Sandhivata kc004 kop

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Management of Sandhigata vata with ‘Trayodashanga Guggulu’- A clinical evaluation, Guruprasad. Aggithaya, PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa.

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Sandhivata kc004 kop

  1. 1. BY Dr. Guruprasad Aggithaya B.A.M.S. (R.G.U.H.S, Bangalore) Dissertation submitted toRajiv Gandhi University of Health Sciences, Karnataka, Bangalore in partial fulfillment of the requirements for the degree of “Ayurveda Vachaspati” [M.D.] in KAYACHIKITSA GUIDE Prof. Pramod Kumar Mishra M.D (Ayu) (RSU) HOD. Dept. of KayachikitsaDEPARTMENT OF POST GRADUATE STUDIES IN KAYA CHIKITSAA.L.N.RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE, KOPPA - 577126 CHIKMAGALUR DISTRICT, KARNATAKA, INDIA SEPTEMBER - 2006
  2. 2. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYA CHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Declaration I here by declare that this dissertation entitled “Management of Sandhigata vata with ‘Trayodashanga Guggulu’- A clinical evaluation” is a bonafide and genuine research work carried out by me under the guidance of Prof. Pramod Kumar Mishra Department of Post Graduate Studies in Kaya Chikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa. Date: Dr. Guruprasad. Aggithaya Place: Koppa P.G.Scholar, Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  3. 3. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYA CHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Certificate This is to certify that the dissertation entitled “Management of Sandhigata vata with ‘Trayodashanga Guggulu’- A clinical evaluation” is a bonafide research work done by Dr. Guruprasad Aggithaya in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (M.D.) in Kaya Chikitsa, under Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. Date: Guide: Place: Koppa Prof. Pramod Kumar Mishra M.D(Ayu) (RSU) HOD, P.G. Studies in Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  4. 4. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYA CHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Endorsement This is to certify that the dissertation entitled “Management of Sandhigata vata with ‘Trayodashanga Guggulu’- A clinical evaluation” is a bonafide research work done by Dr. Guruprasad Aggithaya under the guidance of Prof. Pramod Kumar Mishra, Department of Post Graduate Studies in Kaya Chikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P.G. Centre, Koppa. Date: Dr. Tarani Kanta Mohanta M.D.Ph.D (Ayu)(Jamnagar) Place: Koppa Dean, A.L.N.Rao Memorial Ayurvedic Medical College, Koppa –577126, Dist: Chikmagalur
  5. 5. COPYRIGHT I here by declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate thisdissertation in print or electronic format for academic/research purpose. Dr. Guruprasad AggithayaDate: P.G.Scholar,Place: Koppa Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126© Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. INDEX INDEX Page No. INTRODUCTION 1-3Chapter – I OBJECTIVES 4Chapter – II REVIEW OF LITERATURE 5-46 DISEASE REVIEW Historical Review 5-8 Etymiology 8-10 Anatomical aspect of Sandhi 10-15 Nidana 16-23 Poorvarupa 24 Rupa 25-28 Upasaya-Anupasaya 28 Samprapti 29-31 Upadrava 32 Sadhya asadhyata 32 Chikitsa 33-37 Pathya Apathya 38-39 Differencial diagnosis 40 Modern perspective of the disease 41-46 DRUG REVIEW Trial drug 47-56 Standard drug 57-61Chapter –III METHODOLOGY 62-82Chapter –IV RESULTS 83-90Chapter –V DISCUSSION 91-103Chapter –V CONCLUSION 104 SUMMARY 105-106 REFERENCES BIBLIOGRAPHY ANNEXURE
  7. 7. ABBREVIATIONS ABBREVIATIONS1. A.F.U - After follow up.2. A.H. - Astanga Hrudaya3. A.K - Amara kosha4. A.P. - Agni Purana5. A.S. - Astanga Sangraha6. A.T - After treatment.7. A.V. - Atharva Veda8. B. P. - Bhava Prakasha9. B.R. - Bhaishajya Ratnavali10. B.Su. - Brahmana sutra11. Bas.Raj. - Basavarajeeyam12. Bh.Sa. - Bhela Samhita13. C.D. - Cakradatta14. Ch - Charaka Samhita15. Chi. - Chiktsa sthana16. Ct. - Chandogyopanisat17. J.L.N - Illustrated text book of Dravyaguna Vol-2 by J.L.N. Shasthry.18. K.S. - Kasyapa samhita19. Khi - Khila sthana20. Ks. - Kausika sutra21. Kt. - Kenopanisat22. M.B - Mahabharatha23. M.K. - Madhyama khanda
  8. 8. ABBREVIATIONS24. M.N. - Madhava nidana25. Ni. - Nidana sthana26. P.K. - Purva khanda27. P.Su. - Panini sutra28. Pr. - Prakarana29. Pr.K. - Prathama Khanda30. Pu. - Purana31. R. - Ramayana.32. S.K.D. - Sabda Kalpa druma33. Sha. - Sarira sthana34. Si. - Siddhi sthana35. Su. - Susrutha samhita36. Su. - Suthrasthana.37. Thr. - Thritheeya sthana38. U.K. - Uttara khanda39. Vi. - Vimanasthana40. Y.R. - Yogaratnakara
  9. 9. Introduction
  10. 10. Objectives
  11. 11. Review of literature
  12. 12. Methodology
  13. 13. Results
  14. 14. Discussion
  15. 15. Conclusion
  16. 16. Summary
  17. 17. References
  18. 18. Bibliography
  19. 19. Annexure
  20. 20. CONTENTS LIST OF TABLESNo SUBJECT Pg No1. Types of Sandhis 102. Rasa visheshatha nidana of Sandhigatavata 173. Guna visheshatha nidana of Sandhigatavata 184 Veerya visheshatha nidana of Sandhigatavata 185 Time and forms of Ahara 186. Types of Ahara 197. Vihara nidana of Sandhigatavata 20-218. Manasika nidana of Sandhigatavata 21-229. Kala nidana of Sandhigatavata 2210. Roopa of Sandhigatavata according to various acharyas 2512. Chikitsa sutra of Sandhigatavata according to various acharyas 3313. Pathya for sandhigata vata. 3814 Apathya for Sandhigata vata 3915 Age wise distribution of 40 patients of Sandhigatavata 4016 Sex wise distribution of 40 patients of Sandhigatavata 6717 Religion wise distribution of 40 patients of Sandhigatavata 6818 Marital status wise distribution of 40 patients of Sandhigatavata 6819 Economic status of 40 patients of Sandhigatavata 6920 Occupational incidence of 40 patients of Sandhigatavata 6921 Nature of work in 40 patients of Sandhigatavata 7022 Habitate wise incidence of 40 patients of Sandhigatavata 7023 Main symptoms in 40 patients of Sandhigatavata 7124 Duration of illness in 40 patients of Sandhigatavata 72 Family history of disease of muscular skeletal system in 40 7225 patients of Sandhigatavata26 Dietary habits in 40 patients of Sandhigatavata 7327 Ahara Pramana in 40 patients of Sandhigatavata 7428 Dominant rasa in 40 patients of Sandhigatavata 7429 Dominant ahara guna in 40 patients of Sandhigatavata 7530 Nidra incidence in 40 patients of Sandhigatavata 7631 Pramana of vyayama in 40 patients of Sandhigatavata 76
  21. 21. CONTENTS32 Prakruti in 40 patients of Sandhigatavata 7733 Distribution of 40 patients of Sandhigatavata according to Sara 7734 Distribution of 40 patients of Sandhigatavata according to Satwa 7835 Samhanana.in 40 patients of Sandhigatavata 7936 Satmya in 40 patients of Sandhigatavata 7937 Abhyavaharana shakti in 40 patients of Sandhigatavata 8038 Jarana sakthi in 40 patients of Sandhigatavata 8039 Vyayama sakthi in 40 patients of Sandhigatavata 8140 Weight incidence in 40 patients of Sandhigatavata 82 Effect of trial drug on patients of Sandhigatavata after 60 days of 8341 treatment. Effect of Trial drug on patients of Sandhigatavata after 60 days of 8342 follow up. Effect of Standard drug on patients of Sandhigatavata after 60 8443 days of treatment44. Effect of Standard drug on patients of Sandhigatavata after 60 84 days of follow up.45. Comparative effect of therapies in the management of main 85 symptoms on 40 patients after 60 days of treatment46 Comparative effect of therapies in the management of main 86 symptoms on 40 patients after 60 days of follow up47. Overall effect of therapy by Trial drug after 60 days of treatment 8748. Overall effect of therapy by Trial drug after 60 days of follow up. 8749 Overall effect of therapy by Standard drug after treatment 8850. Overall effect of therapy by Standard drug after follow up. 8851. Inter-group comparison after 60 days of treatment 9952. Inter-group comparison after 60 days of follow up 100
