clinical presentation on osteoarthritis (sandhi gata vata)

2014.09.16

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OUTLINEOUTLINE

q Objectivesq Case presentation

o Complaints of the patiento Clinical Examinationo D/ Do Diagnosiso Review of Ayurveda

q Review of Modern

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OBJECTIVESOBJECTIVES

¨ 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

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CASE SUMMARYCASE SUMMARY

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¨ 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

CASE PRESENTATIONCASE PRESENTATION

q Name : Mr K. M Silva

q Age : 52 Yrsq Address : Udubeddawa, Kuliyapitiyaq Nationality : Sri Lankanq Religion : Buddhistq Marital Status : Marriedq Date of Admission : 11th July 2014 (Ward 09)

q Ward No : 11q Bed No : 22q Occupation : Mechanic for 16 yrs, Concrete

worker for 5 yrs

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MAIN COMPLAINT & DURATIONMAIN COMPLAINT & DURATION

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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

No other compliansOTHER COMPLAINTS & DURATIONOTHER COMPLAINTS & DURATION

o According to the patient, before 20 yrs; asymptomatico 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 Jointso Deviation of the RT Knee joint has noticed before 3 yearso 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

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q Medical History

Hypertension 0 , Diabetes Mellitus 0 , Hypercholesteremia 0

q Surgical History

q Psychiatric History

q Treatment History • Pain killers only

• Admitted for Ayurvedic treatment for the first time on 11th

July 2014 to ward No 09 & then shifted to ward No 11

NA

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80 yrs

52 yrs

IHD

70 yrs

20 yrs 12 yrs

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o Diet: Break fast - Not taken usually

Lunch - Not taken usuallyDinner - 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 outsideWater intake: Sufficient

o Appetite: Not changed due to the diseaseo No allergies for any kind of food

20- 30 yrs

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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

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o Bowel habits : Once/ DayColour - YellowOdour - Normal

o Micturition : D- 3 / N -1 timesColour - PaleOdour - Normal

o Social status : Living near to the river side

o Occupational history: Mechanic – Long term standing, Night shift

Concrete worker – Heavy lifting

o General condition - Weak o BP - 130 /80 mmHg o PR - 74 / mino RR - 14 / mino Weight - 38 kgo Height - 5 Fto Tongue - Not coated (Niräma) o Temperature - Normalo Skin - Normal

GENERAL PHYSICAL EXAMINATION

o Pallor - Mild

o Thyroid

o Icterus

o Cyanosiso Clubbingo Enlarged LN

NADNAD

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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

• Interphalangeal joints (RT)– Extension is limited

q Gait: Painful & Difficult (Pain while waliking in LT HIPJ & RT KJ)

Limited due to edema , pain & deformity

Limited due to edema & pain

SYSTEMIC EXAMINATION

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Limited due to edema , pain & deformity

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

JOINTS

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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

Spine17

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

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NAD clinicaly

1. Nädi: i. Gati - 74/ min ii. Yati - Samäntaraiii. Akåti - Pürnaiv. Samhati - Mådu

2. Mutra : D - 3/ N -1 times3. Mala : Once/Day, Samhata mala4. Jihvä : Niräma5. Çabda : Prakåta Håd & Pupphuça çabda6. Sparça : Sandhi sphuöana7. Dåk : Prakåta8. Akåti : Deviation & enlargement of RT Knee Joint, enlargement

of both Elbow joints Nodules in PIPJ & DIPJ

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I. Prakåti : Väta Kapha / Rajas TamasII. 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, Kaphao Düñya - Rasa, Rakta, Mämsa, Medas, Asthi, Majjäo Prakåti - Väta, Kaphao Deça - Asthi Sandhio Käla - Cira kälao Bala - Roga bala: Kåccha sädhya

Ätura bala: Madhyamao Lakñana - Prasäraëäkuaïcana vedanä, Sandhi çotha & Vikåtio

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21III. 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 AfterPrawara Madhya

X. Vayah : Madhyama (52 Yrs)

1. Präëa vahä Srotas2. Udaka vahä Srotas3. Çukra vahä Srotas4. Mutra vahä Srotas5. Puriña vahä Srotas6. Sweda vahä Srotas7. Mano vahä Srotas

