Introduction

The word ankylosing spondylitis comprises of two Greek words: Ankylose meaning stiff / rigid and Spondylos meaning vertebra. It’s a chronic progressive inflammatory disease primarily affecting axial skeleton, peripheral joints, & extra-articular structures usually with sacroiliitis. The symptoms are mostly marked in early morning and after inactivity but are reduced by movement/ exercises. It usually manifests in 2^nd or 3^rd decade with male: female ratio of 2:1 to 3:1. The genetic involvement of TNF- A, HLA-B27, IL-1 causes immune mediated inflammation. As disease progresses, stiffness in spine may limit range of motion, affecting posture and mobility. In modern medicine NSAIDs & DMARDs are used for management of ankylosing spondylitis but show limited results. So, there is a need to search a satisfactory management in ayurveda. A patient of ankylosing spondylitis was treated as per ayurvedic management of Kati-Pristha Trik Graha where major symptoms are Stambha & Shula in Kati-Prisha Pradesh (low back region) having Vata-Kapha predominance. Current case was successfully treated by Ayurveda line of manag. with Sodhana (Bio-purificatory therapies) followed by Shamana Chikitsa (oral medications).

Case Report

A 37-year-old male, non-alcoholic, non-smoker, married serviceman visited Panchakarma O.P.D of I.P.G.A.E.R at SVSP with complaints of difficulty in forward bending, morning stiffness and low back pain since last 1 year. After careful investigations, patient was admitted to male Panchakarma ward on 28^th March 2024 for panchakarma procedures. The patient was on ayurvedic treatment since beginning of his signs and symptoms. No such relevant family history was found.

Clinical findings

The patient had several episodes of squeezing type of lower back pain, difficulty in forward bending along with morning stiffness lasting throughout day since last 1 year along with disturbed sleep due to pain and reduced appetite. Cold temperature, long standing (>10 mins), prolonged sitting (> 20 mins), walking (>30 mins), exercises especially forward bending, prolong lying in supine posture at night and changing posture while sleeping aggravated symptoms while mild stretching,

Diagnostic assessment

The patient had symptoms of pain and stiffness along with disturbed sleep and loss of appetite. According to Acharya Susruta, Shula (pain) can never happen without the involvement of Vata.^[1] So, these features can be corelated with various conditions mentioned in Ayurvedic classics like Gridhrasi, Amavata, Katigraha and Kaphavrita Vata. In Gridhrasi there is a specific pattern of constant pain which is felt in the lumber region that radiates to the Kati (buttock), Pristha (back), Uru (thigh), Janu (knee), Jangha (calf), Pada (foot).^[2]

This is not found in our case, so Gridhrasi is eliminated. In Amavata, there is Angamarda, Aruci, Trishna, Alasya, Gaurav along with Jwara and Vrischikvata Vedana^[3] which are majorly not found in this case, so it was also excluded. The primary Samprapti of Vatavyadhi are Srotavarodha (obstruction) and Kshaya (degeneration). Acharya Charaka has mentioned Kati-Pristha-Trik Graha under the umbrella of 80 types of Vataja Nanatmaja Vyadhi.^[4]

Acharya Sodhala has mentioned Katigraha as a separate disease in Vatavyadhi Cikitsa Adhyaya where there is involvement of Ama along with Vata causing Stambha in the Katipradesha.^[5] This indicates that Avarana of Kapha in Sandhi leads to the obstruction and aggravation of Vata in Kati Pradesh. Considering the signs and symptoms it was corelated with Kati-Pristha-Trik Graha and treated accordingly.

Figure 2: Ingredients for Patra Pottali Swedana

Therapeutic Assessment

Snehana (oleation), Swedana (fomentation) and Basti (medicated enema) are line of treatment of Vatavyadhi. Here patient was having complaints of Shula and Stambha which are Lakshana of Vata Prakopa along with Graha which is due to Kapha. The primary aim should be Vata Prashamana along with Kapha Shamana. So, treatment started with Sarvanga Abhyanga (external oleation therapy) for 30 mins with Prasarani Taila taken quantity sufficient. The patient was given Patra Pinda Swedana (bolus fomentation) for 15 days which is indicated for Vatakapahaja condition.

Follow-Up and Outcome

The haematological investigation was repeated on 20^th April 2024 where CRP was reduced to 6 mg/L. Significant improvement were noted in other parameters(table). Stiffness, pain, fatigue, appetite, sleep and acute phase reactants (CRP) were reduced after treatment. There was an improvement in functional capacity and global condition of the patient.Two follow ups were done after discharge on 15^th day 31^st day.

Subjective Parameters

Discussion

The line of treatment of Vatavyadhi is Snehana, Swedana, Mridu Samsodhana.^[6] At first Snehana (oleation) was done as Sarvanga Bahya Abhyanga (message) with Prasarani Taila for 15 days. Snehana helps provide unctuousness, softness and moistness in the body.^[7] Prasarni Taila is indicated in impairment of Snayu, Sandhi, Asthi and Mamsa Peshi as it helps in relaxing and soothing the constricted structures. Swedana (fomentation) helps in mitigating Stambha (rigidity), Gaurava (heaviness) and Shita (coldness)^[8] from body and also helps in Ama Pachana and movement of Dosha from Sakha to Kostha. Patra Pottali Pinda Swedana is a type of Snigdha-Ruksha Sankara Swedana (bolus fomentation) which is indicated for Vata-Kapha Janya Vyadhi.^[9] It contains the leaves mentioned in Swedopaga Gana of Acharya Charaka having Ushna Virya, Snigdha, Sukshma Guna and Vata-Kaphahara Karma. By the virtue of Guna, it pacifies Vata-Kapha and does Ama Pachana. Basti acts on Pakwashaya and no any remedy other than Basti is effective in combating Vata Vikara.^[10] It is considered as “Ardha Cikitsa” (half treatment).^[11] It expels Dosha and Mala from the body and restores Agni, Bala, Varna and Vaya.^[12] Erandamuladi Basti possesses Deepana and Lekhana Karma.^[13]