A STUDY ON THE EFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA By Patil Uday J. Dissertation Submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA In partial fulfilment of the requirements for the degree of AYURVEDA VACHASPATI (DOCTOR OF MEDICINE) In SWASTHAVRITHA Under the guidance of Dr. Sajitha K. M.D. (AYU)DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHA VRITHAS.D.M. COLLEGE OF AYURVEDA AND HOSPITAL, HASSAN, 573201 2006
A STUDY ON THE EFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA By Patil Uday J. Dissertation Submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE In partial fulfilment of the requirements for the degree of AYURVEDA VACHASPATI (DOCTOR OF MEDICINE) In SWASTHAVRITHA Under the guidance of Dr. Sajitha.K, M.D (Ayu) Asst. Prof, Dept of SwasthavrithaDEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL, HASSAN -573201 2006
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA DECLARATION BY THE CANDIDATEI hereby declare that this dissertation / thesis entitled “A STUDY ON THEEFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA” is abona fide and genuine research work carried out by me under the guidance of Dr.Sajitha K. Asst. Professor, Department of Post Graduate Studies In SwasthaVritta,S. D. M. College of Ayurveda and Hospital, Hassan – 573 201.Date:Place: Hassan Patil Uday J.
DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201 (Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka) CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A STUDY ON THEEFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA” is abona fide research work done by Patil Uday J in partial fulfilment of therequirement for the degree of Ayurveda Vachaspati (M.D. Ayurveda) inSwasthavritha.Date:Hassan: Dr. Sajitha K. Asst. Professor P.G. Studies in Dept of Swasthavritha S D M College of Ayurveda, Hassan
DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201 (Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka) ENDORSEMENT BY THE H O D; PRINCIPAL / HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A STUDY ON THEEFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA” is abona fide research work done by Patil Uday J. under the guidance of Dr. Sajitha K.,Asst Professor, Department of Post Graduate Studies In Swasthavritha, S.D.M.College of Ayurveda, Hassan - 573201.Dr. Ramana G.V. Dr. Prasanna N RaoProfessor and Head PrincipalP G Studies in SwasthaVritta, S D M College of Ayurveda,S D M College of Ayurveda, Hassan.Hassan.Date: Date:Place: Place:
ACKNOWLEDGEMENT I bow my head on the foot of Prof. S. Prabhakar, secretary of SDME society, forgiving me an opportunity to pursue post graduation in SDMCA, Hassan I owe my humble gratitude and regards to Prof Dr. Gurudip singh, Director ofPG studies, SDMCA&H, HASSAN for evincing keen interest in my endeavours and forcontinued encouragement I am greatly thankful to Dr. P. N. Rao, Principal who provided the necessaryfacilities for the completion of this research work. I express my sincere gratitude and respect to Prof. Dr. Ramana. G. V. for hisguidance and timely suggestions and Dr. Sajitha K, Guide, advice, constant inspirationenabled me to complete this work. I am grateful to Dr. Shashikiran, Dr. Suhaskumar Shetty, for timelyinformation and librarian for his co-operation. I am thankful to all the teaching and non teaching staffs of S.D.M. College ofAyurveda and Hospital, Hassan for their support and co-operation. I am Grateful to Dr. Basant, Dr. Gururaj, Dr. Aditi, Dr. Manish, Dr. Srikant,Dr. Sanjeev, Dr. Prashant Lande, Dr. Satish Wagh, Dr. Vaibhav and all myclassmates for their never-ending encouragement. I wish my thanks to all my seniors,juniors and under graduates who helped me in every aspects of my work. I heartily acknowledge the help rendered to me by Dr. Anand, Dr. Abhijit, Dr.Prmod, Dr. Shailendra, Dr. Mayur, and Dr. Ashok A. I feel immensely privileged to credit this work to my parents, brother, wife,affection of my loving child Parth and other family members who constantly kept mesupporting against all odds. Dr. Patil Uday Jayawantrao
LIST OF ABBREVIATIONSA -Janu Basti groupA. Hr. -Ashtanga HridayaA. Sa. -Ashtanga SangrahaAth. -AtharvavedaB -Naturopathy Techniques groupBh. Pr. -Bhava PrakashBh. Ra. -Bhaishajya RatnavaliCa. Sa. -Charaka SamhitaCi. -ChikitsaM. M.W. -Monier. M. WilliamsMa. Ni. -Madhava NidanaMad.Kh. -Madhyama KhandaNi -NidanasthanaPu -PurvardhSh. -SharirasthanaSu. -SutrasthanaSu. Sa. -Sushruta SamhitaUt. -UttaraardhVi -VimanasthanaYo. Ra. -Yoga Ratnakara
ABSTRACTBackground To carry out the daily activities, normal movements of joints are very essential.Osteoarthritis acts as main hurdle in performing daily activities, in which joints aremainly affected leading to pain, immobility and discomfort. Non-pharmacological management is the foundation of treatment of osteoarthritis.Therefore, naturopathy gives a hope of treating this condition with different techniquesused externally.Objectives1. To evaluate the effect of Janu-Basti in the management of Sandhi Vata.2. To evaluate the effect of Naturopathy techniques in the management of Sandhi Vata.3. To compare the efficacy of Janu Basti and Naturopathy techniques.Methods It is a comparative study with pre-test and post test design with two groupsconsisting of 15 patients each.Group A- Patients of this group were advised Janu Basti with Tila Taila for 7 days.Group B- Patients of this group were given naturopathy techniques externally for 7 days.
Results Naturopathy techniques provided significant relief in Shoola (34.64%) in 53.33%of patients, Shotha (3.83%) in 86.66% of patients, Kriya alpata (43.13%) in 66.66% ofpatients, Flexion angle of knee joint (7.20%) in 73.33% of patients, Time taken to cover50m distances (17.66%) in 100% of patients of Sanhi Vata. Janu-Basti with Tila tailaprovided significant relief in Shoola (32.85%) in 46.66% of patients, Shotha (2.65%) in43.33% of patients, Kriya alpata (39.16%) in 46.66% of patients, Flexion angle of kneejoint (5.19%) in 73.33% of patients, Time taken to cover 50m distance (12.08%) in73.32% of patients.Interpretation By Naturopathy techniques blood circulation increases to joints due tovasodilatation, relieves congestion, improves nutrition of the joint, reduces muscle spasmand inflammation; soften adhesions, improves the range of motion and lubrication. Janu-Basti acts as an effective Bahya Shamana Chikitsa and relieves symptomslike Stambha, Gaurava and Sheetata.Conclusion Clinical study has proved that non pharmacological management in the form ofexternal treatments gives significant relief in osteoarthritis.
