Matravasti sandhivata pk010-gdg
Upcoming SlideShare
Loading in...5
×
 

Matravasti sandhivata pk010-gdg

on

  • 829 views

A COMPARATIVE CLINICAL STUDY TO EVALUATE THE EFFECT OF MATRABASTI AND PARISHEKA WITH SHATAHVADI TAILA IN SANDHIGATAVATA (OSTEOARTRITIS), Jairaj. P. Basarigidad, Post graduate department of ...

A COMPARATIVE CLINICAL STUDY TO EVALUATE THE EFFECT OF MATRABASTI AND PARISHEKA WITH SHATAHVADI TAILA IN SANDHIGATAVATA (OSTEOARTRITIS), Jairaj. P. Basarigidad, Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103.

Statistics

Views

Total Views
829
Views on SlideShare
827
Embed Views
2

Actions

Likes
0
Downloads
81
Comments
0

1 Embed 2

http://www.slashdocs.com 2

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Matravasti sandhivata pk010-gdg Matravasti sandhivata pk010-gdg Document Transcript

    • A Comparative Clinical Study to EvaluateThe EffectOf Matrabasti and Parisheka with Shatahvadi Taila in Sandhigatavata (Osteoarthirits) By Jairaj. P. Basarigidad Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. (PANCHAKARMA) In PANCHAKARMA Under the guidance of Dr. G. Purushothamacharyulu, M.D. (Ayu) And co-guidance of Dr. Shashidhar.H. Doddamani, M.D. (Ayu) Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2005.
    • Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled “ AComparative Clinical Study to Evaluate The Effect of Matrabasti andParisheka with Shatahvadi Taila in Sandhigatavata (Osteoarthirits)” is abonafide and genuine research work carried out by me under the guid-ance of Dr. G. Purushothamacharyulu, , Professor and H.O.D, M.D. (Ayu)Post-graduate department of Panchakarma and co-guidance of Dr.Shashidhar. H. Doddamani, M.D.(Ayu) , Assistant Professor, Post graduatedepartment of Panchakarma.Date:Place: Gadag. Jairaj. P. Basarigidad
    • CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “ A Compara-tive Clinical Study to Evaluate The Effect Of Matrabasti and Parisheka withShatahvadi Taila in Sandhigatavata (Osteoarthirits)” is a bonafide researchwork done by Jairaj. P. Basarigidad in partial fulfillment of therequirement for the degree of Ayurveda Vachaspathi. M.D.(Panchakarma).Date:Place: Gadag Dr. G. Purushothamacharyulu, M.D. (Ayu). Professor & H.O.D Post graduate department of Panchakarma.
    • ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “ A Compara-tive Clinical Study to Evaluate The Effect Of Matrabasti and Parishekawith Shatahvadi Taila in Sandhigatavata (Osteoarthirits)” is a bonafideresearch work done by Jairaj. P. Basarigidad under the guidanceof Dr.G. Purushothamacharyulu, M.D. (Ayu), Professor and H.O.D, Postgradu-ate department of Panchakarma and co-guidance of Dr. Shashidhar.H.Doddamani, M.D. (Ayu), Assistant Professor, Post graduate department ofPanchakarma.Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Panchakarma.
    • CERTIFICATE BY THE CO- GUIDE This is to certify that the dissertation entitled “AComparative Clinical Study to Evaluate The Effect Of Matrabasti andParisheka with Shatahvadi Taila in Sandhigatavata (Osteoarthirits)” is abonafide research work done by Jairaj. P. Basarigidad in par-tial fulfillment of the requirement for the degree of AyurvedaVachaspathi. M.D. (Panchakarma).Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).Place: Assistant Professor, Post graduate Department of Panchakarma.
    • COPYRIGHT Declaration by the candidate I hereby declare that the Rajiv Gandhi University of HealthSciences, Karnataka shall have the rights to preserve, use and dissemi-nate this dissertation / thesis in print or electronic format for academic /research purpose.Date: Jairaj. P. BasarigidadPlace: Gadag.© Rajiv Gandhi University of Health Sciences, Karnataka.
    • I ACKNOWLEDGEMENT “Knowledge is proud that he has learned so much; wisdom is humble that heknows no more.”. This work is the result of the combined effort of a good number ofpeople who include researchers, academicians, friends, colleagues, parents and laymen. I dedicate this work to my respected parents Shri. P. F. Basarigidad andSmt. M. P. Basarigidad who are the prime reasons for all my success. The inspiring forces throughout this research work; was my guideDr. G. Purushothamacharyulu M.D.(Ayu), H.O.D. P.G. Department of Panchakarma,P.G.S & R.C, D.G.M.A.M.C, Gadag, the person who has devoted his life for theupliftment of this ancient system of medicine, who became a source of light whenever Iwas in darkness. I am deeply indebted for his guidance, broadmindedness and affectiontowards me. Words can not express the zeal of ecstasy while depicting my deep source ofgratitude to my proficient co-guide Dr. Shashidhar.H. Doddamani M.D.(Ayu), Asst.Professor, P.G. Department of Panchakarma, P.G.S.& R.C, D.G.M.A.M.C, Gadag. Hisfruitful suggestions, optimistic view shower head on me during this whole period &inspired me to accomplish this work in all aspects. I express my deep gratitude to Dr. G. B. Patil, Principal, D.G.M.A.M.C, Gadag,for his encouragement as well as providing all necessary facilities for this research work. I express my sincere gratitude to Dr. P. Shivaramudu M.D. (Ayu), Professor andDr. Santhosh. N. Belavadi M.D. (Ayu), Lecturer P. G. Department of Panchakarma for theirsincere advices and assistance. I express my sincere gratitude to a eminent teacher and researchers ofPanchakarma Dr. H. S. Kasture M.D. (Ayu), for his valuable guidelines. I express my sincere gratitude to Dr. V. Varadacharyulu M.D. (Ayu), Dr. M. C. PatilM.D. (Ayu), Dr. Mulgund M.D. (Ayu), Dr. K. S. R. Prasad M.D. (Ayu), Dr. Dilip Kumar M.D. (Ayu),Dr. R.V. Shetter M.D. (Ayu), Dr. Kuber Sankh M.D. (Ayu), Dr. Girish. Danappagoudar M.D. (Ayu),Dr.B.M.Mulkipatil M.D. (Ayu), Dr.Shashikant Nidagundi M.D. (Ayu), Dr.Jagadish Miti M.D. (Ayu),Dr.M.D.Samudri M.D. (Ayu), Dr. Shankaragouda M.D. (Ayu), Dr. Veena M.D. (Ayu) and other PGstaff for their constant encouragement.
    • II I also express my sincere gratitude to Dr. G. S. Hiremath M.D.(Ayu), Dr.B.G.Swamy,Dr. V.M. Sajjan, Dr. U.V. Purad, Dr. S.D. Yerageri, Dr. S.H. Redder, Dr. Gacchinamathand other undergraduate teachers for their support in the clinical work. I am thankful to Shri. Nandakumar (Statistician), Dr. Arun Baburao Biradar, Shri.V.M. Mundinamani (Librarian), Shri. B.S. Tippanagoudar (Laboratory technician), Shri.Basavaraj (X-Ray technician) and other hospital and office staff for their kind support inmy study. I cann’t move further before thanking to my intimate friends Dr. Santosh, Dr.Shashi, Dr. Jagadish, Dr. Sharanu, Dr. Girish, Dr. Pradeep, Dr. Kendadamath, Dr. V.M.Hugar, Dr. Shaila. B., Dr. P. Chandramouleeswaran, Dr V.S. Hiremath, Dr.Pattanashetti, Dr. Santoji, Dr. Jaggala, Dr. Udaykumar, Dr. Ratnakumar, Dr. KalmathB.L., Dr. Venkareddi, Dr. Bingi, Dr. Sajjan, Dr. Ganti, Dr. Pradeep, Dr. Sobagin, Dr.Shakuntala, Dr. Subin, Dr. Satheesh, Dr. Febin, Dr. Sreenivasa Reddy, Dr. Varsha, Dr.Vijay Hiremath, Dr. Suresh Hakkandi, Dr. Manjunath Akki, Dr. Ashwini Dev, Dr. L.Biradar, Dr. Jagadish. H, Dr. Sharanu, Dr. Anand, Dr. Suvarna, Dr. Anita, Dr. Kumbar,Dr. G. G. Patil, Dr. Sarve, Dr. Jigalur, Dr. Muttu, Dr. Prasannakumar, Dr. Madhushree,Dr. Sibaprasad, Dr. Payappagoudar. and other post graduate scholars for their support. I acknowledge my patients for their wholehearted consent to participate in thisclinical trial. I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. Even though more words can never replace the emotions one feels, still I crave toconvey a cordial thanks to my younger brother cum friend Santosh whose belief & wholehearted co-operation has always remained as the source of energy to me in this world ofuncertainly.Date :Place : Dr. Jairaj. P. Basarigidad.
    • III LIST OF ABBREVIATIONS⇒ A. H. – Ashtanga Hridaya.⇒ B. P. – Bhavaprakasha.⇒ C. S. – Charaka Samhita.⇒ G. R. – Good response.⇒ M. R. – Moderate response.⇒ N. R. – No response.⇒ P. R. – Poor response.⇒ S. S. – Susruta Samhita.⇒ AS. – Ashtanga sangraha.⇒ BR. – Bhaishajya ratnavali.⇒ MN. – Madhava nidana.⇒ No. – Number.⇒ Pt.’s – Patients.⇒ Sl. – Serial number.⇒ Vag. – Vagbhata.⇒ VS. – Vangasena samhitha.⇒ YR. – Yogaratnakara.
    • IV ABSTRACT Bastikarma and Swedana are the most important among the Panchakarmas. It hasalready been proved that the karmas are beneficial in managing the Vatavyadhees.Sandhigatavata is the most common joint disorder worldwide. The study “ A comparative clinical study to evaluate the effect of Matrabasti andParisheka with shatahvadi Taila in Sandhigatavata (Osteoarthritis)” is focused onimportant techniques i.e. Parisheka and Matrabasti and also common clinical entitySandhigatavata. Parisheka and Matrabasti with shatahvadi taila are believed to have aappreciable role in the management of such degenerative conditions by impartingstrength to the body musculature and nervous system. The objectives of this study are 1)To evaluate the effect of Parisheka inSandhigatavata (Osteoarthritis), 2) To evaluate the comparative effect of Matrabasti andparisheka in Sandhigatavata (Osteoarthritis), 3) To evaluate the additive efficacy ofMatrabasti in Sandhigatavata (Osteoarthritis). The aim of this study was to find out the effect of Parisheka in the management ofSandhigatavata, and to check its advantage over Parisheka in association with Matrabastiin managing the same disease. Therefore, two groups were made and the results obtainedin both the individual groups were compared. The study design selected for the presentstudy was prospective comparative clinical trial.
    • V In group A (Parisheka and Matrabasti) 8 patients (53.33%) had good response tothe treatment (> 60% improvement in all the parameters) and 7 patients (46.33%) hadmoderate response to the treatment (31-60% improvement in all the parameters) . In group B (Parisheka) 13 patients (86%) had moderate response to the treatmentand 2 patients (13.33%) had poor response to the treatment (1-30% in all the parameters).Among the group A and B the parameters Ruk and Walking time shows highlysignificant, where as other parameters are not significant in the comparative study (Byusing unpaired t-test, p<0.05). At the same time overall treatment response was better in the Parisheka andMatrabasti group as no patient in the Parisheka group got good response. This suggeststhat there was considerable improvement in both the groups but Parisheka and Matrabastigroup got more beneficial effects. Sandhigatavata is a Vatavyadhi affecting people in the vardhakya avastha. Thedisease is characterized by dhatu kshaya and lakshanas reflective of vitiated Vata.Therefore, the agents/therapies of brimhana-shoolahara-stambhahara-balya propertiesshould be used in this disease. Parisheka imparts Snehana and Swedana and opens up thesrotas in the shareera facilitating more nourishment and free movement of Vata dosha.Matrabasti is prime treatment for Vatavyadhees inturn plays vital role in correctingpathology of the disease and gives remarkable results. This results in the relief of symptomatology of the disease, when these twoprocedures performed together by acting locally and systematically. Ingredients ofshatahvadi taila possess properties such as Vedanashamaka, Shotahara and alsoVatanulomaka. Thereby, it is an ideal treatment of choice in SandhigatavataKey words: - Parisheka, Matrabasti, Sandhigatavata, Dhatukshaya, Swedana, Basti,Osteoarthritis, Vardhakya.
    • VI TABLE OF CONTENTS Chapters Page No.1. Introduction 1-32. Objectives 4-53. Review of literature 6-964. Methodology 97-1135. Results 114-1616. Discussion 162-1777. Conclusion 178-1798. Summary 1809. Bibliography10. Annexure
    • VII LIST OF TABLESTable Table Showing the Page No. No. 01. Different layers of Twak and diseases originating from each layer 02. Sites of different types of sandhis 03. Contraindicated for Anuvasana 04. Measurements of Bastiyantra 05. Netra dosha and Putaka dosha 06. Indications of Matrabasti 07. Dose of Matrabasti according to Age 08. Samyak, Ati and Heena yoga laxanas of Anuvasana basti 09. Properties of Swedana dravyas 10. Sweda yogyas 11. Sweda ayogyas 12. Samyak swinna lakshanas 13. Ati swinna lakshanas 14. Aaharaja nidana of Sandhigatavata 15. Viharaja nidanas of Sandhigatavata 16. Lakshanas of Sandhigatavata 17. Vyavachedaka nidana between Sandhigatavata and Vataraktha 18. Vyavachedaka nidana between Sandhigatavata and Amavata 19. Vyavachedaka nidana between Sandhigatavata and Kroshtrukasheersha 20. Differential diagnosis between OA, RA, Gout and Rheumatic fever 21. Distribution of patients by Age in both groups 22. Overall response of patients by Age in both Groups 23. Distribution of patients by Sex in both groups 24. Overall response of patients by Sex in both Groups 25. Distribution of patients by Occupation in both groups 26. Overall response of patients by Occupation in both Groups 27. Distribution of patients by Economical status in both groups 28. Distribution of patients by Religion in both groups 29. Distribution of patients by Dietary habits in both groups 30. Distribution of patients by Agni in both groups 31. Overall response of patients by Agni in both Groups 32. Distribution of patients by Koshta in both groups
    • VIII33. Overall response of patients by Koshta in both Groups34. Distribution of patients by Nidra in both groups35. Distribution of patients by Vyasana in both groups36. Distribution of patients by Deha prakriti in both groups37. Overall response of patients by Deha prakriti in both Groups38. Distribution of patients by Satmya in both groups39. Distribution of patients by Ruk in both groups40. Overall response of patients by Ruk in both Groups41. Distribution of patients by Graha in both groups42. Overall response of patients by Graha in both Groups43. Distribution of patients by Sparsha akshamatva in both groups44. Overall response of patients by Sparsha akshamatva in both Groups45. Distribution of patients by Sandhigati asaamarthya in both groups46. Overall response of patients by Sandhigati asaamarthya in both Groups47. Distribution of patients by Atopa in both groups48. Overall response of patients by Atopa in both Groups49. Distribution of patients by Shotha in both groups50. Overall response of patients by Shotha in both Groups51. Distribution of patients by Presenting complaints in both groups52. Distribution of patients by Chronicity in both groups53. Overall response of patients by Chronicity in both Groups54. Distribution of patients by Mode of onset in both groups55. Overall response of patients by Mode of onset in both Groups56. Distribution of patients by Aharaja nidana in both groups57. Overall response of patients by Aharaja nidana in both Groups58. Distribution of patients by Viharaja nidana in both groups59. Overall response of patients by Viharaja nidana in both Groups60. Distribution of patients by Mansika nidana in both groups61. Distribution of patients by Radiological interpretation in both groups62. Distribution of patients by overall response in both groups63. Before and after treatment values of all parameters in Group – A64. Before and after treatment values of all parameters in Group – B65. Individual study subjective and Objective parameters in Group-A66. Individual study subjective and Objective parameters in Group-B67. Inter-group comparison
    • IX LIST OF GRAPHSGraph No. Graph Showing the 01. Distribution of Patients by age in both groups 02. Distribution of patients by Sex in both groups 03. Distribution of patients by Occupation in both groups 04. Distribution of patients by Economical status in both groups 05. Distribution of patients by Religion in both groups 06. Distribution of patients by Dietary habits in both groups 07. Distribution of patients by Agni in both groups 08. Distribution of patients by Koshta in both groups 09. Distribution of patients by Nidra in both groups 10. Distribution of patients by Vyasana in both groups 11. Distribution of patients by Deha prakriti in both groups 12. Distribution of patients by Satmya in both groups 13. Distribution of patients by Ruk in both groups 14. Distribution of patients by Graha in both groups 15. Distribution of patients by Sparsha akshamatva in both groups 16. Distribution of patients by Sandhigati asaamarthya in both groups 17. Distribution of patients by Atopa in both groups 18. Distribution of patients by Shotha in both groups 19. Distribution of patients by Presenting complaints in both groups 20. Distribution of patients by Chronicity in both groups 21. Distribution of patients by Mode of onset in both groups 22. Distribution of patients by Aharaja nidana in both groups 23. Distribution of patients by Viharaja nidana in both groups 24. Distribution of patients by Mansika nidana in both groups 25. Distribution of patients by overall response in both groups LIST OF FLOW CHART Flow chart No. Flow chart showing 01. The samprapti of Sandhigatavata LIST OF PHOTOGRAPHSPhotograph No. Photograph showing 01. The anatomy of large intestine and rectum 02. Anatomy of Skin 03. Anatomy of Knee joint 04. Ingredients of Shatahvadi taila, Procedure of Matrabasti and parisheka
    • Ayurvedic classics narrate the observations of great sages like Charaka, Susruta,Vagbhata and Kashyapa. Their accomplishments are available as authouritive classics ofthis. It emphasizes man as conglomeration of the panchamahabhutas and atma. Thepanchamahabhutas are present in the body in the form of dosha, dhatu and malascomprising various organs and organ systems, these together forms the physical andmaterial aspect of man. A critical, careful and unbiased study of the classical Ayurvedic texts shows thatby the time the samhitagranthas were compiled, the science and art of Ayurveda hadalready passed through the stage of specialiazation. So it is time tested and formulatedafter conducting various reaserches on the basis of criteria’s available on those days.Ayurveda speaks about preservation of health first and then the correction of itsdisturbances, that is diseases. Ayurveda opines disease or vyadhi is a state in which both the mind and bodysuffer from pain, misery and even injury. The causative factors may vary depending onthe different entities but actually Tridoshas (Vata, Pitta and Kapha) are the intrinsiccausative factors, which get vitiated due to extrinsic factors and their balance is disturbed. Ayurveda prescribes various therapeutic measures either in the form ofPurificatory (Samshodhan) or Pacificatory (Samshamna) for the alleviation of the diseaseof both mind and physique. Panchakarma comprises five major preventive and therapeutic procedures amongthe unique achievements of our science; these are Vamana, Virechana, Niroohabasti,Anuvasanabasti and Nasyakarma. Acharya Susruta being first and foremost eminentsurgeon incorporates the Raktamokshana also into the above mentioned list, considering 1 Introduction
    • the two types of Basti under one. Panchakarma which is considered as five fold therapiesoccupise unique place among all the therapeutic measures list, because of its uniquenature not only to treat the disease radically but also by fulfilling both the basic goals ofAyurveda i.e “swasthasya swasthya rakshanam aturasya vikara prashamanam”. Theterm Panchakarma even the number is five but the word “pancha” gives the meaning“vistara” i.e elobarate procedure. Chakrapanidatta vividly emphasized about therestriction of Panchakarmas number to five, he opined that the term karma denotes theextensive management and pronounced potency for elimination of impurities. Snehanaand Swedana etc does not fulfill this goal and hence these are not included in it. For systematic and successful performance of these procedures it includes threemain aspects to consider which are in the form of poorvakarma, pradhanakarma andpaschatkarma. As Dalhana mentioned Pachana, Snehana and Swedana as poorvakarmas.Pachana is oral administration of certain drugs to relieve ama and strengthens the agni.Snehana is a oleation therapy which is administered through external or internal route.Swedana is a application of heat to the body to make perspire. Eventhough Swedana is included in poorvakarma it stands unique because of itswide spread application and efficacy. Swedana plays prime role in preparing body for theAdaptation of Pradhankarmas or Panchakarmas and also it is considered aspradhanakarma in certain conditions like Swedasadhya vyadhis. Among the varities ofSwedana, Parisheka is also included about which ample descriptions are available inclassics and it governes its own importance due to its systematic application and differentmodes of administration under the headings of Sheka, Parisheka and Dhara etc. 2 Introduction
    • When we consider Panchakarma procedures for their clinical efficiency andindications, Bastikarma has been placed a prime position by virtue of its wide indicationsand applicability like shodhana, shamana, brumhana and karshana etc basing on theproperties of the drugs employed in the procedure. Even it is considered as“Ardhachikitsa” and mentioned that it eliminates the vitiated doshas from all over thebody because of its wide action like “Aapadatalamastakam”. Swedana and Bastikarma occupies important place in treating Vatavyadhees,Vata is the master of all the doshas and is responsible for all types of functions andmovements in the body because of its Gati and Gandhana properties, so 80 varities ofVatavyadhees are mentioned in the treatises. The ability of any work of every individual is depends upon the ability of usinghis joints. The moment the person looses the power of locomotion the person not onlyfeels themselves a miserable creature but also becomes a burden to respective family andsociety. Sandhigatavata is one such clinical entity among Vatavyadhees which affects thelocomotion of senior citizens of this world in which dhatukshaya is prime factor which ischaracterized by certain symptoms like joint stiffness, joint pain, swelling and difficultyof joint movement etc. Among all the treatment modalities of Sandhigatavata Parisheka and Matrabastiare considered here for the study. 3 Introduction
    • NEED FOR THE STUDY The principle of Ayurveda chikitsa includes both Swedana and Bastikarma in thetreatment of Vatavyadhees. Swedana being one of the poorvakarma indicated in vatajaand vatakaphaja disorders mainly. Especially Parisheka is one among the Swedana inwhich lukewarm taila, kashaya etc poured in a regular stream on the whole or part of thebody, specifically when taila is used it mitigates Vata by accomplishing both Snehanaand Swedana simultaneously. Bastikarma is pradhanakarma which is mentioned as Ardhachikitsa, Matrabasti isa type of Anuvasanabasti having wide indications. It is well tolerated by the patientsbecause of its dose, no such complications and it can be administered at any time. Sandhigatavata is most common clinical entity among Vatavyadhees encounteredin clinical practice. It can be compared with Osteoarthritis of contemporary science asboth are similar in presentation with the symptometology- Pain, Swelling and Restrictionof joint movements etc of affected joints. According to WHO Osteoarthritis is the secondcommonest musculoskeletal problem in the world population. Many researches havebeen done in modern science to get effective treatment, as NSAIDs (analgesics) aregiving symptomatic relief only and also not safe, but could not found any safe andeffective medicaments. Research is going on even with Ayurvedic therapeutic measuressince 3-4 decades with Guggulu compounds and Shodhana measures. As Sandhigatavata is one among the Vatavyadhees and found very common insenile conditions. Matrabasti and Parisheka are expected to give better results in thisentity, Shatahvadi taila is used for these two procedures which is indicated in Vatavyadhi 4 Objectives
    • So present study entitled “A COMPARATIVE CLINICAL STUDY TOEVALUATE THE EFFECT OF MATRABASTI AND PARISHEKA WITHSHATAHVADI TAILA IN SANDHIGATAVATA (OSTEOARTHRITIS)” isundertaken.OBJECTIVES OF THE STUDY 1) To evaluate the effect of Parisheka in Sandhigatavata. 2) To evaluate the comparative effect of Matrabasti and Parisheka in Sandhigatavata. 3) To evaluate the additive efficacy of Matrabasti in Sandhigatavata. 5 Objectives
    • HISTORICAL REVIEW A critical review of the history from the primitive stage to the new millenniumassists one to understand the future in a better way. Man always struggled with presentand attempted for the better future and these can be achieved with a better perspective.when the past and present experiences and truths are checked and planned at proper time.History helps to reveal the hidden facts and ideas of the concerned subject.KARMABASTI KARMA As Matrabasti is a vikalpa of Anuvasana basti which is a variety of Basti, sohistorical review is done along with Basti here. Charaka Samhita1 : The scattered references regarding Basti are available invarious chapters of Charaka Samhita, but in Siddhisthana out of 12 chapters, 8 chapterscontribute to Basti. First two chapters of Siddhisthana deals with properties of Bastisamyak yoga, Ayoga lakshanas, indications and contraindications of Basti. This denotesthe importance of Basti in the field of Panchakarma. Susruta Samhita2 : In Susruta Samhita, four chapters ( 35th-38th ) have beendevoted completely for the description of the Basti in Chikitsasthana. In which detailedinformation regarding Bastinetra, indication, contra-indications, complications,classification of Basti etc are available. Ashtanga Sangraha3 : 28th chapter of Sutrasthana has been devoted to Bastionly. In this chapter, classification, indication, contra-indication, dosage, process ofadministration etc. have been described in detail. Also four chapters of Kalpasthana havebeen contributed to Basti. In these chapters, description regarding importance of Basti,different types of Basti, Sneha Basti Vyapad etc are available. 6 Historical Review
    • Ashtanga Hridaya4 : In this Samhita, 19th chapter of Sutrasthana Basti Vidhi and4th and 5th chapter of Kalpasthana named as Basti Kalpa and Basti Vyapada Siddhiexplain the every aspect of Basti. Kashyapa Samhita5 : In Kashyapa Samhita, Basti has been explained in detail inSiddhisthana and Khilasthana. He equated Basti to Amruta. Bhela Samhita6 : In Bhela Samhita, description of Basti is available in fourchapters of Siddhisthana namely Bastimatriyasiddhi, Upakalpasiddhi, Phalamatrasiddhiand Dasha Vyapadika Bastisiddhi. Chakradatta7 : In this text, two chapters named Anuvasanadhikara andNiruhadhikara are dealt with Anuvasana and Niruha Basti respectively. Vangasena8 : Vangasena has devoted “Basti Karmadhikara” chapter fordescription of Basti. Sharangadhara Samhita9 : Three chapters of Uttarakhanda namely BastiKalpana Vidhi, Niruha Basti Kalpana Vidhi and Uttara Basti Kalpana Vidhi describedvarious aspects of Anuvasana Basti, Niruha Basti and Uttara Basti respectively. As the time progressed in the recent times authors of Ayurveda has alsocontributed for the Bastikarma by modifying the Bastiyantra, i.e. replacing the olderequipments by rubber or plastic material. 7 Historical Review
    • SWEDANA KAMRA The time during and after the Samhitakala provide ample descriptions onSwedana. Charaka Samhita10 : Acharya Charaka was the first to describe Swedakarmaunder the Shadupakramas. He explained in detail about definition, classification,indications, contra-indications and benefits of Swedana. Susruta Samhita11 : Susruta also given in detail explanation about it, with slightdifference in classification. Vagbhata12 : He had also allotted separate chapters for Sweda karma inAshtanga sangraha and Ashtanga Hridaya. Bhela Samhita13 : Bhela had also described Swedana in detail in the Swedaadhyaya of sutrasthana. Kashyapa Samhita14 : He added Hastasweda and Pradehasweda too inclassification. Sharangadhara Samhita15 and Chakradatta16 : had also described aboutMridu, Madhya and Mahan Swedana karma. Bhavaprakasha17, Bhaishajyaratnavali18 and Yogaratnakara19 : hademphasized the utility of Swedakarma in various clinical conditions. About Sweda karma various literary works belonging to the Classical Age ofIndian Literature20 like Kasika and Harsacharita had also mentioned its usefulness. We find the ample description about therapeutic use of Parisheka21a-h in major textsof Ayurveda. Charaka considered Parisheka as Bahirparimarjana Chikitsa.22 8 Historical Review
    • SANDHIGATAVATAVedic Period In the Vedic period, like in Atharvaveda the words “Januni and Ashtivantau”were used to denote knee joints.23 The disease Sandhigatavata had not been mentioned assuch, but Atharvaveda had mentioned Parvashoola and Vateekrita24 two diseases similarto Sandhigatavata. Rigveda while describing various skills of Ashwinikumaras hadrecorded their skill in treating joint diseases too.25 One of the mantras of Rigveda statesthat, “I am removing your diseases from each organ, hair and joint”.26 In Atharvaveda,records about Vatavikaras are mentioned. A mantra says, “destroy the balasa seated inthe organs and joints which is responsible for loosing bones and joints”.27Samhita Kala In that period we find systematic description of the disease according to NidanaPanchaka. Charaka Samhita28 : Acharya Charaka has mentioned the diseaseSandhigatavata under Vatavyadhi Chikitsa (28th chapter) but hasn’t mentioned anyspecific line of treatment for this. Susruta Samhita29 : Acharya Susruta has added one symptom i.e. “HantiSandhi” and described the lakshanas of Sandhigatavata in Nidanastana (1st chaptr) and inChikitsa Sthana (4th chapter) specific line of treatmen has been prescribed. Bhela Samhita30 : There is no explanation about Sandhigatavata. However he hasexplained the asthi-majjagata Vata wherein we find the symptom Sandhi Vichyuthi. 9 Historical Review
    • Sangraha Kala Astanga Sangraha31 and Astanga Hridaya32 : In Astanga SangrahaNidanasthana (15th chapter) 15 Lakshanas and in Chikitsasthana (21st chapter) 4 varietiesof Chikitsa are explained. The Nidanas are similar to Charaka Samhitha and Chikitsa isas Susruta Samhitha. In Astanga Hridaya Nidanas are explained in Nidana Sthana (15thchapter) and chikitsa in Chikitsa sthana (21st chapter). Madhava Nidana33 : He has mentioned an additional symptom, Atopa in thesymptomatology of Sandhigatavata ( 22 nd chapter) rest are same as in Susruta Samhitha. Bhavaprakash34 and Yogaratnakara35 : Bhavaprakasha explained theLakshanas and treatment of Sandhigatavata in Madhyama khanda Vatavyadhyadhikara(24th chapter). Yogaratnakara : also is not left behind in explaining about Lakshanas andtreatment of Sandhigatavata in Vatavyadhyadhikara of Pooravardha. Chakradutta36 and Bhaisajyaratnavali37 : Description is similar to SusrutaSamhita. Both the texts haven’t dealt with the aspect of Nidana. Osteoarthritis (OA) is the most common joint disorder arising with greaternumber of affected population. Even in giant dinosaurs, osteophytes leading to ankylosiswere detected. In all mammalian species like whales and dolphins and in fish birds andsome amphibians, Osteoarthritis is observed.38 In the early ages, Hippocrates observed the prevalence of OA in aged individuals(Benard, 1944).39 Heberden (1803) studied this disease in detail and the nodes on thefingers in OA disease were named after him.40 Osteoarthritis was differentiated fromRheumatoid Arthritis and named as degenerative arthritis by Nichols and Richardson(1909) on morbid anatomical grounds.41 Although the most ancient of the diseases, OAwas first identified as a distinct entity in the 20th century.42 Gold th ait in 1904 made adistinction between hypertrophic and atrophic arthritis and A. E. Garrod recognized OAas a clinical entity in 1907.43(Rheumatology –Kelly and William). 10 Historical Review
    • VYUTPATTI AND PARIBHASHABastiThe word Basti is derived form ‘vas + tich’ and is masculine gender.“Vasu nivase”44 - Means residence.“Vas-aachadane” - That which gives covering“Vas vasane surabhikarane” - That which gives fragrance“Vasti vaste aavrunothi moothram” - That which covers the urine.“Nabheradhobhage mootradhare” - The position of basti is just below the nabhi (umbilicus) and is the collecting organ of urine in the body i.e. urinary bladder. In the context of Panchakarma the term basti is used in different meaning.“Vastina deeyate iti vasti”45“Vastibhir deeyate yasmat tasmat vastiriti smritha”46“Vastina deeyate vastini va Purvamanyattavasto vasti”47Matrabasti“Hraswaya snehapanasya matrayaha yojitaha samaha”48 Matrabasti is a type of Anuvasana which is having main ingredient sneha which isadministered in the hraswamatra. The word Basti gives the meaning of urinary bladder.As it is used as a device for Bastikarma. In Panchakarma therapy the term Basti is usedto designate the procedure. 11 Vyutpatti & Paribhasha
    • Swedakarma Sweda49 : - Sweda is a word of masculine gender. Sweda word is coined by thecombination of “Swit” dhathu and “Dhanj” pratyaya. Sweda is a shareeramala, which isassociated with body heat mechanism. Karma50 : - Karma word is derived from the dhathu “Kru”. Performance of anact is called karma. Here, swedakarma means the act of producing sweda and it is oneamong the Shadupakramas and poorvakarma.Parisheka51 Pouring of the regular stream of Vasa, Taila, Grita, Kshreera, Mutra, Kanji etc inlukewarm state.Sandhigatavata The word “Sandhigatavata” is comprised of three words, viz. Sandhi, Gata andVata. Sandhi52 :- Sandhi is a word of masculine gender. Sandhi is coined from threeparts ‘Sam’, ‘Dha’ and ‘Kihi’. “Sandhaanamiti, asthidvayasamyogasthanam”- The placeof union of something together is called sandhi. Here, it means the union of bones. Gata53 : - Gata word exists in all the three genders and it is derived from ‘Gama’dhathu and ‘Ktin’ pratyaya. “Gachati, janaati, yaateeti va” - That which has went orreached. Hence, gata word may be used to denote an initiation of movement, carryingsomething along with, to reach a particular site, through any particular pathway orleading to occupancy at a particular site. Here, in the context of Sandhigatavata, theoccupancy is at asthi-sandhis in the body. 12 Vyutpatti & Paribhasha
    • Vata54 : - Vata is a word of masculine gender. The word is coined from “Vaa”dhathu and “Ktin” pratyaya. Vata is derived from “Va gati gandhanayoho” i.e. to move,to make know, to become aware of. The term Gati means prapti, Jnana. Gandhana is likeUtsaha, Prakashana. Considering different meaning of Gati and Gandhana it isunderstood that the term Vata act as receptor as well as stimulator. It is one among thetridoshas. Thus, collectively the word Sandhigatavata means the disease resulting fromthe settling of vitiated Vata dosha in the bony joints of the body. The word “Osteoarthritis” is a combination of three words. “Osteon”, “arthron”and “itis” respectively means bone, joint and inflammation55. The meaning of this wordis “inflammation to the bony joint”. In fact, there is no inflammation in this disease;hence, the disease is also known as Osteoarthrosis and Degenerative joint disease. 13 Vyutpatti & Paribhasha
    • SHAREERA The word shareera comprises both structural and functional aspects of the body.As focus of this study is on Bastikarma and Parisheka, a discussion on the anatomy andphysiology of skin and also rectum where these procedures are applied, is necessary priorto the discussion on the anatomy and physiology of joints which are the site of thisdisease.Guda Shareera In the context of Arsaroga Susruta has explained in detail about the anatomicalstructure of guda. Guda is a part, which is the extension of sthoolantra with 41/2 angulain length. It has got 3 valis (parts) named as Gudavalitrayam.56 Pravahini – That which does pravahana. Visarjini – That which does visarajana. Samvarani – That which does samvarana. Gudostha is a structure present about a distance of 1½ yavapramana from the endof hairs. The first vali samvarani starts at a distance of 1 angula from gudostha. The widthof each vali will be 1 angula and of the colour of elephant’s palate.57 Charaka considered uttaraguda and adharaguda while describing about thekoshtangani. The modern commentators consider them as rectum and anus respectively.58All acharyas have considered guda as one among the dashajeevitha dhamani and also oneamong the bahyasrotas.59-61 The rectum forms the last 15cm of digestive tract and is an expandable organ forthe temporary storage of fecal material. Movement of fecal material into the rectumtriggers the urge to defecate. 14 Shareera
