This document provides an overview of rheumatoid arthritis (RA) and its Ayurvedic counterpart Amavata. It discusses the epidemiology, pathogenesis, clinical manifestations, deformities, diagnosis, and treatment of RA. For Amavata, it describes the nidana (causes), samprapti (pathogenesis), lakshanas (symptoms), and chikitsa (treatment) according to classical Ayurvedic texts such as Madhav Nidana. The document contains sections on the clinical features, complications, investigations, and multimodal management of RA as well as the classical references to Amavata in Ayurveda.

1. RHEUMATOID ARTHRITIS
(AMAVATA)
Presented by:
Dr. Swati Bhatt
P.G Scholar 2nd year
Dept. of Panchkarma
UAU Gurukul Campus Haridwar

2. CONTENTS
 Rheumatism
 Rheumatoid Arthritis
 Epidemology
 Pathogenesis
 Assessment criteria
 Clinical manifestations
 Deformaties of RA
 Diffrential diagnosis
 Laboratory investigations
 Treatment
 Introduction of Aamvata
 Nidana
 Samprapti
 Lakshana
 Sadhya-asadhyata
 Chikitsa sutra
 Different formulations
 Pathya-apathya
 Upadrava

3. RHEUMATISM
 Rheumatism is a general term for an acute and chronic
conditions characterised by inflammation, stiffness of
muscles, pain in joints and associated structures.
 It includes Arthritis (infectious, Rheumatoid, Gouty),
Arthritis due to Rheumatic Fever/ Trauma, Degenerative
Joint Disease, Neurogenic Arthropathy, Myositis,
Bursitis, Fibromyositis, Tennis Elbow, Tendinitis, and
many other diseases.

4. RHEUMATOID ARTHRITIS
 RA is a chronic, systemic, inflammatory disorder of unknown etiology
that primarily involves joints with characteristic features of persistent
inflammatory synovitis usually involving peripheral joints in a
symmetrical distribution.
 Most typical features-
a. A symmetrical polyarthritis
b. Morning stiffness
c. An elevation of the ESR
d. Appearance of autoantibodies that target immunoglobins in the
serum

5. EPIDEMOLOGY
▪ 1-3% population worldwide is affected.
▪ With the peak prevalence at the age of 30-50 years.
▪ Women are affected 3 or 4 times more commonly than men.
▪ Up to 14 million people around the world have Rheumatoid
arthritis. (World Health Organisation 2021)

6. PATHOGENESIS OF RHEUMATOID ARTHRITIS
NORMAL JOINT

7. Cont…
Non specific
inflammation
Genetic
susceptibility
 Immunological
mechanism
Activation of
synoviocytes
Inflammatory
synovitis
Immune response
(T/B cell activation)
Infectious agents

14. As disease progress
Multiple joint of both side involve
Inflamed and destroyed

16. Rheumatoid Arthritis criteria (1987 revision,
American Rheumatism Association)
1. Morning stiffness (in/around joints, > 1hr before maximal
improvement)
2. Arthritis (swelling) of 3 or more joint areas (observed by physician)
3. Symmetric arthritis (swelling NOT bony overgrowth)
4. Arthritis of Hand joints (wrist, MCPs or PIPs)
5. Rheumatoid nodules (observed by physician)
6. Rheumatoid factor (serum)
7. Radiographic changes (erosions and /or periarticular osteopenia in
hand/wrist joints)
Requirements: ≥ 4 of the above 7 criteria. Criteria 1-4 must have been present for at
least 6 weeks.
Reference: Arnett et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis
Arthritis Rheum 31:315 1988.

