Arthritis of the Knee joint

Case Presentation on
Sandhigata vata w.s.r to
Osteoarthritis

Presented by
Dr. K. P. D. C. Perera
MD Scholar
Department of Nidana Cikitsa
Institute of Indigenous medicine
University of Colombo
CASE SUMMARY

 A 71 yrs old female patient from

Baduraliya has come to National
Ayurveda teaching hospital with
severe right knee joint pain and
difficulty with walking for 2 months

 She had admitted to ward No.03 on

18th June 2017
BASIC DETAILS
 Name of the patient : Mrs. Lileenona Kannangara
 Age : 71 yrs
 Address : G.S. Mawatha, Gurugodakanda, Baduraliya
 Nationality : Sri lankan
 Religion : Buddhist
 Marital status : Married
 Date of admission : 18th June 2017
 Ward No : 03
 Bed No : 04
 Occupation : Viewing machine operator – 8 yrs (age at 17)
Laborer in tea factory for 20 yrs (started at age 50)
PRESENTING COMPLAIN AND DURATION

 Difficulty in walking due to pain, edema in right knee joint - for 2 months
 Stiffness in right knee joint - for 2 months
 Neck and lower back pain - for 8 yrs

OTHER COMPLAINS AND DURATION

 Constipation – for 2 months

 Hyper cholesterolemia - 8 months
HISTORY OF PRESENTING ILLNESS

 According to the patient, 8 years ago she has fallen down and had got a
severe lower back pain. X ray was taken and diagnosed as slipped disk in
her lower back area.
 Gradually, pain was affected to cervical region and both knee joints
 The pain has recurrently occurred while with excessive working and
reduced in resting. then she has stopped her occupation
 Allopathic medicines have taken when the pain was increased
 2 months ago, she has started her occupation again and while she was
working suddenly she had felt a sprain like sensation in her right knee joint
with a sound.
 After that she has got a continuous severe pain in that area.
HISTORY OF PRESENTING ILLNESS cont……..

 Visited traditional medical practitioner and taken treatments for 2 weeks

 But the pain has increased and associated with swelling and stiffness.

 Then she has admitted to National Ayurveda Teaching Hospital - Rajagiriya

HISTORY OF PAST ILLNESSES

Medical history
Measles – age at 10 yrs old

Surgical history
LRT done – age at 38yrs

Psychiatric History
NAD
HISTORY OF THE TREATMENT

 Allopathic medicines – occasionally

 Traditional medicine – 2 weeks

 Admitted to the National Ayurveda Teaching Hospital – Rajagiriya for

Ayurveda treatments

 For Hypercholesterolemia – Atorvastatin 10mg nocte (8 months)

PERSONAL HISTORY

 Diet Breakfast Rice, Vegetables

Lunch Occasionally fish
Dinner Not taken green leaves
Not taken milk, eggs
Mixed irregular diet pattern
Not taken on time
Reduced starchy foods intake Water intake
Loss of appetite
No food allergies
Not given proper attention to diet
PERSONAL HISTORY cont…..

 Sleep : 10pm to 4 am (disturbed sleep)

 Exercise : excessive exercise due to her occupation

 Addiction : plain tea three times per day

 Bath : once a week, night bath with worm water

body wash evening with worm water, daily

 Education : up to O/L

 Socioeconomic condition : Middle

FAMILY HISTORY Normal male
Normal female
Patient

72 yrs 75 yrs Dead female

Dead male

68 yrs 71 yrs
60 yrs 62 yrs 65 yrs
Sudden death

Mental
retarded
GENERAL EXAMINATION

 Appearance : Anxious, frail, emaciated lady

Elevated veins can be seen
No any abnormal deformities & scar marks seen
 Skin : Dry skin, Brown pigmentation present,
 Nails : Black color
 Pallor : Mild
 Cyanosis : No central and peripheral cyanosis
 Clubbing : No
 Lymph nodes : Not enlarged
 Jaundice : No
 Thyroid gland : NAD
 Weight : 43 Kg Height:142.2cm BMI : 21.3
 Temperature : Normal
SYSTEMIC EXAMINATION
LOCO MOTOR SYSTEM

Gait : Not smooth symmetrical gait

Pain while walking – so Antalgic gait present

Arms : Shoulder -
Elbow - Appearance normal,
Forearm - Range of movements normal but mild painful
Wrist - Locking of MCP and IP joints
MCP , IP -

Legs : LT & RT Hip - Range of movements limited due to pain

Trendelenburg test (– )

LT & RT knee joint - Right knee joint edema, crepitation +++ & pain
Range of movements limited & painful
Left knee joint mild crepitation & mild pain
SYSTEMIC EXAMINATION…cont.

