issn:2277-7881; impact factor :7.816(2022); ic value:5.16 - AWS

Cover Page

DOI: http://ijmer.in.doi./2022/11.04.15

ISSN:2277-7881; IMPACT FACTOR :7.816(2022); IC VALUE:5.16; ISI VALUE:2.286 Peer Reviewed and Refereed Journal: VOLUME:11, ISSUE:4(1), April: 2022 Online Copy of Article Publication Available (2022 Issues): www.ijmer.in

Digital Certificate of Publication: http://ijmer.in/pdf/e-Certificate%20of%20Publication-IJMER.pdf Scopus Review ID: A2B96D3ACF3FEA2A

Article Received: 2nd April 2022 Publication Date:10th May 2022

Publisher: Sucharitha Publication, India

81

A HOLISTIC APPROACH OF AYURVEDA IN THE MANAGEMENT OF AMAVATA (RHEUMATOID ARTHRITIS)

Dr. Jajbir Singh

Phd Ayurveda Scholar Department of Ayurveda & Research

Desh Bhagat University Mandi Gobindgarh Distt Fatehgarh Sahib, Punjab, India

ABSTRACT

According to Ayurveda, freedom from disease is not only health to be healthy, a person should be happy physically, mentally, socially and also spiritually. Drastic change in life style of human and pollution have not only created social problems but also have a great impact over health which has led to exacerbation of certain disorders which is Amavata (Rheumatoid Arthritis) is one of them. Pain relating to body or mind or both has been an obstacle in the pathway leading to happy life. Sometimes pain can be so severe as to disable the person, cripple and make him confined to bed. Joint disorder, particularly Amavata (Rheumatoid arthritis) is a leading cause of disability. Amavata is common musculoskeletal conditions affecting individuals across the country. Amavata is one of the chronic diseases mainly affecting the joints with pain of severe degree being the main symptom with progressive destruction of the joints with crippling and deformities, arthritis poses an unavoidable clinical situation and prolonged morbidity warranting an active care. It is seen most commonly in the patients due to their changing dietetic habits, social structure, environment and mental stress and strain. Ama and Vata are the two main pathognomic factors held responsible for causation of Amavata. Derangement of Agni that is Agnimandya is a chief factor responsible for the formation of Ama, which is main pathological entity of the disease. The etiological factor for both vitiation of Vata and formation of Ama are responsible for the manifestation of the disease. General management of Amavata includes Nidan Parivarjan/ elimination of cause, Langhan, Deepan, Pachan to promote Agni, Appropriate Elimination of Ama by Selective Sodhan , Dietary Restrictions advocating Katu, Tikta, Usna, Laghu and Use of Medication for Pain & Inflammation , Snehana, Swedan, Vasti in chronic Niramawastha, Local care of Inflamed Joints, Exercise & Physiotherapy, Samshaman Treatment with specific drugs, Rehabilitative procedures and long follow-ups. Keywords: Amavata, Musculoskeletal, Dietetic, Nutritional, Samshaman, Rehabilitative. I) INTRODUCTION

In Ayurveda this disease described as Amavata, first in Madhav Nidan. This disease is dominated pathologically by Ama and Vata. Due to different causative factors, there is improper metabolism of food which results formation of an intermediate product which is toxic in nature known as Ama. This Ama, if not excreted from the body, it absorbed in the body and produce pain, inflammation and stiffness in joints. Rheumatoid Arthritis (R.A.) is a chronic systemic inflammatory disease of unknown cause, chiefly affecting synovial membranes of multiple joints. The disease has a wide clinical spectrum and considerable variability in joints and extra-articular manifestations. The prevalence in the general population is 1-2% and male & female ratio is 1:3. The usual age of onset is 20-40 yrs, although Rheumatoid Arthritis may begin at any age. Susceptibility to Rheumatoid Arthritis has genetically determined. If not treated appropriately, Rheumatoid Arthritis has a strong tendency to shorten life and cause severe disability.

II) ETYMOLOGY OF AMAVATA

Nomenclature of the disease is very important for easy identification and understanding, of a particular disease. It is done on the basis of vitiated doshas, manifested symptoms, involved dushya, hetu and the basic pathological factor etc. So far as Amavata is concerned as the term itself denotes, it is formed by the union of two words Ama & Vata which are the two predominant pathological factors acting in the disease process. Acharya Madhava adds other dosha also.

III) DEFINITION OF AMAVATA

Acharya Madhav was given the appropriate definition of Amavata. Vitiated Vata and Ama simultaneously enters in the kostha trika and sandhi pradesha leading to gatra stabdhata and trika samdivendana. This condition is known as Amavata. The term ‘yugapat’ means simultaneous vitiation of vata and kapha dosha, as main pathogenic factor of the disease.

