katigraha kc002 kop

BY Dr. SARAT. K. BABU

B.A.M.S. (R.G.U.H.S, Bangalore)

Dissertation submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore in partial fulfillment

of the requirements for the degree of “Ayurveda Vachaspati” [M.D.]

in

KAYACHIKITSA

GUIDE CO-GUIDE Dr. Taranikanta Mohanta M.D, Ph.D (Ayu) Jamnagar Prof. Dept. of Kayachikitsa A.L.N.R.M.A.M.C. Koppa

DEPARTMENT OF POST GRADUATE STUDIES IN KAYA CHIKITSA A.L.N.RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE, KOPPA -

577126 CHIKMAGALUR DISTRICT, KARNATAKA, INDIA

MARCH - 2006

Dr. Rashmi Rekha Mishra M.D(Ayu), (U.U) Prof. Dept. of Kayachikitsa A.L.N.R.M.A.M.C. Koppa

Ayurmitra

TAyComprehended

A.L.N.Rao Memorial Ayurvedic Medical College, Koppa – 577126 Dist: Chikmagalur

Department of Post Graduate Studies in KAYA CHIKITSA

Declaration

I here by declare that this dissertation entitled “A Clinical evaluation of

Kativasthi and Nirgundi Erandadi Kashaya in the management of Katigraha”, is a

bonafide and genuine research work carried out by me under the guidance of

Dr.Tarani Kanta Mohanta Department of Post Graduate Studies in Kaya Chikitsa,

A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa.

Date:

Place: Koppa

Dr.Sarat .K. Babu P.G.Scholar,

Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126

Ayurmitra

TAyComprehended



Certificate

This is to certify that the dissertation entitled “A Clinical evaluation of

Kativasthi and Nirgundi Erandadi Kashaya in the management of Katigraha” is a

bonafide research work done by Dr. Sarat .K. Babu in partial fulfillment of the

requirement for the degree of Ayurveda Vachaspati (M.D.) in Kaya Chikitsa, under

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

Date:

Place: Koppa

Guide:Dr. Tarani Kanta Mohanta

M.D. Ph. D (Ayu) Jamnagar Professor, P.G. Studies in Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126



Certificate


Kativasthi and Nirgundi Erandadi Kashaya in the management of Katigraha”is a

bonafide research work done by Dr. Sarat .K. Babu in partial fulfillment of the

requirement for the degree of Ayurveda Vachaspati (M.D.) in Kaya Chikitsa under

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

Date:

Place: Koppa

Co-Guide:Dr. Rashmi Rekha Mishra

M.D (Ayu), U.U Professor, P.G. Studies in Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126



Endorsement


Kativasthi and Nirgundi Erandadi Kashaya in the management of Katigraha” is a

bonafide research work done by Dr. Sarat .K. Babu under the guidance of Dr. Taranikanta Mohanta, Department of Post Graduate Studies in Kaya Chikitsa,

A.L.N. Rao Memorial Ayurvedic Medical College and P.G. Centre, Koppa.

Date:

Place: Koppa

Dr.Jagadeesh Kunjal M.D. (Ayu)

Principal, A.L.N.Rao Memorial Ayurvedic Medical College, Koppa –577126, Dist: Chikmagalur

COPYRIGHT

I here by declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation in print or electronic format for academic/research purpose.

Date:

Place: Koppa

Dr. Sarat .K. Babu

P.G.Scholar, Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126

© Rajiv Gandhi University of Health Sciences, Karnataka

INDEX Titles Page No.

INTRODUCTION 1-6

Chapter - I OBJECTIVES 7

Chapter - II REVIEW OF LITERATURE 8-95

A) Disease review 8-85

Historical review 8-19

Vyutpathi 20

Rachana 21-32

Nidana 33-44

Samprapti 45-51

Poorvaroopa 52

Roopa 53-67

Upashaya, Anupashaya, Sadhyaasadyata 68

Chikitsa 69-82

Pathya apathya 83-85

B) Drug Review 86-95

Chapter - III METHODOLOGY 96-116

A) Materials and Methods 96-103

B) Observations 104-116

Chapter - IV RESULTS 117-134

Chapter - V DISCUSSION 135-156

Chapter - VI CONCLUSION 157-158

SUMMARY 159-160

REFERENCES

BIBLIOGRAPHY

ANNEXURES

Tables

Sl.No: List of Tables Page

No:

1 Hetu of vatavyadhi and katigraha 36 - 42

2 Samprapti Ghatakas of Katigraha 51

3 Pathya - Apathya 83

4 Greenough and Fraser scoring method of pain 102-

103

5 Age wise distribution of 50 patients of Katigraha 104

6 Sex wise distribution of 50 patients of Katigraha 105

7 Religion wise distribution of 50 patients of Katigraha 106

8 Occupation wise distribution of 50 patients of Katigraha 107

9 Distribution of 50 patients of Katigraha according to nature of

occupation 108

10 Marital status wise distribution of 50 patients of Katigraha 109

11 Socioeconomic status wise distribution of 50 patients of

Katigraha

110

12 Dietary pattern of 50 patients of Katigraha 111

13 Family history of 50 patients of Katigraha 112

14 Distribution of 50 patients of Katigraha according to weight 113

15 General nidana observed in 50 patients of katigraha 114

16 Main symptoms observed in 50 patients of katigraha 115

17 Associated symptom observed in 50 patients of katigraha 116

18 Effect of trial drug combination on objective parameters

after treatment of 25 Katigraha patients

117

19 Effect of trial drug combination on objective parameters

after follow up of 25 katigraha patients

118

20 Effect of control drug on objective parameters after

treatment of 25 katigraha patients

120

21 Effect of control drug on objective parameters after follow

up of 25 katigraha patients

121

22 Effect of trial drug combination on subjective parameters

after treatment of 25 katigraha patients

123

23 Effect of Trial drug combination on subjective parameters after Follow up of 25 katigraha patients

124

24 Effect of control drug on subjective parameters after

treatment of 25 katigraha patients

125

25 Effect of control drug on subjective parameters after follow

up of 25 katigraha patients

126

26 Over all efficacy of Trial drug therapy after treatment on 25

Katigraha patients

127

27 Over all efficacy of Trial drug therapy after follow up on 25

Katigraha patients

127

28 Over all efficacy of control drug therapy after treatment on

25 Katigraha patients

128

29 Over all efficacy of control drug therapy after follow up on

25 Katigraha patients

128

30 Comparative effects of therapies on objective parameters

after treatment

129

31 Comparative effects of therapies on objective parameters

after follow up

130

32 Comparative effect of therapies on subjective parameters after treatment

131

33 Comparative effects of therapies on subjective parameters

after follow up

132

34 Comparative effect of over all therapies after treatment 133

35 Comparative effects of over all therapies after follow up 134

Charts and Graphs

Sl.No: List of Charts Page

No:

1 Schematic Representation of samprapti of Katigraha. 50

List of Graphs

1. Age wise distribution of 50 patients of Katigraha. 104

2. Sex wise distribution of 50 patients of Katigraha 105

3. Religion wise distribution of 50 patients of Katigraha 106

4. Occupation wise distribution of 50 patients of Katigraha 107

5. Distribution of 50 patients of Katigraha according to nature of

occupation 108

6. Marital status wise distribution of 50 patients of Katigraha 109

7. Socioeconomic status wise distribution of 50 patients of

Katigraha

110

8. Dietary pattern of 50 patients of Katigraha 111

9. Family history of 50 patients of Katigraha 112

10. Distribution of 50 patients of katigraha according to weight 113

11. General nidana observed in 50 patients of katigraha 114

12. Main symptoms observed in 50 patients of katigraha 115

13. Associated symptom observed in 50 patients of katigraha 116

14. Comparative effects of therapies on objective parameters after treatment

129

15. Comparative effect of therapies on objective parameters

after follow up

130

16. Comparative effects of therapies on subjective parameters after treatment

131

17. Comparative effects of therapies on subjective parameters

after follow up

133

18. Comparative effect of over all therapies after treatment 133

19. Comparative effects of over all therapies after follow up 134

ABBREVIATIONS

A.H.Chi. Ashtanga Hridaya Chikitsasthana.

A.H.Ni. Ashtanga Hridaya Nidanasthana.

A.H.Su Ashtanga Hridaya Suthrasthana.

Amar. Amarakosha.

A.S.Su. Ashtanga Sangraha Sutrasthana.

A.S.Chi. Ashtanga Sangraha Chikitsasthana.

BP Back Pain Reasons and Remedies

BR Bhaishajya Ratnavali

B.P.N. Bhava prakasha Nigantu

Ca.Sa.Chi. Charaka Samhita Chikitsasthana.

Ca.Sa.Ni. Charaka Samhita Nidanasthana.

Ca.Sa.Su. Charaka Samhita Suthrasthana.

Ca.Sa.Si Charaka Siddhi.

Ca.Sa. Vi Charaka samhita vimanasthana

Chau. Ana. Chaurasia Anatomy.

Dalh. Dalhana

Das. Sur. Clinical Surgery by S Das

G. N. Gadanigraha

H. Sa. Hareeta Samhita

Harrison’s. Harisson,s principle of Internal Medicine.

L.B.P.H.P Low back pain hand book

Med. Pharm. Essentials of medical pharmacology.

N.S. Nibandha Sangraha.

P V S. P.V.Sharma.Dravya guna vijnana

S.E.D. Sanskrit English Dictionary.

S.K.D. Sanskrit Kannada Dictionary.

S.E.D.M.W M Sanskrit English Dictionary Monier William.

Sha. Sa. Pra Sharangadhara samhita prathama khanda

Su.Sa.Chi. Sushruta Samhita Nidanasthana.

Su.Sa. Chi. Sushruta Samhita Chikisthana.

Su.Sa. Su. Sushruta Samhita Suthrasthana.

Su.Sa. Sh. Sushruta Samhita Shareerasthana.

Su.Sa. Ka Sushruta Samhita Uttaratantra.

Vg. S. Vangasena Samhita

Vach. Vachaspati

. Y.R Yoga Ratnakara

.

ABSTRACT

Locomotion is one of the prime necessities of every human being. Katigraha is

one of the vatavyadhi, which affects the normal function of the lower limb. Even

though this disease, not being a life threatening one, it hampers daily activity of the

person. It is a neurological as well as musculo-skeletal disorder, cardinal features

being restricted movements of the spine and pain in low back region.

OBJECTIVES

The objectives of the present study are-

To evaluate the therapeutic effect of combined application of Nirgundi

Erandadi kashaya and Kativasthi in bringing symptomatic relief in patients of

Katigraha.

To study the role of Nirgundi Erandadi kashaya and Kativasthi in obtaining

complete relief in patients of Katigraha and its comparison with effect of oral

administration of Diclofenac sodium tablets.

Detailed study of the action of drugs of both groups individually and in

combination.

Detailed study of the disease covering classical and modern literature.

Methodology:

Total 50 patients who fulfilled the inclusion criteria were randomly selected

for the study. The patients were grouped in to two.

* Trial group –

Number of patients – 25

Kativasthi – Katigrahantaka Taila

Duration – 21 days

Oral medicine – Nirgundi erandadi kashaya

Dose – 50 ml B.D. after food


Control group –


Oral medicine – Diclofenac sodium

Dose – 50 mg B.D. after food


Interpretation and results:

At the end of treatment schedule of 21 days, the results were collected and

statistically analyzed. It was found that control group gave highly significant relief

(p<0.001) in the management of symptoms especially pain and tenderness and

signs based on various objective and subjective parameters when compared to trail

group. Further analysis was done after 21 days of follow up. Here the trial group

showed highly significant results (p<0.001) than the control group where even

recurrence of the condition was seen.

Conclusion:

The trial drug combination of Katibasti and Nirgundi Erandadi kashaya

showed high significance in decreasing pain, stiffness and tenderness, which

was noted completely after follow up.

Control drug therapy showed significant result in reducing pain and tenderness

soon after the treatment but recurrence of the condition was seen after the

follow up period. It had a mild result in decreasing the stiffness. Moreover, the

control drug Diclofenac sodium was reported to give various side effects like

gastric irritation on the course of the treatment.

On comparison of both groups after the follow up period, it is found that the

trial drug therapy was more efficient in relieving the signs and symptoms of

katigraha.

ACKNOWLEDGEMENT

I am obliged to my beloved parents and family members for their constant efforts, encouragements

and inspirations through out the work.

On the completion of this thesis work, I extend my sincere gratitude to my revered Guide Dr.

Tarani Kanta Mohanta, M.D, PhD (Ayu), who was the vital and kinetic force of this thesis; with

out his initiation this piece of work would not have been accomplished in stipulated time.

I owe my sincere regards and boundless gratitude to Dr. Rashmi Rekha Mishra M.D (Ayu) my Co-

guide for her constant encouragement and valuable suggestions that inspired me and her vast

treasure of knowledge, which always fascinated me.

I am grateful to Sri. Aroor Ramesh Rao, President, A.L.N. Rao Memorial Ayurvedic Medical

College, Koppa for giving me an opportunity to do my post-graduate studies.

My immense thanks to Dr. Jagadish Kunjal, M.D (Ayu), Principal, A.L.N Rao Memorial

Ayurvedic Medical College, Koppa, for his help and support in completing this work

I am obliged to Dr. Lucas M.D (Ayu), FRAS (Lon), Dept. of Dravya guna for his motivational

inspiration and support.

My sincere gratitude to all my respected teachers in the Dept. of Kaya chikitsa; HOD Prof. P.K

Mishra, MD(Ayu), Dr. Narayana Sharma, M.D(Ayu) and Dr. C.B Singh, M.D(Ayu).

I owe a deep debt of gratitude to my uncle Dr K.B. Sudhikumar and my aunt Dr. Mini

Sudhikumar for their guidance, valuable suggestions and moral support, which kindled my inner

enthusiasm and lead me through out the study.

My special thanks to Padmashree Dr. K. Rajagopal D.A.M, M.B.B.S for his valuable piece of

suggestion, which became the base for my study.

I remain grateful forever to Dr.Shyamalan PhD and my senior Dr.Christy J.T for their complete

guidance in the statistical work.

I am obliged to the respected teachers of Dept. of Rasa shastra and Bhaishajya kalpana; Dr. D.K

Mishra, M.D (Ayu) and Dr. Galib, M.D (Ayu) for their guidance.

My earnest gratitude to the respected teachers of the faculty of Dravya guna; Dr. Sanjaya K.S,

M.D (Ayu) and Dr. Sreedhar, M.D (Ayu) for their extensive help in the study along with Dr. H.R

Pradeep, M.D (Ayu) and Dr. Sathish Sringeri, M.D (Ayu).

I am glad to express my sincere thanks to Dr. Banamali Das, Dept. of Kayachikitsa and Dr.

Rajesh Kumar, M.D (Ayu) from the Dept. of Shalakya.

I will always treasure the guidance and support given by Dr. Rammohan, Dr.Ramesh N.V, Dr.

Lalitha Bhasker, Dr. Sreenivas and Dr. Abhinetri Hegde; Consultant Physicians of Ayurvedic

college hospital for their support during various stages of my work.

No words can explain the gratitude to my friend Shwetha, for her continuous motivation, patient

hearing of my queries and valuable suggestions through out the course of my work.

I will be failing in my duties if I do not express my immense gratitude to my classmates Dr.

Vijayendra, Dr. Prathibha Hullur, Dr. Binu A, Dr.Prashanth B.K, Dr. Roshy, Dr.Vishwanath,

Dr. Krishnakishore, Dr. Sanjeev, Dr. Suja, Dr. Kavitha, and Dr.Pankaj.

It will be reprehensible if I do not extend my gratitude to my seniors Dr. Purushotham K.G, Dr.

Pradeep K.V, Dr. Anil P Varkey, Dr. Clarence, and Dr. Leeladhar for their support.

With immense pleasure, I extend my heart full thanks to my good friends Dr. Ratheesh, Dr. Guru

Prasad, Dr. Dayanand R.D, Dr. Harvin George, with out whose support this thesis work would

not have been complete.

My heart full thanks to my friend Dr. Prabeesh. K, Prabhakara Ayurveda Pharmacy, Kozhikode

for preparing and providing me the medicine for the study.

With amicable gratitude, I thank my friends Dr S. Sooraj, Dr Sreejith Sreekumar, Dr. Vivek

Sanker, and Dr. Saji Sridhar for being my pillars of support through out my study.

My thanks to Dr. Sachin, Dr. Harihara Prasad, Dr. Raghuram, Dr. Susheel Shetty for their

valuable suggestions and moral support.

My special thanks to all PG juniors, House surgeons and others for their constant support.

I would like to express my gratitude to Miss.Amrutha, and Mrs.Jyothsna for their sincere support

in lab investigations.

My sincere thanks to Mrs.Triveni, Miss.Manjula (Librarians), Mrs. Jyothi and other office staffs

and hospital staffs for all kinds of support.

I am grateful to all the patients who became a part of my study.

Finally, I thank all those who helped me directly or indirectly to complete this work and last but

not the least I will always cherish the love and consideration extended by my dear roommates and

colleagues Ravi,, James, Partha, Pradeep, Sandesh for being with me through out.

Date :

Place : Koppa Dr. Sarat .K. Babu

Introduction

INTRODUCTION

Ayurveda the science of life is the natural healing system of India, its tradition going

back to ancient times. Memorized by Brahma, this science was developed and put

forth in action by the great seers and sages who are indeed the gemstones of the great

Indian culture.

The day man appeared in this universe, ailment also emerged along with him. As he

tried to explore the nature, knowingly or unknowingly found something fruitful to his

body and mind from the core of land. Then he tried to analyze it and named it as

knowledge for life. However, this knowledge took long time to develop into a science,

as it had to escape from the fetters of mysticism imposed upon it by long held

fallacious notions on life and its various intricacies. That knowledge is named

Ayurveda; science of life as a whole and medical science in particular, gathered the

cognizance and flourished in centuries. Ayurveda originated as a part of Vedic

science that provides a comprehensive understanding of the entire universe of matter,

mind and consciousness. It reflects healing wisdom of the ancient Saraswati culture

that was one of the cradles of the world civilization. This exquisite piece of wisdom

was inscribed by our great visionaries gifting us the greatest chattels of this

everlasting science of healing- our classics. So it can be considered as a healing gift to

us from the enlightened vedic culture.

As new observations were added to total body of scientific knowledge, theories were

modified and fortified in the light of logical reasoning and based on these

observations it grew. This dynamic aspect of science is perhaps the most outstanding

attribute all science especially to a science of living.

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Introduction

Acharya Caraka says,

“Pareekshaam abhiprashamsanti kushalaah” 1

A constant re-examination or re-evaluation of every theory or fact is therefore, the

very essence of science.

Vata, one among the tripod of human living being is said to be superior most

in all aspects; for every action or movement, strongest in its ability to produce

diseases and worst mortality. Diseases related to Vata are innumerable and

presentation of it is in the whole body. Even though a large number of symptoms

suggest the abnormality of Vata the cardinal symptom of vitiation of this Dosha is

pain which is known as Shula in Sanskrit. This pain is universally understood as a

marker of the disease and it is the most common symptom that makes a person to seek

the physician’s advice.

In a normal daily life, living without ambulation is almost impossible

for any human being, from the time immemorial to ultramodern life. The quote ‘A

man is as strong as his back’ clearly indicates the importance of back and of course it

is the most neglected part in the body. The most common disorder, which affects the

movement of leg particularly in most productive period of life, is low back pain.

Katigraha is one such condition caused by vitiated vayu characterized by pain and

stiffness in the katipradesha. Even though it is not mentioned as a separate disease in

bruhatrayees ample references are found in other texts like Gada Nigraha by Acharya

shodhala and Sharangadhara Samhita. Sharangadhara has included it under the vataja

nanatmaja vyadhis marking its importance.

This problem, that evidently has a favorable natural history even then it can be

remarkably disabling, has challenged health care providers. While, a small percentage

of patients with low back pain accounts for a disproportionate amount of medical and

Page:

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Introduction

economic expenses, the medical system (both conventional as well as complimentary)

often is unable to identify them early. Indeed, patients at high risk for becoming

disabled often receive more diagnostic tests and less focus in medical management

leading to surgical condition as they persist in making complaints. Because such

problems, affects not only the social and economic position of the individual and his

family but also leads to draining of national resource due to work hours lost, resulting

into diminished production.

The importance of back pain in world is underscored by the following:

1) The annual societal cost of back pain in the United States is estimated to be

between $20 and $50 billion.

2) Back symptoms are the most common cause of disability in patients under 45

years of age.

3) 50% of working adults, in one survey, admitted to having a back injury each year

and

4) Approximately 1% of the U.S. population is chronically disabled because of back

pain.2

According to a survey, low back pain is extraordinarily common, and second

only to the common cold with a lifetime prevalence of 60 to 90% and an annual

incidence of 5%.3

As the medical science recognized the severity, a medicament that relieves the pain,

improves the functional ability, restore from functional disability and controls the

condition with cost effectiveness is the need of the century.

Sequential administration of the Snehana, Svedana, Basti, are lines of treatment of

vatavyadhi as expounded in the Ayurvedic literature.4 Apart from these procedures,

the Shamana line of treatment that includes oral administration of medicine is of

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Introduction

utmost importance as the administration is very easy and also effective. Only few of

research works have been carried out in relation to the Shamana treatment. Other than

the therapies mentioned in the classics various other techniques have been developed

by experts later. Kativasthi is one such treatment prescribed for vatavyadhis especially

katigraha, which shows its excellent result in relieving pain and stiffness by its

simultaneous generation of Snehana and Swedana property. Many herbal

combinations are described in Ayurveda and their therapeutic effect in katigraha is yet

to be explored. The oil used, Katigrahantaka Taila, is one such product from the

expert traditional Ayurvedic practioners having an excellent vatahara property owing

to the qualities of the ingredients present. The oral medicine Nirgundi Erandadi

kashaya mentioned in Sahsrayoga too serves the above purpose.

By looking at the individual herbal constituents, it appears that this combination

should be very proficient in combating the Katigraha. However, the proof of the

pudding is in its eating. Therefore, the present research work is planned to evaluate

the relative merit of the trial drug therapy (Kativasthi with Katigrahantaka Taila and

oral administration of Nirgundi Erandadi kashaya) in comparison to Control drug

(Diclofenac Sodium), which is prescribed in regular practice, in the present day. In

this comparative clinical study, patients were selected, placed randomly under two

groups. One group received treatment with Trial drug combination and another with

Control drug.

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Introduction

The present dissertation work entitled - “A Clinical Evaluation of Kativasthi and

Nirgundi Erandadi Kashaya in the Management of Katigraha”consists of following

parts -

* Review of literature

* Clinical study

* Discussion

* Conclusion and Summary

Review of literature comprises of two separate chapters.

. The first chapter is named disease review. The first part of it, where brief description

of the historical aspect of the illness from Vedic era to the present time is being

explored is entitled as Historical review.

The second part of it elaborates the general description of disease

Katigraha. The etymological derivation, etiology, anatomy, clinical manifestations,

pathogenesis, prognosis and general principle of treatment Katigraha/Lowback ache

are discussed here.

The composition of the drug compounds Katigrahantaka Taila and

Nirgundi Erandadi Kashaya is detailed in the second chapter entitled Drug review.

The properties of the individual herbs used in the preparation of the medicinal

compound in brief are also given here.

Clinical study is the topic of second part of the dissertation. The

materials and methods of the present work with complete description of the

assessment criteria are given here. The descriptive statistical analysis of the sample

taken for the study is methodically elaborated. The observations, results and their

statistical analysis are presented in order with tables and graphs.

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Introduction

In the chapter entitled Discussion, the results obtained are critically

analyzed to unravel the truth of efficacy of the combination taken for the study. The

Conclusions drawn from the present clinical research work are detailed in the chapter

Summary and Conclusion.

This clinical study is a sincere effort to add newer combinations of Shamana

treatment with proved efficacy to the list already present. The treatment adopted here

may have some edge over the other combinations prescribed in routine practice, with

this hope; the present work is carried out. It is also hoped that this work will pave new

avenues for enthusiastic research workers to further advance in this field and find a

better cure for this lingering malady. With this noble intention, this work is presented.

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Objectives

OBJECTIVES

The objectives of the present study are-



Katigraha.

To study the role of Nirgundi Erandadi kashaya and Kativasthi in obtaining




combination.


Hypothesis:

1. Null hypothesis - The combination of Kativasthi and Nirgundi Erandadi

Kashaya does not have any action in the treatment of katigraha.

2. Alternate hypothesis - The combination of Kativasthi and Nirgundi

Erandadi Kashaya have good results in the management of katigraha.

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Disease Review

DISEASE REVIEW

HISTORICAL REVIEW:

The knowledge of historical background of any particular disease is essential for

tracking the origin and progressive development of that disease. Information

regarding the disease can be considered complete with the knowledge of its historical

background. Hence, an attempt has been made to trace the references regarding

Vatavyadhi in general and Katigraha in particular beginning right from the Vedic

Period. For the total coverage of historical aspect, it has been divided in to:

I. Vedic period

II. Upanishad and Purana period

III. Samhita period

IV. Sangraha period and others

I. Vedic period

The disorders, which impair the movement of hip and legs, are as old as the

existence of human being as walking is an inevitable function since the existence of

man on the earth to search for the food. Many disorders leading to impairment of

movements of legs are known since Vedic period.

In Vedas, Katigraha is not mentioned in any form. While in Atharva Veda the

word, ‘Vatakrita’ is mentioned. Here ‘Vatakrita’ word denotes Vatavyadhi.

Anukam, Anukyam are the words used in many occasions to denote spine or

back. The word Prushtha has been mentioned in many places in Rig Veda5 and Yajur

Veda6. In Atharva Veda, Vata is addressed not to leave the body but bear the limbs

until the old age7. Prayers saying “keep Ojus in Ooru spread in Jaghana and Prushtha,

which is having the capacity to straight and erect the foot and responsible for

unimpaired organs of the entire body” is also been found in Atharva Veda8.

