Sandhivata kc037 gdg


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Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the management of Sandivata By Dr. Shivakumar.C.Sarvi, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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Sandhivata kc037 gdg

  1. 1. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the management of Sandivata By Dr. Shivakumar.C.SarviDissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. In KAYACHIKITSA Under the guidance of Dr. V. VARADA CHARYULU, M.D. (Ayu) And co-guidance of Dr. RAGAVENDRA. V. SHETTER, M.D. (Ayu) Post graduate department of Kayachikitsa, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2006. 1
  2. 2. Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled“Evaluation of the Efficacy of Abhadi choorna and Ksheerabala tailaJanubasti in the management of Sandivata.” is a bonafide and genuineresearch work carried out by me under the guidance ofDR. V. VaradaCharyulu, , Professor and H.O.D, Post-graduate M.D. (Ayu)department of Kayachikitsa and co-guidance of Dr. Ragavendra. V. Shetter, , Post graduate department of Kayachikitsa.M.D.(Ayu)Date: Signature of ScholarPlace: Gadag Dr.Shivakumar.C.Sarvi 2
  3. 3. CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “Evaluation ofthe Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in themanagement of Sandivata” is a bonafide research work done by Dr.Shivakumar.C.Sarvi in partial fulfillment of the requirement for the degreeof Ayurveda Vachaspathi. M.D. (Kayachikitsa).Date:Place: DR. V. VaradaCharyulu, M.D. (Ayu). Professor & H.O.D Post graduate department of Kayachikitsa. 3
  4. 4. CERTIFICATE BY THE CO- GUIDE This is to certify that the dissertation entitled “Evaluation ofthe Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in themanagement of Sandivata” is a bonafide research work done by Dr.Shivakumar.C.Sarvi in partial fulfillment of the requirement for the degreeof Ayurveda Vachaspathi. M.D. (Kayachikitsa).Date: Dr. Ragavendra. V. Shetter, M.D. (Ayu)Place: Assistant Professor, Post graduate Department of Kayachikitsa 4
  5. 5. ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “Evaluation ofthe Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in themanagement of Sandivata” is a bonafide research work done by Dr.Shivakumar.C,Sarvi under the guidance of DR. V. VaradaCharyulu, M.D. (Ayu) ,Professor and H.O.D, Postgraduate department of Kayachikitsa and co-guidance of Dr. Ragavendra. V. Shetter, M.D.(Ayu) , assistant professor Postgraduate department of Kayachikitsa.DR. V. VaradaCharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Kayachikitsa. 5
  6. 6. COPYRIGHT Declaration by the candidate I hereby declare that the Rajiv Gandhi University of HealthSciences, Karnataka shall have the rights to preserve, use and disseminatethis dissertation / thesis in print or electronic format for academic / researchpurpose.Date: Signature of ScholarPlace: Gadag Dr. Shivakumar.C.Sarvi© Rajiv Gandhi University of Health Sciences, Karnataka. 6
  7. 7. LIST OF ABBREVIATIONS USED AS – Ashtanga Sangraha AH – Ashtanga Hridaya Aru. – Arunadatta A.T – After treatment B.T – Before Treatment B.P – Bhavaprakasha B.R – Bavarajeeyam Bh.S – Bhela Samhita Ca.S – Charaka Samhita Chi. – Chikitsa Sthana Chak. – Chakrapani Dal. – Dalhana S.L.R - Straight leg raising Gang. – Gangadhara K.S – Kashyap Samhita M.N – Madhav Nidana Ni. – Nidana Sthana N.S – Not Significant SU.S – Sushruta Samhita Sa.S – Sharangadhara Samhita Sha.S – Shareera Sthana Su. – Sutra Sthana Si. – Siddhi Sthana Vi. – Vimana Sthana Y.R. – Yoga Ratnakara
  8. 8. LIST OF TABLESSl. Contents PageNo No01 Samanya nidana of Sandhivata 1102 Roopa of Sandhivata mentioned in various classics 1903 Vyavachedakanidana between Sandhivata & Vataraktha 2004 Vyavachedakanidana between Sandhivata & Amavata 2105 Vyavachedakanidana between Sandhivata & Krostukashirsha 2106 Differential diagnosis between O.A, R.A,Gout & Rheumatic 22 fever07 Chikitsa sutra mentioned in different Samhita 4208 Grading of parameters09 Demographic data related to evaluation of Abadi churna in 74 Sandhivata10 Demographic data related to Evaluation of Ksheerabala taila 75 Janubasti in Sandivata11 Distribution of patient according to age among groups. 7612 Distribution of patient according sex among groups. 7713 Distribution of patient according to occupation 7814 Distribution of patient according to Economical status 7915 Distribution of patient according to Religion 8016 Distribution of patient according to Diet 8117 Distribution of patient according to affected to leg of Sandhivata 8218 Distribution of patient according to Agni 8319 Distribution of patient according to Koshta 8420 Distribution of patient according to Habits in patients 8521 Distribution of patient according to Prakriti of patients 8622 Distribution of patient according to different nidana bhavas. 8723 Distribution of patient according to Chronicity of the disease 88 among groups24 Showing the incidence of Swelling in the patients 8925 Showing the incidence of walking time in the patients 9026 Showing the incidence of range of Flexion deformity in the 91 patients.27 Showing the incidence of Pain in the patients. 9228 Showing the incidence of Stiffness in the patients. 9329 Showing the incidence of Tenderness in the patients. 9430 Showing the incidence of Crepitus in the patients 9531 Showing the incidence of Weight of the body in the patients 9632 Master Chart – Subjective Parameter – Group- A 9733 Master Chart – Objective Parameter – Group- A 9734 Master Chart – Objective Parameter – Group- B 9835 Master Chart – Subjective Parameter – Group- B 9836 Statistical Assessment of Individual Study Group – A 99 (Subjective& Objective Parameter)37 Statistical Assessment of Individual Study Group – B (Objective 99 Parameter)
  9. 9. 38 Statistical Assessment of Comparative study of Group – A with 100 Group – B39 Over all assessment 102 LIST OF PHOTOS, FLOW CHARTS AND GRAPHS Sl. No Name of the Figure Page No 1. Photo showing Drugs used in clinical trail 2. Photo showing Janu basti procedure 3. Flow chart of Samprapti of Sandhivata List of Graphs 1 Distribution of patient according to age among groups. 76 2 Distribution of patient according sex among groups. 77 3 Distribution of patient according to occupation 78 4 Distribution of patient according to Economical status 79 5 Distribution of patient according to Religion 80 6 Distribution of patient according to Diet 81 7 Distribution of patient according to affected to leg of 82 Sandhivata 8 Distribution of patient according to Agni 83 9 Distribution of patient according to Koshta 84 10 Distribution of patient according to Habits in patients 85 11 Distribution of patient according to Prakriti of patients 86 12 Distribution of patient according to different nidana 87 bhavas. 13 Distribution of patient according to Chronicity of the 88 disease among groups 14 Showing the incidence of Swelling in the patients 89 15 Showing the incidence of walking time in the patients 90 16 Showing the incidence of range of Flexion deformity in 91 the patients. 17 Showing the incidence of Pain in the patients. 92 18 Showing the incidence of Stiffness in the patients. 93 19 Showing the incidence of Tenderness in the patients. 94 20 Showing the incidence of Crepitus in the patients 95 21 Showing the incidence of Weight of the body in the 96 patients 22 Over all assessment 102
  10. 10. TABLE OF CONTENTS Chapters Page No.1. Introduction 1- 32. Objectives 43. Review of literature 5-574. Methodology 58-725. Observation and Results 73-1026. Discussion 103-1127. Conclusion 1138. Summary 1149. Bibliography 115-12510. Annexure
  11. 11. ABSTRACT Sandhi-Gata-Vata (osteoarthritis) is common amongst the elderly andobese persons. Since knee is the weight bearing joint it is more susceptible to wear andtear. Sandhi-Gata-Vata (osteoarthritis) resulting in wear and tear of this joint termed asSandhi-Gata-Vata. It is largely seen in the population and known to be major cause forchronic disability. The objectives of this study are 1) To evaluate the efficacy of abhadichurna in the management of sandhigatavata (osteoarthritis), 2) To evaluate the efficacyof ksheera bala tail janu basti in the management of sandhigatavata (osteoarthritis) and The aim of this study was to find out the effect of Abhadi choorna in themanagement of Sandhigathavata and to check its advantage of ksheera bala tail janu bastiin managing the same disease. Therefore, two groups were made and the results obtainedin both the individual groups. The study design selected for the present study wasprospective clinical trial. In-group A (Abhadi choorna), not a single patient had good response tothe treatment (> 75% improvement in all the parameters) and 4 patients (26.6%) hadmoderate Response to the treatment (50-75% improvement in all parameters) and11(73.3%) patients had poor response. In group B (Ksheera bala tail janu basti), 1 patienthad good response to the treatment and 7(46.6%) patients had moderate response to thetreatment, 7(46.6%) patients had poor response in both the groups A and B theparameters showed high significance but in comparison parameters showed nonsignificant value.
