E-ISSN:2456-3110

Case Report

Ankylosing Spondylitis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 1 January
Publisherwww.maharshicharaka.in

Role of Virechan in the management of Ankylosing Spondylitis - A Case Study

Rupali D1*, Sanjay S2
DOI:10.21760/jaims.9.1.52

1* Dave Rupali, Post Graduate Scholar, Dept of Rog Nidan and Vikriti Vigyan, Pt Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India.

2 Srivastava Sanjay, Professor and HOD, Dept of Rog Nidan and Vikriti Vigyan, Pt Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India.

Ankylosing Spondylitis is probably an autoimmune disorder with genetic component HLAB27 as important causative factor and having characteristic inflammatory back pain. As is a gradually progressive condition over several years until structural damage manifests clinically as sacroiliitis, loss of spinal mobility and reduce quality of life. It is also called as Marie Stumpell and Bechterew’s disease. It affects primarily the sacroiliac joint, spine, certain peripheral joints, tendon can also be affected and extra articular manifestation may be present sometimes. Ankylosing Spondylitis is a chronic systemic inflammatory disease that can cause the vertebrae to fuse in advanced stages. It is more common in male than female. Signs and symptoms typically begin in early adulthood. No satisfactory treatment is available in modern medicine for this disease. In the present case report, a 21 year old female patient presented with complaints pain the lower back region accompanied by early morning stiffness and pain radiating to B/L hip joints. This pain was insidious in onset which brought the patient to OPD of Arthritis Clinic (Aamvata) of Pandit Khushilal Sharma Government Ayurveda Institute Bhopal. As per Ayurvedic classics, this condition can be correlated with Aamvata and treated with Panchkarma procedure Virechan karma. The outcome was very remarkable she got symptomatic relief assessed by Bath Ankylosing Spondylitis Disease Activity Index without causing any adverse effect.

Keywords: Ankylosing Spondylitis, Virechan, Aamvata, Ayurveda

Corresponding Author How to Cite this Article To Browse
Dave Rupali, Post Graduate Scholar, Dept of Rog Nidan and Vikriti Vigyan, Pt Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India.
Email: 		Rupali D, Sanjay S, Role of Virechan in the management of Ankylosing Spondylitis - A Case Study. J Ayu Int Med Sci. 2024;9(1):323-328.
Available From
https://jaims.in/jaims/article/view/2901

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-11-17 2023-11-24 2023-12-04 2023-12-14 2023-12-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared. `NIL YES 13.53 NONE

© 2024by Rupali D, Sanjay Sand 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].

J Ayu Int Med Sci 2024;9(1)323
Rupali Dave et al. Role of Virechan in the management of Ankylosing Spondylitis

Introduction

Ankylosing Spondylitis classified as Seronegative Spondyloarthropathies unified by the following features like absence of rheumatoid factor, sacroiliac joint involvement seen association with HLA B-27, pathologic changes in the ligamentous attachments rather than synovium, bony proliferation leading to ankylosis.[1] In a global recent study, the diagnosed

prevalence of Ankylosing Spondylitis in India is currently around 1.65 million and is estimated to grow at an annual growth rate of 2.95% to reach 2 million in 2028. Ankylosing Spondylitis (AS) is typically diagnosed in people younger than 40 years, and about 80% of patients develop their first symptoms when they are younger than 30 years. Less than 5% of patients present when they are older than 45 years. AS is more common among men than women.[2] AS causes destruction of articular cartilage and bony ankyloses, especially of the sacroiliac and vertebral apophyseal joints between tuberosities and process. The disease present as lower back pain and spinal immobility, usually in the 2nd and 3rd decades of life. Peripheral joints such as hips, knee and shoulder are involved in at least one third of cases. Approximately 90% of patients are HLA B-27 positive. The role of HLA B-27 is unknown, it is presumably related to the ability of this MHC variant to present one or more antigen that somehow trigger the disease, but neither the antigen nor the pathogenic immune cell is known.[3] Patients having family history of AS are more likely to develop the disease. People who have Crohn’s, Ulcerative Colitis or psoriasis may be more likely to develop the disease.[4]

Early symptoms of AS include spinal pain and stiffness in lower back and hips, especially in the morning and after periods of inactivity and relieved by movement. As the disease progresses it destroy the nearby articular tissues or through fusion forming a long bony column referred to as “bamboo spine” this is the hallmark symptoms in the spine in advance stages. Non-steroidal anti-inflammatory drugs NSAID, corticosteroids and various diseases modifying anti rheumatic drugs are used to treat or manage AS. However these treatments are of limited benefit. Corticosteroids are associated with numerous side effects especially given systemically over long period of time. No effective treatment has been available for AS.[5]

