“A CLINICAL STUDY ON THE EFFECT OF RASONA PINDA WITH ASTA VARGA KASHAYA ANUPANA

AND MATRA VASTI IN THE MANAGEMENT OF GRIDHRASI VATA”

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT FOR THE

DEGREE OF DOCTOR OF MEDICINE (AYURVEDA)

GUIDE

Dr. PRAKASH CHANDER M.D. (Kaya Chikitsa.),

PROFESSOR & HEAD OF DEPARTMENT,

P.G.UNIT (K.C.)

Dr.K.SIREESHA 2007

Post Graduate Department of Kaya Chikitsa Dr.B.R.K.R.Govt.Ayurvedic College / Hospital

Hyderabad.

(Affiliated to Dr.NTR University of Health Sciences, Vijayawada)

Dr. N.T.R.UNIVERSITY OF HEALTH SCIENCES Vijayawada, A.P.

Post Graduate Department of Kaya Chikitsa

Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad Place: Hyderabad, Date: / /2007.

CERTIFICATE This is to certify that Dr. K. SIREESHA is a bonafide final year Post-

graduate scholar of M.D. (Ay) in the speciality of Kaya Chikitsa of this

institute. She has worked for her thesis on the topic titled “A clinical study on

the effect of Rasona Pinda with Asta Varga Kashaya Anupana and

Matra Vasti in the management of Gridhrasi Vata” as per the

requirements laid down by the Dr.N.T.R.University of Health Sciences,

Vijayawada, for the purpose.

I forward this thesis for further evaluation by adjudicators.

Dr. PRAKASH CHANDER M.D. (Ay.) Professor & H.O.D P.G.Unit of Kaya Chikitsa Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad, A.P.

Dr. N.T.R.UNIVERSITY OF HEALTH SCIENCES

Vijayawada, A.P.

Post Graduate Department of Kaya Chikitsa Dr.B.R.K.R.Govt.Ayurvedic College, Hyderabad

Place: Hyderabad, Date: / /2007.

CERTIFICATE This is to certify that Dr. K.SIREESHA is a final year Post-graduate

Scholar of M.D. (Ay) in the speciality of Kaya Chikitsa of this institute. She

has written the dissertation entitled “A clinical study on the effect of Rasona

Pinda with Asta Varga Kashaya Anupana and Matra Vasti in the

management of Gridhrasi Vata.” in partial fulfillment for the degree of

Doctor of medicine under my direct supervision and guidance. The candidate

has put in all her efforts in the successful completion of her studies.

Dr. PRAKASH CHANDER.

M.D. (Ay.)

“Namami Dhanvantarimadi Devam, Surasurairvandit Padapadmam | Loke Jararugbhay Mrutyunasham,

Datarmisham Vividhoushadhinam ||”

ACKNOWLEDGEMENTS The present thesis work is dedicated to Golden feet of Sri Lord Venkateswara.

It is a great privilege for me to have worked under the guidance of

Dr. PRAKASH CHANDER M.D (Ay), Professor & Head of Dept. of P.G. Unit (K.C),

who has guided and supervised my work with his valuable suggestions in this entire

dissertation work.

I offer earnest thanks to Dr.M.Srinivasulu for his timely suggestions and valuable

discussion for completion of thesis work.

It gives me a moment at great pleasure on this occasion to thank and

acknowledge the important and unforgettably needed help rendered by Dr.V.Vijaya Babu

M.D (Ay) Reader P.G Unit K .C with out which this work would not have been

completed.

I express heartful thanks to Dr. K.V.Bhaswanth Rao, Dr M.L.Naidu, Dr. Vijaya

lakshmi, Dr.Ramlingeswar, Dr Raghupathi Goud, Dr Murali Mohan, Dr.Nageswara

Babu, Dr. Srikanth Babu, for their valuable suggestions and support.

I owe my special thanks to Dr K.V.S.Prabhakaram A.D AYUSH Dept.,

Dr. P. Murali Krishna, M.D.(Ay), Assistant Professor, S.V.Ayurvedic College, Tirupati,

and Dr. G.Puroshothamacharyulu M.D and Dr.D. Ram Gopal M.D who trained me in a

right path in the field of Ayurveda .

I am highly thankful to Dr.K.Sadasiva Rao,, Principal, Dr.B.R.K.R.Govt.

Ayurvedic College, Hyderabad, Dr.L.Radha.Krishna Murthy Hospital Superintendent for

giving us the concern facilities for the successful completion this work.

My head bows at the feet of my parents who are solely responsible for my

existence. I am equally thankful to my in-laws, my husband M. Satya Srinivas, my son

Sudarsan and my brother Kishore for their valuable support.

I am very thankful to my colleagues Dr. J.Sivanarayan, Dr. G.Lavanya,, Dr. V.Laxmi

Prasoona and my senior Dr M.Padmaja for their kind co-operation.

Finally I express my thanks to all my patients who have co-operated with me at all levels in my

clinical study.

(Dr. K. SIREESHA)

Parts Index Page no.

Part-I 1. Introduction 2. Review of Historical aspect

1-4 5-9

Part-II DISEASE ASPECT 1) Gridhrasi vata meaning and definition 2) Sareeram 3) Nidanam 4) Poorva roopa 5) Roopa 6) Samprapti 7) Upadravas and Sadhyasadhyata 8) Sapeksha Nidana

10-11 12-24 25-32

33 34-44 45-52 53-54 55-56

Part-III 1) Chikitsa. 2) Pathyapathya

57-61 62-65

Part-IV DRUG ASPECT 1) Description of Individual drugs

2) Description of Matra Vasti.

66-79 80-82

Part-V CLINICAL STUDY 1) Materials and methods 2) Observations 3) Results.

83-89

90-102 103-110

Part-VI 1) Discussion 2) Summary 3) Conclusion 4) Bibliography 5) References 6) Annexure

111-115 116-117 118-119

u INTRODUCTION

Life started from a single organism and extends to more complex state

during the evolution. In this process of evolution vertebrates accomplished their

role by having a complex axial skeletal system among the other groups of living

beings. It is very much primitive in fishes, amphibians and developed in birds and

animals respectively. In the group of mammals, the animals, which move on four

legs possess cartilages between the adjacent vertebrae instead of discs as in

human. In evolutionary process man remain as the only animal, which stands in

up right posture.

During the man’s evolution the transition from the quadrupedal to bipedal

state led first to straightening and then to inversion of lumbar curvature (lumbar

lordosis). The erection of the trunk has been obtained partly by backward tilting of

pelvis and partly by the bending of the lumbar column.

The vertebral column of quadrupeds relaxes absolutely during rest. Indeed

the presence of curvatures in the vertebral column, man never attains absolute rest

in any posture and owing them to suffer with problems related to vertebral

column.

Obviously the life style of a person has changed a lot in accordance with

the time. As the advancement of busy, professional and social life, improper

sitting postures in offices and factories, continuous and over exertion, jerking

movements during traveling and sports-all these factors created un due pressure on

the spine. All these factors will result in the most common disorder in most

productive period of life. - Back pain. Out of which 40% of persons will have

radicular pain and this comes under the umbrella of Sciatica.

1

Gridhasi 1 is a shoola pradhana vataja nandmaja vyadhi affecting locomotor

system and leaving the person disable from daily routine activity. Gridhrasi 2 the

name itself indicates way of gait shown by the patient due to extreme pain i.e. like

Gridhra or Eagle.

Gridhrasi3 is a condition where vata affects the gridhrasi nadi characterized

by Ruk(pain), Sthamba(stiffness),Toda(pin prickling sensation) starting from Spik,

Kati, Prista(buttocks, lumbar and spinal column) radiating down to posterior

border of Uru (thigh), Janu(knee), Jangha, pada and impairment of lifting of thigh.

Signs and symptoms of Gridhrasi are nearly same and can be compared

with sciatica. The knowledge of this condition to the modern medical science is

just two century old while this is known to Ayurveda since last five thousand

years.

According to survey low back pain is extra ordinary common and second

ordinary to common cold with a lifetime prevalence of 60%-90% and annual

incidence of five percent. 80% of population will experience back pain at some

time in their life. In a nutshell prevalence of sciatica ranges from 11%-40%. No

population appears immune although physical fitness might maintain the health.

Back pain4 is one of the major medical, social and economic problem in our

society. The severity of the back pain ranges from minor niggles to excruciating

pain, but the problem as whole is remarkably wide spread.

A recent calculation suggested that the pre-neolithic hunter gatherer man only

performed about 5o lifts per day where as a 20th century man performs ten times

that figure.

Sciatica continues to be one of the most challenging problems in primary care.

2

It is associated with enormous costs in terms of direct health care

expenditures, and indirect work and disability related loses.

Pain often is persistent during the episode, and many patients do not have

complete resolution of their symptoms but have “flares” against a background of

chronic pain.

The incidence of sciatica in those employed in heavy industry is some 5

times than in light industry. However the information available is not entirely

consistent in that, there is also a high incidence in those who performs sedentary

work particularly if they spend a lot of time in motor vehicles.

The knowledge of cost of sciatica is essential in indicating the importance

of the problem and the need for extra resources to improve our current facilities.

A medicament, which relieves the pain, improves the functional ability

restore from functional disability and controls the condition with cost

effectiveness, is the need of the hour.

The treatment of sciatica in modern medicine comprises analgesic, bed rest

etc., Unfortunately analgesics are liable to many side effects particularly by

repeated and prolonged use.

An Ayurvedic approach is helpful to improve quality of life in the patient

of Gridhrasi and for certain extent by administering the Ayurvedic treatment

surgical intervention can be avoided or postponed.

While going through the treatments of Gridhrasi 5, sequential administration

of snehana, swedana, vasti, sira vyadha and agni karma are lines of treatment

explained in Ayurvedic classics. Apart from these procedures, certain samana

yogas for oral administration are also explained.

3

Among various treatments Vasti is a unique procedure, which eliminates

the aggravated doshas from the body, as such it was described as half of the

treatment of kaya chikitsa.

Matra vasti is a simplest type of vasti explained in classics. There is no

restricted regimen for it. It is a cost effective, and time saving procedure when

compared to other vasti karmas. Hence I selected matra vasti with Balaswagandha

tailam for my present study.

Lasuna is considered as best vatahara dravya according to vagbhata, which

is a major ingredient of swalpa rasona pindam. This yoga possesses deepana,

pachana, rasayana, vedana samaka properties. Swalpa rasona pindam6 specially

indicated for Gridhrasi in Bhaisajya Ratnavali. It is selected for my present study.

Astavarga kashaya7 is selected as anupana. It is best vatahara mentioned in sahasra

yogam kashaya prakaranam.

Different works have been carried out in different views. Still an added

effort was made by understanding the problem with available sources of literature

and tried to manage the condition, thinking that this may help in giving better

management for patient and helping them in relieving their sufferings.

The clinical study is a sincere effort to add new dimension in the treatment

of Gridhrasi. It is also hope that this work may pave new avenues for enthusiastic

workers to further advance in this field and find a better cure for this problem,

with this noble intension this theses work is selected.

4

HISTORICAL ASPECT

Historical review can be classified into

I) Vedic Kala

II) Pauranika Kala

III) Samhita Kala

IV) Sangraha Kala

I) VEDIC KALA: Historical aspect of Gridhrasi can be taken from vedic

period itself. Rigveda8 attributed medical powers to Indra who helped

the lame srona in restoring his walking power. Some commentators

consider srona as a sage, but srona also indicates a cripple and also a

disease perhaps related to sroni. But it is not clear whether this

lameness is due to a disease of sroni. There is a reference in Atharwana

veda9, which requires a special mention i.e., “the piercing pain from

feet, knee, hips and hinder parts (Sroni parinama) and spine”. So this

reference denotes the pain in the same regions of Gridhrasi though the

name of the disease has not been mentioned.

II) PAURANIKA KALA: In Garuda Purana a separate chapter is described

for Vata Vyadhi. In this Chapter Gridhrasi is described as an entity. Agni

Purana also holds identical description.

III) SAMHITA KALA:

CHARAKA SAMHITA:

In Sutrasthana -Padabhyanga 10 is indicated in Gridhrasi.

-Gridhrasi has been described as Swedya vyadhi11.

-Gridhrasi is described in Vataja nanatmaja Vyadhi 12

In Chikitasa sthana - Lakshana and Chikitsa 13 of Gridhrasi are described.

5

SUSHRUTA SAMHITA:

In Nidana Stana – symptomatology14 and Pathology of Gridhrasi has been

described.

In Chikitsthana – Siravedha15 is described for Gridhrasi.

In sarira sthana – siravedha16 site for Gridhrasi is indicated.

ASTANGA SANGRAH:

In Sutrasthana – Gridhrasi17 is included under 80 types of vata vikara.

- Site for siravedha18 in Gridhrasi has been described.

In Nidana Sthana - pathogenesis and symptomatology of Gridhrasi 19 has been

described.

ASTANGA HRIDAYA20:

– Similar description as in sangraha.

KASHYAPA SAMHITA21:

Gridhrasi considered as one among Aseetivatavikaras.

BHELA SAMHITA:

Basti and Rakta mokshana22 are indicated for Gridhrasi.

HARITA SAMHITA:

Harita23 was the first to give importance to gridhrasi by naming 22nd Chapter of

Tritiya sthana as Gridhrasi cikitsadhyaya.

IV) SANGRAHA KALA:

MADHAVA NIDANA: Description is similar as in charaka but some specific

symptoms have been highlighted i.e Dehasya pravakrta24 in Vataja

type,mukhapreseka and bhaktadwesha in vatakaphaja type.

6

SHARANGA DHARA SAMHITA:

Gridhrasi is counted under 80 Vata Nanatmaja vyadhis25 in 7th Chapter of

purva khanda chikitsa of gridhrasi is described in 2nd and 5th Chapter of

madhyamakhanda26,27.

BHAVA PRAKASHA: Gridhrasi has been described according to charaka.

Chakradutta28 suggested to burn little finger of the affected limb if

Gridhrasi is not subsided by any treatment.

VANGASENA SAMHITA:

Vangasena29 used the term vata balasa for vata kaphaja Gridhrasi. For the

first time its vishesha chikitsa has been given. Tapta taila Istika Swedana,

Upanaha, Deepana, Pachana, Vamana, Virechana, Vasti and Siraveda.

Sigerist has observed that sudden sharp nature of sciatica attack struck

primitive people as demon magic.

Hippocrates30 believed sciatica was prevalent during summer and autumn

months.

In 4th Century B.C Caelius Aurelianus31 clearly described symptoms of

Sciatica. The disease arises from observable or hidden causes eg. A sudden jerk

or movement during exercise, unaccoustomed digging in the ground, exertion on

lifting a weight from below; termination of haemorrhoidal bleeding.

The oldest of scientific surgical text is Edwin Smith surgical papyrus, this

scroll was found in a grave near Luxor, Egypt in 1862. The Papyrus describes

Sciatica, when even than was recognized as connected with vertebral problems.

Pore (1510-1590) of France observed that severe backache caused by heavy

work with spine held flexed continuously.

Fontane F of Florence 1797 observed root compression leads to Paresis in

Sciatica.

7

Domenico cotugno, Italian anatomist 1736-1822 coined the word Sciatica

in 1764. He described Sciatica as Cotugno’s disease. He was the first to describe

two types of Sciatica the nervous and the arthritic recorded in 1764. He described

etiology, pathology and clinical manifestations of Sciatica.

In his first book, Nervosa commentarious he described that dropsy of the

dual funnel enclosing the Sciatic nerve causes Sciatica. In his subsequent book

treatise on nervous Sciatica of 1775, he described cause of Sciatica as

accumulation of acrid fluid in the outer vaginae of ischiadic (Sciatic) nerve. He

pointed out that Sciatica may lead to semi parlysis and muscle wasting.

Richard Bright (1789-1858) described neuralgia in his book. He

considered Sciatica as inflammatory affection of the investing membrane of the

nerve.

C.E. Brown sequard (1817-1894) described root pain compression at the

inter vertebral foramen and recognized degeneration of the intervertebral disc.

Ernst charles Lasegue, French physician (1816-1883) described wasting of

muscles in the affected limbs will be seen in Sciatica. He demonstrated that

elevation of the extended lower extremity causes pain along Sciatic nerve in

Sciatica. Recorded by J.J. Forst, Lasegue’s pupil in 1881.

Louis T.J. Landouzy, French physician 1845-1917, described a form of

Sciatica complicated by atrophy of the muscles of the affected leg known as

Landouzy’s Sciatica.

Joel Ernest Goldthwait, American Physician suggested that inter vertebral

disc injury may be the cause of Sciatica, Lumbago, Paraplegia etc. reported in

1911.

Elsberg in 1915 operated on a patient with Sciatica, finding ruptured

ligamentum flavum compressing fourth lumbar nerve root.

8

Puttiv in 1927 regarded that variability of angle at the lumbo sacral facets

predisposes to Sciatica. Baker in 1929 reported a root compression case from

lumbo sacral disc protrusion diagnosed as neuritis affecting the Sciatic nerve.

William Jason Mixter with Joseph seaton Barr, demonstrated the role

played by inter vertebral disc herniation in the causation of Sciatica published in

1934.

In 1956 Jemonet W.D. observed the association of bladder dysfunction with

bilateral sciatica. Mathews J.A. advocated the importance of rest in bed for cases

of Sciatica in 1977.

It occurs in all ages but more frequently among the middle aged, there is

pain in one or both hips; the latter case can be called Double Sciatica.

Thus Gridhrasi or Sciatica takes origin from the vedic period in Ayurvedic

texts and described by modern scientist since a long time.

The information given in Ayurvedic texts regarding Gridhrasi clearly

indicates that the disease was not generally prevalent in those days. The particular

information also indicates that the activities of human are not prone to cause,

pressure on the nerve roots with consequent Sciatica.

In modern civilization and other related activities the prevalence of

Gridhrasi has considerably increased.

9

GRIDHRASI VATA – MEANING AND DEFINITION

UTPATTI: The word Gridhrasi1 is of feminine gender, Gridhra’ +So’

“Atonupasargakah”- adding’kah” pratyaya leads to Gridhra + So+ Ka by lopa of

‘O’ and ‘k’,”Sha” is replaced by “Sa” by rule “ Dhatwadesh sah sah”In female

gender by adding “Dis” pratyaya the word Gridhrasi is derived.

The word ‘Gridhrasi’ is derived from Dhatu “Grudhu” – to covet, desire

and strive after greedily on eager for.

Grudhra refers to bird (Eagle) that desires to eat flesh always.

Gait of the patients is said to resemble the gait of Eagle hence the name

Gridhrasi.

“Gridhyati2 maamsamabhi kankshati satatam iti”

“Grudhro mamsa lolupa manushyatam syati peedyati nashyati vaa”

Gridhrasi is a peculiar vata roga, which affects a person who is greedy of

flesh.

Gridhrasi is a nerve of the lower extremity, which is resemble to Eagle beak

in shape.

Definition: Charaka3 has given the following definition. A condition where the

pain starts initially from kati, then the waist, back, thigh, knee and calf muscle are

gradually affected with stiffness, pain and pricking sensation and associated with

frequent twitching is called “GRIDHRASI”.

Susruta4 and his commentators define, Gridhrasi limiting the affected part.

Dalhana defined Gridhrasi limiting the affected part. The condition is said

to be Gridhrasi where the movements of Sakthi are restricted due to vata vitiating

the kandaras of heel and the related toes.

All the other authors followed Charaka.

10

Synonyms of Gridhrasi:

According to Ayurveda vangmayam,

1. Gridhrasi : The patient who suffers with Gridhrasi walks like Eagle. The

Gridhrasi nadi is curved similar to the nose of Grudha i.e. Eagle.

2. Rhinghini5: Vachaspati Misra who has written commentary on Madhava

Nidana explained the word Rhinghini. This term indicates skhalana of

Tarunasthi of vertebral column.