CONTENTS List of Tables and Figures Introduction and objectives 1-2 I. Literary Review of Sandhi Vata Historical Considerations3-4 Nirukti-Paribhasha5-6 Anatomy of Janu-sandhi 7-10 Nidana 11-17 Poorvaroopa and Roopa 18-19 Samprapti 20-25 Vyavachedaka Nidana 26 Sadhyasadhyata 27 Chikitsa 28-30 Osteoarthritis 31-36 Naturopathic techniques for Sandhi Vata 37-44 Janu-Basti 45-47 Mode of Action 48-50 II. Methodology 51-55 Results56-75 Discussion 76-86 Conclusion 87-88 Summary 89-91 Bibliographic References 92-94 Annexure 95-96
LIST OF TABLES AND FIGURESSL. CONTENT OF TABLE PAGENO. NO. 1 REFERENCES OF SANDHI VATA 4 2 RASA VISHESHA AHARAJA NIDANA 13 3 GUNA VISHESHA AHARAJA NIDANA 13 4 VIRYA VISHESHA AHARAJA NIDANA 13 5 DRAVYA VISHESHA AHARAJA NIDANA 14 6 AHARAKRAMA NIDANA 15 7 VIHARAJA NIDANA 15-16 8 MANSIKA NIDANA 16 9 KALAJA NIDANA 1610 ANYA NIDANA 1711 ROOPA OF SANDHI-VATA MENTIONED IN VARIOUS CLASSICS 1812 CHIKITSA SOOTRA MENTIONED IN DIFFERENT SAMHITA 2813 DRUG REVIEW 4714 AGE WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI-VATA 5615 SEX WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI-VATA 56 RELIGION WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI- 5716 VATA OCCUPATION WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI- 5717 VATA DEHA PRAKRITI WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI 5918 VATA19 SARA WISE DISTRIBUTION OF 30 OF SANDHI VATA 59 SAMHANANA WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI 6020 VATA21 PRAMANA WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI VATA 60 SATMYA (AHARA) WISE DISTRIBUTION OF 30 PATIENTS OF 6022 SANDHI VATA23 SATVA WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI VATA 61 ABHYAVAHARANA SHAKTI WISE DISTRIBUTION OF 30 PATIENTS 6124 OF SANDHI VATA JARANA SHAKTI WISE DISTRIBUTION OF 30PATIENTS OF SANDHI 6125 VATA VYAYAMA SHAKTI WISE DISTRIBUTION OF 30 PATIENTS OF 6226 SANDHI VATA CARDINAL SIGNS AND SYMPTOMS RECORDED IN 30 PATIENTS OF 6227 SANDHI VATA CHRONICITY WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI 6228 VATA CHARACTERISTIC OF KULAJA VRITTANT REPORTED BY 30 CASES 6329 OF SANDHI VATA SHOWING DISTRIBUTION OF VIHARATMKA NIDANA RECORDED 6430 IN 30 CASES OF SANDHI VATA
SHOWING DISTRIBUTION OF AHARATMAKA NIDANA IN 30 CASES 64 31 OF SANDHI VATA EFFECT OF JANU-BASTI ON SYMPTOMS OF SANDHI VATA 66 32 PATIENTS EFFECT OF JANU-BASTI ON CLINICAL SIGNS OF SANDHI VATA 66 33 PATIENTS EFFECT OF NATUROPATHY TECHNIQUES ON SYMPTOMS OF 68 34 SANDHI VATA PATIENTS EFFECT OF NATUROPATHY TECHNIQUES ON CLINICAL SIGNS OF 68 35 SANDHI VATA PATIENTS 36 TOTAL EFFECT ON SHOOLA 69 37 TOTAL EFFECT ON ATOPA 69 38 TOTAL EFFECT ON KRIYA ALPATA 69 39 TOTAL EFFECT ON SHOTHA 70 40 TOTAL EFFECT ON TIME TO COVER 5OM DISTANCE 70 41 TOTAL EFFECT ON FLEXION ANGLE OF KNEE JOINT 71 EFFECT OF JANU-BASTI ON SYMPTOMS OF SANDHI VATA 71 42 PATIENTS AFTER 15 DAYS EFFECT OF JANU-BASTI ON CLINICAL SIGNS OF SANDHI VATA 72 43 PATIENTS AFTER 15 DAYS EFFECT OF NATUROPATHY TECHNIQUES ON SYMPTOMS OF 72 44 SANDHI VATA PATIENTS AFTER 15 DAYS EFFECT OF NATUROPATHY TECHNIQUES ON CLINICAL SIGNS OF 73 45 SANDHI VATA PATIENTS AFTER 15 DAYS EFFECT OF JANU-BASTI ON SYMPTOMS OF SANDHI VATA 73 46 PATIENTS AFTER 30 DAYS EFFECT OF JANU-BASTI ON SIGNS OF SANDHI VATA PATIENTS 74 47 AFTER 30 DAYS EFFECT OF NATUROPATHY TECHNIQUES ON SYMPTOMS OF 74 48 SANDHI VATA PATIENTS AFTER30 DAYS EFFECT OF NATUROPATHY TECHNIQUES ON SIGNS OF SANDHI 75 49 VATA PATIENTS AFTER 30 DAYSFIGURE NO. FIGURE PAGE NO. 1 SAMPRAPTI IN DHATUKSHAYA JANYA SANDHI VATA 23 2 SAMPRAPTI IN AVARANA JANYA SHADHI VATA 24 3 SAMPRAPTI IN ABHIGHATA JANYA SANDHI VATA 25 4 SHOWING AGE WISE DISTRIBUTION 58 5 SHOWING SEX WISE DISTRIBUTION 58 6 SHOWING RELIGION WISE DISTRIBUTION 58 7 SHOWING OCCUPATION WISE DISTRIBUTION 59 8 SHOWING CARDINAL SIGNS AND SYMPTOMS 63 9 SHOWING CHRONICITY WISE DISTRIBUTION 63
INTRODUCTION AND OBJECTIVES Research is done for establishing new facts Many times research is conduct tovalidate old principles with fresh proofs. Research is constructed with suitableexperimental methods and honest observations are made to arrive at a logic conclusion. In our body, bones form the arms of the lever and fulcrum is at a joint wheremovement takes place. To carry out the daily activities, normal movements of joints arevery essential. Sandhi-Vata acts as main hurdle in performing daily activities, in whichjoints are mainly affected leading to pain, immobility, and discomfort. Sandhi-vatadescribed in Ayurveda can be correlated with osteoarthritis mentioned in modern science. ‘Arth’ means joint and ‘itis’ means inflammation. Osteoarthritis is the mostcommon type of arthritis; occurs due to the breakdown of cartilage in the joint. Amongthe elderly and obese persons Osteoarthritis is a leading cause of chronic disabilityespecially affecting the knee joints. Since knee is the weight bearing joint it is moresusceptible to wear and tear. Other factors like heavy journey, agriculture, housework isalso contributing. In the age group of 45-65 years 30% of population is suffering from this disease.More than 355 million people around the world today are suffering from chronic pain ofarthritis. W.H.O. estimates that within the growing population the number of people over50 years of age will be doubled by the year 2020. Hence, it has declared 2001-2010 as the‘Decade of bone and joint diseases’. In the contemporary science treatment is mainly aimed at Non–pharmacologicalmethods. Now there is a trend to find out non-pharmacological measures as much aspossible for the management of various disorders. Among non–pharmacological
treatment physical heat therapy is given importance. In addition, non-pharmacologicmanagement is the foundation of osteoarthritis. Naturopathy is a part of Swasthavritha, which deals with the different nature curetechniques. Naturopathy utilizes change in temperature as therapy. To regulate varioussystems external and easiest access is skin. Skin is a giant sense organ and covers wholebody. So the naturopathy techniques can be correlated to Bahirparimarjan Chikitsamentioned in Ayurvedic classic. Treatment in the form of Janu-basti, Abhyanga, Avagahaetc. have been proved of their efficacy on Sandhi Vata. The naturopathy likes derivativemassage, wax bath, alternate hot and cold pack, exercises, mustard pack etc. alsoconstitute non-pharmacological interventions, which are harmless, cheap and said to beeffective. Hence a study is planned to study their efficacy along with Janu Basti ascontrol in Sandhi vata patients. The objectives of the present study are to provide scientific basis for the therapies that is practiced are highly beneficial in the treatment of Sandhi vata. The following are the main objectives of this study.4.To evaluate the effect of Janu-Basti in the management of Sandhi Vata.5.To evaluate the effect of Naturopathy techniques in the management of Sandhi Vata.6.To compare the efficacy of Ayurvedic Bahirparimarjan Chikitsa and naturopathytechniques employed for the treatment of Sandhi Vata.
HISTORICAL CONSIDERATIOS History of Indian medicine is usually studied under the headings of Prevedicperiod, Vedic period, Samhita Kala, Sangraha Kala, Nighantu Kala and Adhunika Kala.History of medicine also reveals some aspects of the disease. In classics the general description of Sandhi Vata is available. There is no reference regarding Sandhi Vata in Prevedic period. During Vedicperiod in Atharvaveda the references regarding the occurrence of Sandhi Vikara (Ath.2/33/7, 6/14/1), the importance given for Vata (Ath.8/2/3, 2/10/3) and disorders of Vata(Ath. 9/8/21) are available. In Samhita period we find systematic description of the diseases according toNidana Panchaka. Caraka Samhita, explained Sandhi Vata in Chikitsa sthana.1 Sushruta Samhita narrates its Lakshana in Nidanasthana2 and Chikitsa inCikitsasthana.3
Ashtanga Sangraha Nidanasthana describes its Lakshana4 and Chikitsa of SandhiVata in Cikitsasthana.5 Ashtanga Hridaya has described Lakshansa in Nidanasthana6 and line of treatmentin Cikitsasthana.7 In Madhava Nidana Lakshana of Sandhi Vata are given same as that of Sushruta.8 Bhavaprakasha explains the Lakshana and treatment of Sandhi Vata in MadhyamaKhanda Vatavyadhyadhikara.9 Yogaratnakara also explained about Lakshana and treatment of Sandhi Vata inVatavyadhyadhikara of Purvardha.10 In Bhaishajya Ratnavali Vatavyadhi Prakarana deals with treatment aspects ofSandhi Vata.11 The commentators of Samhita and Sangraha especially Chakrapani and Dalhanacontributed a lot for better understanding of the disease. Table 1 References of Sandhi Vata Literatures References Caraka Samhita Chikitsasthana 28 Sushruta Samhita Nidanasthana 1; Chikitsasthana 4 Ashtanga Sangraha Nidanasthana 15; Chikitsasthana 23 Ashtanga Hridaya Nidanasthana 15; Chikitsasthana 21 Yogaratnakara Purvardha, Vatavyadhyadhikara
Bhavaprakasha Madhyamakhanda Vatavyadhyadhikara 24 Madhava Nidana Purvardha, Vatavyadhyadhikara 22 Bhaishajyaratnavali Vatavyadhi Prakarana 23 NIRUKTI AND PARIBHASHA The word ‘Sandhi-Vata’ is comprised of 2 words i.e., Sandhi and Vata.Etymology, definition and specific interpretation of the terms are explained as follows.Sandhi Vyutpatti - Sam + Dha + Kihi (Shabda Kalpa Druma) Nirukti - ‘Asthi Samyogasthane’ (Vaiydyaka Sabdasindhuh) Means junction, connection, combination, and union with containing a conjugation,transition from one to another (Sanskrit – English dictionary by M.M.W.) Paribhasha - Sandhi Pullinga, Sandhanamiti, Yuga Sandhini Yugashabde Deha Sandhini Marmashabde Cha Drishtavyaha (Shabda Kalp Druma). In general, Sandhi means the junction between two things. In Ayurveda, ShareeraSandhi is a technical word indicating that it is the place where two or more bones meettogether and the joint may be fixed type or with less or more movement.
