journal of ayurveda...ornal of rea official pulication of ational nstitte of area, jaipur, ajasthan...

Journal of Ayurveda Official publication of National Institute of Ayurveda, Jaipur, Rajasthan1

Journal of AyurvedaA Peer Reviewed Journal

Vol. XIV No. 1 JAN - MAR 2020

CONTENTS

Editorial

Clinical Studies

Ayurveda Manuscripts - Need of preservation and exploration for mankindProf. Sanjeev Sharma

Clinical Evaluation of the role of Sanshamana and Sanshodhana Chikitsa in the Management of Pakshaghat (Hemiplegia)*Dr. Amit Chowdhary, **Dr. Rachna Gupta, ***Dr. Amit Sharma, ****Prof. C. M. Sharma, *****Prof. Ajay Kumar Sharma

Clinical evaluation of pushkaradi compound in respiratory allergic disorders in children

Clinical evaluation of Pathya Ahara and Avipattikara Churna in the management of Amlapitta

*Dr. I. A. M. Leena, **Dr. Nisha Kumari Ojha

*Dr. Manjit Singh, **Dr. Sarvesh Kumar Agrawal

Significance Of Kriya kalpa In Occular Dieases*Dr. Gulab Chand Pamnani, **Dr. Rajendra Kumar Soni,***Dr. Prabhakar Vardhan

Effect of Virechana Therapy in the Management of Psoriasis: A Case Study

Ayurvedic management of Type-2 Diabetes mellitus – A case report

*Dr. Monika Kumari, **Dr. K K Singh, ***Dr. V.B. Kumavat, ****Dr. Prabhakar Vardhan

*Dr Abhishek Upadhyay, **Dr Radhika Pukale, ***Dr Deepti Sharma

Management of Acrosclerosis through Ayurveda – A case Report*Dr. Sunil Kumar

Ayurveda management of lumbar degenerative disc disease along with gait disability: a case study*Dr. Sarvesh Kumar Singh, **Dr. Kshipra Rajoria, ***Dr. Suman Dadhich

2

3

19

29

40

47

53

60

71

Case Studies

Literary Reviews


EDITORIAL

Ayurveda Manuscripts - Need of preservation and exploration for mankind

Āyurveda has enjoyed a continuous process of scientific development and not a mere mechanical process. The different facts gathered by the seekers over the time gradually evolved into an organized version as science of life. These scientific observations and experiences were checked and re-checked by the successive generations of scholars in their own way in the light of new data, to arrive at more scientific and reliable conclusions. The science as shared by ancient scholars was very popular in those days. Before the invention of modern methods of documentation, knowledge sharing was done through oral tradition only. Gradually, the importance of documentation was recognized and materials used for the same include rock, metal plates, leaves, etc. This journey suffered a great set back during the colonial period and mid-20th century after merging of numbers of princely states into Indian union. Enormous manuscripts were displaced, destroyed (partial or complete) or lost during these periods. These scattered and untouched manuscripts are still to be recovered. Huge number of manuscripts especially Ayurveda manuscripts were written and preserved by different Rajas, Maharajas and Maharanas.

Manuscripts on medicine roughly have been estimated to be ranged between 20,000 – 1,00,000. Several of these are now in institutions such as Oriental Manuscripts Libraries, Indological Research Institutions, Universities, Mutts & Archives, foreign libraries and many are still in private collections. When a manuscript is lost the work is permanently lost for future generations. The manuscripts are ancient documents and so, are very prone for damage. This fact requires an immediate and perfervid attempt for their preservation. In the ancient times the preservation methods were only their manual copying but now these are well advanced like preservation of the original versions from insects and other damaging agents, photo copying , microfilming and digitalization etc. Besides hand written material on palm leaves, barks and paper, inscriptions on rocks and metal surface can also be called Manuscripts as they were also hand written. Manuscriptology is study of Manuscripts. It deals with all the endeavors from possession and preservation to publication of the manuscript. The information regarding collected manuscripts should be displayed in the form of catalogues. Prolific knowledge is preserved in the form of manuscripts which has a potential to take the mankind various years ahead in terms of scientific advancement. The conservation and availability of this ancient wisdom in the public domain will enrich the literary wealth, open the new areas for contemplation for the scholars and also will change the dynamics of current research work. The work is concerned with the possession of the manuscript from the potential sources, their conservation, making digital prints, criticism and publication so that the work could be laid in public domain. The future prospects includes the training programs in manuscriptology keeping in vision to prepare more trained personnel who can take this field as a full time carrier and the work can be enhanced nationwide.

Prof. Sanjeev SharmaDirector


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ORIGINAL RESEARCH ARTICLE - CLINICAL STUDY

Clinical Evaluation of the role of Sanshamana and Sanshodhana Chikitsa in the Management of Pakshaghat (Hemiplegia)

*Dr. Amit Chowdhary, **Dr. Rachna Gupta, ***Dr. Amit Sharma, ****Prof. C. M. Sharma, *****Prof. Ajay Kumar Sharma

*Prof and HOD, Dept of Panchakarma, Quadra Institute of Ayurveda, Roorkee Haridwar, **Associate Prof, Dept of Kriya Sharir, Quadra Institute of Ayurveda, Roorkee Haridwar, ***Lt Indian Army, MD Bhagwati Ayurveda and Panchakarma research Centre, Jaipur,

****D.M. (Neurology) Prof. and Head, Dept. of Neurology, SMS Medical College, Jaipur, *****Former Director, Prof & Head, P.G. Dept. of Kaya Chikitsa, N.I.A. Jaipur

ABSTRACT

Keywords : Pakshaghata, Vata Vyadhi, Sanshamana, Sanshodhana

Address for Correspondence: Dr. Amit ChowdharyProf and HOD, Dept. Of Panchakarma, Quadra Institute of Ayurveda, Roorkee HaridwarEmail ID : [email protected] No : 7888464485

How to Cite the Article : Chowdhary A, Gupta R, Sharma A, Sharma CM, Sharma AK, Clinical Evaluation of the role of Sanshamana and Sanshodhana Chikitsa in the Management of Pakshaghat (Hemiplegia) JOA XIV- 1, 2020; 3 - 18

For the current research project, it was decided to select 100 Patients of Pakshaghat (Hemiplegia), which were divided into four groups of 25 each and given different treatments for 2 months. Group 1 i.e. Allopathic Group was taken as the control Group, in Group 2- Shodhana Chikitsa (Deepana-Pachana, Snehana (Bahya & Abhyantra), Swedana, Virechana, Sansarjana Krama and Basti Chikitsa ) was given, in Group 3- Shamana Chikitsa with (Ekangaveer Rasa, Shatawari Guggulu and Kutaki Vati) was given and in Group 4- Shodhana Chikitsa and Shamana Chikitsa was given together.

In all 100 patients CT SCAN STUDY (B.T and A.T) was taken as one of the main investigation tool out of other routine investigations like CBC, ESR, Blood Urea, S. Creatinine, Lipid Profile, Blood Sugar LFT, S. Uric Acid, Urine R/M and X-ray Chest etc. to evaluate the effect of the treatment. After Completion, it was observed that all the four groups were effective in managing Pakshaghat (Hemiplegia). But patients of Group 4 i.e. Shodhana Chikitsa and Shamana Chikitsa together had shown much significant results. The success of the course was that there were no side effects at all with given medication.

Introduction:

Pakshaghat[1] is a very important disease mentioned among Vata Vyadh is as it makes the patient a cursed creature, so for his normal activities are concerned. The patient not only suffers a physical disability but also

JOAjournalofayurveda.in P ISSN No:2321-0435


Chowdhary A, Gupta R, Sharma A, Sharma CM, Sharma AK, Clinical Evaluation of the role of Sanshamana and Sanshodhana Chikitsa in the Management of Pakshaghat (Hemiplegia) JOA XIV- 1, 2020; 3 - 18

go through psychological and mental problems, which disturb his normal life. This disease not only makes a person handicap but also makes him/ her dependent on his family. Some words quoted by the father of a Pakshaghat patient was that “My son walks in dreams, but how long can he sleep?”

The clinical condition similar to Pakshaghat in modern medical science is described by the term Hemiplegia. The Commonest cause of Hemiplegia is Cerebral Vascular Accident (CVD) or Stroke[2]. This is the 3rd most common cause of severe Physical disability. Annual incidence[3] of Stroke is 180-300/ 1, 00,000, which are going to rise due to less healthy lifestyles.

Need of the study:

Ayurveda has achieved wide recognition and acceptance in recent years. The basic axioms of Ayurveda have stood the test of time and experience. However if modern physiological approach is added to understand them then its acceptability could be widened. Scrutiny of various Ayurvedic principles in light of modern principles can unreveal hidden physiological concepts in them. The present study is an attempt to portray the above points. Considering this poor prognosis of Hemiplegia and nature of the disease it was decided to evaluate certain Ayurvedic measures that could help in restoring quality of life of paralyzed patients.

Patients included in the trial underwent Deepana Pachana, Bahya and Abhyantara Snehana, Swedana, Virechana, Sansarjan Krama and lastly Basti Karma (Niruha basti and Anuvasana Basti) along with Shamana Drugs. These therapies constitute the holistic approach in the treatment of Pakshaghat.

Though, various Acharyas mention Shamana and Shodhana chikitsa[4] for the management of Pakshaghat. Further due to its safe and effective remedial nature, it has been accepted globally and has brought the world once again towards Ayurveda. So the present research work was undertaken to evaluate the role of Sanshodhana and Sanshamana therapy in the management of Pakshaghat along with the control group of Allopathic medicines.

Aims and objectives:

The current research project was undertaken with following aims and objectives -

1. Conceptual and Clinical studies on Pakshaghat vis-a-vis Hemiplegia.

2. To clinically evaluate the efficacy of Shamana Chikitsa in the Management of Pakshaghat.

3. To clinically evaluate the efficacy of Shodhana Chikitsa in the Management of Pakshaghat

4. To compare the efficacy of Shamana Chikitsa and Shodhana Chikitsa in the Management of Pakshaghat (Hemiplegia).

5. To develop safe and effective remedy for managing Pakshaghat (Hemiplegia).

Materials and methods:

The study was conducted on 100 Patients of Pakshaghat (Hemiplegia), which were divided in independent four groups viz., patients of Group 1 were treated with allopathic medicine as per the underlying cause; patients of Group 2 were treated with Shodhana chikitsa; patients of Group 3 were treated with Shamana chikitsa as internal application and patients of Group 4 were treated with the Shodhana and Shamana Chikitsa together. Patients for this study were selected randomly from the O. P. D. & I. P. D. of NIA Hospital, Jaipur and SMS Medical College Hospital, Jaipur as per the selection criteria.

Selection of patients:

Inclusive criterias:

1. Patients presenting with Classical and Cardinal Signs and symptoms of Pakshaghat (Hemiplegia).

2. Age: 20 – 70 years.

3. All Patients other than excluded criteria’s were included in the study.

Exclusive criterias:

1. Age less than 20 and more than 70 Years.

2. Patients found to be suffering from Hemiplegia due


to Tumour, Abscess, Trauma, Aneurysm or Febrile conditions.

3. Patients presenting with Pakshaghat that is associated with other Systematic diseases like Malignant Hypertension and Hemiplegia complicating with Heart disease.

4. Chronicity more than 5 years.

5. Intracranial Infections- Encephalitis, Meningitis etc.

6. Comatose and Unconscious Patients.

7. Hemiplegia caused due to congenital defects like Cerebral Agenesis, Sclerosis etc.

8. Patients suffering from marked impaired mental functions.

Plan of study: Management including drugs, dosage and duration

Group 1: Control Group/ Allopathic Group

25 patients suffering from various types of Paralysis (Hemiplegia due to Cerebro Vascular Accident or Thrombosis or Embolism) were selected on clinical examination and confirmation and were recommended respective allopathic Medicines as per the underlying cause.

Group 2: Shodhana Group

1. Deepan Pachana: Panchakola Choorna[5] 5 Gm Twice Daily for 3 days with lukewarm water.

Snehana and Swedana

A. Bahya Snehana: Dashmoola taila[6] generalized body massage daily for 7 days for 45 minutes daily.

B. Abhyantara Snehana: Cow Ghee was given for Abhyantara Snehapana with initial dose of 50 ml and in increasing dose of 25 ml for at best for 7 days. Swedana: Sarwanga Swedana was performed during Snehapana i.e for 7 days.

2. Virechana: After the gap of 1 day of Snehana, Virechana karma was performed with Triphala Choorna in the dose of 5-10 Gm with Sukhosna Jala

once at bed time only for one day.

3. Sansarjan Karma: All the patients were asked to follow Sansarjana Karma at the bet for 7 days.

4. Basti Karma: Karma Basti krama was performed for 30 days.

Niruha basti: with Dashmoola Kwath[7] alternately withAnuvasana Basti: with Dashmoola Taila.

5. After Basti krama all the patients were subjected to further Bahya Snehana and Swedana for 10 days.

The total Course of Duration was about 2 months.

Group 3: Shamana group

All the Patients will be advised to take 1. Ekangaveera rasa[8] 250 mg twice daily with

lukewarm water for 30 days.

2. Shatawari Guggulu[9] 500 mg thrice daily with lukewarm water for 30 days.

3. Kutaki vati 250 mg H.S with lukewarm water for 30 days.

Group 4: Shodhana and Shamana Chikitsa together

These patients were recommended all the procedures up to Sansarjan Karma as discussed in patients of group 2. Basti was conducted along with the Shamana drugs, as mentioned in patients of group 3.

Investigations to be performed:

Following investigations were advised to exclude the cases as per the exclusion criteria’s as mentioned earlier.

1. Complete Haemogram- TLC, DLC, Hb gm %, ESR

2. Blood urea

3. Serum creatinine

4. Liver function test

5. Blood sugar

6. Lipid profile



7. URIC ACID

8. URINE R/M

9. X-RAY CHEST

10. CT SCAN STUDY[10] (B.T and A.T)

Criterias for assesment:

A) Subjective Improvement

Patients were assessed on following symptoms as per Symptom Rating Scales, developed by Prof. A. K. Sharma et al.

i. Chestanivriti- Loss of function (Sensory & Motor function of limbs)

ii. Ruja - pain Sensation (Sensory function)

iii. Vakstambha - Speech disorder/ dysarthria (Sensory function)

iv. Achetanta - Contraction of tendons / Spasticity (Movement, strength, bulk, tone and reflexes of the muscles.)

v. Hastapadasamkocha- contraction of extremities (Sensory & Motor function of limbs)

The subjective parameters mentioned in Ayurvedic classic for Pakshaghat were taken into consideration (Ch.ch.28/53-55). These symptoms represent impaired neurological functions, which were included in 4 main groups (according to Hutchinson’s clinical examination of nervous system)[11]. Such as:

a) Sensory functions

b) Motor functions

c) Cranial nerve examination

d) Autonomic dysfunction

The improvement in these parameters was assessed by the Symptom Rating Scale developed by Prof. A.K. Sharma et al.

B) Clinical Improvement

For assessing the results, the following symptoms were selected which are given as follows –

1) Finger Movements

2) Motor functions of Arm

3) Motor functions of leg

4) Sitting from lying down

5) Standing from sitting position

6) Loss of speech - Dysarthria

7) Muscle tone (Rigidity/ Spasticity)

8) Loss of muscle power

9) Reflexes

10) Loss of sensation

11) Facial Palsy

12) Hand grip power in mm of Hg

13) Walking downstairs

14) Increasing walking capacity

15) Tiredness (Klama)

16) Pain (Ruja)

B) Radiological assesement:

Computerized Tomography (CT) scan brain (before and after treatment) was done in all the patients.

Criterias for assessment of Severity of disease:

The improvement in the Severity of disease was assessed by the Assessment Rating Scale, developed by Prof. A.K.Sharma et al. as mentioned below.

Total items 1-16 (Total Score 56)

0-14 = Normal

15-28 = Mild

29-42 = Moderate

43-56 = Severe

Observations and results:

For the clinical study, 100 clinically diagnosed and confirmed cases of Pakshaghat (Hemiplegia) were registered out of these, 3 cases were dropped out from the study in the initial phase of trial and the study was carried out by following complete protocol in 97 cases.



Majority of the subjects in this trial were Hindu 70 (70%), Males 74 (74%) and Married 92 (92%). Out of them most of the participants were between the age groups of 51 -60 yrs; 27 (27%) and 41-50 yrs; 25 (25%). Regarding level of education maximum patients were uneducated 52 (52%). Considering the socio-economic status maximum 72 (72%) subjects belonged to lower class. Maximum 58 patients (58%) were non-vegetarian. Maximum patients were addicted 53 (53%) consuming Pan, Supari followed by Smoking. Maximum patients were having Avara Ahara Shakti 54 (54%), Madhyama Samhanana 86 (86%), Madhyama Pramana 87 (87%), Madhyama Satmya 52 (52%), Madhyama Satva 29 (29%) and Tamasika Prakriti 69 (69%).

While considering the Vyayama Shakti maximum Subjects were having Madhyama Vyayama Shakti 60 (60%), suffering from Anidra 52 (52%), Mandagni 61 (61%) and Mridu Koshta 49 (49%).

Regarding the incidence of onset maximum patients has history of sudden onset of disease 88 (88%) and maximum patients came for treatment in hospital with in a month 22 (22%).

Maximum patients were having Right side paralysis 57

(57%), with No Family History 91 (91%), and moderate general condition 57 (57%). Maximum patients were from Jangala Pradesh 91 (91%), having Morning time of onset of Disease 46 (46%) and Majority of them had taken allopathic treatment previously 78 (78%).

While considering the Nature of lesion, Maximum patients were having Infarct in their Computerized Tomography (CT) Scan Report 86 (86%). Majority had Hypertension 27 (27%) followed by Diabetes Mellitus. 13 (13%) and Maximum patients were having Depressive Emotional Status 41 (41%).

Regarding the Improvement in Computerized Tomography (CT) Scan report majority 82 patients (82%) had No Significant Improvement in Computerized Tomography Scan report. While 15 patients (15%) showed Improvement in Computerized Tomography Scan reports (Infarct/ Haemorrhage was resolved). 2 patients did not show any changes and only 1 Patient (1%) had history of increased number of infarct in his Computerized Tomography Scan report.


Table No. I: The incidence of Improvement in Computerized Tomography Scan observed in 100 regis-tered cases of Pakshaghat.

