Dr (Ms) R.L.D.S. RanasingheMD Scholar, Dept of Kaya Chikitsa , University of Colombo, Rajagiriya.

Prof (Ms) E.R.H.S.S EdiriweeraDept of Kaya Chikitsa , IIM,University of Colombo, Rajagiriya.

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g Objectives

g Case presentation

g Review of Ayurveda

g Review of Modern

g Acknowledgement

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gUnderstand the patho-physiology, signs and symptoms & treatments of AmavatagGeneral review on related Modern

AspectsgImprove diagnosis skills of diseasesg presentation skills to present case

studies

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vName : Mr S.G.W Rudrigu

vAge : 33 Yrs

v Date of Admission : 09th September 2013

v Ward No : 11

v Bed No : 15

v Address : No. 12/10, Handala, Wattala.

v Occupation : Spray painter for 16 yrs

v Nationality : Sinhalese

v Religion : Catholic

vMarital Status : Married

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vMain complaint with duration:

Pain, stiffness & edema of several joints

notably wrist, hand, ankle & feet (3 months)

vOther complaints:

Thirst, Nocturia, Increase sweating (3 months)

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o According to the patient,

o 3 months before; the patient was asymptomatic. Suddenly he got throbbing pain over both the upper limbs along with lethargy ,generalized weakness and thirst. Simultaneously pain was shifted to the RT & LT lower limbs.

o 1 week after the onset of disease, he suffered from fever with edema and Pain in the joints: the RT elbow, RT & LT Knee wrist joints, RT & LT Knee Shoulder joints & then to the RT & LT Knee Joints gradually.

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¬ Medical HistoryRT & LT Knee joint edema at ate age of 7 yrsDiabetes Mellitus - Identified before 3 months with the onset of the

diseaseFBS- 194 mg/ dL (2013. 08. 07)

¬ Surgical History - minor surgery has done in the ankle joint after RTA

¬ Psychiatric History

¬ Treatment History

1. Allopathic treatment for Diabetes Mellitus – 3/ 12

2. Allopathic treatment for joint pain & edema – 8/ 52- No improvement with allopathic treatment

3. Admitted for Ayurvedic treatment for the first time just before 3 /52

- NAD

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53 yrs DM+ , Rheumatoid Arthritis

35yrs

DM+ 30 yrs

DM+

27 yrs

DM+

57 yrs

7 yrs 3 yrs8

o Diet: Break fast - Bread & Curries, Short eats

Lunch - Rice, Vegetables, Egg

Meat (Chicken, Beef, Mutton)-Daily

Dinner - Rice, Vegetables & meat

More like to eat Spicy & Fried food.

o Appetite: impaired appetite at the onset of the disease

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o Sleep : Disturbed due to Nocturia

o Bath : Evening with cold water, Daily

o Bowel habits : Once/ Day, Colour - YellowOdour - NormalCharacter - Asamhata Mala, Sticky

o Micturition : D / N – 3/2 times

Colour - PaleOdour - Normal

o Addiction : No addictions

o Social status : Living near to the sea side & river side 10

• General condition - Average

• BP - 130 /80 mmHg

• PR - 74 / min

• RR - 14 / min

• Weight - 67 kg

• Height - 164 cm

• Tongue - Coated • Temperature - intermittent febrile Usually in the

evening • Skin - Normal

GENERAL PHYSICAL EXAMINATION

• Thyroid • Pallor NAD • Icterus

• Cyanosis• Clubbing• Enlarged LN

NAD

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1) LOCO MOTOR SYSTEM

§ Gati (Range of movements) :• Left Shoulder joint - Abduction

- Adduction- Rotation- Elevation

• Left wrist joint - Flexion- Extension - Rotation

§ Sandhi sputana (Joint crepitus ) - Presented in both knee joints

§ Sparsha asahyata (Joint tenderness)§ Sandhi shota (Joint swelling ) § Rakta varnata (Redness) § Ushnata (Heat)

§ Mamsa ksaya/ shosha (Muscle wasting) - NAD

Limited due to edema & pain

Limited due to edema & pain

- Presented in affected joints

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GALS:

