INTRODUCTION:

Osteoarthritis (OA)^16,22, which effects about 250 million people worldwide is a leading cause for disease burden, work disability and health care costs¹. This chronic degenerative disease is characterized by loss of articular cartilage and new bone formation beneath the damaged cartilage, along with the development of bone spurs referred to as osteophytes². Currently, there is a tendency to consider knee OA as an inflammatory condition with associated cartilage and bone degradation³, which leads to stiffness, pain and impaired movement at the knee joint. Conventional treatment for knee OA can be divided into surgical and non-surgical interventions.

Surgical interventions involve knee joint arthroplasty whereas non-surgical therapy includes patient education, intra-articular injection, exercise, physiotherapy, weight loss, oral supplements and oral medication such as the administration of non-steroidal anti-inflammatory drugs (NSAIDs)⁴. However, prolonged and indiscriminate use of NSAIDs have been associated with numerous side effects such as gastrointestinal bleeding, renal failure, myocardial infraction and stroke (especially for NSAIDs in the COX-2 category)⁵. Several studies have also confirmed that appropriate exercise and local muscle strengthening are effective in reducing knee pain and improving overall physical function⁶. There is thus a continued need to explore cost effective therapies for knee OA^18,21.

Ayurveda provides several remedies for sandhigata vata, the nearest (Ayurvedic) equivalent for knee OA²³. These Ayurvedic remedies include abhyanga (massage with special medicated oils), agnikarma (cauterization), snehpana(oral administration of medicated oils and ghee), swedana (controlled prespiraion), janu vasti (specialized application of medicated oils on knee), sandhi picchu (procedure by which a cotton pad immersed in medicated oil is placed over the effected knee joint), upanaha (application of a herbal paste over the knee and left undisturbed for several hours), yoga postures and the oral intake of ayurvedic formulations⁷. Ginger (Gingibor officianalis), Boswellia serrata, Curcuma domestica and Guggulu kalpas are prominent constituents of the oral ayurvedic formulations. Studies appear to indicate that the oral intake of Boswellia serrata⁸ and Amrutbhallataka (ABFNO2)⁹or cauterization therapies (agnikarma)¹⁰ to be effective in the alleviation of knee OA symptoms. In a seminal work¹¹ 71 patients with knee OA were given individualized Ayurvedic treatment and the results were compared to a batch of 74 patients who received conventional therapy. The group subject to individualized ayurvedic treatment outperformed the conventional group, with regard to alleviation of symptoms. There is thus ample scope (borne out by rigorous scientific studies) in the application of Ayurvedic methods for the treatment of knee OA¹⁷.

In our hospital we have undertaken a set of projects to design cost effective integrated indigenous therapies (IITs) for the treatment of common ailments effecting every section of the populace. In this connection we report (as case study) a novel Ayurvedic treatment of knee OA¹⁹.

Case report:

A 44 year old female patient admitted in Central Ayurveda Research Institute, Kolkata hospital with the complaints of Sandhi Shula i.e. severe pain²⁰ and swelling over the both knee joint and difficulty in walking since 5 years. The patient was taking allopathic treatment for long period of time though not regularly, but didn’t get relief. She was advised to get knee replacement by orthopedic sergeants. Examinations of the patients revealed Sandhi Sotha around the both Knee joints, tenderness > 4, Vata- Poornadriti Sparsha in both knee joints. The range of movement was restricted for both extention and fexion and movement was limited to 110 degree for flexion and extension was limited to 30 degree. Patient was slightly pallor, vital pulse rate 74 /min, regular blood pressure 140/80, X-ray of joint revealed join space reduction in both knee joint, more so there is a tri-compartmental feature bilaterally of both knee along with mild Osteopenia. The diagnosis of Osteoarthritis was established on the basis of above findings. In consideration with the findings of clinical examinations and investigations following treatment was given:

Table 1: Management plan

S. No.	Treatment	Dose	Duration
1.	Pippali Churna Chopchini Churna Dosamoolaristha	2gm 2gm twice daily b.d. 30 ml	30 days
2.	Ksheerabala taila	30 ml external application (Abhyaga)	30 days
3.	Leaves of Nirgundi Eranda oil	500 gm were collected and chopped into small pieces to prepare Four boluses
4.	Aswagandha Kashaya	Once daily in morning (Kashaya Vasti)	30 days
5.	Doshanga Lepa	Once daily in afternoon in both knee (Janu Lepa)	30 days

Abhyanga:

The standard Ksheerabala Taila from the pharmacy of CARI, Kolkata has been collected, 30ml of Ksheerabala Taila has been measured through measuring cap heated at the temperature of 40⁰C (as per tolerability of the patient) the oil externally applied (Abhyanga) all over the body for about 30 minutes every day. Particularly the Janu Sandhi has also been giving with pressure message by rotation forward and backward. During this procedure the patient may ask for slow movement of flexion and extension of knee independently.

