Rheumatoid arthritis

Rheumatoid arthritis Or Amavata (Rheumatism)

Rheumatoid arthritis is a chronic multisystem disease of unknown cause. It is an autoimmune disease, which exhibit variety of systemic manifestations. Among many symptoms synovitis, usually involves peripheral joints in a symmetric distribution.

Autoimmune diseases are illnesses that occur when the body’s tissues are mistakenly attacked by their own immune system. The potential of synovial inflammation to cause cartilage damage and bone erosion and subsequent change 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 single joint illness of a brief duration with minimal joint damage, but most will have a restless progressive polyarthritis (multiple joint involvement) with marked functional impairment.

Epidemiology: The prevalence of RA is approximately 0.8% of the population: women are affected approximately three times more often than men. The prevalence increases with age, and sex difference diminish in the older age group. The onset is most frequent during the fourth and fifth decade of life. The disease can begin at any age and even affects children (juvenile idiopathic arthritis), Rheumatoid arthritis that begins in people under 16 years of age is referred to as juvenile idiopathic arthritis, but it most often starts after 40 years of age and before 60 years of age. RA is seen throughout the world and affects all races.

Cause: The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited (hereditary). Certain genes have been identified that increase the risk for rheumatoid arthritis. It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body’s own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.

Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco, exposure to silica mineral, and chronic periodontal disease all increase the risk of developing rheumatoid arthritis.

Effect or RA on body:

  • This type of arthritis is an autoimmune disorder, which means our immune system has begun to attack its own tissues instead of protecting them.
  • Inflammation is a normal response by our immune system against infections, wounds and foreign objects. In rheumatoid arthritis, the inflammatory immune response is wrongly directed towards our joint tissues.
  • The chemicals substances produced by our immune system, attacks the soft tissues (Synovium) of the joints and cause inflammation in them.
  • This leads to swelling, stiffness, redness and pain in the joints.
  • This inflammatory process progresses to damage the bone cartilages and the joint surfaces. If left unchecked, it further produces joint deformities and disability.
  • Smaller joints are generally first affected in a symmetrical manner. Potentially any joint can get affected with the disease.
  • Along with the joints, other organs and systems of the body, including the lungs, heart, and kidneys, eyes can also get affected.

In ayurveda there is available exceptionally detail description about the rheumatoid arthritis, under the heading of Ama Vata. Almost all the scholars or acharayas have discussed about the Ama vata in almost all the classics. The term Ama vata is formed by the combination of two words i.e Ama and vata. Here “Ama” means unripe, immature and undigested food . It is resulted as a consequence of impaired functioning of ‘kayagni’ or digestion . According to vagbhata; the one of the great scholar of ayurveda, due to the hypo functioning of ushma (Agni) or gastric secretions, the anna-rasa or the food particles underwent digestion process get fermented or putrified (dushta). It is this state of Rasa, which is known as ‘Ama’. When this ama get combined with the vitiated doshas especially vata along causes Amavata.

According to ayurveda the cause of Amvata is:

Etiological Factors or causative factors: Hetu

  • Indulgence in incompatible foods and habits.
  • Excess of physical activity immediately after taking fatty foods.
  • Those with poor digestive capacity.
  • Use of food and drink, which are heavy to digest.
  • Use of food, which is rough, cold, dry, unclean, antagonistic in nature.

Emotional factors such as passion, anger, greed, confusion, envy; grief, excitement, fears etc.
Is responsible for Amavata. 

Sign and symptoms:

Clinically Ra is a chronic polyarthritis. In approximately two third of patients, it begins with fatigue, anorexia, generalized weakness, vague musculoskeletal symptoms until the appearance of synovitis become apparent. Specific symptoms usually appear gradually as several joints, especially those of hands, wrists, knees, and feets become affected in a symmetric fashion. The onset is more acute, with a rapid development of polyarthritis, often accompanied by other symptoms, including fever, lymphadenopathy, and splenomegaly.

The aggravation of lining of joints results in swelling, pain, redness, stiffness, firmness and warmth in the affected area. The cells of inflamed lining discharge compounds which might hurt the skeletal substance and cartilage. This process might cause disfigurement of joint which causes pain and other symptoms and some tome leads to permanent deformity. While rheumatoid arthritis is a chronic illness, meaning it can last for years. Rheumatoid arthritis is typically a progressive illness that has the potential to cause significant joint destruction and functional disability.

Articular or related to joint manifestation/ sign & symptoms

Pain, swelling, and tenderness,may initially be poorly localized to the joints. Pain in affected joint, aggravated by movement, is the most common manifestation of established RA.

  • Common Sign and symptoms may include:
    • joint pain in the feet, hands, and knees,
    • swollen joints,
    • tender joints,
    • loss of joint function,
    • stiff joints,
    • joint redness,
    • joint warmth,
    • joint deformity.