• Gait: Slow and painful gait

• Arms: Difficulty in pronation and supination (painful) in LT wrist joint

Pain – When squeezed the hand across the metacarpals of the LT hand

Power Grip - reduced (Difficulty in holding)

� Legs: Sandhi sputana both knee joints

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SPINE:

• Thoracic Spine: Internal and external rotation- Normal

• Lumbar Spine:• Flexion-Normal

• Extension-Normal

• Lateral Bending-Normal

• Cervical Spine:• Rotation-Normal

• Flexion, Extension and Lateral bending-Normal

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JOINTS:

• Inspection• Swelling

• Redness

• Deformities - NAD

• Palpation.• Tenderness & warmth (MCP, PIP, DIP, MTP, Wrist, Elbow

joints)

• Stiffness of the joints

MCP, PIP, DIP, MTP Wrist joints

Symmetrical involvement

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2) CARDIOVASULAR SYSTEM

• S1, S2 - Clear . No thrills or murmurs

3) RESPIRATORY SYSTEM

• No added sounds

4) GIT

P/A • No tenderness• No organomegaly

5) CNS

NAD Clinically

Higher functionsSensory system

• Cranial nerves16

Motor functions•Reflexes- LT knee jerk exaggerated• Other Reflexes - Normal

I. Prakriti : Vata Pitta

II. Vikriti : Will be described in next slide

III. Sara : Rasa, Rakta, Mamsa, Asthi, Majja, Sukra - Madhya Sara

IV. Sanhanana : Madhya Samhata

V. Pramana : Madhya pramana (Weight-67 kg, Height -164 cm BMI = 25)

VI. Sattva : Madhya Sattva

VII. Satmaya : Shad Rasa Satmaya

VIII. Ahara shakti: Before After

i. Abyavarana shakti : Prawara Madhya

ii. Jarana shakti : Prawara Madhya

IX. Vyayama shakti : Before After

Prawara Madhya

X. Vayah : Madhyama (35 Yrs)17

¬ Hethu (Nidana) – Viprakrusta NidanaAhara : Katu Rasa, Snigdha, Guru guna

AtisewanaViharana : Seeta jala sewana, Spray painting

(chemicals)Vyadhi : Madumeha+

¬ Dosha - Vata, Kapha¬ Dushya - Rasa, Rakta, Mamsa, Asthi, Majja, Sukra.¬ Prakiti - Vata, Pitta¬ Desha - Anupa Desha Near to the riverside & Seaside¬ Kala - Adana kala¬ Bala - Roga bala: Kruccha sadya

Atura bala: Madhyama

¬ Lakshana - Edema, pain & stiffness of the joints

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1. Nadi:

i. Gati - 72/ min

ii. Yati - Samanthara

iii. Akruti - Purna

iv. Samhati - Mrudu

2. Mutra : D/ N – 3 / 2 times

3. Mala : Once/Day, Asamhata mala

4. Jivha : Ama

5. Shabda : Prakrita hrid & pupphusa shabda Ubhaya Janusandhi sphutana

6. Sparsha : Ushna sparsa in affected sandhis

7. Druk : Prakrita

8 . Akriti : Madhyama

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1. Prana vaha Srotas : Prakrita

2. Udaka vaha Srotas : Vikrita; Thalu shosha+

3. Anna vaha Srotas : Vikrita

4. Rasa vaha Srotas : Vikrita; Sandhi shota+

5. Rakta vaha Sorts : Vikrita; Sandhi shota+

6. Mamsa vaha Srotas : Prakrita

7. Medo vaha Srotas : Prakrita

8. Asthi vaha Srotas : Vikrita; Sandhi sula, Shota +

9. Majja vaha Srotas : Prakrita

10. Shukra vaha Srotas : Vikrita; Madhu +

11. Muthra vaha Srotas : Vikrita; Ratrimutrata +

12. Purisha vaha Srotas : Vikrita; Asamhata mala+

13. Sweda vaha Srotas : Vikrita; Atisweda+

14. Mano vaha srotas : Prakrita

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Ø Dosha : Vata, Kapha

Ø Dushya : Rasa, Rakta, Mamsa, Asthi, Majja , Sukra

Ø Adishtana : Sharirika

Ø Srotas :