Patra Pinda Swedan:

The fresh leaves of nirgundi (vitex negundo), 500gm in quantity were collected and chopped into small pieces. Required quantity of eranda oil was taken in pan and heated. Slices of 4 lemons were added into it. When the lemon slices became slightly fried the powder of Shatahwa and Methika 100gm was added. When the mixture turned brownish Saindhav was added and stirred well. Then the leaves were added. When the leaves were fried the mixture was taken out. The sliced leaves and other ingredients which were fried and processed in the herbal oils were tied in a clean cloth. The upper free ends of the clothes were tied with strong thick threads so as to form a bolus of leaves i.e. Patra pinda. Four boluses were prepared.

The bolus was dipped in oil which is kept on heating apparatus at a constant temperature in pan. The patra pinda were gently rubbed with mild pressure in the manner similar to the abhyanga. The treatment procedure was carried out for 30 minutes.

Kashaya Vasti:

Patients was asked to take light meal i.e. neither too Snigdha nor too Ruksha and not more than three fourth of the usual quantity. Before administration of Ashwagandha Kashaya Vasti, Abhyanga with Ksheerabala was done to the whole body. Thereafter, Patra Pinda Swedana was done.

After these Purvakarma, the patient was advised to tale left lateral position with left lower extremity staright and right lower extremity flexed on knee and hip point. The patient was asked to keep his left hand below the head. Balataila was applied to anus in small amount. 100ml of Ashwagandha Kashaya was prepared separately and mixed with Balataila was taken in enema syringe. Rubber catheter oleated with Balataila was attached to enema syringe. After removing the air from enema syringe, rubber catheter was administered into the anus of the patient upto the length of 4-5 inches. The patient was asked to take deep breath while introducing the catheter and drug. The total Ashwagandha Kashaya was not administered in order to avoid entrance of vayu into the Pakvashaya which may produce pain.

After the administration of Vasti, patient was advised to lie in supine position and patient’s buttocks were gently tapped and legs were raised few times so as to raise the waist. After a while patient was advised to get up from the table and take rest.

Janu Lepa:

Most of the Sandhivata patient complaints of pain, tenderness and inflammation in both knee joint. In this regard to reduce the pain, tenderness and inflammation local application of Janu Lepa was very helpful. For this purpose 20gm of Doshanga Lepa was heated at 40^oC, prior to application patient was seated in a comfortable chair. The patient was asked to straighten the both legs and kept both knee joint over a tool and applied with luke warm heated oil. The heated lepa was applied on both knee joints in a thick coated and kept the knee straight for two (02) hours. After two (02) hours the lepa had been cleaned up with hot water.

Observation and result:

Table 2: Assessment on day 1, 15 and 30

S. No.	Assessment parameter	Visit 1	Visit 2	Visit 3
1.	Haemoglobin	14.1 gm/dl	14.3 gm/dl	14.2 gm/dl
2.	ESR (fall in 1^st hour)	20 mm	19 mm	21 mm
3.	Vatapurnadriti-sparsa	Audible crepitus	Palpable crepitus	Palpable crepitus
4.	Shotha	Moderate	Mild	Absent
5.	Sandhi shoola	Severe	Mild	Absent
6.	Prasaranakkunchana pravriti savedana	Prevent complete flexion	Pain with winching of face	Pain without winching of face
7.	Walking distance	50-60 meters	120-130 meters	2.5 km

After treatment with Abhyanga, Patra Pinda Swedan, Kashaya Vasti and Janu Lepa for thirty (30) days and with oral medication for thirty (30) days.

Table 3: Assessment of symptoms

Clinical features	BT	After Ashwagandha Kashaya Vasti		After completion of entire treatment
Clinical features	Grading	Grading	Percentage of relief (%)	Grading	Percentage of relief (%)
Shoola (pain)	3	3	0%	1	66%
Shotha (Swelling)	1	1	0%	0	100%
Prasarana Akunchanayoh Pravrutthishca Savedana (pain during contraction and extention of limbs)	2	2	0%	1	50%
Hanti Sandhi Gatah Sandhi (impairment of functions inflexion)	2	2	0%	1	50%
Hanti Sandhi Gatah Sandhi (impairment of functions in extention)	1	1	0%	0	100%
Morning stiffness	2	2	0%	1	50%
Crepitus on movement	3	3	0%	3	0%
Joint deformities	1	1	0%	1	0%
Tenderness	1	1	0%	0	100%