Non articular (not related to joint) symptoms may include:

    • rheumatoid nodules,
    • fever,
    • fatigue,
    • Nausea/ vomiting

Cardinal Signs and symptoms of Amavata according to ayurveda:

  1. (Vriscik damsha vata vedana) Severe pain like scorpion bites pain.
  2. (Sanchari Vedana) shifting pain or moving in nature.
  3. (Stambha) stiffness of joints
  4. (Jwara ) Fever or Increase in temperature
  5. (Karmahani) loss of movements or restricted movement
  6. (Sandhi Vikruti) joint deformity.
  7. (Kshudhamandya) Loss of appetite, anorexia
  8. Morning pain severe in nature

Signs and Symptoms of Amavata according to doshik dominance

  • Vitiated Vata produces colicky pain, body ache, abdominal distension, giddiness, stiffness of back and waist, constriction and spasm of blood vessels.
  • Vitiated Pitta produces fever, diarrhea, thirst, giddiness and delirium.
  • Vitiated Kapha produces vomiting, anorexia, indigestion, fevers with cold, lassitude and heaviness in body.

Classification of Amavata according to ayurveda:

  1. Vataja – Where only vata is predominant (pain is severe in this type).
  2. Pittanubandhi – Where pitta is predominant along with the vata dosha, so mixed symptoms of vata and pitta will be there like burning sensation and redness of the affected joints with severe pain, inflammation and tenderness also.
  1. Kaphanubandhi – Where kapha is predominant along with vata dosha. So symptoms will be like stiffness or loss of movement , itching , heaviness in the local part or in whole body, lethargy atc will be seen.

Prognosis (Sadhyasadhyata)

Disease with early onset and single dosha prominence in young individual can be cured with proper treatment and with religiously following the do’s and don’ts.

As the disease become chronic it involves multiple systems, which makes the disease uncurable. If it is present with signs of complications then it may produce serious threats to life.

Diagnosis: 

  • Physical examination: This includes complete clinical examination of the joints, skin, and muscles strength etc along with other symptoms appeared by the doctor.
  • Laboratory tests: One common test for rheumatoid arthritis is rheumatoid factor, an antibody that is present eventually in the blood of most people with rheumatoid arthritis. (An antibody is a special protein made by the immune system that normally helps fight foreign substances in the body.) Not all people with rheumatoid arthritis test positive for rheumatoid factor, however, especially early in the disease. Also, some people test positive for rheumatoid factor, yet never develop the disease.

Other common laboratory tests include a white blood cell count, a blood test for anemia, and a test of the erythrocyte sedimentation rate (often called the ESR), which measures inflammation in the body. C-reactive protein is another common test that measures disease activity.

  • X rays: X rays are used to determine the degree of joint destruction. They are not useful in the early stages of rheumatoid arthritis before bone damage is evident, but they can be used later to monitor the progression of the disease. 

Complications of rheumatoid arthritis:

  • Dryness of the eyes can lead to corneal abrasion.
  • Rheumatoid inflammation of the lung lining (pleura) causes pleuritis a typical type of chest pain with deep breathing,
  • Inflammation of the tissue surrounding the heart (pericardium), called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward.
  • Rheumatoid disease can reduce the number of red blood cells (anemia)
  • Rheumatoid arthritis can also reduce white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty’s syndrome) and can increase the risk of infections.
  • The risk of lymph gland cancer (lymphoma) is higher in patients with rheumatoid arthritis, especially in those with sustained active joint inflammation.
  • . Nerves can become weak and get pinched in anywhere in the body especially the wrists to cause carpal tunnel syndrome. 

Ayurvedic line of treatment for Rheumatoid arthritis:

  • Use of AamaPachak herbs (Anti- endotoxics-carminatives and digestive) is most beneficial in the treatment of rheumatoid arthritis.
  • Fasting (Langhan), hot fomentation (swedan), purgation (virechan), oleation (snehpan) and douche (vasti) chikitsa should be done.
  • Use of herbal medicines and preparations to reduce pain, stiffness and other related symptoms.

Treatment

Amavata (Rheumatoid arthritis) occurs when an individual indulges in factors that aggravte Vata dosha and Ama (Toxins) in the body. Improper digestion and weak metabolism leads to accumulation of Ama (Toxins) in our body. This Ama combined with the aggravated Vata dosha, localize in the joints and produces pain, swelling and stiffness.

In the initial stage, ayurvedic medications that metabolizes the Ama (toxins) and eliminate them out of the body should be taken.

Later, herbal medications and especially panchakarma mode of treatment which includes Rooksha swedana, several potali swedana, mild virechana, basti chikitsa and other type of procedures that pacify the aggravated Vata dosha should be prescribed after completely assessing the patient’s condition.

The choice of the treatment is made based on the assessment of the condition of the patient and the severity of the disease.

Moreover a healthy planned diet is essential to support the normal functioning of our immune system thus reduces the disease exacerbations and nourish the weakened joints. It thus reduces the severity and frequency of symptoms of the disease and its relapse too.

Patients with rheumatoid arthritis often avoid exercise due to fear of pain, but this will further weaken the muscles and deform the joints. It is important to practice simple exercises. Rest and exercise should be well balanced according the condition of the patient.

 

Simplified Yoga practice initially under the guidance of expert, helps in maintaining the muscle strength and improves the flexibility of the joints and also helps in its extraction from the body.

Pranayama helps to relax the mind and minimize the hyperactivity of the immune system.

