E-ISSN:2456-3110

Case Report

Management of Asthimajjagata

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 5 May
Publisherwww.maharshicharaka.in

The management of Asthimajjagata Vata w.s.r. to Avascular Necrosis of Femoral Head with Ayurveda recipes - A Case Study

Thakur C1*, Srivastava S2
DOI:10.21760/jaims.9.5.40

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

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

In musculoskeletal clinics, one of the conditions that is more frequently observed, is Avascular necrosis (AVN) of the head of the femur. Basically, it is an osteonecrosis caused by a wound or any obstruction in the arteries supplying blood to the bone tissue. The most frequent type of necrosis is AVN of the femur head because the artery supplying that region is very thin and readily injured by simple dislocation or a sub capital fracture, which causes a lack of food to the tissue and necrosis. Usually, men are more prone to Avascular necrosis than women. There is no specific treatment available in modern medicine other than surgery. Additionally, the prognosis is not good and the cost is high. Present case was aimed to evaluate the efficacy of Ayurvedic procedures in the conservative management of AVN of the femoral head. In this present case a 27 Years old male was diagnosed with AVN of bilateral hip joint was presented with bilateral groin pain associated with limitation of movements of hip joint and pain in back, with difficulty in walking He was given Manjishthadi Majja Basti along with other Panchakarma therapies and oral medicines. After the treatment, the pain decreased, range of movement of both hip joints improved. This case shows that Ayurveda treatment is helpful in the management of Avascular necrosis and helps in improving quality of life.

Keywords: Ashthi Majja Gata Vata, Panchkarma, Avascular Necrosis

Corresponding Author How to Cite this Article To Browse
Chhaya Thakur, Post Graduate Scholar, Dept of Rog Nidan Vikriti Vigyan, Pt Khushilal Sharma Government Ayurveda Institute, Bhopal, Madhya Pradesh, India.
Email: 		Thakur C, Srivastava S, The management of Asthimajjagata Vata w.s.r. to Avascular Necrosis of Femoral Head with Ayurveda recipes - A Case Study. J Ayu Int Med Sci. 2024;9(5):238-243.
Available From
https://jaims.in/jaims/article/view/3402

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-03-17 2024-03-27 2024-04-08 2024-04-18 2024-04-26
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 23.87

© 2024by Thakur C, Srivastava 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].

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Introduction

Avascular necrosis (osteonecrosis) is a progressive disorder where the cellular death of bone component due to interruption of the blood supplies to the bone in transiently or permanently.[1] Avascular necrosis (AVN) is also called Osteochondritis Dissecans / Chandler’s Disease in young adults with 60% of the cases being bilateral.[2] While it can affect any bone, AVN is particularly common in the hip joint. It generally affects people between age of 30 to 50 years. Several factors like trauma, genetic factors, metabolic factors, use of glucocorticoids, diseases that promotes hypercoagulable states are the etiological factors of AVN.[3] Initially, patients are asymptomatic, but with the passage of time, AVN leads to joint destruction, requiring surgical intervention in latter stages, total hip replacement (THR) is required.[4] It typically affects the epiphysis of long bones at weight-bearing joints. The upper arm, knee, and ankle joints are also affected in the case of AVN. Usually, men are more prone than women. Patient of AVN of femoral head is often having pain in hip or groin region radiating to buttocks, thigh or knees, exacerbated by heavy weight and sometimes often by coughing.[5] As per the clinical features, this condition can be correlated with Asthi - Majjagata Vata in Ayurveda. The sign and symptoms of Asthimajjagata Vata are Bhedoasthiparvanam (breaking type of pain in bones), Sandhishoola (Joint Pain), Mamsakshaya (Muscular Wasting), Balakshaya (weakness), Sandhishaithilyam (flexity of joints), Aswapna Satatruka (sleeplessness due to continuous pain), Shiryantiva Cha Asthi-Dourbalyani (destruction of bony tissue causing generalized weakness).[6]

