PPT created by Dr R.L.D.S Ranasinghe, Post Graduate Scholar, University Of Colombo, Sri Lanka.

1. 2014.09.16
1

2. OUTLINE
q Objectives
q Case presentation
o Complaints of the patient
o Clinical Examination
o D/ D
o Diagnosis
o Review of Ayurveda
q Review of Modern
2

3. OBJECTIVES
¨ To understand the patho-physiology, signs and
symptoms & treatments of Sandhigataväta
¨ To review on related Modern Aspects
¨ To improve diagnosis skills
¨ To improve the presentation skills
3

4. CASE SUMMARY
4
¨ Mr K. M Silva, 52 Yrs from
Kuliyapitiya
¨ having difficulties to move
Joints notably RT KJ, Both
Elbow Js, LT Hip & joints of
both Hands due to oedema,
Pain & Deformities
¨ for 20 yrs
¨ has not taken regular
treatment before
¨ admitted to ward no 9 on
11th July 2014

5. CASE PRESENTATION
q Name : Mr K. M Silva
q Age : 52 Yrs
q Address : Udubeddawa, Kuliyapitiya
q Nationality : Sri Lankan
q Religion : Buddhist
q Marital Status : Married
q Date of Admission : 11th July 2014 (Ward 09)
qWard No : 11
q Bed No : 22
q Occupation : Mechanic for 16 yrs, Concrete
worker for 5 yrs
5

6. MAIN COMPLAINT & DURATION
6
1. Difficulty in movements due to Pain, Oedema & Stiffness of
Right Knee Joint, Both elbow joints & both hands (PIP, DIP)
- 20 yrs
2. Deviation of RT KJ- 3 yrs
3. Pain in Left Hip Joint- 1 month
OTHER COMPLAINTS & DURATION
No other complians

7. o According to the patient, before 20 yrs; asymptomatic
o Then he got oedema in both Ankle joints
o After 1yr, oedema over little finger of the RT hand (PIP&
DIP) & RT wrist joint
o 1 yr later Oedema occurred in both Knee Joints
o Deviation of the RT Knee joint has noticed before 3 years
o Before 1 month pain arouse in LT Hip joint
o Pain -during movements only. No resting pain. Not
associate with food, climate or time.
o Stiffness in joints lasting not > 15 min
7

8. q Medical History
Hypertension 0 , Diabetes Mellitus 0 , Hypercholesteremia 0
q Surgical History
q Psychiatric History
q Treatment History
• Pain killers only
NA
• Admitted for Ayurvedic treatment for the first time on 11th
July 2014 to ward No 09 & then shifted to ward No 11
8

9. 80 yrs
52 yrs
IHD
70 yrs
20 yrs 12 yrs
9

10. o Diet: Break fast - Not taken usually
Lunch - Not taken usually
Dinner - Rice, Vegetables, Egg
Meat (Chicken, Beef, Mutton)-Twice a week
More like to get Spicy & Fried food
Not taken on time. S/T taken from outside
Water intake: Sufficient
o Appetite: Not changed due to the disease
o No allergies for any kind of food
20- 30 yrs
10

11. o Addiction : Plain tea with sugar 10-15 times/ d
Alcohol 1/ 2 bottle occasionally
Cigarette 2-3/ d
Beatle chewing 3- 4 times/ d
o Sleep : 11 pm to 5 am (Disturbed due to Nocturia)
o Bath : Evening with cold water, Daily
35 yrs
11

12. 12
o Bowel habits : Once/ Day
Colour - Yellow
Odour - Normal
o Micturition : D- 3 / N -1 times
Colour - Pale
Odour - Normal
o Social status : Living near to the river side
o Occupational history: Mechanic – Long term standing, Night shift
Concrete worker – Heavy lifting

13. GENERAL PHYSICAL EXAMINATION
o General condition - Weak
o BP - 130 /80 mmHg
o PR - 74 / min
o RR - 14 / min
o Weight - 38 kg
o Height - 5 Ft
o Tongue - Not coated (Niräma)
o Temperature - Normal
o Skin - Normal
o Pallor - Mild
o Thyroid
o Icterus
o Cyanosis
o Clubbing
o Enlarged LN
NAD
NAD
13

