A Compartive Clinical Study of therapeautic effect of Rambana Rasa with and...

[Full title: A Compartive Clinical Study of therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata w.s.r. Rheumatoid Arthritis]

ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 18 A Compartive Clinical Study of therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata w.s.r. Rheumatoid Arthritis Dr. Sanjay D. Late 1 , Dr. G. Vinay Mohan 2 , Dr. M. B. Rudrapuri 3 , Dr. G. S. Dharmannavar 4 1 Post Graduate Scholar, 2 Professor & HOD, 4 Lecturer, Dept. of Kayachikitsa, 3 Professor, Dept. of Rasashashtra, Shri Shivayogeeshwar Rural Ayurvedic Medical College and Hospital, Inchal, Dist:Belgaum, Karnataka, INDIA. I NTRODUCTION The terminology of Ayurveda itself explains that, it is a vast literature on living a healthy life and how to prevent one form of disease prevailing in society, due to modernization of lifestyle. In this world, one cannot find even a single substance which is devoid of pharmacological action and can be used for benefit of living organism on the basis of their properties. Through its miraculous remedies, it has offered Address for correspondence: Dr. Sanjay D. Late Post Graduate Scholar, Dept. of Kayachikitsa, Shri Shivayogeeshwar Rural Ayurvedic Medical College and Hospital, Inchal, Dist:Belgaum, Karnataka, INDIA. E-mail: sanjaylate 12@gmail.com Submission Date: 02/09/2019 Accepted Date: 13/10/2019 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.4.5.5 shelter to the ailing mankind, under its huge wings in the past as well as present. The present study is aimed at finding out an effective remedy for Amavata , which is a well known affecting masses. For this, we delved into the sea of Ayurveda and selected Rambana Rasa as Ama Pachak and Dosha Shamaka for treatment. Amavata is such a disease not deals with important in ancient classics. It is well described in 7 th century by Madhavnidan . Madhavkar being 1 st described Amavata as independent disease along with its etiology pathogenesis, sign, symptoms, prognoses and Chakradatta has 1 st described line of treatment with Ayurvedic herbs. Amavata is disease of Madhyam Rogamarga , as Ama and Vata which vitiates Tridosha . The disease affects Sandhimarma which leads to morbidities and which inturn many cause death. The clinical features of Amavata have been recognized in Ayurveda before centuries itself. The two oldest texts on Ayurvedic medicine, the Charak Samhita and Sushruta Samhita [3] A B S T R A C T Amavata is the most challenging disease for the medical science, as it causes severe intolerable pain and severe deformities making the patient disable and bed ridden. As it is the disease of Rasavaha Srotas and having several features similar to Rheumatoid Arthrtis, Amavata can be co-related with Rheumatoid Arthritis (RA). Ama and vitiated Vata play dominant role, though all Dosha take part in the causation of the disease, Amavata is the outcome of Agnidushti, Amotpatti and Sandhivikruti , with the passage of the time most of the dietary habits, changing lifestyle and environment have been contributing to the disease, the risk factor include age, gender, genetics and environmental exposure. Worldwide, the annual incidence of RA is approximately 1%, increasing with age and peaking between the age of 35 and 50 years. So, patients are continuously looking for the treatment from Ayurveda to overcome this challenge. Ramban Rasa is unique formulation which is favorable in the management of the Amavata , as mentioned by Yogratnakar, Bhaishajya Ratnawali, Bhav Prakash and other classical text Key words: Ramaban Rasa, Amavata, Rheumatoid Arthritis, Eranda Sneha.