Case Report

A 27 years old male patient came to the OPD of Pt. Khushilal Sharma Government Ayurveda Institute, Bhopal having complaints pain in B/L hip joints which radiates to both thigh region (Rt. > Lt.), morning stiffness more than 30 minutes, pain in B\L groin region, pain during prolonged sitting, difficulty in walking, restricted movement of both lower limb, sleeplessness due to pain. The patient was well before 11 months then gradually pain start in right hip joint with stiffness which radiates in lower limb then after 3 months his condition

become worsened and felt pain in left hip joint too. The pain aggravates during prolonged sitting on the chair or any other activity. The pain was so severe so his gait has been changed. Moreover, his day-to-day activities were also hampered due to pain and stiffness. The patient had received allopathic treatment for 5-6 months but did not get satisfactory relief. Thus, he approached further for Ayurvedic management.

Local Examination

1. Tenderness present in bilateral hip region (R>L)

2. Significant loss in the range of movement.

3. Gait-Trendelenburg sign positive.

4. Painful internal and external rotation.

Ashtavidha Pariksha

NadiVata - Pittaja
MutraPrakrut
MalaSnigdha
JivhaSaam
ShabdhaSpastha
SparshaSamasheetoshna
DrikPrakrut
AakritiMadhyam

Samprapti Ghatak

DoshaVata - Kapha
DushyaAsthi, Majja, Sandhi, Rakta, Sira, Snayu
SrotasAsthivaha, Majjavaha ,Medovaha
SrotodushtiSang
RogamargMarmaasthisandhi
AdhishthanAsthi - Sandhi
UdhabhavasthanAam - Pakwashaya
Vyakta-SthanAsthi - Sandhi

Aaturbala Pramana Pariksha

PrakrutiVata - Pittaja
SaraRaktasara
SamhananaMadhyama
PramanaWeight - 71kg, Height - 180cm
SatmyaMadhyama
SatvaMadhyama
AharashaktiMadhyama
VyayamashaktiAvara
VayaYuvavastha
DeshaSadharana

Personal History

  • Diet - Vegetarian
  • Appetite - Normal
  • Bowel - Clear
  • Bladder - Normal
  • Sleep - Disturbed
  • Addiction - Not any

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  • Occupation - Medical Representative

Past illness - No history of any major illness

Family History - Not Significant related to present illness

Surgical History - Not Significant

Vital Examinations

  • Pulse Rate - 74/minute, Regular
  • Blood Pressure - 120/80 mmHg
  • Temperature - 98.7°F
  • Respiratory Rate - 19/minute

Investigation

Blood investigation dated April 04, 2023

1. Hb% - 14.1 g/dl

2. Sickling test - Negative

Radiological Report

MRI - MRI scan (08/04/2023) revealed Grade II AVN on right side and Grade III AVN on left side of femoral head.

X-ray B\L Knee Joint (03/04/2023)

jaims_3402_02.JPG

jaims_3402_01.JPG

Treatment administered

This diagnosed case of Avascular necrosis of the femoral head was admitted to the male private ward of Pt. Khushilal Sharma Government Ayurveda Institute, Bhopal with IPD no. 20231953 and undergo the following procedures.

Table 4: Oral Ayurveda medicines were administered in the patient.

DrugsDoseTimeDuration
Kaishora Guggulu1BDAfter meal8 weeks
Singhnad Guggulu1BDAfter meal8 weeks
Punarnavadi Guggulu1BDAfter meal8 weeks
Vatvindhwansak Rasa1BDAfter meal8 weeks
Mahamanjishthadi Kwath30 ml BDAfter meal8 weeks
Manjishthadighan Vati2BDAfter meal4 weeks
Cap. Gandh Tailam1BDAfter meal8 weeks
Cap. Ashwagandha1BDAfter meal4 weeks
Cap. Nucart OA2BDAfter meal4 weeks
Cap. Boniheal1BDAfter meal8 weeks

