E-ISSN:2456-3110

Case Report

Silajathu Rasayana

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 11 NOVEMBER
Publisherwww.maharshicharaka.in

Silajathu Rasayana in management of Ankylosing Spondylitis - A Case Report

Hariharan Mk1*, Giri PV2
DOI:10.21760/jaims.9.11.50

1* Hariharan Mk, Post Graduate Scholar, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Ollur, Thrissur, Kerala, India.

2 Giri PV, Professor, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Ollur, Thrissur, Kerala, India.

Ankylosing Spondylitis is a chronic seronegative inflammatory condition that primarily impacts the sacroiliac joint and spine, potentially leading to the fusion of spinal bones. The exact cause of this condition remains unknown. A 50 year old female patient was admitted to the Kayachikitsa inpatient department of Vaidyaratnam Ayurveda College, Ollur, presenting with both knee pain and swelling, pain in both elbow joints, and generalized back pain. She was treated by following the Amavatha management protocol, which included internal administration of Ayurvedic formulations such as Amrithotharam Kashaya, Indukantham Kashaya, Yogaraja Guggulu, Punarnavasam, and Rasnapanchakam Kashaya. External therapies such as Churna Pinda Sweda, Snehapana, Sarvanga Taila Dhara and Virechana. Silajathu Rasayana were administered in the final stage of the treatment. After six weeks of treatment, the patient experienced significant relief from upper and lower back pain, reduced elbow pain, and noticeable improvement in knee joint swelling and discomfort. This case study emphasizes the efficacy of Ayurvedic management especially Rasayana chikitsa in achieving substantial symptom improvement within a short duration.

Keywords: Ankylosing spondylitis, Rasayana therapy, Silajathu Rasayana, Amavata, Case report

Corresponding Author How to Cite this Article To Browse
Hariharan Mk, Post Graduate Scholar, Dept of Kayachikitsa, Vaidyaratnam Ayurveda College Ollur, Thrissur, Kerala, India.
Email: 		Hariharan Mk, Giri PV, Silajathu Rasayana in management of Ankylosing Spondylitis - A Case Report. J Ayu Int Med Sci. 2024;9(11):336-342.
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https://jaims.in/jaims/article/view/3861

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-10-02 2024-10-12 2024-10-22 2024-11-02 2024-11-18
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© 2024by Hariharan Mk, Giri PVand 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(11)336
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Hariharan MK et al. Silajathu Rasayana in management of Ankylosing Spondylitis

Introduction

Radiographic axial spondyloarthritis (axSpA), also referred to as ankylosing spondylitis (AS), is a chronic, progressive, immune-mediated form of arthritis. It is distinguished by the absence of rheumatoid factor and inflammation affecting the axial skeleton, peripheral joints, entheses, and extra-articular sites such as the eyes and intestines. Radiographic sacroiliitis serves as the defining characteristic of AS, although patients often report back pain symptoms for years before radiographic changes become apparent.[1] As it affects approximately 1 in 200 people, while axSpA impacts over 1 in 100.[2] The condition typically begins before the age of 45,[3] with about 80% of individuals experiencing their first symptoms before turning 30, and fewer than 5% being diagnosed after 45. AS is more common in men than women, and relatives of affected individuals have a higher risk of developing the condition.[4] The progression of AS varies widely, ranging from mild stiffness with normal radiographs to severe cases involving a completely fused spine, bilateral hip arthritis, severe peripheral arthritis, and extra-articular complications. Early in the disease, pain tends to be persistent, later becoming intermittent with alternating phases of exacerbation and remission. In women, AS is less likely to progress to complete spinal ankylosis. However, there may be a higher prevalence of isolated cervical ankylosis and peripheralarthritis.[5] Since the onset often occurs during the most productive years of adulthood, AS significantly impacts physical function, work productivity, and overall quality of life. Consequently, AS represents a significant healthcare and socioeconomicconcern.[6]

This condition may be correlated with Amavata according to Ayurvedic classics. In Amavata, the vitiated dosha settle in the Trika Sandhi, which includes the lumbosacral and sacroiliac joints. This leads to stiffness throughout the body, including the spine.[7] The condition of Stabdhata (stiffness) arises due to ankylosis and spondylitis. Jadya, characterized by stiffness and loss of mobility, is also mentioned as a symptom of Amavata. Additionally, Saruja Shotha, which refers to painful swelling in various parts of the body, signifies pain and inflammation on either axial or peripheral part of the body based on Dosha affiliation.[8]

This case represents an uncommon presentation of AS, as it involves a 50-year-old woman who exhibited significant improvement with Ayurvedicmanagement.

