTI

Virudha Ahara + Virudha Vihara

Agnidusti in Amashaya

Formation of Amarasa

Sanchara through Dhamani all over

The body by vata dosha

Samadosha Accumulates in the

Slesma sthanas like

Amashaya, Sandhi etc

Enters Into Kosta, Trika Sandi

Leads to

Gatra Stabdata

Karoti Sarujam shotam

Yatra doshaha prapadyate

Leads to painful swelling of joints wherever the vikrita dosas travels.

Angamarda, Aruchi, Apaka,

Gourava, Jwara, Sandi Ruja

Sandi shota

Amavata.


31

Amavata

Purva roopa of Amavata

In the classics it is not clearly mentioned purva roopa of Amavata. But

however in such condition Avyakta lakshana prior to the manifestation of

disease is considered as the purva poorpa 135 with the help of this the purva

roopa of Amavata can be considered as follows

1. Dourbalyam (Weakness)

2. Haridaya gourava (heaviness in chest)

3. Gatra stabdam (Stiffness of the body)

4. Apaka (indigestion)

5. Anga mardu (Aching all over body)

6. Gourava (Heaviness)

7. Aruchi (loss of taste)

8. Alasya (lack of enthusiasm)

9. Jwara (fever)

10. Sandhi vedana (Joint pain)

Roopa of Amavata

“Utpanna Vyadhi bhodakameva lingam rupam” 136

It means which gives the idea about the manifested disease is known as

‘Rupa’.

Madhavakara 137 while describing Amavata lakshana, he has considered

them in to two heading one is samanya lakshana another is lakshana

samachaya of pravrudhu Amavata.

Samanya Laxanas are as follows

1. Angamarda (body ache)

2. Aruchi (Tastelessness)

3. Trishna (Thirst)

4. Alasya (lack of enthusiasm)

5. Gouravam (Heaviness all over body)

6. Jwara (Fever)

7. Apaka (Indigestion)

8. Shunata Anganam (Swelling all over the body mainly in joints)

Pravriddha Lakshana of Amavata:

It is the advanced stage of disease and very troublesome to patients as

well as for physicians. According to Kriyakala and stage wise development, it is

the worst stage of disease. Articular and Extra-articular feature present in this


32

Amavata

stage have been elucidated by Acharya Madhavakara, Bhava Mishra and Yoga

Ratnakara.

According to Madhavakara 138

1. Sarujam Sandhishotha – Hasta, Pada, Shiro, Gulpha, Janu, Uru Sandhis are

chiefly involved in Amavata.

2. Vrishchika danshavata vedana – This kind of pain shows the presence of

Ama at the site of pain.

3. Utsahahani – A subjective feeling in which lack of enthusiasm can be seen

in suffering person. It is due to insufficient nutrition of Sharira Dhatus,

Indriya and Mana.

4. Bahumutrata – Presence of vitiated or dushita Ama causes sroto –

abhishyanda in the body, which leads to increase of kleda. This Bahumutrata

occurs for the excretion of excess kleda from the body.

5. Kukshikathinya – Vitiated Samana and Apana Vata along with the Ama

leads to Kukshikathinya, which is the rigidity of abdomen.

6. Kukshishoola – Srotorodha due to Ama causes obstruction to normal

movement of vitiated samana and apana Vata resulting in pain in abdomen.

7. Nidra Viparyaya – Due to vata vriddhi, pain gets aggravated at night and

keeps the patients awaken which leads to Nidra Viparyaya.

8. Chardi 139

Continuous formation of dosha leading to excitation of Amashaya by

Vata causes Chhardi.

9. Bhrama - Presence of Kapha in Srotas and Vitiated Vata causes Bhrama.

10. Murchcha - Inability of the sensory organs to perceive the sense objects is

Murchcha. Loss of motor function occurs in Murchcha due to upatapa of

Indriya by Vitiated Vatadi doshas 140

11. Hritgraha - It is due to Rasavaha srotodushti (its mulasthana is Hridaya) and

vitiation of Samana Vata, Vyana Vata and Avlambaka kapha. Hritgaurava is

also produced due to above reason when vitiation is mild.In R.A. cardiac

manifestations like Pericarditis, Myocarditis, Conduction defects etc. can

occur.


33

Amavata

12. Vibandha – It is due to vitiated Apana Vata and improper degradation of

Ahara into Sara and Kitta.

13. Antrakujana – In this feature, increased bowel sounds are present due to

movement of Vitiated Vata in the intestine.

14. Anaha – It is the stagnation of vitiated vata in Kukshi.

15. Agnimandya – Vicious cycle of disease (Agnimandya-Shuktatva –

Annavisha) produces Agnimandya again and again.

16. Praseka – It means lalasrava. 141Excessive thick, mucoid, salivary secretions

are produced due to Samarasa, which shows Rasavaha and Udakavaha

srotodushti.

17. Gaurava – Due to Vitiated Kapha there is feeling of heaviness in Hridaya

and body parts preferably in Joints.

18. Vairasya 142

Perception of different taste than normal due to Sama Rasa and

vitiated Bodhaka Kapha.

19. Daha - Due to Vitiation of Pitta sometimes localized or generalized Daha

occurs.

Warmth of the joint is usually evident on examination. In its most aggressive

form, rheumatoid vasculitis can cause Mononeuritis multiplex (Harrison

1994).

20. Trishna – Trishna is due to Agnidushti, Sama Pitta and Vata. It shows

Rasavaha, Udakavaha srotodushti in disease process.

Table No.2 Similarity between Amavata and Rheumatoid Arthritis

Rheumatoid Arthritis Amavata

Morning stiffness Gatra sthabdata or sandhi sthabdata

Arthritis of 3 or more joints Bahu sandhi shotha

Arthritis of hand joints Hasta, sandhi shotha

Symmetrical arthritis Bahu sandhi shotha (ubhaya)

Angavaikalya Rheumatoid nodule

Rheumatoid factor ----

Radiological changes ----


34

Amavata

The first 4 criteria of RA can be correlated with the inflammatory

condition of amavata. But rheumatoid factor and radiological changes cannot be

correlated to any conditions of amavata. Hence on symptomatology amavata can

be best correlated to RA.

Pratyatma Lakshana (Cardinal Signs and Symptoms)

Pratyatma Lakshanas are main clinical features on which the disease can

be clearly differentiated from other identical forms of disease. In Amavata,

sandhis are the main site of manifestation of clinical features, thus joint associated

symptoms are considered as Pratyatma lakshana of disease Amavata.

These are as follows:

(a) Sandhi Shoola (Joint Pain)

In Amavata, Vitiation of Asthi and Majjagata Vata causes pain in

Sandhis and in severe stage, it is found as Vrishchika Dansha vata.

The most common manifestation of established R.A. is pain in affected

joints, which is aggravated by movements. During rest and especially early

morning stiffness are also characteristic features of R.A. Pain originates

predominantly from joint capsule, which is abundantly supplied with pain fibres

and is markedly sensitive to stretching or distension (Harrison 1994).

(b) Sandhi Shotha (Joint Swelling)

Sandhi Shotha (Ekangika shotha) results when vitiated dosha afflicts

Twaka, Rakta, and Mamsa in joints 143 Madhavakara has described that shotha

result due to the affliction of Ama and Vata Pradhana Tridosha in joints.

Joint swelling in R.A. is the result of accumulation of synovial fluid,

hypertrophy of synovium and thickening of joint capsule.

(c) Stabdhata (Stiffness)

The restriction or loss of movements of joints. Gatra stabdhata is

caused due to spreading of Ama through out the body by vitiated Vata.144, 145

In majority of patients, the onset is insidious with joint stiffness,

especially early morning stiffness, which gradually gets reduced by evening. This

diurnal rhythm worse on arising in the morning and than relieving towards

evening probably reflects the diurnal variation in plasma cortisol level.


35

Amavata

(d) Sparshasahyata (Tenderness)

Sparshasahyata can be included in Sandhishoola in which patient cries

with pain even when the gentle pressure is applied to affected part. Some times

person himself cannot touch the affected part due to pain.

According to Modern text pain on movement and tenderness are the

cardinal signs of the disease (Becron -1971).

Table-No 3,Lakshans According to different Ayurvedic classics 146,147,148,149,150

No. Lakshana MN B.P. B.R. Y.R. G.N. A.N

1 Agnidourbalya + + - + + -

2 Alasya + + - + +

3 Anaha + + - + + -

4 Angamarda + + - + + -

5 Anga sonata + + - + + -

6 Antra kujan + + - + + -

7 Apaka + + - + + -

8 Aruchi + + - + + -

9 Bahu mutrata + + - + + -

10 Bhrama + + - + +

11 Chardi + + + + + -

12 Daha + + - + + -

13 Gourava + + - + + -

14 Hritgraha + + - + + -

15 Janghadi Pradesha Vyadha - - + - - -

16 Jwara + + - + -

17 Kukshi Kathinyata + + - + -

18 Kukshi sula + + - + -

19 Murcha + + - +

20 Nidra Viparayaya + + - +

21 Pandu Varna - - + - -

22 Prasekam + + - + + -

23 Sandhi gourava + - - - + +

24 Sandhi Ruja + + - + + +


36

Amavata

25 Sandhi shotha + + - + + +

26 Sandhi Graha - - - - - -

27 Sosha - - + - - -

28 Trishna + + + + + -

29 Ushnata - - + - - -

30 Utsaha Hani + + - + + -

31 Vairasyam + + - + + -

32 Vishuchi - - + - - -

33 Vitvibandha + + - + + -

34 Vruschika damsavata peeda + - - - + -

Table No.4, Showing the Sthananusara Laxana

Stanika Laxana Shareerika Laxanas Manasika Laxana

Sandhi shotha, Sandhi

shoola, Gatra

sthabdata, Daha, Raga,

Kandu.

Angamarda, Kukshishoola, Aruchi,

Bahumutrata, Trusna, Peeta mutrata,

Alasya, Takratulyata, Gourava,

Nidraviparyaya, Jwara, Antrakoojana,

Apaka, Anaha, Agnimandya,

Grahanidosha, Praseka, Asyavairasya

Utsahahani,

Moorcha,

Bhrama, Alasya.

Sapeksha Nidana

Sapeksha nidana becomes necessary when two or more disease have a few

important laxanas similar to each other and in such condition in order to avoid any

error in adopting the line of treatment. The differential diagnostic is done on the

basis of few points such as difference in samprapti accompanying laxanas,

upashaya anupashaya etc.

Here the disesae, which was exhibited with sandhi shotha and

sandhishoola specially, are considered for differential diagnosis.

1) Vatarakta

2) Sandhigatavata

3) Krostaka sheersha

4) Sandhiga sannipata

5) Sandhi aghata


37

Amavata

Vatarakta -

Usually manifests with supti, discolouration and shithilatha of sandhi, pain

is of pricking and splitting nature, sudden onset or disappearance of joint pain.

Anguli sandhies are first affected, then it spread to other parts of the body slowly

like akuvisha, all the affected joints are having pain equally, joint swelling is non

fleeting, no morning stiffness.

Sandhigata vata –

Because of lack of sleshmaka kapha for the friction of joints, it cause pain

and swelling. Here joint movement is accompanied with pain. This is sthira ie.,

non fleeting, the hip and the knee are often affected usually effects middle aged or

elderly persons. Symptoms subside by using sneha therapies.

Krostaka sheersha –

This is the condition, wherein provocated vata and rakta give rise to janu

sandhi shotha and shoola, no other joints are involved. Shotha resembling the

head of jackal, non-fleeting, severe pain in affected joint pain may increase during

night.

Sandhiga Sannipata –

This is a type of sannipata jwara usually manifests due to tridoshakaraka

hetus, swelling and pain of the joints are non fleeting, non variant pain, usually

along with anidrata and severe cough.

Sandhi aghata –

This is of traumatic origin, pain and swelling will be restricted to the

affected joint. Non-fleeting, subsides after few days.

Types of Amavata

Madhava Nindan while explaining the doshanubandha lakshana 151 he maid 3

types where as while expressing about the sadhyasadhayata of Amavata he maid 7

types on the basis of involvement of the doshas 152.By combining the above two

points Amavata is of seven types on the basis of dosas they are as given below

1. Vata pradhana -- In this mainly predominance of sula will be present.

2. Pitta pradhana – Daha and Raga are present in the joints.

3. Kapha Pradhana – Staimitya, Gourava & kandhu are the main symptom of

this variety.

4. Vata pitta paradhana – Combined symptoms of both pitta & vata.

5. Vata kapha pradhana -- Combined symptoms of both vata & kapha.

6. Pitta kapha pradhan -- Combined symptoms of both pitta & kapha.


38

Amavata

7. Sannipatika -- Combined symptoms of both all dosas.

According to Sharangadhara four types of Amavata are considered

1] Vataja Amavata

2] Pittaja Amavata

3] Kaphaj Amavata

4] Sannipataja Amavata

According to the presence of lakshana Amavata is classified in to two

types first one is Samanya Amavata 153 and second is Pravrudha Amavata.154

According to time period of Amavata it is of two types.

1. Naveena Amavata, 2. Jirana Amavata.

A unique classification of Harita explained in Harita Samhita based on

presentation of the disease. Those are, 155

a) Vistambhi b) Gulmee c) Snehi

d) Pakwama e) Sarvanga

a) Vistambhi - This presents with constipation, feeling of heaviness, in the

abdomen, flatulence pain in the basti area.

b) Gulmee - Symptoms simulating like gulma, spasmodic pain in abdomen,

increased audible peristaltic sounds.

c) Snehi - Unctonsness of the body, inactivity, loss of appetite, passing of

unctuous and undigested stools.

d) Pakwama - Passing of yellowish, black or dark bluish dehydrated pakwama

through anus, fatigue, exhaustion, condition is not associated with basti shoola.

e) Sarvanga - Pain in kati, prusta and vakshana region, pain in basti, region,

audible peristaltic sound, swelling, heaviness in the head, excessive excretion of

ama are the symptoms.

Upadrava of Amavata

The symptoms of advanced stage of Amavata are considered to be as

Upadrava of Amavata roga. Vacaspati mentioned symptoms of advanced stage of

Amavata are as upadrava but the commentator of Madhakosa Vijayarakshita

differentiates the symptoms of advanced stage of Amavata from Upadrava.

According to him Khanja, Sankocha, occur in Amavata. But further Vachaspati

includes the disease expounded within the title of vata vyadhi under Upadrava. So

it is worth to be considering Angavaikalya is an Updarava considered by Harita.

Even in Madhava Nidhava the Amavata Updravas are mentioned, they are

Trit, Chardi, Bhrama, Moorcha, Hradgraha, Jadya, Antrakoojana, Anaha etc 156


39

Amavata

All the Systems will invalue or get disturbed in the Amavata. It is not

treated in time it produce anatomical deformities like sandhi vikruti and Hrid

Graha. So proper management is must from the on set of disease. The upadrava

depends upon the type of kapha involved in samprapti. If Ama combins with

shleshka kapha & gets lodged in sandhi sthana creates sandhi vikruti and if Ama

combines with Avalambak kapha resides in Hridaya develops Hrid Graha.

Upashaya / Anupasaya

If the relief occurs by using the Oushandi, Ahara or Vihara are to be

considered as Upasaya11. In the oppsite sence if relief not occurs are counted as

Anupasaya.157

Same types of lakshnas will find in different rogas. If we take example of

Amavata lakshanas such as sandhi shotha, sandhi shool etc, are likely to be found

in other diseases like vatarakta, sandhigatavata, kostakasirsa etc. In this type of

conditions when the lakshanas are found similar to that of another disease it is

difficult to diagnose the disease and adopt the treatment. In this difficult condition

Upashaya and Anupashaya have advised.

Upashaya for Amavata are Ruksha sweda, langhana Usnakala etc Where

as Anupasayas are snigdha sweda, Santarpana etc.

Sadhya Asadhyata 158

Amavata have got Anubandha with single dosa, naveena avasta, lakshanas

are in mild form, no presence of Upadrava indication of sadhyata of Amavata. If

involvements of any two dosas produce Vyapyata of the Amavata where as

involvement of all the three dosas, involvement of all the joints, Purana Amavata

including with upadravas will become krichra sandhya vyadhi.

Chikitsa of Amavata

Aim of chikitsa is to cure the disease and bring back dosas normal. The

treatment for ‘Ama’ condition is Apatrapana or Langhana. Langhana included

both sodhana and samana. If dosas are alpa langhana is advised. If dosds are

madhyama langhana pachana is indicated. But if dosas are prabhuta sodhana is

advised.

Regarding with Amavata chakaradatta 159 has explained complete Amavata

chikitsa in first time. The principles of treatment for Amvata are as follows

1. Langhana

2. Swedana

3. Tikta katu deepena drugs


40

Amavata

4. Virechana

5. Snehapana

6. Anuvasana and Kshara abasti 7. Ruksha Upanaha 160

8 Sankara sweda161

1] Langhana

Langhana has advised by Charak in Amasayotaja vyadhi, Rasaja vyadhi

and in Ama vikara. Langhana is of three types Langhana, Langhanapanchana and

Doshavasechana charaka included 10 types in langhana chikitsa which are

Vamana, Virechana, Niruhabasti.Pipasa, Atapa, Pachana, Upavasa & Vyayama 162

Vagbhata classified langhana in to two types Shodhana & Shamana.

