Arthritis (sandhivat): An overview
by Alakananda Devi (Alakananda Ma), M.B., B.S. (Lond.)
In this article we will give a general overview of arthritis or sandhivat and its relevance in an Ayurvedic practice, saving specialized topics of each specific type of arthritis for later articles. We will particularly consider three major common arthritic conditions: rheumatoid arthritis (ama vata), gout (vatarakta/vatashonita) and osteoarthritis.
Arthritis is an inflammatory condition of one or more joints, manifesting typically with pain, tenderness, swelling, and morning stiffness of the affected joint or joints. Since joint cartilage is an upadhatu of asthi dhatu, the condition results from invasion of doshas into asthi. Sleshak kapha may be dried up by vata (ruksha) or burnt by pitta ama, while vyana vayu may by blocked in the affected joints, cause roughening (khara) of the articular surfaces. Occurrence of arthritis indicates the vyakti stage of disease, which may have been preceded by joint discomfort or cracking and popping during the sthana samshray stage. Left untreated, most arthritic conditions progress to the bheda stage with deformity, destruction of the articular surface and loss of function.
Arthritis is a common condition affecting both women and men, especially in the latter decades during the vata time of life. Rheumatoid arthritis affects approximately 1% of the population with woman being affected three times as often as men. (1) Gout likewise affects 1% of the population with men affected twice as often as women (2), while osteo-arthritis is extremely common, affecting over 20 million individuals in the United States alone (3). By some estimates, more than half of adults over sixty five are affected by osteoarthritis. With the greying of the boomer generation, a segment of the population often interested in yoga and alternative therapies, more and more clients with osteoarthritis are likely to present for Ayurvedic therapies.
Of the three types of arthritis we are considering, rheumatoid arthritis is most often seen in vata prakruti, gout in pitta or pitta-kapha prakruti, while osteoarthritis typically may be seen to have a kapha component. At the same time it is important to appreciate that vata plays an important role in all forms of sandhivat. “If vata is localized in the joints, it causes loss of function, pain and cracking sound in them.” (4). “If vata is located in a joint there occurs swelling like an air-filled bladder in touch and pain during contraction and extension of limbs.”(5). Ayurvedic therapies for arthritic conditions should always be individualized based on the prakruti-vikruti paradigm, for there is no short and simple explanation of doshic involvement per Western biomedical diagnostic label.
A rheumatologist based in Pune, Dr Aravind Chopra, concluded after study of Charak Samhita and Madhava Nidhan that classical descriptions of arthritic diseases cannot be accurately matched with the disease entities currently described in Western biomedicine (6). This is in part because ancient physicians had many forms of arthritis to contend with including infective arthritis such as syphilitic arthritis and hereditary afflictions like haemophiliac arthritis, and in part because of the diagnostic methods used. Darshanam, sparshanam and prashanam (inspection, palpation and clinical interview)will lead to an individualized diagnosis whereas the syndromes described in modern rheumatology are more standardized and by definition based upon laboratory results. Rheumatoid arthritis is diagnosed based on the presence of rheumatoid factor, gout on uric acid levels and the diagnosis of osteoarthritis is typically based on radiology. In practice, the client with arthritis is likely either to present with a diagnosis from a rheumatologist or to need referral for a definitive Western diagnosis.
Ayurveda offer a unique perspective on arthritis through the concepts of agni and ama. Due to vitiation of agni, particularly visham agni, ama accumulates in the gut and is then carried by vata to the joints. As Chopra points out, modern biomedicine has validated the link between arthritis and the gut as the cause of “various forms of seronegative arthritis and post-infective and reactive arthritides” (6). The treatment model used in Ayurveda thus includes a process for returning the toxins to the gut for excretion, rehabilitation of agni and lifestyle and dietary changes to address the initial cause of vitiation of agni and build-up of ama.