Dr. Sanjay D. Late et al. Therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata. ISSN: 2456-3110 ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 19 often refer to symptoms such as joint pain and swelling like diagnostic features. Amavata is a disease of chronic joint and body pain, accompanied by a swelling of some or all of the synovial joints. These symptoms are typically accompanied by immobility, a loss of taste, thirst, indigestion, a lack of enthusiasm, a feeling of heaviness, and fever. If the condition is allowed to progress the pains may begin to migrate from place to place, with an deep stinging and burning sensation. There may be scanty, frequent urination, and sleep may become distributed. The digestion will continue to worsen, with bowel irritability and spasm, constipation, nausea and vomiting. There may be dizziness with profuse perspiration and extreme stiffness. After birth human beings goes through various stages of life. These stages are concerned with Bala of Sharira (e.g. Madhyam Vayavastha - Pravara Bala ) and prone to particular disease. Thus Agni is one of the most important factors which can afflict the healthy stage of human being. The second is hereditary factor which also have the capacity to afflict the healthy internal environment of human being. The disease rheumatoid arthritis can be presented as very similar to Amavata . The disease Rheumatoid arthritis is chronic in nature and affect mostly middle age group i.e. Madhyam Vayavastha . Rheumatoid arthritis is the most common persistent inflammatory arthritis, occurring throughout the world and in all ethnic group. The prevalence is highest in Indians. The clinical course is prolonged, with intermittent exacerbations and remissions. Rheumatoid arthritis occurs in 0.5-1.0% of the population; women affected three times more often than men; prevalence increases with age, onset most frequent in fourth and fifth decade. As Amavata is compared to Rheumatoid Arthritis we have underestimated the morbidity and mortality of rheumatoid arthritis. Our goal must be to intervene and focus on less toxic drug as early as possible in disease process. Ramaban Rasa is effective in Amavata as well as in Agnidushti and Eranda Sneha is used to treat vitiated doshas as it is a Vatahara . Hence present study of therapeutic effect of Ramban Rasa with Eranda Sneha and without Eranda Sneha in treatment of Amvata is being selected. M ATERIALS AND M ETHODS Study was carried out on the patients suffering from Amavata attending OPD and IPD of Shri Shivayogeeshwar Rural Ayurvedic Medical College and Hospital, Inchal, institute irrespective of sex, religion, occupation, etc Criteria for selection of patients Inclusion Criteria 1 Subject of age between 18-60 years. 2 Both the sexes i.e. Male or Female. 3 Subjects having Sandhi Shool, Sandhi Shoth, Sandhi Stabdhta, Sparsh Asahishnutwa (Pain on touchtenderness) and other associated Lakshanas of Amavata . Exclusion Criteria 1 Subject pre diagnosed with any history of Hypertension, malignancy, HIV, Diabetes Mellitus, Rheumatic Fever or any chronic systemic disease. 2 Pregnant women and lactating mothers. 3 Patients having history of Amavata for more than 3 year. Withdrawal from study 1 Discontinuation of treatment during trial. 2 Development of any complication. Evidence of any inter-current illness which may interrupt the efficacy of drug. 3 Evidence of any inter-current illness which may interrupt the efficacy of drug. Diagnostic Criteria The diagnosis was done on the basis of signs and symptoms as described in various Ayurvedic classics like Sandhi Shoola and Sandhi Shotha etc. Also criteria of American College of Rheumatology (ACR-EULAR 2010 Classification) of RA taken into consideration as follows;

