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Evaluation of the efficacy of MASHABALADI TAILA IN MANYASTHAMBA (CERVICAL SPONDYLOSIS) By Shajil. N., Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

Manyastambha kc028 gdg

  1. 1. Evaluation of the efficacy of MASHABALADI TAILA IN MANYASTHAMBA (CERVICAL SPONDYLOSIS) By Shajil. N. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)] Department of Kayachikitsa Post Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2002-2005
  2. 2. J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 Endorsement by the H.O.D, Principal/ head of the institution This is to certify that the dissertation entitled “Evaluation of the efficacy ofMashabaladi taila in Manyasthamba (CERVICAL SPONDYLOSIS)” is a bonafideresearch work done by “Shajil. N.” under the guidance of Dr. SHIVA RAMA PRASADKETHAMAKKA, M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Reader in Kayachikitsa,DGMAMC, PGS&RC, Gadag, in partial fulfillment of the requirement for the post graduationdegree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University ofHealth Sciences, Bangalore, Karnataka.. (Dr. V. Varada charyulu) (Dr. G. B. Patil) Professor & HOD Principal, Dept. of Kayachikitsa DGM Ayurvedic Medical College, PGS&RC Gadag Date: Date: Place: Gadag Place:
  3. 3. D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 This is to certify that the dissertation entitled “Evaluation of the efficacy ofMashabaladi taila in Manyasthamba (CERVICAL SPONDYLOSIS)” is a bonafideresearch work done by “Shajil. N.” in partial fulfillment of the requirement for the postgraduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev GandhiUniversity of Health Sciences, Bangalore, Karnataka. Date: Dr. SHIVA RAMA PRASAD KETHAMAKKA M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)] Place: Gadag Guide READER IN KAYACHIKITSA DGMAMC, PGS&RC, Gadag
  4. 4. Declaration by the candidate I here by declare that this dissertation / thesis entitled ““Evaluation of the efficacyof the Mashabaladi taila in Manyasthamba (CERVICAL SPONDYLOSIS)” is a bonafideand genuine research work carried out by me under the guidance of Dr. SHIVA RAMAPRASAD KETHAMAKKA, M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Reader inKayachikitsa, DGMAMC, PGS&RC, Gadag.DatePlace (Shajil.N)
  5. 5. © Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnatakashall have the rights to preserve, use and disseminate this dissertation/ thesis in print orelectronic format for the academic / research purpose.DatePlace (Shajil. N)© Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. Acknowledgement “Many hands make light work”. This work carries some memories to express andrecord about some distinguished personalities with whom I had inspired during the course ofthis thesis. I express my obligation to my guide Dr Shiva Rama Prasad Kethamakka, M.D.(Ayu)M.A.,Ph. D (Jyotish), Reader in Kayachikitsa, for his time to time help and criticalsuggestion associated with expert guidance at the completion of this dissertation. I express my deep gratitude to Dr. V. Varadacharyulu M.D.(Ayu), Professor & H.O.D.,for his advice and encouragement of every step of this work. I express my obligation to beloved principal Dr. G. B. Patil, Principal for hisencouragement as well as providing all necessary facilities for this research work. I express my profound sense of gratitude to various departments H.O.D.s, teachersand colleagues of sister concern departments along with the ministerial, X-ray technicianand sub staff of the D.G.M. Ayurvedic Medical College, Gadag. I express my sincere appreciation to Dr. Shashidar. H. Doddamani, Dr. R. V. Shettar,Dr. Kuber Sankh, Dr. P. Shivaramudu, Dr. Dilipkumar, Dr. V.M.Sajjan, Dr. U.V.Purad andDr. Santhosh Belavadi. I express my sincere thanks to Mr. Nandakumar for his help instatistical analysis of results. I am grateful to the management and staff of Parassinikkadavu Ayurveda College,Kannur, Kerala, for their inspiration and support during the postgraduate studies. I thank the manager of the Southern Capsulation and Pharmaceuticals PVT. LTD.Aroor, Cochin and Dr. P. S. Gopi (DMO, ISM Rtd) for the capsulation of the MashabaladiThailam in gelatin form. I acknowledge my father Vaidya Vibhooshan K. P. Raman Vaidyan and mother M.Karthiyayini for their wholeheartedness. I am thankful to my wife Smt. Lisha Shajil andrelatives - Shri. Anil.N, Shri, Sunil.N, Leena.N, Shri. Damodaran, Smt. Leela and Shri. Lijufor their inspiration and moral support to complete this study successfully. Last but not least all the patients those supported my dissertation with their valuableopine needs a warm thanks giving by heart.Place:Date: SHAJIL.N
  7. 7. Abstract Evaluation of the efficacy of Mashabaladi taila in Manyasthamba (cervical Spondylosis) By Shajil. N Over time, arthritis of the neck (cervical Spondylosis) may result from bony spursand problems with ligaments and disks. Injuries can also cause spinal cord compression.Manyasthamba - Cervical Spondylosis is a non-specific term describing the morphologicalmanifestations of progressive degeneration of the spine at the neck, creating pressure onnerves and spinal cord at the level of the neck. Neck stiffness. Cervical Spondylosis is acommon degenerative condition of the cervical spine that most likely is caused by age-related changes in the inter-vertebral disks. Avitaminosis, nutritional deficiencies leadingcalcium deficiency were observed to lead inflammation and degeneration of cervicalvertebra resulting nerve compression causing cervical Spondylosis. Out of few symptomatic CS, Anti inflammatory, analgesic and disease modifyinganti rheumatic drugs are the drugs of choice in contemporary system of medicine. Reductionof sleshma Kapha, which normally align the joints, causes the vitiated Vata to settling in thejoints. Manyasthamba, Vata Vyadhi by its nature with the symptoms such as pain andstiffness is pacified through Vata Kapha management. Nasya with taila pacifies the VataKapha mainly the Vata. Mashabaladi is the combination of drugs having the property VataKapha hara. In the constituents of Mashabaladi yoga, having madhura Rasa, which pacifiesVata and maintain Kapha Dosha. The indication of Mashabaladi thaila is Manyasthamba,pakshagatha etc. as it has brumhana effect. In total 41 patients were selected for the study. Both internal and external use ofMashabaladi taila has their effects to achieve the statistical significance as P=<0.001, whichis highly significance for the all parameters, reported at the study. It is significantly recommended that the Mashabaladi taila be used to achieve goodresults in long term to pacify Vata, Kapha and combat the degenerative changes emerge inthe later ages such as 4th to 6th decades.
