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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 4  |  Page : 281-286

An interventional study of multimodal Ayurveda treatment in Amavata (rheumatoid arthritis)


1 Department of Panchakarma, J. S. Ayurveda Mahavidyalaya and P. D. Patel Ayurveda Hospital, Nadiad, Gujarat, India
2 Department of International Studies, J. S. Ayurveda Mahavidyalaya and P. D. Patel Ayurveda Hospital, Nadiad, Gujarat, India

Date of Submission07-Aug-2020
Date of Decision15-Oct-2020
Date of Acceptance21-Dec-2020
Date of Web Publication11-Feb-2021

Correspondence Address:
Dr. Chintan Janakkumar Bhatt
Post Graduate Department of Panchakarma, J. S. Ayurveda Mahavidyalaya and P. D. Patel Ayurveda Hospital, Nadiad, Gujarat.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_75_20

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  Abstract 

Background: Amavata (Rheumatoid arthritis) is described as Kasta Sadhya Vyadhi (difficult to treat disease) in Ayurveda. Pain in joints with swelling is a cardinal feature of this disease. It can be correlated with rheumatoid arthritis described in conventional medical science, where corticosteroids and some non steroidal anti-inflammatory drugs are used for induction of remission, which cause certain dangerous side effects in the patients. Ayurveda promises an effective therapy for it. Objective: The present clinical trial was conducted to provide a safe, economical and effective therapy to the patients of Amavata. The present study was conducted in 30 patients having classical symptoms of Amavata. Materials and Methods: The patients were treated with internal medications, Panchakrama procedures and physiotherapy. Patients having an acute or chronic systemic illness or infection were excluded from the study. Result: The observations and results obtained were analyzed statistically applying the “t” test. This multimodal Ayurveda treatment showed 61.10% relief in sign and symptoms of Amavata in all the patients. Ayurveda treatment procedures and medication used for the treatment of Amavata have Agni Deepana, Ama Pachana, Vata Shamaka, and Rasayana effects in the body which are helpful in to retard disease process and to reduce signs and symptoms of the disease. A significant decrease in the erythrocyte sedimentation rate in all the patients was also noticed. All the results obtained were highly significant statistically. Conclusion: The therapeutic interventions adopted in the study have shown beneficial effects in the patients of Amavata and is free from side effects.

Keywords: Amavata, multimodal Ayurveda treatment, rheumatoid Arthritis


How to cite this article:
Bhatt CJ, Patel MM, Gupta SN, Patel KB. An interventional study of multimodal Ayurveda treatment in Amavata (rheumatoid arthritis). J Indian Sys Medicine 2020;8:281-6

How to cite this URL:
Bhatt CJ, Patel MM, Gupta SN, Patel KB. An interventional study of multimodal Ayurveda treatment in Amavata (rheumatoid arthritis). J Indian Sys Medicine [serial online] 2020 [cited 2021 Mar 7];8:281-6. Available from: https://www.joinsysmed.com/text.asp?2020/8/4/281/309125




  Introduction Top


Amavata is one of the most difficult to treat diseases mentioned in Ayurveda. Amavata is a disease of Madhyma Rogamarga (disease of internal pathway) which involves Aasthi-Sandhi (Bones- Joints). The revolutionize lifestyle, varieties of groceries, and sophisticated living has given their contribution in occurrance of new diseases and those diseases which were not common, now developed as a fiery predicament. Amavata is one such disease. The basic pathology in the Amavata is the formation of Ama in the body due to Agnimandya (low digestive fire), followed by vitiation of all the three Doshas, and predominantly Vata.[1]Ama and Vata are the two leading factors in the occurrence of the disease. Agni (digestive fire) is the one, which maintains the health. When a low digestive fire person indulges in faulty food habits and activities result is Ama production. Ama influenced by the vitiated Vata, moves all over the body with more liking towards the Sleshma Sthana (site of Kapha) like Sandhis (joints). Convoying with body ache, loss of taste, feeling of heaviness, laziness, fever, and swelling of joints, etc. the disease manifests. When “Pitta” also gets associated, it causes burning sensation around the joints. If not treated in right time, ends up with deformities like contracture of joints. Rheumatoid arthritis, a disease seen with similar symptoms to Amavata, is one of the burning problems of this era. A disease in future makes man to depend on others by afflicting the joints, altering the appearance, affecting the other systems makes the life miserable. In modern medicine, the treatment of the disease includes steroids and immunomodulator drugs together with no steroidal anti-inflammatory drugs (NSAIDs). Long-term use of these drugs has many adverse effects on the other systems of the body. In this regard, a lot of studies has been taken place and still going on. In Ayurveda classics many treatment modalities like Shodhana (purification) and Shamana (pallaiative) are mentioned. The main aim of this study was to evaluate the effectiveness of multimodal Ayurevda treatment protocol in the patients of Ayurevda (rheumatoid arthritis) [Figure 1].
Figure 1: Collection of images of patients in different position of before and after treatment

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  Materials and Methods Top


A clinical study

This clinical study was carried out in 30 clinically diagnosed patients of Amavata (rheumatoid arthritis).

