Role of Agnikarma in Sandhigata Vata (osteoarthritis of knee joint).

INTRODUCTION: Sandhigata Vata is one of Vata Vyadhi characterized by the symptoms such as Sandhishoola (joint pain) and Sandhishopha (swelling of joint). Osteoarthritis (OA) is degenerative joint disorder, represents failure of the diarthrodial (movable, synovial-lined) joint. OA of knee joint comes under the inflammatory group which is almost identical to Sandhigata Vata described in Ayurveda with respect to etiology, pathology, and clinical features. Agnikarma (therapeutic heat burn) is one which gives instant relief from pain by balancing local Vata and Kapha Dosha without any untoward effects. AIM: To evaluate the efficacy of Agnikarma with Rajata and Loha Dhatu Shalaka in the management of Janugata Sandhivata (OA of knee joint).
MATERIALS AND METHODS: A total of 28 diagnosed patients of Janugata Sandhivata were registered and randomly divided into two groups. In Group-A, Agnikarma was done with Rajata Shalaka while in Group-B Agnikarma was performed by Loha Shalaka in four sittings. Assessment in relief of signs and symptoms was done by weekly interval, and Student's t-test was applied for statistical analysis.
RESULTS: Group-A provided 76.31% relief in pain while Group-B provided 83.77% relief. Relief from crepitus was observed in 57.13% of patients of Group-A, while 57.92% of patients of Group-B. There was statistically insignificant difference between both the groups. Loha Shalaka provided better result in pain relief than Rajata Shalaka.
CONCLUSION: Agnikarma is effective nonpharmacological, parasurgical procedure for pain management in Sandhigata Vata (OA of knee joint).

RCT Entities:   Population Interventions Outcomes

Introduction

Pain is an unfavorable sensation that brings an individual to the physician due to a halt from his routine works. The condition is more painful when mobile joints such as Janusandhi (knee joint) of the body are involved due to Sandhigata Vata. The disease Sandhigata Vata is more prone to be affected to knee joint because it is most frequently involved joint in daily routine work, weight bearing joint of the body, and more prone to develop in overweight patients. In the pathogenesis of Sandhigata Vata, Vata Dosha dominant with symptoms such as Vedana (pain during joint movement) and Shopha (swelling). The joint stiffness and crepitus (specific sound during joint movement) are symptoms that may be co-related in modern parlance with osteoarthritis (OA) of the knee joint. OA is the second most common rheumatologic problem and is the most frequent joint disease having prevalence of about 22–39% in India. Among them, 29.8% persons between 45 and 64 years of age group report diagnosed arthritis.[1] OA of the knee joint is seen most common in the clinical practice of elderly population. Below 45 years of age, this disease is common in men and involves one or two joints, while in female, 55 years of age, usually involving multiple joints.[2] OA is the most common form of arthritis and leading cause of chronic disability mostly in all the population. For the management of OA, patients need to take analgesics for daily and lifelong. In OA, surgical therapy-like knee joint replacement is very costly and even after surgery patient has to continue some medicine for a long duration. The use of analgesics and steroids in old age may produce adverse effects such as gastritis, hyperacidity, and sometimes renal failure.[3] Agnikarma is a nonpharmacological treatment which has definite role in Sandhigata Vata. The emphasis of the Ayurvedic approach of Agnikarma is to relieve the pain in OA. It may be more effective in the management of Janugata Sandhivata (OA of knee joint). Sushruta has given direction for treatment of the Sandhigata Vata by Agnikarma.[4] While describing the indications of Agnikarma, he also explained that Agnikarma can be done when severe pain occurs in Twaka, Mamsa, Sira, Snayu, Sandhi, and Asthi due to vitiation of Vata Dosha.[5]

Hence considering these facts, the current study has been planned to evaluate the efficacy of Agnikarma with Rajata and Loha Dhatu Shalaka in the management of Janugata Sandhivata (OA of knee joint).