3. Rhandrini: Dalhana used this term while commenting on Susrutha.

(Su.Ni.1/75). It means degeneration of Tarunasthis of verterbral column.

4. Radhana6: This term is used by Kashiram in Gudardha deepika commentary

on Sarangadhara Samhita. It indicates pressure. In this context it indicates

compression of Sciatic nerve.

According to Greek and Modern medicine in 15th Century the term Cyetica

and scyetyka were used to indicate this condition.

Sciatica is derived from Greek word Ischiadikas i.e., pertaining to ischium,

the term is used for the disease as well as the nerve.

Definition:

SCIATICA7 is a type of neuritis characterized by severe pain along the path

of Sciatic nerve or its tributaries. Inflammation/injury of the nerve causes pain that

passes from the back or thigh down its length into entire lower limbs. (Principles

of Anatomy and Physiology). It is also termed as contugno’s disease.

11

SHAREERA - MODERN ASPECT

Sciatica 8 is pain in the distribution of sciatic nerve. The initial pain in the

lower part of the back is known as Lumbago. The two viz. Sciatica and lumbago

are often associated.

Therefore there is a necessity of describing two anatomical structures.

1) Sciatic nerve

2) Lumbo-sacral region of the verterbral column.

Sciatic nerve: Sciatic nerve is the main terminal branch of the sacral plexus which

is formed by L5, part of L4 & S1,S2,S3 spinal nerves.

The Sciatic nerve is the largest nerve in the body measuring about 2cm in

breadth at its commencement. It consists of two separate nerves in one sheath.

1) Common peroneal nerve

2) Tibial nerve

The sciatic nerve leaves the pelvis through the greater sciatic foramen,

usually below the piriformis and descends between the greater trochanter of the

femur and ischial tuberosity along the posterior surface of the thigh to the popliteal

surface, where it divides into tibial and common peroneal nerves. Branches in the

thigh supply the hamstring muscles. Rami from tibial trunk pass to the semi

tendinosus, semi membranosus, long head of biceps, ischial head of adductor

magnus. A ramus from the common peroneal trunk supplies the short head of

Biceps.

TIBIAL NERVE:

Tibial nerve is formed by lower two lumbar (L4, L5) and upper three sacral

segments (S1, S2, S3). The tibial nerve forms the largest component of the thigh. It

begins its own course in upper part of the popliteal space. It descends vertically

through this space and the dorsum of the leg to the dorso medial aspect of the

12

ankle, from which point its terminal branches and lateral plantar nerves continue

into the foot.

Branches from the Tibial proper:

1) Motor branches: To the gastrocnemius; plantaris, soleus; popliteus, tibialis

posterior; flexor digitorum longus, flexor hallucis longus.

2) A sensory branch, the medial sural cutaneous nerve from common

popliteal to form sural which supplies the skin of the dorso lateral part of

leg and lateral side of the foot.

3) Articular branches pass to the knee and ankle joints. Terminal branches

are two.

(i) The medial plantar nerve sends motor branches to:

a) Flexor digitorum

b) Abductor hallucis

c) Flexor hallucis brevis

d) First lumbrical muscles

Sensory branches to the medial side of the sole, plantar surfaces of

the medial three and one half phalanges of the same toes.

(ii) The lateral plantar nerve sends motor branches to all the small

muscles of the foot except those innervated by the medial plantar

nerve and sensory branches to the lateral portions of the sole. The

plantar surface of the lateral one and half toes and the phalanges of

the toes.

Common Peroneal nerve (External popliteal):

Common peroneal nerve is derived from the dorsal branches of ventral rami

of the L4, L5 & S1, S2 nerves. It descends obliquely along the lateral side of the

popliteal fossa to the head of the fibula, winds round the lateral surface of the neck

13

of fibula deep to peroneus longus, and divides into the superficial and deep

peroneal nerves.

Previous to its division, it gives articular and cutaneous branches.

Branches given off the popliteal space are sensory and include the superior and

inferior articular branches to the knee joint and lateral sural cutaneous nerve,

which joins the medial sural cutaneous nerve, supplies external malleolus and the

lateral side of the foot and fifth toe.

The 3 terminal branches are the recurrent articular and the superficial and

deep peroneal nerves, the articular nerve accompanies the anterior tibial recurrent

artery, supplying the tibio fibular and knee joints and a twig to the tibialis anterior

muscle.

Superficial peroneal nerve (Musculo cutaneous):

It passes between peronei and extensor digitorum longus, pierces deep

fascia in the distal third of the leg, and divides into medial and lateral branches. In

its course it supplies muscular branches to peroneus longus and peroneus brevis

and filaments to the skin of the lower part of the leg.

Medial branch supplies the medial side of great toe, adjacent sides of the

second and third toes.

Lateral branch supply the contiguous sides of third and fourth and of fourth

and fifth toes. It also supplies skin of lateral side of the ankle.

Deep Peroneal nerve:

Muscular branches: Tibialis anterior, extensor hallucis longus extensor digitorum

longus and peroneus tertius; articular branches supply the ankle joint.

Lateral terminal branches supply extensor digitorum brevis, Interosseous

branches to tarsal and metatarso phalangeal joints of second; third and fourth toes.

14

Lumbo Sacral region:

Vertebral column is divided into

1) Cervical spine, consisting of 7 vertebrae

2) Thoracic spine with 12 vertebrae

3) Lumbar spine with 5 vertebrae

4) Sacrum: Even though it consists of five sacral vertebrae, in adult they are

fused in one known as sacrum.

5) Coccyx: It is fused structures of four coccygeal vertebrae in an adult.

Sometimes both sacrum and coccyx may even fuse with each other in later

adulthood.

CURVATURE OF THE SPINE:

During evolution 9 the transition from quadrepedal to the bipedal state led

first to the straightening and then to the inversion of the lumbar curvature. The

erection of trunk has been obtained partly by backward tilting of pelvis and partly

by bending of Lumbar column.

On the first day of life 1. The lumbar column is concave anteriorly at 5

months.

2. The lumbar curve is still slightly concave anteriorly but the concavity

disappears at 13months.

3. From 3 years onwards lumbar lordosis begins to appear.

4. Becoming obvious by 8 years.

5. And assuming the definitive adult state at 10 years.

Elongation takes place rapidly as a child learns to walk. In the average

adult lumbar region comes to form about 32% of the total length of the

spine. As well as the lumbar lordosis there are cervical, thoracic and

15

sacral curvatures, which increase its resistance to axial compression forces

10 times that of a straight column. Thoracic kyphosis is a feature

common to all mammals, where as lumbar lordosis is especially human

kind is connected with the erect posture on straight legs.

The features of the lumbar lordoses and the vertebral column are at rest.

1) The angle of the sacrum formed between the horizontal and the plane

containing the superior aspect of S1, averages 30°.

2) The lumbo sacral angle lying between the axis of L5 and the sacral axis

averages 140°.

3) The angle of pelvic tilt formed by the horizontal and the line joining the

promontory to the superior border of the pubic symphysis averages 60°.

4) The index of lumbar lordosis can be determined by joining the supero

posterior border of L1 to the posterior inferior border of L5. The

perpendicular to this line is usually maximal at L3 and represents the index

of lordosis. It is greater as Lordosis is more marked and almost

disappears when the column is straight.

Lumbar Vertebrae:

In man each typical presacral vertebra is composed of four parts.

1) The body, which is primarily for transmission of forces.

2) The lamina and pedicles, which enclose the spinal canal.

3) The spinous and transverse processes for muscle and ligament attachment.

4) The posterior facets, which guide and limit motion between vertebrae.

The vertebral body lies anteriorly and is the largest part of the vertebra. The

Vertebral arch is shaped like a Horse shoe and behind the vertebral body. It bears

on each side an articular process, which divides the arch into an anterior pedicle

16

and a posterior lamina the spinous process is attached to the midline posteriorly.

The vertebral arch therefore is attached to the vertebral body by the pedicles.

Transverse processes are attached to the arch near the articular processes.

In the vertical plane these various constituents like in anatomical

correspondence making three pillars an anterior major pillar comprising the

stacked vertebral bodies and two posterior minor pillars made up to the articular

processes.

The vertebral body has a dense bony cortex surrounding a spongy medulla.

The cortex of the superior and inferior aspects is called the vertebral plateau. The

sagittal section comprises two fans like sheaves of oblique fibres. The first arising

from the superior surface fans out at the level of the two pedicles to reach the

corresponding superior articular processes and spinous process. The second,

arising from the inferior surface, fans out at the level of the two pedicles to reach

the corresponding inferior articular processes and spinous process. The criss-

crossing of these three trabecular systems constitutes zones of maximum

resistance as well as a triangular area of minimum resistance. This triangle is

made up only of vertical trabeculae and explains the wedge-shaped compression

fractures that occur.

Each vertebra can be compared to a lever system where the articular

processes constitute the fulcrum. This lever system allows the absorption of axial

compression forces applied to the vertebral bodies and indirect absorption in the

posterior ligaments and muscles. In the lower lumbar vertebrae the diameter of

spinal canal is comparatively greater. The center of this cylinder does not coincide

with the center of the vertebral plateaux so when upper vertebra rotates on the

lower one the upper vertebral body must slide over that of the lower vertebra. The

shearing forces that ensue limit the rotation so that it is minimal both segmentally

and over the whole lumbar spine.

17

The stacked vertebral bodies of the spinal column acts as a pillar and due to

the secondary curves make the backbone some sixteen times stronger than if it

were straight. They permit spine to transmit the weight of the body to the pelvis

and reduces the muscular effort otherwise needed to keep a person upright.

Inter vertebral Disc:

The inter vertebral disc accounts for about 1/3 rd of total height of the

lumbar spine. The vertebrae in mammals articulate with another adjacent

vertebrae by means of inter vertebral discs. The mobility, and the need for

simultaneous load bearing, necessitates some form of hydrostatic structure to

convert unidirectional forces into stresses acting in all directions.

The disc has two components.

1. Anulus fibrosis

2. Nucleus pulposus.

Annulus fibrosis: Annulus forms a fibro cartilaginous ring, more fibrous and

elastic peripherally, more cartilaginous in the inner part. The Annular fibers are

gathered in concentric lamellae, successive layers overlapping in alternatively

oblique directions. Thus nucleus is enclosed in an inextensible casing formed by

the vertebral plateaux and the annulus, whose woven fibers in the young prevent

any prolapse of the nucleus.

The many elastic fibers of the young, healthy annulus gradually disappears

during the aging process.

Nucleus Pulposus: Nucleus pulposus comprises 40% of the disc and is a semi

fluid gel readily deformable but incompressible. It is the central core of the IV

Disc. Collagen fibers form a three-dimensional honeycomb network, enmeshing

the muco protein gel with its rich content of muco poly saccharides or

proteoglycans, chondroitin 6-sulfate. Nucleus pulposus acts as a perfect

hydrostatic medium. It distributes axial load radially to be absorbed by the fibers

18

of the surrounding annulus fibrosus. The hydrostatic action is predicted because

of its high water content. When a vertebral plateau presses on the IVD the nucleus

bears 75% of force and the annulus 25%. The nucleus transmits some of the force

to the annulus in the horizontal plane and the tangential tensile strain is 4-5 times

the applied external load.

With age the nucleus looses its water absorbing capacity and the pre-loaded

state tends to be lost. Hence the lack of flexibility of the vertebral column in aged.

During standing the water in the gelatinous matrix of the nucleus escapes

into the vertebral body through microscopic pores and during course of the day

disc becomes thinner. At night the water absorbing capacity of the nucleus draws

water back into the nucleus from vertebral bodies and disc regains its original

thickness. Therefore flexibility of the vertebral column greatest in the morning

and at this time the spine is longer than in evening. Nucleus is a noto chordal

remnant.

Functions of the Annulus:

1. Forms the chief structural unit between vertebral bodies and provides a

mobile segment.

2. Encloses and retains the nucleus pulposus.

3. Restricts and regulates movement. Eg. Sagittal lumbar movement is

restricted almost entirely by tough annulus. In full flexion when the

articular process are more separated, some half of the diagonal lamellae

restrict rotation to a degree and are thus under stress during this movement.

4. By virtue of an inherent elasticity, the annulus fibrosus helps to absorb the

shock of compression forces, which are sustained as a circumferential

tensile stress in the annulus. The diagonal strapping effect of the fibrous

lamellae is important here.

19

The posterior post especially the postero lateral part of the annulus is a site of

potential weakness because

Thinning and bifurcation of Annular fibers posteriorly.

Fibrous tissue is adopted to withstand tension rather than pressure and

in the lordotic lumbarspine; gravitational compression falls most heavily

on the posterior aspects of the vertebral body joints.

Posterior longitudinal ligament is attenuated, thin and expanded at the

level of the disc.

The eccentric position of the nucleus pulposus, which lies closer to

posterior aspect of the disc.

The susceptibility of this locality to succumb to under the stress of

rotation strains.

Functions of pulposus

1. Its fluid permits the formation of a mobile segment and allows an even

distribution of compression forces over the opposed surfaces of vertebral

disks.

2. The viscid gel acts like a dynamic hydraulic suspension system. This gel

spreads the pressure uniformly over the entire surfaces of the vertebral

bodies and so behaves like a shock absorber.

In a young adult the normal intervertebral disc will yield and deform only

at pressure over 1400 pounds, but in an older individual this occurs with

only about 350 pounds.

The normal disc is actually more resistant to trauma than bone and is

not what gives under extreme pressure or the vertebrae will fracture before

the disc.

20

The spinal disc serves two functions.

1. To provide mobility to the spine.

2. To act as a shock absorber.

Movements of the discs:

During extension the upper vertebra moves posteriorly reducing the

interspace posterior and driving the nucleus anteriorly. The nucleus presses on the

anterior fibers of the annulus increasing their tension and this tends to restore the

upper vertebra to its normal position.

During flexion the upper vertebra moves anteriorly reducing the interspace

anteriorly and driving the nucleus posteriorly. The nucleus now presses on the

posterior fibers of the annulus increasing their tension.

During axial rotation the central fibers of the annulus are stretched,

compressing the nucleus and causing the internal pressure to rise.

Flexion and axial rotation tend to tear the annulus and drive the nucleus

posteriorly through tears in the annulus. Whatever force is applied to the disc, the

internal pressure is increased and the fibers of the annulus are stretched. Owing to

the relative movement of the nucleus, the stretching of the annulus tends to oppose

this movement.

The hydrostatic properties of the nucleus and the relatively high pressure

that is exhibits relieves the annulus fibrosus from vertical stress, thus making

tilting movements of loaded lumbar spine easier.

Nutrition of the Disc:

The adult disc is virtually a vascular. Nutrition appears to depend upon

imbibition of fluid into it from the vertebral bodies and from spare vessels of the

annulus during the first years of life. This process must obviously be assisted by

21

the rhythmic movements and compression of daily activities and it is of interest

that there is a diurnal variation in body height.

There is a reason that active movements assists normal fluid imbibition

processes between spongiosa and pulposa, this may be a factor in delaying the

slow inevitable drying up of the discs with ageing.

The lack of directly penetrating vessels makes the intervertebral disc, the

largest avascular structures in the body. Diffusion of solutes can take place

through the central portion of the hyaline cartilaginous end plates as well as

through the annulus fibrosus. Posteriorly the areas available for diffusion are

smaller. The central part of the disc, and particularly the boundary zone between

the nucleus pulposus and annulus fibrosus is exposed to possible deficiency of

nutrition.

The disc appears to live and thrive on movement change and die slowly

through lack of it. There is now a shift of emphasis from the idea that disc

disorders result from purely mechanical derangement, to the view that nutrition

and metabolism of the disc and the biochemistry of degenerative change, are of

equal importance.

LIGAMENTS:

The ligaments of the lumbar region are stronger and denser than elsewhere.

The anterior longitudinal, posterior longitudinal ligaments are linked at

each vertebral level by the Intervertebral disc.

Other ligaments connect arches of adjacent vertebrae - ligamentum flavum,

inerspinous, supraspinous ligament, anterior and posterior ligament of articular

processes, inter transverse ligament.

Action of ligaments: The dense anterior longitudinal ligament is stronger than the

posterior ligament and limits extension of the vertebral column. The ligamenta

flava help to restore the vertebral column to its original position after bending

22

movements and is important in resisting rotation. The spinous processes are

connected by the supra spinous and infraspinous ligaments which particularly

limit, flexion.

Movements of the Vertebral column:

The mechanical stability of the column is assured by reason of the axis of

rotation passing through the bodies and not through the neural arches, so that the

bodies are not displaced from each other during movement.

The spinal column has 3 degrees of freedom; it is allowed flexion and

extension, lateral flexion and rotation. The range of these elementary movements

at each individual joint is very small but the movements are cumulative over the

whole column. Moll and wright found an initial increase in mean spinal mobility

form the 15-24 decade to the 25-34 decade followed by a progressive decrease

with advancing age of as much as 50 percent of mobility.

Flexion and extension in the anterior posterior plane occur in all regions of

the column and these movements are particularly free at the specialized atlanto-

occipital joint, free in the lumbar and cervical region and very restricted in the

thoracic region. Rotation is free in the specialized altanto – axial joints but else

where it is determined by the shape of the apophyseal joints.

Kapandji- Lumbar spine contributes 60° flexion and 35° extension to spinal

mobility. For thoraco lumbar region taken as a whole, flexion is maximally 105°

and extension 60°, to range of lateral flexion to each side is 20° in the lumbar

column. Axial rotation from side to side during standing is 20° in lumbar column

and 90° for the thoraco lumbar region taken as a whole.

The thoracic movement is most limited because these vertebrae are tied to

the ribs. All the mobility depends to a considerable extent on the muscles and

ligaments of both the spine and the back.

23

Morris (1973) – Intrinsic spinal stability is provided by intervertebral discs

and ligaments, and extrinsic stability imparted to vertebral column by the action of

muscles. The intrinsic stability is the result of pressure within the disc, which

tends to push the vertebral bodies a part and the tension provided by the ligaments

which tends to pull the bodies together. Thus the vertebral segments and discs are

firmly bound together by ligaments under tension:

1. A longitudinal system, which binds all the vertebrae together into a

mechanical unit.

2. A longitudinal system, which secures one segment to another.

This arrangement accounts for relative stability of the spine dissected free of

musculature.

Morris, Lucas, and Bresler (1961) showed that flexibility between two

vertebrae varies directly with the square of the vertical height of the disc and

indirectly with the square of the horizontal diameter of the body. Thus for a given

load and cross-section an increase in the height of the disc and the length of the

ligaments tends to increase the apparent flexibility, while an increase in the cross-

sectional size of the disc tends to reduce apparent flexibility. Because of the

proportionally greater height of the lumbar disc, the range of intervertebral motion

is somewhat greater in the lumbar region; but because of the greater horizontal

diameter, the flexibility is less than in thoracic region.

24

NIDANA

Gridhrasi is included under vatavyadhis, where specific etiological factors

are not mentioned; hence Nidana of vatavyadhi can be considered as nidana of

Gridhrasi. Charaka Samhita1 and Bhava Prakasha2 clearly mentioned the

causative factors of vatavyadhi, but in Sushruta samhita3,4, Astanga Sangraha5 and

Astanga Hridaya6,7 the causes of vatavyadhi have not been clearly described.

However, in these texts the causative factors of provoked vata dosha are available.

Since Gridhrasi is considered as Nanatmaja vatavyadhi, the provocative

factors of vata can also be taken as causes of Gridhrasi.

In addition to this, in Charaka samhita8, Ashtanga Sangraha9 and Ashtanga

Hrudaya10, two specific causes of vatavyadhi i.e., Dhatukshaya and Avarana have

been mentioned.

