Literature Review on Sandigata Vata w.s.r to Osteoarthritis in Ayurveda

Introduction

Sandhigata vata is a type of vata vyadhi which commonly occurs in old age due to vata vitiation and depletion of body tissues (dhatus). The disease was first described by Acharya Charaka by the name of ‘Sandhigata Anila’ in Vata Vyadhi , Sandhivata is accepted by Acharya Chakrapani as gulpha vata or sandhigata vata. Acharya Sushruta has described the diseases in vatavyadhi chapter under the subheading of sandhigata vata [1]. In vriddhavastha, all dhatus undergo kshaya, Thus, leading to vataprakopa and making individual prone to many diseases. Among them sandhigatavata stands top in the list with the symptoms like pain, swelling, crepitus, and restricted joint movements. There is not separate explanation of sandigata vata but it is explained under vatavyadhi in every Samhita and sangraha grantha.

In modern science, janusandhigata vata is correlated with Osteoarthritis of knee. It is degenerative joint disorder which is strongly associated with ageing and is a major cause of pain and disability in older people. It is most common form of arthritis that effects all joints, especially weight bearing and frequently used joints. The disorder is characterized by progressive deterioration and loss of articular cartilage accompanied by remodelling of bones and soft tissue on and an around the involved joints due to an active response of chondrocytes in articular cartilage and inflammatory cells in surrounding tissues [2]. Primary OA is the most common one, occurring in old age and mostly affecting weight bearing joints (knee and hip), trapezio-metacarpal joint and DIP joints. While secondary OA occurs at any age after adolescence and mostly involves the hip joint. Underlying primary disease of the joint leads to the degeneration, congenital maldevelopment, post-traumatic irregularities, obesity, avascular necrosis, mal-alignment (Bow legs) or internal defragment of knee (loose body). Clinical features include involment of major joints of lower limb, frequently bilateral. Pain being the earliest symptom is initially intermittent, later constant dullull aching type at first, cramp-like later and triggered after starting an activity after a period of rest. Coarse crepitus, swelling (late feature, due to effusion by inflamed synovial tissue), stiffness (initially due to spasm, later due to capsular contracture and incongruity of joint surface), feeling of instability of the joint and locking of joint resulting from loose bodies and frayed menisci is seen.

Samprapti (Pathophysiology)

No specific samprapti has been explained for Sandhigatavata. So, the samprapti of sandhigatavata is assumed to be the same as that of general samprapti of Vatavyadhi [13].

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Differential Diagnosis [15]

• Udbhavasthana: Pakvashaya
• Vyaktasthana: Asthi – Sandhi

Chikitsa of Sandhigata Vata

The main aim of the chikitsa is promotion and preservation of health in healthy individual, and elimination of the disease i.e. curative treatment. Although Acharya Charaka has not mentioned about specific chikitsa, the general vatavyadhi chikitsa can be taken into consideration. Acharya Sushruta was the first to mention the treatment principles of sandhigatavata i.e.

• Snehana
• Upanaha
• Agnikarma
• Bandhana
• Unmardana

Formulations [20]

• Gugglu: Trayodasanga guggulu Rasnadi guggulu Yograj guggulu Maha yograj gugglu Salaki guggul
• Churna: Panchakola churna Haritaki churna Narsingh churna Rasnadi churna
• Rasaushadi: Vātavidhamsa rasa, Vatagajankusha, Vatachintamani rasa Prawal pisti
• Arista: Dashmoolaarista
• Kwatha: Dashmoola kwatha, Rasnadi kwatha, Rasnasaptka kwatha
• Snehana: Mahanarayan taila

Discussion

Sandigata vata is one of the most prevalent joint related diseases in the population. Sandigata vata is one of vatavyadhi which is mainly cause due to the dhatu kshaya (deplertion of tissue) mainly in old age. It includes signs and symptoms like vatapurna dratisparsha (tenderness), shotha (swelling), prasarana kunchan pravriti savedna (Pain during extension and flexion of joints). Excessively aggravated Vata inside joints causes swelling in the joints, and pain during extension & contraction of the joints. Vata prakopa factors in association of asthi kshaya causes are to presumed as nidanic factor of sandhigata vata. Rooksha and alpa ahara (dry and less diet) or langhana (fasting) will aggravates vata by virtue of rooksha and laghu gunas, dravyas of katu ,tikta and kashya are basically vata prakopa rasas.The excessive physical activities, excessive sexual intercourses ,exercise and marg gamana etc causes dryness and dhatus kshaya by causing vata prakopa. This vitated vata invades sandhi causing destruction of sandhi and manifestation of the diseases.

In sandigata vata there is usually vitiation of vata and dhatu kshaya so various sodhana and shamana therapies are done in order to restore the dynamic balance of vata and dhatu. Drugs which have properties of shothahara (anti- inflammatory), vatahara, vedanasthapana (analgesic), and rasayana (rejuvenative) are useful to treat this condition. Under panchakarma, swedana is a pre-procedure in which sweating is induced. After swedana, cellular metabolism improves that flushes the toxins away. Swedana done after abhaynga/ snehana enables free circulation in the joints, reduces pain, stiffness and swelling, strengthens and rejuvenates the joints, eases movement. Treatment of sandhivata usually begins with a basic process like mriduvirechana. It cleanses the body to restore patency of the srotas, which improve the access of healing material as well as nourishment to the body components. In addition, this also helps in maintaining or restoring the optimum equilibrium in tridosha. Eranda Taila is indicated for mriduvirechana in vatavyadhi chikitsa. The eranda beeja, having vibhedana (purgative), srotoshodhana (channel cleansing), anulomana (correct the apana vayu imbalance) actions, is used for mriduvirechana. Due to the vatahara action it is the best among the medicaments used for virechana (purgative therapy).

