Ssps sandhigatavata pk001-gdg

By

Subin. V.R.

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

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI M.D. (PANCHAKARMA)

In

PANCHAKARMA

Under the guidance of

Dr. G. Purushothamacharyulu,M.D. (Ayu)

And co-guidance of

Dr. Shashidhar.H. Doddamani,M.D. (Ayu)

Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College,

Gadag – 582103.

2005.

Evaluation of Efficacy of Shashtikashalipinda

swedakarma in the managament of

Sandhigatavata (Osteoarthritis)

Ayurmitra

TAyComprehended

Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore.

DECLARATION BY THE CANDIDATE

hereby declare that this dissertation / thesis entitled “Evaluation

of the Efficacy of Shashtikashalipindaswedakarma in the management

of Sandhigatavata (Osteoarthritis)” is a bonafide and genuine research work

carried out by me under the guidance of Dr. G. Purushothamacharyulu, M.D.

(Ayu), Professor and H.O.D, Post-graduate department of Panchakarma and co-

guidance of Dr. Shashidhar. H. Doddamani, M.D.(Ayu), Assistant Professor,

Post graduate department of Panchakarma.

Date:Place: Subin. V.R.

I

Ayurmitra

TAyComprehended

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “Evaluation of

the Efficacy of Shashtikashalipindaswedakarma in the management of

Sandhigatavata (Osteoarthritis)” is a bonafide research work done by Subin.

V.R. in partial fulfillment of the requirement for the degree of Ayurveda

Vachaspathi. M.D. (Panchakarma).

Date:

Place: Dr. G. Purushothamacharyulu, M.D. (Ayu).

Professor & H.O.D


ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF

THE INSTITUTION




V.R. under the guidance of Dr.G. Purushothamacharyulu, M.D. (Ayu), Profes-

sor and H.O.D, Postgraduate department of Panchakarma and co-guidance of

Dr. Shashidhar.H. Doddamani, M.D. (Ayu), Assistant Professor, Post graduate

department of Panchakarma.

Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil.

Professor & H.O.D, Principal.


CERTIFICATE BY THE CO- GUIDE




V.R. in partial fulfillment of the requirement for the degree of Ayurveda

Vachaspathi. M.D. (Panchakarma).

Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).

Place: Assistant Professor,

Post graduate Department of Panchakarma.

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and dissemi-

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

research purpose.

Date: Subin V.R.

Place:

© Rajiv Gandhi University of Health Sciences, Karnataka.

I

Acknowledgement “Many hands make light work”. I take this opportunity to mention my deep gratitude to several personalities who have helped me in the successful completion of this work.

I express my obligation to my honorable Guide Dr. G. Purushothamacharyulu M.D. (Ayu), H.O.D., P.G. Department of Panchakarma, P.G.S&R, D.G.M.A.M.C, Gadag for his critical suggestions and expert guidance for the completion of this work.

I am extremely grateful and obliged to my co-guide Dr. Shashidhar.H. Doddamani, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag for his guidance and encouragement at every step of this work.

I express my deep gratitude to Dr .G.B Patil, Principal, D.G.M.A.M.C, Gadag, for his encouragement as well as providing all necessary facilities for this research work.

I express my sincere gratitude to Dr. P. Shivaramudu M.D (Ayu), Assistant Professor and Dr. Santhosh. N.Belavadi MD (Ayu), Lecturer for their sincere advices and assistance.

I express my sincere gratitude to Dr. V. Varadacharyulu M.D (Ayu), Dr.M.C.Patil M.D (Ayu), Dr. Mulgund M.D (Ayu), Dr. K. S. R. Prasad M.D (Ayu), Dr. Dilip Kumar M.D (Ayu), Dr. R.V. Shetter M.D (Ayu), Dr. Kuber Sankh M.D (Ayu), Dr.G.Danappa Gowda M.D (Ayu) and other PG staff for their constant encouragement.

I also express my sincere gratitude to Dr.B.G.Swamy, Dr.V.M.Sajjan, Dr.U.V.Purad, Dr.Mallagowder, Dr.K.S.Paraddi, Dr.G.Yargeri, Dr.S.H.Radder and other undergraduate teachers for their support in the clinical work. I thank to Shri. Nandakumar (Statistician), Dr. Arun Baburao Biradar, Shri. V.M. Mundinamani (Librarian), Shri. B.S. Tippanagoudar (lab technician), Shri. Basavaraj (X-Ray technician) and other hospital and office staff for their kind support in my study.

I express my sincere thanks to my colleagues and friends Dr. Satheesh.R.Warrier, Dr. Febin .K. Anto, Dr.Renjith.P.Gopinath, Dr.Shajil.N, Dr.Shyju Ollakode, Dr. Sreenivasa Reddy, Dr. Hadimani, Dr. C. S. Hanumanta Gouda, Dr. Sankadal, Dr. Vanitha, Dr.Naveen, Dr.Santhosh.L.Y, Dr.Varsha.S.Kulkarni, Dr.P.Chandramouleeswaran, Dr.Uday Kumar, Dr. K. Krishnakumar, Dr.Ashwini Dev, Dr.Ratna Kumar, Dr.Jayaraj Basarigidad, Dr.Kendadamath, Dr.V.M.Hugar, Dr.Shyla.B, Dr. Suresh Hakkandi, Dr.Manjunath Akki, Dr. L. R.Biradar, Dr.Vijay Hiremath, and other post graduate scholars for their support.

II

I pay homage to my late ancestors whose lives and achievements in Ayurveda have inspired me to take up Ayurveda as my profession. I pay my respect to my elder uncle Brahmasree Ashtavaidyan Vaidyamadham Cheriya Narayanan Nambudiri who has been a source of inspiration for many.

I also express my obligations to my elders Sreemati Umadevi Antarjanam,

Ashtavaidyan Dr. V.M. Brahmadathan Nambudiri, Ashtavaidyan Dr. V.M. Rishikumaran Nambudiri, Prof. V.M. Narayanan, Shri. V.M. Narayanan, Ashtavaidyan V.N. Neelakandhan Nambudiri, Ashtavaidyan V.S. Krishnan Nambudiri, Shri. V.S. Dileepan, Shri. C.R. Dinesh, Dr.V.N.Prasanna, Dr. K. N. Subrahmanian, Shri. K.P. Damodaranunni, Shri. Dipu Karuthedam, Dr. V.N. Vasudevan and Dr. V.B. Rajeev for their constant encouragements. I am also thankful to my maternal grand father and grandmother and several other relatives for their moral support.

I would like to mention the support and inspiration provided by Dr.

R.Ramabhadran, Director (ISM, Kerala), Dr. P. S. Gopi, Retd. DMO (ISM, Kerala), Dr. D. Ramanathan, CCIM Member, Shri. M.P.R. Bhattathirippad (G.M., Vaidyamadham Vaidyasala) and Dr. Saidas, Retd. Joint Director (ISM, Kerala). I also acknowledge the support and inspiration provided by my teachers Dr. K.P. Muralidharan, Principal, S.J.S. Ayurveda College, Chennai, Dr. S. Swaminathan, H.O.D., Samhita & Siddhanta, S.J.S. College, Dr. S. Venugopal, Reader in Sanskrit, Dr. Vasudevareddy, H.O.D. Shalya dept. and Dr. Ramdas Maganti, H.O.D., Kaya chikitsa, S.J.S. College. I also thank Shri. C. S. Bhatt and family and Shri. Prasad and family for the support and encouragement provided during my stay at Gadag.

I acknowledge my patients for their wholehearted consent to participate in

this clinical trial. I express my thanks to all the persons who have helped me directly and indirectly with apologies for my inability to identify them individually.

Finally I dedicate this work to my respected parents Shri. V. S. Raman and Sreemati C. M. Leela who are the prime reasons for all my success. Date : Signature of the scholar Place : (Dr. Subin V.R.)

III

ABSTRACT

The study “Evaluation of the efficacy of Shashtikashalipindaswedakarma

in the management of Sandhigatavata (Osteoarthritis)” is focused on an important

technique of pinda sweda and a common disorder Sandhigatavata.

Shashtikashalipindasweda is believed to have a note worthy role in the management of

such degenerative conditions by imparting strength to the body musculature and nervous

system. Sandhigatavata is the most common joint disorder worldwide.

The objectives of this study are 1) to evaluate the efficacy of

Shashtikashalipindaswedakarma in Sandhigatavata (Osteoarthritis), 2) to evaluate the

efficacy of Bashpaswedakarma in Sandhigatavata (Osteoarthritis) and 3) to evaluate the

comparative efficacy of Shashtikashalipindaswedakarma and Bashpaswedakarma in

Sandhigatavata (Osteoarthritis).

The aim of this study was to find out the effect of

Shashtikashalipindaswedakarma in the management of Sandhigathavata and to check its

advantage over Bashpaswedakarma in managing the same disease. Therefore, two groups

were made and the results obtained in both the individual groups were compared. The

study design selected for the present study was prospective comparative clinical trial.

In group A (Shashtikashalipindaswedakarma), 7 patients (46.66%) had

good response to the treatment (> 60% improvement in all the parameters) and 8 patients

(53.33%) had moderate Response to the treatment (31-60% improvement in all the

parameters). In group B (Abhyanga & Bashpasweda), 14 patients (93.33%) had

moderate response to the treatment and one patient (6.66%) had poor response to the

treatment (1-30% in all the parameters). Among the groups A and B the parameters ‘Ruk’

and ‘AIMS score’ showed high significance and other parameters were not significant in

the comparative study (as by using unpaired t-test, p-value is <0.05).

IV

Observance of Shamana sweda gunas were performed in both the

treatment groups and all the benefits were found highly significant in both the groups. At

the same time overall treatment response was better in the Shashtikashalipindasweda

group, as no patient in the Bashpa sweda group got good response. This suggests that

there was considerable improvement in both the groups but Shashtikashalipindasweda

group got more beneficial effects.

Sandhigatavata is a Vatavyadhi affecting people in the vardhakya avastha.

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

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

should be used in this disease. Shashtikashalipindaswedakarma imparts Swedana and

opens up the srotas in the shareera facilitating more nourishment and free movement of

Vata dosha. This results in the relief of stambha and facilitates free movement of the

sandhis. All the drugs are having shoolahara properties and the Swedana by itself is

shoolahara due to the pacification of Vata. Thereby, it is an ideal treatment of choice in

Sandhigatavata.

Key words: - Shashtikashalipindaswedakarma; Sandhigatavata; Osteoarthritis;

Bashpaswedakarma; Shamana sweda gunas; Dhatu kshaya; Degeneration.

V

LIST OF ABBREVIATIONS

⇒ A. H. – Ashtanga Hridaya.

⇒ B. P. – Bhavaprakasha

⇒ C. S. – Charaka Samhita.

⇒ G. R. – Good response.

⇒ M. R. – Moderate response.

⇒ N. R. – No response.

⇒ P. R. – Poor response.

⇒ S. S. – Sushruta Samhita.

VI

TABLE OF CONTENTS Chapters Page No.

1. Introduction 1-4

2. Objectives 5-7

3. Review of literature 8-70

4. Methodology 71-97

5. Results 98-145

6. Discussion 146-160

7. Conclusion 161-162

8. Summary 163

9. Bibliography

10. Annexure

VII

LIST OF TABLES Page No. 1. Table showing different layers of Twak and diseases originating from each layer 13 2. Table showing the composition of sweat 19 3. Table showing the sites of different types of sandhis 21 4. Table showing properties of Swedana dravyas 26 5. Table showing Sweda yogyas 27 6. Table showing Sweda ayogyas 28 7. Table showing Samyak swinna lakshanas 30 8. Table showing Ati swinna lakshanas 31 9. Table showing Aaharaja nidana of Sandhigatavata 47 10. Table showing Viharaja nidanas of Sandhigatavata 47 11. Table showing lakshanas of Sandhigatavata 58 12. Table showing vyavachedaka nidana between Sandhigatavata and Vataraktha 62 13. Table showing vyavachedaka nidana between Sandhigatavata and Amavata 62 14. Table showing vyavachedaka nidana between Sandhigatavata and Kroshtrukasheersha63 15. Table showing differential diagnosis between OA, RA, Gout and Rheumatic fever 63 16. Table showing gunas of Shashtikashali 71 17. Table showing chemical composition of rice 73 18. Table showing gunas of Bala 74 19. Table showing gunas of Go-ksheera 75 20. Table showing gunas of Nirgundi 76 21. Table showing gunas of Chincha 77 22. Table showing gunas of the ingredients of Gandharvahastadi Kwatha 78 23. Table showing gunas of the ingredients of Sahacharadi taila 80 24. Table showing the variables in AIMS 95 25. Table showing the distribution of patients by age 99 26. Table showing the response of patients in age groups 100 27. Table showing the distribution of patients by sex 101 28. Table showing the response of patients in sex groups 102 29. Table showing the distribution of patients by occupation 103 30. Table showing the response of patients in occupation groups 104 31. Table showing the distribution of patients by economical status 105 32. Table showing the distribution of patients by religion 106 33. Table showing the distribution of patients by dietary habits 107 34. Table showing the distribution of patients by agni 108 35. Table showing the response of patients in agni types 109 36. Table showing the distribution of patients by koshta 110 37. Table showing the response of patients in koshta types 111 38. Table showing the distribution of patients by Nidra 112

VIII

39. Table showing the distribution of patients by vyasana 113 40. Table showing the distribution of patients by prakriti 114 41. Table showing the response of patients in prakriti types 115 42. Table showing the distribution of patients by satmya 116 43. Table showing the distribution of patients by various grades of ruk 117 44. Table showing the response of patients in ruk grades 118 45. Table showing the distribution of patients by various grades of graha 119 46. Table showing the response of patients in graha grades 120 47. Table showing the distribution of patients by various grades of Sparsha akshamatva 121 48. Table showing the response of patients in Sparsha akshamatva grades 122 49. Table showing the distribution of patients by various grades of Sandhigati asaamarthya123 50. Table showing the response of patients in Sandhigati asaamarthya grades 124 51. Table showing the distribution of patients by various grades of atopa 125 52. Table showing the response of patients in atopa grades 126 53. Table showing the distribution of patients by various grades of shopha 127 54. Table showing the response of patients in shopha grades 128 55. Table showing the percentage of presenting complaints 129 56. Table showing the distribution of patients by various grades of duration 130 57. Table showing the response of patients in duration grades 131 58. Table showing the distribution of patients by various grades of onset 132 59. Table showing the response of patients in onset grades 133 60. Table showing the distribution of patients by various joints affected 134 61. Table showing the response of patients of various joints affected 135 62. Table showing the distribution of patients by the type of joint involvement 135 63. Table showing the distribution of patients by various Aharaja nidanas 137 64. Table showing the response of patients of various Aharaja nidanas 139 65. Table showing the distribution of patients by various viharaja nidanas 140 66. Table showing the response of patients of various viharaja nidanas 141 67. Table showing the distribution of patients by various manasika nidanas 142 68. Table showing the distribution of patients by radiological interpretations 143 69. Table showing the distribution of patients by overall treatment response 143 70. Chart showing the before and after treatment values of clinical & functional parameters in group A 143 71. Chart showing the before and after treatment values of clinical & functional parameters in group B 143 72. Chart showing the before and after values of Sweda kaarmukata parameters 73. Table showing the individual study of group-A 143 74. Table showing the individual study of group-B 143 75. Chart showing inter group comparison 143 76. Table showing the study of Sweda kaarmukata parameters 143

IX

LIST OF FIGURES, PHOTOGRAPHS AND GRAPHS Title Page No.

1. Figure showing section of skin 15 2. Figure anatomy of knee joint and lumbar spine 22 3. Flow chart on types of Sweda 33 4. Flow chart on Samprapti 55 5. Photo of drugs used in Shashtikashalipindasweda 74 6. Photo of procedure of Shashtikashalipindasweda and bashpa Sweda 89 7. Graph showing distribution of age 99 8. Graph showing distribution of sex 101 9. Graph showing distribution of occupation 103 10. Graph showing distribution of economical status 105 11. Graph showing distribution of religion 106 12. Graph showing distribution of diet 107 13. Graph showing distribution of agni 108 14. Graph showing distribution of koshta 110 15. Graph showing distribution of nidra 112 16. Graph showing distribution of vyasana 113 17. Graph showing distribution of deha prakriti 114 18. Graph showing distribution of satmya 116 19. Graph showing distribution of ruk 117 20. Graph showing distribution of graha 119 21. Graph showing distribution of sparsha akshamatva 121 22. Graph showing distribution of sandhigati asamarthya 123 23. Graph showing distribution of atopa 125 24. Graph showing distribution of shopha 127 25. Graph showing distribution of chief complaints 129 26. Graph showing distribution of joints affected 133 27. Graph showing distribution of aharaja nidana 136 28. Graph showing distribution of viharaja nidana 139 29. Graph showing distribution of overall assessment 143

INTRODUCTION

Ayurveda is termed as the science of life wherein are laid down the good

and bad of life, the happy and unhappy life, and what is wholesome and what is

unwholesome in relation to life. It is important to realize that Ayurveda is not confined to

life only; it takes the whole subject of life in its various ramifications. The purpose of life

is four-fold, to achieve dharma (virtue), artha (wealth), kama (enjoyment) and moksha

(salvation). In order to attain success in this four-fold purpose of life, it is essential to

maintain life not only in a disease-free state but also in a positive healthy state of body,

mind and spirit. Equal importance is given to mental health; hence, strict mental

discipline and strict adherence to moral values is considered a pre-requisite for mental

health, which influences the physical state of the body.

Ayurveda is the rich storehouse of time-tested and effective recipes for the

treatment of several obstinate and otherwise incurable diseases. More important than

these recipes are the specialized therapies, which while curing such diseases strengthen

the immune system in the body and help in the preservation of positive health. These

specialized therapies in Ayurveda are called as Panchakarmas. It is no wonder that the

scientists and physicians in India and abroad are evincing deep interest in the classical

form of Ayurvedic treatment. Panchakarma therapy primarily aims at cleansing the body

of its accumulated impurities and nourishing the tissues. Once this is achieved, it

becomes very easy to rejuvenate the tissues and prevent the process of ageing. This helps

the individual to lead a disease free old age and he/she becomes capable of serving the

society with his/her accumulated experience without any mental disability and physical

decay.

Introduction 1

The term ‘Panchakarma’ literally means five-fold therapy. The word

‘Pancha’ has a meaning ‘Vistara’ (elaborate) also. Thus, it implies the meaning elaborate

procedures. Both the meanings are really true in their sense. The therapies that are

included under this collective term are Vamana karma, Virechana karma, Nirooha basti,

Anuvasana basti and Nasya karma. Sushruta’s school, which deals with surgery

primarily, includes Rakthamokshana in the place of Nasya karma.

Panchakarmas play a vital role in Ayurvedic therapeutics and as such they

occupy an important place in Ayurveda. It is not known why the number was restricted to

five, but it is definite that these measures were in vogue in the times of Charaka samhita.

Charaka samhita begins with the bheshaja chatushka in sutra sthana, which is primarily

devoted to the drugs used in Panchakarma. Chakrapanidatta extensively discussed the

restriction of the number of Panchakarmas to five. He noted that, here the word karma

denotes the extensive management and pronounced potency for elimination of impurities.

Snehana, Swedana etc. are not covered by this definition and as such are not included in

it.

It is necessary at this state to make it clear that these Panchakarmas do not

imply simple administration of emesis, purgation, enema or nasal drops as is

conventionally understood. Elaborate methods are described for the preparation of these

therapies, their administration, preparation of the individual prior to the administration of

these and the management of the patient after the therapy is administered.

Prior to the administration of these therapies, the body of the patient is to

be suitably prepared and the therapeutic measures used for this purpose are called Poorva

karmas or preparatory therapies. According to Dalhana, Pachana, Snehana and Swedana

Introduction 2

are the Poorva karmas. Pachana involves the internal administration of medicines having

teekshna-rooksha-ushna properties and those that are capable of eradicating the ama

dosha and strengthening the agni. Snehana is administered in two different ways, viz.,

bahya (external) and abhyantara (internal). The external form of Snehana is done through

different types of massages, matra basti, anuvasana basti, karna poorana, anjana etc. with

the help of unctuous preparations (ghrita, taila, vasa and majja). Swedana involves the

application of heat (from various medicinal and non-medicinal sources) to the whole

body or the affected part alone.

During the course of time, some special massage therapies have been

developed in Ayurveda. These special massage therapies cause both oelation and

fomentation of the body. Apart from curing some of the obstinate and otherwise incurable

diseases, these special massage therapies help in rejuvenating the body. If used

periodically, they prevent the ageing process while simultaneously preventing the

manifestation of diseases. Thus these therapies, apart from their utility as preparatory

measures for the Panchakarmas are specialized therapies in their own merit.

Among these modified therapies, Pinda sweda is the most important. In

Shashtikashalipindasweda, a bolus of payasam made up of new coarse rice cooked in

cows milk and bala kwatha is used for fomentation/massage on the body. A successfully

employed Shashtikashalipindasweda is believed to help to a great extent, the patients

suffering from different neuro-muscular disorders and also several systemic diseases.

Vata, the most important among the doshas when excited by its

aggravating factors, produces a variety of diseases. These diseases are collectively termed

as Vatavyadhis. In this group, there are sub-classes according to the nature of

Introduction 3

manifestation and specificity of the affected body part. When the vitiated Vata gets seated

in the ashayas, dhathus, sandhis etc., the conditions are termed as Gatavatas. In this

group, the most important disease condition is Sandhigatavata, which is also the most

common joint disorder in the humans. This disease is characterized by pain in the joints,

joint stiffness, joint swelling, difficulty in joint movements and crepitations.

Sandhigatavata is considered as Osteoarthritis in modern parlance due to the resemblance

in the aetio-pathological factors and clinical features.

Vatavyadhi, in general, and Sandhigatavata in particular is treated with

Snehana and Swedana therapies. The chapter on the treatment of Vatavyadhi, as per

Charaka samhita, emphasizes the adoption of both these therapies in curing these

diseases. Also, Sandhigatavata is characterized by its association with dhatu kshaya as it

commonly occurs in the old age. This is representative of the degenerative state of the

body. Shashtikashalipindasweda is believed to have a note worthy role in the

management of such degenerative conditions by imparting strength to the body

musculature and nervous system. Therefore, this study had been undertaken as an attempt

to help the patients suffering from Sandhigatavata in our society and also to evaluate the

efficacy of this treatment modality over another treatment modality of the same group

(Bashpa sweda) in managing this disease.

Introduction 4

Need for the study : Swedakarma or sudation or fomentation therapy is one among the

Poorvakarmas (Panchakarma sub-procedures). Swedakarma itself is said to be the best

treatment for Vata and Kapha disorders. Sankara sweda is one among the thirteen Sweda

karmas described by Charaka. Shashtikashali can be made use for this purpose, which

relieves the pain and nourishes the body.

Sandhigatavata is the most common joint disorder worldwide. The overall

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

female to male ratio of 1:1. In the contemporary system of medicine, NSAIDs and

surgery are practiced in the management of this disease, but have their own limitations.

This disease restricts the normal movements of the affected joint, thereby rendering the

patient incapable of performing his/her normal activities.

Contemporary medical science is able to pacify the painful condition

through analgesics and surgery mainly. But, this provides only temporary relief, as the

underlying pathology is not managed. So, in search of an effective therapeutic measure to

counter the degenerative process and also provide cure to the disease,

Shashtikashalipindasweda was considered as the therapy in this study. It has been

considered to provide all the benefits of Swedakarma and have a rejuvenating effect over

the patient’s body. This study, along with focusing the efficacy of

Shashtikashalipindasweda in Sandhigatavata, also compared its efficacy with the efficacy

of another Swedana technique (Bashpasweda) in Sandhigatavata.

Objectives 5

It will be relevant to mention some of the research works conducted earlier

on Shashtikashalipindasweda, Bashpasweda and on the management of Sandhigatavata

with Panchakarma therapies.

• Rangachari V G (IPGTRA, Jamnagar) studied on the comparative efficacies of

Navarakkizhi and Pizhichil in 1963.

• Chaturvedi, G N and Singh, R H published their work “Studies on Panchakarma

therapy-III - A clinical study on the treatment of certain neuromuscular and

articular disorders with Pindasweda” in 1964.

• Shinde, S K (IPGTRA, Jamnagar) worked on Bashpaswed ka vaigyanika evam

prayogik adhyayan.

• Reddy, S A (Govt. Ayurveda College, Trivandrum) studied Pindasweda with

special reference to Shashtikashalipindasweda in 1984.

• Sinha, A K (Puri University) studied the clinical effect of

Shashtikashalipindasweda in Sandhigatavata (Osteoarthritis) in 1993.

Shashtikashalipindasweda and Bashpasweda are simple techniques;

ingredients are easily available and economical. Also, these are indicated in the

management of Sandhigatavata and have no proven adverse effects. This study was

intended to assess the efficacy of these Sweda techniques in the management of this

disease and to compare the efficacy of Shashtikashalipindaswedakarma with that of

Bashpaswedakarma. So the present study “Evaluation Of The Efficacy Of

Shashtikashalipindaswedakarma In The Management Of Sandhigatavata

(Osteoarthritis)” was undertaken.

Objectives 6

Objectives Of The Study :

To evaluate the efficacy of Shashtikashalipindaswedakarma in Sandhigatavata

(Osteoarthritis).

To evaluate the efficacy of Bashpaswedakarma in Sandhigatavata

(Osteoarthritis).

To evaluate the comparative efficacy of Shashtikashalipindaswedakarma and

Bashpaswedakarma in Sandhigatavata (Osteoarthritis).

Objectives 7

Historical view

Karma

It is customary, on the part of researchers belonging to various fields of

knowledge, to search the Vedas, as they are the prime sources of ancient wisdom. Such a

search of Vedas for references regarding Panchakarmas, Swedana in particular was not

fruitful.

The works during and after the samhitakala provide ample description on

Panchakarmas and their Poorvakarmas i.e. Snehana and Swedana. Among the

samhitagranthas, Charaka samhita (1000B.C.)1 was the first to describe Swedakarma

under the Shadupakramas. In this text, one can find definition, classification, indications,

contra-indications and benefits of Swedana. Bhela2, considered contemporary to Charaka,

had also described Swedana in detail in the Sweda adhyaya of sutrasthana. Kashyapa

samhita3, written by Vriddha Jeevaka (600B.C.) did mention Swedakarma and

descriptions are found with minor differences from Charaka samhita. The next book that

provides equal details is Sushruta samhita4 written in 2nd century A.D. Ashtanga

samgraha5 and Ashtanga hridaya6 had also allotted separate chapters for Sweda karma.

All these texts have recorded the technique of pindasweda too7a,b,c,d,e,f.

Various literary works belonging to the Classical Age of Indian Literature

(320 AD – 740 AD) 8 had also mentioned the usefulness of Swedakarma. Later textbooks

on Ayurveda such as Sharangadhara samhita9 and Chakradatta10 had described Swedana

karma under a separate chapter, while texts such as Bhavaprakasha11,

Bhaishajyaratnavali12 and Yogaratnakara13 had mentioned the utility of Swedakarma in

various diseases.

Historical Review 8

Even though all major textbooks on Ayurveda had mentioned the

medicinal use of Shashtikashali14a,b,c. and its importance among shalees, nowhere it’s

utility as pindasweda was described. References for Shashtikashali are available in the

works of Krishna atreya, Kharanada and Parashara as quoted by Arunadatta in his

Sarvangasundari commentary on Ashtanga hridaya15. Textbooks on Ayurveda originating

from Kerala such as Chikitsamanjari16, Arogyakalpadruma17, Ayurvedic Treatments of

Kerala18 etc. had described Shashtikashalipindasweda as an effective Swedana technique

in various diseases. Encyclopedia Britannica19 states that the cultivation of rice for food

and medicinal purposes started in India 4000 years ago and gradually spread to other

parts of the world. Buchanan (1807) has recorded that Navara (Malayalam name of

Shashtikashali) was grown in Kerala in the early 19th century20.

Vyadhi

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

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

“Januni and Ashtivantau” were used to denote knee joints21. The disease Sandhigatavata

had not been mentioned as such in Vedic literature. But, Rigveda while describing

various skills of Ashwinikumaras had recorded their skill in treating joint diseases too22.

One of the mantras of Rigveda states that, “I am removing your diseases from each

organ, hair and joint”23. Atharvanaveda had mentioned Parvashoola and Vateekrita24,

two diseases similar to Sandhigatavata. In Atharvanaveda, records about Vatavikaras are

mentioned25. A mantra says, “destroy the balasa seated in the organs and joints which is

responsible for loosing bones and joints”26.

Historical Review 9

Samhitagranthas. and Samgrahagranthas except Sharangadhara samhita

had described the disease Sandhigatavata with lakshana-chikitsa under the

Vatavyadhees27a,-h. Even though the description of Sandhigatavata is unavailable in

Bhela samhita28, it is assumed that the verses are missing, as the description of Gatavatas

such as amashayagatavata, pakwashayagatavata and raktagatavata etc. is available.

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

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

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

amphibians, Osteoarthritis is observed29.

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

individuals (Benard, 1944)30. Heberden (1803) studied this disease in detail and the nodes

on the fingers in OA disease were named after him31. Osteoarthritis was differentiated

from Rheumatoid Arthritis and named as degenerative arthritis by Nichols and

Richardson (1909) on morbid anatomical grounds32. Although the most ancient of the

diseases, OA was first identified as a distinct entity in the 20th century33. Gold th ait in

1904 made a distinction between hypertrophic and atrophic arthritis and A.E Garrod

recognized OA as a clinical entity in 190734.

Historical Review 10

Vyutpatti & Paribhasha

The word Shashtikashalipindaswedakarma is comprised of five words viz.,

shashtika, shali, pinda, sweda and karma.

Shashtika35 : - Shashtika is a word of masculine gender. When ‘Kan’ pratyaya is added

to the word ‘Shashti’, the word shashtika is derived. “Shastikaaha shashtiratrena

pachyante” - Shashtika are those particular types of grains, which get matured in sixty

nights.

Shali36 : - Shali is a word of masculine gender. Shali word is coined by the

combination of ‘Shru’ dhathu and ‘Inj’ pratyaya. “Kantakena vina shuklaaha

haimantaaha shaalayaha smritaaha” - White coloured grains from which chaff has been

separated and are grown in hemanta ritu are called shali.

Pinda37 : - Pinda is a word of masculine gender. When ‘Ach’ pratyaya is added to

‘Pindi’, the word pinda is derived. “Pindi samhatau, bolaha” - Pinda means bolus (a

rounded mass) or lump.

Sweda38 : - Sweda is a word of masculine gender. Sweda word is coined by the

combination of “Swit” dhathu and “Dhanj” pratyaya. Sweda is a shareeramala, which is

associated with body heat mechanism.