Page: 8

Disease Review

Another hymn says, “Keep the thigh of the body 100 years, keep the prushtha

healthy for 100 years.9” In addition, the diseases are named involving spine etc. quote

from Atharva Veda says- “I have removed the distressful disease reached through

your legs, knees, pelvis and yoni to the spine from your Ushniha Nadi.10” Spine and

dorso-lumbar spine are named separately by the words Kikasa and Anukam

respectively.11

“Yakshma” a disease condition described in detail in Vedas said to

involve any part of the body including Prushtha, Ooru, Shroni, Asthi, and Majja12,

13,14. In Atharva Veda15 also the association of weakness of Majja and pain legs is

described.

Based on above Vedic descriptions it appears that many varieties of Vata

disorders were prevalent during Vedic period, which impaired the normal bodily

movements, especially those of spine.

II. Upanishad and Puraana period

Upanishads used the term Anukam for spine as similar to that of Vedas. There

are elaborate description of the functions and types of Vata, its locations, qualities etc.

•In Kenopanishad the description given for Vayu as one which is always in

motion and continuing efforts. 16

•Eeshopanishad also described it in a similar fashion.

•Candokyopanishad highlighted the Chala property of Vayu and described its

association with body and movements.17, 18

•Kathopanishad named the word Sushumna for spinal cord, which comes out

piercing the skull.19

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Disease Review

•In Prashnopanishad the anatomy of the spinal cord and its functions are depicted.

According to it, Sushumna is one of the 101 Nadis going upwards. With the help

of this naadi the Udana Vayu moves to and fro from foot and legs to head. 20

Brahmasootra reveals the importance of Vyana Vata as the one that resides in

the joints and responsible for the movements of the joint. The circulation is

considered as the function of Samana.21

In Garuda Purana, health related subjects are described in details. A separate

chapter is available as Vatavyadhi Nidana.22

Paanini has mentioned Vata Kopa as well as Vata Shamana. He has given the

term Vaatiki for disorders of Vata. Sushumna has been described in Harsha

Charita. Sushumna comes out through the lower orifice of Mastishka according to

‘Shankara’ on ‘Taitareeya’.

III. Samhita Period

Caraka Samhita:

Caraka Samhita is the first and foremost treatise that elaborates Vata,

Vatavyadhi at full length. The role of Vata Dosha in health and disease is described in

the first chapter itself. He allotted major part of 12th chapter entitled Vatakalakaleeya

for the description of Vata, its normal functions and both intrinsic and extrinsic

factors for its aggravation. In 17th chapter Kiyantashiraseeya, the two modes of

morbidity of Vata i.e., Chaya and Prakopa as well as different courses of Doshas in

the pathogenesis of disease are described. He has mentioned shula as a symptom of

provoked vata.

In Maharogadhyaaya, the 20th chapter in Sootrasthana, where he enlists nanatmaja

vata vyadhi, though Kati graha has not been mentioned, other symptoms of spinal

disease like Prushtha graha, Trikagraha, pada shula , supti, , etc. are found.

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As he has not given place for Vatavyadhi in Nidana Sthana, he stressed the

importance of Vata in 28th chapter of Chikitsa Sthana. He further described five

varieties of Vata and etiology of its morbidity along with its clinical features. The

description of morbidity of Vata included the different clinical manifestation

according to the site of involvement. The unique pathogenesis of vata vitiation due to

the obstruction to its passage or functioning is elucidated in full detail.

In addition, the elaborate description of treatment of imbalance of Vata in general,

and at specific sites and when the passage is obstructed in particular is also made in

the same context.

This chapter also includes the complete description of certain common Vatavyadhis in

regards its etiology, pathogenesis, general principles of treatment as well as treatment

in particular.

Different references related to Katigraha in charaka samhita :

Ø Prushtha graha, Trika graha is explained as nanatmaja vata vyaadhi23

Ø Kati sangraha as one of the swedya vyaadhi 24

Ø Prushtha, Kati graha as symptom of vrukkaja vidhradhi25

Ø Kati shula as a symptom in Gridhrasi26

Ø Vata vikara of Prushtha due to excess use of Katu rasa27

Ø Different types of pain in Kati and Prushtha in Vataja jwara28

Ø Jangha ooru sadana as Swedana atiyoga29

Ø Trika, Prushtha rogas as a lakshana of Gudagatha Vata30

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Ø TrikaVedana as a lakshana of Pakvashayagata Vata31

Ø Kati Shula, Trika & Prushtha Shula lakshanas of Vataja Arshas32

Sushruta Samhita:

Anatomy was much advanced during Sushruta’s period. He has counted 300

bones and 24 prakaaras of joints in relation to the spine. In Sharira Sthana, Sushruta

has described the structure of Prushtha, Pada and its joints.. He clearly mentioned in

Marma Sharira that trauma on Kukundara Marma leads to sensory and motor loss of

lower limbs and leads to disability (Vaikalyata). In Siravyadha Sharira he described

the position, place and method of Siravyadhana in Vatavyadhi cases.

Sushruta has given much importance by allotting the first chapter of Nidana

Sthana itself for Vatavyadhis. He portrayed some allied conditions like Gridhrasi,

Khanja, Pangu, Kalayakhanja etc. but references for Katigraha are not found. In

Bhagna Nidana chapter he made many original observations pertaining to

Sandhimukta (dislocation or herniation) Kandabhagna (fracture). His description

pertaining to classification, clinical features, prognosis etc, of Sandhimukta suits for

lumbar disc prolapse which is responsible for majority of Low back ache and sciatica

cases.

Sushruta allotted two chapters in Chikitsa Sthaana for treatment for

Vatavyadhis. General therapies of Vata are in Vatavyadhi Adhyaya and the

subsequent chapter, which is named Mahavatavyadhi Chikitsa, is filled with specific

therapeutic measures to be adopted in Gridhrasi, Vatarakta, Pakshaghata etc. In

Chikitsa Sthaana, also he kept the Vata Vyadhi Chikitsa chapter subsequent to

Bhagna Chikitsa chapter, which reflects its relations. The therapies described in

Bhagna Chikitsa also useful in Katigraha cases especially of Abhighataja origin. He

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Disease Review

described traction, manipulation etc, briefly to restore the dislocations which suits to

Katigraha cases also.

He described identical treatment for Gridhrasi, Khanja, Pangu, Vatakantaka,

Padadaha, Padaharsha, Dhamaneegata Vataroga etc, which is Siravyadha along with

general measures of Vataroga. He has mentioned the use of some oral drugs like

Shatdharana yoga, Lavana, Svedana, Nasya, external measures and suitable

environment etc. All these can be adopted in Katigraha also since it is a condition

produced by vitiated vata dosha. Nevertheless, no direct reference for this is found in

Sushruta Samhita.

However, unlike Caraka, Sushruta has not mentioned Kati shula as a symptom of

gridhrasi.

Different references related to Katigraha in Sushruta samhita:

Ø In Pakwashaya gata vata Acharya has included Trika Vedana as a symptom33

Ø Kati Shula is observed as a symptom in Vataja arshas34, vankshanotha vidhradhi35,

bhagna, and in seventh stage of Sarpavisha akshepa36.

Bhela Samhita:

Acharya Bhela has described 45 kasherukas in the Prushtha (back) and 15 in Greeva

(neck). Probably he has counted the discs along with the vertebrae. The description of

Vata its normal and morbid states in Bhela Samhita are almost analogous to Caraka

Samhita in many respects. He has classified Vata vyaadhi into two groups- Sarvanga

and Ekanga vata, all the pain dominating diseases of Kati and Prushtha being enlisted

in Ekanga vata roga. Bhela mentions two types of Prushtha diseases Upakshari and

Kshari.

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Disease Review

Kati shula is observed as a complication of many diseases like vataja kasa. Mandagni

and impeded movement of vata are the main cause of Kati shula. While describing the

Yapana basti he has mentioned it will relieve the pain at Kati.

However, the description of Heenaanga (degeneration?) and Adhikaanga

(osteophytes?) with Vata Rogas is found interesting since they are the causes for Low

back ache.

In 24th chapter of Chikitsa Sthana some general and special measures of Vata hara

chikitsa along with Vatahara Tailas are discussed

Hareeta Samhita:

Hareeta described the etiological factors of Vata Prakopa very elaborately. He

has illustrated the Vata disorders classifying according to five varieties of Vata with

mentioning about 16 diseases for each type. He allotted separate chapters for

Aamavata and Gridhrasi Vata. He cited Prushthastambha and Oorusthambha also as

disorders of Vyana Vata

Kashyapa Samhita:

In Kashyapa Samhita there is no specific chapter for Vata Vyadhi Chikitsa.

However, the general aspects of Vata and its aetiopathogenesis are discussed in

Sutrasthana in similar lines as that of Charaka. Kashyapa observed Asthi and Majja as

sites of Vata which indicate the Prushtha as Vata Sthana the involvement of which

may lead to Katigraha.

According to him, Kati shula is one of the complication occuring due to dushprajata.

He has advised swedana as a treatment for it.

He elaborated the use of Sneha, Sveda, and Vasti. He described the use of Lashuna

elaborately indicating the use in Vatarogas in particular for both prevention and cure

allotting a separate chapter in Kalpa Sthana.

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Disease Review

His description of therapies of Phakka Roga may be useful at the treatment of

severe Katigraha where the movements of limbs are hampered, particularly the

adaptation of Citraradha etc, in alleviating Vata and restoring the walk with the use of

Citraradha.

IV. Sangraha period and others

Ashtanga Sangraha and Hridaya:

Vruddha Vaagbhata illustrated Vata, its physiological and pathological states

correlating the views of both Caraka and Sushruta incorporating his original

observations in his work Ashtanga Sangraha.

He has specifically mentioned that the site of Vata at the lower part of the

body. He has made fundamental observations pertaining to the role of Sheeta and

Ushna Gunas in the etiopathogenesis of Vata resulting in to Chaya, Prakopa and

Prashama.

Vruddha Vagbhata has described the five varieties of Vata more elaborate to

facilitate their application in clinical purposes in Doshabhedeeya chapter of

Sutrasthana and Vata Vyadhi Nidana.

Vruddha Vagbhata has given place for Vata Vyadhis in both Nidana Sthana and

Chikitsa Sthana similar to Sushruta. In Nidana Sthana he detailed individual

etiological factors for vitiation and their clinical features for all the five varieties of

Vata in Vatarakta Nidana chapter.

Even though it is not mentioned specifically, the impaired functions in Katigraha like

Gati, Prasarana, Aakunchana, can be attributed to those by Vyana Vata as per the

citations of Vruddha Vagbhata. Apana Vata also moves in Shroni and Ooru as

connoted by him.

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Both these texts have mentioned about Kati shula in the disease of provoked vata,

seated in pakwaasaya. 37

Kati toda and Kati bheda are mentioned as a poorva roopa of vata rakta.38 Sarvadhatu

avruta vata produces pain in Prushtha and shroni.

Arunadutta:

Arunadutta in his Sarvanga Sundari commentary on Ashtanga Hridaya defines

clearly that due to Vata in Kandara the pain is produced at the time of raising leg

straight and it restricts the movement of thigh. This is an important clinical test now a

day for the diagnosis of sciatica and low back ache known as Straight Leg Raising

Test.

Madhava Nidana:

Madhavakara described Vata Vyadhis in 4 chapters i.e., Vata Vyadhis,

Vatarakta, Oorusthambha and Aamavata, a pattern which had been adopted by many

of his subsequent authors.

He had described Vatavyadhis more elaborately incorporating all the symptoms

described by Charaka, Sushruta and Vagbhata.

He has given detailed description of shula. Vayu is said to be responsible for all types

of pain. Prushtha shula and trika shula are mentioned in the symptoms of vataja

shula. . Prushtha shula has been mentioned as the disease of vata kaphaja

predominance.

The symptom Kati shula manifests in the following diseases-

* Sangraha grahani39

* Vataja arsa40

* Vatanubandhi raktaarsa41

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* Aamavata42

* Aanaha43

Gadanigraha:

Vaidya Shodhala had mentioned at the introduction of Vata Rogadhikara that

Vatavyadhis leads to all other disorders.

This is the only work where Katigraha is explained as a separate disease condition

along with the vatavyadhis. Vaidya Shodhala described Vatavyadhis in four separate

chapters i.e., Vatavyadhi, Vatarakta, Oorusthambha and Aamavata.

A clear description regarding the samprapti, lakshana of Katigraha is explained by the

author in the Kayachikitsa khanda, Vataroga adhikara.44 How ever, it is to be noted

that he has mentioned details of the disease only in the chikitsa adhyaya of

vatarogadhikara along with the treatment of all other vatavyadhis, details of which he

has mentioned in the nidana adhyaya.

In this text treatment part of Katigraha or Katisthambha has been explained at two

places

a) 2nd chapter Prayoga Khanda

b) 19th chapter of Kayachikitsa Khanda

He has described various formulations for Katishula and has specifically indicated

Trayodashanga guggulu for Katigraha.

In the Prayoga Khanda Tailadhikara he has mentioned:

• Chathurtha prasarani tailam and Molaka Tailam for Katisthambha45

• Trutheeya maha masha tailam for various ailments of Kati, Jangha and Janu.46

In addition, he has pointed out the necessity of Raktadushtihara therapies in Vatarogas

when the usual measures have failed to achieve the desired results.

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Disease Review

Sharangdhara Samhita:

This is another treatise where Katigraha is mentioned as a vyadhi. The author has

mentioned Kati graha among the Nanatmaja vata Vyadhis in its Pradhama khanda 7th

chapter.47 Adhamalla in his commentary says that it is a Vedana vishesha (specific

type of pain) due to Sthambha (stiffness).

In addition, the author has mentioned various treatments for katigraha and Katishula

in detail. He has indicated Rasna Sapthakam Kashayam especially for Katigraha

and Eranda Sapthakam kashayam for various ailments of katipradesha.

He has also indicated Ajamodadyam choornam for Ruja in katipradesha.

Bhava Prakasha

In this book, Trika shula has been mentioned as a separate disease. He has

explained trika as a joining place of 2 bones and Prushtha vamsha. Pain in trika is

called trika shulam. In addition, various treatments like valukasweda, agnisweda and

trayodashanga guggulu have been advised in this.

Rasa Ratna Samuchaya

In this treatise of Vagbhata, Kati shula has been mentioned as an invariable symptom

in the context of Aamavata.

Yogaratnakara:

The author has introduced various terms to denote backache like Kati shula,

Kati vata and Kati pida in the asheeti vataroga chikitsa. In addition, he has advised

Erandataila prayoga, and preparations like eranda beeja payasa, Modaka with Taila,

ghruta, ardraka rasa etc. for such conditions.

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Disease Review

Sahasrayogam:

It is compiled by an unknown author or authors containing description of

numerous preparations particularly used traditionally in Kerala. Abundant yogas for

Vata disorders, Gridhrasi and allied conditions can be found in this text. Prominent

among them are:

Sahacaradi Kashayam, Nirgundierandadi kashayam, Ashtavargam Kashayam,

Rasonadi Kashayam, Rasnairandadi Kashayam, Dhanvantaram Tailam, Avartita

Ksheerabala Tailam, Dhanyaamla Avagaha Svedam, Prabhanjanavimardanam

Tailam, Karpasasthyadi Tailam, Panchasneham, Narasimha Choornam etc.

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Disease Review

VYUTPATHI

The word katigraha as it indicates is constituted by two words ‘kati’ and ‘graha’. The

word ‘kati’ is derived from the dhatu “kat + in” and it is considered as a ‘sharira

avayava vishesha’, a bodily part where the dress is tightened.48

The term ‘graha’ is derived from the dhatus ‘Adant-Churam-Atmam-Saka-Set’. The

term is explained as ‘Graho Grahanam’, by Durga das, which means to catch.

Kavikalpadruma has explained it as ‘aadane’, which means to collect or to catch.49

So from these two references it can be derived that the term Katigraha collectively

indicates a condition charecterised by a catch or stiffness in Katipradesha.

PARIBHASHA

The term katigraha is explained by acharya shodhala as a condition characterised by the

vitiated vayu either shuddha or with ama, taking ashraya in the katipradesha causing ruja and

stiffness in the area.

Sharangadhara has explained it as ‘katisthambhena vedana vishesha’ a condition marked by

pain and stiffness in the kati pradesha.50

PARYAAYA

The paryaayas of kati includes:

‘Shroni’ and

‘Kakudbha’, which are indicative if the waist or the pelvis.

Another paatanthara paryaaya is ‘Kankali’.51

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Disease Review

RACHANA SHAREERA

In Katigraham the vitiated Vata get lodges at Katipradesha. Therefore, before going to

the disease aspects, the anatomy and physiology of Kati are to be under stood

properly. In classics we have scattered reference of anatomical and physiological

consideration of Kati. Here an attempt is made to enumerate those structures, which

are helpful in maintaining the stability of the joints.

In Ayurveda, Sandhis are mainly classified into two types; 52

1) Sthira Sandhi

2) Chala Sandhi

Again they are sub classified into eight types.53

1) Kora 5) Tunnasevani

2) Udookala 6) Vayasa tunda

3) Samudga 7) Mandala

4) Pratara 8) Shankhavarta

Acarya Sushruta- father of Surgery considered sandhi in kati under Chala Sandhi

and sub classified under Tunnasevini54.

Other factors, which are to be highlighted in understanding the Sandhi are-

Shleshaka Kapha

Among five variety of Kapha, Shleshaka Kapha resides in joints. It keeps the

joints firmly united, protects their articulation opposes their separation and

disunion55.

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Disease Review

Shleshmadhara Kala

It is the fourth Kala, which is situated in all joints of living beings. As wheel

moves on well by lubricating the axis, joints also function properly if supported with

Kapha. This helps in lubrication of joints56.

Vyana Vata

Vata governs every movement in the body. Vyana Vata is one among the five

varieties of Vata, which resides at Hridaya and controls most of the motor functions.

The Gati or physical movement is also one of its functions.

Gayadasa commenting on Sushruta has quoted the wordings of an unknown

author as though the Vyana Vata is functioning all over the body it resides in the

Sandhi57.

Ahcarya Vagbhata states that Vata is located in the Asthi with relation to

'Ashrayashrayi Sambandha'. Generally, augmentation or diminution of Doshas would

be given similar effect on their respective Dhatus but in case of Vata it is opposite;

with increase in Vata, Asthi Kshaya occurs58.

Sushruta in Sharirasthana explains different structures of the human body.

Among them, structures coming under Katipradesha are listed below.

Snayu

Among nine hundred Snayus, sixty are present in Kati. It may be of Pratana

variety, which is found in all Sandhis.

Importance – As a boat consisting of planks becomes capable of carrying load of

passengers in river after it is tied properly with bundle of ropes, all joints in the body

are tied with many ligaments by which persons are capable of bearing load59.

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Disease Review

Peshi

Those fleshy masses demarcated from each other are known as Peshi. They

are strong structures that help to maintain alignment of the joint60.

Sanghata

Assemblages of bones are fourteen. If trika is considered as shronikaanda

bhaga (lumbosacral joint and sacroiliac joint) one sanghata is being mentioned.61

ANATOMY OF LOW BACK

In this recent period, the allopathic science has developed rapidly. A better

understanding of diseases especially conditions like lumbar disc prolapse, lumbar

spondylosis, lumbar canal stenosis which are now considered commonest causes of

low back ache have been made.

However, in olden days the physician knew the pathology of sciatica. Sciatica has

been recorded since antiquity and is mentioned by Shakespeare. Its association with

backache and spinal deformity was well described by the second half of the 19th

century.

Physicians interested in backache are not inclined to read essay on anatomy, they are

more interested in the bottom line- how do I Treat? However Physicians need an

understanding of anatomy to get to light to appreciate to which element lumbar spine

can be injured and thus become painful to prescribe treatment on rational basis.

1) LUMBAR VERTEBRAE 62

Each lumbar vertebra is divided in to three sets of functional elements.

1) Anterior element - consisting vertebral body

2) The middle elements - consisting of pedicles

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Disease Review

3) Posterior elements - laminae, articular process, spinous process, accessory

process, transverse process, mamillary process.

a) ANTERIOR ELEMENT

These are the essential components of vertebral column endowing it with bulk and

height. They sustain compression loads applied to the vertebral column, including not

only body weight, but also the compression loads imparted by contraction of back

muscles.

b. THE MIDDLE ELEMENTS/ PEDICLES

They are the only connection between the posterior and anterior elements. It transfers

the controlling forces in the posterior to anterior elements.

c. POSTERIOR ELEMENT

Regulates the passive and active forces applied to the vertebral column and

there by control its movements.

i) Articular process provides a locking mechanism that resists forward sliding, and

twisting of the vertebral bodies. The spinous processes, transverse processes,

mamillary processes, and accessory processes provides areas for muscle attachments

and constitute lever that enhances the action of the attached muscles.

ii) The lamina transmits the forces from spinous process and the inferior articular

processes to the pedicles. Thus they are susceptible to injuries such as pars intra

articular fractures.

2) JOINTS

When any two lumbar vertebrae are articulated they form a three joint complex

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Disease Review

called the motion segment. An intra vertebral disc forms the principle between two

vertebral bodies. The other 2 joints are formed by the articulation of superior articular

processes of the vertebra and inferior articular process of the vertebra above. These

are known as zygophyseal/ Apophyseal/ Facet joints.

3) INTRA VERTEBRAL DISCS

Each intra vertebral disc consists of three components.

i) Central gelatinous nucleus pulposus

ii) Surrounding annulus fibrosis

iii) Pair of vertebral end plates

i) CENTRAL GELATINOUS NUCLEUS PULPOSUS

Nucleus consists of a matrix of proteoglycans that bind considerable amount water.

ii) SURROUNDING ANNULUS FIBROSIS

It consists concentric laminae of collagen fibers. In each laminae the fibers are

parallel and oriented 65 degree from the vertical, but the direction of inclination

alternates in successive laminae. The inner fibers of the annular fibrosus envelop the

nucleus pulposus and are attached to the margins of the vertebral end plates. The outer

fibers are attached to the margins of the vertebral bodies and constitute the

ligamentous portion of the annulus fibrosus.

iii) VERTEBRAL END PLATES

These are the cartilaginous substance which covers the superior and inferior surface of

each vertebral body within the area encircled by the ring apophysis. The two end

plates of each disc cover the nucleus pulposus as well as the inner 2/3rd of the annular

fibrosus.

The foremost function of disc is to separate the vertebral bodies so that movements

may occur between the vertebral bodies. The disc must be sufficiently compliant to

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Disease Review

allow movement but sufficiently strong to with stand compression. Compression

between vertebral bodies is fundamentally resisted passively by the sheer bulk of the

annulus fibrosus. The role of nucleus pulposus is to brace the annulus pulposus and

there by braced it is able to with stand the compression loads, and an impairment of

nucleus function compromises the ability of annulus to withstand compression loads

causing it to fail by buckling.

4. ZYGOPHYSEAL JOINTS

These are the typical synovial joints endowed with cartilage, capsule and synovial

membrane. The articular facets exhibit variations in both the shape of their articular

surface and general direction in which they face. Such variations determine the extent

to which joints can prevent forward sheer translations between vertebral bodies and

axial rotations of the inter-body joint. These movements are resulted by the impaction

of interior articular process of the vertebra below. The only movement permitted by

the lumbar zygophyseal joints sliding movement in a vertical direction, which is

executed during flexion and extension of the vertebral column.

5. LIGAMENTS

The role of ligaments of the lumbar spine has been over emphasized. In effect, no

ligaments can stabilize the lumbar spine.

Major ligaments are:

1) Anterior longitudinal ligament

2) Posterior longitudinal ligament

3) Ligamentum flavum

4) Supraspinatum ligament

5) Inter spinous ligament

6) Inter transverse ligament

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Disease Review

7) Ilio lumbar ligament

1) Anterior longitudinal ligament

These are broad, strong fibrous band attached to the anterior surface of all vertebrae.

It decreases in width at the level of disc. It consists of tendons from crus of

diaphragm.

2) Posterior longitudinal ligament

It runs posterior to the body of vertebrae separating it from dural sac. It is loosely

attached and has inter- woven connection with disc. It has only a nominal role in

resisting separation of posterior ends of vertebral bodies during flexion.

3) Ligamentum flavum

It connects laminae and extends laterally to the articular facet. It is thickest in lumbar

region. It assists in restoring the column to correct attitude after flexion position and

may protect disc from injury.

4) Supraspinatum ligament

It joins the tips of the spinous processes of the vertebrae with aid of intra spinous

ligament.

5) Inter spinous ligament

It connects the adjoining spinous processes from their tips to roots.

6) Inter transverse ligament

These are essentially membranes that extend between adjacent transverse processes.

They constitute part of facial system that separates the muscles of the ventral

compartment from the posterior compartment.

7) Ilio lumbar ligament

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Disease Review

Binds Transverse process of L5 to the Ileum. It resists forward sliding, lateral bending

and axial rotation of L5 on sacrum.

6. MUSCLES

Muscles directly control the movement of vertebral column. In relaxed standing

posture almost all muscles are relaxed except slight activity in psoas and abdominus.

a. The psoas major:

It arises from the antero-lateral aspect of the lumbar spine and inserts into the lesser

trochanter of the femur. It is a flexor of the hip. Its fibers run too close to lumbar spine

to exert significant lumbar movement of lumbar vertebra. There fore it cannot flex the

lumbar spine. However, upon contraction as in the exercise of the sit-ups the psoas

exerts immense pressure on the vertebral disc.

b. Quadratus lumborum;

It is wide rectangular muscle that consist a complex aggregation of various oblique

and longitudinally running fibers that connects the lumbar transverse process; the

ileum and the 12th rib. Its main action is fixation of 12th rib during respiration. It has

a weak action to flex the lumbar spine laterally.

While bending forward first 60 degree of movement occurs at lumbar spine and

followed by additional movement, 25 degree at hips and pelvis. Glutei and hamstrings

lock the initial flexion of the pelvis. At the end of flexion, all spinal muscles are

relaxed and the humans are at maximum strain at the movement. Extension of the

back with loads shows increased activity in back muscles.

