Evidence Based Ayurvedic Treatment Guideline for Management of Sandhivata (Osteo-arthritis)

Pathya Apathya

• Pathya Aahara: Godhuma, Mamsa, Raktashali, Godugdha, Ajadugdha, Ghrita, Draksha, Ama, Madhuka, Ushna Jala, Sura, Surasava, Madhura – Amla – Lavana Rasa pradhana ahara.
• Pathya Vihara: Atapa Sevana, Mridu Shayya, Ushnodaka Snana etc.
• Apathya Aahara: Yava, Kodrava, Chanaka, Kalaya, Sheeta Jala, Ati Madya Pana, Sushka Mamsa, Katu-Tikta-Kashaya Rasa pradhana ahara.
• Apathya Vihara: Chinta, Ratri Jagarana, Vega Vidharana, Shrama, Anashana, Vyavaya, Vyayama, Chankramana, Kathina Shayya.
• Bahu Doshaja Sandhivata: Samshodhana
• Madhyama Doshaja Sandhivata: Langhana, Pachana and Shamana
• Alpa Doshaja Sandhivata: Langhana and shaman therapy

Samsodhana Therapy

Osteoarthritis or Sandhivata mainly occurring due to obesity having Bahu Doshua condition requires Samshodhana. Following Panchakarma treatment can be effective for treatment of Sandhivata of obese patients;

• Vamana: By Madanaphala Pippali Yoga
• Virechana: Abhayadi Modak and Trivruta Avaleha, Argavdhadi Kashaya, Triphala Kashaya
• Asthapana Basti: Dashamuladi Niruha basti, Erandamuladi Niruha Basti

Raktamokshana Therapy

If there is involvement of Rakta Dhatu in Samprapti of Sandhivata, Rakta Mokshana by Jalauka (Bloodletting through leech) from affected joint can provide instant relief in pain and help to break down pathology. Rai PK, et al. carried out a clinical research titled ‘Efficacy of leech therapy in the management of osteoarthritis (Sandhivata)’. A series of 32 patients with osteoarthritis were selected for that clinical study from the S.S. Hospital, Banaras Hindu University, and Varanasi. Leech was applied on affected part in that clinical trial. During the whole study period it has been observed that pain and stiffness start decreasing after the first sitting of leech therapy and after the last follow-ups there was a significant decrease in symptoms including pain, stiffness, and tenderness. The scar of the leech bite was also observed on the bite site but it became clear in 2-3 weeks after the completion of last sitting of leech therapy. In some patients itching was also observed and subsided after 2-3 hours of removal of leech. The bleeding of the bite site was also observed up to more than 1 hour in few cases. No radiographical changes occurred after completion of the study. On basis of that pilot study they concluded that leech therapy is beneficial in reduction of pain, tenderness, stiffness, crepitus, and swelling in the patients of osteoarthritis. With the help of leech therapy, quality of life of the arthritis patients can be improved. The hazards of prolong use of analgesic; anti- inflammatory drugs by using leech therapy can be avoided.

Agnikarma Therapy

Patients of osteoarthritis having severed joint pain can be treated effectively by Agnikarma on affected joint with Pancha Dhatu Loha Shalaka. A research work conducted by Nilesh Jethava et al entitled ‘Role of Agnikarma in Sandhigata Vata (osteoarthritis of knee joint)’ concluded that Agnikarma (therapeutic heat burn) provides instant relief from pain by balancing local Vata and Kapha Dosha without any untoward effects. A total of 28 diagnosed patients of Janugata Sandhivata were registered and randomly divided into two groups. In Group-A, Agnikarma was done with Rajata Shalaka while in Group-B Agnikarma was performed by Loha Shalaka in four sittings. Assessment in relief of signs and symptoms was done by weekly interval, and Student's t-test was applied for statistical analysis. Group-A provided 76.31% relief in pain while Group-B provided 83.77% relief. Relief from crepitus was observed in 57.13% of patients of Group-A, while 57.92% of patients of Group-B. There was statistically insignificant difference between both the groups. Loha Shalaka provided better result in pain relief than Rajata Shalaka [6].

Shamana Therapy

After Shodhana or proper Langhana and Pachana, Shamana therapy can effectively manage the remaining symptoms. Drugs used for Pachana or Agnidipana in patients of Sandhivata:

• Rasna
• Lasuna
• Panchatikta Drvya Kashaya
• Agnitundivati
• Sanjivani vati
• Lasunadi vati
• Hingvastaka Churna
• Shivakshara Pachana Churna etc can be used to correct Agni before starting the Shamana therapy.

Drugs Used as Shamana therapy for Treatment of Shandhivata

Rational Use of above Mentioned Formulation in Treatment of Sandhivata

According to Sadvidhakriyakala of Sandhivata, the use of above mentioned treatment modalities can be effective, if used properly.