ImprovementGroup A Group B Group C Group D Total / %No. % No. % No. % No. % No. / %

No Significant 19 76 21 84 23 92 19 76 82Resolved/ Improved 4 16 3 12 2 8 6 24 15

Unknown 2 8 0 0 0 0 0 0 2Increased 0 0 1 4 0 0 0 0 1

Total 25 100 25 100 25 100 25 100 100



Table No. II: Clinical (Subjective) improvement in the symptoms of Pakshaghat (Hemiplegia) in all the four Groups-

Sr. No. Symptoms Groups Relief % S.D. (±) S.E. (±) t p Results

1. Chestanivriti- Loss of functions

A 40.323 0.6903 0.1409 7.3931 <0.0001 HSB 27.941 0.8307 0.1661 4.5747 <0.001 HSC 18.841 0.8718 0.1744 2.9824 <0.01 SD 30.159 0.658 0.1343 5.8941 <0.001 HS

2. Ruja- pain Sensation

A 39.474 0.6469 0.132 4.7331 <0.001 HSB 35.294 0.5859 0.1172 4.0959 <0.001 HSC 15.789 0.4359 0.0872 2.753 <0.05 SD 38.71 0.5898 0.1204 4.1533 <0.001 HS

3. Vakstambha- Speech disorder

A 32.558 0.7755 0.1583 3.6849 <0.01 SB 21.429 0.4899 0.098 3.6742 <0.01 SC 20.455 0.8602 0.172 2.0925 <0.05 SD 35.897 0.6539 0.1335 4.3705 <0.001 HS

4. Achetanta- Contrac-tion of tendons

A 42.105 0.7802 0.1593 6.2792 <0.001 HSB 27.692 0.8426 0.1685 4.2724 <0.001 HSC 18.75 0.8718 0.1744 2.753 <0.05 SD 32.258 0.637 0.13 6.4087 <0.001 HS

5.Hastapada samko-cha- contraction of

extremities

A 34.426 0.7974 0.1628 5.3756 <0.001 HSB 23.881 0.8602 0.172 3.7199 <0.001 HSC 18.75 0.8718 0.1744 2.753 <0.05 SD 30.769 0.702 0.1433 5.8158 <0.001 HS

6.Hatva Pakshame-

kam (affected side)

A 35.484 0.8805 0.1797 5.0999 <0.001 HSB 22.388 01 0.2 03 <0.01 SC 16.667 0.8699 0.174 2.5291 <0.05 SD 28.333 0.55 0.1123 6.3089 <0.001 HS

7.Sharira adhama chetana (Loss of

sensation)

A 37.5 0.6123 0.125 07 <0.001 HSB 29.032 0.8426 0.1685 4.2724 <0.001 HSC 22.034 0.8718 0.1744 2.9824 <0.01 SD 34.545 0.5882 0.1201 6.5933 <0.001 HS

8.Shaitya- Heaviness

A 40.909 0.6124 0.125 09 <0.001 HSB 58.571 0.9522 0.1904 8.6117 <0.001 HSC 29.412 0.7071 0.1414 5.6569 <0.001 HSD 52.632 0.7372 0.1505 8.3066 <0.001 HS



Table No. III: Clinical (Functional) improvement in the symptoms of Pakshaghat (Hemiplegia) in all the four Groups-

Sr. No. Symptoms Groups Relief % S.D. (±) S.E. (±) t p Results

1.Finger

Movements

A 50.943 0.8999 0.1837 6.1245 <0.001 HSB 37.931 0.8327 0.1665 5.2842 <0.001 HSC 29.63 0.8602 0.172 3.7199 <0.01 SD 42.593 0.8065 0.1646 5.8216 <0.001 HS

2. Motor functions of Arm

A 53.333 0.978 0.1996 5.0091 <0.001 HSB 42.593 1.0376 0.2075 4.4332 <0.001 HSC 29.412 0.866 0.1732 3.4641 <0.01 SD 52.174 0.8341 0.1703 5.8737 <0.001 HS

3. Motor functions of leg

A 54.348 0.9546 0.1949 5.3459 <0.001 HSB 43.636 0.9781 0.1956 4.9075 <0.001 HSC 25.532 0.9183 0.1837 2.6134 <0.05 SD 45.652 0.8502 0.1735 5.0419 <0.001 HS

4. Sitting from lying down

A 40 0.702 0.1433 4.6526 <0.001 HSB 26.087 0.7703 0.1541 3.1157 <0.01 SC 29.167 0.7681 0.1536 3.6453 <0.01 SD 39.13 0.6757 0.1379 5.438 <0.001 HS

5. Standing from sitting position

A 39.024 0.702 0.1433 4.6526 <0.001 HSB 32.609 0.8165 0.1633 3.6742 <0.01 SC 25 0.7703 0.1541 3.1157 <0.01 SD 42.222 0.658 0.1343 5.8941 <0.001 HS

6. Loss of speech - Dysarthria

A 45.238 0.833 0.17 4.6561 <0.001 HSB 33.333 0.6455 0.1291 4.6476 <0.001 HSC 25.532 0.8718 0.1744 2.753 <0.05 SD 35.135 0.5882 0.1201 4.5112 <0.001 HS

7.Muscle tone (Ri-gidity / Spastic-

ity)

A 32.202 0.7211 0.1472 5.3787 <0.001 HSB 37.143 0.8406 0.1681 6.1858 <0.001 HSC 39.13 0.8622 0.1724 6.2633 <0.001 HSD 44.444 0.8165 0.1667 7 <0.001 HS

8. Loss of muscle power

A 40.323 1.0826 0.221 4.7136 <0.001 HSB 39.506 1.1372 0.2274 5.6276 <0.001 HSC 36 1.222 0.2444 4.4189 <0.001 HSD 44.928 0.8065 0.1646 7.8465 <0.001 HS

9. Reflexes

A 37.778 0.6903 0.1409 5.0273 <0.001 HSB 35 1.0279 0.2056 4.0858 <0.001 HSC 29.63 0.5686 0.1137 5.6276 <0.001 HSD 33.333 0.847 0.1729 4.338 <0.001 HS



10. Loss of sensation A 39.535 0.6241 0.1274 5.5602 <0.001 HSB 26.667 0.5859 0.1172 4.0959 <0.001 HSC 29.412 0.7638 0.1528 3.9279 <0.001 HSD 40 0.4423 0.0903 8.3066 <0.001 HS

11. Facial Palsy

A 50 0.7697 0.1571 3.9782 <0.001 HSB 25 0.4583 0.0917 3.0551 <0.01 SC 27.586 0.4761 0.0952 3.3607 <0.01 SD 51.852 0.6539 0.1335 4.3705 <0.001 HS

12. Hand grip power

A 37.313 0.9546 0.1949 5.3459 <0.001 HSB 21.429 0.6455 0.1291 4.6476 <0.001 HSC 25.352 0.7916 0.1583 4.5476 <0.001 HSD 40 0.8165 0.1667 7 <0.001 HS

13.Walking

downstairs

A 29.032 0.847 0.1729 4.338 <0.001 HSB 20.588 0.7681 0.1536 3.6453 <0.01 SC 19.718 0.8699 0.174 3.2189 <0.01 SD 26.984 0.8065 0.1646 4.3029 <0.001 HS

14.Increasing

walking capacity

A 48.913 1.2619 0.2576 7.2792 <0.001 HSB 25 0.5774 0.1155 8.6603 <0.001 HSC 21 0.8981 0.1796 4.6763 <0.001 HSD 36.458 0.9315 0.1901 7.6694 <0.001 HS

15.Tiredness

(Klama)

A 32.075 0.6903 0.1409 5.0273 <0.001 HSB 37.5 0.8505 0.1701 4.9383 <0.001 HSC 25.455 0.5831 0.1166 4.802 <0.001 HSD 47.368 0.6124 0.125 9 <0.001 HS

16. Pain (Ruja)

A 36.585 0.6469 0.132 4.899 <0.001 HSB 45.946 0.6272 0.1254 5.4212 <0.001 HSC 34.884 0.5774 0.1155 5.1962 <0.001 HSD 41.026 0.702 0.1433 4.6526 <0.001 HS

The best results obtained in patients of group D are possibly due to combined use of Shodhana & Shamana therapy.

Inter Group Comparision For Clinical (Subjective) Improvement

Table No. IV: Clinical (Subjective) improvement in the symptoms of Pakshaghat (Hemiplegia) in all the four Groups -

Sr. No. Symptoms Comparison in Groups Mean

difference t p Results

1. Chestanivriti- Loss of Functions

Group A vs. Group B 0.4183 2.663 >0.05 N.SGroup A vs. Group C 0.6983 4.445 <0.05 SGroup A vs. Group D 0.2917 1.838 >0.05 N.SGroup B vs. Group C 0.2800 1.801 >0.05 N.SGroup B vs. Group D 0.1267 0.8063 >0.05 N.SGroup C vs. Group D 0.4067 2.5893 >0.05 N.S



2. Ruja- pain Sensa-tion

Group A vs. Group B 0.07833 0.6583 >0.05 N.SGroup A vs. Group C 0.3217 2.703 >0.05 N.SGroup A vs. Group D 0.1667 1.387 >0.05 N.SGroup B vs. Group C 0.4000 3.396 >0.05 N.SGroup B vs. Group D 0.08833 0.7423 >0.05 N.SGroup C vs. Group D 0.4833 4.104 <0.05 S

3. Vakstambha- Speech disorder

Group A vs. Group B 0.1117 0.5700 >0.05 N.SGroup A vs. Group C 0.1917 0.9783 >0.05 N.SGroup A vs. Group D 0.1667 0.8422 >0.05 N.SGroup B vs. Group C 0.08000 0.4126 >0.05 N.SGroup B vs. Group D 0.2783 1.421 >0.05 N.SGroup C vs. Group D 0.3583 1.829 >0.05 N.S

4. Achetanta- Con-traction of tendons

Group A vs. Group B 0.5050 3.712 <0.05 SGroup A vs. Group C 0.7050 5.182 <0.01 H.SGroup A vs. Group D 0.3750 2.729 >0.05 N.SGroup B vs. Group C 0.2000 1.485 >0.05 N.SGroup B vs. Group D 0.1300 0.9556 >0.05 N.SGroup C vs. Group D 0.3300 2.426 >0.05 N.S



5.Hastapada sam-kocha- contraction

of extremities


6.

Hatva Pak-shamekam (affect-

ed side)


7.Sharira adhama chetana (Loss of

sensation)




8.Shaitya- Heavi-

ness

Group A vs. Group B 0.4650 3.173 >0.05 N.SGroup A vs. Group C 0.2950 2.013 >0.05 N.SGroup A vs. Group D 0.5000 3.377 >0.05 N.SGroup B vs. Group C 0.7600 5.239 <0.01 SGroup B vs. Group D 0.03500 0.2388 >0.05 N.SGroup C vs. Group D 0.7950 5.424 <0.01 S

All the results were evaluated by ANOVA test.

Inter group comparision for clinical (functional) improvement

Table No. V: Clinical (Functional) improvement in the symptoms of Pakshaghat (Hemiplegia) in all the four Groups-



1. Finger Move-ments


2. Motor functions of Arm

Group A vs. Group B 0.3650 2.401 >0.05 N.SGroup A vs. Group C 0.5650 3.717 <0.05 SGroup A vs. Group D 0.04167 0.2714 >0.05 N.SGroup B vs. Group C 0.2000 1.330 >0.05 N.SGroup B vs. Group D 0.3233 2.127 >0.05 N.SGroup C vs. Group D 0.5233 3.443 >0.05 N.S

3. Motor functions of leg


4. Sitting from lying down





5. Standing from sitting position


6. Loss of speech - Dysarthria


7.Muscle tone (Ri-gidity / Spastic-

ity)


8. Loss of muscle power


9. Reflexes




10. Loss of sensation Group A vs. Group B 0.2367 2.144 >0.05 N.SGroup A vs. Group C 0.3567 3.231 >0.05 N.SGroup A vs. Group D 0.04167 0.3736 >0.05 N.SGroup B vs. Group C 0.1200 1.098 >0.05 N.SGroup B vs. Group D 0.1950 1.766 >0.05 N.SGroup C vs. Group D 0.3150 2.853 >0.05 N.S



11.Facial Palsy


12. Hand grip power


13. Walking down-stairs


14. Increasing walk-ing capacity

Group A vs. Group B 1.042 5.578 <0.0001 H.SGroup A vs. Group C 1.202 6.435 <0.0001 H.SGroup A vs. Group D 0.5833 3.092 >0.05 N.SGroup B vs. Group C 0.1600 0.8657 >0.05 N.SGroup B vs. Group D 0.4583 2.454 >0.05 N.SGroup C vs. Group D 0.6183 3.311 >0.05 N.S




15. Tiredness (Kla-ma)


16. Pain (Ruja)



17. Assessment scale

Group A vs. Group B 4.678 2.490 >0.05 N.SGroup A vs. Group C 6.238 3.321 >0.05 N.SGroup A vs. Group D 1.083 0.5709 >0.05 N.SGroup B vs. Group C 1.560 0.8390 >0.05 N.SGroup B vs. Group D 03595 1.914 >0.05 N.SGroup C vs. Group D 5.155 2.744 >0.05 N.S


This may be possible because the Shamana therapy gives better results when administered with Shodhana therapy. Complete cure was not observed in any patient. There was not a single adverse or toxic effect recorded during and after the course of therapy in all the patients of all the four Groups (A, B, C and D).

But while considering the t-statistics of the observations, it is clear that patients of Group A (Allopathic drugs) and Group D who were treated by Shodhana and Shamana Chikitsa together produced more pronounced improvement than the patients of the groups treated with Group B (Shodhana) and Group C (Shamana therapy) respectively.

CT SCAN OF Group-A (B.T AND A.T)

1.B.T. (Intraparenchymal Hematoma of 17 x 19 mm noted in left thalamo-capsular region with minimal perifocal edema).

2. A.T. (Near complete resolve Intraparenchymal hematoma with minimal residual chronic infarct seen).

Before Treatment After Treatment

CT SCAN OF Group-B (B.T AND A.T)

1.B.T. (MCA Territory infarct in Left Fronto-temporo-parietal lobe including Basal Ganglia).

2. A.T. (left MCA territory infarct zone transform into Gliotic area. No secondary hemorrhage seen).

BeforeTreatment

AfterTreatment



CT SCAN OF Group-D (B.T AND A.T)

1.B.T. (Intraparenchymal Hematoma of 46 x 30 mm noted in left capsule- ganglionic region with perifocal edema and upto 4 mm midline shift.).

2. A.T. (Near complete resolved Intraparenchymal hematoma with no midline shift).

CT SCAN OF Group - C (B.T & A.T)

1. B.T. (Subacute infarct in right posterior limb of internal capsule. Third and lateral ventricles are dilated. Sylvian fissures and superficial sulcal spaces are prominent-DCA).

2. A.T. (Size of infarct convert into Gliotic cavity)




ReferencesConclusions:

Following conclusions can be drawn from the current research work-

y Patients of all groups showed encouraging results in the management of Pakshaghat (Hemiplegia).But the result produced in the patients of Group –D was excellent where a combined treatment (Shodhana and Shamana Chikitsa both) was administered to the patients as compared to Group A (Allopathic group), than Group B (Shodhana Group) and Group C (Shamana group) respectively.

y Inter Group Comparisons of patients of all groups in the symptom of Assessment Scale with the patients of all other groups were found to be statistically Insignificant (p>0.05) respectively, which proves the Importance of Ayurvedic treatment in the management of Pakshaghat (Hemiplegia) disease.

y The complete restoration in muscle power on the affected side and recovery from the disability caused due to CVA in patients of Pakshaghat (Hemiplegia) are very rare.

y Considering all these factors, it can be concluded that Shamana and Shodhana Chikitsa together can be considered as potent treatment modality for managing Pakshaghat (Hemiplegia), which is even more compatible to Modern medicines, without producing any toxic or harmful effects in the body as compared to other Ayurvedic treatment – only Shamana or Shodhana therapy and Allopathic Treatment.

y Hence the Shamana and Shodhana Chikitsa administered together can be considered as potent treatment modality for managing Pakshaghat (Hemiplegia).


1. Charaka, Charaka Samhita with Vidyotini Hindi Commentary. Vol.1 Sastri KN, Chaturvedi GN. (Sashtri RD, et al. editor). Reprint: 2012, Sutrasthana 16/17-20, Varanasi, India: Caukhambha Bharati Academy; pp. 321

2. Harrison, Harrison’s Principles of Internal Medicine, Mc Graw-Hill Medical Publishing House U.S.A: 2005, Vol. 2,19th edn. Chapter 446, Cerebro- Vascular Diseases; pp. 2559-2586.

3. Davidson’s Principles and practice of medicine by Nicki R. Colledge Churchill Livingstone, 21st ed, 2010, chapter-26, Neurological Disease- Cardio Vascular Disease; pp 1180.

4. Charaka, Charaka Samhita with Vidyotini Hindi Commentary. Vol. 2. Sastri KN, Chaturvedi GN. (Sashtri RD, et al. editor). Reprint: 2012, Chikitsasthana 5/2, Varanasi, India: Caukhambha Bharati Academy; pp. 787.

5. Sarangdhar Samhita, ‘DIPIKA Hindi Vyakhya’ edited by pandit Brahmanand Tripathi, Chaukhambha Surbharti Prakashan, Varanasi print, 2012. Madhayama Khanda 6/13-14; pp174.

6. Bhaisajya Ratnavali of Kaviraj Govind das Sen ‘Sidhiprada hindi vyakhya’ edited by Prof Sidhi Nandan Mishra, Chaukhambha Surbharti Prakashan, Varanasi edn, 2012. Karna Rogadhikar 62/28; pp970.

7. Bhaisajya Ratnavali of Kaviraj Govind das Sen ‘Sidhiprada hindi vyakhya’ edited by Prof Sidhi Nandan Mishra, Chaukhambha Surbharti Prakashan, Varanasi edn, 2012. Shotha Rogadhikar 42/05; pp767.

8. Ayurveda Sara Sangraha, Baidyanath Ayurved Bhawan reprint 2010; Aushadh Guna Dharam Shastra; pp 266-268.

9. Ras Ratna Samuchaya of Vagbhatacharya with Ras Prabha Hindi Commentary by Dr. Indra Dev Tripathi Chaukhambha Sanskrit Sansthan, Varanasi Reprint, 2012; Sheetavata Sparshadiroga-Chikitsa 21/129-131; pp 280.

10. CT Differential Diagnosis- Satish k Bhargava, Jaypee Brothers Medical Publishers (P) Limited, New Delhi, 1st Edi. 2006.

11. Hutchinson’s Clinical Method by - Michael Glynn and William M Drake; Saunders Elsevier, 23rd edition, chapter 14 Nervous System, pp 283-329.


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Clinical evaluation of pushkaradi compound in respiratory allergic disorders in children

*Dr. I. A. M. Leena, **Dr. Nisha Kumari Ojha

*MD Scholar, **Associate Professor & HOD, P.G. Department of Balroga, N.I.A. Jaipur

ABSTRACT

Keywords : Pushkaradi Yoga, Respiratory disorders, Allergic disorders

Address for Correspondence: Dr. Nisha Kumari OjhaAssociate Professor, Dept. Of Balroga, National Institute of Ayurveda, JaipurEmail ID : [email protected] No : 9468650449

How to Cite the Article : I.A.M. Leena, Ojha NK, Clinical evaluation of pushkaradi compound in respiratory allergic disorders in children, JOA XIV- 1, 2020; 19 - 28

Allergic rhinitis is a global health problem affecting the large population & its prevalence is increasing.In the Modern medicine, its management includes antihistamines, bronchodilators, mast cell stabilizers and corticosteroids. But most of the time, these are associated with many adverse effects. This produces a need to explore and utilize ancient wisdom of Ayuveda to find right solutions to the problem. So there is a need of a drug having low-cost and long lasting required for RAD and should be affordable for all socio-economic sectors within the population. Design: randomized control trial Participants: Children aged between 2-16 years. Methods: 60 patients were selected from OPD and IPD of National Institute of Ayurveda, Jaipur. That were satisfied the inclusion and exclusion criteria. They were randomly divided in two groups. In Group A administered Pushkaradi compound and in group B Placebo drugfor 12 weeks of duration with follow up at every forth night. Results: Statistical evaluations of overall morbidity features showed excellent result in group A patient. In intergroup comparison highly significant gain was seen in group A over group B . Conclusion: The trial drug “Pushkaradi compound” is effective , safe and palatable in reduce incidence of the symptoms of allergic disorders.

Introduction:Allergic diseases are common illnesses that have increasing in prevalence in the developed and developing countries and posing a serious health problem and economic burden. Recognizing the problem in children is very essential since the spectrum of presentation is variable and multiple, for proper management.

Allergic rhinitis is a global health problem affecting at



least 10 to 25% of the population and its prevalence is increasing. In India prevalence of Respiratory allergic diseases in school going children has been reported between 5-20% in different geographic regions. Male to female ratio % is 64:36. Respiratoryallergic disorders come under Type I hypersensitivity (Anaphylactic) reaction. Typical complaints include intermittent nasal congestion, itching, sneezing, clear rhinorrhea, conjunctional irritation, loss of sense of smell andtaste, headache, wheezing, cough and dyspnoea..

Although direct description of allergy is not given in the classical texts of Ayurveda, but on keen observation, there are mounting contexts regarding allergens and allergic manifestations in ancient Ayurvedic texts. For e.g. causative factors described for the Shvasa, Kasa and Hikka are dust, smoke, cold place, cold water, wind, excessive physical exercise, virrudha and rukshaahara and wrong eating practices (Cha. Chi. 17/10-16), (A. H. U. 19/1-2). Here allergy can be described as Anurjta and Apathya (Cha. Soo. 25/30-32), Asatmya (Ka.S. Khila 5-12), Ahita(Cha. Soo 25/33-34), Anupashaya(A.S. Ni. 1/10), Viruddha(A.S. Soo. 9/7-8) etc. can be considered under Anurjakabhava. Manasikabhavas also play an important role in the etiopathogenesis of allergic disorders (Cha.Vi. 2/9), (Su. U. 1/26). All allergic manifestations are due to rasadushti, which are of ama , in nature at pachakagni and bhutagni level.

Allergies are the hypersensitive reactions of the body to a foreign substance (Vijatiya dravya) which has not undergone proper agnipaka (metabolized)after entering into the body thus resulting into ama. It can also be said as Pragnaparadha of the immune system where the dhi, dhriti and smriti of the immune mechanism get hampered.

