Changes

== Vidhi Vimarsha (Applied Inferences ) ==  

== Vidhi Vimarsha (Applied Inferences ) ==  

''Vatarakta'' is a group of inflammatory rheumatic diseases. Pathogenesis of these ailments is related to aggravation of v''ata dosha'' due to vitiation of ''rakta dhatu''. The primary sites of involvement are small joints of hands and feet.     

Vatarakta is a group of inflammatory rheumatic diseases. Pathogenesis of these ailments is related to aggravation of [[vata dosha]] due to vitiation of [[rakta dhatu]]. The primary sites of involvement are small joints of hands and feet.     

=== Etiological factors ===

=== Etiological factors ===

==== Diet ====

==== Diet ====

Excess intake of salty, sour and pungent foods with spices and deep fried in oil are observed to cause the disease. The soft drinks with alkalis, excess consumption of fatty substances, alcohol, aquatic animals, dried flesh are known to vitiate ''rakta''. A study carried on 178 participants revealed that excess intake of ''amlarasa'' could be a risk factor for joint inflammation, dentine hypersensitivity, stomatitis, halitosis, heartburn and papules.<ref>Panara KB, Acharya R. Consequences of excessive use of Amlarasa (sour taste): A case-control study. AYU [serial online] 2014 [cited 2018 Aug 15];35:124-8.Sourced from: http://www.ayujournal.org/text.asp?2014/35/2/124/146204</ref> Consumption of astringent, pungent, bitter, ''ruksha'' food items (grains of low nutritional values and those with dry property) vitiate ''vata dosha''. Consumption of ''tikshna''<ref name= "multiple1">Sushruta. Nidana Sthana, Cha.1 Vatavyadhi Adhyaya verse 42. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.</ref>  (sharply acting) and ''vidahi'' (which causes burning) are other factors responsible for vitiating ''rakta''.<ref name = "multiple2">Vagbhata. Nidana Sthana, Cha.16 Vatavyadhi Nidana Adhyaya verse 1. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.page no:535</ref>     

Excess intake of salty, sour and pungent foods with spices and deep fried in oil are observed to cause the disease. The soft drinks with alkalis, excess consumption of fatty substances, alcohol, aquatic animals, dried flesh are known to vitiate [[rakta]]. A study carried on 178 participants revealed that excess intake of ''amlarasa'' could be a risk factor for joint inflammation, dentine hypersensitivity, stomatitis, halitosis, heartburn and papules.<ref>Panara KB, Acharya R. Consequences of excessive use of Amlarasa (sour taste): A case-control study. AYU [serial online] 2014 [cited 2018 Aug 15];35:124-8.Sourced from: http://www.ayujournal.org/text.asp?2014/35/2/124/146204</ref> Consumption of astringent, pungent, bitter, ''ruksha'' food items (grains of low nutritional values and those with dry property) vitiate [[vata dosha]]. Consumption of ''tikshna''<ref name= "multiple1">Sushruta. Nidana Sthana, Cha.1 Vatavyadhi Adhyaya verse 42. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.</ref>  (sharply acting) and ''vidahi'' (which causes burning) are other factors responsible for vitiating [[rakta]].<ref name = "multiple2">Vagbhata. Nidana Sthana, Cha.16 Vatavyadhi Nidana Adhyaya verse 1. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.page no:535</ref>     

The dietary habits like intake of food during indigestion (''ajirna''), incompatible food (''viruddhahara''), eating food before proper digestion of previous meal (''adhyashana'') are causes of vitiation of ''vata'' due to improper digestion and metabolism.

The dietary habits like intake of food during indigestion (''ajirna''), incompatible food (''viruddhahara''), eating food before proper digestion of previous meal (''adhyashana'') are causes of vitiation of [[vata]] due to improper digestion and metabolism.

==== Psychological factors ====

==== Psychological factors ====

Anger is known to vitiate ''pitta'' and secondarily ''rakta''.

Anger is known to vitiate [[pitta]] and secondarily [[rakta]].

==== Lifestyle habits ====

==== Lifestyle habits ====

Sleeping in daytime and vigil during the night; injuries, not purifying the body (by ''shodhana karma''); starvation, excess traveling, sporting in water, jumping, leaping, excessive walking in hot season, excessive sexual intercourse and suppression of natural urges are responsible for vitiation of ''vata''.  

