Management of juvenile spondyloarthropathy through Ayurveda:- a case report.

Juvenile Spondyloarthropathies are the inflammatory arthritis before the age of 16 years and are characterized by the involvement of both synovium and enthesis leading to spinal and oligoarticular peripheral arthritis, principally in genetically predisposed (HLA-B27) individuals. These arthropathies are having poorer chance of remission with conventional treatment in comparison to other juvenile arthritis; with less than 20% going into remission within five years of diagnosis. This paper is a retrospective observational study of this condition in one patient receiving Ayurvedic treatment in Paediatric Unit of Ch. Brahm Prakash Ayurved Charak Sansthan. A 15 years adolescent boy with the complaints of inability to stand and walk due to pain and swelling in large joints of body; was carried to Balroga OPD by parents. On the basis of history, physical examination and investigations, the condition is diagnosed Aamavata as per ayurvedic approach and juvenile spondyloarthropathy as per modern medical science. This case is managed on the principle of treatment of Aamavata with administration of Ajamodadi churnam and Mishreya ark as deepana-pachana drugs followed by administration of Simhnad Guggulu and Lakshadi Guggulu with Maharasnadi kashayam and Dashmoolaristam for 3 months. Rheumayoga gold was also given from 4th week onward for 3 months. Panchkarma in the form of Baluka swedana and Kshara basti was also administered for 2 weeks after one month of oral medication. This treatment results in complete remission of all the signs and symptoms including pain and swelling of joints. The case is followed up for next three years without any relapse or progression in the disease. The case study infers that early intervention of Ayurvedic treatment in juvenile spondyloarthropathies may result in complete remission as well as may prevent progression of the disease. The case study provides a good hope for the management of this ailment as well as new ray for research.

Background

Juvenile Spondyloarthropathies (JSpA) are the inflammatory arthritic diseases that exhibit overlapping clinical features and shared genetic predisposition which occur before the age of 16 years. They are characterized by the involvement of both synovium and enthesis leading to spinal and oligoarticular peripheral arthritis, principally in genetically predisposed (HLA-B27) individuals. The principal clinical entities are enthesitis related arthritis, undifferentiated spondyloarthritis, ankylosing spondylitis, reactive arthritis, psoriatic arthritis and enteropathic arthritis [1]. In comparison with other forms of juvenile arthritis, JSpA is likely to have a poorer outcome [2]. Observational studies suggest that continuous disease activity for more than five years forecasts disability and that disease remission occurs in less than 20% of children within five years of diagnosis [3]. Ayurveda describe a joint disorder namely Aamvata which have symptoms almost similar to those of spondyloarthropathies.

Case history

A 15 years adolescent boy was carried to Balroga OPD by parents with the complaints of inability to stand and walk due to sandhi vedana & sandhi shotha (pain and swelling in large joints of body) for last one month. The patient was taking anti-inflammatory & analgesic drugs (ibuprofen 400 mg tds & serratiopetidase 10 mg tds) for the complaints for last one month with minimal relief.

On enquiry the patient told that onset was acute with overnight pain and swelling of left ankle joint, which is followed by swelling and pain in left knee joint in few days. Then the pain and swelling gradually involve right knee joint as well. Before the onset of symptoms he had suffered a minor trauma to ankle and an episode of loose stools one week back which may be considered as factor for derangement of agni & aggravation of Vata.

During the course of the disease all these joints remained painful and swollen. He also suffered an episode of severe abdominal pain and loose stool around beginning of the 4th week of illness for which he was admitted to emergency department of an allopathic hospital. At the end of four weeks illness he suffered bleeding per rectum for which he again went to allopathic hospital, got evaluated but doesn’t continue allopathic treatment and came to our OPD.

On enquiry patient told that pain is continuous, aching in nature, aggravated in night and by cold foods & movement of joints, mild relief with pain killers and associated with swelling and stiffness in joints, restricted movements, loss of appetite and fever.

