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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......

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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  • 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. 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. 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. 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. 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. © Rajiv Gandhi University of Health Sciences, Karnataka
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 joints.it 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. 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. 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. 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. 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. 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. 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 OA.vi) 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. 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. 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. 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
  • 34. Review of literature  FIGURE NO - 1 SAMPRAPTI IN DHATUKSHAYA JANYA SANDHIVATA UKTA NIDANA SEVANA VARDHAKYA DHATUKSHAYA VATA PRAKOPA KSHAYA OF KAPHA BHAVA IN THE BODY CIRCULATION THROUGH SHLESHAKA KAPHA KSHAYA RASAYANI IN SANDHI KHAVAIGUNYA IN SANDHI STHANASAMSHRAYA IN SANDHI SANDHIVATAEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   20
  • 35. Review of literature  FIGURE NO - 2 SAMPRAPTI IN AVARANA JANYA SHADHIVATA MEDOVRIDDHI(MEDOVARANA) (MARGAVARANA TO THE FLOW OF POSHAKARASA)VATAPRAKOPA POSHAKARASA NYUNATA TO ASTHIDHATU EXCESSIVE PRESSURE OVER WEIGHT BEARING JOINTCIRCULATION THROUGH ASTHIDHATU KSHAYA RASAYANI IN SANDHI VYANAVATA PRAKOPA IN SANDHI KHAVAIGUNYA IN SANDHI STHANASAMSHRAYA IN SANDHI SANDHIVATAEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   21
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  • 51. Review of literature Assistive devices: - Many patients with OA of hips and knee are more comfortable; wearing shoes withgood shock-absorbing properties orthoses. The use of an appropriately selected cane can reduce hiploading by 20-30%. Patients with specific physical disabilities may benefit from physical andoccupational therapy.Weight management: - There is a longitudinal association between obesity and OA of knee in men andwomen. Therefore, primary preventive strategies may include measures to avoid weight gain, or toachiever weight loss in over weight patients.Supplements: - Glucosamine sulphate and chondrotin sulfate.Yoga: It is one of the ancient science which inter relates with our culture. It s pratices in daily liferestores the health and relieves the symptoms. The Asanas which give relief to artritis isPavanamuktaasana. These Asana sare very easy to practise and help him releiving stress by looseningthe joints.Rehabilitation: Simple changes around the home and daily activites can cause drastic improvement inthe symptomatology of O.A. • Use of higher chair, which requires less effort to get in and out should be considered • To reduce the force acting across the injured joint patient is advised to use a walking stick which acts as a third limb. • Footwear with hard soles and high heels should be avoided. • Mental and physical support from the family members will be useful in the rehabilitation of the patient.SURGERICAL LINE OF MANAGEMENT:Surgical procedures are of value in the management of OA. They may be grouped under 3 majorcategories. • Procedures to correct mal alignment and eliminate abnormal joint stresses (osteotomies), not only may slow down disease progression but may-also bring healthier articular cartilages into opposition and provide symptomatic relief. • Debridement with removal of free bits of cartilage or large ecostoses may relieve pain and locking and help in prevention of rapid and extensive cartilage degeneration. • In advanced disease, arthroplasty or joint replacement may be required to reduce pain and improve function; at times arthrodesis is required to control pain, even though motion must be sacrificed101.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   37
  • 52. Review of literature  DRUG REVIEW AJAMODA(101,102,103,104)Botanica Name :- Apium leptophyllumFamily :- ApiaceaeVernacular name :- Hindi – Ajamoda, English –Celery fruitSynonymes : - Deepyaka,Karavi,Gandhala,Shikimoda,KriminashiniIntroduction : - It is bennial stem consisting of small ovoid fruit bulk colour yellowish brown in colour.Chemical compositin : - essential oils and fixed oilsProperties : - Rasa – Katu,Tikta Guna - Laghu,Ruksha Virya - Ushna Vipaka - KatuKarma : - Vata Kapha shamaka, Rasayana, Vrushya,Indication : - Agnideepaka,krimighna,vatashamaka,mutrala,balyaUsefull Part :- Seeds PIPPALI(105,106,107,108)))Botanical Name :- Piper longumFamily :- PiperaceaeVernacular name :- Hindi – Pipal English –Long pepperSynonymes : - Maagadhi,Vaidehi,Kana,Chapala,ShaundiIntroduction : - It is a large creeper,the fruits are long after supuration becomes red in colour and afterdrying becomes black colour.Chemical compositin : -Properties : - Rasa – Katu Guna - Laghu, Snigdha,TeekshnaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   38
  • 53. Review of literature  Virya - Anushnasheeta Vipaka - madhuraKarma : - Vata Kapha vardhaka, Rasayana, Vrushya,Indication : - Amavata, Arsas, Sotha, Prameha, Agnimandya,Shwasa,Kasa,HikkaUsefull Part :- Root,fruit VELAM (Vayuvidanga) (109,110,111,112,113)Botanical Name :- Embelica rebesFamily :- MyrsinaceaeSynonymes :- Krimigna, Tandula, Vella, Amogha, Jantuhantri,Gana :- Krimigna, Kushtagna, Truptigna (Ca) Surasadi gana, Pippalyadi (Vag & Su)Botanical discription :- A large shurb slender branches long the bark studded with lenticles Fruits areglobose 3-4 mm smooth black when ripe like pepper cornProperties :- Rasa - Katu, Kashaya Virya - Usna Guna - Laghu, Rooksha, Teekshna Vipaka - KatuKarma :- Vatahara, Vishagna Krimigna – Shotahara SHATAPUSHPA(113,114,115,116,117)Botanical name :- Foeniculum vulgareFamily :- UmbelliferaeSynonyms :- Atlambi, Karavi, Madhura, SitachatraGana :- Asthapanopaga, Anuvasanopaga. (Ca)Varieties :- A graveolens and A sowa have been concidered as two varitesEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   39
  • 54. Review of literature Botanical discription :- A glabrous perenal herb 30 - 90 cm hight leaves are bipinnet white flowers,fruits are slender vittae large etcChemical constituents :- Fruit are seed oil carvone dihydrocarvone, limonene, apiol dils- apial, Anethol,Fenchone, etcProperties : - Rasa - Katu, Tikta Guna - Laghu, Tikshna Veerya - Ushna, Vipaka – KatuKarma :- Vata kapha hara, DipanaUsefull part :- Beeja CHITRAKAMOOLA(118,119,120,121,122))Latin name :- Plumbago zeylanicaFamily :- PlumbaginaceaeSynonames :- Anala, Dahana, Agni, Jyoti, Agnika, Sikhi, Hutasana.Gana :- Dipaniya, Sulapr, Ashamana, Arshogna, Lekhaneeya. (Ca) Pippalyadi, Mustadi, Amalaky, Adi, Varunadi. (Su) Vaghbhata quoted 3 Varites sweta pita and AsitaBotanical discription :- A perinnial herb leaves thin ovate subacute flowers in elongata spikes fruitscapsule, oblong pointed thick pericarpChemical composition :- Root contain plumbagin chitranone, plumbagic acid acts on control nervoussystemProperties : Rasa - Katu Guna - Laghu, Ruksha, Teekshna Veerya - Ushna Vipaka - KatuKarma : - Agnideepaka, Grahi, Shoolhara, Rasayana, Vata-Kapha hara, Garbhashaya sankochaka, etc.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   40
  • 55. Review of literature Part used :- Root bark SHUNTI(123,124,125,126,127)Latin name :- Zingiber officinaleFamily :- ZingiberaceaeSynonames : - Mahoshadha, Vishwa, Nagara, Vishoushadha, Sringavera, Katubhadra.Varnacular Name : - Hindi - Soth Kannada - Sunti Malayalam - Chukku Tamil - Chukku Oriya - ShunthisHabitat : - Mostly seen in southern states of India,Bengal, Punjab etc.Discription :- it is a rhizome, growing under the groundPart used :- SteemProperties : - Rasa - Katu Guna - Laghu, Snigdha Veerya - Ushna Vipaka - Madhura HARITAKI(128,129,129,130,131)Latin name :- Terminalia chebulaFamily :- CombretacaeSynonames :- Abhaya, Patya, Prapatya, Amruta, Jaya, Avyata, Shiva, Nandini, VijayaProperties :- Rasa- Madhura, Amla, Katu, Tikta, KashyaDoshakarma :- Kapha- Vata Shamaka VRUDHADARUK(132,133,134)Botanica Name :- Ipoemia petalodeaFamily :- ConvolvulaceaeEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   41
  • 56. Review of literature Vernacular name :- Hindi - Bidhara English - Elephant creepar Telegu - SamudraphenaSynonymes : - Chagantri, AvegiIntroduction : - It is alarge creepar and is cavered with haer all over . Flowers are either pink or red aspurpleChemical compositin : - Seed contain oloic acid nercetion and kaempferol from leavesProperties : - Rasa - Kasaya, Katu, Tikta Guna - Laghu, Snigdha Virya - Ushna Vipaka - UshnaKarma : - Vata Kapha hara, Rasayana, Vrushya,Indication : - Amavata, Arsas, Sotha, Prameha, AgnimandyaUsefull Part :- Root SAINDHAVA LAVANA(135,136,137,138)This is the best in the lavanavarga, Rock salt is the common name for the mineral haliteSanskrit :- Saindhava, Stitashiva, Manimantha, SindoojaVernacular name :- Hindi :- Senda namak English :- Rock salt Kannada :- SaindavaVarga :- Lavana vargaProperties : - Rasa - Lavana Guna - Snigda, Rooksha, Sukshma Veerya - Sheeta Vipaka -Karma :- Tridoshahara, Rochana, DeepanaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   42
  • 57. Review of literature Indications :- Ajeerna, Anaha, Vataviara, Gulma, Shoola & Udara rogaEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   43
  • 58. Materials & Methods  V{tÑàxÜ @G MM `tàxÜ|tÄá 9 `xà{Éwá Methodological approach is the backbone of research.Utmost care is taken in designing amethodology for conducting a result. The therapeutic measures, drugs and procedures of Ayurvedahave remained in the practice since long on the basis of methodology prevalent in ancient times. Thisis the time that the rationality of Ayurvedic therapeutic approach is explained on rational lines.Clinical trial is a way of research and its best method to evaluate any drug or line of treatment. Thetrial is a carefully designed experiment with the aim of solving unrewarding problems conducted onscientific lines. Research is a careful investigation or inquiry in a systematized manner to establishnew facts and discarding the old facts or correcting them. The ultimate aim of any research is in thefield of medical science is to find out suitable remedies for particular ailment and to promote health.The clinical trial is experiment therapeutics. The Ayurvedic therapeutic measures, drugs, procedureshave mentioned in practice since long on the basis of the methodology prevailed in ancient times .Clinical research involves the experimentation of drug or therapy on a population and recording thefeed back based on which postulations are made regarding the usefulnes of drug.The clinical trialswhich is carefully designed experiment with the aim of solving the unrewading problems conductedon scientific line is the only way to achieve the above objects. Research methodolgy involves thesystematic procedures by which the researcher starts from initial identification of the problem to itsfinal conclusion.a)RESEARCH AAPROACH: In the present study the investigators objective is to study Management of Sandhigata vataby Ajamodadi vati by its vedanahara and shothahara property. The efficacy of trial drug is determinedby finding out the difference between the baseline data of the parameters to the after treatment data.b)STUDY DESEIGN:The study design selected for present study is Single random sampling technique clinical trial.C) SAMPLE SIZE AND GROUPING:In the sample size for the present study were 30 patients suffering from sandhigata vata.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   43