Sleeping in daytime and vigil during the night; injuries, not purifying the body (by ''shodhana karma''); starvation, excess traveling, sporting in water, jumping, leaping, excessive walking in hot season, excessive sexual intercourse and suppression of natural urges are responsible for vitiation of [[vata]].  

In general, the delicate persons who are indulged in sweet and rich food substances and are not in habit of physical activities, the ''vata'' and ''rakta'' are vitiated. Those who have sedentary lifestyles with least walking are most prone to ''vatarakta''. <ref name = "multiple1" />,<ref name = "multiple2" />,<ref name = "multiple3">Madhavakara Vata rakta Nidana. In:Brahmananda Tripathi ,editor,Madhava Nidana. Volume I,?ed,Varanasi:Chaukhambha Sanskrit Pratishthana.2002. Pg.556-563  </ref>

In general, the delicate persons who are indulged in sweet and rich food substances and are not in habit of physical activities, the [[vata]] and [[rakta]] are vitiated. Those who have sedentary lifestyles with least walking are most prone to ''vatarakta''. <ref name = "multiple1" />,<ref name = "multiple2" />,<ref name = "multiple3">Madhavakara Vata rakta Nidana. In:Brahmananda Tripathi ,editor,Madhava Nidana. Volume I,?ed,Varanasi:Chaukhambha Sanskrit Pratishthana.2002. Pg.556-563  </ref>

   

   

The above factors can cause vitiation of blood by aggravation of its ''tikshna'' (sharply acting) property and vitiation of ''vata dosha'' by aggravation of its ''ruksha'' (dry) property. The properties like ''sukshma'' (minuteness) and ''sara'' (moving) of both ''vata'' and ''rakta'' are affected to cause the disease process. ''Drava'' (fluidity) of ''rakta'' is affected leading to obstruction in free movement of ''vata''.

The above factors can cause vitiation of blood by aggravation of its ''tikshna'' (sharply acting) property and vitiation of [[vata dosha]] by aggravation of its ''ruksha'' (dry) property. The properties like ''sukshma'' (minuteness) and ''sara'' (moving) of both [[vata]] and [[rakta]] are affected to cause the disease process. ''Drava'' (fluidity) of [[rakta]] is affected leading to obstruction in free movement of [[vata]].

=== Pathogenesis ===

=== Pathogenesis ===

The pathogenesis involves aggravation by ''avarana''(obstruction) of movement of ''vata'' by the vitiated ''rakta''. Therefore, the treatment is focused upon pacification of ''rakta'' to remove obstruction and pacification of ''vata''. The pathogenesis starts from small joints of lower extremities.<ref name = "multiple2" /> The onset of disease is acute and the vitiation of ''rakta'' occurs quickly. <ref name = "multiple1" />

The pathogenesis involves aggravation by ''avarana''(obstruction) of movement of [[vata]] by the vitiated [[rakta]]. Therefore, the treatment is focused upon pacification of [[rakta]] to remove obstruction and pacification of [[vata]]. The pathogenesis starts from small joints of lower extremities.<ref name = "multiple2" /> The onset of disease is acute and the vitiation of [[rakta]] occurs quickly. <ref name = "multiple1" />

=== Clinical features ===

=== Clinical features ===

#In case of involvement of deeper tissues, swelling, hardness of affected site, discoloration, suppuration, pulsating, pricking or burning sensation can occur.  

#In case of involvement of deeper tissues, swelling, hardness of affected site, discoloration, suppuration, pulsating, pricking or burning sensation can occur.  

Above features are observed at sites of joints, ligaments and blood vessels as per the ''dosha'' dominance in ''vatarakta''.  

Above features are observed at sites of joints, ligaments and blood vessels as per the [[dosha]] dominance in ''vatarakta''.  