Materials and Methods

Patients (n = 30) suffering from sign and symptoms of Sandhigata Vata, such as pain, tenderness, stiffness and crepitus in knee joint, were registered from OPD and IPD of Shalya Tantra Department, IPGT and RA Hospital, Jamnagar irrespective of sex, caste, religion, etc.

Informed written consent was taken from all the patients. The study was commenced after Institutional Ethics Committee approval (No: PGT/7/A/Ethics/2010-2011/1858; dated: 01/09/2010).

Inclusion criteria

Patients suffering from Janugata Sandhivata (OA of knee joint)

Age group of 45–70 years

Patients of either gender.

Exclusion criteria

Patients below 45 years and above 70 years age

Patients with diabetes mellitus (DM), rheumatoid arthritis (RA)

Other diseases such as paralysis, Parkinson's disease, severe anemia, and cancer patients

Secondary OA due to tuberculosis (TB), syphilis, AIDS, leprosy, etc

Sandhigata Vata other than Janugata Sandhivata

Pregnant patients as they are contraindicated for Agnikarma.

Investigations

Routine hematological and biochemical investigations such as blood sugar (fasting and postprandial), uric acid, RA factor, lipid profile, and routine urine analysis were carried out before starting treatment to rule out any other pathology. Radiological examination was carried out before and after completion of treatment.

Grouping

Total 30 selected patients were randomly divided into two groups (1) Group-A and (2) Group-B (n = 15 each).

Group-A: Patients were treated by Agnikarma with Rajata Shalaka

Group-B: Patients were treated by Agnikarma with Loha Shalaka.

Agnikarma was done in four sittings with a weekly interval.

Requirements

Agnikarma Shalaka: Specification of Rajata and Loha Shalaka was depicted in Table 1

Table 1

Specification of Shalaka

Triphala Kwatha (decoction):It was used for the cleaning of local part before Agnikarma

Haridra Churna (powder of Curcuma longa L. rhizome): It was used for dusting after Agnikarma (dressing purpose)

Ghritakumari (Aloe barbadensis Miller. leaf): It was used as soothing effect after Agnikarma (dressing purpose)

Madhu-Sarpi (honey and ghee): It was used after Agnikarma for healing of wound.

Methodology

Procedure of Agnikarma

The procedure performed in three stages as Purva Karma, Pradhana Karma, and Paschata Karma mentioned by Acharya Sushruta.[6]

Purva Karma

Snigdha Picchila Annapana (rice and curd) was given prior to the procedure. The site of Agnikarma is washed with Triphala Kwatha and wiped with dry sterilized gauze and covered with a cut sheet. Shalaka was heated up to red hot (Rajata Shalaka approximately for 3–4 min and Loha Shalaka approximately for 15 min). Ghritakumari pulp, Haridra Churna kept ready for dressing.

Pradhana Karma

In OA of the knee joint, supine position was adopted as it is comfortable to the patient. Irrespective of a specific site, Agnikarma was done at maximum tender site affected at the knee joint. The minimum space was kept between two Agnikarma points to avoid overlapping of Dagdha Vrana. After Agnikarma, fresh Ghritakumari pulp was applied on Dagdha to relieve burning pain.

Pascha Karma

After wiping of Ghritakumari pulp, honey and ghee was applied on Dagdha Vrana, after that dusting of Haridra Churna was done. Patient was observed for 30 min after procedure and advised Pathyapathya as mentioned in Sushruta Samhita[7] until the healing of Samyak Dagdha Vrana. Patients were strictly advised not to allow water contact at Dagdha Vrana site for 24 h.

Assessment criteria

Subjective parameters

The assessment of relief of sign and symptoms was done after completion of treatment by following graded subjective parameters. The grade of pain, crepitus, and tenderness were noted before and after treatment.

Objective parameter

The measurement of swelling at knee joint was recorded at three sites that are midpoint of patella, 2 inches above and below patella. The goniometric reading of knee joint on flexion and extension was measured with the goniometer.