All the etiological factors of vatavyadhis as well as vata prakopa are taken

as Nidana of Gridhrasi and is classified as follows:

1. Viprakrista nidana: The person who steals the wealth of God11 or

Bramhana and who deceives his master or who opposes his teacher will

suffer from vatavyadhi. (Vaidya chintamani – vatavyadhi karma vipakam)

2. Sannikrista nidana: a) Aharaja

b) Viharaja

c) Kalaja

d) Agantuja

e) Anyahetu

25

a) Aharaja Nidana: The excessive intake of rasas like katu, tikta, kashaya,

laghu, rooksha gunas and seta veerya leads to vataprakopa.

“Sarvada sarva bhavanam samanyam vriddi karanam” 12

The dravya, which possess similar properties, increases the other dravya,

which is resumblant to it in properties.

Dhanya - Mudga, Masoora, Adhaki, Kalaya, Nishpava etc.

Phalas - Jambu, Bilwa, Kapitha etc.

Sakas - Kareera, Karavellaka, Patola, Rakta punarnava.

Alpasana leads to dhatu kshaya thereby causing vataprakopa. Adhyasana,

visamasana causes ama which obstructs the srotas hence aggravates vata.

As per “Vayordhatu kshayat kopo margasyavaranenacha”13

b) Viharaja : Prajagaram – increases ruksha guna in body and aggravates vata.

Langhana, plavana, athyadwa sevana, vyayama – as a result of this

excessive and continuous exertion results in dhatu kshaya and aggravates

vata. Diwaswapna14 increases pitta and kapha, which obstructs the channels

and leads to vata prakopa.

Vegavadharana is a condition when any of the natural urges are

suppressed, then vata prakopa takes place. So far Gridhrasi is concerned

malavarodha is most important to cause vataprakopa15 . This causes pain in

sacral region, pindikodwestanam, and backache and also produce many

diseases in the lower limbs like Gridhrasi etc. Vagbhata16 also stated that

avarodha of apanavata causes a variety of vatavyadhis.

c) Kalaja : Vata vitiation takes place in varsha, Grishma and Sharat ritu. It

also aggravates in Aparahnakala, Jeernannakala, Apararatra and in sheeta

kala. During vriddhavastha17 vata prakopa takes place.

26

d) Agantuja: Abhigata due to external causes are considered specially while

carrying heavy loads, wrestling with a person of superior strength, leaping

and jumping etc.

Marmabhighata particularly to kukundara, nitamba marmas leads to

Gridhrasi.

Kunkundara18 (Marma abhigata) loss of power and sensation in lower

extremities and may result in pain and difficulty in walking. (Su.Sa.6/48).

Nitamba: Injury, causes swelling, weakness, pain paresis in lower limbs

and even death in due course of time.

Falling off from back of animals and higher places also cause

marmabhigata.

The pathological19 changes in the vertebral column are mainly occurred by

physical strain. In physical activity, standing alone increases load on the disc four

fold compared to supine strengthening exercises almost double the load in the disc

over the standing posture. It illustrates the impact of physical activity on the

vertebral column.

Most of the activities we are observing in society are already described in

Ayurveda as Nidana in Vatavyadhi.

The prolonged stooped posture imposes loads on the posterior ligaments of

the spine and the fibers of inter vertebral disc, stretched ligaments increase joint

laxity, which can lead to hyper flexion injury. Ligament damage seems to occur

during traumatic sporting activity with the spine at its end range of motion. In

above conditions the tensile forces works on ligaments, which are capable of only

withstanding tensile forces, if it is excessive it ruptures ligaments.

27

Attempting to lift and twist with awkward loads so that extension and

rotatory movements are involved together produces Interverbetral disc rupture in

lumbar region. The excessive compressional load acting on the nucleus pulposus is

the basis for disc degeneration, vertical compression of spinal segments the

vertebral end plates are the first to fracture leads to osteo arthritic changes in the

inter vertebral joints

Segmental instability occurs when the normal movement between vertebrae

is lost because of degenerative changes involving any one of the components of

disc followed by Sub luxation.

Fractures, Dislocations and disc prolapse when compress the spinal cord

results in paralysis of limbs which can be attributed to injury of marmas. Hence

Agantuja nidana is a prime factor in the disorders of the vertebral column.

Anya hetu:

Dosha Asrik sravanadapi - Excessive elimination of mala, rakta during vamana,

virechana, vasti karmas leads to vata prakopa. This can be considered as

Iatrogenic cause.

28

Etiological factors of vata prakopa &vata vyadhi with reference to Gridhrasi.

NIDANA CS SS AS AH MN BP Aharaja Rasa Katu, Tikta, Kashaya + + + +

Laghu + + + + Ruksha + + + + +

Guna

Seeta + + + + Karma Vistambi + Veerya Sheeta +

Adhaki + + Bisa + Harenu + Chanaka + Kalaya + Koradusha + Masura + + Mudga + + Nivara + Nishpava + + Saluka + Suskashaka +

Dravya

Syamaka + Abhojana + + + + Alpasana + + + Visamasana + + + + Adhyasana + +

Krama

Pramitasana + + Atigamana + + + + Atihasya + + Atilanghana + + + Atiplavana + + Atipradharana + Atiprajagarana + + + + + + Ati prapatana + Ati prapidana + Ati pratarana + + Ati raktamokshana + + Ati Sharma + Ati vichestitam + + + Ati vyayam + + + + + Ati Adhyayana + + Kriyati yoga + + + + +

Kayika (atiyoga)

Padati charya +

29

Asama bhramana, chalana, vikshepa, asamotkshepa

+

Balavat vigraha + + Bhara harana + + + Diwa Swapna + + Dukhasana sayya + + Kastabhramanachalana vikshepa + Vegadharana + + + + + +

Mityayoga

Vishamapochara + Bhaya, Chinta, Soka + + + + + Krodha + +

Manasika

Mada + Aparahna + + + + Apararatra + + Grishma + + Pravata + + Shisira + Seeta kala + +

Kalaja

Varsha + + + Agantuja Abhighataja + + Gaja, Ustra, Ashwa, Shighrayana

patana + +

Marmaghata + + Dosa Asrik sravana + + + + Dhatu kshaya + + + Ama + + + Rogati karshana + + +

Anyahetuja

Margavarana +

Causes of Sciatica 20:

Sciatica is neuralgia in the distribution of Sciatic nerve or its component

nerve roots.

I. Compressive causes:

a) Congenital – Spina bifida, Spondylolisthesis.

b) Traumatic - Fracture of hip joint

Vertebral fractures

Lumbo sacral sprain and strain.

30

c) Mechanical pressure on the nerves-

In the spinal cord - Tumors of cauda equina. Arachnoiditis, Haemorrhage /

infection irritating meninges of the cord.

In the cord space – Protruded inter verterbal disc, extra medullary tumors.

In vertebral column – Sondylolisthesis, spondylosis, Bone tumor, stenosis

of intervertebral canal and lateral recess hypertrophy of apophyseal facets.

In the back - Fibrositis of posterior longitudinal ligament.

In the thigh and buttock - Neurofibroma, Hermorrhage within or adjacent

to nerve sheath.

In the pelvis - Sacro iliac arthritis, Tumors of lumbo sacral plexus.

Other destructive disease:

Neoplastic: Metastatic carinoma, multiple myeloma, Hodgkins and Non

Hodgkins lymphoma.

Infections: Infection in vertebral column due to pyogenic organisms –

staphylococci, Tubercular bacilli, Spinal epidural abscess.

Several metabolic diseases of bone such as hyper parathyroidism,

osteoporosis precipitates bone dysfunction. This in turn leads to vertebral body

weakness, leading to vertebral fractures, protrusion, herniation etc.

Inflammatory causes : - Rheumatoid arthritis - Ankylosing spondylitis - Lumbar spondylitis - Osteo arthritis of lumbar spine. - Tuberculosis of vertebral column and spine.

31

II. Non-compressive causes:

Ischaemic necrosis in Diabetes Mellitus, leprosy, direct injury due to

penetrating wounds. Eg. Gunshot or misplaced injections, claudication of sciatic

nerve, compression injury to Sciatic nerve by foetal head during delivery.

Some times over exposure to cold or sitting on chatted grass may induce

the pain.

Catamenial sciatica: The unusual developmental anamoly of implantation of

endometriosis in the Sciatic nerve at the sciatic notch may cause sensorimotor

Sciatic nerve palsies. These may be associated with peri menstrual pain in the

buttock or posterior aspect of the thigh.

32

POORVA RUPA

“Poorva rupam pragutpathi lakshanam vyadhehi” 1

For every disease certain premonitory symptoms are noted before it is

clearly established in the body. Such symptoms are called Poorva roopa.

“Avyakta lakshanam tesham poorva roopamiti smritam

Atma rupam tu yad vyaktam apayo laghuta punaha ” 2

According to Charaka Avyakta lakshanas are purvaropa of vatavyadhi.

According to Chakrapani 3commentary on Avyakta, few mild early symptoms are

to be taken as purva rupa. The very specific symptoms if manifest insignificantly

can be considered as poorvarupa of Gridhrasi. Sthamba, Ruk, Toda,

Muhuspandana, Grihnati.

Diagnosis at this stage of illness gains paramount importance. The

effective treatment at this stage reduces the degree of morbidity.

33

ROOPA

“Utpanna vyadhi bhodaka meva lingam rupam” 1

Lakshanas, which occur after the manifestation of vyadhi, known as Rupa.

Vyakta purva rupa is Rupa.2

Charaka 3classified Gridhrasi into two varieties.

1. Vataja

2. Vata shleshmaja.

Considering all the clinical manifestations of Gridhrasi, it may be subdivided into

samanya lakshnas and vishesha lakshanas.

Samanya Lakshanas:

These lakshanas are seen in both vataja and vata kaphaja type of gridhrasi.

RUK: “Ruk satatam shoolam” 4

“Ruk shoolam” 5

“Ruja vedana” 6

In Gridhrasi, Ruk-pain is starting from sphik and radiating towards kati,

prista, uru, janu, jangha and pada. Non-radiating pain felt at sites like kati, uru,

janu, jangha, pada is also considered as symptom of Gridhrasi.7

This typical radiating pain involving legs is suggestive of Sciatica where

pain is felt along the course of Sciatic nerve.

Toda: “Todah sooci vyadhanavat vyadha”8

“Toda vicchinna shoolam” 9

Intermittent pain similar to feeling of pinprick.

34

Sthamba:

“Sthamba nischalakaram”9

“Sthamba bahu uru janghadeevam sankuchanadhya bhava10

“Sthamba nishkriyatvam”11

It is stiffness at uru and jangha region in Gridhrasi, due to pain the

movement i.e., restricted in the muscles and joints of lower limb. This stiffness

affects gait of the patient.

Sakthna kshepa nigrahanyat:

“Kshepam prasaranam tam nigrahanyat avarudyat ityarthah”12

Hence, word kshepam means prasarana or extension. According to

Dalhana it is the sign of restriction during extension of leg. This is more clear by

commentary of Arunadutta on Astanga Hridaya12 explained as urdwa prerana

avarundati i.e., restriction in raising the leg. As the extension of the legs worsens

the pain patient prefers to assume the flexed position of the legs.

Kati Uru Janu madhya Bahu vedana:

A distinct feature in Gridhrasi mentioned by Harita13, severe pain at kati,

uru and Janu region.

Muhu spandana:

“Spandana Spuranam” 14

“Spandanam Hi Kinchit chalanam” 15

Spurana refers to the fasciculation. This symptom is seen in the muscle

supplied by the Sciatic nerve.

35

Pain in Payu:

Described by Vangasena16 only. This may be due to derangement of

Apanavayu. Payu is one of main sthanas of Apana vayu and Apana Vayu governs

functions of defecation. Therefore, when apana vayu is vitiated constipation

results and pain in peri anal region occurs.

Few of symptoms are exclusively mentioned in Basavarajeeyam17. These

symptoms include sopha, kara pada vidaha krit, sweda, moorcha, Bhrama and

trishna. Some of these symptoms are indicative of vitiation of pitta dosha in

Gridhrasi.

VISESHA LAKSHANAS:

Vataja Gridhrasi:

Dehasya vakrata: Madhava described this symptom, which means the patient of

Gridhrasi acquires a particular posture because of pain. The patient of Gridhrasi

keeps the leg in flexed position and tries to walk without much extension in the

affected side. Because of extreme pain, sthamba, toda etc., the patient assumes a

typical limping posture.

It can be considered as Sciatic scoliosis – maintained by reflex contraction

of the para spinal muscles.

Stabdata Brisham:

The severe degree of stiffness is seen in the patient suffering from Vataja

Gridhrasi.

Spuranam:

“Spuranam Gatra deshe swalpa chalanam”18

“Spuranam punah punah chalanam” 19

A type of muscle twitching in kati, uru, Janu, Jangha is similar to that of

spandana or muhuspandana.

36

Suptata:

The patient experiences varied degree of parasthesis or sensory loss in the

affected limb.

Vata Kaphaja Gridhrasi:

In Gridhrasi when anubanda of kapha dosha is present following lakshanas

are seen.

Vahni mardava:

Decreased abhyavaharana and jarana shakti causes loss of appetite.

Tandra:

“Tandrayantu prabhodito api klamayati nidrabheda ”20

Due to tama, vata and kapha there will be a feeling of drowsiness or

inability of sense organs to grasp followed with yawning and fatigue without any

work.

Mukha praseka:

Excessive salivation in the mouth occurs due to kapha in association with ama.

Baktadwesha:

“Dveshamayati yo jantu bhaktadvesha sa ucchate” 21

Because of loss of appetite and kapha dusti, patient feels aversion towards food.

Arochaka:

“Arochakastu prarthite apyupayoga samaye anabhilasha”22

“Aruchi prarthita Anna Bhakshana Asamarthya mucchyate”23

Dislike of consuming food. The patient fails to appreciate the taste in the

mouth irrespective of state of appetite. Vata and kapha are involved because the

seat of bodhaka kapha is jihwa, which does raso bodhana.

37

Gaurava:

Heaviness particularly occurs in the lower limb.

Staimityam:

“Staimityam gatranaam nirutsaahatvam” 24

Inertness of body, feeling of freezing sensation in the affected lower limb, due to

kapha vitiation patient feels as if his lower extremities are covered with wet cloth.

Rupa of Gridhrasi according to different Acharyas

Samanya Lakshanas CS SS AH AS HS BP MN YR VS BR Kati prista uru janu jangha pada –Ruk

+ + + + +

Kati prista uru janu jangha pada –Toda

+ + + + +

Kati prista uru janu jangha pada – Sthamba

+ + + + +

Kati prista uru janu jangha pada –Muhuspandana

+ + + + +

Sakthnaha kshepam nigrahaniyat + + + + Kati uru janu madhye bahu vedana + Parshni pratyanguleenam tu kandara yanilardita

+ + +

Pain in payu + Sopha, karapada vidaha + Specific Vataja Deha vakrata, Toda + + + Stabdata + + + Janu jangha uru sandhi spurana + + + + Suptata + Specific Vata kaphaja Tandra + + + + + Gaurava + + + + Arochaka + + + + Vahni mardava + + + + + Mukha praseka + + + + + Bhakta dwesha + + + + + Staimitya +

38

Clinical features of Sciatica:

The clinical course of Sciatica depends on the nature of the underlying

pathology.

In most patients the pains are caused by a ruptured intervertebral disc. In

some patients the symptoms are produced by Arthitis in the Sacroiliac joint or

spine, spondylolisthesis, lumbar canal stenosis that are commonly seen.

A fully developed prolapsed inter vertebral disc25 consists of

(1) Pain in the sacroiliac region, radiating into the buttock, thigh, calf and foot.

(2) A stiff or unnatural spinal posture.

(3) Some combination of paraesthesias, weakness and reflex impairment.

The most common history is that of severe low back pain after an injury.

The acute attack subsides with in a few days sciatic pain eventually develops after

the appearance of low back pain. As the Sciatic pain increases in intensity and

extent, the backache become less and occasionally may be entirely absent.

Intermittency of symptoms is characteristic, and each succeeding attack is

usually more severe.

Pain:

The pain of herniated intervertebral disc varies from severe to mild forms.

With most severe pain, patient is forced to stay in bed. The patient is usually most

comfortable lying on his back with legs flexed at the knees and hips. The pain is

frequently made worse by an activity that increases intra spinal and intra discal

pressures such as coughing, sneezing and bearing down during defecation.

When the condition is less severe walking is possible, though fatigue sets in

quickly, with a feeling of heaviness and drawing pain.

39

Sitting and standing up from a sitting position are particularly painful. Pain

is characteristically provoked by pressure over the course of the Sciatic nerve at

the classic points of valliex (Sciatic notch, retro trochanteric gutter, and posterior

surface of thigh, head of fibula. Pressure at one point may cause radiation of pain

and tingling down the leg pain is referred to the involved dermatome.

Reduced mobility: Forward bending in particular is restricted26. In acute stage

with marked muscle spasm all mobility is restricted.

List of trunk:

The lumbar spine most often deviates away from the affected side. The

disk is usually lateral to the nerve root 27, and the tilt of the spine away from the

affected side. Protrusion medial to the nerve root causes a list to the painful side.

The disk is often accentuated when bending forward.

A list or tilt will elevate one iliac crest. This asymmetry is responsible for

the commonly diagnosed “longer leg on one side” and the erroneous assignment

of the back pain to asymmetry of leg length.

The patient stands with affected leg slightly flexed at the knee and hip, so

that only the ball of the foot sets on the floor. In walking, the knee is flexed

slightly, and weight bearing on the painful leg is brief and cautious, giving a limp.

It is particularly painful for the patient to go up and down stairs.

Neurological signs: Motor signs are present in about 96% of cases and include

atrophy of leg muscles, determined by measuring leg circumferences and muscle

weakness.

Weakness of dorsi flexion of large toe and inability to walk on heels

indicate fifth lumbar root involvement by fourth lumbar disk.

40

Inability to walk on toes because of calf muscle paresis points to first sacral

root involvement by the fifth lumbar disk.

Sensory signs found in 80% of patients.

Nerve tension signs:

Straight leg – Raising Sign (S.L.R.):

It is the active attempt made by patient to raise the entire leg with the leg in

complete extension. In case of sciatica extension of the leg is below 90°.

The degree of limitation is roughly proportional to the severity of pain.

Elongation of nerve root by straight leg raising or by flexing the leg at the

hip and extending it at the nee (lasegue maneuver) is most consistent

among pain provoking signs. Crossed leg pain is pathognomic of severe

disc prolapse.

Variations of the lasegue maneuver –

Bragard sign: Accentuation of the pain by dorsi flexion of foot.

Neris sign: With patient standing, forward bending of the trunk will

cause flexion of the knee on the affected side.

Naffziger sign: Sciatica may be provoked by forced flexion of the head and

neck, coughing, or pressure on both jugular veins, all of which increase the

intra spinal pressure.

Sicard sign: The pain may be elicited by carrying out test with

dorsiflexion of big toe.

There are typical patterns of symptoms for each level of root involvement.

41

Lumbar root lesions

Disc level Root Sensory loss

Motor weakness Reflex loss Pain distribution

L3-L4 L4 Antero medial calf and shin

Quadriceps (knee extension) thigh adduction, Tibialis anterior (foot dorsiflexion)

Knee Lateral thigh.

L4-L5 L5 Antero lateral leg, Dorsum of foot, great toe

Peroneii (foot eversion), tibialis anterior (foot dorsiflexion) gluteus medius (Hip abduction) Toe dorsiflexion.

None or rarely reduced ankle reflex.

Buttock, back and side thigh, lateral lower leg.

L5-S1 S1 Lateral malleolus, lateral foot, heel and web of fourth & fifth toes.

Gastrocnemius, soleus (foot plantor flexion) Abductor hallucis (toe flexors), gluteus maximus (Hip extension)

Ankle Buttock, Back of thigh and calf to heel.

Cauda equina syndrome:

A large midline disc herniation may compress several roots of cauda

equina. Patients have bilateral leg pain. Peri anal numbness, saddle dysesthesia

and loss of anal reflex are seen or diminished rectal tone characterizes an

advanced cauda equina syndrome. Sensory deficit involves lower sacral roots.

