International Journal of Health Sciences and Research Vol.10; Issue: 11; November 2020 Website: www.ijhsr.org Review Article ISSN: 2249-9571

Ankylosing Spondylitis a Conceptual Review - Ayurveda Perspective

Swarnakant Jena1, Parwati2, Prasanth Dharmarajan3, Santosh Kumar Bhatted4

1,22nd yr. P.G. Scholar, Dept. of Panchakarma, All India Institute of Ayurveda, New Delhi 3Assistant Professor, Dept. of Panchakarma, All India Institute of Ayurveda, New Delhi 4Associate Professor& Head, Dept. of Panchakarma, All India Institute of Ayurveda, New Delhi

Corresponding Author: Swarnakant Jena

ABSTRACT

Ankylosing spondylitis is an inflammatory disease affecting the lower back of the body starting with sacroiliitis. In later stage affect the whole spine by fusing the vertebrae. Seen in early adulthood which affects most of life. In Ayurveda, management of this type of musculoskeletal disorder comes under Vatavyadhhis. Therefore different treatment modalities are applied to manage pain and other symptoms seen in AS. In this study focus was given to interpret the concept of Ama with Vata Dosha as correlating the inflammatory signs seen in AS and other symptoms of Ama associated with Vata. Treatment principle of this basis helped to provide significant relief in patient suffering with Ankylosing spondylitis.

Key word: Ankylosing spondylitis, Ayurveda, vatavyadhi

INTRODUCTION population is directly related to the Ankylosing spondylitis is a chronic frequency of HLA-B27 antigen. The immunomediated inflammatory arthritis frequency of HLA-B27 in the north Indian included in the so called group of population is 6%, similar to that in Spondyloarthrosis (SpA). It typically Caucasians is 0-1%2. Chronic back pain and develops in males in their third decade of progressive spinal stiffness are the most life and affect mainly the axial skeleton and common features of the disease. Impaired the sacroiliac joints. Although the oldest spinal mobility postural abnormalities, hip description dates from the time of Galen, it and buttock pain, enthesitis and dactylitis was not until the 19th century that the are associate with AS. Extraskeletal disease could be accurately diagnosed on manifestation like IBS (50%), acute anterior the basis of reports by Vladimir Bekhterev, uveitis (25-35%) and psoriasis (10%)3. Adolph Strumpell, and Pierre Marie. The There is increase in flow of patients in HLA-B27 allele is known to have a strong Indian systems of medicine due to poor association with the disease.1 Prevalence of response of treatment and associated side spondyloarthropathy in India seen by Indian effect in contemporary medical science. In data on the epidemiology of Ayurveda there is description regarding the spondyloarthropathy (SpA) are scare. management of such disorders based on the Prevalence data from the first Indian stages of expression under the concept of community oriented programme for control Vatavyadhi. There are 80 types of of rheumatic disease (COPCORD) survey independent Vatavyadhis4 are mentioned showed the rural prevalence of back pain to and Avarana of Vata with other doshas are be 17.3%. Among of that AS is likely to be also mentioned as another. Compared with about 0.2%. The prevalence of AS in a main clinical findings in patients of AS are

