Rheumatoid arthritis is a chronic, disabling autoimmune condition, as the body is filled with ‘rheum’, a form of aama (toxins deposited in the cells as a result of improper digestion). This is a good example of an autoimmune condition (a disordered self-protective mechanism) characterised by inflammation, soreness and stiffness of muscles, and pain in joints and associated structures. This can be successfully managed by an Ayurvedic approach including panchakarma, dietary adjustments and herbs. In addition to the pacification of doshas, removal of ama and kindling of agni, the Ayurvedic pharmacopoeia offers specific herbal combinations that are of significant effect in this condition.

Amavata (Rheumatoid Arthritis): An Ayurvedic Approach

Rheumatoid arthritis is described as “Amavata” in Ayurveda. The word ‘Ama’ literally means, undigested, toxic or unwholesome product, which is produced in the body due to weakening of digestive fire. This ‘Ama’ is then carried by vitiated ‘Vayu’ and travels throughout the body and accumulates in the joints, which is the seat of ‘Kapha’(one of the three bodily humors i.e. Vata, Pitta and Kapha). As this process continues, all the joints are gradually affected, which results in severe pain and swelling in the joints. Here, pain is due to vitiated “Vata”, swelling due to affected Kapha. When ‘Pitta’ also gets aggravated, it causes burning sensation around the joints.

Ancient Ayurvedic classics says that all the diseases affecting the locomotor system are grouped under the single name Vātarakta in Charaka, Sushruta (where it is conspicuously not even mentioned) and Vagbhata Samhita (the “Brihatrayi” or “three major writings”). Specific details regarding amavāta are sparse in all of these ancient treatises. However an elaborate description of the presentation and treatment of amavāta is found in later works including Sarangadhara Samhita, Chakradatta and Madhava Nidana.

Samanya Lakshana Of AMAVATA (Symptoms Common to All People Regardless of Constitution)

• Angamarda (pain in specific areas of the body)

• Aruchi (loss of appetite)

• Trishna (increased thirst)

• Alasya (loss of zest or enthusiasm for life)

• Jwara (increased body temperature)

• Apaka (low agni)

• SandhiStabdata, Sandhi Shoota, Sandhi Shopha (stiffness, inflammation and swelling of the joints)

In addition to these symptoms, amavāta can have many others in specific individuals including frequent urination, reduction of perspiration, hyper salivation, nausea and vomiting, constipation,flatulence. Although Vāta is the preeminent dosha involved in this condition,on the basis of doshanubandha lakshanas (signs connected to specific dosha), amavāta can be classified into three types:

• Vāta – will manifest with sharp, cutting pain and more digestive symptoms

• Pitta – will manifest with daha (burning sensation) throughout the body and in the joints with more intense redness

• Kapha–will manifest with more heaviness, rigidity and perhaps itching

Pattern of joints affected: Rheumatoid arthritis usually affects the same joints on both sides of the body.

•In the early stages, rheumatoid arthritis typically affects small joints, especially the joints at the base of the fingers, the joints in the middle of the fingers, and the joints at the base of the toes. It may also begin in a single, large joint, such as the knee or shoulder, or it may come and go and move from one joint to another.

• As the condition progresses, most people have inflammation of the joints in the arms or legs, and between 20 and 50 percent of people have inflammation of the large central joints (eg, hips) and spine.

Joint Symptoms — The joint symptoms of rheumatoid arthritis usually begin gradually and include pain, stiffness, redness, warmth to the touch, and joint swelling.

The joint stiffness is most bothersome in the morning and after sitting still for a period of time. The stiffness can persist for more than one hour.

● Hands — The joints of the hands are often the very first joints affected by rheumatoid arthritis. These joints are tender when squeezed, and the hand's grip strength is often reduced. Occasionally, rheumatoid arthritis may lead to visible redness and swelling of the entire hand.

