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Evaluation of comparative efficacy of Alambushadi yoga and Dhanyamla Kayaseka in Amavata (Rheumatoid Arthritis) ...

Evaluation of comparative efficacy of Alambushadi yoga and Dhanyamla Kayaseka in Amavata (Rheumatoid Arthritis)
By Shyju Ollakkod under the Guide Dr. Shiva Rama Prasad Kethamakka from D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE
Gadag - 582 103

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2001amavata-shyju 2001amavata-shyju Document Transcript

  • Evaluation of comparative efficacy of Alambushadi yoga and DhanyamlaKayaseka in Amavata (Rheumatoid Arthritis) By Shyju Ollakkod As partial fulfillment of post graduation degree Ayurveda Vachaspati M.D. (Kayachikitsa) Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka Guide Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm) M.A. (Jyotish) Reader in Kayachikitsa Post graduation and research center, Kayachikitsa Co-Guide Dr. Shashidhar.H.Doddamani M.D. (Ayu) Asst. Professor Post graduation and research center, PanchakarmaD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE Gadag - 582 103 Post graduate studies and research center Department of Kayachikitsa 2001-2004 1
  • This is to certify that the contents of this thesis entitled “Evaluation of comparativeefficacy of Alambushadi yoga and Dhanyamla Kayaseka in Amavata (RheumatoidArthritis)” has been worked out by SHYJU OLLAKKOD, under my supervision with closeguidance. Even though this disease, Amavata has been mentioned in Ayurvedic texts, theaetiology, pathogenesis etc., needs further evaluation and research. It is as developed andexplained by SHYJU OLLAKKOD is unique and scientific and will definitely help inelucidation of this disease in Ayurvedic and Modern scientific parlance and further planningwith the management. This study is not an ersatz, not produced just for any Degree, Diploma or Titles. Thiswork is applied, scientific and an original contribution in the field of research in Ayurveda. I am fully satisfied with the work and recommend the dissertation to be put beforethe M.D. (Ayurveda Vachaspathi) Kayachikitsa panel of Rajiv Gandhi University of HealthSciences, Bangalore for adjudication. Dr. SHIVA RAMA PRASAD KETHAMAKKA M.D.(K.C)(Osm), M.A.(Jyo) Guide READER IN KAYACHIKITSA DGMAMC, PGS&RC, Gadag 2
  • J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER DEPARTMENT OF KAYACHIKITSA GADAG, 582 103 Certificate This is to certify that SHYJU OLLAKKOD has worked for his thesis on the topicentitled “Evaluation of comparative efficacy of Alambushadi yoga and DhanyamlaKayaseka in Amavata (Rheumatoid Arthritis)”. He has successfully done the work under the guidance Dr. Shiva Rama PrasadKethamakka M.D. (Ayu) (Osm), M. A. (Jyotish) and Co-guidance of Dr. Sashidhar H.Doddamani, M.D (Ayu). We here with forward this thesis for the evaluation and adjudication. (Dr. V. Varada charyulu) (Dr. G. B. Patil) 3
  • Certificate This is to certify that Shyju Ollakode has undertaken the present work entitled“Evaluation of the comparative efficacy of Alambushadi Yoga and Dhanyamla Kayaseka inAmavata (Rheumatoid Arthritis)” under my direct co-guidance. He has completed hisresearch studies very sincerely, meticulously and methodically. The present research work bears ample evidences of original work and thoughts onthe topic. The observations reported in this thesis were checked and verified by me fromtime to time. I am fully satisfied with his work recommended this thesis for adjudication forthe degree of Doctor of Medicine (Ayurveda Vachaspati) from of Rajiv Gandhi University ofHealth Sciences, Bangalore.Place : GadagDate : Co-Guide Dr. Shashidhar.H.Doddamani Asst. Professor, Post graduation and research center, Panchakarma 4
  • Acknowledgement “Love is the only inspiration”. This work carries some memories to express andrecord about some distinguished personalities with whom I had inspired during the courseof this thesis. I express my obligation to my honorable guide Dr. K. Shiva Rama PrasadKethamakka, M.D. (Ayu)(Osm), Reader in the P.G. department of Kayachikitsa, P.G.S. &R., D.G.M.A.M.C., Gadag for his critical suggestions and expert guidance for thecompletion of this thesis. I am extremely grateful and obliged to my co-guide Dr. Shashidhar H. DoddamaniAsst. Professor, P.G.S. & R., D.G.M.A.M.C., Gadag under whose guidance and inspirationsI have been able to complete this research work. I express my deep gratitude to Dr. V. Varadacharyulu M.D.(Ayu), Prof. & H.O.D.,P.G. Department of Kayachikitsa, P.G.S. & R., D.G.M.A.M.C., Gadag for his advice andencouragement at every step of this work. I express my obligation to beloved principal Dr. G. B. Patil, D.G.M.A.M.C., Gadag forhis encouragement as well as providing all necessary facilities for this research work. I express my sincere appreciation to Dr. R.Y.Shetter, Dr. S.H.Redder, Dr. KuberSankh, Dr. M.C.Patil, Dr. V.M.Sajjan, Dr. B.G.Swami, Dr. U.V.Purad, Dr. K.S.Parradi & Dr.Smt. Jayashree for their whole hearted co-operation and advice. I am grateful to Padmashree Dr. P.K.Warier, Dr. A.P.Haridasan, Dr. T.V.Sankarankutti Warier, Dr. E. Surendra Warier, Dr. Rama Devi, Dr. C. Jayadevan Warier, Dr.Dilipkumar, Dr. A.K.Manojkumar, Dr. Hullur, Dr. Prashant, Dr. Shrinivas Acharya, Dr.Anjaneya Murthy and Dr. Manoj Kaloor for their inspiration and support during my post-graduate study and research. I am grateful to Shri. D.N.Patil, Vicec-principle K.L.E.Society’s Pharmacy College,Gadag for his wholehearted co-operation and advice in the study. 5
  • I thank to Shri. V.M.Mundinamani, librarian and Shri. S.B. Surreban, libraryassistant, Shri. Babu & Smt. Leela, Panchakarma technicians, and Shri.B.S.Tippanagoudar, lab technician for their kind support in my study. I tender my sincerethanks to Shri. Venkiteswaran, IT officer, Panjab National Bank, Calicut and Shri.Nandakumar for their help in statistical analysis of results. I wish to express thanks to my colleagues Dr. Hanmanthgoudar, Dr. Shankargouda,Dr. Vanita, Dr. Shakuntala, Dr. Naveen, Dr. Biju, Dr. E.M.Muhammed, Dr. NaseemaMuhammed, Dr.Subin Vaidyamatham, Dr. Febin K.Anto, Dr. Ranjit P. Gopinath, Dr. Shajil,Dr. Satheesh Warier, Dr. T.P.Joshi, Dr. Venkkareddiyar P.H., Dr. Ratnakumar, Dr.Udaykumar, Dr. Chandrashekharamouli, other post-graduate scholars, Dr. Nanda, Dr.Jyothi and other house surgeons and U.G. scholars of my institute. I express my sincere thanks to Shri. Arunkumar B. Biradar, (Giridhara South NorthComputer Services, Adarsha Nagar, Gadag) and Smt. Syma, (Safe hands, Calicut) forcompleting this type mater sincerely and correctly in due time. I acknowledge to my wife Smt. Aswathi Shyju, Shri. Prasanthan O, Smt. Radhika,Shri. Surendran U.K. and Smt. Sunanda O. for their inspiration and moral support tocomplete this work successfully. I acknowledge my patients for their wholehearted consent to participate in thisclinical trial. Lastly I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. I dedicate this work done as partial fulfillment of Post graduation degree, to my ever-remembering respectful mother Smt. O. Maidhily Amma. Shyju Ollakkod 6
  • Index Pages1 Introduction 01 to 062 Literary review 07 to 513 Drug review 52 to 654 Materials and Methods 66 to 805 Observations and Results 81 to 1576 Discussion and conclusion 158 to 1877 Summary 188 to 189 Bibliography Annexare – case sheet 7
  • LIST OF TABLES1. Samprapti Ghatakas 292. Comparison of Lakshanas as per different Ayurvedic treaties 353. Srotas involvement 394. Combinations and proportions of Alambushadi Yoga 525. Combination and proportions of Dhanyamla 636. Questionnaires for assessment of pain 727. Ayurvedic health assessment questionnaires 758. AIMS questionnaires 759. Health assessment 7610. Distribution of patients by age 8211. Distribution of patients by sex 8312. Distribution of patients by religion 8413. Distribution of patients by occupation 8514. Distribution of patients by socioeconomic status 8615. Distribution of patients by food habits 8716. Distribution of patients by predominant rasa 8817. Distribution of patients by addiction 8918. Distribution of patients by nadi 9019. Distribution of patients by prakriti 91 8
  • 20. Distribution of patients by satmya 9221. Distribution of patients by nidana 9422. Distribution of patients by RA-test 9523. Distribution of patients by nature of pain 9624. Distribution of patients by doshanubandha 9725. Distribution of patients by severity 9826. Chief complaints before and after treatment in group A 9927. Associated complaints before and after treatment in group A 10328. Vata vriddhi lakshanas before and after treatment in group A 10429. Kapha vriddhi lakshanas before and after treatment in group A 10530. Pitta kshaya lakshanas before and after treatment in group A 10631. Samavata lakshanas before and after treatment in group A 10632. Rasa Dushti lakshanas before and after treatment in group A 10733. Asthi Dushti lakshanas before and after treatment in group A 10834. Majja Dushti lakshanas before and after treatment in group A 10835. Other Dhatu Dushti lakshanas before and after treatment in group A 10936. Ama lakshanas before and after treatment in group A 10937. Sama mala lakshanas before and after treatment in group A 11038. Statistical analysis of chief complaints in group A 11139. Statistical analysis of different indices in group A 11240. Statistical analysis of GDA and AHA in group A 11341. Statistical analysis of functional parameters in group A 11442. Statistical analysis of objective parameters in group A 11543. Statistical analysis of disease activity score in group A 11644. Chief complaints before and after treatment in group B 11745. Associated complaints before and after treatment in group B 12046. Vata vriddhi lakshanas before and after treatment in group B 12347. Kapha vriddhi lakshanas before and after treatment in group B 12448. Pitta kshaya lakshanas before and after treatment in group B 12549. Samavata lakshanas before and after treatment in group B 12650. Rasa Dushti lakshanas before and after treatment in group B 12751. Asthi Dushti lakshanas before and after treatment in group B 12852. Majja Dushti lakshanas before and after treatment in group B 12853. Other Dhatu Dushti lakshanas before and after treatment in group B 129 9
  • 54. Ama lakshanas before and after treatment in group B 12955. Sama mala lakshanas before and after treatment in group B 13056. Statistical analysis of chief complaints in group B 13157. Statistical analysis of different indices in group B 13258. Statistical analysis of GDA and AHA in group B 13359. Statistical analysis of functional parameters in group B 13460. Statistical analysis of objective parameters in group B 13561. Statistical analysis of disease activity score in group B 13662. Chief complaints before and after treatment in group C 13763. Associated complaints before and after treatment in group C 14164. Vata vriddhi lakshanas before and after treatment in group C 14265. Kapha vriddhi lakshanas before and after treatment in group C 14366. Pitta kshaya lakshanas before and after treatment in group C 14467. Samavata lakshanas before and after treatment in group C 14468. Rasa Dushti lakshanas before and after treatment in group C 14569. Asthi Dushti lakshanas before and after treatment in group C 14670. Majja Dushti lakshanas before and after treatment in group C 14671. Other Dhatu Dushti lakshanas before and after treatment in group C 14772. Ama lakshanas before and after treatment in group C 14773. Sama mala lakshanas before and after treatment in group C 14874. Statistical analysis of chief complaints in group C 14975. Statistical analysis of different indices in group C 15076. Statistical analysis of GDA and AHA in group C 15177. Statistical analysis of functional parameters in group C 15278. Statistical analysis of objective parameters in group C 15379. Statistical analysis of disease activity score in group C 15480. Over all result 15581. Showing the difference of Natural & Gelatin caps in Group-A 17482. Showing the difference of Natural & Gelatin caps in Group-C 17583. Statistical analysis of comparative efficacy among groups 176 10
  • LIST OF GRAPHSGraph no. Title of the graph Page no.01. Distribution of patients by age 8202. Distribution of patients by sex 8303. Distribution of patients by religion 8404. Distribution of patients by occupation 8505. Distribution of patients by socioeconomic status 8606. Distribution of patients by food habits 8707. Distribution of patients by rasa 8808. Distribution of patients by addiction 8909. Distribution of patients by nadi 9010. Distribution of patients by prakriti 9111. Distribution of patients by satmya 9212. Distribution of patients by nidana 9413. Distribution of patients by RA-test 9514. Distribution of patients by nature of pain 9615. Distribution of patients by doshanubandha 9716. Distribution of patients by severity 9817 Improvement of chief complaints in group A 11218. Improvement of different indices in group A 11319. Improvement of GDA and AHA in group A 11420. Improvement of functional parameters in group A 11521. Improvement of objective parameters in group A 11622. Improvement of disease activity score in group A 11723. Improvement of chief complaints in group B 132 11
  • 24. Improvement of different indices in group B 13325. Improvement of GDA and AHA in group B 13426. Improvement of functional parameters in group B 13527. Improvement of objective parameters in group B 13628. Improvement of disease activity score in group B 13729. Improvement of chief complaints in group C 15030. Improvement of different indices in group C 15131. Improvement of GDA and AHA in group C 15232. Improvement of functional parameters in group C 15333. Improvement of objective parameters in group C 15434 Improvement of disease activity score in group C 15435 Overall result 155 List of PhotographsChart number Description Page number 1 Wrist joint swelling 35 2 Ingredients of Alambushadi yoga 52 3 Ingredients of Dhanyamla 61 4 Equipment used in the preparation of Dhanyamla 62 12
  • Chapter-1 Introduction Ayurveda assigns the locomotor and associated motor functions to the fiveKarmendriyaas viz., Vak, Pani, Payu, Pada and Upastha. Vata is the driving force toperform the normal activities of Karmendriyas. Pitta perform its functions throughsubstantive and metabolic power which is the cause of bio chemical energies, and Kaphathrough the nourishing and preserving powers which protect the human organism. A normal daily life with out using Karmendriyas is almost impossible for any humanbeing from the time immemorial to ultra modern civilized life. The most common disorder, which affect the locomotor system in the mostproductive period of life i.e. 30 – 50 years is Amavata. Amavata is a condition in which improperly metabolized intermediate bye -productknown as Ama becomes the core cause of the degenerative process and get deposited byimbalanced Vata at different joints (Sleshmasthanas) Rheumatoid Arthritis (RA), an auto-immune musculo skeletal disorder, explained inmodern medicine has a close resemblance with the clinical entity of Amavata. Amavata vis-a-vis Rheumatoid Arthritis is one of the dreaded diseases that themankind faces today. Even though, Amavata is not proved to be fatal, it cripples theaffected patients. This dreadful disease producing stiffness of body becomes a cause ofmany other diseases also. It can affect many facets of a patient’s life. For example his family, occupational andcommunity relationships. It affect not only the social and economical position of theindividual and his family but it leads to the draining of national resource due to the workhours lost, resulting in diminished production. 13
  • The incidence of Amavata (Rheumatoid Arthritis) is reported to be 1-2 % of generalpopulation with a female to male ratio of 3:1. The crippling nature, repetitive attacks and chronic course of Amavata, forced thescientific world to conduct extensive studies on Amavata. Unfortunately, man has notsucceeded in eradicating this disease and failed to come out with successful therapeuticmeasures that can cure the patient completely. In Ayurveda also many scientific studieswere carried out in different centers. The earliest known example of RA was found in Platicarpus (a large swimmingreptile), which lived about 100 lakhs years back. The oldest skeleton showing the changesof RA was of Ape-man who lived 2 lakhs years ago. The findings in the Egyptianmummies also reveal that the antiquity of RA dates back to the beginning of civilizationitself. No vivid description is available about Amavata either in Charaka, Susrutha,Ashtanga Sangraha and Ashtanga Hrudaya Samhithas. However Charaka made amention about Amavata with reference to the treatment of Vata roga, only to describe thevitiation of Vata Dosha with Ama. For the first time Madhavakara dealt with the productionof the disease Amavata. The Ayurvedic treatises Anjana Nidana and Basavarajiya alsodescribed Amavata; still a diverse clinical manifestation is the characteristics ofBasavarajiya. In recent years an intense study of different conditions primarily involving themusculoskeletal structures (Rheumatology) has been made and it revealed thatinflammatory or degenerative changes occur in disease like RA. Diseases of connectivetissue are responsible for much temporary or permanent disablement. The current trend hypothesizes and establishes the role of various free radicals inthe pathogenesis of the disease RA. 14
  • Despite the awareness of the disease, reasonable explanations for the cause andsource of RA are still obscure in modern science. Hence no rational curative measures areknown. Anti-inflammatory Analgesics and Disease Modifying Anti Rheumatic Drugs(DMARD) are the drugs of choice in contemporary system of medicine. Unfortunately al theanalgesics are liable to give many side effects particularly by repeated and prolonged use.The more effective drugs may associate with more serious and irreversible reactions. Ayurveda, the age old Indian System of Medicine, advocates a reliablemanagement of diseases with due consideration to protect the normal health while treatingthe disease with highly efficacious and easily available drugs based on humoral theory. Ayurvedic approach to the disease Amavata is to re establish the body structure andto balance the vitiated Doshas. Alleviation of Vata Dosha has special importance in themanagement. Langhana, Swedana, Deepana, Rechana, Snehapana and Vasthi are thetherapeutic measures advocated. In recent past years several experimental and clinical studies have been carried outby Ayurvedic scientists at various centers, with an aim to study the disease Amavata and toevolve safer anti arthritic drugs. • In 1956 Gujral and his associates have screened a large number of indigenous drugs. Guduchi, Sunti, Rasna etc., are some of the listed anti arthritic drugs. • In 1962,Zala studied on the topic “A treatise on Amavata”. • In 1966 Sisodia and Lakshmi narayana worked on the drug Guduchi (Tinospora cordifolia) and proved it as an effective anti rheumatic and diuretic. • In 1966 Rai and Gupta proved the anti-inflammatory properties of Guduchi. • In 1970 Shastry worked on “Sinhanada Guggulu and its actions on Amavata”. • In 1971 Patel worked on “Ama vat ka Sameekshatmak Adhyayan”. 15
  • • In 1974 Sharma studied “Amavata Rog par Eranda Ksheerapak ka ek adhyayan’. • In 1978 Pandit worked on “A study of Suddha guggulu on rheumatoid Arthritis • In 1980 Shah worked on Jamnagar ke Amavata Vyadhi ka Nidan Chikitsatmak Sarvekshan”. • In 1980 Warrier Jayadevan worked on “Role of Rasayana and Dhanyamla Pinda Sweda in the manegement of Amavata” • In 1981 Vyas studied “Ama vat the Aam Ka Mahatv evam iski Suddha guggulu se chikitsa ka Adhhyayan”. • In 1983 Shukla studied on the topic “Amavata ka Adhyayan evam Ayurvedeeya Vishishta Chikitsa”. • In 1982 Khare et al studied the ethanolic, aquous and ethereal extracts of Thrivrut mula (Operculina turpethum) and showed anti inflammatory activity against carrageenin induced rat paw oedema, collon pellet induced granuloma and formaline induced arthritis in rats Above-mentioned works were successful to some extent. Pain and swelling werethe main problem in the management of these cases. Later on observing certaindrawback of the earlier studies, a principal approach as per the text has been planned inthe study by Acharya and Singh (1988). In this study Ama Panchana and Shodhanaapproach did provide better results in those patients. However, the management of painand swelling in the acute condition left a room to work in terms of Sulahara and Sothaharamodality to provide relief during the acute phases. After a lot of deliberation and planning it was thought to approach Amavata from twoangles viz., by internal and external application of medicines. In the acute stage of Amavatathe patient is bedridden with unbearable pain and severe restriction of the movements ofthe affected joints. The traditional physicians of Kerala practice Sweda karma with 16
  • Dhanyamla externally known as Dhanyamla Kayaseka effectively in such conditionssuccessfully. Therefore, this Swedana method is selected in this study to evaluate its rolein Amavata in general and in case of pain and swelling in particular. The known fact that Ama Pachana, Agnivardhana, ThriDoshasamana and maintainresistance threshold or immunity power can prevent the disease, led us to look into thepossibility of checking Amavata by internal administration of such a combination of drugs. Alambushadi yoga is a formula mentioned for treatment of Amavata in MadhavaChikitsa and Chakradatta. Alambusha, Thrivrut, Guduchi, Gokshura, Sunti, and Thriphalaare combined in a specific proportion as per the reference. The ingredients of both preparations are easily available and cost effective.Objectives of the study: 1. To evaluate the efficacy of Alambushadi yoga in Amavata. 2. To evaluate the efficacy of Dhanyamla Kayaseka in Amavata. 3. To assess the additive efficacy of Alambushadi yoga and Kayaseka in Amavata. The study was conducted through a prospective clinical trial of 21 days duration and21 days follow up, from 3 groups of total 27 patients. The assessment was in terms ofclinical signs and symptoms, lab investigations, Disease Activity Score and Improvementcriteria as per the recent International parameters viz., ACR Criteria (American college ofRheumatology Criteria) and EULAR Criteria (European League Against RheumatismCriteria). Analysis of diversity in symptomatology laid down by different Ayurvedic treatises,their response to the treatment and Ayurvedic Health Assessment (AHA) were also carriedout in this study. The fact that the work has been done after meticulous sifting of the loop –holes andinadvertent errors that have slipped in to the previous works, justifies this endure to providepossible answers to many of those unanswered queries regarding the disease Amavata. 17
  • Followed modalities at the studies are very encouraging and we consider our selvesfortunate to have contributed in justifying the dicta of Acharyas, who by the sheer strengthof wisdom and observation have left behind a rich legacy of positive health care. The study propels us to advocate further works to be done in the field with largersamples and inclusion of such other amenities, which might have been dispensed withowing to various reasons, in the present study. It is hoped that the present study will opennew vistas and provide the platform for further investigative drives in the same field. 18
  • Chapter-2 Literary review This chapter deals with historical aspects, Nidana, Purva rupa, Rupa, Samprapti,Upadrava and Pathyapathya of Amavata from different classics under two headings. 1.Historical review 2. Disease reviewHISTORICAL REVIEW The Vedas, the prime documented source of knowledge in India including that ofmedicines, give no reference regarding the disease Amavata. Among Brihatrayees,Charaka Samhita gives good description about the etiology, clinical manifestation andtreatment of Ama, but there is no direct reference regarding Amavata as a disease. Ofcourse indirect references are available in Charaka Samhita Chikitsa Sthana in twocontexts. The therapy to indication of the Kamsa Haritakai in Svayadhu Chikitsa1 andVatsakadi Phanda in Pandu chikitsa2 include Amavata also. But later in the Chikitsa in the28th Chapter its seems that the word Amavata is used to connote Avarana of Vata3 by Amaand not Amavata as a disease entity. Even though no reference of Amavata is found in Susruta, the classification andelaborate description about the anatomy of the joints gives way for better understanding ofthe joint diseases in general. Similarly, Vaghbata also gives no details about this disease entity but whilementioning the indication of Vatsakadi Yoga and Vyoshadi Yoga in Vata Vyadhi Chikitsahas included Amavata also4. 19
  • In Bhela Samhita and Kashyapa Samhita also a distinct description of this diseaseis absent. It is to be noted that the 10th Chapter of Sutra Sthana of Bhela Samhita dealswith Amapradosha in detail. Later on it was Harita who devoted a complete chapter in Harita Samhita anddiscussed the etiology, clinical manifestation, prognosis, treatment aspects and dietetics atlarge5. He has also classified the disease Amavata into four types. Such classifications notfound in any other text. However the period of this Harita Samihitha is doubtful. Anjana Nidana written by Acharya Agnivesha deals with the Nidana and Lakshanaaspects in short. As mentioned earlier, it was Madhavakara who gave this disease entity a separatestatus and devoted a full chapter6. There after, Chakradatta added treatment aspects atlength and mentioned the line of treatment and effective drug remedies7. Likewise, BhavaPrakasha8, Yoga Ratnakara 9 , Bhaishajya Ratnavali10 and Vangasena11 also mentionedsome drug compounds for the treatment of Amavata. In the modern period Maha Mahopadhyaya Gananath Sen conducted someextensive studies on joint diseases attempts were also made to compare Amavata withsome joint disorders mentioned by modern medical science12. He has coined the term Rasavata for Amavata. Later on Prof. Y.N.Upadhyaya (1953) and others considered Amavatawith Rheumatoid Arthritis. 20
  • DISEASE REVIEW The disease nomenclatures as Amavata comprise of two meaningful terms Amaand Vata, which form the pathogenic basis of the disease.Etymology of Amavata: 1. The words Ama and Vata unite to form the word Amavata. This suggests the predominance of these two factors in the pathogenesis of Amavata13. 2. Vata in association with Ama is termed as Amavata. The virulent Ama circulates in whole the body propelled by the vitiated Vata. So the propulsion of Ama by Vata is illustrated with this derivation14. 3. Ama is produced due to indigestion and along with Vata it is a well-known disease entity15. 4. The improperly formed Anna Rasa is Ama and it causes vitiation of Vata, which is known as Amavata16. So, from all the above derivations it is clear that the nomenclature of the disease isbased on the main pathogenesis of the disease which it self clarifies the importance ofthese two factors.Definition: Simultaneously, vitiated Ama and Vata when lodge in the Trika and Sandhi leadingto Stabdhata of the body parts then this condition is known as Amavata. Madhukoshacomments on the word "Yugapat" and explains it as simultaneously Vata and Kapha17 whileAtanka Darpana states it as Ama and Vata, as both are held responsible for thepathogenesis of Amavata18. The following opinions are available for the term Trika. (1) Katimanyamsa Sandhi (Shoulder Gridle) 19 (2) Sroni Kanda Bhaga (Hip joint) 20 (3) Bahu Grivasthi Traya Sanghata (Scapular region) 21 21
  • (4) Pristha vamsaDhara (Ilio Sacral and Lumbo sacral region) 22 Trika means, where three bones unite to form a Sandhi or a joint or a union ofanatomical structures.Rheumatoid Arthritis: Rheumatism derives from rheumatismos (Greek) designatingmuscus as an evil humor which flows from brain to the joints and other portions of the bodyproducing pain23. The Rheumatoid arthritis is a chronic inflammatory joint disease. It is a symmetrical,destructive and deforming polyarthritis, in which small and large joints are affected alongwith associated systemic disturbances and a variety of extra articular features. There maypresence of circulating antiglobulin antibodies in the blood i.e. Rheumatoid factor.Rheumatoid arthritis is a non-suppurative proliferative synovitis that often progresses todestruction of articular cartilage and ankylosis of joint24,25,26. In Anjana Nidana, the vitiation of Ama and Vata are stated to take place due to theirown respective causes. Hence it is necessary to consider these terms separately.AMA IN AMAVATA The production of Ama is a central phenomenon in Amavata. In Ayurveda, verymuch importance is given to the concept of Ama, as the disease itself is also known asAmaya i.e. caused by Ama. The presence or absence of Ama i.e. Samavastha orNiramavastha decides the line of treatment of the disease.Etymology of Ama: • Ama means the undigested or unprocessed matter27. • Ama means that is subject of digestion28. • Ama means that is detrimental to groups of srotas29.Definitionof Ama: The term in ordinary parlance means unripe, uncooked, immature and undigestedparticles. In the context of Ayurveda this term refers to the events that follows and factors, 22
  • which arrives as the consequence of impaired functioning of Agni. It is necessary to analyzedifferent definitions of Ama given in different texts. Some of which are as follows: (1) Due to the hypo functioning of Ushma the food which is not completely/ properly digested, yields immature Rasa in Amashaya and due to retention it undergo fermentation and/ or putrefaction. This state of Rasa is spoken of as Ama30. (2) The Adya Ahara Dhatu is known as Ama, which is undigested and formed due to hypo functioning of Agni, in Ama shaya31. (3) The matter that has not undergone Vipaka, leads to Durgandha (bad smell), which is large in quantity, which is Picchila (Sticky) and which leads to Gatra sadana is called as Ama32. (4) The food residue that is not digested due to impairment of Agni is known as Ama and it is considered as the root cause of all the diseases33. (5) According to some, Apakva Anna Rasa is Ama, while some consider accumulation of Mala as Ama and while others opine that the first stage of vitiation of Dosha as Ama34. Even though both Charaka and Susruta have described the diseases associatedwith Ama, Vagbhata was the earliest author to define Ama35. Three words from thedefinition of Ama as given by Vaghbhada require further explanations. 1. Ushma 2. Adya Dhatu 3. Amashaya Ushma: - There are different opinions about Ushma. According to ArunaduttaUshma is Agni36. Hemadri consider it as Rasagni37. Only Sreedasapanditha explainedUshma as Jatharagni38. Here Dalhana’s statement that Ama is also produced due to hypofunctioning of the Dhatwagni should also be considered39. Therefore Ushma indicate eitherJatharagni or Dhatwagni in respect of the genesis of Ama, depending on the pathologicalprocesses exhibited. 23
  • Adya Dhatu: - The fuel of Agni, in the development or genesis of Ama is stated as.Adya Dhatu. Arunadatta consider it as Rasa Dhatu40, and Hemadri consider it as Rasawhich is not capable of executing its functions and also not capable of transforming intoRakta41. Chandranandana and Sreedasapanditha consider it as AharaRasa42. The identityof Adya Dhatu depends on the Agni. i.e. Agni not only feeble but also not capable ofconducting its normal functions. Therefore the Adya Dhatu may be Ahara Rasa, RasaDhatu or any other Dhatu. Amashaya:- The word Amashaya has two meanings. Hemadri define Amashaya asa receptacle of undigested or incompletely digested food43. It is also the place where Amais produced. Amashaya is one of the two places of Pithadhara Kala44. The Samana Vatasecretes Pachaka Pitta from Pithadhara Kala for the purpose of digestion of food due to thestimulation.Etiology Of Ama: Following are the chief causative factors of Ama mentioned by Charaka45,46. (1) Ahara: Abhojana (not taking meals), Atibhojana (taking meals in excess quantity), Ajirnabhojana (eating prior to digestion of previous meals), Vishmasana (taking sometimes in excess and sometimes in less quantity of food), Asatmya bhojana, Viruddha bhojana, Dvishta - Asuchi bhojana, Guru, Ruksha, Sheeta, Sushka, Vishtambhi and Vidahi bhojana. (2) Iatrogenic Causes: Erroneous administration of Virechana, VAmana, Sneha Karma. (3) Vihara: Vegavidharana, Prajagarana, Dukkha Sayya. (4) Manasika: Food consumption while afflicted with mental instability due to KAma, Krodha, Lobha, Moha, Irshya, Soka, Mana, Udvega, Bhaya etc. (5) Miscellaneous: Adverse Desa, Kala, Ritu (Vaishmya) and Vyadhikarsana (emaciation due to disease). 24
  • Samprapti Of Ama: The Samprapti of Ama can be described in following manner, in connection tomalfunctioning of Agni and regardless of Agni.(I) Related to Agni:- Whatever kind of food, is consumed has to be acted upon first by Jatharagni andthen only it is rendered useful to the body47.(a) Jatharagni:- It is the chief controller of all the other types of Agni in the body andthey depend on Jatharagni for their augmentation or hypo functioning48. It digests the foodand separates the Rasa and Kitta parts and also aids moieties to the rest of Agni49. Most ofthe definitions of Ama are directed to the hypo functioning of Jatharagni, as it is not properlydigesting the Ahara, which leads to the production of Ama Rasa.(b) Bhutagni:- After completion of Sanghata Bheda (breaking down of foodparticles) by Jatharagni, the five Bhutagni digest the particles of their own respectiveclasses50. This action of Bhutagni further continues after the digestion of Rasa as well as atthe level of Dhatu due to presence of five Bhuta in Dhatu also.(c) Dhatwagni:- At the Dhatu level, there are seven types of Dhatwagni51. Afterdigestion by Jatharagni, the Rasa is subjected to two types of digestion by their respectiveDhatwagni to form Kitta and Prasada parts. So, when the Jatharagni unable to digest the food properly then it is attempted to beprocessed by Bhutagni and Dhatwagni. If they also fail, then Ama is formed at the level ofDhatu. Dhatwagnimandya and Bhutagnimandya can also occur irrespective of Jatharagnimandya. Following are some of the citations regarding hypo functions of Dhatwagni andBhutagni. 1. Medoroga is produced due to the inability of Dhatwagni to digest properly, and then it is called as Ama52. 25
  • 2. Due to hypo functioning of Dhatwagni and Bhutagni, Ama is formed which leads to diseases like Sosha, Vrana, Vidradhi etc. The part of Dhatu at which Agni is degraded, formation of Ama takes place which leads to manifestation of Pidaka etc. in that part53 3. Dhatukshaya or Dosha Prabhava causes Apachaya of Dhatushma54. Thus, Dhatwagnimandya and Bhutagnimandya also lead to formation ofAma and they may or may not be associated with Jatharagnimandya.II) Malasancayajanya Ama Accumulation of Mala in the body is termed as Ama55. Purisha, Mutra and Swedaare the Sthula Mala. Kapha, Pitta, excretory products in the apertures Sweat, nails, Roma,Sneha of Akshi, Twak and Purisha are the Mala of Dhatus respectively56. The materials, which stuck in Srotas and are apt for elimination, the ParipakvaDhatu (metabolites or pus), vitiated Doshas and the harmful factors of body are known asMala57. The excess accumulation of blood urea, uric acid, cholesterol etc. that are metabolicwaste products of the body due to improper metabolism lead to various disorders. Thesebeing in excess exert adverse effect on digestion and metabolism and may be acclaimed asAma.(III) Prathama Dosha Dushti: The first phase of vitiation of Dosha is Ama. Commenting on the treatment of AmajaSotha, Chakrapani has mentioned that the Dosha, most of the times, are unprocessedduring the first phase of vitiation58. This Prathama Dosha Dushti Avastha isSanchayavastha where the Dosha gets accumulated at their definitive places59,60. Vruddha(elevated) Dosha that are in excess than their normal state, fill their normal Srotasescompletely and then enter into Kosta. This forms the stage of Prakopa. The vitiated Doshavitiate the Dhatu and then in turn Mala is vitiated61. 26
  • (IV) Dosha Murchajanya Ama: Some are of the opinion that highly vitiated Dosha interacts to produce Ama i.e. astoxic substances are produced from Kodrava62.(V) Ama visha: The Ama Dosha formed by unwholesome food habits like Viruddhasana,Adhyasana, Ajirnasana etc. are known as Ama visha. It is very difficult to treat due to itsAsukriya (prompt action) and opposite natures of treatment of Ama and Visha63.Physical properties of Ama: 113 In physical properties Ama closely aligned to Kapha Dosha.Drava, Guru, Snigdha,Picchila, Thantumat, Anekavarna, Durgandha, Avipakwa, and Asamyukta are the physicalproperties of Ama. These may be applied to the Ama developed both in gastro intestinaltract and Dhatus. According to Charaka, Ama has Visha sadrusa linga, but there is nosimilarity in Guna. Still Ama act like poison. It may also be noticed that the physiochemical properties of Ama resemble those of Pritvi and Ap Bhutas. Ama has a tendencyfor accumulation and blockage of micro channels ie. Srotorodha.Ama in Biochemical version: A study in 1998 by R.H Singh and D.Ramesh babu about the nature of Amabased on the characteristics described in Ayurvedic texts and modern biochemical &immunological parameters showed that the accumulation of Ama corresponds with theincreased antigenicity in the body64. Sometimes they act as visha or antigens, ensue a series of reactions leading to theformation of autoantibodies against body’s own normal tissue. It usually happens in hypofunctioning of Dhatwagni and also Pachakamsas. By this issue metabolism get hamperedleading to the prolonged accumulation of a variety of unwanted and incompatible productsin the system. It could cause different types of systemic disorders including autoimmunedisorders and metabolic disorders like Amavata. 27
