The management of Asthimajjagata Vata w.s.r. to Avascular Necrosis of Femoral...

[Full title: The management of Asthimajjagata Vata w.s.r. to Avascular Necrosis of Femoral Head with Ayurveda recipes - A Case Study]

CASE REPORT May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 238 The management of Asthimajjagata Vata w.s.r. to Avascular Necrosis of Femoral Head with Ayurveda recipes - A Case Study Chhaya Thakur 1 , Sanjay Srivastava 2 1 Post Graduate Scholar, Dept. of Rog Nidan &Vikriti Vigyan, Pt. Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India. 2 Professor and HOD, Dept. of Rog Nidan &Vikriti Vigyan, Pt. Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India. I NTRODUCTION Avascular necrosis (osteonecrosis) is a progressive disorder where the cellular death of bone component due to interruption of the blood supplies to the bone in transiently or permanently [1] Avascular necrosis (AVN) is also called Osteochondritis Dissecans / Chandler’s Disease in young adults with 60% of the Address for correspondence: Dr. Chhaya Thakur Post Graduate Scholar, Dept. of Rog Nidan &Vikriti Vigyan, Pt. Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India. E-mail: thakurchhaya 1113@gmail.com Submission Date: 17/03/2024 Accepted Date: 26/04/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.5.40 cases being bilateral [2] While it can affect any bone, AVN is particularly common in the hip joint. It generally affects people between age of 30 to 50 years. Several factors like trauma, genetic factors, metabolic factors, use of glucocorticoids, diseases that promotes hypercoagulable states are the etiological factors of AVN [3] Initially, patients are asymptomatic, but with the passage of time, AVN leads to joint destruction, requiring surgical intervention in latter stages, total hip replacement (THR) is required [4] 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 [5] As per the clinical features, this condition can be correlated with Asthi - Majjagata Vata in Ayurveda. The sign and symptoms of Asthimajjagata Vata are Bhedoasthiparvanam A B S T R A C T In musculoskeletal clinics, one of the conditions that is more frequently observed, is Avascular necrosis (AVN) of the head of the femur. Basically, it is an osteonecrosis caused by a wound or any obstruction in the arteries supplying blood to the bone tissue. The most frequent type of necrosis is AVN of the femur head because the artery supplying that region is very thin and readily injured by simple dislocation or a sub capital fracture, which causes a lack of food to the tissue and necrosis. Usually, men are more prone to Avascular necrosis than women. There is no specific treatment available in modern medicine other than surgery. Additionally, the prognosis is not good and the cost is high. Present case was aimed to evaluate the efficacy of Ayurvedic procedures in the conservative management of AVN of the femoral head. In this present case a 27 Years old male was diagnosed with AVN of bilateral hip joint was presented with bilateral groin pain associated with limitation of movements of hip joint and pain in back, with difficulty in walking He was given Manjishthadi Majja Basti along with other Panchakarma therapies and oral medicines. After the treatment, the pain decreased, range of movement of both hip joints improved. This case shows that Ayurveda treatment is helpful in the management of Avascular necrosis and helps in improving quality of life. Key words: Ashthi Majja Gata Vata, Panchkarma, Avascular Necrosis.

