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| CASE REPORT |
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| Year : 2020 | Volume
: 3
| Issue : 1 | Page : 20-24 |
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Ayurvedic approach to ankylosing spondylitis: A case study
Karishma Singh, Gopesh Mangal
Department of Panchakarma, National Institute of Ayurveda, Jaipur, Rajasthan, India
| Date of Submission | 14-Oct-2019 |
| Date of Acceptance | 15-May-2020 |
| Date of Web Publication | 14-Jul-2020 |
Correspondence Address:
Dr. Karishma Singh
Department of Panchakarma, National Institute of Ayurveda, Jaipur - 302 002, Rajasthan
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JACR.JACR_7_20
Ankylosing spondylitis (AS) is a condition posing major challenge to health-care system. The disease is characterized by inflammatory stiffening of the spine, affecting the cartilaginous joints of the spine and the sacroiliac joints. Non-steroidal anti-inflammatory drugs and steroids are the drugs of choice in conventional systems but fail to provide a complete cure. There is no direct reference to the disease in Ayurveda, but based on the clinical picture, treatment can be planned. A 25-year-old male diagnosed with AS with bilateral hip arthritis since the past six years was treated by Patrapinda swedana and Erandamooladi basti in Kala krama along with Shamana (~palliative) therapy for 16 days. The disease activity was analyzed using AS Disease Activity Score. Other quality of life parameters were also incorporated for the assessment. After completion of the treatment, considerable improvement was recorded in subjective parameters, pain was decreased, stiffness was resolved, and appetite was improved. Spinal mobility was also improved. Considerable improvement was appreciated in the patient assessed by quality-of-life parameters.
Keywords: Ankylosing spondylitis, Eranadamooladi basti, Panchakarma, Patrapinda swedana
How to cite this article:
Singh K, Mangal G. Ayurvedic approach to ankylosing spondylitis: A case study. J Ayurveda Case Rep 2020;3:20-4 |
| Introduction | |  |
Ankylosing Spondylitis (AS) or “Marie Strumpell Disease” is a seronegative inflammatory arthritis of the spine of unknown etiology. The disease more often manifests in young males than in females with the ratio of approximately 3:1 in the second or third decade.[1] The prevalence of AS is generally believed to be between 0.1% and 1.4% globally.[2] The prevalence of AS in India is 0.03%.[3] There is no single agent that has been associated with the causation of AS. There seems to be a complex interaction between raised serum levels of Immunoglobulin A and acute-phase reactants of inflammation, the body's immune system, and the HLA-B27 gene. Yet, there are no thorough reports on the clinical, immunological, and immunogenetic aspects of this disease from India.[4] There has been an alarming increase in the incidence of AS, among Indian young adults in their late 20s and early 30s. AS affects 1 in 100 of the adult population and is particularly prevalent in men.[5]
AS presents in the early stages with an inflammatory arthritic pain that typically involves the sacroiliac (SI) joints initially and later the other spinal regions. Disease progression leads to spinal ossification, osteoporosis, and altered spinal biomechanics. The spine may eventually fuse in a kyphotic position. AS may affect the lumbar, thoracic, and cervical spinal regions. Other skeletal manifestations include dactylitis (sausage-shaped digits), heel pain (achilles tendon insertion), and hip arthritis. AS manifests as inflammatory pain and morning stiffness beginning in the sacroiliac joints with subsequent spread to the lumbar, thoracic, and cervical regions. Morning stiffness lasts at least for an hour but often many hours, and the low back pain is caused by inflammation of the SI joints and vertebral column. Nocturnal exacerbation of pain that forces the patient to rise and move may be frequent. Pain at the cervical region and of the thoracic spine, especially with chest expansion, is caused by the involvement of the cervical and costovertebral joints. The spinal inflammation coincides with the formation of syndesmophytes and squaring of the vertebrae, sometimes evolving into the classical bamboo spine. This causes fusion or joining up of the joint bones and stiffness and immobility. This is the hallmark symptom in the spine in AS.[6] Spinal ankylosis leads to limited chest expansion, limited neck motion, flattening of the lumbar spine (loss of lumbar curvature), and thoracic kyphosis. As the disease progresses, it destroys the nearby articular tissues or joint tissues. The original and new cartilages are replaced by the bone through fusion. The most specific findings involve the loss of spinal mobility with limitation of anterior and lateral flexion and extension of lumbar spine and chest expansion.
