Efficacy of Ayurvedic treatment in the management of Avascular Necrosis - A...

[Full title: Efficacy of Ayurvedic treatment in the management of Avascular Necrosis - A Case Study]

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CASE REPORT January 2023 Journal of Ayurveda and Integrated Medical Sciences | January 2023 | Vol. 8 | Issue 1 189 Efficacy of Ayurvedic treatment in the management of Avascular Necrosis - A Case Study Pramod Bana 1 , Aayushi Mogra 2 , Shraddha Sharma 3 , Aruna Ojha 4 , Manoj Kumar Sharma 5 1,2 Post Graduate Scholar, 3 Assistant Professor, Department of Kayachikitsa, Pt. Khushilal Sharma Govt. Auto. Ayurveda College and Institute, Bhopal, Madhya Pradesh, India. 4 Professor and HOD, PG Dept. of Kayachikitsa, Govt. Ayurveda College, Raipur, Chhattisgarh, India. 5 Senior Resident, Medicine Department, LNCT Medical College, Bhopal, Madhya Pradesh, India. I NTRODUCTION Avascular necrosis (AVN) is a condition in which a circumscribed area of bone becomes necrotic as a consequence of loss of its blood supply [1] It typically affects the epiphysis of long bones at weight-bearing joints. In severe cases the destruction of the subchondral bone or the collapse of the entire joint can occur [2] AVN usually involves the epiphysis (end part of Address for correspondence: Dr. Pramod Bana Post Graduate Scholar, Department of Kayachikitsa, Pt. Khushilal Sharma Govt. Auto. Ayurveda College and Institute, Bhopal, Madhya Pradesh, India. E-mail: pramodbana 1051@gmail.com Submission Date: 16/11/2022 Accepted Date: 23/12/2022 Access this article online Quick Response Code Website: www.jaims.in Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA a long bone), such as the femoral and humeral heads and the femoral condyles, but small bones can also be affected. In clinical practice, AVN is most commonly encountered in the hip [3,4] In Ayurveda , there is no direct description of AVN in classical texts. Here in AVN, it seems that the predominant Dosha and Dushya are Vata (air humor) & Asthi (bones) respectively, in the chronic stage there is Tridosha involvement occurs. Clinical presentation of AVN can closely resemble with Asthikshaya, Asthimajjagata Vata and Asthibhagna , out of these Asthimajjagatvata is more similar to AVN by its pathogenesis and symptoms. The sign and symptoms of Asthimajjagata Vata are Bhedoasthiparvanam ( breaking type of pain in bones), Sandhishoola (Joint pain), Mamsakshaya (muscular wasting), Balakshaya Sandhishaithilyam (flaxity (weakness), of joints), Aswapna Satatruka (sleeplessness due to continuous pain), Shiryantiva Cha Asthi-Dourbalyani (destruction of bony tissue causing generalized weakness) [5] The modern modalities of AVN are not satisfactory and also having adverse effect A B S T R A C T Avascular necrosis (AVN) of the femoral head is a rare skeletal disease that typically manifests as hip joint or lower pelvic pain. Avascular necrosis of the femoral head is a condition in which there is limited collateral circulation and the blood supply to the head of the femur is disrupted, resulting in ischemic and subsequent necrosis. In India about 16000 peoples develops AVN of femoral head every year. In modern medicine treatment of AVN includes NSAID, bone grafting and replacement of hip joints. There is no specific conservative medicine in modern medical science for AVN yet. In Ayurveda all musculoskeletal diseases are considered under Vatavyadhi. Symptoms of AVN are similar to Lakshana of Asthimajjagata Vata described by Charak . The present case report is subjected to assess the efficacy of Ayurvedic protocol in the management of femoral head of AVN. A 35 years old male patient presented with Pain and stiffness at the left hip joint. Limited range of motion of the effected joint for 2 years. After reviewing all investigations including MRI, this case was diagnosed as left sided grade AVN of the femoral head. The patient was administrated with Panchatiktaksheer Basti (200 ml) for 8 days then Dashmoolasiddha Majja Basti (100 ml) for 21 days. The follow-up was done for 1 month. After therapeutic intervention significant improvements were noticed such as reduction in VAS scale and improvement in movements of hip joints. The present case study documents that Shaman Aushadh along with Basti therapy can be effective in AVN and improve the quality of life of patient. Key words: Asthimajjagat Vata, Avascular Necrosis, Dashmoolasiddha Majja Basti.