Case Report

A 50-year-old female patient presented with complaints of pain and swelling in both knee joints, both elbow joints, and the upper and lower back. Her symptoms initially began 10 years ago with pain and swelling in all digits and both elbows, for which she sought allopathic treatment and experienced relief. However, the condition recurred after three months, prompting her to continue regular follow-ups with allopathic care.

In 2016, she transitioned to Ayurvedic treatment, which effectively alleviated her pain and swelling. After one year, she gradually developed pain and swelling in both knee and elbow joints, along with generalized pain in the upper and lower back. She resumed allopathic treatment and initially responded well, but over time, the effectiveness of the treatment diminished, providing insufficient pain relief. Seeking better management for her condition, she was admitted to the inpatient department of Vaidyaratnam Ayurveda Collegeon2/4/24.

There was no relevant family history noted. On general examination, patient was obese with BMI of 33.96 kg/m2 and vitals were within normal limit.

Personal History

Appetite: Good
Bowel: Irregular
Micturition: Regular
Sleep: Reduced
Diet: Mixed
Allergy: Nil
Habit: No smoking, alcoholism

Systemic examination

On examination of Locomotor system

  • Cervical spine - No abnormality detected
  • Thoracic spine - On palpation, mild tenderness over T7, T8 spinous process.
  • Lumbar spine - on lateral flexion, a mild limitation in left side was noted
  • Shoulder joint B/L - Normal on inspection, palpation and ROM

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Hariharan MK et al. Silajathu Rasayana in management of Ankylosing Spondylitis
  • Elbow Joint B/L - Normal on inspection, palpation and ROM (mild pain on left elbow while flexion)
  • Hip joint - Normal on inspection, palpation and ROM- (flexion is painful on left side)
  • Knee Joint
    • Right - On inspection mild swelling and warmth,
    • ROM - possible with mild pain on flexion and extension
    • Left - On inspection mild swelling present, no warmth,
    • And moderate pain on flexion and extension
  • Ankle Joint - Normal on inspection, palpation and ROM

Timeline representation

2014Pain& swelling on joints of digit & elbow-taken allopathic Rx
↓
2016As the symptoms recurring in 3-month gap-underwent ayurvedic op management for 3 months
↓
2017Pain & swelling on both knees, both elbow pain, generalized back pain
↓
2017-24On allopathic treatment. Earlier well responded, later not responding
↓
2024 AprilAdmitted in VAC Hospital, Ollur for the management

Investigation

jaims_3861_01.JPG
Picture 1: HLAB27 report

Haematology

  • 03/04/2024 - ESR-60 mm/hr, RA - < 8 IU/ml
  • 13/04/2024 - HLA-B-27 - Positive
  • 14/05/2024 - ESR-40mm/hr, CRP-<2.5IU/ml

jaims_3861_02.JPG
Picture 2: X ray findings

X ray findings
Grade 2 bilateral sacroiliitis, Sacralization of lumbosacral joint

Diagnostic criteria

ASAS Classification Criteria for Axial Spondyloarthritis[9]

  • Back pain ≥ 3months, and age at onset < 45-year-old
  • Sacroiliitis on imaging (Grade2 Bilaterally),
  • With 1 or more SpA Features - Inflammatory backpain

Arthritis
H/o Dactylitis
Earlier good response to NSAIDs
HLA - B27

Modified New York Criteria for Ankylosing Spondylitis[10]

  • Low Back pain & Stiffness for more than 3months, which improves with exercise, but is not relieved by rest
  • Sacroiliitis on imaging (Grade2 Bilaterally)

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Hariharan MK et al. Silajathu Rasayana in management of Ankylosing Spondylitis

As per these criteria, the disease is diagnosed as Ankylosing spondylitis. Reactive arthritis is excluded as there is no history of previous infection before the onset of symptoms.