Ø Samuttana : Amasha

Ø Agni : Mandagni

Ø Ama : Ama

Ø Srotodushti : Sanga

Ø Udbhawastana : Sarvanga sandhi

Ø Sadhya Asadhyata : Kruccha sadhya

Ø Roga marga : Madhyama (Marma, Asthi,Sandhi)

Rasa Vaha Srotas ,Rakta Vaha SrotasMamsa Vaha Srotas, Asthi Vaha SrotasMajja Vaha Srotas, Shukra Vaha SrotasUdaka Vaha Srotas, muta, Mutra Vaha SrotasSweda Vaha Srotas

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q FBS - 194 mg/dl (2013.08.07)

99 mg/dl (2013.10.10) Within normal range with drug control

q UFR Reaction - AcidicAlbuminSugar Pus cellsEpithelial cells

q CRP - 12mg/ dL Raised

q ESR - 11/ 1st hr Raised

q PCV - 48%

q RF - < 8 IU/mL

Occasional

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AMAVATA SANDHISHOTA

SSANDHIGATAVATA

GAMBHIRA VATA RAKTA

Nidana Viruddha ahara, Snigdaahara, Alpa chesta etc.

Vata kopakaraAhara, Viharana

Vata & Raktakopakara Ahara, Viharana

Rupa Angamarda, Aruchi, Trushna, Alasya etc

Shula, Shota, Prasaranakunchana Vedana

Daha, Supti, Vaivarnya, Sphutana etc

Sthana Start from small joints of hands & spread

Mainly start with weight bearing large joints

Start from the end parts of the hands & feet

Dosha Kapha, Vata Vata Predominant Vata, Pitta

Differential diagnosis

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Rheumatoid Arthritis Gout Osteoarthritis

INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE DISEASE

PROLIFERATION OF SYNOVIAL MEMBRANE

IMPAIRED PURINE METABOLISM

DEGENERATION OF ARTICULAR CARTILAGE

ATLEAST 3 JOINTS ARE INVOLVED

MONOARTICULAR WEIGHT BEARING JOINTS

MORNING STIFFNESS -1HR

MORNING STIFFNESS-NA

MORNING STIFFNESS- 15MTS

PAIN- EXTREME PAIN-MILD PAIN-MILD

Differential diagnosis

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PAIN SUBSIDE BY WORKING

OR EXERCISE

NO RELATION PAIN AGGRAVATED DURING

WORKING-RELEVIED BY REST.

MIDDLE AGE-20-35

F:M- 3:1

MIDDLE AGE-ABOVE 40

M:F- 8:1

ABOVE 50YRS

F:M- 2:1

R.A - POSITIVE

E.S.R-RAISED

SERUM PURINE LEVEL IS

MORE THAN 600MG

E.S.R- NORMAL

R.A -NEGATIVE

X -RAY SHOWS REDUCED

JOINT SPACE, SOME TIMES

DEGRATION OF BONE MASS

X RAY X-RAY SHOWS OSTEOPHYTES

AND DEGENERATIVE

CHANGES

Cont.

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NAVA AMAVATA PRAVRUDHA AMAVATA JEERNA AMAVATA

1.ARUCHI. 1.INVOLVEMENT OF HASTA, PADA SIRO, GULPHA,TRIKAETC

1. DESTRUCTION OF ARTICULAR CARTILAGE.

2.ALASYA. 2.SHOTHA ,STABDHATA 2.OSTEOPOROSIS.

3.GOURAVA. 3.EXTREME PAIN. 3.DEFORMITIES.

4. JWARA 4.PRASEKA,ARUCHI. 4.POLYARTHRITIS.

5.HRILLASA 5.HRIDAYA GOURAVA AND HRITGRAHA.

