Sandhi sw05 has

A STUDY ON THE EFFICACY OF AYURVEDA AND

NATUROPATHY IN SANDHI VATA

By

Patil Uday J.

Dissertation Submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

In partial fulfilment of the requirements for the degree of

AYURVEDA VACHASPATI

(DOCTOR OF MEDICINE)

In

SWASTHAVRITHA

Under the guidance of

Dr. Sajitha K. M.D. (AYU)

DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHA VRITHA

S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL, HASSAN,

573201

2006

Ayurmitra

TAyComprehended

A STUDY ON THE EFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA

By

Patil Uday J.

Dissertation Submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

In partial fulfilment of the requirements for the degree of

AYURVEDA VACHASPATI (DOCTOR OF MEDICINE)

In

SWASTHAVRITHA

Under the guidance of

Dr. Sajitha.K, M.D (Ayu)

Asst. Prof, Dept of Swasthavritha

DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA

S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL,

HASSAN -573201

2006

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled “A STUDY ON THE

EFFICACY OF AYURVEDA AND NATUROPATHY IN SANDHI VATA” is a

bona fide and genuine research work carried out by me under the guidance of Dr.

Sajitha K. Asst. Professor, Department of Post Graduate Studies In SwasthaVritta,

S. D. M. College of Ayurveda and Hospital, Hassan – 573 201.

Date:

Place: Hassan

Patil Uday J.


S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201

(Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka)

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A STUDY ON THE


bona fide research work done by Patil Uday J in partial fulfilment of the

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

Swasthavritha.

Date: Hassan: Dr. Sajitha K. Asst. Professor P.G. Studies in Dept of Swasthavritha

S D M College of Ayurveda, Hassan


S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201

(Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka)

ENDORSEMENT BY THE H O D; PRINCIPAL / HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “A STUDY ON THE


bona fide research work done by Patil Uday J. under the guidance of Dr. Sajitha K.,

Asst Professor, Department of Post Graduate Studies In Swasthavritha, S.D.M.

College of Ayurveda, Hassan - 573201.

Dr. Ramana G.V. Dr. Prasanna N Rao Professor and Head Principal P G Studies in SwasthaVritta, S D M College of Ayurveda, S D M College of Ayurveda, Hassan. Hassan. Date: Date:

Place: Place:

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose.

Date: Place: Hassan Patil Uday J.

© Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENT

I bow my head on the foot of Prof. S. Prabhakar, secretary of SDME society, for

giving me an opportunity to pursue post graduation in SDMCA, Hassan

I owe my humble gratitude and regards to Prof Dr. Gurudip singh, Director of

PG studies, SDMCA&H, HASSAN for evincing keen interest in my endeavours and for

continued encouragement

I am greatly thankful to Dr. P. N. Rao, Principal who provided the necessary

facilities for the completion of this research work.

I express my sincere gratitude and respect to Prof. Dr. Ramana. G. V. for his

guidance and timely suggestions and Dr. Sajitha K, Guide, advice, constant inspiration

enabled me to complete this work.

I am grateful to Dr. Shashikiran, Dr. Suhaskumar Shetty, for timely

information and librarian for his co-operation.

I am thankful to all the teaching and non teaching staffs of S.D.M. College of

Ayurveda and Hospital, Hassan for their support and co-operation.

I am Grateful to Dr. Basant, Dr. Gururaj, Dr. Aditi, Dr. Manish, Dr. Srikant,

Dr. Sanjeev, Dr. Prashant Lande, Dr. Satish Wagh, Dr. Vaibhav and all my

classmates for their never-ending encouragement. I wish my thanks to all my seniors,

juniors and under graduates who helped me in every aspects of my work.

I heartily acknowledge the help rendered to me by Dr. Anand, Dr. Abhijit, Dr.

Prmod, Dr. Shailendra, Dr. Mayur, and Dr. Ashok A.

I feel immensely privileged to credit this work to my parents, brother, wife,

affection of my loving child Parth and other family members who constantly kept me

supporting against all odds.

Dr. Patil Uday Jayawantrao

LIST OF ABBREVIATIONS

A -Janu Basti group

A. Hr. -Ashtanga Hridaya

A. Sa. -Ashtanga Sangraha

Ath. -Atharvaveda

B -Naturopathy Techniques group

Bh. Pr. -Bhava Prakash

Bh. Ra. -Bhaishajya Ratnavali

Ca. Sa. -Charaka Samhita

Ci. -Chikitsa

M. M.W. -Monier. M. Williams

Ma. Ni. -Madhava Nidana

Mad.Kh. -Madhyama Khanda

Ni -Nidanasthana

Pu -Purvardh

Sh. -Sharirasthana

Su. -Sutrasthana

Su. Sa. -Sushruta Samhita

Ut. -Uttaraardh

Vi -Vimanasthana

Yo. Ra. -Yoga Ratnakara

ABSTRACT

Background

To carry out the daily activities, normal movements of joints are very essential.

Osteoarthritis acts as main hurdle in performing daily activities, in which joints are

mainly affected leading to pain, immobility and discomfort.

Non-pharmacological management is the foundation of treatment of osteoarthritis.

Therefore, naturopathy gives a hope of treating this condition with different techniques

used externally.

Objectives

1. To evaluate the effect of Janu-Basti in the management of Sandhi Vata.

2. To evaluate the effect of Naturopathy techniques in the management of Sandhi Vata.

3. To compare the efficacy of Janu Basti and Naturopathy techniques.

Methods

It is a comparative study with pre-test and post test design with two groups

consisting of 15 patients each.

Group A- Patients of this group were advised Janu Basti with Tila Taila for 7 days.

Group B- Patients of this group were given naturopathy techniques externally for 7 days.

Results

Naturopathy techniques provided significant relief in Shoola (34.64%) in 53.33%

of patients, Shotha (3.83%) in 86.66% of patients, Kriya alpata (43.13%) in 66.66% of

patients, Flexion angle of knee joint (7.20%) in 73.33% of patients, Time taken to cover

50m distances (17.66%) in 100% of patients of Sanhi Vata. Janu-Basti with Tila taila

provided significant relief in Shoola (32.85%) in 46.66% of patients, Shotha (2.65%) in

43.33% of patients, Kriya alpata (39.16%) in 46.66% of patients, Flexion angle of knee

joint (5.19%) in 73.33% of patients, Time taken to cover 50m distance (12.08%) in

73.32% of patients.

Interpretation

By Naturopathy techniques blood circulation increases to joints due to

vasodilatation, relieves congestion, improves nutrition of the joint, reduces muscle spasm

and inflammation; soften adhesions, improves the range of motion and lubrication.

Janu-Basti acts as an effective Bahya Shamana Chikitsa and relieves symptoms

like Stambha, Gaurava and Sheetata.

Conclusion

Clinical study has proved that non pharmacological management in the form of

external treatments gives significant relief in osteoarthritis.

CONTENTS

List of Tables and Figures

Introduction and objectives 1-2

I. Literary Review of Sandhi Vata

Historical Considerations

3-4 Nirukti-Paribhasha

5-6

Anatomy of Janu-sandhi 7-10

Nidana 11-17

Poorvaroopa and Roopa 18-19

Samprapti 20-25

Vyavachedaka Nidana 26

Sadhyasadhyata 27

Chikitsa 28-30

Osteoarthritis 31-36

Naturopathic techniques for Sandhi Vata 37-44

Janu-Basti 45-47

Mode of Action 48-50

II. Methodology 51-55

Results

56-75

Discussion 76-86

Conclusion 87-88

Summary 89-91

Bibliographic References 92-94

Annexure 95-96

LIST OF TABLES AND FIGURES SL. NO.

CONTENT OF TABLE PAGE NO.

1 REFERENCES OF SANDHI VATA 4 2 RASA VISHESHA AHARAJA NIDANA 13 3 GUNA VISHESHA AHARAJA NIDANA 13 4 VIRYA VISHESHA AHARAJA NIDANA 13 5 DRAVYA VISHESHA AHARAJA NIDANA 14 6 AHARAKRAMA NIDANA 15 7 VIHARAJA NIDANA 15-16 8 MANSIKA NIDANA 16 9 KALAJA NIDANA 16 10 ANYA NIDANA 17 11 ROOPA OF SANDHI-VATA MENTIONED IN VARIOUS CLASSICS 18 12 CHIKITSA SOOTRA MENTIONED IN DIFFERENT SAMHITA 28 13 DRUG REVIEW 47 14 AGE WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI-VATA 56 15 SEX WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI-VATA 56

16 RELIGION WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI-VATA

57

17 OCCUPATION WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI-VATA

57

18 DEHA PRAKRITI WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI

VATA 59

19 SARA WISE DISTRIBUTION OF 30 OF SANDHI VATA 59

20 SAMHANANA WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI

VATA 60

21 PRAMANA WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI VATA 60

22 SATMYA (AHARA) WISE DISTRIBUTION OF 30 PATIENTS OF

SANDHI VATA 60

23 SATVA WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI VATA 61

24 ABHYAVAHARANA SHAKTI WISE DISTRIBUTION OF 30 PATIENTS

OF SANDHI VATA 61

25 JARANA SHAKTI WISE DISTRIBUTION OF 30PATIENTS OF SANDHI

VATA 61

26 VYAYAMA SHAKTI WISE DISTRIBUTION OF 30 PATIENTS OF

SANDHI VATA 62

27 CARDINAL SIGNS AND SYMPTOMS RECORDED IN 30 PATIENTS OF

SANDHI VATA 62

28 CHRONICITY WISE DISTRIBUTION OF 30 PATIENTS OF SANDHI

VATA 62

29 CHARACTERISTIC OF KULAJA VRITTANT REPORTED BY 30 CASES

OF SANDHI VATA 63

30 SHOWING DISTRIBUTION OF VIHARATMKA NIDANA RECORDED

IN 30 CASES OF SANDHI VATA 64

31 SHOWING DISTRIBUTION OF AHARATMAKA NIDANA IN 30 CASES

OF SANDHI VATA 64

32 EFFECT OF JANU-BASTI ON SYMPTOMS OF SANDHI VATA

PATIENTS 66

33 EFFECT OF JANU-BASTI ON CLINICAL SIGNS OF SANDHI VATA

PATIENTS 66

34 EFFECT OF NATUROPATHY TECHNIQUES ON SYMPTOMS OF

SANDHI VATA PATIENTS 68

35 EFFECT OF NATUROPATHY TECHNIQUES ON CLINICAL SIGNS OF

SANDHI VATA PATIENTS 68

36 TOTAL EFFECT ON SHOOLA 69 37 TOTAL EFFECT ON ATOPA 69 38 TOTAL EFFECT ON KRIYA ALPATA 69 39 TOTAL EFFECT ON SHOTHA 70 40 TOTAL EFFECT ON TIME TO COVER 5OM DISTANCE 70 41 TOTAL EFFECT ON FLEXION ANGLE OF KNEE JOINT 71


PATIENTS AFTER 15 DAYS 71

43 EFFECT OF JANU-BASTI ON CLINICAL SIGNS OF SANDHI VATA



SANDHI VATA PATIENTS AFTER 15 DAYS 72

45 EFFECT OF NATUROPATHY TECHNIQUES ON CLINICAL SIGNS OF

SANDHI VATA PATIENTS AFTER 15 DAYS 73



47 EFFECT OF JANU-BASTI ON SIGNS OF SANDHI VATA PATIENTS

AFTER 30 DAYS 74


SANDHI VATA PATIENTS AFTER30 DAYS 74

49 EFFECT OF NATUROPATHY TECHNIQUES ON SIGNS OF SANDHI

VATA PATIENTS AFTER 30 DAYS 75

FIGURE NO. FIGURE PAGE NO.

1 SAMPRAPTI IN DHATUKSHAYA JANYA SANDHI VATA 23 2 SAMPRAPTI IN AVARANA JANYA SHADHI VATA 24 3 SAMPRAPTI IN ABHIGHATA JANYA SANDHI VATA 25 4 SHOWING AGE WISE DISTRIBUTION 58 5 SHOWING SEX WISE DISTRIBUTION 58 6 SHOWING RELIGION WISE DISTRIBUTION 58 7 SHOWING OCCUPATION WISE DISTRIBUTION 59 8 SHOWING CARDINAL SIGNS AND SYMPTOMS 63 9 SHOWING CHRONICITY WISE DISTRIBUTION 63

Introduction &

Objectives

INTRODUCTION AND OBJECTIVES

Research is done for establishing new facts Many times research is conduct to

validate old principles with fresh proofs. Research is constructed with suitable

experimental methods and honest observations are made to arrive at a logic conclusion.

In our body, bones form the arms of the lever and fulcrum is at a joint where

movement takes place. To carry out the daily activities, normal movements of joints are

very essential. Sandhi-Vata acts as main hurdle in performing daily activities, in which

joints are mainly affected leading to pain, immobility, and discomfort. Sandhi-vata

described in Ayurveda can be correlated with osteoarthritis mentioned in modern science.

‘Arth’ means joint and ‘itis’ means inflammation. Osteoarthritis is the most

common type of arthritis; occurs due to the breakdown of cartilage in the joint. Among

the elderly and obese persons Osteoarthritis is a leading cause of chronic disability

especially affecting the knee joints. Since knee is the weight bearing joint it is more

susceptible to wear and tear. Other factors like heavy journey, agriculture, housework is

also contributing.

In the age group of 45-65 years 30% of population is suffering from this disease.

More than 355 million people around the world today are suffering from chronic pain of

arthritis. W.H.O. estimates that within the growing population the number of people over

50 years of age will be doubled by the year 2020. Hence, it has declared 2001-2010 as the

‘Decade of bone and joint diseases’.

In the contemporary science treatment is mainly aimed at Non–pharmacological

methods. Now there is a trend to find out non-pharmacological measures as much as

possible for the management of various disorders. Among non–pharmacological

treatment physical heat therapy is given importance. In addition, non-pharmacologic

management is the foundation of osteoarthritis.

Naturopathy is a part of Swasthavritha, which deals with the different nature cure

techniques. Naturopathy utilizes change in temperature as therapy. To regulate various

systems external and easiest access is skin. Skin is a giant sense organ and covers whole

body. So the naturopathy techniques can be correlated to Bahirparimarjan Chikitsa

mentioned in Ayurvedic classic. Treatment in the form of Janu-basti, Abhyanga, Avagaha

etc. have been proved of their efficacy on Sandhi Vata. The naturopathy likes derivative

massage, wax bath, alternate hot and cold pack, exercises, mustard pack etc. also

constitute non-pharmacological interventions, which are harmless, cheap and said to be

effective. Hence a study is planned to study their efficacy along with Janu Basti as

control in Sandhi vata patients.

The objectives of the present study are to provide scientific basis for the therapies that

is practiced are highly beneficial in the treatment of Sandhi vata. The following are

the main objectives of this study.



6. To compare the efficacy of Ayurvedic Bahirparimarjan Chikitsa and naturopathy

techniques employed for the treatment of Sandhi Vata.

Review of literature

HISTORICAL CONSIDERATIOS

History of Indian medicine is usually studied under the headings of Prevedic

period, Vedic period, Samhita Kala, Sangraha Kala, Nighantu Kala and Adhunika Kala.

History of medicine also reveals some aspects of the disease.

In classics the general description of Sandhi Vata is available.

There is no reference regarding Sandhi Vata in Prevedic period. During Vedic

period in Atharvaveda the references regarding the occurrence of Sandhi Vikara (Ath.

2/33/7, 6/14/1), the importance given for Vata (Ath.8/2/3, 2/10/3) and disorders of Vata

(Ath. 9/8/21) are available.

In Samhita period we find systematic description of the diseases according to

Nidana Panchaka.

