Ayurveda is hope for suffering humanity in today’s world where no one found complete treatment solution for commonest chronic inflammatory joint disease Amavata (Rheumatoid Arthritis). This causes swelling, pain and stiffness of joints. Chronic condition may cause debility, deformities of joints and crippling. Unfortunately the man has not succeeded in eradicating this diseases and find to come out with successful therapeutic measures that can cure the patient completely. Ayurveda can play a wide role in treatment of Amavata. So need to study Ayurveda classics with deep understanding is demand of today. Ayurveda texts like charak samhita, sushruta samhita, Ashtang hridya and Asthtang samgrah had widely mentioned about Ama and Amavrita Vata. First time, Madhav nidana mentioned Amavata as separate disease. After that vangsena, chakaradutta, bhaishjya ratnavali has elaborated the treatment modalities of Amavata. Ayurveda focus on Nidaan i.e cause of disease and symptoms of disease. Ayurveda has described detailed list of causative factors of Amavata. So study of this causative factor will help scientific society to eradicate this disease. As we are very well aware that in modern scientific world, cause of Rheumatoid arthritis is still unknown. Ayurveda says chikitsa(Treatment) is Nidaan Parimarjna( removal of cause). When cause of disease is unknown then how a physician can provide proper treatment. This study has focus on nidaan(causative factors), samprapti(Pathogenesis) and Sathyata/ Asathyata (Prognosis) of disease Amavata according to Ayurveda classic texts.

Keywords: amavata, rheumatoid arthritis, ayurveda texts, traditional knowledge, indian system of medicine

Amavata is mainly caused by two factors ama and vata.

Etymology of Amavata

1. ‘Amena sahita vata Amavata’. The virulent Ama circulates in the whole body propelled by the vitiated vata dashas producing block in the body channels that stations itself in the sandhi giving rise to Amavata.¹
2. The combinations of ‘Ama’ and vata form Amavata. It shows the predominance of Ama & vata in the samprapti of Amavata.²
3. Ajeerna produce ‘Ama’ & along with vata it produce Amavata.³

Definition

‘Ama’ is produced by agnimandya of both Jatharagni and Dhatwagnis. Even though ama is a cause for various diseases, in Amavata it is the main causative factor. Ama and vata vitiated simultaneously and disease is manifested mainly in joints of hasta, pada, sira, trika, gulpha, janu and uru. The main symptoms produced are Angamarda Aruchi, Trishna, Alasya, Gouravam, Apaka & Shotha.⁴

Role of ama in amavata

The main causative factor for the manifestation of Amavata is Ama. So it is necessary to know about the Ama in detail.

Etymology of ama

1. The unprocessed or undigested food partical is Ama.⁵
2. Ama means, “Which is subject of digestion”.⁶

Definition of ama

1. The first Rasa dhatu, which has been inadequately digested due to the weakness of digestive fire and accumulating in the stomach in the abnormal state, is known as Ama.^7,8
2. The undigested Adya Ahara dhatu is Ama.⁹
3. The food material which will not undergone vipaka, leads to Durgandha, which is large in quantity, which is picchila & which leads to Gatra Sadana is called Ama.
4. Due to impairment of digestive fire the undigested remained food material is ‘Ama’.
5. Apakva Anna Rasa is Ama & some other considers the accumulation of mala as Ama & still other opines the first stage of vitiation of dosha as Ama.

Ama may be classified as below

Ama produced due to hypo functioning of Agni i.e

1. Ama due to Jatharagni Mandya.
2. Ama due to Dhatvagni Mandya.
3. Ama due to Bhutvagni Mandya.

Ama produced irrespective of the action of Agni

1. Accumulation of mala.
2. Ama due to interaction & virulently vitiated doshas
3. First phase of doshic vitiation.

Vata in amavata

Voluntary & involuntary functions are all under the control of Vayu. In Amavata the normal function of Vata is disturbed. It produces stabdhata & sandhigraha leading to the restricted movements of joints & it will become the responsible for crippling effect seen in the patients. This shows the predominance of vata dosha in the pathogenesis of Amavata. Now let us carry a brief description of vata dosha. The word vata derived from “Va gati gandhanyoh” it means to move, to make known, and to enthuse.¹⁰

