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Amavata gokshura-kc

  1. 1. “MANAGEMENT OF AMAVATA WITH SPECIAL REFERENCE TO RHEUMATIOD ARTHRITIS PATIENTS OF POSITIVE RHEUMATOID FACTOR” By Dr.Samina M. Sindgikar.B.A.M.S., Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In Partial Fulfillment of the requirements for the degree of DOCTOR OF MEDICINE (AYURVEDA) In KAYACHIKITSA Under the Guidance of Dr.S.G.Mangalagi M.D (Ayu) Professor Department Of Post Graduate Studies in Kayachikitsa Government Ayurveda Medical College, Mysore –570 021. Co-Guide Dr.Gopinath. MD.(Ayu), Professor Department of Post-Graduate Studies in Kayachikitsa,, G.A.M.C., Mysore. DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA GOVERNMENT AYURVEDA MEDICAL COLLEGE, MYSORE. 2010 i
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  7. 7. Dedicated to My Beloved Brother Late. Nadeem Ahmed vii
  8. 8. ACKNOLEDGEMENT I am highly indebted to my Guide Dr.S.G.Mangalagi, Professor and former H.O.D. of P.G. Studies in Kaya Chikitsa, Government Ayurvedic Medical College, Mysore for his valuable suggestions and guidance in completing this work successfully. I submit my heartfelt thank to him for all his encouragement and help in the success of my endeavor. I am highly indebted to my beloved parents Sri.Mohmmad Akil, Smt.Husain Banu and my brothers Sri.Khudabaksh, Mr.Faruk and my sister Shabana and their children’s Imran, Habib, Nilofer, Parwaiz Afshan, Mazeen Akhtar, Nayeem,Tuba Tazeen, and Ashraf , for their everlasting love and affection throughout my career. I sincerely bow my head to late Dr.M. Ishwar Reddy. I am thankful to Dr.Aruna Professor and H.O.D. of P.G. Studies in Kaya Chikitsa, Government Ayurveda Medical College, Mysore, for her timely help during my study. I am thankful to my co-guide Dr.Gopinath for his timely help during my study. I am thankful to Dr.Ashok.D.Satpute our Principal, Govt. Ayurvedic Medical College Mysore. for his timely help during my study. I wish to convey my thanks to my teachers Dr.Shantaram, Dr Umashankar, Dr. Naseema. Akthar, Dr. Chandramouli H.M., Dr.Gajanana.Hegde, Dr. Uma soudi, Dr. Rajendra, Dr.Ksheersagar, Dr.Maitrey for their encouragement during my studies. I am highly indebted to my long time well wisher Mr.Channabassappa. Kodli for his constant help, affection and love throughout my career. I wish to thank Physicians, other staff of the hospital, college staff and library staff for their kind co-operation. viii
  9. 9. I wish to convey my sincere thanks to my P.G colleagues i.e. my classmates, seniors and juniors for help & co-ordination during my Clinical trial. I wish to thank late Dr. Shakuntala for their encouragement during my studies I am thankful to my friends Dr.Usha kiran, Dr.Usha, Dr. Kiran Gowda, Dr. Nirmala and Dr. Jyothi, Dr.Nasreen, Dr. Pankaja, Dr.Jagdeesh yaji, Dr. Geeta.p. I wish to convey my thanks to Dr.Arun.Shrivastava Immunologist KLE medical college and hospital Belgaum, and Dr. R.M.Umargi M.D. Physician Bijapur for their timely suggestions during my study. My special thanks to Dr.Ananthshayana, his wife Mrs. Veena, his mother and daughter Dhruthi for their constant help throughout my P.G study. My special thanks to my class mates Dr.Ranjani, Dr.Vyasraaj, Dr. Pallavi, Dr. Kiran kumar, and my junior Dr. Sridhar Murthy. I am thankful to Dr.Karthik.Pandith Proprietor S.N. Pandit Ayurvedic Pharmacy, Mysore. for the preperation of shunti gokshura kashyaya, Nimbamrutha eranda taila. I am thankful to Dr.Jeetandra. Shetty and Dr.lalitha my friends and Proprietor Prakruthi Remedies pvt. Ltd. Karwar for the preperation of maharasnadi kwatha and Bruhatsaindhavadhya Taila, and constant help throughout my P.G study. I acknowledge my sincere thanks to Dr. Lancy D’ souza for helping in statistical analysis and interpretation. I wish to thank all my patients without whom the study wouldn’t have happened. I express my thanks to one and all, who have helped me directly & indirectly with apologies for my inability to recall them individually. Dr.Samina M Sindgikar ix
  10. 10. LIST OF ABBREVIATIONS MN - Madhavanidana BP - Bhava Prakasha YR - Yoga Ratnakara HS - Hareeta Samhita GN - Gada Nigraha SKD - Shabda Kalpa Druma CD - Chakra Datta BYT - Bruhat Yoga Tarangini YT - Yoga Tarangini BR - Bhaishajya Ratnavali VS - Vanga Sena BRJ - Basavarajeeyam RRS - Rasa Ratna Samucchaya AV - Amavata RA - Rheumatoid Arthritis A.D - Atanka Darpana A.H - Astanga Hridaya A.K - Amarakosha A.S - Astanga Sangraha A.T - After Treatment B - Basavarajeeyam B.N.R. - Brihat Nighantu Ratnakara B.P - Bhava Prakasha B.R - Bhaishajya Ratnavali B.S - Bhela Samhita B.T - Before Treatment C.D - Chakra Datta C.K - Chikitsa Kalika C.S - Charaka Samhita x
  11. 11. Ch - Chikitsa sthana D.G.V - Dravya Guna Vijnana Dur - During treatment G.A - Gray’s Anatomy G.N - Gada Nigraha H.A - Human Anatomy H.S - Hareeta Samhita HS - Highly Significant I - Indriya sthana I.M.M - Indian Materia Medica K.S - Kashyapa Samhita Kal - Kalpa sthana M.M.H - Materia Medica of Hindus Ma - Madhyama khanda Ni - Nidana sthana NS - Not Significant P.I.M - Principles of Internal Medicine P.P.S - Principles & Practice of Surgery P.S - Pathology for the Surgeon Pu - Poorvakhanda R.R.S - Rasa Ratna Samucchaya S.E.D - Sanskrit English Dictionary S.K.D - Shabda Kalpa Druma S.M.D - Stedman’s Medical Dictionary S.S - Sushruta Samhita S.Y - Sahastra Yoga Sh - Shareera sthana Sh. S. - Sharngadhara Samhita SS - Statistically Significant Su - Sutra sthana U - Uttara tantra Ut - Uttarardha V.S - Vanga Sena Vi - Vimana sthana xi
  12. 12. Y.R - Yoga Ratnakara Y.T - Yoga Tarangini ABSTRACT Background and Objectives: The present study was intended on the disease Amavata with special reference to Rheumatoid arthritis patients of positive rheumatoid factor. Objectives of the study was • to evaluate combined effect of Amavata chikitsa in patients of positive rheumatoid factor. • Studying the changes in rheumatoid factor titer values before and after treatment. Methods: Total 20 patients having classical signs and symptoms of Amavata (RA) were included in the study after diagnosing according to ARA Criteria, and patients having positive rheumatoid factor were selected for the study. Patients were assigned into single group Materials used for the study were 1. Shuntydi kwatha 2. Sapthamusthi yusha 3. Maharasnadi kwatha 4. Simhanada guggulu 5. Nimbamrutha eranda taila for virechana 6. Brihat saindhvdhya taila for anuvasana 7. Niruha basti The parameters were Sandhishotha (joint circumference), Erythrocyte sedimentation Rate and rheumatoid factor titer, clinical assessment and functional xii
  13. 13. assessment data were collected on the first day, 15th day, after 30th day and after 48 days of treatment. Statistical methods applied: • Descriptive statistics ,cross tabs procedure, paired samples t test • The statistical analysis was done by using the rheumatoid titer value in comparison with various intervals of treatment using paired t test and Repeated measure ANOVA. Interpretation and conclusion As the disease is genetic and autoimmune in origin the permanent complete remission is not possible. The drugs used acts as antioxidants and immunomodulator. Hence controls the disease Amavata. In the present study it was noted that pts. felt considerable reduction in morning stiffness, pain and swelling. Out of 20 patients in 65% of patients the titer values decreased, in 15% of patients showed negative values, 15% of patients showed increase in the values and 5% showed no change in values. Keywords: Amavata Rheumatoid Arthritis Shunti gokshura kwatha Sapthamusthi yusha Nimbhamruthadi eranda taila Triphala kshara basti Simhanada Guggulu Maharasnadi Quatha xiii
  14. 14. Valuka sweda. CONTENTS Introduction 1 Objectives 3 Review of Literature Vyutpatti 4 Nirukthi 5 Nidana 7 Samprapti 11 Poorvaroopa 20 Roopa 21 Bheda 29 Upashaya Anupashaya 32 Sapeksha Nidana 33 Sadhyasadhyata 36 Upadrava 37 Investigations 40 Chikitsa 43 Pathya-apathya 62 Drug review 63 Previous works 66 Methodology 67 Observation & Results 76 Discussion 96 Recommendations 99 Conclusion 100 Summary 102 Bibliography 111 Annexure 113 xiv
  15. 15. List of Tables Sl.. No Tables Page # 1 Showing the Nidana of Amavata according to different acharayas 7 2 Showing the samanya lakshanas of Amavata 21 3 Showing the pravridha Amavata lakshanas 22 4 Showing the doshanubandhi lakshanas 23 5 Similarity between Amavata and rheumatoid arthritis 28 6 Showing the Sapeksha Nidana 33 7 Showing the shamanaushadhis according to different authors 48 8 Showing properties of shunti gokshura kwatha 50 9 Showing the properties of maharasnadi kwatha 51 10 Showing the properties of Simhanada guggulu 54 11 Showing the properties of dravyas used for Sapthamusthi yusha 55 12 Showing the properties of Brihat saindhvdhya taila 56 13 Showing the properties of Triphala kashya 58 14 Showing the properties of nimbamruthadi eranad taila 59 15 Yoga basthi 70 16 Showing incidence of Amavata on the basis of age 76 17 Showing incidence of Amavata on basis of sex 76 18 Showing the incidence of Amavata on the basis of their education 77 19 Showing the incidences of Amavata according to their socio- economic status 77 20 Showing the incidences of Amavata according the occupation 77 21 Chi-square of SEX, OCCU, EDU, location, SES, FH. 78 22 Showing the incidences of Amavata according to Ahara 78 23 Showing the incidences of chronicity of the disease 78 xv
  16. 16. 24 Chi-square test of chronicity of the disease 78 25 26 Showing the location Showing the incidences of family history 79 79 27 Showing changes in rheumatoid titer value 79 28 Stastical analysis of joint circumference 80 29 Stastical analysis of joint circumference 80 30 Stastical analysis of snadhi shoola 82 31 Contingency Coefficient of snadhi shoola 82 32 Stastical analysis of snadhi shoota 82 33 Contingency Coefficient snadhi shoota 83 34 Showing the Stastical analysis of morning stiffness 83 35 Contingency Coefficient of morning stiffness 83 36 Showing the Stastical analysis of range of movement 84 37 Contingency Coefficient of range of movement 84 38 Showing the Stastical analysis of rise of local temperature 84 39 Contingency Coefficient of rise of local temperature 84 40 Showing the Stastical analysis of General functional capacity 85 41 Contingency Coefficient of General functional capacity 85 42 Statistical analysis of walking time 86 43 Contingency Coefficient of walking time 86 44 Statistical analysis of grip strength 86 45 Contingency Coefficient of grip strength 87 46 Showing the statistical analysis of foot pressure 87 47 Contingency Coefficient of foot pressure 87 48 Master chart 105 xvi
  17. 17. Illustrations Page # 1 Showing the depiction of Nidana 10 2 Showing the samprapti 14 3 Pathogenesis of Rheumatoid Arthritis 17 4 Showing the probable mode of action sthanika sweda 72 5 Mean of knee joint circumference 80 6 Mean of Elbow joint circumference 81 7 Mean of Ankle joint circumference 81 8 Mean of Wrist joint circumference 81 9 Incidence of sex 89 10 Incidence of occupation 89 11 Incidence of chronicity 89 12 Incidence of family history 90 13 Rheumatoid factor 90 14 Statistical analysis of sandhi shoola 90 15 Statistical analysis of shootha 91 16 Statistical analysis of morning stiffness 91 17 Statistical analysis of Range of movements 92 18 Statistical analysis of rise of local temperature 92 19 Statistical analysis of General functional capacity 93 20 Statistical analysis of walking time 93 21 Statistical analysis of Grip strength 93 22 Statistical analysis of Foot pressure 94 23 Showing the Mean Value of Rheumatoid Factor 94 24 Showing the Mean Value of ESR 94 xvii
  18. 18. List of Figures SL.NO. FIGURES PAGE# 1 Showing swan neck deformity, ulnar deviation, Boutenniere 18 2 Showing normal joint, osteo arthritis joint and rheumatoid arthritis 18 3 Showing deformities in the hands 19 4 X-ray showing radiological changes 19 5 Shunti 65 6 Gokshura 65 7 Kulatha 65 8 Pippali 65 9 Mudga 65 10 Yava 65 11 Mulaka 65 12 Dhanyaka 65 xviii
  19. 19. Amavata possess a challenge to the physician owing to its apparent chronicity, incurability, complications and morbidity. The disease has a high resemblance to rheumatoid arthritis; despite of the administration of best available modern drugs, the disease has a tendency to persisting progress and cripples the patients. It is commonest among chronic inflammatory joint diseases in which joints become swollen, painful, and stiff. No doubt allopathic system of medicine has got an important role to play in overcoming agony or pain, restricted movement and crippling caused by the articular disease. Drugs are available to ameliorate the symptoms due to inflammation in the form of NSAID’s and the long term suppression is achieved by the DMARD’s. But most of the NSAID’s have gastrointestinal side effects whereas DMARD’s have bone marrow, renal and hepatic suppression. Hence, the management of this disease is merely insufficient in other systems of medicine and patients are continuously looking with a hope towards Ayurveda to overcome this challenge. Till now more than 214 works have been carried out at various Ayurvedic institutions out of which 5 research works have been carried out at GAMC Mysore, this large number of works itself suggests faith of patients in Ayurvedic management. All the above researchers tried with single, compound herbal and herbomineral medicine to evaluate their efficacy. But the study was mainly based on classical signs and symptoms of the disease. In this present work the study is under taken with special reference to patient having “positive rheumatoid factor” and the changes in the “titre value” which are studied before and after treatment. The presence of rheumatoid factor is of prognostic significance because patients with high titer tend to have more severe and progressive disease with extra articular manifestations. A test for the presence of rheumatoid factor is employed to confirm a diagnosis in individuals with a suggestive clinical presentation and if present in high titers to designate patients at risk for severe systemic disease. So also the complete chikits sutra is adopted in the present study.
