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Evaluation of Rasnapanchaka Guggulu in sandhigata Vata, Syal Kumar, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG,

Evaluation of Rasnapanchaka Guggulu in sandhigata Vata, Syal Kumar, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG,

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    Sandhivata kc016 gdg Sandhivata kc016 gdg Document Transcript

    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata INTRODUCTIONThe Indian subcontinent abounds as it were in a variety and diversity of health traditions.We have with us what is perhaps the longest unbroken health tradition, which has not only a streamof practitioners but also a traditional and theoretical backing in terms of Ayurvedic system of medi-cine. They have made their presence felt even outside India. A healthy body and healthy mind is the aim of all medical system. Ayurveda is one such systemthat prevailed thousands of years ago. It was considered the most advanced and scientificallyproven on those days. It still continues to shine .The present millennium has shown us numerousdisorders and we know that the changes in atmosphere and the living condition are among thecauses. This results in serious disorders like cancer to AIDS. To handle these problems, Ayurvedahas the correct way. Nowadays the competition among the medical systems is increasing day by day. The modernmedical systems uses the most modern techniques in the aspect of treatment and research studies. Itis the duty of Ayurvedic scholars to conduct proper research and invent new methods and medi-cines, which will be a boon to the society. The present work is conducted to evaluate the action of“Rasnapanchaka guggulu” in sandhigata vata (Osetoarthritis). Rasnapanchaka is a classical yogadealt in sahasrayoga, which specifically mentioned for asthigata vatavyadhies. Among the Ayurvedic practitioners Osetoarthritis is called as sandhivata. But in all classicaltreatises it is mentioned as sandhigata vata. This study is an attempt to help the patients suffering from Sadhigata vata (Osetoarthritis) in oursociety. 1
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataThe Need Of StudyThe life style of man has become mechanical. The time and more desire have made the man unableto follow the swastha niyamas, thereby becoming victims of diseases. The man today even in hisyoung adult age suffering from the degenerative diseases like Sandhigata vata (Osetoarthritis), Vatarakta (Gouty arthritis), Siragranthi (Atherosclerosis) etc. Among such disease Sandhigata vata (OA),the condition where pain and swelling in the joints present giving rise to restricted movements. It isthe most common type of arthritis and most common joint disorders in the world, which is consid-ered as the number one cause of disability. Contemporary medical science are able to pacify thepainful condition of the above said disease through highly effective analgesics and anti-inflammatorydrugs and if needed through the surgical treatment as the final, which may give rise to complicationand cost effective.So to overcome the degenerative process in the young adult age and pacify the pain without pro-ducing the complications, the research of treatment is essential. Of course many research workshave been made on this diseases but no successful invention is invented yet. In Ayurveda the ancientIndian system of medicine, has suggested good old techniques and recipes to pacify the painfulconditions without causing any complication and prevent further development of degenerative pro-cess.Lots of studies done with some of the medicine like Sallaki etc. Sallaki-Boswellia serrata whenadministered alone the result was not good .So only when it is supplemented with other NSAID’ssignificant reduction in clinical symptoms was seen. Thus the study has not given a satisfactoryresult1.Most of the other studies conducted were not a comparative with a standard modem drugs. Herethe trial is a comparative study with standard modern drug Nimesulide. The drug Nimesulide isselected due to its good tolerability profile. Analysis of data for an Italian post-marketing survey inwhich 22938 patients had taken Nimesulide therapy for 1-3 weeks; the overall incidence of side 2
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vataeffects reported was 8.2%(1887 patients). In 2.2%(498patients) of patients the adverse effectwhere severe enough that it necessitated drug withdrawal.The incidence of adverse event and with-drawal rates were similar in elderly (8.8% and 2.2%) and paediatric (7.1% and 1.1%) patients.With Nimesulide direct gastrodeodenal endoscopic studies have shown lower incidence of gastricmucosal toxicity than with other NSAID’s like Diclofenac and Indomethacin2.So still more research works are essential to establish the same by using research techniques and bystatistical methods. Thus the present study on “Evaluation of Rasnapanchaka guggulu in sandhigatavata” has been selected with positive thoughts.Sandhigata vata (OA) is the commonest joint disease in humans. Among the elderly, knee joint OAis the leading cause of chronic disability in developed countries. Some 10,000 people in the UnitedStates are unable to walk independently from bed to bathroom3.Because of OA, about 20-30% of people in India are affected by some complaints of knee jointduring there lives. Females are found to be more affected by this disorder4.The pattern of joint involved in OA is prior vocational and avocational over load. Thus ankle OA iscommon in ballet dancers, elbow OA in baseball pitchers, and metacarpophlangeal joint OA inprizefighters. OA is not very common at any of these sites in general population.This is a study concentrating only on knee joint OA due to the increased number of cases. Most ofthe knee OA cases are due to the improper work pattern and food habits. Desha is also a precipi-tating factor for OA. The place where study is conducted is of jangala, ultimately chances of occur-rence of vata predominant diseases are natural. Sandhigata vata is one among the vata vikaras.In recent years more and more attention has been paid to the ailments and physicians are no longersatisfied with simply treating the symptoms with out proper understanding to the underlying pathol-ogy. This happens due to the lack of confidence in the action of Ayurvedic drugs .To create an aware-ness and also to convince that this Ayurvedic drug is effective hence this work was under taken. 3
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataAims And ObjectivesThe main aim of the study is to co-relate the action of trial drug “Rasnapanchaka guggulu” with themodern standard drug “Nimesulide” clinically.Contemporary practitioners are not satisfied with the Guggulu products available now a day so theyare using the hit and trial method during their daily practice. Lot of Guggulu preparations are avail-able in the market as pills, choornas, kwathas, etc, even though they are prescribed by the physi-cians it is not giving a satisfactory results to the disease Sandhigata vata.Guggulu is considered as one of the best medicines for deranged vata especially the vata, whichvisited in sandhi, asthi etc. Susrutha has dealt the importance of guggulu in the chikitsasthana ofmahavatavyathi. From this we can understand the important of this wonder drug.Guggulu is aromatic, light, penetrating into minute parts of the body, sharp, heat making in potency,pungent in taste and digestion, laxative, unctuous, slimy and wholesome to heart. New guggulu is anaphrodisiac and a constructive tonic. Old guggulu is anti fat and hence reduce corpulence. It de-stroys the deranged vayu in koshta, bones and joins just as a thunderbolt will destroy trees5.Guggulu is considered as one of the anti-inflammatory, anti-rheumatic, hypolipedemic and hypocholesteremic drug.Due to all these above factors Guggulu is selected as one of the major drug for this study. Lots ofworks were done by guggulu in the same aspect by several scholars throughout India, but still somelacuna is missing among those. It feels that this study will overcome all those underlined and will fulfillthe needs.The present work eventhough by guggulu preparations is focussed exclusively on sandhigata vata.In this study the most modern techniques are adopted in the aspect of diagnosis, assessment andmedicine preparation. All together this study gives a scientific approach in the management of sandhigatavata. 4
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata1.Historical Review:-All the historical aspects related to this work is mentioned under this heading.Ayurveda itself is a historical science, which originated thousands of years ago. What ever thediseases dealt in major Ayurvedic classics will be having the same period of origin. Sandhigata vatais one among those diseases, which was told in major Ayurvedic classics.It can be seen that even in the Vedic period the joint disorders where mentioned. One of the mantrasof rigveda describes that “Im removing your diseases from each organ, hair and joints”6. In AdharvaVeda records about vatavikaras are mentioned-“destroy the balasa seated in the organs and joinswhich is responsible for loosing bones and joints”7.In Agnipurana total number of joints in human body and treatments for sandhigata samavata wasmentioned8.There was a period where the science developed and flourished much and considered as the goldenperiod of Ayurveda.In Charaka samhita, Charaka has clearly mentioned about sandhigata vata as “sandhigato anila” inthe chikitsa sthana9In Susrutha samhita under vatavyadhi nidana he has mentioned about sandhigata vata 10In Astanga samgraha and hrudya same views of Charaka and Susrutha is mentioned11.In Bhela samhitha under “asthimajjagata vatavyadhi” a description sandhivichyuti is available12. 5
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataIn Hareetha samhitha the treatment aspect for sandhigata vata is mentioned13In madhyama kala and adhunika kala some of the Acharyas mentioned much about this disease.Madhava nidana, supposed to be the best in nidana aspect has clearly explained this disease14. InBhava prakasha under vatavyadhi chapter Sandhigata vata lakshanas are explained and its treat-ment mentioned15.In other Ayurvedic treatises like Yogaratnakara, Gadanigraha, Vangasena, etcboth the treatment aspect and clinical entity has been found either in the words of Charaka orSusrutha16.Lots of research studies where carried out on this disease, one among was the clinical trial studywith Sallaki17Other postgraduate research works where done on this disease with guggulu preparations and withVasti karmas in various colleges across India.Sandhigata vata can be correlated as Osteoarthritis in modern science. This is due to the nature ofdisease and similarity of cardinal symptoms. Osteoarthritis is the most common joint disorders inhuman being and other vertebrates. Even in giant dinosaurs osteophytes leading to ankylosis weredetected. In all mammalian species like whales and dolphins and in fish, birds and some amphibiaOsteoarthritis is observed18.In early ages Hippocrates, the father of modern medicine observed the prevalence of Osteoarthritisin aged individuals.(Benard,1944).Due to the detailed study of this disease by Heberdon (1803) theOsteoarthritis nodes on the figures was named after him.Osteoarthritis was differentiated from Rheu-matoid arthritis and named as degenerative arthritis by Nichols and Richardson (1909) on morbidanatomical grounds.The appearance of Herberdon’s node in relation with age, sex and hereditary factors was men-tioned by Strecher, (1940). Intermittent claudication in the Osteoarthritis of lower limb including hip, 6
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vataknee and ankle was observed by Boyd, (1949).The term Osteoarthritis was used due to the absence of synovial thickening or inflammatory infiltra-tion in uncomplicated condition by Kellgren, (1961). The term Osteoarthritis, Hypertrophic arthri-tis, Osteoarthrosis are mentioned under degenerative arthritis by Samuel L Turek, (1989).ETYMOLOGY OF SANDHIGATA VATASandhigata vata is one among the vatavyadhies told by acharyas. Its word meaning is, the diseasewhich oreginates when vata resides in sandhi.The term sandhigata vata is a combination of threewords ie; sandhi,gata and vata.1.Sandhi:-The word sandhi is formed by the combination of sam + dha + kihi19Nirukthi:- Sandhirnama samyogaha Astidwaya samyogasthana.20According to susrutha, there are various types of sandhies in the body like those of peshi snayu,sirasandhis etc, but in this context we have to consider asthisandhi as the meaning of sandhi.21Sandhi can be correlated as junction,joint,connection,combination, union with, containing a conju-gation, transition from one to another, is the term for a junction.2.Gata:- The word gata is formed by the combination of GUM + KTHA. The meaning of this word indicates the movement.3.Vata:-The term vata is derived from the root “Va Gati Gandhanayoh” ie; to move , to enthuse, to makeknown and to became aware of22.Bhela states that so long as vata lasts, as long does life exists23. 7
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataVagabhata states that vata has its control over the function of the body, swift action, strength capac-ity to visiate other factors, independent movement and the large number of diseases produced dueto its vitation24.The chalatva or mobility has been qualified to be very swift25.Vata is amrutha (incorporeal- adrishya , as Chakrapani explains) and anavastita(unstable)26.Normal functions of vata are:enthusiasm, inhalation, exhalation, movements of body parts etc27.Vata is divided into five according to its respective seats in human body. They are Prana, Udana,Vyana, Samana and Apana, among these Vyanavata which is situated in the “Heart” does the func-tion of movement and all most all the Cheshtas of the body28.According to Vagbhata Vata is located in the asthi with relation to Ashrayashrayi sambhandha.Generally the Doshas and Dhatus are inter related, when doshas increases particular dhatus relatedwith it also increases and viceversa . But in the case of vata and asti , when vata increases asthidecreases29.The word Osteoarthritis is a combination of three words. Osteon, Arthron and Itis, means Bone,Joint and inflammation .The meaning of this word is inflammation to the bony joint.Osteoarthritis (Osteoarthrosis), (OA) is the most common form of arthritis. The cartilage lining theend of the bones, forming the joint, or the shock absorber gradually erode over a period of time.The bone ends thicken and over grow. This process occurs primarily in weight bearing joints, and isassociated with inflammation. 8
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataDEFINITION1.Sandhigata vata:-In almost all the Ayurvedic treatises disease sandhigata vata is mentioned in vata vyadi adhyaya.Charaka has mentioned that when vitiated vayu reached in one or more sandhies it is called assandhigata vata. In this disease the joint gets vitiated by vayu and palpation is fell like a bag filled withair. There will be pain during extention and flexon30.Susrutha mentions that when vayu dosha vitiates the joints it produces shula and shotha31.All most all tha acharyas have supported the above two greats by the mentioning the same symp-toms.Madhavacharya, considered as the nidana sreshta adds some more points which give some speci-ficity to this disease. He adds one extra symptom “Atopam” than other Acharyas32. This can beconsidered as one of the classicals symptoms of sandhigata vata(OA).2. Osteoarthritis:-Osteoarthritis is defined as a degenerative, non inflammatory joint disease charecterised by destruc-tion of articular cartilage and formation of new bone at the joint surface and margines 33.Osteoarthritis (OA), also unanemously called degenerative joint disease, represents failure of adiarthrodial joint. In idiopathic (primary) OA the most common form of the disease, no predisposingfactor is apparent. Secondary OA is pathologically indistinguishable from idiopathic OA but is at-tributed to an underlying cause34. 9
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataEPIDEMIOLOGYSandhigata vata (OA) is the most common joint disease of humans. Among the eldery knee OA isthe leading cause of chronic disability. Under the age of 55 years, the joint distribution of OA in menand women is similar. In older individuals, hip OA is more common in men, while OA of interpha-langeal joints and the thumb base are more common in women. Similarly radiographic evidence ofknee OA and , especially symptomatic knee OA is more common in women than in men.Racial differences exists in both the prevalence of OA and the pattern of joint involvement. TheChinese in Honkong have a lower incidence of hip OA than whites .OA is more frequent in nativeAmericans than in whites. Intertphalangeal joint OA and especially hip OA are much less commonin South African blacks than in whites in the same population.Age is the most powerfull risk factor for OA. In a radiographic survey of women less than 45 yearsold , only 2% had OA. Between the age of 45 to 64 Years the prevalence was 30% and for thoseolder than 65 years it was 68%. In males the figure was similar but some what lower in the older agegroup35.ANATOMY AND PHYSIOLOGYAs mentioned earlier this study was given more importance and concentration to the knee jointsOsteoarthritis. For that a detailed information about this particular joints is very much essential.It is by great fortune that Acharya Susrutha had enlightened the world of surgery in early days. Hewas the first person to descect the human body and became the authority of early anatomy. All theseaspects can be well discovered from his works. He in his classics has described each and every partof the human body anatomy in detail. 10
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataIn Susrutha samhitha sareerasthana he has classified the joints into eight divisions- named as theobjects which they respectivey rescemble in shape. The Knee joints was described under Koratype of sandhi- hinged or lap-shaped36.Being a master in anatomy Susrutha had no problem in inventing and explaining Marma’s. Marma’sare vital points situated in specific parts of the body, when injured causes casuality and even death.There are 107 Marmas in the human body. In that a single lower extremity is having eleven Marmas.In the sandhies(joints) altogether 20 Marmas are mentioned . Amoung these Susrutha has describedsome of them which resides in janusandhi (Knee joint)37.Janu marma is situated in the union of the thigh and the knee. Any injury to it results in khanjata. Animarma is situted on both the sides above three fingure width from the janu (Knee). Any injury to itcauses swelling and paralysis of the leg38.The above Marmas comes under the group called the vaikalyakara Marmas- causes loss of functionto the corresponding parts or organs when injured39.Acharya Vagbhata in Ashtanga hrudaya while describing about the divisions of kapha, has men-tioned about the properties and function of Sleshaka kapha. The kapha which resides in the sandhiesand which gives firmness to it is called as Sleshaka kapha40.Acharya Susrutha has also described about the Sleshaka kapha. He states that the kapha situated inthe joints, keeps them firmly united, protects their articulation. It opposes their separation and dis-union and also nourishes the sandhi41. 11
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Thigh bone Thigh Muscle Femur Quadriceps Protective sac Bursa Thigh muscle Knee cap Gastrocnemius Patella Bearing surface Knee ligament Femoral condyle Lig. patellac Knee ligament Cartilage Lateral meniscus Fibula Shin bone TibiaDiagram No. 1 Knee JointThe knee joint is a synovial joint of the condylar variety. It is a compound joint having two distinctarticualr surfaces on the medial and lateral condyles of the femur, for articulation with the corre-sponding surfaces on the medial and lateral condyles of the tiba. The anterior aspect of the lowerend of the femur articulates with the posterior aspect of the patella. The knee joint is complexbecause its cavity is partially divided into upper and lower parts by plates of cartilager called themedial and lateral menisci.The proximal articular suface covers the anterior, inferior and posterior aspects of the medial andlateral condyles of the femur. Anteriorly the medial and lateral articualr surfaces are contineous witheach other, but posteriorly they are separated by the intercondylar notch.The part of the femoralarticular surface situated on the anterior aspect of its lower end articulates wirth the patella. It isconcave from side to side and is subdivided by a vertical groove into a larger lateral part and a 12