Intertransversarii Laterales- Connects consecutive transverse process and are

presumed to act synergistically with Quadratus lumborum in lateral flexion of Lumbar

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Disease Review

spine. Lumbar back muscles – Lie behind and cover the posterior elements of

Lumbar vertebrae.

a) Inter transversarii mediales – small muscles that connect the accessory process and

mamillary process of one vertebra to other. They serve as large proprioceptor

transducers.

b) Interspinales – Short muscles that connect the spinous process of adjacent lumbar

vertebrae. They also probably serve a proprioceptive function.

c. Multifidus

The multifidus is para median muscle fascicles that stem from each of the lumbar

spinous process and radiate to caudal insertion on mamillary process and the ileum

and the sacrum. The main action of this muscle is to extend the lumbar spine or

control its flexion, but it also opposes the flexion effect of the abdominal muscles

where they contract to produce rotation of the lumbar spine.

7) NERVE SUPPLY

Vertebral bodies receive the supply from Gray rami communicantes and ventral rami

in the form of anterior and posterior longitudinal (sinu vertebral nerves) plexuses. The

I.V. Disc innervation is provided by rami communicantes anterolaterally and sinu

vertebral nerves posteriorly. The structures posterior to the intervertebral foramen are

supplied by branches of dorsal rami.

8) BLOOD SUPPLY

From Pairs of Lumbar arteries, the upper four of which arise from the descending

aorta, whereas the fifth one arises from median sacral artery.

Vein – the venous drainage of vertebral bodies starts as a subchondral post capillary

plexus beneath each vertebral end plate.

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Disease Review

BIOMECHANICS OF LUMBAR SPINE

The cardinal movements of the lumbar spine are Flexion, Extension, Axial rotation

and lateral Flexion.

*Flexion and Extension

Flexion and Extension involve the combination of sagittal rotation and translation.

During flexion of the lumbar spine, each vertebra rotates and translates anteriorly; a

reciprocal combination occurs in extension. The range of rotation is about 6- 100 per

segment, and the range of translation is about 2mm. Translation is resisted primarily

by zygapophyseal joints and secondarily by annulus fibrosis of vertebral joints.

Rotation is resisted annulus fibrosis, capsules of zygapophyseal joints, ligaments of

IV joints, and most importantly by active or passive tension of back muscles

supplemented by passive tension in the thoracolumbar fascia.

Extension is limited primarily by bony impaction. Either the spinous process impact

against each other or the inferior articular process impacts against the laminae below.

*Axial rotation

Because there are no primary rotators of the lumbar spine, axial rotation is a

movement imposed secondarily on the lumbar vertebrae and their joints.

Rotation is achieved by the oblique abdominal muscles acting on the thorax, the

movements of which impose a screwing effect on the lumbar spine from L1 to the

sacrum.

The motion is resisted by impaction of zygapophyseal joints and by tension developed

in the annulus fibrosus; resistance limits the range of rotation at each lumbar segment

to <30.

*Lateral flexion- Little is known about the lateral flexion of the lumbar spine, which

involves a complex and variable combination of lateral bending and rotatory

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Disease Review

movements of the inter body movements and diverse movements of the

zygapophyseal joints.

MECHANICAL INJURIES

Flexion

Flexion movements of the lumbar spine are not hazardous if the movements remain

strictly in the sagittal plane. The discs and zygapophyseal joints are well designed to

withstand this movement. More over biomechanical studies have failed to

demonstrate injury to the intervertebral disc simply with flexion.

Because the back muscles are the major contributors to controlling or resisting

flexion, in principle, they are foremost liable to injuries during flexion. Acute muscle

tears may occur during forceful flexion or extension; otherwise, however lumbar

spine is intrinsically resistant to injury under these circumstances.

Extension

Several types of injuries may befall the lumbar spine during forceful extension

movements. During forceful extension, movement is initially arrested by the inferior

articular processes against the lamina. This impaction may cause a chiseling effect on

the lamina, resulting in pars inter articular fracture. Otherwise, if lamina resists the

impaction, the continuous extension force is dissipated as posterior rotation of contra

lateral zygapophyseal joint, which may result in disruption of joint capsule.

Flexion and torsion

The lumbar spine is practically vulnerable to injury during flexion movements

combined with torsion. The flexion movements prestress the annulus fibrosis, thereby

reducing its capacity to withstand subsequent axial rotation. Mean while, because the

zygapophyseal joints are subluxated, smaller portions of their surfaces are in contact

to resist rotation.

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Disease Review

Usually axial rotation occurs around an axis through the vertebral body, but the

contralateral zygapophyseal joint soon becomes compressed. Continued torsion

results in rotation about an axis through the compressed joint. The contra lateral joint

moves backwards and the intervertebral disc shears side ways.

The resultant injuries are several. Subchondral fractures may occur on the

compression side as well as overt fractures of the articular process and fractures of

pars inter artiularis.

Compression

Compression injuries of the intervertebral disc may result from excessive axial

loading by gravity or muscle action. Gravitational injuries occur in instances such as a

fall on the buttocks. Muscular injuries may result from severe exertion or pulling.

The critical feature of a compression injury is fracture of the end plate. This does not

hurt and may heal but initiate the process known as internal disc disruption. The

homeostasis of the nucleus pulposus is interfered by an inflammatory response or by

an elusive autoimmune mechanism. The matrix of nucleus pulposus undergoes a

biochemical and biophysical degeneration. It decreases its water binding capacity and

its bracing effect on annulus fibrosus. This leads to subluxation of vertebrae and loss

of disc height resulting in the condition called isolated disc resorption.

Disc resorption becomes painful by chemicals or other mechanical means.

Inflammatory chemicals from the nucleus pulposus may stimulate the endings of

nerve fibers in the outer annulus fibrosus. As fewer and fewer laminae remains to

sustain the normal everyday process applied to the annulus fibrosus, the remaining

intact fibers have to bear an increasingly greater load. The increasing stress on theses

fibers constitutes a mechanical bais of pain from annulus fibrosus.

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Disease Review

NIDANA

The word Nidana is used in Ayurvedic classics in a broad sense. This word is derived

from the Sanskrit Dhaatu ‘Ni’ that carries the meaning—to determine. (Ni—Niscaya deeyate

jnaanam). This word refers to etiopathogenesis of the disease either in general or to the

etiology of illness in particular. From the perspective of treatment, Nidana has utmost

importance as the avoidance of etiological factor forms the first and foremost line of

treatment. This is followed by specific treatment as per etiopathogenesis of the disease.

Nidana in general may be categorized into three groups:

•Asatmendriyaartha samyoga

•Prajnaparadha

•Parinama

In addition, to obtain a vague picture of the factors involved Nidana can be divided

into Samanya & Vishesha Nidana.

The description of Nidana for all the disorders is not uniform in Ayurvedic literature.

In certain diseases, we can find description of both Saamaanya as well as Vishesha Nidana,

but it is restricted to Saamanya Nidana with regard to many other diseases.

Though the etiologies of all the Vatavyadhis are similar, the samprapti & clinical

presentation is unique for each Vatavyadhi, distinguishing them from one another.63

Charaka64 & Bhavaprakasha65 clearly mentions the causative factors of Vatavyadhi;

but in Sushruta samhita, Ashtanga Sangraha & Ashtanga Hrudaya etc. the causes of

vatavyadhi have not been clearly described. However, in these texts the causative factors of

provoked vatadosha are available.66, 67,68,69,70

In Gadanigraha written by Shodhala we can get a clear reference of Katigraha as a

disease along with other vatavyadhis.

Even though Katigraha is not projected as a separate disease in Bruhatrayees, from a

reference by Cakrapani while commenting on Caraka Nidana 8/40, it may be diagnosed as a

separate disease. He says that ‘any symptom may manifest as a separate disease also’.

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Disease Review

However, in these references also an exclusive Nidana for Katigraha cannot be found.

From the Adhishtana and lakshana of Katigraha we can make out that the condition is

precipitated by vatadosha. So the Nidana factors for Vatavyaadhi in general can be considered

as the Nidana of Katigraha. Moreover, Asthi being the dhaatu involved in the pathogenesis,

Nidana for Asthivaha and Purishavaha srotodushti may act as Nidanas for Katigraha.

In addition to these Caraka and Vagbhata has mentioned Dhatukshaya and

Margavarodha to be the root cause of all the Vatavyadhis.71, 72, 73

Therefore, all the etiological factors of Vatavyadhi as well as Vata Prakopa are taken

as Nidana of Katigraha and the same is elaborated in the following subtitles.

A) Aaharaja (dietetic factors)

B) Viharaja (behavior factors)

C) Aagantuja (external factors) and

D) Anya Hetuja (miscellaneous factors)

A) Aaharaja: The causative dietetic factors included under this group have been again

subdivided into the following 8 groups.

i. Dravyatah: In this group, all the dietetic articles responsible for Vata Prakopa have

been included.

ii. Gunatah: This group include the quality of dietetic articles like Rooksha, Sheeta etc.

which lead to the Prakopa of Vata

iii. Rasatah: The various tastes of the dietetic articles, the excessive use of which lead to

the Prakopa of Vata have been included in this group.

iv. Karmatah: Excessive use of Visht’hambhi article may lead to the Prakopa of Vata and

it has been included under this heading.

v. Veeryatah: For instance, the Sheeta Veerya articles cause the Prakopa of Vata.

vi. Matratah: Less eating or fasting comes under this heading.

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vii. Kalatah: The Vata Prakopa occurs at the end of digestion. Eating before digestion of

the previous meal also leads to Vata Prakopa. In addition, it has been observed that

the backache is precipitated by cold exposure.

viii. Mithyopayogatah : The violation of the rules like not to drink water when hungry or

not to eat when thirsty also lead to Vata Prakopa.

ix. Desha swaroopa:

Jangala desha is also an etiological factor for backache. Most of the etiological

factors said above are the etiological factors of vataja shula. Pakwashaya is the main

seat of vata. The purisadhara kala also serves the function of asthidhara kala. Hence,

the factors of purisa vaha sroto duśti are worth mentioning here. The purisha

vegarodha, ati bhojana, ajirna and durbala agni are the causes for purisa vaha sroto

duśti.

B) Viharaja: The causative factors related to the habit and regimen of the patient has been

subdivided into two groups’ viz. I. Karmatah, II. Kalatah.

I. Karmatah: Such habits of (a) Kayatah (somatic) and (b) Manah (psychic) which lead to

the Prakopa of Vayu have been included under this heading.

a) Kayatah: The etiological factors of Vata related with the body have been further

subdivided into the following sub-groups.

(1) Mithyaprayogatah: The faulty habits of the body or improper use of body which

may lead to the Prakopa of Vaayu have been included under this heading.

(2) Atiyogatah: The excessive uses of the Karmendriyas or the parts of the body,

which cause Prakopa of the Vayu, have been included under this heading.

b) Manah: The psychic factors responsible for Vata Prakopa have been included under this

heading.

II. Kalatah: The periodic factors responsible for Vata Prakopa have been included under this

heading.

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Disease Review

C) Aagantuja:

External factors like trauma leading to Vata Prakopa have been under this heading.

D) Anya Hetuja:

All other causatives factors of the Prakopa of Vata, which could not be included in

any of above classification, have been presented under this heading. The details of the

causative factors are enlisted in table no.1.

In general, by the activity of the etiological factors the addition of the qualities similar to the

one present in the Vata Dosha causes its morbidity. As per this principle it is clear that the

factors mentioned in the above list cause imbalance of Vata Dosha. So also these factors may

cause the illness Katigraha, as this diseases is regarded as one of the Vatavyadhi.

• Hetu (Etiological factors) of Vata Prakopa and

Vata Vyadhi so also Katigraha

Table No. 1:

Causes Ca. Su. A.S. A.H. B.P

(A) AAHARAJA (Dietetic causes)

I. Dravyatah (Substantial)

Aadhaki (Cajanus cajan) - + - - -

Bisa (Nelumbuo nucifera) - + + - -

Chanaka (Cicer arietinum) - - + - -

Chirbhata (Cuccumus melo) - - + - -

Harenu (Pisum sativum) - + - - -

Jaambava (Eugenia jambolena) - - + - -

Kalaya (Lathyrus sativus) - + + - -

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Kalinga (Holarrhena antidysenterica) - - + - -

Kariya (Capparis decidua) - - + - -

Koradusha (Paspalum scrobiculatum) - + - - -

Masoora (Lens culinaris) - + - - -

Mudga (Phaseolus mungo) - + - - -

Nishpaava (Dolichos lablab) - + - - -

Neevara (Hygroryza aristata) - + - - -

Shaluka (Nelumbium speciosum) - - + - -

Shushkashaaka (Dry vegetable) + - - -

Shyaamaka (Setaria italica) - + - - -

Tinduka (Diospyros tomentosa) - - + - -

Trunadhaanya (Grassy grain) - - + - -

Tumba (Lagenaria valgaris) - - + - -

Uddalaka (A variety of Paspalum

scrobiculatum) - + - - -

Varaka (Carthamus tinctorius) - + - - -

Viroodhaka (Germinated Seed) - - + - -

II. Gunatah

Rukshanna (ununctous diet) + + + + +

Laghvanna (light diet) - + + - +

Gurvanna (heavy diet) - - + + -

Sheetaanna (cold diet) + - + - -

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Disease Review

III. Rasatah

Kashaayaanna (astringent taste) - + + + +

Katvanna (acrid taste) - + + + +

Tiktaanna (Bitter taste) - + + + +

IV. Karmatah

Vishthambhi (constipative diet) - - + - -

V. Veeryatah

Sheeta (cold) - - - - -

VI. Maatratah

Abhojana (fasting) + + - - +

Alpaashana (dieting) + - + + -

Vishmaashana (Taking unequal food) - + - - -

VII. Kaalatah

Adhyashana (eating before digestion of

previous meal) - + - - -

Jeernanta (After digestion) - + + + +

Pramitashana (Taking food in improper time) - - + + +

(B) VIHAARAJA (Behaviour)

I. Karmatah

1. Mithyayogatah

Ashmabhramana (Whirling stone) - - + - -

Ashmachalana (Shaking of stone) - - + - -

Ashmavikshepa (Throwing of stone) - - + - -

Ashmotkshepa (pulling down stone) - - + - -

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Balavat vigraha (wrestling with superior

healthy one) - + + - -

Damyagaja nigraha (subduing untameable

elephant) cow and horse - - + - -

Divaasvapna (day sleep) + + - - -

Dukhaasana (uncomfortable sitting) + - - - -

Dukhashayya (uncomfortable sleeping) + - - - -

Ghadhotsadana (strong rubbing) - - + - -

Kashtabhramana (whirling of wood) - - + - -

Kashtachalana (shaking of wood) - - + - -

Kashta vikshepa (throwing of wood) - - + - -

Kashtotkshepa (pulling down wood) - - + - -

Lohabhramana (whirling of metal) - - + - -

Lohachalana (Shaking of metal) - - + - -

Lohavikshepa (Throwing of metal) - - + - -

Lohotkshepa (Pulling down metal) - - + - -

Paragatana (Strike with others) - - + - -

Shilabhramana (Whirling of rock) - - + - -

Shilachalana (Shaking of rock) - - + - -

Shilavikshepa (Throwing of rock) - - + - -

Shilotkshepa(Pulling down rock) - - + - -

Bhaaraharana (Head loading) - + + - -

Vegadharana (Voluntary suppression of

natural urges) + + + + +

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Disease Review

Vegodeerana (Forceful drive of natural urges) - - + + -

Vishamopachara (Abnormal gestures) + - - - -

2. Atiyogatah

Atigamana (excessive walking) + - + - -

Atihaasya (Loud laughing) - + + + -

Atijrumbha (Loud yawning) - + - - -

Atikharacapakarshana (Violent stretching

of the bow) - - + + -

Atilanghana (Leaping over ditch) + + + - -

Atiplavana (Excessive bounding) + + - - -

Atiprabhaashana (Continuous talking) - - + + -

Atipradhaavana (Excessive running) + + - - -

Atiprajaagarana (Excessive awakening) + + + + +

Atiprapatana (Leaping from height) - + - - -

Atiprapeedana (Violent pressing blow) - + - - -

Atipratarana (Excessive swimming) - + + - -

Atiraktamokshana (Excessive Blood letting) - - - - +

Atisrama (over exertion) - - - - +

Atisthaana (standing for a long period) - + - - -

Ativyaayaama (Violent exercise) + + + + +

Ativyavaaya (excessive sexual intercourse) + + + + +

Atiadhyayana (excessive study) - + + - -

Adyaasana (sitting for a long period) - + - - -

Atyuccabhaashana (speaking loudly) - - - + -

Gajaaticarya (excessive riding on elephant) - - + + -

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Kriyaatiyoga (excessive purification therapy) - - + + +

Paadaaticarya (walking long distances) - + - - -

Rathaticarya (excessive riding on chariot) - + - - -

Turan’gaaticarya (excessive riding on horse) - + - - -

II. Manah

Bhaya (fear) + - + + +

Chinta (worry) + - + - -

Krodha (Anger) + - - - -

Mada (Intoxication) - - - - +

Shoka (Grief) + - + + +

Utkantha (Anxiety) - - + - -

III. Kalatah

Abhra (cloudy season) - + - - -

Aparaahnna (evening) - + + + +

Apararatra (the end of the night) - - + + -

Greeshma (summer season) - - + + -

Pravata (windy day) - + + - -

Shishira (winter) - - - - +

Sheetakaala (early winter) - + - - +

Varsha (rainy season) - + + - +

(C) AAGANTUJA

Abhighata (trauma) + - - - -

Gaja, Ushtra, Ashvasrnghrayanapatamsana

(Falling from speedy, running elephant,

camel and horse) + - - - -

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Disease Review

(D) ANYA HETUJA

Aama (undigested article) + - - - +

Asruk kshaya (loss of blood) + + + - -

Dhaatukshaya (loss of body elements) + - - - -

Doshakshaya (depletion of dosha) + - - - -

Rogaatikarshana (emaciation due to disease) + - - - -

Gadakruta mamskshaya (wasting due to

disease) - - - - +

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Disease Review

CAUSES OF LOW BACK ACHE The causes of lowback ache can be classified in following way:

A) Reasons in the Back

B) Reasons other than Back

A) In the back

Congenital causes – Spina Bifida, Spondylolisthesis, Hemivertebra, Split vertebra,

Abnormality in the articular process, Sacralisation of the transverse process of the 5th

lumbar vertebra.

Traumatic causes – Lumbosacral strain, injuries to intervertebral joints, ligaments

and muscles, spondylolisthesis, compression fracture, vertebral process fracture and

ruptured disc.

Functional defects – Anteroposterior imbalance (pregnancy, potbelly, fixed flexion

deformity of the hip joints) and lateral imbalance (scoliosis, leg length discrepancy).

Inflammatory causes – Pyogenic osteomyelitis, Tuberculosis, Rheumatoid arthritis,

brucellosis, ankylosing spondylitis, Myositis, fibrositis.

Degenerative causes – Osteo arthritis(Spondylosis), Senile osteoporosis,

Degenerative disc disease.

Neoplastic causes

Primary tumours e.g. multiple myeloma, eosinophilic granuloma, haemangioma,

Osteoid osteoma.

Metastatic tumours from breast, bronchus, kidney, supra renal, prostate, thyroid,

gastro intestinal tract.

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Disease Review

C) Reasons other than Back

Abdominal Disorders e.g. pancreatitis, cholecystitis, biliary calculus, peptic

ulcer, hiatus hernia.

Pelvic Disorders e.g. inflammatory condition of the ovaries and tubes, any intra

pelvic tumour.

Genito urinary causes e.g. renal infection, renal or ureteric calculus, prostatitis,

prostatic carcinoma, seminal vesiculitis.

Vascular disorders e.g. ischemic pain from occlusion of the aorta or iliac arteries

and aneurismal dilatation of the aorta may cause backache.

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Disease Review

SAMPRAPTI

The manner of dosha vitiation right from the contact with the Nidanas & the course

they follow, culminating in the development of specific clinical manifestation is

known by the name Samprapti.

Every factor connected with the process of disease at various stages is considered in

detail in Samprapti. It gives a clear idea of the disease process helping in the proper

management of the condition.

Gadanigrahakara considers katigraha to be one among the vata vyadhis. It clearly

projects Vata dosha as the major factor behind the whole pathogenesis involved in

Katigraha. He explains that the vitiated shudha or sama vayu takes its ashraya in the

katipradesha causing pain and stiffness. In the dominance of Vata dosha, Shula is the

main presenting symptom. It is already mentioned that all the Nidanas of Vatavyadhi

& vata prakopa can be regarded as Nidana of Katigraha.

Acharya Caraka explained – due to the intake of Vatakara Ahara Vihara Vata vitiation

take place. This vitiated Vata lodges in Rikta Srotas i.e. Srotas in where Shunyata of

Snehadi Guna is present. Vata after settling in Rikta Srotas produce disease related to

that Srotas74.

Acarya Vagbhata frames the Samprapti of Vata Vyadhi like – Dhatukshaya

aggravates Vata and the same is also responsible to produce Riktata of Srotas. Thus

the vitiated Vata travels through out the body and settles in the Rikta Srotas and

further vitiates the Srotas leading to the manifestation of Vata Vyadhi 75.

Here an attempt has been made to explain how this Srotoriktata occurs due to

Nidanasevana.

The chief properties of Parthiva Dravya are Guru, Sthula, Sthira, Gandha Guna in

excess. These are the properties, which are necessary for Sthairya and Upacaya of the

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Disease Review

body. Excessive intake of Dravyas having Laghu, Ruksha, Sukshma, Khara properties

lead to Guru and Sneha Guna Abhava due to their opposite quality. Thus it leads to

Dhatukshaya in the body. Akasha is the Mahabhuta that produces Sushirata and

Laghuta in the body. Vayu Mahabuta fills up this Sushirata. So due to Dhatukshaya

Akasha Mahabhuta increases in the body producing Sushirata and Laghuta

simultaneously Vayu fills it up.

From this description it can be stated that the meaning of word ‘Riktata’ is Sushirata

i.e. increase in Akasha and Vayu Mahabhuta. While commenting on word ‘Riktata’

Cakrapani says that ‘Riktata’ means lack of Snehadiguna.

DhatuKshaya as a reason for Katigraha

Due to various Nidanas and old age vata will take its domination in the body. This

will lead to Kapha Abhava. In addition, Jataragni and Dhatvagni get impaired, by

which Dhatus formed will not be of good quality. Degeneration of body elements

takes place due to predominance of Vata in its Ruksha, Khara, etc. Guna and loss of

Kapha in quality and quantity.

As the Shleshma Bhava decreases in the body, the Kapha Bheda i.e. Shleshaka Kapha

in the joints also decreases in quality and quantity. Reduction of Kapha in Sandhis

makes Sandhi Bandhana Shithilata. Ashrayashrayi Sambandha also leads Asthidhatu

Kshaya. Asthi being the main participant of the joint its Kshaya leads Khavaigunya in

the joints.

In this condition if Nidana Sevana done further produces Vata Prakopa. If Vata

Prakopa is not corrected by appropriate means and simultaneously if the person

indulges in Asthivaha and Majjavaha Sroto Dushtikara Nidana, the Prakupita Vata

spreads all over the body through these Srotas. In the meantime, Sthanasamshraya of

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Disease Review

Prakupita Vata take place in the Khavaigunyayukta Sandhi in Katipradesha. This

localized Vayu due to its Ruksha, Laghu, Kharadi Guna over power and undo all

properties of Sleshaka Kapha producing stiffness and pain in the katipradesha

ultimately resulting in the disease Katigraham.

Samprapti of katigraha can be explained and understood based on Shat kriya kalas –

Sanchaya, Prakopa, Prasara, Sthanasamshraya, Vyaktha & Bhedavasthas.

1) Sanchaya Avastha

This stage represents the inceptive phase of the disease when the dosha is stated to

have accumulated and stagnated in its own sthaanas. Chayavastha is characterized by

vague and ill-defined symptomatology though however, some symptoms

characteristic of dosha involved may be noted. Those include dullness, sense of

fullness in the abdomen by vata and heaviness of limbs, laziness due to kapha.

There will be aversion towards the similar and attraction towards the contraries. In

this context, the person may feel an aversion towards those factors responsible for the

chaya of vata. If this stage is neglected or if proper treatment measures are not

adopted it enters the second phase of prakopa.

2) Prakopa avastha

Vilayana roopa vrudhi or increased quantity of swollen and excited

aggravated dosha, which is confined to its own location, constitutes the prakopa

avastha. If the person continues contact with particular Nidanas even after chaya

lakhanas are seen it ultimately results in this stage.

In the present context the vatakara Nidanas like balavadvigraha, ativyayaama etc.

leads to further aggravation and excitation of vata dosha providing perfect base for

manifestation of a vata vyadhi.

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Disease Review

This stage may give rise to symptoms characteristic of doshas like abdominal pain,

thirst, burning sensation, disinclination for food, nausea etc.

Neglecting this stage results in the third stage of prasara.

3) Prasara Avastha

The term prasara means to spread. In this stage, the excited and swollen dosha is

stated to spread over and extend to other parts, organs and structures of the body.

It is to be noted that vayu which possess the power of locomotion or extreme mobility

is responsible for this expansion. The prakupita dosha sometimes singly or in two or

all three of them together, with rakta, expand and swarms the body in all directions.

As they move in different directions it causes various disorders and dysfunctions, the

nature and location of which depends on the direction the doshas move.

In the present context when the excited vata spreads to the marga of shleshaka kapha

present in the joints of katipradesha it causes anga saada.

So we can conclude the first three stages of kriya kala that a vague and varied

presentation of symptoms are manifested which does not give enough ground to

diagnose it as katigraha. If the disease is detected in this stage, it becomes easy to

arrest the progression of the disease with timely interventions like adoption of proper

ahara and vihara.

4) Sthana Samshraya Avastha

The vitiated doshas relocate themselves in sites of other doshas vitiating the dushyas

present there and marks the beginning of specific diseases pertaining to the site.