  22. 22. CONTENTS LIST OF FIGURESNo. Pg No.1. Age wise distribution of 40 patients of Sandhigatavata 672. Sex wise distribution of 40 patients of Sandhigatavata 683. Religion wise distribution of 40 patients of Sandhigatavata 684. Marital status wise distribution of 40 patients of Sandhigatavata 695. Economic status of 40 patients of Sandhigatavata 696. Occupational incidence of 40 patients of Sandhigatavata 707. Nature of work of 40 patients of Sandhigatavata 718. Habitat wise distribution of 40 patients of Sandhigatavata 719. Symptomatology in 40 patients of Sandhigatavata 7210. Duration of illness in 40 patients of Sandhigatavata 7311. Family history of disease in 40 patients of Sandhigatavata. 7312. Dietary habit in 40 patients of Sandhigatavata 7413. Ahara pramana in 40 patients of Sandhigata vata 7414. Dominant rasa in 40 patients of Sandhigatavata 7515. Dominant ahara guna in 40 patients of Sandhigatavata 7616. Nidra incidence in 40 patients of Sandhigatavata 7617. Pramana of vyayama in 40 patients of Sandhigatavata 7718. Prakruti in 40 patients of Sandhigatavata 7819. Distribution in 40 patients of Sandhigatavata according to sara. 7820. Distribution in 40 patients of Sandhigatavata according to Satwa 7921. Distribution in 40 patients of Sandhigatavata according to Samhanana 7922. Distribution in 40 patients of Sandhigatavata according to satmya 8023. Abhyavaharana shakti in 40 patients of Sandhigatavata 8124. Jarana sakthi in 40 patients of Sandhigatavata 8125. Vyayama sakthi in 40 patients of Sandhigatavata 8226. Weight incidence in 40 patients of Sandhigatavata 82
  23. 23. CONTENTS27. Comparative effect of therapies in the management of main 85 symptoms on 40 patients after 60 days of treatment28. Comparative effect of therapies in the management of main 86 symptoms on 40 patients after 60 days of follow up29. Comparative effect of overall therapies on patients after 60 days of 89 treatment30. Comparative effect of overall therapies on patients after 60 days of 90 follow up LIST OF CHARTSNo. Pg No. 1. Chart showing etiopathogenesis of Sandhigatavata 31
  24. 24. ACKNOWLEDGEMENT ACKNOWLEDGEMENTI am obliged to my beloved parents B.Balakrishna Aggithaya and Shantha.B.Aggithaya for theirconstant efforts, encouragements and inspirations through out the work.On the completion of this thesis work, I extend my sincere gratitude to my revered GuideProf.Pramod Kumar Mishra, M.D(Ayu),(RSU), who was the vital and kinetic force of this thesis;with out his initiation this piece of work would not have been accomplished in stipulated time.I am grateful to Sri. Aroor Ramesh Rao, President, A.L.N. Rao Memorial Ayurvedic MedicalCollege, Koppa for giving me an opportunity to do my post-graduate studies.I express my gratitude to the Dean of our college Prof.T.K.Mohanta M.D,Ph.D. PG Dept. ofKaya chikitsa for his unflinching support during this course of study.My immense thanks to Dr. Sanjaya K. S, M.D (Ayu), Principal, A.L.N Rao Memorial AyurvedicMedical College, Koppa, for his help and support in completing this work.I owe my sincere regards and boundless gratitude to Dr. Rashmi Rekha Mishra M.D (Ayu) andDr. C, B. Singh for their constant encouragement and valuable suggestions.I remain grateful forever to Dr.Shyamalan PhD and my senior Dr.Christy J.T for their completeguidance in the statistical work.I am obliged to the respected teachers of Dept. of Rasa shastra and Bhaishajya kalpana; Dr. D.KMishra, M.D (Ayu) Dr. Galib M.D (Ayu), Dr. Harikrishna M.D (Ayu).for their guidance forpreparing the medicine..My earnest gratitude to the respected teachers of the faculty of Dravya guna; Dr. JagadeehKunjal M.D. (Ayu), Dr. Sreedhar, M.D (Ayu) for their extensive help in the study along withDr.H.R Pradeep, M.D (Ayu).I am glad to express my sincere thanks to Dr. Banamali Das, Dept. of Roganidana and Dr. RajeshKumar, M.D (Ayu) from the Dept. of Shalakya and Dr. Sahana MD (Ayu) from Dept of Shalya.
  25. 25. ACKNOWLEDGEMENTI will always treasure the guidance and support given by Dr. Rammohan, Dr. Lalitha Bhasker,Dr. Sreenivas and Dr. Abhinetri Hegde; Consultant Physicians of Ayurvedic college hospital fortheir support during various stages of my work.I will be failing in my duties if I do not express my immense gratitude to my seniors Dr. PrathibhaHullur, Dr.Prashanth B.K,Dr. Krishnakishore, Dr. Sanjeev, Dr. Suja, Dr. Kavitha, andDr.Pankaj, Dr. Purushotham K.G, Dr. Anil P Varkey, Dr. Clarence, and Dr. Leeladhar for theirsupport.I am thankful to my class-mates Naga, Abhay, HHP, Anita, Draksha, Vasu, Joshi, Kamat,Nalini for their helping hand.With immense pleasure, I extend my heart full thanks to my room-mates Ratheesh, Harvin,Susheel Shetty with out whose support this thesis work would not have been complete.My thanks to Raghuram, Daya, Ilanchezian, Binu, Sarat, Ravi, James, Partta,Viji, Chandrakala,Sachin, Sandhesh for their valuable suggestions and moral support.I also thank all my UG class-mates (1996 - 2001).My special thanks to all PG juniors, House surgeons and UG students for their constant support.I would like to express my gratitude to Miss.Amrutha, for sincere support in lab investigations.My sincere thanks to Mrs.Triveni, Miss.Manjula (Librarians), Mrs. Jyothi and other office staffsand hospital staffs for all kinds of support.I am grateful to all the patients who became a part of my study.I am heartily thankful to my sisters Gayathri and Gowri. And also to all family members whohelped me during my study.Finally, I thank all those who helped me directly or indirectly to complete this work.Date :Place : Koppa Dr. Guruprasad. A
  26. 26. ABSTRACT ABSTRACTINTRODUCTION: Disorders of the musculoskeletal system are prevalent throughout the worldaffecting all age group. Among this, important one is Sandhigata vata, whichproduces disastrous consequences like physical disability in community. Sandhigatavata can be compared to Osteoarthritis, which is one of the degenerative joint disorderand it represents failure of the disarthroidal part. The present study is done tounderstand the disease which is explained in the classics. Even though this disease isconsidered as Kashta sadhya, it can be managed when proper treatment is given inappropriate time. Here an attempt is made to find the efficacy of the drugTrayodashanga Guggulu on Sandhigata vata.OBJECTIVES:The objectives of the present study are1) To evaluate the efficacy of Trayodashanga Guggulu in Sandhigatavata.2) To study in detail about the disease Sandhigata vata covering both Ayurvedic and modern literatures.3) To assess the merits and demerits of the trial drug Trayodashanga Guggulu.4) To assess the merits and demerits of the standard drug Simhanada Guggulu.5) To compare the efficacy of the trial drug(Trayodashanga Guggulu) with the standard drug(Simhanada Guggulu)6) Study of the trial drug and standard drug covering Classical Ayurvedic literatures.
  27. 27. ABSTRACTMETHODOLOGY: Total 40 patients were selected who fulfilled the inclusion criteria wererandomly selected for the study. These persons grouped into two.ie trial and standardgroup. The Trial group patients were given Trayodashanga guggulu in the dose of 3gms twice daily after food with Ushna jala as Anupana. The duration of treatment wasfor 60 days. Follow up study was done for 60 days in every 15 days visit. The Standard drug patients were given Simhanada guggulu in the dose of 3gms twice daily after food with Ushna jala as Anupana. The duration of treatment wasfor 60 days. Follow up study was done for 60 days in every 15 days visit.INTERPRETATION AND RESULTS: At the end of 60 days of treatment schedule Trial drug (Trayodashangaguggulu) showed highly significant effect in Atopa where as moderate significant insandhi shula, Sandhi shotha and tenderness where as standard drug (Simhanadaguggulu) showed highly significant result in Sandhi shotha and moderate significantresult in other symptoms. After 60 days of follow up study, Trial drug showed highly significant resultin the Sandhi shula, Tenderness and Atopa where as Standard drug showed highlysignificant result in Sandhi shotha.CONCLUSION: • Trial drug (Trayodashanga guggulu) provided highly significant result in the Sandhigata vata by reducing Sandhi shula, Atopa, Tenderness. • Trayodashanga guggulu acts as Rasayana, Balya and also Vedana sthapana. • Standard drug has highly significant result in Sandhi shotha.