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vatasmaller medial part. A small part of the inferior surface of the medial condyle, adjacent to theanterior part of the inter condylar notch comes in contact with the patella in extreme flexion of thejoint.The distal articular surface of the knee joint are present on the upper surfaces of the medial andlateral condyles of tibia. These surfaces are slightly concave centrally, and flat at the periphery,where they are covered by corresponding menisci.The posterior surface of pattela bears a large articular area for the femur. It is convex and is dividedby a ridge into a large lateral part and a small medial part. The attachment of the capsule of the kneejoint is complicated because of the presence of the patella anteriorly, and because of the fact thatanteriorly the capsule blends indistinguishably with the lower tendinous part of the quadriceps femo-ris muscles.Anteriorly below the pattela the capsule is replaced by the ligamentum patella.This ligament is at-tached above to the non articular lower part of the posterior surface of the patella and below to theupper smooth part of the tibal tuberocity.Posterior aspect of the capsule is strengthened by theoblique popletial ligament. The anterior cruciate ligament is attached below to the anterior part ofthe intercondylar area of the tibia.The posterior crusiate ligament is attached below to the posteriorpart of the inter condylar area of the tibia.The medial and lateral menisci of the knee joint are intra articular disk made of fibro cartilage. Theyhave a thick peripheral border and a thin inner border.The synovial membrane of the knee joint covers all the structures within the joint excepting thearticular surface and the surface of the menisci.It lines the inner side of the tendaneous expansion ofthe quadriceps femoris and some parts of the tibia and femur enclosed within the capsule. Justabove the patella the synovial membrane forms a pouch called the suprapatellar bursa. 13
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataThe arteries supplying the joint are the descending genicular,the genicular branch of popletial, thereccurent branches of anterior tibial,and the descending branches of the lateral circumflex femoralbranch of the arteria profunda femoris.The nerves are derived from the obturator, femoral,tibial and common peroneal nerves42.Muscles Producing The Movements of The Knee JointFlexion:-Biceps femoris,semitendinosus and semimembranosus, assisted by gracilis,sartorius andpopliteus.When the foot is on the ground , gastrocnemius and plantaris are capable of participatingin the movement .Extention :- Quadriceps femoris with some assistance from tensor fascia latae.Medial rotation of the flexed leg :- Popliteus, semimembranosus and semitendenosus, assistedsartorius and gracilisLateral rotation of the flexed leg :- Biceps femoris alone 43.Joints are surrounded by a membrane called the synovial membrane (synovium) , which froms acapsule around the ends of the bone involved. This membrane secretes a liquid called the synovialfluid . It has many functions , all of them important . Among these, it serves as a lubricant, a shockabsorber and a nutrient carrierAs a lubricant, it is without equal, when the joint is healthy. It makes the joint slicker than wet ice!.When our bodies can’t produce enough glucosamine and chondroitin, however, the normally thicksynovial fluid becomes thin and watery.In this state, it can’t do the job it was intended to do as alubricant .As a shock absorber, our cartilage, immersed in the synovial fluid, protects our bonesfrom the tremendous empact they would receive when we walk, run, jump, Etc. This fluid also asremarkable properties as a shock absorbing, or hydraulic, fluid. It belongs to a rather unusual groupof liquids known as dilatent liquids. These liquids are charecterized by the rare quality of becomingthicker, that is, more viscous, when shear is applied to them. Thus, the synovial fluid in our knees andhips assume a very viscous nature at the moment of shear in order to protect the joints, and then it 14
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata thins out again to its normal viscosity instantaneously to resume its lubricating function between shocks. All this happens over and over again, very rapidly, during the course of vigorous exercise, such as during an engagement in sports, dancing, walking,etc. When our bodies can’t produce enough glucosamine and chondroitin, this whole mechanism breaks down . The viscosity is dramati- cally reduced, giving thin, watery synovial fluid, which then fails as the shock absorber and lubricant it normally excels at. This results in the pain, stiffness and decreased mobility that characterize Osteoarthritis. Now we will dicuss the role of synovial fluid as a nutrient carrier. When we take knees ease, we get the building blocks needed to rebuild cartilage. Now we have to get those building blocks to the cartilage, so the re-building can take place. Cartilage it self is avascular, that is, it does not have any blood vessels. Hence , the synovial fluid is the liquid that must carry the raw materials from the blood to the cartilage. This can happen by a number of mechanisms. First, it can occur via diffusion, which is a rather slow process in this situation. A second and more efficient, process is convection , which is achieved through exercise. One way to visualize what happens in convection is to think of our cartilage as a sponge immersed in the synovial fluid. When we exercise our knee, for example , it is like repeatedly squeezing that sponge out in a bucket of synovial fluid . Another method of viewing convection would be as a pumping action produced by exercise, in which nutrient-containing syn- ovial fluid is constantly washing over the cartilage . In this way, our cartilage is constantly getting supplied by the nutrients (glucosamine/chondroitin)dissolved in our synovial fluid when we exercise our joints.44 1. A normal knee joint is never straight. It has on an aveage 7 degree varus.(Men: 3-5 degree, women 5-7 degree)2. It is a superficial joint and is more prone to injury.3. Though it is a hinge joint, slight rotation and side ward movement is possible in flexion of the knee45. 15
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataNIDANA OF SANDHIGATA VATAThe word nidana is derived from “NI-DHATU”, which carries the meaning to decide a problem.“Nishchayat vyadhianenethi nidanah”46According to the treatment point of view, knowlekge of hetu is important so as to enable the physi-cian to advice the patient to avoid the nidana.Madhava nidhana has clearly mentioned that nidana of all the diseases is due to the vititation ofmala47.Sandhigata vata is a disease caused by vata disorder and is included under the vatavyadhies by allAcharyas. There is not much difference in the case of the nidanas amoung the vata vyadhies. Thedifference is occurring mainly in the case of samprapti, ie;in all the vatavyadhies, vataprakopakaranasare almost same and the different forms of appearance like sandhigata vata,ghridrasy, pakshaghataetc, are only due to the samprapthi vishesha of visiated vata.1.Aharaja nidana:-Consumption of Aharas having vatika property causes vitiation of vata in the bodyRasas like tikta, katu, kashaya vitiates vata48.Aharas having tha gunas laghu, ruksha,sheeta vitiates vata49.The intake of particular dravya also increase vata. They are :-Koradusha, Shyamaka, Neevara , Mudga, Masura, Adhaki, Harenu, Kalaya, Nishpava, Chanaka,Jambu, Tinduka, Varaka, Uddalaka, Vishtambi and Virudhaka dravyas.The time and method of taking food is important. Abhojana, heenabhojana, shushkabhojana,trushitabhojana,kshutitambu pana etc visiates vatadosha. Adhyasana, vishamasana, pranitasana etcalso vitiates vata dosha. 16
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata2.Viharajanya nidana:-Ayurvedic classics have given important to proper vyayama. But if the vyayama is doing more,which cannot withstand the body , vata prakopa occurs. The viharas which vitiates vata areativyayama, atiprajagarana, plavana, atyadva, pradhavana, prataran, atyuchabhashana,bharaharana,dukhashayya, prapeetana, atiadhyayana, ativyavaya, srama, divaswapna, upavasa,abhighata, apastamsana, marmabhighata, atiraktasaranana, vegadharana, vishamopachara,dhatukshaya, rogatikarshana,etc.3.Manasika karana:-According to Acharyas mental factors like chinta, shoka, krodha, bhaya etc vitiate vata dosha.Direction of sence organs is one of the functions of manas and vata is said to be the controller andconductor of mind 50.Therefore, by above factors, the upset of mind and relatively as a consequence of it vataprakopa inthe indriyayatana as well as in the body is possible which simultaneously can produce the psychic aswell as the somatic disorders51.4. Age factor:-As per the Ayurvedic theories in the later stages of human life (old age ) vata will be predominant.52During this period eventhough there is a natural tendancy to visiate vata, due to vatakara aharavihara vataprakopa takes place there by causing kapha khaya in the body. Due to this process theSleshaka kapha situated in the sandhi does kshaya causing vataprakopa in the particular part. 17
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata5.Stoulya factor:-It is stated in Ayurvedic classics that stulas are more prone to diseases. Acharya Susrutha indicatethe relation between stoulya and vataroga. Dalhana made the comment on this aspect telling vatavikarais resulted due to the margavarodha produced by meda to vata53.6. Vyayama factor:-One of the main cause for dhatudshya is ativyayama which further leads to vatakopa . While ex-plaining about dosha gati Charaka has mentioned that ativyayama is responsible for displacement ofdoshas from koshta to shakha54.Vyayama is good for langhana, due to that it is included in the apatharpana chikitsa. In case ofsandhigata vata ativyayama causes vata vrudhi which leads to the Sleshaka kapha kshaya.7. Other nidans:-Some of the acharyas have described some general factors which help in the causation of thedisease. These factors are clearly told in the context of vata vikaras.a). Desha:- According to Ayurveda desha is divided into three depending up on the dosha predomi-nance. The desha where vata dosha is predominant is called as jagala desha55. Those who residesin these deshas will be having the predominance of respective doshas. This is the cause forperdominence of vata roga for those who stays in jangala desha when compared to other diseases.When considering the deha desha, it is divided into three depending upon the predominance ofeach dosha. Eventhough doshas are spreaded all over the body they are more concentrated in someparts .In the three divisions of body, urdhwanga, madhyamanga and adhoanga; adhoanga is the seatof vata. Here Sandhigata vata, a vatavyadhi appears in the adhoanga which is important factor forthis roga. 18
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vatab). Kala:- Kala is an important factor in the production of the disese, especially in ritusandhieschances of getting diseases are more. Vata kopa is more seen in night times. This is a clear indicationin the case of sandhigata vata because noctornal aching is a specific clinical symptom.Vata will alsoaggravate in the late stages of digestion, ie; after the completion of digestion56.Ayurveda has classi-fied the rithus into six.In these rithus each doshas has got their own involvement . Vata is havingnatural chaya in greeshma , kopa in varsha and shamana in sharat. So more vata vikaras can be seenin varsha rithu57.c). Prakruti:-Ayurveda is the only medical science which soundly mentioning about the individualPrakruti (consultution). It is the specific combination of doshas in a particular way during the fertili-zation of sperm and ovum in the early satges of an individual .Totally there are seven prakrities ,amoung these vata prakriti is considered as heena prakruti58. One who is born with the vata prakrutiwill be more susceptible for getting vatika diseases. Also if the vata prakriti person is having vatikavikaras, it will be very difficult for its cure59d).Vaya:- In all individuals life period, early stages will be predominant by Kapha, middle stage byPitta and the late by late by Vata.This is the cause for having Vata vikaras more in old ages. In themiddle age Pitta vikaras can be seen more and in childhood Kapha vikaras60.e). Satwam:- Satwam is considered as the capacity of the mind to withstand against things goingwrong . A person who is having a good satwabala will be easier for treating. Vagbhata while thepathachatushtaya mentions the qualities of rogi.He mentiones that the patient should be satwavan-having good satwa 61. Charaka states that people who are more susceptible to manodoshas likegrief, greed , ego, etc, will be more prone to the disease62.f).Satmyam:- Human body is composed of dosha, dhatu and malas. They got the ability to increaseand decrease for its vitiation .When the qualities which are equal to these, increases and which areopposite decreases . This is a general principle of nature63. Rooksha, lakhu, sheeta, etc are the 19
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vataqualities of vata. Tikta, katu,kashayas are the rasas causes vitation to Vata64. One who is consumingfood with all these above qualities regularly ie, if he becomes satmya, definitely vata will be vitiatingand further causes vata vyadhies. 65RISK FACTORS OF OSTEOARTHRITIS1.Age factor:-Age is the most powerful risk factor for OA. In a radiogrtaphic survey of women less than 45 yearsold , only 2% had OA. Between the ages of 45 to 64 years the prevalence was 30%, and thoseolder than 65 years it was 68%. In males the figures were similar but some what lower in the olderage group.Under the age group of 55 years , the joint distribution of OA in men and women is smilar .In olderindividuals hip OA is more common in men, while OA of interphalangeal joints and the thumb baseis more common in women . Similarly radiographic evidence of knee OA and , especially symptom-atic knee OA is more common in women than in men.2. Sex factor:- It is told that women are at high risk than men in developing OA, particularly aftermenopause. Most of the epidemiological studies suggest that hormone replacement therapy confersa protective effect on the development of knee and hip Osteoarthritis. The effects of sex hormoneson cartilage may vary with menopausal status and stage of Osteoarthritis.3. Hereditay factors:- The relation of heredity is less ambiguous. Thus, the mother and sister of awomen with distal interphalangeal joint OA (Herbeden’s node) are respectively twice and thrice aslikely to exhibit OA in these joints as the mother and sister of an unaffected women. Point mutationin the cDNA coding for articular cartilage collagen have been identified in families with chondrodys-plasia and pollyarticular secondary OA. 20
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata4. Race Factor:- Racial difference exists in both the prevalence of OA and th pattern of jointinvolvement .The Chinese in Hong kong have a lower incidense of hip OA than whites. OA is morefrequent in native americans than in whites. Interphalangeal joint OA and especially hip OA aremuch less common in South Africans blacks than in whites in the same population . Whether thesedifference are genetic or are due to difference in joint usage related to life style or occupation isunknown.5. Obesity factor:- Obese persons have a high risk of OA. For those in the highest quintile for bodymass index at base line examination , the relative risk for developing knee OA in the ensuing 36years was 1.5 for men and 2.1 for women. For severe knee OA, the relative risk rose to1.9 for menand 3.9 for women, suggesting that obesity plays an even larger role in the etiology of the mostserious cases of knee OA6.Occupational factor:- Repetitive movements may lead to excessive strain leading to erosion andjoint damage. Vocational activities such as those performed by jackhammer operators, cotton milland shipyard workers and coal miners may lead to OA in the joint exposed to repetitive occupa-tional use. Men whose jobs require knee bending and at least medium physical demand had ahigher rate of radiographic evidence of knee OA, and more server radographic changes, than menwhose jobs required neither.7. Traumatic factor:- Trauma to the joint seems to enhance the occurance of arthritis. It disturbs thealignment of the joints and over a period of time , this malalignment may lead to excessive wear andtear leading to arthritis. In both human and animal models, anterior cruciate ligament insufficiencyand meniscus damage lead to knee OA. Although damage to the articualr cartilage may occur at thetime of injury, with the use of affected joint, even normal cartilage will degenerate if the joint isunstable . A person with a trimaleolar fracture will almost certainly develop ankle OA. 21
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata8.Abnormal enzyme factor:-66 Though not conclusively proved , it is suspected that some abnormalenzyme released by the cartilage cells may lead to cartilage break down and joint distruction .From all the above nidana factors obesity factor, age factor,aharaja factor and viharaja factor soundspredominant . So nidna parivarjana should be done befor starting the treatment. Even nidanaparivarjana helps in relieving the disease in the early stages.PATHOLOGY67 The change in OA are usually seen in load – bearing areas of the articulare cartilage . In theearly stages the cartiage is thicker than normal but, with progression of OA, the joint surfaces thins,the cartilage softens, the integrity of the surface is breached and verical cleft develp deep cartilageulcers, extending to bone appear. Areas of fibrocartelagenous repair develop, but the repair tissue isinferior to pristine hyaline articualr carilage in its ability to withstand mechanical stress. All of thecartilage is metabolically active, and the chondrocytes replicate forming cluster. Later the cartilagebecomes hypocellular. Remodeling and hypertrophy of bone are also major feartures of OA. Appositional bonegrowth occurs in the subchondral region, leading to the bony sclerosis seen radiographically .Theabraded bone under a cartilage ulcer may take on the appearance of ivory . Growth of cartilage andbone at the joint margins leads to osteophytes, which alter the contour of the joint and may restrictmovement . Periarticular muscle wasting is common and may play a major role in symptoms and indisability. 68PATHOGENESIS:- The articular cartilage is an excellent shock absorber in terms of its bulk properties , at most itis only 1to2mm thick , too thin to serve as the sole shock-absorbing in the joint. Additional protec-tive mechanisms are provided by subchondral bone and periarticular muscles. 22
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataArticular cartilage serves two essential functions in the joint, both of which are mechanical. First itprovides remarkably smooth bearing surface , so that , with joint movement , the bones glide effort-lessly over each other. With sinovial fluid as lubricant , the coefficient of friction for cartilage rubbedagainst cartilage, even under physiological loading is 15 times lower than that of two ice cubespassed across each other. Secondly , the articualr cartilage prevents concentration of stress, so thebones do not shatter when the joint is loaded.Articular cartilage is composed of two major macromolecular species, proteoglycans (PGs), whichare responsible for the compressive stiffness of the tissue and its ability to withstand load, andcollagen , which provides tensile strength and resistance to shear. Although lysomalproteases(cathepsins) have been demonstrated with in the cells and matrix of normal articular carti-lage, their low pH optium makes it likely that the proteoglycanase activity of these anzymes will beconfined to an intracellular site or the immediate pericellular area. Cartilage also contains a family ofmatrix metalloproteinases(MMPs) including stromelysin, collagenase, and gelatinase which candegrade all the components of extracellular matrix at neutral pH. Each is secreated by thechondrocytes as a latent proenzyme that must be activated by proteolytic cleavage of its N- termi-nal sequence.The turn over of normal cartilage is effected through a degradative cascade, for which many inves-tigators consider the drive force to be interleukin (IL)1, a cytokine produced by mononuclear cells(including synovial lining cells) and synthesized by chondrocytes II- 1 stimulates the synthesis andsecretion of the latest MMPs and of tissue plasminogen activator. Plasminogen , the substrate for thelater enzyme , may be synthesized by the chondrocyte or mat enter the carilage from the synovialfluid. Both plasminogen and stromelysin may play a role in activation of the latent MMPs. In additionto its catabolic effect on cartilage , at concentration even lower than those needed to stimulatecartilage degradation, IL-1 supressess PG synthesis by the chondrocyte, inhibiting matrix repair. 23
