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            "3276": {
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                "title": "Referencing guidelines",
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                        "*": "{{#seo:\n|title=Referencing guidelines\n|titlemode=append\n|keywords=Referencing guidelines,Referencing guidelines of carakasamhitaonline,Charak Samhita\n|description=Instructions about how to give Referencing\n|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg\n|image_alt=carak samhita\n|type=article\n}}\n<p style=\"text-align:justify;\">The references should be numbered consecutively in order in which they are first mentioned in the text (not in alphabetic order) and placed as endnote. In the text they should be indicated above the line (super scripted). Ex.<sup>[1]</sup> Use the style of the examples mentioned below, which are based on the formats used by the NLM in Index Medicus. The titles of journals should be abbreviated according to the style used in Index Medicus. Use complete name of the journal for non-indexed journals. Avoid using abstracts as references. \n<br/>\nThe commonly cited types of references are shown here: \n</p>\n==Articles in Journals==\n\n===Standard journal article (for up to six authors)=== \n\nDeole YS, Ashok BK, Shukla VJ, Ravishankar B, Chandola HM.  Psychopharmacological Study on Antidepressant effect of Brahmi Ghrita. AYU Int Res J Ayurveda 2008;29(2):77-83.\n\n===Standard journal article (for more than six authors)=== \n\nList the first six contributors followed by et al.\nNozari Y, Hashemlu A, Hatmi ZN, Sheikhvatan M, Iravani A, Bazdar A, et al. Outcome of coronary artery bypass grafting in patients without major risk factors and patients with at least one major risk factor for coronary artery disease. Indian J Med Sci 2007;61:547-54.\n\n===Volume with supplement=== \n\nShen HM, Zhang QF. Risk assessment of nickel carcinogenicity and occupational lung cancer. Environ Health Perspect 1994;102 Suppl 1:275-82.\n\n===Issue with supplement=== \n\nPayne DK, Sullivan MD, Massie MJ. Women's psychological reactions to breast cancer. Semin Oncol 1996; 23(1, Suppl 2):89-97.\n\n==Books and Other Monographs==\n\n===Book of Personal author(s)===\n\nPatwardhan K..Human Physiology in Ayurveda, Jaikrishnadas Series. 1st ed. Varanasi:Chaukhambha Orientalia;2008.\n\n===Editor(s), compiler(s) as author=== \n\nDeole Y.S.,Basisht G., editors. Charak Samhita New Edition. Jamnagar: Charak Samhita Research Training and Skill Development Centre; 2020.\n\n===Chapter in a book=== \n\nSingh R.H.,Singh G., Sodhi J.S., Dixit U.. Deerghanjivitiya Adhyaya. In: Deole Y.S., Basisht G.,editors. Charak Samhita New Edition. 1st ed. Jamnagar: Charak Samhita Research Training and Skill Development Centre; 2020.pp.--.\n\n==Electronic Sources as reference==\n\n===Journal article on the Internet===\n\n#Basisht GK. Symbiohealth-Need of the hour. AYU [serial online] 2011 [cited 2020 Jan 6];32:6-11. Available from: http://www.ayujournal.org/text.asp?2011/32/1/6/85715\n\n===Monograph on the Internet===\n\n#Deole Y.S., Shilwant A.A., authors. [[Ojas]] [monograph on the Internet]. Jamnagar: [[Charak Samhita Research, Training and Development Centre]]; 2020 [cited 2020 September 15]. Available from: http://www.carakasamhitaonline.com/index.php?title=Ojas.\n\n===Homepage/Web site===\n\n#carakasamhitaonline.com[homepage on the Internet]. Jamnagar: [[Charak Samhita Research, Training and Development Centre]]; CCA-NC-SA 4.0 [updated 2020 Jul 29; cited 2020 Sep 15]. Available from: http://www.carakasamhitaonline.com/index.php?title=Main_Page.\n\n===Part of a homepage/Web site===\n\n#Gujarat Ayurved University [homepage on the Internet]. Jamnagar: The University;  [updated 2019 Dec 31; cited 2020 Jan 07]. Gujarat Ayurved University; Available from: http://ayurveduniversity.edu.in/\n\n==References from Ayurvedic Classical Texts and Samhitas==\n\nIn case of multiple references from same Samhita, the reference shall be quoted in the text in square bracket in following format:\n\n[Abbreviated form of name of samhita, name of section, chapter number / verse number] \n\nThe details of abbreviations shall be given at the end of article. The detail bibliographic information shall be listed as only one reference in the endnotes. \n\nFor example, if the reference is from [[Charak Samhita]], then the reference can be quoted as [Cha. Sa. Sutra Sthana 1/40]\n\nFor single references and standard references from other samhita, the following format shall be followed. \n \n== Bibliographic details for citation ==\n\nThe following bibliographic details are important for any text. \n*Name of the original author/translator/commentator. \n*Name of the text. \n*Names of editor \n*Number of edition \n*Place of publication\n*Name of publisher\n*Year of publication. \n*Page numbers. \n*Online source: If the source is online edition, then the source or URL of the website shall be quoted with date and time of accessing the source.