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A Comparative Study of Virechana karma and Basti karma in Amavata W.S.R.T. Rheumatoid Arthritis, By Suresh N. Hakkandi Department of Panchkarma, D.G.M. Ayurvedic Medical College, Hospital and P.G. …

A Comparative Study of Virechana karma and Basti karma in Amavata W.S.R.T. Rheumatoid Arthritis, By Suresh N. Hakkandi Department of Panchkarma, D.G.M. Ayurvedic Medical College, Hospital and P.G. Research Center, Gadag.


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  • 1. “A Comparative Study of Virechana karma andBasti karma in Amavata W.S.R.T. Rheumatoid Arthritis” By Suresh N. HakkandiDissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. (PANCHAKARMA) In PANCHAKARMA Under the guidance of Dr. G. Purushothamacharyulu, M.D. (Ayu) And co-guidance of Dr. Shashidhar.H. Doddamani, M.D. (Ayu) Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2006.
  • 2. Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE hereby declare that this dissertation / thesis entitled “A ComparativeStudy of Virechana karma and Basti karma in Amavata W.S.R.T. Rheumatoid Arthriyis”is a bonafide and genuine research work carried out by me under the guidanceof Dr. G. Purushothamacharyulu, , Professor and H.O.D, Post- M.D. (Ayu)graduate department of Panchakarma and co-guidance of Dr. Shashidhar. H.Doddamani, , Assistant Professor, Post graduate department of M.D.(Ayu)Panchakarma.Date: Suresh N. HakkandiPlace: Gadag.
  • 3. CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A ComparativeStudy of Virechana karma and Basti karma in Amavata W.S.R.T.Rheumatoid Arthritis” is a bonafide research work done by Suresh N.Hakkandi in partial fulfillment of the requirement for the degree of AyurvedaVachaspathi. M.D. (Panchakarma).Date:Place: Gadag Dr.G.Purushothamacharyulu, M.D. (Ayu). Professor & H.O.D Post graduate department of Panchakarma.
  • 4. ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “A ComparativeStudy of Virechana karma and Basti karma in Amavata W.S.R.T.Rheumatoid Arthritis” is a bonafide research work done by Suresh N.Hakkandi under the guidance of Dr.G. Purushothamacharyulu, M.D. (Ayu),Professor and H.O.D, Postgraduate department of Panchakarma and co-guidanceof Dr. Shashidhar.H. Doddamani, M.D. (Ayu), Assistant Professor, Post graduatedepartment of Panchakarma.Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Panchakarma.
  • 5. COPYRIGHT Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.Date: Suresh N. HakkandiPlace: Gadag.© Rajiv Gandhi University of Health Sciences, Karnataka.
  • 6. Abstract Virechanakarma and Bastikarma are the most important among thePanchakarmas. It has already been proved that the karmas are beneficial in managingthe Amavata, and it is the most common joint disorder worldwide. The study “A Comparative Study of Virechana karma and Basti karma inAmavata W.S.R.T. Rheumatoid Arthritis” is focused on important techniques i.e.Nittyavirechana and Yogabasti and also common clinical entity Amavata.Nittyavirechana with Eranda tial and Yogabasti with Erandamooladi niruha andBrihatsandhavadi anuvasana are believed to have a appreciable role in themanagement of such crippling nature, reptitive attacks and chronic course ofAmavata. The objectives of this study are 1] To evaluate the effect of Nittyavirechana inAmavata 2) To evaluate the additive efficacy of Yogabasti in Amavata3) To evaluatethe comparative effect of Nittyavirechana and Yogabastib in Amavata The aim of this study was to find out the effect of Nittyavirechana andYogabasti in the management of Amavata, and to check the comparative effect inmanaging the same disease. Therefore, two groups were made and the results obtainedin both the individual groups were compared. The study design selected for thepresent study was prospective comparative clinical trial. In group A (Nittyavirechana) 01 patients (6.66%) had good response to thetreatment and 11 patients (73.33%) had moderate response to the treatment and03(20%) patients show mild response after the treament.
  • 7. In group B (Yogabasti) 6 patients (40%) had good response to the treatmentand 9 patients (60%) had moderate response to the treatment. Among the group A andB the parameters Gulph, Pada and Uru shows highly significant, where as otherparameters are not significant in the comparative study (By using unpaired t-test,p<0.05). At the same time overall treatment response was better in the Nittyavirechanaand Yogabasti. This suggests that there was considerable improvement in both thegroups but Yogabasti group got more beneficial effects. Amavata is a Kapkavata vyadhi affecting people in the Madhyama avasta. Thedisease is obtained by the involvement of Ama and Vata, characterized by Ruja andShotha in Sandhi sthanas. Therefore, the agents/therapies of Amapachana, Lekhana,Vatanulomana etc, properties should be used in this disease. Nittyavirechana impartsAgnideepana, Vatanulomana and opens up the srotas in the shareera facilitating morenourishment and free movement of Vata dosha. Yogabasti is prime treatment forAmavata in turn plays vital role in correcting pathology of the disease and givesremarkable results. This results in the relief of symptomatology of the disease, by acting locallyand systematically. Ingredients of Eramdamooladi niruhabasti and Brihatsaindhavaditail possess properties such as Vedanashamaka, Shotahara Lekhana and alsoVatanulomaka. There by, it is an ideal treatment of choice in Amavata.Key words: - Nittyavirechana, Yogabasti, Amavata, Rheumatoid Arthritis,Vaishwanara choorna Eranda tail, Eeandamooladi niruha, Brihatsaindhavadianuvasana.
  • 8. Acknowledgement One of the great pleasure of life is doing the things that others says youcannot do it, by the grace of god, bless of eiders I take this opportunity to express myregards to the persons who helped in completing this work. I express my deep sense of gratitude to his great holiness Jagadguru ShriAbhinava Gavisiddheshwara mahaswamiji for their divine blessings. Words fail miserably when I try to express my gratitude to my mentor, myguide Dr.G.PurushottamacharyluM.D(Ayu), H.O.D of P.G.Department ofPanchakarma. For his incessant, untiring, round the clock guidance with all thediligence. His sustained fostering and encouragement instilled considerableimpetus in me enabling to achieve this milestone which otherwise would havelacked this particular finish. Indeed, I will cherish the affectionate guidance of my co-guideDr.Shashidhar H.Doddamani M.D (Ayu), Asst professor of P.G.Department ofPanchakarm. For his invincible and radical thinking were very valuable inachieving this research work invoking scientific spirit throughout the course of thestudy. I express my sincere and deep gratitude to Dr.G.B.Patil, Principal,D.G.M.A.M.C, Gadag, for his wholehearted encouragement as well as providing allnecessary facilities for this research work. I express my sincere gratitude to Dr.P.Shivaramudu M.D (Ayu), AssistantProfessor and Dr. Santhosh.N.Belavadi MD (Ayu), Lecturer of P.G.Department ofPanchakarma for his excellent advices. I also express my sincere gratitude to Dr.S.D.Yargeri R.M.O. for his moralsupport and special care in providing the all the facilities during this trail work. I express my sincere gratitude to Dr.V.Varadacharyulu, Dr.M.C.Patil, Dr.Mulgund, Dr.Dilip Kumar, Dr.R.V.Shetter, Dr. K.S.R.Prasad, Dr.G.Danappa Gowdar,Dr. Kuber Sankh, Dr.J.G.Mitti, Dr.Sheshikanath.Nidagundi, Dr. Samudri and otherPG staff for their constant encouragement. I thank Dr. B. G. Swami, Dr.U.V.Purad, Dr.B.M,Mulkipatil and otherundergraduate teachers for their support in the clinical work. I thank to Shri.Nandakumar (Statistician), Shri.V.M.Mundinamani (Librarian), Mr.Surebana andother hospital and office staff for their kind support during my study.
  • 9. Indeed, I will cherish the affectionate of my Father, my Mother, my wifeDr. Pratibha, my son Satvika, my sister Jayashree, brother-in-law Sharanappa, mybrother Shambanna Bavihalli and all my family members who have been a source ofinspiration for my entire carrier. I cardinally thank Dr. B. S. Savadi, Dr. Sambayya, Dr. K. B. Hiremath, Dr. A.S. Patil, Dr. C. S. Karamudi, Dr. S. S. Shiruramath, Dr. Srikant P.L., Dr Rudrakshi,Dr. S. R. J., Dr. Manohar, Dr. S. M. Patil, Dr. B. V. Desai, Dr. Hunagund, Dr. SyedPasha, Raghavendra Kulakarani and other staff of S. J. S. Ay. Medical collegeKoppal. I express my sincere thanks to my friends Dr.Babu Menon, Dr.Dattu Vijapur,Chandranna M., Ramesh Gadad, Anand Ballary, Dr.Santhosh.L.Y, Dr. Subin, Dr.Sateesh, Dr. Febin, Dr. Varsha, Dr. D. S. Swami, Dr.V.M.Hugar, Dr.JayarajBasarigidad, Dr.Venkaraddi, Dr.B.L.Kalmath, Dr.P.Chandramouleeswaran,Dr.Shaila.B. Dr.Uday Kumar, Dr.Ratna Kumar, Dr.Ghanti, Dr.Pradeep, Dr.Sobagin,Dr.Manjunath.Akki, Dr.G. G. Patil, Dr.Ashwindev, Dr.V.S.Hiremath,Dr.L.M.Biradar, Dr.Jagadisha.H., Dr.Sharanu, Dr. Krishna J. Dr. Shivakumar Sarvi,Dr.Anand, Dr.Umesh, Dr.Suvarna, Dr. Anita Dr.Devendrappa, Dr.Sibaprasad,Dr.Madhushree, Dr.Ashok.M.J, Dr.Payappagoudar, Dr. Prasanna, Dr. Nataraj, Dr.Udayaganesh, Dr. Adarsha, Dr. Shailej, Dr. Muktha and other post graduate scholarsfor their support. I would like to mention the support and inspiration provided by my Father-in-law Shri.Shantappa Budihal & family for their support and encouragement during mystudy. I acknowledge my patients for their wholehearted consent to participate in thisclinical trial. I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. Finally I dedicate this work to my respected parents Shri. N. S. Hakkandi,Smt. F. N. Hakkandi and my wife Dr. Pratibha who are the prime reasons for allmy success.Date: Signature of the scholarPlace: (Dr.Suresh N. Hakkandi)
  • 10. TABLE OF CONTENTS Chapters Page No. 1. Introduction 1-4 2. Objectives 5 3. Review of literature 6-85 4. Methodology 86-104 5. Observation and Results 105-136 6. Discussion 137-154 7. Conclusion 155-156 8. Summary 157-158 9. Bibliography 159-171 10. Annexure
  • 11. List of tablesTable No. Page No.1. Showing bhoutik composition of virechana dravya 142. Showing doses of Virechana drugs according to Sharangdhara 193 showingvirechana matra according Koshta 194 showing Assessment parameters of Virechana 205 showing Samyak Yoga Lakshana of Virechana 216 showing Virechana Vyapat 217 Showing Amavata Nidana according to various Acharyas 498 Showing the similarity between Amavata and Rheumatoid Arthritis 569 showing lakshans According to different Ayurvedic classics 5810 Showing the Sthananusara Laxana 5911 showing various Upakramas have been prescribed by different 68 Acharyas for the treatment of Amavata:12 showing extra articular features of RA 7913 showing differential diagnosis regarding with Amavata 8114 Showing the Composition and Properties of Vaishwanara Churna 8815 Showing the Properties of Drugs of Brihat Saindhavadi Taila 8916 showing Erandamooladi Vasti Dravyas 9117 showing distribution of patients by age groups 10618. Showing distribution of patients by Sex 10719 showing distribution of patients by religion. 10820 showing distribution of patients by occupation. 10921 showing distribution of patients by socio-economical status 11022 showing distribution of patients by dietary habits. 11123 showing the distribution of patients by duration of disease 11224 showing the distribution of patients by treatment history 11325 showing distribution of patients by nature of Koshta. 11426 showing distribution of patients by Jatharagni. (Status of Jatharagni). 11527 showing distribution of patients by nature of Mala pravritti 11628 showing distribution of patients by type of Desha. (Nature of Habitat). 11729 showing distribution of patients by Vyasana. (Addiction). 11830 showing the distribution of patients by Nidra in both Groups. 11931 showing the distribution of patients by Deha prakriti in both Groups. 12032 showing the distribution of patients by Satmya. 12133 Showing the presence of RA factor in both group 12234 Showing the presence of ASLO titer in both group 12335 Showing the presence of CRP titer in both group 12436 Showing the types of Amavata in both groups 12537 Showing the distribution of patients by Mode of onset in both Groups. 12638 showing distribution of patients by Nidana 12739 showing the distribution of symptoms of Amavata in both Groups 12840 Showing the over all effect of treatment in both Groups. [ last graph] 129
  • 12. 41 showing Data related to the response of treatment in group A 13142 showing Data related to the response of treatment in group B 13243 showing statistical analysis of subjective and objective 133 parameters in group A44 showing statistical analysis of subjective and objective 134 parameters in group B45 showing the comparative statistical analysis 135 of subjective and objective parameters in both groupsList of graphs1 showing distribution of patients by age groups 1062. Showing distribution of patients by Sex 1073 showing distribution of patients by religion 1084 showing distribution of patients by occupation 1095 showing distribution of patients by socio-economical status 1106 showing distribution of patients by dietary habits. 1117 showing the distribution of patients by duration of disease 1128 showing the distribution of patients by treatment history 1139 showing distribution of patients by nature of Koshta. 11410 showing distribution of patients by Jatharagni. (Status of Jatharagni). 11511 showing distribution of patients by nature of Mala pravritti 11612 showing distribution of patients by type of Desha. (Nature of Habitat). 11713 showing distribution of patients by Vyasana. (Addiction). 11814 showing the distribution of patients by Nidra in both Groups. 11915 showing the distribution of patients by Deha prakriti in both Groups. 12016 showing the distribution of patients by Satmya. 12117 Showing the presence of RA factor in both groups 12218 Showing the presence of ASLO titer in both groups 12319 Showing the presence of CRP titer in both groups 12420 Showing the types of Amavata in both groups 12521 Showing the distribution of patients by Mode of onset in both Groups. 12622 showing distribution of patients by Nidana 12723 showing the distribution of symptoms of Amavata in both Groups. 12924 Showing the over all effect of treatment in both Groups. 130List of flow chart1] Flow chart showing Samprapti of Amavata 522] Flow chart showing pathogenesis of RA 76
  • 13. IntroductionIntroduction Ayurveda, the fountain head of Indian medicine was conceived as ascience and preached in this country some thousands of years ago, long before theother countries could dream of systematizing the concept of the remedies forhuman ailments. With the march of time, most of the dietary habits, social structure, lifestyle, and environment have been changing. Occurrence of Amavata on largescale is one of the outcomes of this modification. It is commonest among chronicinflammatory joint diseases in which joints become swollen, painful, and stiff. Itis a debilitating disease in view of its chronicity and complications. Therefore, ithas taken the foremost place among the joint disorders. It continues to posechallenge to physician due to severe morbidity and crippling nature and claimingthe maximum loss of human power making it a biggest world wide burningproblem irrespective of races. It is equated with Rheumatoid Arthritis, aninflammatory Auto-immune disorder. The lives of more than one million people are physically impaired due toRheumatic disorders and one fifth of these are severely disabled. The onset ismore frequent during 4th and 5th decade of life with 80% of patients developingthe disease between the ages of 35 to 50 years. Women are affectedapproximately 3 times more often than men. Pregnancy is often associated withremission of the disease in the last trimester with subsequent relapses afterdelivery. About 10% of the patient will have an affected first degree relative. Agenetic susceptibility to altered immune responses probably is important in R.A. Amavata was first described as an independent disease in MadhavaNidana. It is a disease of Madhyama Roga Marga as it affects Sandhis andHridaya Marma. Though Ama and Vata are the predominant pathogenic factors A Comparative Study of Virechana karma and Basti karma in Amavata 1 W.S.R.T. Rheumatoid Arthritis
  • 14. Introductionbut the disease represents Tridoshic vitiation. The affliction of Sandhis by Vatadosha in association with Ama, reflects the equal role of both Dosha and Dushyain the causation of this disease. Moreover, the chief pathogenic factors, beingcontradictory in nature posses difficulty in planning the line of treatment. No doubt allopathic system of medicine has got an important role to playin overcoming agony of pain, restricted movement and disability caused by thearticular diseases. Simultaneously prolonged use of allopathic medicines are notonly giving rise to many side effects, toxic symptoms and adverse reactions butalso more serious complications like organic lesions etc. are caused by them. Hence the management of this disease is merely insufficient in othersystems of medicine and patients are continuously looking with a hope towardsAyurveda to overcome this challenge.Till now 160 Ph.D and P.G. works havebeen carried out at various Ayurvedic Institutions and about 25 Reseach workshave been carried out in P.G. Institutes. This large number itself suggests its largeoccurrence and faith of patients in Ayurvedic Management. For the present study, on Amavata as Shamana therapy Nittyvirechanawith Eranda Taila and Yogabasti with Erandamooladi kwatha niruha andBruhatsandhavadi taila anuvasana has been chosen, for the comparative effect ofboth. Many works with Virechana Karma and Ksharabasti on Amavata have beensuccessfully carried out. But evaluate the comparitive effect of the results ofNittyavirechana and Yogabasti was conducted in this study. Both the therapieschosen fulfill the regimen of specific treatment of Amavata mentioned inChakradatta. Total 30 patients of Amavata were treated. These patients were randomlydistributed into 2 groups which are 15 patients reciveing Nittyavirechana withEranda taila and another 15 patients recived Yogabasti with Erandamooladi A Comparative Study of Virechana karma and Basti karma in Amavata 2 W.S.R.T. Rheumatoid Arthritis
  • 15. Introductionkwatha niruha and Bruhatsandhavadi taila anuvasana Out of the above saidgroups Yogabasti with Erandamooladi kwatha niruha and Bruhatsandhavadi tailaanuvasana provided significantly better improvement in Rogi bala, Agni bala,Deha bala and Chetasa bala than the other group. The complete study has been made into two major divisions - theconceptual study & the clinical study. The conceptual study is grouped into aliterary review of Virechana, Basti Amavata and drug review, the clinical studycontains the Observations, Results, Discussion and Conclusion and lastlyBibliography.Need for the study: The Panchakarma therapy is an integral part of Ayurveda many diseasesaccording to Ayurveda are direct result of Srotavarodha particularly due to theAgnimandya and Ama1. Panchakarma play a vital role in Ayurvedic therapeutics. Shodhana strikes at the root of malas and eradicates them2 and as such the disorders treated with Samshodhana do not reoccur while those treated with other methods might reappear.3 Many of the chronic progressive disease like Rheumatoid Arthritis (RA) do not have an effective line of management, recent studies on RA have suggested positive results with Panchakarma. RA is an immuno inflammatory disease that affects joints and extra articular tissues4. RA occurs throughout the world and in all ethnic groups 5. The prevalence is highest in Indians. In caucasians it is around 1.0 to 1.5% with a female : male ratio 3:16. The onset of RA may occur any time in life. Approximately 70% of RA occurs between the 3rd and 7th decades7. . The disease draws attention for the consideration of research firstly due to the gravity of the problem, secondly due to the lack of suitable known A Comparative Study of Virechana karma and Basti karma in Amavata 3 W.S.R.T. Rheumatoid Arthritis
  • 16. Introduction modern drugs for treatment and lastly it is an intriguing disease and challenge to clinicians and research workers. In the management of Amavata Ayurveda gives importance to Shodhanakarma among Shodhana Virechana and Bastikarma have got vital role8 in curingand preventing the disease. The present study intends to give new light on the comparative effect ofVirechana and Basti in Amavata so “A comparative study of Virechana karmaand Basti karma in Amavata with special reference to Rheumatoid Arthritis” isunder taken. A Comparative Study of Virechana karma and Basti karma in Amavata 4 W.S.R.T. Rheumatoid Arthritis
  • 17. Objectives ObjectivesThe above study was carried out with following Aims and Objects: 1. To study the effect of Nittyavirechana with Eranda taila in Amavata. 2. To evaluate the efficacy of Yogabasti with Erandamooladi kwatha niruha and Bruhatsandhavadi taila anuvasana in Amavata. 3. To compare the efficacy of above two procuder in Amavata. A Comparative Study of Virechana karma and Basti karma in Amavata 5 W.S.R.T. Rheumatoid Arthritis
  • 18. Historical reviewHistorical review of Virechana Ayurveda has propagated treatment for most of the disease, in thattreatment mainly we find two types according to Kayachikitsa Siddhanta, andthose are Shamana and Shodhana. Shamana means mitigating doshas in the bodywhen they have aggravated, though after mitigating once again they may reoccur,where as Shodhana procedure is nothing but eliminating the doshas out of thebody. In this there is no chance of reoccur. Virechana is such a treatment modality, which eliminates doshas fromGuda marga. This Virechana have well explained in Samhita kala and Sangrahakala.Samhita kala1] Charaka samhita; Explanation of Virechana dravya sangraha, Virechana yogas, itsprosuder,9,10,11 different types of Virechana dravya kalpa in Kalpa sthana,12 inSiddhi sthana we find fine explanation of Virechana Samyag laxana, Ayogalaxana, Atiyoga laxana, Virechana yogya, Ayogya, Virechana Vyapat and itsChikitsa have delt.13,14,152] Susruta samhita: In Susruta samhita Chikitsa sthana the complete procedure of Virechana,its definition, Samyag laxana, Ayoga laxana, Atiyoga laxana, Virechana yogya,Ayogya, Virechana Vyapat and its Patikara have completely explained.16,17 Insutra sthana different virechana dravyas and its preparation is explained.18,193] Astanga sangraha: In the astang sangraha sutra sthana 27th chapter whole Virechana karmahave explained,20 in kalpa sthana Virechana yogas and Vyapats are discussed.21 A Comparative Study of Virechana karma and Basti karma in Amavata 6 W.S.R.T. Rheumatoid Arthritis
  • 19. Historical review4] Astang hridaya: In the 18th chapter of his Sutra sthana complete Virechana procedure,22 inhis Kalpa sthana Virechana yogas and Vyapats are mentioned.23,245] Sangraha kala: We find well contribution of Virechana in Sharangadhara samhita,25Kasyapa samhita Siddhi sthana,26 Bhavaprakasha poorva khanda,27 YogaratnakaraVirechanadhikara28 and Chakradatta Virechanadhikara.29Historical review of vasti In the literature it is necessary to know the past events of concerenedsubject. From ancient period it self-science of Ayurveda have started. So it isnecessary to know about the systemic documents of Veda, Purana, Yogicliterature and our Ayurvedic text.1] Veda kala Direct reference of Vasti karma will not be found in Veda, butexplanation of Vasti is their as “Vishitam te Vastibilam”302] Purana kala Vasti is indicated as the principal remedy in the probleme of increase ofVatadosha in Agnipurana.31 Different Snehas have told to use for Vastiaccourding to season.323] Yogic literature Gheranda samhita includes Vasti in Satkarma, mainly two types ofVasti have explained on their besis of administration ie first is Jala vasti whichwill be done in water, second one is Sushkavasti which is done on land.4] Samhita kala Most of the Ayuevedic classical text have given much importance to Vastikarma, that’s why we found separate Adhyayas for explaining Vasti karma and A Comparative Study of Virechana karma and Basti karma in Amavata 7 W.S.R.T. Rheumatoid Arthritis
  • 20. Historical reviewwhile dealing the treatment of each disease we will find the elaborate version ofVasti Dravya and preparation. Vasti revieve of Samhita can be studied by referring Charaka samhita,Susruta samhita, Astanga sangraha and Astanga hridaya.Charaka samhita Charaka has explained definition of Vasti, Types of Vasti, priparetion ofVasti, Procuder of Vasti, Karmukata of Vasti, Vasti Vyapat its Chikitsa, Vastidravyas etc.33Susruta samhita Susruta widely explained definition of Vasti, Types of Vasti, priparetionof Vasti, Procuder of Vasti, Karmukata of Vasti, Vasti Vyapat its Chikitsa, Vastidravyas etc in his Chikitsa sthana.34Vagbhata Both in Astanga sangraha35 and Hridaya36 elobarate discription of Vastihave told in Sutra sthana and regarding Vasti Dravya we will find in Kalpasthana.37,38Kashyapa Samhita: In Kashyapa Samhita, Basti has been explained in detail in Siddhisthanaand Kalpasthana.39Bhela Samhita: In Bhela Samhita, description of Basti is available in four chapters ofSiddhisthana namely Bastimatriya Siddhi, Upakalpa Siddhi, Phalamatra Siddhiand Dosha Vyapadika Basti Siddhi.40Harita Samhita: In this text, only 3rd chapter of Sutrasthana deals with Basti.41 A Comparative Study of Virechana karma and Basti karma in Amavata 8 W.S.R.T. Rheumatoid Arthritis
  • 21. Historical reviewChakradatta: In this text, two chapters named Anuvasanadhikara and Niruhadhikara aredealt with Anuvasana and Niruha Basti respectively.42Vangasena: In Chikitsa Sarasangraha, Vangasena has devoted “Basti Karmadhikara”chapter for description of Basti.Sharangadhara Samhita: Three chapters of Uttarakhanda namely Basti Kalpana Vidhi, NiruhaBasti Kalpana Vidhi and Uttara Basti Kalpana Vidhi described various aspects ofAnuvasana Basti, Niruha Basti and Uttara Basti respectively.43, 44,45Bhavaprakasha: In this Grantha, 5th chapter of Purvakhanda has been contributed to thedescription of Basti. Vrana Basti – this type of Basti has been explained in thisGrantha.46Kalyanakaraka: In this text, Basti is described in Vatarogadhikara only.Todarananda: In this text, Basti is described in the chapter Basti Vidhi.Historical review of Amavata An off shoot of Atharva and Rigveda, this science of medicine is withoutbeginning, but Ayurveda saw throughout many people, who organized it intobeautifully woven treatises, incorporating newer diseases and their treatment,which cropped up during their times. It is evident in the Samhitas that the mostprevalent and deadly diseases have been devoted separate chapters were includedas secondary diseases under the major category. A Comparative Study of Virechana karma and Basti karma in Amavata 9 W.S.R.T. Rheumatoid Arthritis
  • 22. Historical review Amavata might not have been widely prevalent and severely crippling as itwas during the time of Madhava Nidana, as we see only passing references to thedisease have been made in the Bruhatrayees. Madhava was the first person todevote separate chapter for Amavata. Thus the birth of this disease and itsformative years can be glanced, starting from Vedic period.Vedic period (5000 BC to 1000 BC): Clear cut explanations of Amavata are not available in Vedic Samhitas,but disease caused by Kapha have been more or less described under the majorheading Balasa, but the diseases of joints are not included here. Sayana hasquoted few references indicating arthritic syndromes, such as- Rapasi47: Disease arising due to sin (Rigveda) characterized by pain inmultiple joints also referred to as Papa. Yakshma and treatment with Jala, VayuYava, Kushta have been indicated. Jayanya48: This disease is said to affect the bones cervical vertebrae andarise from women through Sanga. Whether the disease refers to rheumatoidarthritis is still not clear. Grahi49 (Rigveda and Atharvaveda): This has been described as thedisease of joints but characteristic features have not been clearly mentioned.Treatment of this disease with Dashavruksha has been mentioned. Vatikrut50: This disease has been described as a serious ailment caused byVata and treatment with Pippali and Vishanashaka has been mentioned. Sandhivikruti51 (Atharvaveda): This disorder is caused by Sleshma andcan be treated with prayers.Samhita period (1000 BC TO 600 AD): Charaka Samhita: Charaka has described in detail Ama and AmaPradoshaja Vikara and their treatment with Langhana and Ullekhana.52 A Comparative Study of Virechana karma and Basti karma in Amavata 10 W.S.R.T. Rheumatoid Arthritis
  • 23. Historical review Charaka had described treatment for Amavata while dealing with Avarana 53Chikitsa in Vatavyadhi, which indicate Pramehahara and Medohara Vidhi.Amavata finds a mention in the list of therapeutic indication of Kamsa Hareetaki54in Shwayathu Chikitsa and Vishaladi Phanda in Pandu Chikitsa.55 The treatment of Shariragata Ama in Grahani Chikitsa by Charaka56 issimilar to the description of Amavata Chikitsa by Bhava Mishra i.e. Langhana,Pachana and oral administration of Panchakola Phanta57, same is the case withAmavata Chikitsa of Chakrapani in Chakradatta58.Sushruta Samhita: The description of Amavata in Sushruta Samhita isconspicuous by its absence.Bhela Samhita: The tenth chapter in Sutra Sthana deals with Ama Pradosha. Thisdescription has some resemblance with that of Amavata.Harita Samhita: A complete chapter on Amavata finds a mention in HaritaSamhita59. The classification of Amavata is quite unique and not followed by anyof the later works in this field.Anjana Nidana: This work is claimed to be written by Acharya Agnivesha,contains detailed description about etiology, premonitory symptoms, clinicalmanifestations and complications.Sangraha Kala (600AD-1600AD): Astanga Sangraha and Astanga Hridaya have ignored the disease thoughthe word Amavata is included in the therapeutic index of compounds VatsakadiYoga60 and Vyoshadi yoga61.Madhava Nidana62: Madhavakara stated this disease as a separate entity and hasdealt separate chapter.Chakradutta: Chakrapanidutta has described the treatment for Amavata63. A Comparative Study of Virechana karma and Basti karma in Amavata 11 W.S.R.T. Rheumatoid Arthritis