In the initial stage of Amavata shodhana is not beneficial when the dosas

are in Sama stage & spread all over the body their elimination is not possible. So

the first aim is to mobilize the doshas from shakha to kostha Upavasa type of

langhana helps in bringing the dosas from Shakha to kostha.

In Amavata there is a predominanace of vata is their but it is in the form of

sam & this langhana (Upavasa) is indicated in samavata that’s why their will be

no any controversy for using langhana in Amavata.

Mainly langhana does Dosha pachana and agnisandhukshana by this the

‘Ama’ present in the Amavata gets digested & gradually Agni will excited their

after.

2] Swedana

Swedana is the therapy, which relieves the stambha, Gourava, Sheeta &

produces Sweda 163 The main symptoms of Amavata are stambha, Gourava,

Sheeta & Shroto avarodha. Where swedana relives these all cardinal symptoms.

Usually by seeing the dosha dooshya samoorchana in Amavata ruksha sweda has

been recommended where as in Nirama conditions snigdha. Due to its heat,

causes relaxation of muscles & tendons & promotes blood circulation, by this

local metabolic process gets activates by this pain gets relief.

If there is involvement of few joints the local types of swedana can be

advised. But if the involvement is of multiple joints Sarvanga swedana should be

advised.

By the help of swedana digestive capacity will increase softness of the

limbs, smoothness and clearness of the skin, relish for food, clearness of the

channels, absence of somnolence & drowsiness and free movement of joints


41

Amavata

above this dosas which are moistened by snehana gets liquefy and carried down in

to the kostha 164

3) Deepana (Tikta & Katu dravyas)

These drugs mainly having the properties like Agnideepana,

Amapachana,165 Avarana dosha Nivarana (Pachana) by these qualities they

acts as Srotosodhaka.

In Amavasta of Amavata, doshas are sticked strongly to srotasa, so they

cannot be removed by snehana and swedana. In such conditions deepana

upakrama will helps to increase the Agni 166 and does Amapachana leading the

detachment of dosha from the Srotases and removal of Srotoradha. It is well

known that Deepana, Pachana is an essential process to be performed in Ama

predominance disease.

4] Virechana

After the administration of Langana, Swedana, Tikta, Katu and Deepana

drugs, the patient should be subjected to Virechana therapy since the doshas

rendered nirama by these therapeutic measures require elimination from the body

by shodhana. Now the question arises why virechana alone should be given and

not vamana too, because usually vamana precedes virechana. If virechana is given

alone the kapha located in the amashaya may produce mandagni and its

consequences.167 How ever this rule has been relaxed in the case of Udararoga,

gulma etc. The same may also be followed in case of amavata because of the

following reasons.

a) Production of ama is the result of Avarana of pitta sthana by the kledaka

kapha and it is the most suited therapy for the sthanika dosha pitta.

b) Symptom of amavata like anaha, vibandha, antrakujana, kukshishula etc.

are indicative of pratiloma gati of vayu. This is best conquered by

virechana, while vamana is likely to aggravate this condition.

c) Further more, though virechana has been described to be the best remedy

for pitta dosha, yet it is effective in the vitiated kapha and vata dosha also

to some extent. So in this way it appears to be the most appropriate

therapeutic measures in this condition. The use of eranda taila in amavata

suggests that in this disease snigdha and not ruksha virechana should be

employed, since it does not produce generalised snehana effect but by its


42

Amavata

snigdha, ushna etc. characteristics, it augments the agni in addition to its

vata anulomana action.

5) Snehapana

Up to the administration of Virechana we are concentrating on the

eradication of Ama. Once Ama digested in the body the other factor which is Vata

becomes dominant in the body or due to the Apatarpana chikitsa of Ama may

provoca Vata. For this snehapana is advised in Amavata. More over Snehana is

mailnly indicatied in chrinic condtion of Amavata. This Snehapana is used due to

the following benefits which are digestive activity becomes very intense,

Alimentary tract become very clean, by this production of Ama will stop in the

body.

Even after the Shodhna karma, Shamana sneha have advice to retain the

Bala of the Patient.

6] Basti

In amavata both anuvasana as well as Niruha basti have been advocated.

Anuvasana basti removes the dryness of the body caused by amahara treatment,

alleviates vata dosha, maintains the functions of Agni and nourishes the body.

The niruha basti eliminates Doshas brought into kostha by the Langana and allied

therapies. In addition to generalised effect, basti produces local beneficial effects

also by removing the anaha, antra kujana, vibandha, etc. Bruhat Saidhavadi Taila

has been mentioned for anuvasana and ksharabasti for asthapana.

Depending upon the use of different drugs, vasti causes samshodhana and

samshamana effects. Sushruta has stated that the action of basti is mainly due to

veerya. He further elaborates that the drugs used in basti karma will however

spread in the body from pakwashya due to their veerya. So basti karma

eliminates the morbid doshas and dushyas from the entire body by srotosuddhi.

So its effects are tridoshahara.

Its effects are not only limited up to rectum and Samsodhana of malas but

it produces widespread systemic effect. Basti can produce its effect through

medicament effect (Pharmacological effect) and effect of volume (Pressure

effect). Thus with the help of suitable medicaments, vasti therapy may modify

the colonic physiology and alter pathogenic krimis by prakritivighatana, on the

other hand certain Basti may enrich the normal bacterial flora of the colon and

may be expected to promote their sustaining role in body. By doing so, it


43

Amavata

modulate the rate of endogenous synthesis of vit B12, which may have a role to

play in maintanance and regeneration of nerves.

7] Ruksha Upanaha

According to Bhavaprakshana in the Amavata for the local benefit of

Sandhishoola and Sandhishotha this Ruksha Upanaha has advised.168

8] Sankara sweda

In Bhisjjya ratnavali Sankara sweda with making Potali of

Karpasasti, Kulattha, Tila, Yava, Erandamoola, Atasi etc are kept in boiling Kanji

and maid Swedana.169

Various Upakramas have been prescribed by different Acharyas for the

treatment of Amavata as follows:

Table No 5. Upakramas according to Different Acharyas

Sr. Upakrama H.S. V.M C.D. V.S. B.P. B.R.

1 Langhana - + + + + +

2 Swedana - + + + + +

3 Tikta - + + + + +

4 Katu - + + + + +

5 Deepana dravyas - + + + + +

6 Virechana + + + + + +

7 Snehapana - + + + + +

8 Basti + + + + + +

9 Anuvasana-Saindhavadi

Tail - - + - - +

10 Kshara Basti - - + - - +

11 Ruksha sweda

by Balukaputa - - + + + -

13 Pachana - - - - - +

14 Vamana - - - - - +

Yoga Ratnakara has followed Bhava Mishra


44

Amavata

Pathya Apathya.

“If the person is taking Pathya ahara then what is the necessary of taking

medician, if the person is not taking Pathya than what is the necessary of taking

the medicine” this shows the importance of Pathya in the Management of any

disease.

Pathya has important role in the prevention and exacerbation of the

disease process. As per the classics any drug or diet that is katu, tikta by rasa,

Ushna and Teekshna in guna and having vatahara, kaphara, amapachana action is

considered as pathya.

The list of Pathya mentioned in texts;

1. Dravyas - Punarnava, rasna, patola, karavellaka, vartaka, shigru, gokshura,

vriddha daru, ballataka, ardraka (YR), Shyamaka (BP), Varuna, Vastuka (YT)

2. Mamsa - Jangala mamsa rasa (Y.R.B.P), Lavaka mamsa with takra (Y.T)

3. Aharadravya - Puranashali, Yava, Purana Shastikashali, Kulattha

4. Anya - Eranda Taila, Usnodaka, procedures like Rukshasweda, Langhana,

Snehapana, Basti, Lepa, Virechana are considered as pathya. The pathyas of

jwara also considered as pathyas of amavata (HS)

The drugs or diets having guru, picchili, abhishyandhi gunas and which

causes provocation of vata, kapha and formation of ama are considered as

Apathya

All nidanas of amavata are considered as apathya - Masha, Anupamamsa,

Dadhi, Guda, Ksheera, Mathsya, Upodhika, Shimbhi dhanyam, Sheetajalasnana,

Abhyanga considered as apathyas for the disease process.


45

Rheumatoid Arthritis

Rheumatoid arthritis

In Rheumatoid arthritis the onset in majority of the patients is insidious

with joint pain, stiffness & symmetrical swelling of membrane of peripheral

joints. As the disease progresses there is a tendency for it to spread to involve the

wrists, elbows, knees & other joints. The mandibular, acromioclavicular &

sternoclavicular joints are sometimes affected as indeed in every symovial joint.

The history of arthritis is as old as mankind, as the ape-man himself had

arthritis of the spines. Detailed study of this age old, complicated crippling

clinical entity confirms its close association with other branches of medicine such

as neurology, cardiology, endocrinology, bacteriology, geriatrics, pediatrics and

orthopedics.

Rheumatoid arthritis is a chronic disease of the joints, usually

polyarticular, marked by inflammatory changes in the synovial membranes &

articular structures. Hence the knowledge of anatomy & pathophysiology of the

joints is very important, as the synovial joint is involved in Rheumatoid arthritis

this is being elaborated here

Epidomology

Scientists estimate that about 2.9 million people have rheumatoid arthritis

RA occurs in all races & ethnic groups. Although the diseases often begin in

middle age and occur with increased frequency in older people, children & young

adults also develop it. Like some other forms of arthritis, RA occurs much more

frequently in women than in men about 2-3 times as many women as men have

the disease. Server RA is found at four times the expected rate in the first-degree

relatives of probands with zero +ves disease.

Etiology of Rheumatoid Arthritis: 170 to 175

The disease Amavata is best compared with Rheumatoid arthritis in the

modern parlance. Rheumatoid arthritis (RA) is a chronic multisystem disease of

unknown cause. It has been suggested that RA might be a manifestation of the

response to an infectious agent in a genetically susceptible host. Because of the

worldwide distribution of RA, it has been hypothesized that if an infectious agent

is involved, the organism must be ubiquitous. A number of possible causative

agents have been suggested, including Mycoplasma, Epstein-Barr virus (EBV),

cytomegalovirus, parvovirus, and rubella virus, but convincing evidence that these

or other infectious agents cause RA has not emerged. The process by which an


46


infectious agent might cause chronic inflammatory arthritis with a characteristic

distribution also remains a matter of controversy. Recent work has focused on the

possible role of "super antigens" produced by a number of microorganisms,

including staphylococci, streptococci and M. arthritidis. Super antigens are

proteins with the capacity to bind to HLA-DR molecules and particular Vb

segments of the heterodimeric T cell receptor and stimulate specific T cells

expressing the Vb gene products. The role of super antigens in the etiology of RA

remains speculative. Of all the potential environmental triggers, the only one

clearly associated with the development of RA is cigarette smoking.

Sero positive RA aggregates in families Genetic factors versus their

interaction with environmental facilitators is unclear HLA DR4 is found in 70%

of Caucasian sero positive patients compared to 25% of controls. Increased

relative risk of 4-5 times for the DR4 positive persons; although a minority are

affected African Americans tend not to exhibit this predilection

Anatomy of joints:

Synovial joints:

Articulations of the synovial type utilize on entirely different principle

from the non-synovial fibrous and cartilaginous joints. Although the bones

involved are linked together by a fibrous capsule & frequently by accessory

ligaments inside or outside of this, the major parts of the articular surfaces

concerned are in contact but not continuity. They are covered by a relatively thin

stratum of hyaline cartilage (occasionally of fibro cartilage) and the actual contact

is between these cartilaginous surfaces which are characterized by a very low co-

efficient of friction (0.002 or less).

Synovial joints have the following components:

1. A joint capsule that isolates the joint from surrounding tissue.

2. A joint cavity formed by the surrounding joint capsule.

3. A synovial membrane (synoviam) that is the inner lining of the joint capsule.

4. Synovial fluid that is secreted by the synovium & serves as the lubricant &

carries nutrients for the joint.


47


5. Bones that come together to form the joint.

6. Hyaline (Articular) cartilage covers & protects the ends of the bones that

participate in the joint.

There may be other structures present in or near the joint such as disks,

cartilage (menisci) tendons, ligaments burscea important characteristics of

these structures include.

The joint capsule is composed of two layers, an outer fibrous layer & inner

synovium (identified above) the outer layer has many joint receptors innervating

it but is not vascularized. Opposite to it synovium is well vascularized but poorly

innervated. The articualr cartilage has two important functions including the

ability to minimize friction & wear between to opposing joint surfaces during

movement & to dissipute forces on the joint over a wider area. Thus decreasing

stress on the contacting joint surfaces.

Synovial fluid contains hyaluronate (hyaluranic acid) and a glycoprotien

called lubricin. Both are responsible for the lubrication of joint, although they are

specific for certain components. Hyaluronic acid is important for the lubrication

of the joint capsule while lubricin is necessary for cartilage on cartilage

lubrication.

Synovial fluid is also medium by which mutrients are carried to and

wastes are carried from through the avascular components of the joint.

The ends of the long bones that form the synovial joints are composed of

soft spongy type of bone called subchondral bone. Hyaline (articular) cartilage

covers this bone & protects it except for the very ends of the bone; long bones are

usually very strong.

Effects of the disease:

Rheumatoid arthritis can attack any synovial joint in the body. Except the

distal interphalageal joints, it has the greatest affinity for the small joints of hand,

wrist, & foot. In many cases the joint involvement in the limbs becomes relatively

symmetrical. Further, the cervical spine, usually the superior aspect becomes

affected & patients must be watched carefully for disruption of the atlanto axial


48


joint in advanced cases of the disease, subluxation at the atlantoaxial joint can

occur.

Early in the course of the disease several changes in joint structures occur.

Joint effusion & inflammation of the synovium occur producing a soft tissue

swelling that is easily detected during evaluation of the patient. Additionally,

changes in the ends of the bones forming the joints may be present early in the

disease process.

The earlier changes are welling and congestion of the synovial membrane

and overlying connective tissue which becomes infiltrated with lymphocytes,

plasma cells & macrophages. Effusion of the synovial tissue takes place during

the active phase of the disease. Subsequ4ently hypertrophy of the synovial

membrane occurs. Inflammatory granulation tissue or pannus is formed spreading

over & under the articular cartilage, which progressively destroyed. Later fibrous

adhesions may form between the layers of pannus across the joint space & fibrous

or even bony ancylosis may seen. The synovial fluid secreted by the synovium is

thought to save two main purposes, lubrication of the joint & provision of

nutrients to the avascular articular cartilage. In this disease process, an interaction

between antibodies & antigen’s occurs, and causes alterations in the composition

of the synovial fluid. Ultimately, digestants are formed in the fluid, which attacks

the surrounding tissue. Once the composition of this fluid is altered, it is less able

to perform the normal functions noted above and more likely to become

destructive.

The muscles adjacent to inflame its atrophy and there may be focal

infiltration with lymphocytes.

The changes in the synovium & synovial fluid briefly described above, are

responsible for a large amount of joint & soft tissue destruction the destruction of

bone eventually leads to laxity in tendons & ligaments under the strain of daily

activities and other forces, these alterations in bone & joint structure result in the

deformities frequently seen in patients with Rheumatoid arthritis considerable

destruction of the joint can occur with pannus invading the subchondral bone.

Bone destruction occurs at areas where the hyaline cartilage & the

synovial lining do not adequately cover the bone. If the disease progress to a more


49


advanced stage, the articular cartilage may lose its structure & density resulting in

an inability to withstand the normal forces placed on the joint. In these advanced

cases, muscle activity causes the involved ended of the bones to be compressed

together causing further bone destruction. Further the disease can irreversibly

change the structure & function of a joint to the degree that other degenerative

changes may occur.

Especially in the weight bearing joints of the body, this joint destruction

can progress to the degree that joint motion is significantly limited & joints can

become markedly unstable.

Pathogenesis of Rheumatoid Arthritis: 176 to 180

In contemporary medical science, Amavata can be best correlated to

Rheumatoid Arthritis (Y.N.Upadhyaya). It is described as an autoimmune

disorder. The propagation of Rheumatoid Arthritis is an immunologically

mediated event, although the original initiating stimulus has not been clear. One

view is that the inflammatory process in the tissue is driven by T4 helper cells

infiltrating the synovium. Evidence for this includes,

• The predominance of T4 cells in the synovium

• The local production of lymphokines by these infiltrating T cells

• Amelioration of the disease by removal of T cells by thoracic duct

drainage or suppression of their function by total lymphoid irradiation.

Since T lymphocytes produce a variety of cytokines that promote B cell

proliferation and differentiation into antibody forming cells. T cell activation may

also produce local B cell stimulation. The resultant production of immunoglobulin

is rheumatoid factor that can lead to immune complex formation. With

consequent compliment activation there will be exacerbation of inflammatory

process by the production of anaphylatoxins and haemostatic factors. This tissue

inflammation is reminiscent of delayed type of hypersensitivity reaction occurring

in response to soluble antigens or microorganisms. It is how ever unclear that

whether this represents a response to persistent exogenous antigens or to altered

auto antigen such as collagen or immunoglobulin.


50


Flow chart-2

Pathogenesis of Rheumatoid arthritis

Localization of antigen in Joints

Processing by antigen presenting cells

Interaction with T call receptor

Release of immunopotentiating cytokines

Endothelia call activation

Expression of adhesion molecules

Homing of T – lymphocytes

IL – 2 production & T cell proliferation

Production of T cell cytokines

β - Lymphocyte proliferation

Local synthesis of antiglolovlin antibodies

Formation of immure complexes

Activation of complement pathway

Neutrophil chemotaxis & cytolysis

Lymphokine production

Macrophage activation.