Pakwashaya (lower gastrointestinal tract) is the site of action for basti karma. It is the main site of Vata dosha. Hence, basti is mainly useful for the treatment of vitiated vata. It is convenient and comfortable in administration. Medicated oil and medicated decoction strengthen the joints and soft tissues and this therapy rejuvenates the tissues and eliminates the toxins from the body. A case study done by Fernando et al. in 56 yr old women suffering from janu sandhigata vata, was admitted and treated with Ksheera

vaitaran basti for 1st 7 days and vata shamak kwatha and janu vasti with Gugguladi taila in next 17 days and significant improvement in tenderness, swelling and pain upon flexion and extension was observed [21]. Another study observing the effect of Erandamooladi niruha basti and Dashamooladi anuvasana basti as yoga was done where 80.77% relieve in pain, 84.39% relieve in stiffness, 100% relieve in fatique and restricted movement reduced by 100 % and deformity reduced by 74.15% [22].

Other than that, janu basti is a strongly appreciated procedure in management of sandhigata vata. In janu basti, medicated oil is polled over the knee joint for a particular duration of time. It is beneficial in pain and swelling of the knee joint. A case study was done in a 61year old male patient with the diagnosis of knee OA since 2 yrs, and was advised to take janu basti with Mahanarayan taila followed by Dashmoola kwatha nadi-svedana. Mahanaryana Taila being vata shamaka, relieves ruksha, sheeta guna responsible for janu sandhivata and Dashmoola kwatha svedana is sothahara and vata shamaka showing significantly positive result in relieveing sotha, sandhi shola and savedana prasaran akunchan [23]. Studies have revealed that the lipid medium is highly suitable for penetration of the drug molecule through stratum corneum. On this basis, it can be assumed that the different oils used serve as a lipoidal medium for penetration of drug molecules and exert immediate effect.

Pathya ahara vihara are mainly focused in mitigating the vitiated vata and providing adequate nourishment to dhatus. Madhura, amla, lavana rasa are vata shamaka in nature. Godughda, goghrita, mamsa rasa, shali dhanya are balya, snighda and thus promote nourishment. Plain ghee is said to contain Vitamin D which plays an important role to utilize calcium and phosphorus in blood and bone building. The administration of ghrita internally has been proved effective in Sandhigata Vata. Effects of Panchatikta Ghrita and Gugulu tiktaka ghrita has been studied for successful manangement of janugata sandhhivata [24, 25]. Similarly, anti-inflammatory and anti-arthritic activities of guggulu in formaldehyde induced arthritis in albino rats, has been studied which supports the rationale behind the use of guggulu Kalpana [26]. The extract of Haridra (Curcuma domestica) was used as an anti-inflammatory drug in a trial and proved to be effective than the ibuprofen. Curcumin, an active ingredient in Haridra, inhibited the matrix degradation of articular explants and chondrocytes. Also, the extract of ginger was tested for its efficacy against ibuprofen and a placebo and the extract was found be effective in pain management due to the anti-inflammatory potential attributed due to its actions upon hydroxy-methoxy-phenyl compounds. Also, the gum resin of B. serrata, Shallaki, usually contains boswellic acids which help to preserve the structural integrity of joint cartilage and maintain a healthy immune mediator cascade at the cellular level [27].

A pilot study done in 5 patients with dietary herb formulation (Methika, Jeerak and Ajmoda) for pain reduction and vatanuloman and Shatavari and Ashwagandha as a Balya given for total 2 months and observation were done on basis of Visual Analogue Scale and significant improvement was seen [28].

Marma chikitsa is rapidly flourishing branch of ayurveda for pain management. In a study done among 15 patients, 80% relief in pain was seen upon stimulating manibandha, kshipra, kurpara and janu marma 15-18 times, thrice a day (single stimulus was for 0.8 sec) for 90 days. Stimulation of marma produces analgesia by secreting a number of prostaglandin inhibitors, and other opioid- like substances which are hundred times more potent than opium [29]. Also, leech therapy provided quick symptomatic alleviation in pain and swelling in some clinical case studies. Tenderness and restricted joint movements were also eased gradually, as were symptoms such as crepitation and stiffness in joints. The leech saliva contains a number of pharmacologically active biological substances such as hirudin and hyaluronidase which are proved to have analgesic, anti‐inflammatory, and anesthetic activities. The therapy proved more effective than the topical application of analgesics or NSAIDs [30]. Pain management is also attained by agnikarma (therapeutic heat burn). The ushna (hot) guna of agni pacifies the shita (cold) guna of vata, removes the avarana effectively and stabilizes the movement of vata, and reduces the joint pain. Acharya Charaka mentioned that agni is the best treatment for shoola (pain).

Conclusion

Sandhigata vata is one of the most prevalent joint diseases in the population. It occurs primarily because of dhatu kshaya (depletion of tissues) in vriddhavastha (old age), which restricts daily activities such as walking, dressing, bathing, etc. Since it is one of vatavyadhi, vata shamaka different shamana and shodana therapy is done to subsides the diseases. The findings showed that with the collective approach of different Shodhana procedures, including Snehana (internal oleation), Svedana (sudation) Basti (medicated enema) and Mrudu Virechana (soft purgation), upanaha, jalauka,agnikarma, avagahana and shamana treatment (Pacification) like vatahara, vedanahara dravya , sandhigata vata can be efficiently cured.