  8. 8. Table of contents Evaluation of the efficacy of Mashabaladi taila in Manyasthamba (CERVICAL SPONDYLOSIS) Heading Page numberChapter -1 Introduction 1 to 9Chapter –2 Objectives 10 to 12Chapter –3 Review of literature 13 to 40Chapter –4 Methodology 41 to 73Chapter –5 Results 74 to 116Chapter –6 Discussion 117 to 134Chapter –7 Conclusion 135 to 136Chapter –8 Summary 137 to 140 Bibliographic References I to VIII Annex – Case sheet 1 to 7
  9. 9. List of tablesSno Table Heading Page1 Comparison of manyasthamba lakshana 282 Level of disc herniation 333 Chikitsa of manyasthamba 404 Showing the Ayurvedic health assessment 705 Showing the method of final result declaration 736 Distribution of patients by age –Group A 757 Distribution of patients by age –Group B 758 Distribution of patients by gender – Group A 789 Distribution of patients by gender –Group B 7810 Distribution of patients by religion - group-A 8011 Distribution of patients by religion - group-B 8012 Distribution of patients by occupation –Group A 8213 Distribution of patients by occupation –Group B 8214 Distribution of patients by socio economical status – Group A 8415 Distribution of patients by socio economical status – Group B 8416 Distribution of patients by disease duration – Group A 8617 Distribution of patients by disease duration – Group B 8618 Distribution of patients by pain gradation – Group A 8819 Distribution of patients by pain gradation – Group B 8920 Statistical variances and significance of the pain (A & B) groups 9021 Group relationships of pain (A & B) groups 9022 Distribution of patients by stiffness (A & B) groups 9223 Statistical variances and significance of stiffness (A & B) groups 9224 Group relationships of stiffness (A & B) groups 9225 Distribution of patients by tenderness - group-A 9326 Distribution of patients by tenderness - group-B 9327 Distribution of patients by Agni variances – Group A 9528 Distribution of patients by Agni variances – Group B 9529 Distribution of patients by Ahara Nidana – Group A 97
  10. 10. 30 Distribution of patients by Ahara Nidana – Group B 9731 Distribution of patients by vihara Nidana –Group A 9932 Distribution of patients by vihara Nidana –Group B 10033 Distribution of patients by vysana Nidana –Group A 10234 Distribution of patients by vysana Nidana –Group B 10235 Distribution of patients by Nidra Sukham – Group A 10436 Distribution of patients by Nidra Sukham – Group B 10437 Distribution of patients by Manasika Lakshana - Group A 10638 Distribution of patients by Manasika Lakshana - Group B 10639 Distribution of patients by Associate Complaints – Group A 10740 Distribution of patients by Associate Complaints – Group B 10741 Overall response to the treatment Group-A 10942 Result of Group-A 11043 Overall response to the treatment Group-B 11144 Result of Group-B 11245 Overall response to the treatment in comparison with Group-A and B 11346 Group A individual study of statistical analysis 11447 Group B individual study of statistical analysis 11448 Comparative study of Group-A and Group-B after treatment 11549 Test to know the stability about the groups 11650 Pharmacological properties of the ingredients of Mashabaladi Taila 12851 Karma and Doshaghnata of the ingredients of Mashabaladi Taila 12852 Overall response to the treatment in comparison with Group-A and 132 Group-B List of figuresSno Pictures heading Page1 Cervical vertebrae (C1-4) Postrio-superior view 162 Cervical vertebrae (C2-T1) Right-Lateral view 173 Pathogenesis of cervical Spondylosis 374 Manyasthamba Samprapti 385 Ingredients of Mashabaladi taila 426 Finished Mashabaladi taila capsules 52
  11. 11. List of graphsSno Graph heading Page1 Showing the age distributions of group-A & B 772 Showing the distribution by Gender of group-A & B 793 Showing the distribution by religion of group-A & B 814 Showing the distribution by occupation of group-A & B 835 Showing the distribution by socio-economical status of group-A & B 856 Showing the distribution of patients by disease duration group-A & B 887 Showing the distribution of patients by pain gradation group-A & B 918 Showing the distribution of patients by tenderness group-A & B 949 Showing the distribution of patients by Agni variances group-A & B 9610 Showing the distribution of patients by Ahara Nidana group-A & B 9811 Showing the distribution of patients by vihara nidana group-A & B 10112 Showing the distribution of patients by vyasana nidana group-A & B 10313 Showing the distribution of patients by Nidra Sukham group-A & B 10514 Showing Distribution of patients by Manasika Lakshana- Group A& B 10615 Showing Distribution of patients by Associate Complaints–Group-A & B 10816 Result of Group-A 11017 Result of Group–B 11218 Comparative result of Group-A and Group-B 11319 Comparative results of Group-A and Group-B 133
  12. 12. Chapter –1 Introduction Pain in the neck is common and may be a natural consequence of ageing in peopleover 50. Like the rest of the body, bones in the neck (cervical spine) progressivelydegenerate, as we grow older. Over time, arthritis of the neck (cervical Spondylosis) mayresult from bony spurs and problems with ligaments and disks. The spinal canal may narrow(stenosis) and compress the spinal cord and nerves in the arms. Injuries can also cause spinalcord compression. The pain that results may range from mild discomfort to severe, cripplingdysfunction. This disease is having a prevalence of 0.1-1% of the general population, with a maleto female ratio 3:1 ratio and more commonly affects population in the productive period oflife. Even though it seems to be a very small but rapidly undertaking the deep turn of thepopulation towards many spinal problems, such as lumbar, thoracic and cervicalSpondylosis1. This disease is occurring in middle and later decades of life particularly above forty-five years of age, under the influence of the Vata Dosha. During the 4th to 5th decade of thelife, according to Ayurveda, Vata influence is more in association of Dhatu ksheenata, i.e.debility of the tissue built. Other wise this can be said as the acceleration of the degenerativeprocess takes place, which ultimately leads to the many more problems of spinal origin. Cervical Spondylosis is a common degenerative condition of the cervical spine thatmost likely is caused by age-related changes in the inter-vertebral disks. Clinically, severalsyndromes, both overlapping and distinct, are seen: neck and shoulder pain, suboccipitalpain and headache, radicular symptoms, and cervical spondylotic myelopathy (CSM). As 1
  13. 13. disk degeneration occurs, mechanical stresses result in osteophytic bars, which form alongthe ventral aspect of the spinal canal. Frequently, associated degenerative changes in the facet joints, hypertrophy of theligamentum flavum, and ossification of the posterior longitudinal ligament occur. All cancontribute to impingement on pain-sensitive structures (nerves and spinal cord), thuscreating various clinical syndromes. Spondylotic changes often are observed in the ageingpopulation. However, only a small percentage of patients with radiographic evidence ofcervical Spondylosis are symptomatic. Occupational based disorders are classified separately in the disease classificationsof contemporary medical practice. The people at their work places, forced to undergopostures of unwanted for long period, which makes one to have the occupational baseddiseases. With the emergence of computer technology in recent years, the average income ofcomputer engineers ranges well above the general working class. However, this comes witha price. Stress and long working hours in front of computers can lead to cervical pain as wellas pathological abnormalities. Many computer engineers develop something called CervicalSpondylosis. Cervical Spondylosis is defined by the degenerative changes of the spine at the neck,creating pressure on nerves and spinal cord at the level of the neck. It is usually consideredby many to be a natural aging phenomenon because it usually occurs in people of age 50 orolder2. 2
  14. 14. Studies show that people can develop Cervical Spondylosis by sitting in front of thecomputer screen for extended period of time, tilting the neck forward, head down or with aposture leaning forward.Symptoms may include3: 1. Pain in the neck, radiating to the shoulder blades, top of the shoulders, upper arms, and hands or back of the head. 2. Numbness and tingling in the arms, hands and fingers; some loss of sensation feeling in the hands; and impairment of reflexes. 3. Muscle weakness and deterioration; diminished reflexes. 4. Neck stiffness. 5. Headache 6. Dizziness; unsteady gait 7. Crunching sounds with movement of the neck or shoulder muscles. 8. With advanced disease, loss of bladder control and leg weakness Vata disorders are dealt by Acharyas as Vata Vyadhi includes the above-discussedspinal originate problems, especially cervical Spondylosis as “Manyasthamba”. Truly, theManyasthamba is one of the Vatajananatmaja Vyadhi4-5 a disease referred to the Siras in theneck region. Even though Manyasthamba is a condition pertaining to the veins 6 of the neck(greevagata siras) with its signs and symptoms resembles the cervical Spondylosis. The commonest cause for cervical Spondylosis or such type of diseases is thedegenerative changes effected in the cervical region. Ayurveda though describes much of itspathological entities with reference to that of Dosha excitations or vitiation of Vata andAvarana, where in the root expression of the Vata vitiation is degeneration. 3