Karma39 : - Karma word is derived from the dhathu ‘Kru’. Performance of an act

is called karma. Here, swedakarma means the act of producing sweda and it is one

among the Shadupakramas and poorvakarmas. Thus, collectively, the word

Shashtikashalipindasweda means the act of producing sweat by the application of

shashtikashali boluses.

The word “Sandhigatavata” is comprised of three words, Viz., sandhi, gata

and vata.

Vyutpatti 11

Sandhi40 : - Sandhi is a word of masculine gender. Sandhi is coined from three

parts ‘Sam’, ‘Dha’ and ‘Kihi’. “Sandhaanamiti, asthidvayasamyogasthanam”- The place

of union of something together is called sandhi. Here, it means the union of bones.

Gata41 : - Gata word exists in all the three genders and it is derived from ‘Gama’

dhathu and ‘Ktin’ pratyaya. “Gachati, janaati, yaateeti va” - That which has went or

reached. Hence, gata word may be used to denote an initiation of movement, carrying

something along with, to reach a particular site, through any particular pathway or

leading to occupancy at a particular site. Here, in the context of Sandhigatavata, the

occupancy is at asthi-sandhis in the body.

Vata42 : - Vata is a word of masculine gender. The word is coined from ‘Vaa’

dhathu and ‘Ktin’ pratyaya. It is one among the tridoshas. Thus, collectively, the word

Sandhigatavata means the disease resulting from the settling of vitiated Vata dosha in the

bony joints of the body.

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

‘arthron’ and ‘itis’ respectively means bone, joint and inflammation43. The meaning of

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

disease; hence, the disease is also known as Osteoarthrosis and Degenerative joint

disease.

Vyutpatti 12

Shareera

Focus of this study is on Shashtikashalipindaswedakarma. Therefore, a

discussion on the anatomy and physiology of skin, where the Shashtikashalipinda is

applied, is necessary prior to the discussion on the anatomy and physiology of joints that

are the sites of this disease.

Twak shareera

Ayurveda has recognized twak as an upadhatu of mamsa44. The twak is a

modification of mamsadhatu in its developmental state i.e. during intrauterine life45.

Sushruta described the seven layers of twak and the diseases arising from the twak46. The

following table shows the thickness of the seven layers of twak and the diseases arising

from them.

Table No. 1. Showing the different layers of twak

Sl. Layer of twak Size Diseases arising from each layer

1 Avabhasini 1/18 Vrihi Sidhma, Padma, Kantaka

2 Lohitha 1/16 Vrihi Tilakalaka, Nyaccha, Vyanga

3 Swetha 1/12 Vrihi Charmadala, Ajagalli, Mashaka

4 Tamra 1/8 Vrihi Kilasa, Kushta

5 Vedinee 1/5 Vrihi Kushta, Visarpa

6 Rohinee 1 Vrihi Granthi, Apachi,

Arbuda, Shlipada, Galaganda

7 Mamsadhara 2 Vrihi Bhagandara, Vidradhi, Arshas

According to Sushruta, these seven layers of twak are formed, as the

cream is formed layer after layer in the boiling milk.

Shareera 13

Charaka slightly differs from Sushruta and had described only six layers

of twak without naming them47. Order of these six layers is 1) udakadhara, 2) asrigdhara,

3) sidhma-kilasa sambhavadhishthana, 4) dadrukushta sambhavadhishthana, 5) alaji-

vidradhi sambhavadhishthana and 6) arumshika adhishthana. Among these if, the

innermost layer i.e. arumshika adhishthana is injured the patient goes into shock and

develops a very serious skin disease called arumshika, a type of boils on the phalanges

and elbow joint.

Bhrajakapitta, one among the panchavidha Pittas, is located in the twak. It

is this bhrajakapitta that takes up and metabolizes the drugs applied in the form of

abhyanga, parisheka, avagaha, alepa etc48.

Modern View

Most of the modern scientists recognize the possibilities of considering

skin as a Large, Highly Complex Organ and as a Structuraly Integrated Organ System.

The components of the integumentary system are the cutaneous membrane or skin and

the associated hairs, nails and exocrine glands. The system accounts for about 16% of

ones body weight49.

Cutaneous membrane has two components – the superficial epithelium or

epidermis and the underlying connective tissues of the dermis. The associated or

accessory structures are located in the dermis and protrude through the epidermis to the

skin surface. Function of the skin is supported by an extensive network of blood vessel

branches (through the dermis) and sensory receptors that monitor touch, pressure,

temperature and pain. The loose connective tissue of the subcutaneous layer or superficial

fascia or the hypodermis which lies beneath the dermis separates the integument from the

deep fascia around the other organs such is muscles and bones.

Shareera 14

General functions of the skin: -

Protection of underlying tissues and organs.

Excretion of salts, water and organic wastes.

Maintenance of normal body temperature.

Synthesis of a steroid, vitamin D3 that is subsequently converted to the hormone

calcitriol, important to normal calcium metabolism.

Storage of nutrients.

Detection of touch, pressure, pain and temperature stimuli and the relay of that

information to the nervous system.

HISTOLOGY OF SKIN :

Epidermis

It provides mechanical protection and keeps microorganisms outside the

body; this layer consists of a stratified squamous epithelium. The most abundant

epithelial cells, called kertinocytes, form several different layers. In thick skin, found on

the palms of the hands and soles of the feet, five layers can be distinguished. Only four

layers can be distinguished in the thin skin that covers the rest of the body.

Five layers of epidermis, beginning at the basement membrane and

traveling toward the free surface, are stratum germinativum, stratum spinosum, stratum

granulosum, and stratum lucidum and stratum corneum. The innermost epidermal layer is

the stratum germinativum, which is firmly attached to the basement membrane that

separates the epidermis from the loose connective tissue of the adjacent dermis. Stratum

spinosum which is a spiny layer consists of 8 -10 layers of cells. Stratum granulosum or

Shareera 15

grained layer consists of 3-5 layers of kertinocytes displaced from the stratum spinosum.

In the thick skin of the palms and soles, a glassy stratum lucidum covers the stratum

granulosum. Stratum corneum, which is found at the surface of both thick and thin skin,

consist of 15 – 30 layers of keratinized cells.

Keratinization or cornification occurs on all exposed skin surfaces suspect

the anterior surface of the eyes. The dead cells within each layer of the stratum corneum

remain highly interconnected by desmosomes. Those connections are so secure that

cornified cells are generally shed in large groups or sheets rater than individuals. This

arrangement places the deeper portions of the epithelium and underlying tissues beneath a

protective barrier composed of dead, durable and expendable cells.

Epidermal growth factor (EGF) is one of the peptide growth factors

produced by the salivary glands and glands of the duodenum. This has wide spread

effects on epithelia, especially the epidermis. Its effects include –

Promoting the divisions of germinative cells in the stratum germinativum and

stratum spinosum.

Accelerating the production of keratin in differentiating epidermal cells.

Stimulating epidermal development and epidermal repair after injury.

Stimulating synthetic activity and secretion by epithelial cells.

The colour of the skin is due to an interaction between pigment (carotene

and melanin) composition and concentration and the dermal blood supply.

Dermis

The dermis lying beneath the epidermis has two major components – a

superficial papillary layer and a deeper reticular layer. The papillary layer consists of

Shareera 16

loose connective tissue. This region contains the capillaries and the sensory neurons that

supply the surface of the skin. The reticular layer deep to the papillary layer consists of

an interwoven meshwork of dense irregular connective tissue. Bundles of collagen fibers

leave the reticular layer to blend into those of the papillary layer above. Accessory organs

of epidermal origin, such as hair follicles and sweat glands, extend into the dermis. In

addition, the reticular and papillary layers of the dermis contain networks of blood

vessels, lymph vessels and nerve fibers.

Dermal circulation and innervations

Arteries supplying the skin form a network in the subcutaneous layer

along its border with the reticular layer of the dermis. This network is called the

cutaneous plexus. Tributaries of these arteries supply the adipose tissues of the

subcutaneous layer and the tissues of the integument. As small arteries travel toward the

epidermis, branches supply the hair follicles, sweat glands, and other structures in the

dermis. On reaching the papillary layer, these small arteries form another branching

network, the papillary plexus, which provides arterial blood to capillary loops that follow

the contours of the epidermis-dermis bound artery. These capillaries empty into a

network of small veins connected to larger veins in the subcutaneous layer.

Nerve fibers in the skin control blood flow, adjust gland secretion rates

and monitor sensory receptors in the dermis and the deeper layers of the epidermis. The

epidermis also contains the extensions of sensory neurons that provide sensations of pain

and temperature. The dermis contains similar receptors as well as other more specialized

receptors.

Shareera 17

Hypodermis

The connective tissue fibers of the reticular layer are extensively

interwoven with those of the subcutaneous layer. Although the hypodermis is not a part

of the integument, it is important in stabilizing the position of the skin in relation to

underlying tissues, such as skeletal muscles or other organs, while permitting

independent movement50.

Sweat glands51

Among the associated structures of the skin, only sweat glands are

discussed here due to their contextual relevance. The skin contains two different types of

sweat glands or sudoriferous glands – apocrine glands and merocrine sweat glands.

Apocrine sweat glands communicate with hair follicles in the armpits

(axillae), around the nipples and in the groin. These are coiled tubular glands that produce

a sticky, cloudy and potentially odorous secretion. Apocrine sweat glands begin secreting

at puberty. The sweat produced is a nutrient source for bacteria, which intensity its odour.

Myoepithelial cells contract, squeezing the gland and thereby discharging the

accumulated secretion into the hair follicles. The secretary activities of the glands cells

and the contractions of myoepithelial cells are controlled by the nervous system and by

circulating hormones.

Merocrine sweat glands, also known an eccrine sweat glands, are far more

numerous and widely distributed than apocrine glands. They are smaller than apocrine

sweat glands and they do not extend as far into the dermis. Palms and soles have the

highest numbers. These are coiled, tubular glands that discharge their secretions directly

onto the surface of the skin.

Shareera 18

The sweat produced by merocrine sweat glands is called sensible

perspiration. Sweat is 99 percent water, but it also contains some electrolytes (chiefly

sodium chloride), organic nutrients and waste products. It has a pH of 4-6.8 and the

presence of sodium chloride gives sweat a salty taste. The functions of merocrine sweat

gland include: (1) cooling the surface of the skin to reduce body temperature, (2)

excretion of water and electrolytes and (3) protection from environmental hazards55.

Table No. 02. Showing the composition of sweat52

Sl. Test Normal ranges

1 PH 4-6.8

2 Specific gravity 1.001-1.008

Electrolytes (mEq/l)

3 Potassium 4.3-14.2

4 Sodium 0-104

5 Calcium 0.2-6

6 Magnesium 0.03-4

7 Chloride 34.3

8 Proteins (mg/dl) 7.7

Metabolites (mg/dl)

9 Amino acids 47.6

10 Glucose 3.0

11 Urea 26-122

12 Lipids -

Sweda and Swedavahasrotas

Sweda is produced from medodhathu as a mala during dhathuparinama53.

When the body becomes hot, the udaka that comes out from the romakupas is called

sweda54. Sweda is an apyadravya55. Sweda is brought to the surface of the skin through

Shareera 19

the swedavaha srotases by the action of vyanavata56. The excretion of the sweda bestows

moisture and delicate nature to the skin57. According to Hemadri, the hair on the skin is

supported by the sweda58.

Medas and romakupa are the moolas of swedavaha srotas59. They get

vitiated due to ativyayama, atisantapa, indiscriminate indulgence in cold & heat, krodha,

shoka and bhaya60. Their vitiation produces the following lakshanas- aswedana

(anhydrosis), atiswedana (hyperhydrosis), parushya (roughness of the body),

atislakshnata (excessive smoothness of the body), paridaha (general burning sensation)

and lomaharsha (horripulations)61.

Sandhishareera

The word sandhi indicates ‘sandhana’ i.e. the union of two or more

structures together. Here, it means the union of two or more asthis including taruna asthis

and dantas.

Shleshaka kapha62 :- This division of kapha is situated to all the sandhis and does the

function of sandhisamshleshana.

Vyanavata63 :- Vyanavata is located in hridaya but at the same time functions throughout

the body and giving all the movements of the body such as prasarana, akunchana,

vinamana, unnamana and tiryak gamana. It is responsible for rasa samvahana, sweda and

raktha sraava.

Shleshmadharakala64 :- Located in the sandhi, it is responsible for proper alignment of all

joints. As the lubrication of the aksha (axis) results in proper movements of the wheel,

the shleshmadharakala in the body is responsible for the proper joint movements.

Shareera 20

Functionally, Sushruta had classified sandhis into two varieties65- (1)

chestavanta sandhi (movable) and (2) sthira sandhi (immovable). Cheshtavanta sandhis

are present in sakhas (upper and lower limbs), hanu (temporomandibular joint) and kati

(hip). All the remaining i.e. cranial sutures, intervertebral, costovertebral,

sternoclavicular, sternocostal and dental are sthira sandhis (immovable or slightly

movable joints).

Structurally, joints are of eight types66, viz., kora (resembling a budding

flower), ulookhala (resembling a mortar), saamudga (as if fitted into one another), pratara

(floating, i.e. supported by a cushion like intervertebral discs), tunnasevani (sutural, i.e.

both the articular ends are supported and jammed and one another), vaayasatunda (a

cow’s beak like portion of a bone enters into a similarly shaped hole), mandala (rounded)

and sankhaavarta (looks like the circles of a snail or sankha).

Table No. 03. Showing the sites of different sandhis.

Sl. Name of Sandhis Sites 1 Kora In anguli (interphalangeal joints),

manibandha (wrist), gulpha (ankle), janu (knee) & kurpara (elbow)

2 Ulookhala Kaksha (shoulder), vankshana (hip),& danta (alveolar sockets & teeth)

3 Saamudga Amsapeetha (sternoclavicular), guda (sacrococcygeal), bhaga (symphysis pubis), & nitamba (lumbosacral)

4 Pratara Greevaprishta (intervertebral) 5 Tunnasevani Shira, kati & kapala (sutural joints) 6 Vaayasatunda Hanusandhi (temporomandibular) 7 Mandala Kantha (tracheal rings) 8 Sankhaavarta Shrothra (cochlea)

In total, there are 210 sandhis in the body according to Ayurveda67.

Shareera 21

Modern View

The human skeleton is designed with a number of individual bones that

are articulated at joints to allow the movements in different directions, angles and

positions68. In this particular study, only cases with Osteoarthritis of knee and lumbar

spine have been considered. So, the descriptions of these are being dealt with in detail

here.

Knee Joint69

The knee is structurally complex and subjected to severe stresses in the

course of normal activities. Although the knee functions as a hinge joint, the articulation

is far more complex than that of the elbow or even the ankle. The rounded femoral

condyles roll across the top of the tibia, so the points of contact are constantly changing.

The joint permits flexion and extension and very limited rotation. There is no single,

unified capsule at the knee joint, nor is there a common synovial cavity. A pair of fibro

cartilage pads, the medial and lateral menisci, lies between the femoral and tibial

surfaces. The menisci – (1) act as cushions, (2) conform to the shape of the articulating

surface as the femur changes position and (3) provide lateral stability to the joint.

Prominent fat pads cushions the margin of the joint and assist the many bursae in

reducing the friction between the patella and other tissues.

Ligaments

Seven major ligaments stabilize the knee joint. They are the patellar

ligament, two popliteal ligaments, the anterior cruciate and posterior cruciate ligaments,

the tibial collateral ligament and the fibular collateral ligament.

Shareera 22

Muscles associated

Flexors of the knee - biceps femoris, semimembranosus, semitendinosus

and the sartorius.

The flexion of knee and rotation (lateral) of the thigh is done by sartorius

muscle. The first three flexors are collectively known as hamstring muscles. Collectively,

the knee extensors are known as the quadriceps femoris (Vastus muscles).

Blood supply

The external iliac artery crosses the surface of the iliopsoas muscle and

penetrates the abdominal wall to emerge on the anteromedial surface of the thigh as

femoral artery. The deep femoral artery, which gives rise to the medial and lateral

circumflex arteries, supplies blood to the ventral and lateral regions of the skin and deep

muscles of the thigh. The femoral artery at the popliteal fossa becomes the popliteal

artery. This artery crosses the popliteal fossa and branches to form the posterior and

anterior tibial arteries. The venous drainage of the knee and associated structures is

through the great saphenous and small saphenous veins which inturn drains to femoral

vein.

Innervations

1. Femoral nerve, through its branches to the vasti, especially the vastus medialis.

2. Sciatic nerve, through the genicular branches of the tibial and common peroneal

nerves.

3. Obturator nerve, through its posterior division.

Shareera 23

Lumbar spine70

The five lumbar vertebrae are the largest of the vertebrae. The body of a

typical lumbar vertebra is thicker than that of a thoracic vertebra and the superior and

inferior surfaces are oval rather than heart-shaped. Other noteworthy features include the

following :

(1) Lumbar vertebrae neither have whole facets nor demifacets on their body,

(2) The slender transverse processes, which lack costal facets, projects dorsolaterally,

(3) The vertebral foramen is triangular,

(4) The stumpy spinous processes projects dorsally,

(5) The superior articular process face medially and

(6) The inferior articular process face laterally.

The lumbar vertebrae bear the most weight. Their massive spinous

processes provide surface area for the attachment of lower back muscle that reinforce or

adjust the lumbar curvature.

Muscles associated

Spinal extensors or erector spinae (spinalis, longissimus and iliocostalis),

sacrospinal muscles, semispinalis, multifudus, interspinalis, intertransversarii and

rotators, quadratus lumborum.

Blood supply

Lumbar arteries and lumbar veins [connected to the azygos vein (right

side) and hemizygos vein (left side)].

Innervations

Lumbar plexus and its branches.

Shareera 24

Snayus71 :- Totally there are 900 snayus in the body; among them 600 are in the

extremities, 10 in the janu, 60 in the kati and 80 in the prishta. The pratanavati type of

snayus is located in the sandhis of the body. All the joints are attached with snayus that

are responsible for their compactness.

Peshishareera72 :- There are 500 peshis in body; among them, 400 are in the extremities

(upper and lower), 5 in the janu and 10 in the prishta. All the siras, snayus, asthis, parvas

and sandhis are covered by peshis that protects them.

Marmas73 :- Marmas are the vital anatomical points in the human body. The janu marma

is located between jangha and urvi and if injured causes khanjata. It is a sandhi marma of

3 angula measurement and is a vaikalyakaramarma. In the prishta, there are 4 pairs of

important marmas. They are (1) kateekataruna - 2 in number, asthi marmas of ½ angula

and are a kalantarapranahara marmas, (2) kukundara – 2 in number, sandhi marmas of ½

angula and are vaikalyakara marmas, (3) nitamba – 2 in number, asthi marma of ½ angula

and are kalantarapranahara marmas and (4) parshwasandhi – 2 in number, siramarmas of

½ angula and are kalanatarapranahara marmas.

Synovial fluid

Synovial membrane secretes a liquid, the synovial fluid. It has many

functions - serves as a lubricant, a shock absorber and a nutrient carrier. This belongs to a

rather unusual group of liquids known as dilatent liquids. These liquids are characterized

by the rare quality of becoming thicker when shear is applied to them. Thus, the synovial

fluid in our knees and hips assume a very viscous nature at the moment of shear in order

to protect the joints, and then it thins out again to its normal viscosity instantaneously to

resume its lubricating function between shocks. Synovial fluid is the liquid that must

carry the raw materials from the blood to the cartilage.

Shareera 25

Sweda karma

The process which relieves stambha (stiffness), gourava (heaviness),

sheeta (coldness) and which induce sweda (sweating) is known as Sweda karma74. In

general, Sweda karma represents the therapy by which a person is made to sweat.

Swedana will cure Vata, Kapha and Vatakaphaja disorders75. But, it is not recommended

in disorders due to excitement of Pitta.

Even though, swedana is poorva karma, it has its own entity as pradhana

karma in some diseases. Charaka included Sweda karma in Shadupakramas and he has

treated it as main therapy76. For samshodhana purpose, it is considered as poorva karma.

In sweda sadhya diseases it acts as main therapy.

Properties of Swedana drugs77

Generally guru, teekshna and ushna dravyas induce sweating. Drugs with

the sara, snigdha, rooksha, sukshma, drava and sthira gunas are also utilized in Sweda

karma.

Table No. 04. Showing the properties, action and predominance of mahabhootas of

swedana dravyas:

Sl. Properties Main actions Mahabhuta

1 Ushna Anutsaha, moorchakrit, swedakrit and dahakrit Agni

2 Teekshna Daha-pakakara, shodhananga, sraavana Agni

3 Snigdha Snehakrit, mardavakrit, bala-varnakrit Apa and Prithwi

4 Rooksha Opposite to snigdha and stambhakara, khara Vayu and Agni

5 Sara Anulomana, prerakata and pravrittisheela Vayu and Agni

6 Sthira Chirakaritha, sthairyakara and stambhakara Prithwi

7 Sookshma Sookshmachidrapraveshayogyata, vivarana sheelata

Akasha, Vayu and Agni

8 Guru Sada, upalepa, tarpanakrit and brimhanakrit Prithwi and Jala

9 Drava Kledana, alodana, syandanakaraka Jala

Sweda karma 26

Swedayogyas (Swedarhas) 78,79,80

Table No. 05. Showing the persons and diseases that are fit for swedana.

Sl. Vyadhi C.S. S.S. A.H. Sl. Vyadhi C.S. S.S. A.H.1 Pratishyaya + - + 30 Uru ruk / graha + - + 2 Kasa + - + 31 Jangha ruk / graha + - + 3 Hikka + - + 32 Kshavathu + - - 4 Swasa + - + 33 Khalli + - + 5 Alaghava + - - 34 Ayama + - + 6 Karna shoola + - - 35 Sheeta + - - 7 Manya shoola + - - 36 Vepathu + - + 8 Shira shoola + - - 37 Vatakantaka + - + 9 Swara bheda + - + 38 Sankocha + - + 10 Gala graha + - - 39 Ayamashoola + - + 11 Ardita + - + 40 Stambha + - + 12 Ekanga roga + - + 41 Gourava + - + 13 Pakshaghata + - + 42 Supti + - + 14 Ardita + - + 43 Nasyarha + + + 15 Vinamaka + - + 44 Bastyarha + + + 16 Koshtanaha + - + 45 Shodhaneeya + + + 17 Vibandha + - + 46 Aahritashalya - + - 18 Mutraghata + - - 47 Anupadrava

moodhagarbha - + -

19 Vijrimbhaka + - + 48 Samyak prajata - + - 20 Parshwagraha + - + 49 Bhagandara - + - 21 Prishtagraha + - + 50 Arsha - + - 22 Kateegraha + - + 51 Ashmari - + - 23 Kukshigraha + - + 52 Shleshma roga - - + 24 Gridhrasi + - + 53 Amaroga - - + 25 Mutrakrichra + - + 54 Hanugraha - - + 26 Vriddhi + - + 55 Arbuda - - + 27. Angamarda + - + 56 Granthi - - + 28 Pada ruk / graha + - + 57 Shukraghata - - + 29 Janu ruk / graha + - + 58 Adhyamaruta

(Urustambha) - - +

Sushrutha had specified that those who are fit for Nasya, Basthi and

Shodhana are Poorvam Swedyas ; Ahritashalya, Moodhagarbha and Samyak prajata are

Paschat Swedyas ; and Bhangandara & Arsha are Poorvam Cha Paschat cha Swedyas81.

Sweda karma 27

We can conclude that, in general, there are three categories of diseases

wherein swedana is indicated – a) Vatapradhana rogas, b) Kaphapradhana rogas and c)

Shodhaneeya & Shadyakarmayogyas.

Sweda ayogyas (Sweda anarhas) 82,83,84

Table No. 06. Showing the persons and diseases those are unfit for Swedakarma.

Sl. Vyadhi C.S. S.S. A.H. Sl. Vyadhi C.S. S.S. A.H.1 Kashayanitya + - - 24 Adhyaroga

(Vataraktha) + - +

2 Madyanitya + + - 25 Durbala + + + 3 Garbhini + + + 26 Ativisushka + - - 4 Rakthapitha + + - 27 Ksheenaoja + - - 5 Pithakopa + - + 28 Timira + - + 6 Atisara + + - 29 Pandu - + + 7 Rooksha + - - 30 Kshaya - + + 8 Madhumeha + + + 31 Kshama - + + 9 Vidagdhabradhna + - + 32 Ajeerna - + - 10 Bhrashtabhradna + - + 33 Chardi - + - 11 Visha + + - 34 Moorcha - - + 12 Madyavikara + - + 35 Stambhaneeya - - + 13 Shrantha + - - 36 Visarpa - - + 14 Nashtasamjna + - - 37 Kushta - - + 15 Sthoola + - + 38 Peeta dugdha - - + 16 Pithameha + - - 39 Peeta sneha - - + 17 Trishna + + + 40 Peeta dadhi - - + 18 Kshut + - + 41 Peeta madhu - - + 19 Krodha + - + 42 Krita virechana - - + 20 Shoka + - + 43 Glani - - + 21 Kamala + - + 44 Bhaya - - + 22 Udara + + + 45 Pushpitha - - + 23 Kshatha + - + 46 Sootha - - +

Reasons for the exemption of these diseases from swedana have been

explained by various acharyas. Sushrutha stated that in these conditions, which are

contra-indicated for swedana, if swedana is performed either the body gets destroyed, or

the diseases progress to incurable stage. He also permits the performance of swedana in

Sweda karma 28

durbala and ajeernabhaktha, if their vikaras are curable only by swedana85. Chakrapani,

commenting on the verses of Charaka, says that kashayanityas become rookshas and

atistabdha gatras; hence, the swedana if performed causes parvabheda. Also persons

suffering from rakthapitha, pithameha, kamala etc. and pittaprakriti persons are

exempted from swedana even prior to shodhana as it may cause further pittakopa.

Madhumeha persons develop shareera shaithilya and in such a condition, swedana is

contra indicated. He also adds that if the condition of the patient is Sweda eka sadhya,

then the sweda be permitted. 86

Arunadatha, commenting on the verses in Ashtangahridaya, states that

swedana if done to an atisthoola person causes medovilayana resulting in shareera

kshobha. For rooksha, durbala, kshataksheena, kshama etc. The swedana may cause

extreme emaciation. A person having good appetite if undergoes swedana suffers from

dehaglani. In kamala and pandu rogas, the Swedakarma causes pitta vidradhi resulting in

roga vridhi. In garbhini, the swedana induces gabrha vyapat. For pushpitha ladies, it

causes excessive bleeding. For sootha, it causes emaciation. 87

As Vagbhata88 had stated if these conditions are atyayika, then mridu

sweda can be stated, Arunadatha89 too supports this view. Hemadri90 further states that

even if a condition/disease is aswedya, the stage being atyayika (due to the inevitability

of swedana) mridu sweda can be performed.

In general, we can conclude that Swedakarma is contra-indicated in four

conditions: – (1) pitta, (2) raktha, (3) durbala avastha and (4) sweda asaha. Also it is to

be noted that swedana can be performed in mridu mode if these conditions are sweda eka

sadhya.

Sweda karma 29

Samyak swinnalakshanas91

Table No. 07. Showing the lakshanas to be observed on the patient.

Sl. Lakshana C.S. S.S. A.H. 1 Seetha vyuparama + - + 2 Shoola vyuparama + - + 3 Sthambhanigraha + - - 4 Gouravanigraha + - - 5 Sanjathamardava + + + 6 Swedasrava - + - 7 Vyadhihani - + - 8 Laghutva - + - 9 Seetharthiva - + -

Among these shoola vyuparama, sthambhanigraha, gourvanigraha,

laghutva, mardava and vyadhihani are not evident immediately after swedakarma every

day, but manifest after the total course of proper swedana. Sheeta vyuparama, swedasrava

and seetharthitva are to be observed daily at the end of swedakarma daily.

Aswinnalakshanas

If the swedana performed is not sufficient or proper, then the lakshanas

opposite to the samyak swinnalakshanas occur. Dalhana adds that heaviness of the body,

ushnabhilasha and hardness of the body also occur. He has stated that mithya swinna

means both alpa swinna and mithya swinna (improper sudation) and that vyadhi vridhi

also occurs. 92

Atiswinnalakshanas 93,94,95

If the swedana performed is in excess, it leads to many complications.

Sweda karma 30

Table No. 08. Showing the Atiswinna lakshanas on the patient.

Sl. Lakshana C.S S.S. A.H.1 Pitta prakopa + + + 2 Murcha + + + 3 Shareerasadana + - - 4 Trishna + + + 5 Daha + + - 6 Swaradourbalya + - + 7 Angadourbalya + - + 8 Sandhipeeda - + + 9 Sphototpathi - + - 10 Rakthaprakopa - + - 11 Bhranthi - + - 12 Vidaha - + - 13 Klama - + - 14 Bhrama - - + 15 Jwara - - + 16 Syava-raktha mandaladarshana - - + 17 Chardi - - +

Management of Atiswinna: -

Charaka96 advises the adoption of greeshma ritu charya along with

consumption of madhura-snigdha-seetha aharas and to follow snigdha-seetha upacharas.

This includes consumption of sasharkara mantha, jangala mriga-pakshimamsa, ghee, milk

and shashtikashali. Madya should be avoided. Ahara dravyas with lavana, amla, katu and

ushna properties and viharas such as vyayama should be avoided. Patient should live in

seethagriha during the day and in the room cooled by moon rays in the night.

Seethadravyas like chandana can be applied over the body. Mukthamani dharana also

can be done. Patient can also be taken to cool forests and ponds. He/She should not

indulge in intercourse. 97 Sushruta says that all kinds of seetha upachara should be

performed immediately98.

Sweda karma 31

Vagbhata had advised the adoption of stambhana chikitsa in case of

atiswinna. 99 Drugs, which are having the properties of laghu, manda, seetha, slakshna,

rooksha, sookshma, sura & drava and having tiktha-kashaya-madhura rasas, are

stambhana oushadhas. These are to be administered internally and externally to prevent

further complications of the patients.

Classification of Sweda

Several types of classification of Sweda are made with different points of

view.

A. According to agni bheda. 100

1. Sagni (Thermal) & 2. Niragni (Non-thermal).

B. According to guna bheda. 101

1. Rooksha (Dry) & 2. Snigdha (Unctuous).

C. According to sthana bheda. 102

1. Ekanga (Local) & 2. Sarvanga (Total).

D. According to rogi bala and roga bala. 103 Mrudu (Gentle), Madhyama (Medium) &

Mahan (Maximum).

E. According to the source of heat. 104,105 Tapa (Direct heat), Ushma (Steam),

Upanaha (Poultice) & Drava (Warm liquid).