6.APAKTHI. 6.CHARDI,BHRAMA,MOORCHA, ANAHAM.

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Diagnosis

� Viruddha ahara, Snigdaahara, Alpa chesta Seta jala, Vata sparsa etc.� Angamarda, Aruchi,

Trushna, Alasya etc� Start from small joints

of hands & spread� Kapha, Vata

� Inflammatory disease� At least 3 joints are involve� Morning stiffness� Pain� Middle age- 33 yrs� E.S.R-Raised� CRP -Raised

Amavata sandhi shota Rheumatoid Arthritis

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ë Duration : 3 weeks (2013.09.20 - 2012.10.15)

ë Improvements: Fever & Ama conditions subsided

Internal medications

§ Denibadi decoction 120 ml, bd, before meal

§ Kaphahara kwatha 2 tablespoonful, bd, before meal

§ Chandra prabha vati 2 bd with hot water, after meal

� Haritakyadi vati 2 bd with hot water, after meal

External applications

§ Dashanga Lepaya – To affected joints, morning & evening with juice of tamarind leaves

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Patya Ahara

•Yava•Kulatta•Rakta shali•Drumstics•Punarnava•Bittergourd•Ginger•Rasona•Ginger with takra•Hot water

Patyapatya

� Warm water bath � a gentle walk after

consumption of food

Patya Viharana

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Apatya Ahara Apatya Viharana

• Guru snigdha ahara• Sweets • Uncooked food• Salty food• Oily food• Fast food• Fish• Milk• Ghee• Cold water

� Cold breeze and excessive wind� Bathing with cold water � water intake immediately

after consuming food

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Etymology of Amavata

�

- Ama and Vata unites to form Amavata

(Vijayaraksihta)•

- Vata associated with Ama creating a disease Known as Amavata

(Vijayarakshita)

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•(Amarakosha)

- The substance which undergoes a typical change in the processes of digestion is known as Ama

•(Amarakosha)

Etymology of Ama

•

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Ma. Ni. 25/ 1-5

AAetiopathogenisisetiopathogenisis of of AmavataAmavata

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Aetiology of Amavata

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Samprapti of Ama Vata

AharaViruddhaahara, Snigdhaahara, Guru Ahara

ViharanaDiwa svapna, Nischalata,

ManasikaChinta, Shoka. Bhaya, Krodha

Agni mandya

Sanchaya

PrakopaAma visha

Sama Vata

Sleshma sthana

Dhamani

Dushti by Tridosha

Prasara

Rasavaha srotas Trika sandhipravesha

Daurbalya, Sandhi shota, Shula

Sandhisthabdata

Amavata

Dushti by Tridosha

StahanaSamsraya

Vyakti36

Rupa- General clinical features

Ma. Ni. 25/ 6� Body ache� Anorexia� Thirst � Malaise� A feeling of heaviness� Fever� Indigestion � Inflammation of the body parts(myositis , fibrositis, arthritis etc)

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Pravruddha Amavata (Exacerbation of Amavata)

Ma. Ni. 25/ 7- 1038

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• When Amavata gets exacerbate Pravruddha Amavata(most distressing of all the diseases)

• Where ever the (Ama) Dosha reaches joints of the hands feet cervical region (pelvic &

shoulder)girdles , knees & thighs

• The affected part is excessively painful as if it is bitten by scorpions

Produces painful swelling

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• anorexia & a feeling of heaviness

• loss of the drive • bad taste in the mouth• poly urea & a burning

sensation • hardness in the abdomen• colicky pain &• reversal of normal sleeping

habit • thirst

• vomiting • vertigo• Fainting• pericardial discomfort • constipation• stiffness• gurgling intestinal

sounds• meteoric & other

troublesome complications

It gives rise to

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Features of doshik predominance in Amavata

(Ma. Ni 25/11)� with the predominance of Pitta

there is redness & heat(locally)

� whereas with predominance of Vatathe pain is severe

� In Kapha, feeling of being coveredwith wet cloths, heaviness & itching

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Amavata Prabheda

• Doshanubandha Lakshanas (BP)

(1) Vatanubandha : Sasulam

(2) Pittanubandha : Sadaha, Saraga

(3) Kaphanubandha : Stimitatam

• Doshanubandha (Madhavakara)

Vata,Pitta,Kapha,VP,VK,PK,Sannipataja.