  12. 12. Sandhigatavata is a Vatavyadhi affecting people in the vardhakya avastha.The disease is characterized by dhatu kshaya and lakshanas reflective of vitiated Vata.Therefore, the agents/therapies of brimhana-shoolahara-stambhahara-balya propertiesshould be used in this disease. Janu basti imparts Snehana & Swedana and opens up thesrotas in the shareera facilitating more nourishment and free movement of Vata dosha.This results in the relief of stambha and facilitates free movement of the sandhis. All thedrugs in the Abhadi choorna are having shoolahara Srotoshodhaka balya, Rasayanaproperties; it is an ideal treatment of choice in Sandhigatavata.Key words: - Abhadi choorna; Sandhigatavata; Osteoarthritis; Janu basti Dhatu kshaya;Degeneration.
  13. 13. Acknowledgement One of the great pleasure of life is doing the things that others says youcannot do it, by the grace of god, bless of eiders I take this opportunity to express myregards to the persons who helped in completing this work. I express my deep sense of gratitude to his great holiness Jagadguru ShriAbhinava Gavisiddheshwara mahaswamiji for their divine blessings. I express my obligation to my honorable Guide Dr. V. Varadacharyulu M.D(Ayu), H.O.D., P.G. Department of Kayachikitsa, P.G.S & R, D.G.M.A.M.C, Gadagfor his critical suggestions and expert guidance for the completion of this work. I am extremely grateful and obliged to my co-guide Dr.Raghvendra.V.Shettttar M.D, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag forhis guidance and encouragement at every step of this work. I acknowledge my sincere gratitude to Dr. K. S. R. Prasad , Professor for theirsincere advices and assistance. I express my sincere and deep gratitude to Dr.G.B.Patil, Principal,D.G.M.A.M.C, Gadag, for his wholehearted encouragement as well as providing allnecessary facilities for this research work. I express my sincere gratitude to Dr. G. Purushothamacharyulu, Dr.M.C.Patil,Dr. Mulgund, Dr. P.Shivaramadu, Dr. Dilipkumar, Dr. Danappagoudar, Dr. KuberSankh, Dr. Santhosh. N.Belavadi, Dr. Jagadish metti, Dr. Nidagundi Dr.Shankergouda and other PG staff for their constant encouragement. I express my sincere thanks to my colleagues and friends Dr. B. L. Kalmat,Dr. Venkareddy, Dr. Uday Kumar, Dr. Ratna Kumar, Dr. S. C. Sarvi, Dr. Krishna. J,Dr. Umesh, Dr. Ashok. Akki, Dr. Ashok. M. G, Dr. Shekar Sharma, Dr. Shivaleela,Dr. K. M. Angandi, Dr. Sulochana, Dr. Sanjeeva, Dr.Niraj kumar, Dr. Prasanna Joshi,Dr. Vijaylakshmi, Dr. Veena. J, Dr. Manjunath. Akki, Dr. Suresh. N. Hakkandi, Dr.Ashwini Dev, Dr. Vijay Hiremath, Dr. L.R.Biradar, Dr. Santhosh.L.Y, Dr. Satish. R,Dr. Sharnbasappa Angadi, Dr. Anand H, Dr. Anitha, Dr. Jagadisha and other postgraduate scholars for their support & my room mates Manju, Santosh, Manthesh. I also express my sincere gratitude to Dr.S.D.Yargeri R.M.O. for his moralsupport and special care in providing the all the facilities during this trail work. I thank Dr. B. G. Swami, Dr.U.V.Purad, Dr. Paradi, Dr.Shankergouda,Dr.B.M,Mulkipatil and other undergraduate teachers for their support in the clinical
  14. 14. work. I thank to Shri. Nandakumar (Statistician), Shri.V.M.Mundinamani (Librarian),Mr.Surebana and other hospital and office staff for their kind support during mystudy. My cordial thanks to Dr. J.C.Shirol, Dr.V.C.Shirol, Dr. Karanth, Dr.Srinivasinternees for their significant contribution during my profession. Indeed, I will cherish the affectionate of my Mother, my Father,Smt.Shanthabai, Dr. Channaveerappa. Sarvi my sister Laleetha, brother-in-lawShashidar, my brother Mr. Mallikarjun and Babi, Smt. Suma all my family memberswho have been a source of inspiration for my entire carrier. I acknowledge my patients for their wholehearted consent to participate in thisclinical trial. I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. Finally I dedicate this work to who are the prime reasons for all my success.Date: Signature of the scholarPlace: (Dr.Shivakumar.Sarvi)
  15. 15. IntroductionIntroduction Sandhigatavata is the most common form of joint disorder. It is a majorcause of morbidity and disability as well as burden on healthcare resourcesespecially for the elderly. This disease keeps an insidious attack, which runs formany years causing the loss of function as well as deformity of the jointsespecially weight bearing joints like knee joint. Among elderly knee OA is theleading cause of chronic disability and some 1,00,000 people in the United Statesare unable to walk independently from bed to bathroom because of knee OA.1 The shortest description of this disease is available in Charaka2, Sushruta3and Ashtangahridaya.4 The later authors explained the clinical aspect of thisdisease in the wordings of either Charaka or Sushruta. So detail description ofSandhivata is not available in Ayurveda. But in contemporary science a greatwork has been carried out in this filed. Now researches are going on not only onindividual joints but they are concentrating on different sites within the joints.Eg, patellofemoral compartment Vestibio femoral. There have been advances in understanding of this disease. No longer isosteo-arthrosis regarded as a simple consequence of aging and cartilagedegeneration. Indeed, the former diagnostic label of ‘degenerative joint disease’is now recognized to be a ‘misnomer’. A single definition of Osteoarthritisremains elusive. A workshop held in 1995 proposes following consensusdefinition. “Osteo-arthritis disease is the result of both mechanical and biologicalevents that destabilize the normal coupling of degradation and synthesis ofarticular cartilage chondrocytes and extra cellular matrix and subchondral bone.” Though there is a lot of an advance in understanding of this disease, day-by-day the disease has become a problem. As a constellation of clinical andanatomical features, analogous to heart failure, indeed OA might with advantageEvaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 1 the management of Sandigatavata
  16. 16. Introductionbe renamed ‘joint failure’. Management of this disease is facing lot of difficulties.Contemporary science has failed to find a solution for this disease. It is clearlysaid that current treatment of Osteo-arthrosis is purely to control symptomsbecause there is no disease modifying Osteo-arthrosis drug yet. Intra articularsteroids are widely used in OA particularly for the knee, these injections mayprovide marked symptomatic relief for weeks to month. Because studies inanimal models have suggested that glucocorticoids produce cartilage damage, andfrequent injections of large amounts of steroids have been associated with jointbreakdown in humans, the injection should generally not be repeated in a givenjoint more often than every 4 to 6 months. From the very early ages Indian physicians have identified and recordedan innumerable herbs and minerals. Their studies were so accurate and extensivethat they still continue to provide a strong basis for the practice andexperimentations. In the present study, after consolidating all these views a package therapywas planned, this includes Abhadi choorna5 taken orally & ksheerabalataila Janubasti.6 The present study was carried out to assess the efficacy of classical line oftreatment in Sandhivata, with the aim to study the role of Abhadi choorna orally& Ksheera bala tail, Janubasti in the management of Sandhivata. Assessment wasmade on the basis of symptomatology. In the study an attempt is made to analyzeEtiopathogenesis, nidana and symptoms of Sandhivata based on informationavailable in contemporary science. In spite of the scientific advancement in the field of Medicine, a largenumber of people suffer from OA all over the world without a permanent relieffrom this disease. As such the demand and need for suggesting complete, Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 2 the management of Sandigatavata
  17. 17. Introductioncomplacent solace was felt. A sincere, dedicated research work was carried outand the same is humbly placed before ‘scholarly jury’ for consideration andacceptance.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 3 the management of Sandigatavata
  18. 18. ObjectivesObjectives of study The life style of the man has become mechanical. The timeand more desires have made the man unable to fallow the Swastha niyamas thereby becoming victim for the diseases. The man today even in his young adult agesuffering from the degenerative diseases like Sandhivata the conditions where thepain and swelling in the joints are present. Giving rise to the restrictedmovements,7 and also it is not a single disease rather it is end result of Varity ofpatterns of joint failure together or lesser extent it is always characterized by thedegeneration of articular cartilage and simultaneously proliferation of new bone.Radiological autopsy studies show that oesteoartritis prefentially targets onlycertain small and large joints there is steady rise in over prevalence from age 60 –65, 80% of people are having some radiological evidence of O.A. though only 20– 30 % have associated symptoms. Knee O.A is more prevalent & the over allprevalence of the disease in the population above 40 years of age is about 49 %with male to female ratio 1:1.8 Contemporary medical science is able to pacify thepain full conditions of above said disease through highly effective analgesics andanti-inflammatory drugs. If needed through the surgical method and ultimatelygive rise to complication & least effective. So to over come the degenerativeprocess in young adult age pacify the pain contemporary medical science is usingNSAIDS but larger anti inflammatory drugs are usually no more effective andcarry on increased risk of gastric erosion or hemorrhage in elderly distinctwomen.9 In addition a recent review of the literature abou5t non-steroidal anti-inflammatory the chance of hospital admission or death due to serious G.E eventup to 16 per thousand per year.10 To evaluate the efficacy of Abhadi churna in sandhigatavata. To evaluate the efficacy of ksheerabala tail janu basti in sandhigatavata.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 4 the management of Sandigatavata
