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Line 22: − − ==[[Chikitsa Sthana]] Chapter 27, Chapter on the Management of Urustambha (Disorders of thigh and hip)== − − === Abstract === − − The chapter deals with the management of ''urustambha'' which literally means stiffness of thighs. Patients present with pain and inability to move pelvis and lower extremities. This is the only disease in which [[Panchakarma]] are contraindicated. It can be misdiagnosed as ''vata'' dominant disorder due to its clinical presentation, however, ''kapha'' and ''meda'' are main culprits in the pathogenesis. Etiological factors, pathogenesis, clinical presentation, prognosis and treatment of ''urustambha'' are described in this chapter. − − '''Keywords''': ''Viruddha, ama-visha, tridosha dushti, Saama-tridosha, Asthigata kapha, medahkaphaavrita-vata, Sneha-Shaitya-Sthairya'' in ''Uru, Rukshana, Kapha-meda-vaatahara'' treatment. Line 53:
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<big>'''[[Chikitsa Sthana]] Chapter 27. Management of Urustambha (Disorders of thigh and hip) </big>'''
<big>'''Abstract </big>'''
The chapter deals with the management of ''urustambha'' which literally means stiffness of thighs. Patients present with pain and inability to move pelvis and lower extremities. This is the only disease in which [[Panchakarma]] are contraindicated. It can be misdiagnosed as ''vata'' dominant disorder due to its clinical presentation, however, ''kapha'' and ''meda'' are main culprits in the pathogenesis. Etiological factors, pathogenesis, clinical presentation, prognosis and treatment of ''urustambha'' are described in this chapter.
'''Keywords''': ''Viruddha, ama-visha, tridosha dushti, Saama-tridosha, Asthigata kapha, medahkaphaavrita-vata, Sneha-Shaitya-Sthairya'' in ''Uru, Rukshana, Kapha-meda-vaatahara'' treatment.
{{Infobox
{{Infobox
|title = Urusthambha Chikitsa
|title = Urusthambha Chikitsa
}}
}}
=== Introduction ===
=== Introduction ===
श्रिया परमया ब्राह्मया परया च तपःश्रिया |
श्रिया परमया ब्राह्मया परया च तपःश्रिया |
अहीनं चन्द्रसूर्याभ्यां सुमेरुमिव पर्वतम् ||३||
अहीनं चन्द्रसूर्याभ्यां सुमेरुमिव पर्वतम् ||३||
धीधृतिस्मृतिविज्ञानज्ञानकीर्तिक्षमालयम् |
धीधृतिस्मृतिविज्ञानज्ञानकीर्तिक्षमालयम् |
अग्निवेशो गुरुं काले संशयं परिपृष्टवान् ||४||
अग्निवेशो गुरुं काले संशयं परिपृष्टवान् ||४||
भगवन् पञ्च कर्माणि समस्तानि पृथक् तथा |
भगवन् पञ्च कर्माणि समस्तानि पृथक् तथा |
निर्दिष्टान्यामयनां हि सर्वेषामेव भेषजम् ||५||
निर्दिष्टान्यामयनां हि सर्वेषामेव भेषजम् ||५||
दोषजोऽस्त्यामयः कश्चिद्यस्य तानि भिषग्वर! |
दोषजोऽस्त्यामयः कश्चिद्यस्य तानि भिषग्वर! |
न स्युः शक्तानि शमने साध्यस्य क्रियया सतः ||६||
न स्युः शक्तानि शमने साध्यस्य क्रियया सतः ||६||
shriyA paramayA brAhmayA parayA ca tapaHshriyA |
shriyA paramayA brAhmayA parayA ca tapaHshriyA |
ahInaM candrasUryAbhyAM sumerumiva parvatam ||3||
ahInaM candrasUryAbhyAM sumerumiva parvatam ||3||
dhIdhRutismRutivij~jAnaj~jAnakIrtikShamAlayam |
dhIdhRutismRutivij~jAnaj~jAnakIrtikShamAlayam |
agnivesho guruM kAle saMshayaM paripRuShTavAn ||4||
agnivesho guruM kAle saMshayaM paripRuShTavAn ||4||