In Ayurveda, the roga that can be included under RADs are mainly Sadyah Pratisyaya (Su. U. 24/3), Vatika Pratisyaya (Su. U. 24/6), (Ma. Ni. 58/16-17) , (A.H.U. 19/4), (Cha. Chi. 26/105), (Ka. Chi. 12/6) Dushta Pratisyaya (Cha. Chi. 26/107-109), (A.H.U. 19/9-11), (Su. U. 24/14-15) and Tamakashvasa (Su. U. 24/3), (Su.U. 51/8-10)

Ayurveda has unique concept of Vyadhikshamatva (Cha. Soo. 28/7) and various measures and recipes are described to achieve it. Considering these facts, a clinical study to evaluate the effect of an Ayurvedic compound, has been planned. The proposed multimodal drug, “PushkaradiCompound (Bhai. Rat. 71/75) ” is having few potent herbal medicines possessing Rasayana, Aampachaka, antiallergic, anti-inflammatory and mucolytic and adaptogenic effect.

Methods

Aims and objectivesA. clinical study of Pushkaradi Compound in the management of respiratory allergic disorders in children with the following aims and objectives:

1. To give symptomatic relief.

2. To restore normal or best possible long-term air way function.

3. To reduce the risk of severe attacks.

4. To ensure normal growth and development in children

5. To improve the quality of life by providing an effective safe and economical remedy for prevention of RADs

6. Establishment of relation of prakriti with allergic disorders of children.

7. Evaluation of the side effects of the study drug.

Study type

A Double blind randomized and placebo controlled study.

Selection of Cases

¾ Source – Children for the present study were screened out from the O.P.D. and I.P.D. of P.G Department of Kaumarabhrithya, National Institute of Ayurveda, Jaipur.

¾ Age Group – Children between 2 years to 16 years were included for the study.

¾ Number of Cases – Total 66 cases was screened out of which 08 numbers of cases are discontinued.

I.A.M. Leena, Ojha NK, Clinical evaluation of pushkaradi compound in respiratory allergic disorders in children, JOA XIV- 1, 2020; 19 - 28


Grouping of Patients

Screened cases registered for the study were randomly divided into two groups using random allocation software.

¾ Group A - This group of children were administrated the trail drug Pushkaradi Compound.(Pushkaradi Compound I)

¾ Group B - This group of children were administered placebo (Pushkaradi Compound II)

Pre-assessment Criteria

Children from O.P.D. and I.P.D. of N.I.A. were screened out by the symptom-checklist in the form of pre-assessment questionnaire constituting 14 questions.

Inclusion Criteria

¾ Age 2-16 Years

¾ Cardinal features of respiratory allergy

¾ History of at least 4 episodes in last one year.

Exclusion Criteria

Patients suffering from systemic illness like- Pneumonia, Tuberculosis, Pleural effusion, Emphysema, Lung Abscess, Bronchiectasis, Pleurisy, Nasal Polyposis, Chronic debilitating disease and Congenital anomalies.

Discontinuation criteria

9 Appearance of features of respiratory infections.

9 Uncontrolled severe asthmatic attacks

9 Any other acute illness.

9 Parents not willing to continue

Side-effects Evaluation criteria

To rule out possible side effects of the study drug documentation of information from the patient on every follow up, related to the features as tachycardia, tremor, headache, sedation, drowsiness, weight gain oral thrush, reflex coughing etc.

Clinical Assessment

Assessment of clinical symptoms – Rhinorrhea, smell obliteration, sneezing, nasal obstruction, headache, change in voice, fever, dyspnea, itching (nasal/eye), wheezing, cough and sore throat, depending on the severity was done on four-point scale.

Morbity Score= incidence x Severity

Laboratory Assessment

¾ Peak Expiratory Flow Rate (PEFR)

¾ Blood – Hb%, TLC, DLC, TEC, IgE

Drug

The studying drug “Pushkaradi compound” was selected from Bhaishajya Ratnavali. Trial drug compound had following ingredients.


Table no. I: Showing the ingredients of trial drug

S.N. Name Botanical Name Parts Used Ratio

1 Pushkaramula Inula racemosa Root 01 part

2 Ativisha Aconitum heterophyllum Root 01 part

3 Sringi Pistacia intergrima Gall 01 part

4 Pippali Piper longum Fruit 01 part

5 Yavasa Alhagi camelorum Whole Plant 01 part


The trial drug Pushkaradi compound was used in the form of syrup in order to enhance its palatability for easy administration to children. It was prepared by the Pharmacy of N.I.A. Jaipur.

Dose and duration

The proposed Ayurveda compound was prescribed in doses according to body weight of children for 12 weeks


(2ml/kg/day). Follow up was done fortnightly.

Placebo

The placebo for the study was also in the form of syrup (Pushkaradi Compound II) composed of sugar. Children were called for follow up every fortnightly. Any discomfort or untoward side effects were noted.

Common observations and results

Table no. II: Showing common observations of trial

Sr. No. factors Classification Group A Group B

1. Age (yrs)

2-6 20 66.66 17 56.66

7-11 06 20 04 13.33

12-16 04 13.33 09 30.00

2. SexMale 16 53.33 18 60.00

Female 14 46.66 12 40.00

3.Religion

Hindu 22 73.33 20 66.66

Muslim 06 20.00 08 26.66

4.

Sikh 02 06.66 02 06.66

HabitatUrban 28 93.33 25 83.33

Rural 02 6.66 05 16.66

5. Socioeconomic Status

Higher 04 13.33 05 16.66

Middle 17 56.66 10 33.33

Lower 09 30.00 15 50.00

6. Agni Status

Mandagni 21 70 20 66.66

Vishamagni 03 10 05 16.66

Teekshnagni 03 10 03 10.00

Samagni 03 10 02 06.66



7. Koshtha

Mrudu 07 23.33 06 20.00

Madhya 13 43.33 20 66.66

Krura 10 33.33 04 13.33

8. Incidences of A.A., A.R. and Mixed group

Allergic Asthma(AA) 09 30.00 06 20.00

Allergic Rhinitis(AR) 11 36.66 14 46.66

A.A.+A.R. 10 33.33 10 33.33

9. Hereditary InfluencePresent 22 73.33 23 76.66

Absent 08 26.66 07 23.33

10. Type of A.R.

Seasonal 05 16.66 06 20.00

Perennial 13 43.33 15 50.00

Mixed (perennial with seasonal exacer-bation) 12 40.00 09 30.00

11. Associated Allergic Manifestation

Allergic Rhinitis 10 33.33 12 40.00

Allergic Asthma 08 26.66 09 30.00

Allergic Dermatitis 04 13.33 04 13.33

Allergic Conjunctivi-tis 04 13.33 02 06.66

Allergic Gastritis 02 06.66 02 06.66

H/O Drug allergy 02 06.66 01 03.33

Chart No.-1 Showing Provocating factors / Allergen wise distribution (in percentage)



Chart No. 2 - Showing Risk factor wise distribution (in percentage)

Chart No. 3- Showing incidences of all the morbidity features in last three months( in percentage)

Table No. 3: Showing Statistical Presentation of Laboratory investigations



*/** -Significant ,***-Highly significant ,****-Extremely significant , NS-Not significant

Table no. IV: Showing statistical Presentation of all the Morbidity features after Treatment in Group A



Table no. V: Showing statistical Presentation of all the Morbidity features after treatment in Group B

Discussion

The polyherbal compound drug “Pushkaradi Compound” is the combination of drugs having katu and tiktarasa, laghu, ushna and teekshnaguna and katuvipaka,ushna virya and Kapha Vata shamaka prabhava . It shows signs of srotoshodaka properties which may possibly assist to eliminate sluggish dosha in the srotas. Ushnavirya and laghuguna having the properties of vilayana, pachana , srotoshodaka. Due to this viscosity of kaphadosha is reduced ,mucolytic and expectoration of kapha ensures the respiratory tract on coughing.

Most of the drug has KaphaVatashamakaprabhava. Thus kaphashamaka properties of drug help in breaking the srothorodha and digestion of ama, which leads to proper functioning of the body.Some ingredients of the study drug having rasayana properties which supported to increase both qualitatively and quantitatively improvement in all dhathu of the body. Piperlongum, Inula racimosa, Aconitum heterophyllum contains rasayanaprabhava, immunomodulating activities and anti-inflammatory

activities.

The components of the study drug might have acted at various levels in breaking the pathogenesis of the allergic disorders.

Some hampers the immediate hypersensitivity reaction by inhibiting histamine release, or by inhibiting mast cell degranulation as for e.g. Piperlongum depletes histamine from bronchial and lung tissues . Mast cell inhibitory activity is possessed by Piperlongum and Inularacemosa. On the other hand some are effective for late phase allergy owing to the inhibitory action on leukotrine systems as or by reducing the eosinophil count.

The efficacy of trial drug in reducing the nasal discharge is because of the vata and kapha shamaka prabhava of the drug. The anti-allergic effect of various ingredients is responsible for the overall relief in the symptoms, including nasal discharge, sneezing, itching etc.

Conclusion

• Pushkaradi compound, a multimodal drug is an



effective recipe in reducing the morbidity pattern of RADs, as compared to the previous morbidity history.

• Statistical evaluations of overall morbidity features showed excellent result in group A patient, treated with Syrup Pushkaradi Compound. Some cardinal features such as nasal discharge, sneezing, and itching (Nasal/Eye) demonstrated extremely significant improvement while, loss of smell, nasal obstruction, wheezing, headache, dyspnoea, and cough had highly significant improvement. Fever, hoarseness of voice, inflammation of throat showed significant improvement. On the other hand, in group B statistically except nasal discharge and throat inflammation all the outcomes were insignificant.

• In intergroup comparison highly significant gain was seen in group A over group B at the level of (P<0.001) for inflammation of throat, whereas for nasal obstruction, loss of smell, sneezing, nasal obstruction, fever, wheezing, and cough, significant (P<0.01) advantage was observed in group A over group B.

• The follow up study depicts the sustained effect of the therapy.

• Appreciative improvement was observed in Hb%, TLC, PEFR, Eosinophil count. TEC and IgE show marked reduction.

• No untoward effect of the study drug was observed during the study.

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27. Oman drugs, 2005 http:// www. Omandrugs com / herbal main htm.

28. Jennings K. et al. Res, Ind. Med. Yoga Home.1978; 13:4.

29. Srivastava S., Gupta P.P., Prasad R., Dixit K.S., Palit G., Ali. B. et al. “Evaluation of anti-allergic activity (Type I hypersensitivity) of Inula racemosa.” Indian J.Physiol. Pharmacol. 1999 Apr; 43(20): 235-41.

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Clinical evaluation of Pathya Ahara and Avipattikara Churna in the management of Amlapitta

*Dr. Manjit Singh, **Dr. Sarvesh Kumar Agrawal

*MD Scholar, **Assistant Professor, P.G. Department of Swasthavritta and Yoga, N.I.A, Jaipur

ABSTRACT

Keywords : Ahitaahra, Dyspepsia, Pathya, Rasa, Tikta, Veerya, Vipaka

Address for Correspondence: Dr. Manjit SinghAssistant Professor, Dept. Of Swasthavritta and Yoga, National Institute of Ayurveda, JaipurEmail ID : [email protected] No : 9018850999

How to Cite the Article : Singh M, Agrawal SK, Clinical evaluation of Pathya Ahara and Avipattikara Churna in the management of Amlapitta, JOA XIV- 1, 2020; 29 - 39

Introduction: The main cause for several diseases, which we are witnessing today, is considered to Ahitaahara sevana. The disease Amlapitta is no exception to this condition. This unhealthy life style disturbs the normal physiology of digestion and leads to many digestive disorders and Amlapitta is one of them. Prevalence of dyspepsia is about 20-30% worldwide. Antacids are among the most widely used medicines all over the world. US Food and Drug Administration (FDA) warned that there is increase risk of fractures with the use of Proton Pump Inhibitor (PPI). As compared to modern medicine, Ayurveda has a lot to offer in cases of Gastro Intestinal Disorders such as hyperacidity or functional dyspepsia. In the management of Amlapitta, Acharyas told to use the diet and drugs which having Tikta - Madhura Rasa, Madhura Vipaka, Sheeta Virya & Laghu property with Kapha-Pittahara action. Methods: Considering the role of diet an attempt was made for clinical evaluation of Pathya Ahara and Avipatikara Churna in the management of Amlapitta. 60 selected patients were taken for study randomly divided into two groups A and B, 30 in each group. Group A was given Avipattikara Churna and no diet restriction was advised to this group and Group B was given Avipattikara Churna along with prescribed diet chart for 6 weeks duration and fallow up was done at every second week. Result: Among both the groups Group B showed (p<0.001) extremely significant results than Group A. Conclusion: This shows that Pathya diet plays an important factor in the management of disease and also can enhance the efficacy of medicine.

Introduction:

Ayurveda is as old as human civilization based on two principles i.e. to maintain the health of the healthy person and to cure the illness of the diseased person.[1]

Food pattern of people has undergone numerous changes from Stone Age to space age. These changes have been always for the better aspect of life. Most of the diseases are deeply rooted in underprivileged dietary habits



Singh M, Agrawal SK, Clinical evaluation of Pathya Ahara and Avipattikara Churna in the management of Amlapitta, JOA XIV- 1, 2020; 29 - 39

like Ajirna bhojana, Akala Bhojana, Akala Anashana, Viruddha Bhojana, Atimatra, Amla, Lavana, Katu Rasa etc; improper life style like Vegavidharana, Divaswapna, Ratri Jagarana etc; and Manasika Bhavas like Chinta, Shoka, Bhaya, Krodha etc. This unhealthy life style disturbs the normal physiology of digestion and leads to many digestive disorders and Amlapitta is one of them. Dyspepsia is a condition of great clinical significance as large proportion of patients visiting gastroenterology clinics all over has dyspepsia.[2,3] Prevalence of dyspepsia is about 20-30% worldwide.[4] In a study from Chandigarh, India, of 2048 individuals, 155 (7.5%) had dyspepsia (defined as intermittent or persistent pain, nausea or discomfort referable to the upper alimentary tract that has been present for one month or more and was unrelated to exertion).[5] Therefore, from the limited data available, it may be concluded that 7.6 to 49% of Indian population report dyspeptic symptoms. The food has been given the prime importance since Vedic period, Acharya Kasyapa opines that health is dependent on food; he also considers food as Mahabheshaja[6] Acharya Charka emphasises that the body as well as disease are formed by food, wholesome and unwholesome food are responsible for happiness and misery in life.[7] Acharya kashyapa states that “no medicine is equivalent to food; it is possible to make a person disease free with just proper diet”.[8] The main cause for several diseases, which we are witnessing today, is considered to Ahitahara sevana. So, treatment should be aimed at restoring and maintenance of good health without any artificial aids and relief from the discomfort associated with Amlapitta.

Need of the study:

Antacids are among the one of the most widely used medicine all over the world. US Food and drug Administration (FDA) warned that there is increase risk of fractures with the use of Proton Pump Inhibitor.[9]

By taking antacids the person neutralizes acid which is the first line of immunity and becomes more prone to various infections. Ayurveda Vaidyas are providing cure for the patients of these chronic dyspeptic disorders. Several single and compound drugs have been tried

in this disease but still the problem persists because physicians are not fully concentrating on role of diet as mentioned in Ayurveda, so one has to consider diet and lifestyle modifications to get good results. As compared to modern medicine Ayurveda has a lot to offer in cases of Gastrointestinal Disorders such as hyperacidity/ functional dyspepsia. Acharyas told to use the diet and drugs which are having Tikta - Madhura Rasa, Madhura Vipaka Sheeta Virya & Laghu Ruksha property with Kapha-Pittahara action. So an attempt was made to clinically evaluate Pathya Ahara and Avipattikara Churna in the management of Amlapitta with following aims & objectives:

Aims and objectives:

1. To make a dietary schedule for prevention of Amlapitta.

2. To study the clinical effect of ‘prescribed diet module (Pathya Ahara)’ in Amlapitta.

3. To evaluate clinical effect of ‘Avipattikara churna’ in the management of Amlapitta.

Materials and methods:

Literary Study: Study was reviewed through various Samhitas and information collected from other books in the field of Ayurveda and modern science. Regarding Amlapitta (dyspepsia) and its dietary management on the basis of this review a dietary module for Amlapitta was prepared.

Clinical Study: On the basis of literary study the prepared diet module was clinically tested as compared to Avipattikara churna[10] on the uncomplicated cases with classical symptoms of Amlapitta irrespective of age, sex, caste, religion and profession.

Study setting: The study had been carried out in the Department of Swasthavritta and Yoga of National Institute of Ayurveda, Jaipur.

Type of study: Randomized clinical study

Duration of study: Duration of the trail for each group was of 6 weeks and assessment was done after every 2



weeks.

Sampling: Simple sequential sampling

Randomization: Simple randomization

Allocation concealment: Central

Inclusion criteria:

1. Patients fulfilling proposed diagnostic criteria

2. Patients of either sex were taken for this study.

3. Patients between 20 – 70 yrs of age were selected.

4. Participants from whom the written consent is obtained.

Exclusion criteria:

1. Patients with severe I.B.S.

2. Known case of peptic & gastric ulcers.

3. Patients suffering with diabetic mellitus.

4. Patients suffering from any systematic disorder which interfere with present study will be excluded.

5. Pregnant Women.

Ethical Committee clearance:

The submitted synopsis protocol was approved by “Intuitional Ethics Committee, National Institute of Ayurveda Jaipur” with No.IEC/ACA/2016/77 dated 26-05-2016.

Consent to participate in study: A detailed consent form was prepared with concern to the present study. Participants were detailed about merits and demerits of research work, duration of trial drug and route of administration of formulation before taking consent. During follow up regular records were further documented in the case sheet.

Baseline data recording:

History of the patients was taken and systemic examination was done and clinical proforma was filled. Follow-up was done at the interval of 2 weeks.

Intervention: In group A: In this group ½ Karsha (6 gms) of Avipattikar churna was given twice a day ½ hour before major meals to 30 patients. This drug was provided from NIA hospital’s OPD pharmacy, no diet restrictions were given to this group.

In group B: A printed diet chart was prepared and was strictly advised to fallow along with Avipattikar churna in 30 patients of this group. The patients of either group those not fallowing the drug and diet were discarded from the study. (Diet chart shown in Table No.2)

Diet and restrictions: No restriction of diet was given to Group A. In Group B diet chart with advice to use abundantly, moderate use and avoid using food items were listed (Table No.2) with guidelines for intake of food were mentioned.

Table I: Showing distribution of the patients in each group

Groups Intervention No of Registered Pts.

No of Pt. Completed Therapy.

Duration of Therapy

Group A Avipatikar Churna 30 30 6 Weeks

Group B Diet Module + Avipatikar Churn 30 30 6 Weeks

Preparation of drug: Already prepared Avipattikara churna was given from the OPD pharmacy of National Institute of Ayurveda, Jaipur.