 People with rheumatoid arthritis develop carpal tunnel syndrome because swelling compresses a nerve that runs through the wrist; this syndrome is characterized by weakness, tingling, and numbness in certain areas of the hand. Certain characteristic hand deformities can occur with long-standing rheumatoid arthritis. The fingers may develop characteristic, exaggerated profiles, called swan neck deformities and boutonniere deformities, and they may drift together in the direction of the small finger. The tendons on the back of the hand may become very prominent and tight, which is called the bow string sign.

● Wrist — The wrist is the most commonly affected joint of the arm in people with rheumatoid arthritis. In the early stages of rheumatoid arthritis,it may become difficult to bend the wrist backward.

● Elbow — Rheumatoid arthritis may cause inflammation of the elbow. Swelling of this joint may compress nerves that travel through the arm and may cause numbness or tingling in the fingers.

● Shoulder — The shoulder may be inflamed in the later stages of rheumatoid arthritis, causing pain and limited motion.

● Foot — The joints of the feet are often affected in the early stages of rheumatoid arthritis, especially the joints at the base of the toes. Tenderness at these joints may cause a person to stand and walk with his or her weight on the heels, with the toes bent upward. The top of the foot may be swollen and red, and, occasionally, the heel may be painful.

● Ankle — Rheumatoid arthritis may cause inflammation of the ankle.Inflammation of this joint may cause nerve damage, leading to numbness and tingling in the foot.

● Knee — Rheumatoid arthritis may cause swelling of the knee,difficulty bending the knee, excessive looseness of the ligaments that surround and support the knee, and damage of the ends of the bone that meet at the knee.Rheumatoid arthritis may also cause the formation of a Baker's cyst (a cyst filled with joint fluid and located in the hollow space at the back of the knee).

● Hips — The hips may become inflamed in the later stages of rheumatoid arthritis. Pain in the hips may make it difficult to walk.

● Cervical spine — Rheumatoid arthritis may cause inflammation of the cervical spine, which is the area between the shoulders and the base of the head. Inflammation of the cervical spine may cause a painful and stiff neck anda decreased ability to bend the neck and turn the head.

● Cricoarytenoid joint — In about 30 percent of people with rheumatoid arthritis, there is inflammation of a joint near the windpipe called the cricoarytenoid joint. Inflammation of this joint can cause hoarseness and difficulty breathing.

Other symptoms - Although joint problems are the most commonly known issues in rheumatoid arthritis, the condition can be associated with a variety of other problems.

Rheumatoid Nodules — Rheumatoid nodules are painless lumps that appear beneath the skin. These nodules may move easily when touched, or they may be fixed to deeper tissues. They most often occur on the underside of the forearm and on the elbow, but they can also occur on other pressure points, including the back of the head, the base of the spine, the Achilles tendon, and the tendons of the hand.

Inflammatory Conditions — Rheumatoid arthritis may produce a variety of other symptoms, depending on which tissues are inflamed.

● Inflammation of the tissue lining the chest cavity and surrounding the heart may cause chest pain and difficulty breathing.

●Inflammation of the lung that is not due to infection may cause shortness of breath and a dry cough.

●Abnormal nerve function may cause numbness, tingling, or weakness.

●Inflammation of the white part of the eye may cause pain or vision problems.

●Enlargement of the spleen may cause a fall in the number of white blood cells, which may lead to infections.

RHEUMATOID ARTHRITIS DIAGNOSIS

There is no single test used to diagnose rheumatoid arthritis. Instead, the diagnosis is based upon many factors, including the characteristic signs and symptoms, the results of laboratory tests, and the results of x-rays.

A person with well-established rheumatoid arthritis typically has or has had at least several of the following:

● Morning stiffness that lasts at least one hour and that has been present for at least six weeks

● Swelling of three or more joints for at least six weeks

● Swelling of the wrist, hand, or finger joints for at least six weeks

● Swelling of the same joints on both sides of the body

● Changes in hand x-rays that are characteristic of rheumatoid arthritis

● Rheumatoid nodules of the skin

● Blood test positive for rheumatoid factor and/or anti-citrullinated peptide/protein antibodies

AYURVEDIC MANAGEMENT OF AMAVATA

• In Ayurveda, Amavata is treated by the following measures:

1. Ahara or Diet: One should take old rice, buttermilk, wet ginger, garlic, wheat, bitter gourd and horse gram in his diet. Avoid consumption of dairy products, sweets, oily foods, junk and fast foods, salty and sour foods, jaggery, black gram, fish, cold drinks and ice creams.

