A study on assessment of Agnibala and Koshtha in Amavata and their...

[Full title: A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A.]

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Original Research Article This work is licensed under a CC BY 4.0 License International Research Journal of Ayurveda & Yoga Vol. 6 (7),01-12, July,2023 ISSN: 2581-785 X : https://irjay.com/ DOI: 10.47223/IRJAY.2023.6701 A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A. Anamika Yadav 1 , Sushil Kumar Dubey 2 , Vivek Anand 3 1-Assistant Professor, Department of Kriya Sharir, Dr. Vijay Ayurveda Medical College, Hospital and Research Centre, Bandaha Kala Kaithi, Varanasi UP, India. 2-Assistant Professor, Department of Kriya Sharir, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., India 3-Assistant Professor, Department of Dravyaguna, Shivalik Ayurvedic Medical College and Hospital, Bijarwa, Bankat Azamgarh, U.P., Varanasi UP, India INTRODUCTION Human life is considered a valuable opportunity to achieve the prime goals of life, viz. Dharma, Artha, Kama and Moksha' . To achieve all these things, one needs a healthy and calm life. The whole ancient society tried to achieve all four prime life goals so that they had a smooth, sound, safe, assured, steady, and healthy lifestyle. On the other hand, Article Info Article history: Received on: 08-06-2023 Accepted on: 12-07-2023 Available online: 31-07-2023 Corresponding author- Anamika Yadav, Assistant Professor, Department of Kriya Sharir, Dr. Vijay Ayurveda Medical College, Hospital and Research Centre, Bandaha Kala Kaithi, Varanasi UP, India Email: yadavanamika@bhu.ac.in ABSTRACT: Introduction: Mandagni has been considered one of the primary indigenous factors for the manifestation of Amavata , so there might be the effect of the causative factors affecting the status of Agnibala of an individual. Hence an attempt can be made to observe the status of Agnibala and Koshta with particular reference to different inflammatory markers present in subjects of Aamvata . Material and Method: The main goal of the study was to evaluate the Agnibala and Koshtha of the Amavata Patients and to determine the relationship between Agni and Koshtha with the inflammatory parameters of Rheumatoid Arthritis as the characteristics of Amavata are similar to Rheumatoid Arthritis. The aims and Objectives of the study include the Assessment of Koshtha using a self-developed Standard Proforma for Koshtha Assessment (KAQ). Agnibala , using a standard proforma developed by Singh A et al., 2016 Amavata patients were encouraged to undertake Haematological examinations along with Investigations of Inflammatory markers of Rheumatoid arthritis and their reports were collected and analysed for additional statistical analysis. BHU's CCI lab and other standard laboratories were used for the research. The data were then statistically analysed. Results and Conclusion: According to the Agni Bala assessment from this study, it can be said that Mandagni is the main causative factor for the development of Amavata . A good correlation has been found between symptoms of Amavata and ACR criteria of Rheumatoid Arthritis from this study. A significant association was found between Madhyam Koshtha and Amavata as provocative factors. There is also a significant correlation found between Koshtha and Agni. Keywords: Amavata, Koshtha, Ayurveda, Ama, , Agni , Rheumatoid Arthritis

