Amavata is a Kapkavatavyadhi affecting people in the Madhyamaavasta. The disease is obtained by the involvement of Ama and Vata, characterized by Ruja and Shotha in Sandhisthanas. In this study the aims and objectives are to evaluate the effect of Nittyavirechana in Amavata, To evaluate the additive efficacy of Yogabasti in Amavata and To evaluate the comparative effect of Nittyavirechana and Yogabasti in Amavata.
This was a prospective comparative clinical trial. Patients were randomly distributed into 2 groups which are 15 patients receiving Nittyavirechana with Erandataila and another 15 patients received Yogabasti with Erandamooladikwathaniruha and Bruhatsandhavaditailaanuvasana
Results in group A 6.66% patients had good, 73.33% patients had moderate and 20% patients had mild response to the treatment. In group B 40% patients had good response, 60% patients had moderate response to the treatment. There was considerable improvement subjective and objective parameters in both the groups but Yogabasti group got more beneficial effects.
Nittyavirechana imparts Agnideepana, Vatanulomana and opens up the Srotas in the Shareera facilitating more nourishment and free movement of Vatadosha. Yogabasti is prime treatment for Amavata in turn plays vital role in correcting pathology of the disease and gives remarkable results

Shashidhar.H. Doddamani

Suresh N. Hakkandi

English

Ayushdhara (E-Journal)

