A case report on the management of Amavata by Agni Chikitsa Lepa with Manjishtadi Kshara Basti

Rakshitha Kumari; Niranjan Rao; C Padmakiran

A case report on the management of Amavata by Agni Chikitsa Lepa with Manjishtadi Kshara Basti

Kumari R.^1*, Rao N.², Padmakiran C.³

DOI:

^1* Rakshitha Kumari, RMO, Shree Dharmasthala Manjunatheswara College of Ayurveda, Udupi, Karnataka, India.

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

³ C Padmakiran, Associate Professor, Department of PG Studies in Panchakarma, Shree Dharmasthala Manjunatheswara College of Ayurveda, Udupi, Karnataka, India.

Treatment of the disease with the collective involvement of Agni, multiple Dhatu and Dosha are challenge to the clinical practitioner. One such disease with increasing prevalence is Amavata. The involvement of Agni, Ama, all the Dosha and multiple Dhatu makes it difficult to manage. The Sama stage of the disease with the involvement of Vata and Kapha is to be managed with Deepana, Pachana, Ruksha, Ushna, Teekshna line of management. As there is involvement of Vata and Kapha, Basti Chikitsa formulated on the basis of Teekshna, Kaphaghna Basti are the ideal treatment. With this concept in backdrop, a male patient diagnosed as Amavata with raised RA factor was treated with Agnichikitsa Lepa externally and Manjistadi Kshara Basti in Kala Basti course for 7 days. Clinically patient showed significant reduction in symptoms of Amavata, RA factor, ESR, Uric acid after 7 days of course. Hence, combined Rukshana, Deepana, Pachana with Vata, Kapha Shamana will help in managing the Amavata.

Keywords: Amavata, Ayurveda, Agnichikitsa Lepa, Manjistadi Kshara Basti, Kaphagna Basti, Rukshana.

Corresponding Author	How to Cite this Article	To Browse
Rakshitha Kumari, RMO, , Shree Dharmasthala Manjunatheswara College of Ayurveda, Udupi, Karnataka, India. Email:	Rakshitha Kumari, Niranjan Rao, C Padmakiran, A case report on the management of Amavata by Agni Chikitsa Lepa with Manjishtadi Kshara Basti. J Ayu Int Med Sci. 2022;7(5):159-165. Available From https://jaims.in/jaims/article/view/1896

Introduction

Rheumatoid arthritis is a chronic, progressive autoimmune disease characterized by bilateral symmetrical involvement of joints with some systemic clinical features.^[1] The prevalence rate of this disease is about 3% with male to female ratio of 1:3. Rheumatoid factors are proteins produced by immune system that can attack healthy tissue in the body. High levels of Rheumatoid factor (RF) in the blood are most often associated with autoimmune diseases such as Rheumatoid arthritis and Sjogrens syndrome. The presence of RF does not necessary indicate the presence of RA. If RF is negative then suggest sero negative arthritis. The ESR measures the degree of inflammation in the joints.

Clinical features of Amavata resembles with symptoms of Rheumatoid arthritis.^[2] Amavata is mainly produced due to Ama and vitiation of Vata Dosha. The Ama is carried by the aggravated Vata and deposited in Shleshma Sthana like Sandhi producing features like Angamardha, Aruchi, Alasya, Sandhiruk, Sandhishotha.^[3] When the Gambheera Dhatu are involved, the disease will present with a painful crippling state in the patient.

These symptoms hamper the quality of life of the patient affecting physical, psychological, economic and social life of the patient. Hence, early management in the form of normalizing Agni and Vata becomes the prime line of treatment in Amavata.

The management of Amavata includes Langhana, Swedana and use of drugs having Tikta, Katu Rasa with Deepana property.^[4] This line helps in the management of associated Ama. The Agni Mandya and Sama stage are contraindicated for any other treatment. Hence, removing the Ama in Koshta and Shakha and enhancing/normalizing Jataragni are of prime importance in the management of Amavata. As the Ama is Jataragni is circulated all over the body including deeper Dhatu is by the aggravated Vata Dosha, controlling Vata Dosha is also the prime line of management. Hence, a combination of treatment, which act on Agni, removing the Ama Dosha, controlling the Vata and Kapha Dosha, helps in formation of normal foremost Rasa Dhatu are of treatment of choice in initial stages of Amavata.^[5]

The Agni Chikitsa Lepa is an important Deepana,

Pachana, Rukshana Chikitsa practiced since decades in the management of Saama diseases. As the name suggests, its main site of action is Jataragni with action on Rasa Dhatu. The 10 drugs used in the preparation is having Ruksha, Ushna, Teekshna property by virtue of which it will cause Agni Deepana, Ama Pachana.^[6] Once the Agni is normal, the Ama is removed in Koshta. The foremost Rasa Dhatu will be formed normally leading to the nourishment of all other Dhatus. Hence, the basic Samprapti is reversed in Amavata if managed early.