It has got the other synonyms like Anila, Maruta, Pavana etc.,¹¹

Gunas(properties) of vata

Ruksha, Seeta, Laghu, Sukshma, Chala, Visada, Parusha & Khara.^12,13

Functions of normal vata

Vayu sustains the body with expiration, inspiration, enthusiasm, movement of various parts. Sharpness of sense perception, initiation of the natural urges and many other functions.¹⁴

1. Tantrayanradhara
2. Cheshta Pravartaka
3. Mano Niyanta & Praneta
4. Sharvendriya
5. Uttyojaka
6. Sharvendriya Artha Abhivodha
7. Sharva sharira dhatu Vyuhakara
8. Sharira Sandhanakar
9. Vak pravartaka
10. Sabdasparsa Prakrti
11. Srota sparsana mula
12. Harsha utsahayoni
13. Agni samirana
14. Mala ksepta
15. Grabhakrti Karta
16. Ayusha Anuvratti¹⁵

Importance of vata

Pitta, Kapha, Dhatu & Mala are movement less, unless they are brought to the proper place by vata to carry out their functions. Thus Vayu makes the functions of all the tissues of body.¹⁶

Symptoms produced due to ama

1. Srotorodha 2. Bala bramasa 3. Gaurava 4. Anila Mudhata 5. Alasya 6. Apaki 7. Nisthivana 8. Mala sanga 9. Aruchi 10. Klama 11.Vit, Mutra, Nakha, Dhatu, Chakshu Pitata/Raktata/Krishnata12. Prusthtasthi, Katisandhi Ruk 13. Siroruk 14. Nidra 15. Mukhavairasya 16. Jvara 17. Atisara 18. Romaharsa.

Symptoms of vataprakopa¹⁷

1. Parava Samkocha 2. Stambha 3. Asthi Paravabheda 4. Lomaharsa, Pralapa, Hasta-Pristha-siro-graha 5. Khanjata-Pangulya 6. Kubjata 7. Sosha 8. Anidra 9. Grabha-sukra-Rajonasa 10. Spandana 11. Gatra Suptata 12. Sira, Nasa, Akshi, Jatru, Grivahanunam-Bheda, Toda-Arti 13. Akshepa 14. Moha 15. Ayasa

Cause or nidana of amavata

Nidana is defined as the factors which deranges the dynamic state of doshic equilibrium provokes the disease is known as Nindan. This Nidana helps us to decide the line of treatment as well as prognosis of the disease.

Amavata Ninda is of multifaceted various Acharya’s mentioned their different views for the productions of Ama in Amavata.

Madhavakara¹⁸ delt the separate Nidana as

1. Viruddha Ahara (Incompatible food)
2. Viruddha Chestha (Incompatible actions)
3. Mandagni (Hypo functioning of agni)
4. Nischala (Lack of exercise)
5. Snigdha Ahara followed by immediate exercise.

Besides these intakes of Kanda, mula and sakha and excessive exertion are etiological factors opined by Harita.¹⁹ In Anjana Nidana, the factors which vitiates vata, pitta and kapha are considered under Nidana.²⁰

These all above Nidana can be included less than two heading

1). Unwholesome diet 2). Erroneous habits.

Unwholesome diet means “which aggravates the body humors but not expel them out of the body”.²¹ Charaka has mentioned 18 types of unwholesome diet (Viruddha Ahara)²² some of the virudha Ahara are as follows

Milk along kulatha, 2. Panase fruit with matsya 3. Mixtures of equal quantities of honey & ghee 4. Boiled curd²³

Erroneous habits (Viruddha chesta) mainly included alternate use of cold and heat, suppression of natural urges, sleeping during daytime, walking at night, over indulgence in work.