  28. 28. INTRODUCTION INTRODUCTION As one of the famous proverbial saying goes- Health is wealth, it seems thatthe concept of health has never been dealt in any medical science as realistic as inAyurveda. The signs of well being or freedom from illness are well depicted in theancient treatise. The integration of body components, compactness of muscles andother tissues, stability and pleasantness of mind and senses, good appetite, timelydigestion, undisturbed metabolism, elimination of urine and faeces, tolerance towardsaffects of hunger, thirst, heat, cold and exercise, normal sleep – wake pattern and gainof strength colour, complexion and life span put together define a healthy individual.1 The description gains more weightage even in this present modern era whenthe concept of health as described by WHO includes the state of physical and mentalwell being, appears to be influenced by the ancient theories of Ayurveda. In contrary, the pathological picture sets in when the rhythmic proceedings ofabove said mechanisms are disturbed and the individual will no longer be consideredto be healthy. This disarray of events leading to ill health will be caused by thedisturbance of the chief humoral factors governing the body that is the Tridoshas,which again is brought about by exposure to various etiological factors pertaining toAhara, Vihara and Vichara. Among the Tridoshas, Vata is given a prime importance with respect to eitherphysiological or pathological conditions. The other two doshas being inert, theirequilibrium depends on vata.2 The vayu is considered to be the chief motivating forcebehind all the activity as it has been described as the engine which runs the machineof the body3. Vayu is also chief driving force of the all the movements, which getdisturbed when vayu gets vitiated. The vayu vitiated by the etiological factors flowing Page 1
  29. 29. INTRODUCTIONin adverse routes produces diseases related to the site of localization and theirdisturbed functions. Once such disease caused due to the predominance of vayu isSandhigata vata. This is a pathological condition which manifests when the Sandhiswhich are the important seat of Kapha, are affected by Vayu. This disease is oftencompared to the degenerative disorder afflicting the joints and having world wideincidence and prevalence in plenty i.e. Osteoarthritis. The prevalence is 30% in theage group of 45-65 years and 68% for those older than 65 years. Men are more likelyto suffer below the age of 45 years and women above 55 years. Besides destroying thejoints, this disease makes the person crippled and dependent to attend his normalduties. Ayurvedic remedies have always been successful in the treatment of thisailment and its effects, especially the preparations of Guggulu. One such formulationconsisting of thirteen in valuable drugs called ‘Thrayodashanga guggulu’ has beenmentioned in Cakradatta, as directly indicated in Sandhisthita vata4. Most of theingredients are bruhmana in nature and more importantly guggulu which is said tohave vata alleviating property. This drug has been selected for trial to asses itsefficacy in reliving one from complaints of Sandhigata vata.This study highlights both conceptual and clinical aspects related to the diseaseSandhigata vata, which is divided in to following chapters- Chapter 1 - Objectives. This chapter highlights on main aims of this study. Chapter II- Review of literature It deals with the conceptual study of both Sandhigata vata and Osteoarthritis. It covers all the relevant matters related to the disease. Page 2
  30. 30. INTRODUCTION Chapter III- Methodology Details of the clinical trial of Trayodashanga guggulu and Simhanada guggulu with observations during the study are explained. Chapter IV- Results The results of the entire study have been explained with appropriate graphs for easy understanding. Chapter V- Discussion Discussions on Sandhigata vata and Osteoarthritis, discussion on clinical trial with observations and results have been described. Chapter VI- Summary and Conclusion Complete abstract of the dissertation and the conclusion are enumerated.Previous works done: 1) Kohla PR,Rasnadi guggulu ki nirmithi evam sandhigata vata mein upayukta (Dissertation), Nagpur,1990. 2) Chacha ML, Clinical study of Sandhigata vata with special effect of Parijatha guggulu (Dissertation), Ahamedabad, 1992. 3) Neetha Kumari, Evaluation of Rasnadi guggulu in treatment of Osteoarthritis (Sandhigata vata),(Dissertation), Varanasi, 1998. 4) Lal ji, Clinical study on the effect of Simhanada guggulu and Murivenna taila in the management of Osteoarthritis of Knee joint (Dissertation), Jaipur, 2002 Page 3
  31. 31. OBJECTIVES OBJECTIVESThe objectives of the present study are1) To evaluate the efficacy of Trayodashanga Guggulu in the treatment of Sandhigatavata.2) To study in detail about the disease Sandhigata vata covering both Ayurvedic and modern literatures.3) To assess the merits and demerits of the trial drug Trayodashanga Guggulu.4) To assess the merits and demerits of the control drug Simhanada Guggulu.5) To compare the efficacy of the trial drug(Trayodashanga Guggulu) with the control drug(Simhanada Guggulu)6) Study of the trial drug and control drug covering Classical Ayurvedic literatures.7) To establish an effective treatment with the trial drug for Sandhigata vata.Hypothesis:a) Null hypothesis: Trayodashanga Guggulu is not effective in the treatment of Sandhigatavata.b) Scientific hypothesis: Trayodashanga Guggulu is effective in the treatment of Sandhigatavata. Page 4
  32. 32. DISEASE REVIEW DISEASE REVIEWHISTORICAL ASPECT OF SANDHIGATA VATA: All the historical aspect related to this work is mentioned under this heading.Veda kala:• Rigveda5 In this five types of Vata is considered as Pancha prana.One of the Mantras ofRigveda described about removing the disease from each organ (hairs and joints)• Atharvaveda6 In Atharvaveda, there are references about the disease pertaining to Sandhi andSandhi vishlesa.Purana Kala:• Ramayana [Before 500B.C] 7 In this treatise, importance of Vayu in maintenance of health and life ismentioned. There is also explanation about the pathological effect caused by the Vayusuch as Pain and immobility of Joints.• Mahabharatha [4th Cent B.C-4th Cent A.D] 8 In this treatise, Vata has been given important and it is called as Panchakarma(having 5 functions) and Bhagavan.• Agnipurana: 9 In Agnipurana total number of joints in human body and treatments forSandhigata Samavata is mentioned.Upanishat kala: Elaborate description of vata is available in the Upanishats. Page 5
  33. 33. DISEASE REVIEW• Kenopanishat: 10 In this book, vayu is defined as the one that has constant movement, motionand continued efforts.• Chandogyopanishat: 11 This book has highlighted the chala property of vata and has shown its closeassociation with bodily actions and movement.Samhita kala:• Charaka samhita [1000B.C] 12 Charaka mentions Sandhigata vata roga in the chapter Vatavyadhi chikitsa.He names the disease as Sandhigata anila. He explains this disease with Dhatugataanila vikaras and not mentioned in Nanatmajavatavikara. A separate nidana or thetreatment principles are not found in the text.• Sushrutha Samhita [700-600B.C] 13 Sushruta mentions general nidana in Nidana sthana (vata vyadhi nidana) andseperate treatment principles mentioned in Chikitsa sthana(Vatavyadhi chikitsa).• Bhela Samhita [800-700B.C] 14 There is no clear description is available about Sandhigata vata. But inAshtimajjagata vata, ‘Sandhivichyuti’is explained as one of the lakshana.• Haritha Samhitha [800-700B.C] 15 Acharya Haritha explains that there are 84 Vathaja nanathmaja vikaras.Among these, 32 are Vyana vata prakopaja vikaras. He also mentions that all theDhatugata vata vikaras are due to Vyana vata prakopa and further tells about thetreatment aspect of Sandhigata vata. He also makes the mention of ‘Sandhi shotha’in Shukra gata vata. Page 6
  34. 34. DISEASE REVIEWSangraha kala:• Ashtanga Sangraha and Ashtanga Hrudaya [600A.D -1600A.D] 16 The disease is described with treatment.• Madhava Nidana [800A.D] 17 Acharya Madhavakara agrees with Acharya Charka with respect to Nidana andAcharya Sushrutha with respect to lakshanas, except for the term Atopa which he usesinstead of Shopha.• Bhavaprakasha [1400A.D] 18 Bhavamisra follows Acharya Sushruta while describing the disease and itsmanagement which he discusses in vatavyadhi chapter of Madhyama Khanda.Chakradatta [1100A.D] 19 Chakrapani Datta gives the same views as Sushruta in treatment aspects of thisdisease.• Bhaishajya ratnavali 20 The treatment aspect of this disease is mentioned.• Yogaratnakara [1600A.D] 21 He has given the same views as of Charaka and Susrutha but separate treatmentprinciples are mentioned.• Basavarajeeyam[ 1133-1183 A.D] 22 Vaidya Basavaraja explains this disease as Sandhi Vata. He gives different lakshanas of this disease but agrees on nidana mentioned by Charaka. He explains about the sandhivatari rasa. Page 7