As there is involvement of Kapha Dosha with Vata, Basti is to be selected as a line of management. The Basti formulated should have Ushna, Teekshna, Kapha Vatahara property. Hence Kshara Basti is formulated based on the concept of Kaphaghna Basti.^[7] Manjista effect on Tridosha - It is Madhura, Kashaya and Tiktarasa. Ruksha and Guru Guna. Ushna Virya and Katu Vipaka.^[8] The bioactive ingredients in this red root makes it a Kapha-Pitta Shamaka Dravya i.e., actively balances the Pitta Dosha and Kapha and Vata Dosha. As there is involvement of Rakta Dosha, the Teekshna Basti may cause Rakta Dooshana. The Manjista which is having the Rakta Prasadana effect will take care of the Rakta Dosha. With this idea in back drop, a case was selected and treated with Agni Chikitsa Lepa externally with Manjistadi Kshara Basti in a course of Kala Basti. The details of the case treated are;

Case Report

A male patient of aged about 57 years working as farmer presented with complaints of multiple joint pain since 3 years associated with swelling over the joints and morning stiffness.

Detailed history: A male patient of aged about 57 years k/c/o HTN apparently healthy 3 years back. Joint pain initially started in the proximal interphlangeal joints bilaterally in the upper limb, after a week he noticed stiffness in the fingers. Later pain started in the B/L elbow joints in the period of 5 month. Gradually pain started in wrist, shoulder, knee and ankle joints bilaterally. Severity of the pain started increasing and associating with swelling, redness. Nature of pain is throbbing type. Pain aggravating in morning hours after getting up from the bed, after intake of sweet food, curd, fruits like banana and stiffness in the joints at least for 30 mins. Pain used to relive to some extent after exercise. There was reduced appetite,

excessive salivation, loss of taste, heaviness, no interest in routine work. No h/o of fever.

Treatment history: There was a history of occasional joint pain since 2018 and most of the time it was mild in nature and rarely required any anti-inflamatory and analgesics. A single dose of non-steroidal anti inflamatory drug was sufficient for pain relief. In the beginning pain got reduced due to analgesic medication and later again there was severe aggravation of pain. For further management he approached our hospital.

Details of the examination are given in Table no. 1 and Table no. 2.

Table 1: Examination

Nadi	84/min
Mutra	Prakruta
Mala	Amayukta
Jihva	Upalepatwam
Shabdha	Prakruta
Sparsha	Ruksha
Druk	Prakruta
Aakruti	Prakruta
Prakriti	Vata-Pitta
Sara, Satva, Saatmya, Samhanana, Pramana	Madhyama
Aharashakti, Vyayamashakti	Alpa
Vaya	Madhyama

Table 2: General examination

Appetite	Reduced
Bowel	Once in 2 days hard stools associated with bloating in the abdomen.
Micturation	Regular
Sleep	Disturbed due to pain
Systemic examination
RS	NVBS heard
CVS	S1S2 heard, no murmur
CNS	HMF intact

Musculo skeletal system examination - on 26/8/2020

Inspection

Difficulty in extension of phalanges of both upper limbs
Difficulty in flexion of arms
Swelling in the Interphalangeal joints

Palpation

Tenderness in between shoulder, wrist, knee and ankle joints,

Raise in temperature

Hematological report - 26/8/2020

Hb - 14.9gm%
ESR - 30mm/hr
Uric acid - 7.2mg/dl
RA factor - 62.0 IU/ml positive
CRP - negative
S.O - negative

Based on above history, clinical examination, investigations, patient was diagnosed as Amavata with Saama stage. Hence, planned for Agnichikitsa Lepa externally and Manjistadi Ksara Basti in Kala Basti course for 7 days.

Treatment

Agni Chikitsa is a therapy practiced since decades in the hospital. Basically, it was practiced in a folklore practitioner family in Bolambar, Ankola district which was modified and prescribed in our hospital.