\n \nFollowing are some examples of citing sources of [[Ayurveda]] classical texts.\n \n==Charak Samhita==\n\n=== Original Charak Samhita ===\n\n==== Present Electronic edition ====\n\nThe '''cite this page''' link on Mediawiki sidebar (can be seen on the left side of screen) of each chapter page can be used to use citation tools of this present edition. We encourage researchers to properly cite the content of this edition in their works. \n\nThis edition can be cited as: \n\nContributors. Main Page. In: Deole Y.S.., Basisht G., eds. Charak Samhita New Edition. 1st ed. Jamnagar, Ind: CSRTSDC; 2020. http://www.carakasamhitaonline.com/index.php?title=Main_Page&oldid=35892. Accessed Date like November 11, 2020.\n\n==== Print edition examples ====\n\nCharak. Charak Samhita. Edited by Jadavaji Trikamji Aacharya. 1st ed. Varanasi: Krishnadas Academy;2000. p.--.\n\n=== Sthana and Adhyaya in Charak Samhita ===\n\n==== Present Electronic edition example ====\n\n===== Sthana (section) =====\n\nDwivedi R.B.. '''Sutra Sthana.''' In: Deole Y.S., Basisht G., eds. Charak Samhita New Edition. 1st ed. Jamnagar, Ind: CSRTSDC; 2020. http://www.carakasamhitaonline.com/index.php?title=Sutra_Sthana&oldid=35718. Accessed November 11, 2020.\n\n===== Adhyaya (chapter) =====\n\nSingh R.H., Singh G., Sodhi J.S., Dixit U.. '''Deerghanjiviteeya Adhyaya.''' In: Dixit U., Deole Y.S., Basisht G., eds. Charak Samhita New Edition. 1st ed. Jamnagar, Ind: CSRTSDC; 2020. http://www.carakasamhitaonline.com/index.php?title=Deerghanjiviteeya_Adhyaya&oldid=36008. Accessed November 11, 2020.\n\n==== Print edition examples ====\n\nCharak. Sutra Sthana, Cha.1 Deerghanjivitiya Adhyaya. In: Jadavaji Trikamji Aacharya, Editors. Charak Samhita.1st ed. Varanasi: Krishnadas Academy;2000. p.1-24.  \n\n=== Verse in Charak Samhita ===\n\n==== Present Electronic edition example ====\n\nSingh R.H., Singh G., Sodhi J.S., Dixit U.. Deerghanjiviteeya Adhyaya '''verse 03'''. In: Dixit U., Deole Y.S., Basisht G., eds. Charak Samhita New Edition. 1st ed. Jamnagar, Ind: CSRTSDC; 2020. http://www.carakasamhitaonline.com/index.php?title=Deerghanjiviteeya_Adhyaya&oldid=36008. Accessed November 11, 2020.\n\n==== Print edition examples ====\n\nCharak. Sutra Sthana, Cha.1 Deerghanjivitiya Adhyaya verse 03. In: Jadavaji Trikamji Aacharya, Editor. Charak Samhita.1st ed. Varanasi: Krishnadas Academy;2000. p.4.   \n\n=== Commentary/ Tattva vimarsha/ Vidhi vimarsha in Charak Samhita ===\n\n==== Present Electronic edition example ====\n\nSingh R.H., Singh G., Sodhi J.S., Dixit U.. Deerghanjiviteeya Adhyaya '''vidhi vimarsha.''' In: Dixit U., Deole Y.S., Basisht G., eds. Charak Samhita New Edition. 1st ed. Jamnagar, Ind: CSRTSDC; 2020. http://www.carakasamhitaonline.com/index.php?title=Deerghanjiviteeya_Adhyaya&oldid=36008. Accessed November 11, 2020.\n\n==== Print edition examples ====\n\nChakrapani, Charak. Sutra Sthana, Cha.1 Deerghanjivitiya Adhyaya ver.03. In: Jadavaji Trikamji Aacharya, Editor. Charak Samhita.1st ed. Varanasi: Krishnadas Academy;2000.p.4. \n\n==Sushruta Samhita==\n\n=== Original Sushruta Samhita ===\n\nSushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.--.\n\n=== Sthana and Adhyaya in Sushruta Samhita ===\n\nSushruta. Sutra Sthana, Cha.1 Vedotpattim Adhyaya. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1-10.\n\n=== Verse in Sushruta Samhita ===\n\nSushruta. Sutra Sthana, Cha.1 Vedotpattim Adhyaya verse 3. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.\n\n=== Commentary in Sushruta Samhita ===\n\nDalhana, Sushruta. Sutra Sthana, Cha.1 Vedotpattim Adhyaya verse 3. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.\n\n==Ashtanga Hridayam ==\n\n=== Original Ashtanga Hridayam ===\n\nVagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.p.--.