Sandhivata kc037 gdg

Evaluation of the Efficacy of Abhadi choorna and

Ksheerabala taila Janubasti in the management of

Sandivata

By

Dr. Shivakumar.C.Sarvi

Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore.

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI M.D.

In

KAYACHIKITSA

Under the guidance of

Dr. V. VARADA CHARYULU, M.D. (Ayu)

And co-guidance of

Dr. RAGAVENDRA. V. SHETTER, M.D. (Ayu)

Post graduate department of Kayachikitsa,

Shri D. G. Melmalagi Ayurvedic Medical College,

Gadag – 582103.

2006.

1

Ayurmitra

TAyComprehended

Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled

“Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila

Janubasti in the management of Sandivata.” is a bonafide and genuine

research work carried out by me under the guidance of

DR. V. VaradaCharyulu, M.D. (Ayu), Professor and H.O.D, Post-graduate

department of Kayachikitsa and co-guidance of Dr. Ragavendra. V. Shetter,

M.D.(Ayu), Post graduate department of Kayachikitsa.

Date: Signature of Scholar

Place: Gadag Dr.Shivakumar.C.Sarvi

2

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “Evaluation of

the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the

management of Sandivata” is a bonafide research work done by Dr.

Shivakumar.C.Sarvi in partial fulfillment of the requirement for the degree

of Ayurveda Vachaspathi. M.D. (Kayachikitsa).

Date:

Place: DR. V. VaradaCharyulu, M.D. (Ayu).

Professor & H.O.D

Post graduate department of Kayachikitsa.

3

CERTIFICATE BY THE CO- GUIDE




Shivakumar.C.Sarvi in partial fulfillment of the requirement for the degree

of Ayurveda Vachaspathi. M.D. (Kayachikitsa).

Date: Dr. Ragavendra. V. Shetter,

M.D. (Ayu)

Place: Assistant Professor, Post graduate Department of Kayachikitsa

4

ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF

THE INSTITUTION




Shivakumar.C,Sarvi under the guidance of DR. V. VaradaCharyulu, M.D. (Ayu),

Professor and H.O.D, Postgraduate department of Kayachikitsa and co-

guidance of Dr. Ragavendra. V. Shetter, M.D.(Ayu), assistant professor Post

graduate department of Kayachikitsa.

DR. V. VaradaCharyulu, M.D. (Ayu) Dr. G. B. Patil.

Professor & H.O.D, Principal.

Post graduate department of Kayachikitsa.

5

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and disseminate

this dissertation / thesis in print or electronic format for academic / research

purpose.

Date: Signature of Scholar

Place: Gadag

Dr. Shivakumar.C.Sarvi

© Rajiv Gandhi University of Health Sciences, Karnataka.

6

LIST OF ABBREVIATIONS USED

A S – Ashtanga Sangraha

A H – Ashtanga Hridaya

Aru. – Arunadatta

A.T – After treatment

B.T – Before Treatment

B.P – Bhavaprakasha

B.R – Bavarajeeyam

Bh.S – Bhela Samhita

Ca.S – Charaka Samhita

Chi. – Chikitsa Sthana

Chak. – Chakrapani

Dal. – Dalhana

S.L.R - Straight leg raising

Gang. – Gangadhara

K.S – Kashyap Samhita

M.N – Madhav Nidana

Ni. – Nidana Sthana

N.S – Not Significant

SU.S – Sushruta Samhita

Sa.S – Sharangadhara Samhita

Sha.S – Shareera Sthana

Su. – Sutra Sthana

Si. – Siddhi Sthana

Vi. – Vimana Sthana

Y.R. – Yoga Ratnakara

LIST OF TABLES

Sl. No

Contents Page No

01 Samanya nidana of Sandhivata 11 02 Roopa of Sandhivata mentioned in various classics 19 03 Vyavachedakanidana between Sandhivata & Vataraktha 20 04 Vyavachedakanidana between Sandhivata & Amavata 21 05 Vyavachedakanidana between Sandhivata & Krostukashirsha 21 06 Differential diagnosis between O.A, R.A,Gout & Rheumatic

fever 22

07 Chikitsa sutra mentioned in different Samhita 42 08 Grading of parameters 09 Demographic data related to evaluation of Abadi churna in

Sandhivata 74

10 Demographic data related to Evaluation of Ksheerabala taila Janubasti in Sandivata

75

11 Distribution of patient according to age among groups. 76 12 Distribution of patient according sex among groups. 77 13 Distribution of patient according to occupation 78 14 Distribution of patient according to Economical status 79 15 Distribution of patient according to Religion 80 16 Distribution of patient according to Diet 81 17 Distribution of patient according to affected to leg of Sandhivata 82 18 Distribution of patient according to Agni 83 19 Distribution of patient according to Koshta 84 20 Distribution of patient according to Habits in patients 85 21 Distribution of patient according to Prakriti of patients 86 22 Distribution of patient according to different nidana bhavas. 87 23 Distribution of patient according to Chronicity of the disease

among groups 88

24 Showing the incidence of Swelling in the patients 89 25 Showing the incidence of walking time in the patients 90 26 Showing the incidence of range of Flexion deformity in the

patients. 91

27 Showing the incidence of Pain in the patients. 92 28 Showing the incidence of Stiffness in the patients. 93 29 Showing the incidence of Tenderness in the patients. 94 30 Showing the incidence of Crepitus in the patients 95 31 Showing the incidence of Weight of the body in the patients 96 32 Master Chart – Subjective Parameter – Group- A 97 33 Master Chart – Objective Parameter – Group- A 97 34 Master Chart – Objective Parameter – Group- B 98 35 Master Chart – Subjective Parameter – Group- B 98 36 Statistical Assessment of Individual Study Group – A

(Subjective& Objective Parameter) 99

37 Statistical Assessment of Individual Study Group – B (Objective Parameter)

99

38 Statistical Assessment of Comparative study of Group – A with Group – B

100

39 Over all assessment 102

LIST OF PHOTOS, FLOW CHARTS AND GRAPHS

Sl. No Name of the Figure Page No 1. Photo showing Drugs used in clinical trail 2. Photo showing Janu basti procedure 3. Flow chart of Samprapti of Sandhivata List of Graphs 1 Distribution of patient according to age among groups. 76 2 Distribution of patient according sex among groups. 77 3 Distribution of patient according to occupation 78 4 Distribution of patient according to Economical status 79 5 Distribution of patient according to Religion 80 6 Distribution of patient according to Diet 81 7 Distribution of patient according to affected to leg of

Sandhivata 82

8 Distribution of patient according to Agni 83 9 Distribution of patient according to Koshta 84 10 Distribution of patient according to Habits in patients 85 11 Distribution of patient according to Prakriti of patients 86 12 Distribution of patient according to different nidana

bhavas. 87

13 Distribution of patient according to Chronicity of the disease among groups

88

14 Showing the incidence of Swelling in the patients 89 15 Showing the incidence of walking time in the patients 90 16 Showing the incidence of range of Flexion deformity in

the patients. 91

17 Showing the incidence of Pain in the patients. 92 18 Showing the incidence of Stiffness in the patients. 93 19 Showing the incidence of Tenderness in the patients. 94 20 Showing the incidence of Crepitus in the patients 95 21 Showing the incidence of Weight of the body in the

patients 96

22 Over all assessment 102

TABLE OF CONTENTS

Chapters Page No.

1. Introduction 1- 3

2. Objectives 4

3. Review of literature 5-57

4. Methodology 58-72

5. Observation and Results 73-102

6. Discussion 103-112

7. Conclusion 113

8. Summary 114

9. Bibliography 115-125

10. Annexure

ABSTRACT

Sandhi-Gata-Vata (osteoarthritis) is common amongst the elderly and

obese persons. Since knee is the weight bearing joint it is more susceptible to wear and

tear. Sandhi-Gata-Vata (osteoarthritis) resulting in wear and tear of this joint termed as

Sandhi-Gata-Vata. It is largely seen in the population and known to be major cause for

chronic disability.

The objectives of this study are 1) To evaluate the efficacy of abhadi

churna in the management of sandhigatavata (osteoarthritis), 2) To evaluate the efficacy

of ksheera bala tail janu basti in the management of sandhigatavata (osteoarthritis) and

The aim of this study was to find out the effect of Abhadi choorna in the

management of Sandhigathavata and to check its advantage of ksheera bala tail janu basti

in managing the same disease. Therefore, two groups were made and the results obtained

in both the individual groups. The study design selected for the present study was

prospective clinical trial.

In-group A (Abhadi choorna), not a single patient had good response to

the treatment (> 75% improvement in all the parameters) and 4 patients (26.6%) had

moderate Response to the treatment (50-75% improvement in all parameters) and

11(73.3%) patients had poor response. In group B (Ksheera bala tail janu basti), 1 patient

had good response to the treatment and 7(46.6%) patients had moderate response to the

treatment, 7(46.6%) patients had poor response in both the groups A and B the

parameters showed high significance but in comparison parameters showed non

significant value.

Sandhigatavata is a Vatavyadhi affecting people in the vardhakya avastha.

The disease is characterized by dhatu kshaya and lakshanas reflective of vitiated Vata.

Therefore, the agents/therapies of brimhana-shoolahara-stambhahara-balya properties

should be used in this disease. Janu basti imparts Snehana & Swedana and opens up the

srotas in the shareera facilitating more nourishment and free movement of Vata dosha.

This results in the relief of stambha and facilitates free movement of the sandhis. All the

drugs in the Abhadi choorna are having shoolahara Srotoshodhaka balya, Rasayana

properties; it is an ideal treatment of choice in Sandhigatavata.

Key words: - Abhadi choorna; Sandhigatavata; Osteoarthritis; Janu basti Dhatu kshaya;

Degeneration.

Acknowledgement One of the great pleasure of life is doing the things that others says you

cannot do it, by the grace of god, bless of eiders I take this opportunity to express my

regards to the persons who helped in completing this work.

I express my deep sense of gratitude to his great holiness Jagadguru Shri

Abhinava Gavisiddheshwara mahaswamiji for their divine blessings.

I express my obligation to my honorable Guide Dr. V. Varadacharyulu M.D

(Ayu), H.O.D., P.G. Department of Kayachikitsa, P.G.S & R, D.G.M.A.M.C, Gadag

for his critical suggestions and expert guidance for the completion of this work.

I am extremely grateful and obliged to my co-guide Dr.

Raghvendra.V.Shettttar M.D, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag for

his guidance and encouragement at every step of this work.

I acknowledge my sincere gratitude to Dr. K. S. R. Prasad , Professor for their

sincere advices and assistance.

I express my sincere and deep gratitude to Dr.G.B.Patil, Principal,

D.G.M.A.M.C, Gadag, for his wholehearted encouragement as well as providing all

necessary facilities for this research work.

I express my sincere gratitude to Dr. G. Purushothamacharyulu, Dr.M.C.Patil,

Dr. Mulgund, Dr. P.Shivaramadu, Dr. Dilipkumar, Dr. Danappagoudar, Dr. Kuber

Sankh, Dr. Santhosh. N.Belavadi, Dr. Jagadish metti, Dr. Nidagundi Dr.

Shankergouda and other PG staff for their constant encouragement.

I express my sincere thanks to my colleagues and friends Dr. B. L. Kalmat,

Dr. Venkareddy, Dr. Uday Kumar, Dr. Ratna Kumar, Dr. S. C. Sarvi, Dr. Krishna. J,

Dr. Umesh, Dr. Ashok. Akki, Dr. Ashok. M. G, Dr. Shekar Sharma, Dr. Shivaleela,

Dr. K. M. Angandi, Dr. Sulochana, Dr. Sanjeeva, Dr.Niraj kumar, Dr. Prasanna Joshi,

Dr. Vijaylakshmi, Dr. Veena. J, Dr. Manjunath. Akki, Dr. Suresh. N. Hakkandi, Dr.

Ashwini Dev, Dr. Vijay Hiremath, Dr. L.R.Biradar, Dr. Santhosh.L.Y, Dr. Satish. R,

Dr. Sharnbasappa Angadi, Dr. Anand H, Dr. Anitha, Dr. Jagadisha and other post

graduate scholars for their support & my room mates Manju, Santosh, Manthesh.

I also express my sincere gratitude to Dr.S.D.Yargeri R.M.O. for his moral

support and special care in providing the all the facilities during this trail work.

I thank Dr. B. G. Swami, Dr.U.V.Purad, Dr. Paradi, Dr.Shankergouda,

Dr.B.M,Mulkipatil and other undergraduate teachers for their support in the clinical

work. I thank to Shri. Nandakumar (Statistician), Shri.V.M.Mundinamani (Librarian),

Mr.Surebana and other hospital and office staff for their kind support during my

study.

My cordial thanks to Dr. J.C.Shirol, Dr.V.C.Shirol, Dr. Karanth, Dr.Srinivas

internees for their significant contribution during my profession.

Indeed, I will cherish the affectionate of my Mother, my Father,

Smt.Shanthabai, Dr. Channaveerappa. Sarvi my sister Laleetha, brother-in-law

Shashidar, my brother Mr. Mallikarjun and Babi, Smt. Suma all my family members

who have been a source of inspiration for my entire carrier.

I acknowledge my patients for their wholehearted consent to participate in this

clinical trial. I express my thanks to all the persons who have helped me directly and

indirectly with apologies for my inability to identify them individually.

Finally I dedicate this work to who are the prime reasons for all my success.

Date: Signature of the scholar

Place: (Dr.Shivakumar.Sarvi)

Introduction

Introduction

Sandhigatavata is the most common form of joint disorder. It is a major

cause of morbidity and disability as well as burden on healthcare resources

especially for the elderly. This disease keeps an insidious attack, which runs for

many years causing the loss of function as well as deformity of the joints

especially weight bearing joints like knee joint. Among elderly knee OA is the

leading cause of chronic disability and some 1,00,000 people in the United States

are unable to walk independently from bed to bathroom because of knee OA.1

The shortest description of this disease is available in Charaka2, Sushruta3

and Ashtangahridaya.4 The later authors explained the clinical aspect of this

disease in the wordings of either Charaka or Sushruta. So detail description of

Sandhivata is not available in Ayurveda. But in contemporary science a great

work has been carried out in this filed. Now researches are going on not only on

individual joints but they are concentrating on different sites within the joints.

Eg, patellofemoral compartment Vestibio femoral.

There have been advances in understanding of this disease. No longer is

osteo-arthrosis regarded as a simple consequence of aging and cartilage

degeneration. Indeed, the former diagnostic label of ‘degenerative joint disease’

is now recognized to be a ‘misnomer’. A single definition of Osteoarthritis

remains elusive. A workshop held in 1995 proposes following consensus

definition. “Osteo-arthritis disease is the result of both mechanical and biological

events that destabilize the normal coupling of degradation and synthesis of

articular cartilage chondrocytes and extra cellular matrix and subchondral bone.”

Though there is a lot of an advance in understanding of this disease, day-

by-day the disease has become a problem. As a constellation of clinical and

anatomical features, analogous to heart failure, indeed OA might with advantage

Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the management of Sandigatavata

1

Introduction

be renamed ‘joint failure’. Management of this disease is facing lot of difficulties.

Contemporary science has failed to find a solution for this disease. It is clearly

said that current treatment of Osteo-arthrosis is purely to control symptoms

because there is no disease modifying Osteo-arthrosis drug yet. Intra articular

steroids are widely used in OA particularly for the knee, these injections may

provide marked symptomatic relief for weeks to month. Because studies in

animal models have suggested that glucocorticoids produce cartilage damage, and

frequent injections of large amounts of steroids have been associated with joint

breakdown in humans, the injection should generally not be repeated in a given

joint more often than every 4 to 6 months.

From the very early ages Indian physicians have identified and recorded

an innumerable herbs and minerals. Their studies were so accurate and extensive

that they still continue to provide a strong basis for the practice and

experimentations.

In the present study, after consolidating all these views a package therapy

was planned, this includes Abhadi choorna5 taken orally & ksheerabalataila Janu

basti.6

The present study was carried out to assess the efficacy of classical line of

treatment in Sandhivata, with the aim to study the role of Abhadi choorna orally

& Ksheera bala tail, Janubasti in the management of Sandhivata. Assessment was

made on the basis of symptomatology. In the study an attempt is made to analyze

Etiopathogenesis, nidana and symptoms of Sandhivata based on information

available in contemporary science.

In spite of the scientific advancement in the field of Medicine, a large

number of people suffer from OA all over the world without a permanent relief

from this disease. As such the demand and need for suggesting complete,


2

Introduction

complacent solace was felt. A sincere, dedicated research work was carried out

and the same is humbly placed before ‘scholarly jury’ for consideration and

acceptance.


3

Objectives

Objectives of study

The life style of the man has become mechanical. The time

and more desires have made the man unable to fallow the Swastha niyamas there

by becoming victim for the diseases. The man today even in his young adult age

suffering from the degenerative diseases like Sandhivata the conditions where the

pain and swelling in the joints are present. Giving rise to the restricted

movements,7 and also it is not a single disease rather it is end result of Varity of

patterns of joint failure together or lesser extent it is always characterized by the

degeneration of articular cartilage and simultaneously proliferation of new bone.

Radiological autopsy studies show that oesteoartritis prefentially targets only

certain small and large joints there is steady rise in over prevalence from age 60 –

65, 80% of people are having some radiological evidence of O.A. though only 20

– 30 % have associated symptoms. Knee O.A is more prevalent & the over all

prevalence of the disease in the population above 40 years of age is about 49 %

with male to female ratio 1:1.8 Contemporary medical science is able to pacify the

pain full conditions of above said disease through highly effective analgesics and

anti-inflammatory drugs. If needed through the surgical method and ultimately

give rise to complication & least effective. So to over come the degenerative

process in young adult age pacify the pain contemporary medical science is using

NSAIDS but larger anti inflammatory drugs are usually no more effective and

carry on increased risk of gastric erosion or hemorrhage in elderly distinct

women.9 In addition a recent review of the literature abou5t non-steroidal anti-

inflammatory the chance of hospital admission or death due to serious G.E event

up to 16 per thousand per year.10

To evaluate the efficacy of Abhadi churna in sandhigatavata.

To evaluate the efficacy of ksheerabala tail janu basti in sandhigatavata.


4

Historical Review

Historical Review

Historical review is necessary to understand origin and progressive

development, that has taken place for centuries together. There is no direct

reference of the disease sandhigatavata in the vedic period. But indirect

references in their most rudimentary form are available here and there. The

references available in Rigveda and Atarraveda, pertaining to vata, its bhedha

shlesaka kapha sthana, and also joint disorders, and drugs used in vata rogas.11

Vyadhi

Sandhis and the diseases affecting them were well known in the Vedic

period. One can observe description of body parts in Atharvanaveda where in the

words “Januni and Ashtivantau” were used to denote knee joints.12 The disease

Sandhigatavata had not been mentioned as such in Vedic literature. But in

Rigveda while describing various skills of Ashwinikumaras had recorded their

skill in treating joint diseases too13. One of the mantras of Rigveda states that, “I

am removing your diseases from each organ, hair and joint”14. Atharvanaveda had

mentioned Parvashoola and Vateekrita15, two diseases similar to Sandhigatavata.

In Atharvanaveda, records about Vatavikaras are mentioned16. A mantra says,

“destroy the balasa seated in the organs and joints which is responsible for loosing

bones and joints”17. In purana kala18, 19 also references regarding sandivata are

available.

Samhitagranthas and Samgrahagranthas except Sharangadhara samhita

had described the disease Sandhigatavata with lakshana-chikitsa under the

Vatavyadhees20, 21,22, 23, 24, 25, and 26. Even though the description of Sandhigatavata

is unavailable in Bhela samhita27, it is assumed that the verses are missing, as the

description of Gatavatas such as amashayagatavata, pakwashayagatavata and

raktagatavata etc. is available. In harita samhita28 also references regarding this


5

Historical Review

disease are available,also in chakradatta29, gadanigraha30 & Basavarajeeyam31

mentioned about this disease.

Osteoarthritis (OA) is the most common joint disorder in human beings

and other vertebrates. Even in giant dinosaurs, osteophytes leading to ankylosis

were detected. In all mammalian species like whales and dolphins and in fish

birds and some amphibians, Osteoarthritis is observed32.

