AMAVATA (RHEUMATOID ARTHRITIES).
1) NIRUKTI:-Rheumatoid arthritis is the chronic progressive disease causing inflammation and stiffening of the joints.
Amavata is the disease related with Rasavaha srotas in which both ama and Vata are aggravated, affecting various Kapha dosha sites like joints and heart.
Rheumatoid arthritis (RA) is a chronic multisystem disease. Although there are a variety of systemic manifestations, the characteristic feature of RA is persistent inflammatory synovitis, usually involving peripheral joints in a symmetric distribution. The potential of the synovial inflammation to cause cartilage destruction and bone erosions and subsequent changes in joint integrity is the hallmark of the disease. Despite its destructive potential, the course of RA can be quite variable. Some patients may experience only a mild oligoarticular illness of brief duration with minimal joint damage, whereas others will have a relentless progressive polyarthritis with marked functional impairment.
2) VYAKHYA:-
When the aggravated ama simultaneously afflicts the (pelvic and shoulder) girdles and other joints such as spine, peripheral joints etc. making the body stiff, the condition is known as amavata.
3) HETU:-According to the modern science, the cause of RA is yet unknown. It has been suggested that RA might be the manifestation of the response to an infectious agent in a genetically susceptible host. Because of the worldwide distribution of RA, it has been hypothesized that if an infectious agent is involved, the organism must be ubiquitous. A number of possible causative agents have been suggested, including Mycoplasma, Epstein-Barr virus (EBV), cytomegalovirus, parvovirus and rubella virus, but convincing evidence that these or other infectious agents cause RA has not emerged. The process by which an infectious agent might cause chronic inflammatory arthritis with a characteristic distribution also remains a matter of controversy. One possibility is that there is persistent infection of articular structures or retention of microbial products in the synovial tissues which generates a chronic inflammatory response. Alternatively, the microorganism or response to the microorganism might induce an immune response to components of the joints by altering its integrity and revealing antigenic peptides. In this regard, reactivity to type 2 collagen and heat shock proteins has been demonstrated. Another possibility is that the infecting microorganism might prime the host to cross-reactive determinants expressed within the joint as a result of “molecular mimicry”. Recent evidence of similarity between products of certain gram-negative bacteria and EBV and the HLA-DR4 molecule itself has supported this possibility. Finally, products of infecting microorganisms might induce the disease. Recent work has focused on the possible role of “superantigens” produced by a number of microorganisms, including staphylococci, streptococci and M.arthritidis. Superantigens are proteins with the capacity to bind to HLA-DR molecules and particular Vb segments of the heterodimeric T cell receptor and stimulate specific T cells expressing the Vb gene products. The role of superantigens in the etiology of RA remains speculative. Of all the potential environmental triggers, the only one clearly associated with the development of RA is cigarette smoking.
According to our ancient medical science;
Sedentary habits with hypofuctioning digestive mechanism, incompatible diet and regimen, physical exercise after taking fatty food are the causative factors for the amavata.
4) PURVARUPA:-In approximately two-thirds of patients, it begins insidiously with fatigue, anorexia, generalized weakness and vague musculoskeletal symptoms until the appearance of synovitis becomes apparent. This prodrome may persist for weeks or months and defy diagnosis. Specific symptoms usually appear gradually as several joints, especially those of the hands, wrists, knees and feet become affected in a symmetric fashion. In approximately 10% of individuals, the onset is more acute, with a rapid development of polyarthritis, often accompanied by constitutional symptoms, including fever, lymphadenopathy and splenomegaly. In approximately one-third of patients, symptoms may initially be confines to one or few joints. Although the pattern of joint involvement may remain asymmetric in a few patients, a symmetric pattern is more typical.
Though Madhav has also suggested few purvarupa ghataka observed in amavata such as bodyache, anorexia, thirst, a feeling of heaviness, fever, indigestion and inflammation of the body parts as the general signs and symptoms of amavata.