Difficulty with urination including either frequency or overflow incontinence may

develop relatively early.

Lumbar canal stenosis and spondylotic caudal radiculopathy:

Osteo Arthritic or spondylotic changes may lead to compression of one or

more caudal roots. The problem is exaggerated if there is a congenital narrow

lumbar canal. The roots are caught between the posterior surface of the vertebral

body and the ligamentum flavum posteriorly. Lateral recess stenosis, alluded to

above, may also contribute to root compression.

42

Symptoms are of neurogenic claudication. Nonspecific low back pain and

root pains followed by paraesthesias in the lower limbs, which come on with

walking down hill, and relieved by rest. In acute condition patient gains relief by

squatting or lying down with the legs flexed at the hips and knees. Standing, and

particularly standing with the lumbar spine in extension, aggravates the condition.

Osteo Arthritis: Pain is centered in the affected part of spine, is increased by

movement, and is associated with stiffness and limitation of motion. A slightly

flexed posture is preferred. Discomfort is accentuated when the erect posture is

resumed.

Spondylolisthesis: Anterior displacement of a vertebral body in relation to

inferior adjacent vertebra can cause root compression with resultant leg pain and

weakness. Pain often aggravated by walking or standing.

Investigations

Imaging of spine:

Plain x-rays of lumbar spines: To identify the spondylotic changes and narrowing

in the lumbar spine or sacro-iliac lesion or hip joints.

Myelogram: To know the disc protrusion and to differentiate such lesions from

tumors.

Nuclear magnetic resonance imaging (NMR): To assess any root lesion.

Computed Tomography scan (C.T.Scan): Useful in the identification of a

stenosed canal, destructive lesion of vertebral bodies and posterior elements or

presence of paravertebral soft tissue mass.

Magnetic Resonance Imaging (M.R.I): Which virtually replaces C.T.Scan. study

of degenerative disc.

The symptom “Sakthnaha Kshepam Nigrahaneeyaat” is identical to S.L.R.

test described in modern classics. The symptom “Dehasya vakrata” is nothing but

the Sciatica Scoliosis” and suptata refers to the parasthesia.

43

UPASAYA AND ANUPASAYA

This may be explained as the therapeutic diagnosis of an illness. The

Involvement of the Remedial agents, regimens of diet and behavioral rules, which

are contrary to the causes of illness, providing the result is called Therapeutic

diagnosis of an illness.

Upasaya for Gridhrasi has not been mentioned separately. But, if there is

uncertainty as whether the vyadhi is urusthamba or Gridhrasi, to differentiate these

two we can adopt Upasaya. If symptoms aggravate on the application of oil, then

we consider it to be uru sthamba 28 and if the symptoms subside we can consider it

as Gridhrasi.

All the factors, which bring about the equilibrium of the vitiated vata, can

be considered as upasaya.

Samanya chikitsa sutra of vata vyadhi and chikistsa sutra mentioned in the

classics by different acharyas are the upasaya for Gridrasi.

The nidana mentioned for Vatavyadhi, Gridhrasi are considered as

Anupasaya

44

SAMPRAPTHI

“Vyadhi janaka dosha vyapara vishesha yuktam vyadhi

Jameha samprapti shabdena vachyam”1

The process of pathological changes in the body commencing from nidana

to complete manifestation of the disease is called Samprapti.

The Samprapti of Gridhrasi depends on Age, Sex, occupation and dietary

habits of the people. Estimation of Samprapti is essential to treat disease

successfully. Chikitsa is nothing but “Samprapthi Vighatanam”.

The pathogenesis of vata vyadhi takes place in two ways. When a person is

exposed to vata prakopakara nidana his dhatus will not be nourished by virtue of

soshana. Rasa dhatu kshaya takes place and further dhatus are not nourished

properly. As a result of Dhatu kshaya2, srotas become khara, ruksha, parusha and

results into sroto riktata (devoid of Snehamsa). These rikta srotas gets filled with

vata dosha and results many vata vyadhis either in the whole body or target

organs.

Vitiated kapha, Ama obstructs vata dosha. It causes srotorodha and

generates vatavyadhi at avarodha sthana.

Vatavyadhi Samanya Samprapti

Nidana

Dhatukshaya

Vataprakopa

Margavarodha

Vatavyadhi

45

Gridhrasi Visesha Samprapti

Nidana

Agantuja Abhigataja Marmagathaja

Vatavriddhi

Dhatu kshaya

Avarana

Vatavikriti

Ama

Agnimandya

Sroto avarodha

Margavarodha

Sroto Rikta

DOSHA DUSHYA SAMMURCHANA AT THE SITE OF KHAVAIGUNYA

Gridhrasi

STHANA SAMSRAYA AT KATI, PRISTA, URU, JANU, JANGHA, PADA

46

SAMPRAPTI GHATAKAAS

Dosha : Vata : Vyana vayu, Apana vayu Kapha : Sleshmaka kapha Dushya : Rasa, Rakta, Mamsa, Asthi, Kandara, Snayu Srotas : Chestavaha, Sangnavaha Sroto dusti prakara : Sangam Agni Jataragni, Dhatwagni Udbhavasthana : Pakwasaya Sanchara sthana : Prista vamsha Adhistana : Spik, Kati Prista and Adhosakha Rogamarga : Madhyama

Dosha: According to Susruta, Sakthnah kshepam nigrahaneeyat is one of the

cardinal symptoms of Gridhrasi. The kshepana and utshepana etc., activities are

attributed to vyanavata. Morbid vyana vayu is the primary cause of illness.

Apana vayu having its site in kati & sakthi is also involved. Sleshmaka kapha gets

involved as it resides in sandhi.

Dushya: Susruta3 clearly indicated the involvement of Kandara, which are

upadhatu of mamsa.

Dalhana considered kandara as mahasnayu, which starts from Gulpha to

vitapa. One of the causes of this disease is mamsa lolupatwa (according to

derivation of Gridhrasi). So mamsa dhatu is considered as one of the dushyas.

Hareeta4 points Rakta dhatu as one of the dushya in pathogenesis.

Symptoms like pain at Kati and Prista is suggestive of involvement of

Asthi. Since there is emaciation of dhatus due to lack of nourishment, rasadhatu is

also involved.

47

Srotas:

Chestavaha and sangnavaha srotas

The movements are performed by chestavaha srotas. The sensations are

perceived by Sagnavaha srotas.

Sciatic nerve composes both Sangnavaha and chestavaha srotases.

In Gridhrasi vata the leg movements are impaired along with sensory

impairment i.e., Parasthesia etc.

Agni:

Praseka, Arochaka, Bhaktadwesha are some of the distinguishing clinical

manifestation of Vatakaphaja Gridhrasi and is indicative of Jatharagni Mandya.

Udbhavasthana:

The involvement of Vata Dosha in the pathogenesis of Gridhrasi reveals

that the disease stems out from the Pakwasaya. Similar to any other Nanatmaja

type of Vatavyadhi Gridhrasi is also considered as Pakwashayodbhava vyadhi.

Sancharasthana:

Distribution of symptoms like pain in the low back region extending up to

the thigh legs and heal indicates the lower half of the body as the Sanchara sthana.

Adhishthana:

Sphik, Kati, Uru, Prushta, Jangha, Pada are the adhishtana of Gridhrasi.

To sum up, the specific etiological factors leads to the vitiation of Vyana

Vayu. Abnormal vyana vayu stemming out from the Pakwashaya circulates in the

lower part of the body and gets localized in the kati, prishta, uru, janu, jangha,

48

pada. Vyana vayu afflicts the mamsa, asthi etc. dhatu involving cheshtavaha,

sagnavaha srotas producing the severe pain originating in the Kati prushta

radiating to Jangha, Janu and Pada region.

Asthi dhatu and vata are having Ashraya Ashrayee sambandha5. Vata

prakopa leads to Asthi dhatu kshaya. Therefore vata prakopa is associated with

loss of both anatomical and physiological integrity of bone.

In vardhakya period, there is predominance of vata dosha therefore

tarunastis of pristavamsa loose the inherent snigdhata and become brittle and are

prone to fracture.

The main pathology of Gridhrasi is degenerative - leading to fracture of

Kati Kaserukasthis and pain experienced by the patient is due to pressure on the

vatavaha nadis.

Degeneration suggests deterioration or worsening of the physical properties

of a tissue with pathological changes in the cells resulting in destruction or

inhibition of function.

In aging process6 changes take place, which cause an overall decrease in the

density of bone and decrease in bony strength. There is a loss of support in the

horizontal beams of bone in the vertebral body, which leads to buckling of the

vertical beams. This creates a gradual increase of concavity of upper and lower

surfaces of the vertebral body.

Age related7 changes in bone cells and matrix have a strong impact on bone

metabolism. Osteo blast from elderly invididuals has reduced reproductive and

biosynthetic potential when compared with osteo blasts from younger individual.

Proteins deposited in the matrix lose their biological punch over time. The end

result is a skeleton populated by bone forming cells that have a diminished

capacity to make bone. Reduced physical activity increases the rate of bone loss.

49

Increased porosity results from reduction in bone mass known as

Osteoporosis.

The intervertebral disc and vertebral bodies develop grow and age together.

It is quite impossible to affect one of these structures alone, as the other must

sooner or later also be involved, even to a lesser extent.

As degenerative changes proceeds:

- Annulus fibrosus and nucleus pulposus are indistinct with fibro cartilage

replacing the nuclear area.

- Proteoglycan content and hydration decreases in the nucleus.

- Vertebral column becomes less flexible.

- Circumferential tears develop in peripheral annulus and radial tears

appear at nucleus and inner annulus. There is failure of disc to act as

the shock absorbing system. There is a consequent reduction in the

ability to withstand normal strains of movement and possibility of

increased wear and tear on all the ligaments and joint structures.

- Fissuring may occur. If there are multiple fissures a loose fragment will

develop and this causes major alteration in the disc mechanics. Torsion

and flexion cause failure of annulus into a posterior protrusion. If the

fragment displaces further the whole thickness of annulus gives way as

the fragment is extruded as a herniation. Compression affects vertebral

end plate and body. Nuclear extrusion into the vertebral body can form

schmorl’s nodes.

Small protrusion compresses the nerve root, which causes severe

pain without much loss in nerve conduction.

50

Large protrusion blocks conduction. The physical signs are marked

sensory loss and motor paralysis.

- Continued narrowing of disc occurs with osteophyte formation at end

plate annular junction. Later end plate sclerosis occurs.

- With continued dessication and cleft formation empty spaces or vacuum

may occur with in the disc.

Disc herniations8 has been shown to incite intense irritations of nerve roots

and dramatic increase in the local concentrations of biochemical agents known to

be inflammogenic.

Ex. Prostaglandin E2, Interleukin-6, Metallo proteinases etc.

As disc prolapse heals by shrinkage the thickness of the disc reduces. The

disc is only one part of the complex arrangement between vertebrae allowing

controlled movements in all directions. So derangement of this part sooner or later

affects the other parts (facet joints and posterior ligaments).

The altered mechanics leads to osteo arthritis of facet joints. With aging

the porosity of the bone of the facet increases. Concurrently there is loss in joint

space. Osteophytes begin to develop. As cartilage fails, bone looses its mass and

its normal function.

Osteophytes encroach upon Inter vertebral foramen causing pressure on

spinal nerve roots. The joint capsule is stretched by excessive movements and the

contained nerve endings give rise to pain.

The spinal nerve roots are sensitive to mechanical deformation due to

intraspinal disorders such as disc herniations or protrusions, spinal stenosis,

degenerative disorders and tumour.

51

Compression causes vascular occlusion affecting nutrition of nerve root. It

may also induce conduction block. There is an increase in neuro transmitters

related to pain.

Nucleus pulposus may elicit inflammatory reaction when outside the

intervertebral space. Proteoglycans have direct irritating effect on nerve tissue.

Disc cells produce reduction in nerve conduction velocity.

Biochemical effects of Nucleus pulposus:

1. Direct neurotoxic effect on nerve tissue.

2. Vascular impairment

3. Inflammatory reactions.

Instability across motion segment occurs as degeneration progresses. Disc

degenerate anteriorly, ligaments buckle or hypertrophy and changes with facet

arthritis progress the central canal as well as neuro foramen is less accommodating

in rotation. As body rotates because of altered anatomy and mechanics, narrowing

occurs and can lead to torsional stresses. This can produce irritation and

inflammation of nerve roots.

52

UPADRAVA AND SADHYASADHYATA

UPADRAVA:

“Roga arambaka dosha prakopa janya anya vikara”

Upadrava is the complication produced in a disease, which develops after

the formation of main disease.

When the main disease has been produced, a dosha or doshas has become

further vitiated owing to abnormal diet, behaviour etc. A secondary disease is

super added and this is known as upadrava1.

In practice the following things may be considered as Upadravas

1. Khanja vata

2. Sosha

1. Khanja vata2: As a result of stabdata and sakti utkshepa nigrahana there is

restriction in extension of leg, the patient has to keep the leg in a semi-

flexed position. This gives rise to limp in walking.

2. Sosha: Gridhrasi is vata vyadhis affecting the vata nadis, on account of

pain all movements are restricted in the affected leg. Continuous pain

restricts the patient to make minimum movements and the mamsa dhatu

under goes sosha. Inability to walk and crippling are other upadravas.

SADHYA SADHYATA

Susruta considers vata vyadhi as mahagada due to its tendency to be

incurable or fatal. Vagbhata calls it as Maharoga. Most of the Acharyas have told

that vata vyadhi, generally are very difficult to cure3, 4. A separate prognosis has

not been mentioned. On the basis of which it may be said that Gridhrasi in which

the vitiated vata is seated in majja dhatu or if Gridhrasi is accompanied with

53

kudavata, Angasosha and sthamba may or may not be cured even after careful

treatment. But if this condition occurs in a strong person, is of recent origin and

without any associated disease, then it is curable.

Susruta mentions that a patient of vatavyadhi, if develops the complications

like shota, sputa twacha, Bhagna, Kampa, Admana and pain in internal organs,

then he will not survive 5. .

The following conditions can be considered to decide sadhya sadhyatwa:

• The pain due to muscle fatigue is sadhya.

• Muscles subjected to prolonged work become fatigued as a result become

locally painful and tender and it may be relieved by rest and by adopting

measures that promote muscle blood flow.

• The pain due to muscle spasm alone is sadhya. If associated with arthritis

is kasta sadhya.

• Sciatic pain due to spondylosis in early stages can be taken as kasta sadhya.

• The spondylolisthesis, which is defined, as forward slipping of vertebral

body on the below it is also kasta sadhya.

• The degenerative disc conditions, osteo arthritis of the inter vertebral joints

are yapya.

• The disc prolapse and the fractures, which compress the spinal cord or

nerve root, can be considered as asadhya, which results in paralysis of

lower limbs.

Most of the conditions affects the vertebral column are kasta sadhyas or

yapya due to the involvement of asthidhatu, on marma, sandhis6 which are

considered under Madhyama roga marga.

54

SAPEKSHA NIDANA

Many of the diseases have resemblance with one another as the symptoms

are concerned. But their line of treatment differs basically. Chikitsa should be

started after confirmation of disease by differential diagnosis.

Cardinal symptoms of Gridhrasi are:

- Pain starting in the sphik, kati, prista radiating down the lower limb.

- Saktyukshepa nigrahanyat - Restriction in raising the leg.

Other symptoms like sthamba, toda, spurana etc., may be present.

Gridhrasi has to be differentiated from the following to arrive at a

diagnosis.

1) Urusthamba1:

- The vitiated kapha along with medha obstructs the vata and pitta in uru

pradesha producing immobilization of thigh and calf.

- The patient experiences strange feeling that leg does not belong to

himself. He is unable to perceive the cold sensation in the affected

limb.

- The movement of the lower limb is completely stopped due to severe

pain.

- Urusthamaba is associated with jwara, chardi, angamarda etc., which are

not found in Gridhrasi. In Gridhrasi the posterior aspects of thigh, calf

along with kati, janu, pada, are involved. Movement is possible.

55

2) Khanja2: Difficulty in walking with involvement of one lower limb.

Akshepana is present.

3) Pangu: Both limbs are affected resulting in total immobilization of lower

limb.

4) Kalaya kanja: The feature of muktasandhi bandhana resulting in criss

crossed manner in walking with kampana.

5) Gudagata vata3: In addition to pain symptoms like emaciation in back,

sacral region, thigh, calf, foot, retention of faeces, urine and flatus, colic,

flatulence and formation of stone may also be present.

6) Khalli: According to Gayadasa, Khalli is a severe painful state of both

Gridhrasi4 and Vishwachi. Both upper and lower limbs are affected

simultaneously.

Avamotana (Mardana like shoola) of pada jangha uru karamoola is seen.

Avamotana is not present in Gridhrasi.

56

CHIKITSA

Samprapti vighatanam is termed as chikitsa.

Charaka1 and Susruta2 recommended siravyadha as the first line of

treatment in Gridhrasi.

Chakradatta3 has given the treatment of Gridhrasi in detail. He stressed that

vasti should be administered after proper Agni deepana, Ama pachana and Urdhva

sodhana. He said that administration of Vasti before urdhvasuddhi is insignificant.

Bhava Prakasha4 advised vamana and virechana before administration of

vasti.

Bhela samhita5 has mentioned sneha unmardana and sneha vasti, Rakta

mokshana.

Vangasena6 has repeated the necessity of Urdhwa sodhana before vasti. He

mentioned deepana, pachana, vamana, virechana, vasti, ishtika sweda & Upanaha.

Chikitsa for Gridhrasi as mentioned by different authors.

Chikitsa C.S. S.S. A.H. A.S. B.P. Y.R. H.S. B.S. C.D. V.S.

Snehana + + + + +

Swedana + + +

Vamana + + + +

Virechana + + + +

Vasti + + + + + + +

Siravedana + + + + +

Agni karma + + + + + +

57

The details of these procedures are given below.

1. Snehana: Snehapana must be adopted at first in all cases of Gridhrasi,

except in cases associated with Ama, kapha. In cases of Ama, Kapha,

deepana and pachana are to be adopted preceding snehapana to facilitate

niramavastha and deepthagni.

2. Swedana: After appropriate snehana is achieved sweda karma must be

adopted. The swedas also must be used preceded by sneha abhyanga and

mixed with snehas i.e., Snigdha sweda. Sankara, prastara, Nadi7 are usually

adopted. However 13 types of swedas may be used according to the

necessity. Shoola and Sthamba can be controlled by swedana.

3. Sodhana: The disorders that are subdued by sodhana will not reoccur. The

following karmas are taken by under the sodhana karma.

a) Vamana

b) Virechana

c) Vasti

a) Vamana: After sneha sweda, vamana should be adopted if necessary.

Chakrapani mentioned urdwa sodhana followed by vasti. This will be

beneficial for vatakaphaja Gridhrasi to alleviate kapha dosha.

b) Virechana: Gridhrasi is considered as a disorder of Rakta origin by some

acharyas like Hareetha.

Sneha yukta virechana must be adopted in vata disorders which are

not subsided by sneha swedas. According to vruddha vagbhata virechana

will facilitate excretion of malas in Rakta mamsa which are brought to

pakwasaya by sneha swedas. Virechana will possess some fibrinolytic anti-

58

coagulant property by stimulation of Rasa rakta samvahana. Hence it

facilitates proper nutrition of disc and reduction of prolapsed disc.

c) Vasti karma8: The vasti karma is said to be pradhana chikitsa for vata

disorder because it immediately enters into pakwasaya, strikes at the root

of the vitiated vata dwelling in other parts of the body and so is

automatically alleviated.

Susruta9 stressed the various effects on the body. It will increase

strength, complexion, restoration and normality of dosha dhatu mala. Useful in

gridhrasi and other types of vata rogas and relieves stiffness and contractures

also.