17. 2020 ACR-EULAR CLASSIFICATION
Joint Involvement
1 Large joint 0
2-10 Large joint 1
1-3 Small joint, +/- 1 Large joint 3
>10 Joints (at least 1 small joint) 5
Serology (need at least 1)
Negative RF, negative anti CCP Ab 0
Low positive RF or Low positive anti CCP Ab 2
High positive RF or high positive anti CCP Ab 3
Acute Phase reactants (need atleast 1)
Normal CRP and normal ESR 0
Abnormal CRP and abnormal ESR 1
Duration of symptoms
< 6 weeks 0
≥ 6 weeks 1
➢ For patients with atleast 1 joint
with definite clinical synovitis,
not better explained by another
disease.
➢ Rule out-
▪ Psoriatic arthritis
▪ Viral polyarthritis
▪ Gout
▪ CPPD
▪ SLE
≥ 6 / 10 Definite RA

18. CLINICAL MANIFESTATIONS
1. Articular
2. ExtraArticular

19. ARTICULAR MANIFESTATION
 Pain and swelling in affected joint aggravated by
movement.
 Morning stiffness of more than 1hr duration.
 Joints involved-
▪ MCP and PIP joints of hands & MTP of feet 90%
▪ Knees, ankles & wrists 80%
▪ Shoulders 60%
▪ Elbows 50%
▪ TMJ, Acromio-clavicular joint & SC joints 30%

20. EXTRA-ARTICULAR MANIFESTATION
 Patients that are more likely to get are:
▪ High titres of RF/ anti-CCP
▪ HLA DR4+
▪ Male
▪ Early onset disability
▪ History of smoking

21. EXTRA-ARTICULAR INVOLMENTS
 Constitutional symptoms ( most common)
 Rheumatoid nodules(30%)
 Hematological-
 normocytic normochromic anemia
 leucocytosis /leucopenia
 thrombocytosis
 Felty’s syndrome-
 Chronic Rheumatoid Arthritis
 Spleenomegaly
 Neutropenia

22.  Pleuropulmonary- pleural effusion, pneumonitis , pleuro-
pulmonary nodules, ILD
 CVS-asymptomatic pericarditis , pericardial effusion,
cardiomyopathy
 Rheumatoid vasculitis- mononeuritis multiplex, cutaneous
ulceration, digital gangrene, visceral infarction
 CNS- peripheral neuropathy, cord-compression from
atlantoaxial/ midcervical spine subluxation, entrapment
neuropathies
 EYE- kerato-conjunctivitis sicca, episcleritis, scleritis

23. CLINICAL SPECTRUM OF RA
Early PIP swelling Active with some deformity Late stage deformities

24. DEFORMITIES
IN RA

25. SWAN NECK DEFORMITY
DIP Hyperflexion with PIP Hyperextension

26. BOUTONIERE DEFORMITY
PIP Flexion with DIP hyperextension

27. Z deformity of the thumb Cock-up toe deformity

28. DIFFRENTIAL DIAGNOSIS
 Crystal induced arthritis (Gout)
 Osteoarthritis
 Psoriatic arthritis
 Systemic lupus erythematosus
 Ankylosing spondylitis
 Lyme disease cases erosive
arthritis
 Sjogren’s syndrome

29. VARIANTS OF RA
 JUVENILE RA- Found in patients under 16 years with acute onset of fever and
predominant involvement of knees and ankles.

30. Cont…
 Ankylosing Spondylitis/ Rheumatoid
Spondylitis- Rheumatoid involvement of spine
especially of sacro-iliac joints in young male
patients has HLA-B27 association.
 Felty’s syndrome- (Polyarticular) RA with
splenomegaly and hematological dearrangements.
 Psoriatic Arthritis- Rheumatoid arthritis and
Psoriasis are corelated to each other. Change in the
skin and nails often precedes the arthritis by many
years but these two may occur together. In this-
RF Test- Negative and disease is relatively mild.

31. LABORATORY INVESTIGATIONS IN RA
 Complete Blood Count (CBC)
 Erythrocyte sedimentation rate ESR
 C- reactive protein (CRP)
 Rheumatoid Factor (RF)
 Anti- CCP antibodies
 Antinuclear antibody (ANA)

32. X- RAY FINDINGS
 Decalcification and diminished joint space may be seen.

33. RADIOGRAPHIC FEATURES
 Peri-articular osteopenia
 Uniform symmetric joint space narrowing
 Marginal subchondral erosions
 Joint Subluxations
 Joint destruction
 Ultrasound detects early soft tissue lesions.
 MRI has greatest sensitivity to detect synovitis and marrow changes.