  19. 19. Historical ReviewHistorical Review Historical review is necessary to understand origin and progressivedevelopment, that has taken place for centuries together. There is no directreference of the disease sandhigatavata in the vedic period. But indirectreferences in their most rudimentary form are available here and there. Thereferences available in Rigveda and Atarraveda, pertaining to vata, its bhedhashlesaka kapha sthana, and also joint disorders, and drugs used in vata rogas.11Vyadhi Sandhis and the diseases affecting them were well known in the Vedicperiod. One can observe description of body parts in Atharvanaveda where in thewords “Januni and Ashtivantau” were used to denote knee joints.12 The diseaseSandhigatavata had not been mentioned as such in Vedic literature. But inRigveda while describing various skills of Ashwinikumaras had recorded theirskill in treating joint diseases too13. One of the mantras of Rigveda states that, “Iam removing your diseases from each organ, hair and joint”14. Atharvanaveda hadmentioned Parvashoola and Vateekrita15, two diseases similar to Sandhigatavata.In Atharvanaveda, records about Vatavikaras are mentioned16. A mantra says,“destroy the balasa seated in the organs and joints which is responsible for loosingbones and joints”17. In purana kala18, 19 also references regarding sandivata areavailable. Samhitagranthas and Samgrahagranthas except Sharangadhara samhitahad described the disease Sandhigatavata with lakshana-chikitsa under theVatavyadhees20, 21,22, 23, 24, 25, and 26. Even though the description of Sandhigatavatais unavailable in Bhela samhita27, it is assumed that the verses are missing, as thedescription of Gatavatas such as amashayagatavata, pakwashayagatavata andraktagatavata etc. is available. In harita samhita28 also references regarding thisEvaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 5 the management of Sandigatavata
  20. 20. Historical Reviewdisease are available,also in chakradatta29, gadanigraha30 & Basavarajeeyam31mentioned about this disease. Osteoarthritis (OA) is the most common joint disorder in human beingsand other vertebrates. Even in giant dinosaurs, osteophytes leading to ankylosiswere detected. In all mammalian species like whales and dolphins and in fishbirds and some amphibians, Osteoarthritis is observed32. In the early ages, Hippocrates observed the prevalence of OA in agedindividuals (Benard, 1944) 33 Heberden (1803) studied this disease in detail andthe nodes on the fingers in OA disease were named after him34. Osteoarthritis wasdifferentiated from Rheumatoid Arthritis and named as degenerative arthritis byNichols and Richardson (1909) on morbid anatomical grounds35. Although themost ancient of the diseases, OA was first identified as a distinct entity in the 20thcentury36. Gold th ait in 1904 made a distinction between hypertrophic andatrophic arthritis and A.E Garrod recognized OA as a clinical entity in 1907.37Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 6 the management of Sandigatavata
  21. 21. Disease reviewAyurvedic reviewVyutpatti & Paribhasha1. Sandhi Vyutpatti - SAM + DHA + KIHI Nirukti - • Sandirnama Samyogaha38 • Asthidwaya Samyogasthana39 Sandhyarnama, asthanam, anyonya, sangam, asthani, junction, connection,combination, union with containing a conjugation, transition from one toanother40.Paribhasha: Sandhi pullinga, sandhanamiti, Yuga sandhini yugashabde dehasandhini marmashabde cha drishtavyaha41 In general, sandhi means the junction between two things in Ayurvedashareera sandhi is a technical word indicating that it is the place where two aremore bones meet together and the joint may be fixed type or of less or moremovement. Acharya Sushrutha told that, in our body there are innumerable2) GataVyutpatti- Gam – gamane42 Gam + Ktha43 Nirukti- Vata, Prapte, labdhe, Patite, Cha, Sameepe44, Come to, approached, arrived at, Being in, situated in, continued in, Paribhasha45- Gatam - thrillingam, gacchati, Janati, Yatteti3) Vata Vyutpatti - Va - Gati gandhanayoho Va - Gati sevanayoho Va + Kthaha46Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 7 the management of Sandigatavata
  22. 22. Disease review Pullinga Va + Kthaha47 Nirukti - Sparsha matra vishesha gunake bhutabheda - Pavane - dehasya dhatubheda cha48 - Wind, Air,as one of the humours of the body49 The word ‘Osteoarthritis’ is a combination of three words. ‘Osteon’,‘arthron’ and ‘it is’ respectively means bone, joint and inflammation50. Themeaning of this word is ‘inflammation to the bony joint’. In fact, there is noinflammation in this disease; hence, the disease is also known as Osteoarthrosisand degenerative joint disease.Prayaya of Sandhigata Vata Different authors named this disease according to their own views, ie. asfollows. • Sandhigata anila51 • Kudavata52 • Sandhi vata53 • Jeerna vata54Terminology of Osteoarthritis55 :- Four names, none of which are adequate are used interchangeablyto describe the disease. They are Osteoarthritis, Osteoarthrosis, Degenerative jointdisease and Hypertrophic arthritis. Osteoarthritis is less than ideal since theprimary event is not inflammatory, although secondary synovitis is usuallypresent. Osteoarthrosis is perhaps the best because the inflammation is secondaryand the suffix denotes an increase and an invasion, physiologic or pathologic, or ageneral over production. This early on, is a relatively clear description of what thedisorder is. Degenerative joint disease is unsuitable, since degenerative impliesaging, a running down, deterioration, and a catabolic process; in fact for longEvaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 8 the management of Sandigatavata
  23. 23. Disease reviewperiods, often years, the disease may not be clinically progressive. Hypertrophicarthritis now completely out of style, describes one phase the osteophytosis orovergrowth of bone.Nidana56, 57, 58, 59, 60, 61, 62, 63 Even though classics of Ayurveda do not mention the Nidanas of Sandhi-Gata-Vata, one has to compile the relevant references mentioned in differentcontexts like Vata Vyadhi Nidana (Ca.Sa.Ci.28/15-17, Su.Sa.Su.21/19,A.Hr.Ni.1/14-15, Yo.Ra.Pu.Vat.1-4, Bh.Pr.Ci.Vat.1-2, Ma.Ni.Pu.22/1-3),Asthivahasroto Dushtikarana (Ca.Sa.Vi.5/27), Majjavahasroto Dushtikarana(Ca.Sa.Vi.5/28). Nidana can be classified under various headings with different views.Among them one classification is Sannikrishta and Viprakrishta Karana. Herewith the complimentary references the Nidanas of Sandhi-Gata-Vata is classifiedon this basis.Sannikrishta Hetu – Ativyayama, Abhighata, Marmaghata, Bharaharana, Sheeghrayana,Pradhavana, Atisankshobha.Viprakrishta Hetu –Rasa – Kashaya, Katu, TiktaGuna – Rooksha, Sheeta, LaghuDravya – Mudga, Koradusha, Nivara, Shyamaka, Uddalaka, Masura, Kalaya,Adaki, Harenu, Shushkashaka, Vallura, Varaka.Aharakrama – Alpahara, Vishamashana, Adhyashana, PramitashanaManasika – Chinta, Shoka, Krodha, BhayaViharaja – Atijagarana, Vishamopacara, Ativyavaya, Shrama, Divasvapna,Vegasandharana, Atyucchabhashana. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 9 the management of Sandigatavata
  24. 24. Disease reviewSome of the important Nidanas are discussed below-Ativyayama Excessive physical exercises act as one of the important Nidana forSandhi-Gata-Vata. Running, walking, jogging etc. if done excessively or violentlywill affect the structures of Sandhi. They mainly affect the Joint stability by overexertion. But if done properly they stabilize the Joint.Bharaharana Carrying excessive load causes excessive pressure and stretching effectover the structures of the joint. As knee is weight bearing joint, carrying excessiveload will have direct affect on articular disc. The constant compression will leadto wear and tear effect leading to degenerative changes in the discs.Abhighata Abhighata to joints due to Prapatana etc., lead to structural deformity inthe joints. Joint is an organ rather than a single structure. It is stabilized bydifferent structures like Asthi, Snayu, Peshi, and Kala etc. Hence any trauma tothese structures will alter the structural integrity of the joint. Hence Abhighata isan important Nidana for Sandhi-Gata-Vata.Atisankshobha It is a Nidana for Asthivaha Sroto Dushti. Since Asthivaha Srotas isinvolved in Sandhi-Gata-Vata this can be considered as Nidana for the same.Violent activities like Atyadhva, Plavana, Langhana, Balavat Vigraha,Pradhavana etc. will have its effect on joint. As told earlier knee is the weight-bearing joint, the violent exercises or activities will alter the structural integrity ofthe joint.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 10 the management of Sandigatavata