• Avastha bhedena: (Madhavakara)

Samanya.

Pravrudha.

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Sadhya asadhya bhava -Prognosis

Ma. Ni. 25/12

� One Dosha involved → curable� Two Dosha involved → relievable� Three Dosha involved → difficult to cure

(Inflammation of all over the body)

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Upadrava (Complications)

•Sankocha and Khanjata (Vijayarakshita)•Kalaya khanjata (Bhavaprakasha)• Jadya, Antrakujana, Anaha, Chardi (Anjana Nidana)•Angavaikalya (Harita)•Akshepana (Gayadasa)•Vatavyadhi (Vachaspati vaidya )

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Amavata Cikitsa

(Bha. Pra.Ma.Kha 26/ 14,15)• Langhana(fasting) • Swedana (sudation)• Use of drugs of Tikta katu rasa • Deepana (stimulating appetite)• Virecana (purgaation)• Oleation (snehapana)• Vasti (enema) • Ruksha sweda valuka pottalee (use of bags of heeted sand) • Upanaha (applying poultiecs) without use of sneha

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Anthah parimarjana

1. Ama pacana, Jvara hara

1. Pachanamruta Decoction, Pata ½ bd, Before meal2. Murva 10 Decoction, Pata ½ bd, Before meal3. Amrutashtaka Decoction, Pata ½ bd, Before meal4. Beli mul 16 Decoction, Pata ½ bd, Before meal 5. Denibadiya Decoction, Pata ½ bd, Before meal6. Hinguvastaka Churna, 30 grns, bd with hot water, After meal7. Sudarsana Churna 30 grns, bd with hot water, After meal8. Seetarama Vati 3 bd, bd with hot water, After meal9. Avipattikara Churna 30 grns, bd with hot water, After meal

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2. After Ama Pachana – Nirama avastha

1. Rasna 7 Decoction, Pata ½ bd, Before meal2. Rasna 13 Decoction,Pata ½ bd, Before meal3. Sinhanada Guggulu 2 bd with Bavila, sudulunu water , After meal4. Hinguwashtaka churna 30 grns, with hot water, After meal5. Rasnadi guggulu, 2 bd, with hot water, After meal6. Vata gajendrsinha rasa, 2 bd, with hot water, After meal7. Amavatari rasa, 2 bd, with hot water, After meal

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Madhumeha Cikitsa- Along with Amavat chikitsa

� Nishatripal veniwelgata Decoction, Pata ½ bd, Before meal� Triphala Churna, 30 grns, bd with hot water, After meal� Haritakyadi Vati, 2 bd, with hot water, After meal� Somanatha Rasa, 2 bd, with hot water, After meal

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Bahir parimarjanaØ Swedana- Ruksha sweda

• Valuka pottali

• Pottali sweda by using ruksha dravya such as Saindava, Karpasa, Kulattha, Tila, Eranda, Atasi, Punarnava,

Ø Snehana – Ruksha sneha Abhyanga (In Nirama avastha)

1. Mee taila2. Saidavadi taila3. Amavata taila4. Nirgundi taila

Ø Lepa1. Dhusturadi Lepa2. Satapushpadi Lepa3. Hinsrapadi Lepa4. Humbas mati pattuwa5. Dasanga Lepa6. Delipothu pattuwa 50

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Rheumatoid Arthritis is a chronic Systemic Inflammatory disorder of unknown etiology

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• Affects 0.5- 1.0% of the population world wide• Peak prevalence between the ages of 30 and 50 years