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataThe balance of the system lies with at least two inhibitors, tissue inhibition of metalloproteinase(TIMP)and plasminogen acivator inhibitor1 (PAI 1) which are synthesized by the chondrocyte and limit thedegenerative activity of MMPs and plasminogen activator, respectively . If TOMP or PAI –1 isdestroyed or is present in concentrations that are insufficient relative to those of active enzymes,stromelysin and plasmin are free to act on matrix substrates. Stomelysin can degrade the proteincore of the PG and activate latent . Conversion of latent stromelysin to an active, highly destructiveprotenase by plasmin provides a second mechanism for matrix degradationPathophysiology of cartilage changes in OA, most investigators feel that the primary changes in OAbegin in the cartilage . A change in the arrangement and the size of the collagen fibers is apparent .The biochemical data are consistent with presence of a defect in the collagen network of the carti-lage, perhaps due to disruption of the glue that bind adjacent fibres together in the matrix . This isamong the earliest matrix changes observed and appeared to be irreversible. Although wear may be a factor in the loss of cartilage , strong evidence supports the con-cept that lysosomal enzyme and MMPs account for much of the loss of cartilage matrix in OA.Whether their synthesis and secretion are stimulated by IL-1or by other factors ,MMPs,plasmin,and cathepsins all appear to be involved in the bresk down of articular cartilage in OA .The IMPand PAI-1 may work to stabilize the system, at least temporarly , while growth factor such as IGF-1, TGF-b, and basic fibroblast growth factor (FGF), are implicated in repair process that may healthe lesion or , at least stabilize the process. The Chondrocytes in OA cartilage undergo active cell division and are very active meta-bolically, producing increased quantities of DNA, RNA ,collagen, PG and non collagenous pro-teins. Prior to cartilage loss and PG depletion, this marked biosynthetic activity may lead to anincrease in PG concentration, which may be associated with thickening of the cartilage and a stageof homeostasis refered to as “compensated” OA.These menchanisms may maintain the joint in areasonably functional state for years. The repair tissue however often does not hold up as well undermechanical stress as normal hyaline cartilage, and eventually, at least in some cses, the rate of PGsynthesis falls off and “end-stage” OA develops, with full thickness loss of cartilage. 24
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataPOORVAROOPA OF SANDHIGATA VATA Poorvaropa is the prodromal symptoms of a forthcoming disease, which do not clarify thepeculiarity of the dosha taking part in the samprapti of the disease. These symptoms will be few andnot clear69.According to Madhavanidana, Poorvaropa are the symptoms, which are produced during the pro-cess of sthanasamsraya by vitiated doshas, when samprapti has not been completed and diseasehas not been manifested70.Sandhigata vata being one of the vatavyadhi the Poorvaropa of vatavyadhis can be considered asthe Poorvaropa of Sandhigata vata. Here Acharyas are specifying that the unmanifested symptomsof the particular vatavyadhi should be considered as poorvaroopa.71 From the recorded data of the patients we can say that the poorvaroopa of Sandhigata vata ismanifested with guruthwa (heaviness of joints) occasional twinkling sensation and pain, which isignored by the patient and finally it, turns to rupavastha.Roopa: -When symptoms in the stage of poorvaroopa become fully or clearly manifested then these arecalled as Roopas. Samsthana, Vyanjana, linga, lakshana, china and akruti are the synonyms ofroopa72.The cardinal symptoms mentioned by Acharyas for Sandhigata vata are:1. Vata poorna druti sparsha (Air filled bag in touch)2. Sotha (Inflammation)3. Prasarana akunchana pravruthi vedana (Pain during flexion and extention of the joints)4. Sandhi soola(Joint pain)5. Atopa.(Crepitation) 1
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Table No.1Sl.No: Samhitha Lakshanas 1. Charaka Samhitha Vatapoorna druthi sparsha, sopha, Prasarana akunchana pravruthi vedana. 2. Ashtanga hrudaya Vatapoorna druthi sparsha, sopha, Prasarana akunchana pravruthi vedana. 3. Madhava nidana Sandhi soola, atopa 4. Susrutha Samhitha Sandhi soola, Sandhi sopha 5. Bhava prakasha Sandhi soola, Sandhi sopha 6. Gata nigraha Sandhi soola, Sandhi sopha 1.Vatapoorna druthi sparsha: - Charaka and Vagbhata have mentioned the typical characteristic of the sopha. The sopha resembles like an air filled bag in touch. Only these two Acharyas have mentioned about this specific character73. 2. Sopha: - All most all the Acharyas have mentioned about the presence of sopha in Sandhigata vata 74. 3. Prasarana akunchana vedana: - Acharyas have mentioned about the pain during the movement of the joint. In Sandhigata vata extension and flexion of the joints makes severe pain. This is specifically dealt by Charaka and Vagbhata75. 4. Sandhi soola: - In Sandhigata vata joint pain is mentioned by all the acharyas76. 3. Atopa: - This is the specific symptom of Sandhigata vata mentioned by Madhavacharya. It is the characteristic sound produced from the joints77. 2
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Upadrava: - (Complications) Upadrava is produced after the formation of the main disease and it is dependent on the main disease.Upadrava may be major or minor. Sandhigata vata – Osteoarthritis if becomes long standing will be having the complications like muscle wasting, varus deformity, intra articular loose bodies etc. This stage is very complicated one where the patient feels much difficulty in managing the daily routines. Symptoms of Osteoarthritis: - 78 1. Pain 2. Stiffness 3. Restricted range of joint movement 4. Swelling of the joint 5. Tenderness 6. Crepitation 1. Pain: - Joint pain in OA is often described as a deep ache and is localized to the involved joint. Typically the pain is aggravated by joint use and relieved by rest , but as the disease progresses , it may become persistent. Nocturnal pain interfering with sleep is also seen. 2. Stiffness :- Stiffness of the involved joint happens in the morning or after a period of inactivity.3.Restricted range of movements:- Due to the pain and stiffness the joint movements will be restricted and difficult. If there isloose bodies in a joint there will be locking or giving away of joints. 3
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata4. Swelling of the joint: - In the physical examination the joint may reveal soft tissue swelling and synovial effusions.Palpation may reveal some warmth over the joint.5. Tenderness:-Localized tenderness will be present during the physical examination.6.Crepitation:- Bony crepitus is a characteristic sign of OA. The growth of cartilage and bone at the jointmargins leads to osteophytes, which when comes into contact produces the Crepitation.Upashaya Anupashaya: -The judicious application of a) Drugs (oushadha) b) Diet (anna) and c) practices (vihara), prescribedjointly or severally either antagonistic 1) to the cause of the disease 2) to the disease itself or 3) to both,the cause and the disease, or similar to 4) the cause of the disease 5) to the disease or 6) to both, thecause and the disease, constitutes Upashaya when it produces relief in the symptoms and Anupashayawhen it aggravates the symptoms. It is a trial and error treatment79. Upashaya and anupashaya are very much important, especially during the treatment. Usuallydrugs having properties like unctuousness, ushna, etc are prescribed in vatavyadhi due to their efficacyto pacify the qualities of vata such as sheetatwa, roughness etc. This should be adopted only in thecondition of niramavastha of vatavyadhi, which helps in subsiding vata. This is the upashaya method.When the same drugs are prescribed in samavastha of vata vyadhi the disease aggravates causingcomplications. This is anupashaya. 4
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataSamprapti: -Ahara Virudhahara, Adhyasana, AgeernasanaVihara OccupationAbhighata InjuryOver weight Joint stressManasika karanaVayaVataprakruti VathaprakopaSex Blocking ofGenetic factor channels in sandhi Sthanasamsraya in sandhi Asthikshaya in sandhi Sleksha kapha kshaya/ Vyana vata kopa Sadhigata VataChart No.1 Schematic representation of Nidana and Samprapti of Sandhigata vata.Several etiological factors contributing to diseases and the vitiation of doshas attack the body everynow and then. Some of them can be avoided by adopting proper precautionary measures while somefactors like kala, deha etc are mostly inevitable. If the body’s power of resistance, vyadhikshamatwa ishigh and the dhatus, srotasas and agni are functioning well the body fights against the etiological factors 5
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vatasuccessfully, there by maintaining health. But if the etiological factors are stronger than the resistancepower of the body they vitiate the dosha and indirectly the dooshya also and the process of diseasestarts. All the stages from the very contact of the body with hetus to the development of the disease,including all its avasthas are together called the samprapti of the disease.Sandhigata vata being a vatavyadhi, for its samprapti, the samprapti of vatavyadhi should be consid-ered. Charaka mentions that due to the vatakara aharavihara vata vitiates and travels through the body.The vitiated vata finally enters and settles in srotamsi riktani resulting the production of different types ofvatavyadhis pertaining to the region80.Acharya charaka and vagbhata clearly state that dhatukshaya and margavarodha are the two causativefactors for vata vyadhi81. Acharya vagbhata clearly states that due to the intake of excessdhatukshayakara ahara and vihara or prolonged use, the srotasas become empty and the vata travelsthrough that srotasas. It fills the srotasas and due to the avarana by other doshas in the srotas the vatabecomes stronger and vitiation takes place82. . Acharya Charaka clearly states that the vayu, which isvitiated by its nidana and due to its respective sites different varieties of vatavyadhis, are produced83.While explaining the five divisions of vata by Vagbhata, Vyanavata one of the divisions of vata resides inthe heart and travels all over the body, helps in the functions like walking, body movements etc.84In Sandhigata vata the function of Vyanavata is affected, i.e.; difficulty in moving the joints. So it is clearthat in Sandhigata vata, which is one of the vatavyadhi vyanavayu vitiation is taking place.It is specifi-cally told by acharya Charaka that in nanathmaja vatavyadhis anubandha of pitta or kapha should beconsidered. Also specifies that the knowledge of it depends on the understanding of specific doshalakshanas85. 6
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataIt is mentioned that kapha helps in binding of the joints and maintaining its strength. In the specificproperties of Pancha kapha, sleshaka kapha is that resides in the Sandhi. It helps in proper binding ofthe joints86. By these statements it is clear that in the Sandhi, kapha is also important for it’s functioning.It is very important to discuss the changes happening during the dosha kshaya. The decreased doshasbecome incapable of performing their normal functions of the body. This state is manifested in the formof decreased activity of that particular dosha87.Acharya Charaka has clearly mentioned that when the kshaya of a particular dosha occurs, the qualitiesand functions natural to that dosha do not appear in the body. The are also reduced.88 According toVagbhata when kapha kshaya occurs lakshanas like bhrama, sleshmashayanam shunyatwam, hrudravaand sledhasandhi takes place. Here the slathasandhi is due to the kapha kshaya in the sandhi ie; sleshakakapha kshaya. So as per Acharyas references in Sandhigata vata vataprakopa, vyanavayu, and kaphakshaya, sleshaka kapha is taking place.1. Sankhya samprapti: - Only one variety of Sandhigata vata is mentioned.2. Vikalpa samprapti: - In Sandhigata vata increased vayu gunas like rooksha, laghu etc.3. Pradhanya samprapti: - Being one of the vatavyadhi vata pradhanata can be seen than other two.4. Bala samprapti: - As it is a vatavyadhi and mostly occurs in the vardhyakya kala the bala of the vyadhi will be more5.Kala samprapti: -In Sandhigata vata the pain and other symptoms aggravates at night, also this disease is seen in thevardhkya avasthas of an individual. 7
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataSamprapti Ghatakas:- Dosha – Vata; Vyanavata vrudhi Kapha; Sleshaka kapha kshaya Dushya – Asthi, Majja, Snayu Srotas - Asthi vaha, Majja vaha, Medo vaha, Mamsa vaha Agni - Jataragni, Dhatwagni Ama - Jataragnimandhya, Medagni mandhya, Asthyagni mandhya Roga marga – Madhyama Udbhavasthana – Pakwashaya Vyaktastana – Sandhi.The Chikitsa for Sandhigata vata should be nidana parivarjana and samprapti vighatana. The sampraptistage helps in the dosha dooshya sammorchana process. So for normalising these processes Chikitsa isdone.Sadhya sadhyata:-Before starting the treatment sadhyasadhyata is very much important. A physician who knows theavasthas of disease, whether it is curable or not or is difficult to cure by the lakshanas etc, can plan thetreatment accordingly which helps in fast recovery. So knowledge about sadhyasadhyata helps in thetreatment.Vatavyadhis are considered as one of the Mahagadhas by the Brihatrayees. The vatavyadhi, which isold and if the bala of the patient is decreased and that of vyadhi is high, wont respond to the treatment.Generally vatavyadhis are very difficult to cure due to the deep-seated nature of the disease. Sandhigatavata is one among the vatavyadhis, which usually occurs in the vardhakya kala, the kala which ispredominant of vata. Which is purana, having a long history, which originated in the jangala pradeshaand also that which is having a family history, will also be difficult in curing. So which comes under thesecategory can be called as asadhya. Due to this Acharya had mentioned that, for sandhigata vata thetreatment should be continuous due to its chronisity. 8
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataVyavachedaka Nidana: - Vyavachedaka nidana or differential diagnosis helps a physician to establish accurate diagnosisof the disease. This is a method to diagnose the particular disease by comparing its signs and symptomswith other similar diseases. Sandhigata vata is mainly a disease of the bony joints. So virtually every disease thateffects the joints enters into the differential diagnosis of Sandhigata vata. The most common differentia-tion that has to be made is between Sandhigata vata, vatarakta, amavata and kroshtuka sheersha. Sandhigata vata is the disease, which appears during the age of vata predominance i.e.; on thelast third of one’s life. This is the age where, the bala of all dhatus gradually decreases due to the gradualdeterioration of the nourishing capacity of rasadhatu89. So also the concurrent deterioration in thevyadhikshamatwa shakthi. This condition is also due to the action of vata, which is by itself capable ofemaciating all dhatus. Even if the individual is enjoying an apparent health, the effects of old age begin toshow in the weight – bearing joints, because of the gradual loss of both in the physical strength and inthe vyadhikshamatwa shakthi. In view of asrayasrayee bhava, particularly between Asthi and Vata90the effect is more pronounced on the bones of the affected joints . It should also be noted that thedisease, Sandhigata vata is mainly a vata vikara so it will be having the similar characters of other vatikarogas, which affects on the sandhi. The most common joint affected is the knee joint. But other jointsmay also be affected depending up on the wear and tear due to the excessive use. Erosion and degen-eration of the cartilage and bone in the joints are the commonest lesion. Because of the almost opposingqualities of vata and kapha, the sleshaka kapha of the joints suffers considerably leading to the loss ofintegrity of the joint affected. 9
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataDetailed Vyavachedaka nidana of sandhigata vata and other related diseases are given below in thetable. Table No. 2 showing Vyavachedaka nidana of sandhigata vata and vatarakta Sandhigata vata Vatarakta 1. Nidana Vatakara ahara vihara Vidahi virudaha raktakopanahara, Vidiheena swapnajagara mythuna Abhighata, ashudha shareera, etc 2. Poorvaroopa Vatakopa lakshanas Kushta sama , sada , sladhangata sandhishu kandu sfuranam, bhutwa b h u t w apranashyanti -muhur avirbhavanti. 3. Roopa Sandhi soola Prasarana Teewra ruja akunchana vedana Sandhi sopha Vatapoorna druti sparsha Gradhita paki swayadhu 4. Ahishtana Sandhi Padamoola, hastha moola 5. Doshas Vata Vata , raktha 6. Upashaya Ushna, snigdha Sheetha 10
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Table No. 3 showing Vyavachedaka nidana of sandhigata vata and amavata Sandhigata vata Amavata1. Nidana Vatakara ahara vihara Virudhahara cheshta2. Poorvaroopa Vatakopa lakshanas Hrudaya dowrbalya gowrava3. Roopa Sandhisoola Prasarana Vruschika damshtravat soola akunchana vedana Sandhi sophaVatapoorna druti sparsha Pidaka yukt sopha4. Adhishtana Sandhi Hasta , pata , shira , gulpha, trika , janu , uru sandhies5. Dosha Vata Kapha , vata6. Upashaya Ushna, snigdha Rooksha, ushnaTable 4 showing Vyavachedaka nidana of sandhigata vata and kroshtuka sheersha Sandhigata vata Kroshtuka sheersha 1. Nidana Vatakara ahara vihara Vatakara aharavihara 2. Poorvaroopa Vatakopa lakshanas Vata kopa lakshanas 3. Roopa Sandhi soola Prasarana akunchana vedana Maharuja Sandhi sophaVatapoorna druti sparsha Janu Sopha 4. Adhishtana Sandhi Janu madhya 5. Dosha Vata Vata, raktha 6. Upashaya Ushna, snigdha Snigdha, sheeta 11
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Table No. 5 showing differential diagnosis of Osteoarthritis and Rheumatoid arthritis Osteoarthritis Rheumatoid arthritis1. Symptoms Pain and swelling on major Inflammation in multiple joints Weight bearing Joints, smaller joints more involved, crepitation, tenderness, morning stiffness, pain. enlargement of joint space.2. Mode of own set Gradual Abrupt3. Joints involved Weight bearing joints Mostly smaller joints4.Systemic features Auto immune disease,rise in temperature, anemia, etc5. Investigations RA- ve , ESR normal usually, ESR raised,RA+ve, X ray Narrowing of joint space, X Ray soft tissue swelling Subchondral bony sclerosis, Narrowing of joint space, osteophytes etc. Subchondral sclerosis.Table No. 6. showing differential diagnosis of Osteoarthritis and Gout Osteoarthritis Gout1. Symptoms: Pain and swelling on major Polyarticular pain, Weight bearing Joints, swelling and inflammation, crepitation, tenderness Limited movement of joint with enlargement of joint space warmth redness, and exquisite tenderness2. Mode of onset Gradual Acute3. Joints involved Weight bearing joints Metatarsophalangeal joints involved mostly4. Systemic features5. Investigations RA- ve, ESR normal usually, Serum uric acid increased Xray Narrowing of joint space. X Ray – punched out lesions in Subchondral bony sclerosis, subchondral bone. osteophytes etc. 12
