E-ISSN:2456-3110

Case Report

Study on Bala Amavata

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 3 March
Publisherwww.maharshicharaka.in

A Case Study on Bala Amavata w.s.r. to Juvenile Rheumatoid Arthritis

A Gurav A1*, Shailaja U2
DOI:10.21760/jaims.9.3.44

1* Akshay A Gurav, Associate Professor, Department of Kaumarabhritya, Tmaes Ayurvedic Medical College Shivamogga Karnataka Phd Scholar Parul Institute of Ayurveda, Vadodara, Gujarat, India.

2 Shailaja U, Professor Head, Department of Kaumarabhritya, Sri Dharmasthala Manjunatheshwara College of Ayurveda Hospital, Karnataka, India.

Introduction: Amavata is one of the most difficult to cure (Krichhrasadhya) diseases mentioned in Ayurveda. The main pathological factor in the development of this disease is “Ama”. This Ama is carried by “Vata” and travels throughout the body and gets lodges in the joints, which is the seat of “Kapha”. Accumulation of Ama in all the joints, results in Shotha (edema), Shoola (pain) and Stabdhata (stiffness) in the joints. Clinically, it is closely related to Rheumatoid Arthritis, which is a chronic inflammatory autoimmune disease involving multiple joints of the body. Methodology: A 13years boy with multiple joint pain, diagnosed as Amavata treated with Ayurvedic treatment modalities like Patrapinda Sweda and Virechana. Result: Remarkable improvement was noticed in pain, swelling, morning stiffness and restricted joint movement within first two months. Discussion: In modern medicine, the treatment of this disease includes steroids and Immunomodulator drugs together with non-steroidal anti-inflammatory drugs (NSAIDs), which acts as only Symptomatic treatment, whereas Virechana karma is one of the important bio-purificative methods which is indicated for complete elimination of Dushita Doshas and Ama from the body. Hence this article highlights on the importance of Ayurvedic treatment in the management of Amavata (Rheumatoid Arthritis).

Keywords: Amavata, Rheumatoid Arthritis, Auto-immune Disease

Corresponding Author How to Cite this Article To Browse
Akshay A Gurav, Associate Professor, Department of Kaumarabhritya, Tmaes Ayurvedic Medical College Shivamogga Karnataka Phd Scholar Parul Institute of Ayurveda, Vadodara, Gujarat, India.
Email: 		A Gurav A, Shailaja U, A Case Study on Bala Amavata w.s.r. to Juvenile Rheumatoid Arthritis. J Ayu Int Med Sci. 2024;9(3):267-272.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-01-12 2024-01-22 2024-02-01 2024-02-11 2024-02-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
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© 2024by A Gurav A, Shailaja Uand 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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Akshay A. Gurav et al. Case Study Bala Amavata w.s.r. to Juvenile Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic multi-system disease, with characteristic features of persistent inflammatory synovitis that usually involve peripheral joints in symmetric distribution.[1] Persistent synovial inflammation often causes cartilage damage and bone erosions that badly disturbs joint integrity, as an outcome of which one third of patients suffer from working disability by five years.[2] RA is correlated with Aamavatamentioned in Ayurveda.[3]

The disease Amavata is a most common crippling and disabling disorder. It is a chronic disorder with clinical manifestations of joint swelling, pain, and stiffness in the ankle, knee, hip, wrist, elbow, and shoulder joints. By its clinical appearance, it can be compared with Rheumatoid Arthritis. RA is commonly treated by contemporary science with Non-steroidal anti-inflammatory drugs (NSAIDs) and DMARD’s. It is known that these drugs gives symptomatic relief and do not modify disease with progression. In Ayurveda a different concept of RA management has been mentioned by Acharyas.

Further discussed patient is a known case of RA showing classical symptoms, with positive RA factor and raised erythrocyte sedimentation ratio (ESR).This case provides scientific evidence for Ayurvedic principle in treating Amavata. Remarkable improvement was noticed in pain, swelling, morning stiffness and restricted joint movement within first two months. Previously, patient used to take oral analgesics, which were sparingly required in only first month. RA factor showed marked reduction after two months which later reduced within normal range.

Case Report

A male child of 13 years old from Belur, Hassan district, was brought to SDM college of Ayurveda and Hospital, Hassan by his mother with complaint of pain and stiffness of multiple joints notably wrist, hand, ankle, feet and even ribs since 4 months, associated with abdominal pain immediately after intake of food since 4 months. As per history narrated by mother, four months before the child was asymptomatic, but suddenly he got fever which was followed by pain in multiple joints including metacarpal joints. Pain persisted throughout

the day which was shooting type pain. The joint pain was continued even after subsiding of fever. Due to this the child faced difficulty in doing the daily activity. The severity of the pain was in such a way that the child couldn’t even wear the school bag. For the same they consulted many tertiary health centres but didn’t get satisfactory relief so for further line of treatment they approached our hospital.

Birth history

Full term /NVD/Birth Weight 2.7 Kg/Baby Cried Immediately after Birth

Developmental history

Gross motor & fine motor development were normal as per the chronological age.

Family history

Non consanguineous marriage. No any other relevant history for present condition.

