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Clinical Presentation on Rheumatoid Arthritis (Amavata)

This document presents a case study of a 33-year-old male patient diagnosed with amavata, detailing his medical history, symptoms, physical examination, and treatment plan through Ayurvedic practices. Key findings include joint pain, stiffness, and edema which evolved from an asymptomatic state, alongside failure of allopathic treatments. It highlights the patho-physiology of the condition and discusses potential dietary and lifestyle modifications for improvement.

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Dr (Ms) R.L.D.S. Ranasinghe MD Scholar, Dept of Kaya Chikitsa , University of Colombo, Rajagiriya. Prof (Ms) E.R.H.S.S Ediriweera Dept of Kaya Chikitsa , IIM, University of Colombo, Rajagiriya. 1
g Objectives g Case presentation g Review of Ayurveda g Review of Modern g Acknowledgement 2
gUnderstand the patho-physiology, signs and symptoms & treatments of Amavata gGeneral review on related Modern Aspects gImprove diagnosis skills of diseases g presentation skills to present case studies 3
vName : Mr S.G.W Rudrigu vAge : 33 Yrs v Date of Admission : 09th September 2013 v Ward No : 11 v Bed No : 15 v Address : No. 12/10, Handala, Wattala. v Occupation : Spray painter for 16 yrs v Nationality : Sinhalese v Religion : Catholic v Marital Status : Married 4
vMain complaint with duration: Pain, stiffness & edema of several joints notably wrist, hand, ankle & feet (3 months) vOther complaints: Thirst, Nocturia, Increase sweating (3 months) 5
o According to the patient, o 3 months before; the patient was asymptomatic. Suddenly he got throbbing pain over both the upper limbs along with lethargy ,generalized weakness and thirst. Simultaneously pain was shifted to the RT & LT lower limbs. o 1 week after the onset of disease, he suffered from fever with edema and Pain in the joints: the RT elbow, RT & LT Knee wrist joints, RT & LT Knee Shoulder joints & then to the RT & LT Knee Joints gradually. 6
¬ Medical History RT & LT Knee joint edema at ate age of 7 yrs Diabetes Mellitus - Identified before 3 months with the onset of the disease FBS- 194 mg/ dL (2013. 08. 07) ¬ Surgical History - minor surgery has done in the ankle joint after RTA ¬ Psychiatric History ¬ Treatment History - NAD 1. Allopathic treatment for Diabetes Mellitus – 3/ 12 2. Allopathic treatment for joint pain & edema – 8/ 52 - No improvement with allopathic treatment 3. Admitted for Ayurvedic treatment for the first time just before 3 /52 7
53 yrs DM+ , Rheumatoid Arthritis 35yrs DM+ 30 yrs DM+ 27 yrs DM+ 57 yrs 7 yrs 3 yrs 8
o Diet: Break fast - Bread & Curries, Short eats Lunch - Rice, Vegetables, Egg Meat (Chicken, Beef, Mutton)-Daily Dinner - Rice, Vegetables & meat More like to eat Spicy & Fried food. o Appetite: impaired appetite at the onset of the disease 9
o Sleep : Disturbed due to Nocturia o Bath : Evening with cold water, Daily o Bowel habits : Once/ Day, Colour - Yellow Odour - Normal Character - Asamhata Mala, Sticky o Micturition : D / N – 3/2 times Colour - Pale Odour - Normal o Addiction : No addictions o Social status : Living near to the sea side & river side 10
GENERAL PHYSICAL EXAMINATION • General condition - Average • BP - 130 /80 mmHg • PR - 74 / min • RR - 14 / min • Weight - 67 kg • Height - 164 cm • Tongue - Coated • Temperature - intermittent febrile Usually in the evening • Skin - Normal • Thyroid • Pallor NAD • Icterus • Cyanosis • Clubbing • Enlarged LN NAD 11
1) LOCO MOTOR SYSTEM § Gati (Range of movements) : • Left Shoulder joint - Abduction - Adduction - Rotation - Elevation • Left wrist joint - Flexion - Extension - Rotation Limited due to edema & pain Limited due to edema & pain § Sandhi sputana (Joint crepitus ) - Presented in both knee joints § Sparsha asahyata (Joint tenderness) § Sandhi shota (Joint swelling ) § Rakta varnata (Redness) § Ushnata (Heat) - Presented in affected joints § Mamsa ksaya/ shosha (Muscle wasting) - NAD 12
GALS: • Gait: Slow and painful gait • Arms: Difficulty in pronation and supination (painful) in LT wrist joint Pain – When squeezed the hand across the metacarpals of the LT hand Power Grip - reduced (Difficulty in holding) — Legs: Sandhi sputana both knee joints 13
SPINE: • Thoracic Spine: Internal and external rotation- Normal • Lumbar Spine: • Flexion-Normal • Extension-Normal • Lateral Bending-Normal • Cervical Spine: • Rotation-Normal • Flexion, Extension and Lateral bending-Normal 14
JOINTS: • Inspection • MCP, PIP, DIP, MTP Wrist joints • Swelling Symmetrical involvement • Redness Deformities - NAD • Palpation. • Tenderness & warmth (MCP, PIP, DIP, MTP, Wrist, Elbow joints) • Stiffness of the joints 15