Pathogenesis or samprapti of amavata²⁴

The impairment of Agni will produce the condition of Ama. Mainly agnimandya initially affects digestion followed by metabolism. Hence in this state of Agni, the Rasadhatu is not formed up to the standard level & it is considered as Ama. This ‘Ama’ along with Vyana Vayu and also by virtue of its Vishakari guna it quickly moves to all kapha sthanas, through Hridaya and Dhamanes. This Vidhagada Ama, in kapha sthana is further contaminated by doshas and assumes different colours, because of the Atipichhilata.

If Ama gets obstructed in to channels and promotes further vitiation of vata dosha, this morbid Ama circulates ubiquitously in the body propelled by vitiated vata with predilection for sleshma sthana. On the dhamanies with the other doshas it facilitates sroto abhisyanda and srotorodha causing sthanasmsraya manifested stabdhata (stiffness), sandhisula (joint-pain), sandhishotha (swelling), Anga-marda(bodyache), Apaka(indigestion), Jwara (fever), Anga gourava (heaviness of body), Alasya(laoghess) etc symptoms of Amavata.

According to the commentators on Madhava Nidana the Samprapti of Amavata can be summarized according to Shatkriyakal.

Sanchaya & prakopa: When a person is exposed to aetiological factors like Viruddha Ahara, does vyayama after intake of snigdha ahara, Chinta, Krodha etc., Agnimandya is there leading to Tridoshadushti and Amotpatti in the Sanchaya and Prakopavastha.

Prasara: With the help of Vata (Biophysical mechanism), this Ama gets Prasara to shleshma sthana producing mild sandhishoola etc. along with Ama symptoms. Then Ama gets interacted with Tridosha and further modified (Vidagdha) to great extent and yagapatakupitavanta of Ama and Vata takes place via Rasavaha srotasa (Dhamani).

Sthana sanshraya: This prasarita Ama, which viscid, unctuous and guru endures Sthana Sanshraya in Hridaya, Trika Sandhi and Sarvanga (Srotoabhishyanda) leading to Dosha-dushya Sammurchchana. Primarily the disease is not manifested completely, so only initial mild symptoms like Aruchi, Apaka etc. are observed which can be considered as purva rupa of the disease Amavata.

Vyakti: As it reaches vyakti stage most of the symptoms of Amavata are manifested like Vrishchika dashavata vedana, stabdhata etc. In Adibala Pravrita cases (Karmajanya, Mata-pita apcharajanya etc.) Khavaigunya is already there and with the minor nidana sevana disease in manifested.

Bheda: In chronic stage or if the disease is left untreated it reaches bhedavastha- producing updrava like Sankocha, Khanjata etc.

The Samprapti Ghatakas, which are involved on the Amavata, are as follows.

1. Dosha- mainly vata (vyana, samana, Apana) and kapha (Kledaka,Bodhaka, sleshmaka)
2. Dhatu -Rasa, Mamasa. Asthi, Majja.
3. Upadhatu -Snayu and Kandara.
4. Srotases -Annavaha, Rasavaha, Asthivaha, Majjavaha.
5. Srotodusti -Sanga, Vimaragagmana.
6. Udbharasthana- Amashya (Ama), Pakvasaya (vata).
7. Adhisthana -whole body
8. Vyaktasthana -Sandhi
9. Avayava -Sandhi.
10. Vyadhiswabhava -Mainly Ashukar.
11. Sanchara Sthana -Hridya, Dhamani.
12. Roga Marga -Madhyama roga marga
13. Agni -Jataragni Mandya, Dhatwagni Mandya.

Prodromal symptoms/purva roopa²⁵ of amavata

Avyakta lakshana prior to the manifestation of disease is considered as the purva poorpa.

1. Dourbalyam (Weakness) 2. Haridaya gourava (heaviness in chest) 3. Gatra stabdam (Stiffness of the body) 4.Apaka (indigestion) 5. Anga marda (Aching all over body) 6. Gourava(Heaviness) 7. Aruchi (loss of taste) 8. Alasya (lack of enthusiasm) 9. Jwara (fever) 10. Sandhi vedana (Joint pain)

Roopa of amavata

“Utpanna Vyadhi bhodakameva lingam rupam”²⁶

It means which gives the idea about the manifested disease is known as ‘Rupa’.