LOCO MOTOR SYSTEM..cont

 Ankle - NAD

 Deviation of legs (bow legs can be seen)

 Spine :
Cervical spine - Rotation, Flexion, Extension and lateral bending limited
due to pain and stiffness

Thoracic spine - Internal and external rotation – normal

Lumbar spine - Flexion, Extension and lateral bending limited due to pain
SYSTEMIC EXAMINATION…cont.

CARDIOVASCULAR SYSTEM

 Pulse - 72/ min, regular, low volume, Mrudu

 BP - 110/70 mmHg
 JVP - Not seen
 S1, S2 - Clear, No thrills or murmurs
 Radial, Brachial, Carotid, Femoral, Popliteal, Post. Tibial, Dorsalis pedis – pulse +
(left & right)

RESPIRATORY SYSTEM

 Trachea central,
 Chest expansion reduced in inspiration but symmetrical
 Breath sounds normal and no added sounds
SYSTEMIC EXAMINATION…cont.

GIT SYSTEM

 Missing teeth, tongue mild coated, dark color spots present

 No tenderness and abnormal masses palpable
 No any organomegaly

CNS SYSTEM

 Cranial nerves - NAD

 Speech - Normal
 Motor functions - NAD
 Sensory system - NAD
ASHTAVIDHA PARIKSHA

 Nadi : Gati - 72/min Yati - Samantarala / regular

Akruti - Sukshma Sanhati - Mrudu

 Mutra : D- 8/ N- 0, Pale yellow color, no any abnormalities

 Mala : once in two days, constipated, yellow color, no undigested foods

 Jihva : Appearance - Coated

Color - Light Pink
Size - Normal
Movements - Normal
Black color spots present in the tongue
ASHTAVIDHA PARIKSHA cont….

 Shabda : Heart sounds

Lung sounds normal
Abdominal sounds

 Sparsha : Dry skin

Crepitation present in both knee joints. But more prominent in right
knee joint
Interphalangeal joints stiffness also present in both hands
pain in the cervical area, lumbar region and knee joints when touching
ASHTAVIDHA PARIKSHA cont….

 Druk : Appearance: Sunken eye lids and dark eye circle

Color : NAD
Size : NAD
Movements: NAD

 Akruti : Emaciated body (Krusha durvala sharira)

Slightly bow legs can be seen
DASAVIDHA PARIKSHA

 Prakruti Pariksha
Somatic : Vata pitta
Psychic : Rajasika
DASAVIDHA PARIKSHA cont….
 Vikruti Pariksha
Nidana : Viprakrushta Nidana
Ahara - Alpasana, Anashana, Vishamasana
Viharana - Ati vyayama, Ratri jagarana, Ati chinta

Sannikrushta nidana
Abhigataja, Ati vyayama

Dosa : Vruddha vata, Heena kapha

Dusya : Rasa, Rakta, Mamsa, Medas, Asthi, Majja

Desa : Bhumi desa - Anupa desha

Atura desa - Asthi, Sandhi
DASAVIDHA PARIKSHA cont….