Though vasti therapy has its scope in all kinds of ailments implicating

different types of doshas, dushyas and Adhistanas, vasti is supposed to be

principal treatment for vatic disorders.

The relative importance of vata10 is already known as it has predominant

influence on the three principal routes of diseases namely sakha, koshta and

marmasthi sandhi. Moreover vata is responsible for the formation,

communication and spread of sweda, mala, mutra, kapha and other biological

substances in the body. Vasti being the principal treatment for such and

important factor is considered the therapeutic procedure of maximum

importance. This is why vasti is said to be half of the whole treatment and

sometimes as complete treatment.

Niruha vasti, causes sodhana of malas from all parts of the body

including srotases and sushumna.

Anuvasana vasti, be adopted after niruha with appropriate taila in

Gridhrasi. It causes sneha of entire body spreading the properties of medicines

used in processing of tailas. It will first enter into pakwasaya the main seat of

59

vata. The taila acts by its snehana, guru, ushna subdues the ruksha laghu and

seeta gunas of vata.

Siravydhana:

Charaka11 opines that the sira located in between the kandara and gulpha

should be selected for the purpose of Siravyadha.

4 inches below indravasti marma12.

4 Angula below vasti 13.

Agnikarma:

Between kandara and gulpha 14

4 angulas below indra vasti marma in posterior side of leg little toe of the

affected leg should be burnt 15.

Hareeta has specified loha salaka for dahana karma16

After sodhana chikitsa, Gridhrasi patient has to be given samana chikitsa.

Shamanoushadis used in Gridhrasi according to different acharyas.

Kalpanas Y.R. S.S. B.P. B.R. C.D G.N. Churnas

Ajamodadi churnam + + Abadi churnam + Krishnadi churnam + + Rasnadi churnam + Aseethaka churnam + Kalka, lepa Mahanimba kalka + + Rasona kalka + Swalpa rasona pinda + + Gunja phala lepa +

60

Kalpanas Y.R. S.S. B.P. B.R. C.D G.N. Kashaya

Panchamula kashaya + + + + Maharasnadi qwatha + + + Sephali patra kashaya + + + + Rasna saptaka qwatha +

Gutikas Rasna guggulu + + + + + Trayodashanga guggulu + + + Yogaraja guggulu + + Mahayogaraja guggulu + Pathyadi guggulu + + + Abha guggulu + Simhanada guggulu + Vatagajankash ras + Vatarakshasa ras + Swachanda bhairava ras +

Taila Bala tailam + + Vajeegandhadi + + + Saindavadya tailam + + Vishagarbha tailam + + Prasarini tailam + + Narayana tailam + Vishnu tailam + Rasna pootika tailam +

61

PATHYAPATHYA

No separate pathyapathya has been mentioned in the Ayurvedic texts. But

some details have been stated in the upasaya, anupasaya. Since Gridhrasi is one of

the vatarogas, the pathyapthya of vata vyadhis may also be considered here.

The following are stated to be hitakara in vatavyadhi.

1. AHARA:

a. Mamsarasa of ajasiras (head of the goat), ambuja (which are bares

on water) anupa (born in marshy areas), and mamsada (which a live

on flesh) animals.

b. Milk

c. Mamsa of above stated animals

d. Fruits which are sour like dadima etc (which do not aggravate pitta)

e. Four varieties of sneha i.e., Ghee, Gingili oil, Muscle fat and bone

marrow.

f. Which are snigdha to which lavana is added.

2. VIHARA:

a. Pariseka with warm decoctions.

b. Samvahana- light massage.

c. Use of thick garments made of wool, silk and cotton.

d. Living in a warm room or in that not exposed to wind or in an inner

chamber.

e. Use of flat bed

f. Basking in the glare of fire.

g. Abstinence from sex.

Since Gridhrasi may also be caused by the vitiation of vata and kapha, the

dietary articles, which may aggravate kapha, should not be used.

62

In apathya, nidana parivarjana is important, the viharas like excessive

walking, jumping, driving which is particularly capable of causing injury to the

pristhavamsa should definitely be avoided and the patient should take complete

rest, both during the treatment and afterwards also.

The following special ahara kalpa are particularly useful:

Table showing pathya and apathya in Gridhrasi:

FACTOR PATHYA APATHYA Staple food Old red rice, wheat black gram, horse

gram Green gram, recently produced

dhanya, masura, kalaya, kodrav, yava Rasas Sweet, acidic, salty Bitter, pungent, astringent Properties All diets must be in hot state, mridu,

sthira, vrushya, pusthi Under feeding rough, unmetous, cool, light, guru, abhishyandi.

Vegetables Leafy vegetables like kasamarda, punarnava, mundi

Leafy vegetables, mrinala , kanala

Fruits Jeeraka , hingu, lasuna, dadima, parushaka, badara, draksha ,orange

---

Phala sakas Like pumpkin, brinjal, bruhati, karela, snake guard, drumstick

Bimbi, kosataki, jambu, betelnut, tola, medi.

Root vegetables

Moolak, soorana, puttagodugu All other vegetables, suskha sakas

Others All types of snehas, ghritas, vasa, taila, majja, processed in deepaneeya vatahara & virechana drugs.

----

Non-vegetarian

Horse, goat, ass, elephant, swans, chakravaka, frog, crocodile, chicken, peacock, fish, sour salt fish , juices of aquatic and marshy animals which are fatty , preparation of meat of bilesaya and prasaha animals.

----

Drinks Sura, asava , milk, coconut water, hot water be used for drinking

Udaka mandha (gruel), water of tank, honey or strea

Vihara sareeraka

Abhyaga (massage), (unaction), moordhin taila, jentaka sweda, sweda abhyanga, unmardhana, peedana, parisheka, ushna avagaha with vatahara drugs wherever possible

Viharas mentioned as nidana , coitus, sleeplessness, anxiety

Nivasa Nivata sthana, niratapasthana, ushanasadhana, hemanthokta vidhi, garbhagriha (inner heated apartmen), soft bed, agnisantapa, under ground residence, well covered bedding and seating. Particularly with heavy wrappers.

Cold atmosphere, cold air,

63

MANAGEMENT OF SCIATICA

A. Conservative Treatment:

1) Rest:

- Complete rest in bed supine position for 3-6 weeks.

- When pain relieved, plaster jacket to immobilize the lumbar spine

for 3-6 months.

- A lumbar corset worn at all times during the day.

2) Medication: Analgesic, anti-inflammatory and occasionally muscle relaxant

medication will help the patient.

3) Heat and cold:

Ice: Useful in acute phase. Slows the nerve impulses in the area, which

interrupts the pain. Ice packs decrease circulation to the area of

contact, which reduces inflammation, swelling, spasm and therefore

pain.

Heat: Heat may be superficial (hot packs / infrared) or deep (ultra sound /

short wave diathermy)

- Because of increased vasodilatation, heat should not be used in the

acute phase of injury.

- The heat increases the blood flow to the damaged or inflamed tissue,

clearing away noxious metabolites and bringing oxygen to the area.

4) Traction: Traction has also been used over the centuries to treat low back pain

on the theory that stretching the muscles and separating the vertebra will have a

positive effects on the disc.

64

5) Exercise: Once the phase of acute pain has passed, gradual exercise is of

considerable value in improving the mobility of the affected portion of the spine

and power in weakened muscles.

6) Miscellaneous forms:

a. Trans cutaneous Electrical Nerve Stimulation (TENS) 17: It is a pulsed

electrical current, which is used for pain relief. TENS stimulates the large, fast

conducting nerve fibres, which override the smaller slower afferent fibers

conducting noxious stimuli thus closing the gate of pain perception.

b. Epidural steroid 18: Epidural cortico steroid injection can be recommend as

additional therapy especially in the acute phase of the conservative management of

Sciatica.

B) Surgical treatment: Before considering surgical interventions C.T.Scan,

M.R.I., Myelogram or other useful investigation must be done to localize the

lesion.

Absolute indication:

1. Cauda equina syndrome: The acute massive disc herniation that causes

bladder and bowel paralysis is usually a sequestered disc that requires

immediate surgical excision for the best prognosis.

2. Increasing neurological deficit.

Relative indication:

a) Failure of conservative treatment.

b) Recurrent Sciatica.

c) A disc rupture into a stenotic canal

d) Recurrent neurological deficit.

65

DRUG REVIEW

SELECTION OF DRUG

Gridhrasi is a disease, which is a common problem to society because here

income-generating people are mostly affected. The patient goes on trying one

medicine after another without satisfactory or complete relief. Moreover

adversely affected by extensive use of NSAIDS, only symptomatic treatment is

suggested in Modern medicine. Therefore another type of medications has been

selected to note the effect of this problem.

In the present clinical study, I have selected Swalpa Rasona pinda with

Astavarga kashaya Anupanam and Matra vasti with Balawagandha tailam.

The drugs selected for the study are cheap, economical and easily available.

Vatakapha are the doshas involved in disease. The disease involves Asthi

and sandhis.

Though vata and kapha are the doshas in Gridhrasi, the impact of Agni is

not ignored in the pathogenesis of Gridhrasi. “Lasunah prabhanjananam” –

Lasuna is considered as best vatahara dravyas according to Vagbhata. Moreover

the ingredients of the above drugs posess Rasayana, Deepana, Pachana Properties.

Indeed Rasayana dravyas enhance the assimilation of all dhatus including asthi

dhatu.

The Deepana pachana properties of dravyas increase Jataragni perhaps

Ashti dhatwagni and also pacifies kapha.

As “Vasti vataharanam srestam” Matra vasti with Balaswagandha tailam

has been taken for trail.

Being taila-based medicine it is used for all vatarogas especially asthi

related vatarogas.

66

Swalpa Rasona Pindam:

Reference: Bhaishajya Ratnavali 26/93-97

Ingredients: Lasuna

Hingu

Jeeraka

Saindavalavanam

Souvarchala lavanam

Trikatu

Lasuna: 3 parts

Other Ingredients: 1 part

Method of preparation: The peel and middle green stalk of garlic

cloves are removed. The cloves are soaked in buttermilk over night,

dried in shade and powdered. It is mixed with powders of ghrita bharjita

hingu, jeeraka, saindavalavanam, souvarchala lavanam, trikatu.

Capsules of 500 mg each are prepared

Dose : 1 capsule t.i.d for 40 days

Anupana: Astavarga kashayam (30 ml t.i.d)

Indications: Ardita, Apatantraka, Ekanga roga, Sarvanga roga,

Urusthamba, Gridhrasi, Krimi roga, Udara roga, Kati prista roga.

67

ASTAVARGA KASHAYAM

Reference: S.Y kashayam prakaranam.125

Ingredients: “Bala sahachara eranda sunti rasna suradrumaih sa sindhuvara lasinaih astavargo anilapaha”

Bala,Sahachara, Eranda,Sunti,Rasna, Devadaru,Nirgundi,Lasuna-Kashaya

Prepared from the above drugs is vata hara

Method of Preparation: The Kashaya kalpana is done according to

Sarangadhara Samhita.

• Drug 1part

(Bala,Sahachara,Eranda,Sunti,Rasna,Devadaru,Nirgundi,Lasuna-each6

g.ms) Total Qwatha Churnam 48 g.m.s

• Water 16 parts (800 m.l )

• Drugs mixed with water then boiled, and reduced to 1/8 th part i.e 90 m.l.

Dose: 30 ml t.i.d

The ingredients of the above formulations possess Deepana, pachana,

Angamarda, prashamana, Brimhana, vatanulomanam.

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BALASWAGANDHA TAILAM

Reference: S.Y.Taila Prakaranam

Ingredients:

Kashaya dravyas

Bala Aswagandha Laksha

Kalka dravya

Rasna Musta Durva Devadaru

Madhuka Haridra Chandana Kusta

Sariba Kaunti Manjista Agaru

Shati Kumuda Usira Satahva

Tailam: 640ml

Dadi mastu : 2560ml

Method of Preparation:

Preparation of kasahaya: Bala, Aswagandha, laksha 215 gms each are

taken and 2560 m.l of water is added and boiled then reduced to 1/4th i.e. 640 m.l

The prepared kasaya (640 m.l) is added to Prastha (640 m.l) of Tila tailam,

4 parsthas (2560 m.l) of Dadhimastu (Supernetent water from the cows curd).

A bolus of 17 drugs (kalka dravyas) each 10 g.ms i.e. 170 g.ms is added to

the above mixture and boiled on mild fire till sneha paka lakshanas are attained.

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DESCRIPTION OF INDIVIDUAL DRUGS

RASONA

Sanskrit name : Lashuna

Botanical name : Allium sativum

Family : Apiaceae

Vernacular name : Telugu – Vellulli

Part used : Bulb

Properties : Rasa - Amla varjita pancharasa; Guna: Snigdha, Teekshna, Picchila, Guru, Sara

Veerya : Ushna ; Vipaka : Katu

Doshagnata : Kaphavata samaka, pitta vardhaka

Karma : Deepana, pachana, balya, brimhana, rasayana, sothahara, bhagnasthi sandhanakara, shoolehara

Chemical constituents : Alliin, Allisatin; Diallyl trisulphide, Vitamins, Enzymes (Allinase, Myrosinase, peroxidase,) Prostaglandins, proteins.

Biological activity : Anti-inflammatory, Anti-arthritic, anti-microbial bacterisidal.

• Oil Extract of garlic when given to overectomized rat promotes intestinal

transference of calcium by modulating the activities of both intestinal alkaline phosphatase and Ca +2 activated ATP ase . It also enhanced better preservation of bone mineral content. (Phytother Res 2006 May ;20(5):408-15).

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HINGU

Sanskrit name : Hingu

Botanical name : Ferula asafetida

Family : Umbelliferae

Vernacular name : Telugu – Inguva

Part used : Niryasa

Properties : Rasa - Katu; Guna: Laghu, Snigdha, Teekshna Veerya: Ushna ; Vipaka : Katu

Doshagnata : Kaphavata samaka, pitta vardhaka

Karma : Shoolaharam, Deepana, pachana, vatanulomana, sara, krimighna, rochana, chedaniya, bhedaniya, Balya, Artava jananam.

Chemical constituents : Lutcolin, a-pinene, phellandrene, aseresinotannol, Farnesiferol A..

Biological activity : Anti-inflammatory.

JEERAKA Sanskrit name : Jeeraka

Botanical name : Cuminum cyminum

Family : Umbelliferae

Vernacular name : English – Cuminum seeds; Telugu – Jeelakarra

Part used : Fruits

Properties : Rasa - Katu; Guna: Laghu, Rooksha, Teekshna Veerya: Ushna; Vipaka: Katu

Doshagnata : Kaphavata samaka, pitta vardhaka

Karma : Deepana, pachana, Balya, Grahi, shoolaprashamana

Chemical constituents : Alpha-pinene, Alpha – phellandrene, volatile oil consists of cumaldehyde.

71

SAINDAVA LAVANAM

Sanskrit name : Saindavah

Latin name : Sodii chloridum

Vernacular name : English – Rock salt

Properties : Rasa - Lavana; Guna: Laghu, Snigdha, Sukshma; Veerya: Anushna; Vipaka: Madhura

Doshagnata : Tridoshahara

Karma : Deepana, pachana, ruchya.

SOUVARCHALA LAVANA

Properties : Guna: Laghu, Sukshma, vishada

Doshagnata : Vatahara, slightly pittkara

Karma : Deepana, pachana, rochana, snehana, shoolahara.

MARICHA

Sanskrit name : Maricha

Botanical name : Piper nigrum

Family : Piperaceae

Vernacular name : English – Black pepper; Telugu – Miriyalu

Part used : Fruit

Properties : Rasa - Katu; Guna: Laghu, Ruksha, Teekshna, Sukshma; Veerya: Ushna ; Vipaka: Katu

Doshagnata : Kaphavata samaka, pitta vardhaka

Karma : Deepana, lekhana, Shoolaprashamaman, pramadhi.

Chemical constituents : Piperine, piperethine, ascorbic acid.

Biological activity : Anti-bacterial and anti-tumor activity.

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PIPPALI

Sanskrit name : Pippali Botanical name : Piper longum Family : Piperaceae Vernacular name : English- Long pepper; Telugu – Pippallu Part used : Fruit Properties : Rasa - Katu; Guna: Laghu, Snigdha, Teekshna

Veerya: Ushna; Vipaka : Madhura Doshagnata : Vatasleshmahara Karma : Dipaniya, shoolaprasamana, Vatanulomana,

sara, Rechana Chemical constituents : Pipeine, Pellitorine, piper longuimine. Biological activity : Anti-inflammatory, Anti-tubercular activity,

Anti-spasmodic, piperine-revealed a hyptensive effect, produced a non-specific blocade of contractions induced by Acetylcholine, histamine, serotonin in isolated intestine of guineapig.

SHUNTI

Sanskrit name : Shunti Botanical name : Zingiber officinale Family : Zingiberaceae Vernacular name : English-Ginger; Telugu – Sunti Part used : Rhizome Properties : Rasa - Katu; Guna: Guru, Ruksha, Teekshna

Veerya: Ushna; Vipaka: Madhura Doshagnata : Vatakaphahara Karma : Deepana, Bhedana, Sula prasamana, pachana,

sophaharam. Chemical constituents : Zingiberene, Zingiberol, sesquiterpenes,

Hydroxy aryl compounds Biological activity : Anti-inflammatory, anti-oxidant,

Bioavailability, enhancer, antihistaminic.

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BALA

Sanskrit name : Bala

Botanical name : Sida condifolia

Family : Malvaceae

Vernacular name : English – Countrymallow; Telugu – Chittamutti

Part used : Root

Properties : Rasa - Madhura; Guna: Laghu, Snigdha, picchila; Veerya: Sita; Vipaka : Madhura.

Doshagnata : Vatapittahara

Karma : Balya, Brimhana

Chemical constituents : Ephedrine, vasicinone, phytosterol etc.

Biological activity : Anti inflammatory, Analgesic, Immuno-enhancing property.

SAHACHARA

Sanskrit name : Sahachara

Botanical name : Barleria prionitis

Family : Acanthaceae

Vernacular name : Telugu – Mullugorinta

Part used : Root, leaves

Properties : Rasa - Tikta, Madhura ; Guna: Laghu Veerya: Ushna; Vipaka : Katu

Doshagnata : Kaphavatahara

Chemical constituents : Barlerin, Acetyl barlerin, Scutellarein-7-neophespe ridoside.

Biological activity : Dieuritic activity

74

ERANDA

Sanskrit name : Eranda

Botanical name : Ricinus communis

Family : Euphorbiaceae

Vernacular name : English – Castor; Telugu – Amudamu

Part used : Root

Properties : Rasa - Madhura, Katu, Kashaya ; Guna: Snigdha, Teekshna, Sukshma ; Veerya : Ushna; Vipaka : Madhura

Doshagnata : Kaphavatahara

Karma : Rechana, angamarda prasamana, bhedana, vrishya, sophahara

Chemical constituents : Lupeol, Ricinine, Palmitic, stearic acid.

Biological activity : Anti-inflammatory.

RASNA

Sanskrit name : Rasna

Botanical name : Pluchea lanceolata

Family : Zingiberaceae.

Vernacular name : English–Lesser galang; Telugu – Sannarashtram

Part used : Rhizome

Properties : Rasa - Tikta; Guna: Guru; Veerya: Ushna; Vipaka: Katu

Doshagnata : Kaphavatahara

Karma : Amapachana, shoolahara

Chemical constituents : Galangin, Diaryl-heptanoids

Biological activity : Diaryl-heptanoids exhibited prostaglandin synthesis inhibiting activity.