2) CARDIOVASULAR SYSTEM • S1, S2 - Clear . No thrills or murmurs 3) RESPIRATORY SYSTEM • No added sounds 4) GIT P/A • No tenderness • No organomegaly 5) CNS NAD Clinically Higher functions Sensory system • Cranial nerves Motor functions •Reflexes- LT knee jerk exaggerated • Other Reflexes - Normal 16
I. Prakriti : Vata Pitta II. Vikriti : Will be described in next slide III. Sara : Rasa, Rakta, Mamsa, Asthi, Majja, Sukra - Madhya Sara IV. Sanhanana : Madhya Samhata V. Pramana : Madhya pramana (Weight-67 kg, Height -164 cm BMI = 25) VI. Sattva : Madhya Sattva VII. Satmaya : Shad Rasa Satmaya VIII. Ahara shakti: Before After i. Abyavarana shakti : Prawara Madhya ii. Jarana shakti : Prawara Madhya IX. Vyayama shakti : Before After Prawara Madhya X. Vayah : Madhyama (35 Yrs) 17
¬ Hethu (Nidana) – Viprakrusta Nidana Ahara : Katu Rasa, Snigdha, Guru guna Atisewana Viharana : Seeta jala sewana, Spray painting (chemicals) Vyadhi : Madumeha+ ¬ Dosha - Vata, Kapha ¬ Dushya - Rasa, Rakta, Mamsa, Asthi, Majja, Sukra. ¬ Prakiti - Vata, Pitta ¬ Desha - Anupa Desha Near to the riverside & Seaside ¬ Kala - Adana kala ¬ Bala - Roga bala: Kruccha sadya Atura bala: Madhyama ¬ Lakshana - Edema, pain & stiffness of the joints 18
1. Nadi: i. Gati - 72/ min ii. Yati - Samanthara iii. Akruti - Purna iv. Samhati - Mrudu 2. Mutra : D/ N – 3 / 2 times 3. Mala : Once/Day, Asamhata mala 4. Jivha : Ama 5. Shabda : Prakrita hrid & pupphusa shabda Ubhaya Janu sandhi sphutana 6. Sparsha : Ushna sparsa in affected sandhis 7. Druk : Prakrita 8 . Akriti : Madhyama 19
1. Prana vaha Srotas : Prakrita 2. Udaka vaha Srotas : Vikrita; Thalu shosha+ 3. Anna vaha Srotas : Vikrita 4. Rasa vaha Srotas : Vikrita; Sandhi shota+ 5. Rakta vaha Sorts : Vikrita; Sandhi shota+ 6. Mamsa vaha Srotas : Prakrita 7. Medo vaha Srotas : Prakrita 8. Asthi vaha Srotas : Vikrita; Sandhi sula, Shota + 9. Majja vaha Srotas : Prakrita 10. Shukra vaha Srotas : Vikrita; Madhu + 11. Muthra vaha Srotas : Vikrita; Ratrimutrata + 12. Purisha vaha Srotas : Vikrita; Asamhata mala+ 13. Sweda vaha Srotas : Vikrita; Atisweda+ 14. Mano vaha srotas : Prakrita 20
Ø Dosha : Vata, Kapha Ø Dushya : Rasa, Rakta, Mamsa, Asthi, Majja , Sukra Ø Adishtana : Sharirika Ø Srotas : Rasa Vaha Srotas ,Rakta Vaha Srotas Mamsa Vaha Srotas, Asthi Vaha Srotas Majja Vaha Srotas, Shukra Vaha Srotas Udaka Vaha Srotas, muta, Mutra Vaha Srotas Sweda Vaha Srotas Ø Samuttana : Amasha Ø Agni : Mandagni Ø Ama : Ama Ø Srotodushti : Sanga Ø Udbhawastana : Sarvanga sandhi Ø Sadhya Asadhyata : Kruccha sadhya Ø Roga marga : Madhyama (Marma, Asthi,Sandhi) 21
q FBS - 194 mg/dl (2013.08.07) 99 mg/dl (2013.10.10) Within normal range with drug control q UFR Reaction - Acidic Albumin Sugar Pus cells Epithelial cells q CRP - 12mg/ dL Raised q ESR - 11/ 1st hr Raised q PCV - 48% q RF - < 8 IU/mL Occasional 22
Differential diagnosis AMAVATA SANDHISHOTA SSANDHIGATA VATA GAMBHIRA VATA RAKTA Nidana Viruddha ahara, Snigda ahara, Alpa chesta etc. Vata kopakara Ahara, Viharana Vata & Rakta kopakara Ahara, Viharana Rupa Angamarda, Aruchi, Trushna, Alasya etc Shula, Shota, Prasaranakunchan a Vedana Daha, Supti, Vaivarnya, Sphutana etc Sthana Start from small joints of hands & spread Mainly start with weight bearing large joints Start from the end parts of the hands & feet Dosha Kapha, Vata Vata Predominant Vata, Pitta 23
Differential diagnosis Rheumatoid Arthritis Gout Osteoarthritis INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE DISEASE PROLIFERATION OF SYNOVIAL MEMBRANE IMPAIRED PURINE METABOLISM DEGENERATION OF ARTICULAR CARTILAGE ATLEAST 3 JOINTS ARE INVOLVED MONOARTICULAR WEIGHT BEARING JOINTS MORNING STIFFNESS - 1HR MORNING STIFFNESS-NA MORNING STIFFNESS- 15MTS PAIN- EXTREME PAIN-MILD PAIN-MILD 24
PAIN SUBSIDE BY WORKING OR EXERCISE Cont. NO RELATION PAIN AGGRAVATED DURING WORKING-RELEVIED BY REST. MIDDLE AGE-20-35 F:M- 3:1 MIDDLE AGE-ABOVE 40 M:F- 8:1 ABOVE 50YRS F:M- 2:1 R.A - POSITIVE E.S.R-RAISED SERUM PURINE LEVEL IS MORE THAN 600MG E.S.R- NORMAL R.A -NEGATIVE X -RAY SHOWS REDUCED JOINT SPACE, SOME TIMES DEGRATION OF BONE MASS X RAY X-RAY SHOWS OSTEOPHYTES AND DEGENERATIVE CHANGES 25
NAVA AMAVATA PRAVRUDHA AMAVATA JEERNA AMAVATA 1.ARUCHI. 1.INVOLVEMENT OF HASTA, PADA SIRO, GULPHA,TRIKA ETC 1. DESTRUCTION OF ARTICULAR CARTILAGE. 2.ALASYA. 2.SHOTHA ,STABDHATA 2.OSTEOPOROSIS. 3.GOURAVA. 3.EXTREME PAIN. 3.DEFORMITIES. 4. JWARA 4.PRASEKA,ARUCHI. 4.POLYARTHRITIS. 5.HRILLASA 5.HRIDAYA GOURAVA AND HRITGRAHA. 6.APAKTHI. 6.CHARDI,BHRAMA,MOORC HA, ANAHAM. 26