8. Rasa vahä Srotas : Vikåti9. Rakta vahä Srotas : Vikåti10. Mämsa vahä Srotas : Vikåti (Mäàsa çoña)11. Medo vahä Srotas : Vikåti (Kñudra Sandhi Çula+ )12. Asthi vahä Srotas : Vikåti13. Majjä vahä Srotas : Vikåti14. Anna vahä Srotas : Vikåti15. Väta vahä Srotas : Vikåti (Gati Daurbalya)

Prakåti

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(Sandhi Çula+, Çota + , Sandhi sphutana)

(Päëdu (Anaemic))

ÄharaViñamäçana, AnäçanaAlpäçana, Katu, KañäyaRasa,Tékñëa, Snigdha, Guru guëa Atisewana

ViharanaÇéta jala sewana, Ati çrama

Mänasika

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Asthi vahä SrotasVäta vahä SrotasMajjä vahä SrotasMedo vahä Srotas

Circulation throughthe Srotas

Dhätu kñaya Väta Kopa

Rakta vahä Srotas

Anna vahä Srotas

Rasa vahä Srotas

Çleñaka kaphaAsthi dhätu kñaya

Khavaiguëya in Sandhi

• Sandhi çotha• Prasäraëäkuìacana

vedanä• Vätapurëa drutisparça

Vyakti

PrasaraSaïcaya

Prakopa

Sthäna Saàçraya in Sandhi

Sandhi VikåtiBheda

q Doña : Väta Vitiated, Kapha Dicreasedq Düñya : Rasa, Rakta, Mämsa, Medas, Asthi, Majjäq Adiñtäna : Çärérikaq Srotas :

q Samutthäna : Pakväçayaq Agni : Viñamaq Äma : Nirämaq Srotoduñöi : Saìgaq Udbhawa sthäna : Asthi Sandhiq Roga märga : Madhyama (Marma, Asthi, Sandhi)q Sädhya Asädhyatä : Kåccha sädhya

Rasa Vahä Srotas , Rakta Vahä Srotas

Mämsa Vahä Srotas, Medo Vahä Srotas

Asthi Vahä Srotas, Majja Vahä Srotas

Anna Vahä Srotas, Väta Vahä Srotas

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q FBS - 99 mg/dl (2014.07.23)

q UFR Reaction - AcidicPus cellsEpithelial cells

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+

Occasional

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1. Ämaväta Sandhi Çotha

2. Gambhira Väta Rakta

3. Asthi Majjä Gata Väta

4. Kroñöuka Çérña

5. Sandhi gata Väta

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

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Ca Ci 29/ 21-23

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

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q Väta & Rakta getting affected together produces;

q A very painful swelling of the knee joint resembling the head of the big fox

Su Ni 1/ 76

Ma. Ni 22/ 58

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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

Ca Ci 28/ 37

Su Ni 1/ 27-2, Yo .Ra V.V/ 1

As Hri Ni 15/14

Ma. Ni 22/ 21

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RÜPARÜPA --

Ca.Sa Su. Sa As Hri As Sa Ma.Ni Yo Ra Bha Pr

Sandhi Çüla (Joint pain)

+ + + + + + +

Sandhi çopha/çotha(Joint Swelling)

+ + + + + +

Vätapurëadrutisparça

+ + +

Hanti Sandhi (loss of function)

+ + +

Prasäraëäkuìacanavedanä (Pain on movement)

+ + +

Ätopa (cracking sound )

+

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ÄMAVÄTA SANDHI GATA VÄTA

GAMBHIRA VÄTA RAKTA

Nidäna Viruddha Ähara, Snigda Ähara, Alpachesta etc.

Väta kopakaraÄhara, Viharaëa

Väta & Raktakopakara 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

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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 Prasäraëäkuìacanavedanä

DIAGNOSIS

¨ Sandhi Gata väta

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CIKITSÄ

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k…yaRÖate ivc][>

Su Ci 4 /8

As Hri Ci21/ 22

C.D 22/ 9

CIKITSÄ CONT.

Treatment Su. Ci As Hri As Sa Bha Pr Bha Ra Yo Ra C.D

Snehana + + + + + +

Abhyanga +

Mardana + + + + +

Svedana + + +

Upanaha + + + + + + +

Bandhana + + + +

Agnikarma + + + + +

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A_y¼ < Svedn< biStnRSy< õehivrecnm! iõGxaMllv[< SvaÊ v&:ym! vatamyaphm!.