34. Treatment
Currently there is no cure for Rheumatoid arthritis.
• Reduce inflammation.
• Reduce pain.
• Prevent joint and organ damage

35. TREATMENT OPTIONS
Medications
Physical therapy
Exercise
S
U
R
G
E
Y

36. MEDICINES
Disease modifying anti-
rheumatic drugs
(DMARDs)
Steroids
Non-
Non steroidal anti
inflammatoru drugs
(NSAIDS)steroidal
anti

37. NSAIDs
 Releive pain
 Reduce inflammation
Ibuprofen
Naproxen
IRRITATION
BURNING
SENSATION
GI BLEEDING
PEPEPTIC ULCER
LIKE DISEASE
Impair Renal function
Side effects

38. Steroids
❖ Hydrocortisone
❖ Prednisolone
❖ Methylprednisolone
Reduce pain and stiffness
7-14 days = Acute disease
Larger course = Chronic disease

39. Dose of Prednisolone
5-10 mg/day
15-20 mg/day
S
I
D
E
E
F
F
E
C
T
S
OSTEOPOROSIS WEIGHT GAIN INCREASED BP
INCREASED
BLOOD SUGAR
CATARACT RISK WEAKEN IMMUNE
SYSTEMEA

40. Disease modifying
anti-rheumatic
drugs (DMARDs)
➢ Slow down or prevent the progression of RA.
➢ Save the joints and other tissues from permanent damage.
Methotrexate
Sulfasalazine
Leflunomide
DMARD of choice for the treatment
of RA

41. Surgery
 May help restore your ability to use your joint.
 It can also reduce pain and improve function.
▪ Synovectomy
▪ Tendon repair
▪ Joint fusion

42. Total joint replacement

43. AMAVATA

44. Amavata = Ama + Vata

45. AMAVATA – Madhav Nidana 25/5
;qxiRdqfirkoUrfódlfUèkços'kdks A
LrCèka p dq#rks xk=ekeokr% l mP;rsAA

46. INTRODUCTION
 Amavata is the condition explained in
Laghutraye, not in Brahatraye.
 First explained in Madhav nidana by
Madhavkara.
 Later books like Chakradatta, Yoga Ratnakar,
Bhaishjya Ratnavali, etc quotes the shlokas of
Madhav Nidana to explain the disease
Amavata without much change.

47. SOME OF THE CLASSICAL REFERANCES
OF AMAVATA
 Charak Samhita-
• While describing the Therapeutic uses of Kansa Haritki (Ch. Chi. 12/51-52)
• Vishaladi phanta in Pandu roga (Ch. Chi. 16/61-62)
• In the description of Avarana Chikitsa (Ch. Chi. 28/195)
 Astanga Hridya- Term Amavata is used while enlisting the therapeutic use of these drugs-
• Vatsakadi yoga (Ah. Chi. 21/47)
• Vyoshadi yoga (Ah. Chi. 21/49-50)

48. Cont…
 Chakradutta- contributed principal line of treatment and effective drug formulation for Amavata.
 Harit Samhita- described the detailed description on Amavata.
 Anjana Nidana- has described the Nidana and Lakshana of Amavata.
 Gadnigraha- has also described the detailed description of Amavata including Nidanapanchak,
Sadhya-asadhyata and Chikitsa of Amavata.
 Others- Yoga Ratnakar, Bhavprakash, Bhaisajya Ratnavali, Yoga tarangini, Vasavrajiyam,
Vangasen, Sharangdhar Samhita, Ras Ratnakar, Bhrihat Nigantu Ratnakar etc.