Table 3: The Ingredients of Agni Chikitsa Lepa

Name of the drug	Quantity
Dry drugs
1. Lashuna (Allium sativum)	10 buds
2. Lavanga (Syzygium aromaticum)	10gm
3. Maricha (Piper nigram)	10gm
4. Sarshapa (Brassica campestris)	5gm
5. Haridra (Curucuma longa)	5gm
Wet Drugs
6. Kshudra agnimantha (Clerodendrum phlemoidis)	§ Leaves of these drugs are used. § Each drug is taken in equal quantity § Quantity sufficient enough to prepare a paste to apply all over the body of the patient § Quantity varies according to the patient
7. Vanatulasi (Ocimum basilicum)
8. Nirgundi (Vitex nigundo)
9. Papata (Pavetta indica)
10. Bandha (Bradelta scandes)

Preparation of Agni Chikitsa

All the wet drugs (fresh leaves of Kshudra Agnimantha, Vana Tulasi, Nirgundi, Papata, Bandha) were washed and the thick mid veins present in the leaves were removed and chopped into small pieces. Then dry drugs are added and grinded into a smooth semisolid paste by adding required quantity of boiled and cooled water. Fresh paste of Agni Chikitsa was prepared daily just before application during the course of treatment.

Method of application and administration

Patients were asked to take hot water bath.

It is advised in 3 forms;

Pralepa
Pradeha
Alepa

Pralepa: It can be applied in cold form, thin and it can be removed as soon as it gets dried or allowed to remain even after drying as per the requirement.

Pradeha: Can be applied hot or cold, thick and removed soon after drying.

Alepa: It can be applied hot or cold, is neither too thin nor too thick can be removed soon after drying or can be allowed to remain for some time even after drying.

Agni Chikitsa was applied in opposite direction of hair follicle to the whole body below the neck in thickness of approximately 2.6mm. Paste falls off from the body of the patient when it is dried. It was not removed manually. Whole procedure was repeated for 7 days.

During these 7 days patients were asked to take light diet in the form of rice gruel and green gram soup. Hot water should be used for drinking as well as bathing.

Manjistadi Kshara Basti

Basti is administered in Kala Basti course. The dose and ingredient of Basti are;

Dose of Basti

Matrabasthi with Brihath Saindavadi Taila - 80ml

Manjistadi Ksara Niruha Basti - 480ml

The ingredients and its quantity in Matra Basti

Saindhava Lavana (Rock salt)
Shreyasi (Scindapsus officinalis)
Rasna (Pluchea lanceolata)
Shatapushpa (Anethum sowa)
Yavani (Trachyspermum ammi)
Maricha (Piper nigrum)
Shunti (Zingiber officinalis)
Kusta (Saussurea lappa)
Sauvarchala (Sochal salt)
Vida (Vida salt)
Ajamoda (Carum roxburghianum)

Madhuka (Glycyrrhiza glabra)
Jiraka (Cuminum cyminum)
Pushpaka (Inula racemosa)
Kana (Piper longum)
Eranda Taila (Ricinus communis)
Shatapushpa Ambu (Anethum sowa)
Kanji (Fermented gruel)
Mastu (Curd water)

Method of preparation

All the ingredients are mixed and boiled till total moisture is lost from the oil, and then filtered. The filtrate is then stored in a clean bottle away from heat, light and moisture. (Bhaishajya Ratnavali 29/222-227)

Table 5: The Ingredients and its quantity in Kshara Basti

Ingredients	Quantity
Makshika	80 ml
Saindhava Lavana	5 gm
Moorchitha Tila Taila	60 ml
Manjistadi Kalka (Manjista - Rubia cordifolia), (Amalaki - Emblica officinalis, Vibitaki - Terminalia bellerica, Haritaki - Terminalia chebula), (Guduchi - Tinospora cordifolia), (Nimba Twak - Azadiracthta indica),(Shatha Pushpa - Pimpinella anisum)	40gm
Manjistadi Kwatha (Manjista - Rubia cordifolia), (Amalaki - Emblica officinalis, Vibitaki - Terminalia bellerica, Haritaki -Terminalia chebula), (Katuki - Picrorhiza kurrooa), (Daruharidra - Berberis aristata), (Guduchi - Tinospora cordifolia), (Nimbatwak - Azadiracthta indica),	100 ml
Gomutra	100 ml
Kaanji	100 ml
Total	480ml

Preparation of Manjistadi Ksara Basti

The above Basti drugs are mixed in a standard order into a smooth mixture. It is filtered, made luke warm and filled in the enema can.