Diagnosis — Viruddha ahara, Snigda ahara, Alpa chesta Seta jala, Vata sparsa etc. — Angamarda, Aruchi, Trushna, Alasya etc — Start from small joints of hands & spread — Kapha, Vata — Inflammatory disease — At least 3 joints are involve — Morning stiffness — Pain — Middle age- 33 yrs — E.S.R-Raised — CRP -Raised Amavata sandhi shota Rheumatoid Arthritis 27
ë Duration : 3 weeks (2013.09.20 - 2012.10.15) ë Improvements: Fever & Ama conditions subsided Internal medications § Denibadi decoction 120 ml, bd, before meal § Kaphahara kwatha 2 tablespoonful, bd, before meal § Chandra prabha vati 2 bd with hot water, after meal — Haritakyadi vati 2 bd with hot water, after meal External applications § Dashanga Lepaya – To affected joints, morning & evening with juice of tamarind leaves 28
Patyapatya Patya Ahara •Yava •Kulatta •Rakta shali •Drumstics •Punarnava •Bittergourd •Ginger •Rasona •Ginger with takra •Hot water Patya Viharana — Warm water bath — a gentle walk after consumption of food 29
Apatya Ahara Apatya Viharana • Guru snigdha ahara • Sweets • Uncooked food • Salty food • Oily food • Fast food • Fish • Milk • Ghee • Cold water — Cold breeze and excessive wind — Bathing with cold water — water intake immediately after consuming food 30
31
Etymology of Amavata — - Ama and Vata unites to form Amavata (Vijayaraksihta) • - Vata associated with Ama creating a disease Known as Amavata (Vijayarakshita) 32
• (Amarakosha) - The substance which undergoes a typical change in the processes of digestion is known as Ama • (Amarakosha) Etymology of Ama • 33
Aetiopathogenisis of Amavata Ma. Ni. 25/ 1-5 34
Aetiology of Amavata 35
Samprapti of Ama Vata Ahara Viruddha ahara, Snigdha ahara, Guru Ahara Viharana Diwa svapna, Nischalata, Manasika Chinta, Shoka. Bhaya, Krodha Agni mandya Sanchaya Prakopa Ama visha Sama Vata Sleshma sthana Dhamani Dushti by Tridosha Prasara Dushti by Tridosha Rasavaha srotas Trika sandhi pravesha Daurbalya, Sandhi shota, Shula Sandhi sthabdata Amavata Stahana Samsraya Vyakti 36
Rupa- General clinical features Ma. Ni. 25/ 6 — Body ache — Anorexia — Thirst — Malaise — A feeling of heaviness — Fever — Indigestion — Inflammation of the body parts (myositis , fibrositis, arthritis etc) 37
Pravruddha Amavata (Exacerbation of Amavata) Ma. Ni. 25/ 7- 10 38
39
• When Amavata gets exacerbate Pravruddha Amavata (most distressing of all the diseases) • Where ever the (Ama) Dosha reaches joints of the hands feet cervical region (pelvic & shoulder)girdles , knees & thighs • The affected part is excessively painful as if it is bitten by scorpions Produces painful swelling 40
• anorexia & a feeling of heaviness • loss of the drive • bad taste in the mouth • poly urea & a burning sensation • hardness in the abdomen • colicky pain & • reversal of normal sleeping habit • thirst • vomiting • vertigo • Fainting • pericardial discomfort • constipation • stiffness • gurgling intestinal sounds • meteoric & other troublesome complications It gives rise to 41
Features of doshik predominance in Amavata (Ma. Ni 25/11) — with the predominance of Pitta there is redness & heat(locally) — whereas with predominance of Vata the pain is severe — In Kapha, feeling of being covered with wet cloths, heaviness & itching 42
Amavata Prabheda • Doshanubandha Lakshanas (BP) (1) Vatanubandha : Sasulam (2) Pittanubandha : Sadaha, Saraga (3) Kaphanubandha : Stimitatam • Doshanubandha (Madhavakara) Vata,Pitta,Kapha,VP,VK,PK,Sannipataja. • Avastha bhedena: (Madhavakara) Samanya. Pravrudha. 43
Sadhya asadhya bhava -Prognosis Ma. Ni. 25/12 — One Dosha involved → curable — Two Dosha involved → relievable — Three Dosha involved → difficult to cure (Inflammation of all over the body) 44
Upadrava (Complications) •Sankocha and Khanjata (Vijayarakshita) •Kalaya khanjata (Bhavaprakasha) •Jadya, Antrakujana, Anaha, Chardi (Anjana Nidana) •Angavaikalya (Harita) •Akshepana (Gayadasa) •Vatavyadhi (Vachaspati vaidya ) 45
Amavata Cikitsa (Bha. Pra.Ma.Kha 26/ 14,15) • Langhana(fasting) • Swedana (sudation) • Use of drugs of Tikta katu rasa • Deepana (stimulating appetite) • Virecana (purgaation) • Oleation (snehapana) • Vasti (enema) • Ruksha sweda valuka pottalee (use of bags of heeted sand) • Upanaha (applying poultiecs) without use of sneha 46
Anthah parimarjana 1. Ama pacana, Jvara hara 1. Pachanamruta Decoction, Pata ½ bd, Before meal 2. Murva 10 Decoction, Pata ½ bd, Before meal 3. Amrutashtaka Decoction, Pata ½ bd, Before meal 4. Beli mul 16 Decoction, Pata ½ bd, Before meal 5. Denibadiya Decoction, Pata ½ bd, Before meal 6. Hinguvastaka Churna, 30 grns, bd with hot water, After meal 7. Sudarsana Churna 30 grns, bd with hot water, After meal 8. Seetarama Vati 3 bd, bd with hot water, After meal 9. Avipattikara Churna 30 grns, bd with hot water, After meal 47