49. NIDANA
fo#)kgkjps"VL; eUnkXusÆu'pyL; p A
fLuXèka Hkqäorks áUua O;k;kea dqoZrLrFkk AA
(Ma.Ni.25/26)
 Aaharaja nidana
 Viharaja nidana
 Manshik nidana

50. Amavata - Pathogenesis
Dietary factors Lifestyle Mental health
❑ Virudha, Snidgha,
Guru ahara
❑ Sedentary lifestyle (Nischesta)
❑ Diva shayan
❑ Chinta, Shoka , Bhaya,
Krodha
Agnimandhya
Formation of amaras
Movement of amaras to Shlesmasthan
❑ Habit of exercise after
taking snigdha ahara
Vata Prakopa
Amaras reaches to Dhamni + Dushti by Tridosha
Kleda utpatti in Shrotas – Daurbalya
– Hridaya Gaurav
Entry of Ama into Kostha, Trika, and Sandhi
Amavata

51. Samprapti ghatak
Dosha Vata- Vyana, Samana, Prana
Pitta- Pachaka
Kapha- Sleshma
Dushya Rasa, Rakta, Mansa, Snayu, Asthi, Sandhi, Kandara
Srotasa Rasavaha, Asthivaha
Srotodusti Sanga
Adhisthana Sarva sandhiya
Udbhava Sthana Amashayotha
Vyakta Sthana Kaphasthana i.e. Sandhi, Uras, Amashya
Vyadhi Swabhava Chirakari
Rogamarga Madhyam
Agni Jatharagni And Dhatvagnimandya

52. LAKSHAN
v³~xenksZ·#fpLrp`".kk ákyL;a xkSjoa Toj%A
vikd% 'kwurk·³~xkukekeokrL; y{k.ke~AA
(Ma. Ni. 25/6)
lokZax ,dkax lafèkLFk 'kksFkkÆrxzgxkSjoa A
TojksikdkfXuekU|sp p r`".kk pkekfuyk—r AA
(Anjana Nidana)

53. DOSHAANUBADHA LAKSHAN
fiÙkkRlnkgjkxa p l'kwya ioukuqxe~ A
fLrfera xq#d.Mwa p dQnq"Va rekfn'ksr~AA
(Ma.Ni.25/11)

54. PRAVRADHA -AMAVATA -LAKSHAN
l d"V% loZjksxk.kka ;nk çdqfirks HkosRk~A
gLriknf'kjksxqYQf=dtkuw#lfUèk"kqAA
djksfr l#ta 'kksFka ;= nks"k% çi|rs A
l ns'kks #T;rs·R;Fk± O;kfo) bo o`f'pdS%AA
tu;sRlks·fXunkScZY;a çlsdk#fpxkSjoEk~A
mRlkggkÇu oSjL;a nkga p cgqew=rkEk~AA
dq{kkS dfBurka 'kwya rFkk fuækfoi;Z;Ek~ A
r`V~NÆnHkzeewPNkZPJ gn~xzga foMf~oc)rke~A
tkM;kU=dwtekukga d"VkPJU;kuqin~oku~AA
(Ma.Ni.25/ 7-10)

55. Sadhyata- Asadhyata
,dnks"kkuqx% lkè;ks f}nks"kks ;kI; mP;rs A
loZnsgpj% 'kksFk% l —PNª% lkfUuikfrd% AA
(Ma.Ni. 25/12)
➢ Saadhya Amavata – Eka Doshaja
➢ Yapya Amavata – Dvidoshaja
➢ Krichhasadhyata – Sannipatika

56. Chikitsa sutra
ya?kua Losnua frDra nhiukfu dVqfu pA
fojspua Lusgikua cLr;Üpkeek:rsAA
lSU/kok/;sukuqokL; {kkjcfLr% iz'kL;rs A
¼pØnr vkeokrkf/kdkj½
ya?kua Losnua frDra nhiukfu dVqfu pA
fojspua Lusgikua cLr;Üpkeek:rsAA
:{k% Losnks foèkkrO;ks ckyqdkiksVySLrFkk A
miukgk'p drZO;kLrs·fi LusgfooÆtrk%AA
(Yog Ratnakar)

