sandhivata kc004 kop
DESCRIPTION
Management of Sandhigata vata with ‘Trayodashanga Guggulu’- A clinical evaluation, Guruprasad. Aggithaya, PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa.TRANSCRIPT
BY Dr. Guruprasad Aggithaya
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 Prof. Pramod Kumar Mishra
M.D (Ayu) (RSU) HOD. Dept. of Kayachikitsa
DEPARTMENT OF POST GRADUATE STUDIES IN KAYA CHIKITSA A.L.N.RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE, KOPPA -
577126 CHIKMAGALUR DISTRICT, KARNATAKA, INDIA
SEPTEMBER - 2006
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 “Management of Sandhigata
vata with ‘Trayodashanga Guggulu’- A clinical evaluation” is a bonafide and
genuine research work carried out by me under the guidance of Prof. Pramod Kumar
Mishra 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. Guruprasad. Aggithaya P.G.Scholar,
Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
A.L.N.Rao Memorial Ayurvedic Medical College, Koppa – 577126 Dist: Chikmagalur
Department of Post Graduate Studies in KAYA CHIKITSA
Certificate
This is to certify that the dissertation entitled “Management of Sandhigata
vata with ‘Trayodashanga Guggulu’- A clinical evaluation” is a bonafide research
work done by Dr. Guruprasad Aggithaya 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:Prof. Pramod Kumar Mishra
M.D(Ayu) (RSU) HOD, P.G. Studies in Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
A.L.N.Rao Memorial Ayurvedic Medical College, Koppa – 577126 Dist: Chikmagalur
Department of Post Graduate Studies in KAYA CHIKITSA
Endorsement
This is to certify that the dissertation entitled “Management of Sandhigata
vata with ‘Trayodashanga Guggulu’- A clinical evaluation” is a bonafide research
work done by Dr. Guruprasad Aggithaya under the guidance of Prof. Pramod
Kumar Mishra, 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. Tarani Kanta Mohanta M.D.Ph.D (Ayu)(Jamnagar)
Dean, 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. Guruprasad Aggithaya
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
INDEX
Page No.
INTRODUCTION 1-3
Chapter – I OBJECTIVES 4
Chapter – II REVIEW OF LITERATURE 5-46
DISEASE REVIEW
Historical Review 5-8
Etymiology 8-10
Anatomical aspect of Sandhi 10-15
Nidana 16-23
Poorvarupa 24
Rupa 25-28
Upasaya-Anupasaya 28
Samprapti 29-31
Upadrava 32
Sadhya asadhyata 32
Chikitsa 33-37
Pathya Apathya 38-39
Differencial diagnosis 40
Modern perspective of the disease 41-46
DRUG REVIEW
Trial drug 47-56
Standard drug 57-61
Chapter –III METHODOLOGY 62-82
Chapter –IV RESULTS 83-90
Chapter –V DISCUSSION 91-103
Chapter –V CONCLUSION 104
SUMMARY 105-106
REFERENCES
BIBLIOGRAPHY
ANNEXURE
ABBREVIATIONS
ABBREVIATIONS
1. A.F.U - After follow up.
2. A.H. - Astanga Hrudaya
3. A.K - Amara kosha
4. A.P. - Agni Purana
5. A.S. - Astanga Sangraha
6. A.T - After treatment.
7. A.V. - Atharva Veda
8. B. P. - Bhava Prakasha
9. B.R. - Bhaishajya Ratnavali
10. B.Su. - Brahmana sutra
11. Bas.Raj. - Basavarajeeyam
12. Bh.Sa. - Bhela Samhita
13. C.D. - Cakradatta
14. Ch - Charaka Samhita
15. Chi. - Chiktsa sthana
16. Ct. - Chandogyopanisat
17. J.L.N - Illustrated text book of Dravyaguna
Vol-2 by J.L.N. Shasthry.
18. K.S. - Kasyapa samhita
19. Khi - Khila sthana
20. Ks. - Kausika sutra
21. Kt. - Kenopanisat
22. M.B - Mahabharatha
23. M.K. - Madhyama khanda
ABBREVIATIONS
24. M.N. - Madhava nidana
25. Ni. - Nidana sthana
26. P.K. - Purva khanda
27. P.Su. - Panini sutra
28. Pr. - Prakarana
29. Pr.K. - Prathama Khanda
30. Pu. - Purana
31. R. - Ramayana.
32. S.K.D. - Sabda Kalpa druma
33. Sha. - Sarira sthana
34. Si. - Siddhi sthana
35. Su. - Susrutha samhita
36. Su. - Suthrasthana.
37. Thr. - Thritheeya sthana
38. U.K. - Uttara khanda
39. Vi. - Vimanasthana
40. Y.R. - Yogaratnakara
Introduction
Objectives
Review of literature
Methodology
Results
Discussion
Conclusion
Summary
References
Bibliography
Annexure
CONTENTS
LIST OF TABLES
No SUBJECT Pg No
1. Types of Sandhis 10
2. Rasa visheshatha nidana of Sandhigatavata 17
3. Guna visheshatha nidana of Sandhigatavata 18
4 Veerya visheshatha nidana of Sandhigatavata 18
5 Time and forms of Ahara 18
6. Types of Ahara 19
7. Vihara nidana of Sandhigatavata 20-21
8. Manasika nidana of Sandhigatavata 21-22
9. Kala nidana of Sandhigatavata 22
10. Roopa of Sandhigatavata according to various acharyas 25
12. Chikitsa sutra of Sandhigatavata according to various acharyas 33
13. Pathya for sandhigata vata. 38
14 Apathya for Sandhigata vata 39
15 Age wise distribution of 40 patients of Sandhigatavata 40
16 Sex wise distribution of 40 patients of Sandhigatavata 67
17 Religion wise distribution of 40 patients of Sandhigatavata 68
18 Marital status wise distribution of 40 patients of Sandhigatavata 68
19 Economic status of 40 patients of Sandhigatavata 69
20 Occupational incidence of 40 patients of Sandhigatavata 69
21 Nature of work in 40 patients of Sandhigatavata 70
22 Habitate wise incidence of 40 patients of Sandhigatavata 70
23 Main symptoms in 40 patients of Sandhigatavata 71
24 Duration of illness in 40 patients of Sandhigatavata 72
25 Family history of disease of muscular skeletal system in 40
patients of Sandhigatavata
72
26 Dietary habits in 40 patients of Sandhigatavata 73
27 Ahara Pramana in 40 patients of Sandhigatavata 74
28 Dominant rasa in 40 patients of Sandhigatavata 74
29 Dominant ahara guna in 40 patients of Sandhigatavata 75
30 Nidra incidence in 40 patients of Sandhigatavata 76
31 Pramana of vyayama in 40 patients of Sandhigatavata 76
CONTENTS
32 Prakruti in 40 patients of Sandhigatavata 77
33 Distribution of 40 patients of Sandhigatavata according to Sara 77
34 Distribution of 40 patients of Sandhigatavata according to Satwa 78
35 Samhanana.in 40 patients of Sandhigatavata 79
36 Satmya in 40 patients of Sandhigatavata 79
37 Abhyavaharana shakti in 40 patients of Sandhigatavata 80
38 Jarana sakthi in 40 patients of Sandhigatavata 80
39 Vyayama sakthi in 40 patients of Sandhigatavata 81
40 Weight incidence in 40 patients of Sandhigatavata 82
41 Effect of trial drug on patients of Sandhigatavata after 60 days of
treatment.
83
42 Effect of Trial drug on patients of Sandhigatavata after 60 days of
follow up.
83
43 Effect of Standard drug on patients of Sandhigatavata after 60
days of treatment
84
44. Effect of Standard drug on patients of Sandhigatavata after 60
days of follow up.
84
45. Comparative effect of therapies in the management of main
symptoms on 40 patients after 60 days of treatment
85
46 Comparative effect of therapies in the management of main
symptoms on 40 patients after 60 days of follow up
86
47. Overall effect of therapy by Trial drug after 60 days of treatment 87
48. Overall effect of therapy by Trial drug after 60 days of follow up. 87
49 Overall effect of therapy by Standard drug after treatment 88
50. Overall effect of therapy by Standard drug after follow up. 88
51. Inter-group comparison after 60 days of treatment 99
52. Inter-group comparison after 60 days of follow up 100
CONTENTS
LIST OF FIGURES
No. Pg No.
1. Age wise distribution of 40 patients of Sandhigatavata 67
2. Sex wise distribution of 40 patients of Sandhigatavata 68
3. Religion wise distribution of 40 patients of Sandhigatavata 68
4. Marital status wise distribution of 40 patients of Sandhigatavata 69
5. Economic status of 40 patients of Sandhigatavata 69
6. Occupational incidence of 40 patients of Sandhigatavata 70
7. Nature of work of 40 patients of Sandhigatavata 71
8. Habitat wise distribution of 40 patients of Sandhigatavata 71
9. Symptomatology in 40 patients of Sandhigatavata 72
10. Duration of illness in 40 patients of Sandhigatavata 73
11. Family history of disease in 40 patients of Sandhigatavata. 73
12. Dietary habit in 40 patients of Sandhigatavata 74
13. Ahara pramana in 40 patients of Sandhigata vata 74
14. Dominant rasa in 40 patients of Sandhigatavata 75
15. Dominant ahara guna in 40 patients of Sandhigatavata 76
16. Nidra incidence in 40 patients of Sandhigatavata 76
17. Pramana of vyayama in 40 patients of Sandhigatavata 77
18. Prakruti in 40 patients of Sandhigatavata 78
19. Distribution in 40 patients of Sandhigatavata according to sara. 78
20. Distribution in 40 patients of Sandhigatavata according to Satwa 79
21. Distribution in 40 patients of Sandhigatavata according to Samhanana 79
22. Distribution in 40 patients of Sandhigatavata according to satmya 80
23. Abhyavaharana shakti in 40 patients of Sandhigatavata 81
24. Jarana sakthi in 40 patients of Sandhigatavata 81
25. Vyayama sakthi in 40 patients of Sandhigatavata 82
26. Weight incidence in 40 patients of Sandhigatavata 82
CONTENTS
27. Comparative effect of therapies in the management of main
symptoms on 40 patients after 60 days of treatment
85
28. Comparative effect of therapies in the management of main
symptoms on 40 patients after 60 days of follow up
86
29. Comparative effect of overall therapies on patients after 60 days of
treatment
89
30. Comparative effect of overall therapies on patients after 60 days of
follow up
90
LIST OF CHARTS
No. Pg No.
1. Chart showing etiopathogenesis of Sandhigatavata 31
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
I am obliged to my beloved parents B.Balakrishna Aggithaya and Shantha.B.Aggithaya 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
Prof.Pramod Kumar Mishra, M.D(Ayu),(RSU), 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 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.
I express my gratitude to the Dean of our college Prof.T.K.Mohanta M.D,Ph.D. PG Dept. of
Kaya chikitsa for his unflinching support during this course of study.
My immense thanks to Dr. Sanjaya K. S, M.D (Ayu), Principal, A.L.N Rao Memorial Ayurvedic
Medical College, Koppa, for his help and support in completing this work.
I owe my sincere regards and boundless gratitude to Dr. Rashmi Rekha Mishra M.D (Ayu) and
Dr. C, B. Singh for their constant encouragement and valuable suggestions.
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) Dr. Galib M.D (Ayu), Dr. Harikrishna M.D (Ayu).for their guidance for
preparing the medicine..
My earnest gratitude to the respected teachers of the faculty of Dravya guna; Dr. Jagadeeh
Kunjal M.D. (Ayu), Dr. Sreedhar, M.D (Ayu) for their extensive help in the study along with
Dr.H.R Pradeep, M.D (Ayu).
I am glad to express my sincere thanks to Dr. Banamali Das, Dept. of Roganidana and Dr. Rajesh
Kumar, M.D (Ayu) from the Dept. of Shalakya and Dr. Sahana MD (Ayu) from Dept of Shalya.
ACKNOWLEDGEMENT
I will always treasure the guidance and support given by Dr. Rammohan, Dr. Lalitha Bhasker,
Dr. Sreenivas and Dr. Abhinetri Hegde; Consultant Physicians of Ayurvedic college hospital for
their support during various stages of my work.
I will be failing in my duties if I do not express my immense gratitude to my seniors Dr. Prathibha
Hullur, Dr.Prashanth B.K,Dr. Krishnakishore, Dr. Sanjeev, Dr. Suja, Dr. Kavitha, and
Dr.Pankaj, Dr. Purushotham K.G, Dr. Anil P Varkey, Dr. Clarence, and Dr. Leeladhar for their
support.
I am thankful to my class-mates Naga, Abhay, HHP, Anita, Draksha, Vasu, Joshi, Kamat,
Nalini for their helping hand.
With immense pleasure, I extend my heart full thanks to my room-mates Ratheesh, Harvin,
Susheel Shetty with out whose support this thesis work would not have been complete.
My thanks to Raghuram, Daya, Ilanchezian, Binu, Sarat, Ravi, James, Partta,Viji, Chandrakala,
Sachin, Sandhesh for their valuable suggestions and moral support.
I also thank all my UG class-mates (1996 - 2001).
My special thanks to all PG juniors, House surgeons and UG students for their constant support.
I would like to express my gratitude to Miss.Amrutha, for 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.
I am heartily thankful to my sisters Gayathri and Gowri. And also to all family members who
helped me during my study.
Finally, I thank all those who helped me directly or indirectly to complete this work.
Date :
Place : Koppa Dr. Guruprasad. A
ABSTRACT
ABSTRACT
INTRODUCTION:
Disorders of the musculoskeletal system are prevalent throughout the world
affecting all age group. Among this, important one is Sandhigata vata, which
produces disastrous consequences like physical disability in community. Sandhigata
vata can be compared to Osteoarthritis, which is one of the degenerative joint disorder
and it represents failure of the disarthroidal part. The present study is done to
understand the disease which is explained in the classics. Even though this disease is
considered as Kashta sadhya, it can be managed when proper treatment is given in
appropriate time. Here an attempt is made to find the efficacy of the drug
Trayodashanga Guggulu on Sandhigata vata.
OBJECTIVES:
The objectives of the present study are
1) To evaluate the efficacy of Trayodashanga Guggulu in Sandhigatavata.
2) To study in detail about the disease Sandhigata vata covering both Ayurvedic
and modern literatures.
3) To assess the merits and demerits of the trial drug Trayodashanga Guggulu.
4) To assess the merits and demerits of the standard drug Simhanada Guggulu.
5) To compare the efficacy of the trial drug(Trayodashanga Guggulu) with the
standard drug(Simhanada Guggulu)
6) Study of the trial drug and standard drug covering Classical Ayurvedic
literatures.
ABSTRACT
METHODOLOGY:
Total 40 patients were selected who fulfilled the inclusion criteria were
randomly selected for the study. These persons grouped into two.ie trial and standard
group.
The Trial group patients were given Trayodashanga guggulu in the dose of 3
gms twice daily after food with Ushna jala as Anupana. The duration of treatment was
for 60 days. Follow up study was done for 60 days in every 15 days visit.
The Standard drug patients were given Simhanada guggulu in the dose of 3
gms twice daily after food with Ushna jala as Anupana. The duration of treatment was
for 60 days. Follow up study was done for 60 days in every 15 days visit.
INTERPRETATION AND RESULTS:
At the end of 60 days of treatment schedule Trial drug (Trayodashanga
guggulu) showed highly significant effect in Atopa where as moderate significant in
sandhi shula, Sandhi shotha and tenderness where as standard drug (Simhanada
guggulu) showed highly significant result in Sandhi shotha and moderate significant
result in other symptoms.
After 60 days of follow up study, Trial drug showed highly significant result
in the Sandhi shula, Tenderness and Atopa where as Standard drug showed highly
significant result in Sandhi shotha.
CONCLUSION:
• Trial drug (Trayodashanga guggulu) provided highly significant result in the
Sandhigata vata by reducing Sandhi shula, Atopa, Tenderness.
• Trayodashanga guggulu acts as Rasayana, Balya and also Vedana sthapana.
• Standard drug has highly significant result in Sandhi shotha.
INTRODUCTION
INTRODUCTION
As one of the famous proverbial saying goes- Health is wealth, it seems that
the concept of health has never been dealt in any medical science as realistic as in
Ayurveda. The signs of well being or freedom from illness are well depicted in the
ancient treatise. The integration of body components, compactness of muscles and
other tissues, stability and pleasantness of mind and senses, good appetite, timely
digestion, undisturbed metabolism, elimination of urine and faeces, tolerance towards
affects of hunger, thirst, heat, cold and exercise, normal sleep – wake pattern and gain
of strength colour, complexion and life span put together define a healthy individual.1
The description gains more weightage even in this present modern era when
the concept of health as described by WHO includes the state of physical and mental
well being, appears to be influenced by the ancient theories of Ayurveda.
In contrary, the pathological picture sets in when the rhythmic proceedings of
above said mechanisms are disturbed and the individual will no longer be considered
to be healthy. This disarray of events leading to ill health will be caused by the
disturbance of the chief humoral factors governing the body that is the Tridoshas,
which again is brought about by exposure to various etiological factors pertaining to
Ahara, Vihara and Vichara.
Among the Tridoshas, Vata is given a prime importance with respect to either
physiological or pathological conditions. The other two doshas being inert, their
equilibrium depends on vata.2 The vayu is considered to be the chief motivating force
behind all the activity as it has been described as the engine which runs the machine
of the body3. Vayu is also chief driving force of the all the movements, which get
disturbed when vayu gets vitiated. The vayu vitiated by the etiological factors flowing
Page 1
INTRODUCTION
in adverse routes produces diseases related to the site of localization and their
disturbed functions.
Once such disease caused due to the predominance of vayu is
Sandhigata vata. This is a pathological condition which manifests when the Sandhis
which are the important seat of Kapha, are affected by Vayu. This disease is often
compared to the degenerative disorder afflicting the joints and having world wide
incidence and prevalence in plenty i.e. Osteoarthritis. The prevalence is 30% in the
age group of 45-65 years and 68% for those older than 65 years. Men are more likely
to suffer below the age of 45 years and women above 55 years. Besides destroying the
joints, this disease makes the person crippled and dependent to attend his normal
duties.