  • 24. Historical review Vangasena64 and Vrinda Madhava followed Madhava with few additionsin the treatment aspect. Works like Bhava Prakasha65, Yogaratnakara66 andBhaishajya Ratnavali67 have only corroborated the descriptions with additionalprinciples of treatment.Adhunika Kala (1600AD onwards): Mahopadhyaya Acharya Gananath Sen has coined the term Rasavata forAmavata. In Yoga Shastra the practice of Shushka Basti for improving Jatharagniand treating Amavata has been mentioned68. Y.N.Upadhyaya (1955) has corelatedthe disease with rheumatoid arthritis. Later research workers have agreed withY.N.Upadhyaya.Modern History of Rheumatoid Arthritis69 First Century AD: The rheumatoid/rheumatology is derived from the root‘Rheuma’, which refers to a substance that flows and probably was derived fromphlegm, an ancient primary humor, which was believed to originate from brainand flow to various parts of the body causing ailments.1642 A.D.: The word rheumatism is introduced into the literature by the Frenchphysician Dr.G.Baillou who emphasized that arthritis could be a systemicdisorder.1800 A.D.: Landre Baervier a physician from Salta Petruver in Paris seemed tohave described the disease for the first time he called it Gartte AsthaniquePrimitivae.1857 A.D.: Sir Garrod proposed the name Rheumatoid Arthritis, Bannatyne alsoin 1959 published his pathological observations on the disease but he coulddifferentiate it from Osteoarthritis only in his later edition. A Comparative Study of Virechana karma and Basti karma in Amavata 12 W.S.R.T. Rheumatoid Arthritis
  • 25. Historical review1928 A.D.: The American committee for the control of rheumatism is establishedin U.S. by Dr.R.Pemberton, renamed American Association for the study andcontrol of rheumatic disease (1934), then American Rheumatism Association(1937) and finally American college of Rheumatology (ACR) (1988).1940 A.D.: The terms Rheumatology and Rheumatologist are first coined by Drs.Hollander and Comroe respectively.1948 A.D.: Roses identified some criteria for diagnosis of RA.1958 A.D.: American Rheumatic Association suggested uniform criteria fordiagnosis.1987 A.D.: The criteria were revised. In the beginning it was thought to be an infective condition especially inearly 20th century. French scientists thought it to be due to tuberculosis. Hench and Kendell introduced steroids in the management of rheumatoidarthritis described paediatric onset, juvenile RA in 1896. Later Felty A.R.described Felty’s syndrome. Recent advancement in immunology has opened new vistas in themanagement of RA. Unfortunately till date the etiology of RA is unknown thepathogenesis is speculative, the treatment is only palliative and there is no cure tothis disease. A Comparative Study of Virechana karma and Basti karma in Amavata 13 W.S.R.T. Rheumatoid Arthritis
  • 26. Virechana karmaRevive of virechana karma Virechana is one of the Shodhana karma described by Acharyas. It is aspecific process for elimination of Pitta Dosha, but other two Dosha to someextent. It is less tedious procedure than Vamana and hence less possibility ofcomplications, and could be done easily. So Virechana karma is widely practicedShodhana therapy in routine.Definition: The process of elimination of Dosha from Adhomarga is known asVirechana 70. Sometimes actions of expelling Doshas through both Urdhva (Vamana) andAdhomarga are also termed commonly as Virechana. For instance Caraka hasmentioned Yoga of Vamana and Virechana both. Even for Niruha Basti andShodhana Nasya Virechana term is used. But in this context Virechana can beunderstood as a procedure-involving intake of medicine through oral route andexpelling vitiated Pitta Dosha and Mala through Adhomarga71.Pharmacodynamics of Virechana Karma: The Bhuta predominance as well as the properties of drug should beanalyzed in detail to explain the Pharmacodynamics of the particular drug inVirechana Karma. Contrary to Vamana Dravya, Virechana Dravya possessessome properties, which are not in accordance with the Bhautik constitution72.Table-1, Bhoutik composition of virechana dravyaBhautik Composition Properties expected Properties present Sneha Ushna Bhumi Manda Tikshna Jala Sthula Sukshma Guru Vyavayi Virechana Dravya has Guna, which are not in accordance with Bhutas,which may be explained in terms of Vichitra Pratyayarabdhata. This Vichitra A Comparative Study of Virechana karma and Basti karma in Amavata 14 W.S.R.T. Rheumatoid Arthritis
  • 27. Virechana karmaPratyayarabdhata causes bivalent action of the drug an action in the Shakhas,which is entirely opposite to the Koshta. The drugs with properties like Ushna, Tikshna, Vyavayi and Sukshma byvirtue of their penetrative as well as infiltrative properties enter Hridaya and fromthere they spread through Dhamanis. These drugs cleanse the adhesive bodyHumours by their Agneya Guna and thoroughly disintegrate them by TikshnaGuna. This brings the Doshas to Amasaya. Proper Snehana and Svedana havedone previously facilitate this process. The circulating metabolic abnormal orwaste products are thus treated by this process and actively excreted to theintestinal lumen. In the Koshta contrary to the Vamana Dravya, further actiontakes place according to the Bhuta predominance and Adhobhaga Prabhava of thedrugs. This bivalent property makes the Virechana drug practically lesscomplicated and easily employable. Moreover this is the only reason for theelimination of Dosha through Virechana from Kaphasthana (Amashaya),Pittasthana (Pachyamanashaya) and Vatasthana (Pakvashaya). But the action ofVamana is focused in Amashaya only.Indications and contraindications of virechana karma: Prior to subjecting the patient to any therapy, it is necessary to examinewhether the patient is fit for proposed therapy or not. Following are theindications and contra indications for Virechana karma.Indication:1. DoshaUtklishta Pitta, Kapha Samsrshta Pitta, Pittasthanagata Alpa Kapha,Kaphasthanagata Bahu Pitta73.Pakvashayagata Pitta or Kapha Pitta74.Pitta Avrata Vata, Kapha Avrta Vata75. A Comparative Study of Virechana karma and Basti karma in Amavata 15 W.S.R.T. Rheumatoid Arthritis
  • 28. Virechana karma Caraka advises that Tiryakgata Dosha should be taken back to Koshta,gradually by proper acts and after that elimination should be carried out. Thisdenotes that Virechana is the treatment of choice in Tiryakgata Dosha as seen inKushta.2. Dushya For Rasa, Rakta etc, Vikaras Virechana Karma is described in direct orindirect way76, 77,78.3. In Svastha794. Purvakarma of Rasayana and Vajikarana 80.5. Virechana is indicated in disorders like, Gulma – Vatadhikya, Kamala –Paittika, Gara – Tridoshaja, Unmada –Tridoshaja, Kushta – Tridoshaja etc.From the above references it becomes clear that Virechana karma has a specificaction on various conditions of all three Doshas. It is a procedure of choice forhealthy as well as diseased person.Contraindication: In Classics, Contra indications of Virechana are explained in detail. Theycan be summarized in following headingsIncapable to tolerate the stress of therapy like Vilanghita, Durbala, Subhaga,Navaprasuta etc Sama Avastha of the disorders like Navapratisyaya, Ajirna, NavajvaraDiseases of rectum like Kshata Guda, Muktanala.Some conditions like Ratri Jagarita, Atisnigdha, Atiruksha, Bhayoptapta,Chintaprasakta.Disorders like Adhoga Raktapitta, Hradroga, Atisara, Rajayakshma, Urusthambhaetc81, 82,83. A Comparative Study of Virechana karma and Basti karma in Amavata 16 W.S.R.T. Rheumatoid Arthritis
  • 29. Virechana karmaTypes of virechanaI. According to Mechanism of Action: Virechana Dravya is several in numbers. According to Caraka, there are 3types of Virechana Dravya Viz, Trivrt, Aragvadha and SnuhiKshira areconsidered as the best Sukha Virechana, Mrdu Virechana and Tikshna Virechanarespectively84. Acharya Caraka also described Bhedaniya, Virechanopaga andAnulomana, which are also suggestive of the types of Virechana. ButSharangadhara has given a specific description regarding the types ofAdhobhagahara karma; they are Anulomana, Sramsana, Bhedana and Rechana85.II. According to Prayoga Bheda: Curna, Vati, Asava, Arista, Avaleha, Sneha and Kashaya etc, Virechanayoga can be administered in this form of preparation.III. Based on Part of the Dravya used: Sushruta describes the following drugs with priority for VirechanaKarma86.Mula Virechana Syama TrivrtPhala Virechana HaritakiTaila Virechana ErandaSvarasa Virechana KaravellakaPaya Virechana Snuhi.Caraka also describes in general Virechana drugs like Mulini, Phalini, Lavana andKshira etc.iv. Classification according to quality: Caraka and Sushruta have used the terms like Snigdha Virechana andRuksha Virechana. A Comparative Study of Virechana karma and Basti karma in Amavata 17 W.S.R.T. Rheumatoid Arthritis
  • 30. Virechana karmaProcedure of virechana For easy understanding purpose whole Virechana procedure can begrouped under headings like I. Purva Karma II. Pradhana Karma and III. PascatKarmaI.Purvakarma: Purvakarma includes,Sambhara Samgraha- Collection of all the necessary equipments, drugs, diet etcused for the therapy.Atura Pariksha- The detail examination of the Dosha, Dooshya, Atura Bala etc tobe carried out to know fitness of individual to Shodhana87.Atura Siddhata- Snehana and Svedana are to be carried out prior to VirechanaKarma88. After observing Samyak Snigdha Lakshana by Snehapana, 3 daysVishrama Kala is given prior to Virechana. During those days SarvangaAbhyanga and Bashpa Sveda are performed.Diet- Snigdha, Ushna, Drava, Mamsarasa, Yusha, Amla Rasa Ahara is preferableduring Vishrama Dina. But Kapha Vardhaka Ahara is to be strictly avoided89.Manasopacara- Whole procedure of Virechana is to be explained to boostconfidence of the individual.Matra Vinischaya- Matra should be selected in such a way that the desired effectof Shodhana may be achieved without any complications. The dose is to bedecided based on Atura, Agni, Koshta and Aushadha.While describing the process of Virechana the dose mentioned of Trivrta yoga isone Aksha (1 tola).However Sharangdhara has given the dose schedule, which seems to be applicablenow a day. A Comparative Study of Virechana karma and Basti karma in Amavata 18 W.S.R.T. Rheumatoid Arthritis
  • 31. Virechana karmaTable-2, Doses of Virechana drugs according to Sharangdhara 90,91Kalpana Hina Matra Madhyama Matra Uttama MatraKvatha ½ Pala (2 tola) 1 Pala ( 4 tola) 2 Pala (8 tola)Curna 1 tola 2 tola 4 tolaKalka etc.Table-3, Matra according KoshtaAuthors Mrdu Koshta Madhyama Koshta Krura KoshtaSushruta92 Mrdu Matra Madhyama Matra Tikshna MatraVangasena 1 tola 2 tola 3 tolaiii) According to Vagbhata, persons having less strength, Shodhita previously,having less quantity of Dosha, having thin structure and unknown Koshta shouldbe administered Mrdu Aushadha with very less quantity93.II Pradhana Karma:Pradhana Karma includes,Administration of Virechana YogaObservation and management during Virechana VegaObservation of-Shuddhi Lakshana-Virechana Vyapat if anyAdministration of Virechana yoga: Caraka has explained method of Virechana elaborately in Charaka94 as, aftercompletion of Snehana and Svedana, by finding that the individual is cheerful,slept well, and fully digested his meal, is advised to perform auspicious rites.Thereafter considering the Vaya, Bala, Dosha, Bheshaja etc, and after passing thetime of Kapha Prakopa in morning the individual should be given VirechanaYoga in empty stomach. A Comparative Study of Virechana karma and Basti karma in Amavata 19 W.S.R.T. Rheumatoid Arthritis
  • 32. Virechana karma After administration of the drug, cold water is sprinkled on the face toavoid vomiting and then the individual is asked to gargle with hot water and tohave fragrance of flower etc. He should be protected from direct cold wind andshould take rest in the bed. He is advised to not to retain the Vega as well asdon’t make Pravahana95.2. Observation and management during Virechana Vega:During all the time, Vaidya should concentrate on the manifestation of Lakshanaof Jirna-Ajirna Aushadha, Shuddhi and Vyapat etc.3. Observation of Shuddhi Lakshana:Virechana Shuddhi can be assessed as shown in the Table-4, based on parameterslike Vaigiki, Maniki, Antiki and Laingiki Lakshana.Table-4, Assessment parameters of VirechanaShuddhi Hina Madhyama PravaraVaigiki 10 Vega 20 Vega 30 VegaManiki 2 Prastha 3 Prastha 4 PrasthaAntiki Kaphanta Kaphanta KaphantaLaingiki Lakshana As per described in Table-5Manifestation of Samyak yoga, Atiyoga, Ayoga Lakshana and Vyapat should beobserved as per texts 96,97,98,99,100,101 Samyak Yoga Lakshana: Among different Laingiki Lakshana documented in the classics some aremanifested on the day of Virechana and others on later days. In comparison toother Shuddhi Lakshana the Laingiki Lakshana is given much importance 102. A Comparative Study of Virechana karma and Basti karma in Amavata 20 W.S.R.T. Rheumatoid Arthritis
  • 33. Virechana karmaTable-5Samyak Yoga Lakshana of VirechanaLakshana Caraka Sushruta VagbhataSrotovishuddhi + - -Indriya Prasada + + -Buddhindriya and Manas Shuddhi + - -Laghuta + + -Agnivriddhi + - -Anamayatva + +Vit-Pitta-Kapha-Vata Kramena Prapti + + -Vatanulomana - +Absence of Ayoga Lakshana - - +Manahprasada - + -Dourbalya + - -Glani + - -Aruci + - -Hrdaya-Varna Vishuddhi + - -Kshudha – Trshna + - -Vegapravartanam in Proper time + - -Virechana Vyapat: The complications arising due to improper Virechana Karma are known asVirechana Vyapat. Ayoga and Atiyoga of Virechana may lead to manifestation ofVyapat 103,104,105Opinions of Acharyas regarding Virechana Vyapat are shown in Table-6Table-6, Virechana VyapatVyapat Caraka Sushruta VagbhataAdhmana + + +Parikartika + + +Parisrava + + +Hrdgraha + - +Gatragraha + - SarvangagrahaJivadana + + +Vibhramsha + - Guda VibhramshaStambha + - - A Comparative Study of Virechana karma and Basti karma in Amavata 21 W.S.R.T. Rheumatoid Arthritis
  • 34. Virechana karmaKlama + - -Upadrava + - -Vamana - + +Savashesha Aushadhitva - + +Jirna Aushadhitva - + +Hina Aushadhitva - + -Vata Shula - + VedanaAyoga - + +Atiyoga - + +Hridaya-Upasarana - + -Vibandha - + -Pravahika - + +Visamjnata - - +III. Paschat Karma: Following points can be considered under Paschat KarmaTat Kalina Paschat Karma: After the stoppage of Virechana Vega, the hands, feet and face of the individualshould be well washed and he should be consoled for sometime and instructed tofollow Pathya as explained in the context of Snehana and Virechana 106.Kalantarina Paschat Karma:Individual is instructed to follow appropriate Samsarjana Krama’s as per the • Shuddhi Lakshana • Peyadi Samsarjana • Tarpandi Samsarjana. Samsarjana Krama is a specific dietary regimen, which is to be followedafter Shodhana Karma. The aim of this Krama is to increase Agni Bala gradually,which has become weak due to Shodhana. Caraka reveals importance by givingexample that small sources of fire, if simulated by adding small and light fuel, A Comparative Study of Virechana karma and Basti karma in Amavata 22 W.S.R.T. Rheumatoid Arthritis
  • 35. Virechana karmalater on become so big that it can burn anything. Similarly by applyingSamsarjana Krama Jatharagni can be increased to such an extent that it can digestall types of food 107. Caraka has mentioned that Peya, Vilepi, Akrita yusha and Krita yushashould be administered for the period of 3, 2, and 1 meal times to the patienthaving Pravara, Madhyama and Avara type of Shuddhi respectively 108. Sushruta has described Yusha of Kulattha, Adhaki, Mudga and MamsaRasa for this purpose. Dalhana advises that the Peya should be given in theconditions of Kshina Kapha, but when Vata is dominant Mamsa Rasa should berecommended 109. When proper Virechana doesn’t occur at that time instead of PeyadiKrama, Tarpana is indicated. It is also recommended that the persons addicted toalcohol, having Vata Pitta Prakrti and if Kapha and Pitta are dominant even afterVirechana Karma, Cakrapani mentioned that in the place of Peya and Vilepi,Svaccha and Ghana Tarpana should be given respectively 110.Importance of Virechana Vamana and Virechana are the main principal remedies in cleaning thesystem of all the doshas from the body. On this Dalhana opines, PakwashayagataVata, Pitta and Kapha will be eliminated by 1, 2, 3 Vastis, Dhuma, Nasya, Kavalaetc also eliminate the doshas little by little. Where as Vamana and Virechana willeliminate the doshas completely out of the body.111, 112Different varities of virechana If we gone through our ayurvedic texts mainly we found three types ofVirechana, wheather it may be Anulomana, Srousana, Bhedhana or Rechana,those three types are A Comparative Study of Virechana karma and Basti karma in Amavata 23 W.S.R.T. Rheumatoid Arthritis
  • 36. Virechana karma1] Virechana, which is done after Snehana and Swedana followed by Samsarjanakarma.2] Sadhyovirechana, which is given in the emergency condition, with out Snehanaand Swedana like Vamanavyapata, Kosthabadhata or for the shake ofKoshasuddhi.3] Nittyavirechana which is giving daily for long time with out consideringSnehana and Swedana followed by Samsarjana karma with consideration ofKostha and Bala of patient, it may be continued for 8 days or 15 days or 1 monthand so on.1] Virechana This type of Virechana has already explained in the previous pages.2] Sadhyovirechana Sadhyovirechana contains two words, one is Sadhyo and another isVirechana, Sadhyo means at that movement or immediate. Virechana meanseliminating doshas from Guda marga by takeing Aoushadha with Mukhamarga.So totally Sadhyovirechana means instant elimination of doshas with Gudamargaby taking Aoushadha through Mukhamarga with or without considering Snehanaand SwedanaScope of Sadhyovirechana1] Second stage of Vishavega2] Urdhvaga raktapitta3] Amavata4] Vamana Ayoga and Atiyoga5] Vibhanda6] Alasaka A Comparative Study of Virechana karma and Basti karma in Amavata 24 W.S.R.T. Rheumatoid Arthritis
  • 37. Virechana karma7] In weak person if there is a Bahudoshas and if dosha paka have attaineddirectly Bhedhaniya Aoushadha or Bhedhaniya Ahara dravya can be advised.Like this still in many conditions we will find in our classics.113 Sadhyovirechana does the effect of eliminating Vishapadhartha andaccumulated fecous thus does Vatanulomana. Due to administering Sadhyovirechana with or without consideringSnehana and Swedana using of Snehika virechana is beneficial, this holds goodbecause of in Ruksha person Snigdha virechana have advised.114, 115 Other wisegiving Ruksha virechana to a person who has not under gone for Snehapana willdestroy like dry stick when bends it. We get strong reference of using Sahdyovirechana with Eranda tailcombining with Triphala kwatha in Chakradatta116 Yogaratnakara117 andSharangdhara118 uttara khanda. Even for the test of Krura kostha, Madhyama kostha and Sadharana kosthathis type of Sahdyovirechana helps. In Kruradikostha giving Eranda tail as a Sahdyovirechana is the choice ofdrug. Even instead of Eranda tail Ksheera can also be used in that condition.1193] Nittyavirechana The literary meaning of Nittyavirechana includes two words, one is Nittyaand another is Virechana. Nittya means everyday or consecutive days for two ormore than two days, Virechana means eliminating doshas from Guda marga bytakeing Aoushadha with Mukhamarga. So Nittyavirechana gives the meaning asadministering virechana Aoushadha everyday or consecutive days for two or morethan two days. A Comparative Study of Virechana karma and Basti karma in Amavata 25 W.S.R.T. Rheumatoid Arthritis
  • 38. Virechana karmaParyayanama of Nittyavirechana 1] Nittya shodhana 2] Nittya anulomana 3] NittyavirechanaScope of Nittyavirechana A debilitated person who has under gone Shodhana therapy earlier and aperson who has very little quantity of doshas inside the body but he is emaciatedand he whose nature of Kostha is not known should be given mild drugs in smalldoses, better still in repeated doses, other wise it will create doubt of fatalcondition. If in a debilitated person the doshas are found to be in motion [Chalandoshana] and in large quantity they should be removed out of the body little bylittle using mild drugs and if they are in little quantity they should be mitigated byShamana therapy. Other wise if they remain in side the body for long time causestrouble to the body and might even kill the person if they are not expelled out ofthe body. 120,121,122 Dalhana opines Chalana doshan as Kupitan doshan, Indu commentator ofAsthangha sangraha opines on Chalana doshan, as doshas are in Prabhuta matradoshas should be eliminated with Mrudu Virechana dravya. Arunadatta commentson above version, as taking Virechana Aoushadha everyday day is Shrestha orVaram. Before giving Shodhana Karma we should win over Kapha and Vata in theMandagni and Krurakostha than only Virechana aoushadha can be given.123, 124,125 Even Bhoja also opinions that if doshas are less aggravated they should bemitigated by Shamana chikitsa, if the Bahudosha condition is their, they should beeliminated little by little with out harming the patient. A Comparative Study of Virechana karma and Basti karma in Amavata 26 W.S.R.T. Rheumatoid Arthritis
  • 39. Virechana karma Doshas, which are mitigated by Shamana chikitsa, are likely to reappearagain but those, which are expelled out of the body by Shodhana Karma i.e. byVamana and Virechana, do not re-occur. This statement does not holds good insome conditions like Udararoga, Amavata, etc because in these diseases everydaythe re-accumulation of doshas will takes place that’s why in these type ofcondition Nittyavirechana helps in eliminating the doshas which accumulatedaily. In above told condition Mrudu type of Nittyavirechana helps. Mrudumeans we can use Draksha, Paya, Ushnambu or Tail, Commenting on TailAdamalla opines to consider Eranda tail. While explaining Abhayadimodaka it is well explained that when takingNittyavirechana in little quantity there is no any restriction of food or otheractivities or in this condition Tarpanadi karma can be followed other wiseShastika shali anna with Yavagu of Mudga and other grams or Jangala mamsarasawith Shastika shali anna is benifisial.126Benefits if Nittyavirechana1] Helps to eliminate doshas which accumulate everyday.2] Act as Rasayana if they are taken for long time. For example Eranda tail andAbhayadimodaka. A Comparative Study of Virechana karma and Basti karma in Amavata 27 W.S.R.T. Rheumatoid Arthritis
  • 40. Basti karmaVasti karmaVyutpatti “Vasti” the word derived from the root “Vas” with the suffix of Prattyaya“Tich”.Nirukti and Paribhasha 1. Using Ajadi Vasti Putaka for the use of giveing Aoushadha is called Vasti.127 2. Due to giving medicine by Vasti Putaka is called Vasti.128, 129,130 3. Due to administering medicine in to Gudamarga with Vasti is called Vasti.131 4. Which is Sadhyakarma with Mootradhara Putaka is Vasti.132 5. The karma while moveing in Nabhi, Kati, Parshwa, Shroni churns up the stool including all the other doshas located their, and appropriately eliminates them with easy after doing Snehana of body is called Vasti.133Vasti Karmukhata Vasti is one of the best Chikitsa in Panchakarma, its action will not berestricted to only Pakwashaya Shodhana where as it acts all over the body. Bymixing different drugs it acts as Shodhana, Shamana, Lekhana, Brouhana,Vajikarana, Vayasthapana etc.134 So Vasti can be used in any type. Now its modeof action will be explained as follows. Just as the cloth absorbs only colour from the solution of Kusumbha andother coloring substances, so also the Vasti expels out from the body only thedoshas, which have been maid moist.135, 136 The body is sustained by Vayu because of its ability to cause detachmentof any adhesion. Vayu alone or along with other doshas get aggravated in its ownhabitat. Vasti by its Shodhana action causes downward movement of that Vayu A Comparative Study of Virechana karma and Basti karma in Amavata 28 W.S.R.T. Rheumatoid Arthritis
  • 41. Basti karmaalong with Pitta, Kapha and feces. Because of allivetion of this Vayu, all thediseases pervading the whole body get alleviated.137 Chakrapani comments over above point and says, science Vasti causesalleviation of basic Vayu located in Pakwashaya other connected Vayus elsewhere in the body gets automatically alleviated. This holds good similardestruction of a tree by cutting its root. This explains the cure of all the diseasesof the body by simply correcting the Vayu located in its basic habitat ie colon. In Charaka siddhi Vasti is described to draw out all doshas from the footto the head by its Virya. Medicine injected through rectum remains in the intestines in the region ofthe pelvis and below the umbilical region. The potency Vasti dravya spreasds allover the organism from the Pakwashaya just as the potency of the water poured atthe root of the tree tends to permeate the whole tree through its minutest cells andfibers. The liquid part of Vasti is emitted out through the rectum either by it selfor with feocal matter etc. But its potency acts over whole organism through theintervention of Apana and other Vayus. The potency of the Vasti dravya in thePakwashaya acts on the while organisam from top to toe, like the sun in the havenacting on the humidity of the earth below. Vasti if applied correctly tends toeliminate completely from the system all the doshas accumulated in the region ofthe back, waist and abdomen.138, 139,140Importance of Basti karma Vata is the Neta141 of all Dosas, it is considered as Ishvara142 and it is the 143,144causative factor for all trimargaja rogas . For this type of Vata Vasti is thebest amoung other Karmas.This Vasti is considered as Ardha chikitsa because ofdisease produced by Vata are 80 in number.145 A Comparative Study of Virechana karma and Basti karma in Amavata 29 W.S.R.T. Rheumatoid Arthritis
  • 42. Basti karma Vasti can be utilized in Bala, Vridha, Krasha, Sthoola, Kshina dhatuperson, and in Sthree.146 In the Snehadi karma Basti is chief, because of havingShodhana effect, Shamana effect, Sangrahana effect, Vajikarana effect, Brohanaeffect etc.147 Vasti is beneficial if it is used with different drugs in Vata, Pitta, Kapha,Samsargaja and Sannipataja disorders.148, 149 Vasti is Amruta samana in Shishu and Ashishu, 150 when Vasti is used incombination of Niruha and Anuvasana it eradicates all type of diseases.151 Main specialty of Vasti is first it do the Utkleshana of doshas thanShodhana of doshas and lastly Shamana of doshas.152, 153,154 It is the only one Karma which we found to be given continuously for 324days, if Vasti is taken for such days person neither become old nor sick, lives forthousand years with keen sense organs, devoid of sins shining like gods, like astallion in matters of sex, like a elephant in strength with steady mind, senseorgans and digestive activity.155 Vasti if appropriately administered keeping in view the strength of patientdoshas involved in the causation of disease, nature of disease of disease, physicalconstitution of patient and properties of different groups of drugs prescribed fordifferent diseases cures these ailments.156 No other therapeutic measures other than Vasti cleanses the body quicklyand easily, causes depletion and nourishment instantaneously and is free from anyadverse effect.157 Vasti is useful in Pangu, Urustambhs, Bhagna etc.158 Virechana and Vamana therapy no doubt causes elimination of doshas butit involves intake of recipe ingredients of which are pungent, sharp, hot etc.Those A Comparative Study of Virechana karma and Basti karma in Amavata 30 W.S.R.T. Rheumatoid Arthritis
  • 43. Basti karmaingredients causes’ unpleasantness eruption nausea cardiac discomfort and pain inthe gastrointestinal tract.159 Infants have immature tissue and less of strength, there is diminution andreduction in strength in old people. For both these category Virechana andVamana therapy is contraindicated. Asthapana type of Vasti can however begiven for elimination of doshas and nourishment of body. Vasti therapyinstantaneously promotes strength, complexion, sense of exhilaration andtenderness as well as unctuousness of body.160Basti Effect: (1) Promotive aspects • Sustains Age. • Provides better life, improves strength, digestive power, voice and complexion. • Perform all functions • Provide firmness • Corpulence quality. • Lightness in viscera / systems because removes morbid matter from all over the body. • Restores normalcy. • Increases Relish (2) Curative aspect • Relieves Stiffness • Relieves contractions and adhesions. • Effective in paralytic conditions • Effective in dislocation and fracture conditions A Comparative Study of Virechana karma and Basti karma in Amavata 31 W.S.R.T. Rheumatoid Arthritis
  • 44. Basti karma • Effective in Those conditions where vata aggravated in Shakha / extremities. • Relieves pain • Effective in disorders of GI tract • Effective in diseases of Shakha and Kostha. • Effective in diseases of vital parts, upper extremities localized or general parts. • Beneficial to debilated and weak persons. • Arrest premature old age and the progress of white hair. (3) Preventive aspects • Beneficial in constipation. • Effective to purify various systems of the body.(4) Effect on dhatu : • Increases the quantity and quality of sperm • Effective to restore the normal functions of blood and other dhatus. • It provides strength by increasing muscle power. • Beneficial as geriatrics5) Effect on Brain and Psychology • Improves intellectual power • Provides clarity of mind • Improves clarity of sense organs • Induces sound sleep • Lightness • Exhilaration • Invigorates eyesight A Comparative Study of Virechana karma and Basti karma in Amavata 32 W.S.R.T. Rheumatoid Arthritis