F. According to the method of sudation. 1061. Sankara (Mixed), 2. Prastara (hot bed),

3.Nadi (Steam kettle), 4. Parisheka (Affusion), 5. Avagaha (Bath), 6. Jentaka

(Sudatorium), 7. Asmaghna (Stone bed), 8. Karshu (Trench), 9. Kuti (Cabin), 10.

Bhu (Ground bed), 11. Kumbhi (Pitcher bed), 12. Kupa (Pit sudation) and 13.

Holaka (Under bed).

G. According to the usefulness in the Chikitsa, Samshamaneeya &

Samshodhanangabhoota. 107

Sweda karma 32

H. According to the route of application. Bahya & Abhyantara108.

I. On the basis of applicability in children. Hasta, Pradeha, Nadi, Prastara, Sankara,

Upanaha, Avagaha and Parisheka. 109

Niragni Sweda is further classified into ten types, viz., vyayama

(exercise), ushna sadana (warm rooms), guru pravarana (heavy blankets), kshudha

(hunger), bahupana (excessive drinking), bhaya (fear), krodha (anger), upanaha (plasters),

ahava (war) and atapa (sun bath). 110

Dalhana had said that jentaka, karshu, kuti, kupa and holaka are tapa

swedas ; sankara, prastara, ashmaghna, nadi, kumbhi and bhu are ushma swedas. 111

Bashpasweda and Shahtikashalipindasweda belong to the Ushma type of

Swedana. Dalhana has defined Ushma sweda as “Ushma bashpaha”. He has opined that

all the techniques of ushma sweda can be collectively called as bashpa sweda. 112

Nadi sweda

This is done with the steam coming from the vessel full of boiled

mamsarasa, milk, curd, dhanyamla or vataharapatrabhanga kwatha. The top of the vessel

is to be covered with kambala etc. for the prevention of excessive heat affecting the

patient. 113 Otherwise, the mouth of another vessel, which has a hole in its side, should

cover the top of this vessel. Sandhibandhana is done on the mukhas of the vessels. To the

hole of the upper vessel, a nadi (tube) resembling hastishunda (trunk of an elephant) of

one or ½ vyama (hand) length, having three folds and made of trina, kasha etc. is

connected. Before performing nadi sweda, the patient should be done abhyanga and

covered with a thick blanket. This is a very good method of swedana where all the angas

are done proper sudation without any difficulty. 114 The Bashpasweda used in this study is

a modification of this classical technique.

Sweda karma 33

Sankara sweda115

The process of thermal sudation by means of a bolus containing tila,

masha etc. with or without wrapping cloth is known as sankara sweda or pinda sweda. It

is of two types viz., Snigdha &Ruksha.

Sudation is done with the boluses of the seeds of tila, masha, kulatha

mixed with amla dravya, ghee, taila, mamsa, odana, payasa and krishara is called as

Snigdha pinda sweda. It is specially indicated in Vata rogas.

Sudation with the excreta of various animals like cow, ass, camel, pig etc.

and other substances such as satushayava, sand, powder, stones, dry cow dung cake, iron

powder etc. is called as ruksha pinda sweda, which is indicated in Kapha rogas.

According to Sushruta and Vagbhata, Upanaha type of sweda is

considered as one among saagni swedas. At the same time, Charaka and Vagbhata have

considered this as a niragni sweda also. Chakrapani, commenting on Charaka samhita,

stated that upanaha is of two types – Sagni & Niragni. 116 The sagni upanaha is nothing

but sankara sweda itself. An example for it is the Kolakulathadi yoga explained in

Charaka samhita Suthrasthana- 3/18.

All the Pindaswedas are based on the principle of Sankarasweda. 117

Pinda swedas

As this study is on a major technique of pinda sweda, it will be relevant to

describe in brief other techniques of pinda sweda too.

Sweda karma 34

Pinda sweda is a process by which the whole body or a specific part of the

body is made to perspire by the application of certain heated medicinal puddings applied

externally in the form of pinda or boluses tied up in square pieces of cloths. The

technique is a combination of snehana (oelation), mardana (massage) and swedana

(fomentation). Pinda Sweda will come under sankara sweda of Charaka and Kashyapa

and ushma sweda of Sushruta and Vagbhata.

The following pinda swedas are being practiced commonly.

1. Shashtikashalipindasweda

2. Patrapotalipindasweda

3. Choornapindasweda

4. Valukasweda

5. Tushapindasweda

6. Jambeerapindasweda

7. Mamsapindasweda

8. Kukkutandapindasweda

9. Mashapindasweda

10. Godhumapindasweda

11. Dhanyapindasweda

12. Haridradi pindasweda

1. Shashtikashalipindasweda 118

Details of this process will be discussed in the methodology chapter as this

study deals specially about Shashtikashalipindasweda.

Sweda karma 35

Effects Of Shashtikashalipindasweda - The effects of this treatment, if

properly done, are many. It cures powerful Vatarogas affecting all parts of the body;

diseases due to Rakthaprakopa; diseases which are very difficult to treat and diseases

which are affecting the strength (or immunity) of the body. In addition to these,

Shashtikashalipindasweda cures all types of diseases of the nervous system, chronic

rheumatism, pain in the joints, emaciation of the limbs and diseases born of vitiated

blood. This karma makes the body strong and sturdy with well-developed musculature. It

maintains the metabolism in a healthy condition from every point of view. This treatment

is found to be efficacious in subjects suffering from blood pressure and in certain kinds of

skin diseases resulting from impurity of the blood. This may also be resorted to once a

year, by healthy persons to keep up perfect health during old age and to prevent

premature aging.

2. Patrapotalipindasweda 119

Also known as “Ila kizhi” or “Pachakkizhi” (common names), this type of

pinda sweda uses cut Vataharapatras in the form of pottali. Patras of arka, eranda, shigru,

nirgundi, karanja, chincha etc. are taken in equal quantity and cut into small pieces.

Coconut scrapings and citrus fruit can also be mixed together with the patras. This

mixture should be roasted in suitable taila (e.g. Bala taila, Masha taila, Nimba taila etc.)

fit for disease. After proper frying, the mixture should be tied as two boluses in clean,

square clothes.

Sweda karma 36

These pindas are again heated in suitable taila and applied to the body in

comfortable heat. Out of the two pindas, one pinda should be in the vessel over gentle fire

while the other pinda is used for massage. Bolus should be taken by the right hand and

the intensity of heat is tested by the outer surface of the left hand before starting the

procedure. The patient should be well massaged with vatahara taila or taila suitable to

disease in prior. As soon as the bolus, which is in use losses the heat, it should be

replaced by the bolus, which is kept over the fire. Left hand of the attender should do the

light massage in the direction of the bolus.

The process has to be done without any interruption for a minimum time

of 30 minutes on the first day. Application should be done by asking the patient to

position in all the seven postures. If the physician decides to perform the therapy for 7

days, the duration should be increased by five minutes each day, thus reaching 45

minutes on the fourth day. From there it is reduced by five minutes per day to reach the

original duration (30 minutes) on the seventh day. If the therapy is for 14 days, the

increase in the duration is the same reaching the maximum of one hour on the seventh

day. Sometimes is the duration on eighth day also and from there, the duration is reduced.

These are subject to the individual rationality of the physician.

After the prescribed duration, the oil is wiped off the body with a dry

towel. Patient should be protected from immediate exposure to cold, sun, wind etc. and

allows to take rest for a few minutes. Then he is advised to take bath in water boiled with

vataharapatras.

Sweda karma 37

The drava in which the bolus is heated may be dhanyamla, gomutra,

vataharakashaya etc. The bolus of the contents should be changed daily or at least once in

three days. Two attendants are needed for the karma – one to perform the pinda sweda

and other to heat the bolus. Indications are prasupthi, kampa, angamarda, pakshaghata,

askhepaka, gridhrasi, sandhigatavata, kateeshoola etc.

3. Choornapindasweda120

This is performed with boluses of medicinal powders and is also known as

‘Podikkizhi’ (common name). Powders of rasa, ashwagandha, sarala, shunti, vacha,

shigru, devadaru, sarshapa, kola, kulatha, masha, godhuma, mudga, tila etc has to be

taken and added saindhava lavana. Each has to be taken 10 gms and 30 gms of coconut

scrapings and 2 or 3 pieces of citrus fruits can also be added. These powders and other

items well mixed are to be fried in suitable oils and made into two boluses.

The procedure and duration are same as the patrapottali sweda. This

procedure is the snigdha variety of choorna pinda sweda. The rooksha variety of choorna

pinda sweda is also common. Powders of kulatha, tusha etc are fried in iron pan along

with saindhava lavana without oil and then made into bolus.

Snigdha choornapindasweda is indicated in Vatarogas like apabahuka,

gridhrasi etc. and rooksha choornapindasweda is indicated in saama-kaphanubandha

Vatarogas like amavata.

4.Valuka sweda121

In this the bolus is prepared of sand. This is a typical rooksha sweda

indicated in amavata, vatarakta, urustambha etc. Here, the sand can be fried in dhanyamla

along with saindhava lavana. Much care should be taken in testing the heat of the bolus

and only moderate heat should be applied.

Sweda karma 38

5.Tushapindasweda 122

It is a process by which the bolus is prepared by the husk of the paddy.

Husk of the wheat also can be used. It is a household practice in our country in swasa and

kasa.

6.Jambeerapindasweda 124

Drugs used in this are jambeeraphala, saindhava lavana, and fried powders

of methika, kulatha, haridra and shatapushpi. 10 citrus fruits of big size should be cut into

the small pieces and 30 gms of haridra choorna and 5 gms of saindhava is added and fried

in suitable oil and made into bolus. It is beneficial in pakshaghata, apabahuka, sandhi

gatavata, bhagna etc.

7. Mamsapindasweda 125

It is similar to Shashtikashalipindasweda. If mamsa is alone made into

bolus, the drava dravya for cooking and heating is mamsa rasa. If mamsa is used along

with shashtikashali, balamoola kwatha along with ksheera are the drava dravyas for

cooking the mamsa and shali and also for heating the bolus. Meat of goats, hen, pig,

peacock etc. are generally used.

It is mainly indicated in emaciation (Shosha) prominent conditions such as

atrophy, dystrophy, myopathy, pakshaghata, balavata etc. It arrest the premature aging,

promotes the growth, tonicity and strength of muscles.

Sweda karma 39

8. Kukkutandapindasweda 126

Egg yolk of hen is used for this technique. Two lemon fruits are taken and

cut into pieces. It is mixed with three boiled egg yolks and fried in suitable oils and made

into bolus. It is beneficial in ardita, greevagraha, hanugraha, apabahuka etc.

9. Mashapindasweda 127

Here, instead of Shashtikashali, masha (Phaseolus radiatus) is used and the

procedure, duration and indications are similar to Shashtikashalipindaswedakarma.

10. Godhumapindasweda

Here, instead of Shashtikashali, godhuma (wheat) is used and the

procedure, duration and indications are similar to Shashtikashalipindasweda.

11. Haridradi pindasweda 128

This is specially indicated in Kshata (Trauma). Here, haridra choorna and

laja choorna are taken in more quantity and sarja choorna, jeeraka choorna and manjishta

choorna in less quantity. The white part of two boiled eggs is mixed thoroughly with

these powders and the end product is used as a bolus.

12. Dhanyapindasweda 129

Fried powders of masha, mudga, tila, sarshapa, shashtikashali, kulatha,

methika, shatapushpa and eranda beeja are made into bolus. Also, these can be cooked in

milk squeezed from coconut scrapings and made into bolus and used instead of

shashtikashalipinda.

Sweda karma 40

Swedakarmas & Karmukata

Swedakarma has four major actions over the body - (1) stambhaghnata, (2)

gouravaghnata, (3) seethaghnata and (4) swedakarakata.

1. Stambhaghnata

Stambha means stiffness. This attribute is a resultant of excess seetha guna

and also influence of factors such as samanavata, sleshakakapha, ama, mamsa, vasa &

medas is contributory to the production of stambha. Samanavata is rooksha gunapradhana

and hence if vitiated does excessive shoshana of shareera there by producing contractures

and stiffness. Sleshakakapha is snigdha and pichila and hence if decreased (kshaya)

results in less lubrication of joints causing stiffness.

Swedakarma being snigdha and ushna corrects both these deranged dosha

ghatakas and relieves stiffness. Chakrapani had stated that stambha also means

obstruction or block. Therefore, swedana not only relieves stiffness, but also clears

blocking of passages (srotorodha). Srotas as a structural entity is Kaphapradhana. Ayana

or transport is the most important function of srotas. This is under the control of Vata.

There by it is evident that there is a predominant influence of Vata and Kapha over the

srotas. Vitiation of these two hampers the structural and functional aspects of the srotas.

We know that swedana has the opposite qualities to that of Vata & Kapha, thereby

producing a palliative effect on them and the srotas is becoming normal. It is well known

that unless there is a srotodushti there is no disease. Thus, it is evident that swedana

clears the srotodushti or sanga.

In other words, by contact of bearable warmth, the area in contact gets

more circulation. The lumina of the contracted body architecture get smoother and

wider. This rendering a stiff entity smooth relieves variety of obstructions. Widening of

Sweda karma 41

the core and simultaneous liquefaction of the solid or semi-solid material makes the flow

easier. Widening of the tract and fluid character of the material inside makes the

obstructions released slowly.

2. Gouravaghnata

Heaviness of the body is being relieved by Swedana. By means of

swedana, the fluids in the body are being excreted through the sweda (sweat) and hence

the feeling of lightness in the body. Swedana stimulates the nerve endings and promotes

muscle strength.

3. Seethaghnatha

Seethaghnatha has to be understood as the patient is relieved of the

coldness existing prior (the ushna guna pradhana sweda karma is performed). In fact, by

the excretion of sweat, the heat in the body is being transferred out.

4. Swedakarakata

Swedana produces perspiration. This is a mala (excretory product). In

this, the wastes of all the layers of skin, muscles, nerves, rasa, raktha, meda etc. are

mixed. Therefore, it is a mechanism of excreting the metabolic wastes in the body

tissues.

Apart from these major actions, Swedana also produces the following

effects.

Sweda karma 42

1. Doshadraveekarana

Snehana performed prior to swedana makes the doshas mridu and

eradicates the mala sanga. The swedana penetrates to each and every channel in the body

and liquefies the doshas. These liquefied doshas has to be eliminated from the body

means of shodhana karma.

2. Vata shamana

Snehapoorvayukthasweda pacifies the Vata dosha, thereby curing the

pureesha-mutra-shukra sanga. By its properties opposite to that of Vata, it pacifies the

Vata. Sweda is also one of the upakramas of Vata.

3. Gatra vinamana

Charaka says that by application of oil and heat, even dry wood can be

bent then what is the wonder about shareera. It cures harsha, ruk, ayama, shopha,

stambha and graha and produces mardava, thereby permitting normal flexible body

movements.

4. Agnideepana

As swedana is ushna guna pradhana, it does the ama pachana there by

promoting the agni in the body.

5. Twak mardava & Prasadana

Perspiration is dependent on skin, where in the hair follicles which are the

moolas of swedavaha srotas are situated. Due to sweating and excretion of wastes, the

skin becomes soft and pleasant.

Sweda karma 43

6. Bhakthasradha

As the swedana promotes agni, more interest on food consumption is

resulting.

7. Srotosuddhi

The mechanism of making srotosuddhi has been explained under the

action stambhaghnata.

8. Nidra-Tandra nasha

Swedana pacifies Vata. Vata is responsible for the functions of indriyas

wherein nidra and tandra are affecting. Sweda also pacifies Kapha thereby making the

body light, and providing relaxation. Thus it prevents excessive sleep & drowsiness.

9. Sandhicheshtakara

Swedana relieves stambha and graha thereby promoting the sandhicheshta.

10. Dosha shodhana

The doshas situated in the dhathus, koshta and sakha-asthi and those leena

in the srotas gets kledana by snehana and gets liquefied by the swedana and comes to the

koshta and get ready for elimination by means of shodhanakarma.

Sweda karma 44

Modern View On Mechanism Of Action

Rapid diffusion of lipid soluble substances through cell membranes and

the dependency of the rate of diffusion on solubility in lipids have been proved.

Application of heat on an unctuous area causes the generation of a temperature gradient

across the cell membrane. Besides facilitating the diffusion of liquid substances through

the cell membrane, this plays key role in the formation of lipoid vesicles from the

dropouts in the membrane in areas of flow temperature. This causes an expansion in the

cell volume as well as surface area. But it cannot expand freely especially in the

peripheral direction as it is bound by other cells around. This makes the blebbing of cell

membrane inside.

The temperature gradient and pressure gradient caused by the heat further

helps in blebbing in this particular direction. These lipoid vesicles or blebs detached

from the cell organelle or other side of membrane and remain there till a critical surface is

reached. This membrane then blebs out and spread further. The whole phenomenon of

dropping of cell membrane vesicles and their incorporation into other membranous

structure was described as “Membrane flow hypothesis” by Palade in 1959.

Sweda karma 45

TYPES OF SWEDA

01. Snigdha 02. Rooksha

01. Ekanga 02.Sarvanga

01. Samshamaneeya 02. Samshodhaneeya

01. Mridu 02. Madhyama 03. Mahan

01. Sagni 02. Niragni

Tapa Upanaha Ushma Drava

Pani Pradeha Pinda Parisheka

Kamsya Bandhana Samstara Avagaha

Phala Sankara Nadi

Valuka Ghanashma

Vastra Kumbhi

Ghatika Kupa

Kuti

Jentaka

01. Vyayama 02.Ushnasadana 03. Gurupravarana 04. Kshudha

05. Bahupana 06. Krodha 07. Bhaya 08. Upanaha

09. Aahava 10. Aatapa

Sandhigatavata

Sandhigatavata is a disorder caused by the localization of vitiated doshas

in the asthi sandhis of the body. It is one among the many Vatavyadhees described by all

acharyas.130 It comes under the various Gatavatas explained in Vatavyadhiprakarana. 131

Terminology of Osteoarthritis132 :-

Four names, none of which are adequate are used interchangeably to

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

and Hypertrophic arthritis. Osteoarthritis is less than ideal since the primary event is not

inflammatory, although secondary synovitis is usually present. Osteoarthrosis is perhaps

the best because the inflammation is secondary and the suffix denotes an increase and an

invasion, physiologic or pathologic, or a general over production. This early on, is a

relatively clear description of what the disorder is. Degenerative joint disease is

unsuitable, since degenerative implies aging, a running down, a deterioration, a catabolic

process; in fact for long periods, often years, the disease may not be clinically

progressive. Hypertrophic arthritis now completely out of style, describes one phase the

osteophytosis or overgrowth of bone.

Nidana

Specific nidana for Sandhigatavata is not mentioned in any Ayurvedic

texts. The nidanas for the Vatavyadhees in general itself is the nidana of Sandhigatavata.

The nidanas for Vatavyadhi and Vataprakopa are listed under the following headings:-

1.Aharaja, 2.Viharaja, 3.Manasika, 4.Abhighataja and 5.Anyat.

Sandhigatavata 46

Table No. 09. Showing the aharaja nidana133,134,135,136

Sl. Nidana C.S. S.S. A.H. B.P.1 Rooksha bhojana + + + + 2 Laghu bhojana + + - + 3 Seethanna + + - + 4 Alpa bhojana + + + - 5 Ama + - - + 6 Abhojana + + - + 7 Pramita bhojana - - + - 8 Vishama bhojana - + - - 9 Tikta-katu-kashaya rasa - + + + 10 Adhyashana - + - - 11 Sushkasaka - + - - 12 Vallura-varaka-uddalaka-koradusha-syamaka-adhakee-

harenu-kalaya-nishpava - + - -

In short, the excessive consumption of tikta-katu-kashaya rasas, laghu-

rooksha-sheeta gunapradhana aharas and dravyas such as shushkasaka etc and food habits

such as alpa bhojana, abhojana, pramita bhojana, vishama ashana and adhyashana causes

the vitiation of Vatadosha in the body.

Table No. 10. Showing the viharaja nidana

Sl. Nidana C.S. S.S. A.H. B.P. 1 Ativyavaya + + + + 2 Atiprajagara + + + + 3 Vishama upachara + - + - 4 Plavana + + - - 5 Atyadhva + + - - 6 Ativyayama + + + + 7 Dukshashayya + - - - 8 Dukhaasana + - - - 9 Divaswapna + - - - 10 Vegadharana + + + + 11 Gaja-ashwa-ushtra-sheeghrayana + + - - 12 Vega udeerana - - + - 13 Atyuchhabhashana - - + - 14 Prapatana + + - - 15 Pradhavana - + - - 16 Prapeedana - + - - 17 Bharaharana - � - -

Sandhigatavata 47

Manasika Nidanas

Mental factors like chinta, shoka, krodha, bhaya etc are the aggravating

factors of Vata. Vata is the controller of manas. Hence, any affliction to manas vitiates

the Vatadosha.

Abhighataja Nidanas :-

Abhighata to shareera especially to the marmas vitiates the Vatadosha. In

case of Sandhigatavata, the abhighata to the sandhis, janu marma, and other marmas like

kateekataruna, kukundara, nitamba, parshwasandhi etc are important causative factors.

Anyat (other nidanas): -

Panchakarma apacharas like atidoshasravana, atirakthasravana, atiyoga of

langhana, apatamsana etc and dhatukshayakarabhavas like rogakarshana, gadakrita

atimamsakshaya, etc vitiate Vata. Dhatukshaya is an important vitiating factor of Vata.

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

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

Vatavyadhis137. All types of avaranas are also important vitiating factors of Vata. Vata

dominates vardhakya avastha138. During this period, dhatukshaya occurs causing Vata

prakopa.

Living in jangaladesha is another causative of Vata prakopa139. Vata gets

vitiated in the end of day and night140. Vata also get vitiated during the end of greeshma

ritu, varsha ritu and shishira kala141. Vata prakriti persons are more susceptible to Vata

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

Vata vikaras.

Sandhigatavata 48

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

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

bearing joints. This gradually weakens the sandhis and produces Sandhigatavata. Excess

exercise may not only vitiate Vata but further leads to shleshaka kapha kshaya

contributing to Sandhigatavata. Excess walking and excessive weight bearing also are

important in the context of Sandhigatavata. Abhighata to marmas or sandhis is another

important risk factor for Sandhigatavata. Vardhakya avastha characterized by

dhatukshaya leading to peshi-snayu-marma shosha, thereby resulting in looseness of

joints is also a major risk factor for Sandhigatavata. The factors like that vitiate

asthivahasrotas (ativyayama, atisamkshobhana, asthivighattana and vatalasevana) 142 also

need to be mentioned in the nidana of Sandhigatavata.

Risk factors for Osteoarthritis (OA) 143

• Age factor –

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

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

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

have radiological evidence of OA in one or both knees and 30% in one or both hips.

• Sex factor –

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

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

hands, men and women are affected equally, though the lesions often appear at a young

age in men. Only 3% of elderly men have primary OA in the hands.

Sandhigatavata 49

• Hereditary factor –

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

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

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

• Race factor –

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

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

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

and especially hip OA are much less common in South African blacks than in whites in

the same population. Whether these differences are genetic or are due to differences in

joint usage related to life style or occupation is unknown.

• Obesity factor –

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

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

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

risk rose to 1.9 for men and 3.9 for women, suggesting that obesity plays an even larger

role in the etiology of the most serious cases of knee OA.

• Occupational factor –

Repetitive movements may leads to excessive strain leading to erosion and

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

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

radiographic changes.

Sandhigatavata 50

• Traumatic factors –

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

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

to excessive wear and tear leading to OA.

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

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

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

Classification based on causes144

I. Primary

A. Idiopathic, B. Primary generalized osteoarthritis and C. Erosive osteoarthritis.

II. Secondary

A. Congenital or developmental defects (Hip dysplasias, shallow acetabulum,

Morquio’s syndrome, etc.),

B. Traumatic

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

C. Inflammatory (RA, psoriatic arthritis, septic arthritis, pseudogout),

D. Endocrinal influence (Acromegaly, diabetes mellitus, sex hormone

abnormalities, hypothyroidism with myxedema) and

E. Metabolic (Gout, itemochromatosis, ochronosis, chondrocalcinosis, paget’s

disease).

Sandhigatavata 51

Poorva roopa

Poorva roopa is the prodromal symptoms of a forth-coming disease, which

do not clarify the peculiarity of the dosha taking part in the samprapthi of the disease.

These symptoms will be few and not clear. 145 These are produced at the stage of

sthanasamshraya, when the disease has not completely evolved. 146

Specific poorvaroopa have not been mentioned for Sandhigatavata in

Ayurveda. Hence, the poorvaroopa of Vatavyadhi can be considered. Thus the

unmanifested symptoms of the particular Vatavyadhi should be considered as

poorvaroopa.

Observations based on the present clinical trail reveals that sandhi-gurutva

(heaviness of joints) and occasional pain in the joints, which were ignored by the patients,

were the poorvaroopas.

Samanya samprapti

Samprapti of Sandhigatavata has not been separately discussed in any of

the textbooks of Ayurveda. Hence, the common samprapti of Vatavyadhees are to be

considered here.

Charaka and Vagbhata had stated that the kupitavata circulate through the

empty channels in the body (riktasrotas) and fills them. This settling in the channels

produces Vata specific symptoms in the avayavas related to those channels. 147 Another

possibility is that the kupitavata entering the srotas can get avarana by other doshas etc

and manifest the symptoms. 148,149 Both these mechanisms are possible in case of

Sandhigatavata. The general pattern of samprapti is as follows: –

Sandhigatavata 52

Intake of rooksha-sheeta ahara & vihara like ativyayama, abhighata etc Reduction

of sneha bhava in the body Dhatukshaya where by sushirata in the channels

results Vata purana of these channels Manifestation of symptoms.

That is, the above said ahara vihara induces reduction of sneha bhava and

simultaneously produces vata kopa due to the dhatu kshaya. Reduction of shleshaka

kapha occurs and this allows the settling of vitiated vata (vyana vata) in the joints thereby

gradually resulting in the manifestation of Sandhigatavata.

Concept of Gatavata

As the disease belongs to Gatavata group of Vatavyadhees, it will be

relevant to discuss the concept of Gatavata here. While mentioning Gatavata, acharyas

have mentioned the gatatva of dhatu, upadhatu, ashaya, avayava etc. The various

terminologies used to denote this Gatavata are gate, sthithe, avasthite, ashrite, prapte, etc.

150 These all terminologies can imply two important factors – A) related to the gati of the

vitiated Vata and B) related to the occupation of a particular site.

When these two factors combine then such a condition is termed by

adding objective of that site, for e.g. Sandhigatavata. Though Vata is present all over the

body, its gata condition specially indicates its abnormal localization at the particular

dhatu or ashaya. In this condition, the etiological factors are only of Vata and not of dual,

i.e., not of both dosha and dooshya. For example, in Vataraktha, the atisevana of ahara

vihara vitiating Vata and Rakta at a time leads to the prakopa of both simultaneously,

resulting in Vataraktha. While in Sandhigatavata, the kopa of Vata alone occurs and this

vitiated Vata by involving the sandhis produces Sandhigatavata.

Sandhigatavata 53

Particularities of these Gatavatas are that here the Vata vitiation is active,

Vata dosha is more important, vitiation of Vata is due to it’s own nidanas and there is a

state of dhatu kshaya and rikta srotas. 151

Also the samprapti of Sandhigatavata can be discussed under two headings

for better understanding – 1. Dhatukshayajanya and 2. Margavaranajanya.

Dhatukshayajanya

Here-in, the initiation of the process of samprapti is due to the strong

involvement of nidana factors such as vardhakya avastha, abhighata, ativyayama,

marmaghata etc. These factors lead to the Vata vridhi followed by Kapha kshaya. This

results in agni mandya. Then the state of dhatukshaya is the resultant and hence there is

kshaya of asthi dhatu too. Kapha kshaya reflects in the decrease of shleshaka kapha also.

This permits the settling of vitiated Vata in the sandhis and then the manifestation of the

symptoms.

Margavaranajanya

Here, the samprapti process is initiated by the nidana ghataka, sthoulya.

Sthoulya results in increase of medas only and mal-nourishment of subsequent dhatus

including asthi. This results in Vata prakopa. But, its gati is obstructed by vridha medas.

This leads to gradual avarana of Vata and there by lodging of it in the sandhis due to

nidana specificity and hence, the manifestation of symptoms.

Sandhigatavata 54

Sushruta has indicated manifestation of Vata vikaras as a complication of

sthoulya. 152 That is the intake of sleshmala ahara etc results in the formation of ama and

production of medas due to atisneha. This causes sthoulya. Along with many other

complications, the sthoola’s body movements are reduced. Due to avrita marga by Kapha

and medas, nourishment of subsequent dhatus does not occur leading to their kshaya.

Vata vikaras manifests as the resultant of medahkritha margavarana. 153

Three main factors involving in the production of Sandhigatavata, in any

form of samprapti are –

Kopa of vyana vata, which normally controls all the movements of the body

Kshaya of shleshaka kapha, which normally aligns the joints and maintains its

compactness and

Deterioration of sleshmadhara kala, which lubricates the joints.

Samprapti ghatakas

• Dosha – Vata –Vyana vata vridhi

Kapha – Shleshaka kapha

• Dushya – Asthi, Majja, Peshi, Snayu, Sleshmadhara kala

• Srotas – Asthivaha, Medovaha, Majjavaha, Mamsavaha

• Agni – Jatharagni, Asthidhatwagni, Medodhatwagni

• Ama – Jatharagni mandyajanya, Asthidhatwagni mandyajanya,

Medodhatwagni mandyajanya

• Udbhava – Pakwashaya

• Rogamarga – Madhyama

• Adhisthana – Sandhi

Sandhigatavata 55

Pathogenesis of Osteoarthritis 154

The association between OA and aging is non-linear; the prevalence

increases exponentially beyond the age of fifty. About 80% to 90 % of the individuals, of

both sexes, have evidence of OA by the time they reach the age of 65. The age related

changes in cartilage include alteration in proteoglycans and shorten fatigue life. Despite

this relationship, it is an over simplification to consider OA as merely a disease cartilage

wear and tear.

Chondrocytes play a primary role in the process and constitute the cellular

basis of the disease. For example, the chondrocytes in the osteoarthritic cartilage produce

IL-1 and TNE-alpha, which are known to stimulate the production of catabolic

metalloproteinases and inhibit the synthesis of both type 2 collagen and proteoglycans.

The effects of these cytokines are potentiated because their receptors show an increased

sensitivity. Other mediators, such as prostaglandin derivatives and IL-6, also have a role

in this cascade of matrix degradation. Most of these cytokines also have pro-

inflammatory properties, and inflammatory cells are present in many osteoarthritic joints.

The precise events that lead to the secretion of cytokines however are not clear.

Degeneration & OA

OA is caused by the degeneration of the articular cartilage in the joints

involved. In the regions involved, the cartilaginous matrix and the chondrocytes swell.

