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Evaluation of efficacy of Ajamodadi vati in Sandhigatavata(Osteoarthritis) By Dr. Shakuntala Totar, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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Sandhivata kc045gdg

  1. 1. “Evaluation of efficacy of Ajamodadi vati in Sandhigatavata(Osteoarthritis)” By Dr.Shakuntala.Totar Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. K.Shiva Rama Prasad M.D,C.O.P(German),M.A(Ph.D)Jyotish Department of Kayachikitsa Department of KayachikitsaPost Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2007-2010
  2. 2. D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 This is to certify that the dissertation “Evaluation of efficacy of Ajamodadivati in Sandhigatavata (Osteoarthritis)” is a bonafide research work done by Dr. Shakuntala. Totar in partial fulfillment of the requirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajiv Gandhi University of Health Sciences, Bangalore, and Karnataka. GuideDate: Prof. Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish)Place: Professor in Kayachikitsa
  3. 3. J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 Endorsement by the H.O.D, principal/ head of the institution This is to certify that the dissertation entitled “Evaluation of efficacy ofAjamodadi vati in Sandhigata vata (Osteoarthritis)” is a bonafide research workdone by Dr. Shakuntala. Totar under the guidance of Prof. Dr. Shiva Rama PrasadKethamakka, M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish), Professor in Kayachikitsa inpartial fulfillment of the requirement for the post graduation degree of “AyurvedaVachaspati M.D. (Kayachikitsa)” Under Rajiv Gandhi University of Health Sciences,Bangalore, Karnataka. Professor & HOD (Dr. G. B. Patil) Dept. of Kayachikitsa Principal, PGS&RC DGM Ayurvedic Medical College, Gadag
  4. 4. Declaration by the candidate I here by declare that this dissertation / thesis entitled “Evalualation of efficacyof Ajamodadi vati in Sandhigatavata(Osteoarthritis)” is a bonafide and genuineresearch work carried out by me under the guidance of , Prof. Dr. Shiva Rama PrasadKethamakka, M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish), Professor in Kayachikitsa,DGMAMC, PGS&RC, Gadag.Date:Place:
  5. 5. Dr.Shakuntala.Totar Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka shallhave the rights to preserve, use and disseminate this dissertation/ thesis in print or electronicformat for the academic / research purpose.Date:Place: Dr.Shakuntala.Totar
  6. 6. © Rajiv Gandhi University of Health Sciences, Karnataka
  7. 7. Acknowledgement: I take this privilege to express my gratitude to all those distinguished personalities whoinspired me during the course of my study and painted my life book with sweet memories by their moralsupport. I am sincerely grateful to Prof. Dr. K.Shiva Rama Prasad M.D, C.O.P (German), M.A (Ph.D) Jyotish, Department of Kayachikitsa for his guidance and timely help. I extend my gratitude to Dr.G.B.Patil, Principal, for his encouragement and providing all necessary facilities for this research work. I submit myself with deep sense of gratitude to Dr. R.V.Shettar for his precious guidance, advice and kind co-operation. I express my gratitude to Dr.Ashok.Patil for his guidance and support. I acknowledge with sincere thanks to Dr.P.Shivaramudu, Dr.Purushothamaacharyalu, Dr S.N.Belwadi, Dr. G.N.Danappagoudar, Dr.J.Mitti, Dr. Kuber.Sankh, Dr. Mulgund, Dr. Nidgundi, Dr. G.S.Hiremath, Dr. B.G.Swami, Dr. U.V.Purad, Dr. S.D.Yarageri and all other teaching staff for their help during the trial. I render my sincere gratitude to Mr. V.M.Mulimani and assistants for providing valuable books in time throughout the course. I am also thankful to Shri.B.S.Tippangoudar (lab technician) Shri.Basavraj (X-Ray dept) for their kind support in my study. I also thank all other teaching and non-teaching staff for their support. I express my sincere thanks to my seniors Dr.Veena.Jigalur and Dr.Prasanna.Joshi. I also express my deepest gratitude to my classmates Dr.Ishwar.Patil, Dr.Naik, Dr. Bodke, Dr.Kanti, Dr.Asha and Dr.Deepa. I am especially thankful to my juniors Dr.Vijay, Dr.Bhagyesh, Dr.Surej and Dr.Baba My main inspiration is - Success is a vehicle which moves on a wheel called smart work but journey is imposible without fuel called Self confidence. A smile on my face throughout the work was maintained by my ever-loving son Mr. Achintya. I express my deepest gratitude to my parents Mr.Siddappa.Totar and Smt.Ratnamma.Totar. Last but not the least I thank all those unexpressed names who encouraged and helped me a lot along with my kith and kin and all my friends. (Dr Shakuntala.Totar)
  8. 8. Abstract  AbstractAbstract of management of sandhigatavata by Ajamodadi vati Dr Shakuntala.S.Totar Ayurveda opines that Vyadhi is a condition in which body suffers from pain. Hence it is believedthat reliving the pain is the main treatment to state that the disease is subsided. The most commoncomplaints in the clinics is joints pain which is classically called sandhigata vata. The intensity ofsandhigatavata janya peeda depends upon Vyanavata, Sleshakakapha and sleshmadhara kala vitiation.The pain flow impels Manas to complete pain cycle. The concept of sandhigata vata even though notdescribed elaborately in the classics but witness maximum number of patients. Sandhi-Gata-Vata(osteoarthritis) is common amongst the elderly and obese persons. Since knee is the weight bearing jointit is more susceptible to wear and tear. Commonly Sandhi-Gata-Vata (osteoarthritis) is resulting in wearand tear of this joint and mucus membrane. Sandhi-Gata-Vata is largely seen in the elderly population andknown to be major cause for chronic disability. Ajamodadi vati with the ingredients with Ajamoda, pippali, vrudhadaruka ,vayuvidanga,Shatapushpa; Chitrakamula; Nagara;Haritaki; Vrudhadaruka; saindhavalavana; Guda express itself as ananti-inflammatory and analgesic action by regulating the shleshmadhara kala shotha fluid by its dryingcapacity of kleda. Ajamodadi vati proves to be effective on sandhigata vata especially in sandhi vedana by itsvedanahara property and sandhi shopha by its shophahara property. The result observed is withconsiderable moderate response of 54% and mild response 23%. Out of the samples only one patient hadmarked response. Among 30 patients 6 patients had not responded to the treatment.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)   
  9. 9. Abstract  LIST OF ABBREVIATIONS USED A S – Ashtanga Sangraha A H – 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 Gang. – Gangadhara K.S – Kashyap Samhita M.N – Madhav Nidana M.R-Marked response Mo.R-Moderate response Mi.R-Mild response Ni. – Nidana Sthana N.R – Not responded NSAID- NonSteroidal-Anti-Inflamatory drugs SU.S – Sushruta Samhita Sa.S – Sharangadhara Samhita Sha.S – Shareera Sthana Su. – Sutra Sthana Si. – Siddhi Sthana Vi. – Vimana Sthana Y.R. – Yoga RatnakaraEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)   
  10. 10. VÉÇàxÇàá Éy `tÇtzxÅxÇà Éy Éy ftÇw{|ztàtätàt ãAáAÜ àÉ báàxÉtÜà{Ü|à|á uçT}tÅÉwtw| ätà|Chapter Content Pages1 Introduction 1–52 Objectives 6–73 Literary Review 8 - 424 Materials and Methods 43 – 495 Results 50 – 706 Discussion 71 – 787 Conclusion 798 Summary 80 - 839 Bibliographic References 1-710 Annex 1 – Master charts data of trial 1 – 1011 Annex 2 - Case sheet 1-6
  11. 11. gtuÄxá Éy `tÇtzxÅxÇà Éy Éy ftÇw{|ztàtätàt ãAáAÜ àÉ báàxÉtÜà{Ü|à|á uçT}tÅÉwtw| ätà|SL TITLE OF TABLE PAGE1 Samanya Nidana of Vata Vyadhi as Explained in Different 14 Treatises.2 Roopa of Sandhigata vata asmentioned in various classics 223 Showing Vyavachedaka nidana between Sandhigatavata and 23 Vataraktha4 Showing Vyavachedakanidana of Sandhigatavata and Amavata 245 Showing Vyavachedakanidana of Sandhigatavata & 24 Kroshtrukasheersha6 Showing Differential diagnosis between OA, RA, Gout and 25 Rheumatic fever.7 Showing Cikitsa Sootra mentioned in different Samhita. 308 Showing the demographic data of trial cases 519 Distribution of patients by Age Gender 5210 Results by Gender 5211 Results of patients by Age Group 5312 Distribution of patients by Religion 5413 Distribution of patients by Occupation 5514 Distribution of patients by Economical Status 5515 Evaluation of pain data 5616 Associated complaints: 5617 Table Showing mode of onset of disease 5718 Joint involved 5719 Nature of pain 58