AS cannot be mirrored directly with any particular disease condition in Ayurveda classics. However, on the basis of pathogenesis and symptoms, AS can be correlated to clinical conditions such as Pravruddha amavata, Trika sarujashotha, Asthimajjagata vata, and Kaphavrita vyana mentioned in classical texts. In the present case, Agnimandya (~decreased digestive power) was noticed in the patient with Ama lakshana in Mala[7] (~sticky, improperly formed stool which drowns in water) and Jihva (~coated tongue). Shoola (~pain) and Graha (~stiffness) in Kati (~pelvis), Prishtha (~posterior region of the trunk from the neck to the pelvis) and Trikapradesha (~region around the shoulder girdle) are the cardinal features of AS. Kati, Prishtha, and Trika are the Sthana (~adobe) of Vata. As the patient had pain in bilateral hip joints and stiffness, all along the spine that would persist throughout the day, the patient was diagnosed as Kati-prishta-trika graha. Though Prishtha graha and Trika graha have been mentioned as Vata nanatmaja vikara[8] (~diseases occurring solely due to morbid Vata), but in the current case, Ama was associated. Considering the involvement of Vata dosha associated with Ama in the present case, the treatment protocol was aimed at Swedana (~fomentation), Sroto shodhana, and pacification of morbid Vata. Thus, Nirgundi (Vitex negundo Linn.) Patrapinda swedana, and Erandamooladi basti (Kala krama) were planned for 16 days along with Shamana aushadha.
| Case Report | | |
A 25-year-old male patient approached with complaints of pain in the bilateral hip joints which started in the posterior aspect, gradually involved the anterior aspect of the hip joint too, stiffness persisting throughout the day causing painful walking for six years. The patient also reported locked knee joints, owing to which his both knees could not touch the ground and remained in air while sitting in cross-legged position. His condition worsened gradually in the past 3 months making it difficult for him to sit for more than 10 min continuously. Pain was also developed in the bilateral shoulder joints. He complained difficulty in bending forward and restricted movements at the hip joints for 6 years and knee joints for 4 years. The condition was diagnosed as AS with arthritis 4 years ago by his physician. The course of the disease was intermittent with worsening of symptoms in between. The patient was admitted in indoor ward for management.
Patient examination
Dashavidha pariksha (~Ten fold examination)
Prakriti of the patient was Vata pitta. Further examination revealed symptoms of Vikrita vata (~disturbed Vata), Madhyama satva (~average psychological strength), and Sarva rasa satmya (~habitual of taking all six tastes in diet). Samhanana (~compactness) and Pramana (~body built) were found to be Madhyama (~normal). His Vyayama shakti (~muscle strength) was Madhyama and Aharashakti (~intake and digestion capacity)[9] was Avara (~subnormal). Walking was painful, and thus, gait was affected.
Ashtavidha pariksha (Eight fold examination)
Nadi (~pulse) was Vata kaphaja. Urine was normal with a frequency of 4-5 times a day. Bowel history revealed the frequency of once a day but was unsatisfactory (incomplete evacuation); Mala (~bowel) was Sama. Jihwa (~tongue) was coated. He had Anushna sparsha (~touch was not too hot) and normal Shabda (~voice) of Pitta prakriti. His Drishti (~vision) was not affected. Srotas involved were Rasavaha,[10]Raktavaha,[11] and Asthivaha srotasas.[12] Possible Srotodushti in the present case could be Sanga due to Srotorodha caused by Ama.
