|Year : 2011 | Volume
| Issue : 2 | Page : 207-212
Clinical effect of Nirgundi Patra pinda sweda and Ashwagandhadi Guggulu Yoga in the management of Sandhigata Vata (Osteoarthritis)
Alpesh Joshi1, Charmi S Mehta2, Alankruta R Dave3, VD Shukla4
1 M.D.(Ayu.), Medical Officer, Government of Gujarat, India
2 Lecturer, Department of Kayachikitsa, J.S. Ayurveda College, Nadiad, Gujarat, India
3 Associate Professor, Department of Kayachikitsa, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, India
4 Ex. Head, Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, India
|Date of Web Publication||2-Feb-2012|
Alankruta R Dave
Associate Professor, Department of Kayachiktsa, IPGT and RA, Gujarat Ayurved University, Jamnagar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Sandhigata Vata is one among the 80 Nanatmaja Vata Vyadhies. Sandhigata Vata and Osteoarthritis have common symptoms, and hence, both are considered as similar entities by a majority of Ayurvedic scholars and same has been adopted here. Osteoarthritis is the most common joint disease among human beings today. In this study, a total of 116 patients were registered, out of them 101 patients had completed the full course of treatment, while 15 patients left against medical advice. The 101 patients of Sandhigata Vata were treated in two groups. Group A: In this group 50 patients of Sandhigata Vata were treated with Nirgundi Patra pinda sweda for 21 days and Ashwagandhadi Guggulu Yoga 3 g/day for 45 days was given orally. Group B : In this group 51 patients of Sandhigata Vata were treated with only Ashwagandhadi Guggulu Yoga 3 g/day for 45 days. To assess the effect of the therapy objectively, all the signs and symptoms of Sandhigata Vata were given a score, depending upon their severity. Also functional tests like walking time, climbing stairs, and joint movement, were measured as a criteria for assessment. Both the groups showed good results, but Group B showed better results in comparison to group A.
|How to cite this article:|
Joshi A, Mehta CS, Dave AR, Shukla V D. Clinical effect of Nirgundi Patra pinda sweda and Ashwagandhadi Guggulu Yoga in the management of Sandhigata Vata (Osteoarthritis). AYU 2011;32:207-12
|How to cite this URL:|
Joshi A, Mehta CS, Dave AR, Shukla V D. Clinical effect of Nirgundi Patra pinda sweda and Ashwagandhadi Guggulu Yoga in the management of Sandhigata Vata (Osteoarthritis). AYU [serial online] 2011 [cited 2019 Jul 23];32:207-12. Available from: http://www.ayujournal.org/text.asp?2011/32/2/207/92588
| Introduction|| |
Sandhigata Vata has been described in the Vata Vyadhi Chapter in classical texts. As per modern medical science, Osteoarthritis (OA) is characterized by focal loss of cartilage, with evidence of accompanying periarticular bone response in the form of subchondral bone sclerosis and attempted new bone formation in the form of bony overgrowths called osetophytes.  Osteoarthritis is the most common joint condition.  The most common form of arthritis, accounts for more than 85% of the arthritic cases. Most people find osteoarthritis to be a nuisance that eventually becomes significant enough to impact their daily activities, but sometimes there are more serious complications. The possible complications of osteoarthritis include chondrolysis, osteonecrosis, hair line crack in the bone, infection in the joint, and deterioration or rupture of the tendons and ligaments around the joint, leading to loss of stability, and so on.
In modern medical science, OA can be managed with analgesics and Nonsteroidal Anti-inflammatory Drugs (NSAIDs), joint replacement surgery, and the like. Recent studies on NSAIDs published in JAPI (Journal of the Association of Physicians of India) suggest that these drugs do increase the risk of chronic renal disease. NSAIDs, although beneficial, have adverse effects, such as, liver toxicity, aseptic meningitis, renal failure, and toxic dermal macrolysis. Also, surgery does not give long-lasting results in many patients. Keeping all these views in mind, the study was planned to find safe, effective, and lasting treatment options for osteoarthritis.