Release of monokines & other mocyte medictor

Immune complex phagocytes by neutrophills & Monocytes.

Release of mediators of acute inflammation (Vasoactive amines proteases,

Lenkotrienes, Oxygen radicals, prostaglandins, polypeptides).


51


Activation of macrophages & chondrocytes.

Pannus formation

Enzymatic destruction of cartilage bone

Acute phase, fever muscle wasting

Prodromal symptoms 181, 182

Morning stiffness, generalized weakness, mascolo skeletal pain, fatigue,

anorexia, weight loss etc.

Clinical Features:

1. Artichlar 183, 184

In the majority of patients the onset is insidious with joint pain. Stiffness

& symmetrical swelling of a number of peripheral joints. Initially the pain may be

experienced only on movement of joints, but rest pain especially early stiffness is

characteristic features.

In typical case the small joints of the fingers & toes are the first to be

affected. Swelling of the proximal but not distal, interphalaugeal joints given the

fiugers a spindled appearance & swelling of metatassophalargeal joints results in

broadening of the forefoot. Fever, weight loss profound fatigue, anorexia &

malaise with out joint symptoms occur less often.

It’s the disease advances there is a tendency for it to spread to involve.

Wrists, elbows, shoulders, knees, ankles, subtarsal midtarsal joints. The

advancement of pathogenesis is bad to muscle atrophy, tendon sheath & joint

destruction results in limitation of joint motion, joint instability with anterior

subluxation of MTP joints in common with ulnar deviation of the fingers in

addition to this lymphadenopwthy, osteoporosis muscle weakness & wasting,

tenosynovitis, bursitis, popliteal cysts, sometimes subcutaneous nodules are

formed. Apart from this scleromalacia, Keratoconjantivitis, scleritis is bound to

occur. Asymptomatrl periconditis, Pl. effusion may occur infrequently. Some of

the characteristic features of Rheumatoid arthritis are:


52


a Hands – spindling of proximal interphalangeal joints & swelling of

metacaspopalangeal joints dorsum of wrist. Weakness of grip or triggering of

fiugers. Swan – neck and boutonniere fingers. Z – Deformity of the thumbs.

Ulnar deviation of fingers & drop fingers from rupture of extensor tendons.

b Feet – Dorsal subluxation of toes with overriding & callosities may develop.

c Knee joint – Synovial effusion occurs early followed by fixed flexion, orvarus

or valgus deformities. Synovial rupture may lead to release of fluid into

popliteal space calf. Attesnatively effusion may distend popliteal bursa to

produce a bakes’s cyst, synovitis of bursae may occur at other sites.

d Cervical spine – Subluxation of cervical bodies or altantoaxial joint.

E Crycocastynoid joints – May occasionally be affected causing dysphasia,

hoarseness or stridor.

Table No 6, Extra articular features 185, 186

Systemic

Fever, Weight loss, Fatigue, Susceptibility to

infection

Vasculitis

Digital arthritis, Unloss Pyoderma

ganzdemosm,Mononearitis,

multiple Visural artiritis.

Muscaloskeletal

Muscle wasting, Tenosynovitis, Bursitis,

Osteoporosis

Cwrdiae

Pericarditis,Myocorditis,

Endocarditis, Conduction defects

CoronoryVasculations,

Granulomatis arthritis.

Haematological

Anamia, Thrombouptosis, Eosimophelia

Pulmonory

Nodules, Pl. Effusions, Fibrosing

alveolitis, Bronehiolitis, Eapalan’

syndrome Nodules

Sinuses, Fistulae Neurological

Cenicalchord, Compression,

Newropathies

Occular

Episcleritis, Scleritis, Scbromaleria, Sicca

syndrome Skin

Pulmar erythema, Psoariasis


53


Infection: Increased frequency in Rheumatoid arthritis

1] Antimelear antibodies in 50%. 2] Elevated CRP, alkaline phospate platelets.

Differential diagnosis:

Rheumatoid Arthritis differentiated from other diseases having similar

features like Joint Pain on the basis of presenting Signs and Symptoms &

biochemical investigations. These diseases are as follows:

1. Gout :

In pathological investigation high serum uric acid level is present.

Response to administration of Colchicine is found in this condition.

2. Osteoarthiritis :-

Radiological appearance differs, absence of subcutaneous nodules and

R.A. factor. In typical case, Heberdon’s nodes appear in relationship to DIP

joints and ESR usually with in normal limits.

3. Polymyalgia Rheumatica :-

In this condition ESR is very high and peripheral joint signs are

minimal. (Onset of Rheumatoid Arthritis in elderly mimic Polymyalgia

Rheumatica)

4. Polyarthritis Nodosa :-

May resemble Rheumatoid Arthritis, but radiological changes are

minimal. Severe systemic symptoms and necrotising vasculitis at early stage of

polyarthritis may be present, but joint erosions and typical Rheumatoid Arthritis

deformity are rare in later stage.

5. Systemic Lupus Erythematosis :-

It is characterized by the presence of numerous autoantibodies,

circulating immune complexes and widespread immunologically determined

tissue damage. Chronic inflammatory arthritis and tenosynovitis may lead to

deformities and contractures, but erosive changes are very uncommon.

6. Rheumatic Fever: -

First, attacks are usually under 15 years of age in 70% of case. It is

characterized by flitting type of joint pain and sustained fever. Spindling of

finger joint is rare. Myocarditis, endocarditis and nodules on the different

histological picture are present.


54


Some other diseases are as follows from which we have to differentiate

the disease Rheumatoid Arthritis.

• Acute Suppurative Arthritis

• Tuberculous Arthritis

• Reiters Syndrome

• Hypertrophic Osteoarthropathy

• Chronic Arthropathy

• Sarcoid Arthritis

• Scleroderma

• Arthritis with Erythema Nodosum

• Spondylitis

• Psoriatic Arthritis

Table No 7, Symptoms of R.A which may require differential diagnosis

Symptoms Possibilities to be considered

Acute or severe pain in one or a few

joints

Joint sepsis – fever may be

absent

Fracture – even without obvious

trauma

Unexplained weakness Cervical spine involvement

producing cord compression

Unilateral calf swelling Ruptured Baker’s cyst – this is

frequently misdiagnosed as a

deep venous thrombosis

Painful red eye Scleritis-requires expert

opthalmological assessment

Complication of Rheumatoid Arthritis:

• Septic Arthritis

• Amyloidosis – The synovium is infiltrated with amyloid protein.

• Systemic Vasculitis

• Spinal Cord Compression

• Felty’s syndrome – Splenomegaly with neutropenia leads to

repeated infections and weight loss known as felty’s syndrome.


55


Prognosis: 187, 188

The course and prognosis in R.A. is very difficult to predict because of

its variability. 25% of the severe patients may have complete remission of

symptoms and fit for all normal activities. 40% of the cases suffer with moderate

type of functional impairment despite exaggeration and remission. 25% may be

more severely disabled and 10% may be severely crippled almost limited to bed.

Prognosis may be very poor in many cases as follows:

1. High titre of rheumatoid factor

2. Insidious onset of the disease

3. More than one year with active phase without any remission

4. Early development of nodules and erosions

5. Extra-articular manifestation

6. Several functional impairment

The median life expectancy of persons suffering with rheumatoid

arthritis is shortened by three to seven years. Factors co-related with early death

include disability, disease duration or severity, glucocorticoid use and age of

onset of disease.

Laboratory findings 189

Hematology:

Normchromic or hypochromic anemia, which usually occurs in about

22% of females & 11% of males in adult type. The anemia is more marked in

children & occurs in about 60% of patients. The anemia is due to chromic

inflammation.

Erythrocyte sedimentation rate :

During active phase the ESR is raised in about 85-95% of cases.

Serological

RF: +ve in 50 – 60 % of cases.

CRP: +ve in acute phase of the disease.

Radiological:


56


Initially only soft tissue swelling of joints may be seen, but with

progressive periarticular osteoporosis, narrowing of joint spaces with marginal

erosions & cup & pencil deformities massive bone resorptions develop marginal

sclerosis & entophyte formation indicate secondary osteo – arthritis.

Diagnosis:

- Clinical picture CRP positive

- Elevated ESR Positive Rh factors

Management

1. Relief of symptoms

2. Suppression of active & progressive disease.

3. Conservation & restoration of function in affected joints.

These are achieved by

1. Treatment of the patient’s drug, rest, physiotherapy, surgery.

2. Modification of environment – aids, appliances, housing, occupation, statutory

social benefits.

General treatment

Physical rest, anti inflammatory drug therapy & maintenance exercises is

the corner stones of treatment for exacerbation of Rheumatoid arthritis. The rest

from physical & emotional stress provided by 2 – 3 wks in hospital is usually

sufficient to induce a marked remission of symptoms with out recourse to strict

bed rest. In few patients a period of complete bed rest may be required to induce a

remission. Rest splints can be used to support a particular painful joint to correct

flexion deformities.

Medications: Most people who have Rheumatoid arthritis take medications.

Some medications are used only for pain relief; others are used to reduce

inflammation. Some medications are disease modifying antirheumatic drugs

DMARDs are used to try to slow the course of the disease.


57


In articular corticosteroid injections are given to bring symptomatic relief.

Non-steroidal anti – inflammatory drug therapy is beneficial initial stages, which

has low incidence of side effects.

Chloroquine phosphate or hydroxy chloroquine sulphate, the antimalierials

are used us the initial adjunct to basic therapy.

Auranofin an oral gold compound, pencil amine parental gold are also

used, prednisolone a corticosteroid is also used in the treatment.

Immunomodulators are also used.

Surgical treatment.

The primary purpose of these procedures is to reduce pain, improve the

affected joints function, and improve the patient’s ability to perform daily

activities.

Surgical decompression & synovectomy are needed when corticosteroids

and physical measures have failed to relieve movement of limbs.


58

Drug review

Drug Review

As mentioned earlier, a specific line of treatment aiming at samprapti vighatana is

dealt in our classics. It involves deepana, pachana, shodhana and shamana depending on

the strength of dosha and dushya etc. Accordingly in the present study Patyadi churna,

eranda taila, Vaitaranabasti. These are discussed in detail in the following pages.

1) Patyadi churna: 190

Patyadichurna is best deepana pachana drug; it is specially indicated in

amavata chikitsa along with Shota andAgnimandy. It destroys the Amavata, shota and

diminuation of digestive fire.

The ingredients of Patydi churna are Haritaki, Shunti and Yavani. The properties

of individual drugs are tabulated in the Table no 8.

2) Eranda Taila 191, 192, 193, 194

As mentioned in chikitsa aspects, sneha virechana is indicated in amavata.

Eranda taila is considered to be the best among the snehas for virechana. So it is used as

Sadyovirechana.195 Eranda taila possesses ushna, guru, sara, teekshna, sukshama, picchila

and visra gunas. By rasas it is katu, kashaya, madhura and tikta and is having madhura

vipaka. The actions of eranda tala are found to be srotovishodhana, lekhana, deepana,

balya and rasayana.

It has got vatashleshamhara effect and effective in conditions like janga, kati, urushoola,

anaha and vibandha.

The castor oil cheifly consists of ricinoleate of glycerol or tririninolin with a small

quantity of plantin and stearin. The glycerides of ricinoleic acid C17H32 OHCOOH are

mainly responsible for the purgative effect.

Activity

Oil is a non irritant purgative, when it reaches the duodenum it is decomposed by

the pancreatic juice into ricinoleic acid, which irritates the bowels, stimulates the

intestinal glands and the muscular coat and cause purgation i.e., when given by mouth oil

is saponified and free acid is liberated which procures the effect. It acts in 4 to 5 hours

causing liquid stools without pain and gripping and has a sedative effect on the intestine.

Ricinoleic acid is absorbed into the blood and tissues. Ricinin is a voilent irritant of the

intestine.

Evaluation of efficacy of Vaitaranabasti in Amavata-An observational study 59

Drug review

In short, castor oil is one of the cheapest, simplest and most important useful

purgative of the pharamacopiea in all delicate conditions of children and aged people.

3) Vaitaranabasti: 196

The Vaitaranabasti is indicated in Shula,Anaha and Amavata. The ingredients and

quantities are

1. Saindhava lavana --12 gms (1 Karsha)

2. Guda --24 gms (1/2 Pala)

3. Chincha --48 gms ( Pala.)

4. Murchitatilataila --120 ml (Eeshat (little).)

5. Gomutra --192 ml (1 Kudava)

1) Saindhava Lavana. (Rock salt) 197, 198

This is the best in the lavanavarga. Rock salt is the common name for the

mineral Halite.

Components - NaCl can have impurities of gypsum or transparent cubes. It has a

pure saline taste.

Rasa - lavana

Guna - laghu, snigdha, sukshma.

Veerya - ushna.

Vipaka - madhura.

Properties - chakshushya, hridya, ruchikara, promotes appetite and assists

digestion and assimilation. It posses a stronger purgative property

also.

2) Guda (Jaggery). 199, 200

It is often called as Medicinal sugar. It contains natural goodness of minerals

and vitamins inherently present in sugarcane juice and this crowns it as one of the

most wholesome and healthy sugars in the world.

Synonyms - Panek, gur, vella, sharkara.

Varieties - Puranaguda, matsyandika, khandasarkara, vimalajata,


Drug review

nirmalaguda.

Components - Magnesium, potassium, iron; 2.8gm/100gm.

Medicinal use - Dry cough, cough with sputum, indigestion, constipation,

mootrashothani, raktashothani, medokara, kaphakara, vatashamaka, balya,

vrushya. More gunas are found in puranaguda.

Rasa - Madhura

Guna - Kshara, snigdha.

Veerya - Natiseeta

Vipaka - Madhura

3) Amleeka(Tamarind). 201

Latin name - Tamarindus indicia Linn.

Kula - Simbi kula

Family - Leguminoseae.

Latin - Tamarindus

Sanskrit - Chincha, chukrika, chukra, amlica, amli, tittidika, suktha,

sukthika.

Composition - Tartaric, citric, malic, acetic, potassium tartarate etc. In the seed

There is a 63% carbohydrate.

Rasa - Amla

Guna - Guru, ruksha.

Veerya - Ushna

Dosha - When ripe kapha pitta nashaka and vata nashaka.

Uses - Tamarind and its seeds are applied externally on

Inflammation. Fruit is very good in taste and is used in anorexia,

polydypsia, indigestion, and liver disorders. In heart diseases

sherbet is given. Kshara is used in urinary disorders and

abdominal pain. (Shankha Vati).


Evaluation of efficacy of Vaitaranab

Drug review

asti in Amavata-An observational study

Indication-Raktapitta, Gulma, Unmada, Kasa, Shota, Ruja,Anaha and Ama

Properties-Kapha and Vata

Guna -Teeksna, ushna, laghu and khsara gunas.

Rasa - Katu, tikta and kashaya

5) Gomutra: 204

Indication - Vrana, prameha, pain in ears, yoni and head. All kinds of injuries are

relieved with tila taila. It is used for alleviation of vata, as bastidravya, nasyadravya, for

internal administration and in abhyanga and dietary articles.

Properties - Vatagni, aggravates pitta, does not aggravate kapha, deepana,

pachana, brimhana, balya, preenana, lekhana, promotes skin health, intellect, digestive

power, health of eyes, complexion, strength and stability of mamsadhatu, krimigna,

reduces the quantity of urine, good for hairs, cleanses the garbhasaya and yoni, helps in

overcoming aging process.

Composition - Palmitic acid (9.1%), stearic acid (4.3%), arachidic acid (0.8%),

oleic acid (45.4%), linoleic acid (40.4%).

By taila moorchana the unpleasant odour of the oil is changed, amadosha is removed and

good color and fragrance are obtained. It enhances the potency of the taila also.

4) Tila Taila (Moorchita). 202, 203

Guna - Sukshma, vyavai, vishada, guru, sara, vikashi, teekshna,

Rasa - Madhura, thikta-accompanying kashaya

himasparsha.

62

Evaluation of efficacy of Vaitaranab

Drug review

asti in Amavata-An observational study 63

Sl. No

.

Drug Latin Name

Rasa Guna Veerya

Vipaka Doshagnata

Karmukata Prayojyanga

1 Haritaki Terminalia

chebula

KashayaPradhana

Pancha rasa

LaghuRuksha

Ushna Madhura Tridosha Shothahara, vedana,

sthapana, anulomana,

mrudurechana, deepana,

pachana

Phala

2 Shunti Zinghibu officinale

Katu Laghu Snigdha

Ushna Madhura Kapha vata shamaka

Truptigna, rochana, deepana, pachana, vatanulomana shothahara amapachana

Kanda

3 Yavani Tachyspermumamm

i

Katu tikta

LaghuRukshaTeeksh

na

Ushna Katu Kaphavata

Shamaka

Rochana, deepana,

vatanulomana, shoolapra

shamana

Phala

Table No 8, Showing the composition and properties of Patyadi churna

Materials and Methods

Materials and methods The materials taken for the study are

1) Patyadi churna

2) Eranda taila

3) Vaitaranabasti

1) Patyadi churna

The ingredients of Patyadi churna are Haritaki Shunti and Yavani are taken in

equal quqntity and churna prepared with the help of Rasashastra department.