  • 45. Basti karma • Spright lightness of mind(6) Effective at any age and in any season • Basti is non antagonistic to healthy, diseased and old persons • Applicable in all seasons • Basti can be administered in child and older person too, because it is free from complications.Types of Basti Two types of basti • Niruha basti, Auvasana basti 161 • Niruha basti, Snehika basti 162 • Shita basti, Sukhoshna basti 163 Three types of basti • Asthapana basti, Auvasana basti, Uttara basti.165, 166,167 • Utkleshana basti, Shodhana basti, Shamana basti 168,169,170,171 • Karma basti, Kala basti, Yoga vasti.172, 173,174 • Vatahara basti, Pittahara basti, Kaphahara basti.175 • Sneha basti, Anuvasana basti, Matra basti.176 • Teekshna basti, Mrudu basti, Sadharana basti.177 • Kaphavatahara basti, Kaphapittahara basti, Pittaraktahara basti.178Four types of basti • Asthapana basti, Auvasana basti, Uttara basti Matra basti.179 • Pakvashayagata basti, Shiro basti, Kati basti, Vrana basti.Five types of Madhutailika basti 1] Madhutailika basti180 2] Youktaratha basti181 A Comparative Study of Virechana karma and Basti karma in Amavata 33 W.S.R.T. Rheumatoid Arthritis
  • 46. Basti karma 3] Doshahara basti182 4] Siddha basti183 5] Mustadiyapana basti.184Six types of Vasti [On the Basis of Rasa predominance in the Basti Dravya] (1) Madhura Rasa Skandha Dravya Basti (2) Amla Rasa Skandha Dravya Basti (3) Lavana Rasa Skandha Dravya Basti (4) Katu Rasa Skandha Dravya Basti (5) Tikta Rasa Skandha Dravya Basti (6) Kasaya Rasa Skandha Dravya BastiEight types of basti 185 1. Chatuprasruyika basti 2. Panchaprasruyika basti 3. Shatprasruyika basti 4. Saptaprasruyika basti 5. Astaprasruyika basti 6. Navaprasruyika basti 7. Ekadasa Prasrta Basti 8. Dwadashaprasruyika basti.Ten types of Vasti [On the Basis of chief drug] (1) Ksira Basti (2) Mamsa Rasa Basti (3) Gomutra Basti (4) Rakta Basti (5) Kshara Basti (6) Dadhimastu Basti A Comparative Study of Virechana karma and Basti karma in Amavata 34 W.S.R.T. Rheumatoid Arthritis
  • 47. Basti karma (7) Amlakamji Basti (8) Prasanna Krta Basti (9) Sura Krta Basti (10) Asava Krta Basti Fifteen types of basti 1] Vatahara basti 2] Pittahara basti 3] Kaphahara basti 4] Raktahara basti 5] Kaphavatahara basti 6] Kaphapittahara basti 7] Pittaraktahara basti 8] Pittavatahara basti 9] Pittaraktahara basti 10] Raktakaphahara basti 11] Raktavatahara basti 12] Vatapittakaphahara basti 13] Vatapittaraktahara basti 14] Kaphapittaraktahara basti 15] Vatapittakapharaktahara bastiBrief introduction about some important Vasti a. Niruha Basti (Evacuative or Un-unctuous Enema): In Niruha Basti, Kashaya (decoction) is the predominant content. With the Kashaya, Madhu, Saindhava, Sneha and Kalka are the ingredients commonly used. Its synonyms are Asthapana Basti, Kashaya Basti etc. A Comparative Study of Virechana karma and Basti karma in Amavata 35 W.S.R.T. Rheumatoid Arthritis
  • 48. Basti karma The Basti, which eliminates the vitiated Dosha from the body and increase the strength of the body because of its potency, is called Niruha Basti. Because of this enema stabilizes the age (Vaya), stabilizes the normal functions of Dosha and Dhatu and stabilizes Deha i.e. strength of the body, is called Asthapana Basti 187. Depending upon drugs and preparations used in Basti it may be classified as follows: 188 Madhutailaika Basti Yuktaratha Basti Yapana Basti Siddha Basti b. Anuvasana Basti (Unctuous Enema): In this type of Basti only Sneha is used. According to the quantity of oil given, it is subdivide as follows: The Sneha Basti which will not cause any harm even if it is retained for one day and can be administered after taking food, therefore it is called Anuvasana BastiSneha Basti 1/4th to the quantity of Niruha i.e. 6 Pala (298ml).Anuvasana Basti The quantity of Sneha is half of the Sneha Basti i.e. 3 Pala (144ml).Matra Basti This is the minimum quantity of Sneha Basti (½ of Anuvasana Basti) i.e. 1½ Pala (72ml). 189,190A Comparative Study of Virechana karma and Basti karma in Amavata 36 W.S.R.T. Rheumatoid Arthritis
  • 49. Basti karma B) Anatomical Classification: It depends upon the part of the body used for the administration of Basti.Internal application: • Pakvashayagata Basti • Uttara Basti a. Garbhashayagata Basti b. Mutrashayagata BastiExternal application: Vranagata Basti Kati Basti Shiro Basti Netra Basti C) According to the number of Basti to be used: Karma Basti - 30 Basti - 12 Niruha & 18 Anuvasna Basti Kala Basti - 16 Basti - 6 Niruha & 10 Anuvasana Basti Yoga Basti - 8 Basti - 3 Niruha & 5 Anuvasana Basti In the above types fixed sequence of Niruha and Anuvasana Basti isfollowed.Rectal Administration: Substances may be introduced into the rectum for exciting evacuation orfor medication, which later may be intended for effect in three different locations. • For effects on the contents of the colon for which the term "endocolonic might be suggested to differentiate it from, • Effect to be exerted on the tissue of the colon, for which the term encolonic might be a suitable designation and • For administration by the way rectal medication intended for systemic action for which the term diacolonic might be employed. • Before one resorts to rectal administration it is a good rule to make a digital examination of the rectum. A Comparative Study of Virechana karma and Basti karma in Amavata 37 W.S.R.T. Rheumatoid Arthritis
  • 50. Basti karma • Rectum distended with fecal matter should be cleaned out by an evacuate enema before it is given the task of receiving medication. • Rectal injections, also known as enemas, clysters or Lavements may be large or small.Why rectal administration?1. When it is desired to spare the stomach and intestine from the action of the drug or to protect the drug from the action of the digestive ferments.2. With children, who will not take disagreeable tasting medicaments, or with the insane, who refuse to swallow, rectal administration may become an important recourse.3. Such a bitter substance as strychnine can best be given to children in suppository form provided this method of administration is carried out gently, skillfully and tactfully.Enemas: Rectal injections, also known as enemas, clysters or lavements, maybe"large" or "small". An enema of less than half a liter might be considered a smallenema and of more than half a liter is a large enema. 1. When a rectal enema is given by means of a syringe with a short tip, it is deposited just within the sphincter of the anus, a portion of the rectum that is normally very intolerant of sudden distention. It is indeed this irritability, which is responsible for the prompt evacuation of any fecal matter that arrives in this part of the bowel. For this reason, even a small quantity of fluid, when given rapidly, tends to cause evacuation. 2. When, on the other hand, the enema is administered very slowly, it suppresses evacuation reflex and reaches to the upper part of the colon which is not only more retentive but also more absorptive than the rectum. A Comparative Study of Virechana karma and Basti karma in Amavata 38 W.S.R.T. Rheumatoid Arthritis
  • 51. Basti karma 3. After the drug once passes the anal sphincter, will pass easily up to the sigmoid and descending colon, across and down to the caecum regardless of the position of the body of the patient. a. Cool large enemas are believed to excite the gallbladder for contraction and are advocated in the treatment of catarrhal jaundice. Irritation of the colon is a long established form of treatment for the various types of jaundice. Garbat and Jacobi offer an experimental demonstration of the possible efficacy of this treatment. They found that within a period of from three or twelve minutes after the instillation of various solutions high into the rectum a flow of bile was obtained from the duodenal tube, that would continue for from eighteen to sixty minutes without any interruption. b. Hence, the introduction of various solutions into the upper part of the rectum produces drainage into the duodenum of bile that comes directly from the liver and without contraction of the gallbladder.(A) Evacuate enemas:1. Evacuate enemas in increasing order to potency, should be repeated every three or four hours, care being taken not to over distend the colon, until success is secured or the uselessness of the procedure becomes evident.2. Whether large or small, hot or cold, simple or medicated enemas should be employed to secure evacuation in any one case depends on the conditions present.3. If the rectum merely is to be emptied of feces, 0.5-liter enema given rapidly with the patient in the sitting posture suffices. If, on the other hand the most thorough possible cleansing of the bowel is aimed at (colonic A Comparative Study of Virechana karma and Basti karma in Amavata 39 W.S.R.T. Rheumatoid Arthritis
  • 52. Basti karma flushing), the largest possible quantity of warm water from 1 to 2 liters is slowly introduced with the patient recumbent in the lateral or Sims position ; or, better still in the knee-chest position.4. On the other hand, a small (0.25 liter), cool enema rather quickly injected into the bowel, to stimulate it to evacuation, maybe considered one of the least objectionable procedures, even when employed quite habitually.(B) Oil enemas: Though oil enemas are essentially evacuant enemas, they are given withthe technique of the retention enema, because they are to be retained for manyhours, usually over night.Indications:1. To soften feces, in constipation characterized by the formation of hard scybala and in that due to partial obstruction of the colon.2. For evacuate action, in so-called spastic constipation, in pelvirectal constipation and in any other form of constipation and in which oral administration of cathartics is contraindicated by gastric disturbance.3. For soothing action, in excessive irritability of the colon and rectum, in colitis and in proctitis.4. It has been suggested that oil enemas might inhibit absorption of toxic products. That the oil has the power of removing substances soluble in it is shown by the fact that it is passed dark yellow or olive green and of offensive odour. There is no definite knowledge, however, of the degree to which thisproperty might be of clinical value. A Comparative Study of Virechana karma and Basti karma in Amavata 40 W.S.R.T. Rheumatoid Arthritis
  • 53. Basti karmaRules:1. The oil must be pure and free from rancidity. This is more important than that it come from a certain source. (Thus poppy seed oil, oil of sesame or cottonseed oil, when pure, is just as good for this purpose as olive oil).2. The oil should be placed in a basin of hot water until it has acquired blood heat (100 F).3. The oil enema is given at bedtime, unless it produces discomfort and interferes with sleep. In such case it may be taken early in the morning, and the patient may lie in bed for three or four hours after ward.4. The patient should understand that, unless the oil remains in the intestine for several hours at lest satisfactory results cannot be expected. The total quantity to be injected depends, therefore, on the patients ability to retain it.5. This is so variable that no definite quantity can be stated. The principle to be followed is to have the patient gradually increase the amount injected at successive times until a satisfactory amount can be introduced and retained.(C) Retention enemas:Technique: It is well to precede a retention enema by a cleansing enema, so as tounload the lower part of the bowel of fecal matter that may be contained in it,thereby lessening distention and favoring retention.1. The smaller in bulk the enema the better it is retained.2. Still, to be retained, it must also be quite devoid of irritating properties. A Comparative Study of Virechana karma and Basti karma in Amavata 41 W.S.R.T. Rheumatoid Arthritis
  • 54. Basti karma3. The retention of an irritative substance may be favored by making its solution as nearly isotonic as possible, and by using colloidal fluid, such as starch water as diluents.4. If the fluid is introduced very slowly and steadily, the rectum does not become as readily aware of the distention and retains a quantity of fluid that would otherwise be expelled.5. Giving the enema at body temperature favors retention, as extremes of temperature excite peristalsis.6. The patient should assume the recumbent position for at least an hour after the injection, and should be instructed to resist any inclination to evacuation as much as possible.(D) "Nutrient" enemas: Why? The attempt has been made to maintain nutrition by rectal feedingwhen it is impossible or undesirable to introduce food into the stomach, or when itcannot be retained. But the colon has hardly any digestive power and it absorptivecapacity even for water-soluble substances of large molecular size is very poorand nil for fat.Rules:1. Not more than three nutrient enemas should be given in the twenty - four hours, at about eight hour intervals. The amount should at first not exceed 150 cc., to be gradually increased to 300 when given as ordinary enemas, though when given by proctoclysis the quantity may reach 1 liter.2. After each administration the patient should keep as quite as possible for at least two hours and suppress any desire to evacuate the bowel. A Comparative Study of Virechana karma and Basti karma in Amavata 42 W.S.R.T. Rheumatoid Arthritis
  • 55. Basti karma3. In point of fact patients who need nutrient enemas should be kept in bed continuously; at rest in bed lessen the consumption of calories by at least 25 per cent.4. A daily cleansing enema is advisable. This should precede the nutrient enema by about an hour.(E) Medicated enemas: Medicated enemas are given by the technique of retention enemas. Theymay be employed, as previously stated, for endocolonic, encolonic or diacolonicaction. Oil may be used as a vehicle for diacolonic administration of oil-solublevolatile bodies. On the basis of extensive experience by Gwathmey.Thus from above description we can easily understand the role of madhu,saindhav and sneha in each basti. Above description resembles to the ayurvedicdescription of basti karma up to maximum extent. Though modern sciencedeveloped other advanced routes for the drug administration so now days they arenot using this route but they cant deny the importance of this route A Comparative Study of Virechana karma and Basti karma in Amavata 43 W.S.R.T. Rheumatoid Arthritis
  • 56. AmavataDisease Review Amaravata describes a wide range of joint disease manifestations.Amavata is mainly caused by two factors ama and vata.Etymology of Amavata 1. ‘Amena samhita vata Amavata’. The virulent Ama circulates in the whole body propelled by the vitiated vata dasa producing block in the body channels that stations itself in the sandhi giving rise to Amavata191. 2. The combinations of ‘Ama’ and vata form Amavata. It shows the Pridomminance of Ama & vata in the samprapti of Amavata 192. 3. Ajeerna produce ‘Ama’ & along with vata it produce Amavata193.Definition ‘Ama’ is produced by agnimandya of both Jatharagni and Dhatwagnis.Even though ama is a cause for various diseases, in Amavata it is the maincausative factor. Ama and vata vitiated simultaneously and disease is manifestedmainly in joints of hasta, pada, sira, trika, gulpha, janu and uru. The mainsymptioms produced are Angamarda Aruchi, Trishna, Alasya, Gouravam, Apaka& Shotha 194.Importance of Ama in Amavata The main causative factor for the manifestation of Amavata is Ama. So itis necessary to know about the Ama in detail.Etymology of Ama 1. The unprocessed or undigested food partical is Ama 195. 2. Ama means, “Which is subject of digestion”. 196 A Comparative Study of Virechana karma and Basti karma in Amavata 44 W.S.R.T. Rheumatoid Arthritis
  • 57. AmavataDefinition of Ama 1. The first Rasa dhatu, which has been inadequately digested due to the weakness of digestive fire and accumulating in the stomach in the abnormal state, is know as Ama 197,198. 2. The undigested Adya Ahara dhatu is Ama 199. 3. The food material which will not undergone vipaka, leads to Durgandha, which is large in quantity, which is picchila & which leads to Gatra Sadana is called Ama. 4. Due to impairment of digestive fire the undigested remained food material is ‘Ama’. 5. Apakva Anna Rasa is Ama & some other considers the accumulation of mala as Ama & still other opines the first stage of vitiation of dosa as Ama.On the basis of the for going, Ama may be classifieds as below I) Ama produced due to hypo functioning of Agni i.e 1) Ama due to Jatharagni Mandya. 2) Ama due to Dhatvagni Mandya. 3) Ama due to Bhutvagni Mandya. II) Ama produced irrespective of the action of Agni 1) Accumulation of mala. 2) Ama due to interaction & virulently vitiated dosas 3) First phase of dosic vitiation.Vata in Amavata Voluntary & involuntary functions are all under the control of Vaya. InAmavata the normal function of Vata is disturbed. It produces stabdhata &sandhigraha leading to the restricted movements of joints & it will become the A Comparative Study of Virechana karma and Basti karma in Amavata 45 W.S.R.T. Rheumatoid Arthritis
  • 58. Amavataresponsible for crippling effect seen in the patients. This shows that predominanceof vata dosa in the pathogenisis of Amavata. Now let us carry a brief description of vata dosa. The word vata derived 200from “Va gati gandhanyoh” it means to move, to make known, to enthuse . Ithas got the other synonyms like Anila, Maruta, Pavana etc.201Gunas of Vata Ruksha, Seeta, Laghu, Sukshma, Chala, Visada, Parusha & Khara 202,203.Functions of Normal Vata Vaya sustains the body with expiration, inspiration, enthusiasm, movement ofvarious parts. Kneenees (sharpness) of sense perception, initiation of the naturalurges and many other functions204. 1. Tantrayanradhara 2. Cheshta Pravartaka 3. Mano Niyanta & Praneta 4. Sharvendriya Uttyojaka 5. Sharvendriya Artha Abhivodha 6. Sharva sharira dhatu Vyuhakara 7. Sharira Sandhanakar 8. Vak pravartaka 9. Sabdasparsa Prakrti 10. Srota sparsana mula 11. Harsha utsahayoni 12. Agni samirana 13. Mala ksepta 14. Grabhakrti Karta 15. Ayusha Anuvratti 205. A Comparative Study of Virechana karma and Basti karma in Amavata 46 W.S.R.T. Rheumatoid Arthritis
  • 59. Amavata Importance of Vata Pitta, Kapha, Dhatu & Mala are movementless, unless they are brought to the proper place by vata to carry out their functions. Thus Vayu makes the functions of all the tissues of body 206. Symptoms produced due to Ama 1. Srotordha 2. Balabramasa 3. Gaurava 4. Anila Mudhata 5. Alasya 6. Apaki 7. Nisthivana 8. Mala sanga 9. Aruchi 10. Klama 11. Vit, Mutra, Nakha, Dhatu, Chakshu Pitata/Raktata/Krishnata 12. Prusthtasthi, Katisandhi Ruk 13. Siroruk 14. Nidra 15. Mukhavairasya 16. Jvara 17. Atisara 18. Romaharsa. Symptoms of Vataprakopa 207 1. Parava Samkocha 2. StambhaA Comparative Study of Virechana karma and Basti karma in Amavata 47 W.S.R.T. Rheumatoid Arthritis
  • 60. Amavata 3. Asthi Paravabheda 4. Lomaharsa, Pralapa, Hasta-Pristha-siro-graha 5. Khanjata-Pangulya 6. Kubjata 7. Sosha 8. Anidra 9. Grabha-sukra-Rajonasa 10. Spandana 11. Gatra Suptata 12. Sira, Nasa, Akshi, Jatru, Grivahanunam-Bheda ,Toda-Arti 13. Akshepa 14. Moha 15. Ayasa Nidana of Amavata Nidana is defined as the factors which deranges the dynamic state of doshic equilibrium provokes the disease is known as Nindan. This Nidana helps us to decide the line of treatment as well as prognosis of the disease. Amavata Ninda is of multifaceted various Acharya’s mentioned their different views for the productions of Ama in Amavata. Madhavakar 208 has delt the separate Nidana as 1. Viruddha Ahara (Incompatible food) 2. Viruddha Chestha (Incompatible food) 3. Mandagni (Hypofunctiony of agni) 4. Nischala (Lack of exercise) 5. Snigdha Ahara followed by immediate exercise.A Comparative Study of Virechana karma and Basti karma in Amavata 48 W.S.R.T. Rheumatoid Arthritis
  • 61. Amavata Besides these intakes of Kanda, mula and sakha and excessive exertion are itiological factors opeined by Harita 209. In Anjana Nidana which vititate vata, pitta and kapha are considered under Nidana 210. These all above Nindan can be included under two heading 1. Unwholesome diet & 2.Erroneous habits. Unwholesome diet means “which aggravates the body humors but not 211 expel them out of the body” . Charaka has mentioned 18 types of 212 unwholesome diet (Viruddha Ahara) some of the virudha Ahara are as follows 1. Milk along kulatha, 2. Panase fruit with matsya 3. Mixtures of equal quantities of honey & ghee. 4. Boiled curd 213. Erroneous habits (Viruddha chesta) mainly included alternate use of cold and heat, suppression of natural urges, sleeping daytime, walking at night, over indulgence in work. Table No-7, Amavata Nidana according to various Acharyas. Sr Nidana H.S. M.N. A.N. i.Viruddha ahara - + - ii.Guru ahara + - - iii. Tarpite kandashakastu + - - iv. Mandagni + + - v. Viruddha cheshta - + - vi. Avyayama + - vii. Snigdha bhuktavato hiannam vyayama - + -viii. Swa prakopnaiha : - - + Vatadosha Pittadosha Kaphadosha ix. Vyavayina + - - A Comparative Study of Virechana karma and Basti karma in Amavata 49 W.S.R.T. Rheumatoid Arthritis
  • 62. AmavataSamprapti of Amavata 214 The impairment of Agni will produce the condition of Ama. MainlyAgnimandya initially affects digestion followed by metabolism. Hence in thisstate of Agni, the Rasadhatu is not formed up to the standard level & it isconsidered as Ama. This ‘Ama’ along with Vyana Vayu and also by virtue of itsVishakari guna it quickly moves to all kapha sthanas, through Hridaya andDhamanes. This Vidhagada Ama, in kapha sthana is further contaminated bydosas and assumes different colours, because of the Atipichhilata. If Ama gets obstructed in to channels and promotes further vitiation ofvata dosha, this morbid Ama circulates ubiquitously in the body propelled byvitiated vata with predilection for shesma sthana. On the dhamanies with the otherdosas it facilitates sroto abhisyanda and srotorodha causing sthanasmsrayamanifested stabdhata (stiffness), sandhisula (joint-pain), sandhishotha (swelling),Anga marda(body ache) Apaka(indigestion), Jwara (fever), Anga gourava(heaviness of body), Alasya(laoghess) etc symptoms of Amavata. According to the commentators on Madhava Nidana the Samprapti ofAmavata can be summarized accourding to ShatkriyakalSanchaya & Prakopa: When a person is exposed to aetiological factors likeViruddha Ahara, does vyayama after intake of snigdha ahara, Chinta, Krodha etc.,Agnimandya is there leading to Tridoshadushti and Amotpatti in the Sanchayaand Prakopavastha.Prasara: With the help of Vata (Biophysical mechanism), this Ama gets Prasarato shleshma sthana producing mild sandhishoola etc. along with Ama symptoms.Then Ama gets interacted with Tridosha and further modified (Vidagdha) to greatextent and yagapatakupitavanta of Ama and Vata takes place via Rasavaha srotasa(Dhamani). A Comparative Study of Virechana karma and Basti karma in Amavata 50 W.S.R.T. Rheumatoid Arthritis
  • 63. AmavataSthana Sanshraya: This prasarita Ama, which viscid, unctuous and guru enduresSthana Sanshraya in Hridaya, Trika Sandhi and Sarvanga (Srotoabhishyanda)leading to Dosha-dushya Sammurchchana. Primarily the disease is not manifestedcompletely, so only initial mild symptoms like Aruchi, Apaka etc. are observedwhich can be considered as purva rupa of the disease Amavata.Vyakti: As it reaches vyakti stage most of the symptoms of Amavata aremanifested like Vrishchika dashavata vedana, stabdhata etc. In Adibala Pravritacases (Karmajanya, Mata-pita apcharajanya etc.) Khavaigunya is already thereand with the minor nidana sevana disease in manifested.Bheda: In chronic stage or if the disease is left untreated it reaches bhedavastha-producing updrava like Sankocha, Khanjata etc.The Samprapti Ghatakas, which are involved on the Amavata, are as follows. 1. Dosha-Tridosha mainly vata(vyana, samana, Apana) and kapha ( Kledaka, Bodhaka, slemaka) 2. Dhatu -Rasa, Mamasa. Asthi, Majja. 3. Upadhatu -Snayu and Kandara. 4. Srotases -Annavaha, Rasavaha, Asthivaha, Majjavaha. 5. Srotodusti -Sanga, Vimaragagmana. 6. Udbharasthana- Amashya (Ama), Pakvasaya (vata). 7. Adhisthana -whole body 8. Vyaktasthana -Sandhi 9. Avayava -Sandhi. 10. Vyadhiswabhava -Mainly Ashukar. 11. Sanchara Sthana -Hridya, Dhamani. 12. Roga Marga -Madhyama roga marga 13. Agni -Jataragni Mandya, Dhatwagni Mandya. A Comparative Study of Virechana karma and Basti karma in Amavata 51 W.S.R.T. Rheumatoid Arthritis
  • 64. Amavata FLOW CHART-1 SAMPRAPTI Virudha Ahara + Virudha Vihara Agnidusti in Amashaya Formation of Amarasa Sanchara through Dhamani all over The body by vata dosha Samadosha Accumulates in the Slesma sthanas like Amashaya, Sandhi etc Enters Into Kosta, Trika Sandi Leads to Gatra Stabdata Karoti Sarujam shotam Yatra doshaha prapadyate Leads to painful swelling of joints wherever the vikrita dosas travels. Angamarda, Aruchi, Apaka, Gourava, Jwara, Sandi Ruja Sandi shota Amavata.A Comparative Study of Virechana karma and Basti karma in Amavata 52 W.S.R.T. Rheumatoid Arthritis
  • 65. AmavataPurva roopa of Amavata In the classics it is not clearly mentioned purva roopa of Amavata. But however in such condition Avyakta lakshana prior to the manifestation of 215 disease is considered as the purva poorpa . With the help of this the purva roopa of Amavata can be considered as follows 1. Dourbalyam (Weakness) 2. Haridaya gourava (heaviness in chest) 3. Gatra stabdam (Stiffness of the body) 4. Apaka (indigestion) 5. Anga mardu (Aching all over body) 6. Gourava (Heaviness) 7. Aruchi (loss of taste) 8. Alasya (lack of enthusiasm) 9. Jwara (fever) 10. Sandhi vedana (Joint pain)Roopa of Amavata “Utpanna Vyadhi bhodakameva lingam rupam” 216. It means which gives the idea about the manifested disease is known as ‘Rupa’. 217 Madhavakara while describing Amavata lakshana, he has considered them in to two heading one is samanya lakshana another is lakshana samachaya of pravrudhu Amavata. Samanya Laxanas are as follows 1. Angamarda (body ache) 2. Aruchi (Tastelessness) 3. Trishna (Thirst) A Comparative Study of Virechana karma and Basti karma in Amavata 53 W.S.R.T. Rheumatoid Arthritis
  • 66. Amavata 4. Alasya (lack of enthusiasm) 5. Gouravam (Heaviness all over body) 6. Jwara (Fever) 7. Apaka (Indigestion) 8. Shunata Anganam (Swelling all over the body mainly in joints)Pravriddha Lakshana of Amavata: It is the advanced stage of disease and very troublesome to patients aswell as for physicians. According to Kriyakala and stage wise development, it isthe worst stage of disease. Articular and Extra-articular feature present in thisstage have been elucidated by Acharya Madhavakara, Bhava Mishra and YogaRatnakara.According to Madhavakara 2181. Sarujam Sandhishotha – Hasta, Pada, Shiro, Gulpha, Janu, Uru Sandhis are chiefly involved in Amavata.2. Vrishchika danshavata vedana – This kind of pain shows the presence of Ama at the site of pain.3. Utsahahani – A subjective feeling in which lack of enthusiasm can be seen in suffering person. It is due to insufficient nutrition of Sharira Dhatus, Indriya and Mana.4. Bahumutrata – Presence of vitiated or dushita Ama causes sroto – abhishyanda in the body, which leads to increase of kleda. This Bahumutrata occurs for the excretion of excess kleda from the body.5. Kukshikathinya – Vitiated Samana and Apana Vata along with the Ama leads to Kukshikathinya, which is the rigidity of abdomen. A Comparative Study of Virechana karma and Basti karma in Amavata 54 W.S.R.T. Rheumatoid Arthritis
  • 67. Amavata6. Kukshishoola – Srotorodha due to Ama causes obstruction to normal movement of vitiated samana and apana Vata resulting in pain in abdomen.7. Nidra Viparyaya – Due to vata vriddhi, pain gets aggravated at night and keeps the patients awaken which leads to Nidra Viparyaya.8. Chhardi 219 Continuous formation of dosha leading to excitation of Amashaya byVata causes Chhardi.9. Bhrama - Presence of Kapha in Srotas and Vitiated Vata causes Bhrama.10. Murchcha - Inability of the sensory organs to perceive the sense objects is Murchcha. Loss of motor function occurs in Murchcha due to upatapa of Indriya by Vitiated Vatadi doshas 22011. Hritgraha - It is due to Rasavaha srotodushti (its mulasthana is Hridaya) and vitiation of Samana Vata, Vyana Vata and Avlambaka kapha. Hritgaurava is also produced due to above reason when vitiation is mild. In R.A. cardiac manifestations like Pericarditis, Myocarditis, Conduction defects etc. can occur.12. Vibandha – It is due to vitiated Apana Vata and improper degradation of Ahara into Sara and Kitta.13. Antrakujana – In this feature, increased bowel sounds are present due to movement of Vitiated Vata in the intestine.14. Anaha – It is the stagnation of vitiated vata in Kukshi.15. Agnimandya – Vicious cycle of disease (Agnimandya-Shuktatva – Annavisha) produces Agnimandya again and again. A Comparative Study of Virechana karma and Basti karma in Amavata 55 W.S.R.T. Rheumatoid Arthritis