Table II: Patient Diet Chart



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ASSESSMENT CRITERIA[11]: Assessment was done on the subjective parameters. The change in the fallowing parameters was evaluated as:



Table III: Showing scoring of all symptoms

Severity Absent Mild Moderate Severe

Score 0 1 2 3

Statistical Analysis: Improvement in the cardinal signs and symptoms of the disease on the basis of symptom Grade score was assessed. The information gathered on the basis of above observations was subjected to statistical analysis on GraphPad IntaStat 3 software. Wilcoxson’ paired test was applied within the group for all the subjective parameters like Tiktamloudgar, Hritkanthdaha, Kalma, Aruchi etc. Mann Whitney

unpaired test was applied for the subjective parameters to compare the effect of therapies of the two groups.Level of significance:Insignificant p>0.05Significant p<0.05 & p<0.01Highly significant p<0.001

Observations:



Table IV: Showing effect of therapy in Group A on Subjective parameters

Table V: Showing effect of therapy in Group B on subjective parameters

Results:Effect of Therapies:

S.No. Symptoms

Mean

%SD

(±)

SE

(±)p value Remarks

BT

n=30

AT

n=30BT-AT

1. Tiktudgara 1.966 1.40 0.566 29 0.817 0.149 P<0.001 V.SIG.

2. Amlodgara 1.533 1.167 0.366 24 0718 0.131 P<0.05 SIG.

3. Hriddaha 1.200 0.933 0.266 22 0.583 0.106 P<0.05 SIG.

4. Kanthadaha 1.300 1.100 0.200 15 0.484 0.088 P>0.05 N.SIG.

5. Udarshoola 1.567 1.367 0.200 12 0.487 0.087 P>0.05 N.SIG.

6. Klama 1.333 1.167 0.166 12.5 0.379 0.068 P>0.05 N.SIG.

7. Utklesha 1.500 1.233 0.266 18 0.739 0.135 P>0.05 N.SIG.

8. Avipaka 1.607 1.33 0.333 21 0.669 0.120 P<0.05 SIG.

9. Aruchi 1.367 1.167 0.200 15 0.406 0.074 P<0.05 SIG.

10. Gaurava 1.167 0.933 0.233 20 0.62 0.114 P<0.05 SIG.

S.No Symptoms

Mean

%SD

(±)

SE

(±)p value Remarks

BT

n=30

AT

n=30BT-AT

1. Tiktudgara 1.967 1.433 0.533 27 0.814 0.149 p<0.01 M.SIG.

2. Amlodgara 1.667 0.466 1.200 72 0.998 0.181 p<0.001 E.SIG.

3. Hriddaha 2.033 1.133 0.900 44 0.803 0.146 p<0.001 E.SIG.

4. Kanthadaha 2.166 1.3 0.866 40 0.819 0.149 p<0.001 E.SIG.

5. Udarshoola 1.567 1.00 0.566 36 0.817 0.149 p<0.001 E.SIG.

6. Klama 2.167 1.767 0.400 18 0.770 0.140 p<0.05 SIG.

7. Utklesha 1.460 1.067 0.400 27 0.724 0.132 p<0.01 M.SIG.

8. Avipaka 2.000 0.600 1.400 70 0.968 0.176 p<0.001 E.SIG.

9. Aruchi 1.700 0.766 0.933 55 0.868 0.158 p<0.001 E.SIG.

10. Gaurava 2.100 1.533 0.566 27 0.124 0.124 P<0.01 M.SIG.


Table IV: Inter & Intra-group comparison between Group A and Group B for subjective parameters


Subjective ParametersGroup – A(Wilcoxon)

Group – B(Wilcoxon)

Intra Group comparison difference between BT & AT

p value & U value on difference of BT & AT( M a n n -Whitney test)

BT(n=30)Mean±SD

AT(n=30)Mean±SD

BT(n=30)M e a n ±SD

AT(n=30)Mean± SD

Group-AMean±SD

Group-BMean±SD

Tiktudgara 1.96 ± 1.27

1.40 ± 1.13

1 . 9 6 ±1.09

1.43 ± 1.07 0.50 ± 0.81P<0.005

0.53 ± 0.81P<0.001

U =467P>0.05N.SIG

Amlodgara 1.53 ± 1.13

1.16 ± 0.98

1.66 ±1.18 0.46 ± 0.68

0.36 ± 0.0.71P<0.01

1.20 ± 0.99P<0.001

U =671P<0.003V.S

Hriddaha 1.20 ± 1.27

0.93 ± 1.11

2.06 ± 0.88

1.13 ± 0.73 0.26 ± 0.58P<0.05

0.90 ± 0.80P<0.001

U=621P <0.05 SIG.

Kanthadaha 1.30 ± 1.08

1.10 ± 0.92

2.16 ± 0.81

1.30 ± 0.94 0 . 2 0 ±0.48P>05

0.86 ± 0.81P<0.001

U=806P <0.05SIG.

Udarshoola 1.56±1.19 1.36 ± 1.18

1.56±1.22 1.00 ± 0.01 0 . 2 0 ± 0.48P>0.05

0.56± 0.81P<0.005

U =559P <0.05SIG.

Klama 1.33 ± 1.18

1.16 ± 1.08

2 . 1 6 ±0.94

1.76 ± 0.97 0 . 1 6 ±0.37P>05

0.40 ± 0.77P<0.05

U =492P >0.05N.S.

Utklesha 1.50 ± 1.25

1.23 ± 1.13

1 . 4 6 ±0.04

1.06 ± 0.94

0.26 ± 0.73P>05

1.40 ± 0.72 P< 0.001

U =504P >0.05N.S.

Avipaka 1.66 ± 1.18

1.33 ± 1.06

1 . 8 6 ±0.83

0.26 ± 0.45

0.33 ± 0.66P< 0.05

1.60 ± 0.82P<0.001

U =621P< 0.007V.S.

Aruchi 1.36 ± 1.29

1.16 ± 1.17

2.00 ±1.11 0.60 ± 0.67

0.20 ± 0.40P< 0.05

1.40 ± 0.96P<0.001

U =734P <0.001E.S.

Gaurava 1.16 ±1.34

0.93 ± 1.20

2.10 ± 0.71

1.53 ± 0.93 0.23 ± 0.62P>05

0.56 ± 0.67P<0.001

U =584P<0.05SIG.



Graph 6: Showing comparative effect of therapies

Discussion:

Probable mode of action of drug and diet:

Avipattikar churna is used in Agnimandya (loss of appetite), Constipation, and Hyperacidity (Amlapitta). It’s bitter, pungent, astringent in taste, cool (in action) and sweet in post digestive effect removes excess Pitta dosha. Its laxative effect also removes toxins (ama) from digestive system. The dietary items have same properties which have additive effect and helped in giving relief in the Group B, so it showed improvement at all the levels of the therapy as compared to Group A. This means diet when advised with medicine can prove more effective and can enhance the effect of medicine. Acharyas have said that without following proper diet (Pathya Ahara) no drug can be beneficial so here this was seen that prescribed diet has increased the effectiveness of medicine as well as shown its own importance. On comparing the groups for efficacy, Effect was highly significant in Group B at all the levels.

In Amlapitta samprapti the participating dosha are Pitta (rise and vititiation of Amla, Ushna, and Drava guna), Vata (Ruksha and Chala guna are increased), Kapha (vitiated and increased Snigdha, Guru, Sthira guna) which leads to Agnimandya, hence vidagdha avastha, leading to lakshana (signs & symptoms). Dietary factor and Pitta and Vata prakrati play a predominant role in the aetiology of Amlapitta.

1. Nidana parivarjan is the first line of treatment in any disease. Therefore all the Pathya Ahara mentiond in Ayurveda texts regarding Amlapitta disease are Tikta, Madhura, Kashaya rasa, Sheeta veerya and Madhura vipaka and Pitta shamaka which has opposite action on the patho-physiology of the Amlapitta.

2. The properties of Tikta rasa are Krimihara, Dahahara, Aruchihara, Agnivardhaka, Pachana, Kapha Pitta shmaka, Sheeta and Laghu.

3. Madhura rasa is also Pitta shamaka, Dahahara etc. So all these predominant properties were present in the food items included in the diet module have the anti acidity, digestive, appetizer, laxative, etc.

4. The normal pH of gastric acid is 1.5 to 3.5 this acid plays a key role in digestion of proteins by activating digestive enzymes but when this acid is increased by taking more acidic foods the pH is increased which leads to many diseases like hyperacidity, gastric ulcers, acidosis etc.[12]

5. All food items included in this diet module were mostly alkaline (pH more the7) in nature so that the gastric pH should be neutralized and this has showed significant results.

Suggestions for future studies:

1. Studies should be conducted on IPD patients with self prepared diet module for more accurate results



on diet.2. Studies should be done on laboratory analysis of

indicated diet on a particular disease.

3. Similar study may be carried out with a sample of high precision, so that results will be more accurate and valid.

4. In this study, the clinical subjective parameters were analyzed. Another study can be conducted using laboratory standards, i.e., by analyzing the gastric aspirations and going to detailed blood investigations.

Conclusion:1. Among both the groups Group B showed (p<0.001)

extremely significant results than Group A in all parameters.

2. While evaluating the overall effect of therapy, it was observed that in study group 6.66% patients remain unchanged while in control group 30%patients remain unchanged.

3. Pathya Ahara is safe and also improves the efficacy of medicine.

4. Amlapitta is a psychosomatic disease means mental factors play major role with physiological factors, when diet, lifestyle and mental condition get disturbed due to hurry and worries in life, they leads to agnivaishamya which causes annavisha formation and finally disease Amlapitta originates.

5. This disease mainly involves the Rasa, Rakta, Annavaha and Purishavaha Srotasa.

6. It was observed that patients suffering with Amlapitta (dyspepsia) have strong interest in dietary modifications as part of their therapeutic management. Unfortunately, dietary advice plays only a minor part in published guidelines for the management in Dyspepsia or in other diseases.\

7. No side effect was reported from any group, except few patients complained of mild diarrhoea due to intake of Rajmasha (Red beans) however it is Pathya according to treatment principles of Amlapitta.

References

1. Dwidedi Lakshmidhar editor & commentator: CARAKA SAMHITA, Sutrasthana:, Publications Chokhamba Krishnadas Academy Varanasi.U.P Ch.30 shaloka no. 26

2. El-Serag HB, Talley NJ. Systemic review: the prevalence and clinical course of functional dyspepsia. Aliment Pharmacol Ther 2004;19:643-54

3. Abid S, Siddiqui S, Jafri W. Discriminant value of Rome III questionnaire in dyspeptic patients. Saudi J Gastroenterol 2010;17:129-33.

4. Grainger SL, Klass HJ, Rake MO, et al. Prevalence of dyspepsia: the epidemiology of overlapping symptoms. Postgrad Med J 1994; 70:154- 161.

5. Singh V, Trikha B, Nain CK, Singh K, Vaiphei K. Epidemiology of Helicobacter pylori and peptic ulcer in India. J Gastroenterol Hepatol 2002;17:659-65

6. Tiwari Prof. P.V. English commentary: KASAYAP SAMHITA-Khilasthanam;: Choukhamba Vishvabharti Varanasi, 1996 1st edition:chapter 4 shaloka 6.

7. Dwidedi Lakshmidhar editor & commentator: CARAKA SAMHITA, Sutrasthana:, Publications Chokhamba Krishnadas Academy Varanasi.U.P. Chapter-28, Saloka-45, Page no.605

8. Tiwari Prof. P.V. English commentary: KASAYAP SAMHITA-Khilasthanam;: Choukhamba Vishvabharti Varanasi, 1996 1st edition. chapter 4 shaloka 5

9. https:/www.fda.gov/drugs

10. Saxena Nirmal, commentary on VENGASENA SAMHITA or CHIKITSASARA SAMGRAHA:Vol-2, Amlapitta Chikitsa, , publisher Chwkhamba Sanskrit Series Office,Varanasi,U.P. Saloka No-78, Page No-772

11. S. Shastri, Madhava Nidanam- Madhukosha comm. With Hindi Vidyotini Comm. Vol. I & II, Chaukhambha Sanskrit Sansthanan, Varanasi.

12. httpn;//en.m.wikipedia.org/gastric acid



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LITERARY REVIEWS

Significance Of Kriya kalpa In Occular Dieases*Dr. Gulab Chand Pamnani, **Dr. Rajendra Kumar Soni,***Dr. Prabhakar Vardhan

*Associate Professor, **Assistant professor, ***Assistant professor, P.G. Department of Shalakya Tantra, National Institute of Ayurveda, Jaipur

ABSTRACT

Keywords : Kriyakalpa, Ocular therapeutic, Urdhwa-jatrugata Roga

Address for Correspondence: Dr. Gulab PamnaniAssociate Professor Dept. Of Shalakya Tantra, National Institute of Ayurveda, JaipurEmail ID : [email protected] No : 9461154942

How to Cite the Article : Pamnani GC, Soni RK, Vardhan P, Significance Of Kriyakalpa In Occular Dieases, JOA XIV- 1, 2020; 40 - 46

Introduction: Shalakya Tantra is one of the eight branches of Ayurveda dealing with Urdhwajatrugata Rogas (diseases of eyes, nose, ears, head & throat). Ophthalmology comprises the major part of Shalakya tantra. The treatment approach of Shalakya Tantra not only involves internal use of medications but it also includes use of various local procedures, surgical & parasurgical procedures.Kriyakalpas are the therapeutic procedures practiced in Shalakya Tantra having wide range of implications in management of disorders of ophthalmology. It includes selection of specific procedure, preparation of special drug form and finally its proper application to the particular part. Acharya Sushruta has described 5 major Kriyakalpas i.e, Tarpana, Putapaka, Seka, Aschyotana & Anjana1 whereas in addition to these Acharya Sharandhara has added two more procedures- Pindi & Vidalaka2. Kriyakalpa is used for both the purposes, i.e, for Swasthya Samrakshana (prevention from disease) & Vikara Prashamanam (curing the disease). Aims and Objectives: A meticulous search of classic Ayurvedic texts, available contemporary literature pertaining to Kriyakalpas, as well as clinical wisdom of stalwarts of Ayurveda was analyzed to draw safe and effective practical applicability as per presentation of the disease, Dosha and healthy individuals as well. Results and discussion: Practical approach for Kriyakalpa Dravyas and procedure in ocular diseases and healthy individual, doses and duration of Each Kriyakalpa, indication & contra-indications of Kriyakalpas have been described and leads from these protocols can be utilized for the better management of ocular ailments and complications.

Introduction:

Shalakya tantra is one of the eight branches of Ayurveda dealing with Urdhwajatrugata Rogas (diseases of eyes, nose, ears, head & throat). Ophthalmology comprises the major part of Shalakya tantra. The treatment approach of Shalakya tantra not only involves internal use of




medications but it also includes use of various local procedures, surgical & parasurgical procedures.

Kriya kalpas are the therapeutic procedures practiced in Shalakya Tantra having wide range of implications in management of disorders of ophthalmology. It includes selection of specific procedure, preparation of special drug form and finally its proper application to the particular part. Acharya Sushruta has described 5 major Kriyakalpas i.e, Tarpana, Putapaka, Seka, Aschyotana & Anjana[1] whereas in addition to these Acharya Sharandhara has added two more procedures- Pindi & Vidalaka[2].

Kriyakalpa is used for both the purposes, i.e, for Swasthya samrakshana (prevention from disease) & Vikara prashamanam (curing the disease).

SEKA:

Seka is the procedure of medicating the eye with a fine stream of liquid or decoction from the height of 4 angulas[3]. It is indicated in acute & aggravated conditions of eye[3]. Duration of Seka varies according to pathological condition & therapeutic type of irrigating fluid. On the basis of action it is of three types – Snehana, Lekhana & Ropana[4]. Snehana seka is for 400 Matra kala used in Vataja disease, Lekhana for 200 Matra kala in Kaphaja diseases & Ropana for 600 Matra kala in Pittaja & Raktaja diseases. Samyak Seka Lakshana are Rog Nivritti (Relieved from Disease), Swabhavik Varna (Getting natural colour), Vedana Shanti (Relief from pain), etc[5]. Seka is used in Balwan Dosha Vyadhi[6]

Various drugs used for Seka in various ocular conditions-

Sr.No. Drug Conditions

01. Triphala Kwath All ocular diseases02. Stri Stanya Nayanabhighata (Ocular trauma)

03.Amalki swaras, Sahijana patra swaras along with

Madhu & SaindhavaNavin Abhishyanda ( Acute conjunctivitis)

04. Amla dravyas decoction Vataja Abhishyanda (Allergic conjunctivitis)

05.Deocotion from Bilvadi panchmoola, Erandamoola,

SahijanaVataja Abhishyanda (Allergic conjunctivitis)

06.Decoction of Daruharidra, Chandana, Ela, Draksha,

Lodhra, Darbha, Yashtimadhu,etc

Pittaja Abhishyanda (Acute purulent conjunctivitis) Pittaja Adhimantha (Acute

congestive glaucoma)

07. Triphala, Lodhra, Yashtimadhu, SarkaraRaktaja Abhishyanada (Acute mucopurulent

conjunctivitis)08. Decoction of Sahijana, Khadira Pothaki (Trachoma)09. Yashtimadhu, Amalaki, & Patola Kumbhika vartma (Blepharitis)

ASCHYOTANA:

Instillation of few drops of medicines in the form of Kwatha, Kshira, Drava, Sneha, etc into the open eyes from the height of two Angula is called as Aschyotana[7]. It is considered as Adya upakrama (first line of treatment) in all ocular diseases[8]. There are three types of Aschyotana- Snehana, Lekhana & Ropana[9]. 10 drops of Snehana Aschyotana in Vataja disease, 7-8 drops of Lekhana Aschyotana in Kaphaja diseases & 12 drops

of Ropana Aschyotana in Pittaja & Raktaja diseases is indicated. Aschyotana can be used in Alpabalavyadhi[10].

Aschyotana is useful in painful conditions, irritation and foreign body sensation of eyes, itching of eyes, redness and features of inflammation, burning and excessive watering etc[11].

Various drugs used for Aschyotana in various ocular conditions:



Sr.No Drugs Conditions

01. Triphala Swaras Netrabhishyanda (Conjunctivitis)

02.Kwatha of Root of Eranda, Bhrihati, Bilwa,

Gambhari, etcVataja Netra Roga

03. Swaras of Nimbi patra & Lodhra twak Vataja Abhishyanda (Allergic conjunctivitis)

04. Amalaki, Gambhari, HaritakiPittaja Abhishyanda (Acute purulent

conjunctivitis)

05.Swarasa of Shunthi, Triphala, Vasa, Nimba,

LodhraKaphaja Abhishyanda (Mucopurulent

conjunctivitis)

06.Swarasa of Haridra, Triphala, Daruharidra, Mishri, Yashtimadhu mixed with Stri stanya

Abhighatajanya netrashoola (Pain due to ocular trauma)

07. Ghrita siddha with Nimba, Guduchi Kukunaka

08. Karvir patra swarasa Navin Abhishyanda (Acute conjunctivitis)

09. Amalaki & Patola kwatha Upanaha (Dacryocystitis)

10.Lodhra, Saindhava, Draksha, Yashtimadhu

mixed with goat’s milkLinganasha (Immature cataract)

ANJANA:

Anjana is the topical application of drug in the form of smooth paste or fine powder into the conjunctival fornix with an applicator called Shalaka12. It is indicated particularly when the acute symptoms of the ocular problem (Samavastha) have been subsided, i.e. in Jeernavastha or Niramavastha. According to Acharya

Sushruta Anjana, on the basis of action is divided into 3 types- Lekhana, Ropana & Prasadana13. Lekananjan is used in Kaphaja diseases of eyes. Ropananjana gives strength and complexion to the eyes. Prasadananjana is prepared with Madhura and Snigdha medicines.Time for using Anjana-

Vataja diseases Sandhya kala ( evening)Pittaja diseases Ratri (night)Kaphaja disease Pratah kala (morning)

On the basis of bhaishjya kalpana[14]-

Types ConditionsGutika Guru dosha (severe diseases)

Rasakriya Madhya dosha (moderate)Churna Laghu dosha (mild disease)

A Shalaka (applicator) of 8 Angula long, thin at the middle & round edges are considered as best for Anjana karma. Swarna, Rajata, Tamra, stones or finger can be used as Shalaka.

Various Anjana in various conditions:



Sr.No. Drugs Conditions01. Triphala varti Netra srava02. Manahshiladya anjana Timira, kandu03. Chandraprabha varti Arma (Pterygium), Pishtaka ( Pinguecula)04. Pathyadi varti All ocular diseases

PUTAPAKA :

It is similar to Tarpana vidhi except the preparation method, as the plant extract is prepared by ball of medicine rapped by green leaves and the layer of mud getting after combustion is used like Tarpana. It is of three types- Snehana, Lekhana & Ropana.[15] Various Putapaka are-

Sr.No Drugs Conditions01. Krishnadi Putapaka Lekhana karma02. Pakwavataputraka Putpaka Ajakajaat (anterior staphyloma)03. PippalyadiPputapaka Kaphaja timira

TARPANA:Ocular oleation is the therapeutic procedure of retaining medicated Ghrita or liquid in the eye by making a compact circular boundary around orbital fossa using Masha (white lentil) dough or Tarpana goggles[16]. It gives nourishment to the eyes and cures Vata-Pitta predominant diseases[17].

Sneha Dharan kala- according to Adhishthan and Doshas-

Dosha adhishthan Aushadh Dharan KalaSandhigata Roga 300 matraVartmagata Roga 100 matraShuklagata Roga 500 matra

Krishanagata Roga 700 matraDrishtigata Roga 800 or 1000 matraSarvagata Roga 1000 matra

Vataj Roga 1000 matraPittaj Roga 800 matra

Kaphaj Roga 500 matra

Samyak tarpana lakshana consists of Prakash Kshamata (Tolerance to light), Swasthyam (Health), Netralaghav (Lightness in eyes), normal complexion of the parts of eyes, Laghutva in Nimesh-Unmesh (Easiness in closing and opening of eyes) 18 .some of the diseases that can be treated with Tarpana are Computer vision Syndrome, Dry eye syndrome, Degenerative Disorders e.g. AMD, Refractive Errors, Early Cataract, Optic neuritis etc.