  12. 12. 20 Effect on Routin activities affected 5821 Distribution of patients by Mode of Onset 5922 Ditribution of patients by Srotas 5923 Distribution of patients by Ahara Nidana in sandhi shoola 6024 Distribution of patients by Vihara Nidana 6125 Distribution of patients by Manasikanidana 6126 Distribution of patients by Dosha bhedha 6227 Showing the distribution of patients by different grades of 63 Vatapoorana druti sparsha before and after treatment28 Showing the distribution of patients by Atopa Before and After 63 treatments29 Showing the distribution of patients by Prasanna akunchanayoho 64 savedana pravrutti30 Showing the distribution of patients by different grade of Sandhi 65 shotha Before and After treatment.31 Showing distribution of patients by different grades of 66 Sandhigraha32 Showing distribution of patients by different grades of Sparsha 67 akshamatva33 Showing Total results 6834 Showing Subjective parameters 6935 Showing Objective parameters 7036 Showing subjective Parameters based on Gradings 7037 Showing Objective Statistical Assesment of Data. Annex-1- 138 Showing Subjective Parameters Of Master charts Annex-1- 339 Showing Chief Complaints Annex-1- 540 Showing Present Illness of Master Chart Annex-1- 741 Showing Srotas Annex-1- 9
  13. 13. ZÜtÑ{á Éy `tÇtzxÅxÇà Éy Éy ftÇw{|ztàtätàt ãAáAÜ àÉ báàxÉtÜà{Ü|à|á uçT}tÅÉwtw| ätà|SL TITLE OF GRAPH PAGE1 Distribution of patients by Age Gender 522 Results of patients by Gender (Ajamodadi vati) 533 Results of patints by Age Group 534 Distribution of patients by Religion 545 Distribution of patients by Occupation 556 Distribution of patients by Economoical Status 567 Distribution of patients by Ahara Nidana 608 Distribution of patients by Vihara Nidana 619 Distribution of patients by Manasika Nidana 6210 Distribution of patients by Dosha bhedha 6311 Showing the distribution of patients by different grade of vatapoorana 63 drutisparsha before and after treatment12 Showing the distribution of patients by different grades of Atopa before 64 and after treatment13 Showing the distribution of patients by different grade of prasanna 65 akunchanayoho savedana pravrutti before and after treatment14 Showing the distribution of patients by different grade of Sandhi shotha 66 before and after treatment15 Showing the distribution of patients by differents by different grades of 67 Sandhigraha before and affter treatment16 Showing the distribution of patients by different grades of Sandhigraha 68 before after treatment17 Total Result 6818 Changes in subjective parametare (before and after treatment) 7119 % of improvement in subjective parameters 71
  14. 14. Y|zâÜxá tÇw c{ÉàÉá `tÇtzxÅxÇà Éy Éy ftÇw{|ztàtätàt ãAáAÜ àÉ báàxÉtÜà{Ü|à|á uçT}tÅÉwtw| ätà|SL TITLE OF FIGURES AND PHOTOS PAGE1 Samprapti in dhatukshaya janya sandhivata 202 Samprapti in Avarana janya Sandhivata 213 Showing Knee Osteoarthritis 364
  15. 15. Introduction V{tÑàxÜ @D MM ÇàÜÉwâvà|ÉÇ General introduction: The Indian subcontinent abounds as it vary in variety and diversity of health traditions. Wehave with us what is perhaps the longest unbroken health traditions and the oretical backing in termsof Ayurvedic system of medicine. They have made their presence felt even outside India. The purposeof life is four-fold, to achieve Dharma (virtue), Artha (wealth), Kama (enjoyment) and Moksha(salvation).1 In order to attain success in this four-fold purpose of life, it is essential to maintain lifenot only in a disease-free state but also in a positive healthy state of body, mind and spirit. Equalimportance is given to mental health, hence, strict mental discipline and strict adherence to moralvalues is considered a pre-requisite for mental health, which influences the physical state of the body.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                            Page 1 
  16. 16. Introduction Ayurvedic classics narrate the observations of great sages like Charaka, Susruta, Vagbhataand Kashyapa. Their accomplishments are available as authoritive classics of this. It emphasizes manas conglomeration of the panchamahabhutas and atma. The entities viz Panchamahabhutas are presentin the body in the form of dosha, dhatu and malas comprising various organs and organ systems, thesetogether forms the physical and material aspect of man. A critical, careful and unbiased study of theclassical Ayurvedic texts shows that by the time the samhita granthas were compiled, the science andart of Ayurveda had reservation of health first and then the correction of its disturbances that isdiseases. Ayurveda opines disease or vyadhi is a state in which both the mind and body suffers frompain, misery and even injury.2 The causative factors may vary depending on the different entities butactually, Tridoshas (Vata, Pitta and Kapha) are the intrinsic Causative factors, which are vitiated dueto extrinsic factors and their balance is disturbed. Ayurveda prescribes various therapeutic measureseither in the form of Purificatory (Samshodhan) or Pacificatory (Samshamna) for the alleviation of thedisease of both mind and physique3 There have been advances in understanding of this disease. No longer is osteoarthritis,regarded as a simple consequence of aging and cartilage degeneration. Indeed, the former diagnosticlabel of ‘degenerative joint disease’ is now recognized to be a ‘Misnomer’. A single definition ofOsteoarthritis remains elusive. A workshop held in 1995 proposes following consensus definition.“Osteoarthritis disease is the result of both mechanical and biological events, which destabilize thenormal coupling of degradation and synthesis of articular cartilage chondrocytes and extracellularmatrix and subchondral bone.” Though there is a lot of an advance in understanding of this disease, day by day the diseasehas become a problem. As a constellation of clinical and anatomical features, analogous to heartfailure, indeed ‘OA’ might with advantage be renamed ‘joint failure’. Management of this disease isfacing lot of difficulties. Contemporary science has failed to find a solution for this disease. It is said that currenttreatment for osteoarthritis is purely control of symptoms because there is no disease modifyingosteoarthritis drug yet. Intraarticular steroids are widely used, even though they provide marked reliefEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                            Page 2 
  17. 17. Introductionfrom symptoms but they lost their effect from a week to month. Because studies in animal modelshave suggested that glucocortciods produce cartilage, damage and frequent injections of large amountof steroids have been associated with joint breakdown in humans. Among the Ayurvedic practitioners, osteoarthritis called as SANDHIVATA. But in allclassical treatises it is mentioned as SANDHIGATA VATA. This study is an attempt to help the patients suffering from sandhigata vata in our societythough the administration of AJAMODADI VATI. Hence a research has been conducted to evaluatethe efficacy of Ajamodadi vati in sandhigata vata. AJAMODADI VATI is a classical yoga with theingredients Ajamoda; Pippali; Vayuvidanga; Shatapushpa; Chitrakamula; Nagara; Haritaki;Vrudhadaruka; saindhava lavana; Guda. INCIDENCE AND PREVELENCE: Sandhigatavata can be compared with Osteoartrhitis of contemprorary medical science.Osteoarthritis is the second musculoseletal disorder in the world population(30%) afterbackpain(50%). The reported prevalence of osteoartrhitis from a study in rural India is (5.78%).Among 80% of world population the prevelence is usually seen in the age group of 60-65 yrs withsome radiological evidences.Only20-30% of O.A are associated with symptoms4 PURPOSE OF STUDY: Sandhigatavata is the most common form of joint disorder amongst the elderly and obese persons. It is a major cause of morbidity and chronic disability as well as burden on health care resources especially for the elderly. This disease keeps an insidious attack, which runs for many years causing the loss of function as well as deformity of the joints. Elderly osteoarthritis is the leading cause of chronic disability and some 1, 00,000 people in the United States are unable to walk independently from bed to bathroom because of OA4.Because of O.A about 20-30% of people of India are affected by some complaints of knee joint pain during their lives. Females are found to be more affected by this disorder5. In spite of the scientific advancement in the field of Medicine, a large number of people suffer from OA all over the world without a permanent relief from this disease.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                            Page 3 