  20. 20. Prevelance of RA is approximately 0.8% of population (range 0.3 to 2.1%) between the age of 35 and 50 years. There is a female prepondarence of 3:1 and 70% cases being between the ages of 25 and 59.
  21. 21. To evaluate combined effect of amavata chikitsa in patients of positive rheumatoid factor. Studying the changes in rheumatoid factor titer values before and after treatment.
  22. 22. Shabdha vyutpathi nirukti and paribhasha Ama and vata are the two important factors in the pathogeneesis of the disease amavata. Ama Ai –prefix to verbs and noun-means –near, near to, or towards. M –poison The product which is near to poison or act like poison is ama. Ama (sthri)-Aa+Am+karmanimatra-pakarahitam-means being undigested.1 Ama (pum)-amayate eshath pachyate iti-means subjected to incomplete digestion.2 Amaya is a synonym of vyadhi for the most of disease caused by ama. Nirukti Due to hypo functuning of Agni the apkwa rasa dhatu formed in amashaya is ama.3 Apakwa, asamyukta, durgandha and bahupichila rasa dhatu formed in amashaya is ama.4 According to some acharyas –apakwa annarasa is ama.5 -accumulation of mala is ama.6 -1st stage of vitiation of dosha is ama.7 The toxic substance formed by the interaction of virulent doshas 8 . Samanya lakshanas of ama- Srotorodha, balabramsha, gowarava, anilamudhata, alasya, apaka, nisteva, malasanga, aruchi and klama.9 The ama when mix with doshas then it is called as Sama dosha.
  23. 23. ruksha abhilasha and upashaya from katu ruksha dravyas.10 Vata The term vata is drived from VA gati gandhanayoh means to move, to enthuse, to make known, to make aware of, effort and to enlighten.11 According to sharangadhara, shareera vata is that force which keeps the kapha, pitta, dhatus, malas in motion, very much like the wind which proples the clouds from one place to other in the sky.12 Amavata nirukthi Pum (amo apako hethu vataha swanama khyata roga visheshaha) –the term amavata indicates its samprapthi.13 Pum amayati peedayati ama. Amayati-to be afflicted. Peedayati-to annoy or torment.14 Amam cha vatam amavata- ama and vata unite to form the word amavata. The vitiated ama and vata involve the trika sandhi and other joints producing the disease amavata.15 Rheumatoid arthritis It wasn't until 1859 that the disease earned a proper name. Sir Alfred Garrod, the London physician, coins the clinical term 'Rheumatoid arthritis' and the first reference is made in medical literature.16 The antibody known as the rheumatoid factor is isolated in the blood of people with rheumatoid arthritis. The test was first developed by Dr Eric Waaler in 1940 and developed by Dr H.M. Rose and colleagues. It is therefore still occasionally referred to as the Rose-Waaler or Waaler-Rose test. 17 An autoantibody is an antibody (a type of protein) manufactured by the immune system that is directed against one or more of the individual's own proteins. It is derived from the Greek "auto" which means "self", "anti" which means "against" and "body".18
  24. 24. peripheral joints in a symmetric distribution. The potential of the synovial inflammation to cause cartilage destruction and bone erosion and subsequent changes in the joint integrity is the hallmark of the disease. Despite its destructive potential, the course of RA can be quite variable. Some patients may experience only a mild oligoarticular illness of brief duration with minimal joint damage, where as others will have a relentless progressive polyarthrits with marked functional impairment.19
  25. 25. The nidana of amavata as explained by different acharays are listed below, Table 1: showing the nidana of amavata according to different authors Sl.No. MN VS GN BYT HS YR BP 1 Virudhahara + + + + - + + 2 Viruddha Cheshta + + + _ - + + 3 Mandagni + + + + + + + 4 Nischalata + + + _ - + + 5 Vyayama soon after snigdha bhojana + + + _ - + + 6 Kandashakha sevana _ _ _ + + _ _ 7 Vyavaya _ _ _ + + _ _ 1) Viruddhahara –dietry unwary or the diet which is inamicable to the body. 2) Viruddhacheshta –unwholesome habits. 3) Mandagni –slugghishness of Agni. 4) Nishchalata -Sedentary Life 5) Snigdha bhuktavato vyayama –exercise or any type of heavy physical activity soon after heavy food.20 6) Kandamula sevana –consuming of under ground modified tubers. 7) Vyavya. Virudhahara The food taken in larger quantity and having qualities like guru, sheeta,
  26. 26. In which factor causes Utklesha (provoking) of Dosha, in the body with having the capacity of eliminate them out of the body are called Viruddha. 22 Virudha chesta Viruddha Chesta is not clearly mentioned in the Ayurvedic classics, the habits which exerts unfavourable effect on the body are considered as virudha e.g. Suppression of natural urges (Vegavidharana), Day time sleeping (Divasvapa), Awakening at night (Ratrijagara), Performing such acts which are beyond one's capacity (Sahasa), Cold water bath (Sheetodaka Snana), Exposure to eastern wind, Sleeping on a uneven bed. Mandagni Is the root cause of all the diseases, sluggishness of Agni takes place due to its own causes i.e. ajeerna, abhojana, atibhojana, upavasa, which results in production of ama, leading to jatharagnimandya as a result the strength and functions of dhatwagni and bhutagni are decreased.23 Due to mandagni proper nourishment to dhatu does not take place which leads to dhatu kshaya and inturn it leads to vitiation of vata. Nishchalata Physical inactivity or sedentary life stye is responsible kapha vridhi resulting in Agni mandya and ama formation. Snigdha Bhuktvato Vyayama: Usually exercise is done on empty stomach, but exercise after consuming snigdha, guru ahara causes amavata. Normally a good blood supply is very essentials in gastro-intestinal tract for the digestion of heavy meal. But when a person indulges in any type of physical activity just after consuming meal, blood circulation to the skeletal muscle increases
  27. 27. Kandamula sevana The kanda mula as explained in hareeta samhita are pindashaka, surana, palandu, alu, tanbula, vranakanda, hastikanda, varahakanda, which are heavy to digest and having guru, snigdha and manda gunas leading to impairment of agni and formation of ama. Aetiology of Rheumatoid Arthritis Acc to modern science the exact cause is still to be explored. The most accepted concept regarding R.A. is that it is an Auto-immune disorder. The possible causative factors are: 1. Heredity: The disease is triggered by T- lymphocyte activation in genetically predisposed individuals with defined HLA class II haplotypes.24 2. Infection: Infectious agents like Mycoplasma, E-B Virus, CMV, and ParvoVirus or Rubella virus may be having a role in the manifestation of R.A. A persistent infection of articular structure or retention of microbialproducts in the synovial tissue generates a chronic inflammatory response.25 3. Super Antigen Driven Disorder: Super Antigens are proteins producedby a number of micro-organisms like Staphylo-cocci, Strepto-cocci, and M.arthritidis etc. They have capacity to bind to HLA-DR molecules and Tcellreceptors, which stimulates specific T-cells. The micro organism corresponse to the micro-organism might induce an immune response to
  28. 28. 5. Endocrine Secretions: The incidence of R.A. in females and striking amelioration during pregnancy has suggested a possible disturbance of gonadal functions. Some studies suggest that women with R.A. have reduced fertility because antispermatozoan or antiovarian antibodies may be involved in auto-immune diseases.Endocrine factors play a part in 20 – 25% cases which occur within a year of menopause.27 6. Autoimmunity: Most recently R.A. has been classified among the diseases of Auto-immune disorder, due to immune response against autologous immunoglobulin G (Ig. G) .It has been suggested that sensitization to self antigens could be a consequence of enzymatic or free radical change to proteins such as Immunoglobulin (IgG) or type II collagen leading to the development of idiotypic antibodies or a defect in glycosylation of IgG.28 7. Psychological Factors: Clinical experiences support this concept, that in certain patients, the course of the disease appears to be influenced by emotional and personality factors. Illustration no. 1 showing the depiction of nidana in disease process. Viruddhaharadi nidana sevana Exogenous antigen Amotpatti Genetic succeptibility Individual host response Kha vaigunya
  29. 29. Immune complex mediated tissue injury ( antigen- antibody reaction) Amavata/ Rheumatoid Arthritis SAMPRAPTI Ama is morbid factor, which plays vital role in causing amavata, the quality of ama present in amavata is slimy in nature and posses different colour due to involvement of all the three doshas in it. Such a state of ama in close association of vata dosha circulates all over the body through dhamani and gets lodged in kaphasthana (shleshmasthana pradhavathi). This refers to sandhi because sleshka kapha is located in sandhi.29 “Vayuna prerito hi amaha sleshmasthanam pradhavati Sleshakaha sandhishu sthitaha sleshyathi yojayati sandinam karotiti shleshakaha30 It is observed that circulating ama causes shotha and shoola particularly in those sandhis where in ama and doshas are lodged--- karoti sarujam shotham yatra dosha prapadhyate sadoshe rujyate atyartham.31 This can be correlated to migratory charater of pain, which occurs in rheumatic fever. Ama exhibits toxic effects in the body and abhishyandhana occurs toxic effects in the body and abhishyandana occurs. Bhavaprakasha commenting on the world Abhishyandana opines that there is congestion in the blood vessels which carries rasa rakta to the affected sandhis (rasavaha siravarodham krutva) due congestion there is inflammation of small blood vessels and heaviness occurs in the joint (samsrutya rasavaha siravarodham krutva
  30. 30. yathastu sirabhyaha sa dhrudaha smrutaha). Further severly vitiated doshas in association with ama enters into the heart and produces haviness in the heart (gouravam hrudayasya cha). The role of ama and vata is vital in causing amavata, therefore when both simultaneously enter into trika sandhi the body gets stiffness. Trika sandhi is composed of iliosacral joint. “Yugapatkupitavantaha trikasandhi praveshakou” .32 As the disease progress shotha and shoola affects other joints too. They are HastaSandhi, Hastanguli, Manibanda, Koorpara, Pada sandi, Gulfa sandi, Jaanu sandhi, Trika Sandhi, Shira Sandhi. 1) Sanchaya Avastha (1st stage of Samprapti): This stage, represent the first phase of Dosha Dushti. Sanchaya of dosha instead of free circulation as in its normal state is the doshika vitiation. Vitiated Doshas are the root causes of disturbance of Jatharagni, which cause of formationof Ama. In case of Amavata, two processes take place simultaneously. One is excessive formation of Ama and other is vitiation of Tridosha i.e. Vata.A person consuming Viruddha Ahara proper digestion of food does not take place resulting in formation of Ama. Ama because of its Guru, Sheeta, Sthira, Snigdha and Picchila guna further reduces the Agni. 2) Prakopa Avastha (2nd stage of Samprapti): In this stage, the accumulated dosha becomes vitiated while remaining at its site. During this stage, the dosha becomes virulent andcapable of inflicting others, but remains at their own site during this stagealso. Hence, if the person continues to take a causative factor of Amavata, dhatukshaya and dhatvagnimandya may arise. Dhatukshaya appears due to deprivation of nutrient material because instead of Adya Rasa Dhatu only Ama is produced. Dhatvagnimandya will be result of sluggishness of