2. After Ama Pachana – Nirama avastha 1. Rasna 7 Decoction, Pata ½ bd, Before meal 2. Rasna 13 Decoction,Pata ½ bd, Before meal 3. Sinhanada Guggulu 2 bd with Bavila, sudulunu water , After meal 4. Hinguwashtaka churna 30 grns, with hot water, After meal 5. Rasnadi guggulu, 2 bd, with hot water, After meal 6. Vata gajendrsinha rasa, 2 bd, with hot water, After meal 7. Amavatari rasa, 2 bd, with hot water, After meal 48
Madhumeha Cikitsa- Along with Amavat chikitsa — Nishatripal veniwelgata Decoction, Pata ½ bd, Before meal — Triphala Churna, 30 grns, bd with hot water, After meal — Haritakyadi Vati, 2 bd, with hot water, After meal — Somanatha Rasa, 2 bd, with hot water, After meal 49
Bahir parimarjana Ø Swedana- Ruksha sweda • Valuka pottali • Pottali sweda by using ruksha dravya such as Saindava, Karpasa, Kulattha, Tila, Eranda, Atasi, Punarnava, Ø Snehana – Ruksha sneha Abhyanga (In Nirama avastha) 1. Mee taila 2. Saidavadi taila 3. Amavata taila 4. Nirgundi taila Ø Lepa 1. Dhusturadi Lepa 2. Satapushpadi Lepa 3. Hinsrapadi Lepa 4. Humbas mati pattuwa 5. Dasanga Lepa 6. Delipothu pattuwa 50
51
Rheumatoid Arthritis is a chronic Systemic Inflammatory disorder of unknown etiology 52
Epidemiology • Affects 0.5- 1.0% of the population world wide • Peak prevalence between the ages of 30 and 50 years • RA has an incredibly high disease burden and cost to society • Drastic affect on quality of life • Increased disability (80% disabled after 20 years of disease) • Patients with RA have shorter life expectancies 53
Aetiology — Gender : women before the menopause are affected3 times more than men & equal sex incidence thereafter — Familial : Increase incidence in those who with a family history of RA — Genetic factors: Human Leucocyte Antigen HLA- DR4 & HLA- DrB1 54
Rheumatoid Arthritis: Key Features • Inflammatory synovitis • Palpable synovial swelling • Morning stiffness >1 hour, fatigue • Symmetrical and polyarticular (>3 joints) • Typically involves wrists, MCP, and PIP joints • Typically spares certain joints — Thoracolumbar spine — DIPs of the fingers and IPs of the toes 55
Rheumatoid Arthritis:Key Features (cont’d) • May have nodules: subcutaneous or periosteal at pressure points • Rheumatoid factor • 45% positive in first 6 months • 85% positive with established disease • Not specific for RA, high titer early is a bad sign • Marginal erosions and joint space narrowing on x-ray • Symptoms >6 weeks’ duration • Often lasts the remainder of the patient’s life 56
Non -Articular manifestations 57
The Normal Joint 58
Pathogenesis of Rheumatoid Arthritis Inflammed synovial tissue (synovitis) • Villous hyperplasia • Intimal cell proliferation • Inflammatory cell infiltration T cells, B cells, macrophages and plasma cells • Production of cytokines and proteases • Increased vascularity • Self-amplifying process 59
Deformities of Rheumatoid Arthritis 60
Investigations Blood screening: — ESR — C Reactive Protein — FBC with differential — RF — Serum calcium phosphate & alkaline phosphate — Serum uric acid — ASOT Additional imaging techniques: • CT scans • AP & Lateral tomography (x-ray) • MRI scan • USS (good for assessing the presence of fluid) 61
Differential diagnosis Rheumatoid Arthritis Gout Osteoarthritis INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE DISEASE PROLIFERATION OF SYNOVIAL MEMBRANE IMPAIRED PURINE METABOLISM DEGENERATION OF ARTICULAR CARTILAGE ATLEAST 3 JOINTS ARE INVOLVED MONOARTICULAR WEIGHT BEARING JOINTS MORNING STIFFNESS - 1HR MORNING STIFFNESS-NA MORNING STIFFNESS- 15MTS PAIN- EXTREME PAIN-MILD PAIN-MILD 62
PAIN SUBSIDE BY WORKING OR EXERCISE Cont. NO RELATION PAIN AGGRAVATED DURING WORKING-RELEVIED BY REST. MIDDLE AGE-20-35 F:M- 3:1 MIDDLE AGE-ABOVE 40 M:F- 8:1 ABOVE 50YRS F:M- 2:1 R.A - POSITIVE E.S.R-RAISED SERUM PURINE LEVEL IS MORE THAN 600MG E.S.R- NORMAL R.A -NEGATIVE X -RAY SHOWS REDUCED JOINT SPACE, SOME TIMES DEGRATION OF BONE MASS X RAY X-RAY SHOWS OSTEOPHYTES AND DEGENERATIVE CHANGES 63
Differential diagnosis RHEUMATIC FEVER SEPTIC ARTHRITIS PSORIATIC ARTHRITIS C.V.S DISEASE STAPHYLOCCUS AUREUS GENITIC STREPTOCOCCUS .P FEVER D.I.P ARTHRITIS GENITIC ARTHRITIS SACRO ILITIS FEVER MYALGIA IRITIS 64
ANOREXIA PERICARDITIS ASSYMMETRIC OLIGO ARTHRITIS SYMMETRY NEPHROTIC SYNDROME NAIL CHANGES CNS EPILEPSY LEUCOCYTOSIS Cont.. 65
§ Evaluate the progress & continue the relevant treatment § Physiotherapy § Rehabilitation of the Patient 66
Acknowledgement — Department of Kaya chikitsa, Institute of Indigenous Medicine, University of Colombo, Rajagiriya. — Director, National Ayurveda Hospital Sri Lanka. — RMO, National Ayurveda Hospital Sri Lanka. 67
68

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Clinical Presentation on Rheumatoid Arthritis (Amavata)

  • 1.