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Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 2 today, everyone is trying to gain good financial status and fulfil all their physical desires; therefore, today's metaphysical society faces an unsteady, weakened, hard, and everyday changing lifestyle. The gift of this lifestyle and diet is emerging in the form of newer diseases; one of them is Amavata (Rheumatoid Arthritis). Amavata is one of the commonest crippling disorders caused by the impairment of Agni . Amavata further leads to deterioration in the form of physical deformities as well as mental frustration. Amavata is the most common disease among various joint disorders. The changing lifestyle and dietetic pattern are also manifested as the daily increment in the number of patients. Mandagni and Vata play a significant role in the Stabddhata, Sandhigaurav , etc 1 So, the Amavata results from a combination of Ama and Vata . Due to Mandagni , both Ama and Vata get vitiated and reach to joints and produce swelling, pain, and Disability, and thus, the disease is made 2 The term ' Nidana ' is related to the etiology and diagnosis of a disease. The factors responsible for the weakening of Agni and aggravation of Vata are well considered as the causes for the production of Amavata . Mandagni is the most important among the causative factors of Ama 3 Ayurveda has some unique entities, and Koshtha is one of them. The word Koshtha is used for a vacant place from the mouth to the anus having a covering, where things can be kept in a lot. The term Koshtha refers to the nature of the digestive tract or Alimentary tract, which usually represents the motility of the intestines and movement of food, faecal matter in the alimentary canal, and elimination of the stool. According to the dominance of Doshas or Deha Prakriti, Koshtha is generally divided into three types i.e. Krura, Mridu , and Madhyam where the dominance of Vata, Pitta , and Kapha Dosha is seen respectively.Assessment of Koshtha is important for the diagnosis and treatment of diseases. Koshtha Pariksha helps with the choice of Aushadhi and Aushadhimatra . Koshtha Pariksha also plays an important role in advising Pathya-Apathya and Aahara-Vihara . Mandagni has been considered as one of the primary indigenous factors for the manifestation of Aamavata , so there might be the effect of the causative factors affecting the status of Agnibala of an individual. Hence an attempt can be made to observe the status of Agnibala and Koshtha with particular reference to different inflammatory markers present in the subjects of Aamvata . Keeping all these concepts in mind, this observational study is conducted to find out the Agni Bala and Koshtha of Amavata patients and their correlation with inflammatory markers of Rheumatoid Arthritis. Review of literature The term Aamvata comprises of two words Ama and Vata meaning i.e. Vata Dosha is associated with Ama (an endogenous toxic compound) which causes acute disease mainly in Kapha Dosha sites, particularly joints. It was first described in Madhavnidana . Its sign and symptoms have a resemblance with Rheumatoid disease /Arthritis. Indulgence in faulty dietary and lifestyle habits like intake of Viruddha Ahara (Incompatible food), lack of physical activity or performing physical activity after taking Guru and Snigdha Aahar , Viruddha Chesta and Mandagni leads to the formation of Aama which will ultimately lead to the manifestation of Aamvata 4 Due to the poor strength of Agni (digestive fire), the Ahara Rasa is not properly formed in the stomach and in this state, it is known as Ama. 5 In another sense, it can be said that the first Dhatu that is Rasa Dhatu is not formed properly and (food) is termed as Ama . This Ama can be considered as metabolites like lactic acid formed due to improper metabolism of carbohydrates, fats, and proteins. Pathogenesis of Amavata :Ama together with Dushit Vata / Prakopit Vata circulates all over the body through Sira and Dhamani and gets lodged in Kaphasthana i.e. Sandhi which leads to the manifestation of Amavata 6 Signs and symptoms of Amavata Samanya lakshana of Amavata: Angamarda (Body ache), Aruchi (Anorexia), Trishna (Thirst), Aalasya(Lethargy), Gourav (Heaviness in the body), Jwara (Pyrexia), Apakti (Indigestion), Angashunata (Swelling in the body) 7 Pravridha lakshana of Amavata: Hasta Padashiro Gulpha Trika Janu Uru Sandhi Sa Rujam Shotham (Pain and swelling in hand, feet, ankle, knee, hip and spinal joints), Rujyate Atyartham (Excruciating pain), Vyaviddha iva Vrishcika (Nature of pain is like that of scorpion sting), Agnidaurbalya (Hindered digestive mechanism, Praseka (Excessive salivation ) , Aruchi (Anorexia) , Gauravam (Heaviness) , Utsahahani (Lack of enthusiasm), Vairasya (Altered taste in the mouth), Daham (Burning sensation), Bahumutratam (Excessive urination) Kukshau kathinatam

[Find the meaning and references behind the names: Board, Sir, Male, Trt, Lakshan, Ana, Hrd, Part, Sleep, Blood, Age, Patient, Pandu, Sample, Given, Full, Female, Rate, Esr, Non, League, Roga, Sle]