Ayurvedic remedies have always been successful in the treatment of this
ailment and its effects, especially the preparations of Guggulu. One such formulation
consisting of thirteen in valuable drugs called ‘Thrayodashanga guggulu’ has been
mentioned in Cakradatta, as directly indicated in Sandhisthita vata4. Most of the
ingredients are bruhmana in nature and more importantly guggulu which is said to
have vata alleviating property. This drug has been selected for trial to asses its
efficacy in reliving one from complaints of Sandhigata vata.
This study highlights both conceptual and clinical aspects related to the disease
Sandhigata vata, which is divided in to following chapters-
Chapter 1 - Objectives.
This chapter highlights on main aims of this study.
Chapter II- Review of literature
It deals with the conceptual study of both Sandhigata vata and Osteoarthritis.
It covers all the relevant matters related to the disease.
Page 2
INTRODUCTION
Chapter III- Methodology
Details of the clinical trial of Trayodashanga guggulu and Simhanada guggulu
with observations during the study are explained.
Chapter IV- Results
The results of the entire study have been explained with appropriate graphs for
easy understanding.
Chapter V- Discussion
Discussions on Sandhigata vata and Osteoarthritis, discussion on clinical trial
with observations and results have been described.
Chapter VI- Summary and Conclusion
Complete abstract of the dissertation and the conclusion are enumerated.
Previous works done:
1) Kohla PR,Rasnadi guggulu ki nirmithi evam sandhigata vata mein upayukta
(Dissertation), Nagpur,1990.
2) Chacha ML, Clinical study of Sandhigata vata with special effect of Parijatha
guggulu (Dissertation), Ahamedabad, 1992.
3) Neetha Kumari, Evaluation of Rasnadi guggulu in treatment of Osteoarthritis
(Sandhigata vata),(Dissertation), Varanasi, 1998.
4) Lal ji, Clinical study on the effect of Simhanada guggulu and Murivenna taila
in the management of Osteoarthritis of Knee joint (Dissertation), Jaipur, 2002
Page 3
OBJECTIVES
OBJECTIVES
The objectives of the present study are
1) To evaluate the efficacy of Trayodashanga Guggulu in the treatment of
Sandhigatavata.
2) To study in detail about the disease Sandhigata vata covering both Ayurvedic
and modern literatures.
3) To assess the merits and demerits of the trial drug Trayodashanga Guggulu.
4) To assess the merits and demerits of the control drug Simhanada Guggulu.
5) To compare the efficacy of the trial drug(Trayodashanga Guggulu) with the
control drug(Simhanada Guggulu)
6) Study of the trial drug and control drug covering Classical Ayurvedic
literatures.
7) To establish an effective treatment with the trial drug for Sandhigata vata.
Hypothesis:
a) Null hypothesis:
Trayodashanga Guggulu is not effective in the treatment of Sandhigatavata.
b) Scientific hypothesis:
Trayodashanga Guggulu is effective in the treatment of Sandhigatavata.
Page 4
DISEASE REVIEW
DISEASE REVIEW
HISTORICAL ASPECT OF SANDHIGATA VATA:
All the historical aspect related to this work is mentioned under this heading.
Veda kala:
• Rigveda5
In this five types of Vata is considered as Pancha prana.One of the Mantras of
Rigveda described about removing the disease from each organ (hairs and joints)
• Atharvaveda6
In Atharvaveda, there are references about the disease pertaining to Sandhi and
Sandhi vishlesa.
Purana Kala:
• Ramayana [Before 500B.C] 7
In this treatise, importance of Vayu in maintenance of health and life is
mentioned. There is also explanation about the pathological effect caused by the Vayu
such as Pain and immobility of Joints.
• Mahabharatha [4th Cent B.C-4th Cent A.D] 8
In this treatise, Vata has been given important and it is called as Panchakarma
(having 5 functions) and Bhagavan.
• Agnipurana: 9
In Agnipurana total number of joints in human body and treatments for
Sandhigata Samavata is mentioned.
Upanishat kala:
Elaborate description of vata is available in the Upanishats.
Page 5
DISEASE REVIEW
• Kenopanishat: 10
In this book, vayu is defined as the one that has constant movement, motion
and continued efforts.
• Chandogyopanishat: 11
This book has highlighted the chala property of vata and has shown its close
association with bodily actions and movement.
Samhita kala:
• Charaka samhita [1000B.C] 12
Charaka mentions Sandhigata vata roga in the chapter Vatavyadhi chikitsa.
He names the disease as Sandhigata anila. He explains this disease with Dhatugata
anila vikaras and not mentioned in Nanatmajavatavikara. A separate nidana or the
treatment principles are not found in the text.
• Sushrutha Samhita [700-600B.C] 13
Sushruta mentions general nidana in Nidana sthana (vata vyadhi nidana) and
seperate treatment principles mentioned in Chikitsa sthana(Vatavyadhi chikitsa).
• Bhela Samhita [800-700B.C] 14
There is no clear description is available about Sandhigata vata. But in
Ashtimajjagata vata, ‘Sandhivichyuti’is explained as one of the lakshana.
• Haritha Samhitha [800-700B.C] 15
Acharya Haritha explains that there are 84 Vathaja nanathmaja vikaras.
Among these, 32 are Vyana vata prakopaja vikaras. He also mentions that all the
Dhatugata vata vikaras are due to Vyana vata prakopa and further tells about the
treatment aspect of Sandhigata vata. He also makes the mention of ‘Sandhi shotha’
in Shukra gata vata.
Page 6
DISEASE REVIEW
Sangraha kala:
• Ashtanga Sangraha and Ashtanga Hrudaya [600A.D -1600A.D] 16
The disease is described with treatment.
• Madhava Nidana [800A.D] 17
Acharya Madhavakara agrees with Acharya Charka with respect to Nidana and
Acharya Sushrutha with respect to lakshanas, except for the term Atopa which he uses
instead of Shopha.
• Bhavaprakasha [1400A.D] 18
Bhavamisra follows Acharya Sushruta while describing the disease and its
management which he discusses in vatavyadhi chapter of Madhyama Khanda.
Chakradatta [1100A.D] 19
Chakrapani Datta gives the same views as Sushruta in treatment aspects of this
disease.
• Bhaishajya ratnavali 20
The treatment aspect of this disease is mentioned.
• Yogaratnakara [1600A.D] 21
He has given the same views as of Charaka and Susrutha but separate treatment
principles are mentioned.
• Basavarajeeyam[ 1133-1183 A.D] 22
Vaidya Basavaraja explains this disease as Sandhi Vata. He gives different
lakshanas of this disease but agrees on nidana mentioned by Charaka. He explains
about the sandhivatari rasa.
Page 7
DISEASE REVIEW
Sutra kala:
Bramhana sutra: 23
This text has given importance to Vyana vata. While explaining the
movements of joints it is said that vyana vata is the one, which resides in the joints
and performs all the movements.
Panini sutra: 24
Panini was well aware of vata, its kopa and samana. He has mentioned the
term vatiki to denote disorders of vata.
ETIMOLOGY OF SANDHIGATAVATA:
The term sandhigatavata is a combination of two words i.e,
1. Sandhi
2. Gata vata
Sandhi:
The word sandhi is formed by the combination of the sam+dha+kihi.25
In amarakosa, we get the meaning of the sandhi as slesha which means union
or combination.
Sandhi is considered as union of two structures. Charaka mentions that sandhi
is the samyoga sthana of the two asthis. The asthi sandhis are only considered as the
sandhis and the union of pesi, snayu and siras are not considered.26
It is the moola of majjavaha srotas and also considered as one of the
madhyama roga marga. There are 210 sandhis are present in our body.
Concept of Gata Vata
Gata vata is further comprised of two words, Gata and Vata
Gata:
Here the word gata denotes the state of vata.
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Vata
Among three doshas,Vata is given importance. The word Vata originated from
the root “Va Gati Gandhanayo” which when suffixed by ‘Ktan’, gives rise to the word
Vata.
There are five types of Vata, ie Prana, Udana, Samana, Vyana, Apana. They
are having the seperate functions like, Purana, Udwahana, Viveka (rasa mootra
purisha pruthakkarana), Praspandana and Dharana.
Vyana vata has been given the karma in different treatises such as
- Praspandana (Sushruta)27
- Shareera chalana (Dalhana)28
- Gati, Apakshepana, Uthkshepa (Vagbhata)29
- Sandhicharitha (Dalhana)30
- Vahana (Rasa samvahana)31
- Pancha chesta.[Prasarana, Akunchana, Unnamana,Vinamana,
Tiryakgamana]32
- Pancha chesta [Gati, Prasarana,Uthkshepa, Nimesha, Unmesha] 33
Although these functions said to be done by vyana vata, it can be seen in other
types also. Praspandana karma can be seen in prana vata during swasa praswasa kriya.
By the above reference we infer that any act of praspandana etc. function happen only
with the coordinated union of all the types of vayu. To maintain the coordinated union
of vayu, Vahana is important which is performed by vyanavata.
In Ayurvedic literatures, Sthitha, Militha, Gata are to be considered as
synonymous words.
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The pathogenesis of Gatavata can be occurs in two ways
- Margavarana janya – due to margavarana there will be srothorodha
which leads to soshana of dhatus and also vitiation of vata. The
vitiated vata situates the srotas which became rikta by soshana of
dhatu.
- Dhatu kshaya janya – the rikta dhatuvaha srotas will be filled by
the vitiated vata.
In gatavastha, the vitiation of vata is given importance. Here vata will be
prabala state rather than in avarana. So gata vata condition shows prabala vata
lakshana.
In Hareeta samhita, Hareeta explains all the Dhatugata conditions are
explained under the heading of Vyana vata prakopaja vikara.34
Anatomical aspect of Sandhi:
There are two types of sandhi present in our body, 35 they are
1. Chestavantha – movable joints, the examples are the sandhis of Shakha,
Hanu, Kati, Greeva.
2. Sthira – the remaining sandhis other than chestavantha.
Another classification of sandhis36 is,
No Type of Sandhi Structure Examples. 1. Kora Hinge joint anguli, manibandha, janu,
kurpara, 2. Ulukhala Ball & socket joint kaksha, vankshana and
dashana 3. Samudga Saddle joint Amsapeeta, Guda, Bhaga,
Nithamba 4. Prathara Plain gliding joint Greeva, Prishtavamsh 5. Tunnasevani Sutures Sira, Kati, Kapala 6. Vayasatunda Condyloid joints Hanu 7. Mandala Circular joint Kanta, Hrdaya, Kloma,
Nadi 8. Sankhavartha Bony labyrinth Shrotr, shrungataka
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Snayu: 37
Snayu looks like a Shana (jute) and it is considered as the part of sandhi. It is
the upadhatu of medas and also moola of mamsavaha srotas. There are 900 snayus are
present in human body. They are classified into four types they are, Prathanavathi,
Vrutha, Pruthula and Sushira. Prathanavathi snayu is present in all the sandhis. The
vrutha snayus also considered as Kandara.it has the function of prasarana and
akuchana of body parts.
The ligaments which are present in the joints are separate which leads to
stability.
Sleshmadara kala: 38
This is the fourth kala, the kleda which is present in between the dhatvashaya
will get paka by respective dhatwagni and kalas are produced.
Sleshmadhara kala is considered as the seat for the sleshma (Shleshaka kapha)
and it gives integrity to the body.
Just as the application of oil to the axils produce easy movements to the wheel,
the easy movement of the Sandhis is similarly brought about the lubricating
effect the Shleshma dhara kala lining the Sandhis.
The Synovial membrane can be compared with Shleshmadhara kala, which
leads to easy movement of joints by secreting synovial fluid. Type B
Synoviocytes will secrete the synovial fluid.
Siras: 39
Siras are upadhatu of raktha which helps in sarana. There are four types; they
are vatavaha, pittavaha, kaphavaha and rakthavaha.
Siras are mainly situated in marma and nourishing the snayu, asthi and sandhi.
They are 700 in number.
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Pesi: 40
There are 500 pesis in our body. The sira, snayu, asthi, parva and sandhis are
covered by the pesis and get strength.
Sandhimarma: 41
Marmas are the vital points of the body. They are 101 in number. According to
Dalhana marmas are situated in mamsa, sira, sandhi etc.42
Depending on the structural base marmas are divided into 5. They are mamsa
marma, sira marma, snayu marma, asthi marma and sandhi marma. All the marmas
comes under these 5 categories.
There are 20 types of sandhi marmas. They are janu, kurpara, seemantha,
adhipathi, gulpha, manibandha, kukundara, avartha and krukatika.43
JOINTS 44
Two or more bones unite to form joints.
There are three types of joints explained.
• Fibrous joints.
• Fibro-cartilagenous joints.
• Synovial joints.
Fibrous and Fibro-cartilagenous joints:
In this type, the fibrous or Fibro-cartilaginous tissues unite the two bones. This
joint will present where there is little requirement of movement.
Examples:
For fibrous joint: joints present in skull bone.
For Fibro-cartilaginous joint: Symphisis pubis, Inter vertebral discs.
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Synovial joints:
This type of joints provides maximum range of movement.
Eg: Most limb joints, Tempero-mandibular joint.
Structures present in synovial joint are,
1. Articular cartilage.
2. Synovial fluid.
3. Intra articular disc.
4. Joint capsule and synovial membrane.
Articular cartilage:
In synovial joint, the articular surface is covered with a layer of articular
cartilage.
In normal cartilage, there are no cell divisions. But in this chondrocytes there are
continuous process of destruction and synthesis of the cartilage matrix throughout life.
Constituents:
It is an avascular tissue that consists of cartilage cells [Chondrocytes], Type II
collagen and smaller amounts of other proteins which is present in the matrix of
proteo glycans.
The matrix consists of:
1) Type II collagen fibers:
It forms the meshwork in between the proteo glycan molecules.
2) Hydrated gel of proteo glycan molecules:
In this, the important one is Aggrecan.
Aggrecan consists of:
A] Core protein.
B] Glycosaminoglycan[GAG] : It is the long chain of disaccharides.
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The important GAG is Chondroitin sulphate and Keratan sulphate.
3) Hyaluronan:
A long GAG in which numerous aggrecan will be connected.
4) Link protein:
N- Terminus of aggrecan joins to the hyaluronan by small glycoprotein called
Link protein.
Articular cartilage has two essential functions:
It provides a smooth bearing surface so that with the movement, bone glide
effortlessly over each other. Articular cartilage prevents concentration of stresses, so
the bones do not shatter when the joint is loaded. Large complexes of aggrecan and
Hyaluronan form the articular cartilage. Aggrecan has a strong, negative charge
because of the sulphate and hydroxyl groups in glycosaminoglycan. And also it binds
large number of water molecules. So it occupies the maximum possible volume
available. So the expansive force of charged and hydrated aggrecan and restrictive
force of collagen gives the articular cartilage an excellent shock absorbing properties.
Synovial fluid:
Surfaces of articular cartilage separated by space called Synovial fluid. It is
basically ultra filtrate of plasma into which synovial cells secrete Hyaluronan and
proteoglycan. It lubricates the joint.
Intra articular discs:
Intra articular discs are the fibro cartilagenous disc which is present within the
joint space. It is present in some joints only and acts as shock absorbers.
Joint capsule:
Joint capsule is a fibrous structure, richly supplied by blood vessels,
lymphatics and nerves. It joins the two bones of the synovial joint. Ligaments and a
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regional thickening of joint capsule stabilize the joint. Inner surface is lined by
synovial membrane.
Synovial membrane:
This membrane contains outer layer of blood vessels and loose connective
tissues. Inner layer consists of Type A and Type B synoviocytes. Most of
inflammatory and degenerative joint diseases associated with thickening of synovial
membrane and infiltration by lymphocytes, polymorphs and macrophages. Many
joints contain bursae which are hollow sacs lined by synovium.
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NIDANA
In Ayurvedic classics, the term Nidana has been defined in two different
senses. One of these definitions explains Nidana as that which points or indicates a
disease or that which gives a complete knowledge of a disease or that which helps in
diagnosing a disease.45
The other part defines Nidana as those which have a tendency to produce a
disease process after inducing a chain of pathological events in the body like Dosha
prakopa etc or in short, the etiological factors of the disease. The ahita ahara vihara
which vitiates the doshas and the dusta doshas which tend to vitiate the dushyas are
included in to the category of Nidana.46
Being an important member of the Panchakas aiding in roga pareeksha,
nidana not only helps in diagnosis and differential diagnosis, but also helps in
determining the prognosis of the disease. Nidana has an important role to play in
Chikitsa also, as the shortest route of avoiding or getting rid of the disease is said to
be Nidana parivarjana.
In this context, the terminology Nidana covers the etiological factors causing
the disease entity Sandhigata vata. Sandhigata vata is one of the vata vikara. Vata
vyadhi can be an effect of either of the two pathological events namely Dhatukshaya
or Margavarodha. Each occurring due to different sets of nidana and so does
Sandhigata vata. Since separate etiological factors have not been mentioned with
respect to Sandhi gata vata, the same nidanas which have been explained in the
context of vata vyadhi should be considered.
Notes:
• vata prakopaka nidana 47
• + vata vyadhi nidana.48
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The nidanas can be categorized into:
Aharatha
Viharatha
Manasika
Kalakrutha
Aharatha:
Ahara is an important factor responsible for the maintenance of health, as it is
pancha bhoutika. Bala and ayush is gained by ahara. It is the form of nutrition to the
basic elements of the body or the shareera dhatu. Dhatu kshaya is a main cause of vata
prakopa. So here the cause of dhatu kshaya is been considered keeping in view of
their final effect on the functions of vata. Therefore different factors relating to the
ahara has been tabulated.
A) Rasa visheshatha nidana:
Table no: 2 showing Rasa visheshatha nidana:
Rasa Ch Su A.S B.P M.N Y.R Ba.Raj H.S
Kashaya - * * + - - - -
Katu - * * + - - - -
Tikta - * * + - - - -
* vata prakopaka nidana. + vata vyadhi nidana.
Kashaya, katu and tikta are the rasas, which vitiates vata and also leads to
snehadigunasunyatha. So this nidanas can be the cause for sandhigatavata.
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B) Guna vishesatha nidana:
Table no: 3 Showing Guna visheshatha nidana:
Guna Ch Su A.S B.P M.N Y.R Ba.Raj H.S
Ruksha + * * + + + + -
Shitha + * * - + + + -
Laghu + * - + + + + -
Sushka - * * - - - - -
* vata prakopaka nidana. + vata vyadhi nidana.