  • According to modern physiology, a variety of transforming and trans mutatingsubstances are present in the body like enzymes, catalysts, cathepsins, lysins etc. Whenthey are unable to function properly, entirely different metabolites are formed which thebody is not acquainted to process65. These improperly metabolized intermediate byproducts may be termed as ‘Ama’. They accumulate in the body in different systemsaffecting the normal mechanisms of that particular system. Both Ama & free radical produce diseases and are generated in the process ofmetabolism. Free radicals produced during intracellular chemical transformation may beidentified as Ama, although the understandings of both concepts are different.Concept of Free radicals: Gomverg developed free radical theory in the biochemistry before 100 years. Henarrated that the free radical species may involve in the living system. But the credit goesto Slater (1966) who established attractive feature of cytotoxicity mechanism generated bythe process of metabolism. Now free radical is accepted as common and important biochemical intermediates implicated in very large number of diseases like inflammation,cancer, arterio sclerosis, shock, myocardial perfusion, injury, liver & kidney diseases,diabetes, muscle damage, aging etc66,67. Chemically the body’s free radicals are mostly unstable variations of oxygen atomthat vary from their stable parent by having an extra electric charge in the outer electronshell. These apparently minor changes makes free radicals want to bind instantly withnearby molecules in order to offset the extra change and become stable. Thus a freeradical is really a temporary stopping-point leading from one stable molecule to another.The normal life span of unstable particle can be measured in thousands of a second;millions of these fleeting molecules are emitted in every cell as it processes life-givingoxygen through the metabolism of food. 28
  • Most important free radicals in the biological system are radical derived oxygen likesuper oxide, hydrogen peroxide and hydroxyl radical. Super oxide and hydrogen peroxideare although free radical and oxidizing agents, but not reacting in nature. The hydroxylradical is an extremely reactive oxidizing radical that reacts with bio-molecules. All of themajor classes of bio molecules may be attracted by the free radicals but lipids are probablymost susceptible. Cell membrane is rich source of Polyunsaturated Fatty Acids (PUFAs),which are attracted by oxidative radical. This destruction of PUFAs is known as lipidperoxidation, which proceeds to self-perpetuating chain reaction. Aldehydes are alwaysformed in lipid break down. Therefore chain reaction directly damage cell membrane andindirectly damage other components by the production of aldehydes. Proteins and nucleicacids appeared less susceptible than PUFA to free radical attack. Free radicals are so pernicious because of their indiscriminate binding with manyvital molecules in the body, including DNA. They cause cross-linking of collagen moleculethere by a mistake in the molecule structure of collagen. Cross linkage is only one exampleof the damage free radicals can inflict. They can also split up nearby molecules, break offpieces of molecules, garble information in various parts of cells, clog all membranes,promote cancerous mutations and impair the functioning of mitochondria. Some cholesterolresearchers believe that free radicals are responsible for the harm that cholesterol does toour bodies. All of the major classes of bio molecules may be attracted by free radicals but lipidsare probably most susceptible. Cell membranes are rich source of Poly unsaturated fattyacids (PUFA), which are attracted by oxidative radical. This distruction of PUFA is known aslipid peroxidation, which proceeds to self perpetuating chain reaction. Aldehydes are alwaysformed in lipid brake down. Therefore chain reaction directly damage cell membrane andindirectly damage other components by the production of aldehydes. Proteins and neucleicacids appeared less susceptible than PUFA to free radical attack. 29
  • Even though the FR is destructive in nature in some instances, they are extremelygood to have white cells in the immune system use. Free radicals to bond with invadingbacteria and viruses and kill these invaders68.Anti oxidants69: To protect it self from damage, every cell produces enzymes to degrade, neutralizeand detoxify free radicals. These “ free radical scavengers” include various antioxidants(such as Super oxide dismutase and catalase) that can bind to highly reactive oxygen ionsand render them harmless before they attack a vulnerable molecule. Free radicals and Antioxidants are produced in cells at a time. In normal healthyperson both are kept in balance and used as they need to be by the bythe surpelativeintelligence of DNA. When there is an imbalance in the driving force or intelligence at thecellular level free radicals over whelm the anti oxidants and there by tissue damage results.So the damage caused by free radical is secondary, not causal. In many physical influences body become overwhelmed by Free radicals: Subjectedto environmental pollutants, smoking over exposure to sunlight, vitamin deficiency,malnutrition, dehydration, genetic predisposition to name but a few.Symptoms produced due to Ama70: Ø Srotorodha (Obstruction in Channels) Ø Balabramsa (Lowering of immunity or debility) Ø Gaurava (feeling of heaviness) Ø Anila Mudhata (Hindrance to normal path of Vata) Ø Alasya (Unwillingness to perform of duties in spite of capability) Ø Apakti (Indigestion) Ø Nisthivana (Accumulation of excessive Saliva in mouth) 30
  • Ø Mala Sanga (Constipation) Ø Aruchi (non perception of taste) Ø Klama (Anayasa Srama) Ø Vit, Mutra, Nakha, Dhatu, Chakshu Pitata / Raktata / Krishnata Ø Prushtasthi, Kati Sandhi Ruk (Pain in lumber region and joints) Ø Siroruk (Headache) Ø Nidra (Sleep) Ø Mukhavairasya (Distaste in mouth) Ø Gatra Syavathu (Oedema) Ø Jvara (fever) Ø Atisara (loose motions) Ø Romaharsa (Horripilation)Most of the symptoms are produced either by the hypo functioning of Agni or due to theobstruction of the Srotas by Ama. When Ama is in contact with Dosha and Dushya they arecalled as Sama Dosha and Sama Dushya respectively. The symptoms of Sama Dosha andSama Dushya are as follows.Sama Dosha: - In Ayurvedic texts symptoms of Samavastha and Niramavastha of theDoshas, Dushyas and Malas are described as a guide line only. Infact the sphere of suchsymptomalogy is very wide71.Sama Vata: -72 Constipation, Impaired appetite, stiffness of body parts, drowsiness, gurgling sounds(Antra kujana) gradual or when severely vitiated sudden manifestation of pain, oedema,pinprick sensation and restricted movements of body parts are Sama Vata lakshanas. 31
  • These symptoms are aggravated by oleation, during the morning hours, at night and duringthe cloudy climate. Some of the above symptoms that are found in case of Amavata also may be due tothe involvement of Ama and Vata in both the cases.Sama Pitta: -73 Durgandha swasa, Durgandha udgara, Haritha syava shteevana, Ghanashteevana, Amlodgara, Kanta daha and Hrid daha are Sama Pitta lakshanas.Sama Kapha: -74 Avila, Thantumat, Sandra, Kantopaliptam, Durgandha shteevana, Kshut vighata,and Udgara vighata are Sama Kapha lakshanas.Sama Dhatu: -75 In the event of Ama being produced in Dhatu due to Dhatwagnimandya, such Dhatuis known as Sama Dhatu. The symptoms of Sama dhatus are not described in Ayurvedictexts because, these are not specific and cannot be observed independently. Anyhow,Dhatu Dushti lakshanas may be considered in this context. Sama Rasa produces Agni mandya, Aruchi, Angamarda, Hrillasa, Tandra,Akalavalipalita, Jvara, Pandu and Klaibya76. Sama Rakta produces Asyapaka, Medrapaka, Gudapaka, Twak vikara, Yakrit rogaand Pleeha roga77. Sama mamsa produces Galaroga, Jihwa roga, Mamsa vikara, Kielam, Arshas andOshtaprakopa78. Sama medas produces Medograndhi, Athisweda, Padapani daha, Sthoulyam,Danthadi Malam and Chikkana deha79. Sama asthi produces Asthi sula, Asti bheda and Kesadivikaras80. Sama majja produces Parshwa ruk, Nethrabhishyandam and Bhrama81. 32
  • Sama sukra produces Aharshana, Sukrameha, Klaibya, Apraja, and Garbha nasaand Virupa praja82.Sama Mala: -83 Ama in contact with Mutra and Purisha are known as Sama Mala. Sama mutraproduces Mutra roga and Meha. Susruta has explained the ymptoms of Sama Mala as -Apsu avasidana, Durgandha, Ghana, Picchila, Vicchina and causes Sadana, Vishtambha,Shiroruk and Prishtakateegraha.Principles and line of treatment of Ama: 84 (1) Elimination of Ama from Urdhva or Adhomarga with the use of hot salt water or Phalavarti (2) Swedana (fomentation) (3) Langhana - Upavasa (fasting) (4) Dipana and Pachana drugs. When symptoms of Jirnahara appear oral medication should be done for Pachana ofDosha adhered to Amashaya and for augmentation of Agni. (5) AsthApana and Anuvasana Basti and Snehapana are advocated when Ama iscompletely nullified ie.digested.VATA IN AMAVATA Vata plays an important role in the Samprapti of Amavata so its brief description isnecessary.Etiology: The term Vata is derived from root Va and Pratyaya (Suffix) Tan. Va signifiesGati and Gandhana Karma of Vayu85.Guna: Ruksha, Seeta, Laghu, Sukshma, Chala, Visada, Parusha and Khara are the Gunasof Vata86.Functions of normal Vata (Karma): 87 33
  • Ø Upholder of structure and function of the body (TantrayantraDhara) Ø Impeller of upward and downward movements (Cheshtapravartaka) Ø Controller and conductor of mind (Mano Niyanta and Praneta) Ø Inspires all senses (Sarvendriya Uddyojaka) Ø Conveyer of all senses stimuli (Sarvendriya Artha Abhivodha) Ø Marshaller of body elements (Sarva Sarira Dhatu Vyuhakara) Ø Synthesizing principle in the body (Sarira Sandhanakara) Ø Impeller of speech (Vak Pravartaka) Ø Cause of feeling and audition (Sabda Sparsa Prakrti) Ø Source of auditory and tactile senses (Srotra Sparsana Mula) Ø Origin of all excitement and animation (Harsha Utsahayoni) Ø Stimulator of Agni (Agni Samirana) Ø Desiccator of morbid humors (Dosha Samsoshana) Ø Eliminator of excrement and deobstruents of the gross and subtle body channels (Mala Ksepta) Ø Modeler of fetal form (Garbhakrti Karta) Ø Sustaining Principle of life (Ayusha Anuvrtti)Importance: Pitta, Kapha, Dhatu and Mala are functionless, unless they are brought to the properplace by Vata to carry out their functions. Thus Vata governs functions of all the tissues ofthe body88. A person whose Vata Dosha is not impended, which is at its own place, not vitiatednor reduced, that person lives for hundred years without ailment89. 34
  • Vata gets vitiated due to Dhatukshaya or occlusion in the channels i.e.Margavarodha. Vata, Pitta and Kapha circulate ubiquitously through all the channels of thebody90. Vata on account of its quality of subtleness is really the impeller of the other twohumors. When Vata is provoked, it agitates the other two-humors and causes occlusion ofthe body channels thereby producing disorders. It also leads to the diminution of the bodynutrient fluid and other body elements91.Etiological factors of vitiation of Vata: 92 Ahara: Ruksha, Seeta, Alpa, Laghu, Abhojana. Vihara: Vyavaya, Atiprajagarana (keeping awake at night for long time), VishamaUpachara (Improper nourishment), Dosha-Rakta Atistravana, Langhana (Fasting), Plavana(Swimming), Atyadhva (Walking large distances), Vyayama (Exercise), Ativicheshta(improper body movements in excess), Dukkha Sayyasana (Uneven bedding), Divaswapna(Day time sleep) Vegavidharana, Abhighata (Trauma), Marmaghata, Patana (falling downfrom vehicles). Manasika: Chinta, Soka, Krodha, Bhaya. Miscellaneous: Dhatukshaya, Rogatikarsana (emaciation due to disease).Symptoms of Vata prakopa: 93 1. Parva Samkocha (Flexion), 2. Stambha (restriction of movements) 3. Asthiparva Bheda (Pain), 4. Lomaharsa, Pralapa, Hasta-Pristha-Siro-Graha (Stiffness), 5. Khanjata-Pangulya (Crippling), 6. Kubjata (Lordosis, Scoliosis), 7. Sosha (Wasting), 8. Anidra (insomnia) 35
  • 9. Garbha-Sukra-Rajonasa (genital disorders), 10. Spandana (Tremors), 11. Gatra Suptata (Impairment of Sensation), 12. Sira-nasa-Akshi-Jatru-Grivahanunam-Bheda-Toda-Arti (Different types of pain) 13. Akshepa (convulsion or spasm), 14. Moha (Delusions), 15. Ayasa (Fatigue).Chikitsa of Vata: 94 • Snehanam, • Seka, • Swedanam, • Snigdha-Ushna Basti, • Mridu Samsothanam, • Anuvasana by Medura-MamSara • Abhyangam, sa and Taila, • Mardanam, • Dipana -Pachana drugs, • Veshtanam, • Sneha Svadu Lavana - Amla Usna • Trasanam, Bhojana, • Paishtika or Gaudika Madya. The Vata plays a predominant part in the Samprapti of Amavata. By virtue of vitiatedVata deleterious effects of virulent Ama get manifested in the body.Nidana for Amavata95Madhavakara has mentioned the specific etiological factors for Amavata. 1. Viruddha Ahara (Incompatible food) 2. Viruddha Cheshta (Incompatible work) 3. Mandagni (Hypo functioning of Agni) 4. Nischala (Lack of exercise) 36
  • 5. Snigdha Ahara followed by immediate exercise1.Virudha Ahara (Incompatible food) Acharya Charaka clearly mentions that wholesome diet is an essential factor for theformations of body and any unwholesome diet is responsible for disease. Wholesome dietis required to meet the needs of body’s basal metabolism in the form of energy. ViruddhaAhara (Incompatible food) produces Dosha utklesa instead of meeting the basic needs.Utklishta Dosha is abnormal functional states. If they are not eliminated from body thefunctions of Agni and Dhatus will be affected96. Affliction of Agni may seriously affect their normal functions. When the processes ofdigestion and metabolism are affected, improperly metabolized intermediate bye products(Ama) are produced in body. The Ama in turn may cause Dhatwagnimandya97. Viruddha is Dhatu prathyanika i.e. Dhatu virodhaka (Antagonistic to Dhatus). Itleads to Dhatukshaya due to inadequate nourishment of Dhatu98. Acharya Charaka has mentioned 18 types of Viruddha Ahara99. The following itemsare mentioned in different classics as Viruddha Ahara. 1. Milk immediately after fruits or vice versa 2. Sour substance along with milk. 3. Milk with salt, horse gram, green gram and cow grams. 4. Rhizomes black gram 5. Wheat preparations in gingelly oil. 6. Hot drinks after alcohol, curd, or honey 7. Cold and hot substances together 8. Raw and boiled substances 9. Banana with curd and butter milk 10. Pain fruit, curry of kakamachi with long pepper, black pepper, honey, jaggery. 37
  • 11. Upodaka prepared with gingelly seeds. 12. Chicken with curd 13. Ghee kept in bronze vessel for 10 days 14. Raddish with jaggery 15. Fish with Jaggery or Sugar 16. Gingelly seeds with Kanjika. 2. Viruddha Cheshta: (Incompatible work) Viruddha Cheshta is not clearly mentioned in texts, still considering the main themeof Dosha utklesa due to Viruddha, following may be considered as Viruddha Cheshta. 1. Seetoshna vyathyasa (Alternate use of heat & cold) 2. Vegavidharana (Suppression of natural urges) 3. Diva swapna (Sleeping day time) 4. Ratri jagarana (Waking at night) 5. Sahasa etc. (Over indulgence in work)3. Mandagni (Hypo functioning of Agni) Mandagni is the root cause of all diseases100. Mandagni i.e. Diminished digestionand metabolism always affect Pachana or digestion and metabolism, which are thecontinuous processes in the body. Ama is the immediate resultant of Mandagni.4. Nischala (Lack of exercise) Lack of exercise leads to Kapha Dosha vrudhi, leading to Agnimandya. Accordingto Dr.C.Dvarakanath many of the functions of Kapha are among those, which modernphysiology includes under the activities of skeletal and anabolic system101.5. Snigdha Ahara followed by immediate exercise. TriDoshas are not constant but kept on fluctuating according to age, day, night andafter ingestion of food. Chakrapani interprets that the three basic elements increase duringAvastha paka and are produced during Nishta paka102. 38
  • Due to Snigdha Ahara, Kapha Udeerana takes place in large quantity duringPrathama Avastha paka103. Exercise is held responsible for throwing the Dosha fromKoshta to Sakha104. Immediate exercise after taking food leads to improper digestion andthus Apakwa Ahara Rasa is formed. Harita Samhita has mentioned eating of kanda, mula and Sakha as one of theNidana for Amavata. In view of Anjana Nidana, Ama and Vata get vitiated due to their own respectivecauses to produce the disease. Hence individual etiological factors of Ama and Vata mayalso be considered as etiological factors of Amavata.Etiology of Rheumatoid Arthritis: 105,106,107,108,109,110. According to modern medicine, the cause of RA is still obscure .So far two viewsregarding its origin have been postulated i.e.1. Infective theory - A mild fever of infection in the joint could be the causative factor for this disease. Some others, saying that the joint becomes previously sensitized, have modified this theory.2. Non-infective theory - Congenital predisposition, gastro-intestinal disturbances and endocrine imbalance have been postulated as the causative agents for this condition. It has been suggested that the sensitization to self-antigens could be aconsequence of enzymatic or free radical damage to proteins such as IgG or type-IIcollagen, the development of ant idio type antibodies or defect in glycosation of IgG. Over work and psychological stress cause first attack as well as relapses.Samprapti of Amavata : 111. In a state of pre-existing Mandagni if a person is exposed to etiological factors, thenAma is formed in Amashaya along with vitiation of Vata Dosha. This morbid Ama circulatesin the body propelled by vitiated Vata with the predilection for Sleshma sthana. Here, by the 39
  • action of Vata Dosha, Ama becomes more virulent and reaches Dhamani. In the Dhamanisit blends with Vata, Pitta, Kapha and consequently attains various colours, becomes heavyand viscous. These qualitites facilitates Srotoabhishyanda and Srotoavorodha. Thesechange in the Srotas, endures Sthanasamshraya, leading to the manifestation of symptomslike Hrit gourava, Hritdourbalya and in the Sandhi, Sotha, Sula, etc. If Kapha and Pitta arealso involved with above symptoms, speific symptoms of these Dosha will also manifest. The disease takes its root in Annavaha Srotas with the production of Ama. TheStrength of all the Agni in the body is ddeclined with result of production of Ama112.Rasavaha Srotas are the nearest and opened. Hence, these are mainly afflicted. ThoughAma circulates in the whole body, the chief presentation of the disease is in the Kaphasthanas, due to similarity of Guna of Ama and Kapha. Trika is the main sthana of thecontroller Avalambaka Kapha. Also due to specific Nidana sevana and Picchilatwa ofSleshaka kapha in Sandhis it is the main site of Pathogenesis. Other parts of locomotorsysytem like muscles, tendons, ligaments are also affected and Gatra graha or Gatrasthabdhata appears. Sushruta explains a similar description as the part of body in which Ama prevalesthat part is affected with the clinical features of Ama and the resultant symptoms areaccording to that particular Dosha involved. According to the commentator Dalhana, theabove explanation is given to emphasis the treatment of Amapeedita desha114.Samprapti of Amavata according to Shadkriya Kala:Sanchaya and Prakopa: Accumulation (Samhati) of Dosha is Chaya; and Vilayana isPrakopa115. In these stages Jatharagni mandya, Ama formation, vitiation of Tridosha,Stabdhapurna Kostata, Anga gaurava, Dhatukshaya and Dhatwagni mandya takes place.Prasara: Virulent Ama circulates in the whole body due to Chala and Seeta Guna ofvitiated Vata. There is appearance of Atopa, Angasada, Aruchi, Avipaka, Daurbalya, andAngamarda etc. 40
  • Sthana Samsraya: The vitiated Ama and Vata lodge in the site of pathogenesis i.e. Trikaand Sandhi. In this stage the Purva Rupa are presented like Stabdhata, Sandhi Ruja, Jvara,and Agni mandya, Hrid-gaurava, Daurbalya etc.Vyakti: The clinical features of Amavata like Sotha, Ruja, Graha and Gaurava in Sandhiare the symptoms of its complete manifestation.Bheda: Bhedavastha suggests the chroncity of the disease Amavata. The Udarka of thedisease like Samkocha, Khanjata, Pangulya etc occur in the body.Table no-1: Samprapti ghataka: 1 Dosha Tridoshaja mainly Vata (Vyana, Samana, Apana) and Kapha (Kledaka, Bodhaka, lesaka) 2 Dhatu Rasa, Mamsa, Asthi, Majja 3 Upadhatu Snayu, Kandara 4 Srotases Annavaha, Rasavaha, Asthivaha, Majjavaha 5 Srotodusti Sanga, Vimargagamana 6 Udhbhavasthana Amashaya - production of Ama Pakvasaya- Mula Sthana of Vata 7 Adhisthana Whole body 8 Vyaktisthana Sandhi (Whole body) 9 Avayava Sandhi 10 Vyadhisvabhava Mainly Chirakari 11 Sanchara Sthana Hridaya, Dhamani, Rasayani 12 Roga marga Madhyama roga marga 13 Agni Jatharagni mandya, Dhatwagni mandyaPathogenesis of RA: 116,117,118,119,120. Following factors are involved in the causation of RA (1) Genetic susceptibility (2) A primary exogenous antigen (3) An auto-immune reaction within synovial membrane (4) Mediator of joint damage. 41
  • Autoimmune reaction within synovial membrane: Unknown provoking stimulus Inflammatory synovitis T cells and memory cells appearance in the joint Activation of endothelial cells of Synovial capillaries ICAM - 1 Further attachment and transmigration of other inflammatory cells like neutrophils, macrophages Activation of monocytes, macrophages Release of cytokines and chemokines IL-1, TNF-α, IFN-γ Activation of B cells with antibody production Immune complexes in the sera, synovial fluid and synovial membrane. Mediators of the joint damage: Inflammatory synovium Sensitized T cells, activated β cells, macrophages, neutrophils, synoviocytes IL-1, IL-2, IL-3, IL-4, IL-6, IFNγ, GM-CSF, TGFβ, TNF-α, TNF-β Proteases, elastases, various free radicals (O20-, OHo, Hocl etc.) Destruction of articular cartilage, bone pannus formation The activity of these cytokines and chemokines also appears to account forsystemic manifestations of RA. 42
  • Pathology: 121,122,123,124,125. Most severe alterations are manifested in the joints.(1) Initially synovium becomes ooedematous, thickened and hyper plastic.(2) A dense peri-vascular inflammatory infiltrate composed of lymphoid follicles, plasma cells and macrophages fills the synovial trauma.(3) Vascularity is increased.(4) Aggregates of organizing fibrin cover portions of synovium and float in the joint space as rice bodies.(5) Neutrophils accumulate in synovial fluid.(6) The inflammed and hyperaemic synovium creeps over the articular surface forming a pannus and causes erosion of the underlying cartilage.(7) The mediators released by the inflammatory cells and synoviocytes result in osteoclastic activity allowing the synovium to penetrate into the bone forming juxtra articular erosions, subchondral cysts and osteoporosis.(8) After the cartilage has been destroyed fibro cellular pannus bridges the opposing bones forming fibrous ankylosis that eventually ossifies ultimately resulting bony ankylosis.(9) The inflammed synovial sheaths cause irreversible damage or even rupture of thetendons and ligaments.PURVA RUPA OF AMAVATA Purva rupa of Amavata is not distinctly mentioned in Classics. But in such conditionsAvyakta lakshana prior to the manifestation of disease is considered as Purva rupa126.Hence on this basis following can be considered as Purva rupa of Amavata.1. Apaka (Indigestion)- Agnimandya due to Nidana sevana hampers the digestion and metabolism. 43
  • 2. Angamarda (Aching all over the body)- Inadequate nourishment of Dhatu and presence of Ama had to subjective feeling of aching all over the body.3. Gourava (Heaviness)- The presence of Ama and vitiated Kapha generate heaviness in the body. Also Sama Rasa and vitiated Kapha generate Hritgourava i.e. subjective feeling of heaviness in chest.4. Aruchi (Loss of Taste)- Vitiation of Rasa Dhatu and Bodhaka Kapha impairs the function of Rasanendriya.5. Alasya (Lack of enthusiasm)- Insufficient nourishment of Dhatu leads to Alasya thus lowering resistance of body6. Jwara (Fever)- Agnimandya and Rasa Dushti produce jwara in the body to pacify the circulating Ama.7. Sandhi Stabdhata (Joint stiffness)8. Sandhi vedana (Joint pain)- Sandhi is the seat of Sleshaka Kapha. It lubricates and resists the wear and tear of Sandhi. Snigdha and picchila Guna are predominantly present in this type of Kapha. Due to direct affliction of Majjavaha srothas and similarity in Guna of Ama and Kapha, Sandhi become the main site of pathogenesis. The Sthana- Samsraya of virulent Ama in the Sandhi and vitiated Vata, affect the function of Sandhi and hence Stabdhata and vedana are felt in joints.Prodromal Symptoms of RA: -127,128 Morning stiffness, fatigue, anorexia, generalized weakness, vague musculo skeletalsymptoms like pain, weight loss etc.. are the prodromal symptoms of Rheumatoid Arthritis. 44
  • RUPA OF AMAVATA Madhavakara has described the Rupa of Amavata as Samanya and Pravrudhalakshana129.Samanya Rupa: 1. Angamarda (Aching all over the body) 2. Aruchi (Loss of taste) 3. Trishna (Thirst) 4. Alasya (Lack of enthusiasm) 5. Gourava (Heaviness) 6. Jwara (Fever) 7. Apaka (Indigestion) 8. Angasunata (Swelling of body parts)Pravridha Rupa: 1. Sandhi Ruja and Sandhi Sotha of Hasta- Pada – Sira –Gulpha- Trika –Janu and Uru (Pain and Inflammatory swelling in the joints) 2. Vruschika damsavat peeda (Pain like scorpion sting) 3. Agni Daurbalya (Weakness of Agni) 4. Praseka (Salivation) 5. Aruchi (Loss of taste) 6. Gourava (Heaviness) 7. Utsahahani 8. Vairasya (anorexia) 9. Daha (Burning sensation) 10. Bahu mutrata (Profuse urination) 11. Kukshi Kathinyata 12. Kukshi sula (Pain in Abdomen) 13. Nidra Viparyaya (Loss of sleep) 14. Thrit (Thirst) 15. Chardi (Vomiting) 16. Bhrama (Giddiness) 17. Murcha (Fainting) 18. Hrit graha (Pain in the Heart) 19. Vit Vibandha (Constipation) 45
  • 20. Jadhyata 21. Antra Kujana (Intestinal gurgling) 22. Anaha (Distention) 23. Vatopadravas. Anjana Nidana has mentioned the involvement of Sandhi as Ekanga and Sarvanga.In this treatise, Sandhi Sotha, Sandhi graha, Sandhi Gourava, Jwara, Apaka, Agnimandyaand Trishna are the clinical features attributed to Amavata130. Interestingly the same symptoms are considered as cardinal symptoms of RA bymodern medicine. Basavarajiya has mentioned a group to different symptoms131. They are Janghadipradeshe vyadha, Pandu Varna, Peeta netrata, Sosha, Vishuchi, and Ushnata. In Haritha Samhita, Amatisara has also been mentioned as symptom of Amavata.Harita has also described the symptoms of Sarvanga Amavata. These are Kati-Prishta-Vamksha Toda, Basti Sula, Jathara garjana as in Gulma, Sopha and SiroGurutva. According to Gananath sen, in Amavata Jwara may or may not be associated. 46
  • Table No 2: Comparison of Lakshanas as per different Ayurvedic treatises: -132,133,134,135 No. Lakshana M.N B.P B.R Y.R A.N 1 Agni dourbalya + + - + - 2 Alasya + + - + - 3 Anaha + + - + - 4 Angamarda + + - + - 5 Angasoonata + + - + - 6 Antra Kujana + + - + - 7 Apaka + + - + - 8 Aruchi + + - + - 9 Bahu mutrata + + - + - 10 Basti Sula - - - - - 11 Bhrama + + - + - 12 Chardi + + + + - 13 Daha + + - + - 14 Gourava + + - + - 15 Hrit graha + + - + - 16 Jadhyata - - - - - 17 Janghadi pradeshe vyadha - - + - - 18 Jwara + + - + - 19 Kukshi Kathinyata + + - + - 20 Kukshi sula + + - + - 21 Murcha + + - + - 22 Nidra viparyaya + + - + - 23 Pandu varna - - + - - 24 Prasekam + + - + - 25 Sandhi Gourava + - - - + 26 Sandhi Ruja + + - + + 27 Sandhi Sotha + + - + + 28 Sandhi Graha - - - - + 29 Sosha - - + - - 30 Trishna + + + + - 31 Ushnata - - + - - 32 Utsaha Hani + + - + - 33 Vairasyam + + - + - 34 Vatopadravas - - - - - 35 Vishuchi - - + - - 36 Vit Vibandha + + - + - 37 Vruschika damsavat peeda + - - - -Sandhi Sotha: Sandhis are the main seat of pathogenesis in Amavata. Srotorodha due toAma and vitiated Kapha leads to Vimargagamana of vitiated Vata and Sandhi Sotha136. Italso causes Sandhi Ruja 47
  • Sandhi Ruja: Severe pain like that of a scorpion sting, involvement of few joints in the initialstage and progressive involvement of other joints like that of fingers, wrist, elbow, shoulder,joints of the feet, ankle, knee, hip, trika and tempero mandibular joints are typical inAmavata. Sandhi Ruja may include the meaning of Sparsa asahishnuta (Tenderness) also,which is substantiated by the fact that according to modern texts tenderness is a veryimportant sign of RA.Sandhi Graha: Anjana Nidana has used the word “Graha”. Vagbhata has used a similarterm ‘Gatra Stabdhata’ instead of the word ‘Graha’. He defines, ‘Gatra Stabdhata’ as theinability to perform the ‘Namana’ (bending movements) at the affected joints like knee,wrist, etc.. According to Arunadatta and Hemadri the word ‘Graha’ is an adjective of‘Stambha’ that means Samkochadi Abhava or Nishkriyata137. Said definition signifies the joint stiffness or restriction of range of movement or lossof movement of joints.Praseka: Praseka is Prasakta Nisthivana, means Lalasrava138. Excessive, thick, mucoidsalivary secretions are produced due to Sama Rasa.Vairasya: Perception of different tastes than original is Vairasya139. It is produced due toSama Rasa and vitiated Bodhaka Kapha.Trishna: Ama prabhavaja Trishna occurs due to Sama Pitta. Aruchi, Adhmana and KaphaPraseka are its accompaniments140.Chardi: Vitiated Tridosha causes it due to agitation of Amashaya141.Kukshikathinya: Kukshi means abdomen and Kathinyata means hardness142. Theproduction of Ama and vitiation of Samana and Apana Vata lead to rigidity of abdomen.Kukshi Sula: It is caused due to obstruction to normal motion of vitiated Samana and ApanaVata. 48
  • Vit - Vibandha: Due to vitiated Apana Vata and improper degradation of Ahara in to Saraand Kitta.Antra Kujana: Due to movements of vitiated Vata in the intestines.Anaha: The vitiated Vata gets stagnated in the Kukshi. It does not make upward ordownward movement leading to Anaha143.Bahumutrata: Sroto Abhishyanda is caused due to vitiated Ama increasing the Kleda in thebody. Kleda Vahana is the function of Mutra. Hence Bahumutrata occurs.Alasya: The Prinana Karma of Rasa is hampered due to undigested Ahara Rasa affectingthe mental factor. Hence inspite of capability, a person cannot carry out his normalduties144.Utsaha Hani: Lack of interest develops due to insufficient nutrition of Sarira Dhatus, Indriyaand Mind.Hrit-graha: The term Hridaya is made up of three roots "Hr. harane, Da Dane and YaGatau". These signify the circulatory function of Hridaya. It is Mula of Pranavaha andRasavaha Srotas145. Also, it is the seat of Vyana Vayu, Sadhaka Pitta and AvlambakaKapha. After completion of digestion of Ahara Rasa; Samana Vata guides it to Hridaya In the pathogenesis of Amavata chiefly Samana Vayu, Vyana Vayu, AvalambakaKapha and Sleshaka Kapha are vitiated. Hence due to Rasavaha Srotodusti and vitiation of Samana and Vyana Vayu andAvalambaka Kapha, the functioning of Hridaya is affected146.Hrit-gaurava: The vitiated Avalambaka Kapha and Sama Rasa produce this symptom.Bhrama: Feeling of circulatory movement in head is Bhrama It is caused due to vitiatedVata147.Murcha: Inability of the, sensory organs to percept the sense objects is Murcha148. Also lossof motor function occurs in Murcha149. It is due to Upatapa of Indriya by vitiated VatadiDosha150. 49
  • Daha: Daha means Santapa151.It is the feature of vitiated Pitta. Warmth of the joint isusually evident on examination.Jadya:Jadya is Akarmanyata152. It is the inability of movement and occurs due todeformities.Nidra Viparyaya: The pain keeps the patient awake at night and hence daytime sleep isobserved in the patients.Gaurava: A feeling of body covered with wet skin and heaviness in the head region istermed as Gaurava153.It is due to vitiated Kapha.Angasunata: Oedema of the body parts is Angasunata. It is produced due toVimargagamana of vitiated Vata, Pitta, Kapha and Rakta.Pandu Varna: Prakruta Varna is the function of Pitta. Vitiation of Pitta is the cause ofPandu Varna. Anaemia is a common complication of RA.Peeta netrata: Vitiated Pitta produces peeta netrata.Sosha: Affliction of Prinana karma of Rasa Dhatu and vitiation of Vata leads to Sosha.Ushnata: Vitiation of Pitta produces Ushnata.Janghadi pradeshe vyadha: Vimargagamana of vitiated Vata by Kapha and Ama leads toJanghadi pradeshe vyadha.Amatisara: Affliction of Grahani may produce Amatisara. 50
  • These symptoms can be reclassified according to the Srotas involvement in thefollowing manner in table No 3: No Srotas Symptoms 1 Annavaha Aruchi, Apaka, Agni Daurbalya, Chardi, Vishuchi, Praseka 2 Udakavaha Trishna 3 Rasavaha Angamarda, Aruchi, Gaurava, Jwara, Agni Daurbalya, Praseka, Utsahahani, Vairasya, Hrit graha, Angasunata 4 Raktavaha Pandu varna, Pita netrata, Ushnata 5 Mamsavaha Sosha 6 Medovaha Alasya, Trishna, Sosha 7 Majjavaha Sandhi Sula, Sandhi Sotha, Bhrama, Murcha, Jadya, Janghadi pradeshe vyadha 8 Purishvaha Kukshi Kathinyata, Kukshi Sula, Vit Vibandha, Antra Kujana, Anaha 9 Mutravaha Bahumutrata 10 Manovaha Utsahahani, Nidra ViparyayaClinical features of RA:Articular lesions-154,155. Pain, swelling, redness and temperature are the symptoms of articularmanifestations. Pain in affected joints aggravated by movement is the most commonmanifestation of RA. Pain originates predominantly from joint capsule, which is abundantlysupplied with pain fibers and is markedly sensitive to stretching as distention. Joint swelling results from accumulation of synovial fluid, hypertrophy of thesynovium and thickening of the joint capsule. 51
  • Morning stiffness of greater than one-hour duration is almost invariable feature ofinflammatory arthritis. Patient may feel more stiffness after a period of rest also. Initiallymotion is limited due to pain. The inflamed joint is usually held in flexion to minimize thejoint volume and minimize distention of joint capsule. Later fibrous or bony ankylosis or softtissue contractures lead to fixed deformities. In the typical case, small joints of figures and toes are first to be affected. Swellingof proximal interphalangeal joints gives the fingers ‘spindled appearance’. The diseaseprogresses to involve wrist, elbows, shoulders, knees, ankles, subtalar and midtarsal joints.The hip joints become involved only in more severely affected; but neck pain and stiffnessof cervical spine is common. The tempero mandibular, acromio clavicular, andcricoarytenoid joints are some times affected, as indeed all are synovial joints. Deformities at first are correctable but later permanent contracture develops. Theseare flexion contractures of small joints of hands and feet, knees, Hip, and elbows,ulnardeviation of fingers, swan neck, boutonniere, Z deformity of thumb, valgus deformitiesat sub talar joints and hallux valgus. Osteoporosis secondary to RA is common. Fine ‘rubbing’ crepitation is felt over RAJoints from the presence of granulation tissue (pannus) as the bone ends are devoid ofcartilage. Dorsal subluxation of ulnar styloid of the wrist, metatarso phalangeal joints of thefore foot and atlanto axial sub luxation of cervical spine may be present in RA.Extra articular lesions: 156,157 (1) Skin: Palmar erythema, psoriasis. (2) Subcutaneous nodules: Rheumatoid nodules develop in 20 to 30% of persons with RA. Common locations include olecrenon bursa, proximal ulna, occurring over bony prominences at site of pressure or function. (3) Myositis: Muscle wasting around inflamed joints. 52
  • (4) Eyes: Scleritis, Keratoconjunctivitis sicca. (5) Heart: Pericarditis, Myocarditis (6) Vasulitis: Purpuric rashes, pyoderma gangrenosum. (7) Haematological: Anaemia, thrombocytosis, eosinophilia (8) Respiratory: Pleurisy (9) Nervous system: Neuropathy, cervical nerve root compression, uscle wasting. (10) Lymphatic: Spleenomegaly, lymphadenopathy (11) AmyloidosisTypes of presentation: a) Classical: Pain, stiffness and swelling of small joints of hands and wrists. Symptoms fluctuate in severity from day to day. b) Palindromic: Intermittent episodes of pain, swelling and redness, usually single joint followed by rapid return to normal after several days. c) Systemic: Weight loss, pleurisy and pericarditis but minimal joint involvement. d) Polymyalgic: Pain and stiffness in shoulders and hip with subsequent sinuvitis. e) Monoarthitic: Single joint involvement usually knee. f) Acute onset: Sudden overnight onset with stiffness and pain. g) With generalized lymphadenopathy Remissions and exacerbations are the hallmarks of the disease. This means that there are periods of time when the patient "feels good" and times when the patient "feels worse There will likely be times that a patient with RA "feels cured". But rarely does the disease "go away", although at times the symptoms might temporarily remit. In a small percentage however, the disease progresses relentlessly to joint destruction and crippling. 53
  • CLASSIFICATION OF AMAVATA:According to Dosha: Seven types of Amavata are mentioned in Madhava Nidana158. 1) Vata Pradhana: This variety is associated with predominance of Sula; which is innovating feature of vitiated Vata. In Amavata, Sula is present due to Chala and Seetsa Guna of Vata. 2) Pitta Pradhana: Daha and Raga of the joint are manifested in this type of Amavata. Due to Ushna and Tikshna Guna of vitiated Pitta, Daha occurs in the joint. The increased circulation may be responsible for appearance of Raga. (3) Kapha Pradhana: Staimitya, Gourava & Kandu are the manifestation of this variety. Staimtiya is the feeling of a wet cloth around the joint. It occurs due to increased Picchila, Sthira and Seeta Guna of vitiated Kapha. Kandu is a pathogenic feature of vitiated Kapha. Due to similarity of Guna of vitiated Kapha and Ama and Sroto-Abhishyanda, itching sensation is felt at the joint. (4) Vata Pitta Pradhana: Associated symptoms of Vata and Pitta are produced. (5) Vata Kapha Pradhana: Symptoms of both Vata and Kapha are produced. (6) Pitta Kapha Pradhana: This variety is found with mixed symptoms of Pitta and Kapha (7) Sannipatika: Symptoms of all the three Doshas are found in this variety. A different type of classification of Amavata is found in Harita Samhita. According tothis text four types of Amavata are as follows.(1) Vishtambhi: Sarira Gourava, Adhmana and Basti Sula are the symptoms.(2) Gulmi: Jathara garjana, Gulmavat Peeda, Kati jadhata.(3) Snehi: Gatra Snigdhata, Jadya, Mandagni, and excretion of Vijjala and Snigdha Ama 54
  • (4) Pakva: There is excretion of Pita Syama Vijjala and Pakva Ama, Srama andKlama are present in this type. According to chronicity Amavata can be classified into two: 1. Nava Amavata 2. Jirna Amavata A clear parameter for considering Amavata as Nava or Jirna has not been laid down,but generally after one year Amavata is considered to be Jirna. On the basis of the severity of the disease Amavata can be classifiedSamanya Amavata and Pravridha Amavata stage. In sAmanya stage symptoms are moreor less general and less severe and in Pravridha stage symptoms are prominent andassociated with Upadravas. 55