==== Types ====

==== Types ====

''Uttana vatarakta'' involves ''twacha'' (skin) and ''mamsa'' (muscular tissue). ''Gambhira vatarakta'' involves all other tissues. The ''uttana vatarakta'' progresses to ''gambhira vatarakta'' in due course of time.<ref name ="multiple1" />,<ref name ="multiple2" />

''Uttana vatarakta'' involves ''twacha'' (skin) and [[mamsa dhatu]] (muscular tissue). ''Gambhira vatarakta'' involves all other tissues. The ''uttana vatarakta'' progresses to ''gambhira vatarakta'' in due course of time.<ref name ="multiple1" />,<ref name ="multiple2" />

=== Differential diagnosis ===

=== Differential diagnosis ===

''Vatarakta, amavata'' and ''sandhigata vata'' are three most common rheumatological clinical conditions. The clinical presentations need to be differentiated for diagnosis and designing treatment protocol.  

Vatarakta, amavata and sandhigata vata are three most common rheumatological clinical conditions. The clinical presentations need to be differentiated for diagnosis and designing treatment protocol.  

{| class="wikitable"

{| class="wikitable"

! scope="col"| ''Sandhigata Vata''

! scope="col"| ''Sandhigata Vata''

|-

|-

| ''Dosha''

| [[Dosha]]

| ''Vata'' associated with ''pitta''

| [[Vata]] associated with [[pitta]]

| ''Vata'' associated with ama, mainly kapha

| [[Vata]] associated with ama, mainly kapha

| ''Vata'' associated with ''vata''

| [[Vata]] associated with [[vata]]

|-

|-

| ''Dushya''

| ''Dushya''

| ''Rakta'',''Twak'', ''Mamsa''

| [[Rakta dhatu]],Twak, [[Mamsa dhatu]]

| ''Rasa''

| [[Rasa dhatu]]

| ''Asthi'',''Majja''

| [[Asthi dhatu]],[[Majja dhatu]]

|-

|-

| Clinical Features

| Clinical Features

|-

|-

| Treatment

| Treatment

| ''Sneha, virechana, basti'' with drugs of mild property, ''raktamokshana''  

| Sneha, [[virechana]], [[basti]] with drugs of mild property, ''raktamokshana''  

| ''Langhana, basti'' with drugs of sharp acting property  

| [[Langhana]], [[basti]] with drugs of sharp acting property  

| ''Snehana, basti, brimhana''

| [[Snehana]], [[basti]], [[brimhana]]

|}

|}

Rheumatoid arthritis and gout are two most common rheumatological conditions.  

Rheumatoid arthritis and gout are two most common rheumatological conditions.  

Those patients with involvement of small joints of extremities resemble rheumatoid arthritis, on the other hand patients with mono-articular or oligo-articular arthritis and associated elevated uric acid resemble gout. There is a difference of opinion among Ayurvedic physicians, some call ''vatarakta'' as gout and others call rheumatoid arthritis. Some Ayurvedic physicians consider ''amavata'' as rheumatoid arthritis.  However, it can be observed that the patients diagnosed as rheumatoid arthritis show clinical features of vitiation of ''vata'' associated with ''kapha dosha''. Whereas, the patients diagnosed as gouty arthritis show clinical features of vitiation of ''vata'' associated with ''pitta dosha''. Therefore, the former case can be treated on the lines of ''vatarakta'' associated with ''kapha'', while the latter can be treated on principles of ''vatarakta'' associated with ''pitta''. On close observation it is noted that in ''amavata'' there is involvement of large joins of extremities and sacroiliac joints which is consistent with rheumatoid variant or ankylosing spondylitis. Ayurvedic management depends upon correction of imbalance of ''dosha, dushya'' and ''prakriti'' of the individual and can be viewed as working through epigenetic pathway. On the other hand, modern medicine system works by antagonizing the pro-inflammatory proteins or acting through “genetic pathway”. It becomes clear that both systems achieve the objective using different ways. It can be compared to digging the tunnel from both sides. However, the direction of diagnosis and treatment needs to be clearly based upon clinical assessment of ''dosha'' dominance. The serological parameters can only be utilized for assessment of therapy.  