  15. 15. Avarana7, which is specified phenomenon of Vata interactions with the other Dosha,causes the different pathologies in the body. The causes for such a presentation tries toexplain the underlying pathology in terms of structural and functional changes.Why the topic chosen Anti inflammatory, analgesic8 and disease modifying anti rheumatic drugs are thedrugs of choice in contemporary system of medicine. Fortunately all the analgesics are liableto many side effects particularly by repeated and prolonged usage. The contemporarymedical science is depend upon Physiotherapy and rest for the regulating or retarding thedisease in association with the above said medicaments. Ayurveda the age-old Indian system of medicine advocates a reliable management ofdiseases with due consideration to protect the normal health while treating the disease withhighly efficacious and easily available drugs based on humorl theory. Ayurvedic approach to the disease management of Manyasthamba is to retard thedegeneration or to strengthen the dhathus as the pacifying the Vata Dosha has specialimportance in the management. Nasya is described as having a significant role amongShodhana therapy as it does the important action shirah shodhana clearing the channels ofhead by clearing the Dosha samghata deep rooted in the channels of indriya situated9. In recent and past years several experimental and clinical studies have been carriedout by Ayurvedic scientists at various centers with an aim to study the diseaseManyasthamba and to evolve safer. Cervical Spondylosis is a non-specific term describing the morphologicalmanifestations of progressive degeneration of the spine. 4
  16. 16. SPONDYLO is a Greek word meaning vertebra10. Spondylosis generally meanchanges in the vertebral joint characterised by increasing degeneration of the inter-vertebraldisc with subsequent changes in the bones and soft tissues. From the IV to V decade, it is clear that IVD undergoes progressive desiccation,becomes more compressible and less elastic and secondary changes ensue. Although themajority of individuals over 40 years of age demonstrate significant radiological evidence,but only a small percentage develop symptoms. The changes result in neural compressionresulting in radiculopathy or compression of the spinal cord resulting in myelopathy. Boththe neural and spinal cord compression will result in radiculomyelopathy. Males predominate for myelopathy. There is no such proclivity for disc disease.CSM is the most common cause of nontraumatic spastic paraparesis and quadriparesis. Inthe 1997 Moore and Blumhardt series, 23.6% of patients presenting with nontraumaticmyelopathic symptoms had CSM.Race: Cervical Spondylosis may affect males earlier than females, but this is not true in allstudied populations11.Sex: Irvine et al defined the prevalence of CSM using radiographic evidence. In males,prevalence was 13% in the third decade, rising to nearly 100% by age 70 years. In females,the prevalence ranged from 5% in the fourth decade to 96% in those older than 70 years. Another study, in 1996, by Holt and Yates examined patients at autopsy. At age 60years, one half of the men and one third of the women had a significant amount of disease. 5
  17. 17. In 1992, Rahim and Stambough noted that spondylotic changes are most common inthose older than 40 years. Eventually, more than 70% of men and women are affected, butthe radiographic changes are more severe in men than in women.Role of Ayurveda and recent advances in Manyasthamba Ayurveda the age-old Indian system of medicine advocates a reliable managementfor the diseases with due consideration to protect the normal health based on Tridoshatheory, treating the disease with highly efficacious and easily available drugs. Anti-inflammatory and disease modifying anti rheumatic drugs are the drugs ofchoice in contemporary system of medicine. Fortunately all the analgesics are liable to manyside effects particularly in prolonged use. Ayurvedic approach to the Manyasthamba is to retard the degeneration process andstrengthening the Dhatus and pacifying the Vata Dosha has special importance in themanagement of any degenerative phenomenon. Nasya is described as a significant Shodhana therapy as it has the important actioni.e. clearing the channels of head (Shirah Shodhana) by cleansing the Dosha which is deeprooted in the channels. In recent and past, Ayurvedic scientists at various centres with an aim to study theManyasthamba and to evolve safer and economical medicaments for it have carried outseveral experimental and clinical studies. The works are successful to some extent to relievepain and stiffness, common complaints of this condition. In 1992, S. Hebbar from G.A.M.C. Mysore, worked on Manyasthamba with specialreference to its management by Nasya. 6
  18. 18. In 1994, Vijaya Lakshmi from G.A.M.C. Mysore, worked on Medical managementof cervical Spondylitis. Only few works were carried out related to the present topic .In the classics the lineof treatment was told as Rooksha Sweda and Nasya. Much of Inflammation is seen only atthe initial stage and not at the later stage .The later stages can be named as degenerativephases. Rooksha Sweda12 is applicable only in the inflammatory stage, whereas in thedegenerative phase Brumhana Nasya and Vata pacifying drugs are more effective13. The above works were successful to some extent. Pain and stiffness in the chroniccondition left a room to work in terms of shulahara and stambhahara modality to providerelief during the chronic phases.Options of Treatment in contemporary medical science14? In broad terms, the options for the treatment of cervical Spondylosis are eitherconservative or surgical. Conservative treatment encompasses immobilisation with acervical collar (usually a soft collar), use of analgesics or muscle relaxants, and physicaltherapy. Surgery may be performed either by the anterior or the posterior approach and mayinvolve either single or multiple cervical segments. Anterior cervical discectomy and fusionimplies removal of the offending disk and osteophytes with fusion via either a bony graft orinstrumentation (e.g., cage or plate). The alternative is a vertebrectomy (also known ascorpectomy) in which the relevant vertebral body is removed. The posterior approachinvolves either a laminectomy or some form of a laminoplasty. Although the formerinvolves removal of the lamina, the latter is a technique that aims to enlarge the spinal canalby preserving and elevating the lamina roof over the dura, and it typically has less potentialthan laminectomy to cause spinal instability. 7
  19. 19. Treatment usually is conservative, with nonsteroidal anti-inflammatory drugs,physical modalities, and lifestyle modifications most commonly used. Surgery occasionallyis performed. Many of the treatment modalities for cervical Spondylosis have not beensubjected to rigorous, controlled trials. Surgery is advocated for cervical radiculopathy in thepatients who have intractable pain, progressive symptoms, or weakness that fails to improvewith conservative therapy. Surgical indications for CSM remain somewhat controversial15.Natural History of Cervical Spondylosis Cervical Spondylosis is a disorder characterised by degenerative disk disease, theformation of spondylotic ridges and osteophytes, facet and uncovertebral joint arthritis,ossification of the posterior longitudinal ligament, redundancy of the ligamentum flavum,and vertebral body listhesis. Injury to nerve roots or the spinal cord may occur either directlyvia mechanical trauma or compression, or indirectly via arterial insufficiency or venousstasis. To put into perspective the results of treatment, either conservative or surgical, it isimportant to know the natural history of cervical Spondylosis. Ideally, it is necessary toknow the natural history of both cervical spondylotic radiculopathy and myelopathy. Withrespect to cervical spondylotic myelopathy, there are no reliable data. The study by Lees andTurner 16 is often cited as a description of the natural history of cervical Spondylosis. However, it is clear that some of the patients in their study underwent various formsof therapy, but a distinction was not made between those who were treated and those whowere not. Therefore, their conclusion that cervical spondylotic myelopathy is a disease witha lengthy clinical course marked by long periods of non-progressive disability should beregarded with some caution. 8
  20. 20. 17 Clarke and Robinson described their experience with untreated patients amongsttheir larger series of patients with cervical spondylotic myelopathy. They found thatprogression was common, albeit gradual, and that improvement was rare and concluded thatprognosis was generally poor. With respect to cervical spondylotic radiculopathy,longitudinal studies suggest that symptoms may resolve with time. In the population- basedstudy of residents of Rochester, Minnesota, 3 90.5% of patients with cervical radiculopathywere asymptomatic or only mildly affected after a mean follow-up period of almost 6 years.This figure includes those patients who were treated surgically, but these were a minority(26%) of the whole group. The clinical manifestations of cervical spondylotic myelopathy include weakness andspasticity due to motor long-tract dysfunction, sensory impairment due primarily to dorsalcolumn involvement, and bladder dysfunction. Cervical Spondylosis may also manifest onlywith neck and head pain or with signs and symptoms attributable to cervical radiculopathy. The syndrome of cervical spondylotic myelopathy must be distinguished from theserelated clinical entities. With the natural history of cervical Spondylosis, can it be altered bysurgery? Are there particular circumstances that should dictate either surgical intervention orconservative measures? Is surgery more or less indicated if symptoms are due to cervicalroot or spinal cord compression? Is there any value of the natural herbal management i.e.Ayurveda? All these questions can be answered with this clinical trail undertaken. 9
  21. 21. Chapter –2 Objectives of study The present study intended to focus on the disease evaluation i.e. Manyasthamba vis-à-vis cervical Spondylosis and the management with Mashabaladi taila internal and externalthrough Nasya. Mashabaladi yoga is mentioned at Chakradatta with reference to the management ofManyasthamba is prepared in taila form as avartita to fortify the efficacy and also toadminister per Nase, and capsulated in 300 mg gelatine capsule. The compound ofMashabaladi Yoga reduces pain, and swelling in association with anti degenerativeproperties as it pacifies the Vata. So the combination is assumed as most suitable in themanagement of Manyasthamba. In this regard the objectives proposed in the study are discussed one after another asunder -1) To evaluate the vedana samakatawa (analgesic effect) of Mashabaladi Taila inManyasthamba (Cervical Spondylosis) The condition Manyasthamba is effecting the neck region with the symptoms such aspain and stiffness. Manyasthamba and its management through various methods are possibleviz, Vatahara dravya, vedana stapaka dravya, Mardana, etc. One out of them is Mashabaladithailam, which is administered as Pratimarsha Nasya in both Nase and/, or internally in theform of capsule at present study. The specificity of the shoolaghna and Vatahara effect is studied as the analgesiceffect of contemporary. Pain relief is to offer for the patient by al means. Shoola hara(vedansthapana) nervine tonics Vatahara these said properties are effective over Dosha 10