Dr. Sanjay D. Late et al. Therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata. ISSN: 2456-3110 ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 20 Morning stiffness lasting for > 1 hour. Arthritis of 3 or more joint areas. Arthritis of hand joints. Symmetrical Arthritis. Presence of Rheumatoid factor (positive RA factor). Raised ESR. Criteria for assessment Clinical features of Amavata mentioned in Ayurvedic classics were considered for diagnosis and assessment. Subjective Parameter 1 Sandhi Shoola ( Vruschik Dandhavat Vedana / joint pain). 2 Sandhi Shoth (joint swelling). 3 Sandhi Stabdhata (joint stiffness). 4 Sandhi Sparshaasahatvam (joint tenderness). Objective Parameter: (ACR 2010) 1 Walking time 2 Foot pressure 3 Grip strength Investigative Parameter 1 RA factor 2 ESR Criteria for establishment of diagnosis of disease Data was collected from commencing the therapy also periodically as per the criteria described below. Table 1: Clinical assessment grade with scoring Subjective Grade with score Sandhi Shoola Severe : 3 Moderate : 2 Mild : 1 No Complaint : 0 Sandhi Shotha Severe : 3 Moderate : 2 Mild : 1 No Swelling : 0 Sandhi Stabdhata For > Two hr : 3 For 30 min to 2 Hr : 2 For 5 min to 30 min: 1 For 5 min : 0 Sandhi Sparshaasahatva m Resists to touch : 3 Winces and withdraw s the affected joints : 2 Wincing of face on pressur e : 1 No complaint s : 0 Objective Walking time (for 25 feet in number of second) >40 sec : 3 31-40 sec : 2 21-30 sec : 1 15-20 sec : 0 Foot pressure <10 kg : 3 15-10 kg : 2 20-16 kg : 1 25-21 kg : 0 Grip strength Under 70 mmHg : 3 119-70 mmHg : 2 199-120 mmHg : 1 200 mmHg or more : 0 Investigative parameter RA factor Positiv e : 1 Negative : 0 ESR (in 1 st hour ) >50 : 3 Between 36-50 mm/hr : 2 Betwee n 21-35 mm/hr : 1 Between 0-20 mm/hr : 0 Drug formulation Rambana Rasa was prepared in Rasashastra and Bhaishyajya Kalpana Dept. under guidance of teachers. Eranda Sneha was procured from standard pharmacy. Admistration of drug Group A (20 Patients ) : Ramban Rasa 125 mg BD with Eranda Sneha 10 ml BD for 21 days. Group B (20 Patients) : Ramban Rasa 125 mg BD without Eranda Sneha for 21 days. O BSERVATION AND R ESULTS As grading used assessment parameters were ordinal in nature, “Wilcoxon Signed Rank test” is used for intra-group comparison (i.e. before and after

Dr. Sanjay D. Late et al. Therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata. ISSN: 2456-3110 ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 21 treatment of a group) while for inter-group comparison, (i.e. for comparing two groups with each other) “Mann-Whitney U test” is used. We have tested hypothesis for each parameter and result is interpreted accordingly. The level of significance is kept at 0.05. Proper summary statistics like mean, median, S.D., IQR (Inter Quartile Range) are provided along with graphical and diagrams. Table 2: Comparison between Group A and Group B Parameters Group N Mean Rank Sum of Ranks Mann- Whitney U P- Value Sandhi Shoola Group A 20 27.53 550.50 59.500 0.000 Group B 20 13.48 269.50 Total 40 Sandhi Shotha Group A 20 22.40 448.00 162.000 0.241 Group B 20 18.60 372.00 Total 40 Sandhi Stabdhata Group A 20 23.60 472.00 138.000 0.059 Group B 20 17.40 348.00 Total 40 Sandhi Sparsha Asahatvam Group A 20 23.20 464.00 146.000 0.070 Group B 20 17.80 356.00 Total 40 ESR Group A 20 23.00 460.00 150.000 0.114 Group B 20 18.00 360.00 Total 40 Walking time Group A 20 21.55 431.00 179.000 0.480 Group B 20 19.45 389.00 Total 40 Foot pressure Group A 20 23.38 467.50 142.500 0.060 Group B 20 17.63 352.50 Total 40 Grip Strength Group A 20 23.65 473.00 137.000 0.058 Group B 20 17.35 347.00 Total 40 For comparison between Group A and Group B, we have used Mann Whitney U test. From above table we can observe that P-Values for almost parameters are greater than 0.05. Hence we conclude that there is no significant difference between Group A and Group B, but Group A have more significant result than Group B. Table 3: Overall assessment of therapy Variables Group A Group B Sandhi Shoola Significant Significant Sandhi Shotha Significant Significant Sandhi Stabdhata Significant Significant Sandhi Sparshasahatvam Significant Significant Walking time Significant Significant Grip strength significant Significant Foot pressure Significant Significant RA factor Insignificant Insignificant ESR Significant significant RA and ESR factors are mere investigations and not assessment parameters, they will not be considered while calculating overall improvement.