  18. 18. Introduction According to WHO Osteoarthritis is the second commonest musculoskeletal problem in the world population. Sandhigatavata is the most common joint disorder worldwide. The overall prevalence of the disease in the population above 40 years of age is about 49% with a female to male ratio of 1:16. The man today even in his young adult age suffering from the degenerative diseases like Sandhivata the condition where the pain and the swelling in the joints are present giving rise to the restricted movements,7 and also it is not a single disease rather it is the end result of variety of patterns of joint failure together or lesser extent it is always characterized by the degeneration of articular cartilage and simultaneously proliferation of new bone. Radiological autopsy studies show that osteoarthritis preferentially targets only certain small and large joints there is steady rise in over all prevalence from age 60-65. 80% of people are having some radiological evidence of O.A. though only 20-30% has associated symptoms. In the contemporary system of medicine, NSAIDs and surgery are practiced in themanagement of this disease, but have their own limitations. it using NSAIDS but larger antiinflammatory drugs are usually no more effective and carry on increased risk of gastric erosion, orhemorrhage in elderly distinct women8. In addition a recent reviews of the literature about non-steroidal anti-inflammatory the chance of hospital admission or death due to serious G. E. event up to16 per thousand per year. This disease restricts the normal movements of the affected joint, thereby rendering thepatient incapable of performing his/her normal activities. Contemporary medical science is able topacify the painful condition through analgesics and surgery mainly. But, this provides only temporaryrelief, as the underlying pathology is not managed. Hence it becomes essential to search a new wayfor the treatment of sandhigata vata osteoarthritis which proves to be a ray of hope for further researchworks. Human intellect and intellectual efforts never allowed him to be satisfied. Different remedialmeasures keep being increasing in pace with ever increasing medical needs. Anti-inflamatory andanalgesic drugs are the basic choice of community. Unforunately all the analgesic are liable to givemany side effects particularly by repeated and prolonged usage. Occasionaly more effective drugactions associate with more serious irreversible reactions.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                            Page 4 
  19. 19. Introduction So, in Ayurveda the ancient Indian system of medicine has suggested good old techniques andrectifies the painful condition without causing any complications and thus preventing the furtherdevelopment of degenerative changes. Thus the present study is under taken 9. However the management of pain and swelling in the acute condition left a room to work interms of AJAMODADI VATI modality to provide relief during acute phases. RESEARCH QUESTIONS: • To evaluate the Vedanahara property of Ajamodadi vati in sandhigatavata. • To evaluate the Shothahara property of Ajamodadi vati in sandhigatavata. LACUNAE IN CURRENT KNOWLEDGE: The traditional knowledge is based upon the humeral theory that too management based uponthe Prabhava of a dravya.Thus in Ayurveda presently many researches are undertaken with referenceto that of pharmacodynamics and pharmaco kinetics. The trends are changed where an evidence basedtherapeutics are to be shown to the scientific community. It is a thought that there are no properdisease management techniques or medicaments available with Ayurveda.But many vedanasthapakaand shothahara dravyas established and recorded from ages. Thus an atempt is made to know theefficacy of management of sandhigata vata through Ajamodadi vati. HYPOTHESIS: It is clear to state that the vedana and shotha are the main features of sandhigatavata, whereinvedanahara and shothahara are the drugs of choices. In Ayurveda the herbs acting as vedanahara andshothahara are suggestive of pain releivers.Thus in this study an effort is being made to discuss onsymptoms and the treatment to be adopted in the patients suffering from sandhigata vata.Thisapproach is based on the symptomatic management in Ayurveda viz lakshanika chikitsa. It is the hope that the present study will open new areas of research and provide the platformfor further investigation drives in Ayurveda field that are searching for a fast pain relief managementby contemporary scientific methods.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                            Page 5 
  20. 20. Objectives  V{tÑàxÜ @E MM bu}xvà|äxáMillions of people worldwide affected with Joint pain yet we have a limited knowledge of whatmakes our joints painful. As recent reports released by the WHO, musculo skeletal disorders arethe most frequent cause of disability in the modern world, and the prevalence of these diseases isrising at an alarming rate. The most prominent reason for either pain or loss of joint mobility asdegeneration along with loss of functions with chronic or episodic pain is leading one’s to notEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 6 
  21. 21. Objectives only distress but also impaired quality of life. Current clinical trial helps to lessen joint pain withthe effectiveness of drug combination that produces unwanted negative side effects, there byprecluding their long-term use. In short, patients who are suffering from the debilitatingdegenerating effects with joint pain for which there is no satisfactory treatment is treated with thepresent study combination which is intended to focus on the symptom evaluation i.e. SandhiShoola (joint pain). 1) To evaluate the Vedanahara property (analgesic effect) of Ajamodadi vati in Sandhigata vata. Ajamodadi vati by virtue of its Ushna guna dominance is a Vata hara that comprises of Tridosha hara properties because of the sheeta guna addatives, which reduces pain in the joint and acts as Rasayana, which will take care of Vata vitiation there by restores the Vata to its normal functions along with restructuring the joint structure. The Laghu and snigdha guna with their penetrability and unctuous enters deep in to the synovial cavity of joint very fast to act locally as analgesic and intactness makes the reconstruction of joints with its embedded quality of unctuousness. The Ajamodadi Vati assessment in this trial as general pain reliever is estimated through the subjective and objective assessment. 2) To evaluate the Shothahara prabhava (anti-inflammatory effect) of Ajamodadi vati in Sandhigata VataAjamodadi vati as discussed above substantiates the structure and pacify the Vata thus the effectof sothahara, reduction of sopha in the joint takes place. In turn which will take care of Vatavitiation there by restores the Vata to its normal functions. The Laghu guna with its penetrabilityto deep enters the joint very fast to act as anti-inflammatory. The Ajamodadi Vati assessment inthis trial as inflammation reliever is estimated through the subjective and objective assessments.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 7 