  31. 31. and macro channels. The accumulated stagnated andaggravated doshas start circulating towards sleshma sthana with the action of vitiated Vata. This Ama gets Prasara to sleshma sthana producing mild Sandhi Shotha etc. Ama gets interacted with Tridosha and further modified (Vidagdha) to great extent and Yogapata Kupitavanta of Ama and Vata takes place via Rasavaha Srotasa (Dhamini). 4) Sthana Sanshraya Avastha (4th stage of Samprapti): In this stage, during circulation when the vitiated Dosha come in contact with such a tissue whose micro channels are either with or drainage, then they interact with that tissue to produce the lesion therein. Thus, along with Ama, Vata circulates in the whole body and gets settled in the Sleshma Sthana especially the Sandhi. So, after lodging of the Ama and vitiated Vata, pathogenesis starts in the Sandhi Sthana. This stage is also called the stage of Dosha Dushya Sammurcchana and also known as Purva Rupa Avastha. In this stage, the Purva Rupa the disease appears, primarily the disease is not manifested completely, so any initial mild symptoms like Aruchi, Apaka etc. are observed which can be considered as Purvarupa of the disease Amavata. 5) Vyakti Avastha (5th stage of Samprapti): In this stage, the patient is not managed or the patient continuous to indulge in the etiological factors then the disease passes to the next stage where manifestation of the disease occurs and it is known as Vyaktavastha. So, in this stage pathogenic feature of Amavata like Sandhi Shotha, Sandhi Ruja, Sandhi raha and Gaurava becomes completely manifested. In this stage, typical pain present in Sandhi like scorpion sting. In Adibala Pravritta cases i.e. Karmajanya, Matri-Pitri Apacharajanya etc. Khavaigunya is already there and with the minor Nidana Sevana disease inmanifested. 6) Bheda Avastha (6th stage of Samprapti) :
  32. 32. changes taking place gets complicated in the Doshas, Dushyas, Srotasa, etc. are unusual unpredictable profound greatly damaging and irreversible. In chronic stage of Amavata lead untreated it reaches Bheda Avastha producing Upadrava like Sankocha, Khanjata, etc. As regards the samprapti of Amavata, all the authors who have dealt with it have given an unanimous opinion i.e. Illustration no. 2 showing the samprapti Viruddha ahara Contact with antah koshta Kledaka kapha, samana vayu, agni becomes disturbed Process of digestion get deranged Ama produced in Amashaya Ama & dushta dosha enters rasayini Mixes with rasa & rasadushti Dhooshitarasa & rasadhatwagni—rasadhatwagnimandya Ama +dushta kapha produced Dushta kapha+Ama+vidagdha rasa Hrudayagamana by samana vata
  33. 33. Leads to sandhi shotha Amavata Pathology of Rheumatoid Arthritis:- In the early stage of the Rheumatoid Arthritis the most obvious histological changes are confined to the synovial microvasculature. Initially synovial membrane becomes grossly edematous, thickened and hyperplastic, transforming its smooth contour to one covered by delicate and bulbous fronds. The characteristic histologic features are:- 1. Infiltration of synovial stroma by a dense perivascular inflammatory infiltrate composed of lymphoid follicles (mostly CD4 + helper T-cells), plasma cells, and macrophages filling the synovial stroma. 2. Increased vascularity owing to vasodilation and angiogenesis, with superficial hemosiderin deposits. 3. Aggregation of organizing fibrin covering portion of the synovium and floating in the joint space as rice bodies. 4. Accumulation of neutrophils in the synovial fluid and along the surface of synovium but usually not in the synovial stroma. 5. Osteoclastic activity in underlying bone, allowing the synovium to penetrate into the bone forming juxta articular erosion, subchondral cysts and osteoporosis. 6. Pannus Formation - The pannus is a fibro cellular mass of synovium and synovial stroma consisting of inflammatory cells, granulomatous tissue and fibroblasts which causes erosion of the underlying cartilage. In time, after the cartilage has been destroyed, the pannus bridges the opposing bone forming and fibrosis ankylosis which eventually ossifies ultimately resulting in bony ankylosis. Inflammation in the tendons, ligaments and occasionally the adjacent skeletal muscle frequently accompanies the arthritis.
  34. 34. nodules arise in the regions of the skin that are subjected to pressure, including the ulnar aspect of the forearm, elbows, occiput, and lumbosacral area. Less commonly they form in the lungs, spleen, pericardium, myocardium, heart valves, aorta, and other viscera. Rheumatoid nodules are firm; non tendor and round to oval in shape and in the skin arise in the subcutaneous tissue. Microscopically they have a central zone of fibrinoid necrosis surrounded by a prominent in of epitheloid histiocytes and numerous lymphocytes and plasma cells.33
  35. 35. Illustration no. 3 showing the pathogenisis of Rheumatoid Arthritis
  36. 36. Antigen (genetic susceptibility) Antigen presentation to CD4 helper T cells Sensitisation of T-cells Release of cytokines (eg:Iα-2, IFN-γ, INF-α) Macrophage activation Release of cytokines Fibroblasts & chondrocytes synovial cells Release of collagens PGE-2 & other enzymes Chronic inflammation, destruction of bone cartilage, fibrosis Beta cell activation Production of IgG antibodies Autosensitisation of IgG Formation of RF IgG anti IgG complex Immune complex mediated joint injury Fibroblast synovial cell proliferation Osteoclasts activation
  37. 37.   Figure 2 showing normal joint, osteo arthritis joint and rheumatoid arthritis 
  38. 38. Figure 4 X-ray showing radiological changes
  39. 39. POORVA ROOPA As explained in vagasena amavatadhikara. Ajeeranadhyo raso jataha sanchitaha sankramana vai Ama sangaha sa labhate shiro gatra rujakaraha.34 Due to ajeerna the formed ama accumulates in the body and causes shirha and gatra rugha. With these two symptoms early diagnosis of amavata is impossible. In modern, it is described that the prodromal symptoms like fatigue, weakness, joint stiffness, vague arthralgia, myalgia and parasthesia of extremities may precede the appearance of joint swelling by several weeks. Anorexia, weight loss, lethargy and myalgia occur commonly through out its course and may also precede the onset of articualr symptom by weeks or months.
  40. 40. The lakshanas of amavata as explained by different acharays can be categorized and described under the following headings. 1. Samanya lakshanas. 2. Pratyatma lakshanas. 3. Doshanubandha lakshanas. 4. Pravrudha lakshanas.35 Samanya lakshanas. 1.Samanya Amavata lakshanas The constitutional symptoms of the disease are: Table 2 showing the samanya lakshanas of amavata Lakshanas MN GN BP HS BYT RRS VS YR BRT Angamarda + + _ _ + _ + + _ Aruchi + _ _ _ + _ + + _ Trishna + _ _ _ + _ + + _ Alasya + + _ _ + _ + + _ Gourava + _ _ _ + _ + + _ Jwara + _ _ + + _ + + _ Apaka + _ _ _ + _ + + _ Agnimanya + _ _ _ + + + + _ Shoonatanga + _ _ + + + + + _ Sandhishoola _ _ _ + _ + _ _ _
  41. 41. All the diseases have some cardinal features which help in exact diagnosis 1. Sandhishoola is the main complaint and the shoola is severe, continous and vrushikadamshvat, which aggravets after prolonged rest, winter and cloudy weather. 2. Sandhishotha swelling in the joints. 3. Stabdhata i.e. stiffness in the joints or difficulty in joint movements, which is predominant in early morning hours and subsides as the day progresis. 4. Sashbadha sandhi which is explained in yogaratnakara, i.e. crepitations in the joints. Pravrudha amavata lakshana Table 3 showing the pravridha amavata lakshanas Sl. No. Lakshanas MN GN BP HS BYT RRS VS YR BRT 1 Sandhishoola + + + + + _ + + _ 2 Sandhishotha + + + + + _ + + _ 3 Agni mandhya + + + _ + _ + + _ 4 Praseka + + + _ + _ + + _ 5 Aruchi + + + _ + _ + + _ 6 Gourava + + + _ + _ + + _ 7 Utsaha hani + + + _ + _ + + _ 8 Asya vairasya + + + _ + + + + _ 9 Daha + + + _ + + + + _ 10 Bahumootrata + + + _ + + + + _ 11 Kukshi katinatha + + + _ + + + + _ 12 Kukshishoola + + + _ + + + + _ 13 Nidraviparyaya + + + _ + + + + _ 14 Trishna + + + _ + + + + _
  42. 42. 18 Hridgraha + + + _ + _ + + _ 19 Malabaddhata + + + _ + _ + + _ 20 Jaadya + + + _ + _ + + _ 21 Aantrakoojana + + + _ + _ + + _ 23 Aanaha + + + _ + _ + + _ 24 Grahani dosha _ _ _ _ _ _ _ + _ 25 Angavaikalyata _ _ _ + _ _ _ _ _ 26 Peeta mootrata _ _ _ _ _ _ _ _ + 27 Takratulya mootrata _ _ _ _ _ _ + _ + 28 Vasatulya mootrata _ _ _ _ _ _ _ _ + Doshanubandha lakshanas 1. Vatanubandha- severe pain- ruja 2. Pittanubandha- redness burning sensation- daha and raga 3. Kaphanubandha- itiching, heaviness and feeling as if body is covered with wet cloth- kandu, guruta. Table 4 showing the doshanubandhi lakshanas Lakshanas MN GN BP HS BYT VS YR BRT Vatanubandhi Shoola + + + _ _ + + _ Pittanubandha Daha, Raga + + + _ + + + _ KaphanubandhaSthaimitya, + + + _ + + + _
  43. 43. The Shotha is always associated with varying degrees of Shoola, which is because of vitiated Vata. The intensity of pain varies according to the degree of involvement of vata. Usually severe pain, simulating scorpion bite i.e. severe acute burning type of pain, disturbing the sleep is characteristic feature of Amavata. The pain aggravates on oil massage, during cold and cloudy weather in early morning hours and in the night because of samavata. Few joints may be involved in the initial stage and progressively involvement of other joints occurs as the disease advances. The most commonly involved joints are the joints of hand, foot, ankle, hip, wrist, shoulder etc. Inability to perform the movement of the affected joints constitutes the gatastabdata or otherwise this may be termed as stiffness of joints, which is again the consequence of Samaras. The contemporary science also considers joint pain, stiffness and symmetrical swelling of number of peripheral joints as the characteristic feature. The generalized stiffness is frequent after the period of inactivity i.e. in the morning hours, which is also used as quantitative guide to the active inflammatory process. In our science, it can be used as a parameter to assess the degree of Ama involved. Because of the involvement of vitiated rasadhatu and presence of Ama and vitiated vata, the patient exhibits a number of samanya lakshanas.The symptoms like aruchi, apaka, alasya and anga gourava are produced by Ama and angamarda is due to samavata. Jwara and trishna are indicative of rasavaha srotodushti, trishna may also occur because of srotorodha of udakavaha srotas by Ama. These generalized symptoms indicate that vata, kapha, Ama, and rasavaha srotas are mainly involved in the disease process. These may even present in the disease other than Amavata, also where vata, kapha, and Ama are mainly involved.