Caraka Samhita, explained Sandhi Vata in Chikitsa sthana.1

Sushruta Samhita narrates its Lakshana in Nidanasthana2 and Chikitsa in

Cikitsasthana.3

Ashtanga Sangraha Nidanasthana describes its Lakshana4 and Chikitsa of Sandhi

Vata in Cikitsasthana.5

Ashtanga Hridaya has described Lakshansa in Nidanasthana6 and line of treatment

in Cikitsasthana.7

In Madhava Nidana Lakshana of Sandhi Vata are given same as that of Sushruta.8

Bhavaprakasha explains the Lakshana and treatment of Sandhi Vata in Madhyama

Khanda Vatavyadhyadhikara.9

Yogaratnakara also explained about Lakshana and treatment of Sandhi Vata in

Vatavyadhyadhikara of Purvardha.10

In Bhaishajya Ratnavali Vatavyadhi Prakarana deals with treatment aspects of

Sandhi Vata.11

The commentators of Samhita and Sangraha especially Chakrapani and Dalhana

contributed a lot for better understanding of the disease.

Table 1

References of Sandhi Vata

Literatures References

Caraka Samhita Chikitsasthana 28

Sushruta Samhita Nidanasthana 1; Chikitsasthana 4

Ashtanga Sangraha Nidanasthana 15; Chikitsasthana 23

Ashtanga Hridaya Nidanasthana 15; Chikitsasthana 21

Yogaratnakara Purvardha, Vatavyadhyadhikara

NIRUKTI AND PARIBHASHA

The word ‘Sandhi-Vata’ is comprised of 2 words i.e., Sandhi and Vata.

Etymology, definition and specific interpretation of the terms are explained as follows.

Sandhi

Vyutpatti - Sam + Dha + Kihi (Shabda Kalpa Druma)

Nirukti - ‘Asthi Samyogasthane’

(Vaiydyaka Sabdasindhuh)

Means junction, connection, combination, and union with containing a conjugation,

transition from one to another

(Sanskrit – English dictionary by M.M.W.)

Paribhasha - Sandhi Pullinga, Sandhanamiti, Yuga Sandhini Yugashabde Deha

Sandhini Marmashabde Cha Drishtavyaha (Shabda Kalp Druma).

In general, Sandhi means the junction between two things. In Ayurveda, Shareera

Sandhi is a technical word indicating that it is the place where two or more bones meet

together and the joint may be fixed type or with less or more movement.

Bhavaprakasha Madhyamakhanda Vatavyadhyadhikara 24

Madhava Nidana Purvardha, Vatavyadhyadhikara 22

Bhaishajyaratnavali Vatavyadhi Prakarana 23

Acharya Sushruta explains about the innumerable junctions between Peshi,

Snayu, Sira, Asthi, etc. But the description about Sandhi is concerned Asthi Sandhi1.

Vata

Vyutpatti- Va - Gati Sevanayoho

Va + Kta

(Shabda Kalpa Druma)

The term ‘Vata’ is derived by the application of ‘Kta’ or Krt Pratyaya to the verb

root ‘Va’ which means ‘Gati and Gandhana’.

Nirukti - Va - Gati Gandhanayoho (Sushruta Samhita)

The term ‘Gati’ is having meanings like Prapti, Jnana, Gamana, Moksha and the

meaning of ‘Gandhana’ is like Utsaha, Prakashana, Soocana, (Shabdasthoma) Gandhana,

Prerana (Siddhanta Kaumudi).

Considering the different meanings of Gati and Gandhana it is understood that the

term ‘Vata’ act as a receptor as well as stimulator. Hence it can be said that Vata is the

biological force, which recognize and stimulate all the activities in the body.

Sandhi -Vata

After going through the different references the definition can be stated as – the

vitiated Vata when get lodged at one or more than one Sandhi and producing the features

like pain in the joint, swelling on palpation, crepitus and stiffness in the joint termed as

Sandhi-Vata.

JANU-SANDHI In Sandhi Vata the vitiated Vata gets lodged at different Sandhi. Therefore before

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

properly. Here an attempt is made to study anatomical and physiological consideration of

Sandhi in general and Janu-sandhi in particular.

In Ayurveda, Sandhi is mainly classified into two types.

1) Sthira Sandhi

2) Chala Sandhi12

Again they are sub classified into eight types.

1) Kora 2) Ulookala 3) Samudga 4) Pratara

5) Tunnasevani 6)Vayasa tunda 7)Mandala 8)Shankhavarta

Acharya Sushruta considered Janu-Sandhi under Chala Sandhi and sub classified

under Kora Sandhi.13

Other factors that are to be highlighted in understanding the Sandhi are

Shleshmaka Kapha- Shleshmaka Kapha is one among five variety of Kapha, which

reside in joints. It helps in lubrication of joints.14

Shleshmadhara Kala-It is the fourth Kala, which is situated in all joints. As wheel

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

Kapha. This helps in formation of synovial fluid and to control friction of bones.15

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

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

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

Sushruta has quoted that the Vyana Vata is functioning all over the body hence it also

resides in the Sandhi.16 Acarya Vagbhata states that Vata is located in the Asthi with

relation to 'Ashrayashrayi Sambandha'. Generally augmentation or diminution of Doshas

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

With increase in Vata, Asthi Kshaya occurs.17

Sushruta in Sharirasthana explains different structures of the human body. Among

them, structures coming under Janu-Sandhi are listed below.

Snayu- Among nine hundred Snayus ten Snayus of Pratana variety are present in Janu-

Sandhi. As a boat consisting of planks becomes capable of carrying load of passengers in

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

many ligaments by which persons are capable of bearing load.18

Peshi- The fleshy mass covering bony structures that can be demarcated from each other

is known as Peshi. Among the five hundred Peshi, five are present in Janu Sandhi. They

are strong structures that help to maintain alignment of the joint.19

Sanghata- Assemblages of bones are known as Sanghata. Out of total fourteen, one is

situated in Janu-Sandhi.20

Knee Joint

The knee joint is the largest and most complex joint of the body. The complexity

is due to the result of fusion of three joints in one. It is formed by fusion of the lateral

femoro-tibial, medial femoro-tibial and femoro-patellar joints.

It is a compound synovial joint, incorporating two condylar joints between the

condoyle of the femur and tibia, one saddle joint between the femur and the patella.

In synovial joints the osseous surfaces concerned are not in continuity although

the bones involved are linked. The synovial joints evolve from fibrous and cartilaginous

joints by subsequent developments. These synovial joints are made up of unique

structures like fibrous capsule, articular surfaces, synovial membrane, synovial fluid,

ligaments, muscles etc.

Articular surfaces- The knee joint is formed by (1) the condyles of the femur, (2) the

condyles of the tibia and (3) the patella. The femoral condyles articulate with the tibial

condyles below and behind with the patella in front.

Fibrous capsule- The fibrous capsule has parallel but interlacing bundles of white

collagen fibers. It is complex, partly deficient and partly augmented by expansions from

adjacent tendons. It forms a cuff with its ends attached continuously round the articular

ends of the Tibia and Femur.

Synovial membrane- Derived from embryonic mesenchyme and lines fibrous capsule,

covers exposed osseous surfaces, intra-capsular ligaments and tendons. It is absent from

intra-articular discs or menisci and ceases at the margins of articular cartilages.

Synovial Intima- Also called as lamina propria synovialis or synovial lining layer. It

consists of pleomorphic synoviocytes embedded in a granular, amorphous, fiber free inter

cellular matrix. It helps in removal of debris and synthesis of components of Synovial

fluid.

Synovial fluid- It occupies synovial joints, bursae and tendon sheaths. It is clear, pale

yellow, viscous, and slightly alkaline. A protein probably lubricin rather than hyaluoric

acid is the lubricating factor but it amplifies its secondary lubricating activity. It provides

liquid environment with small range of pH, nourishes articular cartilage, discs, menisci. It

renders lubrication and reduces erosion.

Menisci- It is a fibro cartilagenous disc which is crescent shaped. It deepens the articular

surfaces of the chondyles of the tibia. It partially divides the joint cavity into upper and

lower compartments. It has two ends, two borders and two surfaces. It helps to make the

articular surfaces more congruent; act as shock absorbers, lubricates the joint cavity and

gives rise to proprioceptive impulse.

Other Structures-Ligaments- The capsules and ligaments of Synovial joints unit the

bones, help to direct bone movement and prevent excessive and undesirable motion. Thus

more the ligaments, stronger are the joints. In knee joint tibial collateral lig, fibular

collateral lig, oblique popliteal lig, arcuate popliteal lig, ligamentum patellae, cruciate

ligament etc. helps to maintain stability.

Muscle tone- Muscle tendons that cross the joints are the most important stabilizing

factors, due to tonicity of the respective muscles. In knee, muscle tone is extremely

important in reinforcing joints. For this the thigh muscles are helpful.

Bursae- Apertures in fibrous capsule through which synovial membranes protrude are

called as Bursae. They are numerous; as many as 13 bursae have been described around

the knee, four anterior, four laterals & five medial.

Blood Supply-1.Five genicular branches of the popliteal artery. 2. The descending

genicular branch of the femoral artery. 3. The descending branch of the lateral circumflex

femoral artery. 4. Two recurrent branches of the anterior tibial artery. 5. The circumflex

fibular branch of the post-tibial artery.

Nerve Supply- 1.Femoral nerve – Through its branches to the vastus medialis.2. Sciatic

nerve-Through the genicular branches of the tibial and common peroneal nerves. 3.

Obturator nerve – Through its posterior division.

NIDANA

In Bruhatrayees and Laghutrayees we find the description of Sandhi Vata in Vata

Vyadhi, hence Sandhi Vata is considered as a part of Vata Vyadhi.

Acharyas have not mentioned particular Nidana for Sandhi Vata, so we can

take common Nidana given for Vata Vyadhi21 along with Asthi and Majjavahasroto

Dushti Karana.22

These Nidana can be classified under various headings with different contexts.

The complimentary references of the Nidana of Sandhi Vata can be classified on the

following basis.

a) Aharaja

b) Viharaja

c) Manasika

d) Kalaja

e) Anya

Nidana mentioned under the above five groups are tabulated in Table 1to5. Some

of the important Nidana that may cause Sandhi-Vata are being discussed here in details:

Aharaja Nidana- Ahara is the most common contributing factor for the producing of a

disease. Intake of Ahara having Kashaya, Katu, Tikta Rasa; Sheeta, Ruksha, Laghu Guna

and indulgence in Alpashana, Vishmashana, Adhyashana, Pramitashana lead to

aggravation of Vata. Dravyas like Shushkashaka, Vallura, Varaka, Nivara, Koradusha,

Kalaya, Tumba, Kalinga, Chirbhota etc cause Vata vitiation.

Ativyayama- Excessive physical exercises act as one of the important Nidana for Sandhi

Vata. Running, walking, jogging etc if done excessively or violently will affect the

structures of Sandhi. They may affect the joint stability by over exertion. But if done

properly they stabilize and strengthen the Joints.

Bhara-Vahana- Carrying excessive load causes excessive pressure and stretching

effect over the structures of the joint. As knee is a weight-bearing joint, carrying

excessive load will have direct affect on the joint. The constant compression will lead

to wear and tear effect leading to degenerative changes in the joint.

Abhighata- Abhighata to the joint due to Prapatana etc. leads to structural deformity in

the joint. Joint is an organ rather than a single structure as it is stabilized by different

structures like Asthi, Snayu, Peshi, and Kala etc. Hence any trauma to these structures

will alter the structural integrity of the joint. Hence Abhighata is an important Nidana for

Sandhi Vata.

Ati-Sankshobha- It is a Nidana for Asthivaha Sroto Dushti. Since Asthivaha Srotas is

involved in Sandhi Vata this can be considered as Nidana for the same. Violent activities

like Atyadhva, Plavana, Langhana, Balavat Vigraha, Pradhavana etc. will have adverse

effect on joint. As told earlier knee is the weight-bearing joint, and violent exercises or

activities will alter the structural integrity of the joint.

Marmabhighata-The concept of Marmabhighata in the causation of Sandhi Vata seems

to be more rational. Janu Sandhi is one of Vaikalyakara Sandhi Marma23. Thus Janu

sandhi is a vital point, which comprises of Asthi, Snayu, Sira and Mamsa.

Pain in the joints not necessarily be only associated with bony changes. But

involvement of other joint structures may also give rise to symptoms pertaining to joint.

Therefore, in recent days more study is emphasized on the different structures involved in

the pathology of arthritis like consistency of soft tissue, fibrous material, liquid and

cartilaginous substance of the joint. From this new point the Ayurvedic view towards the

involvement of Marma in the disturbance of the joint is justified. Hence Marmabhighata

as a Nidana in case of Sandhi Vata is to be given importance.

Samanya Nidana of Vatavyadhi as explained in different treatises

(1) Aharaja Nidana

a) Rasa Vishesha Aharaja Nidana (Table-2)

Nidana Ca.Sa. Su.Sa. A.Hr. Ma.Ni. Yo.Ra. Bh.Pr. A.Sa.

Kashaya - + + - - + +

Katu - + + - - + +

Tikta - + + - - + +

b) Guna Vishesha Aharaja Nidana (Table-3)

c) Virya Vishesha Aharaja Nidana (Table-4)

d) Dravya Vishesha Aharaja Nidana (Table-5)

Nidana Ca.Sa Su.Sa A.Hr Ma.Ni Yo.Ra Bh.Pr A.Sa.

Vallura - + - - - - -

Varaka - + - - - - -

Shuskha Shaka - + - - - - -

Uddalaka - + - - - - -

Neevara - + - - - - -

Mudga - + - - - - -

Masura - + - - - - -

Kalaya - + - - - - +

Harenu - + - - - - -

Nishpava - + - - - - -


Rooksha + + + - - + +

Laghu + + + - - + +

Sheet + + + - - + +

Vishtmbhi - - - - - - +

Abhishyndi + - - - - - -

Heen - - - - - - +

Shushka - - - - - - +


Sheeta - + + - - + +

Koradusha - + - - - - -

Shyamaka - + - - - - -

Adhaki - + - - - - -

Tumba - - - - - - +

Kalinga - - - - - - +

Chirbhita - - - - - - +

Bisa - - - - - - +

Shaluka - - - - - - +

Jambav - - - - - - +

Tinduka - - - - - - +

Karira - - - - - - +

Chanak - - - - - - +

Virudhaka - - - - - - +

Trunadhany - - - - - - +

e) Aharakrama Nidana (Table-6)

Nidana Ca.Sa Su.Sa A.Hr Ma.Ni Yo.Ra Bh.Pr A.Sa .

Pramitashana + - + - - + +

Anashana - + - + + + -

Vishamashana - + - - - - -

Adhyashana - + - - - - -

Trusheetashana - - - - - - +

kshudhitambupana - - - - - - +

Viruddhanna + - - - - - -

(2) Viharaja Nidana (Table-7)


Ati Vyayama + + + + + - -

Langhana + + - + + - +

Plavana + + - + + - -

Atyadhwa + - - + + - +

Pradhavana - + - - - - +

Tarana - + - - - - +

Prapatana - + - - - - +

Atyuchabhashana - - + - - - -

Balavadvigraha - + - - - - +

Abhighata + + - + + + +

Prapeedana + + - - - - -

Bharaharana - + - - - - -

Dukhashayya + - - + + - -

Dukhasana + - - + + - -

Gaja,Ushtra, adi

Sheegrhayana

+ + - + + - -

Ati

kharchapkarshna

- - - - - - +

Govajigajnigraha

shmadi sahasa

- - - - - - +

Atiadhyayana - + - - - - +

Ati vyavaya + + + + + + +

Jagarana + + + + + + +

Vegadharana + + + + + + +

Vega-udirana - - + - - - +

Shrama - - - - - + -

Vicheshta + - - + + - -

Purhapavana - - - - - + -

Divasvapna + - - + + - -

Himadana - - - - - + -

(3) Manasika Nidana (Table-8)

(4) Kalaja Nidana (Table-9)

(5) Anya Nidana (Table-10)


Chinta + - + + + + -

Shoka + - + + + + +

Krodha + - - + + + -

Bhaya + - + + + + +

Utkantha - - - - - - +


Varsha - - - - - + +

Greeshma - - + - - - +

Shishira - - - - - + -

Jeernanna - - + - - + +

Ahoratrinta - - + - - + +


Atiraktasravana + - - + + + -

Atidoshasravana + - - + + - -

Dhatukshaya + - - + + + +

Rogatikarshana + - - + + - -

Ama + - - + + + -

Marmaghata + - - + + - -

POORVAROOPA

Poorvaroopa of Sandhi-Vata is not available in classics. In Vatavyadhi

unmanifested symptoms (Avyakta) or mild exhibition of actual features of the disease

itself is considered as its Poorvaroopa.24 Therefore prior to the full manifestation

of Sandhi Vata, appearance of some of its symptoms can be considered as

Poorvaroopa.

