Effect of Sri Lankan traditional medicine and Ayurveda on Sandhigata Vata (osteoarthritis of knee joint).

Reported case was a 63-year-old female with end-stage osteoarthritis (OA) (Sandhigata Vata) of the left knee joint accompanied by exostoses. Radiology (X-ray) report confirmed it as a Kellgren-Lawrence grade III or less with exostoses. At the beginning, the Knee Society Rating System scores of pain, movement and stability were poor, and function score was fair. Srilankan traditional and Ayurveda medicine treatment was given in three regimens for 70 days. After 70 days, external treatment of oleation and 2 capsules of Shallaki (Boswellia serrata Triana and Planch) and two tablets of Jeewya (comprised of Emblica officinalis Gaertn., Tinospora cordifolia [Willd.] Millers. and Terminalia chebula Retz.), twice daily were continued over 5 months. Visual analogue scale for pain, knee scores in the Knee Society online rating system and a Ayurveda clinical assessment criteria was used to evaluate the effects of treatments in weekly basis. After treatment for 70 days, the Knee Society Rating System scores of pain, movement and stability were also improved up to good level and function score was improved up to excellent level. During the follow-up period, joint symptoms and signs and the knee scores were unchanged. In conclusion, this OA patient's quality of life was improved by the combined treatment of Sri Lankan traditional medicine and Ayurveda.

Introduction

Main aims of the clinical trials are to show the efficacy and safety of a therapy after initial indications are determined in preclinical studies, but the results obtained from a clinical trial have become less important in identifying the specific indications of a therapy.[1] At present, “omics” based pharmacology contributes to individualized medicine, which attempts to find more specific indications for therapies by identifying biomarkers[2] rather considering cohorts of the population. Similarly, Ayurveda and Sri Lankan Traditional Medicine (STM) generally prescribe therapies based on the identification of individual or the specific patterns of the patient by analyzing the symptoms and other characteristics. Therefore, case studies give much more confidence to clinicians in traditional medical systems rather than analyzing different cohorts.

Osteoarthritis (OA) of the knee is a degenerative disease of the knee joints which significantly restricts the functions of knee joints. Janu Sandigatavata is considered to be its close equivalent to OA in Knee of modern medical science. In old age, there is progressive decaying in the body structures resulting in various degenerative disorders including Sandhigatavata due to the predominance of Vata.[3] The objective of the treatment is to decrease pain while attempting to maintain or increase the range of knee motion and to minimize disabilities in daily living activities. The conventional pharmacological management of OA includes the administration of analgesics and nonsteroidal antiinflammatory drugs (NSAIDs), but their use neither provides adequate pain relief nor deceleration in disease process. In addition, NSAIDs are associated with serious adverse effects, at least some of them may be may be related to the pharmacogenomical incompatibility. Most of the time, the traditional medicine and Ayurveda have used individualized pharmacogenomical assessment (Prakruti) approach to the patient. In order to capture that concept into the picture, targeted individualized pattern based black box method[4] of treatments for management of Janu Sandigatavata in this reported case.

Case Report

Reported case was a 63-year-old female patient with end-stage OA of the left knee joint accompanied by exostoses. When patient was 49 years old, developed a pain in the left knee joint, and early-stage OA of the knee joint was diagnosed by X-ray. Therefore, patient took NSAIDs and received conservative therapies and steroidal injections to the knee joint. However, pain in the knee joint progressively increased; on the other hand, activities of daily living (ADL) decreased with age while patient continued to receive the conservative therapies. At the age of 62, she consulted to Department of Indigenous Medicine, requesting STM. Patient reported pain in the left knee joint while walking and showing a Kellgren-Lawrence[5] grade III or less in the radiographs with exostoses [Figure 1]. Patient gave a self-reported visual analogue scale (VAS) pain score of between 7 and 8, which was moderate to severe pain according to the scale. Also, knee had a clinically detectable joint effusion. According to online Knee Society clinical rating system,[67] final grading score of pain and stability was 43 (i.e., poor) and knee function score was 60. Pateint was diagnosed as having OA of the knee.

Figure 1

Radiograph Findings: Kellgren-Lawrence grade III or less: (a) Degenerations, (b) spurs, (c) narrowing bone space (d) exostoses

Sri Lankan traditional and Ayurvedic medicine formulae were given in black box method in three treatment regimens. All the test drugs used in treatment were prepared according to the authentic texts and Ayurvedic Pharmacopeia.[8]

First regimen (day 1–14)

A volume of 120 ml of Kwatha (decoction) of Eranda Saptaka decoction and 120 ml of Punarnavashtaka decoction twice a day before meals, two pills of Yogarajaguggulu (250 mg) with lukewarm water and Chandra Kalka [Table 1][9] (as pill of 250 mg) with 40 ml of Mahadalu Anupana [Table 2][9] 2 times a day for 12 days twice a day after meals were given.

Table 1

Ingredients of Chandra Kalka

Table 2

Ingredients of Mahadalu Anupana

Nirgundi oil (30 ml) was applied on Janu Pradesha (knee joints). Then, in every afternoon at 2.00 p.m., 30 g of paste of Murungadi Pathtu [Table 3] (Sri Lankan traditional herbal paste)[8] was applied on the knee region and it was kept on for 4 h.