Madhavakara²⁷ while describing Amavata lakshana, he has considered them in to two heading one is samanya lakshana another is lakshana samachaya of pravrudhu Amavata.

General symptoms/samanya laxanas

1. Angamarda (body ache) 2. Aruchi (Tastelessness) 3. Trishna (Thirst) 4. Alasya (lack of enthusiasm) 5. Gouravam (Heaviness all over body) 6. Jwara (Fever) 7. Apaka (Indigestion) 8. Shunata Anganam (Swelling all over the body mainly in joints)

Acute symptoms/pravriddha lakshana

It is the advanced stage of disease and very troublesome to patients as well as for physicians. According to Kriyakala and stage wise development, it is the worst stage of disease. Articular and Extra-articular feature present in this stage have been elucidated by Acharya Madhavakara, Bhava Mishra and Yoga Ratnakara.

According to madhavakara²⁸

1. Sarujam Sandhishotha: Hasta, Pada, Shiro, Gulpha, Janu, Uru Sandhis are chiefly involved in Amavata.
2. Vrishchika danshavata vedana: This kind of pain shows the presence of Ama at the site of pain.
3. Utsahahani: A subjective feeling in which lack of enthusiasm can be seen in suffering person. It is due to insufficient nutrition of Sharira Dhatus, Indriya and Mana.
4. Bahumutrata: Presence of vitiated or dushita Ama causes sroto: abhishyanda in the body, which leads to increase of kleda. This Bahumutrata occurs for the excretion of excess kleda from the body.
5. Kukshikathinya: Vitiated Samana and Apana Vata along with the Ama leads to Kukshikathinya, which is the rigidity of abdomen.
6. Kukshishoola: Srotorodha due to Ama causes obstruction to normal movement of vitiated samana and apana Vata resulting in pain in abdomen.
7. Nidra Viparyaya: Due to vata vriddhi, pain gets aggravated at night and keeps the patients awaken which leads to Nidra Viparyaya.
8. Chardi:²⁹ Continuous formation of dosha leads to excitation of amashaya by vata cause vomiting.
9. Bhrama: Presence of Kapha in Srotas and Vitiated Vata causes Bhrama.
10. Murchcha: Inability of the sensory organs to perceive the sense objects is Murchcha. Loss of motor function occurs in Murchcha due to upatapa of Indriya by Vitiated Vatadi doshas³⁰
11. Hritgraha: due to Rasavaha srotodushti (its mulasthana is Hridaya) and vitiation of Samana Vata, Vyana Vata and Avlambaka kapha. Hritgaurava is also produced due to above reason when vitiation is mild. In R.A. cardiac manifestations like Pericarditis, Myocarditis, Conduction defects etc. can occur.
12. Vibandha: due to vitiated Apana Vata and improper degradation of Ahara into Sara and Kitta.
13. Antrakujana: increased bowel sounds are present due to movement of Vitiated Vata in the intestine.
14. Anaha: It is the stagnation of vitiated vata in Kukshi.
15. Agnimandya: Vicious cycle of disease (Agnimandya- Shuktatva – Annavisha) produces Agnimandya again and again.
16. Praseka: lalasrava.³¹ Excessive thick, mucoid, salivary secretions are produced due to Samarasa, which shows Rasavaha and Udakavaha srotodushti.
17. Gaurava: Due to Vitiated Kapha there is feeling of heaviness in Hridaya and body parts preferably in Joints.
18. Vairasya:³² Perception of different taste than normal due to Sama Rasa and vitiated Bodhaka Kapha.
19. Daha: Due to Vitiation of Pitta sometimes localized or generalized Daha occurs. Warmth of the joint is usually evident on examination. In its most aggressive form, rheumatoid vasculitis can cause Mononeuritis multiplex (Harrison1994).
20. Trishna: Trishna is due to Agnidushti, Sama Pitta and Vata. It shows Rasavaha, dakavaha srotodushti in disease process (Table 1).

The first 4 criteria of RA can be correlated with the inflammatory condition of amavata. But rheumatoid factor and radiological changes cannot be correlated to any conditions of amavata. Hence on symptomatology amavata can be best correlated to RA.

