An Ayurvedic approach for the management of Avascular Necrosis (AVN) - A Case...

[Full title: An Ayurvedic approach for the management of Avascular Necrosis (AVN) - A Case Study]

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[Find the meaning and references behind the names: Sharma, Gupta, Sanjay, Long]

CASE REPORT May 2023 Journal of Ayurveda and Integrated Medical Sciences | May 2023 | Vol. 8 | Issue 5 265 An Ayurvedic approach for the management of Avascular Necrosis (AVN) - A Case Study Sakshi Gupta 1 , Sanjay Srivastava 2 1 Post Graduate Scholar, Department of Rog Nidan Evum Vikriti Vigyan, Pt. Khushilal Sharma Government (Auto.) Ayurveda College & Institute, Bhopal, Madhya Pradesh, India. 2 Professor & HOD of Rog Nidan Evum Vikriti Vigyan, Pt. Khushilal Sharma Government (Auto.) Ayurveda College & Institute, Bhopal, Madhya Pradesh, India. I NTRODUCTION Avascular necrosis (AVN) is a condition that occurs due to disruption and loss of blood supply to the bone which leads to cellular death of bone tissue, also known as osteo, aseptic, or ischemic bone necrosis. Several factors like trauma, genetic factors, metabolic factors, use of glucocorticoids, diseases that promotes Address for correspondence: Dr. Sakshi Gupta Post Graduate Scholar, Department of Rog Nidan Evum Vikriti Vigyan, Pt. Khushilal Sharma Government (Auto.) Ayurveda College & Institute, Bhopal, Madhya Pradesh, India. E-mail: guptasakshi 21 dec 18@gmail.com Submission Date: 08/03/2023 Accepted Date: 15/04/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.5.46 hypercoagulable states are the etiological factors of AVN [1] Avascular Necrosis (AVN) is a chronic and degenerative disease affecting bone due to temporary or permanent cessation of the blood supply causing the bone structure collapse, resulting in bone destruction, pain, and loss of joint function. Initially, patients are asymptomatic, but with the passage of time, AVN leads to joint destruction, requiring surgical intervention and in latter stages, total hip replacement (THR) is required [2] It typically affects the epiphysis of long bones at weight-bearing joints. The upper arm, knee, and ankle joints are also affected in the case of AVN. Usually, men are more prone than women. Patient of AVN of femoral head is often having pain in hip or groin region radiating to buttocks, thigh or knees, exacerbated by heavy weight and sometimes often by coughing [3] Factors like pain in lower limbs, alcohol history, hidden diseases, disease of lower limbs etc. may lead to the misdiagnosis of the AVN [4] In early stages AVN is difficult to diagnose from clinical findings A B S T R A C T Background - Avascular Necrosis (AVN) is a disease affecting bone due to temporary or permanent cessation of the blood supply which finally leads to the destruction of the joints. AVN is asymptomatic in the early stage but as the disease progress there is constant pain with decrease in the function of joints. AVN of femoral head is the most common type of among all AVN. On the basis of Dosha and Dushya Avascular Necrosis resembles with the Asthimajjagata Vata . Raktavaha Srotas, Asthivaha Srotas and Majjavaha Srotas are hampered in Asthimajjagata Vata Case Report - This is the case of 56 year old female came to our hospital having complaints pain in B/L hip joints which radiates to both thigh region (Rt. > Lt.), morning stiffness more than 30 mintues, pain in groin region, difficulty in walking, sleep disturbed due to pain and indigestion Aim and Objective - To evaluate the efficacy of various Panchakarma procedure especially Manjisthadi Majja Basti . Result - The therapy provided marked relief in pain and stiffness along with improvement in gait and difficulty in walking was reduced Conclusion - AVN is a chronic degenerative disease which occurs when a blood flow to the bone is interrupted or reduced. On the basis of this case study, it can be concluded that Manjisthadi Majja Basti along with various Panchakarma procedure is effective in the management of AVN of femoral head. Key words: Avascular Necrosis, Asthimajjagata Vata, Manjisthadi Majja Basti

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[Find the meaning and references behind the names: Mala, April, Shakti]