Sample size

Thirty patients were selected with simple sampling method, irrespective of their age, sex, religion, etc., from Outdoor Patient Department (OPD) and Indoor Patient Department (IPD) of Department of Kayachikitsa and Panchakarma of P.D. Patel Ayurveda Hospital, Nadiad.

Study design

This study is a single arm an observational clinical study.

Statistical analysis

The data obtained in this clinical study were statistically analyzed by using Student’s paired “t” test.

Primary outcome

The proposed outcome is to assess with grade score of the Sandhishula (pain in joints), Sandhi jadyata (stiffness in joints), Sandhi shotha (swelling in joints), restriction of movements and range of motion (ROM) end feel.

Secondary outcome

The erythrocyte sedimentation rate (ESR) is the secondary outcomes for this study.

Diagnostic criteria

The presence of the following signs is diagnostic criteria:

  • Sandhiśula


  • Sandhijādyatā,


  • Sandhiśotha\,


  • Restriction of movement, and


  • Presence of any four out of the six classification criteria of American College of Rheumatology (ACR) clinical classification criteria for rheumatoid arthritis.[2]


  • Inclusion criteria

    The criteria of inclusion of patients were based on the signs and symptoms of Amavata are:

  • Morning stiffness (>1h),


  • Arthritis of three or more joints, and


  • Symmetrical arthritis.


  • The patients were selected randomly irrespective of their age, sex, religion, etc.

    Exclusion criteria

    The patients having any other chronic systemic illness, metabolic diseases like gout, with severe deformities, and endocrinology diseases were excluded from the study.

    Criteria for assessment

    All the symptoms were given score to assess the effect of the treatment objectively. ESR was recorded before and after the treatment.

    ROM end feel[3] was documented before treatment (B.T.) and after treatment (A.T.) as follows:

    • Fixed contracture = Rock-hard end feel


    • Poor = 1–3degrees of play at the end feel


    • Fair = 4–6degrees of play at the end feel


    • Good = 7–10degrees of play at the end feel


    • Excellent = Springy and bouncy end feel; 11+ degrees of play.


    As many of the patients with rheumatoid arthritis having negative rheumatoid arthritis (RA) factor; also because of inconveniency in the clinic RA factor is not invovled as assessment criteria [Table 1].
    Table 1: Gradation of symptoms for assessment

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      Treatment Schedule Top


    Multimodal Ayurveda treatment schedule was given to the 30 patients of Amavata registered in the study.[4]

    Vardhman Pippali Krama

    Pippali churna was given with warm water in (Increasing dose) for 13 days (started with one gram twice on the first day, increased 1 g each day up to maximum dose of 5 g twice on the fifth day, maintained maximum dose, i.e., 5 g twice for 5 days and then reduced 1 g each day reaching to initial dose of 1 g twice on 13th day).

    Svedana Karma (sudation therapy)

    Bashpa Svedana was given once a day, Valuka Svedan was given in the morning and in night time every day. Nadi Svedan with passive stretching on affected joints was given twice a day after Virechan Karma. Svedan Karma was given from first day up to 30th day of treatment except for 3 days of Samsarjan Karma.

    Virechan Karma (purgative therapy)

    Mrudu Virechana with Erand Sneha (Castored Oil) was performed on 13th day after the Sarvanga Bashpa Svedan with Nirgundi Patra.

    Samsarjan Karma

    Three days of Samsarjan Karma was followed after Virechan Karma.

    Basti Karma (Ano rectal administration of the medicine)

    Niruha Basti of Dashmooladi drugs 320 ml was also given every day up to the end of the I.P.D. treatment.

    Shaman Aushadhi (palliative therapy)

    Oral medicaments including Rasnapanchak Kvatha 40 ml twice a day,[5]Yograj Guggulu[6] 1 gm thrice day, Ashvagandha churna 2 g, and Vatavidhvansha Rasa 250mg twice a day was given to her after Virechana.