5) RUPA:-Pain, swelling and tenderness may initially be poorly localized to the joints. Pain in affected joints, aggrevated by movement is the most common manifestation of established RA. It corresponds in pattern to the joint involvement but does not always correlate with the degree of apparent inflammation. Generalized stiffness is frequent and is usually greatest after periods of inactivity. Morning stiffness of greater than 1 hour duration is an almost invariable feature of inflammatory arthritis and may serve to distinguish it from various noninflammatory joint disorders. Notably, however, the presence of morning stiffness may not reliably distinguish between chronic inflammatory and noninflammatory arthritids, as it is also found frequently in the latter. The majority of patients will experience constitutional symptoms such as weakness, easy fatigability, anorexia and weight loss. Although fever to 40degree C occurs on occasion, temperature elevation in excess of 38degree C is unusual and suggests the presence of an intercurrent problem such as infection.
When amavata gets exacerbated it becomes most distressing of all the diseases. Wherever the ama dosha reaches, it produces painful swellings such as in the joints of the hands and feet, cervical region (pelvic and shoulder) girdles, knees and thighs. The affected part is excessively painful as if it is being bitten by scorpions. It gives rise to hypofuctioning of the digestive system, excessive salivation, anorexia and a feeling of heaviness, loss of the drive, bad taste in mouth, polyuria and a burning sensation, hardness in the abdomen, colicky pain and reversal of normal sleeping habit, thirst, vomiting, vertigo, fainting, precordial discomfort, constipation, stiffness, gurgling intestinal sounds, meteorism and other troublesome complications.
6) PRAKARANURUPA RUPA:-With the predominance of pitta there is redness and heat (locally); whereas with the predominance of vata, the pain is severe. If kapha is predominant, a feeling of being covered with wet clothes, heaviness and an itching sensation are present.
7) SAMPRAPTI: - When a person of sedentary habits with hypofuctioning digestive mechanism indulges in incompatible diet and regimen, or does physical exercise after taking fatty food the ama is formed and propelled by vayu and reaches various sites of shleshma. During its movement it also vitiates vata. When it reaches the various sites of kapha; it assimilates and vitiates kapha which is similar to it in the qualities. Due to its vidhagda nature; it also vitiates the pitta. Due to its abhishyandi and guru qualities channels get blocked; due to which vata which has already got vitiated ; vitiates to the extreme levels. The ama thus circulates along with the vitiated vata and damages normal functioning of heart. When it reaches the arteries, it produces kleda in various channels under the influence of vitiated doshas; which further induces weekness in body and heaviness in heart.
8) DOSHA-DUSHYA ADHISHTHANA: -
a) Dosha: - Vatapradhan tridosha,
b) Dushya: - Rasa, snayu, kandara.
c) Adhishthana: - All the joints,
d) Srotodushti: - Sanga,
e) Rogamarga: - Madhyama rogamarga.
9) UPADRAVA: - a) Hrudvikar,
b) Atitivra santapa,
c) Amavataja nodules,
d) Pneumonia,
e) Phupphusavaran shotha,
f) Mastishkavaran shotha,
g) Twaihaka visphota,
h) Vrukkashotha,
i) Koria (Anganatana).
10) UDARKA:-
11) ARISHTA LAKSHANA:-
12) VYADHI VYAVACHCHHATI: - In 1987, the American college of Rheumatology
The criteria:-
a) Morning stiffness: Stiffness in and around the joints lasting 1 hour before maximal improvement.
b) Arthritis of three or more joint areas: At least three joint areas, observed by a physician simultaneously, have soft tissue swelling or joint effusions, not just bony overgrowth. The 14 possible joint areas involved are right or left proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle and metatarsophalangeal joints.
c) Arthritis of hand joints: Arthritis of wrist, metacarpophalangeal joint or proximal interphalangeal joint.
d) Symmetric arthritis: Simultaneous involvement of the same joint areas on both sides of the body.
e) Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surfaces, or juxtaarticular regions observed by a physician.
f) Serum rheumatoid factor: Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in less than 5% of normal control subjects.
g) Radiographic changes: Typical changes of RA on posteroanterior hand and wrist radiographs that must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints.
13) SADHYA-ASADHYA VICHAR:- When one dosha is involved, the disease is curable; with the involvement of two doshas it is said to be relievable. When all the three doshas are involved and there is an inflammation all over the body the condition is difficult to cure.
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