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Pramod Bana et al. Efficacy of Ayurvedic treatment in the management of Avascular Necrosis ISSN: 2456-3110 CASE REPORT January 2023 Journal of Ayurveda and Integrated Medical Sciences | January 2023 | Vol. 8 | Issue 1 190 in long term use. Therefore, this case report documents the better Ayurvedic protocol for AVN. A IM AND O BJECTIVES 1 To find out an effective Ayurvedic protocol for AVN. 2 To assess the efficacy of Panchtiktakshira Basti and Dashmoola Majja Basti in the management of AVN M ATERIALS AND M ETHODS Selection and source of patient For this study, the patient was registered from the IPD of Pt. Khushilal Sharma Govt. Ayurveda Hospital, Bhopal. Plan of study The patient was treated with Shamana Aushadhi along with Panchakarma therapy. C ASE S TUDY For this clinical study the patient was admitted to Pt. Khushilal Govt Ayurvedic Hospital and Institute Bhopal, IPD no. 32628 of age 35 yr/male with complaints of pain in left hip joint with severe stiffness, could not raise left leg and lower backache. Diagnosed as AVN (grade-2) of femoral head on the basis of sign and symptoms and investigations. History of Past Illness Medical history - Patient had skin infection and COVID, taking steroids for longer duration Surgical history - NAD Personal History ▪ Diet - Mixed diet, prefers spicy. ▪ Appetite - Normal ▪ Bowel - Clear ▪ Bladder - Normal ▪ Sleep - Disturbed due to pain. ▪ Allergy and addiction - Nil. Examination Ashtavidha Pariksha ▪ Nadi (Pulse) - Vata - Kapha , 80/ min. ▪ Mootram (Urine) - Normal ▪ Malam (Stool) - Normal ▪ Jivha (Tongue) - Normal ▪ Shabdam (Voice) - Normal ▪ Sparsham (Touch) - Normal. ▪ Drika (Eyes) - Normal ▪ Aakriti (Built) - Moderately, no deformities Investigation ▪ Serum Uric Acid - 5.2 mg/dl ▪ MRI of Left Hip Left sided grade 2 AVN and Minimal left hip joint effusion.

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Pramod Bana et al. Efficacy of Ayurvedic treatment in the management of Avascular Necrosis ISSN: 2456-3110 CASE REPORT January 2023 Journal of Ayurveda and Integrated Medical Sciences | January 2023 | Vol. 8 | Issue 1 191 Treatment Plan S N Treatme nt Drug Used Dose Duratio n Anupan a 1. Basti Basti Panchtiktaksh eer Basti Dashmooladi Siddha Majja Basti 200 m l 100 m l 8 days 21 days - - 2. Shamana Aushadhi Ekangveer Ras 200 mg , Sameerpanna g Ras 250 mg, Godanti 100 mg BD 30 days Luke warm water Maharasandi Kwath 20 ml BD 30 days - Kukkutand Twak Bhasm 250 mg 250 m g BD 30 days - Chingati Satva 500 mg BD 30 days - Salai Guggul 400 mg BD 30 days Luke warm water Panchtikt Ksheer Basti Plan Day Basti Dose Time of Basti Adanakala Time of Basti Pratyagamana kala 1. K 200 ml 10:15 am 2:00 pm 2. K 200 ml 11:15 am 4:00 pm 3. K 200 ml 10:40 am 2:50 am 4. K 200 ml 10:30 am 4:10 pm 5. K 200 ml 10:15 am 4:15 am 6. K 200 ml 11:00 am 4:45 pm 7. K 200 ml 10:45 am 4:30 am 8. K 200 ml 11:15 am 3:00 pm Dashmoolasiddha Majja Basti Plan Day Basti Dose Time of Basti Adanakala Time of Basti Pratyagamana Kala 1. M 100 ml 1:00 pm 7:00 pm 2. M 100 ml 11:30 am 9:00 pm 3. M 100 ml 11:20 am 9:30 pm 4. M 100 ml 11:30 am 10:00 pm 5. M 100 ml 11:30 am 9:00 pm 6. M 100 ml 11:30 am 9:30 pm 7. M 100 ml 11:45 am 8:15 pm 8. M 100 ml 11:00 am 10:00 pm 9. M 100 ml 11:30 am 8:00 am 10. M 100 ml 11:45 am 7:45 pm 11. M 100 ml 12:30 pm 8:00 am 12. M 100 ml 11:30 am 4:15 pm 13. M 100 ml 11:30 am 7:00 am 14. M 100 ml 12:15 am 11:00 pm 15. M 100 ml 12:30 am 10:15 pm 16. M 100 ml 11:30 am 4:00 am 17. M 100 ml 11:30 am 7:00 am 18. M 100 ml 11:45 am 7:00 am 19. M 100 ml 12:00 pm 7:00 am 20. M 100 ml 11:30 am 7:00 am 21. M 100 ml 11:45 am 7:00 am O BSERVATIONS AND R ESULTS VAS score was used to assess pain in left lower limb which explained in table and it showed significant reduction in pain scale.