DISCUSSION:

Among the disease of loco motor system Osteoarthritis is the most commonly condition which causes wear and tear of the joints and leads to disability. It is an inflammatory disorder causes pain, swelling, restricted movements of joints. This patient suffering with excruciating pain which becomes unbearable even on mild touch and results in the formation of crepitus. For breaking the Samprapti (pathogenesis of Janu Sandhivata)²⁵, Ushna (hot), Kapah Vatahara, Deepana, Apitizer, Pachana, Carminative, Sothahara, Vedana Sthapana (analgesic), Balya (strength promoting factor) and Rasayana Dravyas (anti-inflammatory and anti-oxidant) is essential. For this reason the regiment like Pippali Churna, Chopchini Churna, Dasmularishtha given for Deepan, Pachan and Balya purpose and Ksheeraba Taila Abhangya is consider to be best treatment in Vata Vyadhi for his Vedana Sthapana property.

Patra Pinda Swedan is therapeutic technique where Snehan and Swedan are applied using herbs and oils. Leaves of medicinal plants having Analgesic and Anti-inflammatory properties are the important ingredient of the procedure. Patra pinda sweda relieves pain, stiffness and swelling associated with arthritis and other painful conditions, pacifies the morbidity of vata, pitta and kapha in the affected joints, muscles and soft tissues, causes sweating and brings about lightness and a feeling of health in the affected joints, muscles and soft tissues.

As a whole the effect of Ashwagandha Kashaya Vasti is encolinic (action on tissue of colon), endcolonic (action inside colon) and diacolonic (for system action). The mean retention time of Ashwagandha Kashaya Vasti observed was 35±4.5min. Thus Vasti Dravyas when reaches in large and small intestine get absorbed from intestinal mucosa, further due to Laghu, Ushna and Tikshna Guna (properties) of Vasti Dravya, obstruction of channels are broken down the and morbid material from all over the body are expelled out, thus breaks the pathogenesis of disease Sthaulya (obesity).¹²

Vasti help in Vatanulomana by Tikta (bitter), Katu (astringent) Rasa (taste) and Tikshna Guna present in Ashwagandha Kashaya Vasti, thus helps in the correction of passage of Apana Vayu and these qualities irritate the intestine leading to increased contraction of intestine hence provides less time for absorption of fat from intestine. Vasti therapy may be stimulator for many intraluminal, luminal and whole body function¹³

Ashwagandha Kashaya Vasti possess cholagogue property, Tikta, Katu Rasa, Tikshna properties irritate the intestine leading to increased propulsive movement of intestine.¹⁴

Hence, provides less time for absorption of fat from intestine.

Dravyas present in the Ashwagandha Kashaya Vasti possess choleretics action which causes excretion of bile which further leads to decrease absorption of fat from intestine

Ashwagandha Kashaya Vasti has irritant property which damage the structure of villi in intestine hence causes decreased capacity for absorption¹⁵

Sandhigatavata²² is a Nirupstambhit Vatavyadhi caused by Dhatukshay. With age, rukshata of Vata dosha increases, and consequently, Dhatushaya increases. Janu Sandhi Lepa by Doshanga Lepa consider beneficial for this patient by relieving the local pain²⁴ as it contain all Ushna, Viryatmak, Tikhna, Vataghna, Vedana Sthapana and Sothahara Dravyas. Overall all these combined effect gives strength to the supporting muscle of the knee joint. Due to these above properties thus the patient’s joint movement also been improved.

CONCLUSION:

Osteoarthritis one of the most specific articular disorder significantly hindering the effected person from doing even the primary day to day activity. Middle aged population can also affected by this disease. People who suffers from the disease are usually sufferers for their life management is usually difficult at later stage of the disease. The patient treated in this present case study has got remarkable relief. Therefore it can be concluded that discipline use of classical Ayurvedic treatment along with Panchakarma therapy in the background of accurate diagnosis can be helpful for the patient suffering from Osteoarthritis. To avoid the painful intervals, gradual advancement of the disease condition ad repeated uses of NSAIDS Ayurvedic management is the only option considering the economic and long term therapeutic efficacy. Use of external therapy like Abhyanga, Patra Pinda Swedan, Kashaya Vasti and Janu Lepa offers the add-on advantage of reducing exposure to oral medication. This study will helpful for future researchers for further collaborative research with modern medication in case of end stage of Osteoarthritis.

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Received on 17.03.2023 Modified on 04.05.2023

Research J. Pharm. and Tech 2023; 16(12):5901-5905.

DOI: 10.52711/0974-360X.2023.00956