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DEVADARU

Sanskrit name : Devadaru

Botanical name : Cedrus deodar

Family : Pinaceae

Vernacular name : English – Himalayan cedar; Telugu- Devadaru

Part used : Bark

Properties : Rasa - Tikta, Katu, Kashaya ; Guna: Laghu, Snigdha ; Veerya : Ushna; Vipaka : Katu

Doshagnata : Kaphavatahara

Karma : Kaphavatahara, deepana, sophahara

Chemical constituents : Deodarin, toxifolin, p-methyl acetophenone

Biological activity : Anti inflammatory, anti cancer activity.

NIRGUNDI

Sanskrit name : Nirgundi

Botanical name : Vitex negundo

Family : Verbinaceae

Vernacular name : English – five leaved chaste; Telugu- Vavili

Part used : Leaf

Properties : Rasa - Katu, tikta ; Guna: Laghu, Ruksha. ; Veerya: Ushna; Vipaka: Katu.

Doshagnata : Kaphavatahara

Karma : Vatakaphahara, vishagna, vranaropana, aruchihara, sophahara, gridhrasihara, deepana, soolahara.

Chemical constituents : Ethyl acetate, phenol, camphene etc.

Biological activity : Anti inflammatory, Analgesic, anti-arthritic.

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77

ASWAGANDHA

Sanskrit name : Aswagandha

Botanical name : Withania somnifera

Family : Solanaceae

Vernacular name : Telugu – Pennerugadda

Part used : Root

Properties : Rasa - Katu, Tikta, Kashaya; Guna: Snigdha, Laghu ; Veerya : Ushna; Vipaka : Katu

Doshagnata : Vatakaphahara

Karma : Balya, brimhana, sophahara

Chemical constituents : Withanolide, withasominiferin, nicotine, sominolide.

Biological activity : Anti inflammatory, analgesic, anti-anxiety effect, antibacterial activity against mylobacterium,tuberculae, antidepressant, immunomodulatory, immunosuppressive and antitumor activity

• The anti-inflammatory activity in rats is marked and compared to that of prednisolone.

• Being balya,when used as adjuvant,has shown low relapsing&lasting relief.

TILA TAILAM Properties : Rasa - Madhura Tikta, Kashaya ;

Guna: Guru, Sukshma, Vikasi, Vishada.; Veerya: Ushna; Vipaka: Madhura

Doshagnata : Vatakaphahara

Karma : Vikasi, vishada, Brimhana, lekhana, balya.

DADHI MASTU

Properties : Kaphavatahara, sramahara, sroto vishodaka.

DESCRIPTION OF BALASWAGANDHA TAILAM

Sl.

No.

Sanskrit name

Botanical name & family

Rasa Guna Virya Vipaka Doshagnata Karma Chemical constituents

Biological activity

1. Chandana Santalum album Santalaceae

Tikta, Madhura

Laghu, Ruksha

Sita Katu Kapha pittahara Angamarda prasamana, visaghna

α,β-santanialic acids, santalenes.

2. Majista Rubia cordifolia Rubiaceae

Madhura tikta

Guru ruksha

Ushna Katu Kapha pittahara Sophahara, vishaghna, deepana

Rubimallin, antitumour cyclic hexa peptides

Antibacterial spasmolytic antitumor activity

3. Durva Cynodon dactylon Poaceae

Kashaya, Madhura

Laghu Sita Madhura Kaphapitta hara Prajasthapana, varnya

Methoxy propionic acid, benzoic acid, sitosterol

Antiviral activity

4. Yasti Madhu

Glycirrhiza glabra Fabaceae

Madhura Guru, snigdha

Sita Madhura Trisdosha hara Sandhaniya, sonitasthapana, rasayana

Glycyrrhizin Glycyrretic acid, diacetate

Anti-arthritic, anti inflammatory, anti diuretic.

5. Kachura Hedychium spicatum Zingeberaceae

Katu, tikta, kashaya

Laghu, tikshna

Ushna Katu Kapha vatahara Grahi shulahara T-hydroxy hedychenone Hedychenone

Anti-inflammatory, Spasmolytic effect

6. Sariba Hemidesmus indicus Asclepidaceae

Madhura tikta

Guru, snighda

Sita Madhura Tridosha hara Grahi Saponin Ethyl acetate extract, Hemidesmini-ne, Hexane extract

Anti inflammatory, anti- bacterial, immuno modulator activity.

78

79

7. Usheera Veteveria

zizanoides Graminae

Tikta madhura

Rukhsa, laghu

Sita Katu Kapha pittahara Pachana, sthamabana, angamarda, prasamana

Kshusitoneol, zizanol, epizizanol

Juvinile harmone activity

8. Musta Cyperus rotundus Cyperaceae

Tikta katu kashaya

Laghu ruksha

Sita Katu Kapha pitta hara Deepana, pachana, grahi, lekhana

Triterpenoid, cyperenone, rotundone, β-sitosterol.

Spasmolytic antibacterial dieuritic tranquilising anti-inflammatory.

9. Kusta Sausurea lappa Asteraceae

Tikta Katu Madhura

Laghu Ruksha Tikshna

Ushna Katu Vata kapha hara Lekhaniya, vrishya

Sesquiterpines, Costunolide, ar -curcumene

Useful in osteo arthritis

10. Agaru Aqualaria agallocha Thymeliaceae

Katu tikta Laghu tikshna

Ushna Katu Vata kapha hara Rasayana, dusta vrana

Agarotetrol, aquilochin, agarol, kusnol

11. Haridra Curcuma longa Zingeberaceae

Tikta katu Ruksha, laghu

Ushna Katu Kapha vata hara Lekhana, visaghna

Curcumin PE extract

Antibacterial, Anti inflammatory, anti arthritic.

12. Satahwa Anetheum sowa Umbelliferae

Katu tikta Laghu tikshna

Ushna Katu Vata kapha hara Deepana, Shoolahara, adhmanahara

Carvone, dill-apial, β-sitosterol

Apetite stimulating fungi cidal property

13. Kumuda Nymphea stellata Nymphaceae

Madhura, Kashaya, tikta

Laghu, snigdha, picchila

Sita Madhura Tridoshahara Mutra virajaneeya Grahi

Luteolin Dieuritic, Hypnotic

14. Padma Prunus puddum Rosaceae

Kashaya tikta

Laghu, snigdha

Sita Katu Kaphapittahara Vedana sthapana garbha sthapana

Puddumin prunetin.

DESCRIPTION OF MATRA VASTI

Matra vasti is type of Anuvasana vasti. The quantity of matra vasti is half

the dose of anuvasana vasti. i. e. 60 ml19 (6 tola).

“Yadesta ahara chestasya sarva kalam niratyayaha”20

There are no restrictions regarding diet and activities. It can be administered

any time without any hesitation.

“Vata rugnecha matra vasti sadamata”21

It is indicated in vata rogas.

Purva karma:

Patient is advised to take light meal (3/4th quantity of usual dosage)

After having meal, the patient is made to walk 100 feet and asked to

attend natural urges (if necessary).

External oleation and fomentation is done over kati, uru, jangha

regions.

60ml bala aswagandha tailam is added to fine powders of saindavalavanam

and satapushpa and churned well. Vasti dravya is made luke warm and taken in

glycerine syringe. Rubber catheter No. 9 is joined to glycerine syringe. Oleation of

catheter is done for easy passage through anus. Air from catheter is removed by

pushing oil into catheter.

Pradhana karma:

Patient is advised to lie down in left lateral position (left lower limb straight

and right lower limb flexed at knee and hip joint). The patient is asked to keep left

80

hand below the head. Anal orifice is lubricated with oil. The catheter is slowly

introduced. While inserting the catheter patient is advised to take deep breathe to

relax the anal sphincter. The vasti dravya is pushed inside slowly with the constant

speed without shaking. Then slowly catheter is removed.

Paschat karma:

Patient is made to lie in supine position, both legs are raised, and tapping is

done on buttocks to prevent the expulsion of vasti dravya immediately.

During administration if the patient feels urge of faeces and flatus, vasti

netra is withdrawn. The process is continued after he attends the urges.

After vasti procedure, the patient is advised to lie on the bed for at least

20 minutes.

After expulsion of vasti dravya patient develops lightness of body, good

sleep, indriya prasadam, vega pravartanam22. Next matra vasti should be given

after excretion of urine and stool. This procedure is continued for 7 days.

The veerya of vasti dravya23 is conveyed from apana to samanavata may

regulate the functions of agni then to udana vyana and prana thus providing its

efficacy all over the body.

Vata is master in aggravating of three doshas. When it is much advanced

and affect the body no other remedy except vasti can check its force as coast

checks the force of tides of sea24.

Vasti dravyas lying in the pakwashaya, through its veerya25 draws the

morbid doshas lodged in the entire body from foot to head, just as the sun situated

in the sky takes up the moisture from the earth.

81

As per Acharya Parashara26 Guda(Anus) is the main route of the body and

having blood vessels in it, if we administered the vasti in anus its nourishes all the

limbs and organs of the body.

The active fraction of vasti dravya spreads all over the body, just as water

poured at the route reaches all parts of the tree through the micro and macro

channels. As such it is considered as ardha chikitsa and complete treatment by

some acharyas.

Taila by its snehana, guru, ushna guna subsides ruksha laghu, seeta gunas of

vata.

Matra vasti can be given to children, women and aged people also. It has no time

regulation. It can be given at any time. So it is more beneficial at present era

wherethe people are having very busy life style.

82

MATERIALS AND METHODS

Aim of the study: The present clinical study is intended to know the effect of

swalpa Rasona pinda with Astavarga Kashaya anupanam and matra vasti in

gridrasi vata.

Location of study: The cases for the study and clinical trail were selected from

the in patients and out patients department of P.G. Unit, Kayachikitsa,

Government Ayurvedic Hospital, Erragadda, Hyderabad.

40 cases were selected and studied.

Selection of patients:

Inclusion criteria:

1. Gridhrasi diagnosed according to classical signs and symptoms.

2. Patients of age above 20 and below 60.

3. SLR test positive.

Exclusion criteria:

1. Proven cases of Malignancy

2. Congenital abnormalities in lumbar spine.

3. Known cases of Tuberculosis.

4. History of trauma causing fractures.

5. Surgical indications such as progressive neurological deficit, bilateral signs

and symptoms of bowel and bladder involvement.

83

Diagnostic Criteria:

The parameters for diagnosis are completely based on classical symptoms

like Ruk, Toda, Sthamba in the spik, kati, prista, uru, janu, Jangha and pada region

with or without other symptoms. The test for Sciatica like Straight Leg Raising

Test (SLR) was considered.

The following laboratory investigations are to be done for diagnosis of

Gridhrasi.

X-ray lumbo sacral spine AP-View, lateral view was done to exclude and

include in the study.

Investigations:

a) CBP

b) ESR

c) Routine Urine Examination for sugar and albumin.

Research Design:

The patients were divided into two groups: Group A & Group B

Group-A: 20 patients were taken for study. They were administered

• Swalpa Rasona pindam

• Dose: 1cap. t.i.d. for 40 days

• Anupana: Astavarga Kashaya 30ml tid (for 40 days) Group-B: 20 patients were taken for the study in this group also. They

were administered

• Matra Vasti with Balaswagandha tailam for 7 days

• Swalpa Rasona pindam

• Dose: 1 cap. tid for 40 days.

• Anupana: Astavarga Kashayam Dose: 30ml tid.

84

A detailed clinical history of patients, occupation, dietary habits, history of

injury, family history, etc., have been taken and recorded. They were asked to

report for every 10 days for follow up.

Depending upon the history and symptomatology, the provisional diagnosis

is made which is confirmed by S.L.R.Test. After detection, the case is registered

and all the clinical features, reports of laboratory investigations were recorded.

Diet:

All the patients selected for the study were kept on normal diet consisting

of rice, chapaties, vegetables and milk. They were given instructions from

excessive exercise, eating fleshy mutton, spices etc.

ASSESSMENT CRITERIA:

Both subjective and Objective assessments were done in all the patients

before and after treatment.

Subjective Parameters:

Separate grading has been given for subjective assessment

parameters that include the following:

1) Sthamba 2) Ruk 3) Toda 4) Spandana

5) Daha 6) Pain in payu 7) Deha vakrata 8) Sosha

9) Vibandha 10) Aruchi 11) Gourava 12) Agnimandya

13) Tandra 14) Suptata

85

RUK:

No pain : 0

Occassionally painful : 1

Pain without limping and slight difficulty in walking : 2

Pain with liming but without support : 3

Painful, can walk only with support : 4

Painful unable to walk : 5

Sthamba:

No stiffness : 0

Mild stiffness (can perform daily routine work without difficulty: 1

Moderate stiffness (difficulty in performing daily routine) : 2

Severe stiffness (Totally unable to perform daily routine) : 3

Toda:

No pricking sensation : 0

Mild pricking sensation (occasionally in a day) : 1

Moderate pricking sensation ( frequent ) : 2

Severe pricking sensation (Persistent) : 3

Spandana (Fasciculation):

No fasciculation : 0

Mild fasciculation (sometimes 5-10min.) : 1

Moderate fasciculation (Daily 10-30 min.) : 2

Severe fasciculation (Daily >30min) : 3

86

Daha (Burning):

Absent : 0

Occassionally in a day : 1

Frequent and persistent : 2

Suptata (Numbness)

Absent : 0

Occassionally in a day : 1

Frequent and persistent : 2

Aruchi

Agnimandya

Gourava Absent : 0

Tandra Present : 1

Sosha

Vibandha

Objective parameters:

1. Numerical Rating scale (NRS)

2. S.L.R. Test

3. Oswestry Disability Index (ODI)

The grading for the pain was given on the basis of numerical rating scale.

NRS shows the pain intensity on a scale of 0-10, with 0 indicating no pain

and 10 the worst pain imaginable.

0 1 2 3 4 5 6 7 8 9 10

No pain Moderate pain Worst possible pain

The patients were asked to mark their pain levels on the NRS.

87

Grade Severity Scale reading

0 No pain 0

1 Mild pain 1-3

2 Moderate pain 4-6

3 Severe pain 7-9

4 Worst possible pain (Unimaginable/Unspeakable)

10

Straight leg raising test

i) > 90° - 0

ii) 71° - 90° - 1

iii) 51° - 70° - 2

iv) 31°-50° - 3

v) Upto 30° - 4

ODI: Oswestry Disability index (Oswestry Low Back Pain Disability

Questionnaie) is use to measure patient’s functional disability.

Grade Severity Scale reading

0 Minimal disability 0-20%

1 Moderate disability 21-40%

2 Severe disability 41-60%

3 Crippled 61-80%

4 Bed bound 81-100%

88

Assessment of Results:

Classification of Response Percentage of alleviation of symptoms

1. Good 60% and above

2. Moderate 30-60%

3. Mild 0-30%

89

OBSERVATIONS

A total number of 40 patients were selected in the present clinical study.

Patients were divided into two groups.

Group A: 20 patients were given oral medicine for 40 days.

(Swalpa Rasona Pindam with Asta Varga Kashaya Anupana)

Group B: 20 patients were administered Balaswagandha taila matra vasti for

7 days along with oral medicine for 40 days.

For convenience of assessment of results the patients were classified into

various groups depending upon their age, sex, occupation, diet etc.

Method of Observation: While doing the clinical study, the signs and symptoms

of the disease mentioned in the classics were observed in each case recorded and

studied and also the SLR test, NRS, ODI are noted compulsory before and after

the treatment.

They are taken as criteria for assessment. The subsidiary symptoms if any,

were also noted during the period of treatment.

The review of signs and symptoms were noted every 10 days and changes

if any, were recorded. The signs and symptoms were finally observed at the end

of the period of treatment, other observations were also noted which are having

importance in Gridhrasi vata.

90

TABLE No. 1: INCIDENCE OF DISEASE BASED ON AGE GROUP

Group-A Group-B Age in years

No. of patients Percentage No. of patients Percentage

21-30 3 15% 2 10%

31-40 8 40% 4 20%

41-50 7 35% 6 30%

51-above 2 10% 8 40%

012345678

No.

of p

atie

nts

21-30 31-40 41-50 above 51

Age in years

Group AGroup B

In Group-A: The maximum cases recorded are in the age group of 31-40% i.e.,

40% in the age group 41-50 years the incidence is 35%

In Group-B: It is observed that the incidence of disease is more prevalent in the

age group 51-above i.e., 40%.

91

TABLE No.2: INCIDENCE OF DISEASE BASED ON SEX

Group-A Group-B Sex

No. of patients Percentage No. of patients Percentage

Male 8 40% 8 40%

Female 12 60% 12 60%

0

2

4

6

8

10

12

No.

of p

atie

nts

Male Female

Sex

Group AGroup B

According to the present clinical study 60% of patients were found to be

females and 40% are males in both groups A & B. This table reveals that females

are slightly more prone to disease than males.

92

TABLE NO. 3: INCIDENCE OF DISEASE BASED ON DIET

Group-A Group-B Diet

No. of patients Percentage No. of patients Percentage

Mixed 20 100% 19 95%

Veg 0 - 1 5%

0

5

10

15

20

No.

of p

atie

nts

Mixed Veg

Diet

Group AGroup B

This table indicates the prevalence of disease is more in mixed diet in both

groups.

93

TABLE No.4. INCIDENCE OF DISEASE BASED ON OCCUPATION

Occupation is also important factor to be considered in Gridhrasi Vata. It

was categorized into 1) Housewives 2) Workers/farmer 3) Students 4)

Sedentary group.

In Sedentary group, retired employees, software engineers, and

businessmen are included.

Group-A Group-B

Occupation No. of

patients Percentage No. of

patients Percentage

Housewife 9 45% 10 50%

Workers/Farmers 4 20% 1 5%

Students 1 5% 1 5%

Sedentary group 6 30% 8 40%

0

2

4

6

8

10

No.

of p

atie

nts

Housewives Workers/farmers Students Sedentary

Occupation

Group A Group B

The above table shows that Gridhrasi is commonly noted in Housewives

45% in Group A and 50% in Group B.

94

Table No.5. INCIDENCE BASED ON SOCIO-ECONOMICAL STATUS

Group-A Group-B Economical

status No. of patients

Percentage No. of patients

Percentage

Middle class 14 70% 6 30%

Lower class 12 60% 8 40%

02468

101214

No.

of p

atie

nts

Middle class Lower classEconomic status

Group AGroup B

40 patients were categorized into two classics according to their Socio-

Economic status as Middle & Lower class. The above table indicates Gridhrasi is

commonly noted in middle class in both groups i.e., 70% in Group-A, 60% in

Group-B.

95

Table No. 6. INCIDENCE OF DISEASE BASED ON RELIGION

Group-A Group-B

Religion No. of

patients Percentage No. of

patients Percentage

Hindu 15 75% 13 65%

Muslim 2 10% 3 15%

Christian 3 15% 4 20%

02468

10121416

No.

of p

atie

nts

Hindu Muslim ChristianReligion

Group AGroup B

Among 40 patients, disease is more prevalent in Hindus in both

groups 75% in Group-A, 65% in Group-B.

96

Table No. 7. INCIDENCE OF DISEASE BASED ON PRAKRITI

Group-A Group-B

Prakruti No. of

patients Percentage No. of

patients Percentage

Vata pitta 6 30% 8 40%

Vata kapha 13 65% 12 60%

Kapha pitta 1 5% 0 0

02468

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No.

of p

atie

nts

Vatapitta Vatakapha Kaphapitta

Prakruti

Group AGroup B

In Group-A, maximum number of patients was found in Vata kapha prakruti i.e.,

65%.

In Group-B, maximum number of patients was found in Vata pitta prakruti i.e.,

60%.

97

Table No. 8. INCIDENCE OF DISEASE BASED ON ADDICTIONS

Group-A Group-B

Addictions No. of

patients Percentage No. of

patients Percentage

Smoking 3 15% 3 15%

Alcohol 5 25% 5 25%

Tobacco 7 35% 10 50%

None 5 25% 2 10%

0

2

4

6

8

10

No.

of p

atie

nts

Smokng Alcohol Tobacco None

Addictions

Group AGroup B

From the above table 25% have habit of consuming alcohol, 15% had the

habit of smoking in both groups. 7 patients (35%) in Group A and 10 patients

(50%) in Group B have the habit of Tobacco chewing.