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Table No.7 showing differential diagnosis of Osteoarthritis and tubercular arthritis Osteoarthritis Tubercular arthritis1. Symptoms: Pain and swelling on major Restricted movements in all Weight bearing Joints Crepitation, direction with tenderness positive muscle spasm. Enlargement of joint space2. Mode of onset Gradual Insidious Onset3 . Joints involved Weight bearing joints Single Large Joint4. Systemic features Weight loss, anorexia, malaise, high sweat5 . Investigations RA- ve , ESR normal usually, Montoux test +ve,High ESR , Xray Narrowing of joint space. Microbacterium tuberculosis Subchondral bony sclerosis, from aspirated fluid biopsy osteophytes etc. of lymph node. Table No.8 showing differential diagnosis of Osteoarthritis and Gonococcal arthritis Osteoarthritis Gonococcal arthritis1.Symptoms: Pain and swelling on major Severe pain, macular, vesicular, weight bearing Joints, crepitation or pustular rashes enlargement of joint space, tenderness2. Mode of onset Gradual Acute3. Joints involved Weight bearing joints Asymmetrical , Polyarticular4. Systemic features Fever5. Investigations RA-ve, ESR normal usually, Synovial fluid, blood, skin lesion cultures. Xray Narrowing of joint space. 13
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Table No.9 showing differential diagnosis of Osteoarthritis and Rheumatic fever Osteoarthritis Rheumatic fever 1. Symptoms Pain and swelling on major Painful and tender joints, Pain weight bearing joints, shifting in nature crepitation,tenderness, enlargement of joint space. 2. Mode of onset Gradual Acute 3. Joints involved Weight bearing joints Poly articular 4. Systemic features Carditis, fever, chorea 5. Investigations RA-ve , ESR normal usually, ESR raised , C-reactive protein high, Xray narrowing of joint space, WBC elevated. subchondral bony sclerosis, osteophytes etc.InvestigationsLab Investigations:- Usually in primary OA the ESR may be normal or slightly accelerated. Anemia and leukocyto-sis are absent . Rheumatic factor studies are absent . Synovial fluid analysis reveals minimal abnormali-ties useful in the differential diagnosis. Viscosity is good and mucin clot formation with glacial aceticacid is normal. Slight increases in cell count are noted91. 14
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata X-Ray reveals: - Loss of joint space (Due to destruction of articular cartilage) Sclerosis (Due to increased cellularity and bone deposition) Subchondral cyst (due to synovial fluid intrusion into the bone) Osteophytes (Due to revascularisation of remaining cartilage and capsular traction ) Bony collapse (Due to compression of weakened bone) Loose bodies (Due to fragmentation of osteochondral surface) Deformity and malalignment (Due to destruction of capsules and ligaments. Bone Scan shows increased up take of technetium – 99m, MRI and CT scan alsohelps to diagnose Subchondral cyst, Osteophytes, etc92. 15
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataCHIKITSAThe word Chikitsa was derived from the root word ‘KITH’. It means to cure the disease93. Chikitsais also called as the kriya done against roga94.Chikitsa is the kriya done for vyadhiharana95.Charaka states that Chikitsa is not only removing the causative factor of the disease but also to bringback the equellibrium of doshas96.Sandhigata vata is a vatavyadhi. Vata vyadhies are occurred due to dhatukshaya or avarana97.In the aspect of Chikitsa the line of treatment of vatavyadhi is the use of Sarpi, Taila, Vasa, Majja, andtreatments like Seka, Abhyanga and Vasthi are indicated by Charaka98.In Pancha karma Vasthi is told as important treatment for vata vyadhies. It is also told as sampoornaChikitsa99.Other treatments are vatahara oushadhas, ahara and vihara.88Principles of treatment : -Our Acharyas have designed a particular treatmant for a particular disease, which is clearly known asChikitsa sidhanta. In this disease, Susrutha has more emphasised the treatments like local applicationslike, dahana, agnikarma, etc rather than the internal medication.Acharya Susrutha has clearly mentioned the treatment for Sandhigata vata. He states that for vata,which vitiates in the sandhi should do snehana, upanahana, agnikarma, bandhana and mardana100.In other classics like Ashtanga hrudaya, Chakradatta, Bhavaprakasha, Bhaishajyaratnavalli,Yogaratnakara, etc, the treatment principles of Susrutha had been adopted for sandhigata vata101. 16
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataAmong all Acharyas Susrutha only mentioned the specific line of treatment for sandhigata vata. Herethe treatments mentioned by Susrutha will be discused in detail.1.Snehana: -The qualities of sneha is drava, sukshma, sara, snigdha, pichila, guru, sheetala, manda and mrudu. Allmost all these qualities are just opposite to Vata properties. So by the theory opposite qualities sub-sides and similar qualities increasees, these above qualities will defenitely pacify Vata.Snehas are divided into two; Bahya and Abhyantara.Abhyantara are Bhojana, Pana, Nasya andVasthi.Bahyasnehas are Abhyanga, Lepa, Mardana, Udvartana, Samvahana, Murthithaila, Gandoosha,Karnapoorana, Akshitarpana, Parisheka and Pichu102.Snehana is the first line of treatment in vatavyadhies. In vatavyadhies, dhatus gets dried and becomesatrophy. Snehana nourishes the dhatus as well as does balavardhana (strengthens) and agnivardhana(proper digestion)103. One who is adopting snehana in the right manner will be having good jataragni,koshtashudhi, nourished dhatus, good bala and varna, jidendriya, devoid of premature ageing andeven he lives for hundred years. These are the gunas of snehana are according to acharya Vagbhata104.In the treatment of sandhigata vata Acharya Dalhana states that both bahya and abhyantara snehasshould be administered105.2. Upanahana: -Upanahana is a type of swedana. Charaka has mentioned about the eligible persons for swedana. Inpersons who are having shula in janu pradesha and in sopha also this type of sweda can be done106.Charaka has described Upanahana as a variety of Swedana107. 17
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataSusrutha acharya has described and divided sweda into four groups and in that he has told about theupanaha sweda. It is a kind of sweda done by applying herbal paste over the affected part and tiedwith a cloth108. The dravyas, which used for bandhana should be the leather of ushnaveerya animals asper Charaka. If it is not available silk cloth or woolen cloth can also be used109.In vatavyadhi Charakamentions that for upanaha kriya eranda patra can be used110.Vagbhata is having the opinion that vataharapatras should be used for upanahana111. Charaka while explaining vatavyadhi chikitsa says that thedrug which are mixed with snehana should be used for upanahana karma112. Susrutha mentions thatvatahara drug’s roots should be made into a paste with kanji in that saindhavalavana and sneha shouldbe mixed to form a paste. The paste should be heated and applied in the affected parts. 113. Theduration of upanahana is mentioned as, that which is tied in the morning should be removed in the nightand that which tied in the night should remove in the morning114.3. Bandhana: -Upanaha sweda is divided into three by Susrutha.They are pradeha , sankara and bandhana. In thebandhana sweda the upanaha dravyas are tied into the affected part and there by the action of themedicine is attained115.4. Mardana: -Mardana is usually done in vatavyadhis .It is a form of bahya sneha by applying oil externally andmassage is done by gentle pressure. This helps the oil to absorb and improves the blood circulationand lymph drainage from the part.5. Agnikarma: -Agnikarma is a surgical procedure, so it is clearly mentioned by Acharya Susrutha. He states thatagnikarma is of twagdagda, mamsadagda, siradagda, snayudagda, and sandhidagda116. According toDalhana in sira, snayu, asthi and sandhi vikaras even dahanakarma of mamsa itself gives good relief.117 . 18
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataSusrutha states that when vitiation of twak, mamsa, sira, snayu, asthi and sandhies by vata, whichcauses chronic pain, agnikarma gives a good relief.The materials used for agnikarma are pippali, ajashakrut, godanta, shara, jambavoshtila, kshoudraand guda. Acharya specifically tells that kshoudra and sneha should be used in sira, snayu, sandhi andasthigata vayu. The above-mentioned procedures are the specific line of treatment adopted by AcharyaSusrutha.VASTHI: -Vasthi is the procedure of introducing medical recipes in the form of decoction, oil etc.. through rectal,vaginal or urethral route and evacuating it to produce the effect of introduced medicaments.Vasthi isone among the panchakarmas and it has given much importance in vatavyadhi Chikitsa due to itsability to pacify vata. Charaka has told Vasthi as balavardhaka, sughopacharyam, srishtapureeshakritsugham, brihmanam and vatanashanam118. According to Ashtanga hrudaya, Vasthi is important invatadhika samsarga sannipata diseases as kevalavatavyadhi. It is the best treatment than any othertreatments for vata vitiation119 Vata is the cause for vitiation of other dosha so that vata is consideredas sarvarogakaraka. For this vitiated vata the only remedy to pacify it is Vasthi. So it is mentioned thatif we are taking all the treatments, half the treatment is by Vasthi. Also some says that even all thetreatments is depending on Vasthi i.e. Vasthi can even cure the diseases where all other treatmentmethods failed120.Vasthi though administered, have wide systemic action. It is likened to the cutting of the roots of a treeresults in the automatic destruction of the trunk, branches, sprouts, flowers, fruits, leaves etc.121Vasthi is of three kinds – nirooha, anuvasana and uttaravasthi.122 . Nirooha is also known as asthapanavasthi, administered through the rectum making use of decoction of drugs mainly. 19
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataAnuvasana means that which remains in the body for some time without causing any harm. It is alsoknown as sneha vasthi. It is administered through the rectum, making use of medicated oil to alleviatevata and to nourish.Uttara vasthi is administered through vaginal and urethral passages. Decoction of drugs and medicatedoil are made use for this.Vasthikarma the method of administration of medical recipes into pakvashaya finds a top place amongthe panchakarma. Since it produces shodhana of doshas, samshamana of disease, samgrahana ofmalas and so many other karmas at one stroke. As vasthi is composed of various kinds of medicaldrugs including snehana, kashaya etc, it eliminates the prakupita doshas and it stabilizes the chayajadoshas which increased in its own site123.Vata is the motive force behind the functions like elimination or retention of pureesha, mootra, pitta andother malas in their respective sites. It is the main etiological factor in the manifestation of diseasespertaining to sakha, koshta, marmas, urdwanga, and various organs of the whole body. There is nobetter remedy other than the vasthi in alleviation of vata, which vitiated excessively. Due to this AcharyaCharaka praises vasthi Chikitsa as half of the Chikitsa124. 20
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataShamanoushadhies in Sandhigata vata :-Kwatha125 : Maharasnadi Kwatha Dhanwantaram Kwatha Sahacharadi KwathaKalka : Takaramoola kalka with takra126Choorna : Alambushadya Choorna127 Abhadi Choorna128Vati : Ajamodadi vati129Guggulu preparations: Kaisora guggulu 130 Yogaraja guggulu130 Brihat Yogaraja guggulu132 Trayodashanga guggulu133 Adityapake guggulu 134 Simhanada guggulu 135Rasoushadi : Panchananarasa louha136 Vatarakshasa rasa137Sneha: 1. Dhanwatharam Thailam138 2. Phalatrikadi Sneha139 3. Majja Sneha140 4. Prasarani Thailam 141 5. Sidhartha Thailam 142 6. Nakula Thailam 143 21
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataPathyaapathya:-Treatment is nidana privargana and samprpti vighatana. So for nidana parivarjana pathyapathya isvery essential. Pathya id termed as ahara and vihara, which prevents the aggravation of the diseaseand helps in curing the disease without any side effects. Charaka already states that pathya is thatwhich is suitable to the body and mind during healthy and in diseased conditin. Sandhigata vata beinga vatavyadhi the samanya vatavyadhi pathyapathya should be adopted for itPATHYAAhara1. Rasavarga - madhura, amla , lavana2. Shukadhanya varga - naveena godhuma, sali samvatsarothitha, rakthasali, shashtikasali3. Shimbi varga - naveena tila, naveena masha, kulatha,4. Shaka varga - patola, shigru, vartaka, lasuna,5. Phala varga - draksha, pakwamra, parushaka, jambeera, dadima, pakvatala phala6. Mamsa varga - ushtra, go, varaha, mahisha, mayura, bheka, nakula, chataka, kukkuta, tittira,sheelindra, kurma, rohita etc.7. Jalavarga - ushna jala, shritasheetala jala, nalrikela jala8. Dugdha varga - go, aja, dadhi, ghritha, kilata, kurchila9. Mutra varga - gomutra10. Madhya - dhanyamla, sura11. Sneha - tila, ghritha, vasa, majjaViharaBhushayya, snana, samvahana, etc. 22
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataAPATHYA: -Ahara: -1. Rasa – Katu, tiktha, kashaya2. Shimbi dhanya – Rajamasha, nishpara, mudga, kalaya3. Shuka dhanya – Trunya dhanya, trunaka, kangu, koradhusha, neevara, shamaka, chanaka4. Phalavarga – Jambu, udumbara, kramuka, tinduka5. Mamsa varga – Suska mamsa, kapotha, pravata6. Jalavarga – Sheetambu, tadajala7. Ksheera – Gardhaba ksheeraVihara: -1. Manasa – Chinta, shooka, bahya2. Shareerika – jagarana, shrama, vyavaya,vyayama,chankramana, vegadharana, etc.Now a days due to the change of life style and culture, people are exposed to modernised foodstuffs.This does a severe impact especially to Sandhigata vata patients. So following are some foodstuffsand activities, which should and shouldn’t take in this modern era.Food :–Can be taken : - Orange juice, carrot, all fibrous fruits and ceratinoids.Should be avoided – Fast foods, cold beverages, and liquor.Activities: -Should do – Slight walking, slight swimming, steam bath, etc.Shouldn’t do- Long standing and sitting , automobile driving , staying in A.C,etc. 23
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 144Management Of Osteoarthritis :-Treatment of Osteoarthritis is aimed at reducing pain, maintaining mobility and minimizing disability .Thevigor of the therapeutic intervention should be detected by the severity of the condition in the individualpatient. For those with only mild disease, reassurance, instruction in joint protection and an occasionalanalgesic may be all required .For those with severe OA a comprehensive program comprising aspectrum of non pharmacological measures supplemented by an analgesic or anti inflammatory drug isappropriate.Non-pharmacological measure, reduction of joint loading, correction of poor posture, and a supportfor excessive lumbar lordosis can be helpful. Patients with OA of knee or hip should avoid prolongedstanding, kneeling and squatting. Obese patients should be counseled to lose weight.Rest periods during the day may be helpful. But complete immobilization of the painful joint is rarelyindicated. In patients with unilateral OA of the hip or knee, a cane held in the contra lateral hand mayreduce joint pain by reducing the joint contact force. Bilateral disease may necessitate use of crutchesor a walker.Physical therapy, application of heat to the joint may reduce pain and stiffness. A hot water shower isalso preferable. Occasionally a better analgesia may be obtained with ice than with heat.Drug therapy of OA today is palliative, no pharmacologic agent has been shown to prevent, delay theprogression of or reverse the pathologic changes of OA in humans.Intra or periarticular injection of a depot gluco corticoid preparation may provide marked symptomaticrelief for weeks to months. Because studies in animal models have suggested that glucocorticoids mayproduce cartilage damage, and frequent injection of large amounts of steroids have been associatedwith joint breakdown in humans, the injection should generally not be repeated in a given joint moreoften than every 4 – 6 months. 24
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataJoint replacement surgery should be reversed for patients with advanced OA in whom aggressivemedical management has failed. Osteotomy, which is surgically more conservative, can eliminate con-centrations of peak dynamic loading and may provide effective pain relief in patients with hip or kneeOA. Arthroscopic removal of loose cartilage fragments can prevent locking and relieve pain. Chondro-plasty also has some popularity as treatment for OA, but well controlled studies of its efficacy arelacking.Internal Medication145:-Indomethacin tab - 25 Mg. 2-3 times dailyPiroxicam tab - 10-30 Mg. DailyIbuprofen tab - 1.2 -1.8 g/day in 3-4 divided doses after food.Diclofenac tab - 50 Mg. bidNimesulide tab - 100-200 Mg. bid.Rehabilitation146: - Simple changes around the home and daily activities cause dramatic improvement in the symptoma- tology of Osteoarthritis. a) Use of higher chair, which require less effort to get in and get out, should be considered. b) Patients are advised to limb the stairs leading the good leg taking one stair at a time and to descent the stairs leading with the bad leg, again taking one stair at a time. c) To reduce the force acting across the injured joint patient is advised to use a walking stick, which acts as a third limb. The stick should be held in the hand opposite to the affected part. A walking stick, by providing a third limb through which forces can be transmitted, enables the reduction of force across the injured joint. d) Footwear with hard soles and high heels should be avoided. e) Mental and physical support from the family members will be useful in the rehabilitation of the patient. 25
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Exercises147: - Mainly two types of exercises are mentioned. They are flexibility exercise and strengthening exercise. Flexibility exercise – Sit in a chair and rest the foot on another chair, then gently press the knee towards the floor. Strengthening exercise – To strengthen the knee straight the leg and press the knee on to the bed, hold for 6 seconds, repeat 5-10 times. YogaYoga is the one of the ancient science of our land, which inter relates with our culture. Its practises indaily lifes restores the health and relief to disease. The Asanas which give relief to Arthritis is thePavanamukthasana. These Asanas are very easy to practise and help him relieving stress by looseningthe joints148. 26
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Drug Review: - This study is a comparative clinical study of the Ayurvedic drug Rasnapanchaka Guggulu as trial drugwith the Modern standard drug Nimesulide tab as control drug. Here a detailed and separate descrip-tion of the individual drugs is going to mention.Trial Drug :The trial drug is the Rasnapanchaka Guggulu. Rasnapanchaka is a combination of five drugs which ismentioned in the Sahasrayoga in the context of vata vitiated in sandhi, Asthi and Majja149. Along withthis guggulu is added and is administered.Criteria for selection of this drug: - . The composition of this drug is purely herbal . There is no known toxicity or allergy or drug incompatibility was found. . It is easily available in the local market. . There is no controversy in identifying the drug. . Easy to manufacture and to make the capsule. . The cost of the capsules are less. . There is unique and no any clinical study conducted with this composition. 27
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 150Detailed description of each drug in Rasnapanchaka Guggulu :- 1.RASNA: - Botanical name – Alpinia galanga Family - Zingeberacea Synonyms - Sugandha , Kulanjana Hindi – kalijan Kannada - Doddarasagadde Malayalam - Chittaratha Tamil - Perarathai Oriya - Rasna Habitat - Bengal ,Bihar , Madhya pradesh , Kashmir , Himalaya , etc.Description - This is a perennial , aromatic, rhizomatous herb , 1.8 – 2.1 m in height ; leaves oblonge –lanceolate , glabrous , acuminate , very shortly petioled , ligule short, rounded , ciliate ; flowers fragrant, greenish white with red veined lips , in dense panicles ; fruits capsules orange red when ripe.Parts used - RhizomesProperties : Rasa - tikta, katu Guna - guru Veerya - ushna Vipaka - katu Dosha karma - kapha vata hara 28