bhagavan pa~jca karmANi samastAni pRuthak tathA |
bhagavan pa~jca karmANi samastAni pRuthak tathA |
nirdiShTAnyAmayanAM hi sarveShAmeva bheShajam ||5||
nirdiShTAnyAmayanAM hi sarveShAmeva bheShajam ||5||
doShajo~astyAmayaH kashcidyasya tAni bhiShagvara! |
doShajo~astyAmayaH kashcidyasya tAni bhiShagvara! |
na syuH shaktAni shamane sAdhyasya kriyayA sataH ||6||
na syuH shaktAni shamane sAdhyasya kriyayA sataH ||6||
śriyā paramayā brāhmayā parayā ca tapaḥśriyā|
śriyā paramayā brāhmayā parayā ca tapaḥśriyā|
ahīnaṁ candrasūryābhyāṁ sumērumiva parvatam||3||
ahīnaṁ candrasūryābhyāṁ sumērumiva parvatam||3||
dhīdhr̥tismr̥tivijñānajñānakīrtikṣamālayam|
dhīdhr̥tismr̥tivijñānajñānakīrtikṣamālayam|
agnivēśō guruṁ kālē saṁśayaṁ paripr̥ṣṭavān||4||
agnivēśō guruṁ kālē saṁśayaṁ paripr̥ṣṭavān||4||
bhagavan pañca karmāṇi samastāni pr̥thak tathā|
bhagavan pañca karmāṇi samastāni pr̥thak tathā|
nirdiṣṭānyāmayanāṁ hi sarvēṣāmēva bhēṣajam||5||
nirdiṣṭānyāmayanāṁ hi sarvēṣāmēva bhēṣajam||5||
dōṣajō'styāmayaḥ kaścidyasya tāni bhiṣagvara!|
dōṣajō'styāmayaḥ kaścidyasya tāni bhiṣagvara!|
na syuḥ śaktāni śamanē sādhyasya kriyayā sataḥ||6||
na syuḥ śaktāni śamanē sādhyasya kriyayā sataḥ||6||
“Oh Lord, all the five therapies ([[Panchakarma]]) are explained together as well as separately as therapeutic measure for all the diseases. Is there any curable disease caused by ''doshas'' for the cure of which these five therapies are contraindicated?” [3-6]
“Oh Lord, all the five therapies ([[Panchakarma]]) are explained together as well as separately as therapeutic measure for all the diseases. Is there any curable disease caused by ''doshas'' for the cure of which these five therapies are contraindicated?” [3-6]
==== Atreya’s answer ====
==== Atreya’s reply ====
अस्त्यूरुस्तम्भ इत्युक्ते गुरुणा तस्य कारणम् |
अस्त्यूरुस्तम्भ इत्युक्ते गुरुणा तस्य कारणम् |
सलिङ्गभेषजं भूयः पृष्टस्तेनाब्रवीद्गुरुः ||७||
सलिङ्गभेषजं भूयः पृष्टस्तेनाब्रवीद्गुरुः ||७||
astyūrustambha ityuktē guruṇā tasya kāraṇam|
astyūrustambha ityuktē guruṇā tasya kāraṇam|
saliṅgabhēṣajaṁ bhūyaḥ pr̥ṣṭastēnābravīdguruḥ||7||
saliṅgabhēṣajaṁ bhūyaḥ pr̥ṣṭastēnābravīdguruḥ||7||
Thus ends the chapter on management of ''urustambha'' written by Agnivesha, redacted by Charaka and completed by Dridhabala.
Thus ends the chapter on management of ''urustambha'' written by Agnivesha, redacted by Charaka and completed by Dridhabala.
=== ''Tattva Vimarsha'' ===
=== ''Tattva Vimarsha'' / Fundamental Principles===
*''Urustambha'' occurs due to consumption of diet and lifestyle having mutual contradictory properties like hot and cold, unctuous and dry etc.
*''Urustambha'' occurs due to consumption of diet and lifestyle having mutual contradictory properties like hot and cold, unctuous and dry etc.
*Inadequate digestion leading to vitiation of all ''dosha'' causes the basic pathogenesis.
*Inadequate digestion leading to vitiation of all ''dosha'' causes the basic pathogenesis.
*''Kapha'' is the main dosha and ''meda'' is ''dushya''. ''Avarodha'' (blockage) by excess fat and lipids in the vessels going downwards in thigh region is the type of pathogenesis.
