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PPT created by Dr R.L.D.S Ranasinghe, Post Graduate Scholar, University Of Colombo, Sri Lanka.
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2014.09.16
1
OUTLINEOUTLINE
q Objectivesq Case presentation
o Complaints of the patiento Clinical Examinationo D/ Do Diagnosiso Review of Ayurveda
q Review of Modern
2
OBJECTIVESOBJECTIVES
¨ To understand the patho-physiology, signs and symptoms & treatments of Sandhigataväta
¨ To review on related Modern Aspects
¨ To improve diagnosis skills
¨ To improve the presentation skills
3
CASE SUMMARYCASE SUMMARY
4
¨ Mr K. M Silva, 52 Yrs from Kuliyapitiya
¨ having difficulties to move Joints notably RT KJ, Both Elbow Js, LT Hip & joints of both Hands due to oedema, Pain & Deformities
¨ for 20 yrs¨ has not taken regular
treatment before¨ admitted to ward no 9 on
11th July 2014
CASE PRESENTATIONCASE PRESENTATION
q Name : Mr K. M Silva
q Age : 52 Yrsq Address : Udubeddawa, Kuliyapitiyaq Nationality : Sri Lankanq Religion : Buddhistq Marital Status : Marriedq Date of Admission : 11th July 2014 (Ward 09)
q Ward No : 11q Bed No : 22q Occupation : Mechanic for 16 yrs, Concrete
worker for 5 yrs
5
MAIN COMPLAINT & DURATIONMAIN COMPLAINT & DURATION
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1. Difficulty in movements due to Pain, Oedema & Stiffness of Right Knee Joint, Both elbow joints & both hands (PIP, DIP)- 20 yrs
2. Deviation of RT KJ- 3 yrs
3. Pain in Left Hip Joint- 1 month
No other compliansOTHER COMPLAINTS & DURATIONOTHER COMPLAINTS & DURATION
o According to the patient, before 20 yrs; asymptomatico Then he got oedema in both Ankle joints o After 1yr, oedema over little finger of the RT hand (PIP&
DIP) & RT wrist joint o 1 yr later Oedema occurred in both Knee Jointso Deviation of the RT Knee joint has noticed before 3 yearso Before 1 month pain arouse in LT Hip joint
o Pain -during movements only. No resting pain. Not associate with food, climate or time.
o Stiffness in joints lasting not > 15 min
7
q Medical History
Hypertension 0 , Diabetes Mellitus 0 , Hypercholesteremia 0
q Surgical History
q Psychiatric History
q Treatment History • Pain killers only
• Admitted for Ayurvedic treatment for the first time on 11th
July 2014 to ward No 09 & then shifted to ward No 11
NA
8
80 yrs
52 yrs
IHD
70 yrs
20 yrs 12 yrs
9
o Diet: Break fast - Not taken usually
Lunch - Not taken usuallyDinner - Rice, Vegetables, Egg
Meat (Chicken, Beef, Mutton)-Twice a week More like to get Spicy & Fried food
Not taken on time. S/T taken from outsideWater intake: Sufficient
o Appetite: Not changed due to the diseaseo No allergies for any kind of food
20- 30 yrs
10
o Addiction : Plain tea with sugar 10-15 times/ d
Alcohol 1/ 2 bottle occasionally
Cigarette 2-3/ d
Beatle chewing 3- 4 times/ d
o Sleep : 11 pm to 5 am (Disturbed due to Nocturia)
o Bath : Evening with cold water, Daily
35 yrs
11
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o Bowel habits : Once/ DayColour - YellowOdour - Normal