Obviously, this stage represents the prodromal phase or the stage of poorvaroopa and

the disease is yet to manifest fully.

This dosha dushya sammurchana is due to srotovaigunya or the pathological

involvement of related srotas. In this context, various vatakara Nidanas especially

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Disease Review

those giving undue strain to the katipradesha produces srotovigunata in the channels

present there. The vitiated dosha (vyana, apana) undergoes localization at the site of

khavaigunya. Here the dosha vitiates the dushya (asthi, snayu, peshi, majja) by

confining itself to the katipradesha and does the shoshana of shleshaka kapha present

in the joints resulting in katigraha. The resultant symptoms of pain and stiffness are

found in a mild form distinctive of poorvaroopa of vata vyadhis.

5) Vyaktha Avastha

The disease manifests completely with its symptoms fully developed and

unambiguous in form in this stage.

This stage is marked by the presence of pain due to the vitiated vata and stiffness due

to shoshana of the shleshaka kapha in the joints of katipradesha. The normal

movements at the katipradesha are hampered due to the stiff joints.

6) Bhedavastha

The disease when neglected in vyakthavastha it attains bhedavastha. This stage can

make the condition worse by manifestation of degenerative changes in the dooshyaas

(asthi) which are irreversible. The disease proceeds into more severe forms due to

extensive dhatukshaya. It finally attains asadhyata in this stage.

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Disease Review

Chart No : 1

Samprapthi of Katigraham

UKTA NIDANA SEVANA VARDHAKYA

DHATUKSHAYA

VATA PRAKOPA KSHAYA OF KAPHA BHAVA IN THE BODY

CIRCULATION THROUGH SHLESHAKA KAPHA KSHAYA RASAYANI IN SANDHI OF KATI

KHAVAIGUNYA IN SANDHI OF KATI

STHANASAMSHRAYA IN KATI

KATIGRAHAM

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Disease Review

Table No: 2

Samprapti Ghatakas of Katigraha

Vāta Vyana

Apana

(Vrudhi)

•Dosha

Kapha Śleshaka

(Kshaya)

Dhaatu Asthi

•Dushya

Upadhaatu Snayu

•Udbhava sthaana Pakwaashaya

•Vyakta sthaana Kati

•Sancharasthana Ardha sharira

•Srotas Asthivaha, Purishavaha

•Mārga Madhyama roga marga

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Disease Review

POORVAROOPA

Poorvaroopa are indications of impending diseases. They occur prior to

complete manifestation of disease and may suggest the forthcoming illness.76 During

the course of the Samprapti of an illness, the morbid Doshas circulating ubiquitously

in the body tend to localize in an area and produces some of the unique symptoms

and is referred by the name Poorvaroopa. Diagnosis at this stage of the illness gains

paramount importance, as the effective treatment at this stage definitely reduces the

possible organic damage as well as degree of morbidity.

In classics, the description regarding the Poorvaroopa of Katigraha is not available.

Even then, few of the general citations in the classics pertaining to the occurrence of

the Poorvaroopa in Vatavyadhi is worth mentioning. Acharya Charaka is of the

opinion that, in general the vague symptoms, or else any few symptoms of the

respective Vatavyadhi in its minimal severity, that too in their initial stage are the

Poorvaroopa.77 This nature of the Poorvaroopa is described as Avyakta Lakshana.

Author of the Madhukos’a commentary emphasize the vague nature of the

Poorvaroopa.

By the consideration of above cited general rule of Poorvaroopa in regards to

Vatavyadhi, Katigraha being a Vatavyadhi, Poorvaroopa of this disease may be

assumed. Vague pain, mild discomfort in the low back and limitation in the spinal

movements in its minimal severity may be considered as Poorvaroopa of katigraha.

The development of these symptoms following excessive exercise straining the back,

or else direct trauma to the back are always corroboratory of Katigraha.

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Disease Review

ROOPA

Roopa appears in the Vyaktaavastha i.e., fifth Kriyaakaala of the

disease. This is the unique stage of the illness, where in it is clearly recognizable as all

its characteristic signs and symptoms manifest. Here in this stage, the dosha-dushya

sammoorchana is completed with the manifestation of all the lakshanas of vyadhi

including the pratyatma linga, which are essential for the diagnosis of the disease.

Katigraha being a vatavyadhi is characterized by pain and stiffness at

the katipradesha. These symptoms manifest in a clear and distinguishable form from

its vague and mild form in poorvaroopavastha. The term katigraha itself is self-

explanatory pointing out the characteristic feature of graham or stiffness. The

condition is such that almost all the movements at the katipradesha or the lower back

region are hampered preventing the person from performing his day-to-day activities.

Acharya Charaka has hinted regarding various vatavyadhis, which can occur

according to the Hetu and Sthana vishesha, other than those he has explained in

detail78. Based on this excerpt various disorders can be considered due to vitiated vata

taking ashraya in katipradesha, including katigraha. This progression occurs due to

various Nidanas mentioned earlier including direct injury to the Katipradesha.

Ruja:

Acarya Shodhala while explaining katigraha has mentioned pain as one of the

prime symptom. Ruja is the term used by him to describe the character of pain in

this disease.

‘Ruja Vedana.’79

‘Ruk Satatam Shulam’80

‘Ruk Shulam’81

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Disease Review

In a typical case, pain is confined to the katipradesha or the Lumbo sacral and

sacroiliac region only. Pain can arise due to the vitiated vyaana vata, which dries up

the shleshaka kapha in the joints creating friction. If the vitiation is due to any

abhighaata pain can manifest because of injury to the sandhi as well as the

surrounding structures. Radiation of pain towards the lower limb is not seen in a

typical case, but can be found in few low back disorders where there is a defect in the

Inter vertebral discs, which is giving tension to a nerve root passing out.

Graham :

The characteristic feature of katigraha is graha or stiffness at the katipradesha. The

vitiated vata when it takes ashraya in katipradesha it leads to the shoshana of the

shleshaka kapha present in the sandhis there. The shoshana of shleshaka kapha leads

to the hampered functioning of the joints preventing all the movements at the

katipradesha. Thus, the movements at the Lumbo-sacral region like flexion, extension,

lateral flexion and rotation are hampered either completely or partially. The degree of

affection varies depending on the presentation of etiological factors, such as the site of

the structures injured and the extent of injury and duration.

Tenderness - Apart from these two classical symptoms, tenderness can be elicited in

conditions when there is severe pain. It can be elicited by pressing the thumb along

the whole length of the spinal column. Tenderness may be elicited by pressing upon

the side of spinous process in an attempt to rotate the vertebra. This can also be

elicited by giving gentle blows on either side of the spine. It must be remembered that

at times the patient may flinch with pain as soon as the skin is being touched.In such

cases pinch up the skin to differentiate whether the pain is in the skin or in the spine.

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Disease Review

BACK-ACHE82

In 1911 Meddlton and teacher in Glusgo reported for the first time a case of rupture of

a disc caused by exertion as opposed to severe trauma. The break through in

understanding spinal degenerative diseases came in the early 1930’s. In 1929 ‘Dandy’

reported two cases where loose disc fragments had been removed surgically from

within the spinal canal.

Types of low back pain:

1) Local pain

2) Pain referred to the spine

3) Pain of spine origin referred to legs and gluteal region

4) Radicular pain

5) Muscular spasm

1) Local pain:

Local pain is caused by processes that compress or irritate sensory nerve endings.

They are usually due to fractures, tears or stretching of pain sensitive structures. The

site of pain is near to the affected part of spine. Local pain does not change according.

to the position suggests spine tumor or infection.

2) Referred pain

It may arise from pelvis or abdomen (this usually occurs from abdomen or pelvis) and

rarely radiates to spine.

3) Pain of spine origin referred to legs and gluteal region

Disease occurring in upper lumbar region may refer pain to the lumbar region, groin

or anterior thighs. Disease affecting lower lumbar spine may produce pain radiation to

buttocks, thighs or rarely calves & feet.

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4) Classic radicular pain;-

It is usually sharp and radiates from the spine to within the territory of nerve root.

Coughing, sneezing often produces this pain. Patients observe increase in pain during

postural changes sitting stretches the sciatica nerve (L5&S1roots), because the nerve

passes posterior to the hip. Femoral nerve passes anterior to the hip. Its root from L2,

L3.and it is not stretched during sitting position.

5) Muscular spasm

The pain associated muscle spasm although obscure in origin, is commonly associated

with many spinal disorders. Abnormal postures, taut para spinal muscles, and dull

pain accompany the spasms.

Common related conditions, which generate low back pain and stiffness, include

.1) LUMBO SACRAL STRAIN

This condition develops from mechanical stress and strain, which the lumbo sacral

region renders itself. It occurs in both acute and chronic forms. The acute may be due

to sudden blow forcing the joint position beyond the range of movement. The spinal

muscles yield when they are off guard and ligaments sustain full force of injury.

Clinical features include pain and tenderness localized to lumbar region and

restriction of all movementsof spine. The chronic from occurs in individuals with

poor musculature and an increase in the normal lumbar lordosis. Gradually the pain

becomes constant due to gradual attacks. Sciatic pain may be present in case of root

compression.

Management:

1. Local heating in form of hot water bag or infra red or short wave diathermy.

2. NSAID’S

3. Rest

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Disease Review

4. Spinal supportive prescriptions like lumbar belt.

2) LUMBAGO (FIBROSITIS)

Fibrositis causing backache often reveals one or more tender nodules lying

superficially in the erector spine of its attachments. In the lumbar region, it is known

as lumbago. The pain causes suddenly as the patient bends his back. If neurological

symptoms are present, it is probable that disc herniations are present. The nodules

may be that of rheumatic fibrositis or local muscular spasm due to nerve root

irritation.

3) LUMBAR DISC DISEASE

This disorder is a common cause of chronic or recurrent low back & leg pain. This

disease is most likely to occur in L5-S1; L4-L5 region. But upper levels also involved

rarely. Degeneration of nucleus pulposus and the annulus fibroses, which increases

with age, may have been asymptomatic & painful. A sneeze, cough, may cause

nucleus pulposus to prolapse, pushing the frayed annular fibrosis posterior. In severe

disc disease, the nucleus may protrude through annulus fibrosus or become extruded

to lie as a free fragment in the vertebral canal. The symptoms of prolapsed disc

consist of pain, abnormal posture, and limitation to spine movement, particularly

flexion or radicular pain. The pattern of radicular pain may suggest involvement of

several nerve roots, a dermatome pattern of sensory loss or deep tender reflex loss.

Lumbar disc diseases are usually unilateral. But bilateral involvement can be seen in

long central disc herniation, that compresses nerve roots at same level.

Other conditions which generate low back pain are:

I. CONGENITAL ANOMALIES OF SPINE83

1) Spina bifida

2) Meningocele

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3) Meningo-myocele

4) Syringo-myocele

5) Myocele

1) SPINABIFIDA This develops due to the failure of fusion of the posterior part of

spine resulting in a defect through which the membranes and even spinal cord may

herniate. Usually it affects one vertebra commonly in the lumbosacral region.

SPINA BIFIDA OCCULTA

Spina bifida occulta is due to failure of the neural arches to unite posterior. There is

no protrusion of the cord membranes is noticed. This is suspected by the presence of a

cicatrial thickening or dimple or tuft of hair or dilated vessel or a fibro fatty tumor or

a naevo lipoma over the bony deficiency. A fibrous band, the membrena reunions

connect the skin to the spinal theca. As soon as the child grows older the theca is

pulled by the membrane reunions and symptoms like back ache, aneuresis, foot drop,

weakness of the lower limbs and even paralysis may appear. A few cases remain

symptom less and diagnosed by X-ray taken for some other purposes.

2) MENINGOCELE

This condition is due to the protrusion of meninges through the defective spine. It

contains C.S.F.

3) MENINGO-MYOCELE

In this, addition to protrusion of the membrane, normal spinal cord and cauda- equina

lies within the sac, may be adherent to posterior aspect of the sac. This condition

is quite common in living children and is differentiated from meningocele by presence

of dark shadows of the cord or nerves or transillumination.

4) SYRINGO-MYOCELE

In this condition the central canal of the spinal cord becomes dilated and lies within

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Disease Review

the sac and becomes adherent to the posterior wall.

5) MYOCELE

Myocele is most common. The spinal cord opens out and leakage of C.S.F.

continuously. It is incompatible with life.

II. DEFORMITIES OF THE SPINE83

1) Scoliosis

2) Kyphosis

3) Lordosis

1) SCOLIOSIS

It means deviation of the spine to one side. Slight deviation is expected during

fracture or injury to the spine.

TYPES:

A. Mobile scoliosis

B. Structural scoliosis

A. Mobile scoliosis

It is a transient and the vertebrae are not rotated. Again 3 types are noticed in this.

i. Postural:

This is seen particularly in adolescent girls. The curve in mild and convex to left

diagnosing feature is that when patient bends forward it straightens fully.

ii. Compensatory:

It is seen in patients with unilateral short leg, ocular disorder, torticolis etc. in cases of

short leg, the diagnosis is done by asking the patient to sit. The curvature disappears

during sitting position.

iii. Sciatic scoliosis:

Usually in patients with sciatica and lumbar disc prolapse, the clinical feature of the

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Disease Review

underlying cause will manifest.

B. Structural scoliosis

It is always associated with rotation of the vertebrae. The bodies rotate towards the

concavity. Once the deformity is developed, it is liable to be increased when the

growth of the patient stops completely.

The causes for this are-

i. Congenital like hemi vertebrae, fused vertebrae, fused ribs, absent disc

ii. Paralytic scoliosis- it is due to paralysis from poliomyelitis, cerebral palsy, and

muscular dystrophy. About 1/3rd of the patients suffering from neurofibromatosis

develop scoliosis.

2) KYPHOSIS

Excessive posterior convexity of the thoracic spine is defined as kyphosis.

a. Postural kyphosis-

It is associated with defects of flat foot, women after child birth, or obesity.

b. Compensatory kyphosis-

Is seen in lumbar lordosis, congenital dislocation hip or fixed flexion deformity of the

hip.

c. Senile kyphosis-

Senile kyphosis is seen in elderly people. Degeneration of disc produces increasing

stoop characteristic of the aged. The disc space is narrowed and the vertebrae slightly

wedged. There is hardly any pain unless Osteoarthritis is present.

3) LORDOSIS

This is an increased anterior curvature of lumbar spine. It may be postural or

congenital dislocation of hip. Tuberculosis of hip and mal-united fracture of the femur

may lead to this condition. This deformity also develops to correct the centre of

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Disease Review

gravity of the body in case of last trimester of pregnancy, large uterine fibroid or fatty

abdomen.

III. ANKYLOSING SPONDILITIS85

It is an autoimmune disease with a definite genetic background. Prostitis probably

plays a part. The pathology is that the intra vertebral disc is first replaced by vascular

connective tissue and then undergoes ossification affecting the periphery of the

annulus fibrosus and the intra vertebral ligaments. The disease often starts around the

sacro iliac joints. Pain and stiffness of lumbar spine and the buttocks are the main

presenting complaint. Occasionally pain may mimic sciatica. The onset is insidious

and only noticed during getting up form the bed. Malaise, fatigue, and loss of weight

are the general symptoms. Usually men are affected more in age group of 15- 35 yrs.

IV. SPONDYLOLISTHESIS86

The anterior slippage of one vertebra on to the next lower vertebra due to

degenerative changes in the facet joints and / or inter vertebral disc at the same level.

i. Epidemiology

a. 10% of women over the age 60 yrs have a first or second degree slip

b. L4-L5 most common followed by L3-L4.

c. 5 times more in women over 40 yrs of age.

ii. Clinical features:

a. Primarily low backache due to facet arthrosis.

b. Progression may lead to symptoms of spinal canal stenosis due to neural

compression at the level of slippage.

c. Leg pain may be primary complaint in 40 % characterized by pseudo claudication.

iii. Treatment

a. Non- surgical exercise programs such as flexion exercise, aerobic conditioning.

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b. Bracing- intermittently to control symptoms during exacerbations.

c. Medicines- NSAID’s and analgesics for short duration.

d. Facet joint epidural blocks may give symptomatic relief of unknown long-term

efficacy.

iv. Surgical:

a. Needed approximately 10 -15 %

b. Patients presenting neurology complaints do better than low back ache patients.

V. NEOPLASTIC CONDITIONS OF SPINE87

Metastases lesions are much more common than primary spine tumors in the elderly.

In patients of age over 21 yrs, 70 % of primary spinal neoplasms are malignant.

1) PRIMARY TUMORS:

In this most consistent complaints are back pain and patient tends to be progressive,

unrelenting, unrelated to activity. 40 % of patients present with weakness.

a. Benign tumors:

Is less common in the elderly and hemangioma is the most common type, it occurs in

10% of all people rarely symptomatic. The other primary tumors include-

osteochondroma, osteoblastoma, giant cell tumor and aneurismal bone cyst.

b.Malignant tumors

Multiple myeloma and plasma cytoma are usually seen. The patients of plasma

cytoma may have prolonged survival despite eventual progression. Solitary plasma

cytoma of the spine has approximately 60 % .5 year disease free survival rate and the

treatment for solitary cytoma is irradiation and surgery reserved for only retracting

cases.

c. Chondroma

It is rarely present and usually 50 to 60 age group. The most common sites are sub

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Disease Review

occipital and sacro coccygeal regions of spine. Surgical extirpation with wide margins

is the only curative procedure.

2) METASTAIC TUMORS:

Axial skeleton is the 3rd common site after lungs and liver. Lumbar spine is most

common area in the spine. In this most common symptom is backache. The most

common tumor metastasis to spine is breast followed by lung, prostrate, G.I. tract and

the kidney.

Treatment

1. Radiation and chemotherapy

2. Surgery is reserved for specific cases like non-radiosensitive tumor, progressive

neurological deficit while under going radiation, patients with limited life span- to

reduce pain or stabilize the spine.

VI. INFLAMMATORY CONDITIONS88

Pott’s disease

This is the most common disease that affects spine in India. It usually attacks the

children and young adults. In prodromal stage, there are weight losses, evening raise

of temperature, and pain usually being the main complaint. It is slight in the beginning

and dull aching in the night. It becomes worse during walking or movement. Two

common complications are cold abscess and paraplegia. If the disease affects the

lumbar spine, the pain usually is localized in the area, but may be referred to lateral

aspect of thigh. There will be limitations to movements, and the deformity is minimal.

Abscess formation is mainly in the form of ilio psoas abscess, which burrow into the

thigh and the inguinal ligament or the pelvis and the perineum where fistula forms on

bursting. Nervous symptoms are rare as spinal canal is spacious. Pott’s paraplegia is

due the compression soft inflammatory material or by a bony sequestrum.

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Treatment

1. Anti tubercular treatment

2. Antibiotics

VII. ACUTE OSTEOMYELITIS OF THE SPINE89

It is very rare and characterized by sudden onset of fever and severe local pain. There

are hardly any collapses of the affected vertebra owing to early recumbence of the

patient. In late cases there will be pyogenic abscess not cold abscess.

VIII. MALLINGERS LOW BACK ACHE90

No organic cause, but that the patient complains of pain, usually due to psychological

disturbances and anxiety states.

IX. SPINAL STENOSIS91

No universally accepted definition is present. Generally it is defined as less than 100

mm3 of area within the dura available in the neural canal. Confirmation is by MRI,

which gives evidence of compression of cauda equina. It usually affects the

population of age more than 65 years.

i) Clinical features:

1. Pseudo claudication or neurogenic claudication provoked by standing or walking.

2. Description of pain, numbness, weakness.

3. Symptoms in bilateral legs, along with back ache.

4. Ankle reflexes are reduced or absent.

5. Knee reflexes are reduced or absent.

6. Muscle weakness

7. Extended posture in lumbar spine exacerbates symptoms.

8. Symptoms may wax and wane in intensity.

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ii) Treatment:

a. Lumbar flexion exercises.

b. Epidural cortisone-symptomatic relief.

c. Calcitonin-to reduce symptoms.

iii) Surgical:

Lumbar laminectomy

If it is due to instability concomitant fusion is necessary.

X. PAGET’S DISEASE92

It is a disease characterized by excessive and abnormal remodeling of bone.

Aggressive bone resorption followed by excessive and disorganized bone formation

leading to dense sclerotic but weak bone.

i. Clinical Features:

a. Increased frequency with age

b. Presents local pain & tenderness.

c. May lead to pathological fractures, which results in pain.

d. Neuromuscular complaints are normal- like weakness; paralysis & incontinence

may result from enlargement of involved vertebrae causing spinal stenosis or fracture

of vertebra.

ii. Treatment:

a. Calsitonin 1.5-2 I.U/Kg/day

b. Diphosphonates 20mg/kg/day for 1month.

XI. DISC HERNIATION93:

The incidence of disc herniation is higher in individual of 30-40years old. More than

95% disc herniations occur at L4-L5 or L5-S1 area. In this 75% of disc herniation

resolves spontaneously. There will be recurrent attacks of back pain occur first later

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Disease Review

on the frequency increases with greater intensity and duration. Pain and paresthesia

begin radiates to legs, further back pain becomes less severe and leg pain progresses.

These symptoms that are severe back pain and leg pain may occur without

documentation of disc herniation on imaging. Prevalence of disc bulges increases with

age. Approximately 5-10%of patients with sciatica (persistent) require surgery.

Spontaneous recovery occurs in not only leg pain but also strength and sensory signs.

Although invasive treatments may accelerate resolution of and surgery may provide

more rapid pain relief. The majority of surgery is done for patients who have failed

conservative line of management.

XII. CAUDA EQUINA SYNDROME94

Incidence is<1% of patients, with lumbar spine. It usually occurs due to extrinsic

pressure on cauda equina by massive herniated nucleus pulposus.Other causes are

epidural abscess, epidural tumor, epidural haematoma and trauma.

Symptoms and signs:

Lumbar spine pain, B/L motor or sensory changes saddle anesthesia, bowel or bladder

dysfunction.

Management:

Surgical decompression may arrest further neurological progression.

XIII. ARTICULAR DYSFUNCTION OF SACROILIAC JOINT:

In this condition movement abnormality of one pelvic bone on other because of

increase or decrease in joint mobility. The exact patho-physiology is unknown.

Possible factors are

1. Inflammation

2. Capsular or ligamentous strain

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3. Compression

4. Trauma

5. Hyper or hypo mobility.

Clinical features

Acute onset of pain while lifting heavy weights, pain refers to buttocks, groin and

lower extremities.

Management:

Medications- NSAID, physiotherapy-traction, bracing-sacro iliac joint belts.

XIV. BERTOLOTTI’S SYNDROME.

Pseudo articulation of L5 transverse process to sacrum, pain is rarely present.

Management:

A. Manual therapy methods processes

B. Analgesics

C. Surgery-resection if medicines fails.

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UPASHAYA, ANUPASHAYA AND SADHYAASADHYATA

Upashaya are the medicines, diets and regimens, which bring about happiness

either by acting directly against the cause of the disease or it may produce such effect

on the disease indirectly. Upashaya is rightly called as exploratory therapy.

When identical symptoms having two or more disease are meeting hostilely

(or encountered) in such conditions, disease could be best differentiated by adopting

Upashaya.Upashaya for katigraha has not been mentioned particularly. How ever the

Nidana mentioned for Vatavyadhi, can be considered as Anupashaya.

It is essential to know the Sadhyasaadhyata of a disease before the treatment.

Caraka says, “A physician who can distinguish between curable and incurable

diseases and initiate treatment in time with the full knowledge about the various

aspects of the therapeutics can certainly accomplish his object of curing the disease.95

The Sadhyaasadhyata depends upon the severity of the condition, intensity of

etiological factors, extent of damage and other associated conditions. Though the

prognosis of Katigraha has not been separately mentioned, it can be assessed on

general rule of prognosis of Vatavyadhi. The disorders of Vata have been termed as

MahaGadha and the condition, which are associated with Kunjana, Sandhichuti,

Kubjata, Amsasamshosha, Panguta, and Stambha and if Doshas are deep seated in

Asthi and Majja then they are amendable to intensive appropriate treatment or even

sometimes becomes incurable. It is further stated that when the patient has sufficient

strength and without any complications and if the disease is treated in earlier stage,

then it can be cured96. Sushruta considers the Vatavyadhi as Mahagada due to its

tendency to be fatal or incurable. Vaagbhata calls it as Mahaaroga. Most of the

Aacaaryas has told that Vatavyaadhi, generally are very difficult to cure.97, 98

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Sushruta mentions that a patient of Vatavyaadhi, if develops the complications

like Shoona (oedema/inflammation) Suptatvaca (Tactile senselessness), Bhagna

(fracture), Kampa (tremors) Aadhmaana (distension of abdomen with tenderness) and

pain in internal organs, then he does not survive.99

CHIKITSA

Katigraha one of the Vatavyadhi is produced by the vitiated vata stemming out

from the pakvashaya, localizing in the Kati pradesha, afflicts the Asthi Dhaatu, and

vitiates the Snayu and Kandara of the Kati pradesha. The resultant condition is

characterized by pain and stiffness of the Katipradesha. It is difficult to unify an

effective treatment for this, as the involvement of aama cannot be ruled out. In cases

of Katigraha due to Shuddha vata, usually Kshaya in Shleshaka Kapha is found which

leads to the stiffness of the joint. Therefore, the procedures aiming at the rectification

of the imbalances in Vata Dosha as well as Kapha Dosha if associated forms the sheet

anchor of treatment of Katigraha.

The general principles of treatment of Vata Dosha should be adopted in cases

of Katigraha after the assessment of Dooshya, Prakruti, Vaya, Linga, Bala, Satwa,

Satmya. The treatment of Katigraha includes various measures to suit its varied

clinical entities, stages and associated complaints. The treatment also constitutes the

Aahara, Vihara, Shodhana, Samana and surgical measures. The specific Nidanas of

the diseases must be identified and efforts must be made for its Parivarjana. The

etiological factors mentioned previously pertaining to Aahara Vihara etc are to be

avoided with special reference to the identification of the actual cause of the patient’s

present condition. After reviewing the classics, it is ideal to start the management with

general principles of Vatahara therapies.