2) Eranda Taila

Plain eranda taila was purchased and moorchana was done using drugs haridra,

triphla, musta, hrivera, lodhra, vatanukara according to classical method at D G M A M C

Pharmacy and then used it for Sadyovirechana purpose.

3) Vaitaranabasti

All Ingredients of Vaitaranabasti were identified (Saindhavalavana, Guda, Chincha,

Murchitatiala taila and Gomutra) and were used to prepare just before administration of

basti according to the preparation of Niruha basti

Diagnosis

The diagnosis will be made on the basis of classical signs and symptoms

mentioned in the Ayurveda and modern texts and criteria laid down by American

Rheumatism Association (1988) following features are employed for confirmation of


1) Morning stiffness (> = 1hr)

2) Swelling of three or more joints

3) Swelling of hand joints (PIP, MP)

4) Symmetrical swelling

5) Subcutaneous nodules (Rheumatoid nodules)

6) Presence of serum rheumatoid factor

7) Radiological changes (Hands & wrist)

Criteria 1 to 4 must have been continuous for 6 weeks or longer must be

observed by physician. A diagnosis of Rheumatoid Arthritis requires that, four of the

above seven criteria should be present.

Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational Study 64


Research Design

After the diagnosis, as on the above parameters, the selected patients were

assigned for the Clinical trial as follows.

Source of data:

Patients suffering from Amavata have selected from P.G.S & R.C. O.P.D. of

shree D.G.M. A.M.C. and Hospital Gadag.

Sample size & grouping:

A minimum sample of 30 patients with Amavata diseases have taken with

irrespective of sex

Selection criteria

Patients were selected strictly as per present inclusive and exclusive criteria

a) Inclusive criteria:

1. Classical signs and symptoms will be considered for the selection of patients.

2. Patients of Amavata having the history of less than 5 years.

3. Patients of Amavata between the age group of 20 to 60 years of either sex.

4. Patient fit for Bastikarma.

b) Exclusive criteria :

1. The patient of Amavata having the systemic diseases like Diabetes mellitus,

Asthma, Hypertension, Rheumatic heart disease & Heart diseases etc.

2. Pregnant women and lactating mothers.

3. Patient with marked joint deformities

4. Patients suffering from gout, septic arthritis and allied joint disorders.

5. Patients with complications of Amavata. (Rheumatoid Arthritis)

Study duration: 30 days

Study design: An observational study

Deepan-Pachana:

The patients were administered Patyadichurna internally in a dose of 3 – 6 Gms

thrice daily with a cup of hot water, half an hour before food. The treatment was given

till the nirama laxanas were observed.



Sadyovirechana:

Eranda taila in the quantity of 15 to 30ml was given in between 8 to 9am when

the patient is not so hungry for 1 day for the purpose of Sadyovirechana according to the

kosta of the patient. A cup of hot water was advised as anupana and Parihara kala was

advised for 1 day

Basti:

After the one day pariharakala of the Sadyovirechana, Vaitarana basti has given

for 8 days in the quantity of 300 ml And after that 16 days pariharakala has been advised.

Valuka sweda was advised whenever patient complaints increased pain and stiffness

during the course of the treatment.

Method of Preparation and Administration of Basti

• Mix jaggery in water and evaporate the required amount of water till it becomes

dense as to be used as honey.

• Prescribed quantity of Saindhava Lavana is added and churned thoroughly.

• After proper mixing of above constituents, the Moorchita tila taila should be

added slowly while churning in a slightly heated temperature.

• Tamarind is mixed and squeezed well in hot water and to be used as Kalka.

• The above kalka is to be added into the vessel and continue the churning.

• Finally Gomutra of prescribed amount is added very slowly while the churning

process continues

This was filtered and indirectly warmed in a boiling water vessel to make it Luke

warm. The niruha basti was given in empty stomach. On that morning after evaluation of

bowels and bladders patient was sent to panchakarma theatre and subjected for local

abhyanga and sweda. Then the patient was asked to lie down on the table in the left

lateral position, with the left knee extended, right limb flexed both at the hip and knee

joint and resting on the left knee. The head was supported by the patient’s left hand.

Plastic enema can with a capacity of 1200ml was taken and plain rubber catheter of the

size no.12 was used for the purpose insertion of basti in the anal orifice and the inserting

end of the catheter was smeared with oil for lubrication. The rubber catheter connected

to the enema can filled with Vaitaranabasti was gently inserted about 4 inches into the

rectum parallel to spinal column. Simultaneously the patient was asked to take deep



breaths; the catheter was removed with some amount of drug still remaining in the can to

prevent the entry of air into the colon. Then the patient was asked to turn into the supine

position, raised his both legs three times and his buttocks were gently patted and his

palms and soles were rubbed. Patient was advised to remain in the table till he feels the

urge for defecation. After defecation they were allowed to take hot water bath and then

light food. The quantity of Vaitaranabasti administered was 300ml per each time. Valuka

sweda was advised whenever patient complaints increased pain and stiffness during the

course of the treatment. After completion of the 8 days bastikarma 16 days Parihara kala

have advised,

Data Collection

All the patients were thoroughly examined by both subjectively and objectively.

Detailed history pertaining to the mode of onset, previous ailment, previous treatment

history, family history, habits, Ashtavidhapareeksha and Dashavidhapareeksha and

physical examination findings were noted. Routine investigations were done to exclude

other pathologies.

Examination of the patient

History – History taking of patient is very important to diagnose the diseases especially

of Amavata patient. When medical history focusing on the pain in the joints, specific

things to discussed when taking the history of a man with Amavata symptoms include a

history of morning stiffness of joints, symmetrical arthritis, arthritis of more than three

joints etc.

Inspection – In case of Amavata, joints should be examined by inspection. We can

observe the swelling, redness of joints etc. Even we can observe the deformity of joints

and this can see the gait change.

Palpation – Should be accurate to identify the Jwara, Ushnata of joints, Sparshasahatwa

of joints can be finding by this palpation.

Percussion – It helps to know the Kukshikathinnyata of Udara. It can also be used to

identify the Adhmana and Anilasanga.

Auscultation – It helps in finding the invalment of Hridaya and also helps in the

Adhmana and Anilasanga by hearing the sound like (gudu gudu).



Investigations and selection of patient

Both objective and subjective parameters were considered for the selection of

patient

Objective parameters

The below investigations are done before the selection of patient for the study.

1] Hb%

2] E S R

3] C R P

5] RA

Subjective parameters

The subjective parameters taken for this study are

1] Bahusandhishula

2] Bahusandhishota

3] Stabdata

4] Spershasahishnuta

Method of assessment

Subjective parameters and objective parameters of base line data to after

treatment data are done for comparison of the assessment of result.

Grading of the Parameters:

1) Bahusandhiahula (Pain) Score

No complaints 0

Patients tells about pain after enquiry 1

Patient frequently complaints about pains 2

Excruciating condition 3

2) Bahusandhishota (Swelling) Score

No complaints 0

Slightly obvious 1

Covers well the bony prominence 2

Much elevated so that joints seems grossly deformed 3



3) Stabdata (Morning Stiffness) Score

No complaints 0

Up to 30 mints 1

Up to 60 mints 2

More than 60 mints 3

4) Spershasahishnuta (Tenderness) Score

No complaints 0

Says a tender joint 1

Winces the affected joint 2

Winces and withdraws the affected joint 3

5) Hb%

The numerical value of Hb% was taken before and after for the assessment.

6) ESR

The numerical value of ESR was taken before and after for the assessment.

7) CRP

The presence or absence of CRP was taken before and after for the assessment.

8) RA

The presence or absence of RA was taken before and after for the assessment.

1) Clinical Assessment:

Details of the assessment of clinical signs and symptoms are as follows

A) Quantitative assessment of pain:

Both NRS and VAS method is used for quantitative pain assessment.

a) NRS method: NRS is an easily performed ordinal scale, grading pain in

number of categories. The following questions was asked to the patient

how often is it painful for you:



Table No.9, Showing the Quantitative assessment of pain:

No Daily function Never Some

times

Most of

times

Always

1 Dress yourself 0 1 2 3

2 Get in and out of bed 0 1 2 3

3 Lift a cup of glass to your lips 0 1 2 3

4 Walk out doors on flat grounds 0 1 2 3

5 Wash and dry your entire body 0 1 2 3

6 Bend down to pick up clothing from the

ground

0 1 2 3

7 Turn faucets on or off 0 1 2 3

8 Get on or out of car/bus etc.. 0 1 2 3

b) VAS method: A vas can be interpreted as a ratio scale and is more sensitive to

change. The VAS is 100mm long horizontal scale with ‘no pain’ at one end and ‘worst

passable pain’ at the other end without intervening categories.

0 100mm

No pain worst passable pain

Paints were asked to mark ‘X’ on the scale for how much pain they had in the past week.

2) Ritchie articular index (RAI):

RAI is a graded joint tenderness score based 53 joints. The index sums grades of

tenderness. The following 53 joints were considered as RAI

Single joints:

Elbows, Wrists, Hips

Knees, Ankles, Talocalcaneal joints

Mid tarsal joints



Units:

Temperomandibular joints,

Cervical spine (assessed by passive motion)

Sterno clavicular joints

MCP joints

PIP joints

MTP joints

Different grades of tenderness declared before and after are used to calculate RAI

3) Joint tenderness and swelling -28 joint count (T-28 and S-28):

The 28 joint counts is a not graded and not weighted count, measuring tenderness

and swelling separately. As this 28 joint count has higher reproducibility or lower inter

observer variability, is most valid and take least time consumption. The following are the

28 joints.

Shoulder, Elbow, Wrist,

MCP joints, PIP joints, Knees.

4) Extra Articular Manifestation of RA Index (EAMRAI):

This index sums grades of different extra articular manifestation such as systemic,

musculo skeletal, dermal, eye, respiratory, cardiac, neurological, hematological,

reticuloendthelial and other manifestations.

Complaints Score

No complaints 0

Mild 1

Moderate 2

Severe 3

5) Global Diseases Activity (GDA):

a) Patients assessment of Global Diseases Activity

b) Physician’s assessment of Global Diseases Activity

This is measured on a 100 mm horizontal Visual Analyzing Scale (VAS) using

the Arthritis Impact Measurement Scale (AIMS).



0 100mm

No pain worst passable pain

Considering all the ways the arthritis affects the patients were asked to mark ‘X’

on the scale for how well he or she was doing.

5) Ayurvedic Health Assessment (AHA):

Ayurvedic Health Assessment is done according to the Swasthy laxanas

mentioned by Acharya Kashypa.

Table No 10, Showing the Ayurvedic Health Assessment (AHA):

No Very

Satisfied

Sometimes

satisfied

Sometimes

disturbed

Very

disturbed

1 Annabhilasha 0 1 2 3

2 Bhuktasya paripakam 0 1 2 3

3 Shishtavit 0 1 2 3

4 Shristamutra 0 1 2 3

5 Shareera laghavam 0 1 2 3

6 Suprasannendrium 0 1 2 3

7 Sukhaswapnam 0 1 2 3

8 Sukhaprabutanam 0 1 2 3

9 Balam 0 1 2 3

10 Varnam 0 1 2 3

11 Soumanasyam 0 1 2 3

12 Samagnita 0 1 2 3

II) Functional Assessment:

1) Arthritis Impact Measurement Scale (AIMS):

AIMS is a scale of impact due to arthritis. It sums graded of various variable.



Table No 11, Showing the Arthritis Impact Measurement Scale (AIMS):

No Variable Very

Satisfied

Sometimes

satisfied

Sometimes

disturbed

Very

disturbed

1 Mobility level 0 1 2 3

2 Walking and bending 0 1 2 3

3 Hand and finger functions 0 1 2 3

4 Arm functions 0 1 2 3

5 Self care tasks 0 1 2 3

6 Household tasks 0 1 2 3

7 Social activity 0 1 2 3

8 Support from family and

friends

0 1 2 3

9 Arthritis pain 0 1 2 3

10 Work 0 1 2 3

11 Level of tension 0 1 2 3

12 Mood 0 1 2 3

2) Physical Disability:

It is the patients self assessed disability for the assessment of physical

functioning. It will be obtained by standardized observation of ability to perform specific

works. The following health assessment Questionnaires prepared by Stanford University

School of Medicine is used to assess physical disability



Table No 12, Showing Physical Disability

No Activities Without any

difficulty

With some

difficulty

With much

difficulty

Unable

to do

1 Dressing and Grooming 0 1 2 3

2 Arising 0 1 2 3

3 Eating 0 1 2 3

4 Walking 0 1 2 3

5 Hygiene 0 1 2 3

6 Reach(to get down/pick

up

0 1 2 3

7 Grip 0 1 2 3

8 Activities 0 1 2 3

3) Walking Time:

Patients were asked to walk a distance of 40 feet and time taken was recorded

before and after the treatment and after follow up.

4) Grip Strength:

To find the functional capacity of affected upper limb, the patient’s ability to

compress an inflated ordinary spigmomanometer cuff under standard condition was

carried out before and after treatment and after follow up.

5) Range of movements:

The range of movements of major joints is determined.

Joint movements Score

No movement 0

Up to 50% 1

Up to 70% 2

Above 70% and less than full range 3

Full range 4



6) Disease Activity Score (DAS):

The Disease Activity Score Is statistically derived index combined tender joints,

swollen joints, ESR and General health. It was validated in several studies.

Clinical variable Value

Tender joint count (0-28)

Swollen joint count (0-28)

ESR (mm/hr)

VAS general health patient (mm)

Overall Assessment of the treatment:

The results were classified in to four groups as listed below

1) Completely relieved

2) Good response

3) Moderate response

4) No response

1) Criteria for completely relieved:

A minimum of the following five requirements must be fulfilled for at least two

consecutive months in a patient with definite or classic RA.

a) Morning stiffness not exceeding 15 min

b) No fatigue

c) No joint pain

d) No joint tenderness or pain in movement

e) No soft tissue swelling in joints or tendon sheath

f) ESR (Western) less than 30mm/hr (females) or 20mm/hr (males)

As the study duration was 15 days with 15 days follow up, the above criteria were

consider after the treatment and after the follow up.

2) Criteria for Good response:

Change in DAS 28 from base line is more than 1.2 (i.e.>1.2)

ACR criteria: 50% and above improvement in



A. Tender joint count

B. Swollen joint count

And 3 of the following 5

a) Patient pain assessment

b) Patient global assessment

c) Physician global assessment

d) Patient self-assessed disability

e) Acute phase reactant

3) Criteria for Moderate response:

Change in DAS 28 from base line is more than 0.6 and less than or equal to 1.2

(i.e.>0.6 and -<1.2)

ACR criteria: above or equal to 20% and below 50% improvement in

A) Tender joint count

B) Swollen joint count







4) Criteria for No response:

Change in DAS 28 from base line is less than or equal to 0.6 (i.e.-<0.6)

ACR criteria: below 20% improvement in

A) Tender joint count

B) Swollen joint count








Observations and Results

Demographic Data

Table No 13, showing distribution of patients by age groups

Age Group No of patients %

20-30 6 20

31-40 7 23.33

41-50 11 36.66

51-60 6 20

Out of 30 patients 6 patients (i.e.20%) were in the age group of 20-30 years, 7 patients

(i.e.23.33%) were in the age group of 31-40 years, 11 patients (i.e.36.66%) were in the

age group of 41-50 years, and 6 patients (i.e.20%) were in the age group of 51-60 years.

6 711

6

2023.33

36.66

20

05

10152025303540

Age %

No of Patients

Distribution of patients by Age group

20-3031-4041-5051-60

Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 77


Table No 14, showing distribution of patients by Sex

Sex No of patients %

Male 9 30

Female 21 70

Out of 30 patients 9 patients (i.e.30%) were males and 21 patients (i.e.70%) were

Females.

9

2130

70

010

20304050

6070

No of patients

%Sex

Distribution of patients by Sex

MaleFemale



Table No 15, showing distribution of patients by Socioeconomic Status

Socioeconomic Status No of patients %

Poor 4 13.33

Middle 20 66.66

Upper middle 4 13.33

Higher 2 6.66

Out of 30 patients 4 patients (i.e.13.33%) were in the Poor class socioeconomic group, 20

patients (i.e.66.66%) were in the middle class socioeconomic group, 4 patients

(i.e.13.33%) were in the upper middle class socioeconomic group, and 2 patients

(i.e.6.66%) were in the higher class socioeconomic group.

4

20

4 2

13.33

66.66

13.336.66

0

10

20

30

40

50

60

70

No of Patients

%Socioeconomic status

Distribution of patients by Socioeconomic Status

PoorMiddleUpper middleHigher



Table No 16, showing distribution of patients by Dietary habits

Dietary habits No of patients %

Veg 13 43.33

Mixed 17 56.66

Out of 30 patients 13 patients (i.e. 43.33%) were vegetarian and 17 patients (i.e. 56.66%)

were mixed diet habit.

1317

43.33

56.66

0

10

20

30

40

50

60

Nomof patients

%Daitary Habits

Distribution of patients by Dietary habits

VegMixed



Table No 17, showing distribution of patients by Treatment history

Treatment history No of patients %

Allopathic 28 93.33

Allopathic + Ayurvedic 2 6.66

Out of 30 patients 28 patients (i.e. 93.33%) were taken Allopathic treatment and 2

patients (i.e. 6.66%) were taken both allopathic and Ayurvedi treatment.