Acharya Sushruta explains about the innumerable junctions between Peshi,Snayu, Sira, Asthi, etc. But the description about Sandhi is concerned Asthi Sandhi1.VataVyutpatti- Va - Gati Sevanayoho Va + Kta (Shabda Kalpa Druma) The term ‘Vata’ is derived by the application of ‘Kta’ or Krt Pratyaya to the verbroot ‘Va’ which means ‘Gati and Gandhana’.Nirukti - Va - Gati Gandhanayoho (Sushruta Samhita) The term ‘Gati’ is having meanings like Prapti, Jnana, Gamana, Moksha and themeaning of ‘Gandhana’ is like Utsaha, Prakashana, Soocana, (Shabdasthoma) Gandhana,Prerana (Siddhanta Kaumudi). Considering the different meanings of Gati and Gandhana it is understood that theterm ‘Vata’ act as a receptor as well as stimulator. Hence it can be said that Vata is thebiological force, which recognize and stimulate all the activities in the body.Sandhi -Vata After going through the different references the definition can be stated as – thevitiated Vata when get lodged at one or more than one Sandhi and producing the features
like pain in the joint, swelling on palpation, crepitus and stiffness in the joint termed asSandhi-Vata. JANU-SANDHI In Sandhi Vata the vitiated Vata gets lodged at different Sandhi. Therefore beforegoing to the disease aspects, the anatomy and physiology of Sandhi are to be under stoodproperly. Here an attempt is made to study anatomical and physiological consideration ofSandhi in general and Janu-sandhi in particular. In Ayurveda, Sandhi is mainly classified into two types. 1) Sthira Sandhi 2) Chala Sandhi12 Again they are sub classified into eight types. 1) Kora 2) Ulookala 3) Samudga 4) Pratara 5) Tunnasevani 6)Vayasa tunda 7)Mandala 8)Shankhavarta Acharya Sushruta considered Janu-Sandhi under Chala Sandhi and sub classifiedunder Kora Sandhi.13 Other factors that are to be highlighted in understanding the Sandhi areShleshmaka Kapha- Shleshmaka Kapha is one among five variety of Kapha, whichreside in joints. It helps in lubrication of joints.14Shleshmadhara Kala-It is the fourth Kala, which is situated in all joints. As wheelmoves on well by lubricating the axis, joints also function properly if supported withKapha. This helps in formation of synovial fluid and to control friction of bones.15Vyana Vata- Vata governs every movement in the body. Vyana Vata is one among thefive varieties of Vata, which resides at Hridaya and controls most of the motor functions.
The Gati or physical movement is also one of its functions. Gayadasa commenting onSushruta has quoted that the Vyana Vata is functioning all over the body hence it alsoresides in the Sandhi.16 Acarya Vagbhata states that Vata is located in the Asthi withrelation to Ashrayashrayi Sambandha. Generally augmentation or diminution of Doshaswould be given similar effect on their respective Dhatus but in case of Vata it is opposite.With increase in Vata, Asthi Kshaya occurs.17 Sushruta in Sharirasthana explains different structures of the human body. Amongthem, structures coming under Janu-Sandhi are listed below.Snayu- Among nine hundred Snayus ten Snayus of Pratana variety are present in Janu-Sandhi. As a boat consisting of planks becomes capable of carrying load of passengers inriver after it is tied properly with bundle of ropes, all joints in the body are tied withmany ligaments by which persons are capable of bearing load.18Peshi- The fleshy mass covering bony structures that can be demarcated from each otheris known as Peshi. Among the five hundred Peshi, five are present in Janu Sandhi. Theyare strong structures that help to maintain alignment of the joint.19Sanghata- Assemblages of bones are known as Sanghata. Out of total fourteen, one issituated in Janu-Sandhi.20 Knee Joint The knee joint is the largest and most complex joint of the body. The complexityis due to the result of fusion of three joints in one. It is formed by fusion of the lateralfemoro-tibial, medial femoro-tibial and femoro-patellar joints. It is a compound synovial joint, incorporating two condylar joints between thecondoyle of the femur and tibia, one saddle joint between the femur and the patella.
In synovial joints the osseous surfaces concerned are not in continuity althoughthe bones involved are linked. The synovial joints evolve from fibrous and cartilaginousjoints by subsequent developments. These synovial joints are made up of uniquestructures like fibrous capsule, articular surfaces, synovial membrane, synovial fluid,ligaments, muscles etc.Articular surfaces- The knee joint is formed by (1) the condyles of the femur, (2) thecondyles of the tibia and (3) the patella. The femoral condyles articulate with the tibialcondyles below and behind with the patella in front.Fibrous capsule- The fibrous capsule has parallel but interlacing bundles of whitecollagen fibers. It is complex, partly deficient and partly augmented by expansions fromadjacent tendons. It forms a cuff with its ends attached continuously round the articularends of the Tibia and Femur.Synovial membrane- Derived from embryonic mesenchyme and lines fibrous capsule,covers exposed osseous surfaces, intra-capsular ligaments and tendons. It is absent fromintra-articular discs or menisci and ceases at the margins of articular cartilages.Synovial Intima- Also called as lamina propria synovialis or synovial lining layer. Itconsists of pleomorphic synoviocytes embedded in a granular, amorphous, fiber free intercellular matrix. It helps in removal of debris and synthesis of components of Synovialfluid.Synovial fluid- It occupies synovial joints, bursae and tendon sheaths. It is clear, paleyellow, viscous, and slightly alkaline. A protein probably lubricin rather than hyaluoricacid is the lubricating factor but it amplifies its secondary lubricating activity. It provides
liquid environment with small range of pH, nourishes articular cartilage, discs, menisci. Itrenders lubrication and reduces erosion.Menisci- It is a fibro cartilagenous disc which is crescent shaped. It deepens the articularsurfaces of the chondyles of the tibia. It partially divides the joint cavity into upper andlower compartments. It has two ends, two borders and two surfaces. It helps to make thearticular surfaces more congruent; act as shock absorbers, lubricates the joint cavity andgives rise to proprioceptive impulse.Other Structures-Ligaments- The capsules and ligaments of Synovial joints unit thebones, help to direct bone movement and prevent excessive and undesirable motion. Thusmore the ligaments, stronger are the joints. In knee joint tibial collateral lig, fibularcollateral lig, oblique popliteal lig, arcuate popliteal lig, ligamentum patellae, cruciateligament etc. helps to maintain stability.Muscle tone- Muscle tendons that cross the joints are the most important stabilizingfactors, due to tonicity of the respective muscles. In knee, muscle tone is extremelyimportant in reinforcing joints. For this the thigh muscles are helpful.Bursae- Apertures in fibrous capsule through which synovial membranes protrude arecalled as Bursae. They are numerous; as many as 13 bursae have been described aroundthe knee, four anterior, four laterals & five medial.Blood Supply-1.Five genicular branches of the popliteal artery. 2. The descendinggenicular branch of the femoral artery. 3. The descending branch of the lateral circumflexfemoral artery. 4. Two recurrent branches of the anterior tibial artery. 5. The circumflexfibular branch of the post-tibial artery.