57. SOME CLASSICAL FORMULATIONS
 SWARASA KALPANA- Sunthi Paka (S.S)
 KALKA KALPANA-
▪ Sunthi Kalka (S.S)
▪ Shatyadi kalka (B.P, B.R)
 GUGGLU KALPANA-
▪ Shiva Gugglu (B.R)
▪ Sinhanada Gugglu (C.D)
▪ Vatari Gugglu (B.R)
▪ Vyadhi Shardool Gugglu (B.R)
▪ Yogaraj Gugglu (C.D, B.P, B.S)
 VATI, VATAK, LEH ETC-
▪ Sanjeevani Vati
▪ Agnitundi Vati
▪ Aamvatari Vatika
▪ Ajmodadi Vatak (C.D, B.P, B.R)
▪ Rasona Pinda (C.D, B.S, B.P)
▪ Gudamlaka (H.S)
 RASA SHASTRIYAYOGA-
▪ Amavatari Ras (B.R)
▪ Vatagajendra Ras (B.R)
▪ Vidangadi Loha (B.R)

58. Cont…
 KWATHA KALPANA-
▪ Danya nagradi kwatha (S.S)
▪ Rasna Dasmool Kwatha (C.D, B.P, B.R)
▪ Rasna Panchak Kwatha (C.D, B.P, B.R)
▪ Maha Rasnadi Kwatha (S.S, B.P, B.R)
▪ Panchkol Kwatha (B.P)
▪ Sunthayadi Kwatha
▪ Dasmooladi Kwatha
 CHURNA KALPANA-
▪ Panchsama Churna (S.S, Y.R)
▪ Ajmodadi Churna (S.S)
▪ Lavana Bhaskar Churna (S.S)
▪ Chitrakadi Churna (B.P, B.R)
▪ Panchkola Churna (B.P)

59. Cont…
 SNEHA KALPANA-
1. GHRITA- Sunthi Ghrita, Guduchi Ghrita,
Ashwagandha Ghrita
2. TAILA- Eranda Taila, Prasarani Taila,
Dashmooladi Taila, Saindhavadhya Taila,
Mahanarayana Taila
 NIRUHA BASTI YOGA-
▪ Erandamooladi Basti
▪ Kshar Basti
▪ Vaitrana Basti
 LEPA-
▪ Hinstradi lepa
▪ Dasanga lepa
 Single drug use-
▪ Aragvadha pallav prayoga
▪ Eranda bhrashta haritaki (B.P)
 Rasayana-
▪ Amrita Bhallataka
▪ Ashwagandha Rasayana
▪ Gugglu
▪ Rasna

60. EKALAUSHADI
Sunthi
Guduchi
Chopchini Ashwagandha
Rasna Bhallataka

61. SOME AVAILABLE PATENT DRUGS
 Dazzle Oil & Cap. (Vasu)
 Rumalaya Fort (Himalaya)
 Rheumatil Oil & Gel (Dabur)
 Rheumartho (Baidhynath)
 Rheumo Gold (SDH)
 Arnopen (Phyto)
 Arthro Tab (Deep Ayurveda)

62. PATHYA-APATHYA
 Pathya-
Eranda Taila, sunthi, ajwayein,karela,
parwal, yava, takra, kulthi, usnodaka,
sandhav, sauf, sahajan, kodo
Rukshan, swedana, langhan, chankraman,
mriduvyayam
 Apathya-
Amla rasa
Dahi, matshya, gud, dugdh, upodika,
mash, pishtaana, guru, abhishyandi
bhojan
Purvi vayu, vegadharan, ratri jagran,
aalashya, chinta, shoka, Sheet kala,
Meghodaya kala, Prataha kala

63. UPADRAVA
Acharya Upadrava
Madhavakar Mentioned in Pravadhamana lakshana
Vijay Rakshita Sankocha and Khanja
Vachaspati Various Vatika disorders
Harita Angavaikalya

64. Some published articles showing the efficacy
of Panchkarma in Aamvata

65. Cont..

66. THANK YOU….