The Basti was administered adopting standard operative procedure.

Table 6: The course of Basti given was;

Days	1	2	3	4	5	6	7	8
Morning		MK	MK	MK	MK	MK	MK	M
Afternoon	M	M	M	M	M	M	M	M

Manjistadi Ksara Basti is a type of Niruha Basti having Tikshna Guna, Lekhana property.

Observations

Table 7: Related with Basti Pratyagamana Kala

Date		26/8/2020	27/8/	28/8/	29/8/	30/8/	31/8/	1/9	2/9
Dose	Morning	-	480ml	480ml	480ml	480ml	480ml	480ml	60ml
Dose	Afernoon	60ml	60ml	60ml	60ml	60ml	60ml	60ml	60ml
Time of Administration	Morning	-	6.30AM	6.30AM	6.30AM	6.30AM	6.30AM	6.30AM	6.30AM
Time of Administration	Afernoon	2.30PM	2.30PM	2.30PM	2.30PM	2.30PM	2.30PM	2.30PM	2.30PM
Time of Expulsion	Niruha	-	6.35AM	6.40AM	6.35AM	6.40AM	6.45AM	6.45AM	6.40AM
Time of Expulsion	Matra	6PM	6.30PM	6PM	7PM	7PM	8PM	9PM	9PM
Retention Time	Niruha	-	5min	10min	5min	10min	15 min	15 min	10min
Retention Time	Matra	3Hrs 30Min	4 Hrs	3Hrs 30Min	4Hrs 30Min	4Hrs 30Min	5Hrs 30Min	6Hrs 30Min	6Hrs 30Min
Number of Evacuations	Niruha		3	4	3	4	3	3	3
Number of Evacuations	Matra	1	1	1	1	2	1	2	2

Table 8: Samyak Nirudha Lakshana

Lakshana	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Day 8
Mala Shodhana	+	+	+	+	+	+	+	+
Mutra Shodhana	-	-	-	-	+	+	+	+
Adho Vayu Nirgamana	-	-	+	+	+	+	+	+
Ruchi	-	-	-	+	+	+	+	+
Agnideepti	-	-	-	+	+	+	+	+
Ashaya Laghuta	-	-	-	+	+	+	+	+
Rogopashanti	-	-	-	-	-	+	+	+
Prakritista	-	-	-	-	-	+	+	+
Bala	-	-	-	+	+	+	+	+

Table 9: Samyak Anuvasana Lakshana

Lakshana	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Day 8
Shakruta Shodhana	+	+	+	+	+	+	+	+
Dhatu Prasada	-	-	-	-	+	+	+	+
Indriya Prasada	-	-	-	-	+	+	+	+
Swapna Bahulya	-	-	-	-		+	+	+
Shareera Lagava	-	-	-	-	+	+	+	+
Bala Janana	-	-	-	-	-	-	+	+
Mutra Shodhana	-	-	+	+	+	+	+	+
Adhovayu Nirgamana	+	+	+	+	+	+	+	+

Results

After 7 days of treatment, there was significant improvement seen in clinically and Shamana Oushadi was given in Basti Parihara

Kala after that again hematological test was done there was significant improvement seen. The severity of symptoms like multiple joint pain, swelling, morning stiffness were reduced significantly. Appetite is normal. Weakness reduced. Hematological test showed significant changes which are mentioned in Table no. 8

Table 8: Hematological test

Investigation	On 26/8/2020	On 18/9/2020
Hb (GM%)	14.9	14
ESR (mm/1 hour)	30	15
Uric Acid (mg/dl)	7.2	5.6
RA Factor (IU/ml)	62.0 (Positive)	36.4 (Positive)
CRP (mg/L)	Negative	Negative
A.S.O (IU/ml)	Negative	Negative

Discussion

Amavata is a chronic disease and usually manifest itself over a period of a few months due to indulged in Viruddhaahara, Snigdhaahara, Vishamashana, Divaswapna, Chinta, Bhojanottara Vyayama. All these factors lead to Mandagni and formation of Ama.^[9] In this patient Nidanas like excessive consumption of food like sweet, curd, banana leads to Kapha Vridhi and formation of Ama. The Ama is carried by the aggravated Vata and deposited in Shleshma Sthana like Sandhi producing features like Angamardha, Aruchi, Alasya, Sandhiruk, Sandhishotha.^[10] When the Gambheera Dhatu are involved, the disease will present with a painful crippling state in the patient. These symptoms hamper the quality of life of the patient affecting physical, psychological, economical social life of the patient.^[11] Hence, early management in the form of normalizing Agni and Vata becomes the prime line of treatment in Amavata.