  • 59. Materials & Methods D) SOURCE OF DATA: a) Patients suffering from Sandhigata vata were selected from the Post graduation studies and research centre,Department of Kayachikitsa,O.P.D and I.P.D of Shri. D.G.M.A.M.C & Hospital,Gadag, with pre-set inclusion and exclusion criteria. b) Literary aspect of the study will be collected from classical Ayurvedic and contemporary text and updated with recent medical journals, previous research work done on same topic. c) Trial drug Ajamodadi vatie)SELECTION CRITERIA: • Exclusion criteria: o Patients below 30 years and above 70 year of age o Pregnant woman & lactating mother. o Associated with simple or compound fractures. o Associated with any other systemic or metabolic disorders. o Patient on steroid therapy o Patient under gone surgery • Inclusion criteria: o Patients suffering from the symptoms of Sandhivata (Osteo-arthritis) o Patients of either gender aged between 30-70 years are included-as the condition is commonly found in the either sex,but not specific to the old age.CRITERIA OF DIAGNOSIS:The diagnosisis made on the basis of signs and symptomsof the patient. By methodical examination ofthe patient especially joints.DURATION OF STUDY:Ajamodadi vati were given to the patient for the duration of 30 days with fixed /dose of 3grms/24 hrsin divided doses observing the patient closely at the interval of 3 days and recording the events forevery 10 days.The medicine is withdrawn after the trial period of 30 days and a follow up period of 15days.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   44
  • 60. Materials & Methods Data CollectionPatients were thoroughly examined both subjectively and objectively. Detailed history pertaining tothe mode of onset, previous ailment, previous treatment history,family history, habits,ashtavidhapareeksha and dashavidhapareeksha and physical examination findings were noted.Routine investigations were done to exclude other pathologies. Radiological features also wereinvestigated.HistoryThe common symptoms with which a patient generally presents are pain,swelling, stiffness,mechanical disorders (e.g. Locking, giving way, click etc.)Joint Examination:161Examination of the joints can be summerised simply as”look,feel and move’’ the joint(i.einspection,palpation and then the range of movements along with jerks)With practise the Cliniciancan develop a systematic review of the joints.Compare the corresponding joints on the two sides ofthe body and always take care to avoid causing undue discomfort.Inspection • Both the lower limbs were fully exposed • Patient was first examined in the standing position, both from front and behind secondly in the seated position, thirdly in the supine position and lastly in the prone position. • Swellinga) The limits of the swelling were clearly made out.b) The gradings were allotted on the basis of criteria explained in the end of this section.c) The Varna of the Shopha was examined (Raga, Shyava or Prakrutha).d) Any deformities like genus valgum, varum etc. were examined.e) Joint instability or buckling of the joint was examined.f) Any abnormalities in the gait were examined.g) Walking time was recorded (the time taken to cover 21 metres).h) Any presence of muscular spasm was examined.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   45
  • 61. Materials & Methods i) Muscular wasting above and below the joint was examined.Palpation • Local temperature was examined with the back of the hand and compared to that of the other side. • Local tenderness was also examined. • SwellingA) Fluctuation test was performed by pressing the suprapatellar pouch with one hand and feeling theimpulse with the thumb and the fingers of the other hand placed on either side of the patella or theligamentum patellae.B) Patellar tap was elicited by pressing the suprapatellar pouch with one hand driving the whole of itsfluid into the joint proper as to float the patella in front of the joint. With the index finger of the otherhand, the patella is pushed backwards towards the femoral condyles with a sharp and jerky movement.The patella can be felt to strike on the femur, which is known as the patellar tap. • Palpation of popliteal fossa - The patient was made to lie down prone on the table. The knee joint was flexed and the popliteal fossa was palpated. The knee joint, popliteal artery, areolar tissue, veins and nerves and the tendons in and around the popliteal fossa were all palpated carefully to detect any pathology here. • Significance of click - If the click was associated with discomfort or pain, careful examination was done. Commonest cause of intra-articular click is OA. • Patello-femoral and femoro-tibial components were palpated for any tenderness or irregularity.MovementsThe movements permitted in the knee joint are mainly flexion and extension. Minor degrees ofabduction, adduction and rotations may be permitted when the joint is partly flexed. Both active andpassive movements were examined. • Flexion and Extension: Normally, the knee can be flexed until the calf extended till the thigh and leg form a straight line.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   46
  • 62. Materials & Methods  • • Abduction and adduction: These movements are virtually absent with knee straight, but slight degrees of abduction and adduction are possible when the knee is semi- flexed. • Rotation: This movement is also not possible when the knee is straight. When the hip and knee are flexed to 90 degrees, some degree of rotation is possible.AuscultationDuring active or passive movement, the palm of one hand of the physician was placed over the patellaand crepitus was felt.JOINT CREPITUS:This can be detected by feeling the joint with one handwhile it is moved passively with other hand.This may indicate osteoartritis, or loose bodies in the joint spaces but should be differentiated fromnon-specific clicking of joints.Mobility grading:VAS(0-100)Mobility is measured in visual analogue scale which is used to notice the movement extension ofaffected joints.ASSEMENT OF CLINICAL RESPONSE:Subjective and objective parameters were made out to asses the clinical response in the total numberof patients.I) Subjective parameters: Ruk (Pain) 01. Grade 0 – No Complaints 02. Grade 1 – Tells on Enquiry 03. Grade 2 – Complains Frequently 04. Grade 3 – Excruciating Condition Graha (Stiffness) 01. Grade 0 – Absent 02. Grade 1 – PresentEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   47
  • 63. Materials & Methods  Sparshaakshamatva (Tenderness) 01. Grade 0 – No Complaints 02. Grade 1 – Says the joint is tender 03. Grade 2 – Winces the affected joint 04. Grade3 –Winces and withdraws the affected joint. Shotha (Swelling) 01. Grade 0 – No Complaints 02. Grade 1 – Slightly obvious 03 Grade 2-covers well over the bony prominence 04 Grade 3-Much elevated Atopa (Crepitations) 01. Grade 0 – None 02. Grade 1 – Felt 03 Grade 2-HeardAll these parameters of baseline data to post-medication data (31st day) were compared for clinicalassessment of the results (assessment was also recorded on the 8th day too).II) Objective parameters:A) Hemoglobin % The haemoglobin content of the whole blood is reported in terms of grams of Hb per 100 ml of blood(g/dl).Normal ranges are 14- 18 g/dl in males and 12-16 g/dl in females. Hemoglobin is responsible for the cell’s ability to transport oxygen and carbon di oxide it is estimated.B) Erythrocyte sedimentation rate: Erythrocyte sedimentation rate is measured in the graduated tubes under Westergren’s method (pippete method).This facilitates to understand possible presence of organic disease or to follow the course of the disease. It is universally accepted that it is a good prognostic method in clinical laboratory.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   48
  • 64. Materials & Methods C) Differential count: It is of a daily routine investigation to estimate the polymorphs. eosinophils. lymphocytes, etc where the general health of the patient is estimated.D) Joint pain grading 0 to 10 Joint pain grading is based upon the moderate universal pain assessment tool which is a visual analouge scale to asses pain patients.E)Local temperature: Increase of the temperature is common in joint swelling and pain conditions. A surface digital skin thermometer is used to check the local temperature.F) Redness Redness is measured in visual analouge scale which is used from light red to dark red.G) Swelling in mm: It is measured with a tape graded with mm and cms.H) X-rayof affected joints: It is an optional for further assesment of the pain condition and to notice the fulfilment of exclusion criteria.Walking time to cover 21meters was recorded and distributed into the following grades. Grade 0 – Up to 20seconds Grade 1 – 21-30seconds Grade 2 – 31-40seconds Grade 3 – 41-50seconds Grade 4 – 51-60secondsAll these parameters of baseline data to post-medication data (28th day) were compared for clinicalassessment of the results (assessment was also recorded on the 14th day too).Overall Assessment Of Clinical ResponseGood Response : 3.33% improvement in clinical and functional parametersModerate Response: 53.33% improvement in clinical and functional parametersPoor Response : 23.33% improvement in clinical and functional parametersNo Response : 20% clinical and functional parameterEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   49
  • 65. Results  V{tÑàxÜ @H MM exáâÄàá Present study registers 30 patients, out of 38 approached patients as the patients whodiscontinued their data has not been included. The remaining 30 patients of Sandhigata vata viz Osteoarthritis is an individual, fulfilling the criteria of diagnosis and inclusive criteria were included in thestudy for the evaluation of efficacy of Ajamodadi vati in Sandhigata Vata. All the patients were examined before and after the trial according to the case sheet formatgiven in the annex. Both subjective and objective criteria were recorded. The data recorded arepresented under the following headings. I) Demographic data II) Evaluating Pain Data III) Results of 30 patients IV) Statistical evaluationsEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   50