*''Kapha'' is the main dosha and ''meda'' is ''dushya''. ''Avarodha'' (blockage) by excess fat and lipids in the vessels going downwards in thigh region is the type of pathogenesis.
*Oleation and panchakarma therapy is contraindicated in ''urustambha''.
*Oleation and [[Panchakarma]] therapy is contraindicated in ''urustambha''.
*Constant administration of therapies for ''samshamana'' (pacification), ''kshapana'' (reduction) and ''shoshana'' (drying up by absorption) of ''kapha'' and ''ama'' are indicated in ''urustambha''.
*Constant administration of therapies for ''samshamana'' (pacification), ''kshapana'' (reduction) and ''shoshana'' (drying up by absorption) of ''kapha'' and ''ama'' are indicated in ''urustambha''.
*''Rukshana'' (drying up) therapies with diet, lifestyle and medicinesis administered to absorb morbid ''dosha'' causing obstruction.
*''Rukshana'' (drying up) therapies with diet, lifestyle and medicinesis administered to absorb morbid ''dosha'' causing obstruction.
*All the therapeutic measures which alleviate ''kapha'' but do not aggravate vata should always be employed for the treatment of ''urustambha''. These therapeutic measures should be administered while protecting the subject’s physical strength and power of metabolism.
*All the therapeutic measures which alleviate ''kapha'' but do not aggravate vata should always be employed for the treatment of ''urustambha''. These therapeutic measures should be administered while protecting the subject’s physical strength and power of metabolism.
=== ''Vidhi Vimarsha'' ===
=== ''Vidhi Vimarsha'' / Applied Inferences===
''Urustambha'' resembles ''vata'' disorder because of clinical picture of painful weakness of pelvic girdle and lower extremities muscles. However, it should not be treated as ''vatic'' disorder as basically it is caused by vitiation of ''kapha'' and ''ama'' formation leading to obstruction of ''vata''.
It is caused by poor lifestyle and diet with excess fat and inadequate digestion leading to ''ama'' and vitiation of three ''dosha'' of which ''kapha'' is predominant. ''Ama'', vitiated three ''dosha'' and deranged ''meda'' (fat) get deposited in the muscles of lower extremities and strangulate them.
Since it is ''tridoshic'' disorder with increased ama, [[Panchakarma]] is contraindicated.
Specific treatment is internal and external ''rukshana'' (consumption therapies) consisting of:
*Consumption of the ''amadosha'',
*Releasing the ''medas'' which is strangulating/ deposited / adhered with the muscles
*First pacify only ''kapha'' by consumption
*Swimming against the flow of water.
*''Pachana,'' digestion regularization for the ''pitta dosha''.
*Aggressive physiotherapy.
*All the myopathies should be treated as per line of treatment mentioned in ''urustambha''.
*Differential diagnosis between ''urustambha, mamsa-medogata vata'' (disorder due to vitiated ''vata'' located in ''mamsa'' and ''meda''), ''pittavrita vyana'' (''vyana'' covered by vitiated ''pitta'') and ''kapha avrita vyana'' (''vyana'' covered by vitiated ''kapha'') is necessary. These sets of disorders refer to genetic and acquired muscular disorders (inflammatory and degenerative disorders).