The proteoglycans in these regions are smaller then the normal. The proportion of

chondrotin sulfate falls and the proportion of keratin sulfate rises. The change in the

character of the proteoglycans exposes the collagen fibers in the cartilage. Poorly formed

Sandhigatavata 56

type I collagen tends to replace the type II collagen normal in the cartilage. In the

degenerating regions, small fissures develop in the cartilage. The fissures separate

irregular brands of cartilage that project perpendicular to the articular surface, a change

called fibrillation. Clumps of chondrocytes are often present near the clefts. As years

pass, much or all of the articular cartilage is slowly worn away. Eventually, only irregular

patches of articular cartilage remain on the articular surfaces of the bones1.

Degeneration of the synchondral joints of the spine causes loss of water

from the nucleus pulposus. It becomes smaller and less resilient and often is fissured or

calcified. Chondrotin sulfate is lost from the nucleus. Keratin sulfate and collagen

accumulate in it. The thin cartilaginous plates that separate the intervertebral disc from

the vertebrae degenerate, becoming fissured or fibrillated like the articular cartilages in

the osteoarthritic diarthrodial joints. Often the nucleus pulposus herniate through the

cartilaginous plate into one or both of the adjacent vertebrae. The herniated part of the

nucleus pulposus is usually 1-2cm across and is called a Schmorl’s node. The annulus

fibrosis of the disc is weakened, allowing the disc to bulge anteriorly and laterally2.

Weightman has shown that the ability of the articular cartilage to

withstand fatigue testing diminishes progressively with age3. Because OA is most

common in aging patients, it is often proposed that the disease is an intrinsic part of the

aging process. The wear and tear theory assumes a decreasing capacity with the age of

articular cartilage to resist mechanical stress4.

Sandhigatavata 57

Roopa

Sandhigatavata manifests in the body with the following lakshanas.

1. Vatapoornadrithisparshaha shothaha: - Swelling over the joint resembling an air–

filled bag on touch. Arunadatta says that the shopha is similar to an air –filled

bag. 155

2. Prasarana akunchanayoho savedana pravritti: - Painful flexion and extension is

another feature of Sandhigatavata. 156

3. Hanti sandheen: - This, according to Dalhana, is the absence of joint movements

(flexion & extension) implying the joint damage. According to Gayadasa, it is the

difficulty in joint movements. According to the Madhukosha commentary on

Madhava nidana, it means that the Vata vitiated in the joints either hampers the

functioning of joints or produce stiffness etc. 157

4. Shoola: - Pain in the joints. 158

5. Atopa: - Crepitus (Characteristic sound produced from the joints). 159

Table No. 11. Showing the lakshanas of Sandhigatavata.

Sl Lakshana C.S. S.S. A.H. Others 1 Shoola - + - Madhavanidana

Bhavaprakasha Gadanigraha

2 Shotha + + + Bhavaprakasha Gadanigraha

3 Vatapoornadrithi sparshaha sothaha

+ - + -

4 Prasarana akunchanayoho savedana pravritti

+ - + -

5 Hanti sandheen - + - Madhavanidana Bhavaprakasha Gadanigraha

6 Atopa - - - Madhavanidana 7 Sandivishlesha - - - Madhukosha 8 Sandhi stambha - - - Madhukosha 9 Prasarana akunchanayoho

abhava - - - Dalhana

10 Prasarana akunchanayoho asamarthya

- - - Gayadasa

Sandhigatavata 58

Acharyas of Ayurveda have not mentioned that Sandhigatavata affects

only any particular sandhi of the body. Modern medicine also supports this view.

Clinical features of Osteoarthritis 160

Symptoms

No systemic manifestations

Pain on use; pain at rest in severe and advanced diseases

Localized stiffness 15-30 minutes in morning and after immobilization in daytime

Muscle spasm

Limitation of motion in advancing disease

Symptoms uncommon before age 40, except in secondary OA

Pain related to specific joints

Joints most commonly involved –

Distal interphalangeal joints

Proximal interphalangeal joints

First carpometatarsal joint

Scaphotrapezoid joints

Knees

Hips, often unilateral

Spine, cervical and lumbar

First metatarsophalangeal joint

Signs

• Joints, enlarged, synovium and capsule synovial fluid, and bony and cartilage

Proliferation

• Tenderness, local at joints

• Crepitus, creaking, grating, cracking

• Warmth without redness of joints

• Palpable osteophytes

• Joint effusion of normal or high viscosity fluid

Sandhigatavata 59

• Deformity of joint with preservation of function with exception of hip joint and

First carpometacarpal joint

• Sometimes episodic course, e.g. primary generalized OA

• Soft synovial proliferation without bony proliferation, rare

• Genu varus and valgus

• Hallux valgus

• Heberdens and Bouchar’s nodes and first carpometacarpal enlargement

• Rare involvement: elbows, shoulder, metacarpophalangeal, lateral

metatarsophalangeal, proximal interphalangeal and joints of feet, ankle, subtalar

and midtarsal, thoracic spine.

Diagnosis of OA is made accurately by clinical history, physical examination

radiological study, and when etiology and pathogenesis are not clear, by certain

laboratory examinations. The symptoms and signs are usually confined to one or only a

few joints. If many joints are involved, the diagnosis is more likely a systemic form of

rheumatic disease. 161

Radiologic and laboratory characteristics of Osteoarthritis162

Normal radiographic findings occur in early OA. Joint space narrowing

follows degeneration and disappearance of hyaline cartilage. Early in the disease with

effusion and swelling of cartilage, there may be joint space widening. Subchondral bony

sclerosis or eburnation is very characteristic and represents deposition of excessive new

bone. Marginal osteophytes in a variety of patterns in various joints reflect bone, cartilage

and synovial cell proliferation. Sub location and gross deformities with loose bodies in

the joint appears late. Radiologic criteria for diagnosis of osteoarthritis as defined in the

Atlas on standard radiographs is given below:

Sandhigatavata 60

1. Formation of osteophytes in the joints margins or at ligamentous attachments, e.g.

tibial spine

2. Periarticular ossicles, mainly distal and proximal interphalangeal joints

3. Narrowing of the joints space associated with sclerosis of subchondral bone and

4. Altered shape of bone end e.g. head of the femur.

The following five step grading system is used according to the number of

criteria present: 0 = No OA, 1 = Doubtful OA, 2 = Minimal OA, 3 = Moderate OA

and 4 = Severe OA.

There are no specific laboratory abnormalities in primary OA. The

synovial fluid is essentially normal, a few cells above normal counts, a slightly reduced

viscosity or string test, a normal mucin clot and total protein concentration. An increased

concentration of inorganic pyrophosphate (PPi) is found in OA and is positively

correlated with the severity of radiologic OA. The application of thermography and

scintillation scans of joints has little or no clinical usefulness but has shown negligible

evidence of inflammation in OA compared to the inflammatory arthropathies.

Association of OA has also been noted with elevated Westergren

sedimentation rate, elevated C-reactive protein, serum uric acid and ASO titers. In

primary generalized OA, elevated serum cholesterol and transient rises in other acute

phase reactants occur, Specific laboratory studies may be needed for diagnosis of

secondary OA associated with specific primary disease. Arthroscopy thus far has little

practical use in OA.

Sandhigatavata 61

Vyavachedakanidana

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

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

common differentiation is to be made with Vatarakta, Amavata and Kroshtrukasheersha.

Table No. 12. Showing Vyavachedakanidana between Sandhigatavata and Vataraktha

Sl. Criteria SGV Vatarakta 1 Nidana Vatavridhikara

ahara-vihara Vidahi, viruddha, rakthaprakopakara ahara

2 Poorva roopa Avyaktharoga lakshana

Kushtasama

3 Roopa Sandhishoola, Prasarana akunchanayohovedana, Sandhi shopha, Vatapoornadrithi sparsha

Teevra ruk, Grathita-paki shvayathu

4 Adhisthana Sandhi Padamoola, Hastamoola

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

Table No. 13. Showing Vyavachedakanidana of Sandhigatavata and Amavata

Sl. Criteria SGV Amavata 1 Nidana Vatavridhikara

ahara-vihara Viruddha ahara-cheshta

2 Poorva roopa Avyaktharoga lakshana

Hridaya dourbalya, gourava

3 Roopa Sandhishoola, Prasarana akunchanayohovedana, Sandhi shopha, Vatapoornadrithi sparsha

Vrischika damshavat peeda, Pidakayukta shopha

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

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

Sandhigatavata 62

Table No. 14. Showing Vyavachedakanidana of Sandhigatavata & Kroshtrukasheersha

Sl. Criteria Sandhigatavata Kroshtrukasheersha 1 Nidana Vatavridhikara

ahara-vihara Vatavridhikara ahara-vihara

2 Poorva roopa Avyaktharoga lakshana Avyaktharoga lakshana 3 Roopa Sandhishoola,

Prasarana akunchanayohovedana, Sandhi shopha, Vatapoornadrithi sparsha

Maharuja, Janushopha

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

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

fever.

Sl. Criteria OA RA Gout Rheumatic Fever

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

Inflammation in multiple joints, morning stiffness >30ms

Polyarticular pain, swelling & inflammation, exquisite tenderness

Painful and tender joints

2 Mode of On set

Gradual Abrupt Acute Acute

3 Joints Involved

Weight bearing joints

Polyarticular Metatarso- phalangeal joints

Polyarticular

4 Systemic Features

- Autoimmune disease, rise in temperature, anemia etc.

- Carditis, fever, chorea

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

ESR raised, X-ray-soft tissue swelling.

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

ESR increased, CRP high, WBC elevated.

Sandhigatavata 63

Upadravas (Complications) 163 Upadrava is produced after the manifestation of the pradhana vyadhi and it

is dependent on it. Osteoarthritis if long standing will be having complications like

muscle wasting, various deformity, intra articular loose bodies etc. This state is very

complicated one where the patient feds much difficulty in managing the daily routines.

Upashaya-anupashaya164

Upashaya & anupashaya are very much important; especially during the

treatment usually drugs having snigdha & ushna gunas are prescribed as these pacify the

Vata kopa. This should be adopted in the nirama avastha of vatavyadhi only. This is the

upashaya method. When the same drugs are prescribed in the saama avastha of

vatavyadhi the disease aggravates. This is the anupashaya.

Sadhyaasadhyata

Vatavyadhis are considered as one among the mahagadas by acharyas. 165

Generally, Vata rogas are very difficult to cure due to the deep–seated nature of them.

Sandhigatavata usually occurs in the vardhakya kala, the kala, which is predominant of

Vata. Charaka had mentioned some Vatavyadhees, which are either not curable due to

sthana gambheerata or curable with effort in case they are of recent origin, in strong

patients and if without any complications. Khudavatata is one among them, which

according to Chakrapani is Sandhigatavata. 166

Sandhigatavata 64

Chikitsa

Treatment of a disease in Ayurveda starts with nidana parivarjana. This

has to initiated first before administering any medicine or adopting any line of treatment.

Line of treatment of Sandhigatavata

(1) Snehana167

All types of bahya & abhyantara snehana are to be adopted in treatment in

order to pacify the Vridhavata and to provide enough sneha amsha to the body that has

underwent kshaya. Various modalities of abhyantara snehana are bhojana, pana, nasya

and snehabasti. Various modalities of bahya snehana are abhyanga, lepa, mardana,

udvartana, samvahana, moordha taila, gandusha, karnapoorana, akshitarpana, parisheka

and pichu.

(2) Upanaha168

This is of two types- 1) saagni and 2) niragni. Saagni upanaha is nothing

but Sankara sweda. Niragni upanaha is the tying of Vatahara dravyas over the affected

body part for a time period of 12 hours.

(3) Agnikarma169

This procedure is a Shastra karma explained by Ayurveda. This karma

utilizes various heated materials to cauterize the particular body part affected. Sushruta

states that in the vitiation of Vata in twak, mamsa, sira, snayu and sandhi Agnikarma

provides good relief. Dahana karma is a synonym of Agnikarma.

(4) Bandhana170

This has been explained under Upanaha.

Sandhigatavata 65

(5) Unmardana171

This is a massage technique utilized in case of bahya snehana procedures.

The massage is performed by applying gentle pressure.

Apart from these, the Basti karma should also be adopted, as it is the

parama oushadha for Vata. 172

Shamana oushadhees

1) Kwatha : - Maharasnadi, Rasnadi, Dhanvantaram, Sahacharadi.

2) Choorna : - Alambushadi choorna, Abhadi choorna.

3) Vati : - Ajamodadi vati, Tab. Sallaki, Tab. Sallaki plus.

4) Guggulu : - Kaishoraguggulu, Yogarajaguggulu, Brihat yogaraja,

Adityapakaguggulu, Simhanadaguggulu.

5) Rasaoushadhi : - Panchanana rasa, Vatarakshasa, Brihat vatachintamani.

6) Sneha : - Dhanvantaram taila, Kottam chukkadi taila, Sahacharadi taila,

Vatashani taila.

Pathya173

Ahara

1. Rasas : - Madhura-amla-lavana

2. Shukadhanya : - Nava godhuma, Nava shali, Rakta shali, Shashtika shali.

3. Shimbi varga : - Nava tila, Masha, Kulatha.

4. Shaka varga : - Patola, shigru, vartaka, lashuna.

5. Mamsa varga : - Ushtra, Go, Varaha, Mahisha, Magura, Bheka, Nakula, Chataka,

Kukkuta, Tittira, Kurma.

Sandhigatavata 66

6. Jala varga: - Ushnajala, Shrithasheetajala, Narikelajala.

7. Dugdhavarga: - Go, Aja, Dadhi, Ghritha, Kilata, Kurchika.

8. Mutravaga: - Gomutra.

9. Madyavarga: - Dhanyamla, Sura.

10. Snehavarga: - Tilaja, Ghrita, Vasa, Majja.

Vihara

Veshtana, Trasana, Mardana, Snana, Bhushayya, etc.

Among present day food stuffs & activities-

1. Can be taken: - Orange juice, carrot, all fibrous fruits and certainoids.

2. Should do: - Slight walking, swimming, steam bath etc.

Apathya174

Ahara

1. Rasa: - Katu, Tikta, Kashaya.

2. Shimbivarga: - Rajamasha, Nishpava, Mudga, Kalaya.

3. Shukavarga: - Truna, Kangu, Koradusha, Neevara, Syamaka.

4. Phalavarga: - Jambu, Udumbura, Kramuka, Tinduka.

5. Mamsavarga: - Sushka mamsa, Kapota, Paravata.

6. Jalavarga: - Sheeta jala.

7. Ksheeravarga: - Gardabha.

Sandhigatavata 67

Vihara

1. Manasika: - Chinta, Shoka, Bhaya.

2. Shareerika: - Jagarana, Shrama, Vyayama, Vyavaya, Chankramana, Vegadharana etc.

Among the present day food stuffs and activities-

1. Can be taken: - Fast food, cold beverages, liquor.

2. Should be avoided: - Long standing sitting, driving, staying in AC etc.

Management of Osteoarthritis175

This involves many measures like pharmacological means, non-

pharmacological means and surgery.

Pharmacological means –

1. Simple analgesics

A large number of medicines are prescribed for relief of pain. The

recognition that pain in OA is not necessarily due to inflammation has led to an increased

awareness of the role of simple analgesics in the treatment. The ACR guidelines

emphasize the use of acetaminophen (Tylenol) as the first line treatment for OA.

2. Opioid containing analgesics

Code line and propoxyphene can be used for short periods to treat

exacerbations of pain.

3. NSAIDS

Trials comparing simple analgesics and NSAIDs found that

acetaminophen along can control pain in a substantial number of patients with OA

celecoxib, a cox-2 inhibitor, and rofecoxib are recent advances among NSAIDs.

Sandhigatavata 68

4. Local analgesics

Among the local applications, capsaicin cream is used commonly.

5. Intra articular cortico-steroid injections.

6. Intra articular administration of hyaluronic acid like products.

Agents used to treat Osteoarthritis

Acetaminophen, NSAIDS (Salicylates, Propionic acids, Acetic acid,

Oxicams), Cyclo-oxgenase inhibitors, Irritants/Counter irritants, Hyaluronic acids and

Glucocorticoids.

Non-pharmacologic means

Patient education

Exercise: - To maintain range of motion, muscle strength and general health.

Patients may also be referred to aerobic exercise programs such as fitness walking

or swimming.

Assistive devices: - Many patients with OA of hips and knee are more

comfortable; wearing shoes with good shock-absorbing properties orthoses. The

use of an appropriately selected cane can reduce hip loading by 20-30%. Patients

with specific physical disabilities may benefit from physical and occupational

therapy.

Weight management: - There is a longitudinal association between obesity and

OA of knee in men and women. Therefore, primary preventive strategies may

include measures to avoid weight gain, or to achiever weight loss in over weight

patients.

Supplements: - Glucosamine sulphate and chondrotin sulfate.

Sandhigatavata 69

Surgery176

Surgical procedures are of value in the management of OA. They may be

grouped under 3 major categories. Procedures to correct mal alignment and eliminate

abnormal joint stresses (osteotomies) not only may slow down disease progression but

may-also bring healthier articular cartilages into opposition and provide symptomatic

relief. Debridement with removal of free bits of cartilage or large ecostoses may relieve

pain and locking and help in prevention of rapid and extensive cartilage degeneration. In

advanced disease, arthroplasty or joint replacement may be required to reduce pain and

improve function; at times arthrodesis is required to control pain, even though motion

must be sacrificed.

Sandhigatavata 70

SAMPRAPTI OF SANDHIGATAVATA

Ahara

Vihara

Vardhakya Sthoulya

Abhighata

Ativyayama

Vataprakopa and Kapha kshaya

Agnimandya Margavarana of Vata by vridha medas

Dhatu kshaya

Asthi kshaya

Vatapurana in rikta srotas

Sthanasmashraya in sandhis

Shleshaka kapha kshaya and Vyana vata kopa

SANDHIGATAVATA

Dha

tuks

haya

jany

a sam

prap

ti

Margavaranajanya sam

prapti

DRUG REVIEW

1) Shashtikashali

All the textbooks of Ayurveda claim that this rice variety is the most beneficial in the Vreehivarga.

Table No. 16. Showing the rasa, guna, veerya, vipaka, guna and doshakarmas of Shashtikashali177.

Botanical Name Family Synonyms Parts used Rasa Veerya Vipaka Guna Dosha karma

Oryza sativa Linn.

Gramineae Vreehi, Tandula, Dhanya

Grain, Spirit, Vinegar

Madhura; Kashaya anurasa

Sheetha Madhura Mrudu, Snigdha, Grahi, Laghu, Sthira, Balavardhana, Tarunyasthapaka, Dehadardhyakrit

Tridoshaghna

Pittanilahara,

Kaphashukrala

Charaka had stated that there are two varieties of Shashtikashali, viz., goura and krishnagoura and that goura is the best

among them. Vagbhata and Arunadatha178 have accepted this view. But, Sushrutha179 had given a list of Shashtikashalees among

which Shashtika (goura) is the best one. Dalhana180, commenting on the same verse, had said that among these varieties Shashtika is

the gourashashtika and rest all are either krishnashashtikas or gourakrishnas. Dalhana also says that even though Shashtika is a

Vreehibheda and the best one among them, there is a difference between other Vreehis and Shashtika. That is, Shashtika gets matured

fast (sheeghrapaki) and Vreehes mature late (chirapaki).

71

In this study, the white (goura) variety of Shashtika was used.

Incidentally, the year of conduction of this study (2004) was observed as the International Year Of Rice. The

compendium of papers published on the seminar “Science-Society Interface on Medicinal and Aromatic Rices”, organized by

M.S.Swaminathan Research Foundation, Chennai and Kerala Agricultural University, Thrissur in partnership with National Medicinal

Plants Board, Govt. Of India and International Fund for Agricultural Development, Rome at the Paddy Research Institute, Pattambi,

Kerala provides some valuable information on Shashtikashali.

Morphology & Duration of growth181

Navara (Shashtikashali’s Malayalam name) is in the group of very early maturing type of rice (Some farmers claim that

they have harvested it within 57days). If it is grown in proper field (commonly rain fed upper and low land) and there is no fault in

cultural practices, it matures in the sixtieth day. However, in no case its duration will exceed 90 days.

There are two clearly distinguished ecotypes existing in this cultivar - one with golden-yellow glumes and the other

with black glumes. Within each ecotype, there are two different forms - one with awn and another without awn. Thus, in this variety

there exists four morphologically distinguishable strains, but adapted to same kind of agro-ecological conditions. Plant generally

grows up to 1metre tall. Grains are narrowly ellipsoid, small, slender and light in weight with red kernel.

72

Chemical constitution182

There are few reports to show that this variety of rice possesses some characteristic amino acids (Menon & Potty,

1995,1997,1998). These authors have attempted to understand the amino acid composition in the two known strains. It shows that total

free amino acid composition in them is more when compared to other high yielding varieties. They reported that the amino acid

content varies under different agro-ecological conditions. According to them, the methionine might be the responsible active

compound for the medicinal quality. Methionine is the only common amino acid with either linkage and is an important donor of

active methyl groups.

Although variety like Navara is being used in the traditional medicine for a very long time, the bio-chemical or physico-

chemical components governing its unique medicinal property is neither established nor scientifically validated.

Table No. 17. Showing chemical composition of rice183

Moisture 12.4% Ash 0.4% Crude fiber 0.2% Carbohydrate 79.2% Protein 7.4% Fat 0.4%

Processing of Shashtikashali in Goksheera and Balamula Kashaya will be explained in the treatment schedule.

73

2) BALA

The rasa-guna-veerya-vipaka-guna-doshakarmas of Bala184 is summarized in the table given below.

Botanical

Name

Family Synonyms Parts

used

Rasa Veerya Vipaka Guna Doshakarmas

Sida

cordifolia

Linn.

Malvaceae Vatyalika

Kharayashika

Odanika

Samanga

Mula

Beeja

Madhura Sheetha Madhura Laghu

Snigdha

Pichila

Vatapitha-

shamaka

Major components of seeds are alkaloids. Alkaloids contain mainly ephedrine. It also contains fatty acid, mucin,

potassium nitrate and resin. It is the agrya oushadha in Vatarogas. Locally, it is applied over inflammation and eye disorders. It is a

nervine tonic and cardiac tonic.

74

3) GOKSHEERA

The rasa-guna-veerya-vipaka-guna-doshakarmas of Goksheera is summarized in the table given below.

English Name

Varga Synonyms Rasa Veerya Vipaka Guna Doshakarmas

Cow’s

Milk

Dugdha-

Varga

Gavya

Payaha

Madhura

Sheetha

Madhura

Mridu

Snigdha

Bahala

Slakshna

Pichila

Guru

Manda

Prasanna

Rasayana

Jeevaneeya

Rakthapithahara

Vatapithaghna

It is made up of 87.4% water and 12.6% milk solids (3.75 fat, 8.9% milk solids-not-fat). The milk solids-not-fat

contains protein (3.4%), lactose (4.8%) and minerals (0.7%). Cows milk is a heterogeneous mixture of proteins. About 80% of total

proteins in milk are casein and 20% is whey protein. It also contains small amount of various enzymes (lipoprotein lipase, alkaline

phophatase, lactoperoxidase etc.) and traces of non-protein nitrogenous compound (e.g.: ammonia, urea, creatinine, uric acid etc.) 185.

75

4) NIRGUNDI – The rasa-guna-veerya-vipaka-guna-doshakarmas of Nirgundi186 is summarized in the table given below.

Botanical

Name


used

Rasa Veerya Vipaka Guna Doshakarma

Vitex

Negundo

Linn.

Verbenaceae Sephalika

Swetasurasa

Vrikshaka

Sinduvara Leaves

Root

Seeds

Katu

Tiktha

Ushna Laghu

Rooksha

Sothahara

Kapha-

vata-

shamana

Leaves contain a colourless essential oil of the drug, and a resin ; fruits contain an acid resin, an astringent organic acid,

malic acid, traces of an alkaloid and a colouring matter. Leaves are useful as anti-inflammatory ; also over sprained limbs, contusions,

leech bites etc. Oil is useful in glandular swelling, sloughing wounds, ulcers etc. Rheumatic patients will be benefited by baths of

Nirgundi leaves boiled in water. Root is used in dyspepsia, colic, rheumatism, worms, boils and leprosy. Various extracts of the leaves

and root of the Vitex negundo possess anti-inflammatory and analgesic activities187.

76

5) CHINCHA – The rasa-guna-veerya-vipaka-guna-doshakarmas of Chincha188 is summarized in the table given below.

Botanical

Name


used

Rasa Veerya Vipaka Guna Doshakarma

Tamarindus

indicus

Linn.

Leguminoseae Chukrika

Chukra

Amlika

Fruit-

pulp

Seeds

Leaves

Flowers

Bark

Amla Ushna Amla Guru

Rooksha

Kapha-

pitha-

shamana;

Vata-

shamana

Pulp contains tartaric acid 5%, citric acid 4%, malic and acetic acids, tartaric of Potassium 8%, invert sugar 25-40%, gum and

pectin. Seeds contain a fixed oil and insoluble matter. Seeds contain albuminoids, fat, carbohydrates 63.22%, fibre and ash containing

phosphorus and nitrogen. Fruit contains trace of oxalic acid. Therapeutically useful as laxative, antidote for intoxication from Dathura,

Pachana, in inflammatory swellings etc. Poultice of leaves are recommended as applications to inflammatory swelling to relieve pain.

77

6) Gandharvahastadi Kwatha189 –

It was prepared according to the Kashayakalpana.

No valid information on the chemical composition is available regarding

this yoga. This Kwatha can be administered along with Saindhavalavana or Guda. This

pacifies Vatakopa, increases the strength of Jatharaagni, promotes taste and induces

proper Malashodhana. The chemical compositions and therapeutic actions of the

individual drugs in this Yoga are as follows: -

Eranda190 – It contains stable oil (45%), slimy substance, sugar, white juice and

salt (10%). Seeds contain toxic element called ricin. This dissolves in alcohol.

Ricin contains ricin oil, palmitin and sterine. Oil obtained is clean, light,

yellowish and without much smell, but slightly pungent. Internally used, it is

Vatashamaka, Rasayana, and Medhya and hence indicated in Pakshaghatha,

Arditha, Gridhrasi, Kampa, Shiroruk and Angaruk. Castor oil is best as purgative.

Externally applied, it alleviates Vata, Shopha and Ruk and therefore used in

Kateegraha, Gridhrasi, and Amavata.

Chirubilva191 – Extract of seed gives a yellowish oil (37.4%). Bark is applied

locally as anti-inflammatory. It is indicated in indigestion, tastelessness, Krimi,

Udarashoola, Udara, Arbuda, Arshas etc.

Chithraka192 – It contains a pungent, yellow and irritant principle called

plumbagin (91%). It doesn’t dissolve in cold water; dissolves easily in alcohol or

boiled water. It is a stimulant in low dose, but sedative in higher doses

(internally). It is widely used in Arshas, Grahani, Krimi, Shopha, Pleehavikaras,

Yakritvikaras etc. Also useful externally in Sleepada, Shopha, Swithra, Amavata

etc.

Clinical study 78

Shunti193 – It contains 1-5% yellow volatile oil, gingerol, gingerin, carbohydrates,

oil and resin. It is the best medicine in digestive system diseases. Also, indicated

widely in Vatarogas, Rakthadushya, Swasa, Shopha, Amavata etc.

Hareethaki194 – Fruit contains tannin (24.6-32.5%). Constituents of tannin are

chebulagic acid, chebulinic acid and corilagin. Also, it contains sugar, amino

acids, phosphorus etc. 36.4% oil can be extracted from the fruit pulp. Local

application of Hareethaki is anti-inflammatory. It is useful in Vata disorders,

Amapradoshajavikaras, Vataraktha, Prathishyaya, Kasa, Swarabheda,

Shukrameha, Visarpa etc.

Punarnava195 – It contains punarnavine (0.04%), a bitter alkali, potassium nitrate

(0.52%) etc. It is anti-inflammatory, Rakthashodhaka, Anulomana, Deepana and

Muthrala and indicated in Shopha, Rakthapitha, Pandu, Kasa, Swasa,

Muthrakrichra and Muthraghatha.

Dusparshaka196 – Gum of the stem is called Yasasharkara (Manna). It contains

26.4% ikshusharkara. It is indicated externally in Shopha and Rakthasrava.

Internally, it is useful in Chardi, Trishna, Swasa, Mutrarogas, Arshas, Tvakdosha

etc.

Musali197 – It contains asparagin, albumin matter, slimy substance and celluloid.

It is Shukrala, Muthrala, Balya, Brimhana, and Rasayana. It is useful in

Vatapithapradhanavyadhees. It is an alternate food for diabetes patients, as it

doesn’t contain any starch.

Clinical study 79

7) Sahacharadi Taila198,199 –

It was prepared according to the Snehakalpana. No valid information on

the chemical composition is available regarding this yoga. This Yoga is indicated in

Vatavyadhees, especially, those affecting the lower part of the body. The chemical

compositions and therapeutic actions of the individual drugs in this Yoga are as follows: -

♥ Sahachara200– Externally used in inflammation, ulcers, urticaria, boils, tooth ache

etc. Internally cures Rakthadushya, Vataraktha, Vatavyadhees especially

adharangavyadhis.

♥ Devadaru201 – It contains dark coloured oil and resin. Internally useful in all

rukpradhana vyadhees, in Aruchi & Krimi, in Rakthadushya & Kaphajakasa.

♥ Shunti202 – It contains 1-5% yellow volatile oil, gingerol, gingerin, carbohydrates, oil

and resin. It is the best medicine in digestive system diseases. Also, indicated widely

in Vatarogas, Rakthadushya, Swasa, Shopha, Amavata etc.

Clinical study 80

CLINICAL STUDY

Methodological approach is the backbone of research. Utmost care is

taken in designing a methodology for conducting a research. Clinical research involves

the experimentation of a drug/therapy on a population and recording the feedback based

on which postulations are made regarding the usefulness of the drug/therapy in the

disease. Hence, in this section, the researchers put forward the systemic procedures,

which are followed by the researchers right from the identification of the problem to the

final conclusion.

Research Approach

In the present study, the investigator’s objective was to “evaluate the

efficacy of Shashtikashalipindaswedakarma in the management of Sandhigathavata

(Osteoarthritis)”. The efficacy was determined by finding out the difference between the

baseline data of the parameters to the after treatment data. Also, this was compared with

another technique of Swedakarma, Bashpasweda, to study any advantage of

Shashtikashalipindaswedakarma over Bashpasweda karma in the management of

Sandhigathavata.

Study Design

The study design selected for the present study was prospective

comparative clinical trial. Here, Shashtikashalipindaswedakarma group of patients are

compared with the Bashpaswedakarma group of patients. Demographic data and disease-

specific data are collected according to the case-record form given in the appendix.

Clinical study 81

Reasons For Selection Of The Study Design

The results and conclusions of a clinical trial depends on the study design.