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With the due consideration of this, following principles of treatment can be

advocated.

1. Snehana - Oleation therapy

2. Svedana - Sudation therapy

3. Virecana Karma - Therapeutic purgation.

4. Basti - Therapeutic enema.

5. Vatahara Chikitsa - Elimination of vitiated Vata Dosha.

6. Vedanaashaamaka Chikitsa - To pacify the severity of pain.

7. Yogaasana and various Therapeutic spinal exercises.

Apart from this, various external measures are also advised for subsiding the

vitiated vata.

SNEHANA:

Snehana or oleation therapy can be used externally (Bahya) and internally

(Abhyantara) in case Katigraha . Bahya snehana can be performed in the form of

Snehadhara, Abhyanga, Avagaha, Parisheka, Kativasthi etc. Sushruta states that

Sneha applied externally will reach the Majja Dhatu in 900 Matrakalas100. This proves

the mode of action of bahya snehana in Katigraha.

Snehapana can be adopted in Katigraha except in conditions of Ama, AvritaVata,

Ajeerna, Aruchi etc. In case of associated Ama or Kapha Dosha, Langhana and

Pachana are the first line of treatment preceding Snehapana to facilitate the

Niramaavasta. Both Ghruta paana and Taila paana can be effectively adopted

according to the conditions after attaining Niraamavastha.

SWEDANA:

After achievement of proper Snehana, Swedana karma must be adopted.

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Svedana helps in the liquification of the Doshas there by assisting in clearing the

Srotas. Among the different forms of Sweda procedures, Avagaha Sweda, Pizhichil,

Naadi Sweda, Patrapinda Sweda, Pinda Sweda, and Upanaaha Sweda may be

performed efficiently in Katigraha. Swedana may be done in entire body or in affected

part of the body like kati, Prushta etc alone. Swedana is also useful in relieving

stiffness in Prushta and Kati pradesha.

MRIDU SAMSHODHANA

VIRECANA:

Virecana has an important role in Katigraha. The action of Virecana is not only

limited to particular site but has effects on the whole body. In Vatavyadhi most of the

authors mentioned Mridu Virecana.101

VriddhaVagbhata specifies that Virecana must be employed in Vata disorders

that are not subsided by Snehana and Swedana. Oral administration of ‘Eranda Sneha’

along with milk is ideal for the Virecana purpose102. This will help in both Vata

Anulomana as well as smooth excretion of Mala. The Sneha Virecana clears

obstruction in the Srotas and relieves Vata vitiation very quickly103. Thus Sneha

Virecana of Mridu nature helps in controlling Shoola in katigraha..

BASTI:

Basti is said to be the Pradhana Chikitsa for Vata Rogas because it immediately

enters into Pakwashaya and corrects the root of vitiated Vata Dosha dwelling in other

parts of the body. Further Basti Chikitsa has been glorified as ‘Ardha Chikitsa’ or

Poorna Chikitsa of Vata.104

Sushruta stressed that the disorders of Vata either Sarvanga or Ekanga can be

corrected by Basti alone. Basti has various effects on body like increase of strength,

complexion, restoration and equilibrium of Dosha Dhatu and Malas. It is useful in

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Disease Review

almost all Vata Rogas and relieves stiffness and contractures. Vangasena advised

sodhana and administration of basti 105. Vangasena in Bastikarmaadhikara has quoted

Vaitarana Basti, which is useful in KatiShula, Uru Shula, Prushta Shula, Shotha, and

other Vataja disorders.

By these facts, Basti is most important among the Pan`cakarma in the treatment

Katigraha. No other Chikitsa has the capacity to pacify and regulate the force of Vata

apart from Basti.106

VEDANASHAMAKA CHIKITSA:

Though this classification is not mentioned in any of the treatises, we can see many

Vedanashamaka combinations prescribed for Katigraha in the recent texts. These

combinations probably contain Kupilu, or Guggulu. As pain is one of the cardinal

symptoms in Katigraha these medications may be effectively prescribed as

Lakshanika Chikitsa.

VATAHARA CHIKITSA:

As mentioned earlier Vatahara Chikitsa is the primary line of treatment in Katigraha.

It includes both Shamana and Shodhana procedures. This can be adopted as the

unique principle of treatment in Katigraha.

YOGAASANA:

- The yoga exercises are the most effective and acclaimed as the best suitable

for both prevention and management of low backache.

- Spinal exercises play a vital part in the relief of chronic low back pain and in

the prevention of back injuries.

EXTERNAL MEASURES:

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Several types of external measures that are effective in Vatavyadhi are

mentioned in the form of Snehana and Swedana. These measures can relieve the pain

in cases of Katigraha. To relieve the symptoms of affected parts of the body like

Stabdata (rigidity), Graha (stiffness), these external measures are effective.

These external measures include Snehabhyanga, Sweda, Upanaha, Parisheka,

Pradeha, Avagaha, Upavestana, Mardana etc and the measures like Annalepa with

Tailas and other preparations, Dhaara, pindasweda, kayaseka etc.

SNEHAS:

TAILAS:

There is no medicine more superior to Taila in alleviating the Vata. Taila processed

with Vatahara drugs due to its Ushna, Vyavayi, Gurugunas will alleviate the Vata

disorders sited in subtle Srotas.

Tailas in general can be used for Pana, Abhyanga, Nasya and Basti. It is said that the

Bala also is improved by the use of Tailas. Almost all the usual Vatahara Tailas

alleviate Vedana.

Some of the Tailas used are

1. Rasona Taila (Cakradatta)

2. Moolaka Taila

3. Nirgundi Taila

4. Karpasasthyadi Taila

5. Vrushamooladi Taila

6. AnuTaila (Sushruta)

7. Lasuna Taila

8. Narayana Taila (Cakradatta)

9. Mahanarayana Taila

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Disease Review

10. Vajigandhadi Taila (Y R)

11. Masha Taila (Cakradatta)

12. Swadanstradi Taila (V S)

13. Kubja prasaarini Taila

14. Vishagarbha Taila (Vaidya Chintamani)

15. Shatavari Taila (Sharangadara Samhita)

16. Nakula Taila (Bhaishajya Ratnavali)

GHRITAS AND OTHER SNEHAS

1. Dashamooladi Ghrita

2. Dashamooladi Majjasneha

3. Triphaladi Chatursneha

4. Vidarigandhadi Ghrita (Sushruta)

5. Bhadradharvadi Sneha (Sushruta)

6. Ashwagandhadi Ghrita (Sushruta)

7. Chagalyadi Ghrita (S S)

8. Panchatikta Ghrita (Y R)

9. Rasnadi Ghrita (R R S)

SAMANA CIKITSA:

Several preparations are enlisted in classical texts. There are different type of

preparations like Choorna, Kwatha, Arishta, Ghrita, Taila, Lepa, Vati, and Guggulu

Kalpas. Some of the examples include Maharasnadi Kwatha, Rasna Saptaka Kwatha,

Sahacharaadi Kwatha, Shephalika Kwatha, Narasimha Choorna, Guggulu Tikta

Ghrita, Bala Taila, Dhanvantari Taila, Yogaraj Guggulu, Amrita Guggulu,

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Disease Review

Lasunapaka, Vaatavidhvamsa Rasa, Kubja Vinoda rasa and BrihatVaatachintamani

Rasa.

KATI BASTI

Swedana:

The process wherein Stambha, Gaurava, Seeta are relieved and

which induces Sweda is known as Swedana Karma.107 Generally, Guru, Ushna

Dravyas induce Swedana and the drugs having exactly opposite qualities like Laghu,

Mandha, Tikshna Gunas causes stiffness of the body. 108

Kati Basti:

This procedure is unique, in the sense comprising both Snehana and Swedana

or it may be put like this ‘Snehayukta Sweda’. The Basti, which is performed in the

kati Pradesha, is Kati Basti. Sus’ruta has mentioned the Vistarapramana of Kati has

Astadashaangula i, e 18 Angula. The word Basti is having the meaning of “Vas

Nivase” “Vas Aachhadane” “Vas Surabhikarane”. Here the word “Vas Aachhadane”

holds good for Kati Basti. The word meaning is “to cover” “that which surrounds” or

“Aavaranam”109. Hence, “Dharana” or maintainence of certain substances in the Kati

Pradesha for a stipulated time may be considered as Basti.

The word ‘Vas Nivase’ means “to reside”. Specifically this holds good for

Niruha, Anuvasana, or Uttara Basti. However, in case of Kati Basti when oil is

retained it may also be considered for the definition. So here, Kati Basti where the oil

is retained for stipulated period is not a misinterpretation.

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In this procedure, oil is used for the purpose of treatment. Hence, this may be

considered from the point of Drava Sweda.

Types of Swedana according to Sushruta110 and Vagbhata 111

1. Taapa

2. Ushma

3. Upanaaha

4. Drava

In case of Caraka Samhita Sankara , Prastara , Pariseka etc 13

types of Sweda are enlisted112 . Keeping the above said in the mind it may be viewed

that Kati Basti is one among the Drava Sweda. Simultaneously it may also be viewed

from the point of Pariseka and Avagaha because Vridha Vagbhata opines Drava

Sweda is of 2 varities i,e Pariseka and Avagaha 113. However, when they are viewing

about Pariseka they considered sprinkling (Sinchana) of medicaments and for

Avagaha, immersions are considered. In case of the Kati Basti immersion /covering

of the Kati region with oil may be forcing us to consider this variety as Avagaha

Sweda. When the oil is going to be changed during the procedure of Kati Basti little

sprinkling may be observed though it is local. Hence, variety of Pariseka may also be

considered. While dealing with the Drava Sweda Cakradatta mentioned it is useful in

case of Vataja disorders or Pittayukta and Kaphayukta Vataja disorders 114 and in

Bhavaprakasha While dealing with Swedana Taila, Kwatha, Ksheera, Mamsarasa on

to be and for Drava Sweda 115 .

Where stands Kati Basti?

According to different types of classifications, Kati Basti may

be put under following groups:

I According to Agni Bheda it is: Saagni sweda

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Disease Review

II. According to Sthaana Bheda : Ekaanga Sweda

III. According to Guna Bheda : Snigdha Sweda

IV. According to Roga And Rogi Bala : Madhyama Sweda

V. According to Taapaadi 4 Bhedas : Drava Sweda

VI. According to Sankaraadi 13 types : Parisheka / Avagaaha

VII. According to Samshamana and Samshodhanaangabhoota Bheda :

Samshamaneeya Sweda.

According to Hareeta , there are 7 types of Sweda 116.

1. Loshta

2. Bashpa

3. Agni

4. Ghata

5. Jala

6. Phala

7. Vaaluka

Kati Basti may be considered under Jala Sweda though literal meaning of Jala is

water because of proximity with liquid nature of Jala Kati Basti may be considered as

Jala Sweda.

According to Kashyapa (8 types) it may be viewed under

Avagaha and Pariseka Sweda.

According to Bhela (8 types) Jala Sweda is the source for Kati

Basti

Utilitarian factor:

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Disease Review

While defining Swedana it has been said that Stambha,

Gaurava, Seeta are going to be reduced and it induces Swedana. Kati Basti also does

the same thing off course in reduced intensity.

While dealing with the Samyak Sweda Lakshanas 117 and uses of Swedana certain

things are quoted 118, 119. All of them are not exactly fitting into the context of Kati

Basti. Few of them may be summarized as below.

1. Induces Twak MardaVata and Twak Prasaadana.

2. Restoration of functions of Sandhi by removing Stambha.

3. Reduces Gaurava and Tandra.

4. Reduces Seeta quality locally.

5. Induces Swedana locally.

Among Samyak and Asamyak Sweda Lakshanas following may be attributed to Kati Basti.

Samyak:

Shula Uparama

Seeta Uparama

Stambha Nigraha

Gaurava Nigraha

Mardhava

Sweda Srava

Vyadhiharatwa

Laghutwa

Ati Sweda :

Pitta Prakopa

Ati Sweda

Asamyak:

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Disease Review

No Shula Uparama

Feeling of coldness

Stambha

Gaurava

Procedure of Katibasti:

Poorva Karma:

The patient was advised to avoid Vatakara Aahara and Vihara. The

Taila was made into lukewarm indirectly by placing it in a vessel containing water.

Oushadha:

Katigrahantaka Taila

Upakarana:

Table, vessels, spoon, gas stove, wheat floor, cotton, water.

Pradhana Karma:

The procedure was explained in brief to the patient. The patient was

made to lie prone on the table and Kati Pradesha is exposed. Meanwhile sufficient

quantity of wheat floor was taken and made into dough by adding required quantity of

water. The dough was made into a shape of circular ring corresponding to the area of

tenderness in the lumbo-sacral region. The inner and outer walls of the circular ring

were properly sealed over the skin to prevent the leakage of the Taila from the circular

ring. Then the heated Taila was poured in little amount to check the tolerance of heat

by the patient. According to the tolerance of the lukewarm oil, it is slowly poured

inside the circular ring with a help of a spoon. Constant temperature of the oil was

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Disease Review

maintained inside the circular ring by rotating the oil with a finger. Once the

temperature of the oil is decreased, it was replaced with lukewarm oil again. The

procedure was continued until the patient attains Samyak Swinna Lakshanas or upto

40 to 50 minutes. The same procedure was repeated for 21 days. Once used oil was

reused for consequent 3 days. On 4th day, the oil was replaced with fresh oil.

Paschat Karma:

After the procedure, oil was completely removed out from the circular

ring with the help of a cotton or spoon. The dough ring was also removed from the

back. Mild massage over the area was done. Then the patient was advised to take

lukewarm water bath after 15 to 20 minutes.

MANAGEMENT OF LOW BACK ACHE120

Radical treatment of the Low back ache is planned with the due

consideration of the etiology of the illness. Relieving the pain and other discomfort by

different measures should not be the sole purpose of the treatment. Key principles

include:

1) Prevention

"Prevention is better than cure," it is told in classics, in this study preventive

measures are very essential things, some different posture are mentioned here.

In sitting posture:

- To maintain the good sitting posture.

- To Avoid a long time sitting posture.

- Change in position for every 15 minutes.

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Disease Review

- A seat placed at a height from the ground that is slightly less than the length

of the leg from knee to foot.

- The lumbar spine can be kept in contact with the squab support at the back of

the chair.

In standing posture:

- To avoid asymmetrical standing

- Keep knees relaxed on comfortably straight position.

In lying posture:

- The side lying position is generally a safe and comfortable posture for sleeping

- To maintain the proper position to getting out of bed

- Keep the spine in a neutral position

During work:

- Avoid forward bending while working.

- Do not wear the high heel shoes.

- Use of better techniques while lifting.

Other major points in prevention are weight reduction and avoidance of any unusual

activity that can hurt the back. Correct sitting, standing and sleeping postures, lessen

the intradiscal pressure. Keep trunk muscles in optimal condition by regular exercise

such as brisk walking, swimming etc.

2) Non-operative treatment

Heat and Cold - In the acute patient, the application of therapeutic heat and

cold usually precedes traction or exercise. Modalities include the use of hydro collator

packs, whirlpool, diathermy, ultrasound and phonophoresis.

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Disease Review

Traction- the mechanical benefit of traction is to decrease the lordosis of the lumbar

spine. It can be applied in a sustained manner or intermittent manner.

Bed rest and manipulation – It is the centrepiece of non-operative treatment of

Lumbar disc herniation. An adequate period of bed rest is of at least 2 weeks. A firm

resting surface is important. Any comfortable position can be assumed but resting in

prone, because of the associated hyperextension, is discouraged. After the proposed

period the patient is gradually mobilized but should return to bed if the pain

reappears.

3) Drug therapy

more frequently used medications include non steroidal anti inflammatory drugs and

acetaminophen. Muscle relaxants are another class of drugs that are frequently used.

Anti depressants and anti neuralgic agents are useful for patients with radiating painof

a burning quality that typifies neural origin.

4) Surgical interventions

- If not relieved by conservative treatment.

- Quick recurrence of symptom.

- Evidence of large prolapse causing pressure on cauda equina.

- Surgical options include – Laminectomy (removal of lamina), discectomy

(removal of herniated disc), facetectomy (removal of facet joint), (widening of

foramen) foraminostomy.

Selective injection treatment for backache

They are based on principles of regional anesthesia. Lidocaine is the

most widely used agent in the concentration of 0.5 – 2%. Onset of action is 1-5

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Disease Review

minutes and duration is 1-2 hrs. Bupivacaine has slower onset of action 5- 20 min but

provides longer pain relief.

Cortico steroids are injected locally to relieve inflammation and pain.

Steroids can be injected to epidural space or into the desired foramen under

fluoroscopy.

PATHYA – APATHYA

The diet and regimen that is congenial to the health both in healthy and

diseased are referred by the name Pathya. Quite opposite to this the food and regimen

that are otherwise is named as Apathya. Pathya and Apathya in regards to the

Vatavyaadhi in general is also considered as Pathya and Apathya of Katigraha as

elaborated in Yogaratnaakara (Y.R) and in Basavarajeeyam.121, 122

Table No: 3 PATHYA:

I. Ahaara Y.R B.R.

Rasa: Lavana -

Shooka Dhanya Varga: Godhooma, Godhooma

Raktashaali Puranadhaanya

Shami Dhanya Varga: Masha Masha

Kulattha Kulattha

Maamsa Varga: Kukkut’a

Tittiri

Barhi (Peacock) -

Chataka

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Jaangalamaamsa

Matsya Varga: Shileendhra

Parvata

Nakra -

Gagrara

Khudisha

Jhasha

Shaakha Varga: Patola, Kooshmanda,

Kaaravellaka

Shigru Moolaka, Tikta, Patola

Vaartaaka,

Soorana, Tarkkari

Phala Varga: Dadima

Parooshaka

Badara -

Draksha

Gorasa Varga: Ghruta, Dugdha

Kilaata, Dadhi koorcika -

Sneha Varga: - Taila

Anya Dravya : Lashuna, Bruhati,Vaastuka,

Tamboola Kasamarda,

Dunduka, Mishi, Kataka

Matsyandika, Punarnava

Vatsaka, Mundi, Jeeraka

II. Karma Y.R. B.R.

- -

Abhyanga

APATHYA:

I. Ahara Y.R B.R.

Rasa: Kashaaya, Tikta, Katu -

Anna: Anashana Guru & Abhishayandi

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Jala Varga: Tataaka and Tatinijala Sheetaambu

Pradushta (jala) salila

Shookadhanya Varga: - Navadhaanya

Shameedhanya: Mudga, Mudgaka

Nivara, Shyamakacoorna Sarshapa

(Kangani) Kuruvinda Nishapava

Kalaaya

Chanaka

Shakha Varga: - Shakala, Kanda, Trapu

Alaabu, Ervaaru, Bimba

Koshataki Dravya

Kareera Kareera

Anya Dravyas Kshaudra Mrinali, Sharasinimba

Tikta, Nimba

II. Vihara

Chinta, Prajagara Sheeta pavana sevana

Vegavidharana

Shrama, Vyavaya

Chankramana

khatwa (sleeping on cot)

III. Karma

Chardi, Langhana

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Drug Review

DRUG REVIEW

Therapeutic effect of any drug combination, to the benefit of the patients, suffering

from Katigraha depends upon its ability to pacify the Vata, placate the cardinal

symptoms and breaking the Sampraapthi. Katigraha is a disease where pain is seen

predominantly along with stiffness of the low back region.

Among the various kashayas mentioned as vata shamaka in sahasrayoga, Nirgundi

Erandaadi Kashaaya is also mentioned. If we go through the properties of the

individual drugs used in this kashaya, we can see that all of them have a specific

action for alleviation of Vata dosha.

In addition to general Shamanaushadhi’s, special attention is necessary to subdue the

presenting clinical features in the form of external measures. Taila is considered

superior to allevate Vaata Dosha due to its Snigdha and Ushna properties. Hence,

Katibasti with Katigrahantaka Taila is adopted in this study. This taila had been in use

by traditional practioners of kerala for katigraha and other vatavyadhis. In the

following lines, the details of the drugs used in Nirgundi Erandadi Kashaya and

Katigrahantaka Taila are given. This will justify the therapeutic utility of the drugs

administered orally and as external measures in patients of Katigraha.

The main objective of the present clinical study is to evaluate the effect of Nirgundi

Erandadi Kashaya and Katibasti with Katigrahantaka Taila in the management of

Katigraha. The properties of these drugs are summarized below.

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Drug Review

A) NIRGUNDI ERANDADI KASHAYA123

CONTENTS :

Name of the drug Latin name Quantity

1) Nirgundi Vitex negundo

2) Eranda Ricinus communis

3) Sahachara Barleria prionitis 1 part each

4) Bala Sida Rhombifolia

5) Shunthi Zingiber officinale

6) Water 16 parts

Preparation of Nirgundi Erandadi Kashaya :

The five different drugs mentioned were collected, cleaned and weighed. These were

made into coarse powder and 16 parts of water was added and boiled until 1/8th of the

water remained. This Kashaya was filtered through a clean cloth, bottled and stored.

PROPERTIES OF INDIVIDUAL DRUGS

NIRGUNDI124

Kula - Nirgundi Family - Verbanaceae Botanical name – Vitex Negundo Gana – Caraka – Vishaghna, Krimighna Susruta – Surasadi gana Properties · Rasa – Katu, Tikta · Guna – Laghu, Rooksha · Virya - Usna

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Drug Review

· Vipaaka – Katu· . Dosaghnata - Kapha vaata hara

. Karma – Vedanasthapana, Balya, Srotoshodhaka ERANDA125

Kula - Eranda Family - Euphorbiaceae Botanical name – Ricinus Communis Gana – Caraka – Bhedaneeya, Swedopaga, Angamardaprashamana, Maduraskanda. Susruta – Vidaarigandhaadi, Vaatasamshamana Properties · Rasa – Madhura, Katu, Tikta · Guna – Guru, Snigdha, Teekshna, Sookshma · Virya - Usna · Vipaaka – Madhura · Dosaghnata - Kapha vata hara, Pitta vardhaka.

Taila is Pitta Shamaka.

. Karma – Vedanasthapana, Shulahara, Angamarda prashamana, Balya,Deepana.

SAHACARA126

Kula - Vaasa Family - Acanthaceae Botanical name - Barleria prionitis Properties · Rasa - Tikta, madhura

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Drug Review

· Guna - Laghu snigdha · Virya - Usna · Vipaaka - Katu · Dosaghnata - Kapha vaata shamaka . Karma – shothahara, vedana sthapaka, naadi bala prada, jwaraghna, vishaghna, Rakta shodhaka, shukra shodhana BALA127

Kula - Kaarpaasa Family - Malvaceae Botanical name – Sida Rhombifolia Gana – Caraka - Balya, Brumhaneeya, Prajaasthaapana, Madhura skanda. Susruta – Vaatasams’amana Properties · Rasa - Madhura · Guna – Guru, Snigdha, Picchila · Virya – Sheeta · Vipaaka - Madhura · Dosaghnata – Vata pitta shamaka . Karma – Balya, Brumhana, Ojovardhaka, Naadi bala prada, Anulomana, Snehana, Rasaayana. The roots are cooling, astringent, stomachic, nervine and cardiac tonic. SHUNTI128

Kula - Ardraka Family - Zingiberaceae

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Drug Review

Botanical name – Zingiber officinale Properties · Rasa - Katu · Guna - Laghu snigdha · Virya - Usna · Vipaaka – Madhura · Dosaghnata - Kapha vata hara . Karma – Shothahara, Vedana sthapaka, Vata shamaka, Naadi Uttejaka. B) KATIGRAHANTAKA TAILA Contents : Name of the drug Latin name 1) Nirgundi Vitex negundo 2) Tila taila Sesamum indicum 3) Shunthi Zingiber officinale 4) Pippali Piper longum 5) Maricha Piper nigrum 6) Hingu Ferula narthex 7) Lashuna Allium sativum Quantity Nirgundi patra swarasa – 60 liters

Tila taila – 30 liters

Trikatu, Hingu, Lashuna – 1.5 kilogram each

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Drug Review

Method of preparation:

The above-mentioned drugs were taken in appropriate quantity and kalka was

prepared. To the murchita Tila taila above mentioned quantity of swarasa and kalka

were added. The taila was boiled in mandaagni until snehapaka lakshanas were seen.

The prepared katigrahantaka taila was filtered and stored in sterile glass containers.

PROPERTIES OF INDIVIDUAL DRUGS

NIRGUNDI Kula - Nirgundi Family - Verbanaceae Botanical name – Vitex Negundo Gana – Caraka – Vishaghna, Krimighna Susruta – Surasaadi gana Properties · Rasa – Katu, Tikta · Guna – Laghu, Rooksha · Virya - Usna · Vipaaka – Katu· . Dosaghnata - Kapha vata hara

. Karma – Vedanasthapana, Balya, Srotoshodhaka

HINGU129

Kula – Shatapushpa Family - Umbelliferae Botanical name – Ferula narthex Gana – Caraka – Sagnasthaapaka, Deepaniya, Katukaskanda

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Drug Review

Susruta – Pippalyaadi gana, Ooshakaadi gana Properties · Rasa – Katu · Guna – Laghu, Snigdha, Teekshna · Virya - Ushna · Vipaaka – Katu· . Dosaghnata - Kapha vata shamaka

. Karma – Vedanasthapana, Shulaprashamana, vatahara, Nadi uttejaka, sagnasthaapana, Akshepahara.

LASHUNA130

Kula - Rasona Family - Lilliaceae Botanical name – Allium sativum Properties · Rasa – Katu pradhana amla varjita pancharasa · Guna – Snigdha, Teekshna, Picchila, Guru, Sara · Virya - Usna · Vipaaka – Katu· . Dosaghnata - Vaata hara

. Karma – Vedanasthapana, shothahara, Paarshva shula hara, Naadi uthejaka SHUNTI Kula - Ardraka Family - Zingiberaceae Botanical name – Zingiber officinale

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Drug Review

Properties · Rasa - Katu · Guna - Laghu snigdha · Virya - Usna · Vipaaka – Madhura · Dosaghnata - Kapha vaata hara . Karma – Shothahara, Vedana sthapaka, Vata shamaka, Nadi Uttejaka.