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 3 shulam, (Hardness and pain in abdomen) Nidraviparyaya (Disturbed sleep), Trt (Thirst), Chardi (Nausea), Bhrama (Fainting), Murccha (Unconsciousness), Hrd graha (Stiffness in pericardium), Vidvibaddhatam (Constipation) , Jadya ( Stiffness), Antrakujanam (intestinal gurgling) .Anaha (Distension in abdomen) 8 American College of Rheumatology Criteria (ACR)/ European League Against Rheumatism (EULAR) . 9 In this classical text the word ' Amavata ' is used in the following aspects- • Avarana of Vata , Medasavritta Vata/Adhya Vata 10 • Therapeutic use of Kamsa Haritaki in Swayathu Chikitsa 11 • Therapeutic use of Vishaladi Phanta in Pandu Roga 12 • Paripaka Kala of Jvara 13 MATERIAL AND METHODS Assessment of Agnibala and Koshtha in Patients of Amavata Selection of Patients: It is an Observational study and the patients were selected on a Non-randomized Sampling Technique Population and sample The population for the conduction of the given study was defined as either gender aged between 18-60 years registered during 2020 and 2022. A total of 74 subjects were registered, out of which 54 were female, and 20 were male. Patients who fulfilled the diagnostic criteria of Amavata were selected from the OPDs of Panchkarma and Medicine (Rheumatology), Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi- 221005. The patients were provided with detailed information about the purpose and methods used in the study and written consent was obtained before registration. The Ethical Committee of Institute of Medical Science, Banaras Hindu University and PG Medical board, Institute of Medical Science, Banaras Hindu University, Varanasi has approved this study. Ethical Clearance Number (Ref. No:- EC/2166). CTRI Registration No.- CTRI/2021/02/031020 Inclusion Criteria 1 The patient full filled the ACR diagnostic criteria of R.A. and had features of Samanya and Praviddha Lakshana of Amavata. 2 Subjects of either sex belonging to age between 18-60 years. 3 Volunteers who were willing to be a part of the study by giving written consent in a prescribed format. Exclusion Criteria 1 The patients with ages below 18 years and above 60 years. 2 Volunteers have any recurrent or chronic illnesses. 3 History of any known disease/illness, tuberculosis, malignancy, etc. 4 Various other joint disorders Osteoarthritis, Osteoporosis, Ankylosing Spondylosis, Systemic lupus erythematosus (SLE), etc. 5 The following parameters will be evaluated for the response: After the selection of the subjects, they will be subjected to the assessment of the following : Clinical Assessment Criteria: • Patients were registered as per Samanya and Pravridha Lakshan of Amavata given in Ayurvedic Samhitas and as per American College of Rheumatology Criteria 2010(ACR ). • Demographic Details: Including Age, Sex, Marital Status, Habitat, Diet, Education, Occupation, Socio-Economical Status, duration of Illness, Onset and Symmetry of Disease, Tenderness, and Swelling of Joints, Aharaj, Viharaj , and Mansik Nidan, Aatura Deha bala Pariksha , Systemic Examination of the Amavata Patients were recorded. • Koshtha by the use of Self-developed Standard Proforma for Koshtha Assessment (KAQ) • Agnibala , with the help of standard proforma developed by Singh A et al., 2016 Haematological parameters - Complete blood count (CBC) including, Erythrocyte sedimentation rate (ESR) and Hemoglobin percentage(Hb%) • Inflammatory markers - Including Rheumatoid Factor CRP (C-reactive protein), R.A. factor (Rheumatoid Factor), Anti ccp (Anti-cyclic citrullinated peptide), ANA, HLAB 27 • Lab investigations were carried out in the CCI lab in BHU and other standard laboratories. RESULTS Rheumatoid Arthritis affects all age groups; the maximum number of patients registered were between 41-50 years of age group (27.02%). This observation confirms the reported incidence of this disease in India Out of 74

[Find the meaning and references behind the names: Mode, Range, Less, Desha, Veg, Normal, Urban, Married, Males, Cases, Six, Shoka, Rest, Areas, High, Bhaya, Year, Habit, Middle, Post, Chinta, Mean, Hla, Table, Farmer, Lower, Weeks, Positive]