Overall assessment of therapy

Cured: 91–100% improvement

Marked improvement: 70–90% improvement

Moderate improvement: 50–69%improvement

Mild improvement: 25–49% improvement

Unchanged: <25% improvement.

Statistical analysis

Paired t-test was applied for assessment of individual group whereas unpaired t-test was used to assess the comparative efficacy of the Agnikarma in Group-A with Group-B.

Observations

Out of 30 registered patients, 28 completed the therapy (14 in each group). Demographic data of the study that is age, sex, religion, socioeconomic status, etc., are depicted in Table 2. Cardinal symptom of OA that is joint pain and crepitus was observed in all registered patients.

Table 2

General observations

Results

Group-A (Rajata Shalaka) provided 76.31% relief in pain while in Group-B (Loha Shalaka) provided 83.77% relief and found highly significant (P < 0.001). Agnikarma by Rajata Shalaka provided 57.13% relief from crepitus in Group-A, and Agnikarma by Loha Shalaka provided 57.92% relief from crepitus in Group-B. Statistically, both the groups showed statistically significant (P > 0.05) results in crepitus as there is not structural change in knee joint after Agnikarma [Tables 3 and 4].

Table 3

Effect of therapy on signs and symptoms in group-A

Table 4

Effect of therapy on signs and symptoms in group-B

Effect of Agnikarma on swelling of knee joint

In Group-A, 04.21% and while in Group-B, 04.67% relief was observed in the level of swelling measured at midpoint of patella, which was found statistically found significant (P < 0.05) after 4 weeks of treatment.

Agnikarma with Rajata Shalaka in Group-A provided 04.31% relief while Loha Shalaka in Group-B provided 04.71% relief in the girth measured at 2 inches above the patella, which was found statistically significant (P < 0.05).

Group-A provided 04.17% relief while Group-B provided 04.22% relief in swelling measured at 2 inches below the patella, which was found statistically significant (P < 0.05) [Tables 3 and 4].

Effect of Agnikarma on knee joint movements

In goniometric observation, angle of extension was found increased by 10.40% in Group-A and 6.19% in Group-B. Angle of flexion was found reduced 33.70% in Group-A and 39.16% in Group-B [Tables 3 and 4].

In X-ray of the knee joint, there was no any change found in osteophytes and space reduction before and after Agnikarma treatment, because it is the structural defect.

Comparison of both the groups

On comparing the data of both the groups, statistically insignificant difference was observed in all the parameters [Table 5].

Table 5

Comparative efficacy of group-A with group-B on sign and symptoms

Overall assessment

Total cured patients were 28.57% while marked improvement was observed in 25% of the total patients. The moderate change was observed in 28.57% patients while 14.26% and 3.57% patients were observed in mild improvement and unchanged category, respectively [Table 6].

Table 6

Overall effect of therapy

During treatment and follow-up period no any adverse effect was found.

Discussion

In the present study, 100% of patients were reported in the age group of 45–65 years. Demographic studies revealed that osteoarthritic changes commence between the 4th and 5th decades of life.[8] Maximum 73.33% patients were belonged to Hindu religion; this is due to the Hindu-dominant population in the study area.[9] The study conducted in urban area so majority of the patients 86.66% were belonging to urban habitat. In this study, 66.66% of patients were observed from the middle class. 73.33% literate patients were observed might be due to awareness regarding the health and the location of the hospital in urban area.

The majority of patients 50% followed Viruddhashana in their routine diet which leads to Agni Vaishamya and Vataprakopa resulting in Dhatukshaya which coupled with old age leads to Sandhigata Vata. This type of dietary habit affects the Agni resulting in formation of Aama, leading to Agnimandya and Dhatvagnimandya, which ultimately obstructs the Srotas. Due to obstruction of Srotas, Vata gets vitiated and affects Sandhi of knee resulting into Janugata Sandhivata. Maximum patients were having Madhyama Koshtha (63.33%). Maximum 50% patients had Madhyama built, whereas 40% patients had Sthula built. It is observed that Sthaulya (obesity) causes excess Vriddhi (increase) of Dushita Medas and deprive nutrition to later Dhatus, especially Asthi and Majja which are the Dushyas of Sandhigata Vata. In Madhyama built patients, the cause of Sandhigata Vata is taking Apathyakara Ahara and Vihara as prevailing in the modern lifestyle. Maximum patients (60%) were found to be having some addiction. Among them, tobaccos chewing addicted patients were 23.33%. Provocative findings of tobacco chewing on OA of knee joint have been reported from various studies including Framingham study.[10]