ROOPA

The clinical features of Sandhi Vata explained by various Acharyas are listed in table.

Table-11

Roopa of Sandhi-Vata mentioned in various classics

Symptoms Ca.Sa. Su.Sa. A.Hr. A.Sa. Ma.Ni. Bh.Pr. Yo.Ra.

Sandhi Shoola + + + + + + +

Sandhi Shotha + + + + + +

Sandhi Stabdhata + +

Kriyatiyoga - - + - - - -

Vishmopachara + - - + + + +

Pravata + - - - - - +

Sangkshobha + - - - - - -

Asthnamativighatana + - - - - - -

Utpeshadatya + - - - - - -

Atopa +

Sandhi Shoola

All the Acarya have described this symptom. Charaka and Vagbhata explain that

pain in the joint occurs during Prasarana and Akunchana Pravrutti.

Sandhi Shotha

Most of the classics explained this symptom. Charaka and Vagbhata explained the nature of Shotha

i.e., it is felt like bag filled with air (Vata Poorna Driti Sparsha).

Sandhi Stabdhata

Sushruta initially described this symptom, later by texts like Madhava Nidana,

Yogaratnakara and Bhavaprakasha.

They have coined the term Sandhi Hanana or Hanti. While commenting on this

word Dalhana and Gayadasa explained as ‘Akunchanaprasaranayoh Abhavah’ and

‘Prasaranakuncanayoh Asamarthah’ respectively. With this we can infer that the word

Hanti refers to inability to move the joints.

In the opinion of Madhukoshakara, Hanti refers to Sandhi Vishlesha, Stambha

Adi Vikara. Hence with the above references, Hanti refers to Sandhi Stabdhata.

Atopa

This symptom is explained in Madhava Nidana. While commenting on the word

Atopa in another context, Madhukoshakara quotes the opinion of Gayadasa and Kartika

i.e. ‘Atopaha Chalachalanamiti Gayadasaha, Gudaguda Shabdamiti Kartikah’. Also

Bhavamishra says ‘Atopo – Gudagudashabdaha’. Thus we can say that Atopa in this

context is the sound produced by the movement of joints i.e., crepitus.

Thus with the help of different references and by the opinion of commentators it

can be concluded that Sandhi Shoola, Sandhi Shotha, Sandhi Stabdhata and Atopa are the

clinical features of Sandhi Vata.25

SAMPRAPTI

The total course from the Dosha vitiation, resultant Dhatu affliction and evolution

of Vyadhi is Samprapti. Samprapti explains all the series of pathological stages involved.

The Samanya Samprapti of Vata Vyadhi, which is explained in classics, can be

considered as the Samprapti of Sandhi Vata.

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

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

Shunyata of Snehadi Guna is present. Vata after settling in Rikta Srotas produce

disease related to that Srotas26.

Acharya Vagbhata frames the Samprapti of Vata Vyadhi like Dhatukshaya

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

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

further vitiates the Srotas leading to the manifestation of Vata Vyadhi27.

Srotoriktata occurs due to Nidanasevana as follows.

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

properties are necessary for Sthairya and Upacaya of the body. Excessive intake of Dravyas having

Laghu, Ruksha, Sukshma, Khara properties lead to Guru and Sneha Guna Abhava due to their

opposite quality. Thus it leads to Dhatukshaya in the body. Akasha Mahabhuta produces Sushirata and

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

Mahabhuta increases in the body producing Sushirata and Laghuta simultaneously Vayu fills it up.

From this description it can be stated that the meaning of word ‘Riktata’ is Sushirata i.e. increase in

Akasha and Vayu Mahabhuta. While commenting on word ‘Riktata’ Chakrapani says that ‘Riktata’

means lack of Snehadiguna.

For the purpose of understanding the Samprapti of Sandhi Vata can be studied under three heading. They are1. Dhatukshayajanya 2. Avaranajanya 3. Abhighatajanya

1. Dhatukshayajanya Sandhi Vata-In old age Vata Dosha dominates in the body. This

will lead to Kapha Abhava. Also Jataragni and Dhatvagni get impaired so Dhatu will not

be form in good quality. Degeneration of body elements takes place due to predominance

of Vata in its Ruksha, Khara etc Guna and loss of Kapha in quality and quantity.

As the Shleshma Bhava decreases in the body Shleshaka Kapha in the joints also

decreases in quality and quantity. Reduction of Kapha in Sandhis makes Sandhi

Bandhana Shithilata. Ashrayashrayi Sambandha also leads Asthidhatu Kshaya. Asthi

being the main participant of the joint its Kshaya leads Khavaigunya in the joints. In this

condition if Nidana Sevana done leads Vata Prakopa. If Vata Prakopa is not corrected by

appropriate means and simultaneously if the person indulges in Asthivaha and Majjavaha

Sroto Dushtikara Nidana, the Prakupita Vata spreads all over the body through these

Srotas. In the meantime Sthanasamshraya of Prakupita Vata takes place in the

Khavaigunyayukta Sandhi. This localized Vayu due to its Ruksha, Laghu, Kharadi Guna

over power and undo all properties of Sleshaka Kapha producing disease Sandhi Vata.

2. Avarana Janya Sandhi Vata-In Sthula Sandhi Vata occurs in weight bearing joints.

In them Medodhatu will be produced in excess due to the Atisnehamsha of Amarasa The

excessive Medas will produce obstruction for the flow of nutritive materials to the future

Dhatus that is Asthi, Majja and Shukra leads to their Kshaya28.

The excessive fat deposited all over the body will produce Margavarana of Vata 29

Prakupita Vata due to Margavarana starts to circulate in the body. While traveling it

settles in the joint where Khavaigunya is already exists. After Sthanasamshraya it

produces the disease Sandhi Vata in the same process mentioned in the earlier context.

3. Abhighatajanya Sandhi Vata- Trauma is considered as

secondary cause of Osteoarthritis. By the Abhighata the

integrity of the joint is disturbed. Due to Abhighata to the

Asthi involved in Sandhi leads to provocation of Sthanika

Vata that is. Vyana Vata (Ashrayashrayi Sambandha).

Ruksha Guna of Vata and Ushanata produced by Abhighata

will does the Shoshana of Shlashmaka Kapha in the joint.

This produces the degenerative change in joint cartilage

(lack of nutrition). In another way Vata is vitiated in the joint

by the Siramarga Avarana of Vata due to Abhighata30. This

vitiated Sthanika Vata will produce series of changes in the

joint after Dosha Dushya Sammurchana and produces Sadhi

Vata Lakshana.

Thus with the help of Samanya Samprapti of Vata Vyadhi the Samprapti of Sandhi Vata can be divided into Dhatukshaya Janya, Avarana Janya and Abhighata Janya Sandhi Vata. This will help in deciding the prognosis and planning the treatment of the disease.

Samprapti Ghataka:

Dosha – Vata – Vyana – Vriddhi; Kapha – Shleshaka – Kshaya

Dooshya – Peshi, Snayu, Asthi, Majja

Srotas – Mamsavaha, Medovaha, Asthivaha, Majjavaha

Agni – Jataragni, Asthi-Dhatvagni

Ama – Jataragni Mandya Janya

Roga Marga – Madhyama

Udbhavasthana – Pakvashaya

Sancharasthana - Sarvasharira

Adhishtana – Sandhi

Vyaktasthana – Sandhi

FIGURE - 1

SAMPRAPTI IN DHATUKSHAYA JANYA SANDHI VATA

NIDANA SEVANA VARDHAKYA

DHATUKSHAYA

VATA PRAKOPA KSHAYA OF KAPHA BHAVA

IN THE BODY

CIRCULATION THROUGH SHLESHAKA KAPHA KSHAYA

RASAYANI IN SANDHI

KHAVAIGUNYA IN SANDHI

STHANASAMSHRAYA IN SANDHI

SANDHI VATA

FIGURE - 2

SAMPRAPTI IN AVARANA JANYA SHADHI VATA

(MEDOVARANA) (MARGAVARANA TO THE

FLOW OF POSHAKARASA)

VATAPRAKOPA POSHAKARASA NYUNATA TO

ASTHIDHATU

EXCESSIVE PRESSURE OVER

WEIGHT BEARING JOINT

CIRCULATION THROUGH ASTHIDHATU KSHAYA

RASAYANI IN SANDHI

VYANAVATA PRAKOPA

IN SANDHI


STHANASAMSHRAYA IN SANDHI

SANDHI VATA

MEDOVRIDDHI

FIGURE - 3

SAMPRAPTI IN ABHIGHATA JANYA SHADHI VATA

AGHATA TO ASTHI STHANIKA VATAPRAKOPA

KSHATOSMA

VATA PRAKOPA DOSHDUSHYA

SAMURCHANA

SHLESHAKA KAPHA KSHAYA


SANDHI VATA

ABHIGHATA

VYAVACHEDAKA NIDANA

Vyavachedaka Nidana or differential diagnosis plays a prime role in arriving at an

exact decision between diseases presenting a similar clinical feature. While making the

diagnosis of Sandhi-Vata the following disorders that are having similar features has to

be excluded. They are

1) Amavata (Ma.Ni.25/7)

2) Vatarakta (Ca.Sa.Ci.29/23)

3) Kroshtukasheersha (Ma.Ni.22/58)

4) Sandhibhagna (Ma.Ni.44/2)

5) Asthi Majjagata Vata (Ma.Ni.22/18)

There are some conditions (Dosha Vriddhi Kshaya Lakshana, Panchakarma

Vyapat) where in symptoms related to Sandhi are seen. They are listed below.

1) Kapha Vruddhi (A.Sa.Su.19/6)

2) Kapha Kshaya (A.Sa.Su.19/9)

3) Mamsa Kshaya (A.Sa.Su.19/10)

4) Medo Kshaya (Ca.Sa.Su.17/66-67)

5) Asthi Kshaya (Ca.Sa.Su.17/66-67)

6) Majja Kshaya (Su.Sa.Su.15/13)

7) Ojo Visramsa (Su.Sa.Su.15/29)

So while diagnosing Sandhi-Vata, factors like Vriddhi or Kshaya of Dosha and

Dhatu should be differentiated apart from above-mentioned disorders. This will help in

successful treatment.

SADHYASADHYATA

Sandhi-Vata is a variety of Vata Vyadhi, and also Madhyama roga Margaja

Vyadhi. The disease in elderly persons is kastasadhya and Sandhi-Vata is usually

afflicted in elderly aged. Diseases of Gambheera dhatu are Yapya and Sandhi-Vata Asthi

dhatu is involved.

In Caraka Samhita it has been stated that Khudavata (Sandhi-Vata) will not yield

to treatment because of its Gambheera sthan31. Further it states that it may cured by full

effort when the disease in new, Upadrava rahita and in strong person32. So Sandhi-Vata

being a disease of old age may not be considered as Sukhsadhya. It may be Krichsadhya

or Yapya depending upon the time of onset and chronicity.

CHIKITSA

The main aim of treatment is to restore Swasthya. It means to restore

normal functions of Agni, Dosha, Dhatu, and Mala and to maintain mental health.

The primary importance of Chikitsa lies in Samprapti Vighatana.

Sandhi-Vata is a Vataja disorder. The general treatment of Vata Vyadhi can be

adopted, keeping an eye on the etiology. Regarding the specific line of treatment of

Sandhi-Vata, Caraka is silent. Later authors like Sushruta had mentioned effective line of

treatment for the same. Other books like Astanga Hridaya, Astanga Sangraha,

Yogaratnakara, and Bhavaprakasha had mentioned specific line of treatment.

The below chart shows Chikitsa sutra mentioned in different texts

Table -12

Chikitsa Sootra mentioned in different Samhita

Treatment Su.Sa. A.Sa. A.Hr. Yo.Ra. Bh.Pr. Bh.Ra.

Snehana + + + + +

Abhyanga +

Mardana + + + +

Svedana + + +

Upanaha + + + + + +

Bandhana + + +

Agnikarma + + + +

SNEHANA

Sandhi-Vata is a variety of Vata Vyadhi, where Snehana would be very effective.

According to the use it can be administered in two ways –

Abhyantara Prayoga

Bahya Prayoga33

Abhyantara Sneha: Here Sneha in the form of Pana can be administered in case

of Sandhi Vata.

Bahya Sneha: Bahya Sneha is many like Abhyanga, Lepa, Pichu, Mardana, and

Parisheka. In case of Sandhi Vata we get the mentioning of Abhyanga and

Mardana.

Abhyanga means to do some 'movements' or 'Gati'. For the purpose of Abhyanga

Sukhoshna Taila or Sneha is used. Abhyanga should be done slowly in Anuloma Gati, in

joints it should be done in circular manner. Abhyanga should be done minimum for 5

minutes because the Veerya of Taila will reach Majja Dhatu in 900 Matra-Kalas. It is

Vatahara, Pushtikara34. Mardana is like Abhyanga but applied pressure is more.

SWEDANA

Swedana is a variety of Shadvidhopakrama. It is helpful in neutralizing

Stabdhata, Shitata and Gauravata.35 Vatanashak drugs or drugs having Ushna

Veerya, Guru, Drava, Sthira, Sara, Snigdha, Ruksha, Sukshma, Tikshna can be take

for Swedana.36

UPANAHA

Charaka consider Upanaha as a variety of Swedana.37

Roots of Vatahara drugs should be pasted together with Kanji and mixed with abundant quantity of

Saindhava Lavana and Sneha. After making this lukewarm, it should be applied to the affected part.

The paste of drugs included in the Kakolyadi, Eladi or Surasadi Gana as well as

pastes of Sarshapa, Tila, or Atasi or Krishara, Payasa, Utkarika and Veshavara or the

drugs of Salvana Sweda should be similarly applied to the affected part folded in piece of

thin linen and tied up.38

Duration- Upanaha, which is tied in the morning, should be removed in the night and

which is tied in the night should be removed in the morning.

BANDHANA

In Bandhana Dravya is tied to the affected apart. For the purpose of Bandhana,

Charaka opines that leather of Ushna Veerya animal can be used. In the absence of this

silk or woolen cloth can be used.39 Astanga Hridaya opines that 'Vatahara' Patra40 should

be used and Charaka suggests Eranda Patra.41

AGNIKARMA

Unique treatment indicated in case of Sandhi Vata. Here Dahana or cauterization

is done in the part affected.42 Dahana Karma should be done in the affected joint till the

Samyaka Lakshana appear.

These are the different treatment modalities mentioned by different authors for

Sandhi-Vata.

OSTEOARTHRITIS

Osteoarthritis is also called as Degenerative Joint Disease or Arthrosis or wear-

and-tear arthritis. It represents the failure of diarthrodial joint.

It is one of the most common joint diseases of humans. Osteoarthritis of knee is

the leading cause of chronic disability in developed countries. Primary Osteoarthritis is

idiopathic and secondary Osteoarthritis is due to many causes like secondary to trauma,

due to endocrinal disorders, metabolic causes, etc.

Risk factors for Osteoarthritis

Age – It is one of the powerful risk factor in old age people.

Sex – Both Males and females are affected, but osteoarthritis is more generalized

and more severe in older women. It is twice as common in women as in men.

Osteoarthritis of knee is common in women.

Women less than 45 years old – 2%

45 – 65 years – 30%

Older than 65 years – 68% will suffer.

Genetic – Point mutation in the cDNA coding for articular cartilage collagen have

been identified in families with chondrodysplasia and polyarticular osteoarthritis.