28

2

93.33

6.660

20

40

60

80

100

Treatment Taken %

No of Patients

Distribution of patients by Treatment history

Allopathic

Allopathic +Ayurvedic



Table No 18, showing distribution of patients by Koshta

Nature of koshta No of patients %

Mridu 6 20

Madyama 15 50

Krura 5 16.67

Sama 4 13.33

Out of 30 patients 6 patients (i.e. 20%) were having Mridu koshta, 15 patients (i.e. 50%)

were having Madyama koshta, 5 patients (i.e. 16.67%) were having Krura koshta and 4

patients (i.e. 13.33%) were having Sama koshta.

6

15

5 4

20

50

16.6713.33

05

101520253035404550

Koshta%

No of Patients

Distribution of patients by Koshta

Mridu

MadyamaKrura

Sama



Table No 19, showing distribution of patients by Jataragni

Status of Jataragni No of patients %

Manda 11 36.66

Vishama 7 23.33

Teekshahna 4 13.33

Samagni 8 26.66

Out of 30 patients 11 patients (i.e. 36.66%) were having Mandagni, 7 patients (i.e.

23.33%) were having Vishamagni, 4 patients (i.e. 13.33%) were having Teekshnagni and

8 patients (i.e. 26.66%) were having Samagni.

117

48

36.66

23.33

13.33

26.66

0

5

10

15

20

25

30

35

40

No of Patients

%Jataragni

Distribution of patients by Jataragni

MandaVishamaTeekshahnaSamagni



Table No 20, showing distribution of patients by Vyasana

Vyasana No of patients %

Tobacco 2 6.66

Smoking 1 3.33

Alcohol consumption 1 3.33

None 27 90

Out of 30 patients 2 patients (i.e.6.66%) were habituated to tobacco chewing, 1 patient

(i.e. 3.33%) were having habit of smoking, 1 patient (i.e. 3.33%) were having the habit of

consuming Alcohol an27 patients (i.e. 90%) were not having the above mentioned

vyasanas.

2 1 1

27

6.663.333.33

90

0102030405060708090

No of Patients

%Vyasana

Distribution of patients by Vyasana

TobaccoSmokingAlcohol consumptionNone



Table No 21, showing distribution of patients by Dehaprakruti

Dehaprakruti No of patients %

Vata 5 16.66

Pitta 1 3.33

Kapha 1 3.33

Vata-Pitta 9 30

Vata-Kapha 11 36.66

Kapha-Pitta 3 10

Sannipataja 0 0

Out of 30 patients, 5 patients (i.e.16.66%) were Vata prakriti persons, 1 patient

(i.e.3.33%) were Pitta prakriti person, 1 patient (i.e.3.33%) were Kapha prakriti person, 9

patients (i.e.30%) were Vata-Pitta prakriti persons, 11 patients (i.e.36.66%) were Vata-

Kapha prakriti persons, 3 patients (i.e.10%) were Kapha-Pitta prakriti persons and

Sannipataja prakriti persons are not found.

51 1

9 11

30

16.66

3.333.33

30

36.66

10

005

10152025303540

No ofpatients

%Dehaprakruti

Distribution of patients by Dehaprakruti

Vata

Pitta

Kapha

Vata-Pitta

Vata-Kapha

Kapha-Pitta

Sannipataja



Table No 22, showing distribution of patients by Occupational Status

Occupational No of patients %

Housewife 2 6.66

Sedentary 21 70

Labor 7 23.33

Out of 30 patients, 2 patients (i.e.6.66%) were house wives, 21 patients (i.e.70%) were

sedentary and 7 patients (i.e.23.33%) were labor.

2

21

7 6.66

70

23.33

010203040506070

No of Patients

% Occupational Status

Distribution of patients by Occupational Status

HousewifeSedentaryLabor



Table No 23, showing distribution of patients by Religion

Religion No of patients %

Hindu 22 73.33

Muslim 8 26.66

Christian 0 0

Out of 30 patients, 22 patients (i.e.73.33%) were Hindu religion, 8 patients (i.e.26.66%)

were Muslim religion and No one belongs to Christian religion.

228

0

73.33

26.66

00

20

40

60

80

No of Patients

%Religion

Distribution of patients by Religion

HinduMuslimChristian



Table No24, Showing distribution of patients by RA factor

RA factor No of patients %

Positive 5 16.66

Negative 25 83.33

Out of 30 patients, 5 patients (i.e.16.66%) were having RA factor positive and 25 patients

(i.e.83.33%) were having RA factor negative.

5

2516.66

83.33

0

20

40

60

80

100

No of Patients

%RA factor

Distribution of patients by RA factor

PositiveNegative



Table No 25, showing distribution of patients by CRP Titer

CRP Titer No of patients %

Positive 9 30

Negative 21 70

Out of 30 patients, 9 patients (i.e.30%) were having CRP Titer Positive and 21 patients

(i.e.70%) were having CRP Titer Negative.

921

30

70

0

20

40

60

80

No of patients

%CRP titer

Distribution of patients by CRP Titer

PositiveNegative



Table No 26, showing distribution of patients by Bahusandhishoola response to the

treatment

Bahusandhishoola No of patients %

Completely relived 3 10

Good Response 4 13.33

Moderate Response 23 76.66

No response 0 0

Out of 30 patients, 3 patients (i.e.10%) were got 100% response, 4 patients (i.e.13.33%)

were got Good response, and 23 patients (i.e.76.66%) were Moderate response to the

treatment in Bahusandhishoola.

3 4

23

01013.33

76.66

001020304050607080

No of patients

%Bahusandhishoola

Bahusandhishoola response to the treatment

Completely relived Good Response Moderate Response No response



Table No 27, showing distribution of patients by Bahusandhishota response to the

treatment

Bahusandhishota No of patients %


Good Response 0 0

Moderate Response 3 10

No response 9 30

Out of 30 patients, 18 patients (i.e.60%) were got 100% response, and 3 patients

(i.e.10%) were got Moderate response to the treatment in Bahusandhishota. and other 9

(30%) patients were not responded to the treatment.



18

0 39

60

0

10

30

0

10

20

30

40

50

60

No of Patients

%Bahusandhishota

Bahusandhishota response to the treatment

Completely relived

Good Response

Moderate Response

No response

Table No 28, showing distribution of patients by Bahusandhigraha response to the

treatment

Bahusandhigraha No of patients %

Completely relived 22 73.33

Good Response 0 0


No response 8 26.66

Out of 30 patients, 22 patients (i.e.73.33%) were got 100% response, and 8 (26.66%)

patients were not responded to the treatment.



22

0 08

73.33

0 0

26.66

0

1020

304050

607080

No of Patients

%Bahusandhigraha

Bahusandhigraha response to the treatment


Table No 29, showing distribution of patients by Sparshasahishnuta response to the

treatment

Sparshasahishnuta No of patients %


Good Response 0 0


No response 0 0

Out of 30 patients, 30 patients (i.e.100%) were got 100% response in Sparshasahishnuta,



30

0 0 0

100

0 0 00102030405060708090

100

No of Patients

%Spershasahishnuta

Sparshasahishnuta response to the treatment


Table No 30, showing distribution of patients by walking time response to the

treatment

walking time No of patients %


Good Response 0 0


No response 21 70

Out of 30 patients, 9 patients (i.e.30%) were got Moderate response, and to the

treatment in walking time and 21 (70%) patients were not responded to the treatment.



0 09

21

0 0

30

70

010

20304050

6070

No of Patients

%Walking Time

walking time response to the treatment


Table No 31, showing distribution of patients by Grip Strength response to the

treatment

Grip Strength No of patients %




No response 1 3.33

Out of 30 patients, 2 patients (i.e.6.66%) were got good response, 3 (10%) patients were

got moderate response, 1 patient (i.e.3.33%) was not responded to the treatment. And

other 14 patients were not had any problem of grip strength before treatment



02

3

10

6.66

10

3.33

0

2

4

6

8

10

No of Patients

%Grip Strength

Grip Strength response to the treatment


Table No 32, showing distribution of patients by Range of movements’ response to

the treatment

Range of movements No of patients %




No response 10 33.33

Out of 30 patients, 8 patients (i.e.26.66%) were got good response, 12 (40%) patients

were got moderate response, and 10 patients (i.e.33.33%) were not responded to the

treatment in range o movements.



0

812 10

0

26.66

40

33.33

05

10152025303540

No of Patients

%Range of movements’

Range of movements’ response to the treatment


Table No 33, showing distribution of patients by DAS criteria response to the

treatment

DAS criteria No of patients %


Good Response 15 50

Moderate Response 14 46.66

No response 1 3.33



Out of 30 patients, 15 patients (i.e.50%) were got good response, 14 (46.66%) patients

were got moderate response, 1 patient (i.e.3.33%) was not responded to the treatment in

DAS criteria

0

15 14

1 0

5046.66

3.330

10

20

30

40

50

No of Patients

%DAS criteria

DAS criteria


Table No 34, showing the overall effect of treatment

Result No of patients %


Good response 13 43.33

Moderate response 17 56.66

No response 0 0

Out of 30 patients, 13 patients (i.e.43.33%) were got good response, 17 (56.66%) patients

were got moderate response.



0

13 17

0 0

43.33

56.66

00102030405060

No of Patients

%Treatment Effect

Showing the overall effect of treatment

Completely relived Good responseModerate responseNo response

Table No 35, showing the Data related to the response of Treatment to Subjective parameters Sl No.

OPD No

Bahusandhishula Bahusandhishota Bahusandhigraha Spershasahishnuta

BT AT AF BT AT AF BT AT AF BT AT AF 1 2285 2 1 1 1 0 0 1 0 0 1 0 0 2 2249 2 1 1 1 0 0 1 0 0 1 0 0 3 2315 3 1 1 2 0 0 1 1 1 1 0 0 4 2321 2 1 1 2 1 0 1 0 0 1 0 0 5 2431 2 1 1 2 1 1 1 0 1 1 0 0 6 2419 2 1 1 1 0 0 1 0 0 1 0 0 7 2449 2 1 1 1 0 0 1 0 0 1 0 0 8 2450 2 1 1 1 0 0 1 0 0 1 0 0 9 2475 2 0 1 1 0 0 1 0 0 1 0 0



10 2516 2 1 1 1 0 0 1 0 0 1 0 0 11 2426 2 1 0 1 0 0 1 1 0 1 0 0 12 2614 2 1 0 2 1 0 1 0 0 1 0 0 13 2657 2 0 1 1 0 0 1 0 0 1 0 0 14 2778 2 1 0 1 0 0 1 0 0 1 0 0 15 2811 3 1 1 2 1 0 1 1 1 1 0 0 16 2862 3 1 1 2 1 1 1 0 0 1 0 0 17 2920 3 1 1 2 0 0 1 0 0 1 0 0 18 2896 2 0 1 1 0 1 1 0 0 1 0 0 19 2984 2 0 1 1 0 1 1 0 1 1 0 0 20 3013 2 0 1 1 0 1 1 0 1 1 0 0 21 3086 2 0 1 1 0 0 1 0 0 1 0 0 22 3085 2 0 1 1 0 0 1 0 0 1 0 0 23 3154 2 1 1 2 1 1 1 0 0 1 0 0 24 3220 2 0 1 1 0 0 1 0 1 1 0 0 25 3011 2 1 1 1 0 0 1 0 0 1 0 0 26 3273 2 1 1 1 0 1 1 0 0 1 0 0 27 3341 2 0 1 1 0 1 1 0 0 1 0 0 28 3461 2 0 1 1 0 1 1 0 0 1 0 0 29 3533 2 0 1 1 0 1 1 0 1 1 0 0 30 3548 2 0 1 1 0 1 1 0 1 1 0 0 Table No 36, showing the Data related to the response of Treatment to objective

parameters Sl.No OPD

No Hb% ESR CRP RA

BT AT AF BT AT AF BT AT AF BT AT AF1 2285 9.8 9.4 9.6 28 20 20 - - - - - - 2 2249 10.2 10.4 10.2 110 48 100 - - - + + + 3 2315 9.4 9.00 9.6 70 30 56 + + + + + + 4 2321 10 11 10 20 10 10 - - - - - - 5 2431 9.6 10 10 27 8 9 - - - - - - 6 2419 10 10.2 10 21 14 10 - - - - - - 7 2449 8.6 9 9 35 20 18 - - - - - - 8 2450 10 10 10 25 22 18 - - - - - - 9 2475 11.2 11.2 11 38 15 10 - - - - - -



10 2516 12.4 12 11 18 10 10 - - - - - - 11 2426 13.2 13 13.2 48 99 74 + + + - - - 12 2614 9.6 10 10 39 14 10 - - - - - - 13 2657 10 10 10 38 24 20 - - - - - - 14 2778 10.4 10.4 10 23 10 12 - - - - - - 15 2811 9.6 10 10 21 18 15 - - - - - - 16 2862 9.4 10 10 10 12 10 + + + - - - 17 2920 9 9.2 9 55 55 40 - - - - - - 18 2896 9 10 10 15 12 10 - - - - - - 19 2984 10.6 11 10 22 18 15 - - - - - - 20 3013 10.2 10 10 50 48 30 - - - - - - 21 3086 10.2 10 11 15 18 22 - - - - - - 22 3085 11.8 12 11 10 26 10 + + + - - - 23 3154 12 12 12 64 44 40 + + + + + + 24 3220 11.2 11 11 31 20 24 + + + + + + 25 3011 9.8 9 9 33 28 24 + + + - - - 26 3273 9.2 9 10 68 50 30 + + + - - - 27 3341 11.4 11 11 54 40 38 - - - - - - 28 3461 11 10 11 28 21 20 - - - - - - 29 3533 12 12 11 54 34 20 - - - + + + 30 3548 11 11 11 52 36 26 + + + + + +

Table No 37, showing the Data related to the response of Treatment to objective parameters

Sl.No OPD No NRS VAS RAI EAMRIA BT AT AF BT AT AF BT AT AF BT AT AF

1 2285 6 1 3 100 30 40 6 0 0 1 1 1 2 2249 6 1 3 100 40 60 14 2 3 1 1 1 3 2315 10 6 6 100 50 70 7 0 2 2 1 1 4 2321 14 6 5 100 40 60 12 2 6 1 1 1 5 2431 10 4 4 100 60 70 6 2 5 1 1 1 6 2419 12 1 3 100 30 40 4 1 2 3 1 0 7 2449 6 1 2 100 30 40 6 0 0 1 1 1 8 2450 12 1 2 100 30 50 4 0 0 3 1 0 9 2475 10 6 6 100 30 40 4 0 0 1 1 1



10 2516 8 2 4 100 30 40 4 0 1 1 1 1 11 2426 9 5 5 100 40 60 3 0 0 2 1 1 12 2614 10 4 4 100 40 40 6 1 1 2 1 1 13 2657 11 5 5 100 20 40 7 0 1 1 0 0 14 2778 4 1 3 100 30 40 6 1 2 1 0 0 15 2811 10 4 4 100 20 30 3 0 0 1 0 0 16 2862 10 6 6 100 50 70 9 1 0 1 0 0 17 2920 10 4 2 100 20 30 8 0 0 1 0 0 18 2896 6 2 4 100 30 40 6 2 0 1 1 1 19 2984 6 3 5 100 30 50 6 1 0 1 1 1 20 3013 8 4 4 100 30 50 9 1 0 1 1 1 21 3086 7 0 3 100 30 40 5 1 0 1 0 0 22 3085 7 0 3 100 40 60 8 0 3 1 0 0 23 3154 8 4 4 100 40 60 6 0 0 1 0 0 24 3220 7 4 6 100 50 60 5 1 0 1 1 1 25 3011 7 1 4 100 40 60 10 2 0 1 0 1 26 3273 7 0 3 100 30 70 7 1 0 1 1 1 27 3341 8 2 4 100 30 50 8 1 0 1 1 1 28 3461 7 0 4 100 30 40 8 0 0 1 1 1 29 3533 6 3 3 100 20 40 7 0 0 1 1 1 30 3548 6 4 5 100 20 30 12 1 0 1 1 1

Table No38, Showing the Data related to the response of Treatment to objective parameters

Sl.No OPD

No GDA AIMS Physical

Disability Walking time

BT AT AF BT AT AF BT AT AF BT AT AF1 2285 80 30 30 6 2 4 3 1 1 38 30 34 2 2249 80 40 60 6 2 4 3 1 1 38 30 34 3 2315 80 30 40 15 11 11 7 2 2 45 38 40 4 2321 80 40 40 25 12 11 12 5 7 40 30 35 5 2431 90 30 40 28 13 14 11 3 4 43 38 40 6 2419 80 30 40 24 3 1 10 1 1 38 30 34 7 2449 80 30 40 6 2 4 3 1 1 40 30 32 8 2450 90 30 50 24 3 1 11 1 1 35 30 30



