E-ISSN:2456-3110

Research Article

Rheumatoid Arthritis

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 5 June
Publisherwww.maharshicharaka.in

A clinical study to effect of Dhanyamla Parisheka in Rheumatoid Arthritis

Sharma M A.1*, Rao N.2, Shetty S.3
DOI: http://dx.doi.org/10.21760/jaims.7.5.4

1* Athreya Sharma M, Post Graduate Scholar, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.

2 Niranjan Rao, Professor and HOD, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.

3 Sandesh Kumar Shetty, Associate Professor, Department of PG Studies in Swasthavritta, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.

Background: Bahirparimarjana Chikitsa is one of two modes of treatment explained in Ayurvedic medical science. Doshas move from internal Koshta to Shaakha during disease pathology or Roga Samprapti. Swedana is considered one such treatment protocol to bring Doshas from Shaakha to Koshta. Parisheka is a method of Swedana by pouring medicated water or oil over the body. Dhanyamla Parisheka is a Rooksha inducing Parisheka Sweda. Amavata is a disease with predominant Kapha and Vata Dosha. Its Vyaktha Sthana is predominantly Sandhi with severe pain and swelling. Treatment of Amavata includes Rooksha Swedana. Symptoms of rheumatoid arthritis largely correlate with the symptoms present in Amavata. Global prevalence rates of Rheumatoid Arthritis with genetic associations in India is 0.1-0.4%. Methods: In this study, 50 patients diagnosed with Rheumatoid arthritis were selected and subjected for Dhanyamla Parisheka. This study involves estimation of Rheumatoid factor, C-reactive protein and Anti streptolysin O titre levels before treatment and after follow-up period and evaluation of pain, swelling, tenderness and range of movement of joints involved in the subjects before and after Dhanyamla Parisheka for 7 days. The results are suggestive of effect of the Dhanyamla Parisheka. Results: There was statistically significant reduction in Rheumatoid arthritis score in the subjects. Interpretation: Dhanyamla Parisheka is an effective Bahirparimarjana Chikithsa in subjects with rheumatoid arthritis.

Keywords: Parisheka Swedana, Dhanyamla Parisheka, Amavata, Rheumatoid Arthritis

Corresponding Author How to Cite this Article To Browse
Athreya Sharma M, Post Graduate Scholar, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.
Email: 		Athreya Sharma M, Niranjan Rao, Sandesh Kumar Shetty, A clinical study to effect of Dhanyamla Parisheka in Rheumatoid Arthritis. J Ayu Int Med Sci. 2022;7(5):20-28.
Available From
https://jaims.in/jaims/article/view/1831

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-05-02 2022-05-04 2022-05-11 2022-05-18 2022-05-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2022by Athreya Sharma M, Niranjan Rao, Sandesh Kumar Shettyand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Generally Swedana therapy[1] cannot be directly considered as a Panchakarma procedure.

It comes under the Poorvakarmas of Panchakarma procedures.[2]

These Poorvakarmas play important role in achieving Upasthitha Dosha Avastha[3] and as Lakshanika Chikithsa.[4]

In diseases such as Amavata[5] the severity of the symptoms draws a patient towards modern medicine for relief in symptoms to achieve basic daily activities. Rooksha Sweda[6] is one of the foremost Bahirparimarjana Chikithsa[7] in Amavata.

With similar aim to develop better compliability and preparation for further Panchakarma procedures Dhanyamla Parisheka,[8] a type of Rooksha Parisheka Sweda is chosen in cases diagnosed of rheumatoid arthritis by haematological examinations[9] and diagnostic criteria[10] for rheumatoid arthritis.

The study was done on patients of rheumatoid arthritis with the aim to evaluate the effect of Dhanyamla Parisheka in rheumatoid arthritis under the consideration of correlation to Amavata.

Materials and Methods

Source of the data

In the study, 50 patients diagnosed as Rheumatoid arthritis were taken from IPD/OPD of Shri Dharmasthala Manjunatheswara Ayurveda Hospital, Udupi.

Method of collection of the data

Screening

Subjects screened at outpatient department of Panchakarma in Shri Dharmasthala Manjunatheshwara Ayurveda Hospital, Udupi.