There was no history of any kind of skin eruptions, pain or redness in eyes, pain or stiffness of small joints of hands or feet, cervical pain, painful micturition, chest pain, involuntary movements of limbs etc.

Past history

History of typhoid 4 years back, fracture around right elbow 5 years back, no other relevant past history.

Patient’s diet and nutritional history doesn’t reveal any kind of stressor, he was on vegetarian diet with occasional intake of junk food. No history of tea, tobacco, alcohol or other addictions.

Drug history

Patient has taken anti-inflammatory & analgesic drugs (ibuprofen 400 mg tds & serratiopetidase 10 mg tds) for last one month for present complaints.

Family history

Father had suffered some joint problem at the age of 19 years. No other relevant history of any illness found in other family members.

Genetic history

Patient was found to be HLA-B27 positive.

Socio-economic history

Patient belongs to lower middle class, living in sub urban area of Delhi. The periphery is not clean with large dirty drain nearby to the colony of the patient. Source of water is piped water supply.

Examinations

Patients is carried to the OPD with poor general condition, weight 42 kg, height 170.6 cm, pulse rate 106/min regular, febrile (1010 f), BP-110/60 mm of Hg, marked pallor, dry coated tongue, no icterus, no gross lymphadenopathy, no clubbing or cyanosis, no skin lesions.

Dashvidha pariksha

The patient is of Vataj prakruti, Asthisara, madhayama sahanana, sama pramana, madhyama satva, mandagni, avara vyayam shakti, sarvanga santapa, signs of Aam like lipta jivha, daurblaya, anna-anabhilasha, klesha were present.

Chest

Normal in shape & appearance with symmetrical bilateral expansion, normal lung field resonance and equal bilateral air entry without any added sounds.

CVS

Apex beat in left 5th intercostal space medial to midcalvicular line, S1S2- WNL, no murmurs.

Abdomen

Scaphoid abdomen, soft non tender without any organ palpable.

CNS

Conscious, oriented to time, person & place, Cranial nerves-intact.

Local examination

Darshana pariksha (Inspection)

Sotha & Raga of sandhis (large swollen and red left ankle, left knee, right knee bilateral knee effusion (Fig. 1) and bilateral hip joints) with Mansha shosha (severe muscle atrophy of thigh, pelvic girdle muscles).

Fig. 1

Bilateral knee effusion before treatment.

Sparshana pariksha (Palpation)

All the affected sandhis (joints) were having Santapa & are Sparsha Asaha (warm and tender) with Stambha (minimal active as well as passive movements).

Ashthavidha pariksha

The Ashthavidha pariksha points to the Aam production in the body (Supplementary Table 1).

Investigations

Initial investigations (last week of June 2016); CRP-+ve, Montoux Test-negative, RA factor-negative, ASO titre-negative; Arthocentesis reports shows TLC- 1750 cells/mm3 with 98% polymorphs & 2% lymphocytes, sugar-10 mg/dL, proteins- 4.4 gm/dL; CBC shows Hb-10 gm%, TLC-8600/ul, DLC-P-60%, L-32%, E−6%, M-2%. ESR- 59 mm fall in 1 h and Repeat CBC after 20 days shows ESR -120 mm fall in 1 h.

At the time of ayurvedic consultation (1st week of August 2016): CRP- +ve and ESR- 128 mm fall in 1 h.

Nidana panchaka & diagnosis

On the basis of history, clinical findings and initial investigations the case was initially diagnosed as poly-articular arthritis which was later on revised as non specific juvenile spondyloarthropathy after completion of 6 weeks of persistent arthritis and positive report for HLA-B27. The diagnosis of JSpA in 15 years adolescent boy without any positive family history and onset from ankles was expected to not have good prognosis as per modern science knowledge and same was conveyed to the patient’s attendants.