The gunas like laghu, ruksha, kara etc. leads to the kshaya of the sneha guna of
the body, which further leads to dhatukshaya and also vitiation of the vata dosha. So
these gunas also can also cause sandhigata vata vyadhi.
C) Veerya visheshatha nidana:
Table no: 4 showing Veerya visheshatha nidana:
Veerya Ch Su A.S B.P M.N Y.R Ba.Raj H.S
Shita - * * - - - - -
* vata prakopaka nidana. + vata vyadhi nidana.
Sheeta veerya is the factor for the vitiation of Vata dosha. So this can be
considered as one of the viprakrshta nidana for Sandhi gata vata.
D) Time and forms of ahara:
Table no: 5 showing Time and forms of Ahara:
Ch Su A.S B.P M.N Y.R Ba.Raj H.S
Alpa + - * - + + + -
Pramitha - - * + - - - -
Abhojana + * - + + + + -
Virodhi - - + + - - - +
Apatharpana - - - - - - - -
* vata prakopaka nidana. + vata vyadhi nidana
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The forms of Ahara like Virodhi, Alpa, causes Vata vitiation thus produces Sandhi
gata vata.
E) Type of ahara:
Table no: 6 showing Type of Ahara:
Nidana Ch Su A.S B.P M.N Y.R B.Raj H.S Shaka - * - - - - - - Vallura - * - - - - - - Varaka - * - - - - - -
Uddalaka - * - - - - - - Koradusha - * - - - - - Syamaka - * - + - - - - Nivara - * - + - - - - Mudga - * - + - - - - Adhaki - * - + - - - - Harenu - * - - - - - - Kalaya - * * - - - - - Nishpava - * * + - - - - Vistambhi - - * - - - - - Virudaka - - * - - - - - Truna dhanya - - * - - - - - Chanaka - - * + - - - - Karira - - * - - - - - Tumba - - * - - - - - Kalinga - - * - - - - - Cirabhita - - * - - - - - Bisa - - * - - - - - Saluka - - * - - - - - Jambava - - * - - - - - Tinduka - - * - - - - - Thriputa - - - + - - - - Satheena - - - + - - - - Makusta - - - + - - - - Mangalyaka - - - + - - - - Masura - * - + - - - -
* vata prakopaka nidana. + vata vyadhi nidana.
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2) Viharatha nidana:
Various viharas can stimulate or irritate those anatomical sites where a
function of vata (movements) is more required. Particularly the weight bearing joints
which tend to become the target. Initially the injury may be at the molecular level
which further aggravates being able to involve the tissues of the sandhi generally in
case of irreversible injury.
Vyana vata is responsible for different chestas (movements). Here viharaja
nidana means the atiyoga, ayoga or mithyayoga of these chestas which leads to the
vata prakopa. Viharaja nidana is also leads to abhigata of body parts (sandhi) which
also become one of the pre disposing factors for sandhigata vata.
Table no: 7 showing Viharatha nidana:
Nidana Ch Su AS BP MN YR Ba.Raj HS
Ati vyayama + * * + + + + +
Ativyavaya (nidhwana)
+ - * + + + + -
Langhana + * * - + + + -
Prajagara + * * + + + + +
Plavana (pratarana)
+ * * + + + + -
Atiyadhva + - - - + + + +
Ativicesta + - * - + + + -
Dukhasayya + - - - + + + -
Dukha asana (vishamasana)
+ - * - + + + +
Diva swapna + - - - + + + -
Vega sandharana
+ * * + + + + -
Vego udeerana - - * - + + + -
Abhighata + * * + + + + -
Srama - - - + - - - -
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Kreeda - - - - - - - +
Dathu kshaya + - + + - - - -
Ucha bhashana - - * - - - - -
Abisangha - - - - - - - +
Atiasruk sravana
+ - * + - - - +
Ati virechana + - * + - - - +
Ativamana + - * + - - - -
Prana apana samana sandharana
- - - - - - - +
Vishamopachara
+ - - - + + + -
Bharaharana - * * - - - - -
Ksheena bala - - - - - - - +
Atimamsa ksaya
- - - + - - - -
Gajaturaga yana
+ * * - + + + -
* vata prakopaka nidana. + vata vyadhi nidana.
3) Manasika karana:
Mana is Ubhayendriya, which is the main part to attain Jnhanotpatti. Manas is
controlled by Vata (Niyantha pranetha cha manasaam). Indriyas are also controlled by
Vata only.
So manasika nidana considered as one of cause of Vata vyadhi because
Asathmendriyartha samyoga is one type of nidana.
Table no: 8 showing Manasika nidana:
Nidana Ch Su AS BP MN YR Ba.Raj HS
Chinta + - - + + + + +
Soka + - * + + + + -
Krodha + - - - + + + -
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Bhaya + - * + + + + -
Utkanta - - * - - - - -
Ksheena indriya
- - - - - - - +
Madana kopa
- - - + - - - -
* vata prakopaka nidana. + vata vyadhi nidana.
4) Kalaja:
Kala is of two types; Nithyaga and Avasthika. Nityaga kala pertains to the kala
related to rtus and Avastika kala is related to pathological state of doshas according to
the age of person.
Table no: 9 showing Kalaja nidana:
Nidana Ch Su AS BP MN YR Ba.Raj HS
Payodasamaya (Varsa rtu)
- * * + - - - -
3rdpart Dina-kshana
- - - + - - - -
Sisira - - - + - - - -
Grishma - - * - + + + -
Bhuktanta - * - - - - - -
Pravrt - * - - - - - -
Seeta kala - * - - - - - -
Vrudha - * - - - - - -
Usha kala - * - - - - - -
Aparahna - * * - - - - -
Jeerna anna - * * + - - - -
Apararatri - - * - - - - -
Purvavata - - * + - - - -
* vata prakopaka nidana. + vata vyadhi nidana.
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Influence of the time factor (kala) on the doshas has been given importance in
Ayurvedic classics. In general, the vata is predominant at the end of the digestion,
evening or at the end of the digestion.
Here old age will be main precipitating factor for production of Vatavyadhi.
Although other nidanas can also cause vitiation of vata, it is considered as
Vyabhichari causes for Vatavydhi. In Vrudhavasta, the dhatus are in the state of
ksheena, that which provides platform for the diseases. They are more prone to get
Sandhi gata vata.
There are six rtus in which tridoshas are having its own state of kshaya or
vrudhi. By considering this, vata is having sanchaya in Greeshma, prakopa in Varsha
and shamana in Sharath.49 By this we can analyse that due to the rukshata in
Greeshma vata gets Sanchaya, due to sheetata of Varsha gets Prakopa and ushnata of
sharat rtu does the Vata shamana. In Vata prakopaka rtus, person prone to get Sandhi
gata vata. The possible effect of these factors may be due to not adopting the rules of
Rtu charya and the purification measures in the rtu sandhi as advocated in classics.
Prakruti is also given importance while disease is considered. Vata prakruti
persons are more prone to vata vyadhi. While explaining Vata prakruti, Charaka told
that Anavasthita sandhi(loosening of joints), because of chala guna and Sathatha
sandhi shabda gami( continuous crepitus in joints while walking) because of
vaishadhya guna of Vata.50
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POORVA RUPA
The unclear signs and symptoms produced by the vitiated doshas during the
process of sthana samsraya, which indicate the forth coming disease are called as
poorva rupa. This marks the beginning of amalgamation of vitiated doshas and
dushyas.51 In the context of vata vyadhi, it has been said that the under manifestation
of signs and symptoms or avyakta lakshanas should be regarded as poorva rupa.52
Even in case of sandhigata vata also, feebly manifested signs and symptoms of
the disease can be considered as poorva rupa. In sandhigata vata, shoshana of shareera
takes place due to the localization of the prakupita vata, as a result of which the
person starts feeling laghuta. Lakshanas of sandhigata vata i.e shotha, shula etc are
also found in avyakta avastha.
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RUPA
In the disease process, the same unclear signs and symptoms of poorva rupa
when gets clearly manifested so as to indicate an existing disease will be called as
rupa.53 In short the signs and symptoms of a completely manifested disease are called
as rupa or lakshanas. The same rule holds good with sandhigata vata also, where in
the symptoms of the disease like shotha, shula etc which were unclear and feeble
during the sthana samsraya gets clearly manifested defining the disease.
Table no: 10 showing Roopa of Sandigata vata according to various Acharyas:
Laxanas Ch54 Su55 A.S56 A.H57 B.P58 Y.R59 M.N60 Ba raj61
Sandhi Soola - + - - + + + +
Sotha or sopha - + - - + + - -
Vatapurna druti sparsa
+ - + + - - + -
Hanti sandhin - + - - + + - -
Prasarana akuncanayoho pravrttisavedana
+ - + + - - - -
Atopa - - - - - - + -
Shareera gandhaliptata
- - - - - - - +
Anga peeda - - - - - - - +
Romaharsha - - - - - - - +
Vilapana - - - - - - - +
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The cardinal symptoms are as follows:
1. Vata poorna druti sparsa
2. Sandhi soola
3. Sandhi sputana or Atopa
4. Prasarana Akunchana pravruthi savedana
5. Sandhi shotha or shopha
1) Hanti sandhin:
In the commentary-Nibandha sangraha and Athanka darpana, they gives the
explanation that, Hanti sandheen means abhava in Prasarana akunchana etc functions
of the Sandhi.62 In Madhukosha commentary, it means complications of sandhi like
Sandhi vishlesha, Sandhi sthambha etc.63 Gayadasa gives openion about Sandhi
vishlesha as there will be difficulty of movement without the dislocation.64
Vata is responsible for the Gati especially vyana vata leads to Pancha chesta of
the body (Prasarana, akuncana, Unnamana, Vinamana, Tiryakgamana). So
impairment of Vyana vata leads to difficulty in movement.
2) Sandhi shula:
Shula is the main symptom of the Vata vitiation. All the Acharyas mentioned
that there is no Shula without the vitiation of vata.65
Sandhi shula is the main symptom in the Sandhigata vata. In Asthi-Majjagata
vata also this is the main symptom. So we can conclude that the sandhi shula is
produced due to the effect of Ashrayee dhatu kshaya (Asthi) due to the vitiation of
Vata.
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3) Atopa or Sandhi sputana:
This specific symptom is explained by Acharya Madhava. Shabda is the
indriyartha which indicates the predominance of qualities of Vata. Sandhigata vata is
localized vata vyadhi in which prakupita vayu affects Sandhi. This sthana samsraya is
the result of srotoriktata present at sandhi; that means akasa mahabhuta is increased at
the site of sandhi.
The Atopa can be correlated to the crepitus in a joint. This is due to the
Osteophyte formation at the time of remodeling of joint. This becomes evident only
when there is marked degeneration.
4) Prasarana akunchana pravruthi savedana:
There is a natural elasticity or contractility in the joint by virtue of which the
movement in different direction can be performed. This is destroyed due to the
vitiated vata, with the result the patient is not able to move his joint freely especially
in the extension and contraction. If he tries to move, there will be severe pain. This
phenomenon has been explained by different terminologies such as Stambha etc.
5) Sandhi shotha:
It is one of the main symptoms in Sandhigata vata. Sushrutha explained it as
Sandhi shopha because Shopha is the swelling which is Ekadesha sthitha.66 Acharya
Charaka explained as shotha.
By commenting on shotha, Arunadatta explains that, the swelling look like the
air filled bag.67
In Ashtanga samgraha, Vagbhata includes shopha as one of the Vyana vata
vikara.68
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6) Vata purna druti sparsha:
Sparsha is of two types, Ushna sparsha and Sheeta sparsha. In
Yogarathnakara, there is reference that the person who is suffering from Vata roga
will have Sheeta sparsha.69 In Sandhigata vata, usually the joints will be look like air
filled bag to touch and cold.
Acharya Basavaraja also explained some other symptoms like Shareera
Gandha lipta, Romaharsha, Vilapana which shows the chronicity of the disease.
UPASAYA AND ANUPASAYA
Upashaya is the temporary relief which is gained by the procedures such as
Oushadhi etc.It is also considered as therapeutic test to attain correct diagnosis of the
disease when it becomes difficult due to its effects in manifestation of signs and
symptoms.70
Anupasaya and Upasaya is the application of Ahara, Oushadha, Vihara,
prescribed either antagonistic or similar to the nidana, to the Hetu, vyadhi or to both
Hetu and Vyadhi together. It is considered as Upashaya when it decreases the
symptoms and when it aggravates the symptoms it is called Anupashaya.
For example when abhyanga swedana, usna ahara etc reduce the symptoms of
Sandhigatavata. In samavastha, like in Amavatha the same treatments aggravate the
condition. So it is a treatment and also a diagnostic approach.
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SAMPRAPTI
For the better understanding of the disease, the knowledge of Samprapti I.e the
etio pathogenesis of the disease is essential.
Samprapti can be defined as the process of disease from its inceptive phaseto
fully manifestation. This process starts from the Nidana sevana or consumption of the
etiological factor causing dosha prakopa, circulates through out the body, localization
then manifestation and differentiation.71 To the pathological point of view, dosha,
dhatu, srotas is essencial in relation of Sandhigata vata.
Srotas is also called as Dhatuavakasha, 72 which is formed from the Akasha
mahabhuta. Akasha and Vayu mahabhuta are interrelated73 and Vayu is situated in the
emptiness [Riktata] created by the Akasha mahabhutha.
In Samprapti, ‘Riktata of srotas’ present in the sandhi is considered as the
‘Khavaigunya’, which is the platform for manifestation of disease Sandhigata vata.
Chakrapani gives explanation about Riktata as ‘Thuccha’ or ‘Snehadi guna
shunyata’.74
While explaining vata prakopa lakshanas, Charaka has mentioned the term
“Sushirata” which may be taken as Riktata.75
In sandhigata vata, we can take the Snehadi guna shunyata in two different
conditions. As the sneha is the main guna of the shleshma, shunyata can be considered
as the Shleshma kshaya. Shleshaka kapha is present in the sandhi which is responsible
for the integrity of joints and proper lubrication. The depletion of this leads to Riktata
of srotas.
Dhatus are the snehayukta dravya present in the body. As the sandhi is made
up of different dhatus, upadhatus and other essential factors, the intake of the dhatu
kshayakara nidana will lead to there will be dhatukshaya which is turn causes snehadi
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DISEASE REVIEW
guna shunyata[riktata]. In short, one can say that the loss of snehana of the joint is
responsible for the pathogenesis of Sandhigata vata.
Vata prakopa can occur in two ways.76
1) Dhatukshayajanya and
2) Margavaranajanya (obstruction)
Vagbhata77 clearly explains that Dhatukshayaja nidanas are also responsible
for the vitiation of the vata along with the riktata. The prakupita vata situates in the
rikta srotas present in the sandhi thus producing the symptoms of Sandhigata vata.
In margavarodhajanya condition, the other doshas such as Kapha and Pitta fills
the Srotas present in the sandhi and does the Avarana of vata. Due to avarana, the
avruta vata becomes strong and vitiated, leads to further dhatu shoshana78 thus
producing the symptoms of the Sandhigata vata.
Medo roga(sthoulya) may also lead to Sandhigata vata as vata vyadhi is said
as one of the complication of the medoroga. Due to the Avarana of meda to the
pathway of the vata, there will not be proper nourishment to other dhatus leading to
vata vikaras.79
Samprapti ghatakas:
Dosha - Vatavrudhi, [Vyanavata],
Kapha kshaya [sleshaka kapha].
Dushya - Asthi, Snayu [sandhi avayava].
Srotas - Important srotas are asthi vaha, majja vaha other less important
are medovaha and mamsavaha srotas.
Agni - Dhatwagni.
Rogamarga - Madhyama.
Udbhavasthana- Pakwashaya.
Sanchara stana- Sarva deha.
Vyaktasthana - Sandhi.
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DISEASE REVIEW
Page 31
Chart No. 1. Showing Etio-pathogenesis of Sandhigata vata:
Sthana samshraya in sandhi
Sleshma Sira-Impared sravana
Sleshma dhara kala
Asti Snayu Kandara
Vatapurna drthi sparsha Sula
Ahara Vihara Manasika
Rikta srotas
Nidana
Gada krutaKala
Vata prakopa Dhatu kshaya
VATA PRAKOPA
Vata prasara
Avarana of Vata
Fills in the Srotas
Sotha
Shoshana
Stambha
Kshaya
Atopa
Anya dosa prakopa
DISEASE REVIEW
UPADRAVA
Upadrava is the Complication of a disease. The Dosha which causes the main
disease is itself responsible for the upadrava.
Upadrava will be manifested in three ways i.e. complications that starts along
with the disease, complications after full manifestation of the disease and
complications produced after cure of the disease.80
Asthi shithilata, pesi kshaya can be considered as the complication which
manifests along with Sandhigata vata and Sandhi vishlesha will be its after effect.
Complications such as deformity and immobility of joints will interfere the
routine works.
SADHYASADHYATHA
Sushrutha and Vagbhata have included Vata vyadhi under the Ashta maha
gada, 81 because of its ashukarita and Upadrava. As the disease Sandhi gata vata is one
of the Vata vyadhi, it is difficult to cure.
Charaka while explaining sadhyasadhyata, mentions that ‘Khuda vata is Kasta
sadhya or asadhya. Commenting on Khuda vata, Chakrapani opines that Khudavata
itself is Gulphavata or Sandhi gata vata.82
Acharya Hareeta concludes that the Mamsa gata, medo gata vata is Sadhya,
rest of Gata vata is Kasta sadhya or Asadhya for treatment.83
As Sandhi gata vata is the disease of Madhyama roga marga. It is considered
as Kashta sadhya.
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DISEASE REVIEW
CHIKITSA
The main scopes of the Chikitsa are of two. They are promotion and
preservation of health in healthy individual, and elimination of the disease ailing and
afflicted i.e. curative treatment. According to the Amarakosha chikitsa is Ruk
prathikriya84 where as in Vaidyaka shabda sindhu, it is defined as ‘roga nidana
pratheekara’.
The term rogapanayana and ruk pratikriya convey nearly the same meaning
viz, measures calculated to the removal of disease and treatment of the disease
respectively. The term roga nidana pratikriya stresses on the removal of causation
factors of the diseases.
Acharya Sushruta was the first to mention the treatment principles of
Sandhigatavata. Although Charaka has not mentioned about specific chikitsa, the
general Vatavyadhi chikitsa is taken in to consideration.
