Introduction
In the present time due to modern lifestyle, unhealthy eating habits, hectic schedule and stress, incidence of Ama related diseases are increasing. One of the most common diseases is Amavata. In Ayurveda, Madhavkar (700 A.D.) first mentioned Amavata as a separate disease. The word Amavata has two components i.e., Ama and Vata. These two components contribute to the morbidity and disease process in Amavata.
The main causative factor Ama is formed due to malfunctioning of the digestive and metabolic mechanisms. Ama with Vata gets localized in the body tissues and joints resulting in pain, stiffness, swelling, tenderness etc. and presents as Amavata disease.
The features of Amavata are much identical to Rheumatoid Arthritis. The disease is chronic, progressive, autoimmune disorder characterized by bilateral symmetrical involvement of joints with some systemic clinical manifestation. In global scenario, more than one million people are affected by rheumatic disorders and one fifth of these are severely disabled. The prevalence of the disease is approximately 0.8% of the total population worldwide (range 0.3% to 2.1%) with male and female ratio of 1:3. The onset is most frequent during the fourth and fifth decades of life, with 80% of patients developing the disease between age group of 35 and 50.
Case Report
A 48 years old female patient presented with one year history of pain and stiffness in multiple joints, swelling in hand and wrist joints with intermittent low-grade fever. Initially, pain was started from both hands and wrist joints and progressively it involved bilateral shoulder joints, knee joints and ankle joints. Pain was pricking and severe in nature. It was aggravating on cold exposure and by rest, and relieved by physical activity, hot fomentation and on exposure to sunlight. Along with joint pain, she had stiffness in multiple joints which was more in morning hours and after inactivity and lasted for about 1–2 hours. Patient also told that she developed swelling in bilateral hands and wrist joints. She had complaint of loss of appetite but no history of fatigue, weight loss or diarrhoea. She had no history of Diabetes, Hypertension or any other major illness in the past.
Examination
General Physical Examination
Patient was fully conscious, cooperative and well oriented to time, place and person at the time of history taking. She had moderate built and appeared to be of her age. There was normal color of skin without any hypo/hyper pigmentation. No skin lesion was present. Eyebrows were bilaterally symmetrical, no loss of lateral 1/3rd of eyebrows. There was no periorbital edema. Pupil: Regular, reactive to light bilaterally. Ear, Nose, Throat and Paranasal sinuses were clear from any discharge, collection, sign of infection or inflammation. Lips were pinkish in color. Oral hygiene was well maintained.
Systemic examination of respiratory, cardiovascular, CNS and G.I.T. systems revealed no abnormality detected.
Local Examination
Upper Limb:
- Joints involved: PIP, MCP and wrist joints
- Movement: Restricted (bilateral)
- Symmetry: Symmetrical
- Swelling: Present in both PIP and MCP joints
- Deformity: Not present
- Redness: Not present
Lower Limb:
- Joints involved: Bilateral knee and ankle joints
- Movement: Restricted
- Symmetry: Symmetrical
- Swelling: Not present
- Deformity: Not present
- Redness: Not present
Palpation Findings:
- Temperature: Not raised
- Joint crepitus: Present at knee joints bilaterally
- Nodules: Not present
Differential Diagnosis
- Amavata (Rheumatoid Arthritis)
- Sandhivata (Osteoarthritis)
- Vatarakta (Gout)
Investigations done
- Hemoglobin – 11.8 g/dl
- Total Leukocyte Count – 10.4 × 10³ /mcL
- Differential Leukocyte Count – L 24%, M 13.2%, N 62.8%
- Platelet Count – 205000 /mcL
- ESR – 110 mm fall in first hour
- RA Factor – Positive
- C-Reactive Protein – Positive
- Serum Uric Acid – 6.3 mg/dl
- All other parameters remained normal.
Positive Findings for Diagnosis:
- Clinical presentations suggestive of Amavata
- Symmetrical involvement of more than 3 joints (PIP, MCP, wrist, knee and ankle)
- Morning stiffness
- Swelling in bilateral hands
- Intermittent low-grade fever
- Elevated ESR
- Positive serum rheumatoid factor
- Positive C-reactive protein
Diagnosis
Diagnosis was made on the basis of symptoms described in the classics of Ayurveda and criteria fixed by the American Rheumatology Association (1988).
Criteria for Diagnosis of Rheumatoid Arthritis
- 1 large joint – Score 0
- 2–10 large joints – Score 1
- 1–3 small joints – Score 2
- 4–10 small joints – Score 5
- Negative RF and ACPA – Score 0
- Low positive RF or ACPA – Score 2
- High positive RF or ACPA – Score 3
- Duration < 6 weeks – Score 0
- Duration > 6 weeks – Score 1
- Normal CRP and ESR – Score 0
- Abnormal CRP and ESR – Score 1
Patient with total score ≥ 6 are considered to have Rheumatoid Arthritis.
Final Diagnosis: Rheumatoid Arthritis (Amavata).
Therapeutic focus and assessment
As per the principles of Aama Vata Chikitsa described in Ayurvedic classics, patient was treated with Langhana, Deepana-Pachana along with oral drugs viz. Singhnada Guggulu, Vishtinduk Vati, Dashmoola Kashayam and Baluka Swedana as local treatment.