  22. 22. predominance and Dushya Dhatus to regulate normally by fragmenting the underneathpathologies. As the patient experiences at the most pain and inconvenience due to the stiffness atneck region. The analgesic effect of Mashabaladi taila in Manyasthamba can be evaluatedby the means of studying the pain and stiffness with specified parameters. Understandingthe cumulative effect of the Mashabaladi yoga is possible through the above said methods. The Mashabaladi yoga comprises of Kapha Vata hara in nature, which reduces painand stiffness and there by regulate the concern organ pathology. This can be understood thatthe study of base line data to the final data differences after the drug administration to thepatient’s those who are included by the present parameters of exclusion and inclusioncriteria.2) To evaluate the vyathiharthwa (disease regression) of Mashabaladi taila inManyasthamba (cervical Spondylosis) The Vyadhi, Manyasthamba is a Vata Vyadhi by its nature. Traditionally, it isbelieved that the degeneration of joints and related structures is inevitable and progressive innature as the Vata ages are achieved, i.e. the progressive age from 5th decade onwards. Butthe degeneration is witnessed now a day at the early age groups, which is alarming for thehealth associates. In the present study the specifically the regression of degeneration is estimatedthrough the Kapha vruddhi kara bhavas accumulation in the body by offering the Vataantagonistic management. The antagonistic management of the Vata activates the boneintegrity to re-establish and there by the normal bony component with its functions re-establishes. 11
  23. 23. Such improvement on functional or structural components in the cervical jointswhere the disease regression study is made through noticing the effect of Mashabaladi tailain Manyasthamba i.e. cervical Spondylosis. It can be evaluated by either understanding thecumulative effect of the above said yoga at hypothetical level or directly estimating thedisease regression through parameters.3) To evaluate the cumulative effect of Pratimarsha Nasya and internal administrationof the Mashabaladi taila in Manyasthamba (cervical Spondylosis) Pratimarsha Nasya (Brumhana Nasya) is per Nase administration of medicine givessnehana – unctuousness and rechana – elimination effect in the head and surroundings.Nasya karma when it is done properly and regularly, keeps the person’s eye, nose, and earunimpaired it is also prevent premature graying of hair, head ache etc. It alleviates thedisease of urdwajathru like Manyasthamba, Ardhita etc. The cumulative effect of the Avartita Mashabaladi taila internally and as PratimarshaNasya is studied to establish the relation to the management. 12
  24. 24. Chapter –3 Review of literature The disease references are much available in Vedas and Samhita as only Vata vikara.It is evidential that there is no direct reference of the disease as Manyasthamba is availablefrom vedic literature, but can definitely find indirect references here and there. In theRigveda and Atharvana Veda we can see the details of Vata bheda, Sleshmaka Kapha18.Sandhi Vyadhi and medicines used in Vata Vyadhi. The references are found from Bhruhatrayes and Laghu trayees many more about thedisease Manyasthamba. Manyasthamba is highlighted in early 20th century and even theyhave mentioned the Shodhana and Shamana line of managements. Charaka Thrimarmeeya chapter of Siddhi Sthana19, he explained Manyasthamba isbecause of head injury i.e. shiro abigatham and considered “Antharayama” as 20Manyasthamba. Similarly Vagbhata also refer Manyasthamba is a symptom of“Antharayama”. In further while explaining the Nasya vidhi, he has indicated Nasyaespecially Brumhana Nasya for Manyasthamba21. Susruta Samhita dealt Manyasthamba as the prodromal symptom of Apathanaka, aVata Vyadhi. But Gayadasa, commentator of Susruta, considers Manyasthamba asindividual disease entities because of its causative factors are discussed separately as adisease22-23. Later texts of Ayurveda Madhava Nidana24, Bhavaprakasha25 and SharangadharaSamhita26 dealt Manyasthamba as individual disease by discussing its detailed pathologyalong with its specific line of treatment. Chakradutta27, Vangasena28 and Bhaishajaya 13
  25. 25. Ratnavali29 also discussed Nidana and treatment for Manyasthamba as an individual entityof disease. At the present day of context, the contemporary science explains elaborateddescription of cervical Spondylosis, which is degenerative disease, has been studied under aseparate branch named as Rheumatology linked with the bonny lesions30.Etymology of Manyasthamba The Manyasthamba comprised of two meaningful words, Manya and sthamba, whichmakes the meaning of stiffness of the neck muscles. It clearly states the pathogenesis of theneck and its contents. The derivation of the Manyasthamba is as follows31. “Manya” means the back of the neck or the part below the head, manya and Greeva are synonyms. “Sthamba” relays the meaning of stopping or retarding the functions of the neck i.e. inability of neck movements With the above stated definitions and derivations we can draw a conclusion as suchthe disease Manyasthamba is a disease of the neck where the movements are restricted ordisturbed because of the underlying pathology. The pathology is either degeneration or oflocal pathological entities, either because of the internal humoral vitiation or exogenicfactors32.Paribasha33 Vata is vitiated either because of Avarana or Dhatu kshaya. When Vata covered byKapha or Dosha accumulation makes Manyasthamba. Even though Manyasthamba is told asa vataja nanatmaja Vata Vyadhi Kapha Dosha associations are also inscribed in theSamprapti. 14
  26. 26. This is because the Vata is vitiated and lodging in the Kapha sthana so the Kaphainvolvement can occur. When any disease is not treated properly at the initial stage it maylead to further deterioration. Such activity is happening even in Manyasthamba too. At theinitial stage of the disease the Kapha Anubandhatwam is acknowledged. When it becomeschronic, it becomes as a total Vata disorder, which is degenerative condition in nature.Surface Anatomy of the disease concernVertebral column34-35-36 The total numbers of bone present in the body are together called as skeleton. Themain division of skeleton is into axial and appendicular. The axial skeleton includesvertebral column, sternum, ribs, and skull. The appendicular skeleton includes these bonesof the upper and lower limbs and girdle bones. The vertebral column extends from the baseof the skull through the whole length of the neck and trunk. It consists of thirty-threeseparate irregular bones called vertebra placed in series and connected together by ligamentsand discs of fibro-cartilage to form a flexible curved support for the trunk. The vertebral column varies length but it is about 70cm in man and 60cm in women.Th vertebra is named according to region in which they lie. They are 7 cervical, 12 thoracic,5 lumbar, 5 sacral, 5 coccygeal. With the exception of the first two cervical vertebrae all other vertebra consists of alarge anterior weight bearing body and a posterior placed vertebral arch. The arch springsfrom the postero-lateral aspects of the body and with its surrounds large hole, vertebralforamina. When the vertebra are placed in series these foramina together with the ligamentaflava, that unite the adjacent laminae form the vertebral canal which lodges the spinal chordwith its meaning and blood vessels. 15
  27. 27. Atlas (first cervical) vertebra The first cervical vertebra is called the atlas it looks very different from a typicalcervical vertebra as it has no body and no spine. It consists of two lateral masses jointanteriorly by a short anterior arch, and posteriorly by a much longer posterior arch. Thearches give the atlas a ring like appearance. The large transverse process pierced by aforamen transversarium, projects latterly from the lateral mass. The superior aspects of eachlateral mass shows an elongated concave facet, which articulates with the correspondingcondyle of the occipital bone. Figure –1 Cervical vertebrae (C1-4) Postrio-superior viewThe axis (second cervical) vertebra The most conspicuous feature of the axis, which distinguishes it from all othervertebra, is the presence of a thick finger like projection arising from the upper part of the 16
  28. 28. body. This projection is called the densor odontoid process. The anterior aspect of the densbears a convex oval facet for articulation with the anterior arch. Its posterior aspect shows atransverse grove for the transverse ligament. The pedicles, laminae and spine are the thickand strong, the inferior articular facets are placed below the junction of the pedicles and thelaminae. Figure –2 Cervical vertebrae (C2-T1) Right-Lateral viewThe seventh cervical vertebra The seventh cervical vertebra differs from a typical vertebra in having a long thickspinus process, which ends in a single tubercle. The tip of the process forms a prominentsurface landmark. Because of this fact this vertebra is referred to as the vertebra prominence. 17
