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A COMPARATIVE STUDY OF ERANDA PAKA AND AJAMODADI CHURNA IN THE MANAGEMENT OF AMAVATA , DEEPAK S.M. 2002 – 2003, DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA, S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118.
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A COMPARATIVE STUDY OF ERANDA PAKA AND AJAMODADI
CHURNA IN THE MANAGEMENT OF AMAVATA
Dissertation submitted to the Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka in partial fulfillment of the regulations for the award of the
degree of
DOCTOR OF MEDICINE (AYU)
By
DEEPAK S.M., B. A. M. S.
GUIDE
DR.U.N. PRASAD, M.D. (AYU) Professor and H.O.D.
Department of Kayachikitsa S.D.M. College of Ayurveda, Udupi
CO-GUIDE
DR. V.K. SRIDHAR HOLLA, M.D.(AYU) Assistant Professor
Department of Kayachikitsa S.D.M. College of Ayurveda, Udupi
DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA
S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118.
2002 – 2003
DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA
S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118
CERTIFICATE
This is to certify that the dissertation entitled “A comparative
study of Eranda Paka and Ajamodadi Churna in the management of Amavata” is the record of the research work conducted by Deepak S.M.
under my direct supervision and guidance in S. D. M. College of
Ayurveda, Udupi.
The candidate has put in sincere effort in both the conceptual and
clinical studies.
This title has not been awarded Degree, Diploma, Associateship,
Fellowship or similar honors from this University.
I recommend and forward the same for being submitted for
evaluation to the adjudicators.
Place : Udupi Date :
Dr. U. N. Prasad, M.D. (Ayu) Professor and Head of the Department of
Post graduate studies in Kayachikitsa
S. D. M. College of Ayurveda, Udupi.
DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA
S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118
CERTIFICATE
This is to certify that the dissertation entitled “A comparative
study of Eranda Paka and Ajamodadi Churna in the management of Amavata” is the record of the research work conducted by Deepak S.M
under my direct supervision and guidance.
The candidate has put in sincere effort in both the conceptual and
clinical studies.
I recommend the same for being submitted for evaluation to the
adjudicators.
Place : Udupi Date :
Dr. U. N. Prasad, M.D. (Ayu) Professor and Head of the Department of
Post graduate studies in Kayachikitsa
S. D. M. College of Ayurveda, Udupi.
ACKNOWLEDGEMENTS
I am Ever Indebted To Lord Almighty,
My Venerated Parents,
Respected Teachers And
Affectionate Friends
Dedicated to
My Beloved Father
CONTENTS LIST OF CHARTS
LIST OF TABLES
LIST OF GRAPHS
LIST OF ABBREVIATIONS
Page No
PART - I: INTRODUCTION 1
PART - II: CONCEPTUAL STUDY Chapter I - Historical Review 5
Chapter II - Vyutpatti of Amavata 11
Ama and Vata 12
Nidana 30
Samprapti 35
Poorvaroopa 41
Bheda 43
Roopa 46
Upadrava 55
Investigations 58
Upashaya Anupashaya 62
Sadhyasadhyata 65
Sapeksha Nidana 67
Chikitsa 69
Pathya-Apathya 76
Chapter III - Drug Review 79
PART - III: CLINICAL STUDY
Materials and Methods 87
Observations 99
Results 104
PART – IV: DISCUSSION 128
PART –V: SUMMARY AND CONCLUSION 145
BIBLIOGRAPHY
APPENDIX-CASE SHEET
LIST OF GRAPHS
Graph No. Contents
1. Age groupwise distribution of patients
2. Percentage of patients of different sex
3. Percentage of patients of different religion
4. Incidence of Literacy
5. Percentage of patients of different marital status
6. Incidence of socio-economical status of patients
7. Occupation wise distribution of patients
8. Distribution of patients according to their habits
9. Prakriti wise distribution of patients
10. Vikruti wise distribution of patients
11. Percentage of patients according to Satva
12. Percentage of patients according to Sara
13. Percentage of patients according to Samhanana
14. Percentage of patients according to Satmya
15. Percentage of patients according to Abhyavaharana Shakti
16. Percentage of patients according to Aahara-Jarana Shakti
17. Percentage of patients according to Vyayama Shakti
18. Percentage of patients according to Vaya
19. Effect of Eranda Paka on cardinal symptoms of Amavata
20. Improvement in general symptoms recorded in patients treated with
Eranda Paka
21. Over all effect of Eranda Paka on general symptoms of Amavata
22. Effect of Eranda Paka on symptoms of Ama
23. Effect of Eranda Paka on total symptom score of Ama
24. Effect of Eranda Paka on different clinical parameters
25. Effect of Eranda Paka on TLC
26. Effect of Eranda Paka on Hb%
27. Effect of Eranda Paka on ESR
28. Over all effect of treatment in 10 patients of Amavata
29. Effect of Ajamodadi Churna on cardinal symptoms of Amavata
30. Effect of Ajamodadi Churna on general symptoms of Amavata
31. Total effect of Ajamodadi Churna on general symptoms of Amavata
32. Effect of Ajamodadi Churna on symptoms of Ama
33. Total effect of Ajamodadi Churna on symptoms of Ama
34. Effect of Ajamodadi Churna on different clinical parameters
35. Effect of Ajamodadi Churna on TLC
36. Effect of Ajamodadi Churna on Hb%
37. Effect of treatment on ESR
38. Overall effect of Ajamodadi Churna in patients of Amavata
39. Comparison of the effect of treatment on the cardinal symptom of
Amavata
40. Comparison of effect of treatment on general symptom in two
groups
41. Comparison of effects on symptoms of Ama in two groups
42. Comparison of effects on range of joint movement
43. Comparison of effects on foot pressure between the groups
44. Comparison of the effect on hand grip power
45. Comparison of effect on body weight
46. Comparison of effect on haemoglobin percentage
47. Comparison of effect on erythrocyte sedimentation rate
48. Comparison of overall effect of the treatments in both the groups
LIST OF TABLES
Table No. Contents
1. Lakshanas of Amavata according to different authors
2. Properties and therapeutic effect of the individual drugs in Eranda
Churna
3. Properties and therapeutic effect of the individual drugs in
Ajamodadi Churna
4. Properties and therapeutic effect of the individual drugs in
Panchakola Phanta
5. Age Group of Patients
6. Sex Incidence of Patients
7. Religion of patients 20 patients of Amavata
8. Literacy incidence in patients of Amavata
9. Marital status of Amavata patients
10. Socio-economic status of patients
11. Incidence of occupation in Amavata patients
12. Study of Habit incidence
13. Study of patients Prakriti in the study
14. Incidence of Vikriti
15. Incidence of Satva in the Study
16. Study of Saratah Incidence in the Study
17. Study of patients Samhanana in the study
18. Satmya Incidence
19. Study of patients Ahara-Abhyavaharana Shakti
20. Study of Patients Ahara-Jarana Shakti the Study
21. Study of patients Vyayama Shakti in the study
22. Vaya incidence
23. Effect of Eranda Paka on cardinal symptoms of Amavata
24. Effect of Eranda Paka on general symptoms of Amavata
25. Overall effect of Eranda Paka on general symptoms of Amavata
26. Effect of Eranda Paka on the symptoms of Ama
27. Overall effect of Eranda Paka on symptoms of Ama
28. Effect of Eranda Paka on circumference of limbs
29. Effect of Eranda Paka on different clinical parameters
30. Effect of treatment on body weight of patients of Amavata
31. Effect of Eranda Paka on different hematological values
32. Over all effect of treatment in 10 patients of Amavata
33. Effect of Ajamodadi Churna on cardinal symptoms of Amavata
34. Effect of Ajamodadi Churna on general symptoms of Amavata
35. Total effect of Ajamodadi Churna on general symptoms
36. Effect of Ajamodadi Churna on symptoms of Ama
37. Total effect of Ajamodadi Churna on symptoms of Ama
38. Effect of Ajamodadi Churna on circumference of the limbs
39. Effect of Ajamodadi Churna on different clinical parameters
40. Effect of Ajamodadi Churna on body weight of patients of Amavata
41. Effect of Ajamodadi Churna on different hematological parameters
42. Over all effect of treatment in 10 patients of Amavata
43. Comparison of effect of treatments on cardinal symptoms of
Amavata
44. Comparison of effect on general symptoms
45. Comparison of effect on symptoms of Ama between the groups
46. Comparison of effect on different clinical parameters
47. Comparison of the effect on body weight in both the groups
48. Comparison of effect on different haematological values
49. Comparison of overall effect of treatment in two groups
LIST OF CHARTS
Chart no. Contents
1. Schematic representation of Nidana of Amavata
2. Schematic representation of Samprapti in the light of Kriyakalas
3. Schematic representation of the evolution of Poorvaroopa
4. Schematic representation of the evolution of Roopa
5. Schematic representation of the evolution of Upadrava
LIST OF ABBREVIATIONS
1. A.H. : Ashtanga Hridaya
2. A.P.I. : A.P.I.Text Book Of Medicine
3. A.S. : Ashtanga Sangraha
4. A.K. : Amarakosha
5. A.V.S. : Atharvaveda Sayana Bhashya
6. Basa : Basavarajeeyam
7. B.P. : Bhava Prakasha
8. B.R. : Bhaishajya Rathnavali
9. C.S. : Charaka Samhita A
10. C.D. : Chakra Datta
11. Ckr. : Chakrapani.
12. D.P.P.M. : Davidson’s Practice and Principles of Medicine
13. Dl. : Dalhana
14. D.N. : Dhanvantari Nighantu
15. D.G. : Dravya Guna Vijnana
16. E.M.P. : Essentials Of Medical Pharmacology
17. G.N. : Gada Nigraha
18. H.P.I.M. : Harrison’s Principle Of Internal Medicine
19. H.S. : Harita Samhita.
20. K.S. : Kashyapa Samhita
21. K.K. : Kalyanakaraka
22. K.N. : Kaiyadeva Nighantu
23. M.K.A. : Malavikagnimitra
24. Madhu. : Madhukosha
25. M.N. : Madhava Nidana
26. M.P.N. : Madanapala Nighantu
27. R.P.B.D. : Robbin’s Pathologic Basis Of Disease
28. R.R.S. : Rasa Ratna Samucchaya
29. R.N. : Raja Nighantu
30. R.V. : Rugveda
31. S.N. : Saligrama Nighantu Bhushana
32. S.K.D. : Shabda Kalpa Druma
33. Sh.S. : Sharangadhara Samhita
34. S.S. : Sushruta Samhita
35. T.B.P. : Text Book Of Pathology By Harsh Mohan
36. Vag. : Vagbhata
37. Vang. : Vangasena
38. W.I. : The Wealth Of India
39. Y.R. : Yogaratnakara
ABBREVIATIONS OF STHANAS AND KHANDAS
1. Chi. : Chikitsa Sthana
2. Ind. : Indriya Sthana
3. Ka. : Kalpa Sthana
4. Ma.Kha. : Madhyama Khanda
5. Ni. : Nidana Sthana
6. Po.Kha. : Poorva Khanda
7. Sha. : Shareera Sthana
8. Si. : Siddhi Sthana
9. Su. : Sutra Sthana
10. Ut. : Uttara Tantra
11. Vi. : Vimana Sthana
Introduction
INTRODUCTION
“Necessity is the mother of invention”, true to this sermon the invention:
“Ayurvedo Ayam” and the necessity “Rogastasysa Apahartaraha” Kasya?
“Shreyaso Jeevitasya cha”. Roga was hence the research problem, which led to
dawn of a philosophy, a religion, a science and the second important milestone
after the birth of man away from the land of immortals.
“Jignyasa Nama Pareksha” is a virtue that develops as a response to the
stimulus of a problem, which haunts a human being to restrict him in his
pursuits. Inventions like the microscope by Robert Koch, penicillin by Alexander
Fleming are examples of such responses from the recent past.
The history of medical science hence begins with the advent of Ayurveda
and takes many twists and turns gifting the modern world with awesome
discoveries and inventions enough to create a revolution. The revolution in
medical science has been progressing a lot since then as rightly put below.
“We can put it down as one of the principles learned from the history of
science that a theory is only overthrown by a better theory, never merely by
contradictory facts. Attempts are first made to reconcile contradictory facts to
the existing conceptual scheme by some modification of the concept. Only the
combination of a new concept with facts contradictory to old ideas finally brings
about a scientific revolution and when this has taken place then in short years
1
Introduction
discovery follows upon discovery and the branch of science in question
progresses by leaps and bounds”.
-James B. Somnant
The process of research hence continues with renewed momentum
whenever a medical problem is encountered especially that which becomes
more knotty and mysterious each time attempts are made to decipher it. Ama
Vata or Rheumatoid arthritis (Y.N. Upadyaya) as perceived in modern parlance
is one such medical problems that cripples a man to an extent to render him
unfit for independent living. The patient experiences pain, which is so miserable
as to promote a statistical study on the suicide rates in Rheumatoid Arthritis
(RA) patients.
Leave alone the articular manifestation the extra articular effects on the
other systems are even more deleterious. In the musculoskeletal system it
causes skeletal muscle atrophy and osteoporosis, pleuropulmonary
manifestation of respiratory system, the vasculitis phenomenon of the vascular
system peripheral neuropathies of nervous system, scleritis and other
manifestation of opthalmic system, haematological manifestation like anaemia
and splenomegaly are the common complications of the disease. R.A. effects
approximately 0.8% of the population without race bias. Females are affected
three times more than males. Interestingly, studies indicate that climate and
urbanization have a major effect on the incident and severity of R.A. studies to
discover the mechanism of etiology, pathogenesis and treatment have been
2
Introduction
inconclusive at best and the disease continues to elude the modern researches
in all perspectives of objectivity.
In this situation, the Ayurvedic viewpoint on the disease assumes
significant relevance, according to which Ama the toxic byproduct of a
transformative error in body’s metabolic homeostasis conjugates with Vata the
supreme controller of homeostasis and the prime Dosha to manifest the
symptoms of Ama Vata.
Ama is produced whenever the factors governing mechanisms that
render the gross nutrients assimilable and compatible to the body elements are
overwhelmed both at the digestive and metabolic levels. Though the major
sources of Ama is from the Adishtana of Jatharagni initiated by Prakupita
Doshas, it is also produced at the Dhatwagni level when the inherent
compatibility of an equilibrium of contradictions in the Gunas of Doshas are
disrupted, a concept consistent with the description of autoimmunity in modern
medicine.
The Ayurvedic approach to the treatment is the need of the hour as no
system is successful in providing the complete cure to this disease. A
comprehensive Ayurvedic management with Langhana-a concept over sighted
by the modern scientists as accidental and inconsequential, promises to make a
significant difference in the management of R.A. Among the Ayurvedic drugs
Eranda and Ajamoda are among the best Amapachakas and their effects in
3
Introduction
Amavata has been hailed in Yogaratnakara. A well-organized clinical study
comparing the effect of Eranda Paka and Ajamodadi Churna is another attempt
to search an effective remedy for Amavata.
4
Conceptual Study
HISTORICAL REVIEW
An offshoot of Atharva and Rigveda, this science of medicine is without
beginning, but Ayurveda saw throughout many people, who organized it into
beautifully woven treatises, incorporating newer diseases and their treatment
which cropped up during their times. It is evident in the Samhitas that the most
prevalent and deadly diseases have been devoted separate chapters were
included as secondary diseases under the major category.
Amavata might not have been widely prevalent and severely crippling as
it was during the time of Madhava Nidana, as we see only passing references
to the disease have been made in the Bruhatrayees. Madhava was the first
person to devote separate chapter for Amavata. Thus the birth of this disease
and its formative years can be glanced, starting from Vedic period.
Vedic period (5000 BC to 1000 BC):
Clear cut explanations of Amavata are not available in Vedic Samhitas,
but disease caused by Kapha have been more or less described under the
major heading Balasa, but the diseases of joints are not included here. Few of
references indicating arthritic syndromes have been quoted by Sayana. Such
as
Rapasi1: Disease arising due to sin (Rigveda) characterized by pain in
multiple joints also referred to as Papa. Yakshma and treatment with Jala, Vayu
Yava, Kushta have been indicated.
5
Conceptual Study
Jayanya1: This disease is said to effect the bones cervical vertebrae
and arise from women through Sanga. Whether the disease refers to
rheumatoid arthritis is still not clear.
Grahi1 (Rigveda and Atharvaveda): This has been described as the
disease of joints but characteristic features have not been clearly mentioned.
Treatment of this disease with Dashavruksha has been mentioned.
Vatikrut1: This disease has been described as a serious ailment caused
by Vata and treatment with Pippali and Vishanashaka has been mentioned.
Sandhivikruti1 (Atharvaveda): This disorder is caused by Sleshma and
can be treated with prayers.
Samhita period (1000 BC TO 600 AD):
Charaka Samhita: Charaka has described in detail Ama and Ama
Pradoshaja Vikara and their treatment with Langhana and Ullekhana.2
Charaka had described treatment for Amavata while dealing with
Avarana Chikitsa in Vatavyadhi3 which indicate Pramehahara and Medohara
Vidhi. Amavata finds a mention in the list of therapeutic indication of Kamsa
Hareetaki4 in Shwayathu Chikitsa and Vishaladi Phanda in Pandu Chikitsa.5
The treatment of Shariragata Ama in Grahani Chikitsa by Charaka6 is
similar to the description of Amavata Chikitsa by Bhava Mishra i.e. Langhana,
6
Conceptual Study
Pachana and oral administration of Panchakola Phanta7, same is the case with
Amavata Chikitsa of Chakrapani in Chakradatta7.
Sushruta Samhita: The description of Amavata in Sushruta Samhita is
conspicuous by its absence.
Bhela Samhita: The tenth chapter in Sutra Sthana deals with Ama
Pradosha. This description has some resemblance with that of Amavata.
Harita Samhita: A complete chapter on Amavata finds a mention in
Harita Samhita9. The classification of Amavata is quite unique and not followed
by any of the later works in this field.
Anjana Nidana: This work is claimed to be written by Acharya
Agnivesha, contains detailed description about etiology, premonitory symptoms,
clinical manifestations, complications.
Sangraha Kala (600AD-1600AD):
Astanga Sangraha and Astanga Hridaya have ignored the disease
though the word Amavata is included in the therapeutic index of compounds
Vatsakadi Yoga10 and Vyoshadi yoga10.
Madhava Nidana11: Madhavakara accorded this disease the status of a
independent disease and has dealt the topic threadbare.
Chakradutta: Chakrapanidutta has described the treatment for
Amavata8.
7
Conceptual Study
Vangasena12 and Vrinda Madhava followed Madhava with few additions
in the treatment aspect. Works like Bhava Prakasha13, Yogaratnakara14 and
Bhaishajya Ratnavali15 have only corroborated the descriptions with additional
principles of treatment.
Adhunika Kala (1600AD onwards):
Mahopadhyaya Acharya Gananath Sen has coined the term Rasavata
for Amavata.
In Yoga Shastra the practice of Shushka Basti for improving Jatharagni
and treating Amavata has been mentioned16. Y.N.Upadhyaya (1955) has
corelated the disease with rheumatoid arthritis. Later research workers have
agreed with Y.N.Upadhyaya.
Modern History of Rheumatoid Arthritis:17
First Century AD: The rheumatoid/rheumatology is derived from the root
‘Rheuma’, which refers to a substance that flows and probably was derived
from phlegm, an ancient primary humor, which was believed to originate from
brain and flow to various parts of the body causing ailments.
1642 A.D.: The word rheumatism is introduced into the literature by the French
physician Dr.G.Baillou who emphasized that arthritis could be a systemic
disorder.
8
Conceptual Study
1800 A.D.: Landre Baervier a physician from Salta Petruver in Paris, seemed to
have described the disease for the first time he called it Gartte Asthanique
Primitivae.
1857 A.D.: Sir Garrod proposed the name Rheumatoid Arthritis, Bannatyne
also in 1959 published his pathological observations on the disease but he
could differentiate it from Osteoarthritis only in his later edition.
1928 A.D.: The American committee for the control of rheumatism is
established in U.S. by Dr.R.Pemberton, renamed American Association for the
study and control of rheumatic disease (1934), then American Rheumatism
Association (1937) and finally American college of Rheumatology (ACR) (1988).
1940 A.D.: The terms Rheumatology and Rheumatologist are first coined by
Drs. Hollander and Comroe respectively.
1948 A.D.: Roses identified some criteria for diagnosis of RA.
1958 A.D.: American Rheumatic Association suggested uniform criteria for
diagnosis.
1987 A.D.: The criteria were revised.
In the beginning it was thought to be an infective condition especially in
early 20th century. French scientists thought it to be due to tuberculosis.
9
Conceptual Study
Hench and Kendell introduced steroids in the management of
rheumatoid arthritis described paediatric onset, juvenile RA in 1896. Later Felty
A.R. described Felty’s syndrome.
Recent advancement in immunology have opened new vistas in the
management of RA. Unfortunately till date the etiology of RA is unknown the
pathogenesis is speculative, the treatment is only palliative and there is no cure
to this disease.
10
History
REFERENCES:
1. History of Indian Medicine. P.V.Sharma
2. C.S.Vi. 2/13
3. C.S.Chi. 28/195
4. C.S.Chi. 12/51, 52
5. C.S.Chi. 16/162
6. C.S.Chi. 15/75-80
7. B.P.Madya.Kha. Amavata, Chi./14-16
8. Chakradutta 25/1
9. H.S.Tri.Stha. 21
10. A.H.Chi. 21/47
11. M.N. 25
12. Vang. Amavata Rogadhikara
13. B.P. 26
14. Yr.Po. Amavata Chikitsa
15. B.R. 29
16. Gheranda Samhita 1/49
17. Rheumatology Secrets.
Conceptual Study
AMAVATA
In our classics depending upon the permutation and combination of
Doshas, involved Dhatus, Vedana, Adishtana, Avayava, Gati, specefic
symptoms and so on, naming of the disease is done.
The disease Amavata is named after the involvement of pathological
factors – Ama and Vata. These two are the central phenomenon of the disease.
Vyutpatti of Amavata:
1. Amam Cha Vatam Cha Amavatam:1 The word Amavata comprises of two
meaningful terms Ama and Vata which form the pathogenic basis of the
disease.
2. Amena Sahito Vata Amavata:2 This derivation highlights the propulsion of
Ama by Vata to produce Amavata.
3. Amo Apaaka Hetuh Vataha Swanaama Khyaata Rogavisheshaha:3 That
which is the result of improper digestion is Ama and with Vata the disease is
popularly known as Amavata.
Definition:
Yugapath Kupithavantaha Trikasandhi Praveshakau
Stabdham Cha Kuruthe Gatramamavathaha Sa Uchyate4
Amavata is a condition where Stabdhata of the body occurs due to
lodging of vitiated Ama and Vata in the Trika Sandhi.
11
Conceptual Study
From the above definition it is clear that for well understanding of the
disease Amavata, it is necessary to know the role of Ama and Vata in detail.
AMA:
The first twin of the pathological duo of Amavata, Ama is the root cause
of all Vikaras more so in Amavata and it prompts a detailed study as discussed
below.
Etymology:
1. “Am+Nich”: ‘Am’ Dhathu with ‘Nich’ Pratyaya constitutes the word Ama.7
2. Amyate Gamyate Pakadyartham Iti Amah:7 The substance which goes into
the process of digestion is Ama.
3. Amyate Ishath Pachyathe:3 It means substance which is incompletely
digested or uncooked is Ama.
4. Amyate Peedyate Srotas Samooho Anena Iti Ama:7 Substance which harms
a group of Srotas is Ama. This etymology of Ama is nearer to the disease
Amavata.
Definition of Ama:
In Samhitas various definitions of Ama are available. Some of them are:
1. Usmano Alpa Balatvena Dhatumadyamapachitam
Dushtam Amashaya Gatam Rasamamam Prachakshyate8
Due to hypo-functioning of Ushma (Agni), the first Dhatu - the Rasa is
not properly formed; instead the Annarasa undergoes Fermentation or
12
Conceptual Study
putrefaction (Dushta) and remains in Amashaya. It is this state of Rasa which is
spoken of as Ama.
2. Amasayasthaha Kayagnerdourbalyadavipachita
Adya Ahara Dhathuryaha Sa Ama Iti Keerthithaha9
This quotation gives the same meaning as above.
3. Avipakvam Asamyuktam Dourgandhyam Bahu Picchilam
Sadanam Sarvagatranam Amam Ityabhideeyate9
The substance which has not undergone Vipaka giving rise to foul
smelling and slimy substance causing Gatra Stabdhata in the body is termed as
Ama.
4. Aharasya Rasaha Shesho Yo Na Pakvo Agni Laghavat
Samoolam Sarvaroganam Ama Ityabhideeyate9
Because of Mandagni, the residue of Ahara Rasa which is immature,
forming the root cause of all diseases is labeled as Ama.
5. Amam Anna Rasam Kechit Kechit Malasanchayam
Prathamam Dosha Dushtim Cha Kechit Amam Prachakshate9
Here, the 3 different opinions about Ama are compiled by Vijaya
Rakshita. First view is about the improperly digested food and the second
describes the accumulation of Malas in the different parts of the body.
According to the third view, the first stage of Dosha Dushti is Ama.9
13
Conceptual Study
ETIOLOGY OF AMA:
The causative factors of Ama are described detailed in Charaka
Samhita10,11. These can be classified into Aharaja, Viharaja, Manasika and
Anya Hetuja.
Aharaja Hetu:
Abhojana (not taking food), Atibhojana (excessive consumption of food)
Ajeerna Bhojana (taking food before the previous food gets digested), Asatmya
Bhojana (taking unwholesome food), Viruddha Bhojana (simultaneous
consumption of food having antagonistic properties). Consumption of Dwishta
(unpalatable), Ashuchi Ahaara (unclean food), Rooksha, Sheeta, Shushka,
Vishtambhi Vidahi Bhojana.
Viharaja Hetu:
Improper administration of Samshodhana and Snehana, Vega
Vidharana, Prajaagara and Dukhashayya (sleeping on uneven mattress) can
also initiate production of Ama.
Manasika Hetu:
Food consumed by a person in the state of Bhaya, Krodha, Shoka also
leads to Ama Utpatti.
Anya Hetu:
Desha, Kaala, Rutuvaishamya, Vyaadhikarshana are mentioned as the
causative factors for Ama.
14
Conceptual Study
LAKSHANAS OF AMA:12
The following explains the generalized symptoms with their
etiopathogenesis of manifestation which may be later modified by individual
Doshas to show its specific presentations.
Symptoms Etiopathogenesis
Srotodushti Picchila and Snigdha Guna of Ama
Balabramsha Mandagni causing lack of nutrients
Gourava Snigdha, Picchila, Guru Gunas of Ama
Alasya Snigdha, Picchila, Guru Gunas of Ama
Malasanga Disturbance to Vata by Srotorodha
Anila moodhata Disturbance to Vata by Srotorodha
Apakti The qualities of Ama in turn leads to
Agnimandya forming a vicious cycle
Nishteeva Madagni causing Kaphotklesha
Aruchi As a result of Ajeerna
Klama Due to Dhatvagnimandya
Above said symptoms are the general symptoms produced by Ama.
Further, when this Ama comes in contact with Dosha, Dushya and Mala it is
termed as Sama Dosha, Sama Dushya and Sama Mala. Assessment of Sama-
Nirama is very much helpful for the treatment.
15
Conceptual Study
SAAMA DOSHA LAKSHANAS:5
If Ama combines with the Vayu then it gives rise to Vibandha
(constipation), Mandagni (impaired digestion), Stambha (stiffness), Antra
Kujana (gurgling sound). Further, Vedana (pain), Shopha (edema), Nistoda (pin
prick sensation) gradually affects the body parts one after the other. The
Lakshanas will aggravate during morning hours, night hours, during cloudy
days, and by Snehana. Sama Pitta is durgandhayukta, Amlarasa, Harita-shyava
Varna and is Guru Sama Kapha is Durgandhayukta, Avila, Tantula, there by
sticks to Kanta Pradesha, prevents Udgara.
NIRAMA DOSHA LAKSHANAS:5
Nirama Vayu shows Alpa Vedana, Nirvibandha and has Ruksha and
Vishada qualities, Vedana subsides on Snehana. Nirama Pitta is of Tamra or
Peeta Varna, Ushna, Katu Rasa, Sara, Vigandha and improves the Agni and
Ruchi. Nirama Kapha is Phenavat, Pindita, Nirgandhi and has Pandu Varna,
Vaktra Shuddhi will be there as it comes out easily. Separate symptomatology
of Sama Dushya has not been mentioned as the manifestations are similar to
the Dhatu Pradoshaja Vikaras itself.
CONCEPT OF AMA:
In other words, Ama reflects the products of deranged homeostatic
mechanisms in the body. This clogs the controlling centers and pathways of
normal physiologic functions marking the beginning of pathogenesis in the form
of Sammurcchana of Nidana, Dosha and Dushya.
16
Conceptual Study
In Ashtanga Hridaya Doshopakramaniya Adhyaya, Acharya Vagbhata
has described in length about the treatment of vitiated Doshas in the form of
Vatasyopakrama, Pittasyopakrama, and Kaphasyopakrama. Later, he highlights
the formation of Ama and its treatment. He has given equal importance to Ama,
as that to Dosha. The presence or absence of Ama i.e. Sama Avastha and
Nirama Avastha decides the line of treatment of disease.5
MECHANISM OF PRODUCTION OF AMA - A PERSPECTIVE:13
Physiology:
A normal homeostatic function involves input from the food, processing
by the action of Agni at the levels of Amasaya, Mahabhoota and Dhatus,
transformation of the raw materials in to the vital elements (Sara) consistent
with tissue compatibility and waste products (Kitta or Malas) warranting
expulsion. This process affects the nourishment of Dhatus, development and
maintenance of Vyadhikshamatva (the capacity of the body to resist the disease
onslaught) initiated by Kshut (appetite), Trit (thirst) and Malavisarjana
(excretion).