PIPPALI131

Kula - Pippali Family – Piperaceae Botanical name – Piper longum Gana – Caraka – Kasahara, Hikkanigrahana,shirovirechana, vamana, Truptighna, Deepaniya, Shulaprashamana. Susruta – Pippalyaadi gana, Oordhvabhaagahara, Shirovirechana Properties · Rasa – Tikta, Katu · Guna – Laghu, Snigdha, teekshna · Virya – Anushna sheeta · Vipaaka – Madhura · Dosaghnata - Kapha Vaata hara

. Karma – Vatahara, Rakthashodhaka, Rasayana, Balya

MARICHA132

Kula - Pippali Family – Piperaceae

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Drug Review

Botanical name – Piper nigrum Gana – Caraka –Shirovirechana, Deepaniya, Shulaprashamana, Krumighna. Susruta – Pippalyadi gana, Trayooshana Properties · Rasa – Katu · Guna – Laghu, Teekshna · Virya – Ushna · Vipaaka – Katu · Dosaghnata - Vaata Kapha hara

. Karma – Vatahara, Srotoshodhaka, Rakthashodhaka, Rasayana, Naadi uthejaka, Balya, Vatanulomana TILA133

Kula - Tila Family - Pedaliaceae Botanical name – Sesamum indicum Properties · Rasa – Madhura . Anurasa – Kashaaya, Tiktha · Guna – Guru, snigdha · Virya - Usna · Vipaaka – Madhura · Dosaghnata - Vaata hara, Kapha Pitta kopaka

Tridosha shamaka on undergoing samskaara. . Karma – Snehana, Vedana sthapaka, Vata shamaka, Nadi Uttejaka, Sandhaneeya, Vrana shodhana, Vrana ropana

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Drug Review

By a thorough study of the properties, we can see that most of the drugs in above

formulations are Vatakaphahara in nature. Some drugs like Eranda, Sahachara and

Trikatu act as Vedanashamaka directly according to Karma. Drugs like Bala is said to

be Rasayana hence act as Dhatu Vrudhikara also. Drugs like Eranda have

Vedanasthapana, Balya and Vatanulomana property that is very essential in breaking

the Samprapti.

In a nutshell, the herbs used in the preparation of

1) Nirgundi Erandadi Kashaya and

2) Katigrahantaka Taila

are efficacious in bring out the relief in signs and symptoms, break the

samprapti and balance the Dhatu Dushti in Katigraha.

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Methodology

MATERIALS AND METHODS

Research is defined as scientific and diligent study, investigation or experimentation

in order to establish facts and analyze their significance. Research is done for

establishing new facts, discarding the old or modifying them. Many times research is

done to validate old principles with fresh proofs. Always research need not end with

positive results. In research one problem is constructed with suitable experimental

methods and honest observations are made to arrive at a logic conclusion.

Aim of the study:

The study is related to the evaluation of the therapeutic effect of Nirgundi

Erandadi kashaya and Kativasthi in patients suffering from Katigraha and is designed

with the following objectives.



Katigraha.

To study the role of Nirgundi Erandadi kashaaya and Kativasthi in obtaining




combination.


Source of data:

Patients of either sex who attended the outpatient and in patient deparments of

A.L.N.Rao Memorial Ayurvedic medical college, Koppa in the period from

December 2004 to august 2005 complaining of low backache and stiffness were

screened. Out of these 50 patients suffering from Katigraha fulfilling the below

Page: 96

Methodology

mentioned inclusion criteria were taken for the study. The complete profile of the

patient was prepared as per the detail proforma consisting of all the relevant data like

symptamatology, physical signs and patient’s constitution along with elaborate

assessment of pain, using standard questionnaires.

Inclusion criteria:

♦ Patients with Pratyaatma lakshanas of Katigraha

♦ Patients of both sex aged between 16-60 years.

Exclusion criteria:

♦ Patients having associated diseases like Tumors, Diabetes, Tuberculosis,

Fractures, Pelvic disorders and other complications.

♦ Patients having marked deformities of spinal column.

♦ Patients with other systemic disorders.

Investigations:

♦ Routine hematological investigations like Hb%, TC, DC, ESR

♦ RBS and serum Cholesterol if necessary.

♦ Routine Urine investigations.

♦ Routine radiological examination of the Lumbo sacral spine in Anteroposterior

and lateral position.

Design:

It is a single blind clinical study with pre-test and post-test design wherein 50

patients of either sex diagnosed as Katigraha were randomly allocated into trial Group

(Kativasthi and Nirgundierandadi kashaya group) and control Group (Diclofenac

sodium group).

Relevant investigations were adopted for diagnosis and to assess the improvement.

Page: 97

Methodology

Intervention:

Trial Group:







Control Group:





Assessment criteria:

The state of the disease katigraha, changes after the intervention, improvement

or otherwise was determined by adopting standard methods of scoring by means of

objective and subjective parameters. Assessment was done initially before the

intervention and there after every week in both the groups till the completion of

proposed period of treatments. This assessment criterion is detailed in the following

pages.

Page: 98

Methodology

I. Objective criteria

1. Maneuvers conducted are:

a) SLR test

b) Pump handle test

c) Coin test

d) Schober’s Test

i) Flexion

ii) Extension

2. Tenderness

II. Subjective criteria

1. Pain

2. Stiffness

3. Lateral flexion

4. Rotation

METHOD OF GRADING

♦ Straight leg raising test

0 Can lift up to 900




4 Cannot lift

Page: 99

Methodology

♦ Coin test

0 Can bend without difficulty

1 Can bend with difficulty but no support

2 Can bend with difficulty but need support

3 Cannot bend

♦ Pump handle test

0 Can perform the test

1 Can perform the test with difficulty

2 Cannot perform the test

♦ Tenderness

0 No pain

1 Patient says it’s paining

2 Patient winces

3 Patient winces and withdraws the part

4 Patient does not allow to touch the part.

♦ Extension (Schobers test)

0 Extension up to 2.5 cm

1 Extension up to 2 cm


3 Extension < 1 cm

♦ Flexion (Schobers test)

0 Flexion up to 4 cm



3 Flexion <1 cm

Page: 100

Methodology

♦ Lateral flexion

0 Can do lateral flexion easily

1 Can lateral flex with difficulty

2 Cannot perform lateral flexion.

♦ Rotation

0 Can rotate easily

1 Rotation with difficulty

2 Cannot rotate.

♦ Stiffness

0 None

1 Less than 15 minutes

2 15 to 30 minutes.

4 More than 30 minutes.

♦ Pain 0 No Pain (score 61-66)

1 Mild (score 41-60)

2 Moderate (score 21-40)

3 Severe (score <20)

TOTAL EFFECT

COMPLETE REMISSION – 100% relief in signs and symptoms and movement

by patients without any pain were considered as

complete remission.

Page: 101

Methodology

MARKED IMPROVEMENT – 75 - 99% relief in signs and symptoms were

considered as marked improvement.

MODERATE IMPROVEMENT –50 - 74% relief in signs and symptoms

were considered as moderate improvement.

MILD IMPROVEMENT - 25 – 49% relief in signs and symptoms

Were considered as mild improvement.

UNCHANGED – No reduction in signs and symptoms.

Pain Table no - 4 •Greenough and Fraser scoring method:

Question Answer Points

Never 6

Occasionally 4

Almost every day 2

How often do you have to take pain

killers for your pain?

several times every day 0

Never 6

Rarely 4

1-2 times per month 2

How often do you have consultation

with a doctor?

1-2 times per week 0

full time at regular job 9

full time at a lighter job 6

part time 3 At present, are you working?

not working 0

not at all 6

a little 4

half the day 2

So you need to rest during the day

because of pain?

Over half the day 0

Normally 9

as many as usual, but slowly 6

A few, not as many as usual 3

At present, can you undertake household

chores or additional jobs?

not at all 0

as much as usual 9 At present, can you undertake sports or

active pursuits, such as dancing? almost as much as usual 6

Page: 102

Methodology

Some, much less than usual 3

not at all 0

no effect 3

mildly or moderately affected 2

Difficult 1

How much does back pain affect your

ability to dress?

not possible 0

no effect 3


Difficult 1


ability to sit?

not possible 0

no effect 3


Difficult 1


ability to walk?

not possible 0

no effect 3


Difficult 1


ability to sleep?

not possible 0

no effect 3


Difficult 1


ability to travel?

not possible 0

no effect 6


Difficult 2


sex life?

not possible 0

• The higher the score, the better the performance status.

Statistical Analysis:

For assessing the improvement of symptomatic relief and to analyze

statistically the observations were recorded before, after the treatment and after

follow- up. The mean, percentage, S.D, S.E, and t-value (paired t-test) were calculated

from the observation recorded. The total result including the overall effect of therapy

is given in tables for the two groups.

Page: 103

Methodology

OBSERVATIONS:

Table No:5

Age wise distribution of 50 patients of Katigraha :

Age group

in yrs

Trial

group

Control

group

Total Percentage

11 - 20 2 1 3 6

21 - 30 3 4 7 14

31 - 40 9 8 17 34

41 - 50 8 9 17 34

51 - 60 3 3 6 12

Age incidence in this study showed a maximum number of patients in the age group

of 31 – 50 years, i.e. 68%. In the age group of 21 – 30 years 14% of patients were

obtained, and in the age group of 51 – 60 years 12% of patients were recorded.

Minimum numbers of patients were seen from the age group 11 – 20, i.e. 6%.

Graph No: 1

Age wise distribution of 50 patients of Katigraham

0

5

10

15

20

25

30

35

11 ~ 20 21 - 30 31 - 40 41 - 50 51 - 60

Page: 104

Methodology

Table No:6

Sex wise distribution of 50 patients of Katigraha

Sex Trial

group

Control

group

Total Percentage

Male 16 15 31 62

Female 9 10 19 38

The percentage of males (62%) was seen to be more in this study compared to the

percentage of Females (38%).

Graph No:2

Sex wise distribution of 50 patients of Katigraham

0

10

20

30

40

50

60

70

MALE FEMALE

Page: 105

Methodology

Table No:7

Religion wise distribution of 50 patients of Katigraha

Religion Trial

group

Control

group

Total Percentage

Hindu 9 10 19 38

Muslim 8 7 15 30

Christian 8 8 16 32

Among the patients selected for the study 38% were Hindus, 30% were Muslims and

32% were Christians.

Graph No:3

Religion wise distribution of 50 patients of Katigraha

05

10152025303540

HINDU CHRISTIAN MUSLIM

Page: 106

Methodology

Table No:8

Occupation wise distribution of 50 patients of Katigraha

Occupation Trial

group

Control group Total percentage

House wife 4 3 7 14

Unemployed 2 3 5 10

Labour 8 7 15 30

Service 4 5 9 18

Business 4 4 8 16

Student 3 3 6 12

More incidence (30%) were seen in patients from the labour category. 18% of patients

were from the service category and16% of patients from the business category.12%

were in student category and 10% were unemployed.

Graph No:4

Occupation wise distribution of 50 patients of Katigraha

0

10

20

30

House wife Unemployed Labour Service Business Student

Page: 107

Methodology

Table No:9

Distribution of 50 patients of Katigraha according to nature of occupation

Occupation Trial

group

Control

group

Total percentage

Standing 8 9 17 34

Sitting 4 3 7 14

Bending 3 2 5 10

Traveling 8 7 15 30

Walking 2 4 6 12

Occupation which involved standing erect for long duration predisposed the patients to strain

of the back. In the present study 34% of the patients had similar occupation. 30% had to travel

in two wheelers etc .as a part of their occupation leading to strain at low back. 14% of patients

had to sit for long duration. 12% had to walk more and 10% had to bend their back more as a

part of their work.

Graph No:5

Distribution of 50 patients of Katgraha according to nature of occupation

05

10

15

20

25

30

35

STANDING SITTING BENDING TRAVEL WALKING

Page: 108

Methodology

Table No:10

Marital status wise distribution of 50 patients of Katigraha

Marital

status

Trial

group

Control

group

Total Percentage

Married 17 16 33 66

Unmarried 7 9 16 32

Widow

and

widower

1 0 1 2

Among the patients 66% were married, 32% were unmarried and 2% of them were

widows.

Graph No:6

Marital state wise distribution of 50 patients of Katigraha

0

10

20

30

40

50

60

70

MARRIED UNMARRIED WIDOW

Page: 109

Methodology

Table No:11

Socio-economic Status wise distribution of 50 patients of Katigraha

Socio-

economic

status

Trial

group

Control

group

Total Percentage

Lower 13 12 25 50

Middle 8 7 15 30

Upper 4 6 10 20

The study showed more incidences (50%) of the condition in patients hailing from a

lower socio economic conditions owing to the nature of work, condition of living etc.

About 30% of patients were from middle class and only 20% from upper class

suffered from the condition.

Graph No:7

Socio-economic Status wise distribution of 50 patients of Katigraha

0

10

20

30

40

50

UPPER MIDDLE LOWER

Page: 110

Methodology

Table No:12

Dietary pattern of 50 patients of Katigraha

Dietary

pattern

Trial

group

Control

group

Total percentage

Vegetarian 10 11 21 42

Non-Veg 15 14 29 58

Among the patients selected for the study 58% turned out to be non vegetarians and

only 42% of them stuck to vegetarian food.

Graph No:8

Dietary pattern of 50 patients of Katigraha

0

10

20

30

40

50

60

VEGETARIAN NONVEGETARIAN

Page: 111

Methodology

Table No;13

Family history of 50 patients of Katigraha

Family

history

Trial

group

Control

group

Total percentage

Positive 8 9 17 34

Negative 17 16 33 66

Among the patients selected for the study 66% did not had a similar family history.

Only 34% of them had a related family history.

Graph No:9

Family history of 50 patients of Katigraha

010203040506070

POSITIVE NEGATIVE

Page: 112

Methodology

Table No:14

Distribution of 50 patients of Katigraha according to weight

Weight

in kg

Trial

group

Control

group

Total percentage

31 – 40 1 1 2 4

41 - 50 3 3 6 12

51 - 60 4 5 9 18

61 - 70 8 7 15 30

71 - 80 5 6 11 22

81 - 90 2 2 4 8

91- 100 2 1 3 6

The incidence was more (30%) seen in patients having weight in the range of 61 – 70

kg. 22% of patients were from the weight category of 71 – 80 kg and 18% from the 51

– 60 kg range.

Graph no :10

Distribution of 50 patients of Katigraha according to weight

0

5

10

15

20

25

30

31-40 41-50 51-60 61-70 71-80 81-90 91-100

Page: 113

Methodology

Table No:15

General Nidana observed in 50 patients of Katigraha

Nidana Trial

group

Control

group

Total percentage

Vatakara

ahara

9 8 17 34

Vatakara

vihara

14 15 29 58

Manasika 2 2 4 8

Maximum percentage of patients (58%) was seen with a history of indulgence in

Vatakara viharas. Vatakara aharas were observed in 34% of the patients and manasika

nidanas were seen in 8%.

Graph no :11

Distribution of 50 patients of Katigraha on basis of Nidaanas

0

10

20

30

40

50

60

vatakaravihara

vatakaraahara

manasika

Page: 114

Methodology

Table No:16

Main symptoms observed in 50 patients of Katigraha

Main

symptom

Trial

group

Control

group

Total Percentage

Pain 25 25 50 100.00

Stiffness 25 25 50 100.00

The two main symptoms were seen in all the patients.

Graph no :12

Distribution of 50 patients of Katigraha on basis of main symptoms

0

5

10

15

20

25

PAIN STIFFNESS

Page: 115

Methodology

Table No:17

Associated symptom observed in 50 patients of Katigraha

Associated

symptoms

Trial

group

Control

group

Total Percentage

Tenderness 18 14 32 64

About 64% of the patients had tenderness associated with the main complaints.

Graph no :13

Distribution of 50 patients of Katigraha on basis of associated symptoms

0

10

20

30

40

50

60

70

TENDERNESS

Page: 116

Results

RESULTS

EFFECT OF TRIAL AND CONTROL DRUG THERAPY IN KATIGRAHA

Table no:18

Effect of Trial drug combination on objective parameters after treatment of 25

katigraha patients:

Measures Sl.

No

Objective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

SLR Test

2.35

1.87

0.48

44.00

0.585

0.117

4.095

<0.001

2

Coin Test

2.98

2.62

0.36

36.00

0.489

0.097

3.674

<0.010

3

a)

Schobers

Test

Flexion

2.50

2.02

0.48

40.00

0.653

0.130

3.67

<0.010

b)

Extension

2.62

2.22

0.40

40.00

0.500

0.100

4.00

<0.001

4 Pump

Handle

Test

2.89

2.45

0.44

40.00

0.583

0.116

3.77

<0.001

5

Tenderness

3.01

2.73

0.28

32.00

0.458

0.091

3.055

<0.010

On examination, the effects of Trial drug therapy on various objective parameters

before and after the treatment in 25 patients of katigraha are documented. The

statistical analysis of SLR test in trial group revealed that the mean SLR score of

katigraha that was 2.35 before the treatment was reduced to 1.87 after the treatment.

Page: 117

Results

This change is statistically highly significant (P<0.001) by 44%. Statistical analysis of

coin test revealed a highly significant change (P<0.001) by 36%.

The statistical analysis of Schobers test for flexion showed a moderate significance

(P<0.010) by 40% and for extension showed a high significance (P<0.001) by 40%.

The statistical analysis for pump handle test by trial drug showed a high significance

(P<0.001) by 40%. The statistical analysis of tenderness showed that the trial drug

therapy provided a moderate significance (P<0.010) by 32%.

Table no:19

Effect of Trial drug combination on objective parameters after Follow up of 21

days on 25 katigraha patients:

Measures Sl.

No

Objective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

SLR Test

2.35

1.59

0.76

64.00

0.663

0.132

5.728

<0.001

2

Coin Test

2.98

1.64

0.64

64.00

0.489

0.097

6.531

<0.001

3

a)

Schober’s

Test

Flexion

2.50

1.78

0.72

60.00

0.678

0.135

5.307

<0.001

b)

Extension

2.62

2.02

0.60

60.00

0.50

0.10

6.00

<0.001

4 Pump

Handle

Test

2.89

2.17

0.72

64.00

0.613

0.122

5.865

<0.001

5

Tenderness

3.01

2.33

0.68

64.00

0.556

0.11

6.106

<0.001

Page: 118

Results

On examination, the effects of Trial drug therapy on various objective parameters

after follow up in 25 patients of katigraha are documented. The statistical analysis of

SLR test in trial group revealed that the mean SLR score of katigraha that was 2.35

before the treatment was reduced to 1.59 after the follow up. This change is

statistically highly significant (P<0.001) by 64%. Statistical analysis of coin test

revealed a highly significant change (P<0.001) by 64%.

The statistical analysis of Schobers test for flexion showed a high significance

(P<0.001) by 60% and for extension also showed a high significance (P<0.001) by

60%.



therapy provided a high significance (P<0.001) by 64%.

Page: 119

Results

Table no:20

Effect of Control drug on objective parameters after treatment of 25 katigraha

patients:

Measures Sl.

No

Objective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

SLR Test

2.33

1.45

0.88

68.00

0.725

0.145

6.062

<0.001

2

Coin Test

2.80

2.28

0.52

48.00

0.585

0.117

4.437

<0.001

3

a)

Schobers

Test

Flexion

2.50

1.94

0.56

56.00

0.506

0.101

5.526

<0.001

b)

Extension

2.11

1.51

0.60

56.00

0.577

0.115

5.196

<0.001

4 Pump

Handle

Test

2.88

2.2

0.68

60.00

0.627

0.125

5.421

<0.001

5

Tenderness

2.90

2.14

0.76

64.00

0.663

0.132

5.728

<0.001

On examination, the effects of control drug therapy on various objective parameters

before and after the treatment in 25 patients of katigraha are documented. The

statistical analysis of SLR test in control group revealed that the mean SLR score of

katigraha that was 2.33 before the treatment was reduced to 1.45 after the treatment.

This change is statistically highly significant (P<0.001) by 68%. Statistical analysis of

coin test revealed a highly significant change (P<0.001) by 48%.

Page: 120

Results

The statistical analysis of Schobers test for flexion showed a high significance


The statistical analysis for pump handle test by control drug showed a high

significance (P<0.001) by 60%. The statistical analysis of tenderness showed that the

control drug therapy provided a high significance (P<0.001) by 64%.

Table no:21

Effect of Control drug after follow up of 21 days on objective parameters of 25

katigraha patients:

Measures Sl.

No

Objective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

SLR Test

2.33

2.01

0.32

28.00

0.556

0.111

2.873

<0.010

2

Coin Test

2.80

2.44

0.36

28.00

0.637

0.127

2.822

<0.010

3

a)

Schobers

Test

Flexion

2.50

2.26

0.24

24.00

0.435

0.087

2.752

<0.020

b)

Extension

2.11

1.67

0.44

36.00

0.650

0.130

3.38

<0.010

4 Pump

Handle

Test

2.80

2.52

0.28

32.00

0.541

0.108

2.584

<0.020

5

Tenderness

2.90

2.20

0.70

20.00

0.408

0.081

2.449

<0.020

Page: 121

Results


after follow up in 25 patients of katigraha are documented. The statistical analysis of

SLR test in control group revealed a moderate significance after follow up (P<0.010)

by 28%. Statistical analysis of coin test revealed a moderate significant change

(P<0.010) by 28%.

The statistical analysis of Schobers test for flexion showed a mild significance

(P<0.020) by 24% and for extension showed a moderate significance (P<0.010) by

36%.

The statistical analysis for pump handle test by control drug showed a mild

significance (P<0.010) by 32%. The statistical analysis of tenderness showed that the

control drug therapy provided a mild significance (P<0.020) by 20% after follow up.

Page: 122

Results

Table no:22

Effect of Trial drug combination on subjective parameters after treatment of 25

katigraha patients:

Measures Sl.

No

Subjective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

Pain

3.02

2.74

0.28

28.00

0.458

0.091

3.055

<0.010

2

Stiffness

2.98

2.62

0.36

36.00

0.489

0.097

3.674

<0.010

3

Lateral

Flexion

2.92

2.52

0.40

36.00

0.577

0.115

3.464

<0.010

4

Rotation

3.14

2.82

0.32

28.00

0.556

0.111

2.873

<0.010

In the present work, pain is scored as per Greenough and Fraser method, by following

twelve questions. Each question carries scores with a minimum of 0 to a maximum of

9. Higher the score, better the performance status. Each patient answered all the

questions in every 7 days of interval during the treatment. Hence, after 21 days the

total score was calculated and analyzed as per statistical methods. On examination,

the effects of Trial drug therapy on pain after treatment in 25 patients of katigraha

were documented. The statistical analysis of pain in trial group revealed a moderate

significance (P<0.010) by 28%. Statistical analysis of stiffness revealed a moderate

significance (P<0.010) by 36%.

The statistical analysis of lateral flexion showed a moderate significance (P<0.010) by

36% and for rotation showed a moderate significance (P<0.010) by 28%.

Page: 123

Results

Table no:23

Effect of Trial drug combination on subjective parameters after Follow up of 21

days on 25 katigraha patients:

Measures Sl.

No

Subjective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

Pain

3.02

2.30

0.72

68.00

0.541

0.108

6.646

<0.001

2

Stiffness

2.98

2.34

0.064

64.00

0.489

0.097

6.537

<0.001

3

Lateral

Flexion

2.92

2.16

0.76

64.00

0.663

0.132

5.728

<0.001

4

Rotation

3.14

2.42

0.72

64.00

0.613

0.122

5.865

<0.001

The statistical analysis of pain in trial group after follow up revealed a high

significance (P<0.001) by 68%. Statistical analysis of stiffness also revealed a high


The statistical analysis of lateral flexion showed a high significance (P<0.001) by

64% and for rotation showed a high significance (P<0.001) by 64%.

Page: 124

Results

Table no:24

Effect of control drug on subjective parameters after treatment of 25 katigraha

patients:

Measures Sl.

No

Subjective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

Pain

2.99

2.19

0.80

68.00

0.645

0.125

8.196

<0.001

2

Stiffness

3.00

2.68

0.32

28.00

0.556

0.111

2.873

<0.010

3

Lateral

Flexion

2.84

2.60

0.24

24.00

0.435

0.087

2.752

<0.020

4

Rotation

3.00

2.72

0.28

24.00

0.541

0.108

2.584

<0.020

The statistical analysis of pain in control group after treatment revealed a high



The statistical analysis of lateral flexion showed a mild significance (P<0.020) by

24% and for rotation also showed a mild significance (P<0.020) by 24%.

Page: 125

Results

Table no:25

Effect of control drug on subjective parameters after Follow up of 21 days on 25

katigraha patients:

Measures Sl.

No

Subjective

Parameter BT AT BT-

AT

% S.D

(+-)

S.E

(+-)

t

value

p value

1

Pain

2.99

2.71

0.28

20.00

0.613

0.122

2.281

<0.050

2

Stiffness

3.00

2.84

0.16

16.00

0.374

0.074

2.138

<0.050

3

Lateral

Flexion

2.84

2.64

0.20

16.00

0.50

0.10

2.00

<0.100

4

Rotation

3.00

2.72

0.28

16.00

0.737

0.147

1.899

<0.100

The statistical analysis of pain in control group after follow up revealed a mild

significance (P<0.050) by 20%. Statistical analysis of stiffness also revealed a mild


The statistical analysis of lateral flexion showed insignificance (P<0.100) by 16% and

for rotation also showed insignificance (P<0.100) by 16%.