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

management of Sandhigathavata and to check its advantage over Bashpaswedakarma in

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

both the individual groups were compared.

Source Of Data

Patients suffering from Sandhigathavata were selected from the P.G.S & R

(Panchakarma) OPD & IPD of Shri D G Melmalgi Ayurvedic College Hospital.

Sample Size & Grouping

The sample size for the present study was thirty patients suffering from

Sandhigathavata as per the selection criteria. Patients were randomly distributed to both

the groups of equal size. In group A, 15 patients received Shashtikashali

pindaswedakarma and in group B, 15 patients received Bashpaswedakarma.

Selection Criteria

The cases were selected strictly as per the pre-set inclusion and exclusion

criteria.

A) Inclusion Criteria

♣ Patients fit for Snehana & Swedana

♣ Patients with the clinical features of Sandhigathavata (Osteoarthritis)

♣ Patients between 30 and 60 years of age

♣ No discrimination of sex & chronicity

♣ Patients with radiological findings of Osteoarthritis along with clinical

features

Clinical study 82

B) Exclusion Criteria

Θ Patients below 30 and above 60 years of age

Θ Patients suffering from Gout, Rheumatoid Arthritis, Septic Arthritis and other

cases of secondary Osteoarthritis.

Θ Patients with marked deformity

Θ Patients with systemic disorders like Hypertension, Diabetes mellitus etc.

Θ Pregnant women and lactating mother

Θ Patients unfit for Snehana & Swedana

Duration Of The Study

The total study duration was 28 days, i.e., 14 days of Swedana and 14 days

as pariharakala for both the groups. Follow-up was done for one month.

Data Collection

Patients were thoroughly examined both subjectively and objectively.

Detailed history pertaining to the mode of onset, previous ailment, previous treatment

history, family history, habits, ashtavidhapareeksha and dashavidhapareeksha and

physical examination findings were noted. Routine investigations were done to exclude

other pathologies. Radiological features also were investigated.

Clinical study 83

Examination Of Knee Joint & Lumbar Spine

KNEE JOINT203

History

The common symptoms with which a patient generally presents are pain,

swelling, stiffness, mechanical disorders (e.g. Locking, giving way, click etc.) and limp.

Inspection

• Both the lower limbs were fully exposed

• Patient was first examined in the standing position, both from front and behind,

secondly in the seated position, thirdly in the supine position and lastly in the

prone position.

• Swelling

A) The limits of the swelling were clearly made out.

B) The gradings were allotted on the basis of criteria explained in the end of

this section.

C) The Varna of the Shopha was examined (Raga, Shyava or Prakrutha).

D) Any deformities like genus valgum, varum etc. were examined.

E) Joint instability or buckling of the joint was examined.

F) Any abnormalities in the gait were examined.

G) Walking time was recorded (the time taken to cover 21 metres).

H) Any presence of muscular spasm was examined.

I) Muscular wasting above and below the joint was examined.

Palpation

• Local temperature was examined with the back of the hand and compared to that

of the other side.

• Local tenderness was also examined.

Clinical study 84

• Swelling

A) Fluctuation test was performed by pressing the suprapatellar pouch with

one hand and feeling the impulse with the thumb and the fingers of the

other hand placed on either side of the patella or the ligamentum patellae.

B) Patellar tap was elicited by pressing the suprapatellar pouch with one hand

driving the whole of its fluid into the joint proper as to float the patella in

front of the joint. With the index finger of the other hand, the patella is

pushed backwards towards the femoral condyles with a sharp and jerky

movement. The patella can be felt to strike on the femur, which is known

as the patellar tap.

• Palpation of popliteal fossa - The patient was made to lie down prone on the table.

The knee joint was flexed and the popliteal fossa was palpated. The knee joint,

popliteal artery, areolar tissue, veins and nerves and the tendons in and around the

popliteal fossa were all palpated carefully to detect any pathology here.

• Significance of click - If the click was associated with discomfort or pain, careful

examination was done. Commonest cause of intra-articular click is OA.

• Patello-femoral and femoro-tibial components were palpated for any tenderness

or irregularity.

Movements

The movements permitted in the knee joint are mainly flexion and

extension. Minor degrees of abduction, adduction and rotations may be permitted when

the joint is partly flexed. Both active and passive movements were examined.

• Flexion & Extension: Normally, the knee can be flexed until the calf extended till

the thigh and leg form a straight line.

Clinical study 85

• Abduction & adduction: These movements are virtually absent with knee straight,

but slight degrees of abduction and adduction are possible when the knee is semi-

flexed.

• Rotation: This movement is also not possible when the knee is straight. When the

hip and knee are flexed to 90 degrees, some degree of rotation is possible.

Auscultation

During active or passive movement, the palm of one hand of the physician

was placed over the patella and crepitus was felt.

LUMBAR SPINE204

History

• Trauma: An enquiry was made whether trauma initiated the presenting complaints

or it aggravates these.

• Pain: An enquiry was made about the onset, exact site, its nature, any radiation or

presence of any referred pain. Dull and continuous pain is a feature of

inflammatory lesion of the spine, which will be aggravated by movements. A

sudden sharp pain may be complained of in case of disc prolapse during lifting

weight in the stooping position.

• Aggravating factors: Movement of the spine aggravates the pain.

• Relieving factors : Usually, rest relieves pain.

• Deformity: Scoliosis, kyphosis or lordosis.

• Stiffness of the back

Clinical study 86

Inspection

• Curvature of the spine; whether kyphosis (forward bending), lordosis (backward

bending) or scoliosis (lateral bending) was present was examined.

• Gait was examined for its normalcy or any abnormalities.

• Swelling, if present, was examined.

Palpation

• Tenderness: Thumb was pressed along the spinous processes from above

downwards along its whole extent.

• Wasting and rigidity of the erector spinae muscle was felt for.

Percussion

Percussion over the spine was sometimes performed to elicit the

tenderness.

Movements

• Movements of the lumbar spine are flexion, extension, lateral flexion and

rotations. These were tested to determine the rigidity of the spine.

1. Flexion - The patient was asked to lean forward keeping the knees

straight. The physician’s hand was placed over the spine to note the

movements of the spinous processes. The movements of the spine and hip

flexion were also noted.

2. Extension - The patient was asked to lean backwards (look up the ceiling).

3. Lateral flexion - The patient was asked to bend sideways while standing.

Clinician holds the pelvis firmly from the back.

4. Rotations: Patient was asked to sit down so as to flex his/her pelvis.

He/she was then instructed to rotate the trunk to the right and to the left.

Clinical study 87

Treatment Schedule

Group A – Shashtikashalipindaswedakarma

Poorvakarma205a

Poorvakarma of the Shashtikashalipindaswedakarma involves the

preparation of shashtikashalipindas, preparation of the patient and Abhyanga.

1. Requirements

→ Balamula (cleaned & cut) - 600gm

→ Shashtikashali (cleaned & made coarse) - 400gm

→ Goksheera - 2400ml

→ Water - 9600ml

→ Sahacharadi Taila - 50-100ml

→ Gandharvahastadi Kwatha - 15ml

→ Clean, square cloth pieces - 4 in no.

→ Twine -One roll

→ Attenders -Three

2. Preparation of shashtikashalipindas

600gm of Balamula was boiled in 9600ml of water on moderate fire and

reduced to 2400ml. This was done in the night previous to the performance of the Karma.

The decoction was filtered and half the quantity (1200ml) was kept aside. Next day

morning, the other half part of the decoction and half the quantity of cow’s milk (1200ml)

were mixed in a vessel and kept on the fire. To this, the clean & coarse Shashtikashali

(400gm) was added. The cooking was continued till the Shashtikashali assumed the form

of a semisolid paste or pudding.

Clinical study 88

The cooked shali was divided into four equal parts and each was put in

the clean, square cloth pieces. Then, one by one, each part was made into bolus. For this,

the four corners of the cloth piece is held together between the fist of the left hand and

with the right hand all the corners except one were inserted into the bolus and the one

corner left was used to cover the held part to make a tuft. Then, a twine was rounded

several times over the tuft and was tied. Likewise, other boluses were also made. The

pindas were held by this tuft (appr. 3” length) during the procedure.

3. Preparation of the patient

The patient was asked to pass his natural urges, prior to his entry into the

Panchakarma theatre. The procedure was done in between 7-10 AM. After performing

the sacred rights, the patient was asked to sit on the Taila droni. He was then

administered 15ml of Gandharvahastadi Kwatha mixed in 60ml of luke warm water.

Then, the Sahacharadi Taila was heated to luke warm and Abhyanga was performed to

the head & whole body for approximately fifteen minutes.

Pradhanakarma205b

• The remaining part of the Balamula Kwatha and Goksheera (1200ml each) were

mixed and taken into a vessel and kept on fire, which was little distant from the

Taila droni. The shashtikashalipindas were heated in this drava during the whole

process. Initiallly, all the 4 boluses were heated for 5 minutes. One attender was

posted to carry out the heating of the boluses and two others to perform the

Karma.

• Two of the heated boluses were supplied to the two attenders standing on either

side of the patient. The heat of the boluses was checked for excess heat or

insufficiency.

Clinical study 89

• Fixing the duration: The duration of the Karma was fixed 60minutes on the first

day. Then, it was increased by 5 minutes on each day to reach 90minutes on the

7th day. The Karma was performed for the same time duration on the 8th day too.

From then, it was reduced by 5 minutes per day to reach 60minutes on the 14th

day.

• The boluses were applied over the body with the right hand, while the left hand

massaged the applied part. Procedure was started from the upper part of the body

and then progressed to the lower parts. Generally, the direction of the bolus

application was in the anulomagati except over the joints where the boluses were

applied in circular direction. The attender on each side applied the boluses and

massaged every part of the body on his side, except the scalp, eyes and the

reproductive organs. Special attention was given to the affected body part.

Massage was started in the first posture of patient sitting erect with the legs

extended, then in the supine posture, then left lateral, then again supine, then right

lateral, then again supine and finally sitting. The time of massage in each of these

postures was decided on the basis of total time duration on that particular day.

• As and when the boluses used lost their warmth, they were replaced by the

boluses, which were kept for heating. The regular changing of the boluses is of

importance, as to prevent the patient feeling cool.

• By the time the massage was over, the mixture of the decoction and milk that was

on the fire would also have completely used up having been absorbed by the

pudding and transferred onto the body of the patient during the process. When the

massaging was finished, all the bolus bags were opened out and the pudding

remnants were taken and applied to the body of the patient and rubbed by the

hands acting as in the massaging process.

• The same procedure was continued for 14days.

Clinical study 90

Paschatkarma205c

The pudding sticking to the patient’s body was removed by scraping with

cut pieces of X-ray sheet (without sharp edges). The oil on the head was removed by

gentle wiping with a dry towel. The head and the body thus cleaned were again to be

anointed with Sahacharadi Taila and bathed. The interval between the application of the

oil and bath was not more than 5 minutes. For bathing, water boiled and cooled down to

comfortable warmth was used for the head and hot water for the body.

Pathya during treatment period & pariharakala

The pathyacharana is an important factor which was followed for 28days

including the treatment period & pathyacharana. The Snehapanavidhi was prescribed to

the patients. Patients were advised to take katu-tiktha-kashaya-rooksha varjitha

aharadravyas in light quantity. Rice gruel with little milk was advised as the ideal food.

Patient was advised to drink hot water only. Patient was advised to avoid sexual

intercourse, blocking of natural urges, traveling, exercise, over-speech, uneven sitting &

lying postures, exposure to wind, cold, heat and dust, anger and grief.

Group B - Bashpaswedakarma

Poorvakarma

Poorvakarma of the Bashpaswedakarma involves the preparation of

decoctions of Nirgundi & Chincha, preparation of the patient and Abhyanga.

1. Requirements

⇒ Nirgundipatra (Fresh) - 250gm

⇒ Chinchapatra (Fresh) - 250gm

⇒ Water - 8litres

⇒ Sahacharadi Taila - 50-100ml

⇒ Gandharvahastadi Kwatha - 15ml

⇒ Attenders - Two

Clinical study 91

1. Nirgundipatras and Chinchapatras were washed and boiled in 8litres of water and

reduced to 4liters.

2. The patient was asked to pass natural urges, prior to the entry into the

Panchakarma theatre. The procedure was done in between 7-10AM. After

performing the sacred rights, the patient was asked to sit on the Taila droni. He

was then administered 15ml of Gandharvahastadi Kwatha mixed in 60ml of luke

warm water. Then, the Sahacharadi Taila was heated to luke warm and Abhyanga

was performed to the head & whole body for approximately 35 minutes (5

minutes in each of the 7 postures).

Pradhanakarma

• Initially, the decoction of the Nirgundi and Chinchapatras (4litres) was kept over

the burning charcoal in the lower compartment of the Bashpaswedanayantra, in

two separate vessels. To this, again little quantity of fresh leaves was added.

• The patient, who has been anointed with the Sahacharadi Taila, was asked to lie

down on the upper compartment of the Bashpaswedanayantra. Then his whole

body except the head was covered with the doom, thereby exposing his whole

body to the decoction steam. The patient was asked to gently move his extremities

and body so as to prevent excess concentration of warmth over one part.

• The patient was continued to steam exposure until total perspiration (especially

sweat over the forehead & nose).

Paschatkarma

After the sudation, patient was withdrawn from the Swedanayantra and the

body was cleaned off the sweat by a clean towel. After rest for 10 minutes, patient was

advised to take hot water bath (heated & cooled water for the head).

Clinical study 92

Pathya during treatment period & pariharakala

The pathyacharana is an important factor which was followed for 28days

including the treatment period & pathyacharana. The Snehapanavidhi was prescribed to

the patients. Patients were advised to take katu-tiktha-kashaya-rooksha varjitha

aharadravyas in light quantity. Rice gruel with little milk was advised as the ideal food.

Patient was advised to drink hot water only. Patient was advised to avoid sexual

intercourse, blocking of natural urges, traveling, exercise, over-speech, uneven sitting &

lying postures, exposure to wind, cold, heat and dust, anger and grief.

Methods Of Assessment Of Clinical Response

Clinical parameters and functional parameters were made out to assess the

clinical response in both the groups.

Clinical Parameters

1. Subjective

• Ruk (Pain) :- Grade 0 – No Complaints

Grade 1 – Tells on Enquiry

Grade 2 – Complains Frequently

Grade 3 – Excruciating Condition

• Graha (Stiffness) :- Grade 0 – Absent

Grade 1 – Present

2. Objective

• Sparshaakshamatva :- Grade 0 – No Complaints

(Tenderness) Grade 1 – Says the joint is tender

Grade 2 – Winces the affected joint

Grade3 –Winces and withdraws the

affected joint.

Clinical study 93

• Sandhigathi-Asaamarthya :-

(Limitation of joint movement) Grade 0 – No movement

Grade 1 – Up to 50% of the full

range of joint motion

Grade 2 – 50-75% of the full

range of joint motion

Grade 3 – >75% & <full range

Grade 4 – Full Range of joint

Motion

• Shotha (Swelling) :- Grade 0 – No Complaints

Grade 1 – Slightly obvious

Grade 2 – Covers well over the bony

prominence

Grade 3 – Much elevated

• Atopa (Crepitations) :- Grade 0 – None

Grade 1 – Felt

Grade 2 – Heard

Functional parameters –

AIMS (Arthritis Impact Measurement Scale) 206 and walking time207 were

considered to assess the functional improvement.

1. Subjective – AIMS is the scale of impact due to arthritis. It sums up the grades of

various variables.

Clinical study 94

Sl. Variables Very

satisfied

Somewhat

satisfied

Neither

satisfied nor

dissatisfied

Somewhat

dissatisfied

Very

dissatisfied

01. Mobility

level

1 2 3 4 5

02. Walking and

bending

1 2 3 4 5

03. Hand and

finger

function

1 2 3 4 5

04. Arm

function

1 2 3 4 5

05. Self care

tasks

1 2 3 4 5

06. House hold

tasks

1 2 3 4 5

07. Social

activity

1 2 3 4 5

08. Support

from family

and friends

1 2 3 4 5

09. Arthritis

pain

1 2 3 4 5

10. Work 1 2 3 4 5

11. Level of

tension

1 2 3 4 5

12. Mood 1 2 3 4 5

Clinical study 95

2. Objective: - Walking time to cover 21meters was recorded and distributed into the

following grades.

Grade 0 – Up to 20seconds

Grade 1 – 21-30seconds




All these parameters of baseline data to post-medication data (28th day)

were compared for clinical assessment of the results (assessment was also recorded on

the 14th day too).

Assessment Of Swedakarmukatha

This was done to ascertain the efficacy of both the Karmas in inducing the

benefits of Swedana in the individual groups. The following parameters were designed

basing on the Shamana-Sweda gunas explained by Sushrutha35.

• Agnideepti :- Grade 0 – No change/Absent

Grade 1 – Slight improvement/Present

Grade 2 – Good improvement

• Maardava :- Grade 0 – No change/Absent



• Tvakprasada :- Grade 0 – No change/Absent



Clinical study 96

• Tandrahaani :- Grade 0 – Absent

Grade 1 – Present

• Bhakthasradha :- Grade 0 – Absent

Grade 1 – Present

• Sandhicheshta :- Grade 0 – No movement

Grade 1 –Up to 50% of the full range of joint

motion

Grade 2 – 50-75% of the full range of joint

motion

Grade 3 – >75% & <full range

Grade 4 – Full Range of joint Motion

• Srothonirmalatva :- Grade 1 – Very satisfied

Grade 2 – Somewhat Satisfied

Grade 3 – Neither satisfied nor dissatisfied

Grade 4 – Somewhat dissatisfied

Grade 5 – Very dissatisfied

Overall Assessment Of Clinical Response

• Good Response : >60% improvement in clinical and functional

parameters

• Moderate Response : 31-60% improvement in clinical and functional

parameters

• Poor Response : 1-30% improvement in clinical and functional

parameters

• No Response : 0 % or No improvement in clinical and functional

parameters

Clinical study 97

37 patients were registered for the present study. Out of this, 7 patients

were excluded (2 drop outs and 5 not fulfilling the criteria for diagnosis); hence, their

data has not been included here. The remaining 30 patients of Sandhigatavata fulfilling

the criteria for diagnosis, were treated in the following two groups –

Group A – Shashtikashalipindasweda – 15 patients.

Group B – Abhyanga and Bashpasweda – 15 patients.

All the patients were examined before and after the treatment according to the

case sheet format given in the appendix. Both the subjective and objective changes were

recorded along with the assessment of Swedakaarmukata. The data recorded are

presented under the following heading –

I. Demographic data

II. Data related to the disease

III. Data related to over all response to the treatment

IV. Statistical analysis of the clinical and functional parameters and inter group

comparison.

V. Statistical analysis of the Swedakaarmukata.

Observation & Results 98

I. DEMOGRAPHIC DATA

A. Table No. 25. Showing Distribution of patients by age in both the treatment

groups (A & B):

Age

group

No. Of Patients.

In Group A

% No. Of Patients.

In Group B

% Total No.

Of

patients

Total

%

31-40 1 6.66 1 6.66 2 6.66

41-50 4 26.66 3 20 7 23.33

51-60 10 66.66 11 73.33 21 70

Among the 15 patients in the group A maximum number of patients fell in

the age group 51-60 i.e. 10 patients (66.66%), where as 4 patients (26.66%) fell in the age

group 41-50 and only one patient (6.66%) fell in the age group 31-40. Among the 15

patients in the group B, maximum numbers of patients, fell in the age group 51-60 i.e. 11

(73.33%), where as 3 patients (20%) fell in the age group 41-50 and only one patient

(6.66%) fell in the age group 31-40. In the study as a whole (30 patients), 2 patients

(6.66%) fell in the age group 31-40, 7 patients (23.33%) fell in the age group 41-50 and

21 patients (70%) fell in the age group 51-60.

Distribution of pts. by age

1

4

10

13

11

0246

81012

30-40 40-50 50-60

Age group

No.

of P

ts.

No. of Pts In Gr. A No. of Pts in Gr. B


B. Table No. 26 Showing the overall response of patients in various age groups in both

the treatment groups (A & B):

Group A Group B Total Age

Group No GR MR No MR PR No GR MR PR

31-40 1 - 1 1

1 - 2 - 2 -

41-50 4 2 2 3 3 - 7 2 5 -

51-60 10 5

5 11 10 1 21 5 15 1

Among the 15 patients in Group A, the only one patient in the age group

31–40 responded moderately; whereas in the 4 patients in the age group 41–50, 2 patients

had good response (50 %) and 2 patients had moderate response (50%) and in the 10

patients in the age group 51-60, 5 patients had good response (50 %) and 5 patients had

moderate response (50 %). Among the 15 patients in Group B, the only one patient in

the age group 31-40 responded moderately; whereas in the 3 patients in the age group

41–50 all the 3 had moderate response and in the 11 patients in the age group 51–60, 10

patients had moderate response (90.09%) and one patient responded poorly (9.09 %). In

the study as a whole (30 patients), 2patients in the age group 31–40 had moderate

response; in the 7 patients in the age group 41–50, 2 patients had good response (28.57

%) and 5 patients had moderate response (71,42%) and in the 21 patients in the age group

51-60, 5 patients had good response (23.8 %), 15 patients had moderate response

(71.42%) 15 patients had moderate response and one patient responded poorly (4.76 %).


2.A. Table No. 27. Showing the distribution of patients by sex in both the

treatment groups (A & B):

Sex No. Of Patients In

Group A

% No. Of Patients In

Group B

% Total No.

Of

Patients

Total

%

Male 7 46.66 7 46.66 14 46.66

Female 8 53.33 8 53.33 16 53.33

Among the 15 patients in the group A, 7 patients were males (46.66%) and

8 patients were females (53.33%). Among the 15 patients in the group B, 7 patients were

males (46.66%) and 8 patients were females (53.33%). In the study as a whole (30

patients), 14 patients were males (46.66%) and 16 patients were females (53.33 %).

Distribution of Pts by sex

7

8

7

8

6.5

7

7.5

8

8.5

Male FemaleSex

No. of

pts.

No. of Patients. In Gr. A

No. of Patients. In Gr. B


B. Table No. 28. Showing the overall response of patients of both sexes in both the


Group A Group B Total Sex

No GR MR No MR PR No GR MR PR

Male 7 3 4 7

7 - 14 3 11 -

Female 8 4 4 8 7 1 16 4 11 1

Among the patients in the group-A, 3 males (42. 85%) had good response

where as 4 males (57.14%) had moderate response; in the same group, 4 females (50%)

had good response and 4 females (50%) had moderate response. Among the 15 patients

in the group B, all the 7 males had moderate response, where as among the females, 7

(87.5%) had moderate response and 1 (12.5%) had poor response. In the study as a

whole (30 patients), among the 14 males, 3 (21.42%) had good response and 11 (78.57%)

had moderate response; whereas among the 16 females, 4 (25%) had good response, 11

(68.75 %) had moderate response and 1 (6.25%) had poor response.


3.A Table No. 29. Showing the distribution of Patients by Occupation in both the

treatment in both the treatment groups (A & B):

Occupation No. Of

Patients

In Group A

% No. Of

Patients

In Group B

% Total No.

Of Patients

Total %

Sedentary 4 26.66 3 20 7 23.33

Active 9 60 6 40 15 50

Labour 2 13.33 6 40 8 26.66

Others - - - - - -

Among the 15 patients in the group A, 4 patients (26.66%) were of

sedentary, 9 patients (60%) were active and 2 patients (13.33%) were labours. Among

the 15 patients in the Group B, 3 patients (20%) were sedentary, 6 patients (40%) were

active and 6 patients (40%) were labours. In the study as a whole (30 Patients), 7 patients

(23.33%) were sedentary, 15 patients (50%) were active and 8 patients (26.66%) were

labours.

43

9

6

2

6

0 002468

10

No.of

Pts.

Sedentary Active Labour Others

Occupation

Distribution of pts by occupation

No. of Patients. In Gr. A No. of Patients. In Gr. B


B. Table No. 30. Showing the overall Treatment Response in patients of various

occupations in both the treatment groups (A & B):

Group A Group B Total Occupation No GR MR No MR PR No GR MR PR

Sedentary 4 2 2 3 3 - 7 2 5 -

Active 9 4 5 6 6 - 15 4 11 -

Labour 2 1 1 6 5 1 8 1 6 1

Others - - - - - - - - - -

Among the 15 patients in group A, in the 4 sedentary patients, 2 patients

(50%) got good response and 2 (50%) got moderate response where as in the 9 active

patients, 4 patients (44.44%) got good response and 5 patients (55.55%) got moderate

response and in the 2 labour patients, 1 patient (50%) got good response and 1 patient

(50%) got moderate response. Among the 15 patients in the group B, all the 3 sedentary

patients got moderate response (100%) and all the active patients got moderate response

where as in the 6 labor patients, 5 patients got moderate response (83.33%) and 1 patient

got poor response (16.66%). In the study as a whole, among the 7 sedentary patients, 2

patients got good response (28.57%) and 5 patients got good response (71.42%). Among

the 15 active patients, 4 patients got good response (26.66%) and 11 patients got

moderate response and in the 8 labour patients, 1 patient got good response (12.5%), 6

patients got moderate response (75%) and 1 patient got poor response (12.5%).


4. Table No. 31. Showing the distribution of patients by Economical status in

both the treatment groups (A& B):

Economical

status

No. Of

Patients In

Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Poor 3 20 7 46.66 10 33.33

Middle class 7 46.66 7 46.66 14 46.66

Aristocrat 5 33.33 1 6.66 6 20

Among the 15 patients in group A, 3 patients were poor (20%), 7 patients

were of the middle class (46.66%) and 5 patients were aristocrat (33.33%). Among the 15

patients in the group B, 7 patients were poor (46.66%), 7 patients were of middle class

(46.66%) and1 patient was aristocrat (6.66%). In the study as a whole (30 Patients), 10

patients were poor (33.33%), 14 patients were of the middle class (46.66%) and 6

patients were of aristocrat (20%).

3

7 7 7

5

1

01234567

No.ofpts

Poor Mid ArsEconomical status

Distribution of pts by economical status



Table No. 32. Showing the distribution of patients by Religion in both the treatment

groups (A&B):

Religion No. Of Patients

In Group A

% No. Of

Patients

In Group B

% Total No. Of

Patients

Total

%

Hindu 10 66.66 11 73.33 21 70

Muslim 4 26.66 4 26.66 8 26.66

Christian 1 6.66 - - 1 3.33

Among the 15 patients in group A, 10 patients were Hindus (66.66%), 4

patients were Muslims (26.66%) and 1 patient was Christian (6.66%). Among the 15

patients in group B, 11 patients were Hindus (73.33%) and 4 patients were Muslims

(26.66%). In the study as a whole (30 patients), 21 patients were Hindus (70%), 8

patients were Muslims (26.66%) and 1 patient was Christian (3.33%).

10 11

4 41 00

5

10

15

No.ofpts

Hindu Muslim Christian

Religion

Distribution of pts by religion



Table No. 33. Showing the distribution of Patients by Dietary habit in both the treatment

groups (A &B):

Dietary

habit

No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Vegetarian 6 40 10 66.66 16 53.33

Mixed 9 60 5 33.33 14 46.66

Among the 15 patients in group A, 6 patients were vegetarians (40%) and

9 patients were having mixed dietary habits (60%). Among the 15 patients in group B, 10

patients were vegetarians (66.66%) and 5 patients were having mixed dietary habits

(33.33%). In this study as a whole (30 patients), 16 patients were vegetarians (53.33%)

and 14 patients were having mixed dietary habits (46.66%).

6

109

5

02468

10

No.ofpts

Vegetarian MixedDietary habit

Distribution of pts by diet



7.A Table No. 34. Showing the distribution of Patients by Agni in both the treatment

groups (A & B):

Agni No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Manda 7 46.66 9 60 16 53.33

Teekshna - - - - - -

Vishama 5 33.33 4 26.66 9 30

Sama 3 20 2 13.33 5 16.66

Among the 15 patients in group A, 7 patients were having Manda agni

(46.66%), 5 patients were having vishama agni (33.33%) and 3 patients were having

sama agni (20%). Among the 15 patients in group B, 9 patients were having Manda agni

(60%), 4 patients were having vishama agni (26.66%) and 2 patients were having sama

agni (13.33%). In the study as a whole, 16 patients were having manda agni (53.33%)

patients were having vishama agni (30%) and 5 patients were having sama agni

(16.66%). No patients reported with Teekshna agni in this study.

79

0 0

54

32

02468

10

Noofpts

Md Tk Vs SAgni

Distribution of pts by agni



B. Table No. 35. Showing the overall treatment response in Patients by of all types of

Agni in both the treatment groups:

Group A Group B Total Agni No GR MR No MR PR No GR MR PR

Manda 7 3 4 9 8 1 16 3 12 1

Teekshna - - - - - - - - - -

Vishama 5 2 3 4 4 - 9 2 7 -

Sama 3 2 1 2 2 - 5 2 3 -

In the group A, among the 7 patients of Manda agni, 3 patients had good

response (42.85%) and 4 patients had moderate response (57.14%) whereas among the 5

patients of vishama agni, 2 patients had good response (40%) and 3 patients had

moderate response (60%) and among the 3 patients of sama agni, 2 patients had good

response (66.66%) and 1 patient had moderate response (33.33%). In group B, among the

9 patients of manda agni, 8 patients had moderate response (88.88%) and 1 patient had

poor response (11.11%) where as all the 4 patients of vishama agni responded moderately

and both the patients of sama agni responded moderately. In the study as a whole (30

patients), among the 16 patients of manda agni, 3 patients had good response (18.75%),

12 patients had moderate response (75%) and 1 patient had poor response (6.25 %)

whereas among the 9 patients of vishama agni, 2 patients had good response (22.22%)

and 7 patients had moderate response (77.77%) and among the 5 patients of sama agni 2

patients had good response (40 %) and 3 patients had moderate response (60%).


8. A. Table No. 36. Showing the distribution of patients by koshta in both the treatment

groups

Koshta No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Madhya 5 33.33 4 26.66 9 30

Mridu 1 6.66 1 6.66 2 6.66

Krura 9 60 10 66.66 19 63.66

Among the 15 patients in group A, 5 patients were having Madhya koshta

(33.33%), 1 patient was having Mridu koshta (6.88%) and 9 patients were having Krura

koshta (60%). Among the 15 patients in group B, 4 patients were having Madhya koshta

(26.66%), one patient was having Mridu koshta (6.66%) and 10 patients were having

Krura koshta (66.66%). In the study as a whole (30 patients), 9 patients were having

Madhya koshta (30%), 2 patients were having Mridu koshta (6.66%), and 19 patients

were having Krura koshta (63.66%).