Ayurvedic examination details

Dasavidha Pareeksha

  • Prakriti: Kapha Vata Prakriti
  • Dosha vitiated: Vyana Vayu, Shleshaka kapha
  • Dhatu: Rasa, Mamsa, Asthi,
  • Upadhatu: Kandara, Snayu
  • Sara: Madhyama
  • Samhanana: Pravara
  • Satva: Madhyama
  • Satmya: Madhura, Katu, Tiktha
  • Srotas: Asthivaha, Mamsavaha, Rasavaha
  • Pramana: Sthoola
  • Aharasakthi : Madhyama
  • Abyavaharana Sakthi: Madhyama
  • Jarana Sakthi: Madhyama
  • Vyayama Sakthi: Madhyama
  • Vaya: Madhyama
  • Kala: Greeshma
  • Vyadhavastha: Purana
  • Desham: Bhoomi - Sadharana, Deha - Sandhi, Prishta
  • Rogamarga: Madhyama

Roga Nirnayopaya Nidana

  • Aharaja Nidana include intake of sweets, and spicy foods excessively, intake of Dadhi.
  • Viharaja Nidana like sedentary life, reduced sleeping hours, washing vessels, cleaning floor just after food.

Poorvaroopa - Sopha in Sandhi of Anguli & Koorpara

Roopa - Janu Sopha & Soola, Koorpara Soola, Angamarda on lowback & upper back

Samprapti

Vatha Vardhaka Nidana + Kapha Dushti, Ama Janma

↓
Sthanasamraya in Prishta, Janu, Koorpara
↓
Produces symptoms like Sopha, Ruk

Upasaya - Ushna, Rooksha

Anupasaya - Sheeta, Snigdha

Roga Nirnaya - Amavata

Therapeutic intervention

DateInternal MedicineDoseTime of administration
02/04/24 -
17/04/24		Amrithotharam Kashaya15m Kashaya +45 ml lukewarm waterBefore food, 6am, 7pm
Indukantham Kashaya 15m Kashaya +45 ml lukewarm waterAt 1pm before food
Yogaraja Guggulu1-0-1With Amrithotharam Kashaya
Punarnavasavam 30 mlBD after food
18/04/24 –
19/04/24
23/04/24 -
25/04/24
27/04/24-
30/04/24		Rasna Panchaka Kashaya15m Kashaya +45 ml lukewarm waterBefore food, 6am, 7pm
Indukantham kashaya 15m Kashaya +45 ml lukewarm waterAt 1pm before food
Yogaraja guggulu1-0-1With Rasnapanchaka Kashaya
Punarnavasava 30mlBD after food

Treatment given

DateProcedureMedicine
03/04/24 - 16/04/24Choorna Pinda SwedaKolakulathadi Churna in Dhanyamla steam
17/04/24 - 19/04/24Mensus days
20/04/24 - 22/04/24Snehapana Guggulu Tikthaka Ghritha (30ml, 50ml, 50ml respectively)
23/04/24 - 25/04/24Sarvanga DharaMadhu Yashtyadi Taila
26/4/24Virechana Avipathi Choorna 25gm with honey at 9:30 am
27/4/24 - 30/4/24Sarvanga DharaMadhu Yashtyadi Taila
1/5/24 - 3/5/24Snehapana Guggulu Tikthaka Ghritha 30ml
04/05/24 - 06/05/24Silajathu Rasayana12gm Shilajatu with Triphala Kashaya
07/05/24 - 09/5/24Silajathu Rasayana12gm Shilajatu with Patola Kashaya
10/5/24-12/524Silajathu Rasayana12gm Shilajatu with Yashti Kashaya

Outcome assessment

  • Visual Analogue Scale: Before treatment (BT)- 8 and After treatment (AT)- 2
  • ASDAS (Ankylosing spondylitis disease activity score)11

