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Grudhrasi kc004-hyd

  2. 2. Dr. N.T.R.UNIVERSITY OF HEALTH SCIENCES Vijayawada, A.P. Post Graduate Department of Kaya Chikitsa Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad Place: Hyderabad, Date: / /2007. CERTIFICATE This is to certify that Dr. K. SIREESHA is a bonafide final year Post-graduate scholar of M.D. (Ay) in the speciality of Kaya Chikitsa of thisinstitute. She has worked for her thesis on the topic titled “A clinical study onthe effect of Rasona Pinda with Asta Varga Kashaya Anupana andMatra Vasti in the management of Gridhrasi Vata” as per therequirements laid down by the Dr.N.T.R.University of Health Sciences,Vijayawada, for the purpose. I forward this thesis for further evaluation by adjudicators. Dr. PRAKASH CHANDER M.D. (Ay.) Professor & H.O.D P.G.Unit of Kaya Chikitsa Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad, A.P.
  3. 3. Dr. N.T.R.UNIVERSITY OF HEALTH SCIENCES Vijayawada, A.P. Post Graduate Department of Kaya Chikitsa Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad Place: Hyderabad, Date: / /2007. CERTIFICATE This is to certify that Dr. K.SIREESHA is a final year Post-graduateScholar of M.D. (Ay) in the speciality of Kaya Chikitsa of this institute. Shehas written the dissertation entitled “A clinical study on the effect of RasonaPinda with Asta Varga Kashaya Anupana and Matra Vasti in themanagement of Gridhrasi Vata.” in partial fulfillment for the degree ofDoctor of medicine under my direct supervision and guidance. The candidatehas put in all her efforts in the successful completion of her studies. Dr. PRAKASH CHANDER. M.D. (Ay.)
  4. 4. “Namami Dhanvantarimadi Devam, Surasurairvandit Padapadmam | Loke Jararugbhay Mrutyunasham,Datarmisham Vividhoushadhinam ||”
  5. 5. ACKNOWLEDGEMENTS The present thesis work is dedicated to Golden feet of Sri Lord Venkateswara. It is a great privilege for me to have worked under the guidance ofDr. PRAKASH CHANDER M.D (Ay), Professor & Head of Dept. of P.G. Unit (K.C),who has guided and supervised my work with his valuable suggestions in this entiredissertation work. I offer earnest thanks to Dr.M.Srinivasulu for his timely suggestions and valuablediscussion for completion of thesis work. It gives me a moment at great pleasure on this occasion to thank andacknowledge the important and unforgettably needed help rendered by Dr.V.Vijaya BabuM.D (Ay) Reader P.G Unit K .C with out which this work would not have beencompleted. I express heartful thanks to Dr. K.V.Bhaswanth Rao, Dr M.L.Naidu, Dr. Vijayalakshmi, Dr.Ramlingeswar, Dr Raghupathi Goud, Dr Murali Mohan, Dr.NageswaraBabu, Dr. Srikanth Babu, for their valuable suggestions and support. I owe my special thanks to Dr K.V.S.Prabhakaram A.D AYUSH Dept.,Dr. P. Murali Krishna, M.D.(Ay), Assistant Professor, S.V.Ayurvedic College, Tirupati,and Dr. G.Puroshothamacharyulu M.D and Dr.D. Ram Gopal M.D who trained me in aright path in the field of Ayurveda . I am highly thankful to Dr.K.Sadasiva Rao,, Principal, Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad, Dr.L.Radha.Krishna Murthy Hospital Superintendent forgiving us the concern facilities for the successful completion this work. My head bows at the feet of my parents who are solely responsible for myexistence. I am equally thankful to my in-laws, my husband M. Satya Srinivas, my sonSudarsan and my brother Kishore for their valuable support. I am very thankful to my colleagues Dr. J.Sivanarayan, Dr. G.Lavanya,, Dr. V.LaxmiPrasoona and my senior Dr M.Padmaja for their kind co-operation.Finally I express my thanks to all my patients who have co-operated with me at all levels in myclinical study. (Dr. K. SIREESHA)
  6. 6. Parts Index Page no.Part-I 1. Introduction 1-4 2. Review of Historical aspect 5-9Part-II DISEASE ASPECT 1) Gridhrasi vata meaning and definition 10-11 2) Sareeram 12-24 3) Nidanam 25-32 4) Poorva roopa 33 5) Roopa 34-44 6) Samprapti 45-52 7) Upadravas and Sadhyasadhyata 53-54 8) Sapeksha Nidana 55-56Part-III 1) Chikitsa. 57-61 2) Pathyapathya 62-65Part-IV DRUG ASPECT 1) Description of Individual drugs 66-79 2) Description of Matra Vasti. 80-82Part-V CLINICAL STUDY 1) Materials and methods 83-89 2) Observations 90-102 3) Results. 103-110Part-VI 1) Discussion 111-115 2) Summary 116-117 3) Conclusion 118-119 4) Bibliography 5) References 6) Annexure
  7. 7. u INTRODUCTION Life started from a single organism and extends to more complex stateduring the evolution. In this process of evolution vertebrates accomplished theirrole by having a complex axial skeletal system among the other groups of livingbeings. It is very much primitive in fishes, amphibians and developed in birds andanimals respectively. In the group of mammals, the animals, which move on fourlegs possess cartilages between the adjacent vertebrae instead of discs as inhuman. In evolutionary process man remain as the only animal, which stands inup right posture. During the man’s evolution the transition from the quadrupedal to bipedalstate led first to straightening and then to inversion of lumbar curvature (lumbarlordosis). The erection of the trunk has been obtained partly by backward tilting ofpelvis and partly by the bending of the lumbar column. The vertebral column of quadrupeds relaxes absolutely during rest. Indeedthe presence of curvatures in the vertebral column, man never attains absolute restin any posture and owing them to suffer with problems related to vertebralcolumn. Obviously the life style of a person has changed a lot in accordance withthe time. As the advancement of busy, professional and social life, impropersitting postures in offices and factories, continuous and over exertion, jerkingmovements during traveling and sports-all these factors created un due pressure onthe spine. All these factors will result in the most common disorder in mostproductive period of life. - Back pain. Out of which 40% of persons will haveradicular pain and this comes under the umbrella of Sciatica. 1
  8. 8. Gridhasi 1 is a shoola pradhana vataja nandmaja vyadhi affecting locomotorsystem and leaving the person disable from daily routine activity. Gridhrasi 2 thename itself indicates way of gait shown by the patient due to extreme pain i.e. likeGridhra or Eagle. Gridhrasi3 is a condition where vata affects the gridhrasi nadi characterizedby Ruk(pain), Sthamba(stiffness),Toda(pin prickling sensation) starting from Spik,Kati, Prista(buttocks, lumbar and spinal column) radiating down to posteriorborder of Uru (thigh), Janu(knee), Jangha, pada and impairment of lifting of thigh. Signs and symptoms of Gridhrasi are nearly same and can be comparedwith sciatica. The knowledge of this condition to the modern medical science isjust two century old while this is known to Ayurveda since last five thousandyears. According to survey low back pain is extra ordinary common and secondordinary to common cold with a lifetime prevalence of 60%-90% and annualincidence of five percent. 80% of population will experience back pain at sometime in their life. In a nutshell prevalence of sciatica ranges from 11%-40%. Nopopulation appears immune although physical fitness might maintain the health. Back pain4 is one of the major medical, social and economic problem in oursociety. The severity of the back pain ranges from minor niggles to excruciatingpain, but the problem as whole is remarkably wide spread. A recent calculation suggested that the pre-neolithic hunter gatherer man onlyperformed about 5o lifts per day where as a 20th century man performs ten timesthat figure. Sciatica continues to be one of the most challenging problems in primary care. 2
  9. 9. It is associated with enormous costs in terms of direct health careexpenditures, and indirect work and disability related loses. Pain often is persistent during the episode, and many patients do not havecomplete resolution of their symptoms but have “flares” against a background ofchronic pain. The incidence of sciatica in those employed in heavy industry is some 5times than in light industry. However the information available is not entirelyconsistent in that, there is also a high incidence in those who performs sedentarywork particularly if they spend a lot of time in motor vehicles. The knowledge of cost of sciatica is essential in indicating the importanceof the problem and the need for extra resources to improve our current facilities. A medicament, which relieves the pain, improves the functional abilityrestore from functional disability and controls the condition with costeffectiveness, is the need of the hour. The treatment of sciatica in modern medicine comprises analgesic, bed restetc., Unfortunately analgesics are liable to many side effects particularly byrepeated and prolonged use. An Ayurvedic approach is helpful to improve quality of life in the patientof Gridhrasi and for certain extent by administering the Ayurvedic treatmentsurgical intervention can be avoided or postponed. While going through the treatments of Gridhrasi 5, sequential administrationof snehana, swedana, vasti, sira vyadha and agni karma are lines of treatmentexplained in Ayurvedic classics. Apart from these procedures, certain samanayogas for oral administration are also explained. 3