AYUSHDHARA             ISSN: 2393-9583 (P)/ 2393-9591 (O)  An International Journal of Research in AYUSH and Allied Systems AYUSHDHARA | September - October 2018 | Vol 5 | Issue 5  1857          A COMPARATIVE STUDY OF VIRECHANA KARMA AND BASTI KARMA IN AMAVATA W.S.R. TO RHEUMATOID ARTHRITIS Suresh N. Hakkandi1*, Shashidhar.H. Doddamani2 *1Professor and Head, PG Dept. of Panchakarma, S.J.G Ayurvedic Medical College, Koppal, Karnataka, India. 2Research officer (Scientist -3), Regional Ayurveda Research Institute for Metabolic Disorders, Bengaluru, India.  KEYWORDS: Nittyavirechana, Yogabasti, Amavata, Rheumatoid Arthritis, Vaishwanarachoorna, Eranda tail, Erandamooladiniruha, Brihatsaindhavadianuvasana.               ABSTRACT Amavata is a Kapkavatavyadhi affecting people in the Madhyamaavasta. The disease is obtained by the involvement of Ama and Vata, characterized by Ruja and Shotha in Sandhisthanas. In this study the aims and objectives are to evaluate the effect of Nittyavirechana in Amavata, To evaluate the additive efficacy of Yogabasti in Amavata and To evaluate the comparative effect of Nittyavirechana and Yogabasti in Amavata. This was a prospective comparative clinical trial. Patients were randomly distributed into 2 groups which are 15 patients receiving Nittyavirechana with Erandataila and another 15 patients received Yogabasti with Erandamooladikwathaniruha and Bruhatsandhavaditailaanuvasana Results in group A 6.66% patients had good, 73.33% patients had moderate and 20% patients had mild response to the treatment. In group B 40% patients had good response, 60% patients had moderate response to the treatment. There was considerable improvement subjective and objective parameters in both the groups but Yogabasti group got more beneficial effects. Nittyavirechana imparts Agnideepana, Vatanulomana and opens up the Srotas in the Shareera facilitating more nourishment and free movement of Vatadosha. Yogabasti is prime treatment for Amavata in turn plays vital role in correcting pathology of the disease and gives remarkable results.  INTRODUCTION Amavata was first described as an independent disease in Madhava Nidana. Amavata is characterized by Angamarda (body ache), Aruchi (tastelessness), Trishna (thirst), Alasya (lack of enthusiasm), Gouravam (heaviness all over body), Jwara (Fever), Apaka (indigestion) and Shunata Anganam (swelling all over the body mainly in joints).[1] It is a disease of Madhyama Roga Marga as it affects Sandhis and Hridaya Marma. Though Ama and Vata are the predominant pathogenic factors but the disease represents Tridoshic vitiation. The affliction of Sandhis by Vatadosha in association with Ama, reflects the equal role of both Dosha and Dushya in the causation of this disease. Moreover, the chief pathogenic factors, being contradictory in nature possess difficulty in planning the line of treatment.  Rheumatoid arthritis (RA) is a chronic systemic autoimmune inflammatory disease that affects mainly the small joints of the hands and feet. RA is one of the most common inflammatory joint diseases and causes premature mortality, disability and compromised quality of life. Burden of RA is widely prevalent throughout the world. The worldwide prevalence is 0.8% and steadily increases to 5% in women over the age of 70. Rheumatoid arthritis is two to three times more common in women than in men. In India the prevalence is to be 0.7%.[2] This condition can be correlated to rheumatoid arthritis which is characterized by Joint pain, tenderness, swelling or Research Article *Address for correspondence Dr Suresh N. Hakkandi Professor and Head,  PG Dept. of Panchakarma  S.J.G Ayurvedic Medical College, Koppal, Karnataka, India.  Email: sureshhakkandi@gmail.com  Ph. No. 9448609362 AYUSHDHARA, 2018;5(5):1857-1861 AYUSHDHARA | September - October 2018 | Vol 5 | Issue 5  1858 stiffness for six weeks or longer, Morning stiffness for 30 minutes or longer, more than one joint is affected, small joints (wrists, certain joints of the hands and feet) are affected, the symmetrical joints of the body are affected, along with pain, many people experience of fatigue, loss of appetite and low-grade fever.[3] AIMS AND OBJECTIVES 1. To study the effect of Nittyavirechana with Erandataila in Amavata.  2. To evaluate the efficacy of Yogabasti with Erandamooladikwathaniruha and Bruhat-sandhavaditailaanuvasana in Amavata. 3. To compare the efficacy of above two procedure in Amavata. Materials and Methods A total of 30 patients having the features of Amavata were selected for the study irrespective of sex, occupation, religion and socio-economic status from Shalakyatantra OPD & IPD of DGM. Ayurveda Medical College and Hospital, Gadag. The materials taken for the study are Vaishwanara churna,  Erandataila, Bruhatsaindha-vaditaila, Erandamooladi Niruhabasti, and Placebo Capsules.  The diagnosis was made on the basis of classical signs and symptoms mentioned in the Ayurveda and modern texts and criteria laid down by American Rheumatism Association (1988).[4] Following features are employed for confirmation of RA. 1) Morning stiffness (> = 1hr)  2) Swelling of three or more joints  3) Swelling of hand joints (PIP, MP)  4) Symmetrical swelling  5) Subcutaneous nodules (Rheumatoid nodules) 6) Presence of serum rheumatoid factor 7) Radiological changes (Hands & wrist) Criteria 1 to 4 must have been continuous for 6 weeks or longer must be observed by physician. A diagnosis of RA requires that, four of the above seven criteria should be present.  