International Journal of Health Sciences and Research (www.ijhsr.org) 28 Vol.10; Issue: 11; November 2020 Swarnakant Jena et.al. Ankylosing spondylitis a conceptual review – ayurveda perspective pain (Shola), stiffness (Stambha) and 2) To understand the pathogenesis of Ama heaviness (Gouraba) in Ayurveda both the associated category of Vatavyadhis and symptoms are found in Vata and Kapha its possible Ayurvedic management. Dosha5. But the inflammatory signs like enthesitis, dactylitis can be due to Pitta. MATERIALS AND METHODS Derangement of all Doshas are found in AS. The article is based on a review of Hypothesis was made after reviewing Ayurvedic texts. Literature related to various published articles and research Vatavyadhis, Amavata, Ankylosing studies are on ankylosing spondylitis, few spondylitis and other relevant topics have disease conditions like Amavata. been collected. The main Ayurvedic texts Katishoola, Ashtimajjagata Vata, used in this study are Charak Samhita, Katitrikaprishtahgraha etc. can be also Sushruta Samhita, Astanga Samgraha, compared with Ankylosing spondylitis as Astanga Hrudaya, Madhava Nidana, per the stages which were described in Sarangadhara Samhita and available different Ayurveda texts. Rationality behind commentaries on these. We have also this article are by gone through various texts referred to the modern texts and searched and after comparing the patient condition, various websites to collect information on Vata Doshas are main Dosha with the relevant topics. involvement of Ama. Conceptual: Aim and objectives: Pathophysiology of AS6: 1) To explore various disease condition based on concepts and principles which Ankylosing spondylitis is a chronic, can be correlate to Ankylosing immune-mediated inflammatory disease that spondylitis. is associated with inflammation in the sacroiliac joints, the axial skeleton, enthesis, peripheral joints, uvea and other structures.

Image 1:

Macrophages infiltration

synovitis

myxoid appearing bone marrow

Proliferating fibroblasts, neovascularization and over expression of TNF,IL-1, VEGF

Infiltrating cells include CD4+ and CD8+lymphocytes T-cells

pannus and granulation tissue

bone resorption and proteoglycan breakdown

bone eroded by osteoclast

heals by endochondral ossification

bone ankylosis

Abbreviations: TNF- tissue necrotic factor, IL- interleukin, VEGF- vascoendothelial growth factor.

AS is characterized by chronic driving force for structural damage in AS. inflammation and progressive ankylosis. Long term inflammation of the joint of the Commonly accepted that inflammation is spine. The underlying mechanism is

International Journal of Health Sciences and Research (www.ijhsr.org) 29 Vol.10; Issue: 11; November 2020 Swarnakant Jena et.al. Ankylosing spondylitis a conceptual review – ayurveda perspective believed to be autoimmune or residue due to improper digestion. And autoinflammatory7. these particles are moved with blood, lymph Autoimmune disease occurs when and got vitiated after involving different the body is working hard to defend against Doshas resulting various abnormalities potentially hazardous substance to our anywhere in the body. Mainly rheumatoid bodies such as allergens, toxins, infections arthritis is considered as Amavata, there are or food, but does not see the difference also various inflammatory joint conditions between the invaders and our own body where will also considered as involvement cells. of Ama. Disorder like Sjogren’s syndrome, Ayurveda view: Reiter’s arthritis, ankylosing spondylitis Concepts of autoimmune disease are also can be considered as involvement of mostly correlate with Ama dominant disease Ama with Doshas as per conditions. in Ayurveda. Ama is the undigested food

Pathogenesis of Ama8: Image 2:

Mandagni (improper digestive power)

Apakwaanna Rasa (undigested food residue)

Production of Ama

Circulation of Ama through Rasayani

Srotodushti and vitiate Doshas And symptoms manifest as per Dosha called Samavata, Samapitta and Samakapha.

Starting from Mandagni, Ayurveda quoted individuals with low fiber, high fat diet10. as “Rogah sarvepi mandagnou”9, all disease Metabolic syndrome involves biochemical are starting with involvement of improper abbreviations in signalling pathways which digestive fire. By various unsuitable diet regulate lipid metabolism and chronic habits with improper lifestyle leads to as inflammations11. Mandagni. It results in formation of proper The Ayurvedic concepts of Ama are digestive material and goes circulating in similar to the Egyptian concepts of Ukedu, the body. These substances are called as and the old theory of intestinal auto Ama in Ayurveda. During circulation when intoxication propounded by Metchnikoff12. got suitable place to lodge it affect that part Thus, he believed that proteolytic gut and resulting into disease. Such diseases bacteria can produce toxic by-products, called as Samarogas. from digestion of dietary proteins. These toxic by-products of digestion accumulated Correlation of diet, digestion, with age and caused disease13. Therefore the inflammation and Ama: theory of Ama, its production and Mandagni leads to Samarogas and developing any inflammatory or immune inflammatory substances leads to bony disorder by disturbing normal body ankylosis. The correlation of Ama with physiology. This gives a ways to understand inflammation and the pathogenesis of the Ankylosing spondylitis pathways Ankylosing spondylitis helps to treat AS according to Ayurveda by involvement of through Ayurveda. Many human studies Ama with the dominant Doshas. have found high level of systemic markers of inflammation (like C-reactive proteins, intraleukin-6 and Tissue necrotic factors) in