Trauma – Direct or indirect injuries to the articular cartilage lead to its

degeneration. Fractures of different bones, especially of weight bearing with or

without involving the joint can also cause alteration of ligaments and in articular

surface of joint.

Repetitive stress – Abnormal posture, abnormal gait, and unequal length of leg

will exert stress and strain over the joint.

Endocrine disorders – Acromegaly, Hyperparathyroidism, Diabetes mellitus,

Obesity, etc. also may lead to osteoarthritis.

Metabolic disorders – Like Ochronosis, Wilson’s disease may give rise to

Osteoarthritis.

Calcium deposition diseases – Like CPPD deposition may lead to Osteoarthritis.

PATHOLOGY

Although the cardinal pathologic features of osteoarthritis are progressive loss of

articular cartilage, osteoarthritis is not a disease of any single tissue but a disease of an

organ, the synovial joint. The most striking morphologic changes in osteoarthritis are

usually seen in load bearing areas of the articular cartilage.

Osteoarthritis develops in either of two settings:

1. The biomaterial properties of the articular cartilage and sub-chondral bone are

normal, but excessive loading on the joint causes the tissue fail, or

2. The applied load is reasonable, but the material properties of the cartilage or

bone are inferior.

In the early stages the cartilage is thicker than normal. With the progression of

osteoarthritis, joint surface thins then the cartilage softens. The integrity of the surface is

breached and vertical clefts develop. They are called as fibrillation. This is followed by

deep cartilage ulcers, extending to bone. All the cartilage is metabolically active and the

chondrocytes replicate, forming clusters (clones). Later cartilage becomes hypo cellular.

There will be appositional bone growth in the bony sub-chondral region, leading to the

bony sclerosis. Growth of cartilage and bone at the joint margins leads to osteophytes,

which alter the contour of the joint and may resist movement.

The biochemical changes which occur in cartilage in osteoarthritis are increase

in water content, decreased collagen, proteoglycan, monomersize, hyaluronate, keraten

sulphate, and chondrotin sulphate, increase in proteoglycan synthesis, collagenase, and

proteoglycanase.

CLINICAL FEATURES

Symptoms

Joint Pain- It is often described as a deep ache and is localized to the involved

joint. Typically, the pain of osteoarthritis is aggravated by joint use and relieved

by rest, but as the disease progresses, it may become persistent.

Stiffness- Progressive stiffness of the involved joint upon arising in the morning

or after a period of inactivity may be prominent but usually lasts less than 20 min.

It is due to spasm of muscles. There is no relation between the severity of

degeneration and morning stiffness.

Signs

Swelling- Physical examination of the osteoarthritis joint reveals localized soft

tissue swelling of mild degree. It is due to the changes in articular ends

themselves, particularly peri-articular lipping.

Crepitus- The sensation of bone rubbing against bone evoked by joint movement

is called as crepitus. It is one of the characteristic sign of osteoarthritis joint.

Local Warmth ness- On palpation of the joint local rise in temperature is an

indicative of sign of inflammation.

Muscle Atrophy- Peri-articular muscle atrophy may be due to disuse or due to

reflex inhibition of muscle contraction.

Others- In advanced stage there may be gross deformity, bony hypertrophy,

subluxation and marked loss of joint motion.

Laboratory and Radiological Findings

The Diagnosis of osteoarthritis is usually based on clinical and radiographic

features. In the early stages, the radiograph may be normal, but joint space narrowing

becomes evident, as articular cartilage is lost. Other characteristic radiographic findings

include subchondral bone sclerosis, subchondral cysts, and osteophytosis. A change in

the contour of the joint, due to bony remodeling, and subluxation may be seen. There is

often great disparity between the severity of radiographic findings, the severity of

symptom and functional ability in osteoarthritis.

No laboratory studies are diagnostic for osteoarthritis, but specific laboratory

testing may help in identifying one of the underlying causes of secondary osteoarthritis.

Analysis of synovial fluid reveals mild leukocytosis with a predominance of mononuclear

cells. Approaches such as magnetic resonance imaging and ultrasonography have not

been sufficiently validated to justify their routine clinical use for diagnosis of

osteoarthritis or monitoring of disease progression.

TREATMENT

Treatment of osteoarthritis is aimed to reducing pain, maintaining mobility, and

minimizing disability. The vigor of the therapeutic intervention should be indicated by

the severity of the condition in the individual patient. For those with only mild disease,

reassurance, instruction in joint protection, and an occasional analgesic, may all that

required; for those with more severe osteoarthritis especially of the knee or hip, a

comprehensive programs comprising spectrum of non-pharmacological measures

supplemented by an analgesic and/or NSAID is appropriate.

Non-Pharmacological Measures

Reduction of Joint Loading

Osteoarthritis may be caused or aggravated by poor body mechanics. Correction of

poor posture and a support for excessive lumbar lordosis can be helpful. Excessive

loading of the involved joint should be avoided; patients with osteoarthritis of the knee or

hip should be avoided prolonged standing, kneeling and squatting. Obese patients should

be counseled to loose weight. Patients with medial compartment knee osteoarthritis are

wedged in sole my decrease the pain. Complete immobilization of painful joint is rarely

indicated. In patients with unilateral osteoarthritis of knee or hip, a cane, held in the

contra lateral hand, may reduce joint pain by reducing the joint contact force. Bilateral

disease may necessitate use of crutches or walker.

Physical Therapy

Application of heat to the osteoarthritis joint may reduce pain and stiffness. A variety

of modalities are available; often the least expensive and most convenient is a hot shower

or bath. Occasionally, better analgesia may be obtained with ice than with heat.

It is important to note that patients with osteoarthritis of weight bearing joints are

less active and tend to be less fit with regard to musculo-skeletal and cardiovascular

status than normal controls. An exercise program should be designed to maintain range

of motion, strengthen peri-articular muscles, and improve physical fitness. The benefit of

aerobic exercise includes increase in aerobic capacity, muscle strength, and endurance;

less exertion with a given workload and weight loss. Those who exercise regularly live

longer and are healthier than those who are sedentary. Patients with hip or knee

osteoarthritis can participate safely in conditioning exercises to improve fitness and

health with out increasing their joint pain or need for a analgesics or NSAIDs.

Disuse of the osteoarthritis joint, because of pain will lead to muscle atrophy, because

particular muscles play a major role in protecting the articular cartilage from stress,

strengthening exercise are important. In individuals with knee osteoarthritis strengthening

of a particular muscle may result, with in weeks, in a decrease in joint pain as great as

that seen with NSAIDs.

Drug therapy of osteoarthritis

Therapy for osteoarthritis today is palliative, no pharmacological agent has been

shown to prevent, delay the progression, or reverse the pathologic changes of

osteoarthritis in human. Although claims have been made that some NSAIDs have a

“chondroprotective effect”. It controlled clinical trails in human with osteoarthritis to

support this view are lacking. In management of osteoarthritic pain, pharmacological

agents should be used as adjuvants to non-pharmacological measures, such as those

described above, which are keystone of osteoarthritis. NSAIDs often decrease joint pain

and improve mobility in osteoarthritis - on an average about 30% reduction in pain and

15% improvement in function. Intra articular injection of hyaluronic acid is being used

for treatment of patients with knee osteoarthritis who have filed a program of non-

pharmacological therapy and simple analgesics.

Naturopathy is a drugless system of healing which incorporates the natural

inherent principles like mud, water, sunlight, air and ether in treatment. It is a way of

living. The body corrects by itself and the healing will be faster by undertaking the

various treatment modalities of this system.

People who adopt the natural system of healing will not suffer with diseases and

these treatments enable for elimination of the disease from root. By providing the

elements which are depleted this system works in healing.

Naturopathic techniques for Sandhi-Vata

1. Derivative massage Massage is employed for eliminating muscle contraction and for breaking of

adhesions.43 Slight pain is often produced by the first manipulation but it subsides within

short time.

In derivative massage Fulling, friction and deep kneading are most effective. In

the manipulation of a joint, begin with light friction and pressure. If these applications are

tolerated, add digital massage, working between the ligaments and following all the

irregularities of the ends of the bones so far as accessible. Later add percussion, first

tapping, afterward hacking. The derivative manipulations which are first employed

should be continued in connection with application to the joint, since the effect of

kneading a joint is to increase the circulation through it, while the effect of derivative

massage is not to carry the blood through the joint, but rather around it, thus relieving

excessive local congestion or hyperemia, by diverting the blood into other channels.

Centripetal friction applied to the tissues relieves painful joints by increasing the

surface circulation and so diverting the blood from the joint itself. Derivative massage

restores the normal secretion, improves nutrition of the joint and may increase vital

activity. In cases of extremely painful joints in which heat and congestion are marked

symptoms, derivative massage may be employed upon the soft parts both above and

below the joint44. Tapping helps the muscles to develop its contractile power. A little

moderate kneading and percussion cause muscles to contract and become stronger. Deep

circular kneading loosens the muscles. Kneading under and around the muscles breaks up

adhesions. These all types should be done with Tila Taila. Material- Tila Taila, chair.

Indication- stiff and swollen joints, inflammatory conditions, tubercular joints, fractures,

sprains, bruises. Contraindication- diphtheria, gonorrhea.45

2. INFRA RED THERAPY

Infra Red lies beyond the red boundaries of visible spectrum. Infrared has

a wavelength ranging from 750nm to 40000 nm and frequency 4x 10 Hz and 7.5

x 10 Hz. These rays have extremely strong heat reaction. According to biological

research far infrared (4-1000microns) rays are absorbed very easily by the

human body. The sources are the Sun, soil, mineral etc. When intensity of

infrared is high in the body we feel healthy and will be able to over come

ailments, however when it begins to decline, the human body will be subjected to

attack by ailments and diseases.

Physiological effect (Metabolic changes)-Infra Red treatment produces heating effect in

the superficial epidermis. Thus, resulting in vasodilation, this increases blood circulation

in that area. This will lead to more oxygen supply and nutrient supply in that area leading

to drainage of waste products resulting in the relief of pain and healing of oedema and

other skin conditions (superficial wounds). The sedative effect on nerve endings lead to

reduction in the muscle spasm.

Neurological effects- I.R.R. are used for muscle relaxation, thus helping in treatment of

inflammation. I.R.R. due to sedative effects on the nerve endings helps in relieving pain,

muscle spasm and neuralgia.

Application-Material required for application are infrared lamp, chair. Patient should

remove cloths from the part, which has to be treated by I.R.R. Patient should be

instructed not to touch the lamp and should not sleep during treatment. Lamp should be

place at a distance of 12-15 inches and at 900 to the affected part so that maximum rays

fall on the affected part. The treatment should end with erthema and not with burns. So

duration should be carefully seen.

Contraindications-1.Area of anesthesia or thermal hypothesia. 2. Patient of arterial

diseases. 3. Disorders with the possibility of hemorrhage, gastric ulcers, haemoptysis etc.

4.Skin diseases like psoriasis, eczema, etc. 5.Vascular insufficiency. 6. Active or acute

pathology of ulcers. 7. In pregnant ladies and during menstruation.46

3. WAX BATH

Mode of Action- It is seen that water at 450 c. temperature would be uncomfortable hot

and ultimately causes damage. The specific heat of water is 4.2 kj/kg/ degree C and

specific heat of wax is 2.72 kj/kg/ degree C. therefore the amount of energy released by

wax is 10 C cooler than that of water.

When the part is immersed in wax the cooler skin causes a thin layer of wax

solidify on the surface. This thin static layer act as insulator of the skin from the hotter

sounding wax, some air may be trapped between these solidified layers and adding to

insulating effect. The wax transmits heat energy to the tissue by giving up energy as it

solidifies. The latent heat of fusion without any temperature change the amount of energy

is 35kj/kg. The low conductivity of wax prevents much heat loss from the skin surface. It

also prevents water loss from skin and skin gets moisture, this moisture helps to soften

adhesions and scar tissue.

The solid wax melts with a temp of 540 C that may cause burns to the human skin. T o

avoid this burn in the treatment of wax bath liquid paraffin is mixed in different ratio that

will reduce the melting point of wax at 400C to 440C in this temp there is no risk of skin

burn. This therapy often named paraffin wax bath as liquid paraffin is mixed with wax in

6:1 or 7:1 ratio. Other material may be used in the form of Vaseline and glycerin to make

the mixture more smooth that to prevent adhesion of wax to the skin. Paraffin liquid wax

is melted and stored for use in a thermostatically controlled stainless steel box.

Method of Application- Preparation of patient- Inspection of the treatment area, shape,

size and location-Elimination of cloths, rings. Identification of skin condition. The patient

should be in comfortable position. Preparation of apparatus- the wax should be melted

completely. The temperature of the wax should be maintained at 450C. In toweling

method the towel is immersed in the melted paraffin wax then it is picked up, removes

extra wax and applied over the area. Repeat 8-12 times. Duration of treatment is 15 to 30

minutes. Material- Wax bath tub, cotton towel, metal strip, and chair.

Advantages- 1. Low specific heat allows for application at a higher temperature than

water without the risk of burn. 2. Low thermal conductivity allows heating of tissues

gradually thus reducing the risk of over heating the tissue. 3. Melted state allows for

even distribution of heat to areas like finger and toes. 4. Oils used in the wax add

moisture to the skin. 5. Wax remains malleable after removal, allowing for use as an

exercise tool. 6. Comfortable moist heat. 7. Relatively in expensive to replace wax.

Indication- Reduction of pain, reduction of muscle spasm, correction of contracted

deformity, softening of adhesive scar, to break stiffness, arthritic joint, increase range of

motion and post operative fracture pain after healing of wounds.

Contraindication- Open wounds, allergic skin, skin condition, defective arterial blood

supply and impaired skin sensation.47

4. EXERCISES

Flexion- patient will be in prone lying position, resistance is applied to the

posterior aspect of the lower leg just above the bed, give the stabilization to the hip and

tell patient to do flexion. Extension- patient should be in the sitting position, give the

resistance to the anterior aspect of the lower leg, give the stabilization to the hip and

thigh, and tell him to do extension.48

For without resistance the patient sits at the edge of bed or chair and actively

flexes and extends the knee joint in free-swinging movement within the limits of pain.49

Resistance can be offered when the test is being performed against the motion and to

assess the strength of a muscle. Manipulation with resistance is for treating for disuse

atrophy. Without resistance is for improving the range of motion and for lubrication of

the joint. It maintains endurance of muscle.50

Advantages- easy to perform, improves the range of motion at the knee, facilitate joint

lubrication, and to provide joint relaxation. Increases blood circulation.51

5. MUSTARD PACK

The Mustard pack is especially applicable to cases in which a very quick and

strong revulsive effect is desired as for the relief of severe pain or to secure strong

derivative effects.

For mustard pack wring a towel or a cloth out of hot water to which ground

mustard will be added in proportion of ½ ounce. Spread this upon the part (knee) to

which the application is to be made. Care must be taken to avoid excessive irritation or

blistering of the skin.52 Material- Cotton towel, gas stove, vessel, water, ground mustard,

and chair.

1. SARSHAPA (Brassica Junca)

Family: Crucifereae

Pharmacological properties:

Rasa: Katu

Guna: Tikshna

Veerya: Ushna.

Vipaka: Katu.

Doshakarma: Kaphavatashamaka.

Part used: Bija churna

Chemical composition: seeds contain 30-38% fixed oil and nitrogenous matter

24.6%

Pharmacological actions: It is Shothahara, Vedanasthapana, Vidahi, Lekhana,

Sphotajanana, Swedajanana, Dipana, Pachana, Krimighna, Vamaka,

Plihavriddhihara.

6. THE ALTERNATE HOT AND COLD KNEE PACK

In this form of application the skin is first heated considerably above its

normal temperature, and then the temperature is lowered by the use of cold

water. In alternate applications the heating and cooling are several times

repeated. The reaction which takes place as the result of the applications may be

made chiefly circulatory in character or both circulatory and thermic. This form of

application is therefore a most efficient means of stimulating nutritive changes,

obtaining derivative effects, etc and that without creating thermic disturbances of

any kind in the body.53

It is very strongly influences both the arteries and the veins. It is our most

powerful derivative procedure, its effects being almost wholly derivative in character.54

By lowering the pressure in the veins, the arterial circulation through the affected part is

facilitated, thus encouraging the nutrition and functional activity of the cells which are

engaged in combating living germs, or which are seeking to repair damages which may

have originated in any way.