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataChemical composition - It consists of campheride , galangin and alpenin . It contains an volatile oil,cosists of methyle cinnamate, cineole , camphor and pinene . It also contains oily pungent galangol ,alpinol , galangin and di-oxyflavanol . Oushadha Guna - Deepana, pachana, amahara, kaphavata roga shamana, vedanasthapana,shwasaghna, kasaghna, vishaghna.Ganas - Vedanasthapana, anuvasanopaka, vayasthapana, arkadigana.Therapeutic Uses- Used for vata shamana, vedanashamana, kasa, swasa, vatarakta, jwara, vishagnaand rasayana. 29
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata2. AMRUTHA:- Botanical name - Tinospora cordifolia Family - Menispermaceae Synonyms - Guduchi , chinnaruha , bhishakpriya , etc. Hindi - Gulanca, giloy , amrta . Kannada - Amrtaballi , yuganiballi Malayalam - chittamrthu Tamil - Amurutavalli , cintilikkoti . Oriya - Guduchi Habitat - Throughout India in forests.Description - A large extensively spreading glabrous , perennial deciduous twinnerwith succulent stems and papery bark ; leaves simple , alternate , cordate , entire , glabrous , 7 – 9nerved ; flowers yellow in lax recemes , arising from nodes on the old wood , male flowers in cluster ,female flowers usually solitary ; fruits drupes , red when ripe . The surface of stem appears to be closelystudded with warty tubercles and the surface skin is longitudinally fissured. On removal of the surfaceskin the dark greenish mucilaginous stem is seen. Parts used - Stem, root, leaves. Properties - Rasa - tikta, katu Guna - laghu, snigdha Veerya - ushna Vipaka - madhura Dosha karma - tridosha shamana 30
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataChemical composition - It consists of tinosporin , tinosporide , tinosporaride, cardifolide, cardifol,leptacosanol , clerodanefuranoditerpene , diterpenoid furanolactone tinosporidine, columbin , etc.Oushadha guna - Jwaraghna , rakta shodhaka , grahi , deepana , dhatupushtikara rasayana .Ganas - Vayasthapana , dahaprashamana , tripthighna , trishnanigrahana , guduchyadi , patoladi ,kakolyadi .Therapeutic Uses - Used in jwara , vatarakta , trishna , chardi , kushta , amavata , rasayana. 31
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata3. ERANDA :- Botanical name - Ricinus communis Family - Euphorbiaceae Synonyms - Gandharvahastha , panchangula , vatari Hindi - erandi , erand Kannada - haralu , manda , oudla Malayalam - avanakku Tamil - erandamu , amudamu Oriya - Jada Habitat - Throughout IndiaDescription - A perennial , bushy , soft-wooded small tree with a thin greyish brown bark ; leavespalmately lobed with seven or more serrate lobes , paniculate recemes with crowded male flowers onthe upper half of the inflorescence and the pistillate at the basal half , sometimes a few pistillate flowersat the top also ; fruits globose , explosively dehiscent , 3-seeded capsules , when young it is green andcovered with fleshy prickles; seeds oblong with smooth , hard mottled crustaceous testa with a whitecaruncle at the top enclosing oily and fleshy endosperm. Parts used - Roots , leaves , flowers , seeds , oil. Properties - Rasa - madhura , katu , kashaya Guna - guru , snigdha , teekshna , sookshma Veerya - ushna Vipaka - madhura Dosha karma - tridosha shamana 32
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Chemical composition - The seed contains 40 – 52 % oil , 20% protein , 10% sugar , 1%carbohydrate .It contain triglyceride of ricinoleic acid ( about 80% ). Other glycerides are also presentin the drug , where the fatty acids are represented by isoricimoleic , linoleic , stearic and isostearic acid. Oushadha Guna – virechana kara , suklashodhaneeya , vatahara , vedanasthapana , shophaghna ,deepana , krimighna , medhya and mootrashodhaneeya . Ganas - Bhedaneeya , angamardaprashamana , vidareegandhadi , vatashamana .Therapeutic Uses - Moola - vatashamana , vasthi karma Juice of leaves - kamala Taila - virechana 33
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 4. Devadara :- Botanical name - Cedrus deodara Family - Pinaceae Synonyms - Bhadradaru , indradaru , bhutari Hindi - debdar , deyodar Kannada - devadaru Malayalam - devataram Tamil - devataram Oriya - devadarus Habitat - Himalayas , in the areas of elevation from 1,050 – 3,600m. Description - A large handsome evergreen conifer tree reaching up to 85m in height , with almostrough , black , furrowed bark and spreading branches ; shoots dimorphic ; leaves needle like , trique-trous , sharp , pointed ; male cone solitary , cylindric at the ends of branchlets , composed of imbricat-ing thin woody placental scales ; seeds pale brown , wings longer than the seeds. The heart wood is light yellowish brown , turning brown on exposure. It is oily fragrant andstrong.Parts used - Leaves , heart wood , oil Properties -Rasa - katu , tikthaGuna - laghu snigdha , teekshnaVeerya - ushnaVipaka - katuDosha karma - vata kapha shamana 34
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataChemical composition - It is having a reddish oil which consists of sesquiterpineOushadha guna - Shopha hara ,Tantra hikka jwara hara, Pramehahara , Pinasa kasa hara, Kandu hara , Raktadosha hara etc. Ganas - Sthanyashodhana , Anuvasanopaka , Vatashamana Uses - Sthanya shodhana , Swedajanana , Vedanashamaka , Kushtaghna , Jwaraghna , Krimighna , Medorogahara . Therapeutic Uses - Sthanya sodhana, Swedajanana, Vedanashamaka, Kushtaghna 35
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata5.Nagara :- Botanical name - Zingiber officinale Family - Zingiberaceae Synonyms - Shunti , nagara , vishwa bheshaja , ushna , etc. Hindi - soth Kannada - sunti Malayalam - chukku Tamil - Chukku Oriya - ShunthisHabitat - Mostly seen in southern states of India, Bengal, Punjab etc.Description - It is a rhizome, growing under the ground.Parts used - stemProperties - Rasa - katu Guna - laghu, snigdha Virya - ushna Vipaka - madhura Doshakarma - kapha vata shamana Chemical composition - It consists of volatile oil (1-4%) starch (40-60%) fat (10%) protein(10%)Fibre (5%) inorganic materials (6%) residual moisture (10%). It includes Alpha – zingiberene , Beta –bisabolene , Alpha – farnesene , Beta – sequiphellandrene and ar-curcumene , phenolic ketones ofoleo-resene include gingeroles like shogaols , zingerone , paradols , gingediols , hexa hydrocurcuminand also o-methyl ethers of these compounds. 36
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Oushadha Guna - Swarya , Vrushya , Shula hara , Kasa hara , Sleepada hara , Shopha hara ,Udara hara,etc. Ganas - Triptighna , arshoghna , depaneeya , shoola prashamana , trishnanigrahana , pippalyadi ,trikatu , panchakola.Therapeutics Uses – Kasa, swasa , shopha , ajeerna , udara , arsha , shoola and amavata. 37
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata6.Guggulu: - Botanical name - commiphora mukul Family - Burseraceae Synonyms - Amisha , Mahishasha , Devadhoopa , Kumbhee Hindi - Gugal Kannada - Guggulu Malayalam - Gulgulu Tamil - Gukkulu Oriya - Gugul Habitat – In arid rocky tracks of Rajputana , Bellari , Mysore , Sindh and Baluchistan Description – A small armed tree with spinescent branches and ash-colored rough bark, peel-ing off in flakes, young parts glandular, pubescent; leaves alternate, 1-3 foliate, obovate , serrate –toothed in the upper parts , lateral leaflets when present only less than half the size of the terminal ones; flowers small , brownish red , polygamous in fascicle ; stamens 8-10 , alternately long and short ; fruitsavoid drupes , red when ripe. Guggul of commerce is the pale yellow or brown aromatic gum resin obtained from the bark.The gum resin consists of irregular roundish masses of various sizes. It is opaque, reddish brown incolor and has a dusty surface. Parts used - Resinous gum 38
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Properties - Rasa - tikta , katu , madhura Guna - laghu , rooksha , teekshna Veerya - ushna Vipaka - katu Doshakarma - Tridoshashamana , mainly vata shamanaChemical composition - The gum-resin contains steriods , diterpenoids , carbohydrates and aliphaticesters . The purified gum gives pentosan , pentose and furfural . It contains z – guggulosterone, i.e –guggulosterone and three new sterol viz; guggulosterol 1,2 and 3.Oushadha Guna – vatarogahara , vedanashamana , amavatahara , sandhivatahara , medorogahara .Ganas - Vedanasthapana ganaTherapeutic Uses - Medoroga , kushta , yakrut vikara , vatavyadhy and rasayana. 39
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Rasnapanchaka guggulu medicine preparation method :- Drugs Quantity Parts used 1. Rasna - 3 parts - Tuberous root 2.Amrutha - 2 parts - Stem 3. Eranda - 2 parts - Root 4. Devadara - 1 part - Wood 5. Nagara - 1 part - Root 6. Guggulu - 9 parts - Rescene Above medicines like ,Rasna , Amrutha , Eranda and Nagara are well identified andcleaned . After that it wsa dried and powdered in fine form . Guggulu shodhana and Medicine Preparation :-Guggulu which is available in the market contains lots of impurities .So first the impurities like dirt , sand, other visible particles are seperated from it manually . Then it is thoroughly washed in fresh water toremove water-soluble impurities. After that it was dried in sunlight. This guggulu is tied in a cloth andwas immersed in cow’s milk in a dolayantra and heated till it becomes a soft mass. The purified gugguluis taken out washed in fresh water and dried in sunlight to remove the water content. The dried gugguluis then fried in cows ghee which removes the sticky nature of it. Fried guggulu is then spread in a paperand crushed, sothat some of the ghee particles will be absorbed by the paper . Then it is rubbed withclean cottosn cloth so that most of the ghee will be removed from the powder . It is again put into thesunlight . After getting proper dryness it is transferred into a khalwa yantra and mardana was done forgetting fine powder . If the mardana is once completed it was filtered with fine mesh to get fine powder.This process is repeated until the whole guggulu gets fine powder form. 40
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataThe devadaru was cleaned well and was crushed into small pieces. It was then put into a big vesselwith fresh water. After that in medium fire it was made into decoction.The powders of required quan-tities of Rasna, Guluchi , Erenda , Nagara are mixeds in a large vessel and equal part of guggulu powderwas taken and mixed along with that . Then this mixture was put into a wet grinder in small quantities .Decoction of devadara is added little by little during the grinding . Like this the bhavana was done withdevadara decoction for three times . The thick paste like medicine was then taken out and spread overclean metal plates . It was then placed under the sun for drying. After it was completely dried in the sun, was transferred into khalwa yantra for mardana. The mardana is done to make it into fine powder.After each mardana it was filtered by net until it became fine powder . Then this fine powder wasplaced in shades to get the warmth and to dry up the water content if still persists . Then it wastransferred into a dry air tight container .Later this powder was placed into a special machine for filling inside the capsules. Each 500mgcapsule consists of 3 parts of Rasna , 2 parts of Amrutha , 2 parts of Eranda , 1 part of Devadara , 1part of Nagara and equal ( 9 ) parts of Guggulu. The colour of the capsule is dark brown.Mechanism of action :-Rasna panchaka is a classical medicine used from the time of Sahasrayoga and it has proved antiinflammatory , analgesic and adaptogenic ( rasayana ) activity . Guggulu is a proven anti inflammatoryanalgesic herbal drug . It is proposed that this drug can act as a rasayana as well as vedanasthapakaand shodhahara .Dose – 50mg / kg body weight in divided doses twice daily in empty stomach , ie; for an averageperson of 60 kg body weight , 3 gms daily .Anupana – luke- warm water. 41
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata2. CONTROL DRUG151.It was already told that this is a comparative study of the Ayurvedic drug Rasnapanchaka guggulu withthe standard modern drug Nimesulide as Control drug. NIMESULIDE:-Nimesulide is considered as one of the best NSAID now a days in the Modern medicine.Efficiency ofNimesulide is demonstrated clinically in a large variety of conditions associated with pain andinflammation.Some of these conditions are Rheumatoid arthritis, Osteoarthritis, Degenerative arthriticconditions, Musculoskeletal injuries etc.In all these conditions Nimesulide was found to be as effectiveas or more effective as usual therapeutic doses of Piroxicam,Naproxen, Ibuprofen etc.PHARMACOLOGY:-Nonsteroidal anti inflammatory drug or NSAID’s are a group of drugs which form the base of treat-ment for a variety of conditions involving inflammation, pain and fever. NSAID’s available so far ,though quite useful, have certain limitations.They have predominantly anti- inflammatory effects but the analgesic and antipyretic effects areinadequate.Additionally they have gastric irritation properties causing severe gastro intestinal bleedingin some cases.Nimesulide is a potent anti- inflammatory agent with adequate analgesia and antipyretic effect equiva-lent to Paracetamol.Nimesulide has minimal gastric irritation as compared to other available NSAIDswhich is related to it’s weak Prostaglandin synthesis inhibiting property. 42
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataCHEMISTRY AND STRUCTURE ACTIVITY RELATIONSHIP:-Nimesulide is a nonsteroidal anti inflammatory drug (NSAID) which is weakly acidic.It differs fromother NSAIDs in that it’s chemical structure does not contain a carboxyl group but instead it hassulfanilamide moiety as the acidic group.It is a weak inhibitor of Prostaglandin synthesis and it exerts it’seffect through a variety of mechanisms interfering with production/action of mediators other than Pros-taglandins.MECHANISM OF ACTION:-1.Inhibition of superoxide anion generation by activated neutrophils without influencing their phagocyticor chemotactic responsiveness.2.Scavenging of hypochlorons acid and hydroxyl ions generated during the phagocytic process.3.Inhibition of histamine release from human basophils and tissue mast cells.4.Inhibition of platelet activating factor (PAF) synthesis in stimulated human neutrophils.5.Inhibition of synthesis of metaloproteinase thus preventing the breakdown of osteoarthritic humancartilage.6.Inhibition of bradykinin and tumour necrosis factor-alpha (TNF-alpha) which is responsible for therelease of hyperalgesic cytokinase.DOSE AND ADMINISTRATION:-Adults:- Oral………..100mg bid [Tablet] Rectal………200mg [Suppositories]Children:- Suspension or Granules 5mg/kg/day in 2-3 divided doses. 43
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataCONTRAINDICATIONS:- Nimesulide is contraindicated in cases of hypersensitivity, active peptic ulcer disease, moderate tosevere hepatic impairment. Caution should be exercised in patients with compromised renal function(particularly elderly) , congestive cardiac failure, cirrhosis also to those who are volume or salt de-pleted, pregnancy and lactation.ADVERSE REACTIONS:- Nimesulide has a good tolerability profile. Gastro intestinal disturbances include:- Epigastric pain 4.1% , Heart burn 3.1% , Nausea 0.8% , Diarrhoea 0.3% , Vomiting 0.2% Dermatological reactions:- Rash 0.1% , Pruritis 0.1% CNS effects:- Dizziness 0.1% , Somnolence 0.1% , Headache 0.1% Mild renal toxicity was reported in two patients who had received Nimesulide 800mgdaily (usual dose being 100-200mg BD)INTERACTIONS:-Drugs which displace Nimesulide from the plasma binding site : Fenofibrate , Salicylic acid , Valproicacid and Tolbutamide.Drugs which may be displaced from plasma proteins by Nimesulide : Methotrexate, Furosemide andSalicylic acid.Efficiency may be increased : Exercise caution with concomitant use of Warfarin.Theophyllin : Efficiency of slow release theophyllin preparations is reduced. 44
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataMATERIALS AND METHODSResearch is a careful investigation or inquiry in a systematised manner to establish new facts and dis-carding the old facts or correcting or modifying them . The ultimate aim of any research is in the field ofmedical science is to find out suitable remedies for particular ailment and to promote health .The clinical trial is an experimental therapeutics . The Ayurvedic therapeutic measures , drugs , proce-dures have remained in practice since long , on the basis of the methodology prevailed in ancient times.The clinical trial which is carefully designed experiment with the aim of solving the unrewarding prob-lems , conducted on scientific line is the only way to achieve the above objects .Research methodology involves the systemic procedures by which the researcher starts from the initialidentification of problem to its final conclusion .1.Research approach :-Experimentation is the most powerful research approach . Experimentation research is an approach intrials . In the present study the investigators objective is to evaluate the therapeutic effect of Rasnapanchakaguggulu in the management of Sandhigata vata . Efficacy can be determined by finding out the differ-ence between the base line data and assessment data .2. Research design :-The research design suited for the present study is randomized control trial. In this study the treatmentgroup is compared with a control group receiving modern drug therapy. These groups are constructedby random allocation of patients to either treatment with Ayurvedic capsule Rasnapanchaka gugguluand modern drug tablet nimesulid. This study was for a period of one year .Demographic data and dataregarding the disease Sandhigata vata are collected according to the case record form given in theappendix . 45
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata3. Reasons for selecting the research design :-The results and conclussions of a clinical trial depends on the study design.This study is to find out theeffect of Rasnapanchaka guggulu capsule over the modern tablet Nimesulide by comparing their clinicalresponse .Randomized control clinical trial is specifically effective in taking care of variables and toreach valid conclusions . The purpose of randomization is to eliminate bias and ensure that the patientshave an equal chance of being allocated to either of the treatment groups and the investigations prefer-ence is not allowed to interfere .4. Population :-Adult patients with Sandhigata vata attending the out patient division of DGM Ayurveda MedicalCollege Hospital , Gadag were included under the study.5. Sample :-The sample for the present study consists of thirty adult patients with Sandhigata vata reporting toDGM Ayurvedic Medical College OP and selected as per selection criteria . Patients were randomizedinto two groups. Group A – 20 patients will subjected to receive Rasnapanchaka guggulu capsulesand, Group B- 10 patients will be subjected to receive the modern medicine Nimesulide tablets.6. Selection criteria:-The cases were selected as per the inclusion criteria and were treated . Age limit for the selection of thepatients are between 30 – 70 irrespective of sex.a) Inclusive crieteria:- - Pain and tenderness over the knee joint - Swelling of the knee joint - Radiological changes - Crepitation of the knee joint - Age of the patients between 30 – 70 - No discrimination of sex. 46
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata b) Exclusive criteria :- - Patients below 30 and above 70 years of age - Patients developed deformity - Pregnant women and lactating mother - Systemic dissorders like hypertention,diabetic and traumatic cases7. Time and duration of study:- The duration of the study was one year. Data was collected from the first week ofDecember 2000. Individual patients were monitored for 60 days for the efficacy of the trial drug.8. Data collection:- Patients selected were thoroughly examined both subjectively and objectively . Detailedgeneral history and physical examination findings were noted . Routine investigations of blood weredone to exclude other pathology.9. Examination of Knee joint 152:- Osteoarthritis is the commonest kind of knee joint disorder found in elderly peoples. Athorough physical examination is mandatory for the patient with knee joint pain. Before taking history , a glance is given at the overall picture presented by the patient.The patient will be having the pain and swelling on the knee joint .Usually the patient having pain in theknee joints will be very cautious in moving and flexing the legs . Face gives an idea how badly the painis affecting him. 1) History:-Knee joint pain is a system hard to evaluate . Hence a detailed history in chronological sequence is thefirst stand by . A patient with knee problems usually presents with the following complaints. 47