Page: 126

Results

TOTAL EFFECT OF THERAPIES

Table no:26

Over all efficacy of Trial drug therapy after treatment on 25 Katigraha patients:

Category No. of patients %

Complete remission 0 0

Marked improvement 2 8

Moderate improvement 8 32

Mild Improvement 11 44

Unchanged 4 16

In this group 32% of patients were assessed under moderate improved category. 44%

patients were assessed under improved category. Only 8% showed marked

improvement. 16% were under unchanged category, where as nobody included under

complete relief.

Table no:27

Over all efficacy of Trial drug therapy after follow up on 25 Katigraha patients:






Unchanged 0 0

After follow up 40% of patients were assessed under moderate improved category.

36% patients were assessed under mildly improved category. 24% showed marked

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Results

improvement. Nobody was included in unchanged category and none was included

under complete relief.

Table no:28

Over all efficacy of control drug therapy after treatment on 25 Katigraha

patients:






Unchanged 1 4

In this group, 48% of patients were assessed under moderate improved category. 16%

patients were assessed under improved category. 32% showed marked improvement.

4% were under unchanged category, where as nobody included under complete relief.

Table no:29

Over all efficacy of control drug therapy after follow up on 25 Katigraha

patients:






Unchanged 8 32

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Results

After follow up, 12% of patients were assessed under moderately improved category.

52% patients were assessed under mildly improved category. Only 4% showed

marked improvement. 32% were under unchanged category, where as nobody

included under complete relief.

COMPARATIVE EFFECT OF THERAPIES

Table no:30

Comparative effect of therapies on objective parameters after treatment:

Groups SLR CT Flex Ext PHT Tenderness

Trial 44 36 40 40 40 32

Control 68 48 56 56 60 64

Graph no:14

Comparative effect of therapies on objective parameters after treatment:

01020304050607080

SLR CT Flx Ext PHT TND

From the above data, it is seen that the control group got better results after treatment

in all objective parameters.

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Results

Table no:31

Comparative effects of therapies on objective parameters after follow up:

Groups SLR CT Flex Ext PHT Tenderness

Trial 64 64 60 60 64 64

Control 28 28 24 36 32 20

Graph no:15

Comparative effects of therapies on objective parameters after follow up:

0

1020

30

40

5060

70

SLR CT Flx Ext PHT TND

The same data after the proposed period of follow up showed an increased relief and

better results in the trial group due to the long-standing effect of the therapy and less

side effects.

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Results

Table no:32

Comparative effects of therapies on subjective parameters after treatment:

Groups Pain Stiffness Lat flex Rotation

Trial 28 36 36 28

Control 68 28 24 24

Graph no:16

Comparative effects of therapies on subjective parameters after treatment:

0

10

20

30

40

50

60

70

Pain Stiffness Lat Flex Rotation

From the above data assessed on subjective parameters after treatment, a better relief

in the magnitude of pain was seen in the control group. In case of stiffness, lateral

flexion and rotation a better result was seen in the trial group.

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Results

Table no:33

Comparative effects of therapies on subjective parameters after follow up:

Groups Pain Stiffness Lat flex Rotation

Trial 68 64 64 64

Control 20 16 16 16

Graph no:17

Comparative effects of therapies on subjective parameters after follow up:

0

10

20

30

40

50

60

70

Pain Stiffness Lat Flex Rotation

The same data after follow up period showed a prominent relief of pain, stiffness, and

an increase in ability to lateral flex and rotation in the trial group.

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Results

OVER ALL COMPARATIVE EFFECTS

Table no: 34

Comparative effect of over all therapies after treatment:

Groups Complete Marked Moderate Mild Unchanged

Trial Group 0 8 32 44 16

Control Group 0 32 48 16 4

Graph no:18

Comparative effect of over all therapies after treatment:

05

101520253035404550

complete marked moderate mild unchanged

From the above data, it is clear that both groups do not provide complete relief. In the

marked improvement category, better results were seen in control group (32%). In the

trial group, marked improvement was seen in 8%.

In the moderately improved category also a high result was seen in control group, i.e.

48% where as 32% result was seen in trial group. In the mildly improved category,

trial group showed the better results i.e. 44% and in unchanged group trial group

showed 16%. The results for control group in above both categories were 16% and

4% respectively.

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Results

Table no:35

Comparative effects of over all therapies after follow up:

Groups Complete Marked Moderate Mild Unchanged

Trial Group 0 24 40 36 0

Control Group 0 4 12 52 32

Graph no:19

Comparative effects of over all therapies after follow up:

0

10

20

30

40

50

60

complete marked moderate mild unchanged

From the above data, it is clear that both groups do not provide complete relief after

follow up. In the marked improvement category, better results were seen in trial group

(24%). In the control group, marked improvement reduced to 8%.

In the moderately improved category also a high result was seen in trial group, i.e.

40% where as only 12% result was seen in control group. In the mildly improved

category, control group showed the better results i.e. 52% and trial group had 36%

results. In unchanged group, none remained in trial group where as in control group

32% remained.

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Discussion

DISCUSSION

The present dissertation work entitled – “Clinical Evaliuation of Katibasti and

Nirgundierandadi Kashaya in the Management of Katigraha” consist of following parts:

* Review of literature

* Clinical study

* Discussion

* Conclusion and Summary

Discussion about Review of literature:

Review of literature comprises of two separate chapters.

. The first chapter is named disease review. The first part of it, where brief description of

the historical aspect of the illness from Vedic era to the present time is being explored is

entitled as Historical review.

The second part of it elaborates the general description of disease

Katigraha. The etymological derivation, etiology, anatomy, clinical manifestations,

pathogenesis, prognosis and general principle of treatment Katigraha/Lowback ache are

discussed here.

The composition of the drug compounds Katigrahantaka Taila and

Nirgundi Erandadi Kashaya is detailed in the second chapter entitled Drug review. The

properties of the individual herbs used in the preparation of the medicinal compound in

brief are also given here.

The key points coming under these headings are being discussed below.

Vata is a force, which has got two functions; one is to recognize and other is to stimulate

all the activities in the body. Due to its Chala Guna it moves all over the body. The

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Discussion

movement or Gati of the motive force Vata, has to be analyzed properly. By virtue of this

property vata has the nature of moving to different parts of the body, localize there and

produce disease pertaining to that structure. Katigraha is not mentioned as a separate

disease condition in any of the Bruhatrayees directly. Even though Acarya caraka has not

mentioned the condition directly, but by his quotation “Hetu sthaana visheshat ca bhavet

roga vishesh krit” he has indirectly mentioned all those conditions which can arise due to

localization of vaata in specific parts of the body.

Katigraha is one such condition in which the vitiated vata is localizing in the

katipradesha and producing stiffness and pain there.

This is a condition in which the gatatva of vata can be considered. In case of

Gatatva the aggravated Vata finds a suitable place for its lodgment. The suitable place

may be such as Dhatu, Upadhatu, Ashaya, and Avayava. Due to consumption of Vata

Vardhaka Ahara and Vihara the aggravated Vata while moving throughout the body

lodges in Khavaigunya Yukta Srotas. After getting lodged at those parts it impairs the

functions of particular structure and produces disease.

Kati is an area where there is a conglomeration of various sandhis, snaayu, and

peshis. Sandhi is a place where two or more structure unites. In the context of Asthi

Sandhi means a junction between two bones. Sandhi is not a single structure rather it is

considered as an organ. There are different structures, which helps in maintaining the

stability of the joint. Snayu or ligament, are those structures which helps in proper

binding of the joint. They unite the bones and help to direct the bone movement and

prevent the excessive and undesirable motion. Muscle tone helps to maintain the

alignment of the joint. Shleshaka Kapha or Synovial fluid, which fills up the cavities,

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Discussion

occupies the Synovial joint, bursae and tendon sheaths. It provides the lubricant factors,

nutrient to the cartilage, disc, and helps in keeping the joint firmly united.

Shleshmadharakala situated in the joints supported by Shleshaka Kapha helps in

lubrication. Therefore the vitiation of vata can cause pathologies of these structures in the

kati pradesha leading to there hampered functioning.

The contemporary science explains the pathology of Katigraha in two settings.

One is due to the sub standard biomaterial of the joint (Dhatukshaya). Second is due to

increased applied pressure over the joint (Avarana). In Dhatukshya Janya Katigraham due

to old age and Vatakara Ahara Vihara there will be qualitative change in the joint

material gradually leading to disease manifestation. The other set of Samprapti where in

due to continuous pressure due to various factors like accumulated purisha the joint may

get affected (Due to Avarana) leading to disease manifestation. But here the characteristic

symptom of stiffness may or may not be seen but the referred pain can be obtained. This

demarcation in Samprapti helps in planning the treatment.

As Vata and Asthi are having Ashraya Ashrayi relation between them it

contributes to further worsening of symptoms. In addition to this, if the Marma related to

the low back region is affected, one can predict the prognosis of the condition as poor.

When there are structural changes in the joints the disease can be categorized as

Asadhya. The Cikitsa Sootra of Kati graha is Snehana, Svedana. Since it is a Vata Vikara

and Dhatukshaya is the resultant, Snehana and Svedana would be an ideal line of

treatment. In the contemporary science treatment is mainly aimed at Non–

pharmacological methods and analgesics. Among Non–pharmacological treatment

physical heat therapy is given importance. Katigraham is characterized by joint pain, and

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Discussion

stiffness. The heat applied to the joint helps in combating many of the symptoms. In

present clinical study, kati-basti may act both as Svedana and Snehana (as oil is used).

But in any of the allied sciences Snehana as principle line of management is not

mentioned. Since in this disease, as Vata is the Prakupita Dosha and Kshaya of Snehadi

Guna is seen which can result in degeneration, Snehana would be an ideal line of

management. Along with this, the administration of the kwatha will help in correcting the

movement of vaata by the property of anulomana by virtue of the guna and karma of

ingredients present.

Discussion about Kati Basti:

The present study deals with the evaluation of Kati Basti shows following analyzed

factors.

1. About Prakruti

2. About quantity of oil

3. About height of the dough

4. About diameter of the dough

5. About temperature

6. About duration

1. Prakruti:

In the present study, the patients who are having Vaata and kapha predominance showed

tolerance to temperature more than other Prakruti. Such persons were able to tolerate up

to 460 C temperatures. This owes to the quality of Vaata and Kapha wherein Seeta

predominance is observed. These recordings were done with the help of pyrometer. The

persons who were having Pitta predominant Prakruti i,e Pitta Vaata and Pitta Kapha

Page: 138

Discussion

showed minimum tolerance to temperature (410 C). This owes to the Pitta Dosha wherein

tolerance to Uhsna Guna is minimal. Hence it may be viewed that the persons who are

having predominance of Vaata and Kapha Prakruti may tolerate more temperature when

compared to Pitta predominant Prakruti.

2. Quantity of oil:

During the study, it has been observed and standardized that minimum of 250 ml of oil is

required per procedure. Less than 250 ml showed minimum improvement in the pain and

suggests the minimum requirement. More than 250 ml of oil shows the clinical

improvement similar to that of 250 ml. hence it may be opined that more than 250 ml is

also not beneficial.

3. Height of the dough:

After a systematic series of experimentation, it came to a conclusion that the height of the

dough must be 2 cm. if it is less than 2 cm, 250 ml of oil cannot be retained properly. If

the height is more than 2 cm it is also of no use.

4. Diameter:

Different diameters ranging from 6 cm to 15 cm were tried in this study. Ultimately 12

cm of diameter was considered as the ideal diameter as it was able to retain 250 ml of oil

in the stipulated 2 cm of the height. Simultaneously reduction in pain and other faculties

were also observed. Diameter less than 12 cm even though they are having 2 cm of height

could not retain 250 ml of oil.

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Discussion

5. Temperature:

In the present study the maximum temperature recorded was 460 C. Minimum of 410 C

was observed as the temperature tolerance. When we viewed the Prakruti it was related

with Kapha Vata and Pitta respectively.

Hence it may be viewed that a fixed temperature cannot be taken as norm.

6. Duration:

During this series, minimum of 30 minutes, maximum of 50 minutes time was observed.

This observation pertaining to minimum duration observed in Pitta predominant Prakruti

whereas maximum duration seen in Vaata Kapha predominance. This observation again

stress on individual Dosha/ Prakruti which is holding key in the decision of Samyak

Swinna Lakshanas. Hence it is not possible to put a maximum or minimum time barrier

for all the patients. A range of minimum of 30 minutes and maximum of 50 minutes may

be considered as standard.

In the above said parameters, parameters like duration, temperature varies in

different individuals. Remaining parameters like quantity of oil, height of dough,

diameter may be viewed as constants.

Clinical study is the topic of second part of dissertation. The materials and methods of the

present work with complete description of the assessment criteria are given here. The

descriptive statistical analysis of the sample taken for the study is methodically

elaborated. The observations, results and their statistical analysis are presented in order

with tables and graphs.

In the chapter entitled discussion, the results obtained are critically analyzed to reveal the

truth of efficacy of the combination taken for the study. The final conclusions drawn

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Discussion

from the present clinical research work are detailed in the chapter summary and

conclusion.

Discussion about clinical study:

This clinical study is a sincere effort to add newer combinations of shamana treatment

with proved efficacy to the list already present. The present work is carried out with the

hope that the treatment adopted here may have some edge over the other combinations

prescribed in routine practice. It is also hoped that this work will pave new avenues for

enthusiastic research workers to further advance in this field and find a better cure for this

lingering malady. With this noble intention this work is presented.

PLAN OF STUDY

The present study has been carried out on 50 patients treated in two groups. The criteria

of diagnosis was based upon the classical signs and symptoms of the disease and

confirmed by various clinical tests like SLR, Schobers test, coin test and pumphandle

test. The patients with marked deformities of spinal column and those with associated

systemic disorders were excluded from the study.

25 patients out of the total 50 patients of Katigraha studied underwent Katibasti with

Katigrahantaka taila and administration of Nirgundi erandadi Kashaya internally 50 ml

twice daily after food for 21 days.

25 patients of the second group were given the standard control drug Diclofenac sodium

50mg twice daily after food for 21 days. Follow up was given for 21 days from next day

after the treatment for both groups.

The improvement in the symptoms of the disease and the changes in the clinical tests

after the treatment were the main criteria of assessment. The total effects of the therapies

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Discussion

were also assessed in terms of complete remission, marked improvement, moderate

improvement mild improvement and unchanged.

DIAGNOSTIC CRITERIA AND ASSESSMENT CRITERIA:

To diagnose katigraha the main symptoms pain and stiffness was considered. Both

main symptoms of pain and stiffness were present in all patients but the intensity of pain

may defer from patient to patient.

Various movements of the spine were elicited by various objective and subjective criteria

including standard questionnaires. The objective criteria included SLR test, Schobers test,

coin test, pump handle test and grading for tenderness.

The subjective criteria included assessment of pain, stiffness, lateral flexion and rotation.

Pain was assessed by using the standard questionnaire of Greenough and Fraser method.

INVESTIGATION:

Routine hematological investigations like Hb%, TC, DC, ESR and Routine Urine

investigations were done in all cases. RBS and serum Cholesterol were done in some

cases to rule out systemic diseases. Routine radiological examination of the Lumbo sacral

spine in Antero posterior and lateral position was done in selected cases to rule out

various abnormalities.

NIDANATMAKA ASPECTS

Age:

Maximum numbers of patients were obtained in the age group of 31 – 50 years, i.e. 68%.

In the age group of 21 – 30 years 14% of patients were obtained, and in the age group of

51 – 60 years 12% of patients were recorded. Minimum numbers of patients were seen

from the age group 11 – 20, i.e. 6%.

This finding clearly shows that the age group of 31- 50 years are mostly affected.

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Discussion

Sex:

Male patients i.e. 62% exceeded the female patients who were 38%.This may be due to

demographic facts.

Religion:

Among the patients selected for the study 38% were Hindus, 30% were Muslims and

32% were Christians. This may be due to demographic facts.

Occupation:

More incidence (30%) were seen in patients from the labor category. 18% of patients

were from the service category and16% of patients from the business category.12% were

in student category and 10% were unemployed.

Maximum number of patients belonged to the categories of hardworking life style.

Nature of occupation:

Occupation which involved standing erect for long duration predisposed the patients to

strain of the back. In the present study 34% of the patients had similar occupation. 30%

had to travel in two wheelers etc .as a part of their occupation leading to strain at low

back. 14% of patients had to sit for long duration. 12% had to walk more and 10% had to

bend their back more as a part of their work.

Marital status:

Among the patients 66% were married, 32% were unmarried and 2% of them were

widows.

Socio-economic Status:

The study showed more incidences (50%) of the condition in patients hailing from a

lower socio economic conditions owing to the nature of work, condition of living etc.

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Discussion

About 30% of patients were from middle class and only 20% from upper class suffered

from the condition.

Dietary pattern:

Among the patients selected for the study 58% turned out to be non vegetarians and only

42% of them stuck to vegetarian food.

Family history:

Among the patients selected for the study 66% did not had a similar family history.

Only 34% of them had a related family history. This clearly shows that the disease have

no genetic predisposition.

Weight:

The incidence was more (30%) seen in patients having weight in the range of 61 – 70 kg.

22% of patients were from the weight category of 71 – 80 kg and 18% from the 51 – 60

kg range.

Nidana:

Maximum percentage of patients (58%) was seen with a history of indulgence in

Vaatakara viharas. Vaatakara ahaaras were observed in 34% of the patients and manasika

nidaanas were seen in 8%.

Main symptoms:

The two main symptoms of pain and stiffness were seen in all the patients.

Associated symptom:

About 64% of the patients had tenderness associated with the main complaints.

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Discussion

Discussion of Results:

EFFECT OF THERAPIES

The assessment of the results was made by adopting the standard methods of scoring

questionnaires and the signs and symptoms of katigraha. It included assessment for

objective and subjective criteria by means of various tests and standard questionnaires

along with all signs and symptoms as per Ayurvedic classics.

Effect of trial drug therapy on objective criteria after treatment:

On examination, the effects of Trial drug therapy on various objective parameters before

and after the treatment in 25 patients of katigraha are documented. The statistical analysis

of SLR test in trial group revealed that the mean SLR score of katigraha that was 2.35

before the treatment was reduced to 1.87 after the treatment. This change is statistically

highly significant (P<0.001) by 44%.

Statistical analysis of coin test revealed a highly significant change (P<0.001) by 36%.

The statistical analysis of Schobers test for flexion showed a moderate significance




therapy provided a moderate significance (P<0.010) by 32%.

Effect of trial drug therapy on objective criteria after follow up:

On examination, the effects of Trial drug therapy on various objective parameters after

follow up in 25 patients of katigraha are documented. The statistical analysis of SLR test

in trial group revealed that the mean SLR score of katigraha that was 2.35 before the

treatment was reduced to 1.59 after the follow up. This change is statistically highly

Page: 145

Discussion

significant (P<0.001) by 64%. Statistical analysis of coin test revealed a highly

significant change (P<0.001) by 64%.

The statistical analysis of Schobers test for flexion showed a high significance (P<0.001)

by 60% and for extension also showed a high significance (P<0.001) by 60%.




Effect of control drug therapy on objective criteria after treatment:


before and after the treatment in 25 patients of katigraha are documented. The statistical

analysis of SLR test in control group revealed that the mean SLR score of katigraha that

was 2.33 before the treatment was reduced to 1.45 after the treatment. This change is

statistically highly significant (P<0.001) by 68%. Statistical analysis of coin test revealed

a highly significant change (P<0.001) by 48%.

The statistical analysis of Schobers test for flexion showed a high significance (P<0.001)

by 56% and for extension showed a high significance (P<0.001) by 56%.

The statistical analysis for pump handle test by control drug showed a high significance

(P<0.001) by 60%. The statistical analysis of tenderness showed that the control drug


Effect of control drug therapy on objective criteria after follow up:

On examination, the effects of control drug therapy on various objective parameters after

follow up in 25 patients of katigraha are documented. The statistical analysis of SLR test

Page: 146

Discussion

in control group revealed a moderate significance after follow up (P<0.010) by 28%.

Statistical analysis of coin test revealed a moderate significant change (P<0.010) by 28%.

The statistical analysis of Schobers test for flexion showed a mild significance (P<0.020)

by 24% and for extension showed a moderate significance (P<0.010) by 36%.

The statistical analysis for pump handle test by control drug showed a mild significance

(P<0.010) by 32%. The statistical analysis of tenderness showed that the control drug

therapy provided a mild significance (P<0.020) by 20% after follow up.

Effect of Trial drug therapy on subjective parameters after treatment:

In the present work, pain is scored as per Greenough and Fraser method, by following

twelve questions. Each question carries scores with a minimum of 0 to a maximum of 9.

Higher the score, better the performance status. Each patient answered all the questions in

every 7 days of interval during the treatment. Hence, after 21 days the total score was

calculated and analyzed as per statistical methods. On examination, the effects of Trial

drug therapy on pain after treatment in 25 patients of katigraha were documented. The

statistical analysis of pain in trial group revealed a moderate significance (P<0.010) by

28%. Statistical analysis of stiffness revealed a moderate significance (P<0.010) by 36%.

The statistical analysis of lateral flexion showed a moderate significance (P<0.010) by

36% and for rotation showed a moderate significance (P<0.010) by 28%.

Effect of Trial drug therapy on subjective parameters after follow up:

The statistical analysis of pain in trial group after follow up revealed a high significance

(P<0.001) by 68%. Statistical analysis of stiffness also revealed a high significance

(P<0.001) by 64%.

Page: 147

Discussion

The statistical analysis of lateral flexion showed a high significance (P<0.001) by 64%

and for rotation showed a high significance (P<0.001) by 64%.

Effect of control drug therapy on subjective parameters after treatment:

The statistical analysis of pain in control group after treatment revealed a high



The statistical analysis of lateral flexion showed a mild significance (P<0.020) by 24%

and for rotation also showed a mild significance (P<0.020) by 24%.

Effect of control drug therapy on subjective parameters after follow up:

The statistical analysis of pain in control group after follow up revealed a mild

significance (P<0.050) by 20%. Statistical analysis of stiffness also revealed a mild


The statistical analysis of lateral flexion showed insignificance (P<0.100) by 16% and for

rotation also showed insignificance (P<0.100) by 16%.

Probable mode of action of KatiBasti

It is very difficult to explain and conclude regarding the exact mode of action of Kati

Basti. Here an attempt is made to explain the probable mode of action of Kati-Basti.

Kati-Basti is a Bahya Svedana, Snehana (if oil is used) and more over it is an Sthanika

Shamana Cikitsa.

Acarya Sushruta in Shareerasthana explains – Out of the four Tiryak Dhamanis,

each divides gradually hundred and thousand times and thus become innumerable. These

cover the body like network and their openings are attached to Romakoopa. Through

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Discussion

them only Veeryas of Abhyanga, Parisheka, Avagaha, Alepa enter into the body after

under going Paka with Bhrajaka Pitta in skin (Su.Sa.Sh.9/9 & Dal).

One more reference in Sushruta Cikitsasthana explains – Sneha used in Avagaha

produces Shareera Bala by saturating through Siramukha, Romakoopa and Dhamani

(Su.Sa.Ch.24/33).

Sushruta in Sutrasthana explains, Lepa like Bahirparimarjana treatments yield

result by entering to Romakoopa thereby circulating through Svedavaha Srotas

(Su.Sa.Su.18/4).

Vagbhata in Ashtanga Hridaya while explaining the functions of Bhrajaka Pitta

narrated that – Bhrajaka Pitta will be do Pacana of drugs used in Abhyanga, Parisheka,

and Lepa (A.H.12/14 & Aru, A.S.20).

Thus with the above references it can be said that drugs used in KatiBasti

procedure get absorbed through and produce action according to the property of the

medicine.

Kati-Basti procedure is a Bahya Shamana Cikitsa. It is Bahya Svedana and

Snehana (If Sneha is used) therapy. Svedana has the functions of neutralizing Stambha,

Gaurava and Sheetata. In Katigraham joint stiffness is one of the clinical features. Kati-

Basti is considered to have action on this symptom. The Stabdhata of Sandhi is mainly

due to Sheeta property of Vata. This Sheeta Guna is neutralized by Ushna Guna of

retained medicine.

As Sneha Dravya is used as media in case of Katibasti their action further

facilitates in alleviating Vata. Sneha Dravya has Drava, Sara, Snigdha, Picchila, Guru,

Sheeta, Mrudu and Manda Guna predominantly. The Vata Dosha, which is the key factor

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Discussion

in the casuation of Katigraha, has almost opposite quality to this. Moreover Sneha

Dravya has similar property to that of Kapha Dosha. In Katigraham Sthanika

Kaphakshaya is due to Agantu Vata Dosha. Thus on one hand Sneha Dravya neutralizes

the Vata Dosha and on the other hand nourishes the Sthanika Kapha Dosha. This helps in

Samprapti Vighatana.

Mode of action of Katigrahantaka Taila

Taila is considered to have the supreme action against vata to pacify it and when it is

processed with efficient vaatahara drugs its action is amplified. The taila used here as

base is Tila taila. Tila is an excellent vata hara drug possessing guru snigdha properties

and ushna veerya. It also has the karma of vedana sthapana thus making it efficient in

alleviating pain.The prescribed taila for katibasti is having the drug Nirgundi as the chief

ingredient. As the taila is prepared with the svarasa of nirgundi the action is enhanced.

Nirgundi is an efficient vatahara drug possessing ushna veerya and is having the

property of sroto shodhana. This property is making it capable to correct the gati of vata.

Apart from this the vedanasthapana property nirgundi owes to pacification of pain and

balya property helps in strengthening of affected part.

Hingu and Lashuna are drugs possessing ushna veerya. This potency of the drugs makes

it capable of subsiding vata making it an efficient vata hara drug.

Shunthi, Pippali and Maricha are also efficient vaata hara drugs and possess teekshna

guna which makes them srotoshodhaka thus helping in proper penetration of the qualities

of oil in to the system. They also possess the vedanasamaka karma helping in subsiding

pain. Moreover they have the rasayana property helping in Dhatu vardhana or proper

nourishment of the affected area.