  • 68. Amavata16. Praseka – It means lalasrava 221. Excessive thick, mucoid, salivary secretions are produced due to Samarasa, which shows Rasavaha and Udakavaha srotodushti.17. Gaurava – Due to Vitiated Kapha there is feeling of heaviness in Hridaya and body parts preferably in Joints.18. Vairasya 222 Perception of different taste than normal due to Sama Rasa and vitiated Bodhaka Kapha.19. Daha - Due to Vitiation of Pitta sometimes localized or generalized Daha occurs.Warmth of the joint is usually evident on examination. In its most aggressiveform, rheumatoid vasculitis can cause Mononeuritis multiplex (Harrison 1994).20. Trishna – Trishna is due to Agnidushti, Sama Pitta and Vata. It shows Rasavaha, Udakavaha srotodushti in disease process.Table No.8 Similarity between Amavata and Rheumatoid Arthritis Rheumatoid Arthritis Amavata Morning stiffness Gatra sthabdata or sandhi sthabdata Arthritis of 3 or more joints Bahu sandhi shotha Arthritis of hand joints Hasta, sandhi shotha Symmetrical arthritis Bahu sandhi shotha (ubhaya) Rheumatoid nodule Angavaikalya Rheumatoid factor ---- Radiological changes ---- The first 4 criteria of RA can be correlated with the inflammatorycondition of amavata. But rheumatoid factor and radiological changes cannot be A Comparative Study of Virechana karma and Basti karma in Amavata 56 W.S.R.T. Rheumatoid Arthritis
  • 69. Amavatacorrelated to any conditions of amavata. Hence on symptomatology amavata canbe best correlated to RA.Pratyatma Lakshana (Cardinal Signs and Symptoms) Pratyatma Lakshanas are main clinical features on which the disease canbe clearly differentiated from other identical forms of disease. In Amavata,sandhis are the main site of manifestation of clinical features, thus joint associatedsymptoms are considered as Pratyatma lakshana of disease Amavata.These are as follows:(a) Sandhi Shoola (Joint Pain) In Amavata, Vitiation of Asthi and Majjagata Vata causes pain inSandhis and in severe stage, it is found as Vrishchika Dansha vata. The most common manifestation of established R.A. is pain in affectedjoints, which is aggravated by movements. During rest and especially earlymorning stiffness are also characteristic features of R.A. Pain originatespredominantly from joint capsule, which is abundantly supplied with pain fibresand is markedly sensitive to stretching or distension (Harrison 1994).(b) Sandhi Shotha (Joint Swelling) Sandhi Shotha (Ekangika shotha) results when vitiated dosha afflicts 223Twaka, Rakta, and Mamsa in joints . Madhavakara has described that shotharesult due to the affliction of Ama and Vata Pradhana Tridosha in joints. Joint swelling in R.A. is the result of accumulation of synovial fluid,hypertrophy of synovium and thickening of joint capsule.(c) Stabdhata (Stiffness) The restriction or loss of movements of joints. Gatra stabdhata iscaused due to spreading of Ama through out the body by vitiated Vata.224, 225 A Comparative Study of Virechana karma and Basti karma in Amavata 57 W.S.R.T. Rheumatoid Arthritis
  • 70. Amavata In majority of patients, the onset is insidious with joint stiffness,especially early morning stiffness, which gradually gets reduced by evening. Thisdiurnal rhythm worse on arising in the morning and than relieving towardsevening probably reflects the diurnal variation in plasma cortisol level.(d) Sparshasahyata (Tenderness) Sparshasahyata can be included in Sandhishoola in which patient crieswith pain even when the gentle pressure is applied to affected part. Some timesperson himself cannot touch the affected part due to pain. According to Modern text pain on movement and tenderness are thecardinal signs of the disease (Becron -1971).Table-No 9,Lakshans According to different Ayurvedic classics 226,227,228,229,230 No. Lakshana MN B.P. B.R. Y.R. G.N. A.N 1 Agnidourbalya + + - + + - 2 Alasya + + - + + 3 Anaha + + - + + - 4 Angamarda + + - + + - 5 Anga sonata + + - + + - 6 Antra kujan + + - + + - 7 Apaka + + - + + - 8 Aruchi + + - + + - 9 Bahu mutrata + + - + + - 10 Bhrama + + - + + 11 Chardi + + + + + - 12 Daha + + - + + - 13 Gourava + + - + + - 14 Hritgraha + + - + + - 15 Janghadi Pradesha Vyadha - - + - - - 16 Jwara + + - + - 17 Kukshi Kathinyata + + - + - 18 Kukshi sula + + - + - 19 Murcha + + - + 20 Nidra Viparayaya + + - + 21 Pandu Varna - - + - - A Comparative Study of Virechana karma and Basti karma in Amavata 58 W.S.R.T. Rheumatoid Arthritis
  • 71. Amavata 22 Prasekam + + - + + - 23 Sandhi gourava + - - - + + 24 Sandhi Ruja + + - + + + 25 Sandhi shotha + + - + + + 26 Sandhi Graha - - - - - - 27 Sosha - - + - - - 28 Trishna + + + + + - 29 Ushnata - - + - - - 30 Utsaha Hani + + - + + - 31 Vairasyam + + - + + - 32 Vishuchi - - + - - - 33 Vitvibandha + + - + + - 34 Vruschika damsavata peeda + - - - + -Table No.10, Showing the Sthananusara Laxana Stanika Laxana Shareerika Laxanas Manasika Laxana Sandhi shotha, Sandhi Angamarda, Kukshishoola, Aruchi, Utsahahani, shoola, Gatra Bahumutrata, Trusna, Peeta mutrata, Moorcha, sthabdata, Daha, Raga, Alasya, Takratulyata, Gourava, Bhrama, Alasya. Kandu. Nidraviparyaya, Jwara, Antrakoojana, Apaka, Anaha, Agnimandya, Grahanidosha, Praseka, AsyavairasyaSapeksha Nidana Sapeksha nidana becomes necessary when two or more disease have a fewimportant laxanas similar to each other and in such condition in order to avoid anyerror in adopting the line of treatment. The differential diagnostic is done on thebasis of few points such as difference in samprapti accompanying laxanas,upashaya anupashaya etc. Here the disesae, which was exhibited with sandhi shotha andsandhishoola specially, are considered for differential diagnosis. 1) Vatarakta 2) Sandhigatavata 3) Krostaka sheersha A Comparative Study of Virechana karma and Basti karma in Amavata 59 W.S.R.T. Rheumatoid Arthritis
  • 72. Amavata 4) Sandhiga sannipata 5) Sandhi aghataVatarakta - Usually manifests with supti, discolouration and shithilatha of sandhi, painis of pricking and splitting nature, sudden onset or disappearance of joint pain.Anguli sandhies are first affected, then it spread to other parts of the body slowlylike akuvisha, all the affected joints are having pain equally, joint swelling is nonfleeting, no morning stiffness.Sandhigata vata – Because of lack of sleshmaka kapha for the friction of joints, it cause painand swelling. Here joint movement is accompanied with pain. This is sthira ie.,non fleeting, the hip and the knee are often affected usually effects middle aged orelderly persons. Symptoms subside by using sneha therapies.Krostaka sheersha – This is the condition, wherein provocated vata and rakta give rise to janusandhi shotha and shoola, no other joints are involved. Shotha resembling thehead of jackal, non-fleeting, severe pain in affected joint pain may increase duringnight.Sandhiga Sannipata – This is a type of sannipata jwara usually manifests due to tridoshakarakahetus, swelling and pain of the joints are non fleeting, non variant pain, usuallyalong with anidrata and severe cough.Sandhi aghata – This is of traumatic origin, pain and swelling will be restricted to theaffected joint. Non-fleeting, subsides after few days. A Comparative Study of Virechana karma and Basti karma in Amavata 60 W.S.R.T. Rheumatoid Arthritis
  • 73. AmavataTypes of Amavata 231 Madhava Nindan while explaining the doshanubandha lakshana he maid 3types where as while expressing about the sadhyasadhayata of Amavata he maid 7types on the basis of involvement of the dosas 232 .By combining the above twopoints Amavata is of seven types on the basis of dosas they are as given below 1. Vata pradhana -- In this mainly predominance of sula will be present. 2. Pitta pradhana – Daha and Raga are present in the joints. 3. Kapha Pradhana – Staimitya, Gourava & kandhu are the main symptom of this variety. 4. Vata pitta paradhana – Combined symptoms of both pitta & vata. 5. Vata kapha pradhana -- Combined symptoms of both vata & kapha. 6. Pitta kapha pradhan -- Combined symptoms of both pitta & kapha. 7. Sannipatika -- Combined symptoms of both all dosas. According to Sharangadhara four types of Amavata are considered 1] Vataja Amavata 2] Pittaja Amavata 3] Kaphaj Amavata 4] Sannipataja Amavata According to the presence of lakshana Amavata is classified in to twotypes first one is Samanya Amavata 233 and second is Pravrudha Amavata234.According to time period of Amavata it is of two types. 1. Naveena Amavata, 2. Jirana Amavata. A unique classification of Harita explained in Harita Samhita based onpresentation of the disease. Those are; 235 a) Vistambhi b) Gulmee c) Snehi d) Pakwama e) Sarvanga A Comparative Study of Virechana karma and Basti karma in Amavata 61 W.S.R.T. Rheumatoid Arthritis
  • 74. Amavataa) Vistambhi - This presents with constipation, feeling of heaviness, in theabdomen, flatulence pain in the basti area.b) Gulmee - Symptoms simulating like gulma, spasmodic pain in abdomen,increased audible peristaltic sounds. c) Snehi - Unctonsness of the body, inactivity, loss of appetite, passing ofunctuous and undigested stools.d) Pakwama - Passing of yellowish, black or dark bluish dehydrated pakwamathrough anus, fatigue, exhaustion, condition is not associated with basti shoola.e) Sarvanga - Pain in kati, prusta and vakshana region, pain in basti, region,audible peristaltic sound, swelling, heaviness in the head, excessive excretion ofama are the symptoms.Upadrava of Amavata The symptoms of advanced stage of Amavata are considered to be asUpadrava of Amavata roga. Vacaspati mentioned symptoms of advanced stage ofAmavata are as upadrava but the commentator of Madhakosa Vijayarakshitadifferentiates the symptoms of advanced stage of Amavata from Upadrava.According to him Khanja, Sankocha, occur in Amavata. But further Vachaspatiincludes the disease expounded within the title of vata vyadhi under Upadrava. Soit is worth to be considering Angavaikalya is an Updarava considered by Harita. Even in Madhava Nidhava the Amavata Updravas are mentioned, they areTrit, Chardi, Bhrama, Moorcha, Hradgraha, Jadya, Antrakoojana, Anaha etc 236. All the Systems will invalue or get disturbed in the Amavata. It is nottreated in time it produce anatomical deformities like sandhi vikruti and HridGraha. So proper management is must from the on set of disease. The upadravadepends upon the type of kapha involved in samprapti. If Ama combins with A Comparative Study of Virechana karma and Basti karma in Amavata 62 W.S.R.T. Rheumatoid Arthritis
  • 75. Amavatashleshka kapha & gets lodged in sandhi sthana creates sandhi vikruti and if Amacombines with Avalambak kapha resides in Hridaya develops Hrid Graha.Upashaya / Anupasaya If the relief occurs by using the Oushandi, Ahara or Vihara are to beconsidered as Upasaya. In the oppsite sence if relief not occurs are counted asAnupasaya 237.Same types of lakshnas will find in different rogas. If we take example ofAmavata lakshanas such as sandhi shotha, sandhi shool etc, are likely to be foundin other diseases like vatarakta, sandhigatavata, kostakasirsa etc. In this type ofconditions when the lakshanas are found similar to that of another disease it isdifficult to diagnose the disease and adopt the treatment. In this difficult conditionUpashaya and Anupashaya have advised. Upashaya for Amavata are Ruksha sweda, langhana Usnakala etc Whereas Anupasayas are snigdha sweda, Santarpana etc.Sadhya Asadhyata 238. Amavata have got Anubandha with single dosa, naveena avasta, lakshanasare in mild form, no presence of Upadrava indication of sadhyata of Amavata. Ifinvolvements of any two dosas produce Vyapyata of the Amavata where asinvolvement of all the three dosas, involvement of all the joints, Purana Amavataincluding with upadravas will become krichra sandhya vyadhi.Chikitsa of Amavata Aim of chikitsa is to cure the disease and bring back dosas normal. Thetreatment for ‘Ama’ condition is Apatrapana or Langhana. Langhana includedboth sodhana and samana. If dosas are alpa langhana is advised. If dosds aremadhyama langhana pachana is indicated. But if dosas are prabhuta sodhana isadvised. A Comparative Study of Virechana karma and Basti karma in Amavata 63 W.S.R.T. Rheumatoid Arthritis
  • 76. Amavata 239 Regarding with Amavata chakaradatta has explained complete Amavatachikitsa in first time. The principles of treatment for Amvata are as follows 1. Langhana 2. Swedana 3. Tikta katu deepena drugs 4. Virechana 5. Snehapana 6. Anuvasana and Kshara abasti 7. Ruksha Upanaha 240 8 Sankara sweda 2411] Langhana Langhana has advised by Charak in Amasayotaja vyadhi, Rasaja vyadhiand in Ama vikara. Langhana is of three types Langhana, Langhanapanchana andDoshavasechana charaka included 10 types in langhana chikitsa which areVamana, Virechana, Niruhabasti.Pipasa, Atapa, Pachana, Upavasa & Vyayama 242Vagbhata classified langhana in to two types Shodhana & Shamana. In the initial stage of Amavata shodhana is not beneficial when the dosasare in Sama stage & spread all over the body their elimination is not possible. Sothe first aim is to mobilize the doshas from shakha to kostha Upavasa type oflanghana helps in bringing the dosas from Shakha to kostha. In Amavata there is a predominanace of vata is their but it is in the form ofsam & this langhana (Upavasa) is indicated in samavata that’s why their will beno any controversy for using langhana in Amavata. Mainly langhana does Dosha pachana and agnisandhukshana by this the‘Ama’ present in the Amavata gets digested & gradually Agni will excited theirafter. A Comparative Study of Virechana karma and Basti karma in Amavata 64 W.S.R.T. Rheumatoid Arthritis
  • 77. Amavata2] Swedana Swedana is the therapy, which relieves the stambha, Gourava, Sheeta &produces Sweda58. The main symptoms of Amavata are stambha, Gourava, Sheeta& Shroto avarodha. Where swedana relives these all cardinal symptoms. Usuallyby seeing the dosha dooshya samoorchana in Amavata ruksha sweda has beenrecommended where as in Nirama conditions snigdha. Due to its heat, causesrelaxation of muscles & tendons & promotes blood circulation, by this localmetabolic process gets activates by this pain gets relief. If there is involvement of few joints the local types of swedana can beadvised. But if the involvement is of multiple joints Sarvanga swedana should beadvised. By the help of swedana digestive capacity will increase softness of thelimbs, smoothness and clearness of the skin, relish for food, clearness of thechannels, absence of somnolence & drowsiness and free movement of jointsabove this dosas which are moistened by snehana gets liquefy and carried down into the kostha 244.3) Deepana (Tikta & Katu dravyas) These drugs mainly having the properties like Agnideepana, Amapachana,245 Avarana dosha Nivarana (Pachana) by these qualities they acts as Srotosodhaka. In Amavasta of Amavata, doshas are sticked strongly to srotasa, so theycannot be removed by snehana and swedana. In such conditions deepana 246upakrama will helps to increase the Agni and does Amapachana leading thedetachment of dosha from the Srotases and removal of Srotoradha. It is wellknown that Deepana, Pachana is an essential process to be performed in Amapredominance disease. A Comparative Study of Virechana karma and Basti karma in Amavata 65 W.S.R.T. Rheumatoid Arthritis
  • 78. Amavata4] Virechana After the administration of Langana, Swedana, Tikta, Katu and Deepanadrugs, the patient should be subjected to Virechana therapy since the doshasrendered nirama by these therapeutic measures require elimination from the bodyby shodhana. Now the question arises why virechana alone should be given andnot vamana too, because usually vamana precedes virechana. If virechana is givenalone the kapha located in the amashaya may produce mandagni and itsconsequences.247 How ever this rule has been relaxed in the case of Udararoga,gulma etc. The same may also be followed in case of amavata because of thefollowing reasons.a) Production of ama is the result of Avarana of pitta sthana by the kledaka kapha and it is the most suited therapy for the sthanika dosha pitta.b) Symptom of amavata like anaha, vibandha, antrakujana, kukshishula etc. are indicative of pratiloma gati of vayu. This is best conquered by virechana, while vamana is likely to aggravate this condition.c) Further more, though virechana has been described to be the best remedy for pitta dosha, yet it is effective in the vitiated kapha and vata dosha also to some extent. So in this way it appears to be the most appropriate therapeutic measures in this condition. The use of eranda taila in amavata suggests that in this disease snigdha and not ruksha virechana should be employed, since it does not produce generalised snehana effect but by its snigdha, ushna etc. characteristics, it augments the agni in addition to its vata anulomana action.5) Snehapana Up to the administration of Virechana we are concentrating on theeradication of Ama. Once Ama digested in the body the other factor which is Vata A Comparative Study of Virechana karma and Basti karma in Amavata 66 W.S.R.T. Rheumatoid Arthritis
  • 79. Amavatabecomes dominant in the body or due to the Apatarpana chikitsa of Ama mayprovoca Vata. For this snehapana is advised in Amavata. More over Snehana ismailnly indicatied in chrinic condtion of Amavata. This Snehapana is used due tothe following benefits which are digestive activity becomes very intense,Alimentary tract become very clean, by this production of Ama will stop in thebody. Even after the Shodhna karma, Shamana sneha have advice to retain theBala of the Patient.6] Basti In amavata both anuvasana as well as Niruha basti have been advocated.Anuvasana basti removes the dryness of the body caused by amahara treatment,alleviates vata dosha, maintains the functions of Agni and nourishes the body.The niruha basti eliminates Doshas brought into kostha by the Langana and alliedtherapies. In addition to generalised effect, basti produces local beneficial effectsalso by removing the anaha, antra kujana, vibandha, etc. Bruhat Saidhavadi Tailahas been mentioned for anuvasana and ksharabasti for asthapana. Depending upon the use of different drugs, vasti causes samshodhana andsamshamana effects. Sushruta has stated that the action of basti is mainly due toveerya. He further elaborates that the drugs used in basti karma will howeverspread in the body from pakwashya due to their veerya. So basti karmaeliminates the morbid doshas and dushyas from the entire body by srotosuddhi.So its effects are tridoshahara. Its effects are not only limited up to rectum and Samsodhana of malas butit produces widespread systemic effect. Basti can produce its effect throughmedicament effect (Pharmacological effect) and effect of volume (Pressureeffect). Thus with the help of suitable medicaments, vasti therapy may modify A Comparative Study of Virechana karma and Basti karma in Amavata 67 W.S.R.T. Rheumatoid Arthritis
  • 80. Amavatathe colonic physiology and alter pathogenic krimis by prakritivighatana, on theother hand certain Basti may enrich the normal bacterial flora of the colon andmay be expected to promote their sustaining role in body. By doing so, itmodulate the rate of endogenous synthesis of vit B12, which may have a role toplay in maintanance and regeneration of nerves.7] Ruksha Upanaha According to Bhavaprakshana in the Amavata for the local benefit ofSandhishoola and Sandhishotha this Ruksha Upanaha has advised.2488] Sankara sweda In Bhisjjya ratnavali Sankara sweda with making Potali ofKarpasasti, Kulattha, Tila, Yava, Erandamoola, Atasi etc are kept in boiling Kanjiand maid Svedana.249 Various Upakramas have been prescribed by different Acharyas for thetreatment of Amavata as follows: Table No-11 V.MSr. Upakrama H.S. C.D. V.S. B.P. B.R. .1 Langhana - + + + + +2 Swedana - + + + + +3 Tikta - + + + + +4 Katu - + + + + +5 Deepana dravyas - + + + + +6 Virechana + + + + + +7 Snehapana - + + + + +8 Basti + + + + + + Anuvasana-Saindhavadi9 - - + - - + Tail10 Kshara Basti - - + - - + Ruksha sweda11 - - + + + - by Balukaputa13 Pachana - - - - - +14 Vamana - - - - - +Yoga Ratnakara has followed Bhava Mishra. A Comparative Study of Virechana karma and Basti karma in Amavata 68 W.S.R.T. Rheumatoid Arthritis
  • 81. AmavataPathya Apathya. “If the person is taking Pathya ahara then what is the necessary of takingmedician, if the person is not taking Pathya than what is the necessary of takingthe medicine” this shows the importance of Pathya in the Management of anydisease. Pathya has important role in the prevention and exacerbation of thedisease process. As per the classics any drug or diet that is katu, tikta by rasa,Ushna and Teekshna in guna and having vatahara, kaphara, amapachana action isconsidered as pathya.The list of Pathya mentioned in texts;1. Dravyas - Punarnava, rasna, patola, karavellaka, vartaka, shigru, gokshura,vriddha daru, ballataka, ardraka (YR), Shyamaka (BP), Varuna, Vastuka (YT)2. Mamsa - Jangala mamsa rasa (Y.R.B.P), Lavaka mamsa with takra (Y.T)3. Aharadravya - Puranashali, Yava, Purana Shastikashali, Kulattha4. Anya - Eranda Taila, Usnodaka, procedures like Rukshasweda, Langhana,Snehapana, Basti, Lepa, Virechana are considered as pathya. The pathyas ofjwara also considered as pathyas of amavata (HS) The drugs or diets having guru, picchili, abhishyandhi gunas and whichcauses provocation of vata, kapha and formation of ama are considered asApathya All nidanas of amavata are considered as apathya - Masha, Anupamamsa,Dadhi, Guda, Ksheera, Mathsya, Upodhika, Shimbhi dhanyam, Sheetajalasnana,Abhyanga considered as apathyas for the disease process. A Comparative Study of Virechana karma and Basti karma in Amavata 69 W.S.R.T. Rheumatoid Arthritis
  • 82. Rheumatoid ArthritisRheumatoid arthritis In Rheumatoid arthritis the onset in majority of the patients is insidiouswith joint pain, stiffness & symmetrical swelling of membrane of peripheraljoints. As the disease progresses there is a tendency for it to spread to involve thewrists, elbows, knees & other joints. The mandibular, acromioclavicular &sternoclavicular joints are sometimes affected as indeed in every symovial joint. The history of arthritis is as old as mankind, as the ape-man himself hadarthritis of the spines. Detailed study of this age old, complicated cripplingclinical entity confirms its close association with other branches of medicine suchas neurology, cardiology, endocrinology, bacteriology, geriatrics, pediatrics andorthopedics. Rheumatoid arthritis is a chronic disease of the joints, usuallypolyarticular, marked by inflammatory changes in the synovial membranes &articular structures. Hence the knowledge of anatomy & pathophysiology of thejoints is very important, as the synovial joint is involved in Rheumatoid arthritisthis is being elaborated hereEpidomology Scientists estimate that about 2.9 million people have rheumatoid arthritisRA occurs in all races & ethnic groups. Although the diseases often begin inmiddle age and occur with increased frequency in older people, children & youngadult’s also develop it. Like some other forms of arthritis, RA occurs much morefrequently in women than in men about 2-3 times as many women as men havethe disease. Server RA is found at four times the expected rate in the first-degreerelatives of probands with zero +ves disease. A Comparative Study of Virechana karma and Basti karma in Amavata 70 W.S.R.T. Rheumatoid Arthritis
  • 83. Rheumatoid ArthritisEtiology of Rheumatoid Arthritis: 250 to 255 The disease Amavata is best compared with Rheumatoid arthritis in themodern parlance.9 Rheumatoid arthritis (RA) is a chronic multisystem disease ofunknown cause. It has been suggested that RA might be a manifestation of theresponse to an infectious agent in a genetically susceptible host. Because of theworldwide distribution of RA, it has been hypothesized that if an infectious agentis involved, the organism must be ubiquitous. A number of possible causativeagents have been suggested, including Mycoplasma, Epstein-Barr virus (EBV),cytomegalovirus, parvovirus, and rubella virus, but convincing evidence that theseor other infectious agents cause RA has not emerged. The process by which aninfectious agent might cause chronic inflammatory arthritis with a characteristicdistribution also remains a matter of controversy. Recent work has focused on thepossible role of "superantigens" produced by a number of microorganisms,including staphylococci, streptococci and M. arthritidis. Super antigens areproteins with the capacity to bind to HLA-DR molecules and particular Vbsegments of the heterodimeric T cell receptor and stimulate specific T cellsexpressing the Vb gene products. The role of super antigens in the etiology of RAremains speculative. Of all the potential environmental triggers, the only oneclearly associated with the development of RA is cigarette smoking. Sero positive RA aggregates in families Genetic factors versus theirinteraction with environmental facilitators is unclear HLA DR4 is found in 70%of causascian sero positive patients compared to 25% of controls. Increasedrelative risk of 4-5 times for the DR4 positive persons; although a minority areaffected African Americans tend not to exhibit this predilection.11 A Comparative Study of Virechana karma and Basti karma in Amavata 71 W.S.R.T. Rheumatoid Arthritis
  • 84. Rheumatoid ArthritisAnatomy of joints:Synovial joints: Articulations of the synovial type utilize on entirely different principlefrom the non-synovial fibrous and cartilaginous joints. Although the bonesinvolved are linked together by a fibrous capsule & frequently by accessoryligaments inside or outside of this, the major parts of the articular surfacesconcerned are in contact but not continuity. They are covered by a relatively thinstratum of hyaline cartilage (occasionally of fibro cartilage) and the actual contactis between these cartilaginous surfaces which are characterized by a very low co-efficient of friction (0.002 or less).Synovial joints has the following components:1. A joint capsule that isolates the joint from surrounding tissue.2. A joint cavity formed by the surrounding joint capsule.3. A synovial membrane (synoviam) that is the inner lining of the joint capsule.4. Synovial fluid that is secreted by the synovium & serves as the lubricant & carries nutrients for the joint.5. Bones that come together to form the joint.6. Hyaline (Articular) cartilage covers & protects the ends of the bones that participate in the joint. There may be other structures present in or near the joint such as disks, cartilage (menisci) tendons, ligaments burscea important characteristics of these structures include. A Comparative Study of Virechana karma and Basti karma in Amavata 72 W.S.R.T. Rheumatoid Arthritis
  • 85. Rheumatoid Arthritis The joint capsule is composed of two layers, an outer fibrous layer & innersynovium (identified above) the outer layer has many joint receptors innervatingit but is not vascularized. Opposite to it synovium is well vascularized but poorlyinnervated. The articualr cartilage has two important functions including theability to minimize friction & wear between to opposing joint surfaces duringmovement & to dissipute forces on the joint over a wider area. Thus decreasingstress on the contacting joint surfaces. Synovial fluid contains hyaluronate (hyaluranic acid) and a glycoprotiencalled lubricin. Both are responsible for the lubrication of joint, although they arespecific for certain components. Hyaluronic acid is important for the lubricationof the joint capsule while lubricin is necessary for cartilage on cartilagelubrication. Synovial fluid is also medium by which mutrients are carried to andwastes are carried from through the avascular components of the joint. The ends of the long bones that form the synovial joints are composed ofsoft spongy type of bone called subchondral bone. Hyaline (articular) cartilagecovers this bone & protects it except for the very ends of the bone, long bones areusually very strong.Effects of the disease: Rheumatoid arthritis can attack any synovial joint in the body. Except thedistal interphalageal joints, it has the greatest affinity for the small joints of hand,wrist, & foot. In many cases the joint involvement in the limbs becomes relativelysymmetrical. Further, the cervical spine, usually the superior aspect becomesaffected & patients must be watched carefully for disruption of the atlanto axial A Comparative Study of Virechana karma and Basti karma in Amavata 73 W.S.R.T. Rheumatoid Arthritis
  • 86. Rheumatoid Arthritisjoint in advanced cases of the disease, subluxation at the atlantoaxial joint canoccur. Early in the course of the disease several changes in joint structures occur.Joint effusion & inflammation of the synovium occur producing a soft tissueswelling that is easily detected during evaluation of the patient. Additionally,changes in the ends of the bones forming the joints may be present early in thedisease process. The earlier changes are welling and congestion of the synovial membraneand overlying connective tissue which becomes infiltrated with lymphocytes,plasma cells & macrophages. Effusion of the synovial tissue takes place duringthe active phase of the disease. Subsequ4ently hypertrophy of the synovialmembrane occurs. Inflammatory granulation tissue or pannus is formed spreadingover & under the articular cartilage, which progressively destroyed. Later fibrousadhesious may form between the layers of pannus across the joint space & fibrousor even bony ancylosis may seen. The synovial fluid secreted by the synovium isthought to save two main purposes, lubrication of the joint & provision ofnutrients to the avascular articular cartilage. In this disease process, an interactionbetween antibodies & antigen’s occurs, and causes alterations in the compositionof the synovial fluid. Ultimately, digestants are formed in the fluid, which attacksthe surrounding tissue. Once the composition of this fluid is altered, it is less ableto perform the normal functions noted above and more likely to becomedestructive. The muscles adjacent to inflame its atrophy and there may be focalinfiltration with lymphocytes. A Comparative Study of Virechana karma and Basti karma in Amavata 74 W.S.R.T. Rheumatoid Arthritis
