Multi-modal treatment approach in management of Sandhigata Vata w.s.r. to...

[Full title: Multi-modal treatment approach in management of Sandhigata Vata w.s.r. to Osteoarthritis]

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[Find the meaning and references behind the names: Gupta, Nirmal, Shah, Ama, Anila]

ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2017 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2017 | Vol. 2 | Issue 4 107 Multi-modal treatment approach in management of Sandhigata Vata w.s.r. to Osteoarthritis Dhaval Dholakiya, 1 Nirmal Alodaria, 2 Kaushik Vyas, 3 Drashti Shah, 4 S.N. Gupta 5 1 Lecturer, 5 Professor & HOD, Dept. of Kayachikitsa, 2 Lecturer, Dept. of Roganidana & Vikruti Vigyana, 3 Lecturer, Dept. of Shalya Tantra, J. S. Ayurved College, Nadiad, Gujarat, 4 Dept of Kayachikitsa, I.P.G.T. & R.A., G.A.U, Jamnagar, Gujarat, India. I NTRODUCTION Charaka the pioneer of Kayachikitsa was the first who described Sandhigata Vata as Sandhigata Anila [1] Sushruta has described the disease under the broad umbrella of Vatavyadhi. [2] In Jaravastha (old age) vitiation of Vatadosha is common. The vitiated Vata either combines with other Dushyas, Ama etc. or separately locates in the joints which is Madhyama Rogamarga , and generate Sandhigata Vata [3] The disease is either Kashta-sadhya or Yapya . On the basis of symptomatology and nature of the disease, Sandhigata Vata is much similar to Osteoarthritis, which is most common form of arthritis in old people. Address for correspondence: Dr. Dhaval M. Dholakiya Lecturer, Dept. of Kayachikitsa, J. S. Ayurved College, Nadiad, Gujarat, India. E-mail: vddhavaldholakiya 1910@gmail.com Submission Date : 05/08/2017 Accepted Date: 25/08/2017 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.v 2 i 4.9334 Osteoarthritis is one of the major causes of chronic disability, affecting the quality of life. According to a survey, osteoarthritis tops all the ailments in the country. Prevalence of osteoarthritis in India is more among menopausal women [4] Osteoarthritis is occurring primarily in older persons, characterized by joint pain,tenderness, crepitus, limitation of movements, occasional effusion and inflammation without systemic effects, erosion of the articular cartilage, hypertrophy of bone at the margins (i.e., osteophytes), subchondral sclerosis, and a range of biochemical and morphologic alterations of the synovial membrane and joint capsule. Pathologic changes in the late stages of OA include softening, ulceration, and focal disintegration of the articular cartilage, synovial inflammation also can occur [5] Clinical manifestations of OA range from mild to severe, and affects weight bearing joints such as knees, hips, feet, spine and also hands and later leading to chronic disability [6] Osteoarthritis is the second most common rheumatologic problem and it is the most frequent joint disease with a prevalence of 22% to 39% in India [7] Nearly, 45% of women over the age of 65 years have symptoms while radiological evidence is A B S T R A C T The disease like Sandhigata Vata which is similar to modern disease entity Osteoarthritis, is a silent enemy of the physical ability of human beings. Besides other Vata provoking factors Jara (old age) is an important factor and hence the disease is prevalent more in aging population. The provoked Vata gets seated in the Sandhis (Joints) and damages the joint structure ( Hantisandhin ). Functional and structural deterioration is obvious in the disease. For effective management of the disease Multi-modal treatment approach is the need of time. Amapachana, Snehana, Swedana, Lekhana, Basti, Upnaha, Agnikarma, Shamana Yoga etc. treatment modalities are used in Sandhigata Vata according to the patient condition Multi-modal approach in the management of Sandhigata Vata (osteoarthritis) is much useful to treat patient successfully Key words: Sandhigata Vata, Osteoarthritis, Amapachana, Lekhana, Snehana, Swedana.