In the Ayurvedic texts this condition is caused due to Ama Dosha and Vata dosha in which aggravated Vata is associated with metabolic toxins (Ama) and mainly affects joints Trika Sandhi i.e. Sacroiliac Joint. Ayurvedic treatments in this case were directed towards to relieve pain and stiffness and to prevent or delay spinal deformity. This study shows that symptoms of patient successfully managed by Virechan process.[6]

Case Report

A 21-year-old female patient visited the OPD of Arthritis Clinic (Aamvata) of Pt. Khushilal Sharma Government Ayurveda Institute Bhopal with chief complain of pain in lower back region with morning stiffness more than 45 minutes and pain radiating to B/L hip joint since 1 year and this pain gradually improve with activity. She took allopath treatment NSAID, Corticosteroid, anti-inflammatory drugs, DMARDs. Patient did not get satisfactory relief with this medicine. On the basis of history taking and checking her X-ray report and the blood report patient advise for HLA B-27 antigen test. After the positive result of Hlab-27, through this we are going to understand a case of AS in the line of Aamvata and patient was given oral medication and planned for Virechan Karma.

Complaints of Patient

1. Pain in lower back region radiating to B/L hip joint

2. Tenderness noted at Sacroiliac Joint

3. Morning Stiffness more than 45 minutes

4. Pain in B/L hand, shoulder, hip and ankle joint

5. Restricted lumbar spine movements

6. Sleep disturbed due to pain

Examination on Admission

General Examination

BP = 110/70mmhg 
Pulse = 70/min 
Temp. = 98.6°F 
RR = 20/min
Weight = 50kg 
Height = 5ft2inch 
Edema = Absent
Pallor = Absent


J Ayu Int Med Sci 2024;9(1)324
Rupali Dave et al. Role of Virechan in the management of Ankylosing Spondylitis

Systemic Examination

In the systemic examination Abdomen was mildly distended non tender, bowel sounds were present. Findings of respiratory and cardiovascular system were within the normal limits. Patient was conscious and well oriented.

Personal History

  • Surgical History - No
  • No history of Trauma
  • No smoking and alcohol addiction
  • Diet - Mixed
  • Appetite - Irregular
  • Sleep - Disturbance

Investigation

HLAB-27 was positive with increased level of C-reactive protein and ESR. In X-ray radiographs sacroiliitis was detected.

Treatment

1.Baluka SwedanBaluka - 1 kgAjwain - 20 gm (For 5 days)Saindhav - 20 gm
2.Kati BastiKati Basti with Saindhawadi Tail + Murivennam Tail
3.Sarwang Abhyang SwedanSarwang Abhyang Swedan with Sendhwadi + Murivennam Tail
4.SnehpanSnehpan with Mahatikta Ghrut 25/11/22 to 03/12/22
5.VirechanVirechan Kwath Dravya 250 ml
Sneha Dravya (Eranda Tail - 70 ml)
18 Vega (05/12/22)
6.Samsarjan Karma05 days (05/12/22-09/12/22)

Treatment Plan

Virechana Karma was planned (Deepan Pachana, Snehapan, Virechana Kwath, and Samsarjan Karma). Deepan Pachana - 500mg Chitrakadi Vati with Panchkola Phanta (Muhurmuh) for 2 days. Virechana Karma - Firstly asses the patient Kosht Jaran and Abhyvaran Shakti for Snehapan.

1 to 7 days - Snehapan was started with an initial dose of 40ml of Mahatikta Ghrut once a day and followed by a light diet. The amount of Ghrut was increased by 40ml daily, upto 280 ml on the 7th day as per the protocol of classical text Snehapan Lakshan (Vata-Anuloman, Deeptoagni, Udgaarshudhi, Laghuta, Trishna).

8 to 10 days- Abhyang with Vatashamak Taila and Nadi Swedana was started on 8th day for three consecutive days after the appearance of symptoms of Snehapan on the 7th day.

Virechana Karma was done by administration of Kutaki, Nishoth, Haritaki, Aragwadha Siddha Kwath 200 ml, castor oil 100 ml.

Wait for 1-hour, if Virechan Vega was not started then 500mg Ichhabhedi Rasa was given. After some time Virechana Vega was started and a total of 18 Vega (passed stool) were observed.

From 11th day onward - Samsarjana Karma a process of resuming to a normal diet) by prescribing Peya, Vilepi, Akruta Yush, Krut Yush, Krushara.

Then normal diet successively for 5 days. After it from the 16th day, Pathyakar Aahar was suggested.

