A case study on Amavata (Rheumatoid Arthritis)

Azara Qureshi; Riyanka Kumari

A case study on Amavata (Rheumatoid Arthritis)

Qureshi A.^1*, Kumari R.²

DOI:

^1* Azara Qureshi, Assistant Professor, Babe Ke Ayurvedic Medical College and Hospital, Daudhar, Moga, Punjab, India.

² Riyanka Kumari, Assistant Professor, Babe Ke Ayurvedic Medical College and Hospital, Daudhar, Moga, Punjab, India.

Aama and Vata are the chief pathogenic factors responsible for the Aamavata. It is the disease of Madhyam Rogamarg. Asthi and Sandhi are the chief sites for the manifestation of cardinal symptoms such as Sandhishool, Sandhisotha, Sandhigraha. Based on clinical symptomatology it can be correlated with the disease “Rheumatoid Arthritis” in modern texts. Present case, female patient aged 48 years having history of pain and morning stiffness in multiple joints for one year, swelling in both hand and wrist joints for 2 months, Intermittent low-grade fever for 2 months was registered in our OPD. Complete history and clinical evaluation lead to the diagnosis of Aamavata. Considering the signs and symptoms, patient was treated on the line of Aamavata. Langhana, Deepana- Pachana, local Ruksha Swedana were done along with oral drugs for 30 days. Before starting the treatment, the grading was done on the basis of subjective criteria and after treatment, the grade was reduced. There was no side effect observed during and after the treatment. Therapy gives significant relief in symptoms of Aamavata.

Keywords: Aamavata, Aama, Vata, Rheumatoid Arthritis, Langhana, Pachana, Ruksha Baluka Swedana

Corresponding Author	How to Cite this Article	To Browse
Azara Qureshi, Assistant Professor, , Babe Ke Ayurvedic Medical College and Hospital, Daudhar, Moga, Punjab, India. Email:	Azara Qureshi, Riyanka Kumari, A case study on Amavata (Rheumatoid Arthritis). J Ayu Int Med Sci. 2023;8(1):201-206. Available From https://jaims.in/jaims/article/view/2240

Introduction

In the present time due to modern life style, unhealthy eating habits, hectic schedule and stress, incidence of Ama related diseases are increasing. One of the most common disease is Amavata. In Ayurveda, Madhavkar (700 A.D.) first mentioned Amavata as a separate disease.^[1] The word Amavata has two components i.e., Ama and Vata. These two components contribute to the morbidity and disease process in Amavata. The main causative factor Ama is formed due to malfunctioning of the digestive and metabolic mechanisms. Ama with Vata gets localized in the body tissues and joints resulting in pain, stiffness, swelling, tenderness etc. and presents as a Amavata disease.

The features of Amavata are much identical to Rheumatoid Arthritis. The disease is chronic, progressive, autoimmune disorder characterized by bilateral symmetrical involvement of joints with some systemic clinical manifestation. In global scenario, more than one million people are affected by rheumatic disorders and one fifth of these are severely disabled. The prevalence of the disease is approximately 0.8% of the total population worldwide (range 0.3% to 2.1%) with male and female ratio of 1:3. The onset is most frequent during the fourth and fifth decades of life, with 80% of patients developing the disease between age group of 35 and 50.^[2]

Case Report

A 48 years old female patient presented with one year history of pain and stiffness in multiple joints, swelling in hand and wrist joints with intermittent low-grade fever. Initially, pain was started from both hands and wrist joints and progressively it involved bilateral shoulder joints, knee joints and ankle joints. Pain was pricking and severe in nature. It was aggravating on cold exposure & by rest and relieved by physical activity, hot fomentation & on exposure to sunlight. Along with joint pain, she had stiffness in multiple joints which was more in morning hours and after inactivity and lasts for about 1-2 hour. Patient also told that she developed swelling in bilateral hands and wrist joints. Also, she had complained of loss of appetite. She gave no history of fatigue, weight loss, diarrhoea. She had no history of Diabetes, Hypertension or any other major illness in the past.