In the early ages, Hippocrates observed the prevalence of OA in aged

individuals (Benard, 1944) 33 Heberden (1803) studied this disease in detail and

the nodes on the fingers in OA disease were named after him34. Osteoarthritis was

differentiated from Rheumatoid Arthritis and named as degenerative arthritis by

Nichols and Richardson (1909) on morbid anatomical grounds35. Although the

most ancient of the diseases, OA was first identified as a distinct entity in the 20th

century36. Gold th ait in 1904 made a distinction between hypertrophic and

atrophic arthritis and A.E Garrod recognized OA as a clinical entity in 1907.37


6

Disease review

Ayurvedic review

Vyutpatti & Paribhasha

1. Sandhi

Vyutpatti - SAM + DHA + KIHI

Nirukti -

• Sandirnama Samyogaha38

• Asthidwaya Samyogasthana39

Sandhyarnama, asthanam, anyonya, sangam, asthani, junction, connection,

combination, union with containing a conjugation, transition from one to

another40.

Paribhasha: Sandhi pullinga, sandhanamiti, Yuga sandhini yugashabde deha

sandhini marmashabde cha drishtavyaha41

In general, sandhi means the junction between two things in Ayurveda

shareera sandhi is a technical word indicating that it is the place where two are

more bones meet together and the joint may be fixed type or of less or more

movement. Acharya Sushrutha told that, in our body there are innumerable

2) Gata

Vyutpatti- Gam – gamane42

Gam + Ktha43

Nirukti- Vata, Prapte, labdhe, Patite, Cha, Sameepe44, Come to,

approached, arrived at, Being in, situated in, continued in,

Paribhasha45- Gatam - thrillingam, gacchati, Janati, Yatteti

3) Vata

Vyutpatti - Va - Gati gandhanayoho

Va - Gati sevanayoho

Va + Kthaha46


7

Disease review

Pullinga Va + Kthaha47

Nirukti - Sparsha matra vishesha gunake bhutabheda

- Pavane - dehasya dhatubheda cha48

- Wind, Air,as one of the humours of the body49

The word ‘Osteoarthritis’ is a combination of three words. ‘Osteon’,

‘arthron’ and ‘it is’ respectively means bone, joint and inflammation50. The

meaning of this word is ‘inflammation to the bony joint’. In fact, there is no

inflammation in this disease; hence, the disease is also known as Osteoarthrosis

and degenerative joint disease.

Prayaya of Sandhigata Vata

Different authors named this disease according to their own views, ie. as

follows.

• Sandhigata anila51

• Kudavata52

• Sandhi vata53

• Jeerna vata54

Terminology of Osteoarthritis55 :-

Four names, none of which are adequate are used interchangeably

to describe the disease. They are Osteoarthritis, Osteoarthrosis, Degenerative joint

disease and Hypertrophic arthritis. Osteoarthritis is less than ideal since the

primary event is not inflammatory, although secondary synovitis is usually

present. Osteoarthrosis is perhaps the best because the inflammation is secondary

and the suffix denotes an increase and an invasion, physiologic or pathologic, or a

general over production. This early on, is a relatively clear description of what the

disorder is. Degenerative joint disease is unsuitable, since degenerative implies

aging, a running down, deterioration, and a catabolic process; in fact for long


8

Disease review

periods, often years, the disease may not be clinically progressive. Hypertrophic

arthritis now completely out of style, describes one phase the osteophytosis or

overgrowth of bone.

Nidana56, 57, 58, 59, 60, 61, 62, 63

Even though classics of Ayurveda do not mention the Nidanas of Sandhi-

Gata-Vata, one has to compile the relevant references mentioned in different

contexts like Vata Vyadhi Nidana (Ca.Sa.Ci.28/15-17, Su.Sa.Su.21/19,

A.Hr.Ni.1/14-15, Yo.Ra.Pu.Vat.1-4, Bh.Pr.Ci.Vat.1-2, Ma.Ni.Pu.22/1-3),

Asthivahasroto Dushtikarana (Ca.Sa.Vi.5/27), Majjavahasroto Dushtikarana

(Ca.Sa.Vi.5/28).

Nidana can be classified under various headings with different views.

Among them one classification is Sannikrishta and Viprakrishta Karana. Here

with the complimentary references the Nidanas of Sandhi-Gata-Vata is classified

on this basis.

Sannikrishta Hetu –

Ativyayama, Abhighata, Marmaghata, Bharaharana, Sheeghrayana,

Pradhavana, Atisankshobha.

Viprakrishta Hetu –

Rasa – Kashaya, Katu, Tikta

Guna – Rooksha, Sheeta, Laghu

Dravya – Mudga, Koradusha, Nivara, Shyamaka, Uddalaka, Masura, Kalaya,

Adaki, Harenu, Shushkashaka, Vallura, Varaka.

Aharakrama – Alpahara, Vishamashana, Adhyashana, Pramitashana

Manasika – Chinta, Shoka, Krodha, Bhaya

Viharaja – Atijagarana, Vishamopacara, Ativyavaya, Shrama, Divasvapna,

Vegasandharana, Atyucchabhashana.


9

Disease review

Some of the important Nidanas are discussed below-

Ativyayama

Excessive physical exercises act as one of the important Nidana for

Sandhi-Gata-Vata. Running, walking, jogging etc. if done excessively or violently

will affect the structures of Sandhi. They mainly affect the Joint stability by over

exertion. But if done properly they stabilize the Joint.

Bharaharana

Carrying excessive load causes excessive pressure and stretching effect

over the structures of the joint. As knee is weight bearing joint, carrying excessive

load will have direct affect on articular disc. The constant compression will lead

to wear and tear effect leading to degenerative changes in the discs.

Abhighata

Abhighata to joints due to Prapatana etc., lead to structural deformity in

the joints. Joint is an organ rather than a single structure. It is stabilized by

different structures like Asthi, Snayu, Peshi, and Kala etc. Hence any trauma to

these structures will alter the structural integrity of the joint. Hence Abhighata is

an important Nidana for Sandhi-Gata-Vata.

Atisankshobha

It is a Nidana for Asthivaha Sroto Dushti. Since Asthivaha Srotas is

involved in Sandhi-Gata-Vata this can be considered as Nidana for the same.

Violent activities like Atyadhva, Plavana, Langhana, Balavat Vigraha,

Pradhavana etc. will have its effect on joint. As told earlier knee is the weight-

bearing joint, the violent exercises or activities will alter the structural integrity of

the joint.


10

Disease review

Marmabhighata

The concept of Marmabhighata in the causation of Sandhi-Gata-Vata

sounds more rational. Janu-Sandhi is a variety of Vaikalyakara Sandhi-Marma64.

Marma is a vital point, which comprises of Asthi, Snayu, Sira, Mamsa and

Sandhi. Hence any Marma is made up of all these structures, like wise the Janu-

Sandhi.

Pain in the joints not necessarily be only associated with bony changes.

But involvement of other joint structures may also give rise to symptoms

pertaining to joint. Therefore, in recent days more study is emphasized on the

different structures involved in the pathology of Arthritis like consistency of soft

tissue, fibrous material, liquid and cartilaginous substance of the joint. From this

new point the Ayurvedic view towards the involvement of certain Marma in the

disturbance of the joint i.e. painful joint will be anticipated. Hence

Marmabhighata as a Nidana in case of Sandhi-Gata-Vata is to be given

importance.

TABLE.2

SAMANYA NIDANA OF VATA VYADHI AS EXPLAINED IN DIFFERENT TREATISES

Nidana Ca. Sam Su. Sam A.H MN YR BP Aharaja Nidana Kashaya - + + - - +

Katu - + + - - + Tikta - + + - - + Rooksha + + + + + + Laghu + - + + + - Sheeta + - + + - - Vallura + - - - - - Varaka + - - - - - Shuskha Shaka - + - - - - Uddalaka - + - - - - Neevara - + - - - - Mudga + - - - - - Masura + - - - - - Harenu + - - - - -


11

Disease review

Kalaya + - - - - - Nishpava - + - - - - Viharaja Nidana Ati Vyayama + + + + - - Langhana + + - + + - Plavana + + - + + - Atyadhwa + - - + + - Pradhavana - + - - - - Pratarana - + - - - - Atyuchabhashana - + - - - - Balavadvigraha - + - - + - Abhighata + + - + - + Marmaghata - - + + - - Bharaharana + - - - + - Dukhashayya - - + + - - Dukhasana + - - - - - Sheegrhayana + - + + - - Prapeedana - + - - - - Atiadhyayana + - - - - -

Ati vyavaya + + + + + + Atijagarana + + + + + + Vegadharana + + + + + -

Vishamopachara + - - + + - Shrama - - - - - + Upavasa + + + + + +

Puravata sevana - - - - - +

Divasvapna + - - - - -

Manasika karana

Cinta + - + + + +

Shoka - + + + + -

Krodha - - - - - -

Bhaya - - - - + -

4) Anyat (other nidanas): -

Panchakarma apacharas like atidoshasravana, atirakthasravana, atiyoga of

langhana, apatamsana etc and dhatukshayakarabhavas like rogakarshana,

gadakrita atimamsakshaya, etc vitiate Vata. Dhatukshaya is an important vitiating

factor of Vata. Sthoulya is another causative factor for Vata prakopa. The meda-

avarana of Vata is the mechanism causing inter-relationship between sthoulya and

Vatavyadhis65. All types of avaranas are also important vitiating factors of Vata.


12

Disease review

Vata dominates vardhakya avastha66. During this period, dhatukshaya occurs

causing Vata prakopa.

Living in jangaladesha is another causative of Vata prakopa67. Vata gets

vitiated in the end of day and night68. Vata also get vitiated during the end of

greeshma ritu, varsha ritu and shishira kala69. Vata prakriti persons are more

susceptible to Vata vikaras. Persons who are rooksha-kashaya-katu-tikta satmya

are also more susceptible to Vata vikaras.

Among all the types of nidanas mentioned some need special attention.

Adhyashana leads to excessive body weight and this results in more pressure over

weight bearing joints. This gradually weakens the sandhis and produces

Sandhigatavata. Excess exercise may not only vitiate Vata but further leads to

shleshaka kapha kshaya contributing to Sandhigatavata. Excess walking and

excessive weight bearing also are important in the context of Sandhigatavata.

Abhighata to marmas or sandhis is another important risk factor for

Sandhigatavata. Vardhakya avastha characterized by dhatukshaya leading to

peshi-snayu-marma shosha, thereby resulting in looseness of joints is also a major

risk factor for Sandhigatavata. The factors like that vitiate asthivahasrotas

(ativyayama, atisamkshobhana, asthivighattana and vatalasevana) 70also need to

be mentioned in the nidana of Sandhigatavata.

Risk factors for Osteoarthritis (OA)71

Age factor –

Age is the most powerful risk factor for OA. The association between OA

and aging is non-linear. It usually begins after a person is 40 or more years old.

By the age of 60 years, almost everyone has OA. More than 80% of people over

60 years old have radiological evidence of OA in one or both knees and 30% in

one or both hips.


13

Disease review

Sex factor –

It is told that women are at high risk than men in developing OA. Over

30% of women (elderly) have OA in the interphalangeal joints of the hands.

Except in the hands, men and women are affected equally, though the lesions

often appear at a young age in men. Only 3% of elderly men have primary OA in

the hands.

Hereditary factor –

The relation of heredity is less ambiguous. Thus, the mother and sister of a

woman with distal interphalangeal joint OA are respectively twice and thrice as

likely to exhibit OA as the mother and sister of an unaffected woman.

Race factor –

Racial difference exists in both the prevalence of OA and the pattern of

joint involvement. OA is more frequent in Native Americans than in whites. The

Chinese in Hong Kong have a lower incidence of hip OA than in whites.

Interphalangeal joint OA and especially hip OA are much less common in South

African blacks than in whites in the same population. Whether these differences

are genetic or are due to differences in joint usage related to life style or

occupation is unknown.

Obesity factor –

Obese persons have a high risk of OA. For those in the highest quintile for

body mass index at base line examination, the relative risk for developing knee

OA in the ensuing 36 years was 1.5 for men and 2.1 for women. For severe knee

OA, the relative risk rose to 1.9 for men and 3.9 for women, suggesting that

obesity plays an even larger role in the etiology of the most serious cases of knee

OA.


14

Disease review

Occupational factor –

Repetitive movements may leads to excessive strain leading to erosion and

joint damage. Men whose jobs require knee bending and at least medium physical

demand had a higher rate of radiographic evidence of knee OA and more severe

radiographic changes.

Traumatic factors –

Trauma to the joint seems to enhance the occurrence of arthritis. It

disturbs the alignment of the joints and over a period of time, this malalignment

may lead to excessive wear and tear leading to OA.

According to the cause of OA, it is classified as primary and secondary.

Primary OA is the term used when the disorder arises form unknown or hereditary

causes. Secondary OA describes cases in which direct causes for the disorder are

known.

Classification based on causes72

I. Primary

Idiopathic, Primary generalized osteoarthritis and Erosive osteoarthritis.

II. Secondary

Congenital or developmental defects (Hip dysplasias, shallow acetabulum,

Morquio’s syndrome, etc.),

Traumatic

a. Acute, b. Chronic and c. Charcot’s arthropathy,

Inflammatory RA, psoriatic arthritis, septic arthritis, pseudogout,

Endocrinal influence Acromegaly, diabetes mellitus, sex hormone abnormalities,

hypothyroidism with myxedema and Metabolic Gout, itemochromatosis,

ochronosis, chondrocalcinosis, paget’s disease.


15

Disease review

Samprapti

From the onset of Dosha Dushya Dushti till the evolution of the Vyadhi

there occurs various Vikriti. Samprapti explains such series of pathological stages

involved. It tells us about the total pathogenesis of a disease.

The Samanya Samprapti of Vata Vyadhi that is explained in classics can

be considered as the Samprapti of Sandhi-Gata-Vata or a base to understand the

Samprapti of Janu-Sandhi-Gata-Vata.

Acarya Caraka explained73 – due to the intake of Vatakara Ahara Vihara

Vata vitiation take place. This vitiated Vata lodges in Rikta Srotas i.e. Srotas in

where Shunyata of Snehadi Guna is present. Vata after settling in Rikta Srotas

produce disease related to that Srotas.

Acarya Vagbhata frames the Samprapti of Vata Vyadhi like –

Dhatukshaya aggravates Vata and the same is also responsible to produce Riktata

of Srotas. Thus the vitiated Vata travels through out the body and settles in the

Rikta Srotas and further vitiates the Srotas leading to the manifestation of Vata

Vyadhi 74.

Here an attempt has been made to explain how this Srotoriktata occurs due

to Nidanasevana. The chief properties of Parthiva Dravya are Guru, Sthula,

Sthira, Gandha Guna in excess. These are the properties, which are necessary for

Sthairya and Upacaya of the body. Excessive intake of Dravyas having Laghu,

Ruksha, Sukshma, Khara properties lead to Guru and Sneha Guna Abhava due to

their opposite quality. Thus it leads to Dhatukshaya in the body. Akasha is the

Mahabhuta that produces Sushirata and Laghuta in the body. Vayu Mahabuta fills

up this Sushirata. So due to Dhatukshaya Akasha Mahabhuta increases in the

body producing Sushirata and Laghuta simultaneously Vayu fills it up.


16

Disease review

From this description it can be stated that the meaning of word ‘Riktata’ is

Sushirata i.e. increase in Akasha and Vayu Mahabhuta. While commenting on

word ‘Riktata’ Cakrapani says that ‘Riktata’ means lack of Snehadiguna. For the

purpose of understanding the Samprapti of SandhiVata can be studied under two

heading.

They are -

1. DhatuKshaya Janya and

2. Avarana Janya Sandhi-Gata-Vata.

1. DhatuKshaya Janya Sandhi-Gata-Vata

In old age Vata Dosha dominates in the body. This will lead to Kapha

Abhava. Also Jataragni and Dhatvagni gets impaired, by which Dhatus formed

will not be of good quality. Degeneration of body elements takes place due to

predominance of Vata in its Ruksha, Khara, etc. Guna and loss of Kapha in

quality and quantity.

As the Shleshma Bhava decreases in the body, the Kapha Bheda i.e.

Shleshaka Kapha in the joints also decreases in quality and quantity. Reduction of

Kapha in Sandhis makes Sandhi Bandhana Shithilata. Ashrayashrayi Sambandha

also leads Asthidhatu Kshaya. Asthi being the main participant of the joint its

Kshaya leads Khavaigunya in the joints.

In this condition if Nidana Sevana done further produces Vata Prakopa. If

Vata Prakopa is not corrected by appropriate means and simultaneously if the

person indulges in Asthivaha and Majjavaha Sroto Dushtikara Nidana, the

Prakupita Vata spreads all over the body through these Srotas. In the meantime

Sthanasamshraya of Prakupita Vata take place in the Khavaigunyayukta Janu-

Sandhi. This localized Vayu due to its Ruksha, Laghu, Kharadi Guna over power

and undo all properties of Sleshaka Kapha producing disease SandhiVata.


17

Disease review

2. Avarana Janya Sandhi-Gata-Vata

In Sthulas usually Sandhi-Gata-Vata occurs in weight bearing joints. In

them Medodhatu will be produced in excess due to the Atisnehamsha of

Amarasa75. The excessive Medas will produce obstruction for the flow of nutritive

materials to the future Dhatus i.e Asthi, Majja and Shukra leads to their Kshaya.

The excessive fat deposited all over the body will produce Margavarana of

Vata76 (Su.Sa.Su. 15/32 – Dal.). Prakupita Vata due to Margavarana starts to

circulate in the body. While traveling it settles in the joint where Khavaigunya is

already exists. After Sthanasamshraya it produces the disease Sandhi-Gata-Vata

in the same process mentioned in the earlier context.

Thus with the help of Samanya Samprapti of Vata Vyadhi the Samprapti

of Janu-Sandhi-Gata-Vata can be divided into Dhatukshaya Janya and Avarana

Janya. This will help in deciding the prognosis and planning the treatment of the

disease.

Samprapti Ghataka:

Dosha – Vata – Vyana – Vriddhi; Kapha – Shleshaka – Kshaya

Dooshya – Peshi, Snayu, Asthi, Majja

Srotas – Mamsavaha, Medovaha, Asthivaha, Majjavaha

Agni – Jataragni, Asthi-Dhatvagni

Ama – Jataragni Mandya Janya

Roga Marga – Madhyama

Udbhavasthana – Pakvashaya

Sancharasthana - Sarvasharira

Adhishtana – Sandhi

Vyaktasthana – San


18

Disease review

Poorvaroopa77

Particular mentioning of Poorvaroopa of Sandhi-Gata-Vata is not available

in classics. In Vatavyadhi also unmanifested symptoms (Avyakta) or mild

exhibition of actual features of the disease itself (Alpa vyakta) is considered as its

Poorvaroopa. Hence clinical features of Sandhi-Gata-Vata in milder

form can be considered as Poorvaroopa.

ROOPA

The clinical features of Sandhi-Gata-Vata explained by various Acarya are

listed in Table

Roopa of Sandhi-Gata-Vata mentioned in various classics

Symptoms Ca.Sa. Su.Sa. A.Hr. A.Sa. Ma.Ni. Bh.Pr. Yo.Ra.

Sandhi Vedana + + + + + + + Sandhi Shotha + + + + + +

Sandhi Stabdhata + + Atopa +

Sandhi Vedana

All the Acarya have described this symptom. Caraka77 and Vagbhatas78

explain that pain in the joint is elicited during Prasarana Akunchana Pravrutti.

Sandhi Shotha

Most of the authors explained this symptom. Caraka and Vagbhatas

explained the nature of Shotha i.e., it is felt like bag filled with air (Vata Poorna

Driti Sparsha).

Sandhi Stabdhata

Sushruta79 initially described this symptom, later by texts like Madhava

Nidana80, Yogaratnakara81 and Bhavaprakasha82.

They have coined the term Sandhi Hanana or Hanti. While commenting on

this word Dalhana83 and Gayadasa explained as Akunchanaprasaranayoh


19

Disease review

Abhavah and Prasaranakuncanayoh Asamarthah respectively. With this we can

infer that the word Hanti refers to inability to move the joints.