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Hariharan MK et al. Silajathu Rasayana in management of Ankylosing Spondylitis
SymptomsBTAT
Total back pain84
Peripheral pain or swelling80
Duration of morning stiffness85
Patient global82
ESR mm/hr6040

ASDAS - BT: 5 (>3.5 Suggest Very high disease activity)

AT: 2.7 (2.1 – 3.5 – High disease activity)

Greater than 2-point change in ASDAS score indicates Clinically Important Improvement

  • BASDAI (Bath Ankylosing Spondylosis Disease Activity Index)[12]
SymptomsBTAT
Fatigue81
Neck pain, back pain and hip pain84
Pain and swelling in other joints80
Enthesitis70
Morning stiffness (intensity)85
Morning stiffness (duration)75

BASDAI - BT: 7.8

AT: 2

Discussion

This case involves a 50-year-old female patient presenting with swelling and pain in both knees, pain in both elbows, generalized upper and lower back pain, fatigue, and morning stiffness lasting up to 1 hour and 30 minutes. She tested positive for HLA-B27. Following the Ayurvedic treatment protocol for Amavatha, significant improvements were observed in the patient's symptoms, including pain and swelling in the knees, elbow pain, and moderate relief in generalized back pain and morning stiffness.

The treatment protocol included the administration of Amrithotharam Kashaya, known for its Ama Pachana (digestion of Ama), Tridoshahara (balancing all three doshas), antioxidant, and anti-inflammatory properties. It contains phenolic acids such as quinic acid, protocatechuic acid, gallic acid, and chebulic acid.[13] Indukantha Kashaya, a modified form of Indukantha Ghritha, was used for its Ama Pachana, Balavardhana (strengthening), and Vatamayahara (Vata-balancing) effects. Yogaraja Guggulu, particularly indicated for Amavatha, provided Agni-Deepana (digestive fire enhancement),

Tejo-Vardhaka (energy-boosting), and Sandimajjagata Vatahara (relief for joint and marrow-related conditions).[14] Punarnavasa was included for its Sophahara (anti-inflammatory) and Jwarahara (antipyretic) properties, as well as its effectiveness in managing chronic conditions.

Externally, Choorna Pinda Sveda with Kolakulathadi Churna in Dhanyamla steam was performed, which alleviated muscle spasms, reduced inflammation, and improved collagen extensibility, resulting in increased range of motion (ROM). Following the initial Ama Pachana, Rasnapanchakam Kashaya was administered for its effects on Sama Sandi Asthi and Majja (joints, bones, and marrow).[15]

After initial Ama Pachana, the Vata Vyadhi Chikitsa- Snehana, Svedana and Mridu Sodhana was planned. As part of that, Snehapana with Guggulu Tikthaka Ghritha was given for three days to manage joint, bone, and marrow-related conditions.[16] As the patient was hesitant to consume ghee internally, external Snehana (oleation) was performed using Madhuyashtyadi Taila. This oil, with its Lavana (salty), Amla (sour), and Madhura (sweet) properties, nourished the affected areas, reducing pain, stiffness, and inflammation. Once the patient achieved the desired Samyak Snigda Svinna Avastha (properly oleated and sweat-induced state), Mridu Virechana was administered using 25 g of Avipathi Churna with honey.[17]

Prior to starting Rasayana therapy, the body should be prepared with Sneha (oleation) to build the strength and resilience required to effectively endure and benefit from the potency oftheRasayana. For that Sarvanga Taila Dhara for four days and three days of Snehapana with Guggulu Tikthaka Ghritha were done. Silajathu Bhavana was performed in Maharasnadi Kashaya, chosen for its suitability in both the disease and the patient. In ankylosing spondylitis, ankylosing of the bones are happening, in that the Lekhana (scraping) action of Shilajathu may be beneficial. Based on this logic, Silajathu Rasayana was chosen.[18]

Conclusion

This comprehensive Ayurvedic treatment protocol successfully managed the symptoms of ankylosing spondylitis in this patient, leading to significant improvements in pain, swelling, stiffness, and fatigue.