  • 66. Results Table No 8 : Showing the demographic data of trial cases Sl, OPD,No Age Gender Religion Occupation Economic status Results No 1 1040 43 Male Hindu Active Middle Moderate 2 1326 38 Female Hindu Labor Middle Moderate 3 1791 55 Female Muslim Active Middle Moderate 4 2132 38 Male Hindu Labor Poor Moderate 5 1043 60 Male Hindu Active Higher middle Moderate 6 2450 52 Male Hindu Active Higher middle Mild 7 2452 45 Female Hindu Active Middle Moderate 8 2079 72 Male Hindu Active Higher middle Moderate 9 1824 40 Female Hindu Active Higher middle Mild 10 1722 60 Female Hindu Active Middle Moderate 11 7973 50 Male Hindu Active Higher middle Mild 12 2152 55 Female Muslim Active Middle Moderate 13 4414 65 Female Hindu Labor Poor Moderate 14 2916 57 Female Hindu Active Middle Moderate 15 2131 52 Female Hindu Active Middle Mild 16 2512 51 Female Hindu Active Higher middle Mild 17 3271 35 Female Hindu Labor Poor Not respond 18 5360 60 Male Hindu Active Middle Not respond 19 1041 42 Female Hindu Labor Middle Marked 20 1770 55 Female Muslim Labor Middle Mild 21 2136 57 Male Hindu Labor Middle Moderate 22 3154 55 Male Hindu Active Higher middle Not respond 23 3271 57 Male Hindu Sedentary Higher class Moderate 24 2757 49 Female Hindu Active Middle Moderate 25 3791 57 Female Hindu Active Higher middle Moderate 26 3017 54 Male Hindu Active Middle Not respond 27 3197 48 Female Muslim Active Middle Not respond 28 4001 50 Female Hindu Active Higher middle Not respond 29 4007 47 Female Hindu Active Higher middle Mild 30 4127 56 Male Hindu Active Middle Moderate a) Distribution of patients by Gender and Age. There is no specificity observed with reference to the gender because the prevalence ofSandhigata vata is common in both males and females,but females may be more prone due toosteoporosis in post menapausal period, but the age certainly has effect because as age advances thekapha kshaya goes on increasing and vrudhapya is Vatadhikya avastha. So it can be ruled out that Agefactor is considerable criteria in Sandhigata vata.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   51
  • 67. Results  Table No. 9 : Distribution of patients by Age Gender Age Male Female Total % Nos % Nos % 20-30 00 00 00 00 00 00 30-40 31 03.33 03 10 04 13.33 40-50 72 06.66 06 20 08 26.66 50-60 08 26.66 08 26.66 16 53.33 60-70 01 03.33 01 03.33 02 06.66 12 39.98 18 59.99 30 99.98 Graph 1 : Distribution of patients by Age Gender 16 14 12 10 8 6 4 2 0 20 - 30 30 - 40 40 - 50 50 - 60 60 - 70 70 -80 By observing the tabulation only 1 Female Patients had marked response. But maximum Malei,e 7 among 12 had moderate response among 18 Female patients had moderate response. This provesthe result to be 50-60% as an analgesic. Mild response was seen in 2 male patients among 12 and 5female patients among 18. This proves the result to be 15-25% and both 3 in each male and femaleamong 12 and 18 respectively.Table No. 10 : Results by GenderGender Total no % Marked % Moderate % Mild % Not % of Response Response responded patientsMale 12 40 0 0 7 58.33 2 16.66 3 25Female 18 60 1 5,55 9 50 5 27.77 3 16.6Total 30 100 1 16 7 6Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   52
  • 68. Results  Graph 2 : Resultsof Patientsby Gender (Ajamodadi Vati) 10 8 Marked R esponse 6 Moderate R esponse Mild Response 4 Not Responded 2 0 Male FemaleTable No. 11 : Results of patients by Age GroupAge Total % Marked % Moderate % Mild % Not % Response Response Response Respoded20-30 0 0 0 0 0 0 0 0 0 030-40 4 13.33 0 0 2 50 1 25 1 2540-50 8 26.66 1 12.50 3 37.50 2 25 2 2550-60 16 53.33 0 0 9 56.25 5 31.25 2 12. 5060-70 2 06.66 0 0 2 100 0 0 0 0Total 30 1 12.50 16 8 5 Graph 3 : Results of patients by Age Group 9 8 7 6 20 -30 5 30 - 40 4 3 40 - 50 2 50 - 60 1 0 60 -70 Marked Moderate Mild Response Not Respons Respons RespondedResults :After chronological tabulation of the patients under the age groups of decade wise it can be concludedthat majority of Sandhigata Vata is seen among the age group of 50-60 prevalence is approximetlyEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   53
  • 69. Results 55% in this age group and an analgesic shows efficacy of moderate response up to 53% and mildresponse up to 31%. In the rest of age groups, moderate response is seen considerably.Distribution of patients by Religion Religion does not have any impact in giving rise to painful condition but due to circumstancesprevailing in the religion may lead to aggrevation of pain. The area of trial is Hindu dominant thus thepopulation is of more Hindus, the table is self-explanatory shown. The result of trial also exhibits thesame ratios of response shown in tablesTable No.12 : Distribution of patients by ReligionReligion Nos Marked % Moderate % Mild % Not % respondedHindu 26 1 3.84 14 53.84 6 23.07 5 19.23Muslim 4 0 0 2 50 1 25 1 25Christian 0 0 0 0 0 0 0 0 0Others 0 0 0 0 0 0 0 0 0Total 30 1 3.84 16 7 6 Graph 4 : Distribution of patients by Religion 14 12 10 8 Hindu 6 Muslim 4 Christion 2 Other 0 Marked Moderae Mild Responded Not Responded Responded RespondedDistribution of patients by Occupation The occupation at the trial is classified as three categories viz Sedentary, Active, and labor.The distributions of these classes are observed as active group dominance w,r,t pain is exhibited andEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   54
  • 70. Results can be interrelated as more chalatva to the joins leads to kapha kshaya literally to the decrease ofsynovial fluid in the articular cartilage.Table No. 13 : Distribution of patients by OccupationOccupation Nos % Marked % Moderate % Mild % Not % respondedSedentary 1 3.33 0 1 100 0 0Active 22 73.33 0 12 54.54 6 21.21 4 18.18Labor 7 23.33 1 14.28 4 57.14 1 14.28 1 14.28Total 30 1 17 11 5 Graph 5 : Distribution of patients by Occupation 12 10 8 6 4 Sedentary 2 Active 0 Labor Marked Moderate Mild Not Responded Responded Responded RespondedTable No.14 : Distribution of patients by Economical StatusEconomical Number % Marked % Moderate % Mild % Not %status s response respon dPoor 3 0.10 0 2 66.66 0 1 33.33Middle 16 53.33 1 6.25 10 62.5 2 12.5 3 18.75Higher 8 26.66 0 3 37.5 4 50 1 12.5middleHigher 3 0.10 0 1 33.33 1 33.3 1 33.33class 3Total 30 16 7 6Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   55
  • 71. Results  Graph 6 : Distribution of patients by Economical Status 10 8 Poor 6 4 Middle 2 Higher middle 0 Higher class Marked Moderate Mild Not Response Respond Respond RespondResults The economical class plays an important role in disease manifestation and also at thepacification of the disease. Thus, the study of the economical status with reference to the clinical trialis necessary. The no of middle class people have more considerable analgesic effect is seen i.emoderate response in middle class people.Evaluating pain data: The data collected at trial is very valuable at the evaluation of pain in different conditions withspecial references to shoola and shotha of sthoola sandhi mainly associated complaints are noticed atthe study. All these symptoms of prime and associated are tabulated according to complaints of thepatients.Table No. 15 : Evaluation of pain data Complaints Number of patients % Sandhi shotha 29 96.66Prasarana akunchana savedana 30 100 pravrutti Sandhi graham 28 93.33 Sandhigati asmarthata 23 76.66 Sparsha akshamatwa 24 80Table No.16 : Associated complaints: Complaints Number of patients % Klama 20 66.66 Jwara 13 43.33 Angamarda 15 50Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   56
  • 72. Results Results: Among 30 patients all of them suffered from pain with variable intensity.29 of them had sandhishotha either grading 1 or 2 and 93% of them had sandhigraha which restricted their activities. Nearly75-80% patients had sandhigatiasmarthata and sparsha akshamatwa. The associated complaints were klama for 20 patients(67%)and jwara for 43% and angamardafor 50%.History of present illnessThe criteria’s for consideration are I) Mode of onset a) Chronic b) Insidious c) Acute d) Traumatic II) Joints involved a) Axial b) Cervical c) Lumbar d) Spine e) Knee f) Ankle g) Hip h) Inter phalangeal III) Nature of pain a) Pricking b) Aching c) Generalised d) Burning IV) Routine activities affecteda) Yes b) NoTable No.17 : Table Showing mode of onset of disease Mode of onset No of patients % Chronic 12 40 Insidious 03 10 Acute 15 50 Traumatic 0 0Table No.18 : Joint involved Joints involved No of Patients % Axial 02 06.66 Cervical 02 06.66 Lumbar 05 16.66 Spine 02 06.66 Knee 21 70 Ankle 08 26.66 Hip 03 10 Inter phalangeal 14 46.66Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   57
  • 73. Results TableNo. 19 : Nature of pain Nature of pain No of patients % Pricking 03 10 Aching 13 43.33 Generalized 14 46.66 BurningTable No. 20 : Effect on Routin activities affected Routine activities affected No of patients % Yes 20 66.66 No 10 33.33 Total 30Resultsa) Mode of Onset By observing the tabulation, it can be concluded that 50% of patients suffered with acute painand 40% with chronicity and insidious was 10%b) Joints involved As the most weight bearing joint is knee joint and hence 21 patients among 30 i,e 70% hadknee joint pain.14 patients i,e aprox 47% patients had interphalangeal pain and 2 patients each hadaxial cervical and spinal joint pain, 5 patients (17%) had lumbar and 8 patients had ankle and 3patients had hip joint pain.c) Nature of pain By resulting the tabulation 14 patients i.e 47% had generalized pain and 13 patients had achingtype of pain and 3 patients have pricking type of paind) Affect on routine activities Among 30 patients the routine activities of 20 patients were affected i.e Sandhigata vata has67% affect an routine activities hurdles.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   58
  • 74. Results Table No. 21 : Distribution of patients by Mode of OnsetSl, No Mode of onset Joint Involved Nature of pain Rotine01 Chronic Cervical Aching Yes02 Acute Cervical, lumbar, ankle, hip Pricking Yes03 Chronic Lumbar, knee, ankle Aching Yes04 Acute Knee Pricking Yes05 Chronic Knee Pricking Yes06 Acute Lumbar, knee Generalized Yes07 Chronic Knee, lumbar Generalized Yes08 Acute Knee Aching Yes09 Acute Axial, knee Generalized Yes10 Acute Axial, knee Aching Yes11 Insidious Knee Aching Yes12 Chronic Knee Generalized Yes13 Insidious Knee,Interphalangeal Generalized Yes14 Chronic Knee, hip Generalized Yes15 Chronic Knee, interphalangeal Generalized Yes16 Acute Knee, interphalangeal Generalized Yes17 Acute Knee, interphalangeal Generalized Yes18 Acute Knee, interphalangeal Aching Yes19 Acute Ankle, hip Aching Yes20 Chronic Knee, interphalangeal Generalised Yes21 Chronic Knee, interphalangeal Aching Yes22 Acute Knee, interphalangeal Generalized Yes23 Insidious Lumbar, knee Generalized Yes24 Acute Knee, interphalangeal Aching Yes25 Chronic Knee, spine Aching Yes26 Acute Ankle, interphalangeal Aching Yes27 Chronic Ankle, interphalangeal Aching Yes28 Chronic Knee, interphalangeal Aching Yes29 Chronic Ankle, interphalangeal Aching Yes30 Acute Interphalangeal, knee Generalised YesTable No. 22 : Ditribution of patients by Srotas Annavaha Nos of patients % Ajeerna 7 23.33 Agnimandya 11 36.66 Rasavaha 0 0 Aruchi 8 26.66 Jwara 3 10 Majjavaha 0 0 Astinistoda 10 33.33 Sandhi saithilya 16 53.33 Sandhi shopha 16 53.33 Sthabdha 0 0 Asthitoda 4 13.33 Asthi shoola 25 83.33 Roukshyam 3 10Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   59