International Journal of Health Sciences and Research (www.ijhsr.org) 30 Vol.10; Issue: 11; November 2020 Swarnakant Jena et.al. Ankylosing spondylitis a conceptual review – ayurveda perspective

Lakshana of Ama yukta vata and its  Sacroiliitis on imaging (radiographs or correlation: MRI) plus one or more spondyloarthritis Different Ayurveda treatise mention various features. symptoms with involvement of Ama and  HLA-B27 plus two or more other Vata as mentioned below: spondyloarthritis features.

Table 1: Where the spondyloarthritis features are Sl no Sama vata lakshana Sl no Sama Lakshana14 inflammatory back pain, arthritis, enthesitis, 1 Bibandha 1 Srotorodha uveitis, dactylitis, psoriasis, Chron’s 2 Agnisada 2 Balabhramsa 3 Stambha 3 Gourava disease, good response to NSAIDs, family 4 Antrakujana 4 Anilamudhata history of SpA, elevated ESR. 5 Vedana 5 Alasya 6 Sopha 6 Apakti 7 Nistoda 7 Nisthiva Samprapti vighatana: 8 Angapidana 8 Malasanga 9 Aruchi 10 Klama According to the chief complain and condition the patients the aetiopathogenesis Here in AS, chief complains are pain, of this disease can be correlate as stiffness with other associated symptoms Table 3: Sl no which affects normal life style. This disease 1 Dosha Vatakapha mainly affect to Asthi and Sandhi, so the 2 Dushya Rasa, Asthi, Sandhi, Mamsa 3 Agni Vishama and Mandagni symptoms as described by Madhava nidana 4 Srotas Asthivaha, Rasavaha for Amavata can be correlated to AS. 5 Srotodushti Sanga Table 2: 6 Vyadhimarga Bahya and Madhyama Sl no Amavata symptoms Ankylosing spondylitis symptoms 7 Utpati sthana Pakwashaya 1 Angamarda Pain of the body parts 8 Sanchara sthana Pristha, Kati 2 Sandhishoola Joint pain 9 Upashaya Ushna, sweda 3 Gatrastabdha Body stiffness 10 Vyadhiswabhava Chirakari 4 Dourvalya Weakness 5 Gaurava Heaviness 6 Alasya Lethargy Pain is prime features of Vata with 7 Nidranasa Disturbed sleep due to pain Stambha and Gourava due to Kapha so as 8 Utsaha hani Lack of vigour per main feature of AS, doshik involvement will be Vata and Kapha here. Both are also These are the main symptoms which found source of Ama. These vitiated Doshas along in cases of Ankylosing spondylitis. And with Ama are then affect the Katitrika associated symptoms which could be seen pradesha (sacroiliac joint) and Asthi dhatu as early stage or intermittently these are are main contents to affects. The Ama with Jwara (febrile feeling), Aruchi (anorexia), Vata dosha goes to Asthidhatu so the Trishna (thirst), Anaha (flatulence), Apaka symptoms of Asthimajjagata vata are seen (indigestion), Bibandha (constipation). as Sandhishoola (joint pain), These are the symptoms which could be Mamsakshyaya (weight loss, lethargy), compared with both Amavata as well Satataruk (continuous pain), etc. in later ankylosing spondylitis. stage it also affects whole spine so spinal In contemporary science they also pain and stiffness seen in lumbar, cervical have various criteria for diagnosis of and also difficulties in chest expansion. ankylosing spondylitis, one among them is 15 Mostly patient were came after several year ASAS (Assessment of spondyloarthritis and after onset of pain so in later stage international society) criteria for Ankylosing development of Bamboo spine seen as spondylitis is mentioned as: diffusion of vertebrae seen in radiological imaging. ASAS classification criteria for axial Treatment plan: spondyloarthritis are Treatment includes medication,  Back pain for 3months or longer physiotherapy, and in rare cases, surgery. In  Age at onset < 45years contemporary, main goal to relieve pain and