J Ayu Int Med Sci 2024;9(11)340
Hariharan MK et al. Silajathu Rasayana in management of Ankylosing Spondylitis

The case underscores the potential of Ayurvedic interventions in addressing chronic autoimmune conditions like ankylosing spondylitis. The integration of Ayurvedic treatment procedures, along with Rasayana therapy, resulted in remarkable symptom relief, enhanced overall quality of life, and notable improvements in laboratoryparameters.

References

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2. Dean LE, Jones GT, MacDonald AG, Downham C, Sturrock RD, Macfarlane GJ. Global prevalence of ankylosing spondylitis. Rheumatology. 2014 Apr 1;53(4):650-7.

3. Braun A, Saracbasi E, Grifka J, Schnitker J, Braun J. Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain?. Annals of the rheumatic diseases. 2011 Oct 1;70(10):1782-7.

4. Wang R, Ward MM. Epidemiology of axial spondyloarthritis: an update. Current opinion in rheumatology. 2018 Mar 1;30(2):137-43.

5. Fauci, [et al.], Harrison’s Principles of Internal Medicine. 19th edition, Vol 1. New York: published by McGraw- Hill Education copyright 2008, chapter 384, P 2171

6. Dagfinrud H, Kjeken I, Mowinckel P, Hagen KB, Kvien TK. Impact of functional impairment in ankylosing spondylitis: impairment, activity limitation, and participation restrictions. The Journal of rheumatology. 2005 Mar 1;32(3):516-23.

7. Rana R, Kumar P, Sharma CS, Kumari S. A Literary Review of Amavata. International Research Journal of Ayurveda and Yoga. 2022 Jul 31;5(7):149-57.

8. Bhandarkar VA, Kulkarni VR, Khandare VJ, Sanjeev V. AMAVATA: A LITERATURE REVIEW.

9. Rudwaleit M, Braun J, Sieper J. ASAS classification criteria for axial spondyloarthritis. Zeitschrift für Rheumatologie. 2009 Sep;68:591-3.

10. Moll JM, Wright V. New York clinical criteria for ankylosing spondylitis. A statistical evaluation. Annals of the rheumatic diseases. 1973 Jul;32(4):354.

11. Machado P, Landewé R, Lie E, Kvien TK, Braun J, Baker D, van der Heijde D, Assessment of Spondylarthritis international Society. Ankylosing Spondylitis Disease Activity Score (ASDAS): defining cut-off values for disease activity states and improvement scores. Annals of the rheumatic diseases. 2011 Jan 1;70(1):47-53.

12. Calin A, Nakache JP, Gueguen A, Zeidler H, Mielants H, Dougados M. Defining disease activity in ankylosing spondylitis: is a combination of variables (Bath Ankylosing Spondylitis Disease Activity Index) an appropriate instrument?. Rheumatology. 1999 Sep 1;38(9):878-82.

13. Giri P V, Dr. Nitin Madav Kamat. Assessment of ama pachana effect of amrithotharam kashayam in rheumatoid arthritis. Tilak Maharashtra Vidyapeeth,Pune;2019.

14. Srikanth D.A Comparative Clinical Study on the Therapeutic Effect of Vaitarana Basti and Yogaraja Guggulu in Amavata WSR To Rheumatoid Arthritis(Doctoral dissertation, Rajiv Gandhi University of Health Sciences (India)).

15. P V Sharma. Cakradatta Sanskrit text with English Translation. edition 2013. Vol. 25/7. Chaukhambha Orientalia; 228 p.

16. Bargi AA. Ayurvedic management of Infertility-A Case Report. Journal of Ayurveda and Integrated Medical Sciences. 2023 Jun 24;8(5):260-4.

17. Yadav M, Mangal G. A Review of Unique Panchakarma Modality Sarvangadhara. International Ayurvedic Medical Journal. 2021 Oct 16;9:2481–5.

18. Meena H, Pandey HK, Arya MC, Ahmed Z. Shilajit: A panacea for high-altitude problems. Int J Ayurveda Res. 2010;1(1):37–40.

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