  44. 44. dhatu and Ama by vata and kapha, the symptoms are produced either directly by the vitiation of doshas or as a sequence of their vitiation on different srotases in the body. Since the food is improperly digested because of agnimandya and due to the presence of Ama, subsequent less production nutrient factors leads to the deprivation of the dhatu, so the patient feels weakness and loss of weight. Persistent Ama and associated vitiated of vata leads to the condition like vibandha, anaha, kukshishoola, antrakoojana, kukshikatinata etc. Hareeta adds amatisara also in these symptoms. The improper digestion leads to the formation of more mala, for this reason, bahumootrata is present. Symptoms of Rheumatoid Arthritis Rheumatoid Arthritis is a systemic disorder, which is manifested by various symptoms. They can be classified into two parts 1. Articular Features 2. ExtraArticular Features Joint features:- Rheumatoid Arthritis is typically distal, symmetrical, small joint polyarthritis involving the proximal interphalangeal and metacarpophalangeal joints of the hands, the wrists, metatarsophalangeal joints, ankles, knees and cervical spine. The shoulders, elbows, and hip are less frequently involved. Any synovial joint in the body may be affected including temporomandibular joints. The periarticular synovial structures, such as bursae and tender sheaths are commonly inflamed. The most common symptoms described by patients are pain and pronounced stiffness. Pain originates predominantly from the joint capsule which is abundantly
  45. 45. accumulation of synovial fluid, hypertrophy of the synovium, and thickening of the joint capsule. The inflamed joints are usually held in flexion to maximize joint volume and minimise distention of the capsule. Later, fibrous or bony ankylosis or soft tissue contractures lead to fixed deformities, warmth is usually evident on examination especially of large joints such as the knee but erythema is infrequent. Muscle wasting serves to accentuate the local swelling of the joint. The swelling of the proximal interphalangeal joints of the hand gives the classical fusiform or spindle shape appearence in the fingers associated with muscle wastings. Progressive destruction of the articular cartilage, subchondral bone and periarticular soft tissues eventually combines to produce the characteristic deformities seen in the long standing rheumatoid arthritis. In parallel with these clinical changes there are characteristic radiological appearance which includes - I. Soft tissue swelling. II. Juxta articular osteoporosis. III. Loss of joint space due to erosion of the articular cartilage. IV. Bone erosions at the points of attachment of the synovium V. Joint deformities. Extra-articular features:- Rheumatoid arthritis is a systemic disease with a variety of extra-articular manifestation. The majority of the patients exhibit atleast some extra articular feature and these tend to be more numerous and more severe in those with high titre of Rheumatoid factor in the blood. Rheumatoid nodules:- Subcutaneous and intracutaneous nodules are a hall mark of the disease,
  46. 46. articular features of the deases are listed below Systemic Musculoskeletal- Fever, Muscle wasting, Weight loss, Tenosynovitis, Fatigue, Bursitis, Susceptibility to infections Osteoporosis. Haematological Lymphatic- Anaemia, Splenomegaly, Thrombocytosis, Felty's Syndrome, Eosinophillia. Vasculitis Cardiac- Digital arteritis, Pericarditis, Ulcers, Myocarditis, Pyoderma gangrenosum, Endocarditis, Mononeuritis multiplex Conduction Defects, Visceral arteritis Coronary vasculitis, Grannlomatous aortitis. Pulmonary Neurological- Nodules Cervical cord compression, Pleural effusions Compression neuropathies, Fibrosing alveolitis Peripheral neuropathy, Bronchiolitis Mononeuritis multiplex, Caplan's syndrome, Occular Amyloidosis- Episcleritis Nodules, Scleritis Sinuses, Scleromalacia Fistulae, Keratoconjunctivitis sicca.36 American Rheumatism Association (A.R.A.) criteria for diagnosis 1988 1. Morning stiffness ( > one hour ) 2. Arthritis three or more joints area. 3. Arthritis of hand joints. 4. Symmetrical arthritis. 5. Rheumatoid nodules.
  47. 47. Comparing the clinical features of amavata and Rheumatoid Arthritis Table 5 similarity between amavata and rheumatoid arthritis Amavat Rheumatoid arthritis Hasta sandhi shootha and shoola Inflammation and severe pain mcp and pip joints Pada sandhi soola and shootha Inflammation and severe pain mtp and sub tarsal joints Hasta gulpha janu sandhi shootha 1st smaller joints of hands feet and symmetrical involvement, next bigger joints are affected Shira sandhi shoal Frequently cervical spine is involved Trik sandi shoola Illiosacral joint is involved Angagowarava Heaviness in the body Angamarda Mayalgia Rujjyate atyartham vyadhidha iva Severe pain in joints with tenderness Jaddyya Limited movements Satabdhata Morning stiffness Angavaikalya Deformity of joints Sankocha Subluxation, ulnar deviation and B/L contractures of elbow Khanja Limping gait due to deformity. Karoti sarujam shotham yatra dosha prapadyate Fleeting and migratory arthritis Hrudgraha / hrudayagowrava Weakness, heaviness and pain in heart
  48. 48. BHEDA A. Classification according to Doshanubandha37 1. Anubandha of one Dosha: i. Vatanubandha ii. Pittanubandha iii. Kaphanubandha 2. Anubandha of two doshas: i. Vatapittaja ii. Vatakaphaja iii. Pittakaphaja 3. Anubandha of three doshas: Tridoshaja: The symptoms of three varieties of eka doshanubandh amavata are explained in visishta lakshanas of Amavata previously. Mixed symptoms are seen in other types of Amavata according to predominance of dosha. B. Classification according to the severity of disease. 1. Samanya Amavata 2. Pravriddha Amavata C. Classification according to the clinical manifestation 38 1. Vishtambi: This type present is with vibandha, udaragourava, anaha, bastishoola. 2. Gulmee:
  49. 49. 3. Snehi: Snigdhata in the body, inactivity, aruchi, passing of unctuous, undigested and dehydrated stools. 4. Pakwama: The symptoms are passing the yellowish, black, or dark bluish dehydrated pakwama from the anus, fatigue, exhaustion. This condition is not associated with bastishoola. 5. Sarvanga: Pricking type of pain in kati, prishta and vaksha region, bastishoola, audible peristaltic sounds, swelling, heaviness in the head, excessive excretion of Ama are the symptoms. In modern science, from the clinical point of view, RA is divided into 3 stages 39 1. Potentially reversible soft tissue proliferations: In this stage, the disease is limited to the synovium. Where synovial hypertrophy and effusion occurs. No radiological abnormalities are seen in X-rays. 2. Controllable but irreversible soft tissue destruction and early cartilage erosion. X-ray shows a reduction in the joint space but the outline of the articular surface is maintained. 3. Irreversible soft tissue and bony changes. The pannus ultimately destroys the articular cartilage and erodes the subchondral bone. The joint becomes ankylosed usually in a deformed position
  50. 50. angavaikalyatha.
  51. 51. UPASHAYA AND ANUPASHAYA There is no direct reference recording upashaya and anupashaya of Amavata in our classics Hareeta explains that sheeta jala snana worsens the condition. Bhavaprakash in the context of samavata explains that snehadi upakramas, during early morning hours, in the night and in the presence of megha(cloudy season) aggravets the disease . These can be considered as anupashaya of the Amavata. Rooksha sweda and ruksha upanaha are useful in cases of Amavata. Along with this, langhana and ushnakala are considered the upashaya of Amavata. In modern scienceit is explained that early morning hours, night and winter season aggravets the disease. The symptoms of Amavata increases mainly during early morning hours and night because of sheeta guna which increases the srotoabhishyandana by provocating both vata and Ama. As the sun rises, because of ushnaguna, amapachana to some extent and pacification of vata leads to dilatation of srotas by which decreases the pain and stiffness in the patient.
  52. 52. Particulars Amavata Vatarakta Krostituka Sheersha Sandhigata vata Age Mainly children young adults Between 20- 40 years After 20 years Above 40 years Dosha Vata-kapha Vata-rakta Vata-rakta Vata Dooshya Rasa Rakta Rakta Ashi Srotas Rasavaha Raktavaha Raktavaha Rasavaha Joints involved Mainly large joints small joints also involved Small joints like MCD, PIP, DIP etc., Knee joint only Any of the weight bearing joint Involvement of heart Involved Rarely involved/ as a later complication Not involved Not involved Deformity of joints Deformity common No residual pathological effects No deformity Occational deformity Symmetrical involvement Symmetrically involved Symmetrical Symmetrical Symmetrical Shifting character Having shifting character No shifting character No shifting character No shifting character Pyrexia Hyper pyrexia Low grade pyrexia occasionally Not present Not present
  53. 53. Systemic Lupus Erythematosis In SLE, the joint involvement is not symmetrical, nor is ankylosis and erosions are common. The presence of antinuclear antibody factor (ANA) is in favour of SLE, although its presence does not confirm SLE. It is present in 25% of cases of RA though in low titers. Osteoarthritis This occurs in old age, one or two larger joints are involved commonly knee. There is complete lack of systemic features of RA, such as jwara (fever) weight loss fatigue etc; the distal interphalangeal joints are often involved hberdens nodes are present. Pain relives after rest, increases as the day progresses. Rheumatic Fever The commonest age group involved is from 5-15 years, usually starts with previous history of evidence for recent streptococcal infection. Presents with fever, arthralgia, carditis, subcutaneous nodules, chorea, with laboratory findings i.e. increased anti streptolysin ‘O’ titre. Acute phase may show leucocytosis, elevated ESR & CRP. Gout There will be history of previous attacks or Gout in ancestors may be present. Joints mainly involved are joints of phalanges, especially the ball of great toe. The attacks usually begin at night with excruciating pain, which subsides towards early morning. The presence of visible urate of sodium may be seen. Psoriatic Arthropathy
  54. 54. Septic Arthritis A joint once affected remains until the source of infection is removed. Suppuration takes place in the joint signs of septicemia may be seen. Tuberculous Arthritis Usually this comes as a secondary manifestation. Signs and symptoms of TB will be present. Gonococcal Arthritis History of gonococal infection or urethritis along with conjunctivitis and irido cystitis may be present. Meningococcal Arthritis It produces cerebrospinal fever, it resembles gonococcal arthritis, except that it is less severe, which produces a rashes may be of purpuric origin, blood culture will be positive for meningococcal organism. Fluid from the joint also contains the organism.
  55. 55. SADHYASADHYATHA Sadhyasadhyatha are the prognostic value of the disease. This can be assessed by the involvement of dosha, datu, rogamarga, roga, rogibala and the nidana panchakas. Accordingly, in Amavata, if there is involvement of single dosha (ekadoshanuga), recent onset, mild symptoms and upadravas are indicative of sadhyata of disease. Involvement of two doshas (Dvidoshaja) suggests the yapyata of the disease. Involvement of all the doshas, swelling throughout the body (Sarvadeha Shotha) chronic and presence of upadravas indicative of asadhyata of the disease 40 In the same way, the course and the prognosis of RA is very much variable, the poor prognosis may be associated with: High titre of RA factor Insidious onset of disease. More than a year of active disease without remission. Early development of nodules. Extra-articular manifestations Early development of erosions. Deformities.
  56. 56. UPADRAVA Madhavakara has mentioned agni dourbalyata, aruchi, gourava, utsahahani, asyavairasya, daha, bahumootrata, kukshikatinata, kuksishoola, nidraviparyaya, trushna, moorcha, hrutgraha, chardi, gourava, vidvibaddhata, antrakoojana and anaha as the upadravas of Amavata. According to Vijayarakshitha, sankocha and khanja are the upadravas. Vachaspathi considers different vatavyadhi dealt in vatavyadhi nidana chapter are additional upadravas. Hareeta mentioned anga vaikalyata as the lakshana of Amavata, which can be considered as upadravas of the disease. Therefore, the following upadravas are dealt in Ayurvedic literature. 1. Sankocha Yogaratnakara mean it as vikunchana that means keeping the affected parts in flexed position. Practically it can be observed that, the position of the affected joint will be mostly flexed. 2. Anga vaikalya Means the structural deformity of shareera, it may in the form of ankylosis or nodule formation. 3. Kanjatha This can be considered as laming or as the change in the gait or inability to walk due to permanent pathological changes took place in the sandhis 4. Vataroga Vachaspathi says that chronic state of Amavatha lead to some Vataja disorder.