o Micturition : D- 3 / N -1 timesColour - PaleOdour - Normal
o Social status : Living near to the river side
o Occupational history: Mechanic – Long term standing, Night shift
Concrete worker – Heavy lifting
o General condition - Weak o BP - 130 /80 mmHg o PR - 74 / mino RR - 14 / mino Weight - 38 kgo Height - 5 Fto Tongue - Not coated (Niräma) o Temperature - Normalo Skin - Normal
GENERAL PHYSICAL EXAMINATION
o Pallor - Mild
o Thyroid
o Icterus
o Cyanosiso Clubbingo Enlarged LN
NADNAD
13
LOCO MOTOR SYSTEM
q Gati (Range of movements):• LT & RT knee joints - Abduction
- Adduction- Elevation
• LT & RT Elbow joints- Flexion- Extension - Rotation
• Hip (LT) -Elevation-Rotation
• Interphalangeal joints (RT)– Extension is limited
q Gait: Painful & Difficult (Pain while waliking in LT HIPJ & RT KJ)
Limited due to edema , pain & deformity
Limited due to edema & pain
SYSTEMIC EXAMINATION
14
Limited due to edema , pain & deformity
o Inspection§ Swelling
PIP, DIP, both Elbow Js, RT Ankle, Both KJs (> in RT KJ) & LT Hip
§ Deformities Deviation & Enlargement of RT KJ, Nodes on Hands (PIP, DIP)
§ Muscle wasting
o Palpation§ Swelling –Pitting (Disappear with the removal of finger)§ Crepitus (Both KJ)§ Stiffness of the joints (RT KJ, LT Hip, PIP, DIP) (< 15 min) § Tenderness - NAD§ Inflammation- NAD
JOINTS
15
16
qThorasic Spine: Internal and external rotation- Normal
qLumbar Spine: painful (At the time of admission)
§ Flexion-Normal.
§ Extension-Normal.
§ Lateral Bending-Normal.
q Cervical Spine:
§ Rotation- Normal
§ Flexion, Extension and Lateral bending- Normal
Spine17
SYSTEMIC EXAMINATION CONT
q CARDIOVASULAR SYSTEM
• S1, S2 - Clear . No thrills or murmurs
q RESPIRATORY SYSTEM
• Bilateral equal air entry • No added sounds
q GIT
P/A • No tenderness• No organomegaly
q CNS
• Higher functions• Motor functions• Sensory system• Cranial nerves• Reflexes
18
NAD clinicaly
1. Nädi: i. Gati - 74/ min ii. Yati - Samäntaraiii. Akåti - Pürnaiv. Samhati - Mådu
2. Mutra : D - 3/ N -1 times3. Mala : Once/Day, Samhata mala4. Jihvä : Niräma5. Çabda : Prakåta Håd & Pupphuça çabda6. Sparça : Sandhi sphuöana7. Dåk : Prakåta8. Akåti : Deviation & enlargement of RT Knee Joint, enlargement
of both Elbow joints Nodules in PIPJ & DIPJ
19
I. Prakåti : Väta Kapha / Rajas TamasII. Vikåti
o Hetu (Nidäna) – Viprakåñöa Nidäna
Ähara : Viñamäçana, Anäçana, Alpäçana, Katu,
Kañäya Rasa, Tékñëa, Snigdha, Guru guëa Atisewana
Viharaëa : Çéta jala sewana, Ati çrama, Rätré jägaraëa
o Doña - Väta, Kaphao Düñya - Rasa, Rakta, Mämsa, Medas, Asthi, Majjäo Prakåti - Väta, Kaphao Deça - Asthi Sandhio Käla - Cira kälao Bala - Roga bala: Kåccha sädhya
Ätura bala: Madhyamao Lakñana - Prasäraëäkuaïcana vedanä, Sandhi çotha & Vikåtio
20
21III. Sära : Rasa, Rakta, Mämsa, Medas, Asthi & Majjä
Madhya Sära
IV. Samhanana : Madhya Samhata
V. Pramäna : Madhya pramäëa
VI. Sattva : Madhya Sattva
VII. Sätmaya : Ñad Rasa Sätmaya
VIII. Ähära Çakti: Before After• Abyavaraëa Çakti : Madhya Madhya• Jaraëa Çakti : Madhya Madhya
IX. Vyäyäma Çakti : Before AfterPrawara Madhya
X. Vayah : Madhyama (52 Yrs)