  • 87. Rheumatoid Arthritis The changes in the synovium & synovial fluid briefly described above, areresponsible for a large amount of joint & soft tissue destruction the destruction ofbone eventually leads to laxity in tendons & ligaments under the strain of dailyactivities and other forces, these alterations in bone & joint structure result in thedeformities frequently seen in patients with Rheumatoid arthritis considerabledestruction of the joint can occur with pannus invading the subchondral bone. Bone destruction occurs at areas where the hyaline cartilage & thesynovial lining do not adequately cover the bone. If the disease progress to a moreadvanced stage, the articular cartilage may lose its structure & density resulting inan inability to withstand the normal forces placed on the joint. In these advancedcases, muscle activity causes the involved ended of the bones to be compressedtogether causing further bone destruction. Further the disease can irreversiblychange the structure & function of a joint to the degree that other degenerativechanges may occur. Especially in the weight bearing joints of the body, this joint destructioncan progress to the degree that joint motion is significantly limited & joints canbecome markedly unstable.Pathogenesis of Rheumatoid Arthritis: 256 to 260 In contemporary medical science, Amavata can be best correlated toRheumatoid Arthritis (Y.N.Upadhyaya). It is described as an autoimmunedisorder. The propagation of Rheumatoid Arthritis is an immunologicallymediated event, although the original initiating stimulus has not been clear. Oneview is that the inflammatory process in the tissue is driven by T4 helper cellsinfiltrating the synovium. Evidence for this includes, • The predominance of T4 cells in the synovium A Comparative Study of Virechana karma and Basti karma in Amavata 75 W.S.R.T. Rheumatoid Arthritis
  • 88. Rheumatoid Arthritis • The local production of lymphokines by these infiltrating T cells • Amelioration of the disease by removal of T cells by thoracic duct drainage or suppression of their function by total lymphoid irradiation. Since T lymphocytes produce a variety of cytokines that promote B cellproliferation and differentiation into antibody forming cells. T cell activation mayalso produce local B cell stimulation. The resultant production of immunoglobulinis rheumatoid factor that can lead to immune complex formation. Withconsequent compliment activation there will be exacerbation of inflammatoryprocess by the production of anaphylatoxins and haemostatic factors. This tissueinflammation is reminiscent of delayed type of hypersensitivity reaction occurringin response to soluble antigens or microorganisms. It is how ever unclear thatwhether this represents a response to persistent exogenous antigens or to alteredauto antigen such as collagen or immunoglobulins.20Flow chart-2Pathogenesis of Rheumatoid arthritis Lucalization of antigen in Joints Processing by antigen presenting cells Interaction with T call receptor Release of immunopotentiating cytokines Endothelia call activation Expression of adhesion molecules Homing of T – lymphocytes A Comparative Study of Virechana karma and Basti karma in Amavata 76 W.S.R.T. Rheumatoid Arthritis
  • 89. Rheumatoid Arthritis IL – 2 production & T cell proliferation Production of T cell cytokines β - Lymphocyte proliferation Local synttesis of antiglolovlin antibodies Formation of immure complexes Activation of complement pathway Neutrophil chemotaxis & cytolysis Lymphokine production Macrophage activation. Release of monokines & other mocyte medictor Immune complex phagocytosis by neutrophills & Monocytes.Release of mediators of acute inflamation (Vasoactive amines proteases,Lenkotrienes, Oxygen radicals, prostaglandins, polypeptides). Activation of macrophages & chondrocytes. Pannus formation Enzymatic destruction of cartilage bone Acute phase, fever muscle wasting A Comparative Study of Virechana karma and Basti karma in Amavata 77 W.S.R.T. Rheumatoid Arthritis
  • 90. Rheumatoid ArthritisProdromal symptoms 261,262 Morning stiffness, generalized weakness, mascolo skeletal pain, fatigue,anorexia, weight loss etc.Clinical Features:1. Artichlar 263,264 In the majority of patients the onset is insidious with joint pain. Stiffness& symmetrical swelling of a number of peripheral joints. Initially the pain may beexperienced only on movement of joints, but rest pain especially early stiffness ischaracteristic features. In typical case the small joints of the fingers & toes are the first to beaffected. Swelling of the proximal but not distal, interphalaugeal joints given thefiugers a spindled appearance & swelling of metatassophalargeal joints results inbroadening of the forefoot. Fever, weight loss profound fatigue, anorexia &malaise with out joint symptoms occur less often. It’s the disease advances there is a tendency for it to spread to involve.Wrists, elbows, shoulders, knees, ankles, subtarsal midtarsal joints. Theadvancement of pathogenesis is bad to muscle atrophy, tendon sheath & jointdestruction results in limitation of joint motion, joint instability with anteriorsubluxation of MTP joints in common with ulnar deviation of the fingers inaddition to this lymphadenopwthy, osteoporosis muscle weakness & wasting,tenosynovitis, bursitis, popliteal cysts, sometimes subcutaneous nodules areformed. Apart from this scleromalacia, Keratoconjantivitis, scleritis are bound tooccur. Asymptomatrl periconditis, Pl. effusion may occur infrequently. Some ofthe characteristic features of Rheumatoid arthritis are: A Comparative Study of Virechana karma and Basti karma in Amavata 78 W.S.R.T. Rheumatoid Arthritis
  • 91. Rheumatoid Arthritisa Hands – spindling of proximal interphalangeal joints & swelling of metacaspopalangeal joints dorsnm of wrist. Weakness of grip or triggering of fiugers. Swan – neck and boutonniere fingers. Z – Deformity of the thumbs. Ulnar deviation of fingers & drop fingers from rupture of extensor tendons.b Feet – Dorsal subluxation of toes with overriding & callosities may develop.c Knee joint – Synovial effusion occurs early followed by fixed flexion, orvarus or valgus deformities. Synovial rupture may lead to release of fluid into popliteal space calf. Attesnatively effusion may distend popliteal bursa to produce a bakes’s cyst, synovitis of bursae may occur at other sites.d Cervical spine – Subluxation of cervical bodies or altantoaxial joint.E Crycocastynoid joints – May occasionally be affected causing dysphasia, hoarseness or stridor.Table No-12 Extra articular features 265,266Systemic VasculitisFever, Weight loss, Fatigue, Susceptibility to Digital arteritis, Unloss Pyodermainfection ganzdemosm,Mononearitis, multiple Visural artiritis.Muscaloskeletal CwrdiaeMuscle wasting, Tenosynovitis, Bursitis, Pericarditis,Myocorditis,Osteoporosis Endocarditis, Conduction defects CoronoryVasculations, Granulomatis arthritis.Haematological PulmonoryAnamia, Thrombouptosis, Eosimophelia Nodules, Pl. Effusions, Fibrosing alveolitis, Bronehiolitis, Eapalan’Nodules syndromeSinuses, Fistulae NeurologicalOccular Cenicalchord, Compression,Episcleritis, Scleritis, Scbromaleria, Sicca Newropathiessyndrome Skin Pulmar erythema, Psoariasis A Comparative Study of Virechana karma and Basti karma in Amavata 79 W.S.R.T. Rheumatoid Arthritis
  • 92. Rheumatoid ArthritisInfection: Increased frequency in Rheumatoid arthritis1] Antimelear antibodies in 50%. 2] Elevated CRP, alkaline phospate platelets.Differential diagnosis: Rheumatoid Arthritis differentiated from other diseases having similarfeatures like Joint Pain on the basis of presenting Signs and Symptoms &biochemical investigations. These diseases are as follows:1. Gout : In pathological investigation high serum uric acid level is present. Response to administration of Colchicine is found in this condition.2. Osteoarthiritis :- Radiological appearance differs, absence of subcutaneous nodules and R.A. factor. In typical case, Heberdon’s nodes appear in relationship to DIP joints and ESR usually with in normal limits.3. Polymyalgia Rheumatica :- In this condition ESR is very high and peripheral joint signs are minimal. (Onset of Rheumatoid Arthritis in elderly mimic Polymyalgia Rheumatica)4. Polyarthritis Nodosa :- May resemble Rheumatoid Arthritis, but radiological changes areminimal. Severe systemic symptoms and necrotising vasculitis at early stage ofpolyarthritis may be present, but joint erosions and typical Rheumatoid Arthritisdeformity are rare in later stage.5. Systemic Lupus Erythematosis :- It is characterized by the presence of numerous autoantibodies, circulating immune complexes and widespread immunologically determined A Comparative Study of Virechana karma and Basti karma in Amavata 80 W.S.R.T. Rheumatoid Arthritis
  • 93. Rheumatoid Arthritis tissue damage. Chronic inflammatory arthritis and tenosynovitis may lead to deformities and contractures, but erosive changes are very uncommon.6. Rheumatic Fever: - First, attacks are usually under 15 years of age in 70% of case. It is characterized by flitting type of joint pain and sustained fever. Spindling of finger joint is rare. Myocarditis, endocarditis and nodules on the different histological picture are present. Some other diseases are as follows from which we have to differentiatethe disease Rheumatoid Arthritis. • Acute Suppurative Arthritis • Tuberculous Arthritis • Reiters Syndrome • Hypertrophic Osteoarthropathy • Chronic Arthropathy • Sarcoid Arthritis • Scleroderma • Arthritis with Erythema Nodosum • Spondylitis • Psoriatic ArthritisSymptoms of R.A which may require differential diagnosis are – Table No-13Symptoms Possibilities to be consideredAcute or severe pain in one or a few Joint sepsis – fever may be absentjoints Fracture – even without obvious traumaUnexplained weakness Cervical spine involvement producing cord compressionUnilateral calf swelling Ruptured Baker’s cyst – this is frequently misdiagnosed as a deep venous thrombosisPainful red eye Scleritis-requires expert opthalmological assessment A Comparative Study of Virechana karma and Basti karma in Amavata 81 W.S.R.T. Rheumatoid Arthritis
  • 94. Rheumatoid ArthritisComplication of Rheumatoid Arthritis: • Septic Arthritis • Amyloidosis – The synovium is infiltrated with amyloid protein. • Systemic Vasculitis • Spinal Cord Compression • Felty’s syndrome – Splenomegaly with neutropenia leads to repeated infections and weight loss known as felty’s syndrome.Prognosis: 267,268 The course and prognosis in R.A. is very difficult to predict because ofits variability. 25% of the severe patients may have complete remission ofsymptoms and fit for all normal activities. 40% of the cases suffer with moderatetype of functional impairment despite exaggeration and remission. 25% may bemore severely disabled and 10% may be severely crippled almost limited to bed. Prognosis may be very poor in many cases as follows: 1. High titre of rheumatoid factor 2. Insidious onset of the disease 3. More than one year with active phase without any remission 4. Early development of nodules and erosions 5. Extra-articular manifestation 6. Several functional impairment The median life expectancy of persons suffering with rheumatoidarthritis is shortened by three to seven years. Factors co-related with early deathinclude disability, disease duration or severity, glucocorticoid use and age ofonset of disease. A Comparative Study of Virechana karma and Basti karma in Amavata 82 W.S.R.T. Rheumatoid Arthritis
  • 95. Rheumatoid ArthritisLaboratory findings269Haematology: Normochromic or hypochromic anemia, which usually occurs in about22% of females & 11% of males in adult type. The anemia is more marked inchildren & occurs in about 60% of patients. The anemia is due to chromicinflamation.Erythrocite sedemntation rate :During active phase the ESR is raised in about 85-95% of cases.ScrologicalRF: +ve in 50 – 60 % of cases.CRP: +ve in acute phase of the disease.Radiological : Intially only soft tissue swelling of joints may be seen, but withprogressive periarticular osteoporosis, narrowing of joint spaces with marginalerosions & cup & pencil deformities massive bone resorptions develop marginalsclerosis & osteophyte formation indicate secondary osteo – arthritis.Diagnosis :- Clinical picture CRP positive- Elevated ESR Positive Rh factors A Comparative Study of Virechana karma and Basti karma in Amavata 83 W.S.R.T. Rheumatoid Arthritis
  • 96. Rheumatoid ArthritisManagement1. Relief of symptoms2. Suppression of active & progressive disease.3. Conservation & restoration of function in affected joints. These are achieved by1. Treatment of the patient’s drug, rest, physiotherapy, surgery.2. Modification of environment – aids, appliances, housing, occupation, statutory social benefits.General treatment Physical rest, anti inflammatory drug therapy & maintenance exercises isthe corner stones of treatment for exacerbation of Rheumatoid arthritis. The restfrom physical & emotional stress provided by 2 – 3 wks in hospital is usuallysufficient to induce a marked remission of symptoms with out recourse to strictbedrest. In few patients a period of complete bed rest may be required to induce aremission. Rest splints can be used to support a particular painful joint to correctflexion deformities.Medications: Most people who have Rheumatoid arthritis take medications.Some medications are used only for pain relief; others are used to reduceinflammation. Some medications are disease modifying antirhematic drugsDMARDs are used to try to slow the course of the disease. A Comparative Study of Virechana karma and Basti karma in Amavata 84 W.S.R.T. Rheumatoid Arthritis
  • 97. Rheumatoid Arthritis In articular corticosteroidal injections are given to bring symptomaticrelief. Non-steroidal anti – inflammatory drug therapy is beneficial initial stages,which has low incidence of side effects. Chloroquine phosphate or hydroxy chloroquine sulphate, the antimalierialsare used us the initial adjunct to basic therapy. Auranofin an oral gold compound, pencillamine parentral gold are alsoused, prednisolone a corticosteroid is also used in the treatment.Immunomodulators are also used.Surgical treatment. The primary purpose of these procedures is to reduce pain, improve theaffected joints function, and improve the patient’s ability to perform dailyactivities. Surgical decompression & synovectomy are needed when corticosteroidsand physical measures have failed to relieve movement of limbs. A Comparative Study of Virechana karma and Basti karma in Amavata 85 W.S.R.T. Rheumatoid Arthritis
  • 98. Drug ReviewDrug Review As mentioned earlier, a specific line of treatment aiming at sampraptivighatana is dealt in our classics. It involves deepana, pachana, shodhana andshamana depending on the strength of dosha and dushya etc. Accordingly in thepresent study vaishwanara churna, eranda taila, bruhat saindhavadi taila Anuvasanabasti, Erandamoladi niruha basti . These are discussed in detail in the following pages.Vaishwanara Churna 270 Vaishwanara choorna is best deepana pachana drug and has properties liketeekshna, ushna, ruchya etc. It is specially indicated in amavata chikitsa along withadhmana, gulma, parinama shoola and hrdroga. It overcomes mandagni, shula, shothaand ama symptoms. The ingredients of vaishwanara choonra are manimantha, yavani, ajamoda,nagara and haritaki. The properties of individual drugs are tabulated in table no.8which is given in the following pages.Eranda Taila 271,272,273,274 As mentioned in chikitsa aspects, sneha virechana is indicated in amavata.Eranda taila is considered to be the best among the snehas for virechana. Eranda tailapossesses ushna, guru, sara, teekshna, sukshama, picchila and visra gunas. By rasas itis katu, kashaya, madhura and tikta and is having madhura vipaka. The actions oferanda tala are found to be srotovishodhana, lekhana, deepana, balya and rasayana.It has got vatashleshamhara effect and effective in conditions like janga, kati,urushoola, anaha and vibandha. The castor oil cheifly consists of ricinoleate of glycerol or tririninolin with asmall quantity of plantin and stearin. The glycerides of ricinoleic acid C17H32OHCOOH are mainly responsible for the purgative effect. A Comparative Study of Virechana karma and Basti karma in Amavata 86 W.S.R.T. Rheumatoid Arthritis
  • 99. Drug ReviewActivity Oil is a non irritant purgative, when it reaches the duodenum it is decomposedby the pancreatic juice into ricinoleic acid, which irritates the bowels, stimulates theintestinal glands and the muscular coat and cause purgation ie., when given by mouthoil is saponified and free acid is liberated which procues the effect. It acts in 4 to 5hours causing liquid stools without pain and gripping and has a sedative effect on theintestine. Ricinoleic acid is absorbed into the blood and tissues. Ricinin is a voilentirritant of the intestine. In short, castor oil is one of the cheapest, simplest and most important usefulpurgative of the pharamacopiea in all delicate conditions of children and aged people.Brihat Saindhavadi Taila 275 This taila is considered as an ideal remedy for amavata in the form of basti,abhyanga and pana. It also gives strength to agni and indicated in major sandhishoola conditions.Contents Saindhava, gajapippali, rasna, shatapushpa, yamanika, sarjika, maricha, kusta,shunti, sauvarchala, vida, vacha, ajamoda, yastimadhu, jeeraka, puskaramula, pippali,each should be 1/2 pala, eranda taila, 1 prastha, shatapuspa kashaya 1 prastha, kanjikaand mastu 2 prasthas each. The properties of individual drugs are tabulated followingpage.Erandamula niruha basti 276 Ingredients are Erandamula, Palasha, Laghupanchamula, Rasna, Ashwagandha,Atibala, Guduchi, Punarnava, Aragvadha, Devadaru, Madanaphala, Shatahwa,Hreebera, Priyangu, Pippali, Yashti, Saindhava, Madhu and taila [sneha]Erandamuladi niruha basti is Vatashamaka. A Comparative Study of Virechana karma and Basti karma in Amavata 87 W.S.R.T. Rheumatoid Arthritis
  • 100. Table No. 14 Showing the Composition and Properties of Vaishwanara Churna Sl. Drug Latin Name Rasa Guna Veerya Vipaka Doshagnat Karmukata Prayojyanga No. a 1 Manimantha Sodium chloride Lavana Snigdha Sheeta Lavana Tridosha Deepana, pachana, Lavana Teekshna vatanulomana Laghu Sukshma 2 Yavani Tachyspermuma Katu tikta Laghu Ushna Katu Kaphavata Rochana, deepana, Phala mmi Ruksha Shamaka vatanulomana, Teekshna shoolapra shamana 3 Ajamoda Carum Katu Laghu Ushna Katu Kaphavata Vidahi, deepana, Phala roxburghianum tikta Ruksha shamaka vatanulomana, Teekshna shoola prashamana, kaphagna 4 Nagara Zingiber Katu Laghu Ushna Madhura Kaphavata Tripthigna, Kanda officinale Snigdha shamaka rochana, deepana, pachana, vatanulomana, shothahara 5 Haritaki Terminalia Kashaya Laghu Ushna Madhura Tridosha Shothahara, Phala chebula Pradhana Ruksha vedana, sthapana, Pancha anulomana, rasa mrudurechana, deepana, pachana 88
  • 101. Table No-15 Showing the Properties of Drugs of Brihat Saindhavadi TailaSl.No. Drug Latin Name Rasa Guna Veerya Vipaka Doshagnata Karmukata Prayojyanga01 Saindhava Sodium chloride Lavana Snigdha Sheeta Lavana Deepana Deepana, Lavana Teekshna Pachana pachana, Laghu Vatanulomana vatanulomana Sukshma Tridoshahara02 Sreyasi Piper retrofractum Katu Laghu Ushna Madhura Kaphavata Rochana, Phala Ruksha Shamaka deepana, vatanulomana,03 Shatapuopa Anethum sowa Katu Laghu Ushna Katu Kaphavata Rochana, Phala Tikta Ruksha shamaka Deepana, Teekshna pachana, anulomana, shothahara04 Rasna Vanda roxburghii Katu Guru Ushna Katu Kaphavata Vedanasthapana Moola shamaka Amapachana Rasayana05 Vavanika Trachyspermum Katu Laghu Ushna Katu Kaphavata Rochana, deepana Phala amni Tikta Ruksha shamata vatanulomana Teeksha06 Sarija Sodium carbonate Kshara Laghu, Ushna Katu Kaphahara Deepana, Kshara snigdha pachana, Sukshma mootrala, Soumya shulahara07 Maricha Piper nigrum Katu Laghu Ushna Katu Vata kapha Deepana pachana Phala Teekshna shamaka vatanulomana pramathi 89
  • 102. 08 Kusta Saussurea lappa Tikta Laghu Ushna Katu Kapha vata Deepana, Moola Katu Ruksha shamaka pachana, Madhura Teekshna anulomana09 Shunti Zinghibu Katu Laghu Ushna Madhura Kapha vata Truptigna, Kanda officinale Snigdha shamaka rochana, deepana, pachana, vatanulomana shothahara amapachana10 Suvacchala Nacl Lavana Vishada Ushna Lavana Vata nashaka Rochaka bhedaka Lavana Laghu deepana pachana Sukshma vibandhahara11 Vida ---- Lavana Laghu Ushna Lavana Vata kapahara Deepana Lavana Teekshna vaanulomana Ushna ruchikala Ruksha shulahara Vyayayi12 Vacha Acorus calaus Katu Laghu Ushna Katu Kaphavata Medhya, vedana, Moola Tikta Teekshna sthapana, deepana, triptigna13 Ajamoda Carum roxbur Katu Laghu Ushna Katu Kaphavata Deepana, Phala giahum Tikta Sukshma shamaka vatanulomana, Teekshna shulaprashamana14 Madhuka Glycerrhiza Madhura Guru Sheeta Madhura Vatapitta Rasayana, balya Moola glabra Snigdha shamaka medhya, vatanulomana sandhaveerya 90
  • 103. 15 Jeeraka Cyminum Katu Laghu Ushna Katu Kapha vata Deepana, pachana Phala cuminum Ruksha shamaka vatanulomana shulaprashamana16 Puskaramul Inula raumosa Tikta Laghu Ushna Katu Kaphavata Deepana pachana Moola a Katu Teekshna shamaka vatanulomana shotharaha17 Kaha Piper longum Katu Laghu Anusha Madhura Kaphavata Deepana Phala Snigdha Sheeta shamaka truptigna Teekshna vatanulomana rasayana balyaTable No-16 Erandamooladi Vasti Dravyas Sl. Drug Latin Name Rasa Guna Veerya Vipaka Doshagnata Karmukata No.01 Erandamoola Ricinus communis Snigdha,Teekshna Madhura Madhura Ushna Kaphavata Shotahara Soukshma shamaka vayasthapana ballya02 Palasha Butea Laghu Ruksha Katu Tikta Katu Ushna Kaphavata Deepana Grahi monosperma Kashaya shamaka Anulomana03 Rasna Pluchea lancioleta Guru Tikta Katu Ushna Kaphavata Deepana shamaka Rechana Anulomana04 Bala Sida cardifolia Laghu Snigdha Madhura Madhura Seeta Vatapitta Vatanulomana Picchila shamaka Rasoyana05 Guduchi Tinospora Guru Snigdha Tikta Madhura Ushna Tridoshahara Deepana Ballya cardifolia Kashaya Rasayana06 Ashwaganda Withenia Laghu Snigdha Katu Tikta Madhara Ushna Kaphavata Sothahara somnifera Madhara shamaka Vedanasthapana 91
  • 104. 07 Punarnava Boerhavia diffusa Laghu Ruksha Madhura Madhara Ushna Tridoshahara Lekhana Tikta Sothahar Kashaya08 Aragvadha Cassia fistula Guru Mrudu Madhara Madhara Seeta Vatapitta Rechana Snigdha shamaka09 Devadaru Cedrus deodara Laghu Snigdha Tikta Katu Ushna Kaphavata Sothahara shamaka Vedanasthapana10 Madana phala Randia spinosa Laghu Ruksha Kashaya Katu Ushna Kaphavata Vedanasthapana Madhura Pabhava shamaka Sothahara Katu Tikta Vamana11 Shala parni Disodium Guru Snigdha Madhura Madhura Ushna Tridoshahara Sothahara Gangiticum Tikta12 Prasnaparni Ureria picta Laghu Snigdha Madhura Madhura Ushna Tridoshahara Sothahara Tikta13 Gokshura Tribulas terestris Guru Snigdha Madhura Madhura Seeta Vatapitta Sothahara shamaka Vedanasthapana14 Kantakari Solanamsurattense Laghu Ruksha Katu Tikta Katu Ushna Kaphavata Sothahara Teekshna shamaka15 Bruhati Solanum indicum Laghu Ruksha Katu Tikta Katu Ushna Kaphavata Sothahara Teekshna shamaka16 Vacha Acorus calamus Laghu Ruksha Katu Tikta Katu Ushna Kaphavata Sothahara Teekshna shamaka17 Hapusha Juniperus Laghu Ruksha Katu Tikta Katu Ushna Kaphavata Vedanasthapana cmmunis Teekshna shamaka18 Shatavha Anithum sowa Laghu Ruksha Katu Tikta Katu Ushna Kaphavata Vedanasthapana Teekshna shamaka Sothahara19 Priyangu Callicarpa Guru Ruksha Kashaya Katu Seeta Vatapitta Vedanasthapana Macrophylla Madhura shamaka Sothahara Tikta 92
  • 105. 20 Yastimadhu Glycyrrhiza Guru Snigdha Madhura Madhura Seeta Vatapitta Vedanasthapana glebra shamaka21 Kana Pipper longama Laghu Snigdha Katu Madhura Anushna Kaphavata Deepaka Teekshna seta shamaka Turptighna22 Vatsaka beeja Holirina Laghu Ruksha Kashaya Katu Seeta Kaphapitta Sothahara antidysentrika Tikta shamaka23 Musta Cyprus roturdus Laghu Ruksha Kashaya Katu Seeta Kaphapitta Deepana Tikta Katu shamaka Pachaka24 Taksharyashaila Laghu Ruksha Tikta Katu Katu Ushna Kaphavata Vedanasthapana shamaka Sothahara25 Saindhava Sodium chloride Laghu Snigdha Swadu Madhura Seeta Tridoshahara Deepana lavana Pachaka Ruchya26 Makshika Laghu Ruksha Madhura Seeta Tridoshahara Lekhana Balya Deepana27 Tail Guru Madhura Madhura Ushna Kaphavata Brhana shamaka Lekhana28 Gomootra Cows urine Laghu Ruksha Kashaya Katu Ushna Kaphavata Vedanasthapana Tikta Katu shamaka Sothahara Rechaka 93
  • 106. Material and MethodsMaterials and methods The materials taken for the study are 1) Vaishwanara churna 2) Eranda taila 3) Bruhat saindhavadi taila 4) Erandamooladi Niruha basti 5) PaciboCapsules1) Vaishwanara Churna The ingredients of the churna were manimantha, yavani, ajamoda, nagara andharitaki are identified correctly and churna prepared with the help of Rasashastradepartment.2) Eranda Taila Plain eranda taila was purchased and moorchana was done using drugsharidra, triphla, musta, hrivera, lodhra, vatanukara according to classical method at DG M A M C Pharmacy and then used for Nittyavirechana purpose.3) Brihat Saindhavadi Taila For anuvasana basti Brihat Saindhavadi Taila ingridients are identified, thoseare saindhava, gaja pippali, rasna, shatapuspa, yamanika, sarjika, maricha, kostha,shunti, souvarchala, vida, vacha, ajamoda, yasti madh, jeeraka, pushkaramula, pippali,eranda taila, shatapuspa kashaya, kanjika and mastu. According to the priparetion ofSneha Brihat Saindhavadi Taila was maid in D G M A M C Pharmacy and then usedfor Anuvasana basti 4) Erandamooladi Niruha basti All Ingredients of Erandamooladi Niruha basti were identified ( Erandamula,Palasha, Laghupanchamula, Rasna, Ashwagandha, Atibala, Guduchi, Punarnava, A Comparative Study of Virechana karma and Basti karma in Amavata 94 W.S.R.T. Rheumatoid Arthritis
  • 107. Material and MethodsAragvadha, Devadaru, Madanaphala, Shatahwa, Hreebera, Priyangu, Pippali, Yashti,Saindhava, Madhu and taila ) and are used to prepare just before administration ofNiruha basti according to the preparation of Niruha basti dravya. 5) PaciboCapsules Capsules were prepared by filling starch powder.Diagnosis The diagnosis will be made on the basis of classical signs and symptomsmentioned in the Ayurveda and modern texts and criteria laid down by AmericanRheumatism Association (1988) following features are employed for confirmation ofRA.1) Morning stiffness (> = 1hr)2) Swelling of three or more joints3) Swelling of hand joints (PIP, MP)4) Symmetrical swelling5) Subcutaneous nodules (Rheumatoid nodules)6) Presence of serum rheumatoid factor7) Radiological changes (Hands & wrist) Criteria 1 to 4 must have been continuous for 6 weeks or longer must beobserved by physician. A diagnosis of RA requires that, four of the above sevencriteria should be present.Research Design After the diagnosis, as on the above parameters, the selected patients were assigned for the Comparative clinical trial as follows. A Comparative Study of Virechana karma and Basti karma in Amavata 95 W.S.R.T. Rheumatoid Arthritis
  • 108. Material and MethodsSource of data: Patients suffering from Amavata have selected from P.G.S & R.C. O.P.D. of shree D.G.M. A.M.C. and Hospital Gadag.Sample size & grouping: A minimum sample of 30 patients with Amavata diseases have equallydistributed in two groups. Group A – 15 patients have received Virechana Group B- 15 patients have received Yogabasti.Selection criteria Patients were selected strictly as per present inclusive and exclusive criteria a) Inclusive criteria: 1. Classical signs and symptoms will be considered for the selection of patients. 2. Patients of Amavata having the history of less than 5 years. 3. Patients of Amavata between the age group of 20 to 60 years of either sex. 4. Patient fit for Virechana and Bastikarma. b) Exclusive criteria : 1. Patients of Amavata having the history of more than 5 years. 2. Patients of Amavata less than 20 years and more than 60 years of age. 3. The patient of Amavata having the systemic diseases like Diabetes mellitus, Asthma, Hypertension, Rheumatic heart disease & Heart diseases etc. 4. Patients unfit for Virechana and Bastikarma. 5. Pregnant and lactating mothers. A Comparative Study of Virechana karma and Basti karma in Amavata 96 W.S.R.T. Rheumatoid Arthritis
  • 109. Material and MethodsStudy durationFor group ANittyavirechana The patients were administered vaishwanara choorna internally in adose of 3 – 6 Gms thrice daily with a cup of hot water, half an hour before food. Thetreatment was given till the nirama laxanas were observed. Eranda taila in the quantityof 15 to 30ml was given in between 8 to 9am when the patient is not so hungry for 8days for the purpose of Nittyavirechana, according to the kosta of the patient. A cupof hot water was advised as anupana and Parihara kala was advised for 16 days. InParihara kala one Placibo capsules was advised to take daily.For group BYogabasti The patients were administered Vaishwanara choorna internally in adose of 3 – 6 Gms thrice daily with a cup of hot water, half an hour before food. Thetreatment was given till the nirama laxanas were observed. After finding niramaLaxshana Yogabasti has given with Bruhatsaindhavadi taila Anuvasana basti andErandamooladi Niruha basti. Parihara kala was advised for 16 days. In Parihara kalaone Placibo capsules were advised to take daily for benefit of good follow up. Valuka sweda was advised whenever patient complaints increased painand stiffness during the course of the treatment for both groups.Method, Preparation and Administration of Basti In this study Yogabasti patterned was followed. In this course five anuvasanabasti with Bruhat saindhavadi taila and three Eranadamooladi niruha basti wereadministered. The anuvasana basti was given first day after finding Nirama laxshana.On that morning after evaluation of bowels and bladders patient was advised to take A Comparative Study of Virechana karma and Basti karma in Amavata 97 W.S.R.T. Rheumatoid Arthritis