According to ‘Atanka darpana’ commentary- Both vata & Ama are responsible (simultaneously) for the pathogenesis of the

disease. Here Ama can be taken as ‘vitiated kapha’ as per Chakrapani in chikitsa sthana. Lakshana & Chikitsa of Ama or vitiated kapha are alike, this can be interchanged.

Cover Page






82

Trika sandhi – Variety of description is found regarding the word ‘trika’.

According to Madhav Nidan – it includes kati, manya, amsa sandhi According to Dlalhana the word trika means –

1. Sroni kanda bhaga (sacral region or sacrum) 2. Bahu greeva samghata sthala (scapular joint, acronio – clavicular joint)

According to Aruna data, Trika means pristha dhara According to Hemadree it is pristhavamsadhara (ileosacral & lumboscral)

Finally, then it can be concluded that the word ‘trika’ means sacral joint, scapular joint, intervertebra joint, sacroiliac joint, cervical joint.

All sakhagata sandhi It seems that trika means the sites where 3 bones unite or the sites seem triangular shape. IV) CLASSIFICATION OF AMAVATA The disease Amavata can be classified on the following basis –

1. According to involvement of Doshas 2. According to the severity of the disease 3. According to the chronicity of the disease 4. According to the clinical manifestation 5. According to the prognosis

1. On the basis of involved Doshas Madhav has described 7 types of Amavata according to the involvement dosha.

Eka doshaja - (1) Vataja (2) Pittaja (3) Kaphaja

Dvidoshaja - (4) Kapha pittaja (5) Kapha vataja (6) Vata pittaja

Tridoshaja - (7) Sannipataja 2. On the basis of severity

According to the severity it can classified as – 1. Samanya Amavata 2. Pravriddha Amavata

3. On the basis of chronicity Acharya Gananathsen classifies Amavata on the basic of chronicity. 1. Naveena Amavata – less than 1 year old. 2. Purana (Jirna) Amavata – more than 1 year.

4. On the basis of clinical manifestation

A unique type of classification can be seen in Harita Samhita. 1. Vistambhi Amavata – Adhmana, Basti shula present 2. Gulmi Amavata – Gulmavat pida, Jathara garjana, kati jadyata present 3. Snehi Amavata – Associated with snigdhata, Jadyata, Mandagni and excretion of snehayukta Mala. 4. Sarvangi Amavata – Associated with kati, pristha desha shotha, Bastishula, Antrakujana, Shotha, Siroguruta & Amamala. 5. PakwAmavata – Nirama mala pravritti, absence of basti shula and presence of shrama and klama

5. According to prognosis / chikitsa parinama According to chikista parinama, it is classified into – 1. Sadhya Amavata - Eka doshaja 2. Yapya Amavata - Dwi doshaja

Cover Page






83

3. Sannipatika Amavata - Kricchasadhya

V) NIDANA PANCHAKA OF AMAVATA Nidana panchaka are the five parameters which are used in the diagnosis of a disease. Vyadhi vinischaya can occur either by

one nidana or by two nidanas or by whole. These five parameters are – NIDANA

Nidana of Amavata is grouped here as under: 1. Amotpadaka – Viruddhahara, viruddha chesta etc. leads to formation of ama and disease production. 2. Vata prakopaka – Due to provocation of vata dosha equilibrium status of tridosha, sapta dhatu and malas get hampered which leads to the disease condition. 3. Prajnaparadha – Prajnaparahdha leads to Ahita Ahara vihara etc, which lastly produce the disease. 4. Kulaja vikara – From the very birth, there is ‘kha-vaigunya’ in sandhis, when it is excited by proper environment, manifestation of the disease occurs. 5. Agantuka – It includes age, sex, environment (Sheeta, Anupa) and various situations like, sheeta vata sevana at the time of sweating, sleeping on a wet or damp ground etc. Acording to Madhava, Nidana of Amavata includes 4 factors.

(i) Viruddha ahara (incompatible diets) (ii) Viruddha chesta. (iii) Mandagni. (iv) Snigdha bhojanottara vyayam According to Gananatha sen Guru, Snigdha, Atimadhura bhojana which produces Rasadosha is the Nidana of Amavata. He

has also mentioned that it affects to those persons which have less physical activities. The Nidana described in Bhavaprakasha, Yogaratnakar and Vangasen samhita are same as like Madhava nidana. Anjana Nidana viewed that pathogen Ama and Vata get provoked due to their own respective causes to promote the disease.