The hot application diverts the blood into the cutaneous branches of the collateral

arteries or into anastomosing vessels, thus preventing undue accumulation of blood and

consequent embarrassment of the affected tissues. The adjustment of the hot and cold

pack depends on the different parts of body on which it has to be applied and the

circulation of which it is desired. Contraindications- Acute inflammation and pain.

Method- The cold pack should be kept alive by rubbing the parts for one minute each time when the

pack is changed. The hot pack should be exchanged every 15-20 minutes by the cold pack for 30

seconds to 1 minute so as to empty the veins restore the tone of the vessels and prevent great

accumulation of heat in deeper parts. The pack should be changed after every 5-8 minutes or as soon as

the temperature begins to approach that of body. The duration of pack varies from 15 minute to 1 hour

according to condition and tolerance of patient. Continue the application until the desired effect is

produced.55 Material- cotton packs, Lenin cloth, vessels, chair, water, gas stove.

7. THE HOT FOOT BATH

Method- The temperature required for getting positive effects is 1040F to 1220F. The

bath should begin at a temperature of 1020F to 1040F, and should be gradually increased

until by the end of two or three minutes a maximum temperature of 1150F to 1220F is

reached. The duration may be from 5 minutes to half an hour as per condition. The feet

should be completely immersed in water; increasing the depth of the water may intensify

the effect. Material- Foot bath tub, water, gas stove, vessels, and chair.

Physiological Effects- Hot Foot Bath produces same effects as the general hot bath. At

first the pulse is slowed and the brain congested, but after three or four minutes the pulse

rate is increased, and the brain becomes anemic, these conditions persist for some time

after the bath is terminated. The footbath at 1080 to 1150 for 20 minutes causes elevation

of the temperature in the external auditory canal amounting to one degree Fahrenheit. The

rectal temperature at the same time fell to the same extent. Arterial tension was increased

by 8 mm.

Therapeutic Applications- This bath is more commonly used as a derivative measure.

At a temperature of 1030F to 1100F the hot footbath is an exceedingly useful means of

balancing the circulation, by the dilatation of the blood vessels of the legs relieving

congestion of the brain and other organs in the upper half of the body.

The hot footbath is also of very great service as a means of relieving or preventing

a cold resulting from accidental chilling of the feet, if applied soon after exposure. The

prolonged hot footbath (980F to 1060F) dilates the vessels of feet, and produces collateral

anemia of the pelvic viscera.56

Bahya Shamana Chikitsa

A patient can be administered Aoushadhi as Anta-Parimarjana, Bahi-Parimarjana

and Shastra-Pranidhana.57 Janu-Basti may be included in Bahi-Parimarjana type of

treatment. Janu-Basti is a Bahya Samshamana Chikitsa (Retaining type).

JANU-BASTI

Vagbhata has described four types of oil application on head under Murdha Taila,

which are Shiro-Abhyanga, Shiro-Seka, Shiro-Picu and Shiro-Basti. As one of the

meanings of Basti is to fill and reside, therefore the word Basti has been added to word

‘Shiro’. In Shiro-Basti, oil is kept on head by putting a cap for prescribed period of time.

Later on some physicians made an artificial pit around the knee with the help of

Masha powder to keep hot oil for prescribed period and named it as Janu-Basti.

Basti

Meanings related to organ- Organ that lies below the umbilicus (Nabhi).

Meanings related to Karma- Here the urinary bladder of animals is used to inject the

drugs into the rectum “Bastina Deyata Eti Bastih Tasya Vidhi”58.

The word 'Basti' is used here with the meaning of “to reside”, “to retain”. In

'Janu-Basti' the medicine is made to retain over the Janu-Sandhi for a prescribed time.

Procedure of Janu-Basti- All the procedures are performed in systematic manner.

According to Sushruta it can be performed in three stages like

1. Poorva karma 2. Pradhana karma 3. Paschat karma59.

The procedure of Janu-Basti is explained accordingly

I. Poorva karma- This includes preparatory measures taken for smooth conduction of

the procedure. They are

1. Atura Pareeksha- The patient is examined with reference to Prakriti, Vikriti etc. ten

factors by applying Pratyaksha, Anumana and Aptopadesha. This will assess Vyadhibala

and Dehabala 60. Then affected knee should be Examined properly and mark the tender

area. Examine for scares, wounds in the joint.

2. Sambhara Sangraha- Materials required for Smooth conduction of Janu-Basti

procedure have to be collected. They include – A metal ring, Masha powder, medicine

(Tila Taila), spoon, bowl, vessel, water, gas stove, and cotton.

3. Atura Siddhata- Patient is asked to lie down on the table. Expose the affected knee.

II. Pradhana karma -This includes

1. Basti Yantra Dharana- Initially paste of Masha powder is prepared by adding

sufficient quantity of water to it. Then with the help of a metal ring and Paste of Masha a

pit is constructed around Janu-Sandhi of about 2-3 Angula heights. The concavity of pit

(Basti Yantra) should be well sealed to retain the medicine.

2. Taila Dharana- The bowl containing Medicine (Tila Taila) is heated gently by

keeping over hot water. Then gently heated luke warm medicine is poured slowly and

carefully on the Janu-Sandhi along the side of the Basti Yantra. The heat of the medicine

should be sufficient enough to tolerate by the patient. The quantity of the medicine

should be two Angulas above the skin surface.

3. Maintenance of constant temperature of medicine- Keep on changing the medicine

with the heated one so that a constant temperature is maintained through out the

procedure.

4. Removal of Taila and Basti Yantra- After the prescribed time the oil should be

removed from the Basti Yantra. Then BastiYantra is to be removed.

Since it is a type of Sweda and Sneha, Samyak Sweda and Samyak Sneha

Lakshanas can consider. Among Samyak Sweda Lakshana Sheetoparama,

Stambhanigraha, Gauravanigraha and Vyadhihani can be considered for assessment. In

case of Samyak Snigdha Lakshanas Snigdha Gatratva and Mrudu Gatratva can take for

assessment. The procedure is performed for 30min each day.

III. Paschat karma- After removing the oil and Basti Yantra, Mrudu Abhyanga is done

over the Janu-Sandhi for about 5 min. Duration - This treatment is done for 7days.

Benefits of Janu-Basti- It relieves the symptoms like Shoola, Stabdhata.The procedure

acts on various properties of Vata that are instrumental in the pathology of Sandhi Vata

mainly due to Snehana and Swedana. Also medicines used in the procedure help in

alleviating Vata.

Drug Review

The trial drug selected for doing Janu-basti is Tila Taila. The pharmacological properties, chemical constituents and pharmacological actions of Tila Taila are summarized below. Table No- 13- Drug review Rasa Madhura

Veerya Ushna

Vipaka Madhura

Guna Guru, Drava, Picchila, Sara, Manda, Sookshma, and Teekshna

Doshakarma Vatakaphahara

Pharmacological

actions

Used in different traumatic conditions, Promotes bodily strength. It

is Sanghatakara, does Snehana.

ABSORPTION THROUGH SKIN

Acarya Sushruta in Shareerasthana explains – Out of the four Tiryak Dhamanis,

each divides gradually hundred and thousand times and thus become innumerable. These

cover the body like network and their openings are attached to Romakoopa. Through

them Veeryas of Abhyanga, Parisheka, Avagaha, Alepa enter into the body after under

going Paka with Bhrajaka Pitta in skin61.

Sushruta in Sutrasthana explains, Lepa like Bahirparimarjana treatments yield result by

entering to Romakoopa thereby circulating through Swedavaha Srotas62.

Vagbhata in Ashtanga Hridaya while explaining the functions of Bhrajaka Pitta

narrated that – Bhrajaka Pitta do the Pachana of drugs used in Abhyanga, Parisheka, and

Lepa63.

Thus with the above references it can be said that drugs used in Bahya

Samshamana Chikitsa (Naturopathy techniques, Janu-basti) get absorbed through and

produce action according to the property of the medicine.

The skin anatomically consists of three distinct layers.

Epidermis- It consists of keratinocytes, melanocytes, langerhan’s cells and merkel cells.

The terminal point of keratinocytes differentiation is the formation of the stratum

corneum. Formation of this layer is the most important function of the epidermis. It

protects the skin against water loss, prevents the absorption noxious agents, and can be

thought of as consisting of bricks and mortar. Corneocytes forms the bricks and barrier

lipids form the mortar. ‘Granular cells’ which are stratum corneum helps in maintaining

skin hydration and their products serve as ultra violet filters. Lamellar granules also are

found within granular cells. These contain probarrier lipids.

Dermis-It is a thick, highly vascular layer made up of ground substance, fibroblasts and

collagen fibers, together with appendages of skin, sweat glands and pilo-sebaceous

follicles. It is metabolically active part of the skin.

Subcutaneous Tissue-It is a fibro fatty layer with varying quantities of adipose tissue in

different regions of the body. It provides physical and thermal protection to the deeper

structures of the body.64

Drug Delivery- The primary barrier to absorption of exogenous substances through the

skin is stratum corneum. Rate of absorption is directly proportional to concentration of

drug in vehicle, partition co-efficient, diffusion co-efficient and thickness of the stratum

corneum. Physiological factors that effect per cutaneous absorption include hydration,

occlusion, age, intact versus disrupted skin, temperature and anatomic site.

Among vehicles greases are anhydrous preparations that are either water insoluble

or fatty. Fatty agents are more occlusive than water-soluble. They restrict trans-epidermal

water loss and hence preserve hydration of the stratum corneum.

Absorption depends upon lipid solubility of the drug since the epidermis as a lipid

barrier. The dermis however is freely permeable to many solutes. Suspending the drug in

an oily vehicle can enhance absorption through the skin. Because hydrated skin is more

permeable than dry skin.

Application of medicaments, heat and massage definitely helps in eliminating the

number of noxious elemtes through skin. The application of heat in different forms of

Swedana promotes local circulation and metabolic activities and also opens the pores of

the skin to permit transfer of medicaments and nutrients towards to needed sites and

elimination of vitiated Doshas and Malas through skin and perspiration.65

Biophysical effect of temperature

Circulatory effect- There is stimulation of superficial capillaries and arteriole causing

local hyperemic and reflex vasodilation. This will affect increased blood flow at the site.

The temperature must be controlled between 104F to 113F. This hyperemia may result

systemic change such as decrease in mean blood pressure, increase in pulmonary minute

ventilation.

Metabolic reaction- Temperature will raise the chemical activity in cell and metabolic

rate will increase. The energy expenditure will increase and protein denaturation will

occur in human tissue.

Vascular effect- There are three factors that cause vasodilation- an axon reflex, release

of chemical mediators, secondary to temp elevation, local spinal cord reflex.

Neuromuscular effect- Heat is Effective to provide analgesic and assist resolution of

pain muscle guarding spasm. Heating of peripheral nerve elevate pain threshold

remarkably reduce muscle spasm.

Connective tissue effect- Temperature elevation in combination with a stretch can alter

visco-elastic properties of connective tissue. The elastic properties of connective tissues

result in plastic elongation.

Effect on the skin – Skin becomes moist and pliable following wax application. This

helps to soften adhesion and scar in the skin prior to mobilization and stretching

procedures.66

METHODOLOGY

Sandhi vata is a major social problem as large percentage of population suffers from this affliction.

This being a degenerative type of disease, its progress is more in geriatric age, posing difficulty in day-

to-day life of the person. This is the age in which all Dhatu begin to degenerate, ultimately leading to

Vata Prakopa. When this Prakupita Vata gets lodged in Sandhi, it gives rise to the disease Sandhi Vata.

Non-pharmacologic management is the foundation of treatment of osteoarthritis. Therefore,

naturopathy gives a hope of treating this condition with different techniques used externally. These

techniques can be correlated to Bahirparimarjan Chikitsa mentioned in Ayurvedic classics. Hence,

study is planned with the following aims to prevent the suffering of the patients.

AIMS



9. To compare the efficacy of Janu Basti-an Ayurvedic Bahirparimarjan Chikitsa and Naturopathy

techniques employed for the treatment of Sandhi Vata.

SELECTION OF PATIENTS

The patients were selected from OPD and IPD of S.D.M.College and Hospital of Ayurveda, Hassan

irrespective of age, sex, religion, occupation, marital status etc. The detail clinical history was taken

and examination was done as per case proforma prepared for this purpose.

Laboratory investigations

1. Hematological – Total count, Differential count, E.S.R., Hb%.

2. Radiograph – X-rays wherever necessary.

Inclusion Criteria

1. Patients complaining of pain, swelling, and restricted mobility of knee joints.

2. Patients between the ages of 40 to 60 yrs.

3. Patients with unilateral or bilateral knee joint involvement were included.

Exclusion Criteria

1. Patients with deformities in knee joints.

2. Patients suffering from other systematic disorders such as obesity (BMI above 30), infective

arthritis, injury to joints etc.

Diagnostic criteria

Diagnosis of patient was established on the basis of signs and symptoms mentioned in classics as

follows.

Symptoms- Shoola (Pain in knee joints)

Kriya alpata (Difficulty in movements of knee joints)

Shotha (edema of knee joints)

Atopa (Crepitus in knee joints)

RESEARCH DESIGN

For a scientific trial, proper design is required so as to assess the efficacy of the therapy, in turn to

achieve the objectives. This study is a comparative study with pre-test and post-test design.

30 patients of Sandhi Vata were randomly divided into the following two groups each group consisting

of 15 patients.

Janu Basti (A) Group

The patients of this group were given Janu-basti with Tila Taila in the morning for 30 minutes.

For this purpose the patient was asked to lie down on the table and then with the help of a paste made

from black gram (Masha) flour by adding little water, a two inches high wall was erected around the

knee joint. Then tolerable hot oil was poured in this artificial cavity and the oil was changed to

maintain the temperature. The process was done once daily continuously for 7 days.

Naturopathy (B) Group

The naturopathy techniques were given externally to the patients of this group.

Morning- Naturopathy technique of derivative massage with Tila taila followed by infrared

therapy was done.

Afternoon- Wax bath with molten wax and flexion and extension exercises with and without

resistance of knee joint was done.

Evening- Mustard pack, Alternative hot and cold knee pack and hot footbath were done. The

temperature of taila and these techniques was of tolerable heat. The total duration of these techniques

was of approximately 60 min.

The patients were allowed to take their routine light diet during the period of the study. No other

medicine was given internally.

ASSESSMENT CRITERIA

Efficacy of therapy was assessed in the reduction of signs and symptoms before and

after the course of study. Following symptoms were mainly considered for assessing the

effect of the therapies.

Symptoms –

Shoola

Kriya alpata

Shotha

Atopa

Variations in the intensity of symptoms were observed.

For assessing functional improvement, following criteria was considered.

1. Flexion movement at the knee joint.

2. Extension movement at knee joint.

3. Circumference of knee joint.

4. Time taken to cover 50-meter distance in walking.

Grading: Following scoring scale was adopted for signs and symptoms assessment.

1. Shoola:

No Shoola - 0

During movement - 1

During rest – 2

2. Kriya Alpata

Normal functioning - 0

Can do mild to moderate work -1

Cannot do any work -3

3. Crepitus

No crepitus - 0

Palpable crepitus - 1

Audible crepitus –2

FOLLOW UP After completion of 7 days course, the patients were asked to report for the follow up study every

15 days for the next one-month period.

Materials

Measuring tape was used for measuring the circumference of Knee Joint, Goniometer for

counting the flexion angle of knee joint and Hand Watch for counting the time taken for covering fifty

meters.

Thumb Kneading

Infrared Therapy

Circular Friction

Mustard Pack

Alternate Hot & Cold Pack

Hot Foot Bath

Wax Pack

Janu-Basti

GENERAL OBSERVATIONS

For any research work, the data should be collected systemically and must be

presented in a way that the reader can understand in a better manner.