  29. 29. The transverse processes are also large and have prominent posterior tubercles. In thisvertebra the vertebral artery and vein do not transverse the foramen transversarium of thisvertebrae an accessory vertebral vein passes through the foramen.Anatomy of inter vertebral joints All vertebrae from 2nd cervical to 7th cervical vertebrae articulate by cartilaginousjoints between their bodies, synovial joints between their articular process (Zygapophysical)and fibrous joints between their laminae and also between their transverse and spinousprocess.Inter-vertebral disc It is a fibro-cartilagenous disc, which bends the two adjacent vertebral bodies, exceptthe axis. Morphologically it is a segmental structure as opposed to the vertebral body, whichis inter-segmental.Inter-vertebral discs Shape: The shape of the inter-vertebral disc corresponds to that of thevertebral bodies between which it is placed.Inter-vertebral discs Thickness: It varies in different region of the column and in differentparts of the same disc. In cervical region the disc are thicker in front than behind.Structure of inter-vertebral disc: Each disc is made up of three parts, viz., Nucleuspulposes, annulus fibrosus and cartilaginous plate. The individual component description isas follows.Nucleus pulposus: It is the central part of the disc, which is soft and gelatinous at birth. Itswater content is 90% in newborn and 70% in old age. It is kept under tension and acts as ahydraulic shock absorber. It represents the remains of the notochord and contains few multinucleated notochordal cells during the first decade of life. After which there is a gradual 18
  30. 30. replacement of the mucord material by fibro cartilage derived mainly from the cells ofannulus fibrosus and partly from the cartilaginous plates covering the upper and lowersurfaces of the vertebrae. Thus with advancing age the disc becomes amorphous anddifficult to differentiate from the annulus. Its water binding capacity and the elasticity arereduced.Annulus fibrousus: It is the peripheral part of the disc made up of a narrower outer zone ofcollagenous fibres and a wider inner zone of fibro cartilage. The laminae form incompletecollars, which are convex downwards and re corrected by strong fibrous bands. Theyoverlap into one another at obtuse angles. The outer collagenous fibers bend with anteriorand posterior longitudinal ligaments.Cartilaginous plate: Two cartilaginous plates lie one above the other below the nucleuspulposes. Disc gains its nourishment from the vertebrae by diffusion through these plates.Function of inter-vertebral discs: Inter-vertebral discs give shape to the vertebral column.They act as a vertebral series of shock absorbers or buffers. Each disc may be linked to acoiled up spring.Movements of the cervical column: Range of movements between vertebrae is restrictedby the limited deformities of inter-vertebral discs. Whose greater thickness at cervicalcolumn increases individual range. It is also limited by the topography of the zygophysialjoints and by concomitant changes in tension of the ligamentous syndesmoses. Thus the totalrange of vertebral movement includes flexion, extension, lateral flexion rotation.Flexion: In flexion the anterior longitudinal ligaments become relaxed and the anterior partof inter-vertebral discs are composed. While at its limit the posterior longitudinal ligament 19
  31. 31. ligamentum flora, inter-spinous and supra-spinous ligaments and posterior fibres of inter-vertebral discs are tensed.Extension: In extension the opposite event of flexion occurs. Tension of the anteriorlongitudinal ligament, Anterior disc fibres and approximation of spines, zygopophyses andcompression of posterior disc fibres, limits extension.Lateral flexion: Here the inter-vertebral discs are laterally compressed and contra-laterallytensed and lengthened motion being limited by tension of antagonist muscles and ligaments.It is always combined with rotation, lateral movements occur in any part of the column butare greatest in cervical and lumbar region.Rotation: Rotation involves twisting of vertebrae relative to each other, with torsionaldeformation of intervening discs. Movement is slight at cervical level.Neuro anatomyCervical plexus37-38 The cervical plexus is formed by the vertebral rami of the upper four cervicalnervous. The rami emerge between the anterior and posterior tubercles of the cervicaltransverse processes, grooving the costo transverse bars. The four roots are with one anotherto form three loops. The plexus is related posteriorly to the muscles, which arise from the posteriortubercles of the transverse process i.e., the Levator scapulae and the scanlenus medius.Anteriorly to the pre-vertebral facia, the interior jugular vein and sterno mastoid. 20
  32. 32. Branches A) Superficial cutaneous branches 1. Lesser occipital (c2) 2. Greater auricular(c2,c3) 3. Transverse (anterior) cutaneous nerve of the neck (c2,c3) 4. Supra clavicular (c3,c4) B) Deep branches 1. Communicating branches 2. Muscular branches (a) rectus capitis anterior from c1 (b) rectus captis lateratus from c1,c2 (c) longus capitis from c1,c2,c3 (d) lower root of anasa cervicalis c2c3Muscles supplied by cervical branches 1. Stermomastoid – c2 and accessory nerve 2. Trapezius – c3-c4 3. Lavetor scapularis – c3c4c5 4. Phrenic nerve c3c4c5 5. Longus colli c3-8 6. Scalenus medius c3-8 7. Scalenus anterior c4-6 8. Scalenus posterior c6-8Phrenic nerve This is a mixed nerve and carrying motor fibres to the diaphragm and sensory fibresfrom the diaphragm, the pleura, the pericardium, and part of the peritoneum. 21
  33. 33. Origin: It arises chiefly from the 4th cervical nerve but receives contributions from c5 maycome directly from the root or indirectly through the nerve to the subclavius.Ayurvedic in sight of Shareera There are four asthi sandhis in neck (kandda). They are movable joints, which havelimited movements (prasthara sandhis). The ligaments (snayu) present in manya are two39-40.Marma41 Vagbhata defines that marma is the meeting of mamsa, asti, sira, snayu, dhamani andsandhi and is the place where the prana is felt. Manya is a sira marma. Based on the vulnerability, the marmas are classified in to five types. In that manyais vaikalya kara marma, the name of the marma is derived from the word ‘vikala’, whichmeans deform or cripples. Thus it is understandable here that these marma on receivinginjury or insults shall result in the deformity of the related body parts in diseased conditionof the pathology happens to proliferate in to these marma sites. Then it is likely that thebody parts are crippled or deformed even after the control of disease.Bony component development factors42 According to the Ayurvedic literature, the body is, made up of seven dhatus. Out ofthen asthi is the gambhir, 5th dhatu by chronological order. It is hard, stable and gives shapeto body. It is formed from pruthvi, teja, vayu and akasa. Susruta explains the pitrja bhavas (inherited from father) which support the evolutionof the asthi Dhatu, in the foetal stage. The influence of the factor is not confirmed to the lifeof the foetus in the uterus. But they play a very significant role in the development of asthiDhatu43. 22
  34. 34. According to modern observation the hard, soft and hollow parts of the body aredeveloped from ectoderm, mesoderm, and endoderm44. But according to Ayurveda theorgans and other structure of the body are evolved from the sapta Dhatu. According to the law of successive production of Dhatu “krama parinama Nyaya45”asthi is produced from its previous one that is from meda. Pruthvi Guna is much morepresent in bones. Meda creates a compact mass of Pruthvi, Agni, anila etc by its own heatand forms the bones. Vata creates sponginess of the interior of bones, which is filled withsneha obtained from meda. This is also called the majja (the marrow) vayu and akasa andothers from the spongy substance as well.Development46-47 Ossification of bones begins in the third month of intra- uterine life and advanceswith age. Initially they are cartilaginous, and complete their ossification at the age of 25, buteven there some remain in a cartilaginous stage till the end of life. In a person with a KaphaPrakruti the bones are firm and tough48.Bony components degenerative factors49 Degenerative diseases in Ayurveda view, many a times appear to be the vitiation ofVata as well as the deterioration of the body tissues that are termed as Dhatu. We know that the ageing process is also understood as a degenerative process, whichcomes as an on slat of time Ayurveda has mentioned that ageing process is a disease thatoccurs naturally that no body can avoid hence, grouped under the classificationSwabhavabala pravritta Vyadhi In Susruta Samhita50. Old age is considered to be a period ofVata predominance. Where in body gets dry, light and becomes depleted of essence. 23
  35. 35. Degeneration is not only as an in balance of Dosha, but also to know it in terms oflack of good quality Rasa Dhatu in other words, when we see degeneration. Process in thebody importance should be laid on to provide the body with pure nutrients essence i.e., RasaDhatu, for which it is essential to maintain a good state of metabolism. Ayurveda says that all the ailments are due to a low digestive and metaboliccapacity, which is termed as mandagni51. It is not enough to load the system with requiredamount of foodstuff. The power of digestion and metabolism is termed as Agni in Ayurveda.The concept of Agni in Ayurveda is vital when we want to deal with health or disease. Aweak Agni will turn the so-called balanced diet in to a disease. Generating toxins in the bodyis called as Ama. An inefficient state of digestion and nutritional essence, Rasa Dhatu,which in turn will badly effect the production of the subsequent body tissues and ultimatelypave for disease of degenerative in origin.Digestion and metabolism relations to degenerative disorders52 An efficient power of digestion in the gastrointestinal track includes properfunctioning of the main and accessory organs of the Maha Srotas. Many other chemicals thatwe come in to contact with our daily life have been found to be endocrine disruption, whichinterfere in the endocrine functioning of the organism there by posing a threat to the healthand harming the very process of procreation and degeneration.Patho-physiology of cervical Spondylosis53-54 The age related changes in cartilage include alterations in proteoglycas and collagen,which decrease tensile strength and shorten fatigue life. Despite this relationship, it is anover simplification to consider osteo-arthritis as merely a disease of cartilage wear and tear.Chondrocytes play a primarily role in the nervous function. Process and constitute the 24