  • 110. Material and Methodslight food (onefourth of his normal quantity). Then the patient was sent topanchakarma theatre and subjected for local abhyanga and sweda. Then the patientwas asked to lie down on the table in the left lateral position, with the left kneeextended, right limb flexed both at the hip and knee joint and resting on the left knee.The head was supported by the patient’s left hand. The plastic glycerin enema syringewith a capacity of 100ml and plain rubber catheter of the size no.12 were used for thepurpose of anuvasana basti the anal orifice and the inserting end of the catheter weresmeared with oil for lubrication. The rubber catheter connected to the enema syringefilled with brihat saindhavadi taila was gently inserted about 4 inches into the rectumparallel to spinal column. Simultaneously the patient was asked to take deep breaths;the catheter was removed with some amount of drug still remaining in the syringe toprevent the entry of air into the colon. Then the patient was asked to turn into thesupine position, raised his both legs three times and his buttocks were gently pattedand his palms and soles were rubbed. Patient was asked to remain in the sameposition for half an hour. Patient was watched for the evacuation of drug. Afterevacuation they were allowed to take hot water bath and then light food The quantity of bruhat saindhavadi taila taken was 80ml; the course ofanuvasana basati was given for alternate days and was ended with two continuousanuvasana basti. The niruha basti was started on the second day of the course. The niruhabasti dravya was prepared at the time of administration, first 12 gms of finelypowdered saindhava lavana was taken in the Khalva and was mixed 60 ml ofMakshika with Peshani, than 60ml of Tila tail was taken and churned with the same.After this 10gm fine powder of Kalka dravya was made paste and well churned with A Comparative Study of Virechana karma and Basti karma in Amavata 98 W.S.R.T. Rheumatoid Arthritis
  • 111. Material and Methodsthe previous mixture. Finally 400 – 500 ml of Kwatha, which is prepared fromErandamooladi kwatha choorna, was mixed up to the uniform consistency. This was filtered and indirectly warmed in a boiling water vessel to make itLuke warm. The niruha basti was given in empty stomach state in the similar mannerto that of anuvasaha basti. The purva karma and pradhana karma were similar to thatof anuvasana. Plastic enema can with a capacity of 1200ml was taken instead ofenema syringe. Patient was advised to remain in the table till he feels the urge fordefecation. After defecation they were allowed to take hot water bath and then lightfood. The quantity of Erandamooladi niruha basti administered was 500-600ml pereach time. Valuka sweda was advised whenever patient complaints increased pain andstiffness during the course of the treatment. After completion of Yogabasti 16 days Parihara kala have advised, in thisperiod placebo Capsule was continued daily once.Data Collection All the patients were thoroughly examined by both subjectively andobjectively. Detailed history pertaining to the mode of onset, previous ailment,previous treatment history, family history, habits, Ashtavidhapareeksha andDashavidhapareeksha and physical examination findings were noted. Routineinvestigations were done to exclude other pathologies.Examination of the patientHistory – History taking of patient is very important to diagnose the diseasesespecially of Amavata patient. When medical history focusing on the pain in thejoints, specific things to discussed when taking the history of a man with Amavatasymptoms include a history of morning stiffness of joints, symmetrical artheitis,arthritis of more than three joints etc. A Comparative Study of Virechana karma and Basti karma in Amavata 99 W.S.R.T. Rheumatoid Arthritis
  • 112. Material and MethodsInspection – In case of Amavata, joints should be examined by inspection. We canobserve the swelling, redness of joints etc. Even we can observe the deformity ofjoints and this can see the gait change.Palpation – Should be accurate to identify the Jwara, Ushnata of joints,Sparshasahatwa of joints can be finding by this palpation.Percussion – It helps to know the Kukshikathinnyata of Udara. It can also be used toidentify the Adhmana and Anilasanga.Auscultation – It helps in finding the invalment of Hridaya and also helps in theAdhmana and Anilasanga by hearing the sound like (gudu gudu).Investigetions and selection of patient Both objective and subjective parameters were considered for the selection ofpatient for both groupsObjective parameters The below investigations are done before the selection of patient for the study. 1] Hb% 2] E S R 3] A S L O titer 4] C R P 5] Rh factorSubjective parameters The subjective parameters taken for this study are 1] Ruja 2] Shotha 3] Stabdata 4] Ushnata A Comparative Study of Virechana karma and Basti karma in Amavata 100 W.S.R.T. Rheumatoid Arthritis
  • 113. Material and Methods The above four criteria ware considered for all the seven joints which areexplained by Madhavakara in his Madhukosha.Method of assessment Subjective parameters and objective parameters of base line data to after treatment data are done for comparison of the assessment of result.Grading of parameters Results are calculated by observing Subjective parameters by grading method.Grading was done as in the bellow manner.1] Hasta sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade 1 = any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 = any two of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 3 = any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All the four Ruja, Shotha, Stabdhata and Ushnata are present.2] Pada sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade 1 = any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 = any two of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 3 = any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All four Ruja, Shotha, Stabdhata and Ushnata are present.3] Gulpha sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade 1 =any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 =any two of the Ruja, Shotha, Stabdhata and Ushnata are present. A Comparative Study of Virechana karma and Basti karma in Amavata 101 W.S.R.T. Rheumatoid Arthritis
  • 114. Material and MethodsGrade 3 =any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All the four Ruja, Shotha, Stabdhata and Ushnata are present. 4] Trika sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade 1 =any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 =any two of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 3=any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All the four Ruja, Shotha, Stabdhata and Ushnata are present.5] Janu sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade1 =any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 =any two of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 3 =any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All the four Ruja, Shotha, Stabdhata and Ushnata are present.6] Uru sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade 1 =any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 =any two of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 3 =any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All the four Ruja, Shotha, Stabdhata and Ushnata are present.7] Sira sandhiGrade 0 = All the Ruja, Shotha, Stabdhata and Ushnata are absent.Grade 1 =any one of the Ruja, Shotha, Stabdhata and Ushnata was present.Grade 2 =any two of the Ruja, Shotha, Stabdhata and Ushnata are present. A Comparative Study of Virechana karma and Basti karma in Amavata 102 W.S.R.T. Rheumatoid Arthritis
  • 115. Material and MethodsGrade 3 =any three of the Ruja, Shotha, Stabdhata and Ushnata are present.Grade 4 = All the four Ruja, Shotha, Stabdhata and Ushnata are present.8] Hb% The numerical value of Hb% was taken before and after for the assessment.9] ESR The numerical value of ESR was taken before and after for the assessmentOverall Assessment of the Treatment To assess the overall effect of therapy, the criteria laid down by ARA (1967)were adopted. The results are classified into four groups as listed below.Grade I - Complete Remission1 = No systemic sign of rheumatoid activity2 = No signs of inflammation3 = No evidence of activity in any extra articular process, including nodules tinovaginitis and iritis.4 = No lasting impairment of joint mobility other than that associated with irreversible changes5 = No elevation in ESR6 = Articular deformity or extra articular involvement due to irreversible changes may be present.Grade II - Major Improvement1 = No systemic sign of rheumatoid activity with the exception of an elevated sedimentation rate and vasomotor imbalance2 = Major signs of inflammation resolved, such as warmth, redness of joint structures. A Comparative Study of Virechana karma and Basti karma in Amavata 103 W.S.R.T. Rheumatoid Arthritis
  • 116. Material and Methods3 = No new rheumatoid process of intra articular or extra articular structures.4 = Minimum joint swelling may be present.5 = Impairment of joint mobility associated with minimum residual activity may be present.6 = Articular deformity or extra-articular involvement due to irreversible changes may be present.Grade III - Minor Improvement1 = Diminution of systemic signs of Rheumatoid activity.2 = Signs of joint inflammation only partially resolved3 = No evidence of extension of rheumatoid activity into additional articular or extra articular structures.4 = Decreased but not minimum joint swelling present.5 = Impairment of joint mobility may be present.6 = Articular deformity or extra articular involvement due to reversible changes may be present.Grade IV – Un improvement or Progression1 = Undiminished signs of rheumatoid activity, regardless of functional activity.2 = Exacerbation of any previously involved joint or joints or development of sites of rheumatoid activity.3 = Roentgenologic changes indicative of progression of the rheumatoid process, excepting hypertrophic changes.4 = In the presence of 1 or more of the afore said criteria, improvement in other feature, including a normal or lowered ESR, not significant. A Comparative Study of Virechana karma and Basti karma in Amavata 104 W.S.R.T. Rheumatoid Arthritis
  • 117. Observation and ResultsObservation and Results In this present clinical study subjective and objective changes were consideredfor the comparative Ayurvedic management of Amavata withYogabasti(Erandamooladi Niruha and Bruhatsaindhavadi Anuvasana) and Nittyavirechana with Eranda taila. Thirty patients were selected after fulfilling the criteriafor diagnosis and were treated in the following two groups – Group A – Yogabasti – 15 patients. Group B – Nittya virechana with Eranda taila – 15 patients. All the patients were examined before and after the treatment according to thecase sheet format given in the appendix. Both the subjective and objective changeswere recorded and are presented under the following heading – Demographic data. Data related to the disease. Data related to subjective and objective parameters before and after treatment. A Comparative Study of Virechana karma and Basti karma in Amavata 105 W.S.R.T. Rheumatoid Arthritis
  • 118. Observation and ResultsDemographic dataTable No.17 showing distribution of patients by age groups. Age Group A Group B % group No % No % Total 20-30 5 33.33 3 20 8 26.66 31-40 4 26.66 6 40 10 33.33 41-50 3 20 4 26.66 7 23.33 51-60 3 20 2 13.33 5 16.66 In Group A – Out of 15 (i.e.50%) patients, 5 patients (i.e.33.33%) were in theage group of 20-30 years, 4 patients (i.e.26.66%) were in the age group of 31-40years, 3 patients (i.e.20%) were in 41-50 years age groups and 3 patients (i.e.20%)were in 51-60 years of age group. In Group B – Among 15 (i.e.50%) patients, 3 patients (i.e.20%) were in 20-30years age group, 6 patients (i.e.40%) were in 31-40 years age group , 4 patients were(i.e.26.66%) were in 41-50 age groups and where as 2 patients were reported in 51-60years age group.Graph No.1 showing distribution of patients by age groups 50 40 30 20 10 0 Group A Group B Total % 20-30 31-40 41-50 51-60 A Comparative Study of Virechana karma and Basti karma in Amavata 106 W.S.R.T. Rheumatoid Arthritis
  • 119. Observation and ResultsTable No. 18. Showing distribution of patients by Sex Sex Group A Group B % No % No % Total Male 04 26.66 04 26.66 08 26.66 Female 11 73.33 11 73.33 22 73.33 Among the 15 patients in the Group A, 4 patients (26.66%) were males, in thesame Group, 11 ware females (73.33%). In group B, 4 patients (26.66%) were males,and females ware 11(73.33%) had moderate response.In the study as a whole (30patients), 08 males (%), and 22( %)patients ware female.Graph No. 2. Showing distribution of patients by Sex in both groups 80 70 60 50 Male 40 30 Female 20 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 107 W.S.R.T. Rheumatoid Arthritis
  • 120. Observation and ResultsTable No. 19 showing distribution of patients by religion. Religion Group A Group B % No % No % Total Hindu 14 93.33 13 86.66 27 90 Muslim 01 6.66 02 13.33 03 10 In Group A – Among 15 patients, 14 patients (i.e.93.33%) were of Hindureligion, 01 patient (i.e.6.66%) were in Muslim community and none of the patientobserved in Christian and other religion. In Group B – Among 15 patients, 13 patients (i.e.86.66%) were of Hindureligion, 02 patients (i.e.13.33%) ware of Muslim community and none of the patientobserved in Christian and other religion.Graph No. 3 showing distribution of patients by religion. 100 80 60 Hindu Muslim 40 20 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 108 W.S.R.T. Rheumatoid Arthritis
  • 121. Observation and ResultsTable No. 20 showing distribution of patients by occupation. Occupation Group A Group B % No % No % Total HW 10 66.66 10 66.66 20 66.66 Sedentary 02 13.33 00 00 02 6.66 Labor 03 20 05 33.33 08 26.66 In Group A – Out of 15 patients, 10 patients (i.e.66.66) were house wife’s,02(13.33) patients were sedentary, and in labor group 03 (20%) patients warenoticed. No patient was observed from occupations. In Group B – Out of 15 patients, 10 patients (i.e.66.66%) were house wife’s,no patients ware in sedentary occupation group, 5 patients(ie.33.33) ware observed inlabor occupation group. Total 20 patients (66.66%) ware house wife’s, 02 patients (6.66%) waresedentary and 08 patients (26.66% ) ware in labor group.Graph No. 4 showing distribution of patients by occupation. 70 60 50 HW 40 Sedentary 30 20 Labor 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 109 W.S.R.T. Rheumatoid Arthritis
  • 122. Observation and Results Table No. 21 showing distribution of patients by socio-economical status. SE status Group A Group B % No % No % Total Poor 08 53.33 08 53.33 16 53.33 M Class 06 40 07 46.66 13 43.33 UM Class 01 6.66 00 00 01 3.33 In Group A – Out of 15 patients, 06 patients (i.e.40%) were in middle classsocio-economic group, 01 patients (i.e.6.66%) were in to high class socio-economicgroup and 08 patients (i.e.53.33%) are in poor socio-economical status group. In Group B – Out of 15 patients, 07 patients (i.e.46.66%) were in middle classsocio-economic group, 08 patients (i.e.53.33%) are in poor class socio-economicgroup and 00 patients (i.e.00%) were in high class socio-economical status group.Graph No. 5 showing distribution of patients by socio-economical status 60 50 40 Poor 30 M Class 20 UM Class 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 110 W.S.R.T. Rheumatoid Arthritis
  • 123. Observation and ResultsTable No. 22 showing distribution of patients by dietary habits. D. Habits Group A Group B % No % No % Total Veg. 11 73.33 11 73.33 22 73.33 Mixed 04 26.66 04 26.66 08 26.66 In Group A – Out of 15 patients, 11 patients (i.e.73.33%) were vegetarian and4 patients (i.e.26.66%) were mixed diet habit. In Group B – Out of 15 patients, 11 patients (i.e.73.33%) were vegetarian and4 patients (i.e.26.66%) were mixed diet habit.Graph No. 6 showing distribution of patients by dietary habits. 80 70 60 50 Veg. 40 30 Mixed 20 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 111 W.S.R.T. Rheumatoid Arthritis
  • 124. Observation and Results Table No.23 showing the distribution of patients by duration of disease Duration Group A Group B % No % No % Total Less than 02 13.33 01 6.66 03 10 1 yr >1-<2 05 33.33 05 33.33 10 33.33 >2-<3 04 26.66 04 26.66 08 26.66 >3-<4 02 13.33 02 13.33 04 13.33 >4-<5 02 13.33 03 20 05 16.66 In Group A – Out of 15 patients, 02 patients (13.33) are having less than oneyear history, 05 patients (33.33) are having more than one year and less than two yearhistory, 04 patients (26.66%) are having more than two year and less than three yearshistory, 02 patients (13.33%) are having more than three year and less than four yearshistory, 02 patients (13.33%) are having more than four years and less than five yearshistory.In Group B – Out of 15 patients, 01 patients (6.66%) are having less than one yearhistory, 05 patients (33.33) are having more than one year and less than two yearhistory, 04 patients (26.66%) are having more than two year and less than three yearshistory, 02 patients (13.33%) are having more than three year and less than four yearshistory, 03 patients (20%) are having more than four years and less than five yearshistory. Graph No.7 showing the distribution of patients by duration of disease 35 30 Less than 1 yr 25 >1-<2 20 >2-<3 15 10 >3-<4 5 >4-<5 0 l A B % ta up up To ro ro G G A Comparative Study of Virechana karma and Basti karma in Amavata 112 W.S.R.T. Rheumatoid Arthritis
  • 125. Observation and ResultsTable No. 24 showing the distribution of patients by treatment history Treatment Group A Group B % history No % No % Total Allopathic 11 73.33 14 93.33 25 83.33 Al & Ay 04 26.66 01 6.66 05 16.66 In Group A – Out of 15 patients, 11 patients (i.e.73.33%) were takenAllopathic treatment and 4 patients (i.e.26.66%) were taken mixed treatment of bothAllopathic and Ayurvedic. In Group B – Out of 15 patients, 14 patients (i.e.93.33%) were takenAllopathic treatment and 01 patients (i.e.6.66%) were taken mixed treatment of bothAllopathic and Ayurvedic. In this study 25 patients (83.33%) have taken Allopathic medicine, where as05 patients (16.66%) have received Ayurvedic medicine before this clinical trial. Graph No. 8 showing the distribution of patients by treatment history 100 80 60 Allopathic 40 Al & Ay 20 0 Group Group % A B Total A Comparative Study of Virechana karma and Basti karma in Amavata 113 W.S.R.T. Rheumatoid Arthritis
  • 126. Observation and ResultsTable No. 25 showing distribution of patients by nature of Koshta. Nature Group A Group B % of Koshta No % No % Total Mridu 06 40 06 40 12 40 Madhyama 03 20 04 26.66 07 23.33 Krura 03 20 03 20 06 20 Sama 03 20 02 13.33 05 16.66 In Group A – Out of 15 patients, 6 patients (i.e.40%) were having Mridukoshta and 3 patients each (i.e.20%) were reported with Madhyama, Krura and Samakoshta. In Group B – Out of 15 patients, 6 patients (i.e.40%) were having Mridukoshta, 4 patients (i.e.26.66%) has Madhyama koshta, 3 patients (i.e.20%) were ofKrura koshta and 2 patients (i.e.13.33%) has Sama koshta.Graph No. 9 showing distribution of patients by nature of Koshta. 45 40 35 Mridu 30 25 Madhyama 20 Krura 15 10 Sama 5 0 Group Group % A B Total A Comparative Study of Virechana karma and Basti karma in Amavata 114 W.S.R.T. Rheumatoid Arthritis
  • 127. Observation and ResultsTable No. 26 showing distribution of patients by Jatharagni. (Status ofJatharagni). Status of Group A Group B % Jatharagni No % No % Total Manda 06 40 07 46.66 13 43.33 Vishama 03 20 02 13.33 05 16.66 Teekshna 00 00 01 6.66 01 3.33 Samagni 06 40 05 33.33 11 36.66 In Group A – Out of 15 patients, 6 patients each (i.e.40%) were having mandaand Samagni, 3 patients (i.e.20%) were having mandagni and no patient was reportedwith teekshnagni. In Group B – Out of 15 patients, 7 patients (i.e.46.66%) were havingMandagni, 5 patients (i.e.33.33%) were having Samagni, 2 patients (i.e.13.33%) werereported with Vishamagni and only 1 patient was with Teekshnagni status.Graph No. 10 showing distribution of patients by Jatharagni. (Status ofJatharagni). 50 40 Manda 30 Vishama 20 Teekshna Samagni 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 115 W.S.R.T. Rheumatoid Arthritis
  • 128. Observation and Results Table No. 27 showing distribution of patients by nature of Mala pravritti. Mala Group A Group B % pravritti No % No % Total Regular 01 6.66 04 26.66 05 16.66 Irregular 01 6.66 00 00 01 3.33 Constipation 07 46.66 04 26.66 11 36.66 Frequently 06 40 07 46.66 13 43.33 In Group A – Out of 15 patients, 7 patients (i.e.46.66%) were constipated, 6patients (i.e.40%) were having frequent mala pravritti and only 1 patients (i.e.6.66%)was having irregular bowel habit. In Group B – Out of 15 patients, 7 patients (i.e.46.66%) has frequent malapravritti, 4 patients (i.e.26.66%) were constipated and no patient was reported withirregular type of bowel habit.Graph No. 11 showing distribution of patients by nature of Mala pravritti 50 40 Regular 30 Irregular 20 Constipation 10 Frequently 0 l A B % ta up up To ro ro G G A Comparative Study of Virechana karma and Basti karma in Amavata 116 W.S.R.T. Rheumatoid Arthritis
  • 129. Observation and ResultsTable No. 28 showing distribution of patients by type of Desha. (Nature ofHabitat). Type of Group A Group B Desha No. of Pt.’s % No. of Pt.’s % 0 0 0 0 Anupa Sadharana 0 0 0 0 Jhangala 15 100 15 100 The place where this study was conducted is in Jangala pradesh. So all the patients are in Jangala desha habitat.Graph No. 12 showing distribution of patients by type of Desha. (Nature ofHabitat). 120 100 80 Anupa 60 Sadharana 40 Jhangala 20 0 No. of % No. of % Pt.’s Pt.’s Group A Group B A Comparative Study of Virechana karma and Basti karma in Amavata 117 W.S.R.T. Rheumatoid Arthritis
  • 130. Observation and ResultsTable No. 29 showing distribution of patients by Vyasana. (Addiction). Vyasana Group A Group B % No % No % Total Tobacco 06 40 04 26.66 10 33.33 Smoking 02 13.33 02 13.33 04 13.33 No habits 07 46.66 09 60 16 53.33 In Group A – Out of 15 patients, 6 patients (i.e.40%) were habituated to tobacco chewing, 7 patients (i.e.46.66%) are no habits and 2 patients (i.e.13.33%) are smokers. In Group B – Out of 15 patients, 02 patients (i.e.13.33%) are smokers, 4 patients h(i.e.26.66%) were habituated to tobacco chewing and patients are out of all habitsGraph No. 13 showing distribution of patients by Vyasana. (Addiction). 70 60 50 Tobacco 40 Smoking 30 20 No habits 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 118 W.S.R.T. Rheumatoid Arthritis
  • 131. Observation and ResultsTable No. 30 showing the distribution of patients by Nidra in both Groups. Group A % % Total % Group Nidra 0 0 0 0 0 0 Sukha Alpa 10 66.6 11 73.33 21 70 Ati 0 0 0 0 0 0 Vishama 5 33.3 4 26.6 9 30 Among the 15 patients in Group A, 10 patients had alpa nidra (66.6%) and 5patients had Vishama nidra (33.3%). Among the 15 patients in Group B, 11 patientshad Alpa nidra (73.33%) and 4 patients had Vishama nidra (26.6%). In the study as awhole (30 patients), 21 patients had Alpa nidra (70%) and 9 patients had Vishananidra (30%). No patient reported with Sukha and Ati nidra in this study.Graph No. 14 showing the distribution of patients by Nidra in both Groups. 80 70 60 Sukha 50 Alpa 40 30 Ati 20 Vishama 10 0 Group % Group % Total % A A Comparative Study of Virechana karma and Basti karma in Amavata 119 W.S.R.T. Rheumatoid Arthritis
  • 132. Observation and ResultsTable No.31 showing the distribution of patients by Deha prakriti in bothGroups. Deha Prakriti Group A % % Total % Group B Vata 2 13.33 1 6.6 3 10 Pitta 0 0 0 0 0 0 Kapha 0 0 0 0 0 0 Vata-pitta 7 46.6 8 53.3 15 50 Vata-kapha 5 33.33 4 26.6 9 30 Pitta-kapha 1 6.66 2 13.3 3 10 Sannipataja 0 0 0 0 0 0 Group A- Out of 15 patients Vata prakriti persons are 2 (ie.13.33), Vatapitta prakriti persons are 7 (ie.46.66), Vatakapha prakriti persons are 5 (ie.33.33), Pittakapha prakriti persons are 1(ie.6.66) and in Pitta, Kapha and Sannipatja are not found. Group A- Out of 15 patients Vata prakriti persons are 1 (ie.6.66%), Vatapitta prakriti persons are 8 (ie.53.33%), Vatakapha prakriti persons are 4 (ie.26.66), Pittakapha prakriti persons are 2(ie.13.33) and in Pitta, Kapha and Sannipatja ware not found.Graph No.15 showing the distribution of patients by Deha prakriti in bothGroups. 60 50 40 Group A 30 % 20 Group B 10 % 0 Total Va ha ta t ta a ha ha a % aj Va pitt Va p ap ap Pi at Ka - ip -k -k ta nn ta tta Sa Pi A Comparative Study of Virechana karma and Basti karma in Amavata 120 W.S.R.T. Rheumatoid Arthritis
  • 133. Observation and Results Table No.32 showing the distribution of patients by Satmya. Satmya Group A Group B % No % No % Total Sarvarasa 10 66.66 10 66.66 20 66.66 sneha Sarvarasa 05 33.33 05 33.33 10 33.33 ruksha In Group A – Out of 15 patients, 10 patients (i.e.66.66%) are Satmya withSarvarasa sneha and 05 patients (i.e.33.33%) are Satmya with Sarvarasa ruksha. In Group B – Out of 15 patients, 10 patients (i.e.66.66%) are Satmya withSarvarasa sneha and 05 patients (i.e.33.33%) are Satmya with Sarvarasa ruksha.Graph No.16 showing the distribution of patients by Satmya. 70 60 50 40 Sarvarasa sneha 30 Sarvarasa ruksha 20 10 0 l A B % ta up up To ro ro G G A Comparative Study of Virechana karma and Basti karma in Amavata 121 W.S.R.T. Rheumatoid Arthritis
  • 134. Observation and ResultsTable No.33 Showing the presence of RA factor in both group RA factor Group A Group B % No % No % Total Positive 05 33.33 05 33.33 10 33.33 Negative 10 66.66 10 66.66 20 66.66 In Group A – Out of 15 patients, 10 patients (i.e.66.66%) are having RA factorNegative and 05 patients (i.e.33.33%) are having RA factor Positive. In Group B – Out of 15 patients, 10 patients (i.e.66.66%) are having RA factorNegative and 05 patients (i.e.33.33%) are having RA factor PositiveGraph No.17 Showing the presence of RA factor in both groups 70 60 50 40 Positive 30 Negative 20 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 122 W.S.R.T. Rheumatoid Arthritis
  • 135. Observation and ResultsTable No.34 Showing the presence of ASLO titer in both group ASLO titer Group A Group B % No % No % Total Positive 02 13.33 04 26.66 06 20 Negative 13 86.66 11 73.33 24 80 In Group A – Out of 15 patients, 13 patients (i.e.86.66%) are having ASLOtiter Negative and 02 patients (i.e.13.33%) are having ASLO titer Positive. In Group B – Out of 15 patients, 11 patients (i.e.73.33%)are having ASLOtiter Negative and 04 patients (i.e.26.66%) are having ASLO titer Positive.Graph No.18 Showing the presence of ASLO titer in both groups 100 80 60 Positive 40 Negative 20 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 123 W.S.R.T. Rheumatoid Arthritis
  • 136. Observation and ResultsTable No.35 Showing the presence of CRP titer in both group CRP Group A Group B % No % No % Total Positive 07 46.66 10 66.66 17 56.66 Negative 08 53.33 05 33.33 13 43.33 In Group A – Out of 15 patients, 08 patients (i.e.53.33%) are having CRPNegative and 07 patients (i.e.46.66%) are having CRP Positive. In Group B – Out of 15 patients, 05 patients (i.e.33.33%) are having CRPNegative and 10 patients (i.e.66.66%) are having CRP Positive.Graph No.19 Showing the presence of CRP titer in both groups 70 60 50 40 Positive 30 Negative 20 10 0 Group Group Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 124 W.S.R.T. Rheumatoid Arthritis
  • 137. Observation and Results Table No.36 Showing the types of Amavata in both groups Deha Prakriti Group A % % Total % Group B Vata 03 20 02 13.33 05 16.66 Pitta 01 6.66 02 13.33 03 10 Kapha 00 00 00 00 00 00 Vata-pitta 03 20 01 6.66 04 13.33 Vata-kapha 06 40 08 53.33 14 46.66 Pitta-kapha 01 6.66 01 6.66 02 6.66 Sannipataja 01 6.66 01 6.66 02 6.66 Group A- Out of 15 patients Vataja Amavata are 3 (ie.20%), Pittaja amavata are 01 (ie.6.66%), Vatakaphaja Amavata are 06 (ie.40%), Pittakaphaja Amavata are 1(ie.6.66), Vatapittaja Amavata are 03(20%), Sannipataja Amavata are 01(6.66%) and we have not found Kaphaja type of Amavata. Group B- - Out of 15 patients Vataja Amavata 02 (ie.13.33%), Pittaja amavata are 02 (ie.13.33%), Vatakaphaja Amavata are 08 (ie.53.33%), Pittakaphaja Amavata are 00(ie.00%), Vatapittaja Amavata are 01(6.66%), Sannipataja Amavata are 01(6.66%) and we have not found Kaphaja type of Amavata.Graph No.20 Showing the types of Amavata in both groups 60 50 Vata 40 Pitta 30 Kapha 20 Vata-pitta 10 Vata-kapha 0 Pitta-kapha A B l % % % Sannipataja ta up up To ro ro G G A Comparative Study of Virechana karma and Basti karma in Amavata 125 W.S.R.T. Rheumatoid Arthritis
  • 138. Observation and ResultsTable No. 37 Showing the distribution of patients by Mode of onset in bothGroups. Mode of Onset Group A % % Total % Group B Chronic 11 73.33 12 80 23 76.66 Insidious 4 26.66 03 20 7 23.33 Acute 0 0 0 0 0 0 Traumatic 0 0 0 0 0 0 In the Group A, among 11 patients (73.33%) are haveing chronic onset, 4patients (26.66%) of insidious onset. In the Group B, 12 patients (80%) of having chronic onset 03 patients(ie.20%) are having insidious.Graph No. 21 Showing the distribution of patients by Mode of onset in bothGroups. 90 80 70 Chronic 60 50 Insidious 40 Acute 30 20 Traumatic 10 0 Group % Group % Total % A B A Comparative Study of Virechana karma and Basti karma in Amavata 126 W.S.R.T. Rheumatoid Arthritis