Hence, the total body homeostasis is the augmented effect of non-
defective functioning of the multiple organizations called Srotases. Each Srotas
has a feeding point, a target point, a controlling center (Srotomula) and a
pathway (Srotas) and its function is appropriate transformation of the input raw
material in to a finished product with elimination of the waste product, effected
by the transformative principle Agni.
17
Conceptual Study
Pathology:
The Vikara or Dhatu Vaishamya is hence a defective transformation,
giving rise to a morbid finished product. The cause for which may exist in the
raw material provided, the Srotomula, the Srotas or in the target tissue, in the
backdrop of impaired Vyadhikshamatva, effected by vitiated Agni and inflicted
by Doshas.
The resulting incompletely transformed product or Ama exhibits certain
characteristic features, it is neither suitable for absorption nor is the body
capable of excreting it. It is toxic and hence hinders the normal functions of the
Srotases. The severity of morbidity is directly proportional to its accumulation.
LEVELS OF EXISTENCE OF AMA:
As mentioned above, the Ama exists at three levels in the body.
A) Ama at Jatharagni level: Amashaya is the substratum of Jatharagni, when
the vitiated Agni acts upon the Ahara, it fails to completely transform Ahara into
nourishing moieties. The resulting Ahara Rasa is a mixture of formed and
unformed elements called Ama, which is thrown out of the Amashaya through
the Urdhwamarga by the Chardi (vomiting) and through the Adhomarga
(diarrhoea), or it may get displaced into the Grahani to remain stagnant. Due to
prolonged stagnation, it may assume the properties of Visha. Further, Ama may
associate with the Doshas, Dhatus and Malas after getting absorbed from
Amashaya and manifest symptoms related with each of them.
Dietetic indiscretions and emotional stresses may between them impair
the functioning of the neurohumoral mechanisms responsible for ensuring
18
Conceptual Study
proper secretion of the digestive juices, the disturbances of the pH in the
gastro-intestinal environment and more often sluggish and sometime hyper-
motility of the stomach and intestine, thus leading to Shuktata or Shuktapaka
where food will be Avipakva, Asamyukta, Bahupicchila and Durgandha, due to
fermentation and putrefaction of the carbohydrate, fat and protein components.
Thus causes the toxic state - Visharupatvam.
This pathogenesis may cause the following metabolic disturbances
• Toxic states:
1. Intermediate toxic byproducts of metabolism
2. Superadded microbial action
• Malnutritional states
Intermediate toxic by products of metabolism: It is clear from the texts that
Sama Ahara Rasa induces the production of various deranged metabolites like,
i. Sama Dosha: In Avasthapaka, there will be Udeerana of the Doshas i.e.
Madhura Avasthapaka – Kapha (Amashaya),
Amla Avasthapaka – Pitta (Pittashaya)
Katu Avasthapaka – Vata (Pakvashaya)
But, due to Apakva Ahara produced by Mandagni, there will be
Udeerana of Dushita Dosha called as Samadosha. Further in Nishthapaka, due
to affliction of Rasa and Rakta Dhatu, there will be further increase of vitiated
Kapha and Pitta in the form of Mala thus contributing to Sama Dosha.
19
Conceptual Study
ii. Bhutagni and Dhatvagni Mandya: Jatharagnimandya will lead to
Bhutagni and Dhatvagni Mandya also. Jatharagni is the Poshaka to the
different Agni of the body, but Bhutagni and Dhatvagni can even get
vitiated independently i.e. irrespective of Jatharagnimandya. Apakva
Ahara from Avasthapaka when gets treated by Manda Bhutagni and
Dhatvagni further causes Vikrita or Dushita Nishthapaka.
a) Sama Dhatu: With affliction of both Avastha and Nishthapaka, the Dhatu
Poshaka Rasa produced is Vikruta. Thus, with production of Sama Rasa
Dhatu, succeeding Dhatu will also get vitiated producing Dhatu
Pradoshaja Vikara. Sama Dhatu Utpatti is due to Bhutagni and
Dhatvagni Mandya but it can even be independent of Jatharagni status.14
b) Sama Mala: The word Mala includes 2 entities.
• Mala of Ahara Rasa i.e. Pureesha, Mutra and Sweda and also the
other Dhatugata Malas.
• Dushita Dosha and Dhatu are also called Mala
Superadded microbial action: Toxins in the intestines in the present days are
greatly attributed to the action of different microbes, thus leading to different
manifestations like:
• Infective gastro-enteritis
• Toxic gastro-enteritis
• Botulism
20
Conceptual Study
Intestinal flora in the human body exists in the state of symbiosis; these
can be very well compared with Sahaja Krimi. Chakrapanidatta15 explains them
as the one which exists within the body without causing diseases. Intestinal
flora breaks the complex molecule which are not broken by the body,
metabolises them into simple molecules by 2 kinds of actions. They are
Fermentation and Putrefaction.
Putrefaction is similar to fermentation but it specifically refers to
conversion of protein substances to smaller molecules with the liberation of
various gases viz. Indol, Skatole, Phenol, Hydrogen sulphate and Ammonia that
are characteristically pungent in odour. Fermentation is related to the
Carbohydrate and fat metabolism by the microbes. Microbe’s metabolism
releases few of the waste products vital for the body like Vit. B groups.
Among these microbes, there are some in borderline populations which
under circumstances become parasitic. There are other groups of virulent
organisms which invade body through food and drinks, producing abnormalities
in the body. e.g.: Salmonella, Staphylococcus, B. botulinus, B. typhosus and
coma bacillus of Koch. Hence, the normal food metabolism also includes the
metabolism by Intestinal flora (Sahaja Krimi).
The following are circumstances which make the body susceptible to the
infection.
• Irradiation, metabolic abnormalities, emotional stress, overstrain, intense
treatment with anti-microbial agents
21
Conceptual Study
• Tissue produces an anti-microbial substance called Properdin. It has
been shown that a low concentration of this substance in an area
coincides with the highest susceptibility to the invasion of the tissue even
by otherwise friendly intestinal flora causing bacteremia.
• Experiments carried out at the Rockfeller institute and other research
centers in U.S.A. have shown that susceptibility to microbial disease can
be caused by manipulation of metabolism. e.g.: with such simple
measures as temporary deprivation of food or feeding an unbalanced
diet rich in Citrate. The resistance was again seen to have been restored
back to normal within 2-3 days by the correction of nutritional errors.
• But in case of epidemics and pandemics the microbes strike human
irrespective of body strength, constitution and other predisposing factors.
Interestingly, this phenomenon is observed when a microbe is newly
introduced in a susceptible population which serves as a virgin soil.
Ama is the immediate cause of most human affliction, exposure to
disease causing microbes results in the disease only in those people where
internal conditions are ripe for colonization. Louis Pasteur and Claude Bernard
argued for years over the primacy of infective agents versus internal conditions,
and it was only on his deathbed that Pasteur finally admitted that Bernard was
right and that the milieu interior is more important than exposure to a pathogen.
This is especially true of diseases in which no pathogen can be detected.6
22
Conceptual Study
Hence, different microbial infection occur in the body when it is made
susceptible by predisposing factors like metabolic abnormalities, emotional
stress, overstrain and other Agnimandyakara and Amotpattikara Nidana.
Malnutritional states:
In chronic disorders, due to Agnimandya or Amotpatti, there will be
predominant manifestation of Dhatukshaya as it is told in Vatavyadhi context
that the Avarana will cause Rasadi Dhatu Kshaya. Depending on the speed of
manifestation, disease can be
• Acute
• Sub-acute and Chronic
Acute conditions include Visuchika, Jwara, Atisara, Pravahika and so on.
Sub-acute and chronic conditions include Grahani Dosha, Udara roga, Pandu,
Amavata, Prameha and so on.
B) Dhatvagni level:
The Ama at Dhatvagni level occurs due to vitiated Dhatvagni first as a
result of a direct influence from Jatharagni as the Dhatvagnis are derivatives of
Jatharagni and Jatharagni hyperfunction or hypofunction results in respective
derangements of Dhatvagnis too16. Secondly, as a result of Dhatvagni
malfunction independent of Jatharagni. The hypofunction of Dhatvagni leads to
morbid increase of the Dhatu involved and hyperfunction leads to its morbid
decrease. The Ama hence formed gets associated with these morbid Dhatus to
23
Conceptual Study
form Sama Dhatus resulting in manifestation of symptoms explained under
Dhatupradoshaja Vikara17.
C) Bhutagni level:
The Ama at the Bhutagni level occurs as a result of Bhutagnimandya, the
mechanism of formation is similar to that mentioned under Dhatvagni level. The
symptoms produced are Shosha, Vrana, Vidradhi and similar diseases18.
Ama as a result of Malasanchaya:9
The Malas (waste products) produced at various levels in the body, when
accumulates beyond tolerable limits also constitutes Ama. The Mutra and
Pureesha are the Malas of Ahara, Kapha that of Rasa, Pitta of Rakta, Vasa and
Khamala of Mamsa, Sweda of Medas, Loma, Asthi and Tvacha Sneha and
Akshi Vit of Majja19. The Shukra is the essence of all Dhatus and it does not
have any Malas. The excessive accumulation of these Malas (Mala Sanchaya)
therefore gets to be called Ama as they are harmful to the normal physiology of
the body.
Production of Ama independent of influence of Agni – as a result of Dosha
Anyonya Sammurcchana:
Strangely, the Doshas exist in the body in an equilibrium of mutually
paradoxical Gunas of Doshas; this equilibrium is inherent and compatible with
the normal bodily functions. This has been called as “Sahajasatmya”32 by
Charaka. This unique coexistence has been compared to the existence of fatal
poison in a serpent without harming it, by Vagbhata. Nevertheless this
24
Conceptual Study
equilibrium sometimes may get disturbed due to excessive aggravation of
Doshas, and the Doshas start affecting each others’ Gunas resulting in the
production of Ama. This process is on the analogy of the production of toxic
material when the grains like Kodrava are kept in water for a long time, this
Ama is highly virulent and can cause incurable diseases. The schematic
representation of the same is given in the chart no. 1.
An interesting feature of this concept is its close resemblance to the
concept of auto immunity in the modern parlance. The Major Histocompatibility
Complex determined by Human Leukocyte Antigens marks the surface proteins
of all the cells of the body. This helps the T cells (responsible for Cell mediated
immunity) to recognize the self antigens from the non-self. When this
mechanism fails, the immune system starts secreting antibodies against body’s
self proteins producing crippling and fatal diseases. They are called Auto
immune diseases and Rheumatoid arthritis is one among them.
25
Conceptual Study
VATA:
The second of the duo Vibhu as it is called Vata in its Prakruta Avastha
sustains the human body. When it becomes Vimarga is responsible for fatal
ailments. The pathogenic sequence of Vatic vitiation requires a comprehensive
background as discussed below.
Nirukti:20
The Nirukti of Vata is as follows, the term Vata is derived from the root
“Va” with “Tan” Pratyaya, it forms the word Vata. The root Vata summerises the
essential Karma of Vata-Gati and Gandhana.
Guna:
Ruksha, Sheeta, Laghu, Sukshma, Chala, Vishada, Daruna and Khara.21
Bheda:
There are five classification of Vata Dosha based on the location and
function. They are Prana, Udana, Samana, Vyana and Apana.22
Karma:23
Vata Dosha has complex psycho somatic integrative function. They are:
Tantra Yantra Dhara (upholds the structure and function of body), Chesta
Pravartaka (motivates the movements), Praneta Niyanta Cha Manasa
(controller and conductor of Mana), Sarvendriyanam Udyojaka (stimulates all
sensory function), Sarvendriya Artha Abhivoda (carrier of all sensory impulses),
Dhatu Vyoohakara (integrator of body elements), Shareera Sandhanakara
26
Conceptual Study
(integrates of bodily structure and function), Vak Pravartaka (stimulator of
speech), Shabda Sparsha Prabrith (cause of feeling and audition), Srota
Sparshayoho mula (primary source of auditory and tactile sensation), Harsha
Utsahayoho Yoni (originator of excitement and animation), Agni Sameerana
(stimulator of Agni), Dosha-Samshoshana (desicator of morbid Dosha), Mala
Kshepta (cleanses the body channels), Garbha Akriti Karta (gives shape to the
fetus), Ayushya Anuvritti (sustainer of life).
Importance:
Following opinions shows the importance and supremacy of Vata:
Charaka opines that the Vayu in its abode with unimpaired functions in
its normalcy, facilitates the Ayus of an individual to be hundred years.24
The Pitta, Kapha, Mala and Dhatus are inert (Pangu) until mobilized by
Vata, which takes them to get localized in specific location and cause disease,
hence Vata controls all other Doshas Dhatus and Malas.25
Vata, Pitta and Kapha are circulating all over the body, Vata the subtle
among them provokes Kapha and Pitta and causes them to lodge in various
places from where the disease originates. The Pitta and Kapha hence occludes
the channels of Vata, thus vitiating Vata; it also gets vitiated by diminution of
tissue elements which may be an independent cause or an effect of occlusion.26
Etiological factors of vitiation of Vata:
Etiological factors which vitiate Vata can be brought under Aharaja,
Viharaja, Manasika and Anya Hetuja.
27
Conceptual Study
Ahara:
Ruksha Ahara (dry food) Sheeta Ahara (cold foods) Alpa Ahara
(subnormal quantity), Laghu Ahara (light food).27
Vihara:
Vyavaya (excessive indulgence in sex), Atiprajagara (night vigil),
Vishama Upachara (improper nourishment), Rakta Atisravana (removing Dosha
and Rakta in excess), Langhana (excessive fasting), Plavana (excessive
swimming), Atyadva (walking excessively),27 Atichesta (excessive improper
body movement), Dukhashayya Asana (uneven mattresses), Divaswapna (day
sleep), Abhighata (trauma), Marmaghata (injury to vital organs), Patana (falls).28
Manasika Karanas:
Includes Chinta (depressive episode), Shoka (depression), Krodha
(excessive anger) and Bhaya (fear).28
Anyahetuja:
Dhatu Sankshaya (depletion of tissue elements) and Rogatikarshya
(emaciation due to disease).28
Symptoms of Vata Prakopa:
Parva Sankocha (contractures), Stambha (immobolity), Asthi Parva
Bheda (painful bones), Lomaharsha (piloerrection), Pralapa (irrelevant speech),
Pani Prishta Shirograha (stiffness of hands, hip, joints of head), Kanja Pangu
(disability of lower limbs), Kubjata (loss of normal lumbar curvature), Anga
28
Conceptual Study
Shosha (wasting), Anidrata (insomnia), Garbha Shukra Rajonasha (disease of
reproductory system), Spandana (involuntary movements), Gatra Suptata
(sensory system abnormality), Shiro Hundana (disorders of scalp), Nasa
Hundana (disorders of olfaction), Jatru Hundana (cervical ankylosis), Griva
Hundana (stiffness of neck), Moha (altered consciousness), Alasya (lethargy)
and Akshepa (convulsive fits).29
Symptoms of Vata Kshaya:
Kshaya of Vata leads to Manda Cheshta (decreased activity), Alpavak
(decreased speech), Apraharsha (erectile dysfunction) and Mudha Samjnyata
(altered consciousness).30
Chikitsa:
Sneha (fatty substance), Swadu, Amla Lavana, Ushna Bhojana (food of
sweet, saline and hot properties), Paishtika or Goudika (types of Madhya),
Abhyanga (external oleation), Mrudu Samshodana (light eliminative therapies),
Mardana (massage), Veshtana (tying clothes), Trasana (supportive
psychotherapy), Seka (stream of oil over the body) and Snigda Ushna Basti
(enemas having Snigda Ushna properties).31
In Amavata, Ama formed will be circulated through out the body by
vitiated Vata, this Sama Vata is responsible for vitiating other two Doshas. So
understanding of Vata is essential in treating Amavata.
29
Conceptual Study
REFERENCES:
1. M.N. 25/2-5
2. M.N. 25/2
3. S.K.D.
4. M.N. 25/5
5. A.H.Su. 13/27-28
6. Ayurveda Life Health and Longevity, RE Svoboda, Pg.162
7. A.K.
8. A.H.Su. 13/25
9. M.N. 25/1-5, Madhu
10. C.S.Chi. 15/42-43
11. C.S.Vi. 2/8
12. A.H.Su. 13/23-24
13. Introduction to Kaya Chikitsa, Dwarakanath
14. S.S.Su. 15/13
15. C.S.Vi. 7/9
16. C.S.Chi. 15/39
17. C.S.Su. 28/8-22
18. Atanadarpana, M.N. 6/22
19. C.S.Chi. 15/18-19
20. S.S.Su. 21/5
21. C.S.Su. 12/4
22. S.S.Ni. 1/11-12
Conceptual Study
23. C.S.Su. 12/8
24. C.S.Chi. 28/4
25. Sh.S.Po.Kha. 5/25
26. C.S.Chi. 28/60, 61
27. S.S.Su. 21/19
28. C.S.Chi. 28/15-18
29. C.S.Chi. 28/20-23
30. S.S.Su. 15/7
31. A.Hr.Su. 13/1-3
32. C.S.Chi. 26/293
Conceptual Study
NIDANA
The word creation is a neologue. It should be actually called as
evolution. Similarly destruction is called involution, because something can
come from something not from nothing.
Circumstances favoring the evolution of a existence is the cause. The
effect can be useful or harmful. Man’s indulgence governs the good or bad
effects he has to enjoy. If his indulgence is Hita, leads to peace. If it is Ahita,
leads to commotion. Besides, the contents of ahita are highly disease specific.
Though being common to quite a few diseases, they lead only to Amavata.
Identifying the causative factors and understanding the role of these
causative factors in the manifestation of the disease is utmost important to
make a proper diagnosis, to predict prognosis and to plan treatment.
Invariably two factors are responsible for the manifestation of the disease
Amavata. As the name indicates, Ama and Vata are those two factors. The
Anjana Nidana author opines Ama and Vata get vitiated due to their own
respective causes to promote disease. Hence, individual etiological factors
responsible for the vitiation of Vata and those etiological factors which produce
Ama may also be considered as etiological factors of Amavata.
Madhavakara has explained following Nidanas for Amavata.1
1. Viruddha Ahara (incompatible diet)
2. Viruddha Cheshta (Erroneous habit)
30
Conceptual Study
3. Mandagni (diminished digestive fire)
4. Nischalata (Sedentary habits)
5. Vyayama soon after Snigdha Ahara.
Besides this, Harita opines that a person consuming Guru Ahara, Kanda
Shaka (tubers) in excess and indulging in excessive Vyavaya is the Nidana of
Amavata.2
To sum up, the causative factors of Amavata can briefly be classified in
to two.
1) Viruddha Ahara- unwholesome diet.
2) Viruddha Cheshta- erroneous habit.
Now it is very important to know what is Viruddha, as Viruddha itself is
the root cause of the disease Amavata. The factors which cause Dosha
Utklesha (vitiation) but do not have the capacity to eliminate those Doshas out
of the body are considered as Viruddha.3
Charaka has elaborately mentioned regarding Viruddha Ahara and
categorized these into 18 types.4 They are Desa (Habitat) Viruddha, Kala
(season) Viruddha, Agni (digestive power) Viruddha, Matra (dose) Viruddha,
Satmya (compatibility) Viruddha, Dosha Viruddha, Samskara (processing)
Viruddha, Veerya (potency) Viruddha, Koshta (bowels) Viruddha, Parihara
(proscription) Viruddha, Avastha (state of health) Viruddha, Krama (order)
Viruddha, Upachara (prescription) Viruddha, Paka (cooking) Viruddha,
31
Conceptual Study
Samyoga (combination) Viruddha, Hrit (palatability) Viruddha, Sampath (quality)
Viruddha, Vidhi (rules of intake) Viruddha.
Besides Charaka also considers the Brashta Niyama of Ashta Vidha
Ahara Vidhi Vishesha Ayatana5 as unwholesome. These Ashta Vidha Ahara
Vidhi Vishesha Ayatana are Prakriti (Natural food habits), Karana (Method of
processing), Samyoga (Combination), Rashi (Quantity), Desha (Habitat), Kala
(Time), Upayoga Samstha (Rules governing intake of food), Upayoktru (The
person who is taking the food).
Viruddha Cheshta includes a wide variety of causative factors. They are
consumption of Snigdha Ahara and doing Vyayama immediately, Sheetoshna
Vyatyasa (alternative use of Sheeta and Ushna), use of Sheetodaka at once
during Bhaya Shrama and so on, Vega Vidharana (suppression of natural
urges), Vega Udeerana (provoking of natural urges), Diva Swapna (day sleep),
Ratri Jagarana (night vigil), Sahasa (act beyond capacity), Karma Kalatipata
(avoidance of medication).
The causative factors of a disease operate in varied patterns in the body
to cause the disease. This depends upon the level of predisposition, in other
words the extent to which the environment is made favorable for the interaction
of Nidana, Dosha and Dushya.6
The capacity of the body to resist this interaction is called Vikara Vighata
Bhava or Pratyaneeka Bala. This Bala differs from person to person. That is
32
Conceptual Study
why we see that inspite of exposure to Nidanas, some people do not develop
the disease and some develop severe disease with negligible exposure. Further
it is also seen that a single causative factor leads to development of many
diseases and many Nidanas are needed for the manifestation of a single
disease.7
Hence, not withstanding the list of Nidanas implicated to cause the
disease Amavata, it is ultimately the Vyadhikshamatva which renders a patient
vulnerable.
Thus Viruddha Ahara and Cheshta are accepted as the causative factors
of disease Amavata. But Viruddha Ahara and Viruddha Cheshta need not
cause same disease in everyone i.e. all the unwholesome diet and erroneous
habits may not vitiate the same Dosha and also vitiation need not be of same
grade as every individual do not have the same Vyadhikshamatva (immunity).8
Schematic representation of Nidana is given in the chart no. 2.
Etiology of Rheumatoid Arthritis:10
The disease Amavata is best compared with Rheumatoid arthritis in the
modern parlance.9 Rheumatoid arthritis (RA) is a chronic multisystem disease
of unknown cause. It has been suggested that RA might be a manifestation of
the response to an infectious agent in a genetically susceptible host. Because
of the worldwide distribution of RA, it has been hypothesized that if an infectious
agent is involved, the organism must be ubiquitous. A number of possible
causative agents have been suggested, including Mycoplasma, Epstein-Barr
33
Conceptual Study
virus (EBV), cytomegalovirus, parvovirus, and rubella virus, but convincing
evidence that these or other infectious agents cause RA has not emerged. The
process by which an infectious agent might cause chronic inflammatory arthritis
with a characteristic distribution also remains a matter of controversy. Recent
work has focused on the possible role of "superantigens" produced by a number
of microorganisms, including staphylococci, streptococci and M. arthritidis.
Superantigens are proteins with the capacity to bind to HLA-DR molecules and
particular Vb segments of the heterodimeric T cell receptor and stimulate
specific T cells expressing the Vb gene products. The role of superantigens in
the etiology of RA remains speculative. Of all the potential environmental
triggers, the only one clearly associated with the development of RA is cigarette
smoking.
Sero positive RA aggregates in families Genetic factors versus their
interaction with environmental facilitators is unclear HLA DR4 is found in 70% of
causascian sero positive patients compared to 25% of controls. Increased
relative risk of 4-5 times for the DR4 positive persons, although a minority are
affected African Americans tend not to exhibit this predilection.11
34
Conceptual Study
Chart No. 1-Schematic representation of Nidana of Amavata:
kashaya, tikta, katu ruksha laghu, sheeta, shushka shaaka vallura, uddalaka, kora dusha, shamaka, vishamashana, adhyashana
Aharatah
Vataja nidana
AtimRuShVisVidVirAka
A
Viharatah
manasika ati shoka, chinta, bhaya, krodha, kshobha,
Shareerika Ativyayama, prapatana, bhagna, ratrijagarana, vegadharana, ativyavaya, raktati sravana.
SVVcRAVVS
NIDANA
atra, Guru ksha, Sheeta ushka, Dvishta htambhi ahi, Aruchi uddha la annapana
haratah
Amaja nidana
Viruddha ahara Shaka Katu ahara Guru ahara Mandagnikaraka
Aharatah
Amavataja nidana
Viharatah Viharatah
hareerika egavarodha, iruddha heshta, atri jagarana, yoga of amana, irechana and nehana
Manasika Kama, Krodha, Lobha, Moha, Irshya, Hree, Shoka, Mana, Udvega Bhaya, Bhojana with these Upatapta manas.
Viruddha Cheshta- Nischalata,Vyayama, Mandagni Karaka.
Conceptual Study
REFERENCES:
1. M.N. 25/1
2. H.S. 21/1, 2
3. A.Hr. 7/45
4. C.S.Su. 28/86-89
5. C.S.Vi. 1/21
6. C.S.Ni. 4/4
7. C.S.Ni. 8/24
8. C.S.Su. 28/7
9. Y.N. Upadhyaya
10. H.P.I.M., 14th edition, pg.1880
11. CIMS, 5Min, Clinical Assistance, pg.88
Conceptual Study
SAMPRAPTI
The pathology of a disease is not always simple; rather it involves
various intricate and sequential mechanisms. This has to be unraveled for the
proper understanding of the disease and then to plan successful treatment.
Intricate mechanisms of the disease process are best understood by means of
Samprapti of the disease.
As elaborated under the title Nidana it is clear that the illness Amavata is
basically caused by the Viruddha Ahara as well as Cheshta. More over this
phenomenon of Viruddha Ahara may not be similar in every patients rather it is
individual specific. This etiology of Viruddha Ahara in the form of Bahya Nidana
is said to be incriminatory in three distinct ways ultimately resulting in the
establishment of the disease. On exposure to Viruddha Ahara it may cause
morbidity of Dosha, impair the functioning of the Jataragni or else it may lead to
the formation of more virulent Amavisha.1
Dosha Dushti:
Consumption of Viruddha Ahara precipitates morbidity of Doshas.2 Due
to the deleterious effect of the Viruddha Ahara, any Dosha may get vitiated or
else any combination of the two Doshas or all the three together. These vitiated
Doshas in turn afflicting the specific Dushya manifests as illness, pertaining to
Amavata. By the deleterious effect of the Viruddha Ahara, there occurs the
morbidity of the Vata Dosha. The clinical manifestations like Anaha, Antrakuja,
Vibandha, Sandhi Sula, Sandhi Jadyata etc are suggestive of vitiation of Vata
35
Conceptual Study
Dosha at different levels. By definition, this Viruddha Ahara only influences the
generation of morbid Doshas, and is incapable of its removal from the body.
Agni Mandya and Amotpatti:
Intake of Viruddha Ahara has detrimental effect on the functioning of the
Jataragni. As mentioned by Acharya Charaka, intake of Viruddha Ahara leads
to Agnimandya which in turn generates the virulent Ama in the body.3 Invariable
involvement of Ama is characteristic of the disease Amavata. Both Koshtagata
as well as Shareeragata Ama are the hallmarks of the pathogenesis of
Amavata. Reduction in the Abhyavaharana Shakti and Jarana Shakti,
symptoms like Praseka, Aruchi, Apakti, Malasanga and similar other symptoms
are indicative of Koshtagata Ama5. Shareeragourava, Alasya, Klama, Sandhi
Shotha, Staimitya are the other common clinical features of Amavata
suggestive of Shareeragata Ama5,6. Moreover, the symptom complex of
Amavata is more indicative of combined effect of Ama as well as morbid Vata
and is popularly known as Samavata4 state. Progressive involvement of the
joints in the form of severe pain and swelling, worsening of the symptoms by
the application of the oil, more severity of the symptoms at the time of sunrise,
as well as on appearance of the clouds in the sky4, all are the typical features
indicative of Samavata state in the disease Amavata.
The Ama and morbid Vata, stemming out from Amashaya circulates in
the whole body. The properties of the Samavata being similar to that of the
Kapha Dosha, Ama and morbid Vayu exhibits an affinity to get lodged in the
36
Conceptual Study
Kapha Sthana. More particularly the vitiated Vata Dosha along with Ama tend to
get localized in the joint. With in the joint, these two pathological factors
undergo a pathological union with the naturally present Doshas in the joints. It is
said that by the interaction with the naturally present Doshas in the joint the
Ama and morbid Vata acquires further virulence and then manifests as
Amavata. Here, the interaction with in the joint causes the generation of
Amavisha1. Perpetuation of the illness for a long duration destroying the joints
is analogous to the effect of Garavisha12 in the body. Progressive damage that
occurs for long is very characteristic of Garavisha. Similarly the pathological
interaction between normal Doshas present in the joint and the morbid Vata as
well as Ama getting localized in the joint, is akin to the damaging effect of the
Garavisha, and hence is named as Amavisha. Thus relating this to the
causation of the illness, indulgence of Viruddha Ahara ultimately culminates in
the generation of Amavisha. Similar to Garavisha, this Amavisha gradually
causes destruction of the body. Later, during the course of the disease,
permanent destruction of the joints results in the Anga Sankocha8, Jadyata8,
Anga Vaikalya10 etc, totally incapacitating the patients and restricting him to the
bed.