Vital examination
Pulse rate was 98/min and regular; blood pressure was 128/86 mmHg, temperature was 99.6°F, and respiratory rate was 18/min. Respiratory, cardiovascular, and central nervous systems did not show any abnormality. Per abdomen examination was normal. Tenderness was present over bilateral SI joints. Family history was positive for the same; his father aged 60 years was also a known case of AS. Pain was squeezing in nature, aggravating on walking, sitting for more than 10 min, changing posture while lying, with climatic variations (increased in cold climate), and on eating Amla dravya (~sour substances). Pain worsened on prolonged lying in the supine position during night. Pain was relieved after some physical activities while stiffness persisted throughout the day.
Past treatment history
The patient was under the supervision of rheumatologist for 6 years. Four years back, he was advised for magnetic resonance imaging (MRI) of the pelvis and HLA-B27. MRI of the hip joints was suggestive of seronegative spondyloarthropathy, i.e., AS or its variant. HLA-B27 was positive. The patient in the past 6 years has been prescribed with a combination of drugs like nonsteroidal anti-inflammatory drugs such as etoricoxib 90 mg, indomethacin 75 mg, and piroxicam 20 mg; DMARDS (Disease Modifying Anti Rheumatic Drugs) such as sulfasalazine 1000 mg; calcium supplements; and corticosteroids (deflazacort 3 mg and injection triamcinolone 40 mg). No improvement was observed with these medicines. Meanwhile, the patient developed other symptoms such as loss of appetite and thus approached Ayurveda.
Assessment criteria
Assessment criteria[13] include evaluation of change in pain, stiffness, restriction of movement, range of motion at the lumbo-sacral spine, and Agnibala. Quality-of-life parameters were also assessed before and after treatment, which included Ankylosing Spondylitis Quality of Life Questionnaire,[14] Ankylosing Spondylitis Disease Activity Score,[15] Bath Ankylosing Spondylitis Disease Activity Index,[16] and Bath Ankylosing Spondylitis Functional Index.[17]
| Treatment Protocol | | |
The treatment protocol included Nirgundi patra pinda swedana and Erandamooladi basti along with Shamana aushadha for 16 days. The plan of Erandamooladi niruha basti[18] is presented in [Table 1]. Anuvasana basti was administered with 60 ml lukewarm Dashamoola taila. Dashamoola taila used in present case is an Anubhuta yoga prepared in Pharmacy, National Institute of Ayurveda. It contains Dashamoola and Tila taila in equal parts, i.e., one part of Dashamoola (each drug in 1/10 part) and one part of Tila taila.
Besides these procedures, Shamana aushadha were also prescribed, which included Rasnasaptaka kwatha[19] (40 ml twice a day) orally on empty stomach, Simhanada guggulu[20] (500 mg thrice a day) before meal with lukewarm water, Mahavata vidhwansana rasa[21] (125 mg thrice a day)orally before meal with luke warm water, and a powdered formulation of Nagaradya churna (1 g), Chopchini churna (1 g), and Ashwagandha churna (3 g) orally after meal, twice daily with cow milk was administered for the same duration, i.e., 16 days. The same medications were prescribed upon discharge for one month with a slight change where Simhanada guggulu was replaced by Trayodashanga guggulu.[22] These medicines were continued for one month, followed by continuation of Rasnasaptaka kashaya for another three months. The patient was under follow-up for six months. Over the past 2 months, the patient was not prescribed any medicine but was advised to refrain from cold and sour substances.
Nirgundi patrapinda swedana
Fresh Nirgundi leaves (approximately 500 g) were washed in water and chopped into small pieces in a pan and fried with 100 ml of Dashmoola taila till the mixture attained brown tinge. 5 g Saindhava Lavana and 5 g Haridra (Curcuma longa Linn.) powder were added to the mixture along with 5 g Ajwain seeds (Trachyspermum ammi Linn.) and two bulbs of Lashuna (Allium sativum Linn.). The prepared material was divided into two parts, placed in two pieces of cloth, and boluses were prepared. After checking the temperature on the dorsum of the hand, the prepared boluses were applied on the whole body by two masseurs in a symmetrical manner. The boluses were reheated in a pan containing oil and re-applied; the procedure was carried out on an empty stomach for 30 min daily.