Those patients with involvement of small joints of extremities resemble rheumatoid arthritis, on the other hand patients with mono-articular or oligo-articular arthritis and associated elevated uric acid resemble gout. There is a difference of opinion among Ayurvedic physicians, some call ''vatarakta'' as gout and others call rheumatoid arthritis. Some Ayurvedic physicians consider ''amavata'' as rheumatoid arthritis.  However, it can be observed that the patients diagnosed as rheumatoid arthritis show clinical features of vitiation of [[vata]] associated with [[kapha dosha]]. Whereas, the patients diagnosed as gouty arthritis show clinical features of vitiation of [[vata]] associated with [[pitta dosha]]. Therefore, the former case can be treated on the lines of ''vatarakta'' associated with [[kapha]], while the latter can be treated on principles of ''vatarakta'' associated with [[pitta]]. On close observation it is noted that in ''amavata'' there is involvement of large joins of extremities and sacroiliac joints which is consistent with rheumatoid variant or ankylosing spondylitis. Ayurvedic management depends upon correction of imbalance of [[dosha]], dushya and [[Prakriti]] of the individual and can be viewed as working through epigenetic pathway. On the other hand, modern medicine system works by antagonizing the pro-inflammatory proteins or acting through “genetic pathway”. It becomes clear that both systems achieve the objective using different ways. It can be compared to digging the tunnel from both sides. However, the direction of diagnosis and treatment needs to be clearly based upon clinical assessment of [[dosha]] dominance. The serological parameters can only be utilized for assessment of therapy.  

    

    

The condition in which blood vessels, connective tissues and tendons are involved such as vasculitis along with thrombosis and embolism, thrombo-angiitis obliterans (Burger’s disease), Raynaud’s disease are also considered under the disease ''vatarakta''.  

The condition in which blood vessels, connective tissues and tendons are involved such as vasculitis along with thrombosis and embolism, thrombo-angiitis obliterans (Burger’s disease), Raynaud’s disease are also considered under the disease ''vatarakta''.  

=== Prognosis considering present developments in medicine ===

=== Prognosis considering present developments in medicine ===

The disease with involvement of single ''dosha'' and new (diagnosed within one year) is curable. The disease with involvement of more than one ''dosha'' and chronic (more than one year) is palliable with medicines and appropriate therapies.   

The disease with involvement of single [[dosha]] and new (diagnosed within one year) is curable. The disease with involvement of more than one [[dosha]] and chronic (more than one year) is palliable with medicines and appropriate therapies.   

=== Management of diseases (Treatment protocols) ===

=== Management of diseases (Treatment protocols) ===

==== Principles of management ====  

==== Principles of management ====  

#''Basti'' (therapeutic enema): ''Basti'' with herbs of ''ruksha'' (dry) property or ''mridu'' (mild) property are used to treat both ''uttana'' (superficial) and ''gambhira'' (deep) types of ''vatarakta''.  

#[[Basti]] (therapeutic enema): [[Basti]] with herbs of ''ruksha'' (dry) property or ''mridu'' (mild) property are used to treat both ''uttana'' (superficial) and ''gambhira'' (deep) types of ''vatarakta''.  

#''Raktamokshana'' (bloodletting):  Bloodletting is prescribed as per ''dosha'' dominance in ''vatarakta'' patients. This gives better results to remove obstruction and reduce vitiation of blood.   

#''Raktamokshana'' (bloodletting):  Bloodletting is prescribed as per [[dosha]] dominance in ''vatarakta'' patients. This gives better results to remove obstruction and reduce vitiation of blood.   

Main drugs:  

Main drugs:  

! scope="col"| Anupana

! scope="col"| Anupana

|-

|-

| ''Vataja''

| [[Vata]]ja

| ''Kaishora guggulu''

| ''Kaishora guggulu''

| 500-1000 mg

| 500-1000 mg

| ''Kokilaksha kwatha'' + ghee + honey

| ''Kokilaksha kwatha'' + ghee + honey

|-

|-

| ''Pittaja'' and ''Raktaja''

| [[Pitta]]ja and [[Rakta]]ja

| ''Mauktika kamduha''

| ''Mauktika kamduha''

| 60-250 mg

| 60-250 mg

| Milk and ''guduchi kwatha''

| Milk and ''guduchi kwatha''

|-

|-

| ''Kaphaja''

| [[Kapha]]ja

| ''Gud-Bhallataka-haritaki vati''

| ''Gud-Bhallataka-haritaki vati''