  • 139. Observation and ResultsTable No 38 showing distribution of patients by Nidana Nidana Group A Total % Group B Prakriti virudha 07 08 15 50 Samaya virudha 08 07 15 50 Samyoga virudha 09 08 16 53.33 Virudha chesta 06 06 12 40 Avayama 04 06 10 33.33 Ativyayama 03 02 05 16.66 Vyaaftersnigdha bhojana 04 05 09 30 Gurubhojana 12 12 24 80 Mandagni 13 11 24 80 Out of thirty patients 15 patients(50%) are having Prakritivirudha nidana andSamayavirudha nidana, 16 patients(53.33%) are having Samyoga virudha nidana, 12patients(40%) are having Virudha chesta nidana, 10 patients(33.33%) are havingAvyayama nidana, 05 patients (16.66%) are having Ativyayama nidana, 09 patients(30%) are having Vyayama after snigdha bhojajna and 24 patients (80%) are havingGurubhojana and Mandagni.Graph No 22 showing distribution of patients by Nidana 90 80 70 Prakriti virudha Samaya virudha 60 Samyoga virudha 50 Virudha chesta 40 Avayama 30 Ativyayama 20 Vyaaftersnigdha bhojana 10 Gurubhojana 0 Mandagni Group A Group B T otal % A Comparative Study of Virechana karma and Basti karma in Amavata 127 W.S.R.T. Rheumatoid Arthritis
  • 140. Observation and ResultsTable No.39 showing the distribution of symptoms of Amavata in both Groups. Symptoms Group A % % Total % Group B Sandhi sotha 15 100 15 100 30 100 Sandhi shoola 15 100 15 100 30 100 Sandhi stabdata 15 100 15 100 30 100 Sandhi ushnata 15 100 15 100 30 100 Jara 07 46.66 06 40 13 43.33 Angamarda 13 86.66 11 73.33 24 80 Aruchi 11 73.33 13 86.66 24 80 Apaka 08 53.33 09 60 17 56.66 Trishna 06 40 07 46.66 13 43.33 Alassya 13 86.66 10 66.66 23 76.66 Bahumootrata 05 33.33 04 26.66 09 30 Hrillasa 03 20 04 26.66 07 23.33 Gourava 12 80 13 86.66 25 83.33 Chardi 02 13.33 01 6.66 03 10 Bhrama 04 26.66 02 13.33 06 20 Nidraviparyaya 08 53.33 06 40 14 46.66 Kostabaddata 06 40 08 53.33 14 46.66 Out of 30 patients all 30 patients(100%) are having Sandhishotha,Sandhishoola, Sandhistabdata, Sandhiushnata, 25 patients(83.33%) are havingGourava, 24 patients(80%) ware having Angamarda and Aruchi, 23 patients(76.66%)ware having Alassya, 17 patients(56.66%) are having Apaka laxshana, 14patients(46.66%) are having Nidraviparyaya and Kosthabadhata, 13 patients(43.33%)ware having Jvara and Trishna, 09 patients(30%) are having Bahumootrata, 07 A Comparative Study of Virechana karma and Basti karma in Amavata 128 W.S.R.T. Rheumatoid Arthritis
  • 141. Observation and Resultspatients(23.33%) are having Hrillasa, 06 patients(20%) are having Bhrama, 03patients(10%) are having Chardi Laxshana.Graph No.23 showing the distribution of symptoms of Amavata in both Groups 100 80 60 40 20 0 Group A % Group B % Total % Sand hi s o tha Sand hi s ho o la Sand hi s tab d at a Sand hi us hnat a J ara Ang amard a Aruchi Ap aka Tris hna Alas s ya Bahumo o t rat a Hrillas a Go urava Chard i Bhrama Nid ravip aryaya Ko s tab ad d ataTable No. 40 Showing the over all effect of treatment in both Groups. Result Group A % % Total % Group B Complete 00 00 00 00 00 00 remission Major 01 6.66 06 40 07 23.33 improvement Moderate 11 73.33 09 60 20 66.66 improvement Mild 03 20 00 00 03 10 improvementOver all effect of treatment in both group: Comparison of the overall effects of the treatment in both the groups revealsthat Yogabasti is more efficacious. Major improvement of the illness was observed in06(40% ) of the patients in Yogabasti group as against 01(6.66%) of the patients inNittyavirechana group. 09(60%) of the patients in Yogabasti group recorded moderate A Comparative Study of Virechana karma and Basti karma in Amavata 129 W.S.R.T. Rheumatoid Arthritis
  • 142. Observation and Resultsimprovement, where as 11(73.33%) patients have show moderate improvement inNittyavirechana. 03(20%) of the patients showed minor improvement inNittyavirechana. From the foregoing it is clear that both Yogabasti and Nittyavirechana are veryeffective in the patients suffering from AmavataGraph No. 24 Showing the over all effect of treatment in both Groups. 80 70 Complete 60 remission 50 40 Major 30 improvement 20 Moderate 10 improvement 0 Mild improvement A B l G % % % ta up up To ro ro G A Comparative Study of Virechana karma and Basti karma in Amavata 130 W.S.R.T. Rheumatoid Arthritis
  • 143. Data related to the response of treatmentTable No 41 showing Data related to the response of treatment in group A S OPD Hasta Pada Gulpha Trika Janu Uru Sira Hb% ESR BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT 1 2322 3 2 2 1 3 1 2 1 3 2 1 1 0 0 11.5 11.6 50 30 2 2451 2 1 4 2 3 2 2 1 2 1 1 0 1 0 10.6 10.8 35 20 3 2515 4 2 2 0 2 1 2 1 3 1 1 0 1 0 9.00 9.33 39 15 4 2475 2 0 4 2 3 2 2 1 3 1 0 0 0 0 10.3 10.6 80 35 5 4595 3 1 2 0 3 1 2 1 3 1 2 1 1 0 9.00 9.00 43 20 6 65 2 0 3 1 4 2 1 0 4 2 1 0 0 0 8.5 8.8 28 16 7 987 4 1 2 1 3 1 1 0 4 2 2 1 1 1 9.4 9.5 74 31 8 1106 2 0 4 2 3 2 2 1 2 0 2 1 1 0 9.8 10.1 99 48 9 1233 4 2 3 1 2 1 2 1 2 0 1 1 0 0 8.3 8.7 92 70 10 1240 2 2 3 2 4 2 1 0 4 2 2 1 0 0 7.92 8.4 82 30 11 1567 4 3 2 1 3 1 2 1 2 1 1 0 1 0 11.3 11.8 26 10 12 1742 3 1 2 2 3 1 2 1 1 0 2 1 0 0 10.23 10.8 28 30 13 94 2 0 3 2 4 2 2 2 2 2 1 1 0 0 8.21 8.61 29 11 14 1112 4 1 2 1 3 2 2 0 3 1 2 0 1 1 8.71 8.92 44 15 15 700 2 1 4 1 4 2 2 1 4 2 1 1 0 0 9.8 10.61 53 20 131
  • 144. Table No 42 showing Data related to the response of treatment in group B S OPD Hasta Pada Gulpha Trika Janu Uru Sira Hb% ESR BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT 1 3703 3 1 2 1 3 1 1 0 2 1 1 0 0 0 9.6 9.8 70 30 2 2874 2 0 2 0 2 1 2 1 3 1 1 0 0 0 11.2 11.3 55 46 3 3081 4 1 2 1 2 1 2 0 2 1 0 0 1 0 9.3 9.5 32 20 4 2661 1 0 4 1 3 1 2 1 0 0 1 0 0 0 8.4 8.7 28 21 5 2694 3 1 0 0 2 0 1 1 1 0 1 0 1 1 10.7 10.9 39 28 6 2691 1 0 3 1 2 1 2 1 1 0 1 0 0 0 10.2 10.3 40 34 7 2556 1 0 2 0 1 1 1 0 2 0 1 0 1 0 10.7 11 78 30 8 2512 4 1 1 0 2 1 2 1 3 1 0 0 0 0 8.2 8.4 55 34 9 2492 2 0 1 0 2 1 2 1 1 0 1 0 1 0 8.7 8.9 28 19 10 2640 4 2 2 1 2 1 1 0 2 0 0 0 0 0 11 11.4 63 28 11 2633 1 0 4 2 3 1 2 1 2 1 1 0 0 0 10.1 10.3 74 23 12 2690 3 2 2 0 2 1 1 0 2 1 0 0 1 0 9.6 9.7 28 15 13 753 2 0 3 1 4 1 2 0 4 2 2 1 0 0 10.4 10.6 55 24 14 2213 2 1 3 1 3 1 1 0 2 1 0 0 1 0 11.4 11.7 67 30 15 4085 4 1 2 1 2 0 2 0 4 2 1 0 1 0 9.3 9.6 96 42 132
  • 145. [2]Table No 43 showing statistical analysis of subjective and objective parameters in group A Sno Parameters Mean SD SE T value P value Remarks 1 Hasta 1.8 0.774 0.2 9.00 < 0.001 HS 2 Pada 1.533 0.743 0.191 8.026 < 0.001 HS 3 Gulpha 1.466 0.743 0.191 7.67 < 0.001 HS 4 Trika 1.133 0.516 0.133 8.518 < 0.001 HS 5 Janu 1.133 0.617 0.159 2.183 < 0.001 HS 6 Uru 0.666 0.487 0.125 5.328 < 0.001 HS 7 Siro 0.4 0.057 0.130 3.076 < 0.001 HS 8 Hb% 0.22 0.086 0.022 10.00 < 0.001 HS 9 ESR 25.8 17.78 4.59 5.620 < 0.001 HS 133
  • 146. Table No 44 showing statistical analysis of subjective and objective parameters in group B (table3) Sno Parameters Mean SD SE T value P value Remarks 1 Hasta 1.733 0.798 0.206 8.412 < 0.001 HS 2 Pada 1.533 0.743 0.191 8.026 < 0.001 HS 3 Gulpha 1.6 0.506 0.131 12.213 < 0.001 HS 4 Trika 1.00 0.377 0.097 10.309 < 0.001 HS 5 Janu 1.666 0.487 0.125 13.328 < 0.001 HS 6 Uru 0.8 0.5606 0.144 5.55 < 0.001 HS 7 Siro 0.333 0.487 0.125 2.666 < 0.001 HS 8 Hb% 0.313 0.172 0.044 7.11 < 0.001 HS 9 ESR 27.466 14.38 3.714 7.39 < 0.001 HS 134
  • 147. Table No 45 showing the comparative statistical analysis of subjective and objective parameters in both groups (table 1) Parameters Mean SD SE PSE T value P value Remarks Hasta A 0.666 0.723 0.186 0.301 1.551 > 0.05 NS B 1.133 0.915 0.236 Pada A 0.6 0.632 0.163 0.243 2.74 < 0.02 HS B 1.266 0.703 0.181 Gulpha A 0.866 0.351 0.090 0.161 4.14 < 0.001 HS B 1.533 0.516 0.133 Trika A 0.466 0.516 0.133 0.196 1.704 > 0.05 NS B 0.8 0.560 0.144 Janu A 0.733 0.703 0.181 0.263 1.520 > 0.05 NS B 1.133 0.743 0.191 Uru A 0.0666 0.258 0.066 0.148 2.698 < 0.02 NS B 0.4660 0.516 0.133 Siro A 0.0666 0.258 0.066 0.112 0.598 > 0.05 NS B 0.133 0.351 0.090 Hb% A 10.14 1.012 0.263 0.397 0.74 > 0.05 NS B 9.846 1.156 0.298 ESR A 28.066 8.647 2.232 4.65 0.287 > 0.05 NS B 26.73 15.8 4.080 135
  • 148. Observation and ResultsStatistical conclusion To compare the mean effect of two groups we used unpaired t test byassuming that the mean effect of two groups is same in all the parameters. From the analysis the parameter Gulpha, Pada, Uru shows highly significantthan other parameters shows not significant after the treatment [from table No 43] ie p< 0.05 The parameter Gulpha shows highly significant than other parameters, ingroup B the mean effect is more with more variation after the treatment [ bycomparing t value, mean and S.D.]. The effect on Pada and Uru shows equal highlysignificant [by comparing P value and t value] The mean effect of Pada and Uru in group B is more with more variation afterthe treatment. Both the objective parameters Hb% and ESR shows not significant as Pis greater than 0.05. The mean effect of objective parameters Hb% and ESR is more in group Awith less variation after the treatment by comparing mean and standard deviation Individually the group B shows more significant than group A in parameterGulpha, Trika, Janu, Uru & ESR. For this we used paired t test by assuming that thedrug is not responsible for change in the observations before & after the treatment. In group A the parameter Hastha, Sira & Hb% shows more highly significantthan group B (by comparing p value & t value from table 44 & 45). A Comparative Study of Virechana karma and Basti karma in Amavata 136 W.S.R.T. Rheumatoid Arthritis
  • 149. DiscussionDiscussion Amavata is chronic progressive systemic disorder that mainly targets tolocomotors system. It is named after two major involvements of two pathogenicfactors Ama and Vata, which mainly affects Sandhi. The classics had explained themanifestation of disease and its treatment. Madhavakara was the first person whoexplained this disease as a separate entity. Chakradatta and Vangasena havecontributed its treatment. This disease occurs in all ethnic groups. Mainly it is more prevalence in urbanarea. Sandhishoola, Sandhishotha, Sandhistabdata and Sandhiushnata are the cardinalclinical features of this disease, apart from this it has many general symptoms likeGourava, Aruchi, Jvara, Angamarda, Apaka etc are seen in this disease. Though amaand vata are chief pathogenic factors, kapha and pitta are also invariably involved inthe pathogenisis of Amavata. To the fact this disease is manifested due to unwholesome diet and regimenand hypo function of Agnis also an important factor for the initiation of diseaseprocess. The samprapti of this disease originated from Annavaha srotas andmadhyama roga marga with invalvment of sleshma sthana first it affects, later itaffects other sthanas like Sandhi, Asthi, Majja etc. Rasa, Asthi and Majja areprimarily involved dushyas, later it affects mamsa, snayu and khandara The ayurvedic line of treatment explained by ancient acharyas mainly dependsup on the stages of disease. The treatment includes Langhana, Deepana, Amapachana,Shodhana and Shamana associated with bahirparimarjana like valukasweda. Deepana and Amapachana help to check the formation of ama and to startsamprapti vighatana. Then the vitiated doshas can be eliminated by virechana and A Comparative Study of Virechana karma and Basti karma in Amavata 137 W.S.R.T. Rheumatoid Arthritis
  • 150. Discussionbasti. After that shamana treatment should be followed to alleviate the remainingdoshas. Valuka sweda can be utilized as a bahirparimarjana chikitsa.Amavata v/s Rheumatoid arthritis The disease Rheumatoid arthritis is identical with the signs and symptomsof Amavata. It always challenge to the physicians due to its chronicity, complicationand morbidity, because of the lack of precise knowledge pertaining to itsetiopathogenesis. Various theories try to explain its etiopathogenesis like hereditary,Neurogenic, vascular, infective, metabolic, endocrinal, autoimmune and psychogenic.Though other theories are not yet discarded the autoimmune mechanism is mostcommonly implicated. This disease mainly affects the musculo skeletal system. It has also extraarticular manifestations affecting cardiovascular, nervous and excretory systems,which is collectively known as connective tissue or collagen disorder. Recently someof the authors emphasize the Arthritis of entropathy, which is similar with Amavata. Ama originated in Amashaya and circulates through out the body with vitiatedvata dosha. The ama visha is further increased by interaction of dosha, dushya due tolocalized concentration of Amavisha. The contribution of srotovaigunnya as well askleda is very much important in the pathogenesis of Amavata. Srotorodha in generalcan be compared with rheumatoid vasculitis one of the serious extra articularmanifestation. These sequential steps in the samprapti of Amavata are quite identicalwith the etiopathogenesis of Rheumatoid Arthritis. The altered activity of the immunesystem, stimulated by exogenous or endogenous antigens probably viral or bacterial inorigin, causes formation of Rheumatoid factor and antibodies. The recent studiesshowed that Rheumatoid Arthritis has not been link to any infection, despite of itresembles to infectious Arthritis [Rheumatic fever]. A Comparative Study of Virechana karma and Basti karma in Amavata 138 W.S.R.T. Rheumatoid Arthritis
  • 151. Discussion Several components of the immune system appear to contribute to thepathogenesis of Rheumatoid Arthritis. The integral role performed by vascularendothelium, circulating memory T- cells, tissue macrophages, plasma cells,Rheumatoid factor and cytokines are initiating and perpetuating Rheumatoid Arthritisinflammation in the joints and throughout the body. The altered immune mechanismin Rheumatoid Arthritis can be correlated with the role of Ama in Amavata. Theproduction of Srotoabhishyanda and kleda is nothing but the inflammatory changes inRheumatoid Arthritis. Once again the etiological factor is much similar with Amavataand the site of the disease is much identical with sleshma sthana and connectivetissues. As already told the despite years of intensive study the etiology of RheumatoidArthritis is still not known the uncertainties in the etiopathogenesis of this diseaseimpeded the exploration of an effective treatment or its prevention. In spite ofavailable treatment, it cripples the ailing for the rest of his life; moreover it affects theyounger and middle-aged people, substantially hampering the economy of the nation.Thus the disease has posed great challenge to the physicians who are engaged inresearch work yet the goal of curing the disease remains long away off. Line of treatment, which is explained in Ayurveda, can reduce pain, swelling,protection of joints and control the disease progression. The early invention inAyurvedic field helped to prevent the development of disabilities and preferablerespond to this disease. Ayurvedic treatment can give the fitness to participate in theroutine activities of daily living and ambulation, with this aim the present study wasunder taken to evaluate and compare the effect of Nittyavirechana and Yogabasti inAmavata. A Comparative Study of Virechana karma and Basti karma in Amavata 139 W.S.R.T. Rheumatoid Arthritis
  • 152. DiscussionStudy method: In the present study, 33 patients of Amavata were registered, in which 30patients completed the course of the treatment. The disease was diagnosed on thebasis of signs and symptoms as described in Ayurvedic and Modern texts, aided byA.R.A. criteria (1988). RA factor test was done in all the patients. Routine Blood,Urine, Stool examination along with S. uric acid were done to rule out otherpathological conditions. The selected patients were randomly divided into following 2 groups.Nittya virechana group: 15 patients were treated in this group with by giving 15-30ml of Eranda taila for 8 days.Yogabasti group: 15 patients were treated in this group with Yogabasti karma. For the assessment of the results guideline laid down by classical text ofAyurveda as well as parameters suggested by A.R.A. (1988) were followed. Theresults obtained were statistically analyzed and percentage of relief, Mean, S.D., S.E.t-value and P-value were calculated by using the paired t-test.Materials and methodsBased on the principles of treatment following drugs were selected for the study.1) Vaishwanara choorna for amapachana2) Eranda taila for virechana3) Brihat saindhavadi taila for anuvasana4) Erandamooladi for niruha bastiVaishwanara Churna It is a good deepana and pachana drug indicated in amavata adhikara. It checksthe formation of ama by increasing the agni and digests the ama which is already A Comparative Study of Virechana karma and Basti karma in Amavata 140 W.S.R.T. Rheumatoid Arthritis
  • 153. Discussionformed. It helps to attain niramavastha, and prepare the body environment for furthershodhanadi treatment.Eranda Taila for Nittyavirechana Eranda taila is considered as the best medicine in the management of amavata,which is used for Nittyavirechana. Because of its sukshma guna it reaches the minutesrotas as and it liquifies the stagnated doshas by its lekhana, usna, teekshna, propertiesthen it removes by its virechana action. It acts as vatanulomana, it pacifies vata by itsmadhura vipaka, snigdha and ushna gunas. It removes the obstruction of vataproduced by ama and kapha and checks the further accumulation of vata in the bodyby sroto vishodhana guna.Probable Mode of Action of Nittyavirechana : In the present study, Nittyavirechana was administered by Eranda taila. Erandataila is Vata-kaphashamaka having specific vyadhihara i.e. Amavatahara action. Ricinpresent in it gets converted to Ricinoelic acid by lipase, which irritates bowel leadingto Virechana as it is having Ushna virya, it also does Pachana karma (Amapachana).Action of Nittyavirechana on Amavata can be understood by the following propertiesof it. Nittyavirechana helps in eliminating the Ama which forms everyday due to Mandagni in Amavata. As told in Astanga sangraha when Prakupita doshas are their, it is better to eliminate little by little in consecutive days. Nittyavirechana acts as Rasayana, by this patients gets good Bala due this Roga bala will come down Virechana has direct effect on Agnisthana and hampered agni (Mandagni) is one of the initiating factors in Amavata. It pacifies the vitiated Kapha and Vata dosha. A Comparative Study of Virechana karma and Basti karma in Amavata 141 W.S.R.T. Rheumatoid Arthritis
  • 154. Discussion It has the property of Srotovishodhana, hence the Srotorodha (Srotoabhishyanda) present in the disease Amavata mainly in Sandhisthana is cleared by Nittyavirechana leading to relief of the symptoms. Virechana is indicated in Sannipaitik condition of morbidity (B.S.) and hence helpful in the disease Amavata. Virechana works well by clearing the morbid doshas, which adhere to Bahya (Rasa etc.) and Madhyama (Marma-Asthi-sandhi) Roga Marga with the tiyaka gamana. Nittyavirechana helps to normalize the pratiloma gati of vata, which produces symptoms like Anaha, Antrakujana, Kuskshikathinya, Kukshishoola etc. in the disease Amavata. Acharya Charaka has given brief description of how Virechana dravyas acts inthe body: The drug here Eranda taila having Ushna-tikshna-sukshma guna reach to theheart by virtue of their potency and circulate through the large and small srotasa andpervade the entire body. Then they liquefy the morbid elements by virtue of itsAgneya guna and disjoins them by its tikshna guna. Then this liquefied morbid massfloating like honey in uncted vessels through the virtue of Anu pravanbhava of thedrug and ultimately reaches Amashaya. From here it forces the morbid factorsthrough the anal canal root due to the Bhautika predominancy of the Jala and Prithviand Adhobhagahara prabhava (Ch. K. 1/4) leading to Virechana.Bruhat Saindhavadi Taila Which is indicated in amavata and used for anuvasana basti as a poorvakarmafor niruhabasti so that it prepare the kosta by its snigdha gunas to receive Niruhabasti. A Comparative Study of Virechana karma and Basti karma in Amavata 142 W.S.R.T. Rheumatoid Arthritis
  • 155. DiscussionTaila mainly possess katu, tikta, lavana and madhura as rasas, laghu, teekshna ruksha,snigdha, sukshma, guru and vyavayi as guna, ushna in veerya, katu in vipaka. Most of the drugs show deepana, pachana, vatanulomana and shothaharaproperties. All the drugs have vatahara and shushma guna and are especiallybeneficial in amavata. This taila was prepared taking eranda taila as base.Erandamooladi niruha Basti The shodhana therapy is a must to treat the disease amavata successfully.Among the shodhanas, basti is said to be ideal as it pacifies both ama and vata.Astangasangrahakara Vagbhata has appreciated the role of Erandamooladi niruhabastiin the treatment of Kaphavata disorders like amavata.Probable Mode of Action of Yogabasti The ingredients of Erandamooladi niruha basti mainly possess deepana,pachana, ushna, sukshma, laghu, ruksha, snigdha, teekshna and lekhana gunas. Thesegunas helps to alleviate ama and vata in the body. In the disease process of amavata, we find the laxanas of avarana vata in thejoints, because of obstruction to flow of vata by ama. The main seat of vata ispakwashaya, hence the eliminative therapy is directed to pakwashaya. After theadministration of basti, the basti dravya is retained only for a limited period inpakwashaya. Even then it can be assumed from the effect produced that, theessentials are absorbed into the system. The drugs analysis of Erandamooladi niruha basti shows that manydrugs of them have deepana and pachana guna, which directly influences the kostagniand thereby dhatagni which in turn leads to pachana of already existing ama andchecks the further production of ama. A Comparative Study of Virechana karma and Basti karma in Amavata 143 W.S.R.T. Rheumatoid Arthritis
  • 156. Discussion It reaches the various parts of the body like sandhis and minute channels likeby its sukshma guna and liquifies the doshas which was present in various forms.Liqification of them is caused by ushna, teekshna lekhana gunas which in turndecreases the sroto abhishyandana, meanwhile usna and snigdhata guna of the contentpacifies the vata. Gomutra, which is the chief content, is helpful to reduce the shothaand ruja as it is mainly indicated in ama. Erandamooladi niruha basti action is seen up to minute channels, where it doesthe lekhana of collected ama and kapha resulting in their liquefaction, whichdecreases the abhishyandi, picchila, guru etc. gunas of ama. At the same time it doesthe srotovishodhana there by decreasing the srotobhishyandana which inturn leads tovatanulomana because of removal of obstruction and finally expels ama and kaphavata out of the body. Brihat saindhavadi taila given along with it does the above said functions as itcontains drugs having similar properties and pallets vata by snehana guna. Thecombined action of these two drugs helps in samprapti vighatana. As all the drugs of Erandamooladi niruha basti have sufficient qualitiesthrough which they can combat the ama, vata and kapha, it seems logical to say that acombination of these drugs can be a potent procedure to treat amavata. But the question is how these drugs are absorbed into the system. None of theresearch wear conducted conclusively to solve this question. But here the difficultyarises in understanding the mode of their absorption and efficacy when administeredin the form of basti but in one interesting quotation Parashara says;mulam gudam shareerasya sirasthatra prathi stithahasarvam shareeram pusnanthi murdhanam yavadashritaha (Ch.Si.4) A Comparative Study of Virechana karma and Basti karma in Amavata 144 W.S.R.T. Rheumatoid Arthritis
  • 157. Discussion This reference says the importance of guda and how it nourishes the otherparts of the body through its siras. The rectum has a rich blood and lymph supply and drugs can cross the rectalmucosa like the other lipid membranes, thus, unionized and lipid soluble substancesare readily absorbed from the rectum the portion absorbed from the upper rectalmucosa is carried by the superior haemorrhoidal vein into the portal circulation,where as that absorbed from the lower rectum enters directly into the systemiccirculation via the middle and inferior hemorrhoidal vein. Even though it is difficult to draw a conclusion regarding the mode of actionof basti, according to the modern pharmacokinetics, the classical literature ofayurveda provides certain concepts, which facilitates one to understand the mode ofaction based on ayurveda principles. The significant improvement in Shoola, Shotha, Stabdata and Ushnatachanges in the basti group when compared to the Nittyavirechana group justifies thatbasti is a more efficient treatment for amavta. Basti has got both doshapratyanika andvyadhi pratyanika effect on the disease Amavata.Discussion along with the argument of results obtained is as follows:General Description of Patients: General description of the patients studied in thepresent series was as follows:Age: All the 33 patients registered for the present study were ranging from 20 to 60years, of which maximum patients (33.33%) were between 31 to 40 years age group,which was followed by 26.66% patients in the age group of 20 to 30 years.Observations of this study were in accordance with the findings of RheumatoidArthritis in middle age (Price and Davidson). A Comparative Study of Virechana karma and Basti karma in Amavata 145 W.S.R.T. Rheumatoid Arthritis
  • 158. DiscussionSex: In this study majority of the patients were female (73.33%) as compared tomale patients (26.66%). Textual references also reflects the predominance ofRheumatoid Arthritis in femalesReligion: Majority of the patients in this series were Hindus (90%), which may bedue to predominance of Hindu community in this particular region.Occupation: Most of the women registered were housewives i.e. 66.66%, whichreflects the general occupation of majority of the females in this area.Economical Status: Majority of the patients i.e. 53.33% in this series were belongingto poor economic status, while rest of the patients(43.33%) were belonging to middleclass and upper middle class (3.33%) economic status. It may be due to the fact that,this study was conducted in a general hospital, where free treatment facilities areavailable. Another possibility was that middle and lower class people are more proneto stress and strain, which may precipitate the disease Amavata.Habitat: Majority of the patients (65.78%) in the present study was from urban area.This may be due to geographical location of the hospital in the urban area.Family History: 86.84% of the patients of this study reported negative family historyof joint disorders whereas 13.15% patients reported positive family history. But togive any conclusion regarding the relation of family history with the incidence ofdisease Amavata, a large-scale survey of the patients is required.Education: In the present study maximum no. of patients (73.69%)were educatedfrom primary to graduate level, while remaining were uneducated (26.31%). It may bedue to urban habitat of the patients.Addiction: Majority of the patients (53.33%), in the present study did not have anyaddiction, tobacco chewing was 33.33% and smoking was 13.33%. All these A Comparative Study of Virechana karma and Basti karma in Amavata 146 W.S.R.T. Rheumatoid Arthritis
  • 159. Discussionaddictions come under Ahitashana and Vishamashana, which lead to Mandagni andformation of Ama. So, addiction may also play role in the aggravation of the diseaseAmavata.Diet: 73.33% patients in the present study were Vegetarian. This data is onlyreflection of predominant diet in this region.Deha Prakriti: In this study, it was found that maximum number of patients i.e. 50%were possessing Vatapitta Prakriti (Table no. 12) followed by 30% Vatakaphaprakriti. In general Kapha Prakriti will have Mandagni leading to Ama formation,which when provoked by Vata and gets settled in respective Sleshma sthana. So, it isjustifiable that Kapha vata prakriti persons are easily prone to Amavata.Sara & Samhanana: Distribution of patients based on Sara & Samhanana indicatesthat maximum no. of patients were of Avara Sara (52.63%) and MadhyamaSamhanana (71.05%).Satva: Majority of the patients in the present study were possessing Madhyama Satva (65.78%) and Avara Satva (26.31%), while only 7.89% were of Pravara Satva.In the Avara and Madhyama Satva persons, stress and strain of daily life mayprecipitate or aggravate the disease Amavata.Satmya: Majority of the patients (63.15%) were of Madhyama Satmya followed byPravara Satmya (23.68%) and Avara Satmya (6.88%).Koshtha: In the present study majority of the patients i.e. 40% had mrudu Koshtha,which was followed by Madhyama Koshtha in 23.33% of the patients it is followedby Krura kosta in 20%. In general Vata and Kapha Prakriti persons, have Krura andMadhyama Koshtha. It justifies the finding of Prakriti, as Prakriti wise distribution ofthis study reveals that maximum no. of patients possess Kapha Vata Prakriti. A Comparative Study of Virechana karma and Basti karma in Amavata 147 W.S.R.T. Rheumatoid Arthritis
  • 160. DiscussionDesha: All the the patients i.e. 100% were from Gadag area i.e. Jangala desha due tothe location of the city in Jangala desha.Chronicity: In the present study, 90% of the patients gave history of chronicity ofmore than one year. It may be due to the fact that Amavata is a chronic disease.Deha Bala: In the present study, majority of the patients (52.63%) were having AvaraDeha Bala, while remaining (47.36%) were having Madhyama Deha Bala. None ofthe patient in the present study was having Pravara Deha Bala. It may be due to thechronic course of the disease, due to which Deha Bala of the patients graduallydeclinesRheumatoid Factor: 33.33% patients, in this study were seropositive . Thisobservation corroborates very well with textual reference (Davidson – 1994).Nidana: Majority of the patients in the present study gave the history of 80% of eachGuru and Mandagni and Samyoga virudhasevana (53.33%) Ahara Sevana, andPrakrivirudha, Samayavirudha ware found of 50%. All these factors leads toMandagni and consequently to the formation of Ama. So it can be concluded that allthe above-mentioned factors play an important role in precipitation and aggravation ofthe disease Amavata.Cardinal Features: Regarding the cardinal features of Amavata, all the patients hadSandhishoola (100%), Sandhishotha [100%), Sandhigraha in 100% and Sandhiushnata also in 100%.General Features: Among the various general features of Amavata, Angamarda andAruchi ware found in 80% of patients and other symptoms observed were Gaurava83.33%, Jwara and Trishna43.33%, Alasya 76.66%, Apaka 56.66%, Nidraviparyaya A Comparative Study of Virechana karma and Basti karma in Amavata 148 W.S.R.T. Rheumatoid Arthritis
