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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
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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
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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)
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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.
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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.
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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.
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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.
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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.
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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, ,
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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.
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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.
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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.
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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
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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
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27. Showing distribution of patients by Bahusandhishota
Response to the treatment 91
28. Showing distribution of patients by Bahusandhigraha
Response to the treatment 92
29. Showing distribution of patients by Sparshasahishnuta
Response to the treatment 93
30. Showing distribution of patients by walking time
Response to the treatment 94
31. Showing distribution of patients by Grip Strength
Response to the treatment 95
32. Showing distribution of patients by Range of movements’
Response to the treatment 96
33. Showing distribution of patients by DAS criteria
Response to the treatment 97
34. Showing the overall effect of treatment 98
35. Showing the Data related to the response of Treatment to
Subjective parameters 99
36. Showing the Data related to the response of Treatment to
objective parameters 100
37. Showing the Data related to the response of Treatment to
objective parameters 101
38. Showing the Data related to the response of Treatment to
objective parameters 102
39. Showing the Data related to the response of Treatment to
objective parameters 103
40. Showing the statistical analysis of Subjective and
Objective parameters 104
41. Showing the mean % improvement of Subjective and
Objective parameters 105
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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
Response to the treatment 89
15. Showing distribution of patients by Bahusandhishota
Response to the treatment 90
16. Showing distribution of patients by Bahusandhigraha
Response to the treatment 91
17. Showing distribution of patients by Sparshasahishnuta
Response to the treatment 92
18. Showing distribution of patients by walking time
Response to the treatment 93
19. Showing distribution of patients by Grip Strength
Response to the treatment 94
20. Showing distribution of patients by Range of movements’
Response to the treatment 95
21. Showing distribution of patients by DAS criteria
Response to the treatment 96
22. Showing the overall effect of treatment
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List of flow chart 1. Flow chart showing Samprapti of Amavata 31
2. Flow chart showing pathogenesis of RA 51
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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
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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.
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational Study
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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…
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational Study
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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.
.
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational Study
4
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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
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational Study
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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
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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.
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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
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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
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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
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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.
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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.
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Historical Review
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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.
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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
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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
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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.
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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
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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
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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
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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.
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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
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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.
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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.
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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
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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’.
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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
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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
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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
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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),
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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.
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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.
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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
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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.
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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 ----
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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.
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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 + + - + + +
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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
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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.
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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
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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
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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
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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
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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
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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
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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.
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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
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Rheumatoid Arthritis
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.
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Rheumatoid Arthritis
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
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Rheumatoid Arthritis
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
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Rheumatoid Arthritis
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.
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Rheumatoid Arthritis
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).
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Rheumatoid Arthritis
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:
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Rheumatoid Arthritis
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
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Rheumatoid Arthritis
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.
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Rheumatoid Arthritis
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.
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Rheumatoid Arthritis
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:
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Rheumatoid Arthritis
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.
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Rheumatoid Arthritis
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.
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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.
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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,
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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).
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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
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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
Page 83
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
Rheumatoid Arthritis
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.
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Materials and Methods
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.
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Materials and Methods
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
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Materials and Methods
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).
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Materials and Methods
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
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Materials and Methods
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:
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Materials and Methods
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
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Materials and Methods
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).
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Materials and Methods
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.
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Materials and Methods
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
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Materials and Methods
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
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Materials and Methods
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
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Materials and Methods
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
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
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
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
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Materials and Methods
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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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
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
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Observations and Results
Table No 27, showing distribution of patients by Bahusandhishota response to the
treatment
Bahusandhishota No of patients %
Completely relived 18 60
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.
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Observations and Results
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
Moderate 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.