Diagnostic criteria

1987 ACR Revised criteria

  • Morning stiffness in and around joints for at least 1 hour.
  • Soft tissue joint swelling observed by physician at least 3 joint groups (R or L: MCP, PIP, wrist, elbow, knee, ankle, MTP).
  • Arthritis of hand joints (MCP, PIP or wrist).
  • Symmetrical swelling of one joint area in (2) above.
  • Rheumatoid nodule.
  • Positive Serum Rheumatoid factor.
  • Radiograph changes on wrist/hands: erosions or juxta-articular osteoporosis.
  • For classification purposes, a patient shall be said to have rheumatoid arthritis if he/she has satisfied at least four of these seven criteria. Criteria 1 through 4 must have been present for at least 6 weeks. Patients with two clinical diagnoses are not excluded. Radiograph is not taken if first four criteria’s are present.

Inclusion criteria

  • Diagnosed cases of Rheumatoid arthritis
  • Patients aged between 18-70 years.
  • Patients consenting to undergo the procedure for a period of 7 days.

Exclusion criteria 

  • Patients with systemic illness.
  • All connective tissue disorders other than Rheumatoid arthritis.
  • Patients not consenting for In Patient admission and follow-up consultation.

Ethical clearance and CTRI registration

  • Ethics clearance certificate was obtained from institutional ethics committee.
  • Trial was registered and completed in www.ctri.gov.in under CTRI no. CTRI/2021/04/042426

Sample size

  • 50 patients diagnosed of Rheumatoid Arthritis were selected.
  • A detailed proforma prepared considering the points pertaining to signs, symptoms and examinations as for Rheumatoid arthritis to confirm the diagnosis.

Study design

This is an open label clinical study with pre-test and post-test design where in 50 patients diagnosed of Rheumatoid Arthritis of either gender was selected based on diagnostic and inclusion criteria.



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Sharma A et al: To effect of Dhanyamla Parisheka in Rheumatoid Arthritis

Interventions

Poorva Karma

  • Erythrocyte sedimentation rate, Rheumatoid factor, C-reactive proteins and Anti Streptolysin – O titre will be checked prior to treatment as per requirement.
  • Patient made to lie down in supine position on the Dhroni.
  • Gauze tied around the head in order to cover the eyes.
  • Ears should be plugged with gauze.
  • Patient is explained the procedure and instructed duration of procedure and not to sleep during the procedure.

Pradhana Karma

  • Warm Dhanyamla is poured with Khindi by two masseurs on either side of the Dhroni.
  • Temperature of Dhanyamla should be around 42°C.
  • Parisheka should be at a medium pace and from a height of 6-12 cm for a duration of 30 minutes.
  • Fresh Dhanyamla used everyday from the Dhanyamla instrument at Shri Dharmasthala Manjunatheshwara Ayurvedic Hospital, Panchakarma Department, Udupi.
  • Swedana: Dhanyamla Parisheka was done for 7 days. Swedana was assessed based on Samyak Swinna Lakshanas such as Sweda Pradhurbhava, Sheetha Vyuparama, Shoola Vyuparama, Sthamba Nigraha, Gaurava Nigraha, Mardavata of Twacha.

Paschat Karma

  • Rub the Dhanyamla on body with soft cloth after treatment.
  • Cover body with clothes soon after.
  • Parameters: Pain, Swelling, Stiffness, Tenderness and range of movement of multiple joints recorded after treatment period.
  • Erythrocyte sedimentation rate, Rheumatoid factor, C-reactive proteins and Anti Streptolysin – O titre will be checked after follow-up treatment.



Results

Symptomatic variables were observed before and after treatment

Table 1: Mean before treatment and after treatment of symptomatic variables.

SN Symptomatic variables Before treatment (Mean) After treatment (Mean) Reduction Percentage
1. Pain 6.2 2.1 66.12%
2. Swelling 0.82 0.2 77.5%
3. Tenderness 0.8 0.3 62.5%
4. Morning stiffness 3.2 0.86 73.125%

The mean and reduction percentage shows gross reduction in the symptomatic variables considered, which are also practically major hurdle in ayurvedic management of rheumatoid arthritis. Pain variable mean difference between mean before treatment and after treatment showed 66.12% reduction. Swelling variable mean difference before and after treatment showed 77.5% reduction. Tenderness in multiple joints variable mean difference before and after treatment showed 62.5% reduction. Morning stiffness in multiple joints variable mean difference before and after treatment showed 73.125% reduction in symptoms.