  22. 22. Review of literature  V{tÑàxÜ @F M M exä|xã Éy Ä|àxÜtàâÜxHISTORICAL REVIEW: A critical review of the history from the primitive stage to the new millennium assists one tounderstand the future in a better way. Man always struggled with present and attempted for the betterfuture by this can we achieve with a better perspective, when the past and present experiences and truthsare checked and planned at proper time. History helps to reveal the hidden facts and ideas of theconcerned subject. Sandhis and the diseases affecting them were well known in the Vedic period. One can observedescription of body parts in Atharvanaveda where in the words “Januni and Ashtivantau”10 were used todenote knee joints. The disease Sandhigatavata had not been mentioned as such in Vedic literature.However, Rigveda while describing various skills of Ashwinikumaras had recorded their skill in treatingjoint diseases too11. One of the mantras of Rigveda states that, “I am removing your diseases from eachorgan, hair and joint.” Atharvanaveda had mentioned Parvashoola and Vateekrita, two diseases similarto Sandhigatavata12. In Atharvanaveda, records about Vatavikaras are mentioned.13 A mantra says,“Destroy the balasa seated in the organs and joints which is responsible for loosing bones and joints”14 As stated in agnipurana total number of joints in human body and treatment of sandhigatasamavata denotes the knowledge of joints,15 since then Charakaacharya-mentioned about sandhigata vataas sandhigatoanila in Chi. Sushruta samita gives references in vatavyadhi nidana about sandhivata.16Astanga samgrahakara and hridayakara also states same as charaka and sushrutaacharya17.Asthimajjagata vatavyadhi a description of sandhivichyuti has been explained in Bhela samhita18.Sandhigata vata has been explained in Harita samhita.19 In madhyama and aadunika kala some aacharyasmentioned about the diseases. NIDANE MADHAVA SHRESTA HA & hence has explained about thisdisease,under vatavyadi chapter sandhigata vata lakshanas along with treatment20.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   8
  23. 23. Review of literature  Yogaratnakar;gadanigraha; vangasena both treatment aspect & clinical entity has been foundeither in words of charaka or sushruta. Sandhigatavata can be correlated as osteoarthritis in modernscince. this is due to the nature of the disease & its similarity of cardinal symptoms. Osteoarthritis (OA) is the most common joint disorder in human beings and other vertebrates.Even in giant dinosaurs, osteophytes leading to alkalosis were detected21. In all mammalian species likewhales and dolphins and in fish birds and some amphibians, Osteoarthritis is observed22. In the early ages, Hippocrates observed the prevalence of OA in aged individuals (Benard,1944)23. Heberden (1803) studied this disease in detail and the nodes on the fingers in OA disease werenamed after him24. Osteoarthritis was differentiated from Rheumatoid Arthritis and named asdegenerative arthritis by Nichols and Richardson (1909) on morbid anatomical grounds25. Although themost ancient of the diseases, OA was first identified as a distinct entity in the 20th century. Gold thait in1904 made a distinction between hypertrophic and atrophic arthritis and A. E Garrod recognized OA as aclinical entity in 190726. Approximation of Herberdon nodes in relation with age; sex and hereditary factors wasmentioned by Strecher(1940)27. Intermitent claudicstion in osteoarthritis of lower limb including hip;knee & ankle joints were observed by Boyd(1949)28 The term osteoarthritis was used to signify the absence of synovial thickening or inflammatoryinfiltration in uncomplicated condition by Kellgren(1961) The term osteoarthritis; Hypertrophic arthritis are mentioned under degenerative arthritis bySamuel.L.Turek(1989)29Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   9
  24. 24. Review of literature  SANDHI SHAREERA: JANU SANDHI - KNEE JOINT The present study was undertaken to assess the efficacy of ajamodadi vati in the management ofsandhi gata vata. Before discussing the disease sandhigata vata it is very essential to understand thestructure of knee joint, functional aspects of articular cartilage, synovial fluid and synovial membrane soall these points are summarised here.In Ayurveda, sandhis are mainly classified into two types; 1) Sthira sandhi 2) Chala sandhi30Again they are subclassified into eight types.31 1) Kora sandhi 5) Tunnasevani 2) Ulookala 6) Vayasa tunda 3) Samudga 7) Mandala 4) Pratara 8) Shankhavarta Acharya Sushruta father of Surgery consider janu sandhi under chala sandhi and subclassification under kora sandhi. Shleshaka kapha:Among five variey of kapha,shleshaka kapha resides in keeps the jointsfirmly united,proects their articulationopposes their seperation and disunion.32 Shleshmadhara Kala - It isthe 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 jointsETYMOLOGY OF SANDHIGATA VATA 1) Sandhi Vyutpatti - SAM + DHA + KIHI Nirukti - Sandirnama Samyogaha33 Asthidwaya Samyogasthana34Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   10
  25. 25. Review of literature  Sandhyarnama, asthanam, anyonya, sangam, asthani, junction, connection, combination, unionwith containing a conjugation, transition from one to another.35Paribhasha : Sandhi pullinga, sandhanamiti, Yuga sandhini yugashabde deha sandhini marmashabdecha drishtavyaha.36 In general, sandhi means the junction between two things in Ayurveda shareera sandhi is atechnical word indicating that it is the place where two are more bones meet together and the joint maybe fixed type or of less or more movement. Acharya Sushrutha told that, in our body there areinnumerable sandhi are present. 2) Vata Vyutpatti - Va - Gati gandhanayoho Va - Gati sevanayoho Va + Kthaha37 Pullinga Va + Kthaha 38Nirukti - Sparsha matra vishesha gunake bhutabheda - Pavane - dehasya dhatubheda cha 39 - Wind, Air, as one of the humours of the body40-41 The word ‘Osteoarthritis’ is a combination of three words. ‘Osteon’, ‘arthron’ and ‘itis’respectively means bone, joint and inflammation42. The meaning of this word is ‘inflammation to thebony joint’. In fact, there is no inflammation in this disease, hence, the disease is also known asOsteoarthritis and Degenerative joint disease.Paryaya of Sandhigata Vata Different authors named this disease according to their own views, ie. as follows. Sandhigata anila43 Khuda vata44 Sandhi vata45 Jeerna vata46Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   11
  26. 26. Review of literature Nidana (47,48,49,50,51,52,53,54) Even though classics of Ayurveda do not mention the Nidanas of Sandhi-Gata-Vata, one has tocompile the relevant references mentioned in different contexts 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 oneclassification is Sannikrishta and Viprakrishta Karana. Here with the complimentary references theNidanas of Sandhi-Gata-Vata is classified on this basis. i) Sannikrishta Hetu – Ativyayama, Abhighata, Marmaghata, Bharaharana, Sheeghrayana, Pradhavana, Atisankshobha. ii) Viprakrishta Hetu – Rasa – Kashaya, Katu, Tikta Guna – Rooksha, Sheeta, Laghu Dravya – Mudga, Koradusha, Nivara, Shyamaka, Uddalaka, Masura, Kalaya, Adaki, Harenu,Shushkashaka, Vallura, Varaka. Aharakrama – Alpahara, Vishamashana, Adhyashana, Pramitashana Manasika – Chinta, Shoka, Krodha, Bhaya Viharaja – Atijagarana, Vishamopacara, Ativyavaya, Shrama, Divasvapna, Vegasandharana,Atyucchabhashana. Some of the important Nidanas are discussed below-Ativyayama Excessive physical exercises act as one of the important Nidana for Sandhi-Gata-Vata. Running,walking, jogging etc. if done excessively or violently will affect the structures of Sandhi. They mainlyaffect the Joint stability by over exertion. But if done properly they stabilize the Joint.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   12
  27. 27. Review of literature Bharahvahana Carrying excessive load causes excessive pressure and stretching effect over the structures of thejoint. As knee is weight bearing joint, carrying excessive load will have direct affect on articular disc.The constant compression will lead to wear and tear effect leading to degenerative changes in the discs.Abhighata Abhighata to joints due to Prapatana etc., lead to structural deformity in the joints. Joint is anorgan rather than a single structure. It is stabilized by different structures like Asthi, Snayu, Peshi, andKala etc. Hence, any trauma to these structures will alter the structural integrity of the joint. Hence,Abhighata is an important Nidana for Sandhi-Gata-Vata.Atisankshobha It is a Nidana for Asthivaha Sroto Dushti. Since Asthivaha Srotas is involved 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-bearingjoint, the violent exercises or activities will alter the structural integrity of the joint.Marmabhighata The concept of Marmabhighata in the causation of Sandhi-Gata-Vata sounds more rational. Janu-Sandhi is a variety of Vaikalyakara Sandhi-Marma (Su. Sa. Sh. 6/7, 12, 13)55. Marma is a vital point,which comprises of Asthi, Snayu, Sira, Mamsa and Sandhi. Hence any Marma is made up of all thesestructures, likewise the Janu-Sandhi. Pain in the joints not necessarily be only associated with bony changes. But involvement of otherjoint structures may also give rise to symptoms pertaining to joint. Therefore, in recent days more studyis emphasized on the different structures involved in the pathology of Arthritis like consistency of softtissue, fibrous material, liquid and cartilaginous substance of the joint. From this new point theAyurvedic view towards the involvement of certain Marma in the disturbance of the joint i.e. painfuljoint will be anticipated. Hence Marmabhighata as a Nidana in case of Sandhi-Gata-Vata is to be givenimportance.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   13