Various Tarpana formulations are- Triphala Ghrita,

Mahatriphala Ghrita , Patoladi Ghrita, Jeevantyadi Ghrita , Saptamrita Ghrita

PINDI:

In Pindi the lukewarm paste of drugs in the form of poultice is applied on the closed eyes for the purpose of sudation & drug application. It can be bandaged over the eyes19. It is indicated in Netrabhishyanda, Adhimantha, Shotha, Netrakandu, Kaphaja Netraroga, etc



Various Pindi in various conditions:

Sr. No. Drugs Conditions01. Eranda patra, Twak, moola Vataja Abhishyanda(allergic conjunctivitis)02. Amalaki, Mahanimba Pittaja Abhishyanda03. Sahijana Patra Kaphaja Abhishyanda04. Nimba Patra with Saidhava Netra shotha, Netra kandu, Netra shoola

VIDALAKA -

It is topical application of drugs in form of paste over the skin of lids[20]. Vidalaka is used in acute inflammatory conditions of eyelids like burning, discharge, excessive tears, swelling, redness, itching, etc[21]. It is of three types according to thickness of paste as Uttama (the best), Madhyama (moderate), and Heen (minimal)[22] . Various Vidalaka in various conditions-

Sr.No. Drugs Conditions01. Saindhava & Lodhra twak churna Netra shoola02. Maricha with Bhringaraj swarasa Arma (Pterygium)03. Gairika, Rakta chandana, Vacha, Shunthi Netra Abhishyanda (Acute conjunctivitis

Through all the above explanations and observation it is very obvious to conclude that Kriya kalpa plays a very important role in Netra Roga Chikitsa.

Discussion

The anatomical and physiological activity of the eye is maintained by the normal functioning of the Doshas. Any equilibrium misbalance from the normal state manifests as disease in the eye, so the treatment is nothing but it is to bring the Doshas back to their normal path. For this we have external and internal medications. Principles of Internal medication remain same for all ailments of the body. External medication i.e. Kriyakalpa literally means treatment; but is in vague for ocular therapeutics since ancient times. It will not be an exaggeration to say that Kriyakalpa is the only field of Ayurvedic ophthalmology which has the potential to contribute to the suffering humanity. All the pharmacological parameters i.e. route of drug administration, solubility and bio-availability, absorbing surface, vascularity of the absorbing surface, physical state of drug, compliance and excretion of the drug are to be followed in Kriyakalpa drug and procedure.

ConclusionMedical science and technology are ever changing and

progressive but the basics remain same. In this way Kriyakalpas described by Acharyas are as useful and practicable in present era as in ancient time. So, one should practice these Kriyakalpas in healthy individuals and in diseases as well. Kriyakalpa is the only field of Ayurvedic ophthalmology which has the potential to contribute to the suffering humanity and very much beneficial for day to day practices.

References

1. Sushruta, Sushrut Samhita with commentary by Dalhanacharya, In: Vd. Jadvji Trikamji Acharya, editor. Uttartantra Kriyakalpa Adhyaya 18, Ver. no.4, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2010. p 633

2. Sharangdhara, Sharangdhara Samhita, In: Acharya Radhakrishna Parashar, editor. Uttar Khanda Netraprasadan Kalpana Vidhi Adhyaya 13, Ver. no.1, Fourth edition, Baidyanath Ayurved Bhavan, Nagpur; 1994. p 579.

3. Sharangdhara, Sharangdhara Samhita, In: Acharya Radhakrishna Parashar, editor. Uttar Khanda Netraprasadan Kalpana Vidhi Adhyaya 13, Ver. no.2, Fourth edition, Baidyanath Ayurved Bhavan, Nagpur; 1994. p 579

4. Sushruta, Sushrut Samhita with commentary by Dalhanacharya, In: Vd. Jadvji Trikamji Acharya, editor. Uttartantra Kriyakalpa Adhyaya 18, Ver. no.45, Edition Reprint, Chaukhamba Sanskrit


Sansthan, Varanasi; 2010. p 636.

5. Sushruta, Sushrut Samhita with commentary by Dalhanacharya, In: Vd. Jadvji Trikamji Acharya, editor. Uttartantra Kriyakalpa Adhyaya 18, Ver. no.48, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2010. p 636.


7. Agnivesh, Dridhabala, Charaka, Charaka Samhita with commentary by Chakrapani dutta, In: Vd. Jadvji Trikamji Acharya, editor. Chikitsasthana Trimarmiy Chikitsa Adhyaya 26, Ver. no.237-238, Fourth edition, Chaukhambha Sanskrit Sansthan, Varanasi; 1994. p 610

8. Vagbhata, Ashtang Hrudaya with commentary by Arundatta and Hemadri, In: Dr.A.M.Kunte, editor. Sutrasthana Ascyotananjan Vidhi Adhyaya 23, ver. no.1, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2011. p 303

9. Sushruta, Sushrut Samhita with commentary by Dalhanacharya, In: Vd. Jadvji Trikamji Acharya, editor. Uttartantra Kriyakalpa Adhyaya 18, Ver. no.45-46, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2010. p 636.



12. Bhavmishra, Bhavprakash with Vidyotini Hindi commentary, In: Pandit Brahmashankar Mishra, editor. MadhyamKhanda Netrarogadhikar Adhyaya 63, Ver. no. 185, Fifth edition, Chaukhambha Sanskrit Sansthan, Varanasi; p 659.


14. Sushruta, Sushrut Samhita with commentary by Dalhanacharya, In: Vd. Jadvji Trikamji Acharya, editor. Uttartantra Kriyakalpa Adhyaya 18, Ver. no.4, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2010.


16. Sushruta, Sushrut Samhita with commentary by Dalhanacharya, In: Vd. Jadvji Trikamji Acharya, editor. Uttartantra Kriyakalpa Adhyaya 18, Ver. no.6-8, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2010. p 633.

17. Vagbhata, Ashtang Hradaya with commentary by Arundatta and Hemadri, In: Dr.A.M.Kunte, editor. Sutrasthana Tarpan-Putpaka Vidhi Adhyaya 24, ver. no.1-3, Edition Reprint, Chaukhamba Sanskrit Sansthan, Varanasi; 2011. p 308.


19. Sharangdhara, Sharangdhara Samhita, In: Acharya Radhakrishna Parashar, editor. UttarKhanda Netraprasadan Kalpana Vidhi Adhyaya 13, Ver. no.21, Fourth edition, Baidyanath Ayurved Bhavan, Nagpur; 1994. p 583.

20. Sharangdhara, Sharangdhara Samhita, In: Acharya Radhakrishna Parashar, editor. UttarKhanda Netraprasadan Kalpana Vidhi Adhyaya 13, Ver. no.30, Fourth edition, Baidyanath Ayurved Bhavan, Nagpur; 1994. p 584

21. Agnivesh, Dridhabala, Charaka, Charaka Samhita with commentary by Chakrapanidutta, In: Vd. Jadvji Trikamji Acharya, editor. Chikitsasthana Trimarmiy Chikitsa Adhyaya 26, Ver. no.231, Fourth edition, Chaukhambha Sanskrit Sansthan, Varanasi; 1994. p 610

22. Bhavmishra, Bhavprakash with Vidyotini Hindi commentary, In: Pandit Brahmashankar Mishra, editor. MadhyamKhanda Netrarogadhikar Adhyaya 63, Ver. no. 160-161, Fifth edition, Chaukhambha Sanskrit Sansthan, Varanasi; p 657




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CASE STUDY

Management of Acrosclerosis through Ayurveda – A case Report*Prof. Sunil Kumar

*Professor, Department of, National Institute of Ayurveda, Jaipur.

ABSTRACT

Acrosclerosis is a generalized disorder of connective tissue in which fibrosis and degenerative changes predominate. A 45 year old female suffering from Acrosclerosis having complains of pain and stiffness in proximal and distal inter-phalangeal joints and tightening of the skin over dorsum of hands, blackish patches on nose, lips and face, flexed fingers was treated on the line of treatment of Gambhir Vatarakta. Vatavidhwamsana Rasa 125mg, Yogendra Rasa 125mg, Amritadi Guggulu 250mg, Tiktaka Ghrita 10ml, all twice a day and Kaala Basti of Dasamoola Taila and Kwatha were administered. She was also underwent Raktamokshana (Leech therapy). Patient got symptomatic relief in pain and swelling. The skin became smooth. She performs routine activities much better after the treatment. This case study demonstrates that Ayurvedic principle of Gambhir Vatarakta is effective in the management of Acrosclerosis.

Keywords : Ayurveda, Kaala Basti, Gambhir Vatarakta, Acrosclerosis, Raktamokshana

Address for Correspondence: Dr. Sunil KumarProfessor & HOD, Department of Sharir Rachana, National Institute of Ayurveda, JaipurEmail ID : [email protected] No : 9414077592

Introduction:

Acrosclerosis causes stiffness of the skin of the fingers, atrophy of the soft tissue of the hands and feet, and osteoporosis of the distal phalanges, along with Reynaud’s phenomenon. The term scleroderma is derived from a Greek term ‘scleros’, which means hard and ‘derma’ which means skin. It is a generalized disorder of connective tissue in which fibrosis and degenerative changes predominate. The most important features of the disease are the thickening and hardening of the skin and distinctive involvement of multiple internal organs, most notably the lungs, gastrointestinal tract, heart, and kidneys[1]. Scleroderma is mainly classified into diffuse and limited form based on the extent of skin involvement and presence of lesions in internal organs. The prevalence rate of this disease is around 5/100,000[2] The disease is commoner in females. The male to female ratio is 1:4.

How to Cite the Article : Kumar S, Management of Acrosclerosis through Ayurveda – A case Report, JOA XIV-1, 2020; 47 - 52



Kumar S, Management of Acrosclerosis through Ayurveda – A case Report, JOA XIV-1, 2020; 47 -52

It’s usually found in the fourth and fifth decades. The initial symptoms include tightness of the extremities and arthralgia. Initial manifestations are edema of the hands and feet, which may extend more proximally. The edema is followed by thickening and tightening of the skin. Skin loses its normal pliability and ultimately becomes “hide bound” and non-pinchable. Later, skin of face gets involved and gives rise to the ‘mouse head’ appearance with microstomia, beaked nose, mask like expression, and difficulty in opening the mouth. There will be pigmentary changes developing over the extremities and anterior chest wall. These are hyper-pigmentation or a combination of spotty hyper and hypo-pigmentation (salt and pepper skin), and telangiectasia over the fingers, palms, face, lips, and tongue. Painful, non-healing, chronic, indolent ulcers are common over the fingers and toe tips[3]

Diagnosis is mainly done clinically. The most important finding is the hard skin, which is not pinchable and devoid of hair. Laboratory investigations help to rule out other conditions. Erythrocyte sedimentation rate (ESR) is moderately raised but it may be normal in early cases and in cases where only the skin is affected. IgG may be elevated during the active phase. Rheumatoid factor is positive in 20-25% and Antinuclear factor (ANF) in about 40% cases in low titers. ANA subset tests can help distinguish two forms of the disease, limited versus diffuse. The limited form is most closely associated with the anti-centromere pattern of ANA staining, while the diffuse form is associated with autoantibodies to Scl-70. Progressive Acrosclerosis can occur with other connective tissue disorders like systemic lupus erythematosus (14%), rheumatoid arthritis (8.4%), and mixed connective tissue disease (2.8%). tIt has to be distinguished from other collagen disorders like dermatomyositis and mixed connective tissue disease. In other disorders like eosinophilic fasciitis, scleredema adultorum Bushke, myxedema, and acromegaly there may be thickening and tightness of the skin.[4]

Presently there is no treatment in modern medicine to halt the progression of the disease. The intervention are mainly done to relieve the symptoms like arthralgia and

to slow the progression of organ damage.[5]

This is a case report of a patient of progressive Acrosclerosis which was managed according to the line of management of Gambhir Vatarakta.

Case Report:-

A 45 year old female came to OPD on dated 06.12.2016. The patient had complains of pain and deformities of proximal and distal inter-phalangeal joints of both hands for last three years. Fingers of both hands of the patient become bluish in winter season as a first symptom 10 years before. It started with the index finger of right hand and later spread to other fingers. Later pain started in the proximal and distal inter-phalangeal joints. She also noticed swelling and stiffness of the joints. Her fingers were stucked in flexed position and she was unable to extend fingers due to pain. There were pus pockets on the fingers. (Figure 3) Later on, red spots appeared on her face and lips, which became darkened after some days. Family history was negative for similar condition. Laboratory investigations were as follows- Hemoglobin (12.8%), ESR (8mm/hr) and serum uric acid (3.9mg/dl) were in normal range and qualitative RA Factor was negative. IgG (1329 mg/dl) was also under reference range. In ANA profile, Proliferative cell nuclear antigen (PCNA) was positive (SLE-3-7%), Scl-70 was positive (Progressive Acrosclerosis (diffuse form-65%), AMA-M2 was positive (PSS-7-25%, Chronic liver disease -7-25%). (figure 1) Above explained laboratory parameters confirmed the diagnosis as progressive Acrosclerosis. X Ray of hand was also performed. (Figure 2) The Patient was admitted in indoor patient department of the hospital on dated 20/1/17. She was advised Vatavidwamana Rasa 125mg, Yogendra Rasa 125mg, Amritadi Guggulu 250mg and Panchathiktaka Ghritha 10ml orally. At the same time Kaala Basti was administered with Dasamoolataila and Dasamoola Kwatha. Raktamokshana was done once in month by leech application. (Figure 5) Patient got symptomatic relief of pain and swelling disappeared. The skin of the fingers which was tight became smooth. She was able to do daily activities normally and was also able to extend her fingers more. The patient was on follow up for every fifteen days for next two months and thereafter



gradually had symptomatic relief.

Table no.I Showing comparison of signs and symptoms of patient before and after treatment

Figure 1 showing scanned reports of ANA profile of the patient

Figure 2 showing X-Ray of hand showing flexion of proximal and distal interphalangeal joint of second, third and fifth digit of right hand and fifth digit of left hand

Symptoms Normal Before treatment After treatment

Range of motion at time of Flexion at proxi-mal interphalangeal joint 100º 30 ºto 60 º 60 ºto70 º

Range of motion at time of Extension at proxi-mal interphalangeal joint 0 º -45 ºto -30 º -30ºto -15 º

Range of motion at time of Flexion at Distal interphalangeal joint 80 º 30 ºto 45 º 45 ºto 60 º

Range of motion at time of Extension at Dis-tal interphalangeal joint 0 º -30 ºto-15 º -20 ºto -15 º

Tightness of skin of fingers - +++++ +



Figure 3 showing pus pocket on proximal inter-phalngeal joint of third digit of right hand

Figure 5 Showing leech application on affected region

Figure 4 showing pus pocket on proximal inter-phalngeal joint of third digit of right hand Before treatment

Figure 6. showing dark black spots on the face and lips in photographs A and B before and after treatment respectively.



A. B.

Figure 7 showing after treatment :- Digits of right hand are in relaxed position as compared to before treatment condition

7. Discussion

The main features of progressive Acrosclerosis are stiffness of the skin of the fingers, atrophy of the soft tissue of the hands and feet, and osteoporosis of the distal phalanges, tightness of the extremities and arthralgia and distinctive involvement of multiple internal organs, most notably the lungs, gastrointestinal tract, heart, and kidneys. The tight atrophic skin is particularly vulnerable to trauma. Edema, ulcers are common over the fingers and toe tips.

Vatarakta is a variety of 80 Vata Roga. Ingestion of foods which are predominantly Lavana, Amla , Katu and Kshara, having irregular diet habits, sleeping during day time, lack of physical exercise etc. are cause of Vata and Rakta Dushti.[6] Vata vitiated by its own etiological factors, while circulating through its own Srotases, is blocked or encircled (Avarnam) by vitiated Rakta and

gets more vitiated. Vata in this state in combination with vitiated Rakta, produces the disease Vatarakta.[7] Vitiated Vayu and Rakta spreads all the body and it gets accumulated in the phalanges of hands and legs producing inflammation, pain warm touch, redness like symptoms. Afterwards it produces these symptoms in other joints.[8]

The disease is stated to be of two varieties on basis of its site of pathogenesis, Uttana in which disease is confined to Twak and Mamsa Dhat and Gambhir in which disease is situated in remaining Dhatus.[9]

The signs & symptoms of Gambhira Vatarakta are stated as following – swelling like nodules which are hard and painful, covered by dark, copper colored skin. There is burning sensation, pricking pain, throbbing sensation and these swellings are likely to inflame and suppurate also.[10]

Thus, signs and symptoms of progressive Acrosclerosis



have the resemblance with the manifestation of Gambhir Vatarakta.

In this case the patient was presented with blackish patches on upper limbs and face having arthralgia and deformities of interphalangeal joints which was very similar to Rheumatoid Arthritis, but RA factor of this patient was negative. These symptoms were very similar to Gambhiravatarakta. So, the management was based on the line of treatment of Vatarakta. Basti and Raktamokshan is the best treatment for vitiated Vata and vitiated Rakta respectively. Shaman treatment was also given along with Basti and Rakmokshan. Vatavidhwamsana, Yogendra Rasa, Amritadi Guggulu, Tiktaka Ghrita, Dasamoola Taila & Dasmoola Kwatha are Vatashamaka and Amritadi Guggulu, Tiktaka Ghrita are Pittashamaka & Raktashodhaka. Combined effect of these drugs has capabilities to address all the manifestation of Progressive Acrosclerosis. Patient had got symptomatic relief in pain and swelling. The skin became smooth and she does her routine activities normally.

8. Conclusion:-

Progressive Acrosclerosis has close resemblance with Gambhira Vatarakta. This case of erythroderma was successfully managed in the line of treatment of Gambhira Vatarakta. This case study demonstrates that Ayurvedic management is effective in progressive Acrosclerosis symptomatically.

References

1. Harrison Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. T. Harrison’s Principles of Internal Medicine. 17th ed. McGraw-Hill; 2009. Page 2096

2. Vandana Pradhan, Anjali Rajadhyaksha, Milind Nadkar, Pallavi Pandit, Prathamesh Surve, Maxime Lecerf ,et al. Clinical and Autoimmune Profile of Scleroderma Patients from Western India, International Journal of RheumatologyVolume 2014, Article ID 983781

3. KrishnaDas K. Textbook of Medicine.5th ed. Jaypee Brother Medical Publisher; 2008. Page 710

4. KrishnaDas K. Textbook of Medicine.5th ed. Jaypee Brother Medical Publisher; 2008. Page 712

5. Harrison 17th ed. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. T. Harrison’s Principles of Internal Medicine. Mc Graw-Hill; 2009. Page 2104

6. Pt.Kashinath Sastri, Dr.Gorakhnatha Chaturvedi, editor. The CharakaSamhita of Agnivesha, Revised By Charaka& Dridhabala, ,Chikitsa Sthana,Vatarakta Chikitsa Adhyay, 29/5-7, Chaukhambha Bharti Academy,Varanasi, 2011 ;720

7. Pt.Kashinath Sastri, Dr.Gorakhnatha Chaturvedi, editor. The CharakaSamhita of Agnivesha, Revised By Charaka& Dridhabala, ,Chikitsa Sthana,Vatarakta Chikitsa Adhyay, 29/8-11, Chaukhambha Bharti Academy,Varanasi, 2011 ;720

8. Pt.Kashinath Sastri, Dr.Gorakhnatha Chaturvedi, editor. The CharakaSamhita of Agnivesha, Revised By Charaka& Dridhabala, ,Chikitsa Sthana,Vatarakta Chikitsa Adhyay, 29/12, Chaukhambha Bharti Academy,Varanasi, 2011 ;721



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JO

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XIV

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CASE STUDY

Ayurveda management of lumbar degenerative disc disease along with gait disability: a case study

*Dr. Sarvesh Kumar Singh, **Dr. Kshipra Rajoria, ***Dr. Suman Dadhich

*Professor, Department of Panchkarma, National Institute of Ayurveda, Jaipur.

ABSTRACTIntroduction – Lumbar degenerative disc disease associated with low back pain is commonly found in present

scenario. It may develop due to presence of lumbar spinal stenosis, disc herniation, facet joint arthropathy etc. Still there is no promising therapy for arresting or rejuvenating the spine in biomedicine and the ultimate option for the disease in present day is lumbar surgery with high risk and higher cost. This case report is a patient of lumbar degenerative disc disease along with gait disability which successfully treated with Ayurveda management. Material and methods – A 52 year male suffering from lumbar degenerative disc disease along with gait disability was treated with Panchakarma therapy along with Ayurvedic oral drugs. In Ayurveda text degenerative disorders comes under the heading of Vatavyadhi. Patient was administered Pancha Tikta Ksheera Basti, Patra Pinda Swedana and oral medicines. Panchakarma therapy was administered for the duration of 16 days and oral medicines were continued for next five months. Result – Modified oswestry disability score, straight leg rising test, visual analogue scale along with Ayurveda assessment criteria were assessed for outcome which shows good improvement. Before treatment patient was suffered from gait disability (forward bending during walk) which was changed to normal gait after five months of treatment.Conclusion- Panchakarma therapy with Ayurvedic oral drugs plays a significant role to manage the degenerative disorders.