Examination

General Physical Examination

Patient was fully conscious, cooperative and well oriented to time, place and person at the time of history taking. She had moderate built and appeared to be of his age. There was normal color of skin without any hypo/hyper pigmentation. No skin lesion was present. Eyebrows were B/L symmetrical, no loss of lateral 1/3^rd of eyebrows. There was no periorbital edema. Pupil: RRR to light B/L. The Ear, Nose, Throat and Paranasal sinus were clear from any discharge, collection, sign of infection and inflammation. Lips were pinkish in color. Oral hygiene was well maintained.

Systemic examination of respiratory, cardiovascular, CNS and G.I.T. system revealed no abnormality detected.

Table 1: Local Examination

Inspection
	Upper Limb	Lower Limb
Joint involved	PIP, MCP and wrist joints	Bilateral knee and ankle joint
Movement	Bilateral restricted (Wrist joints)	Bilateral restricted (Knee joints)
Symmetry	Symmetrical	Symmetrical
Swelling	Present in B/L PIP, MCP	Not present
Deformity	Not present	Not present
Redness	Not present	Not present
Palpation
Temperature	Not raised	Not raised
Joint crepitus	Not present	Present at knee joints B/L
Nodules	Not present	Not present

Differential Diagnosis: Amavata (Rheumatoid Arthritis), Sandhivata (Osteoarthritis), Vatarakta (Gout).

Investigation Done

Hb - 11.8 g/dl

TLC - 10.4 × 10³ mcL

DLC - L- 24%, M-13.2% N-62.8%

PLT - 205000/mcL

ESR - 110 mm fall in first hour

RA Factor - positive

C- reactive protein - positive

Uric acid - 6.3 mg/dl

All other parameters remain same.

Positive findings for diagnosis

Clinical presentations
Symmetrical involvement of more than 3 joints i.e., PIP, MCP, wrist, knee and ankle joints
Morning Stiffness
Swelling in bilateral hands
Intermittent low- grade fever
Investigations
Elevated ESR
Positive serum rheumatoid factor
Positive C-reactive protein

Diagnosis: Diagnosis was made on the basis of symptoms described in the classic of Ayurveda and criteria fixed by American Rheumatology Association in 1988.

Table 2: Criteria for diagnosis of Rheumatoid Arthritis

Criteria	Score
Joints affected
1 large joint	0
2-10 large joint	1
1-3 small joints	2
4-10 small joints	5
Serology
Negative RF and ACPA	0
Low positive RF or ACPA	2
High positive RF or ACPA	3
Duration of symptoms
< 6 weeks	0
> 6 weeks	1
Acute phase reactants
Normal CRP and ESR	0
Abnormal CRP and ESR	1

Patient with score > or = 6 are considered to have RA.

Final Diagnosis

Rheumatoid Arthritis

Therapeutic Focus

As per the principles of Aama Vata Chikitsa described in Ayurvedic classics,^[3] patient was treated with Langhana, Deepana-Pachana along with oral drugs viz Singhnada Guggulu, Vishtinduk Vati, Dashmoola Kasayam and Baluka Swedana as local treatment.

Table 3: Treatment protocol

Medicines	Dose	Route	Anupana
Langhana[4]
Deepana-Pachana[5]
Ruksha Swedana[6]	Once a day
Singhnada Guggulu[7] : (Haritaki, Vibhitaki, Amalaki, Shudhagandhaka, Shuddhaguggulu, Erandmoola)	500mg twice a day after meal	Oral	Plain Water
Vishtinduk Vati[8] : (Shuddha Kupilu, Supari, Maricha, Chincha Phal)	125mg twice a day after meal	Oral	Luke warm Water
Dashmoola Kasayam[9]	40 ml with equal quantity of water	Oral	Plain Water

Advised: Patient was advised general physical activity and advised to avoid Aamajanya Aahara^[10] (Dadhi, Mashapishtkam, Matsay, Guda, Ksheer, Upodika, Dushtaneeram, Purvavataviruddha, Vegarodha, Vishamasana)

Assessment: The results were assessed on the basis of clinical signs and symptoms mentioned in Ayurvedic classics as well as by American Rheumatology Association (1988).^[11] Scoring of the symptoms was done as under:

Table 4

Angamarda (Body ache)
No Angamarda	0
Occasional Angamarda but patient is able to do usual work	1
Continuous Angamarda but patient is able to do usual work	2
Continuous Angamarda which hampers routine work	3
Patient is unable to do any work	4
Aruchi (Anorexia)
Normal desire for food	0
Eating timely without much desire	1
Desire for food, little late than normal time	2
Desire for food only after long intervals	3
No desire for food at all	4
Trishna (Excessive thirst)
Normal feeling of thirst	0
Frequent feeling of thirst, but satisfaction with normal amount of liquid intake	1
Satisfaction after increased intake of fluids, but no awakening during night	2
Satisfaction after increased intake of fluids with regular awakening during nights	3
No Satisfaction after heavy intake of fluids	4
Alasya (Lethargy)
No Alasya	0
Starts work in time with efforts	1
Unable to start work in time but completes the work	2
Delay in the start of work and unable to complete it	3

Never able to start the work and always likes rest	4
Gauravta (Heaviness in the body)
No feeling of heaviness	0
Occasional heaviness in body but can do usual work	1
Continuous heaviness in body but can do usual work	2
Continuous heaviness that hampers usual work	3
Unable to do any work due to heaviness	4
Apaka (Indigestion)
No Apaka at all	0
Occasional indigestion once or twice a week in one meal	1
Occasional indigestion 3-5 times a week in one meal	2
Indigestion 3-5 times week in both meals	3
Indigestion after every meal	4
Agni Daurbalaya (loss of digestive fire)
No Agnimandya	0
Occasional Agnimandya 1-2 times a week	1
Agnimandya 3-4 times a week	2
Agnimandya 4-6 times a week	3
Continuous Agnimandya	4
Vairasyata (Impairment in taste)
Normal taste of mouth	0
Occasional sensation of unpleasant taste	1
Continuous sensation of unpleasant taste but vanishes after eating something	2
Continuous mild sensation of unpleasant taste which persist after eating	3
Severe unpleasant taste throughout the day	4
Daha (Burning sensation)
No burning sensation	0
Occasional retrosternal burning	1
Occasional retrosternal, palm and sole burning	2
Intermittent burning sensation throughout the body	3
Continuous burning sensation throughout the body	4
Bahu Mutrata (Increased frequency of urine)
Absent	0
Urine >3 times at night	1
Urine >5 times at night	2
Urine >7 times at night	3
Kukshi Kathinya (Hardness of abdomen)
Absent	0
Transient	1
Frequent	2
Regular	3
Jadya (Stiffness of body)
No morning stiffness	0
Morning stiffness more than ½ hour but less than 1 hour	1
Morning stiffness > 1 hour but < 6 hours	2
Stiffness all the day through	3
Sandhishula (Pain in joints)
No pain	0
Pain only on movement	1

Pain on rest but no disturbance on routine	2
Severe pain, disturbance on routine activity	3
Sandhijadyata (Stiffness in joints)
No stiffness	0
Stiffness persistently only for half an hour to one hour in the morning	1
Stiffness persisting for a long time (>1 hour)	2
Stiffness for whole day and night	3
Sandhishotha (Swelling in joints)
No swelling	0
Mild swelling	1
Moderate swelling	2
Marked swelling	3

Observations and Results

Table 5: Effect of therapy before and after treatment

Assessment criteria	Before Treatment	After Treatment
RA factor	Positive	Positive
CRP	Positive	Negative
ESR	110 Mm fall in 1st hr.	20 Mm fall in 1st hr.
Pain (Sandhishool)	Grade 2	0
Morning Stiffness (Sandhijadyata)	Grade 3	1
Swelling (Sandhishotha)	Grade 2	0
Analgesic needed	Once a day	Not needed
Angamarda (Body ache)	Grade 3	Grade 1
Aruchi (Anorexia)	Grade 4	Grade 0
Trishna (Excessive thirst)	Grade 1	Grade 0
Alasya (Lethargy)	Grade 3	Grade 1
Gauravta (Heaviness in the body)	Grade 3	Grade 1
Apaka (Indigestion)	Grade 4	Grade 0
Agni Daurbalaya (Loss of digestive fire)	Grade 3	Grade 0
Vairasyata (Impairment in taste)	Grade 2	Grade 1
Daha (Burning sensation)	Grade 4	Grade 2
Bahu Mutrata (Increased frequency of urine)	Grade 0	Grade 0
Nidra Vipraya (Disturbed sleep)	Grade 4	Grade 1
Jadya (Stiffness of body)	Grade 3	Grade 1

Discussion

Ama and Vata are the prime Doshas involved in Aamavata. Vata is the biological force present in the body which recognizes and stimulates all the activities. When the Gati of Vata is obstructed due to Aama in Srotasa then the functional normality of Vata is impaired and that is responsible for causing various Vatavyadhi.^[12]

As Ama and Vata Dosha are the main culprit to cause the disease so that the treatment adopted in this case is Vatahara and Aamapachaka Chikitsa.