Dhatu Dushti:
Deleterious effect of the Viruddha Ahara is not restricted to the Dosha
and Agni, rather it badly influences the Dhatu even. This nature of the Viruddha
Ahara is described as Dhatupratyanika13 effect. It is worth mentioning here that
the Viruddha Ahara is considered as an etiology of Majjavaha Sroto Dushti14
37
Conceptual Study
and the Mula of the Majjavaha Srotas17 being Asthi and Sandhi, this implies the
detrimental effect of the Viruddha Ahara on the Asthi and Sandhi wherein the
disease Amavata manifests. The symptoms like Sandhi Shotha, Sandhi Shoola,
Bhedanavat Shoola in Asthi and Parva Pradesha, Mamsa Kshaya, Sandhi
Sankocha etc. are suggestive of Asthimajja Gata Vata15 and Sandhi Gata
Vata16 in the disease Amavata.
So to say, the indulgence of Viruddha Ahara causes morbidity of Vata
Dosha, generates the Ama, afflicts the Dhatu Asthi and Sandhi, and in all the
pathology perpetuates and destructs the body in the form of Amavisha.
Viruddha produces some alteration in the humoral activity of the body
and results in the production of Ama. This Ama is antagonistic to the bodily
tissues (Dhatu Virodhi). Effect of this may be rapid or gradual. Viruddha has
Dhatu Virodhi Karma by way of producing Ama as a intermediate product in
case of Amavata. Because of Dhatuvirodhi quality of Ama it can be correlated
with autoimmunity in modern parlance.
Madhavakara18 has explained the Samprapti of Amavata as follows in
the presence of Mandagni, if one is exposed to Nidana then Ama is formed in
the Amashaya along with vitiation of Vata Dosha. This Ama circulates in the
body propelled by the vitiated Vata exhibiting an affinity to get lodged in the
Shleshma Sthana i.e. Sandhi. Further, this circulating Ama in the Dhamanis
interact with the normally present Vata Pitta and Kapha Dosha giving rise to
variegated color to the virulent Ama. It becomes qualitatively heavy and
38
Conceptual Study
viscous, facilitating Sroto Abhishyandana and Srotorodha. Alteration in the
Srotas endures Sthana Samshraya leading to the manifestation of symptoms
like Hrutgourava, Dourbalya, Sandhi Shotha and Shoola etc.11
Samprapti Ghataka:
Dosha: Vata predominant Tridosha.
Dhatu: Rasa, Mamsa, Asthi, Majja.
Upadhatu: Snayu, Sandhi.
Srotas: Annavaha, Rasavaha, Asthivaha, Majjavaha, Udakavaha,
Purishavaha, Mutravaha.
Srotodushti: Sanga, Vimargagamana.
Udbhavasthana: Amashaya, Pakvashaya.
Adhishtana: Sarvashareera
Vyakta Sthana: Sarva Shareera more particularly Sandhi
Avayava: Sandhi
Vyadhisvabhava: Chirakari.
Roga Marga: Madhyama
Pathogenesis of Rheumatoid Arthritis:19
In contemporary medical science, Amavata can be best correlated to
Rheumatoid Arthritis (Y.N.Upadhyaya). It is described as an autoimmune
disorder. The propagation of Rheumatoid Arthritis is an immunologically
mediated event, although the original initiating stimulus has not been clear. One
39
Conceptual Study
view is that the inflammatory process in the tissue is driven by T4 helper cells
infiltrating the synovium. Evidence for this includes,
• The predominance of T4 cells in the synovium
• The local production of lymphokines by these infiltrating T cells
• Amelioration of the disease by removal of T cells by thoracic duct
drainage or suppression of their function by total lymphoid irradiation
Since T lymphocytes produce a variety of cytokines that promote B cell
proliferation and differentiation into antibody forming cells. T cell activation may
also produce local B cell stimulation. The resultant production of
immunoglobulin is rheumatoid factor that can lead to immune complex
formation. With consequent compliment activation there will be exacerbation of
inflammatory process by the production of anaphylatoxins and haemostatic
factors. This tissue inflammation is reminiscent of delayed type of
hypersensitivity reaction occurring in response to soluble antigens or micro
organisms. It is how ever unclear that whether this represents a response to
persistent exogenous antigens or to altered auto antigen such as collagen or
immunoglobulins.20
40
Conceptual Study
Chart No. 2-Schematic representation of Samprapti in the light of
Kriyakalas:
Nidana-Viruddha
Vata Prakopa Agnimandya Dhatu Virodhi
Vata Dushti Ama (Koshta) Majjavaha Srotas
Dhamani
Trika Sandhi
Saruja Shotha (in multiple joints)
Sankocha Adi Upadrava
Bheda
Vyakta
Sthana Samshraya
Sanchaya Prakopa Prasara Samavata Dosha
(Amavisha/Garavishatulya)
Conceptual Study
REFERENCES:
1. C.S.Chi. 15/44
2. A.H.Su. 7/45
3. C.S.Vi. 2/9
4. A.H.Su. 13/27
5. A.H.Su. 13/23,24
6. A.H.Su. 13/26
7. A.H.Su. 13/27
8. M.N. 25/7-10
9. H.S.Tri. 21/4
10. M.N. 25/7
11. A.H.Su. 7/29
12. A.S.Su. 9/7
13. C.S.Vi. 5/18
14. C.S.Chi. 28/33
15. S.S.Ni. 1/28
16. C.Vi. 5/8
17. M.N. 25/1
18. H.P.I.M. 14th edition, pg.1881
19. A.P.I. 5th edition, pg-1118
Conceptual Study
POORVA ROOPA
Poorva Roopa are alarms signaling the onset of an ambush, like clouds
indicate the arrival of rain. They sometimes simulate the symptoms of actual
disease and sometimes not, but in any case they indicate occurrence of an
ailment.
Though the Poorva Roopa of Amavata is not explained in the Samhitas,
we can consider few of the Samanya Amavata Lakshanas as its Poorva Roopa.
It is understood from Ayurvedic classics that some of the Poorva Roopa may
continue as Samanya Lakshana of any disease.1
In Amavata before the onset of disease, Ama is formed. The symptoms
produced when Ama only gets involved with Vata before getting lodged in the
Shleshma Sthana, can be considered as Poorva Roopa. The Samanya
Lakshanas2 of Amavata though not very disease specific to Amavata, like
Agnimandya, Aruchi, Angamarda and Gourava can be considered as Poorva
Roopa.
Agnimandya: Nidana Sevana effects the normal functioning of Agni.
Aruchi: Vitiation of Rasa Dhatu and Bodhaka Kapha impairs the
functioning of Rasanendriya.
Anga Marda: Inadequate nourishment of Dhatu and presence of Ama leads to
feeling of aching pain in the body.
41
Conceptual Study
Gaurava: Ama and vitiated Kapha causes feeling of heaviness in the body.
Also Sama Rasa and vitiated Kapha generates Hritgourava, i.e.
subjective feeling of heaviness in chest.
The production of Ama is the central phenomenon in Amavata, hence all
the Ama Lakshana can be considered as Poorva Roopa of this disease.
Prodromals of Rheumatoid Arthritis:
Onset of rheumatoid arthritis in approximately two thirds of patients is
insidiously with, fatigue anorexia, generalized weakness and vague
musculoskeletal symptoms until the appearance of synovitis becomes apparent.
This prodrome may persist for weeks or months and defy diagnosis.3
REFERENCES:
1. A.H.Ni. 1/5
2. M.N. 25/6
3. H.P.I.M. 14th edition, pg.1883
42
Conceptual Study
Chart No. 3-Schematic representation of the evolution of Poorvaroopas:
Nidana-Viruddha
Vata Prakopa Agnimandya Dhatu Virodhi
Vata Dushti Ama (Koshta) Majjavaha Srotas
Dhamani
Trika Sandhi
Saruja Shotha (in multiple joints)
Agnimandya Aruchi Angamarda Gaurava
Sankocha Adi Upadrava
Samavata Dosha (Amavisha/Garavishatulya)
Conceptual Study
BHEDA
For a better understanding, the disease Amavata can be broadly
classified into two categories, the first, on the basis of clinical manifestation and
the second, on the basis of prognosis, with sub classification existing in each
category. The details are as follows;
1. Based on clinical manifestations it is divided into:
A) Dosha Bhedena:
In Amavata, the Pradhana Dosha is invariably Vata. Due to some
supportive factors other two Doshas also get involved; accordingly, we can
observe the symptoms. Madhavakara has explained seven type of Amavata on
the basis of Dosha Pradhanyata1. They are as follows:
1. Vataja: In Vataja type of Amavata, Shoola will be the predominant
symptom. This can be well correlated to the Sheeta and Chala Guna of
Vayu. In Amavata, the path of the Vata is obstructed due to Ama. Hence
the characteristics feature of Vata-shoola will be more.
2. Pittaja: Symptoms Raga and Daha are indicative of Pittaja Amavata.
These are due to the Teekshna, Ushna Guna of Pitta.
3. Kaphaja: Symptoms Sthaimitya, Guruta, Kandu indicate the dominance
of Kapha. Sthaimitya is produced due to Picchila, Sthira and Sheeta
Guna of vitiated Kapha. As Ama and Kapha have similar qualities,
Guruta and Kandu are seen in the Sandhis.
43
Conceptual Study
4. Vatapittaja: Symptoms of Vata and Pitta are seen together in Vatapittaja
type of Amavata.
5. Vatakapha: Here the symptoms of Vata and Kapha are seen together.
6. Pittakapha: Here the symptoms of Pitta and Kapha predominate.
7. Sannipatika: In Sannipatika type of Amavata, symptoms of all the three
Doshas are profoundly seen.
B) Avastha Bhedena:2
Based on the different stages of the disease, Madhavakara has broadly
classified Amavata into two varieties they are,
1. Samanya
2. Pravruddha.
The symptomatology of this has been discussed in chapter Roopa.
C) Lakshana Bhedena:3
Acharya Harita’s classification of Amavata has been unique. According
to him, Amavata is of four types.
1. Vishtambhi: This type of Amavata presents with Shareera Guruta,
Adhmana, and Basti Shoola.
2. Gulmi Amavata: Amavata having Jatara garjana, Gulmavat peeda
and Kati jadata is called as Gulmi.
3. Snehi: Here Gaatra snigdhata, Jadhya, Mandagni and excretion of
Vijala and Snigdha ama are characteristic.
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Conceptual Study
4. Pakva ama: This variety of Amavata presents with excretion of
Shyava vijala pitta and Pakva ama along with Shrama and Klama.
D) Based on prognosis:
Based on the general principle of Sadhyasadhyata, Amavata can be of
two types.
1. Naveena: If the duration of disease is not more than one year, it is called
Naveena Amavata which is Sadhya.
2. Purana: If the duration of Amavata is more than one year, it is called
Purana Amavata which is difficult to treat.
REFERENCES:
1. M.N. 25/11
2. M.N. 25/6-10
3. H.S.Tri.Sth. 21/5-6
45
Conceptual Study
ROOPA Specific signs and symptoms of a disease when manifested distinctly is
considered as Roopa Avastha1 or Lakshana of a disease. Roopa is one of the
key tool in arriving at the diagnosis. Of course this is also helpful in assessing
the Sadhyasadhyata and to plan the treatment.
The Lakshanas of Amavata have been explained in length in the classics
and are listed in the Table No. 1
On keen observation and assessment of Lakshanas, they can be broadly
classified into 3 categories.
1. Lakshana specific to involvement of Sandhi.
2. Lakshana specific to involvement of Ama.
3. Lakshanas produced as a consequence of the disease process. They
are elaborated below:
Lakshana specific to involvement of Sandhi:
The Lakshanas such as Shoola and Shotha in Hasta, Pada, Shira,
Gulpha, Trika, Janu2 and so on are very specific to involved Sandhi. Further
Lakshanas like Shunata Anganam3 (swelling in Sandhi) Sashabdha Sandhi4
(crepitation in joints) also indicates the same.
Gatrasthabdhata (immobility of Sandhi), Jadyata (unable to do the
physical work due to Vedana in the Sandhi Pradesha) Sandhi Vikunchana,
Sankocha, Kanja and so on deformities in the limbs further shows involvement
of Sandhi4.
46
Conceptual Study
As seen in the Samprapti, the vitiated Dosha and Ama will move to the
Kaphasthana9 i.e. Sandhi Pradesha. The involvement of the Asthi and Sandhi is
very much pathognomonic of the disease.
Hence, it can be said that Sandhi Shoola and Shotha2 is one of the
cardinal features of this disease. But keeping in mind the narration of multiple
joints involvement in other diseases in the text, we should consider multiple joint
involvement with Ama Lakshana only as the cardinal symptom of the disease
Amavata.
Lakshana specific to involvement of Ama:
Most of the Lakshanas other than Lakshana related with the Sandhi will
refer to Ama Dosha in the body. If we scrutinize these Lakshanas some of them
are specific to Ama in the Annavahasrotas6, where as some other refer to effect
of Ama on the Rasavahasrotas6.
Chardi, Arochaka and so on are the features suggestive of
Annavahasrotodushti6 specifically by Ama. The symptoms produced due to
Rasavahasrotodushti6 can be considered at two dimensional levels, the
Sthanika and Sarvadaihika Lakshanas3. Aruchi3, Anaha3 and so on are the
Sthanika Lakshanas suggestive of Ama, where as Angamarda3, Alasya3 are
Sarvadaihika Lakshanas suggestive of Ama.
47
Conceptual Study
Lakshanas produced as a consequence of the disease process:
Remaining few symptoms such as Nidraviparyaya4, Bhrama2 Murcha2,
are neither the cardinal features nor the Ama Lakshanas. Basically they are the
effect of pathological process in the body. Shoola is the culprit behind
Nidraviparyaya, where as Bhrama and Murcha point towards the involvement of
Majjavahasrotas10.
Though in this disease is Vata predominant, involvement of Ama is
invariable. Hence, we see Sama Vata Lakshanas7 in the patients of Amavata.
This might be the reason for not mentioning the disease Amavata separately by
Charaka.
Doshanubandha Lakshanas:
(1) Vatanubandha8 : Sasulam
(2) Pittanubandha8 : Sadaha, Saraga
(3) Kaphanubandha8 : Stimitatam, Guru, Kandu
48
Conceptual Study
Table No. 1-Lakshanas of Amavata according to different authors:
LAKSHANA M.N B.P Y.R R.R.S G.N BRJ HS VGA TRA1. Angamarda + + + - + - - + - 2. Aruchi + + + - + - - + - 3. Trushna + + + - + - - + - 4. Hrillasa + + + - + - - + - 5. Gourava + + + - + - - + - 6. Jwara + + + - + - + + - 7. Apaka + + + - + - - + - 8. Angasoonata + + + - + - - + - 9. Sa Ruk Shotha Hasta + + + - + - - + - 10. Sa Ruk Shotha Pada + + + - + - - + - 11. Sa Ruk Shotha Shira + + + - + - - + - 12. Sa Ruk Shotha Gulpha + + + - + - - + - 13. Sa Ruk Shotha Trika + + + - + - - + - 14. Sa Ruk Shotha Janu + + + - + - - + - 15. Sa Ruk Shotha Uru + + + - + - - + - 16. Agnidourabalya + + + - + - - + - 17. Praseka + + + - + - + + - 18. Utsaha Hani + + + - + - - + - 19. Vyrasya + + + - + - - + - 20. Daha + + + - + - - + - 21. Bahumutrata + + + - + - - + - 22. Kushikadhinata + + + - + - - + - 23. Kukshishoola + + + - + - - + - 24. Nidraviparyaya + + + - + - - + - 25. Trut + + + - + + - + - 26. Chardi + + + - + + - + - 27. Brama + + + - + - - + - 28. Moorcha + + + - + - - + - 29. Hrutgraha + + + - + - - + - 30. Vitvibhandha + + + - + - - + - 31. Jadyata + + + - + - - + - 32. Antrakoojana + + + - + - - + - 33. Anaha + + + - + - - + - 34. Vikunchana of Manya - - + - + - - - - 35. Vikunchana of Prushata - - + - + - - - - 36. Vikunchana of Kati - - + - + - - - - 37. Vikunchana of Janu - - + - + - - - - 38. Vikunchana of Trika - - + - + - - - - 39. Sashabda Gatra - - + - + - - - - 40. Srasta Gatra - - + - + - - - - 41. Kati Vyadha - - - + - - - - -
Conceptual Study
42. Sandhi Shotha - - - + - - + - - 43. Uthana Asamartha - - - + - - - - - 44. Deha Pandura - - - - - + - - - 45. Mootra Pandura - - - - - + - - - 46. Peta and Ushna Netra - - - - - + - - - 47. Peeta and Ushna Chardi - - - - - - + - - 48. Jangha Vyadha - - - - - - - - + 49. Uru Vyadha - - - - - - - - + 50. Trika Vyadha - - - - - - + - + 51. Hrut Vyadha - - - - - - - - + 52. Nabhi Vyadha - - - - - - - - + 53. Pada Vyadha - - - - - - - - + 54. Prushta Vedana - - - - - - + - - 55. Manya Vedana - - - - - - + - - 56. Ama Atisara - - - - - - + - - 57. Anga Vaikalya - - - - - - + - - 58. Shosha - - - - - - - - + 59. Visuchika - - - - - - - - +
Conceptual Study
Clinical Manifestations of Rheumatoid Arthritis
Articular manifestations:
Rheumatoid arthritis is characterized by chronic polyarthritis. It begins
insidiously – the earliest manifestations being fatigue, anorexia, generalized
weakness and vague musculoskeletal symptoms and the later symptom being
the appearance of synovitis. Specific symptoms usually appear gradually and
symmetrically as several joints, especially those of the hands, wrists, knees,
and feet, become affected. In approximately 10% of individuals, there is acute
onset, with a rapid development of polyarthritis, often accompanied by
constitutional symptoms, mainly fever, lymphadenopathy, and splenomegaly.
Symptoms may initially be confined to one or a few joints in nearly a third of the
patients. Although a symmetric pattern is more typical, the pattern of joint
involvement may remain asymmetric in a few patients.
Initially, pain, swelling, and tenderness may be poorly localized to the
joints. The most common manifestation of established Rheumatoid Arthritis is
pain in affected joints, aggravated by movement. The pain corresponds to the
joint involvement in pattern but does not always correlate with the degree of
apparent inflammation. Generalized stiffness is frequent and is usually greatest
after periods of inactivity. Morning stiffness of greater than 1 hour duration is an
almost invariable feature of inflammatory arthritis and may serve to distinguish
it from various non-inflammatory joint disorders. The majority of patients will
experience constitutional symptoms such as weakness, easy fatigability,
anorexia, and weight loss. Temperature in excess of 38°C is unusual; on
49
Conceptual Study
occasion the temperature may rise to 40°C, but this may suggest an
intercurrent problem such as infection.
Clinically, synovial inflammation results in swelling, tenderness, and
limitation of motion. Warmth is usually found on examination, especially of large
joints such as knee, but erythema is infrequent. Joint swelling is caused by
accumulation of synovial fluid, hypertrophy of the synovium, and thickening of
the joint capsule. Initially, motion is limited by pain. The inflamed joint is usually
held in flexion as this position provides maximum joint volume and minimum
distention of the capsule. Later, fibrosis or bony ankylosis or soft tissue
contractures form, ultimately leading to fixed deformities.
Although inflammation can affect any diarthrodial joint, Rheumatoid
arthritis most often causes symmetric arthritis, characteristically involving
certain specific joints such as the proximal interphalangeal and
metacarpophalangeal joints. Involvement of the distal interphalangeal joints is
rare. Synovitis of the wrist joints is a nearly uniform feature of RA and may lead
to limitation of motion, deformity, and carpal tunnel syndrome (median nerve
entrapment). When synovitis effects the elbow joint, flexion contractures often
develop, early in the disease. The knee joint is commonly involved with synovial
hypertrophy, chronic effusion, and frequently ligamentous laxity. Baker’s cyst,
caused by the extension of the inflamed synovium into the popliteal space, may
cause pain and swelling behind the knee. Arthritis in the forefoot, ankles, and
subtalar joints can produce severe pain with ambulation as well as a number of
50
Conceptual Study
deformities. Axially, involvement is usually limited to the upper cervical spine.
Lower back pain cannot be ascribed to rheumatoid inflammation, as
involvement of Lumbar spines is not seen. Occasionally, inflammation from the
synovial joints and bursae of the upper cervical spine leads to atlantoaxial
subluxation. This usually presents as pain in the occiput and rarely, may lead to
compression of the spinal cord.
Persistent inflammation can lead to a variety of characteristic joint
changes. These can be attributed to a number of pathologic events, including
laxity of supporting soft tissue structures; damaged or weakened ligaments,
tendons, and the joint capsule; cartilage degradation; muscle imbalance; and
unopposed physical forces associated with the use of affected joints.
Characteristic changes of the hand include (1) radial deviation at the wrist with
ulnar deviation of the digits, often with palmar subluxation of the proximal
phalanges ("Z" deformity); (2) hyperextension of the proximal interphalangeal
joints, with compensatory flexion of the distal interphalangeal joints (swan-neck
deformity); (3) flexion contracture of the proximal interphalangeal joints and
extension of the distal interphalangeal joints (boutonniere deformity); and (4)
hyperextension of the first interphalangeal joint and flexion of the first
metacarpophalangeal joint with a consequent loss of thumb mobility and pinch.
Typical joint changes may also develop in the feet, including eversion at the
hindfoot (subtalar joint), plantar subluxation of the metatarsal heads, widening
of the forefoot, hallux valgus, and lateral deviation and dorsal subluxation of the
toes.
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Conceptual Study
Extra-articular Manifestations:
Rheumatoid arthritis is a systemic disease with various extra-articular
manifestations.
In 20 to 30% of persons with Rheumatoid arthritis, rheumatoid nodules
develop, usually found on periarticular structures, extensor surfaces, or other
areas subjected to mechanical pressure; but they can develop elsewhere,
including the pleura and meninges. Other common locations include the
olecranon bursa, the proximal ulna, the Achilles tendon, and the occiput. The
nodules are of differing size and consistency and are rarely symptomatic, but
on occasion they break down as a result of trauma or become infected. They
are found almost invariably in individuals with circulating rheumatoid factor.
Clinical weakness and atrophy of skeletal muscle are common. Muscle
atrophy may be evident within weeks of the onset of Rheumatoid arthritis and is
usually most apparent in musculature approximating affected joints
Another associated pathological event, rheumatoid vasculitis, can affect
nearly any organ system, and is seen in patients with severe Rheumatoid
arthritis and high titers of circulating rheumatoid factor. When in severe form,
rheumatoid vasculitis can cause polyneuropathy and mononeuritis multiplex,
cutaneous ulceration and dermal necrosis, digital gangrene, and visceral
infarction. Such widespread vasculitis is very rare, but more limited forms are
not uncommon, especially in white patients with high titers of rheumatoid factor.
Limited forms of vasculitis may present as Neurovascular disease either with
52
Conceptual Study
mild distal sensory neuropathy or mononeuritis multiplex as the only sign.
Cutaneous vasculitis usually presents as crops of small brown spots in the nail
beds, nail folds, and digital pulp. Large ischemic ulcers may develope,
especially in the lower extremity. Myocardial infarction secondary to rheumatoid
vasculitis has been reported, as has vasculitic involvement of lungs, bowel,
liver, spleen, pancreas, lymph nodes, and testes. Renal vasculitis is rare.
Pleuropulmonary manifestations, which are more commonly observed in
men, include pleural disease, interstitial fibrosis, pleuropulmonary nodules,
pneumonitis, and arteritis. Presence of pulmonary fibrosis can impair the
diffusing capacity of the lung. Single or clusters of pulmonary nodules may
appear. Associated with pneumoconiosis, the nodules can cause a diffuse
nodular fibrotic process (Caplan's syndrome). In other cases, pulmonary
nodules may cavitate and produce a pneumothorax or bronchopleural fistula. ,
Pulmonary hypertension, secondary to obliteration of the pulmonary
vasculature, is a rare occurrence. In addition to pleuropulmonary disease,
upper airway obstruction from cricoarytenoid arthritis or laryngeal nodules may
develop.
Clinically apparent heart disease attributed to the rheumatoid process is
rare, but autopsy studies have revealed evidence of asymptomatic pericarditis
in 50% of cases. Pericarditis may be asymptomatic, or on rare occasions death
has occurred from tamponade. Chronic constrictive pericarditis may also occur.
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Conceptual Study
Rheumatoid arthritis tends to spare the central nervous system directly,
although vasculitis can cause peripheral neuropathy. Neurologic manifestations
may also result from atlantoaxial or midcervical spine subluxations. Nerve
entrapment secondary to proliferative synovitis or joint deformities may produce
neuropathies of median, ulnar, radial (interosseous branch), or anterior tibial
nerves.
Rheumatoid arthritis involving the eye is seen in fewer than 1% of
patients. Affected individuals usually have long-standing disease and nodules.
The two principal manifestations are mild and transient episcleritis and scleritis.
Felty's syndrome is most common in individuals with long standing
disease. It consists of chronic Rheumatoid arthritis, splenomegaly, neutropenia,
and, on occasion, anemia and thrombocytopenia. These patients frequently
have high titers of rheumatoid factor, subcutaneous nodules, and systemic
manifestations of rheumatoid disease.
Secondary osteoporosis, following rheumatoid involvement, is common
and may be aggravated by glucocorticoid therapy. Osteopenia in Rheumatoid
arthritis involves both juxta-articular bone and long bones distant from involved
joints.
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Conceptual Study
Chart No. 4-Schematic representation of the evolution of Roopa:
1. Angamarda 2. Daha 3. Sashabda Gatra 4. Aruchi 5. Bahumutrata 6. Srasta Gatra 7. Trushna 8. Kushikadhinata 9. Kati Vyadha 10. Hrillasa 11. Kukshishoola 12. Sandhi Shotha 13. Gourava 14. Nidraviparyaya 15. Uthana Asamartha 16. Jwara 17. Trut 18. Deha Pandura 19. Apaka 20. Chardi 21. Mootra Pandura 22. Angasoonata 23. Brama 24. Peta and Ushna Netra 25. Sa Ruk Shotha Hasta 26. Moorcha 27. Peeta and Ushna Chardi 28. Sa Ruk Shotha Pada 29. Hrutgraha 30. Jangha Vyadha 31. Sa Ruk Shotha Shira 32. Vitvibhandha 33. Uru Vyadha 34. Sa Ruk Shotha Gulpha 35. Jadyata 36. Trika Vyadha 37. Sa Ruk Shotha Trika 38. Antrakoojana 39. Hrut Vyadha 40. Sa Ruk Shotha Janu 41. Anaha 42. Nabhi Vyadha 43. Sa Ruk Shotha Uru 44. Vikunjana of Manya 45. Pada Vyadha 46. Agnidourabalya 47. Vikunjana of Prushata 48. Prushta Vedana 49. Praseka 50. Vikunjana of Kati 51. Manya Vedana 52. Utsaha Hani 53. Vikunjana of Janu 54. Ama Atisara 55. Vyrasya 56. Vikunjana of Trika 57. Anga Vaikalya 58. Shosha 59. Visuchika
Vata Prakopa Agnimandya Dhatu Virodhi
Vata Dushti Ama (Koshta)
Dhamani
Trika Sandhi
Saruja Shotha (in multiple joints)
Sankocha Adi Upadrava
Samavata Dosha (Amavisha/Garavishatulya)
Majjavaha Srotas
Nidana-Viruddha
Conceptual Study
Conceptual Study
REFERENCES:
1. A.H.Ni. 1/5
2. M.N. 25/7-10
3. M.N. 25/6
4. Y.R.Po. Amavata Nidana/1, 2
5. A.H.Su. 13/23,24
6. C.S.Vi. 5/8
7. A.H.Su. 13/27
8. M.N. 25/11
9. M.N. 25/1-5
10. C.S.Su. 28/17
11. H.P.I.M. 14th edition, pg.1883, 1884.
Conceptual Study
UPADRAVA
Among the different scholars of Ayurveda, there is a wide range of
difference in relation to Amavata Upadrava.
Yogaratnakara1 has included all the advanced stage manifestations as
its complications whereas Vachaspati includes all Vatavyadhis as its
Upadravas. But, other Acharyas differentiate symptoms of Amavata from its
complications. Vijayarakshita mentions Sankocha and Khanja2 specifically.
Bhavaprakasha3 includes Kalaya Khanja. Anjana Nidana4 includes Jadya,
Antrakujana, Anaha, Trushna, Chardi, Bahumootrata, Shoola, Shayananasha
as Upadrava of Amavata.
Following are the Upadravas which are elaborated;
1. Granthi
2. Angavaikalya
3. Vatavyadhi
4. Sankocha
5. Khanja
Granthi (Rheumatoid nodules):
Granthi is one of the feature of Snayu Dushti5. Develops in 20-30% of
persons with RA. They are usually found on the peri-articular structures,
extensor surfaces and other areas subjected to mechanical pressure, but are
also seen in pleura and meninges. Common locations include Olecranon bursa,
Proximal ulna and so on. Nodules vary in size and consistency.6
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Conceptual Study
Angavaikalya:7
Angavaikalya, one of the Lakshana mentioned by Harita can be
considered as an Upadrava of Amavata as most of the different deformities of
the body parts are produced in the later part of the disease RA.
Deformity of joints:6
• Swan neck deformity
• Boutonniere deformity
• Ulnar deviation
• Eversion at the hind foot, plantar subluxation of the metatarsal heads,
widening of the forefoot, hallux vulgus, lateral deviation and dorsal
subluxation of the toes.