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Pramod Bana et al. Efficacy of Ayurvedic treatment in the management of Avascular Necrosis ISSN: 2456-3110 CASE REPORT January 2023 Journal of Ayurveda and Integrated Medical Sciences | January 2023 | Vol. 8 | Issue 1 192 Improvement in flexion, extension, abduction, adduction, medial and lateral rotation of hip joint are also shown in table. Pain VAS Score [6] Parameter Criteria BT AT Rt Leg Lt Leg Rt Leg Lt Leg Pain (VAS Scale) (0) No pain 0 7 0 2 (1-3) Mild pain (4-6) Moderate Pain (7-10) Severe Pain Showing pre and post treatment changes in movement of hip joints SN Hip Joint Movements BT AT Normal Range Rt. Lt. Rt. Lt. 1. Flexion of Hip Joint 115 ° 70 ° 115 ° 100 ° 110 ° - 120 ° 2. Extension of Hip Joint 10 ° 5 ° 10 ° 10 ° 10 ° - 15 ° 3. Abduction of Hip Joint 30 ° 20 ° 30 ° 30 ° 30 ° - 50 ° 4. Adduction of Hip Joint 25 ° 10 ° 20 ° 25 ° 20 ° - 30 ° 5. Medial Rotation 35 ° 15 ° 35 ° 35 ° 30 ° - 40 ° 6. Lateral Rotation 45 ° 20 ° 45 ° 40 ° 40 ° - 60 ° After giving Ayurvedic treatment patient get 72% relief in left hip joint pain and stiffness during walking. No pain during resting condition. Can raise left leg up to 30 degrees. DISCUSSION Vatavyadhi occurs due to the vitiated Vata Dosha . Asthimajjagata Vata is also occurring due to vitiated Vata. AVN is closely resembles to Asthimajjagata Vata . The clinical feature are Bhedoasthiparvanam (breaking type of pain in bones), Sandhishoola (Joint pain), Mamsakshaya (muscular wasting), Balakshaya Sandhishaithilyam [flaxity (weakness), of joints], Aswapna Satatruka (sleeplessness due to continuous pain) which correlates the symptoms of AVN. The patient of AVN of femur head was treated with Shamana and Shodhana process. In Shaman process we had given Sameer Pannag Rasa, Ekangveer Rasa, Godanti Bhasma, Salai Guggul, Chingati Satva, Kukkutandatvak Bhasma as Shaman drugs for 30 days In Shodhana therapy, we had given Basti Karma . Vata acts as prime Dosha among Tridosha as well as play important role in Samprapti. Basti is described as best for Vatashamana, hence Basti was planned accordingly. Panchtikta Kshira Basti was given for 8 days. Assessment was done after Basti. The therapies yielded complete symptomatic relief from pain, tenderness, general debility and improvement in the gait. Maha Rasnadi Kwath - It is helpful in managing and relieving joint muscle pain, inflammation and stiffness. Sameer Pannag - Improves tissue oxidation overcomes normalizes neuromuscular metabolism. Ekangveer Rasa - Promotes healing of damaged nerves & blood vessels, activate sensory and motor functions. Salai Guggul - In Shaman drugs, Boswellia serrata is also known as Indian oil banum, Salai guggul and Sallaki . It has following actions; 1 Anti-inflammatory and analgesic - Boswellic acid in Salai Guggul helps to reduce joints pain and inflammation by blocking 5-lipo oxygenase enzyme that produces leukotrienes an enzyme responsible for inflammation.