Table 2: Statistical analysis of symptom parameters in subjects.

Parameter Negative ranks Positive Ranks Tie Z value P value Interpretation
N MR SR N MR SR
Pain BT-AT _________ 49 25 1225 1 -6.165 0.000 Highly significant
Swelling BT - AT _________ 28 14.5 406 22 -5.209 0.000 Highly significant
Tenderness BT - AT _________ 22 11.5 253 28 -4.690 0.000 Highly significant
Morning stiffness BT - AT _________ 47 24 1128 3 -6.009 0.000 Highly significant

1. Pain: The results for the parameter of pain shows highly significant interpretation (p<0.00) with wilcoxon signed rank test – Z value (-6.165). Dhanyamla Parisheka Swedana showed significant reduction in pain in multiple joints of the body.

2. Swelling: The results for the parameter of swelling shows highly significant interpretation (p<0.00) with wilcoxon signed rank test – Z value (-5.209). Dhanyamla Parisheka Swedana showed significant reduction in swelling in multiple joints of the body.


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3. Tenderness: The results for the parameter of tenderness shows highly significant interpretation (p<0.00) with wilcoxon signed rank test – Z value (-4.690). Dhanyamla Parisheka Swedana showed significant reduction in tenderness in multiple joints of the body.

4. Morning stiffness: The results for the parameter of swelling shows highly significant interpretation (p<0.00) with wilcoxon signed rank test – Z value (-6.009). Dhanyamla Parisheka Swedana showed significant reduction in Morning stiffness in multiple joints of the body.

Haematological variables were observed before treatment and after follow-up

Table 6: Mean before treatment and after follow-up of haematological variables

SN Haematological variables Before treatment (mean) After treatment (mean) Reduction percentage
1. RA Factor 76.4960 31.364 58.99%
2. ESR 70.84 52.40 26.03%
3. CRP 28.88 6.932 75.99%
4. ASO Titre 155.65 105.36 32.30%

The mean of haematological values before and after follow-up of treatment showed gross reduction of values. The rheumatoid arthritis factor values reduction between before treatment and after follow-up is 58.99%. The Erythrocyte sedimentation rate values reduction between before and after follow-up is 26.03%. The C Reactive protein values reduction between before and after follow-up is 75.99%. The Anti Streptolysin O titre values reduction between before and after follow-up is 32.30%.

1. RA factor

The results for the haematological parameter of RA factor shows highly significant interpretation (p<0.00) with Paired t test – t value (6.909). Dhanyamla Parisheka Swedana showed significant reduction in RA factor.

2. Erythrocyte sedimentation rate

The results for the haematological parameter of Erythrocyte sedimentation rate shows highly significant interpretation (p<0.00) with Paired t test – t value (4.551). Dhanyamla Parisheka Swedana showed significant reduction in Erythrocyte sedimentation rate.

3. C-Reactive proteins: The results for the haematological parameter of C reactive protiens shows highly significant interpretation (p<0.00) with Paired t test – t value (5.052). Dhanyamla Parisheka Swedana showed significant reduction in C reactive protiens.

4. Anti streptolysin – O titre: The results for the haematological parameter of Anti streptolysin-o titre shows significant interpretation (p<0.05) with Paired t test – t value (6.909). Dhanyamla Parisheka Swedana showed significant reduction in Anti streptolysin-o titre.

Rheumatoid scoring based on 1987 ACR criteria: RA score above or equal to 6 is considered definite Rheumatoid arthritis subject. The mean shows gross reduction from definite RA 8.6 to non RA 4.8 by the end of course of treatment and follow up.

Table 12: Statistical analysis of RA score before treatment and after follow up.

Parameter Negative ranks Positive Ranks Tie Z value P value Interpretation
N MR SR N MR SR
RA Score BT - AFU _________ 44 22.50 990 6 -5.841 0.000 Highly significant

The results for the parameter of RA score shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-5.841). Dhanyamla Parisheka Swedana showed highly significant reduction in RA score.

Table 7: Statistical analysis of Haematological values before treatment and after follow-up.