• Z-Deformity of wrist and fingers.
Vatavyadhi:
Vachaspati mentions Vatavyadhi to manifest in the Upadravavastha of
Amavata. But, Vijayarakshita mentions Khanja, Sankocha.
Different neurological manifestations in RA are:
• The subluxation of Atlantoaxial joint is a severe complication and may
lead to compression of spinal cord by the Odontoid process producing
symptoms like bladder dysfunction, sphincter laxity, circummonal
hypesthesia, and long tract signs may occur. It may even lead to sudden
death due to the laceration of the cord by the Odontoid process.
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Conceptual Study
• Affliction of Crico-arytenoid joints leads to hoarseness of voice and even
life threatening upper airway obstruction.
• Tenosynovitis in wrist causes Carpal tunnel syndrome due to median
nerve compression.
• Vasculitis vasonervorum cause motor and sensory type of neuropathy.
• Autonomic nervous system dysfunction cause cold and damp
extremities.
Sankocha:
Inability to extend the limbs or normal fixed state of limb in flexion is
Sankocha.8 Sankocha is due to the affliction of Snayu, Sira and Khandara9.
Yogaratnakara has used the term Vikunchana of different Sandhis.
Inflamed joint is usually held in flexion to maximize joint volume and
minimize distension of the capsule. Later, fibrous and bony ankylosis or soft
tissue contractures lead to fixed deformities.6
Khanja:2
Patients gait gets altered because of Akshepana of Khandara. Gayadasa
clarifies Akshepana as reduced Gati10. This is usually due to painful joints,
contractures and stiffness.6
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Conceptual Study
Chart No. 5-Schematic representation of the evolution of Upadrava:
Vata Prakopa Agnimandya Dhatu Virodhi
Vata Dushti Ama (Koshta)
Dhamani
Trika Sandhi
Saruja Shotha (in multiple joints)
Sankocha Adi Upadrava
Granthi AngavaikalyaVatavyadhi Sankocha Kanja
Samavata Dosha (Amavisha/Garavishatulya)
Majjavaha Srotas
Nidana-Viruddha
Conceptual Study
REFERENCES:
1. Y.R.Amavata Chi. 3-6
2. M.N. 25/7-10
3. B.P.M. Madhu 26/11
4. Anjana Nidana
5. C.S.Su. 28/21
6. H.P.I.M. 14th edition, pg.1883
7. H.S.Tri. 21/4
8. A.H.Su. 12/49 (Hemadri)
9. C.S.Su. 28/29
10. Gay-M.N. 25/7-10
Conceptual Study
INVESTIGATIONS
Immunological assay:1,2
No tests are specific for diagnosing RA. However gamaglobulins with
demonstrable antigamma globulin activity have long been called Rheumatoid
factor (RF) because of their occurrence in serum of over 80% of patients. The
presence of Rheumatoid factor is not specific to RA. It is found in 15% healthy
people and frequency of RF in general population increases with age. It does
not establish the diagnosis of RA but can be of high value in prognosis because
patients with high titers tend to have more severe progressive disease. In
addition a number of conditions like systemic lupus erythematosis, Sjogren’s
syndrome, chronic liver diseases, sarcoidosis, intestinal pulmonary fibrosis,
infective mononeucleousus, hepatitis B, TB, Syiphilis, subacute bacterial
endocarditis, schistosomiasis and malaria.
Blood picture:2
Normochromic, normocytic anaemia is frequently present in RA. Large
iron stores in bonemarrow are usually noted. In general anaemia and
thrombocytosis correlate with disease activity. The WBC count is ususlly
normal. But a mild leucocytosis may be present.
ESR:2
The erythrocyte sedimentation rate is increased in nearly all patients with
active RA. In few patients, the ESR may be continuously elevated even after
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Conceptual Study
the disease activity subsides which may be attributed to elevation of serum
globulin level.
Biochemical investigations
Antinuclear antibodies (ANA):1
Higher titers of ANA are usually associated with highly expressed RA,
but attempts to differentiate SLE from RA is a key in diagnosing RA precisely.
Anti DNA Antibodies (anti n DNA):1
Though higher levels of anti n DNA are associated with SLE, in about
20% of RA patients the levels anti n DNA are usually found increased.
C-reactive proteins and ceruloplasmin levels:1
The C-reactive protein and ceruloplasmin levels are elevated and
gradually such elevations correlate with disease activity and likely hood of
progressive joint damage.
Synovial fluid analysis:2
The fluid is usually turbid with reduced viscosity, increased protein
content and slightly decreased or normal glucose concentration. The white cell
count varies between 5-50,000 cells per microlitre, polymorphoneuclear
leukocytes dominate. A synovial fluid WBC count of more than 2,000 cells per
microlitre with more than 75% polymorphoneuclear leucocytes is highly
characteristic of inflammatory arthritis. The total haemolytic complement C3 and
C4 are markedly diminished in synovial fluid relative to total protein
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Conceptual Study
concentrations as a result of activation of classic compliment pathway by locally
produced immune complexes.2
Cellular morphology:1
In about 95% of patients, both phase and ordinary light microscopy
reveals small dark cytoplasmic granules or 0.5-2.0 µ diameter within 5-100% of
neutrophils. Such neutrophils are called RA cells. A given RA cell may contain
1-20 granules in its cytoplasm. RA cells are not specific fro RA but also occur in
other conditions such as gout and septic arthritis (Scott 1975).
Radiographic evaluation:2
Roentgenograms of the affected joints early in the disease are usually
not helpful in establishing a diagnosis they reveal only that which is apparent
from physical examination namely evidence of soft tissue swelling and joint
effusion. As disease progresses abnormality becomes more pronounced
diagnosis is supported by a characteristic pattern of abnormality including the
tendency towards the systemic involvement. Juxta articular osteopenia may
become apparent within weeks of onset. Loss of articular cartilage and bone
erosion develop after months of sustained activity. The primary value of
radiography is to determine the extent of cartilage destruction and bone erosion
produced by the disease.
Other means of imaging bones and joints including 99mTC biphosphonate
bone scanning2 and magnetic resonance imaging2 may be capable of detecting
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Conceptual Study
early inflammatory changes that are not apparent from standard radiography
but are rarely necessary in routine evaluation of patients with RA.2
REFERENCES:
1. Clinical Diagnosis of Laboratory Methods, Bernard Hennry, pg.477, 478,
932.
2. H.P.I.M. 14th edition, pg.1884.
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Conceptual Study
UPASHAYA ANUPASHAYA
Oushadha, Ahara and Vihara which are responsible for relief from the
symptoms of Vyadhi are known as Upashaya and that which aggravate are
known as Anupashaya1. As said in the Amavata treatment2, Langhana, Tikta,
Katu Deepana and Ushna Ahara Viharas are the Upashaya measures of this
disease, since they carry out Ama pachana thereby giving relief from symptoms
like Jwara, Sandhi Vedana, Angamarda and Gourava and so on.
Ruksha Guna of Ruksha Sweda employed in Amavata is opposite to
Ama Gunas. viz. Snigdha, Picchiladi. It is Srotovishodhakara and Pachaka
hence effectively reduces pain. Besides, Ushna Jala suppresses symptoms of
the disease as it is Pathya3. In brief Ruksha Sweda, Langhana, Ushnakala and
Sayamkala are the Upashaya in Amavata.
Anupashaya:
On the contrary, Sheeta Guru Snigdha Ahara Meghodaya Kala, Pratah
Kala and Snigdha Sweda are considered as Anupashaya4 in this disease.
Snigdha Sweda supports the formation of Ama in early morning hours, cloudy
and rainy days because Sheeta Guna enhances the Vata and Ama. Hence
considered as Anupashaya.
This characteristic feature helps to differentiate Amavata from other
closely related diseases of Sandhi. When the symptoms of two diseases are so
similar as to confuse the physician (“Bhishak Mohakara”), the classics suggest
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Conceptual Study
the use of the concept of Upashaya and Anupashaya to bring out the occult
symptoms (Guda Linga) to diagnose the disease5. When application of oil
relieves the pain, the disease is free from Ama.
REFERENCES:
1. A.H.Ni. 1/67
2. Chakradutta 25/1
3. B.R. 21/232-234
4. A.Hr.Su. 13/27 footnote
5. C.S.Vi. 5/7
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Conceptual Study
SADHYASADHYATA
Physician who wants to be successful should have clear knowledge of
curable and incurable disease, and start treatment in time with well
understanding of various aspects of the disease. This will help in
accomplishing his goal of curing diseases. Physician treating incurable
diseases would loose wealth, fame and earn bad reputation. He will become
victim of legal sanctions.1
Generally Amavata is a Krichrasadhya Vyadhi as it includes Madhyama
Rogamarga2. It is also difficult to treat because of opposite nature of Ama and
Vata. Diseases accompanied by Upadrava becomes Asadhya the same is
applicable to Amavata.
Ekadoshaja Amavata3 caused by minimum Nidana, with few
Lakshanas, of recent origin2 is Sadhya and Harita adds Pakwama type of
Amavata is Sukhasadhya4. When the disease is Dwidoshaja3, having many
Nidanas and Lakshanas, then it become Yapya. Disease becomes
Krichrasadhya by the involvement of Tridosha and when associated with
Sarvangashotha.3 Snehi ama, Vistambi, Gulmi types of Amavata are
Kashtasadhya.4
Shopha anana, Jadya, Ghana udara, Aruchi and Amathisarayuktha
Snehi Amavata is Asadhya according to Harita.5
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Conceptual Study
PROGNOSIS OF RHEUMATOID ARTHRITIS:6
In Rheumatoid arthritis prognosis is variable. Life expectancy is reduced
by 25%. 10-15 yrs mortality is increased in patient with functional impairment.
The overall prognosis is much better in patients whose symptoms are not of
such severity as to require admission to hospital. Poor prognosis may be
associated with high titer of Rheumatoid Factor, insidious onset of disease,
more than a year of active disease without remission, early development of
nodules and erosion, extra articular manifestation, severe functional
impairment.
REFERENCES:
1. C.S.Su. 7/8
2. C.S.Su. 10/18
3. M.N. 25/12
4. H.S.Tritiya sthana 21/21
5. H.S.Tritiya sthana 21/14
6. Davidson’s PPM 18th edition. pg. 848
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Conceptual Study
SAPEKSHA NIDANA
For the diagnosis of any disease physician should have clear knowledge
of other conditions which mimic particular condition. This can avoid the
physician from embarrassment and prevents the patient from taking the
unwanted pain and complications. Therefore for the accurate diagnosis of
Amavata the disease having similar feature has to be excluded. Following are
few conditions which have to be differentiated from Amavata.
1. Vata Shonita:
In the disease process of Vata Shonita, Rakta Dushti plays an important
role. Vata and Shonita1 get vitiated due to each others own causative factors.
Though this disease presents with Shotha in Parshva Sandhi and big joints
also, it classically begins with affliction of big toe2 with skin manifestations unlike
Amavata.
2. Kroshtuka Sheersha:
This is a disease of the knee joint and the question of involvement of
other joints does not arise. Swollen Knee has the appearance of head of a
jackal (Jambuka Shira)3. Here too Vata and Shonita are the two factors
involved.
3. Sandhigata Vata:
Sandhigata Vata typically presents with swelling of the joint that gives a
feeling of a bag inflated with air.8 Notably, use of oil here results in improvement
of symptoms rather than aggravation.
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Conceptual Study
4. Sandhiga Sannipata Jwara:11
In this disease the joint manifestations are secondary to Jwara which is
the cardinal symptom. Besides, excessive mucoid secretion from mouth,
Insomnia and Saruja Kasa differentiates this condition from Amavata
Along with the above mentioned diseases, Shotha and Shoola in Sandhi,
like in Amavata can be seen in Vataja Atisara4, Grahani5, Kshayaja Kasa6,
Vatodara7, Arsha9, Antarvega Jwara10. But these can be differentiated from
Amavata by their own characteristic features.
REFERENCES:
1. C.S.Chi. 29/4
2. C.S.Chi. 29/4
3. A.S.Ni. 15/35 (Indu)
4. C.S.Chi. 19/5
5. C.S.Chi. 15/54
6. B.P. 11/35
7. A.S.Ni. 12/14
8. C.S.Chi. 28/37
9. A.S.Ni. 7/16
10. C.S.Chi. 3/39, 40
11. B.P.Mady.Kha. Sandhiga Sannipata Jwaradhikar/500
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Conceptual Study
CHIKITSA
The treatment modalities for Amavata listed by Chakradatta1 can be
organized into three groups, to be administered in the following order.
1. The treatment aimed at Amapachana - Langhana, Swedana, Tikta, Katu,
Deepana drugs.
2. Shodhana - Virechana and Basti
3. Shamana - Snehapana.
Amapachana:
The first step in the management of Amavata is Amapachana, as it is the
first step in the general management of all the diseases and as Ama is the
prime pathogenic factor in Amavata.
The modalities for Amapachana in the Chakradatta’s Chikitsa Sootra are,
1. Langhana
2. Swedana
3. Tikta, Deepana, Katu Oushadhis to be administered in order.
Langhana:
In the management of Amavata, Upavasa is the ideal line of treatment.
Bhavaprakasha in the context of Jwara, considers Langhana as Upavasa.2 As
both Jwara and Amavata are Amashayotha diseases, Upavasa3 can be
considered as the ideal method of Langhana in Amavata also. This is also
because of unsuitability of the other methods of Langhana, analysed below.
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Conceptual Study
o Chatushprakara samshudhi, cannot be employed because
Samshodhana is contraindicated in the Samavastha of a disease.4
o Pipasa cannot be employed because in morbid patients Jala is
Pranadharaka5.
o Maruta and Atapa Sevana are less efficient for Jatharagni impairment
when compared to Upavasa.
o Deepana, Pachana cannot be employed as Agni affected by Ama is
incapable of Dosha, Ahara and Oushadha Pachana.6
o Vyayama is incompatible in the disease Amavata.
For these reasons, Upavasa is the ideal method of achieving Langhana
in Amavata, which can be achieved by Anashana or Alpabhojana. The
Langhana thus achieved will have Amapachaka effects at the Koshta level as
well as Sarvadaihika level.7
Swedana:
The definition of Sweda8 includes its benefits, viz. Stambha, Gourava
and Sheetagna. Since these are antagonistic to the qualities of Kapha and
Ama, Swedana has an important role to play in the treatment of Amavata.
Snigdha Sweda, Ruksha Sweda and Ekangasweda, Sarvangasweda are
the two fold classifications of Sweda9 and in Amavata, the Ruksha type of
Sweda should be administered for the following reasons;
1. The pathogenesis of Amavata involves spread of Ama and Vata to the
Sleshmasthana, specifically Amashaya and Sandhi.10
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Conceptual Study
2. In all conditions of Amashayagata vata, Ruksha sweda should be
administered.11
As disease is localized in Sandhipradesha, Ekangasweda is ideal. The
Rukshasweda can be advised to the affected Sandhi using Valukapottali or
Rukshopanaha.12
Tiktam Deepanani Katuni Cha:
Administration of Tikta, Katu Deepana oushadhis in Ama achieves
Amapachana both at the Koshta level and Sarvadaihika level. The methods
used for Ama Pachana are potentially Vataprakopaka. But as Langhana is
indicated in Sama Vata condition the danger of Vata Prakopa is minimal
because,13 the Amapachana methods of Langhana, Swedana and Tikta Katu
Deepana drugs are administered only until Niramavastha is achieved. After this,
Nirama Doshas have to be eliminated from the body by Shodhana. The
Shodhana methods which can be employed are Virechana and Basti.
Virechana:
Virechana is the best preferred form of Shodhana in Amavata because
Vamana (Ullekhana),14 though indicated by Charaka in Amachikitsa is
unsuitable here as it aggravates the symptoms of Amavata caused by
Pratilomagati of Vayu like Anaha, Vibandha and Antrakoojana. They can best
be relieved by Virechana. Besides, the production of Ama involves the Avarana
of the Pachaka Pitta by Kledaka Kapha. Virechana administered here provides
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Conceptual Study
dual benefits of removing the Avarana produced by Kledaka Kapha and acting
on the Sthanika Pitta Dosha.
Basti:
Basti forms the second method of Shodhana. Both Niruha and
Anuvasana Bastis should be employed here. The Niruha Basti does the
Shodhana of the Doshas brought to Pakvashaya and the Anuvasana Basti
alleviates Prakupita vata as a consequence of Niruha Basti.
Shamana Snehapana:
This is a third component in the plan of management of Amavata. The
objective of Snehapana here is Shamana. It is important to administer Sneha
only after the disease has become Nirama. Shamana Snehapana in Amavata
provides the following benefits;
o Snehapana prevents the aggravation of Vata and Rukshata as a result of
the previously employed therapeutic measures.15
o It helps in increasing the Bala of the patient who has been debilitated as
a result of previously employed therapeutic measures.15
o Shamana Sneha stimulates the Agni16 which is an important component
in the treatment of Amavata.
o Since the Snehapana has been prescribed in Asthi Majja Gata Vata, it
can be comfortably used in Amavata.
o Vataharana is the inherent property of Sneha, an essential requirement
in the treatment of Amavata.
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General principles in treatment of Rheumatoid Arthritis:17
The goals of therapy of RA are;
1. Relief from pain
2. Reduction of inflammation
3. Protection of articular structures
4. Maintenance of function
5. Control of systemic involvement
The therapy of RA remains empirical and palliative since the etiology,
pathogenesis and mechanism of therapeutic action is speculative till date. The
interdisciplinary approach in the management of RA includes both physical and
medical modalities.
Physical therapy and education:
This includes rest, splinting to reduce unwanted motion of inflamed
joints, exercise to maintain muscle strength and joint mobility, arthrotic and
assistive devices for support and alignment of deformed joints to reduce pain
and improve joint function, patient and family education to give the insight of the
disease and make necessary life style changes to minimize stress on the joints.
Medical management:
This includes four approaches
I. First line of treatment with non steroidal anti-inflammatory drugs (NSAIDs):
Besides aspirin, the new generation NSAIDs have shown to act by
inhibiting cycloxygenase II pathways which is responsible for the inflammatory
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Conceptual Study
activity. They have analgesic anti inflammatory, and anti pyretic properties.
Though non aspirin agents are lesser gastric irritants, the NSAIDs in general
are associated with following side effects
1. Gastric irritation,
2. Azotemia
3. Platelet dysfunction
4. Rash
5. Liver function abnormalities
6. Bone marrow depletion
7. Toxicity in elderly on diuretic therapy.
The NSAIDs have minimal effect on disease progression.
II. Second line of treatment with disease modifying anti rheumatic drugs
(DMARD):
The DMARDs include Gold, Depencillamine, Antimalarials and
Sulphasalazine. They have the capacity to decrease elevated levels of acute
phase reactants, like RA factor, C-reactive protein and ESR. Thus, they modify
the destructive capacity of the disease. They have been shown to induce
remission, but have minimal anti inflammatory activity. Hence, NSAIDs must be
continued during DMARD therapy.
The Folic acid antagonist Methotrexate is currently a frequently utilized
DMARD as its onset of action is more rapid than others. The toxicity of
DMARDs include GIT upset, oral ulceration, hepatic fibrosis and pneumonitis.
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Conceptual Study
Concurrent administration of folic acid may diminish the frequency of the side
effects.
III. Third line of treatment with glucocorticoids:
Low dose (less than 7.5 mg/day) Prednisolone has been advocated as a
useful additive therapy to control symptoms and retard progression of bone
erosions.
IV. Fourth line of treatment with immuno suppressants:
Drugs like Azathioprim and Cyclophosphamide have same effects like
the DMARDs and are used when the DMARD therapy has completely failed. In
higher doses the toxic effects include predisposition to malignant neoplasms.
Recent trials have found that high dose cyclosporine therapy may induce rapid
improvement but are associated with renal and gastrointestinal toxicity.
Cyclosporine has still not been approved for use in RA.
V. Surgery:
Surgery helps patients with severely damaged joints. Surgeries like
Arthroplasty, total joint replacement (especially of hip and knees.), Arthroscopic
synovectomy and Tensosynovectomy can be adopted to give the patient relief
from pain and deformity.
75
Conceptual Study
REFERENCES:
1. Chakradutta 25/1
2. C.S.Chi. 3/142
3. B.P.Madhy.kha.Prathambhaga.1/9 (AnashanamUchyate)
4. A.H.Su. 13/28
5. B.P. 1/14
6. A.H.Su. 8/18
7. C.S.Chi. 15/75
8. C.S.Su. 22/4
9. C.S.Su. 14/66
10. M.N. 25/2 – Madhu
11. C.S.Su. 14/9
12. B.P. Madhya 26/14-15
13. C.S.Chi. 3/283 - Chakrapani
14. C.S.Vi. 2/13 (Ullekhana)
15. C.S.Chi. 28/81
16. C.S.Chi. 15/201
17. H.P.I.M. 14th edition, pg. 1885-1888
Conceptual Study
PATHYAPATHYA
Pathyapathya plays vital role in crushing the disease process as well as
in the recurrence of the disease. Success of treatment depends upon the
practice of Pathyapathya. Vaidyakiya Subhashita quotes,” there is no need to
take the medicine for the one who follows the Pathya properly, contrarily there
is no need to take the medicine for the one who does not follow the Pathya, as
it will be of no use”. Purusha has been carved out of nature itself. That is why
there exists little difference between the constituents of his make and that of his
environment. The dimensions of man’s interaction with his environment include
Ahara, Vihara and Oushadha. A beneficial interaction is termed Hita and a
harmful one is called Ahita, this leads to homeostasis and homeostenosis
respectively. The factors governing this aspect of treatment constitutes the
concept of Pathya and Apathya.
By definition, Pathya means “Patho Anapetam” and “Manasaha Priyam”1
which can be interpreted as “Manoshareera Anupaghati”2. That which is
harmless to both to Shareera and Manas is Pathya. On the contrary, Apathya
means otherwise. Among the Pathya Varga, the methods involved in
administration of Oushadha have been dealt in the chapter of Chikitsa. The
details of Ahara and Vihara are discussed here. Raja Nighantu has listed the
following Hitakara Dravya Samooha3. i.e. which are in general are Pathya for all
diseases. Ghrita, Saindhava, Dhanyaka, Jeeraka, Ardraka, Tanduleeyaka,
Patola, Alabu, Godhuma, Jeerna shali, Gokshura, Hamsodaka and Mudga.
76
Conceptual Study
In Amavata, the Ahara and Vihara which are Vatahara, Kaphahara,
Amapachaka, Agnideepaka and Rasaprasadaka are considered as Pathya. So,
the diet and the Oushada having Katu, Tiktarasa, Ushna, Tikshna guna are
considered as Pathya. They are as follows,
Shuka Dhanya - Purana Shali, Purana Shastika Shali, Yava5
Shami Varga - Chanayusha, Kalayayusha, Kulatta, Kodrava5
Shakha Varga - Nimba Patra, Gokshura, Varuna, Sigru, Ardraka, Lashuna,
Karavellaka, Patola5
Mamsa Varga - Jangala mamsa, Lava mamsa processed with Takra4
Paniya Varga - Ushna Jala, Panchakola siddha jala, Madhya4
Ksheera Varga - Takra4
Mutra Varga - Gomutra4
Harita opines that all the Pathya which are mentioned in Jwara
Rogadikara should be considered in Amavata also6.
Apathya:
The Ahara and Vihara which compliment or supplement the Prakruti of
the Vyadhi are called as Apathya. In Amavata, to be a Apathya it should be
Amakaraka and Vatakaraka. It should cause Mandagni and vitiate the Rasa
Dhatu.
Aharatah Apathya:
Shami Dhanya - Masha Pistaka4,5,7,8 Dvidala dhanya6
Mamsa Varga - Matsya, Anupa4,5,7,8
77
Conceptual Study
Ksheera Varga - Dhadhi, Ksheera, Guda9,5,7,8,10
Mutra Varga - Gomutra9,11
Jala Varga - Dushta jala9,11
Anna - Viruddha, Asatmya, Vishamashana9,11
Guru7,9,11 Picchila Abhishyandi7,9,10,11, Ushna, Drava, Goulya6
Viharatah Apathya:
Poorva Vata, Vegavarodha, Jagarana, Vishamashana9,11
Harita opines that all the Nidana which are Atisarakaraka are Apathya in
Amavata.6
REFERENCES:
1. C.S.Su. 25/45
2. Chakrapani on C.S.Su. 25/45
3. Ra Ni 11/126
4. B.R.Amavata 21/232-234
5. Y.R. Amavata.1,2
6. H.S.Tritiya stana 21/47-49
7. B.P Ma.Amavata.26/129
8. G.N.Kaya chikitsakhanda.22/38.
9. B.R.Amavata 21/235-236
10. Vang.Amavata/123
11. Y.R. Amavata.3,4
78
Drug Review
79
DRUG REVIEW
The therapeutic effect of any drug combination in the patients of
Amavata depends upon its ability to pacify the Ama and Vata Dosha, correction
of Rasa Dhatu abnormality, rectifying the Agni, correcting the structural
abnormality in Sandhis, ability to pacify and bring out reduction in pain,
softening the stiff Sandhis, reducing morning stiffness and such measures.
The drugs used in the clinical trial have been reviewed below:
1. Eranda Paka1
2. Ajamodadi Churna2
3. Panchakola Phanta3
4. Eranda Taila.4
ERANDA PAKA: Contents
Name of the drug Latin Name Quantity
1. Eranda Ricinus communis 750 grams
2. Ksheera Milk 6 liters
3. Ghrita Ghee 375 grams
4. Khandasharkara Sugar candy 1500 grams
5. Pippali Piper longum Linn. 12 grams
6. Maricha Piper nigrum Linn. 12 grams
7. Shunti Zingiber officinale 12 grams
8. Twak Cinnamomum zeylanicum 12 grams
9. Ela Elettaria cardamomum 12 grams
Drug Review
80
10. Patra Cinnamomum tamala 12 grams
11. Nagakesara Mesua ferrea 12 grams
12. Pippalimoola Piper longum Linn. 12 grams
13. Chitraka Plumbago zeylanica 12 grams
14. Chavya Piper retrofractum 12 grams
15. Shatapushpa Anethum sowa 12 grams
16. Shati Hedychium spicatium 12 grams
17. Bilwamoola twak Aegle marmelos 12 grams
18. Yavani Trachyspermum ammi 12 grams
19. Jeeraka Cuminum cyminum 12 grams
20. Krishna jeeraka Carum bulbocastanum 12 grams
21. Haridra Curcuma longa 12 grams
22. Daruharidra Berberis aristata 12 grams
23. Aswagandha Withania somnifera 12 grams
24. Balamoola Sida cordifolia 12 grams
25. Patha Cissampelus pereira 12 grams
26. Hapusha Juniperus communis 12 grams
27. Vidanga Embelia ribes 12 grams
28. Pushkaramoola Inula racemosa 12 grams
29. Goshura Tribulus terrestris 12 grams
30. Kushta Saussurea lappa 12 grams
31. Amalaki Embelica officinalis 12 grams
32. Haritaki Terminalia chebula 12 grams
Drug Review
81
33. Vibheetaki Terminalia bellirica 12 grams
34. Devadaru Cedrus deodara 12 grams
35. Baboola twak Acacia arabica 12 grams
36. Satavari Asperagus racemosus 12 grams
Method of Preparation:
Eranda Paka is herbal compound mainly contains Eranda Beeja, Milk,
Ghee and 33 Prakshepaka Dravyas, tabled above. A special preparation
method, mentioned in Yogaratnakara was followed in preparing Eranda Paka.
Initially Eranda Beeja are collected and its outer covering is removed. Heat
these Eranda Beeja with milk on Mandagni till it turns to pasty consistency. This
paste is grinded well and fried in ghee on an Iron pan. Then 33 Prakshepaka
Dravyas are added, mixed well till it gets granule form.
Dose: Orally in a dose of 15 gms, thrice a day with hot water after food.
Duration: For a duration of 30 days in patients of Group EP.
Eranda is one of the main ingredient in Eranda paka. Eranda is Tikta,
Kashaya and Madhura Rasatmaka, Ushna veerya and Madhura vipaka. Thus
with Madhura rasa and Madhura vipaka contradicts Vata and with Tikta rasa
and Ushna veerya counters Ama. In Amavata, Vedanasthapana and
Shothahara properties plays an important role, which are also the main action
of the Eranda as Eranda is Vata Anulomana, Vedanasthapaka and Shothahara
in nature. The rest 33 Prakshepaka drugs are added in very minute quantity.
Most of them are Deepaka, Pachaka and Vata anulomaka in nature. The
Drug Review
82
different properties and therapeutic effect of the individual drugs are shown in
the table below5 (Table No. 2)
Table no. 2-Properties and therapeutic effect of the individual drugs in Eranda Paka:
Sl.
No.
Name of the
Drug
Latin Name Rasa Guna Veerya Vipaka Doshaghnata Karmukata
1.
Eranda Beeja Ricinus
Communis
Madhura
Katu
Kashaya
Guru
Snigdha
Teekshna
Sookshma
Ushna Madhura Vatakapha
Prashama
Swedopaga
Shothahara
Rasayana, Vedana
Shamaka
2.
Milk Madhura Shigdha,
Mrudu
Sheeta
Guru
Shlaksna
Picchila
Madhura Vata Pittahara Jeevaniya
Rasayana
Vajikara
Balya
Bruhmana
3.