Administration of Basti
The patient was asked to lie down in the left lateral position on a knee height table. Basti nozzle was lubricated with oil and the tip of the nozzle was inserted into the anal orifice in a direction parallel to the spine. The Basti was administered in the same position, while the patient was asked to take a long deep breath to ensure proper administration of Basti. After administration of Basti, the patient was asked to lie in the supine position. For better absorption of Anuvasana basti, legs were raised from the table thrice.
| Followup and Outcome | | |
Considerable relief in signs and symptoms were noted after 16 days of treatment [Table 2]. The patient also reported an increase in Agnibala[9] [Table 3] and improvement in the quality of life [Table 4]. Considerable improvement in spinal mobility was reported by the patient [Table 5] and [Table 6]. Upon assessment, after six month follow-up, the patient reported complete relief in stiffness. The pain was still present but was tolerable. By the end of the treatment, the need of conventional analgesics or anti-inflammatory drugs was not felt by the patient.
| Discussion | | |
Nirgundi patrapinda swedana and Erandamooladi basti were adopted in the management. Patrapinda swedana is a very practical approach of Swedana, as it is easy to adopt and fast in action. Swedana is a mode of Pachana. Moreover, Nirgundi has Vednasthapana, Shothahara, Deepana, Pachana, and Rasayana properties which are helpful in this condition.[23]Erandamooladi basti does Deepana karma and is specially indicated for Trika-prishtha shoola.[18] To manage Ama, Shamana aushadha including Rasnasaptaka kashaya, Simhanada guggulu, Nagaradya churna, and Chopachini churna were advised. Rasnasaptaka kashaya is indicated in Janghagraha (~stiffness in thighs), Kati graha (~stiffness of the lower back), Parshva peeda (~pain in flanks), Prishtha peeda (~pain in back), Uru peeda (~pain in thighs), and Jeerna amavata (~chronic rheumatism due to Ama- undigested material).[19]Simhanada guggulu augments the Agni and is indicated in Amavata.[20]Nagaradya churna contains Kuchala (Kupilu)[24] (1/100 parts) and Shunthi[25] (one part), both of which are Ushna veerya and Amapachaka, thus might have contributed to the Amapachana effect. Chopachini is Swedala (~induces sweating), Balya (~strength promoter), and Raktashodhaka (~blood purifier) and acts as Rasayana (~rejuvenator).[26]Ashwagandha is Ushna in Veerya, Balya, and Shothahara and possesses Rasayana properties.[27] This powdered formulation was added considering their Ushna veerya and Balya properties. Mahavata vidhwamsana rasa contains drugs with Ushna virya, is indicated in Vatavikara, and Shula, diseases occurring due to morbid Kapha.[21]
The treatment was directed to clear the Ama and pacification of Vata dosha, which proved to be beneficial in the present case. Substantial relief was observed in pain and stiffness. The duration of stiffness was reduced from 24 h to near about 1 h in a day. Agnibala was improved. Difficulty in walking was resolved. Pain while sitting on the ground was also reduced. His knees could touch the ground while sitting after treatment [Table 7]. All these observations were due to the effect of Amapachana and Vata shamana. Not only his physical health was improved, but psychologically, he was much relieved for his condition. He developed a positive attitude toward life. Assessment of quality-of-life parameters also revealed the enhanced quality of life after therapy. | Table 7: Distance between lateral epicondyle of bilateral femur (in flexed knee position) to ground surface
Click here to view |
| Conclusion | | |
As Ankylosing spondylitis affects younger population majorly, the life span of the younger sector of the population is compromised. Limitations of conventional health-care system leave the patient distressed and in mental agony. Ayurveda can contribute to such situations. The present case was assessed on Ayurvedic parameters and managed accordingly. A significant improvement was appreciated by the patient within 16 days of treatment. Relief in pain and stiffness can be attributed to combined effect of the Patrapinda swedana, Erandamooladi basti, and Shamana drugs. Although single case report cannot claim to be an efficacious treatment for all such cases and as the disease runs a long course, the same treatment protocol cannot be followed in all cases. Nature of procedures duration and choice of other drugs will differ from case to case. They need to be selected depending on the clinical presentation.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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