Table 5: Panchakarma Therapy

SNProcedureDrug usedQuantityDays
1. UdavartanaTriphala Choorna + Kottamchukkadi Choorna7 days
2. Vashpa SwedanDashamoola Kwath07 days along with Udavartana
3. B/L Vankshan BastiChandanbalakshadi TailNext 15 days
4. Sarvang Patra Pinda
Swedan		Eranda Patra, Nirgundi Patra, Shigru Patra, Ark Patra, Lemon, Harida, Coconut etc.15 days along with Vankshan Basti
5. PishinchilChandanbalakshadi Tail + Balashwagandha TailNext 8 days
6. Manjisthadi Majja Basti (Karma Basti)Anuvasana basti
Chandanbalakshadi Tail
Majja
Saindhav
Niruha Basti
Manjishthadi Kwath
Majja
Madhu
Saindhav
Saunf
Ajwain		60ml
40ml
5 gm
300 ml
40 ml
50 ml
5 gm
20 gm
20 gm		30 days
Anuvasan Basti - 18
Niruha Basti - 12

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Table 6: Steinberg’s classification of avascular necrosis of the femoral head[7]

StageDescription
0No symptoms, Normal or non-diagnostic X-ray, bone scan and MRI
1Mild pain in the affected hip, pain with internal rotation, Normal x-ray, Abnormal bone scan or MRI
2Worsening or persistent pain, increased sclerosis or cysts in the femoral head
3Subchondral collapse, produce crescent sign
4Flattening of femoral head, normal acetabulum, normal joint space

Table 7: Assessment criteria on the Basis of Gradation System

CriteriaGrading
Pain in hip and groin region0 – No pain
1 – Occasional pain and can be ignored
2 – Interfere with task
3 – Interfere with basic needs
4 – Bed rest require
Stiffness of hip joint0 – No stiffness
1 – Occasional stiffness present
2 – Stiffness retains for 30 minutes
3 – Stiffness after sitting and walking for long time
4 – Stiffness whole day or whole night
Restricted range of movement of hip joint0 – No restriction (flexion of 130°)
1 – Restricted initially (flexion of 90°-130°)
2 – Partially restricted (flexion of 70°- 90°)
3 – Restricted with pain (flexion 45°-70°)
4 – No joint movement (flexion 0°-45°)
Gait (limping gait)0 – Normal without pain
1 – Occasional pain during walking
2 – Walk with support with mild pain
3 – Walk with support with severe pain
4 – Unable to walk
Distance walked by patient within 10 minutes0 – 90 feet
1 – 60 feet
2 – 30 feet
3 – < 30 feet

Table 8: Assessment before and after treatment

SNAssessment criteriaBefore treatmentAfter 30 days of treatment
1. Pain in hip and groin region31
2. Stiffness of hip joint30
3. Restricted range of movement of hip joint10
4. Gait (Limping Gait)21
5. Distance walked by patient within 10 minutes30
6. Steinberg’s classification11

Table 9: Observation in Range of Movement of Hip Joint

Range of MovementBefore TreatmentAfter Treatment
Abduction
(30° – 50°)		Right Leg2540
Left Leg3050
Adduction
(20°– 50°)		Right Leg2530
Left Leg3040
Flexion
(110° – 120°)		Right Leg90110
Left Leg100120
Extension
(10° – 15°)		Right Leg1010
Left Leg1015
Internal rotation
(30° – 40°)		Right Leg1015
Left Leg2030
External Rotation
(40° – 60°)		Right Leg2040
Left Leg3050

Discussion

Udavartana

This was done using Triphala Choorna and Kottamchukkadi Choornam, Triphala Choorna includes Haritaki, Vibhitaki and Amalaki having Ruksha and Tridoshahara, Kapha Medahara Guna which helps in removing Avarana. Kottamchukkadi Choornam contains equal quantities of Pushkaramoola, Vacha, Viswa, Suradruma, Lasuna, Sigru, Rasna, Sarshapa Chinchapatra etc. Its Roga Karma - Vataroganashaka, Dosha Karma - Vatakaphahara and Shophahara Guna.

Vashpa Swedana

Swedana drugs are having Ushna and Tikshna Guna which are capable of relieving Stambhana, Gaurava. This was done using Dashmoola Kwatha having Tridoshara (alleviating all deranged Doshas), Vedanasthapana (pain killer) and Shothahara (subside inflammation) properties. It also helps in removing Avarodh which helps in the proper blood circulation.