Acharya Charaka has given common principles of Vata Vyadhi Chikitsa, that is, repeated use of Snehana and Swedana.  According to Acharya Sushruta, Snehana, Upanaha, Agni karma, Bandhana and Mardana are the principles for the treatment of Sandhigata Vata.  Thus, taking these principles into consideration; Abhyanga, Swedana and Shamana therapy were selected for the present study.
Aims and objectives
- To observe the effect of Nirgundi Patra pinda sweda in Sandhigata Vata
- To observe the effect of Ashwagandhadi Guggulu Yoga in Sandhigata Vata
| Materials and Methods|| |
Literary material - A detailed study of Sandhigata Vata and Osteoarthritis was done along with a study on the drugs selected for the present study. Various books of Ayurveda, Modern Science, and the Internet, related to the subject, were referred.
Drugs - Nirgundi and Tila Taila are the main drugs used in Patra Pinda Sweda. Ashvagandha, Rasna, Chopachini, Pippali Moola, Shuddha Kupilu, Nirgundi, Shallaki and Guggulu are the main contents of Ashwagandhadi Guggulu Yoga.
Clinical material - A total of 116 patients fulfilling the criteria of the disease were selected from the OPD and IPD of the Panchakarma Department of I.P.G.T. and R.A. Hospital, Jamnagar, and randomly divided into two therapeutic groups, irrespective of their age, sex, religion, and so on.
Group A: In this group, 51 patients were registered, out of whom 50 completed the full course of the treatment, while remaining one left the treatment against medical advice.
Group B: In this group, 65 patients were registered, out of whom 51 completed the full course of the treatment, whereas, the remaining 14 left the treatment against medical advice.
Inclusion criteria - Patients between the age group of 30 and 60 years, having classical signs and symptoms of Sandhigatavata (Osteoarthritis), and not having any anatomical deformity, were selected for the present clinical research work.
Exclusion criteria - Patients less than 30 and more than 60 years of age, having symptoms of other forms of arthritis and anatomical deformity were excluded.
Criteria for diagnosis
Patients having signs and symptoms of Sandhigata Vata, as described in Ayurvedic texts, were selected for the clinical trial. A detailed history was taken and physical examination was done on the basis of a special proforma incorporating all the signs and symptoms of the disease.
Investigations - Routine hematological and biochemical investigations like random blood sugar, s. cholesterol, s. uric acid were carried out in selected patients to exclude any other pathology as well as to assess the present condition of the patients. R. A. factor was carried out in the patients where it was required for differential diagnosis. The diagnosis was confirmed by x-ray examination of the involved joints wherever possible.
Group A - In this group, patients were given Nirgundi Patra pinda sweda for 21 days with a three-day interval after every week, along with administration of Ashwagandhadi Guggulu Yoga 3 g/day in the form of tablets, thrice a day, for 45 days, with lukewarm water.
Group B - The patients in this group were administered only Ashwagandhadi Guggulu Yoga 3 g/day in the form of tablets, thrice a day, for 45 days, with lukewarm water.
Method of administration of Patrapinda sweda
Preparation of the Patrapinda (Leaves Pack): Fresh Nirgundi leaves are cut into small pieces and then taken in a vessel with a round bottom. About 100 ml of Tila Taila is added to this. With continuous stirring the leaves are then fried. These fried leaves are used for the preparation of packs. The cotton cloth is spread on the working table. About 250 gm of fried leaves are placed on the cloth. The free corners of cloth are approximated to cover the leaves. The free ends of the cloth are folded in its middle and are then tied with a cotton thread to make a round pack with handle.