\n\n=== Sthana and Adhyaya in Ashtanga Hridayam ===\n\nVagbhata. Sutra Sthana, Cha.1 Ayushkamiya Adhyaya. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000. p.1-23.\n\n=== Verse in Ashtanga Hridaya ===\n\nVagbhata. Sutra Sthana, Cha.1 Ayushkamiya Adhyaya verse 3. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.\n\n=== Commentary in Ashtanga Hridayam ===\n\nArunadatta, Vagbhata. Sutra Sthana, Cha.1 Ayushkamiya Adhyaya verse 3. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.\n\n==Any other Ayurveda classical text==\n\nLikewise, any other Ayurveda classical text can be quoted as: \n\nName of the original author. Name of the text. Edited by ---. No. of ed. Place of publication: name of publisher; year of publication. Page numbers.\n\nExamples: \n \n*Kashyapa. Kashyapa Samhita. Edited by P. V. Tewari. Reprint. Varanasi: Chaukhambha vishvabharati;2008. pp.--\n\n== Translated Ayurveda classical text==\n\nThe translated books can be quoted as below:\n\nName of the original author. Name of the text. Translated from (language) by (name of translator). No. of ed. Place of publication: name of publisher; year of publication. Page numbers. \n\n'''Examples:''' \n\n*Madhavakara. Madhava Nidanam (Roga vinischaya). Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007.pp--\n\n*Sharangadhara. Sharangadhara Samhita. Translated from Sanskrit by K.R. Srikantha Murthy. Reprint ed. Varanasi: Chaukhambha orientalia;2016.pp-- \n\n*Bhavamishra. Bhavaprakasha -Volume I. Translated from Sanskrit by K.R. Srikantha Murthy. 1st ed. Varanasi: Krishnadas academy;2000.pp.-\n\n*Bhavamishra. Bhavaprakasha -Volume II. Translated from Sanskrit by K.R. Srikantha Murthy. Reprint ed. Varanasi: Krishnadas academy;2004.pp.-\n\n==Quoting more than once in an article == \n\nIf the author refers same book for more than one time, then the abbreviations like Cha.Sa. Sutra Sthana chapter number/verse number can be used in the running text. It can be followed by a single number of bibliographic citation only once in the reference list.\nFor example if the Charak Samhita is referred more than once, then it can be quoted like this:\n\nThe nutrients present in the food nourish respective dhatu qualitatively and quantitatively. [Cha. Sa. Sutra Sthana 28/4]<sup>[1]</sup> Each dhatu nourishes its next sequential dhatu.[Cha. Sa.Chikitsa Sthana 8/39] <sup>[1]</sup>\n\nSingle number of references can be given in bibliography as:\n\n<sup>1.</sup> Charak. Charak Samhita. Edited by Jadavaji Trikamji Aacharya. 1st ed. Varanasi: Krishnadas Academy;2000.\n\n==Quoting online edition of Charak Samhita ==\n\nThe online chapters or web pages from the present edition can be quoted from '''cite this page''' link of side bar."
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            "3815": {
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                "title": "Rheumatic diseases",
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                        "*": "{{CiteButton}}\n{{#seo:\n|title=Rheumatic diseases\n|titlemode=append\n|keywords=carakasamhitaonline, charak samhita, caraka samhita, Ayurveda, Rheumatic diseases in Ayurveda, management of Rheumatic diseases, research on management of Rheumatic diseases, Indian system of medicine, alternative medicine, health, Rheumatism and rheumatology\n|description= Diagnosis and Management of Rheumatological diseases in Ayurveda\n|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg\n|image_alt=carak samhita\n|type=article\n}}\n{{Infobox\n|title =  Contributors\n\n|label1 = Section/Chapter/topic\n|data1 = [[Concepts and Contemporary Practices]] -[[Nidana]] [[Chikitsa]] / [[Vyadhi]] / Rheumatic diseases \n\n|label2 = Author\n|data2 = Ram Manohar P. <sup>1</sup>\n\n|label3 = Reviewer \n|data3 = [[Gopal Basisht|Basisht G.]]<sup>2</sup>\n\n|label4 = Editors\n|data4 = [[Yogesh Deole|Deole Y.S.]]<sup>3</sup>, Aneesh E. G.<sup>4</sup> \n\n|label5 = Affiliations\n|data5 = <sup>1</sup> Research Director, Amrita School of Ayurveda, Amritapuri, Kollam, Kerala, India.\n\n<sup>2</sup>Rheumatologist, Orlando, Florida, U.S.A.\n  \n<sup>3</sup> Executive Editor and Professor in Kayachikitsa, G.J.Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India \n\n<sup>4</sup>[[Charak Samhita Research, Training and Development Centre]], I.T.R.A., Jamnagar, India\n\n|label6 = Correspondence emails\n|data6 = rammanoharp@gmail.com, \ncarakasamhita@gmail.com\n\n|label7 = Publisher \n|data7 = [[Charak Samhita Research, Training and Development Centre]], I.T.R.A., Jamnagar, India\n\n|label8 = Date of first publication:\n|data8 = January 24, 2022\n\n|label9 = DOI\n|data9 = 10.47468/CSNE.2022.e01.s09.084\n}}\n<p style=\"text-align:justify;\">This article is based on a lecture delivered by Vd. P. Ram Manohar, Research Director, Amrita School of Ayurveda, Amritapuri, Kollam, Kerala, India. in Prof. M. S. Baghel Memorial Lecture Series on November 09, 2021.</p>\n\n==Rheumatism & Rheumatology==\n\nDiseases that affect the muscles, bones, joints, ligaments, and tendons resulting in pain, swelling, stiffness, and potentially causing joint deformities are called \u2018rheumatic disorders\u2019. The study of such associated conditions is called \u2018rheumatology\u2019. Rheumatologists treat a group of diseases called \u201csystemic autoimmune diseases\u201d, otherwise termed as \u201ccollagen vascular diseases\u201d or \u201cconnective tissue diseases\u201d. This is a group of diseases where a person\u2019s immune system attacks his body systems. This ends up causing inflammation, pain, swelling, and organ damage. These may affect the eyes, skin, nerves, kidneys, lungs, heart, and other internal organs. Rheumatoid arthritis, systemic lupus erythematosus, Sjogren\u2019s disease, scleroderma, polymyositis, and vasculitis, etc. are some examples. \n\nThe term rheumatism includes a variety of disorders marked by inflammation, degeneration, or metabolic derangement of connective tissue structures (especially joints and related structures). The clinical features include pain, stiffness, or limitation of movement. It includes such disorders as arthritis, osteoarthritis, bursitis, and sciatica. \n\n==Ayurvedic perspective==\n \nInvolvement of three [[dosha]] and middle pathways of the manifestation of diseases (madhyama rogamarga) can be inferred. Inflammation, degeneration, and metabolic derangement represent tridosha. Involvement of joints and connective tissue represents the middle pathway of manifestation of diseases (madhyama rogamarga).\n\nThe Ayurvedic concept of \u2018joint\u2019 \u2013 termed as \u2018sandhi\u2019 represents not only bony joints but all connective tissues and collagen vascular disorders. [A. Hr. Sutra Sthana 12/47]<ref name= Hridaya > Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.</ref> The connective tissues in the body are all affected by inflammatory, degenerative, or metabolic pathologies. It shows derangement of [[dosha]] in various permutations and combinations. The simultaneous involvement of multiple structures in the disease pathogenesis makes the disease difficult to treat. [A. Hr. Sutra Sthana 13/21]<ref name=Hridaya/> Even in conditions like rheumatoid arthritis (vatarakta) vascular involvement is also very clearly indicated. [A. Hr. Nidana Sthana 16/18]<ref name=Hridaya/>\n\n===Role of [[ama]]===\n\n\u2018[[Ama]]\u2019 is a key concept in the Ayurvedic understanding of physiology, pathology, and therapeutics. Rather than being a single entity or substance, [[ama]] denotes the deranged process of digestion and metabolism. It leads to metabolic byproducts in the body, which cannot be neutralized or eliminated by the body. It can be considered as a state of a substance in which it is not undergoing any further transformation, either digestion or metabolism. In [[Ayurveda]], [[ama]] has been defined from three viewpoints. On a closer examination, it can be understood that these three viewpoints represent [[ama]] in its totality. They are as below:\n \n#[[Ama]] is the byproduct of impaired digestion. \n#[[Ama]] is the accumulation of unexpelled wastes in the body. \n#[[Ama]] is the first expression of aberrations in the physiological process in the body.[Madukosha-M.Ni. 25/1-5]<ref name=MNi> Madhavakara. Madhava Nidanam (Roga vinischaya). Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007</ref>\n[[Ama]] formation may be due to inflammatory, metabolic as well as infective pathologies. [[Ama]] in a particular character triggers autoimmune disorders.\n\n====Classification of [[ama]]====\n'''I. Based on the quality:'''\n#Dormant [[ama]] in tissue (leena): This causes silent and chronic diseases like cardio vascular diseases, cancer etc.  \n#Sudden manifestation of symptoms followed by dormant state (leena \u2013 aleena): Episodic illness like bronchial asthma, rheumatoid arthritis etc. Sudden flare-ups and remissions are the characteristic features of this condition.