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 4 patients taken for the study, 20(27%) were male and 54 (73%)were female. Incidence of the disease is found notably higher in females than in males (3:1) Most of the patients were rural inhabitants 48 (64.9%), and the remaining 26 (35.1%) belonged to urban areas 68 (91.9%) residents were from Sadharana Desha , and 6 (8.1%) were from Jangala Desha . No Anupa Desha inhabitants were identified [Table 7] Out of the total patients who had undergone this study, 50 (67.6%) patients are married, 23 (31.1%) patients are unmarried, and 1 (1.4%) patient is a widow Out of 74 Patients, 70(94.6%) were Hindus, and 4(5.4%) were Muslims The majority of patients in the present series were Intermediate 27 (36.48%) followed by Graduate 17 (22.97%), High School 15 (20.27%), Post Graduate 11(14.86%), Primary Education 4(5.40%), no illiterate patients were registered The majority of patients in the present series were housewives 39(52.70%) followed by Student 18 (24.32%), Service class 5.40%, Farmer 4 (5.40%), Bussiness class and Other 9 (12.16%), through this pattern of occupational incidence can not be a realistically generalized but notably high incidence of housewives supports the Ayurvedic viewpoint of " Nischaltva " a sedentary mode of lifestyle as one of the factors leading to Amavata Duration of Illness of Patients: Out of 74 Patients, 1.35% of patients had symptoms less than six weeks, 31.08% had symptoms more than six weeks, and 67.56 % of patients had symptoms more than a year Categorization of the data based on socio-economic status showed that Out of 74 patients of this series, 20(27.02%) of them belonged to poor socio-economical status, 32(43.24%) of patients belonged to Lower Middle socio-economical status, 15(20.27%) of patients belonged to Middle socioeconomical status and 7(9.45%) to upper socio-economical status Mode of onset of the disease. 54(72.97 %) patients reported Insidious onset, while 20( 27.02%) patients suffered from Gradual onset A maximum of 52(70.3 %) of patients in this series had the Symmetrical type of Rheumatoid Arthritis, and 22(29.7%) patients had Asymmetrical arthritis Diet Pattern of patients: 24 (32.4%) had a Veg diet, and 50( 67.6%) had a mixed diet. Aharaj Nidaan : maximum of 77.02% of patients had the habit of Samashana , 48.64% of patients had the habit of Adhyashana , 36.48% of patients had the habit of Anashana on and off, and 14.86% of patients had the habit of Vishamashana Viharaja Nidana : 71.62% each had the habit of Divasvapna , and 43.24% had the habit of exercise after the Snigdha Ahara , 63.51 % of patients used to work hard or do Ativyayam Manasika Nidana : 36.48 % of patients did not have any of Manasika Nidana . Of the rest patients, 56.75% patients had Chinta, 24.32% had Krodha , 16.21% had Shoka , and only 10.81% had Bhaya as Manasika Nidana factors Visualizing the sample related to the occurrence of Amavata with family history, it was found that 55 (74.3%)had negative (absent) and 19(25.7%) had a positive (present) family history Status of Agni . The presence of Mandagni in 34 (45.94%) followed by Vishamagni in 21 (28.37%), Tikshnagni in 14 (18.91 %), and a minimal proportion, i.e., 5 (6.75%) had Samagni Status of Koshtha . Madhyam Koshtha was found in 39 (52.70%), Krur were 20 (27.02%) Mridu were 15 (20.3 Rheumatoid factor in Amavata patients:63(85.1%) of the patients were seropositive whereas 11(14.9%) were Seronegative for Rheumatoid factor Out of 74 registered cases, 18.9% had a C-reactive protein value within the normal range, while 81.1% had a Creactive protein value of more than 0.6 mg/dl, which shows a positive result showing the process of inflammation Anti-CCP: Out of the total registered cases 37.83% cases had the Anti-CCP value within the normal range while 62.16% of cases had the Anti-CCP value of more than 25 U/ml which shows a positive result and helped in making a diagnosis 13.51% Patients of Amavata are having Hb% 12-13 g % and 17.56% were 11-13 g %,50% were having 8-10.9 g% and 18.91% were found severely anemic having Hb % less than 8 g %. ESR in 63.51% of Amavata patients is found to be abnormal and increased above 20 mm. 36.48 % of patients were having normal ESR values Out of 74 registered cases of Amavata , only 9 patients underwent Anti Nuclear Antibody assay test, So among 9 patients, 55.55% of cases had the anti-nuclear antibody test showing positive results, while 44.44% of cases had the anti-nuclear antibody test showing a negative result HLA B 27: 63(85.1%) were Seronegative, and 11(14.9%) were Seropositive for HLA B 27 Mean and Standard Deviation of Clinical Parameters for Different Types of Koshtha . The difference between Koshtha was not Statistically Significant in all these

[Find the meaning and references behind the names: Fever, Ant, Roopa, Back, Vid, Rupa, General, Property]