14. SYSTEMIC EXAMINATION
LOCO MOTOR SYSTEM
q Gati (Range of movements):
• LT & RT knee joints - Abduction
- Adduction
- Elevation
• LT & RT Elbow joints- Flexion
- Extension
- Rotation
• Hip (LT) -Elevation
-Rotation
Limited due to edema ,
pain & deformity
Limited due to edema
& pain
• Interphalangeal joints (RT)– Extension is limited
q Gait: Painful & Difficult (Pain while waliking in LT HIPJ & RT KJ)
14
Limited due to edema , pain &
deformity

15. JOINTS
o Inspection
§ Swelling
PIP, DIP, both Elbow Js, RT Ankle, Both KJs (> in RT KJ) & LT Hip
§ Deformities
Deviation & Enlargement of RT KJ, Nodes on Hands (PIP, DIP)
§ Muscle wasting
o Palpation
§ Swelling –Pitting (Disappear with the removal of finger)
§ Crepitus (Both KJ)
§ Stiffness of the joints (RT KJ, LT Hip, PIP, DIP) (< 15 min)
§ Tenderness - NAD
§ Inflammation- NAD
15

16. 16

17. Spine
qThorasic Spine: Internal and external rotation- Normal
qLumbar Spine: painful (At the time of admission)
§ Flexion-Normal.
§ Extension-Normal.
§ Lateral Bending-Normal.
q Cervical Spine:
§ Rotation- Normal
§ Flexion, Extension and Lateral bending- Normal
17

18. SYSTEMIC EXAMINATION CONT
q CARDIOVASULAR SYSTEM
• S1, S2 - Clear . No thrills or
murmurs
q RESPIRATORY SYSTEM
• Bilateral equal air entry
• No added sounds
q GIT
P/A
• No tenderness
• No organomegaly
q CNS
• Higher functions
• Motor functions
• Sensory system
• Cranial nerves
• Reflexes
18
NAD clinicaly

19. 1. Nädi:
i. Gati - 74/ min
ii. Yati - Samäntara
iii. Akåti - Pürna
iv. Samhati - Mådu
2. Mutra : D - 3/ N -1 times
3. Mala : Once/Day, Samhata mala
4. Jihvä : Niräma
5. Çabda : Prakåta Håd & Pupphuça çabda
6. Sparça : Sandhi sphuöana
7. Dåk : Prakåta
8. Akåti : Deviation & enlargement of RT Knee Joint, enlargement
of both Elbow joints Nodules in PIPJ & DIPJ
19

20. I. Prakåti : Väta Kapha / Rajas Tamas
II. Vikåti
o Hetu (Nidäna) – Viprakåñöa Nidäna
Ähara : Viñamäçana, Anäçana, Alpäçana, Katu,
Kañäya Rasa, Tékñëa, Snigdha, Guru guëa Atisewana
Viharaëa : Çéta jala sewana, Ati çrama, Rätré jägaraëa
o Doña - Väta, Kapha
o Düñya - Rasa, Rakta, Mämsa, Medas, Asthi, Majjä
o Prakåti - Väta, Kapha
o Deça - Asthi Sandhi
o Käla - Cira käla
o Bala - Roga bala: Kåccha sädhya
Ätura bala: Madhyama
o Lakñana - Prasäraëäkuaïcana vedanä, Sandhi çotha & Vikåti
o
20

21. 21
III. Sära : Rasa, Rakta, Mämsa, Medas, Asthi & Majjä
Madhya Sära
IV. Samhanana : Madhya Samhata
V. Pramäna : Madhya pramäëa
VI. Sattva : Madhya Sattva
VII. Sätmaya : Ñad Rasa Sätmaya
VIII. Ähära Çakti: Before After
• Abyavaraëa Çakti : Madhya Madhya
• Jaraëa Çakti : Madhya Madhya
IX. Vyäyäma Çakti : Before After
Prawara Madhya
X. Vayah : Madhyama (52 Yrs)