Cardinal signs and symptoms/pratyatma lakshana

Pratyatma Lakshanas are main clinical features on which the disease can be clearly differentiated from other identical forms of disease. In Amavata, sandhis are the main site of manifestation of clinical features, thus joint associated symptoms are considered as Pratyatma lakshana of disease Amavata.

These are as follows:

Sandhi shoola (joint pain)

In Amavata, Vitiation of Asthi and Majjagata Vata causes pain in Sandhis and in severe stage, it is found as Vrishchika Dansha vata. The most common manifestation of established R.A. is pain in affected joints, which is aggravated by movements. During rest and especially early morning stiffness are also characteristic features of R.A. Pain originates predominantly from joint capsule, which is abundantly supplied with pain fibres and is markedly sensitive to stretching or distension.

Sandhi shotha (joint swelling)

Sandhi Shotha (Ekangika shotha) results when vitiated dosha afflicts Twaka, Rakta, and Mamsa in joints³³ Madhavakara has described that shotha result due to the affliction of Ama and Vata Pradhana Tridosha in joints.

Joint swelling in R.A. is the result of accumulation of synovial fluid, hypertrophy of synovium and thickening of joint capsule.

Stabdhata (stiffness)

The restriction or loss of movements of joints. Gatra stabdhata is caused due to spreading of Ama throughout the body by vitiated Vata.^34,35

In majority of patients, the onset is insidious with joint stiffness, especially early morning stiffness, which gradually gets reduced by evening. This diurnal rhythm worse on arising in the morning and then relieving towards evening probably reflects the diurnal variation in plasma cortisol level.

Sparshasahyata (tenderness)

Sparshasahyata can be included in Sandhishoola in which patient cries with pain even when the gentle pressure is applied to affected part. Sometimes person himself cannot touch the affected part due to pain. According to Modern text pain on movement and tenderness are the cardinal signs of the disease (Becron -1971) (Tables 2 & 3).

Differential diagnosis/sapeksha nidana

Sapeksha nidana becomes necessary when two or more disease have a few important laxanas similar to each other and in such condition in order to avoid any error in adopting the line of treatment. The differential diagnostic is done on the basis of few points such as difference in samprapti accompanying laxanas, upashaya anupashaya etc.

Here the disease, which was exhibited with sandhishotha and sandhishoola specially, is considered for differential diagnosis.

1) Vatarakta 2) Sandhigatavata 3) Krostaka sheersha 4) Sandhigat sannipata 5) Sandhi aghata

Vatarakta

Usually manifests with supti, discolouration and shithilatha of sandhi, pain is of pricking and splitting nature, sudden onset or disappearance of joint pain. Anguli sandhies are first affected, then it spread to other parts of the body slowly like akuvisha, all the affected joints are having pain equally, joint swelling is non-fleeting, no morning stiffness.

Sandhigata vata

Because of lack of sleshmaka kapha for the friction of joints, it causes pain and swelling. Here joint movement is accompanied with pain. This is sthira ie., non fleeting, the hip and the knee are often affected usually affects middle aged or elderly persons. Symptoms subside by using sneha therapies.

Krostaka sheersha

This is the condition, wherein provocated vata and rakta give rise to janu sandhi shotha and shoola, no other joints are involved. Janu Shotha (swollen knee) resembles the head of jackal, non-fleeting, severe pain in affected joint pain, which may increase during night.

Sandhigat sannipata

This is a type of sannipata jwara usually manifests due to tridoshakaraka hetus, swelling and pain of the joints are non-fleeting, non-variant pain, usually along with anidrata and severe cough.

Sandhiaaghata

This is of traumatic origin, pain and swelling will be restricted to the affected joint. Non-fleeting, subsides within few days.