- 250 g fresh leaves of Nirgundi (Vitex nigundo)
- 18" square cotton cloth two pieces
- Approximately 5' long cotton thread
- Vessel having a round bottom, for frying herbal leaves
- Tila Taila
Heating of the packs: In a round bottomed vessel, 100 ml of Tila Taila is taken and heated. The packs of herbal leaves are placed on the Taila. The packs must be continuously moved stirring in the oil, if the herbal pack is not moved, there is every possibility that the portion of the herbal pack in touch with the heated vessel gets burnt. When the pack is properly heated it is taken out of the vessel. Any oil flowing from the pack is mopped to the edge of vessel. Now the packs are ready for use in sudation procedure.
Preparation of the patient: No specific preparation of the patient is needed and this procedure can be performed at any time of the day depending upon the requirement. This is the unique procedure for applying heat to a portion of the body and it is not usually preferred that the whole body be subjected to Swedana Karma. For the same reason depending upon the comfort of the patient Swedana may be performed in the sitting position or lying down position.
Application of Pinda Sweda: First the medicated oil is smeared on the affected joint, then the therapist massages the affected joints by moving his palm in a circular fashion. Heat is applied to the joint by using this heated herbal packs. To begin with the therapist should confirm the heat in the pack by touching the pack on the dorsum of his hand. Then the heat is applied to the patient's body for Swedana. For this purpose, herbal packs may be momentarily touched on the joint or they may be moved on the joint. By the earlier stated maneuvers, when the heat in the herbal pack is minimum, the therapist should place the pack above and beneath the body part to be treated. This is placed till the herbal pack loses its temperature completely or the temperature in the pack equalizes with that of the body temperature. Sudation is then continued by taking another pack of herbal leaves, which is kept in the vessel for heating, in a similar manner. In this way, sudation is continued for about an hours. This completes the procedure of Patra Pinda Sweda.
Criteria for assessment
The improvement in the patients was assessed mainly on the basis of relief in the signs and symptoms of the disease. To assess the effect of therapy objectively, all the signs and symptoms were given a score depending upon their severity.
The following periodical functional tests were carried out for objective assessment of the improvement of Sandhivata patients.
Walking time - The patients were asked to walk a distance of 25 feet, and the time taken was recorded before and after the treatment.
Climbing stair test - The patients were asked to climb a 25 staircase up and down and the time was recorded before and after the treatment.
Joint movement - The range of movement of each affected joints was measured by using the goniometer, both before and after the treatment.
Overall effect of therapy
Marked improvement - Above 75% relief in the clinical signs and symptoms
Moderate improvement - 51-75% relief in the clinical signs and symptoms
Mild improvement 26 - 50% relief in the clinical signs and symptoms
No improvement 0 - 25% relief in the clinical signs and symptoms
Statistical analysis - The data obtained on the basis of observations were subjected to statistical analysis in terms of mean, percentage, standard deviation, and standard error. The 't' test and 'p' values were calculated by using paired 't' test and considered at the level of P < 0.05 and < 0.05 and P < 0.10 (Insignificant), P < 0.01 (significant), and P < 0.001 (highly significant), to carry out the results.
| Observations|| |
In this study, the maximum number of patients, 25.86% belongs to the 50-60 years age group, 63.79% were female, 100% were having a gradual onset, and 56.03% had chronicity up to one year.
In this study, 56.03% had a positive past history, 69.83% had a negative family history, 85.34% had a Katu Rasa-dominant diet, and 34.48% had Adhyashana; 49.14% of the patients were doing light exercise in their routine life, 37.07% had tension, and 58.11% were having menopause.
All the patients had Dwandwaja Prakruti, with a maximum number of patients, that is, 51.72% having Vata-Kapha Prakruti and 28.45% having Vata-Pitta Prakruti; 68.97% had Rajasika type of Manasa Prakruti.
In Aharaja Nidana, a maximum number of patients, that is, 69.83% had Asatmya Ahara, 63.79% had Ati Katvadi Rasa Sevana, and 62.07% had Ati Ruksha Ahara. In Viharaja Nidana, a maximum number of patients, that is, 49.14% had Ati Cheshta, 39.66% had Vegavidharana, 36.21% had Ati Ratrijagrana, and 32.76% had Ati Vata Atap Sevana. In Manasika Nidana, a majority of the patients, that is, 41.38% had Chinta and 12.93% had Ati Krodha.