22. 1. Präëa vahä Srotas
2. Udaka vahä Srotas
3. Çukra vahä Srotas
4. Mutra vahä Srotas
5. Puriña vahä Srotas
6. Sweda vahä Srotas
7. Mano vahä Srotas
Prakåti
8. Rasa vahä Srotas : Vikåti
9. Rakta vahä Srotas : Vikåti
10. Mämsa vahä Srotas : Vikåti (Mäàsa çoña)
11. Medo vahä Srotas : Vikåti (Kñudra Sandhi Çula+ )
12. Asthi vahä Srotas : Vikåti
13. Majjä vahä Srotas : Vikåti
14. Anna vahä Srotas : Vikåti
15. Väta vahä Srotas : Vikåti (Gati Daurbalya)
22
(Päëdu (Anaemic))
(Sandhi Çula+, Çota + , Sandhi sphutana)

23. Ähara
Viñamäçana, Anäçana
Alpäçana, Katu, Kañäya
Rasa,Tékñëa, Snigdha,
Guru guëa Atisewana
Viharana
Çéta jala sewana,
Ati çrama
Mänasika
Saïcaya Prasara
23
Circulation through
the Srotas
Asthi vahä Srotas
Väta vahä Srotas
Majjä vahä Srotas
Medo vahä Srotas
Dhätu kñaya Väta Kopa
Anna vahä Srotas
Rasa vahä Srotas
Rakta vahä Srotas
Çleñaka kapha
Asthi dhätu kñaya
Khavaiguëya in Sandhi
Prakopa
• Sandhi çotha
• Prasäraëäkuìacana
vedanä
• Vätapurëa drutisparça
Vyakti
Sthäna Saàçraya in Sandhi
Sandhi Vikåti
Bheda

24. q Doña : Väta Vitiated, Kapha Dicreased
q Düñya : Rasa, Rakta, Mämsa, Medas, Asthi, Majjä
q Adiñtäna : Çärérika
q Srotas :
Rasa Vahä Srotas , Rakta Vahä Srotas
Mämsa Vahä Srotas, Medo Vahä Srotas
Asthi Vahä Srotas, Majja Vahä Srotas
Anna Vahä Srotas, Väta Vahä Srotas
q Samutthäna : Pakväçaya
q Agni : Viñama
q Äma : Niräma
q Srotoduñöi : Saìga
q Udbhawa sthäna : Asthi Sandhi
q Roga märga : Madhyama (Marma, Asthi, Sandhi)
q Sädhya Asädhyatä : Kåccha sädhya
24

25. q FBS - 99 mg/dl (2014.07.23)
q UFR
Reaction - Acidic
Pus cells
Epithelial cells
Occasional
q Lipid profile- 149 mg/ dL (Total cholesterol)
q ALP- 271 IU/L
q ESR - 5 mm/ 1st hr , 12mm/ 2 nd hr
q RF - Negative
q Plain X Ray in KJ- Osteophytes+
25

26. 26
1. Ämaväta Sandhi Çotha
2. Gambhira Väta Rakta
3. Asthi Majjä Gata Väta
4. Kroñöuka Çérña
5. Sandhi gata Väta

27. Ma. Ni. 25/ 6
¨ Body ache
¨ Anorexia
¨ Thirst
¨ Malaise
¨ A feeling of heaviness
¨ Fever
¨ Indigestion
¨ Swelling of the body parts (Pitting type of Oedema)
27

28. 28
Ca Ci 29/ 21-
23

29. 29
¨ Swelling
¨ Rigidity
¨ Hardness
¨ Agonizing pain inside the joints
¨ Dusky red / coppery coloration
¨ Burning
¨ Pricking & throbbing pain
¨ Tendency to suppuration
¨ Deformities of the joints

30. 30
Su Ni 1/ 76
Ma. Ni 22/ 58
q Väta & Rakta getting affected together produces;
q A very painful swelling of the knee joint resembling the
head of the big fox

31. 31
Ca Ci 28/ 32
q Splitting pain in the bone & joints
q Loss of strength of the musle
q Loss of sleep
q Constant pain of the body