Sakshi Gupta et al. An Ayurvedic approach for the management of Avascular Necrosis (AVN) ISSN: 2456-3110 CASE REPORT May 2023 Journal of Ayurveda and Integrated Medical Sciences | May 2023 | Vol. 8 | Issue 5 266 and plain radiograph so early MRI should be done to verify clinical suspicion [5] On the basis of clinical presentation, AVN can be correlated with Asthikshaya, Asthimajjagata Vata, and Asthibhagna , out of these Asthimajjagata Vata 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 (weakness) , Sandhishaithilyam (flaxity of joints) , Aswapna Satatruka (sleeplessness due to continuous pain) , Shiryantiva Cha Asthi-Dourbalyani (destruction of bony tissue causing generalized weakness) . [6] Asthimajjagata Vata can be cured if treated in acute stage but it becomes difficult for the complete recovery in chronic stages. The present day modern modalities includes administration of antiinflammatory analgesics, steroid therapy, arthroplasty, femoral head graft, hip compression, hip replacement, osteotomy, and physiotherapy; each of them is having its own limitations and they have serious side effects like loss of memory, weight gain, gastrointestinal disturbance, habit forming nature and dermatological diseases like psoriasis, eczema, contact dermatitis and SLE [7] Since all the surgical treatments are cost worthy and having poor prognosis on AVN an effort is made to evaluate the efficacy of Manjisthadi Majja Basti Karma in the management of the AVN of femoral head. C ASE R EPORT A 56-year-old female patient came to the OPD of Pt. Khushilal Sharma Govt. Ayurveda Institute, Bhopal having complaints pain in B/L hip joints which radiates to both thigh region (Rt. > Lt.), morning stiffness more than 30 minutes, pain in groin region, pain during prolonged sitting, difficulty in walking, restricted movement of both lower limb, sleeplessness due to pain and indigestion The patient was well before 10 months then gradually pain start in right hip joint with stiffness which radiates in lower limb then after 2 months her condition become worsened and felt pain in left hip joint too. The pain aggravates during prolonged sitting on the chair or any other activity. The pain was so severe so her gait has been changed. Moreover, her day-to-day activities were also hampered due to pain and stiffness. The patient had received allopathic treatment (analgesic and physiotherapy) for 5-6 months but did not get satisfactory relief. Thus, she approached further for Ayurvedic management. Table 1: History of Patient SN History Details of the patient 1. Past history Patient suffering from covid in April 2021 2. Family history No, any important family history 3. Personal history Diet - Pure Vegetarian Addiction - No Krur Kostha , taking Alpa Aahar, Avara Jaran Shakti , doing Yoga and exercise daily Sleeplessness Local Examination 1 Tenderness present in bilateral hip region and groin region (R > L) 2 Swelling (mild) - over bilateral hip joint. 3 Significant loss in the range of movement. 4 Gait - Trendelenburg sign positive. 5 Painful internal and external rotation. 6 Involuntary Movement - Absent Table 2: O/E Ashtavidha Pariksha Nadi Vata Kaphaj Mutra Prakrut Mala Kathina Jivha Saam Shabdha Spastha Sparsha Samasheetoshna Drik Prakrut Aakriti Madhyam