Considering the risk factors, 83.62% had repetitive stress, of whom 63.69% were females, 42.24% had psychological stress, it was hereditary in 25.00%, and 22.41% had obesity.
With regard to cardinal symptoms, 100% of the patients had Sandhishula, 96.55% had Sandhigraha and Akunchana Prasaranajanya Vedana, 87.93% had Sandhishotha, 86.21% had Sandhisphutana, and 55.17% had Sparsha sahyata.
The associated symptoms obtained were Daurbalya (78.45%), Angamarda (74.14%), and so on.
All the patients (100%) were found to have knee joint involvement and only 4.31% had ankle joint involvement.
Results on cardinal symptoms
Effect of therapy on X-ray examination
On considering the effect on X-ray examination, the mean gradation was 00.58 before treatment and it slightly decreased to 00.46 after the full course, which showed 20.68% improvement in group A, whereas, the initial mean score was 00.62, and it mildly reduced to 00.52 after the completion of treatment. Thus, 15.62% relief was obtained in group B. Here both the groups were found to be statistically insignificant.
In Group A, marked improvement was seen in 18.00% of the patients, while moderate improvement was seen in 48.00%, whereas mild improvement was found in 32.00% and only 02.00% of the patients had no improvement. However, in group B marked improvement was seen in 01.96%, followed by moderate improvement in 19.60%, and mild improvement in 66.36%; and 11.76% of the patients came under the no improvement category [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10] and [Table 11].
| Discussion|| |
The present study reveals that all the patients (100%) were complaining of Sandhishula. Maximum numbers of patients were having complaints of both Sandhigraha and Akunchana Prasaranajanya Vedana, that is, 96.55% followed by 87.93% patients who were complaining of Sandhishotha, 86.21% patients had Sandhisphutana and 53.45% patients had Sparshasahyata. It can be stated that all the symptoms occurred due to Vata Prakopa and Kapha Kshaya. Also Asthi Dhatu Dushti and Majja Dhatu Dushti, which were caused by Nidana Sevana and Vata Prakopa, were also responsible for the manifestation of the symptoms.
All the patients (100%) were having knee joint (Janu Sandhi) involvement and only 4.31% of the patients had ankle joint (Gulpha joint) involvement. It can be concluded that Sandhivata of knee joint is most common. It supports the theory that this disease occurs mostly in weight bearing joint.
Effect of therapy on cardinal symptoms
In the symptom of Sandhishula, both the groups provided highly significant relief (P < 0.001), but percentage-wise, 60.87% relief was observed in Group A, while in group B it was 45.03%. Thus the best relief was seen in patients of Group A. Pain was produced mainly by Vata Prakopa and Swedana, and the best treatment was Shamana of Prakupita Vata. Therefore, this may be one of the reasons that better relief was found in group A in comparison to group B.
In Sandhishotha both the groups provided statistically highly significant (P < 0.001) relief, but percentage-wise relief of 68.57% was seen in group A and 51.42% in group B, hence, Group A therapy provided better relief in Sandhishotha than Group B therapy. Prakupita Vata got localized in Asthi Sandhi and produced Srotorodha. It occurred due to Vata Sanga, which was responsible for Shotha. Patra pinda sweda induced Srotoshodhana and regulated Vata Dosha, which resulted in Shotha being decreased.
In the present clinical study, a statistically highly significant result (P < 0.001) was observed in both the groups in the symptoms of Sandhigraha. However, percentage-wise more relief was found in group A, that is, 58.26% than in group B (39.31%). Thus, group A provided better relief in Sandhigraha. When the disease aggravated, the vitiated Vata could produce Stambha leading to an inability of movement. It was improved by inducing Swedana because joint activity was regulated by the presence of Vata and Kapha at the joint level. Swedana increased Dhatvagni at the level of the joints, thereby improving the functions of the joints. 