    Dr (Ms) R.L.D.S.Ranasinghe MD Scholar, Dept of Kaya Chikitsa , University of Colombo, Rajagiriya. Prof (Ms) E.R.H.S.S Ediriweera Dept of Kaya Chikitsa , IIM, University of Colombo, Rajagiriya. 1
  • 2.
    g Objectives gCase presentation g Review of Ayurveda g Review of Modern g Acknowledgement 2
  • 3.
    gUnderstand the patho-physiology, signs and symptoms & treatments of Amavata gGeneral review on related Modern Aspects gImprove diagnosis skills of diseases g presentation skills to present case studies 3
  • 4.
    vName : MrS.G.W Rudrigu vAge : 33 Yrs v Date of Admission : 09th September 2013 v Ward No : 11 v Bed No : 15 v Address : No. 12/10, Handala, Wattala. v Occupation : Spray painter for 16 yrs v Nationality : Sinhalese v Religion : Catholic v Marital Status : Married 4
  • 5.
    vMain complaint withduration: Pain, stiffness & edema of several joints notably wrist, hand, ankle & feet (3 months) vOther complaints: Thirst, Nocturia, Increase sweating (3 months) 5
  • 6.
    o According tothe patient, o 3 months before; the patient was asymptomatic. Suddenly he got throbbing pain over both the upper limbs along with lethargy ,generalized weakness and thirst. Simultaneously pain was shifted to the RT & LT lower limbs. o 1 week after the onset of disease, he suffered from fever with edema and Pain in the joints: the RT elbow, RT & LT Knee wrist joints, RT & LT Knee Shoulder joints & then to the RT & LT Knee Joints gradually. 6
  • 7.
    ¬ Medical History RT & LT Knee joint edema at ate age of 7 yrs Diabetes Mellitus - Identified before 3 months with the onset of the disease FBS- 194 mg/ dL (2013. 08. 07) ¬ Surgical History - minor surgery has done in the ankle joint after RTA ¬ Psychiatric History ¬ Treatment History - NAD 1. Allopathic treatment for Diabetes Mellitus – 3/ 12 2. Allopathic treatment for joint pain & edema – 8/ 52 - No improvement with allopathic treatment 3. Admitted for Ayurvedic treatment for the first time just before 3 /52 7
  • 8.
    53 yrs DM+, Rheumatoid Arthritis 35yrs DM+ 30 yrs DM+ 27 yrs DM+ 57 yrs 7 yrs 3 yrs 8
  • 9.
    o Diet: Breakfast - Bread & Curries, Short eats Lunch - Rice, Vegetables, Egg Meat (Chicken, Beef, Mutton)-Daily Dinner - Rice, Vegetables & meat More like to eat Spicy & Fried food. o Appetite: impaired appetite at the onset of the disease 9
  • 10.
    o Sleep :Disturbed due to Nocturia o Bath : Evening with cold water, Daily o Bowel habits : Once/ Day, Colour - Yellow Odour - Normal Character - Asamhata Mala, Sticky o Micturition : D / N – 3/2 times Colour - Pale Odour - Normal o Addiction : No addictions o Social status : Living near to the sea side & river side 10
  • 11.
    GENERAL PHYSICAL EXAMINATION • General condition - Average • BP - 130 /80 mmHg • PR - 74 / min • RR - 14 / min • Weight - 67 kg • Height - 164 cm • Tongue - Coated • Temperature - intermittent febrile Usually in the evening • Skin - Normal • Thyroid • Pallor NAD • Icterus • Cyanosis • Clubbing • Enlarged LN NAD 11
  • 12.
    1) LOCO MOTORSYSTEM § Gati (Range of movements) : • Left Shoulder joint - Abduction - Adduction - Rotation - Elevation • Left wrist joint - Flexion - Extension - Rotation Limited due to edema & pain Limited due to edema & pain § Sandhi sputana (Joint crepitus ) - Presented in both knee joints § Sparsha asahyata (Joint tenderness) § Sandhi shota (Joint swelling ) § Rakta varnata (Redness) § Ushnata (Heat) - Presented in affected joints § Mamsa ksaya/ shosha (Muscle wasting) - NAD 12
  • 13.
    GALS: • Gait:Slow and painful gait • Arms: Difficulty in pronation and supination (painful) in LT wrist joint Pain – When squeezed the hand across the metacarpals of the LT hand Power Grip - reduced (Difficulty in holding) — Legs: Sandhi sputana both knee joints 13
  • 14.
    SPINE: • ThoracicSpine: Internal and external rotation- Normal • Lumbar Spine: • Flexion-Normal • Extension-Normal • Lateral Bending-Normal • Cervical Spine: • Rotation-Normal • Flexion, Extension and Lateral bending-Normal 14
  • 15.
    JOINTS: • Inspection • MCP, PIP, DIP, MTP Wrist joints • Swelling Symmetrical involvement • Redness Deformities - NAD • Palpation. • Tenderness & warmth (MCP, PIP, DIP, MTP, Wrist, Elbow joints) • Stiffness of the joints 15
  • 16.
    2) CARDIOVASULAR SYSTEM • S1, S2 - Clear . No thrills or murmurs 3) RESPIRATORY SYSTEM • No added sounds 4) GIT P/A • No tenderness • No organomegaly 5) CNS NAD Clinically Higher functions Sensory system • Cranial nerves Motor functions •Reflexes- LT knee jerk exaggerated • Other Reflexes - Normal 16
  • 17.
    I. Prakriti :Vata Pitta II. Vikriti : Will be described in next slide III. Sara : Rasa, Rakta, Mamsa, Asthi, Majja, Sukra - Madhya Sara IV. Sanhanana : Madhya Samhata V. Pramana : Madhya pramana (Weight-67 kg, Height -164 cm BMI = 25) VI. Sattva : Madhya Sattva VII. Satmaya : Shad Rasa Satmaya VIII. Ahara shakti: Before After i. Abyavarana shakti : Prawara Madhya ii. Jarana shakti : Prawara Madhya IX. Vyayama shakti : Before After Prawara Madhya X. Vayah : Madhyama (35 Yrs) 17
  • 18.