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[Find the meaning and references behind the names: Guna, Low, Sneha]

Dhaval Dholakiya et.al. Multi-modal treatment approach in management of Sandhigata Vata. ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2017 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2017 | Vol. 2 | Issue 4 108 found in 70% of those over 65 years. OA was estimated to be the 10 th leading cause of nonfatal burden [8] Osteoarthritis strikes women more often than men and it increases in prevalence, incidence and severity after menopause. Etiology of OA is multi factorial and depends on age, gender, body weight, B.M.I., trauma, repetitive stress on affected joints, genetic factors. These all are the risk factors which play an important role in the manifestation of Osteoarthritis [9] Thus, Osteoarthritis is burning issue for society and for treating the patient without any adverse effect, “A multimodal therapy” baseed on clinical condition of patient (Purusham Purusham Vikshaya) is needed. M ATERIALS AND M ETHODS For this study, the basic and conceptual materials were collected from the Ayurvedic classics, namely, Brihatrayee and Laghutrayee , other texts, literature in Modern science concerned with these principles, scientific journals, dissertations, research papers, patients etc For multi-modal treatment approach Panchakarma procedures as well as internal medicaments are used. Narayanataila and Tilataila are used for Abhyanga purpose. Nirgundi-arka and Erandapatra (leafs) are used generally for Bashpasweda . For Virechana purpose Eranda Sneha, Haritaki-draksha Kashaya are much useful. For effective pain management internal medicines like Yograja Guggulu, Kaishor Guggulu, Rasna Guggulu, Kashayas like Rasnapanchakasaptaka are used. For Rasayana purpose Ashvagandha, Balamoola Kvatha are used DISCUSSION Osteoarthritis is also known as degenerative arthritis or degenerative joint disease. It is a clinical syndrome in which low-grade inflammation (Sandhishotha ), results in pain in the joints ( Sandhishoola ), caused by abnormal wearing of cartilage that covers and acts as a cushion inside joints and decrease of synovial fluid that lubricates those joints. As the bone is less protected by cartilage, the patient get pain in the weight bearing joints like knee, ankle, hip etc. Due to pain and swelling the joint can’t move properly as the movement is restricted( Stambha ) and by movements extreme pain ( AakunchanePrasaraneVedana ) occurs. Usually Osteoarthritis takes time to develop but it becomes unbearable even on mild touch-tenderness ( Sparshasahyata ) later on it results in manifestation of crepitus ( Sandhisputana ). Sandhigata Vata and Osteoarthritis can be co-related in that matter Osteoarthritis is most challenging problem for developing as well as developed countries. This is one of the major causes of chronic disability, affecting the quality of life. It is a degenerative, low inflammatory disorder, where joint inflammation initially causes pain and later swelling. Due to pain and swelling, the mobility of joints is restricted and on movement results in excruciating pain, which becomes unbearable even on mild touch in the form of tenderness. The degenerative changes later results in manifestation of crepitus. The current standard modern medical pharmacological management of osteoarthritis includes the administration of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs). However their use neither provides adequate and significant pain relief nor deceleration in disease process. In addition, NSAIDs are associated with adverse effects. Due to which the use of alternative therapies is on the rise. Sandhigata Vata is a Vata dominant disease, in which, Vata-prokopa consequently produces Agni Vaishamya (Agnimandhya) Anuloma Dhatukshaya and Asthivaha Strotodushti. The term Sandhigata Vata denotes a condition in which, Vata is pathologically seated in Asthi Sandhi and causing damage in its structures. Localization of Vata in joints means increase of Vata Guna i.e. Laghu, Ruksa, Visada and Khara in it. Increase of these properties antagonizes the properties of Kapha resulting into Shleshaka Kapha Kshaya . The disease process of the Sandhigata Vata mainly produces by two major pathogenesis of Vata aggravation that is Dhatukshaya and Margaavarana. Dhatukshaya mainly happens due to Kalaja factor, Jara (age) and Vata Vardhaka Nidana Sevana. Margaavarana mainly happens when there is Dushti

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[Find the meaning and references behind the names: Sita, Anna, Fast, Red, Don, Good]