\n#Static or immobile state, [[ama]] cannot be removed from body in this state (achala)\n#Freely moveable state, [[ama]] can be removed easily from the body (chala)\n\n[[Ama]] when becomes deep seated (leena) in the tissue ([[dhatu]]) it triggers auto immune disorders, because body is not able to distinguish between [[ama]] and the tissue ([[dhatu]]).\n\n'''II. Based on quantity:'''\n#Less quantity (alpa)\n#Medium quantity (madhya) \n#Large quantity (bahu)\n\n'''III. Based on location:'''\n#The alimentary canal (koshtha)\n#Peripheral tissues (shakha)\n#Vital points ([[marma]])\n\n'''IV. Based on state of [[dosha]]:'''\n#Undigested (ama)\n#Partially digested (vidagdha)\n#Occluded (vishtabdha)\n\nThe pathology changes based on the type of [[ama]]. If there is infective pathology, it is mostly due to an undigested state. Inflammatory pathologies are due to a partially digested state. [A. Hr. Nidana Sthana 16/1]<ref name=Hridaya/> The occluded state leads to a degenerative type of pathology. For the treatment, separation of [[ama]] from tissue ([[dhatu]]) is very much essential, otherwise, it will cause complications. [A. Hr. Sutra Sthana 13/28]<ref name=Hridaya/>\n\nThe treatment strategies change based on the location of [[ama]] and state of the [[dosha]].\n\n==Joint diseases in [[Ayurveda]]==\n \nA careful study of the classical Ayurvedic texts reveals that joint and connective tissue disorders can be broadly divided into three categories viz \u2018[[Amavata]]\u2019, \u2018Vatarakta\u2019 and \u2018Sandhivata\u2019. These disease entities are quite comprehensive as they represent the possible pathologies that can arise in the joints due to the derangement of [[kapha]], [[pitta]], and [[vata dosha]] respectively. There are other ailments of the joints to be considered like inflammatory swelling of the knee joint (kroshtukashirsha). An accurate fixed modern correlation is not at all possible in any of these conditions. \u2018[[Amavata]]\u2019 is correlated to rheumatoid arthritis, but the concept is much broader than that. It includes many other conditions like rheumatic fever, ankylosing spondylitis etc. In ankylosing spondylitis, when there is axial spondyloarthropathy the symptoms resemble [[amavata]].[M.Ni. Amavatanidana/5] <ref name=MNi/> There will be stiffness in the entire spine. It\u2019s an assortment of conditions put together because it mainly affects musculoskeletal diseases or due to the involvement of autoimmune pathologies. Rather than a fixed correlation, it is always beneficial to keep a separate diagnosis system. A diagnosis in conventional medical system is based on the available criteria. Parallelly, Ayurvedic diagnosis of the same condition can be done based on classical clinical features.\n\n===[[Amavata]]===\n\nThis condition is predominantly seen in younger age where [[ama]] vitiation is happening very quickly. The body is in [[kapha]] dominant stage at this time.\n \nIt is caused by incompatible (virudha) foods. The signs of accumulation of [[ama]] are seen in the premonitory stage. The [[ama]] is accumulated in the bigger and smaller joints. The onset is sudden. It initially affects the big joints and later all joints in the body.\n\n===Vatarakta===\n\nVatarakta is usually seen in middle age. [[Pitta dosha]] dominance is observed in this age. It manifests due to vitiation of blood ([[rakta dhatu]]) and [[vata dosha]] at the same time. It affects not only the joints but also the skin and blood vessels. Typically the disease starts with the symmetrical involvement of smaller joints of both  hands and feet. [Cha.Sa.[[Chikitsa Sthana]] 29/12] [A. Hr. Nidana Sthana 16/7]<ref name=Hridaya/> Symmetrical arthritis is also a typical feature of rheumatoid arthritis described in conventional medicine. \n\nIn later stage, it spreads all over and systemic involvement is seen. [A. Hr. [[Nidana Sthana]] 16/7]<ref name=Hridaya/> In advanced stages, severe deformity of the joints is seen. When the skin is involved, it shows cutaneous manifestations. When blood vessels are involved, it can cause damage to the blood vessels, extreme pain, and even death.\n  \nIt is caused by incompatible foods (viruddha) and foods that cause burning sensation (vidahi). Its progression is slow. In the premonitory stage, relapse and exacerbations is present. This disease evolves in two phases.