Parameters Mean N SD SEM Mean difference % T P value Interpretation
RA factor before treatment 76.496 50 58.19 8.22 45.132 58.99% 6.909 0.000 Highly significant
RA factor after treatment 31.364 50 34.93 4.94
ESR factor before treatment 70.84 50 35.40 5.00 18.44 26.03% 4.551 0.000 Highly significant
ESR factor after treatment 52.40 50 29.53 4.17
CRP before treatment 28.88 50 36.060 5.099 21.95 75.99% 5.052 0.000 Highly significant
CRP after treatment 6.93 50 12.444 1.759
ASO titre before treatment 155.65 50 268.07 37.91 50.29 32.30% 2.072 0.044 Significant
ASO titre after treatment 105.36 50 217.17 30.71

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Table 13: Statistical analysis of range of movement.

Parameter Negative ranks Positive Ranks Tie Z value P value Interpretation
N MR SR N MR SR
Range of movement – Lumbar spine _________ 16 8.5 136 34 -4.000 0.000 Highly significant
Range of movement – Cervical spine __________ 10 5.5 55 40 -3.162 0.000 Highly significant  
Range of movement- Shoulder joint __________ 30 15.50 465 20 -5.477 0.000 Highly significant  
Range of movement- Hip joint __________ 16 8.5 136 34 -4.000 0.000 Highly significant
Range of movement- Knee joint 1 10.5 10.5 19 10.50 199.5 30 -4.025 0.000 Highly significant
Range of movement– Elbow joint ____________ 28 14.50 406 22 -5.292 0.000 Highly significant
Range of movement– Ankle joint ____________ 26 13.50 351 24 -3.162 0.00 Highly significant
Range of movement– Wrist joint ____________ 29 15 435 21 -5.385 0.00 Highly significant
Range of movement– Metacarpo phalangeal joints ____________ 27 14 378 23 -5.196 0.00 Highly significant
Range of movement– Metatarso phalangeal joints ___________ 8 4.5 36 42 -2.828 0.005 Significant

Range of movement: Range of movement reduction of more than 50% of normal range of movement considered abnormal in the study. The following joints assessed at before treatment and after course of treatment with the help of goniometer. Following are the joints with their respective normal range of movement (flexion):

1. Lumbar spine (60°)

2. Cervical spine (90°)

3. Hip joint (125°)

4. Shoulder joint (180°)

5. Knee joint (135°)

6. Ankle joint (15°)

7. Elbow joint (130°)

8. Wrist joint (70°)

9. Metacarpophalangeal joints (90°)

10. Metatarsophalangeal joints (70°)

1. Lumbar spine: The results for the parameter of Range of movement of Lumbar spine (low back) shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test - z value (-4.000). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of lumbar spine.

2. Cervical spine: The results for the parameter of Range of movement of cervical spine (neck) shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-3.162). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of cervical spine (neck).

3. Shoulder joint: The results for the parameter of Range of movement of shoulder joint shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-5.477). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of Shoulder joint.

4. Hip joint: The results for the parameter of Range of movement of Hip joint shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-4.000). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of Hip joint.

5. Knee joint: The results for the parameter of Range of movement of Knee joint shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-4.025). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of Knee joint.

6. Elbow joint: The results for the parameter of Range of movement of elbow joint shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-5.292). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of Elbow joint.

7. Ankle joint: The results for the parameter of Range of movement of Ankle joint shows highly


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significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-3.162). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of Ankle joint.

8. Wrist joint: The results for the parameter of Range of movement of wrist joint shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-5.385). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of wrist joint.

9. Metacarpophalangeal joints: The results for the parameter of Range of movement of Metacarpophalangeal joints (first digit) shows highly significant interpretation (p<0.00) with Wilcoxon signed rank test – z value (-5.196). Dhanyamla Parisheka Swedana showed highly significant improvement in range of movement of Meta carpophalangeal joints.

10. Metatarsophalangeal joints: The results for the parameter of Range of movement of Meta tarsophalangeal joints shows highly significant interpretation (p<0.05) with Wilcoxon signed rank test – z value (-2.828). Dhanyamla Parisheka Swedana showed significant improvement in range of movement of Meta tarsophalangeal joints.