Treatment principles according to different Acharyas are tabulated below:
Table no: 11 showing Chikitsa sutra of Sandigata vata
Chikitsasutra Ch. Su.85 A.S86 A.H87 B.P88 Y.R89 B.R90 C.D91
Sneha - + - + - + + +
Abhyanga - - + - - - - -
Upanaha - + + + - + + +
Agni karma - + + + - - + +
Bandhana - + + - - - + +
Unmardana - + + - - + + +
Sweda - - - - - + - -
Raktavasecan - - + - - - - -
Pradeha - - + - - - - -
Samana - - - + + + + +
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1) Snehana:
The procedure which induces qualities like Snigdhata, Mruduta, Kledata and
Vishyandata in the body, following the internal and external administration of sneha
dravyas are called as Snehana.92 Snehana is said to be the best treatment in case of all
the diseases produced by the Vata, since it is totally antagonist to the qualities of
Vata. Sneha is also said to be tridoshagna as it alleviates vata, pitta and kapha due to
its Snigdhata, Shaityata and samskarasyanuvarthana (yogavahi) respectively.93
According to prayoga bheda there are two types of snehana procedures, they are
• Bahya sneha – in this the sneha dravyas are applied externally as done in
procedures like abhyanga, avagaha, sirovasthi etc.
• Abhyanthara sneha – In this the sneha is administered internally in the form of
pana and basthi.
In the disease Sandhigata vata, the administration of Snehana will be very
effective since Prithwi and Ambu mahabhoota, which are mainly present in the
Snehadravyas are exactly opposite to the Akasha mahabhuta predominantly prevails
in the main factor in the disease pathology i.e. Sroto riktata.
There are two types of sneha94 i.e sthavara and jangama. Among these snehas,
four snehas are considered as pravara and also their quality has been mentioned.
Among these, ghrita is considered as best one and it is pittanila hara, rasa shukra ojo
hitha. Thaila is maruthaghna,balya, sthirakara and it does not increases kapha. Vasa is
best known for eradicating the maharuja which is affecting to Asthi, Sandhi, Sira,
Snayu, Marma and balavan marutha which is situated in the srotas. Majja is
considered as bala- rasa- meda- shleshma and majja vardhaka.95
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DISEASE REVIEW
2) Abhyanga:
Abhyanga is a type of snehana karma where massage is done by applying the
thaila on the body.96
It is said that by abhyanga both kapha and vata will be pacified. It is also
considered as balakari, and dhatu pustikara. Dalhana has given the explanation
regarding the time required for the Sneha dravyas to enter deep to the dhatus
following Abhyanga. According to his explanation, sneha is situated in romakupa up
to 300 matrakala. In 400 matrakala, it enters twacha, in 500 to rakta,in 600 matrakala
to mamsa. It reaches medodhatu in 700 matra kala. The sneha reaches asthi in 800
matrakala. In 900 matrakala sneha enters in to majja thus inducing snigdhata in all the
dhatus. Thus it is considered as the dhatu pustikara.97
Since Sandhigata vata is a disease of Madhyama roga marga where the Asthi,
majja and sandhis are involved; the penetration of sneha dravyas deep in to the dhatus
during abhyanga as said above will be of high therapeutic value.
In 5th century B.C, Hippocratus wrote- “the physician must be experienced in
many things, but assurely in rubbing, because rubbing can bind a joint that is too
loose and can loosen a joint that is too rigid”.98
Upanaha:
The word meaning of Upanaha is bandhana.99 According to sushruta, it is one
among 4 types of swedana karma. In this moola kalka, kanji, pista, lavana, is added
with sneha and thick application is done over the affected part. Then that area is tied
in a cloth. In case of Pittanugata vata, kakolyadi, surasadi or eladi gana dravyas are
used. In kaphanugata vata, tila atasi etc dravyas and in kevala vata, veshavara, salvana
upanaha is adviced. He is also explained that Upanaha is best for Vata.100
Acharya Caraka explains Upanaha as one of the Niragni swedana.101
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DISEASE REVIEW
By commenting on this Chakrapani explains there are two types of Upanaha.
They are Saagni and Niragni upanaha. In Saagni upanaha, tila or masha kalka are
made in to hot and kept on affected part. This is also called as the Sankara sweda. In
Niragni upanaha, ushna veerya drugs are applied and tied by charma, cloth etc.102
Vagbhata explains Vachadi Upanaha in kevala vata.
Acharya Sivadas sen explains the mechanism of the Upanaha as swedana. Due
to the blocking of the heat generated by the body, there will be production of the
sweda in that part.
Agni karma:
The procedures done with the help of agni or the drugs having Agni guna is
called as Agnikarma.103 The severe complications of Sira, Snayu, Asthi and Sandhi,
caused by the vitiation of vata are cured by the Agni karma.104
In snayu- asthi and sandhi gata vata and kaphaja vikara, by using
Kshaudra(sugar candy), Guda(jaggery) or Sneha, the procedure of Agnikarma should
be done. It is indicated in all rtus except in Sharat and Grishma.105
The importance of this procedure is, the diseases which are not cured by the
other procedures like Bhesaja, Shastra, Kshara, and Rasa can be cured by using this
procedure.106
Bandhana:
Bandhana leads to Samhathi. It is the procedure in which the effected part will
be tied by using Rajju etc.107
By doing Bandhana procedure, there will be strength to the joints and also
pressure to the joints will be minimized.
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Unmardana:
It is the procedure of massaging of effected part by Hastatala after application
of oil. By the gentle massage there will be proper circulation to the joints.108
Swedana:
Swedana is of two types109 according to Agni samyoga. They are,
1) Agni sweda- They are of 13 types, namely Sankara, Prastara, Nadi, Pariseka,
Avagaha, Jhentaka, Ashmaghana, Karshoo, Kuti, Bhoo, Kumbhika, Koopa and
Holaka.
2) Niragni sweda: They are of 10 types namely, Vyayama, Ushnasadana,
Gurupravarana, Kshudha, Bahupana, Bhaya, Krodha, Upanaha, Athapa, Yudha.
In Ashtanga Sangraha, Vagbhata has said that swedana is the best remedy to
remove the sthabdatha of the Sandhi (Sandhi sthabdathapaham).110
In case of Sandhigata vata, by doing swedana, there will be Vata nigrahana
which results in decreasing the pathology.
Raktavasechana:
Acharya Vagbhata (Ashtanga samgraha) explained it as avastika chikitsa. In
sira-snayu-sandhi gata vata, if the person is having Svapa(numbness), raktavasechana
is indicated in alpa pramana. If the person feels angamlana with numbness,
raktavasechana is contra indicated because there will be the chance of shosha.111
After raktavasechana, pradeha is applied by taila, lavana, agara dhuma.
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PATHYAAPATHYA
Pathya means wholesome or conducive to health. Pathya is related to Patha
which is having different meanings. It indicates the channels of circulation which is
called as Srotas. Chakrapani comments that Patha is the dosha and dhatus which is
present in srotas. He also quotes that Pantha is the Swastha rakshana and also Vyadhi
prashamana.
So the food and activities which is performed and which is Anpayakari(not
harmful) to person and also to disease is called as Pathya112 it depends on the Matra,
Kala, Kriya, Bhumi,Deha, Desha and Gunanthara
Pathya has been given importance that no medicine is needed if Pathya is
followed properly andthere is no use of medicine if Pathya is not followed properly.
Although specific Pathya is not mentioned for Sandhi gata vata, the
wholesome food and regimens explained for Vata vyadhi is taken as Pathya.
Table No: 12 Pathya for Sandhi gata vata: Ahara Yogarathnaka 113 Bhaishajya rathnavali 114 Sneha ---- Thaila Shaka varga Patola, Kushmanda, Shigru, Varthaka Shuka dhanya varga
Godhuma, Rakta shali Godhuma, purana dhanya.
Shimbi dhanya
Masha, Kulatha Masha, Kulatha
Mamsa Kukkuta, Tittiri, Barhi, Chataka, Jangala mamsa.
---
Mathsya varga
Shilendra, Nakra, Khudisha, Parvathe, Gargara, Jhasha
---
Phala varga Dadima, Parooshaka, Badara, Draksha --- Gavya varga Ghrutha, Dugdha, Kilaata, Dadhi
koorchika ---
Oushadha dravya
Lashuna, Tambula, Masthsyandika, Brihati, Vastuka, Kasamarda, Dunduka, Mishi, Kataka
Lavana Saindhava ---
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DISEASE REVIEW
Apathya for Sandhi gata vata:
In Yogarathnakara and Bhaishajya rathnavali, some of unwholesome foods are
explained which is enlisted below.
Table No: 13
Apathya ahara Yogarathnakara 115 Bhaishajya rathnavali 116 Vihara Chintha, Prajagara,
Vegavidharana, Shrama, Vyavaya, Chankramana, Khatwa(sleeping in cot), Hasthyashwa yana, Dwija gharshana.
Sheeta pravata
Karma Chardi, Food intaken Anashana Guru, Abhishyandi. Shuka dhanya Nava dhanya Shimbi dhanya Mudga, Nivara, Shyamaka,
Kuruvinda, Kalaya, Chanaka.
Mudga, Sharshapa, Nishpava.
Shakha varga Koshataki, Kareera. Kareera Jala varga Thataka, Thatini, Pradusta
salila Sheetambu
Rasa Kashaya, katu, Tikta ----- Other substances Kshudra, Kangu, Nimba Mrunali, Sarasi, Nimba
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DISEASE REVIEW
DIFFERENCIAL DIAGNOSIS
For the accurate diagnosis of the disease, Vyavachedaka nidana (differential
diagnosis) is important. By seeing difference in the causative factors, mode of onset,
clinical features,upashaya- anupashaya, we can conclude the differential diagnosis.
Sandhi gata vata is the disease pertaining to joints, other joint diseases such as
Vatarakta, Amavata will be considered for the differential diagnosis.
Table No: 14
Symptoms Sandhigata vata Vatarakta 117 Amavata 118
Dosha Vata Thridoshaja Vata-Kaphaja
Onset Gradual Gradual Sudden
Progression Constant
Increase &
Decrease Constant
Joint involvement Big Small Big
Spreading [joint] - Small to Big Big to Small
Swelling Articular & Puffy
Articular,
Engorged
Extra articular,
Pitting
Tenderness[pain] Mild Severe, Burning
Severe, Like
Scorpion bite
Crepitus Severe Moderate Absent
Stiffness Severe Severe Moderate
Skin involvement Not involved Involved Not involved
Deformity Present Present Absent
Function Painful,
Restricted
Restricted,
Immobile
Painful,
Restricted
Response to oil Marked relief Moderate relief Aggravates
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DISEASE REVIEW
OSTEOARTHRITIS119
Osteoarthritis is a degenerative disorder of the joint and it is classified as
• Primary
• Secondary
Primary Osteoarthritis:
Primary OA is also called ‘wear and tear’ arthritis and degenerative joint
disease. In this, due to risk factors there will be degradation of articular cartilage
which leads to joint narrowing, remodeling of joint by forming osteophytes and
eventually a non functioning, painful joint. Although OA is a non inflammatory
process mild inflammatory changes occur in the synovium. It is also called idiopathic
OA as no predisposing factor is apparent.
Secondary OA:
It has known underlying cause including congenial or acquired incongruity of
joints, trauma, crystal deposits etc. But it cannot be distinguished from primary OA
pathologically.
Osteoarthritis is considered as the dynamic repair process of synovial joints. It
is more prevalent in aged persons and it is considered as the very common form of
arthritis.
Osteo arthritis is characterised by:
Loss of articular cartilage where there is maximum pressure.
Formation of new bone (Osteophyte) with remodeling of joints.
Most effected joints are knee and hip joint where as knee is most effected than
hip. Osteoarthritis is very common in Elbow, Glenohumeral joint and Ankle joint
also.
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DISEASE REVIEW
Effected joints:
Interphallangeal joints
Heberden’s nodes: Enlargement of distal interphallangeal joints.
Bouchard’s nodes: Enlargement of proximal interphallangeal joints.
Erosive osteoarthritis: This is present in distal and/or proximal interphallangeal
joints.
Generalised osteoarthritis: Characterised by involvement of three or more joints or
group of joints.
Thumb base osteoarthritis: In this, there will be squared appearance of thumb base.
Hip osteoarthritis: In this, the pain will be in inguinal area but may be referred to
buttock or proximal thigh. Flexion may be painless initially but internal rotation will
have pain. Loss of internal rotation occurs early, followed by loss of extension,
adduction, and flexion due to capsular fibrosis and/or osteophytes.
Knee osteoarthritis: Knee osteoarthritis will be manifested in these ways.
In medial femotibial compartment: It leads to varus deformity [Bow-leg]
In lateral femotibial compartment: It leads to valgus deformity [Knock-knee]
In patellofemoral OA: There will be positive shrug sign.
Spine osteoarthritis: This involve Apophysial joint, Intervertibral disc,and also there
may be involvement of paraspinous ligaments.
Pathogenesis:
For the normal functions of the joint, there should be normalcy of the joint
tissues such as cartilage, bone synovium, capsule, ligament, and muscles.
In the case of Primary osteoarthritis, the cause is considered as unknown. But
in case of Secondary osteoarthritis, a clear cause of Trauma or ligament rupture may
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DISEASE REVIEW
be important. By the mechanical, metabolic, genetic, and constitutional loads there
may be damage to the parts of synovial joint and there may be need to repair.
Some times due to the causes, there will be slow but efficient process of
manifestation that lead to anatomically altered but pain free functioning joint. This is
called as Compensated osteoarthritis.
Some times due to the chronic causes or due to poor repair response, there will
be progressive tissue damage and association with more frequent symptoms and this
is called as OA patient with Joint failure.
Cartilage changes:
In normal cartilage, there are no cell division but in the articular cartilage,
chondrocytes metabolically active the cells that are responsible for the synthesis of
cartilage matrix throughout life. Matrix degradation is done by proteolytic enzymes
such as Aggrecanase, which degrades the aggrecan, matrix proteinases[degrades
metalloproteins], Collagenase, and Stromelysin.
Chondrocytes increase their production of matrix components and devide to
produce nests of metabolically active chondrocytes. So there will be maximum
degradation and also production of Aggrecan components. But there will be fall in the
concentration of the Aggrecan. The decrease in the size of hydrophilic Aggrecan
molecules increases the water concentration and swelling pressure in cartilage. There
will be further destruction of the Type II collagen and it makes the cartilage incapable
to bearing weight. By this condition of cartilage there will be fissuring of the cartilage
surface [Fibrillation], development of deep vertical clefts, localised chondrocyte death
and decreased cartilage thickness. These all changes are maximum in weight bearing
part of the joint rather than whole part. The changes in cartilage surface leads to the
deposition of Calcium pyro phosphate and Apatite crystals especially in mid and
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DISEASE REVIEW
superficial zones. The bone below the compromised cartilage increases its trabecular
thickness. Holes (cysts) may develop. As a result there is increased pressure in bones
because cartilages fail in load transmitting function. So there will be production of
new fibrocartilage in the margins of the joints which undergoes endochondral
ossification and forms as Osteophytes. This remodeling and cartilage thickening
slowly alter the shape and the size of the joints. The synovium also shows various
changes in manifestation of Osteoarthritis. Osteochondral bodies commonly occur in
synovium. The Joint capsule also thickens and contracts, usually retaining the stability
of remodeling joint. The skeletal muscle which gives the strength to joint will shows
some fibre atrophy.
Clinical features:
1. Joint pain:
Joint pain is mainly related to the movement, weight bearing and it is relieved
by the rest. Here usually only one or a few joints are painful.
The causes for joint pain in osteoarthritis patients are,
Source Mechanism
1. Synovium Inflammation.
2. Sub chondral bone Medullary hypertension,Micro fractures
3. Osteophyte stretching of periosteal nerve endings.
4. Ligaments Stretch.
5. Capsule Inflammation, Distention.
6. Muscle Spasm.
2. Restricted movement:
Restricted movement is due to Capsular thickening and also by the blocking of
Osteophytes.
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DISEASE REVIEW
3. Crepitus:
Crepitus will be palpable or sometimes audible due to the rough articular
surfaces.
4. Bony swelling:
Bony swelling is seen around joint margins due to the presence of osteophytes.
5. Joint tenderness:
Tenderness is present in joint line or periarticular surfaces.
6. Joint instability.
7. Wasting of muscles.
8. No or only mild synovitis.
Radiographic findings of Osteoarthritis:
The main use of a Radiograph is to assess the severity of structural changes in
the joints.
• Focal narrowing of the joint space without evidence of destruction of margins.
• Formations of osteophytes at the margins of articular surface osteophytes are
osseous outgrowths of cortical and cancellous bone, which blends with normal
bone beneath it.
• Sub chondral sclerosis.
• Cyst like lesions are seen.
• Osteo chondral (loose) bodies are sometimes seen.
• Deformities of joints are seen.
• Chondrocalcinosis may be an additional feature particularly in Knee OA
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DISEASE REVIEW
Treatment:
There is no specific treatment for OA. Treatment is mainly advised for
reducing the pain, minimise the disability and also to reduce structural abnormalities.
The following steps are considered as the management of Osteoarthritis.
For reducing the Pain:
Uses of NSAIDs are advised. Non Steroidal Anti-inflammatory drugs are
medications which, as well as having pain relieving (analgesic) effects, have the effect
of reducing inflammation when used over a period of time.
Full explanation about Osteoarthritis:
• This is to avoid risk factors such as Trauma, Obesity etc.
• Advice about appropriate exercise:
• This should cover both strengthening and aerobics, to strengthening of joints.
• Total joint replacement is required for the minority of people with large joint
Osteoarthritis.
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DRUG REVIEW
DRUG REVIEW
This study contains two sub headings; Compound drug study and Individual
drug study. The trial drug Thrayodashanga guggulu and control drug Simhanada
guggulu explained under this heading.
THRAYODASHANGA GUGGULU:
Reference - Chakradatta
Chapter - Vatavyadhi [chapter no.22]
1) Compound drug study:
Ingredients
Abha, Ashwagandha, Hapusha,
Guduchi, Shatavari, Gokshura, 250 Grams each [1 part each]
Vrudhadaru, Rasna, Shathahwa,
Shati, Yavani, Nagara,
Shudda Guggulu 3 kilo grams [12 parts]
Ghrita 1.5 kilo grams [6 parts]
Method of preparation:
All the ingredients from Bakula to Nagara was taken separately and pounded
well. Then the powder was passed through a sieve to get the filtered form. Shudda
guggulu was taken, pounded well along with Goghritha, and also the filtered powders
should be added. After the proper pounding and mixing, the tablet is rolled of 1 gm
each.