Ghee Madhura Shigdha,
Guru
Sheeta Madhura Vata Pittahara Dhatuvardhaka
4. Kanda Sharkara Madhura Sara
Snigda
Sheeta Madhura Vata Pittahara Vrishya
Bruhmana
5. Nagara Zingiber officinale Katu Laghu
Snigdha
Ushna Madhura Kaphavata
Shamaka
Deepaka, Pachaka
Shoolaprashamana
Vatanulomana
6. Pippali Piper nigrum Katu Laghu
Teekshna
Ushna Katu Vatakapha
Shamaka
Deepana,
Triptighna,
Vatanulomana,
Mrudureehana,
Balya, Rasayana
7. Maricha Piper nigrum Katu Laghu,
Teekshna
Ushna Katu Kaphavata
Shamaka
Deepana,
Pachana,
Vatanulomana
Pramathi
8. Twak Cinnamomum
Zeylanica
Katu Tikta
Madhura
Laghu
Rooksha
Teekshna
Ushna Katu Vatakapha hara Deepana Pachana
Vedanashamaka
9. Ela Elettaria
cardamomum
Katu
Madhura
Laghu
Rooksha
Sheeta Madhura Tridosha hara Deepana Pachana
Vedanashamaka
10. Patra Cinnamomum
tamala
Katu Ushna
Laghu
Ushna Katu Kaphaghna Deepana Pachana
Vedanashamaka
11. Nagakeshara Mesua ferrea
Kashaya
Tikta
Laghu
Rooksha
Ushna Katu Kaphapitta
Shamaka
Deepana Pachana
Vedanashamaka
12. Pippali moola Piper longum Katu Laghu
Snigdha
Teekshna
Anushna Madhura Kaphavata
Shamaka
Deepana,
Triptighna,
Vatanulomana,
Balya, Rasayana
13. Chitraka Plumbago
Zeylanica
Katu Teekshna
Laghu
Rooksha
Ushna Katu Kapha hara Deepaka, Pachaka
Shoolaprashamana
Vatanulomana
14. Chavya Piper
retrofractum
Katu Laghu
Rookhsa
Ushna Katu Kaphavata
Shamaka
Deepaka, Pachaka
Shoolaprashamana
Vatanulomana
15. Shatapushpa Anethum sowa Katu
Tikta
Laghu
Rooksha
Teekshna
Ushna Katu Kaphavata
Shamaka
Rochana,
Deepana,
Pachana,
Anulomana,
Shothahara
16. Shati Hedychium
spicatium
Katu Tikta
Kashaya
Laghu
Teekshna
Ushna Katu Kaphavata
Shamaka
Deepana Rochana
Shoolaprashamana
17. Bilwamoola
Twak
Aegle marmelos
Kashaya
Tikta
Laghu
Rooksha
Ushna Katu Kapha Shamaka Vedana Shamaka
18. Yavani Trachyspermum
ammi
Katu Tikta Laghu
Rooksha
Teekshna
Ushna Katu Kaphavata
Shamaka
Rochana Deepana
Vatanulomana
Shoolaprashamana
19. Jeeraka Cyminum
cuminum
Katu Laghu
Rooksha
Ushna Katu Kaphavata
Shamaka
Deepana, Pachana
Vatanulomana
Shoolaprashamana
20. Krishna Jeeraka Carrium carvi
Katu Laghu
Rooksha
Ushna Katu Kaphavata
Shamaka
Deepana Pachana
Vedanashamaka
21. Haridra Curcuma longa
Tikta Katu Rooksha
Laghu
Ushna Katu Kaphavata Nashaka Vedanashamaka
Varnya Deepana
Anulomana
22. Daruharidra Berberis aristata
Tikta
Kashaya
Rooksha
Laghu
Ushna Katu Kaphapitta hara Shothahara
Vedanashamaka
Anulomana
23. Ashwaganda Withania
somnifera
Madhura
Kashaya
Tikta
Laghu
Snigdha
Ushna Madhura Kaphavata
Shamaka
Shothahara,
Vedanashamaka
Rasayana
24. Balamoola Sida codifolia
Madhura Guru
Snigdha
Picchila
Sheeta Madhura Vata Shamaka Vedanahara
Shothahara
25. Patha Cissampelos
Pereira
Tikta Laghu
Teekshna
Ushna Katu Tridosha Nashaka Anulomana
Vedanashamaka
Deepana pachana
26. Hapusha Juniperus
communis
Katu Tikta Guru
Rooksha
Teekshna
Ushna Katu Kaphavata
Shamaka
Deepana Pachana
27. Vidanga Embelia ribes Katu
Kashaya
Laghu
Rooksha
Teekshna
Ushna Katu Kaphavata
Shamaka
Deepana, Pachana
Anulomana
Krimighna
28. Pushkaramoola Inula recemosa
Tikta Katu Laghu
Teekshna
Ushna Katu Kaphavata
Shamaka
Shothahara
Vedanasthapaka
29. Gokshura Tribulus terestris
Madhura Guru
Snigdha
Sheeta Madhura Vatapitta Shamaka Balya anulomaka
Vedanasthapaka
30. Kushta Saussurea lappa Tikta
Katu
Madhura
Laghu
Rooksha
Teekshna
Ushna Katu Kaphavata
Shamaka
Deepana, Pachana
Anulomana
31. Amalaki Emblica
officinalis
Amla
Pradhana
Guru
Rooksha
Sheeta Madhura Tridosha hara Rochana, Deepana
Anulomana
Pancharasa
Lavana
Rahita
Sheeta Rasayana
32. Haritaki Terminalia
chebula
Kashaya
Pradhana
Pancha Rasa
Laghu
Rooksha
Ushna Madhura Tridosha Shothahara,
Vedanasthapaka,
Anulomana,
Mruduvirechaka,
Deepana, Pachana
33. Vibhitaki Terminalia
bellerica
Kashaya Laghu
Rooksha
Ushna Madhura Tridosha hara Shothahara
Vedanasthapaka
34. Devadaru Cedrus deodara Tikta Laghu
Snigdha
Ushna Katu Kaphavata
Shamaka
Shothahara
Vedanasthapaka
Deepana pachana
35. Babbula Twak Acacia arabica
Kashaya Guru
Rooksha
Sheeta Katu Kaphapitta
Shamaka
Dahasamaka,
Vrushya
36. Shatavari Asperagus
recemosus
Madhura
Tikta
Guru
Snigdha
Sheeta Madhura Kaphapitta
Shamaka
Vedana sthapana
Balya rasayana
Drug Review
83
AJAMODADI CHURNA: Contents
Name of the drug Latin Name Quantity
1. Ajamoda Carum roxburghianum 1 part
2. Vidanga Emblia ribes 1 part
3. Saidhava Sodium cloride 1 part
4. Pippalimoola Piper longum Linn. 1 part
5. Chitraka Plumbago zeylanica 1 part
6. Devadaru Cedrus deodara 1 part
7. Pippali Piper longum Linn. 1 part
8. Maricha Piper nigrum Linn. 1 part
9. Shatapushpa Anethum sowa 1 part
10. Haritaki Terminalia chebula 5 part
11. Vrudhadaru Argyreia speciosa 10 part
12. Nagara Zingiber officinale 10 part
Ajamodadi churna, a compound preparation contains above mentioned
12 ingredients.
Method of preparation:
The first 9 drugs mentioned above are taken 1 part each, where as
Hareetaki is 5 parts, Nagara and Vruddhadaru are taken 10 parts each. These
above mentioned drugs are taken as per classics and made into Churna.
Dose: 5 gms thrice a day with hot water before food.
Duration: For 30 days in patient of group AC.
Drug Review
84
First 9 ingredients are used commonly in both Ajamodadi Churna and
Eranda Paka preparation. These drugs are Deepaka, Pachaka and Vata
Anulomana in nature.5 Details of which are explained in Table No. 3.
Table no. 3-Properties and therapeutic effect of the individual drugs in Ajamodadi Churna: Sl. No.
Name of the Drug Latin Name Rasa Guna Veerya Vipaka Doshagnata Karmukata
01 Ajamoda Carumroxburghianum
Katu, Tikta Laghu Rookshna Teekshna
Ushna Katu KaphavataNashaka
Vedanasthapaka, Deepana, Pachana, Vidahi, Vatanulomana,
02
Vidanga Embelia ribes KatuKashaya
Laghu Rooksha Teekshna
Ushna Katu KaphavataShamaka
Deepana, Pachana, Anulomana
03 Saindhava Sodiumchloride
Lavana SnigdhaTeekshna Laghu Sookshma
Sheeta Lavana DeepanaPachana Vatanulomana Tridoshahara
Deepana, Pachana, Vatanulomana
04 Devadaru Cedrusdeodara
Tikta Laghu Snigda
Ushna Katu KaphavataShamaka
Deepana, Pachana Anulomana
05 Chitraka Plumbago zylanicum
Katu, Tikta Teekshna Laghu Rookshna
Ushna Katu KaphavataShamaka
Vedanastapaka Deepana Pachana
06 Pippali moola Piper longum Katu Laghu, Snigdha, Teekshna
Anushna Madhura Kaphavata Shamaka
Deepana, Triptighna, Vatanulomana, Balya, Rasayana
07 Pippali Piper longum Katu Laghu,Snigdha,
Teekshna
Anushna Madhura Kaphavata Shamaka
Deepana, Triptighna, Vatanulomana, Balya, Rasayana
08 Shatapushpa Anethum sowa KatuTikta
Laghu Rooksha Teekshna
Ushna Katu KaphavataShamaka
Rochana, Deepana, Pachana, Anulomana, Shothahara
09 Maricha Piper nigrum Katu Laghu, Teekshna
Ushna Katu KaphavataShamaka
Deepana, Pachana Vatanulomana
10 Nagara Zingiberofficinale
Katu Laghu, Snigdha
Ushna Madhura Kaphavata Shamaka
Triptighna, Rochana, Deepana, Pachana, Vatanulomana, Shothahara
11 Vriddhadaru Argeriaspeciosa
Tikta Laghu,Snigdha
Ushna Katu KaphavataShamaka
Vedanasthapana, Deepana, Pachana
12 Haritaki Terminaliachebula
Kashaya Pradhana Pancha Rasa
Laghu Rooksha
Ushna Madhura Tridosha Shothahara, Vedanasthapana,Anulomana, Mruduvirechana, Deepana, Pachana
Drug Review
85
PANCHAKOLA PHANTA:3
This yoga contains 5 ingredients which are taken in equal quantity and
made into coarse powder. Phanta is prepared according to the Phanta Vidhi. In
both the group patients’, Panchakola Phanta 20 ml thrice daily administered
before food for a period of three days. The list of ingredients is given below:
Ingredients Proportion
Pippali 1part
Pippali moola 1part
Chavya 1part
Chitraka 1part
Nagara 1part
As discussed earlier Agni Deepana and Ama Pachana holds its
supremacy in treating the disease Amavata Deepana-Pachana helps in
Sampraptivighatana by virtue of its qualities. In Panchakola phanta, most of the
drugs are having Tikshna guna and Ushna veerya. Because of these qualities
it, does the Dosha Niramata and prevents further production of Ama6 (Table No.
4). This in turn brings vitiated Dosha to Koshta so that later it can be removed.
Hence the Panchakola Phanta is opted.
Table no. 4-Properties and therapeutic effect of the individual drugs in Panchakola Phanta:
Sl.No. Name LatinName
Rasa Guna Veerya Vipaka Doshagnata Karmukata
01 Pippali Piperlongum
Katu Lagu,Snigdha, Teekshna
Anushnasheeta Madhura Kaphavata Deepana, Triptigna, Vatanulomana, Mruduvirechana, Balya, Rasayana
02 Pippalimoola
Piper longum
Katu Lagu,Snigdha, Teekshna
Anushnasheeta Madhura Kaphavata Deepana, Triptighna,Vatanulomana, Mruduvirechana, Balya, Rasayana
03 Chavya Piper chaba Katu Lagu,Rooksha
Ushna Katu Kaphavata Deepaka, PachakaShoolaprashamana Vatanulomana
04 Chitraka Plumbagozeylanicum
Katu Lagu,Rooksha Teekshna
Ushna Katu Kaphavata Deepaka, PachakaShoolaprashamana Vatanulomana
05 Nagara Zingiberofficinale
Katu Lagu,Snigdha
Ushna Katu Kaphavata Deepaka, PachakaShoolaprashamana Vatanulomana
Drug Review
Eranda Taila:
Action of Eranda Taila in the management of Amavata has been
compared to the supremacy of the lion in the rivalry between lion and elephant4.
Eranda has Madhura rasa, Katu, Kashaya Anurasa; Snigdha, Tikshna,
Sukshma are its Gunas. It undergoes Madhura vipaka and has Ushna veerya7.
Due to the above said qualities, it does Vata and Kapha Shamana. It is
said that it does Srotovishodhana and thus can be employed in Samavata
condition. For the above said reasons, Taila has been selected for Koshta
Shodhana7.
After the Deepana, Pachana by administering Panchakola phanta for 3
days, Eranda Taila administered 10 ml once in morning hours on empty
stomach for 3 days.
REFERENCES:
1. Y.R. Poorva Kha. Vatavyadhi Chi 1-5
2. Y.R. Poorva Kha. Amavata Chi. 1-3
3. B.R. 5/193
4. B.R. 28/23
5. D.G. vol. II by P.V.Sharma
6. B.P. Madhya Kha. 26/49
7. S.S.Su. 45/114
86
Materials and Methods
MATERIALS AND METHODS
MATERIALS TAKEN FOR THE STUDY:
Eranda Paka: Prepared according to the prescribed method in S.D.M.
Ayurvedic Pharmacy.
Ajamodadi Churna: Prepared according to the prescribed method in S.D.M.
Ayurvedic Pharmacy.
Panchakola Phanta: Prepared using Panchakola phanta churna procured from
S.D.M. Ayurvedic Pharmacy.
Eranda Taila: Procured from S.D.M. Ayurvedic Pharmacy.
METHODS:
Objective of the study:
1) To evaluate effect of Eranda Paka in the management of Amavata
2) To study the efficacy of Ajamodadi Churna in Amavata
3) To compare the efficacy of Eranda Paka and Ajamodadi Churna in Amavata.
Source of data:
20 patients diagnosed as Amavata (Rheumatoid arthritis) from IPD and
OPD of S.D.M. Ayurveda Hospital, Udupi. The patients were randomly grouped
into two groups of 10 each which were called Group EP (Eranda Paka group)
and Group AC (Ajamodadi Churna group)
Study design: Single blind comparative clinical study with pre-test and post-
test design.
87
Materials and Methods
Inclusion criteria:
• Patients aged between 16 – 70 years age
• Signs and symptoms of Amavata
• Criteria for diagnosis of Rheumatoid Arthritis as approved by American
Rheumatism Association (ARA),1987 revision
Exclusion criteria:
• All connective tissue disorders other than Rheumatoid arthritis.
• Systemic Lupus Erythematosus
• With any other systemic disorder
Diagnostic criteria:
Patients were diagnosed on the basis of signs and symptoms of
Amavata and the criteria as approved by ARA, 1987 revision
• Morning stiffness* (Stabdata) (>1hour)
• Arthritis of three or more joints* (Shoola and Shotha in three or more
joints)
• Arthritis of hand joints.*
• Symmetrical arthritis.*
• Rheumatoid nodules.
• Rheumatoid factor.
• Radiological changes.
.
* - Duration of 6 weeks or more.
N.B. Diagnosis of R.A. made with four or more criteria
88
Materials and Methods
Assessment criteria:
The patients were observed on the weekly basis and the change in
subjective signs and symptoms assessed by suitable scoring method and
objective signs using appropriate clinical tools. Details of which are given below.
A. Subjective criteria:
1. Pain in the joints:
Symptom Grading
No pain 0
Mild (on motion only) 1
Moderate (at rest) 2
Severe (wakes patient from sleep) 3
2. Morning stiffness (duration in hours):
Symptom Grading
0-5 min. 0
5 min. - 2 hrs. 1
2 - 8 hrs. 2
8 hrs. or more 3
3. Swelling in the joints:
Symptom Grading
Absent 0
Mild 1
Moderate 2
Severe 3
89
Materials and Methods
4. Redness:
Symptom Grading
Absent 0
Mild 1
Moderate 2
Severe 3
5. Warmth:
Symptom Grading
Absent 0
Mild 1
Moderate 2
Severe 3
6. Tenderness in the joints:
Symptom Grading
No tenderness 0
Says tender 1
Patient winces 2
Winces and withdraws 3
Not allowed to be touched 4
90
Materials and Methods
7. Alasya:
Symptom Grading
Fully active 0
Mild laziness, slow initiative in work 1
Initiative in some works, absent in others 2
Absolute lack of initiative even though capacity for work exists 3
8. Dourbalya:
Symptom Grading
No feeling of weakness 0
Slight weakness 1
Feeling of weakness but ability unimpaired 2
Ability to do duties affected 3
9. Knuckle swelling:
Jewellers rings were used to measure the knuckle swelling. The ring
which passes through knuckle with least resistance was noted. Any change in
the number of the ring after the treatment was recorded.
10. Muscle wasting:
The circumference of arm, fore arm, thigh and calf were measured in
cms using a measuring tape both before and after treatment to have an
objective view of muscle wasting.
91
Materials and Methods
11. Malabaddhata/Vibandha (Constipation):
Symptom Grading
Absent 0
Slight with one motion per day 1
Marked constipation with one motion after two days or more 2
12. Jwara (in degree Fahrenheit):
Symptom Grading
No fever 0
Mild (990 F-1010 F) 1
Moderate (1010 F-1030 F) 2
Severe (>1030 F) 3
13. Sadana - fatigue:
Symptom Grading
No fatigue 0
Works full-time despite some fatigue 1
Patient must interrupt to rest 2
Fatigued at rest 3
92
Materials and Methods
14. Bahumootrata (frequency of micturition per 24 hours):
Symptom Grading
Absent (less than 4 times/24 hrs) 0
Mild (upto 6 times/24 hrs) 1
Moderate (6-10 times/ 24 hrs) 2
Severe (> 10 times/ 24 hrs) 3
15. Chardi (frequency of bouts per 24 hours):
Symptom Grading
Absent 0
Mild (upto 2 vegas/24 hrs) 1
Moderate (2-4 vegas/24 hrs) 2
Severe (4 vegas/24 hrs) 3
16. The other symptoms like Angamarda, Aruchi, Gourava, Brama,
Kukshishoola, Hrithgraha, Anaha, Praseka, Trishna, Hasta pada daha, Kandu
are scored as mentioned below.
Grading
No symptoms 0
Mild symptoms 1
Moderate symptoms 2
Severe symptoms 3
93
Materials and Methods
B. Functional assessment:
To assess the objective improvements following functional assessments
were carried out in patients of Amavata.
1. Grip strength: The patient’s ability to compress the inflated ordinary
sphygmomanometer cuff under standard conditions to assess the functional
capacity of effected upper limb, both before and after treatment.
2. Foot pressure: Foot pressure was recorded both before and after treatment
by the ability of the patient to press a weighing machine, to an objective view of
functional capacity of lower limb.
3. Range of joint movement: By using the Goniometer the range of movement
of all effected joints was noted both before and after treatment.
4. General functional capacity:
• Complete ability to carry on all usual duties without handicap 1
• Adequate normal activity despite handicap of discomfort or limited joint
movement 2
• Limited only to little or none of the usual occupation or self care 3
• Bedridden or confined to wheel chair, little or no self care 4
C. Investigations:
To assess the general condition and to confirm the diagnosis following
investigation were conducted before after the treatment
1. Hemoglobin percentage (Hb% using Sahli’s method)
2. Total Leukocyte count (TC using Neubauer’haemocytometer)
3. Differential Leukocyte count (DC using Neubauer’haemocytometer)
94
Materials and Methods
4. Erythrocyte sedimentation rate (ESR using Westergren’s method)
5. Rheumatoid arthritis factor (using immunoglobulin agglutination method)
6. If required other investigations to rule out other pathologies.
D. Disease activity degrees:
On basis of criteria laid down by American rheumatism association
(1967) the degree of disease activity was estimated for the diagnosis and
therapeutic purpose. Details are as follows:
Grade 0 1 2 3
Morning
stiffness
5 minutes or
less
5 minutes to 2
hours
2 to 8 hours 8 hours or
Fatigue None Works full time
despite some
fatigue
must interrupt
work to rest
Fatigue at rest
Pain None only on
movement
At rest Wakes patient
from sleep.
Patients
estimation
Fine Almost well Pretty good Pretty bad
General
function
Full activity
without difficulty Most activities
but with difficulty
Few activities
cares for self
Little self care
mainly chair and
bed
Grip strength 200mm/Hg or
more 195 to 120
mm/Hg
115 to 70
mm/Hg
under 70mm/Hg
Spread of joint
Involvement
None 0to50 51to100 Over 100
Westergren
ESR
0to20mm 20to35 35to50 above 50
Haemoglobin 12.5gms% 12.4to11gms% 10.9to9.5gms% Less than
9.5gms%
Physicians
estimate
Inactive Minimal active moderately
active
severely active
95
Materials and Methods
E. Overall assessment of the treatment:
The overall effect of the therapies assessed on the basis of criteria laid
down by ARA (1967) was adopted. The results are classified as four groups as
listed below.
Grade I: Complete remission
• No systemic signs of rheumatoid activity.
• No sign of inflammation.
• No evidence of activity in any extra articular process, including nodules,
tino-vaginitis and iritis.
• No lasting impairment of joint mobility other than that associated with
irreversible changes.
• No elevation of erythrocyte sedimentation rate.
• Articular deformity or extra articular involvement due to irreversible
changes may be present.
Grade II: Major improvement
• No systemic sign of rheumatoid activity, with the exception of an
elevated sedimentation rate and vasomotor imbalance.
• Major signs of inflammation resolved, such as heat, redness of joint
structures.
• No new rheumatoid process of intraarticular or extraarticular structures.
• Minimum joint swelling may be present.
96
Materials and Methods
• Impairment of joint mobility associated with minimum residual activity
may be present.
• Articular deformity or extra articular involvement due to irreversible
changes may be present.
Grade III: minor improvement
Any decrease in the signs of rheumatoid activity inadequate to fulfill the
criteria of grade II.
• Diminution of systemic signs of rheumatoid activity.
• Signs of joint inflammation only partially resolved.
• No evidence of extension of rheumatoid activity into additional articular
or extra articular structures.
• Decreased but not minimum joint swelling present.
• Impairment of joint mobility may be present.
• Articular deformity or extraarticular involvement due to irreversible
changes may be present.
Grade IV: Unimprovement or progression
• Undiminished signs of rheumatoid activity, regardless of functional
capacity.
• Exacerbation of any previously involved joint or joints, or development of
sites of rheumatoid activity.
• Roentgenologic changes indicative of progression of the rheumatoid
process, excepting hypertrophy changes.
97
Materials and Methods
• In the presence of one or more of the aforesaid criteria, involvement in
other features, including a normal or lowered ESR, not significant.
• Items which must be present.
INTERVENTION:
Deepana Pachana and Koshta Shodhana:
• Patients were randomly divided into two groups of minimum 10 patients
each.
• Before administration of medication, all patients of both groups were
given Panchakola phanta 20 ml thrice daily before food for first three
days for Deepana - Pachana.
• All patients of both groups were then given Eranda Taila 10ml on empty
stomach in the morning for next three days for Koshta Shodhana.
Eranda Paka and Ajamodadi Churna:
• Patients of Group EP were given Eranda Paka 15 gms three times daily
after food with warm water for 30 days.
• Patients in group AC were given Ajamodadi Churna 5 gms three times
daily after food with hot water for 30 days.
98
Observations
OBSERVATIONS
In both the Eranda Paka and Ajamodadi Churna group, a total of 20
patients suffering from Amavata fulfilling the inclusion criteria were studied. The
observation and the results as well as statistical analysis of these are
elaborated as mentioned below.
• Descriptive statistical analysis.
• Assessment of the effect of Eranda Paka and Ajamodadi Churna in
patients of Amavata, and the assessment of the significance of the
treatment by adapting the paired ‘t’ test.
• Comparison of the effects of treatment between the Eranda Paka group
and Ajamodadi Churna group, and statistical analysis of the comparison
by performing unpaired ‘t’ test.
Descriptive statistical analysis:
Age group of patients: Out of 20 patients of Amavata studied in this work,
maximum number of 6 (30%) patients belonged to the age group of 50 to 60
years, against a minimum of 1 (5%) patient was in the age group of 10 to 20
years. The details are given in the Table No. 5 and Graph No. 1.
Sex incidence of patients: 15 (75%) of patients of Amavata were females as
against only 5 (25 %) of males in the present study. The details are elaborated
in the Table No. 6 and Graph No. 2.
99
Observations
Incidence of Religion: As shown in the Table No. 7 and Graph No. 3 (65%) of
patients were Hindus, 5 (25%) were Muslims and only 2 (10%) of patients were
Christians.
Incidence of Literacy: Prevalence of literates was recorded in the present
study involving 20 patients of Amavata. 45% of the patients were illiterates and
the remaining 55% of patients had education, as detailed in the Table No. 8 and
Graph No. 4.
Incidence of Marital status: Among the 20 patients of Amavata taken for this
study, a maximum of 16 (80%) patients were married as against mere 4 (20 %)
of unmarried people. The details are shown in the Table No. 9 and Graph No. 5.
Socio-economical status of patients: The study revealed that most of the
patients belonged to either poor (35%) or lower middle socio-economical status
(35%) category. None of the patients were either from rich socioeconomic
status or from very rich socioeconomic status. Very poor percentage of patients
were from the middle class socioeconomic status (5%) and the upper middle
class socioeconomic status (5%) category. The details are given in the Table
No. 10 and Graph No. 6.
Incidence of Occupation: It is observed that 12 (60%) of the females in this
study were house wives by their occupation. Also, this formed the largest
category of patients leaving behind the patients engaged in other occupations.
100
Observations
No patients from the business or student category were recorded in any of the
groups. Details are given in the Table No. 11 and Graph No. 7.
Incidence of Habits: Large percentage of patients in this study did not have
any addiction. Only 6 (30%) patients reported addiction to tobacco chewing as
against 14 (70%) of the non addicts. Table No. 12 and Graph No. 8 show the
details of the habits of patients.
Prakriti of patients: All the patients in the present study belonged to the
Dvandaja Prakriti. 6 (30%) patients were of Vatapitta and Vatakapha each. The
maximum 8 (40%) patients were of Pittakapha Prakriti Table No. 13 and Graph
No. 9.
Severity of the Vikriti: The degree of Vikriti was assessed to be Madhyama, in
a maximum of 16 (80%) patients in the present study followed by Avara in 3
(15%) patients and Pravara Vikriti in 1 (5%) patient. Details of the distribution of
the patients according to their degree of Vikriti is given in the Table No. 14 and
Graph No. 10.
Satva of patients: Majority of 14 (70%) patients belong to Madhyama Satva, 3
(15%) were of Pravara Satva and Avara Satva each in this study. The details
are shown in Table No. 15 and Graph No. 11.
Sara of patients: The assessment of Sara in 20 patients of Amavata showed
maximum number of patients having Madhyama Sara 19 (95%) and remaining
101
Observations
1 (5%) patient belong to Avara Sara. Incidence of patients according to their
Sara is detailed in the Table No. 16 and Graph No. 12.
Samhanana of patients: Samhanana of every patient was assessed before
the treatment, and it was observed that among the 20 patients 17 (85%) of the
patients had Madhyma Samhanana. Pravara Samhanana was recorded in just
1 (5%) of the patients. Remaining 2 (10%) of the patients showed characters of
the Avara Samhanana. The detail of the same are given in the Table No. 17
and Graph No. 13.
Satmya of patients: Observation of 20 patients of Amavata revealed that only
1 (5%) of the patients had Pravara Satmya, and the remaining 19 (95%) of
patients showed Madhyama Satmya. Table No. 18 and Graph No. 14 show the
details.
Ahara Abhyavaharana Shakti in patients of Amavata: Interrogation of the 20
patients of Amavata revealed that 12 (60%) of the patients had Madhyama
Abhyavaharana Shakti and 4 (20%) each patients had either Pravara or Avara
Abhyavaharan Shakti. Details are given in the Table No. 19 and Graph No. 15.
Ahara Jarana Shakti of patients: Jarana Shakti of 20 patients suffering from
amavata revealed that majority 12 (60%) had Madhyama Jarana Shakti. 4
(20%) each patients had the Avara and Pravara Jarana Shakti. The same is
shown in the Table No. 20 and Graph No. 16.
102
Observations
Vyayama Shakti of patients: Madhyama Vyayama Shakti is recorded in 13
(65%) of patients. 5 (25%) of the patients had Avara Vyayama Shakti and the
remaining 2 (10%) patients had Pravara Vyayama Shakti. The same is given in
the Table No. 21 and Graph No. 17.
Vaya of the patients: All the 20 patients in this study belonged to Madhyama
Vaya. This has been shown in Table No. 22 and Graph No. 18.