  10. 10. Among various treatments Vasti is a unique procedure, which eliminatesthe aggravated doshas from the body, as such it was described as half of thetreatment of kaya chikitsa. Matra vasti is a simplest type of vasti explained in classics. There is norestricted regimen for it. It is a cost effective, and time saving procedure whencompared to other vasti karmas. Hence I selected matra vasti with Balaswagandhatailam for my present study. Lasuna is considered as best vatahara dravya according to vagbhata, whichis a major ingredient of swalpa rasona pindam. This yoga possesses deepana,pachana, rasayana, vedana samaka properties. Swalpa rasona pindam6 speciallyindicated for Gridhrasi in Bhaisajya Ratnavali. It is selected for my present study.Astavarga kashaya7 is selected as anupana. It is best vatahara mentioned in sahasrayogam kashaya prakaranam. Different works have been carried out in different views. Still an addedeffort was made by understanding the problem with available sources of literatureand tried to manage the condition, thinking that this may help in giving bettermanagement for patient and helping them in relieving their sufferings. The clinical study is a sincere effort to add new dimension in the treatmentof Gridhrasi. It is also hope that this work may pave new avenues for enthusiasticworkers to further advance in this field and find a better cure for this problem,with this noble intension this theses work is selected. 4
  11. 11. HISTORICAL ASPECTHistorical review can be classified into I) Vedic Kala II) Pauranika Kala III) Samhita Kala IV) Sangraha Kala I) VEDIC KALA: Historical aspect of Gridhrasi can be taken from vedic period itself. Rigveda8 attributed medical powers to Indra who helped the lame srona in restoring his walking power. Some commentators consider srona as a sage, but srona also indicates a cripple and also a disease perhaps related to sroni. But it is not clear whether this lameness is due to a disease of sroni. There is a reference in Atharwana veda9, which requires a special mention i.e., “the piercing pain from feet, knee, hips and hinder parts (Sroni parinama) and spine”. So this reference denotes the pain in the same regions of Gridhrasi though the name of the disease has not been mentioned. II) PAURANIKA KALA: In Garuda Purana a separate chapter is described for Vata Vyadhi. In this Chapter Gridhrasi is described as an entity. Agni Purana also holds identical description. III) SAMHITA KALA: CHARAKA SAMHITA: In Sutrasthana -Padabhyanga 10 is indicated in Gridhrasi. -Gridhrasi has been described as Swedya vyadhi11. -Gridhrasi is described in Vataja nanatmaja Vyadhi 12 In Chikitasa sthana - Lakshana and Chikitsa 13 of Gridhrasi are described. 5
  12. 12. SUSHRUTA SAMHITA:In Nidana Stana – symptomatology14 and Pathology of Gridhrasi has beendescribed.In Chikitsthana – Siravedha15 is described for Gridhrasi.In sarira sthana – siravedha16 site for Gridhrasi is indicated.ASTANGA SANGRAH:In Sutrasthana – Gridhrasi17 is included under 80 types of vata vikara. - Site for siravedha18 in Gridhrasi has been described. 19In Nidana Sthana - pathogenesis and symptomatology of Gridhrasi has beendescribed.ASTANGA HRIDAYA20:– Similar description as in sangraha.KASHYAPA SAMHITA21:Gridhrasi considered as one among Aseetivatavikaras.BHELA SAMHITA:Basti and Rakta mokshana22 are indicated for Gridhrasi.HARITA SAMHITA:Harita23 was the first to give importance to gridhrasi by naming 22nd Chapter ofTritiya sthana as Gridhrasi cikitsadhyaya.IV) SANGRAHA KALA: MADHAVA NIDANA: Description is similar as in charaka but some specific symptoms have been highlighted i.e Dehasya pravakrta24 in Vataja type,mukhapreseka and bhaktadwesha in vatakaphaja type. 6
  13. 13. SHARANGA DHARA SAMHITA: Gridhrasi is counted under 80 Vata Nanatmaja vyadhis25 in 7th Chapter ofpurva khanda chikitsa of gridhrasi is described in 2nd and 5th Chapter ofmadhyamakhanda26,27.BHAVA PRAKASHA: Gridhrasi has been described according to charaka. Chakradutta28 suggested to burn little finger of the affected limb ifGridhrasi is not subsided by any treatment.VANGASENA SAMHITA: Vangasena29 used the term vata balasa for vata kaphaja Gridhrasi. For thefirst time its vishesha chikitsa has been given. Tapta taila Istika Swedana,Upanaha, Deepana, Pachana, Vamana, Virechana, Vasti and Siraveda. Sigerist has observed that sudden sharp nature of sciatica attack struckprimitive people as demon magic. Hippocrates30 believed sciatica was prevalent during summer and autumnmonths. In 4th Century B.C Caelius Aurelianus31 clearly described symptoms ofSciatica. The disease arises from observable or hidden causes eg. A sudden jerkor movement during exercise, unaccoustomed digging in the ground, exertion onlifting a weight from below; termination of haemorrhoidal bleeding. The oldest of scientific surgical text is Edwin Smith surgical papyrus, thisscroll was found in a grave near Luxor, Egypt in 1862. The Papyrus describesSciatica, when even than was recognized as connected with vertebral problems. Pore (1510-1590) of France observed that severe backache caused by heavywork with spine held flexed continuously. Fontane F of Florence 1797 observed root compression leads to Paresis inSciatica. 7
  14. 14. Domenico cotugno, Italian anatomist 1736-1822 coined the word Sciaticain 1764. He described Sciatica as Cotugno’s disease. He was the first to describetwo types of Sciatica the nervous and the arthritic recorded in 1764. He describedetiology, pathology and clinical manifestations of Sciatica. In his first book, Nervosa commentarious he described that dropsy of thedual funnel enclosing the Sciatic nerve causes Sciatica. In his subsequent booktreatise on nervous Sciatica of 1775, he described cause of Sciatica asaccumulation of acrid fluid in the outer vaginae of ischiadic (Sciatic) nerve. Hepointed out that Sciatica may lead to semi parlysis and muscle wasting. Richard Bright (1789-1858) described neuralgia in his book. Heconsidered Sciatica as inflammatory affection of the investing membrane of thenerve. C.E. Brown sequard (1817-1894) described root pain compression at theinter vertebral foramen and recognized degeneration of the intervertebral disc. Ernst charles Lasegue, French physician (1816-1883) described wasting ofmuscles in the affected limbs will be seen in Sciatica. He demonstrated thatelevation of the extended lower extremity causes pain along Sciatic nerve inSciatica. Recorded by J.J. Forst, Lasegue’s pupil in 1881. Louis T.J. Landouzy, French physician 1845-1917, described a form ofSciatica complicated by atrophy of the muscles of the affected leg known asLandouzy’s Sciatica. Joel Ernest Goldthwait, American Physician suggested that inter vertebraldisc injury may be the cause of Sciatica, Lumbago, Paraplegia etc. reported in1911. Elsberg in 1915 operated on a patient with Sciatica, finding rupturedligamentum flavum compressing fourth lumbar nerve root. 8
  15. 15. Puttiv in 1927 regarded that variability of angle at the lumbo sacral facetspredisposes to Sciatica. Baker in 1929 reported a root compression case fromlumbo sacral disc protrusion diagnosed as neuritis affecting the Sciatic nerve. William Jason Mixter with Joseph seaton Barr, demonstrated the roleplayed by inter vertebral disc herniation in the causation of Sciatica published in1934. In 1956 Jemonet W.D. observed the association of bladder dysfunction withbilateral sciatica. Mathews J.A. advocated the importance of rest in bed for casesof Sciatica in 1977. It occurs in all ages but more frequently among the middle aged, there ispain in one or both hips; the latter case can be called Double Sciatica. Thus Gridhrasi or Sciatica takes origin from the vedic period in Ayurvedictexts and described by modern scientist since a long time. The information given in Ayurvedic texts regarding Gridhrasi clearlyindicates that the disease was not generally prevalent in those days. The particularinformation also indicates that the activities of human are not prone to cause,pressure on the nerve roots with consequent Sciatica. In modern civilization and other related activities the prevalence ofGridhrasi has considerably increased. 9
  16. 16. GRIDHRASI VATA – MEANING AND DEFINITIONUTPATTI: The word Gridhrasi1 is of feminine gender, Gridhra’ +So’“Atonupasargakah”- adding’kah” pratyaya leads to Gridhra + So+ Ka by lopa of‘O’ and ‘k’,”Sha” is replaced by “Sa” by rule “ Dhatwadesh sah sah”In femalegender by adding “Dis” pratyaya the word Gridhrasi is derived. The word ‘Gridhrasi’ is derived from Dhatu “Grudhu” – to covet, desireand strive after greedily on eager for. Grudhra refers to bird (Eagle) that desires to eat flesh always. Gait of the patients is said to resemble the gait of Eagle hence the nameGridhrasi. “Gridhyati2 maamsamabhi kankshati satatam iti” “Grudhro mamsa lolupa manushyatam syati peedyati nashyati vaa” Gridhrasi is a peculiar vata roga, which affects a person who is greedy offlesh. Gridhrasi is a nerve of the lower extremity, which is resemble to Eagle beakin shape.Definition: Charaka3 has given the following definition. A condition where thepain starts initially from kati, then the waist, back, thigh, knee and calf muscle aregradually affected with stiffness, pain and pricking sensation and associated withfrequent twitching is called “GRIDHRASI”. Susruta4 and his commentators define, Gridhrasi limiting the affected part. Dalhana defined Gridhrasi limiting the affected part. The condition is saidto be Gridhrasi where the movements of Sakthi are restricted due to vata vitiatingthe kandaras of heel and the related toes. All the other authors followed Charaka. 10
  17. 17. Synonyms of Gridhrasi: According to Ayurveda vangmayam, 1. Gridhrasi : The patient who suffers with Gridhrasi walks like Eagle. The Gridhrasi nadi is curved similar to the nose of Grudha i.e. Eagle. 2. Rhinghini5: Vachaspati Misra who has written commentary on Madhava Nidana explained the word Rhinghini. This term indicates skhalana of Tarunasthi of vertebral column. 3. Rhandrini: Dalhana used this term while commenting on Susrutha. (Su.Ni.1/75). It means degeneration of Tarunasthis of verterbral column. 4. Radhana6: This term is used by Kashiram in Gudardha deepika commentary on Sarangadhara Samhita. It indicates pressure. In this context it indicates compression of Sciatic nerve. According to Greek and Modern medicine in 15th Century the term Cyeticaand scyetyka were used to indicate this condition. Sciatica is derived from Greek word Ischiadikas i.e., pertaining to ischium,the term is used for the disease as well as the nerve.Definition: SCIATICA7 is a type of neuritis characterized by severe pain along the pathof Sciatic nerve or its tributaries. Inflammation/injury of the nerve causes pain thatpasses from the back or thigh down its length into entire lower limbs. (Principlesof Anatomy and Physiology). It is also termed as contugno’s disease. 11