  • UPADRAVA OF AMAVATA Madhava Nidana and Anjana Nidana mention Upadravas as Jadya, Antra kujana,Anaha, Trit, Chardi, Bahumutrata, Sula, Samkocha, and Khanjata etc159. According to Acharya Charaka the affliction of Snayu, Kandara and Sira account forStambha, Samkocha and Khanjata160. Vagbhata states that Khanjata is the out come ofaffliction of Kandara in the thigh region due to vitiation of Vata in the lumbo sacral region,i.e. Kati161.Complications of RA: Septic arthritis and Amyloidosis. Pain and swelling behind knee may causeextension of inflamed synovium in to the popliteal space called as Bakers cyst. UPASAYANUPASAYA The use of medicines, dietary regimens and trend which bring about lasting reliefare known as Upasaya162. On the contrary, those which when employed aggravate thesymptoms of the disease are connoted as Anupasaya. In case of Amavata Ushna, Tikta, Katu, Dipana, Laghu Ahara and Ushna Viharaalleviate the symptoms, so these are upasaya measures. Langhana resumes theundigested and unprocessed material in the body to undergo digestion so the symptomslike Guruta, Praseka, Aruchi, Jvara, etc. disappear. Seeta Ahara and Vihara are the maincausative factor of the disease. So, Swedana that is Usna brings about Pachana andVatanulomana by clearing and dilating the channels. Ruksha Sweda is indicated as Rukshais opposite to Snigdha Picchila Guna of Ama. Along with Ushna it reduces the symptoms ofSrotolepa by Ama. Also in Ushna Kala, the symptoms of disease are reduced. In contrast to the above Seeta, Guru, Snigdha Ahara Seeta Kala, Varsha etc. add tothe suffering of the patients. 56
  • Aggravation of symptoms on application of oil is used as a diagnostic tool ofAmavata. In practice, Amla Rasa is found to be a provoking factor in almost every case.Also hard work aggravates the joint symptoms due to strain on the joint factors.SADHYASADHYATA163 Amavata is the disease of Madhyama Roga marga also involving Mahasrotas in thepathogenesis of the disease. Good- if one Dosha is involved produced by limited number of hetu, when few signsand symptoms are present and the disease of recent origin. Palliative- if two Doshas are involved, chronic, having many causative factors, signsand symptoms Difficult to cure- A. If Sotha is present all over the body and all the three Doshas are involved. B. When all the joints of the (1) Hand (2) Feet (3) Head (4) Ankle (5) Waist (6) Knee(7) Thighs are involved with painful swelling. C. The swelling shifts from place to place (joint to joint) when Doshas move fromone place to another with a severe pain resembling that of scorpion sting. D. Poor digestion, salivation, anorexia, heaviness of body, lack of enthusiasm, badtaste in the mouth, burning sensation, profuse urination, hardness of abdomen and pain,loss of sleep, thirst, vomiting, giddiness, fainting, pain the heart, constipation, incapacity ofmovement, intestinal gurgling and distention.Prognosis of RA: 164,165. The course and prognosis in RA is variable. 25% of the severe cases havecomplete remission of symptoms and they become fit for all activities. 40% cases sufferfrom moderate impairment of functions despite exacerbations and remissions. 25% caseshave more severe disability while 10% cases are severely crippled. 57
  • The overall prognosis is much better if the symptoms are never of such severity as to require admission to the hospital. Poor prognosis is associated with - (1) High titres of RF (2) Insidious onset of disease (3) More than a year of active disease without remission. (4) Early development of nodules and erosions (5) Extra articular manifestations. (6) Severe functional impairment INVESTIGATIONS IN AMAVATA166(1) Tests for inflammation: Erythrocyte Sedementation Rate and C-reactive protein (CRP). In active cases the ESR is usually markedly elevated and CRP is highly positive. It tends to parallel the activity of the disease.(2) Immunological test: Rheumatoid factor test (RF test): That is antibodies directed against components of the Fc portion of IgG molecules is the most helpful immunological test and is positive in 75% of cases (RF is found in 10% of normal individuals and 10% with other connective tissue diseases) Antinuclear antibody test may be positive particularly in patients with extra articular manifestations. (3) Roentgen findings in RA Early stage: 1) No Changes during first few months 2) Peri articular fusiform soft tissue swelling. 3) Erosions at joint margins, subchondral bone and articular cartilage 4) Slight narrowing of joint space. 5) Juxta articular osteoporosis 58
  • Late stage: 1) Generalized osteoporosis 2) Pocketed erosion in the subchondral area and pseudo-cysts in the articular ends of bones. 3) Marked narrowing of joint space. 4) Hypertrophy of bone 5) Subluxation and deformities. (3) Other tests: Synovial fluid analysis and synovial biopsy confirms the presence of inflammatory arthritis. Arthroscopy, Roentgenograms, Arthrographs, ultrasound, CT Scan, MRI, bonescanning etc. are useful to establish the extent of local pathology in joints.SAMANYA CHIKITSA: Chakradatta was the first to describe the principles and management of Amavata167.Following these guidelines the later authors advocated further effective remedies168. Ama and Vata, the chief pathogenic factors of Amavata are contradictory in nature.Only Seeta Guna is common in both. The line of treatment and principles proposed appearfirstly to digest the virulent Ama and promote the function of Agni and then Vata SAmakaand Balya Chikitsa are prescribed.(1)Langhana: The drug or procedure that generates a sense of lightness (Laghavakara) in the body isknown as Langhana169. Charaka has mentioned ten types of Langhana viz. four types ofSuddhi, Pipasa, Atapa, Pachana, Upavasa and Vyayama170. Where as Vagbhata hasrecasted Langhana in to broad headings of Sothana and Samana which are further dividedin to five and seven types respectively. In the treatment of Amavata, Upavasa fromLanghana is preferred in the initial stage that is a kind of Samana Chikitsa. 59
  • Langhana brings following changes in the body171,172. 1. Dosha Pachana /Dosha Kshaya: The Sama Dosha is stagnant (Stimita and baddha) in the body. Due to starvation, these are metabolized. 2. Agni Sandhukshana: The unprocessed materials undergo digestion and no fuel from outside is provided to the hypo functioning Jatharagni. So the Agni is excited gradually173. 3. Vijvaratva: Due to cleaning of Srotomagra, Vatanulomana occurs and Ushma is restored to its normal function. 4. Laghuta: Due to Pachana of Guru and Picchila Ama. 5. Kshut: Due to Pachana of Apakva factors. 6. Ruchi: Due to Pachana of Sama Rasa followed by proper functioning of Bhodhaka Kapha and Rasanendriya. 7. Vata- Mutra- Purisha Visarga: The Agnibala promotes the Bala of Grahani, and due to Mala Pachana, Sara Kitta Vibhajana and Vatanulomana excretory functions are also normalized. 8. Hridaya-Udgara-Kantha-Asya Suddhi: Due to Ama Pachana and clearing of Srotas. 9. Tandra and Klama: Produced due to vikruta Kapha perish due to Kapha Samana.9. Sweda Pravritti: Due to Sara Kitta Vibhajana proper Sweda Ghatakas are formed and Langhana causes Romkupa Sothana. Langhana and Pachana are advised in Sarva Sariragata Ama174. Apatarpana is preferred to be the Adya upakrama (treatment of choice) for the Sopha as it is Samanya i.e. good in all Sopha conditions and Pradhanatama due to immediate action175. Langhana should be advocated carefully to avoid Bala Kshaya176. Though Langhana is contraindicated for vitiated Vata, for Ama pachana it can be prescribed in Sama Vata though cautiously177. 60
  • (2) Swedana: The procedure which alleviates Stambha, Gaurava, Sula and Seeta and which isSweda kara is Swedana. It is having Ushna, Tikshna, Sara, Snigdha, Ruksha, Sukshma,Drava, Sthira and Guru properties178. The Swedana brings about Pachana, clears anddilates the channels. Ruksa Sweda that is given by means of sand is considered best forAmavata179. Taking of hot water (Usna Jala Pana) is also a kind of internal Swedana. It isDipana, Pachana, Jwaraghna, SrotoSothana, Balya, Ruchi kara and Swedana180.(3) Tikta Katu Rasa: Tikta and Katu Rasa have the dominance of Vayu Akasha Mahabhuta and VayuTejas respectively181. They bring about Dipana, Pachana, Rochana and Laghuta in thebody. Katu Rasa is Baddha, Chedaka, and Margavivaraka and Kapha Samaka. Tikta Rasais Vishaghna and Lekhana182. Both are Kleda and Meda Nasaka e.g. Chitraka, Guduchi,Sunti etc. These drugs are Agnivardhaka and antagonist to Ama and Kapha.(4) Virechana: After Langhana and Pachanadi Chikitsa, when Dosha are processed and loosened(Nirama) Virechana should be administered to eliminate them out of the body. Because theDosha may again vitiate after Langhana and Pachana treatment but once Sothanaeliminates them, the disease does not recur, as there remains no root cause to induce thedisease183. Virechana is indicated in Amavata because of following reasons. o Production of Ama is result of involvement of Pitta Sthana and Kledaka Kapha both. Kledaka Kapha after leaving its normal site settles at Pitta Sthana, thus hampering the digestive activity of Pachaka Pitta. Virechana helps in this condition by two ways. o It removes the Kledaka Kapha from the Pitta Sthana. o It is the most suited therapy for the Sthanika Dosha Pitta. 61
  • o Symptoms of Amavata like Anaha, Vibandha, Antra kujana and Katisula are indicative of Pratiloma Gati of Vayu, which is made Anulomana by Virechana.Further more, though Virechana has been described to be the best remedy for Pitta Dosha,it is effective in the vitiated Kapha and Vata Dosha also to some extent. So Virechana inthis way appears to be the best Sothana measure for Amavata.(6) Snehapana: The process that brings Snehana, Vishyandana Mruduta and Kleda in the body iscalled Snehana184. Sneha should be used according to the condition (Sama or Niramavastha) and Bala of the patient. It is specially indicated in the chronic conditions due tofollowing reasons: v To prevent the provocation of Vata produced by Ama hara Chikitsa. v As a best Balya regimen for the patient who has got reduction of Bala. v Sneha is Agni Dipana. v Sneha is Vata hara and Vatanulomana. v In Asthimajjagata Vata, Snehapana is also indicated so, it may be beneficial in Nirama Stage of Amavata.(6) Basti: Basti is the best treatment of vitiated Vata. As the disease attains chronicity,Rukshata increases in the body leading to vitiation of Vata. Niruha Basti in addition acts asa Sothana measure. It is also locally effective for the symptoms like Anaha, Vibandhaetc.Anuvasana Basti is Vata hara and Rukshata hara. Due to intermittent remissions thedisease Amavata is neglected most of the time by patients. Thus, it attains chronicity andbecomes deep rooted (Gambhira). Basti due to its Veerya acts the whole body to alleviatethe disease185. Chakrapani has recommended Saindhavadi Taila for Anuvasana and 62
  • Kshara Basti as Niruha Basti. It acts on the subtle levels to remove Dosha from the body,clearing the channels and normalizing the body functions.PATHYAPATHYAPathya: Annavarga - Yava, Kulattha, Raktasali, Syamaka, Kodru Saka - Vastuka, Sigru, Karavellaka, Patola Dugdha Vikara - Ardraka / Lasuna siddha takra Mamsa - Jangala Mamsa Paniya - Tapta Nira Bhallataka, Gokshura, Vruddha Daru, Ardraka, Gomutra and Katu, Tikta and DipanaDravya are beneficial for Amavata.Apathya: Dadhi, Mastu, Guda, Kshira, Masha, Viruddha bhojana, Asatmya bhojana,Vishamasana, Anupa Mamsa, Abhishyandi, Guru, Picchila Dravya. Vihara - Vegavarodha, Jagarana 63
  • Chapter –3 Drug Review A screening of the drugs mentioned in Chakradatta, Bhavaprakasha, Yogaratnakaraetc. were done before selecting drug for this study. It was noted while going through thetexts that a systematic approach has been followed while planning the treatment ofAmavata. Vata dosha poses the treatment with the problem of complexity of diseaseprocess due to the involvement of homologous Dosha-Dushya (Tulya Dosha-Dushya) likethe affliction of Sandhi (of which Asthi is a homologous component) by Vata Dosha inassociation with Ama. Even though Ama and Vata are the Chief pathogenic factors ofAmavata, Pitta and Kapha are also involved in Amavata. Tridosha involvement also makessome complications while treating a patient of Amavata. These points were kept in mindwhile selecting the drug for the study.The details of the herbs included are described in the coming pages.ALAMBUSHADI YOGA 186,187,188Alambushadi yoga is a combination of herbal drugs in a specific proportion mentioned inMadhava Chikitsa, Chakradatta and Yogaratnakara. The combination and proportion of theYoga is as follows in table No 4 : 1 Alambusha (Biophytum sensitivum) 1 part 2 Gokshura (Tribulus terrestris) 2 parts 3 Amalaki (Emblica officinalis) 1 part 4 Vibheetaki (Terminalia bellerica) 1 part 5 Hareetaki (Terminalia chebula) 1 part 6 Sunti (Zingiber officinale) 4 parts 7 Guduchi (Tinospora cordifolia) 5 parts 8 Trivruth (Operculina terpethum) 15 parts 64
  • ALAMBUSHA (Biophytum sensitivum) 189,190,191,192.Family : - OxalidaceaeSynonyms : - Samanga, Peeta pushpa, Kritanjali, Jala pushpa.Identification : - This is an unbranched herb with the stems upto 30cm. in height but usuallyshorter. The leaves are pinnately compound, numoirous, crowded at the apex of the stemand 5 to 12 cm. long with 14 pairs of leaf lets. The leaflets are gradually increase in sizeupward. The flowers are many and crowded at the apices of the numorus peduncles. Thefruit is a capsule.Chemical composition : - Dr. F. Gracia, ,who worked on this plant claims that it contains aninsuline like principle.Parts usd : - Samoola.Rasa : - Tikta, Kashaya Vipaka – Katu Guna – Laghu Veerya – Sheeta.Indications: - Kirtikar and Basu states that seeds are powerede and applied to wounds andto abcess to promote suppuration. The root in decoction is given in Gonorrehea andLithiasis. A recent work (Unpublished) of the Dr. F. Gracia indicates that the palnt indecoction is promising cure for Diabetis millitus. Gross reports that an infusion of the leavesis an expectorant. A recent study from the department of biochemistry in University ofmedical science, New Delhi shows that the extract of this plant has a significanthypocholesterolemic effect.Yoga : - Alambushadi Churna.Dose ; - Churna – 3 -12 gms. Kwatha – 50-100 ml.GOKSHURA (Tribulus terrostris) 193,194,195.Family: - Zigophyllaceae (Gokshurakula)Synonyms: - Swadukantaka (Spiny fruits are having ‘Madhura’ Rasa). Ikshugandhika (plantjuice odour smells like sugarcane juice), Trikantaka (having three horns). 65
  • Identification: - This is an annual or rarely perennial hirsute, grayish or rusty brown, prostatehere with many slender spreading branches, one to two feet or more in length and about0.05inch in thickness. Leaves are opposite and abruptly pinnate. Compound leaflets, 3 to 6or more pairs, almost sessile or with short petioles. Flowers are pseudo axillary or leafopposed, bisexual and bright yellow or rarely white. Each fruit is a stalked grayish spiny;five ribbed or angled more or less spherical structure.Chemical composition: Fruits contain fixed oil, essential oil, resin, nitrate and alkaloid.Parts used: Samoola, fruits, and rootRasa: - Madhura, Vipaka-Madhura, Veerya-Sheeta, Guna-Guru, Snigdha; Doshaghnata-PittaVataghnata. Karma-Vrishya, Dipaka, Balya, Pushtida, BastiSothaka,Vedanasthapakam and Sothaharam.Indications: - Vatavyadhi, Sotha, Mootrakrichra, Ashmari, Prameha, Swasa, Kasa, Arshaand Hridroga.It is a listed drug showing analgesic effect196. It helps to maintain efficient kidney andurinary functions. It contain saponins which on hydrolysis yield steroidal spogenins.Gana: -Mootra virechaniya, Sothahara, Krimighna, Anuvasanopaga (Cha); Vidarigandhadi,Veerataradi, Laghupanchamula, Kantakapanchamoola, Vatasmari bhedana (Su)Yoga: - Rasna saptakam, Sundhyadi kwatha, Amrutadi churna, YogarajagugguluDose: - Choorna 3- 6 gm, Kwatha – 50-100 ml.AMALAKI (Emblica officinalis)197,198,199,200.Family: - Euphorbiaceae (Erandakula).Synonym: - Amraphala, Amlika (fruit is sour in taste), Vayastha, Kayastha (keeps young,Arrest old age), Amritaphala, Shiva (Fruits helps to maintain good health).Identification: - This is a deciduous small or middle sized tree with crooked trunk andspreading branches, bark greenish gray, peeling of inflakes, branches glabrous or finallypubscent 10-20 cm long often deciduous. Sub sessile leaves, 10-13 cm long 2.5 to 2 mm 66
  • broad. Two varieties are available-vanya and gramya. Gramya variety is used in thepresent study.Chemical composition: - Fruit contains vitamin C, B- complex, calcium, iron, galic acid,tannic acid, gum, sugar, albumin and cellulose.Parts used: - FruitRasa: - Amla Pradhana (Vilavana panchaRasa), Vipaka-Madhura, Veerya-Sheeta, Guna-Laghu, Rooksha, Doshaghnata-Tridoshaghnata. Karma-Rasayana, Vrushya, Sara.Indications: - 1. Bahya- Chakshushya, Keshya 2. Pachana samsthana – Rochana, Deepana, Anulomana 3. Raktavaha samsthana – Sonithasthapana, Hridya 4. Prajanana samsthana – Vrishya, Garbhasthapana 5. Mootra –Pramehaghna 6. Satmeekarana – Rasayana It is a listed drug showing antiviral, anti microbial and anti diabetic activity. It is listed inthe drug of choice of gastro intestinal disorders, dental care and geriatric care201.Gana: - Vayasthapana, Virechanopaga (Cha), Triphala, parooshakadi (Su).Yoga: - Yogarajaguggulu, Simhanadaguggulu, Brihatsimhanada guggulu.Dose: - Choorna 5 – 10 grams, leha 20 gm.VIBHEETAKI (Terminalia bellerica) 202,203,204,205,206.Family: - Combretaceae (Hareetaki kula)Synonyms: - Bahuveerya, Vishaghna, Aksha, KalpavrukshaIdentification: - A large deciduous tree, 10-20 m high. Leaves gathered about theextremities of the branches and broadly elliptic. Flowers pale greenish yellow with anoffensive odour. Bark is bluish gray with many fine vertical cracks. Annual rings indistinct. 67
  • Chemical composition: - it contains ‘gallo-tannic’ acid; colouring matter, resins and seedscontain greenish yellow oil.Parts used: - fruit pulp, seeds, and oil.Rasa-Katu, Tikta, Kashaya, Madhura. Vipaka-Madhura. Veerya-Ushna. Guna-Laghu,Rooksha. Doshaghnata-Tridoshaghna.Karma-Netrya, Keshya, Bhedya, Krimighna, Madaka, Vedanasthapaka, Deepaka,Anulomaka, Trishna nigrahana, Jwaraghna and Dhatuvardhaka.Indications: - Sotha, Agnimandya, Adhmana, Chardi, Anidra, Vatavyadi, Jwara, Pratisyayaand Dourbalya. It is a listed drug showing anti inflammatory, anti microbial, astringent andanti diabetic activity. It is a listed drug used in GI disorders, dental care and geriatric care207.Gana: - Jwarahara, Virechanopaga (Cha), Thriphala, Mustadi (Su)Yoga: - Yogaraja guggulu, Brihat saindhavadi tailaDose: - choorna 3-6 gm.HAREETAKI (Terminalia chebula) 208,209,210,211,212,2213.Family: - Combretaceae (Hareetaki kula)Synonyms: -Abhaya (the medicine is safest for use), Pathya, Pootana, Jeevanti, Shiva(having good for health) Kayashta (arrests aging factors), Vayasya (preserves youth),Chetaki (keeps alert jnanendriya).Identification: -Tree is deciduous, grow 25-30 ft height, leaf buds, branch lets tenderleaves with soft, shining rust cloured hairs. Leaves 5-7 cm long 4-5cm broad glabrous ornearly so when mature, not clustered distant, alternate or sub opposite, elliptic-along,pinnately nerved of a common axis. Flowers all hermaphrodites. Drupe- (a flexy fruit havingits preicarp differentiated into outer epicarp, mesocarp and endocarp) pendulous, 2-4 cmlong, ellipsoid, when dry yellowish green hard oblong.Seven types of Hareetaki as Vijaya,Rohini, Pootana, Amrita, Abhaya, Jivanti and Chetaki are classified. It is also classified intotwo varieties as Sweta and Krishna. Swetha (fruit is light yellowish colour and it is 2-4 in 68
  • length) Abhaya (fruit having five ribbed used in eye disease) variety of Hareetaki is used inthe present study.Chemical constituent: Fruit contains 45% tannin, galic acid, albumin, yellow colour,chebulic acid which turn into tannic acid and galic acids when boiled.Parts used: - fruits pulpRasa: -Vilavana panchaRasa, Vipaka-Madhura. Veerya-Ushna. Guna - Laghu, Rooksha;Doshaghnatha - Tridoshaghna. Karma - Chakshushya, Brimhana, Rasayana, Anulomaka,Deepaka, Medhya, Krimighna, Swarya.Indications: - Swasa, Kasa, Vaiswarya, Vibandha, Vishamajwara, Gulma, Adhmana,Kamala, Soola, diseases of spleen and liver, Ashmari, Mutra kruchra, Mootraghata.It is agentle bowel cleanser that has laxative properties. It is a listed drug showing anti microbial,anti diabetic, anti fungal, anti-inflammatory and astringent effects. It is listed among drugsused for GI disorders, dental care and geriatric care214.Gana: - Thriphala, Amalakyadi, Parooshakadi (Su); Prajasthapana, Jwaraghna,Kushtaghna, Kasaghna and Arsoghna (Cha)Yoga: - Pathyadi choornam, Sadhyadi kwatha, Vaiswanara choorna, Yogaraja guggulu,Simhanada guggulu Brihat saindhavadi taila.Dose: - Thriphala choorna 250 mg – 500 mg, Abhayarishta 20-30 mlSUNTI (Zingiber officinale) 215,216,217,218,219.Family: - Zingiberaceae (Haridrakula)Synonyms: - Mahoushadha (one of the best amongst medicines), Viswabheshaja (it isbeing used in many diseases and many recipes)Identification: - This is a perennial herb perennating by means of stout horizontal tuberousjointed aromatic root stock having several sessile lateral tubers with an annual elongateerect leafy shoot 60 cms to 1m length. Leaves are alternate, sub sessile, ovate, lanceotateand lateral veins parallel. 69
  • Chemical Composition: - A yellow pungent substance called ‘Gengerol’, ‘Zingiberine’,Cineole, Borneol and Geraniol are the chief costituents. Is also contains iodine, chlorineVitmanine A, B and C. Other chemicals isolated are Acetaldehyde, Ascorbic acid,Asparagines, Comphene, Chavicol, Citral, Dehydrogingerdoine, Gingerdione, Hexahydrocurcumin, Limonene,Lialool, methionine, myrcene, zingerone and tryptophan. 6 analgesis,11 sedatives, 6 antioxidants, 6 antivirals, 17 bactericide and 8 hepato protective chemicalshave been isolated from zinger220.Part used: - Rhizome.Rasa-Katu, Vipaka-Madhura, Veerya-Ushna, Guna-Laghu, Snigdha. Doshaghnata-KaphaVataghna. Karma- Externally Sheeta prasamana, Sothahara and Vedanasthapaka.Internally it is Ama Pachaka, SrotoSothaka, Deepaka, Pachaka, Rochaka,SoolapRasamana, Jwaraghna, Swarya, and Vrushya.Indications: - Amavata, Sandhivaata, Ajeerna, Aruchi, Agnimandya, Hrillasa, Chardi,Adhmana, Hrid roga, Swasa, Kasa, Pratisyaya.It is a listed drug showing anti-inflammatory, anti microbial and anti fungal activity. It is listedin the drug of choice of GI disorders and Dental care221.Gana: - Soola prasamana, Trishna nigrahana, Triptighna, Arsoghna, Deepaneeya (Cha)Pippalyadi, Trikatu (Su), Panchakola, Shadooshana (Bh.Pr)Yogas: - Sundhyadi kwatha, Nagara choornam, Panchakola choorna, Sadhyadi kwatha,sadhyadi kalka, Rasnadasamoolakam, Rasnapanchakam, Rasna saptakam, Vaiswanarachoorna, Pathyadi choornam, Nagara ghritamDose: - choornam 1-3 gmGUDUCHI (Tinospora cordifolia) 222,223,224,225,226.Family: - Menispermaceae- (Guduchikula)Synonyms: - Amrita (having nector like qualities), madhuparni (leaves yield honey likethick juice) 70
  • Identification: -A glabrous climber with succulent, corky, grooved stems; branches sendingslender pendulous hanging, drooping fleshy roots, terete -cylindrical rounded in crosssection, striate with knobbing projections, pale sometimes shining or glabrous bark, bluishgreen often with a fine blume, leaves membranous, 7-9 nerved 5-10 cm or rarely 12 by 10cm, roundish or sub deltoid, cordate with broad sinus and large barel lobes, obtuse or moreor less cuspidate, reticulately veined with microscopic glistening glands beneath. It growsthroughout India, Burma and Sri Lanka.Chemical constituents: - This contains starch, Berberine and bitter substance.Parts used: Stem, leaves and root (kanda)Rasa: -Tikta, kashaya. Vipaka- Madhura. Veerya-Ushna. Guna-Guru, Snighda;Doshaghnata- Tridoshahara. Karma-Rasayana, Grahi, Balya, Agnideepaka, Amaghna,Krimighna and Vedanasthapaka.Indications: - Jwara, Kamala, Pandu, Meha, Vatarakta, Skin diseases – Kushta, Chardi,Bhrama, Daha. It is a known immunomodulator drug. It is a listed drug showing analgesic,anti-inflammatory, astringent, anti microbial, anti diuretic, antiviral and anti fungal activities.It is a listed drug using in GI disorders, Dental care and Geriatric care. Bitter propertiespresent in the drug show anti-spasmodic, anti pyretic and anti-inflammatory properties. Thedrug posses 1/5th of the analgesic effect of sodium salicilate. A kind of starch called Giloc-ka-sat, prepared from aquous extract of dry stem is used as a tonic227. Javle et al has studied its antiendotoxic effect and found effective. D.P Dhawla hasworked on the effect of T.C in normal lymphopenic mice and found that it hastens theregenerations of thrombocytes. R.S koti et al found it as a drug of choice in multi organdysfunctions in obstructive jaundice229. A.K Pathak et al has isolated a steroid called 20-beta hydroxyecdysnone.Gana: - Vayasthapana, Daha prasamana, Trishna nigrahana, Stanya Sothana, Triptighna(Cha); Gudoochyadi, Patoladi, Aragwadhadi, Kakolyadi, Vallee panchamula (Su). 71
  • Yoga: - Amruta ghritam, Sadhyadi kwatha, Rasna dasamoolakam kwatha, Rasnapanchakam kwatha, Rasna saptakam kwatha, Amrutadi choornam.Dose: - Amruta satwa 50-250 mg. Juice 10-50 mlTRIVRIT (Operculina terpethum) 230,231,232,233,234.Family: - Convolvulaceae (Trivrit kula)Synonyms: - Aruna, Nishodha (reduces ooedema), Rechani (induces sukha virechana),Rochani (Stimulates the taste perception)Identification: - Perennial with milky juice, root long, slender, fleshy, much branches;stems very long, twining twisted together, angled and winged, pubscent, and brown whenold. Leaves 5-8 by 1.3-7 cm ovate or oblong rarely. Slightly tobulate, subacute and more orless pubescent According to Charaka thrivrut is two types based on root colour. I.e sweta andKrishna varna. Krishna varna is used in the present study.Chemical composition: - A glucoside called Turpethin, some ether soluble resin, a volatileoil, a yellow colouring matter, albumin, starch, tignin, salts and ferric oxide.Parts used: - Root bark.Rasa – Katu, Tikta, Madhura, Kashaya. Vipaka-Katu. Veerya-Ushna; Guna-Laghu,Rooksha, Theekshna. Doshaghnata-KaphaPittaghna; Karma-Sukha-virechana, Bhedaka,Sothahara, Jwaraghna;Indications: - Amavata, Jwara, Vatarakta, Sotharoga, Pandu, Pleeha and Vrana roga. It is a listed drug showing anti-inflammatory, anti arthritic and anti microbial activity.It is listed in the drug of choice of GI disorders235.Gana: - Bhedaneeya (Cha), Adhobhagahara, SyAmadi (Su)Yogas: -Trivrit choorna, Trivrit lehyam, Trivritadi kwathaDose: -Root bark powder 250-500mg; Trivrutadi kwatha 20-50ml; Trivrutadi ghrita –30ml 72
  • DHANYAMLA236 Before going into the details of Dhanyamla Kayaseka it is necessary to understandthe term Dhanyamla. A cursory glance itself reveals that the term “Dhanyamla “ isconjugate of two different words, viz ‘Dhanya’ and ‘Amla’ which in conjugation means‘fermented cereal’ in a broad sense. All the three major classics of Ayurveda at someinstance or other have referred to its use at times, singularly or along with other drugs.Maharshi Charaka, Susruta and Vaghbata have included this either in Amlavarga,Santhana kalpana or in Madya vargha. Maharshi Charaka further mentioned the drugsused for Dhanyamla in Nadi sweda and Upanaha.Synonyms: - A perusal of the ancient text of the medicine reveals that a number ofsynonyms have been attributed to Dhanyamla which in most cases refer to a specificattribute and when taken collectively gives a clear idea about the character and propertiesof Dhanyamla. Narisimha has in this context very rightly stated that these synonyms toDhanyamla are complementary to each other and as such there is no difference between‘Dhanyamla’ and ‘Kanjhika’. ‘Guna deepika’, a celebrated lexicon on medical plants givesthe following compilations of synonyms as attributed to Dhanyamla. 1. Aranala: ‘Aranalasya rigathownala gandha‘ i.e having acrid fast spreading odour. 2. Abhishuta:’shunj abhishave’ i.e made of half cooked cereals. 3. Avanthisoma: prepared out of ‘soma’ found in Avanti Desha. 4. Kulmasha: ‘Kula samsthyana’ i.e having half cooked ‘masha’ or black grain. 5. KunJala: Indicative of fermented water. 6. Sowveeraka: Found in Sowveera desha. Among these, Sowveerka’ and ‘Avantisoma’ are synonyms pertaining to geographicalprepondarance or indicative of place. Abhishuta, Dhanyamla, KunJala , Kulmasha etc areindicative of the process of fermentation. Aranala speeks of its acrid odour. 73
  • Properties of Dhanyamla: - The known fact that Dhanyamla, amla or sour in taste servesas an aid in delving into other properties of the Ama in the sense that since it is Amla inRasa the associated qualities of Amla Rasa as stated in the classics, viz, Laghu, Ushna,Snigdha, Deepana, Vatanulomana etc. can be safely attributed to it. The properties ofDhanya like Brimhana, Tarpana, Balya and Vatahara are also supplemented. In brief, Dhanyamla may possess the following properties. • Rasa - Amla • Guna - Leghu, Snigdha, Teekshna, Sheeta sparsa • Vipaka - Amla • Veerya - UshnaGeneral properties: - Deepana, Pachana, Rochana, Bhedi, Vibhandhahrasa, Hrudya,Klamahara, Angasada hara, Dahajwarahara, Hrudrogahara, Panduhara, Krimighna,Arshohara, Grahanihara, and Bastisulahara. It can be used for Astapana. Among other indications for its use, Maharshi Charaka has specified its used inDahajwara where in Avagaha of the patients in Kanji has been recommended237. The sameis also indicated to relieve pain in Arshas238. Further in Rajayakshma when Prathishyayaand Peenasa super imposed on it, renders the ailment complicated, Nadi sweda by Kanjihas been advocated239. Since Amla is Sheeta sparsa and acts so in external wage,Charaka has felt safe to vouch for its use externally as Lepa, Seka etc. in Urusthambhaalso; he mentioned the use of the drug Dhanyamla240. In short while going through the references of the use of Dhanyamla in differentcontext as found in classics, it is able to conclude that the drugs which are used for thepreparation of the Dhanyamla and Dhanyamla as such are preferred in Vatarogas andVatakapha samsargha janya diseases. 74
  • Method of preparation: -241 Dhanyamla can be prepared out of different drugs. Manydrugs are available which easily get fermented. The Yoga mentioned in Sahasrayoga isselected in this study. The combination and proportion of the Yoga is as follows in table 5: Table 5 1 Tandula (Oryza sativa) 5 parts 2 Pruthuka (Pressed form of Oryza sativa) 5 parts 3 Kulatha Dolichos biflorus) 5 parts 4 Laja (Puffed form of Oryza sativa) 20 parts 5 Kangubeeja (Setaria italica) 4 parts 6 Kodravam (Paspalum scrobiculatum) 2 parts 7 Nagara (Zingiber officinale) 1 part 8 Nimbuka (Citrus acida) 4 parts 9 Dipyaka (Carum roxburgianum) 2 parts 10 Water 100parts Traditional physicians of Kerala generally follow this particular combination. On an auspicious day at a time when the astral combinations are favorable, thenecessary drugs and Paraphernalia for the preparation of the Dhanyamla are to becollected. Place a large deep earthenware pot on an oven and pour 200 Prasthas of boiledwater and put the powdered drugs 1-9 separately made into loose bundles in clean clothbags. After putting these drugs into the vessel along with water, it has to be looselycovered with a lid and heated gently and continuously in moderate fire, preferably of paddyhusks, for a period of 7 days. The paddy husks are to be put under and around the vesseland fired taking every precaution that the temperature of the water in the vessel does notrise above the boiling point. On the 8th day the required quantity of the liquid is taken outand added same quantity of hot water. The methodes of preparation adopted in this studyare discussed in the discussion part. 75
  • The important factors to be recommended during the preparation of Dhanyamla isthat § Absolute cleanness should be maintained § Moderate fire should be kept through out he preparationThe details of the ingredients are as follows1. TANDULA (N.O. Graminae, L. N. Oryza sativa) : Tandula possesses Madhura and Kashaya Rasa, Madhura Vipaka as Sheeta Veerya. By Guna it is Guru. It alleviates Pitta Dosha and provokes Kapha Dosha.2. PRUTHUKA (N.O. Graminae, L.N. Oryza sativa): It is made out of Tandula. Prepared by little heating and wet pounding of Tandula.3. KULATHA (N.O. Leguminoceae, L.N. Dolichos biflorus): Kulatha possesses Kashaya Rasa, Katu Vipaka and Ushna Veerya. By Guna it is Laghu, Vidahi and Sara. It acts as Kapha Vatahara. It provokes Pitta Dosha also.4. LAJA (N.O. Graminae, L.N. Oryza sativa): It is made out of Tandula. Prepared by dry frying in a small-mouthed vessel. This process is known to induce Laghu Guna.5. KANGUBIJA (N.O. Graminae, L.N. Setaria italica): Kangubija possesses Kashaya and Madhura Rasa, Katu Vipaka and Ushna Veerya. By Guna it is Guru and Ruksha. It acts as KaphaPitta shamaka and Vata vardhaka. It possesses Sandhaneeya and Vrushya properties.6. KODRAVA (N.O. Graminae, L.N. Paspalum scrobiculatum): Kodrava is of Madhura- Kashaya in Rasa, Katu in Vipaka and Sheeta in Veerya. By Guna it is Laghu and Ruksha. It alleviates Kapha and Pitta Dosha and provokes Vata Dosha.7. NAGARA: Already described in Alambushadi Yoga.8. NIMBUKA (N.O. Rutaceae, L.N. Citrus acida): Nimbuka is of Amla Rasa, Amla Vipaka and Ushna Veerya. By Guna it is Laghu. It pacifies kapha Dosha. It has got Agnideepana, Rochana, Pachana and Trishnanigraha properties. 76
  • 9. DIPYAKA (N. O. Umbelliferae, L.N. Carum roxburgianum): Dipyaka possesses Katu and Tikta Rasa, Katu Vipaka and Ushna Veerya. By Guna it is Laghu, Ruksha. It acts as Samaka for Kapha and Vata Dosha. It has got Shoola Prashamana, Rochana and Krimighna properties. PHYSIOCHEMICAL ANALYSIS REPORT (Analyzed at K.L.E. society’s Pharmacy college, Gadag.) I. Alambushadi Yoga : 01. Loss on drying at 1100 C. = 2.35 % w/w 02. Ash value = 7.57 % w/w 03. Acid insoluble ash = 0.445 % w/w 04. PH of 10 % (w/w) aqueous solution = 5.42 05. Solubility = Highly soluble in water, weakly soluble in Alcohol. 06. Test for Alkaloids a. Mayer’s Test = Positive b. Hager’s Test = Positive 07. Test for Carbohydrates a. Molish Test = Positive (Carbohydrate present ) b. Benedict’s Test = Positive (Reducing sugar present) c. Barfoedt’s Test = Positive (Monosaccherides present) 08. Average weight of Capsule = 0.5152 gram. II. Dhanyamla H 01. P = 3.03 02. Specific gravity = 1.01 03. Test for Alkaloids a. Mayer’s Test = Positive b. Hager’s Test = Positive 04. Test for Carbohydrates a. Molish Test = Positive (Carbohydrate present ) b. Benedict’s Test = Positive (Reducing sugar present) c. Barfoedt’s Test = Positive (Monosaccherides present) 77
  • Chapter –4 Materials and MethodsThe materials and methods of the present study consist of following headings; 1. Selection of patients 2. Grouping of patients 3. Administration of drug 4. Criteria of assessment 5. Method of Kayaseka1. Selection of patients: - 32 patients of Amavata fulfilling the criteria of diagnosis were selected out of 68patients who attended the OPD. Two patients were excluded as they defaulted thetreatment and three patients were excluded as they were not ready for admission.Ultimately 27 patients were selected for study based on inclusion and exclusion criteria as 9patients in each group.(a) Inclusion criteria: - • Age of patients between 15 to 65 years. • Amavata of any Doshanubandha • No discriminations of chronicity and severity of disease.(b) Exclusion criteria: - • Patients below 15 and above 65 years of the age • Patients with complications like deformity, loss of functions and Grandhi. • Pregnant women and lactating mother. • Any other systemic disorders other than Amavata. 78
  • Criteria of Diagnosis: The signs and symptoms of Amavata mentioned in Ayurveda were the main basis ofdiagnosis. In addition, the criteria laid down for Rheumatoid Arthritis by AmericanRheumatism Association were also followed. These have been revised at a conference andthe criteria now in use are as follows242. 1. Morning stiffness for more than 1 hour for more than 6 weeks. 2. Arthritis of 3 or more joints. 3. Arthritis of hands for more than 6 weeks. 4. Symmetrical arthritis for more than 6 weeks. 5. Rheumatoid nodules at any prominence or at extensor surfaces or juxta articular regions as observed by a physician. 6. Serum Rheumatoid factor. 7. Radiological changes- soft tissue swelling, narrowing of joint space, rarefaction and no osteophytes. 8. Swelling at least at one joint. 9. Female. 10. Above 40 years. 11. Bony deformity. A proforma was prepared incorporating all signs and symptoms of Amavatamentioned in Ayurvedic classics and modern literature. It also includes Ashtasthanapariksha, Dasavidha pariksha, and Nidana and Samprapti Ghatakas. At the out set,detailed clinical history was taken and detailed physical examination was done on the basisof the proforma. Rheumatoid factor test, C-Reactive Protein (CRP) test, and routinehaematological tests were also carried out. In addition to the above, ASO titer, blood smearstudy, routine stool and urine examinations, radiological examination and certain biochemical investigations like serum cholesterol, serum uric acid, serum acid phosphate andserum alkaline phosphate were carried out in necessary condition, to exclude otherpathology as well as to confirm the diagnosis. 79
  • The assessment of Vaya, Nadi, Prakriti, Sara, Samhanana, Satmya, Satwa, Aharasakti, Vyayama sakti, State of Agni, Ahara, Nidra, Purisha Pravritti, Mutra Pravritti, Vyasanaand Artava Pravritti were performed in all the cases with special reference to classicalAyurvedic description. Assessment of Dosha vrudhi, Dosha Kshaya, Sama dosha, SamaDhatu, Ama, Sama Mutra, Sama Purisha, Nature of pain, aggravating factors, relievingfactors, family history and Nidana were also performed. All the information for assessment is entered in the proforma in numerical form. Thenumerical data are collected before the treatment, after the treatment and after the followup of 21 days. Certain gradations and declarations are made about the data, which arefollows:1. Bahu Sandhi shoola (Pain) Score No complaints 0 Patient tells about after enquiry 1 Patient frequently complaints 2 Excruciating condition 32. Bahu Sandhi graha (Morning stiffness) Score No complaints 0 Upto 30 minutes 1 Upto 60 minutes 2 More than 60 minutes 33. Bahu Sandhi Sotha (Swelling) Score No complaints 0 Slightly obvious 1 Covers well the bonny prominence 2 Much elevated so that joints seems grossly deformed 34. Sparsa asahishnuta (Tenderness) Score No complaints. 0 Says a tender joint 1 Winces the affected joint. 2 Winces and withdraws the affected joints. 3 80