32. Ca Ci 28/ 37
Su Ni 1/ 27-2,
Yo .Ra V.V/ 1
As Hri Ni
15/14
Ma. Ni 22/ 21
32

33. RÜPA -
Ca.Sa Su. Sa As Hri As Sa Ma.Ni Yo Ra Bha Pr
Sandhi Çüla (Joint
pain)
+ + + + + + +
Sandhi çopha/çotha
(Joint Swelling)
+ + + + + +
Vätapurëa
drutisparça
+ + +
Hanti Sandhi (loss of
function)
+ + +
Prasäraëäkuìacana
vedanä (Pain on
movement)
+ + +
Ätopa (cracking
sound )
+
33

34. ÄMAVÄTA SANDHI GATA
VÄTA
GAMBHIRA VÄTA
RAKTA
Nidäna Viruddha Ähara,
Snigda Ähara, Alpa
chesta etc.
Väta kopakara
Ähara, Viharaëa
Väta & Rakta
kopakara Ähara,
Viharaëa
Doña Kapha, Väta Väta Predominant Väta, Pitta
Düñya Rasa, Rakta, Asthi Asthi, Majja Rasa, Rakta,
Asthi, Majja
Sthäna Start from small
joints of hands &
spread
Mainly start with
weight bearing
large joints
Start from the
end parts of the
hands & feet
34

35. 35
ASTHI MAJJÄ GATA
VÄTA
SANDHI GATA VÄTA
Nidäna Väta kopakara Ähara,
Viharaëa
Väta kopakara Ähara,
Viharaëa
Doña Väta Predominant Väta Predominant, Kapha
Düñya Asthi, Majja Asthi, Majja
Nidrä Alpa NA
Sandhi Çüla Satatä Ruk Prasäraëäkuìacana
vedanä

36. DIAGNOSIS
¨ Sandhi Gata väta
36

37. CIKITSÄ
37
k…yaRÖate ivc][>
Su Ci 4 /8
As Hri Ci
21/ 22
C.D 22/ 9

38. CIKITSÄ CONT.
38
Treatment Su. Ci As Hri As Sa Bha Pr Bha Ra Yo Ra C.D
Snehana + + + + + +
Abhyanga +
Mardana + + + + +
Svedana + + +
Upanaha + + + + + + +
Bandhana + + + +
Agnikarma + + + + +

39. CIKITSÄ CONT-VÄTA VYÄDHI CIKITSÄ
A_y¼ < Svedn< biStnRSy< õehivrecnm!
iõGxaMllv[< SvaÊ v&:ym! vatamyaphm!.
39
o Abhyaìga
o Svedana
o Vasti
o Nasya
o Sneha yukta virecana
o Snigdha
o Amla
o Lavaëa
o Svädu
Yo Ra V. V
Ci/ 1
Rasa

40. CIKITSÄ CONT.
¨ Bahih parimärjana
- Sneha (Abhyanga)
- Sweda
¨ Anthah parimärjana
- Mådu çodhana
¨ Paìcha karma
-Virechana (Sneha yukta)
- Vasti
- Nasya
40

41. From 11.07.2014 to 12.08.2014
¨ Räsna 7 Decoction, Pata ½ bd
¨ Triphaläkwatha 30 ml bd
¨ Chandraprabhä vati 2 bd
¨ Yogaräja Guggulu 2 bd
¨ Daçänga Lepa
From 18.07.2014 to 25.08.2014
¨ Denibadi Decoction, Pata ½ bd
¨ Avipattikara cürna 30 grns bd
¨ Sudarshana cürna 30 grns bd
¨ Vätaroga kalka 30 grns bd
¨ Tala satakuppa paste
41

42. 42
From 25.08.2014 - 01.09.2014
¨ Räsna 7 Decoction, Pata ½ bd
From 01.09.2014 to 16.09.2014
¨ Gändarva hästadi Decoction, Pata ½ bd
¨ Räsna 7 Decoction, Pata ½ bd
¨ Virecana (2014. 08. 06 )(Hingu triguna Taila 2 Aunz)
¨ Dhärä karma (2014. 08. 11- 25)
¨ Pinda Sweda (2014. 08. 25- 15 )
Ø Upaçaya- Joint oedema, Pain reduced