1. Präëa vahä Srotas2. Udaka vahä Srotas3. Çukra vahä Srotas4. Mutra vahä Srotas5. Puriña vahä Srotas6. Sweda vahä Srotas7. Mano vahä Srotas
8. Rasa vahä Srotas : Vikåti9. Rakta vahä Srotas : Vikåti10. Mämsa vahä Srotas : Vikåti (Mäàsa çoña)11. Medo vahä Srotas : Vikåti (Kñudra Sandhi Çula+ )12. Asthi vahä Srotas : Vikåti13. Majjä vahä Srotas : Vikåti14. Anna vahä Srotas : Vikåti15. Väta vahä Srotas : Vikåti (Gati Daurbalya)
Prakåti
22
(Sandhi Çula+, Çota + , Sandhi sphutana)
(Päëdu (Anaemic))
ÄharaViñamäçana, AnäçanaAlpäçana, Katu, KañäyaRasa,Tékñëa, Snigdha, Guru guëa Atisewana
ViharanaÇéta jala sewana, Ati çrama
Mänasika
23
Asthi vahä SrotasVäta vahä SrotasMajjä vahä SrotasMedo vahä Srotas
Circulation throughthe Srotas
Dhätu kñaya Väta Kopa
Rakta vahä Srotas
Anna vahä Srotas
Rasa vahä Srotas
Çleñaka kaphaAsthi dhätu kñaya
Khavaiguëya in Sandhi
• Sandhi çotha• Prasäraëäkuìacana
vedanä• Vätapurëa drutisparça
Vyakti
PrasaraSaïcaya
Prakopa
Sthäna Saàçraya in Sandhi
Sandhi VikåtiBheda
q Doña : Väta Vitiated, Kapha Dicreasedq Düñya : Rasa, Rakta, Mämsa, Medas, Asthi, Majjäq Adiñtäna : Çärérikaq Srotas :
q Samutthäna : Pakväçayaq Agni : Viñamaq Äma : Nirämaq Srotoduñöi : Saìgaq Udbhawa sthäna : Asthi Sandhiq Roga märga : Madhyama (Marma, Asthi, Sandhi)q Sädhya Asädhyatä : Kåccha sädhya
Rasa Vahä Srotas , Rakta Vahä Srotas
Mämsa Vahä Srotas, Medo Vahä Srotas
Asthi Vahä Srotas, Majja Vahä Srotas
Anna Vahä Srotas, Väta Vahä Srotas
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q FBS - 99 mg/dl (2014.07.23)
q UFR Reaction - AcidicPus cellsEpithelial cells
q Lipid profile- 149 mg/ dL (Total cholesterol)
q ALP- 271 IU/L
q ESR - 5 mm/ 1st hr , 12mm/ 2 nd hr
q RF - Negative
q Plain X Ray in KJ- Osteophytes+
Occasional
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1. Ämaväta Sandhi Çotha
2. Gambhira Väta Rakta
3. Asthi Majjä Gata Väta
4. Kroñöuka Çérña
5. Sandhi gata Väta
Ma. Ni. 25/ 6¨ Body ache¨ Anorexia¨ Thirst ¨ Malaise¨ A feeling of heaviness¨ Fever¨ Indigestion ¨ Swelling of the body parts (Pitting type of Oedema)
27
28
Ca Ci 29/ 21-23
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¨ Swelling¨ Rigidity¨ Hardness¨ Agonizing pain inside the joints¨ Dusky red / coppery coloration¨ Burning¨ Pricking & throbbing pain¨ Tendency to suppuration¨ Deformities of the joints
30
q Väta & Rakta getting affected together produces;
q A very painful swelling of the knee joint resembling the head of the big fox
Su Ni 1/ 76
Ma. Ni 22/ 58
31
Ca Ci 28/ 32
q Splitting pain in the bone & joints
q Loss of strength of the musle
q Loss of sleep
q Constant pain of the body
Ca Ci 28/ 37
Su Ni 1/ 27-2, Yo .Ra V.V/ 1
As Hri Ni 15/14
Ma. Ni 22/ 21
32
RÜPARÜPA --
Ca.Sa Su. Sa As Hri As Sa Ma.Ni Yo Ra Bha Pr
Sandhi Çüla (Joint pain)
+ + + + + + +
Sandhi çopha/çotha(Joint Swelling)
+ + + + + +
Vätapurëadrutisparça
+ + +
Hanti Sandhi (loss of function)
+ + +
Prasäraëäkuìacanavedanä (Pain on movement)
+ + +
Ätopa (cracking sound )
+
33
ÄMAVÄTA SANDHI GATA VÄTA
GAMBHIRA VÄTA RAKTA
Nidäna Viruddha Ähara, Snigda Ähara, Alpachesta etc.