  • 75. Results Evaluation of pain in Srotas Sroto dusti lakshanas are the main evaluating criteria in Ayurveda. The main srotas involved inthe samprapti of sandhigata vata are Annavaha srotas exhibiting Ajeerna and Agnimandya lakshanas,Rasavaha viz Aruchi and Jwara the main srotas involved are Asthi and Majja vaha srotas thesymptoms of – are tabulated. This tabulation shows approx 83% of patients have pain, which may restrict day-to-dayactivities along with 54% of shithilata, and shophatwa are seen Among 30 patients suffer fromAsthinistoda, 36% of patients suffer from agnimandya and 30% patients suffer from Astitoda.Table No 23: Distribution of patients by Ahara Nidana in sandhi shoolaAhara Nidana Group %Sheetanna 23 76.66Rookshanna 22 73.33Laghwanna 15 50Shuskanna 10 33.33Katu Rasa 12 40Tikta Rasa 09 30Kashaya Rasa 12 40Upavasa 20 66.66 Graph, 7 : Distribution of patients by Ahara Nidana 25 Sheetanna 20 Rookshann a 15 Laghwanna 10 Shuskanna 5 Katu Rasa 0Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   60
  • 76. Results Table No. 24: Distribution of patients by Vihara NidanaVihara Nidana Group %Ratrijagarana 22 73.33Pradhavana (Running) 00 00Bharavahana 08 26.66Yanam (Riding) 02 06.66Vyayama 03 10Walking 09 30Pratarana (Swimming) 0 0 Graph, 8 : Distribution of patients by Vihara Nidana Ratrijagarana 25 Pradhavana 20 Bharavahana 15 Yanam 10 Vyayama 5 Walking 0 PratarangTable No. 25 : Distribution of patients by ManasikanidanaManasika Nidanas Group %Chinta 24 80Shoka 22 73.33Bhaya 17 56.66Krodha 17 56.66Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   61
  • 77. Results  Graph, 9: Distribution of patients by Manasika Nidana 25 20 Chinta 15 Shoka Bhaya 10 Kroda 5 0Aharaja NidanaAmong 30 patients, 77% Sheetanna, 73% Rookshanna, 50% Laghwana, 33% Shukranna, 40% KatuRasa pradhana, 30% Tikta Rasa pradhana, 40%Kashya Rasa pradhana ahara and 67% of patientsfollow upavasa repeatedly.Viharajanya Nidana74% among 30 patients have the practice of ratrijagarana, 30% Walk beyond limits everyday 27%Lift heavy weights, 10% patients does vyayama, All these constitute viharja nidana.Manasika NidanasAmong 30 patients 80% suffer from Chinta, 73% Shoka and 57% are under bhaya and krodha. Allthese are manasika Nidana for Sandhigata Vata.Table No. 26 : Distribution of patients by Dosha bhedha Dosha bhedha No of Patients % Vataja 04 13.33 Pittaja 0 0 Kaphaja 0 0 Vata-pittaja 14 46.66 Pitta- kaphaja 01 03.33 Kapha – vataja 09 30 Sanipataja 02 06.66Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   62
  • 78. Results  Distribution of patients by Dosha bhedha Vataja Pittaja 15% Kapha-vataja 0% 33% Kaphaja Vata-pittaja 0% 52% Pitta-kaphaja 0% The predominance of Vata – pitta with 47% is seen along with Kapha – vata of 30%, Vatajaof 13%, Sannipataja of 06% and Kaphaja of 03%.Table No. 27 : Showing the distribution of patients by different grades of Vatapoorana drutisparsha before and after treatment. Grade Before % After Treatment % Treatment No of No of Patients Patients III 01 03.33 0 0 II 02 06.66 0 0 I 27 90.00 14 46.66 0 0 0 16 53.33 Total 30 Graph, 11 : Showing the distribution of patients by different grades of Vatapoorana druti sparsha before and after treatment. 30 25 Grade III 20 Grade II 15 10 Grade I 5 Grade 0 0 Before Treatment After Treatment Results: It is observed that vatapoorna druti sparsha was 3% in III grade and 90% in I grade beforetreatment. But after treatment there were no patients found in III and II grade but 47% were enrolledEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   63
  • 79. Results in I grade and 53% in 0 grade .These results conclude that there was marked reduction in vata poornadruti sparsha.Table 28: Showing the distribution of patients by Atopa Before and After treatmentsGroup Before % After Treatment % Treatment No of No of Patients PatientsIII 02 06.66 0 0II 10 33.33 03 10I 16 53.33 22 73.330 02 6.66 05 16.66Total 30 Graph, 12 : Showing the distribution of patients by different gradesof Atopa before and after treatment. 30 25 Grade III 20 15 Grade II 10 Grade I 5 Grade 0 0 Before Treatment After TreatmentResults: Atopa the main characteristic feature of sandhigata vata is 7% in III grade,33% in IIgrade ,53% in I grade and 7% in 0 grade .After administration of medicine for 45 days 10% in IIgrade, 73% in I grade and 17% in 0 grade were observed.Table No. 29 : Showing the distribution of patients by Prasanna akunchanayoho savedanapravruttiGroup Before Treatment % After Treatment % No of Patients No of PatientsIII 06 20 0 0Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   64
  • 80. Results II 15 50 04 13.33I 08 26.66 18 600 01 03.33 08 26.66Total 30 Showing the distribution of patients by different grades of Prasanna akunchanayoho savedana pravrutti before and after treatment. 30 20 Grade III Grade II 10 Grade I 0 Grade 0 Before Treatment After TreatmentResults: All 30 out of 30 patients had pain on flexion and extension among them 6 patients had IIIgrade pain and 15% had II grade and 8 had I grade and only 1 patient had 0 grade pain.After treatmentonly 4 patients had II grade pain,18 had Igrade and 8 patients had 0 grade pain,. Marked decrease in the grades of pain is seen.Table No. 30: Showing the distribution of patients by different grade of Sandhi shotha Beforeand After treatment.Group Before % After Treatment % Treatment No of No of Patients PatientsIII 0 0 0 0II 16 53.33 04 13.33I 12 40 20 66.660 02 06.66 06 20Total 30Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   65
  • 81. Results Results: There were no III grade swelling fond among 30 patients but 16 patients among 30 had II gradeand 12 had I grade and only 2 had 0 grade. After treatment 4 patients had II grade 20 had I grade and6 patients had 0 grade pain.Table No. 31: Showing distribution of patients by different grades of SandhigrahaGroup Before % After Treatment % Treatment No of No of Patients PatientsIII 0 0 0 0II 0 0 0 0I 25 83.33 20 66.660 05 16.66 10 33.33Total 30 99.99 30 99.99Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   66
  • 82. Results  Graph, 15 : Showing the distribution of patients by different grades of Sandhigraha before and after treatment. 25 20 Grade III 15 Grade II 10 5 Grade I 0 Grade 0 Before After Treatment TreatmentResults: 25 patients before treatment had I grade stiffness and 5 had 0 grade stiffness but aftertreatment there was 16% reduction in the grade only 20 patients had I grade and 6 patients had 0 gradepain.Table No. 32: Showing distribution of patients by different grades of Sparsha akshamatva Group Before % After Treatment % Treatment No of No of Patients Patients III 01 03.33 0 0 II 09 30 04 13.33 I 15 50 14 46.66 0 05 16.66 12 40 Total 30Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   67
  • 83. Results  Graph, 16 : Showing the distribution of patients by different grades of Sandhigraha before and after treatment. 15 Grade III 10 Grade II 5 Grade I Grade 0 0 Before Treatment After TreatmentResult: Only 1 patient among 30 had III grade tenderness and 9 had II grade, 15 had I grade and 5 had0 grade. After treatment 4 patients had II grade 14 had I grade and 12 had 0 grade tenderness.Table No. 33: Table Showing Total results Results Number of patients % Marked response 1 3.33 Moderate response 16 53.33 Mild response 7 23.33 Not responded 6 20 Total 30 Graph 17 : Total Results Marked response Not responded 3% 20% Moderate Mild response response 23% 54%Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   68
  • 84. Results  Results: The results of trial drug are observed with subjective and objective parameters. The assessment is done as a comparison to the baseline data to the final data obtained. Initially almost patients are observed with ruja and shotha further are observed with diminished grades of severity. The trial drug AJAMODADI VATI has moderate response with 53% and mild response 23% and 20% patients not responded to the treatment and only 1 patient had marked response. STATISTICAL ASSESMENT: Table No 34: Showing Subjective parametersSl Subjective Mean Mean % of SD SEM t P Value Remarksno parameters BT AT Improvement value01 Vataporna driti 1.033 0.466 54.88 0.568 0.103 5.504 <0.001 Highly Significant Sparsha02 Atopa 1.333 0.933 29.98 0.563 0.1027 3.891 <0.001 Highly Significant03 Prasrna 1.933 0.866 55.21 0.449 0.0819 12.942 <0.001 Highly Significant Akunchanayoho Vedana04 Sandhi Shota 1.4 0.9 35.71 0.572 0.104 4.807 <0.001 Highly Significant05 Sandhigraha 0.866 0.666 23.08 0.406 0.074 2.704 <0.001 Highly Significant06 Akshamatwam 1.233 0.7 43.22 0.571 0.104 5.125 <0.001 Highly Significant RESULTS: The subjective parameters viz vatapoornadruti sparsha has highly sinificant decrease compared to the reading gradient before and after treatment with trasparency of results abt 55%, atopa has 30% result. The charecteristic feature of sandhigata vata prasarana akunchanavoho savedana pravrutti has been reduced by 55% proving the efficacy of ajamodadi vati as an analgesic. The shotha hara property of ajamodadi vati is well established by 36% result. Sandhigraha and sparshaakshamatva has result of 23% and 43% respectively. Hence all the subjective parameters have highly significant result. Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   69
  • 85. Results  OBJECTIVE PARAMETERS: Table No 35 : Showing Objective parametersSl Objective Mean Mean % of SD SEM t P Remarksno parameters BT AT Improvement value Value01 Joint pain 7.766 2.1 73.50 1.268 0.231 24.502 <0.001 Highly Significant02 Local Temp 99.053 98.1 00.96 0.9576 0.1748 05.451 <0.001 Highly Significant03 Swelling 309.533 309.066 05.25 9.722 1.775 00.262 <0.40 Not Significant04 MC Gills 13.10 09.16 30.00 1.874 0.0003 13.13 <0.001 Highly Significant05 Hb% 11.436 11.826 03.00 0.486 0.088 04.43 <0.001 Highly Significant06 ESR 24.2 20.86 13.80 2.454 0.448 07.455 <0.001 Highly Significant07 TC 6600.367 6979.36 57.00 548.40 100.12 03.785 <0.001 Highly Significant08 Mobility 43.33 87.33 101.00 16.938 03.092 14.230 <0.001 Highly Significant09 DC- 50.966 56.3 10.47 2.056 0.467 11.43 <0.001 Highly Polymorph Significant10 Dc- 32.00 30.866 03.54 3.536 0.645 1.758 <0.10 Not Lympocytes significant11 Walking 2.633 1.566 40.52 0.365 0.066 16.16 <0.001 Highly time Significant RESULT: Joint pain, local temperature, Mc gills, Hb%, E.S.R, T.C, mobility, D.C-Polymorphs, walking time all these objective parameters show highly significant result, while swelling and Dc lymphocytes have no significant result. Table No 36: Showing subjective Parameters based on Gradings Sl Subjective Mean Mean % of SD SEM t value P Value Remarks no parameters BT AT Improvement 01 All subjective 1.299 0.75 41.87 0.288 0.11 04.94 <0.001 Highly parameters Significant Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   70