\n \nA.\tSuperficial (uttana): It involves skin and connective tissues.\n\nB.\tDeep (gambhira): It involves joints and other deeper structures.  \n\nEventhough it involves blood and [[vata dosha]] vitiation, it also involves [[ama]] as a key pathogenic factor. In the beginning, the treatment should focus on [[kapha]]-[[vata]] dominance. Vitiation of blood shall be addressed to prevent complications. \n\n====Classification====\n \nVatarakta is classified into 75 subtypes. There are 35 types of [[vata]] predominant vatarakta, 30 types of [[pitta]] predominance, and 10 types of [[kapha]] predominat vatarakta. [Chakrapani on Cha.Sa.[[Chikitsa Sthana]] 29/24-29] But in today\u2019s clinical practice, these sub-classifications are less focused. These subtypes might be 75 different stages of a single disease. Such stage-wise identification and its related treatments should be focused into clinical practice.\n\nSome [[Ayurveda]] scholars correlate malignant conditions with vatarakta. Prolonged chronic inflammation is said to be the leading causative factor for malignancy. Thus it is logical that methotrexate, which is previously used for cancer management has become the mainstream drug for the treatment of rheumatoid arthritis. \n\n====Treatment principles====\n \nVatarakta is said to be a condition where the body is in a state of anger against its systems. [A. Hr. Chikitsa Sthana 22/18]<ref name=Hridaya/>     It is suggestive of autoimmune disorder. Just like anger cannot be appeased suddenly, the treatment of vatarakta also requires patience and an abundant amount of time. The flare-ups are unpredictable. After removing the [[ama]] and the body is purified the treatment should be continued for a long period to prevent a recurrence. This principle of treatment is very relevant in autoimmune diseases.\n\n===Sandhivata===\n\nSandhivata is a degenerative disease of the joints. It is caused by food which causes obstruction (vishtambhi). Usually, it is a gradually progressing disease primarily caused by wear and tear. Sudden onset due to injuries is also observed in some cases.\n \nPain associated with movement is the typical feature of this condition. Swelling of the affected joint is present. On palpation, the joint feels as if filled with air. It may affect any joint.\n\nOsteoarthritis is prevalent in old-aged persons. [[Vata dosha]] dominance is seen in this age group. In sandhivata, the main focus is on [[Vata dosha]]. It is usually correlated to osteoarthritis. Apart from this, other degenerative joint conditions like lumbar and cervical spondylitis also come under the umbrella of sandhivata.\n\n==Ayurvedic perspective of rheumatoid arthritis==\n\nIt is difficult to find an exact match for rheumatoid arthritis (RA) in the classical texts of [[Ayurveda]]. In the early texts of [[Ayurveda]] like Charak Samhita, the major disease described that affects the joints is \u2018Vatarakta\u2019. Vatarakta is described as an inflammatory disease affecting the joints. Some physicians correlate this condition with RA.  \u2018Sandhivata\u2019 is very briefly mentioned in Charak Samhita. In the later texts like Madhava Nidhana, the first description regarding \u2018[[Amavata]]\u2019 is found. It may not be a new disease, but the term is introduced to give more granularity in understanding different clinically important conditions. It might be a condition where vitiation of blood ([[rakta]]) is not predominant. This condition is correlated with RA by some physicians.\n\nBoth correlations might be true. One condition is emphasizing [[ama]] more and the other condition emphasizes blood ([[rakta dhatu]]). A clinical study also reveals that when vitiation of blood is present, [[amavata]] treatment is not enough.<ref name=Furst>Furst DE, Venkatraman MM, McGann M, Manohar PR, Booth-LaForce C, Sarin R, Sekar PG, Raveendran KG, Mahapatra A, Gopinath J, Kumar PR. Double-blind, randomized, controlled, pilot study comparing classic ayurvedic medicine, methotrexate, and their combination in rheumatoid arthritis. J Clin Rheumatol. 2011 Jun;17(4):185-92. doi: 10.1097/RHU.0b013e31821c0310. Erratum in: J Clin Rheumatol. 2011 Oct;27(7):407. PMID: 21617554.</ref> Therefore, personified treatment principles in [[Ayurveda]] include management of both [[ama]] as well as [[rakta dhatu]].