  57. 57. Complications of RA can be attributed to a number of pathologic events including laxity of supporting soft tissue structures damage or weakness or weakening of ligaments tendons and the joint capsule; cartilage degradation; muscle imbalance and unopposed physical forces associated with the use of affected joints. These include • Z-deformity Radial deviation at the wrist with ulnar deviation of the digits often with palmar subluxation of proximal phalanges. • Swan neck deformity Hyperextension of the proximal inter-phalangeal joints with compensating flexion of the distal inter phalangeal joints • Boutonniere deformity Flexion contracture of the proximal interphalangeal joints and extension of the distal interphalangeal joints. • Hyperextension of the first interphalangeal joint and flexion of first metacarpophalangeal joint with a consequent loss of thumb mobility and pinch. Typical deformity may also develop in the feet, including eversion of the hind foot (sub-talar joint) plantar subluxation of the metatarsal heads, widening of the fore foot, hallux valgus and lateral deviation and dorsal subluxation of the toes 41 • The extra articular symptoms explained in symptomatology of RA are
  58. 58. Felty's syndrome Consists Chronic RA, Splenomegaly and Neutropenia. Occasionally, anemia and thrombocytopenia, it is most common in individuals with long-standing disease. These patients frequently have high titers of rheumatoid factor, subcutaneous nodules, and other manifestations of systemic rheumatoid disease. Osteoporosis Secondary to rheumatoid involvement is common and may be aggravated by glucocorticoid therapy. 42
  59. 59. No tests are specific for diagnosis of RA Rheumatoid factor. This is an auto-antibody directed against the fragment of immunologlobulin G (IgG) Rheumatoid Factor can belong to any class of immunoglobulins i.e. IgG- IgM+ IgA or IgE but commonly done tests detect only the IgM type of Rheumatoid Factor. It can be detected in the serum of the patient by the following tests Latex fixation test: This is an agglutination test when antibodies are coated to latex particles positivity in titres more than 1/20 is significant sensitivity is 1:64 Rose - Waaler test - In this agglutination test sheep’s red blood cells are used as carrier sensitivity is 60% One method mixes the patient's blood with tiny latex beads covered with human antibodies (IgG). The latex beads clump or agglutinate if rheumatoid factor (IgM RF) is present. Another method mixes the patient's blood with sheep red blood cells that have been covered with rabbit antibodies. The red blood cells clump if rheumatoid factor is present. A titer is an indicator of how much the agglutination test blood sample can be diluted before rheumatoid factor is undetectable. A titer of 1:20 indicates that rheumatoid factor can be detected when 1 part of blood is diluted by up to 20 parts saline. The lab value for rheumatoid factor of 1:20 or less is considered normal. Nephlometry test This method mixes the patient's blood with antibodies that cause the blood to clump if rheumatoid factor is present. A light is passed through the tube containing the mixture and an instrument measures how much light is blocked by the mixture. Higher levels of rheumatoid factor create a cloudier sample and allow less light to pass through, measured in units. The lab value for rheumatoid factor of 23 or less
  60. 60. polyclonal IgG) or 3 (polyclonal IgM to polyclonal IgG) cryoglobulin.43 Hemoglobin Normochromic, normocytic anaemia is frequently present in active RA. It is thought to reflect ineffective erythropoesis. Erythrocyte Sedimentation rate: It is increased in nearly all patients with active RA. Generally, such elevations correlate with disease activity and the likelihood of progressive joint disease. C-reactive protein: The diagnostic significance of the detection of CRP lies in the fact that the rise and fall in CRP serum concentration closely follows inflammatory process of infection and noninfection genesis. The detection of CRP is more sensitive and more reliable indicator for inflammatory processes than the ESR. The specific diagnostic value of the CRP reaction thus lies in the detection of the activity of the inflammatory arthritis in the acute phase while in the chronic stage of RA CRP is only to be detected occasionally Synovial Fluid Analysis: Confirms the presence of inflammatory arthritis, although none of the findings is specific.44 Radiographic evaluation: This consists of X-rays of both hands and of the affected joints. The following features may be present: • Reduced joint space
  61. 61. synovial hypertrophy. • Deformities of hand and fingers
  62. 62. Chakradatta and baisijyaratnavali have described the treatment for the disease which constitutes langhana, swedana, snehapana, anuvasana and ksharabasti. Bhavaprakasha has added ruksha upanaha sweda to these therapeutic procedures. “Langhanam swedanam tikta deepanani katuni cha | Virechanam snehapanam bastiyashcha Amamarute ||45 Rookshaswedo vidhatavyo valukapotalaistata | Upanahascha kartavyate api sneha vivarkjitaha ||”46 Langhana in amavata. Langhana is the first measure adopted in the management of amavata. As amavata is an amashayotha vyadhi with major involvement of rasa dhatu and according to caharaka in such conditions langhana is to be employed. In ch chi 3/283 explains langhana in samvata, and sama dosha cannot be eliminated until the ama becomes pakwa, to attain this langhana is adopted. However care should be taken that langhana is stopped as soon as nirama vata state is attained. Langhana helps the jatharagni to recover to its original strength, causing agni sandukshana and checks the production of ama, thus langhana prevents pathogenesis of ama formation, and excessive ama into pakwavastha. In present work saptha musti yusha is used which promotes digestive fire and helps in pachana. In the absence of ahara pachakagni digests the doshas hence to facilitate mala pachana treatment begins with langhana. In the samprapthi of amavatha vata vitiates from sanchayavastha itself. In samavatha vikaras anashan is not advisible hence laghu bhojana with special consideration to the pathya explained in amavata chikitse is applied here. According to harita samhita pathya advised in jwara chikitse are also said to be pathya in amavat, hence yusha is useful in amavatha. Also in sharangadhara amavata chikitsa saptha musthi yusha is explained.47 According to nava jwara kala maryada 7, 10, 12 days laghu ahara can be
  63. 63. Vimalendriyata, malotsarga, laghuta, ruchi, kshudha, hruth shudhi, udgara shudhi, kantha shudhi, vyadhi mardavata, tandra nasha. Langhana phala in sama dosha Dosha kshaya, agni deepthi, laghutha, swasthya, kshudha, trishna, ruche, ahara paka and also increases bala and oja. Properties of yusha--- yusho balya sthatatha kantya laghu pako kapha pha yusha is balya kantya laghu paka and kapha hara. Snehapana in amavata. Snehapana is contraindicated in amavata; shodhana ropi snehapana is indicated in jeerna amavata. The sneha used should be processed with drugs having tiktha katu rasa and deepana pachana properties. For achiving snehapana prior to shodhan as purva karma and to relive the symptoms of the disease ie to destroy internal environment responsible for the production and nourishment of ama and to achieve dosha pratyanika and vyadhi prtyanika effects.snehapana is specially in jeerna amavata.48 Swedana in amavata. Swedana in general means making the body to sweat or perspire. In management of amavata ruksha sweda has been advocated in the form of valuka potali.49 .Acc. to charaka valuka sweda is a type of ruksaha sweda and acc to su it is a type of tapa sweda. It helps in reducing inflammatory conditions in the body and helps in cleaning the body channels and these aids in the transportation of doshas from shakas to kostha. The application of heat will cause the local blood vessels to dilate, in part due to local spinal cord reflexes, causing the relaxations of smooth muscle. This in turn results in an increased blood flow so enhancing the oxygen and nutrients supply to the area. The effect of topical heat application may penetrate to the depth of 2cms depending on the appliance and duration. A recent study examined the possible anti inflammatory mechanism of action
  64. 64. Tikta katu deepana drugs However, tikta and katu rasa drugs have been described as allevatiative of vatadosha. Yet these are proven value in this disease. This is due to the amapachana activity of these drugs thus helping in the removal avarana, which is the real cause of vata in this disease. Deepana drugs too act through same mechanism. These therapeutic measures also favour the doshas from shakah to koshta. This may be applied in two ways: 1. Katu tikta rasa samskrita ahara 2. Katu tikta rasa pradhana aoushada Tiktha rasa has ruksha and laghu gunas, it does lekhana deepana and pachana action and useful in aruchi, trushana, murcha and jwara, it absorbs kleda and sleshma. Katu rasa is having laghu, ushana and ruksha gunas, it dilates srotases, dries up sneha, kleda and mala and is shootha hara. Katu and tikta rasa are antagonistic to kapha and pittavardhaka. Hence, they reduce dushtakapha on one hand and increase the power of pachakapitta on other. This results in amapachana, which is predominant in Amavata samprapti.50 Virechana: After the administration of langhana, swedana, tikta, katu, and deepana drugs, and the patient should be subjected to virechana therapy since doshas rendered nirama by these therapeutic measures, require elimination from the body by shodhana. Now, the question arises why the virechana alone should be given and not vamana too, because usually vamana precedes virechana. If virechana is given alone, the kapha located in the amashaya may produce mandagni and its consequences. However, this rule has been relaxed in the case of udaradi etc., the same may also be followed in case of Amavata because of the following reasons: a. Production of Ama is the result of avarana of pittasthana by the kledaka kapha and it is the most suited therapy for the sthanika dosha pitta. b. Symptoms of Amavata like anaha, vibandha, antrakoojana, kukshishoola are indicative of pratilomagati of vayu. This is best conquered by
  65. 65. some extent. Therefore, in this way it appears to be the most appropriate therapeutic measures in this condition d. Eranda sneha is considered sresta in amavata.51 The Ricinoleic Acid, Oleic Acid, Linoleic Acid and other fatty acids found in castor oil are very effective in treatment of rheumatism, arthritis, gout etc. They easily penetrate through the skin. Castor Oil is many a times mixed with other medicines for rheumatism to facilitate their penetration and to enhance the effects. Ricinoleic acid is anti inflammatory in nature. 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 the vatadosha, maintains the functions of agni and nourishes the body. The niruha basti eliminates doshas brought into koshta by the langhana and allied therapies. In addition to generalized effect, basti produces local beneficial effects also by removing the anaha, antrakoojana, vibandha etc. Brihathsaindhavadi taila has been mentioned for anuvasana and ksharabasti for asthapana. Depending upon the use of different drugs, basti causes the samshodhana and samshamana effects. Sushrutha has stated that the action of basti is mainly due to veerya. So basti karma eliminates the morbid doshas and from the entire body by srotoshuddhi. Therefore, its effects are tridoshahara. Its effects are not only limited up to a rectum and samshodhana of malas but it produces widespread systemic effects. Basti can produce its effect through medicament effect (Pharmacological effect) and effect of volume (pressure effect). Thus with the effect of suitable medicaments, basti therapy may modify the colonic physiology and alter pathogenic krimis by prakritivighatana . Some recent hypothetical data about how the basti acts, this includes action through the vascular route-action of some modern drugs through myo-
  66. 66. It causes pressure variation of intestinal mucosa and hence artificially created mild shock, that it acts by a curious bio feed-back mechanism. It may also be exercising its effect by helping GI tract to act as an interactive membrane or by correcting both movement related secretion related activity . It corrects and balances dosik profile, it is involved in fluid related activities – by effecting osmotic pressure variation. It promotes a culture medium for ahealthy colony of bacteria and discourages unhealthy bacterial colonies, it is involved in detoxification, it eliminates kapha and pitta at vata sthana cathartic activity.52