9 2475 80 30 30 15 11 11 7 2 2 38 30 30 10 2516 80 30 40 15 11 5 7 2 2 30 18 18 11 2426 80 30 40 16 8 11 7 1 5 30 25 30 12 2614 90 30 40 12 5 8 5 2 5 30 20 20 13 2657 80 30 30 15 10 9 7 0 2 30 20 20 14 2778 80 30 30 9 0 4 4 0 2 25 20 20 15 2811 90 30 30 12 2 6 5 0 3 28 20 20 16 2862 80 40 40 14 8 7 7 2 3 30 25 25 17 2920 90 30 30 14 3 6 6 0 2 28 20 20 18 2896 80 30 40 13 3 8 5 2 4 28 20 22 19 2984 80 30 50 13 5 6 5 3 5 30 20 28 20 3013 90 30 50 12 5 6 5 3 5 30 20 22 21 3086 80 30 40 14 0 3 5 0 2 30 22 22 22 3085 80 40 30 14 1 3 5 0 3 28 20 20 23 3154 80 40 60 14 6 11 6 3 6 30 25 25 24 3220 90 50 60 19 7 8 7 4 6 40 30 35 25 3011 80 40 60 14 3 7 6 1 4 30 25 26 26 3273 90 30 50 14 2 5 5 1 4 30 25 28 27 3341 90 30 50 13 5 6 6 2 4 30 20 22 28 3461 80 30 40 13 2 6 5 1 3 30 20 20 29 3533 80 30 30 13 4 5 6 2 4 30 24 26 30 3548 80 30 30 12 2 6 5 1 4 38 30 30

Table No 39, showing the Data related to the response of Treatment to objective parameters

Sl.No OPD

No Grip strength Range of

movements DAS AHA

BT AT AF BT AT AF BT AT AF BT AT AF1 2285 0 0 0 14 18 16 5.23 3.05 3.05 6 2 3 2 2249 0 0 0 14 18 16 6.46 3.70 3.97 6 2 3 3 2315 1 0 0 11 17 18 6.36 2.52 4.43 17 6 6 4 2321 2 0 1 8 13 8 6.20 3.36 4.31 17 6 6 5 2431 2 1 1 13 16 16 5.68 3.06 4.05 16 6 6 6 2419 0 0 0 8 20 24 5.30 2.83 3.36 28 3 4 7 2449 0 0 0 14 18 16 5.39 2.52 2.44 6 2 3 8 2450 0 0 0 8 21 15 4.95 2.58 2.86 28 4 3



9 2475 0 0 0 11 18 17 5.39 2.32 2.03 16 6 4 10 2516 1 0 0 11 21 16 5.06 2.03 2.87 19 6 4 11 2426 0 0 0 18 23 18 5.64 3.78 3.85 15 5 4 12 2614 0 0 0 12 16 16 5.74 2.88 2.59 15 5 4 13 2657 0 0 0 13 21 17 6.03 2.64 3.36 14 3 4 14 2778 0 0 0 14 20 16 5.21 2.87 3.36 9 2 3 15 2811 0 0 0 12 21 17 4.42 2.03 2.31 15 5 3 16 2862 1 0 0 11 17 18 5.28 3.27 2.52 18 6 6 17 2920 0 0 0 12 22 18 6.44 3.16 3.28 15 4 3 18 2896 0 0 0 15 21 16 5.41 3.35 2.66 11 6 6 19 2984 0 0 0 9 20 15 5.36 3.28 2.71 11 6 6 20 3013 0 0 0 14 22 18 6.24 3.97 3.28 11 6 7 21 3086 0 0 0 14 22 18 4.92 3.28 2.56 11 1 4 22 3085 0 0 0 14 18 22 5.31 2.10 3.69 11 1 4 23 3154 0 0 0 11 21 16 6.33 3.21 3.54 11 5 7 24 3220 1 0 1 11 20 15 5.66 3.47 3.04 11 1 4 25 3011 0 0 0 17 22 19 6.39 4.03 3.20 11 5 7 26 3273 0 0 0 13 22 18 5.17 2.91 2.44 11 5 7 27 3341 0 0 0 12 21 17 5.17 2.94 2.58 11 5 7 28 3461 0 0 0 15 23 19 5.97 2.95 2.91 10 4 6 29 3533 0 0 0 14 20 18 6.14 3.37 3.08 12 6 7 30 3548 0 0 0 12 17 14 6.70 4.05 3.26 11 5 7

Table No 40, showing the statistical analysis of Subjective and Objective parameters Sl. No

Parameters Mean SD SE T Value P Value Remarks

1 Bahusandhishoola 1.233 0.430 0.075 15.707 <0.001 HS

2 Bahusandhishota 0.933 0.639 0.116 8.043 <0.001 HS

3 Stabdhata 0.733 0.449 0.081 8.928 <0.001 HS

hgj4 Spershasahishnuta 1.00 0.00 0.00 0.00 0.00 HS

5 Assessment of Pain(NRS)

4.3 2.35 0.429 10.023 <0.001 HS

6 Assessment of Pain(VAS)

51.00 12.68 2.316 22.02 <0.001 HS



7 Ritchie Articular Index (RAI)

6.00 2.586 0.472 12.706 <0.001 HS

8 Extra Articular Manifestation of RAI (EAMRAI)

0.566 0.817 0.149 3.798 <0.001 HS

9 Global Diseases Activity (GDA)

41.00 9.595 1.751 23.41 <0.001 HS

10 Arthritis Impact Measurement Scale (AIMS)

7.9 5.195 0.948 8.33 <0.001 HS

11 Physical Disability 2.933 2.531 0.462 6.348 <0.001 HS

12 Walking Time 6.266 2.983 0.518 12.096 <0.001 HS

13 Grip Strength 0.166 0.379 0.069 2.40 <0.001 HS

14 Range of movements 4.266 2.947 0.538 7.926 <0.001 HS

15 DAS Criteria 2.532 0.535 0.097 26.10 <0.001 HS

16 Ayurvedic Health Assessment (AHA)

9.166 5.186 0.946 9.689 <0.001 HS

17 Hb% 0.373 0.381 0.069 5.359 <0.001 HS

18 ESR 14.56 9.779 1.785 8.156 <0.001 HS

Table No 41, showing the mean % improvement of Subjective and Objective parameters

Sl.No Parameters Mean effect Mean % of

Improvement

BT AT

1 Bahusandhishoola 2.133 0.9 57.80

2 Bahusandhishota 1.26 0.33 73.8

3 Stabdhata 1 0.266 73.4

4 Spershasahishnuta 1 0 100



5 Assessment of Pain(NRS) 8.266 3.966 52.02

6 Assessment of Pain(VAS) 100 49 51.00

7 Ritchie Articular Index (RAI) 6.86 0.866 87.37

8 Extra Articular Manifestation of RAI (EAMRAI)

1.233 0.666 45.98

9 Global Diseases Activity (GDA) 83 41.66 49.8


14.46 6.33 56.2

11 Physical Disability 6.2 3.266 47.32

12 Walking Time 33 26.933 18.38

13 Grip Strength 0.26 0.1 63.84

14 Range of movements 12.5 16.76 34.08

15 DAS Criteria 5.65 3.11 44.95

16 Ayurvedic Health Assessment (AHA)

13.43 5 62.93

17 Hb% 10.39 10.36 0.288

18 ESR 37.4 24.7 33.95

Statistical Conclusion

The statistical analysis is done by using paired t test by assuming that the drug is

not responsible for the changes in the observations before and after the treatment.

Among subjective parameters Sparshasahishnuta shows cent percent result and all the

other three parameters shows more highly significant ( by comparing ‘P’ value), The

parameter Bahusandhishoola shows more highly significant than other two

(Bahusandhishota and Bahusandhigraha), with less various and more net mean effect by



comparing ‘t’ value. But in the parameter Sparshasahishnuta is having uniform effect

before and after the treatment.

The percentage of improve of before and after the treatment mean effect in

parameter Bahusandhishota is 73.88%

Among objective parameters except the parameter Grip strength all the other parameter

shows highly significant (by comparing ‘p’ value), But there is a more highly significant

in parameter DAS criteria, GDA, VAS (Assessment of pain) before and after the

treatment by comparing‘t’ value.

There is more mean percentage improvement in the parameter RAI (87.37%), Grip

Strength (63.84%), And AHA (62.93%) and least percentage of improvement in Walking

time (18.38%), but the same parameter shows more highly significant by comparing p

value.

Among parameter Hb% and ESR both parameters shows highly significant (by

comparing ‘P’ value),but there is a more highly significant parameter ESR(by comparing

t value). And mean percentage of improvement in the parameter ESR is 33.95%.


Discussion

Discussion

This chapter deals with the analysis of probable cause of the observations, findings

and the results of the study. It is classified under the following headings.

1) Amavata and Rheumatoid Arthritis.

2) Drug review.

3) Probable mode of action.

4) Clinical Study

1) Amavata and Rheumatoid Arthritis:

• Amavata is chronic progressive systemic disorder that mainly targets to

locomotors system. It is named after two major involvements of two pathogenic

factors Ama and Vata, which mainly affects Sandhi. The classics had explained

the manifestation of disease and its treatment. Madhavakara was the first person

who explained this disease as a separate entity. Chakradatta and Vangasena have

contributed its treatment.

• This disease occurs in all ethnic groups. Mainly it is more prevalence in urban

area. Sandhishoola, Sandhishotha, Sandhistabdata and Sandhiushnata are the

cardinal clinical features of this disease, apart from this it has many general

symptoms like Gourava, Aruchi, Jvara, Angamarda, Apaka etc are seen in this

disease. Though ama and vata are chief pathogenic factors, kapha and pitta are

also invariably involved in the pathogenesis of Amavata.

• The disease is manifested due to unwholesome diet and regimen and hypo

function of Agni is also an important factor for the initiation of disease process.

The samprapti of this disease originated from Annavaha srotas and madhyama


Discussion

roga marga with involvement of sleshma sthana later it affects other sthanas like

Sandhi, Asthi, Majja etc. Rasa, Asthi and Majja are primarily involved dushyas,

further it affects mamsa, snayu and khandara

• The Ayurvedic line of treatment explained by ancient acharyas mainly depends

upon the stages of disease. The treatment includes Langhana, Deepana,

Amapachana, Shodhana and Shamana associated with bahirparimarjana like

valukasweda.

• As the Ama the plays an important role in the pathogenesis of Amavata diseases

Deepana and Pachana has to be advised. Deepana and Amapachana help to check

the formation of ama and to start samprapti vighatana. Then the vitiated doshas

can be eliminated by virechana and basti. After that shamana treatment should be

followed to alleviate the remaining doshas. Valuka sweda can be utilized as a

bahirparimarjana chikitsa.

Amavata v/s Rheumatoid arthritis

• The disease Rheumatoid arthritis is identical with the signs and symptoms of

Amavata. It always challenge to the physicians due to its chronicity, complication

and morbidity, because of the lack of precise knowledge pertaining to its

etiopathogenesis. Various theories try to explain its etiopathogenesis like

hereditary, Neurogenic, vascular, infective, metabolic, endocrinal, autoimmune

and psychogenic. Though other theories are not yet discarded the autoimmune

mechanism is most commonly implicated.


Discussion

• Rheumatoid arthritis is an autoimmune disease in which joints, usually those of

the hands and feet, are symmetrically inflamed, resulting in swelling, pain, and

often the eventual destruction of the joint's interior. Rheumatoid arthritis is the

most common inflammatory joint disease and a major cause of disability,

morbidity, and mortality. It occurs worldwide, affecting approximately one per

cent of adults. Rheumatoid arthritis may be accompanied by fatigue, weight loss,

anxiety, and depression. In rheumatoid arthritis, the immune system attacks the

tissue that lines and cushions joints (certain immune cells, perhaps mast cells,

attack the carbohydrate molecules, known as glycosaminoglycans, in the joints).

Eventually, the cartilage, bone, and ligaments of the joint erode, causing scars to

form within the joint. The joints deteriorate at a highly variable rate.

• From Current Opinion in Rheumatology

The Efficacy and Tolerability of Newer Biologics in Rheumatoid Arthritis: Best

Current Evidence, Posted 05/15/2007, M Asif A Siddiqui, Author Information

Rheumatoid arthritis (RA) is a chronic, inflammatory, incurable disorder of

uncertain etiology, associated with significant morbidity. Patients require

potentially lifelong treatment and there may be a substantial socioeconomic

impact. RA is the most common inflammatory polyarthropathy, affecting ≈1% of

the world's adult population; over two million people are affected by the disease

in the US alone. Generally, the onset of RA is seen in middle age (40-70 years),

with a 2.5-fold higher prevalence in women than in men.

• Early diagnosis and treatment is an integral part of the management of RA, with

the aims of reducing and controlling symptoms of joint pain and inflammation,

minimizing loss of function, and reducing joint damage and disability.[

• This disease mainly affects the musculo skeletal system. It has also extra articular

manifestations affecting cardiovascular, nervous and excretory systems, which is

collectively known as connective tissue or collagen disorder.


http://www.raysahelian.com/autoimmunedisease.html

http://www.raysahelian.com/immune.html

http://www.medscape.com/viewpublication/830_index

Discussion

• Ama originated in Amashaya and circulates through out the body with vitiated

vata dosha. The ama visha is further increased by interaction of dosha, dushya due

to localized concentration of Amavisha. The contribution of srotovaigunnya as

well as kleda is very much important in the pathogenesis of Amavata. Srotorodha

in general can be compared with rheumatoid vasculitis one of the serious extra

articular manifestation. These sequential steps in the samprapti of Amavata are

quite identical with the etiopathogenesis of Rheumatoid Arthritis. The altered

activity of the immune system, stimulated by exogenous or endogenous antigens

probably viral or bacterial in origin, causes formation of Rheumatoid factor and

antibodies. The recent studies showed that Rheumatoid Arthritis has not been link

to any infection, despite of it resembles to infectious Arthritis [Rheumatic fever].

• Several components of the immune system appear to contribute to the

pathogenesis of Rheumatoid Arthritis. The integral role performed by vascular

endothelium, circulating memory T- cells, tissue macrophages, plasma cells,

Rheumatoid factor and cytokines are initiating and perpetuating Rheumatoid

Arthritis inflammation in the joints and throughout the body. The altered immune

mechanism in Rheumatoid Arthritis can be correlated with the role of Ama in

Amavata. The production of Srotoabhishyanda and kleda is nothing but the

inflammatory changes in Rheumatoid Arthritis. Once again the etiological factor

is much similar with Amavata and the site of the disease is much identical with

sleshma sthana and connective tissues.

• As already told the despite years of intensive study the etiology of Rheumatoid

Arthritis is still not known the uncertainties in the etiopathogenesis of this disease


Discussion

impeded the exploration of an effective treatment or its prevention. In spite of

available treatment, it cripples the ailing for the rest of his life; moreover it affects

the younger and middle-aged people, substantially hampering the economy of the

nation. Thus the disease has posed great challenge to the physicians who are

engaged in research work yet the goal of curing the disease remains long away

off.

• Line of treatment, which is explained in Ayurveda, can reduce pain, swelling, and

protection of joints and control the disease progression. The early invention in

Ayurvedic field helped to prevent the development of disabilities and preferable

respond to this disease. Ayurvedic treatment can give the fitness to participate in

the routine activities of daily living and ambulation, with this aim the present

study was under taken to Evaluate the Efficacy of Vataranabasti in Amavata-An

observational study.

Study Method:

• Study Design: An observational study.

• Sample size: 30 patients of Amavata with classical signs and symptoms.

• Study duration: 30 days ( i.e. Treatment 15 days and Follow up 15 days)

• Assessment of results: In the present study results will be assessed according to

the improvement in the clinical signs and symptoms (Ayurveda and Modern texts)

like Bahusandhishoola (Pain), Bahusandhishotha (Swelling), Bahusandhigraha

(Morning Stiffness), Sparshasahishnuta (Tenderness) & associated symptoms like

Angamarda, Aruchi, etc. the functional ability, DAS criteria, RAI criteria, etc. and


Discussion

HB%, ESR, CRP and RA lab investigations and overall improvements also

considered.

Subjective and Objective parameters of baseline data to post-medication data

comparison are used for clinical assessment of results.

• In the present study, 48 patients of Amavata were registered, in which 30 patients

completed the course of the treatment. The disease was diagnosed on the basis of

signs and symptoms as described in Ayurvedic and Modern texts; RA factor test

was done in all the patients. Routine Blood, Urine, Stool examination along with

S. uric acid were done to rule out other pathological conditions.

2) Drug Review:

Based on the principles of treatment following drugs were selected for the study.

• Patyadi choorna for amapachana

• Eranda taila for Sadyovirechana

• Vaitaranabasti

• Patyadi Churna:

• It is a good deepana and pachana drug indicated in amavata adhikara. It checks

the formation of ama by increasing the Agni and digests the ama which is already

formed. It helps to attain niramavastha, and prepare the body environment for

further shodhanadi treatment.

• Eranda Taila for Sadyovirechana:

• Eranda taila is considered as the best medicine in the management of amavata,

which is used for Sadyovirechana. Because of its sukshma guna it reaches the

minute srotas as and it liquefies the stagnated doshas by its lekhana, usna,


Discussion

teekshna, properties then it removes by its virechana action. It acts as

vatanulomana, it pacifies vata by its madhura vipaka, snigdha and ushna gunas. It

removes the obstruction of vata produced by ama and kapha and checks the

further accumulation of vata in the body by sroto vishodhana guna.

Scope of Sadhyovirechana

1] Second stage of Vishavega

2] Urdhvaga raktapitta

3] Amavata

4] Vamana Ayoga and Atiyoga

5] Vibhanda

6] Alasaka

7] In weak person if there is a Bahudoshas and if dosha paka have attained

directly Bhedhaniya Aoushadha or Bhedhaniya Ahara dravya can be advised.

Like this still in many conditions we will find in our classics.