  18. 18. SHAREERA - MODERN ASPECT Sciatica 8 is pain in the distribution of sciatic nerve. The initial pain in thelower part of the back is known as Lumbago. The two viz. Sciatica and lumbagoare often associated. Therefore there is a necessity of describing two anatomical structures. 1) Sciatic nerve 2) Lumbo-sacral region of the verterbral column.Sciatic nerve: Sciatic nerve is the main terminal branch of the sacral plexus whichis formed by L5, part of L4 & S1,S2,S3 spinal nerves. The Sciatic nerve is the largest nerve in the body measuring about 2cm inbreadth at its commencement. It consists of two separate nerves in one sheath. 1) Common peroneal nerve 2) Tibial nerve The sciatic nerve leaves the pelvis through the greater sciatic foramen,usually below the piriformis and descends between the greater trochanter of thefemur and ischial tuberosity along the posterior surface of the thigh to the poplitealsurface, where it divides into tibial and common peroneal nerves. Branches in thethigh supply the hamstring muscles. Rami from tibial trunk pass to the semitendinosus, semi membranosus, long head of biceps, ischial head of adductormagnus. A ramus from the common peroneal trunk supplies the short head ofBiceps.TIBIAL NERVE: Tibial nerve is formed by lower two lumbar (L4, L5) and upper three sacralsegments (S1, S2, S3). The tibial nerve forms the largest component of the thigh. Itbegins its own course in upper part of the popliteal space. It descends verticallythrough this space and the dorsum of the leg to the dorso medial aspect of the 12
  19. 19. ankle, from which point its terminal branches and lateral plantar nerves continueinto the foot.Branches from the Tibial proper: 1) Motor branches: To the gastrocnemius; plantaris, soleus; popliteus, tibialis posterior; flexor digitorum longus, flexor hallucis longus. 2) A sensory branch, the medial sural cutaneous nerve from common popliteal to form sural which supplies the skin of the dorso lateral part of leg and lateral side of the foot. 3) Articular branches pass to the knee and ankle joints. Terminal branches are two. (i) The medial plantar nerve sends motor branches to: a) Flexor digitorum b) Abductor hallucis c) Flexor hallucis brevis d) First lumbrical muscles Sensory branches to the medial side of the sole, plantar surfaces of the medial three and one half phalanges of the same toes. (ii) The lateral plantar nerve sends motor branches to all the small muscles of the foot except those innervated by the medial plantar nerve and sensory branches to the lateral portions of the sole. The plantar surface of the lateral one and half toes and the phalanges of the toes.Common Peroneal nerve (External popliteal): Common peroneal nerve is derived from the dorsal branches of ventral ramiof the L4, L5 & S1, S2 nerves. It descends obliquely along the lateral side of thepopliteal fossa to the head of the fibula, winds round the lateral surface of the neck 13
  20. 20. of fibula deep to peroneus longus, and divides into the superficial and deepperoneal nerves. Previous to its division, it gives articular and cutaneous branches.Branches given off the popliteal space are sensory and include the superior andinferior articular branches to the knee joint and lateral sural cutaneous nerve,which joins the medial sural cutaneous nerve, supplies external malleolus and thelateral side of the foot and fifth toe. The 3 terminal branches are the recurrent articular and the superficial anddeep peroneal nerves, the articular nerve accompanies the anterior tibial recurrentartery, supplying the tibio fibular and knee joints and a twig to the tibialis anteriormuscle.Superficial peroneal nerve (Musculo cutaneous): It passes between peronei and extensor digitorum longus, pierces deepfascia in the distal third of the leg, and divides into medial and lateral branches. Inits course it supplies muscular branches to peroneus longus and peroneus brevisand filaments to the skin of the lower part of the leg. Medial branch supplies the medial side of great toe, adjacent sides of thesecond and third toes. Lateral branch supply the contiguous sides of third and fourth and of fourthand fifth toes. It also supplies skin of lateral side of the ankle.Deep Peroneal nerve:Muscular branches: Tibialis anterior, extensor hallucis longus extensor digitorumlongus and peroneus tertius; articular branches supply the ankle joint. Lateral terminal branches supply extensor digitorum brevis, Interosseousbranches to tarsal and metatarso phalangeal joints of second; third and fourth toes. 14
  21. 21. Lumbo Sacral region: Vertebral column is divided into 1) Cervical spine, consisting of 7 vertebrae 2) Thoracic spine with 12 vertebrae 3) Lumbar spine with 5 vertebrae 4) Sacrum: Even though it consists of five sacral vertebrae, in adult they are fused in one known as sacrum. 5) Coccyx: It is fused structures of four coccygeal vertebrae in an adult. Sometimes both sacrum and coccyx may even fuse with each other in later adulthood.CURVATURE OF THE SPINE: During evolution 9 the transition from quadrepedal to the bipedal state ledfirst to the straightening and then to the inversion of the lumbar curvature. Theerection of trunk has been obtained partly by backward tilting of pelvis and partlyby bending of Lumbar column. On the first day of life 1. The lumbar column is concave anteriorly at 5months. 2. The lumbar curve is still slightly concave anteriorly but the concavity disappears at 13months. 3. From 3 years onwards lumbar lordosis begins to appear. 4. Becoming obvious by 8 years. 5. And assuming the definitive adult state at 10 years. Elongation takes place rapidly as a child learns to walk. In the average adult lumbar region comes to form about 32% of the total length of the spine. As well as the lumbar lordosis there are cervical, thoracic and 15
  22. 22. sacral curvatures, which increase its resistance to axial compression forces 10 times that of a straight column. Thoracic kyphosis is a feature common to all mammals, where as lumbar lordosis is especially human kind is connected with the erect posture on straight legs. The features of the lumbar lordoses and the vertebral column are at rest. 1) The angle of the sacrum formed between the horizontal and the plane containing the superior aspect of S1, averages 30°. 2) The lumbo sacral angle lying between the axis of L5 and the sacral axis averages 140°. 3) The angle of pelvic tilt formed by the horizontal and the line joining the promontory to the superior border of the pubic symphysis averages 60°. 4) The index of lumbar lordosis can be determined by joining the supero posterior border of L1 to the posterior inferior border of L5. The perpendicular to this line is usually maximal at L3 and represents the index of lordosis. It is greater as Lordosis is more marked and almost disappears when the column is straight.Lumbar Vertebrae: In man each typical presacral vertebra is composed of four parts. 1) The body, which is primarily for transmission of forces. 2) The lamina and pedicles, which enclose the spinal canal. 3) The spinous and transverse processes for muscle and ligament attachment. 4) The posterior facets, which guide and limit motion between vertebrae.The vertebral body lies anteriorly and is the largest part of the vertebra. TheVertebral arch is shaped like a Horse shoe and behind the vertebral body. It bearson each side an articular process, which divides the arch into an anterior pedicle 16
  23. 23. and a posterior lamina the spinous process is attached to the midline posteriorly.The vertebral arch therefore is attached to the vertebral body by the pedicles.Transverse processes are attached to the arch near the articular processes. In the vertical plane these various constituents like in anatomicalcorrespondence making three pillars an anterior major pillar comprising thestacked vertebral bodies and two posterior minor pillars made up to the articularprocesses. The vertebral body has a dense bony cortex surrounding a spongy medulla.The cortex of the superior and inferior aspects is called the vertebral plateau. Thesagittal section comprises two fans like sheaves of oblique fibres. The first arisingfrom the superior surface fans out at the level of the two pedicles to reach thecorresponding superior articular processes and spinous process. The second,arising from the inferior surface, fans out at the level of the two pedicles to reachthe corresponding inferior articular processes and spinous process. The criss-crossing of these three trabecular systems constitutes zones of maximumresistance as well as a triangular area of minimum resistance. This triangle ismade up only of vertical trabeculae and explains the wedge-shaped compressionfractures that occur. Each vertebra can be compared to a lever system where the articularprocesses constitute the fulcrum. This lever system allows the absorption of axialcompression forces applied to the vertebral bodies and indirect absorption in theposterior ligaments and muscles. In the lower lumbar vertebrae the diameter ofspinal canal is comparatively greater. The center of this cylinder does not coincidewith the center of the vertebral plateaux so when upper vertebra rotates on thelower one the upper vertebral body must slide over that of the lower vertebra. Theshearing forces that ensue limit the rotation so that it is minimal both segmentallyand over the whole lumbar spine. 17