  35. 35. DISEASE REVIEWSutra kala:Bramhana sutra: 23 This text has given importance to Vyana vata. While explaining themovements of joints it is said that vyana vata is the one, which resides in the jointsand performs all the movements.Panini sutra: 24 Panini was well aware of vata, its kopa and samana. He has mentioned theterm vatiki to denote disorders of vata.ETIMOLOGY OF SANDHIGATAVATA: The term sandhigatavata is a combination of two words i.e, 1. Sandhi 2. Gata vataSandhi: The word sandhi is formed by the combination of the sam+dha+kihi.25 In amarakosa, we get the meaning of the sandhi as slesha which means unionor combination. Sandhi is considered as union of two structures. Charaka mentions that sandhiis the samyoga sthana of the two asthis. The asthi sandhis are only considered as thesandhis and the union of pesi, snayu and siras are not considered.26 It is the moola of majjavaha srotas and also considered as one of themadhyama roga marga. There are 210 sandhis are present in our body.Concept of Gata VataGata vata is further comprised of two words, Gata and VataGata: Here the word gata denotes the state of vata. Page 8
  36. 36. DISEASE REVIEWVata Among three doshas,Vata is given importance. The word Vata originated fromthe root “Va Gati Gandhanayo” which when suffixed by ‘Ktan’, gives rise to the wordVata. There are five types of Vata, ie Prana, Udana, Samana, Vyana, Apana. Theyare having the seperate functions like, Purana, Udwahana, Viveka (rasa mootrapurisha pruthakkarana), Praspandana and Dharana.Vyana vata has been given the karma in different treatises such as - Praspandana (Sushruta)27 - Shareera chalana (Dalhana)28 - Gati, Apakshepana, Uthkshepa (Vagbhata)29 - Sandhicharitha (Dalhana)30 - Vahana (Rasa samvahana)31 - Pancha chesta.[Prasarana, Akunchana, Unnamana,Vinamana, Tiryakgamana]32 - Pancha chesta [Gati, Prasarana,Uthkshepa, Nimesha, Unmesha] 33 Although these functions said to be done by vyana vata, it can be seen in othertypes also. Praspandana karma can be seen in prana vata during swasa praswasa kriya.By the above reference we infer that any act of praspandana etc. function happen onlywith the coordinated union of all the types of vayu. To maintain the coordinated unionof vayu, Vahana is important which is performed by vyanavata. In Ayurvedic literatures, Sthitha, Militha, Gata are to be considered as synonymous words. Page 9
  37. 37. DISEASE REVIEWThe pathogenesis of Gatavata can be occurs in two ways - Margavarana janya – due to margavarana there will be srothorodha which leads to soshana of dhatus and also vitiation of vata. The vitiated vata situates the srotas which became rikta by soshana of dhatu. - Dhatu kshaya janya – the rikta dhatuvaha srotas will be filled by the vitiated vata. In gatavastha, the vitiation of vata is given importance. Here vata will beprabala state rather than in avarana. So gata vata condition shows prabala vatalakshana. In Hareeta samhita, Hareeta explains all the Dhatugata conditions areexplained under the heading of Vyana vata prakopaja vikara.34Anatomical aspect of Sandhi:There are two types of sandhi present in our body, 35 they are 1. Chestavantha – movable joints, the examples are the sandhis of Shakha, Hanu, Kati, Greeva. 2. Sthira – the remaining sandhis other than chestavantha.Another classification of sandhis36 is, No Type of Sandhi Structure Examples. 1. Kora Hinge joint anguli, manibandha, janu, kurpara, 2. Ulukhala Ball & socket joint kaksha, vankshana and dashana 3. Samudga Saddle joint Amsapeeta, Guda, Bhaga, Nithamba 4. Prathara Plain gliding joint Greeva, Prishtavamsh 5. Tunnasevani Sutures Sira, Kati, Kapala 6. Vayasatunda Condyloid joints Hanu 7. Mandala Circular joint Kanta, Hrdaya, Kloma, Nadi 8. Sankhavartha Bony labyrinth Shrotr, shrungataka Page 10
  38. 38. DISEASE REVIEWSnayu: 37 Snayu looks like a Shana (jute) and it is considered as the part of sandhi. It isthe upadhatu of medas and also moola of mamsavaha srotas. There are 900 snayus arepresent in human body. They are classified into four types they are, Prathanavathi,Vrutha, Pruthula and Sushira. Prathanavathi snayu is present in all the sandhis. Thevrutha snayus also considered as Kandara.it has the function of prasarana andakuchana of body parts. The ligaments which are present in the joints are separate which leads tostability.Sleshmadara kala: 38 This is the fourth kala, the kleda which is present in between the dhatvashayawill get paka by respective dhatwagni and kalas are produced. Sleshmadhara kala is considered as the seat for the sleshma (Shleshaka kapha)and it gives integrity to the body. Just as the application of oil to the axils produce easy movements to the wheel, the easy movement of the Sandhis is similarly brought about the lubricating effect the Shleshma dhara kala lining the Sandhis. The Synovial membrane can be compared with Shleshmadhara kala, which leads to easy movement of joints by secreting synovial fluid. Type B Synoviocytes will secrete the synovial fluid.Siras: 39 Siras are upadhatu of raktha which helps in sarana. There are four types; theyare vatavaha, pittavaha, kaphavaha and rakthavaha. Siras are mainly situated in marma and nourishing the snayu, asthi and sandhi.They are 700 in number. Page 11
  39. 39. DISEASE REVIEWPesi: 40 There are 500 pesis in our body. The sira, snayu, asthi, parva and sandhis arecovered by the pesis and get strength.Sandhimarma: 41 Marmas are the vital points of the body. They are 101 in number. According toDalhana marmas are situated in mamsa, sira, sandhi etc.42 Depending on the structural base marmas are divided into 5. They are mamsamarma, sira marma, snayu marma, asthi marma and sandhi marma. All the marmascomes under these 5 categories. There are 20 types of sandhi marmas. They are janu, kurpara, seemantha,adhipathi, gulpha, manibandha, kukundara, avartha and krukatika.43JOINTS 44Two or more bones unite to form joints.There are three types of joints explained.• Fibrous joints.• Fibro-cartilagenous joints.• Synovial joints.Fibrous and Fibro-cartilagenous joints: In this type, the fibrous or Fibro-cartilaginous tissues unite the two bones. Thisjoint will present where there is little requirement of movement.Examples: For fibrous joint: joints present in skull bone. For Fibro-cartilaginous joint: Symphisis pubis, Inter vertebral discs. Page 12
  40. 40. DISEASE REVIEWSynovial joints: This type of joints provides maximum range of movement.Eg: Most limb joints, Tempero-mandibular joint.Structures present in synovial joint are, 1. Articular cartilage. 2. Synovial fluid. 3. Intra articular disc. 4. Joint capsule and synovial membrane.Articular cartilage: In synovial joint, the articular surface is covered with a layer of articularcartilage.In normal cartilage, there are no cell divisions. But in this chondrocytes there arecontinuous process of destruction and synthesis of the cartilage matrix throughout life.Constituents: It is an avascular tissue that consists of cartilage cells [Chondrocytes], Type IIcollagen and smaller amounts of other proteins which is present in the matrix ofproteo glycans. The matrix consists of:1) Type II collagen fibers: It forms the meshwork in between the proteo glycan molecules.2) Hydrated gel of proteo glycan molecules: In this, the important one is Aggrecan. Aggrecan consists of: A] Core protein. B] Glycosaminoglycan[GAG] : It is the long chain of disaccharides. Page 13