Amotpatti karana and Vataprokopaka karana also be considered as aetiological factors of Amavata. He has also mentioned that all athe factors responsible for the vitiation of Tridosha can cause Amavata.

According to Harita Person having Mandagni when regularly takes Guru Anna ahara without performing vyayama becomes

victim of the disease Amavata. He has also mentioned intake of more kandashaka ultimately leads to Amavata. From the above description, shortly we can divide the Nidana of Amavata into the following groups – (1) Aharatmaka (2) Viharatmaka (3) Manasika (4) Others – (i) Mandagni (ii) Nischalatwa (Achalkarmana) (iii) Nidanarthakara vyadhi (iv) Graha stithi

VI) CAUSATIVE FACTORS

1. Improper diet and behavior 2. Improper digestion 3. Suppression of natural urges 4. Sedentary lifestyle 5. Psycho-somatic strain and stress 6. Positive family history, hypersensitivity, drug interaction etc

Cover Page






84

VII) PRODROMAL SYMPTOMS 1. Malaise 2. Weight Loss 3. Vague peri-articular pain and morning stiffness of joints 4. Improper digestion, dyspepsia 5. Constipation

VIII) CLINICAL FEATURES

1. Symmetric joint swelling and stiffness, warmth, tenderness and pain are characteristic. Stiffness persisting for more than 30 minutes is prominent in the morning, subsiding later in the day. Although any joint may be affected, the peripheral joints as well the wrists, knees, ankles and toes are most often involved.

2. Joint pain is very severe as per Ayurveda, pain is like Scorpion bite which is increased during cloudy weather. 3. Mild fever, body ache, lethargy and fatigue. 4. Loss of appetite, Constipation. 5. Heaviness of the body, heaviness over the cardiac region with palpitation. 6. Extra-articular manifestation i.e., Subcutaneous nodules, plural effusion, pericarditis, lymphadednopathy, splenomegaly and

vasculitis. IX) COMPLICATIONS

1. Swan Neck Deformity i.e., Flexion of DIP joint with extension of PIP joint, Ulnar deviation of the fingers, Boutonniere deformity i.e., Hyperextension of DIP joints with flexion of the PIP joints.

2. Cardiac disorder 3. Difficulty in movement 4. Muscular atrophy

X) EXTRA-ARTICULAR FEATURES Rheumatoid Arthritis is a systemic disease. Anorexia, weight loss, lethargy and myalgia occur commonly throughout its course and precede the onset of articular symptoms by weeks or months. Diagnosis

a. Morning stiffness more than 1 hour b. Arthritis of hand joints (wrist involvement especially) c. Symmetrical arthritis d. Rheumatoid factor e. Rheumatoid nodule f. Arthritis of three or more joints g. Radiological changes h. Duration of six weeks or more i. Diagnosis of RA is made with 4 or more criteria

XI) INVESTIGATION

1. During both acute and chronic phases, the ESR and Immunoglobulin (Mostly common IgM and IgG) are typically elevated. 2. R.A. Factor (Rheumatoid Arthritis Factor) 3. ANA (Anti-Nuclear Antibody) 4. Anti CCP (Anti Body to Cyclic Citrullinated Peptide) is the most specific test. 5. ASO Titre 6. Uric Acid 7. Serum Calcium 8. Radiographic findings such as Extra-articular osteoporosis, Joint erosions and narrowing of joint space. 9. Joint fluid analysis is valuable, reflecting abnormalities that are associated with varying degree of inflammation.

Cover Page






85

XII) MANAGEMENT Rheumatoid Arthritis is unpredictable, accurate assessment of the condition is a must at the time of reporting as well as at regular intervals. The clinical course of Rheumatoid Arthritis is divided into two phases:

A) Acute or active phase B) Chronic phase

The treatment differs radically in both these phases of the disease. There may be remissions and exacerbations during the course of

the disease. A) Acute or Active Phase (3 to 4 weeks):- During the acute phase of the disease the acute symptoms such as pain, erythema,

tenderness and swelling are present. Any oil application is contra-indicated in acute phase because it will increase swelling well as pain. Only nadi sveda can be done without oil application.

B) Chronic phase: In this phase by 4-5 weeks of the onset, it is a phase of vigorous activity to train the patient to use the involved joints to the greatest extent for physical independence. In chronic phase as there is no swelling, so oil can be applied. Nadi sveda with prior oil application or panda sveda with minimum or proper oil or both procedures can be given for 7-10days. It is better to use both the processes panda sweda as well as nadi sweda.