Kala : Nityaga kala - increased in excessive exercise and reduced in rest

Avastika kala - Parihani kala

Bala : Roga bala - Yapya/ Kruchcha sadya

Rogi bala - Madyama

Rupa : hanti sandhi - Destruct the joint structure

Shota - Oedema
Shula - Pain in the joints
Prasarana akunchana vedana – Difficulty in moving of joints
DASAVIDHA PARIKSHA cont….
 Sara pariksha
Rasa - Avara (skin discoloration, dry skin, prabha hani)
Rakta - Avara (Hyper cholesterolemia, no bright lustrous look )
Mamsa - Avara (Emaciated body)
Medas - Avara (Emaciated body, not oily skin, hair, eyes, nails)
Asthi - Avara (bone degeneration, asthi vikrutita, cracked nails, teeth loss)
Majja - Avara (not soft skin and body parts, not strong body parts, no strong joints)
Artava - Avara (menopause)
Satva - Madya (not joyful steady mind, over thinking about her family problems)

 Samhanana : Madya samhanana

 Pramana : Madya pramana

DASAVIDHA PARIKSHA cont….
 Satva : Madya satva

 Satmaya : Sad rasa satmaya

 Ahara Shakti : Abhyavarana Shakti : reduced (avara)

Jarana Shakti : reduced (avara)

 Vyayama Shakti : Earlier – Pravara

After - Avara

 Vayah : Jirana
SROTAS PARIKSHA

 Prana vaha Srotas : Prakruti

 Udaka vaha Srotas : Vikrti (dryness of tongue, dryness of lips, dryness of skin)
 Anna vaha Srotas : Vikrti (Aruchi, Udgara, Adhmana)
 Rasa vaha Srotas : Vikrti (dryness of skin, hyper cholesterol)
 Rakta vaha Srotas : Vikrti (roughness of skin, loss of lusture of skin, dryness of
skin)
 Mamsa vaha Srotas : Vikrti (emaciated body, wasting of muscles, arthralgia)
 Medas vaha Srotas : Vikrti (emaciated body, hyperlipidaemia)
 Asthi vaha Srotas : Vikrti (bone degeneration, pain in bones, extreme debility,
decay
of teeth and nails)
 Majja vaha Srotas : Vikrti (not strong, not prominent joints, joint crepitation)
 Artava vaha Srotas : Prakruti
 Sveda vaha Srotas : Prakruti
 Mutravaha Srotas : Prakruti
INVESTIGATIONS

 FBS
 Lipid profile
 UFR
 ESR
 RF – Rheumatoid factor
 ALP – Alkaline phosphatase level
 X- Ray in R/KJ – AP & Lateral view
 X- Ray in Cervical, Thorasic & Lumbar, (AP & Lateral view)
SAMPRAPTI Sanchaya

Ahara Manasika Antahsravi vikrti Sahaja vikrti

Viharana
Viruddha ahara, Ati shoka (hormonal (Hereditary
Ati vyayama
Vishamasana, Anashana Ati chinta disorders) cuases)
Ratree seeta jala sevana
Alpashana, Katu, Kashaya
Abhigata/ Prapatana
Rasa sevana

Dhatu ksaya Vata Kopa

SAMPRAPTI
Prakopa

Rasa dhatu Asthi dhatu Sthana

Rakta dhatu Prasara through the srotas Sandi samsraya
Mansa dhatu
Medas dhatu
Asthi dhatu
Asthi dhatu kshaya
Majja dhatu
Asthi, Sandi vikriti Sandhi shota, shula Vyakti
Prasarana akunchana vedana
Bheda
SAMPRAPTI GHATAKA

Dosha - Vruddha vata and Heena kapha

Dushya - Rasa, Rakta,Mamsa, Asti, Majja
Adishtana - Shareeika
Srotas - Rasavaha Raktavah,
Mamsavaha, Medo vaha srotas
Astivaha srotas, Majja vaha srotas
Anna vaha srotas Vata vaha Srotas
Srotodushti - Sanga
Rogamarga - Madyama
Utbhavastana - Asthi, Sandi
Agni - Mandagni
Ama - Nirama
Sadya/Asadyata - Kruccha sadya
DIFFERENTIAL DIAGNOSIS

 Āmavāta sandhi śota

 Ġambhīra vāta rakta
 Asthi majjā gata vāta
 Sandhi gata vāta
DIFFERENTIAL DIAGNOSIS cont…

 Āmavāta sandhi śota

अङ्गमर्दोऽ रुचिस्त्रुष्णा ह्यालस्यं गौरवं ज्वरः

अपाकः शूनताऽङ्गानामामवातस्य लक्षणम्
(Ma/Ni/25/6)
Clinical features of Āmavāta

aṅgamardo - pain all over the body aruci - loss of taste

truṣṇā - thirst ālasyaṁ - lack of enthusiasm
gauravaṁ - heaviness of the body jvaraḥ - Fever
apākaḥ - Indigestion śūnatā'ṅgānā - Swelling of the body
DIFFERENTIAL DIAGNOSIS cont…