Keywords : Ayurveda medicines, Lumbar degenerative disc disease, Panchakarma therapy, Vatavyadhi.

Address for Correspondence: Dr. Sarvesh Kumar Singh Associate Professor, Department of Panchkarma, National Institute of Ayurveda, JaipurEmail ID : [email protected] No : 8739860237

Introduction:

1. Introduction – Lumbar degenerative disc disease (LDDD) is an age-related deterioration or disintegration of lumbar disc which leads to low back pain (LBP). Herniated disc, osteoarthritis of facet joint, and stenosis of the lumbar spine leads to lumbar disc degeneration.

How to Cite the Article : Singh SK, rajoria K, Dadhich S, Ayurveda management of lumbar degenerative disc disease along with gait disability: a case study – A case Report, JOA XIV-1, 2020; 53 - 59



Singh SK, rajoria K, Dadhich S, Ayurveda management of lumbar degenerative disc disease along with gait disability: a case study, JOA XIV-1, 2020; 53 - 59

LBP is often triggered by lumbar degenerative disease [1-3]. LBP is found most handicapped cause for people beneath the age of 45 years[4-6]. Lumbar disk degeneration is interpreted as a declining disk height, upper and lower plate sclerosis, spinal canal stenosis[7]. In bio medicine there is no promising therapy for arresting or rejuvenating the spine and the ultimate option for the disease in present day is lumbar surgery with high risk and higher cost. In Ayurveda there is no direct correlation of this disease is present but some characteristics of it can be affiliated with Katigraha (~ lumbar spondylosis)[8] Asthigata Vata (vitiated Vata lodged in bone tissue) [9], Gridhrasi (~ sciatica)[10] and Sandhigata Vata (~ osteoarthritis) [11]. All these conditions are covered by Vatavyadhi (disease produced by Vata Dosha vitiation). The present case was also treated on the principal of management of Vatavyadhi. Vata Dosha had a significant participation in the patient's chief complaints that was low back pain, stiffness in the back, radiating pain in the right lower limb and difficulty in walking. As per the treatment protocol to reverse the degeneration, Pancha Tikta Ksheera Basti, Patra Pinda Swedana was adopted as Panchakarma procedures along with Ayurvedic oral medicine in present case. Tikta ksheera Basti is mainly indicated in Astipradoshaja Vikara (~disease originated due to vitiation of bone tissue)[12] and it is also cited that Abhyantara (internal) and Bhaya (external) Snehana (oleation) are the best measures for the disease in Asthigata Vata[13]. Modified oswestry disability score (ODI), straight leg rising test (SLR), visual analogue scale (VAS) along with Ayurveda assessment criteria were assessed for outcome of the therapy.

2. Materials and Methods –

2.1 Case presentation – A 52 year old male came to OPD of National Institute of Ayurveda, Jaipur, India on September 28, 2018 with complaints of low back ache and difficulty in walking. OPD registration number of patient was 70628092018. On examination it was found that the patient was suffering from low back ache, radiating pain to right lower limb, stiffness at back and difficulty in walking and forward bending during walk (propulsive

gait)[ video 1]. This condition had appeared gradually from last four years. Firstly patient developed low back ache and stiffness at back gradually he felt radiating pain in right lower limb. Since last two years patient suffered from gait disability (forward bending during walk). The patient had taken allopathic medicine irregularly for these complaints. On examination, patient was found distressed, tongue was uncoated, Micturation and bowel movement were normal. On tenfold examination (Dashavidha Pariksha) it was found that patient has Vata Kapha Prakrati (physical constitution), Avara Vyayam Shakti (less capability to carry on physical activities) and Madhyama Vaya (middle age). Patient didn’t have any traumatic or operative history. On physical examination the SLR test for lumbar movement and ODI was measured. X ray of LS spine A-P (Anterior-posterior) and lateral view showed degenerative changes. The patient was suffering from lumbar disc degenerative disease. Other laboratory investigations and vital signs were found normal. According to Ayurveda, this case was managed on Vatavyadhi's administration line. Ayurvedic oral medicine was given to the patient included: a combination of Ashwagandha Churna (Withania somnifera), Satavari Churna (Asparagus racemosus), Nagradhya Churna (a proprietary medicine of National Institute of Ayurveda, Jaipur, India) and Sankh Bhasma, Yograj Guggulu, Dashamula Kwatha and Panchasakar Churna. These oral medicines were continued for nex five months. Along with these oral medicines patient was administered a set of Panchakarma therapies includes Patra Pinda Swedana (massage and sudation) and Pancha Tikta Ksheera Basti (enema with decoction of drug). These Panchakarma therapies were administered for sixteen days.

2.2 Plan of study: National institute of Ayurveda, hospital, Jaipur and single case study.

2.3 Ayurveda intervention –

Posology of Ayurvedic oral medicines is mentioned in table no.1

Posology of Panchakarma procedures is mentioned in table no. 2



2.4 Criteria for Assessment: Assessment of patient was done on the basis of grading of Ayurveda parameters, ODI scale, SLR test and visual analogue scale which placed in table no .3.

3. Result – Ayurveda assessment criteria along with Modified ODI, SLR test and VAS were assessed for outcome which shows good improvement (overall assessment of parameters before and after treatment is mentioned in table no. 4). Before treatment patient was suffered from gait disability (propulsive gait) which was changed to normal gait after five months of treatment (video no. 2).

4. Discussion and conclusion – Present study was of low back pain, stiffness at back, radiating pain in right lower limb and difficulty in walking. Patient was suffered from lumbar degenerative disorder. In Ayurveda there is no direct correlation of this disease is present but some characteristics of it can be affiliated with Katigraha, Asthigata Vata, Gridhrasi and Sandhigata Vata. Vitiated Vata Dosha and Vikriti of Asthi Dhatu are mainly found in this condition. It can therefore be considered as Asthigata Vata, as its pathogenesis is bone tissue degeneration and Vata vitiation. All these conditions are covered by Vatavyadhi (disease produced by Vata Dosha vitiation). The present case was also treated on the principal of management of Vatavyadhi. The LDDD's main areas of pathology are intervertebral discs and vertebral bodies of the lumbar spine. The factors like old age, trauma, inflammation, old age etc. leads to degenerative changes at spine. All these causes lead to spondylotic changes at spine. When the disease progress the osteophyte develop between two adjacent vertebrae. These all causative factors are mentioned as Vata Prakopa in Ayurveda. The Vata Dosha gets vitiated and lodges into the Asthi due to Asharya Asharyi Bhava.

In LDDD vitiated Vata lodges at Asthi of lumbar region because Khavaigunya found at lumbar region. This vitiated Vata leads to Dhatu Kshaya (degeneration). Due to Dhatu Kshaya there is need of Brihmana (provide nutrition or anabolic) and Rasayana (immunomodulator) Chikitsa. The drugs and procedures which have Brihmana

and Rasayana property were selected in this case. The pathologic process of Vatavyadhi is break by Basti, by removing Margavarodha (by purification of channels) and Dhatukshaya by its Brihmana (~ nourishing) property. Basti used in this case was mainly made of Tikta Rasa and Madhura Rasa and Tikta Ksheera Basti is also mentioned in treatment of Asthi Pradoshaja Vikara. Tikta Ksheera Basti has Rasayana, Balya effect and also by Ksheera and Sneha provoked Vata get pacify and by it Asthi Dhatu also get nourishment and through Tikta Rasa Asthi Dhatu restores. Tikta Rasa has Sothaghana (anti-edematous and anti-inflammatory) property. Ghṛita and honey have Madhura Rasa (sweet taste) dominance. Combinations of all these drugs are acting as Vatahara (suppressors and eliminators of deranged Vata Dosha) that decreases inflammation and treat LDDD. Patra Pinda Swedana is a kind of Snigdha Swedana has Vatashamaka property which owned by drugs used in this procedure. By simultaneous Snehana and Swedana, Dosha get pacified. Oral medicines used in this also have properties of Brihmana and Doshashamak. Dashamula Kwatha has Tridoshaghna property (alleviates deranged Doshas of the body) and is helpful in all types of Vatika disorders [14]. Ashwagandha and Satavari have Rasayana (immunomodulater) and Balya (nutrition) properties [15]. Yograj Guggulu is a polyherbal formulation used in Vatavyadhies since ancient time [16]. A good result was obtained in this case on all the parameters of disease. Before treatment patient was suffered from gait disability which was changed to normal gait after five months of treatment (video no.2). An informed consent was taken from patient for present case study. Results obtained in this case demonstrate that management of LDDD with Panchakarma and along with Ayurvedic oral medicine may provide a good approach to manage degeneration.

5. Financial support and Sponsorship – Nil

6. Conflict of interest –No conflicts of interest



Table no. I – Ayurvedic oral medicines with dose and duration

Name of the drug used orally Dose Duration and Anupana

Yograj Guggulu 500mg twice dailyWith Dashamula kwatha for five

monthsDashamula kwatha 40 ml. twice daily For five months

Combination of

Ashwagandha Churna

Satavari Churna

Nagradhya Churna

Sankha Bhasma

2gm.

2gm.

2gm.

500mg. twice daily

With luke warm water

For five months

Panchasakar Churna 5gm at bed time With lukewarm water

Table no. – II Panchakarma therapies with method of preparation and application –

Panchakarma

procedure

Method of preparation Method of application Duration

Patra Pinda

Swedana

A bolus form by –

Leaves of Nirgundi (Vitex negundo), Eranda

(Ricinus communis), Shigru (Moringa

oleifera) and Rasona (clove of Allium

sativum), Yavani (Seeds of Trachyspermum

ammi) and Nimbu (Citrus limon)

Dashamula Taila – for heating the bolus

Whole body massage for 45

minutes by a Potali of cotton

bag filled with bolus.

16 days

Pacha Tikta

Ksheera Basti

It was a homogenous colloidal solution

having volume of 520 ml which contained

Madhu (Honey) – 50gm, Saindhav – 5gm,

Panchatikta Ghrita- 50ml, Ashwagandha

Taila- 50gm, Satapushpa Kalka - 15gm and

milk processed with Panchatika Kwath

(combination of five drug i.e. Guduchi,

Nimba, Vasa, Patol and Kantakari) - 350ml.

Given before meal (empty

stomach)

Route of administration –

Per rectal

16 days



Table - III Grading scale of symptoms-

S. No. Symptoms Grading1. Katishula (Low back pain)

No pain 0Occasional pain 1Mild pain but no difficulty in walking 2Moderate pain and slight difficulty in Walking 3Severe pain with severe difficulty in Walking 4

2. Kati Stambha (Stiffness)Never / Completely Disagree 1Rarely / Disagree 2Sometimes / Neutral 3Often / Agree 4Always / Completely Agree 5

3. SLR testNo pain at 90 ° 0Pain >71 up to 90° 1Pain >51 up to 70° 2Pain >31 up to 50° 3Pain below 30° 4

4. ODI scaleMinimal disability (0% - 20%) 0Moderate disability (21% - 40%) 1Severe disability (41% - 60%) 2Crippled (61% - 80%) 3Bed bound (81% - 100%) 4

5. VAS scaleNo pain 0Distress 1Annoying 2 – 3Uncomfortable 4Dreadful 5 – 6Horrible 8Unbearable distress 9Agonizing 10


Table no IV. – Overall assessment of parameters


Assessment parameters Grade

Before treatment After treatment

Katishula 3 2Katistambha 5 3

SLR ( Right limb) 2 (60˚) 1 (70˚)ODI 2 (40%) 1 (26 %)VAS 5 1

References

1. Weiler C, Lopez-Ramos M, Mayer HM, et al. Histological analysis of surgical lumbar intervertebral disc tissue provides evidence for an association between disc degeneration and increased body mass index. BMC Res Notes. 2011; 4:497. [PubMed]

2. Choi YS. Pathophysiology of degenerative disc disease. Asian Spine J. 2009;3:39–44. [PubMed]

3. Quint U, Wilke HJ. Grading of degenerative disk disease and functional impairment: imaging versus patho-anatomical findings. Eur Spine J. 2008;17:1705–1713. [PubMed]

4. Hicks GE, Morone N, Weiner DK. Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates. Spine (Phila Pa 1976) 2009;34:1301–1306. [PubMed]

5. Palepu V, Kodigudla M, Goel VK. Biomechanics of disc degeneration. Adv Orthop. 2012;2012:726210. [PubMed]

6. Lehtola V, Luomajoki H, Leinonen V, Gibbons S, Airaksinen O. Efficacy of movement control exercises versus general exercises on recurrent sub-acute nonspecific low back pain in a sub-group of patients with movement control dysfunction. Protocol of a randomized controlled trial. BMC Musculoskelet Disord. 2012;13:55. [PubMed]

7. Modic MT, Ross JS. Lumbar degenerative disk disease. Radiology. 2007;245:43–61. [PubMed]

8. Sri Vaidya Shodal, Gada Nigraha, with Vidyodini Hindi commentary of Sri Indradeva Tripati. Edited by Sri Gaya Sahaya Pandya, published by Chaukhamba Sanskrit Sansthan Varanasi, 1994, 3rd Edition, VoI. 2, chapter 19 verse 160, Pp 509.

9. Agnivesha, Charaka Samhita, with Vidhyotini Hindi commentary of Pandey Gangasahay. Edited by Pt. Kashinath Sastri published by Chaukumba Bharti Academy, Varanasi, 2012, Chikitsa Sthana chapter 28 Verse 33. Pp. 782

10. Agnivesha, Charaka Samhita, with Vidhyotini Hindi commentary of Pandey Gangasahay. Edited by Pt. Kashinath Sastri published by Chaukumba Bharti Academy, Varanasi, 2012, Chikitsa Sthana Chikitsa Sthana chapter 28 Verse 56. Pp. 787

11. Agnivesha, Charaka Samhita, with Vidhyotini Hindi commentary of Pandey Gangasahay. Edited by Pt. Kashinath Sastri published by Chaukumba Bharti Academy, Varanasi, 2012, Chikitsa Sthana Chikitsa Sthana chapter 28 Verse 37. Pp. 783

12. Agnivesha, Charaka Samhita, with Vidhyotini Hindi commentary of Pandey Gangasahay. Edited by Pt. Kashinath Sastri published by Chaukumba Bharti Academy, Varanasi, 2012, Sutra sthana chapter 28 Verse 27. Pp. 573

13. Agnivesha, Charaka Samhita, with Vidhyotini Hindi commentary of Pandey Gangasahay. Edited by Pt. Kashinath Sastri published by Chaukumba Bharti Academy, Varanasi, 2012, Chikitsa Sthana chapter 28 Verse 93. Pp. 793

14. Brahmasankar M. Bhavaprakasha Nighantu with Vidyotini Hindi commentary published by Chaukhambha Sanskrit Sansthan, Varanasi, 2002, Guḍuchyadivarga, 10th ed. Vol. 41. Pp294.

15. Brahmasankar M. Bhavaprakasha Nighantu with Vidyotini Hindi commentary published by Chaukhambha Sanskrit Sansthan, Varanasi, 2002, Guḍuchyadivarga 10th edition. Vol. 190. Pp. 393.

16. Chakardatta of Shri Chakarpanidata. Edited by Dwivedi R, Published by Chaukhambha Sanskrit Sansthan, Varanasi, 2002, Amavata Chikitsa verse 25-30, 4th edition, Pp.168



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JO

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CASE STUDY

Effect of Virechana Therapy in the Management of Psoriasis: A Case Study

*Dr. Monika Kumari, **Dr. K K Singh, ***Dr. V.B. Kumavat, **** Dr. Prabhakar Vardhan

*Research officer (Ayu), **Assistant Director and Incharge , ***Research officer (Ayu), Maharao Shekhaji Regional Ayurvedic Research Institute for Endocrine Disorders, Jaipur, **** Assistant Professor, PG Dept of Shalakya Tantra, National Institute of Ayurveda, Jaipur.

ABSTRACTRationale: Psoriasis is a chronic and stressful illness which is considered incurable in modern science. As per

ayurveda the disease psoriasis bears resemblance to the ekakushtha which is one among eighteen types of kushtha. Samshodhana (Biological Purification) is the principal therapy which is indicated to treat kushtha in ayurveda. Based on this principle treatment the present case was managed with virechana as per classical guidelines. Background: An Indian male of age 47 years presented in April 2018 with complaints of numerous itchy purplish patches of varying sizes ranging from 0.5 cm in diameter to large confluent areas resembling a land map with silver scales on scalp, back, chest, abdomen, back, upper and lower limbs since 6 months. He had chronic constipation and was also suffering from tolerable pain in metacarpophalangeal and metatarsophalangeal joints since 2006. The Patient had five episodes of remissions of this illness in 1996, 2002, 2006, 2016, and 2017. Intervention and outcome: The patient was treated on prescribed line of treatment i.e. samshodhana (virechana ) as described in ayurveda for kushtha disease. Before treatment the PASI score was 41.3, DLQI score was 19. After the therapy the Psoriasis Area Severity Index (PASI) score reduced to 2.1 and Dermatology Life Quality Index (DLQI) score to 5. Hence 90 % improvement in the disease progress was achieved.

Keywords : Kushtha, ekakushtha, psoriasis, samshodhana, virechana

Address for Correspondence: Dr. Monika Kumari Research officer (Ayu), Maharao Shekhaji Regional Ayurvedic Research Institute for Endocrine Disorders, JaipurEmail ID : [email protected] No : 7597117008

Introduction:

Psoriasis is a chronic, inflammatory papulosquamous disease characterized by multiple relapses. The disease affects 2-3% population of world and presents as erythematous, indurated, scaly plaque over the skin occasionally accompanied by involvement of joints and nails. Male population is affected more in their forties.

How to Cite the Article : Kumari M, Singh KK, Kumawat VB, Vardhan P, Effect of Virechana Therapy in the Management of Psoriasis: A Case Study, JOA XIV-1, 2020; 60 - 70



Kumari M, Singh KK, Kumawat VB, Vardhan P, Effect of Virechana Therapy in the Management of Psoriasis: A Case Study, JOA XIV-1, 2020; 60 - 70

The disease has proved genetic involvement. Due to possibility of remission with every treatment the illness is considered as incurable disease in modern science. Therapies imparted by modern science include Systemic or UV phototherapies which have unacceptable side effects. Hepatotoxicity and nephrotoxicity may occur with treatment with methrotrexate or cyclosporine. Retinoids increase the risk of teratogenecity, and skin cancer may result by repeated use of PUVA (psoralin and long wave ultraviolet radiation) treatments[1].

In Ayurveda science the features of psoriasis very well resemble to features of ekakushtha - a subtype of eighteen types of kushtha (skin diseases)[2] Samshodhana (Biological Purification) is the chief therapy which is indicated to treat kushtha in ayurveda[3]. Based on this principle treatment the present case was given virechana as per classical guidelines. There was marked improvement in disease progress with the treatment regimen. The present case emphasizes that the Ayurveda science has tremendous potential in dealing with such chronic and distressing illnesses.

CASE REPORT:

An Indian male of age 47 years and weight 71.3 Kg came

to OPD of MSRARIED with complaints of numerous itchy purplish patches with silver scales on scalp, back, chest, abdomen, back, upper and lower limbs for 6 months (Fig 1- 4). He had good appetite and was suffering from chronic constipation. He was also suffering from tolerable pain in metacarpophalangeal and metatarsophalangeal joints since 2006. The Patient had five episodes of this illness in 1996, 2002, 2006, 2016 and 2017. Earlier these lesions were restricted to scalp and behind ears only for which he took satisfactory allopathic treatment. In 2016 he remained admitted in National Institute of ayurveda, Jaipur and underwent Basti therapy for this illness and joint pain and got completely relieved and didn’t take any medication thereafter for one year. Also, he did not follow the dietary and behavior regimen as advised by physician of NIA. He used to apply a steroid base ointment with coconut oil with which he was getting symptomatic relief but simultaneously new lesions were also developing. The patient has no family history of this illness. He is a businessman by profession and most of the times remain psychologically involved in his business matters.