As per ayurvedic perspective, there is involvement of joints with signs of Vata vitiation and Aam production. Abhighata, Mandagni causing factors; : - Vata pradhana tridosha (mainly vyana & samana vayu, pachaka pitta & shleshaka kapha); - Rasa, Asthi, Majja, Kandra; - Mandagni; - Jatharagni & Dhatwagni janya; - Annvaha, Rasavaha, Asthivaha, Majjavaha; - Sanga; - Amashyotha; -Sarva sandhi; - Asthi-sandhi- marma (Madhyama); - Chirakari; - Krichasadhya; - Symptoms of Aam in the form of weakness, Atisara, mandagni; - Sandhi saruja shopha (painful joint swelling), Jwara (Fever), Trishna (Thirst), Aruchi (loss of appetite), Utsaha hani (poor work cpacity), Kukshi shoola (abdominal pain), Jadya (inability to perform daily activities); - increase in symptoms by cold food items night, application of oil and Potali swedana. Improvement with light, hot food items, Ruksha swedana.

Thus the diagnosis of Aamvata was made and treatment was started on its line. As the disease was of recent onset but is in balyawastha (childhood period) guarded prognosis was expected as per ayurvedic approach.

Interventions and results

The initial focus was on reducing inflammation of joints, providing relief from pain and alleviating Aam production.

Medications prescribed at first visit were Mishreya ark (for deepana, pachan & raktatisar har)15 ml twice daily with water, Ajmodadi churna 3 g twice daily with warm water, Lakshadi Guggulu and Simhnad Guggulu 500 mg each twice daily with Maharasnadi Kashaya 40 ml and Dashmoolaristam 20 ml with equal water twice daily after meals for a period of one week. The patient was put on bland diet and advised complete rest and hot water fomentation.

In next visit, there was a mild symptomatic relief and on examination bilateral knee effusion was slightly reduced in size with reduction in inflammatory signs. Patient was evaluated for involvement of eyes by ophthalmologist. Two medications were added to previous treatment for next 2 weeks. They are Mahasankh vati 250 mg twice daily with luke warm water and Laghuvishgarbha talium for local application followed by Baluka swedana.

At third visit there was very good symptomatic relief but joint effusions were persisting so a gold preparation in the form of Rheumayoga Gold (containing Suvarna Bhasma 1 mg, Yograj guggul 30 mg, Maharasnadi Kwatham (solid extract) 235 mg, Bang Bhasma 5 mg, Nag Bhasma 5 mg, Loh Bhasma 5 mg, Mandur Bhasma 5 mg, Makshik Bhasma 5 mg, Abhrak Bhasma 5 mg, Rasa Sindur 5 mg) was started as 1 tab twice daily for two weeks.

At fourth visit patient was admitted with the intention to extract out remaining Aam and reduce joint swelling with Panchkarma procedures. The patient was put on Ksharabasti 300 mL daily for 10 days with Patra potali swedana for 10 days. As joint swelling and pain increases during the course of Patra potali swedana, it is replaced by Baluka swedana for next one week. During hospital stay patient was given oral medication which include Ajmodadi churna 3 gms twice daily, Simhnad guggulu and Lakshadi Guggulu 500 mg twice daily with Dashmoola Kwath 30 mL, Balarista 20 mL twice daily and Yavani ark 10 mL twice daily with equal water. By the end of course of treatment in hospital, there was marked decrease in bilateral knee effusion (Fig. 2) with no signs of inflammation in any joints of body. The patient was able to walk freely without pain. Interventions and results with timeline are summerized in Table 1, Table 2.

Fig. 2

Complete remission after treatment.

Table 1

Time line of the case.