 Ġambhīra vāta rakta

गम्भीरे श्वयथुः स्तब्धः कठिनोऽन्तर्भृशार्तिमान्
श्यावस्ताम्रोऽथवा दाह तोद स्फु रण पाकवान्

रुग्विदाहान्वितोऽभीक्ष्णं वायुः सन्ध्यस्थि मज्जसु

छिन्दन्निव चरत्यन्तर्वक्रीकु र्वंश्च वेगवान्

करोति खञ्जं पङ्गुं वा शरीरे सर्वतश्चरन्

सर्वैर्लिङ्गैश्च विज्ञेयं वातासृगुभयाश्रयम्
(Cha/ chi/ 29/21-23)
DIFFERENTIAL DIAGNOSIS cont…

Clinical features of Ġambhīra vāta rakta

Shvayathu – Oedema
Stabdha – Stiffness
Kathina – Hardness
Antar bhrusha arti – Excruciating pain in the interior of the body
Shyava tamra tvak – Blackish brown or coppery coloration [of the skin] and
Daha – Burning sensation
Toda – Pricking pain
Sphurana – Twitching sensation
Pakavan – Suppuration of the joints.
DIFFERENTIAL DIAGNOSIS cont…

 Asthi majjā gata vāta

भेदोऽस्थि पर्वणां सन्धि शूलं मांस बल क्षयः

अस्वप्नः सन्तता रुक् च मज्जास्थि कु पितेऽनिले

(cha/chi/28/33)
Clinical features of Asthi majjā gata vāta
Asthi bheda – Cracking of the bones and joints
Parvanam sandhi shoola – Piercing pain in the joints
Bala kshaya – Diminution of muscle tissue and strength
Asvapna – loss of sleep
Santata ruk – Constant pain
DIFFERENTIAL DIAGNOSIS cont…

 Sandhi gata vāta

वातपूर्ण दृतिस्पर्शः शोथः सन्धिगतेऽनिले

प्रसारणाकु ञ्चनयोः प्रवृत्तिश्च सवेदना
(इत्युक्तं स्थानभेदेन वायोर्लक्षणमेव च)
(cha/chi/28/37)
Clinical features of Sandhi gata vāta

Vata purna Druti sparsha shotha – Oedema of the joints which, on palpation, appears
as if it is a leather bag inflated with air

Prasarana aakunchana pravritti vedana – Pain while making efforts for extensions
and contraction of the joints.
DIFFERENTIAL DIAGNOSIS cont…

 Sandhi gata vāta

According to Susruta nidana

हन्ति सन्धि गतः सन्धीन् शूलशोफौ करोति च

(Su/Ni/01/28)
Loss of function, pain and swelling in joints

According to madava nidana

हन्ति सन्धि गतः सन्धीन् शूला टोपौ करोति च

(Ma/Ni/22/21)
Loss of function, pain and cracking sound in joints
DIFFERENTIAL DIAGNOSIS cont…

 Sandhi gata vāta

According to Ashtanga hrada samhita

वातपूर्णद्रुतिस्पर्श शोफं सन्धिगतोऽ निलः

प्रसारणाकु ञ्चनयोः प्रव्रुत्तिं च स वेदनाम्
(Su/Ni/01/28)
DIFFERENTIAL DIAGNOSIS cont…

 Sandhi gata vāta

According to all authentic text

Joint pain (sandhi sula)

Joint swelling (sandhi sopha/ sotha)
Vata purna drutisparsha
Loss of function (hanti sandhi)
Pain on movement (prasarana kunchana vedana)
Cracking sound (atopa)
FINAL DIAGNOSIS
In Ama vata - Nidana - Ama producing ahara & viharana
associated with jvara & amaja characteristics
start from small joints of hands & spread

In Gambhira vata rakta - Nidana - Vata & Rakta kopakara ahara & viharana
start from end parts of the hands and feet