  41. 41. DISEASE REVIEW The important GAG is Chondroitin sulphate and Keratan sulphate.3) Hyaluronan: A long GAG in which numerous aggrecan will be connected.4) Link protein: N- Terminus of aggrecan joins to the hyaluronan by small glycoprotein called Link protein.Articular cartilage has two essential functions: It provides a smooth bearing surface so that with the movement, bone glideeffortlessly over each other. Articular cartilage prevents concentration of stresses, sothe bones do not shatter when the joint is loaded. Large complexes of aggrecan andHyaluronan form the articular cartilage. Aggrecan has a strong, negative chargebecause of the sulphate and hydroxyl groups in glycosaminoglycan. And also it bindslarge number of water molecules. So it occupies the maximum possible volumeavailable. So the expansive force of charged and hydrated aggrecan and restrictiveforce of collagen gives the articular cartilage an excellent shock absorbing properties.Synovial fluid: Surfaces of articular cartilage separated by space called Synovial fluid. It isbasically ultra filtrate of plasma into which synovial cells secrete Hyaluronan andproteoglycan. It lubricates the joint.Intra articular discs: Intra articular discs are the fibro cartilagenous disc which is present within thejoint space. It is present in some joints only and acts as shock absorbers.Joint capsule: Joint capsule is a fibrous structure, richly supplied by blood vessels,lymphatics and nerves. It joins the two bones of the synovial joint. Ligaments and a Page 14
  42. 42. DISEASE REVIEWregional thickening of joint capsule stabilize the joint. Inner surface is lined bysynovial membrane.Synovial membrane: This membrane contains outer layer of blood vessels and loose connectivetissues. Inner layer consists of Type A and Type B synoviocytes. Most ofinflammatory and degenerative joint diseases associated with thickening of synovialmembrane and infiltration by lymphocytes, polymorphs and macrophages. Manyjoints contain bursae which are hollow sacs lined by synovium. Page 15
  43. 43. DISEASE REVIEW NIDANA In Ayurvedic classics, the term Nidana has been defined in two differentsenses. One of these definitions explains Nidana as that which points or indicates adisease or that which gives a complete knowledge of a disease or that which helps indiagnosing a disease.45 The other part defines Nidana as those which have a tendency to produce adisease process after inducing a chain of pathological events in the body like Doshaprakopa etc or in short, the etiological factors of the disease. The ahita ahara viharawhich vitiates the doshas and the dusta doshas which tend to vitiate the dushyas areincluded in to the category of Nidana.46 Being an important member of the Panchakas aiding in roga pareeksha,nidana not only helps in diagnosis and differential diagnosis, but also helps indetermining the prognosis of the disease. Nidana has an important role to play inChikitsa also, as the shortest route of avoiding or getting rid of the disease is said tobe Nidana parivarjana. In this context, the terminology Nidana covers the etiological factors causingthe disease entity Sandhigata vata. Sandhigata vata is one of the vata vikara. Vatavyadhi can be an effect of either of the two pathological events namely Dhatukshayaor Margavarodha. Each occurring due to different sets of nidana and so doesSandhigata vata. Since separate etiological factors have not been mentioned withrespect to Sandhi gata vata, the same nidanas which have been explained in thecontext of vata vyadhi should be considered.Notes: • vata prakopaka nidana 47 • + vata vyadhi nidana.48 Page 16
  44. 44. DISEASE REVIEWThe nidanas can be categorized into: Aharatha Viharatha Manasika KalakruthaAharatha: Ahara is an important factor responsible for the maintenance of health, as it ispancha bhoutika. Bala and ayush is gained by ahara. It is the form of nutrition to thebasic elements of the body or the shareera dhatu. Dhatu kshaya is a main cause of vataprakopa. So here the cause of dhatu kshaya is been considered keeping in view oftheir final effect on the functions of vata. Therefore different factors relating to theahara has been tabulated. A) Rasa visheshatha nidana:Table no: 2 showing Rasa visheshatha nidana: Rasa Ch Su A.S B.P M.N Y.R Ba.Raj H.S Kashaya - * * + - - - - Katu - * * + - - - - Tikta - * * + - - - - * vata prakopaka nidana. + vata vyadhi nidana. Kashaya, katu and tikta are the rasas, which vitiates vata and also leads tosnehadigunasunyatha. So this nidanas can be the cause for sandhigatavata. Page 17
  45. 45. DISEASE REVIEWB) Guna vishesatha nidana:Table no: 3 Showing Guna visheshatha nidana: Guna Ch Su A.S B.P M.N Y.R Ba.Raj H.S Ruksha + * * + + + + - Shitha + * * - + + + - Laghu + * - + + + + - Sushka - * * - - - - - * vata prakopaka nidana. + vata vyadhi nidana. The gunas like laghu, ruksha, kara etc. leads to the kshaya of the sneha guna ofthe body, which further leads to dhatukshaya and also vitiation of the vata dosha. Sothese gunas also can also cause sandhigata vata vyadhi.C) Veerya visheshatha nidana:Table no: 4 showing Veerya visheshatha nidana: Veerya Ch Su A.S B.P M.N Y.R Ba.Raj H.S Shita - * * - - - - - * vata prakopaka nidana. + vata vyadhi nidana. Sheeta veerya is the factor for the vitiation of Vata dosha. So this can beconsidered as one of the viprakrshta nidana for Sandhi gata vata.D) Time and forms of ahara:Table no: 5 showing Time and forms of Ahara: Ch Su A.S B.P M.N Y.R Ba.Raj H.S Alpa + - * - + + + - Pramitha - - * + - - - - Abhojana + * - + + + + - Virodhi - - + + - - - + Apatharpana - - - - - - - - * vata prakopaka nidana. + vata vyadhi nidana Page 18
  46. 46. DISEASE REVIEWThe forms of Ahara like Virodhi, Alpa, causes Vata vitiation thus produces Sandhigata vata.E) Type of ahara:Table no: 6 showing Type of Ahara: Nidana Ch Su A.S B.P M.N Y.R B.Raj H.S Shaka - * - - - - - - Vallura - * - - - - - - Varaka - * - - - - - - Uddalaka - * - - - - - - Koradusha - * - - - - - Syamaka - * - + - - - - Nivara - * - + - - - - Mudga - * - + - - - - Adhaki - * - + - - - - Harenu - * - - - - - - Kalaya - * * - - - - - Nishpava - * * + - - - - Vistambhi - - * - - - - - Virudaka - - * - - - - - Truna dhanya - - * - - - - - Chanaka - - * + - - - - Karira - - * - - - - - Tumba - - * - - - - - Kalinga - - * - - - - - Cirabhita - - * - - - - - Bisa - - * - - - - - Saluka - - * - - - - - Jambava - - * - - - - - Tinduka - - * - - - - - Thriputa - - - + - - - - Satheena - - - + - - - - Makusta - - - + - - - - Mangalyaka - - - + - - - - Masura - * - + - - - - * vata prakopaka nidana. + vata vyadhi nidana. Page 19
  47. 47. DISEASE REVIEW2) Viharatha nidana: Various viharas can stimulate or irritate those anatomical sites where afunction of vata (movements) is more required. Particularly the weight bearing jointswhich tend to become the target. Initially the injury may be at the molecular levelwhich further aggravates being able to involve the tissues of the sandhi generally incase of irreversible injury. Vyana vata is responsible for different chestas (movements). Here viharajanidana means the atiyoga, ayoga or mithyayoga of these chestas which leads to thevata prakopa. Viharaja nidana is also leads to abhigata of body parts (sandhi) whichalso become one of the pre disposing factors for sandhigata vata.Table no: 7 showing Viharatha nidana: Nidana Ch Su AS BP MN YR Ba.Raj HS Ati vyayama + * * + + + + + Ativyavaya + - * + + + + - (nidhwana) Langhana + * * - + + + - Prajagara + * * + + + + + Plavana + * * + + + + - (pratarana) Atiyadhva + - - - + + + + Ativicesta + - * - + + + - Dukhasayya + - - - + + + - Dukha asana + - * - + + + + (vishamasana) Diva swapna + - - - + + + - Vega + * * + + + + - sandharana Vego udeerana - - * - + + + - Abhighata + * * + + + + - Srama - - - + - - - - Page 20
  48. 48. DISEASE REVIEW Kreeda - - - - - - - + Dathu kshaya + - + + - - - - Ucha bhashana - - * - - - - - Abisangha - - - - - - - + Atiasruk + - * + - - - + sravana Ati virechana + - * + - - - + Ativamana + - * + - - - - Prana apana - - - - - - - + samana sandharana Vishamopacha + - - - + + + - ra Bharaharana - * * - - - - - Ksheena bala - - - - - - - + Atimamsa - - - + - - - - ksaya Gajaturaga + * * - + + + - yana * vata prakopaka nidana. + vata vyadhi nidana.3) Manasika karana: Mana is Ubhayendriya, which is the main part to attain Jnhanotpatti. Manas iscontrolled by Vata (Niyantha pranetha cha manasaam). Indriyas are also controlled byVata only. So manasika nidana considered as one of cause of Vata vyadhi becauseAsathmendriyartha samyoga is one type of nidana.Table no: 8 showing Manasika nidana: Nidana Ch Su AS BP MN YR Ba.Raj HS Chinta + - - + + + + + Soka + - * + + + + - Krodha + - - - + + + - Page 21
  49. 49. DISEASE REVIEW Bhaya + - * + + + + - Utkanta - - * - - - - - Ksheena - - - - - - - + indriya Madana - - - + - - - - kopa * vata prakopaka nidana. + vata vyadhi nidana.4) Kalaja: Kala is of two types; Nithyaga and Avasthika. Nityaga kala pertains to the kalarelated to rtus and Avastika kala is related to pathological state of doshas according tothe age of person.Table no: 9 showing Kalaja nidana: Nidana Ch Su AS BP MN YR Ba.Raj HS Payodasamaya - * * + - - - - (Varsa rtu) 3rdpart Dina- - - - + - - - - kshana Sisira - - - + - - - - Grishma - - * - + + + - Bhuktanta - * - - - - - - Pravrt - * - - - - - - Seeta kala - * - - - - - - Vrudha - * - - - - - - Usha kala - * - - - - - - Aparahna - * * - - - - - Jeerna anna - * * + - - - - Apararatri - - * - - - - - Purvavata - - * + - - - - * vata prakopaka nidana. + vata vyadhi nidana. Page 22