In the opinion of madhukoshakara84, Hanti referes to Sandhi Vishlesha,

Stambha Adi Vikara. Hence with the above references, Hanti refers to Sandhi

Stabdhata.

Atopa

This symptom explained in Madhava Nidana85. While commenting on the

word Atopa in another context, Madhukoshakara quotes the opinion of Gayadasa

and Kartika.

I.e.‘Atopaha Chalachalanamiti Gayadasaha, Gudaguda Shabdamiti Kartikah’.

Also Bhavamishra86 says ‘Atopo – Gudagudashabdaha’

Thus we can say that Atopa in this context is the sound produced by the

movement of joints i.e., Crepitus. Thus with the help of different references and

by the opinion of commentators it can be concluded that Sandhi Shoola, Sandhi

Shotha, Sandhi Stabdhata and Atopa are the clinical features of Sandhi-Gata-Vata

or Janu-Sandhi-Gata-Vata

Vyavachedakanidana

Sandhigatavata is a disease affecting the bony joints. So virtually every

disease that affects the joints has to be differentiated with Sandhigatavata. The

most common differentiation is to be made with Vatarakta, Amavata and

Kroshtrukasheersha.


20

Disease review

Showing Vyavachedakanidana between Sandhigatavata and Vataraktha

Sl. Criteria SGV Vatarakta 1 Nidana Vatavridhikara

Ahara-vihara Vidahi,viruddha, rakthaprakopakara ahara

2 Poorva roopa Avyaktharoga lakshana Kushtasama 3 Roopa Sandhishoola,

Prasarana akunchanayoho vedana, Sandhi shopha, Vatapoornadrithi sparsha

Teevra ruk, Grathita-paki shvayathu

4 Adhisthana Sandhi Padamoola, Hastamoola

5 Doshas Vata Vata, Rakta 6 Upashaya Ushna - snigdha Sheeta

Table No. . Showing Vyavachedakanidana of Sandhigatavata and Amavata

Sl. Criteria SGV Amavata 1 Nidana Vatavridhikara, ahara-vihara Viruddhaahara-

cheshta 2 Poorva roopa Avyaktharoga lakshana Hridaya dourbalya,

gourava 3 Roopa Sandhishoola,


Vrischika damshavat peeda, Pidakayukta shopha

4 Adhisthana Sandhi Hasta,Pada, Gulpha, Trika, Janu

5 Dosha Vata Vata, Kapha 6 Upashaya Ushna, snigdha Ushna-rooksha

Showing Vyavachedakanidana of Sandhigatavata & Kroshtrukasheersha

Sl. Criteria Sandhigatavata Kroshtrukasheersha 1 Nidana Vatavridhikara

ahara-vihara Vatavridhikara ahara-vihara

2 Poorva roopa Avyaktharoga lakshana Avyaktharoga lakshana 3 Roopa Sandhishoola,


Maharuja, Janushopha

4 Adhisthana Sandhi Jan Madhya 5 Dosha Vata Vata, rakta 6 Upashaya Ushna, snigdha Snigdha, seetha


21

Disease review

Table No. 15. Showing Differential diagnosis between OA, RA, Gout and

Rheumatic fever.

Sl. Criteria OA RA Gout Rheumatic Fever

1 Symptoms Pain & swelling on major weight bearing joints, stiffness, crepitations, tenderness, enlargement of joint space

Inflammation in multiple joints, morning stiffness >30ms

Polyarticular pain, swelling & inflammation, exquisite tenderness

Painful and tender joints

2 Mode of On set

Gradual Abrupt Acute Acute

3 Joints Involved

Weight bearing joints

Polyarticular Metatarso- phalangeal joints

Polyarticular

4 Systemic Features

- Autoimmune disease, rise in temperature, anemia etc.

- Carditis, fever, chorea

5 Investigations RA-ve, ESR normal, X-ray- narrowing of joint space, subchondral bony sclerosis, osteophytes etc.

ESR raised, X-ray-soft tissue swelling.

Serum uric acid raised, punched out lesions in subchondral bone.

ESR increased, CRP high, WBC elevated.


22

Figure - 1

Samprapti in dhatukshaya janya sandhivata

UKTA NIDANA SEVANA VARDHAKYA

DHATUKSHAYA

VATA PRAKOPA KSHAYA OF KAPHA BHAVA IN THE BODY

CIRCULATION THROUGH SHLESHAKA KAPHA KSHAYA RASAYANI IN SANDHI

KHAVAIGUNYA IN SANDHI

STHANASAMSHRAYA IN SANDHI

SANDHIVATA

FIGURE - 2

SAMPRAPTI IN AVARANA JANYA SHADHIVATA

MEDOVRIDDHI

(MEDOVARANA) (MARGAVARANA TO THE FLOW OF POSHAKARASA)

VATAPRAKOPA POSHAKARASA NYUNATA TO ASTHIDHATU

EXCESSIVE PRESSURE OVER WEIGHT BEARING JOINT

CIRCULATION THROUGH ASTHIDHATU KSHAYA RASAYANI IN SANDHI

VYANAVATA PRAKOPA IN SANDHI

KHAVAIGUNYA IN SANDHI

STHANASAMSHRAYA IN SANDHI

SANDHIGATAVATA

Disease review

Janu Sandhi - Knee Joint

In Janu-Sandhi-Gata-Vata the vitiated Vata get lodges at Janu-Sandhi.

Therefore before going to the disease aspects, the anatomy and physiology of Janu-

Sandhi are to be under stood properly. In classics we have scattered reference of

anatomical and physiological consideration of Janu-Sandhi. Here an attempt is made

to enumerate those structures, which are helpful in maintaining the stability of the

joints.

In Ayurveda, Sandhis are mainly classified into two types;

1) Sthira Sandhi

2) Cala Sandhi 87

Again they are sub classified into eight types.88

1) Kora 5) Tunnasevani

2) Ulookala 6) Vayasa tunda

3) Samudga 7) Mandala

4) Pratara 8) Shankhavarta

Acarya Sushruta- father of Surgery considered Janu-Sandhi under Cala Sandhi

and sub classified under Kora Sandhi (Su.Sa.Sh.5/27).

Shleshaka Kapha- Among five variety of Kapha, Shleshaka Kapha resides in joints.

It keeps the joints firmly united, protects their articulation opposes their separation

and disunion 89.

Shleshmadhara Kala - It is the fourth Kala, which is situated in all joints of living

beings. As wheel moves on well by lubricating the axis, joints also function properly

if supported with Kapha. This helps in lubrication of joints90.

Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 23management of Sandigatavata

Disease review

Vyana Vata - Vata governs every movement in the body. Vyana Vata is one among

the five varieties of Vata, which resides at Hridaya and controls most of the motor

functions. The Gati or physical movement is also one of its functions.

Gayadasa commenting on Sushruta has quoted the wordings of an unknown

author as though the Vyana Vata is functioning all over the body it resides in the

Sandhi91.

Acarya Vagbhata states that Vata is located in the Asthi with relation to

'Ashrayashrayi Sambandha'. Generally augmentation or diminution of Doshas would

be given similar effect on their respective Dhatus but in case of Vata it is opposite;

with increase in Vata, Asthi Kshaya occurs92.

Sushruta in Sharirasthana explains different structures of the human body.

Among them, structures coming under Janu-Sandhi are listed below.

Snayu - Among nine hundred Snayus, ten are present in Janu-Sandhi. More over in

Shakha and Sandhi, Pratana variety of Snayu is present. Importance – As a boat

consisting of planks becomes capable of carrying load of passengers in river after it is

tied properly with bundle of ropes, all joints in the body are tied with many ligaments

by which persons are capable of bearing load93.

Peshi- The fleshy mass demarcated from each other is known as Peshi. In Janu they

are five in number. They are strong structures that help to maintain alignment of the

joint94.

Sanghata - Assemblages of bones are fourteen. One is situated in Janu-Sandhi95.

Evaluation of the Efficacy of Abhadi choorna and Ksheerabala taila Janubasti in the 24management of Sandigatavata

Modern review

Knee joint

Before discussing the disease Janu-Sandhi-Gata-Vata it is very essential to

understand the structure of knee joint, functional aspects of articular cartilage,

synovial fluid and synovial membrane etc.

Joints or articulations are the site where two or more bones meet. Joints are the

weakest part of the skeleton but their structures resists various forces, such as

crushing or tearing that threaten to force them out of alignment.

Joints are classified structurally and functionally. Fibrous, cartilaginous and

synovial are structural classification. Synarthrosis, amphiarthrosis and diarthrosis are

functional classification.

The present study was undertaken to assess the efficacy of janubasti in the

management of sandhi gata vata. Before discussing the disease sandhigata vata it is

very essential to understand the structure of knee joint, functional aspects of articular

cartilage, synovial fluid and synovial membrane so all these points are summarised

here.

The articular surfaces- Knee joint is formed by

1) The condyles of femur

2) The condyles of tibia

3) The patella

The femoral condyles articulate with tibial condyles below and behind and

with patella in front.

Condyles of Femur - The lower end of femur is widely expanded to form two large

condyles a medial and a lateral. The condyles are partially covered by a large

articular surface, which is divisible into patellar parts.


25

Modern review

The patellar surface covers the anterior surfaces of both condyles and extends

on more lateral condyle than on the medial.

The tibial surfaces cover the inferior and posterior surfaces of the two

condyles and merge anteriorly with the patellar surface. The lateral part of the surface

is short and straight anteroposteriorly. The medial part is longer and curved with

convexity directed medially.

Tibia

Medial condyle -superior articular surface is oval anterio posteriorly. The

peripheral part is flat and articulates with medial memiscus, the central part is slightly

concave and articulates with medial condyles of femur. The raised lateral margin

covers the medial inter condylar tubercle.

Lateral Condyle - The superior articular surface is mearly circular. The peripheral

part is flat and articulates with lateral meniscus. The central part is slightly concave

and articulates with the lateral condyle of femur.

Patella -Patella is the largest sessamoid bone in the body. It is triangular in shape

with its apex directed downwards, which is non articular posteriorly.

Anterior surface is rough and non-articular, the upper 3/4th of the posterior

surface are smooth and articular. The posterior articular surface divided by a verticle

ridge into a large lateral area and a smaller medial area. Structurally knee is a week

joint, because the articular surfaces are non congruent. The tibial condyles are too

small and shallow to hold the large convex femoral condyles. The femero patellar

articulation is also quite insecure because of their shallow surfaces and also the

outward angulation between the axes of thigh and leg.


26

Modern review

The stability of the knee joint is maintained by many factors. Knee joint is

supported by fibrus capsule. The fibrous capsule is very thin and is deficient

anteriorly when it is replaced by quadriceps femoris, patella and ligamentum patella.

Synovial Membrane - It lines the capsule except posteriorly where it is reflected

forwards by the cruciate ligaments forming a common covering for both ligaments.

Semilunar Cartilage (Menisci) - These are two fibro cartilaginons crescents. Which

try to deeper the articular surfaces of the condyles of tibia and partially divides the

joint cavity into the upper and lower compartments.

Ligaments

Ligamentum patella, tibial, collateral ligament, femoral collateral ligament,

oblique popliteal ligament, arcuate popliteal ligament, cruciate ligament.

Explanation of janukapala (patella) is available in Sushruta and Charaka

samhita. Acharya Charaka and Kashyapa while explaining the asthisankhya denotes.

Janvasthini dose, sankyate, chatwaryosthini jangayoho, dwarunalakau, dwecha

khyathe janukapale.

In the olden days also our acharyas had an idea of synovial membrane.

Sushruta clearly mentioned that the fourth kala is Shleshmadharakal a which is

situated in every sandhis and performs lubrication for movement. How a wheel

which is lubricated by oleation functioning normally. Likewise all the sandhis

function normally in the presence of shleshmadhara kala and also protects it form

destruction .

Synovial Fluid - It is found in the cavities of synovial joints. The main function of it

is lubrication and also nourishment of the articular cartilage.


27

Modern review

The physical nature of this is a clear or pale yellow, viscous glariry fluid of

slightly alkaline pH at rest. This nature varies widely between different joints and

spaces.

The physical properties of synovial fluid changes according to the

environment in the joint. Viscosity is very sensitive to changes in dilution and that it

falls with increasing temperature and increasing pH. The elasticity property is also

affected similarly.

The composition of synovial fluid is some protein (about 0.9mgm/ml) and

with added mucin. Hyalouronic acid which is sulphate free mucopolysaccharide

composed of basic units that are polymerised.

The synovial fluid also consists of moncytes, lympocytes, macrophages free

synovial cells and occasional polymorphonuclear leucocytes. Amorphous,

metachromatic particles and fragments of cells and fibrous tissue sometimes found in

synovial fluid are resulted by the slow wear and tear of joint surfaces.

It is very clear by Vagbhata's statement that, shleshmaka kapha not only

supports sandhis but also provides movements in the normal direction.Acharya

Sushruta states that it holds and nourishes the sandhi.

Articular Cartilage

Majority of bones are formed a special variety of hyaline cartilage. Articular

cartilage has a wear resistant, low friction lubricated surface, both slightly

compressible and elastic which is ideally constructed for easy movements over a

similar surface but also absorb enormous forces of compression and shear generated

during weight bearing and muscle action.

This is due to the Shleshaka kapha in the joint. Due to its snigdha and picchila

guna it lubricates the joints and avoids friction on movement. Thus the cartilage acts


28

Modern review

as wear resistant. Elasticity and compressibility of the cartilage is due to the

mridhutwa and shlakshna guna of kapha.

The Extracellular Matrix of Normal Articular Cartilage

Articular cartilage is composed of two major macromolecular species:

Proteoglycans (PGS), which are responsible for the compressive stiffness of the tissue

and its ability to withstand load and collagen, which provides tensile strength and

resistance to shear. Although lysosomal proteases have been demonstrated within the

cells and matrix of normal articular cartilage, their low pH optimum makes it likely

that the proteglycanase activity of these enzymes will be confined to an intracellular

site or the immediate pericellular area. However cartilage also contains a family of

matrix metalloproteinases (MMPs) including stromelysin, collagenase and gelatinase

which can degrade all the components of the extra cellular matrix at neutral pH. Each

is secretedby the chondrocyte as a latent pro enzyme that must be activated by

proteolytic cleavage of its N-terminal sequence. The level of MMP activity in the

cartilage at any given time represents the balance between activation of the

proenzyme and inhibition of the active enzyme by tissue inhibitor (Keneeth, 1996).

Osteoarthritis is the commonest form of arthritis or joint disease and is a very

important cause of pain and disability in advancing years of life. Some degree of

osteoarthritis will develop in everyone in old age and it is estimated that three out of

four persons of more than 60 years of age will have definite evidence of osteoarthritis

in at least one joint, and one out of ten persons beyond the age of 60 years will have

sufficiently advanced disease and have so much trouble that medical advise will be

sought.


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Modern review

In the next two decades the proportion of aged in population is going to

increase steadily and so will increase in the incidence of osteoarthritis and with a

commensurate increase in the cost of treatment of this most common joint disease.

The natural history of osteoarthritis is variable and joint specific. Osteoarthritis may

remain stable or static for many years, or be progressive, or may have periods of

waxing and warning of symptoms.

Osteoarthritis has no effect on longevity of persons affected with this disease, but can

be quite debilitating in terms of limiting activities and diminishing overall quality of

life.

These limitations in activities, usually with pain occurring at or just often

retirement can add an element of anxiety and depression and make the matters worse.

It is therefore necessary for everyone to know what is osteoarthritis, how it develops,

what are the risk factors, and what can be done to alleviate the suffering and

discomfort. With better understanding and knowledge about osteoarthritis along with

availability of medicines and development of operations with successful joint

replacement surgery much can be done to alleviate the pain and deformity and make

the person regain functional ability.

How Healthy Joints Work

Joints are parts of body where one bone meets the other and movement occurs

such as elbow, knee, hip and ankle. Backbone or spine also has large numbers of

small joints, which allow us to move our neck, and back in all possible directions.

Ends of bone which meet each other at joint are covered by cartilage. Cartilage is

white, smooth, glistening material and is very specialized which functions as a

cushioning material and a shock absorber so that hard bones do not rub against each

other, and the cartilage also reduces friction during joint movement since its surface is


30

Modern review

very smooth. In fact no man made material can match the low friction and shock

absorbing properties of healthy cartilage in the joint. Cartilage is made up of tough

fibres of a protein called collagen - Enmeshed in these fibres of collagen are the large

molecules of another protein called proteoglycan. Proteoglycan molecules contain lot

of water in their interior. Water keeps on moving in and out of the domain of

proteoglycan molecules almost like water being sucked in and squeezed out of

sponge. This property of ability to exchange water so easily gives an elastic

characteristic to the cartilage. Collagen fibres give desired strength and proteoglycan

molecules allow reversible compression. The combined structure thus makes up for

the tough but not too rigid quality needed for this very specialized tissue.

The bone ends with cartilage covering are enclosed in a membrane called

synovium. The synovium releases a slippery fluid know as synovial fluid and this

fluid further reduces the friction between moving surfaces capped with cartilage and

ensures that the joint moves easily and smoothly. The synovial fluid or joint fluid

formed by synovial membrane is a special type of fluid that behaves like fluid when

the joint is being moved and during walking when the joint is loaded its character

changes to something like jelly to act as an additional shock absorber. The synovial

fluid nourishes the cartilage. The cartilage has no blood vessels and relies on synovial

fluid moving in and out to provide nutrients and take away the waste products.

Ends of bone, cartilage and synovium are further enclosed in a layer of tissue

called capsule. Capsule is a thick and strong tissue but is capable of stretching when

joint moves. The combination of bone ends with cartilage covering, synovium and

capsule is the joint. The joint is further covered by muscles and tenders, which

support the joint and also provide the power to move the joint.

What Happens in Osteoarthritis


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Modern review

In osteoarthritis changes occur both in the cartilage and the synovial fluid. Changes in

the cartilage are easily seen even without microscope and are therefore well known,

whereas changes in the synovial fluid are not discernible without the use of

specialized tests and equipments. The synovial fluid changes in character and

composition and it loses its characteristic capacity to behave in a jelly like manner and

act as a shock absorber when the joint is loaded. The cartilage therefore has to sustain

more load and impact.

At the same time the cartilage also undergoes subtle changes in chemical

composition in a way that proteoglycans decrease and water content increases. As a

result the collagen fibrils become disrupted and disorganized. The cartilage has now

become soft due to disorganization of tight collagen fibrils, and also swollen due to

increased water content. It has thus become less resistant to forces gradually develops

cracks or fissures, breaks into fragments usually known as fibrillations, becomes thin

and completely disappears in places.

Over a period of time most or all of the cartilage covering at the end of bone

may disappear. This is seen on x-ray as gradual decrease and then disappearance of

joint space. The loss of cartilage leaves the bone end exposed. Similar changes occur

on both sides of the joint and therefore now instead of cartilage moving against

cartilage, a situation develops where bone is moving against bone. These changes

abolish smooth and frictionless movement at the joint. The broken pieces of cartilage

and bone fragments lie in the synovial fluid and this irritates synovial membrane to

produce more fluid. This fluid, of course, is not of the same composition and physical

character as the normal synovial fluid. The joint swells up due to excessive fluid in it.

Bone rubbing against bone, stretching of joint capsule due to excessive fluid

and increased friction in the joint, all three elements produce pain and difficulty in


32

Modern review

moving the joint. This is perceived as stiffness in the joint as the increased effort

required to move the joint. Along with this, the range of joint movements becomes

less. The bone ends gradually become misshapen and develop bony spurn at the

margins called osteophytes. With advancing disease a part of the end of bone may be

extensively rubbed of and this produces severe deformity of the joint. The joint

deformity is most easily seen at the knee joint. In advanced osteoarthritis of knee the

leg does not remain straight but bends to one side commonly towards inside

producing bow leg deformity or sometimes bends outwards to produce knock-knee

deformity. Very briefly changes in the joint is like getting dirt in your eye. Similarly

the cartilage wears down and becomes fragmented into little pieces, which continues

to grind inside the joint.

Which Joints Are Affected?

Although any synovial joint in the body may be affected with osteoarthritis, certain

joints are more often affected and these are as below: -

Knee - is the most commonly involved joint and gives rise to considerable problem

with walking and sitting on floor. The deformity of leg when disease has progressed

beyond a certain point is also seen and recognized by the person himself and others.