103
Observations
Table No. 5-Age Group of Patients:
Total Age in years
No %
10-20 1 5
20-30 4 20
30-40 5 25
40-50 4 20
50-60 6 30
Graph No. 1-Age groupwise distribution of patients:
5%
20%
25%
20%
30%
0%
5%
10%
15%
20%
25%
30%
20ـ10 20-30 30-40 40-50 50-60
Observations
Table No. 6-Sex Incidence of Patients:
Total Sex
No %
Male 5 25
Female 15 75
Graph No. 2-Percentage of patients of different sex:
25%
75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Male Female
Observations
Table No. 7-Religion of patients 20 patients of Amavata:
Total Religion
No %
Hindu 13 65
Muslim 5 25
Christian 2 10
Others 0 0
Graph No. 3-Percentage of patients of different religion:
65%
25%
10%
0%
10%
20%
30%
40%
50%
60%
70%
Hindus Muslims Christian
Observations
Table No. 8-Literacy incidence in patients of Amavata:
Total Education
No %
Illiterate 9 45
Literate 11 55
Graph No. 4-Incidence of Literacy:
55%
45%
0%
10%
20%
30%
40%
50%
60%
Literate Illiterate
Observations
Table No. 9-Marital status of Amavata patients:
Total Marital Status
No %
Single 4 20
Married 16 80
Widowed 0 0
Graph No. 5-Percentage of patients of different marital status:
80%
20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Married Unmarried
Observations
Table No. 10-Socio-economic status of patients:
Total S.E.Status
No %
Poor 7 35
Lower Middle 7 35
Middle 5 25
Upper Middle 1 5
Rich 0 0
Very Rich 0 0
Graph No.6-Incidence of Socio-economical status of patients:
35% 35%
25%
5%
0% 0%
0%
5%
10%
15%
20%
25%
30%
35%
Poor L.Middle Middle U.Middle Rich Very Rich
Observations
Table No. 11-Incidence of occupation in Amavata patients:
Total Occupation
No %
Manual Laborer 6 30
House Wife 12 60
Student 0 0
Business 0 0
Others 2 10
Graph No.7-Occupation wise distribution of patients:
30%
60%
0% 0%
10%
0%
10%
20%
30%
40%
50%
60%
Laborer House-Wife Student Buisness Others
Observations
Table No. 12-Study of Habit incidence:
Total Habit
No %
Alcohol 0 0
Tobacco 6 30
Smoking 0 0
None 14 70
Graph No. 8- Distribution of patients according to their habits:
0%
30%
0%
70%
0%
10%
20%
30%
40%
50%
60%
70%
Alcohol Tobacco Smoking None
Observations
Table No. 13-Study of patients Prakriti in the study:
Total Prakriti
No %
Vata 0 00
Pitta 0 00
Kapha 0 00
Vata-Pitta 6 30
Pitta-Kapha 6 30
Vata-Kapha 8 40
Sama 0 00
Graph No.9- Prakriti wise distribution of patients:
0% 0% 0%
30% 30%
40%
0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Vata Pitta Kapha V-P V-K P-K Sama
Observations
Table No.14-Incidence of Vikriti:
Total Vikriti
No %
Pravara 1 5
Madhyama 16 80
Avara 3 15
Graph No. 10-Vikruti wise distribution of patients:
5%
80%
15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Pravara Madhyama Avara
Observations
Table No.15-Incidence of Satva in the Study:
Total Satva
No %
Pravara 3 15
Madhyama 14 70
Avara 3 15
Graph No. 11-Percentage of patients according to Satva:
15%
70%
15%
0%
10%
20%
30%
40%
50%
60%
70%
Pravara Madhyama Avara
Observations
Table No.16-Study of Saratah Incidence in the Study:
Total Saratah
No %
Pravara 0 0
Madhyama 19 95
Avara 1 5
Graph No. 12- Percentage of patients according to Sara:
0%
95%
5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pravara Madhyama Avara
Observations
Table No. 17-Study of patients Samhanana in the study:
Total Samhanana
No %
Pravara 1 5
Madhyama 17 85
Avara 2 10
Graph No.13. Percentage of patients according to Samhanana:
5%
85%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Pravara Madhyama Avara
Observations
Table No. 18-Satmya Incidence:
Total Satmya
No %
Pravara 1 5
Madhyama 19 95
Avara 0 0
Graph No. 14- Percentage of patients according to Satmya:
5%
95%
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pravara Madhyama Avara
Observations
Table No. 19- Percentage of patients according to Abhyavaharana Shakti:
Total Ahara-Abhyavaharana Shakti
No %
Pravara 4 20
Madhyama 12 60
Avara 4 20
Graph No. 15-Percentage of patients of different Abhyavaharana Shakti:
20%
60%
20%
0%
10%
20%
30%
40%
50%
60%
Pravara Madhyama Avara
Observations
Table No. 20-Study of Patients Ahara-Jarana Shakti the Study:
Total Ahara-Jarana Shakti
No %
Pravara 4 20
Madhyama 12 60
Avara 4 20
Graph No. 16- Percentage of patients according to Aahara-Jarana Shakti:
20%
60%
20%
0%
10%
20%
30%
40%
50%
60%
Pravara Madhyama Avara
Observations
Table No. 21-Study of patients Vyayama Shakti in the study:
Total Vyayama Shakti
No %
Pravara 2 10
Madhyama 13 65
Avara 5 25
Graph No. 17- Percentage of patients according to Vyayama Shakti:
10%
65%
25%
0%
10%
20%
30%
40%
50%
60%
70%
Pravara Madhyama Avara
Observations
Table No.22-Vaya incidence:
Total Vaya
No %
Bala 0 0
Madhyama 20 100
Vruddha 0 0
Graph No. 18- Percentage of patients according to Vaya:
0%
100%
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baala Madhyama Vruddha
Results
RESULTS
Eranda Paka group
Effect on cardinal signs and symptoms:
The oral administration of Eranda Paka had resulted in remission of all
the cardinal symptoms of Amavata as elaborated in the following paragraph.
Effect on Stabdhata:
Patients treated with Eranda Paka marked remission of the symptom
Stabdhata was recorded. 2.3 was the mean initial score of Stabdhata in 10
patients of Amavata came down to 1.1 after the treatment. The improvement to
the tune of 52% is found to be statistically highly significant (P≤0.001) as shown
in the Table No. 23 and Graph No. 19.
Effect on Sandhi Shoola:
Sandhi Shoola, one of the cardinal symptoms of Amavata relieved by
65% as the initial score of Sandhi Shoola which was 2.3 reduced to 0.8 after the
treatment with Eranda Paka. This improvement when analyzed by the paired ‘t’
test found to the highly significant (P≤0.001). Table No. 23 and Graph No. 19
provides the details.
Effect on Sandhi Shotha:
69% of improvement was observed in the symptom Sandhi Shotha.
1.353 was the initial mean score of Sandhi Shotha recorded in the 10 patients
of Amavata in this group. This was brought down to 0.418 after the
104
Results
administration of Eranda Paka. This improvement after the treatment is found to
be highly significant (P≤0.002) as per the paired ‘t’ test. The detail of the
different statistical values are shown in the Table No. 23 and Graph No. 19.
Effect on tenderness:
1.649 was the mean initial score of tenderness before the treatment in
patients of Eranda Paka group. This initial mean score came down to 0.439
after the treatment. The improvement to the tune of 73% was highly significant
(P≤0.001) as revealed by the paired ‘t’ test. Details of the same are given in the
Table No. 23 and Graph No. 19.
Effect on Crepitation:
Crepitation is another cardinal symptom of Amavata. None of the
patients in this Eranda Paka group presented this symptom. Therefore, the
effect of the Eranda Paka in relieving this symptom could not be assessed.
Details of the same are represented in the Table No. 23 and Graph No. 19.
Effect on general symptoms:
Complete cure of the symptom Jwara was observed in all the patients
treated with Eranda Paka. The initial mean score of Jwara was 0.6, and it
became 0 after the treatment. 91% remission of the symptom Aruchi was
recorded in patients of Amavata. The initial mean score of Aruchi which was 2.2
was reduced to 0.2 after the treatment with Eranda Paka. A minimal mean initial
score of 0.5 was observed in the symptom trit. Complete remission of trit was
recorded after the treatment with Eranda Paka. 76% of the improvement was
105
Results
noted in the symptom Alasya. The initial mean score of 2.10 was reduced to 0.5
after the treatment. Before the institution of the treatment the initial mean score
of the symptom Apaka was 2.3. This came down to 0.2 after the treatment. The
improvement by the treatment recorded was 91%. Marked improvement was
observed in the symptom Angamarda also. The initial mean score of
Angamarda was 2.3 and was reduced by 57% after the treatment. The
symptoms like Angasunata, Raga, Staimitya, Angagourava, Kandu and
Antrakujana was not found in any of the 10 patients studied in this group. The
initial mean score of 1.3 of the symptom Daha was reduced by 92% after the
treatment. The mean score of Daha was 0.1 after the treatment. Complete
remission of the Hrillasa was observed in all the patients treated with Eranda
Paka. The initial mean score of 0.1 came down to 0 after the treatment. The
initial mean score of Chardi was 0.10. Cent percent remission of this symptom
was observed after the treatment. Complete remission of the symptom Anaha
was noted in all the patients. The initial mean score of Anaha, which was 1.0
became zero after the employment of the treatment. 0.5 was the initial mean
score of the symptom Praseka in patients treated with Eranda Paka. The
symptom got completely cured after the treatment. The initial mean score of the
symptom Kukshi Shoola was found to be 0.3. This initial score reached to zero
after the treatment releaving 100% cure. 50% of improvement was observed in
patients complaining of disturbed sleep. The initial mean score of the symptom
Nidralpata was 1.0 and that dropped to 0.5 after the treatment. The details of
106
Results
the effect of the Eranda Paka on different general symptoms of Amavata are
given in the Table No. 24 and Graph No. 20.
Effect on total score of general symptoms:
The mean of the total score of general symptoms showed marked
improvement in these symptoms. Initially before the treatment the total score of
general symptom was 18.6 and was reduced to 3.3 after the administration of
the Eranda Paka. An over all improvement of 82% in general symptoms was
recorded in this group. The improvement after the treatment is also statistically
highly significant (P≤0.001) as revealed by the paired ‘t’ test. The details are
given the Table No. 25 and Graph No. 21.
Effect of Eranda Paka on symptoms of Ama:
Significant improvement was noticed in all the symptoms indicative of
Ama by the administration of Eranda Paka. Bala of the patients was improved
by 64% as suggested by the change in the symptom score to 0.80 after the
treatment from the initial score of 2.20. The symptom Gaurava was not
observed in any patients studied in this group. The initial mean score of Alasya,
which was 2.1 before the treatment dropped down to 0.50 after the treatment.
Thus the treatment showed a reduction of Alasya by 76 %. Complete remission
of the symptom Apaka was recorded in patients of Amavata treated with Eranda
Paka. The initial score before the treatment was 1.10, and which came down to
zero after the treatment. The initial mean score of Nistiva was 0.5, which came
down to zero after the treatment recording complete remission of the symptom.
107
Results
91% of the improvement was recorded in the symptom Aruchi. The initial score
of 2.20 reduced to 0.2 after the treatment with Eranda Paka. Proper bowel habit
was restored after the medication with Eranda Paka in patients of Amavata.
Before the treatment the severity score of Vibanda was 1.1, and it became zero
after the treatment suggesting the complete remission. Impaired taste in the
mouth was reduced by the treatment with Eranda Paka to the tune of 64%. The
mean score of Aruchi was reduced by 2.0 from the initial score of 2.2 before the
treatment. Patients felt more comfortable after the treatment as the severity of
the Klama was reduced by the treatment. 2.2 was the initial score of Klama
before the treatment. This score dropped down to 0.8 following the treatment.
Analysis of the symptoms of the Ama before and after the treatment is
elaborated in the Table No. 26 and Graph No. 22.
Statistical analysis of effect on symptoms of Ama:
Before the treatment the total score of symptoms of Ama was 12.7. After
the treatment with Eranda Paka this reduced to 2.4. The total improvement was
to the tune of 81%. This improvement after the treatment was found to be
statistically highly significant (P≤0.001) as assessed by the paired ‘t’ test. The
details of the same is given in the Table No. 27 and Graph No. 23.
Effect on clinical parameters
Effect on circumference of the limbs:
The circumference of the limbs that was assessed before and after the
treatment showed that there was neither increase nor decrease in the
108
Results
circumference after the medication with Eranda Paka. The details of the same
is given in the Table No. 28.
Effect on the range of joint movement:
Range of joint movement was increased after the treatment with Eranda
Paka in patients of Amavata. Initially an average range of 61.98 degree of joint
movement was recorded. This range of joint movement was increased to
78.864 after the treatment. The paired ‘t’ test revealed that this change after the
treatment was not because of the chance factor. The improvement of joint
movement was highly significant. The details are given in the Table No. 29 and
Graph No. 24.
Effect on foot pressure:
Improvement in the foot pressure was recorded in patients of Eranda
Paka group. Before the treatment the average foot pressure of the patients was
30.4 kgs. And this was increased to 38.95 kgs after the treatment. This marked
change after the treatment was also statistically highly significant according to
the paired ‘t’ test. Table No. 29 and Graph No. 24 shows the detail of the
statistical values.
Effect on hand grip power:
After the treatment with Eranda Paka the hand grip power of the patients
was significantly increased. The average hand grip power before the treatment
was 62.000 mm of hg. After the administration of the Eranda Paka it increased
109
Results
to 85.950 mm of hg. This increase in hand grip power after the treatment was
found to be statistically highly significant (P≤0.001). Table No. 29 and Graph
No. 24 shows the detail.
Effect on general functional capacity:
Treatment with Eranda Paka has shown favorable effect on functional
ability of patients of Amavata. The functional disability score before the
treatment was estimated as1.700. And this score came down to 0.800 recording
an improvement by 52%. Statistical analysis by adapting paired ‘t’ test revealed
that this change after the treatment is highly significant (P≤0.001). Details are
given in the Table No. 29 and Graph No. 24.
Effect on body weight:
The body weight of the patients recorded before and after the treatment
showed marginal change. There was very little increase of body weight by
0.100 kg after the treatment. This change following the treatment is statistically
insignificant (P=0.343) as determined by the paired ‘t’ test. The details are given
in the Table No. 30.
Effect on hematological values
Effect on total leukocyte count:
There was marginal decrease in total leukocyte count after the treatment.
The initial TC was 10345.000 cu.mm and this came down to 8759.000 cu.mm.
after the treatment. The details are shown in the Table No. 31 and Graph
No.25.
110
Results
Effect on differential count of WBC’s:
Minimal change was also observed in the differential count of white blood
corpuscles. The statistical analysis by adapting the paired ‘t’ test revealed that
these changes after the treatment are insignificant. The details are given in the
Table No. 31.
Effect on haemoglobin percentage:
Before the treatment the initial haemoglobin percentage was 10.175
gm%. This was then increased to 10.970 gm% after the treatment. This
increase of hemoglobin by 0.795 gm% is statistically insignificant as shown by
the paired ‘t’ test. The details of the same are shown in the Table No. 31 and
Graph No. 26.
Effect on erythrocyte sedimentation rate:
The erythrocyte sedimentation showed a marginal decrease. Before the
treatment the average ESR in patients of Amavata studied in this group was
82.0 mm at 1st hour. A reduction by 38.400 mm at 1st hour was recorded after
the treatment with Eranda Paka. This decrease in the ESR was also statistically
highly significant (P=0.006). Table No. 31 and Graph No. 27 shows the detail.
Over all effect of treatment in 10 patients of Amavata:
The assessment of the overall effect of the treatment revealed that 40%
of the patients recorded complete remission. 30% of the patients showed major
improvement. And an equal percentage of the patients also responded with
minor improvement. All the patients studied in this Eranda Paka group showed
111
Results
different degrees of remission. The details are given in the Table No. 32 and
Graph No. 28.
From the foregoing observations, it is clear that the patients who are
treated with Eranda Paka have shown favorable response in regards to cardinal
symptoms of Amavata, general symptoms of Amavata, clinical parameters,
hematological investigations and overall effect of the medication. Most of these
improvements are found to be statistically highly significant as per the paired ‘t’
test except the few parameters like circumference of the limbs, body weight.
112
Results
Table No. 23-Effect of Eranda Paka on cardinal symptoms of Amavata:
Mean score Paired ‘t’ test Signs and
symptoms B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
Stabdata 2.3(0.483) 1.1 (0.316) 52 0.632 0.20 6.0 ≤0.001
Sandhi
Shoola 2.3 (0.675) 0.8 (0.422) 65 0.527 0.167 9.00 ≤0.001
Sandhi
Shotha
1.353
(0.574)
0.418
(0.498) 69 0.702 0.222 4.214 ≤0.002
Tenderness 1.649
(0.317)
0.439
(0.277) 73 0.269 0.0849 14.249 ≤0.001
Crepitation 0 0 - - - - -
Graph No. 19-Effect of Eranda Paka on cardinal symptoms of Amavata:
2.3
1.1
2.3
0.8
1.35
0.42
1.65
0.44
0 00
0.5
1
1.5
2
2.5
Stabdata S Shoola S Shotha Tenderness Crepetation
B T A T
Results
Table No. 24-Effect of Eranda Paka on general symptoms of Amavata:
Mean score Symptoms
Initial After treatment
Percentage of
relief.
Jwara 0.600 0.000 100
Aruchi 2.200 0.200 91
Trit 0.500 0.000 100
Alasya 2.100 0.500 76
Apaka 2.300 0.200 91
Angamarda 2.300 1.000 57
Anga Sunata 0 0 0
Daha 1.300 0.1000 92
Raga 0 0 0
Staimitya 0 0 0
Gaurava 0 0 0
Kandu 0 0 0
Hrillasa 0.1000 0.000 100
Chardi 0.1000 0.000 100
Anaha 1.000 0.000 100
Praseka 0.500 0.000 100
Antrakujana 0 0 0
Kukshi Shoola 0.300 0.000 100
Vibanda 1.100 0.000 100
Shrama 2.200 0.800 63
Bahumutra 0.500 0.000 100
Bhrama 0.1000 0.000 100
Hridgraha 0.500 0.000 100
Nidralpata 1.000 0.500 50
Results
Graph No. 20-Improvement in general symptoms recorded in patients
treated with Eranda Paka:
0.60
2.20.2
0.50
2.10.5
2.30.2
2.30.1
1.30.10.1
00.1
01
00.5
00.3
01.1
02.2
0.80.5
00.1
00.5
01
0.5
0 0.5 1 1.5 2 2.5
Jwara
Aruci
Trit
Alasya
Apaka
Angamarda
Daha
Hrillasa
Chardi
Anaha
Praseka
Kuksi sula
Vibandha
Shrama
Bahumutra
Bhrama
Hridgraha
Nidralpata
B T A T
Results
Table No. 25-Overall effect of Eranda Paka on general symptoms of
Amavata:
Mean score Paired ‘t’ test Criteria
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
General
symptoms
18.600
(3.406)
3.300
(2.312) 82 2.946 0.932 16.424 ≤0.001
Graph No. 21-Overall effect of Eranda Paka on general symptoms of
Amavata:
18.6
3.3
0
5
10
15
20
B.T. A.T.
Results
Table No. 26-Effect of Eranda Paka on the symptoms of Ama:
Mean score Symptoms
Initial After treatment Percentage of relief
Balabhramsa 2.200 0.800 64
Gaurava 0 0 -
Alasya 2.100 0.500 76
Apakthi 1.100 0.000 100
Nistiva 0.500 0.000 100
Malasanga 1.100 0.000 100
Aruchi 2.200 0.200 91
Klama 2.200 0.800 64
Graph No. 22-Effect of Eranda Paka on symptoms of Ama:
2.2
0.8
0 0
2.1
0.5
1.1
0
0.5
0
1.1
0
2.2
0.2
2.2
0.8
0
0.5
1
1.5
2
2.5
Scor
e
Bala
bram
sha
Gou
rava
Alas
ya
Apak
ti
Nis
htiva
Mal
asan
ga
Aruc
hi
Klam
a
B T A T
Results
Table No. 27-Overall effect of Eranda Paka on symptoms of Ama:
Mean score Paired ‘t’ test Criteria
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
Symptoms
of Ama
12.700
(2.406)
2.400
(2.221) 81 2.111 0.667 15.431 ≤0.001
Graph No. 23-Effect of Eranda Paka on total symptom score of Ama:
12.7
2.4
02468
101214
Tota
l sco
re
B.T. A.T.
Table No. 28-Effect of Eranda Paka on circumference of limbs:
Mean score Paired ‘t’ test Circumference
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
Arm 24.625
(2.698)
24.625
(2.698) - - - - -
Fore arm 23.425
(2.249)
23.425
(2.249) - - - - -
Thigh 44.700
(4.894)
44.700
(4.894) - - - - -
Leg 32.350
(3.859)
32.350
(3.859) - - - - -
Results
Table No. 29-Effect of Eranda Paka on different clinical parameters:
Mean score Paired ‘t’ test Parameters
B.T.(S.D.±) A.T.(S.D.±)
Difference
in mean S.D.± S.E.± ‘t’ P
Range of
joint
movement
in degrees
61.980
(26.315)
78.864
(37.491) 27.24 14.267 4.512 3.742 =0.005
Foot
pressure in
kgs
30.400
(9.216)
38.950
(9.290) 28 2.640 0.835 10.242 ≤0.001
Hand grip
in mm of hg
62.000
(16.700)
85.950
(22.47) 39 13.475 4.261 5.620 ≤0.001
General
functional
disability
1.700
(0.483)
0.800
(0.632) 52 0.568 0.180 5.014 ≤0.001
Graph No. 24-Effect of Eranda Paka on different clinical parameters:
61.98
78.86
30.4
38.95
62
85.95
1.7 0.80
10
20
30
40
50
60
70
80
90
J motion F pressure H grip F disability
B T A T
Results
Table No. 30-Effect of treatment on body weight of patients of Amavata:
Mean score Paired ‘t’ test Criteria
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
Body
weight
51.000
(11.235)
51.100
(11.140)
0.100 0.316
0.1000 1.000 =0.343
Table No. 31-Effect of Eranda Paka on different hematological values:
Mean score Paired ‘t’ test Investigation
B.T.(S.D.±) A.T.(S.D.±)BT-AT
S.D.± S.E.± ‘t’ P
TC /cu.mm. 10345.000
(1977.857)
8759.000
(1828.882)1586.000 1850.064 585.042 2.711 =0.024
DC-
neutrophils-%
68.800
(7.843)
56.100
(14.594) 12.700 18.343 5.800 2.189 =0.056
Lymphocytes 26.100
(8.020)
36.500
(13.534) -0.400 16.748 5.296 -1.964 =0.081
Eosinophils 4.600
(0.966)
6.100
(2.601) -1.500 2.838 0.898 -1.671 =0.129
Monocytes 0.400
(0.516)
0.700
(0.483) -0.300 0.483 0.153 -1.964 =0.081
Basophils 0.1000
(0.316)
0.000
(0.000) 0.1000 0.316 0.1000 1.000 =0.343
ESR – I hour 82.000
(35.640)
43.600
(28.702) 38.400 34.069 10.774 3.564 =0.006
Haemoglobin 10.175
(1.728)
10.970
(1.259) 0.795 1.362 0.431 1.846 =0.098
Results
Graph No. 25-Effect of Eranda Paka on TLC:
10345
8759
7500
8000
8500
9000
9500
10000
10500
TLC
B T A T
Graph No. 26-Effect of Eranda Paka on Hb%:
10.175
10.97
9.6
9.8
10
10.2
10.4
10.6
10.8
11
Hb%
B T A T
Graph No. 27-Effect of Eranda Paka on ESR:
82
43.6
0
20
40
60
80
100
ESR
B T A T
Results
Table No. 32-Over all effect of treatment in 10 patients of Amavata:
Treatment effect No of patients Percentage
Complete remission 4 40
Major improvement 3 30
Minor improvement 3 30
No change 0 00
Graph No. 28-Over all effect of treatment in 10 patients of Amavata:
40
3030
005
10
15
2025
30
35
40
complete Major Minor No change
Results
Ajamodadi Churna group
Effect on cardinal signs and symptoms:
The oral administration of Ajamodadi Churna has resulted in remission of
all the cardinal symptoms of Amavata as elaborated in the following
paragraphs.
Effect on Stabdhata:
69% of improvement was observed in the symptom Stabdhata. 2.200
was the initial mean score of Stabdata recorded in the 10 patients of Amavata
in this group. This was brought down to 1.000 after the oral administration of
Ajamodadi Churna. This improvement after the treatment is found to be
statistically highly significant (P≤0.002) as per the paired ‘t’ test. The detail of
the different statistical values are shown in the Table No. 33 and in Graph No.
29.
Effect on Sandhi Shoola:
Reduction in the severity of the Sandhi Shoola was noted after the
medication. 2.200was the initial mean score of Sandhi shoola recorded in the
10 patients of Amavata in this group. This symptom score then reduced to
1.200 after the administration of Ajamodadi Churna. This improvement after the
treatment is found to be statistically highly significant (P≤0.001) and is assessed
by the paired ‘t’ test. The related statistical values are depicted in the Table No.
33 and in Graph No. 29.
113
Results
Effect on Sandhi Shotha:
Sandhi Shotha, one of the cardinal symptom of Amavata was relieved by
58% as the initial score of Sandhi Shotha which was 1.377 then reduced to
0.565 after the treatment with Ajamodadi Churna. This improvement when
analyzed by the paired ‘t’ test found to the highly significant (P≤0.001). Table
No. 33 and the Graph No. 29 provides the detail.
Effect on tenderness:
1.884 was the mean initial mean score of tenderness before the
treatment in patients of Ajamodadi Churna group. This initial mean score came
down to 0.897 after the treatment. The improvement to the tune of 52% was
highly significant (P≤0.001) as revealed by the paired ‘t’ test. The related
statistical values are shown in the Table No. 33 and in the Graph No. 29.
Effect on crepitation:
None of the patients in this Ajamodadi Churna group presented with this
symptom. There fore the effect of the Ajamodadi Churna on this symptom could
not be assessed. Table No. 33 and in Graph No. 29 shows the details.
Effect on general symptoms:
Best improvement was observed in all the general symptoms of Amavata
in patients treated with Ajamodadi Churna. Following lines elaborate the exact
percentage of improvement. Marked improvement was observed in the
symptom Angamarda. The initial mean score of Angamarda was 2.3 and then
was reduced by 48% after the treatment. The mean symptom score after the
114
Results
treatment was 1.2. By the administration of Ajamodadi Churna the fever came
down significantly in patients of Amavata. The initial score of Jwara was 0.500
and that came down to 0.1000 after the treatment recording 80% of
improvement. 91% remission of the symptom Aruchi was recorded in patients of
Amavata. The initial mean score of Aruchi which was 1.200 then reduced to
0.1000 after the medication. A minimal mean initial score of 0.5 was observed
in the symptom trit. This score came down to 0.200 after the treatment with
Ajamodadi Churna. This means 60% of improvement in the symptom Aruchi by
the medication. 58% of the improvement was noted in the symptom Alasya. The
initial mean score of 1.900 was reduced to 0.800 after the treatment. Before the
institution of the treatment the initial mean score of the symptom Apaka was
1.400. This came down to 0.2 after the treatment. The improvement by the
treatment recorded was 86%. The symptoms like Angashunata, Raga,
Staimitya, Angagourva, Kandu Hrillasa Chardi and Antrakujana was not found
in any of the 10 patients studied in this group. The initial mean score of 1.100 of
the symptom Daha was reduced by 73% after the treatment. The mean score of
Daha was 0.300 after the treatment. Marked remission of the symptom Anaha
was noted in all the patients. The initial mean score of Anaha, which was 1.100,
became 0.200 after the employment of the treatment indicating 90% of
improvement. 0.400 was the initial mean score of the symptom Praseka in
patients treated with Ajamodadi Churna. This reduced to 0.1000 after the
treatment. Thus an improvement by 75% was recorded by the treatment. The
initial mean score of the symptom Kukshi Shoola was found to be 0.500. This
115
Results
initial score reached to zero after the treatment releaving 100% cure. The initial
mean score of Vibandha was 0.600, and this came down to 0.1000 after the
administration of Ajamodadi Churna. Thus 83% of improvement was recorded
in this symptom. The symptom Shrama was reduced by 55% by the treatment
with Ajamodadi Churna. The initial mean score of Shrama was 2.000 and which
reduced to 0.900 after the treatment. 25% of the improvement was recorded in
the symptom Bahumutra after the treatment. The initial mean score of
Bahumutrata was 0.4 and that came down to 0.3 after the treatment. Complete
remission of the symptom was noted in patients treated with Ajamodadi Churna
in relation to the symptoms, Bhrama and Hridgraha. 57% of improvement was
observed in patients complaining of disturbed sleep. The initial mean score of
the symptom Nidralpata was 0.700 and that dropped to 0.300 after the
treatment. The details of the effect of the Ajamodadi Churna on different
general symptoms of Amavata is given in the Table No. 34 and Graph No. 30.
Total effect on general symptoms:
The study showed that after the administration of the Ajamodadi Churna
marked remission of the symptoms was observed. Initially before the treatment
the total score of general symptom was 15.2 and was reduced to 4.9 after the
administration of the Ajamodadi Churna. An over all improvement of 68% in
general symptoms was recorded in this group. The improvement after the
treatment is also statistically highly significant (P≤0.001) as revealed by the
paired ‘t’ test. The details are given in the Table No. 35 and in Graph No. 31.