  67. 67. Table 7 showing the shamanoushadhis according to different authors Yoga ChD BP BYT YT YR BR GN Rasnadi panchaka kwatha + + + Rasna saptaka kwatha + + + + + + + Suntyadi kwatha + + + + + + Shatyadi kwatha + + + + + Pippalyadi kwatha + + Dashamuladi kwatha + + + Rasonadi kashyaya + + Panchakola kwatha + Madhyama rasnadi kwatha + Maharasnadi kwatha + Rasnadi doshamaula kwatha + Rasnadi kwatha + Erandadi kwatha simhasyadi kwatha + + Punarnava kashyaya + + Rasaka yusha with kanjika + + Vishwa, pathya, amruta kwatha + Guduchi, Nagana, kwatha with pippali churna + Guduchi with sunti kwatha + + + Rasona sura, sindhika, sidhamla Bhalltakadi ch, ajamodadi ch + Panchasama ch. + Hingwadi churna + + + + Nagaradi churna + + + + Vaishwanara churna + + + + Panchakola churna + + + + Chitrakadi churna + + + +
  68. 68. Amrutadya churna + + + + + Triteeya alambhusadi churna + + + Yoga ChD BP BYT YT YR BR GN Sunti gruta + + + Kanjikadhya gruta + + Shringaveradhya gruta + Dhantwantara gruta + Maha sunti gruta + Dweteeya sunti gruta + Maha sunti gruta + Dweteeya sunti gruta + Amrutadhya gruta + + Tailas Bruhat saindhavadi taila + + + + + Mahasaindhavadi taila + Prasarini + Dwipancha muladhya + + + Prasarini leha + Khandasuntyavaleha + + + + Shatyadi kalka + + + Rasona panda + + + + Simhanada Guggulu + + + + Yogaraja Guggulu + + + + + Mahayogaraja Guggulu + Bruhat yogaraja Guggulu + Amrita Guggulu + + Vatari Guggulu + Shiva Guggulu + Punarnava Guggulu + + Ajamodadi vati Amavatadri vatika + + +
  69. 69. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 52  Table 8 showing properties of shunthi gokshura kwatha Drugs Latin name Rasa Guna veerya Vipaka Doshgnata Karmukata Pry Shunthi Zingiber officinale Katu Laghu, snigdha ushana Madhura Kapha vata shamaka Trupthighna, rochana, deepana, pachana,vatanulomana, shothahara, amapachan Kan Gokshura Tribulus terrestis Madhura Guru, snigdha Sheete madhura Vatapitta hara Shothahara, vedanasthapaka, balya, mootrala Pha
  70. 70. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 53  Table 9 showing the propertise of maharasnadi kwatha Drug Latin Name Rasa Guna verya Vipaka P.Anga Doshagnata Karmukata Rasna Pluchea lanceolata Tikta, Guru Ushna Katu Patra Kapha vata hara Shothahara Aama jwaragna, vishagn Eranda Ricinus communis Madhura; kashaya, Katuanurasa Snigdha, teekshna, sukshma Ushna Madhura Mula, Patra, beeja, Taila Kapha vata hara Shothahara, Veda amashodhaka,ang Vasa Adathoda vasika Tikta kashaya Ruksha, laghu Sheetha Katu Mula patra pushpa Kapha pittahara Vedanasthapaka,jw swedajanaka, rakt Duralabha Fagonia Cretica Kashaya, tikta,madhura,katu Laghu,snigdha Ushna Madhura Panchanga Vatapittahara Shothahara Mo raktaprasadaka Kachura Curcuma Zedoria Katu, tikta Laghu, teekshna Ushna Katu Kanda Kapha vata hara Shothahara jwaragna Devadaru Cedrus deodara Tikta Laghu, snigdha Ushna Katu Kandasara, taila Kapha vata hara Shothahara jwaragna Bala Sida Cardifolia Madhura Laghu, snigdha, picchila Sheeta Madhura Mula, beeja Vata pittahara Shothahara jwaragna Mustha Cyperus rotundus Tikta, katu,kashaya Laghu, ruksha Sheetha Katu Kanda Kapha pittahara Shothahara, jw balya, deepana pa Nagara Zingiber officinale Katu, Laghu,snigdha Ushna Katu Kanda Kapha vata hara Sheeta prasham Vedanasthapana jw Ativisha Aconitum heterophylum Tikta, katu Laghu,ruksha Ushna Katu Moola(kanda) Tridoshahara Deepana , paachan amapachana haya Terminalia Lavanavarjita Laghu Ushna Madhura Phala Tridoshaha Shothahara, C
  71. 71. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 54  Chebula kashaya Pradhana ruksha ra vedanasthapana,rasayana,anul omaka, jwaraghna a c a c kshura Tribulus terrestis Madhura Guru, snigdha Sheete madhura Phala Vatapittaha ra Shothahara, vedanasthapaka, balya, mootrala H h narnava Boerhavia diffusa Madura, tikta, katu, Kashaya Lagu, rooksha Ushna Madhura Moola, beeja Tridoshaha ra Shotahara, lekhana, vishagna jwaragna, vrishya P , c agvada Cassia fistula Madhura Guru, snigdha Sheeta Madhura phala majja, moola Tridoshaha ra Shotahara, vedanasthapana, sramsana, amashodaka P , t shreya Foenieculu m vulgare Madura, katu, Tikta Lagu, snigdha Sheeta Madhura Phala, taila,moola Vatapittaha ra Medhya, deepana., balya A anyaka Coriandrum sativam Katu, kashaya, tikta, Madhura Lagu, snigdha Ushna Madhura Panchanga Tridoshaha ra Shotahara, balya, deepana, pachana P C hwagan a Withania somnifera Katu, tikta, Madhura Lagu, snigdha Ushna Madhura Moola Kapha vatahara Shotahara, vedanastapaka, Shoolaprashamana, balya T a mrita Tinospora cardifolia Tikta, Kashaya snigdha, guru ushna Madhura khanda Kaphavata kara, pittashama ka Medhya, vatanulomana, rasayana, shoola prashamana B g v pali Piper Katu, kashaya, Lagu, Anush Madhura Phala, Kapha Amapachana, rasayana, P
  72. 72. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 55  longum tikta snigdha, teekshna na moola vatahara rechana, shotahara p ddadar Argyreia speciosa Katu, kashaya, tikta Lagu, snigdha ushna Madhura Moola, Kapha vatahara Shotahara, vedanastapaka, jwaragna, rasayana, G r atavar Asperagus racemosus Madhura,tikta Guru, snigdha Sheeta Madhura Kanda Vatapittaha ra Medhya, balya, rasayana, hrudya S cha Acorus calamus Katu, tikta Lagu, teekshna Ushna Katu kanda Kapha vatahara Shotahara, vedanastapaka A a c hachara Barleria prionitis Tikta, madhura Lagu Ushna Katu Panchanga Kapha vatahara Shotahara, vedanastapaka avya Piper retrofractum Katu Lagu, rooksha Ushna Katu Moola phala Kapha vatahara Deepana, pachana, shoolaprashamana V o p ntakari aya Solanum surattense Tikta, katu Lagu rooksha, Ushna Katu Panchanga Kapha vatahara Shotahara, vedanastapaka S ,
  73. 73. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 56  Table 10 showing the properties of simhanada guggulu Drug Latin Name Rasa Guna Veerya Vipaka P.Anga Doshagnata Karmukata Cont Amalaki Emblica officinalis Lavanarahita pancharasa Guru, rooksha Sheeta Madhura Phala Tridoshahar a Dahaprashamana, chakshusya Tanin Hareetaki Terminalia chebula Kashaya pradhanaLav anarahita pancharasa Lagu, rooksha Ushna Madhura Phala Tridoshahar a Shotahara, vedanasthapaka Cheb chebu Vibheetaki Terminalia bellarica Kashaya Lagu rooksha Ushna Madhura Phala Tridoshahar a Eranda Ricinus communis Madhura; kashaya, Katuanurasa Snigdha, teekshna, sukshma Ushna Madhura Mula, Patra, beeja, Taila Kapha vata hara Shothahara, Vedanasthapaka, balya, amashodhaka,angam ardaprashamana Taila- Amyl invert Guggulu Commiphor a mukul Tikta, katu Lagu rooksha Ushna Katu Niryasa Tridoshshar a Shotahara, vedanasthapaka Volat and re Gandhaka Sulphur Madhura Ushna Katu Rasay deepa visha
  74. 74. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 57  Table 11 showing the properties of dravyas used for sapthamusthi yusha Drugs Latin name Rasa Guna veerya Vipaka Doshgnata Karmuk Kulatha Dolichos biflorus Kashaya Laghu, ruksha, teekshana ushana Amla Kaphavata hara Mudga Phaseolous mungo Madhur Laghu, ruksha Sheeta Katu Kaphapitta hara Yava Kola Piper longum Katu, kashaya, tikta Lagu, snigdha, teekshna Anushna Madhura Kapha vatahara Amapac rasayan rechana shotaha Shunthi Zingiber officinale Katu Laghu, snigdha ushana Madhura Kapha vata shamaka Dhanyaka Coriandrum sativam Katu, kashaya, tikta, madhura Lagu, snigdha Ushna Madhura Panchanga Tridosh Mulaka
  75. 75. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 58  Table 12 showing the properties of brihat saindhavadhya taila Drugs Latin name Rasa Guna Veerya Vipaka Doshgnata Karmukata Pr Saindhava Sodium chloride Lavana Snigdha, tikshana, laghu, sukshma Sheeta Lavana Tridosha shamaka Deepana, pachana, vatanulomana La Sreyasi Piper retrofractum Katu Laghu, ruksha Ushana Madhur a Kapha vata shamaka Rochana, deepana, vatanulomana Ph Rasna Vanda roxburghii Tiktha Guru Ushana Katu Kapha vata shamaka Vedanasthapana, amapachan, rasayana M Sathapush pa Anethum sowa Katu, tiktha Laghu, ruksha, teekshana Ushana Katu Kapha vata shamaka Rochana, deepana, pachana, anulomana, shoothahara Ph Yamanika Trachyspermu m ammi Katu, tiktha Laghu, ruksha, teekshna Ushan Katu Kapha vata shamaka Rochana, deepana, anulomana Ph Sarjika Sodium carbonate Kshara Laghu, snigdha, sukshama Ushana Katu Kapha hara Deepana, pachana, shoolahara, mootrala Ks Maricha Piper nigrum Katu Laghu, teekshana Ushana Katu Vata kapha shamaka Deepana, pachan, vatanulomana, pramathi Ph Kusta Saussurea lappa Tiktha katu madhura Laghu, ruksha, teekshan Ushan Katu Kapha vata shamaka Deepana, pachan, anulomana M
  76. 76. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 59  Shunthi Zingiber officinale Katu Laghu, snigdha ushana Madhur a Kapha vata shamaka Trupthighna, rochana, deepana, pachana,vatanuloma na, shothahara, amapachana Ka Souvarcha la Sodium chloride Lavana Vishada, laghu, sukshma ushana Lavana Vatanashak a Rochaka, bhedaka, deepana, pachaka, vibandha hara La Vida Lavana Laghu teekshana, ushana,ruksha,vyav yi usahna Lavana Vata kapha hara Deepana, vatanulomana, ruchikara, shulahara La Vacha Acorus calamus Katu,tikth a Laghu, teekshana ushana Katu Kapha vata shamaka Medhya, vedanasthapana,deep ana, trupthighana, M Ajamoda Carum roxburghianu m Katu, tiktha Laghu, sukshma, teekshan ushana Katu Kapha vata shamaka Deepana, vatanulomana, shulaprashamana Ph Madhuka Glycyrrhiza glabra madhura Guru, snigdha, sheeta madhur a Vata pitta shamka Rasayana, balya, medhya, vatanulomana, sandhaneeya M
  77. 77. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 60  Jeeraka Cyminum cuminum Katu Laghu, ruksha ushana katu Kapha vata shamak Deepana, pachana, vatanulomana, shulaprashamana Ph Paushakar a Inula recemosa Tiktha, katu Laghu, teekshan ushana katu Kapha vata shamaka Deepana, pachna, vatnulomana M Kana Piper longum Katu Laghu, snigdha, teekshan Anushan a sheeta madhur a Kapha vata shamaka Deepana, trupthighna, vatnulomana , rasyana, balya Ph Table 13 showing the propertis of triphala kashaya Drugs Latin name Rasa Guna veerya Vipaka Doshgnata Karmukata Pryo Amalaki Emblica officinalis Lavanarahita pancharasa Guru, rooksha Sheeta Madhura Tridoshahara Dahaprashamana, chakshusya Phal Hareetaki Terminalia chebula Kashaya pradhanaLavanarahita pancharasa Lagu, rooksha ushna Madhura Tridoshahara Shotahara, vedanasthapaka Phal Vibheetaki Terminalia bellarica Kashaya Lagu rooksha ushna Madhura Tridoshahara Phal
  78. 78. Dr.Samina M.Sindgikar 2010  ment of Amavata w.s.r Rheumatoid Arthritis   Page 61  Table 14 showing the properties of nimbamruthadi eranad taila Latin name Rasa Guna veerya Vipaka Doshgnata Karmukata Ricinus communis Madhura; kashaya, Katuanurasa Snigdha, teekshna, sukshma Ushna Madhura Kapha vata hara Shothahara, Vedanasthapaka, balya amashodhaka,angamardaprashamana Tinospora cardifolia Tikta, kashaya snigdha, guru ushna Madhura Kaphavatakara, pittashamaka Medhya, vatanulomana, rasayana shoola prashamana Adathoda vasika Tikta kashaya Ruksha, laghu Sheetha Katu Kapha pittahara Vedanasthapaka,jwaragna, swedajanaka, raktajanaka Trichosanthes dioica Tiktha Laghu ruksha Ushana Katu Tridosha shamak Vedanasthpaka, anulomana shothahara ika Solanum surattense Tikta, katu Lagu rooksha, Ushna Katu Kaphavatahara Shotahara, vedanastapaka Azadiracta indica Tiktha, kashaya Laghu Sheeta Katu Kaphapitta shamaka Krimighna, rochan, rakthashodhaka amapachaka
  79. 79. There is no known cure for rheumatoid arthritis, but many different types of treatment can alleviate symptoms and/or modify the disease process. The goal of treatment is two-fold: alleviating the current symptoms, and Preventing the future destruction of the joints with the resulting handicap if the disease is left unchecked. Pharmacological treatment of RA can be divided into disease-modifying antirheumatic drugs (DMARDs), anti-inflammatory agents and analgesics. Treatment also includes rest and physical activity. Disease modifying anti-rheumatic drugs (DMARDs) Chemically synthesised DMARDs • azathioprine • ciclosporin (cyclosporine A) • D-penicillamine • gold salts • hydroxychloroquine • leflunomide • methotrexate (MTX) • minocycline • sulfasalazine (SSZ) Cytotoxic drugs: • Cyclophosphamide
  80. 80. Anti inflammatory agents include: • glucocorticoids • Non-steroidal anti-inflammatory drug (NSAIDs, most also act as analgesics) Analgesics include: • paracetamol • opiates • diproqualone • lidocaine topical
  81. 81. PATHYA APATHYA Pathya has important role in the prevention and exacerbation of the disease process. As per the classics any drug or diet i.e. katu , tikta by rasa, ushna and teekshna in guna and having vatahara, kaphahara, Amapachana action is considered as pathya. PATHYA The list pathya mentioned in Texts: 1. Dravya: Punarnava, Rasna, Patola, Karavellaka, Vartaka, Shigru, Gokshura, Vriddhadaru, Bhallataka, Ardraka.Shyamaka, Varuna, vastuka. 2. Mamsa: Jangalamamsa rasa Lavaka mamsa with takra. 3. Aharadravya: Puranashali, Purana shashtika shali, yava, kulatta. 4. Anya: Eranda taila, ushnodaka, procedures like rukshasweda, lepa, langhana, snehapana, basti, virechana. The pathyas of jwara are also considered as pathyas of Amavata. APATHYA All the nidanas of Amavata are apathya: Masha, anupa, mamsa, dadhi, guda, ksheera, matsya, upodhika, shimbhi dhanyam, sheetajala snana, abhyanga.