In the case of rheumatoid arthritis, because of the severity of the illness and relative effectiveness of Western treatments, it is wise for the Ayurvedic practitioner to remain in a complementary role, with special focus on ama and agni as well as palliative therapies. Where osteoarthritis is concerned there is no effective Western treatment, which leaves room for the Ayurvedic practitioner to do whatever he or she can. Even if the net gain is nothing more than a few years longer until joint replacement is required, this is still a benefit for the client because joint replacements do not last for ever. Gout, on the other hand, is eminently treatable with lifestyle changes, an Ayurvedic area of expertise. Charak lists foods now known to be high in uric acid as causative factors for vatashonita. “Meat of aquatic and marshy animals…horse gram, black gram…vinegars, alcohol, incompatible food…aggravate vata rakta”. Pitta soothing diet and lifestyle with particular emphasis on reducing red meat and eliminating alcohol will produce great effects.
The treatment of arthritis is a partnership between practitioner and client (and, in an ideal situation, the client’s rheumatologist). Both palliative and deeper therapies should form part of the plan. At the outset, define the goals. Rheumatoid and osteoarthritis are yapya conditions and are manageable rather than curable. Depending upon the individual’s stage of progression of the disease and the prognosis they have received from their rheumatologist, a valid goal could be disappearance of symptoms, reduction of symptoms, non-progression of the disease or, in the worst case, slower rate of disease progression. It is important for the client to understand the goals and to appreciate the potential outcome of their efforts. It is preferable to get a better-than-expected outcome than to be disappointed. Asses the individual’s level of disability in terms of everyday tasks such as unscrewing jars, turning keys or brushing hair as well as distance they can walk before being limited by pain. Progress is best monitored by subjective charting. If the client records pain and stiffness every morning, using a one to ten scale, recording this on a simple chart, overall trends will be clearly visible despite the daily ups and downs. The client’s lifestyle can be examined in light of their arthritic condition and appropriate adjustments suggested. For one Vata with arthritis, this meant hiring someone to clear her driveway on snowy mountain days or else moving out of the mountains, since a morning of snow removal work inevitably led to an exacerbation of symptoms.
Palliative therapies include daily massage of affected joints with Mahanarayana oil, heat treatments, particularly Ginger baths (ginger is anti-inflammatory) and Turmeric soaks as well as anti-inflammatory home remedies such as Ginger tea. Joint Balm is a valuable palliative and supportive remedy that provides analgesic and anti-inflammatory qualities and makes use of the virtues of castor oil in relieving joint pain and inflammation. Yoga should be approached cautiously with the assistance of qualified yoga therapist. It is crucial that clients with arthritis take ample time to warm up their joints before asana practice or indeed any form of exercise. Yoga can be quite hand-intensive and many with arthritis have affected hands. However, practised with due caution, yoga, swimming and walking are important for maintaining strength and flexibility in the affected joints.
Deeper therapies for arthritis typically begin with rakta shodhan (blood cleansing). One can use an individualized formula or pre-mixed blend such as Blood Cleanse (easier for busy clients to take). Anti-inflammatory blood cleansers such as Turmeric and Guduchi have a pre-eminent role in such formulas. If krumi (parasites) are suspected, the rakta shodhan phase of treatment should include krumighna herbs such as Vidanga or a formula such like Paracleanse. During the period of rakta shodhan Triphala can also be taken to help remove ama and a lighter, cleansing diet can be taken. This is a good time to do an elimination diet if food allergies or sensitivities e.g. to gluten or casein are suspected. Agni dipan and ama pachan herbs should also be used at this time—Dashamoola for vishamagni, mustha or fennnel for tikshnagni and chitrak for mandagni are typically good choices.