In Asthi majja gata vata - Nidana - Vata kopakara ahara viharana

nidra alpa & constant pain present

In sandhi gata vata - Nidana - Vata kopakara ahara viharana

sandi shota, shula, prasarana kunchana vedana present

According to clinical features of this patient – Sandhi gata vata

LINE OF TREATMENT

स्नेहोपनाहाग्निकर्मबन्धनोन्मर्दनानि च
स्नायुसन्ध्यस्थि सम्प्राप्ते कु र्याद्वायाव तन्द्रितः
(Su/ Chi/04/08)
Sneha, upanaha, Agni karma, bandhana, Mardana

स्राव सन्धि शराप्राप्ते स्नेहदाहोपनाहनम्

तैलं सङ्कु चितेऽभ्यङ्गो माष सैन्धव साधितम्
(Ah/ Chi/21/22)
Sneha, dahana, upanaha, taila abhyanga (mixed with masha, saindhava)

स्नेहोपनाहाग्निकर्मबन्धनोन्मर्दनानि च
स्नायुसन्ध्यस्थि सम्प्राप्ते कु र्याद्वाते विचक्षणः
(C.D/ 22/09)
Sneha, upanaha, Agni karma, bandhana, Mardana, vata shamana treatment
LINE OF TREATMENT

स्नायु सन्ध्यस्थि सम्प्राप्ते कु र्याद्वाते विचक्षणः

स्वेद उपनाह सम्मर्द स्नेहनादिक मादरेत् (Y.R/
vata /119)
Sveda, upanāha, sammarda, snehanā

TREATMENT BASED ON

 vāta śamana cikitsā / vāta prabala vāta rakta cikitsā

 poṣaṇa cikitsā (for asthi & sandhi)
TREATMENTS

Internal Treatments
rāsnā paṁcaka kaṣāya pata ½ bd
rāsnā saptaka kaṣāya pata ½ bd
rāsnā daśamūla kaṣāya pata ½ bd For vata shamana
rāsnā viśva kaṣāya pata ½ bd
danti mūlādī kaṣāya pata ½ bd
rāsnā śigru kaṣāya pata ½ bd

Internal Treatments for vatadika vata rakta (associated with inflamation)

vāsā gudūcī kaṣāya pata ½ bd

sinhāsya pancamūlee kaṣāya pata ½ bd
cinnā balā viśva daśāngri rāsnā kaṣāya pata ½ bd
TREATMENTS

māśa balā śuka śimbī kaṣāya pata ½ bd

māśātmagupta vātārī kaṣāya pata ½ bd
rāsnā dvī guṇa kaṣāya pata ½ bd For tarpana
rāsnā 32 kaṣāya pata ½ bd
mahā rāsnādiya pata ½ bd
TREATMENTS

Internal Treatments

Guggulu Vati

Yogaraja Vata gajendrasinha vati

Sinhanaada guggul Rasona vati
Raasnadi guggul
Trayodashanga guggul

Rasayana oushada

Ranahansa rasayana
Ashwagandha rasayana
TREATMENTS

External Treatments

Oil for vata shaman & srotas shodhana Pottali

Shula hara oil Aba, Murunga pottali
Sharshapa oil Nika kola pottali
Nirgundyadi oil Pawatta kola, Nika koladi pottali

Oil for vata shaman & poshana Pottali for vata shaman & poshana
Narayana oil Punnagadi pottali
Pinda oil Tala shatakuppa pottali
Divyanganadi oil
Ashwagandha oil
Ksheera bala oil
TREATMENTS

External Treatments

Lepa

Tala pattuwa
Dashanga lepa – boild with cows milk & grind with ghee
Dashanga lepa with domba oil
Lakshadi lepa – mixed with ghee & honey
Bone marrow pattu
TREATMENTS

Panchakarma Keraleeya Panchakarma

Sneha Abhyanga & Nadi sweda

Sweda Pichu dharana
Virechana – Mrudu vireka Kati vasti
Nasya Greeva vasti
Vasti – Anuvasana vasti Janu vasti
(Hingu triguna oil, Eranda, Bala koranda)
PATHYAPATHYA