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 5 Parameters [Table 1] Mean and standard deviation of clinical parameters for Different types of Agni . The difference between Agni was not statistically significant in all these Parameters except Anti CCP. Anti-CCP was higher in Mandagni and lower in the Tikshnagni group [Table 2] During correlating Agni and Koshtha , among 34 Mandagni participants, Madhyam Koshtha were found 33.8%, Krura Koshtha were 8.1 % and Mrudu Koshtha were 4.1% found. In 14 Tikshanagni participants, Mrudu Koshtha were found 9.5%, Madhyam Koshtha were 6.8% and Krura Koshtha were 2.7% found. Among 21 Vishamagni participants, Krura Koshtha were found 16.2%, Madhyam Koshtha were 8.1% and Mrudu Koshtha were 4.1% found. Among 5 Samagni participants, Madhyam Koshtha was found at 4.1%, Mridu Koshtha was 2.7%, and no Krur Koshtha was found [Table 3] Incidence of symptoms ( Roopa ) shows that 37.8% of patients were having Angamarda (Bodyache), 47.3% Aruchi (Anorexia), 20.3% Trishna (Thirst), 47.3% Alasya (Lethargy), 47.3% Gauravam (Heaviness), 20.3% Jvara(Fever ), 32.4% Apaka (Indigestion), 47.3% Shunata Anganam (Swelling) respectively [Table 4] Incidence of Pravriddha Lakshana shows that 85.1% of patients were having Hasta Padashiro Gulpha Trika Janu Uru Sandhi Sa Rujam Shotham (Pain and swelling in hand, feet, ankle, knee, hip, and spinal joints), Rujyate Atyartham (Excruciating pain) 97.3%, Vyaviddha iva Vrishcika (Nature of pain is like that of scorpion sting) 97.3%, Agnidaurbalya (A hindered digestive mechanism) 82.4 %, Praseka (Excessive salivation) 83.8%, Aruchi (Anorexia) 82.4 %, Gauravam 100% Utsahahani (Lack of enthusiasm)50%, Vairasya (Altered taste in the mouth) 51.4%, Daham (Burning sensation)14.9%, Bahumutratam (Excessive urination) 64.9%, Kukshau Kathinatam shulam (Hardness and pain in the abdomen) 33.8%, Nidraviparyaya (Disturbed sleep) 37.8%, Trt (Thirst) 35.1%, Chardi (Nausea) 35.1%, Bhrama 51.4%, Murcha 16.2%, Hrd Graha (Stiffness in pericordium) 85.1%, Vid Vibadhata (Constipation)33.8%, Jadya (Stiffness)98.6%, Antrakujanam (intestinal gurgling) 33.8%, Anaha (Distension in the abdomen) 33.8% [Table 5] Tenderness Incidence of Tenderness of joints shows 50% of patients had Metacarpophalangeal joint involvement, 43.2% proximal interphalangeal,74.3% thumb interphalangeal joint,86.5% distal interphalangeal joint, 45.9% wrist joint, 63.5% elbow joint, 62.2% Shoulder joint,82.4% Hip joint, 56.8% ankle joint, 41.9% knee joint involvement, 83.8% Metatarsophalangeal,78.4% Back,83.8% Neck joint and 97.3% patients have had the temporomandibular joint involvement respectively. Swelling Incidence of Swelling of joints shows 54.1% of patients were had Metacarpophalangeal joint involvement, 48.6% proximal interphalangeal,77% thumb interphalangeal joint ,86.5% distal interphalangeal joint, 47.3% wrist joint, 71.6% elbow joint, 68.9% Shoulder joint,83.8% Hip joint, 67.6% ankle joint, 48.6% knee joint involvement, 87.8% Metatarsophalangeal,89.2% Back,93.2% Neck joint and 98.6% patients have had the temporomandibular joint involvement respectively. The involvement of the wrist and smaller joints is seen in the classical type of clinical manifestation of RA [Table 6] DISCUSSION Correction of Agni has been depicted as one of the essential aspects of Sharir Kriya , while the derangement of the same will result in the formation of Ama . This fact establishes the role of Ama in the initiation of the majority of diseases in general. It is not uncommon to attribute 'Dushatwa ' to Ama , as Ama is mentioned as one of the primary events in the disease process, and also as Ama fits into one of the defined criteria of Dosha by "independently inflicting the Dhatus ." An attempt has been made to identify Agni and Koshtha in association with inflammatory markers of Rheumatoid arthritis during the present work. Rheumatoid arthritis is a disease in which immunological reactions are supposed to be initiated by a triggering agent. The triggering agent will be either an Exogenous or Endogenous antigen by nature. The study of the etiopathological aspect of Amavata reveals the potential role of specific diets and specific weather conditions as influential factors in rheumatoid disease. However, Viruddhahara has been attributed as the first and foremost etiological factor. Vagbhata has attributed three particular diets characteristic of the Vairodhic Ahara 14 .These are: Characters opposite to Dhatu, Dosha vitiating property, It is retention in the body even after Doshik vitiation. All the above properties have a good resemblance with antigenic substances, otherwise designated as having an ant self nature, leading to the production of immunological derangements.