  25. 25. Disease reviewMarmabhighata The concept of Marmabhighata in the causation of Sandhi-Gata-Vatasounds more rational. Janu-Sandhi is a variety of Vaikalyakara Sandhi-Marma64.Marma is a vital point, which comprises of Asthi, Snayu, Sira, Mamsa andSandhi. Hence any Marma is made up of all these structures, like wise the Janu-Sandhi. Pain in the joints not necessarily be only associated with bony changes.But involvement of other joint structures may also give rise to symptomspertaining to joint. Therefore, in recent days more study is emphasized on thedifferent structures involved in the pathology of Arthritis like consistency of softtissue, fibrous material, liquid and cartilaginous substance of the joint. From thisnew point the Ayurvedic view towards the involvement of certain Marma in thedisturbance of the joint i.e. painful joint will be anticipated. HenceMarmabhighata as a Nidana in case of Sandhi-Gata-Vata is to be givenimportance.TABLE.2SAMANYA NIDANA OF VATA VYADHI AS EXPLAINED IN DIFFERENT TREATISESNidana Ca. Sam Su. Sam A.H MN YR BPAharaja NidanaKashaya - + + - - +Katu - + + - - +Tikta - + + - - +Rooksha + + + + + +Laghu + - + + + -Sheeta + - + + - -Vallura + - - - - -Varaka + - - - - -Shuskha Shaka - + - - - -Uddalaka - + - - - -Neevara - + - - - -Mudga + - - - - -Masura + - - - - -Harenu + - - - - -Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 11 the management of Sandigatavata
  26. 26. Disease reviewKalaya + - - - - -Nishpava - + - - - -Viharaja NidanaAti Vyayama + + + + - -Langhana + + - + + -Plavana + + - + + -Atyadhwa + - - + + -Pradhavana - + - - - -Pratarana - + - - - -Atyuchabhashana - + - - - -Balavadvigraha - + - - + -Abhighata + + - + - +Marmaghata - - + + - -Bharaharana + - - - + -Dukhashayya - - + + - -Dukhasana + - - - - -Sheegrhayana + - + + - -Prapeedana - + - - - -Atiadhyayana + - - - - -Ati vyavaya + + + + + +Atijagarana + + + + + +Vegadharana + + + + + -Vishamopachara + - - + + -Shrama - - - - - +Upavasa + + + + + +Puravata sevana - - - - - +Divasvapna + - - - - -Manasika karanaCinta + - + + + +Shoka - + + + + -Krodha - - - - - -Bhaya - - - - + -4) Anyat (other nidanas): - Panchakarma apacharas like atidoshasravana, atirakthasravana, atiyoga oflanghana, apatamsana etc and dhatukshayakarabhavas like rogakarshana,gadakrita atimamsakshaya, etc vitiate Vata. Dhatukshaya is an important vitiatingfactor of Vata. Sthoulya is another causative factor for Vata prakopa. The meda-avarana of Vata is the mechanism causing inter-relationship between sthoulya andVatavyadhis65. All types of avaranas are also important vitiating factors of Vata.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 12 the management of Sandigatavata
  27. 27. Disease reviewVata dominates vardhakya avastha66. During this period, dhatukshaya occurscausing Vata prakopa. Living in jangaladesha is another causative of Vata prakopa67. Vata getsvitiated in the end of day and night68. Vata also get vitiated during the end ofgreeshma ritu, varsha ritu and shishira kala69. Vata prakriti persons are moresusceptible to Vata vikaras. Persons who are rooksha-kashaya-katu-tikta satmyaare also more susceptible to Vata vikaras. Among all the types of nidanas mentioned some need special attention.Adhyashana leads to excessive body weight and this results in more pressure overweight bearing joints. This gradually weakens the sandhis and producesSandhigatavata. Excess exercise may not only vitiate Vata but further leads toshleshaka kapha kshaya contributing to Sandhigatavata. Excess walking andexcessive weight bearing also are important in the context of Sandhigatavata.Abhighata to marmas or sandhis is another important risk factor forSandhigatavata. Vardhakya avastha characterized by dhatukshaya leading topeshi-snayu-marma shosha, thereby resulting in looseness of joints is also a majorrisk factor for Sandhigatavata. The factors like that vitiate asthivahasrotas(ativyayama, atisamkshobhana, asthivighattana and vatalasevana) 70also need tobe mentioned in the nidana of Sandhigatavata.Risk factors for Osteoarthritis (OA)71Age factor – Age is the most powerful risk factor for OA. The association between OAand aging is non-linear. It usually begins after a person is 40 or more years old.By the age of 60 years, almost everyone has OA. More than 80% of people over60 years old have radiological evidence of OA in one or both knees and 30% inone or both hips.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 13 the management of Sandigatavata
  28. 28. Disease reviewSex factor – It is told that women are at high risk than men in developing OA. Over30% of women (elderly) have OA in the interphalangeal joints of the hands.Except in the hands, men and women are affected equally, though the lesionsoften appear at a young age in men. Only 3% of elderly men have primary OA inthe hands.Hereditary factor – The relation of heredity is less ambiguous. Thus, the mother and sister of awoman with distal interphalangeal joint OA are respectively twice and thrice aslikely to exhibit OA as the mother and sister of an unaffected woman.Race factor – Racial difference exists in both the prevalence of OA and the pattern ofjoint involvement. OA is more frequent in Native Americans than in whites. TheChinese in Hong Kong have a lower incidence of hip OA than in whites.Interphalangeal joint OA and especially hip OA are much less common in SouthAfrican blacks than in whites in the same population. Whether these differencesare genetic or are due to differences in joint usage related to life style oroccupation is unknown.Obesity factor – Obese persons have a high risk of OA. For those in the highest quintile forbody mass index at base line examination, the relative risk for developing kneeOA in the ensuing 36 years was 1.5 for men and 2.1 for women. For severe kneeOA, the relative risk rose to 1.9 for men and 3.9 for women, suggesting thatobesity plays an even larger role in the etiology of the most serious cases of kneeOA.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 14 the management of Sandigatavata
  29. 29. Disease reviewOccupational factor – Repetitive movements may leads to excessive strain leading to erosion andjoint damage. Men whose jobs require knee bending and at least medium physicaldemand had a higher rate of radiographic evidence of knee OA and more severeradiographic changes.Traumatic factors – Trauma to the joint seems to enhance the occurrence of arthritis. Itdisturbs the alignment of the joints and over a period of time, this malalignmentmay lead to excessive wear and tear leading to OA. According to the cause of OA, it is classified as primary and secondary.Primary OA is the term used when the disorder arises form unknown or hereditarycauses. Secondary OA describes cases in which direct causes for the disorder areknown.Classification based on causes72I. PrimaryIdiopathic, Primary generalized osteoarthritis and Erosive osteoarthritis.II. SecondaryCongenital or developmental defects (Hip dysplasias, shallow acetabulum,Morquio’s syndrome, etc.),Traumatica. Acute, b. Chronic and c. Charcot’s arthropathy,Inflammatory RA, psoriatic arthritis, septic arthritis, pseudogout,Endocrinal influence Acromegaly, diabetes mellitus, sex hormone abnormalities,hypothyroidism with myxedema and Metabolic Gout, itemochromatosis,ochronosis, chondrocalcinosis, paget’s disease.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 15 the management of Sandigatavata
  30. 30. Disease reviewSamprapti From the onset of Dosha Dushya Dushti till the evolution of the Vyadhithere occurs various Vikriti. Samprapti explains such series of pathological stagesinvolved. It tells us about the total pathogenesis of a disease. The Samanya Samprapti of Vata Vyadhi that is explained in classics canbe considered as the Samprapti of Sandhi-Gata-Vata or a base to understand theSamprapti of Janu-Sandhi-Gata-Vata. Acarya Caraka explained73 – due to the intake of Vatakara Ahara ViharaVata vitiation take place. This vitiated Vata lodges in Rikta Srotas i.e. Srotas inwhere Shunyata of Snehadi Guna is present. Vata after settling in Rikta Srotasproduce disease related to that Srotas. Acarya Vagbhata frames the Samprapti of Vata Vyadhi like –Dhatukshaya aggravates Vata and the same is also responsible to produce Riktataof Srotas. Thus the vitiated Vata travels through out the body and settles in theRikta Srotas and further vitiates the Srotas leading to the manifestation of VataVyadhi 74. Here an attempt has been made to explain how this Srotoriktata occurs dueto Nidanasevana. The chief properties of Parthiva Dravya are Guru, Sthula,Sthira, Gandha Guna in excess. These are the properties, which are necessary forSthairya and Upacaya of the body. Excessive intake of Dravyas having Laghu,Ruksha, Sukshma, Khara properties lead to Guru and Sneha Guna Abhava due totheir opposite quality. Thus it leads to Dhatukshaya in the body. Akasha is theMahabhuta that produces Sushirata and Laghuta in the body. Vayu Mahabuta fillsup this Sushirata. So due to Dhatukshaya Akasha Mahabhuta increases in thebody producing Sushirata and Laghuta simultaneously Vayu fills it up.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 16 the management of Sandigatavata
  31. 31. Disease review From this description it can be stated that the meaning of word ‘Riktata’ isSushirata i.e. increase in Akasha and Vayu Mahabhuta. While commenting onword ‘Riktata’ Cakrapani says that ‘Riktata’ means lack of Snehadiguna. For thepurpose of understanding the Samprapti of SandhiVata can be studied under twoheading.They are -1. DhatuKshaya Janya and2. Avarana Janya Sandhi-Gata-Vata.1. DhatuKshaya Janya Sandhi-Gata-Vata In old age Vata Dosha dominates in the body. This will lead to KaphaAbhava. Also Jataragni and Dhatvagni gets impaired, by which Dhatus formedwill not be of good quality. Degeneration of body elements takes place due topredominance of Vata in its Ruksha, Khara, etc. Guna and loss of Kapha inquality and quantity. As the Shleshma Bhava decreases in the body, the Kapha Bheda i.e.Shleshaka Kapha in the joints also decreases in quality and quantity. Reduction ofKapha in Sandhis makes Sandhi Bandhana Shithilata. Ashrayashrayi Sambandhaalso leads Asthidhatu Kshaya. Asthi being the main participant of the joint itsKshaya leads Khavaigunya in the joints. In this condition if Nidana Sevana done further produces Vata Prakopa. IfVata Prakopa is not corrected by appropriate means and simultaneously if theperson indulges in Asthivaha and Majjavaha Sroto Dushtikara Nidana, thePrakupita Vata spreads all over the body through these Srotas. In the meantimeSthanasamshraya of Prakupita Vata take place in the Khavaigunyayukta Janu-Sandhi. This localized Vayu due to its Ruksha, Laghu, Kharadi Guna over powerand undo all properties of Sleshaka Kapha producing disease SandhiVata.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 17 the management of Sandigatavata