Mode of action of drugs

Langana (fasting) means the food which gives lightness to the body and it is the first line of management for Amavata which helps in the Pachana of Ama. Deepana-Pachana, Ruksha local Swedana pacify the vitiated Vata in the body and helps in the Pachana of Aama. Swedana Karma helps to liquefy the vitiated Aama Dosha with its Ushna Guna and opens the channels, by virtue of which Vata moves in their normal direction.^[13] Extent and intensity of Swedana depends upon the season, age and the site where it is applied.

Simhnada Guggul have Katu, Tikta Rasa, Laghu, Ruksha Guna, Ushnavirya, Katu Vipaka, Vedhnasthapana, Amapachak, Srotoshodhaka properties which helps in breaking the pathogenesis of Amavata.

Vishtindukadi Vati^[14] composed mainly of Kuchla, along with Maricha, Chincha Phala and Supari which having properties like Vata-Kapha Shamana, and does Aamapachan. It also reduces stiffness of joints.

Ruksha Baluka Sweda have similar qualities, like Shoshana of Ama situated in the Sleshmasthana (joints), thus pacifies symptoms like Sthambha (stiffness) and Shoola (pain) suffered by patient.

Conclusion

From the present case study, it can be concluded that the results obtained after the treatment was encouraging. Ayurvedic management in combination of Panchakarma and Herbo-mineral drugs as described in classical texts is helpful in giving significant relief in signs and symptoms of the disease Aamavata (Rheumatoid Arthritis), thereby improving quality of life. So, this kind of approach can be taken for treating further cases of Aama Vata.

Reference

1. Madhava Nidana commented by vijay rakshit & shri kanthadatta, Madhukosha teeka by Madhavkara chapter 25 Aamavata Nidana page no. 508/2009.

2. API, Text Book of Medicine by Siddharth N. Shah, 7th edition, 2003

3. Acharya Ramnathtrivedi, Chakradutta. Chaukhambha Prakshana, Varanasi. Amavata Chikitsa 25/1

4. Acharya Ramnathtrivedi, Chakradutta. Chaukhambha Prakshana, Varanasi. Amavata Chikitsa 25/1

5. Acharya Ramnathtrivedi, Chakradutta. Chaukhambha Prakshana, Varanasi. Amavata Chikitsa 25/1

6. Vaidhyaraj, Datto Ballal Borkar, Sarth Yogratnakar part 2, Shree Gajanan book depo prakshan pune, Amavata chikitsa, Page no. 25.

7. Acharya Ramnathtrivedi, Chakradutta chaukhambha prakshana Amavata Chikitsa 25/ 31-35, Page no. 168.

8. Vaidhyaraj, Datto Ballal Borkar, Sarth Rasachandeshu, Shree Gajanan book depo prakashan pune, Ajirna adhikar, Page no. 213.

9. Ashtang Hridaya. Chikitsa Sthana 17/14-16

10. Yogratnakar. Ama Vata Chikitsa Chapter 3/4

11. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis and Rheumatism Arthritis & Rheumatism- Arthritis Care & Research; 31(3):315-324).

12. Shastri Pt Kashinath and Chaturvedi Gorakhnath, Charaka Samhita, reprint 2008, Varanasi, Chaukhambha Bharti Academy, Sutra Sthana chap 12.

13. Shastri Pt Kashinath and Chaturvedi Gorakhnath, Charaka Samhita, reprint 2008, Varanasi, Chaukhambha Bharti Academy, Sutra Sthana chap 14/71-76.

14. Acharya Priyarta Sharama. Dravaya Guna Vighyan, Vol.2nd Publication choukhmbha orientaliya Varanasi, Madakari prakarana.Page 83,362,750.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-12-01	2022-12-03	2022-12-10	2022-12-17	2022-12-24
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	19%

Case Report

Rheumatoid Arthritis

Journal of Ayurveda and Integrated Medical Sciences