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Pain :-This may be acute or chronic and there may be a history of trauma.Swelling :-This could be due to the effusion or synovial membrane thickening . Localized swelling could be due tobursal enlargement.Limp :-This may be due to pain , muscle spasm , stiffness or arthritis.Restricted movements :-Locking- It could be due to meniscal tear or loose bodies . In locking patients complaints of inability tocomplete the last few degrees of extention . Rigid block suggests , loose bodies or fixed flexion defor-mity .Deformity :-In genu valgum , varum and recurvatum , patients usually presents with deformity.2) Physical Examination:-As in the other parts of the body examinations of knee joint consists of inspection , palpation , measure-ments , movements and stability tests particular to the knee.The whole limb to be examined is exposedwith the patient wearing short trousers . Examination of the knee is carried out from the front , sides andback.a) Inspection;- Inspection is carried out in the following order . - First look at the height and weight of the patient. - Look for the standing alignment of the knee which should be 3– 7 degrees Valgus. - Look for the abnormality of the feet like flat feet , etc. which may contribute to the knee problem. 48
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata - gait – patient could walk with a limp. - Wasting of the thigh and leg muscles are to be noted - Swelling – This could be due to intraarticular or extraarticular cause. If all the natural depressions above, below and by the sides of the patella are obleterated, the cause could be intraarticular. In extraarticular causes, all the natural fossae will not be obliterated and the swelling usually extends over the patella.Limits of swelling :- - Confined to knee – haemarthrosis / effusion - Beyond knee - could be infectious , tumors or major injuries Localised swellings around knee could be due to bersitis , exostoses or osteophytes.Deformity :- The usual knee deformities are genu valgum, varum and recurvatumGenu valgum is the outward deviation of the longitudinal axies of both tibia and femur. Apex of thecurve or angulation of the knee is medial. The severity of the deformity is measured by noting the intermalleolar distanceKnee flexion test:- This is to detect the cause of genu valgum whether it lies in the femur or tibia. If thedeformity disappears with flexion of the knee , the cause lies in the lower end of the femur and if itpersists on flexion, the cause lies in the upper end of tibia.Genu varum is defined as a lateral angulation of the knee. The longitudinal axis of femur and tibiadeviates medially. 49
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataDiagram No. 2 Genu varum DefomityTypes and causes:- Unilateral – - Due to groth abnormalities of upper tibial epiphysis - Infections like osteomyelitis, etc - trauma near the growth epiphysis of femur - tumours affecting the lower end of femur and upper end of tibia. Bilatereal- - Physiological ( gets corrected by four years ) - Pathological – congenital causes , postural abnormalities , developmental dissorders , metabolic dissorders , endocrine dissorders , degenerative dissorders ( “Osteoarthitis of knee” this is a common cause) , occupational dissorders , idiopathic , Pagets disease , blounts diseaseThe ankle of varum is calculated on a standing radiograph of the whole limb.Genuvarum complex – The primary deformity in genuvarum is lateral angulation of the knee. In re-sponse to this secondary deformities in the tibia and the foot. These together is known as genuvarumcomplex. 50
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataGenu reccurvatum is defined as backward bending of the knee. Up to five degree of genu reccurvatumis some times seen in women with lax ligaments and is uaually generalised .Features - Limitation of knee flexion from mild to severe - efussion and other evidence of knee abnormality is absent. - Some times a dense band that becomes tense during flexion of the knee could be palpated in the proximal part of the patella. - Patella is always located more proximally and some times laterally.Causes :- - congenital disorders - quadriceps contracture is the most common cause in acquired genu reccurvatum - Neurological disorders - Malunited fractures around the knee. During the inspection look for old scars , sinuses , etc . as evidenses of injury , surgery , traumaor infections. Also should look for the position of the patella whether lateral , high or low.b) Palpation :- 1. Temperature - Local rise of temperature felt with the dorsum of the hand. 2. Tenderness - Tenderness should be elicited and graded.Proceed from normalarea to the affected part for better patient complience. Grading can be done as, 0 – no tenderness, 1 –patient says the joint is tender , 2 – patient winces on pressure , 3- patient winces and withdraws,4 – patient will not allow to touch. 51
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata3. Swelling - Swelling of joint is usually due to effusion within the joint which indicates damages to the joints and the presence of a major cause must always be ruled out.Sinovialmembrane thickness is the other common cause .Types of swelling – Small – In these cases there will be bulging of the sides of the patellar ligament and obliteration of the hollows of the me dial and lateral edges of patella. Large – Distention of the supra patellar pouch Localised – this is due to osteophytes , exostosis , bursae , cyst etc. Swelling due to synovial membrane thickness - Swelling due to synovial membrane thickness is almost always due to chronic inflammatory disorders .The feature of the swelling are - prominent , usually above the patella near the suprapatellar pouch - Boggy to feel - Local rise of temperatureTests :- The following tests help to evaluate the swelling of the knee.Patellar tap test :-Step 1 – In the horizontal position , considerable amount of excessive synovial fluid gravitates into thesuprapatellar pouch . From 6” above the patella , excess fluid in the supra patellar pouch is driven backinto the joint by sliding down firmly with index finger and the thumb.Step 2- The tips of the three fingures and the thumb of the free hand is placed over the articular surfaceof the patella and a quick jerk is given down ward. If the fluid is present , a click sound is heard as thepatella can be felt to strike on the femoral condyle and bounces back. 52
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataThe patellar tap is not always reliable . It is negative in tense swelling due to too much fluid , smallswelling due to too little fluid . It is positive only in moderate knee effusions.Crepitation :-Crepitation derived from a joint can be detected by feeling the joint with one hand while it is movedpassively with the other. It is usually felt in Osteoarthritic joints.c) Goneometeric reading:-Measurements of joint movements should be recorded in degrees of flexion , extention , abduction andadduction from the neutral or “0”starting position for the joint . A goneometer should be utilised foraccurate measurements of angles . Needless to say , movements of a joint should be compared withthose of its opposite fello .Ask the patient to move his joint himself . Exhaust to display the full range ofmovement , first in this and then in that direction . This is the extent of active movement . then commensingcautiosly , put the joint through as much movement as feasible without causing pain . This is the range ofpassive movement. Limitation of all movements of a joint indicates arthritis of the joint. Restriction ofcertain movements only suggest an extra articular lesion or mechanical block, eg: by a loose body in thejoint. If passive movement exceeds active movement paralysis of muscles is likely.Walking time:-The patients were asked to walk a distance of 40 feet. The time taken to reach the mark of 40 feet wasrecorded by using a stop watch . This was recorded before the treatment and after the treatment.d) Examination of movements:-The important movements taking place at the knee joint are flexion and extention. In a semiflexedposition slight side to side and rocking movements are possible.Flexion – The normal range of knee flexion is 130 – 150 degrees.Muscle testing – The patient is prone . Examiner places one hand over the pelvis to stabilize it while heoffers graded resistance with the other hand at the ankle as the patient attempts to flex the knee. If knee 53
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vataflexion is tested with the ankle externally rotated , biceps femoris is tested and if the ankles rotatedmedially semimembranosus and semitendinosus are tested.Extention :- The knee should normally extend to a straight line ( 0 degree).Occasionally can hyper extend to 15 degree in some womenMuscle testing - Patient sits with the legs hanging over the edge of the table the examiner then stabilizesthe thigh by one hand over the pelvis or proximal thigh against the resistance provided by the examinerthe patient slowly extends the knee through its range of motion .e) Stability test:-Valgus stress test – The patient is in supine position with the knee extended .Stand on the ipsilateral sideof the patient and place one hand against the lateral aspect of the knee at the joint line . Grasp the anklewith the other hand and attempt to drag the leg laterally to open the medial side of the knee joint. If thereis evidence of pain above , below or at the joint line the test is positive for medial collateral ligamentinjury.Diagram No. 3 Stability TestVarus stress test – Patient is in supine position with the knee extended . Standing on the ipsilateral sideof the patella, place one hand against the medial aspect of the knee. Grip the ankle with the other handand draw the leg medially in an attempt to open the lateral side of the knee joint. If the patient complainsof pain above, below or at the joint line, the test is positive . 54
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 10 . SPECIAL INVESTIGATIONS 153:- The patients who are selected randomly with initial data collection from the DGM AyurvedicCollege Hospital will be subjected to undergo Lab. Investigations and X- Rays.Lab Investigations:-Blood investigations:- -TC -DC -ESR -Hb % -Random Blood Sugar -Serum Alkaline PhosphataseBlood investigations like TC, DC and ESR were investigated to rule out any infections.Hb% is inves-tigated to rule out Anaemia. RBS was investigated to rule out the systemic disease ie, Diabetes.Serum Alkaline Phosphatase was investigated to rule out Osteitis deformans, Osteomalacia, Meta-static bone disease etc.X- Rays:-X- Ray of AP and Lateral views of the affected knee were taken.Reduction of joint space, formation ofosteophytes , loose bodies etc, were taken into consideration for the diagnosis. Post treatment X-raywas not advocated because past studies showed there will not be any change in X-Ray within 60days.11. Treatment shedule :-The patients were selected randomly after initial data collected from the DGM Ayurveda college Hos-pital OP. The patients were made into two groups – 1) Trial group 2) Control group. 55
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata1.Trial Group :-The patients of this group were administered Rasnapanchaka guggulu capsules twice daily in the morn-ing and in evening on empty stomach. Dose – 50mg/kg body weight in divided doses. Anupana – luke warm water For each patients a literature was given to follow the contents strictly. In the literature the Aharaand Vihara which should be taken and not to be was specified.2. Control group :- The patients of this group Modern medicine Nimesulide tablet was administerd twice dailyafter food.Dose 100mg bid.The duration of the treatment was one year .Individual patients were monitored for 60 days with every30 day follow up.12. Assessment of response to trestment :-In this study Ayurvedic and Modern approaches were utilized in the selection of patients, there classi-fication and final analysis of results. The results were assessed on the basis of clinical signs and symp-toms and functional capacity of the patient . Special assessment for detecting range of movementimpairment was done by goneometer and functional capacity by measuring walking time.As the patients impression gives much importance to the final conclusion it was taken to draw a conclu-sion regarding the efficacy of the treatment. A. Clinical assessment –1. Pain of the joint Points No pain - 0 Mild pain ( + ) - 1 Moderate pain (+ +) - 2 Severe pain (+ + + ) - 3 56
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataThe pain is assessed by visual analogous scale or coinage scale. The report of the patient was taken intoconsideration for the duration of the pain.2. Stiffness of the joint :- Present - 1 Absent - 03. Tenderness of the joint :- No tenderness - 0 Tenderness, the patient says the joint is tender - 1 The patient winces - 2 The patient winces and withdraws the affected part - 3 The patient will not allow the joint to be touched - 44. Swelling of the joint:-Swelling is measured with the measuring tape in centimeters. The difference of swelling before and afterthe treatment is noted in the performa .B. Functional assessment :-1. Goneometric reading :- - Range of movement while extension in degrees. - Range of movement while flexion in degrees.2.Walking time :-The time difference in seconds was recorded before and after treatment.After the above diagnostic criteria’s Dashavidha pareeksha and srooto pareeksha were also undertaken to find out clues to our ancient knowledge. Here the methods of examination is based on thesubjective datas collected from the patients. An attempt was made to find out the possible Nidana ofthe disease by enquiring about the Ahara and Vihara’s. 57
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata13.Overall assessment of the treatment :-For assessing the overall effect of the therapy certain criteria were adoptedThe results are classified into four groups as listed below.Grade 1-Excellent - Absence of pain - Absence of stiffness - Tenderness grade 0 - Absence of swelling - Goneometeric reading normal - Walking time normal Grade 2-Good - More than 60% reduction in pain - Absence of stiffness - More than 60% reduction in tenderness - More than 60% reduction in swelling - Improvement of 10 degree in goneometeric reading - Walking time reduced to more than 60% Grade 3-Responded - 25% reduction in pain - 25% reduction in stiffness - 25% reduction in tenderness - 25% reduction in swelling - Improvement of 5 degree in goneometeric reading - 25% reduction in walking time. 58
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Grade 4-Not Responded - Pain persists as such or increased - Stiffness persists as such or increased - Tenderness persists or increased - Swelling persists or increased - No improvement in goneometeric reading - Walking time not improved or increased14. Plan for data analysis :-All the data were statistically analyzed before and after the treatment in both groups and the compari-son was done in between the groups . “t” test was employed to find out the level of significance. 59
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata OBSERVATION AND RESULTS In the present clinical study subjective and objective changes are considered for the assess-ment of Rasnapanchaka guggulu in the management of Sandhigata vata. Total 67 patients were re-ported with clinical symptoms of Sandhigata vata. Among these 52 patients were included in the study satisfying the diagnostic criteria and 25patients were excluded due to age, systemic disorders, deformity, etc. In these 52 patients 27 weregrouped as Group- A (trial) and 15 are selected as Group- B (control) randomly. Lastly 7 patientswere discontinued from Group-A and 5 discontinued from Group- B due to unknown reasons. Finally20 patients from group- A and 10 patients from group- B completed the treatment and follow upsuccessfully. 67 patients reported 25 excluded 42 Selected 27 trial 15 control 7 Dropout 5 dropout 20 Group A 10 Group BFlow chart No.2 chronology of selection of patients in control and trial group. 60
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataTable.No: 10 Showing the criteria of exclusion in 25 excluded patients Sl.no: Reasons Group-A Group-B 1. Age above 70 years 2 1 2. Diabetic 4 2 3. Hypertention 4 3 4. Lactating mother 0 1 5. Trauma 1 1 6. Varus deformity 1 1 7. Muscle wasting 2 2 8. Discontinued 7 5 Total 21 16The total data was collected as follows :-Section : A - Demographic data. B - Data related to disease Sandhigata vata. C - Data related to response to the treatment. 61
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata SECTION – A DEMOGRAPHIC DATA1.Age and Sex :-In the present clinical study 30 patients of Sandhigata vata were randomised into two groups.The agegroup was between 30-70 years irrespective of sex.Table.No: 11.Shows distribution of patients in age and sex among thirty treated cases Sl no: Age in years Male % Female % Total.pts. % 1. 30 – 40 2 6.67 2 6.67 4 13.33 2 40 - 50 2 6.67 4 13.33 6 20 3. 50 – 60 5 16.6 4 13.33 9 30 4. 60 – 70 7 23.33 4 13.33 11 36.66 Total 16 53.27 14 46.57 30 100Of the 30 cases 4 (13.33%) were in the 30-40 years age group. 6 (20%) were in the 40-50 years agegroup. 9 (30%) were in 50-60 years age group. 11 (36.66%) were in 60-70 age group. More patientswere recorded in 50-60 years age group. Males were predominent in this study (16 cases – 53.33%).Diagram No. 4 62
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata2. Social and Economical status :-Table. No:12 shows the Socioeconomical status among the thirty treared patients Sl.no: Socio economical status No.pts. % 1. Poor 4 13.33 2. Middle class 26 86.66 3. Higher class 0 0 Total 30 100Digram No. 5The incidense of snadhigata vata was seen prevalent in the middle income group 26 out of 30 cases(86.66).Poor income group is having 4 out of 30 cases (13.33%). No patients with high income groupwas reported . 63
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata3. Nature of Work:-Table. No:13 Shows the nature of occupation among the thirty treated patients Sl.no. Occupation No.Pts. % 1. Sedentary 12 40 2. Active 18 60 3. Student 0 0 4. Labour 0 0 Total 30 100Digram No. 6According to the nature of the work, 18 out of 30 (60%) of cases were in active group.remaining 12patients (40%) were of sedentary group.4. Food Habits:-Table.No:14 Shows the food habits among the thirty treated patients Sl.no: Food habit No.pts. % 1. Vegetarian 20 66.66 2. Mixed 10 33.33 Total 30 100 64
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataDigram No. 7According to the food habits 20 out of 30 (66.66%) of cases were vegetarians.Remaining 10(33.33%)patients were using mixed diet.5. Deha Prakruti:-Table No.15 shows the Deha prakruti among the thirty treated patients Sl.no. Dehaprakruti No.pts. % 1. Vata 1 3.33 2. Pitta 0 0 3. Kapha 0 0 4. Vata pitta 8 26.66 5. Vata kapha 20 66.66 6. Pitta kapha 1 3.33 7. Sama 0 0 Total 30 100 65
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataDigram No. 8Among the 30 cases , 20 (66.66%)patients out of 30 were of Vata kapha prakruti. 8 patients (26.66%)were of Vata pitta prakruti. One patient (3.33%) each were of Pitta kapha prakruti and Vata prakruti.6.Satwam:-Table.No.16 shows the satwa among the thirty treated patients Sl.no. Satwa No.pts. % 1. Pravara 0 0 2. Madhyama 25 83.33 3. Avara 5 16.66 Total 30 100Digram No. 9Among the 30 cases 25patients (83.33%) were having madhyama satwa .5 patients (16.66%) were having avara satwa. 66
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataSection - B Data related to Disease Sandhigata vata 1. Chief complaints: -Among the 30 treated patients all of them (100%) were having sandhi soola and gamaneativedanasymptoms.29 patients(96.66%) were having prasarana akunchana vedana symptom.27 pa-tients(90%) were having sandhigata sankocha symptom.26 patients (86%) were having sandhi soophasymptom.22 patients (73%) were having the symptom nisharuk.15 patients(50%) were having thesymptom sandhi stabdhata.2 patients(6.6%) had got the symptom vatapoornadruti sparsha.No pa-tients complained of the symptom sandhi vishlekshana.Table No. 17 showing the chief complaints among the 30 treated patients Sl.no. Presenting complaints No.pts. % 1. Sandhi soola 30 100 2. Sandhi sopha 26 86 3. Vatapoornadruti sparsha 2 6.6 4. Prasaranakunchana vedana 29 96.66 5. Sandhi vislekshana 0 0 6. Sandhigati sankocha 27 90 7. Sandhi stabdhata 15 50 8. Nisharuk 22 73 9. Gamane ativedana 30 100 67