    Pathya (therapeutic regimen)

    Patients were kept only on mungo bean soup and boiled vegetables during I.P.D. treatment


      Observation and Result Top


    [Table 2][Table 3][Table 4][Table 5][Table 6][Table 7] show the observation and results of the study. The patients were assessed for improvement of signs-symptoms and ESR investigation before treatment and after completion of 1 month of the treatment.
    Table 2: Age-wise distribution of patients

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    Table 3: Sex wise distribution patients

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    Table 4: Chronicity wise distribution patients

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    Table 5: Effect of treatment on sign and symptoms of Amavata

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    Table 6: Effect of treatment on ESR

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    Table 7: Effect of treatment on ROM end feel

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    In total, 16 patients (53.33%) were in the age group of 41–60 years followed by 11 patients (36.66%) in the age group of 21–40 years, 2 patients (6.66%) in the age group of <20 years, only 1 patient (3.33%) in >60 years of age group [Table 2]. A total of 22 patients (73.33%) were female, and 8 patients (26.67%) were male. Sixteen patients (53.33%) were having a duration of illness between 1 and 3 years, 10 patients (33.33%) were suffering from the disease for less than 1 year, and 4 patients (13.33%) were having symptoms of the disease for more than 3 years [Table 4]. Improvement in the symptom of pain in joints was 54.90% which is statistically highly significant. Stiffness in the joints decreased by 43.10%, i.e., statistically highly significant. Swelling in the joints also decreased by 89.28%, i.e., also statistically highly significant. The improvement in the symptom of restriction in the movements in the joints was 57.14% which is statistically highly significant [Table 5]. A significant decrease in ESR (61.36%) was observed in the patients registered for the study after the completion of the treatment course, which is statistically highly significant [Table 6]. 63.33% patients were having “Good’’ improvement and 36.67% “Springy’’ improvement in end feeling during ROM [Table 7], [Figure 1]. During the treatment, none of the patients showed any adverse reactions.


      Discussion Top


    In this study of all the 30 patients registered 16 patients (53.3%) were in the age group of 41–60 years and most of them (73%) were females. Most of the patients were having a duration of illness 1–3 years. The use of multimodal Ayurveda treatment in sign and symptoms of Amavata in registered patients showed 54.90% relief from the symptom of pain in joints, 43.10% relief from the symptom of stiffness in the joints, 89.28% relief from the swelling in joints, and 57.14% relief from restriction of movements. All these results were found to be statistically highly significant (P < 0.001). A remarkable reduction (61.36%) in ESR was also noticed in the patients registered for the current clinical study and this result is also statistically highly significant (P < 0.001).Total 63.33% of patients having “Good” improvement and 36.67% “Springy” improvement in End feeling during ROM.

    The use of Pippali in increasing and tapering doses is known as “Vardhamana Pippali”. It has Agni Dipana, Ama Pachana, and Rasayan, immunomodulator actions which are helpful in the alleviation of Ama from the body and also correct the Bala Bhramsa (dysfunction of the immune system) which is the main pathological factor in Amavata, i.e., rheumatoid arthritis.[7]

    Svedana is the treatment which reduces Sandhi Jadya (stiffness or contracture), Gaurava (heaviness), and Shaitya (coldness).[8]Vata possessing Shita and Vishada Guna together with Ama is responsible for these deformities in the patients of rheumatoid arthritis. Svedana is useful for Ama pachana and reduces the Shita Guna of Vata as well as Jadyata[9] and hence it can be useful in the treatment of contractures due to long-term rheumatoid arthritis. Stretching improves the muscles’ elasticity and achieves comfortable muscle tone and hence feeling of increased muscle control, flexibility, and ROM.

    Virechana is a therapy which is indicated for Shodhana purpose in Amavata. After the Langhana, Svedana, and Dipana-Pachana, Doshas become Nirama and start to move towards the kostha from Sakha.[10] Hence, Virecana with suitable drug is required to eliminate the Doshas. Eranda sneha is one of the best amongst the Virecana Dravyas.[11] It is said to be best Vatanulomana and Amavatahara.[5]

    Basti is mentioned as Ardhachikitsa and best procedure to control vitiated Vata Dosha. Vata is the second important pathogenic factor of Amavata. Niruha Basti eliminates vitiated Doshas and Malas out of the body.[4] When Ama gets digested by Dipana and Pachana treatment measures described above, Pachita Ama which is now in the form of accumulated mala in the body should be eliminated out of the body by Niruha Basti of Dashmooladi Dravya.

    All oral medicaments possessed Madhura, katu and Tikta Rasa, Ushna Virya, and Madhura Vipaka. The properties of the formulations were Ushna and Laghu able to exert Dipana, Pachana, Shula Prashamana, Sothahara, and Tridosha Shamak action with special pacifying effect on Amavata.