The deformity is usually of bowlegs and sometimes of knock-knees. Usually both

knee joints start to give trouble together, but in some persons disease may be seen to

start and produce symptoms in one knee first and the other knee start to give trouble

after a period of some months.

Hip - is the joint next in frequency to the knee where osteoarthritis develops. In India

hip osteoarthritis is less frequent than knee osteoarthritis due to many reasons, some

of which are not yet understood and defined. The trouble may start first in one hip and

then after some months the other hip starts to give trouble, or both hips can become


33

Modern review

symptomatic within a few weeks of each other. Hips affected with osteoarthritis

become stiff and move less in range than a normal hip. This produces not only pain

but also trouble in sitting on floor, sitting cross-legged and going up and down the

stairs. Eventually it may become impossible for the person to squat on floor, using the

stairs becomes a slow and painful ordeal, one leg appears to have become shorter and

the person limps while walking.

Spine - All parts of spine do not move. The spine can be divided into four parts. The

topmost section is cervical spine which is in the neck area, next is dorsal spine which

covers the length of chest, followed next by lumbar spine which covers length of

spine in relation to abdomen or lower back, and last portion is sacral and cocygeal

spine which covers the area of pelvic and ends at the tip of tailbone. Neck (cervical

spine) and lower back (lumbar spine) are the areas where wide range of movements in

all directions can occur and this is why it is possible for us to look around so easily

and bend our back in every direction. There are many small sized joints in spine and

they all share a part of motion. These small synovial joints can also develop

osteoarthritis and produce backache and difficulty in getting up from sitting and lying

position.

Curiously the pain due to osteoarthritis of these small spinal joints is of two

different types. Some persons will get pain and stiffness in back after a period of rest

and will get relief after walking for few minutes. Opposite to that some persons will

get pain and stiffness after being up and about for past of the day and get relief with

rest. In addition swelling at these joints can press on the nerves and produce symptom

of sciatica or the pain radiating to leg and thigh. Similarly pain from swelling of joints

in cervical spine can radiate to arm and hand.


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Modern review

Hands - Osteoarthritis in hand, most often causes trouble at joint at the base of thumb.

This joint has peculiar shape to allow wide range of thumb movements in all

directions. With this joint becoming stiff and painful the person starts to feel difficulty

in gripping and holding objects. Next commonly affected joints in hand are the small

joints at the end of fingers. At these joints osteoarthritis causes limitation of

movements and some irregular swellings. The end of finger may not straighten fully

and the shape starts to look odd. Fortunately the functional at end of fingers, while

functional difficulty is much more when joint at the base of thumb is affected.

Osteoarthritis

Osteoarthritis is also called as Degenerative Joint Disease or Arthrosis or

wear-and-tear arthritis. It represents the failure of diarthrodial joint.

It is the most common joint disease of humans. Osteoarthritis of knee is the leading

cause of chronic disability in developed countries. Primary osteoarthritis is idiopathic

and secondary osteoarthritis is due to many causes like secondary to trauma, due to

endocrinal disorders, metabolic causes, etc.

Risk factors for Osteoarthritis

Age – It is considered to be one of the powerful risk factor. Old age people are prone

to suffer with osteoarthritis and causes disability in them.

Sex – Both Males and females are affected, but osteoarthritis is more generalized and

more sever in older women. It is twice as common in women as in men. Osteoarthritis

of knee is common in women.

Women less than 45 years old – 2%

45 – 65 years – 30%

Older than 65 years – 68% will suffer.


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Modern review

Genetic – Point mutation in the cDNA coding for articular cartilage collagen have

been identified in families with chondrodysplasia and polyarticular osteoarthritis.

Trauma – Direct or indirect injuries to the articular cartilage lead to its degeneration.

Fractures of different bones, especially of weight bearing with or without involving

the joint can also cause alteration of ligaments and in articular surface of joint.

Repetitive stress – Abnormal posture, abnormal gait, and unequal length of leg will

exert stress and strain over the joint.

Endocrine disorders – Acromegaly, Hyperparathyroidism, Diabetes mellitus, Obesity,

etc. may lead to osteoarthritis.

Metabolic disorders – Like Ochronosis, Wilson’s disease may give rise to

osteoarthritis.

Calcium deposition diseases – Like CPPD deposition may lead to osteoarthritis.

Pathology

Although the cardinal pathologic features of osteoarthritis is a progressive loss

of articular cartilage, osteoarthritis is not a disease of any single tissue but a disease of

an organ, the Synovial Joint. The most striking morphologic changes in osteoarthritis

are usually seen in load bearing areas of the articular cartilage.

Osteoarthritis develops in either of two settings:

1.The biomaterial properties of the articular cartilage and subchondral bone are

normal, but excessive loading of the joint causes the tissue fail, or

2. The applied load is reasonable, but the material properties of the cartilage or bone

are inferior.

In the early stages the cartilages thicker than normal. With the progression of

osteoarthritis, joint surface thins then the cartilage softens. Then the integrity of the

surface is breached and vertical clefts develops. They are called as fibrillation. Then


36

Modern review

there develops deep cartilage ulcers, extending to bone. All the cartilage is

metabolically active and the chondrocytes replicate, forming clusters (clones). Later

cartilage becomes hypo cellular. There will be appositional bone growth in the bony

subchondral region, leading to the bony sclerosis. Growth of cartilage and bone at the

joint margins leads to osteophytes, which alter the contour of the joint and may resist

movement. The biochemical changes in osteoarthritis cartilage are increase in water

content, decrease collagen, proteoglycan, monomersize, hyaluronate, keraten

sulphate, and chondrotin sulphate, increase in proteoglycan synthesis, collagenase,

and proteoglycanase.

Clinical Features

Symptoms

Joint Pain

It is often described as a deep ache and is localized to the involved joint.

Typically, the pain of osteoarthritis is aggravated by joint use and relieved by rest, but

as the disease progresses, it may become persistent.

Stiffness

Progressive stiffness of the involved joint upon arising in the morning or after a

period of inactivity may be prominent but usually lasts less than 20 min. It is due to

spasm of muscles. There is no relation between the severity of degeneration and

morning stiffness.

Signs

Swelling

Physical examination of the osteoarthritis joint reveals localized soft tissue swelling

of mild degree. It is due to the changes in articular ends themselves, particularly

periarticular lipping.

Crepitus


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Modern review

The sensation of bone rubbing against bone evoked by joint movement is called as

crepitus. It is one of the characteristic sign of osteoarthritis joint.

Local Warmth ness

On palpation of the joint local rise in temperature indicative of sign of inflammation.

Muscle Atrophy

Periarticular muscle atrophy may be due to disuse or due to reflex inhibition of

muscle contraction.

Others

In advanced stage there may be gross deformity, bony hypertrophy, subluxation and

marked loss of joint motion.

Laboratory and Radiological Findings

The Diagnosis of osteoarthritis is usually based on clinical and radiographic

features.

In the early stages, the radiograph may be normal, but joint space narrowing

becomes evident, as articular cartilage is lost. Other characteristic radiographic

findings include subchondral bone sclerosis, subchondral cysts, and osteophytosis. A

change in the contour of the joint, due to bony remodeling, and subluxation may be

seen. There is often great disparity between the severity of radiographic findings, the

severity of symptom and functional ability in osteoarthritis.

No laboratory studies are diagnostic for osteoarthritis, but specific laboratory

testing may help in identifying one of the underlying causes of secondary

osteoarthritis. Analysis of synovial fluid reveals mild leukocytosis with a

predominance of mononuclear cells.


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Modern review

Approaches such as magnetic resonance imaging and ultrasonography have

not been sufficiently validated to justify their routine clinical use for diagnosis of

osteoarthritis or monitoring of disease progression.

Treatment

Treatment of osteoarthritis is aimed to reducing pain, maintaining mobility,

and minimizing disability. The vigor of the therapeutic intervention should be dictated

by the severity of the condition in the individual patient. For those with only mild

disease, reassurance, instruction in joint protection, and an occasional analgesic, may

all that required; for those with more severe osteoarthritis especially of the knee or

hip, a comprehensive programs comprising spectrum of non-pharmacological

measures supplemented by an analgesic and/or NSAID is appropriate.

Non-Pharmacological Measures

Reduction of Joint Loading

Osteoarthritis may be caused or aggravated by poor body mechanics.

Correction of poor posture and a support for excessive lumbar lordosis can be helpful.

Excessive loading of the involved joint should be avoided; patients with osteoarthritis

of the knee or hip should be avoided prolonged standing, kneeling and squatting.

Obese patients should be counseled to loose weight. In patients with medial

compartment knee osteoarthritis, a wedged in sole my decrease the pain. Complete

immobilization of painful joint is rarely indicated. In patients with unilateral

osteoarthritis of knee or hip, a cane, held in the contraleteral hand, may reduce joint

pain by reducing the joint contact force. Bilateral disease may necessitate use of

crutches or walker.

Physical Therapy


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Modern review

Application of heat to the osteoarthritis joint may reduce pain and stiffness. A variety

of modalities are available; often the least expensive and most convenient is a hot

shower or bath. Occasionally, better analgesia may be obtained with ice than with

heat.

It is important to note that patients with osteoarthritis of weight bearing joints

are less active and tend to be less fit with regard to musculo-skeletal and

cardiovascular status than normal controls. An exercise program should be designed

to maintain range of motion, strengthen periarticular muscles, and improve physical

fitness. The benefit of aerobic exercise includes increase in aerobic capacity, muscle

strength, and endurance; less exertion with a given workload and weight loss. Those

who exercise regularly live longer and are healthier than those who are sedentary.

Patients with hip or knee osteoarthritis can participate safely in conditioning exercises

to improve fitness and health with out increasing their joint pain or need for a

analgesics or NSAIDs.

Disuse of the osteoarthritis joint, because of pain will lead to muscle atrophy,

because particular muscles play a major role in protecting the articular cartilage from

stress, strengthening exercise are important. In individuals with knee osteoarthritis

strengthening of a particular muscle may result, with in weeks, in a decrease in joint

pain as great as that seen with NSAIDs.

Drug therapy of osteoarthritis

Therapy for osteoarthritis today is palliative, no pharmacological agent has

been shown to prevent, delay the progression of, or reverse the pathologic changes of

osteoarthritis in human. Although claims have been made that some NSAIDs have a

“chondroprotective effect”. Adequately controlled clinical trails in human with

osteoarthritis to support this view are lacking. In management of osteoarthritic pain,


40

Modern review

pharmacological agents should be used as adjuncts to non-pharmacological measures,

such as those described above, which are keystone of osteoarthritis.

NSAIDs often decrease joint pain and improve mobility in osteoarthritis - on

an average about 30% reduction in pain and 15% improvement in function.

Intra articular injection of hyaluronic acid is being used for treatment of

patients with knee osteoarthritis who have filed a program of non-pharmacological

therapy and simple analgesics.

Capsaicin cream reduces joint pain and tenderness when applied topically pts

with knee and hand osteoarthritis.


41

Chikitsa

Chikitsa

The main aim of treatment is to restore Svasthya. It means to restore

normal functions of Agni, Dosha, Dhatu, and Mala and to maintain mental health.

The primary importance of Cikitsa lies in Samprapti Vighatana.

Sandhi-Gata-Vata is a Vataja disorder. So general treatment of Vata

Vyadhi can be adopted, keeping an eye on the etiology of the same. Regarding the

specific line of treatment of Sandhi-Gata-Vata, Caraka is silent. Later authors like

Sushruta had mentioned effective line of treatment for the same. Other books like

Astanga Hridaya, Astanga Sangraha, Yogaratnakara, Bhavaprakasha had

mentioned specific line of treatment.

The below chart shows Chikitsa sutra mentioned in different texts.

Table

Cikitsa Sootra mentioned in different Samhita.

Treatment Su.Sa. A.Sa. A.Hr. Yo.Ra. Bh.Pr. Bh.Ra. Snehana + + + + + Abhyanga + Mardana + + + + Svedana + + + Upanaha + + + + + + Bandhana + + + Agnikarma + + + +

Snehana

Sandhi-Gata-Vata is a variety of Vata Vyadhi, where Snehana would be

very effective. Acc. to the use it can be administered in two ways –

Abhyantara Prayoga

Bahya Prayoga96

Abhyantara Sneha:

Here Sneha in the form of Pana, Bhojana, Basti and Nasya can be

administered in case of Sandhi-Gata-Vata.


42

Chikitsa

Bahya Sneha:

Bahya Snehas are many like Abhyanga, Lepa, Udvartana, Padaghata, Gandoosha,

Karnapoorana, Akshitarpana, Picu, Samvahana, Mardana, Murdhnitaila, and

Parisheka. In case of Sandhi-Gata-Vata we get the mentioning of Abhyanga and

Mardana.

Abhyanga means to do some 'movements' or 'Gati'. For the purpose of

Abhyanga Sukhoshna Taila or Sneha is used. Abhyanga should be done slowly in

Anuloma Gati, in joints it should be done in circular manner. Abhyanga should

be done minimum for 5 minutes because the Veerya of Taila will reach Majja

Dhatu in 900 Matra-Kalas. It is Vatahara, Pushtikara97, 98. Mardana is like

Abhyanga but applied pressure is more.

Svedana

Svedana is a variety of Shadvidhopakrama. It is helpful in neutralizing

Stabdhata, Shitata and Gauravata99. In case of Sandhi-Gata-Vata varieties of

Svedanakrama like Upanaha and Bandhana are indicated.

Upanaha

Both Sushruta and Caraka consider Upanaha as a variety of Svedana100,

101. Roots of Vatahara drugs should be pasted together with Kanji and mixed with

abundant quantity of Saindhava Lavana and Sneha. After making this lukewarm,

it should be applied to the affected part. The paste of drugs included in the

Kakolyadi, Eladi or Surasadi groups as well as pastes of Sarshapa, Tila, or Atasi

or Krishara, Payasa, Utkarika and Vesavara or the drugs of Salvana Sveda should

be similarly applied to the affected part folded in piece of thin linen and tied up102.

Bandhana Dravya in Upanaha

For the purpose of Bandhana, Caraka opines that leather of Ushna Veerya

animal can be used. In the absence of this silk or woolen cloth can be used103.


43

Chikitsa

Astanga Hridayakara opines that 'Vatahara' Patras should be used104 and Caraka

suggests Eranda Patra105.

Duration

Upanaha, which is tied in the morning, should be removed in the night and

which is tied in the night should be removed in the morning106.

Sneha Pramana

According to Vata, Pitta, Kapha, Sneha should be added 1/4,1/6/1/8th of the

Upanaha Dravya.

Bandhana

Acharya Susrutha again subdivides this into 3 types:

a) Pradeha

b) Sankara

c) Bandhana

Pradeha

Thick paste prepared by Amla Kanji in Vataharadravya after adding

Saindhava Lavana and Sneha, Svedana is done. Dalhana called this as

Upanaha107.

Sankara Sweda

In Sankara Sveda, paste made out of Vatahara Dravyas, Amla Kanji,

Saindhava Lavana and Sneha etc., taken in a piece of cloth and Potali is prepared.

Dalhana considered this as Upanaha108.

Bandhana

In Bandhana Upanaha Dravya is tied to the affected apart.


44

Chikitsa

Agnikarma

Unique treatment indicated in case of Sandhi-Gata-Vata. Here Dahana or

cauterization is done in the part affected. Dahana Karma should be done in the

affected joint till the Samyak Laxana.

Hence the different treatment modalities mentioned by different authors

can be concise under these three (Su.Sa.Ci.4/8 & Dal; A.Sa.Ci.23/13;

A.Hr.Ci.21/22; Yo.Ra.Ci.Vat; Bh.Pr.Ci.24/259).

Janu-Basti

Vagbahta has described four types of oil application on head under

Murdha Taila, which are Shiro-Abhyanga, Shiro-Seka, Shiro-Picu and Shiro-

Basti. In Shiro-Basti the head is immersed with oil by putting a cap on the head.

As one of the meanings of Basti is to fill and reside, therefore the word Basti has

been added to Shiro. Shiro-Basti, where oil is kept on head by making an artificial

pit for prescribed time.

Later on some physicians made an artificial pit around the Kati with the

help of Masha powder to keep hot oil for prescribed period and named it as Kati-

Basti. Later on the process was carried out on the affected knee with the name of

Janu-Basti; and now crazy people even start doing Hridaya-Basti on the cardiac

region.

Derivation

Here the term "Janu-Basti" consists of two words i.e.,

1. Janu 2. Basti

Janu

Vyutpatti - Jan - Junn

Nirukti - Uru Jangayormadya Bhaga109(Shabda Stoma Mahanidhi)

Janu-Sandhi i.e., the knee joint


45

Chikitsa

In general 'Janu' means - the junction between Uru and Jangha.

Basti

“Vas” is formed by the Tich Pratyaya.

It belongs to masculine gender.

The word “Vas” means – to reside, to abide, to produce effect of aromatic drugs.

Meanings related to organ

- Organ that lies below the umbilicus (Nabhi).

-Organ in which the urine is collected and retained for some specific Period of

time. (“Bastih- Basteh Avrinoti Mootram”, Nabheradhobhage Mutradhare

Sthane).

-Ashaya.

Meanings related to Karma

- Here the urinary bladder of animals is used to inject the drugs into the rectum

(“Bastinadeyate Eti Bastih”, “Bastibhirdeeyate Yasmaat Tasmat

Bastiritismrutah”110, 111.

The word 'Basti' is used here with the meaning of “to reside”, “to retain”.

In 'Janu-Basti' the medicine is made to dwell or retain over the Janu-Sandhi for a

prescribed time.

Bahya Shamana Chikitsa

In the 11th chapter of Sutrasthana Caraka has classified Trividha Aoushadhi as

Anta-Parimarjana, Bahi-Parimarjana and Shastra-Pranidhana. Janu-Basti may be

included in Bahi-Parimarjana type of treatment.

Again on the basis of mode of application, the Bahya procedures may be

classified into -

1.Massaging type – Abhyanga, Mardana, Udvartana etc.

2.Pouring type – Kaya-Seka, Shiro-Dahra etc.


46

Chikitsa

3.Applying type – Picu, Alepa etc.

4.Retaining type – Shiro-Basti, Kavala, Gandoosha, Karnapoorana etc.

In massaging type body is massaged with the help of suitable drugs. Again

they are sub classified on the basis of nature of drugs used (Abhyanga – oil

Massage, Udvartana – powder Massage), force exerted (Samvahana – gentle

Massage, Abhyanga – pressure Massage), direction of movement (Abhyanga –

towards the direction of hair, Udvartana – Against the direction of hair) etc.

In pouring type medicated Kvatha, Ksheera or Sneha etc., are poured from

a specific distance over the required places. It may be Ekanga like Shiro -Dhara or

Sarvanga like Kaya-Seka. In application type the paste is applied to the affected

part. In Picu a piece of cotton is to be dipped in medicated oil and tied over the

effected part. In case of Alepa, paste of drug is prepared and applied to the part.

In retaining type medicine is made to retain in specific part of the body for a

prescribed time. Eg: Shiro-Basti - The word Basti is used here to indicate, "to

stagnate". In this procedure medicated oil is made to retain for a particular time in

head by constructing a pit.

Janu-Basti procedure is evolved from Shiro-Basti procedure. Hence Janu-Basti is

a Bahya Samshamana Chikitsa (Retaining type).

Sandhi-Gata-Vata is a variety of Vata Vyadhi. The symptoms and treatment of -

Sandhi-Gata-Vata is explained under this chapter in all the classics. The principle

line of management is Snehana, Svedana and Agnikarma. Among which Snehana

and Svedana are Samprapti Vighatana Chikitsa.

Janu-Basti is one such procedure that may do both Svedana and Snehana.

In Janu-Basti the prepared medicine (medicated oil,) is made to retain over the

Janu-Sandhi for a prescribed time.


47

Chikitsa

Procedure of Janu-Basti

All the procedures are performed in systematic manner. According to Sushruta it

can be performed in three stages like

1. Poorva karma

2. Pradhana karma

3. Paschat karma112

The procedure of Janu-Basti is explained accordingly

I. POORVA KARMA

This includes preparatory measures taken for smooth conduction of the procedure.