Dr. Sanjay D. Late et al. Therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata. ISSN: 2456-3110 ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 22 Table 4: Mean % improvement in both groups Parameter Mean % improvement Group A Group B Sandhi Shool 73.90% 37.00% Sandhi Shotha 76.30% 64.10% Sandhi Stabdhata 72.50% 51.20% Sandhi Sparshasahatvam 67.60% 46.30% Walking time 68.40% 56.10% Foot pressure 56.40% 34.10% Grip Strength 60.50% 35.70% Overall % of assessment 72.18% 46.35% Table 5: Distribution of patients according to relief Overall Effect (patient wise) No. of patients Group A Group B Count % Count % Excellent Improvement 01 5.00% 00 00.00% Good Improvement 19 95.00% 04 20.00% Moderate Improvement 00 00.00% 16 80.00% Mild Improvement 00 00.00% 00 00.00% Total 20 100.00% 20 100.00% In group A, 19 patients (95%) were observed with good improvement while 1 patient (5%) was seen with excellent improvement. In group B, 16 patients (80%) realized moderate improvement while 4 patients (20%) were observed with Good improvement. DISCUSSION Mode of action of drug Rambana Rasa as Amapachak, Agnidipak and Doshashamak for the treatment of Amavata . According to modern point of view, drug may acts as antioxidant, anti-inflammatory, analgesic, anti-arthritic, immune modulatory and radical scavenging activities. Eranda Sneha is Madhura, Katu, Kashaya Rasa, Ushna Virya, Madhura Vipaka and having Vata-Kapha- Shamaka property which is having specific Vyadhihara i.e. Amavatahara action. Acharya Charaka has given brief description of how Virechana Dravya acts in the body. In disease Amavata , Srotorodha is mainly present which is clear due to property of Srotovishodhana of Virechana drugs. It has direct affect on Agnisthana and thus also helpful in increasing Agni . Eranda Sneha helps in normalizing the Pratilomagati of Vata thus breaking Samprapti of disease Amavata and thereby relieving sign and symptoms of the disease. CONCLUSION At the end of the study, following conclusion can be drawn on the basis of observation made, results achieved and through Discussion in the present context as below; Amavata as a separate disease is not described in Brihatrayi , first time its detailed description is available in medieval period text Madhava Nidana. Amavata is Chronic disease in nature (Arthritis rank second as the most prevalent chronic ailment after heart disease) and has insidious onset. As the word suggests, in Amavata , the predominant entities in disease process are Ama and vitiated Vata . It is observed that Amavata and Rheumatoid arthritis, very closely resembles each other because of their symptomatology. Maximum patients selected in the present study were between the 35 to 60 years, Maximum patients of this series were males, and maximum number of patients was registered for the study was Kapha-Vata Pradhana Prakriti. Group A ( Rambana Rasa with Eranda Sneha ) provided better results in Sandhi Shoola, Sandhi Shotha, Sandhi Stabdhata, Sandhi Sparshaasahatvam as Ayurvedic parameter of Amavata as well as improvement in Walking time, foot pressure, grip strength. Group B ( Ramabana Rasa without Eranda Sneha ) provided good results in Sandhi Shoola, Sandhi Shotha, Sparsha Sahatva, Sandhi Stabdhata etc. On comparing the effect of two therapies it can be concluded that Group A ( Rambana Rasa with Eranda Sneha ) provided better results a most of the Lakshanas and objective criteria at a significant level. The data of the present series reveals that in Group A out of 20 patients, none of the

Dr. Sanjay D. Late et al. Therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata. ISSN: 2456-3110 ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 23 patients got complete remission, 01 patients (5%) excellent improved, 19 patients (95%) good improved. In Group B, out of 20 patients, none of the patients got complete remission, 04 patients (20%) good improved,16 patients (80%) were moderately improved. The improvement is statistically significant in all two groups, but comparatively group A has more significant relief. No side effects were observed in this study. To achieve more significant results we can increase dose of drugs and duration of treatment. There is no side effect of present dose of Ramban Rasa observed so; we can increase it for more significant results. Further evaluation of this drug is still required for assessing the Side effects and exact mode of action on Large Sample. It can be suggested that Rambana Rasa with Eranda Sneha could provide a better treatment modality in the disease Amavata REFERENCES 1 Ayurved Acharya Shri Sudharshan Shashtri, Ayurved Acharya Shrinsadunndnipadheya, volume-1, Madhav nidan, edition reprint-2003 chukhamba prakashan, Page no. 508. 