Chhaya Thakur et al. Management of Asthimajjagata Vata with Ayurveda recipes ISSN: 2456-3110 CASE REPORT May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 239 (breaking type of pain in bones), Sandhishoola (Joint Pain), Mamsakshaya (Muscular Wasting), Balakshaya (weakness), Sandhishaithilyam (flexity of joints), Aswapna Satatruka (sleeplessness due to continuous pain), Shiryantiva Cha Asthi-Dourbalyani (destruction of bony tissue causing generalized weakness) [6] C ASE R EPORT A 27 years old male patient came to the OPD of Pt. Khushilal Sharma Government 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 B\L groin region, pain during prolonged sitting, difficulty in walking, restricted movement of both lower limb, sleeplessness due to pain. The patient was well before 11 months then gradually pain start in right hip joint with stiffness which radiates in lower limb then after 3 months his 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 his gait has been changed. Moreover, his day-to-day activities were also hampered due to pain and stiffness. The patient had received allopathic treatment for 5-6 months but did not get satisfactory relief. Thus, he approached further for Ayurvedic management. Local Examination 1 Tenderness present in bilateral hip region (R>L) 2 Significant loss in the range of movement. 3 Gait-Trendelenburg sign positive. 4 Painful internal and external rotation. Ashtavidha Pariksha Nadi Vata - Pittaja Mutra Prakrut Mala Snigdha Jivha Saam Shabdha Spastha Sparsha Samasheetoshna Drik Prakrut Aakriti Madhyam Samprapti Ghatak Dosha Vata - Kapha Dushya Asthi, Majja, Sandhi, Rakta, Sira, Snayu Srotas Asthivaha, Majjavaha ,Medovaha Srotodushti Sang Rogamarg Marmaasthisandhi Adhishthan Asthi - Sandhi Udhabhavasthan Aam - Pakwashaya Vyakta-Sthan Asthi - Sandhi Aaturbala Pramana Pariksha Prakruti Vata - Pittaja Sara Raktasara Samhanana Madhyama Pramana Weight - 71 kg, Height - 180 cm Satmya Madhyama Satva Madhyama Aharashakti Madhyama Vyayamashakti Avara Vaya Yuvavastha Desha Sadharana Personal History ▪ Diet - Vegetarian ▪ Appetite - Normal ▪ Bowel - Clear ▪ Bladder - Normal

Chhaya Thakur et al. Management of Asthimajjagata Vata with Ayurveda recipes ISSN: 2456-3110 CASE REPORT May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 240 ▪ Sleep - Disturbed ▪ Addiction - Not any ▪ Occupation - Medical Representative Past illness - No history of any major illness Family History - Not Significant related to present illness Surgical History - Not Significant Vital Examinations ▪ Pulse Rate - 74/minute, Regular ▪ Blood Pressure - 120/80 mmHg ▪ Temperature - 98.7°F ▪ Respiratory Rate - 19/minute Investigation Blood investigation dated April 04, 2023 1 Hb% - 14.1 g/dl 2 Sickling test - Negative Radiological Report MRI - MRI scan (08/04/2023) revealed Grade II AVN on right side and Grade III AVN on left side of femoral head X-ray B\L Knee Joint (03/04/2023) Treatment administered This diagnosed case of Avascular necrosis of the femoral head was admitted to the male private ward of Pt. Khushilal Sharma Government Ayurveda Institute, Bhopal with IPD no. 20231953 and undergo the following procedures. Table 4: Oral Ayurveda medicines were administered in the patient. Drugs Dose Time Duration Kaishora Guggulu 1 BD After meal 8 weeks Singhnad Guggulu 1 BD After meal 8 weeks Punarnavadi Guggulu 1 BD After meal 8 weeks Vatvindhwansak Rasa 1 BD After meal 8 weeks Mahamanjishthadi Kwath 30 ml BD After meal 8 weeks Manjishthadighan Vati 2 BD After meal 4 weeks Cap. Gandh Tailam 1 BD After meal 8 weeks Cap. Ashwagandha 1 BD After meal 4 weeks Cap. Nucart OA 2 BD After meal 4 weeks Cap. Boniheal 1 BD After meal 8 weeks