30 patients of Sandhi-Vata were included for this clinical study. They were

assigned into two groups’ viz. Janu basti / control Group (A Gp), and Naturopathy

/Experimental Group (B Gp). The age, sex, religion, occupation and other observations

noted in the patients of this study were as follows.

Table -14 Age wise distribution of 30 patients of Sandhi-Vata

Age group

In years

A

n = 15 %

B

n = 15 % Total %

40-45 3 20 0 00 3 10

45-50 1 6.66 4 26.66 5 16.66

50-55 2 13.33 3 20 5 16.66

55-60 9 60 8 53.33 17 56.66

Age: It is observed that 10% patients were of 40-45yrs of age, 16.66% were of 45-50yrs,

16.66% were of 50-55yrs of age and 56.66% were of 55-60yrs of age.

Table - 15 Sex wise Distribution of 30 Patients of Sandhi-Vata

Sex group

A

n = 15

%

B

n = 15

%

Total

%

Male 8 53.33 3 20 11 36.66%

Female 7 46.66 12 80 19 63.33%

Sex: It is observed that 36.66% patients were males and 63.33% were females.

Table-16 Religion wise Distribution of 30 Patients of Sandhi-Vata

Religion

A

n = 15

%

B

n = 15

%

Total

%

Hindu 14 93.33 11 73.33 25 83.33%

Muslim 0 0 2 13.33 2 6.66%

Christian 1 6.66 2 13.33 3 10.00%

Religion: Majority of the subjects in the study were Hindus i.e.83.33% followed by

Muslim -6.66% and Christian -10.00%.

Table – 17 Occupation wise Distribution of 30 Patients of Sandhi-Vata

Occupation A

n = 15

%

B

n= 15

%

Total

%

Business 4 26.66 0 00 4 13.33%

House wife 6 40.00 10 66.66 16 53.33%

Teacher 1 6.66 1 6.66 2 6.66%

Agriculturist 0 0.00 2 13.33 2 6.66%

Office work 2 13.33 1 6.66 3 10.00%

Others 2 13.33 1 6.66 3 10.00%

Occupation: Maximum numbers of patients of this study were housewives (53.33%)

followed by businessmen (13.33%). Also 6.66% of agriculturists, 10.00% of office

workers and other non-specific nature of workers were observed in the study.

0

5

10

15

20

A B Total

Figure- 4- Showing Agewise Distrbution

40-45

45-50

50-55

55-60

0

5

10

15

20

A B Total

Figure-5- Showing Sexwise Distribution

Male

Female

0

5

10

15

20

25

A B Total

Figure-6-Showing Religionwise Distribution

Hindu

Muslim

Christian

0

5

10

15

20

A B Total

Figure-7-Showing Occupationwise Distribution

Buisiness

House wife

Teacher

Agriculturist

Office work

Others

Table -18 Deha Prakriti wise Distributions of 30 Patients of Sandhi Vata

Deha Prakriti

A

n = 15

%

B

n= 15

%

Total

%

Vatakapha 9 60 5 33.33 14 46.66

Vatapitta 2 13.33 8 53.33 10 33.33

Kaphapitta 1 6.66 0 00 1 3.33

Kaphavata 0 00 1 6.66 1 3.33

Pittakapha 2 13.33 0 00 2 6.66

Pittavata 1 6.66 1 6.66 2 6.66

Out of the total 30 patients 46.66% were of Vatakapha prakriti, 33.33% of

Vatapitta and 3.33% of Kaphapitta, 3.33% of Kaphavata, 6.66% of Pittakapha and 6.66%

were of Pittavata.

Table – 19 Sara wise Distribution of 30 of Sandhi Vata

Characteristic

A

n= 15

%

B

n= 15

%

Total

%

Pravara 7 46.66 3 20.00 10 33.33

Madhyama 7 46.66 9 60.00 16 53.33

Avara 1 6.66 3 20.00 14 13.33

Sara: Majority of the patients of this study falls under Madhyama Sara (53.33%). Where

as 33.33% were having Pravara Sara and 13.33% Avara Sara.

Table – 20 Samhanana wise Distribution of 30 Patients of Sandhi Vata

Characteristic

A

n= 15

%

B

n= 15

%

Total

%

Pravara 5 33.33 4 26.66 9 30

Madhyama 9 60 10 66.66 19 63.33

Avara 1 6.66 1 6.66 2 6.66

Samhanana: Majority of the individuals 63.33% were having Madhyama Samhanana

followed by 30% of Pravara Samhanana and 6.66% of Avara Samhanana.

Table – 21 Pramana wise Distribution of 30 Patients of Sandhi Vata

Characteristic

A

n= 15

%

B

n = 15

%

Total

%

Pravara 4 26.66 1 6.66 5 16.66

Madhyama 11 73.33 13 86.66 24 80

Avara 0 00 1 6.66 1 3.33

Pramana: 80% of the patients were having Madhyama Pramana followed by 16.66% of

Pravara Pramana and 3.33% of Avara Pramana.

Table -22 Satmya (Ahara) wise Distribution of 30 Patients of Sandhi Vata

Characteristic

A

n = 15

%

B

n = 15

%

Total

%

Pravara 0 0 0 0 0 0

Madhyama 15 100 15 100 30 100

Avara 0 0 0 0 0 0

Satmya: 100% patients of this study were having Madhyama Satmya.

Table- 23 Satva wise Distribution of 30 Patients of Sandhi Vata

Characteristic

A

n =15

%

B

n=15

%

Total

%

Pravara 5 33.33 5 33.33 10 33.33

Madhyama 10 6.66 7 46.66 17 56.66

Avara 0 0 3 20 3 10

Satva: 56.66% were Madhyama Satva followed by 33.33% having Pravara Satva and

10% with Avara Satva.

Table - 24 Abhyavaharana Shakti wise Distribution of 30 Patients of Sandhi Vata

Characteristic

A

n = 15

%

B

n = 15

%

Total

%

Pravara 3 20 3 20 6 20

Madhyama 12 80 10 66.66 22 73.33

Avara 0 00 2 13.33 2 6.66

Abhyavaharana Shakti- It is observed that 73.33% of patients was Madhyama,

followed by Pravara-20% and Avara- 6.66% Abhyavaharana Shakti.

Table – 25 Jarana Shakti wise Distribution of 30Patients of Sandhi Vata

Characteristic

A

n = 15

%

B

n = 15

%

Total

%

Pravara 3 20 3 20 6 20

Madhyama 12 80 10 66.66 22 73.33

Avara 0 0 2 13.33 2 6.66

Jarana Shakti: The Jarana Shakti of this study shows Madhyama (73.33%) followed by

Pravara (20%) and Avara (6.66%).

Table – 26 Vyayama Shakti wise Distribution of 30 Patients of Sandhi Vata

Characteristic A

n = 15

%

B

n = 15

%

Total

%

Pravara 7 46.66 4 26.66 11 36.66

Madhyama 7 46.66 8 53.33 15 50.00

Avara 1 6.66 3 20.00 4 13.33

Vyayama Shakti: Madhyama Vyayama Shakti was found in 50% followed by Pravara in

36.66% and Avara in 13.33% of patients.

Table – 27 Cardinal signs and symptoms recorded in 30 Patients of Sandhi Vata

Clinical features A

n = 15 %

B

n = 15 %

Total %

Shoola 14 93.33 15 100 96.66

Shotha 7 46.66 14 63.64 70.00

Atopa 11 73.33 14 81.82 83.33

Kriya alpta 15 100 15 100 100

Cardinal Features: All the patients of this study were complaining of Kriya alpta that is

100%, Shoola in 96.66%, Atopa in 83.33% and shotha in 70.00%.

Table – 28 Chronicity wise Distribution of 30 Patients of Sandhi Vata

Chronicity

A

n = 15

%

B

n= 15

%

Total

%

0-3years 9 60 8 53.33 17 56.66

3-6years 3 20 3 20 6 20.00

Above 6years 3 20 4 26.66 7 23.33

Chronicity: 56.66% of the patients of this study had the chronicity between 0-3years,

20.00% for 3-6years, and 23.33% more than 6years.

02468

10

121416

A B

Figure-8-Showing Cardinal Signs and Symptoms

Shoola

Shotha

Atopa

Kriya alpta

0

5

10

15

20

A B Total

Figure-9-Showing Chronicitywise Distribution

0-3years

3-6years

Above 6years

Table – 29 Characteristic of Kulaja Vrittant reported by 30 cases of Sandhi Vata

Kulaja vrittant A

n = 15 %

B

n = 15 % Total %

Present 4 26.66 6 40 10 33.33

Absent 11 73.33 9 60 20 66.66

In this study 33.33% patients had Kulaja Vrittant and in 66.66% patients, it was absent.

Table –30

Showing Distribution of Viharatmka nidana recorded in 30 cases of Sandhi Vata

Character

A

n =15

%

B

n = 15

%

Total

%

BharVahana 8 53.33 10 66.66 18 60.00

SukhaAsana 1 6.66 1 6.66 2 6.66

Ati chankramana 5 33.33 4 26.66 9 30.00

Pradhavana 1 6.66 00 00 1 3.33

In this study Bhar vahana as Viharatmka Nidana is seen in 60%, Ati-chankraman

in 30%, Sukhasana in 6.66% and Pradhavana in 3.33%.

Table – 31Showing Distribution of Aharatmaka nidana in 30 cases of Sandhi Vata

Character

A

n = 15

%

B

n = 15

%

Total

%

Veg 7 46.66 9 60 16 53.33%

Mixed 8 53.33 6 40 14 46.66%

In this study from both groups 53.33% patients were of Veg and 46.66% patients

were taking mixed diet.

EFFECT OF THE THERAPIES

In the present study 30 patients of Sandhi Vata were treated in two groups. In group

A 15 patients were given Janu-Basti with Tila Taila and in group B 15 patients were

subjected to different Naturopathy techniques. The signs and symptoms were

assessed before and after treatment based on the assessment criteria mentioned

earlier. The effects of the therapies are being presented here under separate headings.

Effect of Janu-Basti

15 patients of Sandhi Vata were treated with Janu-Basti for 30 minutes each day for 7

days. Its effects on the clinical signs and symptoms were as follows.

Effect on Symptoms

The effect of Janu-Basti on symptoms of Sandhi Vata is shown in Table – 32.

Mean pain of knee joint was significantly (p<0.01) reduced from 1.4 to 0.93 with the

improvement of 32.85%.

Mean score of Kriya Alpata decreased from 1.2 to 0.73 with the improvement of 39.16 %

and was significant (p >0.001).

Effect on signs

The effect of Janu-Basti on signs of Sandhi Vata is shown in Table – 33. The

mean score of swelling reduced from 17.33 cm. to 16.86 cm. with 2.65% improvement,

which was statistically significant (p>0.02).

Atopa was unchanged and insignificant p-00.

The mean score of Flexion angle of knee was increased from 110.26 to114.66

with the improvement of 5.19% highly significant (p<0.001).

The mean score of Time taken to cover 50m distance was reduced from 80

seconds to 70.33 with the improvement of 12.08% and significant (p>0.01).

Table – 32 Effect of Janu-Basti on Symptoms of Sandhi Vata Patients

Table –33 Effect of Janu-Basti on Clinical Signs of Sandhi Vata Patients

Mean Relief

Symptoms

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shoola 1.4 0.93 0.46 32.85 0.51 0.13

3.5 <0.01

Kriya Alpata 1.2 0.73 0.47 39.16 0.52 0.13 3.50 >0.001

Mean Score

Signs

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shotha 17.33 16.8

6 0.46 2.65 0.74 0.19

2.43 >0.02

Atopa 0.73 0.73 00 00 00 00 00 00

Flexion angle

of knee 110. 26

114. 66

5.73 5.19 3.82 0.98 5.80 <0.001

Time to

cover 50m

distance

80 70.3

3 9.67 12.08

13.29

3.43 2.81 >0.01

Effect of Naturopathy Techniques

15 patients of Sandhi Vata were treated with Naturopathy techniques for 7 days. Its effect

on the clinical signs and symptoms were as follows.

Effect on Symptoms

The effect of Naturopathy techniques on symptoms of Sandhi Vata is shown in

Table – 34.

Mean pain was reduced from 1.53 to 1.00 with the improvement of 34.64% and was

highly significant (p>0.001).

Mean score of Kriya Alpata improved from 1.53 to 0.8 on an average it is improved by

43.13%, which was also highly significant (p<0.001).

Effect on signs

The effect of Naturopathy techniques on signs of Sandhi Vata is shown in Table –

35.

The mean score of Shotha was reduced from 35.46cm to 34.10cm with 1.36%

improvement, which was significant (p<0.01).

The mean score of Atopa was unchanged and insignificant (p-00).

The mean score of Flexion angle of knee was increased from 111.06 to118.53

with the improvement of 8%, which is highly significant (p<0.001).

The mean score of Time taken to cover 50m distance was reduced from 88.66seconds to 73seconds with an improvement of 15.66%, which is highly significant (p<0.001).

Table - 34

Effect of Naturopathy techniques on Symptoms of Sandhi Vata Patients

Table –35

Effect of Naturopathy techniques on Clinical Signs of Sandhi Vata Patients

Overall results of all criteria [Sandhi-Vata] on the bases of reduction/ improvement

[after treatment of 7 days]

Mean Score

Symptoms

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shoola 1.53

1.00 0.53 34.64 0.51 0.13 4 >0.001

Kriya Alpata 1.53

0.8 0.66 43.13 0.48 0.12 5.29 <0.001

Mean Score

Signs

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shotha 35.46 34.1

0 1.36 3.83 0.71 0.18

7.36 <0.001

Atopa 1.13 1.13 00 00 00 00 00 00

Flexion angle

of knee 111. 06

118. 53

8 7.20 4.32 1.11 7.16 <0.001

Time to

cover 50m

distance

88.66 73. 00

15.66 17.66 8.20 2.11 7.39 <0.001

Table No. 36 Total effect on Shoola

Response

Difference

in grade

Group

A

%

Group

B

%

Poor 0 8 53.33 7 46.66

Moderate 1 7 46.66 8 53.33

Good 2 0 0 0 0

The response of Shoola in group A is 46.66% (7) patients shown moderate and

53.33% (8) patients shown poor and for group B it is 53.33% (8) patients shown

moderate and 46.66% (7) shown poor.

Table-37 Total effect on Atopa

Response

Difference

in grade

Group

A

%

Group

B

%

Poor 0 15 100 15 100

Moderate 1 0 00 0 00

Good 2 0 00 0 00

Both group A and B shows poor response in Atopa.

Table-38 Total effect on Kriya Alpata

Response

Difference

in grade

Group

A

%

Group

B

%

Poor 0 8 53.33 5 33.33

Moderate 1 7 46.66 10 66.66

Good 2 0 00 0 00

In Kriya Alpata 46.66% of group A and 66.66% of group B patients shows

moderate response.

Table-39 Total Effect on Shotha

Response

Changes

In cm.

Group

A

%

Group

B

%

Nil 0 10 66.66 1 6.66

Mild 1 3 20 9 60

Moderate 2 2 13.33 4 26.66

Good 3 0 0 1 6.66

In-group B 13 patients show mild to moderate relief. In group A 10 patients

shown no change, 3 had mild change and 2 had moderate change.

Table-40 Total Effect on Time to cover 5om distance

Response

Difference

In second

Group

A

%

Group

B

%

Nil 0 3 20 0 00

Mild 0-20 10 66.66 12 80

Moderate 21-40 1 6.66 3 20

Good >41 1 6.66 0 0

In present study 73.32% of group A and all patients of group B shows mild to

moderate change in time taken to cover 50m distance.

Table-41 Total effect on flexion angle of knee joint

Response

Increase in

angle

Group

A

%

Group

B

%

Nil 0 3 20 1 6.66

Mild 0-5 9 60 6 40

Moderate 6-10 2 13.33 5 33.33

Good 11-15 1 6.66 3 20

In present study 11 patients of group A and 11 of group B shows mild to moderate

improvement in flexion angle of knee joint. 1 patient of group A and 3 of group B show

good improvement in flexion.