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata2. Duration :- The duration for which the patient had their illness ranged from 1 month to15 years. 8 of 30 patients(26.66%) were having duration ranged from 3-5 years.7 of 30 patients(23.33%) each were having the duration of 1- 6 months ans 5-10 years.3 of 30 patients(10%) eachwere having the duration of 1-2 years and 10-15 years. One of 30 patients (3.33%) each was havingthe duration of 6 months- 1 year and 2-3 years.TableNo.18 showing the chronicity among the 30 treated patients Sl.no. Chronicity No.Pts. % 1. 1 – 6 months 7 23.3 2. 6 months – 1 year 1 3.33 3. 1 – 2 years 3 10 4. 2 – 3 years 1 3.33 5. 3 - 5 years 8 26.66 6. 5 - 10 years 7 23.33 7. 10 – 15 years 3 10 68
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 3. Involvement of joints:- Among the 30 patients 25(83.33%) were affected in the unilateral joint of the knee.5(16.67%)were involved in the bilateral joints of the knee.Table No.19 showing the pattern of joint involved among the 30 treated patients Sl.no. Pattern No.pts. % 1. Unilateral 25 83.33 2. Bilateral 5 16.67 Total 30 100 4. Nidana:- When considering the aharaja factor among the 30 patients 29 patients(96.66%) each wereconsuming rooksha bhojana and tiktoshna kashaya anna.6 patients(20%)were having pramita bhojana and 4 patients(13.33%) were consuming alpamatrabhojana. Considering the viharaja factor 29 patients(96.66%)were having ativyayama.3patients(20%)were got mental stress like bhaya , dukha, chinta , etc..2 patients(13.33%) were involved in atyucha bhashana.One patient(3.33%)had the routine ofnishajagarana. Table no.20 showing the nidana among the thirty treated patients Slno. Nidana (Ahara) No.pts % Nidana (Vihara) No.pts % 1. Rooksha bhojana 29 96.66 Nishajagarana 1 3.33 2. Alpamatra bhojana 4 13.33 Atyucha bhashana 2 6.66 3. Tiktoshna kashayanna 29 96.66 Ativyayama 29 96.66 4. Pramita bhojana 6 20 Bhaya,dukha,chinta 3 10 69
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 5.Lab investigations :- The mean and standard deviation of lab investigations done in 20 treated patients in trialgroup were taken.In that ESR(wintrobe methode)was 19.65 +/-3.45mm.Hb% (sahlis method)was 10.17 +/- 1.41gm%.WBC was 6510 +/- 1321.34 cells/cu.mm.RBC was5.015 +/- 0.437 million/cu.mm.Random blood sugar was105.05 +/-13.56 mg/dl.Serum alkaline phosphatase was 95.55 +/-21.78 IU/L That of 10 control group patients were ESR(wintrob method) 16.8 +/- 4.76mm.Hb% (sahlis)was 10.52 +/- 1.69 gm%. WBC was 6860 +/- 995.48 cells/cu mm.RBC was 5.05 +/- 0.528 million/cu.mm.Random blood sugar was 99.6 +/- 8.85 mg/dl.Serum alkalone phosphatase was 108.5 +/- 22.66 IU/L.Table No.21 showing the laboratory parameters of 30 treated patients Sl.no. Laboratory parameters Unit Trial Mean+SD _ Control Mean+SD _ 1. ESR (wintrobe method) mm 19.65 +/- 3.45 16.8 +/- 4.76 2. Hb% (sahlis method) gm% 10.17 +/- 1.41 10.52 +/- 1.69 3. WBC cells/cu.mm 6510 +/- 1321.34 6860 +/- 995.48 4. RBC million/cu.mm 5.015 +/- 0.437 5.05 +/- 0.528 5. RBS mg/dl 105 +/- 13.56 99.6 +/- 8.85 6. SAP IU/L 95.55 +/- 21.78 108.5 +/- 22.666. X - ray :- In the study of X ray among 30 patients, 28 patients (93.33%) were having the formationof Osteophytes. 27 patients (90%) got subchondral sclerosis. another 27 patients (90%) were pre-sented minor varus deformity of 1-7 degrees.Because humans got a natural varus deformity in the kneejoint of 1-7 degrees, it is not considered as a deformity.16 patients(53.33%) were presented withunicompart joint space.8 patients (26.66%)were having reduced joint space.3 patients (10%) eachwere presented with increased and unilateral joint space.Only one patient (3.33%)had loose bodies. 70
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataTable No.22 showing the radiological report among the thirty treatd patients Sl.no. Symptoms No.pts. % 1. Joint space - reduced 8 26.66 increased 3 10 unaltered 3 10 unicompartment 16 53.33 general 0 0 2. Formation of osteophytes 28 93.33 3. Subchondral sclerosis 27 90 4. Loose bodies 1 3.33 5. Degree of varus 27 90 71
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Section – C Data related to response to the treatment Clinical conditions of all the patients were assessed before and after the respective treatmentsin trial and control groups. Cardinal symptoms of Sandhigata vata like pain, stiffness, and tendernesswere assessed before and after the treatment. Other factors such as swelling, , goniometric reading andtime taken for 40ft walk were compared before and after the treatment and statistically analyzed byunpaired t test. Group - ASubjective Parameters 1. Pain: - In group-A it is observed that 15 patients (75%) were in grade 2 and 5 patients (25%)werein grade 3.After the treatment 7 patients (35%) had grade0 and 13 patients (65%)had grade 1. This isto say that after the treatment 7 patients (35%) had no pain and 13 patients (65%) is persisting withmild pain. 2. Stiffness: - In group-A it is observed that before starting the treatment 13 patients (65%) were pre-sented with stiffness and 7 patients (35%) with absence of stiffness. After the treatment 17 patients(85%) were having absence of stiffness and 3 patients (15%) were having stiffness. It is observed thatafter the treatment 85% patients were relived from stiffness and 15%with stiffness present. 3. Tenderness: - At the time of presentation one patient (5%) had grade 4 tenderness. 6 patients (30%)were had grade 3 tenderness. 12 patients (60%) were had grade 2 tenderness. One patient (5%) had 72
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vatagrade 1 tenderness. No patients were reported with grade 0 before treatment. After the treatment onepatient (5%) had grade 2 tenderness. 8 patients (40%) were had grade 1 tenderness and 11 patients(55%) were had grade 0 tenderness. This is to mention that after the treatment 5% patients had grade2 tenderness 40% had grade 1 and 55% completely relived from tenderness.Table. No.23Showing the % of clinical symptoms before and after the treatment of group-A Pain Stiffness Tenderness Grade BT % AT % Grade BT % AT % Grade BT % AT % IV 1 5 - - III 5 25 - III 6 30 - - II 15 75 - II 12 60 1 5 I - - 13 65 I 13 65 3 15 I 1 5 8 40 0 - - 7 35 0 7 35 17 85 0 - - 11 55Group – BSubjective Parameters 1. Pain: -In-group –B it is observed that among 10 patients 7 patients (70%) were in grade 2. 3 patients (30%)were in grade 3. No patients were reported with grade 1 and 0 before treatment. After the treatment 6patients (60%) were in grade 0. 4 patients (40%) were in grade 1. It is clear from that among the 10patients 6 patients pains were relived completely and 4 patients grade decrease to 1. 73
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata 2. Stiffness: -It is observed that before treatment among 10 patients 6 patients (60%) were not having stiffness withgrade 0 and 4 patients (40%) was having stiffness of grade 1. After the treatment 9 patients (90%)relived! from stiffness with grade 0 and one patient (10%) still persisting with pain of grade 1. 3. Tenderness: -At the time of presentation among 10 patients 5 patients (50%) were having grade 2 tenderness.5patients (50%) were having grade 3 tenderness. No patients were reported with grade 0, 1 and 4tenderness before treatment. After the treatment 8 patients (80%) were having grade 0 tenderness.2patients (20%) had grade 1 tenderness. After the treatment it was specific that 8 patients (80%) wererelived from tenderness and 2 patients (20%) has tenderness persisting.Table No.24Showing the % of clinical symptoms before and after the treatment of group-B Pain Stiffness TendernessGrade BT % AT % Grade BT % AT % Grade BT % AT % IV - - - - III 3 30 - - III 5 50 - - II 7 70 - - II 5 50 - - I - - 4 40 I 4 40 1 10 I - - 2 20 0 - - 6 60 0 6 60 9 90 0 - - 8 80 Gradation of pain-0 - No Pain Gradation of Stiffness-0-Absent Gradation of tenderness-0-No tenderness I-Mild Pain I-Present I-tenderness, the patient says the joint is tender II-Moderate Pain II-Patient Winces III-Severe Pain III-Pt. Winces and withdraws the affected part IV-Pt. Will not allow the joint to be touched 74
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataObjective ParametersThe objective factors like swelling goniometric reading and time taken for 40 ft walk were comparedbefore and after the treatment and analyzed.Group – A1. Swelling: -In group A it is observed that among 20 patients 5 patients (25%) each were included in grade 3 and5. 4 patients (20%)were included in grade 4.2 patients (10%) were included in grade 2.One patient(10%) was reported in grade 1. 3 patients (15%) was reported in grade 0 before treatment. After thetreatment 5 patients (25%) were in grade 4. 4 patients (20%) were in grade 3.3 patients (15%) werein grade 2. One patient (5%) in grade 1.7 patients (35%) was observed in grade 0.2. Goniometric reading: - In group A it is observed before treatment that among 20 patients One patient(5%) was inthe grade 3. 8 patients (40%) were reported in grade 2. 6 patients (30%) were reported in grade 1 and5 patients (25%) were reported in grade 0.After the treatment all the 20 patients (100%) were re-ported under grade 0. This is in case of extension. In case of flexion before treatment 6 patients (30%)were reported under grade 5. 9 patients (45%) were reported under grade 4. One patient (5%) wasreported under grade 3. No patients were reported under grade 2 and 1.4 patients (20%) were re-ported under grade 0. After the treatment all the 20 patients (100) were observed under grade 0.3. Walking time: - At the time of presentation among 20 patients before treatment in group A , 16 patients(80%) was included in grade 3. 3 patients (15%) were in grade 4. One patient (5%) was included ingrade 2. No patients were reported in 1 and 0. After the treatment 15 patients (75%) were reportedunder grade 2. 2 patients (10%) were reported under grade 3. 3 patients (15%) were reported ingrade 1. No patients were observed in grade 4 and 0. 75
    • Table No.25 Showing the % of objective parameters before and after the treatment in group A Swelling Goneometric Reading Walking Time Grade BT % AT % Grade BT Ext: % BT Flx : % AT Ext: % AT Flx : % Grade BT % AT % 5 5 25 - - 5 - - 6 30 - - - - - - 4 4 20 5 25 4 - - 9 45 - - - - 4 3 15 - - 3 5 25 4 20 3 1 5 1 5 - - - - 3 16 80 2 10 2 2 10 3 15 2 8 40 - - - - - - 2 1 5 15 75 1 1 5 1 5 1 6 30 - - - - - - 1 - - 3 15 0 3 15 7 35 0 5 25 4 20 20 100 20 100 0 - - - -76 Evaluation of Rasnapanchaka Guggulu in sandhigata Vata
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Group - B 1. Swelling: - In-group B it is observed that among 10 patient before treatment, 3 patients (30%)were included in grade 3. 4 patients (40%) were included in grade 4.2 patients (20%) were included ingrade 5.One patient (10%) was included in grade 0. No patients were included under grade 1 andgrade 2.After the treatment 7 patients (70%) were relived from swelling with grade 0.3 patients (30%)were reported in grade 3. No patients were observed under grade 2,3,4 and 5. 2.Gonemetric reading: - In-group B it is observed before treatment among 10 patients, one patient (10%) wasrecorded under grade 0. 7 patients (70%) were recorded under grade 1.2 patients (20%) were re-corded under grade 2. No patients were recorded under 3, 4, and 5. After the treatment all the 10patients (100%) were observed under grade 0.This is in the case of extension. In case of flexion before the treatment 6 patients (60%) were reported under grade 4. 3patients (30%) were reported under grade 5. One patient (10%) was reported under grade 0. Nopatients were reported under grade 1, 2 and 3. After the treatment all the 10 patients (100%) wereobserved under grade 0.3. Walking time: - At the time of presentation among 10 patients in-group B, before the treatment 5patients (50%) were included under grade 4. 4 patients (40%) were included under grade 3. Onepatient (10%) was included under grade 2. No patients were included under grade 1 and 0. After thetreatment 7 patients (70%) were included under grade 1. 3 patients (30%) were included under grade2. No patients were included under grade 4,3, and 0. 77
    • Table NO.26. Showing the objective parameters before and after the treatment in group B Swelling Goneometric Reading Walking Time Grade BT % AT % Grade BT Ext: % BT Flx : % AT Ext: % AT Flx : % Grade BT % AT % 5 2 20 - - 5 - - 3 30 - - - - 4 4 40 - - 4 - - 6 60 - - - - 4 5 50 - - 3 3 30 - - 3 - - - - - - - - 3 4 40 - - 2 - - - - 2 2 20 - - - - - - 2 1 10 3 30 1 - - 3 30 1 7 70 - - - - - - 1 - - 7 70 0 1 10 7 70 0 1 10 1 10 10 100 10 100 0 - - - - Gradation of swelling-0=Nil Gradation of Goneometric reading-0= Nil Gradation of walking time 0= Nil 1=30-32 cm 1=100 -300 1=11-13 min 0 0 2=33-35 cm 2=30 -60 2=14-16 min 3=36-38 cm 3=600 -900 3=17-17 min 0 0 4=39-41 cm 4=90 -120 4= 20-22 min 5=42-44 cm 5=1200 -150078 Evaluation of Rasnapanchaka Guggulu in sandhigata Vata
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataAdverse Drug Reaction (Side effect in studied groups)Table No.27 Showing the side effect of control and trial drugSl.No. Side affects Trial group (20pts.) Control group (10pts.) No.pts. % N o.pts. %1. Nausea -Mild - - - - Moderate - - - - Severe - - - -2. Vomiting -Mild - - - - Moderate - - - - Severe - - - -3. Giddiness -Mild - - - - Moderate - - - - Severe - - - -4. Heart burn -Mild - - 3 30 Moderate - - - - Severe - - - -5. Gastric irritation -Mild- - 3 30 Moderate - - - - Severe - - - -6. Others -Mild - - -- Moderate - - - - Severe - - - - Among the treated patients it was noted during the trial, 3 patients (30%) were reported withmild heartburn and gastric irritation in group-B. No patients were reported reported with any sideeffects in group-A. 79
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataStatistical Analysis: -Table. No.28Showing the statistical analysis of individual study of trial group (A) Parameters Mean SD SE t – value p – value Remarks Pain 1.3 0.823 0.260 4.99 < 0.001 HS Stiffness 0.45 0.510 0.114 3.95 <0.001 HS Tenderness 1.8 0.888 0.249 7.22 <0.001 HS Swelling 2.175 1.718 0.384 5.658 <0.001 HS Goneometric- ext 1.25 0.91 0.203 6.16 <0.001 HS Reading f lx 3.55 1.345 0.425 8.35 <0.001 HS Walking time 0.85 0.44 0.139 6.11 < 0.001 HSTable. No.29Showing the statistical analysis of individual study of control group (B) Parameters Mean SD SE t – value p – value Remarks Pain 1.5 0.453 0.198 7.5 <0.001 HS Stiffness 0.7 0.371 0.163 4.25 <0.001 HS Tenderness 2.3 0.476 0.269 8.55 <0.001 HS Swelling 2.4 1.14 0.521 5.75 <0.001 HS Goneometric- ext 1.2 0.44 0.193 6.21 <0.001 HS Reading f lx 4.1 1.077 0.03 8.66 <0.001 HS Walking time 2.1 0.60 0.26 8.00 <0.001 HS The statistical analysis was done before and after treatment in two groups of all parameters likepain, stiffness, tenderness, swelling, goniometric reading and walking time using paired t test. It isinteresting to note that the p values are <0.001 for all parameters in two groups. But swelling andstiffness is more responded in trial group than control group, which is clarified by corresponding tvalues. 80
    • Evaluation of Rasnapanchaka Guggulu in sandhigata Vata Table No.30 Showing the overall effect of the 30 treated patients: - Sl.no. Assessment Group A. No.pts % Group B No.pts % 1. Excellent 7 35 5 50 2. Good 10 50 3 30 3. Responded 3 15 2 20 4. Not responded - - - -Diagram No. 12Following the subjective and objective parameters, the overall assessment of treatment is carried out inboth studied group. The above parameters showed that only 7 patients (35%) got excellent response ingroup A (trial), compared to 5 patients (50%) in group B. Good response was observed in maximumpatients i.e. 10 patients (50%) in group A and 3 patients (30%) in group B. The response is observedonly in 3 patients (15%) and 2 patients (10%) in-group A and B respectively. Neither any patient ofgroup A never any patient of group B were unresponded to the delivered treatment.The comparative study was done to know the effects of treatment in both the groups in all parameterslike pain, swelling, stiffness, tenderness, goniometric reading and walking time before and after thetreatment. It was found that maximum response was in group B compared to group A. The trial medi-cine is also very much effective in the treatment of Sandhigata vata, although it is inferior to the standardsynthetic medicine i.e. Nimesulide. 81
    • Evaluation of Rasnapanchaka Guggulu in sandhigata VataTable No.31Comparative Study of trail and control group after treatement. Para Group Mean SD SE PSE t- p-value Remarks meters Value Pain Trial 0.65 0.489 0.19 0.752 2.34 <0.05 Sig Control 1.6 0.843 0.46 Stiffness Trial 0.15 0.36 0.0812 0.82 1.83 >0.0 5 NS Control 0 0 0 Tenderness Trial 0.5 0.607 0.136 0.421 2.41 <0.05 Sig Control 0.12 0.237 0.121 Swelling Trial 30.7 13.56 3.032 5.21 2.202 <0.05 Sig Control 36.32 9.531 3.864 Walking Time Trial 15.5 1.13 0.286 0.832 2.791 <0.05 Sig Control 16.4 1.34 0.65 Goneometric e reading x Trial 0 0 0 0 0 - - t Control 0 0 0 f Trial 0.65 1.598 0.357 0.357 1.82 >0.05 NS l x Control 0 0 0From the study it is well evident that the controll drug is ahead in the parameters of pain, tenderness andwalking time compared to the trial drug. The statistical comparison between the control and trial groupshows significant (P<0.05). So it is clear that trial drug has defenit effect over pain, tenderness, swellingand walking time although it is inferior to control drug. But in other two parameters like stiffness andgoneometeric reading, the control drug is not significant (P>0.05) 82
    • DiscussionSandhigata vata (Osteoarthritis) is the most common type of arthritis and the most common joint disorderin he world, the number one cause of disability. In Ayurvedic science all the Acharyas were mentionedabout the disease under vatavyadhi. Vatavyadhies are first among the mahagatas told by acharyas. So wecan assess the importance and chronicity of this disease Sandhigata vata. Osteoarthritis especially kneejoint OA is very common among the elders now a days. In India about 20 – 30 % of people are affectedby the complaints of the knee during their lives. Females are found to be more affected by this disorder.Age is the most powerful risk factor for OA.IN a radiographic survey of women less than 45 years old,only 2% had OA; between the ages of 45to 64 years, however, he prevalence was 30% and for thoseolder than 65 years it was 68%. In males, the figure was similar but somewhat lower in the older agegroups.Given the growing participation of the population in sports, it is important to note that there is no convincingto support an association between specific athletic activities and arthritis if major trauma is excluded.Neither long distance running nor jogging has been shown to cause OA. This apparent lack of associationmay, however, be due to the lack of good-long term studies, the difficulty of retrospective assessment ofactivities, and selection bias, i.e., early discontinuation of the activity by those incurring joint damage. According to Ayurveda the vatakara aharas and viharas like rookshahara, alpahara etc and viharaslike ativyayama, nishajagarana, etc constitutes the triggering of vata. Stoulya is also a major cause for vataprakopa in the sandhies. Due to the over weight of the body, weight bearing joints, especially knee jointshas to bear the whole weight. This causes the wear and tear of the articular cartilage there by causingSandhigata vata. On the contrary vata prakopa occurs due to the kaphakshaya in the sandhies. The boneis not supposed to bare weight, or tear and wear. It is only for transmission of weight. Age is also apredominant factor for this disease. Sandhigata vata occurs usually in the old ages; in this age only vatadosha is predominant. In this disease the srotases like asthi and majja are involved. In long standingsandhigata vata (OA) wasting of muscles happens which can be defined as mamsakshaya in Ayurveda dueto the vitiation of mamsavaha srotas and pratiloma kshaya. So in this case involvement of mamsavahasrotas also takes place. As because the asthi and majja dhatus are diminished the mamsa dhatus alsodiminishes my pratiloma kshaya.