\n\n{| class=\"wikitable\"\n|+ Table 1: Comparison of onset and clinical features of rheumatoid arthritis, [[amavata]] and vatarakta\n|-\n! Rheumatoid Arthritis !! [[Amavata]] !! Vatarakta\n|-\n| | Slow onset in most cases || Slow onset, not specified as a characteristic feature || Slow onset and progress is a typical characteristic similar to the spread of rat\u2019s poison\n|-\n| | First affects fingers and toes of hand and feet || First affects the trika sandhi, which may be the joints in the lumbosacral region or the cervical region  || Specifically mentioned that joints of hands and feet are affected first, especially fingers and toes \n|-\n| | In some cases, general symptoms manifest before joints are affected || Typically, general symptoms manifest before joints are affected || Cutaneous manifestations may be seen in the prodromal stage. Typically starts with joint afflictions\n|-\n| | Typically, joints are affected in a symmetrical fashion || Symmetrical involvement of joints not specified || Joints of both limbs affected at the same time\n|-\n| | Morning stiffness of joints is a key symptom || Stiffness of the whole body is a characteristic sign, morning stiffness is not specified. It is also not specified whether the stiffness affects the joints  || Stiffness is one of the signs. Morning stiffness not specified. \n|-\n| | In the initial stages, there are remissions and flare ups || Remissions and flare-ups are not characteristic signs || Remissions and flare-ups are characteristic signs. \n|-\t \t\n|}\n\nIt is difficult to make a one-to-one correlation. More research works are required to establish specific correlations.\n\n==Treatment==\n[[File: Treatment_algoritam_for_vatarakta.JPG|500px|'''Image 1: Treatment algorithm for vatarakta'''|thumb]]\n[[File: Treatment_algoritam_for_rhematological_diseases.JPG|500px|'''Image 2: Treatment algorithm for rheumatological diseases'''|thumb]]\nThe treatment depends on multiple factors. Rather than using a single medicine, a treatment algorithm is required for each disease. Especially in the case of chronic autoimmune diseases like rheumatoid arthritis, the approach should be to pacify the immune system. The basic causes that triggered immune response shall be found out and treated accordingly. It is a slow and stage-wise process. The various stages of [[ama]], [[dosha]], [[dhatu]] shall be considered. [[Ayurveda]] offers a treatment algorithm based on all these as below Image 1 and 2: \n\nImmediate purificatory treatments are not advised. [A. Hr. Sutra Sthana 13/21]<ref name=Hridaya/> It needs long-term treatment. Bringing the [[dosha]] back from the middle pathway (madhyama rogamarga) and the skin and six [[dhatus]] (shakha) to the gastrointestinal tract (koshtha) is the primary objective. This requires repeated medications for kindling ([[deepana]]) and promoting digestion ([[pachana]]). [A. Hr. Sutra Sthana 13/29]<ref name=Hridaya/> The treatment is decided on the structures involved in the pathogenesis.\n\n===Clinical perspective of pathogenesis===\n \nThe Ayurvedic understanding of pathologies is different from conventional medical science. Pathogenesis of cervical spondylosis occurring in a person sitting continuously in an AC room and that in a person who is working on fields directly under the sun or by riding two -wheelers must be treated in different ways. Because the first condition is caused by the predominance of cold (shita) and dry (ruksha) properties and later is caused by hot (ushna) and dry (ruksha) properties. Even though the radiological investigations may appear similar in both conditions, but Ayurvedic treatment approach will be different. Some patients may get relief by using Karpasastyadi taila and some others with Pinda taila. \n\n===Clinical study on the comparative efficacy of [[Ayurveda]] and conventional treatments=== \n\nIn a study, preliminary testing of Ayurvedic treatment algorithm has been done. In this study, it is found out that if an Ayurvedic approach to diagnosis is followed in parallel to modern medicine diagnosis effective Ayurvedic treatment can be done without compromising scientific design. The study involved three groups. One group received methotrexate and Ayurvedic placebo, other group received Ayurvedic treatments and methotrexate placebo. The third group received Ayurvedic treatment and methotrexate. Placebos for Ayurvedic dosage forms are introduced in this study. American College of Rheumatology (ACR) criteria was applied for