Dhaval Dholakiya et.al. Multi-modal treatment approach in management of Sandhigata Vata. ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2017 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2017 | Vol. 2 | Issue 4 109 of Kapha as well as Meda Dhatu, Mamsa, Asthi and Majja, but in both the ways Agnidushti is common. In Margaavarana Dushti of Medadhatu leads to Stahulya (Obesity) and it creates a vicious cycle of repetitive stress on weight bearing joints with functional deterioration. In females sex steroids decreased up to a great extent immediate after menopause, so that Osteoarthritis develops. Clinical outcome of the patient depends on chronicity, severity, later age, obesity, multiple joint involvement, severe joint destruction and combination with other systemic diseases ( Vyadhisankarya ) does not yield good improvement in symptoms (taking more time). Consider all these facts approach of treatment should be according to patient’s clinical condition, Classification of patient base on clinical presentation (Purushampurusham Vikshaya) Patient with Obesity having the symptoms of Sandhigata Vata. (Margaavaranajanya) Patient with Obesity and history of menopause ( Dhatukshayajanya) having symptoms of Sandhigata Vata. Patient have history of menopause ( Dhatukshayajanya ) without Obesity having symptoms of Sandhigata Vata. Patients having symptoms of Vata Vrudhhi along with Sandhigata Vata. (Vataprakopajanya) Patients having symptoms of Jara-avasthajanya (age>60 years) Vata Vrudhhi along with Sandhigata Vata. (Vataprakopajanya) Patients having symptoms of Ama generalized along with Sandhigata Vata. For effective treatment tripod of , Pathya, Vyayama (Yogasana) and Chikitsa Upkrama is essential. Ahara Ahara Varga Pathya Apathya Anna Varga Godhuma (Wheat), Masha (Black gram), Yava (Barley), Kodrava (Sanva millet), Shyamaka Rakta Shali (Red rise) (Common millet), Chanaka (Chickpea), Kalaya (Common peas) etc. Dugdha Varga (Milk and milk products) Gau (Cow), Aja (Goat) Dugdha, Ghrita (Ghee) - Jala Varga Ushna Jala (Boiled water), Shritashita Jala. Shita Jala (Cold water) Shaka Varga Patola, Rasona (Garlik), Shigru. Sneha Varga Taila, Ghrita. Sandhigata Vata is Vata dominant disease so that we can use the Aharadravya which have quality of Snigdha, Sthira, Ushna. Vihara Do Don’t Avoid grasping action that strain you finger joints Use of fast moving vehicles Spread the weight of an object over several joints Excessive use of the affected parts/Joints Maintain good posture In adequate rest in the nights Limit stair climbing Excessive Langhana Avoid low beds, chairs, and toilets, elevate them when possible. Suppression of natural urges Yogasanas Makarasana, Tadasana, Veerasana, Suryanamaskara. The role of proper Vihara and Yogasanas in Sandhigata Vata ( Osteoarthritis) is vital. “ Vyayama Sthairyakaranam Srestham ” means by the use of these Yogasanas joints become stable in their function. It increases muscle strength and also make

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[Find the meaning and references behind the names: Bala, Surya, Luke, Narayana]