    ¬ Hethu (Nidana)– Viprakrusta Nidana Ahara : Katu Rasa, Snigdha, Guru guna Atisewana Viharana : Seeta jala sewana, Spray painting (chemicals) Vyadhi : Madumeha+ ¬ Dosha - Vata, Kapha ¬ Dushya - Rasa, Rakta, Mamsa, Asthi, Majja, Sukra. ¬ Prakiti - Vata, Pitta ¬ Desha - Anupa Desha Near to the riverside & Seaside ¬ Kala - Adana kala ¬ Bala - Roga bala: Kruccha sadya Atura bala: Madhyama ¬ Lakshana - Edema, pain & stiffness of the joints 18
  • 19.
    1. Nadi: i.Gati - 72/ min ii. Yati - Samanthara iii. Akruti - Purna iv. Samhati - Mrudu 2. Mutra : D/ N – 3 / 2 times 3. Mala : Once/Day, Asamhata mala 4. Jivha : Ama 5. Shabda : Prakrita hrid & pupphusa shabda Ubhaya Janu sandhi sphutana 6. Sparsha : Ushna sparsa in affected sandhis 7. Druk : Prakrita 8 . Akriti : Madhyama 19
  • 20.
    1. Prana vahaSrotas : Prakrita 2. Udaka vaha Srotas : Vikrita; Thalu shosha+ 3. Anna vaha Srotas : Vikrita 4. Rasa vaha Srotas : Vikrita; Sandhi shota+ 5. Rakta vaha Sorts : Vikrita; Sandhi shota+ 6. Mamsa vaha Srotas : Prakrita 7. Medo vaha Srotas : Prakrita 8. Asthi vaha Srotas : Vikrita; Sandhi sula, Shota + 9. Majja vaha Srotas : Prakrita 10. Shukra vaha Srotas : Vikrita; Madhu + 11. Muthra vaha Srotas : Vikrita; Ratrimutrata + 12. Purisha vaha Srotas : Vikrita; Asamhata mala+ 13. Sweda vaha Srotas : Vikrita; Atisweda+ 14. Mano vaha srotas : Prakrita 20
  • 21.
    Ø Dosha :Vata, Kapha Ø Dushya : Rasa, Rakta, Mamsa, Asthi, Majja , Sukra Ø Adishtana : Sharirika Ø Srotas : Rasa Vaha Srotas ,Rakta Vaha Srotas Mamsa Vaha Srotas, Asthi Vaha Srotas Majja Vaha Srotas, Shukra Vaha Srotas Udaka Vaha Srotas, muta, Mutra Vaha Srotas Sweda Vaha Srotas Ø Samuttana : Amasha Ø Agni : Mandagni Ø Ama : Ama Ø Srotodushti : Sanga Ø Udbhawastana : Sarvanga sandhi Ø Sadhya Asadhyata : Kruccha sadhya Ø Roga marga : Madhyama (Marma, Asthi,Sandhi) 21
  • 22.
    q FBS -194 mg/dl (2013.08.07) 99 mg/dl (2013.10.10) Within normal range with drug control q UFR Reaction - Acidic Albumin Sugar Pus cells Epithelial cells q CRP - 12mg/ dL Raised q ESR - 11/ 1st hr Raised q PCV - 48% q RF - < 8 IU/mL Occasional 22
  • 23.
    Differential diagnosis AMAVATA SANDHISHOTA SSANDHIGATA VATA GAMBHIRA VATA RAKTA Nidana Viruddha ahara, Snigda ahara, Alpa chesta etc. Vata kopakara Ahara, Viharana Vata & Rakta kopakara Ahara, Viharana Rupa Angamarda, Aruchi, Trushna, Alasya etc Shula, Shota, Prasaranakunchan a Vedana Daha, Supti, Vaivarnya, Sphutana etc Sthana Start from small joints of hands & spread Mainly start with weight bearing large joints Start from the end parts of the hands & feet Dosha Kapha, Vata Vata Predominant Vata, Pitta 23
  • 24.
    Differential diagnosis RheumatoidArthritis Gout Osteoarthritis INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE DISEASE PROLIFERATION OF SYNOVIAL MEMBRANE IMPAIRED PURINE METABOLISM DEGENERATION OF ARTICULAR CARTILAGE ATLEAST 3 JOINTS ARE INVOLVED MONOARTICULAR WEIGHT BEARING JOINTS MORNING STIFFNESS - 1HR MORNING STIFFNESS-NA MORNING STIFFNESS- 15MTS PAIN- EXTREME PAIN-MILD PAIN-MILD 24
  • 25.
    PAIN SUBSIDE BYWORKING OR EXERCISE Cont. NO RELATION PAIN AGGRAVATED DURING WORKING-RELEVIED BY REST. MIDDLE AGE-20-35 F:M- 3:1 MIDDLE AGE-ABOVE 40 M:F- 8:1 ABOVE 50YRS F:M- 2:1 R.A - POSITIVE E.S.R-RAISED SERUM PURINE LEVEL IS MORE THAN 600MG E.S.R- NORMAL R.A -NEGATIVE X -RAY SHOWS REDUCED JOINT SPACE, SOME TIMES DEGRATION OF BONE MASS X RAY X-RAY SHOWS OSTEOPHYTES AND DEGENERATIVE CHANGES 25
  • 26.
    NAVA AMAVATA PRAVRUDHAAMAVATA JEERNA AMAVATA 1.ARUCHI. 1.INVOLVEMENT OF HASTA, PADA SIRO, GULPHA,TRIKA ETC 1. DESTRUCTION OF ARTICULAR CARTILAGE. 2.ALASYA. 2.SHOTHA ,STABDHATA 2.OSTEOPOROSIS. 3.GOURAVA. 3.EXTREME PAIN. 3.DEFORMITIES. 4. JWARA 4.PRASEKA,ARUCHI. 4.POLYARTHRITIS. 5.HRILLASA 5.HRIDAYA GOURAVA AND HRITGRAHA. 6.APAKTHI. 6.CHARDI,BHRAMA,MOORC HA, ANAHAM. 26
  • 27.