Immunization history

Taken as per National Immunization schedule

Personal history

Diet:

Mixed

Breakfast - Bread & Curries

Lunch - Rice, Vegetables, Egg

Meat (Chicken, Mutton) – Daily

Dinner - Rice, Vegetables & meat

More like to eat Spicy & Fried food.

Appetite:

Impaired appetite at the onset of the disease

Sleep:

Disturbed due to pain

Bowel Habits:

Once/Day

Colour - Yellow

Odour - Normal    

Character - Grathita


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Micturition:

Day - 3, Night - 2 times

Colour - Pale

Odour - Normal

General physical examination

General examinationAnthropometry
Pallor: PresentHeight: 138cm
Icterus: AbsentWeight: 36kg
Cyanosis: AbsentHC: 51cms
Lymphadenopathy: AbsentCC: 60cms
Edema: Present at JointMAC: 18cms

Locomotor System

Range of movements:

Range of movement with pain in all joints

Pain in ribs during respiration

Joint crepitus - Absent

Joint tenderness - Present

Joint swelling - Mild Present

Rubor - Mild present

Calor - Mild present

Muscle wasting - NAD

Gals:

Gait - Slow and painful gait

Arms:

Difficulty in pronation and supination (painful) in both hands

Pain - When squeezed the hand across the metacarpals of the both hand

Power Grip - reduced (Difficulty in holding)

Legs:

Joint pain in both knee joints

Spine:

  • Thoracic Spine: Mobility painful
  • Lumbar Spine:
  • Flexion - painful
  • Extension - painful
  • Lateral Bending - painful
  • Cervical Spine:
  • Rotation - painful
  • Flexion, Extension and Lateral bending - with pain

Joints:

Inspection

  • Swelling - Present
  • Redness - Present
  • Deformities - NAD

Palpation

Tenderness & warmth (MCP, PIP, DIP, MTP, Wrist, Elbow joints) Stiffness of the joints

Cardiovascular system

S1, S2 - Clear. No murmurs

Respiratory system

No added sounds

GIT

P/A: No tenderness, No organomegaly

CNS

Higher functions - NAD

Sensory system - NAD

Cranial nerves - NAD

Motor Function : Reflexes - Normal

Samprapti Ghataka

  • Dosha : Vata, Kapha
  • Dushya : Rasa,Rakta,Mamsa,Asthi
  • Agni : Mandagni
  • Ama : Saama
  • Srotas : Rasa, Rakta, Mamsa, Asthi
  • Srotodushti : Sanga
  • Udbhawastana : Amashaya
  • Adishtana : Sandhi Vishesha Sarvasharira
  • Vyakta Sthana : Sarva Sandhi
  • Roga Marga : Madhyama
  • Sadhya Asadhyata : Kruccha Sadhya

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Differential diagnosis

Amavata[5]Sandhigata Vata[6]Gambhira Vata Rakta[7]
NidanaViruddha Ahara, Snigda Ahara, Alpa Chesta etc.Vata Kopakara Ahara, ViharanaVata & Rakta Kopakara Ahara, Viharana
RupaSandhishoola, Shotha Angamarda, Aruchi, Trushna, Alasya etc.Shula, Shota, Prasaranakunchana VedanaDaha, Supti, Vaivarnya, Sphutana etc.
SthanaStart from small joints of hands & spreadMainly start with weight bearing large joints.Start from the end parts of the hands & feet.
DoshaVata KaphaVata predominantVata, Pitta

Diagnosis - Amavata (Juvenile Rheumatoid Arthritis)

Treatment Given

DayTreatmentRemarks
Day-1
16/11/2017		ü Agnideepana with Pancakolaphanta 30ml tid
ü Chitrakadi Vati 1 tid		No any fresh Complaints
Day - 2
17/11/2017		ü Snehapana With Panchatiktaka Guggulu Ghrita 30mlNo any fresh Complaints
Day - 3
18/11/2017		ü Snehapana With Panchatiktaka Guggulu Ghrita 60mlMild Headache
Day – 4
19/11/2017		ü Snehapana with Panchatiktaka Guggulu Ghrita 90mlMild Headache
Generalized weakness
Day – 5
20/11/2017		ü Snehapana with Panchatiktaka Guggulu Ghrita 120mlNo any fresh Complaints
Day – 6
21/11/2017		ü Snehapana with Panchatiktaka Guggulu Ghrita 150mlSamyak Sneha Lakshana achieved
Day - 7 to Day - 9
22/11/2017 to 24/11/2017		ü Sarvanga Abhyanga with Vishagarbha Taila followed by Patrapinda SwedaNo any fresh Complaints
Day – 10
25/11/2017		ü Sarvanga Abhyanga with Vishagarbha Taila followed by Bhaspa Sweda
ü Virechana[4] With Trivruth Leha (50gms) with Draksha Rasa		Total Vegas - 11
Day - 11 to Day - 14
26/11/2017 to 30/11/2017		ü SamsarjanakramaNo any fresh Complaints

Advised after Discharge:

  • Yogaraja Guggulu 1TID with Lukewarm water after food for 1 month
  • Rasnasaptaka Kwatha 10ml TID with 20ml lukewarm water after food for 1 month