Nerve Supply- 1.Femoral nerve – Through its branches to the vastus medialis.2. Sciaticnerve-Through the genicular branches of the tibial and common peroneal nerves. 3.Obturator nerve – Through its posterior division. NIDANA In Bruhatrayees and Laghutrayees we find the description of Sandhi Vata in Vata Vyadhi, hence Sandhi Vata is considered as a part of Vata Vyadhi. Acharyas have not mentioned particular Nidana for Sandhi Vata, so we can take common Nidana given for Vata Vyadhi21 along with Asthi and Majjavahasroto Dushti Karana.22 These Nidana can be classified under various headings with different contexts. The complimentary references of the Nidana of Sandhi Vata can be classified on the following basis. a) Aharaja b) Viharaja c) Manasika d) Kalaja e) Anya Nidana mentioned under the above five groups are tabulated in Table 1to5. Someof the important Nidana that may cause Sandhi-Vata are being discussed here in details:
Aharaja Nidana- Ahara is the most common contributing factor for the producing of adisease. Intake of Ahara having Kashaya, Katu, Tikta Rasa; Sheeta, Ruksha, Laghu Gunaand indulgence in Alpashana, Vishmashana, Adhyashana, Pramitashana lead toaggravation of Vata. Dravyas like Shushkashaka, Vallura, Varaka, Nivara, Koradusha,Kalaya, Tumba, Kalinga, Chirbhota etc cause Vata vitiation.Ativyayama- Excessive physical exercises act as one of the important Nidana for SandhiVata. Running, walking, jogging etc if done excessively or violently will affect thestructures of Sandhi. They may affect the joint stability by over exertion. But if doneproperly they stabilize and strengthen the Joints. Bhara-Vahana- Carrying excessive load causes excessive pressure and stretching effect over the structures of the joint. As knee is a weight-bearing joint, carrying excessive load will have direct affect on the joint. The constant compression will lead to wear and tear effect leading to degenerative changes in the joint.Abhighata- Abhighata to the joint due to Prapatana etc. leads to structural deformity inthe joint. Joint is an organ rather than a single structure as 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 forSandhi Vata.Ati-Sankshobha- It is a Nidana for Asthivaha Sroto Dushti. Since Asthivaha Srotas isinvolved in Sandhi Vata this can be considered as Nidana for the same. Violent activitieslike Atyadhva, Plavana, Langhana, Balavat Vigraha, Pradhavana etc. will have adverse
effect on joint. As told earlier knee is the weight-bearing joint, and violent exercises oractivities will alter the structural integrity of the joint.Marmabhighata-The concept of Marmabhighata in the causation of Sandhi Vata seemsto be more rational. Janu Sandhi is one of Vaikalyakara Sandhi Marma23. Thus Janusandhi is a vital point, which comprises of Asthi, Snayu, Sira and Mamsa. 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 Marma in the disturbance of the joint is justified. Hence Marmabhighataas a Nidana in case of Sandhi Vata is to be given importance. Samanya Nidana of Vatavyadhi as explained in different treatises (1) Aharaja Nidana a) Rasa Vishesha Aharaja Nidana (Table-2) Nidana Ca.Sa. Su.Sa. A.Hr. Ma.Ni. Yo.Ra. Bh.Pr. A.Sa. Kashaya - + + - - + + Katu - + + - - + + Tikta - + + - - + +
Kriyatiyoga - - + - - - - Vishmopachara + - - + + + + Pravata + - - - - - + Sangkshobha + - - - - - - Asthnamativighatana + - - - - - - Utpeshadatya + - - - - - - POORVAROOPA Poorvaroopa of Sandhi-Vata is not available in classics. In Vatavyadhiunmanifested symptoms (Avyakta) or mild exhibition of actual features of the diseaseitself is considered as its Poorvaroopa.24 Therefore prior to the full manifestationof Sandhi Vata, appearance of some of its symptoms can be considered asPoorvaroopa.ROOPAThe clinical features of Sandhi Vata explained by various Acharyas are listed in table. Table-11 Roopa of Sandhi-Vata mentioned in various classics Symptoms Ca.Sa. Su.Sa. A.Hr. A.Sa. Ma.Ni. Bh.Pr. Yo.Ra. Sandhi Shoola + + + + + + + Sandhi Shotha + + + + + + Sandhi Stabdhata + +
Atopa +Sandhi Shoola All the Acarya have described this symptom. Charaka and Vagbhata explain thatpain in the joint occurs during Prasarana and Akunchana Pravrutti.Sandhi Shotha Most of the classics explained this symptom. Charaka and Vagbhata explained the nature of Shotha i.e., it is felt like bag filled with air (Vata Poorna Driti Sparsha).Sandhi Stabdhata Sushruta initially described this symptom, later by texts like Madhava Nidana,Yogaratnakara and Bhavaprakasha. They have coined the term Sandhi Hanana or Hanti. While commenting on thisword Dalhana and Gayadasa explained as ‘Akunchanaprasaranayoh Abhavah’ and‘Prasaranakuncanayoh Asamarthah’ respectively. With this we can infer that the wordHanti refers to inability to move the joints. In the opinion of Madhukoshakara, Hanti refers to Sandhi Vishlesha, StambhaAdi Vikara. Hence with the above references, Hanti refers to Sandhi Stabdhata.Atopa This symptom is explained in Madhava Nidana. While commenting on the wordAtopa in another context, Madhukoshakara quotes the opinion of Gayadasa and Kartikai.e. ‘Atopaha Chalachalanamiti Gayadasaha, Gudaguda Shabdamiti Kartikah’. Also
Bhavamishra says ‘Atopo – Gudagudashabdaha’. Thus we can say that Atopa in thiscontext is the sound produced by the movement of joints i.e., crepitus. Thus with the help of different references and by the opinion of commentators itcan be concluded that Sandhi Shoola, Sandhi Shotha, Sandhi Stabdhata and Atopa are theclinical features of Sandhi Vata.25SAMPRAPTI The total course from the Dosha vitiation, resultant Dhatu affliction and evolutionof Vyadhi is Samprapti. Samprapti explains all the series of pathological stages involved.The Samanya Samprapti of Vata Vyadhi, which is explained in classics, can beconsidered as the Samprapti of Sandhi Vata. Acharya Caraka explained due to the intake of Vatakara Ahara Vihara Vatavitiation take place. This vitiated Vata lodges in Rikta Srotas i.e. Srotas in whereShunyata of Snehadi Guna is present. Vata after settling in Rikta Srotas producedisease related to that Srotas26. Acharya Vagbhata frames the Samprapti of Vata Vyadhi like Dhatukshayaaggravates Vata and the same is also responsible to produce Riktata of Srotas. Thusthe vitiated Vata travels through out the body and settles in the Rikta Srotas andfurther vitiates the Srotas leading to the manifestation of Vata Vyadhi27. Srotoriktata occurs due to Nidanasevana as follows. The chief properties of Parthiva Dravya are Guru, Sthula, Sthira, Gandha Guna in excess. These properties are necessary for Sthairya and Upacaya of the body. Excessive intake of Dravyas having Laghu, Ruksha, Sukshma, Khara properties lead to Guru and Sneha Guna Abhava due to their
opposite quality. Thus it leads to Dhatukshaya in the body. Akasha Mahabhuta produces Sushirata and Laghuta in the body. Vayu Mahabuta fills up this Sushirata. So due to Dhatukshaya Akasha Mahabhuta increases in the body producing Sushirata and Laghuta simultaneously Vayu fills it up. From this description it can be stated that the meaning of word ‘Riktata’ is Sushirata i.e. increase in Akasha and Vayu Mahabhuta. While commenting on word ‘Riktata’ Chakrapani says that ‘Riktata’ means lack of Snehadiguna. For the purpose of understanding the Samprapti of Sandhi Vata can be studied under three heading. They are1. Dhatukshayajanya 2. Avaranajanya 3. Abhighatajanya1. Dhatukshayajanya Sandhi Vata-In old age Vata Dosha dominates in the body. Thiswill lead to Kapha Abhava. Also Jataragni and Dhatvagni get impaired so Dhatu will notbe form in good quality. Degeneration of body elements takes place due to predominanceof Vata in its Ruksha, Khara etc Guna and loss of Kapha in quality and quantity. As the Shleshma Bhava decreases in the body Shleshaka Kapha in the joints alsodecreases in quality and quantity. Reduction of Kapha in Sandhis makes SandhiBandhana Shithilata. Ashrayashrayi Sambandha also leads Asthidhatu Kshaya. Asthibeing the main participant of the joint its Kshaya leads Khavaigunya in the joints. In thiscondition if Nidana Sevana done leads Vata Prakopa. If Vata Prakopa is not corrected byappropriate means and simultaneously if the person indulges in Asthivaha and MajjavahaSroto Dushtikara Nidana, the Prakupita Vata spreads all over the body through theseSrotas. In the meantime Sthanasamshraya of Prakupita Vata takes place in theKhavaigunyayukta Sandhi. This localized Vayu due to its Ruksha, Laghu, Kharadi Gunaover power and undo all properties of Sleshaka Kapha producing disease Sandhi Vata.2. Avarana Janya Sandhi Vata-In Sthula Sandhi Vata occurs in weight bearing joints.In them Medodhatu will be produced in excess due to the Atisnehamsha of Amarasa The
excessive Medas will produce obstruction for the flow of nutritive materials to the futureDhatus that is Asthi, Majja and Shukra leads to their Kshaya28. The excessive fat deposited all over the body will produce Margavarana of Vata 29Prakupita Vata due to Margavarana starts to circulate in the body. While traveling itsettles in the joint where Khavaigunya is already exists. After Sthanasamshraya itproduces the disease Sandhi Vata in the same process mentioned in the earlier context.3. Abhighatajanya Sandhi Vata- Trauma is considered assecondary cause of Osteoarthritis. By the Abhighata theintegrity of the joint is disturbed. Due to Abhighata to theAsthi involved in Sandhi leads to provocation of SthanikaVata that is. Vyana Vata (Ashrayashrayi Sambandha).Ruksha Guna of Vata and Ushanata produced by Abhighatawill does the Shoshana of Shlashmaka Kapha in the joint.This produces the degenerative change in joint cartilage(lack of nutrition). In another way Vata is vitiated in the jointby the Siramarga Avarana of Vata due to Abhighata30. Thisvitiated Sthanika Vata will produce series of changes in the
joint after Dosha Dushya Sammurchana and produces SadhiVata Lakshana. Thus with the help of Samanya Samprapti of Vata Vyadhi the Samprapti of Sandhi Vata can be divided into Dhatukshaya Janya, Avarana Janya and Abhighata Janya Sandhi Vata. This will help in deciding the prognosis and planning the treatment of the disease.Samprapti Ghataka: Dosha – Vata – Vyana – Vriddhi; Kapha – Shleshaka – KshayaDooshya – Peshi, Snayu, Asthi, MajjaSrotas – Mamsavaha, Medovaha, Asthivaha, MajjavahaAgni – Jataragni, Asthi-DhatvagniAma – Jataragni Mandya JanyaRoga Marga – MadhyamaUdbhavasthana – PakvashayaSancharasthana - SarvashariraAdhishtana – SandhiVyaktasthana – Sandhi
FIGURE - 1 SAMPRAPTI IN DHATUKSHAYA JANYA SANDHI VATA NIDANA SEVANA VARDHAKYA DHATUKSHAYA VATA PRAKOPA KSHAYA OF KAPHA BHAVA IN THE BODYCIRCULATION THROUGH SHLESHAKA KAPHA KSHAYA RASAYANI IN SANDHI KHAVAIGUNYA IN SANDHI STHANASAMSHRAYA IN SANDHI SANDHI VATA
FIGURE - 2 SAMPRAPTI IN AVARANA JANYA SHADHI VATA(MEDOVARANA) MEDOVRIDDHI (MARGAVARANA TO THE FLOW OF POSHAKARASA)VATAPRAKOPA POSHAKARASA NYUNATA TO ASTHIDHATU EXCESSIVE PRESSURE OVER WEIGHT BEARING JOINTCIRCULATION THROUGH ASTHIDHATU KSHAYA RASAYANI IN SANDHI VYANAVATA PRAKOPA IN SANDHI KHAVAIGUNYA IN SANDHI STHANASAMSHRAYA IN SANDHI SANDHI VATA
FIGURE - 3 SAMPRAPTI IN ABHIGHATA JANYA SHADHI VATA ABHIGHATAAGHATA TO ASTHI STHANIKA VATAPRAKOPA KSHATOSMAVATA PRAKOPA DOSHDUSHYA SAMURCHANA SHLESHAKA KAPHA KSHAYA KHAVAIGUNYA IN SANDHI SANDHI VATA
VYAVACHEDAKA NIDANA Vyavachedaka Nidana or differential diagnosis plays a prime role in arriving at anexact decision between diseases presenting a similar clinical feature. While making thediagnosis of Sandhi-Vata the following disorders that are having similar features has tobe excluded. They are 1) Amavata (Ma.Ni.25/7) 2) Vatarakta (Ca.Sa.Ci.29/23) 3) Kroshtukasheersha (Ma.Ni.22/58) 4) Sandhibhagna (Ma.Ni.44/2) 5) Asthi Majjagata Vata (Ma.Ni.22/18) There are some conditions (Dosha Vriddhi Kshaya Lakshana, PanchakarmaVyapat) where in symptoms related to Sandhi are seen. They are listed below. 1) Kapha Vruddhi (A.Sa.Su.19/6) 2) Kapha Kshaya (A.Sa.Su.19/9) 3) Mamsa Kshaya (A.Sa.Su.19/10) 4) Medo Kshaya (Ca.Sa.Su.17/66-67) 5) Asthi Kshaya (Ca.Sa.Su.17/66-67) 6) Majja Kshaya (Su.Sa.Su.15/13) 7) Ojo Visramsa (Su.Sa.Su.15/29) So while diagnosing Sandhi-Vata, factors like Vriddhi or Kshaya of Dosha andDhatu should be differentiated apart from above-mentioned disorders. This will help insuccessful treatment.