  • 86. Results Overall improvement in subjective Parameters based on Gradings Changes in subjective parameters (before and after treatment) 2 1.5 1 0.5 0 % of improvement in subjective parameters 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 subjective parameters Series1Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                         Page   71
  • 87. Discussion V{tÑàxÜ @I MMW|ávâáá|ÉÇ M Tadvidha sambhasha i.e., a healthy discussion paves a way for untying the bundle of thoughtsto bring out new dimension for the better evaluation of problem Sandhigata vata (O,A) which is mostcommonest type of arthritis and the most common joint disorder in the word, the number one cause ofdisability. As it has been mentioned under, the vatavyadhis by Bruhatrayis and these vatavyadhis areat the topmost position among the mahagadas due to its chronicity. According to Ayurveda vatakara ahara constitutes triggering of vata. Sthoulya is also a majorcause for vata prakopa in sandhis. Due to over weight of body, weight bearing joints, especially kneejoint has to bear the whole weight. This causes wear and tear of articular cartilage there by, causingSandhigata vata. On the contrary, vata prakopa occurs due to kaphakshaya in sandhis, due to eachshleshaka kapha gets qualitatively and quantitatively decreased leading to Sandhigata Vata. Brihatrayees mentiond that vata which gets vitiated in sandhis is causative factor forSandhigata vata. The symptoms like vatapoorna druti sparsh, shopha, prasarana, akunchna, vedana,are also mentioned. Acharya madhava considered to be Nidana shresta specifies the symptom as Atopa. This ischaracteristic sound produced from joints during its movement, which can be co-related withcontemporary science. Osteoarthritis, symptom, crepitation. This disease is also called as cripptingdisease due to inability to perform routine activities properly. Now a-days this disease has becomemuch popular resulting in the formation of Arthritis organizations around the world. To clear the miss belief that participation in the sports leads to O, A. there is no anyconvincing reason to support the statement of an association between specific athletic activities andarthritis if major lacuna is excluded. Neither long distance wall running or jogging has been shown tocause O, A. this apparent lack of association may be due to lack of association may be due to lack ofgood long teem studies and the selection basic early discontinuation of the activity by those incurablejoint damage.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   71
  • 88. Discussion This Sandhigata vata usually occurs in old ages in this age only vata dosha is predominant,mainly asthi and majjavaha srotas are involved. but if continues which can be defined asmamsakshaya, in our science due to vitiation of mamsavaha srotas and pratiloma kshaya henceindirectly the involvement of mamsavaha srotas in disease also takes place. A praposed hypothesis always needs prof for its justification from all the angles, this wasstated by Acharya Charaka, long back. After the formation of a hypothesis, it has to be tested andobserved by various methods and eventually the results are obtained. All these should be wellestablished as the grounds of proper reasoning or logic, and finally concluded thus a proposedhypothesis becomes a principal if the reasoning is satisfactory “Rujakaratwat rogaha” here ruja refersto all those pain with a body and mind suffer hence pain is universally understood as a signal ofdisease and is the most common symptom in many diseases “Pain” very easy to say and ask but mostdifficult to suffer. Because pain is the alaem of actual or potential tissue damage, its protective valuebecomes unbearable when we are its victims patient tends to sit with the hand over the joint offectedwich is indicative of extent of stress impact over afflicted even though joint pain is not proved to befatal, it cripples the affected patients.Objectives at discussion Discussion is a sort of engulfing the knowledge of other brains by feeding a little from ours.Discussion with science becomes base establishment of concept. Thus discussion is most essentialphase of any reserch work keeping this in view certain facts which have emerged from study can bestudied under following heading. i) Discussion on demographic data ii) Discussion on Sandhi shoola iii) Discussion on probable mode of action of Ajamodadhi vati iv) Statistical discussion of parameters v) Limitation of study and suggestions i) Discussion on demogrphic dataEvaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   72
  • 89. Discussion The efficacy of a drug cannot be proved unless it is subjected to clinical trials and analyzedstatistically. The clinical study is conducted for 30 patients and observations were systematicallyrepresented in foregons pages. a) Age distributions in study Balya with Kapha predominence, youvana with pitta and Vruddhapya with vatapredominence, are the 3 stages of life since Sandhigata vata is seen to prevail more in vruddhavathaand main etiology is kapha kshaya on other hand there is vaya avstha janya vata vruddhi and vyadhijanya vata vruddhi leading to Sandhigata vata. During trial study it is observed that approx 56% of patients in the age group 50-60 are proneto Sandhi vata and nearly 27% of patients in the age group 40-50 are prone to the same. The subjectsof old age are relieved with pain in weight beraring joints. The trial drug Ajamodadi vati, a rational combination chosen form vedana sthapana gana isbasically a pain relieves. These are of kashaya skanda dravyas. The action over the pain to assess herewe have observed that in the age group of 50-60 are more prone to Sandhigata vata and considerablemoderate response is seen upto 56% in the same age group The bone and joint intact is lost, pain in the joint exist, thus a fair conclusion is drawn thatAjamodadi vati is a pain killer acts as Vata(Sosha) and Kapha(Shotha) hara. The Sandhibandhamoksha(Subluxation) occurs due to Vata aggrevation with is regulated by kapha function ofpromoting the same. The lost integrity of ligaments surrounded and joint edge part of the bone isregulated by the Ajamodadi vati to regulate the pain in Sandhigata vata. b) Gender There is no spcificity in Sandhigata Specially with reference to genders. Becoz it is equallydistributed among males and females. But slight variation in the incidence rates are seen due toincreased susceptibility of females for low calcium in advancing ages. This may be due to haemoralimbalance either in premenopausal or post menopasal period. Hence 60% of females among 30patients were prone to Sandhigata vata while only 40% of male were prone to the same. So 50-60%of marked response is seen.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   73
  • 90. Discussion c) Religion distributions in studyAs data is only areflection of geographical predomince of community living in a limited area of studywith has predominence of hindus. Hence during study 87% of hindu and 13% of muslims areobserved as patients of Sandhigata Vata. d) Occupational distribution in the study It was observed that 7(23%) among 30 lead life as labors, 22(73%) lead Active life and only1(3%) patients lend sedentary life. As the manual workers and active group patients are with vitiationof vata more and susceptible for sandhishoola, these categories are recorded more. This strengthensthe view of vata implications to cause the symptom I,e Sandhishoola is triggered by excessivephysical demand of the joint utility. When the results are observed 57% moderate response was seen in labor group and 55%moderate response was seen in active group of people and only 1 patients had sedentary life style andafter treatment it showed moderate response. e) Economical status distributions in study. Socio-economic condition plays an important role in the path of research work sometimes itmay be cause even. Here as observed middle class patients are more I,e 53% poor (10%), highermiddle (27%) and higher class (10%) Possibility crestes that middle class people are more prone to get loint pains as they aresubjected to stress and strain. Apart from the above said reason, the locality near the trial area andpopulation in sureoundings may alter the data. The response of the drug may vary if balanced dietand balanced rest is not maintained.II) Discussion on sandhishoola: Sandhishoola is a symptom in which the integrity and quality of the joints are reduced,leadingto weakness of the body.Sandhigata vata is the most prevelent major problem in elderly and the mostimportant cause of physical disability.Prevelence of this disease is rising at an alarming rate.Indeveloping countries it occurs mainly in middle aged and elderly population wherein it may causesevere disability and impaired quality of life.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   74
  • 91. DiscussionSANDHIGATAVATA vis-à-vis OSTEOARTHRITIS. Sandhigatavata is the most common joint disorder arising with greater number of affectedpopulation in the world. It comes under the various Gatavatas explained in Vatavyadhi prakarana. Itis caused by the localization of the vitiated Vata dosha in the asthi sandhis of the body. It ischaracterized by the symptoms pertaining to the asthi sandhis like sandhi shoola, sandhi shotha etc. Osteoarthritis is a disease coming under the arthritis group of diseases described by themodern science, which is almost identical to Sandhigatavata in etiology, pathology and clinicalfeatures. Hence, the discussion is made accordingly.Discussion On Shareera. In the context of Asthi sandhi means a junction between two or more bones. Sandhi is not asingle structure rather it is considered as an organ. There are different structures, which supports thestability of the joint like Sanyu or ligament, which helps in proper binding of the joint. They unite thebones and help to direct the bone movement and prevent the excessive and undesirable motion.Muscle tone helps to maintain the alignment of the joint. Shleshaka Kapha present in the Sandhisprovides the lubricant factors, Shleshmadharakala situated in the joints supported by ShleshakaKapha, helps in lubrication. Functions of the Shleshaka Kapha and Shleshmadhara kala described in Ayurveda can be co-related to the synovial fluid situated in synovial joint, that lubricates the knee joint, a nutrient carrierto the cartilage disc, and helps in keeping the joint firmly united. Role of Vyanavata is most important in the movements of the joints. The Marmas areconsidered as the point of union of nerves, vessels and muscular system, which are vital in thestructure and functioning status of the joints. Functions of the peshis and snayus are exactly identicalto that of the muscles and ligaments, related to the joints. Knee works as a hinge joint, but thearticulation is more complex than other hinge joints. Seven major ligaments, flexor and extensormuscles support the movements of the knee joint.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   75
