WITH SPECIAL REFERENCE TO RHEUMATOID ARTHRITIS
Rheumatoid arthritis is a chronic systemic inflammatory polyarthritis that primarily affects small diarthrodial joints of the hands and feet in a symmetrical pattern . The disease tends to be heterogeneous and seems to be variable in severity and unpredictable course . Appropriate knowledge of the principles and manifestations of rheumatoid arthritis helps in the better comprehension and interpretation of the disease Yamagata told in Ayurvedic classics.
Virudha Ahara facilitates dosha pra Opa and leads to the formation of aya dart ha rasa. This is a state of ama avast ha. The same condition with chronicity is converted to visha and is possessing the trait as ashukaritvat, this state can be interpreted as the acute exacerbation of chronic stage of Rheumatoid arthritis. Therefore, virudhaahara can cause doshaprakopa which promote agnimandya or vice versa. Chesta can be better comprehended through the “vyayama” – physical exercise told in the classics. Excessive indulgence in physical activity increases the rooksha, kharagunas influencing agni. Excessive physical activity is grouped as one of the nidanas for vatavyadhi. Mandagni refers to a weak digestive fire. The relevance of this predisposing factor is the formation of ayadartha rasa. It leads to the formation of amaavastha, which in turn can trigger doshaprakopa.Nischalata refers to a state of inertia in inactivity. This can be comprehended in two levels. Mano nischalata and the shareeranischalata, promoting agnimandya.The snigdhapadarthas consumed carry long chain fatty acids or with a significant level of fat content. Such variety of food requires more digestive elements, improved circulation, and stimulation. When the individual performs an increased physical activity, the circulation will be more in the peripheral parts of the body to release energy. This leads to a reduced core circulation. The fate is a diminished digestive activity .
The above described predisposing factors contribute to doshaprakopa or and developing amaavastha, simultaneously or one after the other . The ayadartha rasa or the ama rasa formed is distributed by the vatadosha to different parts of the body – shleshmasthana . It is mentioned specifically as shleshmasthana because the guna of ama and shleshma are same. Therefore it initially manifests at the shleshmasthana like the musculoskeletal joints .
Madhukosha mentions shleshmasthana as the dhamani . Later with the chronicity, other doshas are also subjected to dushti. This brings the addition of more symptoms with time to the existing disease. Distribution of ayadartha rasa by the vatadosha results in developing abhishyandata to the body channels. At the same time, dhatus also get afflicted. Further, the individual manifests tiredness due to lack of nourishment or due to impaired uttarouttaradhatuposhana. Individual experiences heaviness of the body and are not able to perform his or her daily activities .
Involvement of hrudayaand its impairment can be comprehended as because of circulation of saama rasa. Therefore, the circulation is deficient in nutrients. This creates more strain and works load to the heart, to pump more blood. There also can be an impaired nourishment of the body tissues. These factors contribute to other extra-articular manifestations .
The prominent features are associated with the joints or musculoskeletal system. From the contemporary science, the genetic mutation of HLA area of gene DR1 – DW15, DW10, DW13, DW14 all can be referred to as the rasa dushti. Rasa dhatu can be related to the defense system of the body. Rasa is predominant with kapha dosha [25, 26]. Prakrutakapha is bala. Bala can be acknowledged as vyadhikshmatva.
In the pathology of Rheumatoid arthritis lies altered vyadhikshamatva karma. In Rheumatoid arthritis, a cascade of pathological events occurs right from the activation of T – cells. T – Cells trigger the synovial fibroblast triggering the macrophages. T- Cells activate the B – Cells to produce the autoantibody immune complexes including rheumatoid factor and immunoglobulin. This, in turn, attacks the articular and extra-articular parts. T – Cells also trigger macrophages followed by TNF- alpha. They produce the interleukins like the IL1, IL8, IL15, IL17, IL23 and VEGF. This affects the endothelium of vessels, bone cells, chondrocytes and synovial fibroblasts. These inflammatory mediators contribute to the manifestation of pain, redness, and edema .
The stiffness arises due to the formation of lymphoid follicles within the synovial membrane followed by the pannus formation over and under the articular cartilage. This is progressively eroded and destroyed. Later the fibrosis or bony ankylosis may occur. The muscles adjacent to the inflamed joints will be flaccid and weak due to the release of TNF – alpha triggered by the macrophages. They also may be infiltrated with macrophages .
Signs and Symptoms: The general features that are seen in the initial phase of the ailment are the samanyaAmavatalakshanas . They include body ache, anorexia, thirst, laziness, heaviness, fever, indigestion, and swelling. As the disease become chronic, it is reflected with the pravruddhaAmavatalakshanas. A Certain set of features mentioned in Ayurvedic classics can be correlated with the features of Rheumatoid arthritis.
Involvement of pada includes the metatarsophalangeal joints. Subluxation of toes at the metatarsophalangeal joints is common and leads to the dual problem of skin ulceration on the top of the toes and painful ambulation.
Involvement of gulpha, trika, janu, and uru is common but generally occurs somewhat later than the involvement of small joints. Rheumatoid arthritis carries involvement in a symmetric fashion.
Shotha and anaha can be comprehended as the swelling or a synovial cyst. They are seen as fluctuant mass around the involved joints – large or small joints. Synovial cyst from the knee is the best examples of this phenomenon. E.g. Baker’s cyst in the posterior knee.
Involvement of shira can be taken as the bony erosion and ligament damage occurring and leading to the subluxation of C1 – C2 articulation.
Patients with Rheumatoid arthritis have significantly increased morbidity and mortality from coronary heart disease. The characteristic features of Rheumatoid Arthritis with reference to dhatuscan be assimilated from Table: 1.
Table: 1Dhatus and its features.
Appraisal: Amavata does not merely point out to one disease. Amavatasamprapti is applicable for all those diseases that are generating from ama. But, in the disease Amavata, the features mostly manifests in the sandhi. Moreover, they are also associated with other extraarticular features too. The manifestation of symptoms depends on the location of stasis of ama due to the preceding khavaigunya. Therefore Amavatais a broad spectrum disorder, where rheumatoid arthritis reflects only a minor segment of the whole set of features of Amavata. This work shares a new perspective of understanding the whole disease of Amavata with reference to Rheumatoid arthritis. Unfortunately, there is no one single finding on physical examination or laboratory testing that is diagnostic of Rheumatoid arthritis. Instead, the diagnosis of both Amavata and Rheumatoid arthritis remains a clinical one, requiring a collection of a proper history, physical examination added with the skill of the physician.