  24. 24. The stacked vertebral bodies of the spinal column acts as a pillar and due tothe secondary curves make the backbone some sixteen times stronger than if itwere straight. They permit spine to transmit the weight of the body to the pelvisand reduces the muscular effort otherwise needed to keep a person upright.Inter vertebral Disc: The inter vertebral disc accounts for about 1/3 rd of total height of thelumbar spine. The vertebrae in mammals articulate with another adjacentvertebrae by means of inter vertebral discs. The mobility, and the need forsimultaneous load bearing, necessitates some form of hydrostatic structure toconvert unidirectional forces into stresses acting in all directions. The disc has two components. 1. Anulus fibrosis 2. Nucleus pulposus.Annulus fibrosis: Annulus forms a fibro cartilaginous ring, more fibrous andelastic peripherally, more cartilaginous in the inner part. The Annular fibers aregathered in concentric lamellae, successive layers overlapping in alternativelyoblique directions. Thus nucleus is enclosed in an inextensible casing formed bythe vertebral plateaux and the annulus, whose woven fibers in the young preventany prolapse of the nucleus. The many elastic fibers of the young, healthy annulus gradually disappearsduring the aging process.Nucleus Pulposus: Nucleus pulposus comprises 40% of the disc and is a semifluid gel readily deformable but incompressible. It is the central core of the IVDisc. Collagen fibers form a three-dimensional honeycomb network, enmeshingthe muco protein gel with its rich content of muco poly saccharides orproteoglycans, chondroitin 6-sulfate. Nucleus pulposus acts as a perfecthydrostatic medium. It distributes axial load radially to be absorbed by the fibers 18
  25. 25. of the surrounding annulus fibrosus. The hydrostatic action is predicted becauseof its high water content. When a vertebral plateau presses on the IVD the nucleusbears 75% of force and the annulus 25%. The nucleus transmits some of the forceto the annulus in the horizontal plane and the tangential tensile strain is 4-5 timesthe applied external load. With age the nucleus looses its water absorbing capacity and the pre-loadedstate tends to be lost. Hence the lack of flexibility of the vertebral column in aged. During standing the water in the gelatinous matrix of the nucleus escapesinto the vertebral body through microscopic pores and during course of the daydisc becomes thinner. At night the water absorbing capacity of the nucleus drawswater back into the nucleus from vertebral bodies and disc regains its originalthickness. Therefore flexibility of the vertebral column greatest in the morningand at this time the spine is longer than in evening. Nucleus is a noto chordalremnant.Functions of the Annulus: 1. Forms the chief structural unit between vertebral bodies and provides a mobile segment. 2. Encloses and retains the nucleus pulposus. 3. Restricts and regulates movement. Eg. Sagittal lumbar movement is restricted almost entirely by tough annulus. In full flexion when the articular process are more separated, some half of the diagonal lamellae restrict rotation to a degree and are thus under stress during this movement. 4. By virtue of an inherent elasticity, the annulus fibrosus helps to absorb the shock of compression forces, which are sustained as a circumferential tensile stress in the annulus. The diagonal strapping effect of the fibrous lamellae is important here. 19
  26. 26. The posterior post especially the postero lateral part of the annulus is a site of potential weakness because Thinning and bifurcation of Annular fibers posteriorly. Fibrous tissue is adopted to withstand tension rather than pressure and in the lordotic lumbarspine; gravitational compression falls most heavily on the posterior aspects of the vertebral body joints. Posterior longitudinal ligament is attenuated, thin and expanded at the level of the disc. The eccentric position of the nucleus pulposus, which lies closer to posterior aspect of the disc. The susceptibility of this locality to succumb to under the stress of rotation strains.Functions of pulposus 1. Its fluid permits the formation of a mobile segment and allows an even distribution of compression forces over the opposed surfaces of vertebral disks. 2. The viscid gel acts like a dynamic hydraulic suspension system. This gel spreads the pressure uniformly over the entire surfaces of the vertebral bodies and so behaves like a shock absorber. In a young adult the normal intervertebral disc will yield and deform only at pressure over 1400 pounds, but in an older individual this occurs with only about 350 pounds. The normal disc is actually more resistant to trauma than bone and is not what gives under extreme pressure or the vertebrae will fracture before the disc. 20
  27. 27. The spinal disc serves two functions. 1. To provide mobility to the spine. 2. To act as a shock absorber.Movements of the discs: During extension the upper vertebra moves posteriorly reducing theinterspace posterior and driving the nucleus anteriorly. The nucleus presses on theanterior fibers of the annulus increasing their tension and this tends to restore theupper vertebra to its normal position. During flexion the upper vertebra moves anteriorly reducing the interspaceanteriorly and driving the nucleus posteriorly. The nucleus now presses on theposterior fibers of the annulus increasing their tension. During axial rotation the central fibers of the annulus are stretched,compressing the nucleus and causing the internal pressure to rise. Flexion and axial rotation tend to tear the annulus and drive the nucleusposteriorly through tears in the annulus. Whatever force is applied to the disc, theinternal pressure is increased and the fibers of the annulus are stretched. Owing tothe relative movement of the nucleus, the stretching of the annulus tends to opposethis movement. The hydrostatic properties of the nucleus and the relatively high pressurethat is exhibits relieves the annulus fibrosus from vertical stress, thus makingtilting movements of loaded lumbar spine easier.Nutrition of the Disc: The adult disc is virtually a vascular. Nutrition appears to depend uponimbibition of fluid into it from the vertebral bodies and from spare vessels of theannulus during the first years of life. This process must obviously be assisted by 21
  28. 28. the rhythmic movements and compression of daily activities and it is of interestthat there is a diurnal variation in body height. There is a reason that active movements assists normal fluid imbibitionprocesses between spongiosa and pulposa, this may be a factor in delaying theslow inevitable drying up of the discs with ageing. The lack of directly penetrating vessels makes the intervertebral disc, thelargest avascular structures in the body. Diffusion of solutes can take placethrough the central portion of the hyaline cartilaginous end plates as well asthrough the annulus fibrosus. Posteriorly the areas available for diffusion aresmaller. The central part of the disc, and particularly the boundary zone betweenthe nucleus pulposus and annulus fibrosus is exposed to possible deficiency ofnutrition. The disc appears to live and thrive on movement change and die slowlythrough lack of it. There is now a shift of emphasis from the idea that discdisorders result from purely mechanical derangement, to the view that nutritionand metabolism of the disc and the biochemistry of degenerative change, are ofequal importance.LIGAMENTS: The ligaments of the lumbar region are stronger and denser than elsewhere. The anterior longitudinal, posterior longitudinal ligaments are linked ateach vertebral level by the Intervertebral disc. Other ligaments connect arches of adjacent vertebrae - ligamentum flavum,inerspinous, supraspinous ligament, anterior and posterior ligament of articularprocesses, inter transverse ligament.Action of ligaments: The dense anterior longitudinal ligament is stronger than theposterior ligament and limits extension of the vertebral column. The ligamentaflava help to restore the vertebral column to its original position after bending 22
  29. 29. movements and is important in resisting rotation. The spinous processes areconnected by the supra spinous and infraspinous ligaments which particularlylimit, flexion.Movements of the Vertebral column: The mechanical stability of the column is assured by reason of the axis ofrotation passing through the bodies and not through the neural arches, so that thebodies are not displaced from each other during movement. The spinal column has 3 degrees of freedom; it is allowed flexion andextension, lateral flexion and rotation. The range of these elementary movementsat each individual joint is very small but the movements are cumulative over thewhole column. Moll and wright found an initial increase in mean spinal mobilityform the 15-24 decade to the 25-34 decade followed by a progressive decreasewith advancing age of as much as 50 percent of mobility. Flexion and extension in the anterior posterior plane occur in all regions ofthe column and these movements are particularly free at the specialized atlanto-occipital joint, free in the lumbar and cervical region and very restricted in thethoracic region. Rotation is free in the specialized altanto – axial joints but elsewhere it is determined by the shape of the apophyseal joints. Kapandji- Lumbar spine contributes 60° flexion and 35° extension to spinalmobility. For thoraco lumbar region taken as a whole, flexion is maximally 105°and extension 60°, to range of lateral flexion to each side is 20° in the lumbarcolumn. Axial rotation from side to side during standing is 20° in lumbar columnand 90° for the thoraco lumbar region taken as a whole. The thoracic movement is most limited because these vertebrae are tied tothe ribs. All the mobility depends to a considerable extent on the muscles andligaments of both the spine and the back. 23