  28. 28. Review of literature Table No. 1 - Samanya Nidana of Vata Vyadhi as Explained in Different Treatises.Nidana Cha. Sam Su. Sam A.H MN YR BPAharaja NidanaKashaya - + + - - +Katu - + + - - +Tikta - + + - - +Rooksha + + + + + +Laghu + - + + + -Sheeta + - + + - -Vallura + - - - - -Varaka + - - - - -Shuskha Shaka - + - - - -Uddalaka - + - - - -Neevara - + - - - -Mudga + - - - - -Masura + - - - - -Harenu + - - - - -Kalaya + - - - - -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 - - - - + -Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   14
  29. 29. Review of literature Anyat (other nidanas): - Panchakarma apacharas like atidoshasravana, atirakthasravana, atiyoga of langhana, apatamsanaetc and dhatukshayakarabhavas like rogakarshana, gadakrita atimamsakshaya, etc vitiate Vata.Dhatukshaya is an important vitiating factor of Vata. Sthoulya is another causative factor for Vata prakopa. The meda-avarana of Vata is themechanism causing inter- relationship between sthoulya and Vatavyadhis.56 All types of avaranas are alsoimportant vitiating factors of Vata. Vata dominates vardhakya avastha57. During this period, dhatukshayaoccurs causing Vata prakopa. Living in jangaladesha is another causative of Vata prakopa.58 Vata gets vitiated in the end of dayand night59. Vata also vitiated during the end of greeshma ritu, varsha ritu and shishira kala.60 Vataprakriti persons are more susceptible 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 toexcessive body weight and this result in more pressure over weight bearing joints. This graduallyweakens the sandhis and produces Sandhigatavata. Excess exercise may not only vitiate Vata but furtherleads to shleshaka kapha kshaya contributing to Sandhigatavata. Excess walking and excessive weightbearing also are important in the context of Sandhigatavata. Abhighata to marmas or sandhis is anotherimportant risk factor for Sandhigatavata. Vardhakya avastha characterized by dhatukshaya leading topeshi-snayu-marma shosha, thereby resulting in looseness of joints is also a major risk factor forSandhigatavata. The factors like that vitiate asthivahasrotas (ativyayama, atisamkshobhana,asthivighattana and vatalasevana).61 also need to be mentioned in the nidana of Sandhigatavata.Risk factors for Osteoarthritis (OA)62i) Age factor – Age is the most powerful risk factor for OA. The association between OA and aging is non-linear. It usually begins after a person is 40 or more years old. By the age of 60 years, almost everyoneEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   15
  30. 30. Review of literature has OA. More than 80% of people over 60 years old have radiological evidence of OA in one or bothknees and 30% in one or both hips.ii) Sex factor – It is told that women are at high risk than men in developing OA. Over 30% of women (elderly)have OA in the interphalangeal joints of the hands. Except in the hands, men and women are affectedequally, though the lesions often appear at a young age in men. Only 3% of elderly men have primaryOA in the hands.iii) Hereditary factor – The relation of heredity is less ambiguous. Thus, the mother and sister of a woman with distalinterphalangeal joint OA are respectively twice and thrice as likely to exhibit OA as the mother and sisterof an unaffected woman.iv) Race factor – Racial difference exists in both the prevalence of OA and the pattern of joint involvement. OA ismore frequent in Native Americans than in whites. The Chinese in Hong Kong have a lower incidence ofhip 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 differences are genetic or are due todifferences in joint usage related to life style or occupation is unknown.v) Obesity factor – Obese persons have a high risk of OA. For those in the highest quintile for body mass index atbase line examination, the relative risk for developing knee OA in the ensuing 36 years was 1.5 for menand 2.1 for women. For severe knee OA, the relative risk rose to 1.9 for men and 3.9 for women,suggesting that obesity plays an even larger role in the etiology of the most serious cases of knee Occupational factor – Repetitive movements may leads to excessive strain leading to erosion and joint damage. Menwhose jobs require knee bending and at least medium physical demand had a higher rate of radiographicevidence of knee OA and more severe radiographic changes.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   16
  31. 31. Review of literature vii) Traumatic factors – Trauma to the joint seems to enhance the occurrence of arthritis. It disturbs the alignment of thejoints and over a period of time, this malalignment may 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 termused when the disorder arises from unknown or hereditary causes. Secondary OA describes cases inwhich direct causes for the disorder are known.Classification based on causes63I. PrimaryIdiopathic, Primary generalized osteoarthritis and Erosive osteoarthritis.II. SecondaryCongenital or developmental defects (Hip dysplasias, shallow acetabulum, Morquio’s syndrome, etc.),III. 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 withmyxedema and Metabolic Gout, itemochromatosis, ochronosis, chondrocalcinosis, paget’s disease.Samprapti From the onset of Dosha Dushya Dushti till the evolution of the Vyadhi there occurs variousVikriti. Samprapti explains such series of pathological stages involved. It tells us about the totalpathogenesis of a disease. The Samanya Samprapti of Vata Vyadhi that is explained in classics can be considered as theSamprapti of Sandhi-Gata-Vata or a base to understand the Samprapti of Janu-Sandhi-Gata-Vata. Acarya Caraka explained64 – due to the intake of Vatakara Ahara Vihara Vata vitiation takeplace. This vitiated Vata lodges in Rikta Srotas i.e. Srotas in where Shunyata of Snehadi Guna is present.Vata after settling in Rikta Srotas produce disease related to that Srotas (Ca.Sa.Ci.28/18-19).Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   17
  32. 32. Review of literature  Acarya Vagbhata frames the Samprapti of Vata Vyadhi like – Dhatukshaya aggravates Vata andthe same is responsible to produce Riktata of Srotas. Thus the vitiated Vata travels throughout the body,settles in the Rikta Srotas, and further vitiates the Srotas leading to the manifestation of Vata Vyadhi(A.Hr.Ni.15/5-6).65 Here an attempt has been made to explain how this Srotoriktata occurs due to Nidanasevana. Thechief properties of Parthiva Dravya are Guru, Sthula, Sthira, Gandha Guna in excess. These are theproperties, which are necessary for Sthairya and Upacaya of the body. Excessive intake of Dravyashaving Laghu, Ruksha, Sukshma, Khara properties lead to Guru and Sneha Guna Abhava due to theiropposite quality. Thus, it leads to Dhatukshaya in the body. Akasha is the Mahabhuta that producesSushirata and Laghuta in the body. Vayu Mahabuta fills up this Sushirata. So due to Dhatukshaya AkashaMahabhuta increases in the body producing Sushirata and Laghuta simultaneously Vayu fills it up. From a description it can be stated that the meaning of word ‘Riktata’ is Sushirata i.e. increase inAkasha and Vayu Mahabhuta. While commenting on word ‘Riktata’ Cakrapani says that ‘Riktata’ meanslack of Snehadiguna. For understanding, the Samprapti of SandhiVata can study under two heading. They are -1. Dhatu Kshaya Janya and2. Avarana Janya Sandhi-Gata-Vata.1. Dhatu Kshaya Janya Sandhi-Gata-Vata In old age, Vata Dosha dominates in the body. This will lead to Kapha Abhava. Also Jataragniand Dhatvagni gets impaired, by which Dhatus formed will not be of good quality. Degeneration of bodyelements takes place due to predominance 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 thejoints also decreases in quality and quantity. Reduction of Kapha in Sandhis makes Sandhi BandhanaShithilata. Ashrayashrayi Sambandha also leads Asthidhatu Kshaya. Asthi being the main participant ofthe joint its Kshaya leads Khavaigunya in the joints.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   18