Dhaval Dholakiya et.al. Multi-modal treatment approach in management of Sandhigata Vata. ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2017 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2017 | Vol. 2 | Issue 4 110 good posture. In the patient with obesity it plays key role in maintain joint function normally by reduced abnormal Medadhatu Chikitsa Upkrama in patients of Sandhigata Vata base on clinical condition, 1. Involvement of Ama 1 st step: Amapachana by Sunthi / Pippali 2 nd step: Abhayanga, Swedana and Mrudu Virechana Karma 3 rd step: If pain is more dominent during use of the joints then, externally: Agnikarma, Bandhana, Guggulu Lepa, cupping therapy. 4 th step: If swelling is more dominent, difficulty in movement of the joint then, externally: Eranda / Arka Patrapinda Upanaha, Guggulu Lepa. 5 th step: Basti Karma: Niruhabasti - Dashmoola Kvatha, Erandmoola Kvatha. Matrabasti - Narayana Taila, Nirgundi Taila. 2. Involvement of Meda (Obesity) 1 st step: Abhayanga, Swedana and Tikshana Virechana 2 nd step: If pain is more then, externally: Agnikarma, Udavartana with Lodhra-vachaamalaki. 3 rd step: If swelling is more then externally: Eranda / Arka Patrapinda Upanaha, Guggulu Lepa 4 th step: Basti Karma: Niruhabasti - Dashmoola Kvatha, Lekhana Basti / Gaumutra Basti. 5 th step: Makarasana, Tadasana, Veerasana, Surya Namaskara. 3. Obesity with Menopause 1 st step: Abhayanga, Swedana and Tikshana Virechana 2 nd step:- Abhyantara Snehapana of Shatavari Ghruta , 20 ml with luke warm water. 3 rd step: If pain is more then, externally - Agnikarma, Bandhana, Mardana, Guggulu Lepa 4 th step: If swelling is more then, externally - Eranda / Arka Patrapinda Upanaha, Guggulu Lepa. 5 th step: Niruhabasti - Dashmoola Kvatha, Pathyadi Kvatha. 6 th step: Matrabasti - Narayana Taila, Nirgundi Taila, Ashvagandha Taila (menopause) , Tila Taila , Kshira Basti. 7 th step:- Satvavajaya Chikitsa. 4. Menopause without Obesity 1 st step: Abhayanga, Swedana and Mrudu Virechana. 2 nd step: If pain is more then, externally - Agnikarma, Bandhana, Mardana, Guggulu Lepa 3 rd step: If swelling is more then, externally - Guggulu Lepa. 4 th step: Matrabasti - Narayana Taila, Nirgundi Taila, Ashvagandha Taila, Tila Taila, Kshira Basti. 5 th step: Rasayana - Abhyantara Snehapana by Ashvagandha or Shatavari Ghruta 20 ml, Chyavanaprashavleha. 6 th step: Satvavajaya Counseling 5. Involvement of-Vata(Prakopa) 1 st step: Abhayanga, Swedana , Mrudu Virechana , Shamana Snehapana 2 nd step: If pain is more then, externally - Agnikarma, Bandhana, Mardana, Guggulu Lepa 3 rd step: If swelling is more then, externally Eranda / Arka Patrapinda Upanaha. 4 th step: Basti Karma - Matra Basti - Narayana Taila, Nirgundi Taila, Ashvagandha Taila, Bala Taila, Tila Taila. 5 th step: Vajrasana, Pavanamuktasana, Surya Namaskara. 6. Involvement of Jara (age) 1 st step: Abhayanga, Swedana and Mrudu Virechana