  • 161. Discussionand Kostabadhata in 46.66%, Bahumootrata in 30%, Bhrama in 20% and Chardi in10%.Dosha: Maximum number of patients had involvement of Kapha vatavriddhi prakopa[ie46.66%] followed by Vata vriddhi and prakopa in Amavata [ie 16.66]Srotasa: Maximum number of patients had the dushti of Asthivaha, Rasavaha,Majjavaha, Purishavaha, Raktavaha and Annavaha srotasa, which is in accordancewith the main srotasa involved in the disease processInvolvement of Joints: Majority of the patients presented with classical involvementof Hastasandhi, Padasandhi, Gulphasandhi and Janusandhi.Rheumatoid Nodules & Deformity: In this study, 2.63% of the patients hadRheumatoid Nodules and 9 patients had various types of deformity of the joints. Itmay be due to chronic nature of the disease.Effect of the treatment In this study the effect of treatment was assessed on the basis of changesobserved in different sandhi after the treatment in Sandhisoola, Sandhishotha,Sandhistabdata and Sandiushnata. The results are discussed parameter wise as hereunder:Effect on Hasta 79.44% relief was observed in Hasta among the patients of Yogabasti group(group B), 62.78% relief was found among the patients of Nittyavirechana group(group A). The improvement was statistically highly significant in both the groups andcomparatively Hasta had better relief in Yogabasti group. A Comparative Study of Virechana karma and Basti karma in Amavata 149 W.S.R.T. Rheumatoid Arthritis
  • 162. DiscussionEffect on Pada 76.78% relief was observed in Pada among the patients of Yogabasti group(group B), 54.99% relief was found among the patients of Nittyavirechana group(group A). The improvement was statistically highly significant in both the groups andcomparatively Pada had better relief in Yogabasti group.Effect on Gulpha 59.44% relief was observed in Gulpha among the patients of Yogabasti group(group B), 51.11% relief was found among the patients of Nittyavirechana group(group A). The improvement was statistically highly significant in both the groups andcomparatively Gulpha had better relief in Yogabasti group.Effect on Trika 73.33% relief was observed in Trika among the patients of Yogabasti group(group B), 60% relief was found among the patients of Nittyavirechana group (groupA). The improvement was statistically highly significant in both the groups andcomparatively Trika had better relief in Yogabasti group.Effect on Janu 70.24% relief was observed in Janu among the patients of Yogabasti group(group B), 63.33% relief was found among the patients of Nittyavirechana group(group A). The improvement was statistically highly significant in both the groups andcomparatively Janu had better relief in Yogabasti group. A Comparative Study of Virechana karma and Basti karma in Amavata 150 W.S.R.T. Rheumatoid Arthritis
  • 163. DiscussionEffect on Uru 95% relief was observed in Uru among the patients of Yogabasti group (groupB), 60.72% relief was found among the patients of Nittyavirechana group (group A). The improvement was statistically highly significant in both the groups andcomparatively Uru had better relief in Yogabasti group.Effect on Siro 85.72% relief was observed in Siro among the patients of Yogabasti group(group B), 85.72% relief was found among the patients of Nittyavirechana group(group A). The improvement was statistically highly significant in both the groups andcomparatively Gulpha had same relief in both groups.Effect on Hb% 2.21% increment was observed in Hb% among the patients of Yogabasti group(group B), 3.38% increment was found among the patients of Nittyavirechana group(group A). The improvement was statistically highly significant in both the groups andcomparatively Hb% had better improvement in Nittyavirechana group.Effect on ESR 43.59% reduction was observed in ESR among the patients of Yogabastigroup (group B), 51.58% reduction was found among the patients of Nittyavirechanagroup (group A). The improvement was statistically highly significant in both the groups andcomparatively ESR had better improvement in Nittyavirechana group. A Comparative Study of Virechana karma and Basti karma in Amavata 151 W.S.R.T. Rheumatoid Arthritis
  • 164. DiscussionEffect on Ama: Comparison of effects on symptoms of Ama in two groups reveals that, betterimprovement was found in patients treated with Yogabasti. The variance of symptomscore before and after the treatment in Yogabasti group was 10.8 and the same inNittyavirechana group was 8.9 confirming the better efficacy of the Yogabasti inrelieving the symptoms of Ama. The change observed between the groups was alsostatistically significant according to unpaired ‘t’ test.Effect on clinical parametersEffect on the range of joint movement: In an average the range of joint movement was increased by 17.58 degrees inYogabasti group as against the increase by 15.29 degrees in Nittyavirechana group.This implies a better improvement in the range of joint movements in patients treatedwith Yogabasti though the statistical analysis by adapting the unpaired ‘t’ test doesnot justify the significance of variation between the groups.Effect on foot pressure: Comparison of effects of treatments on foot pressure indicates that Yogabastigroup has an edge over the Nittyavirechana in improving the foot pressure after thetreatment. The difference in the mean foot pressure in the Yogabasti group was 9.54kgs as against 8.25 kgs in Nittyavirechana group. Statistical analysis by unpaired ‘t’test could not rule out the possibility of chance factor in causing such a variancebetween the groups.Effect on hand grip power: Yogabasti was found to be more efficacious in improving the hand grip powerin comparison to the Nittyavirechana. After the treatment in Nittyavirechana groupthe increase in the mean handgrip power was 24.95 mm of Hg as against 27.25 mm of A Comparative Study of Virechana karma and Basti karma in Amavata 152 W.S.R.T. Rheumatoid Arthritis
  • 165. DiscussionHg in Yogabasti group. Of course this variation between the groups was statisticallyinsignificant (P=0.744).Effect on general functional capacity: The analysis of the functional disability in both the groups showed thatfunctional capacity of the patients has increased following the treatment. Thefunctional disability score reduced to the tune of 0.9 in both the groups, recording nodifference in the efficacy of two treatments when compared.Over all effect of treatment in both group: Comparison of the overall effects of the treatment in both the groups revealsthat Yogabasti is more efficacious. Major improvement of the illness was observed in06(40%) of the patients in Yogabasti group as against 01(6.66%) of the patients inNittyavirechana group. 09(60%) of the patients in Yogabasti group recorded moderateimprovement, where as 11(73.33%) patients have show moderate improvement inNittyavirechana. 03(20%) of the patients showed minor improvement inNittyavirechana. From the foregoing it is clear that both Yogabasti and Nittyavirechana are veryeffective in the patients suffering from Amavata.Results The results of the study confirmed that both Nittyavirechana and Yogabastihave their own role in the management of amavata as the patients belonging to bothgroups showed remarkable reduction in the symptoms. After the treatment when overall assessment was done to assess improvementbetween the groups. The Yogabasti group shown 40% Major improvement, where asNittyavirechana group shown 6.66% Major improvement, here Major remission hasbeen considered looking into symptomatic relief of the patient. As the disease is A Comparative Study of Virechana karma and Basti karma in Amavata 153 W.S.R.T. Rheumatoid Arthritis
  • 166. Discussionyapya or have autoimmune origin, the complete relief from the disease process cannotbe expected. Moderate improvement was observed in 60% of cases in Yogabastiwhere as in Nittyavirechana group showed moderate improvement in 73.33%, minorimprovement was seen in 20% of cases of Nittyavirechana group and which is nofound in Yogabasti group. This signifies that Yogabasti possibly had a greater role inthe management of amavata. At the end of Deepanapachana with vaishwanara churna treatment there wassignificant change in that reduction of Ama laxshana was observed in both the groups.this signifies there is some role of vaishwanara churna to bring down Amavasta inamavata. But there is no significant difference between the two groups. From this analysis, it becomes evident that effect of Yogabasti was morebeneficial in Shoola, Shotha, Stabdata and Usnata of different Sandhis, whencompared to that of Nittyavirechana group. But as the disease is yapya orautoimmune nature the completely permanent remission cannot be expected. Considering the different incidence and there by generalizing the observationsand results in a population in an incidental study will be inappropriate. More over thesample size is minimum, ie. 30 patients maintaining the accurate homologocitybetween the 2 groups was practically impossible due to difference in various factorslike mode of manifestation of symptoms, chronicity. Influence of dietric factors etc.from patient to patient. Hence allotment of the patients to different groups could notand cannot be equal whatever be the care taken to maintain the homologicity. A Comparative Study of Virechana karma and Basti karma in Amavata 154 W.S.R.T. Rheumatoid Arthritis
  • 167. ConclusionConclusion Disease amavata can be correlated to rheumatoid arthritis, which is one among the chronic destructive polyarthritis systemic disease. The exact etiology of the disease remains unknown, but the pathognomic nidana like ama is believed to be acts as autoantigen, which triggers the immunological reaction in genetically susceptible individuals. The disease amavata is diagnosed on symptomatology specific laboratory tests like RF help in diagnostic and ESR help in assessment of treatment given, the criteria laid down by American Rheumatism Association 1988 which comprises 7 criteria which helps in the diagnosis of RA. Some of the pravruddha amavata laxana and upadravas can be considered as the extra-articular manifestations of amavata (RA). As the disease is genetic and autoimmune in origin the permanent complete remission is not possible. The specific ayurvedic line of management and drugs helps in decreasing the autoantigens and may acts as modifying the immune response to autoantigens. At the same time the drugs are safe can be given for longer duration without any adverse effects. Both virechana and basti group have their specific role in the management of amavata but the clinical study revealed that Yogabasti has a significant role as higher percentage of reduction in symptoms. The active principles of Yogabasti are antagonistic to ama and may acts as antiinflammatory. A Comparative Study of Virechana karma and Basti karma in Amavata 155 W.S.R.T. Rheumatoid Arthritis
  • 168. ConclusionSuggestions for Further study. 1. Study on large samples. 2. Study on Nityavirechana followed by basti. 3. Study on langhana, deepana, virechana followed by basti. A Comparative Study of Virechana karma and Basti karma in Amavata 156 W.S.R.T. Rheumatoid Arthritis
  • 169. SummarySummary Keeping in mind to evaluate the role of shodhana basti over the virechana inthe treatment of amavata, the study was formulated to evaluate the effect of Yogabastiover virechana by eranda taila. The dissertation was made into two parts; the first part contains theintroduction, need for study, historical revive and revive of literature of Virechana,Basti, Amavata and Drugs. Definition, etymology, history, nidana panchaka,classification, upadrava, sadhyasadhyata and treatment of amavata according to theclassics and the etiology. pathogenesis, clinical features, diagnostic, differentialdiagnosis prognosis, complications and treatment of rheumatoid arthritis. In thesecond part the materials and method, observation, results and discussion was made. In this comparative study 30 patients were incidentally selected and groupedinto A as Nittyavirechana group and B as Yogabasti group. Nittyavirechana groupwas treated with vaishwahara churna as deepana pachana and Eranda tailaNittyavirechana for 8 days. But group B received a course of Yogabasti withErandamooladi niruha and Bruhatsandhavadi anuvasana. The duration of thetreatment for both the groups was 24 days. The criteria laid down by ARA (in 1987& 1967) were applied for the diagnosis and assessment of the treatment. The observation of the study included the epidemiological features of thedisease. Doshic involvement, the prakruti, agni, kosta and such other factors from theayurvedic perspectives. It was observed that amavata vis-a-vis RA usually appears in between secondand fifth decades of life. The people belong to urban area, females, poor class,having more susceptible for the disease. The disease is more prevalent in people of A Comparative Study of Virechana karma and Basti karma in Amavata 157 W.S.R.T. Rheumatoid Arthritis
  • 170. Summaryvatapitta and vatakapha prakruti, mandagni, madhyama kosta persons and theinvolvement of vata and kapha appear as a prominent feature. The mean scores of Shoola, Shotha, Stabdata and Ushnata about the jointsbefore and after the treatment of both the groups were subjected for students‘t’ testwith paired and unpaired methods. A significant response was obtained in both groups with the percentagereduction in symptoms. After the treatment, when overall assessment was done toassess improvement between the groups. The Yogabasti group shown 40% majorimprovement where Nittyavirechana group shown only 6.66% major improvement.Moderate improvement was observed in 90% of cases in Yogabasti where as 73.33%moderate improvement and 20% minor improvement was seen in Nittyavirechanagroup. Change in Hb% and ESR value also observed between two groups, but itshows the beneficial effect of Nittyavirechana over Yogabasti group. At the end of treatment there was significant change in shoola, shotha,stabdata and ushnata in Yogabasti group compared to Nittyavirechana group showingthe P value < 0.001. This signifies that Yogabasti possibly had a greater role in themanagement of amavata. A Comparative Study of Virechana karma and Basti karma in Amavata 158 W.S.R.T. Rheumatoid Arthritis
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  • 180. Bibbilography 195) Rajaradha Kantadeva Bahudarena, Shabdha kalpadruma, 3 rd edn. Varanasi : Choukambha Sanskrit Series office ; 1967. p 183. 196) Amarasimha, Amarakosha Manushyavarga Pundit Vishwanath Jha, editor. Delhi: Motilal Banarasi Das; 1976. 197) Ashtangasangraha Suthrasthana chapter 21, sloka 36. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996. 198) Vagbhata, Ashtangahridaya Suthrasthana chapter 13, sloka 25. Varanasi: Krishnadas Academy; 1982.p.187. 199) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 1 - 5th sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 460,461. 200) Vagbhata, Ashtangahridaya Suthrasthana chapter 13, sloka 23-24. Varanasi: Krishnadas Academy; 1982.p.187. 201) Sushrutha, Sushruthasamhitha sutrasthana, “Dalhana” comentry, chapter 21, sloka 5, edited by vaidya jaadavaji trikamji acharya,Varanasi: Chaukhambha Sanskrit Sansthan; 1980.p102. 202) Agnivesa, Charakasamhitha Sutrasthana chapter 12. sloka 4. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.172. 203) Ashtangasangraha Suthrasthana chapter 1, sloka 26. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996, p-7. 204) Ashtangasangraha Suthrasthana chapter 19, sloka 1. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996, p-. 205) Agnivesa, Charakasamhitha Sutrasthana chapter 12. sloka 4. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.172. 206) Sharangadhara, Sarngadharasamhitha Utharakhanda chapter 5, sloka. 3rd ed. Varanasi: Chaukhambha Orientalia; 1983. 207) Agnivesa, Charakasamhitha chikitsasthana chapter 28, sloka 4. Varanasi: Chaukhambha Sanskrit Sansthan; 1994.p.775. 208) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 1st sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 460. 209) Haritha Samhita Varanasi: Krishnadas Academy; 1980, p- 201. 210) Anjana nidana, Agnivesha edited by Ramchandra Shastri Kinjavadekara, Chitrashala Mudranalaya, Pune (1940). 211) Ashtangasangraha Suthrasthana chapter 9, sloka 7. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996.p.200. 212) Agnivesa, Charakasamhitha Sutrasthana chapter 26. sloka 86-87. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.362. 213) Ashtangasangraha Suthrasthana chapter 9, sloka 9. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996.p.201. 214) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 10st sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 462. 215) Agnivesa, Charakasamhitha chikitsasthana chapter 28, sloka 19. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994.p.780.A Comparative Study of Virechana karma and Basti karma in Amavata 168 W.S.R.T. Rheumatoid Arthritis
  • 181. Bibbilography 216) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 7th sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 461. 217) I bid sloka 6-10.p.462. 218) I bid sloka 7-10.p.461, 462. 219) Agnivesa, Charakasamhitha chikitsasthana chapter 20, sloka 20. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994.p.581. 220) Sushrutha, Sushruthasamhitha.uttarasthana chapter 46. sloka 6. Varanasi: Krishnadas Academy; 1980. p.739. 221) Sushrutha, Sushruthasamhitha sutrasthana, “Dalhana” comentry, chapter 15, sloka 4, edited by vaidya jaadavaji trikamji acharya,Varanasi: Chaukhambha Sanskrit Sansthan; 1980.p.67. 222) Agnivesa, Charakasamhitha Sutrasthana chapter 28. sloka 9. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.429. th 223) Agnivesa, Charakasamhitha Sutrasthana chapter 18. 4 ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.249. 224) Sushrutha, Sushruthasamhitha sutrasthana, “Dalhana” comentry, chapter 15, sloka 24, fourth edition ; edited by vaidya jaadavaji trikamji acharya,Varanasi: Chaukhambha Sanskrit Sansthan; 1980.p.72. 225) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 10st sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 461. 226) I bid sloka 6-10.p.461,462. 227) Bhavamishra,Bhavaprakasha Nighantu. Chapter 26, sloka 282-290 Edited by G.S. Pande. , 6th edn. Varanasi : Choukambha Bharati Academy ; 1982. 228) Bhaishajyaratnavali, chapter 29, sloka 20-25.Edited by Ambikadatta Shastry, 15th edn. Varanasi : Choukambha Sanskritha Sansthana ; 2002, p- 435. 229) Yogaratnakara, Indradeva Tripathi, 1st edn. Varanasi: Krishnadasa Academy ; 1998.P 564-566. 230) Gadanigaha: chapter 22, sloka 6-12 Sodhal with Vidyotini Hindi commentary by I.D. Tripathi, editor Ganga Sahaya Pandey, ed. 3, Chaukhambha Sanskrit Bhavan (1999), p-544. 231) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 11th sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 463. 232) I bid sloka 12.p.464. 233) I bid sloka 6.p.462. 234) I bid sloka 7-10.p.463. 235) Haritha Samhita Varanasi: Krishnadas Academy; 1980. 236) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 10st sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 462. 237) Vagbhata, Ashtangahridaya nidanasthana chapter 1, sloka 6-7. Varanasi: Krishnadas Academy; 1982.p.463. 238) Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 12th sloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 464.A Comparative Study of Virechana karma and Basti karma in Amavata 169 W.S.R.T. Rheumatoid Arthritis
  • 182. Bibbilography 239) Chakradatta, chapter 25, sloka 19-20. Edited by Jagadeeshwar Prasad Tripati, 5th edn. Varanasi : Choukambha Sanskrit Office; 1983, p-229. 240) Bhavamishra, Bhavaprakasha, Edited by Bhishagrashro th Bhramhashankara Mishreshastry, 5 edn. Varanasi : Choukambha Sanskrit Sansthan ; 241) Bhaishajyaratnavali, Edited by Ambikadatta Shastry, 15th edn. Varanasi : Choukambha Sanskritha Sansthana ; 2002, p-435. 242) Agnivesa, Charakasamhitha Sutrasthana chapter 22. . 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.288. 243) I bid 244) Sushrutha, Sushruthasamhitha.chikitsasthana chapter 32. sloka 21. Varanasi: Krishnadas Academy; 1980. p.514. 245) Sharangadhara, Sarngadharasamhitha poorvakhanda chapter 4, sloka 1.Varanasi: Chaukhambha Orientalia; 1983.p.17. 246) I bid 247) Ashtangasangraha Suthrasthana chapter 27, sloka 30. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996, p-476. 248) Bhavamishra, Bhavaprakasha, chapter 25. Edited by Bhishagrashro Bhramhashankara Mishreshastry, 5th edn. Varanasi: Choukambha Sanskrit Sansthan ; 249) Bhaishajyaratnavali, Amavatadhikara. Edited by Ambikadatta Shastry, 15th edn. Varanasi : Choukambha Sanskritha Sansthana ; 2002, p-435. 250) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W. B. Saunders company, Philadelphia, Pensylvania. P 1225. 251) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by Blackwell science limited Paris, France. P 7-8. 252) API text book of medicine, Edited by G. S. Sainani, 6th edn. Mumbai : Association of Physicians of India ; 1999. p 1028. 253) Arthritis and Ayurveda by Dr. K. Nishteshwara. P 3. 254) Robins pathologic basis of disease by Cotron et al, published by Harwart pvt limited. Lajpat nagar, N. Delhi. P 140-142. 255) Henry N, Ginsburg, Ira J. Goldburg, Harrison’s Principles of International Medicine, 14th edn. New York. : Mc Graw Hill Companies 1998. p 1933. 256) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W. B. Saunders company, Philadelphia, Pensylvania. P 1225-1230. 257) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by Blackwell science limited Paris, France. P 27-38. 258) API text book of medicine, Edited by G. S. Sainani, 6th edn. Mumbai: Association of Physicians of India; 1999. p 1028. 259) Robins pathologic basis of disease by Cotron et al, published by Harwart pvt limited. Lajpat nagar, N. Delhi. P 1405. 260) Henry N, Ginsburg, Ira J. Goldburg, Harrison’s Principles of International Medicine, 14th edn. New York. : Mc Graw Hill Companies 1998. p 1929-30. 261) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by Blackwell science limited Paris, France. P 90-91. 262) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W. B. Saunders company, Philadelphia, Pensylvania. P 1230-1231.A Comparative Study of Virechana karma and Basti karma in Amavata 170 W.S.R.T. Rheumatoid Arthritis
  • 183. Bibbilography 263) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W. B. Saunders company, Philadelphia, Pensylvania. P 1230-1232. 264) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by Blackwell science limited Paris, France. P 98-106 & 114. 265) API text book of medicine, Edited by G. S. Sainani, 6th edn. Mumbai : Association of Physicians of India ; 1999. p 1028. 266) Robins pathologic basis of disease by Cotron et al, published by Harwart pvt limited. Lajpat nagar, N. Delhi. P 140-142. 267) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W. B. Saunders company, Philadelphia, Pensylvania. P 114-115. 268) Challenge in RA by Haward A. Bird et al, 1st edition 1999, published by Blackwell science limited Paris, France. P 1230-1232. 269) Text book of Rheumatology, by Kelly et al, 5th edition, Published by W. B. Saunders company, Philadelphia, Pensylvania. P 114-115. 270) Bhavamishra, Bhavaprakasha, chapter 26, sloka 50. Edited by Bhishagrashro Bhramhashankara Mishreshastry, 5th edn. Varanasi : Choukambha Sanskrit Sansthan 271) Yogaratnakara, Indradeva Tripathi, 1st edn. Varanasi: Krishnadasa Academy ; 1998. Sloka 1, p 107. 272) Yogaratnakara, Indradeva Tripathi, 1st edn. Varanasi: Krishnadasa Academy ; 1998.Sloka 1, p 107. 273) Agnivesa, Charakasamhitha Sutrasthana chapter 13. sloka 12. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p.182. 274) Sushrutha, Sushruthasamhitha.chikitsasthana chapter 31. sloka 5. Varanasi: Krishnadas Academy; 1980. p-508. 275) Chakradatta, chapter 25, sloka 45-48. Edited by Jagadeeshwar Prasad Tripati, 5th edn. Varanasi: Choukambha Sanskrit Office; 1983, p-231. 276) Ashtangasangraha kalpasthana chapter 4, sloka 5. Prof.K.R.Shrikhantamurthy, editor. Varanasi: Chaukhambha Orientalia; 1996, p-440.A Comparative Study of Virechana karma and Basti karma in Amavata 171 W.S.R.T. Rheumatoid Arthritis
  • 184. SPECIAL CASE SHEET FOR “AMAVATA”[RA] Post Graduate Studies and Research Centre (Panchakarma) Shri. D.G.M.Ayurvedic Medical College, Gadag.Guide : Dr. G. Purushottamacharyalu M.D (Ayu), M.A (Asto)Co-Giide : Dr. Shashidhar H Doddamani M.D (Ayu)Scholar : Suresh N. Hakkandi1. Name of the patient : Sl. No.2. Father’s/Husband’s Name : OPD No.3. Age : ………... yrs IPD No.4. Sex : Male/Female Bed No.5. Religion : Hindu Muslim Christian Others6. Occupation : Sedentary Active Labor Others7. Economical Status : Poor Middle Upper middle Higher8. Diet : Veg Mixed9. Address : …………………………. Phone No. …………………………. E- Mail: …………………………. Pin code:10. Date of Schedule of Initiation:11. Date of Schedule of Completion:12. Result : Completely Good Moderate Poor No Relieved Response Response Response Response13. Consent : I here by agree that, I have been fully educated with the disease and treatment. Here by satisfied whole-heartedly, and accept the medical trial over me.Investigator’s Signature. Patient’s Signature 1
  • 185. Pradhana vedana1) Local features of joints:Sl.No Different joints Ruja Shotha Sthbdata Ushnata BT AT BT AT BT AT BT AT1. Hasta2 Pada3 Gulpha4 Trika5 Janu6 Uru7 Sira2) Associated complaints :Sl.No B/T A/T A/T/F1 Jwara2 Angamarda3 Aruchi4 Apaka5 Trushna6 Alasya7 Bahumoolrata8 Hrullasa9 Gourava10 Agnimandya11 Lalasrava12 Nidra viparyaya13 Chardi14 Bhrama15 Murcha16 Hrudgraha17 Kosta baddata18 Anga shunyata 2
  • 186. II) History of Patient Illness : Mode of onset Insidious Acute Systemic Palindrome Oligo articular Poly articular Mono articular Symmetrical Asymmetrical Sequence of joins involved 1)__ 2) __ 3) __ 4) __5)__ 6)__7)___ Nature of disease Progressive Regressive Constant Intermittent Routine actives affected Mild Moderate Severe Not affected III) History of the Past Illness: IV) Previous treatment History: V) Family History: VI) Personal History: 1) Ahara Vegetarian Taste Sweet Sour Salt Mixed food Predominance Pungent Bitter Astringent 2) Jatharagni Manda Teekshna Vishama Sama 3) Pureesha Pravritti : vibandha Dravavit Prakrita Frequency 4) Mutra Pravritti : Frequency Day Night Mutra Daha 5) Nidra Sukha Alpa Ati Vishamya 6) Vyasana Smoking Alcohol Tobacco No Habits 3
  • 187. 7) Artava Pravritti Days Samanya Alpa Adika RajonivrittiVII) Examination of Patient ( Vital) 0 1) Pulse / Min 2) Blood mm Hg Presser 3) F Temperature 4) Height / Min 5) Respiration /Min 6) Weight KgVIII a) Special Examination (Ayurveda)1. Nadi V P K VP VK PK VPK2. Prakruti V P K VP Vk PK VPK3. Sara Pravara Avara Madhayama4. Samhanana Susamhita Asamhita Madhyma Samhita5. Pramana Height in Cms Weight in Kgs6. Satmya Ekarasa Sarvarasa Ruksha Sneha7. Satwa Pravara Avara Madhyama8. Ahara Shakti Abhyavaharna Jarana9. Vyayam Shakti Pravara Avara Madhayam10. Vaya Balya Yauvana Vardhakya11. Desham (Deha) Bhumi Jangala Anupa SadharanaNidana Aahara Vihara OthersGuru bhojana Virudha Chesta MandagniVirudha Bhojana Prakruti Virudha Avyayama Samaya Virudha Vyayama after snigdha bhojana Samyoga Virudha AtivyayamaSamprapti GhatakasDosha DushyaAdhistana SrotasRoga Marga UdbhaavasthanaSancharasthana VyaktasthanaAdhistana Srotodusti 4
  • 188. VIII b) Special Examination (Joints) Sakha Pareekshaa Scores Before After After Followup Deformity of joints Darshan Swelling a Rhumatic nodules Muscle wasting Skin over the joint Warmth over joint Tenderness Swelling Intra Sparshana articular Extra (peri) articular Bursitis Tenosynovitis Synovial thickening Bony Components Palpable Shravana (Crepitation)VIII c) Special Examination (Extra articular manifestation) Extra articular manifestation Before After After Follow Up Low Grade Fever Loss of appetite Loss of Weight Fatigue Muscle Wasting Anemia Sicca SyndromeVIII d) Assessment of Investigations Sl.No Name of the Test Baseline Values Final Values 1 ESR mm of 1st hour mm of 1st hour 2 Hb% mg% mg% 3 CRP 4 ASO Titer 5 RA IX) Upsaya / Anupasaya : 1) Ruksha sweda – Pain Reduced :Yes / No 2) Snigdha sweda – Pain increased : Yes / No X) Types of Amavata : Doshanubandha Kalanubandha Vataja Pittaja Kaphaja Naveena Pravrudha Jeerna 5
  • 189. XI) Treatment Protocol: For Group-A Patients: Nitya Virechana Poorva Karma Amapachana Drug Used Vaishawanara Choorna No. Days Pradhana Karma Eranda Taila Nitya Quantity Time of No. of Virechana used Administration Vegas 1st day 2nd day 3rd day 4th day 5th day 6th day 7th day 8th dayPaschat Karma :For group – B Patients : Yoga Basti Poorva Karma Amapachana Drug Used Vaishawanara Choorna No. Days Pradhana Karma Sl.No Particulars AB NB AB NB AB NB AB AB 1 Dravya 2 Pramana 3 Date 4 Time 5 Pratyagamana Kala 6 Annya Vasti Vyapat 7 MiscelaneousPaschat KarmaSignature of Co-Guide Signature of Guide Dr. S.H.Dodmani Dr. G. Purshottamacharyulu M. D (Ayu) M. D.(Ayu) 6

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