  32. 32. Disease review2. Avarana Janya Sandhi-Gata-Vata In Sthulas usually Sandhi-Gata-Vata occurs in weight bearing joints. Inthem Medodhatu will be produced in excess due to the Atisnehamsha ofAmarasa75. The excessive Medas will produce obstruction for the flow of nutritivematerials to the future Dhatus i.e Asthi, Majja and Shukra leads to their Kshaya. The excessive fat deposited all over the body will produce Margavarana ofVata76 (Su.Sa.Su. 15/32 – Dal.). Prakupita Vata due to Margavarana starts tocirculate in the body. While traveling it settles in the joint where Khavaigunya isalready exists. After Sthanasamshraya it produces the disease Sandhi-Gata-Vatain the same process mentioned in the earlier context. Thus with the help of Samanya Samprapti of Vata Vyadhi the Sampraptiof Janu-Sandhi-Gata-Vata can be divided into Dhatukshaya Janya and AvaranaJanya. This will help in deciding the prognosis and planning the treatment of thedisease.Samprapti Ghataka:Dosha – Vata – Vyana – Vriddhi; Kapha – Shleshaka – KshayaDooshya – Peshi, Snayu, Asthi, MajjaSrotas – Mamsavaha, Medovaha, Asthivaha, MajjavahaAgni – Jataragni, Asthi-DhatvagniAma – Jataragni Mandya JanyaRoga Marga – MadhyamaUdbhavasthana – PakvashayaSancharasthana - SarvashariraAdhishtana – SandhiVyaktasthana – SanEvaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 18 the management of Sandigatavata
  33. 33. Disease reviewPoorvaroopa77 Particular mentioning of Poorvaroopa of Sandhi-Gata-Vata is not availablein classics. In Vatavyadhi also unmanifested symptoms (Avyakta) or mildexhibition of actual features of the disease itself (Alpa vyakta) is considered as itsPoorvaroopa. Hence clinical features of Sandhi-Gata-Vata in milderform can be considered as Poorvaroopa.ROOPA The clinical features of Sandhi-Gata-Vata explained by various Acarya arelisted in TableRoopa of Sandhi-Gata-Vata mentioned in various classicsSymptoms Ca.Sa. Su.Sa. A.Hr. A.Sa. Ma.Ni. Bh.Pr. Yo.Ra.Sandhi Vedana + + + + + + +Sandhi Shotha + + + + + +Sandhi Stabdhata + +Atopa +Sandhi Vedana All the Acarya have described this symptom. Caraka77 and Vagbhatas78explain that pain in the joint is elicited during Prasarana Akunchana Pravrutti.Sandhi Shotha Most of the authors explained this symptom. Caraka and Vagbhatasexplained the nature of Shotha i.e., it is felt like bag filled with air (Vata PoornaDriti Sparsha).Sandhi Stabdhata Sushruta79 initially described this symptom, later by texts like MadhavaNidana80, Yogaratnakara81 and Bhavaprakasha82. They have coined the term Sandhi Hanana or Hanti. While commenting onthis word Dalhana83 and Gayadasa explained as AkunchanaprasaranayohEvaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 19 the management of Sandigatavata
  34. 34. Disease reviewAbhavah and Prasaranakuncanayoh Asamarthah respectively. With this we caninfer that the word Hanti refers to inability to move the joints. In the opinion of madhukoshakara84, Hanti referes to Sandhi Vishlesha,Stambha Adi Vikara. Hence with the above references, Hanti refers to SandhiStabdhata.Atopa This symptom explained in Madhava Nidana85. While commenting on theword Atopa in another context, Madhukoshakara quotes the opinion of Gayadasaand Kartika.I.e.‘Atopaha Chalachalanamiti Gayadasaha, Gudaguda Shabdamiti Kartikah’.Also Bhavamishra86 says ‘Atopo – Gudagudashabdaha’ Thus we can say that Atopa in this context is the sound produced by themovement of joints i.e., Crepitus. Thus with the help of different references andby the opinion of commentators it can be concluded that Sandhi Shoola, SandhiShotha, Sandhi Stabdhata and Atopa are the clinical features of Sandhi-Gata-Vataor Janu-Sandhi-Gata-VataVyavachedakanidana Sandhigatavata is a disease affecting the bony joints. So virtually everydisease that affects the joints has to be differentiated with Sandhigatavata. Themost common differentiation is to be made with Vatarakta, Amavata andKroshtrukasheersha.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 20 the management of Sandigatavata
  35. 35. Disease reviewShowing Vyavachedakanidana between Sandhigatavata and Vataraktha Sl. Criteria SGV Vatarakta 1 Nidana Vatavridhikara Vidahi,viruddha, Ahara-vihara rakthaprakopakara ahara 2 Poorva roopa Avyaktharoga lakshana Kushtasama 3 Roopa Sandhishoola, Teevra ruk, Prasarana akunchanayoho Grathita-paki vedana, Sandhi shopha, shvayathu Vatapoornadrithi sparsha 4 Adhisthana Sandhi Padamoola, Hastamoola 5 Doshas Vata Vata, Rakta 6 Upashaya Ushna - snigdha SheetaTable No. . Showing Vyavachedakanidana of Sandhigatavata and Amavata Sl. Criteria SGV Amavata 1 Nidana Vatavridhikara, ahara-vihara Viruddhaahara- cheshta 2 Poorva roopa Avyaktharoga lakshana Hridaya dourbalya, gourava 3 Roopa Sandhishoola, Vrischika Prasarana akunchanayoho damshavat vedana, Sandhi shopha, peeda, Vatapoornadrithi sparsha Pidakayukta shopha 4 Adhisthana Sandhi Hasta,Pada, Gulpha, Trika, Janu 5 Dosha Vata Vata, Kapha 6 Upashaya Ushna, snigdha Ushna-rookshaShowing Vyavachedakanidana of Sandhigatavata & KroshtrukasheershaSl. Criteria Sandhigatavata Kroshtrukasheersha1 Nidana Vatavridhikara Vatavridhikara ahara-vihara ahara-vihara2 Poorva roopa Avyaktharoga lakshana Avyaktharoga lakshana3 Roopa Sandhishoola, Maharuja, Prasarana akunchanayoho Janushopha vedana, Sandhi shopha, Vatapoornadrithi sparsha4 Adhisthana Sandhi Jan Madhya5 Dosha Vata Vata, rakta6 Upashaya Ushna, snigdha Snigdha, seethaEvaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 21 the management of Sandigatavata
  36. 36. Disease reviewTable No. 15. Showing Differential diagnosis between OA, RA, Gout andRheumatic fever.Sl. Criteria OA RA Gout Rheumatic Fever1 Symptoms Pain & swelling Inflammation Polyarticular Painful and on in multiple pain, swelling tender joints major weight joints, & bearing joints, morning inflammation, stiffness, stiffness exquisite crepitations, >30ms tenderness tenderness, enlargement of joint space2 Mode of Gradual Abrupt Acute Acute On set3 Joints Weight bearing Polyarticular Metatarso- Polyarticular Involved joints phalangeal joints4 Systemic - Autoimmune - Carditis, Features disease, rise fever, chorea in temperature, anemia etc.5 Investigations RA-ve, ESR ESR raised, Serum uric ESR normal, X-ray- X-ray-soft acid raised, increased, narrowing of tissue punched out CRP high, joint space, swelling. lesions in WBC subchondral subchondral elevated. bony sclerosis, bone. osteophytes etc.Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in 22 the management of Sandigatavata
  39. 39. Disease reviewJanu Sandhi - Knee Joint In Janu-Sandhi-Gata-Vata the vitiated Vata get lodges at Janu-Sandhi.Therefore before going to the disease aspects, the anatomy and physiology of Janu-Sandhi are to be under stood properly. In classics we have scattered reference ofanatomical and physiological consideration of Janu-Sandhi. Here an attempt is madeto enumerate those structures, which are helpful in maintaining the stability of thejoints.In Ayurveda, Sandhis are mainly classified into two types; 1) Sthira Sandhi 2) Cala Sandhi 87Again they are sub classified into eight types.88 1) Kora 5) Tunnasevani 2) Ulookala 6) Vayasa tunda 3) Samudga 7) Mandala 4) Pratara 8) Shankhavarta Acarya Sushruta- father of Surgery considered Janu-Sandhi under Cala Sandhiand sub classified under Kora Sandhi (Su.Sa.Sh.5/27).Shleshaka Kapha- Among five variety of Kapha, Shleshaka Kapha resides in joints.It keeps the joints firmly united, protects their articulation opposes their separationand disunion 89.Shleshmadhara Kala - It is the fourth Kala, which is situated in all joints of livingbeings. As wheel moves on well by lubricating the axis, joints also function properlyif supported with Kapha. This helps in lubrication of joints90. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 23 management of Sandigatavata
  40. 40. Disease reviewVyana Vata - Vata governs every movement in the body. Vyana Vata is one amongthe five varieties of Vata, which resides at Hridaya and controls most of the motorfunctions. The Gati or physical movement is also one of its functions. Gayadasa commenting on Sushruta has quoted the wordings of an unknownauthor as though the Vyana Vata is functioning all over the body it resides in theSandhi91. Acarya Vagbhata states that Vata is located in the Asthi with relation toAshrayashrayi Sambandha. Generally augmentation or diminution of Doshas wouldbe given similar effect on their respective Dhatus but in case of Vata it is opposite;with increase in Vata, Asthi Kshaya occurs92. Sushruta in Sharirasthana explains different structures of the human body.Among them, structures coming under Janu-Sandhi are listed below.Snayu - Among nine hundred Snayus, ten are present in Janu-Sandhi. More over inShakha and Sandhi, Pratana variety of Snayu is present. Importance – As a boatconsisting of planks becomes capable of carrying load of passengers in river after it istied properly with bundle of ropes, all joints in the body are tied with many ligamentsby which persons are capable of bearing load93.Peshi- The fleshy mass demarcated from each other is known as Peshi. In Janu theyare five in number. They are strong structures that help to maintain alignment of thejoint94.Sanghata - Assemblages of bones are fourteen. One is situated in Janu-Sandhi95. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 24 management of Sandigatavata