116
Results
Effect of Ajamodadi Churna on symptoms of Ama:
Symptoms indicative of Ama showed marked remission by the
administration of Ajamodadi Churna. Bala of the patients was improved by 55%
as suggested by the change in the symptom score to 0.900 after the treatment
from the initial score of 2.000. Significant remission of the symptom Gourava
was seen in patients treated with Ajamodadi Churna. Before the treatment the
symptom score of Gourava was 2.300. This reduced to 1.100 after the
treatment. The initial mean score of Alasya, which was 1.900 before the
treatment dropped down to 0.800after the treatment. Thus the treatment
showed a reduction of Alasya by 57%. Marked remission of the symptom Apaka
was recorded in patients of Amavata treated with Ajamodadi Churna. The initial
score before the treatment was 1.400, and which came down to 0.200 after the
treatment. The initial mean score of Nistiva was 0.400, which came down to
0.1000 after the treatment recording 75% remission of the symptom. 92% of the
improvement was recorded in the symptom Aruchi. The initial score of 1.200
reduced to 0.1000 after the treatment with Ajamodadi Churna. Good restoration
of the bowel habit was recorded after the medication with Ajamodadi Churna in
patients of Amavata. Before the treatment the severity score of Vibandha was
0.600, and it became 0.1000 after the treatment suggesting 83% of remission.
Patients felt more comfortable after the treatment as the severity of the Klama
was reduced by the treatment. 2.100 was the initial score of Klama before the
treatment. This score dropped down to 1.000 following the treatment. Analysis
117
Results
of the symptoms of the Ama before and after the treatment is elaborated in the
Table No. 36 and Graph No. 32.
Statistical analysis of effect on symptoms of Ama:
Before the treatment the total score of symptoms of Ama was 11.9. After
the treatment with Ajamodadi Churna this reduced to 4.3. The total
improvement was to the tune of 64%. This improvement after the treatment was
found to be statistically highly significant (P≤0.001) as assessed by the paired ‘t’
test. The details of the same is given in the Table No. 37 and in Graph No. 33.
Effect on clinical parameters
Effect on circumference of the limbs:
The circumference of the limbs that was assessed before and after the
treatment showed that there was neither increase nor decrease in the
circumference after the medication with Ajamodadi Churna. The details of the
same is given in the Table No. 38.
Effect on the range of joint movement:
Range of joint movement was increased after the treatment with
Ajamodadi Churna in patients of Amavata. Initially an average range of 79.690
degree of joint movement was recorded. This range of joint movement was
increased to 94.200 after the treatment. The paired ‘t’ test revealed that this
change after the treatment was not because of the chance factor. The
improvement of joint movement was highly significant. The details are given in
the Table No. 39 and in Graph No. 34.
118
Results
Effect on foot pressure:
Improvement in the foot pressure was recorded in patients of Ajamodadi
Churna group. Before the treatment the average foot pressure of the patients
was 32.800 kgs. And this was increased to 40.050 kgs after the treatment. This
marked change after the treatment was also statistically highly significant
according to the paired ‘t’ test. Table No. 39 and Graph No. 34 shows the
details of the statistical values.
Effect on hand grip power:
After the treatment with Ajamodadi Churna the hand grip power of the
patients was significantly increased. The average hand grip power before the
treatment was 71.750 mm of hg. After the administration of the Ajamodadi
Churna it increased to 98.500 mm of Hg. This increase in hand grip power after
the treatment was found to be statistically highly significant (P=0.005). The
Table No. 39 and Graph No. 34 shows the details.
Effect on general functional capacity:
Treatment with Ajamodadi Churna has shown favorable effect on
functional ability of patients of Amavata. The functional disability score before
the treatment was estimated as 1.900. And this score came down to 1.000
recording an improvement by 0.90 score. Statistical analysis by adapting paired
‘t’ test revealed that this change after the treatment is highly significant
(P≤0.001). Details are given in the Table No. 39 and in Graph No. 34.
119
Results
Effect on body weight:
The body weight of the patients recorded before and after the treatment
showed minimal change. There was mere an increase of 100 gms in the mean
body weight after the treatment. Also this change is statistically insignificant (P=
0.343) as revealed by paired ‘t’ test. The details are given in the Table No. 40.
Effect on hematological values
Effect on total leukocyte count:
There was marginal decrease in total leukocyte count after the treatment.
The initial TC was 9245.000 cu.mm and this came down to 8425.000 cu.mm
after the treatment. This change is found to be statistically insignificant. Table
No. 41 and the Graph No. 35 show the details.
Effect on differential count of WBC’s:
Minimal change was also observed in the differential count of white blood
corpuscles. The statistical analysis by adapting the paired ‘t’ test revealed that
these changes after the treatment are insignificant.
Effect on haemoglobin percentage:
Before the treatment the initial haemoglobin percentage was 11.00 gm%.
This was then increased to 11.63 gm% after the treatment. This increase of
hemoglobin by 0.625 gm% is statistically insignificant as shown by the paired ‘t’
test. The details of the same is shown in the Table No. 41 and the Graph No.
36.
120
Results
Effect on erythrocyte sedimentation rate:
The erythrocyte sedimentation showed a marginal decrease. Before the
treatment the average ESR in patients of Amavata studied in this group was
40.6 mm 1st hour. A reduction by 18.00 mm was recorded after the treatment
with Ajamodadi Churna. This decrease in the ESR was also statistically highly
significant (P=0.001). Table No. 41 and Graph No. 37 shows the details.
Overall effect of treatment in 10 patients of Amavata:
The assessment of the overall effect of the treatment revealed that 10%
of the patients recorded complete remission. 30% of the patients showed major
improvement. And 60% of the patients responded with minor improvement. All
the patients studied in this Ajamodadi Churna group showed different degrees
of remission.
121
Results
Table No. 33-Effect of Ajamodadi Churna on cardinal symptoms of
Amavata:
Mean score Paired ‘t’ test Signs and
symptoms B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D± S.E± ‘t’ P
Stabdata 2.200
0.422
1.000
0.667 54 0.422 0.133 9.000 ≤0.001
Sandhi
Shoola
2.200
0.422
1.200
0.422 45 0.000 0.000 >1e20 ≤0.001
Sandhi
Shotha
1.377
0.501
0.565
0.399 58 0.173 0.0549 14.795 ≤0.001
Tenderness 1.884
0.299
0.897
0.354 52 0.226 0.0715 13.805 ≤0.001
Crepetation 0 0 - - - - -
Graph No. 29-Effect of Ajamodadi Churna on cardinal symptoms of
Amavata:
2.2
1
2.2
1.2 1.377
0.569
1.884
0.897
0 00
0.5
1
1.5
2
2.5
Sco
re
Stabdata S Sula S Sotha Tenderness Crepetation
B T A T
Results
Table No. 34-Effect of Ajamodadi Churna on general symptoms of
Amavata:
Mean score Symptoms
Initial After treatment Percentage of relief.
Angamarda 2.300 1.200 48
Jwara 0.500 0.1000 80
Aruchi 1.200 0.1000 91
Trit 0.500 0.200 60
Alasya 1.900 0.800 58
Apaka 1.400 0.200 86
Angasunata 0 0 -
Daha 1.100 0.300 73
Raga 0 0 -
Staimitya 0 0 -
Gaurava 0 0 -
Kandu 0 0 -
Hrillasa 0 0 -
Chardi 0 0
Anaha 1.100 0.200 90
Praseka 0.400 0.1000 75
Antrakujana 0 0 -
Kukshi Shoola 0.500 0.000 100
Vibanda 0.600 0.1000 83
Shrama 2.000 0.900 55
Bahumutra 0.400 0.300 25
Bhrama 0.300 0.000 100
Hridgraha 0.300 0.1000 66
Nidralpata 0.700 0.300 57
Results
Graph No. 30-Effect of Ajamodadi Churna on general symptoms of
Amavata:
0.50.1
1.20.1
0.50.2
1.90.8
1.40.2
2.31.2
1.10.3
0000
1.10.2
0.40.1
0.50
0.60.1
20.9
0.40.30.3
00.3
0.10.7
0.3
0 0.5 1 1.5 2 2.5
Jvara
Aruci
Trit
Alasya
Apaka
Angamarda
Daha
Hrillasa
Chardi
Anaha
Praseka
Kuksi sula
Vibandha
Shrama
Bahumutra
Bhrama
Hridgraha
Nidralpata
B T A T
Results
Table No. 35-Total effect of Ajamodadi Churna on general symptoms:
Mean score Paired ‘t’ test Criteria
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
General
symptoms
15.200
(4.022)
4.900
(2.132) 68 4.620 1.461 7.050 ≤0.001
Graph No. 31-Total effect of Ajamodadi Churna on general symptoms of
Amavata. 15.2
4.9
02468
10121416
Sco
re
B.T. A.T.
Results
Table No. 36-Effect of Ajamodadi Churna on symptoms of Ama:
Mean score Symptoms
Initial After treatment
Percentage of relief.
Balabhramsa 2.000 0.900 55
Gaurava 2.300 1.100 52
Alasya 1.900 0.800 57
Apakthi 1.400 0.200 86
Nistiva 0.400 0.1000 75
Malasanga 0.600 0.1000 83
Aruchi 1.200 0.1000 92
Klama 2.100 1.000 52
Graph No. 32-Effect of Ajamodadi Churna on symptoms of Ama:
2
0.9
2.3
1.1
1.9
0.8
1.4
0.20.4
0.1
0.6
0.1
1.2
0.1
2.1
1
0
0.5
1
1.5
2
2.5
Sco
re
Bal
abra
msh
a
Gou
rava
Ala
sya
Apa
kti
Nis
htiv
a
Mal
asan
ga
Aru
chi
Kla
ma
B T A T
Results
Table no. 37-Total effect of Ajamodadi Churna on symptoms of Ama:
Mean score Paired ‘t’ test Criteria
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
Symptoms
of Ama
11.900
(1.524)
4.300
(2.312) 64 2.221 0.702 10.820 P=<0.001
Graph No. 33-Total effect of Ajamodadi Churna on symptoms of Ama:
11.9
4.3
0
2
4
6
8
10
12
Scor
e
B.T. A.T.
Results
Table No. 38-Effect of Ajamodadi Churna on circumference of the limbs:
Mean score Paired ‘t’ test Circumference
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
Arm 26.775
(3.566)
26.775
(3.566) 0 - - - -
Fore arm 24.350
(2.404)
24.350
(2.404) 0 - - - -
Thigh 45.050
(4.036)
45.050
(4.036) 0 - - - -
Leg 31.375
(7.400)
31.375
(7.400) 0 - - - -
Table No. 39-Effect of Ajamodadi Churna on different clinical parameters:
Mean score Paired ‘t’ test Parameters
B.T.(S.D.±) A.T.(S.D.±)
improve
ment S.D.± S.E.± ‘t’ P
Range of joint
movement in
degrees
79.690
(25.072)
94.200
(29.662) -14.510 8.256 2.611 5.558 ≤0.001
Foot pressure
in kgs
32.800
(7.220)
40.050
(7.228) 7.250 3.729 1.179 6.149 ≤0.001
Hand grip in
mm of Hg
71.750
(30.278)
98.500
(40.624) 26.750 23.035 7.284 3.672 =0.005
Functional
disability
1.900
(0.316)
1.000
(0.667) 0.900 0.568 0.180 5.014 ≤0.001
Results
Graph No. 34-Effect of Ajamodadi Churna on different clinical parameters:
79.69
94.2
32.840.05
71.75
98.5
1.9 10
10
20
30
40
50
60
70
80
90
100
Sco
re
J motion F pressure H grip F disability
B T A T
Table No. 40-Effect of Ajamodadi Churna on body weight of patients of
Amavata:
Mean score Paired ‘t’ test Criteria
B.T.(S.D.±) A.T.(S.D.±)BT-AT
S.D.± S.E.± ‘t’ P
Body
weight
55.500
(10.721)
55.400
(10.741) 0.1000 0.316 0.1000 1.000 =0.343
Results
Table No. 41-Effect of Ajamodadi Churna on different hematological
parameters:
Mean score Paired ‘t’ test Investigation
B.T.(S.D.±) A.T.(S.D.±)
% of
relief S.D.± S.E.± ‘t’ P
TC /cu.mm 9245.000
(2472.791)
8425.000
(2085.965) 820.000 1413.074 446.853 1.835 =0.100
DC-
neutrophils-%
63.700
(7.394)
64.900
(5.238) 1.200 5.051 1.597 -0.751 =0.472
Lymphocytes 31.600
(7.106)
30.600
(5.232) 1.000 4.876 1.542 0.649 P=0.533
Eosinophils 4.100
(2.132)
4.800
(2.348) 0.700 2.359 0.746 0.938 P=0.373
Monocytes 0.500
(0.527)
0.600
(0.966) 0.1000 0.876 0.277 -0.361 P=0.726
Basophils 0 0 - - - - -
ESR – I hour 40.600
(15.116)
22.600
(13.794) 18.000 10.995 3.477 5.177 P=<0.001
Haemoglobin 11.000
(0.825)
11.625
(0.981) 0.625 0.835 0.264 2.366 =0.042
Results
Graph No. 35-Effect of Ajamodadi Churna on TLC:
9245
8425
8000
8200
8400
8600
8800
9000
9200
9400
Cel
ls p
er c
ubic
mm
TLC
B T A T
Graph No. 36-Effect of Ajamodadi Churna on Hb%:
11
11.63
10.610.710.810.9
1111.111.211.311.411.511.611.7
gm %
Hb%
B T A T
Graph No. 37-Effect of treatment on ESR: 40.6
22.6
0
5
10
15
20
25
30
35
40
45
mm
afte
r 1st
hou
r
ESR
B T A T
Results
Table No. 42-Overall effect of treatment in 10 patients of Amavata:
Treatment effect No of patients Percentage
Complete remission 1 10
Major improvement 3 30
Minor improvement 6 60
No change 0 00
Graph No. 38-Overall effect of Ajamodadi Churna in patients of Amavata:
10
30
60
00
10
20
30
40
50
60
% o
f pat
ient
s
complete Major Minor No change
Results
COMPARISON
Comparison of effect on cardinal signs and symptoms:
By observing the response to the treatments in both the group it is clear
that both the medicines are effective in relieving the cardinal symptoms of the
Amavata. Comparison of the efficacy of the treatments is detailed in the
following paragraphs.
Effect on the symptom Stabdhata:
The effect of the treatment in both the group on the symptom Stabdhata
appears to be equal. In both the groups the difference in the mean symptom
score before and after the treatment is 1.2. This explains equal efficacy of the
treatment in both the groups. Table No. 43 and Graph No. 39 represents the
same.
Effect on Sandhi Shoola:
The difference in means of Sandhi Shoola score before and after the
treatment in the Eranda Paka group was 1.5 as against1.0 in the Ajamodadi
group. This difference proves the better efficacy of the Eranda Paka in relieving
the symptom Sandhi Shoola in comparison to the relief obtained by the
Ajamodadi Churna. Table No. 43 and Graph No. 39 gives the detail.
Effect on Sandhi Shotha:
Favourable response was obtained in both the groups in regards to
effect of the treatment on the symptom Sandhi Shotha. Also, comparatively a
122
Results
better response was observed in the Eranda Paka group. The difference in
mean symptom scores before and after the treatment was 0.935 in the Eranda
Paka group, and is just higher than the one noted in the Ajamodadi Churna
group. In patients treated with Ajamodadi Churna, the difference in mean
scores before and after the treatment was 0.812. Though the statistical analysis
of the same by adapting the unpaired ‘t’ test does not rule out the chance factor
for such a difference between the groups, the efficacy is marginally better in
Eranda Paka group. Details are given in Table No. 43 and Graph No. 39.
Effect on joint tenderness:
Severity of tenderness was reduced in both the groups after the
treatment. The difference in mean scores before and after the treatment in two
groups when compared reveals that the Eranda Paka is better in relieving the
sign joint tenderness. In the Ajamodadi group the difference in mean scores
before and after the treatment was 0.987, and is lesser than the one noted in
Eranda Paka group. Here in patients treated with Eranda Paka the difference in
mean symptom score before and after the treatment was 1.21. Here also the
difference observed between these groups could be due to chance. Statistically
this difference was insignificant (P=0.060). Table No. 43 and Graph No. 39
show the details.
Joint crepetation another cardinal symptom of the illness was not present
in both the groups.
123
Results
Effect on general symptoms:
In patients treated with Eranda Paka a difference of 15.3 was recorded in
the sum total of different scores of general symptoms before and after the
treatment. The value of the same in the Ajamodadi Churna group was 10.3.
This difference in values states that the oral administration of Eranda Paka is
more efficacious in relieving the general symptoms of Amavata. But the
unpaired ‘t’ test could not prove the statistical significance of the variations seen
between the groups. Table No. 44 and Graph No. 40 represents the same.
Effect on Ama:
Comparison of effects on symptoms of Ama in two groups reveals that,
better improvement was found in patients treated with Eranda Paka. The
variance of symptom score before and after the treatment in Eranda Paka
group was 10.3 and the same in Ajamodadi group was 7.6, confirming the
better efficacy of the Eranda Paka in relieving the symptoms of Ama. The
change observed between the groups was also statistically significant according
to unpaired ‘t’ test. Same is represented in Table No. 45 and in Graph No. 41.
Effect on clinical parameters
Effect on circumference of the limbs:
The circumferences of the arm, fore arm, thigh and legs were noted
before and after the treatment in both the Eranda Paka group as well as
Ajamodadi group. Both the group showed no variation in the circumferences
after the treatment.
124
Results
Effect on the range of joint movement:
In an average the range of joint movement was increased by 16.884
degrees in Eranda Paka group as against the increase by 14.51 degrees in
Ajamodadi group. This implies a better improvement in the range of joint
movements in patients treated with Eranda Paka though the statistical analysis
by adapting the unpaired ‘t’ test does not justify the significance of variation
between the groups. Table No. 46 and Graph No. 42 shows the details.
Effect on foot pressure:
Comparison of effects of treatments on foot pressure indicates that
Eranda Paka has an edge over the Ajamodadi Churna in improving the foot
pressure after the treatment. The difference in the mean foot pressure in the
Eranda Paka group was 8.55 kgs as against 7.25 kgs in Ajamodadi group.
Statistical analysis by unpaired ‘t’ test could not rule out the possibility of
chance factor in causing such a variance between the groups. Table No. 46 and
Graph No. 43 gives the detail.
Effect on hand grip power:
Ajamodadi Churna was found to be more efficacious in improving the
hand grip power in comparison to the Eranda Paka. After the treatment in
Eranda Paka group the increase in the mean hand grip power was 23.95 mm of
Hg as against 26.75 mm of Hg in Ajamodadi Churna group. Of course this
variation between the groups was statistically insignificant (P=0.744). Details
are given in the Table No. 46 and Graph No. 44.
125
Results
Effect on general functional capacity:
The analysis of the functional disability in both the groups showed that
functional capacity of the patients has increased following the treatment. The
functional disability score reduced to the tune of 0.9 in both the groups,
recording no difference in the efficacy of two treatments when compared. Table
No. 46 represents the same.
Effect on body weight:
Marginal improvement in body weight was observed in Eranda Paka
group and marginal decrease in body weight was recorded in Ajamodadi group
after the treatment. However the difference is statistically insignificant
(P=0.174). Table No. 47 and Graph No. 45 provides the details.
Effect on haematological values:
Haematological examinations carried out before and after the treatment
in both the groups showed that there was marginal change in TLC and DC. The
changes also found to be statistically insignificant. Details are in Table No. 48.
Better improvement of Hb% was noted in the Eranda Paka group in
comparison to the Ajamodadi group. The average increase of Hb% following
the medication with Eranda Paka was 0.795 gm%. And the same in Ajamodadi
group was just 0.625 gm%. This explains the Eranda Paka has an edge over
the Ajamodadi Churna in improving the Hb%. The variation noted in the two
groups when compared showed statistically insignificant change (P=0.740).
Table No. 48 and Graph No. 46 shows details.
126
Results
Reduction in the ESR following treatment was recorded in both the
groups. However the Eranda Paka group patients showed a better fall in ESR
level. The average fall in ESR after the treatment with Eranda Paka was 38.4
mm after1st hour, as against 18.0 mm after1st hour in Ajamodadi group. Also
statistical significance of this variation noted could not be confirmed by the
unpaired ‘t’ test. Table No. 48 and Graph No. 47 shows the details.
Over all effect of treatment in 20 patients of Amavata:
Comparison of the overall effects of the treatment in both the groups
reveals that Eranda Paka is more efficacious. Complete remission of the illness
was observed in 40% of the patients in Eranda Paka group as against mere
10% of the patients in Ajamodadi group. 30% of the patients in each group
recorded major improvement. In patients treated with Eranda Paka, 30% of the
patients showed minor improvement as against 60% of patients showing this
response in Ajamodadi Churna group. In both the groups no patients were
observed in the “no change” category. Details of comparison are given in the
Table No. 49 and Graph No. 48.
In a nutshell, almost all the parameters of assessment have shown
improvement in both the groups following treatment. In most of these
assessment criteria the Eranda Paka group has shown a better response in
comparison to the Ajamodadi group. The better improvement in the cardinal
symptoms and general symptoms was also statistically significant where as the
clinical parameters as well as laboratory investigations have shown insignificant
change between the groups.
127
Results
Table No. 43-Comparison of effect of treatments on cardinal symptoms of
Amavata:
Unpaired ‘t’ test Symptoms Group
No. of
patients
BT -
AT
Difference
in mean S.D. S.E.M. ‘t’ P
EP 10 1.2 0.632 0.200 Stabdata
AC 10 1.2 0.000
0.422 0.133 - -
EP 10 1.5 0.527 0.167 Sandhishoola
AC 10 1 0.500
0.000 0.000 3.000 P=0.008
EP 10 0.935 0.702 0.222 Sandhishotha
AC 10 0.812 0.123
0.173 0.0547 0.538 P=0.597*
EP 10 1.21 0.269 0.0851 Tenderness
AC 10 0.987 0.223
0.226 0.0715 2.007 P=0.060*
EP 10 0 - - Crepetation
AC 10 0 -
- - - -
Graph No. 39-Comparison of the effect of treatment on the cardinal
symptom of Amavata:
1.2 1.2
1.5
1
0.9350.812
1.21
0.987
0 00
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Des
iffer
e in
eaor
n sc
Stabdata S Sula S Sotha Tenderness Crepetation
EPAC
mnc
e
Results
Table No. 44-Comparison of effect on general symptoms:
Unpaired ‘t’ test Symptoms
Group No. of
patients
BT-AT Difference
in mean S.D. S.E.M. ‘t’ P
EP 10 15.300 2.946 0.932 General
symptoms AC 10 10.3005.000
4.620 1.461 2.886 P=0.010
Graph No. 40-Comparison of effect of treatment on general symptom in
two groups:
15.3
10.3
02468
10121416
Diff
eren
ce in
mea
n sc
ores
EP AC
Results
Table No. 45-Comparison of effect on symptoms of Ama between the
groups:
Unpaired ‘t’ test Symptoms Group
No. of
patientsBT-AT
Difference
in mean S.D. S.E.M. ‘t’ P
EP 10 10.300 2.111 0.668 Ama
AC 10 7.600 2.700
2.221 0.702 2.786 P = 0.012
Graph No. 41-Comparison of effects on symptoms of Ama in two groups:
15.3
10.3
0
2
4
6
8
10
12
14
16
Diff
eren
ce in
mea
n sc
ores
EP AC
Results
Table No. 46-Comparison of effect on different clinical parameters:
Unpaired ‘t’ test Parameters Group
No. of
patients BT-AT
Difference
in mean S.D. S.E.M. ‘t’ P
EP 10 16.884 14.267 4.512 Range of
joint
movement AC 10 14.51 2.374
8.256 2.611 0.455 P=0.654*
EP 10 8.55 2.640 0.835 Foot
pressure AC 10 7.25 1.300
3.729 1.179 0.900 P=0.380
EP 10 23.95 13.475 4.261 Hand grip
AC 10 26.75 -2.800
23.035 7.284 0.332
P=0.744
EP 10 0.9 0.568 0.180 Functional
capacity AC 10 0.9 0.000
0.568 0.180 - -
Graph No. 42-Comparison of effects on range of joint movement: 16.884
14.51
13
13.5
14
14.5
15
15.5
16
16.5
17
Diff
eren
ce in
rang
e of
jt
mov
emen
t
EP AC
Results
Graph No. 43-Comparison of effects on foot pressure between the groups:
8.55
7.25
6.6
6.8
7
7.2
7.4
7.6
7.8
8
8.2
8.4
8.6
Diff
eren
ce in
foot
pre
ssur
e in
Kg
EP AC
Graph No. 44-Comparison of the effect on hand grip power:
23.95
26.75
22.523
23.524
24.525
25.526
26.527
Diff
eren
ce in
han
d gr
ip p
ower
in
mm
of H
g
EP AC
Results
Table No. 47-Comparison of the effect on body weight in both the groups:
Unpaired ‘t’ test Criteria Group
No. of
patients BT-AT
Difference
in mean S.D. S.E.M. ‘t’ P
EP 10 0.100 0.316 0.1000 Body
weight AC 10 -0.1000 0.200
0.316 0.1000 1.415 P=0.174
Graph No. 45-Comparison of effect on body weight: 0.1
-0.1
-0.1-0.08-0.06-0.04-0.02
00.020.040.060.08
0.1
Diff
eren
ce in
bod
y w
eigh
t in
Kgs
EP AC
Results
Table No. 48-Comparison of effect on different haematological values:
Unpaired ‘t’ test Investigations Group
No. of
patients BT-AT
Difference
in mean S.D. S.E.M. ‘t’ P
EP 10 1586.000 1850.064 585.042 TLC
AC 10 820.000 766.000
5.051 1.597 1.309 P=0.207
EP 10 12.700 18.343 5.800 Neutrophil
AC 10 1.200 11.500
5.051 1.597 1.911 P=0.072
EP 10 10.400 16.748 5.296 Lympthocyte
AC 10 1.000 9.400
4.876 1.542 1.704 P=0.106
EP 10 -1.500 2.838 0.898 Eosinophil
AC 10 0.700 -2.200
2.359 0.746 1.885 P=0.076
EP 10 -0.300 0.483 0.153 Monocyte
AC 10 0.1000 -0.400
0.876 0.277 1.264 P=0.222
EP 10 0.1000 0.316 0.1000 Basophil
AC 10 0 0
- -
EP 10 0.795 1.362 0.431 Hb %
AC 10 0.625 0.170
0.835 0.264 0.337 P=0.740
EP 10 38.400 34.069 10.774 ESR
AC 10 18.000 20.400
10.995 3.477 1.802 P=0.088
Graph No. 46-Comparison of effect on haemoglobin percentage:
0.795
0.625
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Diff
eren
ce in
hem
oglo
bin
perc
enta
ge
EP AC
Results
Graph No. 47-Comparison of effect on erythrocyte sedimentation rate: 38.4
18
0
5
10
15
20
25
30
35
40
Diff
eren
ce in
ES
R in
mm
/1st
ho
ur
EP AC
Table No. 49-Comparison of overall effect of treatment in two groups:
Percentage of patients Treatment effect
Group EP Group AC
Complete remission 40 10
Major improvement 30 30
Minor improvement 30 60
No change 00 00
Graph No. 48-Comparison of overall effect of the treatments in both the groups:
40
10
30 3030
60
0 0
0
10
20
30
40
50
60
Ove
rall
impr
ovem
ent i
n %
Completeremission
Majorimprovement
Minorimprovement
No change
Group EP
Group
Discussion
DISCUSSION
The name of the disease Amavata represents Ama and Vata as the two
predominant pathological factors involved in the Samprapti of the disease.
Vitiated Vata Dosha in association with Ama circulating ubiquitously in the body,
gets lodged in the Sandhi, one among the Kaphasthana producing the
symptoms like Sandhi Stabdata, Sandhi Shoola, Sandhi Shopha and other local
and generalized symptoms. Though the literature related to the disease is
restricted to the mentioning of the word Amavata in Brihatrayi, an elaborate
description is found in Chakradatta and Madhava Nidana. All the diseases
affecting the locomotor system are elaborated under the single name Vatarakta
in Charaka, Sushruta and Vagbhata Samhita. Another distinct clinical entity of
the locomotor system, named as Amavata, and its clear clinical presentation is
given in Madhava Nidana. Acharya Chakradatta has given the full account of
the effective treatment of the same in his best work Chakradatta.
Severely disabling as well as perpetuating nature of the illness is
attributed to the unique pathogenesis of the illness. The specific etiological
factors in the form of unwholesome diet and regimen, causes generation of
Ama, as well as morbidity of the Vata Dosha in the Abhyantara Roga Marga.
Trivial involvement of Pitta and Kapha Dosha is also contended as pathological
factors. Ama along with morbid Vata Dosha circulated in the whole body more
particularly in the Madhyama Roga Marga, and tend to get localized in the joint
producing the typical clinical signs and symptoms. During the course of the
128
Discussion
pathogenesis the morbid Dosha afflicts the Sandhi, and in turn its Dhatu
structure viz. Mamsa, Snayu, Asthi, and Majja. Symptoms related to the joints
like Sandhi Shotha, Stabdhata and Shoola are the initial manifestations. And in
the later stages of the disease deformities like Sandhi Sankocha, Sandhi
Jadhyata and Angavaikalya are the hall marks of the disease. In addition to the
symptoms related to the joints, patients are likely to suffer from certain other
symptoms like Sthaimitya, Dourbalya, Agnimandya, Apaka, Vibanda,
Antrakujana, etc. Needless to say the disease cripples the patients in the long
run.