  50. 50. DISEASE REVIEW Influence of the time factor (kala) on the doshas has been given importance inAyurvedic classics. In general, the vata is predominant at the end of the digestion,evening or at the end of the digestion. Here old age will be main precipitating factor for production of Vatavyadhi.Although other nidanas can also cause vitiation of vata, it is considered asVyabhichari causes for Vatavydhi. In Vrudhavasta, the dhatus are in the state ofksheena, that which provides platform for the diseases. They are more prone to getSandhi gata vata. There are six rtus in which tridoshas are having its own state of kshaya orvrudhi. By considering this, vata is having sanchaya in Greeshma, prakopa in Varshaand shamana in Sharath.49 By this we can analyse that due to the rukshata inGreeshma vata gets Sanchaya, due to sheetata of Varsha gets Prakopa and ushnata ofsharat rtu does the Vata shamana. In Vata prakopaka rtus, person prone to get Sandhigata vata. The possible effect of these factors may be due to not adopting the rules ofRtu charya and the purification measures in the rtu sandhi as advocated in classics. Prakruti is also given importance while disease is considered. Vata prakrutipersons are more prone to vata vyadhi. While explaining Vata prakruti, Charaka toldthat Anavasthita sandhi(loosening of joints), because of chala guna and Sathathasandhi shabda gami( continuous crepitus in joints while walking) because ofvaishadhya guna of Vata.50 Page 23
  51. 51. DISEASE REVIEW POORVA RUPA The unclear signs and symptoms produced by the vitiated doshas during theprocess of sthana samsraya, which indicate the forth coming disease are called aspoorva rupa. This marks the beginning of amalgamation of vitiated doshas anddushyas.51 In the context of vata vyadhi, it has been said that the under manifestationof signs and symptoms or avyakta lakshanas should be regarded as poorva rupa.52 Even in case of sandhigata vata also, feebly manifested signs and symptoms ofthe disease can be considered as poorva rupa. In sandhigata vata, shoshana of shareeratakes place due to the localization of the prakupita vata, as a result of which theperson starts feeling laghuta. Lakshanas of sandhigata vata i.e shotha, shula etc arealso found in avyakta avastha. Page 24
  52. 52. DISEASE REVIEW RUPA In the disease process, the same unclear signs and symptoms of poorva rupawhen gets clearly manifested so as to indicate an existing disease will be called asrupa.53 In short the signs and symptoms of a completely manifested disease are calledas rupa or lakshanas. The same rule holds good with sandhigata vata also, where inthe symptoms of the disease like shotha, shula etc which were unclear and feebleduring the sthana samsraya gets clearly manifested defining the disease.Table no: 10 showing Roopa of Sandigata vata according to various Acharyas: Laxanas Ch54 Su55 A.S56 A.H57 B.P58 Y.R59 M.N60 Ba raj61 Sandhi Soola - + - - + + + + Sotha or sopha - + - - + + - - Vatapurna druti + - + + - - + - sparsa Hanti sandhin - + - - + + - - Prasarana + - + + - - - - akuncanayoho pravrttisavedana Atopa - - - - - - + - Shareera - - - - - - - + gandhaliptata Anga peeda - - - - - - - + Romaharsha - - - - - - - + Vilapana - - - - - - - + Page 25
  53. 53. DISEASE REVIEWThe cardinal symptoms are as follows: 1. Vata poorna druti sparsa 2. Sandhi soola 3. Sandhi sputana or Atopa 4. Prasarana Akunchana pravruthi savedana 5. Sandhi shotha or shopha 1) Hanti sandhin: In the commentary-Nibandha sangraha and Athanka darpana, they gives theexplanation that, Hanti sandheen means abhava in Prasarana akunchana etc functionsof the Sandhi.62 In Madhukosha commentary, it means complications of sandhi likeSandhi vishlesha, Sandhi sthambha etc.63 Gayadasa gives openion about Sandhivishlesha as there will be difficulty of movement without the dislocation.64 Vata is responsible for the Gati especially vyana vata leads to Pancha chesta ofthe body (Prasarana, akuncana, Unnamana, Vinamana, Tiryakgamana). Soimpairment of Vyana vata leads to difficulty in movement.2) Sandhi shula: Shula is the main symptom of the Vata vitiation. All the Acharyas mentionedthat there is no Shula without the vitiation of vata.65 Sandhi shula is the main symptom in the Sandhigata vata. In Asthi-Majjagatavata also this is the main symptom. So we can conclude that the sandhi shula isproduced due to the effect of Ashrayee dhatu kshaya (Asthi) due to the vitiation ofVata. Page 26
  54. 54. DISEASE REVIEW3) Atopa or Sandhi sputana: This specific symptom is explained by Acharya Madhava. Shabda is theindriyartha which indicates the predominance of qualities of Vata. Sandhigata vata islocalized vata vyadhi in which prakupita vayu affects Sandhi. This sthana samsraya isthe result of srotoriktata present at sandhi; that means akasa mahabhuta is increased atthe site of sandhi. The Atopa can be correlated to the crepitus in a joint. This is due to theOsteophyte formation at the time of remodeling of joint. This becomes evident onlywhen there is marked degeneration.4) Prasarana akunchana pravruthi savedana: There is a natural elasticity or contractility in the joint by virtue of which themovement in different direction can be performed. This is destroyed due to thevitiated vata, with the result the patient is not able to move his joint freely especiallyin the extension and contraction. If he tries to move, there will be severe pain. Thisphenomenon has been explained by different terminologies such as Stambha etc.5) Sandhi shotha: It is one of the main symptoms in Sandhigata vata. Sushrutha explained it asSandhi shopha because Shopha is the swelling which is Ekadesha sthitha.66 AcharyaCharaka explained as shotha. By commenting on shotha, Arunadatta explains that, the swelling look like theair filled bag.67 In Ashtanga samgraha, Vagbhata includes shopha as one of the Vyana vatavikara.68 Page 27
  55. 55. DISEASE REVIEW6) Vata purna druti sparsha: Sparsha is of two types, Ushna sparsha and Sheeta sparsha. InYogarathnakara, there is reference that the person who is suffering from Vata rogawill have Sheeta sparsha.69 In Sandhigata vata, usually the joints will be look like airfilled bag to touch and cold. Acharya Basavaraja also explained some other symptoms like ShareeraGandha lipta, Romaharsha, Vilapana which shows the chronicity of the disease. UPASAYA AND ANUPASAYA Upashaya is the temporary relief which is gained by the procedures such asOushadhi etc.It is also considered as therapeutic test to attain correct diagnosis of thedisease when it becomes difficult due to its effects in manifestation of signs andsymptoms.70 Anupasaya and Upasaya is the application of Ahara, Oushadha, Vihara,prescribed either antagonistic or similar to the nidana, to the Hetu, vyadhi or to bothHetu and Vyadhi together. It is considered as Upashaya when it decreases thesymptoms and when it aggravates the symptoms it is called Anupashaya. For example when abhyanga swedana, usna ahara etc reduce the symptoms ofSandhigatavata. In samavastha, like in Amavatha the same treatments aggravate thecondition. So it is a treatment and also a diagnostic approach. Page 28
  56. 56. DISEASE REVIEW SAMPRAPTI For the better understanding of the disease, the knowledge of Samprapti I.e theetio pathogenesis of the disease is essential. Samprapti can be defined as the process of disease from its inceptive phasetofully manifestation. This process starts from the Nidana sevana or consumption of theetiological factor causing dosha prakopa, circulates through out the body, localizationthen manifestation and differentiation.71 To the pathological point of view, dosha,dhatu, srotas is essencial in relation of Sandhigata vata. Srotas is also called as Dhatuavakasha, 72 which is formed from the Akashamahabhuta. Akasha and Vayu mahabhuta are interrelated73 and Vayu is situated in theemptiness [Riktata] created by the Akasha mahabhutha. In Samprapti, ‘Riktata of srotas’ present in the sandhi is considered as the‘Khavaigunya’, which is the platform for manifestation of disease Sandhigata vata.Chakrapani gives explanation about Riktata as ‘Thuccha’ or ‘Snehadi gunashunyata’.74 While explaining vata prakopa lakshanas, Charaka has mentioned the term“Sushirata” which may be taken as Riktata.75 In sandhigata vata, we can take the Snehadi guna shunyata in two differentconditions. As the sneha is the main guna of the shleshma, shunyata can be consideredas the Shleshma kshaya. Shleshaka kapha is present in the sandhi which is responsiblefor the integrity of joints and proper lubrication. The depletion of this leads to Riktataof srotas. Dhatus are the snehayukta dravya present in the body. As the sandhi is madeup of different dhatus, upadhatus and other essential factors, the intake of the dhatukshayakara nidana will lead to there will be dhatukshaya which is turn causes snehadi Page 29