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Observations and Results
22
0 08
73.33
0 0
26.66
0
1020
304050
607080
No of Patients
%Bahusandhigraha
Bahusandhigraha response to the treatment
Completely relived Good Response Moderate Response No response
Table No 29, showing distribution of patients by Sparshasahishnuta response to the
treatment
Sparshasahishnuta No of patients %
Completely relived 30 100
Good Response 0 0
Moderate Response 0 0
No response 0 0
Out of 30 patients, 30 patients (i.e.100%) were got 100% response in Sparshasahishnuta,
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 93
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Observations and Results
30
0 0 0
100
0 0 00102030405060708090
100
No of Patients
%Spershasahishnuta
Sparshasahishnuta response to the treatment
Completely relived Good Response Moderate Response No response
Table No 30, showing distribution of patients by walking time response to the
treatment
walking time No of patients %
Completely relived 0 0
Good Response 0 0
Moderate Response 9 30
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.
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Observations and Results
0 09
21
0 0
30
70
010
20304050
6070
No of Patients
%Walking Time
walking time response to the treatment
Completely relived Good Response Moderate Response No response
Table No 31, showing distribution of patients by Grip Strength response to the
treatment
Grip Strength No of patients %
Completely relived 0 0
Good Response 2 6.66
Moderate Response 3 10
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
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 95
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Observations and Results
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
Completely relived Good Response Moderate Response No response
Table No 32, showing distribution of patients by Range of movements’ response to
the treatment
Range of movements No of patients %
Completely relived 0 0
Good Response 8 26.66
Moderate Response 12 40
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.
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Observations and Results
0
812 10
0
26.66
40
33.33
05
10152025303540
No of Patients
%Range of movements’
Range of movements’ response to the treatment
Completely relived Good Response Moderate Response No response
Table No 33, showing distribution of patients by DAS criteria response to the
treatment
DAS criteria No of patients %
Completely relived 0 0
Good Response 15 50
Moderate Response 14 46.66
No response 1 3.33
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Observations and Results
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
Completely relived Good Response Moderate Response No response
Table No 34, showing the overall effect of treatment
Result No of patients %
Completely relived 0 0
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.
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Observations and Results
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
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Observations and Results
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 - - - - - -
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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
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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
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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
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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
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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
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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
10 Arthritis Impact Measurement Scale (AIMS)
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
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Observations and Results
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%.
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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
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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.
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• 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.
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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
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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
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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,
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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.
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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.
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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.
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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;
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 115
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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.
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 116
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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.
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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%).
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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.
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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):
• Among 30 patients 2 patients have got more than 75% improvement, 15 patients
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.
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Discussion
7) Effect on Ritchie Articular Index (RIA):
• Among 30 patients 24 patients have got more than 75% improvement, 5 patients
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):
• Among 30 patients 4 patients have got more than 75% improvement, 16 patients
have got 50% improvement, 9 patients have got more than 25% improvement
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:
• Among 30 patients 3 patients have got more than 75% improvement, 13 patients
have got 50% improvement, 5 patients have got more than 25% improvement
and 9 patient have got bellow 25% improvement.
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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:
• Among 6 patients 2 patients have got more than 75% improvement, 3 patients
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
have got 50% improvement, 12 patients have got more than 25% improvement
and 10 patient have got bellow 25% improvement.
15) Effect on DAS criteria:
• Among 30 patients no one has got more than 75% improvement, 15 patients
have got 50% improvement, 14 patients have got more than 25% improvement
and 1 patient have got bellow 25% improvement.
16) Effect on Ayurvedic Health Assessment (AHA):
• Among 30 patients 6 patients have got more than 75% improvement, 14 patients
have got 50% improvement, 10 patients have got more than 25% improvement.
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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%
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 123
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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
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 124
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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.
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 125
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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
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 126
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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.
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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.
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 128
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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
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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
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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.
Evaluation of Efficacy of Vaitaranabasti in Amavata-An observational study 131
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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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28) I bid
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34) Bhavamishra, Bhavaprakasha madhyakhanda, chapter Amavata chikitsa, sloka
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35) Chakradatta, Chapter 25,sloka 1. Edited by Jagadeeshwar Prasad Tripati, 5th edn.