    Diagnosis — Viruddhaahara, Snigda ahara, Alpa chesta Seta jala, Vata sparsa etc. — Angamarda, Aruchi, Trushna, Alasya etc — Start from small joints of hands & spread — Kapha, Vata — Inflammatory disease — At least 3 joints are involve — Morning stiffness — Pain — Middle age- 33 yrs — E.S.R-Raised — CRP -Raised Amavata sandhi shota Rheumatoid Arthritis 27
  • 28.
    ë Duration :3 weeks (2013.09.20 - 2012.10.15) ë Improvements: Fever & Ama conditions subsided Internal medications § Denibadi decoction 120 ml, bd, before meal § Kaphahara kwatha 2 tablespoonful, bd, before meal § Chandra prabha vati 2 bd with hot water, after meal — Haritakyadi vati 2 bd with hot water, after meal External applications § Dashanga Lepaya – To affected joints, morning & evening with juice of tamarind leaves 28
  • 29.
    Patyapatya Patya Ahara •Yava •Kulatta •Rakta shali •Drumstics •Punarnava •Bittergourd •Ginger •Rasona •Ginger with takra •Hot water Patya Viharana — Warm water bath — a gentle walk after consumption of food 29
  • 30.
    Apatya Ahara ApatyaViharana • Guru snigdha ahara • Sweets • Uncooked food • Salty food • Oily food • Fast food • Fish • Milk • Ghee • Cold water — Cold breeze and excessive wind — Bathing with cold water — water intake immediately after consuming food 30
  • 31.
  • 32.
    Etymology of Amavata — - Ama and Vata unites to form Amavata (Vijayaraksihta) • - Vata associated with Ama creating a disease Known as Amavata (Vijayarakshita) 32
  • 33.
    • (Amarakosha) -The substance which undergoes a typical change in the processes of digestion is known as Ama • (Amarakosha) Etymology of Ama • 33
  • 34.
    Aetiopathogenisis of Amavata Ma. Ni. 25/ 1-5 34
  • 35.
  • 36.
    Samprapti of AmaVata Ahara Viruddha ahara, Snigdha ahara, Guru Ahara Viharana Diwa svapna, Nischalata, Manasika Chinta, Shoka. Bhaya, Krodha Agni mandya Sanchaya Prakopa Ama visha Sama Vata Sleshma sthana Dhamani Dushti by Tridosha Prasara Dushti by Tridosha Rasavaha srotas Trika sandhi pravesha Daurbalya, Sandhi shota, Shula Sandhi sthabdata Amavata Stahana Samsraya Vyakti 36
  • 37.
    Rupa- General clinicalfeatures Ma. Ni. 25/ 6 — Body ache — Anorexia — Thirst — Malaise — A feeling of heaviness — Fever — Indigestion — Inflammation of the body parts (myositis , fibrositis, arthritis etc) 37
  • 38.
    Pravruddha Amavata (Exacerbationof Amavata) Ma. Ni. 25/ 7- 10 38
  • 39.
  • 40.
    • When Amavatagets exacerbate Pravruddha Amavata (most distressing of all the diseases) • Where ever the (Ama) Dosha reaches joints of the hands feet cervical region (pelvic & shoulder)girdles , knees & thighs • The affected part is excessively painful as if it is bitten by scorpions Produces painful swelling 40
  • 41.
    • anorexia &a feeling of heaviness • loss of the drive • bad taste in the mouth • poly urea & a burning sensation • hardness in the abdomen • colicky pain & • reversal of normal sleeping habit • thirst • vomiting • vertigo • Fainting • pericardial discomfort • constipation • stiffness • gurgling intestinal sounds • meteoric & other troublesome complications It gives rise to 41
  • 42.
    Features of doshikpredominance in Amavata (Ma. Ni 25/11) — with the predominance of Pitta there is redness & heat(locally) — whereas with predominance of Vata the pain is severe — In Kapha, feeling of being covered with wet cloths, heaviness & itching 42
  • 43.
    Amavata Prabheda •Doshanubandha Lakshanas (BP) (1) Vatanubandha : Sasulam (2) Pittanubandha : Sadaha, Saraga (3) Kaphanubandha : Stimitatam • Doshanubandha (Madhavakara) Vata,Pitta,Kapha,VP,VK,PK,Sannipataja. • Avastha bhedena: (Madhavakara) Samanya. Pravrudha. 43
  • 44.
    Sadhya asadhya bhava-Prognosis Ma. Ni. 25/12 — One Dosha involved → curable — Two Dosha involved → relievable — Three Dosha involved → difficult to cure (Inflammation of all over the body) 44
  • 45.
    Upadrava (Complications) •Sankochaand Khanjata (Vijayarakshita) •Kalaya khanjata (Bhavaprakasha) •Jadya, Antrakujana, Anaha, Chardi (Anjana Nidana) •Angavaikalya (Harita) •Akshepana (Gayadasa) •Vatavyadhi (Vachaspati vaidya ) 45
  • 46.
    Amavata Cikitsa (Bha.Pra.Ma.Kha 26/ 14,15) • Langhana(fasting) • Swedana (sudation) • Use of drugs of Tikta katu rasa • Deepana (stimulating appetite) • Virecana (purgaation) • Oleation (snehapana) • Vasti (enema) • Ruksha sweda valuka pottalee (use of bags of heeted sand) • Upanaha (applying poultiecs) without use of sneha 46
  • 47.
    Anthah parimarjana 1.Ama pacana, Jvara hara 1. Pachanamruta Decoction, Pata ½ bd, Before meal 2. Murva 10 Decoction, Pata ½ bd, Before meal 3. Amrutashtaka Decoction, Pata ½ bd, Before meal 4. Beli mul 16 Decoction, Pata ½ bd, Before meal 5. Denibadiya Decoction, Pata ½ bd, Before meal 6. Hinguvastaka Churna, 30 grns, bd with hot water, After meal 7. Sudarsana Churna 30 grns, bd with hot water, After meal 8. Seetarama Vati 3 bd, bd with hot water, After meal 9. Avipattikara Churna 30 grns, bd with hot water, After meal 47
  • 48.
