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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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  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. • 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. (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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. (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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. (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
  54. 54. 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
  55. 55. (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
  56. 56. 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