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Dhaval Dholakiya et.al. Multi-modal treatment approach in management of Sandhigata Vata. ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2017 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2017 | Vol. 2 | Issue 4 111 2 nd step: If pain is more then, externally - Mardana, Guggulu Lepa, Agnikarma. 3 rd step: If swelling is more then, externally - Eranda / Arka / Nirgundi Patrapinda Upanaha. 4 th step: Basti Karma: Matrabasti - Narayana Taila, Nirgundi Taila, Ashvagandha Taila, Bala Taila, Tila Taila, Mashadi Taila, Kshira Basti. 5 th step: Rasayana Karma: Abhyantara Snehapana by Ashvagandha Ghruta 20 ml, Chyavanaprashavleha. Probable mode of action Sandhigata Vata with Ama generalized Ama-pachana removes cover of actual disease and Virechana expelled out the Malabhoota Dosha after that, local Upkrama like Upnaha-Agni Karma due to their site specific Ushna properties removes pain and swelling . Sandhigata Vata with Obesity Tikshana Virechana helps to reduce excessive fat from body , which causes mechanical pressure on joints of the body Vyayama and Asana also help by make Agni (Dhatvagni) proper . Sandhigata Vata with Obesity and menopause Tikshana Virechana helps to reduce excessive fat from body, which causes mechanical pressure on joints of the body. Dhaukshaya results in numereous Vata-Vikara like Osetoporosis, so to stop further disease progress - Satvavajaya along with Rasayana is helpful Sandhigata Vata with Menopause (Dhatukshayajanya) without Obesity Mrudu Virechana helps to remov e Malabhoota Dosha. As Dhatukshaya a prime cause , Rasayana and Satvavajaya play a key role to stop disease progress Sandhigata Vata with Vata Vrudhhi Mrudu Virechana helps to remove Malabhoota Dosha as well as make the path normal so that Dosha can easily move (Vatanulomana) Sandhigata Vata associated with Jara-avastha (age>60 years) Mrudu Virechana helps toremove Malabhoota Dosha as well as do Vatanulomana Karma. As Jara (age) a prime cause , Rasayana helps to stop further tissue damage As said in Ayurveda that “treatment which have less side effect and treat all the systems and make the patient well physically as well as mentally is the right path”. In this way by multi-modal approach towards the patient not only towards the disease we can sure treat Sandhigata vata (Osteoarthritis) systematically. Multi-modal approach is shown in detail in flow-chart. Algorithm for treatment of patients of Sandhigata Vata (Osteoarthritis) Obtain History, do functional assessment of particular joint. (X-ray can be done) Differentiate the involvement and condition of Ama, Meda, Dhatukshaya (menopause), Jara (age), Vata . ↓ Involv ement of Ama ↓ Involv emen t of Meda (Obes ity) ↓ Obesity with Menopause ↓ Involv emen t of Jara (age) ↓ Involve ment of- Vata (Prakop a) ↓ Menopaus e without Obesity ↓ Do Amap achan a by Sunthi / Pippal i ↓ Do Abhayanga, Swedana and Tikshana Virechana ↓ Do Abhayanga, Swedana and Mrudu Virechana ↓ Do Abhay anga, Sweda na and Mrud Do treatment of Sthaulya with- Sunthi / Pippali, First treatme nt of Sthauly a with - Varuna di Rasayana and Vata- Prasham ana by Ashvagan dha Vataprasham ana therapy by Ashvaga ndha Shank ha- Shukti Bhasm a along with