  82. 82. DRUG REVIEW The chikitsa sutra of amavata constitutes langhana, deepana, pachana, swedana, shodhana and shaman. Accordingly in this present study, Sapthamusthi yusha in the form of laghu bhojana, and shunti gokshura kwatha for the purpose of langhana, deepana and pachana was given. For the purpose of shodhana Verachana with nimbamrutha eranda taila Anuvasana basti with Brihatsaindhavadhya taila,53 Niruha basti withTriphala and gomutra.54 For the purpose of shamana, Maharasnadi kwatha 55 and Simhanada guggulu 56 Valuka sweda was used for sthanika swedana. Saptha musthi yusha 57 contains the following drugs—kulatha, mudga, dhanyaka, pippali, shunthi, pippali, shuskamulaka—all the drugs are katu tiktha rasa pradhana, kapha vata hara, and deepana pachaka in action. As explained in sharangdhara amavata chikitsa. Shunthi and gokshur 58 kwatha explained in chakradatta, is pachaka and shoolahara. Usually the inflammation and morning stiffness is due to accumulation of fluid within the joint capsule, recent studies have proved that the drava shoshaka action of shunthi helps in drying up of accumulated fluid, and is best kaphavata hara. Gokshura shootahara, vedanasthapaka and balya.
  83. 83. Srothovishodhana, lekhana, deepana, balya and rasayana in action. Kaphavata hara. Kshara basti Triphala kashay 350ml Gomutra 100ml Bruhatsaindhvdhyataila 100ml Madhu 50ml Shatapushpa 15gms Saindhavlavana 5gms Triphala kashaya used for niruha which is tridosha hara, sothahara, vedanasthpaka. Gomutra is katu, tiktha, kashaya and ishat kshara rasa. It is kapha vata hara, indicated in shotha, shoola, anaha, and ama. Madhu is of madhur rasa, kashaya as anurasa, it is helpful in vilekhana, vranashodhana, ropana, srotovishodhana and acts as yogavahi. Saindhava lavan is lavana rasa pradhana and madhur as anurasa. It is tridoshahara; it is of laghu, anushna, avidahi, deepana, pakee, sramsana, pachana, sukshma and snigdha guna. Brihat saindhavadi taila is used for pana, abhyanga and basti in amavata. It is agni deepaka, and indicated in kati, janu, uru, hrith, prusta and parshwa shoola. Maharasnadi kwatha ingredients of this yoga are deepana, pachana, jwaraghna, vedanasthapana, shoola shootha prashamaka, mootrala, balya. The ingredients of simahanada guggulu are kaphavatahara, pittavardhaka, agnideepaka and amapachaka. Valuka sweda In Amavata, the shareerika dosha is kapha (sleshmaka kapha) and agantu dosha is of kaphaja in nature. Here in agantu and sthanika dosha are not contrary to each other and vata prakopa due to margavarodha will be there. Still vata does not require a special attention as it can be set right by removing margavarodha due to
  84. 84. sweda particularly Valuka sweda may conveniently be adopted first along with other shamana therapy. Ingrediants of shunti Gokshura Kwatha Figure 5 Shunti Figure 6 Gokshura Ingrediants of Saptamushti Yusha Figure 7 Kulatha Figure 8 Pippali Figure 9 Mudga Figure 10 Yava
  85. 85. 1. A Pharmaco-clinical study on jyothishmati in the management of Amavata. (Parwar.P.S. Jamnagar.2001). 2. A clinical study on Amavata and its management with Amritadi vati. (Rajeshkumar. M. 2001, Jamnagar.) 3. Role of Amrita Bhallataka in the management of Amavata(Dash Babitha, Jamnagar, 2005) 4. Clinical study of Amavata and its management by Rasnasaptaka quatha and indigenous compounds (Lucknow, 2002). 5. Effect of Shatyadi Quatha in the management of Amavata.(Delhi 2003). 6. A Comparative Clinical Study on the Role of Simhanada Guggulu & Shuddha Kupeelu in the Management of Amavata (Shimla, 2003). 7. A Controlled Clinical Study on the Role of Kshara Basti in the Management of Amavata with Special Reference to Rheumatoid Arthritis (Mysore 2002). 8. clinical assessment of the role of kansa haritaki and virechana in the management of amavata ( Dr. Rita Sahu Jamnagar 2003) 9. a clinical study of amavata and its management with amritadi vati( Dr. Rajesh kumar manglesh Jamnagar 2001) 10. A comparative study to evaluate the effect of shatapushpadi lepa and valuka sveda in the management of shula and shotha in Amavata w.s.r t. Rheumatoid Arthritis, Dr. Poornima. B , Mysore - 2006
  86. 86. After a thorough review of literature in the first part, the second part of the dissertation is dedicated for methodology. Where a detailed explanation is given regarding materials selected, methods adopted, the observations made, the results and conclusions drawn based on the clinical study. Materials used for the study were 1. Shuntydi kwatha 2. Sapthamusthi yusha 3. Maharasnadi kwatha 4. Simhanada guggulu 5. Nimbamrutha eranda taila for virechana 6. Basti Brihat saindhvdhya taila for anuvasana Niruha basti Madhu Saindhava lavana kalka dravya Brihatsaindhavdhya taila Triphala kashaya Gomutra 1. Saptha musthi yusha contains the following drugs—kulatha, mudga, dhanyaka, pippali, shunthi, kola, shuskamulaka. 2. Shunthi and gokshura 1) The above drugs were purchased from S.N.pandith and sons mysore. Yavakuta choorna of gokshur panchanga was prepared and was added with
  87. 87. 3. Maharasnadi Quatha: Ingredients: Rasna, Eranda, vasa, duralabha, kachura, devadaru, bala, musta, nagara, ativisha, abhaya, gokshura, punarnava, Amalathasa, mishreya, dhanyatha, ashwagandha, amrita, pippali, vriddadaru, shatavari, vacha, sahachara, chavya, kantakari.The maharasnadi kwatha manufactured by prakruthi remedies pvt. Ltd. Karwar 4. Simhanada Guggulu: Ingredients: Amalaki, Haritaki, Bibhitaki, Eranda, Guggulu, Gandhaka. The Simhanada Guggulu manufactured by Dhootapapeshwar pharmaceuticals. (Ref: Ayurveda Sara Sangraha) 5. Nimbamrutha eranda taila Ingredients: Eranda Patola Amrita Vasa Nidigdika Nimba For the purpose of study the taila was purchased from s.n.pandit mysore. 6. Brihat saindhvdhya taila Ingredients: Saindhava Sreyasi Rasna Yamanika Maricha Kusta Shunthi Souvarchala Vida Vacha Ajamoda Madhuka Paushakara Kana Jeeraka Sarjika Sathapushpa . This taila was purchased from prakruthi remedies pvt. Ltd. Karwar. 7. Niruha
  88. 88. Saindhava lavana was used from the supply of govt. ayurvedic medical hospital mysore from govt. centrl pharmacy banglore. Fresh triphala kashaya was prepared on the day of basti, triphala was used from the supply of govt. ayurvedic medical hospital. 8. Valukasweda: Pure, uniformly sized, clean, sand should be taken. The gravels in the sand should not be either too big or too small is to be collected. A clean white, good cloth, not too thick nor too thin of the size of 18X18 should be kept ready either one or two, three or four on number or as much as the cloth pieces required. From this cloth using warm sand, potali has to be prepared. Methods Research design Patients of either sex between the age group of 16-60 yrs were selected. Both fresh and treated cases having positive rheumatoid factor, classical signs and symptoms of amavata and ARA criteria were selected. The selected patients were assigned in a single group, and treatment was administered as follows,Shunti 6 mash and gokshur 1 tola in the form of kwatha taken internally early in the morning, after kshudha pradurbhava saptha musti yusha was administered. Preparation of saptha musthi yusha. • 1 part of pippali, shunthi, dhanyaka • 4 parts of kulatha
  89. 89. added for parkshepaka. Duration : Acc. to nava jwara kala maryada 7, 10, 12 days laghu ahara given. In the present study as per pts agnibala langhana was done. Samyak langhita lakshanas Vimalendriyata, malotsarga, laghuta, ruchi, kshudha, hruth shudhi, udgara shudhi, kantha shudhi, vyadhi mardavata, tandra nasha were observed in the patients. Virechana As practically observed 10- 40 ml of nimbamrutha eranda taila was found more effective without causing any vyapth. Virechana yoga was given at sleshma kale gate gnatwa koste samyak virechyet ,followed by ushana jalapana. After administration of virechana yoga patients are advised to follow usnodakopchara, brahmacharya, kashapashaya. In the evening the patients were advised to take laghu supachya ahara. One day vishram was given to the pt after virechan. Basti In this study kshara basti in the form of yoga basti (8 days) was adopted. Table 15: yoga basthi Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Anuvasana Niruha Anuvsana Niruha Anuvasana Niruha Anuvasana Anuvasana On the day of anuvasana in the morning after evacuation of bowels and bladder, pt advised to take light food at 10 am. patient was sent to pancha karma section and subjected to abhyanga with kanaka taila and naadi sweda was done to lower abdomen, lumbar region and thighs, till samyaka swinna lakshanas were
  90. 90. anal orifice and inserting end of the catheter were seamered withoil for lubrication. 80ml of brihatsaindhavdhya taila was taken in the enema syringe; the connecting end of catheter is applied to the syringe. Then the inserting end is gently inserted to about 4 inches into the rectum, pt advised to take deep breaths and slowly the taila in the syreng was pushed slowly. The catheter was removed with some amount of drug still remaining in the syringe to prevent the entry of air into the colon. Then the pt was asked to turn into the supine position and his buttocks were patted gently and palms and soles were rubbed. Pt was asked to remain in the same position for half an hour. Pt was watched for the evacuation of the drug, after evacuation they were allowed to take hot water bath and then light food. Niruha basti was started on following day of anuvasana; pt was advised to be on empty stomach on the day of niruha. The niruha basti dravya was prepared at the time of administration first 30 ml of madhu and 12 gms of saindhava lavana were taken in the morter and are mixed then 70 ml of brihat saindhvadhya taila was added slowly til they get properly mixed after that 24 g ushakadi kalka was added and mixed thoroughly. To this mixture 350ml of triphala kashaya was added slowly and next 150ml of gomutra was added all were mixed well till it gets uniform consistency. This was filtered and indirectly warmed in a boiling water vessel to make it luke warm. Pt subjected to abhyanga with kanaka taila and naadi sweda was done to lower abdomen, lumbar region and thighs, till samyaka swinna lakshanas were observed.then the patient was asked to lie on basti table in left lateral position , with left knee extended and right leg flexed at knee and resting on left knee. The head is supported by patient’s left hand. The above mixed dravya was taken in enema can The anal orifice and inserting end of the catheter were seamered with oil for lubrication, Then the inserting end is gently inserted to about 4 inches into the rectum, pt advised to take deep breaths, till the basti dravya was completely administered, small amount of dravya was left behind to avoid entry of air. Pt was advised to remain in supine position till they get urge for defecation. After defecation pt advised to take hot water bath and light food.