Chhaya Thakur et al. Management of Asthimajjagata Vata with Ayurveda recipes ISSN: 2456-3110 CASE REPORT May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 241 Table 5: Panchakarma Therapy SN Procedure Drug used Quantity Days 1 Udavartana Triphala Choorna + Kottamchukkadi Choorna 7 days 2 Vashpa Swedan Dashamoola Kwath 07 days along with Udavartana 3 B/L Vankshan Basti Chandanbalakshadi Tail Next 15 days 4 Sarvang Patra Pinda Swedan Eranda Patra, Nirgundi Patra, Shigru Patra, Ark Patra, Lemon, Harida, Coconut etc. 15 days along with Vankshan Basti 5 Pishinchil Chandanbalakshadi Tail + Balashwagandha Tail Next 8 days 6 Manjisthadi Majja Basti (Karma Basti) Anuvasana basti Chandanbalakshadi Tail Majja Saindhav Niruha Basti Manjishthadi Kwath Majja Madhu Saindhav Saunf Ajwain 60 ml 40 ml 5 gm 300 ml 40 ml 50 ml 5 gm 20 gm 20 gm 30 days Anuvasan Basti - 18 Niruha Basti - 12 Table 6: Steinberg’s classification of avascular necrosis of the femoral head [7] Stage Description 0 No symptoms, Normal or non-diagnostic X-ray, bone scan and MRI 1 Mild pain in the affected hip, pain with internal rotation, Normal x-ray, Abnormal bone scan or MRI 2 Worsening or persistent pain, increased sclerosis or cysts in the femoral head 3 Subchondral collapse, produce crescent sign 4 Flattening of femoral head, normal acetabulum, normal joint space Table 7: Assessment criteria on the Basis of Gradation System Criteria Grading Pain in hip and groin region 0 – No pain 1 – Occasional pain and can be ignored 2 – Interfere with task 3 – Interfere with basic needs 4 – Bed rest require Stiffness of hip joint 0 – No stiffness 1 – Occasional stiffness present 2 – Stiffness retains for 30 minutes 3 – Stiffness after sitting and walking for long time 4 – Stiffness whole day or whole night Restricted range of movement of hip joint 0 – No restriction (flexion of 130°) 1 – Restricted initially (flexion of 90°-130°) 2 – Partially restricted (flexion of 70°- 90°) 3 – Restricted with pain (flexion 45°- 70°) 4 – No joint movement (flexion 0°- 45°) Gait (limping gait) 0 – Normal without pain 1 – Occasional pain during walking 2 – Walk with support with mild pain

Chhaya Thakur et al. Management of Asthimajjagata Vata with Ayurveda recipes ISSN: 2456-3110 CASE REPORT May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 242 3 – Walk with support with severe pain 4 – Unable to walk Distance walked by patient within 10 minutes 0 – 90 feet 1 – 60 feet 2 – 30 feet 3 – < 30 feet Table 8: Assessment before and after treatment SN Assessment criteria Before treatment After 30 days of treatment 1 Pain in hip and groin region 3 1 2 Stiffness of hip joint 3 0 3 Restricted range of movement of hip joint 1 0 4 Gait (Limping Gait) 2 1 5 Distance walked by patient within 10 minutes 3 0 6 Steinberg’s classification 1 1 Table 9: Observation in Range of Movement of Hip Joint Range of Movement Before Treatment After Treatment Abduction (30° – 50°) Right Leg 25 40 Left Leg 30 50 Adduction (20° – 50°) Right Leg 25 30 Left Leg 30 40 Flexion (110° – 120°) Right Leg 90 110 Left Leg 100 120 Extension Right Leg 10 10 (10° – 15°) Left Leg 10 15 Internal rotation (30° – 40°) Right Leg 10 15 Left Leg 20 30 External Rotation (40° – 60°) Right Leg 20 40 Left Leg 30 50 DISCUSSION Udavartana This was done using Triphala Choorna and Kottamchukkadi Choornam , Triphala Choorna includes Haritaki, Vibhitaki and Amalaki having Ruksha and Tridoshahara, Kapha Medahara Guna which helps in removing Avarana . Kottamchukkadi Choornam contains equal quantities of Pushkaramoola , Vacha , Viswa , Suradruma , Lasuna , Sigru , Rasna , Sarshapa Chinchapatra etc. Its Roga Karma - Vataroganashaka, Dosha Karma - Vatakaphahara and Shophahara Guna . Vashpa Swedana Swedana drugs are having Ushna and Tikshna Guna which are capable of relieving Stambhana, Gaurava. This was done using Dashmoola Kwatha having Tridoshara (alleviating all deranged Doshas ), Vedanasthapana (pain killer) and Shothahara (subside inflammation) properties. It also helps in removing Avarodh which helps in the proper blood circulation. Vankshan Basti In Vankshan Basti, warmth pressure of the oil allows deeper absorption into the muscles, tendons and ligaments, relaxing spasms and reducing pain and stiffness of Vankshan . This was done using Chandanbalalakshadi Tail which contains Til Tail, Sveta Chandana, Bala Mul, Pipalalakh, Lajjalu, Jal, Godugdha, Sveta chandana, Ushir, Yasthimadhu, Satpushpa, Katuki, Devadar, Haridra and Kuth etc. Chandana , has Pitta Shamaka ( pitta pacifying) properties. It also help to reduce skin irritations, itching, burning sensations and inflammation. Bala , which balances all the 3 Doshas , especially Vata . Additionally, it helps relieve the symptoms of pain,