The tablets are properly dried in sunlight and stored.
Dose : 6 gms.
Anupana : Sura, Yusha, Madya, Ushna jala, Ksheera,Mamsa rasa.
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DRUG REVIEW
Individual drug study:
1) ABHA:120
Botanical name : Acacia Arabica willd.
Sanskrit names :Yugalaksha, Bakula
Hindi names :Babbula, Kikara
Kannada names Karijali, Shameruka
Chemical Composition: Bark and legumes contain Tannin
Properties:
Rasa - Kashaya
Guna - Guru, Ruksha
Veerya - Sheeta
Vipaka - Madhura
Dosha - Kapha-pitta shamaka
Karma - Grahi, Kaphahara, Vishagna
Therapeutic uses: Kusta, Krimigna, Kasa, Atisara
Part used: Stem bark
2) ASHWAGANDHA:121
Botanical name Withania somnifera, Dunal
Sanskrit names: Vajigandha, Vatagni
Hindi name: Asagandha
Kannada names: Hiremaddina gida, Angara beru.
Chemical composition: In roots, there is Hallucinogen called somniferin and also
sucrose gum, resin, pigment dyes along with alkaloids and withanolides.
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DRUG REVIEW
Properties:
Rasa - Madhura, Kashaya, Tiktha
Guna - Laghu, Snigdha
Vipaka- Madhura
Veerya- Ushna
Dosha - Kapha vata shamaka
Karma - Balya, Rasayana, Vijikarna
Therapeutic uses: Kshaya, Dourbalya, Vataroga, Shotha, Klaibya.
Part used: Roots
3) HAPUSHA: 122
Botanical name: Juniperus communis
Sanskrit names: Vapusha, Vishagni
Hindi names : Havuber, Havubair
Kannada names: Padmabeeja
Chemical composition: It contains essential oil, flavanoids and fruits contain 50%
volatile oil, oxalic acid and fructose.
Properties:
Rasa - Katu, Tikta, Kashaya
Guna - Gum, Ruksha, Teekshna
Veerya- Ushna
Vipak - Katu
Dosha - Kaphavata shamaka
Karma - Kaphagna, Vatagna, Agnideepana, Vishagna
Therapeutic uses: Pittodara, Arsha, Grahani, Gulma, Shoola, Krumi, Vatodara.
Part used: Fruit
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DRUG REVIEW
4) GUDUCHI: 123
Botanical name: Tinospora cordifolia Willd
Sanskrit names: Amruta, Madhuparnika
Hindi names: Gurcha, Giloe
Kannada name: Amrutha balli
Chemical composition: Alkaloids and terpenoids
Properties:
Rasa - Tikta, Kashaya
Guna - Laghu, Snigdha
Veerya - Ushna
Vipaka - Madhura
Dosha - Tridoshagna and pittasaraka
Karma - Balya, Deepana, Jwaragna, Raktashodhaka, Rasayana.
Therapeutic uses: Kusta, Vatarakta, Jwara, Kamala, Pandu, Premeha.
Part used: Bark stem
5) SHATAVARI: 124
Botanical name: Asparagus racemoses Willd
Sanskrit names: Shataveerya, Vrushya
Hindi name: Shatavari
Kannada name Shatavari
Chemical composition: Fresh tuber is water soluble is 52%, fiber 33% and water 9%
in which 7% of sugar and some mucilaginous principle.
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DRUG REVIEW
Properties:
Rasa - Madhura, Tikta
Guna - Guna, Snigdha
Veerya - Sheeta
Vipaka - Madhura
Dosha - Vata pitta shamaka
Karma - Shoola-hara, Pachaka, Vata vyadhihara, Debility
Therapeutic uses: Shoola roga, Vataroga, Dourbalya
Part used: Tuber
6) GOKSHURA: 125
Botanical name: Tribulus terrestris Linn
Sanskrit names: Trikantaka, Gokantaka
Hindi name: Gokhru
Kannada names: Sanne Neggilu, Neggilu – Mullu
Chemical composition: Alkaloids, Saponins, Potassium nitrate, Sterols,
Sepogenin, Diosgenin, Gitogenin, and Hecogenin.
Properties:
Rasa - Madhura
Guna - Guru, Snigdha
Veerya - Sheeta
Vipaka - Madhura
Dosha - Tridosha shamaka
Karma - Vayugna, Mootrala, Vrushya, Bruhmana
Therapeutic uses: Shoolaroga, Vataroga, Mootra kruchra, Ashmari,
debility.
Part used: Panchanga
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DRUG REVIEW
RAASNA:126
Botanical name: Pluchea lanceolata
Sanskrit names: Sugadha, Suvaha
Hindi name: Rasayana
Kannada names: Dumme raasna
Chemical composition: Clavanoids, Quercetin, Isorhammetin.
Properties:
Rasa - Tikta
Guna - Guru
Veerya - Ushna
Vipaka - Katu
Dosha - Kaphavatahara
Karma - Amapachaka, Virechaka
Therapeutic uses: Shotha, Vatavyadhi, Kasa-Shwasa, Adyavata, Jwara,
Udararoga, Amavata, Vatarakta.
Part used: Leaves
7) SHATAPUSHPA:127
Botanical name: Anethum sowa. Roxb
Sanskrit names: Shatavah, Mishreye
Hindi names: Soya, Sova
Kannada name: Sabasige
Chemical composition: 3-4% volatile oil and stable oil
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DRUG REVIEW
Properties:
Rasa - Katu, Tikta
Guna - Laghu, Ruksha, Teekshna
Veerya - Ushna
Vipaka - Katu
Dosha - Vata kapha shamaka
Karma - Vatahara,kaphahara, Shoolahara, Deepana
Therapeutic uses: Jwara, Shoola, Vrana, Netraroga, atisara
Part used: Seed
8) SHATI:128
Botanical name: Hedychium spicatum
Sanskrit names: Kachur, Gandhasara
Hindi name: Kapur kachri
Kannada names: Seena Kachora, Kachora
Chemical composition: Essential oils
Properties:
Rasa - Katu, Tikta, Kashaya
Guna - Laghu, Teekshna
Veerya - Ushna
Vipaka - Katu
Dosha - Kaphavata shamaka
Karma - Shoolahara, Grahi, Mukhashodhaka
Therapeutic uses: Shoola, Chardi, Kandu, Kasa, Shwasa, Mukharoga.
Part used: Fruit
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DRUG REVIEW
9) AJAMODA: 129
Botanical name: Trachyspermum ammi
Sanskrit names: Yavani, Ugragandhi
Hindi names: Ajwain, Jevain
Kannada names: Omu, Yom
Chemical composition: Essential oil and fixed oil, which is volatile in nature
Properties:
Rasa - Katu, Tikta
Guna - Laghu, Ruksha, Teekshna
Veerya - Ushna
Vipaka - Katu
Dosha - Kaphavata shamaka
Karma - Shoolahara, Krimihara, Deepana, Pachana, Anulomana.
Therapeutic uses: Admana, Anaha, Udararoga, Gulma, Shoolahara,
Krimiroga.
Part used: Seeds
10) SHUNTI: 130
Botanical name Zinziber officinale, Rosce
Sanskrit names: Nagara, Vishwa bheshaja
Hindi name: Sonth
Kannada name: Shunti
Chemical composition: Yellow volatile oil, Gingerol, Gingerin (Resin),
Shogaol, Carbohydrates and starch are present.
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DRUG REVIEW
Properties:
Rasa - Katu
Guna - Laghu, Snigdha
Veerya - Ushna
Vipaka - Madhura
Dosha - Kaphavatagna
Karma - Deepana, Pachana, Amadoshahara, Shoola prashamaka
Therapeutic uses: Amavata, Udararoga, Agnimandhya, Pandu, Shwasa,
Admana.
Part used: Rhizome
11) VRUDHADARU:131
Botanical name: Argyria speciosa
Sanskrit names: Jeernadaru, Ajara
Hindi names: Bidaraa, Dhavapatha
Kannada name: Vidhara
Chemical composition: Contains Amlarala and Kashaya dravya
Properties:
Rasa - Katu, Tikta, Kashaya
Guna - Snigdha
Veerya - Ushna
Vipaka - Madhura
Dosha - Kaphavata shamaka
Karma - Vatarogagna, Dourbalyahara, Vrushyakaraka,
Agnivardhaka
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DRUG REVIEW
Therapeutic uses: Vataroga, Kshayaroga, Dourbalya, Shotha
Part used: Root
12) GUGGULU 132
Botanical name : Commiphora mukul
Sanskrit names : Deva dhupa, Kausika, Pura
Hindi names : Guggulu
Kannada names : Guggulu
Chemical Composition: Essential oil, Myrcene, Dimyrcene
Properties:
Rasa - Tikta, Katu, Kashaya.
Guna - Laghu, Ruksha, Teekshna, vishada, Sukshma, Sara,
Lekhana
Veerya - Ushna
Vipaka - Katu
Dosha - Tridosha hara
Karma - Sotha hara, vedhanastaphana, Vatanulomana,
Nadibhalyakara
Therapeutic uses: Vata roga, Ama vata, Vata rakta, Bhagna.
Part used: Gum resin.
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DRUG REVIEW
STANDARD DRUG
SIMHANADA GUGGULU
Reference: Cakradatta, Bhaishajya Ratnavali
Context: Amavata adhikara
Ingredients:
Hareetaki - 1 Pala.
Vibhitaki - 1 Pala
Amalaki - 1 Pala
Sh. Gandhaka - 1 Pala
Sh. Guggulu - 1 Pala
Eranda taila - 4 Pala
Method of preparation:
First Thriphala kwatha is prepared by using the thriphala yavakuta churna as
above mentioned. Eranda thaila and Guggulu were mixed with the Triphala kwatha
and boiled in low flame. Gradually guggulu dissolved and concentrated. When it
attains bolus like soft mass, then taken from the fire and left for self cooling.
Gandhaka powder was added and mixed well. Then vati is prepared. This vati is
manually dried and preserved.
Individual drug study
1) HAREETAKI 133
Botanical name : Terminalia chebula Retz.
Sanskrit names : Amruta, Vijaya, Abhaya.
Hindi names : Haradar
Kannada names : Alalekayi
Chemical Composition: 30% of Astringent substance, Chebulic acid,
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DRUG REVIEW
Properties:
Rasa - Kashaya pradhana pancha rasa.
Guna - Laghu, Ruksha.
Veerya - Ushna
Vipaka - Madhura
Dosha - Tridosha hara specially vata samaka
Karma - Medhya Rasayana Bruhmana Anulomana Ayushya,
Chakshusya.
Therapeutic uses: Swasa, Kasa, Prameha, Arsha, Eye diseases, Twak roga,
Kamala.
Part used: Fruit (without seed).
2) VIBHITAKI 134
Botanical name : Terminalia bellirica Roxb.
Sanskrit names : Kalidruma, Aksha, Karsha phala
Kannada names : Santhi kayi
Chemical Composition: Mannitol, Glucose, Chebulagic acid, Bellericanin, Fatty
oil.
Properties:
Rasa - Kashaya pradhana pancha rasa.
Guna - Laghu, Ruksha.
Veerya - Ushna
Vipaka - Madhura
Dosha - Tridosha samaka specially kapha hara
Karma - Deepana, Anulomana, Grahi.Chakshusya.
Therapeutic uses: Kapha roga, Swasa, Kasa, Sotha, Vata vyadhi.
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DRUG REVIEW
Part used: (Fruit without seed).
3) AMALAKI 135
Botanical name : Emblica officinalis Gaertn.
Sanskrit names : Dhatri, Vayastha
Hindi names : Amla
Kannada names : Nellikayi
Chemical Composition: Carbohydrate, Fe, Nicotinic acid, Tannin, Galic acid,
Emblicol.
Properties:
Rasa - Amla pradhana pancha rasa.
Guna - Guru, Ruksha.
Veerya - Sheeta
Vipaka - Madhura
Dosha - Tridosha hara specially pitta samaka
Karma - Medhya Rasayana, Vrushya, Vayasthapana, Anulomana
Chakshusya,
Therapeutic uses: Swasa, Kasa, Kshaya, Pandu, Eye diseases, Raktapitta.
Part used: Fruit (without seed)
4) ERANDA 136
Botanical name : Ricinus communis .Linn
Sanskrit names : Chitra beeja, Gandharvahasta.
Hindi names : Arand
Chemical Composition: Castor oil is composed of Triricinolein.
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DRUG REVIEW
Properties:
Rasa - Madhura
Guna - Snigdha, Teekshna, Sukshma
Veerya - Ushna
Vipaka - Madhura
Dosha - Kaphavata samaka
Karma - Vata kapha hara, Deepana Bhedhana, Ama shodhana,
Sotha hara..
Therapeutic uses: Amavata, Katisula, Grudrasi.Sandhi sotha.
Part used: seed oil.
5) GUGGULU 132
Botanical name : Commiphora mukul
Sanskrit names : Deva dhupa, Kausika, Pura
Hindi names : Guggulu
Kannada names : Guggulu
Chemical Composition: Essential oil, Myrcene, Dimyrcene
Properties:
Rasa - Tikta, Katu, Kashaya.
Guna - Laghu, Ruksha, Teekshna, vishada, Sukshma, Sara,
Lekhana
Veerya - Ushna
Vipaka - Katu
Dosha - Tridosha hara
Karma - Sotha hara, vedhanastaphana, Vatanulomana,
Nadibhalyakara
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DRUG REVIEW
Therapeutic uses: Vata roga, Ama vata, Vata rakta, Bhagna.
Part used: Gum resin.
6) GANDHAKA 138
Synonym: Atigandha, Gandhapashana
Guna karma:
Rasa : Katu Madhura
Guna : Laghu Snigdha
Virya : Ushna
Vipaka : Katu
Doshakarma: Kapha vata hara
Karma: Rasayana, Deepana, Pachana, Rakta shodhana.
Therapeutic uses: Kantu, Kusta, Amadosha, Visha dosha.
Dose: 1-8 Ratti.
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METHODOLOGY
METHODOLOGY
Research is a scientific and intelligent study, investigation or experimentation
in order to establish facts and their significance. This is the only way available to re-
establish old facts through modern methodology. It is also useful in case of gaining
knowledge, helps to develop and advance in new directions.
Ayurveda is the science of life. Being an ancient medical science, it is
formulated on the scientific parameters available in those times. And a clinical trial,
which is carefully designed to answer the present generation who are conscious and
wants a scientific explanation for everything that is happening in this world. So a
clinical study is conducted on scientific line with the aim of solving the unsolved
problems is the only way to achieve the above objectives.
This study is an attempt to prove the efficacy scientifically of Trayodashanga
Guggulu on Sandhigatavata, by comparing it with Simhanada Guggulu. Efficacy can
be determined by finding out the difference between the base line data and assessment
data.
Study design:
It is a single blind comparative clinical study with pretest and posttest design
where in 40 patients suffering from Sandhigatavata of either sex of age group in
between 25-65 were selected and randomly allocated into test group and control
group. Duration of study is 60 days.
Source of data:
Patients who were attending the O.P and I.P section of Kayachikitsa
department A.L.N.Rao Ayurveda Medical College Hospital Koppa were taken up for
the study. 40 patients were registered for the study.
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METHODOLOGY
Criteria of selection:
Patient who presented the complaints of joint pain, were examined in detail
regarding the present and past history, food and activity, treatment status etc. and was
recorded in a specially prepared Performa. The patients were investigated with serum
RA, ASO titer and X-ray of joint (AP and Lat).
Inclusion criteria:
1. Patients diagnosed as Sandhi gata vata on the basis of signs and symptoms
according to classical Ayurvedic texts.
2. Patients of either sex between the age of 25-65 years.
3. Early onset of Sandhi gata vata is included.
Exclusion criteria:
1. Sandhigata vata due to congenital development disorders, post traumatic,
neurological and endocrine origin
2. Patients having secondary complications.
3. During pregnancy and lactation period.
Investigations:
Blood - Serum RA factor, ASO titer.
X-ray of effected joints- both AP and Lat.
Preparation of Trial drug:
The trial drug Trayodashanga Guggulu is mentioned in Chakradatta. In this
Guggulu preparation the quantity of the individual drugs is mentioned in the text that
the twelve drugs should be taken in one part, Guggulu is taken twelve parts and Ghrita
is six parts.
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METHODOLOGY
Ingredients:
Abha, Ashwagandha, Hapusha,
Guduchi, Shatavari, Gokshura, 250 Grams each [1 part each]
Vrudhadaru, Rasna, Shathahwa,
Shati, Yavani, Nagara,
Shudda Guggulu 3 kilo grams [12 parts]
Ghrita 1.5 kilo grams [6 parts]
Method of preparation:
All the ingredients from Bakula to Nagara was taken separately and pounded
well. Then the powder was passed through a sieve to get the filtered form. Shudda
guggulu was taken, pounded well along with Goghritha, and also the filtered powders
should be added. After the proper pounding and mixing, the tablet is rolled of 1 gm
each.
The tablets are properly dried in sunlight and stored.
INTERVENTION
Trial group:
Sample size - 20 patients.
Medicine - Trayodashanga Guggulu
Dose - 3 grams twice daily after food.
Duration - 60 days.
Anupana - Ushna jala.
Standard group:
Sample size - 20 patients.
Medicine - Simhanada Guggulu
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METHODOLOGY
Dose - 3 grams twice daily after food.
Duration - 60 days.
Anupana - Ushna jala.
Observation period:
Follow period was done for 60 days.
Assessment criteria:
Scoring methods given to the clinical signs and symptoms and functional
capacity of the patients assesses the improvement in the signs and symptoms. Signs
and symptoms recorded on interval of 15 days for 60 days.