  33. 33. Review of literature  In this condition if Nidana Sevana done further produces Vata Prakopa. If Vata Prakopa is notcorrected by appropriate means and simultaneously if the person indulges in Asthivaha and MajjavahaSroto Dushtikara Nidana, the Prakupita Vata spreads all over the body through these Srotas. In themeantime, Sthanasamshraya of Prakupita Vata take place in the Khavaigunyayuta Janu-Sandhi. Thislocalized Vayu due to its Ruksha, Laghu, Kharadi Guna over power and undo all properties of SleshakaKapha producing disease SandhiVata.2. Avarana Janya Sandhi-Gata-Vata In Sthulas usually Sandhi-Gata-Vata occurs in weight bearing joints. In them Medodhatu will beproduced in excess due to the Atisnehamsha of Amarasa (Su.Sa.Su. 15/32)66. The excessive Medas willproduce obstruction for the flow of nutritive materials to the future Dhatus i.e Asthi, Majja and Shukraleads to their Kshaya. The excessive fat deposited all over the body will produce Margavarana of Vata67 (Su.Sa.Su.15/32 – Dal.). Prakupita Vata due to Margavarana starts to circulate in the body. While traveling it settlesin the joint where Khavaigunya is already exists. After Sthanasamshraya it produces the disease Sandhi-Gata-Vata in the same process mentioned in the earlier context. Thus with the help of Samanya Samprapti of Vata Vyadhi the Samprapti of Janu-Sandhi-Gata-Vata can be divided into Dhatukshaya Janya and Avarana Janya. This will help in deciding the prognosisand planning the treatment of the disease.Samprapti Ghataka:Dosha – Vata – Vyana – Vriddhi; Kapha – Shleshmaka – KshayaDooshya – Peshi, Snayu, Asthi, MajjaSrotas – Mamsavaha, Medovaha, Asthivaha, MajjavahaAgni – Jataragni, Asthi-DhatvagniAma – Jataragni Mandya JanyaRoga Marga – MadhyamaUdbhavasthana – PakvashayaSancharasthana - SarvashariraAdhishtana – SandhiVyaktasthana – SandhiEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   19
  36. 36. Review of literature  POORVAROOPA68 Particular mentioning of Poorvaroopa of Sandhi-Gata-Vata is not available in classics. InVatavyadhi also unmanifested symptoms (Avyakta) or mild exhibition of actual features of the diseaseitself (Alpa vyakta) is considered as its Poorvaroopa (Ca.Sa.Ci.28/19). Hence clinical features ofSandhi-Gata-Vata in milder form can be considered as Poorvaroopa.ROOPA The clinical features of Sandhi-Gata-Vata explained by various Acharya are listed in Table2Roopa of Sandhi-Gata-Vata mentioned in various classicsTable No 2 : Roopa of Sandhigata vata asmentioned 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. Caraka69 and Vagbhatas70 explain that pain in thejoint is elicited during Prasarana Akunchana Pravrutti.Sandhi Shotha Most of the authors explained this symptom. Caraka and Vagbhatas explained the nature ofShotha i.e., it is felt like bag filled with air (Vata Poorna Driti Sparsha).Sandhi Stabdhata Sushruta71 initially described this symptom, later by texts like Madhava Nidana,72Yogaratnakara,73 and Bhavaprakasha74.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   22
  37. 37. Review of literature  They have coined the term Sandhi Hanana or Hanti. While commenting on this word Dalhana75and Gayadasa explained as “Akunchanaprasaranayoh Abhavah” and “Prasaranakuncanayoh Asamarthah”respectively. With this we can infer that the word Hanti refers to inability to move the joints.In the opinion of madhukoshakara76, Hanti referes to Sandhi Vishlesha, Stambha Adi Vikara. Hence withthe above references, Hanti refers to Sandhi Stabdhata.Atopa This symptom explained in Madhava Nidana77. While commenting on the word Atopa in anothercontext, Madhukoshakara quotes the opinion of Gayadasa and Kartika. I.e.‘Atopaha ChalachalanamitiGayadasaha, Gudaguda Shabdamiti Kartikah’. Also Bhavamishra says ‘Atopo – Gudagudashabdaha’(Bhavamishra on Bh.Pr.Ci.24/93).78 Thus we can say that Atopa in this context is the sound produced by the movement of joints i.e.,Crepitus. Thus with the help of different references and by the opinion of commentators it can beconcluded that Sandhi Shoola, Sandhi Shotha, Sandhi Stabdhata and Atopa are the clinical features ofSandhi-Gata-Vata or Janu-Sandhi-Gata-Vata (Ca.Sa.Ci.28/37 & Cakra; Su.Sa.Ni.1/28 & Dal, Gaya;A.Hr.Ni.15/14; Bh.Pr.Ci.24/258; Yo.Ra.Vat.Ni; Ma.Ni.22/21 & Madhu).Vyavachedakanidana Sandhigatavata is a disease affecting the bony joints. So virtually, every disease that affects thejoints has to be differentiated with Sandhigatavata. The most common differentiation is to be made withVatarakta, Amavata and Kroshtrukasheersha.Table No. 3. Showing Vyavachedaka nidana between Sandhigatavata and Vataraktha Sl. Criteria SGV Vatarakta Vatavridhikara Vidahi, viruddha, ahara-vihara rakthaprakopakara ahara 2 Poorva roopa Avyaktharoga Kushtasama Lakshana 3 Roopa Sandhishoola, Teevra ruk, Prasarana akunchanayoho Grathita-paki vedana, shvayathu Sandhi shopha, Vatapoornadrithi SparshaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   23
  38. 38. Review of literature  4 Adhisthana Sandhi Padamoola, Hastamoola 5 Doshas Vata Vata, Rakta 6 Upashaya Ushna – snigdha Sheeta Table No. 4. Showing Vyavachedakanidana of Sandhigatavata and Amavata Sl. Criteria SGV Amavata 1 Nidana Vatavridhikara Viruddha ahara-cheshta ahara-vihara 2 Poorva roopa Avyaktharoga Hridaya dourbalya, Lakshana Gourava 3 Roopa Sandhishoola, Vrischika damshavat Prasarana akunchanayoho peeda, vedana, Pidakayukta shopha Sandhi shopha, Vatapoornadrithi Sparsha 4 Adhisthana Sandhi Hasta, Pada, Gulpha, Trika, Janu etc. 5 Dosha Vata Vata, Kapha 6 Upashaya Ushna, snigdha Ushna-rookshaTable No. 5. Showing Vyavachedakanidana of Sandhigatavata & Kroshtrukasheersha Sl. Criteria Sandhigatavata Kroshtrukasheersha 1 Nidana Vatavridhikara Vatavridhikara ahara-vihara ahara-vihara 2 Poorva roopa Avyaktharoga lakshana Avyaktharoga lakshana 3 Roopa Sandhishoola, Maharuja, Prasarana akunchanayoho Janushopha vedana, Sandhi shopha, Vatapoornadrithi Sparsha 4 Adhisthana Sandhi Jan Madhya 5 Dosha Vata Vata, raktaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   24
  39. 39. Review of literature  6 Upashaya Ushna, snigdha Snigdha, seethaTable No. 6. Showing Differential diagnosis between OA, RA, Gout and Rheumatic fever.Sl. Criteria OA RA Gout Rheumatic Fever1 Symptoms Pain & swelling on Inflammation in Polyarticular Painful and major weight multiple pain, swelling & tender joints bearing joints, joints, inflammation, stiffness, crepitations, morning stiffness exquisite tenderness, enlargement >30ms tenderness 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 in fever, chorea temperature, anemia etc.5 Investigations RA-ve, ESR normal, X- ESR raised, Serum uric acid ESR ray- narrowing of joint X-ray-soft raised, increased, space, subchondral bony tissue swelling. punched out CRP high, sclerosis, osteophytes lesions in WBC etc. subchondral elevated. bone.Vyana Vata - Vata governs every movement in the body. Vyana Vata is one among the five varieties ofVata, which resides at Hridaya and controls most of the motor functions. The Gati or physical movementis 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 the Sandhi83. AcaryaVagbhata states that Vata is located in the Asthi with relation to Ashrayashrayi Sambandha. Generallyaugmentation or diminution of Doshas would be given similar effect on their respective Dhatus but incase of Vata it is opposite; with increase in Vata, Asthi Kshaya occurs84 Sushruta in Sharirasthanaexplains different structures of the human body. Among them, structures coming under Janu-Sandhi arelisted below. Snayu - Among nine hundred Snayus, ten are present in Janu-Sandhi. More over in ShakhaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   25