SADHYASADHYATA Sandhi-Vata is a variety of Vata Vyadhi, and also Madhyama roga MargajaVyadhi. The disease in elderly persons is kastasadhya and Sandhi-Vata is usuallyafflicted in elderly aged. Diseases of Gambheera dhatu are Yapya and Sandhi-Vata Asthidhatu is involved. In Caraka Samhita it has been stated that Khudavata (Sandhi-Vata) will not yieldto treatment because of its Gambheera sthan31. Further it states that it may cured by fulleffort when the disease in new, Upadrava rahita and in strong person32. So Sandhi-Vatabeing a disease of old age may not be considered as Sukhsadhya. It may be Krichsadhyaor Yapya depending upon the time of onset and chronicity. CHIKITSA The main aim of treatment is to restore Swasthya. It means to restorenormal functions of Agni, Dosha, Dhatu, and Mala and to maintain mental health.The primary importance of Chikitsa lies in Samprapti Vighatana. Sandhi-Vata is a Vataja disorder. The general treatment of Vata Vyadhi can beadopted, keeping an eye on the etiology. Regarding the specific line of treatment ofSandhi-Vata, Caraka is silent. Later authors like Sushruta had mentioned effective line oftreatment for the same. Other books like Astanga Hridaya, Astanga Sangraha,Yogaratnakara, and Bhavaprakasha had mentioned specific line of treatment. The below chart shows Chikitsa sutra mentioned in different texts
Table -12 Chikitsa Sootra mentioned in different Samhita Treatment Su.Sa. A.Sa. A.Hr. Yo.Ra. Bh.Pr. Bh.Ra. Snehana + + + + + Abhyanga + Mardana + + + + Svedana + + + Upanaha + + + + + + Bandhana + + + Agnikarma + + + + SNEHANA Sandhi-Vata is a variety of Vata Vyadhi, where Snehana would be very effective. According to the use it can be administered in two ways – Abhyantara Prayoga Bahya Prayoga33 Abhyantara Sneha: Here Sneha in the form of Pana can be administered in case of Sandhi Vata. Bahya Sneha: Bahya Sneha is many like Abhyanga, Lepa, Pichu, Mardana, and Parisheka. In case of Sandhi Vata we get the mentioning of Abhyanga and Mardana. Abhyanga means to do some movements or Gati. For the purpose of AbhyangaSukhoshna Taila or Sneha is used. Abhyanga should be done slowly in Anuloma Gati, injoints it should be done in circular manner. Abhyanga should be done minimum for 5
minutes because the Veerya of Taila will reach Majja Dhatu in 900 Matra-Kalas. It isVatahara, Pushtikara34. Mardana is like Abhyanga but applied pressure is more. SWEDANA Swedana is a variety of Shadvidhopakrama. It is helpful in neutralizing Stabdhata, Shitata and Gauravata.35 Vatanashak drugs or drugs having Ushna Veerya, Guru, Drava, Sthira, Sara, Snigdha, Ruksha, Sukshma, Tikshna can be take for Swedana.36 UPANAHA Charaka consider Upanaha as a variety of Swedana.37 Roots of Vatahara drugs should be pasted together with Kanji and mixed with abundant quantity of Saindhava Lavana and Sneha. After making this lukewarm, it should be applied to the affected part. The paste of drugs included in the Kakolyadi, Eladi or Surasadi Gana as well aspastes of Sarshapa, Tila, or Atasi or Krishara, Payasa, Utkarika and Veshavara or thedrugs of Salvana Sweda should be similarly applied to the affected part folded in piece ofthin linen and tied up.38Duration- Upanaha, which is tied in the morning, should be removed in the night andwhich is tied in the night should be removed in the morning. BANDHANA In Bandhana Dravya is tied to the affected apart. For the purpose of Bandhana,Charaka opines that leather of Ushna Veerya animal can be used. In the absence of this
silk or woolen cloth can be used.39 Astanga Hridaya opines that Vatahara Patra40 shouldbe used and Charaka suggests Eranda Patra.41 AGNIKARMA Unique treatment indicated in case of Sandhi Vata. Here Dahana or cauterizationis done in the part affected.42 Dahana Karma should be done in the affected joint till theSamyaka Lakshana appear. These are the different treatment modalities mentioned by different authors forSandhi-Vata. OSTEOARTHRITIS Osteoarthritis is also called as Degenerative Joint Disease or Arthrosis or wear-and-tear arthritis. It represents the failure of diarthrodial joint. It is one of the most common joint diseases of humans. Osteoarthritis of knee isthe leading cause of chronic disability in developed countries. Primary Osteoarthritis isidiopathic and secondary Osteoarthritis is due to many causes like secondary to trauma,due to endocrinal disorders, metabolic causes, etc.Risk factors for Osteoarthritis Age – It is one of the powerful risk factor in old age people. Sex – Both Males and females are affected, but osteoarthritis is more generalized and more severe in older women. It is twice as common in women as in men. Osteoarthritis of knee is common in women. Women less than 45 years old – 2% 45 – 65 years – 30%
Older than 65 years – 68% will suffer. Genetic – Point mutation in the cDNA coding for articular cartilage collagen have been identified in families with chondrodysplasia and polyarticular osteoarthritis. Trauma – Direct or indirect injuries to the articular cartilage lead to its degeneration. Fractures of different bones, especially of weight bearing with or without involving the joint can also cause alteration of ligaments and in articular surface of joint. Repetitive stress – Abnormal posture, abnormal gait, and unequal length of leg will exert stress and strain over the joint. Endocrine disorders – Acromegaly, Hyperparathyroidism, Diabetes mellitus, Obesity, etc. also may lead to osteoarthritis. Metabolic disorders – Like Ochronosis, Wilson’s disease may give rise to Osteoarthritis. Calcium deposition diseases – Like CPPD deposition may lead to Osteoarthritis.PATHOLOGY Although the cardinal pathologic features of osteoarthritis are progressive loss ofarticular cartilage, osteoarthritis is not a disease of any single tissue but a disease of anorgan, the synovial joint. The most striking morphologic changes in osteoarthritis areusually seen in load bearing areas of the articular cartilage. Osteoarthritis develops in either of two settings:
1. The biomaterial properties of the articular cartilage and sub-chondral bone arenormal, but excessive loading on the joint causes the tissue fail, or 2. The applied load is reasonable, but the material properties of the cartilage orbone are inferior. In the early stages the cartilage is thicker than normal. With the progression ofosteoarthritis, joint surface thins then the cartilage softens. The integrity of the surface isbreached and vertical clefts develop. They are called as fibrillation. This is followed bydeep cartilage ulcers, extending to bone. All the cartilage is metabolically active and thechondrocytes replicate, forming clusters (clones). Later cartilage becomes hypo cellular.There will be appositional bone growth in the bony sub-chondral region, leading to thebony sclerosis. Growth of cartilage and bone at the joint margins leads to osteophytes,which alter the contour of the joint and may resist movement. The biochemical changes which occur in cartilage in osteoarthritis are increasein water content, decreased collagen, proteoglycan, monomersize, hyaluronate, keratensulphate, and chondrotin sulphate, increase in proteoglycan synthesis, collagenase, andproteoglycanase.CLINICAL FEATURESSymptoms Joint Pain- It is often described as a deep ache and is localized to the involved joint. Typically, the pain of osteoarthritis is aggravated by joint use and relieved by rest, but as the disease progresses, it may become persistent. Stiffness- Progressive stiffness of the involved joint upon arising in the morning or after a period of inactivity may be prominent but usually lasts less than 20 min.