    • The last portion of the rectum, the ano-rectal canal, contains small longitudinalfolds, the rectal columns. The distal margins of rectal columns are joined by transversefolds that mark the boundary between columnar epithelium of the proximal rectum and astratified squamous epithelium like that in the oral cavity. Very close to the anus or analorifice, the epidermis becomes keratinized and identical to the surface of the skin. There is a network of veins in the lamina propria and submucosa of the ano-rectalcanal. The circular muscle layer of the muscularis externa in the region forms the internalsphincter and is not under voluntary control. The external anal sphincter guards the anusand is under voluntary control. Pudental nerves carry the motor commands.62Pakwashaya / Large intestine Susrutha63 and Vagbhata64 opine pakwashaya as one of the ashaya. According toArunadatta pakwashaya is the seat of pakwa anna i.e. that which attains pureeshatha.65Charaka and Vagbhata considered this as one among the koshtangas.66,67 Sharangadharahas specified the location of pakwashaya (pavanasaya) as below the Tila i.e. the liver.68 The horseshoe shaped large intestine or large bowel begins at the end of ileumand ends at anus. Average length of about 1.5 meters and width of 7.5cms. It is dividedinto 3 parts: - Caecum – T portion (pouch like) Colon – Large portion. Rectum – The last – 15 cm portion. The caecum collects and stores the chyme and begins the process of compaction.Colon is being subdivided into ascending, transverse, descending and sigmoid colon. Themajor characteristics of colon are the lack of villi. The abundance of goblet cells,presence of distinctive intestinal glands and mucosa does not exist produces anyenzymes. The reabsorption of water is an important function of large intestine (75%) andalso absorbs number of other substances that remain in the fecal matter or that weresecreted into the digestive tract along its length like Vit. K, B5, biotin, urobilinogen, bilesalts and toxins.69 15 Shareera
    • Twak shareera According to Ayurveda twak is an upadhatu of mamsa.70 In the foetal stage ofdevelopment of the Garbha, the different layers of the skin are formed due to themodification of mamsadhatu.71 Susruta72 appreciated the seven layers of twak and thediseases arising from it.Table No. 1. Showing the different layers of twak. Sl. Layer of twak Size Diseases arising from each layer 1 Avabhasini 1/18 Vrihi Sidhma, Padmakantaka 2 Lohitha 1/16 Vrihi Tilakalaka, Nyaccha, Vyanga 3 Swetha 1/12 Vrihi Charmadala, Ajagalli, Mashaka 4 Tamra 1/8 Vrihi Kilasa, Kushta 5 Vedinee 1/5 Vrihi Kushta, Visarpa 6 Rohinee 1 Vrihi Granthi, Apachi, Arbuda, Shlipada, Galaganda 7 Mamsadhara 2 Vrihi Bhagandara, Vidradhi, Arshas Susruta, stated that how the cream forms layer after layer in the boiling milk, likethat seven layers of skin forms. Charaka73 had described only six layers of twak without naming them they are –1) Udakadhara, 2) Asrigdhara 3) Sidhma-kilasa sambhavadhishthana, 4) Dadrukushtasambhavadhishthana, 5) Alaji-vidradhi sambhavadhishthana and 6) Arumshikaadhishthana patient goes into shock and develops a very serious skin disease calledarumshika, if injury occurs at the innermost layer i.e arumshika adhistana. Bhrajakapitta is located in the twak takes up and metabolizes the drugs applied inthe form of abhyanga, parisheka, avagaha, alepa etc.74 16 Shareera
    • Modern View Skin is a Large, Highly Complex Organ and as a Structuraly Integrated OrganSystem. It includes skin and the associated hairs, nails and exocrine glands. The systemaccounts for about 16% of ones body weight.75 Cutaneous membrane has two components – the superficial epithelium orepidermis and the underlying connective tissues of the dermis. The associated oraccessory structures are located in the dermis and protrude through the epidermis to theskin surface.General functions of the skin ◊ Protection of underlying tissues and organs. ◊ Excretion of salts, water and organic wastes. ◊ Maintenance of normal body temperature. ◊ Synthesis of a steroid, vitamin D3 that is subsequently converted to the hormone calcitriol, important to normal calcium metabolism. ◊ Storage of nutrients. ◊ Detection of touch, pressure, pain and temperature stimuli and the relay of that information to the nervous system.Epidermis It provides mechanical protection and keeps microorganisms outside the body;this layer consists of a stratified squamous epithelium. The most abundant epithelial cells,called kertinocytes, form several different layers. Five layers of epidermis, beginning at the basement membrane and travelingtoward the free surface, are stratum germinativum, stratum spinosum, stratumgranulosum, and stratum lucidum and stratum corneum. Keratinization or cornificationoccurs on all exposed skin surfaces except the anterior surface of the eyes. 17 Shareera
    • Epidermal growth factor (EGF) is one of the peptide growth factors produced bythe salivary glands and glands of the duodenum. This has wide spread effects onepithelia, especially the epidermis. Its effects include – Promoting the divisions of germinative cells in the stratum germinativum and stratum spinosum. Accelerating the production of keratin in differentiating epidermal cells. Stimulating epidermal development and epidermal repair after injury. Stimulating synthetic activity and secretion by epithelial cells. The colour of the skin is due to an interaction between pigment (carotene and melanin) composition and concentration and the dermal blood supply.Dermis The dermis lying beneath the epidermis has two major components – a superficialpapillary layer and a deeper reticular layer. The papillary layer consists of looseconnective tissue. This region contains the capillaries and the sensory neurons that supplythe surface of the skin. The reticular layer consists of an interwoven meshwork of denseirregular connective tissue. Accessory organs of epidermal origin, such as hair folliclesand sweat glands, extend into the dermis. The reticular and papillary layers of the dermiscontain networks of blood vessels, lymph vessels and nerve fibers.Dermal circulation Arteries supplying the skin form a network in the subcutaneous layer along itsborder with the reticular layer of the dermis. This network is called the cutaneous plexus.Tributaries of these arteries supply the adipose tissues of the subcutaneous layer and thetissues of the integument. As small arteries travel toward the epidermis, branches supplythe hair follicles, sweat glands, and other structures in the dermis 18 Shareera
    • Nerve supply Nerve fibers in the skin control blood flow, adjust gland secretion rates andmonitor sensory receptors in the dermis and the deeper layers of the epidermis. Theepidermis also contains the extensions of sensory neurons that provide sensations of painand temperature. The dermis contains similar receptors as well as other more specializedreceptors.Hypodermis The connective tissue fibers of the reticular layer are extensively interwoven withthose of the subcutaneous layer. Although the hypodermis is not a part of the integument,it is important in stabilizing the position of the skin in relation to underlying tissues, suchas skeletal muscles or other organs, while permitting independent movement.76Sweat glands77 Among the associated structures of the skin, only sweat glands are discussed heredue to their contextual relevance. The skin contains two different types of sweat glands orsudoriferous glands – apocrine glands and merocrine sweat glands. Apocrine sweat glands communicate with hair follicles in the armpits (axillae),around the nipples and in the groin. These are coiled tubular glands that produce a sticky,cloudy and potentially odorous secretion. Apocrine sweat glands begin secreting atpuberty. The sweat produced is a nutrient sources for bacteria, which intensity its odour.The secretary activities of the glands cells and the contractions of myoepithelial cells arecontrolled by the nervous system and by circulating hormones. 19 Shareera
    • Merocrine sweat glands, (eccrine sweat glands), are far more numerous andwidely distributed than apocrine glands. These are coiled, tubular glands that dischargetheir secretions directly onto the surface of the skin. The sweat produced by merocrine sweat glands is called sensible perspiration.Sweat is 99 percent water, but it also contains some electrolytes (chiefly sodiumchloride), organic nutrients and waste products. It has a pH of 4-6.8 and the presence ofsodium chloride gives sweat a salty taste. The functions of merocrine sweat glandinclude: (1) cooling the surface of the skin to reduce body temperature, (2) excretion ofwater and electrolytes and (3) protection from environmental hazards.Sweda and Swedavahasrotas During dhatuparinama Sweda is produced from medodhathu78. The udaka thatcomes out from the romakupas when body becomes hot is called sweda79 which is anapyadravya80. Sweda is brought to the surface of the skin through the swedavaha srotasesby the action of vyanavata.81 The excretion of the sweda bestows moisture and delicatenature to the skin.82 Hemadri opines that the hair on the skin is supported by the sweda.83Swedavaha srotas moola are medas and romekoopa.84 The vitiating factors areativyayama, atisantapa, indiscriminate indulgence in cold and heat, krodha, shoka andbhaya85. Their vitiation produces the following lakshanas- aswedana (anhydrosis),atiswedana (hyperhydrosis), parushya (roughness of the body), atislakshnata (excessivesmoothness of the body), paridaha (general burning sensation) and lomaharsha(horripulations).86 20 Shareera
    • SANDHISHAREERA The term sandhi means ‘sandhana’ i.e. the union of two or more structurestogether. Here, specifically the union of two or more asthis including taruna asthis anddantas. Saltshaker kapha87:- Among the five varities of kapha, situated in the sandhis. Itkeeps the joints firmly, protects their articulaton opposes their seperation and disunion. Vyanavata 88:- Vata is responsible for every movement in the body. Which is oneamong the varities of vata resides in hrudaya and controls most of the motor fuctions.Vagbhata states that Vata is located in asti, with relation to ashrayaashrayi sambhanda. Shleshmadharakala89:- It is fourth Kala, resides in all the joints of living being.Joints functions properly by the support of kapha as wheel moves on well by lubricatingthe axis. It is responsible for proper alignment and movements of all joints. Functionally, Susruta had classified sandhis into two varieties90 chesthavantasandhi (movable) and (2) sthira sandhi (immovable). Cheshtavanta sandhis are present insakhas (upper and lower limbs), hanu (temporomandibular joint) and kati (hip). All theremaining i.e. cranial sutures, intervertebral, costovertebral, sternoclavicular, sternocostaland dental are sthira type of variety (immovable or slightly movable joints).According to Susruta structurally joints are of eight types.91 21 Shareera
    • Table No: 2 showing the sites of different sandhis. Sl. Name of Sandhis Sites 1 Kora (resembling In anguli (interphalangeal joints), budding flower) manibandha (wrist), gulpha (ankle), janu (knee) & kurpara (elbow) 2 Ulookhala (resembling Kaksha (shoulder), vankshana (hip), a mortar) & danta (alveolar sockets & teeth) 3 Saamudga (as it fitted Amsapeetha (sternoclavicular), One another) guda (sacrococcygeal), bhaga (symphysis pubis), & nitamba (lumbosacral) 4 Pratara (floating) Greevaprishta (intervertebral) 5 Tunnasevani (sutural) Shira, kati & kapala (sutural joints) 6 Vaayasatunda (crows beak Hanusandhi (temporomandibular) like portion of a bone ente- rs similarly shaped hole) 7 Mandala(rounded) Kantha (tracheal rings) 8 Sankhaavarta(looks like Shrothra (cochlea) Circles of snail) According to Ayurveda total no of sandhis in the body are 210. 92MODERN VIEW The human skeleton is designed with a number of individual bones that arearticulated at joints to allow the movements in different directions, angles and positions.93In this particular study, only cases with Osteoarthritis of knee have been considered. So,the descriptions of these are being dealt with in detail here. 22 Shareera
    • Knee Joint 94 The knee is structurally complex and subjected to severe stresses in the course ofnormal activities. Although the knee functions as a hinge joint, the articulation is far morecomplex than that of the elbow or even the ankle. The rounded femoral condyles rollacross the top of the tibia, so the points of contact are constantly changing. The jointpermits flexion and extension and very limited rotation. There is no single, unifiedcapsule at the knee joint, nor is there a common synovial cavity. A pair of fibro cartilagepads, the medial and lateral menisci, lies between the femoral and tibial surfaces. Themenisci – (1) act as cushions, (2) conform to the shape of the articulating surface as thefemur changes position and (3) provide lateral stability to the joint. Prominent fat padscushion the margin of the joint and assist the many bursae in reducing the frictionbetween the patella and other tissuesLigaments Seven major ligaments stabilize the knee joint. They are the patellar ligament, twopopliteal ligaments, the anterior cruciate and posterior cruciate ligaments, the tibialcollateral ligament and the fibular collateral ligament.Muscles Associated Flexors of the knee -biceps femoris, semimembranosus, semitendinosus and thesartorius. The flexion of knee and rotation (lateral) of the thigh is done by sartoriusmuscle. The first three flexors are collectively known as hamstring muscles. Collectively,the knee extensors are known as the quadriceps femoris (Vastus muscles). 23 Shareera
    • Blood Supply Genicular branches of the popliteal artery. The descending genicular branch of the femoral artery. The descending branch of the lateral circumflex femoral artery. Recurrent branches of the anterior tibial artery. The circumflex fibular branch of the post-tibial artery.Nerve Supply Femoral nerve – Through its branches to the basti especially the vastus medialis Sciatic nerve – Through the genicular branches of the tibial and common peroneal nerve. Obturator nerve – Through its posterior division.Snayu95 Totally there are 900 snayus in the body; among them 600 are in the extremities,10 in the janu. The pratanavati type of snayus is located in the sandhis of the body. Allthe joints are attached with snayus that are responsible for their compactness.Peshishareera96 There are 500 peshis in body; among them, 400 are in the extremities (upper andlower), 5 in the janu. All the siras, snayus, asthis, parwas and sandhis are covered bypeshis that protects them.Marmas97 Marmas are the vital anatomical points in the human body. The janu marma islocated between jangha and urvi and if injured causes khanjata. It is a sandhi marma of 3angula measurement and is a vaikalyakaramarma. 24 Shareera
    • Sira and Dhamanis98 The kaphavaha siras carrying prakrita Kapha, maintains the sandhi, ensures itssthirata, increases its bala etc. One of the functions of vatavaha siras is pancha cesta suchas Prasarna Akunchana etc. the raktavaha siras does dhatu purana brings about sthirataand does poshana. Asthi is one of the dhatus; hence these functions are applicable forAsthi dhatu poshana also. The Sparshavaha dhamanis are spread in the upward direction and these have thefunction of carrying the sparsha jnana. The sparsha may be sukhakara or dukhakara.Synovial fluid Synovial membrane secretes a liquid, the synovial fluid. It has many functions -serves as a lubricant, a shock absorber and a nutrient carrier. This belongs to a ratherunusual group of liquids known as dilatent liquids. These liquids are characterized by therare quality of becoming thicker when shear is applied to them. Thus, the synovial fluidin our knees and hips assume a very viscous nature at the moment of shear in order toprotect the joints, and then it thins out again to its normal viscosity instantaneously toresume its lubricating function between shocks. Synovial fluid is the liquid that mustcarry the raw materials from the blood to the cartilage. 25 Shareera
    • Figure No. 03. Showing the anatomy of Knee joint.
    • Figure No. 01. Showing the anatomy of Large intestine and Rectum.
    • Figure No. 02. Showing the anatomy of skin.
    • BASTI KARMA Among the Shodhana therapies Bastikarma is considered as the most importantone due to its wide spread application and effect. It is the procedure in which the drugprepared according to classical reference is administered through rectal canal reachesupto the Nabhi Pradesha, Kati, Parshva, Kukshi churns the accumulated Dosha andPurisha spreads the unctuousness (potency of the drugs) all over the body and easilycomes out along with the churned Purisha and Doshas. Even though it has a resemblancewith the enema therapy, it differs in many aspects like principle, mode of application andthe advantages it renders. As the term Basti means bladder but it is used as a device forBastikarma. Hence, it is used as a name in Panchakarma therapy to designate the process.It is also said that the medicine in suspension, administered through the Bastiyantra, firstreaches the lower abdominal part of the patient. The lower abdominal area or the pelvisalso contains the organ basti (urinary bladder). Due to these reasons the term Basti is usedin Panchakarma.IMPORTANCE OF BASTIKARMA All major texts of Ayurveda emphasized this treatment considering its efficacy. Itstands unique among all the shodhana therapies because it expels the vitiated Doshasrapidly and easily from the body and also causes reducing as well as nourishing the bodyvery fastly.99 Eventhough Vamana and Virechana eliminates the vitiated Doshas form thebody, the drugs used in these therapies contain Katu rasa, Ushna guna and Teekshnagunas, which cannot be taken easily by children or older people. But Basti can be givenin all age groups without any hesitation.100 26 Bastikarma
    • Bastikarma is the prime treatment for Vata and Vata dominating other vikaras asVata being the chief controller among the causative forces of disease.101 According tobasic principles of Ayurveda, Vata is responsible for each and every movements andactivities in the body whether it is of constructive or of destructive nature. On the otherhand Vata is functionally required to co-ordinate with Pitta and Kapha in order toaccomplish various duties assigned to them in the organization of life.102 As the main seat of Vata is considered as Pakwasaya by the adminstation of Bastiinto it, the proper regulation and co-ordination of the functions of Vata dosha occurs in itsown site and also control the related Doshas which are involved in the pathogenesis ofdisease.103 Hence, Basti is also called as Ardhachikitsa by Vagbhata.104 Apart form this ithas multidimentonal effect by possessing various therapeutic actions like Samshodhana,Samshamana and Sangrahana of doshas on the basis of drugs used in it.105 Basti accomplishes rejuvenation, happiness, longevity, strength, improvingmemory, voice, digestive power and complexion. It removes noxious matters form thetissues, pacifies the Doshas. Consequently it affords stability and thus indirectlystrengthens the reproductive capacity in man.106 Kashyapa equated the Bastikarma as‘Amrutam’, because of its wide application even in both infants and in old age people.107Classification of Basti One cannot find any uniformity in classification of Basti among the authors ofclassical texts. As Basti is an important method of therapy in Ayurveda, it can beclassified in various ways for better understanding. Generally the term basti has beenused for all types of Bastikarma, which includes Nirooha, Anuvasana, Uttarabasti etc. But 27 Bastikarma
    • Charaka has used this term Basti exclusively for Nirooha as per the commentary ofChakrapani.108 Similarly the term Basti has also been referred to the method ofShirobasti, Urobasti and Vrinabasti etc. So a rational thinking on various aspects ofBastikarma has brought about the following classification.1091) Adhishtana bheda : According to the site of application of Basti it is classified into two types – a. Internal b. External a. Internal Pakwashayagata The administration of medicine via Gudamarga to Pakwashaya basti Garbhasayagata The administration of medicine via Yonimarga to Garbhashaya basti Mutrasayagata basti The administration of medicine via Mutramarga to Mutrasaya. Vranagata basti The medicine administered through the Vrinamukha by the process of bastikarma b. External : In certain diseases the medicated oil is kept over the part of the body using a capor with flour paste for prescribed period of time and named after the site of application ofoil such as – Shirobasti, Katibasti, Urobasti, etc.2. Dravya bheda: It is based on the major ingredients of Bastidravya - kwatha or snehaand so classified into two types: - i) Nirooha basti – In Niruha Basti, Kashaya (decoction) is the predominantcontent with the Kashaya, Madhu, Saindhava, Sneha and Kalka are the ingredientscommonly used. Its synonyms are Asthapana Basti,110 Kashaya Basti etc. Its action in thebody is beyond the perception of physician.111 28 Bastikarma
    • ii) Anuvasana basti – Sneha is the chief ingredient of Anuvasana. The termAnuvasana is coined due to the unharmful effect of the Bastidravya even if it is retainedinside the koshta. Morever, this type of Basti can be practiced daily without any seriousprecautionary measure, as it is less harmful than nirooha.1123. Karma bheda: Susruta and Vagbhata have made the following classificationaccording to their actions.113-114Shodhana Contains Shodhana dravyas and removes vikrita Doshas andbasti Malas from the bodyLekhana Reduces Medodhatu and produces Lekhana in the bodybastiSneha basti Contains more of Sneha and produces Snehana in the bodyBrumhana Increases the Rasadi dhathus and indirectly it helps in the growth ofbasti body.Utkleshana Causes Utklesha of malas and doshas by increasing its Pramana andbasti causes dravabhoothaDoshahara Purificatory or eliminating type.bastiShamana Causes Shamana of Doshas.basti Sharangadhara added, Shodhana basti to it also he has added Lekhana, Brimhana,Deepana-pachana types of bastis.115 Vataghna basti, Balavarnakrita basti, Snehaneeyabasti, Sukrakrit basti, Krimighna basti, Vrishatvakrit basti has been explained in variouscontexts by Charaka.1164. Sankhya bheda: It is stated that neither Snehabasti nor Niroohabasti can be appliedalone.117 So, Charaka has made this classification based on the number of Snehabastisand Niroohabastis in a treatment.118 viz. a) Karma basti119 b) Kala basti120 c) Yogabasti.121 29 Bastikarma
    • 5. Matra bheda: This classification of basti is based on the quantity of Bastidravyaprescribed. The quantity may vary according to the age, strength of the patient andseverity of the disease.• Dvadashaprasruta basti – In nirooha, the maximum dose or quantity of Bastidravya prescribed is Dvadashaprasruta i.e. 24 palas.122• Prasritayogika basti – Charaka has prescribed various types of Nirooha in different doses like 4,5,6,7,8,9, and 10 prasrutas, considering the strength of the patient and condition of the disease.123• Padaheena basti – In this type of basti, 3 Prasrutas i.e. ¼ of Dvadashaprasruta is less form from the total quantity of Nirooha used i.e. 9 prasruthis.124Anuvasana : is also classified into 3 according to the differ quantity of sneha used • Sneha basti 125 – 6 palas (¼of total quantity of Nirooha) • Anuvasana basti 126 – ½ of the quantity of Snehabasti. • Matra basti 127 – The quantity of sneha that will be digested within 6 hrs.6. Anushangika bheda (Miscellenious)a) Yapana basti.128 b) Siddha basti129 c) Yuktaratha basti 130d) Vaitharana basti 131 e) Ksheera basti 132 f)Ardhamatrika nirooha basti133g) Picha basti 134 h) Mutra basti 135 j) Rakta basti 136 In general approximately 216 kinds of Basti are mentioned by Acharya Charakain various chapters of Siddhisthana. 30 Bastikarma
    • Indications and contraindications of Anuvasana Bastikarma Basti is one of the prime treatment of Ayurveda, hence the knowledge of thesuitability and unsuitability of patients should be kept in mind. All the acharyas havebeen clearly explained as presented below. 137-139 Indications for Anuvasana Basti : Anuvasana is indicated in patients whoare already indicated for asthapana, but special mention has been given to certainconditions like Rooksha, Kevala vataroga and Atyagni where Anuvasana is morebeneficial.Table No; 3 Persons unfit for the Anuvasana basti 140-142 No. Contraindications Ch. Su. Vag. Complications 1. Anasthapya + + + 2. Abhuktabhakta + - + Sneha moves upwards 3. Navajwara + - - 4. Kamala + - + Leads to udara 5. Prameha + - + 6. Arshas + - - Leads to aadhmana 7. Pratishyaya + - - 8. Pandu + + + 9. Arochaka + - - Leads to more annabhilasha 10. Mandagni + - - 11. Durbala + - - Increases the condition 12. Pleehodara + + + 13. Kaphodara + + + Leads to more dosha vardhana 14. Oorustambha + - + 15. Garapeeta + - + 16. Kaphabhishyanda + - + 17. Gurukoshta + - + 18. Shleepada + - + 19. Galaganda + - + 20. Apachi + - + 21. Krimikoshta + - + 22. Prameha - + + 23. Kushta - + + 24. Sthaulya - + + 25. Peenasa - - + 26. Krushna - - + 27. Varchobheda + - + 28. Vishapeeta + - + 31 Bastikarma
    • Basti Yantra : The instrument or device used for basti karma is called as bastiyantra. Itcomprises of two parts – 1.Bastinetra 2. BastiputakaBastinetra (Nozzle/Cannula) : The general meaning of netra is eye, but here netrameans nalika (tube). It can be made of gold, silver, copper or such other higher metals oralloys, long bones of animals, bamboo, wood etc. were used in ancient times. Generally,it must resemble the tail of cow with a tapering end and a wider base. But, according toCharaka it is tubular apparatus with round ends and smooth surfaces143. The dimensionsare different to suit the patients of different age group. The following table furnishes themeasurement of bastiyantra.Table No: 4 Measurements of Bastiyantra144-146 No. Age in Length in Lumen of netra Diameter of narrow end Diameter of broad end years Angula 1. <1 5 1 angula 2. 1-6 6 Size of green gram 1 angula 3. 7- 11 7 Size of black gram 1½ angula 4. 12-15 8 Size of kalayam 2 angula 5. 16- 20 9 Size of wet kalaya 2½ angula 6. > 20 12 Karkandhu 3 angula Susrutha’s opinion 8. 1 6 Green gram Feather of kanku bird must pass through. 9. 8 8 Black gram Feather of eagle must pass through. 10. 16 10 Kalayam Feather of peacock must through. 11 >25 21 Kolasthi Feather of vulture must pass through. 32 Bastikarma
    • Karnika : In order to prevent undue penetration of the bastinetra deep in to therectum, a karnika or rim has to be made. It is to be placed at a required point above thedistal end. Two karnikas are provided on the netra at distance of 2 angulas between one,another at proximal end to tie the bastiputaka properly.147 Bastiputaka : The container or bag used to carry the bastidravya, ready forapplication is known as bastiputaka. In ancient days the urinary bladder of maturedanimals like cow, buffalo, dear, pig, goat etc were used. It was then processed to makesoft and colorful by removing the blood vessels and other impurities. It should be made suitable for well fitting with the bastinetra and should not haveany foul smell. If good bladder is not available some other materials are recommendedfor the purpose. They are the skin of lower limb or neck of monkeys or other animals,thick cloth with sufficient strength and size may also be used.148 Now a days, due to technological development various types of materials areavailable to make up of bastiputaka and even disposable bastinetra are available. Therubber bladder and polythene bags are best choice. Presently in most Panchakarmatheaters the disposable bastiyantras with polythene bags are in use. 33 Bastikarma
    • Table No: 5 Netradosha and putakadosh 149-150No. Netradosha Features Effect1. Hraswata Too short Dravya will not reach pakwasaya2. Deerghata Too long Dravya go beyond the pakwasaya3. Tanuta Too thin Produces kshobha4. Sthoolata Too big Produces lakshana5. Jeernata Old dhatu used Injury to guda6 ShithilabandhanaNot fixed properly to the Dravya comes out putaka 7. Parshwachhidra Hole on side Leakage of dravya happens 8. Vakrata Curved / irregular Dravyagati becomes irregular 9. Assannakarnika Karnika too near Karma becomes of no use10. Prakrustakarnika Karnika too far Causes raktasrava by gudamarma peedana11. Anusrotata Small hole Cannot perform properly12. Mahasrotrata Broad hole Cannot perform properlyNo. Putakadosha Features Effect 1. Vishama Shape not in uniform Gati vishamata happens during pressing 2. Mamsala Muscular tissue present Produces offensive small 3. Chinnachidrayukta Presence of hole Dravya comes out 4. Sthoola Thick one Does not push dravya 5. Jalayukta Anastamosis present Produces leakage 6. Vatala Excess air space Frothy type of dravya 7. Snigdha Unctuous Slip form the hand 8. Klinnata Wet Difficult to pass through The procedures and preparations are classified into three parts: - 1.Poorvakarma(pre-treatment) 2.Pradhanakarma (treatment) 3.Paschatkarma. (post-treatment) The physician who is administering basti should have good theoretical knowledgeand sufficient practical experiences in the therapy. The classical books have explained somany complications that are produced due to improper and in efficient administration. 34 Bastikarma
    • ANUVASANABASTI PROCEDUREPoorvakarma : The body of the patient should be anointed with suitable sneha and gentlyfomented with hot water. Then he is advised to have his prescribed meal and made totake a short walk. Having passed stool and urine he is laid on a couch, which is not veryhigh, and the head must be at lower level. No pillows are used. The patient should lie onhis left side drawing up the right leg and straightening the left leg.151-153Pradhana karma : The oil prescribed for Anuvasana taken in the bastiputaka and tied well placingthe bastinetra in position. The trapped air in bastiyantra is expelled by gently pressing thebastiputaka. Then the anal region and the netra should be smeared with oil. Gently probethe anal orifice with the index finger of the left hand and introduce the bastinetra throughit into the rectum up to first karnika. Keeping in the same position press the bastiputakawith right hand with adequate force. Release carefully the bastinetra when a little quantityof sneha remained inside the bastiputaka.154Paschatkarma : The patient is kept lying on his back as long as it would take to count up tohundread. The patient should be gently struck three times on each of the soles and overthe buttocks. The distal part of the cot should be raised thrice. Allow him to lie forsometime in the same position. If he gets the urge for defecation he may do it. But in theevent of sneha passed immediately another Anuvasanabasti should be given. Afterpassing the motion with sneha in proper time the patient is allowed to take light food if hefeels hungry.155-156 Maximum duration of the withdrawal of snehabasti is 3 yama i.e. 9hours. 35 Bastikarma
    • MATRABASTI Matrabasti is a type of Sneha Basti described by the Acharyas. It is termed sobecause of the dose of Sneha used in it is very less as compared to the dose of SnehaBasti.157-159 If we make an effort to understand the meaning of the term Matra, it gives variousmeaning with respect to different context, such as Measurement, Quantity, Size,Duration, Number, Degree, Movement, Unit of time. It also stated it as prosodial instanti.e. the length of time to pronounce a short vowel. In the present context the term Matragives the meaning for the unit of measurement i.e for the quantity of Bastidravya. Basti also having different meaning according to various context but in presentcontext it is considered as therapeutic procedure of Panchakarma as discussed earlier indetail. Acharya Vagbhata has defined the Matrabasti as the Basti in which the dose ofSneha is equal to Hraswa matra of Snehapana.160-161Indications : According to Charaka, Matrabasti is always applicable to those emaciated due tooverwork, physical exercise, weight lifting, way faring, journey on vehicles, indulgencein women, in debilitated person as well as in those afflicted with Vata disorders.Ashtanga Sangraha, 162 emphasized on regular administration of the Matrabasti and it canbe administered at all times and in all seasons just as Madhu Tailika Basti. 36 Bastikarma
    • Table No: 6 showing indications of Matrabasti 163-165 Sl. No. Indications Ch. A.H. A.S. 01. Karma karshita + - - 02. Bhara karshita + + + 03. Adhva karshita + + + 04. Vyayama karshita + + + 05. Yana karshita + - + 06. Stree karshita + + + 07. Durbala + + + 08. Vata Rogi + + + 09. Bala - + + 10. Vriddha - + + 11. Chintatur - + + 12. Stree - - + 13. Nripa - + + 14. Sukumar - - + 15. Alpagni - + + 16. Sukhatma - + - Contraindication :165 In classics, there are no major contraindications mentionedfor Matrabasti, but Ashtanga Sangraha has stated that Matrabasti should not beadministered in the persons having Ajirna. Qualities : The Matrabasti is promotive of strength without any demand of strictregimen of diet, causes easy elimination of Mala and Mutra. It performs the function ofBrimhana and cures Vatavyadhi. It can be administered at all times in all seasons and isharmless.166 Vagbhata has mentioned that Matrabasti improves Varna and Bala. Headds that it can be given regularly, which is indicated for bala, vriddha, and alpagniperson. No need of parihar after adminstration of Matrabasti, no such complicationsarises. He mentioned it as Varnya, doshaghna etc.165 Acharya Hemadri commenting onthe term sukha stated that, it is devoid of complications.167 37 Bastikarma
    • Dose : “Hraswayaha snehamatrayaha matrabastihi samo bhaveth”168 Matrabastithe term is popular because of its dose only, because sneha is administered in thehraswamatra. According to Vagbhata, Matrabasti is recommended in the dose equal tothe dose of Hraswa Snehapana.169 The Matra which gets digested in 2 Yama i.e. 6 hoursis called as Hraswa Matra of Snehapana, but the dose required to get digested in 2 Yamais not mentioned.165 Susruta has given the dose as ½ of the dose of Anuvasana Basti and according tohim the dose of Anuvasana Basti is ½ of the dose of Sneha Basti. In Sneha Basti, the dosegiven is ¼ of the total dose of Niruha Basti i.e. 6 Pala (24 Tola). Hence, the does ofMatraBasti is 1½ Pala = 6 Tola = 72ml.170 According to Chakrapani, the dose of SnehaBasti is 6 Pala, dose of Anuvasana Basti is 3 Pala and of Matrabasti is 1½ Pala.171Acharya Kashyapa prescribed the quantity of Matrabasti as 2 palas as uttamamatra, 1 ½pala as madhyama matra and 1 prakuncha as hraswa matra. He even stated that half palaof sneha can be given in newborn baby, it can be administered without any hesitation andcomplication too.172 Sharangandhara mentioned sneha matra of Matrabasti as 2 palas (8tolas).173 On the basis of above references, it can be said that the dose of Matrabasti is 1½Pala of Sneha i.e. 6 Tola = 72ml.Table No: 7 Dose of Matra basti according to Age Sl. Age in Years Matra in Tola Sl. Age in Years Matra in Tola 1 1 1/4 11 11 2¾ 2 2 1/2 12 12 3 3 3 3/4 13 13 3½ 4 4 1 14 14 4 5 5 11/4 15 15 4½ 6 6 1½ 16 16 5 7 7 1¾ 17 17 5½ 8 8 2 18 18 6 9 9 2¼ 19 19-70 6 10 10 2½ 20 70 and above 5 38 Bastikarma
    • Food before Basti Procedure: Matrabasti should not be given after the patienthas consumed excessively Snigdha ahara because Sneha taken in double quantity givesrise to Mada and Murccha. Before Matrabasti, the patient should avoid the intake ofexcessively Ruksha ahara because it causes depletion of Bala and Varna. Therefore,patients should be given low Sneha diet before Matrabasti.174 Pathya – Apathya :175 The Matrabasti does not demand any regimen of diet orbehaviour. It can be given at all times and in all seasons without any restriction.However, Ashtanga Sangraha has restricted the day sleep after being treated withMatrabasti. Retention of Matrabasti : The normal Pratyagamana Kala of Sneha Basti is 3Yama i.e. 9 hours. Being a type of Sneha Basti, the Pratyagamana Kala of Matrabasti isalso 3 Yama i.e. 9 hours. There is no harm if Matrabasti retains in the body because,while describing Anuvasana Basti it has been said that it is not harmful to body even inthe event of its being retained in the body for a whole day. Also the dose of Sneha inMatrabasti is very small, which can get easily absorbed in the body without coming out.It is believed that Sneha Basti should be retained in the body. If Basti material returnsmuch earlier, it cannot produce the desire effect in the body.176 Samyaka Yoga Lakshana of Matrabasti : Being a type of Sneha Basti,Samyaka Yoga Lakshana of Sneha Basti are to be taken as Samyaka Yoga Lakshana ofMatrabasti. The Lakshana of Samyaka Anuvasana are the return of Sneha with the fecalmatter without being stuck up anywhere, the clarity of Rakta, Mamsa etc. Dhatus andsense organs, good sleep, lightness of body, increase of strength and regulation of theexcretory urges.177 39 Bastikarma