  • 5. Gourava (Heaviness); associated complaints like Angamarda, Aruchi, Trishna, Alasya, Jwara, Apaka, Angasunata, Agnidourbalya, Praseka, Utsahahani, Daha, Bahumutrata, Kukshi sula, Nidra Viparyaya, Chardi, Bhrama, Murcha, Hrit-graha, Vit Vibandha, Jadhyata, Antra kujana, Anaha, Vatopadravas, Pandu varna, Peeta netrata, Sosha, Vishuchi, Ushnata and Janghadi pradeshe vyadha. Special examination like Dosha vrudhi, Dosha Kshaya, Sama dosha, Sama Dhatu,Ama, Sama Mutra and Sama Purisha lakshanas, muscle wasting and movements affectedwere graded as mentioned below. Score No complaints 0 Mild 1 Moderate 2 Severe 3 Very severe 4 Declarations: -Following declarations were made to change the data into numerical form.a) Bonny components palpable: 0 = Normal, 1 = Abnormalb) Change with rest, change with movement: 1 = Reduces, 2 = Increases, 3 = Constant, 4 = No relationc) Climatic relations: 1 = Changes, 2 = Constant, 3 = No relationd) Deformity: 0 = Absent, 1 = Swan neck, 2 = Boutonniere, 3 = Ulnar deviation, 4 = MCP subluxation, 5 = Ulnar clow hand, 6 = Fixed flexion, 7 = Fixed abduction or adduction, 8 = Shortening, 9 = Genuvalgam, 10 = Genuvaram, 11 = Othere) Dietetic relations: 1 = Before food, 2 = After food, 3 = No relationf) Diurnal change of pain: 1 = Morning, 2 = Evening, 3 = Night, 4 = Constant, 5 = No relation 81
  • g) Bursitis, Crepitation, History of trauma, Synovial thickening, tenosynovitis: 0 = Absent, 1 = Presenth) Nature of Pain: 1 = Ruja, 2 = Toda, 3 = Vruschika damsavat vedanai) Onset of Pain: 1 = Sudden, 2 = Gradualj) Skin: 1 = Dry, 2 = Moistk) Warmth: 0 = Normal, 1 = Decreased, 2 = Risen2. Grouping of Patients : After the diagnosis, the patients were randomly and equally distributed into three groups a. Group A: Alambushadi yoga group b. Group B: Dhanyamla Kayaseka group c. Group C: Both Alambushadi yoga and Dhanyamla Kayaseka group This study was conducted on total 27 patients who could continue the treatment for fullduration and come for follow up till to the last. The patients were selected from OPD & IPDof PGS & R. DGM AMC Hospital, Gadag. Out of 27 patients 18 patients were admitted inIn-patient department of DGM AMC Hospital and other 9 patients were given medicines atOPD level.3. Administration of Drug : Alambushadi yoga capsules were given through oral route. Six capsules were given inthree-divided doses half hour before food in froup A and C. Luke warm water was advisedas Anupana for all. Dhanyamla Kayaseka was carried out on the whole body except the head. First dayseka was done for 30 minutes and increased daily by 5 minutes up to a maximum of 1 hour.Before the process of Seka pulse, temperature, blood pressure, emotional status andinternal organs were examined thoroughly and the patients were also given dueassessment about the outcome of the management. After completion of the procedure theabove data are recorded and analyzed thoroughly. Further patients were kept under 82
  • intensive care for one hour. Then the patients were advised to take complete rest in theward. 3 to 5 litres of fresh Dhanyamla was used every day for a patient. Everyday freshDhanyamla was taken for the procedure. External and internal medicaments were strictly avoided in the follow up periodPathya: All the patients were advised to take light diet luke warm water and some PathyaAhara Vihara mentioned for Amavata.Apathya: - All the patients were advised not to take cold drinks, cold food, day sleep andother Apathya Ahara Vihara mentioned for Amavata.4. Criteria of assessment : Many efforts have been taken in the past years to standardize the assessment ofRA aiming at making the study results interchangable. European League AgainstRheumatism (EULAR) and the American College of Rheumatology (ACR) has laid downcertain criteria for measuring the variables in RA243. Considering all the above suggestions in the present study, results were assessedaccording to the improvement in the clinical signs and symptoms, functional ability,laboratory investigations, disease activity and overall improvement etc.I. Clinical Assessment: -Details of the assessment of clinical signs and symptoms are as follows:1. 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 a number of categories. The following questionnaire was given to the patient244. How often is it painful for you to: 83
  • Table No 6: No Daily Functions Never Some Most of Always times times 1 Dress yourself? 0 1 2 3 2 Get in and out of bed? 0 1 2 3 3 Lift a cup or 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 0 1 2 3 from the floor? 7 Turn faucets on or off? 0 1 2 3 8 Get in and out of a car / bus etc? 0 1 2 3 Scoring: Normal - 0 to 4 Adequate - 5 to 12 Impaired - 13 to 20 Disabled - 21 to 24 b) VAS method: - A VAS can be interpreted as a ratio scale and is more sensitive to change. The VAS is a 100 mm long horizontal scale with ‘no pain’ at one end and ‘worst possible pain’ at the other end without intervienging categories245. 0 100mm No Pain Worst possible pain Patients were asked to mark ‘X’ on the scale for how much pain they had in he past week.2. Ritchie articular index (RAI): - 246 RAI is a graded joint tenderness score based on 53 joints. This index sums gradesof tenderness. The following 53 joints were considered as RAI. Single joints: Elbows Ankles Wrists Talocalcaneal joints Hips Mid tarsal joints Knees 84
  • Units: Temporomandibular joints Cervical spine (assessed by passive motion) Sterno clavicular joints MCP joints PIP joints MTP jointsDifferent grades of tenderness declared before are used to calculate RAI.3. Bahu Sandhi shoola (Swelling 44): -247 Swelling 44 (S-44) is an ungraded joint swelling count based on 44 joints. Among53 joints of RAI, Cervical spine, Hip, Talocalcaneal joints and midtarsal joints are excludedin S-44, as they are difficult to examine for true synovitis.4. Joint tenderness and swelling – 28 joint count (T-28 and S-28): - The 28 joint count is a not graded and not weighted count, measuring tendernessand swelling separately. As this 28 joint count has higher reproducibility or lower interobserver variability, is most valid and take least time consumption248. The following are thecounting 28 joints. • Shoulder • Elbow • Wrist • MCP joints • PIP joints of fingers • Knees 85
  • 5. Sandhi Graha (Morning stiffness): - Different grades of morning stiffness declared before are used.6. Gourava (Heaviness): - Different grades of Gourava declared before are used.7. Indices of Madhavakara, Anjana Nidana and Basavarajiya a) MIA – Signs and Symptoms mentioned in Madhava Nidana. b) ANIA – Signs and Symptoms mentioned in Anjana Nidana. c) BIA – Signs and Symptoms mentioned in Basavarajiya. These indices sum grades of signs and symptoms what they mentioned. Differentgrades of signs and symptoms mentioned before are used to calculate these indices.8. Extra Articular Manifestation of RA Index (EAMRAI): - This index sums grades of different extra articular manifestations such as systemic,musculo skeletal, dermal, eye, respiratory, cardiac, neurological, haematological,reticuloendothelial and other manifestations. Score No Complaints 0 Mild 1 Moderate 2 Severe 3 Very severe 49. Global Disease Activity (GDA): - a. Patient’s assessment of Global Disease Activity249. b. Physician’s assessment of Global Disease Activity250. This is measured on a 100mm horizontal Visual Analogue Scale (VAS) using the Arthritis Impact Measurement Scale (AIMS) questions. 86
  • 0 100mm No complaints Worst possible condition Considering all the ways the arthritis affects the patients were asked to mark ‘X’ onthe scale for how well he/she was doing.10. Ayurvedic Health Assessment (AHA): - AHA is done according to the Swasthya Lakshanas mentioned by AcharyaKashyapa251. Table No 7: S V.S S.W N.N S.W.D V.D N .S 1 Annabhilasha 1 2 3 4 5 2 Bhuktasya paripakam 1 2 3 4 5 3 Srishta Vit 1 2 3 4 5 4 Srishta Mutra 1 2 3 4 5 5 Sarira laghavam 1 2 3 4 5 6 Suprasennendriyam 1 2 3 4 5 7 Sukhaswapnam 1 2 3 4 5 8 Sukhaprabothanam 1 2 3 4 5 9 Balam 1 2 3 4 5 10 Varnam 1 2 3 4 5 11 Soumanasyam 1 2 3 4 5 12 Samagnita 1 2 3 4 5 87
  • II. Functional Assessment: -1. Arthritis Impact Measurement Scale (AIMS): -252Table No 8: AIMS is scale of impact due to Arthritis. It sums graded of various variables. N Variable satisfied satisfied satisfied Somewh Somewh dissatisfi dissatisfi dissatisfi Neither Very Very nor o ed ed ed at at 1 Mobility level 1 2 3 4 5 2 Walking & 1 2 3 4 5 bending 3 Hand & finger 1 2 3 4 5 functions 4 Arm functions 1 2 3 4 5 5 Self care tasks 1 2 3 4 5 6 House hold tasks 1 2 3 4 5 7 Social activity 1 2 3 4 5 8 Support from 1 2 3 4 5 family & friends 9 Arthritis pain 1 2 3 4 5 10 Work 1 2 3 4 5 11 Level of tension 1 2 3 4 5 12 Mood 1 2 3 4 52. Physical Disability: - 253 It is the patient’s self assessed disability for the assessment of physical functioning. Itwill be obtained by standardized observation of ability to perform specific works. Thefollowing health Assessment Questionnaires prepared by Stanford Unversity School ofMedicine is used to assess physical disability253. Table No 9: No Activities Without With some With much Unable to any difficulty difficulty do difficulty 1 Dressing & 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 / 0 1 2 3 pickup) 7 Grip 0 1 2 3 8 Activities 0 1 2 3 88
  • 4. Walking time: - Patients were asked to walk a distance of 40 feet and the time taken was recordedbefore and after the treatment and after follow up.5. Grip Strength: - To find the functional capacity to affected upper limb, the patient’s ability to compressan inflated ordinary sphygmomanometer cuff under standard condition was carried outbefore and after treatment and after follow up.6. Range of movements: - The range of movements of major joints is determined. Score No movement 0 Up to 50% 1 50 to 70 % 2 Above 70% and less than Full range 3 Full range 4 III. Investigations: -1. Acute phase reactants: - Westergren Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)are the two acute phase reactants.2. Hemoglobin percentage: -3. Total lymphocyte count: - IV. Disease activity measures: -254,255. The Disease Activity Score (DAS) is a statistically derived index combined tenderjoints, swollen joints, and ESR and general health. It was validated in several studies. Theoriginal DAS comprised a graded joint tenderness score, the Ritchie Articular Index, and a44 swollen joint count. As a result of new international preferences the DAS 28 is developedwhich included the 28-joint counts for tenderness and swelling 89
  • DAS = 0.5398(RAI) + 0.06465 s (44) + 0.330 (In ESR) + 0.00722 (GH)DAS- 28 = 0.56(T28)+0.28(s-28)+ 0.70 (In ESR)+0.014(GH)RAI - Ritchie Articular Index graded joint tenderness score based on 53 joints.S-44 - Ungraded joint swelling count based on 44 joints.In ESR- Natural logarithm of erythrocyte sedimentation rate.GH - General Health according to the patient.T28 - Ungraded joint tenderness count based on 28 joints.S-28 - Ungraded joint swelling count based on 28 joints.V. Overall Assessment of the treatment (Improvement Criteria): -The results were classified into four groups as listed below. 1. Complete remission. 2. Good improvement / Subsidence. 3. Moderate improvement / Minor Subsidence. 4. No improvement.1. Criteria for complete remission: -256 A minimum of five of the following requirementsmust be fulfilled for at least two consecutive months in a patient with definite or classic RA: i. Morning Stiffness not exceeding 15 minutes. ii. No fatigue. iii. No joint pain. iv. No joint tenderness or pain in movement. v. No soft tissue swelling in joints or tendon sheaths. vi. ESR (Westergren) less than 30mm / hour (females) or 20mm / hour (males). As the study duration was 21 days with 21 days follow up, the above criteria wereconsidered after the treatment and after follow up.2. Criteria for good improvement / Subsidence: - 257 90
  • • EULAR criteria: Change in DAS / DAS-28 from baseline is more than 1.2 (i.e. >1.2)i. ACR criteria: 50% and above improvement in: a. Tender joint count. b. Swollen joint count. And in 3 of the following 5 i. Patient pain assessment. ii. Patient global assessment iii. Physician global assessment. iv. Patient self-assessed disability. v. Acute phase reactant. 3.Criteria for Moderate improvement: -258 • EULAR criteria: Change in DAS / DAS-28 from baseline is more than 0.6 and less than or equal to 1.2 (i.e. >0.6 and <1.2)ii. ACR criteria: above or equal to 20% and below 50 % improvement in: a. Tender joint count b. Swollen joint count And in 3 of the following 5 i. Patient pain assessment ii. Patient global assessment iii. Physician global assessment iv. Patient self-assessed disability v. Acute phase reactant 4. Criteria for no improvement: -259 • EULAR criteria: Change in DAS / DAS-28 from baseline is less than or equal to 0.6 (i.e. < 0.6) iii. ACR criteria: below 20% improvement in: a. Tender joint count b. Swollen joint count 91
  • And in 3 of the following 5 i. Patient pain assessment ii. Patient global assessment iii. Physician global assessment iv. Patient self-assessed disability v. Acute phase reactant5. Methods of Kayaseka 260 Traditional methods of Kayaseka is pouring the medicines by dipping pieces of cleancloth in sufficient warm Drava and squeeze the cloth over the body with the hands. Smallhandy ‘undines’ known as ‘Kindi’ may also be used for pouring the warm medicines over thebody. Before pouring patient should undergo Abhyanga with suitable oil. But in disease likeAmavata, Abhyanga is not advised due to the presence of Ama. The medicine should berepeatedly heated during the procedure to maintain the temperature. Considering all theprinciples, the following procedure is performed in the present study. Sufficient quantity of Dhanyamla i.e. 3-4 litre is made mild warm and kept ready in asteel pot. To maintain the temperature throughout the procedure, the pot is kept on anelectric stove or charcoal store placed near the lower end of the Droni. A Dhara machine isused to perform Kayaseka. It is a lightweight cylindrical instrument of about 30cm length and6-8 cm diameter. Top of the machine has an AC motor and bottom consists of a chamberwith a fan inside. A long rubber tube approximately 1½ -2m and 1 cm diameter is attachedto the chamber. This tube is used to bath with the medicine. The Dhara machine is fixed atthe top with the lower end of Droni near its outlet. Lower end of instrument is properlydipped in Dhanyamla pot that is arranged below on an electric stove. The wholearrangement is aimed to maintain an uninterrupted flow and a temperature of Dhanyamladuring the procedure. 92
  • After performing certain sacred rights, at morning the patient was allowed to sit onthe Taila Droni. Two attendants will stand, two on each side of the Droni, to carry out theprocedure. When the power is switched on, Dhara machine pumps the Dhanyamla from thepot to the Droni as a single stream flow through the long tube. One will pour the Dhanyamlaon one limb and Samvahana or mild message in downward direction will follow it. At thesame time the second one will do mild message in downward direction on the other side.Like this the whole body will be bathed with Dhanyamla without any break in all the sevenpostures. The Dhara will be poured at a medium speed neither too quickly not too slowlyand from a moderate height neither too higher nor too lower from the body. Before starting the procedure and during the procedure also, Dhanyamla will bechecked and ensured that the patients may not feel any discomfort in that temperature. 93
  • Chapter –5 Observations and Results 32 patients were registered for this study. Out of this 5 patients were excluded, sotheir data has not been included here. The remaining 27 patients of Amavata fulfilling thecriteria for diagnosis were treated in the following three groups. Group A- Alambushadi Yoga – 9 patients. Group B- Dhanyamla Kaya Seka – 9 patients. Group C- Both Alambushadi Yoga & Dhyanyamla Kaya Seka – 9 patients. DEMOGRAPHIC DATA The details of age, sex, religion, occupation etc of the 27 patients were as follows 94
  • 1) Distribution of the patients by age: Table 10: Distribution of the patients by age. Age Group A Group B Group C Total Percentage 15-25 01 0 02 03 11.11 26-35 01 01 03 05 18.52 36-45 04 07 01 12 44.44 46-55 03 01 03 07 25.93 56-65 0 0 0 0 0 Group A have maximum number of patients i.e. 4 (44.44%) in the age group of 36-45, and group B also have maximum patients i.e. 7 (77.78%) in the age group of 36-45.Group C have 3 patients each (33.33%) in the age group of 26 – 35 and 46-65. Out of 27patients majority of the patients i.e. 12 (44.44%) were in the age group of 35-45 years.Below depicted graph describe the above statement. Graph No. 01. Distribution of patients by age 7 7 6 5 4 4 Patients 3 3 Group A 3 3 Group B 2 Group C 2 1 1 1 1 1 1 0 0 0 0 0 15-25 26-35 36-45 46-55 56-65 Age 95
  • 2) Distribution of patients by sex Table 11: Distribution of patients by sex Sex Group A Group B Group C Total Percentage Male 2 1 2 5 18.52 Female 7 8 7 22 81.48 Total 9 9 9 27 100 7 patients (77.78%) in group A were females and 2 patients (22.22%) males. Ingroup B 8 patients (88.89%) were females and 1 patient (11.11%) male. In group C 7patients were females (77.78%) and 2 patients (22.22%) males. So, out of 27 patientsmaximum number of patients i.e. 22 (81.48%) were females and males were only 18.52%.Below depicted graph describes the above statement. Graph 02: Distribution of patients by sex 8 8 7 7 7 6 5 Patients 4 3 2 2 2 1 1 0 Male Group A Group B Group C Female Sex 96
  • 3) Distribution of patients by religion Table 12: Distribution of patients by religion.Religion Group A Group B Group C Total Percentage Hindu 9 9 7 25 92.59 Muslim 0 0 2 2 7.41 Christian 0 0 0 0 0 Others 0 0 0 0 0 Total 9 9 9 27 100 All the patients in group A and group B i.e. 9 patients each (100%) were Hindus. Ingroup C 7 patients were (77.78%) were Hindus and 2 patients (22.22%) Muslims. So, out of27 patients maximum number of patients’ i.e. 25 (92.59%) were Hindus and only 7.41% ofpatients were Muslims. There were no patients belong to Christian or other communities.Below depicted graph describes the above statement. Graph 03: Distribution of patients by religion. 9 9 9 Hindu 8 Muslim 7 7 Christian 6 Others 5 Patients 4 3 2 2 1 0 0 0 0 0 0 0 0 0 Group A Group B Group C Religion 97
  • 4) Distribution of patients by occupation Table 13: Distribution of patients by occupation.Occupation Group A Group B Group C Total Percentage Labour 2 1 1 4 14.81 Sedentary 1 0 1 2 7.42 Intellectual 1 1 1 3 11.11 Active 0 3 1 4 14.81Housewives 5 4 5 14 51.85 Total 9 9 9 27 100 5 categories of occupation were considered in this study. In group A and group C , 5patients (55.56%) each were housewives, and in group B 4 patients (44.45%) werehousewives. Labours were 2 patients (22.22%) in group A and 1 patients each (11.11%) ingroup B. There were 1 patient (11.11%) each in instinctual level in all the three group s.Three patients (33.33%) in group B were active and 1 patient (11.11%) in group C. Therewere 1 patient (11.11%) each in sedentary level in group A and C. So, out of 27 patientsmaximum number of patients i.e.14 (51.85%) were housewives. Below depicted graphdescribes the above statement. 5 Labour Sedentary 4 Intellectual Active Graph 4: 3 Housewives Distribution of 5 5 Patients patients by 4 2 occupation 3 2 1 1 1 1 1 1 1 1 1 0 0 0 Group A Group B Group C Occupation 98
  • 5) Distribution of patients by socio-economic status Table 14: Distribution of patients by socio-economic statusstatus Group A Group B Group C Total Percentage Poor 2 4 2 8 29.63 Middle 6 4 4 14 51.85 High 1 1 2 4 14.81 Aristocrat 0 0 1 1 3.71 Total 9 9 9 27 100 2 patients (22.22%) each in group A and group C were in poor class and 4 patients(44.44%). 6 patients (66.67%) in group A were in middle class and 1 patient (11.11%) inhigher class. In group B 4 patients (44.44%) each were in poor and middle class and 1patient in higher class. In group C 4 patients (44.45%) were in middle class, 2 patients(22.22%) each in poor class and higher class and 1 patient (11.11%) in aristocrat class. So,out of 27 patients maximum number of patients i.e. 14 (51.85%) belonged to middlesocioeconomic class. Below depicted graph describes the above statement. Graph No. 05 : Distribution of patients by socioeconomic status. 6 5 4 6 3 Patients 4 4 4 2 2 2 2 1 1 1 1 0 0 0 Poor Group A Group B Group C Middle status High Aristocrat 99
  • 6) Distribution of patients by food habits Table 15: Distribution of patients by food habitsFood habits Group A Group B Group C Total PercentageVegetarian 5 5 5 15 55.56 Mixed 4 4 4 12 44.44 Total 9 9 9 27 100 5 patients (55.56%) each in group A and group B were vegetarians and 4 patients(44.45%) each had mixed food habits. So, out of 27 patients maximum number of patientsi.e. 15 (55.56%) were vegetarians and only 44.44%had mixed food habits Below depictedgraph describes the above statement. Graph No. 06: Distribution of patients by food habits. 5 5 5 5 4 4 4 4 3 Patients 2 1 0 Vegetaria Group A Group B Group C n Food habits Mixed 100
  • 7) Distribution of patients by predominant rasa in diet Table 16: Distribution of patients by predominant rasa in diet Rasa Group A Group B Group C Total Percentage Madhura 4 4 6 14 51.85 Amla 0 2 0 2 7.41 Lavana 1 0 1 2 7.41 Tikta 4 3 2 9 33.33 Katu 0 0 0 0 0 Kashaya 0 0 0 0 0 Total 9 9 9 27 100 4 patients (44.44%) each in group A had Madhura predominant rasa in diet and 1 1patients (11.11%) had Lavana rasa predominancy. In group B 4 patients (44.45%) hadMadhura predominant rasa, 3 patients (33.33%) Tikta rasa and 2 patients (22.22%) hadAmla rasa predominance. In group C 6 patients (66.67%) had Madhura predominance, 2patients (22.22%) Tikta rasa and 1 patient (11.11%) had Lavana rasa predominance. Therewere no patients with Katu and Kashaya rasa predominance in all the three groups. So, outof 27 patients maximum number of patients i.e. 14 (51.85%) had Madhuhra predominancein diet. Below depicted graph describes the above statement. Graph No. 07 : Distribution of patients by predominant rasa in diet. Group A 6 Group B Group C 5 4 6 3 Patients 4 4 4 2 3 2 2 1 1 1 0 0 0 0 0 0 0 0 0 0 101
  • 8) Distribution of patients by addiction Table No 17: Distribution of patients by addiction.Addiction Group A Group B Group C Total PercentageSmoking 02 00 0 02 07.41Alcohol 00 01 02 03 11.11Tobacco 02 03 02 07 25.93No habits 05 05 05 15 55.56 In group A 2 patients (22.22%) each were addicted to smoking and tobacco. In groupB 3 patients (33.33%) were addicted to tobacco and 1 patient (11.11%) addicted to alcohol.In group C 2 patients (22.22%) each were addicted to alcohol and tobacco. 5 patients each(55.55%) in all the three groups were not addicted to any bad habits. So, out of 27 patients’maximum number of patients’ i.e. 15 (55.56%) had no addiction. Graph No. 08 . Distribution of patients by addiction 5 5 5 5 4.5 4 3.5 3 3 Patients 2.5 Group A 2 2 2 2 2 Group B 1.5 Group C 1 1 0.5 0 0 0 0 Smoking Alcohol Tobacco No habits Habits 102
  • 9) Distribution of patients by Nadi Table No18: Distribution of patients by NadiAge Group A Group B Group C Total PercentageVP 03 03 04 10 37.04VK 03 04 04 11 40.74PK 03 02 01 06 22.22 3 patients (33.33%) each in group A had Vata-pitta, Vata-kapha and Pitta-kaphaNadi. In group B 4 patients (44.44%) had Vata-kapha Nadi, 3 patients (33.33%) had Vata-pitta and 2 patients (22.22%) had Pitta-kapha nadi. In group C 4 patients (44.44%) each hadVata-pitta and Vat-kapha nadi, and only 1 patient (11.11%) had Pitta-kapha nadi. So, out of27 patients maximum number of patients i.e.11 (40.74%) had Vata-kapha nadi and 10patients (37.04%) had Vata-pitta nadi. Below depicted graph describes the above statement. Graph No. 09 . Distribution of patients by Nadi 4 4 4 4 3.5 3 3 3 3 3 2.5 Patients 2 2 Group A 1.5 Group B 1 Group C 1 0.5 0 VP VK PK Dosha by Nadi 103
  • 10) Distribution of patients by Prakriti Table no19: Distribution of patients by Prakriti Prakriti Group A Group B Group C Total PercentageVatapitta 06 01 03 10 37.04Vatakapha 0 08 05 13 48.15Pittakapha 03 0 01 04 14.81 6 patients (66.67%) in group A were Vata-pitta prakriti, and 3 patients (33.33%) werePitta-kapha Prakriti. In group B 8 patients (88.89%) were Vata-kapha prakriti and 1 patient(11.11%) was Vata-pitta Prakriti. In group C 5 patients (55.56%) were Vata-kapha Prakriti, 3patients (33.33%) Vata-pitta and only 1 patient (11.11%) Pitta-kapha Prakriti. So, out of 27patients maximum number of patients i.e.13 (48.15%) were Vata-kapha prakriti and 10patients (37.04%) were Vata-pitta Prakriti. Below depicted graph describes the abovestatement. Graph No. 10. Distribution of patients by Prakriti 8 8 7 6 6 5 5 Patients 4 Vatapitta 3 3 3 Vatakapha 2 Pittakapha 1 1 1 0 0 0 Group A Group B Group C Prakriti 104
  • 11) Distribution of patients by Satmya. Table No20: Distribution of patients by Satmya. Satmya Group A Group B Group C Total PercentageSarvarasa,sneha 06 06 09 21 77.78Ekarasa,sneha 0 0 0 0 0Sarvarasa,ruksha 03 02 0 05 18.52Ekarasa,ruksha 0 01 0 01 03.70 6 patients (66.67%) each in group A and group B were sarvarasa sneha satmya. 3patients (33.33%) in group A were Sarva rasa ruksha satmya. In group B 2 patients(22.22%) were Sarva rasa ruksha satmya and 1 patient (11.11%) was Ekarasa rukshasatmya. In group C all the patients (100%) were Sarva rasa sneha satmya. So, out of 27patients maximum number of patients i.e. 21 (77.78%) were sarva rasa sneha satmya.Below depicted graph describes the above statement. Graph No. 11 . Distribution of patients by Satmya Sarvarasa,sneha Ekarasa,sneha 9 Sarvarasa,ruksha Ekarasa,ruksha 8 7 6 5 4 3 2 1 Patients 0 Group A Group B Group C Satmya 105
  • 12) Distribution of patients by Nidana Table No 21: Distribution of patients by Nidana.No Nidana Group Group Group Total Percentag A B C eA Prakritivirudha 04 05 07 16 59.26B Samayavirudha 04 06 05 16 59.26C Samyogavirudha 06 07 03 15 55.56D Gurubhojana 06 04 06 16 59.26E Virudhacheshta 04 06 05 15 55.56F Avyayama 04 04 06 14 51.85G Ativyayama 0 01 01 02 07.41H Vyayama after snigdha 03 04 05 12 44.44 bhojanaI 07 07 07 21 77.78 Mandagni In group A 4 patients (44.44%) had etiological factors of Prakriti viruddha, samayaviruddha, virudhha chheshta and vyayama. 3 patients (33.33%) had Vyayama had Vyayamaafter snigdha bhojana and 6 patients had (66.67%) gurur bhojana and samyoga viruddha asnidana. In group B 5 patients (55.55%) had etiological factors of Prakriti viruddha, 6 patients(66.67%) had samaya viruddha, 7 patients (77.78%) had samyoga virudhha, 1 patient(11.11%) had ati Vyayama and 4 patients had (44.44%) guru bhojana, Vyayama andVyayama after snigdha bhojana as nidana. In group C 7 patients (77.77%) had etiologicalfactors of Prakriti viruddha, 5 patients (55.56%) samaya viruddha, virudhha chheshta andvyayama after snigdha bhojana. 3 patients (33.33%) had samyoga viruddha, 6 patients(66.66% had gurur bhojana and Vyayama and 1 patient (11.11%) had Ati Vyayama asnidana. 7 patients (77.77%) each in all the three groups had mandagni. Out of 27 patients 106
  • majority of the patients i.e. 21 (77.78%) had mandagni as nidana. Below depicted graphdescribe the above statement. Graph No.12. : Distribution of patients by Nidana Group A Group B Group C 8 7 7 777 7 6 6 6 6 6 6 6 5 5 5 5 5 4 4 4 4 44 4 4 3 3 3 2 11 1 0 0 Patients A B C D E F G H I Nidana13) Distribution of patients by RA-test Table No.: Distribution of patients by RA-test RA-test Group A Group B Group C Total PercentagePositive 06 07 04 17 62.96Negative 03 02 05 10 37.04 6 patients (66.67%) in group A were diagnosed as RA positive and 3 patients(33.33%) as RA negative. In group B 7 patients (77.78%) were RA positive and 2 patients(22.22%) were RA negative. In group C 5 patients were RA negative and 4 patients(44.44%) were RA positive. So, out of 27 patients maximum number of patients i.e. 17(62.96%) were RA positive cases and only 37.04% were RA negative cases. Belowdepicted graph describes the above statement. 107
  • Graph 13: Distribution of RA-test Positive patients RA Positive cases Group B Group C 41% 24% Group A 35%14) Distribution of patients by nature of pain Table No 23: Distribution of patients by nature of pain Nature of Pain Group A Group B Group C Total %Vrischika damshavat 05 04 06 15 55.55Ruja 02 02 01 05 18.52Toda 02 03 02 07 25.93 5 patients (55.56%) in group A had Vrichhika damshavat vedana and 2 patients(22.22%) each had Ruja and Toda. In group B 4 patients (44.44%) had Vrichhikadamshavat vedana, 2 patients (22.22%) had Ruja and Toda and 3 patients (33.33%) hadToda. In group C 6 patients (66.67%) had Vrichhika damshavat vedana and 2 patients(22.22%) had Toda and 1 patient (11.11%) had Ruja. So, out of 27 patients maximumnumber of patients i.e. 15 (55.55%) had Vrichhika damshavat vedana. Below depicted graphdescribes the above statement. 108
  • Graph No14: Distribution of patients by nature of pain 6 Vrischika damshavat Ruja 6 5 5 Toda 4 4 Patients 3 3 2 2 2 2 2 1 1 0 Group A Group B Group C Nature of Pain15) Type of Amavata as par doshanubandha Table No 24: Type of Amavata as par doshanubandha:Doshanubandha Group A Group B Group C Total % Vata 1 1 2 4 14.81 Pitta 1 0 0 1 3.70 Kapha 0 0 0 0 0 Vatapitta 2 1 3 6 22.23 Vatakapha 3 6 4 13 48.14 Pittakapha 1 0 0 1 3.70 Tridosha 1 1 0 2 7.42 Total 9 9 9 27 100 109
  • In group A 11.11% of Vatika Amavata, Pittaja Amavata, Pitta-kaphaja Amavata andTridoshaja Amavata were reported. 22.22% of Vata-pitta and 33.34% of Vata-kaphajaAmavata were also reported in group A. In group B Vatika, Vata-pitta and TridoshajaAmavata were 11.11% and Vata-kaphaja Amavata were reported 66.67%. In group C Vatika22.22%, Vata-pitta 33.33% and Vata-kapahja 44.44% Amavata were reported. Out of 27patients majority of the patients i.e. 13 (48.16%) were Vata-kapha type of Amavata. Belowdepicted graph describe the above statement. Graph 15: Amavata as par doshanubandha 0 1 Tridosha 1 0 Pittakapha 0 1 4 Vatakapha 6 3 3 Vatapitta 1 2 0 Kapha 0 0 0 Pitta 0 1 2 Vata 1 1 0 1 2 3 4 5 6 716) Type of Amavata as per severity Table N0 25: Type of Amavata as per severityseverity Group A Group B Group C Total % Naveena 4 2 5 11 41 Pravruddha 5 7 4 16 59 Total 9 9 9 27 100 110
  • In group A 4 patients (44.44%) were reported as naveena Amavata and 5 patients(55.56%) has Pravridha Amavata. In group B 2 patients 22.22% were Naveena and 7patients (77.78%) were Pravridha Amavata. In group C 5 patients (55.56%) were naveenaand 4 patients (44.44%) were Pravridha Amavata. Out of 27 patients majority of the patientsi.e. 16 (59.00%) were Pravridha Amavata and 41.00% were naveena Amavata. Belowdepicted graph describe the above statement. Graph 16: Type of Amavata as per periodicity 8 7 Naveena 7 Pravruddha 6 5 5 4 4 4 3 2 5 1 2 0 Group A Group B Group C All the patients in three groups belongs to Madhyama sara(100%), Madhyama satwa(100%), Madhyama Samhanana (100%), Madhyama Ahara shakti (100%) and Madhyamavyayama shakti (100%). 111
  • Data related to response to the treatment. In this study an effort has been made according to the guideline laid down by ancientAyurvedic classics, ACR 1995 and EULAR in selection of patients and final analysis of theresults. All the signs and symptoms were scored according to the severity grade. The clinicalresponse of the therapy was assessed on the basis of change in severity in NRS/ VASbefore and after treatment. The assessment in relation to the parameters (chief complaints,associated complaints, patient’s global disease assessment, physician’s global diseaseassessment, patient’s self assessed disability, haematological and biochemicalinvestigations, arthritis impact measurement scale, Ritchie articular indices, Disease ActivityScore, Madhavakara index of Amavata, Anjana Nidana index of Amavata, Basavarajiyaindex of Amavata, Ayurvedic health assessment and symptoms of Ama, Dosha and Dushyadushti) overall improvement of the treatment was done as per the recommendations of ACRand EULAR. The details of the results were as follows.Group A (Alambushadi Yoga) As mentioned earlier nine patients of Amavata were treated with Alambushadi yogafor 21 days. The results obtained in this group were as follows. Table:26 Chief complaints before and after treatment in Group A:- No Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III % 1 Sandhigraha 0 0 2 22 6 67 1 11 0 0 7 78 1 11 1 11 2 Sandhi ruk 0 0 1 11 7 78 1 11 1 11 8 89 0 0 0 0 3 Sandhisotha 0 0 2 22 6 67 1 11 1 11 6 67 2 22 0 0 4 Sparsa asahishnuta 0 0 1 11 6 67 2 22 1 11 6 67 2 22 0 0 5 Gourava 0 0 5 56 3 33 1 11 4 44 4 44 1 11 0 01. Sandhigraha:- In Group A it is observed that one patient (11%) presented with Grade III Sandhigraha, six patients (67%) with Grade II and two patients (22%) with Grade I. After treatment five patients of Grade II reduced to Grade I. 112
  • 2. Sandhiruk :- In Group A one patient (11%) presented with Grade III Sandhiruk, seven patients (78%) with Grade II and one patient (11%) with Grade I. After treatment one patient got complete relief and Grade III & Grade II pain in eight patients were reduced to Grade I .3. Sandhisotha:- One patient was presented with Grade III Sandhisotha, Six patients (67%) with Grade II and two patients (22%) with Grade I Sandhi Sotha. After treatment one patient got complete relief. Grade II patients were reduced to 2 (22%) from 6.4. Sparsa asahishnuta:- Two patients (22%) were presented with Grade III, 6 patients (67%) with Grade II and one patient (11%) with Grade I. Four out of six patients in Grade II got relief. After the treatment one patient (11%) got complete relief and no patients in Grade III.5. Gourava:- One patient presented with Grade III, three patients with grade II and five patients Grade I. Four patients (44%) got complete relief , Grade I reduced from five to four(44%), Grade II reduce from three to one(11%), and Grade III from one to zero(0%).Associated complaints: 1. Angamarda :- Three patients were presented with Grade 0 (33%), three patients with Grade I (33%), and three patients with Grade II. After the treatment Grade II was reduced to zero(0%) and two patients got complete relief. 2. Aruchi:- Two patients were presented with Grade I and after treatment they got complete relief (100%). 3. Trishna:- One patient presented with Grade II and two patients with Grade I . After treatment there was no patients in and Grade I reduced from two to one. 4. Alasya :- One patient presented with Grade II and four patients with Grade I. After treatment there was no patients in Grade II and Grade I reduced from four to one. 113
  • 5. Jwara :- Three patients (33%) were presented with Grade I and after treatment all the patients got complete relief.6. Apaka:- One patient was presented with Grade II and two patient with Grade I . After treatment there was no patient in Grade II and Grade I was reduced two (22%) to one (11%).7. Angasoonata:- One patient was presented with Grade II and two patient with Grade I . After treatment all the patients got complete relief.8. Agnidourbalya:- One patient was presented with Grade II and seven (78%) patients with Grade I. After treatment there was no patient in Grade II and Grade I was reduced to one (11%).9. Praseka :- One patient was presented with Grade I and after treatment no patients in Grade I.10. Utsaha hani:- Six patients were presented with Grade I and after treatment no patients in Grade I.11. Daha:- One patient was presented with Grade II and two (22%) patients with Grade I. After treatment there was no patient in Grade II and Grade I was reduced to one (11%).12. Bahumutrata:- One patient was presented with Grade I and after treatment no patients were in Grade I.13. Kukshisula:- One patient was presented with Grade I and after treatment no patients were in Grade I.14. Nidraviparyaya:- One patient was presented with Grade III and two patient with Grade I . After treatment there was no patients in Grade III.15. Chardi:- All the patients were free from the complaint.16. Bhrama:- One patient was presented with Grade I and after treatment no patients were in Grade I. 114
  • 17. Moorcha:- All the patients were free from the complaint.18. Hrit graha:- All the patients were free from the complaint.19. Vit vibandha:- One patient was presented with Grade I and after treatment no patients were in Grade I.20. Jadyata:- One patient was presented with Grade I and after treatment no relief was observed.21. Antrakujana:- One patient was presented with Grade II and two patient with Grade I . After treatment there was no patients in Grade III and number of patients in Grade I were reduced to one.22. Anaha:- One patient was presented with Grade II and two patient with Grade I . After treatment all the patients got complete relief.23. Vatopadrava:- All the patients were free from the complaint.24. Panduvarna:- All the patients were free from the complaint.25. Peetanetrata:- All the patients were free from the complaint.26. Sosha:- Two patients were presented with Grade I and after treatment no relief was observed.27. Vishuchi:- All the patients were free from the complaint.28. Ushnata:- One patient was presented with Grade II and three patients with Grade I . After treatment there was no patients in Grade II and number of patients in Grade I were reduced to two (22%).29. Janghadi pradese vyadha:- One patient was presented with Grade III , three patients with Grade II and three patients with Grade I. After treatment there was no patients in Grade III and number of patients in Grade II were reduced to one (11%). 115
  • Table: 27 Associated complaints before and after treatment in Group A: - Grade Before Grade AfterNo 0 % I % II % III % 0 % I % II % III % Parameters1 Angamarda 3 33 3 33 3 33 0 0 5 56 4 44 0 0 0 02 Aruchi 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 03 Trishna 6 67 2 22 1 11 0 0 8 89 1 11 0 0 0 04 Alasya 4 44 4 44 1 11 0 0 8 89 1 11 0 0 0 05 Jwara 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 06 Apaka 6 67 2 22 1 11 0 0 8 89 1 11 0 0 0 07 Angasoonata 6 67 2 22 1 11 0 0 9 100 0 0 0 0 0 08 Agnidourbhalya 1 11 7 78 1 11 0 0 8 89 1 11 0 0 0 09 Praseka 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 010 Utsaha hani 3 33 6 67 0 0 0 0 9 100 0 0 0 0 0 011 Daha 6 67 2 22 1 11 0 0 8 89 1 11 0 0 0 012 Bahumutrata 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 013 Kukshisula 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 014 Nidraviparyaya 6 67 2 22 0 0 1 11 7 78 2 22 0 0 0 015 Chardi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 016 Bhrama 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 017 Moorcha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 018 Hrit graha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 019 Vit vibandha 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 020 Jadyata 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 021 Antrakujana 6 67 2 22 1 11 0 0 8 89 1 11 0 0 0 022 Anaha 6 67 2 22 1 11 0 0 9 100 0 0 0 0 0 023 Vatopadrava 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 024 Panduvarna 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 025 Peetanetrata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 026 Sosha 7 78 2 22 0 0 0 0 7 78 2 22 0 0 0 027 Vishuchi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 028 Ushnata 5 56 3 33 1 11 0 0 7 78 2 22 0 0 0 029 Janghadi pradese 2 22 3 33 3 33 1 11 3 33 5 56 1 11 0 0 vyadha 116