98

Table No.9. INCIDENCE BASED ON AGNI

Group-A Group-B

Agni No. of patients

Percentage No. of patients

Percentage

Vishamagni 3 15% 6 30%

Mandagni 14 70% 9 45%

Tikshnagni 3 15% 5 25%

02468

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No.

of p

atie

nts

Vishamagni Mandagni Tikshnagni

Agni

Group AGroup B

From the above table it was found that maximum number of patients 70%

in Group-A, 45% in Group-B belong to Mandagni.

99

Table No.10. INCIDENCE OF MODE OF ONSET

Group-A Group-B

Mode of onset No. of

patients Percentage No. of

patients Percentage

Sudden 5 25% 2 10%

Gradual 15 75% 18 90%

02468

1012141618

No.

of p

atie

nts

Sudden GraudalMode of onset

Group AGroup B

Among 40 patients, mode of onset is gradual in Group-A (75%) and Group-B

(90%)

100

Table No. 11. INCIDENCE BASED ON ETIOLOGY

Group-A Group-B

Etiology No. of patients

Percentage No. of patients

Percentage

LS 4 20% 13 65%

LS + IVDP 5 25% 2 10%

IVDP 9 45% 3 15%

Spondylolisthesis 2 10% 2 10%

LS – Lumbar spondylosis

IVDP – Inter vertebral disc prolapse

02468

101214

No.

of p

atie

nts

LS LS+IVDP IVDP Spondylolisthesis

Etiology Group AGroup-B

According to above table, maximum number of cases in Group-A belongs

to IVDP i.e., 40%.

Maximum number of cases in Group-B belongs to LS i.e., 65%.

101

Table No. 12. INCIDENCE BASED ON SYMPTOMS FOR 40 PATIENTS

Sl.No. Symptoms No. of cases Percentage

1 Pain in spik 38 95% 2 Pain in kati 39 97.5% 3 Pain in uru 40 100% 4 Pain in janu 40 100% 5 Pain in jangha 40 100% 6 Pain in pada 33 82.5% 7 Toda 35 86.5% 8 Deha vakrata 16 47.5% 9 Sthamba 33 82.5% 10. Spandana 29 72.5% 11. Mahabaddata 13 33.5% 12. Aruchi 11 27.5% 13. Agnimandya 17 42.5% 14. Gourava 19 47.5%

05

1015202530354045

Pain

in s

pik

Pain

in k

ati

Pain

in u

ru

Pain

in ja

nu

Pain

inJa

ngha

Pain

in P

ada

Toda

Deh

a va

krat

a

Stha

mba

Span

dana

Mah

abad

data

Aru

chi

Agn

iman

dya

Gou

rava

102

RESULTS

The response of the patients to the treatment done was observed according

to the subjective & objective parameters before and after the treatment.

The patients were classified into three groups Good, Moderate and Poor.

Table Showing the incidence of patients in each pain grade before and after

treatment in Group A & B

Group – A Group-B BT AT BT AT Pain

gradation No. of pts.

% No. of pts.

% No. of pts.

% No. of pts.

%

Worst 3 15% 2 10% 1 5% 0 0

Severe 10 50% 3 15% 12 60% 2 10%

Moderate 7 35% 9 45% 5 25% 7 35%

Mild 0 0 6 30% 2 10% 11 55%

No pain 0 0 0 0 0 0 0 0 Group-A: Among 20 patients, before treatment, 3 patients (15%) were presented

Worst pain, 10 patients (50%) were presented severe pain, 7 patients (35%), were

presented Moderate pain. After treatment 2 patients (10%) were presented Worst

pain, 3 patients (15%) were presented Severe pain, 9 patients (45%) were

presented Moderate pain, 6 patients (30%) were presented Mild pain.

Group-B: Among 20 patients, before treatment, 1 patent (5%) presented Worst

pain, 12 patients (60%) presented severe pain, 5 patients (25%) presented

Moderate pain 2 patients (10%) presented Mild pain. After Treatment, there were

no patients in Worst pain, 2 patients (10%) in Severe pain, 7 patients (35%) in

Moderate pain, 11 patients (55%) in Mild pain.

103

Showing the incidence of range of SLR in the patients of most affectedly.

Group – A Group-B BT AT BT AT Range of

SLR (in degrees) No. of

pts. % No. of

pts. % No. of

pts. % No. of

pts. %

31-50 11 55% 5 25% 8 40% 1 5%

51-70 9 45% 8 40% 12 60% 7 35%

71-90 0 0 7 35% 0 0 12 60%

Group-A: Among 20 patients, before treatment, 11 patients (55%) were in the

range of 31-50°, 9 patients (45%) were in the range of 51-70°. After treatment, 5

patients (25%) were in the range of 31-50°, 8 patients (40%) were in the range of

51-70°, 7 patients (35%) were in the range of 71-90°.

Group-B: Among 20 patients, before treatment, 8 patients (40%) were in the range

of at 31-50°, 12 patients (60%) were in the range of 51-70°. After treatment 1

patient (5%) was found in the range of 31-50°, 7 patients (35%) were in the range

of 51-70° and 12 patients (60%) were in the range of 71-90°.

Showing the changes in SLR after treatment

Group – A Group-B Right leg Left leg Right leg Left leg Difference

in degree No. of pts.

% No. of pts.

% No. of pts.

% No. of pts.

%

1-10 7 35% 4 20% 3 15% 3 15%

11-20 3 15% 5 25% 5 25% 3 15%

21-30 1 5% 1 5% 3 15% 2 10%

31-40 0 0 0 0 1 5% 1 5%

Group-A: Among 20 patients, 11 patients showed 1-10° difference, 8 patients

showed 11-20° difference, 2 patients showed 21-30°.

104

Group-B: Among 20 patients, 6 patients showed 1-10° difference, 8 patients

showed 11-20° difference, 5 patients showed 21-30° difference, 2 patients showed

31-40° difference.

Showing the assessment of ODI before and after treatment.

Group – A Group-B BT AT BT AT ODI No.

of pts. % No. of

pts. % No. of

pts. % No. of

pts. %

Bed bound 0 0 0 0 0 0 0 0

Crippled 3 15% 0 0 8 40% 1 5%

Severe 16 80% 9 45% 9 45% 7 35%

Moderate 1 5% 10 50% 3 15% 10 50%

Mild 0 0 1 5% 0 0 2 10%

Group-A: Before treatment, 3 patients (13%) were crippled, 16 patients (80%)

having severe disability, 1 patient (5%) had moderate disability. After treatment,

9 patients (45%) had severe disability, 10 patients (50%) had moderate disability,

1 patient (5%) had mild disability.

Group-B: Before treatment, 8 patients (40%) were crippled, 9 patients (45%)

having severe disability, 3 patients (15%) having moderate disability. After

treatment, 1 patient (5%) was crippled, 7 patients (35%) had severe disability, 10

patients (50%) had moderate disability 2 patients (10%) had mild disability.

105

SYMPTOM WISE RELIEF

Group-A Group-B Symptom BT AT Relieved % BT AT Relieved %

1. Sthamba 47 29 38% 56 10 82%2. Ruk 58 33 43% 56 20 64%3. Toda 47 32 32% 48 13 73%4. Spandana 27 10 63% 32 3 91%5. Daha 13 3 77% 26 5 81%6.Pain in payu 5 2 60% 13 4 69%7.Deha vakrata 8 5 38% 14 3 79%8.Sosha 5 5 0% 5 4 20%9.Vibandha 12 4 67% 10 2 80%10.Aruchi 12 0 100% 6 5 17%11.Gourava 12 4 67% 9 7 22%12.Agnimandya 10 0 100% 4 1 75%13.Tandra 11 1 91% 7 7 0%14.Suptata 34 17 50% 26 5 81%15.N.R.S 56 40 29% 52 31 40%16.SLR right 35 27 23% 34 21 38%17.SLR left 37 31 16% 33 23 30%18.O.D.I 42 29 31% 45 27 40%Mean

0102030405060708090

100

Rel

ieve

d pe

rcen

tage

Stha

mba

Ruk

Toda

Span

dana

Dah

a

Pain

in p

ayu

Deh

a va

krat

a

Sosh

a

Viba

ndha

Aru

chi

Gou

rava

Agn

iman

dya

Tand

ra

Supt

ata

NR

S

SLR

Rt.

SLR

Lt.

OD

I

SymptomsGroup A Group B

106

STATISTICAL ANALYSIS OF CLINICAL RECOVERY OF PARAMETRS

IN BOTH GROUPS

GROUP “A” GROUP ‘B” MEAN

MEAN

S.NO

Parameter B.T A.T

Mean difference

% of Relef

B.T A.T

Mean Difference

% of Relef

1 STAMBA 2.35 1.45 0.9 38 2.8 0.5 2.3 82

2 RUK 2.9 1.65 1.25 43 2.8 1 1.8 64

3 TODA 2.40 1.6 0.8 33 2.4 0.65 1.75 73

4 S.L.R 1.75 1.35 0.4 23 1.7 1.05 0.65 38

5 S.L.R (L) 1.85 1.55 0.3 16 1.65 1.15 0.5 30

6 N.R.S 2.8 2 0.8 28 2.6 1.55 1.05 40

7 O.D.I 2.1 1.45 0.65 31 2.25 1.35 0.90 40

Analysis: Sthamba, Ruk, Toda of subjective parameters along with objective

parameters are taken. Mean is calculated before and after treatment, mean

difference is found. Mean difference in group-B is higher than that of Group A in

all above parameters hence it can be concluded that Group B is significantly

effective i.e Matravasti along with oral medicine is more effective in relieving

symptoms than oral medicine alone.

107

OVERALL RESULT

Group A Group B Result

No. of patients Percentage No. of patients Percentage

Good 3 15% 11 55%

Moderate 12 60% 6 30%

Mild 5 25% 3 15%

Group-A: Among 20 patients, 3 patients (15%) showed good response.

12 patients (60%) responded moderately.

5 patients (25%) showed mild response,.

Group-B: Among 20 patients, 11 patients (55%) showed good response

6 patients (30%) showed moderate response.

3 patients (15%) showed mild response.

Group - A15%

60%

25%

GoodModerateMild

GROUP-B

55%30%

15%

GoodModerateMild

The results have been also presented in the form of Master Chart.

108

DISCUSSION Man is almost unique in standing up right posture balanced on two limbs. The

advantage of this posture is obvious but it also led to considerable stress on the

spine. Gridrasi is not the problem of recent origin, but it was known to man kind

since time immemorial.

Gridrasi is compared with sciatica. The under lying cause may be ruptured

intervertebral disc, arthritis in the sacro iliac joint or spine, spodylolisthesis,

lumbar canal stenosis.

The disease is seen in all ages but more frequently among middle aged.

Though the disorder appears to be benign, it causes great discomfort to the patient

and makes him temporarily disabled to perform the routine social activities, as it is

not mere discomfort but the pathological dominant factor.

Ageing process of the body after forty years is likely vulnerable to variety of

vata vyadhis, gridhrasi is one among them, which requires the attention of the

physician. In all degenerative conditions, involvement of vata is a prime factor.

Discussion on observation:

AGE: Maximum number of patients was found in 31-40 & 51-above age

groups. Today’s life style which leads to irregular exercise, more traveling

abnormal postures, and working for a long time with out proper rest may be the

reason behind this.

In age group of 51& above which is vata prakopa kala – there is progressive

decrease in hydration of inter vertebral disc that leads to degeneration resulting in

disc problem there by causing Gridhrasi No patients were found in 0-20 age group,

because in this group more elasticity is found in the spine. So it works as a good

shock absorber and does not give chance to produce gridhrasi.

111

Sex: This study reveals that higher incidence was observed in females. In many

female patients history of heavy weight lifting i.e. lifting buckets with full of water

was common. Though the male patients are less in this study due to professional

exposure to strain, trauma on the lumbo sacral region, incidence of gridhrasi was

found in significant percent.

Diet: In the present study it was observed that maximum number of patient belong

to mixed diet. In classics it has been clearly mentioned that the disease occurs in

people who are greedy for non-vegetarian food, which is supported by findings of

the present study.

Occupation: From this present study we can come to a conclusion Gridhrasi

effects the person from varied occupation with varied degree of spinal stress and

strain caused by irregular posture of sitting, standing, walking, improper lifting of

heavy weight, driving etc., however more cases observed in House wives.

Socio Economic Study: In the present study- majority of patients belong to

middle class followed by lower class.

Religion: In the present study majority of patients registered for the study were

Hindu’s; the data is only reflection of geographical predominance of the

community.

Addiction: Though addiction history is signifying sciatic neuritis, in the present

study we cannot come to any conclusion, as the sample size is small.

Prakruti: Majority of patients belong to vata kapha prakruti followed by vata pita

prakruti the observation supports the tendency of vataja disorder like gridrasi in

persons having vata prakruti and other doshik prakrutis where vata is

predominantly involoved.

Based on etiology: Lumbar spondylosis is found in Gr A 30% Gr B 65%, Inter

vertebral disc prolapse Gr A 40% Gr B 15%. Spondylolisthesis 10%in each

112

group.Asthidhatu kshaya (degenerative changes) is one of the causes for

provocation of vata. According to modern medicine lumbar spondylosis is

common cause for sciatica. So its supports the cause of Gridrasi is vata prakopa,

mainly due to degenerative changes in lumbo sacral spine both in ayurveda and

modern medicine.

As vata vyadhi becomes chronic it is difficult to treat. The same thing was proved

in the present study. The patients who came in early stage of disease have obtained

good results compared to chronic patients. From this it is clearly indicate, if

patient comes in early stage of disease, gives good result in relieving pain and as

the disease become chronic it is difficult to treat.

Ruk: Statistical analysis revealed that difference of Mean (before treatment mean

–after treatment mean) in Group A is 1.25 and Group B is 1.8. There was 64% of

reduction in pain in-group B where as in Group A it was 43%. Out of 20 cases in

group A:8 patients had good relief of pain, 8 patients moderate relief,4 patients

mild relief. In Gr B12 patients had good relief and 8patients had moderate relief.

Sthamba: Severity of Sthamba was decreased and Mean Difference in Group A is

0.9 and Group B is 2.3,and relieved 38% in Group A and 82% in Group B. Result

of Group A : 3 good ; 12 moderate and 3 mild response . In case of Group B 19

cases showed good response, one mild response.

Toda: Mean difference: Group A 0.08 Group B 1.75; and the relieved %was 33%,

73% in A and B.Result: Group A : 2 cases good relief,11-Moderate, 4 mild where

as in Group B 14 good,2 moderate and 1 mild response was observed.

Daha, Suptata are effectively relieved in Group B than Group A In case of Aruchi,

Gaurava, Agnimandya, Tandra more relief was noted with oral medicine alone.

N.R.S: The mean difference in Group A is 0.8 and 1.05 in Group B and relieved

% was 29,40 respectively in both groups. Severity of pain was relieved more in

Group B than Group A.

113

O.D.I: Mean difference in Group A is 0.65 and Group B is 0.90 and relieved %

was 31,40 in Group A and B.

S.L.R: In Group A increase of SLR angle was 23% and Group B 38% in case of

right leg and 16% in Group A, 30% in Group B in left leg.On the whole result in

Group B on the parameters is highly encouraging.

The Drug Swalpa rasona pinda, Asta varga kashaya anupana action can be

interpreted as follows.Rasona is best vata hara dravya.It also posess-deepana,

pachana, brimhana, rasayana, shoolahara, sothahara, bhagnasthisandhanakara

properties. “Sarvangam prasarati” property described for Lasuna in Saaligrama

nighantu. It enters through micro channels of body and reaches site of

pathogenesis and relieves Ruk, sthamba, kati uru janu Madhya bahu vedana,

sandhi shoola etc

Extract of garlic when given to overectomized rat promotes intestinal

transference of calcium. It also enhanced better preservation of bone mineral

content. (Phyother Res 2006 May; 20-5; 408-15).

Hingu, Jeeraka, Shunti possess anti-spasmodic, muscle relaxant, anti

inflammatory, analgesic effect there by relieving shoola, shotha, sakthi utkhepa

nigrahana etc. Apart from Angamarda prasamana property, Eranda said as

“Marga visodaka”. (Madanapala Nighantu) It causes sroto sodhana and vata

anulomana by which it restores normal circulation of vata, and acts also like

painkiller.

Rasna, Sunti, Nirgundi, Devadaru have anti-inflammatory action, it reduces

nerve inflammation added to this it also posses pain relieving effect.

All the ingredients also possess Deepana, Pachana property, which causes

Ama pacha and Agni deepana. Individual drugs possess shoolahara, sothahara,

Rasayana, Vatakaphahara properties. Combination of above drugs causes potent

Anti-inflammatory, pain relieving effect.The drugs also have effect on the

114

associated symptoms like Aruchi, Agnimandya, Bhaktadwesha, Mukha praseka,

vibanda etc.

Hemadri advised Brimhana treatment in Asthi Kshaya & Vata Vriddhi (Vayu

vriddhou Brimhanam Asthi Kshayae Brimhanam) (A.Hr.Su.11/25). In Asthi

Ashraya Vyadhis the Chikitsa sutra is vasti with tikta rasa dravyas.

Balaswagandha tailam have many herbs having bitter taste (tikta rasa) and

osteogenic action.

Balaswagandha tailam is described as “Pustikaram param” (S.Y.Taila

prakaram). Most of the ingredients of the tailam possess Brimhana snehana

property. As mentioned in Chikitsa sutra Balaswagandha tailam cuases Asthi

dhatu poshana through Brimhana, Balya properties. It also acts as nervine

stimulant.

In Vata vyadhis Brimhana with sneha is indicated. Balaswagnada taila

matra vasti is vataharam, prevents Asthi dhatu kshaya. Tila tailam by its sara,

sookshma, vikasi snigdha, mardava gunas enters into srotas relieves obstruction

causes Dhatu vriddhi (Thereby Asthi dhatu poshana).

Dadhimastu also possess, sroto visodaka,Aharam balyam property

(Bh.Pr.) Rasayana properties of the drugs enhances the proper nourishment of

dhatus. Tilatailam is said asVatagneshu uttamam balyam (C.S.SU.27/285).

Balakrit (Y.R.) The ingredients also possess sulahara, sothahara property.Anti-

inflammatory, Analgesic, Immunomodulatory, properties of Bala, Aswagandha,

Yastimadhu, Sati, Sariba, Musta are experimentally proved.

Thus Matra vasti with oral medicine Swalpa Rasona pindam, Ashta varga

Kashaya anupana helps in relieving Sthamba, Ruk, Toda, Daha, Sakti, Utkshepana

effectively.

115

CONCLUSION

After going through literary aspect and based on the clinical trial: following

conclusions are drawn:

1. Gridhrasi is shoola pradhana vataja nanatmaja vyadhi

2. Gridhrasi can be compared with sciatica based on its etiopathogenesis and

symptomatologies.

3. The pratyatma lakshana Ruk, Toda, Sthamba, Sakti utkshepa Nigraha were

the common presentation in all the patients.

4. Occupation and mainly improper posture plays an important role in the

manifestation of this disease.

5. Swalpa Rasona Pinda with Asta Varga Kasaya Anupana is effective in

management of Gridhrasi and is more effective if given along with Matra

vasti

6. Complications are not occurring during and after the course of treatment.

7. Matra vasti is easy to constitute, and gives least discomfort to both patient

and physician.

8. It is cheap compared to other conventional methods of management of

gridhrasi.

9. There is significant increase in SLR angle and decrease in disability index

and also considerable decrease in intensity of pain in Group B than in

Group A. It can also be concluded that vasti is very effective treatment

modality to provide relief in Gridhrasi with in short duration compared to

Oral medicine alone.