    • Complication of Sneha Basti : Though it is said that there is no majorcomplication by the use of Matrabasti but sometimes complication may be produced dueto obstruction of Sneha by Vata, Pitta, Kapha or by excess of Mala or food and whengiven to a person on empty stomach. These are six conditions of complications likely toarise during the use of Sneha Basti.17801) Vata Avrita Sneha179 –180 : If in a condition of excess of Vata, Sneha is given in coldcondition or in small quantity, it gets Avrita by Vata and will not be able to return as itscourse is obstructed by Vata. Such Sneha produce Agnimandya, Jwara, Adhmana,Stambha, Urupida, Parshwashula. Treatment: In this condition Niruha Basti prepared by Rasna, Pitadaru, Tilvak,Sura, Sauviraka, Kola, Kulattha, Yava, Gomutra, Panchamula should be administered toeliminate the Vatavrita Sneha. 18102) Pitta Avrita Sneha : If excessive Ushna Basti is given in the condition of excessPitta, it produces Daha, Raga, Trasa, Moha, Tamaka and Jwara. Treatment: This condition should be cured with the enema prepared withMadhura and Tikta Dravyas. 18203) Kapha Avrita Sneha : If Mrudu Basti is given in condition of excess Kapha, itcauses Tandra, Sheeta Jwara, Alasya, Praseka, Aruchi, Gaurva, Murccha and Glani. Treatment: It should be corrected with Basti prepared with Kashaya, Katu,Tikshna and Ushna Dravya and with Sura and Gomutra and mixed with Madana Phalaand Amla Dravya. 40 Bastikarma
    • 04) Anna Avrita Sneha 183 : If Basti prepared with Guru Dravya and given after a heavymeal it gets obstructed by Anna. This Annavrita Sneha, leads to Chhardi, Murccha,Aruchi, Glani, Shula, Nidra, Agnimandya and Ama Lakshanas with Daha. Treatment: Such condition is treated by stimulating digestion with decoction andpowders of Katu and Lavana Dravyas. Also Mrudu Virechana and the treatment advisedfor Ama should be adopted. 18405) Purisha Avrita Sneha : In case of accumulation of Mala, if Basti having AlpaBala is administered it produces symptoms like Purisha Sanga, Mutra Sanga, Vata Sanga,Shula, Gaurava, Adhmana and Hridaroga. Treatment : This condition should be treated with Snehana, Swedana along withPhalavarti. The Anuvasana Basti and Niruha Basti prepared with Shyama, Bilva etc.should be used. Also the treatment indicated in Udavarta should be followed. 18506) Abhukta Pranita Basti : If Basti is given in a person with empty stomach itreaches upwards due to absence of any obstruction. Also if Basti is administered in aperson with empty bowel with great force it reaches up very high and from there it mayreach the throat and may come out from the upper orifice of the body. Treatment : In this condition, Niruha Basti and Anuvasana basti of Snehaprepared with Gomutra, Shyama, Trivritta, Yava, Kola, Kulattha should be given and thecondition where it is coming out the throat, it should be treated by Kashaya Dravyas,pressure on the throat and by Virechana and Chhardighna measures. 41 Bastikarma
    • Table No: 8 Showing Samyak, Heena and Atiyoga yoga of Anuvasana basti186 Samyak yoga Heena yoga AtiyogaExpulsion of complete oil Low backache Palpitationwith faecesTissues, senses become Dry skin Faintingclear and functioningnormalSleep becomes usual Dry stool ConvulsionsBody becomes light and ParikartikastrengthensProper flow of natural urges Obstruction of natural urges Cutting pain in gudaImportance Of Matrabasti We can summarize the importance of Matrabasti by considering its advantagesby following points It can be given to bala, vrudha, sukumara, stree, and everybody. There are no restrictions of vihara, even one can perform routine works after administration of Matrabasti. It does not give any complications as other bastis leads, eventhough matra is less it has widespread action throughout the body. Niroohabasti and anuvasanbasti can be administrated alternatively, but Matrabasti alone can be administered everyday continuously without any complications. Matrabasti has no restrictions as of Asthapana and Anuvasana. Matrabasti can be administered anytime irrespective of age, day, and time. No such ahara sevanakrama before or after the administration of Matrabasti. It can be administered to durbala purusha where other bastis are contraindicated in them. It eliminates vitiated dosas along with mala from the body it acts as shodana, shamana, brumhana, vatahara and even balya. 42 Bastikarma
    • Basti Karmukata As it is said that “Guda moolam hi shareeram”, By maintaining the left lateralprocedure, when lying at the time of basti procedure, the Bastidravya reaches thePakwashaya resides in the left side. Charaka opines by attaining this posture, Gudavaleeswill be relaxed. He also mentions that the Grahani is situated in the left side. Chakrapani states that Agni will be in the natural state in the posture whileGangadhara says; Agni, Grahani and Nabhi are present in the left side. Jejjata commentsAgni is present left side over the Nabhi, Guda has got a left sided relation withSthoolantra. So Bastidravya can reach to the large intestine and Grahani, as they arepresent in the same level. Action of basti is possible by Anupravaranabhava of bastidravya i.e. Sneha easilymoves up to grahani, which freely moves in the intestine. Charaka, says bastidravya reachnabhi, katipradesha and kukshi. The action of Basti is mainly due to the Veerya. The drug used in the basti karmawill however spread in the body from Pakwashaya due to their veerya, through theappropriate channels. The veerya is drawn into the body by apanadi vatas i.e. first byApana, then Udana and throughout the body by vyana. Also as water sprinkled at the rootof tree circulates all over the tree by its own specific property. So Bastikarma eliminatesthe morbid Doshas and Dooshyas from the entire body (by Srotosuddhi) whether lodgedin any part. 43 Bastikarma
    • Basti acts mainly on Asthi and Majjavaha srotas. Asthi is the seat of Vata dosha.Dalhana says that Pureeshadharakala and Asthidharakala are one another the same. So wecan assume that if Pureeshadharakala gets purified and nourished; the Asthivaha srotaswill also be purified and nourished. Also another factor is about the relation betweenPittadharakala and Majjadharakala, Pittadharakala and Grahani. As an opinion says aboutthe spread of Bastidravya till Grahani and Grahani is the seat of Agni, the nutrients mayget absorbed and thereby nourishes the Majjadharakala, which is having a strong bondwith vata and the nervous system.Probable Mode of Action It is practically seen that after appropriate administration of Bastikarma the signsand symptoms of Vatavyadhi will be reduced. Left lateral position is the best posture for better and effective administration ofbasti as anal canal turns to left side to rectum, sigmoid colon and descending colon wheremore mala to be dissolved and is present. Moreover, medicines stay at these surfaces, getabsorbed more and show their best effect, especially in Matrabasti. The absorptive area ofmucosa is more on this side. On left side colon area is easily approachable through anusrather than on the right side and this posture relaxes the ileo-ceacal junction and makesthe easy flow into the sigmoid colon. According to modern science, as per Basti/Enema concerned, in trans-rectal route,the rectum has a rich blood and lymph supply and drugs can cross the rectal mucosa likeother lipid membrane. Thus, unionized and lipid soluble substances are readily absorbedfrom the rectum. The portion absorbed from the upper rectal mucosa is carried by thesuperior haemorrhoidal vein in to the portal circulation, whereas that absorbed from thelower rectum enters directly into the systemic circulation via the middle and inferiorhaemorrhoidal veins. 44 Bastikarma
    • The advantage of this route is total gastric irritation is avoided and that by using asuitable solvent the duration of action can be controlled. Moreover, it is often moreconvenient to use drugs rectally in the long time in case of geriatric and terminally illpatients. Bastidravya enters into the Pakwasaya. It is the place where the water andminerals are absorbed in proximal colon. Sodium and potassium which are essentialfundamental factors for nerve impulses and Vit B12 which is essential factor for thedevelopment and proper functioning of the nervous system are also absorbed from thecolon i.e. Pakwasaya. bastikarma helps to increase the absorbing capacity of the colon byits actions. Behind the Pakwashaya, there are large numbers of nerve plexuses originatingfrom the hypo gastric plexus and lumbosacral plexus etc. These plexus will getnourishment and soothing effect from Bastikarma because Basti mainly acts on thePakwashaya, here it nourishes, purifies and expels the unwanted toxins from the Body. Another probable method is based on Veerya. It is possible the Veerya of theBastidravya pass through the autonomic nervous system and expels out vitiated Doshafrom the body. It is described in the modern physiology that the wall of the rectum haspressure receptors. Whenever the stool enters the rectum, these receptors are stimulatedand the defecation reflex is initiated. When Bastinetra is introduced in the rectum the same phenomenon may takeplace, which results in initiation of defecation reflex due to visceral distention andpressure response. 45 Bastikarma
    • As regard the absorption of bastidravya, it is reported that the water is absorbed60%-80% from the gut and normal saline is absorbed freely. Amino acids are alsoreported to be absorbed. Absorption in the proximal colon is better than the distal part.Regulating the Gut Brain : In 1981, Wood described the Enteric Nervous System (ENS) as ‘The Brain of theGut’ that integrates information received and issues an appropriate response. ENSintegrates sensory information from mucosal receptor and organizes an appropriate motorresponse from a choice of predetermined programmes. So enteric nervous system of gutbrain is an integrative system with structural and functional properties that are similar tothose in CNS and physiological and pharmacological properties of Basti chikitsa are saidto be the outcome of modification of gut brain up to certain extent. 46 Bastikarma
    • SWEDA KARMA Sweda karma is that which relieves Stambha (stiffness), Gourava (heaviness),Sheeta (coldness) and induces Sweda (sweating).187 In general, Sweda karma representsthe therapy by which a person is made to sweat. Swedana is able to alleviate Vata, Kaphaand Vatakaphaja disorders 188 but, it is contraindicated in Pitta predominant disorders. Charaka189 included Sweda karma in Shadupakramas and he has emphasizedmuch about it. Even though it is considered as Poorvakarma for Samshodhana purpose, insome of conditions it is considered as Pradhanakarma due to its importance in Swedasadhya disordersProperties of Swedana drugs 190Table No. 9 Showing the properties, action and predominance of Mahabhootas ofSwedana dravyas –Sl. Properties Main actions Mahabhuta1 Ushna Anutsaha, moorchakrit, swedakrit and dahakrit Agni2 Teekshna Daha-pakakara, shodhananga, sraavana Agni3 Snigdha Snehakrit, mardavakrit, bala-varnakrit Aap and Prithwi4 Rooksha Opposite to snigdha and stambhakara, khara Vayu and Agni5 Sara Anulomana, prerakata and pravrittisheela Vayu and Agni6 Sthira Chirakaritha, sthairyakara and stambhakara Prithwi7 Sookshma Sookshmachidrapraveshayogyata, vivarana Akasha, Vayu and sheelata Agni8 Guru Sada, upalepa, tarpanakrit and brimhanakrit Prithwi and Aap9 Drava Kledana, alodana, sandhanakaraka Aap 47 Swedakarma
    • Swedayogyas (Swedarhas) 191-193Table No. 10 Showing the persons and diseases that are fit for Swedana.Sl. Vyadhi C.S. S.S. A.H. Sl. Vyadhi C.S. S.S. A.H. 1 Pratishyaya + - + 30 Uru ruk / graha + - + 2 Kasa + - + 31 Jangha ruk / graha + - + 3 Hikka + - + 32 Kshavathu + - - 4 Swasa + - + 33 Khalli + - + 5 Alaghava + - - 34 Ayama + - + 6 Karna shoola + - - 35 Sheeta + - - 7 Manya shoola + - - 36 Vepathu + - + 8 Shira shoola + - - 37 Vatakantaka + - + 9 Swara bheda + - + 38 Sankocha + - +10 Gala graha + - - 39 Ayamashoola + - +11 Ardita + - + 40 Stambha + - +12 Ekanga roga + - + 41 Gourava + - +13 Pakshaghata + - + 42 Supti + - +14 Ardita + - + 43 Nasyarha + + +15 Vinamaka + - + 44 Bastyarha + + +16 Koshtanaha + - + 45 Shodhaneeya + + +17 Vibandha + - + 46 Aahritashalya - + -18 Mutraghata + - - 47 Anupadrava - + - moodhagarbha19 Vijrimbhaka + - + 48 Samyak prajata - + -20 Parshwagraha + - + 49 Bhagandara - + -21 Prishtagraha + - + 50 Arsha - + -22 Kateegraha + - + 51 Ashmari - + -23 Kukshigraha + - + 52 Shleshma roga - - +24 Gridhrasi + - + 53 Amaroga - - +25 Mutrakrichra + - + 54 Hanugraha - - +26 Vriddhi + - + 55 Arbuda - - +27. Angamarda + - + 56 Granthi - - +28 Pada ruk / graha + - + 57 Shukraghata - - +29 Janu ruk / graha + - + 58 Adhyamaruta - - + (Urustambha) Susruta had specified that those who are fit for Nasya, Basti and Shodhana arePoorvam Swedyas194; Ahritashalya, Moodhagarbha and Samyak prajata are PaschatSwedyas; and Bhagandara and Arsha are Poorvam cha Paschat cha Swedyas. 48 Swedakarma
    • We can conclude that, in general, there are three categories of diseases where inSwedana is indicated – a) Vatapradhana rogas, b) Kaphapradhana rogas and c)Shodhaneeya and Swedyas.Sweda ayogyas (Sweda anarhas) 195-197Table No. 11 Showing the persons and diseases those are unfit for Swedakarma.Sl. Vyadhi C.S. S.S. A.H. Sl. Vyadhi C.S. S.S. A.H.1 Kashayanitya + - - 24 Adhyaroga + - + (Vataraktha)2 Madyanitya + + - 25 Durbala + + +3 Garbhini + + + 26 Ativisushka + - -4 Rakthapitha + + - 27 Ksheenaoja + - -5 Pithakopa + - + 28 Timira + - +6 Atisara + + - 29 Pandu - + +7 Rooksha + - - 30 Kshaya - + +8 Madhumeha + + + 31 Kshama - + +9 Vidagdhabradhna + - + 32 Ajeerna - + -10 Bhrashtabhradna + - + 33 Chardi - + -11 Visha + + - 34 Moorcha - - +12 Madyavikara + - + 35 Stambhaneeya - - +13 Shrantha + - - 36 Visarpa - - +14 Nashtasamjna + - - 37 Kushta - - +15 Sthoola + - + 38 Peeta dugdha - - +16 Pittameha + - - 39 Peeta sneha - - +17 Trishna + + + 40 Peeta dadhi - - +18 Kshut + - + 41 Peeta madhu - - +19 Krodha + - + 42 Krita virechana - - +20 Shoka + - + 43 Glani - - +21 Kamala + - + 44 Bhaya - - +22 Udara + + + 45 Pushpitha - - +23 Kshatha + - + 46 Sootha - - + Various treatise mentioned the reasons for the excluding these diseases fromSwedana. Susruta opined if Swedana performed in contraindicated condition, either thebody gets destroyed, or the diseases progress to incurable stage. He also permits theapplication of Swedana in durbala and ajeernabhaktha, if their vikaras are swedasadhya 49 Swedakarma
    • only.198 Chakrapani stated that Swedana leads to pervabedha if it is performed inkashayanityas by making body rooksha and atistabdha gatra; If it is performed inconditiones viz rakthapitta, pittameha, kamala and pittaprakriti persons even prior toshodhana it leads further pittakopa. Madhumeha persons develop shareera shaithilya andin such a condition, Swedana is contra indicated. He also adds that if the condition of thepatient is Sweda eka sadhya, it can be performed.199 Arunadatta states that Swedana if done to an atisthoola person it causes shareeraksobha by doing medovilayana. For rooksha, durbala, kshataksheena, kshama etc.TheSwedana may cause extreme emaciation. A person having good appetite if undergoesSwedana suffers from dehaglani. In kamala and pandu rogas, the Swedakarma causespitta vidradhi resulting in roga vridhi. In garbhini, the Swedana induces garbha vyapat.For pushpitha ladies, it causes excessive bleeding and for sotha, it causes emaciation.200 Vagbhata given liberty to physician that if atyayika (due to the inevitability ofswedana) condition is present mrudu sweda can be performed, with caution even onanarhas.201 Arunadatta 202 and Hemadri 203 also support this view. Depending on the all above explanations we can make four conditions which arecontraindicated for swedana in general 1) Pitta, (2) rakta, (3) durbala avastha and (4)sweda asaha. 50 Swedakarma
    • Samyak swinnalakshanas 204Table No: 12 showing the lakshanas to be observed on the patient. Sl. Lakshana C.S. S.S. A.H. 1 Seetha vyuparama + - + 2 Shoola vyuparama + - + 3 Sthambhanigraha + - - 4 Gouravanigraha + - - 5 Sanjathamardava + + + 6 Swedasrava - + - 7 Vyadhihani - + - 8 Laghutva - + - 9 Seetharthiva - + - Out of these shoola vyuparama, sthambhanigraha, gourvanigraha, laghutva,mardava and vyadhihani are cannot observed immediately after swedakarma every day,but manifest after the total course of proper swedana. Sheeta vyuparama, swedasrava andseetharthitva are to be observed daily at the end of swedakarma .Aswinnalakshanas Whenver insufficient swedana is performed, then the lakshanas opposite to thesamyak swinnalakshanas occur. Dalhana adds that heaviness of the body, ushnabhilashaand hardness of the body also occur. He has stated that mithya swinna means both alpaswinna and mithya swinna (improper sudation) and that vyadhi vridhi takes place.205 51 Swedakarma
    • Atiswinnalakshanas206-208 If the swedana performed is in excess, it leads to many complications.Table No: 13 showing the Atiswinna lakshanas on the patient. Sl. Lakshana C.S S.S. A.H. 1 Pitta prakopa + + + 2 Murcha + + + 3 Shareerasadana + - - 4 Trishna + + + 5 Daha + + - 6 Swaradourbalya + - + 7 Angadourbalya + - + 8 Sandhipeeda - + + 9 Sphototpathi - + - 10 Rakthaprakopa - + - 11 Bhranthi - + - 12 Vidaha - + - 13 Klama - + - 14 Bhrama - - + 15 Jwara - - + 16 Syava-raktha mandaladarshana - - + 17 Chardi - - +Management of Atiswinna 209 Charaka advises for the consumtion of madhura-snigdha-seetha ahara andupachara and the adoptation of greeshma ritu charya. This includes consumption ofsasharkara mantha, jangala mriga-pakshimamsa, ghee, milk and shashtikashali. Aharadravyas with lavana, amla, katu and ushna properties and even madya, viharas likevyayama and Vyavaya should be avoided. Patient has to live in seethagriha during the 52 Swedakarma
    • day time and in the room cooled by moon rays in the night. Seethadravyas lepana similarto chandana to be applied over the body. Mukthamani dharana also can be done. Patientcan also be taken to cool forests and ponds.210 Susruta 211 says that all kinds of seethaupachara should be performed immediately. Vagbhata had advocated stambhana chikitsa in case of atiswinna.212 Drugs withthe properties of laghu, manda, seetha, slakshna, rooksha, sookshma, sara and drava andhaving tiktha-kashaya-madhura rasas, are stambhana oushadhas. These are to beadministered internally and externally to avoid further complications of the patients.Classification of Sweda Several types of classification of Sweda are made with different points of view.A) According to agni bheda.213 1) Sagni (Thermal) & 2). Niragni (Non-thermal).B) According to guna bheda.214 1) Rooksha (Dry) & 2). Snigdha (Unctuous).C) According to sthana bheda.215 1) Ekanga (Local) & 2). Sarvanga (Total).D) According to rogi bala and roga bala.216 Mrudu (Gentle), Madhyama (Medium) & Mahan (Maximum).E) According to the source of heat.217-218 Tapa (Direct heat), Ushma (Steam), Upanaha (Poultice) & Drava (Warm liquid). 53 Swedakarma
    • F) According to the method of sudation.219 1. Sankara (Mixed), 2. Prastara (hot bed), 3.Nadi (Steam kettle), 4. Parisheka(Affusion), 5. Avagaha (Bath), 6. Jentaka (Sudatorium), 7. Asmaghna (Stone bed), 8.Karshu (Trench), 9. Kuti (Cabin), 10. Bhu (Ground bed), 11. Kumbhi (Pitcher bed), 12.Kupa (Pit sudation) and 13. Holaka (Under bed).G) According to the usefulness in the Chikitsa220 1) Samshamaneeya 2) Samshodhanangabhoota.H) According to the route of application221; 1) Bahya 2) Abhyantara.I) On the basis of applicability in children.222 Hasta, Pradeha, Nadi, Prastara, Sankara, Upanaha, Avagaha and Parisheka. Niragni Sweda is further classified into ten types, viz., vyayama (exercise), ushnasadana (warm rooms), guru pravarana (heavy blankets), kshudha (hunger), bahupana(excessive drinking), bhaya (fear), krodha (anger), upanaha (plasters), ahava (war) andatapa (sun bath).223 Dalhana had said that Jentaka, Karshu, Kuti, Kupa and Holaka are Tapa swedas;Sankara, Prastara, Ashmaghna, Nadi, Kumbhi and Bhu are Ushma swedas.224 54 Swedakarma
    • PARISHEKA Parisheka225a-e is a type of Swedana karma explained by almost all the majortreatise of Ayurveda in different headings like Sheka, Parisheka, Dhara, etc. In generalthe meaning of these gives pouring of regular stream of lukewarm fluid like oil,decoction, and milk et on the body. Acharya Charaka included Pariseka in the Bahiparimarjana chikitsa226 along withAbhyanga, Swedana, Pradeha, Unmardana etc. Acharya Susruta227 explained it underDravasweda, as he stated that Taila, Grita, Vasa and Dhanyamla etc are to be used forParisheka which can be done locally or generally according to the need.228 Acharya Vagbhata also explained it under Dravasweda by giving detaileddiscripton about its procedure, he emphasized that drugs such as Shigru, Varuna,Amrataka, Mulaka, Sarsapa, Surasa, Arjaka, Vasa, Vamsa, Ashmantaka, Ashoka,Shirisha, Arka, Karanja, Eranda, malati patra, Bhanga, Putika, Dashamoola and suchothers which mitigate Vata are boiled in liquids such as mastu, Jala, sura, Dugdha,shukta (sour butter milk ) etc are used either alone or mixed with other drugs asdescribed earlier appropriate to the doshas. The liquid is filled into pot or vesselshaving spout with sieve in front or into long tubes and poured over the part of thebody, which has been anointed with oil, which pacifies Vata or even without suchanointment, but wrapped with cloth, the patient either sitting or lying on couch, pouringbeing done on any part or whole of the body.229 By the detailed explanation of Vagbhatain Ashtanga sangraha, it shows Parisheka can be done in a particular part also. 55 Swedakarma
    • In Ashtanga Hridaya230 also ample description available with slight variation indrugs like Eranda, Karanja, Surasa, Arjaka, Shirisha, Vasa, Vamsa, Arka, Deergavrinta,etc but he also emphasized same procedure. Bhela given explanation as pouring oflukewarm fluids like Taila, Ghrita, Dugda, Mutra, Amla, Kanji and even Vasa on thebody of the person who is fit for Swedana karma.231 Charaka while explaning the treatment of Vatavyadhi he recommended Tail,Grita, Vasa and Majja Parisheka along with Abhyanga and Basti etc, especiallySnigdhaswedha and the measures which causes Brimhana are recomonded.232 Susrutawho is father of surgery, he recommended Snehasheka in case of Sandhivishleshaparticularly in case of Janu, Gulf, and Manibandha sandhi.233 In the context of Dwivraniya cikitsa234 he emphasized importance of Parishekaspecically when there is presence of Vataj sopha he prescribed Taila, Kanji, GritaParisheka to relieve the Shopha condition. Even in the context of Vatavyadhi chikitsa heprescribed Sukhoshna sneha Pariseheka.235 Susruta stated the properties of this procedure under the heading of Sheka as, itrelieves fatigues (Shramagna), pacifies Vata, stabilizes the dislocated joints, and relievespain arised out of injury, burn etc. It does the Dhatuvriddhi by the help of sneha as thetree nourishes by the water.236 Where as Dalhana mentioned Sheka asSarvangaparisheka.237 Bhavaprakasha 238 recorded ample discription of Sheka in Netrachikitsa. Dharakalpa given indication of Ekangasheka in conditions like Gulma, Anaha,Vrana, Shoola, Avritavata etc. 56 Swedakarma
    • Cikitsasangraha gives in detail explanation about Parisheka under the heading ofDhara. Dhara is a method of the Kerala special treatment evolved from the genius of themedical tradition here many such distinctive forms of treatment, not practiced in otherparts of India are conducted by the Kerala physicians. Dhara one amongst them and themost important. Dhara is good for all diseases changing the liquid as per the Dosha condition withnecessary alternates in its processes. It is useful to alleviate any Dosha. For instance oilsmedicated with appropriate medicine in Vata, Ghee prepared with Pitta alliavatingmedicines in Pitta and more oils in Kapha can be used. According to another version thesuitable liquid for Vata is unctuous liquids (oil, ghee etc), for Pitta milk and for Kaphabuttermilk. Sometimes in Pitta diseases as per the conditions Dhara with tender coconutwater or breast milk or cold water is performed. Similarly Kapha dosha dhara with somedecoctions and in Vata with dhanyamla is also conducted. This can be carried on withother liquids also as per description looking into the details of the doshas, diseases andtheir seats. There are varieties of dhara they are mainly grouped as Moordhany, Sarvangeena(all over the body) and Pradeshika (local), out of this pradeshika is done locally in casesof rheumatoid arthritis, swelling, ascitis, abscesses, wounds etc.EKANGADHARA (Dhara on one limb or at a locality) : Ekangadhara does not have many paraphernalia and procedures. But as per thedifference in parts some alterations may become necessary often these are done withvarious liquids commonly employed in dhara on the head or Sarvanga dhara (sometimes 57 Swedakarma
    • the liquids not so commonly employed also) the important once are various decoctionsand juices of certain raw herbs. In some cases cold or warm water is also made use of thequantity of the liquid and other things are settled as per the locality. For instance fordhara in the eyes the total quantity needed for both eyes is of measure (225 ml). It shouldnot be hot to touch. In the strangury etc to do dhara on umbilicus we can either suspendthe dhara vessel or do it by pouring it trough by nozzle of pitcher. Here the quantity ofthe liquid is 1 prasta. For wounds on the limbs or for burns and scalds the quantity is tobe half prasta. But this would have to be altered as per the size of these wounds or burns.Here application of oil on the head is not necessary these can be done as per conveniencein a sitting or lying position. Strict time limit is also not applicable here. If done withproper attention and due care in all aspects, there is no disease that cannot be cured byDhara.239PROCEDURE OF PARISHEKA1. Poorvakarma This includes preparatory measures like preparation of patient, preparation ofmedicine and collection of materials required for the smooth conduction of the procedure. a. Atura Pariksha : The patient is examined in relation to Prakriti, Vikriti etc. byten folds of examination and by applying Pratyaksha, Anumana and Aptopadesha toassess Vyadhi and Deha Bala. Then, the affected knee joint should be examined properlyand mark the tender region. Examine for scares, wounds if any at the joint. b. Atura Siddhata : Patient is asked to lie in supine position or to sit erect byextending lower limbs on the table. Exposed the affected knee properly. Support thelimbs, so that they are placed horizontally and comfortably. 58 Swedakarma
    • 2. Pradhana karma The recommended liquid is filled into pot or vessels having spout with sieveinfront or into long tubes and poured over the part of the body, which has been anointedwith oil, which pacifies Vata or even without such anointment, but wrapped with cloth,the patient either sitting or lying on couch, pouring being done on any part or whole ofthe body at the height of 12 Angula. Ayoga, Atiyoga and Samyakyoga lakshana of Swedamentioned in the classics can be taken for Samyak lakshana of Parisheka. Maintenance of constant temperature of medicine: Keep on changing themedicine with the heated one so that a constant temperature is maintained through out theprocedure. Period For Changing The Liquid: When milk is used for Pariseka, it should bechanged everyday. When Dhanyamla is used. It can be used upto 3 days. Oil also shouldbe changed at 3 days. In the first 3 days, half of the oil used, for next 3 days later half ofits used and on the 7th day all the first and second half both are mixed together, then itshould be discarded (Dharakalpa – Ch. 21 &22)3. Paschat karma After removing the liquid, The oil remained on the joint was wiped out with thehelp ofcleaned cloth, mild massage was done for a minute and patient was asked torelaxe. 59 Swedakarma
    • Swedakarma Karmukata Swedakarma has four major actions over the body - (1) stambhaghnata, (2)gouravaghnata, (3) seethaghnata and (4) swedakarakata. 01. Stambhaghnata : Stambha means stiffness. This attribute is a resultant ofexcess seetha guna and also influence of factors such as samanavata, sleshakakapha, ama,mamsa, vasa and medas is contributory to the production of stambha. samanavata isrooksha gunapradhana and hence if vitiated does excessive shoshana of shareera there byproducing contractures and stiffness. Sleshakakapha is snigdha and pichila and hence ifdecreased (kshaya) results in less lubrication of joints causing stiffness. Swedakarma being snigdha and ushna corrects both these deranged doshaghatakas and relieves stiffness. Chakrapani had stated that stambha also meansobstruction or block. Therefore, Swedana not only relieves stiffness, but also clearsblocking of passages (srotorodha). Srotas as a structural entity is Kaphapradhana. Ayanaor transport is the most important function of srotas. This is under the control of Vata.There by it is evident that there is a predominant influence of Vata and Kapha over thesrotas. Vitiation of these two hampers the structural and functional aspects of the srotas. We know that swedana has the opposite qualities to that of Vata and Kapha,thereby producing a palliative effect on them and the srotas is becoming normal. It is wellknown that unless there is a srotodushti there is no disease. Thus, it is evident thatSwedana clears the srotodushti or sanga 60 Swedakarma
    • In other words, by contact of bearable warmth, the area in contact gets morecirculation. The lumina of the contracted body architecture get smoother and wider. Thisrendering a stiff entity smooth relieves variety of obstructions. Widening of the core andsimultaneous liquefaction of the solid or semi-solid material makes the flow easier.Widening of the tract and fluid character of the material inside makes the obstructionsreleased slowly. 02. Gouravaghnata : Heaviness of the body is being relieved by Swedana. Bymeans of Swedana, the fluids in the body are being excreted through the sweda (sweat)and hence the feeling of lightness in the body. Swedana stimulates the nerve endings andpromotes muscle strength. 03. Sheethaghnata : Seethaghnata has to be understood as the patient is relieved ofthe coldness existing prior (the Ushna guna pradhana sweda karma is performed). In fact,by the excretion of sweat, the heat in the body is being transferred out. 04. Swedakarakata : Swedana induces sweda it is a mala (excretory product)which includes the wastes of all the layers of skin, muscles, nerves, rasa, rakta, meda etcare mixed. Therefore, it is a mechanism of excreting the metabolic wastes in the bodytissues. Apart from these major actions, Swedana also produces the following effects. Doshadraveekarana : Swedana (snigdha) makes the doshas mridu and eradicatesthe mala sanga, penetrates to each and every channel in the body and liquefies the doshas.These liquefied doshas has to be eliminated from the body means of shodhana karma. 61 Swedakarma
    • Vata shamana : Snigdhasweda pacifies the Vata dosha, thereby curing thepureesha-mutra-shukra sanga. By its properties opposite to that of Vata, it pacifies theVata. Swedana is also one of the upakramas of Vata. Gatra vinamana : Charaka says that by application of oil and heat, even dry woodcan be bent then what is the wonder about shareera. It cures harsha, ruk, ayama, shopha,stambha and graha and produces mardava, thereby permitting normal flexible bodymovements. Agnideepana : As Swedana is Ushna guna pradhana, it does the Ama pachanathere by promoting the Agni in the body. Twak mardava and Prasadana : Perspiration is dependent on skin, where in thehair follicles which are the Moolas of Swedavaha srotas are situated. Due to sweatingand excretion of wastes, the skin becomes soft and pleasant. Bhakthasradha : As the Swedana promotes agni, more interest on foodconsumption is resulting. Srotosuddhi : The mechanism of making srotosuddhi has been explained underthe action of stambhaghnata. Nidra-Tandra nasha : Swedana pacifies Vata. Vata is responsible for the functionsof Indriyas where in Nidra and Tandra are affecting. Sweda also pacifies Kapha therebymaking the body light, and providing relaxation. Thus it prevents excessive sleep anddrowsiness. 62 Swedakarma
    • Sandhicheshtakara : Swedana relieves Stambha and Graha thereby promoting theSandhicheshta. Dosha shodhana : The Doshas situated in the Dhathus, Koshta and Sakha-asthiand those Leena in the Srotas gets Kledana by Snehana and gets liquefied by theSwedana and comes to the Koshta and get ready for elimination by means ofShodhanakarma. Acharya Susruta stated that out of the four Tiryak dhamanis, each dividesgradually hundred and thousand times and thus become innumerable. These cover thebody like network and their openings are attached to Romakoopa. Through them onlyVeeryas of Abhyanga, Parisheka, Avagaha, Alepa enter into the body after under goingPaka with Bhrajaka Pitta in skin. One more reference in Susruta cikitsasthana explains –Sneha used in Avagaha produces Shareera bala by saturating through siramukha,Romakoopa and dhamani. In Sutrasthana he explains, lepa like Bahirparimarjanatreatments yield result by entering to Romakoopa thereby circulating through SwedavahaSrotas.Modern View on Mechanism of Action Cell membrane act as a barrier to the passage of water soluble molecules butprovide free passage to lipid and lipid soluble substances. Rapid diffusion of lipid solublesubstances through cell membranes and the dependency of the rate of diffusion onsolubility in lipids have been proved. Application of heat through an unctuous substancecauses the generation of a temperature gradient across the cell membrane. Besidesfacilitating the diffusion of liquid substances through the cell membrane, this plays key 63 Swedakarma
    • role in the formation of lipoid vesicles from the dropouts in the membrane in areas offlow temperature. This causes an expansion in the cell volume as well as surface area.But it cannot expand freely especially in the peripheral direction as it is bound by othercells around. This makes the blebbing of cell membrane inside. The temperature gradientand pressure gradient caused by the heat further helps in blebbing in this particulardirection. These lipoid vesicles or blebs detached from the cell organelle or other side ofmembrane and remain there till a critical surface is reached. This membrane then blebsout and spread further. The whole phenomenon of dropping of cell membrane vesiclesand their incorporation into other membranous structure was described as “Membraneflow hypothesis” by Palade in 1959. Absorption depends upon lipid solubility of the drug. Drugs in oils and other lipidsoluble carriers can penetrate the epidermis as it is a lipid barrier. The movement is slow,particularly through the layers of cell membranes in the stratum corneum. But once thedrug reaches the underlying tissues it will be absorbed into the circulation. Suspendingthe drug in an oily vehicle can enhance absorption through the skin. Because hydratedskin is more permeable than dry skin (Placing a drug in a solvent that is lipid soluble canassist its movement through the lipid barriers). Now, it can be said that it is in this way that the Sneha reaches deep into the bodytissues, causing partial rejuvenation of cell organelles and cell membrane by replacingtheir order components with new ones. Thus the additive efficacy of Snigdha sweda canbe justified. 64 Swedakarma
    • SANDHIGATAVATA Sandhigatavata is one among the Vatavyadhees described by all acharyas.240 It 241comes under the various Gatavatas explained in Vatavyadhiprakarana caused by thelocalization of vitiated doshas in the Asthi sandhis of the body.Terminology of Osteoarthritis242 Four names, none of which are adequate are used interchangeably to describe thedisease. They are Osteoarthritis, Osteoarthrosis, Degenerative joint disease andHypertrophic arthritis. Osteoarthritis is less than ideal since the primary event is notinflammatory, although secondary synovitis is usually present. Osteoarthrosis is perhapsthe best because the inflammation is secondary and the suffix denotes an increase and aninvasion, physiologic or pathologic, or a general over production. This early on, is arelatively clear description of what the disorder is. Degenerative joint disease isunsuitable, since degenerative implies aging, a running down, deterioration, a catabolicprocess; in fact for long periods, often years, the disease may not be clinicallyprogressive. Hypertrophic arthritis now completely out of style, describes one phase theosteophytosis or overgrowth of bone. (Rheumatology Kelly Willium, ch-89) 65 Disease Review