  • Table: 28 Vata Vriddhi Lakshana before and after treatment in group A :Sl. Group-A Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III % 1 Karshya 6 67 2 22 1 11 0 0 6 67 2 22 1 11 0 0 2 Karshnya 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 0 3 Ushna kamitwa 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 0 4 Kampa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 5 Anaha 6 67 2 22 1 11 0 0 8 89 1 11 0 0 0 0 6 Shakrutgraha 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 0 7 Balabhramsa 0 0 8 89 1 11 0 0 7 78 1 11 1 11 0 0 8 Nidrabhramsa 5 56 3 33 1 11 0 0 8 89 1 11 0 0 0 0 9 Pralapa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 10 Bhrama 6 67 3 33 0 0 0 0 7 78 2 22 0 0 0 0 In group A 22% of patients presented with grade I Karshya and 11% with grade IIKarshya. No improvement was observed after the treatment. 11% of patients presented withgrade I Karshnya and no improvement were observed. 55% of patients presented withgrade I Ushnata and got complete relief after the treatment. No patients were presented withthe complaints of Kampa and Pralapa. 22% of patients presented with grade I Anaha and11% with grade II Anaha. After the treatment there were no patients with grade II and gradeI reduced from 22% to 11%. 33% of patients presented with grade I Shakrit graha, and allthe patients got complete relief after the treatment. 89% of patients presented with grade IBala bhramsa and 11% with grade II Bala bhramsa, 77% of grade II was reduced to grade Iafter the treatment. 33% of patients presented with grade I Nidra bhramsa and 11% withgrade II Nidra bhramsa. After the treatment 33% of patients got complete relief. 33% ofpatients presented with grade I Bhrama and after the treatment it were reduced to 22%. 117
  • Table : 29 Kapha Vriddhi Lakshana before and after the treatment in group A :Sl. Group-A Grade before Grade afterNo . Parameters 0 % I % II % III % 0 % I % II % III %1 Agnisada 0 0 8 89 1 11 0 0 7 78 2 22 0 0 0 02 Praseka 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 03 Alasya 3 33 4 44 2 22 0 0 8 89 1 11 0 0 0 04 Swedangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Sheetangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 06 Gourava 6 67 2 22 1 11 0 0 4 44 4 44 1 11 0 07 Slathangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 08 Swasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 09 Kasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 010 Atinidra 7 78 2 22 0 0 0 0 8 89 1 11 0 0 0 0 In group A 88% of patients presented with grade I Agni sada and 11% with grade IIAgni sada. 77% of patients got complete relief and there was no patients with grade II afterthe treatment. 22% of patients presented with grade I Praseka and all the patients gotcomplete relief after the treatment. 44% of patients presented with grade I Alasya and 22%with grade II Alasya. 88% of patients got complete relief and there were no patients withgrade II after the treatment. 22% of patients presented with grade I Gourava and 11% withgrade II. 44% of patients got complete relief. 22% of patients presented with Grade I Atinidraand 11% of the patients got complete relief after the treatment. All the patients in this grouppresented with Grade 0 Swedangata, Sheetangata, Slathangata, Swasa, and Kasa. 118
  • Table :30 Pitta kshaya lakshanas before and after treatment in group A :Sl. Group-A Grade before Grade afterNo . Parameters 0 % I % II % III % 0 % I % II % III %1 Mandagni 1 11 7 78 1 11 0 0 8 89 1 11 0 0 0 02 Shareeraseetata 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 03 Prabhahani 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 0 In group A 78% of patients presented with grade I Mandagni and 11% with grade IIMandagni. After the treatment grade I was reduced from 78 to 11% and there was nopatients with grade II. 11% of patients presented with grade I Shareera sheetatwa and allthe patients got complete relief after the treatment. Table :31 Samavata lakshanas before and after treatment in Group A :Sl. Group-A Grade before Grade afterNo . Parameters 0 % I % II % III % 0 % I % II % III %1 Vibandha 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 02 Agnisada 1 11 7 78 1 11 0 0 8 89 1 11 0 0 0 03 Tandra 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 04 Antrakujana 8 89 2 22 0 0 0 0 9 100 0 0 0 0 0 05 Katiparshwa vedana 2 22 4 44 3 33 0 0 5 56 4 44 0 0 0 06 Sotha 0 0 1 11 7 78 1 11 1 11 6 67 2 22 0 07 Toda 2 22 3 33 4 44 0 0 6 67 3 33 0 0 0 0 Snigdhopakramavri8 dhi 0 0 5 56 3 33 1 11 8 89 1 11 0 0 0 09 Nishi vridhi 3 33 3 33 3 33 0 0 8 89 1 11 0 0 0 0 119
  • In group A 33% of patients presented with grade I Vibandha and Tandra and gotcomplete relief after the treatment. 22% of patients presented with grade I Antrakoojana andgot complete relief after the treatment. 33% of patients presented with grade II Kati-parshwavedana, Snigdhopakrama vridhhi and Nishi vridhhi. There were no patients with thesymptoms in Grade III after the treatment. 11% of patients presented with grade I Shotha,78% with grade II and 11% with grade III. 11 % got complete relief and grade II was reducedfrom 78% to 22% after the treatment. 33% of patients presented with grade I Toda and 44%with grade II. There was no patient with grade II after the treatment. Table:32 Rasa dhatu Dushti Lakshanas before and after treatment in Group A :Sl. Group-A Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Agnisada 1 11 7 78 1 11 0 0 9 100 0 0 0 0 0 02 Aruchi 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 03 Angamarda 4 44 2 22 3 33 0 0 6 67 3 33 0 0 0 04 Hrillasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Tandra 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 06 Akala Valipalita 6 67 1 11 1 11 0 0 6 67 1 11 1 11 1 117 Jwara 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 08 Pandu 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 09 Klaibya 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 In group A 22% of patients presented with grade I Aruchi and 33% of patients withgrade I Jwara. All the patients with these symptoms got complete relief after the treatment.22% of patients presented with grade I Anga marda and 33% with grade II. There was nopaients with the grade III after the treatment. 11% of patients presented with grade IAkalavalipalita, Pandu and grade II Aklavalipalita. But, no improvement got after thetreatment. There were no patients in this group with symptoms of Hrillasa and Klaibya. 120
  • Table :33 Asthi Dhatu Dushti Lakshanas before and after treatment in Group A :Sl. Group-A Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Asthishoola 4 44 3 33 2 22 0 0 7 78 2 22 0 0 0 02 Asthibheda 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Keshadi Vikara 7 78 1 11 1 11 0 0 7 78 1 11 1 11 0 0 In group A 33% of patients presented with grade I Asthi shoola and 22% of patientswith grade I Asthi shoola. 22% of patients got complete relief and there were no patientswith the grade II after the treatment.11% of patients presented with grade I and grade IIKeshadi vikara and got no improvement after the treatment. There were no patients with thesymptom of Asthi bheda. Table :34 Majja Dhatu Dushti Lakshanas before and after treatment in Group A :Sl. Group-A Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Parwa ruk 0 0 1 11 5 56 3 33 0 0 7 78 0 0 0 02 Netraabhishyanda 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Bhrama 6 67 3 33 0 0 0 0 7 78 2 22 0 0 0 0 In group A 11% of patients presented with grade I, 56% with grade II and 33% withgrade III Parwa ruk. After the treatment there was no patients with grade II and III Parwaruk. There were no patients with symptom of Netrabhishyanda. 121
  • Table :35 Other Dhatu Dushti lakshanas before and after treatment in Group A :Sl. Group-A Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Rakta Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 02 Mamsa Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Medo Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 04 Shukra Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 In group A all the patients presented the Rakta Dushti, Mamsa Dushti, Medo Dushtiand Shukra Dushti with grade 0. Table :36 Ama Lakshanas before and after treatment in group A :Sl. Group-A Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Aruchi 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 02 Apakti 0 0 7 78 0 0 0 0 7 78 2 22 0 0 0 03 Klama 1 11 7 78 1 11 0 0 8 89 1 11 0 0 0 04 Alasya 4 44 3 33 2 22 0 0 8 89 1 11 0 0 0 05 Bala bhramsa 0 0 8 89 1 11 0 0 7 78 1 11 1 11 0 06 Tandra 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 07 Nishteeva 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 08 Hrit Visudhi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 09 Guru udara 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 010 Gourava 2 22 4 44 2 22 1 11 5 56 3 33 1 11 0 011 Suptata 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 012 Stambha 1 11 3 33 4 44 1 11 2 22 4 44 2 22 1 1113 Anilamoodhata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 014 Vyakula mutrata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 015 Malasanga 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 0 122
  • In group A 22% of patients presented with grade I Aruchi, Tandra, and Malasanga.All the patients with these symptoms got complete relief after the treatment. 78% of thepatients presented with grade I Apakti and Klama. After the treatment grade I Apaktireduced to 22% and grade I Klama to 11% of patients. 33% of patients presented with gradeI Alasya and 22% with grade II. 45% of patients got complete relief and there were nopatients with the grade II Alasya after the treatment. 89% of patients presented with grade IBala bhramsa, 11% with grade II. After the treatment all the patients of the symptom gotcomplete relief. 11 % of patients presented with grade I Nishteeva and all the patients withthis symptom got complete relief after the treatment. 44% of patients presented with grade IGuru udara and Gourava and all the patients with Guru udara and 33% of Gourava gotcomplete relief. 33% of patients presented with grade I Suptata and Sthambha. All thepatients with the symptom of Suptata got complete relief and grade II Sthambha wasreduced from 44% to 22% after the treatment. All patients in this group presented HritVishudhhi, Anil moodhata and Vyakula mutrata with the grade0. Table : 37: Sama Mala lakshanas before and after treatment in Group A :Sl. Group-A Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Apsu awaseedana 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 02 Ghana mala 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 03 Vicchinna mala 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 04 Durgandha mala 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 05 Picchila mala 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 06 Vishtabdha mala 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 07 Prushtakatigraha 4 44 3 33 1 11 1 11 6 67 3 33 0 0 0 08 Sadana 2 22 7 78 0 0 0 0 9 100 0 0 0 0 0 09 Siroruk 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 010 Samamutra 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 123
  • In group A 33% of patients presented with grade I Ghana mala, Vicchina mala andPrishta kati graha, 44% with grade I Durgandha mala, 22 with grade I Pichhila mala and78%with grade I Shiro ruk. 22% got complete relief with Prishta kati graha and 100% gotcomplete relief with the other symptoms. There was no patients with the symptoms of ofpatients presented with grade I Aruchi, Tandra, and Malasanga. All the patients with thesesymptoms got complete relief after the treatment. Vishtabdha mala and Sama mutra. All thepatients with these symptoms got complete relief after the treatment. Table :38 Statistical Analysis of Chief complaints in Group A:- SD Remarks Differenc p value improve t value before Mean Mean Mean ment after % of e of SE ParameterNo Pain in Numerical1 rating scale 16.11 7.00 9.11 60.12 1.964 0.654 13.91 < 0.001 H. S Pain in Visual2 Analogue scale 71.00 29.67 41.33 61.82 10.782 3.59 11.50 < 0.001 H. S3 Swelling of 44 joints 15.11 6.67 8.44 60.52 4.156 1.385 9.39 < 0.001 H. S4 Swelling of 28 joints 14.11 6.22 7.89 59.84 2.891 0.964 8.18 < 0.001 H. S Tenderness of 285 joints 14.44 6.78 7.67 58.27 2.5 0.833 9.20 < 0.001 H. S6 Morning stiffness 1.89 1.33 0.56 27.78 0.527 0.175 3.16 < 0.025 H. S7 Heaviness 1.56 0.67 0.89 62.96 0.6 0.2 4.44 < 0.005 H. S After the treatment pain in numerical rating scale was reduced by 60.12%, and painin visual analogue scale was reduced by 61.82%. 60.52% improvement was obtained inswelling of 44 joints and 59.84% in S-28 joints. 58.27% improvement in T-28, 27.78%improvement in morning stiffness and 62.96% improvement in heaviness were also 124
  • obtained. The improvement in chief complaints in this group A were statistically highlysignificant (p<0.001) Graph no: 17 Improvement of Chief complaints in Group A Improvement of Chief complaints in Group A 70 61.82 62.96 60.12 60.52 59.84 58.27 60 % of improvement 50 40 27.78 30 20 10 0 Pain in Pain in S-44 S-28 T-28 MS Hea NRS VAS Table:39 Statistical Analysis of different indices in Group A:- Remarks Differenc p value improve t value before Mean Mean Mean ment after % of e of SD SE No Parameter Ritchie articular 1 index (tenderness) 18.22 6.78 11.44 65.59 5.502 1.834 6.24 < 0.001 H. S Madhavakara index 2 of Amavata 14.33 4.89 9.44 70.77 3.464 1.154 7.78 < 0.001 H. S Anjana nidana 3 index of Amavata 7.67 4.00 3.67 50.31 1.224 0.408 8.98 < 0.001 H. S Basavarajiya 4 index 2.33 1.22 1.11 35.19 1.364 0.454 2.44 < 0.05 H. S Extra articular 5 manifestation 2.89 1.22 1.67 77.13 0.707 0.235 7.07 < 0.001 H. S 125
  • 65% improvement in RIA , 70.77% in improvement in MIA, 50.31% improvement inANIA, 35.19% improvement in BIA and 77.13% improvement in EAMRAI were obtained afterthe treatment. Change in all the indices in this group A were statistically highly significant(p<0.001) Graph No 18: Statistical Analysis of different indices in Group A Improvement of indices in Group A 90 77.13 80 70.77 65.59 % of improvement 70 60 50.31 50 40 35.19 30 20 10 0 RAI MIA ANIA BIA EAMRAI Table: 40 Statistical Analysis of GDA and AHA in Group A:- Mean after Difference improvem Remarks of Mean p value t value before Mean % of ent SD SE No Parameter 1 GDA (patients) 65.78 25.44 40.33 62.66 11.034 3.678 10.97 < 0.001 H. S 2 GDA (physicians) 68.00 26.44 41.56 62.34 8.338 2.779 14.95 < 0.001 H. S Ayurvedic health 3 assessment 35.00 22.33 12.67 36.32 3.082 1.027 12.33 < 0.001 H. S 62.66% improvement in patients GDA, 62.34% improvement in physician’s GDA and36.32% improvement in AHA were obtained in group A. Change in GDA and AHA in thisgroup A were statistically highly significant (P<0.001) 126
  • Graph No:19 Improvement of GDA and AHA in Group A Improvement of GDA and AHA in Group A 70 62.66 62.34 60 % of improvement 50 40 36.32 30 20 10 0 Patients GDA Physician GDA AHA Table :41 Statistical analysis of functional parameters in Group A Remarks improve p value Differen t value before Mean Mean Mean ment ce of after % of SE SD No Parameter Arthritis impact measurement 1 scale 37.44 21.33 16.11 42.83 4.044 1.348 11.95 < 0.001 H. S Physical 2 disability 12.78 6.22 6.56 52.92 1.424 0.475 13.81 < 0.001 H. S Walking 3 time 49.67 45.22 4.44 9.18 1.509 0.503 8.83 < 0.001 H. S Grip 4 strength 81.33 88.44 7.11 8.96 3.62 1.206 5.89 < 0.001 H. S Range of 5 movements 73.89 81.56 7.67 10.9 2.872 0.957 8.01 < 0.001 H. S 42.83% improvement in AIMS, 52.92% improvement in physical Disability, 9.18%improvement in walking time, 8.96% improvement in Grip strength and 10.9% improvementin Range of movements were obtained after the treatment. Change in all the functionalparameters in this group A were statistically highly significant ( p<0.001). 127
  • Graph 20, Improvement of functional parameters in Group A Improvement of functional parameters in Group A 60 52.92 % of improvement 50 42.83 40 30 20 9.18 8.96 10.9 10 0 AIM PD WT GS RM Table:42 Improvement of Objective parameters in Group A :- improve p value Differen Remark t value before Mean Mean Mean ment ce of after % of SD SE s No Parameter Erythrocyte 1 sedimentation rate 39.33 35.00 4.33 12.84 1.87 0.623 6.95 < 0.001 H. S 2 C reactive protein 0.89 0.56 0.33 33.33 0.50 0.166 2.00 > 0.05 N. S 3 Haemoglobin 11.23 11.36 0.12 1.17 0.171 0.057 2.14 > 0.05 N. S 4 Lymphocyte count 37.67 38.33 0.67 2.17 1.414 0.471 1.41 > 0.05 N. S 12.84% improvement in ESR, 33.33% in improvement in CRP, 1.17% improvementin Hb% and 2.17% improvement in Lymphocyte count percentage were obtained after thetreatment. Change in ESR was statistically highly significant (p < 0.001). Hb percentage,Lymphocyte count percentage and C reactive protein showed statistically no significantchange (p > 0.05) in this group A. 128
  • Graph 21 Improvement of Objective parameters in Group A Improvement of objective parameters in Group A 35 33.33 30 % of improvement 25 20 15 12.84 10 5 1.17 2.17 0 ESR CRP Hb% LC% Table :43 Statistical analysis of disease activity score in Group A :- improve p value Differen Remark t value before Mean Mean Mean ment ce of after % of SD SE s No Parameter Disease activity 1 score 4.85 3.01 1.84 39.84 0.357 0.119 15.51 < 0.001 H. S Disease activity 2 score - 28 joints 6.51 4.70 1.81 29.25 0.403 0.134 13.50 < 0.001 H. S 39.84% improvement in DAS, and 29.25% improvement in DAS-28 were obtainedafter the treatment. Change in disease activity score according to DAS and DAS 28 werehighly significant in this group. (p < 0.001) 129
  • Graph 22 Improvement of disease activity score in Group A Improvement of Disease activity score in Group A 45 39.84 40 % of improvement 35 29.25 30 25 20 15 10 5 0 DAS DAS-28Group B ( Dhanyamla Kaya Seka). As mentioned earlier nine patients of Amavata were treated with DhanyamlaKayaseka for 21 days. The results obtained in this group were as follows. Table : 44 Chief complaints before and after treatment in Group B:-Sl No Parameters Before After 0 % I % II % III % 0 % I % II % III %1 Sandhigraha 0 0 0 0 5 56 4 44 0 0 6 67 3 33 0 02 Sandhiruk 0 0 4 44 4 44 1 11 4 44 4 44 1 11 1 113 Sandhisotha 0 0 3 33 5 56 1 11 3 33 5 56 1 11 0 04 Sparsa 0 0 3 33 5 56 1 11 1 11 7 78 1 11 0 0 asahishnuta5 Gourava 0 0 7 78 2 22 0 0 6 67 3 33 0 0 0 0 130
  • 1. Sandhigraha :- In Group B four patients (44%) presented with Grade III and five patients (56%) with Grade II Sandhigraha.After the treatment there was no patients with Grade III and Grade II was reduced from five to three(33%).2. Sandhiruk:- One patient presented with Grade III (11%), four patients with Grade II (44%), and four patients with Grade I(44%). After the treatment Grade II was reduced from four to one (11%) and four patients (44%) got complete relief.3. Sandhisotha:- One patient presented with Grade III (11%) five patients with Grade II (56%) and three patients with Grade I (33%). After the treatment three patients got complete relief (33%) and there was no patients with Grade III. Number of patients in Grade II was reduced from five to one (11%)4. Sparsa asahishnuta:- One patient presented with Grade III (11%) five patients with Grade II (56%) and three patients with Grade I (33%). After the treatment six patients got complete relief (67%) and there was no patients with Grade II and Grade III.5. Gourava :- Two patients presented with Grade II and seven patients with Grade I. After the treatment six patients (67%) got complete relief and there was no patients with Grade II and Grade III.Associated complaints:1. Angamarda:- One patient presented with Grade II and four patients with Grade I. After the treatment number Grade 0 patients were increased from four to eight (89%) and Grade I was reduced from four to one (11%). There were no patients with Grade II after the treatment.2. Aruchi:- One patient presented with Grade I and another patient presented with Grade II in this group. After the treatment number patients with Grade 0 was increased from seven to eight (89%) and there was no patients in Grade II.3. Trishna:- Six patients presented with Grade I (67%) and after the treatment all the patients got complete relief (100%). 131
  • 4. Alasya :- Four patients (44%) presented with Grade I. After the treatment number of patients with grade 0 was increased from five to eight (89%) and Grade I patients were reduced from four to one (11%).5. Jwara :- Two patients presented with Grade I (22%) and after the treatment all the patients got complete relief (100%).6. Apaka :- Two patients presented with Grade II and one patient with Grade I. After the treatment number of patient with grade 0 was increased from six to eight (89%) and there was no patient with Grade II.7. Angasoonata :- Two patients presented with Grade I and one patient with Grade II. After the treatment number of patient with grade 0 was increased from six to eight (89%) and there was no patient with Grade II.8. Agnidourbhalya :- Eight patients presented with Grade I and one patient with Grade II. After the treatment eight patients got complete relief (89%). Number of patients with Grade I was reduced from eight to one (11%).9. Praseka :- There was no patients with the symptom.10. Utsaha hani :- Two patients presented with Grade II and six patients with Grade I. After the treatment eight patients got complete relief (89%). Number of patients with Grade I was reduced from six to one (11%).11. Daha :- One patient presented with Grade II got complete relief after the treatment.12. Bahumutrata:- Two patients presented with Grade I and after treatment One got complete relief.13. Kukshisula :- Two patients presented with Grade I and after treatment all the patients got complete relief.14. Nidraviparyaya :- Three patients presented with Grade I and after treatment all the patients got complete relief.15. Chardi :- There was no patients with the symptom. 132
  • 16. Bhrama :- Two patients presented with Grade II and three patients with Grade I. There was no change in grade after the treatment.17. Moorcha :- There was no patients with the symptom.18. Hrit graha:- There was no patients with the symptom.19. Vit vibandha:- Four patients presented with Grade I and after treatment all the patients got complete relief.20. Jadyata :- There was no patients with the symptom.21. Antrakujana:- Two patients presented with Grade I and after treatment all the patients got complete relief.22. Anaha:- Five patients presented with Grade I and after treatment all the patients got complete relief.23. Vatopadrava:- There was no patients with the symptom.24. Panduvarna:- There was no patients with the symptom.25. Peetanetrata :-There was no patients with the symptom26. Sosha:- Three patients presented with Grade I and two patients with Grade II. There was no improvement in grade after the treatment.27. Vishuchi:- There was no patients with the symptom28. Ushnata :- Two patients presented with Grade I and after treatment all the patients got complete relief.29. Janghadi pradese vyadha:- Six patients presented with Grade I and two patients with Grade II. After the treatment number of patients with Grade I reduced from six to three and there was no patients with Grade II. 133
  • Table :45 Associated complaints before and after treatment in Group B:-Sl Before AfterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Angamarda 4 44 4 44 1 11 0 0 8 89 1 11 0 0 0 02 Aruchi 7 78 1 11 1 11 0 0 8 89 1 11 0 0 0 03 Trishna 3 33 6 67 0 0 0 0 9 100 0 0 0 0 0 04 Alasya 5 66 4 44 0 0 0 0 8 89 1 11 0 0 0 05 Jwara 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 06 Apaka 6 67 1 11 2 22 0 0 8 89 1 11 0 0 0 07 Angasoonata 6 67 2 22 1 11 0 0 8 89 1 11 0 0 0 08 Agnidourbhalya 0 0 8 89 1 11 0 0 8 89 1 11 0 0 0 09 Praseka 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 010 Utsaha hani 1 11 6 67 2 22 0 0 8 89 1 11 0 0 0 011 Daha 8 89 0 0 1 11 0 0 9 100 0 0 0 0 0 012 Bahumutrata 7 78 2 22 0 0 0 0 8 89 1 11 0 0 0 013 Kukshisula 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 014 Nidraviparyaya 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 015 Chardi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 016 Bhrama 4 44 3 33 2 22 0 0 4 44 3 33 2 22 0 017 Moorcha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 018 Hrit graha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 019 Vit vibandha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 020 Jadyata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 021 Antrakujana 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 022 Anaha 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 023 Vatopadrava 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 024 Panduvarna 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 025 Peetanetrata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 026 Sosha 5 56 3 33 1 11 0 0 5 56 3 33 1 11 0 027 Vishuchi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 028 Ushnata 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 029 Janghadivyadha 1 11 6 67 2 22 0 0 6 67 3 33 0 0 0 0 134
  • 1. Angamarda:- One patient presented with Grade II and four patients with Grade I. After the treatment number Grade 0 patients were increased from four to eight (89%) and Grade I was reduced from four to one (11%). There were no patients with Grade II after the treatment.2. Aruchi:- One patient presented with Grade I and another patient presented with Grade II in this group. After the treatment number patients with Grade 0 was increased from seven to eight (89%) and there was no patients in Grade II.3. Trishna:- Six patients presented with Grade I (67%) and after the treatment all the patients got complete relief (100%).4. Alasya :- Four patients (44%) presented with Grade I. After the treatment number of patients with grade 0 was increased from five to eight (89%) and Grade I patients were reduced from four to one (11%).5. Jwara :- Two patients presented with Grade I (22%) and after the treatment all the patients got complete relief (100%).6. Apaka :- Two patients presented with Grade II and one patient with Grade I. After the treatment number of patient with grade 0 was increased from six to eight (89%) and there was no patient with Grade II.7. Angasoonata :- Two patients presented with Grade I and one patient with Grade II. After the treatment number of patient with grade 0 was increased from six to eight (89%) and there was no patient with Grade II.8. Agnidourbhalya :- Eight patients presented with Grade I and one patient with Grade II. After the treatment eight patients got complete relief (89%). Number of patients with Grade I was reduced from eight to one (11%).9. Praseka :- There was no patients with the symptom. 135
  • 10. Utsaha hani :- Two patients presented with Grade II and six patients with Grade I. After the treatment eight patients got complete relief (89%). Number of patients with Grade I was reduced from six to one (11%).11. Daha :- One patient presented with Grade II got complete relief after the treatment.12. Bahumutrata:- Two patients presented with Grade I and after treatment One got complete relief.13. Kukshisula :- Two patients presented with Grade I and after treatment all the patients got complete relief.14. Nidraviparyaya :- Three patients presented with Grade I and after treatment all the patients got complete relief.15. Chardi :- There was no patients with the symptom.16. Bhrama :- Two patients presented with Grade II and three patients with Grade I. There was no change in grade after the treatment.17. Moorcha :- There was no patients with the symptom.18. Hrit graha:- There was no patients with the symptom.19. Vit vibandha:- Four patients presented with Grade I and after treatment all the patients got complete relief.20. Jadyata :- There was no patients with the symptom.21. Antrakujana:- Two patients presented with Grade I and after treatment all the patients got complete relief.22. Anaha:- Five patients presented with Grade I and after treatment all the patients got complete relief.23. Vatopadrava:- There was no patients with the symptom.24. Panduvarna:- There was no patients with the symptom.25. Peetanetrata :-There was no patients with the symptom 136
  • 26. Sosha:- Three patients presented with Grade I and two patients with Grade II. There was no improvement in grade after the treatment.27. Vishuchi:- There was no patients with the symptom28. Ushnata :- Two patients presented with Grade I and after treatment all the patients got complete relief.29. Janghadi pradese vyadha:- Six patients presented with Grade I and two patients with Grade II. After the treatment number of patients with Grade I reduced from six to three and there was no patients with Grade II. Table : 46 Vata Vriddhi Lakshanas before and after treatment in Group B :No. Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Karshya 6 67 2 22 1 11 0 0 7 78 1 11 1 11 0 02 Karshnya 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 03 Ushnata 2 22 7 78 0 0 0 0 9 100 0 0 0 0 0 04 Kampa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Anaha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 06 Shakrutgraha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 07 Balabhramsa 0 0 7 78 2 22 0 0 8 89 1 11 0 0 0 08 Nidrabhramsa 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 09 Pralapa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 010 Bhrama 4 44 3 33 2 22 0 0 5 56 3 33 0 0 0 0 In group B 22% of patients presented with grade I Karshya and 11% with grade IIKarshya. After the treatment grade I Karshya reduced from 22% to 11%. 11% of patients 137
  • presented with grade I Karshnya and no improvement were observed. 78% of patientspresented with grade I Ushnata and got complete relief after the treatment. No patients werepresented with the complaints of Kampa and Pralapa. 44% of patients presented with gradeI Shakrit graha, Anaha and got complete relief after the treatment. 78% of patientspresented with grade I Bala bhramsa and 22% with grade II Bala bhramsa. 78% of grade Iwas reduced to 11% and there was no patients with grade II after the treatment. 33% ofpatients presented with grade I Nidra bhramsa and all the patients got complete relief. 33%of patients presented with grade I and 22% with the grade II Bhrama and after the treatmentgrade there was no patients with grade II. Table :47 Kapha Vriddhi Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Agnisada 1 11 7 78 1 11 0 0 9 100 0 0 0 0 0 02 Praseka 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 03 Alasya 3 33 4 44 2 22 0 0 8 89 1 11 0 0 0 04 Swedangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Sheeta 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 06 Gourava 0 0 7 78 2 22 0 0 6 67 3 33 0 0 0 07 Slathangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 08 Swasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 09 Kasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 010 Atinidra 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 0 138
  • In group B 78% of patients presented with grade I Agni sada and 11% with grade IIAgni sada. All the patients got complete relief after the treatment. 11% of patients presentedwith grade I Praseka and all the patients got complete relief after the treatment. 44% ofpatients presented with grade I Alasya and 22% with grade II Alasya. There was no patientswith the grade II and grade I reduced from 44% to 11% after the treatment. 78% of patientspresented with grade I Gourava and 22% with grade II. 67% of patients got complete reliefand grade I Gourava reduced from 78% to 33%. 22% of patients presented with Grade IAtinidra and all the patients got complete relief after the treatment. All the patients in thisgroup presented with Grade 0 Swedangata, Sheetata, Slathangata, Swasa, and Kasa. Table :48 Pitta kshaya Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Mandagni 1 11 7 78 1 11 0 0 9 100 0 0 0 0 0 02 Shareeraseetata 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 03 Prabhahani 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 0 In group B 78% of patients presented with grade I Mandagni and 11% with grade IIMandagni. After the treatment all the patients got complete relief. 11% of patients presentedwith grade I Shareera sheetatwa and Prabha hani and all the patients got complete reliefafter the treatment. 139
  • Table :49 Sama Vata Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Vibandha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 02 Agnisada 0 0 8 89 1 11 0 0 9 100 0 0 0 0 0 03 Tandra 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 04 Antrakujana 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 05 Kadiparswa vedana 3 33 4 44 0 0 0 0 7 78 2 22 0 0 0 06 Sotha 0 0 1 11 7 78 1 11 2 22 6 67 1 11 0 07 Toda 7 78 1 11 0 0 1 11 8 89 0 0 1 11 0 08 Snigdhopakramavridhi 0 0 3 33 4 44 2 22 9 100 0 0 0 0 0 09 Nishi vridhi 0 0 3 33 6 67 0 0 9 100 0 0 0 0 0 0 In group B 44% of patients presented with grade I Vibandha, 89% grade I Agni sada,11% grade II Agni sada, 22% Tandra, 22% of Antra koojana and 33% of grade ISnigdhopakrama vridhhi, ,44% grade II Snigdhopakrama vridhhi, 33% grade I Nishi vriddhi,and 67% of patients with grade II Nishi vriddhi. After the treatment all the patients gotcomplete relief with these complete symptoms. 44% of patients presented with grade I Kati-parshwa vedana and after the treatment it were reduced from 44% to 22%. 11% of patientspresented with grade I Shotha, 78% with grade II and 11% with grade III. 11 % got completerelief, grade II was reduced from 78% to 11% and there were no patients with grade II. afterthe treatment. 11% of patients presented with grade I Toda and 11% with grade III. 11% of 140
  • patients got complete relief with Toda and there was no patient with grade III after thetreatment. Table :50 Rasa Dhatu Dushti Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Agnisada 1 11 7 78 1 11 0 0 9 100 0 0 0 0 0 02 Aruchi 7 78 1 11 1 11 0 0 8 89 1 11 0 0 0 03 Angamarda 4 44 4 44 1 11 0 0 8 89 1 11 0 0 0 04 Hrillasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Tandra 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 06 Akala Valipalita 7 78 1 11 1 11 0 0 7 78 1 11 1 11 0 07 Jwara 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 08 Pandu 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 09 Klaibya 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 In group B 78% of patients presented with grade I, 11% of patients with grade IIAruchi, 33% of patients with grade I Tandra, 22% of patients with grade I Jwara and 33% ofpatients with grade I Pandu. All the patients with these symptoms got complete relief afterthe treatment. 44% of patients presented with grade I Annga marda and 11% with grade IIAngamarda. 45% of the patients with Angamarda got complete relief after the treatment.11% of patients presented with grade I Akalavalipalita, and 11% with grade II Aklavalipalita.But, no improvement got after the treatment. There were no patients in this group withsymptoms of Hrillasa and Kalibya. 141
  • Table :51 Asthi Dhatu Dushti Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Asthisula 5 56 2 22 2 22 0 0 6 67 3 33 0 0 0 02 Asthibheda 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 03 Keshadi Vikara 7 78 1 11 1 11 0 0 7 78 1 11 1 11 0 0 In group B 22% of patients presented with grade I and grade II Asthi shoola and 11%of patients got complete relief and there were no patients with the grade II after thetreatment.11% of patients presented with grade I Asthi bheda, grade I and grade II Keshadivikara and got no improvement after the treatment. Table :52 Majja Dhatu Dushti Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Parwaruk 0 0 3 33 4 44 2 22 1 11 7 78 1 11 0 02 Netraabhishyandam 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Bhrama 3 33 4 44 2 22 0 0 4 44 4 44 1 11 0 0 In group B 33% of patients presented with grade I, 44% with grade II and 22% withgrade III Parwa ruk. After the treatment there was no patients with grade III and grade IIreduced from 44% to 11%. 44% of patients presented with grade I and 22% with grade IIBhrama. After the treatment grade II Bhrama was reduced from 22% to 11%. There were nopatients with symptom of Netrabhishyanda. 142
  • Table :53 Other Dhatu Dushti lakshanas before and after treatment in Group B :No Group-A Grade before Grade after Parameters 0 % I % II % III % 0 % I % II % III %1 Rakta Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 02 Mamsa Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Medo Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 04 Shukra Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 In group B all the patients presented the Rakta Dushti, Mamsa Dushti, Medo Dushtiand Shukra Dushti with grade 0. Table :54 Ama Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Aruchi 7 78 1 11 1 11 0 0 8 89 1 11 0 0 0 02 Apakti 0 0 8 89 1 11 0 0 9 100 0 0 0 0 0 03 Klama 2 22 6 67 1 11 0 0 8 89 1 11 0 0 0 04 Alasya 3 33 4 44 2 22 0 0 8 89 1 11 0 0 0 05 Bala bhramsa 0 0 7 78 2 22 0 0 8 89 1 11 0 0 0 06 Tandra 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 07 Nishteeva 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 08 Hrit Visudhi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 09 Gurudara 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 010 Gourava 0 0 7 78 2 22 0 0 6 67 3 33 0 0 0 011 Suptata 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 012 Stambha 0 0 1 11 4 44 4 44 1 11 5 56 3 33 0 013 Anilamudhata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 014 Vyakula mutrata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 015 Malasanga 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 0 143
  • In group B 11% of patients presented with grade I , grade II and grade III Aruchi andthere were no patients with grade II and III Aruchi after the treatment. 89% of patientspresented with grade I Apakti, 33% with grade I Tandra, 11% with grade I Nishteeva, 44%with grade I Guru udara, 22% with grade I Suptata and 33% with grade I Mala sanga. All thepatients with these symptoms got complete relief after the treatment. 67% of the patientspresented with grade I Klama and 11% with grade II Klama. After the treatment 67% gotcomplete relief and grade I Klama reduced from 67% to 11%. 44% of patients presentedwith grade I Alasya and 22% with grade II. 45% of patients got complete relief and therewere no patients with the grade II Alasya after the treatment. 78% of patients presented withgrade I Bala bhramsa and 22% with grade II. After the treatment 89% of the patients of thesymptom got complete relief. 78% of patients presented with grade I Gaurava and 22% withgrade II Gaurava. 67% of patients with Gaurava got complete relief. 11% of patientspresented with grade I Sthambha, 44% with grade II and grade III Sthambha. 11% of thepatients with the symptom of Sthambha got complete relief and there was no patients withgrade III after the treatment. All patients in this group presented Hrit Vishudhhi, Anilamoodhata and Vyakula mutrata with the grade0. Table :55 Sama Mala Lakshanas before and after treatment in Group B :No Group B Grade Before Grade After Parameters 0 % I % II % III % 0 % I % II % III %1 Apsu awaseedana 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 02 Ghana 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 03 Vicchinna 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 04 Durgandha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 05 Picchila 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 06 Vishtabdham 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 07 Prushtakatigraha 7 78 2 22 0 0 1 11 9 100 0 0 0 0 0 08 Sadana 3 33 6 67 0 0 0 0 9 100 0 0 0 0 0 09 Siroruk 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 010 Sama mutra 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 144