International Journal of Health Sciences and Research (www.ijhsr.org) 31 Vol.10; Issue: 11; November 2020 Swarnakant Jena et.al. Ankylosing spondylitis a conceptual review – ayurveda perspective stiffness and delay complications and spinal helpful. Asthi dhatu and Vata dosha are deformity. NSAIDs, TNF blocker etc are both inversely proportional in Ayurveda use. Physical therapy like exercise can be as described by Ashrayaashrayi useful in AS. Surgery is mostly advised in Bhava20. So to treatment of cases of severe joint deformity occurred. In Asthidhtugata Vyadhis, Basti should Ayurveda treatment based on Dosha, have made up of Tikta Rasa Yukta and Dushya, Agni, Bala etc like 10 factors will prepared from milk21. It will also described by Acharya Vagbhatta16. Here in help in Dhatukshaya Avastha where cases of AS, Ayurveda treatment based on after a long term illness patient got Vatakapha Shamaka which could be also weight loss. So as Ksheerabasti also beneficial in Asthidhatu Gata Vyadhis. may be helpful in these conditions. In Amajanya Vyadhis different 5) Other therapies: therapies like local Achryas described the following line of Basti by putting oil in tendered area for treatment like Deepana/Pachana, relief in pain will helpful. For snehapana, Sodhana in proper Sodhana Rookshana therapies like Vaaluka kala. In Chakradattta the line of treatment swedana, Choorna pinda swedana22 to was described as: remove stiffness from the body. 1) Deepana/Pachana: first line to treat the Agni (digestive power) as main DISCUSSION pathogenesis start after depletion of One type of inflammatory disease Agni. So Deepana and Pachana drugs that, overtime can cause some of the small will suitable which have Tikta (bitter) bones in spine to fuse. The fusing makes the and Katu rasa (taste). It will improve the spine less flexible can result in a hunched digestion and will reduce the formation forward posture. It can be also affect ribs of Ama (toxins). and cervical vertebrae resulting difficulties 2) Snehapana: before going to Sodhana in chest expansion and reducing of neck therapy there are various poorvakarma movement also. Underlying mechanism of procedure to perform, one among the AS is autoimmune and it considered as a Snehapana where medicated Sneha type of seronegative spondyloarthropathy, (Ghee/oil) given by oral route as per meaning that tests show no presence of Agni vala after assessment of Ama. The rheumatoid factor antibodies23. The medicated ghee/oil will reduce the Vayu, available treatment can lessen the symptoms it loosen the channel of body and and possible slow progression of the improve the digestive power with loosen disease. Various Ayurveda treatment any constipation or any waste protocols should gave the same result as to accumulations17. reducing the symptoms, improves the 3) Virechana: Procedure to induce quality of life in patients of Ankylosing laxation. It removes the metabolic waste spondylitis and may stop further progression and will works on Pitta dosha. Pitta of disease. In early stages of AS there is dosha shows the inflammatory signs in chronic dull pain in the lower back or body like burning sensation, redness etc. gluteal region combined with stiffness of the in case of AS virechana will have good lower back24. This condition can be treated effects by elimination of wastes etc18. with as Katishoola or Katigrham with 4) Basti: Vata dosha as prime involvement special Vata alleviating medication. In later of AS and pain as main symptom, Basti stage, loss of spinal mobility and chest will have good effect on alleviate both expansion with reduced lumbar movement Vata and resulting pain alleviation19. In are seen. Comparing to this condition condition of Ama where chronic cases of management to Katiprishtagraha25 by Ankylosing spondylitis, Basti like giving Rookshana with local Basti to reduce Kshara Basti to relief from Ama will pain and stiffness along with different Basti