  57. 57. DISEASE REVIEWguna shunyata[riktata]. In short, one can say that the loss of snehana of the joint isresponsible for the pathogenesis of Sandhigata vata. Vata prakopa can occur in two ways.76 1) Dhatukshayajanya and 2) Margavaranajanya (obstruction) Vagbhata77 clearly explains that Dhatukshayaja nidanas are also responsiblefor the vitiation of the vata along with the riktata. The prakupita vata situates in therikta srotas present in the sandhi thus producing the symptoms of Sandhigata vata. In margavarodhajanya condition, the other doshas such as Kapha and Pitta fillsthe Srotas present in the sandhi and does the Avarana of vata. Due to avarana, theavruta vata becomes strong and vitiated, leads to further dhatu shoshana78 thusproducing the symptoms of the Sandhigata vata. Medo roga(sthoulya) may also lead to Sandhigata vata as vata vyadhi is saidas one of the complication of the medoroga. Due to the Avarana of meda to thepathway of the vata, there will not be proper nourishment to other dhatus leading tovata vikaras.79Samprapti ghatakas:Dosha - Vatavrudhi, [Vyanavata], Kapha kshaya [sleshaka kapha].Dushya - Asthi, Snayu [sandhi avayava].Srotas - Important srotas are asthi vaha, majja vaha other less important are medovaha and mamsavaha srotas.Agni - Dhatwagni.Rogamarga - Madhyama.Udbhavasthana- Pakwashaya.Sanchara stana- Sarva deha.Vyaktasthana - Sandhi. Page 30
  58. 58. DISEASE REVIEWChart No. 1. Showing Etio-pathogenesis of Sandhigata vata: Nidana Ahara Vihara Manasika Kala Gada kruta Vata prakopa Dhatu kshaya Anya dosa prakopa Vata prasara Rikta srotas Fills in the Srotas Avarana of Vata VATA PRAKOPA Sthana samshraya in sandhi Sira- Asti Snayu Kandara Sleshma Sleshma Impared dhara sravana kala Shoshana Kshaya Vatapurnadrthi sparsha Sotha Stambha Atopa Sula Page 31
  59. 59. DISEASE REVIEW UPADRAVA Upadrava is the Complication of a disease. The Dosha which causes the maindisease is itself responsible for the upadrava. Upadrava will be manifested in three ways i.e. complications that starts alongwith the disease, complications after full manifestation of the disease andcomplications produced after cure of the disease.80 Asthi shithilata, pesi kshaya can be considered as the complication whichmanifests along with Sandhigata vata and Sandhi vishlesha will be its after effect. Complications such as deformity and immobility of joints will interfere theroutine works. SADHYASADHYATHA Sushrutha and Vagbhata have included Vata vyadhi under the Ashta mahagada, 81 because of its ashukarita and Upadrava. As the disease Sandhi gata vata is oneof the Vata vyadhi, it is difficult to cure. Charaka while explaining sadhyasadhyata, mentions that ‘Khuda vata is Kastasadhya or asadhya. Commenting on Khuda vata, Chakrapani opines that Khudavataitself is Gulphavata or Sandhi gata vata.82 Acharya Hareeta concludes that the Mamsa gata, medo gata vata is Sadhya,rest of Gata vata is Kasta sadhya or Asadhya for treatment.83 As Sandhi gata vata is the disease of Madhyama roga marga. It is consideredas Kashta sadhya. Page 32
  60. 60. DISEASE REVIEW CHIKITSA The main scopes of the Chikitsa are of two. They are promotion andpreservation of health in healthy individual, and elimination of the disease ailing andafflicted i.e. curative treatment. According to the Amarakosha chikitsa is Rukprathikriya84 where as in Vaidyaka shabda sindhu, it is defined as ‘roga nidanapratheekara’. The term rogapanayana and ruk pratikriya convey nearly the same meaningviz, measures calculated to the removal of disease and treatment of the diseaserespectively. The term roga nidana pratikriya stresses on the removal of causationfactors of the diseases. Acharya Sushruta was the first to mention the treatment principles ofSandhigatavata. Although Charaka has not mentioned about specific chikitsa, thegeneral Vatavyadhi chikitsa is taken in to consideration. Treatment principles according to different Acharyas are tabulated below:Table no: 11 showing Chikitsa sutra of Sandigata vataChikitsasutra Ch. Su.85 A.S86 A.H87 B.P88 Y.R89 B.R90 C.D91Sneha - + - + - + + +Abhyanga - - + - - - - -Upanaha - + + + - + + +Agni karma - + + + - - + +Bandhana - + + - - - + +Unmardana - + + - - + + +Sweda - - - - - + - -Raktavasecan - - + - - - - -Pradeha - - + - - - - -Samana - - - + + + + + Page 33
  61. 61. DISEASE REVIEW1) Snehana: The procedure which induces qualities like Snigdhata, Mruduta, Kledata andVishyandata in the body, following the internal and external administration of snehadravyas are called as Snehana.92 Snehana is said to be the best treatment in case of allthe diseases produced by the Vata, since it is totally antagonist to the qualities ofVata. Sneha is also said to be tridoshagna as it alleviates vata, pitta and kapha due toits Snigdhata, Shaityata and samskarasyanuvarthana (yogavahi) respectively.93According to prayoga bheda there are two types of snehana procedures, they are• Bahya sneha – in this the sneha dravyas are applied externally as done in procedures like abhyanga, avagaha, sirovasthi etc.• Abhyanthara sneha – In this the sneha is administered internally in the form of pana and basthi. In the disease Sandhigata vata, the administration of Snehana will be veryeffective since Prithwi and Ambu mahabhoota, which are mainly present in theSnehadravyas are exactly opposite to the Akasha mahabhuta predominantly prevailsin the main factor in the disease pathology i.e. Sroto riktata. There are two types of sneha94 i.e sthavara and jangama. Among these snehas,four snehas are considered as pravara and also their quality has been mentioned.Among these, ghrita is considered as best one and it is pittanila hara, rasa shukra ojohitha. Thaila is maruthaghna,balya, sthirakara and it does not increases kapha. Vasa isbest known for eradicating the maharuja which is affecting to Asthi, Sandhi, Sira,Snayu, Marma and balavan marutha which is situated in the srotas. Majja isconsidered as bala- rasa- meda- shleshma and majja vardhaka.95 Page 34
  62. 62. DISEASE REVIEW2) Abhyanga: Abhyanga is a type of snehana karma where massage is done by applying thethaila on the body.96 It is said that by abhyanga both kapha and vata will be pacified. It is alsoconsidered as balakari, and dhatu pustikara. Dalhana has given the explanationregarding the time required for the Sneha dravyas to enter deep to the dhatusfollowing Abhyanga. According to his explanation, sneha is situated in romakupa upto 300 matrakala. In 400 matrakala, it enters twacha, in 500 to rakta,in 600 matrakalato mamsa. It reaches medodhatu in 700 matra kala. The sneha reaches asthi in 800matrakala. In 900 matrakala sneha enters in to majja thus inducing snigdhata in all thedhatus. Thus it is considered as the dhatu pustikara.97 Since Sandhigata vata is a disease of Madhyama roga marga where the Asthi,majja and sandhis are involved; the penetration of sneha dravyas deep in to the dhatusduring abhyanga as said above will be of high therapeutic value. In 5th century B.C, Hippocratus wrote- “the physician must be experienced inmany things, but assurely in rubbing, because rubbing can bind a joint that is tooloose and can loosen a joint that is too rigid”.98Upanaha: The word meaning of Upanaha is bandhana.99 According to sushruta, it is oneamong 4 types of swedana karma. In this moola kalka, kanji, pista, lavana, is addedwith sneha and thick application is done over the affected part. Then that area is tiedin a cloth. In case of Pittanugata vata, kakolyadi, surasadi or eladi gana dravyas areused. In kaphanugata vata, tila atasi etc dravyas and in kevala vata, veshavara, salvanaupanaha is adviced. He is also explained that Upanaha is best for Vata.100 Acharya Caraka explains Upanaha as one of the Niragni swedana.101 Page 35