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[Find the meaning and references behind the names: Sharma, Solomon, Janardan, Lawrence, Jun, Sah, Nil, Chang, Med, Prakashan, Prabhakar, Anderson]

Dhaval Dholakiya et.al. Multi-modal treatment approach in management of Sandhigata Vata. ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2017 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2017 | Vol. 2 | Issue 4 112 u Virech ana ↓ Varunadik vatha, Aarogyav ardhini Vati ↓ Kvatha, Aarogy avardhi ni Vati After that Shankh a-Shukti Bhasma along with Shatava ri Churna ↓ Churna, Masha Taila, Balamool a- Kwatha, Ashvagan dha- Ghruta Yograja Guggulu ↓ Churna, Balamoo la- Kwatha, Rasnapa nchaka Kvatha, Erandam oola- Kvatha, Yograja- Guggulu ↓ Shatav ari Churn a Rasay ana - Ashva gandh a Churn a, Masha Taila, Balam oola Kwath a, Ashva gandh a Ghrut a ↓ If pain is more dominent during use of the joints then use- Rasnasaptakakvatha, Yograja and Kaishorguggulu, Nirgundichurna/ Ghanavati Externally: Nirgundi / Erandapatra Pinda Upanaha, Agnikarma, Bandhana, Mardana, Guggulu Lepa ↓ If swelling is more dominent, difficulty in movement of the joint then use, Erandamoola and Dashmoola Kvatha, Gokshuradi Guggulu, Eranda Bhrusta Haritaki Churna, Shallaki Churna, ↓ Basti Karma: 1) Niruhabasti - Dashmoola Kvatha - all conditions, Lekhana Basti / Gaumutra Basti in Obesity with OA. 2) Matrabasti - Narayana Taila, Nirgundi Taila, Ashvagandha Taila (menopause) , Tila Taila (Jara), Kshira Basti (menopause , Jara). CONCLUSION Sandhigata Vata manifests mostly in women in their middle to old age. Obesity worsens the conditions along with age. Functional impairment is obvious when all these factors join together. Multi-modal approach based on patient’s clinical presentation is wholesome remedy for Sandhigata Vata (Osteoarthritis) REFERENCES 1 Charaka, Charaka Samhita, Brahmanand Tripathi, foreword by Dr. Prabhakar Janardan Deshpande, editor. Chaukhamba Surbharati Prakashan, Varanasi, Chikitsa Sthana, 28/37, Vol II, 2008; p.942. 2 Sushruta, Sushruta Samhita, with Ayurveda Tatva Sandipani by Ambikadutt Shastri, editor, Chaukhambha Sanskrit Sansthana, Varanasi, Nidana Sthana, 1/28-29, 2006;p.230. 3 Sushruta, Charaka Samhita, Brahmanand Tripathi, foreword by Dr. Prabhakar Janardan Deshpande, editor. Chaukhamba Surbharati Prakashan, Varanasi, Chikitsa Sthana, Vol II, 28/37, 2008;p.942. 4 Times of India.com [article on Internet]. Osteoarthritis is India’s No. 1 ailment. Bennett, Coleman and Co.Ltd. c 2013. Available from: http://www.articles.timesofindia.indiatimes.com/2007 ‑ 09 ‑ 06/india/27968801_1_tns ‑ arogya ‑ osteoarthritis ‑ hiv ‑ and ‑ cancer. [Updated on 2007 Sep 6, Last accessed on 2011 Jul 31]. 5 Available from : http://www.authorstream.com/Osteoarthritis(last accessed on 2008 jun 24) 6 Gucclone,A.A., Felson,D.T., Anderson,J.J. et al. The effect of specific medical condition on the functional limitations of elders in the Framingham study. Am.J. Public health 1994; 84:351-357. 7 Silman AJ, Hochberg MC. 2 nd ed. Oxford: Oxford University Press; 2001. Epidemiology of the Rheumatic Diseases. 8 Solomon L, Beighton P, Lawrence JS. Rheumatic disorders in the South African Negro. Patrt II. Osteoarthrosis. S Afr Med J. 1975; 49:1737–40. [PubMed] 9 Pai,X.C.,Rymer,W.Z.,Chang,R.W.Sharma,L., Effect of age and osteoarthritis on knee proprioception,Arthritis Rheum.1997;40:2260-2265. How to cite this article: Dhaval Dholakiya, Nirmal Alodaria, Kaushik Vyas, Drashti Shah, S.N. Gupta. Multi-modal treatment approach in management of Sandhigata Vata w.s.r. to Osteoarthritis. J Ayurveda Integr Med Sci 2017;4:107-112. http://dx.doi.org/10.21760/jaims.v 2 i 4.9334 Source of Support: Nil, Conflict of Interest: None declared.

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Vihara, Jara, Aja, Ama, Patola, Mamsa, Majja, Medas, Lekhana, Vyayama, Yapya, Pippali, Ghrita, Sandhigata Vata, Stambha, Asthi, Snehana, Rasna, Yogasana, Rasayana, Ashvagandha, Pathya, Shigru, Shunthi, Dhatvagni, Dushya, Basti, Kaphakshaya, Makarasana, Suryanamaskara, Tadasana, Gau, Medadhatu, Apathya, Kashtasadhya, Vatavyadhi, Jaravastha, Tilataila, Dhatukshaya, Narayanataila, Vatanulomana, Erandapatra, Erandataila, Mashataila, Vatavikara, Haritakichurna, Balataila, Nirgunditaila, Vatadosha, Agnikarma, Vata provoking factors, Pain management, Medical condition, Satvavajaya Chikitsa, Amapachana, Osteoarthritis, Swedana, Vata aggravation, Joint pain, Panchakarma procedure, Kaishor Guggulu, Aarogyavardhini Vati, Aharadravya, Gokshuradi Guggulu, Sandhishotha, Weight bearing joint, Degenerative Joint Disease, Chronic disability, Sparshasahyata, Joint inflammation, Agni Vaishamya, Degenerative arthritis, Margaavarana, Satvavajaya, Madhyama Rogamarga, Dhatukshayajanya, Patient Condition, Shamana yoga, Risk factor, Rasnaguggulu, Shatavari churna, Rasayana Karma, Framingham study, Joint Disease, Balamoola, Yograja Guggulu, Vata Prokopa, Functional limitation, Abhayanga, Rheumatic Disorder, Multi-modal treatment, Upnaha, Knee proprioception, Osteoarthrosis, Rheumatic disease, Internal medicaments, Functional deterioration, Structural deterioration, Multi factorial.