  41. 41. Modern reviewKnee joint Before discussing the disease Janu-Sandhi-Gata-Vata it is very essential tounderstand the structure of knee joint, functional aspects of articular cartilage,synovial fluid and synovial membrane etc. Joints or articulations are the site where two or more bones meet. Joints are theweakest part of the skeleton but their structures resists various forces, such ascrushing or tearing that threaten to force them out of alignment. Joints are classified structurally and functionally. Fibrous, cartilaginous andsynovial are structural classification. Synarthrosis, amphiarthrosis and diarthrosis arefunctional classification. The present study was undertaken to assess the efficacy of janubasti in themanagement of sandhi gata vata. Before discussing the disease sandhigata vata it isvery essential to understand the structure of knee joint, functional aspects of articularcartilage, synovial fluid and synovial membrane so all these points are summarisedhere.The articular surfaces- Knee joint is formed by 1) The condyles of femur 2) The condyles of tibia 3) The patella The femoral condyles articulate with tibial condyles below and behind andwith patella in front.Condyles of Femur - The lower end of femur is widely expanded to form two largecondyles a medial and a lateral. The condyles are partially covered by a largearticular surface, which is divisible into patellar parts. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 25 management of Sandigatavata
  42. 42. Modern review The patellar surface covers the anterior surfaces of both condyles and extendson more lateral condyle than on the medial. The tibial surfaces cover the inferior and posterior surfaces of the twocondyles and merge anteriorly with the patellar surface. The lateral part of the surfaceis short and straight anteroposteriorly. The medial part is longer and curved withconvexity directed medially.Tibia Medial condyle -superior articular surface is oval anterio posteriorly. Theperipheral part is flat and articulates with medial memiscus, the central part is slightlyconcave and articulates with medial condyles of femur. The raised lateral margincovers the medial inter condylar tubercle.Lateral Condyle - The superior articular surface is mearly circular. The peripheralpart is flat and articulates with lateral meniscus. The central part is slightly concaveand articulates with the lateral condyle of femur.Patella -Patella is the largest sessamoid bone in the body. It is triangular in shapewith its apex directed downwards, which is non articular posteriorly. Anterior surface is rough and non-articular, the upper 3/4th of the posteriorsurface are smooth and articular. The posterior articular surface divided by a verticleridge into a large lateral area and a smaller medial area. Structurally knee is a weekjoint, because the articular surfaces are non congruent. The tibial condyles are toosmall and shallow to hold the large convex femoral condyles. The femero patellararticulation is also quite insecure because of their shallow surfaces and also theoutward angulation between the axes of thigh and leg. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 26 management of Sandigatavata
  43. 43. Modern review The stability of the knee joint is maintained by many factors. Knee joint issupported by fibrus capsule. The fibrous capsule is very thin and is deficientanteriorly when it is replaced by quadriceps femoris, patella and ligamentum patella.Synovial Membrane - It lines the capsule except posteriorly where it is reflectedforwards by the cruciate ligaments forming a common covering for both ligaments.Semilunar Cartilage (Menisci) - These are two fibro cartilaginons crescents. Whichtry to deeper the articular surfaces of the condyles of tibia and partially divides thejoint cavity into the upper and lower compartments.Ligaments Ligamentum patella, tibial, collateral ligament, femoral collateral ligament,oblique popliteal ligament, arcuate popliteal ligament, cruciate ligament. Explanation of janukapala (patella) is available in Sushruta and Charakasamhita. Acharya Charaka and Kashyapa while explaining the asthisankhya denotes.Janvasthini dose, sankyate, chatwaryosthini jangayoho, dwarunalakau, dwechakhyathe janukapale. In the olden days also our acharyas had an idea of synovial membrane.Sushruta clearly mentioned that the fourth kala is Shleshmadharakal a which issituated in every sandhis and performs lubrication for movement. How a wheelwhich is lubricated by oleation functioning normally. Likewise all the sandhisfunction normally in the presence of shleshmadhara kala and also protects it formdestruction .Synovial Fluid - It is found in the cavities of synovial joints. The main function of itis lubrication and also nourishment of the articular cartilage. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 27 management of Sandigatavata
  44. 44. Modern review The physical nature of this is a clear or pale yellow, viscous glariry fluid ofslightly alkaline pH at rest. This nature varies widely between different joints andspaces. The physical properties of synovial fluid changes according to theenvironment in the joint. Viscosity is very sensitive to changes in dilution and that itfalls with increasing temperature and increasing pH. The elasticity property is alsoaffected similarly. The composition of synovial fluid is some protein (about 0.9mgm/ml) andwith added mucin. Hyalouronic acid which is sulphate free mucopolysaccharidecomposed of basic units that are polymerised. The synovial fluid also consists of moncytes, lympocytes, macrophages freesynovial cells and occasional polymorphonuclear leucocytes. Amorphous,metachromatic particles and fragments of cells and fibrous tissue sometimes found insynovial fluid are resulted by the slow wear and tear of joint surfaces. It is very clear by Vagbhatas statement that, shleshmaka kapha not onlysupports sandhis but also provides movements in the normal direction.AcharyaSushruta states that it holds and nourishes the sandhi.Articular Cartilage Majority of bones are formed a special variety of hyaline cartilage. Articularcartilage has a wear resistant, low friction lubricated surface, both slightlycompressible and elastic which is ideally constructed for easy movements over asimilar surface but also absorb enormous forces of compression and shear generatedduring weight bearing and muscle action. This is due to the Shleshaka kapha in the joint. Due to its snigdha and picchilaguna it lubricates the joints and avoids friction on movement. Thus the cartilage acts Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 28 management of Sandigatavata
  45. 45. Modern reviewas wear resistant. Elasticity and compressibility of the cartilage is due to themridhutwa and shlakshna guna of kapha.The Extracellular Matrix of Normal Articular Cartilage Articular cartilage is composed of two major macromolecular species:Proteoglycans (PGS), which are responsible for the compressive stiffness of the tissueand its ability to withstand load and collagen, which provides tensile strength andresistance to shear. Although lysosomal proteases have been demonstrated within thecells and matrix of normal articular cartilage, their low pH optimum makes it likelythat the proteglycanase activity of these enzymes will be confined to an intracellularsite or the immediate pericellular area. However cartilage also contains a family ofmatrix metalloproteinases (MMPs) including stromelysin, collagenase and gelatinasewhich can degrade all the components of the extra cellular matrix at neutral pH. Eachis secretedby the chondrocyte as a latent pro enzyme that must be activated byproteolytic cleavage of its N-terminal sequence. The level of MMP activity in thecartilage at any given time represents the balance between activation of theproenzyme and inhibition of the active enzyme by tissue inhibitor (Keneeth, 1996). Osteoarthritis is the commonest form of arthritis or joint disease and is a veryimportant cause of pain and disability in advancing years of life. Some degree ofosteoarthritis will develop in everyone in old age and it is estimated that three out offour persons of more than 60 years of age will have definite evidence of osteoarthritisin at least one joint, and one out of ten persons beyond the age of 60 years will havesufficiently advanced disease and have so much trouble that medical advise will besought. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 29 management of Sandigatavata