  • In group B 44% of patients presented with grade I Ghana mala, Vicchina mala,Durgandha mala, Pichhila mala, 22% of patients with grade I Prishta kati graha, 11% withgrade III Prushtha kati graha, 67% of patients with grade I Sadana and 56%with grade IShiro ruk. All the patients with these symptoms got complete relief after the treatment. Therewere no patients with the symptoms of Apsu awaseedana, Vishtabdha mala and samaMutra. Table :56 Statistical Analysis of Chief complaints in Group B:-No Remarks Differenc p value improve t value before Mean Mean Mean ment after % of e of SD SE Parameter Pain in Numerical 1 rating scale 15.22 5.56 9.11 65.77 2.02 1.60 8.12 < 0.001 H. S Pain in Visual 2 Analogue scale 66.67 23.33 34.89 67.05 4.06 2.10 8.19 < 0.001 H. S 3 Swelling of 44 joints 14.67 4.89 7.33 71.80 2.24 1.10 8.87 < 0.001 H. S 4 Swelling of 28 joints 13.22 4.67 7.67 70.62 2.26 1.34 6.36 < 0.001 H. S Tenderness of 28 5 joints 14.56 6.00 9.67 62.40 2.22 1.16 6.91 < 0.001 H. S 6 Morning stiffness 2.44 1.33 1.67 44.44 0.70 0.20 5.55 < 0.001 H. S 7 Heaviness 1.22 0.33 1.11 77.78 0.67 0.11 8.00 < 0.001 H. S After the treatment pain in numerical rating scale was reduced by 65.77%, and painin visual analogue scale was reduced by 67.05%. 71.80% improvement was obtained inswelling of 44 joints and 70.62% in S-28 joints. 62.40% improvement in T-28, 44.44%improvement in morning stiffness and 77.78% improvement in heaviness were also 145
  • obtained. The improvement in chief complaints in this group A were statistically highlysignificant (p<0.001) Improvement of Chief complaints in Group B 90 77.78 80 71.8 70.62 67.05 % of improvement 65.77 62.4 70 60 50 44.44 40 30 20 10 0 Pain in Pain in S-44 S-28 T-28 MS Hea NRS VAS Table:57 Statistical Analysis of Different indices in Group B:-No Mean after Difference improvem Remarks of Mean p value t value before Mean % of ent SD SE Parameter Ritchie articular index (tenderness) 17.22 6.44 12.78 64.02 2.37 1.69 6.35 < 0.001 H. S 1 Madhavakara index of Amavata 12.78 3.22 13.22 76.35 2.09 1.70 5.59 < 0.001 H. S 2 Anjana nidana index of Amavata 7.56 3.56 6.44 54.78 1.35 0.44 9.07 < 0.001 H. S 3 Basavarajeya index 1.89 1.00 2.11 31.67 1.12 0.35 2.53 < 0.05 H. S 4 Extra articular manifestation 3.33 1.11 2.00 72.09 1.20 0.32 6.86 < 0.001 H. S 5 146
  • 64.02% improvement in RIA , 76.35% in improvement in MIA, 54.78% improvementin ANIA, 31.67% improvement in BIA and 72.09% improvement in EAMRAI were obtainedafter the treatment. Change in all the indices in this group A were statistically highlysignificant ( p<0.001) Improvement of indices in Group B 90 76.35 80 72.09 % of improvement 70 64.02 60 54.78 50 40 31.67 30 20 10 0 RAI MIA ANIA BIA EAMRAI Table:58 Statistical Analysis of GDA and AHA in Group B:-No Remarks Differenc p value improve t value before Mean Mean Mean ment after % of e of SD SE Parameter Global disease assessment 1 (patients) 59.22 18.11 43.00 70.16 3.75 1.80 8.20 < 0.001 H. S Global disease assessment 2 (physicians) 64.44 25.00 37.22 61.94 4.08 1.84 5.92 < 0.001 H. S Ayurvedic health 3 assessment 36.56 20.56 21.11 43.72 1.96 1.00 16.00 < 0.001 H. S 147
  • 70.16% improvement in patient’s GDA, 61.94% improvement in physician’s GDA and43.72% improvement in AHA were obtained in group A. Change in GDA and AHA in thisgroup A were statistically highly significant(P<0.001) Improvement of GDA and AHA in Group B 80 70.16 70 61.94 % of improvement 60 50 43.72 40 30 20 10 0 Patients GDA Physician GDA AHA Table :59 Statistical analysis of functional parameters in Group B :- Remarks Differenc p- value t- value improve before Mean Mean Mean ment after % of e of SD SE Parameter Arthritis impact 1 measurement scale 37.33 19.78 18.78 46.44 2.48 1.94 9.06 < 0.001 H. S 2 Physical disability 13.33 5.00 8.22 62.55 1.64 1.00 8.33 < 0.001 H. S 3 Walking time 55.00 45.22 11.00 17.65 1.97 1.06 9.19 < 0.001 H. S 4 Grip strength 86.56 95.44 18.22 9.73 4.01 2.10 3.38 < 0.01 H. S Range of 5 movements 76.89 82.22 4.56 7.34 2.87 0.86 6.16 < 0.001 H. S 148
  • 46.44% improvement in AIMS, 62.55% improvement in physical Disability, 17.65%improvement in walking time, 9.73% improvement in Grip strength and 7.34% improvementin Range of movements were obtained after the treatment. Change in all the functionalparameters in this group A were statistically highly significant ( p<0.001) Improvement of functional parameters in Group B 70 62.55 60 % of improvement 50 46.44 40 30 17.65 20 9.73 7.34 10 0 AIM PD WT GS RM Table:60 Statistical analysis of objective parameters in Group B :- N Mean after Difference improvem Remarks of Mean p value t value before Mean % of ent SD SE o Parameter Erythrocyte 1 sedimentation rate 41.44 35.56 7.33 17.19 4.53 1.98 6.02 < 0.001 H. S 2 C reactive protein 0.44 0.33 0.44 11.11 0.70 0.11 1.00 > 0.05 N. S 3 Haemoglobin 11.02 11.32 0.10 2.87 0.88 0.16 1.93 > 0.05 N. S 4 Lymphocyte count 37.56 38.78 2.11 3.76 2.64 0.28 4.40 < 0.05 H. S 149
  • 17.19% improvement in ESR, 11.11% in improvement in CRP, 2.87% improvementin Hb% and 3.76% improvement in Lymphocyte count percentage were obtained after thetreatment. Change in ESR and Lymphocyte count percentage were statistically highlysignificant. Hb percentage and C reactive protein showed statistically no significant change(p > 0.05) in this group A. Improvement of objective parameters in Group B 20 17.19 18 16 % of improvement 14 12 11.11 10 8 6 3.76 4 2.87 2 0 ESR CRP Hb% LC% Table:61 Statistical analysis of disease activity score in Group B:- Mean after Difference improvem Remarks of Mean p value t value before Mean % of ent SD SE No Parameter Disease activity 1 score 4.76 2.78 2.47 42.71 0.96 0.19 10.13 < 0.001 H. S Disease activity 2 score - 28 joints 6.43 4.27 2.56 35.13 1.06 0.26 8.36 < 0.001 H. S 150
  • 42.71% improvement in DAS, and 35.13% improvement in DAS-28 were obtainedafter the treatment. Change in disease activity score according to DAS and DAS 28 werehighly significant in this group. (p < 0.001) Improvement of Disease activity score in Group B 45 42.71 40 35.13 % of improvement 35 30 25 20 15 10 5 0 DAS DAS-28Group C ( Alambushadi Yoga and Dhanyamla Kaya Seka). As mentioned earlier nine patients of Amavata were treated with Alambushadi yogaand Dhanyamla Kayaseka for 21 days. The results obtained in this group were as follows. Table : 62 Chief complaints before and after treatment in Group C:- Parameters Before AfterNo 0 % I % II % III % 0 % I % II % III %1 Sandhigraha 0 0 1 11 3 33 5 56 3 33 4 44 2 22 0 02 Sandhiruk 0 0 4 44 4 44 1 11 6 67 2 22 1 11 0 03 Sandhisotha 0 0 1 11 6 67 2 22 5 56 3 33 1 11 0 0 Sparsa4 asahishnuta 0 0 1 11 5 56 3 33 5 56 3 33 1 11 0 05 Gourava 0 0 5 56 4 44 0 0 6 67 3 33 0 0 0 0 151
  • 1. Sandhigraha:- Five patients were presented with Grade III (56%), three patients(33%) with Grade II and one patient with Grade I. After the treatment three patients (33%) got complete relief and the number of patients with Grade II were reduced from three to two (22%) and with Grade III from five to zero.2. Sandhiruk:- Four patients were presented with Grade I (44%), four patients(44%) with Grade II and one patient with Grade III. After the treatment six patients (67%) got complete relief and the number of patients with Grade II were reduced from four to one (11%) and with Grade I from four to two.3. Sandhisotha:- One patient was presented with Grade I (11%), six patients (67%) with Grade II and two patient with Grade III. After the treatment five patients (56%) got complete relief and the number of patients with Grade II were reduced from six to one (11%) and with Grade III from two to zero.4. Sparsa asahishnuta :- One patient was presented with Grade I (11%), five patients (56%) with Grade II and three patient with Grade III (33%). After the treatment five patients (56%) got complete relief and the number of patients with Grade II were reduced from five to one (11%) and with Grade III from three to zero.5. Gourava :- Five patients were presented with Grade I (55%), four patients (44%) with Grade II. After the treatment six patients (67%) got complete relief and the number of patients with Grade II were reduced from four to zero.Associated complaints1. Angamarda:- Two patients were presented with Grade II (22%) and three patients with Grade I (33%). After the treatment number of patients with Grade 0 were increased from four (44%) to seven (78%), with Grade I were reduced from three to two (22%) and with Grade II from two to zero.2. Aruchi :- One patient was presented with Grade II (11%) and four patients with Grade I (44%). After the treatment all the patients got complete relief. 152
  • 3. Trishna :- One patient was presented with Grade I (11%) and got complete relief after the treatment.4. Alasya :- Two patients were presented with Grade I (22%) and there patients with Grade II (33%). After the treatment number of patients with Grade 0 were increased from four (44%) to eight (89%) and with Grade I reduced from two to one (11%).5. Jwara :- Three patients were presented with Grade I (33%) and got complete relief after the treatment.6. Apaka:- Three patients were presented with Grade I (33%) and got complete relief after the treatment7. Angasoonata:- There were no patients with the symptom.8. Agnidourbhalya:- Eight patients were presented with Grade I (89%) and one patient with Grade II (11%). After the treatment all the patients got complete relief.9. Praseka:- There were no patients with the symptom.10. Utsaha hani :- Three patients were presented with Grade I (33%) and two patients with Grade II (22%). After the treatment all the patients got complete relief.11. Daha:- There were no patients with the symptom.12. Bahumutrata:- Two patients were presented with Grade I (22%) and one got complete relief after the treatment.13. Kukshisula:- One patient was presented with Grade I (11%) and got complete relief after the treatment.14. Nidraviparyaya:- Four patients were presented with Grade I (44%) and one presented with Grade II (11%). All the patients got complete relief after the treatment.15. Chardi:- There were no patients with the symptom.16. Bhrama:- Three patients were presented with Grade I (33%) and got no change after the treatment.17. Moorcha:- There were no patients with the symptom. 153
  • 18. Hrit graha:- There were no patients with the symptom.19. Vit Vibandha:- Four patients were presented with Grade I (44%) and got complete relief after the treatment.20. Jadyata:- There were no patients with the symptom.21. Antrakujana:- Three patients were presented with Grade I (33%) and got complete relief after the treatment.22. Anaha:- Four patients were presented with Grade I (44%) and got complete relief after the treatment.23. Vatopadrava:- There were no patients with the symptom24. Panduvarna:- One patient was presented with Grade I (11%) and got no relief after the treatment.25. Peetanetrata:- There were no patients with the symptom26. Sosha:- One patient was presented with Grade I (11%) and another with Grade II. There was no change in Grade after the treatment.27. Vishuchi:- There were no patients with the symptom28. Ushnata:- Three patients were presented with Grade I (33%) and got complete relief after the treatment.29. Janghadi pradese vyadha:- Two patients were presented with Grade I (22%) ,five patients with Grade II (56%) and one patient with Grade III (11%). After the treatment number of patients with Grade II and III were reduced to zero and the number of patients with Grade 0 were increased from one (11%) to five (56%). 154
  • Table : 63 Associated complaints before and after treatment in Group C:- Parameters Before AfterNo 0 % I % II % III % 0 % I % II % III %1 Angamarda 4 44 3 33 2 22 0 0 7 78 2 22 0 0 0 02 Aruchi 4 44 4 44 1 11 0 0 9 100 0 0 0 0 0 03 Trishna 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 04 Alasya 4 44 2 22 3 33 0 0 8 89 1 11 0 0 0 05 Jwara 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 06 Apaka 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 07 Angasoonata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 08 Agnidourbhalya 0 0 8 89 1 11 0 0 9 100 0 0 0 0 0 09 Praseka 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 010 Utsaha hani 4 44 3 33 2 22 0 0 9 100 0 0 0 0 0 011 Daha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 012 Bahumutrata 7 78 2 22 0 0 0 0 8 89 1 11 0 0 0 013 Kukshisula 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 014 Nidraviparyaya 4 44 4 44 1 11 0 0 9 100 0 0 0 0 0 015 Chardi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 016 Bhrama 6 67 3 33 0 0 0 0 6 67 3 33 0 0 0 017 Moorcha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 018 Hrit graha 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 019 Vit vibandha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 020 Jadyata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 021 Antrakujana 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 022 Anaha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 023 Vatopadrava 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 024 Panduvarna 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 025 Peetanetrata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 026 Sosha 7 78 1 11 1 11 0 0 7 78 1 11 1 11 0 027 Vishuchi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 028 Ushnata 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 029 Janghadi vyadha 1 11 2 22 5 56 1 11 5 56 4 44 0 0 0 0 155
  • Table :64 Vata Vriddhi Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Karshya 6 67 2 22 1 11 0 0 6 67 2 22 1 11 0 02 Karshnya 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 03 Ushnata 4 44 4 44 0 0 0 0 9 100 0 0 0 0 0 04 Kampa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Anaha 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 06 Shakrugraha 4 4 5 56 0 0 0 0 9 100 0 0 0 0 0 07 Balabhramsa 1 11 5 56 3 33 0 0 7 78 2 22 0 0 0 08 Nidrabhramsa 5 56 3 33 0 0 0 0 9 100 0 0 0 0 0 09 Pralapa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 010 Bhrama 6 67 3 33 0 0 0 0 6 67 3 33 0 0 0 0 In group C 22% of patients presented with grade I Karshya and 11% with grade IIKarshya. No improvement was observed after the treatment. 11% of patients presented withgrade I Karshnya and no improvement were observed. 44% of patients presented withgrade I Ushnata, 56% with grade I Anaha, Shakruta graha, 33% of patients with grade INidra bramsha and 33% of the patients with grade I Bhrama. All the patients with thesesymptoms got complete relief after the treatment. No patients presented with the complaintsof Kampa and Pralapa. 56% of the patients presented with grade I Bala bramsha and 33%with grade II Bala bramsha. 66% of the patients with Bala bhramsha got complete relief afterthe treatment. 156
  • Table :65 Kapha Vriddhi Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Agnisada 0 0 6 67 3 33 0 0 9 100 0 0 0 0 0 02 Praseka 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Alasya 3 33 3 33 3 33 0 0 8 89 1 11 0 0 0 04 Swedangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Sheeta 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 06 Gourava 1 11 4 44 4 44 0 0 6 67 3 33 0 0 0 07 Slathangata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 08 Swasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 09 Kasa 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 010 Atinidra 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 0 In group C 67% of patients presented with grade I Agni sada, 11% with grade I Kasaand Ati Nidra. All the patients with these symptoms got complete relief after the treatment.33% of patients presented with grade I and grade II Alasya and 66% with this symptom gotcomplete relief. 44% of patients presented with grade I and grade II Gourava and after thetreatment 56% got complete relief. The entire patient in this group presented Praseka,Swedangata, Sheetata, Slathangata and Swasa with the grade 0. 157
  • Table :66 Pitta Kshaya Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Mandagni 1 11 5 56 3 33 0 0 9 100 0 0 0 0 0 02 Shareeraseetata 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 03 Prabhahani 7 78 2 22 0 0 0 0 9 100 0 0 0 0 0 0 In group C 56% of patients presented with grade I Mandagni, 33% with grade IIMandagni, 11% with grade I Shareera Sheetatwa and 22% grade I Prabha hani. After thetreatment all the patients with these symptoms got complete relief. Table :67 Sama Vata Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Vibandha 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 02 Agnisada 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 03 Tandra 5 56 3 33 1 11 0 0 9 100 0 0 0 0 0 04 Antrakujana 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 05 Kadiparswa vedana 1 11 1 11 7 78 0 0 5 56 4 44 0 0 0 06 Sotha 0 0 0 0 8 89 1 11 5 56 3 33 1 11 0 07 Toda 4 44 2 22 2 22 1 11 7 78 1 11 1 11 0 08 Snigdhopakramavridhi 1 11 3 33 2 22 3 33 8 89 1 11 0 0 0 09 Nishi vridhi 1 11 3 33 5 56 0 0 8 89 1 11 0 0 0 0 158
  • In group C 44% of patients presented with grade I Vibandha, 33% with grade ITandra and Antra koojana. After the treatment all the patients with these symptoms gotcomplete relief. 11% of patients presented with grade I Kati parshwa vedana, 78% withgrade II Kati Parshwa vedana and 45% of patients got complete relief with the symptom.89% of patients presented with grade II Shotha and 11% with grade III Shotha and 56 % gotcomplete relief. 33% of patients presented with grade I Toda, 22% with grade II and 11%with grade III Toda. After the treatment 34% of patients with Toda got complete relief. 33%of patients presented with grade I, 22% with grade II and 33% with grade IIISnigdhopakrama vridhhi. After the treatment 78% of the patients with Snigdhopakramavridhhi got complete relief. Table :68 Rasa Dhatu Dushti Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Agnisada 1 11 5 56 3 33 0 0 9 100 0 0 0 0 0 02 Aruchi 5 56 3 33 1 11 0 0 9 100 0 0 0 0 0 03 Angamarda 5 56 2 22 2 22 0 0 9 100 0 0 0 0 0 04 Hrillasa 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 05 Tandra 5 56 3 33 1 11 0 0 9 100 0 0 0 0 0 06 Akala Valipalita 5 56 4 44 0 0 0 0 6 67 3 33 0 0 0 07 Jwara 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 08 Pandu 5 56 4 44 0 0 0 0 9 100 0 0 0 0 0 09 Klaibya 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 159
  • In group C 33% of patients presented with grade I Aruchi, Jwara, 44% of patientswith Pandu and 22% of patients with grade I and grade II Anga marda. All the patients withthis symptoms got complete relief after the treatment. 44% of patients presented with gradeI Akala vali palita and 11% of patients got complete relief after the treatment. There were nopatients in this group with symptoms of Hrillasa and Kalibya. Table :69 Asthi Dhatu Dushti Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Asthisula 2 22 3 33 4 44 0 0 5 56 4 44 0 0 0 02 Asthibheda 7 78 1 11 1 11 0 0 7 78 2 22 0 0 0 03 Keshadi Vikara 5 56 4 44 0 0 0 0 5 56 4 44 0 0 0 0 In group C 33% of patients presented with grade I Asthi shoola and 44% of patientswith grade II Asthi shoola. 33% of patients got complete relief and there were no patientswith the grade II after the treatment.11% of patients presented with grade I and grade IIAsthi bheda and grade II was reduced from 11% to 0% after the treatment. 44% of thepatients presented with Keshadi vikara and got no relief after the treatment. Table :70 Majja Dhatu Dushti Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Parvaruk 0 0 1 11 6 67 2 22 4 44 5 56 0 0 0 02 Netraabhishyandam 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Bhrama 6 67 3 33 0 0 0 0 6 67 3 33 0 0 0 0 160
  • In group C 11% of patients presented with grade I, 67% with grade II and 22% withgrade III Parwa ruk. After the treatment there was no patients with grade II and III Parwaruk. There were no patients with symptom of Netrabhishyanda. Table :71 Other Dhatu Dushti lakshanas before and after treatment in Group C :Sl. Group-C Grade before Grade afterNo. Parameters 0 % I % II % III % 0 % I % II % III %1 Rakta Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 02 Mamsa Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 03 Medo Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 04 Shukra Dushti 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 In group C all the patients presented the Rakta Dushti, Mamsa Dushti, Medo Dushtiand Shukra Dushti with grade 0. Table :72 Sama mala Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Apsu awaseedana 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 02 Ghana 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 03 Vicchinna 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 04 Durgandha 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 05 Picchila 8 89 1 11 0 0 0 0 9 100 0 0 0 0 0 06 Vishtabdham 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 07 Prushtakatigraha 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 08 Sadana 5 56 3 33 1 11 0 0 8 89 1 11 0 0 0 09 Siroruk 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 010 Sama mutra 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 0 161
  • In group C 11% of patients presented with grade I Ghana mala, Durgandha mala andPicchila mala, 56% with grade I Vicchina mala and Prishta kati graha, 56% with grade IShiro ruk. All the patients with these symptoms got complete relief after the treatment. 33%of patients presented with grade I Sadana and 11% with grade II Sadana. After thetreatment 33% of patients with Sadana got complete relief. All the patients in this grouppresented Apsu avaseedana, Vishtabdha mala and Sama mutra with grade 0. Table :73 Ama Lakshanas before and after treatment in group C :Sl. Group C Grade before Grade afterNo Parameters 0 % I % II % III % 0 % I % II % III %1 Aruchi 5 56 3 33 1 11 0 0 9 100 0 0 0 0 0 02 Apakti 0 0 6 67 3 33 0 0 9 100 0 0 0 0 0 03 Klama 3 33 4 44 2 22 0 0 9 100 0 0 0 0 0 04 Alasya 4 44 1 11 4 44 0 0 8 89 1 11 0 0 0 05 Bala bhramsa 0 0 6 67 3 33 0 0 7 78 2 22 0 0 0 06 Tandra 5 56 3 33 1 11 0 0 9 100 0 0 0 0 0 07 Nishteeva 6 67 3 33 0 0 0 0 9 100 0 0 0 0 0 08 Hrit Visudhi 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 09 Gurudara 4 44 5 56 0 0 0 0 9 100 0 0 0 0 0 010 Gourava 0 0 5 56 4 44 0 0 6 67 3 33 0 0 0 011 Suptata 8 89 1 11 0 0 0 0 8 89 1 11 0 0 0 012 Stambha 0 0 1 11 3 33 3 33 3 33 4 44 2 22 0 013 Anilamudhata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 014 Vyakula mutrata 9 100 0 0 0 0 0 0 9 100 0 0 0 0 0 015 Malasanga 4 44 0 0 0 0 0 0 9 100 0 0 0 0 0 0In group C 33% of patients presented with grade I Aruchi, Tandra, Nishtheeva, 11% withgrade II Aruchi, 67% with grade I Apakti, 33% with grade II Apakti, 44% with grade I Klama,22% with grade II Klama, 56% with grade I Guru Udara.and 44% with grade I Malasanga. Allthe patients with these symptoms got complete relief after the treatment. 11% of the patients 162
  • presented with grade I Suptata and got no relief after the treatment. 11% of patientspresented with grade I Sthambha and 33% with grade II and III Sthambha. After thetreatment 33% of sthambha got complete relief. All patients in this group presented HritVishudhhi, Anila moodhata and Vyakula mutrata with the grade0. Table 74 Statistical Analysis of Chief complaints in Group C:- improvement Difference of Mean before Mean after Remarks p- value t- value Mean % of SD SE ParameterPain in Numericalrating scale 13.33 4.22 9.67 75.41 2.14 0.72 12.73 < 0.001 H. SPain in VisualAnalogue scale 54.22 19.33 43.33 66.69 4.73 2.10 6.76 < 0.001 H. SSwelling of 44 joints 12.78 5.44 9.78 62.36 2.40 1.06 3.22 < 0.001 H. SSwelling of 28 joints 11.78 4.11 8.56 68.94 2.04 1.03 5.66 < 0.001 H. STenderness of 28joints 13.78 4.11 8.56 75.04 2.15 1.27 7.62 < 0.001 H. SMorning stiffness 2.56 0.89 1.11 66.67 0.84 0.29 5.77 < 0.001 H. SHeaviness 1.44 0.33 0.89 77.78 0.70 0.20 5.55 < 0.001 H. S After the treatment pain in numerical rating scale was reduced by 75.41%, and painin visual analogue scale was reduced by 66.69%. 62.36% improvement was obtained inswelling of 44 joints and 68.94% in S-28 joints. 75.04% improvement in T-28, 66.67%improvement in morning stiffness and 77.78% improvement in heaviness were alsoobtained. The improvement in chief complaints in this group A were statistically highlysignificant (p<0.001) 163
  • Graph:29 Improvement of Chief complaints in Group C Improvement of Chief complaints in Group C 90 75.41 75.04 77.78 80 68.94 % of improvement 66.69 66.67 70 62.36 60 50 40 30 20 10 0 Pain in Pain in S-44 S-28 T-28 MS Hea NRS VAS Table:75 Statistical Analysis of different indices in Group C:- improvement Difference of Mean before N Mean after Remarks p- value t- value Mean % of SD SE o Parameter Ritchie articular 1 index (tenderness) 19.00 6.22 10.78 60.24 2.89 1.05 4.02 < 0.001 H. S Madhavakara 2 index of Amavata 16.78 3.56 9.56 84.82 2.52 1.49 8.62 < 0.001 H. S Anjana nidana 3 index of Amavata 8.44 2.00 4.00 77.58 1.44 0.89 8.22 < 0.001 H. S Basavarajeya 4 index 3.56 1.44 0.89 70.95 1.35 0.26 8.10 < 0.001 H. S Extra articular 5 manifestation 3.56 1.56 2.22 57.81 1.38 0.44 4.54 < 0.001 H. S 60.24% improvement in RIA , 84.82% in improvement in MIA, 77.58% improvementin ANIA, 70.95% improvement in BIA and 57.81% improvement in EAMRAI were obtained 164
  • after the treatment. Change in all the indices in this group A were statistically highlysignificant (p<0.001) Graph 30: Improvement of different indices in Group C Improvement of indices in Group C 90 84.82 77.58 80 70.95 % of improvement 70 60.24 57.81 60 50 40 30 20 10 0 RAI MIA ANIA BIA EAMRAI Table:76 Statistical Analysis of GDA and AHA in Group C:- improvement Difference of Mean before N Mean after Remarks p- value t- value Mean % of SD SE o Parameter Global disease assessment 1 (patient’s) 57.00 14.00 41.11 81.46 4.51 2.80 7.42 < 0.001 H. S Global disease assessment 2 (physician’s) 62.44 25.22 39.44 63.50 4.31 2.40 11.03 < 0.001 H. S Âyurvedic health 3 assessment 40.11 19.00 16.00 53.02 2.00 2.20 26.16 < 0.001 H. S 81.46% improvement in patient’s GDA, 63.50% improvement in physician’s GDA and53.02% improvement in AHA were obtained in group A. Change in GDA and AHA in thisgroup A were statistically highly significant(P<0.001) 165
  • Graph 31: improvement of GDA and AHA in Group C Improvement of GDA and AHA in Group C 90 81.46 80 % of improvement 70 63.5 60 53.02 50 40 30 20 10 0 Patients GDA Physician GDA AHA Table:77 Statistical analysis of functional parameters in Group C:- improvement Difference of Mean before Mean after Remarks t - value p- value Mean % of SD SE No Parameter Arthritis impact measurement 1 37.44 18.67 17.56 50.98 3.02 1.02 9.40 < 0.001 H. S scale 2 12.22 4.00 8.33 74.81 2.13 0.55 8.03 < 0.001 H. S Physical disability 3 55.89 44.89 9.78 20.61 3.65 2.16 19.90 < 0.001 H. S Walking time 4 86.89 105.11 8.89 21.74 3.74 2.20 4.71 < 0.005 H. S Grip strength Range of 5 81.56 86.11 5.33 6.29 2.23 1.73 2.55 < 0.05 H. S movements 50.98% improvement in AIMS, 74.81% improvement in physical Disability, 20.61%improvement in walking time, 21.74% improvement in Grip strength and 6.29% improvementin Range of movements were obtained after the treatment. Change in all the functionalparameters in this group A were statistically highly significant ( p<0.001). 166
  • Graph 32: Improvement of functional parameters in-group C Improvement of functional parameters in Group C 80 74.81 70 % of improvement 60 50.98 50 40 30 20.61 21.74 20 6.29 10 0 AIM PD WT GS RM Table:78 Statistical analysis of objective parameters in Group C:- Mean after improveme Difference Remarks of Mean t- value p-value before Mean % of SD SE nt No Parameter Erythrocyte 1 sedimentation rate 35.44 28.11 5.89 26.38 4.82 1.30 5.63 < 0.001 H. S 2 C reactive protein 0.67 0.22 0.11 44.44 0.67 0.18 2.53 < 0.05 H. S 3 Haemoglobin 10.61 10.71 0.30 1.01 0.93 0.05 2.00 > 0.05 N. S 4 Lymphocyte count 40.33 38.22 1.22 5.15 1.27 0.39 5.43 < 0.001 H. S 26.38% improvement in ESR, 44.44% in improvement in CRP, 1.01% improvementin Hb % and 5.15% improvement in Lymphocyte count percentage were obtained after thetreatment. Change in ESR, Lymphocyte count percentage and C reactive protein showedwere statistically highly significant (p < 0.001). But change in Hb percentage is found notsignificant (p > 0.05) 167
  • Graph 33: Improvement of objective parameters in Group C Improvement of objective parameters in Group C 50 44.44 % of improvement 40 30 26.38 20 10 5.15 1.01 0 ESR CRP Hb% LC% Table 79 Statistical analysis of Disease activity score in Group C :- % of Mean Mean Difference t- Parameter improve SD SE p- value Remarks before after of Mean value ment No Disease activity 1 score 4.71 2.24 1.97 55.46 1.10 0.25 9.94 < 0.001 H. S Disease activity 2 score - 28 joints 6.27 3.71 2.16 43.53 1.16 0.37 6.85 < 0.001 H. S 55.46% improvement in DAS, and 43.53% improvement in DAS-28 were obtainedafter the treatment. Change in disease activity score according to DAS and DAS 28 werehighly significant in this group. (p < 0.001). Graph 34: Improvement Disease activity score in Group C Improvement of Disease activity score in Group C 60 55.46 50 % of improvement 43.53 40 30 20 10 0 DAS DAS-28 168
  • Total effect of therapies – Among three groups complete remission was registered in 6 patients, where 3patients from group C, 2 patients from group B and 1 patient from group A. Good responseor subsidence was noted in 16 patients where 7 patients from group A, 5 patients fromgroup B and 4 patients from group C. Moderate response or minor subsidence was noted in1 patient in group A, 2 patients each in group B and group C. Out of 27 patients ultimatelyselected for study non of the patients were unresponsive, non-tolerant or defaulter either ingroup A, group B or group C. Result Group-A Group-B Group-C Total %Complete 1 2 3 6 22RemissionGood Response 7 5 4 16 59Moderate 1 2 2 5 19ResponseNot responded 0 0 0 0 00Total 9 9 9 27 100 Graph 35: Depicting total effect of therapy Not Moderate Complete responded Response Remission 0% 19% 22% Good Response 59% 169
  • Chapter –6 Discussion and Conclusion This chapter deals with the analysis of probable cause of the observations, findings andthe results of the study. It is classified under the following headings. 1. Amavata and Rheumatoid Arthritis. 2. Drug review. 3. Clinical Study. 4. Probable mode of action.1.Amavata and Rheumatoid Arthritis: - Amavata is a chronic progressive systemic disorder that primarily targeted to thelocomotor system. Amavata is named after two major pathogenic factors Ama and Vata,which mainly affect Sandhi. Samhita Granthas has explained the role of Ama in diseasemanifestation and their management. Madhavakara was the first to refer this disease as aseparate entity. Subsequently Chakradatta, Bhavaprakasha, Anjana Nidana andBasavarajiya gave a good deal of descriptions regarding this disease and its management. Amavata occurs throughout the globe and in all ethnic groups. There is nogeographical distribution but it is more prevalent in urban communities. Amavata is manifested due to the unwholesome diet and regimen. It increases in thepresent era because of the consumption of the etiological factors and practicing sedentarylife style. Hypo functioning / abnormal functioning of Agni (Mandagni / Vishamagni) has amajor role in the initiation of disease process. Though Ama and Vata are the chiefpathogenic factor, Kapha and Pitta are also invariably involved on the pathogenesis ofAmavata. The Samprapti of this disease is originated from Annavaha srothas and MadhyamaRogamarga with special predilation of Sleshmasthana. Amadosha has an affinity for various 170
  • joint spaces as it resembles physical properties of Sleshaka Kapha, present in joint spacesand tries to settle down there. Involvements of Sleshmasthana in pathology offer a diversegroup of clinical manifestation. Rasa, Asthi, and Majja are primary involved Dushyas.Mamsa and Snayu are affected in the later stage. Bahusandhi sula (pain), Bahusandhi sotha (swelling) and Bahusandhi graha(Morning stiffness) are the main feactures of this disease. Apart from this a number ofconstitutoional symptoms like gourava (Heaviness), Aruchi (Anorexia), Jwara (Fever),AngAmarda (Body ache) etc. are also seen in this disease. Interpretation of clinical pictureof Amavata has been discussed before under the chapter clinical study. The Ayurvedic line of treatment propounded by ancient sages is largely dependsupon the stages of the diseases. The treatment includes Langhana, Deepana, AmaPachana, Sothana and Samana associated with Bahiparimarjana. Deepana and Pachana employed at the outset to check formation of Ama and tostart Samprapti vighatana. This therapy can change Ama to pakwa stage. Then Virechanaand basti can eliminate the vitiated dosha. After this Shamana therapy should be followed toalleviate the remaining dosha and to normalize the affected Dushya. Bahiparimarjana likeRuksha Sweda can reduce Samkocha (stiffness) and Vruschika damsavat vedanainstantaneously. Amavata vis-a-vis Rheumatoid Arthritis. The perception of pathogenesis of RA has undergone remarkable changes. Hunter(1901) and Wilcox (1935) considered it to be a disease of microbial origin. Forrestierintroduced gold for the treatment of RA in the belief that disease was caused byMicobacterium tuberculosis. Klemperer, based on histo pathological picture of fibrinoidchanges, considered it a collagene disease. Since the recovery of Rheumatoid Factor (RF)i.e. Auto-antibodies to IgGFc by Waaler (1940), auto immunity has dominated the thinking.Today there is enough evidence (presence of multiple auto-antibodies in addition to RF in 171
  • synovial fluid as well as in systemic circulation) to incriminate auto immunity in the causationof RA. The current thinking is that RA is the result of interplay of genetic factors,environmental factor(s), (most probably an infection) and sex hormones + contribution ofdiet and stress. Rheumatoid arthritis is analogous to Amavata in clinical manifestation andcomplications. This means that the signs and symptoms may vary from joint complicationssuch as pain, stiffness, swelling and functional impairment, to more constitutionalcomplications such as fatigue, weight loss and fever, to features relating to organicinvolvement such as dyspnoea, dry eyes and hepatic failure. Auto antibody synthesis are clearly occurring in rheumatoid synovium and whateverT cells are present must provide the help required, presumably through a mechanism thatinvolves antigen presentation via Major Histo Compatibility Complex (MHC) class II allotype. Under normal conditions circulating complexes are cleared by compliment receptor Ion red cells. The dominant form immune complex described in RA serum is an IgGRFDimer. The clearance of IgGRF Dimer may fail in RA as it is poor at fixing compliment due toits small size and which is probably why it is persist long enough in the circulation to bedetected. Moreover, unlike in most common immune complexes, being only twice the size ofIgG, IgGRF Dimers should have significant access to the extra vascular tissue space. Highlevel of auto- antibodies and total IgG in RA may precede disease on set by several years.The fluctuating course of RA is consistent with continued shifts in the spectrum of RFmolecular species with variable re establishment of control mechanism. Recent studies onthe role of RF in the RA show that it can be considered as prognostic criteria and notdiagnostic criteria. A strongly positive RF indicates bad prognosis where as weakly positiveor negative RF indicates good prognosis 261. 172
  • The immune complex can generate inflammation by binding IgFc receptors (FcγRIIIa) in normal non-lymphoid tissue chiefly present on macrophages, with the production ofTNF-α and other mediators. Thus, these complexes may predict to cause, not vascularinjury, but cell activation in tissues in which FcγR are expressed. This marries with thecurrent view that the production of cytokines such as tumour necrosis factor alpha (TNF-α)and interleukin-I by activated tissue macrophages is central to the genesis of inflammation inRA262. Synovium is frequently inflamed in RA because of the large number of macrophagespresenting FcγR III, present in it263. The consensus from published reports on adult tissues is that Kupffer cells; alveolarmacrophages, cells in lymphoid organs and bone marrow and placental macrophagesexpress most FcγR III. Recent studies indicate that to these can be added pericardial andsalivary gland macrophages. In dermis, expression is minimal, with the exception of sides ofmechanical stress, where rheumatoid nodules form. A wide range of other normal tissuesshows minimal FcγR III expression. Wide range of clinical expression of RA is because ofthis wide range of FcγR III expression264. This suggest that both synovial and extra articular feature in RA are driven by thesame process; binding IgGRF complex to FcγR III. Still joint manifestation may frequentlydominate and over shadowed the extra articular involvement of the disease. Recent studiessuggest that this may be due to the specific feature of synovium265. Apoptosis is a physiological mechanism for eliminating unwanted cells. Recentstudies propose that Oxygen free radicals produced as a part of inflammatory process leadto mutations in p53 in fibroblasts, rendering them less susceptible to apoptosis. As a result aspecific acute inflammatory process switches to a chronic phase and losses its specificity. 173