43. ¨ Eranda saptaka Decoction+ Rasona, Methi, Abhaya Pata ½ bd
¨ Daça mula Balairaëda Decoction, Pata ½ bd
¨ Dantimulädi Decoction, Pata ½ bd
¨ Daçamul Nikamul Decoction, Pata ½ bd
¨ Yogaräja Guggulu 2 bd with Bavila, sudulunu water
¨ Hinguwashtaka churna 30 grns, with hot water
¨ Punarnava Mandura
¨ Närayaëa Taila abhyanga
¨ Mashabaladi Decoction, Pata ½ bd
¨ Mashatmagupta Decoction, Pata ½ bd
¨ Väta gajendrsinha rasa, 2 bd, with hot water
¨ Ashwagandätaila, abhyanga
¨ Kshéra Balä taila
43

44. 44
¨ Nika kola pottali Pinda sweda (pottali)
¨ Punnagädi pottali
¨ Picu Däraëa
¨ Jänu Vasti
q Anuvasana Vasti- Eraëda, Balä Koraëda, Hingu triguëa Taila
q Ranahansa Rasäyana
q Açwagandhä Rasäyana

45. Pathya Ähära
¨ Steamed red rice
¨ Patola
¨ Murunga
¨ Kohila
¨ Wetakolu
¨ Fish
Pathya Viharaëa
¨ Uñëa jala Sevana
(snäna)
¨ Vyäyäma
Apathya Ähära
¨ Foods which are Väta
vardhaka
¨ Madya
Apathya Viharaëa
¨ Rätree jägaraëa
¨ Divä nidrä
¨ Krodha , Çoka
¨ Séta sparça (Bathing cold
water)
45

46. 46

47. Disease Cikitsa 47
• Ca. Ci 28/37
• Su. Ni 1/27
• As. Hri .Ni 15/14
• As.Sa Ni 15/ 16
• Bha.Pr. Ma. Kha 24/ 258
• Ma. Ni 22/ 21
• Yo. Ra Va. Vy/1
• Not mentioned
• Su. Ci 4/8
• As. Hri .Ci 21/22
• As.Sa Ci 23/ 13
• Bha.Pr. Ma. Kha 24/ 259
• Bha. Ra Vol 2, 26/ 14
• Yo. Ra Va. Vy. Ci / 1
• Ca. Da

48. 48
¨ Nidäna
¨ Pürwa rüpa
¨ Sampräpti
¨ Sädhya Asädhya Bhäva
¨ Rüpa
¨ Cikitsä
Not mentioned
Separately
Only mentioned

49. NIDANA
49
Ca. C 28/15-18

50. NIDÄNA
Ähära
Due to rough, cold, little & light food
Viharaëa
¨ Excessive movement such as leaping,jumping Wayfaring & physical
exercise
¨ Excessive emaciation due to illness
¨ Uncomfortable bed & seat
¨ Day sleep
¨ Suppression of urges
¨ Fasting
¨ Injury in vital parts injury
¨ Falling down from elephants, horses & other fast vehicles
50

51. NIDANACONT.
Mänasika
¨ Anger
¨ Anxiety
¨ Grief
Faulty therapeutic management
¨ Excessive elimination of impurity & blood
¨ Wasting of dhatus
51

52. SAMPRÄPTI
Aggravated vayu Filling up
vacant channels of the body
Make disorders in
Entire body One part of the
body
52
Ca Ci 28/
37

53. 53
OSTEOARTHRITIS

54. Introduction
¨ Osteoarthritis (OA) is a disease of synovial joints
that can result from cartilage degeneration
¨ Most common form of arthritis
¨ Prevalence increases with the age
( Ref: Clinical medicine, Kumar & Clark)
54

55. Joints- most commonly involved
55
o Hand - DIP Joint
- First CMC Joint
o Foot - First MTP joint
o Weight bearing joints
- Vertebra
- Hip
- Knee

56. Classification of Osteoarthritis
2 types
1. Primary osteoarthritis
2. Secondary osteoarthritis
Primary osteoarthritis
q Osteoarthritis not resulting from injury or
disease
q Cause is unknown
56