They are

1.Atura Pareeksha

The patient is examined with reference to Prakriti, Vikriti etc. ten factors by

applying Pratyaksha, Anumana and Aptopadesha. Which will assess Vyadhibala

and Dehabala113.

Then affected knee should be Examined properly and mark the tender area.

Examine for scares, wounds in the joint.

2.Sambhara Sangraha

Materials required for Smooth conduction of Janu-Basti procedure has to

be collected. They include – A metal ring, Masha powder, medicine Ksheera

BalaTaila spoon, bowl, vessel, water, gas stove, and cotton.

3.Atura Siddhata

Patient is asked to lie down or to sit erect on the table. Expose the affected

knee properly. Support the limbs so that they are placed horizontally and

comfortably.


48

Chikitsa

II. PRADHANA KARMA

1.Basti Yantra Dharana

Initially paste of Masha powder is prepared by adding sufficient quantity

of water to it. Then with the help of a metal ring and Paste of Masha a pit is

constructed around Janu-Sandhi of about 2-3 Angula height. The concavity of pit

(Basti Yantra) should be well sealed to retain the medicine.

2.Taila Dharana

The bowl containing Medicine Taila Ksheera Bala tail is heated gently by

keeping over hot water. Then gently heated Luke warm Medicine is poured

slowly and carefully on the Janu-Sandhi along the side of the BastiYantra. The

heat of the medicine should be sufficient enough to tolerate by the patient. The

quantity of the medicine should be two Angulas above the skin surface.

3.Maintenance of constant temperature of medicine

Keep on changing the medicine with the heated one so that a constant

temperature is maintained through out the procedure.

4.Removal of Taila and Basti Yantra

After the prescribed time the oil should be removed from the BastiYantra.

Then BastiYantra is to be removed.

5.Samyak Lakshana

Samyak Lakshana of Janu-Basti is not mentioned in classics. Samyak

Lakshana of Shiro-Basti cannot be interpreted even though Janu-Basti is

modification of it. Since it is a type of Sveda and Sneha, Samyak Sveda and

Samyak Sneha Lakshanas can consider.

Among Samyak Sveda Lakshana Sheetoparama, Stambhanigraha,

Gauravanigraha and Vyadhihani can be considered for assessment. In case of


49

Chikitsa

Samyak Snigdha Lakshanas Snigdha Gatratva and Mrudu Gatratva can taken for

assessment.

5.Time

In case of Vataja disorders the medicine should be retained for ten

thousand Matra Kala. Hence the procedure is performed for 50min each day.

III. PASCHAT KARMA

After removing the oil and BastiYantra Mrudu Abhyanga is done over the

Janu-Sandhi for about 5 min.

Duration - This treatment is done for 14 days.

1. Benefits of Janu-Basti

2. It relieves the symptoms like Shoola, Stabdhata, and Atopa.

3. The procedure acts on various properties of Vata that are instrumental in

the pathology of Janu-Sandhi-Gata-Vata mainly due to Snehana and

Svedana. Also medicines used in the procedure help in alleviating Vata.

4. It is a very safe procedure.

5. The materials required for Janu-Basti are easily available.

6. It is cost effective.

7. Janu-Basti can be done in an outpatient set up also.

Absorption Through Skin

It is very difficult to explain the mode of action of Janu-Basti. Here an

attempt is made to explain the probable mode of action of Janu-Basti.

Janu-Basti is a Bahya Svedana, Snehana (if oil is used) and more over it is an

Sthanika Shamana Cikitsa.

Acarya Sushruta in Shareerasthana explains – Out of the four Tiryak Dhamanis,

each divides gradually hundred and thousand times and thus become innumerable.

These cover the body like network and their openings are attached to Romakoopa.


50

Chikitsa

Through them only Veeryas of Abhyanga, Parisheka, Avagaha, Alepa enter into

the body after under going Paka with Bhrajaka Pitta in skin114.

One more reference in Sushruta Cikitsasthana explains – Sneha used in Avagaha

produces Shareera Bala by saturating through Siramukha, Romakoopa and

Dhamani115.

Sushruta in Sutrasthana explains, Lepa like Bahirparimarjana treatments

yield result by entering to Romakoopa thereby circulating through Svedavaha

Srotas116.

Vagbhata in Ashtanga Hridaya while explaining the functions of Bhrajaka

Pitta narrated that – Bhrajaka Pitta will be do Pacana of drugs used in Abhyanga,

Parisheka, and Lepa117, 118.

Thus with the above references it can be said that drugs used in Janu-Basti

procedure get absorbed through and produce action according to the property of

the medicine.

The skin anatomically consists of three distinct layers.

The epidermis

It consists of keratinocytes, melanocytes, langerhan’s cells and merkel cells. The

terminal point of keratinocytes differentiation is the formation of the stratum

corneum. Formation of this layer is the most important function of the epidermis.

It protects the skin against water loss, prevents the absorption noxious agents, and

can be thought of as consisting of bricks and mortar. Corneocytes forms the bricks


51

Chikitsa

and barrier lipids form the mortar. ‘Granular cells’ which are stratum corneum

helps in maintaining skin hydration and their products serve as ultra violet filters.

Lamellar granules also are found within granular cells. These contain probarrier

lipids.

Dermis

It is a thick, highly vascular layer made up of ground substance,

fibroblasts and collagen fibers, together with appendages of skin, sweat glands

and pilosebaceous follicles. It is metabolically active part of the skin.

Subcutaneous Tissue

It is a fibro fatty layer with varying quantities of adipose tissue in different

regions of the body. It provides physical and thermal protection to the deeper

structures of the body.

Drug Delivery

The primary barrier to absorption of exogenous substances through the

skin is stratum corneum. Rate of absorption is directly proportional to

concentration of drug in vehicle, partition co-efficient, diffusion co-efficient and

thickness of the stratum corneum. Physiological factors that effect per cutaneous

absorption include hydration, occlusion, age, intact versus disrupted skin,

temperature and anatomic site.

Among vehicles greases are anhydrous preparations that are either water

insoluble or fatty. Fatty agents are more occlusive than water-soluble. They

restrict transepidermal water loss and hence preserve hydration of the stratum

corneum.

Absorption depends upon lipid solubility of the drug since the epidermis

as a lipid barrier. The dermis however is freely permeable to many solutes.

Suspending the drug in an oily vehicle can enhance absorption through the skin.


52

Chikitsa

Because hydrated skin is more permeable than dry skin. Application of

medicaments, heat and massage definitely helps in eliminating the number of

noxious elemtes through skin. The application of heat in different forms of

Svedana promotes local circulation and metabolic activities and also opens the

pores of the skin to permit transfer of medicaments and nutrients towards to

needed sites and elimination of vitiated Doshas and Malas through skin and

perspiration.

PHYSIOLOGICAL EFFECTS OF HEAT

Heating the tissues results in increased metabolic activity, increased blood

flow and stimulation of neural receptors in the skin or tissues and many other

indirect effects.

Increased metabolism

The increase in metabolism is greatest in the region where most heat is produced,

which is in the superficial tissues. As a result of the increased metabolism there in

any increased demand for oxygen and foodstuffs, and an increased output of

waste products, including metabolites.

Increased blood supply

As a result of increased metabolism, the output of waste products from the cells is

increased. These include metabolites, which act on the walls of the capillaries and

arterioles causing dilatation of there vessels. In addition, the heat has a direct

effect on the blood vessels, causing vasodilatation, particularly in the superficial

tissues where the heating is greatest. Stimulation of superficial nerve endings can

also cause a reflex dilatation of the arterioles. As a result of vasodilatation there is

an increased flow of blood through the area so that the necessary oxygen and

nutritive materials are supplied and waste products are removed.


53

Chikitsa

Effects of heating on nerves

Heat appears to produce definite sedative effects. The effect of heat on nerve

conduction has still to be thoroughly investigated. Heat has been applied as a

counter irritant, which is the thermal stimulus, may effect the pain sensation as

explained by the gate theory of Melzack and Wall.

Indirect effects of heating

Muscle tissue – Rise in temperature induces muscle relaxation and increases the

efficiency of muscle action, as the increased blood supply ensures the optimum

conditions for muscle contraction.

General Rise in temperature – As blood passes through the tissues in which the

rise of the temperature as occurred, it becomes heated and carries the heat to other

parts of the body, so that if heating is extensive and prolonged a general rise in

temperature occur.

Fall in blood pressure – If there is generalized vasodilatation the peripheral

resistance is reduced, and this causes a fall in blood pressure. Heat reduces the

viscosity of the blood, and this also tends to reduce the blood pressure.

Increased activity of sweat glands – There is reflex stimulation of the sweat

glands in the area exposed to the heat, resulting from the effect of the heat on the

sensory nerve endings. As the heated blood circulates throughout the body it

affects the centers concerned with regulation of temperature, and there is

increased activity of the sweat glands throughout the body.

(Ref. The pharmacological basis of therapeutics – Goodman and Gillman,

Physiology by Robert M. Berne, Clayton’s Electro therapy by Angela Forster,

Nigel Palastanga, Text book of Pharmacology by K.D. Tripati)


54

Chikitsa

Sadhyasadhyata

If Sadhyasadhyata of a particular disease is well under stood and analyzed

by a physician, it leads to the successful management of that disorder. So the

knowledge of Sadhyasadhyata is very essential before the administration of any

therapeutics or medicaments.

Sandhi-Gata-Vata is not a fatal disease, but it cripples the patient and make

him/her burden to others. Due to its tendency to be fatal or incurable, Vata Vyadhi

considered as Mahagadha by almost all Acaryas.

Dhatukshaya is the chief cause of Vata Vyadhi. Dhatukshaya is difficult to treat as

Acarya Vagbhata has elaborated that since body is accustomed to Mala,

Dhatukshaya is more troublesome than Dhatu Vruddhi. Sandhi-Gata-Vata is one

of the Vata Vyadhi therefore it is Kashtasadhya.

The ailments of aged persons are Kashtasadhya and Sandhi-Gata-Vata is the

affliction of elderly persons. Diseases situated in Marma and Madhyama

Rogamarga is Kashtasadhya. Sandhi-Gata-Vata is a disease of Sandhi, which falls

under Madhyama Rogamarga. Further Vata Vyadhi occurring due to vitiation of

Asthi and Majja are most difficult to cure.

In the list of Kashtasadhya Vata Vikara, Acarya Caraka does not mention Sandhi-

Gata-Vata but while commenting on word ‘Khuddavata’ Cakrapani explains the

meaning of Khuddavata as Gulphavata or Sandhi-Gata-Vata. Thus Sandhi-Gata-

Vata can be considered as Kashtasadhya Vata Vyadhi.

Pathya- Apaathya

The Ahara and vihara that prevents aggravation of the disease and aids in

the relief at the same time without initiating another disease are known as pathya.

Acharya Charaka is one step ahead by saying Pathya is one which is suitable to

the body and mind both in health as well as diseased condition.Though no one


55

Chikitsa

Acharyas has mentioned pathya and apathya for sandhigatavata directly, as this

disease being a vatavyadhi we should adapt the samanya vatavyadhi patyapathya.

Pathya

A. Rasavarga - Madhura, Amla, lavana rasa

Shukadhanyavarga - Naveena godhuma, Samvatsarothitashali, Rakta Shali,

Shashtikashali.

Shimbi varga - Naveena tila, Naveena masha, kulatha

Shaka varga - Patola, shigru, vartaka, lasuna

Phala varga - Draksha, dadara, pakva amra, parushaka, jambeera, dadima,

pakvatala phala

Mamsa varga - Ushtra, go, varaha, mahisha, hamsa, mayura, bheka, nakula,

chataka, kukkuta, tithira, sheelindra, kurma, thimingila, rohita etc.

Jalavarga - Ushna jala, Shritasheetajala, Narikelajala

Dugdha varga - Go, aja ksheera, dadhi, grita, kilata, kurchila

Mutra varga - Gomutra

Madhya - Dhanyamla, sura

Sneha - Tila, gritha, vasa majja

Vihara - Bhushayya, snana, samhvahana etc.

Chikitsa - Abhynga, brimhana, sanbrpana, tiladroni, shirobasti, avagaha, nasya,

upanaha, agnikarma.

Apathya

Ahara - Katu, tikka, kashayarasa

Shimbi dhanya - Rajamasha, nishpara, mudga, kalaya

Shuka dhanya - Trunadhanya, trunaka, kangu, koradhusha, neevara,

shyamaka, chanaka

Phala varga - Jambu, udumbara, kramuka, tinduka


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Chikitsa

Mamsa varga - Sushkamamsa (Vallura), kapotha, paravata

Jalavarga - Nadeejala, Sheetambu, tadajala

Ksheera - Gardaba ksheera Vihara

Vihara - Chinta, jagarana, shrama, vyavaya, vyayama, chankramana, Hasti

ashwayana, vegadharana

Chikitsa - Vamana, Raktamokshana


57

Materials and methods

Material and Methods

Sources of data:

a. Patients suffering from Sandhivata will be selected from PG S&R PG

O.P.D of DGM Ayurvedic medical college and hospital by pre-set

inclusion and exclusion criteria.

b. Literary: Literary aspect of study will be collected from classical

ayurvedic and modern texts updated with recent medical journals and

previous work done in different research center.

c. Trial drug Abhadi churna

Ingredients Botanical name quantity

Abha Acasica Arebica 1 part

Rasna Plucha lansiolata 1 part

Guduchi Tinospora cardifolia 1 part

Shatavari Asparagus recemosa 1 part

Shunthi Gingeber officinalis 1 part

Shoufa Anethum sowa 1 part

Aswagandha Withenia sominifera 1 part

Hrivera juniperous communies 1 part

Vidhara Desmodium gungenticum 1 part

Yavani Roxburghiamum ammi 1 part

Composition Ksheera Bala tailam :

Bala moola twak sida cardifolia 1 part

Ksheera milk 4 part

Tila taila sesamum indicum 4 part


58


Abha119

Latin name : Acacia arebica

Family : Mimosaceae

Synonyms : Vabboola, Vabbula, Barbara

Rasa : Kashaya

Guna : Guru, Rooksha

Virya : Sheeta

Vipaka : Katu

Doshaghnata : Kaphapitta

Part Used : Bark, Gum, Leaves, Seeds & pods

Karma : Kusta, Krimi, raktatisara, Prameha, Pradaranashana.

Chemical Composition: Arabic acid, calcium, magnesium & potassium, Malic

acid, sugar, ash, Tannin.

Action and Uses:120 Astringent, demulcent, aphrodisiac, nutritive & expectorant.

It is used gonorrhea, cystitis, vaginitis, leucorrhoea, and coughs.

Rasna121

Latin name :pluchea lanciolata

Family :zingberacea

Synonyms :suganda kulananjana

Ganas :vedanastapaka anuvasanopaka vayastapaka arkadigana

Rasa :tikta katu

Guna :guru

Veerya :ushana

Vipaka :katu

Doshagnata :kapha vata shamaka


59


Parts used :Rhizomes

Karma : vata shamaka vedana shamana kasa swasa vatarakta jwara

vishagna rasayana

Chemical composition122:it consists of campharide galnin alpenin it contains an

volatile oil

Consists of methyle cinnamate cineole camphor pinene it also contains oily

pungent galangon alpinol galanginand di_oxyflaanol

Guduchi123

Latin name : Tinospora cordifolia

Family : Menispermaceae

Synonyms : Amrita, Madhuparni, Chhinna, Rasayani

Gana : Vayasthapana, Dahaprashaman, Trishnanigrahana,

Stanyashodhan, Truptighna.124

Guduchyadi, Patoladi, Aragvadhadi, Kakolyadi,

Vallipanchmoola125

Rasa : Tikta, Kashaya

Guna : Laghu, Snigdha

Virya : Ushna

Vipaka : Madhur

Doshaghnata : Tridoshashamak

Parts used : Stem

Karma : Rasayan, Dipan, Balya, Samgrahi

Rogaghnata : Jvara, Pandu, Kushtha, Vatarakta, Krimi

Chemical Composition:126

Giloin, a glycoside, Gilenin a non-glycoside and Gilosterol are found in

stem. Presence of bitter principles of columbin, chasmonthin and palmarin in the


60


drug has been reported (Chopra et al 1958). Tinosporin, tinosporic acid and

tinosporal have been reported in the stem. (Anon 1976)

Action and Uses:

Guduchi is considered as bitter tonic, astringent, diuretic and a potent

aphrodisiac. Its use has been indicated in heart diseases, hypertension and

rheumatoid arthritis.

The drug has been observed to relax smooth muscles of intenstine, uterus and

inhibit constrictor response of histamine and acetylcholine on smooth muscles

(Gupta et al, 1967). The drug has proved to be effective as antirheumatic and

diuretic as well as having anti-inflammatory properties. (Rai and Gupta, 1966).

The drug is reported to possess one fifth of the analgesic effect of sodium

salicylate.

Sathavari127

Latin name : Aspragus Racemoses

Family : Lliaceae

Gana : Balya vayastapana Madhuraskanda128

Vidarigandadi kantaka panchamoola pitta prashamana129

Synonyms : shatavari

Rasa : madhura tikta

Guna : Guru snigda

Virya : sheeta

Vipaka : madhur

Doshaghnata : tridosha shamka

Part Used : Root Leaves

Karma :. Vata pitta hara Vrashya Rasayana

Chemical Composition: Large number of saponin are found in shatavari


61


Action and Uses: 130Root empolyed in diarrohea

Shunthi131

Latin name : Zingiber officinale

Family : Zingiberaceae

Gana : Truptighna, Arshoghna, Deepaniya, Shoolaprashamana,

Sheetaprashamana,Trishna Nigrahana.132

Pippalyadi, Trikatu133

Panchkola, Shadushana134

Synonyms : Vishwa, Nagar, Shrungavera, Katubhadra

Rasa : Katu

Guna : Laghu, Snigdha

Virya : Ushna

Vipaka : Madhur

Doshaghnata : Kaphavataghna

Part Used : Dried Vhizome

Karma : Pachan, Ruchya, Shothaghna, Shoolaghna,Anulomana.

Chemical Composition:

Camphene, Phellandrene, Zingiberine, Cineol and borneol, ginerol.

Gingerin is the active principle. Other resins and starch, K-Oxalate are also

present .

Action and Uses:135

It is aromatic, carminative, stimulant to the gastrointestinal tract and

stomachic. It removes viscid matter, strengthens memory, and removes

obstruction in the vessels. It is used is nervous diseases, incontinence of urine.


62


Shoupha136

Latin name : Anathum soaa Kurz

Family : Umbelliferae

Gana : Asthapana -Su

Synonyms : Shoupha, Chatra,

Rasa : Katu, Teekta

Guna : Laghu, Ruksha, Teekshna

Virya : Ushna

Vipaka : Katu

Doshaghnata : Vatakapha

Part Used : Phalataila

Karma : Jwarahara, Shelsmahara, Vrunashoola

Chemical Composition: Volatile oil, Epinol, Karvoal, Hydrocarbon

Action and Uses: Carminatives, Somatic, Aromatic, Stimulant and Diuretic. It is

used in Hiccough, Colic & Abdominal pain. Application of roots in Rheumatic &

swellings of the joints.

Ashwaghanda137

Latin name : Withania somnifra

Family : Solanacae

Gana : Balya Branhaneeya Madhura skanda138

Synonyms : Ashvagandha Varka parni

Rasa : Katu, Tiktha, Kashaya

Guna : Laghu, Snigda

Virya : Ushna

Vipaka : Madhura

Doshaghnata : Kaphavata shamaka


63


Part Used : Moola, seeds

Karma : Balya, Hridroga, Ksaya, Shoosa

Chemical Composition:

Alkaliod somniferin Resin Phyto sterol

Action and Uses:

Vajeekara balya Rasayana Root &leaves are used as hypo tonic in

alcoholism leaves used as anti helmentic fruits &seeds are used as diuretics root

application is done in rheumatism in all cases of general debility nervous

exhuration

Havubera139

Latin name : Juniperus communis linn

Family : Pinaceae

Synonyms : Havubera, Hapusha, Hahusa

Rasa : Katu, Tikata


Virya : Ushna

Vipaka : Katu

Doshaghnata : Kaphavata

Part Used : Phala

Karma : Pittodara,Arsha, Grahini, Gulma, Shoola

Chemical Composition: Volatile Oil, Grape Sugar, Resin, Formic & Acetic acid

Action and Uses: Fruit is aromatic, carminative and stimulant, digestive, diuretic.