Clinical assessment:
Sandhi shula Points
No pain [no pain at rest / no pain while walking] - 0
Mild pain [no pain at rest or
mild tolerable pain while walking] - 1
Moderate pain [mild pain at rest, tolerable and
moderate pain while working] - 2
Severe pain [disturbance of sleep due to pain or
pain at rest or un tolerable pain during working] - 3
Atopa of sandhi
No crepitus - 0
Palpable crepitus - 1
Audible crepitus - 2
Tenderness:
No pain on pressure - 0
Pain on pressure and winces - 1
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METHODOLOGY
Patient withdraws affected part while giving pressure - 2
Patient does not allow to touch - 3
Sandhi shotha:
No swelling - 0
Swelling is present slightly in joints - 1
Swelling covering the bony prominence of affected joints - 2
Swelling much elevated so that
the joints seems grossly deformed - 3
Criteria for assessment of total effects of the therapy:
The sum points of all the parameters of assessment before and after treatment
were taken into consideration to assess the total effect of the therapy. It was graded in
terms of percentage of relief in the signs and symptoms.
Total cure - 100% relief
Marked improvement - relief of above 60%
Moderate improvement - 40 to 60% of relief
Improved - relief of more than 40%
Unchanged - 0% of relief
Deterioration - worsening of the signs and symptoms
Statistical analysis:
All data was analysed statistically by calculating the mean, percentage of
change, standard deviation, standard error, t and p values by using student ‘t’ test.
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METHODOLOGY
Observations
In this study on Sandhigata vata, 20 patients were taken in each group (trial
group, control group) totally 40 patients were registered. Here from both groups by
considering Age, Sex, Religion, Deha prakruti, and also by Roga and Rogi pareeksha,
the observations were derived.
1. Age wise distribution in 40 patients of Sandhigata vata
In this study about Sandhigata vata showed maximum number of patients
(50%) between the ages 55-65 yrs. 30% of the patients were in the age group of 45-55
yrs, 15% were in 35- 45 yrs, while 5% of the patients between the ages 25-35 yrs.
Table No. 15 Showing Age Incidence
Sl.No. Age in Years No. of Patients Percentage 1. 25-35 2 5 2 35-45 6 15 3. 45-55 12 30 4. 55-65 20 50
Graph No. 1 Showing Age Incidence :
0
20
40
60
80
100
25-35 35-45 45-55 55-65
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METHODOLOGY
2. Distribution of 40 patients of Sandhigata vata according to sex
In this study, 55% of the patients were females and 45% of patients were
males.
Table No.16 Showing sex incidence
Sl.No. Sex No. of Patients Percentage 1. Male 18 45 2. Female 22 5
Graph No. 2 – Showing sex incidence
0
20
40
60
80
100
Male Female
3. Distribution of 40 patients of Sandhigata vata according to religion.
In this study, maximum numbers of patients were Hindu i.e. 77.5%, Muslims
were 15% and minimum patients were Christian i.e.7.5%
Table No. 17 Showing religion incidence
Sl.No. Religion No. of Patients Percentage 1. Hindu 31 77.5 2. Muslim 6 15 3. Christian 3 7.5
Graph No. 3 Showing religion incidence
0
20
40
60
80
100
Hindu Muslim Christian
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METHODOLOGY
4. Distribution of 40 patients of Sandhigata vata according to marital status
Among 40 patients, 37 patients (92.5%) were married, while 7.5% i.e. 3
patients were unmarried.
Table No. 18 Showing Marital status
Sl.No. Marital status No. of Patients Percentage 1. Married 37 92.5 2. Unmarried 3 7.5
Graph No. 4 Showing Marital status
0
20
40
60
80
100
Married Unmarried
5. Economic status of 40 patients of Sandhigata vata
Maximum of patients got belongs to poor class i.e.70%, 22.5% belonged to
middle class and minimum of 7.5% came from rich class for this study.
Table No. 19 Showing Economic status
Sl.No. Social economic status
No. of Patients Percentage
1. Poor 28 70 2. Middle 9 22.5 3. Rich 3 7.5
Graph No. 5 Showing Economic status
0
20
40
60
80
100
Poor Middle Rich
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METHODOLOGY
6. Occupational incidence of 40 patients of Sandhigata vata
While considering occupation of the patients, maximum patients are House
wife i.e. 45%, then Agriculture i.e. 32.5%, those who are in service are 7.5%,
Business persons are 5% and those who are having occupation other than this
considered together i.e. 10%
Table No. 20 Showing Occupational incidence
Sl.No. Occupation No. of Patients Percentage 1. Business 2 5 2. House wife 18 45 3. Service 3 7.5 4. Agriculture 13 32.5 5. Others 4 10
Graph No.6 Showing Occupational incidence
0
20
40
60
80
100
House wife Agriculture Service Business Others
7. Nature of work of 40 patients of Sandhigata vata:
Maximum number of patients performed their work by walking for long hours
i.e. 47.5%, while 45% performed their work by standing for long hours; 7.5%
developed this disease after sitting for long time.
Table No. 21 Showing Nature of work
Sl.No. Nature of work No. of Patients Percentage 1. Standing 18 45 2. Sitting 3 7.5 3. Walking 19 47.5
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METHODOLOGY
Graph No.7 – Showing Nature of work
0
20
40
60
80
100
Standing Sitting Walking
8. Habitat wise distribution of 40 patients of Sandhigata vata
92.5% of the patients belonged to Anupa desa, while 5% belonged to
Sadharana and 2.5% of patients belonged to Jangala desas.
Table No. 22 Showing the Habitat
Sl.No. Habitat No. of Patients Percentage 1. Sadharana 2 5 2. Jangala 1 2.5 3. Anupa 37 92.5
Graph No. 8 Showing the Habitat
0
20
40
60
80
100
Sadharana Janghala Anupa
9. Distribution of 40 patients according to Lakshanas:
Sandhishula was the common symptom which is present in all the patients
i.e.100%, then Prasarana akunchana pravrthi savedana was present in 95% patients,
stambha was present in 85% patients, in 77.5% patients suffered from Shotha, Atopa
in 70% patients.
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METHODOLOGY
Table No.23 Showing Symptoms
Sl.No. Symptomatology No. of Patients Percentage 1. Sandhi Sula 40 100 2. Sandhi Shotha 31 77.5 3. Sandhi Stambha 34 85 4. Prasarana akunchana
pravrthi savedana 38 95
5. Atopa 28 70
Graph No.9 Showing Symptoms of Sandhi gata vata
0
20
40
60
80
100
Sandhi sula Atopa Prasaranaakunchana
vedana
Sotha Stambha
10. Duration of illness in 40 patients of Sandhigata vata
Maximum patients suffered from this disease below one year (45%), 32.5%
have history in between 1-3 years and 22.5% of patients gave a history of suffering
above 3 years.
Table No. 24 Showing Duration of illness:
Sl.No. Duration of illness No. of Patients Percentage 1. Below 1 year 18 45 2. In between 1-3 years 13 32.5 3. Above 3 years 9 22.5
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METHODOLOGY
Graph No. 10 Showing Duration of illness:
0
20
40
60
80
100
<1 yr 1-3 yrs > 3 yrs
11. Family history of this disease in 40 patients of Sandhigata vata:
Majority of the patients show no family history about this disease (80%). 20%
of patients show family history about this disease.
Table No. 25 Showing incidence of family history:
Sl.No. Family history No. of Patients Percentage
1. Yes 8 20 2. No 32 80
Graph No. 11 Showing incidence of family history:
0
20
40
60
80
100
Yes No
12. Dietary Habit in 40 patients of Sandhigata vata
Maximum no. of patients was consuming mixed type of diet (55%), while
45% of patients are Vegetarian.
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METHODOLOGY
Table No. 26 Showing the Dietary Habit:
Sl.No. Dietary habit No. of Patients Percentage 1. Vegetarian 18 45 2. Mixed 22 55
Graph No. 12 Showing the Dietary Habit:
0
20
40
60
80
100
Veg Mixed
13. Ahara pramana in 40 patients of Sandhigata vata
Most of the patients were taken Sama pramana of Food i.e. 57.5%. While 25%
of patients were taken Alpa pramana of Ahara and minimum of 17.5% patients were
habit of consuming Ati pramana of Ahara.
Table no. 27 showing Ahara pramana:
Sl.No. Ahara pramana No. of Patients Percentage 1. Alpa 10 25 2. Sama 23 57.5 3. Ati 7 17.5
Graph No.13 Showing the Ahara pramana
0
20
40
60
80
100
Alpa Sama Ati
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METHODOLOGY
14. Dominant rasa in 40 patients of Sandhigata vata
Most of the patients consumed the Food which is katu rasa pradhana i.e.
37.5%, and 20% of the patients taken the Ahara which is Lavana rasa pradhana and
17.5% patients took Amla rasa predominant food. 12.5% of the patients took Tikta
rasa pradhana ahara in more quantity while 7.5% of the patients were habituated
to kasaya rasa predominantly in their food and 5% of patients were taken food which
is Madhura rasa dominant.
Table No. 28 Showing Dominant rasa:
Sl.No. Dominant rasa No. of Patients Percentage 1. Madhura 2 5 2. Amla 7 17.5 3. Lavana 8 20 4. Katu 15 37.5 5. Tikta 5 12.5 6. Kasaya 3 7.5
Graph No. 14 Showing Dominant rasa
0
20
40
60
80
100
Madhura Amla Lavana Katu Tikta Kashaya
15. Dominant ahara guna in 40 patients of Sandhigata vata
Here analysis of main qualities of food has been done. Among this 32.5% of
the patients took Laghu guna yukta ahara, while 30% took Ruksha ahara, 20% of
patients took Ushna ahara, 10% of patients took Sheeta ahara, 2% of patients were
habituated to Guru ahara and only 2.5% took Snigdha guna predominant food.
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METHODOLOGY
Table No. 29 Showing Dominant ahara guna:
Sl.No. Dominant ahara
guna No. of Patients Percentage
1. Rooksha 12 30 2. Snigdha 1 2.5 3. Ushna 8 20 4. Sheeta 4 10 5. Guru 2 5 6. Laghu 13 32.5
Graph No. 15 Showing Dominant Ahara guna:
0
20
40
60
80
100
Ruksha Seeta Laghu Snigdha Guru Ushna
16. Nidra incidence in 40 patients of Sandhigata vata
Majority of the patients complained of disturbed sleep i.e. 77.5%, while 22.5%
had sound sleep.
Table No. 30 Showing Nidra incidence:
Sl.No. Nidra No. of Patients Percentage 1. Sound 9 22.5 2. Disturbed 31 77.5
Graph No. 16 Showing Nidra incidence:
0
20
40
60
80
100
Sound Disturbed
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METHODOLOGY
17. Pramana of vyayama in 40 patients of Sandhigata vata
In 40 patients of Sandhi gata vata, 62.5% of the patients developed this disease
after performing Ati vyayama, while 30% of them did in sama pramana and 10% did
less pramana of Vyayama.
Table No. 31 Showing the Pramana of vyayama:
Sl.No. Vyayama No. of Patients Percentage 1. Hina 3 7.5 2. Sama 12 30 3. Ati 25 62.5
Graph No.17 Showing the Pramana of vyayama:
0
20
40
60
80
100
Heena Sama Ati
18. Prakruti in 40 patients of Sandhigata vata
Prakruti was accessed according to classical description. Majority of the
patients belonged to Vata pitta(dwandwaja) prakruti I.e. 55%. Then the patients of
Vata kapha i.e.30% and 10% were Sannipataja prakruti, 5% if the patients belonged to
Vata slesmala praktuti. No patients were observed Ekadoshaja prakruti.
Table No.32 Showing the Prakruti:
Sl.No. Prakruti No. of Patients Percentage 1. Vatapittaja 22 55 2. Vatakaphaja 12 30 3. Pittakaphaja 2 5 4. Sannipataja 4 10 5. Vataja 0 0 6. Pittaja 0 0 7. Kaphaja 0 0
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METHODOLOGY
Graph No.18 Showing the Prakruti:
0
20
40
60
80
100
V P P K V K V P K V P K
19. Distribution of 40 patients of Sandhigata vata according to Sara
Most of the patients had madhyama sara i.e. 82.5%, while 15% had avara sara
and 2.5% patients were having pravara sara.
Table No. 33 According to Sara:
Sl.No. Sara No. of Patients Percentage 1. Pravara 1 2.5 2. Madhyama 33 82.5 3. Avara 6 15
Graph No.19 According to Sara:
0
20
40
60
80
100
Pravara Madhyama Avara
20. Distribution of 40 patients of Sandhigata vata according to Satwa
Maximum number of patients had madhyama satwa i.e. 77.5%, while 20% had
avara satwa and pravara satwa 2.5%.
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METHODOLOGY
Table No. 34 According to Satwa:
Sl.No. Satwa No. of Patients Percentage 1. Pravara 1 2.5 2. Madhyama 31 77.5 3. Avara 8 20
Graph No.20 According to Satwa:
0
20
40
60
80
100
Pravara Madhyama Avara
21. Distribution of 40 patients of Sandhigata vata according to Samhanana
Maximum number of patients had madhyama samhanana i.e. 67.5%, while
17.5% had avara samhanana and 15% of the patients had pravara samhanana.
Table No.35 According to Samhanana
Sl.No. Samhanana No. of Patients Percentage 1. Pravara 6 15 2. Madhyama 27 67.5 3. Avara 7 17.5
Graph No.21 According to Samhanana
0
20
40
60
80
100
Pravara Madhyama Avara
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METHODOLOGY
22. Satmya in 40 patients of Sandhigata vata
Maximum number of patients had madhyama satmya i.e. 70%, while 25% was
avara satmya and pravara satmya is 5%.
Table No.36 According to Satmya:
Sl.No. Satmya No. of Patients Percentage 1. Pravara 2 5 2. Madhyama 28 70 3. Avara 10 25
Graph No.22 According to Satmya:
0
20
40
60
80
100
Pravara Madhyama Avara
23. Distribution of 40 patients of Sandhigata vata according to Ahara shakti
In ahara sakti there are two divisions, they are abhyavarana sakti and jarana
sakti. They are tabulated separately.
a) Distribution according to abhyavarana sakti:
Majority of the patients had madhyama abhyavarana sakti i.e. 80% and 15%
are having avara abhyavarana sakti. 5% of patients had pravara abhyavarana sakti.
Table No. 37 According to Abhyavarana sakti
Sl.No. Abhyavarana sakti No. of Patients Percentage 1. Pravara 2 5 2. Madhyama 32 80 3. Avara 6 15
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METHODOLOGY
Graph no: 23 showing Abhyavarana sakti
0
20
40
60
80
100
Pravara Madhyama Avara
b) Distribution of 40 patients according to Jarana sakti
Most of the patients had madhyama jarana sakti i.e. 72.5% and 22.5% are
having avara jarana sakti. 5% of patients had pravara jarana sakti.
Table No.38 showing Jarana shakti:
Sl.No. Jarana sakti No. of Patients Percentage
1. Pravara 2 5 2. Madhyama 29 72.5 3. Avara 9 22.5
Graph no:24 Showing Jarana shakti:
0
20
40
60
80
100
Pravara Madhyama Avara
24. Distribution of 40 patients of Sandhigata vata according to Vyayama sakti
While considering Vyayama shakti, majority of the patients had avara
vyayama sakti i.e. 80%, while 17.5% had madhyama vyayama sakti and 2.5%
performed pravara vyayama.
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METHODOLOGY
Table No. 39 According to Vyayama sakti
Sl.No. Vyayama sakti No. of Patients Percentage 1. Pravara 1 2.5 2. Madhyama 7 17.5 3. Avara 32 80
Graph No. 25 According to Vyayama sakti
0
20
40
60
80
100
Pravara Madhyama Avara
23. Weight incidence in 40 patients of Sandhigata vata
Majority of patients having weight in between 45-55 kg i.e. 40%. Patients
having 55-65 kg are 35%, while 17.5% patients are having weight in between 35-45
kg. 17.5% were between 65-75 kg.
Table No. 40 Showing the Weight incidence
Sl.No. Weight (Kg) No. of Patients Percentage 1. 41-50 7 17.5 2. 51-60 14 35 3. 61-70 16 40 4. 71.80 3 7.5
Graph No. 26 Showing the Weight incidence
0
20
40
60
80
100
35-45 45-55 55-65 65-75
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RESULTS
RESULTS
Table No:41
Therapeutic effect of Trial drug Thrayodashanga Guggulu in the management of
Sandhigata vata after 60 days treatment:
Mean Sl.
No.
Main
symptoms BT AT BT-AT
% S.D S.E t P
1. Sandhi shula 1.75 1.35 0.40 35 0.598 0.133 2.990 <0.010
2. Tenderness 1.90 1.40 0.50 40 0.688 0.153 3.248 <0.010
3. Atopa 1.90 1.30 0.60 55 0.598 0.133 4.485 <0.001
4. Sandhi sotha 1.90 1.55 0.35 30 0.587 0.131 2.665 <0.020
The trial drug Thrayodashanga Guggulu gives highly significant (< 0.001)
result in the Atopa (crepitus) i.e. 55%. It provided 40% relief in Tenderness which is
moderately significant (<0.010). Also it is moderately significant (<0.010) in Sandhi
shula (35%)
Table No:42
Therapeutic effects of Trial drug Thrayodashanga Guggulu in the management
of Sandhigata vata after 60 days of follow up:
Mean Sl.
No.
Main
symptoms BT AFU BT-AFU
% S.D S.E t P
1. Sandhi shula 1.75 1.05 0.70 60 0.656 0.146 4.765 <0.001
2. Tenderness 1.90 1.15 0.75 65 0.638 0.142 5.251 <0.001
3. Atopa 1.90 1.25 0.65 60 0.587 0.131 4.950 <0.001
4. Sandhi sotha 1.90 1.45 0.45 40 0.600 0.135 3.327 <0.010
The trial drug Thrayodashanga Guggulu showed highly significant (< 0.001)
result in Tenderness (65%). It showed highly significant result (< 0.001) in Sandhi
shula and Atopa (60%).
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RESULTS
Table No: 43
Effect of standard drug (Simhanada Guggulu) in the management of Sandhigata
vata after 60 days of treatment:
Mean Sl.
No.
Main
symptoms BT AT BT-AT
% S.D S.E t P
1. Sandhi shula 1.85 1.55 0.30 30 0.470 0.105 2.853 <0.020
2. Tenderness 2.00 1.65 0.35 30 0.587 0.131 2.665 <0.020
3. Atopa 1.80 1.40 0.40 35 0.598 0.133 2.990 <0.010
4. Sandhi sotha 2.15 1.55 0.60 50 0.680 0.152 3.942 <0.001
The standard drug simhanada guggulu showed highly significant result
(<0.001) in the Sandhi shotha (50%). It provided moderate significant (<0.010) result
in the Atopa (35%). And in the sandhi shula and tenderness showed moderate
significant (<0.020) and the relief is 30%.