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

Sakshi Gupta et al. An Ayurvedic approach for the management of Avascular Necrosis (AVN) ISSN: 2456-3110 CASE REPORT May 2023 Journal of Ayurveda and Integrated Medical Sciences | May 2023 | Vol. 8 | Issue 5 267 Table 3: Samprapti Ghatak Dosha Vata - Kapha Dushya Rakta, Sira, Asthi, Majja, Sandhi Srotas Raktavaha, Asthivaha, Majjavaha Srotodushti Sang Rogamarg Marmaasthisandhi Adhishthan Asthi-Sandhi Udhabhavasthan Aam- Pakwashaya Vyakta Sthan Asthi-Sandhi Investigation Table 4: Blood investigation dated December 08, 2021 1. Hb% 11.6 g/dl 2. ESR 31 mm/hr 3. RBS 107 mg/dl 4. Blood Urea 26.6 mg/dl 5. Serum Creatinine 0.73 6. Serum Calcium 9.2 mg/dl 7. Vitamin D 29.9 ng/dl MRI - MRI scan (15/12/2021) revealed early stage of Grade III AVN on left side and Grade II AVN on right side of femoral head. Assessment Criteria The range of the movement of the hip joint i.e., Adduction, Abduction, Flexion, Extension, Internal rotation, External rotation was measured. [Table No. 8] Assessment was done on the basis of subjective parameters. [Table No.5] Assessment was done on the basis of subjective criteria, signs and symptoms. Pain and morning stiffness was markedly reduced after Karma Basti course. After completion of two rounds of Karma Basti patient was able to walk without any difficulty, leg raising from 30° to 60° and trendlenberg sign was improved. Table 5: Grading of subjective parameters SN Symptom Criteria Grade 1. Pain No pain while walking Mild Pain while walking Moderate Pain while walking Severe pain while walking 0 1 2 3 2. Stiffness No stiffness Stiffness for 10 - 30 min Stiffness for 30 - 60 min Stiffness for more than 1 hr 0 1 2 3 3. Movement of joints Normal Mildly restricted Moderately restricted Severely restricted 0 1 2 3 4. Radiating pain Pain never radiates Occasionally radiating Mostly radiating Radiating all the time 0 1 2 3 5. Gait Unchanged Occasionally changed Walk with support Unable to walk 0 1 2 3 6. Sleep Normal Occasionally disturbed Frequently disturbed Unable to sleep due to pain 0 1 2 3

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[Find the meaning and references behind the names: Ana, Adi, Madhu]

Sakshi Gupta et al. An Ayurvedic approach for the management of Avascular Necrosis (AVN) ISSN: 2456-3110 CASE REPORT May 2023 Journal of Ayurveda and Integrated Medical Sciences | May 2023 | Vol. 8 | Issue 5 268 Treatment Plan This diagnosed case of Avascular necrosis of the femoral head was admitted to the female general ward of Pt. K.L.S. Govt. Ayurveda Hospital, Bhopal with IPD no. 2022808 and undergo the following procedures. Table 6: Panchakarma Therapy S N Date Procedure Drugs used Quantity Days 1. 10/03/ 22 - 16/03/ 22 Udhwarta n Triphala Churna - 07 days 2. 10/03/ 22 - 16/03/ 22 Vashpa Sweda Dashmool Kwatha - 07 days along with Udavart ana 3. 17/03/ 22 - 26/03/ 22 Sarvang Patra Pinda Sweda Eranda Patra, Nirgundi Patra, Shigru Patra, Ark Patra, Lemon, Harida, Coconut etc. - Next 10 day 4. 17/03/ 22 - 26/03/ 22 Pishinchil Ksheerbal a Tail + Vatasham ak Tail - Next 10 days 5. 17/03/ 22 - 31/03/ 22 B/L Vankshan Basti Vatasham ak Tail - 15 days 6. 06/04/ 22 - 09/04/ 22 Sarvang Patra Pinda Sweda Same as above - 4 days 7. 10/04/ 22 - 13/04/ 22 Pishinchil Same as above 4 days 8. 15/03/ 22 - 13/04/ 22 Manjisth adi Majja Basti (Karma Basti) Anuvasan a basti Guggul Tikta Ghrit Majja Sehcharad i Tail Satpushpa Saindhav Niruha Basti Manjistha di Kwatha Majja Guggul Tikta Ghrit Madhu Satpushpa Saindhav 40 ml 40 ml 50 ml 20 gm 5 gm 150 ml 40 ml 40 ml 40 ml 20 gm 5 gm 30 days Anuvas an Basti - 18 Niruha Basti - 12 Table 7: Assessment before and after treatment Symptoms Before treatment After 16 days of t/t After 30 days of t/t Pain 3 2 1 Radiating pain 3 1 0 Stiffness 2 1 0 Movement of joints 2 1 1 Gait 2 1 1 Sleep 3 1 0 Trendelenberg Sign Positive Improved Improved Table 8: Observation in Range of Movement of Hip Joint Range of Movement Before Treatment After Treatment Abduction (30°-50°) Right Leg 20 40 Left Leg 30 50