a) Inclusion criteria 1. Classical signs and symptoms will be considered for the selection of patients. 2. Patients of Amavata having the history of less than 5 years. 3. Patients of Amavata between the age group of 20 to 60 years of either sex. 4. Patient fit for Virechana and Basti karma.  b) Exclusion criteria 1. Patients of Amavata having the history of more than 5 years. 2. The patient of Amavata having the systemic diseases like Diabetes mellitus, Asthma, Hypertension, Rheumatic heart disease and Heart diseases etc. 3. Pregnant or lactating women. Objective parameters The below investigations are done before the selection of patient for the study. 1. Hb%, 2. ESR, 3. ASL O titer, 4. CRP, 5. Rh factor, Subjective parameters The subjective parameters taken for this study are  1. Ruja,  2. Shotha, 3. Stabdata,  4. Ushnata Study Design  The patients were administered Vaishwanara choorna internally in a dose of 3 – 6gms thrice daily with a cup of hot water, half an hour before food. The treatment was given till the Nirama laxanas were observed. For patients of Group A: Erandataila in the quantity of 15 to 30ml was given in between 8 to 9am when the patient is not so hungry for 8 days for the purpose of Nittyavirechana, according to the Kosta of the patient. A cup of hot water was advised as Anupana. Group B: Yogabasti was given with Bruhat-saindhavaditaila Anuvasanabasti and Eranda-mooladi Niruhabasti. For both groups Pariharakala was advised for 16 days. In Pariharakala one Placebo capsules were advised to take daily for benefits of good follow up. Valukasweda was advised whenever patient complaints increased pain and stiffness during the course of the treatment for both groups. Grading  The lab test values were recorded before and after treatment.  The subjective parameter were graded from Grade-0 to Grade-4 based on presence of null, one, two, three or four of the following symptoms in a particular Sandhi: Ruja, Shotha, Stabdhata and Ushnata. Overall Assessment of the Treatment  To assess the overall effect of therapy, the criteria laid down by ARA (1967) were adopted. The results are classified into four groups as listed below. Grade I - Complete Remission 1=No systemic sign of rheumatoid activity 2=No signs of inflammation Suresh N. Hakkandi, Shashidhar.H. Doddamani. A Comparative Study of Virechana Karma and Basti Karma in Amavata  AYUSHDHARA | September - October 2018 | Vol 5 | Issue 5  1859 3=No evidence of activity in any extra articular process, including nodules tendovaginitis and iritis. 4=No lasting impairment of joint mobility other than that associated with irreversible changes 5=No elevation in ESR 6=Articular deformity or extra articular involvement due to irreversible changes may be present. Grade II - Major Improvement 1=No systemic sign of rheumatoid activity with the exception of an elevated sedimentation rate and vasomotor imbalance. 2=Major signs of inflammation resolved, such as warmth, redness of joint structures. 3=No new rheumatoid process of intra articular or extra articular structures. 4=Minimum joint swelling may be present. 5=Impairment of joint mobility associated with minimum residual activity may be present. 6=Articular deformity or extra-articular involvement due to irreversible changes may be present. Grade III - Minor Improvement 1=Diminution of systemic signs of Rheumatoid activity. 2=Signs of joint inflammation only partially resolved 3=No evidence of extension of rheumatoid activity into additional articular or extra articular structures. 4=Decreased but not minimum joint swelling present. 5=Impairment of joint mobility may be present. 6=Articular deformity or extra articular involvement due to reversible changes may be present. Grade IV – Unimprovement or Progression 1=Undiminished signs of rheumatoid activity, regardless of functional activity. 2=Exacerbation of any previously involved joint or joints or development of sites of rheumatoid activity. 3=Roentgenologic changes indicative of progression of the rheumatoid process, excepting hypertrophic changes. 4=In the presence of 1 or more of the before said criteria, improvement in other feature, including a normal or lowered ESR, not significant. Composition of Test Drug  Vaishvanara churna:[5] Manimantha, Yavani, Ajamoda, Nagara and Haritaki.  Brihatsaindhava taila:[6] Saindhava, Sreyasi, Shatapuopa, Rasna, Vavanika, Sarija, Maricha, Kusta, Shunti, Suvacchala, Vida, Vacha, Ajamoda, Madhuka, Jeeraka, Puskaramula and Kana.  Erandamooladi Vasti:[7] Erandamoola, Palasha, Rasna, Bala, Guduchi Ashwaganda, Punarnava, Aragvadha, Devadaru, Madanaphala, Shalaparni, Prasnaparni, Gokshura, Kantakari, Bruhati, Vacha, Hapusha, Shatavha, Priyangu, Yasti-madhu, Kana, Vatsakabeeja, Musta, Taksharya-shaila, Saindhavalavana, Makshika, Taila and Gomootra. RESULTS Table 1: Showing statistical analysis of subjective and objective parameters in group A S.No Parameters Mean SD SE T value P value 1 Hasta 1.8 0.774 0.2 9.00 < 0.001 2 Pada 1.533 0.743 0.191 8.026 < 0.001 3 Gulpha 1.466 0.743 0.191 7.67 < 0.001 4 Trika 1.133 0.516 0.133 8.518 < 0.001 5 Janu 1.133 0.617 0.159 2.183 < 0.001 6 Uru 0.666 0.487 0.125 5.328 < 0.001 7 Siro 0.4 0.057 0.130 3.076 < 0.001 8 Hb% 0.22 0.086 0.022 10.00 < 0.001 9 ESR 25.8 17.78 4.59 5.620 < 0.001     AYUSHDHARA, 2018;5(5):1857-1861 AYUSHDHARA | September - October 2018 | Vol 5 | Issue 