  91. 91. not too thick nor too thin of the size of 18X18 should be kept ready either one or two, three or four on number or as much as the cloth pieces required. From this cloth using warm sand, potali has to be prepared. After the daily regimen in the morning, the warm valuka potali of the required temperature should be applied on the affected part of the body. The sweda is to be conducted according to the Pindasweda either in sitting posture or in whichever posture the patient feels comfortable. In joints, the sweda should be given in circular manner. The temperature of the valuka potali must be maintained uniformly so that the patient should not feel discomfort either by more heat or by low heat. If the sand becomes cold, the potali should be changed and again the warm bolus should be applied to the affected parts until the local signs and symptoms reduce or when the patient feels satisfied. In each affected parts, usually sweda is done for 10-15 minutes. Illustration no.4 showing the probable mode of action Sthanika swedas Sthanika Tapadhikyatha Srotovikaras Sthanika Dhatwagni Vriddhi Raktabhisara Vriddhi (Increased blood circulation) Amapaka Sweda pravritti Sangha get relieved Shareera Laghuta
  92. 92. Assessment criteria I. Clinical assessment 1. Pain in Joint:- 0 - No pain 1. Mild pain of bearable nature, comes occasionally 2. Moderate pain but no difficulty in movement of joint, appears frequently and requires some Upashaya measures for relief. 3. Slight difficulty in joint movements due to pain or severe pain requires medication and remain throughout the day. 4. More difficulty in moving the joints, pain is severer disturbing the sleep and requires strong analgesics. 2. Swelling:- 0 - No swelling. 1 - Slight swelling. 2 - Moderate swelling. 3 - Severe swelling. 3. Stiffness:- 0 - No stiffness or stiffness lasting for 5 minutes. 1 - Stiffness lasting for 5 minutes to 2 hours. 2 - Stiffness lasting for 2 to 8 hours. 3 - Stiffness lasting for more than 8 hours. 4. Redness:-
  93. 93. 5. Warmth:- The temperature of the joint surface was measured using the digital skin temperature measuring instrument. The temperature was compared to the normal body surface. The rise in temperature of the joint surface was scored as follows. 2 - Raised temp. when compared to the normal body temp. 1 - Fall in local warmth 0 - Normal temp. 2 - No change after the treatment II Functional Assessment :- 1. Walking Time:- The patients were asked to walk a distance of 50 feet and the time taken to travel the distance was recorded before and after the treatment. No improvement-1; slightly improved-2; improved-3 2. Grip strength:- To find the functional capacity of the affected upper limb the patients were asked to compress the inflated cuff of the sphygmomanometer under standard conditions and the test was carried out before and after the treatment. No improvement-1; slightly improved-2; improved-3 3. Foot Pressure:- To have an objective view of the functional capacity of the legs, foot pressure was recorded by the ability of the patients to press a weighing machine.
  94. 94. Goniometer both before and after the treatment. Fully restricted-1; partially restricted-2; improved- 3 5. General functional capacity:- 0 - Complete ability to carry on all routine duties without handicap. 1 - Frequent normal activity despite slight difficulty in joint movements. 2 - Few activities are persisting but patient can take care of him or herself. 3 - Few activities are persisting, patient requires an attendant to take care of him / herself. 4 - Patient is totally bedridden. Assessment of the patients were done in the following intervals Initial assessment: Before commencement of the treatment Second assessment: After the 15 days of administration of the treatment. Third Assessment: After the 30 days of administration of the treatment. Fourth assessment After the 48 days of administration of the treatment. Investigation Routine bloods for heamoglobin, TC, DC, ESR were done before and after treatment. Blood for rheumatoid factor was done before and after treatment. Urine for albumin, sugar and microscopic were done before and after treatment.
  95. 95. OBSERVATIONS AND RESULTS Observation: After proper interrogation and examination of the patients, different features of observations were recorded in case sheets. These observations were analysed and recorded here. In the present clinical study, 36 patients were registered out of which 16 was dropout and 20 patients completed the treatment. The incidences of marital status in the present study all the patients were married. The nature of onset in the present is gradual and insidious onset. As per the observations made from the present study, it can be said that Agni is diminished in all cases i.e all the pts were of mandagni. Table 16 showing incidence of amavata on the basis of age Age 51-60 yrs 41-50 yrs 31-40 yrs 21-30 yrs 11-20 yrs Total No. of patients 4 8 6 2 0 20 Maximum no. Of pt were observed in the age group 41-50 yrs(40%), followed by the age group 31-40 yrs(30%), age group 51-60yrs(20%), age group 21- 30yrs(10%) and 0% in 11-20yrs. Table 17: showing incidence of amavata on basis of sex Frequency Percent Valid Percent Cumulative Percent Valid Male 3 15.0 15.0 15.0 Female 17 85.0 85.0 100.0 Total 20 100.0 100.0 Among 20 pts 3 were male(15%) and 17(85%) were female showing the
  96. 96. Frequency Percent Valid Percent Cumulative Percent Valid Un educated 9 45.0 45.0 45.0 Primary schooling 5 25.0 25.0 70.0 High school 4 20.0 20.0 90.0 Graduate 2 10.0 10.0 100.0 Total 20 100.0 100.0 Most of the patients 45% were uneducated, followed by primary schooling 25%, high school 20% and 10% graduate. Table 19: Table showing the incidences of Amavata according to their socio- economic status Frequency Percent Valid Percent Cumulative Percent Valid Very poor 2 10.0 10.0 10.0 Poor 6 30.0 30.0 40.0 Lower middle 8 40.0 40.0 80.0 Middle 4 20.0 20.0 100.0 Total 20 100.0 100.0 Out of 20 pts 40% of pts belong to lower middle class, followed by 30% of pts belonging to poor class, 20% to middle class and 10% to very poor class. Table 20 Table showing the incidences of Amavata according the occupation Frequency Percent Valid Percent Cumulative Percent Valid House wife 9 45.0 45.0 45.0 farmers 8 40.0 40.0 85.0 Private 2 10.0 10.0 95.0 Government 1 5.0 5.0 100.0 Total 20 100.0 100.0 Figure 5 Among 20 pats 45% of patients were house wives, followed by 40%
  97. 97. Table 22 showing the incidences of Amavata according to Ahara Diet Mixed diet Vegetarian Total No. of patients 14 6 20 Percentage 70% 30% 100 In present study 70% of patients were of mixed diet and 30% having vegetarian diet. Table 23 showing the incidences of chronicity of the disease. Table 24 Chi Square Test In present study 55% of patients showed chronicity of 1-5 yrs, followed by more than one year in 40% of patients, 5% above 5 yrs chronicity. SEX OCCU EDU LOCAT SES FH Chi-Square 9.800 10.000 5.200 .800 4.000 12.800 Df 1 3 3 1 3 1 Asymp. Sig. .002 .019 .158 .371 .261 .000 Frequency Percent Valid Percent Cumulative Percent < 1 year 8 40.0 40.0 40.0 1-5 years 11 55.0 55.0 95.0 > 5 years 1 5.0 5.0 100.0 Valid Total 20 100.0 100.0 CHRO_GP Chi-Square 7.900 df 2 Asymp. Sig. .019
  98. 98. Table 25 showing the location Most of the patients were from rural 60% and 40% from urban area. Table 26 showing the incidences of family history Frequency Percent Valid Percent Cumulative Percent Nothing contributry 18 90.0 90.0 90.0 Contributry 2 10.0 10.0 100.0 Valid Total 20 100.0 100.0 Out of 20 patients 90% of patients did’nt had family history of amavata, 10% of patients presented with family history. Table 27 showing changes in rheumatoid titer value Frequency Valid Percent Valid Decrease 13 65.0 Negative 3 15.0 No change 1 5.0 Increase 3 15.0 Total 20 100.0 Out of 20 patients in 65% of patients the titer values decreased, in 15% of patients showed negative values, 15% of patients showed increase in the values and Frequency Percent Valid Percent Cumulative Percent Rural 12 60.0 60.0 60.0 Urban 8 40.0 40.0 100.0 Vali d Total 20 100.0 100.0
  99. 99. Statical analysis of mean of both ankle, knee, elbow and wrist joint circumferences, before and after treatment Table 28 stastical analysis of joint circumference Mean N Std. Deviation Std. Error Mean Pair 1 VAM_JBT 32.5300 20 2.75626 .61632 VAM_JAT 31.1350 20 2.08637 .46653 Pair 2 DAK_JBT 33.5250 20 2.98044 .66645 DAK_JAT 31.5450 20 1.96240 .43881 Pair 3 VAM_GAT 22.3211 19 1.85250 .42499 VAM_GBT 21.2684 19 1.78047 .40847 Pair 4 DAK_GBT 22.3789 19 2.04765 .46976 DAK_GAT 21.5158 19 1.96702 .45127 Pair 5 VAM_KBT 22.1471 17 1.95867 .47505 VAM_KAT 21.3765 17 2.09091 .50712 Pair 6 DAK_KBT 21.7941 17 1.82909 .44362 DAK_KAT 21.0824 17 1.80701 .43826 Pair 7 VAM_MBT 15.4400 20 3.22953 .72215 VAM_MAT 14.9100 20 2.95687 .66118 Pair 8 DAK_MBT 15.2200 20 2.17246 .48578 DAK_MAT 14.6350 20 2.04252 .45672 Table 29 stastical analysis of joint circumference T Df Sig.(2-tailed) Pair 1 VAM_JBT - VAM_JAT 2.909 19 .009 Pair 2 DAK_JBT - DAK_JAT 3.483 19 .002 Pair 3 VAM_GAT - VAM_GBT 6.117 18 .000 Pair 4 DAK_GBT - DAK_GAT 2.902 18 .010 Pair 5 VAM_KBT - VAM_KAT 3.470 16 .003 Pair 6 DAK_KBT - DAK_KAT 2.568 16 .021 Pair 7 VAM_MBT - VAM_MAT 3.170 19 .005 Pair 8 DAK_MBT - DAK_MAT 4.146 19 .001 Illustration 5: Mean of knee joint circumference
  100. 100. Significant decrease in the circumference of both the elbow joints Illustration 7; Mean of Ankle joint circumference It is observed that there is decrease in circumference of both ankle joint by 1.5 cms Illustration 8: Mean of Wrist joint circumference
  101. 101. Table 31 Contigency Coefficient After treatment 5% of pts showed no pain in the joints, 15% of pts showed mild pain and 56% of pts showed moderate pain, 20% of pts showed slight difficulty in joint movement due to pain and 5% of pts showed more difficulty in joint movements due to pain. TREATMENT Total BT AT shool_bt No pain Count 0 1 1 % within treatmen .0% 5.0% 2.5% Mild pain Count 1 3 4 % within treatmen 5.0% 15.0% 10.0% Moderate pain Count 0 11 11 % within treatmen .0% 55.0% 27.5% Slight diff jt movements in pain Count 15 4 19 % within treatmen 75.0% 20.0% 47.5% More diff in moving the joints Count 4 1 5 % within treatmen 20.0% 5.0% 12.5% Total Count 20 20 40 % within treatmen 100.0% 100.0% 100.0% Value Approx. Sig. Nominal by Nominal Contingency Coefficient .588 .000 N of Valid Cases 40
  102. 102. Table 33 Contigency Coefficient After treatment 15% of pts showed no swelling in the joints, 40% showed slight and moderate swelling respectively and 5% of pts showed sever swelling Table 34 Showing the stastical analysis of morning stiffness TREATMENT Total BT AT MOR_BT No stifness Count% within treatment 0 4 4 .0% 20.0% 10.0% Stifness lasting 5m -2hrs Count% within treatment 15 15 30 75.0% 75.0% 75.0% Stifness lasting 2m -8hrs Count% within treatment 4 1 5 20.0% 5.0% 12.5% Stifness lasting >8hrs Count% within treatment 1 0 1 5.0% .0% 2.5% Total Count% within treatment 20 20 40 100.0% 100.0% 100.0% TREATMENT Total BT AT shoot_bt No swelling Count 0 3 3 % within treatment .0% 15.0% 7.5% Slight swelling Count 0 8 8 % within treatment .0% 40.0% 20.0% Mod swelling Count 10 8 18 % within treatment 50.0% 40.0% 45.0% Sever swelling Count 10 1 11 % within treatment 50.0% 5.0% 27.5% Total Count 20 20 40 % within treatment 100.0% 100.0% 100.0% Value Appr. Sig. Nominal by Nominal Contingency Coefficient .563 .000 N of Valid Cases 40
  103. 103. Out of 20 pts 20% of pts showed no morning stiffness, 75% pts showed stiffness lasting for 5mins to 2hrs, 5% of pt showed stiffness lasting for 2 hrs to 8 hrs . Table 36 Showing the stastical analysis of range of movement TREATMENT Total BT AT ROM_BT Fully restricted Count 12 2 14 % within treatment 60.0% 10.0% 35.0% Partially restricted Count 8 0 8 % within treatment 40.0% .0% 20.0% Not restricted Count 0 18 18 % within treatment .0% 90.0% 45.0% Total Count 20 20 40 % within treatment 100.0% 100.0% 100.0% Table 37 Contingency Coefficient 10% of patients showed fully restriction, 18% of patients no restriction in the movements. Value Approx. Sig. Nominal by Nominal Contingency Coefficient .381 .079 N of Valid Cases 40 Value Approx. Sig. Nominal by Nominal Contingency Coefficient .673 .000 N of Valid Cases 40