• RA has an incredibly high disease burden and cost to society

• Drastic affect on quality of life• Increased disability (80% disabled after 20 years of

disease)• Patients with RA have shorter life expectancies

Epidemiology

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Aetiology� Gender : women before the menopause are affected3

times more than men & equal sex incidence thereafter

� Familial : Increase incidence in those who with a family history of RA

� Genetic factors: Human Leucocyte Antigen HLA- DR4 & HLA- DrB1

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Rheumatoid Arthritis: Key Features• Inflammatory synovitis• Palpable synovial swelling• Morning stiffness >1 hour, fatigue

• Symmetrical and polyarticular (>3 joints)• Typically involves wrists, MCP, and PIP joints • Typically spares certain joints� Thoracolumbar spine � DIPs of the fingers and IPs of the toes

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Rheumatoid Arthritis:Key Features (cont’d)

• May have nodules: subcutaneous or periosteal at pressure points

• Rheumatoid factor• 45% positive in first 6 months• 85% positive with established disease• Not specific for RA, high titer early is a bad sign

• Marginal erosions and joint space narrowing on x-ray• Symptoms >6 weeks’ duration

• Often lasts the remainder of the patient’s life

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Non -Articular manifestations

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The Normal Joint

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Pathogenesis of Rheumatoid Arthritis

Inflammed synovial tissue (synovitis)• Villous hyperplasia• Intimal cell proliferation• Inflammatory cell infiltration

T cells, B cells, macrophages andplasma cells

• Production of cytokines and proteases• Increased vascularity• Self-amplifying process

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Deformities of Rheumatoid Arthritis

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InvestigationsBlood screening:

� ESR� C Reactive Protein� FBC with differential � RF� Serum calcium phosphate & alkaline phosphate � Serum uric acid� ASOT

Additional imaging techniques:

• CT scans • AP & Lateral tomography (x-ray)• MRI scan • USS (good for assessing the presence of fluid)

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Rheumatoid Arthritis Gout Osteoarthritis

INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE DISEASE

PROLIFERATION OF SYNOVIAL MEMBRANE

IMPAIRED PURINE METABOLISM

DEGENERATION OF ARTICULAR CARTILAGE

ATLEAST 3 JOINTS ARE INVOLVED

MONOARTICULAR WEIGHT BEARING JOINTS

MORNING STIFFNESS -1HR

MORNING STIFFNESS-NA

MORNING STIFFNESS- 15MTS

PAIN- EXTREME PAIN-MILD PAIN-MILD

Differential diagnosis

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PAIN SUBSIDE BY WORKING

OR EXERCISE

NO RELATION PAIN AGGRAVATED DURING

WORKING-RELEVIED BY REST.

MIDDLE AGE-20-35

F:M- 3:1

MIDDLE AGE-ABOVE 40

M:F- 8:1

ABOVE 50YRS

F:M- 2:1

R.A - POSITIVE

E.S.R-RAISED

SERUM PURINE LEVEL IS

MORE THAN 600MG

E.S.R- NORMAL

R.A -NEGATIVE

X -RAY SHOWS REDUCED

JOINT SPACE, SOME TIMES

DEGRATION OF BONE MASS

X RAY X-RAY SHOWS OSTEOPHYTES

AND DEGENERATIVE

CHANGES

Cont.

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RHEUMATIC FEVER SEPTIC ARTHRITIS

PSORIATIC ARTHRITIS

C.V.S DISEASE STAPHYLOCCUS AUREUS

GENITIC

STREPTOCOCCUS.P

FEVER D.I.P ARTHRITIS

GENITIC ARTHRITIS SACRO ILITIS

FEVER MYALGIA IRITIS

Differential diagnosis

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ANOREXIA PERICARDITIS ASSYMMETRIC OLIGO ARTHRITIS

SYMMETRY NEPHROTIC SYNDROME NAIL CHANGES

CNS EPILEPSY

LEUCOCYTOSIS

Cont..

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§ Evaluate the progress & continue the relevant treatment

§ Physiotherapy

§ Rehabilitation of the Patient

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� Department of Kaya chikitsa, Institute of Indigenous Medicine, University of Colombo, Rajagiriya.� Director, National Ayurveda Hospital Sri Lanka.� RMO, National Ayurveda Hospital Sri Lanka.

Acknowledgement

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