The Pradeha Chikitsa for Vatavyadhi should be having Ushna nature (Kolakulathadi Lepa). Meanwhile another verse suggests the Gandhoushadha as Pradeha which is Vatahara.^[12] The present Agnichikitsa Lepa is prepared by Ushna Veerya Dravya, Gandhoushadha and Vatahara Dravya. Meanwhile in Jwara Chikitsa Adhyaya in the context of Agurvadhi Taila^[13] the medicines mentioned for the preparation are made into Sukoshna, Pradeha which may be used for the treatment of both Vatavyadhi and Jwara Chikitsa. To treat disease Amavata having surplus of Vata and Kapha Dosha, Agni Chikitsa Lepa is introduced. This is having Vatahara, Sama Kaphahara, Gandhoushadha property.

Manjistadi Ksara Basti: Basti is by nature Vatahara.^[14] Manjistadi Ksara Basti having the ingredients which is already mentioned processes Vatahara, Rakthaprasadaka, Kaphahara, Samadosha Nivaraka properties. Owing to the Kshariya nature of the Basti which is aptly fitting the Samprapthi Ghataka like Rasa, Raktha, Vata, Kapha and Samadosha. Thus, the treatment of Agni Chikitsa Lepa and Manjistadi Ksara Basthi helps to mitigate the Dushitha Dosha and Dushya.

Conclusion

From this study it can be concluded that Amavata can be effectively and safely treated by using Manjistadi Ksara Basti. But this a single case study, hence to prove the efficacy there is need to conduct study on large number of patients.

Reference

1. Siddharth N Shah (ed). API text book of medicine. 7th edition, 2006 Pp-1533, pg.no:1160-1164.

2. Siddharth N Shah (ed). API text book of medicine. 7th edition, 2006 Pp-1533, pg.no:1160-1164.

3. Madhavakara. Madhava Nidana, Part 1 With Madhukosha Vyakhya, By Vijaya Rakshitha And Srikanta Datta, Vidyotini Tika by Sudarshana Shasthri, Reprint 2004 Chaukambha Sanskrit Bhavan Varanasi, Pp568, Pg. No:511.

4. Lakshmipati Shastri. Yogaratnakar. Chaukambha Sanskrit Sanshtan, Varanasi 1999, Pp573, pg.no:498

5. Lakshmipati Shastri. Yogaratnakar. Chaukambha Sanskrit Sanshtan, Varanasi 1999, Pp573, pg.no:498

6. Sushrutha. Sushrutha Samhitha: Acharya Jadavji Trikamji, Choukambha Publication, Varanasi, 2000, pp.824.pg.no.514.

7. Agnivesha, Charaka Samhitha, Acharya Jadavji Trikamji, Choukambha Publication 2020 Varanasi; Pp 738, Pg. No:685.

8. Dravya Guna Vijnana; Acharya Jadavji Trikamji, Choukambha Publication, Varanasi.1996.

9. Sri Chakrapanidatta, Chakradatta, Sri Jagadish Prasad Tripati Bavartha Sandipini, Choukambha Publication 1983, Varanasi; Pp672, Pg. No:167-168.

10. Madhavakara, Madhava Nidana, Part 1 With Madhukosha Vyakhya, By Vijaya Rakshitha And Srikanta Datta, Vidyotini Tika by Sudarshana Shasthri, Reprint 2004 Chaukamba Sanskrit Bhavan Varanasi, Pp568,Pg.No:511.

11. Siddharth N Shah (ed). API text book of medicine. 7th edition, 2006 Pp-1533, pg.no:1160-1164.

12. Agnivesha, Charaka Samhitha, Acharya Jadavji Trikamji, Choukambha Publication 2020 Varanasi; Pp 738, Pg. No:34.

13. Agnivesha, Charaka Samhitha, Acharya Jadavji Trikamji, Choukambha Publication 2020 Varanasi; Pp 738, Pg. No:422-423.

14. Vagbhatacharya, Aatanga Hridaya, Pandit Bhishagacharya Harishastri Paradakara, Chaukambha Orientalia 2014, Varanasi; Pp956, Pp:944.

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
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Case Report

Amavata

Journal of Ayurveda and Integrated Medical Sciences