Discussion

The assessment of Dhanyamla Parisheka Swedana is based on Samyak Swinna Lakshanas,[11] its effect in rheumatoid arthritis is evaluated by the parameters of pain, stiffness, swelling, tenderness and range of movement in multiple joints and haematological parameters such as Erythrocyte sedimentation rate, Rheumatoid arthritis factor, C reactive proteins and Anti Streptolysin – O titre.

Rheumatoid arthritis is a chronic inflammatory[12] disease with probable autoimmune origin, presents with symptoms such as morning stiffness, pain, swelling, tenderness and reduced range of movement in multiple joints. These symptoms mostly correlate with symptoms of Amavata. Swedana is of two types Rooksha and Snigdha types.[13] In case of Amavata, Rooksha Sweda is the choice of Swedana.[14]

Parisheka Sweda comes under Drava Sweda according to Sushruta Samhitha where its told to be useful in Pittotkrushta Avastha thus considered useful in inflammatory condition,

Dhanyamla is the drug used for Parisheka Sweda which by nature is Ushna Rooksha thus causing Vata Kaphahara[15] action and also effective Amahara. In whole the Swedana action of bringing Dosha back from Shaakha to Koshta. This may be the reason for evident reduction in symptoms of pain, swelling, morning stiffness, tenderness and improved range of movement in multiple joints.

Though we find significant reduction in haematological values, we cannot attribute it singly to Dhanyamla Parisheka Swedana treatment.

Conclusion

Amavata is a Vyadhi where Kapha and Vata are predominantly involved. In Amavata mainly Kapha Sthana like Sandhi is affected. Rooksha Swedana is considered as the prime Bahirparimarjana Chikitsa for Amavata. Dhanyamla Parisheka is one such Rooksha Swedana procedure.

The present study aimed to evaluate effect of Dhanyamla Parisheka in Rheumatoid arthritis, which was performed keeping in mind most patients struggle to perform daily activities due to the disorder. Patients require symptomatic relief for better compliability in taking treatments and performing daily activities that the Panchakarma procedure of Dhanyamla Parisheka for 7 days suffices as per the relief in symptomatic variables. This can have significant improvement on regular follow-up and prompt treatment in a chronic disorder. The symptomatic parameters show improvement subjectively and statistically as well without causing any adverse effects.

Further scope of research can be towards multicentre study of the same with greater sample size.

Reference

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10. Fauci S. Anthony, Braaunwald Eugene, Ksaper L.Dennis, Hauser L. Stephen, Longo L. Dan, Jameson Larry J., Loscalzo Joseph et.all. Editors, Harrison’s Principles of Internal Medicine, 17th Edi. New York: Mc Graw Hill; Vol 2, pp – 2754, pg no – 2083.

11. Fauci S. Anthony, Braaunwald Eugene, Ksaper L.Dennis, Hauser L. Stephen, Longo L. Dan, Jameson Larry J., Loscalzo Joseph et.al. Editors, Harrison’s Principles of Internal Medicine, 17th Edi. New York: Mc Graw Hill; Vol 2, pp – 2754, pg no – 2083.

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13. Fauci S. Anthony, Braaunwald Eugene, Ksaper L.Dennis, Hauser L. Stephen, Longo L. Dan, Jameson Larry J., Loscalzo Joseph et.all. Editors, Harrison’s Principles of Internal Medicine, 17th Edi. New York: Mc Graw Hill; Vol 2, pp – 2754, pg no – 2083.

14. Agnivesha. Charaka Samhita with commentary By Chakrapanidatta. Trikamji Yadavji Acharya (ed.). Varanasi: Chowkhamba Surabharati Prakashan; Reprint 2014. Pp738, Page no.92

15. Vagbhata, Astanga hrudaya, with commentary from Sarvangasundara of Arunadatta and Ayurvedarasayana of Hemadri,edited by Hari Sadasiva Sastri Paradakara, edition 2010, Varanasi:Chaukhamba Sanskrit Samsthana, Pp 956,page no 82 and 299.

16. Vagbhata, Astanga hrudaya, with commentary from Sarvangasundara of Arunadatta and Ayurvedarasayana of Hemadri, edited by Hari Sadasiva Sastri Paradakara, edition 2010, Varanasi: Chaukhamba Sanskrit Samsthana, Pp 956,page no 82 and 299


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