Following rakta shodhan, pancha karma can be initiated if there are no contra-indications. Purva karma, the preliminary practices, help return the doshas to their seats in abhyantara marga (the digestive tract) while the five actions themselves, particularly virechan and basti, eliminate the toxins from the digestive tract. Mahanarayana oil can be used as either the main abhyanga oil or as supplementary oil massaged on affected areas such as hands and feet prior to the abhyanga proper. Dashamoola can be used in the herbalized steam and dosha specific herbs for basti can be combined with Triphala for deeper cleansing of toxins. Improvement following pancha karma is not necessarily linear. One patient with rheumatoid arthritis experienced an initial improvement in energy, followed by a three month exacerbation of symptoms. During this period we used Simhanad Guggulu, which contains castor oil. It is said that “Only the lion of castor oil can control the mad elephant of rheumatoid arthritis when it is charging through the tissues.” Following this extended period of release of toxins, she felt better than she had ever felt since the diagnosis was made, and began preparing confidently for a second round of pancha karma.
Rasayana therapies follow pancha karma. This is the time when anti-arthritic herbs such as Boswellia, and vata rejuvenatives like Ashwagandha will have their maximum impact. Guggulu compounds will similarly be more effective following pancha karma. A word of caution here. One traditional guggulu formula which has often been favoured for arthritis is mahayogaraj guggulu. Here is an account recorded in a peer reviewed article authored at an Indian toxicology unit. “…a 70-year-old male patient referred to the ADR monitoring cell…was taking a 'herbo-mineral' preparation 'Mahayograj Guggul' in the dose of 4 tablets three times a day, for the complaints of joint pains for well over two years. He got relief from the arthritis but developed symptoms of lead poisioning including severe anaemia with classic basophilic stippling of the RBCs” (8). Rasa sindoor or lead is an intentional ingredient of mahayogaraj guggulu. This report serves to remind us that relief of arthritis symptoms must occur in a context of overall safety by using organic, tested herbs from reliable sources, such as the preparations featured here. In general, Yogaraj Guggulu is likely to be best for Rheumatoid arthritis, Kaishore Guggulu for gout and Triphala Guggulu for osteoarthritis, although allowance should be made for variations both in prakruti and seasons.
Following rasayana, a maintenance program includes continuing use of herbs that support the joints and have anti-inflammatory effects, such as Boswellia, Guggulu, Guduch and Turmeric, as well as preparations like Triphala to continue the gentle reduction of ama. A formula such as Joint Support, which includes the above-mentioned herbs, is valuable at this time.
Although Ayurveda does not delineate specific arthritic syndromes in the same way as modern bio-medicine, we have seen that it has a vital role to play in the management of rheumatoid arthritis, gout and osteoarthritis. While there are many Ayurvedic treatments that provide good palliation of arthritis, Ayurveda’s special emphasis on ama and agni gives an opportunity for reaching a deeper level of healing.
- Randall King MD Rheumatoid Arthritis July 2006 http://www.emedicine.com/EMERG/topic48.htm
- Mark L Francis MD Gout Aril 2006 http://www.emedicine.com/med/topic924.htm
- Carlos J Lozada, MD Osteoarthritis Oct 2008 http://www.emedicine.com/MED/topic1682.htm
- Madhava NidhanamCh22 v21 tr Srikantha Murthy Chaukhambha Orientalia Varanasi 2007
- Charak Samhita, Chikitsathanam xxviii, 37 Tr PV Sharma Chaukhambha Orientalia Varanasi
- Ayurvedic Medicine And Arthritis . Rheumatic Disease Clinics of North America , Volume 26 , Issue 1, Pages 133 - 144 A . Chopra This article is well worth reading and a pdf version can be found at www.bioved.com/images/Ayurvedic%20Medicine%20and%20Arthritis.pdf.
- Charak Samhita, Chikitsathanam xxix 9 op.cit.
- UM Thatte, NN Rege, SD Phatak, SA Dahanukar The flip side of Ayurveda Journal of post graduate medicine 1993, vol 39, issue 4 179-82,182a
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Alakananda Devi (Alakananda Ma) is director of Alandi Ayurvedic Clinic in Boulder, Colorado, and principal teacher of Alandi School of Ayurveda, a traditional ayurvedic school and apprenticeship program. She can be reached at 303-786-7437 or by email at: firstname.lastname@example.org.