It is used in scanty urine chronic bright’s disease, Hepatic dropsy, cough

Gonorrhea, Leucorrhoea & Skin diseases.


64


Vridhadarak140

Latin name : Argyrea speciosa sweet

Family : convolvulaceae

Synonyms : vridhadaraka vidhara samudra shopha

Rasa : katu tikta kashaya

Virya : Ushna

Doshaghnata : Kapha vata shamaka

Part Used : Moola

Karma :Rasayana vata amavata arsha shootha hara

Chemical Composition: Acidic material

Action and Uses: Kaphagna shothahara balya rasayana

Yavani141

Latin name : Tachyspermumammi

Family : Umblliferae

Gana : Sheetaprashamana142

Caturbeeja143

Synonyms : Yavani, Ajamodika, Dipyaka

Rasa : Katu tikta


Virya : Ushna

Vipaka : Katu

Doshaghnata : Kaphavata Shamaka

Part Used : Phala

Karma : Rochana, deepana, vatanulomana, shoolapra shamana

Chemical Composition: Ajavon oil, Thaimol, Carvacrol, Thymene, Carotin,

potassium, and thiamine, Raiboflovin.


65


Action and Uses: As abhyanga in Shoota & vedanayukta vikara, Kasa, Swasa,

Hrddourbalya, Aruchi Agnimandya, Gulma, Phelha, Krimiroga.

Ajamoda144

Latin name : Carum roxbur giahum

Family : Umbelliferae

Gana : Shoolaprashama, Deepaniya145

Pippalyadi146

Synonyms : Ajamoda, Karashwa

Rasa : Katu, Tikta

Guna : Laghu, Sukshma, Teekshna

Virya : Ushna

Vipaka : Katu

Doshaghnata : Kaphavata shamaka

Part Used : Phala

Karma :. Deepana, vatanulomana, shulaprashamana

Chemical Composition: Volatile oil, & Stable oil,

Action and Uses: Balya krimigna hridya balya

Ingrediants of ksheera bala tail.

Ksheera147, 148

Out of eight types of ksheera Go ksheera is the one, which is hitam

Composition; It is made up of 87.4% water 12.6% milk solids.3.4% of protein

4.8% of minerals varios enzymes & nitrogenous compound.

Rasa Madhura

Guna :snigdha

Veerya .Sheeta

Vipaka :Madhura


66


Properties: Brihmana vrishya medhya balya jeevaneeya sandhanaka sarva satmya

Shwasa hara kasa hara .

Uses: pandu shwas Atisara jwara yoni roga &pitta roga

Tila Tail149, 150

Latin name: Sesum Indicum

Composition: Plamatic acid steoric acid olenic acid.

Rasa: Madhura

Guna Sookshma vyavai vishada guru sara

Propeties:vatagna aggravates pitta kapha deepana pachana .It gives strength

&stability to the body ,It is krimigna in nature .

Bala151, 152

Latin name :Sida cardi folia

Gana:Balya brihmaneeya Praja stapana madhura skanda (ca) Vata

sanshamana(su)

Kula : Malvaceae

Synonyms: bala khara yastika

Guna : Laghu snigdha

Rasa: madhura

Vipaka: madhura

Veerya: sheeta

Dosha gnata :pitta shamaka

Karma:grahee pittasra kshata shamana vatahara bala ojo vardhaka

Prayojya Anga :Moola Beeja

Chemical composition: Alkaliods fatty oil photo sterol

Action Uses: cooling astringent Aromatic, Roots are used in nervous &urinary

discards


67


Method of Prepration of drug

The trail drug abhadi churna is prepared as per the churna vidhi.

Ie.all the drugs with there use full parts are collected and made them into

choorna form, and all are taken in equal part.

Method of preparation of Ksheera bala tail

All the drugs are collected required for the preparation of ksheera bala

tail .after collecting kashaya and kalka of bala is prepared ,and equal quantity of

milk is added to that and paka is done for hundered times .

.

Method of collection of data:-

a) The samples are selected for by using S. R. S. techniques.

b) Groups two each having 15 patients.

c) Group A treated with Abhadi churna

D) Group B treated with Ksheera bala taila Janu basti

Study duration:

30 days and fallow –up 30 days

Exclusion criteria

• Patients below 30 years &above 70 years

• Pregnant woman Lactating mother

• Associated with simple or compound fractures

• Associated with trauma

• Associated with any other systematic or metabolic disorders

• Patients on steroid therapy

• Patient undergone surgery

Inclusion criteria


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• Patients suffering from the symptoms of sandhi vata

• Other than the above declared exclusion criteria

Criteria of diagnosis

On the basis of sign symptoms mentioned in the Ayurvedic texts

Posology

Abhadi choorna - 3 gm /day in divided doses

Ksheera bala taila Q.S

Subjective parameters

As designed in the classical Ayurvedic and modern texts

Objective parameters

• Swelling

• Walking time

• Flexion deformity

• ESR

Examination of knee joint

History

The common symptoms with which a patient generally presents

are pain, swelling, stiffness, mechanical disorders (e.g. Locking, giving way, click

etc.) and limp.

Inspection

• Both the lower limbs were fully exposed

• Patient was first examined in the standing position, both from front and

behind, secondly in the seated position, thirdly in the supine position and

lastly in the prone position.

• Swelling


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A) The limits of the swelling were clearly made out.

B) The gradings were allotted on the basis of criteria explained in the

end of this section.

C) The Varna of the Shopha was examined (Raga, Shyava or

Prakrutha).

D) Any deformities like genus valgum, varum etc. were examined.

E) Joint instability or buckling of the joint was examined.

F) Any abnormalities in the gait were examined.

G) Walking time was recorded (the time taken to cover 21 meters).

H) Any presence of muscular spasm was examined.

I) Muscular wasting above and below the joint was examined.

Palpation

• Local temperature was examined with the back of the hand and compared

to that of the other side.

• Local tenderness was also examined.

• Swelling

A) Pressing the suprapatellar pouch with one hand and feeling the

impulse with the thumb performed fluctuation test and the fingers

of the other hand placed on either side of the patella or the

ligamentum patellae.

B) Patellar tap was elicited by pressing the suprapatellar pouch with

one hand driving the whole of its fluid into the joint proper as to

float the patella in front of the joint. With the index finger of the

other hand, the patella is pushed backwards towards the femoral

condyles with a sharp and jerky movement. The patella can be felt

to strike on the femur, which is known as the patellar tap.


70


• Palpation of popliteal fossa - The patient was made to lie down prone on

the table. The knee joint was flexed and the popliteal fossa was palpated.

The knee joint, popliteal artery, areolar tissue, veins and nerves and the

tendons in and around the popliteal fossa were all palpated carefully to

detect any pathology here.

• Significance of click - If the click was associated with discomfort or pain,

careful examination was done. Commonest cause of intra-articular click is

OA.

• Patello-femoral and femoro-tibial components were palpated for any

tenderness or irregularity.

Movements

The movements permitted in the knee joint are mainly flexion and

extension. Minor degrees of abduction, adduction and rotations may be permitted

when the joint is partly flexed. Both active and passive movements were

examined.

• Flexion & Extension: Normally, the knee can be flexed until the calf

extended till the thigh and leg form a straight line.

• Abduction & adduction: These movements are virtually absent with knee

straight, but slight degrees of abduction and adduction are possible when

the knee is semi-flexed.

• Rotation: This movement is also not possible when the knee is straight.

When the hip and knee are flexed to 90 degrees, some degree of rotation is

possible.

Auscultation

During active or passive movement, the palm of one hand of the

physician was placed over the patella and crepitus was felt.


71


Assessment of results

Subjective objective parameters of base line data to post medication data

comparison is used for clinical Assessment of results

Grading of parameters

Pain 0-No complaints 2-Complains frequently 1-Tells on enquiry 3-Excruciating condition

Swelling 0-No complaints 2-Covers well over the bony prominence 1-Slightly obvious 3-Much elevated

Stiffness 0-Absent 1-Present Tenderness 0-No complaints 2-Winces the affected joint

1-Says the joint is tender 3-Winces and withdraws the joint

Walking time (to cover 21 meters)

0- Up to 20seconds 3- 41-50seconds 1- 21-30seconds 4- 51-60seconds 2- 31-40seconds

Flexion deformity

0- Full range of flexion 3- Up to 50% 1->75% & < Full range 2- 50-75%, 4- No Movement

Crepitus 0-None 1-Felt 2-Heard

E.S.R 0 – None, 1 - Present Aims Grading 1-Very Satisfied 4- Somewhat Dissatisfied

2- Somewhat Satisfied 5- Very Dissatisfied 3- Never Satisfied

Overall Assessment Of Clinical Response

• Good Response : >75% improvement in clinical parameters

• Moderate Response : 50-75% improvement in clinical parameters

• Poor Response : up to 50% improvement in clinical parameters

• No Response : 0 % or No improvement in clinical parameters


72

Results

Observation and Results

In the present clinical study subjective and objective changes were

considered for the assessment of Ayurvedic management of Sandigatavatas with

Abhadi churna taken orally & Ksheerabala taila janu basti. Thirty patients were

selected for the study, and were divided into two groups viz. in group A, 15

patients were administered with Abhadi churna taken orally & in group B, 15

patients were given janu basti with ksheerabala taila. All the patients were

assessed before and after the treatment. Both subjective and objective changes

were recorded according to the guidelines of proforma of case sheet.

The data were collected as follows: -

1. Demographic data

2. Data related to etiological factors, type and duration of chief complaints.

3. Data related to subjective and objective parameters before and after

treatment.

4. Data related to incidence of disease.

5. Statistical analysis and assessment for response.


73

Table No. A. Demographic data related to Evaluation of Abadi churna in Sandivata.

Sex Religion Occupation Economical

status

Food habits Response Sl.

No.

O.P.D

Age

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 4226 - + - - - - - + - - - + - - + - - + -

2 3284 - + + - - - - - + - - + - + - - - + -

3 3885 - + + - - - - + - - - + - + - - - - -

4 3489 + - + - - - - - + - - + - + - - - + -

5 4020 + - + - - - + - - - + - - + - - - + -

6 4035 - + + - - - - - - + - + - + - - - + -

7 4096 - + + - - - - - + - - + - - + - - + -

8 3051 - + + - - - + - - - - + - + - - + - -

9 160 + - - + - - - - + - + - - - + - + - -

10 380 - + + - - - - + - - + - - + - - - + -

11 514 + - + - - - + - - - + - - + - - - + -

12 1194 + - + - - - - - + - - + - + - - + - -

13 178 + - + - - - - + - - - + - + - - - + -

14 188 + - + - - - + - - - - + - + - - - + -

15 510 + - + - - - - - + - - + - + - - - + -

1 – Male, 2 – Female, 3 – Hindu, 4 – Muslim, 5 – Christian, 6 – Others, 7 – Sendentary, 8 – Active, 9 – Lobour, 10 – Others, 11 – Higher class, 12 – Middle class, 13 – Poor class, 14 – Veg, 15 – Mixed, 16 – Good, 17 – Moderate, 18 – Mild, 19 –Poor.

74

Table No. B Demographic data related to Evaluation of Ksheerabala taila Janubasti in Sandivata.

Sex Religion Occupation Economical

status

Food habits Response Sl.

No.

O.P.D

Age

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 3974 + - + - - - - - + - - + - + - - + - -

2 3670 + - + - - - + - - - - + - + - - + - -

3 3911 - + + - - - + - - - - + - + - - + - -

4 3915 + - + - - - - - + - - + - + - - - + -

5 4006 + - + - - - - - + - + - - + - + - - -

6 4184 + - + - - - + - - - - - + - + - - + -

7 150 - + + - - - - - - + - + - + - - + - -

8 4051 - + - + - - - - - + - - + - + - + - -

9 4111 + - + - - - - + - - - - + + - - - + -

10 4220 + - + - - - - + - - - + - + - - - + -

11 3650 + - + - - - - - + - - - + + - - + - -

12 4253 - + - + - - - - + - - - + + - - + - -

13 192 - + + - - - - - - + - - + + - - - + -

14 226 - + - + - - + - - - - - + - + - + - -

15 221 - + + - - - - - - + - - + - + - - + -

1 – Male, 2 – Female, 3 – Hindu, 4 – Muslim, 5 – Christian, 6 – Others, 7 – Sendentary, 8 – Active, 9 – Lobour, 10 – Others, 11 – Higher class, 12 – Middle class, 13 – Poor class, 14 – Veg, 15 – Mixed, 16 – Good, 17 – Moderate, 18 – Mild, 19 –Poor.

75

Results

Table.11 Distribution of patient according to age among groups.

Group A Group B Age in Yrs

No. of Patient % No. of Patient

%

30-40 1 6.66% 0 0% 40-50 8 53.33% 11 73.33% 50-60 5 33.33% 2 13.33% 60-70 1 6.66% 2 13.33%

Above chart shows most of the patients were of age group of 40 –50yrs is of 8(53.3%)

in number.. Minimum number of patients were5 (33.3%) of age groups of 60 –70yrs

&age group of 30-40 yrs is of 1 in number. &The other patients were belonging to the

age group of 50-60 yrs is of 5 in number in group A. and in group B maximum of

11(73.3%)patients were belonging to the age group of 40-50 years, and minimum of

2(13.3%) patients were belonging to the age group of 50-60&60-70 respectively.

0

2

4

6

8

10

12

No. of Patient No. of Patient

Group A Group B

30-40

40-50

50-60

60-70


76

Results

Table.12 Distribution of patient according sex among groups.

Group A Group B Sex

No. of Patient % No. of Patient %

Male 8 53.33% 8 53.33%Female 7 46.66% 7 46.66%

Above chart shows most of the patients were belonging male category i.e. 8in number

in both the group i.e. (53.33%) & other patients were belonging to the female

category i.e. 7in number (46.66%)

6.46.66.8

77.27.47.67.8

88.2


Group A Group B

Male

Female


77

Results

Table.13 Distribution of patient according to occupation.

Group A Group B Occupation


Sedentary 4 26.6 5 33.3 Active 4 26.6 2 13.33 Labor 6 40.6 5 33.3 Others 1 6.6 3 20.0

Table shows among 15 patients in Group A, maximum are Labor, i.e. 6(40.6%).

4(26.6%) are Sedentary & Active. Only 1(6.6%) was others. In Group B maximum

patient were Sedentary & Labor i.e., 5(3.33%), active were 2(13.33%) & 3(20%) were

others.

0

1

2

3

4

5

6

7


Group A Group B

Sedentary

Active

Labour

Others


78

Results

Table.14 Distribution of patient according to Economical status

Group A Group B Economical status


Poor 4 26.6 8 53.3 Middle class 10 66.6 6 40.0 High class 1 6.6 1 6.6

Among 15 patients in Group A, maximum patient belongs to middle class i.e. 10in

number (66.6%), whereas 1 patient was of higher class i.e.(6.6%) & other patients

were of poor class.4in number(26.6%). In Group B maximum patients belongs to poor

class i.e. 8 in number (53.3%)where as 6 patients were of middle class (40.0%) &

only 1patient belonging to higher class (6.6%)

0

2

4

6

8

10

12


Group A Group B

Poor

Middle class

High class


79

Results

Table.15 Distribution of patient according to Religion

Group A Group B Religion


Hindu 13 86.6 12 86.4 Muslim 2 13.4 3 13.4 Christian 0 00.0 0 00 Others 0 00.0 0 00

Among 15 patients in Group A maximum 13 patients belongs to Hindu (86.6%).

where as 2 patients were of Muslim,(13.4%) Christians & other religions were not

reported in present study. In Group B maximum of12 patients belongs to Hindu

(86.4%) where as 3 patients were of Muslim (13.4%) Christians & other religions

were not reported in present study.

0

2

4

6

8

10

12

14


Group A Group B

Hindu

Muslim

Christian

Others


80

Results

Table.16 Distribution of patient according to Diet

Group A Group B Diet


Vegetarian diet 12 80 11 73.3 Mixed diet 3 20 5 33.3

In the above table it was observed that maximum patients were of Vegetarian diet,

were12 in number (80%) and 3(20%0) were of mixed diet in Group A in group B The

maximum patients were of Vegetarian diet11 (73.3%), &5(33.3%) were of mixed.

0

2

4

6

8

10

12

14


Group A Group B

Vegetarian diet

Mixed diet


81

Results

Table.17 Distribution of patient according to affected to leg of Sandhivata.

Group A Group B Leg affected

No. Of Patient % No. of Patient %

Right 5 33.33% 3 20% Left 4 26.66% 4 26.66% Both 9 60% 8 53.33%

From above table it shows that among 15 Patient in Group A, maximum of

9(60%) patient presented with Sandhivata to the both legs. & 5(33.35) patients were

effected with Right leg. &5 patients were reported with left leg .In Group B maximum

8 (53.3) patients presented with Sandhivata to both legs, & 4(26.6%) patients were

reported with right leg,& 3 (20%) patients were reported with Sandhivata to left leg.

0123456789

10


Group A Group B

Right

Left

Both


82

Results

Table.18 Distribution of patient according to Agni

Group A Group B Agni


Manda 4 26.6 5 33.4 Vishama 5 33.4 4 26.6 Teekshna 2 13.4 3 20.0 Sama 4 26.4 3 20.0

From the above table it shows that in group A maximum of 5(33.4%) patients

are having agni and minimum of 2(13.4) patients are having teekshagni and remaining

4(26.6%) patients are having manda agni &samagni. In group B maximum of

5(33.3%). Patients are having mandagni and minimum of 3(20.0%)patients are having

teekshagni

0

12

3

45

6


Group A Group B

Manda

Vishama

Teekshna

Sama


83

Results

Table.19 Distribution of patient according to Koshta

Group A Group B Koshta


Mridu 4 26.6 5 33.3 Madhya 5 33.3 4 26.6 Kroora 2 13.4 3 13.4 Sama 4 26.6 3 33.4

From the above table it shows that in group A maximum of 5(33.4%)

patients are having madhyma kosta and minimum of 2(13.4%) patients are having

kroora and remaining 4(26.6%) patients are having mridu &sama kosta agni &. In

group B maximum of 5(33.3%) Patients are having madhyma kosta and minimum of

3(20.0%)patients are having kroora &Sama kosta. And remaining 4(26.6%) patients

are having kroora kosta

0

1

2

3

4

5

6


Group A Group B

Mridu

Madhya

Kroora

Sama


84

Results

Table.20 Distribution of patient according to Habits in patients.

Group A Group B Types of Habits


Smoking 3 20 1 6.6 Tobacco 3 20 1 6.6 Alcohol 2 13.4 5 33.3 None 7 16.6 8 53.3

The above chart shows that in group A maximum of 3(20.0%)patients smoking habit,

and 3(20.0%) patients are having tobacco chewing minimum of habit 2(13.4%)

patients are having habit of alcohol in take, and remaining 7 patients are having no

habits.

In-group B maximum of 5(33.3%) patients are having. habit of alcohol in take, and

minimum of 1(6.6%) of patients having smoking and tobacco chewing habit. other

8(53.3%) patients are having no habits.

0123456789


Group A Group B

Smoking

Tobacco

Alcohol

None


85

Results

Table.21 Distribution of patient according to Prakriti of patients.

Group A Group B Prakriti

No. of Patient % No. Of Patient

%

Vatapitta 6 40 5 33.4 Vatakapha 5 33.4 6 40 Kaphapitta 4 26.6 4 26.6

The above chart shows that maximum of 6(40.0%) patients were belonging to vata

pitta prakriti, and minimum of 4(26.6%) patients were belonging to the vata kapha

prakriti. remaining were 5(33.4%) patients were belonging to vata kapha prakriti in

group A.

In group B maximum of 6(40.0%) patients are having vata kapha prakriti.and

minimum of 4(26.6%)patients are having kapha pitta prakriti, remaining were

5(33.4%) patients were belonging to vata kapha prakriti in group B

0

1

2

3

4

5

6

7


Group A Group B

Vatapitta

Vatakapha

Kaphapitta


86

Results

Table.22 Distribution of patient according to different nidana bhavas.