  • 92. DiscussionDiscussion On Nidana. Ayurvedic philosophy mainly emphasized on Vatakara ahara-vihara in the manifestation ofSandhigatavata. Vardhakya is predominated by Vata dosha and characterized by Dhatu kshaya leadsto reduced Sneha bhava in the body, which in turn, vitiates the Vata dosha and reduces the Kapha,thereby resulting in Karmahani of the sandhis. Also, dhatushaithilya is another feature in Vardhakya,which reflects in peshis and snayus thereby reducing their functional efficiency in supporting thejoints. This is a major risk factor for Sandhigatavata. Various physical activities such as Pradhavana,Bharaharana and Abhighatas due to prapatana, Marma abhighata, Dukha shayya and Dukha asana areimportant Nidanas for Sandhigatavata. Repetitive movements may lead to excessive strain leading toerosion and joint damage. Trauma to the joint enhances the occurrence of arthritis. Sthoulya is anothercausative factor for Sandhigatavata. Vatavyadhee and Sthoulya are having interrelated pathogenesis.(i.e. Medavrita vata) Obese person have a high risk of Osteoarthritis. The relative risk of developingOsteoarthritis, is more in the population belonging to the high quintile body mass index.Discussion On Samprapti Samprapti of Sandhigatavata may be divided into Dhatukshayajanya and Avaranajanya.Modern science explains the pathogenesis of Osteoarthirits in two ways –01. Sub-standard biomaterial of the joint (Dhatukshaya).02. Increased applied pressure over the joint (Avarana). In Dhatukshyajanya Sandhigatavata due to old age and excess use of Vatakara ahara-viharacauses qualitative changes in the joint material gradually leading to disease manifestation i.e. agerelated degenerative changes. Samprapti of Margavaranajanya sandhigatavata initiated by the nidanaghataka Sthoulya involving the avarana of Vata by Kapha and medas, which can be correlated withcomplications of obesity where in due to continuous pressure, joints get affected (due to Avarana)leading to disease manifestation.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   76
  • 93. DiscussionDiscussion On Symptomatology. The lakshanas of Sandhigatavata viz. Vedanayukta pravritti of sandhis, Shotha (Vatapoornadritisparshavat), Atopa and Sandhigati asaamarthya,etc are explained by various treatises ofAyurveda. Modern science, has mentioned similar features along with other symptoms pertaining toindividual joints. Tenderness and joint stiffness (implied by the restriction of joint movements) arespecially monitored in Modern science and further added that any joint can get affected withOsteoarthritis. Acharyas have not paid their attention towards the site of particular joint involvement. Whenthere are structural changes in the joints the disease can be categorized as AsadhyaDiscussion on DOSHA consideration: In sandhigata vata vyanavata and sleshakakapha has got prime importancein its manifestation.The type of vata that invades throughout the body being responsible for all the movements is calledvyanavata and shleshakakapha resides in joints and helps in movements of joints.The vyanavata andshleshaka kapha gets vitiated by nidana and gets loddged itself in sandhi leading to sandhigatavata. It is not concluded that the alone vyanavata is responsible for the pain anywhere.iin the flowdiagram shownat samprapti describes the involvement of rest of vata.Discussion on DHATUS : Authors of Ayurveda have explained that asthi dhatu will be predominant of prithvimahabhuta and they have placed asthi dhatu among parthiva dravya.And Dulhana comenting on thisstates that apart from pritvi their will be presence of vata and agni mahabhuta as these two are havingkharatwa,rukshatwa,parushatw a properties.The properties of asthi are steera, kathina, chirasthayi andbharadharana ksamata.These qualities mimick that of kapha which is the binding force between twostructures.Here in this word structure can be taken as shlesmadhara kala. Asthidhatu with its aashrayaashrayi bhava sambandha to the vata impacts the sandhi withwhich it is joined to make a joint structure.The joints are very much needed for locomotion.Thenourishment disturbances action to vitiate the vata and causing the joints pathology.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   77
  • 94. DiscussionDisscussion on probable mode of action of Ajamodadi vati : As stated earlier Ajamodadi vati is a combination of drugs of Vedanasthapana gana, thus theaction of drug over the vata which is a prime partner of producing pain anywhere in the bodyhereespecially at joints.As the pain is an action of vata As the pain is an action of vata never all vatahara dravyas are indicated to vedana. Only asmall group of drugs reduce pain. Here the Ajamodadi vati action is substantiated. Stastical discussionon Parameters:Statistical disscussion of parameters: The subjective parameters have shown highly significant result but the objective parametersexcept swelling and Dc-polymorphs havenot shown any significant results rest parameters vizHb%,E.S.R,Dc-lymphocytes,Mc gills,mobility all have shown highly significant results.Limitation of the study: 1. The sample size was small 2. The study period was limited. 3. Limited area of experiment restrics the results. 4. Drug is experimented in only one form 5. The drug is only oral to restrict or influence the result.Suggestions : 1. More specific pain relieving herbs or compound medicines in Ayurveda should be evaluated. 2. A clear understanding and protocol to check the pain pathways in Ayurveda should be developed under the limelight of contemporary science. 3. To understand the medicine response as vedana hara and shothahara property as a specified protocol is to be established. 4. The same study can be extended to multi centric study.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page   78
  • 95. Conclusion V{tÑàxÜ @J MMVÉÇvÄâá|ÉÇM 1) There is an intimate relation between vata and kapha in sandhigata vata disease.Restoration of vata to its normal state helps in the treatment of Sandhigata vata 2) Awareness of unwholesome dietory habits and exercise can prevent Sandhigata Vata 3) The pathological entities in sandhivata are vyanavata sleshakapha and sleshmadhara kala 4) Sandhivata even though is explaind as one of the vata derivatives there is no specific nidanas has been explined for sandhivata. general vata vyadhi nidana can be considered for sandhivata 5) The maximum number of patients are in 50-60 age group, which is suggestive of influence of vata dosh and the symptoms of joint pain is being age related. SUGGESTIONS FOR FUTURE STUDIES: 1. The study can be conducted in a massive sample. 2. The treatment schedule can be extended for further benefits. 3. For better results it can be accompanied with panchakarma procedures. 79Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                               Page  
  • 96. SummaryV{tÑàxÜ @K MMfâÅÅtÜç The thesis entitled “Evaluation of the efficacy of Ajamodadi vati in Sandhigatavata”comprises following points: 1. Introduction 2. Objectives of the study 3. Review of literature 4. Methodology 5. Observation and results 6. Discussions 7. Conclusion • Disorders of the musculoskeletal system are prevalent through the world affecting all age group among this; important one is Sandhigatavata which produces disastrous consequences like physical disability in community 80Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page  
  • 97. Summary • The present study is done to understand the disease which is explained in classics even though this disease is considered as Kashta sadhya, itcan be managed when proper treatment is given in appropriate time Here an attempt is made to find the efficacy of the drug “Ajamodadi drug” in sandhivataIntroduction • Gives the explanation about qualities of healthy person importance of vata as well as pathologically and introduction of trial drug “Ajamodadi vati”Objectives • The main aim and objectives of the study has been mentionedReview of literature • This chapter comprises of following headings disease review and drug review • Disease review dealt under the following headings. Disease review and Drug review Historical aspect gives the historical glimpses with regards to the disease Sandhigata vata and traces the various developments rights from the vedic period to preset era under the heading of etymology the description about sandhi and different constituents which forms the sandhi and also concept about gatavata has been mentioned. • Detailed data wise collection about Nidana, Roopa, Samprapti, Sadhya-sadhyata upadrava and Chikitsa along with pathya-apathya of the disease along with some contemporary of coomperative statements. • In Drug review section, a thorough study of ingradients of the compound preparations covering the botanical nomenclature, rasa, guna, veerya, vipaka, chemical constituents etc. • 81Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page  
  • 98. SummaryClinical study • It contains the study design Details of study subjects (Cases), under clinical study description of the patients, grouping, selection, inclusion and exclusion criteria, protocol criteria for assessment of the study.Observational study • Detailed explanation is given on the distribution of the patients according to age, sex, economical status, diet, habits, material status are represented along withPrepartionof the drug • Here a detailed expiation regarding the preparation of the compound drug is mentioned detail.Results • In this results of the study analyzed statistically under this demographic data, analyzed, results are studied under demographic data, evaluating pain data. • Results of so patients and statistical evaluationsDiscussion • In this chapter the nidana panchakas, demographic data, Sandhi shoola, Probable mode of action of Ajamodadi vati, statistical parameters, limitations of study and suggestions were the points discussed along with the obtained results with the variable gradient before and after treatment.Conclusion • An outcome of the whole work conducted is concluded by the justification of the result obtained. 82Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis) Page  