  30. 30. Morris (1973) – Intrinsic spinal stability is provided by intervertebral discsand ligaments, and extrinsic stability imparted to vertebral column by the action ofmuscles. The intrinsic stability is the result of pressure within the disc, whichtends to push the vertebral bodies a part and the tension provided by the ligamentswhich tends to pull the bodies together. Thus the vertebral segments and discs arefirmly bound together by ligaments under tension: 1. A longitudinal system, which binds all the vertebrae together into a mechanical unit. 2. A longitudinal system, which secures one segment to another. This arrangement accounts for relative stability of the spine dissected free of musculature. Morris, Lucas, and Bresler (1961) showed that flexibility between twovertebrae varies directly with the square of the vertical height of the disc andindirectly with the square of the horizontal diameter of the body. Thus for a givenload and cross-section an increase in the height of the disc and the length of theligaments tends to increase the apparent flexibility, while an increase in the cross-sectional size of the disc tends to reduce apparent flexibility. Because of theproportionally greater height of the lumbar disc, the range of intervertebral motionis somewhat greater in the lumbar region; but because of the greater horizontaldiameter, the flexibility is less than in thoracic region. 24
  31. 31. NIDANA Gridhrasi is included under vatavyadhis, where specific etiological factorsare not mentioned; hence Nidana of vatavyadhi can be considered as nidana ofGridhrasi. Charaka Samhita1 and Bhava Prakasha2 clearly mentioned thecausative factors of vatavyadhi, but in Sushruta samhita3,4, Astanga Sangraha5 andAstanga Hridaya6,7 the causes of vatavyadhi have not been clearly described.However, in these texts the causative factors of provoked vata dosha are available. Since Gridhrasi is considered as Nanatmaja vatavyadhi, the provocativefactors of vata can also be taken as causes of Gridhrasi. In addition to this, in Charaka samhita8, Ashtanga Sangraha9 and AshtangaHrudaya10, two specific causes of vatavyadhi i.e., Dhatukshaya and Avarana havebeen mentioned. All the etiological factors of vatavyadhis as well as vata prakopa are takenas Nidana of Gridhrasi and is classified as follows: 1. Viprakrista nidana: The person who steals the wealth of God11 or Bramhana and who deceives his master or who opposes his teacher will suffer from vatavyadhi. (Vaidya chintamani – vatavyadhi karma vipakam) 2. Sannikrista nidana: a) Aharaja b) Viharaja c) Kalaja d) Agantuja e) Anyahetu 25
  32. 32. a) Aharaja Nidana: The excessive intake of rasas like katu, tikta, kashaya, laghu, rooksha gunas and seta veerya leads to vataprakopa. “Sarvada sarva bhavanam samanyam vriddi karanam” 12 The dravya, which possess similar properties, increases the other dravya, which is resumblant to it in properties. Dhanya - Mudga, Masoora, Adhaki, Kalaya, Nishpava etc. Phalas - Jambu, Bilwa, Kapitha etc. Sakas - Kareera, Karavellaka, Patola, Rakta punarnava. Alpasana leads to dhatu kshaya thereby causing vataprakopa. Adhyasana, visamasana causes ama which obstructs the srotas hence aggravates vata. As per “Vayordhatu kshayat kopo margasyavaranenacha”13b) Viharaja : Prajagaram – increases ruksha guna in body and aggravates vata. Langhana, plavana, athyadwa sevana, vyayama – as a result of this excessive and continuous exertion results in dhatu kshaya and aggravates vata. Diwaswapna14 increases pitta and kapha, which obstructs the channels and leads to vata prakopa. Vegavadharana is a condition when any of the natural urges are suppressed, then vata prakopa takes place. So far Gridhrasi is concerned malavarodha is most important to cause vataprakopa15 . This causes pain in sacral region, pindikodwestanam, and backache and also produce many diseases in the lower limbs like Gridhrasi etc. Vagbhata16 also stated that avarodha of apanavata causes a variety of vatavyadhis.c) Kalaja : Vata vitiation takes place in varsha, Grishma and Sharat ritu. It also aggravates in Aparahnakala, Jeernannakala, Apararatra and in sheeta kala. During vriddhavastha17 vata prakopa takes place. 26
  33. 33. d) Agantuja: Abhigata due to external causes are considered specially while carrying heavy loads, wrestling with a person of superior strength, leaping and jumping etc. Marmabhighata particularly to kukundara, nitamba marmas leads to Gridhrasi. Kunkundara18 (Marma abhigata) loss of power and sensation in lower extremities and may result in pain and difficulty in walking. (Su.Sa.6/48). Nitamba: Injury, causes swelling, weakness, pain paresis in lower limbs and even death in due course of time. Falling off from back of animals and higher places also cause marmabhigata. The pathological19 changes in the vertebral column are mainly occurred byphysical strain. In physical activity, standing alone increases load on the disc fourfold compared to supine strengthening exercises almost double the load in the discover the standing posture. It illustrates the impact of physical activity on thevertebral column. Most of the activities we are observing in society are already described inAyurveda as Nidana in Vatavyadhi. The prolonged stooped posture imposes loads on the posterior ligaments ofthe spine and the fibers of inter vertebral disc, stretched ligaments increase jointlaxity, which can lead to hyper flexion injury. Ligament damage seems to occurduring traumatic sporting activity with the spine at its end range of motion. Inabove conditions the tensile forces works on ligaments, which are capable of onlywithstanding tensile forces, if it is excessive it ruptures ligaments. 27
  34. 34. Attempting to lift and twist with awkward loads so that extension androtatory movements are involved together produces Interverbetral disc rupture inlumbar region. The excessive compressional load acting on the nucleus pulposus isthe basis for disc degeneration, vertical compression of spinal segments thevertebral end plates are the first to fracture leads to osteo arthritic changes in theinter vertebral joints Segmental instability occurs when the normal movement between vertebraeis lost because of degenerative changes involving any one of the components ofdisc followed by Sub luxation. Fractures, Dislocations and disc prolapse when compress the spinal cordresults in paralysis of limbs which can be attributed to injury of marmas. HenceAgantuja nidana is a prime factor in the disorders of the vertebral column.Anya hetu:Dosha Asrik sravanadapi - Excessive elimination of mala, rakta during vamana,virechana, vasti karmas leads to vata prakopa. This can be considered asIatrogenic cause. 28
  35. 35. Etiological factors of vata prakopa &vata vyadhi with reference to Gridhrasi. NIDANA CS SS AS AH MN BPAharajaRasa Katu, Tikta, Kashaya + + + +Guna Laghu + + + + Ruksha + + + + + Seeta + + + +Karma Vistambi +Veerya Sheeta +Dravya Adhaki + + Bisa + Harenu + Chanaka + Kalaya + Koradusha + Masura + + Mudga + + Nivara + Nishpava + + Saluka + Suskashaka + Syamaka +Krama Abhojana + + + + Alpasana + + + Visamasana + + + + Adhyasana + + Pramitasana + +Kayika Atigamana + + + +(atiyoga) Atihasya + + Atilanghana + + + Atiplavana + + Atipradharana + Atiprajagarana + + + + + + Ati prapatana + Ati prapidana + Ati pratarana + + Ati raktamokshana + + Ati Sharma + Ati vichestitam + + + Ati vyayam + + + + + Ati Adhyayana + + Kriyati yoga + + + + + Padati charya + 29
  36. 36. Mityayoga Asama bhramana, chalana, + vikshepa, asamotkshepa Balavat vigraha + + Bhara harana + + + Diwa Swapna + + Dukhasana sayya + + Kastabhramanachalana vikshepa + Vegadharana + + + + + + Vishamapochara +Manasika Bhaya, Chinta, Soka + + + + + Krodha + + Mada +Kalaja Aparahna + + + + Apararatra + + Grishma + + Pravata + + Shisira + Seeta kala + + Varsha + + +Agantuja Abhighataja + + Gaja, Ustra, Ashwa, Shighrayana + + patana Marmaghata + +Anyahetuja Dosa Asrik sravana + + + + Dhatu kshaya + + + Ama + + + Rogati karshana + + + Margavarana +Causes of Sciatica 20: Sciatica is neuralgia in the distribution of Sciatic nerve or its componentnerve roots.I. Compressive causes: a) Congenital – Spina bifida, Spondylolisthesis. b) Traumatic - Fracture of hip joint Vertebral fractures Lumbo sacral sprain and strain. 30
  37. 37. c) Mechanical pressure on the nerves- In the spinal cord - Tumors of cauda equina. Arachnoiditis, Haemorrhage / infection irritating meninges of the cord. In the cord space – Protruded inter verterbal disc, extra medullary tumors. In vertebral column – Sondylolisthesis, spondylosis, Bone tumor, stenosis of intervertebral canal and lateral recess hypertrophy of apophyseal facets. In the back - Fibrositis of posterior longitudinal ligament. In the thigh and buttock - Neurofibroma, Hermorrhage within or adjacent to nerve sheath. In the pelvis - Sacro iliac arthritis, Tumors of lumbo sacral plexus.Other destructive disease: Neoplastic: Metastatic carinoma, multiple myeloma, Hodgkins and NonHodgkins lymphoma. Infections: Infection in vertebral column due to pyogenic organisms –staphylococci, Tubercular bacilli, Spinal epidural abscess. Several metabolic diseases of bone such as hyper parathyroidism,osteoporosis precipitates bone dysfunction. This in turn leads to vertebral bodyweakness, leading to vertebral fractures, protrusion, herniation etc. Inflammatory causes : - Rheumatoid arthritis - Ankylosing spondylitis - Lumbar spondylitis - Osteo arthritis of lumbar spine. - Tuberculosis of vertebral column and spine. 31
  38. 38. II. Non-compressive causes: Ischaemic necrosis in Diabetes Mellitus, leprosy, direct injury due topenetrating wounds. Eg. Gunshot or misplaced injections, claudication of sciaticnerve, compression injury to Sciatic nerve by foetal head during delivery. Some times over exposure to cold or sitting on chatted grass may inducethe pain.Catamenial sciatica: The unusual developmental anamoly of implantation ofendometriosis in the Sciatic nerve at the sciatic notch may cause sensorimotorSciatic nerve palsies. These may be associated with peri menstrual pain in thebuttock or posterior aspect of the thigh. 32