Table No: 44
Effect of standard drug (Simhanada Guggulu) in the management of Sandhigata
vata after 60 days of follow up:
Mean Sl.
No.
Main
symptoms BT AF
U
BT-
AFU
% S.D S.E t P
1. Sandhi shula 1.85 1.40 0.45 40 0.604 0.135 3.327 <0.010
2. Tenderness 2.00 1.50 0.50 40 0.688 0.153 3.298 <0.010
3. Atopa 1.80 1.25 0.55 45 0.686 0.153 3.583 <0.010
4. Sandhi sotha 2.15 1.40 0.75 60 0.716 0.160 4.682 <0.001
The standard drug Simhanada Guggulu provided highly significant (<0.001)
result in the Sandhi shotha (60%). It showed moderate significant (<0.010) result in
the Atopa (45%) and in the sandhi shula and tenderness it provides moderate
significant (<0.010) result and relieved the symptoms 40%.
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RESULTS
Table No: 45
Comparative effect of therapies in the management of Main symptoms of 40
patients of Sandhigata vata after treatment:
Group Sandhishoola Tenderness Atopa Sandhi shotha
Trial group 35 40 55 30
Std group 30 30 35 50
While comparing the effect of therapies on main symptoms, it was found that
Trial group showed 35%, 40%, 55% and 30% relief in managing the symptoms like
Sandhi shula, Tenderness, Atopa and Sandhi shotha respectively were as Standard
group showed 30%, 30%, 35% and 50% relief in the symptoms like Sandhi shula,
Tenderness, Atopa and Sandhi shotha respectively.
Graph No: 27
Comparative effect of therapies in the management of Main symptoms of 40
patients of Sandhigata vata after treatment:
0
20
40
60
80
100
shula tenderness Atopa shotha
trial std
Page 85
RESULTS
Table No: 46
Comparative effect of therapies in the management of Main symptoms of 40
patients of Sandhigata vata after follow up:
Group Sandhishoola Tenderness Atopa Sandhi shotha
Trial group 60 65 60 40
Std group 40 40 45 60
While comparing the effect of therapies on main symptoms, it was found that
Trial group showed 60%, 65%, 60% and 40% relief in managing the symptoms like
Sandhi shula, Tenderness, Atopa and Sandhi shotha respectively were as Standard
group showed 40%, 40%, 45% and 60% relief in the symptoms like Sandhi shula,
Tenderness, Atopa and Sandhi shotha respectively.
Here trial group showed better results in the management of Sandhi shula,
Tenderness, Atopa where as standard group (Simhanada guggulu) given better result
in the Sandhi shotha.
Graph No: 28
Comparative effect of therapies in the management of Main symptoms of 40
patients of Sandhigata vata after follow up:
0
20
40
60
80
100
shula tenderness Atopa shothatrial std
Page 86
RESULTS
Table No: 47
Overall effect of therapy by trial drug Trayodashanga guggulu on patients of
Sandhigata vata after 60 days of treatment:
Result No. of patients %
Complete relief 00 00
Marked improvement 04 20
Moderate improvement 04 20
Improved 09 45
Unchanged 03 15
In this group, 45% of the patients were assessed under improved category.20% of
patients showed moderate and marked improvement. 15% showed no response to the
treatment. No body showed complete relief.
Table No: 48
Overall effect of therapy by trial drug Trayodashanga guggulu on patients of
Sandhigata vata after 60 days of follow up
Result No. of patients %
Complete relief 00 00
Marked improvement 03 15
Moderate improvement 07 35
Improved 07 35
Unchanged 03 15
After 60 days of follow up period 35% of patients showed Moderate
improvement were as 35% patients came under improved category. 15% of patients
showed marked relief in the symptoms.15% of patients came under unchanged
category.
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RESULTS
Table No: 49
Overall effect of therapy by Standard drug Simhanada guggulu on patients of
Sandhigatha vata after 60 days of treatment:
Result No. of patients %
Complete relief 00 00
Marked improvement 02 10
Moderate improvement 08 40
Improved 07 35
Unchanged 03 15
In this group after 60 days of treatment the standard group showed 40%
Moderate relief in the symptoms. 35% of the patients showed improved relief.10% of
the patients showed Marked improvement and 15% remained unchanged.
Table No: 50
Overall effect of therapy by control drug Simhanada guggulu on patients of
Sandhigata vata after 60 days of follow up.
Result No. of patients %
Complete relief 00 00
Marked improvement 03 15
Moderate improvement 02 10
Improved 11 55
Unchanged 04 20
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RESULTS
55% of patients showed improvement in the symptoms, 15% belonged marked
improvement. 10% Showed moderate improvement where as remaining 20%
belonged to unchanged category. No body showed complete relief.
Graph No: 29
Comparative effect of overall therapy of 40 patients of Sandhigata vata after 60
days of treatment:
0
20
40
60
80
100
Completerelief
Markedimprovement
Moderate imp Improved Unchanged
trial std
Complete relief was not noted in both the groups. 20% of patients of Trial
group showed marked improvement while it was 10% in Standard group. 20%
showed moderate improvement in Trial group and 40% in Standard group.
Improvement was noted in 45% in Trial group and 35% of patients in Standard group.
15% of patients in Trial group showed no change after the treatment while in Standard
group also it is 15%.
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RESULTS
Graph No: 30
Comparative effect of overall therapy of 40 patients of Sandhigata vata after 60
days of follow up:
0
20
40
60
80
100
Completerelief
Markedimprovement
Moderate imp Improved Unchanged
trial std
After follow up, complete relief was not noted in both the groups. 15% of
patients of Trial group showed marked improvement and also it was 15% in Standard
group. 35% showed moderate improvement in Trial group and 10% in Standard
group. Improvement was noted in 35% in Trial group and 55% of patients in Standard
group. 15% of patients in Trial group showed no change after the treatment while in
Standard group also it is 20%.
Page 90
DISCUSSION
DISCUSSION
The pathological condition in which either of the localized or generalized
symptomatology gets manifested along with severe pain as an effect of localization of
the vitiated vata dosha in different dushyas as the condition may be called as vata
vyadhi. It is also said that vata vyadhi is a consequent result of a special type of
dosha-dushya sammurchana occurring in the body, manifested by either localized or
generalized symptamatology, brought about by the localization of vitiated vata in the
respected dushyas.
Sandhi gata vata is one of the vata vyadhi. Supportive evidences are found in
the Ayurvedic classics indicates that sandhigata vata does possess an etio-
pathogenesis of its own as it is said that a vyadhi is formed only after the completion
of the dosha-dushya sammurchana in the Sthana samshrayavastha marked by a clear
cut manifestation of signs and symptoms. In this context the vata is getting vitiated by
its etiological factors runs through all the pathological stages and on getting localized
in its dushyas which in this case being sandhi produces a specialized form of dosha-
dushya sammurchana and manifest with its clear cut symptoms like shotha shula, so
as to be called as sandhigata vata.
In modern, Sandhi gata vata is compared with the Osteo arthritis which is one
of the degenerative joint disorders. Females are found to be more affected by this
disorder. It causes pain and disability there by hampering man power resources of the
nation. So the priority for health system assumes an important place as the population
becomes older.
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DISCUSSION
Discussion on Etiology:
Although separate etiological factors not mentioned for the disease sandhigata
vata, samanya nidana for vata vyadhi itself is taken in to consideration. The
etiological factors can be divided into aharata, viharata, manasika, kalakruta and gada
kruta.
In proper diet and dietic regimen plays importance in the process of this
disease because ahara provides the nutrients to all the dhatus. By the improper food
and dietic regimen quantitatively or qualitatively produces changes in the process of
digestion and absorption. This leads to dhatu kshaya which in turn causes the vata
prakopa results in sandhigata vata.
The viharaja nidans which pertaining to this disease can stimulates or irritates
the anatomical sites (sandhis), where the depletion of dhatus (sleshma, snayu) takes
place which in turn causes the riktata and also vata prakopa. Vyana vata is responsible
for pancha chesta, the etiological factors will directly causes vyana vata pakopa. This
produces difficulty in movement.
The mental health always contributes the physical well being. The anxiety,
stress, nervousness and mental disturbances reflect on body mechanism and impair
the functions. Vata being essential factor in the maintenance of manas and indriyas,
disturbances in that aspect directly influence over vata.
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DISCUSSION
Discussion on Samprapti:
The samprapti of sandhigata vata follows either of the two different pathways.
The different mechanisms can be explained as said below-
1. The consumption of aharaja, viharaja, manasika, kalaja or gadakruta nidanas
having the tendency to vitiate the vata, either individually or in combination
sill kead to the sanchaya of the vata. The accumulated vata heads towards the
steps of prakopa and prasara. The same etiological factors having the tendency
to destroy the dhatus simultaneously with vitiation of vata will produce dhatu
kshaya. The dhatu kshaya will ultimately results in riktata of the srothas.
The prasarita vata moving all through the body occupies the rikta
srotas and further undergoes vitiation. As the pathology progresses vata gets
stana samsraya in the sandhis, where it undergoes sammurchana with the
dushyas concerned there in. Later when dosha dushya sammurchana gets
completed the conditions gets manifested with clear cut signs and symptoms
and will acquire the name sandhigata vata. The symptoms manifested depend
on the structures involved in it. Sandhi shota gets manifested following
impaired sravana when siras get involved during sthana samshraya. Similarly
stambha may cause due to shoshana of asthi, snayu, and kandara. And Atopa is
due to kshaya of shleshma and shleshma dhara kala. Eventually sandhi shula
and vata purna druti sparsha will occur due to localized Vata in joints.
Ultimately the condition can get worsen leading to destruction the joints
making men crippled and dependent when the disease is not attended to.
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DISCUSSION
2. The consumption of above said nidanas similarly lead to prakopa of other
doshas i.e. pitta and kapha. These doshas get filled in the srothas and cause
avarana of vata. As a result vata prakopa takes place. The vitiated vata later
attains prasara and get localized in the sandhis. At the site of localization, the
vayu undergoes sammurchana with the dushyas there in and in due course gets
manifested with clear cut symptamatology. This causes the pathological entity
called sandhigata vata.
The condition can further progresses to the stage where complications
are produced leading to destruction of the joints, if attention is not given in
proper time.
Discussion on Treatment principles:
All Acharyas are given more importance to Palliative treatment than the
Purificatory measures. Here main procedures explained are, Snehana and its different
forms like Abhyanga and Unmardana, Swedana (Upanaha), Bandhana and
Agnikarma.
Sandhigata vata is a disease which is restricted to individual joints and hence
localized treatments for specific joints will be beneficial.
Discussion on plan of study:
The present study has been carried out on 40 patients treated in two groups,
trial and standard selected from the OPD and IPD of A.L.N Rao Memorial Ayurvedic
Medical College and Hospital, Koppa. The criteria for selection of patients were
based upon the classical signs and symptoms.
Page 94
DISCUSSION
20 patients of sandhigata vata were selected for trial group in which
Trayodashanga guggulu was given in the dose of 3 gms twice daily with ushna jala as
anupana. Duration of the treatment is 60 days.
20 patients of sandhigata vata were selected for standard group in which
Simhanada guggulu was given in the dose of 3 gms twice daily with ushna jala as
anupana. Duration of the treatment is 60 days.
Follow up study was done for 60 days in 15 days visits.
The improvement in the symptoms of diseases after the treatment was the
main criteria of assessment. The total effects of the therapy were also assessed in
terms of complete relief, marked improvement, moderate improvement, improved and
unchanged.
Discussion on observation during study:
57 patients were registered for this study, 17 patients were dropped due to
various reasons. Discussion regarding Observations of all the factors related to disease
is as follows.
1. Age wise distribution – maximum patients in this study was around 55 – 65
years. The probable cause may be due to the hard work, degeneration due to
old age.
2. Sex wise distribution – maximum patients were females nearly about 55%. In
this, most of the females suffer from Janu sandhigata vata. The excess work
load over the knee joint may be pre disposing factor for this disease.
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DISCUSSION
3. Religion wise distribution – 77.5% among the selected patients were Hindus
because the area of the study were Hindu dominated area.
4. Marital status – 92.5% of the patients in this study were married. Since this
disease very commonly seen in last part of middle age majority of the patient
were married.
5. Economical status – maximum number of patients belongs to poor class,
which is 70%. Due to lack of proper nourishment as well as excessive strains
due to manual labor may be the predisposing factor for the disease.
6. Occupational – 45% of this study were house wives and 32.5% were
agriculturists.
7. Habitat wise distribution – 92.5% were from Anupa pradesha since the area
where the study belongs to Anupa desha.
8. Discussion on duration of illness – duration of illness seen in to less than one
year in majority of cases.
9. Family history – maximum patients shown negative family history to this
disease (80%).
Page 96
DISCUSSION
10. Discussion on nidra incidence – maximum number of patients suffered from
disturbance of sleep (77.5%). It may be due to the pain and stiffness which
does not allow sleeping.
11. Discussion on prakruti of the patient – in most of the cases studied, the
patients were vatapittaja prakruti.
12. Discussion on weight incidence – in this study, most of the patients had the
body weight in between the range of 61-70 kgs.
13. Discussion on incidence of main lakshanas. –
• Sandhishula – it was seen in all the patients.
• Prasarana akunchana savedana – was seen in most of patients which disturbed
their routine work.
• Sandhi sthambha – was the symptom which reduced the working capacity of
patients.
• Sandhi shotha, atopa were also seen in most of the patients.
Page 97
DISCUSSION
Discussion on effect of treatment:
Effect of treatment was assessed clinically.
• After treatment
The trial drug Thrayodashanga Guggulu gives highly significant (< 0.001)
result in the Atopa (crepitus) i.e. 55%. It provided 40% relief in Tenderness which is
moderately significant (<0.010). Also it is moderately significant (<0.010) in Sandhi
shula (35%). The standard drug simhanada guggulu showed highly significant result
(<0.001) in the Sandhi shotha (50%). It provided moderate significant (<0.010) result
in the Atopa (35%). And in the sandhi shula and tenderness showed moderate
significant (<0.020) and the relief is 30%.
• After follow up
The trial drug Thrayodashanga Guggulu showed highly significant (< 0.001)
result in Tenderness (65%). It showed highly significant result (< 0.001) in Sandhi
shula and Atopa (60%).The standard drug Simhanada Guggulu provided highly
significant (<0.001) result in the Sandhi shotha (60%). It showed moderate significant
(<0.010) result in the Atopa (45%) and in the sandhi shula and tenderness it provides
moderate significant (<0.010) result and relieved the symptoms 40%. So the trial drug
showed very significant result in the shula, atopa and tenderness. Where as standard
drug showed efficiency in Sandhi shotha.
Over all effect of treatment on sandhigata vata:
During the time of treatment (60 days) trial drug showed high significant
result in the Atopa (crepitus) and showed moderate significant result in the Sandhi
shula, Tenderness and Sandhi shotha where as the standard drug Simhanada guggulu
Page 98
DISCUSSION
showed high significant result in the Sandhi shotha and given moderate significant
result in the Sandhi shula, Tenderness and also in Atopa.
In the follow period of 60 days, the patients observed in each 15 days visit.
After that period the trial drug showed high significant result in the Sandhi shula,
Tenderness and Atopa where as moderate significant result in the Sandhi shotha. The
control group Simhanada guggulu had given high significant result in the Sandhi
shotha and moderate significant result in Atopa, Sandhi shula and Tenderness.
Overall picture of the results obtained showed that both group were effective
in reducing all the symptoms but trial drug Trayodashanga guggulu showed highly
significant in reducing symptoms such as Sandhi shula, Atopa and Tenderness. It also
brought about long standing relief. The control drug Simhanada guggulu found highly
significant in the Sandhi shotha and in rest symptoms it showed moderately
significant result.
COMPARISON OF GROUPS
Inter group comparison after treatment
NO GROUPS SYMPTOMS t- VALUE P- VALUE REMARKS
1 Trial &Std drugs Sandhi shula 0.587 >0.200 Trial = Std
2 Trial &Std drugs Tenderness 0.7417 >0.200 Trial = Std
3 Trial &Std drugs Atopa 1.057 >0.200 Trial = Std
4 Trial &Std drugs Sandhi shotha 0.083 >0.200 Trial = Std
Page 99
DISCUSSION
On the statistical analysis to compare the result obtained after 45 days of
treatment for Sandhi shula between the two groups, an insignificant result was
obtained which indicates that both the groups were equally effective in the
management of Sandhi shula. Even on the other main complaints, Atopa, Tenderness
and Sandhi shotha an insignificant result was obtained on the inter group statistical
evaluation which indicates that both the drugs were equally effective in the
management of chief complaints.
Inter group comparison after follow up
NO GROUPS SYMPTOMS t- VALUE P- VALUE REMARKS
1 Trial &Std drugs Sandhi shula 1.253 >0.200 Trial = Std
2 Trial &Std drugs Tenderness 1.191 >0.200 Trial = Std
3 Trial &Std drugs Atopa 0.995 >0.200 Trial = Std
4 Trial &Std drugs Sandhi sotha 1.436 <0.200 Trial = Std
Statistical evaluation for the inter group comparison after follow up period
showed an insignificant result on all the chief complaints. A highly significant result
was obtained for the Trial drug on Sandhishula, Atopa and Tenderness after the
follow up period compared to a moderate significant relief for the standard drug. But
the inter group comparison between the two groups showed only a statistical
insignificance.
Thus it may be concluded that both the standard and trial drug were equally
effective in management of chief complaints after the treatment as well as after the
follow up
Page 100
DISCUSSION
Probable mode of action of TRAYODASHANGA GUGGULU:
Ayurveda the science with a holistic attitude has considered all aspects of
drug action, interaction, synergism, antagonism etc, in formulating the various yogas
to make them safe and acceptable. In order to achieve this, the Ayurvedic seers have
formulated hundreds of formulations which could be selected depending upon the
necessity. Poly herbal and herbo mineral preparations have two basic components as
ingredients
• Pharmocological components – This is divided in to Pharacodynamic
and Pharmacokinetic components.
• Pharmaceutical components – It includes media (Base), colouring
agents, binding agents, flavouring agents, thinners, preservatives, etc.
In a nut shell there are five basic components present in compound
formulations as ingredients. They are Activators, Potentiators, Antidotes, Bio
availability enhancers and Pharmaceutical agents.