Väta kopakaraÄhara, Viharaëa
Väta & Raktakopakara Ähara, Viharaëa
Doña Kapha, Väta Väta Predominant Väta, Pitta
Düñya Rasa, Rakta, Asthi Asthi, Majja Rasa, Rakta, Asthi, Majja
Sthäna Start from small joints of hands & spread
Mainly start with weight bearing large joints
Start from the end parts of the hands & feet
34
35
ASTHI MAJJÄ GATA VÄTA
SANDHI GATA VÄTA
Nidäna Väta kopakara Ähara, Viharaëa
Väta kopakara Ähara, Viharaëa
Doña Väta Predominant Väta Predominant, Kapha
Düñya Asthi, Majja Asthi, Majja
Nidrä Alpa NA
Sandhi Çüla Satatä Ruk Prasäraëäkuìacanavedanä
DIAGNOSIS
¨ Sandhi Gata väta
36
CIKITSÄ
37
k…yaRÖate ivc][>
Su Ci 4 /8
As Hri Ci21/ 22
C.D 22/ 9
CIKITSÄ CONT.
Treatment Su. Ci As Hri As Sa Bha Pr Bha Ra Yo Ra C.D
Snehana + + + + + +
Abhyanga +
Mardana + + + + +
Svedana + + +
Upanaha + + + + + + +
Bandhana + + + +
Agnikarma + + + + +
38
A_y¼ < Svedn< biStnRSy< õehivrecnm! iõGxaMllv[< SvaÊ v&:ym! vatamyaphm!.
CIKITSÄ CONT-VÄTA VYÄDHI CIKITSÄ
39
o Abhyaìgao Svedanao Vastio Nasyao Sneha yukta virecanao Snigdhao Amlao Lavaëao Svädu
Yo Ra V. V Ci/ 1
Rasa
CIKITSÄ CONT.
¨ Bahih parimärjana- Sneha (Abhyanga)- Sweda
¨ Anthah parimärjana- Mådu çodhana
¨ Paìcha karma-Virechana (Sneha yukta)- Vasti- Nasya
40
From 11.07.2014 to 12.08.2014
¨ Räsna 7 Decoction, Pata ½ bd
¨ Triphaläkwatha 30 ml bd¨ Chandraprabhä vati 2 bd
¨ Yogaräja Guggulu 2 bd¨ Daçänga Lepa
From 18.07.2014 to 25.08.2014
¨ Denibadi Decoction, Pata ½ bd¨ Avipattikara cürna 30 grns bd¨ Sudarshana cürna 30 grns bd¨ Vätaroga kalka 30 grns bd
¨ Tala satakuppa paste
41
42
From 25.08.2014 - 01.09.2014¨ Räsna 7 Decoction, Pata ½ bd
¨ Gändarva hästadi Decoction, Pata ½ bd¨ Räsna 7 Decoction, Pata ½ bd
¨ Virecana (2014. 08. 06 )(Hingu triguna Taila 2 Aunz)¨ Dhärä karma (2014. 08. 11- 25) ¨ Pinda Sweda (2014. 08. 25- 15 )
Ø Upaçaya- Joint oedema, Pain reduced
From 01.09.2014 to 16.09.2014
¨ Eranda saptaka Decoction+ Rasona, Methi, Abhaya Pata ½ bd
¨ Daça mula Balairaëda Decoction, Pata ½ bd¨ Dantimulädi Decoction, Pata ½ bd¨ Daçamul Nikamul Decoction, Pata ½ bd¨ Yogaräja Guggulu 2 bd with Bavila, sudulunu water ¨ Hinguwashtaka churna 30 grns, with hot water¨ Punarnava Mandura¨ Närayaëa Taila abhyanga