General management of Amavata includes: 1. Nidan Parivarjan/ elimination of cause. 2. Langhan, Deepan, Pachan to promote Agni. 3. Appropriate Elimination of Ama by Selective Sodhan. 4. Dietary Restrictions advocating Katu, Tikta, Usna, Laghu. 5. Use of Medication for Pain & Inflammation. 6. Snehana, Swedan, Vasti in chronic Niramawastha. 7. Local care of Inflamed Joints. 8. Exercise & Physiotherapy. 9. Samshaman Treatment with specific drugs. 10. Rehabilitative procedures and long follow-ups

XIII) TREATMENT CLASSICAL PRODUCTS

1. Simhanad Guggulu or Vatari Guggulu -500mg twice daily after food. 2. Mahayogaraj Guggulu or Rasnadi Guggulu – 500mg twice daily after food. 3. Agnitundi Vati/Ramaban Rasa/ sanjivani vati – 250mg twice daily after food. 4. Amavatari Ras/Maha Vata Vidhamsa Ras – 250mg twice daily after food. 5. Dasamularista/Saribadyarista/Maha Rasnadi Kwath – 20ml twice daily after food with warm water. 6. Rasaraj Rasa/Trailokyachintamoni Rasa – 125mg twice daily with honey. 7. Eranda Pak or Eranda Oil – 1 or 2 Tsf daily bed time with warm water/milk.

PHARMACEUTICAL PRODUCTS

1. Arthrum plus/Muscult forte/R-compound/Rumalaya Forte – 1 to 2 Tab/Cap twice/Thrice daily after food. 2. Rumartho with Gold/Rumayog Gold - 1 Cap Twice daily after food. 3. Shigru-1Tab/ Cap Thrice daily after food. 4. Shallaki-1Tab/ Cap Thrice daily after food. 5. Aswagandha-1Tab/ Cap Thrice daily after food. 6. Mrig & Mrig G (Altis) - 1 Cap Twice daily after food. 7. Rumalaya liniment/Mrig oil/Arthrum Oil – Message Gently.

PANCHKARMA 1. Brihat Saindhabadi Oil: Massage gently twice daily (Indicated if there is no swelling/mild swelling) 2. Nadi Sveda with Dasmula, Rasana, Erando, Nirgundi and Saihdhav lavan (Indicated if there is no swelling/mild swelling) 3. Baluka Sweda is helpful 4. Vaitaron vasti is helpful

Cover Page






86

HOME REMEDIES 1. Dry fomentation with sand or salt. Hot compression in the affected joints. 2. Hot water mixed with salt i.e., Fomentation over the affected joints or steam fomentation mix with vitex nirgundo leafs and saindhav salt. 3. Decoction of Nirgundi + Shigru + Turmeric + Ginger – 40ml twice daily after food.

4. Aswagandha Powder – 1 Tsf daily with warm water. 5. Garlic is also helpful. 6. Sahijan (Shigru) may be taken daily. 7. Physiotherapy, regular yoga and exercise with proper guidance are beneficial.

PATHYA Steam bath, fresh, warm and easily digestive diet, garlic, onion, ginger, turmeric, tulsi, black pepper, patol, methi, green vegetables, shijan or dram stick, castor oil warm water as drinks and bath are useful. APATHYA Curd, Cold water, Carbonated drinks, Ice Cream, Urad dal, Brinjal, Pumpkin, Ladies finger, Suppression of natural urges, Living in air condition room, Stress, Over eating, excess intake of rice, Sweets, Non-vegetarian diet etc. XIV) DISCUSSION Ayurveda has adopted the concept of total health which is related to the unique multi-dimensional concept of human life. It is a state of well-being referred to physical, censorial, mental and spiritual well-being. A living being which is termed as Purusha in Ayurveda is a composite entity, consisting of physical body, superadded with highly sensitive apparatus such as different Indriya, Mana and Atma. Ayurveda has holistic approach for maintaining the health. Ayurvedic classics provide clear therapeutic guidelines for the treatment of Amavata. Namely langhana, swedana, Tikta - katu - Deepana drugs, Virechana etc. the treatment is based on Ama pachana and amelioration of vitiated vata. As the disease is born out from the vitiated vata and kapha, in this present study we have selected a shamana yoga which has a definite action on vitiated vata kapha dosha. The total treatment principle of Amavata stands on 3 Process - 1. Ama pachana - by Langhana, Swedana, Pachana, Deepana 2. Ama/vata Nirharana - by Virechan, Snehapana & Basti 3. Agni saramkshana - by Deepana

Ayurveda has proved to be effective in managing and preventing chronic ailments till date. Concepts of Ayurveda have been helpful in treating new diseases arising due to changing lifestyles and environment. This study was an attempt to understand the Disease in Ayurvedic concept and find an effective therapy in preventing the disease. XV) CONCLUSION