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[Find the meaning and references behind the names: Main, Rasa, Sneha]

Sakshi Gupta et al. An Ayurvedic approach for the management of Avascular Necrosis (AVN) ISSN: 2456-3110 CASE REPORT May 2023 Journal of Ayurveda and Integrated Medical Sciences | May 2023 | Vol. 8 | Issue 5 269 Adduction (20°-50°) Right Leg 20 25 Left Leg 30 40 Flexion (110°- 120°) Right Leg 90 100 Left Leg 100 120 Extension (10°-15°) Right Leg 10 10 Left Leg 10 15 Internal rotation (30°- 40°) Right Leg 10 20 Left Leg 20 30 External Rotation (40°- 60°) Right Leg 20 20 Left Leg 40 50 DISCUSSION Avascular necrosis is cellular death of bone components due to interruption of blood supply causing collapse of the bone, resulting in pain, loss of joint function and finally damage of the joint [8] Avascular necrosis is usually of traumatic and non traumatic causes. Some non traumatic AVN are found to be associated with corticosteroid usage, alcoholism, infections, storage disorders, coagulation defects and some autoimmune disease [9] According to Ayurvedic point of view, there is no direct mention of avascular necrosis but on the basis of clinical presentation, there is predominance of Vata Dosha and Vikruti (vitiation) of Asthi Dhatu . In AVN of femoral head, the blood ( Rakta Dhatu ) supply to the femoral head is decreased due to Margavrodha (occlusion of blood vessels) or Abhighata (trauma), and ultimately leads to necrosis. Margavrodha and Abhighata both are also responsible to aggravation of Vata Dosha and increase in Vata Dosha finally resulting into loss of Asthi Dhatu . In advance stage, due to continuous imbalance of Vata Dosha (due to necrosis), it is further responsible for vitiation of Pitta and Kapha Dosha also. So, here Basti is a choice of treatment for AVN, in all Panchakarma procedures, because Basti is the first line of treatment for Vata Dosha [10] and is also beneficial in the imbalance of Pitta, Kapha and Rakta Dosha [11] Here the Avascular necrosis of femoral head on the basis of sign, symptoms, Dosha and Dushya is treated on the line of Asthimajjagata Vata Vikara . Snehan and Swedan is also considered as the line of treatment of Vata Vyadhi [12] Snehan either internal or external is indicated for the disorder of Asthimajjagata Vata [13] Swedan helps in reducing the heaviness and stiffness [14] Rakta, Asthi and Majja are the main involved Dhatus in AVN. In Asthimajjagata Vata patient Manjisthadi Majja Basti (processed with bone marrow) was planned as Manjishthadi Kwatha is Tikta, Katu Rasa Pradhana and Ushna Virya which is Tridoshahara and Raktaprasadaka and Majja helps strengthen Majja Dhatu which in turn nourishes Asthi Dhatu . The ingredients of these Basti include Tikta rasa , Katu Vipaka , Ushna Virya, etc. They all combinedly enhance the properties of Majja and helps in balancing the aggravated Vata Dosha and favours normal functioning of Dhatvagni facilitating increased nutrition to the Asthi Dhatu, also Tikta Rasa has Srotoshodhan properties which help to clear the Srotosanga . The Majja nourishes Asthi by means of its Purana (filling) and Snehan properties and pacifies vitiated Vata in Asthi . In this, Basti Guggultiktaka Ghrita was used as a Sneha and Tikta Dravyas are having Tikta Rasa, Ushana Virya and Madhura and Ka ṭ u Vipaka favour normal functioning of Dhatwagni (metabolic stage), facilitating increased nutrition to the Asthi Dhatu (bony tissue). Thus, it pacifies Vata ; improves the Dhatu Upachaya (metabolism of the tissues) and acts as a rejuvenator of the body and overall, this Basti helps in body metabolism CONCLUSION Manjisthadi Majja Basti (Karma Basti) along with Udhwartan, Vaspha Sweda, Sarvang Patra Pinda Sweda, Pishinchal shows remarkable symptomatic relief in the features of avascular necrosis of femoral head. This case indicates that when treatment is done in accordance with Ayurveda guidelines avascular necro sis can be effectively managed and patient’s quality of life can be enhanced. This result needs to be studied in more numbers of populations for better assessment.