  40. 40. Review of literature and Sandhi, Pratana variety of Snayu is present. Importance – As a boat consisting of planks becomescapable of carrying load of passengers in river after it is tied properly with bundle of ropes, all joints inthe body are tied with many ligaments by which persons are capable of bearing load85 Peshi- The fleshymass demarcated from each other is known as Peshi. In Janu they are five in number. They are strongstructures that help to maintain alignment of the joint86 Sanghata - Assemblages of bones are fourteen.One is situated in Janu-Sandhi87Modern reviewKnee Joint - The knee joint, largest of the human joints, is most complex joint of the body. Thecomplexity is the result of fusion of three joints in one. The original three joints includes the lateralfemorotibial, medial femorotibial and famoro patellarThe 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 and with patella infront.Condyles of Femur - The lower end of femur is widely expanded to form two large condyles a medialand a lateral. The condyles are partially covered by a large articular surface which is divisible intopatellar parts. The patellar surface covers the anterior surfaces of both condyles and extends on morelateral condyle than on the medial. The tibial surfaces cover the inferior and posterior surfaces ofthe two condyles and merge anteriorly with the patellar surface. The lateral part of the surface isshort and straight anteroposteriorly. The medial part is longer and curved with convexitydirected medially.TibiaMedial condyle -superior articular surface is oval anterio posteriorly. The peripheral part is flat andarticulates with medial memiscus, the central part is slightly concave and articulates with medialcondyles of femur. The raised lateral margin covers the medial inter condylar tubercle.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   26
  41. 41. Review of literature Lateral Condyle - The superior articular surface is mearly circular. The peripheral part is flat andarticulates with lateral meniscus. The central part is slightly concave and articulates with the lateralcondyle of femur.Patella -Patella is the largest sessamoid bone in the body. It is triangular in shape with its apex directeddownwards, which is non articular posteriorly. Anterior surface is rough and non-articular, the upper 3/4th of the posterior surface are smoothand articular. The posterior articular surface divided by a verticle ridge into a large lateral area and asmaller medial area. Structurally knee is a week joint, because the articular surfaces are non congruent.The tibial condyles are too small and shallow to hold the large convex femoral condyles. The femeropatellar articulation is also quite insecure because of their shallow surfaces and also the outwardangulation between the axes of thigh and leg.88 The stability of the knee joint is maintained by many factors. Knee joint is supported by fibruscapsule. The fibrous capsule is very thin and is deficient anteriorly when it is replaced by quadricepsfemoris, patella and ligamentum patella.Synovial Membrane - It lines the capsule except posteriorly where it is reflected forwards by thecruciate ligaments forming a common covering for both ligaments.Semilunar Cartilage (Menisci) - These are two fibro cartilaginons crescents. Which try to deeper thearticular surfaces of the condyles of tibia and partially divides the joint cavity into the upper and lowercompartments.Ligaments - Ligamentum patella, tibial, collateral ligament, femoral collateral ligament, obliquepopliteal ligament, arcuate popliteal ligament, cruciate ligament. Explanation of janukapala (patella) isavailable in Sushruta and Charaka samhita. Acharya Charaka and Kashyapa while explaining the asthisankhya denotes. Janvasthini dose,sankyate, chatwaryosthini jangayoho, dwarunalakau, dwecha khyathe janukapale. In the olden days also our acharyas had an idea of synovial membrane. Sushruta clearlymentioned that the fourth kala is Shleshmadharakal a which is situated in every sandhis and performsEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   27
  42. 42. Review of literature lubrication for movement. How a wheel which is lubricated by oleation functioning normally. Likewiseall the sandhis function 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 it is lubrication andalso nourishment of the articular cartilage.89 The physical nature of this is a clear or pale yellow, viscous glariry fluid of slightly alkaline pHat rest. This nature vary widely between different joints and spaces. The physical properties of synovialfluid changes according to the environment in the joint. Viscosity is very sensitive to changes in dilutionand that it falls with increasing temperature and increasing pH. The elasticity property is also affectedsimilarly. The composition of synovial fluid is some protein (about 0.9mgm/ml) and with added mucin.Hyalouronic acid which is sulphate free mucopolysaccharide composed of basic units that arepolymerised. The synovial fluid also consists of moncytes, lympocytes, macrophages free synovial cells andoccasional polymorphonuclear leucocytes. Amorphous, metachromatic particles and fragments of cellsand fibrous tissue sometimes found in synovial fluid are resulted by the slow wear and tear of jointsurfaces. It is very clear by Vagbhatas statement that, shleshmaka kapha not only supports sandhis butalso provides movements in the normal direction.Acharya Sushruta states that it holds and nourishes thesandhi.Articular Cartilage Majority of bones are formed a special variety of hyaline cartilage. Articular cartilage has a wearresistant, low friction lubricated surface, both slightly compressible and elastic which is ideallyconstructed for easy movements over a similar surface but also absorb enormous forces of compressionand shear generated during weight bearing and muscle action. This is due to the Shleshaka kapha in the joint. Due to its snigdha and picchila guna it lubricatesthe joints and avoids friction on movement. Thus the cartilage acts as wear resistant. Elasticity andcompressibility of the cartilage is due to the mridhutwa and shlakshna guna of kapha.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   28
  43. 43. Review of literature 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 tissue and its ability to withstand load andcollagen, which provides tensile strength and resistance to shear. Although lysosomal proteases havebeen demonstrated within the cells and matrix of normal articular cartilage, their low pH optimum makesit likely that the proteglycanase activity of these enzymes will be confined to an intracellular site or theimmediate pericellular area. However cartilage also contains a family of matrix metalloproteinases(MMPs) including stromelysin, collagenase and gelatinase which can degrade all the components of theextra cellular matrix at neutral pH. Each is secretedby the chondrocyte as a latent pro enzyme, that mustbe activated by proteolytic cleavage of its N-terminal sequence. The level of MMP activity in thecartilage at any given time represents the balance between activation of the proenzyme and inhibition ofthe active enzyme by tissue inhibitor (Keneeth, 1996). INVESTIGATIONS:Lab Investigations:Usually in primary OA theESR may be normal or slightly accelerated.Anemia and leukocytosis areabsent.Rheumatic factor studies are absent.Synovial fluid analysis revels minimal abnormalities usefulin the differetial diagnosis.Viscosity is good and musin clot formation with glacial acetic acid isnormal.Slight increases in cell count are noted.X-Ray reveals: Loss of joint space due to destruction of articular cartilage Sclerosis due to increased cellularity and bony deposition Subchondral cyst due to synovial fluid inttusion 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 ligamentsEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   29
  44. 44. Review of literature  Bone scan shows increased up take technetium-99m;MRI and CT scan also helps to diagnose subchondral cyst;osteophytes etc. CHIKITSA The main aim of treatment is to restore Svasthya. It means to restore normal functions of Agni,Dosha, Dhatu, and Mala and to maintain mental health. The primary importance of Cikitsa lies inSamprapti Vighatana. Sandhi-Gata-Vata is a Vataja disorder. So general treatment of Vata Vyadhi can be adopted,keeping an eye on the etiology of the same. Regarding the specific line of treatment of Sandhi-Gata-Vata,Caraka is silent. Later authors like Sushruta had mentioned effective line of treatment for the same. Otherbooks like Astanga Hridaya, Astanga Sangraha, Yogaratnakara, Bhavaprakasha had mentioned specificline of treatment. The below chart shows Chikitsa sutra mentioned in different texts.Table No. 7 Showing Cikitsa Sootra mentioned in different Samhita. Treatment Su.Sa. A.Sa. A.Hr. Yo.Ra. Bh.Pr. Bh.Ra. Snehana + + + + + Abhyanga + Mardana + + + + Svedana + + + Upanaha + + + + + + Bandhana + + + Agnikarma + + + +SNEHANA Sandhi-Gata-Vata is a variety of Vata Vyadhi, where Snehana would be very effective. Acc. tothe use it can be administered in two ways – Abhyantara Prayoga Bahya Prayoga (Su.Sa.Ci.31/2) Abhyantara Sneha:Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   30