2 Vd. Y.G Joshi (edition) 2003, Charak Samhita, Shri Chakradattapani Vicharit Ayurved Dipika Vikhya with yashavant Marathi commentary, vol no -2, vatavyadhi chikista adhaya, pune. vaidyamitra prakashan, page no- 617. 3 Dr. Anant Ram Sharma: Sushruta Samhita volume-1 edited with Susruta Vimarsini Hindi commentary along with special deliberation etc by foreword by Acharya Priyavrat Sharma. page no-455. 4 Kaviraj Dr Ambikadatta Shashtri, Sushrut Samhita, Chaukhamba Prakahsna, Part I, reprint 2014, Sutra Sthana chapter no.35, Page no-173. 5 Davidson, Principles and practice of medicine; 21 th edition, chapter no.25, Page no 1088. 6 Harisons Manual of Medicine ; 18 th edition, section 12, Page no.1072. 7 Achrya Vidyadhar Shukla and Pro. Ravidatta Tripathi, Charak Samhita, Chaukhamba Prakashan, 2010 reprinted, volume II , Chapter 12, Sholka No. 72, Page No – 279. 8 Achrya Vidyadhar Shukla and Pro. Ravidatta Tripathi , Charak Samhita, Chaukhamba Prakashan, 2010 reprinted, volume II , Chapter 16, Sholka No. 61/62, Page No -404. 9 Achrya Vidyadhar Shukla and Pro. Ravidatta Tripathi , Charak Samhita, Chaukhamba Prakashan, 2010 reprinted, volume II , Chapter 28, Sholka No. 195, Page No -716. 10 Storey , G.D.2001. Alfred Baring Gar rod (1819-1907). Rheumatology 40: 1189-1190. 11 Arnett FC, Ed worthy SM, Bloch DA, Mc Shane DJ, Fries JF, Cooper NS, et al. The American Association 1987 revised criteria for the classification of rheumatoid arthritis Rheum 1988,31:15-24. 12 Aletaha D, Neogi T, Silman A, Funovits J, Felson D, et al.2010 Rheumatoid arthritis Classification Criteria : An American College Of Rheumatology/European League. 13 Hench PS, Kendall EC, Slocumb CH, Polley HF,. The effect of hormone of the adrenal cortex (17- hydroxyl - 11- de hydro corticosteriod : Compound E ) and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin 1949;24 :181-97. 14 Achrya Vidyadhar Shukla and Pro. Ravidatta Tripathi ,Charak Samhita, Chaukhamba Prakashan, 2010 reprinted, volume II , Chapter 15, Sholka no.13-15, Page no-360-361. 15 Achrya Vidyadhar Shukla and Pro. Ravidatta Tripathi ,Charak Samhita, Chaukhamba Prakashan, 2010 reprinted, volume II ,Chapter 15,Sholka no.50-51, Page no.-369. 16 Achrya Vidyadhar Shukla and Pro. Ravidatta Tripathi, Charak Samhita, Chaukhamba Prakashan,2010 reprinted,volume II, Chapter 15,Sholka no. 3-4 , Page no.- 358. 17 Dr Bramhanand Tripathi, Ashtang Hrudayam, Chaukhamba Prakahshan, reprint 2014, Chapter 13,Sholka no.25, Page no.188. 18 Ayurved Acharya Shri Sudharshan Shashtri. Ayurved Acharya Shri Sadunndnipadheya ed, volume-1, Madhav Nidan, edition reprint-2003, Chaukhamba Prakashan, Page no-509. 19 Ayurved Acharya Shri Sudharshan Shashtri. Ayurved Acharya Shri Sadunndnipadheya ed, volume-1, Madhav

Dr. Sanjay D. Late et al. Therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata. ISSN: 2456-3110 ORIGINAL ARTICLE Sept-Oct 2019 Journal of Ayurveda and Integrated Medical Sciences | Sept - Oct 2019 | Vol. 4 | Issue 5 24 NIDAN, edition reprint-2003, Chaukhamba Prakashan, Page no-510. 20 Acharya Vidyadhar Shukla and Pro. Ravidatta Tripathi, Charak Samhita, Chaukhamba Prakashan, 2010 edition, volume II, Chapter 15, Sholka no.44, Page no.367. ******************************* How to cite this article: Dr. Sanjay D. Late, Dr. G. Vinay Mohan, Dr. M. B. Rudrapuri, Dr. G. S. Dharmannavar. A Compartive Clinical Study of therapeautic effect of Rambana Rasa with and without Eranda Sneha in Amavata w.s.r. Rheumatoid Arthritis. J Ayurveda Integr Med Sci 2019;5:18-24. http://dx.doi.org/10.21760/jaims.4.5.5 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2019 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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