D I R E C T O R

A T H R E Y A A Y U R V E D I C I N T E G R A T I V E

H E A L T H C E N T E R .

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Vaidya Jayagopal Parla, BAMS, MD(Ayu), MAOM, C-IAYT, CMT

“Roll of Ayurvedic Practitioner in Integrative Case Management of

Amavata”

INTRODUCTION

Rheumatoid Arthritis (RA) is a chronic, systemic, inflammatory and autoimmune disease that affects the smaller and larger

joints of the body.

It is one of the leading causes of chronic morbidity in

developed countries.

Synovial inflammation cause cartilage destruction, bone erosions and subsequently joint deformities

The prevalence of RA is approximately in 1 percent of US

population; women are affected three times more often than

men and mostly occurs between age of 40-60 yrs

INTRODUCTION

Prevalence increases with age and sex difference diminish in the older age group.

Conservative treatment is mostly symptomatic and often

associated with adverse effects. Therefore many RA

patients seek complementary and alterative medicine

to manage illness.

In US about 60-90% arthritis patients use CAM.

RHEUMATOID ARTHRITIS

CRITERIA FOR DIAGNOSING

The criteria are:

1.  Morning stiffness

2.  Pain on movement or tenderness in at least one joint

3.  Swelling in joint

4.  Symmetric joint swelling

5.  Subcutaneous nodules

6.  Radiologic changes

7.  Blood test-Rheumatoid factor in serum

8.  Poor mucin precipitate from synovial fluid

9.  Histologic changes in synovium and nodules

Criteria 1-4 must be continuous for at least 6 weeks

OTHER SYMPTOMS

The symptoms of rheumatoid arthritis come and go depending on the degree of tissue inflammation

Symptoms can include fatigue, lack of appetite, low-grade

fever, muscle and joint aches and stiffness.

IMAGING – EROSION

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IMAGING – BONE MARROW EDEMA

BLOOD TESTS

TREATMENT PROTOCOLS

NSAIDs: Nonsteroidal anti-inflammatory drugs

(NSAIDs) can relieve pain and reduce inflammation.

Over-the-counter NSAIDs include ibuprofen (Advil,

Motrin IB) and naproxen sodium (Aleve)

Side effects may include stomach irritation, heart

problems and kidney damage.

TREATMENT PROTOCOLS

Steroids: Corticosteroid medications, such as

prednisone, reduce inflammation and pain and slow

joint damage. Side effects may include thinning of

bones, weight gain and diabetes.

TREATMENT PROTOCOLS

Disease-modifying antirheumatic drugs

(DMARDs): These drugs can slow the progression of

rheumatoid arthritis and save the joints and other tissues from

permanent damage. Common DMARDs include methotrexate

(Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine

(Plaquenil) and sulfasalazine (Azulfidine).

Side effects vary but may include liver damage, bone marrow

suppression and severe lung infections.

TREATMENT PROTOCOLS

Biologic agents: Also known as biologic response

modifiers, this newer class of DMARDs includes abatacept

(Orencia), adalimumab (Humira), anakinra (Kineret), baricitinib

(Olumiant), certolizumab (Cimzia), etanercept (Enbrel),

golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan),

sarilumab (Kevzara), tocilizumab (Actemra) and tofacitinib

(Xeljanz).

These drugs can target parts of the immune system that trigger

inflammation that causes joint and tissue damage. These types

of drugs also increase the risk of infections. Biologic DMARDs are

usually most effective when paired with a nonbiologic DMARD,

such as methotrexate.

SURGERY

If medications fail to prevent or slow joint damage, you and your

doctor may consider surgery to repair damaged joints. Surgery may

help restore your ability to use your joint. It can also reduce pain

and improve function.

Rheumatoid arthritis surgery may involve one or more of the

following procedures:

•  Synovectomy

•  Tendon repair

•  Joint fusion 

•  Total joint replacement

DEFINITION OF AMAVATA

DEFINITION OF AMA

(Ashtanga Hrudaya)

AMA ATTRIBUTES •  Srotorodha (obstruction of channels)

•  Balabhransha (loss of strength)

•  Gaurava (felling of heaviness)

•  Anilmudhata (obstruction of vayu)

•  Alasya (laziness)

•  Apakti (indigestion)

•  Nisthiva (excessive salivation)

•  Malasanga (constipation)

•  Aruchi (anorexia)

•  Klama (fatigueness)