Time	Clinical events and interventions
Last week June 2016	Onset of joint pain and swelling in Left ankle and left knee jointInvestigation shows RA factor & ASLO – negative, CRP- positive, Synovial fluid- TLC- >1750 cells/mm3 with 98% polymorphsStart allopathic medicine (ibuprofen 400 mg tds & serratiopetidase 10 mg tds)
1st week July 2016	Involvement of right knee and both the hip joints
3rd weekJuly 2016	Episode of severe abdominal pain and loose stool, got indoor treatment at allopathic hospital for 3 days
4th weekJuly 2016	Episode of bleeding per rectumUSG Abdomen- no abnormality detected
2nd August 2016	First visit to our OPD, ESR-128 mm/h, CRP- positive, BASDAI- 8.1Diagnosis of Aamvata (sero-negative polyarthritis) made and started orally Ajmodadi churnam, Mishreya Ark, Lakshadi Guggulu, Simhnad Guggulu with Maharasnadi kashayam and Dashmoolaristam with strict dietary instructions
9th August 2016	Mild improvement, BASDAI-7.1Mahasankh vati added to previous oral medication with local application of laghuvishgarbha tail followed by Baluka swedana
16th August 2016	As 6 weeks of arthritis was completed, clinical diagnosis of JSpA made, ophthalmic examination to rule out iridocyclitis performed which comes out negative, HLA-B27 advised
23rd August 2016	Improvement in pain and joint movement but less improvement in joint swelling, ESR-94 mm/h, CRP-positive, BASDAI-5.1Tab Rheumayog Gold added to previous drug regimen and Mahasankh vati stopped
30th August 2016	Swelling persists, got admittedPanchakarma procedures started- Ksharbasti for 10 days, Patra potali swedanaOral medication- Ajmodadi churnam, Yavani Ark, Lakshadi Guggulu, Simhnad Guggulu with Dashmoola kwatham and Balaristam
4th September 2016	Increase in joint pain and swellingPatra potali swedana replaced by Baluka swedana, rest same continued for 10 days
13th September 2016	Relieved of pain and swelling, BASDAI-1.2, ESR- 42 mm/h, CRP-negative, HLA- B27- positiveOral medication continued for next 3 months
10th January 2017	Patient in complete remission, no complaints and positive clinical findings
February 2020	Patient still in remission with occasional heel pain

Table 2

Summary of Interventions & results.

Duration of treatment	Drugs used	Dosage	Rationale of drug use	Results
1st week	Ajmodadi ChurnaMishreya ArkSimhnad & Lakshadi GugguluMaharasnadi KashayaDashamoolaristam	3 g BD15 ml BD500 mg BD40 ml BD20 ml BD	Deepana, PachanaDeepana, Pachana, VatanulomanShothahar, VataghnaShothahar, VatanulomanShothahar, Vataghna	Reduction in Aam signsReduction in painReduction in pain
2nd -3rd wk	Same as 1st week +Shankh Vati	250 mg BD	Deepana, pachana, Vatanuloman	Complete relief in pain & mild reduction in swelling
4th week	Same as 1st week +Rheumayoga gold	1tab bd	Vatahara, Rasayana	Reduction in swelling & improvement in weakness
5–6th week	Oral medicine+Baluka Swedana &Kshara Basti	300 ml/day	Aamhar, Rukshana, Vatahara	Complete remission of the disease

The oral medication was continued for next three months to prevent relapse of the disease.

Diet

Light bland diet was prescribed throughout the treatment and was indicated during follow up period also. The diet advised includes boiled old rice, breads made up of old wheat flour, soup of pulses like Masoora (lentils), Kulath (horse gram), Mudga (green gram) and Arhara (pigeon pea), vegetables like Parwla (pointed gourd), Vastuka, brinaja, Karvellaka (bitter gourd), bottle gourd etc. The foods asked to avoid were heavy, oily, improperly cooked foods, junk food, milk items like curd etc.

Follow-up and outcome

Initially patient was followed up weekly. At follow ups patient was assessed for effect of therapy, reduction in disease activity, and improvement in daily activity function score as well as appearance of any untoward effect and tolerance of medications. Treatment adherence was assessed by asking patient as well as parents of the patient. The patient show good results with ayurvedic treatment and the outcome is discussed in the Supplementary Tables 2 and 3 in terms of patient assessed outcome and clinician assessed outcome.