  46. 46. Modern review In the next two decades the proportion of aged in population is going toincrease steadily and so will increase in the incidence of osteoarthritis and with acommensurate increase in the cost of treatment of this most common joint disease.The natural history of osteoarthritis is variable and joint specific. Osteoarthritis mayremain stable or static for many years, or be progressive, or may have periods ofwaxing and warning of symptoms.Osteoarthritis has no effect on longevity of persons affected with this disease, but canbe quite debilitating in terms of limiting activities and diminishing overall quality oflife. These limitations in activities, usually with pain occurring at or just oftenretirement can add an element of anxiety and depression and make the matters worse.It is therefore necessary for everyone to know what is osteoarthritis, how it develops,what are the risk factors, and what can be done to alleviate the suffering anddiscomfort. With better understanding and knowledge about osteoarthritis along withavailability of medicines and development of operations with successful jointreplacement surgery much can be done to alleviate the pain and deformity and makethe person regain functional ability.How Healthy Joints Work Joints are parts of body where one bone meets the other and movement occurssuch as elbow, knee, hip and ankle. Backbone or spine also has large numbers ofsmall joints, which allow us to move our neck, and back in all possible directions.Ends of bone which meet each other at joint are covered by cartilage. Cartilage iswhite, smooth, glistening material and is very specialized which functions as acushioning material and a shock absorber so that hard bones do not rub against eachother, and the cartilage also reduces friction during joint movement since its surface is Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 30 management of Sandigatavata
  47. 47. Modern reviewvery smooth. In fact no man made material can match the low friction and shockabsorbing properties of healthy cartilage in the joint. Cartilage is made up of toughfibres of a protein called collagen - Enmeshed in these fibres of collagen are the largemolecules of another protein called proteoglycan. Proteoglycan molecules contain lotof water in their interior. Water keeps on moving in and out of the domain ofproteoglycan molecules almost like water being sucked in and squeezed out ofsponge. This property of ability to exchange water so easily gives an elasticcharacteristic to the cartilage. Collagen fibres give desired strength and proteoglycanmolecules allow reversible compression. The combined structure thus makes up forthe tough but not too rigid quality needed for this very specialized tissue. The bone ends with cartilage covering are enclosed in a membrane calledsynovium. The synovium releases a slippery fluid know as synovial fluid and thisfluid further reduces the friction between moving surfaces capped with cartilage andensures that the joint moves easily and smoothly. The synovial fluid or joint fluidformed by synovial membrane is a special type of fluid that behaves like fluid whenthe joint is being moved and during walking when the joint is loaded its characterchanges to something like jelly to act as an additional shock absorber. The synovialfluid nourishes the cartilage. The cartilage has no blood vessels and relies on synovialfluid moving in and out to provide nutrients and take away the waste products. Ends of bone, cartilage and synovium are further enclosed in a layer of tissuecalled capsule. Capsule is a thick and strong tissue but is capable of stretching whenjoint moves. The combination of bone ends with cartilage covering, synovium andcapsule is the joint. The joint is further covered by muscles and tenders, whichsupport the joint and also provide the power to move the joint.What Happens in Osteoarthritis Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 31 management of Sandigatavata
  48. 48. Modern reviewIn osteoarthritis changes occur both in the cartilage and the synovial fluid. Changes inthe cartilage are easily seen even without microscope and are therefore well known,whereas changes in the synovial fluid are not discernible without the use ofspecialized tests and equipments. The synovial fluid changes in character andcomposition and it loses its characteristic capacity to behave in a jelly like manner andact as a shock absorber when the joint is loaded. The cartilage therefore has to sustainmore load and impact. At the same time the cartilage also undergoes subtle changes in chemicalcomposition in a way that proteoglycans decrease and water content increases. As aresult the collagen fibrils become disrupted and disorganized. The cartilage has nowbecome soft due to disorganization of tight collagen fibrils, and also swollen due toincreased water content. It has thus become less resistant to forces gradually developscracks or fissures, breaks into fragments usually known as fibrillations, becomes thinand completely disappears in places. Over a period of time most or all of the cartilage covering at the end of bonemay disappear. This is seen on x-ray as gradual decrease and then disappearance ofjoint space. The loss of cartilage leaves the bone end exposed. Similar changes occuron both sides of the joint and therefore now instead of cartilage moving againstcartilage, a situation develops where bone is moving against bone. These changesabolish smooth and frictionless movement at the joint. The broken pieces of cartilageand bone fragments lie in the synovial fluid and this irritates synovial membrane toproduce more fluid. This fluid, of course, is not of the same composition and physicalcharacter as the normal synovial fluid. The joint swells up due to excessive fluid in it. Bone rubbing against bone, stretching of joint capsule due to excessive fluidand increased friction in the joint, all three elements produce pain and difficulty in Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 32 management of Sandigatavata
  49. 49. Modern reviewmoving the joint. This is perceived as stiffness in the joint as the increased effortrequired to move the joint. Along with this, the range of joint movements becomesless. The bone ends gradually become misshapen and develop bony spurn at themargins called osteophytes. With advancing disease a part of the end of bone may beextensively rubbed of and this produces severe deformity of the joint. The jointdeformity is most easily seen at the knee joint. In advanced osteoarthritis of knee theleg does not remain straight but bends to one side commonly towards insideproducing bow leg deformity or sometimes bends outwards to produce knock-kneedeformity. Very briefly changes in the joint is like getting dirt in your eye. Similarlythe cartilage wears down and becomes fragmented into little pieces, which continuesto grind inside the joint.Which Joints Are Affected?Although any synovial joint in the body may be affected with osteoarthritis, certainjoints are more often affected and these are as below: -Knee - is the most commonly involved joint and gives rise to considerable problemwith walking and sitting on floor. The deformity of leg when disease has progressedbeyond a certain point is also seen and recognized by the person himself and others.The deformity is usually of bowlegs and sometimes of knock-knees. Usually bothknee joints start to give trouble together, but in some persons disease may be seen tostart and produce symptoms in one knee first and the other knee start to give troubleafter a period of some months.Hip - is the joint next in frequency to the knee where osteoarthritis develops. In Indiahip osteoarthritis is less frequent than knee osteoarthritis due to many reasons, someof which are not yet understood and defined. The trouble may start first in one hip andthen after some months the other hip starts to give trouble, or both hips can become Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 33 management of Sandigatavata
  50. 50. Modern reviewsymptomatic within a few weeks of each other. Hips affected with osteoarthritisbecome stiff and move less in range than a normal hip. This produces not only painbut also trouble in sitting on floor, sitting cross-legged and going up and down thestairs. Eventually it may become impossible for the person to squat on floor, using thestairs becomes a slow and painful ordeal, one leg appears to have become shorter andthe person limps while walking.Spine - All parts of spine do not move. The spine can be divided into four parts. Thetopmost section is cervical spine which is in the neck area, next is dorsal spine whichcovers the length of chest, followed next by lumbar spine which covers length ofspine in relation to abdomen or lower back, and last portion is sacral and cocygealspine which covers the area of pelvic and ends at the tip of tailbone. Neck (cervicalspine) and lower back (lumbar spine) are the areas where wide range of movements inall directions can occur and this is why it is possible for us to look around so easilyand bend our back in every direction. There are many small sized joints in spine andthey all share a part of motion. These small synovial joints can also developosteoarthritis and produce backache and difficulty in getting up from sitting and lyingposition. Curiously the pain due to osteoarthritis of these small spinal joints is of twodifferent types. Some persons will get pain and stiffness in back after a period of restand will get relief after walking for few minutes. Opposite to that some persons willget pain and stiffness after being up and about for past of the day and get relief withrest. In addition swelling at these joints can press on the nerves and produce symptomof sciatica or the pain radiating to leg and thigh. Similarly pain from swelling of jointsin cervical spine can radiate to arm and hand. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 34 management of Sandigatavata