the assessment of clinical efficacy in all groups. It was found that at 6 months, the Ayurveda group showed maxium respondents with 20% improvement as per ACR criteria. After 9 months, the Ayurveda group showed maximum respondents with 70% improvement in ACR criteria, outnumbering the respondents in the allopathic group. Long-term persistant kindling ([[deepana]]) and digestive ([[pachana]]) therapy, with focus on middle pathway of manifestation of diseases (madhyama rogamarga), slowly bringing the [[ama]] was having a larger benefit. This study is recommended as a blueprint for future studies on complementary and alternative medicine. This paper also received the Excellence in Integrative medicine research award in 2012.<ref name=Furst/>\n\n===Management based on underlying pathologies===\n \n[[Amavata]] may express in two conditions, with involvement of blood and without its involvement. If the patient has vitiation of blood (rakta dushti), classical [[amavata]] treatment further vitiates the blood, and worsens the condition. This is because the property of medicines used is hot (ushna) and dry (ruksha) which disturbs blood. If vitiation of blood is present the treatment must include blood soothing (rakta prasadana) and [[ama]]-reducing drugs. Due to this property, Tinospora cordifolia ([[guduchi]]) becomes the most important drug in its treatment. It is one of the rare herb which reduces [[vata]] and [[kapha]] and soothes blood (rakta prasadana) simultaneously. So it can be used in all stages. But Zingiber officinale (sunti) and Pluchea lanceolata (rasna) is used in [[ama]] predominant condition only. If the predominance of blood is more, oils like Yashtimadhu taila, Balaguduchyadi taila etc are used. In a study, it is found that treatment given according to the combined [[ama]] and blood ([[rakta]]) concept yields better results. The 70% improvement is recorded which is equivalent to methotrexate. In the study, some  patients had given only Amrutotaram kashaya which is more for [[ama]]. The other patients were given Balaguduchyadi kashaya, Kokilakshaka kashaya etc. focusing more on blood vitiation (rakta dushti).<ref name=Furst/>\n\n==Conclusion==\n\nRegarding the diagnosis of these rheumatological conditions, modern science diagnosis is also complex and based on assessment of multiple parameters. Specific conditions have been pinpointed by modern medicine through biological or molecular mechanisms. However, from the Ayurvedic perspective, involvement of middle pathway of diseases (madhyama rogamarga), [[ama]] and its classification, and the three broad pathologies viz [[amavata]], vatarakta and sandhivata accommodate all these pathologies.\n  \nCorrelating Ayurvedic disease with a biomedical condition or biomedical disease with an Ayurvedic condition won\u2019t yield desired results because both these approaches have limitations. It is better to diagnose the disease condition separately in each system and later can search for any natural correlations on case to case basis. The retrospective classification may yield more relevant correlations. Disease descriptions in classical Ayurvedic texts reveal that each disease entity described represents a cluster of diseases that stem from a common underlying pathology. Biomedical disease descriptions represent very specific pathological manifestations. From this point of view, a particular disease described in [[Ayurveda]] would correlate with a cluster of diseases in biomedicine. So instead of fixing one-to-one correlation, if we look at stages of disease and [[dosha]]s and treat accordingly the results will be better. In [[Amavata]] more attention should be given to [[kapha dosha]], in vatarakta more attention should be given to [[pitta dosha]], and in sandhivata to [[vata dosha]].\n\n==Related Chapters==\n\n[[Vatarakta Chikitsa]], [[Amavata]]\n\n<div style='text-align:justify;'>\n<big>'''[[Special:ContactMe|Send us your suggestions and feedback on this page.]]'''</big> \n==References==\n<div id=\"BackToTop\"  class=\"noprint\" style=\"background-color:#DDEFDD; position:fixed;\n bottom:32px; left:2%; z-index:9999; padding:0; margin:0;\"><span style=\"color:blue;\n font-size:8pt; font-face:verdana,sans-serif;  border:0.2em outset #ceebf7;\n padding:0.1em; font-weight:bolder; -moz-border-radius:8px; \">\n[[#top| Back to the Top ]]</span></div>"
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