    • NIDANA Even though classics of Ayurveda do not mention the Nidanas of Sandhigatavata,one has to compile the relevant references mentioned in different contexts likeVatavyadhi Nidana (Ch.Ci.28/15-17, Su.Su.21/19, A.Hr.Ni.1/14-15, Yo.Ra.Pu.Vat.1-4,Bh.Pr.Chi.Vat.1-2, Ma.Ni.Pu.22/1-3), Asthivaha srotodushtikarana (Ch.Vi.5/27),Majjavaha srotodushtikarana (Ch.Vi.5/28). Nidana can be classified under various headings with different views. Amongthem one classification is Sannikrishta and Viprakrishta Karana. Here, with thecomplimentary references the Nidanas of Sandhigatavata is classified on this basis.Sannikrishta Hetu : Ativyayama, Abhighata, Marmaghata, Bharaharana, Sheeghrayana,Pradhavana, Atisankshobha.Viprakrishta Hetu : A. Rasa – Kashaya, Katu, Tikta B. Guna – Rooksha, Sheeta, Laghu C. Dravya – Mudga, Koradusha, Nivara, Shyamaka, Uddalaka, Masura, Kalaya, Adaki, Harenu, Shushkashaka, Vallura, Varaka. D. Aharakrama – Alpahara, Vishamashana, Adhyashana, Pramitashana E. Manasika – Chinta, Shoka, Krodha, Bhaya F. Viharaja – Atijagarana, Vishamopacara, Ativyavaya, Shrama, Divasvapna,Vegasandharana, Atyucchabhashana, Dhatu Kshaya. The nidanas of Vatavyadhi are listed under the following headings –1. Aharaja, 2.Viharaja, 3.Manasika, 4.Abhighataja and 5.Anyat. 66 Disease Review
    • Table No: 14 Showing the Aharaja nidana 243-246Sl. Nidana C.S. S.S. A.H. B.P.1 Rooksha bhojana + + + +2 Laghu bhojana + + - +3 Seethanna + + - +4 Alpa bhojana + + + -5 Ama + - - +6 Abhojana + + - +7 Pramita bhojana - - + -8 Vishama bhojana - + - -9 Tikta-katu-kashaya rasa - + + +10 Adhyashana - + - -11 Sushkasaka - + - -12 Vallura-varaka-uddalaka-koradusha-syamaka-adhakee- - + - - harenu-kalaya-nishpavaTable No: 15 Showing the Viharaja nidana. Sl. Nidana C.S. S.S. A.H. B.P. 1 Ativyavaya + + + + 2 Atiprajagara + + + + 3 Vishama upachara + - + - 4 Plavana + + - - 5 Atyadhva + + - - 6 Ativyayama + + + + 7 Dukshashayya + - - - 8 Dukhaasana + - - - 9 Divaswapna + - - - 10 Vegadharana + + + + 11 Gaja-ashwa-ushtra-sheeghrayana + + - - 12 Vega udeerana - - + - 13 Atyuchhabhashana - - + - 14 Prapatana + + - - 15 Pradhavana - + - - 16 Prapeedana - + - - 17 Bharaharana - + - - 67 Disease Review
    • Manasika Nidanas Psychological factors like Chinta, Shoka, Krodha, Bhaya etc are the aggravatingfactors of Vata. As Vata is the controller of Manas, any affliction to Manas vitiates theVatadosha. Some of the important Nidanas are discussed below – Ativyayama : Excessive physical exercises act as one of the important Nidana forSandhigatavata. Running, walking, jogging etc. if done excessively or violently willaffect the structures of Sandhi. They mainly affect the Joint stability by over exertion. Butif done properly they stabilize the Joint. Bharaharana : As knee is weight bearing joint, carrying excessive load causesexcessive pressure and stretching effect over the structures of the joint which have directeffect on articular disc. The constant compression will lead to wear and tear effectleading to degenerative changes in the discs. Abhighata : Abhighata to joints due to Prapatana etc, lead to structural deformityin the joints. Joint is an organ rather than a single structure. It is stabilized by differentstructures like Asthi, Snayu, Peshi, and Kala etc. Hence any trauma to these structureswill alter the structural integrity of the joint. Hence Abhighata is an important Nidana forSandhigatavata. Atisankshobha : It is a Nidana for Asthivaha Sroto Dushti.247 Since AsthivahaSrotas is involved in Sandhigatavata this can be considered as Nidana for the same.Violent activities like Atyadhva, Plavana, Langhana, Balavat Vigraha, Pradhavana etc.will have its effect on joint. As told earlier knee is the weight-bearing joint, the violentexercises or activities will alter the structural integrity of the joint. 68 Disease Review
    • Marmabhighata : The concept of Marmabhighata in the causation ofSandhigatavata sounds more rational. Janu-Sandhi is a variety of Vaikalyakara Sandhi-Marma.248 Marma is a vital point, which comprises of Asthi, Snayu, Sira, Mamsa andSandhi. Hence any Marma is made up of all these structures, like wise the Janu-Sandhi. Pain in the joints not necessarily be only associated with bony changes. Butinvolvement of other joint structures may also give rise to symptoms pertaining to joint.Therefore, in recent days more study is emphasized on the different structures involved inthe pathology of Arthritis like consistency of soft tissue, fibrous material, liquid andcartilaginous substance of the joint. From this new point the Ayurvedic view towards theinvolvement of certain Marma in the disturbance of the joint i.e. painful joint will beanticipated. Hence Marmabhighata as a Nidana in case of Sandhigatavata is to be givenimportance. Anyataha (Other Nidanas) : Panchakarma apacharas like Atidoshasravana,Atirakthasravana, Atiyoga of langhana, Apatamsana, etc and Dhatukshayakarabhavaslike Rogakarshana, Gadakrita atimamsakshaya, etc vitiate Vata. Dhatukshaya is animportant vitiating factor of Vata. Sthoulya is another causative factor for Vata prakopa. The Meda-avarana of Vatais the mechanism causing inter-relationship between Sthoulya and Vatavyadhis.249 Alltypes of avaranas are also important vitiating factors of Vata. Vardhakya avasthadominate by Vata.250 During this period, Dhatukshaya occurs which causes Vata prakopa. 69 Disease Review
    • Living in Jangaladesha is another cause of Vata prakopa.251 Vata gets vitiated inthe end of day and night.252 Vata also get vitiated during the end of Greeshma ritu,Varsha ritu and Shishira kala.253 Vata prakriti persons are more susceptible to Vatavikaras. Persons who are Rooksha-kashaya-katu-tikta satmya are also more susceptible toVata vikaras.Risk factors for Osteoarthritis (OA) 254 Age factor : Age is the most powerful risk factor for OA. The associationbetween OA and aging is non-linear. It usually begins after a person is 40 or more yearsold. By the age of 60 years, almost everyone has OA. More than 80% of people over 60years old have radiological evidence of OA in one or both knees and 30% in one or bothhips. Sex factor : It is told that women are at high risk than men in developing OA.Over 30% of women (elderly) have OA in the interphalangeal joints of the hands. Exceptin the hands, men and women are affected equally, though the lesions often appear at ayoung age in men. Only 3% of elderly men have primary OA in the hands. Hereditary factor : The relation of heredity is less ambiguous. Thus, the motherand sister of a woman with distal interphalangeal joint OA are respectively twice andthrice as likely to exhibit OA as the mother and sister of an unaffected woman. 70 Disease Review
    • Race factor : Racial difference exists in both the prevalence of OA and the patternof joint involvement. OA is more frequent in Native Americans than in whites. TheChinese in Hong Kong have a lower incidence of hip OA than in whites. Interphalangealjoint OA and especially hip OA are much less common in South African blacks than inwhites in the same population. Whether these differences are genetic or due to differencesin joint usage related to life style or occupation is unknown. Obesity factor : Obese persons have a high risk of OA. For those in the highestquintile for body mass index at base line examination, the relative risk for developingknee OA in the ensuing 36 years was 1.5 for men and 2.1 for women. For severe kneeOA, the relative risk rose to 1.9 for men and 3.9 for women, suggesting that obesity playsan even larger role in the etiology of the most serious cases of knee OA. Occupational factor : Repetitive movements may leads to excessive strain leadingto erosion and joint damage. Men whose jobs require knee bending and at least mediumphysical demand had a higher rate of radiographic evidence of knee OA and more severeradiographic changes. Traumatic factors : Trauma to the joint seems to enhance the occurrence ofarthritis. It disturbs the alignment of the joints and over a period of time, this mal-alignment may lead to excessive wear and tear leading to OA. According to the cause of OA, it is classified as primary and secondary. PrimaryOA is the term used when the disorder arises form unknown or hereditary causes.Secondary OA describes cases in which direct causes for the disorder are known. 71 Disease Review
    • Classification based on causes 255I. Primary A) Idiopathic, B) Primary generalized osteoarthritis and C) Erosive osteoarthritis.II. SecondaryA. Congenital or developmental defects (Hip dysplasias, shallow acetabulum, Morquio’ssyndrome, etc),B. Traumatic a. Acute b. Chronic and c. Charcot’s arthropathy,C. Inflammatory (RA, psoriatic arthritis, septic arthritis, pseudogout)D. Endocrinal influence (Acromegaly, diabetes mellitus, sex hormone abnormalities,hypothyroidism with myxedema) and Metabolic (Gout, Itemochromatosis, Ochronosis,Chondrocalcinosis, Paget’s disease).POORVAROOPA Particular mentioning of Poorvaroopa of Sandhigatavata is not available inclassics. In Vatavyadhi also unmanifested symptoms (Avyakta) or mild exhibition ofactual features of the disease itself (Alpa vyakta) is considered as its Poorvaroopa.256Hence clinical features of Sandhigatavata in milder form can be considered asPoorvaroopa. Observations based on the present clinical trail reveal that sandhi-gurutva(heaviness of joints) and occasional pain in the joints, which were ignored by the patients,were the Poorvaroopas. 72 Disease Review
    • SAMANYA SAMPRAPTI The treatment of the disease may be taken as the reversion of the Samprapti. So, itis very important to know the Samprapti or pathology before starting the treatment. Fromthe onset of Dosha-Dushya Dusti, till the evolution of the Vyadhi there occur variousstages. Samprapti explains such series of pathological stages involved. The Samanya Samprapti of Vatavyadhi that is explained in classics can beconsidered as the Samprapti of Sandhigatavata. Charaka and Vagbhata had stated that the kupitavata circulate through the emptychannels in the body (riktasrotas) and fills them.257 This settling in the channels producesVata specific symptoms in the Avayavas related to those channels. Another possibility isthat the Kupitavata entering the Srotas can get Avarana by other doshas etc and manifestthe symptoms.258-259 Both these mechanisms are possible in case of Sandhigatavata. Thegeneral pattern of Samprapti is as follows: – Intake of rooksha-sheeta ahara and vihara like ativyayama, abhighata etcReduction of sneha bhava in the body Dhatukshaya where by Sushirata in thechannels results Vata purana of these channels Manifestation of symptoms. That is, the above said Ahara vihara induces reduction of Snehabhava andsimultaneously produces Vatakopa due to the dhatu kshaya. Reduction of Shleshakakapha occurs and this allows the settling of vitiated vata (vyana vata) in the joints therebygradually resulting in the manifestation of Sandhigatavata. 73 Disease Review
    • Concept of Gatavata As the disease belongs to Gatavata group of Vatavyadhees, it will be relevant todiscuss the concept of Gatavata here. While mentioning Gatavata, acharyas havementioned the gatatva of dhatu, upadhatu, ashaya, avayava etc.260 The variousterminologies used to denote this Gatavata are gate, sthithe, avasthite, ashrite, prapte, etc.These all terminologies can imply two important factors – A) related to the gati of thevitiated Vata and B) related to the occupation of a particular site. When these two factors combine then such a condition is termed by addingobjective of that site, for e.g. Sandhigatavata. Though Vata is present all over the body,its Gata condition specially indicates its abnormal localization at the particular Dhatu orAshaya. In this condition, the etiological factors are only of Vata and not of dual, i.e., notof both Dosha and Dooshya. For example, in Vatarakta, the Atisevana of ahara viharavitiating Vata and Rakta at a time leads to the Prakopa of both simultaneously, resultingin Vatarakta. While in Sandhigatavata, the kopa of Vata alone occurs and this vitiatedVata by involving the Sandhis produces Sandhigatavata. Peculiarities of these Gatavatasare that here the Vata vitiation is active, Vata dosha is more important, vitiation of Vata isdue to it’s own Nidanas and there is a state of Dhatukshaya and Rikta srotas.261 Also the Samprapti of Sandhigatavata can be discussed under two headings forbetter understanding – 1. Dhatukshayajanya and 2. Margavaranajanya. Dhatukshayajanya : Here the process of Samprapti initiation is due to the stronginvolvement of nidana factors such as Vardhakya avastha, Abhighata, Ativyayama,Marmaghata etc. These factors lead to the Vata vridhi followed by Kapha kshaya. Thisresults in agni mandya. Then the state of dhatukshaya is the resultant and hence there isKshaya of asthi dhatu too. Kapha kshaya reflects in the decrease of Shleshaka kapha also.This permits the settling of vitiated Vata in the Sandhis and then the manifestation of thesymptoms. 74 Disease Review
    • Margavaranajanya : Here the samprapti process is initiated by the nidana ghataka,sthoulya. In Sthulas usually Sandhigatavata affects the weight bearing joints. In thesepersons Meda dhatu will be produced in excess quantity due to the Atisnehamsha ofAmarasa.262 The excessive Medas will produce obstruction for the flow of nutritivematerials to the future Dhatus i.e. Asthi, Majja and Shukra leads to their improperformation. The excessive fat deposited all over the body will produce Margavarana ofVata.263 Prakupita Vata due to Margavarana starts to circulate in the body. Whiletraveling it settles in the joint. Where Khavaigunya already exists, after Sthanasamshrayait produces the disease Sandhigatavata. Three main factors involving in the production of Sandhigatavata, in any form ofSamprapti are – Kopa of vyana vata, which normally controls all the movements of the body. Kshaya of shleshaka kapha, which normally aligns the joints and maintains its Compactness. Deterioration of sleshmadhara kala, which lubricates the joints.Samprapti ghatakas01. Dosha – Vata – Vyana vata vridhi and Kapha – Shleshaka kapha02. Dushya – Asthi, Majja, Peshi, Snayu, Sleshmadhara kala03. Srotas – Asthivaha, Medovaha, Majjavaha, Mamsavaha04. Agni – Jatharagni, Asthidhatwagni, Medodhatwagni05. Ama – Jatharagni mandyajanya, Asthidhatwagni mandyajanya, Medodhatwagni mandyajanya06. Udbhava – Pakwashaya07. Rogamarga – Madhyama08. Adhisthana – Sandhi 75 Disease Review
    • Pathogenesis of Osteoarthritis 264 The association between OA and aging is non-linear; the prevalence increasesexponentially beyond the age of fifty. About 80% to 90 % of the individuals, of bothsexes, have evidence of OA by the time they reach the age of 65. The age related changesin cartilage include alteration in proteoglycans and shorten fatigue life. Despite thisrelationship, it is an over simplification to consider OA as merely a disease cartilage wearand tear. Chondrocytes play a primary role in the process and constitute the cellular basisof the disease. For example, the chondrocytes in the osteoarthritic cartilage produce IL-1and TNE-alpha, which are known to stimulate the production of catabolicmetalloproteinases and inhibit the synthesis of both type 2 collagen and proteoglycans.The effects of these cytokines are potentiated because their receptors show an increasedsensitivity. Other mediators, such as prostaglandin derivatives and IL-6, also have a rolein this cascade of matrix degradation. Most of these cytokines also have pro-inflammatory properties, and inflammatory cells are present in many osteoarthritic joints.The precise events that lead to the secretion of cytokines however are not clear.Degeneration and OA OA is caused by the degeneration of the articular cartilage in the joints involved.In the regions involved, the cartilaginous matrix and the chondrocytes swell. Theproteoglycans in these regions are smaller then the normal. The proportion of chondrotinsulfate falls and the proportion of keratin sulfate rises. The change in the character of theproteoglycans exposes the collagen fibers in the cartilage. Poorly formed type I collagen 76 Disease Review
    • tends to replace the type II collagen normal in the cartilage. In the degenerating regions,small fissures develop in the cartilage. The fissures separate irregular brands of cartilagethat project perpendicular to the articular surface, a change called fibrillation. Clumps ofchondrocytes are often present near the clefts. As years pass, much or all of the articularcartilage is slowly worn away. Eventually, only irregular patches of articular cartilageremain on the articular surfaces of the bones. Degeneration of the synchondral joints of the spine causes loss of water fromthe nucleus pulposus. It becomes smaller and less resilient and often is fissured orcalcified. Chondrotin sulfate is lost from the nucleus. Keratin sulfate and collagenaccumulate in it. The thin cartilaginous plates that separate the intervertebral disc fromthe vertebrae degenerate, becoming fissured or fibrillated like the articular cartilages inthe osteoarthritic diarthrodial joints. Often the nucleus pulposus herniate through thecartilaginous plate into one or both of the adjacent vertebrae. The herniated part of thenucleus pulposus is usually 1-2cm across and is called a Schmorl’s node. The annulusfibrosis of the disc is weakened, allowing the disc to bulge anteriorly and laterally. Weightman has shown that the ability of the articular cartilage to withstandfatigue testing diminishes progressively with age. Because OA is most common in agingpatients, it is often proposed that the disease is an intrinsic part of the aging process. Thewear and tear theory assumes a decreasing capacity with the age of articular cartilage toresist mechanical stress. (Cotran Sr, Pathologic basis of disease –28 chapter) . 77 Disease Review
    • ROOPA Sandhigatavata manifests in the body with the following lakshanas.01. Vatapoornadrithisparshaha shothaha: - Swelling over the joint resembling an air–filled bag on touch. Arunadatta says that the shopha is similar to an air –filled bag.26502. Prasarana akunchanayoho savedana pravritti: - Painful flexion and extension isanother feature of Sandhigatavata.26603. Hanti sandheen: - This, according to Dalhana, is the absence of joint movements(flexion and extension) implying the joint damage. According to Gayadasa, it is thedifficulty in joint movements. According to the Madhukosha commentary on Madhavanidana, it means that the Vata vitiated in the joints either hampers the functioning ofjoints or produce stiffness etc.26704. Shoola: - Pain in the joints.26805. Atopa: - Crepitus (Characteristic sound produced from the joints).269Table No: 16 Showing the lakshanas of Sandhigatavata. Sl Lakshana C.S. S.S. A.H. Others 1 Shoola - + - Madhavanidana Bhavaprakasha Gadanigraha 2 Shotha + + + Bhavaprakasha Gadanigraha 5 Hanti sandheen - + - Madhavanidana Bhavaprakasha Gadanigraha 6 Atopa - - - Madhavanidana 7 Sandivishlesha - - - Madhukosha 8 Sandhi stambha - - - Madhukosha 9 Prasarana akunchanayoho abhava - - - Dalhana 10 Prasarana akunchanayoho - - - Gayadasa asamarthya 78 Disease Review
    • Acharyas have not mentioned that Sandhigatavata affects only any particularsandhi of the body. Modern medicine also supports this view.Clinical features of Osteoarthritis 270SYMPTOMS No systemic manifestations Pain on use; pain at rest in severe and advanced diseases Localized stiffness 15-30 minutes in morning and after immobilization in day time Muscle spasm Limitation of motion in advancing disease Symptoms uncommon before age 40, except in secondary OA Pain related to specific jointsJoints most commonly involved – Distal interphalangeal joints Proximal interphalangeal joints First carpometatarsal joint Scaphotrapezoid joints Knees Hips, often unilateral Spine, cervical and lumbar First metatarsophalangeal joint 79 Disease Review
    • SIGNS Joints, enlarged, synovium and capsule synovial fluid, and bony and cartilage. Proliferation. Tenderness, local at joints. Crepitus, creaking, grating, cracking. Warmth without redness of joints. Palpable osteophytes. Joint effusion of normal or high viscosity fluid. Deformity of joint with preservation of function with exception of hip joint and first carpometacarpal joint. Sometimes episodic course, e.g. primary generalized OA. Soft synovial proliferation without bony proliferation, rare. Genu varus and valgus. Hallux valgus. Heberdens and Bouchar’s nodes and first carpometacarpal enlargement. Rare involvement: elbows, shoulder, metacarpophalangeal, lateral metatarsophalangeal, proximal interphalangeal and joints of feet, ankle, subtalar and midtarsal, thoracic spine. Diagnosis of OA is made accurately by clinical history, physical examinationradiological study, and when etiology and pathogenesis are not clear, by certainlaboratory examinations. The symptoms and signs are usually confined to one or only afew joints. If many joints are involved, the diagnosis is more likely a systemic form ofrheumatic disease.271 80 Disease Review
    • Radiologic and laboratory characteristics of Osteoarthritis 272 Normal radiographic findings occur in early OA. Joint space narrowing followsdegeneration and disappearance of hyaline cartilage. Early in the disease with effusionand swelling of cartilage, there may be joint space widening. Subchondral bony sclerosisor eburnation is very characteristic and represents deposition of excessive new bone.Marginal osteophytes in a variety of patterns in various joints reflect bone, cartilage andsynovial cell proliferation. Sub location and gross deformities with loose bodies in thejoint appears late. Radiologic criteria for diagnosis of osteoarthritis as defined in the Atlason standard radiographs are given below: Formation of osteophytes in the joints margins or at ligamentous attachments, e.g. tibial spine Periarticular ossicles, mainly distal and proximal interphalangeal joints Narrowing of the joints space associated with sclerosis of subchondral bone and Altered shape of bone end e.g. head of the femur. The following five step grading system is used according to the number of criteriapresent. 01. 0 = No OA. 02. 1 = Doubtful OA. 03. 2 = Minimal OA 04. 3 = Moderate OA 05. 4 = Severe OA. There are no specific laboratory abnormalities in primary OA. The synovial fluidis essentially normal, a few cells above normal counts, a slightly reduced viscosity orstring test, a normal mucin clot and total protein concentration. An increasedconcentration of inorganic pyrophosphate (PPi) is found in OA and is positivelycorrelated with the severity of radiologic OA. The application of thermography andscintillation scans of joints has little or no clinical usefulness but has shown negligibleevidence of inflammation in OA compared to the inflammatory arthropathies. 81 Disease Review
    • Association of OA has also been noted with elevated Westergren sedimentationrate, elevated C-reactive protein, serum uric acid and ASO titers. In primary generalizedOA, elevated serum cholesterol and transient rises in other acute phase reactants occur,Specific laboratory studies may be needed for diagnosis of secondary OA associated withspecific primary disease. Arthroscopy thus far has little practical use in OA.Vyavachedakanidana Sandhigatavata is a disease affecting the bony joints. So virtually every diseasethat affects the joints has to be differentiated with Sandhigatavata. The most commondifferentiation is to be made with Amavata (Ma.Ni.257), Vatarakta (C.S.Chi.29/23 ) andKroshtrukasheersha. (Ma.Ni.22/48)Table No. 17 Showing Vyavachedakanidana between Sandhigatavata and Vataraktha Sl. Criteria SGV Vatarakta 1 Nidana Vatavridhikara ahara- Vidahi, viruddha, Vata vihara rakthaprakopakara ahara 2 Poorva roopa Avyaktharoga lakshana Visista poorvaroopa 3 Roopa Sandhishoola, rasarana Teevra ruk, Grathita-paki akunchanayoho vedana, shvayathu Sandhi shopha, Vatapoornadrithi sparsha 4 Adhisthana Sandhi Padamoola, Hastamoola 5 Doshas Vata Vata, Rakta 6 Upashaya Ushna - snigdha Sheeta 82 Disease Review
    • Table No. 18 Showing Vyavachedakanidana of Sandhigatavata and AmavataSl. Criteria SGV Amavata1 Nidana Vatavridhikara hara-vihara Viruddha ahara-cheshta2 Poorva Avyaktharoga lakshana Hridaya dourbalya, gourava roopa3 Roopa Sandhishoola, rasarana Angamarda,Aruchi,trusna,Alasya, akunchanayoho vedana, Gourava ,Jwara,Apaka,Angashoonyata Sandhi shopha, Vatapoornadrithi sparsha4 Adhisthana Sandhi (Dependent joint) Bahusandi (Hasta, Pada, Gulpha, Trika, Janu etc.)5 Dosha Vata Vata, Kapha6 Upashaya Ushna, snigdha Ushna-rookshaTable No: 19 Showing Vyavachedakanidana of Sandhigatavata and Kroshrukasheersha.Sl. Criteria Sandhigatavata Kroshtrukasheersha1 Nidana Vatavridhikara ahara-vihara Vata & raktha vridhikaraahara-vihara2 Roopa Sandhishoola, rasarana akunchanayoho Maharuja, Janushopha, vedana, Sandhi shopha, kroshtrukasheershavat Vatapoornadrithi sparsha3 Adhisthana Sandhi Janu Madhya4 Dosha Vata Vata, rakta5 Upashaya Ushna, snigdha Snigdha, seetha 83 Disease Review
    • Table No: 20 Showing Differential diagnosis between OA, RA, Gout and Rheumaticfever.Sl. Criteria OA RA Gout Rheumatic Fever1 Symptoms Pain & swelling Inflammation n Polyarticular Painful and on major weight multiple joints, pain, swelling tender joints earing joints, morning & stiffness, stiffness inflammation, crepitations, tenderness, >30ms exquisite enlargement of tenderness joint space2 Mode of On Gradual Abrupt Acute Acute set3 Joints Weight bearing Polyarticular Metatarso- Polyarticular joints phalangeal Involved joints4 Systemic - Autoimmune - Carditis, Features disease, rise in fever, chorea temperature, anemia etc.5 Investigations RA-ve, ESR ESR raised, Serum uric ESR normal, X-ray- acid raised, increased, narrowing of X-ray-soft joint space, punched out CRP high, subchondral tissue swelling. lesions in bony sclerosis, subchondral WBC osteophytes etc. bone. elevated.Upadravas (Complications) 273 Upadrava is produced after the manifestation of the pradhana vyadhi and it isdependent on it. Susruta stated that Bala kshaya, Mamsa kshaya, Thrishna, Dhatushosha,Jwara, Vamana, Murcha, Atisara, Hikka, Shota, Suptata, Bhagna, Kampa, Admana asupadravas of Vatavyadhees. Osteoarthritis if long standing will be having complicationslike muscle wasting, various deformity, intra articular loose bodies etc. This state is verycomplicated one where the patient feds much difficulty in managing the daily routines. 84 Disease Review
    • Upashaya-anupashaya274 Upashaya is a judicious use of drugs, diet and practices (vihara) results in reliefof symptoms. Upashaya is antagonistic to the cause of disease and to the disease itself(M.Ni.1/8 Madhukosha). Anupashaya is the one, which aggravates the symptoms.Upashaya and anupashaya are very much important; especially during the treatmentusually drugs having snigdha and ushna gunas are prescribed as these pacify the Vatakopa. This should be adopted in the nirama avastha of Vatavyadhi only. This is theupashaya method. When the same drugs are prescribed in the Saama avastha ofVatavyadhi the disease aggravates. This is the anupashaya.Sadhyaasadhyata Vatavyadhees are considered as one among the mahagadas by acharyas.275Generally, Vata rogas are very difficult to cure due to the deep seated nature of them.Sandhigatavata usually occurs in the vardhakya kala, which is predominant of Vata.Charaka had mentioned some Vatavyadhees, which are either not curable due to sthanagambheerata or curable with effort in case they are of recent origin, in strong patients andif without any complications. Khudavatata is one among them, which according toChakrapani is Sandhigatavata.276 Diseases situated in Marma and Madhyama Rogamarga is Kashtasadhya.Sandhigatavata is a disease of Sandhi, which falls under Madhyama Rogamarga. FurtherVatavyadhi occurring due to vitiation of Asthi and Majja are most difficult to cure. 85 Disease Review
    • CHIKITSA The main aim of treatment is to restore Swasthya. It means to restore normalfunctions of Agni, Dosha, Dhatu, and Mala and to maintain mental health. The primaryimportance of Chikitsa lies in Samprapti Vighatana.Genera line of treatment of Sandhigatavata(1) Snehana 277 In order to pacify Vridhavata and also to fulfill sneha amsha which underwentkshaya all types of bahya and abhyantara snehana are to be adopted in treatment.Abhyantara snehana like bhojana, pana, nasya and snehabasti. Bahya snehana in the formabhyanga, lepa, mardana, udvartana, samvahana, moordha taila, gandusha, karnapoorana,akshitarpana, parisheka and pichu.(2) Upanaha 278 Upanaha is therapeutically two types- 1) saagni and 2) niragni. Saagni upanaha isnothing but Sankara sweda. Niragni upanaha is the tying of Vatahara dravyas over theaffected body part for a time period of 12 hours.(3) Agnikarma 279 Unique treatment indicated in case of Sandhigatavata. Here Dahana orcauterization is done at the tender points of the part affected. Susruta states that in thevitiation of Vata in twak, mamsa, sira, snayu and sandhi Agnikarma provides good relief.Dahana karma is a synonym of Agnikarma. 86 Chikitsa
    • (4) Bandhana 280 For the purpose of Bandhana, Charaka opines that leather of Ushna Veeryaanimal can be used. In the absence of this silk or woolen cloth can be used.281 AstangaHridayakara 282 opines that Vatahara Patras should be used.(5) Unmardana 283 This is a massage technique utilized in case of bahya snehana procedures. Themassage is performed by applying gentle pressure. Apart from these, the Basti karmashould also be adopted, as it is the parama oushadha for Vata. No other chikitsa has thecapacity to tolerate not regulate the force of Vata apart from Basti. 284Shamana Oushadhees1) Kwatha : - Maharasnadi, Rasnadi, Dhanvantaram, Sahacharadi.2) Choorna : - Alambushadi choorna, Abhadi choorna.3) Vati : - Ajamodadi vati, Tab. Sallaki, Tab. Shallaki plus.4) Guggulu : - Kaishoraguggulu, Yogarajaguggulu, Brihat yogaraja, Adityapakaguggulu, Simhanadaguggulu.5) Rasaoushadhi : - Panchanana rasa, Vatarakshasa, Brihat vatachintamani.6) Sneha : - Dhanvantaram taila, Kottam chukkadi taila, Sahacharadi taila, Vatashani taila. Shatahvadi taila. 87 Chikitsa
    • PATHYA 285 Ahara1. Rasas : - Madhura-amla-lavana2. Shukadhanya : - Nava godhuma, Nava shali, Rakta shali, Shashtika shali.3. Shimbi varga : - Nava tila, Masha, Kulatha.4. Shaka varga : - Patola, shigru, vartaka, lashuna.5. Mamsa varga : - Ushtra, Go, Varaha, Mahisha, Magura, Bheka, Nakula, Chataka, Kukkuta, Tittira, Kurma.6. Jala varga : - Ushnajala, Shrithasheetajala, Narikelajala.7. Dugdhavarga : - Go, Aja, Dadhi, Ghritha, Kilata, Kurchika.8. Mutravaga : - Gomutra.9. Madyavarga : - Dhanyamla, Sura.10. Snehavarga : - Tilaja, Ghrita, Vasa, Majja. ViharaVeshtana, Trasana, Mardana, Snana, Bhushayya, etc.Among present day food stuffs and activities-1. Can be taken: - Orange juice, carrot, all fibrous fruits and certainoids.2. Should do: - Slight walking, swimming, steam bath etc. 88 Chikitsa
    • APATHYA 286 Ahara1. Rasa : - Katu, Tikta, Kashaya.2. Shimbivarga : - Rajamasha, Nishpava, Mudga, Kalaya.3. Shukavarga : - Truna, Kangu, Koradusha, Neevara, Syamaka.4. Phalavarga : - Jambu, Udumbura, Kramuka, Tinduka.5. Mamsavarga : - Sushka mamsa, Kapota, Paravata.6. Jalavarga : - Sheeta jala.7 .Ksheeravarga : - Gardabha. Vihara1. Manasika : - Chinta, Shoka, Bhaya.2. Shareerika : - Jagarana, Shrama, Vyayama, Vyavaya, Chankramana, Vegadharana etc. Among the present day food stuffs and activities-1. Can be taken: - Fast food, cold beverages, liquor.2. Should be avoided: - Long standing sitting, driving, staying in AC etc. 89 Chikitsa
    • MEDICAL MANAGEMENT OF OSTEOARTHRITIS 287 This involves many measures like pharmacological means, non-pharmacologicalmeans and surgery.Pharmacological means –1. Simple analgesics A large number of medicines are prescribed for relief of pain. The recognitionthat pain in OA is not necessarily due to inflammation has led to an increased awarenessof the role of simple analgesics in the treatment. The ACR guidelines emphasize the useof acetaminophen (Tylenol) as the first line treatment for OA.2. Opioid containing analgesics Code line and propoxyphene can be used for short periods to treat exacerbationsof pain.3. NSAID’s Trials comparing simple analgesics and NSAIDs found that acetaminophenalong can control pain in a substantial number of patients with OA celecoxib, a cox-2inhibitor, and rofecoxib are recent advances among NSAIDs.4. Local analgesics – Among the local applications, capsaicin cream is used commonly.5. Intra articular cortico-steroid injections.6. Intra articular administration of hyaluronic acid like products. 90 Chikitsa
    • Agents used to treat Osteoarthritis Acetaminophen, NSAIDS (Salicylates, Propionic acids, Acetic acid, Oxicams),Cyclo-oxgenase inhibitors, Irritants/Counter irritants, Hyaluronic acids andGlucocorticoids. Exercise – To maintain range of motion, muscle strength and general health. Patients may also be referred to aerobic exercise programs such as fitness walking or swimming. Assistive devices – Many patients with OA of hips and knee are more comfortable; wearing shoes with good shock-absorbing propertiesNon-pharmacological means Patient education. Exercise: - To maintain range of motion, muscle strength and general health. Patients may also be referred to aerobic exercise programs such as fitness walking or swimming. Assistive devices: - Many patients with OA of hips and knee are more comfortable; wearing shoes with good shock-absorbing properties orthoses. The use of an appropriately selected cane can reduce hip loading by 20-30%. Patients with specific physical disabilities may benefit from physical and occupational therapy. Weight management: - There is a longitudinal association between obesity and OA of knee in men and women. Therefore, primary preventive strategies may include measures to avoid weight gain, or to achiever weight loss in over weight patients. Supplements: - Glucosamine sulphate and chondrotin sulfate. 91 Chikitsa
    • SURGERICAL LINE OF MANAGEMENT288 Surgical procedures are of value in the management of OA. They may be groupedunder 3 major categories. Procedures to correct mal alignment and eliminate abnormaljoint stresses (osteotomies) not only may slow down disease progression but may-alsobring healthier articular cartilages into opposition and provide symptomatic relief.Debridement with removal of free bits of cartilage or large ecostoses may relieve painand locking and help in prevention of rapid and extensive cartilage degeneration. Inadvanced disease, arthroplasty or joint replacement may be required to reduce pain andimprove function; at times arthrodesis is required to control pain, even though motionmust be sacrificed. 92 Chikitsa
    • DRUG REVIEW The ingredients of Shatahvadi taila 289 are as follows.Shatahva 290 a, b Latin name – Anethum sowa. Family – Umbeliferae Sanskrit – Shaleeya, Shatapatrika, Shatapushpika. Composition – Dried ripe dill fruit contains a volatile oil 3-4% which is composed of anethine, phellanndriene and di-limonene, apiol, also contain carvotie and hydrocarbone. Rasa – Katu,Tikta Guna – Laghu, Rooksha, Teekshna Veerya – Ushna Vipaka – Katu Dosha – Kapha and Vata shamaka Parts used – Phala, Taila Uses – Carminative, Vedanashamaka, Shothahara, Swedajanana. 93 Methodology
    • Bilva 291 a, b Latin name – Aegle marmelos Family – Rutaceae Sanskrit – Shandilya, Shaitusha, Shreephala, Sadaphala Composition – Phalamajja contains mucilage, pectine, sugar, tannin, volatile oil. Rasa – Kashaya,Tikta Guna – Laghu, Rooksha, Veerya – Ushna Vipaka – Katu Dosha – Kapha and Vatashamaka Parts used – Moola,Twaka, Patra, Phala. Uses – Shothahara, Vedanashamaka.Tila 292 a-c Latin name – Sesamum indicum Family – Pedaliaceae Sanskrit – Homadhanya, Pavitra, Papaghana, Jartila. Composition – Seeds contain fixed oil 50-60%, priteids 22%, Carbohydrate mucilage 4%. Rasa – Madhura, Anurasa -Kashaya and Tikta. Guna – Guru, Snigdha. Veerya – Ushna Vipaka – Madhura Dosha – Vata shamaka, Tridoshashamaka (due to samskara) Parts used – Seed, oil Uses – Vedanashamaka, Sandhaneeya 94 Methodology