  39. 39. POORVA RUPA “Poorva rupam pragutpathi lakshanam vyadhehi” 1 For every disease certain premonitory symptoms are noted before it isclearly established in the body. Such symptoms are called Poorva roopa. “Avyakta lakshanam tesham poorva roopamiti smritam Atma rupam tu yad vyaktam apayo laghuta punaha ” 2 According to Charaka Avyakta lakshanas are purvaropa of vatavyadhi.According to Chakrapani 3commentary on Avyakta, few mild early symptoms areto be taken as purva rupa. The very specific symptoms if manifest insignificantlycan be considered as poorvarupa of Gridhrasi. Sthamba, Ruk, Toda,Muhuspandana, Grihnati. Diagnosis at this stage of illness gains paramount importance. Theeffective treatment at this stage reduces the degree of morbidity. 33
  40. 40. ROOPA “Utpanna vyadhi bhodaka meva lingam rupam” 1 Lakshanas, which occur after the manifestation of vyadhi, known as Rupa.Vyakta purva rupa is Rupa.2 Charaka 3classified Gridhrasi into two varieties. 1. Vataja 2. Vata shleshmaja.Considering all the clinical manifestations of Gridhrasi, it may be subdivided into samanya lakshnas and vishesha lakshanas.Samanya Lakshanas: These lakshanas are seen in both vataja and vata kaphaja type of gridhrasi.RUK: “Ruk satatam shoolam” 4 5 “Ruk shoolam” “Ruja vedana” 6 In Gridhrasi, Ruk-pain is starting from sphik and radiating towards kati,prista, uru, janu, jangha and pada. Non-radiating pain felt at sites like kati, uru,janu, jangha, pada is also considered as symptom of Gridhrasi.7 This typical radiating pain involving legs is suggestive of Sciatica wherepain is felt along the course of Sciatic nerve.Toda: “Todah sooci vyadhanavat vyadha”8 “Toda vicchinna shoolam” 9 Intermittent pain similar to feeling of pinprick. 34
  41. 41. Sthamba: “Sthamba nischalakaram”9 “Sthamba bahu uru janghadeevam sankuchanadhya bhava10 “Sthamba nishkriyatvam”11 It is stiffness at uru and jangha region in Gridhrasi, due to pain themovement i.e., restricted in the muscles and joints of lower limb. This stiffnessaffects gait of the patient.Sakthna kshepa nigrahanyat: “Kshepam prasaranam tam nigrahanyat avarudyat ityarthah”12 Hence, word kshepam means prasarana or extension. According toDalhana it is the sign of restriction during extension of leg. This is more clear bycommentary of Arunadutta on Astanga Hridaya12 explained as urdwa preranaavarundati i.e., restriction in raising the leg. As the extension of the legs worsensthe pain patient prefers to assume the flexed position of the legs.Kati Uru Janu madhya Bahu vedana: A distinct feature in Gridhrasi mentioned by Harita13, severe pain at kati,uru and Janu region.Muhu spandana: “Spandana Spuranam” 14 “Spandanam Hi Kinchit chalanam” 15 Spurana refers to the fasciculation. This symptom is seen in the musclesupplied by the Sciatic nerve. 35
  42. 42. Pain in Payu: Described by Vangasena16 only. This may be due to derangement ofApanavayu. Payu is one of main sthanas of Apana vayu and Apana Vayu governsfunctions of defecation. Therefore, when apana vayu is vitiated constipationresults and pain in peri anal region occurs. Few of symptoms are exclusively mentioned in Basavarajeeyam17. Thesesymptoms include sopha, kara pada vidaha krit, sweda, moorcha, Bhrama andtrishna. Some of these symptoms are indicative of vitiation of pitta dosha inGridhrasi.VISESHA LAKSHANAS:Vataja Gridhrasi:Dehasya vakrata: Madhava described this symptom, which means the patient ofGridhrasi acquires a particular posture because of pain. The patient of Gridhrasikeeps the leg in flexed position and tries to walk without much extension in theaffected side. Because of extreme pain, sthamba, toda etc., the patient assumes atypical limping posture. It can be considered as Sciatic scoliosis – maintained by reflex contractionof the para spinal muscles.Stabdata Brisham: The severe degree of stiffness is seen in the patient suffering from VatajaGridhrasi.Spuranam: “Spuranam Gatra deshe swalpa chalanam”18 “Spuranam punah punah chalanam” 19 A type of muscle twitching in kati, uru, Janu, Jangha is similar to that ofspandana or muhuspandana. 36
  43. 43. Suptata: The patient experiences varied degree of parasthesis or sensory loss in theaffected limb.Vata Kaphaja Gridhrasi: In Gridhrasi when anubanda of kapha dosha is present following lakshanasare seen.Vahni mardava: Decreased abhyavaharana and jarana shakti causes loss of appetite.Tandra: “Tandrayantu prabhodito api klamayati nidrabheda ”20 Due to tama, vata and kapha there will be a feeling of drowsiness orinability of sense organs to grasp followed with yawning and fatigue without anywork.Mukha praseka:Excessive salivation in the mouth occurs due to kapha in association with ama.Baktadwesha: “Dveshamayati yo jantu bhaktadvesha sa ucchate” 21Because of loss of appetite and kapha dusti, patient feels aversion towards food.Arochaka: “Arochakastu prarthite apyupayoga samaye anabhilasha”22 “Aruchi prarthita Anna Bhakshana Asamarthya mucchyate”23 Dislike of consuming food. The patient fails to appreciate the taste in themouth irrespective of state of appetite. Vata and kapha are involved because theseat of bodhaka kapha is jihwa, which does raso bodhana. 37
  44. 44. Gaurava: Heaviness particularly occurs in the lower limb.Staimityam: “Staimityam gatranaam nirutsaahatvam” 24Inertness of body, feeling of freezing sensation in the affected lower limb, due tokapha vitiation patient feels as if his lower extremities are covered with wet cloth. Rupa of Gridhrasi according to different Acharyas Samanya Lakshanas CS SS AH AS HS BP MN YR VS BRKati prista uru janu jangha pada – + + + + +RukKati prista uru janu jangha pada – + + + + +TodaKati prista uru janu jangha pada – + + + + +SthambaKati prista uru janu jangha pada – + + + + +MuhuspandanaSakthnaha kshepam nigrahaniyat + + + +Kati uru janu madhye bahu vedana +Parshni pratyanguleenam tu + + +kandara yanilarditaPain in payu +Sopha, karapada vidaha +Specific VatajaDeha vakrata, Toda + + +Stabdata + + +Janu jangha uru sandhi spurana + + + +Suptata +Specific Vata kaphajaTandra + + + + +Gaurava + + + +Arochaka + + + +Vahni mardava + + + + +Mukha praseka + + + + +Bhakta dwesha + + + + +Staimitya + 38
  45. 45. Clinical features of Sciatica: The clinical course of Sciatica depends on the nature of the underlyingpathology. In most patients the pains are caused by a ruptured intervertebral disc. Insome patients the symptoms are produced by Arthitis in the Sacroiliac joint orspine, spondylolisthesis, lumbar canal stenosis that are commonly seen. A fully developed prolapsed inter vertebral disc25 consists of(1) Pain in the sacroiliac region, radiating into the buttock, thigh, calf and foot.(2) A stiff or unnatural spinal posture.(3) Some combination of paraesthesias, weakness and reflex impairment. The most common history is that of severe low back pain after an injury.The acute attack subsides with in a few days sciatic pain eventually develops afterthe appearance of low back pain. As the Sciatic pain increases in intensity andextent, the backache become less and occasionally may be entirely absent. Intermittency of symptoms is characteristic, and each succeeding attack isusually more severe.Pain: The pain of herniated intervertebral disc varies from severe to mild forms.With most severe pain, patient is forced to stay in bed. The patient is usually mostcomfortable lying on his back with legs flexed at the knees and hips. The pain isfrequently made worse by an activity that increases intra spinal and intra discalpressures such as coughing, sneezing and bearing down during defecation. When the condition is less severe walking is possible, though fatigue sets inquickly, with a feeling of heaviness and drawing pain. 39
  46. 46. Sitting and standing up from a sitting position are particularly painful. Painis characteristically provoked by pressure over the course of the Sciatic nerve atthe classic points of valliex (Sciatic notch, retro trochanteric gutter, and posteriorsurface of thigh, head of fibula. Pressure at one point may cause radiation of painand tingling down the leg pain is referred to the involved dermatome.Reduced mobility: Forward bending in particular is restricted26. In acute stagewith marked muscle spasm all mobility is restricted.List of trunk: The lumbar spine most often deviates away from the affected side. Thedisk is usually lateral to the nerve root 27, and the tilt of the spine away from theaffected side. Protrusion medial to the nerve root causes a list to the painful side.The disk is often accentuated when bending forward. A list or tilt will elevate one iliac crest. This asymmetry is responsible forthe commonly diagnosed “longer leg on one side” and the erroneous assignmentof the back pain to asymmetry of leg length. The patient stands with affected leg slightly flexed at the knee and hip, sothat only the ball of the foot sets on the floor. In walking, the knee is flexedslightly, and weight bearing on the painful leg is brief and cautious, giving a limp.It is particularly painful for the patient to go up and down stairs.Neurological signs: Motor signs are present in about 96% of cases and includeatrophy of leg muscles, determined by measuring leg circumferences and muscleweakness. Weakness of dorsi flexion of large toe and inability to walk on heelsindicate fifth lumbar root involvement by fourth lumbar disk. 40
  47. 47. Inability to walk on toes because of calf muscle paresis points to first sacralroot involvement by the fifth lumbar disk. Sensory signs found in 80% of patients.Nerve tension signs: Straight leg – Raising Sign (S.L.R.): It is the active attempt made by patient to raise the entire leg with the leg in complete extension. In case of sciatica extension of the leg is below 90°. The degree of limitation is roughly proportional to the severity of pain. Elongation of nerve root by straight leg raising or by flexing the leg at the hip and extending it at the nee (lasegue maneuver) is most consistent among pain provoking signs. Crossed leg pain is pathognomic of severe disc prolapse.Variations of the lasegue maneuver – Bragard sign: Accentuation of the pain by dorsi flexion of foot. Neris sign: With patient standing, forward bending of the trunk will cause flexion of the knee on the affected side. Naffziger sign: Sciatica may be provoked by forced flexion of the head and neck, coughing, or pressure on both jugular veins, all of which increase the intra spinal pressure. Sicard sign: The pain may be elicited by carrying out test with dorsiflexion of big toe. There are typical patterns of symptoms for each level of root involvement. 41