• Mild severity of symptoms of Sandhivata having less degeneration of cartilages of joints is a condition occurring due to Kostha Dusti. These types of patients have joint pain when they have flatulence or indigestion. They can be treated effectively with Pancha vidha kashaya kalpana like, Kwath, Churna etc. mentioned above.
• Moderate severity of symptoms having moderately degeneration of cartilages of joints resulting in crepitating sound on movement of joint is a condition of Shakaha Dushti and should be managed with Sneha kalpana like Ghrita, Taila etc. Anuvasan Basti with Panchtikta Taila, Nirgundi tail and Matra basti with Tila taila, Erand taila etc can also be beneficial to manage this condition.
• Severe degeneration of joints leading to unbearable pain and other symptoms like restricted movement of joint, inflammation etc are due to involvement of Marmasthisandhi (Madhyama Rogamarga) in pathogenesis of Sandhivata, which requires fast acting and Sukshama Guna, Vyavayi Guna dominant drugs, which can easily reach to micro channels of bone nutrition and show its effect to reduce the symptoms. The Guggulu kalpana and Ras-Aushadh should be used for such type of pathological condition of Sandhivata.
• Rasayana Aushadha like Pravala pisti, Mukta shukti, Godanti Bhasma, Hiraka Bhasma etc being good source of calcium, should be used having malnutrition and osteoporosis condition associated with Sandhivata.

Evidences of above Mentioned some Ayurvedic Interventions for Treatment of Sandhivata (Osteoarthritis)

Some evidence based clinical researches conducted for treatment of Sandhivata are mentioned here to support above guidelines.

1. Pradeep L, et al. concluded in their research work entitled ‘Effect of Anuvasana Basti with Ksheerabala Taila in Sandhigata Vata (Osteoarthritis)’ that Anuvasana Basti with Ksheerabala Taila has provided significant improvement in the subjective symptoms of Sandhigata Vata. A total of 30 subjects with OA knees were recruited for the study among which 25 subjects (16 female and 9 male) completed the whole course and 5 dropped out. The patients were treated with Anuavasana Basti with Ksheerabala Taila 120 ml for 10 days. 5 g of Saindhava was added to Ksheerabala Taila while administering Basti. The Basti was given daily between 2 pm and 3 pm in the afternoon after food. The subjects were not given any other medications or topical treatments during the trial. The patients were assessed pre-test, post-test and after the follow-up period of 20 days. There was significant reduction (P < 0.05) in subjective symptoms such as pain, swelling, tenderness, crepitus and walking velocity. There was insignificant change in radiological findings. In the overall effect of the therapy, 56% (14) had mild improvement, 48% (08) had moderate improvement and 12% (03) had no improvement [7]. 2. A clinical research entitled ‘Clinical evaluation of Boswellia serrata (Shallaki) resin in the management of Sandhivata (osteoarthritis)’ conducted by Gupta PK, et al. concluded in their research work that Patients’ mobility was improved significantly in both the groups, which indicates the efficacy of Shallaki over chief complaints. Remission in sandhishula, stambha and radiological improvement was found to be better in oral Shallaki group. Remission in sandhishotha was maximum in group B patients treated with Shallaki both orally and locally, whereas equal improvement in sparshasahyata was observed in both the groups. Some patients in group A showed complete relief. Overall effect of therapy suggests that Shallaki provided moderate improvement in maximum subjects [8]. 3. Babul Akhtar, et al. in their research work entitled ‘Clinical study on Sandhigata Vata w.s.r. to Osteoarthritis and its management by Panchatikta Ghrita Guggulu’. In this study total 49 patients having the complaints of Osteoarthritis were randomly divided into 2 groups. In Group A, patients were treated with Panchatikta Ghrita Guggulu Vati along with Abhyanga and Nadi Swedana and in group B patients were treated with only Abhyanga and Nadi Swedana. The data shows that Panchatikta Ghrita Guggulu along with local Abhyanga and Nadi Swedana i.e. group A has provided better relief in the disease Sandhigata Vata [9]. 4. Shah MR, et al. conducted a research work on ‘A Clinical study of Matra Vasti and an ayurvedic indigenous compound drug in the management of Sandhigatavata (Osteoarthritis)’. In this clinical trial, Matra Vasti (therapeutic enema) was given with Bala taila as Vasti is the best treatment for vatavyadhies. It has vatashamaka and rasayana properties. Indigenous compound drug containing Guggulu, Shallaki, Yastimadhu, Pippali, Guduchi, Nirgundi, Kupilu and Godanti was given in one group along with Matra Vasti. In this study, 33 patients of Sandhigatavata completed the treatment. Patients were randomly divided into two groups. Sixteen patients in Group-A (sarvanga Abhyanga-swedana + matravasti) and 17 patients in Group-B (sarvanga Abhyanga–swedana+ matravasti + indigenous compound drug). The results of the study indicate that the patients of both the groups obtained highly significant relief in almost all the signs and symptoms of Sandhigatavata [10]. 5. Kshipra Rajoria, et al. conducted a clinical study entitled ‘Clinical study on Laksha Guggulu, Snehana, Swedana & Traction in Osteoarthritis (Knee joint)’ to assess the efficacy of Laksha Guggulu, Snehana, Swedana & Traction in the management of Osteoarthritis (Knee joint). For the present work, 30 clinically diagnosed patients were selected and randomly divided into three groups. Group a treated with Laksha Guggulu orally, Group B treated with snehana & swedana traction, Group C treated with Laksha Guggulu, Snehana, Swedana & Knee Joint Traction. The various criteria worked upon were joint pain, oedema, tenderness, restriction of joint movement, stiffness, local crepitation, walking distance. Significant results were obtained on pain in joint movement, restriction in joint movement, joint stiffness, and local crepitation nearly in all the groups with best result in combined group or group C [11].