Table - 42

Effect of Janu-Basti on Symptoms of Sandhi Vata Patients after 15 days

Table - 43

Effect of Janu-Basti on Clinical Signs of Sandhi Vata Patients after 15 days

Mean Score Symptoms

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shoola 1.4 0.86 0.53 37.85 0.71 0.13 4 >0.001

Kriya alpata 1.2 0.73 0.47 39.16 0.52 0.13 3.50 >0.001

Table-44

Effect of Naturopathy techniques on Symptoms of Sandhi Vata Patients after 15

days

Table- 45

Mean Score Signs

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shotha 17.33 16.80 0.53 3.05 0.74 0.19

2.77 >0.01

Atopa 0.73 0.73 00 00 00 00 00 00

Flexion angle

of knee 111. 26

114.8

5.2 4.72 4.69 1.21 4.29 <0.001

Time to

cover 50m

distance

80 69.33 10.66 13.32 13. 61

3.51 3.03 >0.001

Mean score Symptoms

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shoola 1.53 1.2 0.33 21.56 0.48 0.125

2.64 >0.01

Kriya alpata 1.53 0.73 0.8 52.28 0.56 0.144 5.52 <0.001

Effect of Naturopathy techniques on Clinical Signs of Sandhi Vata Patients after 15

days

Table - 46

Effect of Janu-basti on Symptoms of Sandhi Vata Patients after 30 days

Mean Score

Signs

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shotha 35.46 33. 93

1.53 4.31 0.91 0.23

6.48 <0.001

Atopa 1.13 1.13 00 00 00 00 00 00

Flexion angle

of knee 111. 06

119. 06

8.53 7.68 4.27 1.10 7.73 <0.001

Time to

cover 50m

distance

88.66 72. 00

16.66 18.79 11.1

2 2.87 5.80 <0.001

Mean Score Symptoms

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shoola 1.53 1.00 0.53 34.64 0.51 0.13 4 >0.001

Kriya alpata 1.2 0.73 0.47 39.16 0.52 0.13 3.50 >0.001

Table – 47

Effect of Janu-basti on Signs of Sandhi Vata Patients after 30 days

Table –48

Effect of Naturopathy techniques on Symptoms of Sandhi Vata Patients after

30 days

Mean Score Signs

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shotha 17.33 16.8

0 0.53 3.05 0.74 0.19

2.77 >0.01

Atopa 0.73 0.73 00 00 00 00 00 00

Flexion angle

of knee 111. 26

114. 8

5.2 4.72 4.69 1.21 4.29 <0.001

Time to

cover 50m

distance

80 69.3

3 10.66 13.32

13.61

3.51 3.03 >0.001

Mean Score Symptoms

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shoola 1.53 1.2 0.33 21.56 0.48 0.125

2.64 >0.01

Kriya alpata 1.53 0.73 0.8 52.28 0.56 0.144 5.52 <0.001

Table - 49

Effect of Naturopathy techniques on Signs of Sandhi Vata Patients after 30 days

Mean Score Signs

BT AT

Mean Difference

% of Relief

S.D + -

S.E. + -

t p

Shotha 35.46 33. 93

1.53 4.31 0.91 0.23

6.48 <0.001

Atopa 1.13 1.13 00 00 00 00 00 00

Flexion angle

of knee 111. 06

119. 06

8.53 7.68 4.27 1.10 7.73 <0.001

Time to

cover 50m

distance

88.66 72. 00

16.66 18.79 11. 12

2.87 5.80 <0.001

Methodology

Observation &

Results

Discussion

DISCUSSION

Discussion on literary view of Sandhi vata

Vata is a force, which has got two functions; one is to recognize and other is to

stimulate all the activities in the body. Due to its Cala Guna it moves all over the body.

The movement or Gati of individual component of Vata has to be analyzed properly.

The aggravated Vata finds a suitable place for its lodgment. The suitable place

may be Dhatu, Upadhatu, Ashaya, and Avayava. Due to consumption of Vata Vardhaka

Ahara and Vihara the aggravated Vata while moving throughout the body lodges in

Khavaigunya Yukta Srotas. After getting lodged at those parts it impairs the functions of

particular structure and produces disease.

Sandhi is a place where two or more structure unites. In the context of Asthi

Sandhi means a junction between two bones. Sandhi is not a single structure rather it is

considered as an organ. There are different structures, which helps in maintaining the

stability of the joint. Snayu or ligament helps in proper binding of the joint. They unite

the bones and help to direct the bone movement and prevent the excessive and

undesirable motion. Muscle tone helps to maintain the alignment of the joint. Shleshaka

Kapha or Synovial fluid, which fills up the cavities, occupies the Synovial joint, bursae

and tendon sheaths. It provides the lubricant factors, nutrient to the cartilage, disc, and

helps in keeping the joint firmly united. Shleshmadharakala situated in the joints

supported by Shleshaka Kapha helps in lubrication.

The Samprapti of Sandhi Vata may be divided into Dhatukshaya Janya, Avarana

Janya and Abhighata Janya.

Even the contemporary science explains the pathology in three settings. One is

due to the sub standard biomaterial of the joint (Dhatukshaya). In this due to old age,

Vatakara Ahara Vihara there will be qualitative change in the joint material gradually

leading to disease manifestation.

Avaranajanya is may be due to increased applied pressure over the joint. In it

complication of obesity leads to disease manifestation. This demarcation in Samprapti

helps in planning the treatment. In abhighata the integrity of the joint is disturbed. Due to

abhighata provocation of Vata occurs. Ruksha guna of Vata and Ushanata produced by

abhighata will do the shoshana of shlashmaka kapha in the joint. This vitiated vata will

produce series of changes in the joint after dosha dushya sammurchana and produces

sadhi vata lakshana (Figure-1, 2and 3).

Sandhi Shoola, Sandhi Shotha, Sandhi Stabdhata and Atopa are the clinical

features of Sandhi Vata.

The Chikitsa Sootra of Sandhi Vata is Snehana, Swedana and Agnikarma. Since it

is a Vata Vikara and Dhatukshaya is the resultant, Snehana and Swedana would be an

ideal line of treatment.

Discussion on observation

The observations pertaining to the Incidence study (Nidanatmaka aspects) of 30

patients, registered for the study, discussed here under in the separate headings.

Age incidence: For this study the inclusion criteria of age group was between 40 and

60 years. Majority of the patients belongs to the age group of 55–60 years (56.66 %),

followed by 45-50 and 50-55 years each (21.2%) as shown in Table–14. The prevalence

of Osteoarthritis of knee is more common in age group of 45 – 65 years -30 %, more then

65 years -68 % (Harrison.2001).

Sex incidence: Majority of the patients (63.33%) were females (Table - 15). The

universal data also says prevalence of Osteoarthritis is more in older women.

Above 50 years pradhanya kala starts. As the age increases there will be

natural process of degeneration of Sharira Bala and Dhatu which provokes Vata

and also diminishes Jatharagni. In females menopause contributes the

degenerative changes. Even in males the degenerative process starts from the

age of 50 years onwards.

Incidence of family history: 33.33% of the patients had the family history.

(Table-29)

Viharamtaka incidence: Majority of patients shows (60%) Bhar vahana as

viharatmaka nidana as over weight is one of the contributing factors in the

disease (Table-30).

Dietary incidence: 53.33% of the patients were taking veg diet (Table-31).

Religion incidence: Study records larger number of Hindus (83.33 %) while

compared to other religions. Data reflects more on the geographical

predominance of a particular area (Table – 16).

Occupational incidence: Most of the patients registered in the study were

housewife (53.33%), who was accustomed to moderate work (Table-17).

Incidence of Deha prakruti: Maximum patients (46.66%) of Sandhi

Vata were of vata kaphaja prakruti (Table-18).

The selected individuals were predominantly belonging to Madhyama Sara

(53.33%), Madhyama Samhanana (63.33 %), Madhyama Satva (56.66 %), Madhyama

Pramana (80.00 %), and Madhyama Satmya (100 %) and with Madhyama Vyayama

Shakti (50.00 %) as shown in Table –19, 20, 21, 22, 23, and 26.

Incidence of Aaharasakti: Majority of the patients (73.33%) had Madhyama

abhyavarana sakti and jarana sakti (Table-24and 25).

Incidence of joint involvement: Majority of the patients (70%) had the

involvement of both the joints.

Incidence of Bowel habits: 20% of the patients had the complaint of

constipation and other had normal bowel habits.

Incidence of addiction: Out of 36.66% male patients’ majority were having the habit

of chewing tobacco, smoking and alcohol. These are the contributing factors for disease.

Sleep pattern: Maximum number of patients (60%) had the history of

disturbed sleep. Due since the age group is of Vata predominance this may be

justified.

Incidence of Clinical Features and Chronicity: In the present clinical study patients

were diagnosed on the basis of clinical features of Sandhi Vata. The most common

complaints of the patients of this series were Kriya alpata (100%), joint pain (96.66%),

joint crepitus (83.33 %) and joint swelling (70%).

In group A all the patients had Kriya alpata but Shotha was present only in

46.66%, Shoola in 93.33% and Atopa in 73.33%. In group B all the patients had Kriya

alpata and Shoola but Shotha was present only in 63.64%, Atopa in 81.82%.

It is very interesting to note the relation between manifestation of clinical features

and age, chronicity. In-group A majority patients had chronic history (0-3 years – 60 %),

belong to the age group 55-60 (60 %). In-group B also about 53.33% of the patients had

the chronicity between 0-3years; belong to the age group 55-60 (53.33%). The above

observation reveals that age and chronicity contribute in the manifestation of symptoms

and severity of the diseases (Table – 27 and 28).

Discussion effect of therapies (Results)

The external oleation therapies and heat therapies are extensively

practiced in Sandhi Vata. The present clinical study has been conducted to

evaluate the effect of different naturopathy techniques like derivative massage,

infrared therapy, etc. The effects of therapies are being discussed here on

individual signs and symptoms of Sandhi Vata.

Effect of therapies on Shoola: In patients of group A the pain was reduced significantly

by 32.85%, in group B the improvement was also significant (34.64%). On this basis of

above results can be said that the effect of Naturopathy techniques is slightly better than

Janu basti group in reducing Shoola (Table-32 and 34).

Effect of therapies on Shotha: In patients of group A the joint swelling was significantly

reduced (p<0.05) by 2.65%. In group B the reduction was 3.83% that was also significant

(p<0.01). On this basis it can be said that Naturopathy techniques have better effect than

Janu-basti in reducing swelling (Table – 33 and 35).

Effect of therapy on Atopa: The mean score of Atopa in both group A and B was not

reduced both were insignificant (Table – 33 and 35).

Effect of therapy on Kirya alpata: In patients of group A there was an

improvement of 39.16% which is significant at p>0.001, in group B improvement

was 43.13% is also highly significant at p<0.001. By the above results it can be

said that Naturopathy techniques is having better efficacy in Kriya Alpata (Table -

32 and 34).

Effect of therapy on Flexion angle of knee joint: In patients of group A the mean score

increment is from110.26 to 114.66 with the improvement of 5.19%. In group B also mean

increment in flexibility is there that is from 111.06 to 118.53 with the improvement of

7.20% both were highly significant (Table - 33 and 35).

Effect of therapy on time to cover 50m distance: In patients of group A the mean score

increment is from 80.00 to 70.33 with the improvement of 12.08% it was significant at

P>0.01. In patients of group B the mean increment from 88.66 to 73.00 with the

improvement of 15.66% and highly significant at P<0.001 Thus it can be said that

average improvement and increment in flexibility was better in naturopathy group (Table

– 33 and 35).

Overall Effect of the Therapies: The overall effect on Shoola was moderate in 46.66%

of the patients of Group A, and 53.33% in Group B. On Atopa there was poor response in

both groups. In Kriya alpata 46.66% of patients of group A and 66.66% of group B were

found moderate improvement. On Shotha 33.33% of patients of group A and 86.66% of

group B was found mild to moderate improvement. In time to cover 50m distance

73.32% patients group A and all (100%) patients of group B shows mild to moderate

change. And in flexion angle of knee joint 73.33% patients of each group A and B shows

mild to moderate improvement. None of the patients were completely recovered or

remain unchanged (Table – 36, 37, 38, 39, 40, 41).

Hence from the above statement it may be summarized that both the therapies

recovery provided better overall effect to the patients of Sandhi Vata.

Effect of Naturopathy techniques: Naturopathy techniques provided significant relief in

Shoola (34.64%), Shotha (3.83%), Kriya alpata (43.13%), and flexion angle of knee joint

(7.20%), time taken to cover 50m distance (17.66%) shows in Table – 34 and 35.

Effect of Janu-Basti with tila taila: Janu-Basti with tila taila provided significant relief

in Shoola (32.85%), Shotha (2.65%), Kriya alpata (39.16%), flexion angle of knee joint

(5.19%), Time taken to cover 50m distance (12.08%) shows in Table – 32 and 33.

Probable mode of action of Naturopathy techniques

Naturopathy utilizes change in temperature as therapy.

In derivative massage fulling, friction and deep kneading are most effective.

Kneading a joint is to increase the circulation through it, while the effect of derivative

massage is not to carry the blood through the joint, but rather around it, thus relieving

excessive local congestion or hyperemia, by diverting the blood into other channels.

Friction relieves painful joints by increasing the surface circulation and so diverting the

blood from the joint itself.

Derivative massage restores the normal secretion, improves nutrition of the joint

and may increase vital activity. Tapping helps the muscles to develop its contractile

power. Percussion cause muscles to contract and become stronger.

Infra Red treatment produces heating effect in the superficial epidermis is

vasodilatation. This will lead to more blood supply and nutrient supply in that area

leading to drainage of waste products resulting in the relief of pain and healing of edema

and other skin conditions. The sedative effect on nerve endings lead to reduction in the

muscle spasm and relax the muscle, thus helping in treatment of inflammation.

Wax pack adds to insulating effect. The wax transmits heat energy to the tissue by

giving up energy as it solidifies. The low conductivity quality of wax prevents much heat

loss from the skin surface. It also prevents water loss from skin and skin gets moisture,

this moisture helps to soften adhesions and scar tissue.

Manipulation by exercises with resistance is for treating disuse atrophy. Without

resistance is for improving the range of motion and for lubrication of the joint. It

maintains endurance of muscle. Mustard pack has strong revulsive effect for the relief of

severe pain.

In alternate hot and cold pack reaction takes place as circulatory and

thermal. They strongly influence both the arteries and the veins. By lowering the

pressure in the veins, the arterial circulation through the affected part is

facilitated, thus encouraging the nutrition and functional activity of the cells which

are engaged in combating germs, or which are seeking to repair damages which

may have originated in any way.

The hot pack application diverts the blood into the cutaneous branches of the

collateral arteries, thus preventing undue accumulation of blood and consequent

embarrassment of the affected tissues.

By Hot Foot Bath at first the pulse is slowed and the brain congested, but after

three or four minutes the pulse rate gets increased, and the brain becomes anemic, these

conditions persist for some time after the bath is terminated. The rectal temperature at the

same time fell to the same extent. Arterial tension gets increases by 8 mm. dilate the

vessels of feet, and produces collateral anemia of the pelvic viscera.

Overall all these factors help in break down the pathology occurs in Sandhi vata

and relief from sign and symptoms.

Probable mode of action of Janu-Basti

Janu-Basti procedure is a Bahya Shamana Cikitsa. It is Bahya Swedana and

Snehana (If Sneha is used) therapy. Swedana has the functions of neutralizing Stambha,

Gaurava and Sheetata. In Sandhi Vata joint stiffness is one of the clinical features. Janu-

Basti may have action on this symptom. The Stabdhata of Sandhi is mainly due to Sheeta

property of Vata. Ushna Guna of retained medicine neutralizes this Sheeta Guna.