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38) I bid
39) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter
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40) Chakradatta, Chapter 25,sloka 19-20. Edited by Jagadeeshwar Prasad Tripati, 5th
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41) Vangasena, Vangasenasamhitha, Amavatarogadhikara, Jain Sankarlalji Vaidya
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42) Bhavamishra, Bhavaprakasha madhyakhanda, chapter 26, sloka 282 Edited by
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48) Arunadatta, Ashtangahridaya sutrasthana chapter 19 sloka 1. Varanasi:
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49) Ashtangasangraha Suthrasthana chapter 28, sloka 2. Prof.K.R.Shrikhantamurthy,
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50) Adamalla, Sharangadhara, Sarngadharasamhitha Utharakhanda chapter 5, sloka
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56) Ashtangasangraha Suthrasthana chapter 28, sloka 61. Prof.K.R.Shrikhantamurthy,
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124) Ashtangasangraha Suthrasthana chapter 19, sloka 1.
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154) I bid sloka 7-10.p.463.
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184) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by
Blackwell science limited Paris, France. P 98-106 & 114.
185) API text book of medicine, Edited by G. S. Sainani, 6th edn. Mumbai :
Association of Physicians of India ; 1999. p 1028.
186) Robins pathologic basis of disease by Cotron et al, published by Harwart
pvt limited. Lajpat nagar, N. Delhi. P 140-142.
187) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W.
B. Saunders company, Philadelphia, Pensylvania. P 114-115.
188) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by
Blackwell science limited Paris, France. P 1230-1232.
189) Text book of Rheumatology, by Kelly et al, 5th edition, published by W.
B. Saunders company, Philadelphia, Pensylvania. P 114-115.
190) Chakrapanidatta, Chakradatta, Amavata chikitsa, 25th Ch. 24th sloka, 2nd
edition, 1998, Priyavrita Sharma, editor, Varanasi: Chowkhambha Sanskrit
Academy: pp 230
Evaluation of Efficacy of Vaitaranabasti in Amavata- An observational study 145
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191) Yogaratnakara, Indradeva Tripathi, 1st edn. Varanasi: Krishnadasa
Academy ; 1998. Sloka 1, p 107.
192) Yogaratnakara, Indradeva Tripathi, 1st edn. Varanasi: Krishnadasa
Academy ; 1998.Sloka 1, p 107.
193) Agnivesa, Charakasamhitha Sutrasthana chapter 13. sloka 12. 4th ed.
Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.182.
194) Sushrutha, Sushruthasamhitha.chikitsasthana chapter 31. sloka 5.
Varanasi: Krishnadas Academy; 1980. p-508.
195) Sharangdhara, Sharangdhara Samhita, Uttara khanda, Virechana vidhi, 4th
Ch. 20th sloka, 1st edition, 1990, Bramhananda Tripathi editor, Varanasi:
Chowkhambha Surbharati Prakashana: pp 345.
196) Chakrapanidatta, Chakradatta, Niruhadhikara, 29th Ch. 32 sloka, 2nd
edition, 1998,Priyavrita Sharma, editor, Varanasi: Chowkhambha Sanskrit
Samsthana: pp 629.
197) Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal
plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 540.
198) Rubin.K.Dr, Chemical components of Rock salt. University of
Hawaii.2003. Available from: www.geophysics.com/hawaii/HI96822. Accessed
on 4th November 2004.
199) Sushrutha, Sushruthasamhitha Suthrasthana chapter 45 sloka 160-167.
Varanasi: Krishnadas Academy; 1980. p. 209. (Krishnadas Ayurveda series 51).
200) . Chemical components of Jaggery- Environ Health Perspect. 1994.
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plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 530.
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Ambikadatta Shastri, editor. Varanasi: Chaukhambha Orientalia; 1983. p. 130.
(Kasi Sanskrit series 152).
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203) Sushrutha, Sushruthasamhitha Suthrasthana chapter 45 sloka 113.
Varanasi: Krishnadas Academy; 1980. p. 205. (Krishnadas Ayurveda series 51).
204) Haritha Samhita chapter 9,Varanasi: Krishnadas Academy; 1980, p- 70.
Evaluation of Efficacy of Vaitaranabasti in Amavata- An observational study 147
Page 170
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
Page 171
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
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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
Page 173
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
Page 174
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
Page 175
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
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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
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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
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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
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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)
10 Arthritis Impact Measurement Scale (AIMS)
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