==== Etiological factors ====
''Tridosha prakopa nidana'' mentioned by Vagbhata comprises of ''sankirna, ajirna, vishama, viruddha, adhyashana, vyapanna-madya, putishushkakrishaamisha'' etc. (Ashtangahridaya Nidanasthana 1/19, 20). Consuming foods having different ''gunas'' altogether (''sankirna''), practice of food and regimen which are antagonistic to the body’s state and stage (''viruddha''), consuming food before the previous one gets digested (''adhyashana'') and repeated development of indigestion (''ajirna'') explained in the aetiology are direct causes for ''tridosha prakopa''. Regular habituation of ''viruddha, adhyashana'' and ''ajirna'' causes accumulation of toxic metabolites in ''rasa dhatu''. These toxic metabolites avert proper utilization of ''rasadhatu'' and elicit ''tridosha prakopa'', which carry untransformed ''rasadhatu'' to ''amashaya''. This ''rasadhatu'', which is having attributes of ''kapha'' is taken to ''amashaya'' to get metabolized (digested) by ''kaphagni'' present there. Thus ''ama rasadhatu'' is a condition of ''koshtha''. If ''amarasadhatu'' fails to get digested, it interacts and combines with elicited ''tridosha'' to become one which is designated as ''saama(tri)dosha''. Thus ''tridosha prakopa'' occurs indirectly also by the toxic metabolites developing due to incompatible practices. As fat predominant circumstance paves for the initiation of pathogenesis of this disease, kapha gains more strength than the other two doshas. Kapha or saamakapha subdues pitta (Abhibhuya itaram dosham uru cet pratipadyate – Ashtangahridaya Nidana 15/48). In medodushtija conditions all the channels will be obstructed by medas (Sushruta Sutra 15/32). If the subject happens to indulge in overexertion, jerks, day-time sleep or awakening in night, the pathogenic factor (saama-kapha-vata) along with medas from koshdha (rasa-dhatu) moves to lower limbs and affects sakthi (lower limbs). Causes for the movement of doshas from koshdha to other rogamargas include overexertion, uncontrolled digestive or metabolic activity, unwholesome practice or vyana hyperactivity. Aavarana (obstruction of the movement of vata) pathogenesis also takes place at the siras supplying lowerlimbs. Prakupita dosha (dosha which gets aggravated by extrinsic causes and are not innately present in the body) is regarded as vata and innate intrinsic dosha is regarded as vayu (prana-udana-vyana-samana-apana) in Classics. Though both vata and vayu can get avarana, here medasaavrita vata (obstruction to vata which got aggravated by extrinsic causes by vitiated medas) takes place. Hence urusthambha has a synonym aadhyavata (Ashtangahridaya Nidana 15), which actually is a synonym of medasaavrita-vata (aadhyavata iti jneyassa kricchro medasaavrite – Madhav Nidan). The movement of vata as well as the active movement of lower limbs (performed by vyana vayu) will be obstructed by the medas and also made motionlessness (mudha-vata) by saamata. Hence the disease got the name by the samsthaana (sign), immobility of uru (urusthambha) caused by medas and ama.
Table 1: Pathological factors involved in urustambha
Vitiated dosha Dushya Prakriti (Sthaani dosha) Desha (Rogamarga)
Kaala (stage of the disease)
Dhatu / Upadhatu Srotas
Vitiated Kapha (Gourava,Sthairya, Shaitya, Snigdha) - Vata (Laaghava & Vaishadya) Rasa(+), Asthi (+) Rasavaha-srotas (+) Majjavaha-srotas (+) Avalambaka Kapha (+)
Paachaka pitta (-)
Samaana (+)
Vyaana (+) Antarrogamaarga (+)
Madhyamarogamaarga (+) Saama kapha (+), Aavrita-vaata, Acute (+)
(+)- Identical with vitiated dosha (-) -not identical with vitiated dosha Samprapti Bala: 11/12 (Pravara)
Reason of limitation of panchakarma in management:
The reason why pancakarma therapies are ineffective in urusthambha is due to four reasons. The tridosha which is getting vitiated due to visharupa ama (toxic metabolites in rasadhatu) become saamadosha on interaction with ama rasadhatu. This saamadosha will be directed to lower limbs by fat. So the two reasons being the adherence (paicchilyam) produced by ama and obstruction by medas. Due to these causes, the doshas are unable to move out of uru. The third reason is asthi is site of vata which is inherently shita (cold leading to stiffness) predominant. Kapha has cold properties leading to obstruction and stiffness. The fourth reason is mudha-vatata (vata in asthi is devoid of movement) due to ama and avarana and hence movement of kapha outwards is not facilitated. Moreover kapha is immobile.
Panchakarma therapy is prescribed only when doshas are in a state of getting expelled out from nearest external orifices. In urusthambha due to adhering nature of doshas, obstruction by fat, decreased metabolic activity in asthi and also due to immobile kapha-vata, srotashodhana (clearing channels), abhishyandana (flowing nature of doshas) or paaka (proper metabolic activity) do not take place. This shows the inadequacy to facilitate mobility and koshdha gati (movement of dosha towards GIT) of doshas. Hence panchakarma therapy is not advisable in this circumstance.