54

1 1

910

02468

10

No.ofpts

Madhya Mridu Krura

Koshta

Distribution of pts by koshta



B. Table No. 37. Showing the overall treatment response in patients of All

types of Koshta in both the treatment groups (A & B):

Group A Group B Total Koshta


Madhya 5 4 1 4

4 - 9 4 5 -

Mridu 1 - 1 1 1 - 2 - 2 -

Krura 9 3 6 10 9 1 19 3 15 1

In group A, among the 5 patients of Madhya koshta, 4 patients got good

response (80%) and 1 patient got moderate response (20%) where as the one patient of

Mridu koshta got moderate response and among the 9 patients of Krura koshta, 3 patients

got good response (33.33%) and 6 patients got moderate response (66.67%). In groupB,

all the 4 patients of Madhya koshta got moderate response and the one patient of Mridu

koshta got moderate response, whereas among the 10 patients of Krura koshta, 9 patients

got moderate response (90%) and one patient got poor response (10%). In the study as a

whole (30 patients), among the 9 patients of Madhya koshta, 4 patients got good response

(44.44%) and 5 patients got moderate response (55.55%) where as both the 2 patients of

Mridukoshta got moderate response and among the 19 patients of Krura koshta, 3 patients

got good response (15.75%), 15 patients got moderate response (78.94%) and 1 patient

got poor response (5.26%).


9. Table No. 38. Showing the distribution of Patients by Nidra in both the


Nidra No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Sukha - - - - - -

Alpa 9 60 11 73.33 20 66.66

Ati - - 1 6.66 1 3.33

Vishama 6 40 3 20 9 30

Among the 15 patients in group A, 9 patients had alpa nidra (60%) and 6

patients had vishama nidra (40%). Among the 15 patients in group B, 11 patients had

alpa nidra (73.33%), 1 patient had ati nidra (6.66%) and 3 patients had vishama nidra

(20%). In the study as a whole (30 patients), 20 patients had alpa nidra (66.66%), one

patient had ati nidra (3.33%) and 9 patients had vishana nidra (30%). No patient reported

with sukha nidra in this study.

00

911

0 1

63

0 2 4 6 8 10 12No. of pts

Sk

Alpa

Ati

Vs

nidr

a

Distribution of pts by nidra



Table No. 39. Showing the distribution of patients by Vyasana in both the treatment

groups (A & B):

Vyasana No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No.

Of

Patients

Total

%

Smoking 2 13.33 1 6.66 3 10

Tobacco 9 60 5 33.33 14 46.66

Alcohol 3 20 6 40 9 30

Others - - - - - -

None 1 6.66 3 20 4 13.33

Among the 15 Patients in group A, 2 patients had smoking habit (13.33%),

9 patients had tobacco habit (60%), 3 patients had alcohol habit (20%) and 1 patient had

no habits (6.66%). Among the 15 patients in group B, 1 patient had smoking habit

(6.66%), 5 patients had tobacco habit (33.33%), 6 patients had alcohol habit (40%) and 3

patients had no habits (20%). In the study as a whole, 3 patients had smoking habit

(10%), 14 patients had tobacco habit (46.66%), 9 patients had smoking habit (30%) and 4

patients had no habits (13.33%). No patient reported in this study had any other habits.

21

9

5

3

6

0 01

3

0

2

4

6

8

10

No.ofpts

Smk Tbc Alc Oth NnVyasana

Distribution of pts by Vyasana



10. Table No. 40. Showing the distribution of Patients by Deha prakrithi in

both the treatment groups ( A & B ):

Deha

prakriti

No. Of

Patients In

Group A

% No. Of

Patients In

Group B

% Total No. Of

Patients

Total

%

Vata 2 13.33 2 13.33 4 13.33

Pitta - - - - - -

Kapha 1 6.66 - - 1 3.33

Vata-pitta 6 40 7 46.66 13 43.33

Vata-kapha 5 33.33 3 20 8 26.66

Pitta-kapha 1 6.66 3 20 4 13.33

Sannipataja - - - - - -

Among the 15 patients in group A, 2 patients were of Vata prakriti

(13.33%), 1 patient of Kapha prakriti (6.66 %), 6 patients of Vata – Pitta prakriti (40%), 5

patients of Vata–kapha prakriti (33.33%) and 1 patient of Pitta-Kapha prakriti (6.66%).

Among the 15 patients in group B, 2 patients were of Vata prakriti (13.33%), 7 patients

of Vata-pitta prakriti (46.66%), 3 patients of Vata-kapha prakriti and 3 patients of Pitta-

kapha prakriti (20%). In the study as a whole (30 patients), 4 patients were of Vata

prakriti (13.33%), 1 patient of Kapha prakriti (3.33%), 13 patients of Vata–pitta prakriti

(43.33%), 8 patients of Vata–kapha prakriti (26.66%) and 4 patients of Pitta–kapha

prakritti (13.33%). No patients reported with Pitta / sannipatha prakriti in this study.

2 2

0 01

0

67

5

3

1

3

0 001234567

No.ofpts

V P K VP VK PK SPrakriti

Distribution of pts by deha prakriti



B. Table No. 41. Showing the overall Treatment Response in patients of all types of

Dehaprakrithi in both the treatment groups ( A & B):

Group A Group B Total Deha prakriti No GR MR No MR PR No GR MR PR

Vata 2 1 1 2 1 1 4 1 2 1

Pitta - - - - - - - - - -

Kapha 1 - 1 - - - 1 - 1 -

Vata-pitta 6 3 3 7 7 - 13 3 10 -

Vata-kapha

5 2 3 3 3 - 8 2 6 -

Pitta-kapha

1 1 - 3 3 - 4 1 3 -

Sannipataja

- - - - - - - - - -

In group A, among the 2 patients of vata prakriti, 1 patient got good

response (50%) and 1 patient got moderate response (50%). The patient of kapha prakriti

got moderate response. Among 6 patients of vata-pitta prakriti, 3 patients got good

response (50%) and 3 patients got moderate response (50%). Among 5 patients of vata-

kapha prakriti, 2 patients got good response (40%) and 3 patients got moderate response

(60%). The patient of pitta-kapha prakriti got good response. In group B, among the 2

patients of vata prakriti, 1 patient got moderate response (50%) and 1 patient got poor

response (50%). All the 7 patients of vata–pitta prakriti got moderate response, all the 3

patients of vata-kapha prakriti got moderate response and all the 3 patients of pitta–kapha

prakriti got moderate response. In the study as a whole (30 patients), among the 4

patients of vata prakriti, 1 patient got good response (25%), 2 patients got moderate

response (50%) and 1 patient got poor response (25%). The only one patient of kapha

prakriti got moderate response. Among the 13 patients of vata-pitta prakriti, 3 patients got

good response (23.07%) and 10 patients got moderate response (76.92%). Among the 8

patients of vata–kapha prakriti, 2 patients got good response (25%) and 6 patients got

good response (75 %). Among the 4 patients of pitta–kapha prakriti, 1 patient got good

response (25%) and 3 patients got moderate response (75%).


11. Table No. 42. Showing the distribution of patients by Satmya in both the


Satmya No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Rooksha 13 86.66 15 100 28 93.33

Snigdha 2 13.33 - - 2 6.66

Among the 15 patients in group A, 13 patients were of rooksha satmya

(86.66%) and 2 patients were of snigdha satmya (13.33%). All the patients of group B,

were of rooksha satmya. In the study as a whole (30 patients), 28 patients were of

rooksha satmya (6.66%) and 2 patients were of snigdha satmya.

1315

2 00

5

10

15

No.of

pts.

Rooksha SnigdhaSatmya

Distribution of pts by satmya



II. DATE RELATED TO THE DISEASE

1. CHIEF COMPLAINTS:

A. RUK

A. 1. Table No. 43. Showing the distribution of patients by different grades of

RUK in both the treatment groups (A & B):

Ruk No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Grade 0 - - - - - -

Grade 1 - - - - - -

Grade 2 7 46.66 6 40 13 43.33

Grade 3 8 53.44 9 60 17 56.66

Among the 15 patients in group A, 7 patients had the ruk of grade–2

(46.66 %) and 8 patients had the ruk of grade –3 (53.44%) before the treatment. Among

the 15 patients in group B, 6 patients had the ruk of grade –2 (40%) and 9 patients had the

ruk of grade 3 (60%). Before the treatment in the study as a whole (30 patients), 13

patients had the ruk of grade–2 (43.33%) before the treatment and 17 patients had the ruk

of grade-3 (56.66%). Before the treatment, no patients reported with grade–0 and grade–1

pains.

0 0 0 0

76

89

0

2

4

6

8

10

No.ofpts

Gr 0 Gr 1 Gr 2 Gr 3Grades of Ruk

Distribution of pts by diff. grades of Ruk



A. 2. Table No. 44. Showing the overall treatment response in patients of different grades

of Ruk in both the treatment groups (A & B):

Group A Group B Total Ruk


Grade 0 - - - -

- - - - - -

Grade 1 - - - - - - - - - -

Grade 2 7 4 3 6 5 1 13 4 8 1

Grade 3 8 3 5 9 9 - 17 3 14 -

In the group A, among the 7 patients of Ruk grade–2, 4 patients got good

response (57.14 %) and 3 patients got moderate response (42.85 %); among the 8 patients

of Ruk grade–3, 3 patients good response (37.5 %) and 5 patients got moderate response

(62.5 %). In the group B, among the 6 patients of Ruk grade–2, 5 patients got moderate

response (83.33%) and 1 patient got poor response (16.66%); all the patients of Ruk

grade–3 got moderate response. In the study as a whole (30 patients), among 13 patients

of Ruk grade–2, 4 patients got good response (30.76%), 8 patients got poor response

(7.69%); whereas among the 17 patients of Ruk grade–3, 3 patients got good response

and 14 patients got moderate response.


B.GRAHA

B. 1. Table No. 45. Showing the distribution of patients by different grades of

Graha in both the treatment groups (A& B):

Graha No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Grade 0 - - - - - -

Grade 1 15 100 15 100 30 100

All the patients (in groups A & B), had grade–1 graha (100%) before the

treatment.

0 0

15 15

0

5

10

15

No. Ofpts

Grade 0 Grade 1Graha

Distribution of pts by DIff. grades of graha`



B. 2. Table No. 46. Showing the overall Treatment Response in Patients of different

grades of Graha in both the treatment groups (A& B):

Group A Group B Total Graha


Grade 0 - - - -

- - - - - -

Grade 1 15 7 8 15 14 1 30 7 22 1

In group A among the 15 patients of grade–1 Graha, 7 patients got good

response (46.66%) and 8 patients got moderate response (53.33 %). In group B among

the 15 patients of grade–1 Graha, 14 patients got moderate response (93.33%) and 1

patient got poor response (6.66%). In the study as a whole (30 patients), among the 30

patients of grade–1 Graha, 7 patients got good response (23.33%), 22 patients got

moderate response (73.33%) and 1 patient got poor response (3.33%).


C. SPARSHAAKSHAMATVA

B. Table No. 47. Showing the distribution of patients by different grades of Sparsha

akshamatva in both the treatment groups (A &B):

Sparsha

akshamatva

No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Grade 0 3 20 4 26.66 7 23.33

Grade 1 3 20 4 26.66 7 23.33

Grade 2 9 60 7 46.66 16 53.33

Grade 3 - - - - - -

Among the 15 patients in group A, 3 patients had Sparsha akshamatva of

grade–0 (20%), 3 patients had Sparsha akshamatva of grade–1 (20%) 3 patients had

Sparsha akshamatva of grade–1(20%) and 9 patients had Sparsha akshamatva of grade–2

(60%) before the treatment. Among the 15 patients in group B, 4 patients had Sparsha

akshamatva of grade–0 (26.66%), 4 patients had Sparsha akshamatva of grade–1

(26.66%) before the treatment. In the study as a whole (30 patients), 7 patients had

Sparsha akshamatva of grade 0 (23.33%), 7 patients had Sparsha akshamatva of grade–1

(23.3%) and 16 patients had Sparsha akshamatva of grade-2 (53.33%) before the

treatment. No patients reported with Group 3 Sparsha akshamatva in this study.

34

34

97

0 00

2

4

6

8

10

No. of pts.

Gr 0 Gr 1 Gr 2 Gr 3Grades

Distribution of pts by Diff. grades of sparsha akshamatwa

No. of Pts. In Gr. A No. of Pts. In Gr. B


C. 2. Table No. 48. Showing the overall Treatment Response in Patients of different

grades of Sparsha Akshamatva in both the treatment groups (A & B):

Group A Group B Total Sparsha

akshama

tva No GR MR No MR PR No GR MR PR

Grade 0 3 1 2 4 3 1 7 1 5 1

Grade 1 3 2 1 4 4 - 7 2 5 -

Grade 2 9 4 5 7 7 - 16 4 12 -

Grade 3 - - - - - - - - - -

In the group A, among the 3 patients of grade-0, 1 patient got good

response (33.33%) and 2 patients got moderate response (66.66%); whereas among the 3

patients of grade–1, 2 patients got good response (66.66%) and 1 patient got moderate

response (33.33%) and among the 4 patients of grade–2, 4 patients got good response

(44.44%) and 5 patients got moderate response (55.55%). In the group B, among the 4

patients of grade–0, 3 patients got moderate response (75%) and 1 patient got poor

response (25%) whereas all the patients of grade–1 and grade–2 got moderate response.

In the study as a whole (30 patients), among the 7 patients of grade–0, 1 patient got good

response (14.28%), 5 patients got moderate response (71.42%) and 1 patient got poor

response (14.28%); where as among the 7 patients of grade–1, 2 patients got good

response (28.57%) and 5 patients got moderate response (71.42%); among the 16 patients

of grade–2,4 patients got good response (25%) and 12 patients got moderate response

(75%).


D.SANDHIGATHIASAAMARTHYA

D.1. Table No. 49. Showing the distribution of patients by different grade of

Sandhigati asaamarthya in both the treatment groups (A & B):

Sandhigati

asaamarthya

No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Grade 0 - - - - - -

Grade 1 10 66.66 7 46.66 17 56.66

Grade 2 5 33.33 8 53.33 13 43.33

Grade 3 - - - - - -

Grade 4 - - - - - -

Among the 15 patients in group A, 10 patients had Sandhigati asaamarthya

of grade-1 (66.66%) and 5 patients had Sandhigati asaamarthya of grade–2 (33.33%)

before the treatment. Among the 15 patients in group B, 7 patients had Sandhigati

asaamarthya of grade–1 (46.66%) and 8 patients had Sandhigati asaamarthya of grade–2

(53.33%). Before the treatment, in the study as a whole (30 patients), 17 patients had

Sandhigati asaamarthya of grade–1 (56.66%) and 13 patients had Sandhigati asaamarthya

of grade–2 (43.33 %). No patients reported with grades-0, 3&4 Sandhigati asaamarthya

before the treatment in this study.

Distribution of pts by Diff. gds. of SGA

0

10

5

0 00

78

0 00

2

4

6

8

10

12

Grade 0 Grade 1 Grade 2 Grade 3 Grade 4Grades

No.

of p

ts.



D. 2. Table No. 50. Showing the overall Treatment Response in patients of

different Grades of Sandhigati asaamarthya in both the treatment groups (A & B):

Group A Group B Total Sparsha

akshama

tva No GR MR No MR PR No GR MR PR

Grade 0 - - - - - - - - - -

Grade 1 10 4 6 7 7 - 17 4 13 -

Grade 2 5 3 2 8 7 1 13 3 9 1

Grade 3 - - - - - - - - - -

Grade 4 - - - - - - - - - -

In the group A, among the 10 patients with grade–1, 4 patients got good

response (40%) and 6 patients got moderate response (60%) where as among the 5

patients with grade–2, 3 patients got good response (60 %) and 2 patients got moderate

response (40%). In the group B, among the 7 patients with grade–1 all got moderate

response, while among the 8 patients with grade–2, 7 patients got moderate response

(87.5%) and 1 patient got poor response (12.5%). In the study as a whole (30 patients),

among the 17 patients of grade–1, 4 patients got good response (23.52%) and 3 patients

got moderate response (76.47%); where as among the 13 patients with grade 2, 3 patients

got good response (23.07%), 9 patients got moderate response (69.28%) and 1 patient got

poor response (7.69%).


E. ATOPA

E. 1. Table No 51. Showing the distribution of patients by different grades of

Atopa with both the treatment groups (A & B):

Atopa No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

Patients

Total

%

Grade 0 4 26.66 3 20 7 23.33

Grade 1 10 66.66 12 80 22 73.33

Grade 2 1 6.66 - - 1 3.33

Among the 15 patients in group A, 4 patients had grade-0 Atopa (26.66%),

10 patients had grade-2 Atopa (6.66%) before the treatment. Among the 15 patients in

group B, 3 patients had grade-0 Atopa (20%) and 12 patients had grade-1 Atopa (80%)

before the treatment. In the study as a whole (30 patients), 7 patients had grade-0 Atopa

(23.33%), 22 patients had grade-1 Atopa (73.33%) and 1 patient had grade-2 Atopa

(3.33%) before the treatment.

43

1012

1 002

46

81012

No.of

pts.

Grade 0 Grade 1 Grade 2Grades

Distribution of pts. by Diff. gds of Atopa



E. 2. Table No. 52. Showing the overall treatment response in patients of different grades

of Atopa in both the treatment groups (A & B):

Group A Group B Total Atopa


Grade 0 4 2 2 3 2 1 7 2 4 1

Grade 1 10 5 5 12 12 - 22 5 17 -

Grade 2 1 - 1 - - - 1 - 1 -

In the group A, among the 4 patients with grade-0 Atopa, 2 patients had good

response (50%) and 2 patients had moderate response (50%); whereas among the 10

patients with grade-2 Atopa had moderate response. In the group B, among the 3 patients

with grade-0 Atopa, 2 patients had moderate response (66.66%), 1 patients had moderate

response (33.33%); where as among the 12 patients with grade-1 Atopa all had moderate

response. In the study as a whole, among the 7 patients with grade-0 Atopa, 2 patients

had good response (28.57%) and 4 patients had moderate response (57.14%) and 1

patient had poor response (14.28%); whereas among the 22 patients with grade-1 Atopa,

5 patients had good response (22.72%) and the 17 patients had moderate response

(72.72%) and the one patient with grade-2 Atopa had moderate response.


F. SHOPHA

F. 1. Table No. 53. Showing the distribution of patients by different gradings of

Shopha in both the treatment groups (A & B):

Shopha No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Grade 0 5 33.33 4 26.66 9 30

Grade 1 7 46.66 5 33.33 12 40

Grade 2 2 13.33 6 40 8 26.66

Grade 3 1 6.66 - - 1 3.33

Among the 15 patients in group A, 5 patients had grade-0 Shopha

(33.33%), 7 patients had grade-1 Shopha (46.66%), 2 patients had grade-1 Shopha

(13.33%) and 1 patient had grade-3 Shopha (6.66%) before the treatment. Among the 15

patients in group B, 4 patients had grade-0 Shopha (26.66%), 5 patients had grade-1

Shopha (33.33%) and 6 patients had grade-2 Shopha (40%) before the treatment. In the

study as a whole (30 patients), 9 patients had grade 0 Shopha (30%), 12 patients had

grade-1 Shopha (40%), 8 patients had grade-2 shopha (26.66%) and 1 patient had grade-3

Shopha (3.33%) before the treatment.

54

7

5

2

6

100

1234567

No.of

pts.

Grade 0 Grade 1 Grade 2 Grade 3Grades

Distribution of pts. by Diff. gds of shopha

No. of Pts. In Gr. A No.of Pts. In Gr. B


F. 2. Table No. 54. Showing the overall treatment response in patients of different grades

of shopha in both the treatment groups (A & B):

Group A Group B Total Shopha


Grade 0 5 2 3 4 3 1 9 2 6 1

Grade 1 7 3 4 5 5 - 12 3 9 -

Grade 2 2 2 - 6 6 - 8 2 6 -

Grade 3 1 - 1 - - - 1 - 1 -

In the group A, among the 5 patients with grade-0, 2 patients got good

response (40%) and 3 patients got moderate response (60%); whereas among the 7

patients with grade-1, 3 patients got good response (42.85%) and 4 patients got moderate

response (57.14%) and the 2 patients with grade-2 got good response and 1 patient with

grade-3 got moderate response. In the group B, among the 4 patients with grade-0, 3

patients got moderate response (75%) and 1 patient got poor response (25%); whereas all

the 5 patients with grade-1 and all the 6 patients with grade-2 got moderate response. In

the study as a whole (30 patients), among the 9 patients with grade-0, 2 patients got good

response (22.22%), 6 patients got moderate response (66.66%) and 1 patient got poor

response (11.11%); whereas among the 12 patients with grade-1, 3 patients got good

response (25%) and 9 patients got moderate response (75%); among the 8 patients with

grade-2, 2 patients got good response (25%) and 6 patients got good response (75%) and

the only 1 patient with grade-3 got moderate response.


G. Table No. 55. Showing the distribution of patients by chief complaints in the

study as a whole (30 patients)

Sl. Presenting complaint No. of Patients %

1 Prasarana akunchanayoho savedana

pravritti

27 90

2 Ruk 30 100

3 Vatapoorna dritisparsha 4 13.33

4 Shopha 21 70

5 Sandhigraha 30 100

6 Sandhigati asaamarthya 30 100

7 Sparsha akshamatva 23 76.66

8 Atopa 23 76.66

Among the 30 patients included in this study, all the patients had the

symptoms Ruk, Sandhi graha and Sandhigati asaamarthya. 27 patients had the symptom

prasarana akunchanayoho savedana pravritti (90%). Only 4 patients had the symptom

Vatapoorna dritisparsha (13.33%) whereas 21 patients had the symptom Shopha (70%)

and 23 patients had the symptom Sparsha akshamatva (76.66%) and an equal number of

patients had the symptom Atopa (76.66%).

Distribution of pts. by chief complaints27

30

4

21

30 30

23 23

0

5

10

15

20

25

30

35

PAS Ruk VPD Shopha SG SGA SPA Atopa

No. of Patients


2. A. Table No. 56. Showing the distribution of patients by duration of the disease in

both the treatment groups (A & B)

Duration No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

>2 years (A) 4 26.66 1 6.66 5 16.66

1-2years (B) 6 40 12 80 18 60

<1year (C) 5 33.33 2 13.33 7 23.33

Among the 15 patients in group A, 4 patients had a duration > 2 years

(26.66%), 6 patients had duration 1-2 years (40%) and 5 patients had a duration < 1 year

(33.33%). Among the 15 patients in group B, 1 patient had a duration > 2 years (6.66%),

12 patients had a duration 1-2years(80%) and 2 patients had a duration < 1 year

(13.33%). In the study as a whole (30 patients), 5 patients had a duration > 2 years

(16.66%), 18 patients had a duration 1-2 years (60%) and 7 patients had a duration < 1

year (23.33%).

2. B. Table No. 57. Showing the overall treatment response in patients of various

durations in both the treatment groups (A & B):

Group A Group B Total Duration


>2 years

(A)

4 1 3 1 1 - 5 1 4 -

1-2years

(B)

6 4 2 12 12 - 18 4 14 -

<1year

(C)

5 2 3 2 1 1 7 2 4 1


In the group A, among the 4 patients with > 2 years duration, only 1

patient had good response (25%) while 3 patients had moderate response (75%); among

the 6 patients with 1-2 years duration, 4 patients had good response (66.66%) while 2

patients had moderate response (33.34%); among the 5 patients with < 1 year duration, 2

patients had good response (40%) while 3 patients had moderate response (60%). In the

group B, the only one patient with > 2 years got moderate response and all the 12 patients

with 1-2 years duration got moderate response while among the 2 patients with < 1 year

duration, 1 patient got poor response (50%) and 1 patient got poor response (50%). In the

study as a whole (30 patients), among the 5 patients with > 2 years duration, 1 patient got

good response (20%) and 4 patients got moderate response (80%); among the 18 patients

with 1-2 years duration, 4 patients got good response (22.22%) and 14 patients got

moderate response (77.77%); among the 7 patients with < 1 year duration, 2 patients got

good response (28.57%), 4 patients got moderate response (57.14%) and 1 patient got

poor response (14.28%).

3.A Table No. 58. Showing the distribution of patients by mode of on set in both

the treatment groups (A &B):

Mode of

onset

No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Chronic 10 66.66 12 80 22 73.33

Insidious 3 20 2 13.33 5 16.66

Acute - - 1 6.66 1 3.33

Traumatic 2 13.33 - - 2 6.66


Among the 15 Patients in group A, 10 patients had chronic onset

(66.66%), 3 patients had insidious onset (20 %) and 2 patients had traumatic onset

(13.33%). Among the 15 patients in group, 12 patients had chronic onset (80%), 2

patients had insidious onset (13.33%) and 1 patient had acute onset (6.66%). In the study

as a whole (30 patients), 22 patients had chronic onset (73.33%), 5 patients had insidious

onset (73.33%), 1 patient had acute onset (3.33%) and 2 patients had traumatic onset

(6.66 %).

C. Table No. 59. Showing the overall Treatment Response in patients of various

modes of onset in both the treatment groups (A & B):

Group A Group B Total Mode of

onset No GR MR No MR PR No GR MR PR

Chronic 10 5 5 12 12 - 22 5 17 -

Insidious 3 1 2 2 2 - 5 1 4 -

Acute - - - 1 - 1 1 - - 1

Traumatic 2 1 1 - - - 2 1 1 -

In the group A, among 10 patients of chronic onset, 5 patients got good

response (50%) and 5 patients got moderate response (50%); among the 3 patients of

insidious onset, 1 patient got good response (33.33%) and 2 patients got moderate

response (66.66%); among the 2 patients of traumatic onset, 1 patient got good response

(50%) and 1 patient got moderate response (50%). In the group B, all the 12 patients of

chronic onset and both the patients of insidious onset got moderate response, while the 1

patient of acute onset got poor response. In the study as a whole (30 patients), among the

22 patients of chronic onset, 5 patients got good response (22.72%) and 17 patients got

moderate response (77.27%); among the 5 patients of insidious onset, patient got good


response (80%) and 4 patients got moderate response (80%) the only one patient of acute

onset got poor response while among the two patients of traumatic onset one patient got

good responses (50%) and one patient got moderate response (50%).

4.1 A. Table No. 60. Showing the distribution of patients by the different joints

affected in both the treatment groups (A & B):

Joint

affected

No. Of Patients

In Group A

% No. Of Patients

In Group B

% Total No. Of

patients

Total

%

Knee 13 86.66 12 80 25 83.33

Lumbar spine 2 13.33 3 20 5 16.66

Among the 15 patients in group A, 13 patients had their knee joint affected

(86.66%) and 2 patients had their lumbar spine affected (13.33%).

Among the 15 patients in group B, 12 patients had their knee joint affected (80%) and 3

patients had their lumbar spine affected (20%). In the study as a whole, 25 patients had

their knee joint affected (83.33%) and 5 patients had their lumbar spine affected

(16.66%).

13 12

2 3

02468

101214

No.of

pts.

Knee Lumbar spineJoint

Distribution of pts. by joints affected



1.B. Table No. 61. Showing the overall Treatment Response in Patients of

various joint involvement in both the treatment groups ( A & B ):

Group A Group B Total Joint

affected


Knee 13 6 7 12

12 - 25 6 19 -

Lumbar

spine

2 1 1 3 2 1 5 1 3 1

In the group A, among the 13 patients with knee joint involvement, 6

patients got good response (46.15%) and 7 patients got moderate response (53.84 %)

where as among the 2 patients with lumbar involvement one patient got good response

(50 %) and 1 patient got moderate response (50%). In the group B, among the 12

patients with knee involvement, all got moderate response where as among the 3 patients

with lumbar involvement, 2 patients got moderate response (66.66 %) and 1 patient got

poor response (33.33 %). In the study as a whole (30 patients), among the 25 patients

with knee involvement, 6 patients got good response (24 %) and 19 patients got moderate

response (76 %) and among the 5 patients with lumbar spine involvement, 1 patient got

good response (20%), 3 patients got moderate response (60%) and 1 patient got poor

response (20%).


4.2 Table No. 62. Showing the distribution of patients by the type of Knee joint

involvement in both the treatment Groups (A & B):

Type of joint

involvement

No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Unilateral 9 69.23 8 66.66 17 68

Bilateral 4 30.76 4 33.33 8 32

Among the 13 patients of knee involvement in group A, 9 patients had

unilateral joint involvement (69.23%) while 4 patients had bilateral joint involvement

(30.76%). Among the 12 patients of knee involvement in group B, 8 had unilateral joint

involvement (66.66%) and 4 patients had bilateral involvement (33.33%). In the study,

among the 25 patients of knee involvement, 17 patients had unilateral involvement (68%)

and 8 patients had bilateral involvement (32%).

5.1. A Table No. 63. Showing the distribution of Patients by various Aharaja

Vatakopa Nidanas in both the treatment groups (A & B):

Aharaja

nidana

No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Tikta rasa 3 20 1 6.66 4 13.33

Kashaya rasa 4 26.66 5 33.33 9 30

Katu rasa 14 93.33 15 100 29 96.66

Alpa bhojana 6 40 11 73.33 17 56.66

Pramita

bhojana

2 13.33 1 6.66 3 10

Rooksha

bhojana

11 73.33 13 86.66 24 80


Among 15 patients in group A, 3 patients had tikta rasa atisevana (20%), 4

patients had kashaya rasa atisevana (26.66%), 14 patients had katu rasa atisevana

(93.33%), 6 patients had alpa bhojana (40%), 2 patients had pramita bhojana (13.33%)

and 11 patients had rooksha bhojana (73.33%). Among 15 patients in group B, 1 patient

had tikta rasa atisevana (6.66%), 5 patients had kashaya rasa atisevana (33.33%), 15

patients had katu rasa atisevana (100%), 11 patients had alpa bhojana (73.33%), 1 patient

had pramita bhojana (6.66%) and 13 patients had rooksha bhojana (86.66%). In the study

as a whole (30 patients), 4 patients had tikta rasa atisevana (13.33%), 9 patients had

kashaya rasa atisevana (30%), 29 patients had katu rasa atisevana (96.66%), 17 patients

had alpa bhojana (56.66%), 3 patients had pramita bhojana (10%) and 24 patients had

rooksha bhojana (80%).

Distribution of pts. by aharaja nidana

3 4

14

6

2

11

1

5

15

11

1

13

02468

10121416

TkR KsR KtR AlBh PrBh RkBhNidana

No.

of p

ts.