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Discussion

Mode of action of Nirgundi erandadi kashaya

Katgraha is a disease in which vata is the vitiated dosha and while adopting the treatment

measures, correction of gati of vata becomes the prime factor to be noted. The prescribed

kashaya owing to the special properties of the ingredients present is considered to have

this action of rectifying the gati of vata. If we are observing the properties of individual

drugs present in the combination the mode of action can be better understood.

Nirgundi is the drug possessing ushna veerya and it helps in attaining anulaomana of

vata. It is an efficient srotoshodhaka helping in rectifying the gati of vata.

Eranda is considered as efficient vata hara as it possess guru snigdha gunas and ushna

veerya. It is vata anulomaka and is vedanasthapaka helping in pacifying pain.

Sahachara is having ushna veerya helping in subsiding vata. It is vedanasthapaka and

nadibalaprada helping in subsiding pain and strengthening of nerves.

Bala is an efficient rasayana drug having supreme action of pacifying vata by its guru

snigdha gunas. It is also having anulomana property correcting the gati of vata. It is

nadibalaprada and balya helping in strengthening of nerves. The brumhana and rasayana

property makes it efficient in dhatu vardhana.

Sunthi is also an efficient vatahara drug possessing ushna veerya and helps in enhancing

the action of other drugs involved in the combination thus increasing the efficiency of the

medicine. It helps the medicine to get metabolize easily and completely. It also shows its

action in the cellular level (Dhatwagni) and helps the cells to uptake the medicine in

optimum level.

Page: 151

Discussion

Role of media

Amount of heat given to the Taila, Kvatha materials privilege interchange of Gunamsha

of both the media and Dravyas. Both Vayu and Agni among Pancha Maha Bhootas

processes Laghu, Sookshma Gunas predominantly. In the process of Taila and Kvatha,

indirect Agni is given to the material. Ions of media will receive the Ushma and they

trespass into the Dravya, which is already drenched or sunken in the fluid and got

softened. Thus ions of water or oil penetrate into the drug and release entire Gunamsha of

Dravya. When such Kvatha, or Taila is administered either externally or internally it

induces the effects of the Dravya.

Mode of action and adverse effects of control drug Diclofenac Sodium134

It inhibits Prosta glandin synthesis reducing pain and inflammation. It also reduces

neutrophil chemotaxis and superoxide production at the inflammatory site reducing

inflammation. It is well absorbed orally, metabolized and excreted in both urine and bile.

The plasma T1/2 is ~2 hrs. It has good tissue penetrability & concentration in synovial

fluid is maintained for 3times longer period than in plasma, exerting extended therapeutic

action in joints.

Adverse effects of diclofenac sodium include epigastric pain, nausea, headache,

dizziness, rashes. In few cases gastric ulceration and bleeding are seen.

Page: 152

Discussion

ABSORPTION THROUGH SKIN

The skin anatomically consists of three distinct layers.

The epidermis

It consists of keratinocytes, melanocytes, langerhan’s cells and merkel cells. The

terminal point of keratinocytes differentiation is the formation of the stratum corneum.

Formation of this layer is the most important function of the epidermis. It protects the

skin against water loss, prevents the absorption noxious agents, and can be thought of as

consisting of bricks and mortar. Corneocytes forms the bricks and barrier lipids form the

mortar. ‘Granular cells’ which are stratum corneum helps in maintaining skin hydration

and their products serve as ultra violet filters. Lamellar granules also are found within

granular cells. These contain probarrier lipids.

Dermis

It is a thick, highly vascular layer made up of ground substance, fibroblasts and

collagen fibers, together with appendages of skin, sweat glands and pilosebaceous

follicles. It is metabolically active part of the skin.

Subcutaneous Tissue

It is a fibro fatty layer with varying quantities of adipose tissue in different

regions of the body. It provides physical and thermal protection to the deeper structures

of the body.

Drug Delivery

The primary barrier to absorption of exogenous substances through the skin is

stratum corneum. Rate of absorption is directly proportional to concentration of drug in

vehicle, partition co-efficient, diffusion co-efficient and thickness of the stratum

Page: 153

Discussion

corneum. Physiological factors that effect per cutaneous absorption include hydration,

occlusion, age, intact versus disrupted skin, temperature and anatomic site.

Among vehicles greases are anhydrous preparations that are either water insoluble or

fatty. Fatty agents are more occlusive than water-soluble. They restrict transepidermal

water loss and hence preserve hydration of the stratum corneum.

Absorption depends upon lipid solubility of the drug since the epidermis is a lipid

barrier. The dermis however is freely permeable to many solutes. Suspending the drug in

an oily vehicle can enhance absorption through the skin. Because hydrated skin is more

permeable than dry skin.

Application of medicaments, heat and massage definitely helps in eliminating the

number of noxious elements through skin. The application of heat in different forms of

Svedana promotes local circulation and metabolic activities and also opens the pores of

the skin to permit transfer of medicaments and nutrients towards to needed sites. It also

initiates elimination of vitiated Doshas and Malas through skin and perspiration.

PHYSIOLOGICAL EFFECTS OF HEAT

Heating the tissues results in increased metabolic activity, increased blood flow

and stimulation of neural receptors in the skin or tissues and many other indirect effects.

• Increased metabolism

The increase in metabolism is greatest in the region where most heat is produced,

which is in the superficial tissues. As a result of the increased metabolism there is an

increased demand for oxygen and foodstuffs, and an increased output of waste products,

including metabolites.

Page: 154

Discussion

• Increased blood supply

As a result of increased metabolism, the output of waste products from the cells is

increased. These include metabolites, which act on the walls of the capillaries and

arterioles causing dilatation of these vessels. In addition, the heat has a direct effect on

the blood vessels, causing vasodilatation, particularly in the superficial tissues where the

heating is greatest. Stimulation of superficial nerve endings can also cause a reflex

dilatation of the arterioles. As a result of vasodilatation there is an increased flow of

blood through the area so that the necessary oxygen and nutritive materials are supplied

and waste products are removed.

• Effects of heating on nerves

Heat appears to produce definite sedative effects. The effect of heat on nerve conduction

has still to be thoroughly investigated. Heat has been applied as a counter irritant, which

is the thermal stimulus, may effect the pain sensation as explained by the gate theory of

Melzack and Wall.

Indirect effects of heating

o Muscle tissue – Rise in temperature induces muscle relaxation and increases the

efficiency of muscle action, as the increased blood supply ensures the optimum

conditions for muscle contraction.

o General Rise in temperature – As blood passes through the tissues in which the

rise of the temperature has occurred, it becomes heated and carries the heat to

other parts of the body, so that if heating is extensive and prolonged a general rise

in temperature occur.

Page: 155

Discussion

o Fall in blood pressure – If there is generalized vasodilatation the peripheral

resistance is reduced, and this causes a fall in blood pressure. Heat reduces the

viscosity of the blood, and this also tends to reduce the blood pressure.

o Increased activity of sweat glands – There is reflex stimulation of the sweat

glands in the area exposed to the heat, resulting from the effect of the heat on the

sensory nerve endings. As the heated blood circulates throughout the body it

affects the centers concerned with regulation of temperature, and there is

increased activity of the sweat glands throughout the body.

(Ref. The pharmacological basis of therapeutics – Goodman and Gillman, Physiology by

Robert M. Berne, Clayton’s Electro therapy by Angela Forster, Nigel Palastanga, Text

book of Pharmacology by K.D. Tripati)

Page: 156

Conclusion

CONCLUSION

Based on the conceptual analysis and observations made in the clinical study, the

following conclusions can be drawn.

The disease Katigraha is a sthana vishesha vatavyadhi.

Strenuous physical work, old age and direct abhigata are the predisposing

factors in the manifestation of the disease.

Maximum incidence of this disease was seen in the age group of 31-50 years.

Work power decrease with the chronicity of the disease.

The trial drug combination of Katibasti and Nirgundi Erandadi kashaya

showed high significance in decreasing pain, stiffness and tenderness, which

was noted completely after follow up(P<0.001).

Control drug therapy showed significant result in reducing pain and tenderness

soon after the treatment but recurrence of the condition was seen after the

follow up period and the significance decreased(P<0.050). It had a mild result

in decreasing the stiffness. Moreover, the control drug Diclofenac sodium was

reported to give various side effects like gastric irritation on the course of the

treatment.

On comparison of both groups after the follow up period, it is found that the

trial drug therapy was more efficient in relieving the signs and symptoms of

katigraha.

LIMITATIONS

The sizes of sample and time period were small to draw a generalized

conclusion. Therefore, the therapy can be tried in a large sample for

appropriate duration to observe its proper efficacy.

Page: 157

Conclusion

The procedure of katibasti was a long-standing procedure, which needed

admission in hospital and specialized care.

RECOMMENDATION FOR FURTHER STUDY

The study is advised on large samples.

Change in formulations in the capsule forms for better palatability and easy

administration.

Various other vatahara tailas told in classics and those used as folklore

medicines can be used after proper assessment.

Page: 158

Summary

SUMMARY

The present dissertation entitled “A CLINICAL EVALUATION OF KATIVASTHI

AND NIRGUNDI ERANDADI KASHAYA IN THE MANAGEMENT OF KATIGRAHA” has

been carried out to find out the efficacy of the therapeutic combinations of Kativasthi

with Katigrahantaka Taila and Nirgundi erandadi kashaya in comparison with control

drug Diclofenac sodium. This study contains Introduction, Objectives, and Review of

literature, Methodology, Results, Discussion and Conclusion.

Chapter 1 - Objectives of the study is explained.

Chapter 2 - Review of literature has detailed descriptions regarding the disease

Katigraha according to the classics. The description about the most resembling

conditions of Katigraha in modern science and treatment has been dealt in detail. The

ingredients of the trial drugs have been studied and explained in brief.

Chapter 3 – Methodology- Material and methods includes criteria for selection and

grouping of patients, treatment schedule and grading of the disease etc. are explained.

Observation of patients includes distribution of patients according to age, sex;

economical status, diet etc. are represented along with the tables and charts.

Chapter 4 – Results – Results of the therapies after the treatment, after follow-up

along with the statistical analysis are mentioned along with tables and charts.

Chapter 5 – Discussion – Includes elaborate discussion about disease, chikitsa, result

of therapies and probable mode of action of drugs.

Page: 159

Summary

Chapter 6 - Conclusion – It is concluded that the combination of trial drugs

“Kativasthi with Katigrahantaka Taila and Nirgundi erandadi kashaya” has a highly

significant result in providing better relief on the main and associated symptoms of

Katigraha compared to the control drug Diclofenac Sodium.

Page: 160

References

REFERENCES

No. Name of book Reference 1. Ca.Sa. Vi 8/ 18 2. Harrison’s Page 116 3. L.B.P.H.B Page 13 4. Ca. Sa Chi. 28/ 101 5. Rigveda 10/ 163 6. Yajurveda 9/ 21 7. Atharva veda 3/11/6 8. Atharva veda 19/60/2 9. Atharva veda 19/67/45 10. Atharva veda 9/8/21 11. Atharva veda 2/33/2 12. Atharva veda 2/33/2, 5, 6 13. Atharva veda 9/37, 21 14. Rig veda 10/163/2, 4 15. Atharva veda 9/7/7, 18 16. Kenopanishad 3/10 17. Chandogyopanishad 4/16/1 18. Chandogyopanishad 4/3/1 19. Kathopanishad 3/10 20. Prashnopanishad 3/7 21. Brahmasootra 1/5/3 22. Garuda purana 146 & 156 chapters 23. Ca.Sa.Su 20/11 24. Ca.Sa.Su 14/22 25. Ca.Sa.Su 17/101 26. Ca.Sa.Chi 28/56 27. Ca.Sa.Su 26/4 28. Ca.Sa.Ni 1/21 29. Ca.Sa.Su 16/8 30. Ca.Sa.Chi. 28/56 31. Ca.Sa.Chi 28/29 32. Ca.Sa.Chi 14/11 33. Su.Sa.Ni 1/23 34. Su.Sa.Ni 2/10 35. Su Sa.Ni 9/36 36. Su.Sa. Ka 4/37 37. A.H.Ni 15/7 38. A.H.Ni 16/5 39. Madhava Nidana 4/17-2 40. Madhava Nidana 5/12 41. Madhava Nidana 5/28 42. Madhava Nidana 25/8 43. Madhava Nidana 27/18 44. G. N 16/160 45. G. N 2/100

References

46. G. N 2/146 47. Sh. Sa. Pra 7/105 48. Amar 49. Sa. K.D., vol. II Page no. 348,349 50. Sh. Sa 7/110 51. Amar 52. Su.Sa.sh 5/24 53. Su.Sa.sh 5/27 54. Su.Sa.sh 5/27 55. A.H. Su 12/18 56. Su.Sa.sh 4/14, 15 57. Dalh. On Su. Sa. Ni 1/13 58. A. H. Su 11/26-28 59. Su.Sa Sh 5/29-36 60. Su.Sa Sh 5/37-38 61. Su.Sa Sh 5/16 62. L.B.P.H.B 63. A.H.Ni 1/10 64. Ca.Sa.Chi 28/15-17 65. BPN 24/1-2 66. Su.Sa.Su 21/19-20 67. Su.Sa.Ni 1/67,68,79 68. A.S.Ni 15/31,34,41 69. A.H.Ni 1/14,15 70. A.H.Ni 15/29,32,33,47 71. Ca.Sa.Chi 28/59 72. A.S.Ni 15/7,8 73. A.H.Ni 15/5,6 74. Ca.Sa.Chi 28/18-19 75. A.H.Ni 15/5-6 76. Ca.Sa.Ni 1/8 77. Ca.Sa.Chi 28/19 78. Ca.Sa.Chi 28/23 79. A.H.Su (Arunadatta) 12/49 80. A.H.Su(Hemadri) 12/49 81. Su.Sa.Ni(Dalh.) 5/13 82. Harrison’s Page 74 83. Harrison’s Page 74 84. Das. Sur. Page 200 85. Harrison’s Page76 86. L.B.P.H.P Page 87. Harrison’s Page77 88. Das.Sur. Page 201 89. Das.Sur Page 202 90. Das.Sur Page 202 91. Das.Sur. Page 200 92. Das.Sur. Page201 93. Harrison’s Page77

References

94. Harrison’s 95. Ca.Sa.Su 10/7 96. Ca.Sa.Chi 28 97. A.H.Ni 8/30 98. Su.Sa.Su 33/4 99. Su.Sa.Su 33/7 100. Su.Sa.Chi 24/30 101. Ca.Sa.Chi 28/83 102. A.S.Chi 23 103. A.S.Chi 23 104. Ca.Sa.Su 1/40 105. Vg.Sa 574-576 106. Su.Sa.Chi 35/29-30 107. Ca.Sa.Su 22/11 108. Ca.Sa.Su 22/16 109. A.S.Su 26/41 110. Su.sa.chi 32/1 111. A.H.Su 17/1 112. Ca.Sa.Su 14/39-40 113. A.S.Su 27/7 114. Ca.Sa.Chi(Chakrapani) 32 115. BPN sweda vidhi 116. H.Sa 4/1 117. A.S.Su 26/22 118. Su.Sa.Chi 32/22 119. A.S.Su 26/37 120. BP 121. Y.R. vatavyadhi Chikitsa 122. B.R. Vataroga 6 123. Sahasrayoga 124. P.V.S Page no 66 125. P.V.S Page no 58 126. P.V.S Page no 185 127. P.V.S Page no 734 128. P.V.S Page no 331 129. P.V.S Page no 350 130. P.V.S Page no 72 131. P.V.S Page no 275 132. P.V.S Page no 362 133. P.V.S Page no 120 134. Med. Pharm Page no 462

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Clinical Proforma Department of Kayachikitsa

A.L.N. Rao Memorial Ayurvedic Medical College Koppa-577126, Chikmagalur

PROFORMA FOR CLINICAL STUDY ON KATIGRAHA

P.G. Scholar: Dr. Sarat.k.Babu Guide: Dr. T.K.Mohanta Co-guide: Dr Rashmi.R.Mishra

B.A.M.S. M.D(Ay),Ph.D M.D(Ay).

Part A: Examination

Name of the Patient : Case No. :

Age : O.P. No. :

Sex : Male / Female I.P. No. :

Religion H/M/C/O : Ward No. :

Marital Status M/UM/W/D : Bed No. :

Socio-economic class : P/M/UM/UC Date of Commencement :

Education : Un/Pr/Sec/Gr Date of Completion :

Occupation : HW/W/B/S/E

Address : Group :

A) Trial

B) Control

I. Chief Complaint Duration BT AT AFU

a) Pain

b) Stiffness

II. Associated Complaint

a) Tenderness

III. History of Present illness

A) Mode of onset

B) History of injury

C) Part first affected (Order of affection)

D) Pain

i) Mode of Onset – Trauma / Spontaneous

ii) Onset – Acute / Chronic

iii) Duration of pain

iv) Site of pain

v) Character

Intensity of pain – Mild / Moderate / Severe / No

E) Predisposing Factors

a) Movements

b) Increased Intra abdominal pressure

c) Seasonal variation

d) Diurnal variation

IV. History of Past illness

A) History of Trauma

B) History of Anesthesia

C) Did the pain begin after delivery Y N Not Significant

D) Treatment history -

Did the patient undergo treatment for:

a. T.B.Spine Y N

b. Osteo myelitis Y N

c. I.V.D.P Y N

d. Tumor Y N

e. Any other disease Y N

If so details: Medicine

Local application

Surgery / Traction etc.,

V. Family History

VI. Personal History

A) Ahara : Veg / Mixed

Habit: Samasana / Vishamasana / Adhyasana / Anasana

Rasapradhana : M/A/L/K/T/KS/Sarva rasa

B) Agni : Samagni / Mandagni / Vishamagni/Tikshnagni (BT), …….. (AT)….(AFU)

C) Koshta : Mridu / Madhyama / Krura (BT), …….. (AT)….(AFU)

D) Nidra : Sound / Disturbed / Irregular / Ratri jagarana

E) Vyasana : Alcohol / smoking / tobacco chewing / Others

F) Vihara: Exercise - Regular/Irregular/Occasional/Only routine work

G) Malapravrutti : Regular / Irregular / Constipation

Loose / Soft / Hard.

Frequency ……………

H) Mootrapravrutti : Regular / Irregular ……….times / day ……..times / night

Color :

VII. Occupational History

Nature of work: Sedentary/Moderate/Heavy

Time of work: Day / Night / Day and Night

VIII. Social History

Hygienic Condition of residence: Poor / Moderate / Good.

IX. Gynecological/Obstetrics History

Part - B

I. General Examination

BT …. AT….AFU

Pulse -

BP -

Heart rate -

Temperature -

Pallor -

Icterous -

Cyanosis -

Clubbing -

Pedal Edema -

Lymphadenopathy

Posture - Asymmetry of shoulders/iliac crests/trochanteric heights

Gait - Painful/Painless

Asymmetry of movements: Present / absent

Dasha vidha Pareeksha

• Prakruthitha – V/P/K/VP/VK/PK/VPK

• Vikruthitha – P/M/A

• Satwatha – P/M/A

• Satmyatha – P/M/A

• Sarathaha – P/M/A (T/R/M/Me/A/Mj/Sh/S)

• Samhanatha – P/M/A

• Aharatha – Abhyavaharana P/M/A (BT), P/M/A (AT)

– Jaranashaktitha P/M/A (BT), P/M/A (AT)

• Vyayamashaktitha – P/M/A

• Pramanatha – Height ……….. ft..…inches

Weight …….kg.

• Vayatha – Baala / Madhyama / Vruddha

B) Ashtavidha Pareeksha

Nadi

Mootra

Mala

Jiwha

Shabda

Sparsha

Drik

Akruthi

C) Srotho Pareeksha

1. Pranavaha: Prakruta Vaikruta

2.Udakavaha: Prakruta Vaikruta

3.Annavaha: Prakruta Vaikruta

4.Rasavaha: Prakruta Vaikruta

5.Raktavaha: Prakruta Vaikruta

6.Mamsavaha: Prakruta Vaikruta

7.Medovaha: Prakruta Vaikruta

8.Asthivaha: Prakruta Vaikruta

9.Majjavaha: Prakruta Vaikruta

10.Sukravaha: Prakruta Vaikruta

11Artavavaha: Prakruta Vaikruta

12.Swedavaha: Prakruta Vaikruta

13.Mutravaha: Prakruta Vaikruta

14. Purishavaha Prakruta Vaikruta

II. Systemic Examination

a) Gastro Intestinal Tract

b) Respiratory System

c) Cardio Vascular System

d) Central Nervous system

e) Loco motor system

• REFLEXES –

Superficial - Plantar

Deep - Knee jerk

- Ankle jerk

III. Local Examination BT…….AT…..AFU

I. a) Inspection

i) Swelling: Present / absent

ii) Alteration in curvature of spine: Present / absent

iii) Muscular wasting: Present / absent

iv) Discoloration: Present / absent

v) Scar/Bruise: Present / absent

vi) Wasting: Present / absent

b) Palpation BT….AT….AFU

i) Local temperature: Present / absent

ii) Local tenderness: Present / absent

iii) Rigidity : Present / absent

c) Percussion

i) Local tenderness: Present / absent BT….AT….AFU

II. Movements

i) Flexion BT….AT….AFU

ii) Extension BT….AT….AFU

iii) Lateral Flexion BT….AT….AFU

iv) Rotation BT….AT….AFU

- Does any of the movement cause pain Yes / No

-Is there any restriction of movements Yes / No

iii. Tests

a) SLRtest

b) Pump handle test

c) Schober’s Test

d) Coin test

IV. Investigation

1. Hematological Investigation: Hb,TC, DC, E.S.R

R.B.S., Serum cholesterol, RA

Factor if needed

2. Routine Urine Investigation: Alb

Sugar

Micro

3. Radiology : X-ray of Lumbosacral spine: AP,

Lateral (if needed)

ASSESSMENT CRITERIA

A) Objective

Signs and Symptoms

Tenderness Coin test

Pump handle test

SLR test

Flexion Extension

BT AT

B) Subjective

Signs and Symptoms

Pain Stiffness Lateral Flexion

Rotation

BT AT

PAIN Parameters BT 7AFU 14AFU 21AFU

Painkillers Consultations Work Rest Household job Sports/dancing Dress wearing Sitting Walking Sleep Travel Sexual life

Symptoms Method BT 7AFU 14AFU 21AFU

Pain Greenough and Fraser scoring method

Scoring Chart

A) OBJECTIVE

i)Tenderness

0 No Pain

1 Patient says it’s paining

2 Patient winces

3 Patient winces and withdraws the part

4 Patient dos not allow to touch the part

ii) Range of Movement

Schobers test ♦ Extension


1 Extension up to 2 cm


0 Extension < 1 cm

♦ Flexion




3 Flexion <1 cm

iii) Other Tests

♦ Straight leg raising test





4 Cannot lift

♦ Coin test

0 Can bend without difficulty

1 Can bend with difficulty but no support

2 Can bend with difficulty but need support

3 Cannot bend

♦ Pump handle test

1 Can perform the test

2 Can perform the test with difficulty

3 Cannot perform the test

B) SUBJECTIVE

•Lateral Flexion

0 Can do lateral flexion easily

1 Can lateral flex with difficulty

2 Cannot perform lateral flexion

•Rotations

0 Can rotate easily

1 Rotation with difficulty

2 Cannot rotate

• Stiffness

0 None

1 Less than 15 minutes

2 15 to 30 minutes.

3 More than 30 minutes.

• Pain

0 No Pain (score 61-66)

1 Mild (score 41-60)

2 Moderate (score 21-40)

3 Severe (score <20)

• Pain -Greenough and Fraser scoring method: Question Answer Points

Never 6 Occasionally 4

Almost every day 2 How often do you have to take pain killers for your pain?

several times every day 0 Never 6 Rarely 4

1-2 times per month 2 How often do you have consultation with a doctor?

1-2 times per week 0 full time at regular job 9 full time at a lighter job 6

part time 3 At present, are you working?

not working 0 not at all 6 a little 4

half the day 2 So you need to rest during the day because of pain?

Over half the day 0 Normally 9

as many as usual, but slowly 6 A few, not as many as usual 3

At present, can you undertake household chores or additional jobs?

not at all 0 as much as usual 9 At present, can you undertake sports or

active pursuits, such as dancing? almost as much as usual 6

Some, much less than usual 3 not at all 0 no effect 3

mildly or moderately affected 2 Difficult 1

How much does back pain affect your ability to dress?

not possible 0 no effect 3


How much does back pain affect your ability to sit?



How much does back pain affect your ability to walk?



How much does back pain affect your ability to sleep?



How much does back pain affect your ability to travel?



How much does back pain affect your sex life?

not possible 0 • The higher the score, the better the performance status.

V. Provisional Diagnosis:

VI. Final Diagnosis:

Part – C

Treatment Schedule

Trial Group -






Control Group -




Any Complications -

Part D

Pathya / Apathya

Signature of the Researcher Signature of the Guide

POST GRADUATE STUDIES AND RESEARCH CENTRE

DEPARTEMENT OF KAYACHIKITSA

A.L.N. RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE

KOPPA-CHICKMAGALUR

PATIENT CONSENT FORM

I __________________________________________ exercising my free power of

choice, hereby give you my complete consent to be included as a subject in the

Clinical trial on “A CLINICAL EVALUATION OF KATIVASTHI AND NIRGUNDI ERANDADI

KASHAYA IN THE MANAGEMENT OF KATIGRAHA”. I have been informed to my

satisfaction by the attending Doctor, the purpose of the Clinical Trial and the nature of

drug treatment, therapeutic procedures, follow-up and probable complications. I am

also ready to undergo necessary Laboratory Investigations to monitor and safeguard

my body functions.

I am also aware of my right to opt out of the trial at any time during the course

of the trial without having to give the reasons for doing so.

Signature of the Doctor Signature of the Patient/Guardian (£Á£ÀÄ N¢/ N¢¹ CxÀð ªÀiÁrPÉÆAqÀÄ

¸À» ºÁQgÀÄvÉÛÃ£É.)

katigraha kc002 kop

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