    Thus, because of all these actions together, it plays an important role in the Samprapti-Vighatana of the Amavata, i.e., rheumatoid arthritis. No side/adverse effects were noticed in any of the patients registered for this clinical study and improvement in the quality of life of the patient by correcting the swelling, pain, and restricted movements of the joints were noticed. This is the observational study and had small sample size.


      Conclusion Top


    The study reveals that, on the basis of observations and discussion, the multimodal Ayurveda treatment protocol has a lot of constructive effects in the patients of Amavata with the highly significant result (P < 0.001) with no any side effects. Hence, the study reinforced that it was having only the 30 patient’s data so it needs a large number of data to further establish the same treatment protocol for the Amavata with special reference to rheumatoid arthritis.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Agnivesha , Charaka Samhita, Elaborated by Charak, Redacted by Dridhabala, Edited by Vaidyamanoramahindi commentary by Acharya Vidhyadhar Shukla, Prof Ravi Dutt Tripathi, Grahanichikitsa Adhyaya, Shloka no. 42–44, Chaukhamba Sanskrit Pratishthan, Delhi; 2012. p. 367.  Back to cited text no. 1
        
    2.
    Arnett FC, Edworthy SM, Bloch DA, Mcshane DJ, Fries JF, Cooper NS, et al. The American rheumatism association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheumatol 1988;31:315-24.  Back to cited text no. 2
        
    3.
    Bob Thomas. Managing contractures in long term care. Sub-acute and long term care managing contractures in long-term care. Phys Therap Rehab Med 2008;19:47.  Back to cited text no. 3
        
    4.
    Vaidya Lakshmipati Shastri, Yoga Ratnakar with vidhyotinihindi commentary, edited by Bhisagratna Brahma Shankar Shastri, Purvardha, Amavata chikitsa shloka 1, 2. Varanasi: Chaukhamba Prakashan; 2013. p. 566.  Back to cited text no. 4
        
    5.
    Vaidya Lakshmipati Shastri, Yoga Ratnakar with vidhyotini hindi commentary, edited by Bhisagratna Brahma Shankar Shastri, Purvardha, Amavata chikitsa, Rasnaadipanchak shloka 1. Varanasi: Chaukhamba Prakashan; 2013. p. 567.  Back to cited text no. 5
        
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    Agnivesha, Charaka Samhita, Elaborated by Charak, Redacted by Dridhabala, Edited by Vaidyamanoramahindi commentary by Acharya Vidhyadhar Shukla, Prof Ravi Dutt Tripathi, Panduchikitsa Adhyaya, Shloka no 81–86. Delhi: Chaukhamba Sanskrit Pratishthan; 2012. p. 406.  Back to cited text no. 6
        
    7.
    Soni A, Patel K, Gupta SN Clinical evaluation of vardhamana pippali rasayana in the management of amavata (rheumatoid arthritis). Ayu 2011;32:177-80.  Back to cited text no. 7
        
    8.
    Agnivesha, Charaka, Dridhabhal.Charaka Samhita withVidyotini hindi commentary of Kashinath shashtri and Gorakhnath Chaturvedi, Sutra Sthana 22/11, Edited by Rajeshvardutta Shashtri. Varanasi: ChaukhambhaVidyabhavan; 1969. p. 428.  Back to cited text no. 8
        
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    Agnivesha, Charaka, Dridhabhal. Charaka Samhita with Vidyotini hindi commentary of Kashinath shashtri and Gorakhnath Chaturvedi, Sutra Sthana22/04, Edited by Rajeshvardutta Shashtri. Varanasi: ChaukhambhaVidyabhavan; 1969. p. 428.  Back to cited text no. 9
        
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    Agnivesha, Charaka Samhita, Elaborated by Charak, Redacted by Dridhabala, Edited by Vaidyamanorama hindi commentary by Acharya Vidhyadhar Shukla, Prof Ravi Dutt Tripathi, Vividhashitapitiyama adhyayam Shloka no. 31–32, Delhi: Chaukhamba Sanskrit Pratishthan; 2012. p. 432.  Back to cited text no. 10
        
    11.
    Maharishi Sushruta, Sushruta Samhita Part -1 of Maharishi Sushruta, Edited with Ayurveda- Tattva- Sandipika hindi commentary, scientific analysis notes, etc. by Kaviraj Ambikadutta Shastri, Foreword by Dr. Pranjivan M Mehta, Sutra sthana Virechandravyavikalpvigyaniya adhyaya shloka 3–4, Varanasi: Chaukhamba Sanskrit Sansthan; 2017. p. 161.  Back to cited text no. 11
        


        Figures

      [Figure 1]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



     

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