  51. 51. Modern reviewHands - Osteoarthritis in hand, most often causes trouble at joint at the base of thumb.This joint has peculiar shape to allow wide range of thumb movements in alldirections. With this joint becoming stiff and painful the person starts to feel difficultyin gripping and holding objects. Next commonly affected joints in hand are the smalljoints at the end of fingers. At these joints osteoarthritis causes limitation ofmovements and some irregular swellings. The end of finger may not straighten fullyand the shape starts to look odd. Fortunately the functional at end of fingers, whilefunctional difficulty is much more when joint at the base of thumb is affected.Osteoarthritis Osteoarthritis is also called as Degenerative Joint Disease or Arthrosis orwear-and-tear arthritis. It represents the failure of diarthrodial joint.It is the most common joint disease of humans. Osteoarthritis of knee is the leadingcause of chronic disability in developed countries. Primary osteoarthritis is idiopathicand secondary osteoarthritis is due to many causes like secondary to trauma, due toendocrinal disorders, metabolic causes, etc.Risk factors for OsteoarthritisAge – It is considered to be one of the powerful risk factor. Old age people are proneto suffer with osteoarthritis and causes disability in them.Sex – Both Males and females are affected, but osteoarthritis is more generalized andmore sever in older women. It is twice as common in women as in men. Osteoarthritisof knee is common in women.Women less than 45 years old – 2% 45 – 65 years – 30% Older than 65 years – 68% will suffer. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 35 management of Sandigatavata
  52. 52. Modern reviewGenetic – Point mutation in the cDNA coding for articular cartilage collagen havebeen identified in families with chondrodysplasia and polyarticular osteoarthritis.Trauma – Direct or indirect injuries to the articular cartilage lead to its degeneration.Fractures of different bones, especially of weight bearing with or without involvingthe joint can also cause alteration of ligaments and in articular surface of joint.Repetitive stress – Abnormal posture, abnormal gait, and unequal length of leg willexert stress and strain over the joint.Endocrine disorders – Acromegaly, Hyperparathyroidism, Diabetes mellitus, Obesity,etc. may lead to osteoarthritis.Metabolic disorders – Like Ochronosis, Wilson’s disease may give rise toosteoarthritis.Calcium deposition diseases – Like CPPD deposition may lead to osteoarthritis.Pathology Although the cardinal pathologic features of osteoarthritis is a progressive lossof articular cartilage, osteoarthritis is not a disease of any single tissue but a disease ofan organ, the Synovial Joint. The most striking morphologic changes in osteoarthritisare usually seen in load bearing areas of the articular cartilage.Osteoarthritis develops in either of two settings:1.The biomaterial properties of the articular cartilage and subchondral bone arenormal, but excessive loading of the joint causes the tissue fail, or2. The applied load is reasonable, but the material properties of the cartilage or boneare inferior.In the early stages the cartilages thicker than normal. With the progression ofosteoarthritis, joint surface thins then the cartilage softens. Then the integrity of thesurface is breached and vertical clefts develops. They are called as fibrillation. Then Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 36 management of Sandigatavata
  53. 53. Modern reviewthere develops deep cartilage ulcers, extending to bone. All the cartilage ismetabolically active and the chondrocytes replicate, forming clusters (clones). Latercartilage becomes hypo cellular. There will be appositional bone growth in the bonysubchondral region, leading to the bony sclerosis. Growth of cartilage and bone at thejoint margins leads to osteophytes, which alter the contour of the joint and may resistmovement. The biochemical changes in osteoarthritis cartilage are increase in watercontent, decrease collagen, proteoglycan, monomersize, hyaluronate, keratensulphate, and chondrotin sulphate, increase in proteoglycan synthesis, collagenase,and proteoglycanase.Clinical FeaturesSymptomsJoint Pain It is often described as a deep ache and is localized to the involved joint.Typically, the pain of osteoarthritis is aggravated by joint use and relieved by rest, butas the disease progresses, it may become persistent.StiffnessProgressive stiffness of the involved joint upon arising in the morning or after aperiod of inactivity may be prominent but usually lasts less than 20 min. It is due tospasm of muscles. There is no relation between the severity of degeneration andmorning stiffness.SignsSwellingPhysical examination of the osteoarthritis joint reveals localized soft tissue swellingof mild degree. It is due to the changes in articular ends themselves, particularlyperiarticular lipping.Crepitus Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 37 management of Sandigatavata
  54. 54. Modern reviewThe sensation of bone rubbing against bone evoked by joint movement is called ascrepitus. It is one of the characteristic sign of osteoarthritis joint.Local Warmth nessOn palpation of the joint local rise in temperature indicative of sign of inflammation.Muscle AtrophyPeriarticular muscle atrophy may be due to disuse or due to reflex inhibition ofmuscle contraction.OthersIn advanced stage there may be gross deformity, bony hypertrophy, subluxation andmarked loss of joint motion.Laboratory and Radiological Findings The Diagnosis of osteoarthritis is usually based on clinical and radiographicfeatures. In the early stages, the radiograph may be normal, but joint space narrowingbecomes evident, as articular cartilage is lost. Other characteristic radiographicfindings include subchondral bone sclerosis, subchondral cysts, and osteophytosis. Achange in the contour of the joint, due to bony remodeling, and subluxation may beseen. There is often great disparity between the severity of radiographic findings, theseverity of symptom and functional ability in osteoarthritis. No laboratory studies are diagnostic for osteoarthritis, but specific laboratorytesting may help in identifying one of the underlying causes of secondaryosteoarthritis. Analysis of synovial fluid reveals mild leukocytosis with apredominance of mononuclear cells. Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 38 management of Sandigatavata
  55. 55. Modern review Approaches such as magnetic resonance imaging and ultrasonography havenot been sufficiently validated to justify their routine clinical use for diagnosis ofosteoarthritis or monitoring of disease progression.Treatment Treatment of osteoarthritis is aimed to reducing pain, maintaining mobility,and minimizing disability. The vigor of the therapeutic intervention should be dictatedby the severity of the condition in the individual patient. For those with only milddisease, reassurance, instruction in joint protection, and an occasional analgesic, mayall that required; for those with more severe osteoarthritis especially of the knee orhip, a comprehensive programs comprising spectrum of non-pharmacologicalmeasures supplemented by an analgesic and/or NSAID is appropriate.Non-Pharmacological MeasuresReduction of Joint Loading Osteoarthritis may be caused or aggravated by poor body mechanics.Correction of poor posture and a support for excessive lumbar lordosis can be helpful.Excessive loading of the involved joint should be avoided; patients with osteoarthritisof the knee or hip should be avoided prolonged standing, kneeling and squatting.Obese patients should be counseled to loose weight. In patients with medialcompartment knee osteoarthritis, a wedged in sole my decrease the pain. Completeimmobilization of painful joint is rarely indicated. In patients with unilateralosteoarthritis of knee or hip, a cane, held in the contraleteral hand, may reduce jointpain by reducing the joint contact force. Bilateral disease may necessitate use ofcrutches or walker.Physical Therapy Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 39 management of Sandigatavata
  56. 56. Modern reviewApplication of heat to the osteoarthritis joint may reduce pain and stiffness. A varietyof modalities are available; often the least expensive and most convenient is a hotshower or bath. Occasionally, better analgesia may be obtained with ice than withheat. It is important to note that patients with osteoarthritis of weight bearing jointsare less active and tend to be less fit with regard to musculo-skeletal andcardiovascular status than normal controls. An exercise program should be designedto maintain range of motion, strengthen periarticular muscles, and improve physicalfitness. The benefit of aerobic exercise includes increase in aerobic capacity, musclestrength, and endurance; less exertion with a given workload and weight loss. Thosewho exercise regularly live longer and are healthier than those who are sedentary.Patients with hip or knee osteoarthritis can participate safely in conditioning exercisesto improve fitness and health with out increasing their joint pain or need for aanalgesics or NSAIDs. Disuse of the osteoarthritis joint, because of pain will lead to muscle atrophy,because particular muscles play a major role in protecting the articular cartilage fromstress, strengthening exercise are important. In individuals with knee osteoarthritisstrengthening of a particular muscle may result, with in weeks, in a decrease in jointpain as great as that seen with NSAIDs.Drug therapy of osteoarthritis Therapy for osteoarthritis today is palliative, no pharmacological agent hasbeen shown to prevent, delay the progression of, or reverse the pathologic changes ofosteoarthritis in human. Although claims have been made that some NSAIDs have a“chondroprotective effect”. Adequately controlled clinical trails in human withosteoarthritis to support this view are lacking. In management of osteoarthritic pain, Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 40 management of Sandigatavata