[Find the meaning and references behind the names: Art, Upadhyaya, Cite, Murthy, Tripathi, Garde, English, Sep, Nil, Prakashan, Madhava, House]

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 6 CONCLUSION A good correlation has been found between symptoms of Amavata and ACR criteria of Rheumatoid Arthritis from this study. According to the Agni Bala assessment, it can be said that Mandagni is the main causative factor for the development of Amavata . A significant association was found between Madhyam Koshtha and Amavata as provocative factors. The association between Agni and inflammatory markers and biochemical parameters like R.A., CRP, ANA, HLA B 27, ESR, and Hb was insignificant. All these Parameters have no significance with Agni except Anti-CCP, which was higher in Mandagni and lowered in the Tikshnagni group.The association between Koshtha and inflammatory markers and haematological parameters was not Statistically Significant. So no correlation can be drawn between Koshtha and inflammatory markers. There is a significant correlation found between Koshtha and Agni . Acknowledgment - Nil Conflicts Of Interest- Nil Source of finance & support – Nil ORCID Anamika Singh , https://orcid.org/ 0000-0002-2196-324 X REFERENCES 1.Tripathi B, Madhavakara. Amavatanidanadhaya (25/4- 6). In: Upadhyaya Yadunandana. Madhukosha of Vijayarakshit on Madhava Nidanam, 1 st part, Varanasi; Chaukhamba Publication: 2007 2. Tripathi B, Madhavakara. Amavatanidanadhaya (25/6). In: Upadhyaya Yadunandana. Madhukosha of Vijayarakshit on Madhava Nidanam, 1 st part, Varanasi; Chaukhamba Publication: 2007 3.Garde G, Ashtanghrudaya, Sartha vagbhat, , editor 12 th ed. Nidanasthana 12/1 pune: present publishing house, 2009. 4. Tripathi B, Madhavakara. Amavatanidanadhaya (25/1). In: Upadhyaya Yadunandana. Madhukosha of Vijayarakshit on Madhava Nidanam, 1 st part, Varanasi; Chaukhamba Publication: 2007 5. Garde G, Ashtanghrudaya, Sartha vagbhat, editor 12 th ed. Sutrasthana 13/25 pune: profesent publishing house, 2009 ; 6. Tripathi B, Madhavakara. Amavatanidanadhaya (25/1- 4). In: Upadhyaya Yadunandana. Madhukosha of Vijayarakshit on Madhava Nidanam, 1 st part, Varanasi; Chaukhamba Publication: 2007 7. Tripathi B, Madhavakara. Amavatanidanadhaya (25/6). In: Upadhyaya Yadunandana. Madhukosha of Vijayarakshit on Madhava Nidanam, 1 st part, Varanasi; Chaukhamba Publication: 2007. 8. Tripathi B, Madhavakara. Amavatanidanadhaya (25/7- 10). In: Upadhyaya Yadunandana. Madhukosha of Vijayarakshit on Madhava Nidanam, 1 st part, Varanasi; Chaukhamba Publication: 2007 9 Aletaha D,. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569-81. doi: 10.1002/art.27584. PMID: 20872595 10.Tripathi R, Charaka Samhita, Vol.1, editor. 1 st ed. Chikitsasthana, 28/195 .Varanasi: Chaukhambha Surbharati Prakashan; 2007. 11.Tripathi R, Charaka Samhita, Vol.1, editor. 1 st ed. Chikitsasthana, 12/52 . Varanasi: Chaukhambha Surbharati Prakashan; 2007. 12. Tripathi R, Charaka Samhita, Vol.1, editor. 1 st ed. Chikitsasthana, 16/61-63 . Varanasi: Chaukhambha Surbharati Prakashan; 2007. 13. Tripathi R, Charaka Samhita, Vol.1, editor. 1 st ed. Chikitsasthana, 3/281 . Varanasi: Chaukhambha Surbharati Prakashan; 2007. 14. Murthy K, Vagbhata: Ashtanga Sangraha, English translation, Sutrasthan 9/25 Chaukambha Orientalia, Varanasi, 2000 How to cite this article: Yadav A, Dubey S.K, Anand V “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A.” IRJAY. [online] 2023;6(7);01-12. Available from: https://irjay.com. DOI linkhttps://doi.org/ 10.47223/IRJAY.2023.6701