10. The study reveals that the disease is more prevalent in middle class and

degeneration or dhathu kshaya is the main cause i.e. lumbar spondylosis.

117

It is also claimed that this Ayurvedic remedy has its advantage over modern

analgesics, because, the Analgesics may occasionally cause allergic reactions,

gastro intestinal disturbance such as nausea, vomiting, dyspepsia and heart burn

etc, whereas this Ayurvedic medicine is totally safe.

In the present study also no such adverse toxic effects are found. This drug

is proved to be well tolerated.

RECOMMENDATIONS FOR FURTHER STUDY

1) Matra Basti can also be recommended for longer period with other Sneha

Dravya also.

2) Sciatica is present in different pathological conditions as a symptom. So

specific condition can be taken for the further studies and the exact effect of

the treatment can be assessed in the particular condition.

3) Same study can be conducted on a large sample to evaluate the efficacy of

matra vasti.

4) Recent technology like M.R.I, C.T, Myelogram, Nerve conduction studies are

adopted for accurate diagnostics and treatment.

5) A detailed study on the Nidanas and the samprapti of the vata vyadhis is

essential to support the etio pathogenesis of Gridhrasi

118

SUMMARY

The present study entitled “A CLINICAL STUDY ON THE EFFECT OF

RASONA PINDA WITH ASTA VARGA KASHAYA ANUPANA AND MATRA

VASTI IN THE MANAGEMENT OF GRIDHRASI VATA” Can be summarized as

below:

Gridrasi is a condition, characterized by severe radiating pain down the leg,

may be considered as sciatica. The global cost of sciatica to our society is

important in indicating the importance of the problem and the need for extra

resources to be directed to improve treatment facilities. The prevalence of

sciatica was described in part-1.

The structure of vertebral bodies, inter vertebral discs, mobility of the

spine, sciatic nerve and its branches are described in detail.

Nidana of gridhrasi was considered as per vata vyadhis. Poorava roopa,

roopa sadhya sadhyata are elaborated in part two.

The drugs in this present study are swalpa rasona pinda, asta varga kashaya

and balaswagandha tailam. The guna karmas for each drugs and their chemical

composition are emphasized in detail in part three.

40 Patients were selected for the study. They are divided in to two groups.

Group A- 20 patients were taken.and given swalpa rasona pinda 1 t.i.d with asta

varga kashaya anupana 30 ml t.i.d.

Group B-20 patients were included in the study. They were administered matra

vasti along with swalpa rasona pinda and asta varga kasaya anupana.

119

The parameters for diagnosis are completely based on classical symptoms

like Ruk, Toda, Stamba in the spik, kati, Prusta, Janu, Jangha and pada region with

or without other symptoms. The test for sciatica like Straight Leg Rasing (S.L.R)

was done. The grading for the pain was given on the basis of numerical rating

scale. Functional disability was measured using Oswestry disability index.

In order to establish the incidence of the disease, the profile of the patients

studied are classified after considering various factors, which are presented

through different tables. Results are given in the form of tables along with short

description in part-5.

It has been observed that patients treated in Group B 60% (Matra vasti

with swalpa rasona pinda and asta varga kasaya anupana) have shown significant

relief when compared to Group A 43% (Swalpa rasona pinda with asta varga

kasaya anupana)

Thus it can be inferred that Vasti with oral medicine shows significant

beneficial action in relieving the symptoms of Gridrasi.

120

BIBLIOGRAPHY

1. Adams and Victor’s Principles of Neurology by Allen H Rooper Robert H Brown 8th edition.

2. Amarakosam – By Viswanath Jha – Published Mothilala, Banarasi, 1975

3. Astanga Hridayam – Edited by Hari sastry Paradkar, Akola,8th Edition Published by Chankhambha Orientalia, Varanasi.

4. Astanga Sangraha with Hindi Vyakarana By Kavirah Atridev Gupta,Reprinted edition 1993,Published by Krishnadas Academy Varanasi.

5. Ayurveda Prabhanavali : Gridhrasi,(Sciatica and its associated conditions . By Purushothamacharyulu &Aruna , Published by Aryavaidya sala Kottakal 1988.

6. Ayurvedeeya pancha karma vignanam by Kastoori, Published by Baidyanath Ayurvedic Bhavan, Calcutta, 1970.

7. Back pain the Facts- 3rd Edition by Malcom I.V Jayson,Oxford university Press 1992.

8. Backache – Its evaluation and conservative treatment by David P.Erans, M.T.P. Press Ltd., Lancaster, 1982.

9. Baishajya Ratnavali – By kaviraja Ambikadatta Sasthri - Published by Chowkamba Sanskrit Series office, Varanasi, 1961

10. Bhava Prakasam – By Brahma Sankara Sastry and Roopa lal Vaishya 8 th Edition 1997.

11. Bhela Samhita English Translation Dr K.H Krishnamurthy Edited by Prof Priyavat Sarma. 1st Edition 2000.

12. Brain’s diseases of Nerves system Edited by Michael Donoghy 11th Edition Oxford University Press.

13. Chakra Datta – By Jagadiswara Prasad Tripati, Published by Chowkambha Sanskrit Series, 1949

14. Charaka Samhita – Edited by Ganga Saha Pandeya Published by Chaukhamba Sanskrit Sanstan Varagal.

15. David Son’s Principles and practice of Medicine, Published by Churchill living stone, Edinburg, 1984

121

16. Dravya Guna - A Text book of Medicinal Plants with illustrations by Dr. Muralidhar Rao. 1st Edition 2005.

17. Dravyaguna vignanum – By Dr J.L.N Sasthry Vol II.

18. Gray’s Anatomy – Published by Longmans, Greece and Company London.

19. Haritha Samhita by Sri Kshema Raj – Sri Krishna Das Mumbai.

20. Indian Medicinal Plants- Orient Long mann Edited by A.VS. Kottakal.

21. Indian Meteria Medica – By Nadakarni.

22. Madava nidana – Sudarsan Sastry Chowkhamba Sanskrit Samsthan 29th Edition 1999. Varanasi

23. Medical Discovery Who and When By Charles Schmidt J.E Spring Field Elinose.

24. Orthopaedic principles and their application by Turek Vol II 4th Edition

25. Principles of Anatomy and Physiology Tortora 8th edition.

26. Sahasra Yogam By Vempati Koteswara Sashastry Ayurveda Parishat Vijayawada 1961.

27. Sarangadhara Samhita – Published by Prof Sri Kantamurthy Published by Chowkamba Orientalia Varanasi.

28. Susrutha Samhitha, Edited by Yadavji Trikomji Acharya and Narayana Ram Acharya Reprinted in 1998 Krishanadas Acadamy Varanasi.

29. The Doctrine of Nerves.By Spilline John D Oxford University press New York ,1981.

30. The Spine Rothman and Simeone 4th Edition Saunders.

31. Vaidya Chintamani – Publsied by Vavilla Ramasastry & sons – 1952.

32. Vangasena – Published by Sri Venkateswara Mudranalaya, Mumbai, 1876.

33. Yogaratnakaram – By laxmipati Sastry 7th Edition 1999 Published by Chowkambha Sanskrit Sansthan Varanasi.

122

123

REFERENCES

PART –I

1. C.S.Su.20/11.

2. Sabda kalpa druma Vol 2 page no 348-349.

3. C.S.Chi 28/56,57.

4. Backpain the facts-Pg no 19,23.

5. C.S. Chi 28/99.

6. B.R.26/93-97.

7. S.Y.125.

8. Rig veda (R. V.2-15.7).

9. Adharvana Veda (9-8-21).

10. CS Su 5/90,92.

11. CS Su14/20-24.

12. CS Su 20/111.

13. CS Chi 28/55,56.

14. SS Ni 1/74.

15. SS Chi5/23.

16. SS Sa8/17.

17. AS Su 20/13.

18. AS Ni 15/56.

19. A S Ni15/56.

20. A.H. Ni 15/54.

21. K S Su27/21.

22. BS Chi24/44,45.

23. H S T Chapter 22/1-12.

24. M N 22/55- 56.

25. Sa.S. Poorva Khanda 7/108.

26. Sa.S.Madhayana Kanda 2/93.

27. Sa.S.Madhayana Kanda 5/6.

28. C.K.22/53.

29. V.S.Vata Vyadhi Adhikar 571,574-575.

30. Medical Discoveries Who and When Pg 433,434.

31. A History of Nuerological Survey Pg 393.

PART 2 1. Amara Kosha Sloka no 2015.

2. Sabda Kalpa Druma Vol II pg no 348,349.

3. C.S.Chi.28/56.

4. S.S.Ni. 1/74.

5. M. N 22/54.

6. Sa. S.Poorva Kandha 7/108.

7. Principles of Anatomy and Physiology-Tortora P no 381.

8. Gray’s Anatomy Pg 1182 to 1189.

9. Back ache its evolution and conservative treatment Pg 53-57.

NIDANA: 1. C.S.Chi.28/15,17.

2. B.P,Utt.Ka .24/1,2.

3. S..S.Su..21/19,20.

4. S.S.Ni 1/67,68,79.

5. A.S.Ni.15/31,34,41.

6. A.H. Ni 1/14,15.

7. A.H. Ni 15/29,32,33,47

8.C.S.Chi 28/59

9.A.S.Ni 15/7,8.

10.A.H.Ni15/5,6.

11.V.C.Vata Vyadhi.Sloka:2

12. C.S.Su.1/44.

13.C.S.Chi.28/58.

14.C.S.Su.21/24.

15.C.Chi.28/18.

16.A.H.Su.4/2.

17. S.S.Su.21/19.

18. S.S.Sa.6/48.

19. Back Ache Its Evolution & Conservative Treatment pg

20. Medicine for Students –Golwalla-pg 621,622

POORVA ROOPA 1. C.S.Ni.1/7.

2. C.S.Chi.28/19.

3. Chakrapani on C.S.Chi.11/12.

ROOPA: 1. Madhu Kosha on M.N.1/7.

2. A.H.Ni.1/5.

3. C.S.Chi.28/56.

4. Aruna Datta on A.H.Su.12/49.

5. Hemadri on A.H.Su.12/49.

6. Dalhana on S.S.Ni.5/13.

7. Madhukosha on M.N.22/54,55.

8. Yogendranath Sen on C.S.Chi. 7/14.

9. Arunadatta on A.H.Su.12/49.

10. Arunadatta on A.H.Su 12/50.

11. Hemadri on A.H.Su.12/50.

12. Dalhana on S.S.Su.Ni 1/74.,Arunadatta on A.H.Ni.15/4.

13. H.S.Tri.22/1,2.

14. Hemadri on A.H.Su.12/50.

15. Arunadatta on A.H.Su.12/49.

16. V.S.Vatavyadhi adhikar-Sloka 571.

17. Basavarajeeyam . Sh.Pr. Vataroga Nidanam/80.

18. Indu on A.S.Su.19/5.

19. Dalhana on S.S. Chi.1/7.

20. Dalhana S.S.Su.45/3.

21. Madhukosha on M..N.14/4.

22. Chakrapani on C.S.Chi.9/20.

23. Chakrapani on C.S.Chi 16/41.

24. Indu on A.S.Su 9/89.

25. Principles of Neurology Adams and Victor Pg 213,14.

26. Arthopadic Principles and their application pg no 1489.

27. Merits Text boom of Neurology pg 439.

28. C.S.CHI.27/20.

SAMPRAPTI: 1. Chakrapani on C.S.Ni.1/11.

2. C.S.Chi.28/18.

3. S.S.Ni.1/74.

4. H.S.Tri.20/2.

5. A.H.Su.11/26.

6. The back functions malfunctions and care Chap II pg 22.

7. Spine and Medical negligence’s Chap X pg 83,84.

8. The Spine Chap VIII Pg 159 to169.

SAPEKSHA NIDANA: 1. C.S.Chi.27/13,14,17,18.

2. M.N.22/59-60.

3. C.S.Chi.28/25.

4. M.N.22/74. UPADRAVA AND SADHYA SADHYATA:

1. C.S.Chi.21/40.

2. S.S.Ni.1/77.

3. A.H.Ni.8/30.

4. S.S.Su.33/4.

5. S.S.Su.33/7.

6. C.S.Su.10/17.

PART 3- CHIKITSA: 1. C.S.Chi.28/120.

2. S.S.Chi.5/49.

3. C.K.23/54.

4. Bh.Pr.II.2/131,132.

5. B.S.Chi.26.

6. V.S.Vata Vyadhi.574-576.

7. C.S.Su.14/13,39-40.

8. C.S.Si.10/6.

9. S.S.Chi.38/116.

10. C.S.Si.1/38-41.

11. C.S.Chi.28/120.

12. C.D.23/54.

13. V.S.Vata Vyadhi.584-587.

14. C.S.Chi.28/120.

15. C.D.22/53-55.

16. H.S.Tri.22/6-12.

17. The Back functions malfunctions and care Chap 19 Pg 216.

18. Back Pain the Facts Chap VII Pg 110.

19. Gayadas on S.S.Chi 35/18.

20. C.S.Si.4/53.

21. C.S.Si 4/52.

22. A.S.Su.28/30.

23. C.S.Si.1/44.

24. S.S.Chi.35/26.

25. S.S.Chi.35/27,28.

26. C.S.Si.1/32.

POST GRADUATE DEPARTMENT OF KAYA CHIKITSA Dr. B.R.K.R. Govt. Ayurvedic College/Hospital, Hyderabad-38

SPECIAL CASE SHEET FOR GRIDHRASI “A clinical study on the effect of RASŌNA PINDAM WITH ASTAVARGA KAŞAYA

Anupanam and MĀTRA VASTI in the Management of Gridhrasi vata”

Name: ` OP NO:

Age / Sex: IP No:

Occupation: DOA:

Address: DOD: Chief Complaints: Associated Complaints: H/O Present illness:

Onset Radiation Duration Type

Intensity Relieving Factors Aggravating Factors Sleep disturbances

H/O Past illness: Trauma □ Fractures □ T.B □ Pelvic Infection □

Malignant Diseases of Spine □ H/O Previous treatment:

Medical Surgical

Personal History:

Diet Height Weight Addictions

Asta staana pariksha:

Nadi Mutra Mala Jihwa

Sabdha Sparsa Drik Akruti

Dasa vidha pariksha :

Prakriti Satvam Samhanana Ahara sakti Pramana

Vikriti Satmyam Saram Vyayama sakti Vayah

General examination: Gait: Local examination: Inspection: Swelling □ Emaciation / Atrophy □ Palpation: Tenderness Spik Prista Kati Uru Janu Jangha Pada 15

days 30 days

40 days

Sthamba

Ruk

Toda

Grihnati

Spandatae Muhu

Kandara Soshana

Parnshni pratyanguli (SU) □ Pain in payu □ Deha Vakrata □

Tandra □ Agnimandya □ Mukha praseka □ Sandhi shula □

Bhakta dwesham □ Gouravam □ Specific test: S.L.R. Lassegue sign AP view Investigations: X-ray L.S. Spine Lat view

C.U.E

C.B.P. Diagnosis: Vataja □ Vata kaphaja □ Treatment: Swalpa Rasōna Pindam with Astavarga Kaşaya Anupanam 1 Cap.tid 30ml.tid Matra Vasti : Balaswagandha Tailam (60ml) – 7 days

Chief complaints Date Time of administr-

ation

Pratyaga-mana kala

Retention period

Results Complications

Before After

S.L.R : Before Degree 15 days 30 days 40 days

R L R L R L R L < 30 30 – 60 60 – 90 > 90

Lassegue sign :

Before 15 days 30 days 40 days R L R L R L R L

Signature Signature Signature P.G. Scholar Co-guide Guide

10

9

N 8

7

R 6

5

S 4

3

2

1

0

15 30 40 Days

0

100% O 80% D 60% I 40% 20%

15 30

40 Days

Functional Disability Oswestry Disability assessment Questionnaire: Questionnaire description: 10 sections describing the pain and its impact with

each section scored from 0-5, with higher values indicating more severe impact.

Section 1: Pain Intensity

• I can tolerate the pain I have without having to use pain killers. [0 points]

• The pain is bad but I manage without taking pain killers. [1 point]

• Pain killers give complete relief from pain. [2 points]

• Pain killers give moderate relief from pain. [3 points]

• Pain killers give very little relief from pain. [4 points]

• Pain killers have no effect on the pain and I do not use them. [5 points]

Section 2: Personal Care

• I can look after myself normally without causing extra pain. [0 points]

• I can look after myself normally but it causes extra pain. [1 point]

• It is painful to look after myself and I am slow and careful. [2 points]

• I need some help but manage most of my personal care. [3 points]

• I need help every day in most aspects of self care. [4 points]

• I do not get dressed, wash with difficulty and stay in bed. [5 points]

Section 3: Lifting

• I can lift heavy weights without extra pain. [0 points]

• I can lift heavy weights but it gives extra pain. [1 point]

• Pain prevents me from lifting heavy weights off the floor, but I can manage

if they are conveniently positioned, for example, on a table. [2 points]

• Pain prevents me from lifting heavy weights but I can manage light to

medium weights if they are conveniently positioned. [3 points]

• I can lift only very light weights. [4 points]

• I cannot lift or carry anything at all. [5 points]

Section 4: Walking

• Pain does not prevent me walking any distance. [0 points]

• Pain prevents me walking more than 1 mile. [1 point]

• Pain prevents me walking more than 0.5 miles. [2 points]

• Pain prevents me walking more than 0.25 miles. [3 points]

• I can only walk using a stick or crutches. [4 points]

• I am in bed most of the time and have to crawl to the toilet. [5 points]

Section 5: Sitting

• I can sit in any chair as long as I like. [0 points]

• I can only sit in my favourite chair as long as I like. [1 point]

• Pain prevents me sitting more than 1 hour. [2 points]

• Pain prevents me from sitting more than 0.5 hours. [3 points]

• Pain prevents me from sitting more than 10 minutes. [4 points]

• Pain prevents me from sitting at all. [5 points]

Section 6: Standing

• I can stand as long as I want without extra pain. [0 points]

• I can stand as long as I want but it gives me extra pain. [1 point]

• Pain prevents me from standing for more than 1 hour. [2 points]

• Pain prevents me from standing for more than 30 minutes. [3 points]

• Pain prevents me from standing for more than 10 minutes. [4 points]

• Pain prevents me from standing at all. [5 points]

Section 7: Sleeping

• Pain does not prevent me from sleeping well. [0 points]

• I can sleep well only by using tablets. [1 point]

• Even when I take tablets I have less than 6 hours sleep. [2 points]

• Even when I take tablets I have less than 4 hours sleep. [3 points]

• Even when I take tablets I have less than 2 hours of sleep. [4 points]

• Pain prevents me from sleeping at all. [5 points]

Section 8: Sex Life

• My sex life is normal and causes no extra pain. [0 points]

• My sex life is normal but causes some extra pain. [1 point]

• My sex life is nearly normal but is very painful. [2 points]

• My sex life is severely restricted by pain. [3 points]

• My sex life is nearly absent because of pain. [4 points]

• Pain prevents any sex life at all. [5 points]

Section 9: Social Life

• My social life is normal and gives me no extra pain. [0 points]

• My social life is normal but increases the degree of pain. [1 point]

• Pain has no significant effect on my social life apart from limiting my more

energetic interests such as dancing. [2 points]

• Pain has restricted my social life and I do not go out as often. [3 points]

• Pain has restricted my social life to my home. [4 points]

• I have no social life because of pain. [5 points]

Section 10: Traveling

• I can travel anywhere without extra pain. [0 points]

• I can travel anywhere but it gives me extra pain. [1 point]

• Pain is bad but I manage journeys over 2 hours. [2 points]

• Pain restricts me to journeys of less than 1 hour. [3 points]

• Pain restricts me to short necessary journeys under 30 minutes. [4 points]

• Pain prevents me from travelling except to the doctor or hospital. [5 points]