  36. 36. cellular basis of the disease. The chondrocytes in osteo-arthritic cartilage produce IL-1 andTNF-alpha, which are known to stimulate the procedure of catabolic metalloproteinase andinhibit the synthesis of both type 2 collagen and proteoglycans. The effects of thesecytokines potentates because their receptors show increased sensitivity. Other mediators,such a prostaglandin derivatives and IL-6, also have a role in this cascade of matrixdegradation. Most of these cytokines also have pro-inflammatory cells are present in manyosteo-arthritic joints. These precise events lead to the secretion of cytokines. Nidana – the aetiology of Manyasthamba It is also essential to determine the exact nature of the disease with special referenceto the Dosha, Dhatu, Malas, Srotas, and Agni involved in this manifestation of disease.Causes in general55: v In addition to age and possibly gender, several risk factors have been proposed for cervical Spondylosis. v Repeated occupational trauma (e.g., carrying axial loads, professional dancing, and gymnastics) may contribute. v Familial cases have been reported; a genetic cause is possible. v Smoking also may be a risk factor. v Conditions that contribute to segmental instability and excessive segmental motion (e.g., congenitally fused spine, and cerebral palsy, Down syndrome) may be risk factors for spondylotic disease. As the Manyasthamba is a Vata Vyadhi, the Vata Vyadhi Nidana has to beconsidered here. Manyasthamba is one among the eighty types of Vata disorders. There isno much difference in the causative factors of Vata diseases. Only due to Samprapti 25
  37. 37. Vishesha of vitiated Vata will leads to variety of Vata disorder like Ardhita, Pakshagata,Manyasthamba etc., the factors which causes vitiation of Vata are classified under thefollowing sub headings. 1. Swaprakopaka Nidana 2. Margavarodhaka Nidana 3. Marmaghatakara Nidana 4. Dhatukshayakaraka Nidana The etiological factors having some properties of Vata causes increase of Vata.According to Samanya Vishesha Siddhanta, the principle of the doctrine is the combinationof similar brings about vrudhi and the dissimilar to kshaya56. Further excessive and constantconsumption of the same etiological factors results in to provocation of Vata. Apart fromthese the factors which favours the provocation of Vata are also to be considered here. Theseetiological factors are classified as follows.Swaprakopaka NidanaAhara (dietetic factors) Excessive and continuos in take of diet possessing the properties of ruksha, SheetaLaghu, and rasas like Katu, Tikta, Kashaya, irregular food habits, in sufficient diet, intake ofdried leafy vegetables, dried food articles, cereals like varaka, kodrava, pulses like syamaka,mudga, kalaya, chanaka, harenu.Vihara57 Ratri jagarana, excessive walking, excessive swimming, excessive riding on horsesand vehicles, ativyavaya, prapatane (talking) adhyasana, bharavahana (weight lifting)ativyayama (excessive exercise) balavat vigraha, (fighting with persons of superior strength). 26
  38. 38. Seasonal factors and Vayah Rainy season and part of the summer season. End part of the day, night, digestion arethe seasonal which makes Vata prokopa in the old age Vata Dosha is dominant makes Dhatukshaya (degenerative changes)Mithyo pachara of Pancha karma58 Improper doing of Vamana, Virechana, Vasti etc., the term denotes has atiyoga aswell as heena yoga. The wrongly carried out methods cause vitiation of Vata Dosha.Psychological factors59 Due to worry, grief, anger, fear, anxiety, the body becomes emaciation causes Vatavitiation.Margavarodhaka Nidana The etiological factors which causes obstruction in the normal movement of Vataresults in the prakopa of Vata.Vegha dharana and udheerane60 Suppression of natural urges and inducing the urges forcefully causes Vata prokopa.In Manyasthamba these factors causes prakopa of Vyanavata, a sthanika Dosha mayaggravate the condition.Ama Due to hypo functioning of Agni, the food that is not completely digested, yieldsimmature Rasa in Amashaya, obstructs the Vatavaha Srotas, causes the vitiation of Vata andmoves around in different directions to produce a Vata Vyadhi. 27
  39. 39. Other Doshas Manyasthamba is told as Vata kaphaja even though it is included in Vatajananatmaka Vyadhi. Here Kapha Dosha involvement is present. The Kapha prokopa aharanidanas causes the obstruction of Vata makes sthanika disease.Kapha prokopa factors Ahara: Excessive and continuous usage of sweet, acidic, salty, cold and heavy foodarticles like yavaka, black gram, curd, milk, nava danyas. Anupa mamsa etc., Vihara: Day sleep, excessive sleep, suppression of vomiting Marmabhigata: Injury to neck causes Vata prakopa resulting kshata of the manyasiras and asthi bramsa, hence it results in to the loss or restriction of neck movements. Theetiological factors such as carrying heavy weight over head, sleeping in irregular surface,etc, can cause the marmagata in the neck region61-62.Dhatu kshaya kara Nidana The Dhatu kshya can arise due to various etiological factors. The Dhatu kshya causesincrease of rukshata thus prakopa of Vata. In old age due to the degeneration of the discsincreases pressure on nerve roots by which nerve roots of the vertebra is compressed and thecompression of vertebra is causing Manyasthamba. Excessive indulgence in exercise or sexcausing Dhatu kshaya is also a cause of Vata prakaopa leads to Manyasthamba. Table –1 Comparison of Manyasthamba Lakshana Madhava Bhava Yoga Susruta Nidana Prakasha RatnakaraDiwaswapna + + + +Asanasthana vikruthi + + + +Urdwanireekshana + + + + 28
  40. 40. Divaswapnam As we all known Divaswapnam causes Kapha prakopa, which is involved in earlystages of the disease to be more specific. It can be interpreted in terms of sleeping in badpostures. Which causes minor trauma to the cervical spine and leads Manyasthamba.Asanasthana Vikruthi63-64-65-66 Here Asana as upaveshanam and sthana as urddwa vibhavanam, which means thepostural disturbances specifically with reference to sitting. Persons sitting or even lyingdown in bad postures, which in turn leads to improper positioning of cervical vertebrae, thisputs uneven pressure over the spinal nerve roots producing different signs and symptoms.We know that when a person sits or sleeps in improper head positions, if that person is ofmiddle age or old aged as he has already developed degenerative changes in the cervicalvertebrae. Which is due to ageing process, hence a wrong posture cause minor traumaaccelerates the pathology of degeneration leading to set of clinical features.Urdwa Nireekshana67-68-69-70 Dalhana clarifies that by looking upwards continuously is vakra position of manyaleads to minor trauma and precipitates the symptoms. In Charaka Samhita abigathwam ofsiras has told one of the reason for Manyasthamba. In the modern science they describedsevere trauma such as suddenly turning the head, continuously looking upwards, repeatedmovements of cervical vertebrae, desk work, clinical work, weight lifting etc., causes forcervical Spondylosis. Apart from the above age is obviously the most importantpredisposing factor. 29
  41. 41. Etiological factors according to modern 71 1) Postural causes v Drooping shoulder v Condition in the muscles fascia, ligaments and glands v Trauma v Occupational strain 2) Condition of the cervical spine v Inter vertebral disc prolapse v Lesions in the vertebral bodies v Trauma: old fractures, dislocation, subluxations v Tuberculosis v Tumour deposits v Ankylosing Spondylitis 3) Intra-spinal conditions v Cord tumours v Syringomyelia v Extradural tumours v Shoulder lesions v Peri-arthritis v Supra spinatus tendnitas v Sub deltoid bursitis 4) Reffered pain v Cardiac ischemia can cause left sided brachial neuralgea v Sub-diaphragmatic lesions like gall bladder lesions cause right sided pain 30
  42. 42. 5) Systematic cause v Diabetic neuropathyPurvaroopa 72 Poorva rupa are the premonitory symptoms, which occur before the completemanifestation of a disease. Commonly all disease will show some premonitory symptomsbefore the disease develops but there are no such premonitory symptoms of Manyasthambaare mentioned in the classics but In general before manifestation of Manyasthamba vitiatedVata will show its symptoms in the body. This includes mild pain in the neck and alsostiffness of neck.Roopa73 The term roopa implies both signs and symptoms, which plays a very important rolein the diagnosis and management of the disease. The lakshana develops after thepoorvaroopa as the Samprapti (pathology) advances from sthana samshraya avastha tovyaktha vastha. At this stage, the Dosha- dushya sammurchana becomes continuous and thetotal signs and symptoms are observed. In this stage of Sammurchita Dosha ruk (pain) andStambha (stiffness) becomes the only signs and symptoms told in the classics as Lakshanapertaining to the Manyasthamba is visualized. These can be classified in association with theother symptoms as under with different headings, which we don’t find in the classics. Theyare - 1 Asymptomatic 2 symptomatic Symptomatic stage can be classified in to - 1. Pain restricted to only manya pradesha 2. Pain radiating down to the arm, fore arm, hand and fingers 31
  43. 43. Asymptomatic stage In the classics, Asymptomatic stage is described as the vrudhvastha. The dhatus willbecomes ksheena, which is a quite natural process in which the Dhatus becomes degeneratedas age progresses. Occasionally, few people in spite of appearing these changes will not show anysignificant signs and symptoms related to the stage of Asymptomatic, as there is noinvolvement of the nerve root. In modern science they explained as follows the vertebra of most people past 50years of age shows some evidence of a degenerate changes. It is important to realise thatsuch finding may be Asymptomatic and of no clinical significance.Symptomatic stage It can be classified as a localised pain in manyapradesha and radiating pain down thearm, fore arm, hand, and fingertip according to the site of the pain. This classification is made on the basis of Manyasthamba pathology involved withthe signs and symptoms. Pain is the symptom produced due to involvement of differentanatomical structures in the disease process. Hence minimal involvement reflects with pain restricted only to manya pradesha andin the advanced cases, it even involves special nerves, which causes the radiation of paindown to the arms depending upon the involvement of nerve root segments. Here the presenting symptom will be stiffness of neck i.e., sthamba of manya. Thesthamba is the resultant of spasticity of neck muscles, which stretches and make neck stiff.Vedana in manya pradesha are manya shoola, this is outstanding clinical symptoms in allmost of all patients. 32