Treatment protocol
Langhana – Given as the first line of treatment
Deepana–Pachana – For Ama pachana
Ruksha Swedana – Once a day (local fomentation)
Oral Medicines:
- Singhnada Guggulu (Haritaki, Vibhitaki, Amalaki, Shudhagandhaka, Shuddhaguggulu, Erandmoola):
500 mg twice daily after meals with plain water. - Vishtinduk Vati (Shuddha Kupilu, Supari, Maricha, Chincha Phal):
125 mg twice daily after meals with lukewarm water. - Dashmoola Kashayam:
40 ml with equal quantity of water, orally, twice daily after meals.
Advice to Patient:
Avoid Aamajanya Ahara (Dadhi, Mashapishtkam, Matsya, Guda, Ksheer, Upodika, Dushtaneeram, Viruddha Ahara, Vegarodha, Vishamasana).
Mild physical activity advised.
Assessment Criteria
Clinical signs and symptoms were assessed based on Ayurvedic parameters and ARA (1988) guidelines. Grading scales used:
Angamarda (Body ache):
0 – None
1 – Occasional, normal activity
2 – Continuous but manageable
3 – Severe, hampers routine
4 – Unable to work
Aruchi (Anorexia):
0 – Normal appetite
1 – Eating timely without much desire
2 – Desire slightly delayed
3 – Desire only after long intervals
4 – No desire at all
Trishna (Excessive thirst):
0 – Normal
1 – Frequent, satisfied with normal intake
2 – Needs more fluids
3 – Awakened at night by thirst
4 – Unsatisfied even after heavy intake
Alasya (Lethargy):
0 – None
1 – Starts work with effort
2 – Delay in starting
3 – Unable to complete tasks
4 – Always wants rest
Gauravta (Heaviness in body):
0 – None
1 – Occasional
2 – Continuous but tolerable
3 – Continuous, hampers work
4 – Unable to do work
Apaka (Indigestion):
0 – None
1 – Once or twice weekly
2 – 3–5 times weekly
3 – Both meals affected
4 – After every meal
Agnimandya (Loss of digestive fire):
0 – None
1 – 1–2 times a week
2 – 3–4 times a week
3 – 4–6 times a week
4 – Continuous
Vairasyata (Impairment of taste):
0 – Normal
1 – Occasional unpleasant taste
2 – Continuous mild unpleasant taste
3 – Persists after eating
4 – Severe all day
Daha (Burning sensation):
0 – None
1 – Occasional retrosternal
2 – Palms/soles burning
3 – Intermittent full-body
4 – Continuous
Bahu Mutrata (Frequent urination):
0 – Absent
1 – >3 times/night
2 – >5 times/night
3 – >7 times/night
Kukshi Kathinya (Abdominal hardness):
0 – Absent
1 – Transient
2 – Frequent
3 – Regular
Jadya (Stiffness of body):
0 – None
1 – Stiffness <1 hr
2 – Stiffness >1 hr
3 – All-day stiffness
Sandhishool (Pain in joints):
0 – None
1 – On movement
2 – On rest but routine ok
3 – Severe, affects activity
Sandhijadyata (Joint stiffness):
0 – None
1 – <1 hr
2 – >1 hr
3 – Persistent whole day
Sandhishotha (Swelling in joints):
0 – None
1 – Mild
2 – Moderate
3 – Marked
Observations and Results
Effect of therapy before and after treatment
RA factor – Positive → Positive
CRP – Positive → Negative
ESR – 110 mm fall in 1st hr → 20 mm fall in 1st hr
Pain (Sandhishool) – Grade 2 → 0
Morning stiffness (Sandhijadyata) – Grade 3 → 1
Swelling (Sandhishotha) – Grade 2 → 0
Analgesic need – Once a day → Not needed
Angamarda (Body ache) – Grade 3 → 1
Aruchi (Anorexia) – Grade 4 → 0
Trishna (Thirst) – Grade 1 → 0
Alasya (Lethargy) – Grade 3 → 1
Gauravta (Heaviness) – Grade 3 → 1
Apaka (Indigestion) – Grade 4 → 0
Agnidourbalya – Grade 3 → 0
Vairasyata – Grade 2 → 1
Daha – Grade 4 → 2
Bahu Mutrata – Grade 0 → 0
Nidra Vipraya (Disturbed sleep) – Grade 4 → 1
Jadya (Body stiffness) – Grade 3 → 1
Discussion
Ama and Vata are the prime Doshas involved in Aamavata. Vata governs all body movements and when obstructed by Ama in the Srotasa, its normal function is impaired, causing Vatavyadhi. As Ama and Vata are the key pathogenic factors, treatment was designed as Vatahara and Aamapachaka Chikitsa.
Mode of Action of Therapy:
- Langhana (fasting) helps in digestion of Ama.
- Deepana–Pachana drugs stimulate Agni and digest Ama.
- Ruksha Swedana pacifies Vata and liquefies Ama due to Ushna Guna, opening channels and restoring balance.
- Simhnada Guggulu – Katu-Tikta Rasa, Laghu-Ruksha Guna, Ushna Virya, Amapachak, Srotoshodhaka actions.
- Vishtindukadi Vati – acts as Vata-Kapha Shamana and Aamapachana, reducing joint stiffness.
- Ruksha Baluka Sweda – absorbs Ama from Sleshma Sthana (joints), relieving Stambha (stiffness) and Shoola (pain).
Conclusion
From this case study, it can be concluded that the results obtained after Ayurvedic management were encouraging.
Combined Panchakarma and Herbo-mineral treatment as per classical texts gave significant relief in signs and symptoms of Aamavata (Rheumatoid Arthritis), improving the patient’s quality of life.
This integrated Ayurvedic approach can be effectively adopted for further cases of Aamavata.