It is due to spasm of muscles. There is no relation between the severity of degeneration and morning stiffness.Signs Swelling- Physical examination of the osteoarthritis joint reveals localized soft tissue swelling of mild degree. It is due to the changes in articular ends themselves, particularly peri-articular lipping. Crepitus- The sensation of bone rubbing against bone evoked by joint movement is called as crepitus. It is one of the characteristic sign of osteoarthritis joint. Local Warmth ness- On palpation of the joint local rise in temperature is an indicative of sign of inflammation. Muscle Atrophy- Peri-articular muscle atrophy may be due to disuse or due to reflex inhibition of muscle contraction. Others- In advanced stage there may be gross deformity, bony hypertrophy, subluxation and marked loss of joint motion.Laboratory and Radiological Findings The Diagnosis of osteoarthritis is usually based on clinical and radiographicfeatures. In the early stages, the radiograph may be normal, but joint space narrowingbecomes evident, as articular cartilage is lost. Other characteristic radiographic findingsinclude subchondral bone sclerosis, subchondral cysts, and osteophytosis. A change inthe contour of the joint, due to bony remodeling, and subluxation may be seen. There isoften great disparity between the severity of radiographic findings, the severity ofsymptom and functional ability in osteoarthritis.
No laboratory studies are diagnostic for osteoarthritis, but specific laboratorytesting may help in identifying one of the underlying causes of secondary osteoarthritis.Analysis of synovial fluid reveals mild leukocytosis with a predominance of mononuclearcells. Approaches such as magnetic resonance imaging and ultrasonography have notbeen sufficiently validated to justify their routine clinical use for diagnosis ofosteoarthritis or monitoring of disease progression.TREATMENT Treatment of osteoarthritis is aimed to reducing pain, maintaining mobility, andminimizing disability. The vigor of the therapeutic intervention should be indicated bythe severity of the condition in the individual patient. For those with only mild disease,reassurance, instruction in joint protection, and an occasional analgesic, may all thatrequired; for those with more severe osteoarthritis especially of the knee or hip, acomprehensive programs comprising spectrum of non-pharmacological measuressupplemented by an analgesic and/or NSAID is appropriate.Non-Pharmacological Measures Reduction of Joint Loading Osteoarthritis may be caused or aggravated by poor body mechanics. Correction ofpoor posture and a support for excessive lumbar lordosis can be helpful. Excessiveloading of the involved joint should be avoided; patients with osteoarthritis of the knee orhip should be avoided prolonged standing, kneeling and squatting. Obese patients shouldbe counseled to loose weight. Patients with medial compartment knee osteoarthritis arewedged in sole my decrease the pain. Complete immobilization of painful joint is rarelyindicated. In patients with unilateral osteoarthritis of knee or hip, a cane, held in the
contra lateral hand, may reduce joint pain by reducing the joint contact force. Bilateraldisease may necessitate use of crutches or walker. Physical Therapy Application of heat to the osteoarthritis joint may reduce pain and stiffness. A varietyof modalities are available; often the least expensive and most convenient is a hot showeror bath. Occasionally, better analgesia may be obtained with ice than with heat. It is important to note that patients with osteoarthritis of weight bearing joints areless active and tend to be less fit with regard to musculo-skeletal and cardiovascularstatus than normal controls. An exercise program should be designed to maintain rangeof motion, strengthen peri-articular muscles, and improve physical fitness. The benefit ofaerobic exercise includes increase in aerobic capacity, muscle strength, and endurance;less exertion with a given workload and weight loss. Those who exercise regularly livelonger and are healthier than those who are sedentary. Patients with hip or kneeosteoarthritis can participate safely in conditioning exercises to improve fitness andhealth with out increasing their joint pain or need for a analgesics or NSAIDs. Disuse of the osteoarthritis joint, because of pain will lead to muscle atrophy, because particular muscles play a major role in protecting the articular cartilage from stress,strengthening exercise are important. In individuals with knee osteoarthritis strengthening of a particular muscle may result, with in weeks, in a decrease in joint pain as great as that seen with NSAIDs.
Drug therapy of osteoarthritis Therapy for osteoarthritis today is palliative, no pharmacological agent has beenshown to prevent, delay the progression, or reverse the pathologic changes ofosteoarthritis in human. Although claims have been made that some NSAIDs have a“chondroprotective effect”. It controlled clinical trails in human with osteoarthritis tosupport this view are lacking. In management of osteoarthritic pain, pharmacologicalagents should be used as adjuvants to non-pharmacological measures, such as thosedescribed above, which are keystone of osteoarthritis. NSAIDs often decrease joint painand improve mobility in osteoarthritis - on an average about 30% reduction in pain and15% improvement in function. Intra articular injection of hyaluronic acid is being usedfor treatment of patients with knee osteoarthritis who have filed a program of non-pharmacological therapy and simple analgesics. Naturopathy is a drugless system of healing which incorporates the naturalinherent principles like mud, water, sunlight, air and ether in treatment. It is a way ofliving. The body corrects by itself and the healing will be faster by undertaking thevarious treatment modalities of this system. People who adopt the natural system of healing will not suffer with diseases andthese treatments enable for elimination of the disease from root. By providing theelements which are depleted this system works in healing. Naturopathic techniques for Sandhi-Vata
1. Derivative massage Massage is employed for eliminating muscle contraction and for breaking ofadhesions.43 Slight pain is often produced by the first manipulation but it subsides withinshort time. In derivative massage Fulling, friction and deep kneading are most effective. Inthe manipulation of a joint, begin with light friction and pressure. If these applications aretolerated, add digital massage, working between the ligaments and following all theirregularities of the ends of the bones so far as accessible. Later add percussion, firsttapping, afterward hacking. The derivative manipulations which are first employedshould be continued in connection with application to the joint, since the effect ofkneading a joint is to increase the circulation through it, while the effect of derivativemassage is not to carry the blood through the joint, but rather around it, thus relievingexcessive local congestion or hyperemia, by diverting the blood into other channels. Centripetal friction applied to the tissues relieves painful joints by increasing thesurface circulation and so diverting the blood from the joint itself. Derivative massagerestores the normal secretion, improves nutrition of the joint and may increase vitalactivity. In cases of extremely painful joints in which heat and congestion are markedsymptoms, derivative massage may be employed upon the soft parts both above andbelow the joint44. Tapping helps the muscles to develop its contractile power. A littlemoderate kneading and percussion cause muscles to contract and become stronger. Deepcircular kneading loosens the muscles. Kneading under and around the muscles breaks upadhesions. These all types should be done with Tila Taila. Material- Tila Taila, chair.Indication- stiff and swollen joints, inflammatory conditions, tubercular joints, fractures,sprains, bruises. Contraindication- diphtheria, gonorrhea.45
2. INFRA RED THERAPY Infra Red lies beyond the red boundaries of visible spectrum. Infrared hasa wavelength ranging from 750nm to 40000 nm and frequency 4x 10 Hz and 7.5x 10 Hz. These rays have extremely strong heat reaction. According to biologicalresearch far infrared (4-1000microns) rays are absorbed very easily by thehuman body. The sources are the Sun, soil, mineral etc. When intensity ofinfrared is high in the body we feel healthy and will be able to over comeailments, however when it begins to decline, the human body will be subjected toattack by ailments and diseases.Physiological effect (Metabolic changes)-Infra Red treatment produces heating effect inthe superficial epidermis. Thus, resulting in vasodilation, this increases blood circulationin that area. This will lead to more oxygen supply and nutrient supply in that area leadingto drainage of waste products resulting in the relief of pain and healing of oedema andother skin conditions (superficial wounds). The sedative effect on nerve endings lead toreduction in the muscle spasm.Neurological effects- I.R.R. are used for muscle relaxation, thus helping in treatment ofinflammation. I.R.R. due to sedative effects on the nerve endings helps in relieving pain,muscle spasm and neuralgia.Application-Material required for application are infrared lamp, chair. Patient shouldremove cloths from the part, which has to be treated by I.R.R. Patient should beinstructed not to touch the lamp and should not sleep during treatment. Lamp should beplace at a distance of 12-15 inches and at 900 to the affected part so that maximum rays