  44. 44. Symptoms74 The typical symptoms of the cervical Spondylosis consists of radiating pain andstiffness of the neck or arms, restricted head movements head aches, spastic paralysis, andweakness in the arms and legs. Because of the combination of neurological symptoms andbone degeneration and the common incidence of arthritis in the elderly, cervical Spondylosismay be difficult to distinguish from primary neurological disease with unrelated arthritis. The degenerative process may begin in any of the joints in the cervical spine, andover time it also cause secondary changes in the other joints. Inter vertebral disc may beprimarily affected. As the disc narrows the normal movement of that segment is altered andthe adjacent joints are subjected to abnormal forces and pressures leading to degenerativearthritis. Dysphagia can results from large anterior osteophytes that are bony growths at thefront of the spine, all though this is rare.Clinical aspects75 The signs and symptoms produced are the results of nerve root compression, spinalcord compression, or both. The most common complaint is neck pain, which limits itsmotion and is aggravated by neck extension. Pain also may radiate in one arm in a patternCharacteristic of the particular root involved. Table –2: Level of disc herniationManifestation C4-C5 C5-C6 C6-C7 C7-T1Root C4 C5 C6 C7compressedWeakness Deltoid Biceps Triceps, wrist, Hand intrinsic extension wrist flexionSensory loss Lateral Lateral arm forearm, Middle finger Ring and little shoulder thumb, lateral aspect finger of fingerReflex Deltoid Biceps Triceps Finger flexioninvolvement pectoralis 33
  45. 45. Lhermitter’s sign76-77 Refer to sudden electrical sensation down the neck and back triggered by neckflexion. It is also is seen in cervical Spondylosis, cervical spine cord tumour, radiationmylopathy.Spurling’s sign78-79 Refers to the reproduction or exacerbation of pain upon pushing down on the headand bending towards the involved side the reduction of the pain when axial traction isapplied to the head is also suggestive of a disc. Finally, in the shoulder abduction test raisingthe affected arm above the head reduces the pain.Huck step tender triad80-81 Classically in cervical Spondylosis has three tender areas, representing the huck steptender triad should be felt for. These are - 1. At the base of the neck anterior to the trapezes 2. Over the insertion of the deltoid 3. In the extensor mass of the fore armManyasthamba Samprapti Samprapti is a series of pathological changes takes place in the body from day ofdevelopment of the disease till to complete manifestation and establishment of the diseasewith its complications. The knowledge of Samprapti is very much essential from Chikitsapoint of view and it also helps to understand complete pathogenesis of a disease, as it hastold by our Acharyas. “Samprapti vightanameva Chikitsa”, which means systemic breakingof Samprapti is called Chikitsa hence a proper knowledge of Samprapti along with its 34
  46. 46. ghatakas is very much essential. An elaborate description of Samprapti of Manyasthamba isnot available in the classics. The Vata Dosha along with Kapha Dosha get vitiated and take asraya at manyapradesha affecting the manya siras causing sthambana and ruja of neck. Bhavamishraexplained the pathogenesis of Manyasthamba elaborately but he did not describe thepathological structural changes in the articular cartilage disc and vertebrae. Vata prakopa Nidanas mentioned like datukshya, which mainly occur during the midand later decades of life time can be interpreted in terms of degenerative changes found inthe cervical spine and disc which is the resultant of ageing process mentioned in the ailedscience. Second one is due to margavarodha. The Nidanas like adhyaashana, vishamasana(oordha Nireekshana, asmasthama sayanam) and other Ama kara Nidanas vitiated first Agnileading to manda Agni and production of Ama causing margkavarodha in this way all theabove Nidanas will causes Vataprakopa either by datukshya or margavarodha. While describing Samprapti of Manyasthamba (cervical Spondylosis) it should beunder stood in this manner. When we go though the pathological changes found at cervicalspine, the change in the ligamentum flavum, which is indicative of early stages of disease.Here at this initial stage we can expect the involvement of Kapha. In the latter stage it involves nerves roots and even spinal cord, which is attributedsolely to Vata vitiation. In some patients we can find shotha localised part and in the alliedscience they claim that swelling is found in early stages i.e., cervical Spondylitis, which issuggestive of vitiation of Kapha. When the due course all diseases are not treated properly itleads to Vatic in nature. In the initial stage we can accept the involvement of Kapha in 35
  47. 47. Manyasthamba (Cervical Spondylosis) but the latter stage, we find the compression of nerveroot due to ostyophytes changes producing different signs and symptoms which arecollectively termed as Manyasthamba (Cervical Spondylosis). It can be attribute the role ofVata Dosha and there is minimal or no involvement of Kapha.Samprapti Ghatakas The knowledge of Samprapti gataka is very much essential while treating a diseasebecause systematic breaking of pathogenesis as Samprapti is known as treatment of aparticular disease Dosha Vata- Vyanavata Kapha sleshma Kapha Dushya asthi, majja, sanyu, mamsa, Agni jatara Agni mandya janya Ama, asthi dhatuagni mandya janya Ama Srotas asthi vaha Srotas Sroto dusthti sanga Udhbhara sthama pakwasaya Sanchar sthana rasayani Roga marga madhayama rogamarga Adhishtanam manya pradesha Vyaktha sthana manya pradesha 36
  48. 48. Figure –3 Pathogenesis of cervical Spondylosis82 Aging Decreased in water content of nucleus pulposes the central portion of disc Disc dehydrates. Cartilaginous disc becomes softening roughening, fibrillation lateral clefts and pits appear followed by erosion Trauma Decreases the height of disc and becomes less ability to resist loading and stress. Collagen fibers fragment and the annulus the out run of the disc, bulges in to spinal and nerve root canals Due to lower height and increased mobility resulting the stress in the vertebral end plates and worn out of cartilage,Cause the development of spurs and the facet joint Hyper trophy and further narrow with nerve root canals. Spinal ligaments thickness looses their elasticity and herniated in to the spinal canal. Cervical Spondylosis 37
  49. 49. Figure –4 Manyasthamba Samprapti Vaya and NidanasDiwaswapna, Asanasthana sayanam Vata prakaopaUrdhwanireekshana Sleshmavarana Stana samshraya in manya siras Kupitha Vata ManyasthambaDescription of Manyasthamba according to shad KriyakalaSanchaya and prokopa83: Accumulation of Dosha is chaya and vilayana is prokopa. In these stages Jatharagnimandya, Ama formation, vitiation of doshas, stabdha Purna koshta, Anga gauravadhatukshaya and dhatwagni mandya take place.Prasara: Virulent Ama circulates in the whole body due to chala and sheeda Guna of vitiatedVata. There is appearance of atopa, Angasada, archer, avipaka, daurbalya, and amgamardhaetc., 38
  50. 50. Sthana samsraya: The vitiated Ama and Vata lodges in the manya pradesha in this stage the purva rupaare presented like stabdhata (stiffness) ruja, . Etc.,Vyakthi: The clinical features of Manyastambha like stabthata, ruja, and graha to manyapradasha are the symptoms of its complete manifestation.Bheda: Bhedavastha suggests the chronicity of the disease Manyastambha.Management of cervical Spondylosis in contemporary science Strong medical reassurance coupled with advice from a physiotherapist aboutposture and improving physical fitness can sometimes be helpful .A small evening dose of atricylic antidepressant may improve sleep but the condition tends to have a chronic andprotracted course in most patients. The surgical procedure proposed for removing the bonespur and possible fusion of two or more cervical vertebrae.Ayurvedic line of management Susruta84 says Nidana parivarjana is Chikitsa. But Charaka85 has further amplifiedthe scope of Chikitsa by saying, Chikitsa aims not only the less exposure to the causativefactors of the disease, but also at the restoration of Doshic equilibrium. Manyasthamba beingVataja Vyadhi, treatment of Vata Vyadhi can be adopted. But, specific line of treatment isdescribed for Manyasthamba.Chikitsa sutra of Manyasthamba 86-87-88-89-90 The steps and procedures to be adopted in the management of the Manyasthamba areas follows. 1. Rooksha Sweda 2. Panchamoolakwatha or dasamoolakwatha sevana 3. Nasya karma 39
  51. 51. Table - 3 Chikitsa of Manyasthamba according to different Acharyas are depicted as under.CHIKITSA Bhava Yoga Susruta Bhaishajya Chakradutta Prakasha Ratnakara Samhita RatnavaliSneham + _ _ _ _Swedam + + _ _ _Nasyakarma + + + + -Nasapanam - + _ + + Bhava Mishra91 mentions that the Abhyanga with thaila or grutha should be done inManyasthamba. Bhavaparakasha and Yogaratnakara indicate Rooksha Sweda and Nasya.Bhaishajyaratnavali and also Chakradutta indicate Mashabaladi yoga Taila Nasapanam92(Nasya) in Manyasthamba. Mashabaladi Taila even can be used as pana i.e. internalmedication, which is the present dissertation topic. Apart from the above mentioned specificmanagement, as the disease is a Vata Vyadhi Vata Chikitsa sutra and methodologies of thepacifying measures of Vata are also adaptable.Upashaya and Anupashaya93 In the process of investigating the disease Upashaya methods that is therapeutic trailswith certain diet, drug activities are also considered as a tool in some cases. As there is noUpashaya and Anupashaya for Manyasthamba mentioned in the classics. But we can selectthe Vata Vyadhi Upashaya because Manyasthamba comes under the Vata Vyadhi some ofthe observations done during clinical trials are listed as cold breezes, continuos workmorning hours, weight lifting as Anupashaya for Manyasthamba. Abhyanga, swedha, rest, avoiding pillows are considered as Upashaya. Even in thecontemporary science they have described the hot massage relieves the pain which is asUpashaya. 40