¨ Mashabaladi Decoction, Pata ½ bd¨ Mashatmagupta Decoction, Pata ½ bd¨ Väta gajendrsinha rasa, 2 bd, with hot water¨ Ashwagandätaila, abhyanga¨ Kshéra Balä taila
43
44
¨ Nika kola pottali Pinda sweda (pottali)¨ Punnagädi pottali¨ Picu Däraëa¨ Jänu Vasti
q Anuvasana Vasti- Eraëda, Balä Koraëda, Hingu triguëa Taila
q Ranahansa Rasäyanaq Açwagandhä Rasäyana
Pathya Ähära
¨ Steamed red rice
¨ Patola
¨ Murunga
¨ Kohila
¨ Wetakolu
¨ Fish
Pathya Viharaëa
¨ Uñëa jala Sevana(snäna)
¨ Vyäyäma
Apathya Ähära
¨ Foods which are Vätavardhaka
¨ Madya
Apathya Viharaëa
¨ Rätree jägaraëa¨ Divä nidrä¨ Krodha , Çoka¨ Séta sparça (Bathing cold
water)
45
46
• Ca. Ci 28/37
• Su. Ni 1/27
• As. Hri .Ni 15/14
• As.Sa Ni 15/ 16
• Bha.Pr. Ma. Kha 24/ 258
• Ma. Ni 22/ 21
• Yo. Ra Va. Vy/1
• Not mentioned
• Su. Ci 4/8
• As. Hri .Ci 21/22
• As.Sa Ci 23/ 13
• Bha.Pr. Ma. Kha 24/ 259
• Bha. Ra Vol 2, 26/ 14
• Yo. Ra Va. Vy. Ci / 1
• Ca. Da
Disease Cikitsa47
48
¨ Nidäna¨ Pürwa rüpa¨ Sampräpti¨ Sädhya Asädhya Bhäva
¨ Rüpa¨ Cikitsä
Not mentioned Separately
Only mentioned
NIDANANIDANA
49
Ca. C 28/15-18
NIDNIDÄÄNANA
ÄhäraDue to rough, cold, little & light food
Viharaëa¨ Excessive movement such as leaping,jumping Wayfaring & physical
exercise
¨ Excessive emaciation due to illness
¨ Uncomfortable bed & seat
¨ Day sleep
¨ Suppression of urges
¨ Fasting
¨ Injury in vital parts injury
¨ Falling down from elephants, horses & other fast vehicles
50
NIDANANIDANA CONT.CONT.
Mänasika
¨ Anger
¨ Anxiety
¨ Grief
Faulty therapeutic management
¨ Excessive elimination of impurity & blood
¨ Wasting of dhatus
51
SAMPRSAMPRÄPTI
Aggravated vayu Filling up vacant channels of the body
Make disorders in
Entire body One part of the body
52
Ca Ci 28/ 37
53
OSTEOARTHRITISOSTEOARTHRITIS
Introduction
¨ Osteoarthritis (OA) is a disease of synovial joints that can result from cartilage degeneration
¨ Most common form of arthritis
¨ Prevalence increases with the age
( Ref: Clinical medicine, Kumar & Clark)
54
Joints- most commonly involved 55
o Hand - DIP Joint- First CMC Joint
o Foot - First MTP joint
o Weight bearing joints- Vertebra- Hip- Knee
Classification of Osteoarthritis
2 types1. Primary osteoarthritis2. Secondary osteoarthritis
Primary osteoarthritisq Osteoarthritis not resulting from injury or
diseaseq Cause is unknown
56
Types of Osteoarthritis Cont.