CIKITSÄ CONT-VÄTA VYÄDHI CIKITSÄ

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o Abhyaìgao Svedanao Vastio Nasyao Sneha yukta virecanao Snigdhao Amlao Lavaëao Svädu

Yo Ra V. V Ci/ 1

Rasa

CIKITSÄ CONT.

¨ Bahih parimärjana- Sneha (Abhyanga)- Sweda

¨ Anthah parimärjana- Mådu çodhana

¨ Paìcha karma-Virechana (Sneha yukta)- Vasti- Nasya

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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

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From 25.08.2014 - 01.09.2014¨ Räsna 7 Decoction, Pata ½ bd

¨ 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

From 01.09.2014 to 16.09.2014

¨ 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

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¨ Nika kola pottali Pinda sweda (pottali)¨ Punnagädi pottali¨ Picu Däraëa¨ Jänu Vasti

q Anuvasana Vasti- Eraëda, Balä Koraëda, Hingu triguëa Taila

q Ranahansa Rasäyanaq Açwagandhä Rasäyana

Pathya Ähära

¨ Steamed red rice

¨ Patola

¨ Murunga

¨ Kohila

¨ Wetakolu

¨ Fish

Pathya Viharaëa

¨ Uñëa jala Sevana(snäna)

¨ Vyäyäma

Apathya Ähära

¨ Foods which are Vätavardhaka

¨ Madya

Apathya Viharaëa

¨ Rätree jägaraëa¨ Divä nidrä¨ Krodha , Çoka¨ Séta sparça (Bathing cold

water)

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• 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

Disease Cikitsa47

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¨ Nidäna¨ Pürwa rüpa¨ Sampräpti¨ Sädhya Asädhya Bhäva

¨ Rüpa¨ Cikitsä

Not mentioned Separately

Only mentioned

NIDANANIDANA

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Ca. C 28/15-18

NIDNIDÄÄNANA

ÄhäraDue 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

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NIDANANIDANA CONT.CONT.

Mänasika

¨ Anger

¨ Anxiety

¨ Grief

Faulty therapeutic management

¨ Excessive elimination of impurity & blood

¨ Wasting of dhatus

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SAMPRSAMPRÄPTI

Aggravated vayu Filling up vacant channels of the body

Make disorders in

Entire body One part of the body

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Ca Ci 28/ 37

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OSTEOARTHRITISOSTEOARTHRITIS

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)

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Joints- most commonly involved 55

o Hand - DIP Joint- First CMC Joint

o Foot - First MTP joint

o Weight bearing joints- Vertebra- Hip- Knee

Classification of Osteoarthritis

2 types1. Primary osteoarthritis2. Secondary osteoarthritis

Primary osteoarthritisq Osteoarthritis not resulting from injury or

diseaseq Cause is unknown

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Types of Osteoarthritis Cont.

2. Secondary osteoarthritis Form of osteoarthritis that is caused by another disease or condition.

q Obesityq Repeated trauma or surgery to the joint structures q Abnormal joints at birth (congenital abnormalities)

Goutq Diabetes and q Other hormone disorders

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Risk Factors

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¨ 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

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

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Nodal osteoarthritis

Bony enlargement of

o Distal interphalangeal joint- Heberden's nodes

o Proximal interphalangeal joint- Bouchard's nodes

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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

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Pathophysiology Cont

¨ OA affects all of the weight-bearing components of the joint:

• Articular cartilage• Menisci• Bone

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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.

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Pathophysiology Cont

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

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D/DCriteria 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 Metatarsophalangeal joints

4.Systemic features

NA Auto immune diseases, rise in temperature,anemia

NA

5.Pathologicalphenomenon

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,

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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

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Radiographic Diagnosis

•Narrowing of the joint space

•Periarticularsclerosis

•Osteophytes

•Sub-chrondralbone cysts

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• Asymmetrical joint space narrowing from loss of articularcartilage

• The medial (inside) part of the knee is most commonly affected by osteoarthritis.

Radiographic Diagnosis cont

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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

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Bow-legged appearance

Bony spurs

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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 Painü Improve Joint Functionü Increase muscle strengthü Maintain Normal Weight

Disease Management

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OA – Non-operative Treatments

•Pain medications•Physical therapy•Walking aids•Shock absorption•Re-alignment through orthotics•Limit strain to affected areas

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