Figure 1. Large conflent thick scaly and purplish psoriatic lesion of land map type on back

Figure 2. Silvery erythematous psoriatic patches on upper limb



Figure 3. Land map type scaly erythematous psoriatic lesions on side of abdomen

Figure 4. Coin shaped erythematous and scaly psoriatic patches on leg

DIAGNOSTIC EVALUATION AND ASSESSMENT

On local examination there were numerous (Mahavastu) well demarcated rough thick (Kin Khara sparsham) purplish erythematous plaques (shyava varna) covered with silvery scales (matsyashaklopamam) ranging from 0.5 cm in diameter to large confluent areas resembling a land map (Fig1-4). Small plaques were present in scalp and upper and lower limbs (Fig2,4) while land map type plaques were present in trunk (Figures 1 and 3). The hypo pigmented healed lesions were also present on upper part of back (Figure 1). Candle grease sign i.e. removal of the scale leaves behind a glossy grease like skin and Auspitz sign (removal of scale leaves behind bleeding points) were present. Koebners phenomena i.e. appearance of the lesions along the line of scratching was also present.

His Blood investigation done on 20/03/2018 showed Hb 16.6g/dl, TLC- 7800, DLC N 64%, L31%,E 02%,Mono 03%, RBC 6.2 million,HCT48.8%, MCV 77.62, MCH

26.4pg, MCHC 34gm/dl, RDW-SD 39.7%, PLT 297000, P-LCR 20, ESR-06 mm/hr. S. Cholesterol 220mg/dl, S. Triglycerides 87mg/dl, S. HDL 44mg/dl, S. LDL 128mg/dl, SW. VLDL 17 mg/dl. FBS 105mg/dl, S. Urea 20mg/dl, S. Creatinine 0.8mg/dl, S. Bilirubin Total 0.4mg/dl, S. Bilirubin Indirect 0.2mg/dl, SGOT 31IU/L, SGPT 37 IU/L, S. Total Protein 6.7gm/dl, S. Albumin 4.1 gm/dl, S. Globulin 2.6gm/dl, S. alkaline Phosphate 186 IU/L, S. uric acid 3.6mg/dl. His blood pressure was 130/90, Height 162.5cm, weight was 71.3 kg and Body Mass Index was 27.

On the basis of history and clinical examination the present case was diagnosed as a case of plaque psoriasis or psoriasis vulgaris and ekakushtha as per the signs and symptoms explained in the classical texts (Tables 1 and 2). His Psoriasis area and severity Index (PASI) was 41.3 and Dermatology Life Quality Index (DLQI) calculated on 27/03/2018 was 19 i.e. very large effects on patient’s life.



Date Presenting complaint

19/03/18

Numerous (Mahavastu) well demarcated rough thick (Kin Khara sparsham) purplish erythematous plaques (shyava varna) covered with silvery scales (matsyashaklopamam) ranging from 0.5 cm in diameter to large confluent areas resembling land mapPASI score:41.3, DLQI score: 19

Date Past medical history and interventions

1996Scaly itchy lesions on scalp behind ears, diagnosed as psoriasis and treated with allopathic treatment, got completely relieved.

2002 Scaly itchy lesions on scalp behind right ear, took allopathic treatment, got completely relieved

2006

Scaly itchy lesions on scalp behind ears, Pain in multiple joints took allopathic treatment, got completely relieved.

Nov 2016Lesion on scalp behind right ear, pain in multiple joints, took basti therapy for 15 days and got completely relieved.

Sept, 2018Didn’t follow the dietary regimen as advised, Developed full blown psoriatic lesions on entire trunk and four limbs and scalp.

Diagnosis: Psoriasis (Ekakushtha)

Therapeutic Interventions

Duration Medication dose Route Frequency AnupanMarch19 2018-March26,2018

1. Chitrakadi vati 2 tablets

Oral Twice a day after meals Warm water

2. Ajmodadi churna 2 grams Oral Twice a day after meals Warm water3. Eranda taila 10 ml Oral Bed time Warm milk

March 27, 2018 Panchatikta ghrita 50ml, Oral Morning empty stomach Warm waterMarch 28, 2018 Panchatikta ghrita 80ml Oral Morning empty stomach Warm waterMarch29, 2018 Panchatikta ghrita 110ml Oral Morning empty stomach Warm waterMarch30, 2018 Panchatikta ghrita 160ml Oral Morning empty stomach Warm waterMarch31, 2018 Panchatikta ghrita 220ml Oral Morning empty stomach Warm water

April1, 2018 777 oil 150 External MorningApril 2, 2018 777 oil 150 External MorningApril 3, 2018 777 oil 150 External Morning

April 4, 2018 Trivrit avleha 50 gm oral morning Warm waterApril 4, 2018 Panchsakara fant 100ml oral 4 times -

Table No I: Time Line



April4,2018-

April8,2018

Samsarjana karma

April4,2018-

April8,2018

Chitrakadi vati 1 tablet oral Twice a day Warm water

Avipattikar churna 10 gm oral Bed time Lukewarm waterMahamanjishthadi kwath

40ml oral Twice a day

April 9, 2018to continue

Arogyavardhuni vati

2 tablets

oral Twice a day Lukewarm water

Argavadhadi kashya 20ml Oral Twice a dayMahamanjishthadi kashaya

40ml Twice a day

Avipattikar churna 10 gm Bed time Lukewarm water

Life style Modification

Advised to sleep early and wake up early, morning walk and to follow ideal daily routine, timely intake of food, to take green leafy vegetables, pomegranate fruit, and barley. Also advised to avoid rice, curd, tea, pickles, fried food, outside eatables and excessive salt.

OutcomeDisappearance of scales, markedly reduced erythema and thickness in lesions. Few lesions healed and vanished. PASI score improved to 2.1 i.e. PASI 90 was attained, DQLI score improved to 5.

Table No II: Ayurveda parameters

Ayurveda parameters Findings in patient

Dosha (biological factors of the body) Vata Kapha dominating Tridosha

Dushya ( Body tissues) Rasa, rakta, meda, lasika

Sthana(Site of localization) Tvak (skin)

Agni (digestive and metabolic factors) Mandagni

Koshtha (Bowel habit) Krura (doesn’t pass stool regularly)


Srotas (structural and functional channels) Annavaha (channels of digestive system)Rasavaha, Raktavaha (Channels of circulatory system)Medovaha (channels of adipose tissues)Pureeshvaha (Channels carrying feces), Svedavaha (channels carrying sweat)

Srtodushti Atipravritti (hyperproliferation of keratinocSytes)

Avastha (stage of disease) Ama avstha (Presence of undigested metabolic end products)

Rogamarga (the pathway of disease manifestation)

Bahya (external pathway )

Sadhyasadhyata(Prognosis) Kricchrasadhya (difficult to cure)


TREATMENT AND OUTCOME

At first appointment on March 19, 2018 the patient presented with features of numerous well demarcated rough thick, purplish erythematous plaques covered with silvery scales, ranging from 0.5 cm in diameter to large confluent areas resembling land map and constipation. As the illness is recognized as ekakushtha so Samshodhan in the form of Virechana therapy was planned for him (Table 1).

His pre-operative blood investigations were done to observe his suitability for virechana therapy. As Purva karma oral medicines e.g. Chitrakadi vati [4],[ 5] Ajmodadi churna for Deepana pachana and eranda tail[6],[ 7] (Table 1) to relieve his constipation were given for seven days. For the rest of the treatment regimen the patient was admitted in the IPD of MSRARIED Jaipur on March 27, 2018 and was started the snehana therapy (intake of medicated oil) with Panchatikta ghrita (Table 1) for 5 days. On fifth day he had achieved the features of samyaka snigdha i.e softness in body parts, agnideepana, snigdha and asamhata varcha[8]. Then sarvanga abhyanga (whole body massage therapy) with 777oil[9],[10] and sarvanga sveda (whole body sudation therapy) was done for three days from April 1, 2018 to April 3, 2018. On April 4, 2018 after sarvanga abhyanga, sarvanga sveda and taking bath the patient was given trivritavleha as virechana yoga at 9: 00AM[11] . The first vega occurred at 11:30 AM which consisted of pellets of stool along with

watery content. Then the patient was given decoction prepared from panchasakara churna at the interval of 2 hrs.12 Till evening 8:00 PM the patient underwent total 10 vega. The total stool content was approximately 2300 ml. He achieved madhyama langiki shuddhi, madhyama maniki shuddhi13 and abara vegiki shuddhi[14]. On April 5, 2018 after doing blood investigations the patient was discharged with the advice of samsarjana krama (specific dietary regimen) as indicated for madhyama shuddhi for five days. He was also advised certain dietary and lifestyle modifications (Table 1) The blood investigations revealed all parameters within normal range some deranged lipid profile was notified for which the patient was given chitrakadi vati from second day of virechana onwards in low dose (Table 1). He was put on Mamjishthadi kwath[15], and Avipattikar churna [16](Table 1). During this time his skin lesions had softened, Itching had vanished and scaling was also reduced. His PASI Score improved to 24.3 i.e. 50% reduction in disease severity (PASI 50) and DLQ was 10.

On 9th april 2018 he was put on Arogyavardhini vati 17 and aragvadhadi kashaya18 in addition to previous medicines. On 20th April the patient was re assessed for signs and symptoms of the illness. There was no itching, minimal scaling and marked reduction in erythema thickness of the lesions (Fig 5-8). Many hypopigmented lesions were also observed which indicate the healing of old psoriatic lesions (Fig 5). His PASI score was 2.1 i.e.



90% improvement in disease severity (PASI 90) and DLQI score was 5 i.e. the disease was producing a little

effect on quality of life. The patient was continued these medicines for 15 days (Table 1).

Figure 5. Healed Psoriatic lesions , no scales, markedly reduced thickness of the lesions and reducederythma

Figure 7. - Healed psoriatic lesions with markedly reduced thickness and scales in side of abdomen

Figure 8. Healed psoriatic lesions with absent scales and erythma on leg

Figure 6. Healed psoriatic lesions, no scales , no erythema

Psoriasis has a significant negative impact on patients’ health. These patients have lower quality of life due to the physical symptoms of this disease such as pruritus, scaling and joint pains. In addition, the financial and psychosocial impact leads to problems of self-esteem,

stigmatization, embarrassment and maladaptive coping responses. The characteristic features of psoriasis very well resemble to Kitibha kushtha 19 and Eka kushtha 20 described in Ayurveda (Table 4).



Table III: Rationality of the therapeutics

Name of medicine administered Rationality

Chitrakadi Vati As preoperative procedure for Deepana i.e. ignition of the digestive fire and pachana i.e. digestion of Ama (undigested food material) and detachment of Lina (morbid) dosha from the dushya and srotas

Erand Taila As the patient had constipation to achieve Apana vata anulomana

Panchatikta ghrita in increasing dose For Snehana (internal oleation) to increase and liquefy dosha (vishyandana)

777 oil Bahya snehana (external oleation), the oil leads to softening of scales has moisturizing, anti-inflammatory effect.

Sarvanga Svedana Svedana to increase agni at all levels and to remove the obstruction in srotas by digesting the ama. Vata dosha pacification. By snehana and svedana dosha move from shakha to Koshtha

Trivrit avleha For virechana Decoction of Panchasakar churna To booster the virechana procedureMamjishthadi kwath As blood purifierAvipattikara churna

As the patient had excessive accumulation of dosha so, to achieve regular expulsion of dosha (nitya virechana) .

Arogyavardhini vati for stimulating the agni and to digest the remaining ama dosha and acts as blood purifier

Argvadhadi kashaya Regular expulsion of dosha from body, so that these could not accumulate

Table IV: Ayurveda interpretation of psoriasis

Lesions in Psoriasis Kitibha kushtha Ekakushtha

Erythematous, purplish ˜ Shyava varna --

Rough and thick lesions ˜ Kina , khara sparsha --

Numerous lesions - ˜ mahavastu

Silvery scales -- ˜ matsyashaklopama

Regarding pathogenesis of psoriasis, it is hypothesized that an unknown antigen starts the activation of T cells which leads to secretion of an array of cytokines viz. EGF, IL-1, IL-6,IL-8, IL12, IL-17, IL23, TNF-alpha etc. by activated T cells, inflammatory cells.

and keratinocytes. Due to these cytokines there is hyper proliferation of keratinocytes, neutrophil migration angiogenesis, up- regulation of adhesion molecule and epidermal hyperplasia[21].



Ayurveda science also considers the entity as one among the diseases which have deleterious effects and difficult to cure[22]. The revered science interprets the disease due to extreme aberrations in dietary regimen such as use of viruddha ahara (wrong food combinations), excessive intake of unctuous and heavy to digest foods, ajiranashana (intake of food before digestion of previous meals), adhyashana (haphazard intake of food), excessive intake of curd, fish, salt and sour substances, suppression of natural urges of urine and stool etc. and aberrations in behavioral regimen[23]. All these factors lead to agni dushti (malfunctioning of digestion and absorption), as a result Ama dosha (maldigested food) is produced. This ama dosha leads to vitiation of three dosha (biological factors) which vitiate rasa (plasma), rakta (blood), mamsa (proteins) and lasika (lymph) and result in manifestation of the illness on skin[24]. Vata dosha led to the excessive roughness in the lesions and scale formation. The inflammatory component is due to pitta dushti. Kapha dushi can be interpreted from hyperproliferation of keratinocytes. In the light of modern science, it can be hypothesized that absorbed parts of the ama (end products of maldigested food) create the antigen in the body which initiates the cascade of the pathogenesis of the present illness. Role of various cytokines and inflammatory cells indicate towards the vitiation of rasa, rakta and lasika dushti, while detectable levels of activated Stat3 (signal transducers and activators of transcription) in Keratinocyte (KC) [25], a protein indicated in development of the disease indicate mamsa dhatu dushti.

In present case involvement of genes can be denied due lack of family history of the illness. Among causative factors he had history of aberrations in dietary regimen viz. as viruddhahara, ajirnashana, adhyashana, intake of curd, pickles, lack of exercise and improper daily routine. These etiological factors would have provoked the ama formation and produced the responsible antigen for the manifestation of the illness. Earlier the lesions were restricted to scalp. The severity of intake of aetiological factors and the conglomeration of aggravated dosha and dushya results in the severity of manifestation of the

disease[26]. In this regard as the patient was not following the ideal diet and behavioral regimen since long time the recurrence of the illness in the form of full-blown psoriatic plaques at multiple areas of body were there. The case was treated on following principles to the break of pathogenesis-

Nidana parivarjana: Life style modifications (Table 1).

Samshodhana (Purification Therapy): As the patient represented presence of excessive vitiation of dosha hence samshodhana in the form of virechana was planned 27 (Table 1).

Samshamana: To pacify the remaining dosha, Mamjishthadi kwatha, Arogyavardhini vati Argvadhadi kashaya were advised (Table 3).

Bahya parimarjina (external purification therapy): For this purpose777 oil was used, as the oil contains 50% Cocos nucifera and 50% Wrightia tinctoria. Its moisturizing effect reduces the dryness of skin, reduces multiplicarion of keratinocytes, softens the skin and reduces irritation (Table 3)

With this treatment 3 kg wt of the patient was reduced and there was significant improvement in the features of the illness. The most widely used scale is PASI among various clinical severity scores for the psoriasis, as it is the most extensively validated. A 75% reduction in the PASI score (PASI 75) is the current benchmark of clinically meaningful improvement in psoriasis. However, PASI of 50 also equates to a clinically meaningful improvement in psoriasis. British Association of Dermatologists defined adequate response to treatment as either attainment of PASI 50 and decrease in ≥5 points in DLQI or attainment of PASI 75[28].

In present case PASI 90 and DLQI 5 was achieved which indicates that Ayurveda, the holistic science is competent enough to confer amazing results in such poorly managed illnesses by the modern science.

CONCLUSION:

Psoriasis a multifactorial systemic illness is one of the



distressing poorly understood and managed illness in modern science. The disease is interpreted as ekakushtha in Ayurveda science. The present case anticipates the fruitful approach of Ayurveda science in dealing with such illnesses. In addition, the role of ideal daily routine and diet regimen has its own value in achieving the present outcome.

PATIENT PERSPECTIVE: ‘I had attained marked relief in my lesions which I couldn’t get since so many months. I am very much satisfied and thankful for bringing me to this stage of almost being normal for which I was aspiring sine long time.’

INFORMED CONSENT: An informed written consent was obtained from the patient before reporting his case.

ACKNOWLEDGEMENT: The present case study has been prepared keeping in view the CARE guidelines[29].

References

1. SL, Gorden KB. The immunology of psoriasis and biologic immunotherapy. J Am Acad Dermatol. 2003:49;44-50. (Pubmed).

2. Trikamji Acharya (ed.) Charaka samhita Deepika commentary by Chakrapanidutta, Chikitsasthan; Kushthachikitsat adhyaya: Chapter no-7, Verse no-13. Varanasi: Chaukhamba Surbharati Prakashan; 2005.p.451

3. Ibid. Chikitsasthan; Kushthachikitsat adhyaya: Chapter no-7, Verse no- 41.p.452.

4. (Ch. Chi 15/17)

5. (Su Chi 33/39)

6. Su.Su.45/114

7. Bh. Pr. Guduchyadi varga 4

8. Ibid. Sutrasthana; Snehadhyaya: Chapter no- 13, Verse no- 58.p.85.

9. A monograph on Clinical and Experimental Studies on the Efficacy of 777 oil, a Siddha preparation in the treatment of Psoriasis, CCRAS, Year: 1987

10. Prof. Kumar Abhimanyu (chief editor) Evidence Based Ayurvedic Practice, based on CCRAS R&D Contributions. Psoriasis. Chapter no 15, CCRAS, new Delhi 110058, 2014.P.49,50

11. Paradakar Shastri (ed.), Ashtanga hrdaya. Kalpa sthana Chapter no-2, Verse no-9. 9th ed. Varanasi: Chaukhamba Surbharati Prakashan; 2011, p. 742

12. Patil Vasant, Principles and Practice of Panchakarma, Chapter 12 Virecana Karma. Chaukhambha Publications: 2016. New Delhi.2016. P. 401

13. Trikamji Acharya (ed.) Charaka samhita Deepika commentary by Chakrapanidutta, Siddhi Sthana; Kalpanasiddhi adhyaya: Chapter no- 1. Verse no-14. Varanasi: Chaukhamba Surbharati Prakashan; 2005 p.679.

14. Ibid. Siddhi sthana; Kalpanasiddhi: Chapter no-1, Verse no- 13.p.679.

15. Narayana Ram Acharya (ed.). Sharangadhara Samhita. Madyama Khanda: Kwatha Kalpana Adhyaya; Chapter no-2. Verse no - 139. Varanasi: Chaukhamba Orientalia, 2016, p. 63

16. Shri Brahmashankar Mishra (ed.), Bhaishajya ratnavali Vol-III.; amlapittachiktsa: Chapter no-56. Verse 25-29. 1st ed. Varanasi: Chaukhamba Sanskrit Bhawan;2006, p.117-118.

17. Ambika dutta shastri. Rasaratna Samucchya. 9th Edition. Chapter No. 20, Verse No 87. Varanasi:Choukhambha Sanskrit Publisher;1994.p100.

18. Paradakar Shastri (ed.), Ashtanga hrdaya. Sutra sthana; Shodhaniya gana adhyaya: Chapter 15, Verse no-17,18. 9th ed. Varanasi: Chaukhamba Surbharati Prakashan;2011, p. 234

19. Trikamji Acharya (ed.) Charaka samhita Deepika commentary by Chakrapanidutta, Chikitsa sthana; Kushthachikitsat adhyaya: Chapter no-7. Verse no- 22. Varanasi: Chaukhamba Surbharati Prakashan; 2005.p.451.

20. Ibid. Chikitsa sthana; Kushthachikitsat adhyaya: Chapter no-7. Verse no- 21. p.451.

21. Patrick Das Rajeev et.al. Current concepts in the pathogenesis of Psoriasis. Indian Journal of Dermatology v.54 (1): 7-12. Jan –Mar 2009

22. Su Su 33/ Trikamji Acharya (ed.) Sushruta samhita Nibandha Samgraha commentary of Dalhana. Sutra sthana Chapter no-33. Verse no-4, 4th ed. Varanasi: Chaukhamba Orientalia, 1980, p. 144.

23. Trikamji Acharya (ed.) Charaka samhita Deepika commentary by Chakrapanidutta, Chikitsa sthana; Kushthachikitsat adhyaya: Chapter no-7. Verse no- 4-8. Varanasi: Chaukhamba Surbharati Prakashan; 2005. P.450.