5.1.B Table No. 64. Showing the overall Treatment Response in Patients having various

Aharaja Vatakopa nidana in both the treatment groups:

Group A Group B Total Aharaja nidana


Tikta rasa 3 2 1 1

1 - 4 2 2 -

Kashaya rasa

4 3 1 5 5 - 9 3 6 -

Katu rasa 14 7 7 15 14 1 29 7 21 1

Alpa bhojana

6 2 4 11 11 - 17 2 15 -

Pramita bhojana

2 1 1 1 1 - 3 1 2 -

Rooksha bhojana

11 5 6 13 12 1 24 5 18 1

In group A, among 3 patients having tikta rasa nidana, 2 patients got good

response (66.66%) and 1 patient got moderate response (33.33%); among 4 patients

having kashaya rasa nidana, 3 patients got good response (75%) and 1 patient got

moderate response (25%); among 14 patients having katu rasa nidana, 7 patients got good

response (50%) and 7 patients got moderate response (50%); among 6 patients having

alpa bhojana nidana, 2 patients got good response (33.33%) and 4 patients got moderate

response (66.66%) ; among 2 patients having pramita bhojana, 1 patient got good

response (50%) and 1 patient got moderate response (50%) ; among 11 patients having

rooksha bhojana nidana, 5 patients had good response (45.45%) and 6 patients had

moderate response (54.54%).


In group B, the one patient having tikta rasa nidana got moderate response and all

the 5 patients having kashaya rasa nidana got moderate response; among the 15 patients

having katu rasa nidana, 14 patients got moderate response (93.33%) and 1 patient got

poor response; all the 11 patients having pramita bhojana nidana got moderate response;

among the 13 patients having rooksha bhojana nidana, 12 patients got moderate response

(92.3%) and 1 patient got poor response (7.69%).

In the study as a whole (30 patients), among the 4 patients of tikta rasa nidana, 2

patients got good response (50%) and 2 patients got moderate response (50%); among the

9 patients of kashaya rasa nidana 3 patients got good response (33.33%) and 6 patients

got moderate response (66.66%); among the 29 patients of katu rasa nidana, 7 patients

got good response (24.13%), 21 patients got moderate response (72.41%) and 1 patient

got poor response (3.44%); among the 17 patients of alpa bhojana nidana, 2 patients got

good response (11.76%) and 15 patients got moderate response (88.23%): among the 3

patients of pramita bhojana, 1 patient got good response (33.33%) and 2 patients got

moderate response (66.66%); among the 24 patients of rooksha bhojana, 5 patients got

good response (20.83%) , 18 patients got moderate response (75%) and 1 patient got poor

response (4.16 %).


5.2.A Table No. 65. Showing the distribution of patients by various Viharaja Vatakopa nidanas in both the treatment groups (A & B):

Viharaja nidana

No. Of Patients In Group A

% No. Of Patients In Group B

% Total No. Of Patients

Total %

Vega dharana 9 60 13 86.66 22 73.33

Vega udeerana

- - 9 60 9 30

Ati vyavaya - - 2 13.33 2 6.66

Nisha jagarana

11 73.33 10 66.66 21 70

Atyucha bhashana

2 13.33 2 13.33 4 13.33

Ativyayama 11 73.33 12 60 23 76.66

Among 15 patients in group A, 9 patients had Vega dharana (60%), 11

patients had Nisha jagarana (73.33%), 2 patients had Athyucha bhashana (13.33%) and

11 patients had Ativyayama (73.33%). Among 15 patients in group B, 12 patients had

Vega dharana (86.66%), 9 patients had Vega udeerana (60%), 2 patients had Ati vyavaya

(13.33%), 10 patients had Nisha jagarana (66.66%), 2 patients had Athyucha bhashana

(13.33%) and 12 patients had Ativyayama (80%). In the study as a whole, 22 patients

had Vega dharana (73.33%), 9 patients had Vega udeerana (30%), 2 patients had Ati

vyavaya (6.66%), 21 patients had Nisha jagarana (70%), 4 patients had Athyucha

bhashana (13.33%) and 23 patients had Ativyayama (76.66 %).

9

13

0

9

02

1110

2 2

1112

0

2

4

6

8

10

12

14

No.of

pts.

Vg Dh Vg Ud A Vyv Ns Jg At U Bh A Vy

Nidana

Distribution of pts. by viharaja nidana



5.2.B Table No. 66. Showing the overall treatment response in patients having various

Viharaja Vatakopa Nidanas in both the treatment groups (A & B):

Group A Group B Total Viharaja

nidana No GR MR No MR PR No GR MR PR

Vega

dharana

9 4 5 13 12 1 22 4 17 -

Vega

udeerana

- - - 9 9 - 9 - 9 -

Ati

vyavaya

- - - 2 2 - 2 - 2 -

Nisha

jagarana

11 5 6 10 10 - 21 5 16 -

Athyucha

bhashana

2 1 1 2 2 - 4 1 3 -

Ativyaya

ma

11 5 6 12 11 1 23 5 17 1

In the group A, among 9 patients of Vega dharana nidana, 4 patients had

good response (44.44%) and 5 patients had moderate response (55.55%); among the 11

patients of Nisha jagarana, 5 patients had good response (45.45%) and 6 patients had

moderate response (54.54%); among the 2 patients of Athyucha bhashana, one patient

had good response (50%) and 1 patient had moderate response (50%); among the 11

patients of Ativyayama, 5 patients got good response (45.45%) and 6 patients got

moderate response (54.54%). In the group B, among 13 patients of Vega dharana nidana,

12 patients had good response (92.3%) and 1 patient had moderate response (7.69%); all

the 9 patients of Vega udeerana and both the patients of Ati vyavaya, patients of Nisha

jagarana and both the patients of Athyucha bhashana had moderate response; among the

12 patients of Ativyayama, 11 patients had moderate response (91.66%) and 1 patient had


poor response (8.33%). In the study as a whole (30 patients), among the 22 patients of

Vega dharana nidana, 4 patients had good response (18.18%), 17 patients had moderate

response (77.27%) and 1 patient had poor response (4.54%); all 9 patients of Vega

udeerana and 2 patients of Ati vyavaya had moderate response; among the 21 patients of

Nisha jagarana, 5 patients had good response (23.8%) and 16 patients had moderate

response (76.19%); among the 4 patients of Athyucha bhashana, 1 patient had good

response (25%) and 3 patients had moderate response (75%) ; among the 23 patients of

Ativyayama, 5 patients got good response (21.73%), 17 patients got moderate response

(73.91%) and 1 patient got poor response (4.34 %).

5.3 Table No. 67. Showing the distribution of Patients by various Manasika

Vatakopa nidanas in both the treatment groups (A &B):

Manasika

nidana

No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Bhaya 1 6.66 4 26.66 5 16.66

Shoka 4 26.66 2 13.33 6 20

Chinta 11 73.33 10 66.66 21 70

Among the 15 patients in group A, only 1 patient had bhaya (6.66%), 4

patients had shoka (26.66%) and 11 patients had chinta (73.33%). Among the 15 patients

in group B, 4 patients had bhaya (26.66%), 2 patients had shoka (13.33%) and 10 patients

had chinta (66.66%). In the study as a whole (30 patients), 5 patients had bhaya

(16.66%), 6 patients had shoka (20%), and 21 patients had chinta (70%).


6. Table No. 68. Showing the distribution of Patients by radiological

interpretations in both the treatment groups:

Radiological

interpretation

No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total

No.

Total

%

Incr. 3 20 - - 3 10

Decr. 9 60 12 80 21 70

Joint

space

Unalt. 3 20 3 20 6 20

Sub. Bon. Scl. 3 20 1 6.66 4 13.33

Osteophytes 15 100 13 86.66 28 93.33

Peri.Art.Oss. 2 13.33 - - 2 6.66

Alt. Bne. End - - - - - -

Among the 30 patients in this study, 3 patients had their affected joint

space increased (10%), 21 patients had their affected joint space reduced (70%), 6

patients had their affected joint space unaltered (10%), 4 patients had subchondral bony

sclerosis (13.33%), 28 patients had osteophytes formation (93.33%), 2 patients had

periarticular ossicles (6.66%) and no patient had altered bone end.


III. Data Related to Overall Response to the treatment: -

Table No. 69. Showing the distribution of patients according to response.

Response No. Of Patients

In Group A

% No. Of

Patients In

Group B

% Total No.

Of Patients

Total

%

Good 7 46.66 - - 7 23.33

Moderate 8 53.33 14 93.33 22 73.33

Poor - - 1 6.66 1 3.33

No response - - - - - -

In group A, 7 patients (46.66%) had good response to the treatment (>

60% improvement in all the parameters) and 8 patients (53.33%) had moderate Response

to the treatment (31-60% improvement in all the parameters). In group B, 14 patients

(93.33%) had moderate response to the treatment and one patient (6.66%) had poor

response to the treatment (1-30% in all the parameters). In the study as a whole, 7

patients (23.33%) had good response, 22 patients (73.33%) had moderate response and 1

patient (3.33%) had poor response.

7

0

8

14

0 1 0 0024

68

101214

No.ofpts

GR MR PR NoResponse

Overall response to the treatment



IV. Statistical analysis of the clinical and functional parameters & Intergroup comparison Table No. 70. Showing the before and after treatment values of all parameters in Gr. A.

Clinical parameters Functional parameters

Ruk Graha Sp. Ak.

SGA Atopa Sopha AIMS Score

Walk time

Sl. No.

OPD No.

B A B A B A B A B A B A B A B A

01. 3575 2 0 1 0 1 0 1 3 1 0 0 0 37 18 3 2 02. 3565 2 0 1 0 0 0 1 3 1 1 0 0 38 18 2 1 03. 3529 3 1 1 0 2 1 1 2 1 1 1 0 46 23 4 3 04. 3560 3 2 1 1 2 1 1 2 2 1 3 2 48 27 4 3 05. 3790 3 1 1 0 2 1 1 3 1 0 1 1 34 21 4 3 06. 3818 3 2 1 1 2 1 1 2 1 1 1 0 41 23 3 3 07. 3914 2 1 1 0 2 1 2 3 1 0 1 0 38 23 3 2 08. 3961 2 1 1 1 1 0 2 2 0 0 1 0 37 25 3 2 09. 3973 2 1 1 0 0 0 2 3 0 0 0 0 31 21 3 3 10. 4003 3 2 1 0 2 0 1 3 1 0 2 1 32 22 4 3 11. 3588 2 1 1 0 2 1 1 3 1 0 0 0 42 21 4 3 12. 4502 3 1 1 0 2 1 2 3 1 0 1 0 31 21 3 2 13. 434 3 2 1 0 1 0 2 3 0 0 0 0 29 20 3 3 14. 4047 3 1 1 0 0 0 1 3 0 0 2 1 33 21 4 2 15. 3527 2 1 1 0 2 1 1 3 1 1 1 0 43 24 3 2 Table No. 71. Showing before and after treatment values of all parameters in Gr. B.

Clinical parameters Functional parameters

Ruk Graha Sp. Ak.

SGA Atopa Sopha AIMS Score

Walk time

Sl. No.

OPD No.

B A B A B A B A B A B A B A B A 16 380 2 1 1 0 0 0 2 3 0 0 0 0 38 30 4 4 17 1045 3 2 1 0 2 1 1 2 1 0 1 1 40 35 4 3 18 1044 3 2 1 0 2 1 1 2 1 1 2 1 37 30 3 2 19 989 3 2 1 0 0 0 1 3 0 0 0 0 39 30 3 3 20 1223 3 2 1 0 1 0 1 2 1 0 2 1 35 27 4 3 21 832 2 1 1 1 2 1 1 2 1 0 1 0 37 28 3 3 22 3526 2 1 1 0 2 1 1 2 1 1 1 1 32 25 3 2 23 1105 3 2 1 0 0 0 1 2 1 0 0 0 30 23 3 3 24 1230 2 1 1 0 1 1 2 3 1 0 2 1 33 24 3 3 25 732 2 1 1 0 2 1 2 3 1 0 2 1 35 27 3 2 26 1046 3 2 1 0 2 1 2 3 1 1 2 0 26 21 3 2 27 4658 3 2 1 0 2 1 2 3 1 1 2 1 37 33 4 4 28 400 3 2 1 1 0 0 2 2 0 0 0 0 37 33 4 4 29 4515 3 2 1 0 1 1 2 3 1 1 1 0 36 29 4 4 30 2071 2 1 1 1 1 0 2 3 1 1 1 0 39 33 3 3


Table No. 73. Showing the individual study of group-A

Parameters Mean S.D S.E t-value p-value Remarks Ruk 1.4 0.507 0.131 10.68 <0.001 H.S. Graha 0.8 0.414 0.106 7.54 <0.001 H.S. Sparsha akshamatva 0.866 0.516 0.133 6.511 <0.001 H.S. Sandhigati asamarthya 1.4 0.632 0.163 8.588 <0.001 H.S. Shopha 0.6 0.507 0.131 4.58 <0.001 H.S. Atopa 0.466 0.516 0.133 3.503 <0.02 H.S. AIMS 15.466 4.867 1.256 12.313 <0.001 H.S. Walking time 0.866 0.516 0.133 6.511 <0.001 H.S. Table No. 74. Showing the individual study of group-B

Parameters Mean S.D S.E t-value p-value Remarks Ruk 1.0 - - - - H.S. Graha 0.866 0.351 0.0901 9.611 <0.001 H.S. Sparsha akshamatva 0.6 0.507 0.1309 4.58 <0.001 H.S. Sandhigati asamarthya 1.0 0.377 0.097 10.309 <0.001 H.S. Shopha 0.666 0.617 0.159 4.188 <0.01 H.S. Atopa 0.666 0.617 0.159 4.188 <0.01 H.S. AIMS 6.866 1.726 0.445 15.429 <0.001 H.S. Walking time 0.4 0.507 0.131 3.053 <0.01 H.S. Table No. 75. Showing the inter group comparison.

Parameters Group Mean S.D S.E P.S.E t-value

p-value

Remarks

A 1.133 0.639 0.156Ruk B 1.6 0.507 0.131

0.211 2.213 <0.05 HS

A 0.2 0.414 0.106Graha B 0.133 0.351 0.091

0.139 0.482 >0.05 NS

A 2.666 4.336 1.119Sparsha akshamatva B 0.6 0.507 0.131

1.126 1.834 >0.05 NS

A 2.733 0.457 0.118Sandhigati asamarthya B 2.533 0.516 0.133

0.177 1.129 >0.05 NS

A 0.333 0.617 0.159Shopha B 0.466 0.516 0.133

0.207 0.642 >0.05 NS

A 0.266 0.457 0.118Atopa B 0.4 0.507 0.130

0.175 0.765 >0.05 NS

A 21.866 2.416 0.623AIMS B 28.533 4.085 1.054

1.224 5.359 <0.001 HS

A 2.46 0.639 0.165Walking time B 3.0 0.755 0.195

0.255 0.534 >0.05 NS


Among the groups A and B the parameters ‘Ruk’ and ‘AIMS score’ shows

high significance and other parameters are not significant in the comparative study (as by

using unpaired t-test, p-value is <0.05). The AIMS sore shows high significance than the

Ruk and the AIMS score is more uniform in the group-A than group-B after the treatment

(by using the co-efficient of variation.

To know the effect on the parameters individually in the groups, we used

the paired t-test; assume that the treatment is not responsible for changes in the

observations of parameters before and after the treatment. In group-A the parameters

Ruk, Sparsha akshamatva, Shopha and walking time shows high significance than the

group-B by comparing the t-values. The parameters Ruk, Sparsha akshamatva, Shopha

and walking time approximately had the same variation in the group-A when compared

to group-B. The mean effect of AIMS scores and variation in group-A is more as

compared to group-B and it showed uniform effect after the treatment in patients. In

group-A Atopa is not having constant effect. In group-B the variation due to the

treatment is zero in the parameter Ruk. Again AIMS score in group-B showed uniform

effect.


V. Statistical analysis of Swedakaarmukata

Table No. 72A. Chart showing the before and after values of Sweda kaarmukata parameters.

Agnideepti Bhakta shraddha

Tandra hani

Sandhi cheshta

Sroto nirmalatwa

Mardava Twak prasada

Sl. No.

B A B A B A B A B A B A B A 01. 0 2 0 1 0 1 1 3 3 1 0 1 0 2 02. 0 2 0 1 0 1 1 3 3 1 0 2 0 2 03. 0 2 1 1 0 1 1 2 3 2 1 2 1 2 04. 1 2 1 1 0 1 1 2 4 3 0 2 0 2 05. 1 2 1 1 0 1 1 2 4 2 1 2 1 2 06. 1 2 1 1 0 1 1 2 3 2 1 2 0 1 07. 0 2 0 1 1 1 2 3 4 2 1 2 1 2 08. 1 2 1 1 0 1 2 2 4 2 0 1 0 1 09. 0 1 0 1 0 1 2 3 3 2 0 1 0 1 10. 1 2 0 1 0 1 1 2 3 1 0 1 0 1 11. 0 2 0 1 0 1 1 2 3 2 0 1 0 0 12. 1 2 1 1 0 1 1 3 3 2 0 1 0 1 13. 0 1 0 1 0 1 2 3 3 2 0 1 0 1 14. 1 2 1 1 0 1 1 3 4 2 1 2 1 1 15. 0 2 0 1 0 1 1 2 3 2 0 1 0 1 Table No. 72B. Chart showing the before and after values of Sweda kaarmukata parameters.

Agnideepti Bhakta shraddha

Tandra hani

Sandhi cheshta

Sroto nirmalatwa

Mardava Twak prasada

Sl. No.

B A B A B A B A B A B A B A 16. 0 1 0 1 0 1 2 3 3 3 0 0 0 0 17. 0 1 0 1 0 1 1 2 4 2 1 1 1 2 18. 0 1 0 1 0 1 1 3 4 2 1 1 1 2 19. 0 1 0 1 0 1 1 3 3 2 0 1 0 2 20. 1 1 1 1 0 1 1 2 3 2 0 1 0 0 21. 0 1 0 1 0 1 1 2 3 2 1 1 1 2 22. 0 1 0 1 0 1 1 2 3 3 0 1 0 1 23. 0 1 0 1 0 1 1 2 3 2 0 1 0 1 24. 0 1 0 1 0 1 2 3 3 3 0 0 0 1 25. 0 2 0 1 0 1 2 3 3 2 0 1 0 1 26. 0 1 0 1 0 0 2 3 3 3 0 0 0 1 27. 0 1 0 1 0 1 2 3 4 3 0 1 0 1 28. 0 1 0 1 0 1 2 3 3 3 0 1 0 1 29. 0 1 0 1 0 1 2 3 3 3 0 0 0 1 30. 0 1 1 1 0 1 2 3 3 2 0 1 0 0


Table No. 76A. Showing the study of Sweda kaarmukata parameters Parameters Mean S.D S.E t-value p-value Remarks Agnideepti 1.866 0.351 0.0908 10.664 <0.001 H.S. Bhakta shraddha 0.533 0.516 0.133 4.00 <0.01 H.S. Tandrahani 0.933 0.258 0.066 14.13 <0.001 H.S. Sandhi cheshta 1.133 0.1516 0.133 8.518 <0.001 H.S. Srotonirmalatva 1.866 0.516 0.133 14.03 <0.001 H.S. Mardava 1.466 0.516 0.133 11.02 <0.001 H.S. Twak prasada 1.33 0.617 0.159 8.383 <0.001 H.S. Table No. 76B. Showing the study of Sweda kaarmukata parameters. Parameters Mean S.D S.E t-value p-value Remarks Agnideepti 1.066 0.256 0.066 16.00 <0.001 H.S. Bhakta shraddha 0.866 0.351 0.0903 9.537 <0.001 H.S. Tandrahani 0.866 0.351 0.0908 9.537 <0.001 H.S. Sandhi cheshta 2.26 0.351 0.0908 12.47 <0.001 H.S. Srotonirmalatva 2.466 0.516 0.133 18.54 <0.001 H.S. Mardava 0.733 0.457 0.118 6.211 <0.001 H.S. Twak prasada 1.066 0.153 0.153 6.967 <0.001 H.S.

To know the Swedakaarmukata in both the groups the parameters were

analyzed. In group-A the parameter Agni deepti showed more significance than the other

parameters and also it differs from the group-B, by comparing the t-values. The

parameter Agni deepti had uniform effect in group-A but in group-B the parameter

Srotonirmamatva had uniform effect. The mean effect of the parameter Sandhi cheshta in

group-A and the parameter Tandra haani was more and same in both the groups. The

variation in Sandhi chesta in group-A was more whereas the parameters Srotonirmalatva

and Mardava had the same mean effect. The parameter Twak prasada in group-B had

more variation whereas the parameters Tandra haani and Mardava had the same

variations.


Discussions on this study are made under the following headings:

1. Sandhigatavata vis-à-vis Osteoarthritis

2. Role of Snehana and Swedana in the management of Sandhigatavata

3. Clinical study

4. Probable mechanism of action of Swedana

5. Discussion on Shashtikashalipindasweda

Sandhigatavata vis-à-vis Osteoarthritis

Sandhigatavata is the most common joint disorder worldwide. It is a

disorder caused by the localization of the vitiated Vata dosha in the asthi sandhis of the

body. It is one among the many Vatavyadhis described by all the acharyas of Ayurveda.

It comes under the various Gatavatas explained in Vatavyadhi prakarana. It is

characterized by the symptoms pertaining to the asthi sandhis like sandhi shoola, sandhi

shopha etc.

Osteoarthritis is a disease coming under the arthritis group of diseases

described by the modern science, which is almost identical to Sandhigatavata in etiology,

pathology and clinical features. Hence, the discussion is made here step by step starting

from the shareera to the roopa.

Sandhis are the union of the asthis and in them are located the Sleshaka

Kapha and Sleshmadhara kala, both of which lubricate the sandhis, thereby reducing the

friction during various joint movements. Various snayus and peshis are responsible for

the compactness of the joints and support in their functions. Also, several marmas are

located in the Sandhis whose protection is inevitable in maintaining the normal functions

Discussion 149

of these sandhis. Role of Vyanavata is most important in the movements of the joints.

The human skeleton is designed with a number of individual bones that are articulated at

joints to allow movements in different directions, angles and positions. Knee functions as

a hinge joint, but the articulation is far more complex than other hinge joints. Seven

major ligaments and flexor & extensor muscles support the movements of the knee joint.

The five lumbar vertebrae are the largest of the vertebrae and those are interconnected

and stabilized by the deep muscles of the spine. The synovial fluid in the synovial joint

serves as a lubricant, a shock absorber and a nutrient carrier.

Functions of the Sleshaka Kapha and Sleshmadhara kala described in

Ayurveda can be co-related to that of the synovial fluid that lubricates the knee joint and

the intervertebral disc that reduces the friction between the vertebrae. The marmas can be

considered as the various points of nervous, vascular and muscular system, which are

vital in the functioning of the joints. Functions of the peshis and snayus are exactly

identical to that of the muscles and ligaments related to the joints.

From the nidana point of view, Ayurveda had highlighted all the Vata

prakopakara nidanas in the generation of Sandhigatavata. Vardhakya avastha

characterized by dhatu kshaya leads to reduced sneha bhava in the body, which in turn,

vitiates the Vata dosha and reduces the Kapha, thereby resulting in karma hani of the

sandhis. Also, dhatusaithilya is another feature in vardhakya, which reflects in peshis and

snayus thereby reducing their functional efficiency in supporting the joints. This is a

major risk factor for Sandhigatavata. Age is the most powerful risk factor for

Osteoarthritis. More than 80% of the people over the age of 60 have radiological

evidence of Osteoarthritis in the joints.

Discussion 150

Various physical activities such as pradhavana, bharaharana and

abhighatas due to prapatana, marma abhighata, dukha shayya and dukha asana are

important nidanas for Sandhigatavata. Repetitive movements may lead to excessive strain

leading to erosion and joint damage. Trauma to the joint enhances the occurrence of

arthritis.

Sthoulya is another causative factor for Sandhigatavata. The meda avarana

of the Vata is the mechanism causing the inter-relationship between Sthoulya and

Vatavyadhis. Obese persons have a high risk of Osteoarthritis. The relative risk for

developing Osteoarthritis, in the population belonging to the highest quintile for body

mass index at the baseline examination is very high.

Another point noteworthy here is that Sandhigatavata being one among the

Gatavatas is caused due to the factors vitiating Vata alone, but the nidanas specific to the

localization of Vata in Sandhis also have some role in the production of the disease. The

dhatu kshaya samprapti characterized by the functional deterioration of the Vata dosha

can be co-related with the degenerative changes in the joints associated with ageing

which causes the cartilage degradation; whereas the marga avaranajanya samprapti

initiated by the nidana ghataka Sthoulya involving the avarana of Vata by Kapha and

medas can be co-related with the complications of obesity leading to excessive pressure

on the weight bearing joints.

The lakshanas of Sandhigatavata, viz., vedanayukta pravritti of sandhis,

shopha (vatapoorna dritisparshavat), atopa and sandhigati asaamarthya are explained by

various textbooks of Ayurveda. Modern science has listed the same features along with

other symptoms pertaining to individual joints. Also tenderness and joint stiffness

Discussion 151

(implied by the restriction of joint movements) find special mentioning in Modern

science. Acharyas of Ayurveda have not mentioned that particularly any one sandhi only

gets affected with Sandhigatavata. Modern science has mentioned that any joint can get

affected with Osteoarthritis. In this view, they have considered the condition of Lumbar

spondylosis also as the Osteoarthritis of the intervertebral joints.

Role of Snehana and Swedana in the management of Sandhigatavata

Snehana and Swedana are both described as Poorva karmas and also find

place among the Shad upakramas. The upakrama of Vata dosha emphasizes the necessity

of these two karmas in correcting the vitiated Vata dosha. Snehana corrects the shuska

dhatus that are the root cause for the Vata vitiation and imparts strength to the body and

agni. Swedana relieves all types of Vata symptoms such as toda, ruk, ayama, shotha,

stambha etc. and smoothens the body part. Repetitive uses of these two karmas are

essential for the total control of Vata and restoration of its normal functions.

Sandhigatavata is a disease of the madhyama rogamarga involving the

asthi sandhis of the body. Asthis are the ashraya of the Vata dosha and the vitiation of

Vata hampers the nourishment of asthis, thereby reflecting in Sandhis also. Such a mal-

nourishment involves the reduction of the Sleshaka Kapha and deterioration of the

Sleshmadharakala. Snehana provides the sneha bhava needed for the nourishment of

these. Also, this controls the vitiated Vata.

Swedana relieves the stambha and gourava related to the joints and related

structures involved in the joint movements. Stambha means stiffness. This attribute is a

resultant of excess seetha guna and also influence of factors such as samanavata,

Discussion 152

sleshakakapha, ama, mamsa, vasa & medas is contributory to the production of stambha.

Samanavata is rooksha gunapradhana and hence if vitiated does excessive shoshana of

shareera there by producing contractures and stiffness. Sleshakakapha is snigdha and

pichila and hence if decreased (kshaya) results in less lubrication of joints causing

stiffness. Swedakarma being snigdha and ushna corrects both these deranged dosha

ghatakas and relieves stiffness. Thus it is very clear that both these karmas are inevitable

in the management of Sandhigatavata.

Clinical Study

Patients of Sandhigatavata were selected the OPD & IPD of Shri D.G.M.

Ayurvedic Medical college by pre-set inclusion and exclusion criteria. Data of 30 patients

who had satisfied the diagnostic criteria, underwent the treatment and reported for the

follow-up are discussed here. The patients were randomly distributed into two groups and

the patients of group-A were administered Shashtikashalipindaswedakarma and the

patients of group-B were administered Abhyanga & Bashpaswedakarma.

Gandharvahastadi Kwatha was administered to the patients of both the groups just prior

to the karma on every day of Swedana. This was done so as to prevent the accumulation

of shareera kleda or abhishyanda which might be produced as a result of swedana.

Sahacharadi taila was used for Abhyanga in both the groups. Patients of both the groups

were advised to take hot water bath after the karma every day and also were advised the

same pathya acharana.

The laboratory investigations like ESR, TC, DC, Hb% and RBS were

performed to rule out the associated systemic diseases. The radiology of the affected joint

Discussion 153

was performed in each and every patient. After scrutinizing the whole literature of

Ayurveda and Modern Medicine, Ruk and Graha were fixed as the subjective parameters

for clinical assessment; Sparsha akshamatva, Sandhigati asaamarthya, Shopha and Atopa

were fixed as the objective parameters for clinical assessment. The subjective parameter

for functional assessment was the total score of the AIMS and the objective parameter for

the functional assessment was the walking time (to cover 21meters).

Most of the patients in this clinical study belonged to the age group 50-60

(70%) thereby supporting the association of vardhakya avastha and Sandhigatavata.

23.33% of the patients belonged to the age group 40-50 and 6.66% of the patients

belonged to the age group 30-40. 50% of the patients belonged to the active group of

occupational status and 26.66% of the patients belonged to the labour group. This

strengthens the viewpoint that this disease is triggered by excessive physical demand on

the joint. 53.33% of the patients were females and 46.66% of the patients were males

supporting the male to female incidence ratio of 1:1.

46.66% of the patients were of the middle class and 33.33% were of the

poor class and 20% were of the aristocrat and this observation is inconclusive to make

any comments. 70% of the patients were Hindus, 26.66% were Muslims and 3.33% were

Christians. This is reflective of the geographical dominance of the religion and do not

have any association with the disease. 53.33% of the patients were vegetarians and

46.66% were of the mixed diet and this is reflective of the diet habit prevalent in the

society. 46.66% of the patients were having tobacco chewing as a habit, 30% were

having alcohol intake as a habit and 10% had smoking habit; this has no association with

the disease state.

Discussion 154

43.33% of the patients were of the Vata-pitta prakriti, 26.66% of the

patients were of the Vata-kapha prakriti, 13.33% of the patients were of the Pitta-kapha

prakriti, 13.33% of the patients were of the Vata prakriti and 3.33% of the patients were

of the Kapha prakriti. 93.33% of the patients were of the rooksha satmya and 6.66% were

of the snigdha satmya, which is reflective of the nature of the diet. This also may have

contributed to the Vata kopa. 76.66% of the patients were having ati vyayama as a nidana

and 96.66% of the patients were having katurasa bhojana.

83.33% of the patients were having Sandhigatavata of the knee joint and

16.66% of the patients were having Sandhigatavata of the lumbar spine. Among the cases

of Sandhigatavata of the knee, 68% was unilateral involvement and 32% was bilateral

involvement. All the patients had the complaints Ruk, graha and Sandhigati asaamarthya,

while 76.66% had Sparsha akshamatva and Atopa, 90% reported with Prasaarna

aakunchanayoho savedana pravritti, 70% with Shopha and 13.33% with Vatapoorna

dritisparsha.

Response to the treatment

Group-A

1) Ruk: - 53.44% of the patients reported with grade 3 ruk and 46.66% reported

with grade 2 ruk. 57.14% of the grade 2 got good response and 42.85% got

moderate response. 37.5% of the grade 3 got good response and 62.5% got

moderate response. In the statistical analysis, the parameter showed high

significance (p-value<0.001) and corresponding t-value10.68.