    2. After AmaPachana – Nirama avastha 1. Rasna 7 Decoction, Pata ½ bd, Before meal 2. Rasna 13 Decoction,Pata ½ bd, Before meal 3. Sinhanada Guggulu 2 bd with Bavila, sudulunu water , After meal 4. Hinguwashtaka churna 30 grns, with hot water, After meal 5. Rasnadi guggulu, 2 bd, with hot water, After meal 6. Vata gajendrsinha rasa, 2 bd, with hot water, After meal 7. Amavatari rasa, 2 bd, with hot water, After meal 48
  • 49.
    Madhumeha Cikitsa- Alongwith Amavat chikitsa — Nishatripal veniwelgata Decoction, Pata ½ bd, Before meal — Triphala Churna, 30 grns, bd with hot water, After meal — Haritakyadi Vati, 2 bd, with hot water, After meal — Somanatha Rasa, 2 bd, with hot water, After meal 49
  • 50.
    Bahir parimarjana ØSwedana- Ruksha sweda • Valuka pottali • Pottali sweda by using ruksha dravya such as Saindava, Karpasa, Kulattha, Tila, Eranda, Atasi, Punarnava, Ø Snehana – Ruksha sneha Abhyanga (In Nirama avastha) 1. Mee taila 2. Saidavadi taila 3. Amavata taila 4. Nirgundi taila Ø Lepa 1. Dhusturadi Lepa 2. Satapushpadi Lepa 3. Hinsrapadi Lepa 4. Humbas mati pattuwa 5. Dasanga Lepa 6. Delipothu pattuwa 50
  • 51.
  • 52.
    Rheumatoid Arthritis isa chronic Systemic Inflammatory disorder of unknown etiology 52
  • 53.
    Epidemiology • Affects0.5- 1.0% of the population world wide • Peak prevalence between the ages of 30 and 50 years • RA has an incredibly high disease burden and cost to society • Drastic affect on quality of life • Increased disability (80% disabled after 20 years of disease) • Patients with RA have shorter life expectancies 53
  • 54.
    Aetiology — Gender: women before the menopause are affected3 times more than men & equal sex incidence thereafter — Familial : Increase incidence in those who with a family history of RA — Genetic factors: Human Leucocyte Antigen HLA- DR4 & HLA- DrB1 54
  • 55.
    Rheumatoid Arthritis: KeyFeatures • Inflammatory synovitis • Palpable synovial swelling • Morning stiffness >1 hour, fatigue • Symmetrical and polyarticular (>3 joints) • Typically involves wrists, MCP, and PIP joints • Typically spares certain joints — Thoracolumbar spine — DIPs of the fingers and IPs of the toes 55
  • 56.
    Rheumatoid Arthritis:Key Features(cont’d) • May have nodules: subcutaneous or periosteal at pressure points • Rheumatoid factor • 45% positive in first 6 months • 85% positive with established disease • Not specific for RA, high titer early is a bad sign • Marginal erosions and joint space narrowing on x-ray • Symptoms >6 weeks’ duration • Often lasts the remainder of the patient’s life 56
  • 57.
  • 58.
  • 59.
    Pathogenesis of RheumatoidArthritis Inflammed synovial tissue (synovitis) • Villous hyperplasia • Intimal cell proliferation • Inflammatory cell infiltration T cells, B cells, macrophages and plasma cells • Production of cytokines and proteases • Increased vascularity • Self-amplifying process 59
  • 60.
  • 61.
    Investigations Blood screening: — ESR — C Reactive Protein — FBC with differential — RF — Serum calcium phosphate & alkaline phosphate — Serum uric acid — ASOT Additional imaging techniques: • CT scans • AP & Lateral tomography (x-ray) • MRI scan • USS (good for assessing the presence of fluid) 61
  • 62.
    Differential diagnosis RheumatoidArthritis Gout Osteoarthritis INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE DISEASE PROLIFERATION OF SYNOVIAL MEMBRANE IMPAIRED PURINE METABOLISM DEGENERATION OF ARTICULAR CARTILAGE ATLEAST 3 JOINTS ARE INVOLVED MONOARTICULAR WEIGHT BEARING JOINTS MORNING STIFFNESS - 1HR MORNING STIFFNESS-NA MORNING STIFFNESS- 15MTS PAIN- EXTREME PAIN-MILD PAIN-MILD 62
  • 63.
    PAIN SUBSIDE BYWORKING OR EXERCISE Cont. NO RELATION PAIN AGGRAVATED DURING WORKING-RELEVIED BY REST. MIDDLE AGE-20-35 F:M- 3:1 MIDDLE AGE-ABOVE 40 M:F- 8:1 ABOVE 50YRS F:M- 2:1 R.A - POSITIVE E.S.R-RAISED SERUM PURINE LEVEL IS MORE THAN 600MG E.S.R- NORMAL R.A -NEGATIVE X -RAY SHOWS REDUCED JOINT SPACE, SOME TIMES DEGRATION OF BONE MASS X RAY X-RAY SHOWS OSTEOPHYTES AND DEGENERATIVE CHANGES 63
  • 64.
    Differential diagnosis RHEUMATICFEVER SEPTIC ARTHRITIS PSORIATIC ARTHRITIS C.V.S DISEASE STAPHYLOCCUS AUREUS GENITIC STREPTOCOCCUS .P FEVER D.I.P ARTHRITIS GENITIC ARTHRITIS SACRO ILITIS FEVER MYALGIA IRITIS 64
  • 65.
    ANOREXIA PERICARDITIS ASSYMMETRIC OLIGO ARTHRITIS SYMMETRY NEPHROTIC SYNDROME NAIL CHANGES CNS EPILEPSY LEUCOCYTOSIS Cont.. 65
  • 66.
    § Evaluate theprogress & continue the relevant treatment § Physiotherapy § Rehabilitation of the Patient 66
  • 67.
    Acknowledgement — Departmentof Kaya chikitsa, Institute of Indigenous Medicine, University of Colombo, Rajagiriya. — Director, National Ayurveda Hospital Sri Lanka. — RMO, National Ayurveda Hospital Sri Lanka. 67
  • 68.