24. Ibid. Chikitsa sthana, Kushthachikitsat adhyaya: Chapter no-7. Verse no- 9. p.450.

25. Enzo Calautti et al. Psoriasis: A STAT3-Centric View. Int J Mol Sci. 2018 Jan; 19(1): 171.

26. Ibid. Nidana sthana; Prameha nidana adhyaya: Chapter no- 4. Verse no-4.p.212.

27. Ibid. Chikitsa sthana, Kushthachikitsat adhyaya: Chapter no-7. Verse no- 41. p. 452



28. Sunil Dogra, Rahul Mahajan, Psoriasis: Epidemiology, clinical features, co-morbidities, and clinical scoring. Indian Dermatology Online Journal. November-December 2016 , Volume 7 - Issue 6 page 47

29. Gagnier J. et al. CARE Group. The CARE guidelines: Consensus based clinical carereporting guideline development. J Clin Epidemiol 2014 Jan, 67 (1).

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CASE STUDY

Ayurvedic management of Type-2 Diabetes mellitus – A case report*Dr Abhishek Upadhyay, **Dr Radhika Pukale, ***Dr Deepti Sharma

*Lecturer, **PG Scholars, ***PG Scholars, PG department of Kayachikitsa, National Institute of Ayurveda, Jaipur.

ABSTRACT

Diabetes mellitus is characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action or both. Diabetes mellitus resembles to Prameha in Ayurveda and is classified as a Santarpanajanya vikara (disorder due to overnutrition). Present case is about a 63 years old overweight, Indian diabetic taking anti-diabetic drugs including insulin (Inj. LANTUS 36 IU) who presented with constipation, distension in abdomen, pain in lower limbs and disturbed sleep. Patient was treated with Phaltrikadi kwatha, Madhumehari Churna, Tab Diabecon-DS,

Vasant Kusumakar Rasa along with other medications. Though the patient consulted for his abdominal symptoms in Ayurveda but with improvement in digestive fire and daily satisfactory clearance of bowel substantial improvement was observed in subjective symptoms with significant reduction in insulin dosage (36 IU to 8 IU) and other modern drugs dosage after Ayurvedic intervention with better glycemic control. This case study highlights the usefulness of Ayurveda and need of integrated medical care for cost effective management of diabetes.

Keywords : Madhumeha, Phaltrikadi kwath, Madhumehari churna, Vasant Kusumakar Rasa, Case Study

Address for Correspondence: Dr. Abhishek Upadhyay Lecturer, Department of Kayachikitsa,National Institute of Ayurveda, JaipurEmail ID : [email protected] No : 9915613039

Introduction:

Diabetes mellitus (DM), a metabolic disorder is characterized by chronic hyperglycemia resulting from defect in insulin secretion, insulin action or both. Epidemiological studies of Type 2 diabetes provide evidence that overeating, especially when combined with obesity diabetic, and under activity is associated

How to Cite the Article : Upadhyay A, Pukale D, Sharma D, Sharma S, Ayurvedic management of Type-2 Diabetes mellitus – A case report ,JOA XIV-1, 2020; 71 - 77



Upadhyay A, Pukale D, Sharma D, Sharma S, Ayurvedic management of Type-2 Diabetes mellitus – A case report ,JOA XIV-1, 2020; 71 - 77

with the development of type 2 diabetes[1]. According to International Diabetic Federation Atlas 2019, an estimated 463 million adults are living with DM with approximately 1 in 13 adults (20-79yrs) being diabetic & prevalence could be alarmingly doubled to 700 million by 2045[2]. In Ayurveda, DM resembles clinically to Madhumeha, a type of Vataja Prameha and is categorized under Santarpanajanya vikara [3] (disorders due to over nutrition). Due to continuous indulgence in etiological factors like lack of exercise, sedentary lifestyle and excess consumption of high calorie foods Kapha (one of the biological humor) and Meda (fatty tissue) get vitiated, which if unchecked further vitiate Kleda (water content of body) and Meda at the level of every cell thus initiating the pathogenesis of DM [4]. This vitiated Kleda produce symptoms like Prabhoota mutra (polyuria) and Aavila mutrata (turbid urine).

Case report

A 63 year Hindu male known diabetic since 15 years and hypertensive reported to our hospital with complaints of constipation, distension in abdomen, pain in lower limbs and disturbed sleep. He belonged to a middle class Indian family with no known record of diabetes in his parents and grandparents. There was no history of diabetes present among siblings but his son was recently diagnosed with diabetes. During the first visit to our hospital patient was on modern anti-diabetic drugs [(Metformin (3g), Glimipride (8g), Tenegliptin (20mg), Pioglitazone (15mg) and Canagliflozin (100mg)] and Insulin Glargine (Long acting human insulin – 36 IU). Main reason for which patient reported to us was constipation and other gastrointestinal symptoms. He was passing hard and sticky stool irregularly with discomfort and unsatisfied evacuation. Constipation was associated with distension of abdomen which got aggravated after meals and occasionally got relieved after clear evacuation of bowel. Frequency of urine was eight to ten times during day time and two to three times during night. Sleep was disturbed and irregular due to nocturia and associated burning and numbness in feet (more during night). History of numbness, tingling and burning in feet along, loss of libido with Tandra (lassitude) and Pindikodveshtana

(pain in calf muscles) was also present.

Clinical Findings

Patient was overweight with Body mass index 27.8 kg/m2 (height - 180 cm, weight - 90kg). Vitals recorded were pulse - 90/min, blood pressure - 130/90 mmHg, respiration – 20/min temperature - 98°F. Cardio-respiratory examination was normal. Neurological assessment showed diminished sensation to touch (light touch, pin prick- pain) over toes and legs (Glove stocking neuropathy) whereas temperature sense was intact for both cold and warm. Laboratory findings at the time of presentation were fasting blood sugar (FBS) – 180 mg/dl, PPBS – 200 mg/dl. Value of HbA1C on 02/04/19 was 8.6%.

Ayurvedic approach to the case

During evaluation of Panch Nidana (Ayurvedic diagnostic methods) excessive indulgence in Santarpana janya (related to overnutrition) dietary factors like Dadhi (curd) and Payas (milk products) were found with factors like Asyasukham (prolonged sitting), Diwaswap (day time sleep) and lack of exercise which increases Kapha dosha. Patient was having symptoms like Madhuryamasya (sweet taste of mouth), Mukha-talu-kantha shosha (dryness of mouth), Aalasya (laziness), Tandra (excess sleep and fatigue) and irregular bowel habits with hard and sticky stool with sense of incomplete evacuation which signify the state of Ama (undigested metabolic wastes) due to vitiated Kapha. Patient also reported symptoms like Prabhoot mootrata (polyuria - approximate amount of urine per void was 200ml) which was more during day as well as night. His Nadi was Kapha-Vata dominant (heavy with high volume), stool was Saama (settles at the bottom of pot), urine was Picchila (turbidity) and Prabhuta (excess quantity and frequency). Tongue was Shwetabha (whitish) and Malavrita (coated). All these factors signify the state of Ama and Agnimandya due to dominance of Kapha. Vitiated Kapha has the tendency to vitiate other components of the body with similar properties like Kleda (water content of the body) and Meda (fatty tissue). There was obstructive (Sanga) type of pathogenesis at the level of koshtha (gastrointestinal system) and Ati pravriti


Upadhyay A, Pukale D, Sharma D, Sharma S, Ayurvedic management of Type-2 Diabetes mellitus – A case report, JOA XIV-1, 2020; 71 - 77

at the level of Mutravaha srotas (genitourinary system).

Therapeutic approach

Considering the vitiated Kapha, Kleda & Meda our treatment protocol focused on Apatarpana chikitsa with Aamapachana, Deepana and Kledanasha properties. Due to dominant abdominal symptoms Nitya Virechana (daily purgation) was done. The treatment included diet, drug and lifestyle modifications.

Diet and lifestyle modifications

Patient was advised to take seasonal fruits (except mango,

grapes, dates, banana & chiku) and one small bowl of porridge in breakfast. For lunch and dinner one bowl

of any one cooked seasonal green leafy vegetable (bitter gourd, bottle gourd, pointed gourd, brinjal preferably) with one small bowl of cooked lentils (preferably green gram, horse gram, masur, pigeon pea) with 2-3 small size multigrain (barley, maize, whole wheat, soybean) flour rotis were advised. Patient was allowed to take one glass of clear buttermilk during daytime and half glass of milk without sugar at bedtime. Patient was advised to avoid eating without feeling hunger, sweets, curd, tubers, black grams, milk products and fried items.

Patient was asked to avoid day time sleep, prolonged sitting and to continue his routine of walking daily which he was doing earlier also but was advised to avoid exercise after eating anything for at least one hour.

Table I: Timeline

Date Chief complaints Test Medications

12/7/19

Constipation,Distension in abdomen,

Pain in lower limbs, Disturbed sleep

Other symptoms –Numbness, tingling & burning in feet, loss of

libido

FBS - 180mg/dlPPBS - 200 mg/dl

1. Phalatrikadi Kashaya – 50 ml twice a day empty stomach

2. Madhumehari choorna 5 g twice a day before meals

3. Yograj Guggulu 1g twice a day after meals

4. Tab Diabecon DS 2 tab twice a day after meals

5. Shilajatwadi lauha 2 tab twice a day after meals

2/8/19

Improvement in constipation and

abdominal symptomsComplaints of

weakness, pain in legs, loss of libido persisted

Serum cholesterol - 202, Triglycerides - 271.8 mg/dl, LDL - 131.4 mg/dl, HDL -

33.5 mg/dl, Urea - 13.0 mg/dl & Serum creatinine - 1.1

mg/dl

same treatment continued



13/9/19

a)Weakness b)Loss of libido

During this period patient experienced

episodes of hypoglycemia and consulted modern

physician where his dosage of drugs and

medicines was tapered

Results on 26/9/19FBS – 160 mg/dl

PPBS – 140 mg/dlHbA1C – 7.8 %

1. Phalatrikadi kashaya 25 ml morning empty stomach

2. Madhumehari choorna 5 gm twice a day before meals

3. Tab. Diabecon DS 2 tab twice a day

4. Triphala choorna 3 g mixed with Lauha bhasma 125 mg twice a day

18/10/19

Loss of libido,Numbness, tingling

& burning in feet improved but persisted

(Dosage of insulin further reduced)

-

1. Phalatrikadi kashaya 25 ml morning empty stomach

2. Madhumehari choorna 5 gm twice a day before meals

3. Tab. Diabecon DS 2 tab twice a day4. Vasantkusumakar ras 125mg BD

5/12/19

Loss of libido, Numbness, tingling


Results on 05/12/19FBS – 110 mg/dl

PPBS – 125 mg/dlHbA1C – 7.0 %

Total Cholestrol – 247 mg/dlTriglycerides – 266.7 mg/dlLDL cholesterol – 152.4 mg/

dlHDL cholesterol – 45 mg/dlvLDL cholesterol – 53.3 mg/

dlSerum creatinine – 1.11 mg/

dl


17/01/2020

Loss of libido, Numbness, tingling


(Dosage of insulin further reduced)

-



Upadhyay A, Pukale D, Sharma D, Sharma S, Ayurvedic management of Type-2 Diabetes mellitus – A case report, JOA XIV-1, 2020; 71 - 77

Table II: Changes in modern medications after Ayurvedic intervention

Changes in modern medications after Ayurvedic intervention Modern medication before Ayurvedic intervention

Modern medication after Ayurvedic intervention

Oral anti-diabetic drugs

Glimepiride (8 mg/day)Metformin (3g/day) Pioglitazone (15mg) Teneglitptin (20 mg)

Canagliflozin (100 mg)

Glimepiride (4 mg/day)Metformin (2g/day)

Pioglitazone (stopped)Teneglitptin (20 mg)Canagliflozin (50mg)

Inj LANTUS(Insulin Glargine)

8/6/19 - 36 IU08/09/19 - 24 IU13/09/19 - 18 IU18/10/19 - 12 IU17/01/20 - 08 IU

Discussion

Present case is a case of Santarpanajanya Madhumeha (Type 2 DM) with Kapha dominant constitutional clinical presentation. Patient was on oral hypoglycemic drugs along with insulin but still laboratory parameters as well as quality of life were not good. As patient was overweight diabetic with constipation and other abdominal symptoms as main cause of concern, so Aptarpana (one with reducing properties) line of treatment was adopted in this case i.e. Aampachana (digesting the metabolic wastes), Deepana (stimulates digestive fire), Kapha & Kleda (water soluble wastes) pacifying treatment [5], along with Nitya virechana (daily purgation) and Rasayan(antioxidant properties).

Madhumehari choorna having ingredients predominant in Katu (pungent), Tikta (bitter), Kashaya (astringent) taste, being Ushna Veerya (hot potency) and having Katu Vipaka helped in stimulating the digestion (Deepana, Pachana) and pacification of vitiated Kleda & Meda. Madhumehari choorna has shown anti-hyperglycaemic and hypolipidaemic activities in clinical trials [6]. Gymnema sylvestre, a main ingredient of the formulation has shown anti-diabetic as well as β-cell regeneration activities. [7] Pterocarpus marsupium Roxb. an ingredient of the formulation has proven anti hyperglycemic activities.[8] The proven hypoglycemic effect of Triphala is well known to scientific community for significant glucose lowering effect and can be attributed to the presence of

menthol and sorbitol [9]. Methika (Fenugreek seed) seeds are high in soluble fiber and have shown reduction in fasting plasma glucose and post prandial plasma glucose levels along with decreased insulin resistance. [10]

Diabecon-DS[11] is a poly herbo-mineral formulation showing combined stimulatory effect on insulin release, by increasing the cellular permeability, reducing the elevated blood glucose level by inhibiting intestinal glucose absorption[12] Meta-analysis of Diabecon has also shown that it significantly reduces the risk factors of coronary artery disease by modulating lipid profile due to anti-cholestrolemic properties, reducing the levels of free fatty acids and re-normalizing lipid abnormalities[13].

Phalatrikadi kashaya [14] acts by improving the Agni

(all enzymatic activities thereby normalizing the metabolic functions) and removing the accumulated toxic metabolites with its Virechaka (purgative) [15] effect. Citrullus cholocynthis one of the ingredient of Phaltrikadi Kashaya is having bowel clearance action and has been found to be effective in reducing accumulation of advanced glycation end products by inhibiting amylase and a-glucosidase activity eventually slowing down the worsening of diabetic pathogenesis, rejuvenation of degenerated cells of Islet of Langerhans[16]. Curcuminoids present in Curcuma longa and Berberis aristata prevent lipid peroxidation in a significant higher degree than the commonly used antioxidant, intervening in free radical


propagation by quenching pre formed free radicals. [17]

Shilajatwadi loha [18] acts as a Rasayana, plays role by re-normalizing the serum lipids and cholesterol possibly due to its androgen receptor and glucocorticoid receptor antagonistic activities and has shown anti-diabetic activity in experimental studies. [19]

Vasant Kusumakar Rasa was added for its antioxidant (Rasayana) effect to reduce the oxidative stress and prevent the diabetic complications. [20]

Combination of Yogarja guggulu, Triphala choorna & Lauha Bhasma were given for symptomatic management for short duration.

Patient Perspective

Patient was satisfied with the Ayurvedic treatment in terms of improvement in quality of life, reduction in insulin and other anti-diabetic drug dosage. He was also satisfied with his blood sugar levels which were in better control after initiating the Ayurvedic treatment.

Conclusion

Patient approached Ayurveda for his abdominal symptoms but after Ayurvedic intervention, improvement in digestive fire, daily satisfactory clearance of bowel, increased energy level was observed. With this reduction in insulin dosage (36 IU to 8 IU) and other modern drugs dosage was observed with better glycemic control. The results of present case study are encouraging and have shown that Ayurveda principles are effective in management of diabetes. The holistic approach of Ayurveda, can definitely pave the way not only to achieve better glycemic control but also to improve the QOL of diabetic population and lowering the economic national and global burden of Diabetes mellitus. However, this is a single case record further documentation of the results of the treatment combination in patients having similar presentation will definitely benefit the diabetic population.

Informed Consent

Written informed consent was obtained from the patient before submitting the case report. Identity of the patient was not disclosed at any point

Conflict of Interest - None


References

1. Colledge, Nicki R, Brian R. Walker, Stuart Ralston, and Stanley Davidson. Davidson's Principles and Practice of Medicine. Edinburgh: Churchill Livingstone/Elsevier, 2010.

2. Saeedi, Pouya et al. “Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition.” Diabetes research and clinical practice vol. 157 (2019): 107843. doi:10.1016/j.diabres.2019.107843

3. Charak Samhita,Sutrasthana, Santarpaniyaadhyaya, 23/5. Available from http://niimh.nic.in/ebooks/ecaraka (Accessed on 26 August 2020)

4. Charak Samhita, Chikitsasthana, Prameha chikitsa adhyaya 6/6. Available from http://niimh.nic.in/ebooks/ecaraka (Accessed on 26 August 2020)

5. Charak Samhita, Chikitsa sthana, Prameha chikitsa adhyaya 6/49. Available from http://niimh.nic.in/ebooks/ecaraka (Accessed on 26 August 2020)

6. Baldev kumar, shweta dewan, hetal.H.Dave, puspendra. Role of stress factor in the pathogenesis of diabetes mellitus and its treatment with medhya rasayana - a clinical study. J Res Educ Indian Med . 2014; 20(2): 103-112.

7. Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER. Antidiabetic effect of a leaf extract from Gymnema sylvestre in non-insulin-dependent diabetes mellitus patients. J Ethnopharmacol. 1990 Oct;30(3):295-300. doi: 10.1016/0378-8741(90)90108-6. PMID: 2259217.

8. Halagappa K, Girish HN, Srinivasan BP. The study of aqueous extract of Pterocarpus marsupium Roxb. on cytokine TNF-α in type 2 diabetic rats. Indian J Pharmacol. 2010;42(6):392-396. doi:10.4103/0253-7613.71922

9. Rajan SS, Antony S. Hypoglycemic effect of triphala on selected non insulin dependent diabetes mellitus subjects. Ancient science of life. 2008 Jan;27(3):45.

10. Gaddam A, Galla C, Thummisetti S, Marikanty RK, Palanisamy UD, Rao PV. Role of Fenugreek in the prevention of type 2 diabetes mellitus in prediabetes. Journal of Diabetes & Metabolic Disorders. 2015 Dec 1;14(1):74

11. Kundu PK, Chatterjee P. Meta-analysis of Diabecon tablets: efficacy and safety. Indian Journal of Clinical Practice. 2010 Feb;20(9):653

12. Babu PS, Srinivasan K. Influence of dietary curcumin and cholesterol on the progression of experimentally induced diabetes in albino rat. Molecular and Cellular Biochemistry. 1995;152(1):13–21.

13. Kundu PK, Chatterjee P. Meta-analysis of Diabecon tablets:



efficacy and safety. Indian Journal of Clinical Practice. 2010 Feb;20(9):653.

14. Charak Samhita, Chikitsasthana, Prameha chikitsa adhyaya 6/4. Available from http://niimh.nic.in/ebooks/ecaraka (Accessed on 26 August 2020)

15. Chaturvedi, A., Rao, P. N., Kumar, M. A., Ravishankar, B., Rao, N., & Ravi, M. Effect and Mechanism of Virechana Karma (Therapeutic Purgation) Over Fructose-Induced Metabolic Syndrome: An Experimental Study. Journal of Evidence-Based Complementary & Alternative Medicine (2016). 21(3), 194–201.

16. Lakhan, D. C. Singh. The Experimental Study of Indravaruni Mool (Citrullus colocynthis schrad.) On hyperglycemia European Journal of Biomedical and Pharmaceutical Sciences(2019) Volume: 6,Issue: 11,192-196

17. Pragati R Gajabhe,Comprehensive Review of Haridra and Daruharidra in Diabetic Retinopathy, International Journal of Pharmaceutical & Biological Archives 2017; 8(5): 14-23

18. Govind Das Sen, BhaishajyaRatnavali,RajayakshmaRogadhikar, Adhyaya edited by Brahma Shankara Mishra. 11th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1993, 166

19. Singh TR, Gupta LN, Kumar N, Kumar V. Anti-diabetic activity of ShilajatvadiLauha, an Ayurvedic traditional herbo-mineral formulation. Int J Health Allied Sci [serial online] 2016 [cited 2020 Aug 26];5:9-14. Available from: http://www.ijhas.in/text.asp?2016/5/1/9/173889

20. Sanjay Motilal Tamoli, Kuldip Raj Kohli, Aakruti Arun Kaikini, Suraj Abhimanyu Muke, Afroj Abdulgani Shaikh, Sadhana Sathaye. Vasant Kusmakar Ras, an ayurvedic herbo-mineral formulation prevents the development of diabetic retinopathy in rats. Journal of Ayurveda and Integrative Medicine, 2020 Volume 11, Issue 3, Pages 270-276. https://doi.org/10.1016/j.jaim.2020.02.002

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