Observation

The total effect of therapy was assessed by Bath Ankylosing Spondylitis Disease Activity

Bath Ankylosing Spondylitis Functional Index (BASFI)

Daily activitiesBefore VirechanAfter Virechan
Putting up socks86
Picking up pen without aid from floor63
Getting up from armless chair without aid42
Reaching up to a higher shell without help83
Getting up from floor108
Standing up for 10 minutes without discomfort80
Climbing 12-15 steps without using rails and walking support102
Looking over shoulder without turning body10
Doing physical activities (gardening etc)41
Doing a full day activity84
Total mean scoring67/10 = 6.729/10 = 2.9

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)[7]

SymptomsBefore VirechanAfter Virechan
Fatigue30
Neck, back, hip pain94
Pain or swelling in other joints91
Level of discomforts82
Morning stiffness - intensity82
Morning stiffness - duration72
Total mean scoring7.31.8

J Ayu Int Med Sci 2024;9(1)325
Rupali Dave et al. Role of Virechan in the management of Ankylosing Spondylitis

Observation in Range of Movements

Range of movementsBefore VirechanAfter Virechan
Lumber flexion10090
Lumber extension3030
Hip flexionRight leg
Left leg		100
100		110
110
Hip extensionRight leg
Left leg		20
20		30
20
AbductionRight leg
Left leg		40
40		50
50
AdductionRight leg
Left leg		15
10		20
20
Hip internal rotationRight leg
Left leg		30
30		45
45
Hip external rotationRight leg
Left leg		40
40		45
45
SLRRight leg
Left leg		90
80		90
90
Faber’s testRight leg
Left leg		Positive
Positive		Negative
Negative
FNSTRight leg
Left leg		Positive
Negative		Positive
Negative

Discussion

The patient condition was approached with a classical line of treatment of Aamvata as the characteristics of Aam and Vata Dosha were clearly reflected in the symptoms mentioned by the patient. Here Panchakarma therapy is designed to eliminate toxins from the body. The Vamaka and Virechaka Dravya induce emesis and purgation respectively due to their specific Prabhav. Virechana is indicated in Aamvata in classical text.[8] Drugs of Virechana are Vyavayi Vikasi[9] Ushna Tikshna Sukshma. Virechana drug having the above properties reach the Hridaya by virtue of its Virya and then following the Dhamani it pervades the whole body through large and small Srotas. On virtue of its Aagneya properties, it causes Vishyandana i.e., melting of the Doshas and by its Tikshana Guna, it is able to disintegrate the accumulated Dosha. Due to Snehana, Dosha smear easily without any hurdle and easily come to Aamashaya from where Virechana evacuates them.[10]

Conclusion

AS is characterized by a chronic inflammatory arthritis predominantly affecting the sacro iliac joints and spine, which can progress to bony fusion of the spine.

It is correlated with Aamvata in Ayurvedic classics according to signs and symptoms. There is currently a large gap between the prevalence of AS and its treatment rates. Though ankylosing spondylitis cannot be cured completely, its symptoms and disease progression can be effectively managed by adopting various Panchakarma procedures at regular intervals. Panchakarma procedures have been proved useful for this manifestation in alleviating symptoms and to reduce severe disability. The present studies shed light on Panchakarma procedures (Virechan) in Ankylosing Spondylitis and it shows remarkable results. It enhances the range of motion and increases the quality of life of patients assessed by the Bath Ankylosing Spondylitis Disease Activity Index and improvement in the quality of life. This study needs to conduct on large number of patients.

References

1. Singh MK, Kumar V. Robbins & Cotran Pathologic Basis of Disease. 10th ed. Vol. 2. Elsevier; Bones Joint and Soft Tissue Tumours, Chapter 26.

2. Wang R, Ward MM. Epidemiology of axial spondyloarthritis: an update. Curr Opin Rheumatol. 2018 Mar;30(2):137-143. [PMC free article] [PubMed]

3. Singh MK, Kumar V. Robbins & Cotran Pathologic Basis of Disease. 10th ed. Vol. 2. Elsevier; Bones Joint and Soft Tissue Tumours, Chapter 26.

4. Kamal V. Textbook of Pathology. Vol. 2. CBS Publishers & Distributors Pvt Ltd; Systemic Pathology, Chapter 27, p. 1520.

5. Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61(Suppl 3):iii8-iii18.

6. Chakradatta, Amavata Chikitsa Prakaranam. Adhaya 25th/1. In: Dwivedi R, editor. Chaukhamba Sanskrit Bhavan Varanasi.

7. Bath Ankylosing Spondylitis Disease Activity Index. Available from: https://www.basdai.com/

8. Chakradatta, Amavata Chikitsa Prakaranam. Adhaya 25th/1. In: Dwivedi R, editor. Chaukhamba Sanskrit Bhavan Varanasi.

9. Sharngadhara Samhita. Varanasi: Chaukhamba Ayurvijnan Granthamala; 2011. p. 50. S. Pu. 4/19.


J Ayu Int Med Sci 2024;9(1)326
Rupali Dave et al. Role of Virechan in the management of Ankylosing Spondylitis

10. Chakrapani. Charaka Samhita (Ayurveda Deepika Commentary of Chakrapani Datta). In: Trikamji Y, editor. Varanasi: Chaukambha Sanskrit Samsthana; 2014. pp. 651-652.


J Ayu Int Med Sci 2024;9(1)327