Amavata is one of the chronic diseases mainly affecting the joints with pain of severe degree being the main symptom with progressive destruction of the joints with crippling and deformities, arthritis poses an unavoidable clinical situation and prolonged morbidity warranting an active care. The General management of Amavata includes Nidan Parivarjan/ elimination of cause, Langhan, Deepan, Pachan to promote Agni, Appropriate Elimination of Ama by Selective Sodhan, Dietary Restrictions advocating Katu, Tikta, Usna, Laghu & Use of Medication for Pain & Inflammation, Snehana, Swedan, Vasti in chronic Niramawastha, Local care of Inflamed Joints, Exercise & Physiotherapy, Samshaman Treatment with specific drugs, Rehabilitative procedures and long follow-ups. References 1) Govind Das. Bhaishajya Ratnavali with Vidhyotini Hindi Commentary by Shri Ambikadatta Shastri 18th edition, Varanasi,

Chaukamba Sanskrith Bhavan, 2005. 2) Gadanigraha - Vidyotini Hindi Comm. Chaukhambha Sanskrit Sansthana Varanasi. 3) Harita Samhita: Hariharprasada Tripathi Chaukhambha Sanskrit Sansthana, 2005. 4) K Sembulingam & Prema Sembulingam. Essentials of Medical Physiology, New Delhi, Jaypee Brothers, 2nd edition, 2003. 5) Kasture H.S., Ayurvediya Panchakarma Vigyana, 5th edition, Baidyanath Ayurveda Bhavana, Nagpur, 1997. 6) Kasyapa Samhita: Srisatayapala Bhisagacarya, Chaukhambha Sanskrit Sansthana. Tenth edition 2005. 7) Manu Smriti edited with the Maniprabha hindi commentary by Pandit Haragovind Sastri, Chowkamba Sanskrit Series,Varanasi. 8) Madhavakara. Madhava Nidanam with Madhu Kosha Sanskrit commentary by Shri. Vijayarakshita and Shrikanta Datta, with the

Cover Page






87

Vidyotini Hindi commentary, edited by Yadunandana Upadhaya, Varanasi, Chaukhambha Sanskrit Sansthan, Part II, reprint 2003.

9) Tripathi B, editor. Madhav Nidana of Madhavkar. Reprint Ed. Ch. 25, Ver. 1-5. Vol. 1 Varanasi: Chaukhabha Sanskrit Sanshtan; 2006. p. 571

10) Tripathi B, editor. Madhav Nidana of Madhavkar. Reprint ed. Ch. 25, Ver. 6. Vol. 1. Varanasi: Chaukhabha Sanskrit Sanshtan; 2006. p. 572.

11) Boon NA, Colledge NR, Walker BR, Hunter JA. Davidson's Principles and Practice of Medicine. 20th ed. Ch.25. Edinburgh: Churchill Livingstone-Elsevier; 2006. Musculoskeletal disorders; pp. 1101–1104.

12) Chaturvedi G, Shastri K, editors. Charaka Samhita of Agnivesha, Siddhi Sthana. Reprint ed. Ch.2, Ver. 13. Varanasi: Chaukhambha Bharati Academy; 2007. p. 981.

13) Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, 3rd, et al. 2010 rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2010; 69:1580–8.

14) Shastri AD, editor. Bhaishajya Ratnavali. 19th ed. Ch. 29, Ver. 1. Varanasi: Chaukhambha Prakashan; 2008. p. 613. 15) Tripathi JP, editor. Chakradatta of Chakrapani. 4th ed. Ch. 25, Ver. 1. Varanasi: Chaukhabha Sanskrit Series; 1976. p.

225. 16) Lipsky Peter E. Rheumatoid arthritis. In: Longo D.L., Kasper D.L., Jameson J.L., Fauci A.S., Hauser S.L., Loscalzo J., editors.

18th ed. vol. II. Mc Graw Hill; New York: 2012. pp. 2738–2752. (Harrison principles of internal medicine). 17) Shastri B.S., editor. 6th ed. vol. I. Chaukhamba Sanskrit Sansthan; Varanasi: 1997. p.565. (Yogaratnakara of unknown author,

Amavata Nidana). 18) Acharya Y.T., editor. Charaka Samhita of Agnivesha, Chikitsa Sthana; Vatashonita Chikitsa: chapter 29, Verse 19 –

23. Chaukhamba Surbharati Prakashan; Varanasi: 2011. p.628. reprint 2011.

issn:2277-7881; impact factor :7.816(2022); ic value:5.16 - AWS

Documents