  • Role of free radicals in RA is analogous to the role of Ama in Amavata. Source ofAma is not limited to the Gastro intestinal tract. Ama may be produced due to impropermetabolism. The production of Sroto abhishyanda and Kledana is also analogous to theinflammatory changes in RA. So Amavata is a disease condition in which improperlymetabolized intermediate byproducts known as Ama becomes the core cause of the diseaseprocess and get deposited by imbalanced Vata at different Sleshma sthanas. The Tridoshic vitiation, affliction of Sandhi by the vitiated Doshas, especially by Vata,affliction of Madhyama Roga marga and Marma make Amavata a dreadful disease. Inaddition, the pathogenic factors are contradictory to each other. The involvement ofhomologous Dosha-Dushya like Vata, Ama and Asthi also pose problems while planning thetreatment. Despite the line of treatment, lengthy prescription and combinations are acclaimed;the effective management and cure of this disease remain as a problem.2. Drug Review: - As elucidated else where in the work, Ama and Vata are the two main factorsinvolved in the pathogenesis of Amavata. Though basically a systemic malady the joints arethe ones chiefly involved wherein the most painful and debilitating effect is felt. Thetreatment thereby expected to be directed to the joints be it internal or external. Alambushadi yoga is a unique combination of deepana, Pachana, sulahara andsothahara drugs found mentioned by Chakradatta and Madhava chikitsa. It containsAlambusha, Gokshura, Guduchi, Sunti, Triphala and Thrivrut in a specific proportion. Alambushadi yoga was made into capsule form. Two types of capsules were used.Cellulose capsules and HPMC capsules (i.e. capsules made from cotton, manufactured byNatural Capsules limited, Bangalore). HPMC capsules may have the advantage of non-animal materials, chemically stable, low moisture content, less brittle even in low humidityand fast dissolution. 174
  • Dhanyamla Kayaseka is a Ruksha Sweda type of Bahiparimarjana chikitsa. RukshaSweda is indicated in the treatment of Amavata. As it can reduce Vruschika damsavatvedana, Sotha and Samkocha instantaneously, it is being practiced since many centuriesThe use of local Swedana Karma in attempting to manage a systemic disease like Amavatahas been supported by the statement in Ashtanga Sangraha, wherein it is stated that, onaccumulation of the Doshas in particular part of the body not responding favorably togeneral purificatory and palliative measures, local therepeutic measures may be tried. Theuse of Dhanyamla Kayaseka in Amavata is thus justified. Dhanyamla was prepared in a steel container of 250 liters at the pharmacy of D.G.MAyurvedic Medical College, Gadag. It was always kept warm through steams comingthrough a pipe. One end of the pipe was dipped in Dhanyamla and the other end connectedwith a pressure cooker, containing water, kept on a gas stove. It was heated morning &evening for 1-2 hours. This method is selected, as it is less difficult and economic tomaintain. Smell, and colour of Dhanyamla was checked regularly to assure the quality. Kayaseka was carried on a wooden Thaila Droni. A seka machine was used toperform the procedure. This method is selected as it requires less manpower and brings perfection. Dhanyamla Kayaseka was performed for a minimum of 30 minutes. Daily timeduration was increased for 5 minutes. A maximum of 60 minutes duration was continuedfrom 7th to 15 days. It was gradually reduced by 5 minutes daily up to 30 minute at the 21stday.Clinical study: It was a prospective clinical trial of 27 patients randomly distributed into 3 groups.The results obtained were statistically analyzed and mean, percentage, SD, SE and t valuesby using paired ‘t’ test were calculated. 175
  • The patients were of either sex in the age group 15-55 years. Age group as well assex of the patients is concerned it reaffirms the classic. I.e. more patients (44.44%) are in35-45 years of age (44.44%) and female are dominant (77.78%). The study records suggested larger number of Hindus (92.59%) compared to otherreligions. However, it will be fallacious to conclude that Hindus are more susceptible toAmavata on the basis since this data is only a reflection of Geographical predominance ofthe community. Occupation was not significant because the majority of housewives(51.85%) may simply correlate with the maximum percentage of female patients in theirstudy. Middle socio economic status patients (51.85%) are dominating in the study. 55.56% of the patients were vegetarians and only 44.44% were having mixed foodhabits. This only reflects the predominant diet of the region. However all the cases under thestudy had a tendency towards Kaphaja Ahara (i.e. Madura Amla Lavana Rasa). Maximum numbers of patients were having Vata kapha prakuti (48.15%), followed byVata Pitta prakruthi (37.04%). As prakruthi is said to be genotypical constitution of the bodyits confirmation regarding the predominance in Amavata will be very helpful to predict aboutthe disease at very early stage of its course. However it can be practiced only afterextensive studies on this particular line. The present study is small and a definite conclusioncannot be drawn. Majority of the patients had Vata kapha Nadi (40.74%) and it signifies theimportance of Vata and Kapha Dosha in Amavata. Majority of the patients had no bad addictions and 25.93% were addicted to tobaccochewing. Tobacco chewing is a very common habit in local population and hence it wouldnot be wise to conclude that Amavata is prevalent in persons having the habit of tobaccochewing. Majority of the patients was Sarvarasa Sneha Satmya (77.78%) and it shows theirgood prognosis. 176
  • Majorities of the patients were having Madhyama Sara, madyma Samhanana,Madhyama satwa and Madhyama Aharasakti- suggesting, as in any other disease, greatersusceptibility among those who were not in the peak of their health. Sandhi Soola, Sandhi Sotha, Sparsa asahishnuta, Sandhi graha and Gourava werepresented by cent percent of patients. Fever is associated with six patients only. Majoritiesof the patients were having Vruschika damsavat vedana. This data reflect the diseaseprocess and substantiate the classic. Maximum number of patients had Mandagni asNidana 77.78%, which suggests the predominance of Ama in Amavata. This is alsocorroborating with classics. Majority of the patients showed RA-positive test (62.96%) and itshows that the typical nature of Rheumatoid Arthitis and bad prognosis in those cases.Majority of the patients presented with Vriscchika Damshvata Vedana (55.55%) and itshows the typical nature of RA. Maximum number of patients presented with Vata-kaphaja(48.15%) and Pravridhha type (59.26%) of Amavata. Cent percentage patients were free from extra articular manifestation in eye,respiratory system, cardiac system and nervous system. Out of extra articularmanifestations majority of the patients were affected with systemic complaints such as lossof appetite. This suggests the early stage of the disease and hence they’re good prognosis.Clinical response of the treatment: In this study an effort has been made according to the guideline lay down by ancientAyurvedic classics, ACR 1995 and EULAR in diagnosing the disease Amavata or RA andthe final analysis of the result. As mentioned in the chapter of materials and methods all thesigns and symptoms were given scoring according to the severity. The efficacy of thetherapy was assessed on the basis of changes recorded in these scoring after thetreatment.I. Effect on Chief complaints - 1. Effect on Sandhi ruk (joint pain) 177
  • 11% of patients were completely relived from joint pain in group A, 44% completelyrelieved in group B and 67% completely relieved in group C. the reduction of severity of paingrad were reported by all of the patients in all the three groups. As per numerical ratingscale improvement in pain was 60.12% in group A, 65.77% in group B and 75.41% in groupC. As visual analogue scale improvement in pain was 61.82% in group A, 67.05% in groupB and 66.69% in group C. the improvement in all the three groups were statistically highlysignificant (p<0.001) (tables25, 37,43, 55, 61 & 73). NRS is a physician’s assessment of pain where as VAS is a patient’s assessment.This may be one of the reasons for difference in improvement as per NRS and VAS of pain.As most of the patients were no highly educated and belongs to rural area some error maycame in visual analogue scale of pain. Obviously, the patients of internal and externalmedications (Alambushadi Yoga and Dhanyamla Kayaseka i.e. group C) showed better andquick relief compared to other groups and Dhanyamla Kayaseka group i.e. group B showedbetter relief compared to Alambushadi Yoga group i.e. group A. Sula is caused by Vata prakopa and in Amavata it is associated with Ama. Theapplication of sweda by Dhanymla, obviously has given best relief in group B by alleviatingthe locally provoked Vata by Srotosuddhi, thus making the free movement of Vayu. Action ofAlambushadi yoga may be added in group C to get better result than group B. 2. Effect on Sandhi graha (Morning stiffness) 33% of patients got complete relief from Sandhi graha with combined medication ingroup C. Best response (66.67%) was reported from group C patients. Compared to groupA patients (27.78%) good improvement was reported from group B patients (44.44%). Theimprovement in all the three groups were statistically highly significant (p<0.001) (Tables25,37,43, 55, 61 & 73). The good result with Dhanyamla Kayaseka may be due to the its direct applicationon the affected joint. 178
  • 3. Effect on Sparsha asahishnuta (Tenderness) The relief from tenderness is highly impressive with the group C (75.04%) comparedto group B (62.40%) and it was good compared to group A (58.27%). 56.00% of patients gotcomplete relief with combined internal and external medication in group C where as 11% ofpatients got completer relief in group A and B. The improvement in all the three groups werestatistically highly significant (p<0.001). The better results of group C and B may be attribute to the local effect of swedanatherapy. 4. Effect on Sandhi sotha (Swelling of joints) 56% of patients with swelling of joints got complete relief with combined internal andexternal medication in group C where as 11% of patients each got complete relief in group Aand B. As per the recommendations for international parameters from EULAR and ACR,improvement was observed for specified 28 joints and 44 joints separately. In both the waypercentage of improvement was reported good in group B (70.62% in S-28 and 71.80% inS-44) compared to group C (68.94% in S-28 and 62.36% in S-44). The improvement ingroup C was reported good compared to group A (59.84% in S-28 and 60.52% in S-44). Theimprovement in all the three groups were statistically highly significant (p<0.001). Thus, Dhanyamla Kayaseka has shown Sothahara effect. 5. Effect on Gourava (Heaviness) Complete relief from complaint of heaviness was observed for 67% of patients eachfrom group B and group C, where over all improvement in heaviness was 17.78% in boththe groups. In group A 44% of patients got complete relief and improvement was 62.96%.The improvement in all the three groups were statistically highly significant (p<0.001). The better effect with group B and group C in case of Gourava also correlated withShareera Laghavakara effect of Swedana therapy. 179
  • II. Effect on different indices -1. Ritchie Articular index (RAI) - RAI is the some of graded tenderness of 53 specified joints. Improvement in RAI wasgood in group A and B compared to group C and there was no difference in improvementbetween group A and B (65.59%). The improvement in all the three groups were statisticallyhighly significant (p<0.001).2. Madhavakara index of Amavata (MIA) - The maximum improvement in MIA was recorded among the patients of group C(Table: 38, 56,74). Group A and group B patients showed an improvement of 70.77% whereas the group C showed 76.35% improvement. The improvement in all the three groups werestatistically highly significant (p<0.001).3. Anjana Nidana Index of Amavata (ANIA) - The maximum improvement in ANIA was also recorded among the patients of groupC (Table: 38,56,74). Group A and group B patients showed an improvement of 50.31%where as group C showed 54.78% improvement. The improvement in all the three groupswere statistically highly significant (p<0.001).4. Basavarajiya Index of Amavata (BIA) - The improvement in BIA was less among the patients of group A and group Ccompared to group B. 70.77% of improvement was reported with group B where as 35.19%improvement in group A and 31.67% of improvement in group C. The improvement in all thethree groups were statistically highly significant (p<0.001). The difference in improvement among the three Ayurvedic indices i.e. MIA, ANIA andBIA may be due to the difference in clinical presentations of Amavata mentioned by thethree different authors. The wide spectrum of symptomatology mentioned by differentauthors may be due to the specific pathology of Amavata i.e. predilection of differentShleshma sthanas to precipitate the disease Amavata. In this study maximum improvement 180
  • was noted with the signs and symptoms mentioned by Madhavakara. Compared to thesigns and symptoms mentioned by Basavarajiya, that mentioned by Anjana Nidana wereresponded good in group A and group C. The complaints of most of the patients in all thethree groups were closed to the Madhavakara index and Anjana niadana index of Amavata,where as only few presented symptoms came under Basavarajiya index. Hence, a furtherstudy in large groups is very essential to apply the study results with the Ayurvedic indicesto the population.5. Extra Articular Manifestations of Rheumatoid Arthritis Index (EAMRAI) The patients of group A showed 77.13% improvement in EAMRAI, where as groupC showed 72.09% which is better than group B (65.59%). The improvement in all the threegroups were statistically highly significant (p<0.001).III. Effect on Global Disease Assessment (GDA) - 1. Patient’s Global Disease Assessment - 81.46% of improvement was reported in GDA made by patients in group C. it isbetter than that in group B (70.16%) which is good than that in group A (66.66%). Theimprovement in all the three groups were statistically highly significant (p<0.001). 2. Physician’s Global Disease Assessment - In physician’s global disease assessment also better improvement was reported withgroup C (63.50%). Here group A showed good response (62.34%) compared to group B(61.94%). The improvement in all the three groups were statistically highly significant(p<0.001). The difference in global disease assessment made by physician and patients may bedue to the same reason that is discussed with the effect on Sandhi ruk in NRS and VAS.IV. Effect on Ayurvedic Health Assessment (AHA) – The maximum improvement in AHA was recorded among the patients of group C(53.02%). Compared to group A (36.32%), the improvement was good with group B 181
  • (43.72%). The improvement in all the three groups were statistically highly significant(p<0.001).V. Effect on Arthritis Impact Measurement Scale (AIMS) - Patients of all the three groups showed good improvement in AIMS. Group Cshowed 50.98%, group B showed 46.44% and group A showed 42.83% improvement inAIMS. The improvement in all the three groups were statistically highly significant (p<0.001).VI. Effect on Physical Disability - 74.81% of improvement of physical disability was reported with group C. As othergroups were concerned group B patients got good improvement (62.55%) compared togroup A (52.92%). The improvements in all the three groups were statistically highlysignificant (p<0.001).VII. Effect on Walking Time - The patients of group C showed 20.61% of improvement in their walking time whereas group B showed 17.65% and group A showed 9.18% improvement. The improvement inall the three groups were statistically highly significant (p<0.001).VIII. Effect on Grip Strength - The maximum improvement in the handgrip strength was recorded among thepatients of group C (21.74%). As the disease RA is concerned, good improvement in gripstrength was recorded in group B (9.73%), compared to group A (8.96%). The improvementin all the three groups were statistically highly significant (p<0.001).IX. Effect on Range of Movements - The ranges of movements were improved 10.90% in group A and that was goodcompared to the improvement in group B (7.34%) and group C (6.29%). The improvement inall the three groups were statistically highly significant (p<0.001).X. Effect on Objective Parameters - 1. Effect on Erythrocyte Sedimentation Rate (ESR) - The mean values of ESR at 1 hour were markedly changed before and aftertreatment in all the three groups. An improvement of 26.38% in group C, 17.19% in group B 182
  • and 12.84% in group A were reported. The reductions in ESR among the patients of threegroups were statistically highly significant. This reduction is highly impressive due to therelief of disease process. 2. Effect on C- Reactive Protein (CRP) -. Marked improvement in CRP was reported after the treatment where group Cshowed 44.44% of improvement, group A showed 33.33% of improvement and group Bshowed 11.11% of improvement. The improvement in group C only showed statisticalsignificance (p<0.001) where as group A and B were not significant. 3. Effect on Haemoglobin percentage (Hb%) - The percentage of improvement of Hb % also is important in RA patients. 2.87% ofimprovement was recorded in group B, 1.17% improvement in group A and 1.01%improvement in group C. The improvement in all the three groups were statistically notsignificant (p>0.05). 4. Effect on Lymphocyte count percentage (LC %) - The LC% showed a decrease of 2.17% in group A, 3.76% in group B and 5.15% ingroup C. The decrease was statistically significant (P<0.001) in group B and group C. As RAis an auto immune disorder, the decrease of elevated lymphocyte count is relevant.XI. Effect on Disease Activity - Disease activity scoring is now accepted as a good parameter to assess the efficacyof treatments in clinical trial. It is a statistically derived index combining out come variablessuch as tender joints or collectively called as core set variables. In this study the treatmentefficacy was assessed as per the DAS and also as per DAS-28 which is a modification fromDAS made later according to the result of new international preferences. Better improvement in disease activity was reported with group C and least withgroup A in this study. Group C showed 55.46% improvement with DAS and 43.53% 183
  • improvement with DAS-28. Group B showed 42.71% with DAS and 35.13% with DAS-28.Group A showed 39.84% improvement with DAS and 29.25% improvement with DAS-28. As the disease RA is concerned, the improvement in disease activity in all the threegroups is very impressive and statistically also it showed highly significant change(p<0.001).XII. Effect on associated complaints – A large number of patients in all the three groups were presented the associatedcomplaints of Angamarda, Aruchi, Trishna, Alasya, Agnidourbalya, Utsaha hani, Nidraviparyaya, Vit vibandha and Janghadi pradeshe vyatha. Complete relief or reduction inseverity was reported with all these complaints in all the three groups with much obviousvariation. Very few patients were presented with the complaints of Jwara, Apaka, Angasunata, Praseka, Daha, Bahumutrata, Kukshi sula, Antra koojana and Ushanata. Completerelief or improvement was reported with all these complaints in all the three groups withoutmany variations. A considerable number of patients presented with Bhrama, Sosha,Jadhyata and Pandu varna. No complete relief or very poor response was reported withthese complaints in all the three groups. No patients have presented the complaints ofChardi, Murcha, Hrit graha, Vatopdrava, Peeta netrata and Vischuchi in all the three groups(Table:26,44,62).XIII. Effect on Vata Vriddhi Lakshanas – A large number of patients in all the three groups were presented with the VataVriddhi Lakshana of Bala bramsa, Slathangata, Anaha and Ushna kamitwa. Complete reliefof Ushna kamitwa, Sakrit graha and Anaha were reported in all the three groups. 11% ofpatients in group A got reduction in severity of Anaha. Complete reduction and reduction inseverity were all most same in all the three groups (Table:27,45,63). Small groups ofpatients in all the three groups were presented Vata Vriddhi Lakshana of Karshya, Kashyna,Nidra bhrimsa and Bhrama. Complete relief or reduction in severity was reported for all 184
  • these symptoms in all the three groups without any noticeable difference. No patients havepresented the complaints of Kampa and Pralapa in all the three groups.XIV. Effect on Kapha Vriddhi Lakshanas : Among Kapha Vriddhi Lakshanas Agnisada, Alasya and Gourava were presented bya large percentage of patients in all the three groups. Complete relief or reductions inseverity grade for a few patients were reported in all the three groups without any noticeabledifference. Few percentages of patients had presented Praseka as a complaint in group Aand group B and Atinidra in all the three groups. Complete relief was reported with thesecomplaints in both the groups A and B; accept for Atinidra in group A where 11% of patientsgot reduction in severity. Other Kapha Vriddhi Lakshanas such as Sweta angata,Sheetangata, Swasa, and Kasa were not reported by any patients in all the three groups(Table:28,46,64).XV. Effect on Pitta Kshaya Lakshanas – All most all the patients in all the three groups were presented Mandagni andcomplete relief was reported after the treatment; accept for 11% of case in group A wherereduction in severity was the result. Few percentages of patients complained Shareerasheetata and Prabha hani. Complete relief was reported with these symptoms too; exceptfor 11% case in group C where reduction in severity was noticed.XVI. Effect on Sama Vata Lakshanas – Sama Vata Lakshanas were presented by all the patients in all the three groups. Outof different Sama Vata Lakshanas Snigdhopakrama Vriddhi and Nishi Vridhhi werepresented by major groups of patients in all the three groups. Complete relief was reportedwith these symptoms without any discrimination of treatment groups. Sotha, Toda and Katiparshwa vedana were also presented by a major percentage of cases. Complete relief orreduction in severity was reported with these symptoms also in all the three groups. A small 185
  • percentage of cases presented Vibandha, Tandra and Antrakoojana as Sama VataLakshana. Complete relief was reported with these symptoms in all the three groups.XVII. Effect on Dhatu Dushti – Rasa dhatu Dushti, Asthi dhatu Dushti and Majja dhatu Dushti Lakshanas werereported in all the three groups. Rakta, Mamsa, Medas and Shukra Dushti Lakshanas wereabsent. So, Amavata involving mainly Rasa, Asthi and Majja Dhatu Dushti may beconsidered in the present study. 1. Effect on Rasa Dahtu Dushti : Mainly Agnisada was presented as Rasa Dushti Lakshana and its result is alreadydiscussed before. A small percentage of cases presented Aruchi, Angamarda, Tandra,Akalavalipalita, Jwara and Pandu. Out of these complaints Aruchi and Jwara werecompletely relieved in all the three groups; except for 11% of case of Aruchi in group B.Complete reduction in severity was reported with Pandu in all the three groups without muchnoticeable difference. Very minimum result was reported with Akalavali palita in the threegroups. Akalavali palita in this case may be not completely related with Amavata but as aresult of total life style. The results of Angamarda and Tandra are already discussed before.No patients have presented with Hrillasa and Tandra in all the three groups. 2. Effect on Asthi Dushti : A large percentage of patients presented with the Asthi sula and a small percentageAsthi bheda and Keshadi vikaras. Complete relief or reduction in severity was observed withAsthi sula in all the three groups without any noticeable difference. But, no noticeableimprovement was observed Asthi bheda and Keshadi vikara except for 11% of Asthi bhedapatients in group C where reduction in severity was reported. 3. Effect on Majja Dushti – Among Majja Dushti Lakshanas, all the patients’ complaint Parwa ruk and a smallgroup of patients complained Bhrama also. The result with Bhrama is already discussed 186
  • before. Complete relief and reduction in severity of Parwa ruk were reported with group C.Complete relief of a single case and reduction in severity of remaining cases were reportedwith group B. Only reduction in severity is reported with group A. No patients havecomplained Netrabhishyanda in all the three groups.XVIII. Effect on Ama Lakshanas – Out of different Ama Lakshanas, all the patients in three groups were complained ofApakti, Bala bhramsa, Stambha and Gourava. Complete relief of Apakti was reported by allthe patients in group B and group C where as 88% of patients in group A got complete relief.Complete relief or reduction in severity of Bala bhramsa and Sthamba were noticed in all thethree groups without any noticeable difference. Few percentages of patients were presentedwith Aruchi, Klama, Alasya, Tandra, Nishtiva, Guru udara, Suptata and Mala sanga in all thethree groups. Out of these symptoms complete relief of 100% of cases were reported withTandra, Nishtiva, Guru udara and Mala sanga in all three groups. Aruchi and Klama werecompletely relieved in group B and group C ; which was 89% in group A. Suptata was bestresponded in group A and group B. The result of Gourava is already discussed before. Nopatients had presented with Hrit visuddhi, Anila moodhata and Vyakula mutrata.XIX. Effect on Sama Mala Lakshana – Sama Purisha Lakshana were presented in all three groups but Sama MutraLakshanas was not presented. Out of Sama Mala Laskhanas complete relief is reported inall the three groups with Ghana Mala, Vicchinna Mala, Durgandha Mala, Picchila Mala andShiro ruk. Sadana was completely relived in group A and group B, where as 89% ofcomplete relief was observed in group C. Prishta kati graha was completely relieved for allthe patients in group C. No patients have presented the complaints of Apsu avaseedana ofMala and Vishtabdha Mala in all the three groups. 187
  • XX. Total effect of therapies – Among three groups complete remission was registered in 6 patients, where 3patients from group C, 2 patients from group B and 1 patient from group A. Good responseor subsidence was noted in 16 patients where 7 patients from group A, 5 patients fromgroup B and 4 patients from group C. Moderate response or minor subsidence was noted in1 patient in group A, 2 patients each in group B and group C. Out of 27 patients ultimatelyselected for study non of the patients were unresponsive, nontolerant or defaulter either ingroup A, group B or group C.XXI. Comparison of Natural capsules and gelatinous capsules Five patients of Group A were given Alambushadi Yoga filled in natural capsules andfour patients were given in gelatinous capsules. From group C four patients were givenAlambushadi Yoga filled in natural capsules and five patients were given in gelatinouscapsules. The improvement noted in chief complaints with these two types of capsules isgiven below. Table 81 Showing the clinical Difference of Natural & Gelatin caps in Group-A Group A - Natural caps Group A - Gelatin caps Difference of Natural & Gelatin caps Parameter percentage Difference Difference Before Before After After N-G Pain 18.2 8 10.2 13.5 5.25 8.25 1.95 19.11 Swelling 16.2 7.2 9.0 13.75 6.0 7.75 1.25 13.88Tenderness 15.2 7.2 8.0 13.5 6.5 7.0 1.0 14.28 Morning 1.8 1.2 0.6 2.0 1.5 0.5 0.1 16.66 stiffness Heaviness 1.8 0.8 1.0 1.25 0.5 0.75 0.25 25 In group A, Alambushadi Yoga filled in natural capsules obviously showed betterimprovement in chief complaints as compared to that in gelatinous capsules.i.e.19.1%of 188
  • better improvement inpain,13.8% in swelling, 14.28% in tenderness, 16.66% in morningstiffness and 25% in heaviness. Table 82 Showing the clinical Difference of Natural & Gelatin caps in Group-A Group C - Natural caps Group C - Gelatin caps Difference of Natural & Gelatin caps Parameter percentage Difference Difference Before Before After After N-G Pain 11.5 1.5 10 14.8 6.4 8.4 1.6 16.0 Swelling 13.5 2.5 11 12.4 3.8 8.6 2.4 21.81Tenderness 14.25 2.75 11.5 13.4 5.2 8.2 3.3 28.69 Morning 2.75 0.5 2.25 2.4 1.2 1.2 1.05 46.66 stiffness Heaviness 1.5 0.25 1.25 1.4 0.4 1.0 0.25 20 In group C Alambushadi Yoga filled in natural capsules obviously showed betterimprovement in chief complaints as compared to that in gelatinous capsules.i.e.16%of betterimprovement inpain,21.81% in swelling, 28.69% in tenderness, 46.62% in morning stiffnessand 20% in heaviness. The better result with natural capsules may be attributed to the advantage of non-animal material and fast dissolution of these capsules. Anyhow further study is needed torule out the therapeutic effect f natural capsules on disease process. It is claimed to bechemically stable, low moisture content and less brittle even in low humidity.XXII. COMPARISON BETWEEN THREE GROUPS – From this clinical study it was obvious that combine therapy of Alambushadi Yogaand Dhanyamla Kayaseka in group C has got edge over the treatment provided in group Aand B as regards to the alleviation of cardinal signs and symptoms or chief complaints.Group B i.e. Dhanyamla Kayaseka provided more relief than group A i.e. Alambushadi Yogain chief complaints. As RAI and EAMRAI are concerned, obviously good improvement wasnoted with group A. Group C stood in second order in RAI and group B in EAMRAI. 189
  • Table : 83 Statistical analysis of comparative efficacy among groups. 2 2 Correctio n factor Mean Mean Status f-ratio Table value SSC SSE SST No. between with in varieties varieties Parameter1 Pain in NRS 2333 172 2333 170 0.93 7.07 0.13 3.40 H.S.2 Pain in VAS 42881 5217 42881 4867 175.26 202.79 0.86 3.40 H.S.3 RAI 3675 1196 3675 1177 9.33 49.06 0.19 3.40 H.S.4 Swelling of 44 joints 1959 547 1959 520 13.48 21.66 0.62 3.40 H.S.5 Swelling of 28 joints 1744 333 1744 329 1.93 13.71 0.14 3.40 H.S. Tenderness of 286 2011 294 2011 276 9.04 11.51 0.79 3.40 H.S. joints7 Heaviness 25 7 25 7 0.15 0.28 0.53 3.40 H.S.8 MIA 3115 569 3115 486 41.59 20.25 2.05 3.40 H.S.9 BIA 51 36 51 29 3.81 1.19 3.19 3.40 H.S.10 EAMRAI 104 27 104 26 0.70 1.06 0.66 3.40 H.S.11 Patients GDA 46459 5233 46459 5199 16.93 216.62 0.08 3.40 H.S.12 Physicians GDA 41929 4659 41929 4574 42.26 190.58 0.22 3.40 H.S.13 AIMS 8251 721 8251 689 16.04 28.69 0.56 3.40 H.S.14 Physical disability 1602 182 1602 164 8.93 6.82 1.31 3.40 H.S.15 Range of movements 925 397 925 350 23.59 14.59 1.62 3.40 H.S.16 ESR 925 259 925 219 20.26 9.12 2.22 3.40 H.S.17 C reactive protein 2 6 2 5 0.26 0.21 1.22 3.40 H.S.18 Haemoglobin % 1 2 1 2 0.11 0.09 1.21 3.40 H.S.19 DAS 118 10 118 8 0.99 0.34 2.89 3.40 H.S.20 DAS-28 128 19 128 16 1.27 0.67 1.89 3.40 H.S.21 Morning stiffness 33 17 33 11 2.78 0.46 6.00 3.40 N.S.22 ANIA 597 112 597 70 20.70 2.93 7.08 3.40 N.S.23 AHA 7433 521 7433 195 162.81 8.12 20.05 3.40 N.S.24 walking time 1908 341 1908 122 109.37 5.07 21.55 3.40 N.S.25 Grip strength 3513 2319 3513 1677 320.59 69.89 4.59 3.40 N.S.26 Lymphocyte count % 0 90 0 32 28.70 1.35 21.23 3.40 N.S. 190
  • To investigate the comparative efficacy of Alambushadi Yoga, Dhanyamla KayaSeka and their combined efficacy in group A, group B and group C respectively theassessment parameters were statistically analyzed using ANOVA test as the rule. Onanalysis it is fond that the comparison of improvements with pain in NRS, pain in VAS,Sandhi sotha, Sparsa asahishnuta, Gourava, RAI, MIA, BIA, EAMRAI, patient’s GDA,physician’s GDA, AIMS, physical disability, range of movements, ESR, Hb%, CRP, diseaseactivity score as per DAS and DAS – 28 among the three groups were statistically highlysignificant. It reveals that the best and better results with these parameters with theseparameters among the three treatment group were due to the group variation i.e. treatmenteffect and not due to the sampling variation. The comparison of improvements with Sandhigraha (morning stiffness), ANIA, AHA, walking time, grip strength and lymphocyte countpercentage among the three groups were statistically not significant. This may be attributedto the small sample in this study. As the treatment effect is concerned with associated symptoms, Vata ViddhiLkshanas, Kapha Vriddhi Lakshanas, Pitta kshaya Lakshanas, Sama Vata Lakshanas,Dhatu Dushti Lakshanas, Ama Lakshanas and Sama Dushya Lakshanas complete relief orreduction in severity was noticed in all the three groups. Still, Majja Dushti Lakshanasshowed better relief with group C compared to group A and group B. It may attributed to thedeep involvement of disease. In general, obviously there was no much difference inimprovement in these symptoms with Alambushadi Yoga, Dhanyamla Kayaseka and withtheir combined use. From the above mentioned results it is obvious that Dhanyamla Kayaseka has betterresult in Amavata compared to the Alambushadi Yoga. When Alambushadi Yoga is addedwith treatment with Dhanyamla Kayaseka the relief become more marked. The better resultin group C compared to group B may be attributed to this additive efficacy. 191
  • 4. Probable mode of action of the drugs: - Ama and Vata are the root cause of Amavata. It can be considered as a metabolicdisease. Agnimandya and Srotorodha are the two inevitable processes in metabolicdiseases. Formation of Ama by Agnimandya, Svotorodha by Ama, its circulation in the bodyand getting lodeged in the Sleshmasthana especially Sandhi contributes towards thesymptom complex, is the etiopathogenisis of Amavata. So Agnideepanam andSrothosothanam become an important line of treatment.Alamushadi Yoga:- The constituents of Alamushadi Yoga rich in Katu and Thikta Rasa, and Ushnaveerya will work at the level of Ama by Deepana and Pachana activities, substantiating theclassics Thikta deepanani Katuni cha. The drug is dominent by Madhura Vipaka hence itpacifies Vata dosha without increasing the Ama qualities. Hence it breaks Ama and Vatacomplex. Trivrut is the main ingredient of Alambushadi Yoga. It is a known anti-inflammatoryanti-arthritic drug. It is being Sukha Rechaka, Sotha hara, Jwaraghna, Thikta KatuRasa,KatuVipaka, Ushna Veerya, Laghu Ruksha Theekshna Guna it corrects Ama, dislodge themfrom Sleshma Sthana establishing the Anulomagati of Vata and there by relieves theooedema and associated complaints. The second major ingrediant is Guduchi. It is a known immuno modulator drug,helping alleviate the free radicals produced during the disease process. Guduchi may helpsto enhance the effectiveness of WBC and to improve the immune system. It is being ananalgesic, anti inflammatory, anti pyretic and anti microbial may act on local pathology of thedisease. Sunti, the third main ingredient contain 6 analgesics and there by relieves the pain. Itcontains 6 anti oxidants, so act at the level of free radicals. It posses anti-inflammatoryproperties there by reduces the disease activity. Ii is being Katu Rasa, Ushna Veerya, 192
  • Deepaka, Pachaka, Srotosothaka Sunti corrects Ama and establishes the Anulomagati ofVata. Tiphala is an antioxydent acts at the level of free radicals and corrects theconstipation along with tonifying the Gastro intestinal track leading to detoxification of thewhole body. It also improves digestion and assimilation. Hareetaki is a natural rejuvanate. Ittones the diseased body and cleanses the endotoxins (Ama). Hareetaki and Vibhitaki areknown and anti-inflammatory and anti microbial drugs. Vibhitaki being the good Chedaniyadrug it clears the Kleda and Abhishyanda from the srothas and relieves the srotorodha.Amalaki is the heighest natural soure of Vitamin C, shows anti-inflammatory and immunomodulating activities. So it acts on local pathology of the disease. Gokshura is a known analegesic drug. It helps to maintain efficient kidney andurinary functions thereby the Kleda may be expelled out properly.Dhanyamla Kayaseka:- The beneficial effects of Dhanyamla Kayaseka appear to be due to its threeconstituent factors. a) Therapeutic effects of Dhanyamla. b) Physical effects of Kayaseka and associated massage. c) Application of heatTherapeutic effects of Dhanyamla:The following points are important while discussing the mode of action of Dhanyamla.1. The Rasa of Dhanyamla is Amla.2. By fermentation the Dhanyas that are principally of Madhura Rasa are converted in to Amla Rasa3. Dhanyamla is used as lukewarm or tolerantly hot to ensure proper Swedana and never in clod condition. 193
  • A close scrutiny reveals that among the Dhanyas used, most of them are Madhura inRasa while nagara and deepyaka are Katu in Rasa .The process of fermentation of thesedrugs is initiated and augmented by the addition of Nimbu, which is of Amla Rasa. Pharmacologically the conversion of Madhura predominant drugs in to Amla Rasa isevidenced. Transformation or change at the Bhuta, Guna, Rasa, Veerya, and Vipaka levelsin connection with the transformation of one Rasa in to another is postulated andsummarized as given below. At Bhouthik level, Madhura Rasa is of Prithvi and Jala predominance. In conversionof Madhura Rasa in to Amla, Prithvi is transformed to Agni; the common factor Jala in boththe Rasa is maintained. It is reflected in the qualitative level that the Gunas of Dhanyas likeGuru; Manda etc. are reduced to Laghu and Theekshna in Dhanyamla, while SnigdhaGuna is maintained. The Vipaka and Veerya are changed to Amla and Ushna respectively. The reason behind the selection of Madhura Rasa for conversion in to Amla may betwo fold. Firstly, Madhura Rasa may be easily convertible to Amla and secondly, the AmlaRasa so obtained as an end product of the fermentation process may by virtue of samskaradiffer from original Amla Rasa and there by more effective in serving the purpose expectedof it. According to the concept of Rasa, Amla Rasa is Vata Sama ka and Pitta Kaphakopaka, Laghu, Snigdha, and Theekshna. It has Pachana and Deepana properties. It isSeeta on touch, but at the same time Ushna in Veerya. Since Dhanyamla is used in warmstate in Kayaseka, it loses its Seeta Guna and hence mitigates Vata. A notable discrepancy that has set in among the stalwarts Charaka and Susruta is inthe context of the Bhouthik constituents of Amla and Madhura Rasa. According to Susruta,the union of Agni and Jala forms Amla Rasa while in the opinion of Charaka, Prithvi andAgni are the constituents. The former might have given importance to the srava and srotoSothana properties of Amla Rasa while the later might have considered its Brimhana Guna. 194