In Sandhisphutana, percentage-wise, better relief was found in group A than in group B. Sandhivata was localized Vata Vyadhi, in which, Prakupita Vayu affected the Sandhi. This Sthanasanshraya was the result of the Srotoriktata present at the Sandhi and Swedana Karma removed the Srotoriktata and regulated the Vata Dosha and resulting Shamana of the Sandhisphutana.
The present study showed that both the groups provided statistically highly significant relief (P < 0.001) in the symptom of Akunchana Prasaranajanya Vedana, but percentage-wise better relief was observed in Group A (60.82%) in comparison to Group B (44.44%). Hence, Group A provided more relief in the symptom of Akunchana Prasaranajanya Vedana. Charaka referred to this symptom as painful Prasarana-Akunchana Pravritti.  However, this symptom might not be seen in the early stages. When the disease aggravated, the vitiated Vata could produce Stambha, when there was inability of movement because pain was produced mainly by the Prakupita Vata. Swedana cured the Prakupita Vata and regulated joint activity by the increased Dhatvagni level.
On examination of the knee joint it was found that there was 17.37% improvement in the knee joint flexion in Group A, whereas, 7.87% improvement in knee joint flexion in group B. Both the groups were found to be statistically highly significant (P < 0.001). Here, percentage-wise group A was higher than group B. Movement was the unique feature of Vata and in Sandhigata Vata; movement was obstructed because of the Sanga type of Srotodushti. This gave rise to Stambha. Also the increased Sheeta Guna of Vata was responsible for Stambha. Swedana Karma relieved Stambha, Gaurava, Sheetata and induced sweating. 
On examining of the walking time, it was found that patients of group A reported 27.36% improvement, while patients of group B reported 10.91% improvement. Both the groups were found to be statistically highly significant (P < 0.001). However, percentage-wise relief was found to be better in group A than in group B. The knee was the chief weight-bearing joint and was mainly affected in the patients of Sandhivata. On account of pain, the patients had difficulty in walking. As the pain reduced, difficulty in walking also reduced. Therefore, for the assessment of this test, the patients were asked to walk a particular distance and time taken for this was noted before and after treatment. Pain was mainly produced by Vata and Swedana was the best treatment for the Shamana of Vata. Hence, better improvement was observed in group A.
The effect on the Climbing Stair Test showed that percentage-wise better relief was observed in Group A than Group B. During the climbing of stairs, pain occurred due to Vata Prakopa. Acharya Charaka has mentioned that Swedana therapy was the best treatment for vitiated Vata- and Kapha-dominant disorders. Sandhivata was a Vata Pradhana disorder. Therefore, it was clear that group A therapy provided better improvement in the climbing stair test.
In group A, recurrence was obtained in 26.00% of the patients and in group B recurrence was obtained in 33.33% patients, in the follow-up period, that is, one month after completion of therapy. Here, in the present study, if the duration of the therapy had been longer then the recurrence rate would have been lower.
Probable mode of action of Patra Pinda Sweda
In Nirgundi Patra pinda sweda, Nirgundi and Tila taila were used. Nirgundi had Kapha-Vata Shamaka, Rasayana, analgesic and anti-inflammatory properties. Tila Taila had Snehana, Sandhaniya, Rasayana, and other properties. Before performing Patra pinda sweda locally abhyang was done. Abhyanga karma was Snehana, Kledakara, Jarahara,  Paushtika, and Kapha-Vata nirodhana. Sneha was used for abhyang, which reached Mamsa, Meda, Asthi, Majja and so on. Dhatu provided nourishment to them. Massage gave strength to the muscles; relaxed the stiff muscles, and increased the blood flow and metabolism.
After Abhyanga Patra pinda sweda was applied to the affected part of the body, which was Sandhichestakara, Srotosuddhikara, Agnideepaka, and Kapha-Vatanirodhana, it decreased the Stambha. It released pain, relaxed the muscles, activated the local metabolic process, increased local blood flow, and thus increased the absorption of Sneha through the skin. After administration of Swedana, it might produce a hypoanalgesic effect by diverted stimuli. In the Sandhivata Sanga type of Srotodusti is present and by doing Swedana this Sanga is relived and shaman of Sandhivata.