International Journal of Health Sciences and Research (www.ijhsr.org) 32 Vol.10; Issue: 11; November 2020 Swarnakant Jena et.al. Ankylosing spondylitis a conceptual review – ayurveda perspective like Erandamooladi nirooha basti26 can be 3. Proft F. Poddubnyy D. Ankylosing applied. Systemic involvement like fever, spondyloarthritis: recent insights and impact weight loss, fatigue etc. with extra articular of new classification criteria. The adv manifestation of disease have to examine Musculoskelet Dis. 2018 jun;10(5-6):129- properly like Bala, Agni etc and plan to go 139. 4. Trikamji Y, editor. Sutrasthana; chapter 20, for a proper Sodhana with treatment to verse no. 10, in: Charakasamhita of alleviate Vatakapha and improves Agnivesha with commentary of Asthidhatus as involvement of Ama and Chakrapanidatta. Varanasi, India: Srotorodha Lakshana are seen. Ayurveda Chaukhamba Surabharati Prakashan; 2020. describe 80Vatavyadhis along with its P. 113. Avarana. So special description of Ama and 5. Trikamji Y, editor. Sutrasthana; chapter 20, its disease can be correlate various verse no. 12 & 18, in: Charakasamhita of pathologies of disease burden shown in this Agnivesha with commentary of era. Most of the condition now develops as Chakrapanidatta. Varanasi, India: autoimmune or any immune mediated Chaukhamba Surabharati Prakashan; 2020. pathologies which affects multiple systems P. 114 & 115. 6. Sangala. J. R., Dakwar. E, “Nonsurgical in human body. As there description of management of ankylosing spondylitis”, Amavata and its variety as per patient journal of Neuroscience, Vol. 24, Issue. 1. condition will shows a path to manage Doi- condition like Ankylosing spondylitis. https://doi.org/10.3171/FOC/2008/24/1/E5. 7. Proft F. Poddubnyy D. Ankylosing CONCLUSION spondyloarthritis: recent insights and impact As per the sign and symptoms of new classification criteria. The adv shown in AS the disease could be correlate Musculoskelet Dis. 2018 jun;10 (5-6):129- with Ama associated Vata Vyadhis where 139. multi system wise symptoms were occurred. 8. Paradakara H S, editor. Sutrasthana; chapter Mainly Shoola with Stambha are seen which 13, verse no. 25, in: Astangahridaya of Vagbhatta with commentary of Arunadatta indicates involvement of Vata and Kapha. & Hemadri. Varanasi, India: Choukhamba Pathogenesis of this condition shown, Surabharati Prakashan; 2020. P. 216. disease occurred in Katitrika after vitiation 9. Paradakara H S, editor. Nidanasthana; of all Doshas with inflammation indicative chapter 12, verse no. 01, in: Astangahridaya of involvement of Pitta. So treatment of Vagbhatta with commentary of according disease condition with Deepana Arunadatta & Hemadri. Varanasi, India: pachana, Virechana followed with Basti Choukhamba Surabharati Prakashan; 2020. karma and external treatment like Ruksha P. 513. svedana and Kati Prishta Basti etc have 10. L. Galland, “diet and inflammation.” shown improvement in terms of relief in Nutrition in Clinical Practice, Vol. 25, no. 6, pain, stiffness and increase in range of pp. 634-640, 2010. 11. Sumantran. V. N., Girish Tillu, “Cancer, movement. Inflammation, and insights from Ayurveda”,