  • In this context, the action of Dhanyamla in clearing the obstructed srotases or passages byAma may be due to the sroto Sothana and srava Guna of Kanji. In Khilasthana, Kashyapahas fortified the purificatory capability (Sroto Shodhana) of Amla Rasa where he hasmentioned the opening and restoration of normal functions of the Doshas and Dhatus by theuse of Amla Rasa after Kledana of the Srotas by Lavana Rasa. The Vatashamaka, Srotovishodhana, Ama Panchana and Vatakaphakharaproperties of Dhanyamla are of significance as regards to the management of Amavata. Allthe properties of Kanji including the warmth with which it is used to bring in sudation directlyincrease the qualities of Pitta, are antagonistic to Vata and Ama Panchana is also assured. Physical effects of Kayaseka and associated massage: Maharshi Susruta has stated that the potency of the drugs are gettingabsorbed through the skins in Bahimarjana Chikitsa. I.e it can enter into the cellular level.The liquid media is capable of carrying the medicinal properties of the constituent drugs andtraverses the subtle pores of the skin and through the multitudinous passages inside thesystem. Bhrajaka Pitta situated in the skin and Vyana Vayu help in assimilation andtransportation. Traversing the minute pores of the body the properties of the medicamentdischarge their functions in uprooting the pathogenesis of Amavata. Dhanyamla act at thelevel of Ama by Deepana Pachana properties and Ushna Veerya. The properties of Dhanyalike Brimhana, Tarpana, Balya and Vatahara are also supplemented. Soft massage is a part of Kayaseka. Research on massage indicate that it contributegreater gain in weight, length, mid arm, mid leg circumference, blood velocity, vessaldiameter and blood flow of femoral artery and post massage sleep.Application of heat: Dhanyamla Kayaseka is type of generalized Swedana that makes the body supple,removes the stiffness of joints, cleanses the internal pathways and brings about bettercirculations. It also improves digestion. 195
  • Modern studies have been carried on the efficacy of Swedana Karma.The SvedanWith the help of pre and post therapy joint angiography, it has been demonstrated thatSwedana therapy produces varying degree of recovery in vascular insufficient joints towhich several clinical and functional improvements can attributed.Swedana has been reported to be effective in treatment of Ostio articular as well as neuromascular group of Vata vitiations. It also lead to the normalization of erythrocytesedimentation rate as well as rate of connective tissue breakdown as reflected in loweredurinary excretion of hydroxyproline and mucopolysaccharides. This observation suggeststhat this therapy not only produces symptomatic relief but also control the disease processand may cause long lasting relief. These factors might be responsible for improving blood circulation and localmetabolic processes causing relaxation of local structures and thus producing relief fromlocal symptoms and functional recovery. The same mechanism might be responsible fororganic systemic recovery and suppression of disease process. 196
  • Conclusion01. Amavata is a disease in which improperly metabolized intermediate byproducts known as Ama become the core cause of the disease. 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.02. 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.03. In this study 27 patients of Amavata were treated in three groups viz. with Alambushadi Yoga in group A (9 patients), with Dhanyamla Kayaseka in group B (9 patients) and combine with Alambushadi Yoga and Dhanyamla Kayaseka in group C (9 patients).04. Out of 27 patients studied in the series, maximum number of patients were between the age group 35-45 years (44.44%), predominance of females (77.78%), Hindus (92.59%), housewives (51.85%), not addicted to any bad habits (48.15%), vegetarians (55.56%) and having Madhura predominant taste (51.85%) were observed in this study. Maximum number of patients belongs to middle socio- economical status (51.85%) having Vatakaphaja nadi (55.56%), Vata-kapha Prakriti (48.15%), Sarva rasa sneha satmya (77.78%), Madhyama sara (100%), Madhyama Satwa (100%), Madhyama samhanana (100%), Madhyama Ahara Shakti (100%) and Madhyama Vyayama Shakti (100%).05. Maximum number of patients had Mandagni as Nidana (77.78%), showed RA- positive test (62.96%) and Vrischika damsavat vedana (55.55%). 197
  • 06. Maximum number of patients had Vata-kaphaja (48.15% ) and Pravridhha Amavata(59.26%).07. Highly significant change was provided by all the three treatment groups in chief complaints, Ritchie Articular Index, Madhavakara Index of Amavata, Anajana Nidana Index of Amavata, Basavarajiya Index of Amavata, Extra Articular manifestation of RA-index, Global disease assessment by patient and physician, Arthritis impact measurement scale, Physical disability, Walking time, Grip strength, Range of movements, ESR, Disease activity score as per DAS, and DAS-28. Change in lymphocyte count percentage was significant in group B and group C. significant change in CRP was provided in group C only. Change in CRP, Hb% and LC % was not significant in group A.08. Complete reduction or reduction in severity of maximum number of associated complaints, Vata vriddhi lakshanas, Kapha vriddhi lakshanas, Pitta kshaya lakshanas, Dhatu Dushti lakshanas, Sama Dushya lakshanas and Ama lakshanas were provided in all the three groups.09. Further comparison showed that treatment with Alambushadi Yoga and Dhanyamla Kaya Seka in group C provided better relief in cardinal symptoms, MIA, ANIA, GDA, AHA, AIMS, Physical disability, walking time, grip strength, ESR, CRP, LC%, DAS and DAS-28. Compared to Alambushadi Yoga in group A, treatment with Dhanyamla Kaya Seka in group B stood in second order as the improvement in these parameters are concerned.10. Alambushadi Yoga and Dhanyamla Kaya Seka in group A and group B respectively provided better relief in RAI. 198
  • 11. As improvement in EAMRAI is concerned, treatment with Alambushadi Yoga stood in first order, and combined therapy with Alambushadi Yoga and Dhanyamla Kaya Seka in second order.12. Compared to Dhanyamla Kaya Seka, treatment with Alambushadi Yoga provided good improvement in CRP.13. As improvement in Hb% is concerned treatment with Dhanyamla Kaya Seka stood in first order and Alambushadi Yoga in second order.14. Statistical analysis of inter group comparison using ANOVA test showed that improvement reported in Sandhi ruk, Sandhi sotha, Sparsha asahishnuta, Gourava, RAI, MIA, BIA, EAMRAI, GDA by patient and physician, AIMS, physical disability, range of movements, ESR, Hb%, CRP, DAS and DAS-28 in all the three groups have significant difference. This implies that the difference in improvement among the three groups is due to the group variation i.e. different treatment methods and not due to sampling variations.15. ANOVA test with Sandhi graha, ANIA, AHA, walking time, grip strength and LC% showed that the difference in improvement noted with these parameters among the three different groups were statistically not significant.16. As associated complaints, Vata vriddhi lakshanas, Kapha vriddhi lakshanas, Pitta kshaya lakshanas, Dhatu Dushti lakshanas, Sama Dushya lakshanas and Ama lakshanas were concerned, obviously there was no much difference in improvement among the three groups.17. On the basis of the for going it may be concluded that the overall relief provided by Dhanyamla Kaya Seka was better in comparision to Alambushadi Yoga. 199
  • 18. It may also be said that if both Alambushadi Yoga and Dhanyamla Kaya Seka are added to routine treatment of Amavata, then the rate of complete relief may be further increased.Limitations of the study: 1. The sample size was small. 2. The period of study was limited. 3. Longer follow up was not done.Scope for the further study: The following recommendations are made on the basis of observations andconclusions for the further studies as well as to overcome the limitations. 01. Same study can be repeated by taking a large number of samples. 02. The effect of the Alambushadi yoga can be studied in longer duration. 200
  • SUMMARY The present study entitled “Evaluation of Comparative efficacy of AlambushaadiYoga and Dhanyamla Kayaseka in Amavata (Rheumatoid Arthritis) “ consists of sixparts. 1. Introduction 2. Review of literature 3. Drug review 4. Material and methods 5. Observations and results 6. Discussion and Conclusion The introduction consists of need of the study, hypothesis, objectives and plan of thestudy. Second part deals with the historical aspects of Amavata, concept of Ama, Vata inAmavata, Nidana, Samprati, Purvarupa, Rupa etc. Third part entitled drug profile deals withthe ingredients of each compound, proportion of each ingredient and method of preparation. The fourth part entitled material and methods describe the plan of the study, criteriaof selection of patients, method adopted for the assessment of results and method of KayaSeka. The fifth part entitled observations and results deals with the demographic data,responds to the treatment in the three groups and the overall relief. Results are given in theform of tables along with a short description separately for each group of the treatments.The improvements in selected parameters are statistically analyzed and presented in theform of tables and graphs. The fifth part designated as analysis, discussion and conclusion is divided into foursections. First section entitled Amavata and Rheumatoid Arthritis deals with the analysis ofetiopathology and the wide spectrum of clinical manifestations of Amavata and Rheumatoid 201
  • Arthritis. The section entitled drug review dealt with the method of collection and preparationof drug and procedure of Kayaseka adopted in the present study. The third section entitledclinical study analyses the demographic data and clinical response to the treatments withlogical interpretations the fourth section entitled probable mode of action discusses theprobable mode of action of Alambushadi Yoga and Dhanyamla Kayaseka in themanagement of Amavata.Conclusion: The conclusions drawn from the present study can be presented with: Ø Alambushadi Yoga and Dhanyamla Kaya Seka in group A and group B respectively provided better relief in Amavata. Ø On the basis of the for going it may be concluded that the overall relief provided by Dhanyamla Kaya Seka was better in comparision to Alambushadi Yoga. Ø It may also be said that if both Alambushadi Yoga and Dhanyamla Kaya Seka are added to routine treatment of Amavata, then the rate of complete relief may be further increased. 202
  • References1. Charaka Samhita Chikitsa 12/52.2. Ibid. 16/61-63.3. Ibid. 28/135.4. Ashtanga Hridaya Chikitsa 21/47-50.5. Harita Samhita Chikisa 21.6. Madhava Nidana 25/04.7. Chakradata 25/19-20.8. Bhavaprakasha 26/282.9. Yoga Ratnakara Amavata Nidana Pp. 564.10. BHaishaijya Ratnawali 29/20.11. Vanga Sena Amavata Rogadhikara 402.12. Siddhanta Nidana 713. Madhava Nidana 25/2-5.14. Madhava Nidana 25/24. Vijaya Rakshita15. Shabdakalpa Druma Pp. 183.16. Siddhanta Nidana 717. Madhava Nidana 25/5. Viajaya Rakshita.18. Madhava Nidana 25/5. Vachaspati.19. Madhava Nidana 25/5. Vachaspati.20. Sushruta Shareera 5/16.21. Ibid.22. Ashtanga Hridaya Sutra 12/15.23. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 1928 203
  • 24. Ibid. pp193025. Ibid.26. Ibid.27. Shabdakalpa Druma Pp.183.28. Amarakosha Prathama Kanda29. Sabda Stoma Mahanidhi30. Ashtanga Hridaya Sutra 13/25.31. Madhava Nidana 25/1-5. Madhukosha.32. Madhava Nidana 25/1-5. Madhukosha.33. Madhava Nidana 25/1-5. Madhukosha.34. Madhava Nidana 25/1-5. Madhukosha.35. Ashtanga Hridaya Sutra 13/25.36. Ibid.37. Ibid.38. Ibid.39. Dalhana40. Ashtanga Hridaya Sutra 13/25.41. Ibid.42. Ibid.43. Ibid.44. Ibid.45. Charaka Samhita Sutra 21/89.46. Charaka Chikitsa 15/42-4347. Ibid. 15/5.48. Ibid. 15/39.49. Ashtanga Hridaya Sutra 12/10-12.50. Charaka Chikitsa 15/13.51. Ibid. 15/15.52. Sushruta Sutra 15/13. Dalhana53. Madhava Nidana 25 Atanka Darpana54. Charaka Chikitsa 8/40. Chakrapani.55. Madhava Nidana 25/1-5. Madhukosha.56. Ashtanga Hridaya Shareera 3/25.57. Charaka Shareera 6/17. 204
  • 58. Charaka Chikitsa 12/17. Chakrapani59. Sushruta Sutra 21/18.60. Ashtanga Hridaya Sutra 12/25.61. Ibid. 11/35. Aundatta.62. Ibid. 13/26.63. Charaka Vimana 2/12.64. Timeless body and ageless mind by Dr|| Deepak Chopra, published by BantamBooks,1540 Broad Way, NewYork, pp67-7865. Ibid66. Ibid67. Ibid68.Free Radical , Article published in the Antiseptic69. Proceedings of second national Ayurveda Congress on jaravyadhi and manasarogas by SAFROHN,Channai, Pp 78-8070. Ashtanga Hridaya Sutra 13/23-24.71. Roga Vignana & Vikrirti Vignana By- Dr. Subhasha Rande et. al. Published by-Kerala Govt. Ayuyrvedic Publication series- 8 Pp.112.72. Madhava Nidana 1/4. Madhukosha.73. Ibid.74. Ibid.75. Roga Vignana & Vikrirti Vignana By- Dr. Subhasha Rande et. al. Published byKerala Govt. Ayuyrvedic Publication series- 8 Pp.115.76. Charaka Sutra 28/8-9.77. Ibid. 28/10-11.78. Ibid. 28/12-13.79. Ibid. 28/14-15.80. Ibid. 28/16-17.81. Ibid. 28/18-19.82. Ibid. 28/18-19.83. Sushruta Uttara 40/17.84. Charaka Vimana 2/13.85. Sushruta Sutra 21/15. Dalhana.86. Charaka Samhita Sutra 12/4.87. Ibid. 205
  • 88. Sharanga Dhara Samhita.89. Charaka Samhita Chikitsa 28/4.90. Ibid. 28/59.91. Ibid. 28/60-61.92. Ibid. 28/15-18.93. Ibid. 28/20-23.94. Ashtanga Hridaya Sutra 13/1-3.95. Madhava Nidana 25/1.96. Sushruta Sutra 20/20.97. Charaka Vimana 2/8-12.98. Charaka Chikitsa 8/40. Chakrapani.99. Charaka Sutra 26/86-87.100. Ashtanga Hridaya Nidana 12/03.101. Introduction to Kaya Chikitsa by- C. Dwarakanatha. II edition 1986. Publishedby Choukhamba Orientalia, Varanasi. Pp. 38-40.102. Charaka Chikitsa 15/13-15. Chakrapani.103. Madhava Nidana 25/01.104. Ashtanga Hridaya Sutra 13/16-17.105. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp1225106. Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999,Published by – Blackwell Science Limited, Paris, France. Pp7-8107. API textbook of Medicine by-Sanai. et.al. VI edition 1999, Pp. 1028.108. Robins Pathologic Basis of disease by Cotron et. al. Published by-Harwart Pvt.Ltd., Lajpath Nagar, N. Delhi. Pp1401 -2109. Harrison’s Principles of Internal Medicine by – Eugene Braunwald et. al. 15thedition 2003. Published by – The Mc Grow Hill Companies. Pp 1933110. Arthritis and Ayurveda by- Dr. K. Nishteshwar pp 3111. Madhava Nidana 25/10.112. Ashtanga Samgraha Sutra 19/28.113. Charaka Chikitsa 22/15. Chakrapani.114. Sushruta Uttara 56/10. Dalhana.115. Sushruta Sutra 21/36. Dalhana. 206
  • 116. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published byW.B.Saunders Company, Philadelphia, Pensylvania. pp 1225 -1230117. Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999, Published by – Blackwell Science Limited, Paris, France. Pp 27-38118. API textbook of Medicine by-Sanai. et.al. VI edition 1999, Pp. 1028.119. Robins Pathologic Basis of disease by Cotron et. al. Published by-Harwart Pvt.Ltd., Lajpath Nagar, N. Delhi. Pp 1405120. Harrison’s Principles of Internal Medicine by – Eugene Braunwald et. al. 15thedition, 2003. Published by – The Mc Grow Hill Companies. Pp 1929-30121. Davidson’s principles and Practice of Medicine by- Cristapher et.al. ELBS. 17thedition published by- Chirchill Livingstone, Pearson Professional Limited, New York.Pp 890-892122. Rheumatoid arthritis – Emerging trends in therapy by- Joshi V. R. IndianPractitioner, January 2000. Vol. 53 No. 1 Pp. 91-98.123. Joint and Musculoskeletal Pain by- P.C. Rishi, Hospital Today. Vol. V No. 9 September 2002. Pp 14-16124. Rheumatoid Arthritis – Managing a recalcitrant disorder by – Iqbal Grewal, Ayurveda Vikas, November to December 1999, Pp.43-44.125. Arthritis and Ayurveda by- Dr. K. Nishteshwar. Pp 4126. Charaka Chikitsa 28/19.127. Challenges in Rheumatoid arthritis pp 90-91128. Text Book of Rheumatology pp 1230-1231129. Madhava Nidana 25/6-10.130. Role of Rasayana and Dhanyamla Pinda Sweda in the Management ofAmavata by- Jayadevan C. Warrier, Gujrat Ayurveda University, Jamnagar, 1990. Pp38-40131. Basavarajiya132. Madhava Nidana 25/6-10.133. Bhavapraksha 26/282-290.134. Bhaishaijya Ratnawali 29/20-25.135. Yoga Ratnakara Amavata Nidana Pp. 564-566.136. Charaka Chikitsa 12/8.137. Ashtanga Hridaya Sutra 12/51. Arundatta And Hemadri.138. Ashtanga Hridaya Sutra 8/25. Arundatta. 207
  • 139. Charaka Sutra 28/9. Chakrapani.140. Charaka Chikitsa 22/15.141. Ibid. 22/20.142. Ashtanga Hridaya Sutra 11/13. Hemadri.143. Charaka Sutra 18/32.144. Sushruta Shareera 4/52.145. Charaka Vimana 5/8.146. Ibid.147. Ashtanga Hridaya Sutra 11/06. Hemadri.148. Sushruta Sutra 15/13. Dalhana.149. Ibid. 15/24.150. Charaka Sutra 28/10.151. Ashtanga Hridaya Sutra 12/5. Hemadri.152. Madhava Nidana 25/10. Mahdukosha.153. Sushruta Shareera 04/55.154. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 1230-32155. Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999, Published by – Blackwell Science Limited, Paris, France. Pp 98-106, 114-15156. API textbook of Medicine by-Sanai. et.al. VI edition 1999, Pp. 1028.157. Robins Pathologic Basis of disease by Cotron et. al. Published by-Harwart Pvt.Ltd., Lajpath Nagar, N. Delhi.158. Madhava Nidana 25/11-12.159. Ibid.160. Charaka Sutra 28/02.161. Ashtanga Hridaya Nidana 15/45.162. Ibid. 1/06-07.163. Madhava Nidana 25/12.164. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 114-15165 Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999, Published by – Blackwell Science Limited, Paris, France.. pp 1230-32166. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. 208
  • 167. Chakradatta 25/19-20.168. Yogaratnakara Amavata Nidana Pp. 564-566.169. Charaka Sutra 22.170. Ibid. 22/18.171. Sushruta Uttara 39/103.172. Charaka Chikitsa 3/140.173. Charaka siddhi 1/12-13.174. Charaka Chikitsa 15/75.175. Sushruta Chikitsa 1/11.176. Charaka Chikitsa 3/141-142.177. Ibid. 3/139. Chakrapani.178. Charaka Sutra 22/11-16.179. Yogaratnakara Amavata Nidana Pp. 564-566.180. Charaka Chikitsa 3/144.181. Ashtanga Hridaya Sutra 10/01.182. Charaka Sutra 26/4-5.183. Ibid. 16/20.184. Ibid. 22/11.185. Sushruta Chikitsa 35/37.186. Madhava Chikitsa187. Chakradatta 25/10-11.188. Yogaratnakara Amavata Nidana Pp. 564-570.189. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 411.190. www.gflora.com/oxalida/biophytum.htm191. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp 1229-32192. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published byChoukhamba Bharteeya Acadamy pp 632-634193. Oushadha Sasyangal by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 399.194. The Useful Plants of India, Publication and Information Directrate, CSIR, NewDelhi, 1986. 209
  • 195. A handbook of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 61-62196. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Published by–Karnataka state council for science and technology Pp.240.197. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published by –Choukhamba Bharteeya Academy. Pp 758-61198. A hand book of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 9-10199. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 326.200. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp 480-84201. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Published by–Karnataka state council for science and technology Pp.242.202. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published by –Choukhamba Bharteeya Academy. Pp 239-240203. A hand book of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 175-176204. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 326.205. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp 1202-4206. The Useful Plants of India, Publication and Information Directrate, CSIR, NewDelhi, 1986.207. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Published by–Karnataka state council for science and technology Pp.242.208. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published by –Choukhamba Bharteeya Academy. Pp 753 - 54209. A handbook of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 67-68210. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 326.211. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp 1205-10 210
  • 212. The Useful Plants of India, Publication and Information Directorate, CSIR, NewDelhi, 1986.213. A User’s Guide to medicinal Plants for Primary Health Care By- P.Rammanohar 1995. Published by- foundation for revitalization for local healthtredition. Banglore. Pp 4-5214. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Publishedby –Karnataka state council for science and technology Pp.242.215. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published by –Choukhamba Bharteeya Acadamy. Pp 331-33216. A handbook of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 24-25217. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 326.218. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp 1308-14219. The Useful Plants of India, Publication and Information Directrate, CSIR, NewDelhi, 1986.220. Spices Herbs and edible Fungi by – George charalombeous Punblished by –Elsevier science, Amsterdam, Netherlands. Pp 216-18221. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Published by–Karnataka state council for science and technology Pp.242.222. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published by –Choukhamba Bharteeya Acadamy. Pp 761-63223. A hand book of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 63-4224. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 326.225. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp1220-21226. A User’s Guide to medicinal Plants for Primary Health Care By- P.Rammanohar 1995. Published by- foundation for revitalization for local healthtredition. Banglore. Pp 8-10227. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Published by–Karnataka state council for science and technology Pp.242. 211
  • 228. Materials and Aromatic Plants Abstracts, Publication and Informationdirectorate, CSIR, New Delhi.229. The Useful Plants of India, Publication and Information Directorate, CSIR, NewDelhi, 1986.230. Dravyaguna Vignana by- Prof. P.V. Sharma 16th edition 1995. Published by –Choukhamba Bharteeya Academy. Pp 420-22231. A handbook of medicinal plants by – Dr. V.C. Neginhal, Published by – V.G.Neginal, Banglore 2003. Pp 160-61232. Oushadha Sasyangala by- Dr. S. Neshamani VI edition 1993. Published By-Kerala Bhasha Institute, Kerala Pp. 326.233. Indian Materia Medica By – K. M. Nadakarni III edition 1986 Published by –Popular Prakshana Private Limited, Bombay. Pp 691-94234. A User’s Guide to medicinal Plants for Primary Health Care By- P.Rammanohar 1995. Published by- foundation for revitalization for local healthtredition. Banglore. Pp 6-7235. Database of medicinal plants by – C. Kameshwar Rao. May 2002. Publishedby –Karnataka state council for science and technology Pp.242.236. Sahasra yoga Edited by – Shri K. V. Krishnan Vaidyan et.al. Published by Vidyarabham Publishers, Allepy, 23rd edition April 2000. Pp.122.237. Charaka Chikitsa 3/259.238. Ibid. 14/44-47.239. Ibid. 8/74.240. Ibid. 27/50-55.241. Sahasra yoga Edited by – Shri K. V. Krishnan Vaidyan et.al. Published by Vidyarabham Publishers, Allepy, 23rd edition April 2000. Pp.122.242. TextBook of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 850-851243. Ibid.244. Ibid.245. Textbook of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 860-65246. Ibid.247. Ibid.248. Ibid. 212
  • 249. Ibid.250. Ibid.251. Kashypa Samhita252. www.arhtritis-research.org253. www.mamashealth.com/default.htm.254. Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999, Published by – Blackwell Science Limited, Paris, France.255. www.muhealth.org/athritis/newsconference /farming.html.256. TextBook of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 1025-26257. Ibid.258. Ibid.259. Ibid.260. Chikitsa Sangraha by – P.S. Warrier. 1st Edition 1975. by Arya Vaidya Sala Kottekkal. Pp 192.261. Text Book of Rheumatology By- Kelley et. el., 5th edition, Published by W.B.Saunders Company, Philadelphia, Pensylvania. Pp 1027-28262. Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999, Published by – Blackwell Science Limited, Paris, France. Pp 62-64263. API textbook of Medicine by-Sanai. et.al. VI edition 1999, Pp. 1032.264. Robins Pathologic Basis of disease by Cotron et. al. Published by-Harwart Pvt.Ltd., pp 1044-45 Lajpath Nagar, N. Delhi.265. Harrison’s Principles of Internal Medicine by – Eugene Braunwald et. al. 15thedition 2003. Published by – The Mc Grow Hill Companies. Pp 1929-31266 Challenges in Rheumatoid arthritis by- Haward A. Bird et. al. I edition 1999, Published by – Blackwell Science Limited, Paris, France.267 Aryavaidyan published by Aryavaidhya Shala,kottakal, Vol XV, No 3-4 ,feb – jul02 ,Pp 157-160268 Ibid269 Proceedings of second national Ayurveda Congress on Jaravyadhi and manasarigas by SAFROHN,Channai270 Effect of massage and use of oil in growth, blood flow and sleep pattern ininfants, by Indian Journal of Medical Research, Dec 2000 Pp 212-217. 213
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  • Annex SPECIAL CASE SHEET FOR “AMAVATA ” DEPARTMENT OF KAYACHIKITSA POSTGRADUATE STUDIES AND RESEARCH, (KAYACHIKITSA) SHRI D.G.M. AYURVEDIC MEDICAL COLLEGE, GADAGGuide:- Dr. K. Siva Rama Prasad. M. D. (Ayu.) M.A. (Astro) Ollakkod ShyjuCo – Guide: Dr. Shashidhar H. Doddamani M. D. (Ayu.) M.D. Scholar 1. Name of Patient Sl. No. 2. Father’s/Husband’s Name OPD No. 3. Age – years IPD No. 4. Sex – Bed No. Hind Musli Christian Other 5. Religion Schedule initiation Schedule completion 6. Occupation Labour Sedentary Intellectual Active House Wife Poor Middle High Aristocrat 7. Economical Status 8. Address Tel:- PIN 9. Selection for Group A Alambushadi Yoga Included Excluded B Dhanyamla Kayaseka 10. Result C Both A & B Complete Minor subsidence Non Tolerant Defaulter remission subsidence Consent: I Son/Daughter/wife of exercise my free will, to participate in the said study. I have been informed to my satisfaction, by the attending physician the purpose of the clinical evaluation and nature of drug treatment. I am also aware of my right to quit at any time during the schedule. Signature of Patient 218
  • 1) Chief ComplaintsS.No Complaints Duration Before After After follow up1 Sandhigraha (Morning stiffness) (A)2 Sandhi Ruk (Pain in Joints) (A,M) Onset H/o Trauma Nature Grade Diurnal change Dietetic relation Relation with Climatic conditions Change with movement Change with rest3 Sandhi Sotha (Swelling) (A,M)4 Sparsha Asahishnuta (Tenderness)5 Gourava (Heaviness) (A,M)Associated complaints6 Angamarda (M)7 Aruchi (M)8 Trushna (M, B)9 Alasya (M)10 Jwara (M)11 Apaka (M)12 Angasoonata (M)13 Agni dourbalya (M)14 Praseka (M)15 Utsaha hani (M)16 Daha (M)17 Bahumootrata (M)18 Kukshi shoola (M)19 Nidraviparyaya (M)20 Chardi (M,B)21 Bhrama (M) 219
  • S.No Complaints Duration Before After After follow up22 Moorcha (M)23 Hritgraha (M)24 Vidwibandha (M)25 Jadhyata (M)26 Antrakoojana (M)27 Anaha (M)28 Vatopadrava (M)29 Panduvarna (B)30 Peetanetrata (B)31 Sosha (B)32 Vishoochi (B)33 Ushnata (B)34 Janghadi pradeshe vyadha (B) 2) History of present illness: Insidious Acute Systemic Palindrome Mode of onset Oligo articular Poly articular Mono articular Symmetrical Asymmetrical Sequence of joints involved 1) 2) 3) 4) Aggravating factors 1) 2) 3) 4) Relieving factors 1) 2) 3) 4) Nature of disease Progressive Regressive Constant Intermittent Routine activities affected Mild Moderate Severe Not affected 3) History of the Past Illness: 4) Previous treatment history: 5) Family History: 220
  • 6) Personal History:a) Ahara: Vegetarian Taste Sweet Sour Salt Predominance Mixed food Pungent Bitter Astringentb) Jatharagni: Manda Teekshna Vishama Samac) Pureesha Pravritti: Vidvibandha Dravavit Prakrita Frequencyd) Mutra Pravritti: Frequency Day Night Mutra Dahae) Nidra: Sukha Alpa Ati Vaishamyaf) Vyasana: Smoking Alcohol Tobacco No Habitsg) Artava Pravritti Days Samanya Alpa Adika Rajonivritti7) Examination of Patient (Vital):a. Pulse /Min b. Blood Pressure mm Hgc. Temperature °Fd. Height cms e. Respiration /min f. Weight Kg7a) Special Examination (Ayurveda)1. Nadi V P K VP VK PK VPK2. Prakruti V P K VP VK PK VPK3. Sara Pravara Avara Madhyama4. Samhanana Susamhita Asamhita Madhyma samhita5. Pramana Height in Cms Weight in Kgs6. Satmya Ekarasa Sarvarasa Ruksha Sneha7. Satwa Pravara Avara Madhyama8. Ahara Abhyavaharana Jarana Shakti9. Vyayam Pravara Avara Madhyama Shakti10. Vaya Balya Yauvana Vardhakya11. Desham (Deha) ê Bhumi Jangala Anupa Sadharana 221
  • (a) Dosha Vruddhi Vata B A Pitta B A Kapha B A Karshya Peeta mootrata Agni sadana Karshnya Peetanetra Praseka Ushna kamitwa Peetavit Alasya Kampa Peetatwak Swetangata Anaha Adhikshudha Sheetangata Shakrudgraha Adhidaha Gowrava Balabhrmsha Slathangata Nidrabhramsha Swasa Pralapa Kasa Bhrama Atinidra(b) Dosha Kshaya Vata B A Pitta B A Kapha B A Angasada Mandagni Bhrama Alpabhashite Shareera Urah shoonyata ahitam sheetatwam Chesta heenata Prabha hani Shira soonyata Vyamoha Hridrava Sandhi Sleshma vruddhi saidhilya (c) Sama Dosha Vata B A Pitta B A Kapha B A Vibandha Durgandha Avilam swasa Durgandha Tantumat Agnisada udgara Harita shyava Tandra Sandra shtevana Antrakujana Ghana (Guru) Kantopaliptam shtevana Kati parshwa Amlodgara Durgandha Vedana shteevana Shodha Kanta daha Kshutvighata Toda Hrit daha Udgaravighata Vicharet Snigdhopakrama vriddhi Nishi vriddhi 222
  • Rasa Agnimandya Hrillasa Jwara Aruchi Tandra /Tama Pandu Angamarda Akala valipalita Klaibya Rakta Asyapaka Medhrapaka Yakrit roga Guda paka Twak vikara Pleharoga(d) Sama Dhatu Mamsa Galaroga Jihwaroga Mamsa vikara Kielam Arshas Ostaprakopa Medas Medograndhi Atisweda Padapanidaha Sthoulyam Dantadimalam Chikkanadeha Asti Astishula Astibheda Keshadi vikara Majja Parwaruk Netrabhi Bhrama shyandam Sukra Aharshana Sukrameha Klaibya Apraja Garbhanasha Virupapraja (e)Ama lakshana Aruchi Tandra Suptata Apakti Nisteeva Stambha Klama Hridayavisuddh Anila mudhata i Alasya Guru udara Vyakulamutra Balabhramsha Gourava Malasanga (f) Sama mutra Mutra roga Meha (g) Sama Apsu avasedana Durgandha Prustakati graha Pureesha Ghana/Bhrusha Pichchila Sadana Vistambham Shiroruk VichchinnaNidana Aahara Vihara Others Guru bhojana Virudha chesta Mandagni Prakruti Virudha Avyayama Virudha bhojana Samaya Viruddha Vyayama after snigdha bhojana Samyoga Virudha Ativyayama 223
  • Samprapti ghatakas Dosha Dushya Adhistana Srotas Roga marga Udbhavasthana Sancharasthana Vyaktasthana Adhistana7b) Special Examination (Joints): Sakha Pareeksha Scores > Before After Follow up Deformity of joint Darshana Swelling Rheumatic nodules Muscle wasting Skin over the Joint Warmth over Joint Tenderness Sparshana Swelling Intra articular Extra (peri) articular Bursitis Tenosynovitis Synovial thickening Bony components Palpable Shravana (Crepitation)7c) Special Examination (Extra articular manifestations): Extra articular manifestations Before After Follow up Low grade fever Systamic Loss of appetite Loss of weight Fatigue Muscle wasting Musculo skeletal Bursitis Tenosynovitis 224
  • Extra articular manifestations Before After Follow up Subcutaneous nodules Vasculitis UlcersSkin Gangrene Pyoderma gangrenosam Nail fold infarcts Sicca syndrome EpiscleritisEye Scleritis Scleromalacia Plural effusion Fibrosing AlveolitisRespiratory Nodules Bronchiolitis Caplan’s syndrome Pericarditis MyocarditisCardiac Endocarditis Aortitis / Aortic regurgitation Conduction disturbances Entrapments syndromeNeurological Cervical compression Peripheral neuritis Mono neuritis multiplex AnaemiaReticuloendothelial Haematological Thrombocytosis Eosinophilia Felty’s syndrome Splenomegale Systemic vasculitisOthe Amyloidosis rs 225
  • 7d) Lab Investigations Screening investigations Sl. No. Name of the test Values 1 Random Blood Sugar 2 RA Test 3 ASO titer 4 Serum Uric acid 5 Serum Cholesterol 6 Serum Alkaline Phosphatase 7 Serum Acid Phosphatase 8 Routine Urine Analysis Sugar Albumin Microscopic 9 Routine Stools examination 10 Blood smear 11 Radiological examination 12 Differential count of N E B M L7e) Assessment of investigations Sl. No. Name of the test Baseline values Final values 1 ESR mm of 1st hour mm of 1st hour 2 Hb% mg% mg% 3 Total Lymphocyte count Per Cms Per Cms 4 CRP 5 Lymphocyte count in %8) Upasaya / Anupasaya 1) Ruksha sweda – Pain reduced : Yes / No 2) Snigdha sweda – Pain increased : Yes / No9) Type of Amavata Doshanubandha Kalanubandha Vataja Pittaja Kaphaja Naveena Pravrudha 226
  • 10) Assessment criteria Criteria Before After Follow up Disease activity measures 1 Sparsha asahishnuta score (Tenderness –28) 2 Bahusandhi Shotha score (Swelling –28) 3 Patient pain assessment Core set 4 Patients Global Disease Assessment (GDA-ICD10) 5 Physicians Global Disease Assessment (GDA-ICD10) 6 Physical Disability / AIMS-2 criteria 7 Acute Phase Reactants - ESR 8 Acute Phase Reactants – CRP 9 Ritchei articular index 10 Bahusandhi Shotha score (Swelling –44) DAS 11 General Health Assessment (HAQ) 12 DAS-28 criteria 13 DAS criteria Improvement criteria 14 ACR criteria 15 EULAR criteria Ayurvedic parameters 16 Ayurvedic Health Assessment (AHA) 17 Basavaraja Index of Amavata (BIA) 18 Anjana Nidana index of Amavata (ANIA) 19 Madhavakara Index of Amavata (MIA) 20 Bahusandhi shoola score (Pain) 21 Jwara (Fever) 22 Sandhi graha (Morning stiffness) Other parameters 23 Grip strength (mm Hg) 24 Walking time (40 ft) 25 Extra Articular manifestations of RA index (EAMRAI) 26 Lymphocyte count 27 Haemoglobin % 28 Joint movement10) Treatment Protocol – Distribution of Alambushadi Yoga Remarks Initial – Day 1 2nd - Day 7 3rd - Day 14 1st Follow up - Day 21 2nd Follow up - Day 42 227
  • Day Date Dhanyamla kayaseka Remarks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21Investigator’s note: – Signature of the scholarSignature of Co-guide Signature of Guide 228
  • Worksheet Tender joint count -53 Swollen joint count -44 Painful joint count -53 Right Left T Right Left T Right Left T B A F B A F B A F B A F B A F B A FNeckShoulderWristMCPPIPHipKneeAnkleMTPTotalTotal 28 Patient pain assessmentVAS - BL 0 1 2 3 4 5 6 7 8 9 10VAS - After 0 1 2 3 4 5 6 7 8 9 10VAS – F-up 0 1 2 3 4 5 6 7 8 9 10 Patient Global disease assessmentVAS - BL 0 1 2 3 4 5 6 7 8 9 10VAS - After 0 1 2 3 4 5 6 7 8 9 10VAS – F-up 0 1 2 3 4 5 6 7 8 9 10 Physician Global disease assessmentVAS - BL 0 1 2 3 4 5 6 7 8 9 10VAS - After 0 1 2 3 4 5 6 7 8 9 10VAS – F-up 0 1 2 3 4 5 6 7 8 9 10 Physical disability /AIMS-2 General Health AssessmentSN Baseline After F-Up Max SN Baseline After F-Up Max1 25 1 62 25 2 63 25 3 94 25 4 65 20 5 96 20 6 67 25 7 98 20 8 99 25 9 3810 25 10 111 25 11 112 25 12 713 60 13 3614 60 14 515 22 15 216 5 16 7T 454 157 229
  • S J Motion Right Left Degree1 Neck Flexion 452 Extension 553 Rotation 704 Lateral bending 405 Flexion 1806 Extension 45 Shoulder7 Lateral Rotation 908 Medial Rotation 909 Abduction 18010 Adduction 011 Elbow Flexion 18012 Extension 3513 Arm Pronation 9014 Supination 9015 Flexion 80 Wrist16 Extension 9017 Ulnar deviation 3518 Radial deviation 2519 Flexion 90 Thumb fingers20 Extension 30 &21 Opposition 18022 Abduction 9023 Flexion 8024 Extension 5525 Lateral Rotation 45 Hip26 Medial Rotation 4527 Abduction 14528 Adduction 1029 Knee Flexion 18030 Extension 031 Ankle Plantar Flexion 13532 Dorsi Flexion 7033 Inversion 35 Foot34 Eversion 2035 Flexion 9036 Extension 30 230
  • Score sheetGrade Conditions0 = No complaints Associated complaints1= Mild Gourava2= Moderate Movements effected3= severe Muscle wasting4 = Very Severe Special examination (Dehadesha) Ayurvedic assessments0 = No complaints Bahusandhi shoola (Pain)1 = Patient tells about after inquiry2 = Patient frequently complains3 = Excruciating condition0 = No complaints Bahusandhi graha (Morning stiffness)1 = up to 30 minutes2 = up to 60 minutes3 = More than 60 minutes0 = No complaints Bahusandhi sotha (Swelling)1 = slightly obvious2 = covers well the bonny prominence3 = much elevated so that joints seems grosslydeformed0 = No complaints Sparsha asahishnuta (Tenderness)1 = Says Tender Joints2 = winces the affected joints3 = winces and withdraws the affected joints DeclarationsBonny components 0 =Normal, 1 = AbnormalpalpableChange with rest , 1 = Reduces, 2 = Increases, 3 =Constant, 4 = No relationChange with movementClimatic relations 1 = changes, 2 =constant, 3 = No relationDeformity 0 = absent, 1 =Swan neck, 2 = Boutonniere, 3 =Ulnar deviation, 4 = MCP subluxation, 5 = Ulnar clow hand, 6 = Fixed flexion, 7 = fixed abduction or adduction, 8 = shortening, 9 = Gnuvalgaum, 10 = Genuvarum, 11 = otherDietetic relations 1 = Before food, 2 = After food, 3 = No relationDiurnal change of pain 1 = Morning 2 = Evening, 3 = Night, 4 =Constant, 5 = No relationBursitis 0 = Absent, 1 = PresentCrepitationH/o TraumaSynovial thickeningTenosynovitisNature of pain 1 = Vruchikadanshavat , 2 = Toda, 3 = Ruja,Onset of pain 1 = sudden, 2 = GradualSkin 1 = Dry, 2 = MoistWarmth 0 = Normal, 1 = decreased, 2 = risen, 231
  • Work sheet – layoutJoint RAI-Graded T-53 Un Graded S-44 Un Graded S-28 Un Graded T-28 Range of s movements Rt Lt Rt Lt Rt Rt Lt Rt Lt Lt B A F B A F B A F B A F B A F B A F B A F B A F B A F B A FT.MS.CA.CElb.Wri.MCPPIPKne.MTPAnk.C.S.Hip.T.C.M.T.Sho.Total T.M. – Temporomandibular , S.C.- Sterno clavicular, A.C - Acromio clavicular, Elb. – Elbow, Wri. – Wrist, Kne. – Knees, Ank. – Ankles, C.S.- Cervical spine, T.C.- Talo calcaneal, M.T. – Mid tarsal joints Quantitative pain assessment : How often is it painful for u to : B A Af a) Dress yourself? b) Get in and out of bed? c) Lift a cup or glass to your lips ? d) Walk out doors on flat ground ? e) Wash and dry your entire body ? f) Bend down to pick up clothing from the floor ? g) Turn faucets on or off ? h) Get in and out of a car / bus etc ? Total Score 232
  • Pain on VASB. L 0 100 mmAfterA.F. No pain Worst possible painHealth Assessment Questionnaire For self Assessed Disability B A AF 1 Dressing & Grooming 2 Arising 3 Eating 4 Walking 5 Hygiene 6 Reach (to get down / pickup 7 Grip 8 Activities Total ScoreArthritis Impact Measurement Scale – (AIMS ) for Global disease activity) B A AF 1 Mobility level (Ex : do errands) 2 Walking and bending (Eg: climb stairs) 3 Hand and finger function (Eg: button a shirt) 4 Arm function (Eg: Comb hair) 5 Self care tasks (Eg: take bath) 6 House hold tasks (Eg: House work) 7 Social activity (Eg: Visit friends) 8 Support from family & friends 9 Arthritis pain 10 Work 11 Level of tension 12 Mood Total Score 233
  • Ayurvedic Health Assessment :- (AHA Criteria) Symptoms B A AF 1 Annabhilasha 2. Bhuktasya paripakam 3 Vit Srishta Mootra 4 Sareera laghavam 5 Suprasennendriyam swapnam 6 Sukha prabotanam 7 Balam 8 Varnam 9 Saumanasyam 10 Samagnita Total scoreGradingsRange of movements – No movement =0, up to 50 % =1, 50 – 70 % =2 , > 75% & <Full range =3, Full range = 4.Quantitative Pain Assessment Never =0, Some time =1 Most of times =2 Always =3HAQ - With out any difficulty = 0, with some difficulty = 1 , with much difficulty =1 Unable to do =3.AIMS – Very Satisfied =1, Some what satisfied = 2, Neither satisfied nor dissatisfied =3 , Some what dissatisfied =4, Very dissatisfied = 5.Disease Activity ScoreDAS = 0.53938 √(RAI) + 0.06465 (S - 44) + 0.330 (Ln ESR) + 0.00722 (GH)DAS 28 = 0.56 √(T – 28) + 0.28 √(S – 28) + 0. 70 (Ln ESR) + 0.014 (GH) 234