  48. 48. Lumbar root lesionsDisc level Root Sensory Motor weakness Reflex loss Pain loss distributionL3-L4 L4 Antero Quadriceps (knee extension) Knee Lateral thigh. medial calf thigh adduction, Tibialis and shin anterior (foot dorsiflexion)L4-L5 L5 Antero Peroneii (foot eversion), None or Buttock, back lateral leg, tibialis anterior (foot rarely and side Dorsum of dorsiflexion) gluteus medius reduced thigh, lateral foot, great (Hip abduction) Toe ankle reflex. lower leg. toe dorsiflexion.L5-S1 S1 Lateral Gastrocnemius, soleus (foot Ankle Buttock, Back malleolus, plantor flexion) Abductor of thigh and lateral foot, hallucis (toe flexors), gluteus calf to heel. heel and maximus (Hip extension) web of fourth & fifth toes.Cauda equina syndrome: A large midline disc herniation may compress several roots of caudaequina. Patients have bilateral leg pain. Peri anal numbness, saddle dysesthesiaand loss of anal reflex are seen or diminished rectal tone characterizes anadvanced cauda equina syndrome. Sensory deficit involves lower sacral roots.Difficulty with urination including either frequency or overflow incontinence maydevelop relatively early.Lumbar canal stenosis and spondylotic caudal radiculopathy: Osteo Arthritic or spondylotic changes may lead to compression of one ormore caudal roots. The problem is exaggerated if there is a congenital narrowlumbar canal. The roots are caught between the posterior surface of the vertebralbody and the ligamentum flavum posteriorly. Lateral recess stenosis, alluded toabove, may also contribute to root compression. 42
  49. 49. Symptoms are of neurogenic claudication. Nonspecific low back pain androot pains followed by paraesthesias in the lower limbs, which come on withwalking down hill, and relieved by rest. In acute condition patient gains relief bysquatting or lying down with the legs flexed at the hips and knees. Standing, andparticularly standing with the lumbar spine in extension, aggravates the condition.Osteo Arthritis: Pain is centered in the affected part of spine, is increased bymovement, and is associated with stiffness and limitation of motion. A slightlyflexed posture is preferred. Discomfort is accentuated when the erect posture isresumed.Spondylolisthesis: Anterior displacement of a vertebral body in relation toinferior adjacent vertebra can cause root compression with resultant leg pain andweakness. Pain often aggravated by walking or standing.InvestigationsImaging of spine:Plain x-rays of lumbar spines: To identify the spondylotic changes and narrowingin the lumbar spine or sacro-iliac lesion or hip joints.Myelogram: To know the disc protrusion and to differentiate such lesions fromtumors.Nuclear magnetic resonance imaging (NMR): To assess any root lesion.Computed Tomography scan (C.T.Scan): Useful in the identification of astenosed canal, destructive lesion of vertebral bodies and posterior elements orpresence of paravertebral soft tissue mass.Magnetic Resonance Imaging (M.R.I): Which virtually replaces C.T.Scan. studyof degenerative disc. The symptom “Sakthnaha Kshepam Nigrahaneeyaat” is identical to S.L.R.test described in modern classics. The symptom “Dehasya vakrata” is nothing butthe Sciatica Scoliosis” and suptata refers to the parasthesia. 43
  50. 50. UPASAYA AND ANUPASAYA This may be explained as the therapeutic diagnosis of an illness. TheInvolvement of the Remedial agents, regimens of diet and behavioral rules, whichare contrary to the causes of illness, providing the result is called Therapeuticdiagnosis of an illness. Upasaya for Gridhrasi has not been mentioned separately. But, if there isuncertainty as whether the vyadhi is urusthamba or Gridhrasi, to differentiate thesetwo we can adopt Upasaya. If symptoms aggravate on the application of oil, thenwe consider it to be uru sthamba 28 and if the symptoms subside we can consider itas Gridhrasi. All the factors, which bring about the equilibrium of the vitiated vata, canbe considered as upasaya. Samanya chikitsa sutra of vata vyadhi and chikistsa sutra mentioned in theclassics by different acharyas are the upasaya for Gridrasi. The nidana mentioned for Vatavyadhi, Gridhrasi are considered asAnupasaya 44
  51. 51. SAMPRAPTHI “Vyadhi janaka dosha vyapara vishesha yuktam vyadhi Jameha samprapti shabdena vachyam”1 The process of pathological changes in the body commencing from nidanato complete manifestation of the disease is called Samprapti. The Samprapti of Gridhrasi depends on Age, Sex, occupation and dietaryhabits of the people. Estimation of Samprapti is essential to treat diseasesuccessfully. Chikitsa is nothing but “Samprapthi Vighatanam”. The pathogenesis of vata vyadhi takes place in two ways. When a person isexposed to vata prakopakara nidana his dhatus will not be nourished by virtue ofsoshana. Rasa dhatu kshaya takes place and further dhatus are not nourishedproperly. As a result of Dhatu kshaya2, srotas become khara, ruksha, parusha andresults into sroto riktata (devoid of Snehamsa). These rikta srotas gets filled withvata dosha and results many vata vyadhis either in the whole body or targetorgans. Vitiated kapha, Ama obstructs vata dosha. It causes srotorodha andgenerates vatavyadhi at avarodha sthana. Vatavyadhi Samanya Samprapti Nidana Dhatukshaya Margavarodha Vataprakopa Vatavyadhi 45
  52. 52. Gridhrasi Visesha Samprapti NidanaAgantuja AgnimandyaAbhigataja AvaranaMarmagathaja Vatavikriti Vatavriddhi Ama Margavarodha Sroto avarodha Dhatu kshaya Sroto Rikta DOSHA DUSHYA SAMMURCHANA AT THE SITE OF KHAVAIGUNYA STHANA SAMSRAYA AT KATI, PRISTA, URU, JANU, JANGHA, PADA Gridhrasi 46
  53. 53. SAMPRAPTI GHATAKAASDosha : Vata : Vyana vayu, Apana vayu Kapha : Sleshmaka kaphaDushya : Rasa, Rakta, Mamsa, Asthi, Kandara, SnayuSrotas : Chestavaha, SangnavahaSroto dusti prakara : SangamAgni Jataragni, DhatwagniUdbhavasthana : PakwasayaSanchara sthana : Prista vamshaAdhistana : Spik, Kati Prista and AdhosakhaRogamarga : MadhyamaDosha: According to Susruta, Sakthnah kshepam nigrahaneeyat is one of thecardinal symptoms of Gridhrasi. The kshepana and utshepana etc., activities areattributed to vyanavata. Morbid vyana vayu is the primary cause of illness.Apana vayu having its site in kati & sakthi is also involved. Sleshmaka kapha getsinvolved as it resides in sandhi.Dushya: Susruta3 clearly indicated the involvement of Kandara, which areupadhatu of mamsa. Dalhana considered kandara as mahasnayu, which starts from Gulpha tovitapa. One of the causes of this disease is mamsa lolupatwa (according toderivation of Gridhrasi). So mamsa dhatu is considered as one of the dushyas. Hareeta4 points Rakta dhatu as one of the dushya in pathogenesis. Symptoms like pain at Kati and Prista is suggestive of involvement ofAsthi. Since there is emaciation of dhatus due to lack of nourishment, rasadhatu isalso involved. 47
  54. 54. Srotas: Chestavaha and sangnavaha srotas The movements are performed by chestavaha srotas. The sensations areperceived by Sagnavaha srotas. Sciatic nerve composes both Sangnavaha and chestavaha srotases. In Gridhrasi vata the leg movements are impaired along with sensoryimpairment i.e., Parasthesia etc.Agni: Praseka, Arochaka, Bhaktadwesha are some of the distinguishing clinicalmanifestation of Vatakaphaja Gridhrasi and is indicative of Jatharagni Mandya.Udbhavasthana: The involvement of Vata Dosha in the pathogenesis of Gridhrasi revealsthat the disease stems out from the Pakwasaya. Similar to any other Nanatmajatype of Vatavyadhi Gridhrasi is also considered as Pakwashayodbhava vyadhi.Sancharasthana: Distribution of symptoms like pain in the low back region extending up tothe thigh legs and heal indicates the lower half of the body as the Sanchara sthana.Adhishthana: Sphik, Kati, Uru, Prushta, Jangha, Pada are the adhishtana of Gridhrasi. To sum up, the specific etiological factors leads to the vitiation of VyanaVayu. Abnormal vyana vayu stemming out from the Pakwashaya circulates in thelower part of the body and gets localized in the kati, prishta, uru, janu, jangha, 48
  55. 55. pada. Vyana vayu afflicts the mamsa, asthi etc. dhatu involving cheshtavaha,sagnavaha srotas producing the severe pain originating in the Kati prushtaradiating to Jangha, Janu and Pada region. Asthi dhatu and vata are having Ashraya Ashrayee sambandha5. Vataprakopa leads to Asthi dhatu kshaya. Therefore vata prakopa is associated withloss of both anatomical and physiological integrity of bone. In vardhakya period, there is predominance of vata dosha thereforetarunastis of pristavamsa loose the inherent snigdhata and become brittle and areprone to fracture. The main pathology of Gridhrasi is degenerative - leading to fracture ofKati Kaserukasthis and pain experienced by the patient is due to pressure on thevatavaha nadis. Degeneration suggests deterioration or worsening of the physical propertiesof a tissue with pathological changes in the cells resulting in destruction orinhibition of function. In aging process6 changes take place, which cause an overall decrease in thedensity of bone and decrease in bony strength. There is a loss of support in thehorizontal beams of bone in the vertebral body, which leads to buckling of thevertical beams. This creates a gradual increase of concavity of upper and lowersurfaces of the vertebral body. Age related7 changes in bone cells and matrix have a strong impact on bonemetabolism. Osteo blast from elderly invididuals has reduced reproductive andbiosynthetic potential when compared with osteo blasts from younger individual.Proteins deposited in the matrix lose their biological punch over time. The endresult is a skeleton populated by bone forming cells that have a diminishedcapacity to make bone. Reduced physical activity increases the rate of bone loss. 49