    • Tila taila (Moorchhita) 293-294 By Taila moorchana the unpleasant odour of the oil is changed, Amadosha isremoved and good color and fragrance are obtained. It enhances the potency of the tailaalso. Composition – Palmitic acid (9.1%), stearic acid (4.3%), arachidic acid (0.8%), oleic acid (45.4%), linoleic acid (40.4%). Rasa – Madhura, Tikta accompanying kashaya. Guna – Sukshma, Vyavai, Vishada, Guru, Sara, Vikashi, Teekshna, Himasparsha. Properties – Vatagni, aggravates pitta, does not aggravate kapha, Deepana- pachana, Brimhana, Balya, Preenana, Lekhana, promotes skin health, intellect, digestive power, health of eyes, complexion, strength and stability of Mamsadhatu, Krimigna, reduces the quantity of urine, good for hairs, cleanses the Garbhasaya and yoni, helps in overcoming aging process. Indication – Vrina, Prameha, pain in ears, yoni and head. All kinds of injuries are relieved with Tila taila. It is used for alleviation of Vata, as Bastidravya, Nasyadravya, for internal administration and in Abhyanga and dietary articles. 95 Methodology
    • Yava 295 a, b Latin name – Hordeum vulgare Family – Graminae Sanskrit – Yava. Composition – Fixed oil or fat, starch, cellulose, nitrogenous principles and ash containing salicic acid, phosphoric acid, iron and lime. Church in his Food grains of India gives followlng analysis of barley. Water –12.5%, Albinoids – 11.5%, Starch- 70%, Fat- 1.3%, Fiber-2.6%, and Ash-2.1%. Rasa – Kashaya, Madhura. Guna – Rooksha, Laghu. Veerya – Sheeta Vipaka – Katu Dosha – Kapha, Pitta shamaka. Uses – Balya, Deepana, Lekhana (in Sthoola).Kanji 296 a, b: Varga – Madhyavarga Sanskrit – Kanji. Guna – Laghu, Teekshna. Dosha – Vata, Kapha shamaka. Uses – Deepaka, Pachaka, Trishna and Dahanashaka. 96 Methodology
    • CLINICAL STUDY The therapeutic measures, drugs and procedures of Ayurveda have remained inthe practice since long on the basis of methodology prevalent in ancient times. This is thetime that the rationality of Ayurvedic therapeutic approach is explained on rational lines.Clinical trial is a way of research and its best method to evaluate any drug or line oftreatment. The trial is a carefully designed experiment with the aim of solvingunrewarding problems conducted on scientific lines.Research Approach. Experimentation is the most powerful research approach. In the present study, theobjective is to “A COMPARATIVE CLINICAL STUDY TO EVALUATE THEEFFECT OF MATRABASTI AND PARISHEKA WITH SHATAHVADI TAILAIN SANDHIGATAVATA (OSTEOARTHRITIS)” The efficacy can be determined byfinding out the difference between the baseline data and after follow up data. SoParisheka alone was compared with Parisheka in association with Matrabasti to studyadvantage of Parisheka with Matrabasti.Study Design The study design set for the present study is ‘Prospective comparative clinicaltrial’. In this Parisheka and Matrabasti group of patients compared with Parisheka groupof patients. Study was done in two groups. Demographic data and disease-specific dataare collected according to the case-record form given in the appendix.Source Of Data Patients suffering from Sandhigatavata were selected from the P.G.S and R(Panchakarma) OPD and IPD of Shri D G Melmalgi Ayurvedic College Hospital. 97 Methodology
    • Sample Size and Grouping The sample size for the present study was thirty patients suffering from Sandhigatavata as per the selection criteria. Patients were randomly distributed to both the groups of equal size. In Group A, 15 patients received Parisheka and Matrabasti and in Group B, 15 patients received Parisheka only. Reasons For Selection Of The Study Design The results and conclusions of a clinical trial depends on the study design. The aim of this study was to find out the effect of Parisheka in the management of Sandhigatavata and to check additive efficacy of Matrabasti in association with Parisheka in the management of Sandhigatavata. Therefore, two groups were made and the results obtained in both the individual groups were compared. Selection Criteria The cases were selected strictly as per the pre-set inclusion and exclusion criteria.A) Inclusion Criteria Patients between 35 and 65 years of age Patients with the clinical features of Sandhigatavata (Osteoarthritis) Patients fit for Basti and Swedana. Patients with radiological findings of Osteoarthritis along with clinical featuresB) Exclusion Criteria Patients developed deformity. Patients with severe form of systemic disorders Pregnant women and lactating mother Patients unfit for Basti and Swedana 98 Methodology
    • Duration Of The Study The total study duration was 24 days, i.e. In group A; 8 days Parisheka alongwith Matrabasti, 16 days pariharakala. In group B; 8days Parisheka, 16 days pariharakala.After treatment follow up was done for one month.Data Collection Patients were thoroughly examined both subjectively and objectively. Detailedhistory pertaining to the mode of onset, previous ailment, previous treatment history,family history, habits, ashtavidhapareeksha and dashavidhapareeksha and physicalexamination findings were noted. Routine investigations were done to exclude otherpathologies. Radiological features also were investigated.Joint Examination (Knee Joint)297History The common symptoms with which a patient generally presents are pain,swelling, stiffness, mechanical disorders (e.g. Locking, giving way, click etc.) and limp.Inspection • Both the lower limbs were fully exposed • Patient was first examined in the standing position, both from front and behind, secondly in the seated position, thirdly in the supine position and lastly in the prone position. 99 Methodology
    • • Swelling a) The limits of the swelling were clearly made out. b) The gradings were allotted on the basis of criteria explained in the end of this section. c) The Varna of the Shopha was examined (Raga, Shyava or Prakrutha). d) Any deformities like genus valgum, varum etc. were examined. e) Joint instability or buckling of the joint was examined. f) Any abnormalities in the gait were examined. g) Walking time was recorded (the time taken to cover 21 metres). h) Any presence of muscular spasm was examined. i) Muscular wasting above and below the joint was examined.Palpation• Local temperature was examined with the back of the hand and compared to that of the other side.• Local tenderness was also examined.• Swelling A) Fluctuation test was performed by pressing the suprapatellar pouch with one hand and feeling the impulse with the thumb and the fingers of the other hand placed on either side of the patella or the ligamentum patellae. B) Patellar tap was elicited by pressing the suprapatellar pouch with one hand driving the whole of its fluid into the joint proper as to float the patella in front of the joint. With the index finger of the other hand, the patella is pushed backwards towards the femoral condyles with a sharp and jerky movement. The patella can be felt to strike on the femur, which is known as the patellar tap. 100 Methodology
    • • Palpation of popliteal fossa - The patient was made to lie down prone on the table. The knee joint was flexed and the popliteal fossa was palpated. The knee joint, popliteal artery, areolar tissue, veins and nerves and the tendons in and around the popliteal fossa were all palpated carefully to detect any pathology here. • Significance of click - If the click was associated with discomfort or pain, careful examination was done. Commonest cause of intra-articular click is OA. • Patello-femoral and femoro-tibial components were palpated for any tenderness or irregularity.Movements The movements permitted in the knee joint are mainly flexion and extension.Minor degrees of abduction, adduction and rotations may be permitted when the joint ispartly flexed. Both active and passive movements were examined.• Flexion and Extension: Normally, the knee can be flexed until the calf extended till the thigh and leg form a straight line.• Abduction and adduction: These movements are virtually absent with knee straight, but slight degrees of abduction and adduction are possible when the knee is semi- flexed.• Rotation: This movement is also not possible when the knee is straight. When the hip and knee are flexed to 90 degrees, some degree of rotation is possible.Auscultation During active or passive movement, the palm of one hand of the physician wasplaced over the patella and crepitus was felt. 101 Methodology
    • Treatment scheduleGroup-A: Parisheka and Matrabasti Group.PARISHEKAPoorvakarma The patient was asked to attend his natural urges prior to entry in thePanchakarma theatre. The procedure was done between 8 to10 AM. After performing thesacred rights, the 1000ml of Shatahvadi taila is taken and kept in a vessel containing hotwater. Then the patient was asked to sit comfortably in Taila droni by extending his bothlegs, two trays are placed under the knees for the purpose of collecting and reuse of thetaila in a cyclic manner.Pradhanakarma The lukewarm oil was supplied to the Panchakarma technicians standing on eitherside of the patient. The oil was checked for excess heat or insufficiency.Fixing the duration : The duration of karma was fixed 30 minutes for 8 days. Cleaned sponges were dipped in Sukhoshna taila (Bearable warmth to the patient)and squeezed by right mist and made to flow on knee joint in a regular stream along withthe direction of inverted thumb. The height of the stream was maintained about 12 angulathroughout the procedure. Mild massage was made with left hand continuously alongwith the Pariseka. The temperature of the taila was maintained throughout the procedure.The fresh oil was taken on every fourth day of the procedure. The snap taken at the timeof procedure is displayed in the photograph.Paschatkarma The oil remained on the joint was wiped out with the help of cleaned cloth, mildmassage was done and patient was asked to relax and instructed to be ready for theMatrabasti as explained below. 102 Methodology
    • MATRABASTI The procedure of administration of Matrabasti in general can be divided into threestagesPoorvakarma The patients were instructed to come after taking light diet (neither too Snigdhanor too Ruksha) and after elimination of stool and urine. The patients were also advisednot to take diet more than 3/4th of routine quantity. The patients were mainly subjectedfor local Abhyanga and Mridu Swedana prior to the administration of Matrabasti. Abhyanga : The local Abhyanga over abdomen, buttock and thighs for 5 – 10minutes was done by lukewarm Shatahvadi taila. Swedana : After Snehana, the patients were subjected for local Mrudu Sweda, byusing Nadi Sweda. Swedana was done on abdomen, buttocks and on thighs for 5 – 10minutes.Pradhanakarma After this Purva Karma the patient was advised to lie down on left lateral positionon the Basti table with left lower extremity straight and right lower extremity flexed onknee and hip joint. The patient was asked to keep his left hand below the head.Shatahvadi Taila was applied to anus in small amount, 75ml of lukewarm ShatahvadiTaila was taken in enema syringe. Rubber catheter oleated with Shatahvadi Taila wasattached to enema syringe. After removing the air from enema syringe, rubber catheterwas administered into the anus of the patient’s upto the length of 4 inches. The patientwas asked to take deep breath and not to shake his body while introducing the catheterand the drug. The total Taila was not administered in order to avoid entrance of Vayu intothe Pakwashaya which may produce pain. 103 Methodology
    • Pashchatkarma After the administration of Basti, the patient was advised to lie in supine positionwith hand and legs freely spread over the table. There after patient’s both legs were raisedfew times so as to raise the waist and gently tapped over the hips. Simultaneously tapswere also given on his soles, over elbow and palms, so that the Matrabasti may spreadthroughout the body and may be retained for the required period. After sometime patientwas advised to get up from the table and take rest in his bed and also not to take daysleep. Basti Pratyagamana Kala was noted in each case.Group –B: Only Parisheka Group. In this group only Parisheka was done as explained in Group –A about Parisheka.Pathyapathya during treatment period and pariharakala The pathyacharana is an important factor which was followed for 24 daysincluding the treatment period. The regimen prescribed for Snehapanavidhi was followedby the patients. Patients were advised to take katu-tiktha-kashaya-rooksha varjithaaharadravyas in light quantity. Rice gruel with little milk was advised as the ideal food.Patient was advised to drink hot water only. Patient was advised to avoid sexualintercourse, suppression of natural urges, traveling, exercise, excessive speech, unevensitting and lying postures, exposure to wind, cold, heat and dust, anger and grief. 104 Methodology
    • Assessment of Clinical Response Subjective parameters and objective parameters were made out to assess theclinical response in both the groups.Subjective Parameters Ruk (Pain) Graha (Stiffness) 01. Grade 0 – No Complaints 01. Grade 0 – Absent 02. Grade 1 – Tells on Enquiry 02. Grade 1 – Present 03. Grade 2 – Complains Frequently 04. Grade 3 – Excruciating ConditionObjective parametersSparshaakshamatva (Tenderness)01. Grade 0 – No Complaints02. Grade 1 – Says the joint is tender03. Grade 2 – Winces the affected joint04. Grade3 –Winces and withdraws the affected joint.Sandhigathi-Asaamarthya (Limitation of joint movement)01. Grade 0 – No movement02. Grade 1 – Up to 50% of the full range of joint motion03. Grade 2 – 50-75% of the full range of joint motion04. Grade 3 – >75% & <full range05. Grade 4 – Full Range of joint Motion 105 Methodology
    • Shotha (Swelling) 01. Grade 0 – No Complaints 02. Grade 1 – Slightly obvious Atopa (Crepitations) 01. Grade 0 – None 02. Grade 1 – Felt Walking time 298 to cover 21meters distance 01. Grade 0 – Up to 20seconds 02. Grade 1 – 21-30seconds 03. Grade 2 – 31-40seconds All these parameters of baseline data to post-medication data (24th day) werecompared for clinical assessment of the results (assessment was also recorded on the 8thday too).Overall Assessment of Clinical Response Good Response – >60% improvement in subjective and objective parameters. Moderate Response – 31-60% improvement in subjective and objective parameters. Poor Response – 1-30% improvement in subjective and objective parameters. No Response – 0 % or No improvement in subjective and objective parameters 106 Methodology
    • 39 patients were registered for the present study. Out of this, 9 patients wereexcluded. (4 drop outs and 5 not fulfilling the criteria for diagnosis) Hence, their data hasnot been included here. The remaining 30 patients of Sandhigatavata fulfilling the criteriafor diagnosis, were treated in the following two Groups – Group A – Parisheka and Matrabasti – 15 patients. Group B – Parisheka – 15 patients. All the patients were examined before and after the treatment according to thecase sheet format given in the appendix. Both the subjective and objective changes wererecorded. The data recorded are presented under the following heading – I. Demographic data II. Data related to the disease III. Data related to over all response to the treatment IV. Statistical analysis of the clinical and functional parameters and inter Group comparison. 107 Observations & Results
    • 1. DEMOGRAPHIC DATAA. Table No.21. Showing the distribution of patients by age in both Groups. Age Groups Group A % Group B % Total % 35-44 1 6.66 0 0 1 3.33 45-54 5 33.3 3 20 8 26.6 55-64 9 60 12 80 21 70B. Table No.22. Showing the overall response of patients by Age in both Groups. Age Group A Group B TotalGroup No GR MR No MR PR No GR MR PR 35-44 1 0 1 0 0 0 1 0 1 0 45-54 5 2 3 3 2 1 8 2 5 1 55-64 9 6 3 12 11 1 21 6 14 1 Among the 15 patients in Group A, the only 1 patient (6.66%) was in the agegroup of 35–44 and responded moderately; whereas in the 5 patients (33.33%) were inthe age group of 45–54, 2 patients had good response (40 %) and 3 patients had moderateresponse (60%) and 9 patients (60%) were in the age group of 55-65, 6 patients had goodresponse (66.66 %) and 3 patients had moderate response (33.33 %). Among the 15 patients in Group B, no patients were in age group of 35-44 years.3 patients (20%) were in the age group of 45–54, 2 had shown moderate response and 1patient had poor response and 12 patients (80%) in the age group of 55–65, 11 patientshad moderate response (91.66%) and 1 patient responded poorly (8.33 %). In the study as a whole (30 patients), 1 patient (3.33%) in the age group 35–44had moderate response; in the 8 patients (26.6%) in the age group 45–54, 2 patients hadgood response (25%) and 5 patients had moderate response (62.5%), 1 patient (12.5%)had poor response and in the 21 patients (70%) in the age group 55-64, 6 patients hadgood response (28.57 %), 14 patients had moderate response (66.66%) and 1 patientresponded poorly (4.76 %). 108 Observations & Results
    • 2. A. Table No. 23. Showing the distribution of patients by sex in both Groups. Sex Group A % Group B % Total % Male 6 40 7 46.6 13 43.3 Female 9 60 8 53.3 17 56.6B. Table No. 24. Showing the overall response of patients by sexes in both Groups. Group A Group B Total Sex No GR MR No MR PR No GR MR PRMale 6 4 2 7 6 1 13 4 8 1Female 9 4 5 8 7 1 17 4 12 1 Among the 15 patients in the Group A, 6 patients (40%) were males, 4 males(66.66%) had good response where as 2 males (33.33%) had moderate response; in thesame Group, among 9 females (60%), 4 females (44.44%) had good response and 5females (55.55%) had moderate response. Among the 15 patients in the Group B, 7 patients (46.66%) were male, 6 males(85.71%) had moderate response and 1 male (14.2%) had poor response, where in thesame Group 8 patients (53.33%) were females, among these 7 patients (87.5%) hadmoderate response and 1 patient (12.5%) had poor response. In the study as a whole (30 patients), among the 13 males (43.3%), 4 (30.76%)had good response and 8 (61.5%) had moderate response and 1 patient (7.69%) had poorresponse; among the 17 females (56.66%), 4 (23.52%) had good response and 12(70.58%) had moderate response and one (5.88%) had poor response. 109 Observations & Results
    • 3. A Table No. 25. Showing the distribution of patients by Occupation in both Groups. Occupation Group A % Group B % Total % Sedentary 4 26.66 6 40 10 33.33 Active 7 46.6 7 46.6 14 46.6 Labour 4 26.6 2 13.3 6 20 Others 0 0 0 0 0 0B. Table No.26. Showing the overall response in patients by occupations in both Groups. Group A Group B TotalOccupation No GR MR No MR PR No GR MR PRSedentary 4 2 2 6 6 0 10 2 8 0Active 7 4 3 7 6 1 14 4 9 1Labour 4 2 2 2 1 1 6 2 3 1Others 0 0 0 0 0 0 0 0 0 0 Among the 15 patients in Group A, in the 4 sedentary patients (26.66%), 2patients (50%) got good response and 2 (50%) got moderate response where as in the 7active patients (46.66%), 4 patients (57.14%) got good response and 3 patients (42.85%)got moderate response and in the 4 labour patients (26.66%), 2 patients (50%) got goodresponse and 2 patients (50%) got moderate response. Among the 15 patients in the Group B, the 6 sedentary patients (40%) gotmoderate response (100%) and in the 7 (46.66%) active patients, 6 (85.71%) gotmoderate response, 1 (14.2%) patient got poor response. in the 2 labour patients (33.3%),1 patient (50%) got good response and 1 patient (50%) got moderate response. In the study as a whole, among the 10 sedentary patients (33.33%), 2 patients gotgood response (20%) and 8 patients (80%) got moderate response where as in the 14active patients (46.66%), 4 patients got good response (28.57%) and 9 patients (64.28%) ,one patient (7.14%) got poor response and in the 6 labour patients (20%), 2 patients gotgood response (33.33%), 3 patients got moderate response (50%) and 1 patient got poorresponse (16.6%). 110 Observations & Results
    • 4. Table No. 27. Showing the distribution of patients by Economical status in bothGroups. Economical status Group A % Group B % Total % Poor 3 20 7 46.66 10 33.33 Middle class 7 46.66 7 46.66 14 46.66 High class 5 33.33 1 6.66 6 20 Among the 15 patients in Group A, 3 patients were poor (20%), 7 patients were ofthe middle class (46.66%) and 5 patients were high-class (33.33%). Among the 15patients in the Group B, 7 patients were poor (46.66%), 7 patients were of middle class(46.66%) and 1 patient was high-class (6.66%). In the study as a whole (30 Patients), 10patients were poor (33.33%), 14 patients were of the middle class (46.66%) and 6patients were of high-class (20%).5.Table No. 28. Showing the distribution of patients by Religion in both Groups. Religion Group A % Group B % Total % Hindu 11 73.3 14 93.33 25 83.3 Muslim 4 26.66 1 6.66 5 16.6 Christian 0 0 0 0 0 0 Among the 15 patients in Group A, 11patients were Hindus (73.3%), 4 patientswere Muslims (26.66%). Among the 15 patients in Group B, 14 patients were Hindus(93.33%) and 1 patient were Muslims (6.66%). In the study as a whole (30 patients), 25patients were Hindus (83.3%), 5 patients were Muslims (16.6%). 111 Observations & Results
    • 6. Table No. 29. Showing the distribution of Patients by Dietary habit in both Groups. Dietary habits Group A % Group B % Total % Vegetarian 5 33.3 8 53.3 13 43.33 Mixed 10 66.6 7 46.6 17 56.66 Among the 15 patients in Group A, 5 patients were vegetarians (33.3%) and 10patients were having mixed dietary habits ( 66.6%). Among the 15 patients in Group B, 8patients were vegetarians (53.3%) and 7 patients were having mixed dietary habits(46.6%). In this study as a whole (30 patients), 13 patients were vegetarians (43.33%) and17 patients were having mixed dietary habits (56.66%).7. A Table No. 30. Showing the distribution of Patients by Agni in both Groups. Agni Group A % Group B % Total % Manda 6 40 10 66.6 16 53.33 Teekshna 0 0 0 0 0 0 Vishama 7 46.6 4 26.66 11 36.6 Sama 2 13.3 1 6.6 3 10B. Table No. 31. Showing the overall response of patients by Agni in both Groups. Agni Group A Group B Total No GR MR No MR PR No GR MR PRManda 6 3 3 10 9 1 16 3 12 1Teekshna 0 0 0 0 0 0 0 0 0 0Vishama 7 3 4 4 3 1 11 3 7 1Sama 2 2 0 1 1 0 3 2 1 0 In the Group A, among the 6 patients (40%) of Manda agni, 3 patients had goodresponse (50%) and 3 patients had moderate response (50%) whereas among the 7patients (46.66%) of Vishama agni, 3 patients had good response (42.85%) and 4 patientshad moderate response (57.14%) and among the 2 patients (13.33%) of Sama agni, 2patients had good response (100%). 112 Observations & Results
    • In Group B, among the 10 patients (66.66%) of Manda agni, 9 patients hadmoderate response (90%) and 1 patient had poor response (10%) where as among the 4patients (26.66%) of Vishama agni 3 patients (75%) moderate response and 1 patient(25%) got poor response. and 1 patient (6.66%) of Sama agni responded moderately. In the study as a whole (30 patients), among the 16 patients (53.33%) of Mandaagni, 3 patients had good response (18.75%), 12 patients had moderate response (75%)and 1 patient had poor response (6.25 %) whereas among the 11 patients (36.66%) ofVishama agni, 3 patients had good response (27.27%) and 7 patients had moderateresponse (63.63%) and 1 patient (9.09%) poor response, and among the 3 patients (10%)of Sama agni 2 patients had good response (66.66%) and 1 patient had moderate response(33.33%).8. A. Table No. 32. Showing the distribution of patients by Koshta in both Groups. Koshta Group A % Group B % Total % Madhya 6 40 3 20 9 30 Mridu 1 6.6 2 13.3 3 10 Krura 8 53.3 10 66.66 18 60B. Table No. 33. Showing the overall response of patients by Koshta in both Groups.Koshta Group A Group B Total No GR MR No MR PR No GR MR PRMadhya 6 5 1 3 3 0 9 5 4 0Mridu 1 1 0 2 2 0 3 1 2 0Krura 8 2 6 10 8 2 18 2 14 2 In Group A, among the 6 patients (40%) of Madhya koshta, 5 patients got goodresponse (83.33%) and 1 patient got moderate response (16.66%), where as the onepatient (6.6%) of Mridu koshta got good response and among the 8 patients (53.3%) ofKrura koshta, 2 patients got good response (25%) and 6 patients got moderate response(75%). 113 Observations & Results
    • In Group B, all the 3 patients (20%) of Madhya koshta got moderate responseand the 2 patients (13.3%) of Mridu koshta got moderate response, whereas among the 10patients (66.66%) of Krura koshta, 8 patients got moderate response (80%) and 2 patientsgot poor response (20%). In the study as a whole (30 patients), among the 9 patients (30%) of Madhyakoshta, 5 patients got good response (55.55%) and 4 patients got moderate response(44.44%) where as among the 3 patients (10%) of Mridukoshta 0ne patient (33.33%) gotgood response and 2 patients (66.6%) got moderate response and among the 18 patients(60%) of Krura koshta, 2 patients got good response (11.11%), 14 patients got moderateresponse (77.77%) and 2 patients got poor response (11.11%).9. Table No. 34. Showing the distribution of patients by Nidra in both Groups. Nidra Group A % Group B % Total % Sukha 0 0 0 0 0 0 Alpa 10 66.6 11 73.33 21 70 Ati 0 0 0 0 0 0 Vishama 5 33.3 4 26.6 9 30 Among the 15 patients in Group A, 10 patients had alpa nidra (66.6%) and 5patients had Vishama nidra (33.3%). Among the 15 patients in Group B, 11 patients hadAlpa nidra (73.33%) and 4 patients had Vishama nidra (26.6%). In the study as a whole(30 patients), 21 patients had Alpa nidra (70%) and 9 patients had Vishana nidra (30%).No patient reported with Sukha and Ati nidra in this study. 114 Observations & Results
    • 10. Table No. 35. Showing the distribution of patients by Vyasana in both Groups. Vyasana Group A % Group B % Total % Smoking 3 20 3 20 6 20 Tobacco 6 40 7 46.6 13 43.33 Alcohol 4 26.6 2 13.3 6 20 Others 0 0 0 0 0 0 None 2 13.33 3 13.33 5 16.66 Among the 15 Patients in Group A, 3 patients had smooking habit (20%), 6patients had tobacco habit (40%), 4 patients had alcohol habit (26.6%) and 2 patients hadno habits (13.33%). Among the 15 patients in Group B, 3 patients had smooking habit(20%), 7 patients had tobacco habit (46.6%), 2 patients had alcohol habit (13.3%) and 3patients had no habits (20%). In the study as a whole, 6 patients had smooking habit(20%), 13 patients had tobacco habit (43.33%), 6 patients had Alcohol habit (20%) and 5patients had no habits (16.66%). No patient reported in this study with any other habits.11. A.Table No.36. Showing the distribution of patients by Deha prakriti in both Groups. Deha Prakriti Group A % Group B % Total % Vata 2 13.33 1 6.6 3 10 Pitta 0 0 0 0 0 0 Kapha 0 0 0 0 0 0 Vata-pitta 7 46.6 8 53.3 15 50 Vata-kapha 5 33.33 4 26.6 9 30 Pitta-kapha 1 6.66 2 13.3 3 10 Sannipataja 0 0 0 0 0 0 115 Observations & Results
    • B. Table No. 37. Showing the overall response of patients by Deha prakriti in bothGroups.Deha Group A Group B Totalprakriti No GR MR No MR PR No GR MR PRVata 2 1 1 1 1 0 3 1 2 0Pitta 0 0 0 0 0 0 0 0 0 0Kapha 0 0 0 0 0 0 0 0 0 0Vata-pitta 7 4 3 8 7 1 15 4 10 1Vata-kapha 5 2 3 4 3 1 9 2 6 1Pitta-kapha 1 1 0 2 2 0 3 1 2 0Sannipataja 0 0 0 0 0 0 0 0 0 0 In Group A, among the 2 patients (13.33%) of Vata prakriti, 1 patient got goodresponse (50%) and 1 patient got moderate response (50%). Among 7 patients (46.6%) ofVata-pitta prakriti, 4 patients got good response (57.14%) and 3 patients got moderateresponse (42.85%). Among 5 patients (33.33%)of Vata-kapha prakriti, 2 patients gotgood response (40%) and 3 patients got moderate response (60%). The patient (6.66%) ofPitta-kapha prakriti got good response. In Group B, among the 1 patient (6.6%) of Vata prakriti got moderate responseAmong the 8 patients (53.3%) of Vata–pitta prakriti 7 patients (87.5%) got moderateresponse and 1 patient got poor response (12.5%). Among the 4 patients (26.6%) of Vata-kapha prakriti 3 patients (75%) got moderate response and 1 (25%) got poor response, allthe 2 (13.3%) patients of Pitta–kapha prakriti got moderate response. In the study as a whole (30 patients), among the 3 patients of Vata prakriti, 1patient got good response (33.33%), 2 patients got moderate response (66.66%). Amongthe 15 patients of Vata-pitta prakriti, 4 patients got good response (26.667%) and 10patients got moderate response (66.66%). Among the 9 patients of Vata-kapha prakriti, 2patients got good response (22.22%) and 6 patients got moderate response (66.66%) and1 patient (11.11%) Among the 3 patients of Pitta–kapha prakriti, 1 patient got goodresponse (33.33%) and 2 patients got moderate response (66.66%). 116 Observations & Results
    • 12. Table No: 38. Showing the distribution of patients by Satmya in both Groups. Satmya Group A % Group B % Total % Rooksha 14 93.3 13 86.6 27 90 Snigdha 1 6.6 2 13.3 3 10 Among the 15 patients in Group A, 14 patients were of Rooksha satmya (93.3%)and 1 patient was of Snigdha satmya (6.6%). Among the 15 patients of Group B, 13patients were of Rooksha satmya (86.6 %) and 3 patients were of snigdha satmya (10%).of Rooksha satmya. In the study as a whole (30 patients), 27 patients were of Rookshasatmya (90%) and 3 patients were of Snigdha satmya.(10%).II. DATE RELATED TO THE DISEASE1. CHIEF COMPLAINTS:A. RUKA1. Table No. 39. Showing the distribution of patients by grades of Ruk in both Groups. Ruk Group A % Group B % Total % Grade 0 0 0 0 0 0 0 Grade 1 0 0 0 0 0 0 Grade 2 5 33.33 7 46.6 12 40 Grade 3 10 66.66 8 53.33 18 60A2. Table No: 40. Showing the overall response of patients by grades of Ruk in bothGroups.Ruk Group A Group B Total No GR MR No MR PR No GR MR PRGrade 0 0 0 0 0 0 0 0 0 0 0Grade 1 0 0 0 0 0 0 0 0 0 0Grade 2 5 3 2 7 6 1 12 3 8 1Grade 3 10 5 5 8 7 1 18 5 12 1 117 Observations & Results
    • In the Group A, among the 5 patients (33.33%) of Ruk grade–2, 3 patients gotgood response (60 %) and 2 patients got moderate response (40 %); among the 10patients (66.66%) of Ruk grade–3, 5 patients good response (50 %) and 5 patients gotmoderate response (50 %). In the Group B, among the 7 patients (46.66%) of Ruk grade–2, 6 patients gotmoderate response (85.7%) and 1 patient got poor response (14.28%); among the 8patients (53.33%) of Ruk grade–3, 7 patients got moderate response (87.5 %) and 1patient got poor response (12.5%). In the study as a whole (30 patients), among 12 patients (40%) of Ruk grade–2, 3patients got good response (25%), 8 patients got moderate response (66.66%) and onepatient got poor response (12.5%); whereas among the 18 patients (60%) of Ruk grade–3,5 patients got good response (27.77%), 12 patients got moderate response (66.66%) and 1patient got poor response (5.55%).B. GRAHAB1. Table No41. Showing the distribution of patients by grades of Graha in both Groups. Graha Group A % Group B % Total % Grade 0 0 0 0 0 0 0 Grade 1 15 100 15 100 30 100B2. Table No 42. Showing the overall response of patients by grades of Graha in bothGroups.Graha Group A Group B Total No GR MR No MR PR No GR MR PRGrade 0 0 0 0 0 0 0 0 0 0 0Grade 1 15 8 7 15 13 2 30 8 20 2 118 Observations & Results
    • In Group A among the 15 patients of grade–1 Graha, 8 patients got good response(53.33%) and 7 patients got moderate response (46.66 %). In Group B among the 15 patients of grade–1 Graha, 13 patients got moderateresponse (86.66%) and 2 patient got poor response (13.33%). In the study as a whole (30 patients), among the 30 patients of grade–1 Graha, 8patients got good response (26.66%), 20 patients got moderate response (66.66%) and 2patient got poor response (6.6%).C. 1. SPARSHAAKSHAMATVATable No. 43. Showing the distribution of patients by grades of Sparsha akshmatva inboth Groups. Sparsha Group A % Group B % Total % Akshamatva Grade 0 3 20 3 20 6 20 Grade 1 3 20 7 46.66 10 33.33 Grade 2 9 60 5 33.33 14 46.66 Grade 3 0 0 0 0 0 0C. 2. Table No. 44. Showing the overall response of patients by grades of Sparshaakshmatva in both Groups.Sparshaak Group A Group B Total-shamatva No GR MR No MR PR No GR MR PRGrade 0 3 1 2 3 3 0 6 1 5 0Grade 1 3 2 1 7 6 1 10 2 7 1Grade 2 9 5 4 5 4 1 14 5 8 1Grade 3 0 0 0 0 0 0 0 0 0 0 119 Observations & Results
    • In the Group A, among the 3 patients (20%) of grade-0, 1 patient got goodresponse (33.33%) and 2 patients got moderate response (66.66%); whereas among the 3patients (20%) of grade–1, 2 patients got good response (66.66%) and 1 patient gotmoderate response (33.33%) and among the 9 patients (60%) of grade–2, 5 patients gotgood response (55.55%) and 4 patients got moderate response (44.44%). In the Group B, among the 3 patients (20%) of grade–0, 3 patients got moderateresponse, whereas among the 7 patients (46.66%) of grade–1, 6 patients (85.71%) gotmoderate response and 1 patient (14.28%) got poor response and among the 5 patients(33.33%) of grade–2, 4 patients moderate response (80%) and 1 patient got poor response(20%). In the study as a whole (30 patients), among the 6 patients (20%) of grade–0, 1patient got good response (16.66%), 5 patients got moderate response (83.33%) where asamong the 10 patients (33.33%) of grade–1, 2 patients got good response (20%) and 7patients got moderate response (70%) and patient (10%) got poor response ; among the14 patients (46.66%) of grade–2, 5 patients got good response (35.71%) and 8 patientsgot moderate response (57.14%) and 1 patient (7.14%) got poor response .D.1. Table No. 45. Showing the distribution of patients by grades of Sandhigatiasamarthya in both Groups. Sandhigati Group A % Group B % Total % Asamarthya Grade 0 0 0 0 0 0 0 Grade 1 11 73.33 5 33.33 16 53.33 Grade 2 4 26.66 10 66.66 14 46.66 Grade 3 0 0 0 0 0 0 Grade 4 0 0 0 0 0 0 120 Observations & Results
    • D. 2. Table No. 46. Showing the overall response of patients by grades of Sandhigatiasamarthya in both Groups.Sandhigati Group A Group B Totalasaamarthya No GR MR No MR PR No GR MR PRGrade 0 0 0 0 0 0 0 0 0 0 0Grade 1 11 5 6 5 4 1 16 5 10 1Grade 2 4 3 1 10 9 1 14 3 10 1Grade 3 0 0 0 0 0 0 0 0 0 0Grade 4 0 0 0 0 0 0 0 0 0 0 In the Group A, among the 11 patients (73.33%) with grade–1, 5 patients gotgood response (45.44%) and 6 patients got moderate response (54.54%) where as amongthe 4 patients (26.66%) with grade–2, 3 patients got good response (75 %) and 1 patientsgot moderate response (25%). In the Group B, among the 5 patients (33.33%) with grade–1,4 patients (80%) gotmoderate response 1 patient (20%) got poor response . while among the 10 patients(66.66%) with grade–2, 9 patients got moderate response (90%) and 1 patient got poorresponse (10%). In the study as a whole (30 patients), among the 16 patients (53.33%) of grade–1,5 patients got good response (31.25%) and 10 patients got moderate response (62.25%), 1patient got poor response (12.5%) .Where as among the 14 patients (46.66%) with grade2, 3 patients got good response (21.41%), 10 patients got moderate response (71.14%)and 1 patient got poor response (7.14%). 121 Observations & Results
    • E. ATOPAE1. Table No. 47. Showing the distribution of patients by grades of Atopa in bothGroups. Atopa Group A % Group B % Total % Grade 0 4 26.66 4 26.66 8 26.66 Grade 1 10 66.66 11 73.33 21 70 Grade 2 1 6.66 0 0 1 3.33E. 2. Table No. 48. Showing the overall response of patients by grades of Atopa in bothGroups.Atopa Group A Group B Total No GR MR No MR PR No GR MR PRGrade 0 4 3 1 4 3 1 8 3 4 1Grade 1 10 5 5 11 10 1 21 5 15 1Grade 2 1 0 1 0 0 0 1 0 0 1 In the Group A, among the 4 patients (26.66%) with grade-0 Atopa, 3 patients hadgood response (75%) and 1 patient had moderate response (25%); whereas among the 10patients (66.66%) with grade-1 Atopa 5 patients had good response (50%) and 5 patientshad moderate response (50%), 1 patient (6.66%) of grade-2 got moderate response. In the Group B, among the 4 patients (26.66%) with grade-0 Atopa, 3 patients hadmoderate response (66.66%), 1 patient had poor response (33.33%); where as among the11 patients (73.33%) with grade-1 Atopa 10 patients had moderate response(90.9%) and1 patient got poor response (9.09%). In the study as a whole, among the 8 patients (26.66%) with grade-0 Atopa, 3patients had good response (37.5%) and 4 patients had moderate response (50%) and 1patient had poor response (12.5%); whereas among the 21 patients (70%) with grade-1Atopa, 5 patients had good response (23.80%) and the 15 patients had moderate response(71.42%) and the 1 patient got poor response(4.76%), 1 patient (3.33%) with grade-2Atopa had poor response. 122 Observations & Results
    • F. SHOTHAF.1. Table No.49. Showing the distribution of patients by grades of Shotha in bothGroups. Shotha Group A % Group B % Total % Grade 0 4 26.6 5 33.33 9 30 Grade 1 6 40 4 26.6 10 33.33 Grade 2 4 26.6 6 40 10 33.33 Grade 3 1 6.66 0 0 1 3.33F2. Table No. 50. Showing the overall response of patients by grades of Shotha in bothGroups. Shotha Group A Group B Total No GR MR No MR PR No GR MR PRGrade 0 4 3 1 5 5 0 9 3 6 0Grade 1 6 2 4 4 3 1 10 2 7 1Grade 2 4 4 0 6 5 1 10 4 5 1Grade 3 1 0 1 0 0 0 1 0 1 0 In the Group A, among the 4 patients (26.66%) with grade-0, 3 patients got goodresponse (75%) and 1 patients got moderate response (25%); where as among the 6patients (40%) with grade-1, 2 patients got good response (33.33%) and 4 patients gotmoderate response (66.66%) and the 4 patients (26.66%) with grade-2, all got goodresponse and 1 patient (6.66%) with grade-3 got moderate response. In the Group B, among the 5 patients (33.33%) with grade-0, all 5 patients gotmoderate response, whereas among the 4 patients (26.66%) with grade-1, 3 patients gotmoderate response (75%) and 1 patient got poor response (25%). Among the 6 patients(40%) with grade-2, 5 patients got moderate response (83.33%) and 1 patient got poorresponse (16.66%). 123 Observations & Results