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[Find the meaning and references behind the names: Shri, Singh, Stavros, Charles, Harish, Borrelli, Robert, Nil, Chang, Med, Chandra, Chen, Prakashan, Michael]

Sakshi Gupta et al. An Ayurvedic approach for the management of Avascular Necrosis (AVN) ISSN: 2456-3110 CASE REPORT May 2023 Journal of Ayurveda and Integrated Medical Sciences | May 2023 | Vol. 8 | Issue 5 270 REFERENCES 1 Robert S Weinstein, Erin A Hogan, Michael J Borrelli, Serguei Liachenko, Charles A O’Brien, Stavros C Manolagas; (2017) The Pathophysiological Sequence of Glucocorticoid-Induced Osteonecrosis of the Femoral Head in Male Mice, Endocrinology , Volume 158, Issue 11, Pages 3817 – 3831, [PubMed] 2 http:/ /emedicine.medscape.com/article/ 386808, updated: Aug 1, 2008. 3 Orban HB, Cristescu V, Dragusanu M. (2009) Avascular necrosis of the femoral head. MAEDICA-a Journal of Clinical Medicine. 1;4(1):26-34. 4 Chen ZW et al (2017), Study on the risk factors for the misdiagnosis of femoral head osteonecrosis. Zhongguo 5 Bohndorf K, Roth A. (2018) Imaging and classification of avascular femoral head necrosis. Orthopade. 47(9):729- 734 [Pubmed] 6 Acharya YT, editor, Shri Chakrapanidatta, commentator, Agnivesha, Charaka Samhita, Chikitsasthana; Vatavyadhichikitsa Adhyaya, 28/33, Chaukhamba Surbharti Prakashan, Varanasi, 2014; page 617. 7 Epstien NN, Tuffanelli DL, Epstein JH. Avascular Bone Necrosis: A Complication of Long Term Corticosteroid Therapy. Arch Dermatol . 1965; 92: 170 – 80 p. (PubMed) 8 Tofferi JK, Gilliland W (2008) Avascular Necrosis. Available via eMedicine. Accessed 18 Sep 2018. 9 Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. (2002) Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 32(2):94 – 124. [PubMed] 10 Bhahmanand Triphathi, editor. Astangharadyam . Sutra Sthana, Chapter 1, Verse no. 25 – 26. 2007 Edn. Delhi: Chaukambha Pratishthan; 2007; 20 p. 11 Kaviraaj Ambikadutta Shastri, editor. Susruta Samhita . Chikitsa Sathana, Chapter 35, Verse no. 6. 2012 Edn. Varanasi: Chaukambha Sanskrit Series Publication; 2012; 189 p. 12 Harish Chandra Singh Kushwaha, editor (2009) Charaka Samhita. 28 th Adhyaya 75-78 th shloka Chikitsasthana. 1 st ed. Varanasi: Chaukhambha Sanskri Sansthan; reprinted 2018. p. 745. 13 Harish Chandra Singh Kushwaha, editor (2009) Charaka Samhita. 28 th Adhyaya 93 rd shloka Chikitsasthana. 1 st ed. Varanasi: Chaukhambha Sanskri Sansthan; reprinted 2018. p. 749. 14 Harish Chandra Singh Kushwaha, editor. (2009) Charaka Samhita. 28 th Adhyaya 80 th shloka Chikitsasthana. 1 st ed. Varanasi: Chaukhambha Sanskri Sansthan; reprinted 2018. p. 746 ******************************* How to cite this article: Sakshi Gupta, Sanjay Srivastava. An Ayurvedic approach for the management of Avascular Necrosis (AVN) - A Case Study. J Ayurveda Integr Med Sci 2023;05:265-270. http://dx.doi.org/10.21760/jaims.8.5.46 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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