ETIOLOGY OF AMAVATA

   NIDANA Madhava

Nidana

Vanga

Sena

Gada

Nigraha

Haritha

Samhita

Yoga

Rathnakara

Bhava

prakasha

1 Virudhahara + + + - + +

2 Virudha cheshta + + + - + +

3 Mandagni + + + + + +

4 Nischala  +

 +

 +

 -

 +

 +

5 Vyayama soon after

snigdha bhojana

+ + + - + +

6 Kandashakha sevana - - - + - -

7 Vyavaya - - - + - -

SYNOVIAL FLUID

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GENERAL SYMPTOMS

VYADHI AVASTHA – PATHOGENISIS

©Tsutomu Takeuchi

TYPES OF AMAVATA

Doshanubandha Lakshanas (Bhava Prakasha) § Vatanubandha- Sashoola

§ Pittanubandha- Sadaaha, Saraaga

§ Kaphanubandha- Sthimita

Doshanubandha (Madhavakara) § Vata, Pitta, Kapha, VP, VK, PK, Sannipataja

Avastha Bhedena (Madhavakara) § Samanya

§ Pravrudha

SYMPTOMS ACCORDING TO PREDOMINANT

DOSHAS

CURABLE AND INCURABLE SYMPTOMS OF

AMAVATA

UPADRAVA (COMPLICATION)

Sankocha and Khanjata (Vijayarakshita)

Kalaya Khanjata (Bhavaprakassha)

Jadya, Antrakujana, Anaaha, Chardi (Anjana Nidana)

Angavaikalya ( Harita)

Akshepana (Gayadasa)

Vatavyadhi (Vachaspati Vaidya)

PANCHAKARMA

1. Virechana

2.  Basti

TREATMENT PRINCIPLES

•  Laghana •  Swedana

•  Use of herbs with Tiktha and Katu rasa

•  Deepana/Pachana

•  Virechana

•  Snehana •  Basti

•  Ruksha sweda, Valuka pottali

•  Upanaha (applying poultiecs) without use of snehana

YUKTI VYAPASHRAYA CHIKITSA

Anthah Parimarjana

§ Amapachana, Jwara hara

§ Dashamoola kashaya – ½ cup before meal

two times a day

§ Hinguvashtaka churna - 6 gms with hot water

before meal two times a day

§ Avipathikara choorna - 12 gms bd with hot

water after meals at night

YUKTI VYAPASHRAYA CHIKITSA

SHAMANA § After Ama pachana- Nirama avastha

§ Rasna + Nirgundi + Eranda – 1 tsp before food AM

§ Simhanada Guggulu 2 bd with hot water after meal OR

§ Yogaraj guggulu – 2 – 2 – 2 with hot water after meal

§ Kaishore Guggulu - 2 – 2 – 2 with hot water after meal

§ ASTISANGHAR + ASHWAGANDHA – 1 tsp before food PM

YUKTHI VYAPASHRAYACHIKITSA

Bahir Parimarjana § Sweda- Ruksha Sweda

§ Pottali sweda by using ksha dravyas such as Saindava, Karpasa,

Kulatha, Tila, Eranda, Ajamoda, Hingu

§ Snehana- Ruksha sneha abhyanga (in nirama avastha)

§ Saindavadi taila

§ Kottamchikkadi Taila

§ Nirgundi Taila

§  Lepa

INDIVIDUAL HERBS FOR AMAVATA

Dashamoola

Guggulu

Ashwagandha

Rasna

Guduchi

Nirgundi

Punarnava

Musta

PATHYA Breakfast examples: 

KAMUT puffed cereal or MILLET puffed cereal or BARLEY puffed cereal with Almond

milk and raisins/cut dates/dried mulberry/ dried blue berries 

Or 

BARLEY cooked over night in a slow cooker or cooker in the morning for at least 90

minutes 

Then added with berries and cut almonds and honey before eating 

Or 

Cook AMARANTH with water and add cut dates and walnuts to coconut oil and sauté

add to the amaranth and mix 

Or 

Scrambled eggs with 1 cup of stir fried (coconut oil) dark green black pepper and

Turmeric

PATHYA

LUNCH Examples: 

Cooked Quinoa  - 11/2 to 2 cup

Dark greens sauteed or stir fried - 2 cup 

Green onions, Scallions, Fennel Bulb, Ginger, Onions, garlic, Chives, Shallots 

 

2 cups of steamed or sautéed or stir fried veggies with Fresh Herbs and Spice

seeds like Cumin, Oregano, Thyme or Basil  

 

 

PATHYA

DINNER SOUP EXAMPLE: with FRESH GINGER, turmeric and black pepper 

 

Vegetable soup with soba noodles 

OR 

Coconut curry soup with veggies and Quinoa noodles   

OR

Butternut or Pumpkin soup with Quinoa 

CASE SCENARIO # 1

A female 51 year old female

Severe ache and pains in multiple joints and is on wheel chair for

the last 2 weeks

Pain was 9 - 10/10 on a numeric pain scale

Intensity of pain causing extreme fatigue and pain in the wrist and

hip joints is keeping the patient up in the night

Patient was diagnosed with Rheumatoid arthritis through MRI

Patient took DAM and started exploring CAM

OUTCOME MEASURES

Subjective symptoms and pain scale

RA factor was negative

C-reactive protein and ESR were repeated after 2 month

and 5 months

DIAGNOSIS

Patient was diagnosed with Rheumatoid Arthritis

MRI showing inflammation and bone erosion in the

Wrist joints.