  52. 52. Chapter –4 Methodology The materials and methods of the present study consists of following headings 1. Selection of patients 2. Grouping of patients 3. Drug review 4. Criteria of assessment1) Selection of patient Patients of Manyasthamba (cervical Spondylosis) fulfilling the criteria of diagnosiswere selected in the present study. Patients were distributed in group A and group Brandomly for the study, based on preset inclusion and exclusion criteria. Patients wereexcluded, as they are discontinuous at the treatment or unable to fulfil the study design.Inclusion criteria 1. People complaining of pain and stiffness with the cervical region 2. Without any discrimination of chronic and severity of the disease 3. All the other condition explained apart from the exclusion criteria are includedExclusion criteria 1. Patients below 15 and above 65 years of the age 2. Pregnant women and lactating mother 3. Any other systemic disorders other than that of Manyasthamba (CS) 4. Any other degenerative diseases associated 41
  53. 53. Criteria of diagnosis The signs and symptoms of Manyasthamba mentioned in Ayurveda and modernscience were the main basis of diagnosis. The selected patients were subjected to followinginvestigations. 1. Radiography of cervical region (radiologist report) 2. Random blood sugar.2) Grouping of patients After the diagnosis, the patients were randomly distributed in two groups as - Group A = Patients will receive Mashabaladi taila capsules internally and Group B = Patients will receive Mashabaladi taila capsules internally in association with the Pratimarsha Nasya of Avruta Mashabaladi taila. This study was conducted on total patients who could continue the treatment for fullduration and come for follow up till to the last. The patients were selected from O.P.D &P.G.S & R.DGMAMC Hospital3) Drug review The main objective of present study is to evaluate the effect of Mashabaladi yogascreening of the drugs mentioned in Chakradatha94, Yogaratnakara95 etc. The details of theherbs included in Mashabaladi yoga are in equal quantity and their identification andpharmacological properties are described here under. 1. Masha (Phascolus mungo) 2. Bala (Sida cordifolia) 3. Kapi kachu (Mucuna purita) 4. Truna (Desmostachya bipinnate) 42
  54. 54. 5. Rasna (Pluchea lanceolata) 6. Aswagandha (Withania somnifera) 7. Eranda (Ricinus communis) 8. Ramada (Ferula foetida) 9. Lavana (Rock salt) 10.Tila taila (Seasum indicum)Individual drug description:1) Rasna (Pluchea lanceolata) 96-97-98-99Family; ZingiberaceaeSynonyms: sugandha mula, yuktha rasa, surasaGana; anuvasanopaga, vaysthanpana (Charaka) arkadigana, sleshma samshamna (Susruta) v Rasa - Tikta, v Guna - Guru, v Vipaka - Katu, v Veerya - Ushna, v Prabhava - VishagnaIdentification: A perenniate, aromatic, rhizomatus herb, 1.8 - 2.1 metre in height, leavesoblong, lanceolate, glabraus, accuminate, very short petioled, ligule short, rounded, ciliated,flowers, fragrant greenish white with red veined lips, in densePanicles, fruit capsules orange red when rip.Chemical combination100: tylophorime, tylöphorimine, mineral matter, pluchinParts used: Rhizomes 43
  55. 55. Properties and uses: The rhizomes are bitter, thermo-genic Nervine tonic, stimulant, antiinflammatory and tonic they are useful in vitiated conditions of Vata and kapha, rheumatoidarthritis, inflammations, asthmaVisishta yoga: Rasna sapthakam kasayam and maha rasnadhi kasayam.Dose: choorna 3-6 gm, kwatha 50-100ml2) Bala (Sida cordifolia) 101-102-103Family - MalvaceaSynonyms: peetha pushpa, sahadevi, vatyalika v Rasa- Amla, Madhura, Kashaya v Vipaka- Madhura v Guna – guru, Snigdha, Pichchila v Veerya – Sheeta v Doshagnadha - Vata pittaghna v Karma- daha Prashamana, Vedana Stapana, sukralaIdentification: A small, erect, grey, pubescent, branched under shrub, with a slender erectstem, the young shoots being covered over with soft grey stellate down, leaves with two tothree small stiff, minute spiny projections at the nodes flowers pale yellow to cream white,axillary and solitary on slender peduncles, fruits 5-6 or 3 chambered with one seed in eachchamber.Chemical composition: The ash contains phytosterol, calcium carbonate, phosphate,potassium nitrate, ephedrine, leaves contain mucilage, tannin, organic and asparagine, rootalso contains aspargin.Parts used: Whole plant 44
  56. 56. Properties and uses: The roots are diaphoretic, aphrodisiac and tonic. They are used invitiated conditions of Vata, swellings104, and fever.Uses- daha, swasa, Vata vihadiDose- juice ½ once to one once, power-20 gmGana Balya, brimhaneeya, praja sthapanDose; Juice 20 mlVisishta yoga; Balarishtam3) Kapi kachu (Mucuna purita) 105-106-107Family: PapilonacieaeSynonyms: Atma guptha, vrushya, markati, kandura, adhyanda, dushparsha v Rasa- Madhura, Tikta v Vipaka – Madhura v Veerya – Ushna. v Guna – guru, Snigdha, v Doshaghnata - Tridosha hara, v Karma – vrishya, brimhaneeya Balya, vajeekaraIdentification: It is found all over India. This is a semi woody annual or more often aperennial thinner, annual shoots with slender ternate, branches that when young are usuallyclothed with short and pressed whitish hairs but become glabrescent orally slightly hairywhen mature bearing alternate pinnately trifotate fairly large leaves that are densely grayChemical composition: It contains Ral, tannin, protein, and manganese,Parts used: seed and root 45
  57. 57. Uses: sukla vardhak, uthajaka, Vata shamak Balya, nervine tonic, diuretic Vata nadidourbalya, ardhita, apabuke pakshagathaGana –Balya, madhuraskandha (Charaka) vidhargandhadhiYoga – vanevee gutika, mashabaladi KwataDose – choorna 5-10 grams root powder 5-10 GmsKwatha ¼ once4) Truna: (Desmostachya bipinnate) 108-109-110Family: GraminceaeSynonyms: kusha v Rasa: Madhura Kashaya, v Guna- Laghu, Snigdha, v Veerya- Sheeta, v Vipaka- Madhura. v Dosha karma- Tridosha shamana.Identification: It grows 1-3 feet length biennial shrub, roots are strong deep-rooted leavesare elongated and arrow shaped light hairy structure seen on the leaves. Petiole 6-14inchlength, and straight. Seed ¼ inch long and round in shape.Chemical composition: containing Indian Melissa oil, citrol, lonone, and vitamin AProperties and Uses: Ushna, Sweda janana, mootrajanana, jwaragna, vatanulomana,uthajaka, kapavatahara, deepana, Pachana, shoola, akshapaka.Parts used: whole plantProperties and uses: Ushna, sedajanana, mootrajanana, jwaragna, Vatanulomana, uthajaka,kapha vata hara, deepana, and Pachana . 46
  58. 58. It is used in pratishya, jawara, atisara, adhmana, soola, akshapa, kateeshoola, amavata,Gana: Truna panchamoolaVisishta yoga : Truna panchamoola kasayaDose: kasaya 20- 100 ml5) Masha (Phascolus mungo) 111-112-113Family; FabaceaeSynonyms; uddulu v Rasa: Madhura v Guna: Guru, Snigdha, v Veerya: Ushna , v Vipaka: Madhura. v Dosha karma: Vata shamana.Identification an erect hairy annual with long twining branches, leaves trifoliate, leafletovate, entire, flower small, yellow on elongating peduncles fruits cylindrical pods, hairywith a short, hooked beak, seeds 1-4 per pod generally black with a white hilum protrudingfrom the seed.Chemical composition: contain Melissa oil, citrol, ionone, and vit. AParts used: roots and seedsProperties: The seeds are sweat, emollient, thermo genetic, diuretic aphrodisiac, tannic,nutrition’s, appetiser, laxative, and nervine tonic they are useful in vitiated conditions inVata neuropathy dyspepsia, anorexia, constipation.Visishta yoga: masha baladi kwatha, masha baladi thailaDose: Choorna 5-10 Gms 47
  59. 59. 6) Ashwa gandha (Withania somnifera) 114-115-116Family: SolanaceaeSynonyms: Varaha karna, vajee gandha, varada, balada, gokarna, gandhata v Rasa-Madhura, Kashaya, Tikta, v Vipaka- Madhura v Veerya-Ushna, v Guna-guru, Snigdha, v Doshaghnata- Kapha, vatagna karma, shukrla vrishya, Rasayana, Balya,Identification: An erect branching under shrub reaching about 150 cm in height, usuallyclothed with minutely satellite tomentum, leaves ovate up to 10 cm long, flowers greenish orlurid yellow in axillary’s fascicles, fruits globase Berrces which are orange coloured whenmature enclosed in a persistent calyx. The fleshy roots when dry are cylindrical, graduallytapering down with a brownish white surface and pure white inside when brokenChemical composition: It contains with aniol, hentria contane, different alkaloids,somnifera;Parts used; RhizomesProperties and uses: The tuberous roots are astringent, bitter, acrid, somniferous,thermogenic, stimulant aphrodisiac and tone. They are useful in vitiated conditions of Vata,tissue-building nervous breakdown, and insomnia. The leaves are bitter and arerecommended in painful swellings and fever.Gana; Balya, brimhaneeya, madhurakandha (Charaka)Visishta yoga: Aswagandharishta, ashwagandhavaleha, aswagandhadi Choorna. 48
  60. 60. Dose Choorna – 5grams Leha – 1-2 teaspoon (20gm) Asava; 20-30 ml7) Eranda (Ricinus communes) 117-118-119Family- EuphorbiaceaeSynonyms – grandhva hasthe, pancharguta, vardhaman, chitraGana; Gudoochaytadi Gana, bhadaneeya, swedopaga, angamardha prashamana madhuraskandha (Charaka) vidarigandhadi Vata shamshamana (Susruta) v Rasa -Madhura, Katu, Kashaya v Vipaka – Madhura. v Veerya- Ushna, v Guna- guru, Snigdha, pichila- Teekshna sookshma, v Doshagnata – Kapha vatagnaIdentification – it grows throughout India, this is a tall branched shrub or almost a small tree2-4 meters or more high the stem and branches are green when young but turns gray leavesalternate, long petiole, stipulate pelt ate, palmate compound viewed broad. Flowers are fairy large, monoceious petals the staminate flowers are usuallylocated in the distal or upper half of the inflorescence in a crowded manner and the petalsare at the base part. Fruits are glabose or globular, oblong explosively dehiscent three sidedcapsule. Seeds oblong 1cm – 15cn long with smooth hard crustaceous test and oily or fleshyendosperm. 49