    • In the study as a whole (30 patients), among the 9 patients (30%) with grade-0, 3patients got good response (33.33%), 6 patients got moderate response (66.66%), whereas among the 10 patients (33.33%) with grade-1, 2 patients got good response (20%) and7 patients got moderate response (70%) and 1 patient got poor response (10%); amongthe 10 patients (33.33%) with grade-2, 4 patients got good response (40%) and 5 patientsgot moderate response( 50%) and 1 patient got poor response (10%) the only 1 patient(3.33%) with grade-3 got moderate response.G. Table No. 51. Showing the distribution of patients by presenting complaints.Sl. Presenting complaint No. of Pt.’s %1 Prasarana akunchanayoho savedana pravritti 26 86.662 Ruk 30 1003 Vatapoorna dritisparsha 3 104 Shopha 21 705 Sandhigraha 30 1006 Sandhigati asaamarthya 30 1007 Sparsha akshamatva 24 808 Atopa 22 73.33 Among the 30 patients included in this study, all the patients had the symptomsRuk, Sandhi graha and Sandhigati asaamarthya. 26 patients had the symptom prasaranaakunchanayoho savedana pravritti (86.66%). Only 3 patients had the symptomVatapoorna dritisparsha (10%) whereas 21 patients had the symptom Shopha (70%) and24 patients had the symptom Sparsha akshamatva (80%) and 22 patients had theSymptom Atopa (73.33%). 124 Observations & Results
    • 2.A. Table No. 52 Showing the distribution of patients by chronicity in both Groups. Chronicity Group A % Group B % Total % >2 years (A) 5 33.33 2 13.33 7 23.33 1-2years (B) 7 46.66 10 66.66 17 56.66 <1year (C) 3 20 3 20 6 202. B. Table No. 53. Showing the overall response of patients by Chronicity of the diseasein both Groups.Duration Group A Group B Total No GR MR No MR PR No GR MR PR>2 years (A) 5 4 1 2 1 1 7 4 2 11-2years (B) 7 3 4 10 9 1 17 3 13 1<1year (C) 3 1 2 3 3 0 6 1 5 0 In the Group A, among the 5 patients (33.33%) with >2 years duration, only 4patient had good response (80%) while 1 patient had moderate response (20%); amongthe 7 patients (46.66%) with 1-2 years duration, 3 patients had good response (42.85%)while 4 patients had moderate response (57.14%); among the 3 patients (20%) with <1year duration, 1 patient had good response (33.33%) while 2 patients had moderateresponse (66.66%). In the Group B, the 2 patients (13.33%) with >2 years, 1 patient got moderateresponse and 1 patient got poor response. Among the 10 patients (66.66%) with 1-2 yearsduration, 9 patients got moderate response (90%) and 1 patient got poor response (10%),while among the 3 patients (20%) with <1 year duration, all patients got moderateresponse. In the study as a whole (30 patients), among the 7 patients (23.33%) with > 2years duration, 4 patients got good response (57.14%) and 2 patients got moderateresponse (28.57 %) and 1 patient got poor response (14.28%), among the 17 patients(56.66%) with 1-2 years duration, 3 patients got good response (17.64%) and 13 patientsgot moderate response (76.47%) and 1 patient got poor response (5.88%), among the 6patients (20%) with <1 year duration, 1 patient got good response (16.66%), 5 patientsgot moderate response (83.33%). 125 Observations & Results
    • 3.A. Table No. 54. Showing the distribution of patients by Mode of onset in both Groups. Mode of Onset Group A % Group B % Total % Chronic 11 73.33 12 80 23 76.66 Insidious 4 26.66 1 6.66 5 16.66 Acute 0 0 1 6.66 1 3.33 Traumatic 0 0 1 6.66 1 3.333.B. Table No. 55 Showing the overall response of patients by Mode of onset of thedisease in both Groups. Mode of Group A Group B Total onset No GR MR No MR PR No GR MR PR Chronic 11 5 6 12 12 0 23 5 18 0 Insidious 4 3 1 1 1 0 5 3 2 0 Acute 0 0 0 1 0 1 1 0 0 1 Traumatic 0 0 0 1 0 1 1 0 0 1 In the Group A, among 11 patients (73.33%) of chronic onset, 5 patients got goodresponse (45.45%) and 6 patients got moderate response (54.54%); among the 4 patients(26.66%) of insidious onset, 3 patient got good response (75%) and 1 patients gotmoderate response (25%); In the Group B, all the 12 patients (80%) of chronic onset got moderate response1 patient (6.66%) of insidious onset got moderate response, while the 1 patient (6.66%)of acute onset got poor response and 1 patient (6.66%) of traumatic onset got poorresponse. In the study as a whole (30 patients), among the 23 patients (76.66%) of chroniconset, 5 patients got good response (21.73%) and 18 patients got moderate response(78.26%); among the 5 patients (16.66%) of insidious onset, 3 patient got good response(60%) and 2 patients got moderate response (40%), both the patients of acute andtraumatic onset got poor response. 126 Observations & Results
    • 4. 1.A Table No. 56. Showing the distribution of patients by Aharaja nidana in bothGroups. Aharaja Nidana Group A % Group B % Total % Tikta rasa 2 13.33 2 13.33 4 13.33 Kashaya rasa 5 33.33 6 40 11 36.6 Katu rasa 13 86.6 14 93.33 27 90 Alpa bhojana 8 53.33 10 66.66 18 60 Pramita bhojana 1 6.6 2 13.33 3 10 Rooksha bhojana 12 80 12 80 24 804.1. B Table No. 57. Showing the overall response of patients by Aharaja nidana of thedisease in both Groups:Aharaja Group A Group B Totalnidana No GR MR No MR PR No GR MR PRTikta 2 1 1 2 1 1 4 1 2 1rasaKashaya 5 4 1 6 6 0 11 4 7 0rasaKatu 13 7 6 14 14 0 29 7 20 0rasaAlpa 8 3 5 10 9 1 18 3 14 1bhojanaPramita 1 0 1 2 2 0 3 0 3 0bhojanaRooksha 12 6 6 12 11 1 24 6 17 1bhojana In Group A, among 2 patients (13.33%) having Tikta rasa nidana, 1 patients gotgood response (50%) and 1 patient got moderate response (50%); among 5 patients(33.33%) having Kashaya rasa nidana, 4 patients got good response (80%) and 1 patientgot moderate response (20%); among 13 patients (86.6%) having Katu rasa nidana, 7patients got good response (53.84%) and 6 patients got moderate response (46.15%); 127 Observations & Results
    • among 8 patients (53.33%) having Alpa bhojana nidana, 3 patients got good response(37.5%) and 5 patients got moderate response (62.5%); among 1 patient (6.66%) havingpramita bhojana got moderate response; among 12 patients (80%) having rookshabhojana nidana, 6 patients had good response (50%) and 6 patients had moderateresponse (50%). In Group B, the 2 patients (13.33%) having Tikta rasa nidana 1 patient gotmoderate response and 1 patient got poor response. all the 6 patients(40%) havingKashaya rasa nidana got moderate response; all the 14 patients (93.33%) having Katurasa nidana got moderate response; among the 10 patients (66.66%) having Alpa bhojananidana, 9 patients got moderate response (90%) and 1 patient got poor response (10%);all the 2 patients (13.33%) having Pramita bhojana got moderate response; among the 12patients (80%) having Rooksha bhojana nidana, 11 patients got moderate response(91.66%) and 1 patient got poor response (8.33%). In the study as a whole (30 patients), among the 4 patients (13.3%) of Tikta rasanidana, 1 patient got good response (25%) and 2 patients got moderate response (50%)and 1 patient got poor response (25%); among the 11 patients (36.66%) of Kashaya rasanidana 4 patients got good response (36.36%) and 7 patients got moderate response(63.36%); among the 27 patients (90%) of Katu rasa nidana, 7 patients got good response(25.92%), 20 patients got moderate response (74%); among the 18 patients (60%) of Alpabhojana nidana, 3 patients got good response (16.66%) and 14 patients got moderateresponse (77.77%) and 1 patient got poor response (5.55%); all the 3 patients (10%) ofPramita bhojana got moderate response; among the 24 (80%) patients of Rookshabhojana, 6 patients got good response (25%), 17 patients got moderate response (70.8%)and 1 patient got poor response (4.16 %). 128 Observations & Results
    • 4.2. A Table No. 58. Showing the distribution of patients by Viharaja nidana in bothGroups. Viahraja Nidana Group A % Group B % Total % Vega dharana 11 73.33 10 66.66 21 70 Vega udeerana 2 13.33 5 33.3 7 23.33 Ati vyavaya 1 6.66 0 0 1 3.33 Nisha jagarana 9 60 9 60 18 60 Atyucha bhashana 1 6.66 3 20 4 13.33 Ativyayama 10 66.66 9 60 19 63.34.2. B Table No. 59. Showing the overall response of patients by Aharaja nidana of thedisease in both Groups. Viharaja Group A Group B Total nidana No GR MR No MR PR No GR MR PRVega 11 6 5 10 9 1 21 6 11 1dharanaVega 2 1 1 5 5 0 7 1 6 0udeeranaAti vyavaya 1 0 1 0 0 0 1 0 1 0Nisha 9 6 3 9 9 0 18 6 12 0jagaranaAthyucha 1 1 0 3 3 0 4 1 3 0bhashanaAtivyayama 10 5 5 9 8 1 19 5 13 1 In the Group A, among 11 patients (73.33%) of Vega dharana nidana, 6 patientshad good response (54.54%) and 5 patients had moderate response (45.45%); among the2 patients (13.33%) of Vega udeerana 1 patient got good response and 1 patient gotmoderate response ; 1 patient (6.66%) of Ativyavaya got moderate response ; among 9patients (60%) of Nisha jagarana, 6 patients had good response (66.66%) and 3 patientshad moderate response (33.33%); 1 patients of Athyucha bhashana got good response ;among the 10 patients (66.66%) of Ativyayama, 5 patients got good response (50%) and5 patients got moderate response (50%). 129 Observations & Results
    • In the Group B, among 10 patients (66.66%) of Vega dharana nidana, 9 patientshad moderate response (90%) and 1 patient had poor response (10%); all the 5 patients(33.33%) of Vega udeerana, 9 patients (60%) of Nisha jagarana and 3 patients (20%) ofAthyucha bhashana had moderate response; among the 9 patients (60%) of Ativyayama,8 patients had moderate response (88.88%) and 1 patient had poor response (11.11%). In the study as a whole (30 patients), among the 21 patients (70%) of Vegadharana nidana, 6 patients had good response (28.57%), 11 patients had moderateresponse (52.38%) and 1 patient had poor response (7.76%); among 7 patients (23.33%)of Vega udeerana one patient had good response (14.28%) and 6 patients had moderateresponse (85.71%); 1 patient (3.33%) of Ati vyavaya had moderate response; among the18 patients (60%) of Nisha jagarana, 6 patients had good response (33.33%) and 12patients had moderate response (66.66%); among the 4 patients (13.33%) of Athyuchabhashana, 1 patient had good response (25%) and 3 patients had moderate response(75%); among the 19 patients (63.3%) of Ativyayama, 5 patients got good response(26.31%), 13 patients got moderate response (68.42%) and 1 patient got poor response(5.26 %). 130 Observations & Results
    • 4.3 Table No. 60. Showing the distribution of Patients by various Manasika Vatakopanidanas in both the treatment Groups (A &B): Manasika Group A % Group B % Total % Nidana Bhaya 1 6.66 3 20 4 13.33 Shoka 1 6.66 1 6.66 2 6.66 Chinta 12 80 8 53.33 20 66.66 Among the 15 patients in Group A, Only 1 patient had Bhaya (6.66%),1 patienthad Shoka (6.66%) and 12 patients had Chinta (80%). Among the 15 patients in Group B,Only 3 patient had Bhaya (20%),1 patient had Shoka (6.66%) and 8 patients had Chinta(53.33%). In the study whole (30 patients), 4 patients had Bhaya (13.33%), 2 patientshad Shoka (6.66%), and 20 patients had Chinta (66.66%).5. Table No: 61. Showing the distribution of patients by Radiological interpretation inboth Groups. Radiological Group A % Group B % Total %interpretationJoint Incr. 2 13.33 0 0 2 6.66space Decr. 10 66.66 9 60 19 63.33 Unalt. 3 20 2 13 33 5 16.66Sub. Bon. Scl. 4 26.66 3 20 7 23.33Osteophytes 15 10 14 93.33 29 96.66Peri.Art.Oss. 1 6.66 1 6. 66 2 6.66Alt. Bne. End 0 0 0 0 0 0 Among the 30 patients in this study, 2 patients had their affected joint spaceincreased (6.66%), 19 patients had their affected joint space reduced (63.33%), 5 patientshad their affected joint space unaltered (16.66%), 7 patients had subchondral bonysclerosis (23.33%), 29 patients had osteophytes formation (96.66%), 2 patients hadperiarticular ossicles (6.66%) and no patient had altered bone end. 131 Observations & Results
    • III. Data Related to Overall Response to the treatmentIII. Table No. 62. Showing the overall response in both Groups. Response Group A % Group B % Total %Good 8 53.33 0 0 8 26.6Moderate 7 46.66 13 86.66 20 66.6Poor 0 0 2 13.33 2 6.6No response 0 0 0 0 0 0 In Group A, 8 patients (53.33%) had good response to the treatment (> 60%improvement in all the parameters) and 7 patients (46.66%) had moderate Response tothe treatment (31-60% improvement in all the parameters). In Group B, 13 patients(86.66%) had moderate response to the treatment and 2 patients (13.33%) had poorresponse to the treatment (1-30% in all the parameters). In the study as a whole, 8patients (26.6%) had good response, 20 patients (66.6%) had moderate response and 2patient (6.6%) had poor response. 132 Observations & Results
    • IV. Statastical analysis of the Subjective and Objective Parameters & InterGroupcomparisionTable No. 63. Showing the before and after treatment values of all parameters in Gr. A.Sl. OPD Subjective 0bjective parametersNo. No. parameters Ruk Graha Sp.Ak. SGA Atopa Shotha Walking time B A B A B A B A B A B A B A01. 5193 3 2 1 0 3 2 1 3 1 0 0 0 45 3302. 5198 2 1 1 0 3 1 1 3 1 0 0 0 58 4203. 1503 3 2 1 0 3 1 1 3 1 1 0 0 42 3404. 204 3 2 1 1 3 2 1 3 1 0 1 0 56 3605. 1224 3 2 1 1 2 2 1 2 2 1 1 0 45 4806. 1015 3 1 1 1 2 2 1 2 1 1 1 0 44 3507. 991 2 1 1 0 3 0 1 3 1 0 0 0 38 2608. 5427 2 1 1 0 3 2 1 3 0 0 1 0 43 3809. 2566 2 1 1 0 3 2 2 3 0 0 2 1 55 4510. 5210 3 2 1 0 2 2 1 2 1 0 3 2 56 4811. 5265 3 2 1 1 3 1 2 3 0 0 2 1 58 3712. 5189 2 1 1 0 3 2 1 3 1 0 1 1 42 3213. 706 3 2 1 0 3 0 2 3 0 0 1 0 54 4714. 1992 2 1 1 0 3 2 2 3 1 0 2 1 46 3315. 1223 2 1 1 0 3 0 1 3 1 0 2 1 56 38Table No. 64. Showing before and after treatment values of all parameters in Gr. B.Sl. OPD Subjective 0bjective parametersNo. No. parameters Ruk Graha Sp.Ak. SGA Atopa Shotha Walking time B A B A B A B A B A B A B A16 1185 3 1 1 0 2 1 1 2 1 0 1 1 44 4217 2243 2 1 1 0 1 1 2 3 0 0 2 1 48 4618 5225 2 1 1 0 1 1 2 3 1 1 1 0 48 3619 5263 3 1 1 0 1 0 1 2 1 0 2 1 56 4820 1315 3 2 1 0 2 1 2 3 1 1 2 1 43 4221 0902 3 1 1 0 0 0 1 2 0 0 0 0 55 4422 1070 2 0 1 1 0 0 2 2 0 0 0 0 57 5623 5293 2 0 1 0 0 0 2 3 0 0 0 0 58 5724 5120 2 1 1 1 2 1 1 2 1 0 1 0 42 3425 5010 3 2 1 0 1 1 2 3 1 1 2 1 59 4226 5176 3 1 1 0 2 1 2 3 1 1 2 0 52 5227 5466 3 1 1 0 1 0 1 2 1 1 0 0 47 3528 5160 3 1 1 0 1 1 2 3 1 0 2 1 42 3229 1450 3 1 1 1 1 0 2 3 1 1 1 0 56 5430 5299 3 1 1 0 2 1 2 3 1 0 0 0 35 33 133 Observations & Results
    • Table No. 65. Showing the individual study of Group-AParameters Mean S.D S.E t-value p-value RemarksRuk 1.066 0.258 0.066 16.15 <0.001 H.S.Graha 0.866 0.352 0.09 9.62 <0.001 H.S.Sparsha akshamatva 0.933 0.594 0.153 6.09 <0.001 H.S.Sandhigati asamarthya 1.533 0.156 0.04 38.32 <0.001 H.S.Shotha 0.666 0.488 0.126 5.285 <0.001 H.S.Atopa 0.6 0.507 0.13 4.615 <0.001 H.S.Walking time 11.3 5.576 1.439 7.873 <0.001 H.S.Table No. 66. Showing the individual study of Group-BParameters Mean S.D S.E t-value p-value RemarksRuk 1.667 0.488 0.126 13.23 <0.001 H.S.Graha 0.8 0.414 0.106 7.547 <0.001 H.S.Sparsha akshamatva 0.6 0.507 0.13 4.615 <0.001 H.S.Sandhigati asamarthya 0.533 0.516 0.13 4.1 <0.01 H.S.Shotha 0.666 0.617 0.159 4.18 <0.001 H.S.Atopa 0.333 0.487 0.125 2.664 <0.02 H.S.Walking time 6.8 5.08 1.313 5.17 <0.001 H.S.Table No. 67. Showing the inter Group comparison.Parameters Group Mean S.D S.E P.S.E t- p- Rema value value rksRuk A 1.466 0.516 0.133 0.191 2.44 <0.05 HS B 1.0 0.534 0.137Graha A 0.133 0.352 0.09 0.139 0.482 >0.05 NS B 0.2 0.414 0.106Sparsha A 0.466 0.516 0.133 0.186 0.720 >0.05 NSakshamatva B 0.6 0.507 0.131Sandhigati A 2.8 0.414 0.106 0.168 1.19 >0.05 NSasamarthya B 2.6 0.507 0.131Shotha A 0.467 0.639 0.165 0.21 0.319 >0.05 NS B 0.4 0.507 0.131Atopa A 0.2 o.414 0.106 0.168 1.19 >0.05 NS B 0.4 o.507 0.131Walking time A 37.866 6.22 1.606 2.702 2.070 <0.05 HS B 43.46 8.416 2.173 134 Observations & Results
    • When we compare the Group A and B the parameter Ruk and Walking timeshows. Highly significant than the other by comparing the mean effect of the two Groupsafter the treatment (As P<0.05). But all other parameters shows non significant. Themean effect after treatment in the parameter Graha , Sandhigati asamarthy, Sopha is morein Group –A with less variationce. (By comparing mean, S.D). Indivisually both the two Groups shows highly significant before and after thetreatment (By comparing P-values). But Group-A more highly significant than Group-Bin all the parameters (By comparing t-values). The mean net effect of the parameter Walking time, Sandhigati asamarthy, andSparsha akshamatva is more in Group-A with more variation (By comparing mean, S.D.)Overall the Group-A is more significant than Group-B in all the parameters. (Bycomparing t- value). In Group A, 53.33% patients had good response and 46.33% patients had moderateresponse to the treatment. Where as in Group-B, 86% patients had moderate response and13.33% patients had poor response to the treatment hence it conveys that the Parishekaand Matrabasti group responded in comparision wiyh the Parisheka group. 135 Observations & Results
    • IGraph No. 01. Showing the distribution of patients by Age in both groups. Distribution of Pt.s by Age in both Groups 25 21 20 15 12 No. of Pt.s 8 9 10 5 5 3 1 0 1 0 35-44 45-54 55-64 Group A Group B Total Age groupsGraph No. 02. Showing the distribution of patients by Sex in both groups. Distribution of Pt.s by Sex in both groups 20 17 15 13 No. of Pt.s 9 10 7 8 6 5 0 Male Fem ale Group A Group B Total SexGraph No. 03. Showing the distribution of patients by Occupation in both groups. Distribution of Pt.s by Occupation in both Grs 16 14 14 No. of Pt.s 12 10 10 8 7 7 6 6 6 4 4 4 2 2 0 0 0 0 Sed Act Lab Oth Group A Group B Total Occupation
    • IIGraph No. 04. Showing the distribution of patients by Economical status in both groups. Distribution of Pt.’s by Economical status in both groups 16 14 14 12 10 No. of Pt.s 10 8 7 7 7 6 6 5 4 3 2 1 0 Poor Middle class High class Group A Group B Total Economical StatusGraph No. 05. Showing the distribution of patients by Religion in both groups. Distribution of Pt.s by Religion in both Grs 30 25 25 20 No. of Pt.s 14 15 11 10 5 4 5 1 0 0 0 0 Hindu Muslim Christian Group A Group B Total ReligionsGraph No. 06. Showing the distribution of patients by Dietary habits in both groups. Distribution of Pt.’s by Dietary habits in both groups 18 17 16 No. of Pt.s 14 13 12 10 10 8 8 7 6 5 4 2 0 Vegetarian Mixed Group A Group B Total Dietary Habits
    • IIIGraph No. 07. Showing the distribution of patients by Agni in both groups. Distribution of Pt.s by Agni in both Grs 20 16 15 11 No. of Pt.s 10 10 7 6 4 5 3 2 1 0 0 0 0 Md Tk Vi Sa Group A Group B Total AgniGraph No. 08. Showing the distribution of patients by Koshta in both groups. Distribution of Pt.s by Koshta in both Grs 20 18 No. of Pt.s 15 10 9 10 8 6 5 3 3 2 1 0 Madhya Mridu Krura Group A Group B Total KoshtaGraph No. 09. Showing the distribution of patients by Nidra in both groups. Distribution of Pt.s by Nidra habits in both grs 25 21 20 No. of Pt.s 15 10 11 9 10 5 4 5 0 0 0 0 0 0 0 Sukha Alpa Ati Vishama Group A Group B Total Nidra Habits
    • IVGraph No. 10. Showing the distribution of patients by Vyasana in both groups. Distribution of Pt.s by Vyasana in both Grs 14 13 12 No. of Pt.s 10 8 7 6 6 6 6 5 4 4 3 3 3 2 2 2 0 0 0 0 Smk Tbc Alc Oth None Group A Group B Total VyasanaGraph No. 11. Showing the distribution of patients by Prakriti in both groups. Distribution of Pt.’s by Deha prakriti in both groups 16 15 14 No. of Pt.s 12 10 9 8 8 7 6 5 4 4 3 3 2 2 2 1 1 00 0 0 0 0 0 0 0 0 V P K VP VK PK T Group A Group B Total Deha PrakritiGraph No. 12. Showing the distribution of patients by Satmya in both groups. Distribution of Pt.s by Satmya in both Grs 30 27 No. of Pt.s 25 20 14 13 15 10 5 2 3 1 0 Rooksha Snigdha Group A Group B Total Satmya
    • VGraph No. 13. Showing the distribution of patients by different grades of Ruk in bothgroups. Distribution of Pt.s by Ruk in both Groups 20 18 15 12 No. of Pt.s 10 10 8 7 5 5 0 0 0 0 0 0 0 Grade 0 Grade 1 Grade 2 Grade 3 Group A Group B Total Ruk assessment GradingsGraph No. 14. Showing the distribution of patients by different grades of Graha in bothgroups. Distribution of Pt.s by Graha in both Groups 30 30 25 No. of Pt.s 20 15 15 15 10 5 0 0 0 0 Grade 0 Grade 1 Group A Group B Total Graha assessment GradingsGraph No. 15. Showing the distribution of patients by different grades ofSparshaakshmatva in both groups. Distribution of Pt.’s by Sparshaakshmatva in both groups 16 14 14 12 10 No. of Pt.s 10 9 8 7 6 6 5 4 3 3 3 2 0 0 0 0 Grade 0 Grade 1 Grade 2 Grade 3 Group A Group B Total Sparshaakshamatva assement gradings
    • VIGraph No. 16. Showing the distribution of patients by different grades of Sandhigatiasamarthya in both groups. Distribution of Pt.’s by Sandhigati Asamarthya in both groups 18 16 16 14 No. of Pt.s 14 12 11 10 10 8 6 5 4 4 2 0 0 0 0 0 0 0 0 0 0 Grade 0 Group A Grade 1 Grade 2 Grade 3 Grade 4 Group B Total Sandhigati Asamarthya assessment gradingsGraph No. 17. Showing the distribution of patients by different grades of Atopa in bothgroups Distribution of Pt.s by Atopa in both Groups 25 21 20 No. of Pt.s 15 10 11 10 8 4 4 5 1 0 1 0 Grade 0 Grade 1 Grade 2 Group A Group B Total Atopa assessment gradingsGraph No. 18. Showing the distribution of patients by different grades of Shotha in bothgroups Distribution of Pt.s by Shotha in both Groups 12 10 10 10 9 8 6 6 No. of Pt.s 6 5 4 4 4 4 2 1 1 0 0 Grade 0 Grade 1 Grade 2 Grade 3 Group A Group B Total Shotha assessement gradings
    • VIIGraph No. 19. Showing the distribution of patients by Presenting complaints in bothgroups. Distribution of Pt.s by presenting complaints 35 30 30 30 30 26 No. of Pt.s 24 25 21 22 20 15 10 5 3 0 A B C D E F G H No. of Patients Presenting complaintGraph No. 20. Showing the distribution of patients by Chronicity in both groups. Distribution of Pt.s by Chronicity in both Grs 18 17 16 14 12 No. of Pt.s 10 10 8 7 7 6 6 5 4 3 3 2 2 0 >2 years (A) 1-2years (B) <1year (C) Group A Group B Total ChronicityGraph No. 21. Showing the distribution of patients by Mode of onset in both groups. Distribution of Pt.s by Mode of onset in both Grs 25 23 20 15 11 12 No. of Pt.s 10 4 5 5 1 0 1 1 0 1 1 0 Chr Ins Ac Tr Group A Group B Total Mode of Onset
    • VIIIGraph No. 22. Showing the distribution of patients by Aharaja Nidana in both groups. Distribution of Pt.s by Aharaja Nidana in both Groups 30 27 24 25 No. of Pt.s 20 18 15 1314 1212 11 10 10 8 4 5 6 5 2 2 3 1 2 0 A B C D E F Aharaja Nidana Group A Group B TotalGraph No. 23. Showing the distribution of patients by Viahraja nidana in both groups. Distribution of Pt.s by VIharaja Nidana in both Grs 25 21 18 19 20 15 1110 No. of Pt.s 9 9 10 9 10 7 5 5 2 3 4 1 0 1 1 0 A B C D E F Group A Group B Total Viharaja NidanaGraph No. 24. Showing the distribution of patients by Manasika nidana in both groups. Distribution of Pt.’s by Manasika Nidana in both groups 25 20 20 No. of Pt.s 15 12 10 8 4 5 3 2 1 1 1 0 Bhaya Shoka Chinta Group A Group B Total Manasika Nidana
    • IXGraph No. 25. Showing the distribution of patients by Overall response in both groups. Distribution of Pt.’s by Overall response in both groups 25 20 20 No. of Pt.s 15 13 10 8 8 7 5 2 2 0 0 0 0 0 0 GR MR PR NR Group A Group B Total Overall response
    • Science is the only media to observe and analyze the all kinds of events in theuniverse. The systematic arrangement of facts and events, ascertained by observationsand interpretation makes the facts a part of the science. Discussions on the study are made under the following headings: 1. Sandhigatavata vis-à-vis Osteoarthritis 2. Probable mode of action of Parisheka in the management of Sandhigatavata 3. Probable mode of action of Matrabasti in the management of Sandhigatavata 4. Clinical studySANDHIGATAVATA vis-à-vis OSTEOARTHRITIS Sandhigatavata is the most common joint disorder arising with greater number ofaffected population in the world. It comes under the various Gatavatas explained inVatavyadhi prakarana. It is caused by the localization of the vitiated Vata dosha in theasthi sandhis of the body. It is characterized by the symptoms pertaining to the asthisandhis like sandhi shoola, sandhi shotha etc. Osteoarthritis is a disease coming under the arthritis group of diseases describedby the modern science, which is almost identical to Sandhigatavata in etiology, pathologyand clinical features. Hence, the discussion is made accordingly.Discussion On Shareera In the context of Asthi sandhi means a junction between two or more bones.Sandhi is not a single structure rather it is considered as an organ. There are differentstructures, which supports the stability of the joint like Sanyu or ligament, which helps inproper binding of the joint. They unite the bones and help to direct the bone movementand prevent the excessive and undesirable motion. Muscle tone helps to maintain the 136 Discussion
    • alignment of the joint. Shleshaka Kapha present in the Sandhis provides the lubricantfactors, Shleshmadharakala situated in the joints supported by Shleshaka Kapha helps inlubrication. Functions of the Shleshaka Kapha and Shleshmadhara kala described inAyurveda can be co-related to the synovial fluid situated in synovial joint that lubricatesthe knee joint, a nutrient carrier to the cartilage, disc, and helps in keeping the joint firmlyunited. Role of Vyanavata is most important in the movements of the joints. The Marmasare considered as the point of union of nerves, vessels and muscular system, which arevital in the structure and functioning status of the joints. Functions of the peshis andsnayus are exactly identical to that of the muscles and ligaments related to the joints. Knee works as a hinge joint, but the articulation is more complex than other hingejoints. Seven major ligaments, flexor and extensor muscles support the movements of theknee joint.Discussion On Nidana Ayurvedic philosophy mainly emphasized on Vatakara ahara-vihara in themanifestation of Sandhigatavata. Vardhakya is predominated by Vata dosha andcharacterized by Dhatu kshaya leads to reduced Sneha bhava in the body, which in turn,vitiates the Vata dosha and reduces the Kapha, thereby resulting in Karmahani of thesandhis. Also, dhatushaithilya is another feature in Vardhakya, which reflects in peshisand snayus thereby reducing their functional efficiency in supporting the joints. This is amajor risk factor for Sandhigatavata. Age is the most powerful risk factor for Osteoarthritis. More than 80% of thepeople over the age of 60 have radiological evidence of Osteoarthritis in the joints. 137 Discussion
    • Various physical activities such as Pradhavana, Bharaharana and Abhighatas dueto prapatana, Marma abhighata, Dukha shayya and Dukha asana are important Nidanasfor Sandhigatavata. Repetitive movements may lead to excessive strain leading to erosionand joint damage. Trauma to the joint enhances the occurrence of arthritis. Sthoulya is another causative factor for Sandhigatavata. Vatavyadhee andSthoulya are having interrelated pathogenesis. (i.e. Medavrita vata) Obese person have ahigh risk of Osteoarthritis. The relative risk of developing Osteoarthritis, is more in thepopulation belonging to the high quintile body mass index.Discussion On Samprapti The Samprapti of Sandhigatavata may be divided into Dhatukshayajanya andAvaranajanya. Modern science explains the pathogenesis of Osteoarthirits in two ways – 01. Sub-standard biomaterial of the joint (Dhatukshaya). 02. Increased applied pressure over the joint (Avarana). In Dhatukshyajanya Sandhigatavata due to old age and excess use of Vatakaraahara-vihara causes qualitative changes in the joint material gradually leading to diseasemanifestation i.e. age related degenerative changes. Samprapti of Margavaranajanya sandhigatavata initiated by the nidana ghatakaSthoulya involving the avarana of Vata by Kapha and medas, which can be correlatedwith complications of obesity where in due to continuous pressure, joints get affected(due to Avarana) leading to disease manifestation. 138 Discussion
    • Discussion On Symptomatology The lakshanas of Sandhigatavata, viz. Vedanayukta pravritti of sandhis, Shotha(Vatapoorna dritisparshavat), Atopa and Sandhigati asaamarthya, etc are explained byvarious treatises of Ayurveda. Modern science, has mentioned similar features along withother symptoms pertaining to individual joints. Tenderness and joint stiffness (implied bythe restriction of joint movements) are specially monitored in Modern science and furtheradded that any joint can get affected with Osteoarthritis. Acharyas have not paid theirattention towards the site of particular joint involvement. When there are structuralchanges in the joints the disease can be categorized as Asadhya.Discussion On Chikitsa The chikitsa of Sandhigatavata is Snehana, Swedana and Agnikarma Since it is aVata vikara and Dhatukshaya of resultant, Snehana and Swedana would be an ideal lineof treatment. In the contemporary science treatment is mainly aimed at Non–pharmacological methods and analgesics. Among Non–pharmacological treatment muchimportance is given to physical heat therapy.PROBABLE MODE OF ACTION OF PARISHEKA Parisheka is a variety of the Swedana, which is described as Poorvakarma forPanchakarma and included in Shada upakramas. Sneha dravya is used as media in case ofParisheka. Its dual action facilitates in alleviating Vata effectively. The Vata dosha,which is the key factor in the casuation of Sandhigatavata, has almost opposite quality toSneha. Moreover, properties of Sneha dravya resembles property to that of Kapha. InSandhigatavata sthanika kaphakshaya occurs due to Agantu vata dosha. Thus, Parishekaneutralizes the Vata dosha and simultaneously nourishes the Sthanika kapha dosha. Thishelps in Samprapti Vighatana of Sandhigatavata. 139 Discussion
    • Sandhigatavata is characterized by joint pain, stiffness, swelling and crepitus.The heat applied to the joint helps in combating many of the symptoms. Parisheka actsboth Snehana as well as Swedana. In this disease degeneration is predominant, Vata is inthe Prakupita avastha and there is Kshaya of sneha bhava. Snigdha sweda would be anideal line of management. The main theme of Vatasyopakrama emphasizes on Snigdha and Ushnabhava.Parisheka is a type of Snigdha sweda through which Snehana and Swedana are carriedout. Snehana corrects the Shuska dhatus which are the root cause for the Vata vitiationand imparts strength. Swedana relieves Toda, Ruk, Ayama, Shotha, Stambha, etc ofsymptoms of Vata and smoothens the body parts. Repetitive uses of this karma isessential for the total control of Vata and restoration of its normal functions. Sandhigatavata is a disease of the madhyama rogamarga involving the asthisandhis of the body. Asthis are the ashraya of the Vata dosha and the vitiation of Vatahampers the nourishment of asthis, which reflects in Sandhis. Such a mal-nourishmentinvolves the reduction of the Sleshaka kapha and deterioration of the Sleshmadharakala.Snehana provides the Snehabhava needed for the nourishment of these in turn controlsthe vitiated Vata. Swedana relieves the Stambha and Gourava of the joints and related structuresinvolved in the joint movements. Stambha means stiffness, this attribute is a resultant ofexcess of seetha guna and also influence of factors such as Samanavata, Shleshakakapha,Ama, Mamsa, Vasa and Medas, which were contributory to occurrence of Stambha.Samanavata is Rooksha guna pradhana and in vitiated state it does excessive Shoshana ofshareera there by resulting in contractures and stiffness. Sleshakakapha is Snigdha andPicchila and in decreased state (Kshaya) results in less lubrication of joints causingStiffness. Parisheka being Snigdha and Ushna corrects both these deranged Doshaghatakas and relieves stiffness. 140 Discussion
    • The ingredients of Shatahvadi taila are Shatahva, Yava, Bilva, Kanji and Tilawhich having properties viz Vatashamaka, Kaphashamaka and possessing actions likeVedanashamaka, Shotahara and Vatanulomana which plays vital role in correcting thepathology. Susruta stated that out of the four tiryak dhamanis, each divides graduallyhundred and thousand times and thus become innumerable. These cover the body likenetwork and their openings are attached to Romakoopa. Through them only Veeryas ofAbhyanga, Parisheka, Avagaha, Alepa enters into the body after under going Paka withBhrajaka pitta located in skin. In Sutrasthana he explains, Lepa in Bahirparimarjanatreatments yield result by entering into Romakoopa thereby enters in circulating throughSwedavaha srotas. Cell membrane act as a barrier to the passage of water soluble molecules butprovide free passage to lipid and lipid soluble substances. Rapid diffusion of lipid solublesubstances through cell membranes and the dependency of the rate of diffusion onsolubility in lipids have been proved. Lipoid substances which are similar to the cellmembrane lipids get directly in corporated into the cell membrane. Some of the lipids andlipid soluble substances directly reach the cytoplasm trough cell membrane. Application of heat through unctuous substance causes the generation of atemperature gradient across the cell membrane. Besides facilitating the diffusion of liquidsubstances through the cell membrane, this plays key role in the formation of lipoidvesicles from the dropouts in the membrane in areas of flow temperature. This causes anexpansion in the cell volume as well as surface area. But it cannot expand freelyespecially in the peripheral direction as it is bound by other cells around. This makes theblebbing of cell membrane inside. 141 Discussion
    • The temperature gradient and pressure gradient caused by the heat further helps inblebbing in this particular direction. These lipoid vesicles or blebs detached from the cellorganelle or other side of membrane and remain there till a critical surface is reached.This membrane then blebs out and spread further thus providing nourishment to thetissues. The whole phenomenon of dropping of cell membrane vesicles and theirincorporation into other membranous structure was described as “Membrane flowHypothesis” by Palade in 1959. Thermal therapy acts by increasing the circulation and local metabolic processwith the relaxation of the musculature. Application of heat causes relaxation of musclesand tendons, improves the blood supply, venous drainage, lymph supply and activates thelocal metabolic processes which are responsible for the relief of pain, swelling,tenderness and stiffness. Trans-dermal absorption depends upon lipid solubility of the drug. Drugs in oilsand other lipid soluble carriers can penetrate the epidermis as it is a lipid barrier. Themovement is slow, particularly through the layers of cell membranes in the stratumcorneum. But once the drug reaches the underlying tissues it will be absorbed into thecirculation. Suspending the drug in an oily vehicle can enhance absorption through theskin. Because hydrated skin is more permeable than dry skin (Placing a drug in a solventthat is lipid soluble can assist its movement through the lipid barriers). Sneha reaches deep into the body tissues, causing partial rejuvenation of cellorganelles and cell membrane by replacing their order components with new ones. 142 Discussion
    • By this mechanism Parisheka fulfills the expected changes in Sandhigatavata. Noone single mechanism appears to be solely responsible for the therapeutic effects ofParisheka. All these are hypothetically proposed aspects.PROBABLE MODE OF ACTION OF MATRABASTI Udbhavasthana of Sandhigatavata is Pakwashaya and Vyaktasthana is Sandhi.Hence, Matrabasti chikitsa has nectarous effect over it. Matrabasti is a type of Snehabasticlassified on the basis of quantity of Sneha dravya used in it. So this can conquer thevitiated vayu in Sandhigatavata effectively. Vyanavata invariably plays an immense role in pathogenesis of Sandhigatavata.The sneha of Bastidravya acts over the Vyanavayu predominantly. So Matrabasti couldbe the best mode of drug administration so far as taste of drug, dosage and Agni isconcerned, in comparison to oral drug administration. Guda is Pradhana marma and the Moola of Siras, that nourishes the whole body.By maintaining the left lateral procedure at the time of Matrabasti procedure, thebastidravya reaches the pakwasaya resides in the left side. Charaka opines that byattaining this posture, gudavalees will be relaxed and the grahani is situated in the leftside. Chakrapani states that agni will be in the natural state in the posture whileGangadhara says agni, grahani and nabhi are present in the left side. Jejjata commentsagni is present left side over the nabhi, guda has got a relation with sthoolantra on leftside. So bastidravya can reach to the large intestine and grahani, as they are present in thesame level. 143 Discussion