5  1860 Table 2: Showing statistical analysis of subjective and objective parameters in group B S.No Parameters Mean SD SE T value P value 1 Hasta 1.733 0.798 0.206 8.412 < 0.001 2 Pada 1.533 0.743 0.191 8.026 < 0.001 3 Gulpha 1.6 0.506 0.131 12.213 < 0.001 4 Trika 1.00 0.377 0.097 10.309 < 0.001 5 Janu 1.666 0.487 0.125 13.328 < 0.001  6 Uru 0.8 0.5606 0.144 5.55 < 0.001 7 Siro 0.333 0.487 0.125 2.666 < 0.001  8 Hb% 0.313 0.172 0.044 7.11 < 0.001 9 ESR 27.466 14.38 3.714 7.39 < 0.001 Table 3: Showing the comparative statistical analysis of subjective and objective parameters in both groups Parameters  Mean SD SE PSE T value P value Remarks Hasta A 0.666 0.723 0.186 0.301  1.551 > 0.05 NS B 1.133 0.915 0.236 Pada A 0.6 0.632 0.163 0.243 2.74 < 0.02 HS B 1.266 0.703 0.181 Gulpha A 0.866 0.351 0.090 0.161 4.14 < 0.001 HS B 1.533 0.516 0.133 Trika A 0.466 0.516 0.133 0.196 1.704 > 0.05 NS B 0.8 0.560 0.144 Janu A 0.733 0.703 0.181 0.263 1.520 > 0.05 NS B 1.133 0.743 0.191 Uru A 0.0666 0.258 0.066 0.148 2.698 < 0.02 NS B 0.4660 0.516 0.133 Siro A 0.0666 0.258 0.066 0.112 0.598 > 0.05 NS B 0.133 0.351 0.090 Hb% A 10.14 1.012 0.263 0.397 0.74 > 0.05 NS B 9.846 1.156 0.298 ESR A 28.066 8.647 2.232 4.65 0.287 > 0.05 NS B 26.73 15.8 4.080 At the end of treatment there are significant changes in Shoola, Shotha, Stabdata and Ushnata in Yogabasti group compared to Nittyavirechana group showing the P value < 0.001. This signifies that Yogabasti possibly had a greater role in the management of Amavata. DISCUSSION The disease Rheumatoid arthritis is identical with the signs and symptoms of Amavata. It always challenges to the physicians due to its chronicity, complication and morbidity, this disease mainly affects the musculo skeletal system. It has also extra articular manifestations affecting cardio-vascular, nervous and excretory systems, which is collectively known as connective tissue or collagen disorder. Line of treatment, Nittyavirechana and Yogabasti, which is explained in Ayurveda, can reduce pain, swelling, and protection of joints and control the disease progression. Ricinoelic acid of Erandataila irritates bowel leading to Virechana as it is having Ushnavirya, it also does Pachana karma (Amapachana). It alleviates Doshavriddi by expelling out, and dose Srotoshodhana. Bruhat Saindhavadi Taila used for Suresh N. Hakkandi, Shashidhar.H. Doddamani. A Comparative Study of Virechana Karma and Basti Karma in Amavata  AYUSHDHARA | September - October 2018 | Vol 5 | Issue 5  1861 Anuvasanabasti as a Poorvakarma for Niruhabasti so that it prepares the Kosta by its Snigdhagunas to receive Niruhabasti. The ingredients of this Taila possess Deepana, Pachana, Vatanulomana, Shothahara properties. The ingredients of Eranda-mooladiniruhabasti mainly possess Deepana, Pachana, Ushna, Sukshma, Laghu, Ruksha, Snigdha, Teekshna and Lekhanagunas. These Gunas helps to alleviate Ama and Vata in the body. CONCLUSION By results and observations it becomes evident that effect of Yogabasti was more beneficial in Shoola, Shotha, Stabdata and Usnata of different Sandhis, when compared to that of Nittyavirechana group. But as the disease is Yapya or autoimmune nature the completely permanent remission cannot be expected. REFERENCES  1. Sri Madhvakara, Madhavanidanam, edited by Yadunandana Upadhyaya, chapter 25, 7thsloka. Chaukhamba Sanskrit Sansthan; 1985 page no. 461. 2. http://www.apiindia.org/pdf/rheumatoid_arthritis_modules/rheumatoid_arthritis_module_i.pdf as accessed on 01/12/2018 3. https://www.arthritis.org/about-arthritis/types /rheumatoid-arthritis/symptoms.php as accessed on 01/12/2018 4. The American Rheumatism Association 1987 Revised Criteria For The Classification Of Rheumatoid Arthritis Accessed From Https:// Onlinelibrary.Wiley.Com/Doi/Epdf/10.1002/Art.1780310302 On 01/12/2018 5. Indradevatripathi, Chakrapanidatta Chakradatta, Amavachikitsa Varanasi, Chaukhambha Sanskrit bhavan, 2012.15-18, 6. Kaviraj Govinda Das Sen. Bhaishajya Ratnavali – Edited with ‘Siddhiprada’ Hindi Commentary by Prof. Siddhi Nandan Mishra, 1st ed. Varanasi: Chaukhambha Surabharati Prakashan; 2005. 29/222-227. 7. Gangasahaya Pandey, The Charaka Samhita of Agnivesha With Ayurveda Deepika Commentary of Chakrapani Dutta And With ‘Vidyotini’ Hindi Commentary By Pt Kashinath Shastri, Chaukhamba Sanskrit Sthana, 1997, Varanasi 5th Edition, Part 2, Siddhisthana, Chapter 3, Sloka 38-42, Page No-917.         Disclaimer: AYUSHDHARA is solely owned by Mahadev Publications - A non-profit publications, dedicated to publish quality research, while every effort has been taken to verify the accuracy of the content published in our Journal. AYUSHDHARA cannot accept any responsibility or liability for the articles content which are published. The views expressed in articles by our contributing authors are not necessarily those of AYUSHDHARA editor or editorial board members. Cite this article as:  Suresh N. Hakkandi, Shashidhar.H. Doddamani. A Comparative Study of Virechana Karma and Basti Karma in Amavata w.s.r. to Rheumatoid Arthritis. AYUSHDHARA, 2018;5(5):1857-1861. 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A COMPARATIVE STUDY OF VIRECHANA KARMA AND BASTI KARMA IN AMAVATA W.S.R. TO RHEUMATOID ARTHRITIS

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A COMPARATIVE STUDY OF VIRECHANA KARMA AND BASTI KARMA IN AMAVATA W.S.R. TO RHEUMATOID ARTHRITIS

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