Table 3

Ingredients of Murungadi Pathtu (paste)

Second regimen (day 15–42)

Treated internally with 120 ml of decoction made using Nika (Vitex negundo L.), Katukaradu (Barleria prionitis L.) and Araththa (Alpinia calcarata Roscoe.), mixed with Chandra Kalka (as pill of 250 mg) twice a day after meals. Nirgundi oil (30 ml) was applied on knee joints, and Potali Sweda (hot fomentation) was performed. In the afternoon at 2.00 p.m., 30 g of paste of Ketakela Pathtu [Table 4][10] was applied and kept for following morning until 8 a.m.

Table 4

Ingredients of Ketakela pathtu (paste)

Third regimen (day 43–70)

Treated internally with 120 ml of decoction of Dashamula, Bala, Venivelgata decoction mixed with Chandra Kalka (as a pill of 250 mg) twice a day after meals. Nirgundi oil (30 ml) was applied on knee joints, and Janu Vasti was performed at 10 a.m. for period of 1 h. In the afternoon at 2.00 p.m., 30 g of paste of Ketakela Pathtu was applied and kept for following morning untill 8 a.m.

Follow up assessment

After 70 days of main regimens, external treatment of oleation with Nirgundi oil and 2 capsules of Shallaki (Boswellia serrata Triana and Planch), procured form Himalaya drug company (two capsules, p.o./twice daily) and one tablet of Jeewya, (comprised of Emblica officinalis Gaertn., Tinospora cordifolia [Thunb]. Miers and Terminalia Chebula, Retz.) procured form 4 Ever Skin Naturals (Pvt.) Ltd., (two tablets, p.o./twice daily) were continued over 5 months without discontinuation. Within this period, patient made several regular visits (i.e., once per 2 weeks) and on evaluation there were no adverse effects observed.

Results

The formal assessment was conducted on days 1, 35 and 70 [Tables 5 and 6]. After 70 days of treatment, reduction in the left knee, joint pain was assessed by VAS, which marked up to level 2–3 along with the improvement of her ADL [Table 5]. Also clinically detected joint effusion and other discomfort symptoms were alleviated at this point. Assessed by the online Knee Society clinical rating system, final grading score of pain, movement and stability was improved up to 71 scoring level (good) and knee function score was also improved up to 70 [Table 5].

Table 5

VAS and online knee society clinical rating system

Table 6

Ayurveda criteria for severity of signs during the treatment

Discussion

In Sandhigata Vata, joint inflammation initially causes pain (Sandhishula) and later swelling (Sandhishotha). Mainly due to pain and swelling, the mobility of joints is restricted (Stabdha) at the initial stage, and later it is aggravated by the anatomical changes that occur in the articular surfaces and the joint capsule and the ligaments. When and if patient try to move the joint, which may result in excruciating pain (Prasarana Akunchanayoho Vedana). However, according to the description in Ayurvedic text the signs, symptoms and signs with a scoring system were noted to evaluate the severity. This assessment was done twice (i.e., in pre- and post-treatment phases). The severity of symptoms and sign was categorized as follows: Mild: 1, moderate: 2 and severe 3 [Table 6].

According to this evaluation based on Ayurvedic criteria also showed that the combined STM and Ayurveda treatment was very effective in alleviating the symptoms and signs of OA [Table 5]. According to the long-term (i.e., 5 months later) records, also joint symptoms have not aggravated both by the knee society clinical scores and Ayurvedic criteria. Patient's remission remained unchanged with the improvement of the clinical symptoms and signs along with ADL.

With effective integration of “omics,” Prakriti-based medicine can play a vital role in this changing scenario of global health wisdom as Ayurveda offers its modalities by way of Ahara (diet), Vihara (lifestyle) and Aushadhi (medication) which are the three pillars of Prakriti-based medicine making it a holistic science.[11] Ayurveda and STM emphasize the treatment of disease in a highly individualized manner as it believes that every individual is unique having different constitution. Therefore, pattern of treatment regimens should towards personalized medical system. This is independent of racial, ethnic, or geographical considerations and may provide appropriate treatment plan. Similarly, these traditional systems classified the drugs according to the Rasapanchaka (Ayurvedic pharmacology), which states that the drug action is ascribed to certain attributes present in the drug namely Rasa (taste), Guna (property), Virya (potency), Vipaka (Post digestive taste) and Prabhava (effect) while in modern pharmacology the drug action is attributed to the chemical structure of a molecule.[12] The Rasapanchak modality can deliver treatment as it takes into consideration the Prakriti of the person as well as the pharmacodynamics and pharmacokinetic properties of a drug unlike a modern treatment that elicits varied response from person to person having same drug for the same disease. Explored results seem to support understanding connectivity of phenotypic features (Prakriti) connect with genotype as personalized medicine which given maximum efficiency and safety for a particular disorder.

Conclusion

The reported patient with end-stage OA (left knee) accompanied by exostoses got relief and improved quality of life by STM and Ayurveda combination therapy. The present case study may open the gate to the achievement of randomized controlled trials to evaluate the effectiveness of this treatment regimen. Chemical analysis of these remedies using modern fractionation and molecular methods may be another avenue, which can be explored in the future.