Importance of rukshana: The biological functions performed by ruksha guna are those opposite to sneha guna. Snehaguna imparts softness, unctuousness, increases strength and improves the complexion. Ruksha removes kleda (water elementary principle) from cells or tissues and causes hardening and eventually roughening takes place. Fat predominance in structures makes them soft while protein in excess makes them hard. Sneha-kleda vriddhi in excess in tissues makes them flaccid and soft. As the sneha-kleda vriddhi cannot be expelled from asthi and brought to koshdha, the treatment principle which is to be applied is either increasing the mobility of kleda and make it move outwards or drying up of kleda by absorption. Rukshana is performed not only by ruksha guna, but also by many gunas which directly or indirectly augment the absorption of kleda. Kashaya-katu-tikta tastes are successively more powerful rukshana rasas.
Vyadhiviparita treatment encompasses reinstalling the functions of samana vayu, vyana vayu and avalambaka kapha. Hetuviparita treatment is Saamadosha management and kaphaavrita vata treatment.
Beneficial diet: Congenial (pathya or roga-saatmya) food should be changed to shyaamaaka, kodrava, uddaala and shaali which are puraana (stored for a long period like one year or more). Shaali though is madhura, puraana will subside kapha and medas. Yusha of shushka moolaka or patola, Jaangala maamsa and other vegetables without ghee and salt (jaangalairghritairmaamsai: shaakaiscaalavanairhitai: - Sushruta Cikitsa 5/38).
Medicines:
The best drug of choice is guggulu (Sushruta Cikitsa 5/40-45). With its (guggulu’s) prabhaava (special attribute), it does rukshana (vaishadyakara) as well as vata-anulomana (ushna-virya) simultaneously.
The best formulation of choice is shaddharana churna which metabolises saama kapha and also medas along with vata-anulomana. Other chief drugs that could be used according to the status are triphala, trikatu, shilajit, karanjaphala, sarshapa etc. Choice of medicine is to be done according to the state and stage of the disease and diseased.
Nourishment in vitiation of vata:If Urusthambha develops in emaciated (Apatarpanotha), santarpana of rasa dhatu has to be done with jaangala maamsa, puraana shaali etc. All the foresaid measures could be done in niraama stage only. The food, regimen and medicine should always be kapha-vatahara.
The treatment should be always kaphahara (rukshana) along with vatahara (anulomana for laghu, vishada gunas). Laaghava (decline of anulomana, effortless execution of activities) Aatma-rupa of vata causes symptoms in vyakti stage. Roukshya (degenerative changes) Aatma-rupa of vata causes symptoms of insomnia and pain (alarm to prevent necrosis) as upadrava due to careless application of rukshana.
Medicated oils:
Medicated oils are to be applied only in niraama-dosha as well as kapha and medas have decreased (aavarana lakshanas disappear) considerably. Medicated oils can alleviate roukshya, vaishadya and laghava without affecting or along with the decline of kapha and medas.
Management of ama dosha:
All these therapeutics are to be administered after metabolizing saama dosha. As ama is of toxic nature, treatment principle of ama-vata (Langhanam swedanam tikto deepanaani katuni ca) has to be applied initially. Then rukshana treatment principle without aggravating vata is explained. The foresaid food, recipes (medicine) and regimen help to achieve rukshana. Katu, tikta and kashaya rasaas are antagonistic to kapha, but aggravates vata. Dravyas which differ from the above principle are shunthi, pippali, rasona (katu dravyaas), guduchi, patola (tikta dravyas) and haritaki (kashaya dravya) will not aggravate vata. The patient should be made to walk on irregular surface will cause strain to lower limbs which is a treatment principle of kapha (nissukhatvam sukhaaya – Ashtanga Hridaya Sutra 13/12). Swimming in cool water would increase the internal temperature which counters the shita guna of kapha which is strongly embedded in shita asthi-dhatu. This would favour kapha kshapana from asthi and its mitigation.
Current clinical practices:
Principles of management:
1. Kshapana of kapha and meda ( reduction of kapha and meda)
2. Rukshana and shoshana (drying and absorbing excess fat and lipids)
3. External application 4. Exercise in the form of swimming against the flow
Important medicines: 1. Bhallataka 2. Guggulu
Name Dose Time Anupana (vehicle)
Bhallatakadi decoction 20 to 40 ml Early morning and before sleep two times --
Triphala guggulu tablet 250 -500 mg Early morning and before sleep two times Bhallatakadi decoction
Chandraprabha tablet 250 -500 mg Early morning and before sleep two times Vardhamana pippali formulation