Activators: They are main ingredients, responsible foe achieving the required
therapeutic action.
Potentiator: This group enhances the activity of the formulations.
Antidote: It will minimize or nullify the adverse drug reactions if any.
Page 101
DISCUSSION
Bio availability enhancers: The drugs in this group enhance the bio availability of
the drug in the body.
Pharmaceutical agents: the ingredients useful in preparation of formulations such as
binding, colouring agents, etc.
Thus every formulation will have one or the other ingredient which resulting
in to safe easily acceptable by the system and exhibits utmost therapeutic effects.
While considering Trayodashanga guggulu the ingredients can be classified in
the similar way.
Activator: The formulation has the main therapeutic action as vedana sthapana and
shothahara which is attributed by the presence of Guggulu as a major ingredient.
Potentiator: The ingredients namely Vrudhadaru, Guduchi, Shathavari,
Ashwagandha, Rasna and Grutha are included under this category as it does the
regeneration of bodily elements by their properties such as Vatasamana, Rasayana and
Balya. Thus it enhances the action of the formulations and are useful in the
longstanding usage of the drug.
Antidote: Guggulu being a resin does not dissolve in the system easily. In larger
doses it can cause constipation, burning sensation in G I tract-urine-eyes etc. This is
counteracted by Vrudhadaru which is a mild laxative, Thriphala which is used at the
time of Shodhana of the Guggulu acts as chakshushya. Gokshura and Hapusha are
Page 102
DISCUSSION
Diuretics and Shothahara. Abha acts as potent Shothahara dravya and is helpful in
reducing GIT, GUT inflammations.
Bio availability enhancers: Nagara, Shati, Shathapushpa, Ajamodha, Yavani, Grutha
are having Deepana, Pachana activity and it is said to improve the dhathwagni.
Various studies have shown the effect of Nagara as bio availability enhancers.
Probable mode of action of SIMHANADA GUGGULU:
Activator: The formulation has the main therapeutic action as vedana sthapana and
shothahara which is attributed by the presence of Guggulu as a major ingredient.
Potentiator: Here Triphala is considered as potenciator as it does the action of anti
inflammatory. Eranda thaila also considered as Vatanulomaka so it reduces pain and
shotha.
Bio availability enhancer: Gandhaka is considered as bio availability enhancer as it
enhances the bio availability of the other active principles present in the formulation.
Page 103
CONCLUSION
CONCLUSION
• Sandhigata vata is a vyadhi produced due to the Vyana vata prakopa.
• Gata vata is the condition in which Vata will be in predominant state and the
condition of the vata should be cared while applying treatment principles.
• While considering nidanas, both Dhatukshayakara and margavarodhakara are
responsible for producing the disease Sandhigata vata.
• This disease is considered as Yapya, because it affects joints which are the
madhyama roga marga.
• The treatment or treatment procedures which give snigdhata, ushnata, Ghana
is useful in this condition.
• In classics, they more emphasized on palliative measures than the purificatory
treatments.
• Sandhigata vata afflicts predominantly in elder persons (51-70yrs), hard
workers and also in females.
• The trial drug showed excellent response on reduction of the symptoms and in
degenerative process.
• The standard drug showed outstanding result in the reduction of Sandhishotha.
• Sandhigata vata is easy to cure if the disease is of recent origin.
Limitations:
• The size of sample was small to draw a generalized conclusion.
• The period of study was limited.
• The study was limited to the patients who attended the OPD wing of
A.L.N.Rao Memorial Ayurvedic Medical College, Koppa.
Recommendation of further study:
• The study can be repeated with large sample and longer duration.
• Same formulation can be tried along with specific panchakarma therapies and
other drugs.
Page 104
SUMMARY
SUMMARY
The dissertation entitled “Management of Sandhigata vata with
Trayodashanga guggulu – A Clinical evaluation” has been carried to find out the
clinical efficacy of Therapeutic drug combination Trayodashanga guggulu on the
patients of Sandhigata vata. This study comprises of following topics,
Introduction:
Gives the explanation about qualities of healthy person, importance of vata
physiologically as well as pathologically and brief introduction about trial drug
Trayodashanga guggulu.
Objectives:
The main aim and objectives of the study has been mentioned along with the
hypothesis under this heading.
1. Review of literature: This chapter comprises of following headings, Disease
review and Drug review.
Disease review dealt under the following headings. Historical aspect – gives
the historical glimpses with regards to the disease sandhigata vata and traces the
various developments right from the vedic period to present era. Here references
regarding the vata dosha, its diseases and the diseases of joints are presented.
Under the heading of etymology the description about Sandhi and different
constituents which forms the Sandhi and also concept about gata vata has been
mentioned.
Page 105
SUMMARY
Detailed data wise collection about Nidana, Poorva roopa, Roopa, Samprapti,
Sadhya-asadhyata, Upadrava and Chikitsa along with Pathya-apathya of the disease
along with some modern aspects of Osteoarthritis have been dealt.
In drug review section, a thorough study of the ingredients of the compound
preparations covering the botanical nomenclature, rasa, guna, veerya, vipaka,
chemical constituents etc.
2. Methodology:
• Clinical study – Under this heading detailed description of the clinical study
with specific reference to patients, grouping, selection, inclusion and exclusion
criteria, protocol, criteria for assessment of signs and symptoms, dose,
duration of the study is mentioned.
• Observational study – Here a detailed explanation is given on the distribution
of the patients according to age, sex, economical status, diet, habits, marital
status are represented along with tables and charts.
• Preparation of the drug - Here a detailed explanation regarding the
preparation of the compound drug has been mentioned in detail.
3. Results: In this, results of the study analyzed statistically, compared and are
presented in tables and graphs.
4. Discussion: Under this heading, discussion regarding nidanapanchaka,
chikitsa and results obtained from this study have been described. The
probable mode of action of the trial drug and control drug was discussed on
the basis of rasapanchakas.
5. Conclusion: In this chapter the conclusion of the above study is done by
highlighting the outcome of the study along with limitation of study and the
scope of further improvement.
Page 106
REFERENCES
References Introduction:
1. Ch.Su. 21/18-19Ka.Khi. 5/6-8. 2. Ch.Su 12. 3. Ch.Su. 13/8 4. C.D. 22/72-75.
Disease review: 5. R.V. 10/163/6. 6. A.V. 6.14.1, 1/12/3. 7. R VII 35, 60, 61. 8. M.B. 12.46.3, 47..66, 155.6, 185, 24-25, 328.26-53 9. A.G.Pu 370//33, 28/40-41. 10. Kt 3/10. 11. Ct 4/16/1, 4/3/1 12. Ch.Chi 28/37. 13. Su. Ni 1, Su.Chi. 5/50-54. 14. Bh. Sa. Ci 24/48-54. 15. H.S.Tr. 20/14. 16. AH. Ni 15/4, AS. Ni. 1/5. 17. M.N 22/21 18. B.P 24/258 19. C.D Chi. 22/9 20. B.R 26/14 21. Y.R 30/119 22. Bas. Raj 6ht prakarana 23. B.Su 25/36, 26/23 24. P.Su 5/1/38, 5/2/129
Etymology :
25. S.K.D Vol. 5 P. 240-2 26. Su.Sha 5/28, Ch.Sha 7/14, Ch.Vi 5/8, A.H Sha 3/16 27. Su.Su 15/1 28. Dalhana – Su.Su 15/1 29. A.H Su 12/7 30. Dalhana Su.Su 15/4 31. Su Ni 1/18 32. Dalhana – Su Ni 1/18 33. Gayadasa – Su Ni 1/18 34. H.S Thritheeya sthana
Anatomical aspect of Sandhi: 35. Su Su 5/24-5 36. Su Sha 5/27 37. A.H Sha 3, Su Sha 5/30 38. A.H Sha 3/10, Su Sha 4/15 39. Su Sha 6/18-20 40. Su Sha 6/38 41. Su Sha 6/4 42. Su Sha 6/15
REFERENCES
43. Dalhana – Su Sha 6/4 44. Davidson Pg no. 761
Nidana: 45. Su Su 3/14 46. Ma Ni 1/5 47. Ch.Su 12/7, Su Su 21/19, A.S Ni 1/5 48. Ch. Chi 28/15-18,Su Ni 1,B.P MK 24/122,Y.R, Bas. Raj 6th , H.S Thr. 20th 49. A.H Su 12/24-5 50. Ch Vi 8/99
Poorvarupa: 51. M.N 1/6 52. Ch Chi 28/24
Roopa: 53. M.N 1/7 54. Ch Chi 28/48 55. Su Ni 1/28 56. A.S Ni 15/12 57. A.H Ni 15/14-5 58. B.P MK 24/258 59. Y.R 30/24 60. M.N 22/21 61. Bas. Raj 6th prakarana 62. Dalhana – Su Ni 1/28, A.D – M.N 22/21 63. Madhukosha – M.N 22/21 64. Gayadasa – Su Ni 15/7 65. Su Su 17/7 66. Su Su 17/3 67. Arunadatta – A.H Ni 15/14-5 68. A.S Ni 16/28 69. Y.R 1st
Upashaya and Anupashaya: 70. M.N 1/8-9
Samprapthi: 71. M.N 1/10 72. Ch Vi 5/9 73. A.S Su 20/2 74. Chakrapani – Ch Chi 28/18-9 75. Ch Su 12/7 76. Ch Ci 28/59 77. A.H Ni 15/5-6 78. Ch Chi 28/61 79. M N 43/8, Su Su 15/5, Ch su 21
REFERENCES
Upadrava: 80. Ch Chi 21/40
Sadhyasadhyatha: 81. Su Su 33/4 82. Ch Chi 28 83. H.S Thr. 20
Chikitsa: 84. A.K 2/6/50 85. Su Chi 4/18 86. A.S Chi 23/3 87. A.H Chi 21/22 88. B.P MK 24/259 89. Y.R 30/119 90. B.R 26/14 91. CD 22/9 92. Ch Su 22/11 93. Ch Ni 1/39 94. Ch Su 13/9 95. Ch su 13/14-7 96. Ch Su 5/86 97. Dalhana – Su Chi 24/30-4 98. M.F.H.H pg.no:14 99. Dalhana – Su Chi 32/12
100. Su Chi 33/14 101. Ch Su 14/64 102. Chakrapani – Ch Su 14/64 103. Su Su 12/1 104. Su Su 12/10 105. Su Su 12/4-5 106. Su Su 12/3 107. Su Su 41/4 108. Ch Sha 8/32 109. Ch Su 14/13 110. A.S Su 26/10 111. A.S Chi 23
Pathyapathya:
112. Ch Su 25/45 113. Y.R 30/414-17 114. B.R 26 115. Y.R 30/418-9 116. B.R 26
Differential diagnosis:
117. M.N 23/13, Ch Chi 29/24-9 118. M.N 25/6 119. H.P.I.M
REFERENCES
Drug review: 120. J.L.N. Pg. no 826. 121. J.L.N. Pg. no 375 122. J.L.N. Pg. no 968. 123. J.L.N. Pg. no 33. 124. J.L.N. Pg. no 540. 125. J.L.N. Pg. no 98. 126. J.L.N. Pg. no 821. 127. J.L.N. Pg. no 258. 128. J.L.N. Pg. no 972. 129. J.L.N. Pg. no 269. 130. J.L.N. Pg. no 871. 131. J.L.N. Pg. no 857. 132. J.L.N. Pg. no 113. 133. J.L.N. Pg. no 209. 134. J.L.N. Pg. no 216. 135. J.L.N. Pg. no 220. 136. J.L.N. Pg. no 483. 137. R.R.S 3/18-19
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DEPARTMENT OF KAYACHIKITSA A.L.N. RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE , KOPPA-577126.
CASE PEROFORMA FOR MANAGEMENT OF SANDHIGATA VATA WITH THRAYODASHANGA GUGGULU A CLINICAL EVALUATION
P.G.Scholar : Dr.Guruprasad.A. .B.A.M.S Guide: Dr.P.K.Mishra M.D(Ayu)., (RSU)
PART-A –EXAMINATION
Name: Group: Age ……… Yrs, Sex M / F Sl.no : Religion: H / M / C / J OPD/IPD: Education: UE / P/ M / H /G Ward/Bed no: Marital status: M / U / W / D D.O.A : Social status: VP/ P/ LM / M /UM / R / VR D.O.D : Occupation: HW / W / B / S / E Diagnosis: Desa : J /A/S Locality: Urban /Rural Result : Address: Main complaints:
Duration B.T A.T A.F.U I II III 1. Sandhi Sotha 2. Sandhi Shoola 3. Tenderness 4. Sandhi Atopa History of Present illness:
1. Sandhi shoola: Onset : Insidious / Gradual / Acute
Course : Progressive / Relapsing / Stationary
Character : Dull aching / Deep pain / Pricking
Shooting / Excruciating Aggravating factor :-
Food : BF / AF Time : M / A / E / N Movement : Squatting / Walking / Climbing stairs / Rest
1
Relieving factor :- Food : BF / AF Time : M / A / E / N
Rest : Yes / No Seasonal : SHI / V /G/ VA/ SHA/ H NSAIDs : Yes / No
2. Sandhi shotha :
Onset: Sudden / Gradual
Course: Progressive / Relapsing / Stationary
Character: Pitting / Non pitting
Site: Anterior / Posterior
Colour: Aruna / Shyama / Swetha
Aggravation: Food : BF / AF Time : M / A / E / N Movement : Squatting / Walking / Climbing stairs / Rest
Relieving factor :-
Food : BF / AF Time : M / A / E / N
Rest : Yes / No Seasonal : SHI / V /G/ VA/ SHA/ H NSAIDs : Yes / No
3. Stiffness:
Morning…….min / After walking…..Min / After rest…min 4.Atopa (Crepitus):
Palpable / Audible / Fine coarse Past History :
Past illness : Injury to the joint : Yes / No
Treated : Yes/ No
: If treated Ayurveda / Allopathic / Homeopathic /Other
Family History:
2
Gynaec History :
M.C. day R IR : Menarche yr : Menopause yr
Menorrhagia / Dysmenorhoea / Metrorrhagia / Leucorrhoea Personal History : Habits :
Habits Duration / Continued
Occasional / Regular
Stopped / Reduced
Relationship to Symptom
Smoking Alcohol Tobacco Snuff Others
Ahara :
Nature : Veg / mixed
Quality : Alpa / Pramita / Sama / Atipramana
Rasa: M / A / L / K / T / Ka / Sarva rasa
Guna : Ruksha / Snigdha / Ushna / Sheeta / Guru / Laghu
Dietetic habit : Matrashana / Vishamanasana / Adhyasana
Virudha ashana / Anasana Nature of work :
Sedentary / Labour / Sitting / Travelling / Walking / Standing / Day / Night
Vishrama :
Proper / Less / Excessive Vyayama :
No / Less / Proper / Excessive / Irregular Nidra :
Sound / Disturbed / Ratri Jagarana / Divaswapa
3
General Examination : 1. Pulse : /min R IR RIR IIR Full Bounding Feeble 2. Blood pressure : / mm of Hg 3. Temperature : F 4. Respiratory rate : /min 5. Nourishment : Good / Moderate / Poor Dasha Vidha Pareeksha :
Prakrititah : V / P / K / VP / VK / PK / VPK
Vaya : Bala / Yuva /Madhyama / Vriddha
Vikrititah : P / M / A
Samhanana: P / M / A Satva : P / M / A Pramana : P / M / A Satmya : P / M / A Aharashakti :
* Abhyavarana P / M / A * Jarana P / M / A
Sara : P / M / A
Vyayama Shakti : P / M / A Sroto Pareeksha :
Pranavaha : Prakrita Vaikrita
Udakavaha : Prakrita Vaikrita
Annavaha : Prakrita Vaikrita
Rasavaha : Prakrita Vaikrita
Raktavaha : Prakrita Vaikrita
Mamsavaha : Prakrita Vaikrita
Medovaha : Prakrita Vaikrita
4
Asthivaha : Prakrita Vaikrita
Majjavaha : Prakrita Vaikrita
Sukravaha : Prakrita Vaikrita
Artavavaha : Prakrita Vaikrita
Swedavaha : Prakrita Vaikrita
Mutravaha : Prakrita Vaikrita
Purishavaha : Prakrita Vaikrita
Systemic Examination :
C.V.S. :
R.S. :
C.N.S. :
P/A : Locomotor System : Examination of effected joint:
Effected joint(joints):
Inspection: Redness / Swelling / Deformity
Palpation :
Tenderness :- Present /Absent Temperature : - Present /Absent Swelling :- Present /Absent
Movement : Painful / No pain / Restricted Investigations:
Hematological :
E.S.R. R.A
5
X-Ray Rt / Lt Ap / L
Samprapthi Ghataka Nidana : Aharata Viharata Sannikrishta Viprakrishta Roopa : Dosha : Dooshya : Srothas : Udbhava sthana : Sanchara sthana : Roga marga : Sthana samshraya: Vyakta sthana : Adhishtana : Samprapti Vyadhi vinischaya Sadhya Sadhyata Chikitsa Result Discussion Signature of Student Signature of Guide
Dr. Guruprasad. A Dr. Pramod Kumar Mishra BAMS. M.D (Ayu),(RSU)
6
ASSESSMENT CRITERIA
Sandhi shula Points
No pain [no pain at rest / no pain while walking] - 0
Mild pain [no pain at rest or
mild tolerable pain while walking] - 1
Moderate pain [mild pain at rest, tolerable and
moderate pain while working] - 2
Severe pain [disturbance of sleep due to pain or
pain at rest or untolerable pain during working] - 3
Atopa of sandhi:
No crepitus - 0
Palpable crepitus - 1
Audible crepitus - 2
Tenderness:
No pain on pressure - 0
Pain on pressure and winces - 1
Patient withdraws affected part while giving pressure - 2
Patient does not allow to touch - 3
Sandhi shotha:
No swelling - 0
Swelling is present slightly in joints - 1
Swelling covering the bony prominence of affected joints - 2
Swelling much elevated so that
the joints seems grossly deformed - 3
7
POST GRADUATE STUDIES AND RESEARCH CENTRE
DEPARTEMENT OF KAYACHIKITSA
A.L.N. RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE
KOPPA-CHIKMAGALUR
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 “Management of
Sandhigata vata with Trayodashanga guggulu – A Clinical evaluation”. 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» ºÁQgÀÄvÉÛãÉ.)
8