Prakriti of patients was noted to know the relation of Prakriti to incidence of OA. In this study, it was found that Vata Prakriti was observed in 26.66% patients in which Vata vitiation played an important role in initiation and manifestation of Sandhigata Vata.

The majority of patients (46.66%) had chronicity up to 1 year suggesting OA is a slowly progressive disease that can also be linked with lifestyle related disorder. All the Yapya Vyadhis (disease which are difficult to cure) are chronic in nature as mentioned in classics;[11] as such observations in this study reflects the chronicity of Sandhigata Vata. The chronicity is inversely proportional to the prognosis of disease that is, if chronicity is less, prognosis will be good. In this study, 96.67% patients were reported pain during walking, during routine activity flexion and extension of the knee joints involves movements of ligaments and frictions of the osteophytes which aggravate the pain. The 80% patients had the history of gradual onset in OA gradual, and slow progression of joint change takes place. About 43.33% of female patients reported menopause; osteoporotic changes occur at the stage of menopause in female, postmenopausal hormonal variations is responsible for bone demineralization leading to osteoporosis and ultimately produces OA changes.[1213]

Vedana (knee joint pain) and Sandhi Sphutana (crepitus) were present in 100% patients were prominently seen in the subjects indicating active phase of the disease. These all symptoms occur due to Vataprakopa and Kaphakshaya, as well as Majja Dhatu Dusti. About 56.67% of patients were having unilateral OA followed by 43.33% of patients were having bilateral OA of the knee joint. The available data showed that unilateral OA is most common in male while bilateral OA is observed in mostly female patients.[14]

Probable mode of action of Agnikarma

After Agnikarma, the Ushna (hot) Guna of Agni pacifies the Shita (cold) Guna of Vayu and reduces the joint pain in the case of Sandhigata Vata. Acharya Charaka described that Agni is the best treatment for Shoola (pain).[15] Ushna Guna of Agni helps to removes the Avarana effectively and stabilizes the movement of Vata, which provide relief from Shoola. As per the modern medicine, therapeutic heat increases blood circulation at knee joint leads to the proper nutrition of the tissue. This induced circulation help to flush away pain producing substances from affected site and ultimately reduces the local inflammation.[16] The osteophytes was recorded unchanged after Agnikarma because it was a structural defect, and it is difficult to correlate the impact of Agnikarma on osteophytes, the Ashukari (quick acting) property of Agni also provided improvement in the movement of joints resulted in relief of crepitus.[17] The heat application is indicated in cases of chronic inflammation.[18] Heat leads to vasodilatation, exudation of fluid, increase in white blood cells and antibodies. This response obtained on heating the tissues is augmentation of these changes for certain period and reduce the chronic inflammation. Shita Guna of Vata in the tissue and muscle is normalized by Agnikarma, the muscle spasm releases which improve flexion and extension of knee joint. Acharyas have quoted that Agnikarma is superior in treating Stambha (stiffness).[19]

Conclusion

After vivid discussion, it can be said that Agnikarma had a definite role in pain relief in patients of Sandhigata Vata. The Agnikarma was done by Twakgata, so there was no statistically different result between Rajata and Loha Shalaka. However in pain relief, Loha Shalaka provided better results than Rajata Shalaka. Agnikarma is a nonpharmacological, OPD procedure required minimum equipment so that it can be used for pain management in Sandhigata Vata.

Financial support and sponsorship

IPGT and RA, Gujarat Ayurved University, Jamnagar.

Conflicts of interest

There are no conflicts of interest.