  45. 45. Review of literature  Here Sneha in the form of Pana, Bhojana, Basti and Nasya can be administered in case ofSandhi-Gata-Vata.Bahya Sneha:Bahya Snehas are many like Abhyanga, Lepa, Udvartana, Padaghata, Gandoosha, Karnapoorana,Akshitarpana, Picu, Samvahana, Mardana, Murdhnitaila, and Parisheka. In case of Sandhi-Gata-Vata weget the mentioning of Abhyanga and Mardana. Abhyanga means to do some movements or Gati. Forthe purpose of Abhyanga Sukhoshna Taila or Sneha is used. Abhyanga should be done slowly inAnuloma Gati, in joints it should be done in circular manner. Abhyanga should be done minimum for 5minutes because the Veerya of Taila will reach Majja Dhatu in 900 Matra-Kalas. It is Vatahara,Pushtikara (Ca.Sa.Su.5/85; Su.Sa.Ci.24/30). Mardana is like Abhyanga but applied pressure is more.Svedana Svedana is a variety of Shadvidhopakrama. It is helpful in neutralizing Stabdhata, Shitata andGauravata (Ca.Sa.Su.22/11). In case of Sandhi-Gata-Vata varieties of Svedanakrama like Upanaha andBandhana are indicatedUpanaha Both Sushruta and Caraka consider Upanaha as a variety of Svedana (Su.Sa.Ci.32/3;Ca.Sa.Su.14/35). Roots of Vatahara drugs should be pasted together with Kanji and mixed with abundantquantity of Saindhava Lavana and Sneha. After making this lukewarm, it should be applied to theaffected part. The paste of drugs included in the Kakolyadi, Eladi or Surasadi groups as well as pastes ofSarshapa, Tila, or Atasi or Krishara, Payasa, Utkarika and Vesavara or the drugs of Salvana Sveda shouldbe similarly applied to the affected part folded in piece of thin linen and tied up (Su.Sa.Ci.32/12).Bandhana Dravya in Upanaha For the purpose of Bandhana, Caraka opines that leather of Ushna Veerya animal can be used. Inthe absence of this silk or woolen cloth can be used (Ca.Sa.Su.14/35-37). Astanga Hridayakara opinesthat Vatahara Patras should be used (A.Hr.Su.17/5) and Caraka suggests Eranda Patra(Ca.Sa.Ci.28/115).Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   31
  46. 46. Review of literature Duration Upanaha, which is tied in the morning, should be removed in the night and which is tied in thenight should be removed in the morning (Ca.Sa.Ci.14/38).Sneha PramanaAccording to Vata, Pitta, Kapha, Sneha should be added 1/4,1/6/1/8th of the Upanaha Dravya.BandhanaAcharya Susrutha again subdivides this into 3 types: a) Pradeha b) Sankara c) BandhanaPradeha Thick paste prepared by Amla Kanji in Vataharadravya after adding Saindhava Lavana andSneha, Svedana is done. Dalhana called this as Upanaha (Su.Sa.Su.18/7 & Dal).Sankara Sweda In Sankara Sveda, paste made out of Vatahara Dravyas, Amla Kanji, Saindhava Lavana andSneha etc., taken in a piece of cloth and Potali is prepared. Dalhana considered this as Upanaha (Su. Sa.Ci. 32/12 & Dal).Bandhana In Bandhana Upanaha Dravya is tied to the affected apart.AGNIKARMA Unique treatment indicated in case of Sandhi-Gata-Vata. Here Dahana or cauterization is done inthe part affected. Dahana Karma should be done in the affected joint till the Samyak Laxana. Hence the different treatment modalities mentioned by different authors can be concise underthese three (Su.Sa.Ci.4/8 & Dal; A.Sa.Ci.23/13; A.Hr.Ci.21/22; Yo.Ra.Ci.Vat; Bh.Pr.Ci.24/259).SHAMANAUSHADIS:Kwatha: Maharsnaadi kwathaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   32
  47. 47. Review of literature  Dhanwantaram kwatha Sahacharadi kwathaKalka: Takaramoola kalka with takraChoorna: Alambhushadya choorna Aabhadi choornaVati: Ajamodaadi vatiGuggulu preparations: Kaishora guggulu Yogaraj guggulu Brihatyogaraj guggulu Trayodashanga guggulu Adityapake guggulu Simhanaada gugguluRasaushadi: Panchananarasa loha Vatarakshasa rasaSneha: Dhanwantaram tailam Phalatrikaadi taila Majja sneha Prasarini tailam Siddharta tailam Nakula tailamPATHYPAATHYAThe Ahara and vihara which prevents aggravation of the disease and aids in the relief at the same timewithout initiating another disease are known as pathya.Acharya Charaka is one step ahead by saying Pathya is one which is suitable to the body and mind bothin health as well as diseased condition.Though no one Acharyas has mentioned pathya and apathya forsandhigatavata directly, as this disease being a vatavyadhi we should adapt the samanya vatavyadhipatyapathya.PATHYA • Rasavarga - Madhura, Amla, lavana rasa • Shukadhanyavarga - Naveena godhuma, Samvatsarothitashali, Rakta Shali, Shashtikashali. • Shimbi varga - Naveena tila, Naveena masha, kulathaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   33
  48. 48. Review of literature  • Shaka varga - Patola, shigru, vartaka, lasuna • Phala varga - Draksha, dadara, pakva amra, parushaka, jambeera, dadima, pakvatala phala • Mamsa varga - Ushtra, go, varaha, mahisha, hamsa, mayura, bheka, nakula, chataka, kukkuta, tithira, sheelindra, kurma, thimingila, rohita etc. • Jalavarga - Ushna jala, Shritasheetajala, Narikelajala • Dugdha varga - Go, aja ksheera, dadhi, grita, kilata, kurchila • Mutra varga - Gomutra • Madhya - Dhanyamla, sura • Sneha - Tila, gritha, vasa majja • Vihara - Bhushayya, snana, samhvahana etc. • Chikitsa - Abhynga, brimhana, sanbrpana, tiladroni, shirobasti, avagaha, nasya, upanaha, agnikarma [104]APATHYA • Ahara - Katu, tikka, kashayarasa • Shimbi dhanya - Rajamasha, nishpara, mudga, kalaya • Shuka dhanya - Trunadhanya, trunaka, kangu, koradhusha, neevara, shyamaka, chanaka • Phala varga - Jambu, udumbara, kramuka, tinduka • Mamsa varga - Sushkamamsa (Vallura), kapotha, paravata • Jalavarga - Nadeejala, Sheetambu, tadajala • Ksheera - Gardaba ksheera Vihara • Vihara - Chinta, jagarana, shrama, vyavaya, vyayama, chankramana, Hasti ashwayana, vegadharana • Chikitsa - Vamana, RaktamokshanaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   34
  49. 49. Review of literature  MANAGEMENT OF OSTEOARTRITIS: Treatment of osteoartritis is aimed at reducing the pain, maintaing mobility and minimisingdisability. The vigor of the therapeutic intervention should be detected by the severity of the condition inthe individual patient. For those only with mild disease, reassurance, instruction in joint protection and anoccasional analgesic may be all required, For those with severe O.A a comperensive programmecomprising a spectrum of non pharmacological measures supplimented by an analgesic or antiinflammatory drug is appropriate. This involves many measures like pharmacological means, non-pharmacological means and surgery.Pharmacological means –1. Simple analgesics A large number of medicines are prescribed for relief of pain. The recognition that pain in OA isnot necessarily due to inflammation has led to an increased awareness of the role of simple analgesics inthe treatment. The ACR guidelines emphasize the use of acetaminophen (Tylenol) as the first linetreatment for OA.2. Opioid containing analgesics Code line and propoxyphene can be used for short periods to treatexacerbations of pain.3. NSAID’sTrials comparing simple analgesics and NSAIDs found that acetaminophen along can control pain in asubstantial number of patients with OA celecoxib, a cox-2 inhibitor, and rofecoxib are recent advancesamong NSAIDs.4. Local analgesics – Among the local applications, capsaicin cream is used commonly.5. Intra articular cortico steroid injections.6. Intra articular administration of hyaluronic acid like products. Chikitsa 90Agents used to treat OsteoarthritisEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   35
  50. 50. Review of literature Acetaminophen, NSAIDS (Salicylates, Propionic acids, Acetic acid, Oxicams), Cyclo-oxgenaseinhibitors, Irritants/Counter irritants, Hyaluronic acids and Glucocorticoids. Exercise – To maintain range of motion, muscle strength and general health. Patients may also bereferred to aerobic exercise programs such as fitness walking or swimming. Mainly two types ofexercises are adviced viz flexibility and strengthening exercises. Assistive devices – Many patients with OA of hips and knee are more comfortable; wearing shoes withgood shock-absorbing propertiesNon-pharmacologi Patient education. Exercise: - To maintain range of motion, muscle strength and general health. Patients may also bereferred to aerobic exercise programs such as fitness walking or swimming. Figure No 3: Showing Knee OsteoarthritisEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   36