Chhaya Thakur et al. Management of Asthimajjagata Vata with Ayurveda recipes ISSN: 2456-3110 CASE REPORT May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 243 emaciation etc. Nagakesar , which contains antiinflammatory, analgesic and antispasmodic activity. Patra Pinda Swedan It relieves stiffness, pain, and swelling improves the range of movements associated with painful conditions of joints, improves blood circulation in the body and soothes nerves, and provides relief from pain [8] Pishichil It is the Brihana type of Snigdha Swedana where Snehana and Swedana occur concurrently Chandanbalakshadi Tail and Balashwagandha Tail were used in the procedure. Balashwagandha Tail balances Vata and Pitta , strengthens muscles, bones, jopints and improve quality of blood Chandanbalalakshadi Tail helps to reduce inflammation and burning sensation. Manjisthadi Majja Basti In all procedures of Panchkarma, Basti is the first line of treatment of Vata Dosha as Dosha Pratyanik Chikitsa . Manjisthadi Majja Basti (processed with bone marrow) was planned which includes Majja and Manjisthadi Kwath with Tikta Rasa, Katu Vipaka, Ushna Virya which is Tridoshahara and Raktaprasadaka. Tikta Rasa has Srotoshodhan properties which help to clear the Srotosanga . Majja nourishes Asthi by means of its Purana (filling) and Snehan properties, that strengthen Majja Dhatu which in turn nourishes Asthi Dhatu. Thus, it pacifies Vata , improves the Dhatu Upachaya (metabolism of the tissues) and acts as a rejuvenator of the body CONCLUSION Based on this case study, it was shown that Manjisthadi Majja Basti , in combination with specific palliative medications, is beneficial in treating Avascular necrosis of the femoral head. In present case, given treatment has significantly reduced discomfort, soreness, stiffness, and improved gait. The overall outcomes were positive and recovery was encouraging and deserving of documentation. Even though there is a huge need for more research, this shows that Ayurveda can be very helpful in the management of AVN when used in conjunction with a thorough diagnostic and treatment plan. REFERENCES 1 Bailey & Loves, Short Practice of Surgery, 25 th Ed., Part 5, Chapter 35, p. 515. 2 Kadlimatti SM, Subbanagouda PG, Sanakal AI, Deshpande M. Ayurvedic management of avascular necrosis of the femoral head – A preliminary study. AYU. 2008;29:154 – 60. 3 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] 4 http:/ /emedicine.medscape.com/article/ 386808, updated: Aug 1, 2008. 5 Orban HB, Cristescu V, Dragusanu M. (2009) Avascular necrosis of the femoral head. MAEDICA-a Journal of Clinical Medicine. 1;4(1):26-34. 6 Acharya YT, editor, Shri Chakrapanidatta, commenta-tor, Agnivesha, Charaka Samhita, Chikitsasthana; Vatavyadhichikitsa Adhyaya, 28/33, Chaukhamba Surbharti Prakashan, Varanasi, 2014; page 617. 7 Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br, 1995; 77(1): 34-41. Pub med citation 8 http://www.iamj.in/posts/images/upload/2300_2304.pdf How to cite this article: Chhaya Thakur, Sanjay Srivastava. The management of Asthimajjagata Vata w.s.r. to Avascular Necrosis of Femoral Head with Ayurveda recipes - A Case Study. J Ayurveda Integr Med Sci 2024;5:238-243. http://dx.doi.org/10.21760/jaims.9.5.40 Source of Support: Nil, Conflict of Interest: None declared.

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Triphala, Basti, Panchakarma, Udavartana, Niruhabasti, Anuvasanabasti, Bone marrow, Surgical intervention, Surgical treatment, Tikta Rasa, Quality of life, Ayurveda treatment, Assessment criteria, Panchakarma therapies, Ayurvedic Management, Case study, Avascular necrosis, Asthimajjagata vata, Total hip replacement, Joint pain, Femoral Head, Range of Movement, Dhatu Upachaya, Oral medicine, Weight bearing joint, Joint movement, Dashamoola Kwatha, Prolonged sitting, Bony tissue, Weight bearing, Patra Pinda Swedan, Hip joint, Triphala choorna, Raktaprasadaka, Internal rotation, External rotation, Treatment administered, Til tail, Bilateral hip joint, Hip joint pain, Limping Gait, Vashpa Swedana.