    • In the Brihatrayees it is mentioned that the vata, which vitiates in the sandhi is the causative factor forSandhigata vata. The symptoms like vatapoornadruti sparsha, shopha and prasarana akunchana vedanaare also explained in them. Madhavacharya who is considered as the nidanasreshta specifies the symptomatopa. This is a characteristic sound produced from the joints during its movement. This symptom can becorrelated with contemporary science Osteoarthritis symptom crepitation. The treatment highlighted forvaravyadhy is also specified for sandhigata vata. Sisruthas line of treatment gives much specification amongall. He advises the treatments like Snehana, Upanahana, Bandhana, Mardana and Agnikarma.Snehana inthe form of bahya and abhyantara is generally administered in vatavrudhi and kaphakshaya conditions. Insandhigata vata vata dosha is aggravated and sleshaka kapha is decreased there for sneha is appropriatemodality for said disease. Upanaha is advocated in local conditions, which instantly reduce the pain andaffected doshas, as well as clears the channels. Upanaha with vatahara dravyas like dasamoola, eranda,arka etc gives a profound relief in sandhigata vata. Bandhana is also advocated in local conditions toreduce the exudations and cellular infiltrations. In Ayurveda, the use of medical herbs for bandhana notonly compresses the swelling and rests the affected part but also it pacifies doshas. On the other hand thecontemporary medical science are using the crape bandage for the same condition.Mardana is said to increase the capillary permeability and vascular drainage. There fore mardana is muchpopular in the therapeutic dilemma of sandhigata vata. It is also used for the differential diagnosis ofamavata when oils are used for mardana. Agnikarma is still popular in Ayurvedic practices. Agnikarma canreduce the pain and acts like acupuncture by blocking the pain receptors and neural conducting systems.Initial line of treatment in modern medicine is administration of NSAID’s. Long standing intake of some ofthe NSAID’s causes side effects like gastric disturbances, heart burn etc. Surgical treatments like arthroscopyand total knee replacement procedures are also done if not responded to the NSAID’s and in advancedstages.The role of diet and regimen in the pathogenesis of disease is already highlighted in the context of nidana.The vatakara aharas like tikta, katau, kashaya annas, sheetajala etc and viharas like jagarana, shrama,vyayama etc. are main among them.This disease is also called as crippling disease due to in ability to perform routine activities properly. Nowdays these disease become much popular resulting in the formation of Arthritis organizations around the
    • world.Selection of therapeutic regimen: -For the management of the disease Sandhigata vata (Osteoarthritis) Ayurvedic preparation Rasnapanchakaguggulu is administered in the form of capsules.Here with the classical yoga Rasnapanchaska told in Sahasrayoga, indicated for the disease of asthi, majjaand sandhi, guggulu is added for better result. The drugs involved are Rasna, Guduchi, Eranda, devadara,shunti, and guggulu. Rasna is good for vata shamana and also as rasayana. Guduchi is also rasayana,amahara and vatashamaka. Eranda is good to passify deranged vata. Devadaru is known to itsvedanashamaka property. And Nagara is considered as shoolaghna. Guggulu one of the main content inthis combination is known to its vata shamaka property and rasayana property. It is also considered asanti-inflammatory, aphrodisiac, rejuvenate etc. As this combination is purely herbal origin no toxicity isreported. So it is conformed that no toxic effect was produced after the administration.In this study the control group of patients were administered with Nimesulide tablets. Nimesulide isconsidered as one of the best NSAID’s now a day in the modern medicine. Efficacy of Nimesulide isdemonstrated clinically in a large variety of conditions associated with pain and inflammation. Some ofthese conditions are Rheumatoid Arthritis, Osteoarthritis, degenerative arthritic conditions etc. The drugNimesulid is selected due to its good tolerability profile and less side effect compared to other NSAID’s.Plan of study: -In this study a specific plan and design was adopted for a better analization.Total 67 patients were reported with clinical symptoms of Sandhigata vata. Among them 52 patients wereincluded in the study satisfying the diagnostic criteria and 25 patients were excluded. Total 30 patientswere completed the course of treatment, 20 patients in trial group (Group-A) and 10 patients in controlgroup (Group-B). Among the 25 excluded patients there were 7 discontinued cases from group-A and 5from group-B.The most excluded cases were Diabetic and hypertensive patients.
    • The disease was diagnosed as Sandhigata vata based on the signs and symptoms explained in classicalAyurvedic and modern books. Routine blood tests were conducted to rule out infections and otherpathologies. Random blood sugar and serum alkaline phosphatase tests were done to exclude diabeticand other bone related diseases and malignancies. The selections of patients were randomly done in two groups irrespective of age and sex. The groupA (trial) patients were treated with Rasnapanchaka guggulu capsules and group –B (control) patients withNimesulide tablets with modern medical supervision. The duration of the treatment for two groups wassame i.e. 60 days due to limited study period.General description of patients: -Age: -In the present study total 30 patients of Sandhigata vata were selected .In this more patients 11(36.66%)were of jeerna or vardhakya age group. Males were predominant in this study 16 patients (53.33%). It isclear that Sandhigata vata occurs during the vardhakya period, the period, which is predominant of vata.This data is coinciding with the data of epidemeology and risk factor (Kenneth.D.Brandt).Social and economical status: -In the present study majority of patients 26(86.66%) were coming under middle class. The area were thestudy is conducted was dominated by business peoples. So most of them will be economically sound. Butthere is no relation between social and economical status with sandhigata vata.Food Habits: - In this study 20 patients (66.66%) were using vegetarian food and remaining, non-vegetarianpatients 10 (33.33%) .In this locality the availability of vegetarians are more due to the vegetable cultivationand is highly populated by Hindus those who are strict in taking vegetarian diet. Some of the exceptionalcases and some Muslim population also reflect in the intake of non- vegetarian.
    • Occupation: - In this study 18 patients (60%) were doing active occupation. Due to the continuous stressaffecting on the joints due to active labor the particular joint becomes degenerated causing Sandhigata vata(Osteoarthritis). 12 patients (40%) were of sedentary. In this group mostly the housewives are includedwho is more prone to this disease. Life style and occupation are regarded as the risk factors in theepidemiology of Osteoarthritis in contemporary medical science. (Arthritis clinical symposia.vol.51.1999).Nidana: -Among the 30 patients 29 (96.66%) were affected with ahraja nidanas like rooksha bhojana andtiktakatukashayanna. In the study conducted place the people are more used to take rookshabhojanasand tiktakatukashayannas. It is specified that the intake of vegetable oils and saturated fats in their fooditems are less. This produces the vitiation of vatacausing vatika disorders.In viharaja nidana 29 patients (96.66%) were prone to do ativyayama like cycling, vocational activities,continuous driving etc.which effect the knee joint producing the disease. These data coincides with theprevalence of OA and the pattern of joint involvement in the contemporary medicine. (Textbook ofOrthopedics).Deha prakruti: -In this study majority of the patients had vata prakriti.20 patients (66.66%). This prakruti is more prone tothe disease Sandhigata vata due to the involvement of vata and kapha doshas. In the disease also vatadosha is predominantly involved. Those having kaphanubandha will be getting more body weight their bycausing damage to the weight bearing joints, especially knee joints. Obesity is known risk factor for kneeOA mentioned by contemporary medicine.Presenting complaints: -All the 30 patients included in the study were presented with typical symptoms of Sandhigata vata. In that30 (100%) patients were presented with sandhisoola, gamane ativedana.29 (96.66%)with prasarana
    • akunchana vedana, 27(90%) patients with sandhigati sankocha, 22(73%) patients nisharuk. No patientsreported sandhi vishlekshana because they are unable to feel and explain it properly. Also only 2 patientsreported symptoms like vatapoornadruti sparsha. This is because the typical symptom will be availableonly those which are developed shortly. As this study is only concentrated on knee joint, two pattern ofjoints were involved. 25(83.33%) patients were having unilateral knee joint involvement and 5(16.67%)were had bilateral involvement.Chronisity of the patients: -Among the thirty treated patients higher percentage of the patients were from 3-5 years of chronisity8(26.66%). 1-6 months and 5-10 years chronisity got 7 (23.33%) patients each. 3 patients (10%) hadhigh chronisity of 10-15 years were also reported. From this it is highlighted that chronisity increasestowards the later stages of the disease.Investigations: -Lab Investigations: -Lab investigations like Tc, Dc, ESR, Hb%, RBS and serum alkaline phosphatase were done. No laboratorystudies are diagnostic for OA but specific laboratory techniques may help in identifying one of the underlinecauses of secondary OA.Radiological Examinations: - In radiological examinations X-ray of knee joint was considered as major diagnostic tool.Among the 30 treated patients more than 90% of the patients were had reduced joint space, formation ofosteophytes, subchondral, slerosis in the radiological reports. These symptoms are the typical of Sandhigatavata (Osteoarthrits). 27 (90%)were had a varus deformity of 1-7 degrees which is considered as naturalin human beings knee joint. These above datas coincides with the modern medical data. It is also high-lighted as OA is degenerative conditions affecting the articulation especially those bears weight (kneejoint). As there will not be any radiological changes with in 60 days that were seen in earlier studies, no X-ray was recommended after the treatment.
    • Clinical response and treatment: -In this study an effort has been made in the treatment and its evaluation aspect by following the Ayurvedicand modern parameters. All the cardinal signs and symptoms were scored according to the severity grade.The clinical response of the therapy was assessed on the basis of change in the severity score after thetreatment. The cardinal symptoms like pain, stiffness, tenderness, swelling, restricted movements and difficultyin walking were taken into consideration and assessed before and after the treatment.1. Effect of Sandhisoola (Joint Pain): -Pain is one of the major complaints found in this study. 35% patients were completely relieved of the kneejoint pain in-group A while 60% were completely relieved in-group B. (Table No. 23, 24). All the patientsin both the groups reported the reduction of severity of pain grade. But group B patients showed betterand quick relief compared to the patients of group A. The improvement of groups is statistically significant.P (< 0.001) corresponding to t = 7.5 (Table No28,29) in group B and t = 4.99 in group A.2. Effect of Sandhi stabdhata (Joint stiffness): -The complete relief from stiffness is impressive in-group B patients 90% (Table No. 24) Compared to85% (Table No. 23) patients in-group A. But all the patients in both the groups reported the improvementof severity grade. No any patients were unresponded to the therapy. The statistical analysis before andafter the treatment is highly significant in both the groups. It was observed that the patients of group B gotinstant relief of stiffness compared to gradual improvement in-group A.3. Effect of Sparshaasahishnutha (Tenderness): -The best response was reported from group-A that 55%(Table No. 23) were relieved from tendernessand 80% are relieved in group-B. (Table No. 24). Both these findings are highly significant value of group-A (<0.001) and group-B (<0.001)(Table No. 28,29).
    • The effect of treatment is more in Group-B than group-A due to the high penetrating action and apparentvolume of distribution of the used modern drug.4. Effect of Sandhi shopha (Joint Swelling): -The sandhi sopha is best responded in the patients of group-B (70%)(Table No. 26).While group-A patients were relived only 35%(Table No. 25) The early response takes place in group-Bthan compared to group-A, due to the predominant anti-inflammatory effect of the control group (Nimesulide).The findings of group-A is statistically highly significant p (<o.oo1) compared to t = 5.658 (Table No. 28).Group-B findings are impressive statistically P (<0.001) compared to t = 5.75. (Table No. 29) Therewere no unresponded cases found in both the groups.5. Effect of goniometric reading: -The Goniometric reading has kept maximum result in extension and flexion of two groups. It is interestingto note that all the patients (100%) (Table No25, 26)Were having normal goniometric readings after the treatment. The statistical analysis of both the groups ishighly significant. P (<0.001) (Table No28, 29). But the group-B patient had slight improvement thangroup-A from the corresponding t value. The difference of response may be due to the more chronicpatient in group-B6. Effect of walking time: -Walking time can assess the functional ability of a patient. Group-B patient showed maximum improve-ment (70%) in walking time compared to group-A (15%). (Table No. 25, 26). Both these findings arehighly significant P (<0.001) (Table No. 28, 29). But the poor complaints and variation in group-A maybe interpreted as the individual walking style and the method of grading adopted in the study.Overall effect of the treatment: -In this study an attempt was made to compare the efficacy of Rasnapanchaka guggulu (a newly formulated
    • combination) with a standard modern drug (Nimesulide). Only 5 (50%) patients in group-B got excellentresults in their clinical symptoms. Where as in group-A 7 (35%) patients were reported as excellent fromtheir clinical symptoms. Good improvement was noted in 3 (30%) in group-B and 10 (50%)patients ingroup-A. 2 (20%) patients were fairly responded to the treatment in group-B compared to 3 (15%)patients in Group-A. No any case (0%) was reported as unresponded to the above treatment in both thegroups (Table No.30).Adverse drug reaction (Side effects)In the study it was noted that in-group B 3 patients (30%) were reported with side effects like gastricdisturbances and heart burn which is of mild intensity. No patients were reported with any such symptomsin-group A. This data once again conforms that the drug Rasnapanchaka guggulu can be administered inthe patients with confidence because of its adaptable nature to the human body (Table No.27).Comparative study between two groups: -From the clinical study it is quiet obvious that the modern synthetic treatment provided to group-B is edgeover the treatment done with poly herbal ”Rasnapanchaka guggulu” in group-A. The improvement ingeneral condition and functional capacity of the patients were observed in both the groups although group-B patients relived the pain, swelling and tenderness faster than group-A. The statistical analysis to investigatethe better treatment between two groups was done. The statistical comparison between two groups showssignificant (P<0.05). So it is clear that trial drug has defenit effect over pain, tenderness, swelling andwalking time though it is inferior to control drug. But in other two parameters like stiffness and goneometricreading, the control drug is not significant (P>0.05) (Table No. 31)Probable Mechanism of action: -The Rasnapanchaka guggulu can reduce the symptoms as well as the degenerative process due to variousactions of individual drugs in it. It is very difficult to draw the exact mechanism of action of the trail drug.But observing the therapeutc effect a hypothesis can be presumed for the mechanism. The contents of this
    • compositions are all Vata Shamaka. The drugs like Rasna, Eranda, Devadara are not only capable ofpassifying Vata but also is very good in promoting the health by normalising the Doshas. Gugglu which isthe main content is aromatic light in nature also penetrates into the minute parts of the body. It is having theproperty of laxativeness which destroyes the accumulation of Malas from the Srotases. Susrutha had toldguggulu as, it destroys the deranged Vayu incarcerated in the Koshta, Bones and Joints, just as a thunderbolt will destroy trees154. Guggulu is used as antiinflammatory and anti-rheumatic drug. This compositioncan also help to control the progressive degeneration, disquamation and necrosis of perichondreal tissuesand chondrocytes of the articular cartilage. Rasna is an known anti-inflammatory drug as well as diseasemodifying agents. Amrutha, Shunti, Devadaruhave immunomodulatory action which can regulate thelysosomal secretion from macrophages in the synovial fluids. Therefor this Rasna panchaka provodessymptomic relief from inflammation and arthralgea through its anti-inflammatory, analgesic and possiblyanti kinin effects. Incase of chemical NSAID’s only symptomatic relife from pain and inflammation ispossible but do not modefy the disease process. Thus the degenerative process continues uncheckedleading to permanent joint disfunction and disability. But Rasnapanchaka guggulu can restore the jointmobility and sucessfully modifies the disease process. It has very high tolerebility profile compared to othersynthetic NSAID’s which cannot tolerate and causes GI disturbancs. So this drug is acting as diseaseprocess modifier, joint nutrition regulator, immunomodulator and anti inflammatory and analgesic agentwithout GI disturbances.155Summary and Conclusion 1. Summary: -The title of this thesis is Evaluation of Rasnapanchaka guggulu in Sandhigata vata.The aim of the study is to accomplish the following objectives. 1. To study disease Sandhigata vata in detail. 2. To evaluate the efficacy of Rasnapanchaka guggulu in relieving pain and inflammation and to stop the degenerative process of Sandhigata vata. 3. To compare the effect of trial drug with the control drug.
    • The study constitutes literary review, methodology of clinical study,observation, analysis, discussion and summary and conclusion.Knee joint is the most prone joint for the disease Sandhigata vata (osteoarthritis). So this study onlyconcentrated the Sandhigata vata of knee joint.For that a through knowledge about the structure of it isessential. A detailed description of anatomy and physiology of knee joint is given in the review of literature.It also includes the etymology of the disease, etiology, pathogenesis, clinical presentation and managementfrom Ayurvedic classics as well as related aspects from modern textbooks. Sandhigatavata being a vatavyadhithe best pavcha karma treatment for it is vasthi. So importance of vasthi in vatavyadhi is also included in theliterary aspect.The clinical study includes the selection criteria, assessment criteria, and treatment schedule and plan anddata analysis. It also includes the detailed description of examination of knee joint and its special investigationsrelated to the disease Sandhigata vata (osteoarthritis). The clinical study was conducted among 30 patients. The sample of the study consists of patientswith Sandhigata vata (osteoarthritis). The symptoms, signs and radiological investigations were the maincriteria for the diagnosis.The patients satisfying the selection criteria were divided randomly into two groups to receive respectivetreatments. After collecting the basic live data, for the experimental group (group-A) patients wereadministered Rasnapanchaka guggulu capsules twice daily with strict ahara and vihara restrictions. Thecontrol group (group-B) patients were administered with modern medicine Nimesulide tablets twice dailywith strict ahara and vihara restriction under the modern medical supervision. The total course of treatmentwas of 60 days with 30 days follow-up. Standard parameters were followed during the selection andassessment procedures. Paired and unpaired ‘t’ tests were done to evaluate the efficacy of the treatmentsand comparative net effect of the treatment and the result respectively.2. Findings of the study: -30 patients of Sandhigata vata (osteoarthritis) were registered for the study. They were randomized intotwo groups and adopted respective trearments. All the patients were in the age range of 30 – 70. The trialgroup showed highly significant result in all parameters (p = <0.001) in the inter comparison of two groupsthe control group (group-B) showed significant result. (P <0.05) (Table No. 31)
    • 3. Conclusions: -In the present study following conclusions are made – 1. There is an intimate relation between vata and kapha in Sandhigata vata disease. 2. Restoration of vata to its normal state helps in the treatment of Sandhigata vata. 3. Awareness of unwholesome dietary habits and exercise can prevent Sandhigata vata. 4. In the study an attempt was made to bring closer the traditional Ayurvedic practise and contempo- rary medical practice for a meaningful and scientific way for the betterment of the peoples. 5. It is observed that male patients were more suffered than female and Sandhigata vata is more affected in the age of 60 – 70 years and in the middle socio economical group. 6. The clinical effect of Rasnapanchaka guggulu was farely competable to that of Nimesulide after the 60 days of treatment. 7. After 60 days of treatment 5 patients (50%) were excellently responded in control group while 7 patients (35%) were excellently responded in trial group. 8. However those who could not get excellent response had a significant reduction in their severity grade in both the groups. There fore it is suggested that the trial drug has a definite effect in reducing the clinical symptoms and degenerative process. 9. It is observed that 3 patients (30%) were complained with mild gastric irritation and heart burn during the course of therapy in Nimesulide group. But no any complaints reported in studied Rasnapanchaka guggulu group. So Rasnapanchaka guggulu is a safe effective drug in the treatment of Sandhigata vata with out any side effects. 4. Limitations: - 1. The size of sample was small to draw generalized conclusion. 2. The period of study was limited. 3. The study was limited to the patients who attended the OPD wing of DGM Ayurveda Medical College, Gadag. 4. Since this is a primary study the proportion of ingredients of the Rasnapanchaka guggulu
    • capsule is limited. If the proportion were increased much more the results would have been better than the present results. 5. If the patients were self-realized about the pathya and apathya, the results would have been excellent.5. Recommendation for further study: - 1. The study can be repeated with larger sample with longer duration 2. The study design can be done with double blind placebo control to get an exact therapeutic effect. 3. Same formulation can be tried along with specific Panchakarma therapies.
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