• Sadhyovirechana does the effect of eliminating Vishapadhartha and accumulated

fecous thus does Vatanulomana. Due to administering Sadhyovirechana with or

without considering Snehana and Swedana using of Snehika virechana is

beneficial, this holds well because of in Ruksha person Snigdha virechana have

advised. Other wise giving Ruksha virechana to a person who has not under gone

for Snehapana will destroy like dry stick when bends it.

• We get strong reference of using Sahdyovirechana with Eranda tail combining

with Triphala kwatha in Chakradatta, Yogaratnakara and Sharangdhara uttara

khanda.


Discussion

• Even for the test of Krura kostha, Madhyama kostha and Sadharana kostha this

type of Sahdyovirechana helps.In Kruradikostha giving Eranda tail as a

Sahdyovirechana is the choice of drug. Even instead of Eranda tail Ksheera can

also be used in that condition.

• Importance of Sadhyovirechana in Amavata: In the present study,

Sadhyovirechana was administered by Eranda taila. Eranda taila is Vata-

kaphashamaka having specific vyadhihara i.e. Amavatahara action. Ricin present

in it gets converted to Ricinoelic acid by lipase, which irritates bowel leading to

Virechana as it is having Ushna virya; it also does Pachana karma (Amapachana).

Action of Sadhyovirechana on Amavata can be understood by the following

properties of it.

• Sadhyovirechana helps in eliminating the Ama which forms due to Mandagni in

Amavata.

• It has direct effect on Agnisthana and hampered Agni (Mandagni) is one of the

initiating factors in Amavata. It pacifies the vitiated Kapha and Vata dosha.

• It has the property of Srotovishodhana; hence the Srotorodha (Srotoabhishyanda)

present in the disease Amavata mainly in Sandhisthana is cleared by

Sadhyovirechana leading to relief of the symptoms.

• Virechana is indicated in Sannipatik condition of morbidity (Bhela.S.) and hence

helpful in the disease Amavata.

• It helps to normalize the pratiloma gati of vata, which produces symptoms like

Anaha, Antrakujana, Kuskshikathinya, Kukshishoola etc. in the disease Amavata.


Discussion

• The drug here Eranda taila having Ushna-tikshna-sukshma guna reach to the heart

by virtue of their potency and circulate through the large and small srotasa and

pervade the entire body. Then they liquefy the morbid elements by virtue of its

Agneya guna and disjoin them by its tikshna guna. Then this liquefied morbid

mass floating like honey in uncted vessels through the virtue of Anu pravanbhava

of the drug and ultimately reaches Amashaya. From here it forces the morbid

factors through the anal canal root due to the Bhautika predominancy of the Jala

and Prithvi and Adhobhagahara prabhava (Ch. K. 1/4) leading to Virechana.

• Vaitaranabasti:

• The shodhana therapy is a must to treat the disease amavata successfully. Among

the shodhanas, basti is said to be ideal as it pacifies both ama and vata.

Chakradatta has appreciated the role of Vaitaranabasti in the treatment amavata.

3) Probable Mode of Action of Vaitaranabasti in Amavata:

• The ingredients of Vaitaranabasti mainly possess deepana, pachana, ushna,

sukshma, laghu, teekshna and lekhana gunas. These gunas helps to alleviate ama

and vata in the body.

• In the disease process of amavata, we find the laxanas of avarana vata in the

joints, because of obstruction to flow of vata by ama. The main seat of vata is

pakwashaya, hence the eliminative therapy is directed to pakwashaya. After the

administration of basti, the basti dravya is retained only for a limited period in

pakwashaya. Even then it can be assumed from the effect produced that, the

essentials are absorbed into the system.


Discussion

• The drugs analysis of Vaitaranabasti drugs have deepana and pachana guna,

which directly influences the kostagni and thereby dhatagni which in turn leads to

pachana of already existing ama and checks the further production of ama.

• It reaches the various parts of the body like sandhis and minute channels like by

its sukshma guna and liquifies the doshas which was present in various forms.

Liqification of them is caused by ushna, teekshna lekhana gunas which in turn

decreases the sroto abhishyandana, meanwhile usna and snigdhata guna of the

content pacifies the vata. Gomutra, which is the chief content, is helpful to reduce

the shotha and ruja as it is mainly indicated in ama.

• Vaitaranabasti action is seen up to minute channels, where it does the lekhana of

collected ama and kapha resulting in their liquefaction, which decreases the

abhishyandi, picchila, and guru etc. gunas of ama. At the same time it does the

srotovishodhana there by decreasing the srotobhishyandana which intern leads to

vatanulomana because of removal of obstruction and finally expels ama and

kapha vata out of the body.

• As all the drugs of Vaitaranabasti have sufficient qualities through which they can

combat the ama, vata and kapha, it seems logical to say that a combination of

these drugs can be a potent procedure to treat amavata.

• But the question is how these drugs are absorbed into the system. None of the

research was conducted conclusively to solve this question. But here the difficulty

arises in understanding the mode of their absorption and efficacy when

administered in the form of basti but in one interesting quotation Parashara says;


Discussion

• mulam gudam shareerasya sirasthatra prathi stithaha

sarvam shareeram pusnanthi murdhanam yavadashritaha (Ch.Si.4)

• This reference says the importance of rectum and how it nourishes the other parts

of the body through its siras.

• The rectum has a rich blood and lymph supply and drugs can cross the rectal

mucosa like the other lipid membranes, thus, unionized and lipid soluble

substances are readily absorbed from the rectum the portion absorbed from the

upper rectal mucosa is carried by the superior haemorrhoidal vein into the portal

circulation, where as that absorbed from the lower rectum enters directly into the

systemic circulation via the middle and inferior hemorrhoidal vein.

• Even though it is difficult to draw a conclusion regarding the mode of action of

basti, according to the modern pharmacokinetics, the classical literature of

ayurveda provides certain concepts, which facilitates one to understand the mode

of action based on ayurveda principles.

• The significant improvement in Shoola, Shotha, Stabdata and Ushnata. So it

justifies that basti is a more efficient treatment for amavta. Basti has got both

doshapratyanika and vyadhi pratyanika effect on the disease Amavata

4) Clinical Study:

• General Description of Patients: General description of the patients studied in

the present series was as follows:

• Age: All the 30 patients registered for the present study were ranging from 20 to

60 years, of which maximum patients (36.66%) were between 41 to 50 years age

group, which was followed by 23.33% patients in the age group of 31 to 40 years.


Discussion

Observations of this study were in accordance with the findings of Rheumatoid

Arthritis in middle age (Price and Davidson).

• Sex: In this study majority of the patients were female (70%) as compared to male

patients (30%). Textual references also reflects the predominance of Rheumatoid

Arthritis in females

• Religion: Majority of the patients in this series were Hindus (73.33%), which

may be due to predominance of Hindu community in this particular region.

• Occupation: Most of the women registered were having sedentary i.e. 70%,

which reflects the general occupation of majority of the females in this area.

• Economical Status: Majority of the patients i.e. 66.66% in this series were

belonging to middle economic status, while rests of the patients (13.33%) were

belonging to upper middle class and the patients were i.e. (6.66%) belongs to

higher economic status. It may be due to the fact that, this study was conducted in

a general hospital, where free treatment facilities are available. Another

possibility was that middle and lower class people are more prone to stress and

strain, which may precipitate the disease Amavata.

• Addiction: Majority of the patients (90%), in the present study did not have any

addiction, tobacco chewing was 6.66% and smoking was 3.33%.and alcohol

consumption was 3.33%. All these addictions come under Ahitashana and

Vishamashana, which lead to Mandagni and formation of Ama. So, addiction may

also play role in the aggravation of the disease Amavata.


Discussion

• Diet: 56.66% patients in the present study were taking both Vegetarian and non

Vegetarian food. And 43.33% patients are taking only Vegetarian food. This data

is only reflection of predominant diet in this area.

• Deha Prakriti: In this study, it was found that maximum number of patients i.e.

36.66% were possessing Vata-kapha Prakriti followed by 30% Vata-pitta prakriti.

In general Kapha Prakriti will have Mandagni leading to Ama formation, which

when provoked by Vata and gets settled in respective Sleshma sthana. So, it is

justifiable that Kapha vata prakriti persons are easily prone to Amavata.

• Koshtha: In the present study majority of the patients i.e. 50% had madyama

Koshtha, which was followed by Mridu Koshtha in 20% of the patients it is

followed by Krura kosta in 16.66%. In general Vata and Kapha Prakriti persons,

have Mridu and Madhyama Koshtha. It justifies the finding of Prakriti, as Prakriti

wise distribution of this study reveals that maximum no. of patients possess

Kapha Vata Prakriti.

• Desha: All the the patients i.e. 100% were from Gadag area i.e. Jangala desha due

to the location of the city in Jangala desha.

• Rheumatoid Factor: 16.66% patients, in this study were seropositive. This

observation corroborates very well with textual reference (Davidson – 1994).

• Cardinal Features: Regarding the cardinal features of Amavata, all the patients

had Sandhishoola (100%), Sandhishotha (100%), Sandhigraha in (100% )and

Sandhi ushnata also in (100%).


Discussion

• Srotasa: Maximum number of patients had the dushti of Asthivaha, Rasavaha,

Majjavaha, Purishavaha, Raktavaha and Annavaha srotasa, which is in accordance

with the main srotasa involved in the disease process

• Involvement of Joints: Majority of the patients presented with classical

involvement of Hastasandhi, Padasandhi, Gulphasandhi and Janusandhi.

• Rheumatoid Nodules & Deformity: In this study no one having Rheumatoid

Nodules

• Effect of the treatment:

• In this study the effect of treatment was assessed on the basis of changes observed

in different sandhi after the treatment in Sandhisoola, Sandhishotha,

Sandhistabdata and Spershasahishnuta. The results are discussed parameter wise

as here under:

• Clinical response of the treatment:

• In this study an effort has been made according to the guideline lay down by

ancient Ayurvedic classics, ACR1995 and EULAR in diagnosing the diseases

Amavata or Rheumatoid Arthritis and the final analysis of the results. As

mentioned in the chapter of materials and methods all the signs and symptoms

were given scoring according to the severity. The efficacy of the therapy was

assessed on the basis of changes recorded in these scoring after the treatment.


Discussion

• Effect on chief complaints:

1) Bahusandhishoola (Joint Pain):

• Among 30 patients 3 patients have got more than 75% improvement, 4 patients

have got 66% improvement, and 23 patients have got 50% improvement

2) Bahusandhishota (Swelling of Joints):

• Among 30 patients 18 patients have got more than 75% improvement, patients

have got 50% improvement, and 9 patients have not got any improvement.

3) Bahusandhigraha (Morning stiffness):

• Among 30 patients 22 patients have got more than 75% improvement, and 9

patients have not got any improvement.

4) Spershasahishnuta (Tenderness):

• Among 30 patients all patients have got 100% improvement

• Effect on different indices:

5) Effect on NRS (Assessment of pain):


have got 50% improvement, 7 patients have got more than 25% improvement

and 6 patients have got bellow 25% improvement.

6) Effect on VAS (Assessment of pain):

• Among 30 patients no one has got the 75% improvement, 18 patients have got

50% improvement, 12 patients have got more than 25% improvement.


Discussion

7) Effect on Ritchie Articular Index (RIA):


have got 50% improvement, and 1 patient have got bellow 25% improvement.

8) Effect on Extra Articular Manifestation of Ritchie Articular Index

(EAMRIA):

• Among 30 patients 9 patients have got more than 75% improvement,3 patients

have got 50% improvement, and other 18 patients have not got any improvement.

9) Effect on Arthritis Impact Measurement Scale (AIMS):



and 1 patient have got bellow 25% improvement.

10) Effect on Global Diseases Activity (GDA):

• Among 30 patients no one has got more than 75% improvement, 22 patients have

got 50% improvement, 8 patients have got more than 25% improvement.

11) Effect on Physical Disability:





Discussion

12) Effect on Walking Time:

• Among 30 patients no one has got more than 50% improvement, 9 patients have

got more than 25% improvement and 21 patient have got bellow 25%

improvement.

13) Effect on Grip Strength:


have got 50% improvement, 1 patient have got more than 25% improvement but

other 26 patient have not complaint of grip strength before treatment.

14) Effect on Range of Movements:

• Among 30 patients 1 patient have got more than 75% improvement, 7 patients



15) Effect on DAS criteria:

• Among 30 patients no one has got more than 75% improvement, 15 patients



16) Effect on Ayurvedic Health Assessment (AHA):


have got 50% improvement, 10 patients have got more than 25% improvement.


Discussion

17) Effect on Hb%:

• Among 30 patients 6 patients have got 2% decrease in their Hb%, 6 patients have

got 4% improvement in their Hb%, and other 18 patients don’t have any changes

in their Hb%.

18) Effect on ESR:

• Among 30 patients no one has not got more than 75% improvement, 9 patients

have got 50% improvement, 14 patients have got more than 25% improvement, 4

patient have got bellow 25% improvement and 3 patients don’t got any

improvement.

19) Effect on RA factor:

• Among 30 patients, only 5 patients were having the seropositive RA factor, but

there is no any change has been seen in these patients after the treatment.

20) Effect on C Reactive Protein (CRP):

• Among 30 patients, only 9 patients were having the CRP positive, but there is no

any change has been seen in these patients after the treatment.

Overall effect of the treatment:

• While seeing the overall effect of the treatment , 57.80% improvement observed

in Bahusandhishoola, 73.8% improvement observed in Bahusandhishota, 73.4%

improvement observed in Bahusandhigraha, more than 75% improvement

observed in Sparshsahishnuta, 52.02% improvement observed in NRS, 51.00%

improvement observed in VAS, 87.37% improvement observed in RAI, 45.98%


Discussion

improvement observed in EAMRAI, 49.8% improvement observed in GDA,

56.2% improvement observed in AIMS, 47.32% improvement observed in

Physical disability, 18.38% improvement observed in Walking time, 63.84%

improvement observed in Grip Strength, 34.08% improvement observed in Range

of Movements, 44.95% improvement observed in DAS, 62.93% improvement

observed in AHA, 0.288% improvement observed in Hb%, 33.95% improvement

observed in ESR,

Results:

• The results of the study confirmed that Vaitaranabasti have their own role in the

management of Amavata, as the patients shows remarkable reduction in the

symptoms. After the treatment when overall assessment was done to assess

improvement, as the disease is yapya or have autoimmune origin, the complete

relief from the disease process cannot be expected. Good improvement was

observed in 13 patients (43.33%) Moderate improvement was observed in 17

patients (56.66%) among the 30 patients.

• At the end of Deepanapachana with Patyadichurna treatment there was significant

change in reduction of Ama laxshana was observed this signifies there is some

role of Patyadichurna to bring down amavasta in Amavata. And also After

administration of Virechana by Eranda taila shows the changes in the reduction of

symptoms like Anaha, Antrakujana, Kukshikatinyata and kukshishoola because it

is only due to the normalization of the pratilomagati of vata by virechana. And

after the treatment by vaitaranabasti administration observed that more significant

reduction in the symptoms of Amavata. From this analysis, it becomes evident


Discussion

that the effect of Vaitaranabasti was more beneficial in Shoola, Shotha, Stabdata,

Sprshasahishnuta and Usnata of different Sandhis, But as the disease is yapya or

autoimmune nature the completely permanent remission cannot be expected.

Current Research

Over the last several decades, research has greatly increased our understanding of

immunology, genetics, and cellular and molecular biology. This foundation in basic

science is now showing results in several areas important to rheumatoid arthritis.

Scientists are thinking about rheumatoid arthritis in exciting ways that were not possible

even 10 years ago.

The National Institutes of Health funds a wide variety of medical research at its

headquarters in Bethesda, Maryland, and at universities and medical centers across the

United States. One of the NIH institutes, the National Institute of Arthritis and

Musculoskeletal and Skin Diseases, is a major supporter of research and research training

in rheumatoid arthritis through grants to individual scientists, Specialized Centers of

Research, and Multipurpose Arthritis and Musculoskeletal Diseases Centers.

Following are examples of current research directions in rheumatoid arthritis supported

by the Federal Government through the NIAMS and other parts of the NIH.

• Scientists are looking at basic abnormalities in the immune systems of people

with rheumatoid arthritis and in some animal models of the disease to understand

why and how the disease develops. Findings from these studies may lead to

precise, targeted therapies that could stop the inflammatory process in its earliest

stages. They may even lead to a vaccine that could prevent rheumatoid arthritis.


Discussion

• Researchers are studying genetic factors that predispose some people to

developing rheumatoid arthritis, as well as factors connected with disease

severity. Findings from these studies should increase our understanding of the

disease and will help develop new therapies as well as guide treatment decisions.

In a major effort aimed at identifying genes involved in rheumatoid arthritis, the

NIH and the Arthritis Foundation have joined together to support the North

American Rheumatoid Arthritis Consortium. This group of 12 research centers

around the United States is collecting medical information and genetic material

from 1,000 families in which two or more siblings have rheumatoid arthritis. It

will serve as a national resource for genetic studies of this disease.

• Scientists are also gaining insights into the genetic basis of rheumatoid arthritis by

studying rats with autoimmune inflammatory arthritis that resembles human

disease. NIAMS researchers have identified several genetic regions that affect

arthritis susceptibility and severity in these animal models of the disease, and

found some striking similarities between rats and humans. Identifying disease

genes in rats should provide important new information that may yield clues to

the causes of rheumatoid arthritis in humans.