2) Graha: - All the patients of group-A presented with Sandhigraha(100%). Among

them 46.66% got good response and 53.33% got moderate response. In the

statistical analysis Graha showed high significance (p-value<0.001) and

corresponding t-value 7.54.

Discussion 155

3) Sparsha akshamatva: - 20% of the patients reported with grade 0 tenderness

whereas 20% reported with grade 1 tenderness and 60% reported with grade 2

tenderness. 33.33% of grade 0 got good response and 66.66% of grade 0 got

moderate response. 66.66% of grade 1got good response and 33.33% got

moderate response. 44.44% of grade 2 got good response and 55.55% got

moderate response. In the statistical analysis the parameter showed high

significance (p-value<0.001) and corresponding t-value 6.511.

4) Sandhigati asaamarthya: - 66.66% of the patients reported with grade 1

Sandhigati asaamarthya and 33.33% of the patients reported with grade 2

Sandhigati asaamarthya. 40% of the patients with grade 1 got good response and

60% got moderate response. 60% of the patients with grade 2 got good response

and 40% got moderate response. In the statistical analysis the parameter showed

high significance (p-value<0.001) with corresponding t-value 8.588.

5) Shopha: - 33.33% of the patients reported with grade 0 Shopha, 46.66% with

grade 1, 13.33% with grade 2 and 6.66% with grade 3. 40% of the patients with

grade 0 got good response and 60% got moderate response. 42.85% of the

patients with grade 1 got good response and 57.14% got moderate response. 100%

of the patients with grade 2 got good response and 100% of the patients with

grade 3 got moderate response. In the statistical analysis the parameter Shopha

showed high significance (p-value<0.001) with corresponding t-value 4.58.

6) Atopa: - 26.66% of the patients reported with grade 0 atopa, 66.66% with grade 1

and 6.66% with grade 2. 50% of the patients with grade 0 showed good response

and 50% got moderate response. 50% of the patients with grade 1 showed good

Discussion 156

response and 50% showed moderate response. 100% of patients with grade 2

showed moderate response. In the statistical analysis the parameter showed high

significance (p-value<0.02) with corresponding t-value 3.503.

7) AIMS score: - The functional parameter AIMS score showed high significance

(p-value<0.001) with corresponding t-value 12.313.

8) Walking time: - The functional parameter walking time (to cover 21meters)


Group-B

1) Ruk: - 40% of the patients had grade 2 ruk and 60% had grade 3 ruk. 83.33% of

the patients with grade 2 ruk got moderate response and 16.66% got poor

response. All the patients of grade 3 got moderate response.

2) Graha: - All the patients had grade 1 graha. 93.33% of the patients got moderate

response and 6.66% got poor response. In the statistical analysis the parameter


3) Sparsha akshamatva: - 26.66% of the patients had grade 0 tenderness, 26.66%

had grade 1 and 46.66% had grade 2. 75% of the patients of the grade 0 got

moderate response and 25% got poor response. All the patients of grade 1 got

moderate response. In the statistical analysis the parameter showed high

significance (p-value<0.001) with corresponding t-value 4.58.

4) Sandhigati asaamarthya: - 46.66% of the patients gad grade 1 and 53.33% had

grade 2. All the patients with grade 1 got moderate response while 87.5% with

grade 2 got moderate response and 12.5% got poor response. In the statistical

analysis this parameter showed high significance (p-value<0.001) with


Discussion 157

5) Shopha: - 26.66% had grade 0 shopha, 33.33% had grade 1 and 40% had grade 2.

75% of the patients with grade 0 got moderate response and 25% got poor

response. All the patients with grade 1 & 2 got moderate response. In the

statistical analysis this parameter showed high significance (p-value<0.01) with


6) Atopa: - 20% of the patients had grade 0 atopa and 80% had grade 1. 66.66% of

the patients with grade 0 got moderate response and 33.33% got poor response.

All the patients with grade 1 got moderate response. In the statistical analysis, this

parameter showed high significance (p-value<0.01) with corresponding t-value

4.188.

7) AIMS score: - This functional parameter showed high significance (p-

value<0.001) with corresponding t-value 15.429.

8) Walking time: - This functional parameter showed high significance (p-

value<0.01) with corresponding t-value 3.053.

Intergroup comparison was done and the parameters Ruk and AIMS score

were highly significant in group-A (P-value<0.05 & p-value<0.001 respectively). The

AIMS score showed high significance than the Ruk and the AIMS score was more

uniform in the group-A than the group-B. Also in the group-A 46.66% of the patients had

good response and 53.33% had moderate response. But in the group-B no patients had

good response, 93.33% of the patients had moderate response and 6.66% had poor

response. Hence, it is clear that the Shashtikashalipindaswedakarma group responded

more in comparison with the Abhyanga & Bashpa sweda group.

Discussion 158

Observations on Swedana

In the present study, apart from the routine observations on the karma like

samyak swinna, ati swinna, mithya swinna etc. observations were made for knowing the

benefits imparted by the Swedakarma. For this, the Shaman sweda gunas explained by

Sushruta were selected as the parameters. Gradings were designed and observations

recorded before the treatment (Day 0), after the course of Swedana (Day 14) and after the

pariharakala (Day 28). The readings of Day 0 and Day 28 were subjected to statistical

analysis.

Both the karmas produced high significance in the parameter Agni deepti

(p-value<0.001 & p-value<0.001 respectively in group-A & group-B). The parameter

Bhakta shradha also showed high significance in both the groups (p-value<0.01 & p-

value<0.001 respectively in group-a & group-b). Both the karmas produced high

significance in the parameter Tandra haani also (p-value<0.001 & p-value<0.001

respectively in group-a & group-b). The parameters Sandhi cheshta, Sroto nirmalatva,

Mardava and Twak prasada also showed high significance in both the groups (p-

value<0.001).

Probable Mechanism of Action of Swedana

Mechanism of action of Swedana will be discussed under the following

headings: -

1) application of heat,

2) Physical effect of massage and

3) Therapeutic effects of medicaments used.

Discussion 159

1) Application of heat : - Application of heat on an unctuous area causes the generation

of a temperature gradient across the cell membrane. Besides facilitating the diffusion of

liquid substances through the cell membrane, this plays key role in the formation of

lipoid vesicles from the dropouts in the membrane in areas of flow temperature. This

causes an expansion in the cell volume as well as surface area. But it cannot expand

freely especially in the peripheral direction as it is bound by other cells around. This

makes the blebbing of cell membrane inside.

The temperature gradient caused by the heat further helps in blebbing in

this particular direction. These lipoid vesicles or blebs gets detached from the cell

organelle or other side of membrane and remain there till a critical surface is reached.

This membrane then blebs out and spread further, thus providing nourishment to the

tissues.

The chief beneficial effects of any kind of thermal therapy are due to the

increase in the circulation and local metabolic process with the relaxation of the

musculature. Application of heat causes relaxation of muscles and tendons, improves the

blood supply and activates the local metabolic processes which are responsible for the

relief of pain, swelling, tenderness and stiffness.

Routine application of heat preceding the application of massage renders

the applied area less painful than when the heat is not applied.

The medicaments used in the Pinda sweda seems to be calculated for

forming a suitable and effective medium for application of heat to the body in the process

of Pinda sweda. This may be the reason for the advantageous effect of

Shashtikashalipindaswedakarma over the Bashpaswedakarma where only the steam

vapours provide the heat.

Discussion 160

2) Physical effect of the massage: - It stimulates the sensory nerve endings thereby

producing relaxation. It produces a hyperaemic effect causing the arterioles to dilatate

and thereby achieving more circulation. Also, the venous and lymphatic return is assisted.

Massage causes movements of the muscles thereby accelerating the blood supply, which

in turn relieves the muscular fatigue. The application of massage may cause displacement

of the exudates and thus may relieve tension and pain. In Bashpasweda massage is

performed only as a part of the Abhyanga procedure. But in

Shashtikashalipindaswedakarma massage is performed during the pre-operative and post-

operative Abhyanga and also during the performance of Pindasweda. This may have

contributed to the advantageous effect of Shashtikashalipindaswedakarma.

3) Therapeutic effects of the medicaments used: - Drugs in oils and other lipid- soluble

carriers can penetrate the epidermis. The movement is slow, particularly through the

layers of cell membranes in the stratum corneum. But once the drug reaches the

underlying tissues it will be absorbed into the circulation. Placing a drug in a solvent that

is lipid soluble can assist its movement through the lipid barriers.

The constituent methionine in the Shashtikashali might be the responsible

active compound for the medicinal quality. Methionine is the only common amino acid

with either linkage and is an important donor of active methyl groups. Cow’s milk

contains fats; hence these may have got absorbed during the Shashtikashalipindasweda.

Bala contains an alkaloid ephedrine and this may also have contributed to the effect.

Nirgundi and Chincha, which are used for Bashpa sweda, may have contributed to the

effect of Bashpa sweda. Nirgundi is Kaphavata shamana, Ushna and has Shothahara

property. Chincha is Vata shamana and has Ushna guna.

Discussion 161

Oil in the form of Sahacharadi taila had been used in this study. This may

also have contributed to the effect. All the drugs of Sahacharadi taila are Vata shamana,

Snigdha and Ushna.Also, the medicinal effect of the Gandharvahastadi Kwatha, which

pacifies the Vata kopa, relieves the mala sanga and strengthens the agni has to be

considered.

Bhrajakapitta, one among the panchavidhapittas, is located in the twak. It

is this Bhrajakapitta that takes up and metabolizes the drugs applied in the form of

Abhyanga, Parisheka, Avagaha, Alepa etc. As a matter of fact, no one single mechanism

appears to be solely responsible for the therapeutic effects of Swedana.

Discussion on Shashtikashalipindasweda

Sandhigatavata is a Vatavyadhi affecting people in the vardhakya avastha.

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

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

should be used in this disease.

Shashtikashali is snigdha, Sthira, bala vardhana, tarunya sthapaka and

deha dardhyakrit. Bala that is used to cook the Shashtikashali and to heat the bolus is

snigdha, rasayana and vatahara. Go-ksheera that is also used to cook the Shashtikashali

and to heat the bolus is snigdha, rasayana and vatahara. These drugs are made use in the

Shashtikashalipindaswedakarma. The karma imparts Swedana and this opens up the

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

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

are having shoolahara properties and the Swedana by itself is shoolahara due to the

pacification of Vata. Thereby, it is an ideal treatment of choice in Sandhigatavata.

Discussion 162

Shashtikashalipindasweda is a modification of Sankara sweda and it

contributes the principles of Snehana and Swedana. All the ingredients of the pinda

sweda are of Snehana nature and Abhyanga also is performed as a part of this procedure.

The massage performed during the procedure is advantageous in relieving shoola and

stambha. Heat is maintained for more time period inside the pinda. Also the pindas are

heated often and hence there is no reduction in the amount of heat applied over the body.

Hence the advantages of the karma can be listed as, 1) temperature gradient produced is

higher which facilitates the absorption of the sneha amsha, 2) simultaneous massage

performed creates the pressure gradient necessary for the absorption of the sneha amsha

and 3) dravyas used are of snehana-brimhana qualities.

Discussion 163

Certain conclusions can be drawn on the basis of the present study.

Shashtikashalipindaswedakarma is a modification of the Sankara sweda (or sagni

upanaha) that comes under the Ushma type of Swedana.

Bashpa sweda is also belonging to the Ushma type of Swedana.

Sandhigatavata is a disease commonly associated with the vardhakya avastha and

dhatu kshaya is a prominent feature in its manifestation.

Shashtikashalipindaswedakarma was selected as the therapy in this study as the

treatment line of Sandhigatavata emphasizes Snehana and Swedana and this

particular karma is capable of exerting both these effects.

No complications (Sweda atiyoga, ayoga & mithya yoga) were observed in this

study.

Observance of Shamana swedagunas were performed in both the treatment groups

and all the benefits were found highly significant in both the groups.

Treatment response of all parameters was highly significant in both the groups,

but in intergroup comparison Ruk and AIMS score was found significant in

Shashtikashalipindasweda group than Bashpa sweda group.

At the same time overall treatment response was better in the

Shashtikashalipindasweda group as no patient in the Bashpa sweda group got

good response. This suggests that there was considerable improvement in both the

groups but Shashtikashalipindasweda group got more beneficial effects.

During the follow-up period (after the 28th day) the results attained seemed to

wear out in the Bashpa sweda group, but results lasted throughout thr follow-up

period in the Shashtikashalipindasweda group.

Conclusion 164

Both the Swedakarmas were found to impart the Shamana sweda gunas explained

by Sushruta.

SUGGESTIONS FOR FUTURE STUDIES

⇒ The study should be conducted in a large sample.

⇒ The study should be conducted for a longer duration so as to know the lasting of

the clinical effects.

⇒ The effects of Shashtikashalipindasweda and Bashpa sweda can be studied by

performing for 21days.

Conclusion 165

SUMMARY

The dissertation work entitled “evaluation of the efficacy of

Shashtikashalipindaswedakarma in the management of Sandhigatavata (Osteoarthritis)”

consists of seven parts. They are

1. Introduction

2. Objectives

3. Review of literature

4. Methodology

5. Results

6. Discussion

7. Conclusion.

The introduction highlights on Panchakarmas, Swedana, Pindasweda and

Sandhigatavata. The objectives part describes the need for the study, previous studies on

Shashtikashalipindasweda, title of the present study and the objectives of the present

study. Review of literature part covers the historical view on Swedana and

Sandhigatavata, Nirukti and Paribhasha of Shashtikashalipindasweda and Sandhigatavata,

Shareera of Twak and Sandhi, description of Swedakarma, Pindaswedas in particular and

description of Sandhigatavata. Methodology part contains review of the properties and

chemical composition of the drugs used, methodology of the clinical study, procedures of

Shashtikashalipindasweda and Bashpa sweda and the parameters for clinical & functional

assessment and the Swedakarmukatha parameters. The results part contain demographic

data, data related to the disease, data related to the overall response to the treatment,

statistical analysis of the clinical and functional parameters & Intergroup comparison and

statistical analysis of Swedakaarmukata. Discussion part consists of the headings

Sandhigatavata vis-à-vis Osteoarthritis, role of Snehana and Swedana in the management

of Sandhigatavata, clinical study, probable mechanism of action of Swedana and

discussion on Shashtikashalipindasweda. Conclusion part contains the conclusions of the

present study and suggestions for future study.

Summary 166

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156. Agnivesa, Charakasamhitha Chikitsasthana chapter 28 sloka 37. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 618. (Kasi Sanskrit series 228). 157. Sushrutha, Sushruthasamhitha Nidanasthana chapter 1 sloka 28. Varanasi: Krishnadas Academy; 1980. p. 261. (Krishnadas Ayurveda series 51). 158. Sushrutha, Sushruthasamhitha Nidanasthana chapter 1 sloka 28. Varanasi: Krishnadas Academy; 1980. p. 261. (Krishnadas Ayurveda series 51). 159. Madhavakara, Madhavanidana chapter 22 sloka 21. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 521. (Chaukhambha Ayurvijnana Granthamala 46). 160. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WB Saunders Company; 1997. p. 1479. 161. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WB Saunders Company; 1997. p. 1479. 162. Kelly William, Textbook of Rheumatology chapter 89. 5th ed. Philadelphia: WB Saunders Company; 1997. p. 1479-1480. 163. Agnivesa, Charakasamhitha Chikitsasthana chapter 21 sloka 40. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 461. (Kasi Sanskrit series 228). 164. Madhavakara, Madhavanidana chapter 1 sloka 8. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 45. (Chaukhambha Ayurvijnana Granthamala 46). 165. Agnivesa, Charakasamhitha Indriyasthana chapter 9 sloka 8. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 368. (Kasi Sanskrit series 228). 166. Chakrapani, Ayurvedadipika teeka on Charakasamhitha Chikitsasthana chapter 28 sloka 12-14. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 620. (Kasi Sanskrit series 228). 167. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: Krishnadas Academy; 1980. p. 420. (Krishnadas Ayurveda series 51). 168. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: Krishnadas Academy; 1980. p. 420. (Krishnadas Ayurveda series 51). 169. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: Krishnadas Academy; 1980. p. 420. (Krishnadas Ayurveda series 51). 170. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: Krishnadas Academy; 1980. p. 420. (Krishnadas Ayurveda series 51).


171. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 4 sloka 8. Varanasi: Krishnadas Academy; 1980. p. 420. (Krishnadas Ayurveda series 51). 172. Vagbhata, Ashtangahridaya Suthrasthana chapter 1 sloka 25. Varanasi: Krishnadas Academy; 1982. p. 16. (Krishnadas Academic series 4). 173. Govindadasa, Bhaishajyaratnavali Vatavyadhi prakarana sloka 442-446. 7th ed. Kaviraj Ambikadatta Shastri editor. Varanasi: Chaukhambha Orientalia; 1983. p. 130. (Kasi Sanskrit series 152). 174. Govindadasa, Bhaishajyaratnavali Vatavyadhi prakarana sloka 447-449. 7th ed. Kaviraj Ambikadatta Shastri editor. Varanasi: Chaukhambha Orientalia; 1983. p. 130. (Kasi Sanskrit series 152). 175. Manek J Nisha, Lane E Nancy, Osteoarthritis:- Current concepts in diagnosis and management. American academy of family physicians 2000. Available from: www.aafp.org. Accessed on 15th March 2003. 176. Kelly William, Textbook of Rheumatology chapter 90. 5th ed. Philadelphia: WB Saunders Company; 1997. p. 1497. 177. Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popular prakashan; 1976. p. 878. 178. Vagbhata, Ashtangahridaya Suthrasthana chapter 6 sloka 7. Varanasi: Krishnadas Academy; 1982. p. 85. (Krishnadas Academic series 4). 179. Sushrutha, Sushruthasamhitha Suthrasthana chapter 46 sloka 8-11. Varanasi: Krishnadas Academy; 1980. p. 215. (Krishnadas Ayurveda series 51). 180. Dalhana, Nibandhasangraha teeka on Sushruthasamhitha Suthrasthana chapter 46 sloka 8-11. Varanasi: Krishnadas Academy; 1980. p. 215. (Krishnadas Ayurveda series 51). 181. Anilkumar. N, Role of Njavara rice in Traditional Healing and Health care system in Kerala. Chennai: MS Swaminathan Foundation; 2004. p. 3. 182. Anilkumar. N, Role of Njavara rice in Traditional Healing and Health care system in Kerala. Chennai: MS Swaminathan Foundation; 2004. p. 8. 183. Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popular prakashan; 1976. p. 878. 184. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 434. 185. Jensen.R.G, Handbook of milk composition. New York: Academic press; 1995. Available from: www.dairyhealth.com. Accessed on 4th November 2004.


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186. Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popular prakashan; 1976. p. 1278-1280. 187. Nair.P.R, Management of Khanja and Pangu with Panchakarma. New Delhi: CCRAS; 1999. p. 113. 188. Nadkarni KM Dr, Indian Materia Medica vol 1. 3rd ed. Bombay: Popular prakashan; 1976. p. 1191, 1192. 189. Sahasrayoga Kwatha Prakarana Vatarogahara, Dr. Ramnivas Sharma and Dr. Surendra Sharma, editors. 2nd ed. Hyderabad: Dakshin prakasan; 1990. 190. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 321-322. 191. Sharma. PV, Dravyagunavigyan vol 2. 5th ed.Varanasi: Chaukhambha Bharathi Academy;1981. p. 717. (Varanasi Ayurveda series). 192. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 370, 371. 193. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 313, 314. 194. Sharma. PV, Dravyagunavigyan vol 2. 5th ed.Varanasi: Chaukhambha Bharathi Academy;1981. p. 754. (Varanasi Ayurveda series). 195. Sharma. PV, Dravyagunavigyan vol 2. 5th ed.Varanasi: Chaukhambha Bharathi Academy;1981. p. 630. (Varanasi Ayurveda series). 196. Sharma. PV, Dravyagunavigyan vol 2. 5th ed.Varanasi: Chaukhambha Bharathi Academy;1981. p. 316. (Varanasi Ayurveda series). 197. Sharma. PV, Dravyagunavigyan vol 2. 5th ed.Varanasi: Chaukhambha Bharathi Academy;1981. p. 555. (Varanasi Ayurveda series). 198. Sahasrayoga Kwatha Prakarana Vatarogahara, Dr. Ramnivas Sharma and Dr. Surendra Sharma, editors. 2nd ed. Hyderabad: Dakshin prakasan; 1990. 199. Vagbhata, Ashtangahridaya Chikitsasthana chapter 21 sloka 67-69. Varanasi: Krishnadas Academy; 1982. p. 727. (Krishnadas Academic series 4). 200. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 748. 201. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 397-398.


202. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plants. Mumbai: Bharatheeya Vidyabhavan; 2000. p. 313-314. 203. Das Somen, A manual on Clinical Surgery chapter 15. 4th ed. Calcutta: Dr.S.Das; 1996. p. 188-192. 204. Das Somen, A manual on Clinical Surgery chapter 18. 4th ed. Calcutta: Dr.S.Das; 1996. p. 219-226. 205a. Mooss.N.S. Vayaskara, Ayurvedic Treatments of Kerala chapter 1. Kottayam: Vaidyasarathy Publications. 1946. p. 3-12. 205b. Mooss.N.S. Vayaskara, Ayurvedic Treatments of Kerala chapter 1. Kottayam: Vaidyasarathy Publications. 1946. p. 3-12. 205c. Mooss.N.S. Vayaskara, Ayurvedic Treatments of Kerala chapter 1. Kottayam: Vaidyasarathy Publications. 1946. p. 3-12. 206. AIMS Score- Arthritis section.2002. Available from: www.arthritis-research.org/aims. Accessed on December 2002. 207. Nair.P.R, Management of Khanja and Pangu with Panchakarma. New Delhi: CCRAS; 1999. p. 40.


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SPECIAL CASE SHEET FOR SANDHIGATAVATA Post Graduate Research And Studies Center (Panchakarma)

Shree DGM Ayurvedic Medical College, Gadag.

Guide : Dr. G.Purushothamacharyulu, PG Scholar : Subin.V.R. MD (Ayu).

Co-Guide: Dr. Shashidhar.H. Doddamani, MD (Ayu). 1. Name of the patient : Sl. No : 2. Father’s / Husband’s Name : OPD No : 3. Age : IPD No : 4. Sex : Bed No : 5. Religion : 6. Occupation : 7. Economical Status : 8. Address :_____________________________ Phone No : ____________________________ Email ID : _____________________________ 9. Type of treatment : Group A Group B

10.Date of Schedule Initiation :

M F

Poor Middle Aristocrat

Hindu Muslim Christian Others

Sedentary Active Labor Others

Date of Schedule Completion : 11. Result:

Good Response

Moderate Response

Poor Response

No Response

12. Consent: I here by agree that, I have been fully educated with the disease and

treatment, here by satisfied whole heartedly, and accept the medical trial over

me.

Investigator’s Signature Patient’s Signature

1

I. COMPLAINTS WITH DURATION :

Sl.

No

Chief complaints Before

Treatment

Duration After

Treatment

After

Follow-

up

1 Sandhisothaha (Swelling)

2 Prasaarana Aakunchanayoho

Savedana Pravruthihi (Pain

on extension & flexion)

3 Sandhigraha (Joint Stiffness)

- Morning stiffness

(15-30 ms)

- Stiffness after disuse

4 Sandhigathi asaamarthya

(Limitation of joint

movement)

5

6

Sparsha akshamatva

(Tenderness)

Atopa (Crepitation)

II. HISTORY OF PRESENT ILLNESS :

Mode of onset

Chronic Insidious Acute Traumatic

Nature of pain

Pricking Aching Generalized Tearing Burning

Variation of pain

Increased on use Increased on disuse Nocturnal

Routine activities affected

Yes No

2

III. HISTORY OF PAST ILLNESS :

Episodes of same illness Yes/No

Obesity Yes/No

Trauma/Fracture of involved or related joint Yes/No

Diabetes Mellitus Yes/No

Hypertension Yes/No

Other Vatavyadhees Yes/No

Vataraktha Yes/No

Acromegaly Yes/No

Septic arthritis Yes/No

Psoriatic arthritis Yes/No

Rheumatoid arthritis Yes/No

Fever Yes/No

Others Yes/No

IV. TREATMENT HISTORY :

Modern Medicine

Ayurveda Medicine/Therapy

Other Systems

Relief with previous treatment Partial / No relief

V. FAMILY HISTORY RELEVANT :

If Yes, specify the relation No

3

VI. PERSONAL HISTORY :

> Ahaara

Veg Mixed

> Agni

Manda Teekshna Vishama Sama

> Koshta

Madhya Mrudu Kroora

> Nidra

Sukha Alpa Ati Vishama

> Vyasana

Smoking Tobacco Alcohol Others None

> Aarthavapravruthi

Alpa Ati Vishama Rajonivruthi

> Malapravruthi (Frequency)

> Muthrapravruthi(Frequency)

Day Night

VII A. VITAL EXAMINATION

Weight in kgs Height in cms Temperature in

degree Celsius

Pulse rate per

Minute

Heart rate per

Minute

Blood pressure in

mm Hg

Respiration per

Minute

4

B. ASHTASTHAANAPAREEKSHA

1. Nadee :

Dosha

Gati

Poornata

Spandana

Kathinya

2. Muthra :

3. Mala :

4. Jihwa :

5. Sabda :

6. Sparsha :

7. Druk :

8. Aakruthi :

VIII. DASAVIDHAPAREEKSHA

A. PRAKRUTHI

V P K VP VK PK SANNIPATHA

B. VIKRUTHI

Hethu AL M A Prakruthi Aasukaari Chirakaari

Dosha AL M A Desa AL M A

Dushya Al M A Kaala AL M A

Bala AL M A Linga AL M A

( AL- Alpa, M- Madhyama, A- Adhika)

5

C. SAARA

Pravara Madhyama Avara

D. SAMHANANA

Susamhatha Madhyasamhatha Asamhatha

E. PRAMAANA

Sama Heena Adhika

F. SAATMYA

Ekarasa Sarvarasa Vyamishra

Rookshasaatmya Snigdhasaatmya

G. SATVA

Pravara Madhya Avara

H. AAHAARASAKTHI

Abhyavahaara Pravara Madhyama Avara

Jaranasakthi Pravara Madhyama Avara

I. VYAAYAAMASAKTHI

Pravara Madhyama Avara

J. VAYAHA

Baala Madhya Vrudha

IX. SROTOPAREEKSHA

Srotas Observed Lakshana

Pranavaha

Annavaha

Udakavaha

Rasavaha

Rakthavaha

Mamsavaha

Medovaha

6

Asthivaha

Majjavaha

Sukravaha

Pureeshavaha

Muthravaha

Swedovaha

Aarthavavaha

X. SPECIAL EXAMINATION OF JOINTS

A. Darshana (Inspection)

1. Joint Swelling

Grading 0 1 2 3

Varna a v h Raag Shyaa a Prakrut a

Herbeden’s N odes Present Absent

2.a. Deformity

Present Absent

b. Joint Instability

Present Absent

3. Gait

Nature

Walking Time (Grade)

4. Joint Movement

Active Completely Restricted Partially Restricted Free

Passive Completely Restricted Partially Restricted Free

5. Muscular spasm

Present Absent

7

6. Muscular Wasting

Above the affected joint Yes No

Below the affected joint Yes No

B. Sparshana (Palpitation)

1. Vaatapoornadruthisparsha

Yes No

2. Local Temperature

Raised Not raised

3. Tenderness

Grading 0 1 2 3

4. Limitation of Joint Movement (In Terms Of Grading)

Axial Joints Cervical Lumbar Spine

Distal Joints

Knee Right Left

Hip Right Left

Ankle Right Left

First Carpometametacarpal Right Left

Distal Interphalangeal Right Left

Proximal Interphalangel Right Left

C. Shravana (Auscultation)

Crepitus Heard Felt None

8

X1. NIDAANAPAREEKSHA

1. Nidaanapareeksha

a. Aahaara

Tiktharasa Athyupayoga Kashayarasa Athyupayoga Katurasa Athyupayoga

Alpa Bhojana Pramitha Bhojana Rooksha Bhojana

b. Vihaara

Vega Dhaarana Vegoodeerana Ativyavaya

Nisaajaagarana Atyucha Bhaashana Ativyaayama

c. Maanasika

Atibhaya Atishoka Atichintha

d. Occupational

e. Chikitsa Aparaadhaja

Shodhanakarma Atiyogaja Yes No

2. Poorvarupa :

3. Upashaya/Anupashaya :

Ushna Seetha

Rooksha Snigdha

4. Rupa :

5. Samprapthi :

XII. SAADHYAASAADHYATA:

9

XIII. LAB INVESTIGATIONS :

Sl.No Name of the Test Values

1. ESR /1st Hr.

2. Hb% Gm%

3. Total Count

WBC Per cm

RBC Per cm

4. Differential Count

N E B M L

5.

Blood Glucose Mg/dl

6.

RA Factor +ve -ve

7. Serum Alkaline Phosphatase : unit/L.

XIV. RADIOLOGICAL EXAMINATION OF JOINTS

( Antero posterior and Lateral View)

1 Joint space Reduced Increased Unaltered

2 Subchondral bony sclerosis Present Absent

3 Formation of osteophytes Present Absent

4 Periarticular ossicles Present Absent

5 Altered shape of bone end Present Absent

10

XV. SWEDAKARMA DAINAMDINA NIREEKSHANA

(SHASHTIKASHALIPINDASWEDA / ABHYANGA & BASHPASWEDA)

DAY TIME DURATION LAKSHANAS

OBSERVED

ANY

UPADRAVAS

UPACHARAS

ADVISED

11

XVI. ASSESSMENT OF RESULTS

A. CLINICAL PARAMETERS

Subjective

Parameters Day 0 Day 14 Day 28

Ruk (Pain)

Graha (Stiffness)

Objective

Parameters Day 0 Day14 Day 28

Sparsha Akshamatva (Tenderness)

Sandhigati Atisaamarthya (Range of Joint Movement)

Sotha (Swelling)

B. SWEDAKAARMUKATA PARAMETERS

Subjective


Agnideepthi

Bhakthasradha

Tandraahaani

Sandhicheshta

Srotonirmalatva

Objective


Maardava

Tvak Prasada

12

C. FUNCTIONAL PARAMETERS

Subjective

(Based on Arthritis Impact Measurement Scale)

Parameters Before treatment After Treatment After Follow-up

Mobility Level

Walking & Bending

Hand & Finger Function

Arm Function

Self care tasks (Exercise & Wt.

Bearing)

Household tasks

Social activity

Support from family & friends

Arthritis Pain

Work

Level of tension

Mood

Objective

Parameters Before Treatment After Treatment After Follow-up

Walking Time

XV11. INVESTIGATORS NOTE :

Signature of Co-Guide Signature of Guide

13

Ssps sandhigatavata pk001-gdg

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