Results

Subjective Parameters

Lakshana’sBTAT
Joint pain+ + ++
Swelling+_
Tenderness+ ++
Morning Stiffness+ +_
Daily Routine Activity++ + +
Redness+_
Muscle wasting__

Objective Parameters

InvestigationBTAT
HB%12.8 gm%14.2 gm%
Total count6,3008,700
Differential countNormalNormal
ESR24 mm/hr.6 mm/hr.
A.S.L.O224.8 IU/ml196.3 IU/ml
R.A Test11.6 IU/ml4.4 IU/ml

Discussion

In Ayurvedic classic, Amavata is divided in two Avasthas i.e., Amavastha and Pakwavastha. If we see the typical history of this patient especially the diet, the child is involved in all the Viruddha Ahara which is responsible for Amavastha which intern leads to the manifestation of the Amavata. So, in this case of Amavastha of Amavata, the main treatment explained is Langhana followed by Deepana & Pachana, Snehana & Swedana and Virechana (Purgation), hence the following line of treatment was carried out in managing the present condition.

Langhana followed by Deepana & Pachana

In this case the Agni plays an important role because, due to the Viruddha Ahara taken by the child there was a Mandagni, leading to increased production of Ama, which in turn increases the severity of the disease. So Langhana is done to stop the further production of Ama.

For the Samprapti Vighatana - Agnideepana and Amapachana was done by using the Panchakola Phanta, Chitrakadi Vati, as both are routinely practiced at our center and even easily taken by the children.

In Jeernaavastha, Langhana was performed


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continuously to the extent of Amapachana, as Langhana is known as best measure for thetreatment of Ama. Langhana in form of Laghu Ahara is prescribed.

Snehana & Swedana

Snehapana was carried out with Panchatikta Guggulu Ghrita, which has Tikta Rasa, Ushna Virya, Madhura, and Katu Vipaka properties, promotes the regular functioning of the Dhatvagni and enables enhanced nutrition for the Asthi and Majja Dhatu. As a result, it balances Vata, enhances Dhatu Upachaya, and revitalizes the body.

Vishagarbha Taila was used for Abhyanga as it is best in Amavata due to its Shoolaghna, Shothagna and Sthanbahara properties.

Sweda is indicated to relieve Stambha, Gaurava, and Shoola in the body. Ruksha Sweda in the form of Patrapinda with Vatahara drugs, helps in reducing Ama, it pacifies the vitiated Vata and relieves pain and stiffness.

Virechana (Purgation) - Srotovishyodhana property

Virechana karmais described for the effective management ofAmavataas aShodhanatherapy. As it is the most suited therapy for theSthanika Pitta Dosha, it might be responsible forAgnivardhanaand evacuation ofAma,which is the main culprit of this disease.[4]

Virechana was done with the Trivrit Leha as it is best Mrudu Virechana which is suitable in Baalyavastha.

Conclusion

Amavata is Santarpanajanya, Rasagata, Amapradhana, Amashaya Samudbhava Vyadhi & Kaphasthanasthitavata. One should adopt Apatarpana Chikitsa until Amapachana. When once Niramavastha is attained then Vatahara Chikitsa principles are adopted. Hence, this case study justifies that management of Amavata through Ayurvedic principles.

References

1. Lipsky Peter E. Rheumatoid arthritis. In: Longo D.L., Kasper D.L., Jameson J.L., Fauci A.S., Hauser S.L., Loscalzo J., editors. 18th ed. vol. II. Mc Graw

Hill; New York: 2012. pp. 2738–2752. (Harrison principles of internal medicine).

2. Young A., Dixey J., Kulinskaya E., Cox N., Davies P., Devlin J. Which patients stop working because of rheumatoid arthritis? Results of five years' follow up in 732 patients from the Early RA Study (ERAS)Ann Rheum Dis.2002; 61:335–340.

3. Mahato R.R., Dave A.L., Shukla V.D. Acomparative study of Rasona Rasnadi Ghanavati and Simhanada Guggulu on Amavata with special reference to rheumatoid arthritis.Ayu.2011;32(1):46–54.

4. Chaturvedi G, Shastri K, editors. Charaka Samhita of Agnivesha, Siddhi Sthana, Ch. 2, Ver. 13. Reprint ed. Varanasi: Chaukhambha Bharati Academy; 2007. p. 981.

5. Shastri B.S., editor. 6th ed. vol. I. Chaukhamba Sanskrit Sansthan; Varanasi: 1997. p. 565. (Yogaratnakara of unknown author, Amavata Nidana).

6. Acharya Y.T., editor.Charaka Samhita of Agnivesha, Chikitsa Sthana; Vatashonita Chikitsa: chapter 29, Verse 19 – 23.Chaukhamba Surbharati Prakashan; Varanasi: 2011. p. 628.Reprint 2011.

7. Acharya Y.T., editor.Charaka Samhita of Agnivesha, Chikitsa Sthana; Vaytavyadhi Chikitsa: chapter 28, Verse 37.Chaukhamba Surbharati Prakashan; Varanasi: 2011. p. 618. reprint 2011.


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