Discussion

The condition was approached and managed with the principles of management of Aamvata. In Aamvata, two main events are contributing to the pathogenesis of the disease. They are production of Aam and also the Vata vitiation. According to Ayurveda, the treatment of Aamvata includes treating Aam with Langhana, Deepana, Pachana with Tikta & Katu dravyas followed by Virechan and treatment of Vata with snehapana and Basti. However a good measure of treating both Aam and Vata is prescribed as use of Ksharabasti [4].

In this case the first line of drugs include deepana and pachana with Ajmodadi churna [5] and Mishreya Ark, swedana and use of Vata anulomana drugs like Dashmoolaristam [6] and Maharasnadi kashayam [7] and also vata shaman and santhi shothahara drugs like Simhnad Guggulu [8]. As there was good initial response in reduction of pain the same treatment plan was advised for next two weeks with addition of Shankhvati for increasing agni and snehana with oil to reduce Vata. But as the swelling persist even after treatment for 3 weeks, addition of a Gold preparation as rasayana and vata pacifying agent Rheumayoga Gold was prescribed for one week but after having incomplete remission patient was admitted and kshara basti [9] administered to extract out remaining Aam and sthanika swedna done with Potali initially followed by Baluka swedana for 2 weeks. The use of Potali swedana worsening the pain and relief with Baluka swedana indicate role of Aam in this condition [10]. With these panchkarma procedures internal shamana drugs were used. This completes the treatment regimen of disease and the patient was completely relieved of pain and swelling of joints. As per recent reasearches on these formulations, Ajmodadi churna shows significant anti-inflamatroy action in rats [11]. Simhnad guggulu has been found effective in the management of Aamvata in various clinical studies in adults [12]. Lakshadi guggulu is also proven for its antiarthritic and chondroprotective activity in in vitro study [14]. Various in vitro and experimental studies have shown that Maharasnadi kashayam possesses anti-inflamatory, analgesic [15], [17] & antioxidant activities [16] through which it produces its anti-arthritic effects. Dashmoolaristam also possesses analgesic and anti-inflamatory activities [18]. The worth of ksharabasti in Aamvata has been proven in various clinical studies [19], [20]. Thus this treatment protocol for JSpA with the use of these formulations and panchakarma procedure is having scientific justification as well.

Drugs were chosen according to prakruti (constitution), satva (mental strength), satmaya (dietary pattern) & vaya (age) of patient and also according to desha (regional variation), kala (seasonal variation), roga avastha (disease severity). For prevention of the condition some rasayana, deepana, pachana & Vata shaman drugs were continued for next 3 months.

At present, the patient is under continuous observation through quarterly follow-ups. The patient is still under clinical remission as of February 2020. This is a significant finding considering the prognosis and unsatisfactory treatment in modern medicine.

This case study infers that early intervention of ayurvedic treatment protocols particularly panchkarma procedures in JSpA are beneficial in inducing remission. Prolonged treatment with ayurvedic medication and following ayurvedic pattern of diet as well as life style can keep patients of JSpA in remission. However as this was a single case study the results and outcomes may vary upon enrolment of large number of patients of JSpA.

Conclusion

This case study concludes that early use of ayurvedic formulations and panchkarma procedures are helpful in reducing pain and swelling in the patients of spondyloarthropathy. Ayurvedic management can induce early remission of the disease and can prevent further relapses. However clinical trials with large number of patients are required to further validate the results.

Patient perspective of treatment

Patient as well as parents was totally satisfied with the treatment. As initially they have taken the patient in wheel chair and after treatment of 6 weeks patient was fully fit to walk or do any routine activity.

Patient consent

Written consent of patient had been taken for publication of this case study.

Source(s) of funding

None.

Conflict of interest

None.