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  • 103. Bibliography 77) Madhavakara, Madhavanidana chapter 22 sloka 21. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 418.78) Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 24sloka 93. 5th ed.Varanasi: Chaukhambha Orientalia; 1988. p. 264-265.79) Susruta, Susrutasamhita Shareerasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 5– 24th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-366.80) Susruta, Susrutasamhita Shareerasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 8 – 17th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-367.81) Vagbhata, Ashtangahridaya Sutrasthana chapter 12 sloka 18-Varanasi:Krishnadas Academy; 1982. P.7.82) Susruta, Susrutasamhita Shareerasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 4 – 14th -15th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-365.83) Susruta, Susrutasamhita Sutrasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 8 – 17th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-265.84) Vagbhata, Ashtangahridaya Sutrasthana chapter 11 sloka 26-28 Varanasi: Krishnadas Academy; 1982. P.7.85) Susruta, Susrutasamhita Shareerasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 5 – 29th -36th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-367.86) Susruta, Susrutasamhita Shareersthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 5 – 37th -38th Sloka.Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-.364.87) Susruta, Susrutasamhita Shareerasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 5 – 16th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-365.88) Susruta, Susrutasamhita Chikitsasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 31– 2nd Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-488.89) Agnivesa, Charakasamhitha Sutrasthana chapter 5 sloka 85th, 4th ed. Varanasi:Chaukhambha Sanskrit Sansthan; 1994. p. 42.90) Susruta, Susrutasamhita Chikitsasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 8 – 17th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-488.91) Agnivesa, Charakasamhitha Sutrasthana chapter 22 sloka 11 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 120.92) Susruta, Susrutasamhita Chikitsasthana, NibandhasangrahaCommentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 32–3 Sloka.Varanasi: 17th Chaukhambha Orientalia; 4th edi, 1980 p-513.93) Agnivesa, Charakasamhitha Sutrasthana chapter 14 sloka 35-37 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 618.94) Susruta, Susrutasamhita Chikitsasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 32–12 Sloka.Varanasi: 17th Chaukhambha Orientalia; 4th edi, 1980 p-514.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)  Page 5 
  • 104. Bibliography 95) Agnivesa, Charakasamhitha Sutrasthana chapter 14 sloka 35-37 4th ed.Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 89.96) Vagbhata, Asthangahrudaya Sutrasthana, Sarvanga sundara commentary; P.V. Sharma, editor. Chapter 27 –5th sloka. Varanasi: Chaukhambha Orientalia; 1978, p- 254.97) Agnivesa, Charakasamhita Chikitsasthana, chapter 28 – 115th sloka , editor, Vaidya Jadavaji Trikamji Acharya,. Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2004, p-622.98) Agnivesa, Charakasamhita Sutrasthana, chapter 14 – 38th sloka , editor,Vaidya Jadavaji Trikamji Acharya,. Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2004, p-89.99) Susruta, Susrutasamhita Sutrasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 18 –7th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-95.100) Susruta, Susrutasamhita Chitsasthana, Nibandhasangraha Commentary, Vaidya Jadavaji Trikamji Acharya, editor. Chapter 32 – 12th Sloka. Varanasi: Chaukhambha Orientalia; 4th edi, 1980 p-513.101) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-88102) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia, Varanasi p-103) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-156.104) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-222.105) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-83106) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-107) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-136.108) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-215.109) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-72110) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-111) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-143,144112) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-212.113) Bhavaprakasha nighantuof Bhavamishra,6 edition,1982,published by Chaukambha Orientalia,Varanasi p-52.114) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-72115) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-116) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-143,144117) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-212.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)  Page 6 
  • 105. Bibliography 118) Bhavaprakasha nighantuof Bhavamishra,6 edition,1982,published by Chaukambha Orientalia,Varanasi p-52.119) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-84120) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-314,315121) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-136122) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-217.123) Bhavaprakasha nighantuof Bhavamishra,6 edition,1982,published by Chaukambha Orientalia,Varanasi p-22,124) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-85125) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-318126) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-138127) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-213128) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-53129) Bhavaprakasha nighantuof Bhavamishra,6 edition,1982,published by Chaukambha Orientalia,Varanasi p-121130) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-351131) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-46132) Kaiyadeva nighantu edited by Priyavrutt.Sharma,I edition 1979, published by Chaukambha Orientalia,Varanasi p-45133) Bhavaprakasha nighantuof Bhavamishra,6 edition,1982,published by Chaukambha Orientalia,Varanasi p-410134) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-857,858135) Raja nighantu,edited by Indradev Tripathi,II edition 1998,published by Chaukambha Orientalia,Varanasi p-152136) Dhanwantari Nighantu,edited by Acharya Priyavrut Sharma,I edision 1982,published by Chaukhamba Orientalia,Varanasi p-74137) Bhavaprakasha nighantuof Bhavamishra,6 edition,1982,published by Chaukambha Orientalia,Varanasi p-209138) Dravya-guna Vigyana vol-II by J.L.N.Shashtri I edition -2004,published by Chaukambha Orientalia,Varanasi p-214139) Methods in Biostatistics for medical students and research workers byB.K.Mahajan sixth edition published by Jaypee brothers medical publishers.Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)  Page 7 
  • 106. Annex-1Table No. 37: Showing Objective Statistical Assesment of Data.Sl, OPD Joint pain Local Temp Swelling MC Gills Hb% ESR TC Mobility DC- Dc- Walking Polymorph Lympocytes timeNo mm01 1040 09 01 99.1 99 430 425 05 03 12 13 35 30 7750 7860 70 90 50 55 29 24 03 202 1326 08 02 99 98 460 455 11 08 10 12 22 18 6750 8120 70 100 52 59 39 30 03 203 1791 08 02 98 98 320 218 14 10 9.8 11 24 20 4076 5108 70 90 50 61 30 20 02 104 2132 07 01 99 98 180 175 11 08 12 12.7 28 20 5078 6121 30 90 52 59 39 30 03 205 1043 06 01 99 98 240 230 10 08 9.8 10 19 19 6050 7712 30 90 52 61 45 37 02 106 2450 07 01 98.5 98 250 245 12 08 13 13 26 20 7050 8275 70 90 51 57 40 32 01 007 2452 08 02 98 97 460 455 16 11 12 12 25 20 6580 6719 70 100 50 57 32 30 03 208 2079 06 01 98 98 260 255 10 06 11.5 12 20 20 6750 7125 30 90 50 59 32 20 03 209 1824 07 01 99 98 400 590 10 06 9.6 10 19 18 6050 8100 30 90 52 54 45 30 03 110 1722 08 02 99 98 230 224 17 12 9.8 10 20 18 8560 9333 30 90 50 55 42 35 03 211 7973 08 01 98 97 170 164 11 07 14.8 15 22 20 5790 6010 70 100 45 50 36 32 03 112 2152 08 02 102 107 350 348 15 10 12 12 30 25 8750 8916 50 70 47 51 28 31 02 113 4414 06 02 99 98 460 454 19 10 10 11 30 22 8750 9120 70 100 59 65 36 40 03 214 2916 07 02 98 97 260 255 13 07 09 10 25 20 5675 5710 30 90 60 65 30 35 03 215 2131 08 02 99 98 315 298 18 15 09 10 30 28 8150 8215 30 90 57 63 30 34 03 2Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 1 
  • 107. Annex-116 2512 08 03 99 97 190 186 11 08 12.5 13 20 20 6175 6256 30 90 47 51 39 40 02 117 3271 07 03 99 97 240 230 07 07 10.2 10.2 25 25 8150 8216 40 90 52 59 39 40 03 218 5360 09 03 99 98 210 202 12 10 12.2 13 20 20 6415 6720 40 70 49 53 30 34 02 119 1041 07 02 100 99 271 268 17 13 12.3 13 28 24 6050 6127 40 100 57 60 28 31 03 220 1770 08 01 101 99 321 318 17 15 12.2 12.5 20 18 8614 8650 40 60 52 59 31 35 02 021 2136 08 03 99 98 247 244 16 07 12 12 20 16 4565 4710 40 90 52 55 29 30 03 222 3154 09 05 99 97 910 401 12 07 13 13 20 20 8496 8612 20 90 48 52 27 30 03 223 3271 09 02 100 98 312 368 14 10 12 12 28 22 6170 6215 40 90 48 54 21 25 03 224 2757 07 03 98 98 248 248 10 07 11 11 20 17 4560 4791 30 50 51 54 29 30 03 225 3791 08 02 99 97 347 341 13 10 13 13.2 22 18 7195 7201 40 90 51 55 22 27 02 126 3017 08 02 99 98 347 339 10 08 13 13 21 18 4351 3401 40 90 47 52 27 30 03 227 3197 08 06 99 97 347 341 14 10 11 11.2 22 19 4196 4207 50 90 48 53 22 27 02 228 4001 09 01 99 97 417 409 15 10 10.7 11 27 25 6945 7120 30 90 47 52 29 30 03 229 4007 08 02 101 99 347 345 18 14 12.7 12 30 22 7125 7201 40 70 51 54 29 30 03 230 4127 09 02 98 97 247 241 15 10 11 11 28 24 7195 7510 30 90 52 55 25 27 02 1 233 63 2971.6 2943 9786 9272 393 275 343.1 354.8 726 626 198011 209381 1300 2620 1529 1689 960 926 79 47Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 2 
  • 108. Annex-1Table No. 38: Showing Subjective Parameters Of Master charts Sl,No OPD,No Vataporna driti Atopa Prasrna Akunchanayoho Sandhi Shota Sandhigraha Akshamatwa Sparsha Vedana01 1040 01 01 01 00 02 01 02 02 01 01 02 0202 1326 01 00 02 01 02 01 01 01 01 01 01 0103 1791 01 01 02 02 01 00 02 02 01 01 01 0004 2132 01 01 01 00 02 01 02 01 01 01 02 0005 1043 01 00 02 01 02 01 01 00 00 00 01 0106 2450 01 00 01 00 01 00 02 00 00 02 0107 2452 01 00 02 01 02 00 02 02 01 00 00 0008 2079 01 01 02 01 03 02 02 01 01 00 00 0009 1824 01 00 01 01 02 01 01 00 01 01 01 0010 1722 01 00 01 01 02 01 02 01 01 01 01 0111 7973 01 01 01 01 02 01 01 01 01 01 01 0112 2152 01 01 02 02 02 01 02 01 01 01 02 0213 4414 01 01 01 01 02 01 01 01 01 01 01 0014 2916 01 01 01 01 02 01 01 01 01 01 02 0115 2131 01 01 02 01 02 01 02 01 01 01 01 01Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 3 
  • 109. Annex-116 2512 01 01 01 01 02 01 02 02 01 01 01 0117 3271 01 00 00 00 01 01 01 01 01 01 01 0118 5360 01 00 01 01 03 01 02 01 01 00 00 0019 1041 01 00 01 01 02 01 01 01 01 01 02 0120 1770 01 01 01 01 02 01 02 01 01 01 01 0121 2136 01 00 01 01 00 00 01 01 01 00 02 0122 3154 02 00 01 01 02 00 01 00 01 00 01 0023 3271 01 00 01 01 01 00 02 00 01 00 01 0024 2757 01 00 03 01 02 01 01 00 00 00 02 0125 3791 01 00 01 01 01 00 02 01 01 01 00 0026 3017 01 01 00 00 02 01 01 01 01 01 03 0227 3197 01 01 02 02 03 02 01 01 01 01 00 0028 4001 01 00 02 01 03 02 00 00 01 01 02 0129 4007 01 01 01 01 02 00 01 01 00 00 01 0030 4127 01 00 02 01 03 02 00 00 01 01 02 01 31 14 40 28 58 26 42 26 26 20 37 21Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 4 
  • 110. Annex-1Table No. 39: Showing Chief Complaints Chief Compleints Associated CompleintsSl,No OPD, No Sandhi Pain Sandhigraha Smarthta Akshmatva Klama Jwara Angamarda Sootha01 1040 + + + + + + + +02 1326 + + + - - + + +03 1791 + + + + + + + +04 2132 + + + + + + - +05 1043 + + + - + + + -06 2450 + + + + + + - -07 2452 + + + + - - - -08 2079 + + + - - - - -09 1824 + + + + + - - +10 1722 + + + + + - - +11 7973 + + + - _ + - -12 2152 + + + + + - + -13 4414 + + + + - - - -14 2916 + + + + + + + -Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 5 