Group A Group B Type of nidana


Swaprakopaka 8 9 Marmaghataka 3 3 Dathukshaya 4 3

The above chart shows that among 15 patients in group A 8(53.3%) patients are

having swaprakopaka nidana, &4(26.6%) patients are having dhatu kshya janya

nidana. other 3(20.0%) patients are having marmaabhigata janya nidana.In group

Bamong 15 patients

9(60.0%) patients are having swaprakopaka nidana &3(26.6%)patients are having

marmabhighata janya nidana. other 3(2606%)patients are having dhatu kshya janya

nidana.

0123456789

10


Group A Group B

Sw aprakopaka

Marmaghataka

Dathukshaya


87

Results

Table.23 Distribution of patient according to Chronicity of the disease among groups.

Group A Group B Duration in months


Up to 1 month 3 20 1-6 months 2 13.3 3 20.0 1-2 year 4 26.6 3 20.0 2-3year 3 20.0 4 26.6 3-4 year 2 13.3 2 13.3 4-5 year 1 6.6 3 20.0

The above chart shows that maximum of 4(26.6%) patients are having chronicity of 1-

2year. and 3(20.0%) patients are having chronicity of 2-3 year, 2(13.3%) patients are

having chronicity of 3-4year, &1(6.6%)patients are having chronicity of 4-5 year.

other 3(20.0%) patients are having duration of 1month in-group A. While in group B

maximum of 4(26.6%) patients are having chronicity of 2-3 years, & 3(20.0%)

patients are having chronicity of 1-2 years, 3(20.0%) patients are having chronicity of

4-5 years, and 2(13.3%) patients are having chronicity of 3-4 years. Other

3(20.0%) patients are having chronicity of 1-6 months.

00.5

11.5

22.5

33.5

44.5


Group A Group B

Up to 1 month

1-6 months

1-2 year

2-3year

3-4 year

4-5 year


88

Results

Table.24 Showing the incidence of Swelling in the patients.

Group A Group B Swelling


Grade 0 0 0% 0 0% Grade 1 0 0% 1 6.66% Grade 2 5 33.33% 4 26.66% Grade 3 10 66.66% 10 66.66%

The above chart shows that maximum of 10(66.6%) patients are having severity of

swelling Grade 3, and minimum of 5(33.3%) patients are having swelling severity of

grade 2in group A .In group B maximum of 10(66.66%) patients are having swelling

severity of grade 3&Minimum of 4(26.6%) patients are having swellingseverity of

grade 2,remaining 1(6.6%) Patient having severity of grade 1

0

2

4

6

8

10

12


Group A Group B

Grade 0

Grade 1

Grade 2

Grade 3


89

Results

Table.25 Showing the incidence of walking time in the patients.

Group A Group B Walking time in Grade

No. Of Patient % No. Of Patient

%

Grade 0 0 0% 0 0% Grade 1 3 20% 1 6.66% Grade 2 2 13.33% 1 6.66% Grade 3 10 66.66% 10 66.66% Grade 4 0 0% 3 20%

The above chart shows that maximum of 10(66.6%) patients are having walking time

of grade 3, & 3(20.0%) patients having walking time of grade1.remaining 2(13.3%)

patients are having grade 2.In group B maximum of 10(66.6%) patients are having

walking time of grade 3, and minimum of 1(6.66%) patient having grade 1&2

respectively.

02468

101214


Group A Group B

Grade 0

Grade 1

Grade 2

Grade 3

Grade 4


90

Results

Table.26 Showing the incidence of range of Flexion deformity in the patients.

Group A Group B Flexion deformity


Grade 0 0 0% 0 0% Grade 1 0 0% 0 0% Grade 2 4 26.66% 4 26.66% Grade 3 9 60% 11 73.33%

The above chart shows that maximum of 9(60.0%) patients are having flexion

deformity of grade 3, and minimum of 4(26.6%) patients are having grade2 in-group

A. In group B

Maximum of 11(73.3%) patients are having flexion deformity of grade 3, and

minimum of 4(26.6%) patients are having grade 2.

0

2

4

6

8

10

12


Group A Group B

Grade 0

Grade 1

Grade 2

Grade 3


91

Results

Table.27 Showing the incidence of Pain in the patients.

Group A Group B Pain


%

Grade 0 0 0% 0 0% Grade 1 0 0% 0 0% Grade 2 11 73.33% 3 20% Grade 3 4 26.66% 12 80%

The above chart shows that maximum of 11(73.3%) patients were having pain

severity of grade 2, and minimum of 4(26.6%) patients are having grade 3 in groupA.

In group B maximum of 12(80.0%) patients are having pain severity of grade 3,and

3(20.0%) patients are having grade2.

0

2

4

6

8

10

12

14

Group A Group B

Pain

Grade 0

Grade 1

Grade 2

Grade 3


92

Results

Table.28 Showing the incidence of Stiffness in the patients.

Group A Group B Stiffness


%

Grade 0 3 20% 2 13.33% Grade 1 12 80% 13 86.66%

The above chart shows that in-group A maximum of 12(80%) patients are having

stiffness of grade 1,and remaining 3(20.0%) patients are having grade 0.

In group B maximum of 13(86.6%) patients are having stiffness of grade 1,and

minimum of 2(13.3%) patients are having grade 0.

0

2

4

6

8

10

12

14

Group A Group B

Stiffness

Grade 0

Grade 1


93

Results

Table.29 Showing the incidence of Tenderness in the patients.

Group A Group B Tenderness


Grade 0 0 0% 0 0% Grade 1 0 0% 1 6.66% Grade 2 9 60% 6 40% Grade 3 6 40% 8 53.33%

The above chart maximum of 9(60.0%) patients are having tenderness of grade 2,and

remaining 6(40%) patients are having grade 3.In group B maximum of 8(53.3%)

patients are having tenderness of grade 3, &remaining 6(40.0%) patients are having

grade 2.

0

2

4

6

8

10

Group A Group B

Tenderness

Grade 0

Grade 1

Grade 2

Grade 3


94

Results

Table.30 Showing the incidence of Crepitus in the patients.

Group A Group B Crepitus


Grade 0 0 0% 1 6.66% Grade 1 5 33.33% 4 26.66% Grade 2 10 66.66% 10 66.66%

The chart shows that maximum of 10(66.6%) patients are having crepitus pf grade

2,and remaining 5(33.3%) are having grade 1in group A. In-group B maximum of

10(66.6%) patients are having grade2, and remaining 4(26.6%) patients are having

grade1.

0

2

4

6

8

10

12

Group A Group B

Crepitus

Grade 0

Grade 1

Grade 2


95

Results

Table.31 Showing the incidence of Weight of the body in the patients

Group A Group B Weight in Kg

No of pts % No of pts %

30-40 0 00 1 6.6 40-50 1 6.6 1 6.6 50-60 3 20.0 3 20.0 60-70 9 60.0 8 53.3 70-80 2 13.3 1 6.6

80-90 0 0 0 0

90-100 0 0 1 6.6

Above chart shows that in group A maximum of 9(60%) patients are in the 60

– 70 kg weight group. Only 1(6.6%) patients are in the 40 – 50 kg weight group.

0

20

40

60

80

Group A Group B

Column 1 30-40 40-5050-60 60-70 70-8080-90 90-100 Column 9


96

Results

Table.32 Master Chart – Subjective Parameter – Group- A

pain stiffness Tenderness Crepitus s.n o.p.d B A B A B A B A

1 4226 2 1 1 0 2 2 2 1 2 3284 2 1 1 0 3 1 2 1 3 3885 2 1 1 0 2 1 2 1 4 3489 2 1 1 0 3 2 2 1 5 4020 2 2 1 1 1 1 2 1 6 4035 2 1 1 0 2 1 2 1 7 4096 2 1 1 1 2 2 2 1 8 3051 3 2 1 1 2 1 2 1 9 160 2 1 1 0 3 2 2 1 10 380 2 1 1 0 1 1 2 1 11 514 2 1 1 0 1 1 2 1 12 1194 2 2 1 0 1 1 2 2 13 178 3 2 1 0 1 0 2 1 14 188 3 2 1 0 3 1 2 1 15 510 3 2 1 0 3 1 2 1

Table.33 Master Chart –objective parameter– Group- A

swelling Walking time

Flexion deformity

E.S.R Sl.No. Opd.no

B A B A B A B A 1 4226 2 1 43 33 2 1 15 10 2 3284 2 1 45 36 2 1 16 10 3 3885 2 1 48 32 2 1 10 10 4 3489 3 2 44 38 2 2 13 10 5 4020 3 2 42 32 3 1 20 20 6 4035 3 2 28 23 2 0 12 10 7 4096 3 2 43 36 2 0 13 10 8 3051 2 2 38 29 3 2 12 10 9 160 2 2 32 21 3 2 15 13 10 380 3 2 43 39 3 2 12 10 11 514 3 2 47 39 3 1 14 12 12 1194 3 2 48 22 3 2 11 10 13 178 3 1 41 22 3 1 10 10 14 188 3 1 43 22 3 2 12 10 15 510 3 1 48 24 3 2 15 13


97

Results

Table.34 Master Chart –Objective-Parameter – Group- B

swelling Walking time

Flexion deformity

E.S.R Sl.No. Opd.no

B A B A B A B A 1 3974 2 1 43 31 2 1 18 15 2 3670 2 0 48 39 3 1 16 10 3 3911 2 1 32 21 3 2 20 25 4 3915 3 2 43 33 3 1 15 18 5 4006 3 2 46 32 3 2 18 15 6 4184 3 2 43 28 3 2 20 22 7 150 3 2 54 43 3 1 18 15 8 4051 3 2 45 38 3 2 21 15 9 4111 1 0 32 15 2 2 20 15 10 4220 3 2 43 35 3 1 18 13 11 3650 3 2 56 49 3 2 19 15 12 4253 2 1 48 29 3 0 14 10 13 192 3 2 54 43 3 2 15 13 14 226 3 2 43 29 2 0 16 12 15 221 3 2 48 28 2 0 12 10

Table.35 Master Chart – Subjective Parameter – Group- B

Pain Stiffness Tenderness Crepitus Sl.No. O.p.d B A B A B A B A

1 3974 3 2 1 1 2 1 2 1 2 3670 2 1 1 0 2 2 2 1 3 3911 3 2 1 0 2 1 2 1 4 3915 3 1 1 0 3 1 2 1 5 4006 3 2 1 1 2 2 2 1 6 4184 3 1 1 0 3 1 2 0 7 150 3 2 1 1 3 2 2 1 8 4051 3 2 1 0 3 2 2 1 9 4111 2 1 1 0 3 1 2 0 10 4220 3 2 1 0 2 1 1 1 11 3650 3 2 1 0 3 2 1 1 12 4253 2 1 1 1 2 2 2 1 13 192 3 2 1 0 3 2 1 0 14 226 3 2 1 0 3 2 2 1 15 221 3 2 1 0 2 1 1 0


98

Results

Table.36 Statistical Assessment of Individual Study Group – A (Subjective& Objective Parameter) Sl.No Parameters Mean S.D S.E t- value P - value Remarks1 Pain 0.466 0.516 0.133 3.503 <0.01 H.S

2 Stiffness 0.8 0.414 0.106 7.547 <0.001 H.S 3 Tenderness 1.0 0.654 0.169 5.917 <0.001 HS

4 Cripatus 0.933 0.258 0.066 14.0 <0.001 H.S

5 Swelling 1.066 0.593 0.153 6.791 <0.001 H.S

6 Walking Time

12.33 7.077 1.827 6.748 <0.001 H.S

7 Flexion deformity

1.2 0.676 0.174 6.68 <0.001 H.S

8 ESR 2.133 1.684 0.434 4.914 <0.001 H.S

Table.37 Statistical Assessment of Individual Study Group – B (Objective Parameter) Sl.No

Parameters Mean S.D S.E t- value P - value Remarks

1 Pain 1.133 0.351 0.0908 12.477 <0.001 H.S

2 Stiffness 0.733 0.457 0.118 6.211 <0.001 HS

3 Tenderness 1.00 0.654 0.169 5.917 <0.001 HS

4 Crepatus 1.00 0.534 0.138 7.24 <0.001 H.S

5 Swelling 1.2 0.414 0.106 11.32 <0.001 H.S

6 Walking Time 11.8 3.509 0.906 13.02 <0.001 H.S 7 Flexion

Deformity 1.466 0.743 0.191 7.67 <0.001 H.S

8 ESR 3.8 1.373 0.354 10.734 <0.001 H.S


99

Results

Table.38 Statistical Assessment of Comparative study of Group – A with Group – B

Sl.No

Parameters Group Mean S.D S.E P.S.E t- value P - value Remark

s

A 1.4 1.507 0.130 1

Pain B 1.666 0.487 0.125

0.180 1.44 >0.05 NS

A 0.2 0.414 0.106 2 Stiffness

B 0.266 0.457 0.118 0.106 1.886 >0.05 NS

A 1.8 0.774 0.2 3

Tenderness B 1.533 0.516 0.133

0.240 1.107 >0.05 NS

A 1.066 0.258 0.066 4 Crepatus

B 0.733 0.457 0.118 0.135 2.46 <0.05 HS

A 1.6 0.507 0.131 5 Swelling

B 1.533 0.743 0.191 0.231 0.29 >0.05 NS

A 29.86 6.93 1.791 6

Walking time B 32.866 8.76 2.263

2.88 1.043 >0.05 NS

A 1.333 0.723 0.186 7

Flexion Deformity

B 1.266 0.798 0.206

0.277

0.241

>0.05

NS

8 ESR A 11.2 2.67 0.691 0.699 5.23 <001 HS

B 14.86 4.22 1.090

Conclusion To compare mean effect of two groups we used un pared t test by assuming

that The mean effect of two groups is same in all the parameters. From the analysis

the objective parameter ESR shows highly significance than the other, (From table

1by comparing P value)

The objective parameter ESR walking time, the mean effect is more in-group B


100

Results

With more variation after the treatment .the parameter FD& swelling the mean effect

is more, the variation in-group B of swelling FD is more (by comparing mean &SD).

Among sub parameters pain in group-B.the mean effect is more after the

treatment, the parameter crepitus having more mean effect is more with less variation

in group A after the treatment.

To know the individual effect of group A&B the analysis is done by

paired t test by assuming that the drug is not responsible for the changes in the

observation before &after the treatment.

The groupB in the objective parameters swelling walking time flexion

deformity& ESR shows more highly significance than group A, where as in the

subjective parameter the pain in groupB and crepitus in group A shows more highly

significance. (Comparing t, p value from table 2&3) and tender ness in-group B is

more highly significant than group A.


101

Results

Table.39 Over all assessment

Group A Group B Response


Good Response 0 0% 1 6.66% Moderate Response 4 26.66% 7 46.66%Poor Response 11 73.33% 7 46.66%No Response 0 0% 0 0%

In-group A, 4 patients (26.66%) had Moderate response to the treatment and

11 patients (73.33%) had Poor response to the treatment. In-group B, 1 patients

(6.66%) had good response to the treatment and 7 patients (46.66%) had Moderate &

poor response to the treatment,. In the study as a whole, 1patients (3.33%) had good

response, 11 patients (36.66%) had moderate response and 18 patient (60%) had poor

response.

02468

1012

Group A Group B

Good Response Moderate Response Poor Response No Response


102

Discussion

Discussion

Discussions on this study are made under the following headings:

1. Sandhigatavata vis-a-vis Osteoarthritis

2. Clinical study

3. Probable mode of action of Abhadi churna

4. Probable mode of action of Janu basti

Sandhigatavata vis-à-vis Osteoarthritis

Sandhigatavata is the most common joint disorder worldwide. It is

a disorder caused by the localization of the vitiated Vata dosha in the asthi sandhis

of the body. It is one among the many Vatavyadhis described by all the acharyas

of Ayurveda. It comes under the various Gatavatas explained in Vatavyadhi

prakarana. It is characterized by the symptoms pertaining to the asthi sandhis like

sandhi shoola, sandhi shopha etc.

Osteoarthritis is a disease coming under the arthritis group of diseases

described by the modern science, which is almost identical to Sandhigatavata in

etiology, pathology and clinical features. Hence, the discussion is made here step

by step starting from the shareera to the roopa.

Sandhis are the union of the asthis and in them are located the Sleshaka

Kapha and Sleshmadhara kala, both of which lubricate the sandhis, thereby

reducing the friction during various joint movements. Various snayus and peshis

are responsible for the compactness of the joints and support in their functions.

Also, several marmas are located in the Sandhis whose protection is inevitable in

maintaining the normal functions of these sandhis. Role of Vyanavata is most

important in the movements of the joints. The human skeleton is designed with a

number of individual bones that are articulated at joints to allow movements in

different directions, angles and positions. Knee functions as a hinge joint, but the


103

Discussion

articulation is far more complex than other hinge joints. Seven major ligaments

and flexor & extensor muscles support the movements of the knee joint. The five

lumbar vertebrae are the largest of the vertebrae and those are interconnected and

stabilized by the deep muscles of the spine. The synovial fluid in the synovial

joint serves as a lubricant, a shock absorber and a nutrient carrier.

Functions of the Sleshaka Kapha and Sleshmadhara kala described in

Ayurveda can be co-related to that of the synovial fluid that lubricates the knee

joint and the intervertebral disc that reduces the friction between the vertebrae.

The marmas can be considered as the various points of nervous, vascular and

muscular system, which are vital in the functioning of the joints. Functions of the

peshis and snayus are exactly identical to that of the muscles and ligaments

related to the joints.

From the nidana point of view, Ayurveda had highlighted all the Vata

prakopakara nidanas in the generation of Sandhigatavata. Vardhakya avastha

characterized by dhatu kshaya leads to reduced sneha bhava in the body, which in

turn, vitiates the Vata dosha and reduces the Kapha, thereby resulting in karma

hani of the sandhis. Also, dhatusaithilya is another feature in vardhakya, which

reflects in peshis and snayus thereby reducing their functional efficiency in

supporting the joints. This is a major risk factor for Sandhigatavata. Age is the

most powerful risk factor for Osteoarthritis. More than 80% of the people over the

age of 60 have radiological evidence of Osteoarthritis in the joints.

Various physical activities such as pradhavana, bharaharana and

abhighatas due to prapatana, marma abhighata, dukha shayya and dukha asana are

important nidanas for Sandhigatavata. Repetitive movements may lead to

excessive strain leading to erosion and joint damage. Trauma to the joint enhances

the occurrence of arthritis.


104

Discussion

Sthoulya is another causative factor for Sandhigatavata. The meda avarana

of the Vata is the mechanism causing the inter-relationship between Sthoulya and

Vatavyadhis. Obese persons have a high risk of Osteoarthritis. The relative risk

for developing Osteoarthritis, in the population belonging to the highest quintile

for body mass index at the baseline examination is very high.

Another point noteworthy here is that Sandhigatavata being one among the

Gatavatas is caused due to the factors vitiating Vata alone, but the nidanas

specific to the localization of Vata in Sandhis also have some role in the

production of the disease. The dhatu kshaya samprapti characterized by the

functional deterioration of the Vata dosha can be co-related with the degenerative

changes in the joints associated with ageing which causes the cartilage

degradation; whereas the marga avaranajanya samprapti initiated by the nidana

ghataka Sthoulya involving the avarana of Vata by Kapha and medas can be co-

related with the complications of obesity leading to excessive pressure on the

weight bearing joints.

The lakshanas of Sandhigatavata, viz., vedanayukta pravritti of sandhis,

shopha (vatapoorna dritisparshavat), atopa and sandhigati asaamarthya are

explained by various textbooks of Ayurveda. Modern science has listed the same

features along with other symptoms pertaining to individual joints. Also

tenderness and joint stiffness (implied by the restriction of joint movements) find

special mentioning in Modern science. Acharyas of Ayurveda have not mentioned

that particularly any one sandhi only gets affected with Sandhigatavata. Modern

science has mentioned that any joint can get affected with Osteoarthritis. In this

view, they have considered the condition of Lumbar spondylosis also as the

Osteoarthritis of the intervertebral joints.


105

Discussion

Clinical Study

Patients of Sandhigatavata were selected the OPD & IPD of Shri D.G.M.