2. Secondary osteoarthritis Form of osteoarthritis that is caused by another disease or condition.
q Obesityq Repeated trauma or surgery to the joint structures q Abnormal joints at birth (congenital abnormalities)
Goutq Diabetes and q Other hormone disorders
57
Risk Factors
58
¨ Age - > 45 yrs¨ Gender- > female¨ Obesity¨ A fracture through a joint¨ Congenital joint dysplasia¨ Pre existing joint damage¨ Occupation- farmers & labourers OA- >Hip¨ Repetitive use¨ Injury associate with some sports
Clinical features
q Joint pain- made worse by exercise, relieved by rest
q Stiffness after rest- last in <30 min
q Swelling or tenderness in one or more joints
q Deformity & enlargement of the joints
q Limited joint movement
q Wasting of surrounding muscle group
q Crepitus - Crunching feeling or sound of bone rubbing on
bone when the joint is used
59
Nodal osteoarthritis
Bony enlargement of
o Distal interphalangeal joint- Heberden's nodes
o Proximal interphalangeal joint- Bouchard's nodes
60
Pathophysiology
¨ Inital event : mitosis of chondrocyte
¨ Second event: Increased synthesis of bone by osteoblasts in the subchondral bone
¨ Third event: metaplasia of the peripheral synovial cells resulting in formation of osteochondrophytes
¨ Fourth event: formation of bony cysts
61
Pathophysiology Cont
¨ OA affects all of the weight-bearing components of the joint:
• Articular cartilage• Menisci• Bone
62
Pathophysiology Cont
Osteoarthritis may result from wear and tear on the joint
•The normal cartilage lining is gradually worn away and the underlying bone is exposed.
63
Pathophysiology Cont
•The repair mechanisms of tissue absorption and synthesis get out of balance and result in osteophyte formation (bone spurs) and bone cysts
64
D/DCriteria OA RA Gout
1.Symptoms Pain & swelling on major weight bearing joints, stiffness, crepitations, tenderness, enlargement of joint space.
Inflammation in multiple joints, morning stiffness>30 mins
Polyarticular pain, swelling and inflammation,tenderness
2.Mode Of onset Gradual Gradual Acute
3.Joints involved Weight bearing joints Poly articular Metatarsophalangeal joints
4.Systemic features
NA Auto immune diseases, rise in temperature,anemia
NA
5.Pathologicalphenomenon
Degeneration Auto immune and vasculitis
Hyper uricaemia
6.Investigation RA- ve, ESR-normal,X-Ray-narrowing of joint space
ESR-raised,X-ray-soft tissue swelling
Serum uric acid raised,
65
Diagnosis
Based on,
Ø Signs and symptoms
Ø Laboaratory studies:
• ESR - Normal
• Full Blood count - Normal
• Rh Factor - Negative
• Synovial fluid - Viscous
Ø X-ray and Radiographic findings
66
Radiographic Diagnosis
•Narrowing of the joint space
•Periarticularsclerosis
•Osteophytes
•Sub-chrondralbone cysts
67
• Asymmetrical joint space narrowing from loss of articularcartilage
• The medial (inside) part of the knee is most commonly affected by osteoarthritis.
Radiographic Diagnosis cont
68
Long-Term Complications
¨ Does not affect the body's organs
¨ Lead to deformities
¨ Severe loss of cartilage in the knee joints can cause the knees to curve out, creating a bow-legged appearance
¨ Bony spurs along the spine can irritate nerves, leading to pain, numbness, or tingling in some parts of the body
69
70
Bow-legged appearance
Bony spurs
71
q OA is a condition which progresses slowly over a period of many years and cannot be cured
q Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition
q Functional treatment goals:ü Control Painü Improve Joint Functionü Increase muscle strengthü Maintain Normal Weight
Disease Management
72
OA – Non-operative Treatments
•Pain medications•Physical therapy•Walking aids•Shock absorption•Re-alignment through orthotics•Limit strain to affected areas
73
74