Line of treatment

Shodhan-:

  1. Snehpana (Ingestion of unctuous substances -: various oils specially prepared with Rasna, Dashmoola, Nirgundi are used for this purpose. Especially castor oil is considered as the best oil to be used in the treatment of amavata.
  1. Langhana (fasting )-: It is done by means of complete fasting of food, or by giving light preparation which will be easy to digest like Mudga Yusha, laja Manda, Peya, (all are varieties of rice water soup), krishara( mixture of rice and cereals like kulith (horse gram) and Yava (barly) etc.
  2. Swedana ( hot fomentation): Is very useful mode of treatment in amavata. Specially complete dry sweda in the form of Ruksha kuti sweda (sauna bath), Dry fomentation-using sands, rock salt( siandhav lavana), dried cow dung powder (gomaya choorna) like dry substances, Upanaha (local application) of non-unctuous substances are very effective in relieving the pain and stiffness.
  3. Virechan (Purgatives)-: Virechan with castor oil is very useful in treating amavata.
  4. Basti (medicated enema) : Various medicated enemas like Vaitaran Basti, Dashmoola Kwath Basti, Kshar Basti, Erandmooladi niruha basti, Yapan Basti etc are useful

Shaman Chikitsa (Internal medications) -: commonly used drugs

  1. Decoctions
  • Rasna-panchak kwatha.
  • Rasna saptak kwatha or maharasnaadi kada
  • Panchakol kwatha or panchakolasava
  • Dashmool kwatha or dashamoolarista
  1. Churna
  • Ajamodadi choorna
  • Panchakola choorna
  • Shunthi choorna
  • Almabushadya choorna
  • Vaishwanar choorna
  1. Vati / Guggulu
  • Singhnada guggulu
  • Mahayogaraj guggulu
  • Mahavata vidwamsana rasa
  • Vatagajankush rasa
  1. Ghrita
  • Panchakola ghrita
  • Rasnadi ghrita
  1. Taila
  • Eranda taila
  • Saindhavadya taila
  • Bhrutsaindhavadi taila
  1. Lepa
  • Shunthi lepa
  • Dashanglepa

Diet 

  • Proper and balanced Dietary regimen is very much conventional medical aid in rheumatoid arthritis.
  • Salt, strong spices and preservatives should be avoided – likewise alcoholic beverages, tea and coffee.
  • Fasting for seven to ten days – taking only herbal teas, garlic, vegetables, decoction of potatoes, and juice extracts from carrots and beets
  • Drink water medicated with pippali, pippali mool, chavy, Chitrak and sonth.
  • Drink 5 – 10 ml castor oil daily at nighttime with 20 ml milk.
  • Eat high fibrous diet.
  • Ginger (Zingiber officinale): Ginger root inhibits production of prostaglandins and leukotrienes, which are involved in pain and inflammation, so it should be used widely.
  • Turmeric (Curcumin longa) is used lavishly for color and flavor in Indian cuisine. It inhibits prostaglandin production and stimulates the creation of cortisol, which relieves inflammation.
  • Aloe vera: Aloe Vera-derived products have significant anti-inflammatory activity.
  • Boswellia (Boswellia serrata) comes from a tree that yields gum when its bark is peeled away. It inhibited the production of leukotrienes, which cause inflammation.
  • Ashvagandha (Withania somnifera) is an Asian plant of the potato family. Its roots have long been used to treat “rheumatism,” high blood pressure, immune dysfunctions, eruption problems and also to ease inflammation. Because of all this, it’s sometimes called the “Indian ginseng.”
  • Very oily, dry, cold food: excessive exertion and totally sedentary life style should be avoided.

Yoga and Arthritis 

Arthritic joint pain is a big discouragement to do any exercise or move the body at all, but without exercise the joints become stiffer and lose range of motion that exacerbates the progression of the disease.

Several studies have shown that yoga is very effective for reducing and even eliminating the symptoms of this disease.

Perform Nadi sodhana, kalapabathi pranayam, anuloma viloma, bhastrika pranayama etc.

Asana: Ardhachakra asana, Bhujanga asana, Halasana, Shirishasan, Shalabha asana.

Rest and Exercise 

People with rheumatoid arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed. Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. 

Stress Reduction

People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease-fear, anger, and frustration-combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress also may affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Meditation and humming any mantra to pacify feelings is the best way.

Facts about rheumatoid arthritis:

  • Rheumatoid arthritis is a chronic disease characterized by periods of disease flares and remissions.
  • In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.
  • Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity.
  • Damage to joints can occur early and does not always correlate with the severity of RA symptoms.
  • The “rheumatoid factor” is an antibody that can be found in the blood of 80% of people with rheumatoid arthritis. Rheumatoid factor is detected in a simple blood test. Possible risk factors for developing rheumatoid arthritis include genetic background, smoking, silica inhalation, periodontal disease, and microbes in the bowels (gut bacteria).
  • The cure for RA is very complicated. The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery.
  • Early RA treatment results in a better prognosis.
  • Rheumatoid arthritis can affect people of all ages. The cause of rheumatoid arthritis is not known.