Pathya Ahara Apathya Ahara

Vata shamaka ahara Vata vardhaka ahara

Nutritive foods

Pathya Viharana Apathya Viharana

ushna jala sevana Ratree jagarana

Yogya vyayama & rest (blend of work & rest) Diva nidra
Manasika vega dharana
Sita jala sevana
Ayurveda Nidana & Samprapti of Vata Roga

रूक्ष शीताल्प लघ्वन्न व्यवायाति प्रजागरैः

विषमादुपचाराच्च दोषासृक्स्रवणादति
लङ्घन प्लवनात्यध्व व्यायामातिविचेष्टितैः
धातूनां सङ्क्षयाच्चिन्ता शोक रोगातिकर्षणात्
दुःख शय्यासनात् क्रोधाद्दिवास्वप्नाद्भयादपि
वेगसन्धारणादामादभिघातादभोजनात्
मर्माघाताद्गजोष्ट्राश्व शीघ्र यानापतंसनात्

देहे स्रोतांसि रिक्तानि पूरयित्वाऽनिलो बली

करोति विविधान् व्याधीन् सर्वाङ्गैकाङ्ग संश्रितान्

(Cha/chi/28/15-19)
 OSTEOARTHRITIS
(Degenerative artheritis/ Osteoarthrosis/ Hypertrophic Artheritis)

 Osteoarthritis is a non inflammatory, degenerative condition of joints

characterized by degeneration of articular cartilage and formation of new
bone (Osteophytes)

 Common in weight bearing joints such as hip and knee

 Also seen in spine and hands

 Both male and females are affected but more common in older women
(post menopausal age)
OSTEOARTHRITIS cont…

Risk factors

 Obesity specially for osteoarthritis in knee

 Abnormal mechanical loading
 Inherited type II collagen defects in premature polyarticular OA
 Inherited in nodal OA
 Occupation
 Infection (septic arthritis)
 Hereditary
 Ageing process in joint cartilage
 Defective lubricating mechanism
 Incompletely treated congenital dislocation of hip
OSTEOARTHRITIS cont…
Classification of OA

Primary Secondary
Osteoarthritis Osteoarthritis

 Due to predisposing causes such

 More common than secondary OA
 Cause unknown as,
 Injury to the joint
 Common in elders where there is
 Previous infection
no previous pathology
 RA
 Mainly due to wear and tear
 CDH
changes occurring in old ages
 Deformity
 Mainly in weight bearing joints
 Obesity
 Hyperthyroidism
OSTEOARTHRITIS cont…

Types of OA

Nodal generalized OA Crystal associated OA OA of premature onset

 Herberden’s nodes  Calcium

 Bouchard’s nodes pyrophosphate
 CMC of thumb  Dihydrate occurs  Previous meniscectomy
 Hallux Valgus/ rigidus  Mainly in elderly  Haemochromatosis
 Knees & hips  Women principally
Apophyseal joints  Affects the knee
OSTEOARTHRITIS cont…

Pathology

 OA is a degenerative condition primarily affecting the articular cartilage

Articular cartilage
Bone
Synovial membrane
Capsule
Ligament
Muscle
OSTEOARTHRITIS cont…
OSTEOARTHRITIS cont…
OSTEOARTHRITIS cont…

Osteoarthritis effects on Capsule Osteoarthritis effects on Ligaments and muscles

OSTEOARTHRITIS cont…
Clinical features of OA

 Pain
 Stiffness
 Muscle spasm
 Restricted movements
 Deformity
 Muscle weakness or wasting
 Joint enlargement and instability
 Crepitus
 Joint effusion
OSTEOARTHRITIS cont…
Radiographic Classification

 Stage I Bony spur only

 Stage II Narrowing of joint space, less than half of the normal joint space

 Stage III Narrowing of joint space, more than half of the normal joint space

 Stage IV Obliteration of joint space

 Stage V Subluxation or sec. lateral arthrosis

OSTEOARTHRITIS cont…
OSTEOARTHRITIS cont…
Special Investigation

Blood tests normal

Radiological features

Cartilage loss
Subchondral sclerosis
Cysts
Osteophytes
OSTEOARTHRITIS cont…
Thank you