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Pramod Bana et al. Efficacy of Ayurvedic treatment in the management of Avascular Necrosis ISSN: 2456-3110 CASE REPORT January 2023 Journal of Ayurveda and Integrated Medical Sciences | January 2023 | Vol. 8 | Issue 1 193 2 Chondro protective - Salai guggul prevents TNF alpha induced expression of matrix metallo proteinases, enhances chondrocyte proliferation and increases glycosaminoglycans levels and protect joint cartilage. 3 Immunomodulator - It controls chronic inflammation and tissue damage by modulatory immune response and inhibiting pro inflammatory cytokines like interleukin-1 beta, tumor necrosis factor Chingati Satva - It is the naturally occurring amino glycoside(glucosamine) in the human body. Kukkutandatvak Bhasma - It is rich in calcium and help in dealing with joint and bone related issues. In S hodhna therapy, Basti Karma was given for 30 days. Panchtikta Kshira Basti was given for 8 days and then Dashmooladi Siddha Majja Basti was given for 21 days. Research studies on Kshira Basti proved to be efficacious in Asthi Kshaya (osteoporosis) conditions. The Kalka Dravyas possess Madhura (sweet), Tikta (bitter), and Kasaya (astringent). The Ushna quality allows the herb to penetrate into the cellular level of the tissues and helps in blood purification and cleansing of the lymphatic system. The Kashaya Rasa is Sandhanakara (improves the compactness) in nature. Ksheera has been mentioned by the Acharyas as Asthi Sandhanakara . Asthi Dhatu is affected in AVN. Drugs of Basti are having Snigdha, Guru and Ushna Virya , which work as Vatashamak drugs. Ksheera Basti is a sort of Niruha Basti containing Ksheera as Dravya (liquid). Madhura and Snigdha are the properties of Ksheera which help to control Vata Dosha and causes Brihmana of Rasadi Dhatu . CONCLUSION We can conclude that in case of AVN ( Asthimajjagata Vata ) the effect of Ayurvedic drugs along with Panchakarma therapy shows drastic improvement and improves the quality of life of the individual, so we recommended Ayurvedic treatment for this disease. REFERENCES 1 sBailey & Loves, Short Practice of Surgery, 25 th Ed., Part 5, Chapter 35, p. 515. 2022 Jan. 2 Lespasio MJ, Sodhi N, Mont MA. Osteonecrosis of the Hip: A Primer. Perm J. 2019;23 [PMC free article] [PubMed] [Ref list] 3 Matthews AH, Davis DD, Fish MJ, Stitson D. Avascular Necrosis. 2022 Jan. [Medline]. [Full Text]. 4 Bose VC, Baruah BD. Resurfacing arthroplasty of the hip for avascular necrosis of the femoral head: a minimum follow-up of four years. J Bone Joint Surg Br. 2010 Jul. 92(7):922-8. [Medline] 5 Acharya YT, editor, Shri Chakrapanidatta, commentator, Agnivesha, Charaka Samhita, Chikitsasthana; Vatavyadhichikitsa Adhyaya, 28/33, Chaukhamba Surbharti Prakashan, Varanasi, 2014; page 617. 6 H Raalston Stuart, D Penmenlan, Strachan Mark WJ and P Hobson Richard, Davidson’s principle of medicine, 23 rd edition 2018, ch.34, page 1343. ******************************* How to cite this article: Pramod Bana, Aayushi Mogra, Shraddha Sharma, Aruna Ojha, Manoj Kumar Sharma. Efficacy of Ayurvedic treatment in the management of Avascular Necrosis - A Case Study. J Ayurveda Integr Med Sci 2023;01:189-193. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2023 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 (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Vatavyadhi, Pain, Bastikarman, Ayurvedic treatment, Patient, Symptomatic relief, Clinical study, Shodhana Therapy, Case report, Basti therapy, Case study, Avascular necrosis, Asthimajjagata vata, Ayurvedic protocol, Joint pain, VAS Score, Femoral Head, Shamana Aushadhi, Ayurvedic Drug, Vas scale, Muscle wasting, Hip joint, Sodhana therapy, Avascular Necrosis (AVN), Bone grafting, Long Bone, Shaman Aushadh.