Evidence based Complementary and REFERENCE Alternative Medicine, Vol. 2012, article ID. 1. Chen B, Li J, He C, et al.: Role of HLA-B27 306346, pp. 11. in the pathogenesis of ankylosing 12. R. E. Svoboda, Ayurveda Life Health and spondylitis (Review). Mol med rep. 2017;15 Longevity, Penguin Books India, 1992. (4):1943-51. 13. L. Galland, “Intestinal toxicity: new 2. Malaviya, Ananad &Subramaniam: indian approaches to a old problem,” Alternative rheumatology association consensus and complementary Therapies, vol.3, pp. statement on the diagnosis and treatment of 288-295, 1997. axial spondyloarthropathies. Indian journal 14. Paradakara H S, editor. Sutrasthana; chapter of rheumatology.5. 16-34.10.1016/S0973- 13, verse no. 23, in: Astangahridaya of 3698 (10)60531-6. Vagbhatta with commentary of Arunadatta

International Journal of Health Sciences and Research (www.ijhsr.org) 33 Vol.10; Issue: 11; November 2020 Swarnakant Jena et.al. Ankylosing spondylitis a conceptual review – ayurveda perspective

& Hemadri. Varanasi, India: Choukhamba Agnivesha with commentary of Surabharati Prakashan; 2020. P. 216. Chakrapanidatta. Varanasi, India: 15. Criteria for diagnosis, Assessment of Chaukhamba Surabharati Prakashan; 2020. Spondyloarthritis international society. P.180. https://www.asas-group.org. 22. Sharma P v, editor, Amavata Chikitsa, 16. Paradakara H S, editor. Sutrasthana; chapter Chapter 25, verse no. 02, in Chakradatta of 12, verse no. 67, in: Astangahridaya of Chakrapani. Varanasi, India, Chaukhamba Vagbhatta with commentary of Arunadatta orientalia; 2013. P. 227. & Hemadri. Varanasi, India: Choukhamba 23. “Question and answers about Ankylosing Surabharati Prakashan; 2020. P. 207. Spondylitis”. NIAMS. June 2016. Archived 17. Trikamji Y, editor. Siddhisthana; chapter from the original on 28 September 2016. 01, verse no. 07, in: Charakasamhita of Retrieved 28 September 2016. Agnivesha with commentary of 24. Longo, Dan Louis; Fauci, Anthony S; Chakrapanidatta. Varanasi, India: Harrison, Harrison’s Principles of Internal Chaukhamba Surabharati Prakashan; 2020. Medicine. Vol.1, Edition 18, McGraw-Hill. P. 678. ISBN 978-0-07-163244-7. 18. Trikamji Y, editor. Siddhisthana; chapter 25. Trikamji Y, editor. Sutrasthana; chapter 20, 01, verse no. 17, in: Charakasamhita of verse no. 11, in: Charakasamhita of Agnivesha with commentary of Agnivesha with commentary of Chakrapanidatta. Varanasi, India: Chakrapanidatta. Varanasi, India: Chaukhamba Surabharati Prakashan; 2020. Chaukhamba Surabharati Prakashan; 2020. P. 680. P.113. 19. Trikamji Y, editor. Siddhisthana; chapter 26. Trikamji Y, editor. Siddhisthana; chapter 15, verse no. 40, in: Charakasamhita of 03, verse no.38-42, in: Charakasamhita of Agnivesha with commentary of Agnivesha with commentary of Chakrapanidatta. Varanasi, India: Chakrapanidatta. Varanasi, India: Chaukhamba Surabharati Prakashan; 2020. Chaukhamba Surabharati Prakashan; 2020. P. 132. P.696. 20. Paradakara H S, editor. Sutrasthana; chapter 11, verse no. 26-28, in: Astangahridaya of How to cite this article: Jena S, Parwati, Vagbhatta with commentary of Arunadatta Dharmarajan P et.al. Ankylosing spondylitis a & Hemadri. Varanasi, India: Choukhamba conceptual review – ayurveda perspective. Int J Surabharati Prakashan; 2020. P. 186. Health Sci Res. 2020; 10(11):28-34. 21. Trikamji Y, editor. Sutrasthana; chapter 28, verse no. 27, in: Charakasamhita of

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International Journal of Health Sciences and Research (www.ijhsr.org) 34 Vol.10; Issue: 11; November 2020