    • Left lateral position is the best posture for better and effective administration ofMatrabasti. Because – In this posture, anal canal turns to left side to rectum, sigmoidcolon and descending colon. Moreover, medicines stay at these surfaces and getsabsorbed more and show its effect, especially in Matrabasti. The absorptive area ofmucosa is more on left side and it is easily approachable through anus rather than on theright side and this posture relaxes the ileo-ceacal juction and makes the easy flow ofBastidravya into the sigmoid colon. The drug given through the Matrabasti reaches to the site of the origin of thedisease. As Susruta mentioned that the veerya of the Basti dravya spreads all over thebody just as water poured at the root reaches all parts of the tree through the micro andmacro channels. While Charaka mentions that Matrabasti by reaching up to the umbilicalregion (transverse colon), sacroiliac region (rectum), flanks and hypochondrial regions(ascending and descending colon) and churning of the fecal and morbid matters presentthere in and at the same time by spreading its unctuous effect in whole body, drawn outthe fecal and morbid matter. While dealing with the action of Basti Vagbhata says, the veerya of Basti beingconveyed to Apana to Samana Vata which may regulate the function of agni then toUdana, Vyana and Apana thus providing its efficacy all over the body. At the same timethis effect of Matrabasti by specifying Vata, restores the displaced Kapha and Pitta attheir original seats. The control gained over Vata leads to the Samprapti vighatana ofdisease. The same action of Basti drugs has been described by Charaka. AdministeredMatrabasti enters into Pakwashaya, Nabhi, Katipradesha and Kukshi. It spreads to allover the body by its Veerya to drain out the morbid dosha lodged in the entire body fromthe foot to the head, just as the sun situated in the sky sucks up the moisture from theearth. 144 Discussion
    • Action of Matrabasti is possible by Anupravaranabhava of bastidravya, whichcontains sneha. Sneha easily moves up to Grahani by Anupravanabhava guna similar tothat of dravya, which freely moves in the utensil. Matrabasti acts mainly on Asthi and Majjavaha srotas. Asthi is the Ashrayasthanaof Vata dosha. Dalhana says that Pureeshadharakala and Asthidharakala are one and thesame. So we can assume that if pureeshadharakala gets purified and nourished; theasthivaha srotas will also be purified and nourished. Pittadharakala and Majjadharakala and Grahani part takes in the action ofMatrabasti. Bastidravya enters till Grahani (Pittadhara Kala) which is the seat of agni.The nutrients may get absorbed and thereby nourishes the Majjadharakala, which ishaving a strong bond with Pittadharakala and Vata. Matrabasti of Shatahvadi taila comprises mainly, Shatahva, Yava, Bilva, Kanjiand Tila having the properties like Snigdha guna, Ushna veerya and Vata-kaphashamakaand acts as Vedanashamaka, Shothahara and Vatanulomana. Thus provides significanteffect on almost all the symptoms of Sandhigatavata. Matrabasti contains Sneha (i.e. Shatahvadi taila) with above mentioned propertieswhich are capable to pacify Vata by their potencies. Due to its less quantity, it facilitate tostay longer period in Pakwashaya (9-10 hours which was observed in this study) andmay acts both locally and systemically. Sandhigatavata possess aggravation of Vata which in turn leads to reduction ofSnehabhava and Dhatukshaya condition. Its incidence is predominant in senile conditionwhere Matrabasti is indicated. Hence, Matrabasti can be administered in all the ageswithout any complications. It plays vital role in the management of Sandhigatavata. Itinduces Snehabhava and corrects Vata in turn checks the pathology of the disease. 145 Discussion
    • According to modern science, the rectum has a rich blood and lymph supply.Drugs can readily cross the rectal mucosa like other lipid membrane. As per Basti/Enemaconcerned, in trans-rectal route, the unionized and lipid soluble substances are readilyabsorbed from the rectum. The concentration gradient of Matrabasti dravya is more inside the lumen ofintestine as compared to rectal venous plexus, which facilitates the absorption. This rectalvenous plexus further divided into internal venous plexus and external venous plexus.Internal venous plexus, situated in the submocosal layer of anal canal and carries intosuperior rectal vein and to external venous plexus. Basti dravya is also absorbed from external venous plexus in three parts, i.e. inlower part through inferior rectal veins and drained into internal pudendal vein, in middlepart through middle rectal vein which is having tributaries, those drains from bladder,prostate and seminal vesicle into internal iliac vein, in upper part through superior rectalvein into inferior mesenteric vein a tributary of portal vein. Matrabasti dravya is also absorbed from the upper rectal mucosa, and is carried bythe Superior mesenteric vein into the portal circulation and enters into Liver. Secondly,the portion absorbed from the lower rectum enters directly into systemic circulation viamiddle and inferior hemorrhoidal veins. This indicates that due to more vascularity in thisarea absorption rate is high. Acharyas also said that “Guda moolam hi shareeram”. The advantage of this route is total gastric irritation is avoided and that by using asuitable solvent the duration of action can be controlled. Moreover, it is often moreconvenient to use drugs rectally in the long time in case of geriatric and terminally illpatients. Matrabasti plays major role in maintaining normal bacterial flora by virtue of itsaction which is supported by some of the studies conducted already. 146 Discussion
    • Pakwashaya is supplied with large numbers of nerve plexuses originating fromthe hypo-gastric plexus and lumbosacral plexus, etc. These plexus will receivenourishment and soothening effect by Matrabasti. Because Matrabasti mainly acts on thePakwashaya, here it nourishes, purifies and expels the unwanted toxins from the bodyand facilitates the normal functions in the body.Regulating the Gut Brain. In 1981, Wood described the Enteric Nervous System (ENS) as ‘The Brain of theGut’ that integrates information received and issues an appropriate response. ENSintegrates sensory information from mucosal receptor and organizes an appropriate motorresponse from a choice of predetermined programmes. So enteric nervous system of gutbrain is an integrative system with structural and functional properties that are similar tothose in CNS and physiological and pharmacological properties of Matrabasti chikitsa aresaid to be the outcome of modification of gut brain up to certain extent. By considering above explanation it is clear that Basti dravya is absorbed throughrectal mucosa either by chemically altered or un-altered state and carried throughout thegeneral circulation gives local and systemic effects by controlling Vata which isbackbone of the disease pathology. When Parisheka and Matrabasti these two procedures performed together,as Parisheka is a Poorvakarma and Matrabasti is a Pradhanakarma. In Sandhigatavata itfulfills both local and generalized effects. Matrabasti plays vital role in by provingsnehabhava and enhancing the strength of dhatus helps in checks out the samprapti.Action of Matrabasti is “Aapadatalamastakam,” it is ideal for all the age groups and canbe given without any complications for longer period. It produces the long-term andstable effect over the body which is being found in the study rather than Parisheka. 147 Discussion
    • The locality of the disease is Sandhi, Parisheka is Snigdha and Ushna in naturewhich is beneficial in Sandhigatavata. As it was performed locally on affected knee jointsit does not cause systemic complications even in old age group. It helps in relieving thesymptoms of the disease by comprising Snehana and Swedana simultaneously. Theprocedural effect of Parisheka can be taken as shamana part of chikitsa in Sandhigatavata. For both Parisheka and Matrabasti procedures Shatahvadi taila was used which isindicated in Vatavyadhi chikitsa, to get unbiased results about the effect of theprocedures in Sandhigatavata and to avoid interference of the biastiy by the effect ofdrug action.Discussion On Clinical study Patients of Sandhigatavata were selected from the OPD and IPD of Shri. D.G.M.Ayurvedic Medical College by pre-set inclusion and exclusion criteria. Data of 30patients who had satisfied the diagnostic criteria, underwent the treatment and reportedfor the follow-up are discussed here. The patients were randomly distributed into twogroups and the patients of group-A were administered Parisheka and Matrabasti; thepatients of group-B were administered Parisheka only. Patients of both the groups wereadvised to take hot water bath after the karma every day and also were advised to followthe same pathya acharana. The laboratory investigations like ESR, TC, DC, Hb% and RBS were performedto rule out the associated systemic diseases. The radiology of the affected joint wasperformed in all patients. After scrutinizing the whole literature of Ayurveda and ModernMedicine, Ruk and Graha were fixed as the subjective parameters; Sparsha akshamatva,Sandhigati asaamarthya, Shotha, Atopa and walkingtime (to cover 21meters) were fixedas the objective parameters. The pre and post treatment data of above mentionedparameters recorded timely as per the special case sheet proforma. 148 Discussion
    • Discussion on Demographic Data Most of the patients in this clinical study belonged to the age group 55-64 (70%)thereby supporting the association of Vardhakya avastha and Sandhigatavata. 26.66% ofthe patients belonged to the age group 45-54 and 3.33% of the patients belonged to theage group 35-44. 46.66% of the patients belonged to the active group of occupationalstatus and 20% of the patients belonged to the labour group. This strengthens theviewpoint that this disease is triggered by excessive physical demand on the joint.56.66% of the patients were females and 43.33% of the patients were males supportingthe male to female incidence ratio of 1:1. 46.66% of the patients were of the middle class and 33.33% were of the poorclass and 20% were of the high class and this observation is inconclusive to make anycomments. 83.3% of the patients were Hindus, 20% were Muslims. This is reflective ofthe geographical dominance of the religion and do not have any association with thedisease. 43.33% of the patients were vegetarians and 56.66% were of the mixed diet andthis is reflective of the diet habit prevalent in the society. 53.33% patients were inflicted with Mandagni, 36.66% patients were inflictedwith Vishamagni. Vikritavastha of Agni directly reflects over the status of Tridoshas. TheVishama and Manda avastha of Jatharagni is closely related with Vata vitiation which isrelated with Sandhigatavata. 60% of the patients were having Krura koshta, This showsthe predominance of Vata in patients by the nature of Koshta itself. 70% of the patientshad the complaint of Alpa nidra, 30% of the patients had the complaint of Vishama nidra.These both are closely related with Vata vriddhi. 40% of the patients were havingtobacco chewing as a habit, 20% were having alcohol intake as a habit and 16.6% hadsmoking habit, this has no association with the disease state. So the data of present studysupport the existence of the pre-disposing factors of Sandhigatavata. 149 Discussion
    • 50% of the patients were of the Vata-pitta prakriti, 30% of the patients were of theVata-kapha prakriti, 10% of the patients were of the Pitta-kapha prakriti, 10% of thepatients were of the Shuddha vata prakriti. Hence, majority of the patients were havingthe existence of Vata dosha in their prakriti constitution. This shows the dominancy ofVata dosha in prakriti related with the disease condition has been well proven. 90% of thepatients were of the rooksha satmya and 10% were of the snigdha satmya, which isreflective of the nature of the diet. This also may have contributed to the Vata kopa. 70%of the patients had Vegadharana as a nidana, 63.3% of the patients had Ativyayama as anidana and 96.66% of the patients were having katurasa bhojana, 80% of the patientswere accustomed to Rooksha bhojana. Sandhigatavata is a Vatapradhana vyadhi which isbeing supported in this study, showing the higher values in particularly Vatakara nidanas.So the data of present study support the existence of the pre-disposing factors ofSandhigatavata. All the patients had the complaints Ruk, Graha and Sandhigati asaamarthya, while80% had Sparsha akshamatva, 73.33% had Atopa, 86.66% reported with Prasaarnaaakunchanayoho savedana pravritti, 70% with Shotha and 10% with Vatapoornadritisparsha.Discussion On Effect Of TherapiesGroup-A 1) Ruk : - 60% of the patients reported with grade 3 ruk and 40% reported with grade 2 ruk. 60% of the grade 2 got good response and 40% got moderate response. 50% of the grade 3 got good response and 50% got moderate response. In the statistical analysis, the parameter showed high significance (p-value<0.001) and corresponding t-value16.15 150 Discussion
    • 2) Graha : - All the patients of group-A presented with Sandhigraha (100%). Among them 53.33% got good response and 46.66% got moderate response. In the statistical analysis Graha showed high significance (p-value<0.001) and corresponding t-value 9.62.3) Sparsha akshamatva : - 20% of the patients reported with grade 0 tenderness whereas 20% reported with grade 1 tenderness and 60% reported with grade 2 tenderness. 33.33% of grade 0 got good response and 66.66% of grade 0 got moderate response. 66.66% of grade 1got good response and 33.33% got moderate response. 55.55% of grade 2 got good response and 44.44% got moderate response. In the statistical analysis the parameter showed high significance (p-value<0.001) and corresponding t-value 6.09.4) Sandhigati asaamarthya : - 73.33% of the patients reported with grade 1 Sandhigati asaamarthya and 26.66% of the patients reported with grade 2 Sandhigati asaamarthya. 45.49% of the patients with grade 1 got good response and 54.54% got moderate response. 75% of the patients with grade 2 got good response and 25% got moderate response. In the statistical analysis the parameter showed high significance (p-value<0.001) with corresponding t-value 38.32.5) Shotha : - 33.33% of the patients reported with grade 0 Shotha, 46.66% with grade 1, 13.33% with grade 2 and 6.66% with grade 3. 40% of the patients with grade 0 got good response and 60% got moderate response. 42.85% of the patients with grade 1 got good response and 57.14% got moderate response. 100% of the patients with grade 2 got good response and 100% of the patients with grade 3 got moderate response. In the statistical analysis the parameter Shotha showed high significance (p-value<0.001) with corresponding t-value 4.58. 151 Discussion
    • 6) Atopa : - 26.66% of the patients reported with grade 0 atopa, 40% with grade 1, 26.66% with grade 2 and 6.66% of the patients reported with grade 3. 75% of the patients with grade 0 showed good response and 25% got moderate response. 33.33% of the patients with grade 1 showed good response and 66.66% showed moderate response. 100% of patients with grade 2 showed moderate response. In the statistical analysis the parameter showed high significance (p-value<0.02) with corresponding t-value 5.285. 7) Walking time : - The parameter walking time (to cover 21meters) showed high significance (p-value<0.001) with corresponding t-value 7.873.Group-B 1) Ruk : - 33.33% of the patients had grade 2 ruk and 66.66% had grade 3 ruk. 85.71% of the patients with grade 2 ruk got moderate response and 14.28% got poor response.. 87.5% of the patients with grade 3 ruk got moderate response and 12.5% got poor response. In the statistical analysis the parameter showed high significance (p-value<0.001) with corresponding t-value 13.23. 2) Graha : - All the patients had grade 1 graha. 86.66% of the patients got moderate response and 13.33% got poor response. In the statistical analysis the parameter showed high significance (p-value<0.001) with corresponding t-value 7.547. 3) Sparsha akshamatva : - 20% of the patients had grade 0 tenderness, 46.66% had grade 1 and 33.33% had grade. All the patients of the grade 0 got moderate response. 85.71% of the patients of grade 1 got moderate response and 14.28% of patients got poor response. In the statistical analysis the parameter showed high significance (p-value<0.001) with corresponding t-value 4.615. 4) Sandhigati asaamarthya : - 33.33% of the patients had grade 1 and 66.66% had grade 2. 80% of the patients with grade 1 got moderate response and 20% of the patients got poor response. 90% with grade 2 got moderate response and 10% got poor response. In the statistical analysis this parameter showed high significance (p-value<0.001) with corresponding t-value 4.1. 152 Discussion
    • 5) Shotha : - 33.33% had grade 0 shotha, 26.66% had grade 1 and 40% had grade 2. All the patients with grade 0 got moderate response. 75% of the patients with grade 1 got moderate response and 25% of the patients got poor response. 83.33% of the grade 2 patients got moderate response and 16.66% 0f the patient got poor response. In the statistical analysis this parameter showed high significance (p- value<0.01) with corresponding t-value 4.18 6) Atopa : - 26.66% of the patients had grade 0 atopa and 73.33% had grade 1. 75% of the patients with grade 0 got moderate response and 25% got poor response. 90.90% of the patients of grade 1 got moderate response and 9.09% of patients got poor response. In the statistical analysis, this parameter showed high significance (p-value<0.01) with corresponding t-value 2.664. 7) Walking time : - This parameter showed high significance (p-value<0.01) with corresponding t-value 5.17. When we compare the group A and B the parameter Ruk and Walking time showshighly significant than the other by comparing the mean effect of the two groups after thetreatment (As P-value<0.05). But all other parameters shows non significant. The meaneffect after treatment in the parameter Graha, Sandhigati asamarthya, Shotha is more inGroup –A with less variance. (By comparing mean, S.D). In Group-a 53.33% of the patients had good response and 46.66% of the patientshad moderate response. But whereas in Group-B no patients had god response, 86.66% ofthe patients had moderate response and 13.33% of the patients had poor response.Hence, it clearly states that overall the Group-A (Parisheka and Matrabasti) is moresignificant than Group-B (Parisheka) in all the parameters (By comparing t- value). Theparameter Atopa shows least mean net effect in group A and B after the treatment. 153 Discussion
    • Conclusions are the essence of whole study. In ancient researchmethodology it is described as "Nigamana". In the discussion part of the study, thework is discussed on the basis of concepts, supported by data and logicalreasoning. The conclusions drawn from the scientific discussion are as follows : Matrabasti is a type of Anuvasana which is very effective in Vatavyadhees can be practiced safely. Parisheka is a type of Sweda belongs to Dravasweda. Sandhigatavata is a type of Vatavyadhi commonly associated with the vardhakya avastha and dhatu kshaya is a prominent feature in its manifestation. Sandhigatavata can be correlated with Osteoarthritis of contemporary science. Parisheka was selected as the therapy in this study as the treatment line of Sandhigatavata emphasizes Snehana and Swedana and this particular karma is capable of exerting both these effects. Matrabasti was selected as the additional therapy in association with Parisheka as it is prime treatment for vatavyadhi like Sandhigatavata. Treatment response of all parameters was highly significant in both the groups, but in intergroup comparison Ruk and Walking time score was found significant in Parisheka and Matrabasti group than Parisheka group. Overall treatment response was better in the Parisheka and Matrabasti group as no patient in the Parisheka group got good response. This suggests that there was considerable improvement in both the groups but Parisheka and Matrabasti group got more beneficial effects. 154 Conclusion
    • During the follow-up period (after the 24th day) the results attained seemed to wear out in the Parisheka group, but results lasted throughout follow-up period in the Parisheka and Matrabasti group. No complications were observed in this study. Parisheka and Matrabasti can be practiced together for better results in Sandhigatavata. Shatahvadi Taila was found very effective in the management of Sandhigatavata.SUGGESTIONS FOR FUTURE STUDIES The study should be conducted in a large sample. The study should be conducted for a longer duration so as to know the lasting of the clinical effects. 155 Conclusion
    • The dissertation work entitled “A comparative clinical study to evaluate the effectof Matrabasti and Parisheka with shatahvadi taila in Sandhigatavata (Osteoarthritis)”consists of seven parts. They are 1. Introduction 2. Objectives 3. Review of literature 4. Methodology 5. Results 6. Discussion 7. Conclusion. The introduction highlights on Panchakarmas, Basti, Matrabasti, Swedana,Parisheka and Sandhigatavata. The objectives part describes the need for the study, title of the present study andthe objectives of the present study. Review of literature part covers the historical view on Basti, Swedana andSandhigatavata, Nirukti and Paribhasha of Basti, Swedana and Sandhigatavata, Shareeraof Guda, Twak and Sandhi, description of Basti, Matrabasti, Swedakarma, Parisheka inparticular and description of Sandhigatavata. Methodology part contains review of the properties and chemical composition ofthe drugs used, methodology of the clinical study, procedures of Matrabasti andParisheka and the subjective and objective parameters for assessment. The results part contain demographic data, data related to the disease, data relatedto the overall response to the treatment, statistical analysis of the subjective and objectiveparameters & Intergroup comparison. Discussion part consists of the headings Sandhigatavata vis-à-vis Osteoarthritis,role of Parisheka in the management of Sandhigatavata and Role of Matrabasti in themanagement of Sandhigatavata, clinical study. Conclusion part contains the conclusions of the present study and suggestions forfuture study. 156 Summary
    • A1. Agnivesa, Charakasamhitha Siddhisthana chapter 1-5, 7, 8, 10-12. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 680-703,709-715, 734-738. (Kasi Sanskritseries 228).2 Susruta, Susrutasamhitha Chikitsasthana chapter 35, 36, 37, 38. Varanasi: KrishnadasAcademy; 1980. p. 525-548. (Krishnadas Ayurveda series 51).3 Ashtangasangraha Suthrasthana chapter 28 - Kalpasthana chapters 4, 5, 6,Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996. p. 485,579-606. (Jaikrishnadas Ayurvedic series 79).4 Vagbhata, Ashtangahridaya Suthrasthana chapter 19 – Kalpasiddhi chapterVaranasi: Krishnadas Academy; 1982. p. 270, 753, 763. (Krishnadas Academicseries 4).5 Vrudhajeevaka, Kashyapasamhita Khilasthana chapter 8 sloka 54. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 289. (Kasi Sanskrit series 154).6. Bhelacharya, Bhelasamhitha Suthrasthana chapter 23. Girijadayal Shukla editor.Varanasi: Chaukhambha Vidyabhavan; 1959. P.267-285.7. Chakrapanidatta, Chakradatta chapter 72- 73. 1st ed. P.V.Sharma editor. Varanasi:Chaukhambha Publishers; 1994. p. 619-629. (Kasi Ayurveda series 17).8. Vangasena, Vangasenasamhitha Bastikarmaadhikara. Jain Sankarlalji Vaidya, editor.Mumbai: Khemnath Srikrishnadas publishers; 1996. p. 952.9. Sharangadhara, Sarngadharasamhitha Utharakhanda chapter 5, 6, 7. 3rd ed. Varanasi:Chaukhambha Orientalia; 1983. p. 318-338. (Jaikrishnadas Ayurveda Granthamala 53).10. Agnivesa, Charakasamhitha Suthrasthana chapter 14. 4th ed. Varanasi: ChaukhambhaSanskrit Sansthan; 1994. p. 87-92. (Kasi Sanskrit series 228).11. Susruta, Susrutasamhitha Chikitsasthana chapter 32. Varanasi: Krishnadas Academy;1980. p. 513-515. (Krishnadas Ayurveda series 51).12 a) Vaghbhata, Ashtangasangraha with Sashilekha teeka Suthrasthana chapter 26Rudraparasava editor. Trichur: Mangalodayam publication; 1913.p. 192-199. b) Vagbhata, Ashtangahridaya Suthrasthana chapter 17. Varanasi: KrishnadasAcademy; 1982. p.253-259. (Krishnadas Academic series 4).13.. Bhelacharya, Bhelasamhitha Suthrasthana chapter 23. Girijadayal Shukla editor.Varanasi: Chaukhambha Vidyabhavan; 1959. p. 38-40. Bibliographic References
    • B14. Vrudhajeevaka, Kashyapasamhita Sutrastana chapter 23 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 24-29. (Kasi Sanskrit series 154).15. Sharangadhara, Sharngadharasamhitha Utharakhanda chapter 2. 3rd ed. Varanasi:Chaukhambha Orientalia; 1983. p 294. (Jaikrishnadas Ayurveda Granthamala 53).16. Chakrapanidatta, Chakradatta. P.V.Sharma, editor. Varanasi: ChaukhambhaPublishers; 1998. p. 183-214. (Kasi Ayurveda series 17).17. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 24. 5th ed.Varanasi:Chaukhambha Sanskrit series 130; 1988. p. 227.18. Govindadasa, Bhaishajyaratnavali chapter 27. 7th ed. Kaviraj Ambikadatta Shastrieditor. Varanasi: Chaukhambha Orientalia; 1983. p. 373-417. (Kasi Sanskrit series 152).19. Yogaratnakara with Vidyotini Hindi commentary Vatavyadhichikitsa sloka 117,Brahmashankar sastry editor. Varanasi: Chaukhambha Sanskrit sansthan; 1988. p.517.(Kasi Sanskrit series 160).20. Sharma P V, Classical age of Indian literature. Varanasi: Chaukhambha SanskritStudies; 1972.p. 67. (Chaukhambha Sanskrit Series Volume LXXXV).21.a) Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 44 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p 90. (Kasi Sanskrit series 228). b) Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 13. Varanasi:Krishnadas Academy; 1980. p.514. (Krishnadas Ayurveda series 51). c) Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 10. Varanasi:Krishnadas Academy; 1982. p.256. (Krishnadas Academic series 4). d) Ashtangasangraha Suthrasthana chapter 26 sloka 4. Dr. Ravidatta Tripathi, editor.Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p. 466, ( Vrajajivan ayurvijnanGranthamala 6 ). e) Bhelacharya, Bhelasamhitha Suthrasthana chapter 23, sloka 18-19. GirijadayalShukla editor. Varanasi: Chaukhambha Vidyabhavan; 1959. p.39. f) Vrudhajeevaka, Kashyapasamhita Sutrastana chapter 23 sloka 26. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 26. (Kasi Sanskrit series 154). g) Vaidyaratnam P.S.Varrier, Chikitsa Samgraham Dhara. 2 nd ed. Kottakal : Aryavaidya sala ; 1994. p. 133,134,149. h) Kasture VG, Ayurvediyapanchakarmavigyan chapter 3. 6th ed. Nagpur: ShreeBaidyanath Ayurved Bhavan Ltd.; 1999. p. 176-182. Bibliographic References
    • C22. Agnivesa, Charakasamhitha Suthrasthana chapter 11, sloka 55 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p 78. (Kasi Sanskrit series 228).23. Shastri Ramgopal, Vedom mein Ayurved. Delhi: Madan Mohanlal AyurvedaAnusandhan Trust; 1956. p. 36.24. Sharma P V, Classical age of Indian literature. Varanasi: Chaukhambha SanskritStudies; 1972.p. 47. (Chaukhambha Sanskrit Series Volume LXXXV).25. Sharma PV, Ayurved ka Vaijnanik Ithihas. 2nd ed. Varanasi: ChaukhambhaOrientalia; 1981. p. 13.26. Shastri Ramgopal, Vedom mein Ayurved. Delhi: Madan Mohanlal AyurvedaAnusandhan Trust; 1956. p. 18.27. Shastri Ramgopal, Vedom mein Ayurved. Delhi: Madan Mohanlal AyurvedaAnusandhan Trust; 1956. p. 69.28. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 618 . (Kasi Sanskrit series 228).29. Susruta, Susrutasamhitha Nidanasthana chapter 1 sloka 28- Chikitsasthana chapter 4sloka 8. Varanasi: Krishnadas Academy; 1980. p. 261,420. (Krishnadas Ayurveda series51).30. Bhelacharya, Bhelasamhitha Suthrasthana chapter 26. Girijadayal Shukla editor.Varanasi: Chaukhambha Vidyabhavan; 1959. p.215-220.31. Vaghbhata, Ashtangasangraha with Sashilekha teeka Nidanasthana chapter 15 sloka15 – Chikitsa chapter 23 sloka 13. Rudraparasava editor. Trichur: Mangalodayampublication; 1913.p. 76, 292.32. Vagbhata, Ashtangahridaya Nidanasthana chapter 15 sloka 14- Chikitsasthan chapter21 sloka 22. Varanasi: Krishnadas Academy; 1982. p.531, 724. (Krishnadas Academicseries 4).33. Madhavakara, Madhavanidana chapter 22 sloka 212. Varanasi: ChaukhambhaSurbharathi Prakashan; 1998. p. 520. (Chaukhambha Ayurvijnana Granthamala 46).34. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 24 sloka 258-259. 5th ed.Varanasi: Chaukhambha Orientalia; 1988. p. 264-265. (Chaukhambha Sanskrit series130).35. Yogaratnakara Vatavyadhinidana – Vatavyadhichikitsa. Vaidya Lakshmipatisastryeditor. Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 520. (Kasi Sanskrit series160). Bibliographic References
    • D36. Chakrapanidatta, Chakradatta chapter 22 sloka 9. 1st ed. P.V.Sharma editor.Varanasi: Chaukhambha Publishers; 1994. p. 184. (Kasi Ayurveda series 17).37. Govindadasa, Bhaishajyaratnavali chapter 26. 7th ed. Kaviraj Ambikadatta Shastrieditor. Varanasi: Chaukhambha Orientalia; 1983. p. 373-417. (Kasi Sanskrit series 152).38. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1471.39. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1471.40. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1471.41. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1471.42. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1472.43. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1472.44. Amarasimha, Amarakosha Manushyavarga 6 sloka 73. Pundit Vishwanath Jha, editor.Delhi: Motilal Banarasi Das; 1976. p. 139.45. Arunadatta, Ashtangahridaya Suthrasthana chapter 19 sloka 1. Varanasi: KrishnadasAcademy; 1982. p. 270. (Krishnadas academic series 4).46. Sharangadhara, Sarngadharasamhitha Utharakhanda chapter 5 sloka 1. 3rd ed.Varanasi: Chaukhambha Orientalia; 1983. p. 319. (Jaikrishnadas Ayu. Granthamala 53).47. Ashtangasangraha Suthrasthana chapter 28 sloka 2. Prof.K.R.Shrikhantamurthy,editor. Varanasi: Chaukhambha Orientalia; 1996. p. 485. (Jaikrishnadas Ayurvedic series79).48. Vagbhata, Ashtangahridaya Sutraasthana chapter 19 sloka 1. Varanasi: KrishnadasAcademy; 1982. p. 283. (Krishnadas Academic series 4).49. Raja Radhakantha Deva Bahadur, Shabdakalpadruma vol 5, 3rd ed.Varanasi:Chaukambha Sanskrit Series; p. 495.(Chaukambha Samskrita Granthamala-93).50. Raja Radhakantha Deva Bahadur, Shabdakalpadruma vol 1, 3rd ed. Varanasi:Chaukambha Sanskrit Series; p. 45.(Chaukambha Samskrita Granthamala-93). Bibliographic References
    • E51. Bhelacharya, Bhelasamhitha Suthrasthana chapter 23, sloka 18-19. GirijadayalShukla editor. Varanasi: Chaukhambha Vidyabhavan; 1959. p.39.52. Raja Radhakantha Deva Bahadur, Shabdakalpadruma vol 5, 3rd ed. Varanasi:Chaukambha Sanskrit Series; p. 240.(Chaukambha Samskrita Granthamala-93).53. Raja Radhakantha Deva Bahadur, Shabdakalpadruma vol 1, 3rd ed. Varanasi:Chaukambha Sanskrit Series; p. 298.(Chaukambha Samskrita Granthamala-93).54. Raja Radhakantha Deva Bahadur, Shabdakalpadruma vol 5, 3rd ed. Varanasi:Chaukambha Sanskrit Series; p. 325.(Chaukambha Samskrita Granthamala-93).55. Mish C Fredrick, Webster’s Ninth New Collegiate Dictionary. Philippines: Merriam-Webster; 1987. p. 835.56. Susruta, Susrutasamhitha Nidanasthana chapter 2 sloka 5. Varanasi: KrishnadasAcademy; 1980. p. 272. (Krishnadas Ayurveda series 51)57.Susruta, Susrutasamhitha Nidanasthana chapter 2 sloka 6-7. Varanasi: KrishnadasAcademy; 1980. p. 272. (Krishnadas Ayurveda series 51).58. Agnivesa, Charakasamhitha Shareerasthana chapter 7 sloka 10. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 338. (Kasi Sanskrit series 228).59. Vagbhata, Ashtangahridaya Shareerasthana chapter 3 sloka 13. Varanasi: KrishnadasAcademy; 1982. p. 388. (Krishnadas academic series 4).60. Agnivesa, Charakasamhitha Shareerasthana chapter 7 sloka 9. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 338. (Kasi Sanskrit series 228).61. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 10. Varanasi: KrishnadasAcademy; 1980. p. 364. (Krishnadas Ayurveda series 51).62. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 24. 4th ed. NewJersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 899.63. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 364. (Krishnadas Ayurveda series 51).64. Vagbhata, Ashtangahridaya Shareerasthana chapter 3 sloka 10-11. Varanasi:Krishnadas Academy; 1982. p. 387. (Krishnadas academic series 4).65. Vagbhata, Ashtangahridaya Shareerasthana chapter 3 sloka 10-11. Varanasi:Krishnadas Academy; 1982. p. 387. (Krishnadas academic series 4). Bibliographic References
    • F66. Agnivesa, Charakasamhitha Shareerasthana chapter 7 sloka 10. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 338. (Kasi Sanskrit series 228).67. Vagbhata, Ashtangahridaya Shareerasthana chapter 3 sloka 12. Varanasi: KrishnadasAcademy; 1982. p. 387. (Krishnadas academic series 4).68. Sharangadhara, Sarngadharasamhitha Poorvakhanda chapter 5 sloka 9. 3rd ed.Varanasi: Chaukhambha Orientalia; 1983. p. 44. (Jaikrishnadas Ayu. Granthamala 53).69. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 24. 4th ed. NewJersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 900.70. Agnivesa, Charakasamhitha Chikitsasthana chapter 15 sloka 17. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 514 . (Kasi Sanskrit series 228).71. Rao Ramasundara M, Sarira rachana vijnana chapter 4. Vijayawada: Susrutaopticals;2003.p. 565.72. Susruta, Susrutasamhitha Shareerasthana chapter 4 sloka 4. Varanasi: KrishnadasAcademy; 1980. p. 355. (Krishnadas Ayurveda series 51).73. Agnivesa, Charakasamhitha Shareerasthana chapter 7 sloka 4. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 337 . (Kasi Sanskrit series 228).74. Susruta, Susrutasamhitha Suthrasthana chapter 21 sloka 10. Varanasi: KrishnadasAcademy; 1980. p. 101. (Krishnadas Ayurveda series 51).75. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 5. 4th ed. NewJersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 148.76. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 5. 4th ed. NewJersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 148-155.77. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 5. 4th ed. NewJersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 160-161.78. Agnivesa, Charakasamhitha Chikitsasthana chapter 15 sloka 18. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 515 . (Kasi Sanskrit series 228).79. Agnivesa, Charakasamhitha Shareerasthana chapter 7 sloka 15. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 339 . (Kasi Sanskrit series 228).80. Agnivesa, Charakasamhitha Shareerasthana chapter 7 sloka 16. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 339 . (Kasi Sanskrit series 228). Bibliographic References
    • G81. Vaghbhata, Ashtangasangraha with Sashilekha teeka Suthrasthana chapter 20 sloka 3.Rudraparasava editor. Trichur: Mangalodayam publication; 1913. p. 147.82. Susruta, Susrutasamhitha Suthrasthana chapter 15 sloka 2. Varanasi: KrishnadasAcademy; 1980. p. 68. (Krishnadas Ayurveda series 51).83. Vagbhata, Ashtangahridaya Suthrasthana chapter 11 sloka 5. Varanasi: KrishnadasAcademy; 1982. p.173. (Krishnadas Academic series 4).84. Agnivesa, Charakasamhitha Vimanasthana chapter 5 sloka 8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 251 . (Kasi Sanskrit series 228).85. Agnivesa, Charakasamhitha Vimanasthana chapter 5 sloka 22. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 252 . (Kasi Sanskrit series 228).86. Agnivesa, Charakasamhitha Vimanasthana chapter 5 sloka 8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 251 . (Kasi Sanskrit series 228).87. Susruta, Susrutasamhitha Suthrasthana chapter 21 sloka 74. Varanasi: KrishnadasAcademy; 1980. p. 102. (Krishnadas Ayurveda series 51).88. Susruta, Susrutasamhitha Nidanasthana chapter 1 sloka 17-18. Varanasi: KrishnadasAcademy; 1980. p. 260. (Krishnadas Ayurveda series 51).89. Susruta, Susrutasamhitha Shareerasthana chapter 4 sloka 14-15. Varanasi: KrishnadasAcademy; 1980. p. 356. (Krishnadas Ayurveda series 51).90. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 24-25. Varanasi: KrishnadasAcademy; 1980. p. 366. (Krishnadas Ayurveda series 51).91. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 27. Varanasi: KrishnadasAcademy; 1980. p. 367. (Krishnadas Ayurveda series 51).92. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 6. Varanasi: KrishnadasAcademy; 1980. p. 364. (Krishnadas Ayurveda series 51).93. Rao Ramasundara M, Sarira rachana vijnana chapter 4. Vijayawada: Susrutaopticals;2003.p. 273-275.94. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 9. 4th ed. NewJersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 269,271.95. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 29-36. Varanasi: KrishnadasAcademy; 1980. p. 367. (Krishnadas Ayurveda series 51). Bibliographic References