| 1-3 grams

| 1-3 grams

A research on ''vatarakta'' concluded that the notion of ''margavarana'' (obstruction in pathway) can be correlated to the pathology of atherosclerosis, and the state of ''uttana vatarakta'' to that of peripheral arterial disease. Identical therapeutic efficacy of ''kaishora guggulu'' and ''amrita guggulu'' was observed in thirty patients of ''uttana vatarakta''. <ref> Ramachandran AP, Prasad SM, Prasad U N, Jonah S. A comparative study of Kaishora Guggulu and Amrita Guggulu in the management of Utthana Vatarakta. AYU [serial online] 2010 [cited 2018 Aug 15];31:410-6. Available from: http://www.ayujournal.org/text.asp?2010/31/4/410/82027 </ref>  

A research on ''vatarakta'' concluded that the notion of ''margavarana'' (obstruction in pathway) can be correlated to the pathology of atherosclerosis, and the state of ''uttana vatarakta'' to that of peripheral arterial disease. Identical therapeutic efficacy of ''kaishora guggulu'' and ''amrita guggulu'' was observed in thirty patients of ''uttana vatarakta''. <ref> Ramachandran AP, Prasad SM, Prasad U N, Jonah S. A comparative study of Kaishora Guggulu and Amrita Guggulu in the management of Utthana Vatarakta. AYU [serial online] 2010 [cited 2018 Aug 15];31:410-6. Available from: http://www.ayujournal.org/text.asp?2010/31/4/410/82027 </ref>  

Another study was carried out to evaluate the antioxidant effect of five ''kashayams'' (''kwaths'' - decoctions) ''manjishtadi kashayam'' (MK), ''rasna erandadi kashayam'' (REK),  ''sahacharadhi kashayam'' (SK), ''maharasnadi'' (or ''rasna dwiguna bhagam'') ''kashayam'' (MRK) and ''dhanwantharam kashayam'' (DK) used in the management of diseases manifested due to vitiation of ''vata'' and ''vatarakta'' (mostly diseases of connective tissues, bones, joints and nervous system). It concluded that the total phenolic content and the antioxidant property of the products justify the protective and corrective effects produced by the products in ''vata'' and ''vatarakta'' disorders. The phenolic content is highest in MK, followed by DK. The phenolic content of MRK, SK and REK are comparable <ref> Sruthi CV, Sindhu A. A comparison of the antioxidant property of fi ve Ayurvedic formulations commonly used in the management of vata vyadhis. J [[Ayurveda]] Integr Med 2012;3:29-32.</ref>. This shows the formulations act by scavenging the free radicals in rheumatic diseases.

Another study was carried out to evaluate the antioxidant effect of five ''kashayams'' (''kwaths'' - decoctions) ''manjishtadi kashayam'' (MK), ''rasna erandadi kashayam'' (REK),  ''sahacharadhi kashayam'' (SK), ''maharasnadi'' (or ''rasna dwiguna bhagam'') ''kashayam'' (MRK) and ''dhanwantharam kashayam'' (DK) used in the management of diseases manifested due to vitiation of [[vata]] and ''vatarakta'' (mostly diseases of connective tissues, bones, joints and nervous system). It concluded that the total phenolic content and the antioxidant property of the products justify the protective and corrective effects produced by the products in [[vata]] and ''vatarakta'' disorders. The phenolic content is highest in MK, followed by DK. The phenolic content of MRK, SK and REK are comparable <ref> Sruthi CV, Sindhu A. A comparison of the antioxidant property of fi ve Ayurvedic formulations commonly used in the management of vata vyadhis. J Ayurveda Integr Med 2012;3:29-32.</ref>. This shows the formulations act by scavenging the free radicals in rheumatic diseases.

=== Potential areas /scope for further research ===

=== Potential areas /scope for further research ===

Study to evaluate the efficacy of ''basti'' and bloodletting therapies in the management of ''vatarakta'' is needed. Further studies to evaluate the effect of Ayurvedic formulations in management of ''vatarakta'' are needed.

Study to evaluate the efficacy of [[basti]] and bloodletting therapies in the management of ''vatarakta'' is needed. Further studies to evaluate the effect of Ayurvedic formulations in management of ''vatarakta'' are needed.

 

== References ==

== References ==