Ayurvedic Medical college by pre-set inclusion and exclusion criteria. Data of 30

patients who had satisfied the diagnostic criteria, underwent the treatment and

reported for the follow-up are discussed here. The patients were randomly

distributed into two groups and the patients of group-A were administered with

Abhadi churna and the patients of group-B were administered with KBT Janu

basti.

The laboratory investigations like ESR, TC, DC, RA, Hb% and RBS were

performed to rule out the associated systemic diseases. The radiology of the

affected joint was performed in each and every patient. After scrutinizing the

whole literature of Ayurveda and Modern Medicine, Ruk, Graha Sparshyasahyta,

and Atopa were fixed as the subjective parameters for clinical assessment;

swelling, walking time, ESR were fixed as the objective parameters for clinical

assessment.

Most of the patients in this clinical study belonged to the age group 40-50

(53.3%) thereby supporting the association of vardhakya avastha and

Sandhigatavata. 33.33% of the patients belonged to the age group 50-60 and

6.66% of the patients belonged to the age group 30-40. 36.66% of the patients

belonged to the labor group of occupational status and 30% of the patients

belonged to the active group. This strengthens the viewpoint this disease is

triggered by excessive physical demand on the joint. 53.33% of the patients were

females and 46.66% of the patients were males supporting the male to female

incidence ratio of 1:1.


106

Discussion

53.33% of the patients were of the middle class and 6.6% were of the poor

class and 40% were of the middle class and this observation is inconclusive to

make any comments. 86.6% of the patients were Hindus, 13.4% were Muslims.

This is reflective of the geographical dominance of the religion and do not have

any association with the disease. 76.7% of the patients were vegetarians and

23.3% were of the mixed diet and this is reflective of the diet habit prevalent in

the society. 23.33% of the patients were having tobacco chewing as a habit,

13.3% were having alcohol intake as a habit and 13.3% had smoking habit; this

has no association with the disease state.

36.6% of the patients were of the Vata-pitta prakriti, 30% of the patients

were of the Vata-kapha prakriti, 23.33% of the patients were of the Pitta-kapha

prakriti, 10% of the patients were of the Tridoshaja prakriti.

Response to the treatment

Group-A

1) Ruk: - 33.3%of the patients reported with grade 3 and 73.3%reported with

grade 2 before the treatment after the treatment 40.0%of the patients got

grade 2 and 60.0%of the patients got grade 1 In the statistical analysis, the

parameter showed high significance (p-value<0.001) and corresponding t-

value 3.503.

2) Graha: - All the patients of group-A presented with (100%) stiffness

before the treatment after the treatment 80.0%of the patients got grade

0,and 20.0%of the patients got grade1this shows highly significant value

i.e (p-value<0.001) and corresponding t-value 7.54.

3) Sparsha akshamatva: -20% patients reported with grade3 tenderness

whereas 40%patients reported with grade 2 tenderness and 40%patients


107

Discussion

reported with grade 1 tenderness before the treatment. After the

treatment26.6%patients got grade 2, response and 60.0%patients got grade

1,13.3% of patients got grade0 response. In the statistical analysis the

parameter showed high significance (p-value<0.001) and corresponding t-

value 6.511.

4) Flexion deformity: 60.0of the patients reported with grade 3 and 40% of

the patients reported with grade 2 flexion deformity before the treatment.

46.6%of the patients with grade2 and 53.3%of the patients got grade

1&13.3% of the patients with grade0 after the treatment. In the statistical

analysis the parameter showed high significance (p-value<0.001) with

corresponding t-value 8.588.

5) Shopha: - 66.6%of the patients reported with grade 3 Shopha, 33.4% with

grade2before the treatment after the treatment 60.0% with grade 2 and

40.0%with grade1. In the statistical analysis the parameter Shopha showed

high significance (p-value<0.001) with corresponding t-value 4.58.

6) Atopa: - 100.0%of the patients reported with grade 2 atopa, before the

treatment after the treatment 93.4% with grade 1 and 6.66% with grade 2.

In the statistical analysis the parameter showed high significance (p-

value<0.02) with corresponding t-value 3.503.

7) Walking time: - 80% of the patients with grade 3,13.3% of patients with

grade2&6.6% of the patients having grade1before the treatment after the

treatment 55.5% of the patients with grade 2,45.5% of the patients with

grade1.in the statistical analysis parameter walking time shows high

significance ( p-value<0.001) with corresponding t-value 6.748.

8) ESR: The parameter shows highly significant p-value. ( p-value<0.001)

corresponding t value 4.914


108

Discussion

Group-B

1) Ruk: - 73.3% of the patients with grade 3 ruk and 26.6% of patients with

grade2.before the treatment after the treatment 66.6%of patients having

grade 2, &33.3% of the patients with grade1.in the statistical analysis the

parameter pain shows highly significant p-value (<0.001) with


2) Graha: - All the patients had grade 1 graha. 100.0% before the treatment

showed high significance (p-value<0.001) with corresponding t-value

6.211.

3) Sparsha akshamatva: - 53.3% of the patients had grade 3 tenderness,

46.66% had grade 2 before treatment, and after the treatment 60% of the

patients got grade 2 &40% of the patients got grade1 in the statistical

analysis the parameter showed high significance (p-value<0.001) with


4) Flexion deformity: 73.3% of the patients gad grade 3 and 26.6%of the

patients had grade 2.before the treatment, after the treatment 46.6% of the

patients had grade2, 33.3% of the patients had grade1&13.6% of the

patients got grade0. In the statistical analysis this parameter showed high

significance (p-value<0.001) with corresponding t-value 7.67

5) Shopha: - 60.0%of the patients had grade 3 shopha, 33.33% had grade

2and 1.5% had grade 1 before the treatment. After the treatment 66.6% of

the patients with grade 2, 20.0%of the patients got grade1 In the statistical

analysis this parameter showed high significance (p-value<0.01) with

corresponding t-value 11.32


109

Discussion

6) Atopa: - 73.3% of the patients had grade 2atopa and 26.6% had grade

1before the treatment. After the treatment 73.3%of the patients got

grade1&. 26.66% of the patients with grade 0. In the statistical analysis,

this parameter showed high significance (p-value<0.01) with


7) Walking time: - 20%of the patients had grade4walking time, 66.6%of the

patients had grade3&13.3% of the patients had grade2before the

treatment. After the treatment20.0%patients had grade3and40.0%of the

patients had grade2, 33.3%of the patients had grade1&6.6%of the patients

had grade0.in the stasticle analysis parameter showed high significance (p-

value<0.001) and corresponding t-value13.02

8) ESR: the parameter ESR showed highly significant value (p-value<0.001)


9) Inter group comparison shows non-significant values but individual group

shows highly significant values. But compared with group A & group B,

Group B shows highly significant values than that of group A.

3. Probable mode of action of Abhadi churna`

Acharya Yogaratnakara has mentioned Abadi churna in context of Vatavyadi

chikitsa. This is indicated for all types of vatavyadies so it considered treating

Sandhivata. The ingredients of this compound drug are acting as shoolahara,

balya. Deepana, pachana and rasayana, this has been discussed as fallows.

The ingredients such as Ashwagandha, Shatavari, Guduchi are acts as

Rasayana. This is very helpful in the management of Sandhivata in which the

dhatu kshaya is the main symptom. The same drug is cmbined with Shunthi,

Ajavayana, Ajamoda and Shopa will act as deepana and pachana in action,

which help in samprapti vigatana of sandhivata, and does srotoshodhana.


110

Discussion

Probable mode of action of Janu-Basti

Janu-Basti procedure is a Bahya Shamana Cikitsa. It is Bahya Svedana

and Snehana (If Sneha is used) therapy. Svedana has the functions of neutralizing

Stambha, Gaurava and Sheetata. In JanuSandhi-Gata-Vata joint stiffness is one of

the clinical feature. Janu-Basti may have action on this symptom. The Stabdhata

of Sandhi is mainly due to Sheeta property of Vata. This Sheeta Guna is

neutralized by Ushna Guna of retained medicine.

If Sneha Dravya is used as media in case of Janu-Basti their action further

facilitates in alleviating Vata. Sneha Dravya has Drava, Sara, Snigdha, Picchila,

Guru, Sheeta, Mrudhu and Manda Guna predominantly. The Vata Dosha, which

is the key factor in the casuation of Janu-Sandhi-Gata-Vata, has almost opposite

quality to this. Moreover Sneha Dravya has similar property to that of Kapha

Dosha. In Janu-Sandhi-Gata-Vata Sthanika Kaphakshaya is due to Agantu Vata

Dosha. Thus only one hand Sneha Dravya neutralizes the Vata Dosha and on the

other hand nourishes the Sthanika Kapha Dosha. This helps in Samprapti

Vighatana.

Atopa is due to Vata Vriddhi and Sthanika Kapha kshaya. This symptom

is due to Khara, Rooksha and Vishada properties of Vata. Snigdha, Picchila and

Mrudhu qualities of Sneha Dravya oppose these qualities.

In Shotha - Rasa, Rakta and Mamsa Dhatus are generally found involved.

They attain or pose in the form of either Sandra or Ghana state. By virtue of Tikta

Rasa, Katu Vipaka and Ushna Veerya of Dashamula Chedana and Visravana of

Dushyas of Shotha will occur. Thus acts as Shothahara. Among Dashamula

except Gokshura all have Ushna Veerya. Even though Gokshura is Sheeta Veerya

by virtue of Madhura Vipaka it privileges to drain the Sanchita Dushtha Kleda at


111

Discussion

the site of Shotha. Also Dashamula has Vedanashamaka and Vatahara property.

With the help of above quality it subsides Shoola.

Role of media

Amount of heat given to the Taila, Kvatha or Ksheerapaka materials

privilege interchange of Gunamsha of both the media and Dravyas. Both Vayu

and Agni among Pancha Maha Bhootas processes Laghu, Sookshma Gunas

predominantly. In the process of Taila, Ksheerapaka and Kvatha the indirect Agni

is given to the material. Ions of media will receive the Ushma and they trespass

into the Dravya, which already drenched or sunken in the fluid and got soften.

Thus ions of water, milk or oil penetrate into the drug and release entire

Gunamsha of Dravya. When such Kvatha, Ksheerapaka or Taila is administered

either externally or internally induces the effects of the Dravya.

Criteria for selection of Ksheera bala tail

1. Ksheerabala taila is indicated in vata vyadhis

2. Ingredients of ksheerabala taila are easily available

3. All the ingredients of ksheerabala taila are having vatashamaka, balya and

brahmana properties.


112

Conclusion

Conclusion

1. Sandhivata equals Osteo-arthrosis, as such difference is only in terminology.

2. Occupation, physiological stress and strain play a vital role in the causation of

sandhi vata OA.

3. Overweight is also a major risk factor in OA.

4. Incidence of OA is more in females.

5. Except in obese patients symptoms were limited to kneejoint, including dosha

dushtilaxana and srotodushti laxana.

6. Pain is the main clinical feature that draws the attention of a patient and brings him

to doctor.

7. Abhadi churna is beneficial in the initial stage of the disease.

8. The therapy janu basti is very effective in krusha and normal weight patients.

9. Drug was less effective in sthulas, when compared with krushas, which suggests

that reduction of weight is highly essential.

10. Though the therapy was found to be beneficial in decreasing symptoms in intra

articular steroid dependent patients, the present fixed therapy was not successful in

giving a complete remession.

11. The study failed to find out radiological changes.

12 Janu basti is effective in decreasing pain and other symptoms. Complete remission

was observed in patients.

13. Janu basti has got a long lasting effect.

14. Therapy is very effective in Fresh cases.


113

Summary

Summary

The dissertation work entitled “evaluation of efficacy of AbhadiChoorna

&KsheeraBala tail janu basti in the management of Sandhigatavata (Osteoarthritis)”

consists of seven parts. They are

1. Introduction

2. Objectives

3. Review of literature

4. Methodology

5. Results

6. Discussion

7. Conclusion.

The introduction highlights on Incidence of Sandhigatavata and

availibity of shortest description in the classics. The objectives part describes the need

for the study, title of the present study and the objectives of the present study. Review

of literature part covers the historical view on Sandhigatavata, Nirukti and Paribhasha

of Sandhigatavata.Shareera of Janu Sandhi, description of Janu Basti in particular and

description of Sandhigatavata. Methodology part contains review of the properties

and chemical composition of the drugs used, methodology of the clinical study,

procedures of Janu basti and the parameters for clinical assessment. The results part

contain demographic data, data related to the disease, data related to the overall

response to the treatment, statistical analysis of the Subjective& Objective parameters

& Inter group comparison of Abhadi Choorna & K.B.T janu basti. Discussion part

consists of the headings Sandhigatavata vis-à-vis Osteoarthritis, clinical study,

probable Mode of action of Abhadi choorna and probable Mode of action of janu basti

are discussed. Conclusion part contains the conclusions of the present study and

suggestions for future study.


114

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125

http://www.dairyhealth.com/

http://www.geophysics.com/hawaii/HI96822

SPECIAL CASE SHEET FOR SANDIVATA ` Post Graduate Research and Studies Centre (Kayachikitsa) Shri. D.G.M.Ayurvedic Medical College, Gadag.

Guide : Dr. Vardhacharula M. D (Ayu) Co-Guide : Dr. R. V. Shettar M. D.(Ayu) P.G.S Scholar : S. C. Sarvi

1. Name of the patient : Sl. No.

2. Father’s/Husband’s Name : OPD No.

3. Age : ………... yrs IPD No.

4. Sex : Male/Female Bed No.

5. Religion :

Hindu Muslim Christian Others 6. Occupation :

Sedentary Active Labor Others 7. Economical Status :

Poor Middle class Higher class 8. Address : …………………………. Phone No. …………………………. E- Mail: …………………………. Pin code:

9. Date of Schedule Initiation:

10. Date of Schedule Completion:

11. Result :

Completely Relieved

Marked Response

Moderate Response

Mild Response

Un Changed

Discontinued

12. Consent : I here by agree that, I have been fully educated with the disease and treatment. Here by satisfied whole heartedly, and accept the medical trial over me.

Investigator’s Signature Patient’s Signature

COMPLAINTS WITH DURATION:

Sl. No

Chief complaints Duration

1 Sandhisotha (Swelling) 2 Prasaarana Aakunchanayoho Savedana Pravruthi (Pain

on extension & flexion)

3 Sandhigraha (Joint Stiffness)

A. Morning stiffness (15-30 ms)

B. Sandhigati asamarthya (limitation of joint movement).

C. Stiffness after disuse 4 Sparsha akshamatva (Tenderness)

HISTORY OF PRESENT ILLNESS: Mode of onset

Chronic Insidious Acute Traumatic Joint involved

Axial Cervical Lumbar Spine Distal joints

Knee Right Left Ankle Right Left Hip Right Left First carpometacarpal Right Left Distal metaphalageal Right Left Proximal interphalageal Right Left

Nature of pain Pricking Aching Generalized Tearing Burning

Routine activities affected Yes No

HISTORY OF PAST ILLNESS:

Episodes of same illness Yes/No Obesity Yes/NoTrauma/Fracture of involved or related joint

Yes/No

Diabetes Mellitus Yes/NoHypertension Yes/NoOther Vatavyadhees Yes/NoFever Yes/NoOthers Yes/No

3

4. Treatment History Modern Ayurvedic Others

Relief with previous treatment : Partially relieved No relief at all

5. Family history – relevant :

Yes No 6. Personal HistoryAhara :

Veg Mixed Agni :

Manda Theekshna Vishama Sama Koshta :

Mrudu Madhya Kroora Mutra pravurti- frequency :

Day Night Vyasana :

Smoking Tobacco chewing

Alcohol None

Malapravurthi- frequency : 1 time 2 time More Constipated

Aarthavapravruti : Alpa Ati Vishama Rajonivrutti

7.Samanya Pareeksha A. Asta sthāna Pareeksha : B. Vital examination

1 Nadi /Min 2 Mala

Frequency 3 Mootra

Day Night 4 Jihwa 5 Shabda 6 Sparsha 7 Druk 8 Akruti

1 Temp /F

2 Pulse /min

3 Resp.rate /min

4 B.P ______mm of Hg

5 Height cms

6 Weight Kgs.

4

C. Dasha vidha Pareeksh� : 1 Prakruti V ( ) P ( ) K ( ) VP ( ) VK ( ) PK ( ) Tridoshaja ( ) 2 S�ra Pravara. ( ) Madhyama. ( ) Avara ( ) 3 Samhanana Pravara ( ) Madhyama. ( ) Avara ( ) 4 Pramana Pravara ( ) Madhyama. ( ) Avara ( ) 5 S�tmya Ekarasa. ( ) Sarva rasa ( ) Vyamishra ( )

Rooksha satmya ( ) Snigda satmya ( ) 6 Satva Pravara ( ) Madhyama ( ) Avara ( ) 7 Ahara Shakti a) Abhyavaharana shakti P ( ) M ( ) A ( )

b) Jarana shakti P ( ) M ( ) A ( ) 8 Vyayam Shakti Pravara ( ) Madhyama ( ) Avara ( ) 9 Vaya Bala ( ) Yuva ( ) Vrudda ( ) 8. Srotopareeksha

SROTAS OBSERVED LAKSHNA Annavaha Rasavaha Astivaha Majjavaha

9.SPECIAL EXAMINATION OF JOINTS A. Darshana (Inspection) 1. Joint Swelling

Grading 0 1 2 3 Varna Raaga Shyaava Prakrutha

2.a. Deformity Present Absent

b. Joint Instability Present Absent

3. Gait Nature Walking Time (Grade)

4. Joint Movement Active Completely Restricted Partially Restricted Free Passive Completely Restricted Partially Restricted Free

5. Muscular spasm Present Absent

6.Muscular Wasting Above the affected joint Yes No Below the affected joint Yes No

5

B. Sparshana (Palpitation) 1. Vaatapoornadruthisparsha

Yes No 2. Local Temperature

Raised Not raised 3. Tenderness

Grading 0 1 2 3 4. Limitation of Joint Movement (In terms of Grading)

Axial Joints Cervical Lumbar Spine Distal Joints

Knee Right Left Hip Right Left Ankle Right Left First Carpometametacarpal Right Left Distal Interphalangeal Right Left Proximal Interphalangel Right Left

C. Shravana (Auscultation)

Crepitus Heard Felt None 10. Nidana 1) Swaprakopakara nidana : a) Ahara Guna :

Seeta Rooksha Laghu Rasa :

Katu Tiktha Kashaya Shuskanna :

Yes No Upavasa :

Yes No b) Vihara

Ratrijagarana

Yanam (Riding)

Bharavahana(Weight lifting)

Vyayama

Pradhavana (Running)

Jumping Pratarana (Swimming)

Walking

c) Manasika : Chinta (worry)

Shoka (grief)

Bhaya (fear)

Krodha (anger)

6

2) Marmaghatakara nidana : 3) Dhatukshayakaraka nidana : 11.LAB INVESTIGATIONS :

TC DC P L E M B

ESR

RBS

Blood

Hb%

Sugar Albumin

Urine

Microscope

Serum alkaline phospate 12.RADIOLOGICAL EXAMINATION OF JOINTS ( Antero posterior and Lateral View)

1 Joint space Reduced Increased Unaltered 2 Subchondral bony sclerosis Present Absent 3 Formation of osteophytes Present Absent 4 Periarticular ossicles Present Absent 5 Altered shape of bone end Present Absent

13.ASSESSMENT OF RESULTS A.CLINICAL PARAMETERS Chief and Associated Complaints 0 Day 15th Day 30th day 60th Day Ruk(pain) Stabdhata(Stiffness) Sparsha akshamatva (Tenderness)

Atopa (Criptus)

B. Objective

Parameters Day 0 Day 7 Day 14 Swelling Walking time Flexion deformity ESR

7

C.FUNCTIONAL PARAMETERS

Parameters BT AT After Follow-up Mobility Level Walking & Bending Hand & Finger Function Arm Function Self care tasks (Exercise & Wt. Bearing)

Household tasks

Social activity

Support from family & friends

Arthritis Pain

Work

Level of tension

Mood

14. INVESTIGATORS NOTE : Signature of Co-Guide Signature of Guide

8

Documents

Sandhivata kc037 gdg