fall on the affected part. The treatment should end with erthema and not with burns. Soduration should be carefully seen.Contraindications-1.Area of anesthesia or thermal hypothesia. 2. Patient of arterialdiseases. 3. Disorders with the possibility of hemorrhage, gastric ulcers, haemoptysis etc.4.Skin diseases like psoriasis, eczema, etc. 5.Vascular insufficiency. 6. Active or acutepathology of ulcers. 7. In pregnant ladies and during menstruation.46 3. WAX BATHMode of Action- It is seen that water at 450 c. temperature would be uncomfortable hotand ultimately causes damage. The specific heat of water is 4.2 kj/kg/ degree C andspecific heat of wax is 2.72 kj/kg/ degree C. therefore the amount of energy released bywax is 10 C cooler than that of water. When the part is immersed in wax the cooler skin causes a thin layer of waxsolidify on the surface. This thin static layer act as insulator of the skin from the hottersounding wax, some air may be trapped between these solidified layers and adding toinsulating effect. The wax transmits heat energy to the tissue by giving up energy as itsolidifies. The latent heat of fusion without any temperature change the amount of energyis 35kj/kg. The low conductivity of wax prevents much heat loss from the skin surface. Italso prevents water loss from skin and skin gets moisture, this moisture helps to softenadhesions and scar tissue. The solid wax melts with a temp of 540 C that may cause burns to the human skin. T oavoid this burn in the treatment of wax bath liquid paraffin is mixed in different ratio thatwill reduce the melting point of wax at 400C to 440C in this temp there is no risk of skinburn. This therapy often named paraffin wax bath as liquid paraffin is mixed with wax in
6:1 or 7:1 ratio. Other material may be used in the form of Vaseline and glycerin to makethe mixture more smooth that to prevent adhesion of wax to the skin. Paraffin liquid waxis melted and stored for use in a thermostatically controlled stainless steel box. Method of Application- Preparation of patient- Inspection of the treatment area, shape,size and location-Elimination of cloths, rings. Identification of skin condition. The patientshould be in comfortable position. Preparation of apparatus- the wax should be meltedcompletely. The temperature of the wax should be maintained at 450C. In towelingmethod the towel is immersed in the melted paraffin wax then it is picked up, removesextra wax and applied over the area. Repeat 8-12 times. Duration of treatment is 15 to 30minutes. Material- Wax bath tub, cotton towel, metal strip, and chair.Advantages- 1. Low specific heat allows for application at a higher temperature thanwater without the risk of burn. 2. Low thermal conductivity allows heating of tissuesgradually thus reducing the risk of over heating the tissue. 3. Melted state allows foreven distribution of heat to areas like finger and toes. 4. Oils used in the wax addmoisture to the skin. 5. Wax remains malleable after removal, allowing for use as anexercise tool. 6. Comfortable moist heat. 7. Relatively in expensive to replace wax.Indication- Reduction of pain, reduction of muscle spasm, correction of contracteddeformity, softening of adhesive scar, to break stiffness, arthritic joint, increase range ofmotion and post operative fracture pain after healing of wounds.Contraindication- Open wounds, allergic skin, skin condition, defective arterial bloodsupply and impaired skin sensation.47 4. EXERCISES
Flexion- patient will be in prone lying position, resistance is applied to theposterior aspect of the lower leg just above the bed, give the stabilization to the hip andtell patient to do flexion. Extension- patient should be in the sitting position, give theresistance to the anterior aspect of the lower leg, give the stabilization to the hip andthigh, and tell him to do extension.48 For without resistance the patient sits at the edge of bed or chair and activelyflexes and extends the knee joint in free-swinging movement within the limits of pain.49Resistance can be offered when the test is being performed against the motion and toassess the strength of a muscle. Manipulation with resistance is for treating for disuseatrophy. Without resistance is for improving the range of motion and for lubrication ofthe joint. It maintains endurance of muscle.50Advantages- easy to perform, improves the range of motion at the knee, facilitate jointlubrication, and to provide joint relaxation. Increases blood circulation.51 5. MUSTARD PACK The Mustard pack is especially applicable to cases in which a very quick andstrong revulsive effect is desired as for the relief of severe pain or to secure strongderivative effects. For mustard pack wring a towel or a cloth out of hot water to which groundmustard will be added in proportion of ½ ounce. Spread this upon the part (knee) towhich the application is to be made. Care must be taken to avoid excessive irritation orblistering of the skin.52 Material- Cotton towel, gas stove, vessel, water, ground mustard,and chair. 1. SARSHAPA (Brassica Junca)
Family: Crucifereae Pharmacological properties: Rasa: Katu Guna: Tikshna Veerya: Ushna. Vipaka: Katu. Doshakarma: Kaphavatashamaka. Part used: Bija churna Chemical composition: seeds contain 30-38% fixed oil and nitrogenous matter 24.6% Pharmacological actions: It is Shothahara, Vedanasthapana, Vidahi, Lekhana, Sphotajanana, Swedajanana, Dipana, Pachana, Krimighna, Vamaka, Plihavriddhihara. 6. THE ALTERNATE HOT AND COLD KNEE PACK In this form of application the skin is first heated considerably above itsnormal temperature, and then the temperature is lowered by the use of coldwater. In alternate applications the heating and cooling are several timesrepeated. The reaction which takes place as the result of the applications may bemade chiefly circulatory in character or both circulatory and thermic. This form ofapplication is therefore a most efficient means of stimulating nutritive changes,obtaining derivative effects, etc and that without creating thermic disturbances ofany kind in the body.53
It is very strongly influences both the arteries and the veins. It is our mostpowerful derivative procedure, its effects being almost wholly derivative in character.54By lowering the pressure in the veins, the arterial circulation through the affected part isfacilitated, thus encouraging the nutrition and functional activity of the cells which areengaged in combating living germs, or which are seeking to repair damages which mayhave originated in any way. The hot application diverts the blood into the cutaneous branches of the collateralarteries or into anastomosing vessels, thus preventing undue accumulation of blood andconsequent embarrassment of the affected tissues. The adjustment of the hot and coldpack depends on the different parts of body on which it has to be applied and thecirculation of which it is desired. Contraindications- Acute inflammation and pain. Method- The cold pack should be kept alive by rubbing the parts for one minute each time when the pack is changed. The hot pack should be exchanged every 15-20 minutes by the cold pack for 30 seconds to 1 minute so as to empty the veins restore the tone of the vessels and prevent great accumulation of heat in deeper parts. The pack should be changed after every 5-8 minutes or as soon as the temperature begins to approach that of body. The duration of pack varies from 15 minute to 1 hour according to condition and tolerance of patient. Continue the application until the desired effect is produced.55 Material- cotton packs, Lenin cloth, vessels, chair, water, gas stove. 7. THE HOT FOOT BATHMethod- The temperature required for getting positive effects is 1040F to 1220F. Thebath should begin at a temperature of 1020F to 1040F, and should be gradually increaseduntil by the end of two or three minutes a maximum temperature of 1150F to 1220F isreached. The duration may be from 5 minutes to half an hour as per condition. The feet
should be completely immersed in water; increasing the depth of the water may intensifythe effect. Material- Foot bath tub, water, gas stove, vessels, and chair.Physiological Effects- Hot Foot Bath produces same effects as the general hot bath. Atfirst the pulse is slowed and the brain congested, but after three or four minutes the pulserate is increased, and the brain becomes anemic, these conditions persist for some timeafter the bath is terminated. The footbath at 1080 to 1150 for 20 minutes causes elevationof the temperature in the external auditory canal amounting to one degree Fahrenheit. Therectal temperature at the same time fell to the same extent. Arterial tension was increasedby 8 mm.Therapeutic Applications- This bath is more commonly used as a derivative measure.At a temperature of 1030F to 1100F the hot footbath is an exceedingly useful means ofbalancing the circulation, by the dilatation of the blood vessels of the legs relievingcongestion of the brain and other organs in the upper half of the body. The hot footbath is also of very great service as a means of relieving or preventinga cold resulting from accidental chilling of the feet, if applied soon after exposure. Theprolonged hot footbath (980F to 1060F) dilates the vessels of feet, and produces collateralanemia of the pelvic viscera.56 Bahya Shamana Chikitsa A patient can be administered Aoushadhi as Anta-Parimarjana, Bahi-Parimarjanaand Shastra-Pranidhana.57 Janu-Basti may be included in Bahi-Parimarjana type oftreatment. Janu-Basti is a Bahya Samshamana Chikitsa (Retaining type). JANU-BASTI
Vagbhata has described four types of oil application on head under Murdha Taila,which are Shiro-Abhyanga, Shiro-Seka, Shiro-Picu and Shiro-Basti. As one of themeanings of Basti is to fill and reside, therefore the word Basti has been added to word‘Shiro’. In Shiro-Basti, oil is kept on head by putting a cap for prescribed period of time. Later on some physicians made an artificial pit around the knee with the help ofMasha powder to keep hot oil for prescribed period and named it as Janu-Basti.BastiMeanings related to organ- Organ that lies below the umbilicus (Nabhi).Meanings related to Karma- Here the urinary bladder of animals is used to inject thedrugs into the rectum “Bastina Deyata Eti Bastih Tasya Vidhi”58. The word Basti is used here with the meaning of “to reside”, “to retain”. InJanu-Basti the medicine is made to retain over the Janu-Sandhi for a prescribed time.Procedure of Janu-Basti- All the procedures are performed in systematic manner.According to Sushruta it can be performed in three stages like 1. Poorva karma 2. Pradhana karma 3. Paschat karma59.The procedure of Janu-Basti is explained accordinglyI. Poorva karma- This includes preparatory measures taken for smooth conduction ofthe procedure. They are1. Atura Pareeksha- The patient is examined with reference to Prakriti, Vikriti etc. tenfactors by applying Pratyaksha, Anumana and Aptopadesha. This will assess Vyadhibala 60and Dehabala . Then affected knee should be Examined properly and mark the tenderarea. Examine for scares, wounds in the joint.