    • H96. Susruta, Susrutasamhitha Shareerasthana chapter 5 sloka 37-38. Varanasi: KrishnadasAcademy; 1980. p. 367-368. (Krishnadas Ayurveda series 51).97. Susruta, Susrutasamhitha Shareerasthana chapter 6 sloka 24, 26. Varanasi:Krishnadas Academy; 1980. p. 373, 374. (Krishnadas Ayurveda series 51).98. Susruta, Susrutasamhitha Shareerasthana chapter 7 sloka 8, 12, 14. Varanasi:Krishnadas Academy; 1980. p. 377. (Krishnadas Ayurveda series 51).99. Agnivesa, Charakasamhitha Siddhisthana chapter 10 sloka 4. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 724. (Kasi Sanskrit series 228).100. Agnivesa, Charakasamhitha Siddhisthana chapter 10 sloka 5-6. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 724. (Kasi Sanskrit series 228).101. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 1. Varanasi: KrishnadasAcademy; 1982. p. 270. (Krishnadas academic series 4).102. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 86. Varanasi: KrishnadasAcademy; 1982. p. 285. (Krishnadas academic series 4).103. Susruta, Susrutasamhitha Chikitsasthana chapter 36 sloka 6. Varanasi: KrishnadasAcademy; 1980. p. 529. (Krishnadas Ayurveda series 51).104. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 87. Varanasi: KrishnadasAcademy; 1982. p. 286. (Krishnadas academic series 4).105. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 3. Varanasi: KrishnadasAcademy; 1980. p. 525. (Krishnadas Ayurveda series 51).106. Agnivesa, Charakasamhitha Siddhisthana chapter 1 sloka 27-28. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 682. (Kasi Sanskrit series 228).107. Vrudhajeevaka, Kashyapasamhita Khilasthana chapter 8 sloka 54. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 289. (Kasi Sanskrit series 154).108. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 18. Varanasi: KrishnadasAcademy; 1980. p. 526. (Krishnadas Ayurveda series 51).109. Kasture VG, Ayurvediyapanchakarmavigyan chapter 6. 6th ed. Nagpur: ShreeBaidyanath Ayurved Bhavan Ltd.; 1998. p. 373.110. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 18. Varanasi: KrishnadasAcademy; 1980. p. 526. (Krishnadas Ayurveda series 51). Bibliographic References
    • I111. Ashtangasangraha Suthrasthana chapter 28 sloka 4. Prof.K.R.Shrikhantamurthy,editor. Varanasi: Chaukhambha Orientalia; 1996. p. 485. (Jaikrishnadas Ayurvedic series79).112. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 17. Varanasi: KrishnadasAcademy; 1980. p. 526. (Krishnadas Ayurveda series 51).113. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 19. Varanasi: KrishnadasAcademy; 1980. p. 526. (Krishnadas Ayurveda series 51).114. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 61. Varanasi: KrishnadasAcademy; 1982. p. 282. (Krishnadas academic series 4).115. Sharangadhara, Sarngadharasamhitha Utharakhanda chapter 5 sloka 19-22. 3rd ed.Varanasi: Chaukhambha Orientalia; 1983. p. 323. (Jaikrishnadas Ayu. Granthamala 53).116. Agnivesa, Charakasamhitha Siddhisthana chapter 8. 4th ed. Varanasi: ChaukhambhaSanskrit Sansthan; 1994. p. 713-715. (Kasi Sanskrit series 228).117. Susruta, Susrutasamhitha Chikitsasthana chapter 37 sloka 77. Varanasi: KrishnadasAcademy; 1980. p. 536. (Krishnadas Ayurveda series 51).118. Agnivesa, Charakasamhitha Siddhisthana chapter 1 sloka 47-48. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 684. (Kasi Sanskrit series 228).119. Vrudhajeevaka, Kashyapasamhita Khilasthana chapter 8 sloka 7. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 277. (Kasi Sanskrit series 154).120. Vrudhajeevaka, Kashyapasamhita Khilasthana chapter 8 sloka 8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 277. (Kasi Sanskrit series 154).121. Vrudhajeevaka, Kashyapasamhita Khilasthana chapter 8 sloka 9. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 277. (Kasi Sanskrit series 154).122. Susruta, Susrutasamhitha Chikitsasthana chapter 37 sloka 39. Varanasi: KrishnadasAcademy; 1980. p. 533. (Krishnadas Ayurveda series 51).123. Agnivesa, Charakasamhitha Siddhisthana chapter 8 sloka 2-14. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 713. (Kasi Sanskrit series 228).124. Susruta, Susrutasamhitha Chikitsasthana chapter 38 sloka 118. Varanasi: KrishnadasAcademy; 1980. p. 548. (Krishnadas Ayurveda series 51).125. Susruta, Susrutasamhitha Chikitsasthana chapter 36 sloka 3. Varanasi: KrishnadasAcademy; 1980. p. 528. (Krishnadas Ayurveda series 51). Bibliographic References
    • J126. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 54. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 701. (Kasi Sanskrit series 228).127. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 53. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 701. (Kasi Sanskrit series 228).128. Agnivesa, Charakasamhitha Siddhisthana chapter 12 sloka 15. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 731. (Kasi Sanskrit series 228).129. Susruta, Susrutasamhitha Chikitsasthana chapter 38 sloka 116. Varanasi: KrishnadasAcademy; 1980. p. 548. (Krishnadas Ayurveda series 51).130. Vangasena, Vangasenasamhitha Bastikarmaadhikara sloka 170. Jain SankarlaljiVaidya editor. Mumbai: Khemnath Srikrishnadas publishers; 1996. p. 999.131. Vangasena, Vangasenasamhitha Bastikarmaadhikara sloka 186-190. Jain SankarlaljiVaidya editor. Mumbai: Khemnath Srikrishnadas publishers; 1996. p. 1000.132. Chakrapanidatta, Chakradatta chapter 73 sloka 29-31. 2nd ed. P.V.Sharma editor.Varanasi: Chaukhambha Publishers; 1998. p. 628. (Kasi Ayurveda series 17).133. Chakrapanidatta, Chakradatta chapter 73 sloka 23-26. 2nd ed. P.V.Sharma editor.Varanasi: Chaukhambha Publishers; 1998. p. 627-628. (Kasi Ayurveda series 17).134. Vagbhata, Ashtangahridaya Chikitsasthana chapter 9 sloka 72-76. Varanasi:Krishnadas Academy; 1982. p. 661. (Krishnadas Academic series 4).135. Agnivesa, Charakasamhitha Siddhisthana chapter 6 sloka 83. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 708. (Kasi Sanskrit series 228).136. Vangasena, Vangasenasamhitha Bastikarmaadhikara sloka 182-185. Jain SankarlaljiVaidya editor. Mumbai: Khemnath Srikrishnadas publishers; 1996. p. 999.137. Agnivesa, Charakasamhitha Siddhisthana chapter 2 sloka 19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 689. (Kasi Sanskrit series 228).138. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 6. Varanasi: KrishnadasAcademy; 1982. p. 272. (Krishnadas Academic series 4).139. Agnivesa, Charakasamhitha Siddhisthana chapter 2 sloka 18-19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 689. (Kasi Sanskrit series 228).140. Agnivesa, Charakasamhitha Siddhisthana chapter 2 sloka 18-19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 689. (Kasi Sanskrit series 228). Bibliographic References
    • K141. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 8. Varanasi: KrishnadasAcademy; 1982. p. 272. (Krishnadas Academic series 4).142. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 22. Varanasi: KrishnadasAcademy; 1980. p. 527. (Krishnadas Ayurveda series 51).143. Agnivesa, Charakasamhitha Siddhisthana chapter 3 sloka 7. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 691. (Kasi Sanskrit series 228).144. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 10-14. Varanasi:Krishnadas Academy; 1982. p. 273-274. (Krishnadas Academic series 4).145. Agnivesa, Charakasamhitha Siddhisthana chapter 3 sloka 8-9. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 691. (Kasi Sanskrit series 228146. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka 7-9. Varanasi: KrishnadasAcademy; 1980. p. 525-526. (Krishnadas Ayurveda series 51).147. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 14. Varanasi: KrishnadasAcademy; 1982. p. 274. (Krishnadas Academic series 4).148. Agnivesa, Charakasamhitha Siddhisthana chapter 3 sloka 10-12. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 692. (Kasi Sanskrit series 228).149. Agnivesa, Charakasamhitha Siddhisthana chapter 5 sloka 4-6. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 702. (Kasi Sanskrit series 228).150. Susruta, Susrutasamhitha Chikitsasthana chapter 36 sloka 8-11. Varanasi:Krishnadas Academy; 1980. p. 529. (Krishnadas Ayurveda series 51).151. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 22-23. Varanasi:Krishnadas Academy; 1982. p. 275. (Krishnadas Academic series 4).152. Agnivesa, Charakasamhitha Siddhisthana chapter 3 sloka 27. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 694. (Kasi Sanskrit series 228).153. Susruta, Susrutasamhitha Chikitsasthana chapter 38 sloka 1-6. Varanasi: KrishnadasAcademy; 1980. p. 539-540. (Krishnadas Ayurveda series 51).154. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 24-26. Varanasi:Krishnadas Academy; 1982. p. 276. (Krishnadas Academic series 4).155. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 26-30. Varanasi:Krishnadas Academy; 1982. p. 276-277. (Krishnadas Academic series 4). Bibliographic References
    • L156. Agnivesa, Charakasamhitha Siddhisthana chapter 3 sloka 28-29. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 694. (Kasi Sanskrit series 228).157. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 52-53. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.701. (Kasi Sanskrit series 228).158. Susruta, Susrutasamhitha Chikitsasthana chapter 35 sloka18. Varanasi: KrishnadasAcademy; 1980. p. 526. (Krishnadas Ayurveda series 51).159. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 67. Varanasi: KrishnadasAcademy; 1982. p.283. (Krishnadas Academic series 4).160. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 68-69. Varanasi:Krishnadas Academy; 1982. p.283. (Krishnadas Academic series 4).161. Ashtangasangraha Suthrasthana chapter 28 sloka 8. Dr. Ravidatta Tripathi,editor. Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p.503, ( Vrajajivanayurvijnan Granthamala 6 ).162. Ashtangasangraha Suthrasthana chapter 28 sloka 8. Dr. Ravidatta Tripathi,editor. Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p.503, ( Vrajajivanayurvijnan Granthamala 6 ).163. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 52. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.701. (Kasi Sanskrit series 228).164. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 68-69. Varanasi:Krishnadas Academy; 1982. p.283. (Krishnadas Academic series 4).165. Ashtangasangraha Suthrasthana chapter 28 sloka 8. Dr. Ravidatta Tripathi,editor. Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p.503, ( Vrajajivanayurvijnan Granthamala 6 ).166. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 52-54. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.701. (Kasi Sanskrit series 228).167. Hemadri, Ayurvedarasayana teeka on Ashtangahridaya Suthrasthana chapter sloka69.Varanasi: Krishnadas Academy; 1982. p. 283. (Krishnadas Academic series 4).168. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 53. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.701. (Kasi Sanskrit series 228).169. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 67. Varanasi: KrishnadasAcademy; 1982. p.283. (Krishnadas Academic series 4). Bibliographic References
    • M170. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Chikitsasthanachapter 35 sloka 18. Varanasi: Krishnadas Academy; 1980. p. 526-527.(Krishnadas Ayurveda series 51).171. Chakrapani, Ayurvedadeepika teeka on Charakasamhitha Siddhisthanachapter 4 sloka 54. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 701.(Kasi Sanskrit series 228).172. Vrudhajeevaka, Kashyapasamhita Khilasthana chapter 8 sloka 104-105. 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 285. (Kasi Sanskrit series 154).173. Sharangadhara, Sharngadharasamhitha Utharakhanda chapter 5, sloka 5. 3rded. Varanasi: Chaukhambha Orientalia; 1983. p 320. (Jaikrishnadas AyurvedaGranthamala 53).174. Susruta, Susrutasamhitha Chikitsasthana chapter 37 sloka 55-56. Varanasi:Krishnadas Academy; 1980. p. 534. (Krishnadas Ayurveda series 51).175. Ashtangasangraha Suthrasthana chapter 28 sloka 8. Dr. Ravidatta Tripathi,editor. Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p.503, ( Vrajajivanayurvijnan Granthamala 6 ).176. Vagbhata, Ashtangahridaya Suthrasthana chapter 19 sloka 29-30. Varanasi:Krishnadas Academy; 1982. p.276-277. (Krishnadas Academic series 4).177. Agnivesa, Charakasamhitha Siddhisthana chapter 1 sloka 44. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.684. (Kasi Sanskrit series 228).178. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 25. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.699. (Kasi Sanskrit series 228).179. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 28. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228).180. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 29-30. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228).181. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 31. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228).182. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 32-33. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228).183. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 34-35. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228). Bibliographic References
    • N184. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 36-37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228).185. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 39. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p.700. (Kasi Sanskrit series 228).186. Agnivesa, Charakasamhitha Siddhisthana chapter 1 sloka 41-43. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 685. (Kasi Sanskrit series 228).187. Agnivesa, Charakasamhitha Suthrasthana chapter 22 sloka 11. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 120. (Kasi Sanskrit series 228).188. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).189. Agnivesa, Charakasamhitha Suthrasthana chapter 22 sloka 11. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 120. (Kasi Sanskrit series 228).190. Kasture VG, Ayurvediyapanchakarmavigyan chapter 3. 6th ed. Nagpur: ShreeBaidyanath Ayurved Bhavan Ltd.; 1998. p. 159.191. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 20-24. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 89. (Kasi Sanskrit series 228).192. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 17-19. Varanasi:Krishnadas Academy; 1980. p. 514. (Krishnadas Ayurveda series 51).193. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 25-27. Varanasi:Krishnadas Academy; 1982. p.259. (Krishnadas Academic series 4).194. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 17-19. Varanasi:Krishnadas Academy; 1980. p. 514. (Krishnadas Ayurveda series 51).195. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 16-19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).196. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 25. Varanasi: KrishnadasAcademy; 1980. p. 515. (Krishnadas Ayurveda series 51).197. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 21-24. Varanasi:Krishnadas Academy; 1982. p.258. (Krishnadas Academic series 4).198. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 25. Varanasi: KrishnadasAcademy; 1980. p. 515. (Krishnadas Ayurveda series 51). Bibliographic References
    • O199. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 16-19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).200. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 21-24. Varanasi:Krishnadas Academy; 1982. p.258. (Krishnadas Academic series 4).201. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 21-24. Varanasi:Krishnadas Academy; 1982. p.258. (Krishnadas Academic series 4).202. Arunadatta, Sarvangasundari teeka on Ashtangahridaya Suthrasthana chapter 17sloka 15. Varanasi: Krishnadas Academy; 1982. p. 257. (Krishnadas Academic series 4).203. Hemadri, Ayurvedarasayana teeka on Ashtangahridaya Suthrasthana chapter 17sloka 15.Varanasi: Krishnadas Academy; 1982. p. 257. (Krishnadas Academic series 4).204. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 13. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).205. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Chikitsasthana chapter 32sloka 22-24. Varanasi: Krishnadas Academy; 1980.p. 514. (Krishnadas Ayurveda series51).206. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 14-15. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).207. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 24. Varanasi: KrishnadasAcademy; 1980. p. 514. (Krishnadas Ayurveda series 51).208. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 16-17. Varanasi:Krishnadas Academy; 1982. p.258. (Krishnadas Academic series 4).209. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 15. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).210. Agnivesa, Charakasamhitha Suthrasthana chapter 6 sloka 27-32. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 47. (Kasi Sanskrit series 228).211. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 24. Varanasi: KrishnadasAcademy; 1980. p. 514. (Krishnadas Ayurveda series 51).212. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 18. Varanasi: KrishnadasAcademy; 1982. p.258. (Krishnadas Academic series 4).213. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 65. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 92. (Kasi Sanskrit series 228). Bibliographic References
    • P214. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 66. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 92. (Kasi Sanskrit series 228).215. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 66. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 92. (Kasi Sanskrit series 228).216. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 7-8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 88. (Kasi Sanskrit series 228).217. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 1. Varanasi: KrishnadasAcademy; 1980. p. 513. (Krishnadas Ayurveda series 51).218. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 1. Varanasi: KrishnadasAcademy; 1982. p.255. (Krishnadas Academic series 4).219. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 39-40. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 90. (Kasi Sanskrit series 228).220. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Chikitsasthana chapter 32sloka 22. Varanasi: Krishnadas Academy; 1980. p. 514. (Krishnadas Ayurveda series 51).221. Kasture VG, Ayurvediyapanchakarmavigyan chapter 3. 6th ed. Nagpur: ShreeBaidyanath Ayurved Bhavan Ltd.; 1998. p. 164.222. Vrudhajeevaka, Kashyapasamhita Suthrasthana chapter 23 sloka 26. 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 277. (Kasi Sanskrit series 154).223. Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 64. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 92. (Kasi Sanskrit series 228).224. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Chikitsasthana chapter 32sloka 3. Varanasi: Krishnadas Academy; 1980. p. 513. (Krishnadas Ayurveda series 51).225. a) Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 44. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 90. (Kasi Sanskrit series 228). b) Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 13. Varanasi:Krishnadas Academy; 1980. p. 514. (Krishnadas Ayurveda series 51). c) Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 10. Varanasi:Krishnadas Academy; 1982. p.256. (Krishnadas Academic series 4). d) Ashtangasangraha Suthrasthana chapter 26 sloka 6. Dr. Ravidatta Tripathi,editor. Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p.466, ( Vrajajivanayurvijnan Granthamala 6 ). Bibliographic References
    • Q e) Vrudhajeevaka, Kashyapasamhita Suthrasthana chapter 23 sloka 26. 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 26. (Kasi Sanskrit series154).226. Susruta, Susrutasamhitha Sutrastanasasthana chapter 11 sloka 55. Varanasi:Krishnadas Academy; 1980. p. 78. (Krishnadas Ayurveda series 51).227. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 13. Varanasi: KrishnadasAcademy; 1980. p. 514. (Krishnadas Ayurveda series 51).228. Susruta, Susrutasamhitha Chikitsasthana chapter 32 sloka 16. Varanasi: KrishnadasAcademy; 1980. p. 514. (Krishnadas Ayurveda series 51).229. Ashtangasangraha Suthrasthana chapter 26 sloka 6. Dr. Ravidatta Tripathi,editor. Delhi: Chaukhambha Sanskrita Pratishtanaa; 1996. p.466, ( Vrajajivanayurvijnan Granthamala 6 ).230. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 10. Varanasi: KrishnadasAcademy; 1982. p.256. (Krishnadas Academic series 4).231. Bhelacharya, Bhelasamhitha Suthrasthana chapter 23, sloka 18-19. GirijadayalShukla editor. Varanasi: Chaukhambha Vidyabhavan; 1959. p.39.232. Agnivesa, Charakasamhitha Siddhisthana chapter 28 sloka 104-105. 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.621. (Kasi Sanskrit series 228).233. Susruta, Susrutasamhitha Chikitsasthana chapter 3 sloka 32-33. Varanasi:Krishnadas Academy; 1980. p. 417. (Krishnadas Ayurveda series 51).234. Susruta, Susrutasamhitha Chikitsasthana chapter 1 sloka 17. Varanasi: KrishnadasAcademy; 1980. p.399. (Krishnadas Ayurveda series 51).235. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Chikitsasthana chapter 4sloka 22-24. Varanasi: Krishnadas Academy; 1980. p. 422. (Krishnadas Ayurveda series51).236. Susruta, Susrutasamhitha Chikitsasthana chapter 24 sloka 31-32. Varanasi:Krishnadas Academy; 1980. p.488. (Krishnadas Ayurveda series 51).237. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Chikitsasthana chapter 32sloka 13. Varanasi: Krishnadas Academy; 1980. p. 514. (Krishnadas Ayurveda series 51).238. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 63. sloka 140-142 4thed.Varanasi: Chaukhambha Sanskrit series 130; 1984. p. 655-666.239. Vaidyaratnam P.S.Varrier, Chikitsa Samgraham Dhara. 2 nd ed. Kottakal : Aryavaidya sala ; 1994. p. 133-134,149. Bibliographic References
    • R240. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 618. (Kasi Sanskrit series 228).241.Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 618. (Kasi Sanskrit series 228).242. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1471243. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 15-18. 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 617. (Kasi Sanskrit series 228).244. Susruta, Susrutasamhitha Suthrasthana chapter 21 sloka 19. Varanasi: KrishnadasAcademy; 1980. p. 103. (Krishnadas Ayurveda series 51).245. Vagbhata, Ashtangahridaya Nidanasthana chapter 1 sloka 14-15. Varanasi:Krishnadas Academy; 1982. p.444. (Krishnadas Academic series 4).246. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 24. 5th ed. Varanasi:Chaukhambha Orientalia; 1988. p. 241-243. (Chaukhambha Sanskrit series 130).247. Agnivesa, Charakasamhitha vimanasasthana chapter 5 sloka 17. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 142. (Kasi Sanskrit series 228).248. Susruta, Susrutasamhitha Shareeasthana chapter 6 sloka 7, 12, 13. Varanasi:Krishnadas Academy; 1980. p. 370. (Krishnadas Ayurveda series 51).249. Susruta, Susrutasamhitha Suthrasthana chapter 15 sloka 32. Varanasi: KrishnadasAcademy; 1980. p. 73. (Krishnadas Ayurveda series 51).250. Vagbhata, Ashtangahridaya Suthrasthana chapter 1 sloka 8. Varanasi: KrishnadasAcademy; 1982. p.7. (Krishnadas Academic series 4).251. Vagbhata, Ashtangahridaya Suthrasthana chapter 1 sloka 23. Varanasi: KrishnadasAcademy; 1982. p.15. (Krishnadas Academic series 4).252. Vagbhata, Ashtangahridaya Suthrasthana chapter 1 sloka 8. Varanasi: KrishnadasAcademy; 1982. p.7. (Krishnadas Academic series 4).253. Vagbhata, Ashtangahridaya Suthrasthana chapter 1 sloka 15. Varanasi: KrishnadasAcademy; 1982. p.11. (Krishnadas Academic series 4).254. Harrisons principles of internal medicine vol 2 Petersdorf R G editor. 10th ed.India: Mcgrawhill; 1987.255. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1472.256. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 617. (Kasi Sanskrit series 228). Bibliographic References
    • S257. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 19. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 617. (Kasi Sanskrit series 228).258. Vagbhata, Ashtangahridaya Nidanasthana chapter 15 sloka 6. Varanasi: KrishnadasAcademy; 1982. p. 531. (Krishnadas Academic series 4).259. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 24-37. 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 617-618. (Kasi Sanskrit series 228).260. Singh Gurdip Prof, Avrithavata and its importance in clinical practice- Souvenir onNational Seminar on Vatavyadhis: 2001. p. 15.261. Susruta, Susrutasamhitha Suthrasthana chapter 15 sloka 32. Varanasi: KrishnadasAcademy; 1980. p. 73. (Krishnadas Ayurveda series 51).262. Dalhana, Nibandhasangraha teeka on Susrutasamhitha Suthrasthana chapter 15 sloka32. Varanasi: Krishnadas Academy; 1980. p. 74. (Krishnadas Ayurveda series 51).263. Cotran SR, Pathologic Basis of Disease chapter 28. 6th ed. Philadelphia: Saunders;2003. p. 1246.264. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 618. (Kasi Sanskrit series 228).265. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 618. (Kasi Sanskrit series 228).266. Susruta, Susrutasamhitha Nidanasthana chapter 1 sloka 28. Varanasi: KrishnadasAcademy; 1980. p. 261. (Krishnadas Ayurveda series 51).267. Susruta, Susrutasamhitha Nidanasthana chapter 1 sloka 28. Varanasi: KrishnadasAcademy; 1980. p. 261. (Krishnadas Ayurveda series 51).268. Madhavakara, Madhavanidana chapter 22 sloka 21. Varanasi: ChaukhambhaSurbharathi Prakashan; 1998. p. 521. (Chaukhambha Ayurvijnana Granthamala 46).269. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1479.270. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1479.271. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1479-1480.272. Susruta, Susrutasamhitha Suthrasthana chapter 33 sloka 5,6,7. Varanasi: KrishnadasAcademy; 1980. p. 144. (Krishnadas Ayurveda series 51).273. Madhavakara, Madhavanidana chapter 1 sloka 8. Varanasi: ChaukhambhaSurbharathi Prakashan; 1998. p. 45. (Chaukhambha Ayurvijnana Granthamala 46). Bibliographic References
    • T274. Agnivesa, Charakasamhitha Indriyasthana chapter 9 sloka 8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 368. (Kasi Sanskrit series 228).275. Chakrapani, Ayurvedadipika teeka on Charakasamhitha Chikitsasthana chapter 28sloka 12-14. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 620. (KasiSanskrit series 228).276. Susruta, Susrutasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 420. (Krishnadas Ayurveda series 51).277. Susruta, Susrutasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 420. (Krishnadas Ayurveda series 51).278. Susruta, Susrutasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 420. (Krishnadas Ayurveda series 51).279. Susruta, Susrutasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 420. (Krishnadas Ayurveda series 51).280. Susruta, Susrutasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 420. (Krishnadas Ayurveda series 51).281.Agnivesa, Charakasamhitha Suthrasthana chapter 14 sloka 35-37. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 89. (Kasi Sanskrit series 228).282. Vagbhata, Ashtangahridaya Suthrasthana chapter 17 sloka 5. Varanasi: KrishnadasAcademy; 1982. p.254. (Krishnadas Academic series 4).283. Susruta, Susrutasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: KrishnadasAcademy; 1980. p. 420. (Krishnadas Ayurveda series 51).284. Vagbhata, Ashtangahridaya Suthrasthana chapter 1 sloka 25. Varanasi: KrishnadasAcademy; 1982. p. 16. (Krishnadas Academic series 4).285. Govindadasa, Bhaishajyaratnavali Vatavyadhi prakarana sloka 442-446. 7th ed.Kaviraj Ambikadatta Shastri editor. Varanasi: Chaukhambha Orientalia; 1983. p. 130.(Kasi Sanskrit series 152).286. Govindadasa, Bhaishajyaratnavali Vatavyadhi prakarana sloka 447-449. 7th ed.Kaviraj Ambikadatta Shastri editor. Varanasi: Chaukhambha Orientalia; 1983. p. 130.(Kasi Sanskrit series 152).287. Manek J Nisha, Lane E Nancy, Osteoarthritis:- Current concepts in diagnosis andmanagement. American academy of family physicians 2000. Available from:www. Aafp.Org. Accessed on 15th March 2003.288. Kelly William, Textbook of Rheumatology chapter 90. 5th ed. Philadelphia: WBSaunders Company; 1997. p. 1497. Bibliographic References
    • U289. Agnivesa, Charakasamhitha Siddhisthana chapter 4 sloka 8. 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p 689. (Kasi Sanskrit series 228).290 a) Dr.gyanendra pandey. Dravya guna vignana part 3. 2 nd ed.Varanasi :chaukambha Krishnadas Academy. 2002. p.428-429. b) Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popularprakashan; 1976. p. 935-936.291. a) Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants.Mumbai: Bharatheeya Vidyabhavan; 2000. p. 441-442. b) Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popular parkashan; 1976. p. 45-46.292. a) Dr.gyanendra pandey. Dravya guna vignana part 3. 2 nd ed. Varanasi:Chaukambha Krishnadas Academy. 2002. p.621-623. b) Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants.Mumbai: Bharatheeya Vidyabhavan; 2000. p. 629-630. c) Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popularprakashan; 1976. p. 1126-1127.293.Govindadasa, Bhaishajyaratnavali Jwarachikitsa prakarana. 7th ed. KavirajAmbikadatta Shastri, editor. Varanasi: Chaukhambha Orientalia; 1983. p. 130. (KasiSanskrit series 152).294. Susruta, Susrutasamhitha Suthrasthana chapter 45 sloka 113. Varanasi:Krishnadas Academy; 1980. p. 205. (Krishnadas Ayurveda series 51).295. a) Susruta, Susrutasamhitha Suthrasthana chapter 46 sloka 42. Varanasi: KrishnadasAcademy; 1980. p. 190. (Krishnadas Ayurveda series 51). b) Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popularprakashan; 1976. p. 653-654.296. a) Susruta, Susrutasamhitha Suthrasthana chapter 46 sloka 214-215. Varanasi:Krishnadas Academy; 1980. p. 196. (Krishnadas Ayurveda series 51). b) Sharangadhara, Sharngadharasamhitha Utharakhanda chapter 10,sloka 12. 3rded. Varanasi: Chaukhambha Orientalia; 1983. p353. (Jaikrishnadas AyurvedaGranthamala 53).297. Das Somen, A manual on Clinical Surgery chapter 15. 4th ed. Calcutta: Dr.S.Das;1996. p. 188-192298. Nair.P.R, Management of Khanja and Pangu with Panchakarma. New Delhi:CCRAS; 1999. p. 40. Bibliographic References
    • i SPECIAL CASE SHEET FOR SANDHIGATAVATA Post Graduate Research And Studies Center (Panchakarma) Shree DGM Ayurvedic Medical College, Gadag. Guide : Dr. G.Purushothamacharyulu, PG Scholar : J. P. Basarigidad MD (Ayu). Co-Guide: Dr. Shashidhar.H. Doddamani, MD (Ayu).1. Name of the patient : Sl. No :2. Father’s / Husband’s Name : OPD No :3. Age : IPD No :4. Sex : M F Bed No :5. Religion : Hindu Muslim Christian Others6. Occupation : Sedentary Active Labor Others7. Economical Status : Poor Middle High8. Address : _____________________________ Phone No : ____________________________ Email ID : ___________________________9. Type of treatment : Group A Group B10.Date of Schedule Initiation : Date of Schedule Completion :11. Result: Good Moderate Poor No Response Response Response Response12. Consent: I here by agree that, I have been fully educated with the diseasetreatment, here by satisfied whole heartedly, and accept the medical trial over me.Investigator’s Signature Patient’s Signature
    • iiI. COMPLAINTS WITH DURATIONSl. Chief complaints Before Duration After AfterNo Treatment Treatment Follow- up 1 Sandhisothaha (Swelling) 2 Prasaarana Aakunchanayoho Savedana Pravruthihi (Pain on extension & flexion) 3 Sandhigraha (Joint Stiffness) - Morning stiffness (15-30 ms) - Stiffness after disuse 4 Sandhigathi asaamarthya (Limitation of joint movement) 5 Sparsha akshamatva (Tenderness) 6 Atopa (Crepitation)II. HISTORY OF PRESENT ILLNESS : Mode of onset Chronic Insidious Acute Traumatic Nature of pain Pricking Aching Generalized Tearing Burning Variation of pain Increased on use Increased on disuse Nocturnal
    • iii Routine activities affected Yes NoIII. HISTORY OF PAST ILLNESS : Episodes of same illness Yes/No Obesity Yes/No Trauma/Fracture of involved or related joint Yes/No Diabetes Mellitus Yes/No Hypertension Yes/No Other Vatavyadhees Yes/No Vataraktha Yes/No Acromegaly Yes/No Septic arthritis Yes/No Psoriatic arthritis Yes/No Rheumatoid arthritis Yes/No Fever Yes/No Others Yes/NoIV. TREATMENT HISTORY : Modern Medicine Ayurveda Medicine/Therapy Other Systems Relief with previous treatment Partial / No reliefV. FAMILY HISTORY RELEVANT : If Yes, specify the relation No
    • iv VI. PERSONAL HISTORY : 01. Ahaara Veg Mixed 02. Agni Manda Teekshna Vishama Sama 03. Koshta Madhya Mrudu Kroora 04. Nidra Sukha Alpa Ati Vishama 05. Vyasana Smoking Tobacco Alcohol Others None 06. Aarthavapravruthi Alpa Ati Vishama Rajonivruthi 07. Malapravruthi (Frequency) 08. Muthrapravruthi(Frequency) Day NightVII A. VITAL EXAMINATION Weight in kgs Height in cms Temperature in degree Celsius Pulse rate per Heart rate per Blood pressure in Minute Minute mm Hg Respiration per Minute
    • v B. ASHTASTHAANAPAREEKSHA 1. Nadee : Dosha Gati Poornata Spandana Kathinya 2. Muthra : 3. Mala : 4. Jihwa : 5. Sabda : 6. Sparsha : 7. Druk : 8. Aakruthi :VIII. DASAVIDHAPAREEKSHA A. PRAKRUTHI V P K VP VK PK SANNIPATHA B. VIKRUTHI Hethu AL M A Prakruthi Aasukaari Chirakaari Dosha AL M A Desa AL M A Dushya Al M A Kaala AL M A Bala AL M A Linga AL M A ( AL- Alpa, M- Madhyama, A- Adhika)
    • vi C. SAARA Pravara Madhyama Avara D. SAMHANANA Susamhatha Madhyasamhatha Asamhatha E. PRAMAANA Sama Heena Adhika F. SAATMYA Ekarasa Sarvarasa Vyamishra Rookshasaatmya Snigdhasaatmya G. SATVA Pravara Madhya Avara H. AAHAARASAKTHI Abhyavahaara Pravara Madhyama Avara Jaranasakthi Pravara Madhyama Avara I. VYAAYAAMASAKTHI Pravara Madhyama Avara J. VAYAHA Baala Madhya VrudhaIX. SROTOPAREEKSHA Srotas Observed LakshanaPranavahaAnnavahaUdakavahaRasavahaRakthavahaMamsavahaMedovaha
    • vii Asthivaha Majjavaha Sukravaha Pureeshavaha Muthravaha Swedovaha AarthavavahaX. SPECIAL EXAMINATION OF JOINTS A. Darshana (Inspection) 1. Joint Swelling Grading 0 1 2 3 Varna Raaga Shyaava Prakrutha Herbeden’s Nodes Present Absent 2.a. Deformity Present Absent b. Joint Instability Present Absent 3. Gait Nature Walking Time (Grade) 4. Joint Movement Active Completely Restricted Partially Restricted Free Passive Completely Restricted Partially Restricted Free 5. Muscular spasm Present Absent
    • viii 6. Muscular Wasting Above the affected joint Yes No Below the affected joint Yes NoB. Sparshana (Palpitation) 1. Vaatapoornadruthisparsha Yes No 2. Local Temperature Raised Not raised 3. Tenderness Grading 0 1 2 3 4. Limitation of Joint Movement (In Terms Of Grading) Axial Joints Cervical Lumbar Spine Distal Joints Knee Right Left Hip Right Left Ankle Right Left First Carpometametacarpal Right Left Distal Interphalangeal Right Left Proximal Interphalangel Right Left C. Shravana (Auscultation) Crepitus Heard Felt None
    • ix X1. NIDAANAPAREEKSHA 1. Nidaanapareeksha a. AahaaraTiktharasa Athyupayoga Kashayarasa Athyupayoga Katurasa AthyupayogaAlpa Bhojana Pramitha Bhojana Rooksha Bhojana b. Vihaara Vega Dhaarana Vegoodeerana Ativyavaya Nisaajaagarana Atyucha Bhaashana Ativyaayama c. Maanasika Atibhaya Atishoka Atichintha d. Occupational e. Chikitsa Aparaadhaja Shodhanakarma Atiyogaja Yes No 2. Poorvarupa : 3. Upashaya/Anupashaya : Ushna Seetha Rooksha Snigdha 4. Rupa : 5. Samprapthi : XII. SAADHYAASAADHYATA:
    • xXIII. LAB INVESTIGATIONS : Sl.No Name of the Test Values 1. ESR /1st Hr. 2. Hb% Gm% 3. Total Count WBC Per cm RBC Per cm 4. Differential Count N E B M L 5. Blood Glucose Mg/dl 6. RA Factor +ve -ve 7. Serum Alkaline Phosphatase : unit/L.XIV. RADIOLOGICAL EXAMINATION OF JOINTS ( Antero posterior and Lateral View) 1 Joint space Reduced Increased Unaltered 2 Subchondral bony sclerosis Present Absent 3 Formation of osteophytes Present Absent 4 Periarticular ossicles Present Absent 5 Altered shape of bone end Present Absent
    • xi XV. PARISHEKA DAINANDINA NIREEKSHANA DAY TIME DURATION LAKSHANAS ANY UPACHARAS OBSERVED UPADRAVAS ADVISED I Day II Day III Day IV Day V Day VI Day VII Day VIII Day XVI. BASTI KARMA NIREEKSHANA : Date of Basti initiation Date of Basti completionObservations Time Amount Time of No. of times Upadrava if Introduced Retention Motion any passedI DayII DayIII DayIV DayV DayVI DayVII DayVIII Day
    • xii XVI. ASSESSMENT OF RESULTS A. CLINICAL PARAMETERS Subjective Parameters Day 0 Day 08 Day 24 Ruk (Pain) Graha (Stiffness) Objective Parameters Day 0 Day 08 Day 24 Sparsha Akshamatva (Tenderness) Sandhigati Atisaamarthya (Range of Joint Movement) Sotha (Swelling) Atopa (Crepitations) Walking timeXV11. INVESTIGATORS NOTE Signature of Co-Guide Signature of Guide