Probable mode of action of Ashwagandhadi Guggulu Yoga
Ashwagandhadi Guggulu Yoga is a polyherbal formulation. The contents of Ashwagandhadi Guggulu Yoga are Ashwagandha, Rasna, Chopachini, Pippalimula, Shuddha Kupilu, Nirgundi, Shallaki and Guggulu. Most of the drugs of this yoga have Ushna Veerya, Vata-Kaphashamaka, Vedanasthapana, Shothahara, Deepana, Anulomana, Balya and Sandhaniya properties. Its pharmacological activities include anti-inflammatory, analgesic, anti-oxidant, immunostimulant, and so on. By these properties this drug is beneficial for the Shamana of Sandhivata.
| Conclusion|| |
Sandhigata Vata is one of the Vatavyadhi described in all the Samhita and Sangraha Granthas. Acharya Charaka was the first to describe the disease separately with the name of 'Sandhigata Anila' under the chapter of Vata Vyadhies. There is no direct reference regarding Nidana and Samprapti of Sandhivata. The maximum number of patients belonged to the 56-60 year age group. A maximum number of patients had 0-1 year chronicity. A majority of patients, that is, 63.79% were female. A majority of the patients, that is, 58.11% had menopause. A statistically significant result was found in both the groups, but on the basis of percentage and relief in signs and symptoms, it was obvious that the overall effect on the patients in Group A was better in comparison to Group B. No significant change in the laboratory investigation was observed in both groups after treatment. The X-ray finding of degenerative changes remained unchanged. The results would have been better if the therapy had continued for a longer duration. Along with this, if exercises were added to the treatment, it could help in improving the joint function.
| References|| |
|1.||API Textbook of Medicine, 19/ 5, edited by Siddharth N. Shah, ed. 7th published by The Association of Physicians of India. 2003. p. 1151. |
|2.||Oxford handbook of Clinical medicine, Murray longmore, ian B. Wilkinson, Supral Rajagopalan, ed. 6 th , published by Oxford university press, United States, 2004. p. 416. |
|3.||Charaka, Charaka Samhita, Chikitsasthana 28, Vatavyadhi chikitsa/82, Revised by Charaka and Dridha bala with Hindi commentary by R.D. Shashtri, edited by Kashinath Shastri, published by chaukhambha Sanskrit series, Varanasi, ed 4 th 1976. p 792, |
|4.||Sushruta, Sushruta Samhita, Vatavyadhichiktsa, Chikitsasthana 4/8, edited by Bhaskar Govinda ghanekar published by Motilal Banarasidas publications, New delhi ed. 5 th 1997. p. 403. |
|5.||Ibidem, Sushruta Samhita Chikitsasthana, Swedaavacharniya chikitsitam, 32 / 22, p. 513. |
|6.||Charaka, Charaka Samhita, Chikitsasthana 28, Vatavyadhi chikitsa, 28/372-74, Revised by Charaka and Dridha bala with Hindi commentary by R.D. Shashtri, edited by Kashinath Shastri, published by chaukhambha Sanskrit series, Varanasi, ed. 4 th 1976. p 783. |
|7.||Charaka, Charaka Samhita, Sutra sthana 28, Langhana Brimhaniya Adhyaya, 22/11, Revised by Charaka and Dridha bala with Hindi commentary by R.D. Shashtri, edited by Kashinath Shastri, published by chaukhambha Sanskrit series, Varanasi, ed. 4 th 1976. p 424. |
|8.||Vagbhatta, Ashtanga Hridaya, Sutrasthana, Dinacharya Adhyay 2/8, edited by Profesor Dilip Pandya, published by Saraswati Pustak Bhandar, Ahmedabad ed. 1 st , 1992. p. 49. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]