Amavata in modern parlance:
Rheumatoid arthritis a systemic disease, though it involves the
cardiovascular, nervous respiratory and similar other systems, mainly affects
the locomotor system is analogous to Amavata in terms of Ayurveda. The
effective curative medical management of the illness is doubted by the chronic
lingering nature of the illness as well as the risk of disabling deformities in
patients suffering from rheumatoid arthritis. In spite of continuous extensive
research works for years in this regard, ambiguity about the aetio-pathogenesis
of the illness still persists. Autoimmune mechanism related to the connective
tissue more particularly the sinovium is mostly accepted as the pathology of the
illness. The ambiguity in most aspects of the disease has impeded the
exploration of effective and curative treatment for this dreaded illness.
129
Discussion
The abnormal activity of the immune system is said to be initiated by the
exogenous or endogenous antigens. Probably these antigens are either viral or
bacterial in origin. The presence of these antigens in the body causes the
formation of RA factors and other antibodies. The combined activity of the
antigen and antibody with in the connective tissues including the joint resulting
in the inflammatory changes is the prime pathological event of the rheumatoid
arthritis. This inflammatory response is always destructive. This unique
pathological process of Rheumatoid arthritis is analogous to the Samprapti of
Amavata in many respects as expounded in Ayurvedic literature. Unwholesome
diet and regimen, mostly in the Vairodhika form causes the initiation of the
illness by the production of Ama as well as morbidity of Vata Dosha. Propelled
by the vitiated Vata Dosha the virulent Ama circulates in the body, and tends to
localize in Sandhi. With in the Sandhi, in combination with the Doshas naturally
present in the joint, the Amadosha and vitiated Vata Dosha acquires still more
virulence and thus produces the perpetuating and disabling illness. This typical
sequence of Samprapti may be compared to the aetiopathogenesis of
Rheumatoid arthritis, beginning from the exogenous or endogenous antigens.
Samprapti Vighatana and there by remission or cure of the illness is
achieved by advocating the different therapeutic procedures. Deepana,
Pachana, Shodhana and Shamana are the procedures said to be efficacious in
patients suffering from Amavata. Ama is the one among the predominant
pathological factor in the Samprapti of Amavata, and is initially treated by
Deepana and Pachana. Thus at the outset of the Samprapti Vighatana an
130
Discussion
attempt is made to eliminate the effect of Ama. As the morbid Dosha acquire
the Pakwa stage by these procedures, this renders ideal stage for the
purificatory procedures. Virechana or the Ksharabasti when employed in
patients of Amavata eliminates the excessive accumulation of vitiated Dosha
further causing the remission of the illness. To complete, Shodhana treatment is
followed by Shamana procedure. Based on these principles of treatment the
present study is planned to evaluate the efficacy of Eranda Paka in patients of
Amavata that constitutes both Shodhana and Shamana treatment. A control
group treated with Ajamodadi Churna is also maintained to prove the efficacy of
the Eranda Paka.
Selection of the regimen:
In the present study, the Eranda Paka and Ajamodadi Churna is taken to
treat the patients of Amavata and to explore the efficacy of these in bringing
about cure of the illness.
Pancha Kola Phanta is administered initially for the purpose of achieving
Amapachana. This herbal combination is said to possess Katu rasa, Katu
vipaka and Ushna veerya and therefore likely to render Amapachana in patients
suffering Amavata. More over, Amapachana is considered to be an essential
procedure before administering the Shodhana treatment. With this rationality
Pancha Kola Phanta was opted to bring about Ama Pachana in the present
study.
131
Discussion
In the classics, Eranda Taila is considered as best among the
medications for the Snigdha Virechana. Following the Deepana and Pachana
the elimination of the excessive accumulation of the Dosha is the treatment of
choice. This is made possible by the oral administration of the Eranda Taila in
prescribed dose. For the same purpose this oil is taken for the study in the
present work.
Eranda is a unique herb having both Shodhana as well as Shamana
effect in patients of Amavata. Also, it is claimed that this is the best drug in
Amavata and efficacious in bringing about the cure of the illness. It is argued
that by virtue of the Snigdha property it alleviates the Vata Dosha. Vyadhihara
property of this drug is also contended. Drugs like Pippali, Chitraka, Sati, etc
are efficacious in rectifying the Amadosha. With this idea Eranda Paka is opted
for this study.
Ajamodadi Churna is an herbal combination containing drugs that render
Amapachana as well as alleviate the morbid Vata Dosha. Pippali, Pippali Moola
Chitraka and similar other drugs in Ajamodadi Churna are efficacious in
achieving the Amapachana. In addition to this the drugs like Devadaru, Bilva
moola, etc., are effective in alleviating the Vata Dosha. This is the rationality of
selecting the Ajamodadi Churna for treating the patients of Amavata in this
study.
132
Discussion
Plan of the study:
20 patients suffering from Amavata are taken for the study and all
completed the course of the treatment. The disease is mainly diagnosed on the
basis of signs and symptoms Amavata as mentioned in the Ayurvedic texts,
aided by the A.R.A. criteria (Hollander et al, 1967). RA test was also carried out
to confirm the diagnosis. To assess the general health status of the patients as
well as to rule out other possible pathologies routine haematological and urine
examination was carried out in all the patients. Routine blood examination was
repeated after the course of the treatment.
These 20 patients of Amavata selected for the study are randomly
segregated in to two groups irrespective of age, sex or creed as well as severity
of the illness. In the first Eranda Paka group Deepana Pachana Shodhana and
Shamana treatment is carried out. Deepana and Pachana are achieved by
administering the Pancha Kola Phanta in a dose of 20 ml thrice a day for three
days. This was followed by Kostasodhana for another three days by oral
administration of Eranda taila in a dose of 10 ml in the morning in empty
stomach. For the next one month course of treatment, Eranda Paka was given
orally in a dose of 15 gms thrice a day with warm water after food.
In the second Ajamodadi Churna group also Deepana Pachana
treatment is initially carried out by the oral administration of Pancha Kola
Phanta for first three days in a dose of 20 ml thrice a day.
133
Discussion
This was followed by the Koshta Shodhana by Eranda Taila given orally
in a dose of 10 ml in the morning in empty stomach for the next three days. For
the next 30 days regimen, patients were orally treated with Ajamodadi Churna
in a dose of 5 gms thrice a day with warm water after food.
Descriptive statistical analysis of patients:
In this study involving 20 patients of Amavata showed majority of the
patients belonged to the age group of 50 to 60 years. Though the illness
rheumatoid arthritis is said to be more common during the 3rd and 4th decade of
the life, this study of 20 patients of Amavata being small could not represent this
general observation. 75% of the patients were females among the 20 recorded
in this study. This observation represents the general observation of prevalence
of the illness in females. Majority of the patients were Hindus in the present
series. The religion has nothing to do with the causation of the illness, and the
predominance of Hindus accounting 65% in this study only represent the
population in around Udupi, which is dominated by Hindus. Most of the patients,
females in particular revealed house hold as their occupation, once again
reflecting the usual occupation of females in this area. As per the socio-cultural
status of this geographical area females usually will not have any addiction. In
the present study involving majority of females showed only 30% of the patients
were addicted and is true to the socio-cultural status of the general population
here. Majority of patients accounting 80% were married as against remaining 20
% of the patients who were unmarried. This only represents the adult age group
of the patients that is taken for the study, and further the illness is more
134
Discussion
common in the later decades of adult age group which is also the marriageable
age of general population. More number of poor and lower middle class people
were recorded in this study, and the poor socio-economic status of the patient
has nothing to do with the causation of the illness, more over this incidence only
represents the socio-economic status of the patients in and around Udupi. 45%
of the patients were illiterates, and 35% of the patients had primary education.
Once again education has no role in the predisposition of the illness, and this
only correspond to the educational status of population at large from which the
present sample is selected.
Ekadoshaja Prakriti as well as Sama Prakriti was not observed in any
patients of Amavata. All the patients belonged to the Dvandvaja Prakriti, and in
that 40% of the patients had Pitta Kaphaja Prakriti. It is said that, diseases due
to morbidity of Vata is common in Vata Prakriti people and also such an illness
is severe in them. This nature of the incidence of the illness is not reflected in
this small sample of 20 patients of Amavata. To substantiate the preponderance
of Amavata in patients having Vata Prakriti a study of larger sample is needed.
The study of the degree of the severity of the illness revealed that 80% of the
patients had Madhyama Vikriti. Interrogation of the patients revealed that 70%
of the patients had Madhyama Satva as against 15 % of patients having Avara
Satva. It is understood that, mental tension and anxiety has some role to do
with the severity of the illness, and the present observation in this sample
showing majority of the patients with either Madhyama or Avara Satva bear the
same understanding. Analysis of the Sara in 20 patients of Amavata revealed
135
Discussion
that 95% of the patients had Madhyama Sara and the remaining 5% had Avara
Sara. None of the patients showed the features of the Pravara Sara. In the
pathogenesis of the Amavata it is clear that morbid Vata Dosha is
predominantly involved. And this morbid Vata has a tendency to cause
depletion of the body elements and that may be reason the patients of Amavata
showing Madhyama or Avara Sara in their physique. In addition to this, most of
the patients belonging to the poor or lower middle socioeconomic status in this
study may have poor nutrition. This further affects the Sara of the patients.
Analogous to Sara of the patients, assessment of the Samhanana of the
patients showed the higher incidence of Madhyama Samhanana. 85% of the
patients had Madhyama Samhanana out of 20 patients of Amavata. Morbid
Vata Dosha has a role in reducing the excellency of the Samhanana of the
patients and poor physical activity due to sever joint pain may further contribute
in the same line. Madhyama Satmya was observed in 95% of the patients of
Amavata. Satmya of the patients has direct bearing with the Sara and
Samhanana, predominance of Madhyama Satmya also explains preponderance
of Madhyama Sara as well as Madhyama Samhanana. Assessment of the Agni
was also carried out in all the patients suffering from Amavata. It was observed
that majority of 60% of the patients had Madhyama Abhyavaharana as well as
Madhyama Jarana Shakti. 20% of the patients had Avara Abhyavaharana and
Jarana Shakti. Impairment of the Agni is a common phenomenon of Amavata.
Impaired functioning leads to impaired ability to consume food as well as
reduced digestive ability. The same is reflected in the present sample with a
136
Discussion
minimum 20% of patients showing good functioning of the Agni. Functional
ability of the patients will be affected either due to the Sandhi Shoola or
Stabdata. Physical strength is likely to be reduced as the depletion of the body
element is a regular phenomenon in patients suffering from Amavata.
Corroboratory to this phenomenon, in the present study also majority of the
patients had reduced ability to do the physical exercise.
The therapeutic effect of the treatments in both the groups was assessed
methodically in regards to the salient features of Amavata, general symptoms of
Amavata, symptoms of Ama, functional disability of the patients, degrees of
disease activity and haematological investigations. Overall effect of the
treatments was also analyzed. The results of the treatments in both the groups
are discussed in the following pages.
Therapeutic effect of the treatments:
The signs and symptoms of Amavata, both cardinal and general
symptoms were scored depending upon the degree of severity of these
symptoms, and the same is elaborated in the chapter on clinical study. The
change in these initial scores of the symptoms after the treatment was noted to
know the therapeutic benefit of these treatments.
Effect on the symptom Stabdhata:
The effect of the treatment in both the group on the symptom Stabdhata
appears to be equal. In both the groups the difference in the mean symptom
score before and after the treatment is 1.2. This explains equal efficacy of the
137
Discussion
treatment in both the groups. And the improvement recorded after the treatment
was statistically highly significant.
Effect on Sandhi Shoola:
The difference in means of Sandhi Shoola score before and after the
treatment in the Eranda Paka group was 1.5 as against 1.0 in the Ajamodadi
group. This difference proves the better efficacy of the Eranda Paka in relieving
the symptom Sandhi Shoola in comparison to the relief obtained by the
Ajamodadi Churna.
Effect on Sandhi Shotha:
Favorable response was obtained in both the groups in regards to effect
of the treatment on the symptom Sandhi Shotha. Also, comparatively a better
response was observed in the Eranda Paka group. Though the statistical
analysis of the same by adapting the unpaired ‘t’ test does not rule out the
chance factor for such a difference between the groups, the efficacy is
marginally better in Eranda Paka group.
Effect on joint tenderness:
Severity of tenderness was reduced in both the groups after the
treatment. The difference in mean scores before and after the treatment in two
groups when compared reveals that the Eranda Paka is better in relieving the
joint tenderness. In the Ajamodadi group the difference in mean scores before
and after the treatment was 0.987 and is lesser than the one noted in Eranda
Paka group. Here in patients treated with Eranda Paka the difference in mean
138
Discussion
symptom score before and after the treatment was 1.21. Here also the
difference observed between these groups could be due to chance. Statistically
this difference was insignificant (P = 0.060).
Joint crepitation another cardinal symptom of the illness was not present
in both the groups.
In patients treated with Eranda Paka a difference of 15.3 was recorded in
the sum total of different scores of general symptoms before and after the
treatment. The value of the same in the Ajamodadi Churna group was 10.3.
This difference in values states that the oral administration of Eranda Paka is
more efficacious in relieving the general symptoms of Amavata. But the
unpaired ‘t’ test could not prove the statistical significance of the variations seen
between the groups.
Effect on Ama:
Comparison of effects on symptoms of Ama in two groups reveals that,
better improvement was found in patients treated with Eranda Paka. The
variance of symptom score before and after the treatment in Eranda Paka
group was 10.3. And the same in Ajamodadi group was 7.6, confirming the
better efficacy of the Eranda Paka in relieving the symptoms of Ama. The
change observed between the groups was also statistically significant according
to unpaired ‘t’ test.
139
Discussion
Effect on clinical parameters
Effect on circumference of the limbs:
The circumferences of the arm, fore arm, thigh and legs were noted
before and after the treatment in both the Eranda Paka group as well as in
Ajamodadi churna group. Both the groups showed no variation in the
circumferences after the treatment.
Effect on the range of joint movement:
In an average the range of joint movement was increased by 16.884
degrees in Eranda Paka group as against the increase by 14.51 degrees in
Ajamodadi churna group. This implies a better improvement in the range of joint
movements in patients treated with Eranda Paka though the statistical analysis
by adapting the unpaired ‘t’ test does not justify the significance of variation
between the groups.
Effect on foot pressure:
Comparison of effects of treatments on foot pressure indicates that
Eranda Paka has an edge over the Ajamodadi Churna in improving the foot
pressure after the treatment. The difference in the mean foot pressure in the
Eranda Paka group was 8.55 kgs as against 7.25 kgs in Ajamodadi Churna
group. Statistical analysis by unpaired ‘t’ test could not rule out the possibility of
chance factor in causing such a variance between the groups.
140
Discussion
Effect on hand grip power:
Ajamodadi Churna was found to be more efficacious in improving the
hand grip power in comparison to the Eranda Paka. After the treatment in
Eranda Paka group the increase in the mean hand grip power was 23.95 mm of
Hg as against 26.75 mm of Hg in Ajamodadi Churna group. Of course this
variation between the groups was statistically insignificant (P=0.744).
Effect on general functional capacity:
The analysis of the functional disability in both the groups showed that
functional capacity of the patients has increased following the treatment. The
functional disability score reduced to the tune of 0.9 in both the groups,
recording no difference in the efficacy of two treatments when compared.
Effect on body weight:
Marginal improvement of body weight was observed in the Eranda Paka
group after the medication. Contrary to this marginal decrease in body weight
was recorded in the Ajamodadi group after the treatment. However the
difference noted in these groups when compared, is statistically insignificant
(P=0.174).
Effect on haematological values:
Haematological examinations carried out before and after the treatment
in both the groups showed that there was marginal change in TLC and DC. The
changes were also found to be statistically insignificant.
141
Discussion
Better improvement of haemoglobin % was noted in the Eranda Paka
group in comparison to the Ajamodadi group. The average increase of Hb%
following the medication with Eranda Paka was 0.795 gm%. And the same in
Ajamodadi Churna group was just 0.625 gm%. This explains the Eranda Paka
has an edge over the Ajamodadi Churna in improving the haemoglobin %. The
variation noted in the two groups when compared showed statistically
insignificant change (P=0.740)
Reduction in the ESR following treatment was recorded in both the
groups. However the Eranda Paka group patients showed a better fall in ESR
level. The average fall in ESR after the treatment with Eranda Paka was 38.4
mm after 1st hour, as against 18.0 mm after 1st hour in Ajamodadi Churna
group. Statistical significance of this variation noted could not be confirmed by
the unpaired ‘t’ test.
Over all effect of treatment in 10 patients of Amavata:
Comparison of the overall effects of the treatment in both the groups
reveals that Eranda Paka is more efficacious. Complete remission of the illness
was observed in 40% of the patients in Eranda Paka group as against mere
10% of the patients in Ajamodadi Churna group. 30% of the patients in each
group recorded major improvement. In patients treated with Eranda Paka, 30%
of the patients showed minor improvement as against 60% of patients showing
this response in Ajamodadi Churna group. In both the groups no patients were
observed in the “no change” category.
142
Discussion
From the foregoing it is clear that both Eranda Paka as well as
Ajamodadi Churna are very effective in the patients suffering from Amavata.
The sequential administration of Pancha Kola Phanta, Koshtashodhana by
Eranda Taila and Shamana Chikitsa by Eranda Paka is found to be very
effective in alleviating signs and symptoms of the disease. Eranda is said to be
very effective as Vata Kaphahara and is helpful in the disease Amavata. Eranda
is described as drug of choice in patients of Amavata. The present clinical data
justifies the Vata Kaphahara as well as Vyadhihara effect of the drug Eranda.
The complete or partial remission of the cardinal symptoms of Amavata proves
the Vyadhihara effect of the herb. The alleviation of the symptoms like Shoola,
Antrakujana, Vibandha, etc., explains the Vatahara effect of the Eranda Paka.
Further the alleviation of the symptoms like Agnimandya, Praseka and similar
other symptoms of Kapha Dosha corroborates the Kaphahara effect of the drug.
Ama is one of the predominant pathological factor in Amavata, the alleviation of
the symptoms of Amavata like Balabramsha, Alasya, Apakti, Malasanga etc.,
prove the therapeutic effect of the Eranda Paka as Amapachaka.
Ajamodadi Churna consists of herbs that render Amapachana and that
pacify Vata Kapha Dosha. The herbs like Pippali, Chavya, Chitraka etc., are
said to improve the digestive ability rendering Amapachana. In patients treated
with Ajamodadi Churna, the remission of the symptoms like Apakti, Praseka,
Hrillasa, Chardi, Malasanga etc., prove the efficacy of the drug in alleviating the
Ama. The herbal combination Ajamodadi Churna also contains herbs like
Devadaru that has proven efficacy to pacify Vata Dosha. Reduction in the
143
Discussion
symptom score of Shoola, Stabdata, Sandhi Sankocha, Balakshaya in patients
treated with Ajamodadai Churna as observed in the clinical data justifies the
efficacy of the drug in this regard. Kaphahara effect of the herbal combination is
proved by the remission of the symptoms like Aruchi, Praseka, Hrillasa, Chardi,
etc., in patients treated with Ajamodadi Churna.
The comparison of the two treatments clearly showed that the Eranda
Paka has an edge over the Ajamodadi Churna in the remission of cardinal
symptoms of Amavata, general symptoms of Amavata, symptoms of Ama,
activity of the disease, functional disability, improvement in the laboratory
investigation findings, hand grip and foot pressure, etc. This corroborates the
textual reference in Bhavaprakasa :
Amavata gajendrasya shareeravana charinaha |
Eka eva nihantyaashu eranda taila keshari || (B.P. Madh. Kha. 26/50)
144
Summary and Conclusion
SUMMARY AND CONCLUSION
This dissertation work entitled “A Comparative Study of Erandapaka and
Ajamodadi Churna in the Management of Amavata” comprises of five parts, viz.
Conceptual study, Clinical study, Discussion and Conclusion.
Introduction:
In the first part, brief introduction to the disease Amavata and to
Rheumatoid arthritis in the modern parlance is given.
Conceptual part:
Conceptual the second part includes 3 chapters. The first chapter deals
with a brief historical review of the disease Amavata starting from Vedic period
to this age. Second chapter includes etymology of Amavata, the concepts of
Ama and Vata in Amavata, Nidana, Poorvaroopa, Roopa, Chikitsa, Upadrava
and Sadhyasadhyata. Along with that description of Rheumatoid arthritis is also
given. In the third chapter under the heading drug review, drug compound and
ingredients there in are described.
Clinical study:
The third part titled ‘Clinical study’ where in a detailed description of
materials and methods are given. Subsequently the results obtained were
subjected to statistical analysis and are given in the form of tables and graphs.
145
Summary and Conclusion
Discussion:
The fourth part entitled as ‘discussion’ includes logical interpretation of
results obtained. The conclusion drawn from those are given below:
1. Among the patients studied in this work maximum of 6 patients (30%)
belonged to age group of 50-60 years. Predominance of females (75%),
Hindus (65%) and domestic workers (60%) was observed in this study.
Addiction to tobacco is seen in 30% of patients and a majority of 45% of
illiterates. Most of the patients were married (80%) and dominant part of
the patients were economically poor (35%), lower middle class (35%).
Predominance of patients using mixed diet (80%) was seen.
2. 40% of patients registered in the study belonged to Pittakapha Prakriti.
Dominance of Madhyama Satwa (70%) along with Madhyama Saara
(95%) and Madhyama Samhanana (95%).
3. Majority of patients showed Madhyama Satmya (95%)
4. Regarding Agni Abhyavarana Shakti and Jarana Shakti was Madhyama
in most of the patients (60%)
5. Statistically insignificant improvement was seen on the symptom
Stabdata in both the groups.
6. Highly significant relief in Sandhi Shoola is observed in Eranda Paka
group against Ajamodadi Churna group.
7. Marginally better results were observed in Eranda Paka group in
reducing the Sandhi Shotha and joint tenderness.
8. Joint crepitations were not observed in both group patients
146
Summary and Conclusion
9. Eranda Paka has shown edge over Ajamodadi Churna in reducing the
general symptoms of Amavata.
10. Statistically significant change is obtained in Eranda Paka group in
reducing the symptoms of ama against Ajamodadi Churna group.
11. No change observed in circumference of arm, forearm, thigh and calf in
both groups before and after treatment.
12. The range of movement increased by 16.884 degrees in Eranda Paka
group against Ajamodadi Churna group (16.51 degrees). The difference
was statistically insignificant.
13. Comparatively better improvements in foot pressure test (8.55 kgs)
observed in Eranda Paka group where as in Ajamodadi Churna group
improvement of 7.25 kgs was seen. Chance factor could not be ruled
out. Improvement in hand grip power was observed in Ajamodadi group
but statistical analysis could not rule out chance factor. Efficacy in
improving the general functioning capacity observed is equal in both the
groups. Marginal improvement in body weight in Eranda Paka group
contrary to marginal decrease in body weight in Ajamodadi Churna group
was observed. But the difference is statistically insignificant.
14. Average reduction of E.S.R. was more in Eranda Paka group against
Ajamodadi Churna group (38.4mm in first hour, 18.0mm in first hour
respectively). Marginal change observed in TLC and DC values in both
groups. Better improvement in Hb% noted in Eranda Paka group.
147
Summary and Conclusion
15. Complete remission is observed in 40% patients belonging to Eranda
Paka group and 10% of patients in Ajamodadi Churna group.30% of
patients in each group, recorded major improvement. Where as 30% of
patients in Eranda Paka group showed minor improvement against 60%
of patients in Ajamodadai Churna group.
To brief, the Eranda Paka group patient showed comparatively better
improvement. Eranda Paka found more efficacious in relieving the cardinal
signs and symptoms and general symptoms of Amavata, symptoms of Ama
improvement in functional ability. Deduction in above said signs and symptoms
comparatively less in Ajamodadi Churna group. Hence it can be said as Eranda
Paka has an edge over Ajamodadi Churna in the management of Amavata.
148
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Case Proforma
DEPARTMENT OF KAYACHIKITSA S.D.M. COLLEGE OF AYURVEDA
KUTHPADY, UDUPI
RESEARCH PROFORMA FOR STUDIES ON AMAVATA
Guide: Prof. U. N. Prasad Co-Guide: Dr. Sridhar Holla
Researcher: Dr. Deepak S. M.
Name : Serial No : Age : Group : Sex : M / F OPD No : Religion : H / M / C / O IPD No : Education : UE / P / M / MS / GR / PG DOA : Marital Status : UM / M / D / W DOD : Social Status : VP / P / LM / M / UM / RVR Diagnosis : Occupation : Result : Postal Address :
MAIN COMPLANTS:
OTHER SYMPTOMS
Duration BT AT 1
AT 2
AT 3
AT 4
Jwara Stabdatha Aruchi Mala Bhaddatha Angamarda Sadana Alasya Hrutgraha Anaha Preseka Trushna Hasta-Pada Daha Bahumootrata Kukshi Shoola Chardi Bhrama Shareera Bhara Antrakoojana Kandu
Case Proforma
HISTORY OF PRESENT ILLNESS:
Onset: insidious / gradual / sudden
Sequence of joint involvement:
1……Since……2……Since……3……Since……4……Since……
5……Since……6……Since……7……Since……8……Since……
Course: Progressive / receding / relapsing / stationery
Aggravating factors:
Relieving factors:
Symmetry of joint involvement: 1 2 3 4 5
HISTORY OF PAST ILLNESS:
FAMILY HISTORY: TREATMENT HISTORY:
Drugs Dosage Duration Details NSAID’S STEROIDS OTHERS
PERSONAL HISTORY:
Vyasana: Coffee/Tea…… Alcohol…… Cigarette…… Tobacco Chewing……
Others……
Duration: Since………Occational / Regular / Stopped / Reduced / Continued
Ahara: Veg / Mixed Samasana / Visamasana / Adyasana / Anasana Dominant Rasa - M / A / L / K / T / Ka Dominant Guna – R / S / U / Sh / G / L
Nature of work: Manual /Sedentary / Labour / Traveling / Walking / Studying / Sitting/
Day/Night.
Vishrama: ……Hours Proper / Less / Excessive
Vyayama: No / Proper / Excessive / Irregular
Nidra: Sound / Disturbed Night …… Day ……
Difficulty in falling Asleep / Staying Asleep
Bowel: Frequency ……… Consistency ………… Colour
Micturation: ………Frequency………quantity………
Case Proforma
OBSTETRIC HISTORY:
No. of delivery ……. Normal…… Surgical Intervention……
Abortions …… Miscarriages …… Last Delivery ……
Years Back……
GYNAECOLOGICAL HISTORY:
Menstrual cycle: …… Regular / Irregular / Menarche …… years
Bleeding ….. days Menorrhagia / Metrorrhagia / Dysmenorrhoea / Leucorrhoea
Menopause since……years
GENERAL EXAMINATION: DASHAVIDHA PARIKSHA
Pulse …… / min Prakrutitah:V/P/K/VP/VK/PK/KP/KV/PV/VPK B.P …… mm / Hg Vikrutitah: P / M / A Temperature……F Satwatah: P / M / A Respiratory rate…… / min Saratah: P / M / A Nourishment: G / F / P Satmyatah: P / M / A Built: Samhanatah: P / M / A Nails: Ahara Shaktitah: Abyavaharana: P / M / A Conjunctiva: JaranaShaktitah: P / M / A Sinuses: Vyayama Shaktitah: P / M / A Lymph nodes: Pramanatah: P / M / A Deformities: Height …… cms Contractures: Weight …… Kgs Nodules: Y / N Vayataha; Bala / Madya / Vradha Others: SYSTEMIC EXAMINATION:
CNS : CVS : RS : GUS : P/A :
ASSESSMENT CRITERIA FUNCTIONAL TEST
BT 1 2 3 4 Joint Motion Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt
Flexion Extension Abduction Adduction Lat. Rot.
Shoulder
Medi. Rot. Flexion Elbow Extension Supination Forearm Pronation
Case Proforma
Uln. Devi. Radi. Devi. Flexion
Wrist
Extension Flexion Extension Abduction Adduction Lat. Rot.
Hip
Medi. Rot Extension Knee Flexion Plant. Flex. Ankle Dorsi. Flex. Inversion Foot Eversion
MCP1 Flexion Extension Abduction Adduction
MCP2 Flexion Extension Abduction Adduction
MCP3 Flexion Extension
MCP4 Flexion Extension Abduction Adduction
MCP5 Flexion Extension Abduction Adduction
PIP1 PIP2 PIP3 PIP4 DIP1 DIP2 DIP3 DIP4
Flexion TOE Extension
Spine Flexion Extension Lat. Bend.
Neck
Rotation
Case Proforma
RING TEST BT 1 2 3 4 No.
Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt 1 2 3 4 5
BT 1 2 3 4 TEST
Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Grip Test Foot Pressure Gen. Functions
BT 1 2 3 4 Circumference Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt
Arm Forearm Thigh Calf INVESTIGATION:
Test BT 1 2 3 4 HB% T.L.C D.C / N D.C / L D.C / E D.C / B D.C / M E.S.R RA Factor Others
RADIOLOGICAL EXAMINATIONS: TREATMENT: OBSERVATION:
Pain Swelling Stiffness Tenderness Warmth RednessJoints Du BT 1 2 3 4 Du BT 1 2 3 4 Du BT 1 2 3 4 Du BT 1 2 3 4 Du BT 1 2 3 4 Du BT 1 2 3 4Rt DIP Lt Rt PIP Lt Rt MCP Lt Rt WRI Lt Rt ELB Lt Rt SH Lt Rt DIP Lt Rt PIP Lt Rt MTP Lt Rt ANK Lt Rt KN Lt Rt HIP Lt Rt JAW Lt Rt STC Lt Rt ARC Lt
Spine C/T/L/S
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