• Scientists are studying the complex relationships among the hormonal, nervous,

and immune systems in rheumatoid arthritis. For example, they are exploring

whether and how the normal changes in the levels of steroid hormones (such as

estrogen and testosterone) during a person's lifetime may be related to the

development, improvement, or flares of the disease. Scientists are also looking at

how these systems interact with environmental and genetic factors. Results from

these studies may suggest new treatment strategies.

• Researchers are exploring why so many more women than men develop

rheumatoid arthritis. In hopes of finding clues, they are studying female and male

hormones and other elements that differ between women and men, such as

possible differences in their immune responses.

• To find clues to new treatments, researchers are examining why rheumatoid

arthritis often improves during pregnancy. Results of one study suggest that the

explanation may be related to differences in certain special proteins between a


Discussion

mother and her unborn child. These proteins help the immune system distinguish

between the body's own cells and foreign cells. Such differences, the scientists

speculate, may change the activity of the mother's immune system during

pregnancy.

• A growing body of evidence indicates that infectious agents, such as viruses and

bacteria, may trigger rheumatoid arthritis in people who have an inherited

predisposition to the disease. Investigators are trying to discover which infectious

agents may be responsible. More broadly, they are also working to understand the

basic mechanisms by which these agents might trigger the development of

rheumatoid arthritis. Identifying the agents and understanding how they work

could lead to new therapies.

• Scientists are searching for new drugs or combinations of drugs that can reduce

inflammation, can slow or stop the progression of rheumatoid arthritis, and also

have few side effects. Studies in humans have shown that a number of compounds

have such potential. For example, some studies are breaking new ground in the

area of "biopharmaceuticals", or "biologics". These new drugs are based on

compounds occurring naturally in the body, and are designed to target specific

aspects of the inflammatory process.

• Investigators have also shown that treatment of rheumatoid arthritis with

minocycline, a drug in the tetracycline family, has a modest benefit. The effects of

a related tetracycline called doxycycline are under investigation. Other studies

have shown that the omega-3 fatty acids in certain fish or plant seed oils also may

reduce rheumatoid arthritis inflammation. However, many people are not able to

tolerate the large amounts of oil necessary for any benefit.

• Investigators are examining many issues related to quality of life for rheumatoid

arthritis patients and quality, cost, and effectiveness of health care services for

these patients. Scientists have found that even a small improvement in a patient's

sense of physical and mental well-being can have an impact on his or her quality

of life and use of health care services. Results from studies like these will help

health care providers design integrated treatment strategies that cover all of a

patient's needs--emotional as well as physical.


Discussion

Hope for the Future

• Scientists are making rapid progress in understanding the complexities of rheumatoid

arthritis--how and why it develops, why some people get it and others do not, why

some people get it more severely than others. Results from research are having an

impact today, enabling people with rheumatoid arthritis to remain active in life,

family, and work far longer than was possible 20 years ago. There is also hope for

tomorrow, as researchers continue to explore ways of stopping the disease process

early, before it becomes destructive, or even preventing rheumatoid arthritis

altogether.


Conclusion

Conclusion:

Amavata is a diseases in which improperly metabolized intermediate by products

knows as Ama become the core cause of the diseases i.e. cause of inflammation

and degenerative processes and the Ama is traversed and get deposited in

different parts of the body by the vitiated vata.

The wide spectrum of clinical manifestation given by different authors may be

because of deposition of Ama at kapha sthana, a specific pathology of Amavata.

Disease amavata can be correlated to rheumatoid arthritis, which is one among the

chronic destructive polyarthritis systemic disease.

The exact etiology of the disease remains unknown, but the pathogenic nidana

like ama is believed to be acts as auto antigen, which triggers the immunological

reaction in genetically susceptible individuals.

The disease amavata is diagnosed on symptomatology specific laboratory tests

like RA Factor and CRP helps in diagnostic and ESR help in assessment of

treatment given, the criteria laid down by American Rheumatism Association

1988 which comprises 7 criteria which helps in the diagnosis of RA.

Some of the pravruddha amavata laxana can be considered as the extra-articular

manifestations of amavata (RA).

As the disease is genetic and autoimmune in origin the permanent complete

remission is not possible.

The specific Ayurvedic line of management and drugs helps in decreasing the

auto antigens and may acts as modifying the immune response to auto antigens.

At the same time the drugs are safe can be given for longer duration without any

adverse effects.

As the disease is genetic and autoimmune in origin the permanent complete

remission is not possible.

The active principles of Vaitaranabasti are antagonistic to ama and may acts as

anti-inflammatory.

Vaitaranabasti have their specific role in the management of Amavata.

Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study

129

Conclusion

Limitations of the study:

1. The Sample size was small.

2. The period of study was limited

Suggestions for Further study.

1. Study on large samples.

2. Study on Nityavirechana followed by basti.

3. Study on langhana, deepana, virechana followed by basti.

4. The effect of the Vaitaranabasti can be study in longer duration.

5. The Radiological studies should be conducted to find the effect of Vaitaranabasti

on bony changes

Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study

130

Summary

Summary

The present study entitled “Evaluation of The Efficacy of Vaitaranabasti in

Amavata - An Observational Study” consists of 7 parts.

1) Introduction

2) Objectives

3) Review of literature

4) Methodology

5) Results

6) Discussion

7) Conclusion

Introduction: The part consists of the general description of Veda, Ayurveda,

importance of Panchakarma, importance of vastikarma in Panchakarma and in vatavyadhi

and also on other doshas and importance of vasti in Amavata.Disease of Amavata

Vaitaranabasti is the trial drug of the study. And incidence, need for study.

Objectives of the study: The part consists of the purpose of the study and objectives of

the study.

Review of literature: This part consists of the historical review, vyutpatti and nirukthi of

both vastikarma and Amavata. In the disease review, nidana, samprapthi, poorvaroopa,

roopa, etc are elaborated, In the karma review, the procedure, indications and

contraindications etc of basti, and the drugs used and the probable mode of action of basti

are discussed and in drug review, drugs used in Vaitaranabasti and its properties are

discussed.

Methodology: This part deals with the preparation of Vaitaranabasti and method of

administration of this Basti, the study design, subjective and objective parameters with

their gradings and. diagnostic criteria, and criteria for assessment of the parameters are

explained. The criteria laid down by ARA (in 1987 & 1967) were applied for the

diagnosis and assessment of the treatment.

Observations and Results: This part is dealt in the result section. The demographic data,

response to treatment and overall response are also dealt. Results are given in the form of

tables along with demographical charts. The improvements in selected parameters are

statistically analyzed and presented in the form of tables and graphs.


Summary

Discussion: This part is divided into four sections. First section entitled – discussion on

review of literature – deals with the Amavata and Rheumatoid Arthritis. In the second

section discussion on Drug Review – which deals with drugs taken for the clinical study

and a brief description of those, the third section deals with the probable mode of action

of Vaitaravabasti in Amavata and the fourth section deals with the clinical study –

observations and results.

Conclusion:

Amavata is a diseases in which improperly metabolized intermediate by products

knows as Ama become the core cause of the diseases i.e. cause of inflammation

and degenerative processes and the Ama is traversed and get deposited in

different parts of the body by the vitiated vata and produces the cardinal

symptoms like Sndhishoola, Sandhishota, Stabdhata , Sparshasahishnut and

Sandhi ushnata.

Vaitaranabasti have their specific role in the management of Amavata.


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25) I bid

26) I bid

27) I bid

28) I bid


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38) I bid

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135) Agnivesa, Charakasamhitha chikitsasthana chapter 28, sloka 19. 4th ed.




137) I bid sloka 6-10.p.462.

138) I bid sloka 7-10.p.461, 462.

139) Agnivesa, Charakasamhitha chikitsasthana chapter 20, sloka 20. 4th ed.


140) Sushrutha, Sushruthasamhitha.uttarasthana chapter 46. sloka 6. Varanasi:



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146) I bid sloka 6-10.p.461,462.

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152) I bid sloka 12.p.464.

153) I bid sloka 6.p.462.

154) I bid sloka 7-10.p.463.

155) Haritha Samhita Varanasi: Krishnadas Academy; 1980.



157) Vagbhata, Ashtangahridaya nidanasthana chapter 1, sloka 6-7. Varanasi:




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162) Agnivesa, Charakasamhitha Sutrasthana chapter 22. . 4th ed. Varanasi:


163) I bid



165) Sharangadhara, Sarngadharasamhitha poorvakhanda chapter 4, sloka

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166) I bid


Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996, p-

476.

168) Bhavamishra, Bhavaprakasha, chapter 25. Edited by Bhishagrashro

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Academy: pp 230


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Samsthana: pp 629.

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SPECIAL CASE SHEET FOR AMAVATA- (RHEUMATIOD ARTHRITIS) Post Graduate Studies and Research Center (Panchakarma)

Shri. D.G.M.Ayurvedic Medical College, Gadag.582103.

Guide: Dr. P.Shivaramudu .M. D (Ayu) P.G.Scholar: Dr. Devendrappa.F.Budi Co-Guide: Dr. Santhosh. N. Belavadi. M D.(Ayu)

1. Name of the patient : Sl. No.: 2. Father’s/Husband’s Name: OPD No: 3. Age : ………... yrs IPD No: 4. Sex : Male/Female Bed No: 5. Religion :

Hindu Muslim Christian Others 6. Occupation :

Sedentary Active Labor Others 7. Economical Status

Poor Middle Upper middle

Higher

. 8. Address : …………………………. Phone No. …………………………. E- Mail: …………………………. Pin code:

9. Date of Schedule of Initiation : 10. Date of Schedule of Completion : 11 Result :

Completely Relieved

Good Response

Moderate Response

Poor Response

No Response

12. Consent : I here by agree that, I have been fully educated with the disease and treatment. Here by satisfied whole heartedly and accept the medical trial over me. Investigator’s Signature. Patient’s Signature

1

1). Pradhana Vedana: SL.No Lakshanas Duration BT AT AF

1 Sandhishoola 2 Sandhishotha 3 Stabdhata 4 Sparshasahishnuta

Total:

2) Anubandi Vedana: Sl No Laxanas Duration BT AT AF

1 2 3 4

Total: 3).Adytana vedana vrittanta: Mode of onset Insidious Acute Systemic

OligoArticular Poly Articular Mono articular Symmetrical Asymmetrical Palindrome

Sequence of joints involved: (1) (2) (3) (4) (5) (6) Aggravating Factors : Reliving Factors :

Progressive Regressive Constant Intermittent Nature of disease :

Mild Moderate Severe Not affected

2

Routine activities affected: 4). Poorva vyadhi vrittanta :

Present Duration Absent

5).Chikitsa vrittanta :

Yes No a) Ayurvedic medicine: If yes details : b) Modern medicine : Yes No If yes details : 6).Kula vrittanta : Present Absent If present Details : 7). Vayaktika vrittana : Veg Mix Ahara : Matra : Alpa Sama Adhika

Samashana Adyashana Vishamashana Dietic habit : Agni : Koshta : Nidra :

Vyasana : Aarthavapravritti :

Manda Teekshana Vishama Sama

Mrudu Madyama Krura

Nature of sleep Day Night Total hrs Sound Disturbed

Smoking Tobacco Alcohol None

Alpa Ati Vishama Rajonivrutti

Sudden Gradual

3

8). Samanya Pareeksha A. Astasthāna Pareeksha: B. Vital examination

1 Nadi

2 Mala

3 Mutra

4 Jihwa

5 Shabda

6 Sparsha

7 Druk

8 Akruti

1 Temperature /F 3 Resp. rate /min4 B.P mm of Hg 5 Height mtr6 Weight Kgs.

C. Dasha vidha Pareekshā:

1 Prakruti V [ ] P [ ] K [ ] VP [ ] VK [ ] PK [ ] Tridoshaja [ ]

Hethu Prakruthi

Dosha Desa

Dushya Kala

2 Vikruti

Bala Linga

3 Sāra Pravara. [ ] Madhyama. [ ] Avara [ ]

4 Samhanana Pravara [ ] Madhyama. [ ] Avara [ ]

5 Pramana Pravara [ ] Madhyama. [ ] Avara [ ]

6 Sātmya Ekarasa. [ ] Sarva rasa[ ]

7 Satva Pravara [ ] Madhyama [ ] Avara [ ]

8 Ahara Shakti Abhyavaharana shakti : P [ ] M [ ] A [ ]

Jarana shakti : P [ ] M[ ] A[ ]

9 Vyayama Shakti Pravara [ ] Madhyama [ ] Avara [ ]

10 Vaya Bala [ ] Yuva [ ] Vrudda

4

D. Sroto Pareeksha: Observed Lakshana.

1 Pranavaha srotas 2 Annava srotas 3 Udakavaha srotas 4 Rasavaha srotas 5 Raktavaha srotas 6 Mamsavaha srotas 7 Medovaha srotas 8 Astivaha srotas 9 Majjavaha srotas 10 Sukravaha srotas 11 Pureeshavaha srotas 12 Mutravaha srotas 13 Swedovaha srotas 14 Artavavaha srotas 15 Manovaha srotas Special Examination of Joints

Sakha Pareekshaa BT AT AF Deformity of joints Swelling Rheumatic nodules

Dar

shan

a

Muscle wasting Skin over the joint Warmth over joint Tenderness

Swelling Intra articular Extra (peri) Articular

Bursitis Tenosynovitis Synovial thickening

Spar

shan

a

Bony Components Palpable Shravana (Crepitation)

Total:

5

9) Laboratory Investigations:

Sl No Investigations BT AT AF 1 Hb% in Gm/dl 2 ESR in MM / 1st hour 3 RA 4 CRP

10) Treatment protocol: a) Deepana pachana --Patyadi churna 3 to 6gms three times witushnodaka for 3-5days. b). Saddyo Virechana – Erand Taila 25-50ml/ at 7-7:30am for one day.

Dose Time of first Vega Time of last Vega Total number of Vegas

c). Vishrama Kala for one day d). Basti: Vaitarana basti for 8 days

Date Pramana Pranidanakala Pratyagamana kala

Nireekshana Any Vyapat Others

6

Assessment of pain

A) NRS Method: SSl.No Daily functions BT AT AF

1 Dress yourself 2 Get in and out of bed 3 Lift a cup of glass to your lips 4 Bend down to pick up clothing from floor. 5 Walk out of doar on flat grounds 6 Wash and dry your entire body Total: B) VAS Method: 0 100 mm Nso Pain Worst possible pain

Pain BT AT AF Measurement in mm

C) Ritchie Articular Index (RAI):

1). Elbow joint 2). Ankle joint 3). Hip joint 4). Wrist joint 5). Knee joint 6). Mid tarsal joints

D) Extra Articular Manifestation of RA Index (EAMRAI):

Sl No Diseases BT AT AF 1 Systemic 2 Musculo skeletal 3 Dermal 4 Eye 5 Respiratory 6 Cardiac 7 Neurological 8 Hematological 9 Reticuloendothilial

Total:

7

E) Global Disease Activity: (GDA) Physician’s assessment of GDA 0 100 mm No Pain Worst possible pain

Pain BT AT AF Measurement in mm

Functional Assessment:

1) Arthritis Impact Measurement Scale (AIMS)

Sl.No Functions BT AT AF 1 Mobility level 2 Walking, Bending 3 Hand and Finger 4 Arm functions 5 Self care tasks 6 Household tasks 7 Social activity 8 Support from family & friends 9 Arthritis pain 10 Work 11 Level of tension 12 Mood

Total: 2) Physical Disability:

No Activities BT AT AF 1 Dressing and Grooming 2 Arising 3 Eating 4 Walking 5 Hygiene 6 Reach (To get down/pick up) 7 Grip

Total:

8

3) Walking Time:

Time Taken Distance

BT AT AF 40 feet

4) Grip Strength:

BT AT AF Grip Strength

5) Range of movements:

Sl.No Movements BT AT AF 1 Knee joint 2 Hip joint 3 Elbow joint 4 Wrist joint 5 Ankle joint 6 Mid tarsal joints

Total:

Ayurvedic Health Assessment: (AHA)

No BT AT AF 1 Annabhilasha 2 Bhuktasya paripakam 3 Srishta vit 4 Srishta mutra 5 Shreera laghavam 6 Suprasannendrium 7 Sukhaswapnam 8 Sukhaprabootanam 9 Balam 10 Varnam 11 Soumanasyam 12 Samagnitas

Total:

9

Sl.No. Criteria (Parameters) BT AT AF

1 Bahusandhishoola

2 Bahusandhishotha

3 Bahusandhigraha or Stabdhata

4 Spershaasahishnuta

5 Assessment of pain (NRS)

6 Assessment of pain (VAS)

7 Ritchie Articular Index (RAI)

8 Extra Articular Manifestation of RA Index (EAMRAI)

9 Global Disease Activity: (GDA)


11 Physical Disability

12 Walking Time

13 Grip Strength

14 Range of movements

15 DAS Criteria

16 Ayurvedic Health Assessment: (AHA)

17 Hb% in Gm/dl

18 ESR in MM / 1st hour

19 RA

20 CRP

Signiture of the Co Guide Signiture of the Guide Dr. Santosh. N. Belavadi Dr. P. Shivaramudu. M.D.(Ayu) M.D.(Ayu)

10

vaitaranabast amavata pk021_gdg

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