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 7 Table 1. Table Showing Comparison between inflammatory markers and Koshtha in 74 Patients of Amavata (MEAN ± S.D ) Variables Mean+SD KOSHTHA Between Koshtha Comparison Krur Mridu Madhyam RA 108.13 ± 171.32 91.80 ± 163.36 102.40 ± 122.35 {?} 2 = 5.03 P=.08 CRP 14.61 ± 29.11 16.21 ± 23.56 18.24 ± 27.48 {?} 2 = 4.59 P=.10 Anti-CCP 194.88 ± 268.12 133.33 ± 192.45 295.38 ± 288.61 {?} 2 = 8.43 P=.01 Hb 10.81 ± 1.26 11.31 ± 1.59 10.881.79 F=.489 P=.61 ESR 37.14 ± 30.29 31.80 ± 25.22 26.49 ± 12.84 {?} 2 = 1.493 P=.47 ANA 59.10 ± 114.40 0 7.83 ± 15.35 {?} 2 = .540 P=.46 HLA B 27 7334.34 ± 3732.25 9258.00 ± 2530.86 8148.95 ± 3466.18 {?} 2 = 3.414 P=.18 Table 2. Table Showing Comparison between inflammatory markers and Agni in 74 Patients of Amavata Variables Mean+SD AGNI Between AGNI Comparison Mandagni Vishamagni Samagni Tikshnagni RA 106.14 ± 124.69 108.13 ± 171.32 66.83 ± 76.94 95.454545 ± 186.38 {?} 2 = 6.33 P=.096 CRP 18.27 ± 27.96 14.61 ± 29.11 14.13 ± 14.71 17.63 ± 26.90 {?} 2 = 4.54 P=.209 Anti-CCP 311.15 ± 288.87 194.88 ± 268.12 156.46 ± 258.15 99.99 ± 140.09 {?} 2 = 12.57 P=.006 Hb 10.85 ± 1.83 10.81 ± 1.26 11.18 ± .98 11.42 ± 1.75 F=.45 P=.71 ESR 26.43 ± 12.509 37.14 ± 30.296 23.67 ± 14.038 35.45 ± 28.328 {?} 2 = 1.95 P=.583 ANA 7.83 ± 15.35 59.10 ± 114.40 0 0 {?} 2 = .54 P=.46 HLA B 27 8185.45 ± 3529.52 7334.34 ± 3732.25 8436.50 ± 2635.26 9394.44 ± 2524.68 {?} 2 = 3.33 P=.34

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 8 Table 3. Agni and Koshtha Crosstabulation AGNI KOSHTHA Total KRUR MADHYAM MRIDU MANDAGNI Count 6 25 3 34 % of Total 8.1% 33.8% 4.1% 45.9% TIKSHNAGNI Count 2 5 7 14 % of Total 2.7% 6.8% 9.5% 18.9% VISHAMAGNI Count 12 6 3 21 % of Total 16.2% 8.1% 4.1% 28.4% SAMAGNI Count 0 3 2 5 % of Total 0.0% 4.1% 2.7% 6.8% Total Count 20 39 15 74 % of Total 27.0% 52.7% 20.3% 100.0% Table 4. Distribution of 74 patients of amavata according to general symptoms (Samanya Lakshan ) Symptoms No. and Percentage of cases Samanya Lakshan Z test for Proportion Present Absent Frequency Percentage Frequency Percentage Angamarda (Bodyache) 28 37.8 46 62.2 {?} 2 = 4.378 P =.047 Aruchi (Anorexia) 35 47.3 39 52.7 {?} 2 = .216 P =.728 Trishna (Thirst) 15 20.3 59 79.7 {?} 2 = 26.162 P =.00 Alasya (Lethargy) 35 47.3 39 52.7 {?} 2 = .216 P =.728 Gauravam (Heaviness) 35 47.3 39 52.7 {?} 2 = .216 P =.728 Jvara (Fever ) 15 20.3 59 79.7 {?} 2 = 26.162 P =.00 Apaka (Indigestion) 24 32.4 50 67.6 {?} 2 = 9.135 P =.003 Shunata anganam (Swelling) 35 47.3 39 52.7 {?} 2 = .216 P =.728

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 9 Table 5. Distribution of 74 patients of amavata according to general symptoms (pravriddha lakshana) Symptoms No. and Percentage of cases (Pravriddha lakshana) Z test for Proportion Present Absent Frequency Percentage Frequency Percentage Hasta padashiro gulpha trika janu Uru sandhi sa rujam shotham (Pain and swelling in hand, feet, ankle, knee, hip and spinal joints) 63 85.1 11 14.9 {?} 2 = 36.54 P=.00 Rujyate atyartham (Excruciating pain) 72 97.3 2 2.7 {?} 2 = 66.21 P=.00 Vyaviddha iva vrishcika (Nature of pain is like that of scorpion sting) 72 97.3 2 2.7 {?} 2 = 66.21 P =.00 Agnidaurbalya (Hindered digestive mechanism) 61 82.4 13 17.6 {?} 2 = 31.135 P =.00 Praseka (Excessive salivation) 62 83.8 12 16.2 {?} 2 = 33.784 P =.00 Aruchi (Anorexia) 61 82.4 13 17.6 {?} 2 = 31.135 P =.00 Gauravam (Heaviness) 74 100 0 0 {?} 2 = P =.00 Utsahahani (Lack of enthusiasm) 37 50 37 50 {?} 2 = .000 P =1.00 Vairasya (Altered taste in the mouth) 38 51.4 36 48.6 {?} 2 = .054 P =.908 Daham (Burning sensation) 11 14.9 63 85.1 {?} 2 = 36.541 P =.00