Types of rheumatoid arthritis (amavata)

Madhava Nindan while explaining the doshanubandha lakshana⁴¹ he made 3 types. Whereas while expressing regarding the sadhyasadhayata of Amavata, he made 7 types on the basis of involvement of the doshas.⁴²By combining the above two points Amavata is of seven types on the basis of doshas they are as given below

1. Vata pradhana: In this mainly predominance of sula will be present.
2. Pitta pradhana: Daha and Raga are present in the joints.
3. Kapha Pradhana: Staimitya, Gourava & kandhu are the main symptom of this variety.
4. Vata pitta paradhana: Combined symptoms of both pitta & vata.
5. Vata kapha pradhana: Combined symptoms of both vata & kapha.
6. Pitta kapha pradhan: Combined symptoms of both pitta & kapha.
7. Sannipatika -- Combined symptoms of both all doshas.

According to Sharangadhara four types of Amavata are considered

1. Vataja Amavata
2. Pittaja Amavata
3. Kaphaj Amavata
4. Sannipataja Amavata

According to the presence of lakshana Amavata is classified in to two types first one is Samanya Amavata⁴³ and second is Pravrudha Amavata.⁴⁴

According to time period of Amavata it is of two types.

1. Naveena Amavata, 2. Jirana Amavata.

A unique classification by Harita Samhita⁴⁵ based on presentation of the disease.

1. Vistambhi: This presents with constipation, feeling of heaviness, in the abdomen, flatulence pain in the Vasti area.
2. Gulmee: Symptoms simulating like gulma, spasmodic pain in abdomen, increased audible peristaltic sounds.
3. Snehi: Unctuousness of the body, inactivity, loss of appetite, passing of unctuous and undigested stools.
4. Pakwama: Passing of yellowish, black or dark bluish dehydrated pakwama through anus, fatigue, exhaustion, condition is not associated with Vasti shoola.
5. Sarvanga: Pain in kati, prusta and vakshana region, pain in Vasti, region, audible peristaltic sound, swelling, heaviness in the head, excessive excretion of ama are the symptoms.

Complications or upadrava of amavata

The symptoms of advanced stage of Amavata are considered to be as Upadrava of Amavata roga. Vachaspati mentioned symptoms of advanced stage of Amavata are as upadrava but the commentator of Madhakosa Vijayarakshita differentiates the symptoms of advanced stage of Amavata from Upadrava. According to him Khanja, Sankocha, occur in Amavata. But further Vachaspati includes the disease expounded within the title of vata vyadhi under Upadrava. So it is worth to be considering Angavaikalya(deformity) is an Updarava considered by Harita. Even in Madhava Nidhava the Amavata Updravas are mentioned, they are Trit, Chardi, Bhrama, Moorcha, Hradgraha, Jadya, Antrakoojana, Anaha etc.⁴⁶

All the Systems will involve or get disturbed in the Amavata. It is not treated in time it produce anatomical deformities like sandhi vikruti and Hrid Graha. So proper management is must from the onset of disease. The upadrava depends upon the type of kapha involved in samprapti. If Ama combines with shleshka kapha & gets lodged in sandhi sthana creates sandhi vikruti and if Ama combines with Avalambak kapha resides in Hridaya develops Hrid Graha.

Suitable and unsuitable medication, diet or actions (upashaya/anupasaya)

If the relief occurs by using the aushadhi, Ahara or Vihara are to be considered as Upasaya. In the opposite sense if relief not occurs are counted as Anupasaya.⁴⁷ Same types of lakshnas will find in different rogas. If we take example of Amavata lakshanas such as sandhi shotha, sandhi shool etc, are likely to be found in other diseases like vatarakta, sandhigatavata, kostakasirsa etc. In this type of conditions when the lakshanas are found similar to that of another disease it is difficult to diagnose the disease and adopt the treatment. In this difficult condition Upashaya and Anupashaya have advised. Upashaya for Amavata are Ruksha sweda, langhana Usnakala etc Whereas Anupasayas are snigdha sweda, Santarpana etc.

Prognosis or sadhya/asadhyata^48,49

Amavata have got Anubandha with single dosha, naveena avasta, lakshanas are in mild form, no presence of Upadrava, is indication of sadhyata of Amavata. If involvements of any two doshas produce Vyapyata of the Amavata whereas involvement of all the three doshas, involvement of all the joints, Purana Amavata including with upadravas will become krichra sandhya vyadhi.

None.

Author declares there are no conflicts of interest towards the article.

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