If Sneha Dravya is used as media in case of Janu-Basti their action further

facilitates in alleviating Vata. Sneha Dravya has Drava, Sara, Snigdha, Picchila, Guru,

Sheeta, Mrudhu and Manda Guna predominantly. The Vata Dosha, which is the key

factor in the casuation of Sandhi Vata, has almost opposite quality to this. Moreover

Sneha Dravya has similar property to that of Kapha Dosha. In Janu-Sandhi Vata Sthanika

Kaphakshaya is due to Agantu Vata Dosha. Thus only one hand Sneha Dravya

neutralizes the Vata Dosha and on the other hand nourishes the Sthanika Kapha Dosha.

This helps in Samprapti Vighatana.

Biophysical effect of temperature

Circulatory effect- There is stimulation of superficial capillaries and arteriole causing

local hyperemic and reflex vasodilation. This will affect increased blood flow at the site.

The temperature must be controlled between 104F to 113F. This hyperemia may result

systemic change such as decrease in mean blood pressure, increase in pulmonary minute

ventilation.

Metabolic reaction- Temperature will raise the chemical activity in cell and metabolic

rate will increase. The energy expenditure will increase and protein denaturation will

occur in human tissue.

Vascular effect- There are three factors that cause vasodilation- an axon reflex, release

of chemical mediators, secondary to temp elevation, local spinal cord reflex.

Neuromuscular effect- Heat is Effective to provide analgesic and assist resolution of

pain muscle guarding spasm. Heating of peripheral nerve elevate pain threshold

remarkably reduce muscle spasm.

Connective tissue effect- Temperature elevation in combination with a stretch can alter

visco-elastic properties of connective tissue. The elastic properties of connective tissues

result in plastic elongation.

Effect on the skin – Skin becomes moist and pliable following wax application. This

helps to soften adhesion and scar in the skin prior to mobilization and stretching

procedures. 6

COMPARISION OF EFFECTS OF THERAPIES

The results of this study showed that the effect of Naturopathy techniques and

Janu-Basti provided significant relief in the signs and symptoms of the disease.

Naturopathy techniques provided better relief than Janu basti in all the signs and

symptoms of Sandhi Vata that is Shoola, Shotha, Kriya Alipata, Flexion angle of knee

joint, and Time taken to cover 50m distance (Table – 32, 33, 34 and 35).

Hence with the above comparison it can be said that Naturopathy techniques

provided better relief than Janu basti with Tila Taila. Though the efficacy is better in

Group B patients, this may be attributed to the more number of treatment modalities

employed in this group like derivative massage, infrared therapy, wax bath, exercises, hot

foot bath, hot and cold pack, and mustard pack where as in group A patients only Janu-

basti was employed with tila taila. The reduction of Shoola, Shotha, Kriya Alpata, and

improvement of flexion at the joint and time to cover 50m distances indicate the efficacy

of Bahya Shaman Chikitsa.

Conclusion

CONCLUSION

The observations pertaining to the literary and clinical study are discussed to

draw the logical conclusions in the second part of the thesis. The conclusions thus drawn

are as follows.

Nidanatmaka aspects of Sandhi Vata: Among 30 patients of Sandhi Vata

registered for the study; majority was belonging to the age group of 55-60 years

(56.66%), female sex (63.33%) and were housewives by occupation (53.33%).

Maximum numbers of patients were of Vatakapha Prakriti (46.66%), Madhyama

Samhanana (63.33%), Madhyama Satva (56.66%), Madhyama Pramana (80%),

Madhyama Satmya (100%), Madhyama Abhyavaharana (73.33%), Madhyama

Jarana Shakti (73.33%), Madhyama Sara (53.33%), and Madhyama Vyayama

Shakti (50%).

As per the clinical presentation all the patients were having Kriya Alpata,

amongst the other main symptoms, Sandhishoola was present in 96.66%,

Sandhishotha was present in 70% and Atopa was in 83.33% of patients.

Chronicity was 0-3 years in 56.66% of patients.

Effect of Janu-Basti with Tila Taila: Janu-Basti with Tila taila provided

significant relief in Shoola (32.85%) in 46.66% of patients, Shotha (2.65%) in

43.33% of patients, Kriya alpata (39.16%) in 46.66% of patients, Flexion angle of

knee joint (5.19%) in 73.33% of patients, Time taken to cover 50m distance

(12.08%) in 73.32% of patients.

Effect of Naturopathy techniques: Naturopathy techniques provided significant

relief in Shoola (34.64%) in 53.33% of patients, Shotha (3.83%) in 86.66% of

patients, Kriya alpata (43.13%) in 66.66% of patients, Flexion angle of knee joint

(7.20%) in 73.33% of patients, Time taken to cover 50m distances (17.66%) in

100% of patients.

Comparison of the effects of therapies: Naturopathy techniques provided better

relief in Shoola, Shotha, Kriya Alpata, Flexion angle of knee joint, Time taken to

cover 50m distances than Janu-Basti with Tila Taila.

Recommendation for further study

Present study pattern can be contributed in the form of prospective clinical study

with increased sample size. Further it is recommended to study the effect of individual

naturopathy techniques separately.

Summary

SUMMARY

The dissertation entitled “A study on the efficacy of Ayurveda and

Naturopathy in Sandhi Vata” comprises of chapters on Disease review,

Naturopathy techniques and Janu-basti review, Methodology, Discussion,

Summary and Conclusion. The study is divided into 2 parts.

Part 1: Literary view of Sandhi Vata.

Disease Review:

Disease Sandhi Vata and Osteoarthritis are elaborately discussed in

this chapter. Definition, risk factors, pathology, investigations, symptoms

and treatment of Osteoarthritis are included.

From the etymology of Sandhi Vata it is understood that Vata is the

sole responsible Dosha involved in this disease.

Sandhi Vata Nidana though is not separately mentioned, the Nidana

responsible for Vatavyadhi can be considered here and broadly classified into

Aharaja and Viharaja; most of the Nidana are Vatakara and are directly

responsible for the functional derangement of Vata.

Purvarupa in Vatavyadhi is said to be in Avyaktavastha. Rupa

according to different authors has been explained. Samprapti is dealt in

detail.

Anatomy of Sandhi, Chikitsa, Sadhyasadhyata, and Vyavachedaka

Nidana is reviewed according to different authors.

Chikitsa is mainly of 2 types Shodhana and Samana. Chikitsa as

followed for Vatayadhi is explained. Here all patients were given Bahya

Shamana Chikitsa.

Literary views of therapies

It is collection of literary views of Naturopathy techniques and Janu-

basti. It deals with the information available regarding the naturopathy

techniques and Janu basti in different texts. Method, mode of action,

indication, contraindication, advantages and the studies conducted earlier

have been included.

Part 2: Methodology

Clinical study describes the aims and the objectives, criteria of selection of

patients, details of inclusion and exclusion criteria, diagnostic criteria,

assessment criteria for assessing the effects of the therapies, the investigations

conducted, and treatment.

After registration, patients were randomly distributed into two Groups as Group A and Group B.

Group A: Janu basti with Tila Taila was givenexternally for 7 days.

Group B: Naturopathy techniques were given externally for 7 days.

After completion of 7 days course, the patients were asked to report for the follow up

study every 15 days for the next one-month period.

Observations

Various observations regarding incidence study like patient’s age, sex,

etc, clinical findings like Aharasakti, Vyayama, Pramana, etc. incidence of

clinical features of Sandhi Vata are tabulated and shown.

Results

Results of the clinical trial were assessed on the basis of grading given for

assessment criteria. Observations were subjected to standard statistical

analysis, the data of which have been presented in the chapter.

Discussion

Here the discussion of Disease review, the probable mode of action of

the therapies, interpretations of the results of the clinical trial has been

included along with the results of the experimental study conducted.

Both observations and results related to the study are discussed with

derivation of possible inferences.

Bibliographic References

Bibliographic References

List of References

1. Ca. Sa. Ci. 28/37 2. Su. Sa. Ni 1/28 3. Su.Sa. Ci. 4/8 4. A. Sa. Ni 15/17 5. A. Sa. Ci. 23/13 6. A. Hr. Ni 15/14 7. A. Hr. Ci. 21/22 8. Ma. Ni. Pu. 22/21 9. Bh.Pr. Ut. Mad. Kh. 24/258-259 10. Yo.Ra Vatavyadhi Ni/25,119 11. Bh.Ra. 26/14 12. Su.Sa. Sh. 5/26. 13. Su. Sa.Sh. 5/32. 14. A.Hr. Ni 12/18. 15. Su. Sa.Sh. 4/14, 15. 16. Su.Sa. Ni 1/13. 17. A.Hr. Su. 11/26-28. 18. Su.Sa. Sh. 5/34-42. 19. Su.Sa. Sh. 5/46. 20. Su. Sa. Sh. 5/28. 21. Ca.Sa. Ci. 28/15-18. 22. Ca. Sa.Vi. 5/17-18. 23. Su.Sa. Sh. 6/7, 12, 13. 24. Ca.Sa. Ci. 28/19 25. Ca.Sa. Ci. 28/37 26. Ca.Sa. Ci. 28/18. 27. A. Hr. Ni 15/5, 6. 28. Su.Sa. Su.15/37. 29. Su.Sa. Su.15/32 30. Su. Sa.Ni 9/12 31. Ca.Sa. Ci. 28/73, 74. 32. Ca. Sa.Ci. 28/73, 74. 33. Su.Sa. Ci. 31/2 34. Su. Sa.Ci. 24/30. 35. Ca.Sa. Su. 22/11. 36. A. Hr. Su.17/18,19 37. Ca.Sa Su. 14/35.

38. Su.Sa. Ci. 32/12. 39. Ca.Sa. Su. 14/37. 40. A.Hr. Su. 17/5.

41. Ca. Sa.Ci. 28/115. 42. A. Sa. Ci. 23/13 43. A Complete Handbook of Nature cure, page-205. 44. The Art of Massage by J. H. Kellogg, page 148-151. 45. A Complete Handbook of Nature cure, page-205. 46. Goel’s Physiotherapy Chap-11/555-557. 47. Goel’s Physiotherapy Chap-14/576-579. 48. Goel’s Physiotherapy Chap-11/142,143. 49. Goel’s Physiotherapy Chap-6/92. 50. Goel’s Physiotherapy Chap-12/154. 51. Goel’s Physiotherapy Chap-6/87. 52. Rational Hydrotherapy, Page 814,956. 53. Rational Hydrotherapy Part-I page-161,188. 54. Rational Hydrotherapy Part-III page-751. 55. Rational Hydrotherapy Part-III page-840-842. 56. Rational Hydrotherapy, part-III, /756-758. 57. Ca. Sa. Su. 11/55. 58. A. Hr. Su.19/1. 59. Su. Sa. Su.5/3. 60. Ca. Sa. Vi. 8/94-96. 61. Su. Sa.Sh.9/9. 62. Su.Sa.Su.18/4. 63. A. Hr. Su. 12/14. 64. Physiology by Robert M. Berne. 65. Essentials of Pharmacology by K. D. Tripathi Cha.2/13. 66. Goel’s Physiotherapy Chap-14/579.

Printed Publications

1. A Complete Handbook of Nature cure of H. K. Bakharu, Jaico Publishing House, 121, M.G. Road, Mumbai.

2. Bhaisajyaratnavali Vidyotini Hindi commentary By Kaviraja Ambikadatta Shastri Chaukhamba sanskrut sansthan, Varanasi 2001.

3. Bhavamisra- Bhavaprakasa (ed) Vidyotini Hindi commentary By Bhisagaratna Pandit Sri. Brahma Sankara Misra Chaukhamba Sanskrit Sansthan Varanasi, 2003.

4. Charaka- Charaka Samhita of Chakrapanidatta (ed) By Vaidya Jadavji Trikmaji Acharya Chowkhamba Sanskrit Sansthan, Varanasi 2001.

5. Charaka- Charaka Samhita,with Charaka Chandrika Hindi commentary by Dr. Brahmanand Tripathi, (ed) chaukhamba surbharti prakashan, Varanasi 2004.

6. Goel’s Physiotherapy by Dr. R. N. Goel, Shubham publication, F-2 sanchi complex, Shivaji Nagar, Bhopal, Vol-I, 2004

7. Madhava Nidanam- Sri Madhavakara Madhukosa Sanskrit commentary by Vijayaraksita and Srikanthaadatta (ed) Vimala Madhuhara Hindi commentary by Dr. Brahmanand Tripathi, Vol-I, Chaukhamba Surbharati Prakashan, Varanasi 2003.

8. Rational Hydrotherapy by Dr. John Harvey Kellogg, Part I, II, III, IV. 9. Sushruta-Sushruta Samhita with Nibandha Sangraha commentary by Dalhana

(ed) Vaidya Jadavji Trikmaji Acarya Chowkhamba Krishnadas Academy, Varanasi, 2004.

10. Sushuruta- Sushruta samhita with Ayurveda Tavtta sandipika Hindi commentary by Kaviraja Ambikadatta Shastri Chaukhamba sanskrut sansthan, Varanasi 2004.

11. Sushruta- Sushruta samhita with Nibandha Sangrha commentary of Sri. Dalhanacharya and Nayachandrika Panjika of Sri. Gayadasacharya (ed) Vaidya Jadavji Trikmaji Acarya Chowkhamba Krishnadas Academy, Varanasi, 2004.

12. The Art of Massage by J. H. Kellogg, Teach services Inc, New York, 254, Donovan Road, Brushton, 1998.

13. Vagabhat- Ashtang Hrdayam with Nirmala Hindi commentary by Dr. Brahmanand Tripathi, (ed) Chaukhamba Sanskrit Prakashan, Delhi 2003.

14. Vagbhata- Ashtang Sangrah with Hindi commentary by Kaviraj Atrideva Gupta Krishnadas Academy, Varanasi 1993.

15. Vagabhat- Ashtang Hrdayam with Ayurveda Rasayana commentary by Hemadri and Sarvangasundara commentary by Arundatta(ed) Pandit Bhisagacharay Harishastri Prabhakar Vaidya,Krishnadas Academy Varanasi 2000.

16. Yogaratnakara with Vaidyaprabha Hindi commentary By Dr. Indradev Tripathi and Dr. Daya Shankar Tripathi, Krishnadas Academy Varanasi, 1998.

Annexure

Case proforma

S.D.M. College of Ayurveda and Hospital, Hassan Dept. of P.G. studies in Swasthavritha

A study on the efficacy of Ayurveda & Naturopathy in Sandhi-Vata Name: Sl. No. Date: Age: OPD / IPD No: Group- A/B Sex: DOA / DOD: Religion: Wt.- Postal Address: Occupation: Main Complaints: Shoola Shotha Kriya-alpata Atopa in Rt, Lt Knee Joint Duration: 0-3yrs, 3-6yrs, above 6yrs Anubandha vedana: Kula vrittant:

Atura Charya- 1. Ahara:

a. Quality- Alpa Pramita Atipramana (veg/mixed) b. Dominant rasa- M A L K T K

c. Guna – Ruksha Snigdha Ushna Sheeta Guru Laghu

d. Dietetic habit – Matrashana, Vishamanasana, Adhyasana, Anasana

e. Addiction-

2. Vihara- Bhar vahan , Sukha asana, Atichankramana, Pradhavana General Examination: 1. Pulse: /min 2. R/R: 3. Blood pressure: /mm of Hg

4. Mala: 5. Mutra: 6. Jihwa: 7. Nidra: Dasha Vidha Pareeksha 1. Prakrititah : 2. Vaya : 3. Vikrititah : P M A 4. Samhanana: P M A 5. Satva : P M A 6. Pramana : P M A 7. Satmya : P M A 8. Aharashakti : Abhyavarana P M A Jarana P M A 9. Sara: P M A 10. Vyayama Shakti : P M A Investigations:

1. Hematological a. Hb% b. E.S.R. c. D.C.: N ____%, L ____%, B____%, E____%, M_____% d. T.C.

2. X-Ray (if done)

Assessment criteria- Complaints B. T. A. T. / / / /

Shoola-- Shotha-- (circumference) Kriya alpta-- Atopa-- Flexion movement at knee joint--

Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt

Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt

Time taken to cover 50mt.distance--

Documents

Sandhi sw05 has