  56. 56. Increased porosity results from reduction in bone mass known asOsteoporosis. The intervertebral disc and vertebral bodies develop grow and age together.It is quite impossible to affect one of these structures alone, as the other mustsooner or later also be involved, even to a lesser extent.As degenerative changes proceeds: - Annulus fibrosus and nucleus pulposus are indistinct with fibro cartilage replacing the nuclear area. - Proteoglycan content and hydration decreases in the nucleus. - Vertebral column becomes less flexible. - Circumferential tears develop in peripheral annulus and radial tears appear at nucleus and inner annulus. There is failure of disc to act as the shock absorbing system. There is a consequent reduction in the ability to withstand normal strains of movement and possibility of increased wear and tear on all the ligaments and joint structures. - Fissuring may occur. If there are multiple fissures a loose fragment will develop and this causes major alteration in the disc mechanics. Torsion and flexion cause failure of annulus into a posterior protrusion. If the fragment displaces further the whole thickness of annulus gives way as the fragment is extruded as a herniation. Compression affects vertebral end plate and body. Nuclear extrusion into the vertebral body can form schmorl’s nodes. Small protrusion compresses the nerve root, which causes severe pain without much loss in nerve conduction. 50
  57. 57. Large protrusion blocks conduction. The physical signs are marked sensory loss and motor paralysis. - Continued narrowing of disc occurs with osteophyte formation at end plate annular junction. Later end plate sclerosis occurs. - With continued dessication and cleft formation empty spaces or vacuum may occur with in the disc. Disc herniations8 has been shown to incite intense irritations of nerve rootsand dramatic increase in the local concentrations of biochemical agents known tobe inflammogenic. Ex. Prostaglandin E2, Interleukin-6, Metallo proteinases etc. As disc prolapse heals by shrinkage the thickness of the disc reduces. Thedisc is only one part of the complex arrangement between vertebrae allowingcontrolled movements in all directions. So derangement of this part sooner or lateraffects the other parts (facet joints and posterior ligaments). The altered mechanics leads to osteo arthritis of facet joints. With agingthe porosity of the bone of the facet increases. Concurrently there is loss in jointspace. Osteophytes begin to develop. As cartilage fails, bone looses its mass andits normal function. Osteophytes encroach upon Inter vertebral foramen causing pressure onspinal nerve roots. The joint capsule is stretched by excessive movements and thecontained nerve endings give rise to pain. The spinal nerve roots are sensitive to mechanical deformation due tointraspinal disorders such as disc herniations or protrusions, spinal stenosis,degenerative disorders and tumour. 51
  58. 58. Compression causes vascular occlusion affecting nutrition of nerve root. Itmay also induce conduction block. There is an increase in neuro transmittersrelated to pain. Nucleus pulposus may elicit inflammatory reaction when outside theintervertebral space. Proteoglycans have direct irritating effect on nerve tissue.Disc cells produce reduction in nerve conduction velocity.Biochemical effects of Nucleus pulposus: 1. Direct neurotoxic effect on nerve tissue. 2. Vascular impairment 3. Inflammatory reactions. Instability across motion segment occurs as degeneration progresses. Discdegenerate anteriorly, ligaments buckle or hypertrophy and changes with facetarthritis progress the central canal as well as neuro foramen is less accommodatingin rotation. As body rotates because of altered anatomy and mechanics, narrowingoccurs and can lead to torsional stresses. This can produce irritation andinflammation of nerve roots. 52
  59. 59. UPADRAVA AND SADHYASADHYATAUPADRAVA: “Roga arambaka dosha prakopa janya anya vikara” Upadrava is the complication produced in a disease, which develops afterthe formation of main disease. When the main disease has been produced, a dosha or doshas has becomefurther vitiated owing to abnormal diet, behaviour etc. A secondary disease issuper added and this is known as upadrava1. In practice the following things may be considered as Upadravas 1. Khanja vata 2. Sosha 1. Khanja vata2: As a result of stabdata and sakti utkshepa nigrahana there is restriction in extension of leg, the patient has to keep the leg in a semi- flexed position. This gives rise to limp in walking. 2. Sosha: Gridhrasi is vata vyadhis affecting the vata nadis, on account of pain all movements are restricted in the affected leg. Continuous pain restricts the patient to make minimum movements and the mamsa dhatu under goes sosha. Inability to walk and crippling are other upadravas.SADHYA SADHYATA Susruta considers vata vyadhi as mahagada due to its tendency to beincurable or fatal. Vagbhata calls it as Maharoga. Most of the Acharyas have toldthat vata vyadhi, generally are very difficult to cure3, 4. A separate prognosis hasnot been mentioned. On the basis of which it may be said that Gridhrasi in whichthe vitiated vata is seated in majja dhatu or if Gridhrasi is accompanied with 53
  60. 60. kudavata, Angasosha and sthamba may or may not be cured even after carefultreatment. But if this condition occurs in a strong person, is of recent origin andwithout any associated disease, then it is curable. Susruta mentions that a patient of vatavyadhi, if develops the complicationslike shota, sputa twacha, Bhagna, Kampa, Admana and pain in internal organs,then he will not survive 5. . The following conditions can be considered to decide sadhya sadhyatwa: • The pain due to muscle fatigue is sadhya. • Muscles subjected to prolonged work become fatigued as a result become locally painful and tender and it may be relieved by rest and by adopting measures that promote muscle blood flow. • The pain due to muscle spasm alone is sadhya. If associated with arthritis is kasta sadhya. • Sciatic pain due to spondylosis in early stages can be taken as kasta sadhya. • The spondylolisthesis, which is defined, as forward slipping of vertebral body on the below it is also kasta sadhya. • The degenerative disc conditions, osteo arthritis of the inter vertebral joints are yapya. • The disc prolapse and the fractures, which compress the spinal cord or nerve root, can be considered as asadhya, which results in paralysis of lower limbs. Most of the conditions affects the vertebral column are kasta sadhyas or yapya due to the involvement of asthidhatu, on marma, sandhis6 which are considered under Madhyama roga marga. 54
  61. 61. SAPEKSHA NIDANA Many of the diseases have resemblance with one another as the symptomsare concerned. But their line of treatment differs basically. Chikitsa should bestarted after confirmation of disease by differential diagnosis. Cardinal symptoms of Gridhrasi are: - Pain starting in the sphik, kati, prista radiating down the lower limb. - Saktyukshepa nigrahanyat - Restriction in raising the leg. Other symptoms like sthamba, toda, spurana etc., may be present. Gridhrasi has to be differentiated from the following to arrive at adiagnosis.1) Urusthamba1: - The vitiated kapha along with medha obstructs the vata and pitta in uru pradesha producing immobilization of thigh and calf. - The patient experiences strange feeling that leg does not belong to himself. He is unable to perceive the cold sensation in the affected limb. - The movement of the lower limb is completely stopped due to severe pain. - Urusthamaba is associated with jwara, chardi, angamarda etc., which are not found in Gridhrasi. In Gridhrasi the posterior aspects of thigh, calf along with kati, janu, pada, are involved. Movement is possible. 55
  62. 62. 2) Khanja2: Difficulty in walking with involvement of one lower limb. Akshepana is present.3) Pangu: Both limbs are affected resulting in total immobilization of lower limb.4) Kalaya kanja: The feature of muktasandhi bandhana resulting in criss crossed manner in walking with kampana.5) Gudagata vata3: In addition to pain symptoms like emaciation in back, sacral region, thigh, calf, foot, retention of faeces, urine and flatus, colic, flatulence and formation of stone may also be present.6) Khalli: According to Gayadasa, Khalli is a severe painful state of both Gridhrasi4 and Vishwachi. Both upper and lower limbs are affected simultaneously. Avamotana (Mardana like shoola) of pada jangha uru karamoola is seen. Avamotana is not present in Gridhrasi. 56
  63. 63. CHIKITSA Samprapti vighatanam is termed as chikitsa. Charaka1 and Susruta2 recommended siravyadha as the first line oftreatment in Gridhrasi. Chakradatta3 has given the treatment of Gridhrasi in detail. He stressed thatvasti should be administered after proper Agni deepana, Ama pachana and Urdhvasodhana. He said that administration of Vasti before urdhvasuddhi is insignificant. Bhava Prakasha4 advised vamana and virechana before administration ofvasti. Bhela samhita5 has mentioned sneha unmardana and sneha vasti, Raktamokshana. Vangasena6 has repeated the necessity of Urdhwa sodhana before vasti. Hementioned deepana, pachana, vamana, virechana, vasti, ishtika sweda & Upanaha. Chikitsa for Gridhrasi as mentioned by different authors. Chikitsa C.S. S.S. A.H. A.S. B.P. Y.R. H.S. B.S. C.D. V.S.Snehana + + + + +Swedana + + +Vamana + + + +Virechana + + + +Vasti + + + + + + +Siravedana + + + + +Agni karma + + + + + + 57