Her blood test results showed that increase ESR

(51mm/h) and increased C-reactive protein (28 mg/l).

Severe pain and swelling of the joint. Extreme fatigue, feverish feeling in the night, loss of appetite as

mentioned in Ayurveda

INTERVENTION

Ayurveda External treatments

1.  Dashamoola decoction - 30 ml BD RASNA, PUNARNAVA, NIRGUNDI

2. Kaishora Guggulu Pills – 2 TID

3. Yogaraj Guggulu Pills – 2 TID 4. Ayurveda Diet and Lifestyle

AJAMODA and VALUKA PINDA SWEDA – 2 times a week

Patients was not taking any prescription medicine. Only over the counter pain medication

ELIMINATION DIET:

Night shades

Large amounts of beans

Dairy

Sugar

Meat in general but specially at night

Coffee

Cold food and drinks

INTERVENTION

RESULTS

After 3 weeks of the intervention her pain was 5/10 on numeric

pain scale.

Visually swelling in the wrists and fingers reduced

Able to move around short distances without the wheel chair

Patient also reported that her general quality of life was also

improved.

During 3 months follow up with Rheumatologist ESR – 13mm/hr

and C-reactive protein – 17mg/l

Patient is in remission for the last 6 years

CASE SCENARIO # 2

A female 57 year old

Bilateral painful knee and wrist joints with swelling for five months

Pain was 8/10 on a numeric pain scale

Severe morning stiffness, fatigue and pain in the

metacarpophalangeal joints

Patient was diagnosed with Rheumatoid arthritis by

Rheumatologist

Taking oral Steroids (20mgs/day), Celebrex (200 mg).

She was under this protocol for 19 months.

OUTCOME MEASURES

Blood test (for C-reactive protein and ESR) was done every three months, for a follow up period of 24 months

DIAGNOSIS

She was diagnosed with Rheumatoid Arthritis

RA factor was positive.

Her blood test results showed that increase ESR

(39mm/h) and increased C-reactive protein (31mg/l).

According to Ayurveda-This patients had the symptoms

of Ama Vata (body ache, anorexia, feeling of heaviness, indigestions and symptoms of inflammation of the

joints)

INTERVENTION

Ayurveda Conventional Medicine

1. Dashamoola decoction - 30 ml BD 2. Kaishora Guggulu Pills – 2 TID

3. Swedana (poultice) – Once a week 4. Ayurveda Diet and Lifestyle

Steroids (20mgs/day) Celebrex (200 mg/day)

Patients was taking conventional medicine since last 18 months

INTERVENTION

Diet

Encourage warm and freshly prepared food, with fresh

ginger, turmeric and garlic, lean meat, bitter greens

Minimize dairy products, oily foods, junk and fast

foods, excessively salty and sour foods, molasses,

large amounts of beans, fish, cold drinks, raw vegetables, salad as a meal, Potato.

INTERVENTION

Lifestyle

PAVANA MUKTASANA SERIES – BIHAR SCHOOL OF

YOGA

RESULTS

Patient reported that gradual reduction in the pain and severity of the symptoms.

After 5 months of the intervention her pain was

2-3/10 on numeric pain scale.

Dose of steroid reduced gradually.

Patient also reported that her general quality of life was also improved.

RESULTS

Base line Blood test showed increase ESR (39mm/h) and increased C-reactive protein (31mg/l).

After 5 months ESR value decreased to 16mm/l and

C- Reactive protein to 26mg/l.

After one year the ESR value decreased to 12mm/l

and C- Reactive protein 19mg/l.

After two years the ESR decreased to 4mm/l and C-

Reactive protein 14mg/l).

DISCUSSION

These case studies demonstrate that Ayurvedic treatments may

be effective in management of Rheumatoid Arthritis. Ayurvedic

protocols can be used along with conventional medicine in the

management of Rheumatoid arthritis.

RA can be compared to AMAVATA explained in Ayurvedic

literature, main cause for this condition is metabolic toxin (AMA)

accumulation in the body and joints.

Detailed literary reference about etio- pathology, signs and

symptoms and management of AMAVATA is explained in various

classical text books of Ayurveda.

CONCLUSION

Evidence from the classical text books provide knowledge about various Ayurvedic modalities for the

management of Amavata

Evidence from current literature indicate that

Ayurvedic approaches are effective in the

management of Amavata.

Ayurvedic understanding of pathogenesis of RA links

to the gut, and the management chiefly consist of diet,

lifestyle changes, panchakarama ( cleansing process)

and herbs.