57. Types of Osteoarthritis Cont.
2. Secondary osteoarthritis
Form of osteoarthritis that is caused by another disease
or condition.
q Obesity
q Repeated trauma or surgery to the joint structures
q Abnormal joints at birth (congenital abnormalities)
Gout
q Diabetes and
q Other hormone disorders
57

58. Risk Factors
58
¨ Age - > 45 yrs
¨ Gender- > female
¨ Obesity
¨ A fracture through a joint
¨ Congenital joint dysplasia
¨ Pre existing joint damage
¨ Occupation- farmers & labourers OA- >Hip
¨ Repetitive use
¨ Injury associate with some sports

59. Clinical features
q Joint pain- made worse by exercise, relieved by rest
q Stiffness after rest- last in <30 min
q Swelling or tenderness in one or more joints
q Deformity & enlargement of the joints
q Limited joint movement
q Wasting of surrounding muscle group
q Crepitus - Crunching feeling or sound of bone rubbing on
bone when the joint is used
59

60. Nodal osteoarthritis
Bony enlargement of
o Distal interphalangeal joint- Heberden's nodes
o Proximal interphalangeal joint- Bouchard's nodes
60

61. Pathophysiology
¨ Inital event : mitosis of chondrocyte
¨ Second event: Increased synthesis of bone by
osteoblasts in the subchondral bone
¨ Third event: metaplasia of the peripheral synovial
cells resulting in formation of osteochondrophytes
¨ Fourth event: formation of bony cysts
61

62. Pathophysiology Cont
62
¨ OA affects all of the weight-bearing
components of the
joint:
• Articular cartilage
• Menisci
• Bone

63. Pathophysiology Cont
Osteoarthritis may result from wear and tear on
the joint
•The normal
cartilage lining
is gradually
worn away and
the underlying
bone is
exposed.
63

64. Pathophysiology Cont
•The repair mechanisms of tissue absorption and
synthesis get out of balance and result in
osteophyte formation (bone spurs) and bone cysts
64

65. D/D
Criteria OA RA Gout
1.Symptoms Pain & swelling on
major weight bearing
joints, stiffness,
crepitations,
tenderness,
enlargement of joint
space.
Inflammation in
multiple joints,
morning
stiffness>30 mins
Polyarticular pain,
swelling and
inflammation,
tenderness
2.Mode Of onset Gradual Gradual Acute
3.Joints involved Weight bearing joints Poly articular Metatarso
phalangeal joints
4.Systemic
features
NA Auto immune
diseases, rise in
temperature,
anemia
NA
5.Pathological
phenomenon
Degeneration Auto immune and
vasculitis
Hyper uricaemia
6.Investigation RA- ve, ESR-normal,
X-Ray-narrowing of
joint space
ESR-raised,
X-ray-soft tissue
swelling
Serum uric acid
raised,
65

66. Diagnosis
Based on,
Ø Signs and symptoms
Ø Laboaratory studies:
• ESR - Normal
• Full Blood count - Normal
• Rh Factor - Negative
• Synovial fluid - Viscous
Ø X-ray and Radiographic findings
66

67. Radiographic Diagnosis
•Narrowing of
the joint space
•Periarticular
sclerosis
•Osteophytes
•Sub-chrondral
bone cysts
67

68. Radiographic Diagnosis cont
• Asymmetrical joint space narrowing from loss of articular
cartilage
• The medial (inside) part of the knee is most commonly affected
by osteoarthritis.
68

69. Long-Term Complications
¨ Does not affect the body's organs
¨ Lead to deformities
¨ Severe loss of cartilage in the knee joints can
cause the knees to curve out, creating a bow-legged
appearance
¨ Bony spurs along the spine can irritate nerves,
leading to pain, numbness, or tingling in some
parts of the body
69

70. 70
Bow-legged appearance

71. Bony spurs
71

72. Disease Management
q OA is a condition which progresses slowly over a period
of many years and cannot be cured
q Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the condition
q Functional treatment goals:
ü Control Pain
ü Improve Joint Function
ü Increase muscle strength
ü Maintain Normal Weight
72

73. OA – Non-operative Treatments
•Pain medications
•Physical therapy
•Walking aids
•Shock absorption
•Re-alignment through
orthotics
•Limit strain to affected
areas
73

74. 74