  63. 63. DISEASE REVIEW By commenting on this Chakrapani explains there are two types of Upanaha.They are Saagni and Niragni upanaha. In Saagni upanaha, tila or masha kalka aremade in to hot and kept on affected part. This is also called as the Sankara sweda. InNiragni upanaha, ushna veerya drugs are applied and tied by charma, cloth etc.102 Vagbhata explains Vachadi Upanaha in kevala vata. Acharya Sivadas sen explains the mechanism of the Upanaha as swedana. Dueto the blocking of the heat generated by the body, there will be production of thesweda in that part.Agni karma: The procedures done with the help of agni or the drugs having Agni guna iscalled as Agnikarma.103 The severe complications of Sira, Snayu, Asthi and Sandhi,caused by the vitiation of vata are cured by the Agni karma.104 In snayu- asthi and sandhi gata vata and kaphaja vikara, by usingKshaudra(sugar candy), Guda(jaggery) or Sneha, the procedure of Agnikarma shouldbe done. It is indicated in all rtus except in Sharat and Grishma.105 The importance of this procedure is, the diseases which are not cured by theother procedures like Bhesaja, Shastra, Kshara, and Rasa can be cured by using thisprocedure.106Bandhana: Bandhana leads to Samhathi. It is the procedure in which the effected part willbe tied by using Rajju etc.107 By doing Bandhana procedure, there will be strength to the joints and alsopressure to the joints will be minimized. Page 36
  64. 64. DISEASE REVIEWUnmardana: It is the procedure of massaging of effected part by Hastatala after applicationof oil. By the gentle massage there will be proper circulation to the joints.108Swedana: Swedana is of two types109 according to Agni samyoga. They are,1) Agni sweda- They are of 13 types, namely Sankara, Prastara, Nadi, Pariseka,Avagaha, Jhentaka, Ashmaghana, Karshoo, Kuti, Bhoo, Kumbhika, Koopa andHolaka.2) Niragni sweda: They are of 10 types namely, Vyayama, Ushnasadana,Gurupravarana, Kshudha, Bahupana, Bhaya, Krodha, Upanaha, Athapa, Yudha. In Ashtanga Sangraha, Vagbhata has said that swedana is the best remedy toremove the sthabdatha of the Sandhi (Sandhi sthabdathapaham).110 In case of Sandhigata vata, by doing swedana, there will be Vata nigrahanawhich results in decreasing the pathology.Raktavasechana: Acharya Vagbhata (Ashtanga samgraha) explained it as avastika chikitsa. Insira-snayu-sandhi gata vata, if the person is having Svapa(numbness), raktavasechanais indicated in alpa pramana. If the person feels angamlana with numbness,raktavasechana is contra indicated because there will be the chance of shosha.111 After raktavasechana, pradeha is applied by taila, lavana, agara dhuma. Page 37
  65. 65. DISEASE REVIEW PATHYAAPATHYA Pathya means wholesome or conducive to health. Pathya is related to Pathawhich is having different meanings. It indicates the channels of circulation which iscalled as Srotas. Chakrapani comments that Patha is the dosha and dhatus which ispresent in srotas. He also quotes that Pantha is the Swastha rakshana and also Vyadhiprashamana. So the food and activities which is performed and which is Anpayakari(notharmful) to person and also to disease is called as Pathya112 it depends on the Matra,Kala, Kriya, Bhumi,Deha, Desha and Gunanthara Pathya has been given importance that no medicine is needed if Pathya isfollowed properly andthere is no use of medicine if Pathya is not followed properly. Although specific Pathya is not mentioned for Sandhi gata vata, thewholesome food and regimens explained for Vata vyadhi is taken as Pathya.Table No: 12Pathya for Sandhi gata vata:Ahara Yogarathnaka 113 Bhaishajya rathnavali 114Sneha ---- ThailaShaka varga Patola, Kushmanda, Shigru, VarthakaShuka dhanya Godhuma, Rakta shali Godhuma, purana dhanya.vargaShimbi Masha, Kulatha Masha, KulathadhanyaMamsa Kukkuta, Tittiri, Barhi, Chataka, Jangala mamsa. ---Mathsya Shilendra, Nakra, Khudisha, Parvathe, ---varga Gargara, JhashaPhala varga Dadima, Parooshaka, Badara, Draksha ---Gavya varga Ghrutha, Dugdha, Kilaata, Dadhi --- koorchikaOushadha Lashuna, Tambula, Masthsyandika, Brihati, Vastuka,dravya Kasamarda, Dunduka, Mishi, KatakaLavana Saindhava --- Page 38
  66. 66. DISEASE REVIEWApathya for Sandhi gata vata: In Yogarathnakara and Bhaishajya rathnavali, some of unwholesome foods areexplained which is enlisted below.Table No: 13Apathya ahara Yogarathnakara 115 Bhaishajya rathnavali 116Vihara Chintha, Prajagara, Sheeta pravata Vegavidharana, Shrama, Vyavaya, Chankramana, Khatwa(sleeping in cot), Hasthyashwa yana, Dwija gharshana.Karma Chardi,Food intaken Anashana Guru, Abhishyandi.Shuka dhanya Nava dhanyaShimbi dhanya Mudga, Nivara, Shyamaka, Mudga, Sharshapa, Kuruvinda, Kalaya, Nishpava. Chanaka.Shakha varga Koshataki, Kareera. KareeraJala varga Thataka, Thatini, Pradusta Sheetambu salilaRasa Kashaya, katu, Tikta -----Other substances Kshudra, Kangu, Nimba Mrunali, Sarasi, Nimba Page 39
  67. 67. DISEASE REVIEW DIFFERENCIAL DIAGNOSIS For the accurate diagnosis of the disease, Vyavachedaka nidana (differentialdiagnosis) is important. By seeing difference in the causative factors, mode of onset,clinical features,upashaya- anupashaya, we can conclude the differential diagnosis. Sandhi gata vata is the disease pertaining to joints, other joint diseases such asVatarakta, Amavata will be considered for the differential diagnosis.Table No: 14 Symptoms Sandhigata vata Vatarakta 117 Amavata 118 Dosha Vata Thridoshaja Vata-Kaphaja Onset Gradual Gradual Sudden Progression Increase & Constant Constant Decrease Joint involvement Big Small Big Spreading [joint] - Small to Big Big to Small Swelling Articular, Extra articular, Articular & Puffy Engorged Pitting Tenderness[pain] Severe, Like Mild Severe, Burning Scorpion bite Crepitus Severe Moderate Absent Stiffness Severe Severe Moderate Skin involvement Not involved Involved Not involved Deformity Present Present Absent Function Painful, Restricted, Painful, Restricted Immobile Restricted Response to oil Marked relief Moderate relief Aggravates Page 40
  68. 68. DISEASE REVIEW OSTEOARTHRITIS119 Osteoarthritis is a degenerative disorder of the joint and it is classified as • Primary • SecondaryPrimary Osteoarthritis: Primary OA is also called ‘wear and tear’ arthritis and degenerative jointdisease. In this, due to risk factors there will be degradation of articular cartilagewhich leads to joint narrowing, remodeling of joint by forming osteophytes andeventually a non functioning, painful joint. Although OA is a non inflammatoryprocess mild inflammatory changes occur in the synovium. It is also called idiopathicOA as no predisposing factor is apparent.Secondary OA: It has known underlying cause including congenial or acquired incongruity ofjoints, trauma, crystal deposits etc. But it cannot be distinguished from primary OApathologically. Osteoarthritis is considered as the dynamic repair process of synovial joints. Itis more prevalent in aged persons and it is considered as the very common form ofarthritis.Osteo arthritis is characterised by: Loss of articular cartilage where there is maximum pressure. Formation of new bone (Osteophyte) with remodeling of joints. Most effected joints are knee and hip joint where as knee is most effected thanhip. Osteoarthritis is very common in Elbow, Glenohumeral joint and Ankle jointalso. Page 41
  69. 69. DISEASE REVIEWEffected joints:Interphallangeal jointsHeberden’s nodes: Enlargement of distal interphallangeal joints.Bouchard’s nodes: Enlargement of proximal interphallangeal joints.Erosive osteoarthritis: This is present in distal and/or proximal interphallangealjoints.Generalised osteoarthritis: Characterised by involvement of three or more joints orgroup of joints.Thumb base osteoarthritis: In this, there will be squared appearance of thumb base.Hip osteoarthritis: In this, the pain will be in inguinal area but may be referred tobuttock or proximal thigh. Flexion may be painless initially but internal rotation willhave pain. Loss of internal rotation occurs early, followed by loss of extension,adduction, and flexion due to capsular fibrosis and/or osteophytes.Knee osteoarthritis: Knee osteoarthritis will be manifested in these ways.In medial femotibial compartment: It leads to varus deformity [Bow-leg]In lateral femotibial compartment: It leads to valgus deformity [Knock-knee]In patellofemoral OA: There will be positive shrug sign.Spine osteoarthritis: This involve Apophysial joint, Intervertibral disc,and also theremay be involvement of paraspinous ligaments.Pathogenesis: For the normal functions of the joint, there should be normalcy of the jointtissues such as cartilage, bone synovium, capsule, ligament, and muscles. In the case of Primary osteoarthritis, the cause is considered as unknown. Butin case of Secondary osteoarthritis, a clear cause of Trauma or ligament rupture may Page 42

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