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 10 Bahumutratam (Excessive urination) 48 64.9 26 35.1 {?} 2 = 6.541 P =.014 Kukshau kathinatam shulam (Hardness and pain in abdomen) 25 33.8 49 66.2 {?} 2 = 7.784 P =.007 Nidraviparyaya (Disturbed sleep) 28 37.8 46 62.2 {?} 2 = 4.378 P =.047 Trt (Thirst) 26 35.1 48 64.9 {?} 2 = 6.541 P =.014 Chardi (Nausea) 26 35.1 48 64.9 {?} 2 = 6.541 P =.014 Bhrama 38 51.4 36 48.6 {?} 2 = 0.54 P =.908 Murcha 12 16.2 62 83.8 {?} 2 = 26.162 P =.00 Hrd graha (Stiffness in pericordium) 63 85.1 11 14.9 {?} 2 = 36.541 P =.00 Vid Vibadhata (Constipation) 25 33.8 49 66.2 {?} 2 = 7.784 P =.007 Jadya (Stiffness) 73 98.6 1 1.4 {?} 2 = 70.054 P =.00 Antrakujanam (intestinal gurgling) 25 33.8 49 66.2 {?} 2 = 7.784 P =.007 Anaha (Distension in abdomen) 25 33.8 49 66.2 {?} 2 = 7.784 P =.007

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 11 Table 6. Distribution of 74 patients of amavata according to Symptoms ( Tenderness and Swelling) Symptoms No. and Percentage of cases Z test for Proportion Present Absent Frequency Percentage Frequency Percentage Metacarpo phalangeal Tenderness 37 50 37 50 P =1.00 Swelling 40 54.1 34 45.9 P =0.56 Proximal Interphalangeal Tenderness 32 43.2 42 56.8 P =0.295 Swelling 36 48.6 38 51.4 P =0.908 Thumb Interphalangeal Tenderness 55 74.3 19 25.7 P =.00 Swelling 57 77 17 23 P =.00 Distal Interphalangeal Tenderness 64 86.5 10 13.5 P =0.00 Swelling 64 86.5 10 13.5 P =0.00 Wrist Joint Tenderness 34 45.9 40 54.1 P =.561 Swelling 35 47.3 39 52.7 P =.728 Elbow Joint Tenderness 47 63.5 27 36.5 P =.27 Swelling 53 71.6 21 28.4 P =.00 Shoulder Tenderness 46 62.2 28 37.8 P =.47 Swelling 51 68.9 23 31.1 P =.002 Hip Joint Tenderness 61 82.4 13 17.6 P =.00 Swelling 62 83.8 12 16.2 P =.00 Ankle Joint Tenderness 42 56.8 32 43.2 P =.295 Swelling 50 67.6 24 32.4 P =.003 Knee Joint Tenderness 31 41.9 43 58.1 P =.201 Swelling 36 48.6 38 51.4 P =.908 Metatarsophalangeal Joint Tenderness 62 83.8 12 16.2 P =.00 Swelling 65 87.8 9 12.2 P =.00 Back Tenderness 58 78.4 16 21.6 .00 Swelling 66 89.2 8 10.8 P =.00 Neck Joint Tenderness 62 83.8 12 16.2 P =.00 Swelling 69 93.2 5 6.8 P =.00 Tempero mandibular Joint Tenderness 72 97.3 2 2.7 P =.00 Swelling 73 98.6 1 1.4 P =.00

[Find the meaning and references behind the names: Aparna]

Anamika et.al , “A study on assessment of Agnibala and Koshtha in Amavata and their association with inflammatory markers in R.A . ” : 2023; 6 (7):01-12 12 Figure 1. Agni of 74 patients of Amavata (Rheumatoid Arthritis) according to Agnibala assessment proforma by Aparna et al. Figure 2. Koshtha of 74 patients of Amavata (Rheumatoid Arthritis) by Self-assessment questionnaire for Koshtha. Figure 3.R.A. Factor of 74 patients of Amavata (Rheumatoid Arthritis) Mandagni 46% Tikshnagni 19% Vishamagni 28% Samagni 7% Agni Mandagni Tikshnagni Vishamagni Samagni Krur 27% Mridu 20% Madhyam 53% Koshtha Krur Mridu Madhyam Negative 15% Positive 85% R . A. Factor Negative Positive

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