2. Vihara or Lifestyle: One should avoid cold breeze and excessive wind. Bathing with cold water should be strictly avoided. Warm water bath is recommended. It is also advisable to take a gentle walk after consumption of food. Also it is good to avoid water intake immediately after consuming food

AYURVEDIC MANAGEMENT OF AMAVATA BY HERBAL DRUGS

 Aushadhi or Drugs:

Guggulu (Commiphora mukul) is the most effective drug in treating ‘Amavata’.

Also herbal preparations of Ashwagandha (Withania somnifera),Rasna (Pluchea Lanceolata), Sunthi (Ginger), Pippali (Long pepper), Gokshura (Tribulus terrestris) and Trivrut (Operculina turpethum) are helpful in ‘Amavata’. Administration of caster oil is also very effective in this disease. The above-mentioned drugs should be taken after consulting a qualified Ayurvedic Physician.

Panchakarma Therapy:

This is purification process. By taking this therapy the body toxins are eliminated from the body. For treating ‘Amavata’ the following processes are followed.

1. Snehana 2. Swedana 3. Virechana 4. Basti

Treatment ofAmavāta (Rheumatoid Arthritis)

 The treatment of amavāta consists of eight principle approaches:

1. Langhana                           

2. Swedana                             

3.  Niruha Vasti

4. Tikta-Katu Ahara               

5.  Upanaha swedana (local)

6. Deepana                              

7.  Aushadis (Medicines)

8. Pachana                             

Additional Treatments according to predominant dosha of the disease

  • Generally, medicines are not given in the very acute stage because mandagni is already present and will not be able to digest food, amarasa, doshas, and medicine simultaneously. Instead, fasting (Langhana) is advised which alleviates the burden on agni by removing the food load. Fasting will also help agni regenerate and begin to digest ama and it will also relieve guruteam(heaviness). Langhana can also be part of therapy in the non-acute stages of the condition. As amavāta is caused by both ama and Vāta, it must not be used beyond the point of ama pachana or it will cause further Vāta prakopa (aggravation).
  • Fomentation Therapy (Swedana) is useful to pacify Vāta and Kapha doshas and lessensrotovarodha (blockage of the channels). In addition it relieves pain and swelling of the joints, heaviness of the body, and stiffness. If appropriate, swedana, virechana, and vastus are administered in the context of a complete Panchakarma regimen.
  • Use of Tikta-Katu Ahara and Aushadis (Bitter and Pungent foods and medicines) areagni-promoting, srotoshodana (channel purifying), appetite-promoting, Kapha-reducing, and creates lightness.
  • Deepana (agni-increasing) and Pachana (cooking) medicines and spices will both prevent further ama from being created and digest the existing ama in koshta, respectively.
  • Snehana-Virechana Is widely utilized for expulsion of excessive Pitta dosha but in amavāta there is another purpose. Amavāta is the result of ama stagnated in the annavahasrota (digestive tract). Virechana karma is the best way to evacuate the ama situated in the small intestines out of the body. This prevents further absorption ofama into the body.
  • Since prakopa ofVāta dosha is part of the cause of amavāta, vasti karma is strongly advocated. Only niruha (decoction-based) and not anuvasana (oil-based) vastis are advised. The aim is to simultaneously reduce and remove both Vāta and ama. Many herbal medicines are used for the niruha vastis, with dashamoola and guduchi being common.
  • Local application of heat through pinda sweda (local application of hot boluses of milk, cooked rice and herbs) and other forms of lepa (poultice) application can be very helpful in opening srirasmi serving affected joints, relieving pain,improving circulation, and reducing swelling.