Vankshan Basti

In Vankshan Basti, warmth pressure of the oil allows deeper absorption into the muscles, tendons and ligaments, relaxing spasms and reducing pain and stiffness of Vankshan. This was done using Chandanbalalakshadi Tail which contains Til Tail, Sveta Chandana, Bala Mul, Pipalalakh, Lajjalu, Jal, Godugdha, Sveta chandana, Ushir, Yasthimadhu, Satpushpa, Katuki, Devadar, Haridra and Kuth etc. Chandana, has Pitta Shamaka (pitta pacifying) properties. It also help to reduce skin irritations, itching, burning sensations and inflammation.


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Bala, which balances all the 3 Doshas, especially Vata. Additionally, it helps relieve the symptoms of pain, emaciation etc. Nagakesar, which contains anti-inflammatory, analgesic and antispasmodic activity.

Patra Pinda Swedan

It relieves stiffness, pain, and swelling improves the range of movements associated with painful conditions of joints, improves blood circulation in the body and soothes nerves, and provides relief from pain.[8]

Pishichil

It is the Brihana type of Snigdha Swedana where Snehana and Swedana occur concurrently. Chandanbalakshadi Tail and Balashwagandha Tail were used in the procedure. Balashwagandha Tail balances Vata and Pitta, strengthens muscles, bones, jopints and improve quality of blood. Chandanbalalakshadi Tail helps to reduce inflammation and burning sensation.

Manjisthadi Majja Basti

In all procedures of Panchkarma, Basti is the first line of treatment of Vata Dosha as Dosha Pratyanik Chikitsa. Manjisthadi Majja Basti (processed with bone marrow) was planned which includes Majja and Manjisthadi Kwath with Tikta Rasa, Katu Vipaka, Ushna Virya which is Tridoshahara and Raktaprasadaka. Tikta Rasa has Srotoshodhan properties which help to clear the Srotosanga. Majja nourishes Asthi by means of its Purana (filling) and Snehan properties, that strengthen Majja Dhatu which in turn nourishes Asthi Dhatu. Thus, it pacifies Vata, improves the Dhatu Upachaya (metabolism of the tissues) and acts as a rejuvenator of the body.

Conclusion

Based on this case study, it was shown that Manjisthadi Majja Basti, in combination with specific palliative medications, is beneficial in treating Avascular necrosis of the femoral head. In present case, given treatment has significantly reduced discomfort, soreness, stiffness, and improved gait. The overall outcomes were positive and recovery was encouraging and deserving of documentation. Even though there is a huge need for more research, this shows that Ayurveda

can be very helpful in the management of AVN when used in conjunction with a thorough diagnostic and treatment plan.

References

1. Bailey & Loves, Short Practice of Surgery, 25th Ed., Part 5, Chapter 35, p. 515.

2. Kadlimatti SM, Subbanagouda PG, Sanakal AI, Deshpande M. Ayurvedic management of avascular necrosis of the femoral head – A preliminary study. AYU. 2008;29:154–60.

3. Robert S Weinstein, Erin A Hogan, Michael J Borrelli, Serguei Liachenko, Charles A O’Brien, Stavros C Manolagas; (2017) The Pathophysiological Sequence of Glucocorticoid-Induced Osteonecrosis of the Femoral Head in Male Mice, Endocrinology, Volume 158, Issue 11, Pages 3817–3831, [PubMed]

4. http:/ /emedicine.medscape.com/article/ 386808, updated: Aug 1, 2008.

5. Orban HB, Cristescu V, Dragusanu M. (2009) Avascular necrosis of the femoral head. MAEDICA-a Journal of Clinical Medicine. 1;4(1):26-34.

6. Acharya YT, editor, Shri Chakrapanidatta, commenta-tor, Agnivesha, Charaka Samhita, Chikitsasthana; Vatavyadhichikitsa Adhyaya, 28/33, Chaukhamba Surbharti Prakashan, Varanasi, 2014; page 617.

7. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br, 1995; 77(1): 34-41. Pub med citation

8. http://www.iamj.in/posts/images/upload/2300_2304.pdf


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