2. Sambhara Sangraha- Materials required for Smooth conduction of Janu-Bastiprocedure have to be collected. They include – A metal ring, Masha powder, medicine(Tila Taila), spoon, bowl, vessel, water, gas stove, and cotton.3. Atura Siddhata- Patient is asked to lie down on the table. Expose the affected knee.II. Pradhana karma -This includes1. Basti Yantra Dharana- Initially paste of Masha powder is prepared by addingsufficient quantity of water to it. Then with the help of a metal ring and Paste of Masha apit is constructed around Janu-Sandhi of about 2-3 Angula heights. The concavity of pit(Basti Yantra) should be well sealed to retain the medicine.2. Taila Dharana- The bowl containing Medicine (Tila Taila) is heated gently bykeeping over hot water. Then gently heated luke warm medicine is poured slowly andcarefully on the Janu-Sandhi along the side of the Basti Yantra. The heat of the medicineshould be sufficient enough to tolerate by the patient. The quantity of the medicineshould be two Angulas above the skin surface.3. Maintenance of constant temperature of medicine- Keep on changing the medicinewith the heated one so that a constant temperature is maintained through out theprocedure.4. Removal of Taila and Basti Yantra- After the prescribed time the oil should beremoved from the Basti Yantra. Then BastiYantra is to be removed. Since it is a type of Sweda and Sneha, Samyak Sweda and Samyak SnehaLakshanas can consider. Among Samyak Sweda Lakshana Sheetoparama,Stambhanigraha, Gauravanigraha and Vyadhihani can be considered for assessment. In
case of Samyak Snigdha Lakshanas Snigdha Gatratva and Mrudu Gatratva can take forassessment. The procedure is performed for 30min each day.III. Paschat karma- After removing the oil and Basti Yantra, Mrudu Abhyanga is doneover the Janu-Sandhi for about 5 min. Duration - This treatment is done for 7days.Benefits of Janu-Basti- It relieves the symptoms like Shoola, Stabdhata.The procedureacts on various properties of Vata that are instrumental in the pathology of Sandhi Vatamainly due to Snehana and Swedana. Also medicines used in the procedure help inalleviating Vata. Drug Review The trial drug selected for doing Janu-basti is Tila Taila. The pharmacologicalproperties, chemical constituents and pharmacological actions of Tila Taila aresummarized below.Table No- 13- Drug reviewRasa MadhuraVeerya UshnaVipaka MadhuraGuna Guru, Drava, Picchila, Sara, Manda, Sookshma, and TeekshnaDoshakarma VatakaphaharaPharmacological Used in different traumatic conditions, Promotes bodily strength. Itactions is Sanghatakara, does Snehana. ABSORPTION THROUGH SKIN Acarya Sushruta in Shareerasthana explains – Out of the four Tiryak Dhamanis,each divides gradually hundred and thousand times and thus become innumerable. Thesecover the body like network and their openings are attached to Romakoopa. Through
them Veeryas of Abhyanga, Parisheka, Avagaha, Alepa enter into the body after undergoing Paka with Bhrajaka Pitta in skin61.Sushruta in Sutrasthana explains, Lepa like Bahirparimarjana treatments yield result byentering to Romakoopa thereby circulating through Swedavaha Srotas62. Vagbhata in Ashtanga Hridaya while explaining the functions of Bhrajaka Pittanarrated that – Bhrajaka Pitta do the Pachana of drugs used in Abhyanga, Parisheka, andLepa63. Thus with the above references it can be said that drugs used in BahyaSamshamana Chikitsa (Naturopathy techniques, Janu-basti) get absorbed through andproduce action according to the property of the medicine. The skin anatomically consists of three distinct layers.Epidermis- It consists of keratinocytes, melanocytes, langerhan’s cells and merkel cells.The terminal point of keratinocytes differentiation is the formation of the stratumcorneum. Formation of this layer is the most important function of the epidermis. Itprotects the skin against water loss, prevents the absorption noxious agents, and can bethought of as consisting of bricks and mortar. Corneocytes forms the bricks and barrierlipids form the mortar. ‘Granular cells’ which are stratum corneum helps in maintainingskin hydration and their products serve as ultra violet filters. Lamellar granules also arefound within granular cells. These contain probarrier lipids.Dermis-It is a thick, highly vascular layer made up of ground substance, fibroblasts andcollagen fibers, together with appendages of skin, sweat glands and pilo-sebaceousfollicles. It is metabolically active part of the skin.
Subcutaneous Tissue-It is a fibro fatty layer with varying quantities of adipose tissue indifferent regions of the body. It provides physical and thermal protection to the deeperstructures of the body.64Drug Delivery- The primary barrier to absorption of exogenous substances through theskin is stratum corneum. Rate of absorption is directly proportional to concentration ofdrug in vehicle, partition co-efficient, diffusion co-efficient and thickness of the stratumcorneum. Physiological factors that effect per cutaneous absorption include hydration,occlusion, age, intact versus disrupted skin, temperature and anatomic site. Among vehicles greases are anhydrous preparations that are either water insolubleor fatty. Fatty agents are more occlusive than water-soluble. They restrict trans-epidermalwater loss and hence preserve hydration of the stratum corneum. Absorption depends upon lipid solubility of the drug since the epidermis as a lipidbarrier. The dermis however is freely permeable to many solutes. Suspending the drug inan oily vehicle can enhance absorption through the skin. Because hydrated skin is morepermeable than dry skin. Application of medicaments, heat and massage definitely helps in eliminating thenumber of noxious elemtes through skin. The application of heat in different forms ofSwedana promotes local circulation and metabolic activities and also opens the pores ofthe skin to permit transfer of medicaments and nutrients towards to needed sites andelimination of vitiated Doshas and Malas through skin and perspiration.65Biophysical effect of temperature
Circulatory effect- There is stimulation of superficial capillaries and arteriole causinglocal hyperemic and reflex vasodilation. This will affect increased blood flow at the site.The temperature must be controlled between 104F to 113F. This hyperemia may resultsystemic change such as decrease in mean blood pressure, increase in pulmonary minuteventilation.Metabolic reaction- Temperature will raise the chemical activity in cell and metabolicrate will increase. The energy expenditure will increase and protein denaturation willoccur in human tissue.Vascular effect- There are three factors that cause vasodilation- an axon reflex, releaseof chemical mediators, secondary to temp elevation, local spinal cord reflex.Neuromuscular effect- Heat is Effective to provide analgesic and assist resolution ofpain muscle guarding spasm. Heating of peripheral nerve elevate pain thresholdremarkably reduce muscle spasm.Connective tissue effect- Temperature elevation in combination with a stretch can altervisco-elastic properties of connective tissue. The elastic properties of connective tissuesresult in plastic elongation.Effect on the skin – Skin becomes moist and pliable following wax application. Thishelps to soften adhesion and scar in the skin prior to mobilization and stretchingprocedures.66 METHODOLOGY Sandhi vata is a major social problem as large percentage of population suffers from this affliction. This being a degenerative type of disease, its progress is more in geriatric age, posing difficulty in day- to-day life of the person. This is the age in which all Dhatu begin to degenerate, ultimately leading to Vata Prakopa. When this Prakupita Vata gets lodged in Sandhi, it gives rise to the disease Sandhi Vata.
Non-pharmacologic management is the foundation of treatment of osteoarthritis. Therefore, naturopathy gives a hope of treating this condition with different techniques used externally. These techniques can be correlated to Bahirparimarjan Chikitsa mentioned in Ayurvedic classics. Hence, study is planned with the following aims to prevent the suffering of the patients.AIMS7. To evaluate the effect of Janu-Basti in the management of Sandhi Vata.8. To evaluate the effect of Naturopathy techniques in the management of Sandhi Vata.9. To compare the efficacy of Janu Basti-an Ayurvedic Bahirparimarjan Chikitsa and Naturopathy techniques employed for the treatment of Sandhi Vata. SELECTION OF PATIENTS The patients were selected from OPD and IPD of S.D.M.College and Hospital of Ayurveda, Hassan irrespective of age, sex, religion, occupation, marital status etc. The detail clinical history was taken and examination was done as per case proforma prepared for this purpose. Laboratory investigations 1. Hematological – Total count, Differential count, E.S.R., Hb%. 2. Radiograph – X-rays wherever necessary. Inclusion Criteria 1. Patients complaining of pain, swelling, and restricted mobility of knee joints. 2. Patients between the ages of 40 to 60 yrs. 3. Patients with unilateral or bilateral knee joint involvement were included.
Exclusion Criteria 1. Patients with deformities in knee joints. 2. Patients suffering from other systematic disorders such as obesity (BMI above 30), infective arthritis, injury to joints etc.Diagnostic criteriaDiagnosis of patient was established on the basis of signs and symptoms mentioned in classics asfollows.Symptoms- Shoola (Pain in knee joints) Kriya alpata (Difficulty in movements of knee joints) Shotha (edema of knee joints) Atopa (Crepitus in knee joints) RESEARCH DESIGNFor a scientific trial, proper design is required so as to assess the efficacy of the therapy, in turn toachieve the objectives. This study is a comparative study with pre-test and post-test design.30 patients of Sandhi Vata were randomly divided into the following two groups each group consistingof 15 patients.Janu Basti (A) Group The patients of this group were given Janu-basti with Tila Taila in the morning for 30 minutes.For this purpose the patient was asked to lie down on the table and then with the help of a paste madefrom black gram (Masha) flour by adding little water, a two inches high wall was erected around the