  • 111. Annex-115 2131 + + + + + + + -16 2512 + + + + + + + -17 3271 + + + + + + - -18 5360 + + + + + + - +19 1041 + + + - + - - +20 1770 + + + + + + + +21 2136 + + - - - + + -22 3154 - + + + + + - -23 3271 + + - - + - + -24 2757 + + + + + - - -25 3791 + + + + + + - +26 3017 + + + + + + - +27 3197 + + + + + + + +28 4001 + + + + + + + +29 4007 + + + + + + - +30 4127 + + + + + - - +Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 6 
  • 112. Annex-1Table No. 40: Showing Present Illness of Master Chart.Sl,No OPD Mode of onset Joints involved Nature of Pain Roatine activities affected C I A T A C L S K An H I P A G B Yes No01 1040 + - - - - + - - - - - + - - + -02 1326 - - + - - + + - - + + - + - - - + -03 1791 + - - - - - + - + + - - - + - - + -04 2132 - - + - - - - - + - - - + - - - + -05 1043 + - - - - - - - + - - - + - - - - +06 2450 - - + - - - + - + - - - - - + - + -07 2452 + - - - - - + - + - - - - - + - + -08 2079 - - + - - - - - + - - - - + - - + -09 1824 - - + - - - - - + + - - - - + - + -10 1722 - - + - - - - - + + - - - + - - + -11 7973 - + - - - - - - + - - - - + - - - +12 2152 + - - - - - - - + - - - - - + - + -13 4414 - + - - - - - - + - - + - - + - - +14 2916 - - + - - - - - + - + - - - + - + -Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 7 
  • 113. Annex-115 2131 + - - - - - - - + - - + - - + - - +16 2512 - - + - - - - - + - - + - - + - + -17 3271 - - + - - - - - + - - + - - + - - +18 5360 - - + - - - - - - + - + - + - - - +19 1041 - - + - - - - - - + + - - + - - + -20 1770 + - - - - - - - - + - + - - + - - +21 2136 + - - - - - - + - + - + - + - - + -22 3154 - - + - - - - - + - - + - - + - + -23 3271 - + - - - - + - + - - - - - + - + -24 2757 - - - - - - - - - + - + - + - - + -25 3791 + - - - - - - + + - - - - + - - + -26 3017 - - - - - - - - - + - + - + - - - +27 3197 + - - - - - - - - + - + - - + - + -28 4001 + - - - - - - - + + - + - + - - + -29 4007 + - - - - - - - - + - + - + - - - +30 4127 - - - - - - - - + - - + - - + - - +Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 8 
  • 114. Annex-1Table No 41: Showing SrotasSl,No OPD,No Annavaha Rasavaha Majjavaha Asthivaha Ajeerna Agnimandya Aruchi Jwara Asthinisthoda Sandhi Sandhi Sthabdha Asthitoda Asthishoola Roukshyam Shaithilya Shopa01 1040 - + + + + + + - + + +02 1326 + - + + + + + - + + +03 1791 + - - - + + + - + + +04 2132 + - - + - - + - - + -05 1043 + + + - - + + - - + -06 2450 + + + + + + + - - + -07 2452 - - - + - - + - - + -08 2079 + + - - + + + - - + -09 1824 - - - - - - + - - + -10 1722 - - + + + + + - + + -11 7973 - - - + - - + - - + -12 2152 - - - - - - + - - + -13 4414 - - - + - - + - - + -14 2916 - - - + - - + - - + -15 2131 - + + + - - + - - - -Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 9 
  • 115. Annex-116 2512 - - - - - + + - - - -17 3271 - - - + - - + - - + -18 5360 - + + - - - + - - + -19 1041 + + + - + + + - - + -20 1770 - + - - - - + - - + -21 2136 - + - + + + + - - -22 3154 - - - + - + + - - + -23 3271 - - - - + + - - - + -24 2757 - + - - + + + - - -25 3791 - - - - - - + - - + -26 3017 - - - - - + + - - + -27 3197 - + - - - - + - - + -28 4001 - - - - - + + - - + -29 4007 - - - - - - + - - + -30 4127 - - - - - - + - - + -Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)                                                  Page 10 
  • 116. SPECIAL CASE SHEET FOR “Evaluation of the efficacy of Ajamodadi Vati in Sandhivata (Osteoarthritis)” POST GRADUATE STUDIES AND RESEARCH CENTER (KAYACHIKITSA) SHRI. D.G.M.AYURVEDIC MEDICAL COLLEGE, GADAGGuide: Scholar:Dr. K. Shiva Rama Prasad Shakuntala. S. Totar1) Name of the Patient Sl.No2) Sex Male Female OPD No3) Age Years IPD No4) Religion Hindu Muslim Christian Other5) Occupation Sedentary Active Labor6) Economical status Poor Middle Higher middle Higher class7) Address Pin8) Birth data Place of Birth AMDate Month Year Time Hours Minutes PM9) Selection Included Excluded10) Schedule dates Initiation Completion / Discontinuation11) Result Marked Moderate Mild Not Response Response Response Responded INFORMED CONSENTI Son/Daughter/Wife of amexercising my free will, to participate in above study as a subject. I have been informed to my satisfaction, bythe attending physician the purpose of the clinical evaluation and nature of the drug treatment. I am also awareof my right to opt out of the treatment schedule, at any time during the course of the treatment.EzÀÄ £Á£ÀÄ ²æÃ/²æêÀÄw _________________________________________________ £À£Àß ¸ÀéEZÀÑ ¬ÄAzÀ PÉÆqÀĪÀ aQvÁì ¸ÀªÀÄäw. ¥Àæ¸ÀÄÛvÀ £ÀqÉ¢gÀĪÀ aQvÁì ¥ÀzÀÞw0iÀÄ §UÉÎ £À£ÀUÉ aQvÀìPÀjAzÀ ¸ÀA¥ÀÇtð ªÀiÁ»w zÉÆgÉwzÀÄÝ ªÀÄvÀÄÛ 0iÀiÁªÁUÁzÀÄgÀÄ aQvÀì¬ÄAzÀ »AwgÀÄUÀ®Ä ¸ÁévÀAvÀæ÷å «zÉ JAzÀÄ w½¢gÀÄvÀÛ£É. gÉÆV0iÀÄ gÀÄdÄ / Patients Signature
  • 117. 1) CHIEF COMPLAINTS WITH DURATION (Subjective Parameters) Complaints - Lakshana Duration Remarks1 Sandhi shotha (Swelling) Prasaarana Aakunchanayoho Savedana Pravruthi2 (Pain on extension & flexion)3 Sandhigraha (Joint Stiffness)4 Sandhigati asamarthya (limitation of joint movement)5 Sparsha akshamatva (Tenderness)2) ASSOCIATED COMPLAINTS Associated Complaints – Duration Remarks Anubandha Lakshana1 Klama (fatigue)2 Jwara (Fever)3 Angamarda4 Any other specify3) OCCUPATIONAL HISTORY (if any)4) PERSONAL HISTORYFood habits Vegetarian Mixed dietTaste preferred Sweet Sour Salty Pungent Bitter AstringentAgni Sama Vishama Manda TeekshnaKosta Mrudu Madhyama KruraNidra Day Night Sound DisturbedAddictions Tobacco Alcohol DrugsBowel habits Normal Loose ConstipatedMenstrual History Regular Irregular Amenorrhea MenopauseFamily history – Specify if any has the same diseaseTreatment history Other system medications Pain relievers Since how long Anti inflammatoryHistory of past illnessAre you pregnant Yes ( ) No ( ) Any steroid therapy Yes ( ) No ( ) Any surgical therapy Yes ( ) No ( )
  • 118. 5) HISTORY OF PRESENT ILLNESS: Mode of onset Chronic Insidious Acute Traumatic Joint involved Axial Cervical Lumbar Spine Distal joints Knee Ankle Hip Inter phalangeal Nature of pain Pricking Aching Generalized Burning Routine activities Yes No affected6) HISTORY OF PAST ILLNESS: Complaint Yes No Episodes of same illness Obesity Trauma/Fracture of involved or related joint Diabetes Mellitus Hypertension Other Vatavyadhees Fever Others7) TREATMENT HISTORY Are you undertaking any treatment? Yes No If yes, what type? Allopathy Ayurvedic Homeopathy other Relief with previous treatment Partially relieved No relief at all8) SAMANYA PAREEKSHAA. Asta sthāna Pareeksha : 1 Nadi Dosha V ( ) P ( ) K ( ) VP ( ) VK ( ) PK ( ) VPK ( ) Gati 2 Mala 3 Mootra Frequency Day Night 4 Jihwa 5 Shabda 6 Sparsha 7 Druk 8 AkrutiB. Vital examination 1 Temp /F 4 Blood Pressure mm of Hg 2 Pulse /min 5 Height cms 3 Respiration /min 6 Weight Kgs.C. Dasha vidha Pareekshā : 1 Prakruti V ( ) P ( ) K ( ) VP ( ) VK ( ) PK ( ) Tridoshaja ( ) 2 Sāra Pravara. ( ) Madhyama. ( ) Avara ( ) 3 Samhanana Pravara ( ) Madhyama. ( ) Avara ( ) 4 Pramana Pravara ( ) Madhyama. ( ) Avara ( ) 5 Sātmya Ekarasa. ( ) Sarva rasa ( ) Vyamishra ( ) Rooksha satmya ( ) Snigda satmya ( ) 6 Satva Pravara ( ) Madhyama ( ) Avara ( ) 7 Ahara Shakti a) Abhyavaharana shakti P ( ) M ( ) A ( ) b) Jarana shakti P ( ) M ( ) A ( ) 8 Vyayam Shakti Pravara ( ) Madhyama ( ) Avara ( ) 9 Vaya Bala ( ) Yuva ( ) Vrudda ( )
  • 119. 9) SROTO PAREEKSHA Srotas ObservationAnnavahaRasavahaAstivahaMajjavaha10) SPECIAL EXAMINATION OF JOINTSA) Darshana (Inspection) Before AfterJoint Swelling Grading 0 1 2 3 0 1 2 3 Varna Raaga Shyaava Prakrutha Raaga Shyaava PrakruthaDeformity Present Absent Present AbsentJoint Instability Present Absent Present AbsentGait Nature Walking TimeJoint Movement Active Completely Partially Free Completely Partially Free Restricted Restricted Restricted Restricted Passive Completely Partially Free Completely Partially Free Restricted Restricted Restricted RestrictedMuscular spasm Present Absent Present AbsentMuscular Above affected Yes No Yes NoWasting joint Below affected Yes No Yes No jointB) Sparshana (Palpitation) Before AfterVaatapoorna Yes No Yes NodruthisparshaLocal Raised Not raised Raised Not raisedTemperatureTenderness Grading 0 1 2 3 0 1 2 3Limitation of Axial Joints Cervical Lumbar Axial Joints Cervical LumbarJoint Movement Spine SpineDistal Joints Right Hip Knee Ankle Hip Knee Ankle Carpo meta Distal Inter Proximal Carpo meta Distal Inter Proximal metacarpal phalangeal Inter metacarpal phalangeal Inter phalangel phalangel Left Hip Knee Ankle Hip Knee Ankle Carpo meta Distal Inter Proximal Carpo meta Distal Inter Proximal metacarpal phalangeal Inter metacarpal phalangeal Inter phalangel phalangelC) Shravana (Auscultation) Crepitus11) RADIOLOGICAL EXAMINATION OF JOINTS ( Antero posterior and Lateral View)Joint space Reduced /Increased /UnalteredSubchondral bony sclerosis Present / AbsentFormation of osteophytes Present / AbsentPeriarticular ossicles Present / AbsentAltered shape of bone end Present / Absent
  • 120. 12) NIDANASwa prakopakara nidanaAhara Guna Seeta Rooksha Laghu Rasa Katu Tiktha Kashaya Shuskanna Yes No Upavasa Yes NoVihara Ratrijagarana Yes ( ) No ( ) Yanam (Riding) Yes ( ) No ( ) Pradhavana Yes ( ) No ( ) Jumping Yes ( ) No ( ) (Running) Bharavahana Yes ( ) No ( ) Vyayama Yes ( ) No ( ) (Weight lifting) Pratarana Yes ( ) No ( ) Walking Yes ( ) No ( ) (Swimming)Manasika Chinta (worry) Yes ( ) No ( ) Shoka (grief) Yes ( ) No ( ) Bhaya (fear) Yes ( ) No ( ) Krodha (anger) Yes ( ) No ( )Marmaghatakara nidanaDhatukshayakaraka nidana13) LAB INVESTIGATIONS:Blood TC DC P L E M B RBS Hb%Urine Sugar: Albumin: Microscope:14) ASSESSMENT OF RESULTS PARAMETERS Before After Follow upSubjectiveVatapoorna Dhruti SparshaAtopa (Criptus)Prasaarana Aakunchanayoho Savedana Pravruthi(Pain on extension & flexion)Sandhi shotha (Swelling)Sandhigraha (Joint Stiffness)Sparsha akshamatva (Tenderness)ObjectiveESR in mmJoint Pain grading 0 to 10 (UPA)Local temperature ° FMc Gill’s pain questionerMobility grading in VAS 0 - 100Swelling in mmWalking time in sec
  • 121. TREATMENT SCHEDULE Oral Ajamodadi vati: 3gms/ 24 hrs (1 gm TDS)Schedule Date Observation / instructions0 day = Initiation11th day = 1st observation21st day = 2nd observation31st day = Test completion45th day = Final Follow UpSCORE SHEET Condition Grading Pain (subjective) 0-No complaints 2-Complains frequently 1-Tells on enquiry 3-Excruciating condition Swelling 0-No complaints 2-Covers well over the bony prominence 1-Slightly obvious 3-Much elevated Stiffness 0-Absent 1-Present Vatapoorna Dhruti Sparsha Tenderness 0-No complaints 2-Winces the affected joint 1-Says the joint is tender 3-Winces and withdraws the joint Crepitus 0-None 1-Felt 2-Heard Haemoglobin, Local Temperature, ESR, Walking time, Mc Gill’s pain questioner, Universal Pain assessment Joint pain grade - are scored as per the readingsUniversal Pain assessment Joint pain grade 15) INVESTIGATORS NOTE:Mc Gill’s pain questioner Scholar: Shakuntala. S. Totar Guide: Dr. K. Shiva Rama Prasad