Rheumatoid Arthritis

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Table of Contents
Casestudies of Contents

Brief Medical History

Presenting Complaints with severity and episode duration

  • Multiple joint pain
  • Swelling legs
  • stiffness in legs

Brief Relevant Medical History (Onset, Duration, Ag/Rel Factors, OTT, Prior Confirmed Diagnoses if applicable):
Patient k/c/o Rheumatoid arthritis since 2 years,developed shoulder joint pain with stiffness 2 years back. Later pain and stiffness was observed in all the major and minor joints. She took allopathic treatment for about 6 months and then stopped. Later after 6 months she again developed multiple joint pain which is aggravating by cold and in morning hours. She feels relieved by hot fomentation. Patient underwent hysterectomy 8yrs back and is on Multivitamin tablets. She is also a k/c/o Allergic bronchitis and uses Asthalin inhaler SOS. Not a known DM/HTN.

Current medication: Multivitamin tablet 1/day

Integrated Summary

Clinical Status
Allopathy Ayurveda
Vital Parameters

1. BP -120/80 mm of Hg
2. Pulse-62
3. RR- NA
4. Weight-70kg
5. BMI-34.6-Obese
6. WHR-0.89
Astasthana Pariksha

1. Nadi - Manda
2. Malam - Prakruth
3. Mutra - Prakruth
4. Jihva - Prakruth
5. Shabda - Prakruth
6. Sparsha - Prakruth
7. Drik - Prakruth
8. Akruti - Sthula

Examinations

1. GC- Fair, Afebrile.
2. CVS- S1, S2 heard
3. CNS-NAD
4. RS- NVBSheard
5. PA- Soft, No Organomegaly

MS system:

Joints involved Pain Stiffness
Ankle joints
++
++
Major joints
++
++
Minor joints
++
++
DasaVidhaPariksha

1. Prakriti- kapha vata
2. Vikriti-vata dosha
3. Sara-Mamsa
4. Samhanana-Madhyama
5. Pramana-Madhyama
6. Satmya-Ushna
7. Satva-Pravara
8. Aharashakti-Madhyana
9. Vyayam Shakti-Madhyama
10. Vaya-Madhyama
11. Desha-sadharana
12. Kala - Roga avasta jeerna
Rogi Bala- Madhyana
Roga Bala- Pravara
DSQ findings     Rating

ADRS70       Med
LUPPN 1       NS
Nidana Panchaka

1. Nidana-Irregular food habits, cold heavy food continuously
2. Purvaroopa-Avyakta
3. Roopa-Fever with chills & rigors associated with multiple joint pains
4. Upashaya-Ushnaaharavihara
5. Samprapti

1. Dosha-Kapha vata
2. Dushya-Mamsa, Asthi, Majja
3. Agni-Dhatwagni
4. Ama- Jataragnijanya
5. Srotas- Mamsa, Asthi, Majjavaha
6. Sroto Dushti Prakara-

Lab Tests

Lab Findings Last Recorded Value Lab Findings Last Recorded Value
FBS
RBS-114
TSH
-
HBA1C
-
TGL
-
Total Chol.
-
HB
13 (20/04/12)
10.7 (3/6/13)
HDL
-
Liver
Normal range
LDL
-
RAF
Positive-19/12/12&20/4/12
CRP
-
Positive 20/4/12
Negative 3/6/13
-
Roga Samprapti Flow Chart

Due to intake of nidana, all Doshas gets aggravated, which vitiates the Vata in kaphasthana, expels in to exterior, then produces swelling along with joint pain.
Differential Diagnosis with reasoning

1. Rheumatoid Arthritis- The joint involvement is characteristically symmetric with associated pain, stiffness, warmth. The stiffness is characteristically worse in the morning and improves during the day; its duration is a useful indicator of the activity of the disease. The stiffness may recur especially after strenuous activity. The usual joints affected by rheumatoid arthritis are the metacarpophalangeal jts, the PIP jts, the wrists, knees, ankles, and toes. nd tenderness.

2. Gouty arthritis- Excruciating pain and swelling in the big toe – often following a trauma, such as an illness or injury. Subsequent attacks may occur off and on in other joints, primarily those of the foot and knee, before becoming chronic. In its chronic stage, gout can affect many joints, including those of the hands. Other problems related to gout can include the formation of tophi, or lumps of crystals under the skin, in the joints and in bone; kidney stones; and impaired kidney function.Uric acid levels are elevated in blood.
Differential Diagnosis with reasoning

1. Amavata- pain and swelling in major and minor joints with Ama lakshanas in body.
2. Vatarakta- Pain in sandhi, starting from foot region extending upwards with Daha, pricking type of pain and discolouration.
3. Sandhivata- Shoola and shopha in sandhi especially in major joints.
Evidence Based Diagnosis with References
Rheumatoid Arthritis
Evidence Based Diagnosis with References
Amavata
Chikitsa Vivechana:

1. Ahara-
i. Follow timely meal. Have freshly prepared warm food.
ii. Cooked vegetables, fruits.
iii. Boiled-Warm jeera/ Coriander seed / mint for Drinking water.
2. AVOID-
i. Refrigerated, deep fried, oily, spicy, salty, canned food items.
ii. Avoid sour food and drinks.
iii. Avoid fermented food preparations, curds.
iv. Green chillies, Channa,brinjal, Green peas, Rajma, Potato, Cabbage, Cauliflower,pickles.
3. Vihara-
a. REGIMEN:
i. Avoid exposure to cold.
ii. Keep yourself warm and covered.
iii. Mild exercises as advised.
iv. Hot water bath.
Details of Allopathy medicine if continued
Kriya-
Type –OPT
Duration – 14days

Primary Treatments- NIL

Main Treatments-
i. Valukasweda-14 days
ii. Sadyovirechana was given after 3 days of valukasweda

Aushadha-
Medications -
• Guggulutiktaka Kashaya (15ml) + Tab Yogaraja guggulu 1+ 10 tsp warm water morning and evening on empty stomach.
• Tab Vishatinduka 2 + Shaddharana 1-three times daily after food.
• Tab Chandraprabhavati 1 after food morning and evening.
• Gandharva hasta taila 3tsp with hot water at bed time.
• Kottamchukkadi taila + Pindataila- Warm and apply half an hour before bath.

Post Treatments- NIL
Chikitsa Paddhati with details of dose of medicine.

Valukasweda- Amavata is a condition dominated with Ama ie., kapha along with vata. Rukshasweda is indicated and hence Valukasweda is preferred.
After 3 days, Virechana was given to remove the liquefied Ama from the body. Patient got 3 virechanavegas with Gandharva hasta erandataila 30ml.
After removal of Amatwa, Valuka Sweda was done using Kottamchukkaditaila and Pinda taila mixture to subside Vata.

Guggulutiktaka Kashaya- Kapha vatahara,kledahara, Lekhanaactions helping toremove Ama and reduce Vata.

Yogarajaguggulu- indicated in Amavata, Sandhi majjagata vata. (BhaishajyaRatnavali)

VishatindukaVati-

Shaddharana Tab- for Amapachana and improving digestion. It removes Amavastha. (Su chi)

Chandraprabhavati- Kaphamedo dushti janyaroga.

Kottamchukkadi taila indicated in all Vatavyadhi, after removal of amavastha.

Pinda taila-Indicated in Nirama vata.
Referral Opinion Sought if any—No

Integrated View – Patient has multiple joint pain with swelling, started from shoulder joint, seen in almost all major and minor joints, aggravating with cold and in morning. Digestion is hampered. Rheumatoid arthritis factor is positive. Hence, the condition of Amavata/ Rheumatoid arthritis is difficult to treat and is advised to continue oral internal medicines and plan for the panchakarma therapies.

Outcome

1. Samyak Lakshanas achieved (Control Charts Summary to be Attached) Sadyo Virechana chart attached-No.1.

2. Standardised Outcome Scales Used (Summary Table to be Attached)

3. Other outcomes as per following table to be duly filled

# Outcome Parameters / / Date-Time: Unit N TSD T TED R-T N/ R/ TSD/ T/ TED/ R-T
1.
Sleep (Nidra)
-
Good
Good
Good
Good
-
-
2.
Appetite (Agni)
-
Good
Good
Good
Good
-
-
3.
Bowels (Mala)
-
Regular
Regular
Regular
Regular
-
-
4.
Urination (Mutra)
-
Regular
Regular
Regular
Regular
-
-
5.
Stress (Manas)
-
Normal
Normal
Normal
Normal
-
-
6.
Vitality (Ojus)
-
Good
Good
Good
Good
-
-
7.
Wellbeing (0-10)
-
5
5
6
7
-
-
8.
BP
-
120/80
120/80
120/80
120/80
-
-
9.
Pulse
-
62
-
-
-
-
-
10.
Weight, Kg
-
70
70
70
70
-
-
11.
W-U, cm
-
34
-
-
-
-
-
12.
Diet (Ahara)
-
Fair
Good
Good
Good
-
-
13.
Exercise (Vyayama)
-
Yoga
-
-
-
-
-
14.
Lifestyle (Vihara)
-
Fair
Fair
Fair
Fair
-
-
15.
Pain in major and minor joints
(0-10)VAS
10
5
2
-
-
16.
Stiffness in joints
(0-10)VAS
8
4
2
-
-
17.
Pain with swelling in ankle joints
(0-10)VAS
9
4
3
-
-

Patient’s Outcome Scale

# Presenting Complaint Weightage Status_TSD Status_TED Status_1 Week Status_1 Month Status_6 Months
1.
Multiple joint pain
50%
poor
Very good
-
Very good
-
2.
Swelling in joints
50%
poor
Very good
-
Very good
-
3.
4.
WEIGHTED AVERAGE SCORE----->
-
-
-
-
IMPROVEMENT SCORE-----> 0.0 -2.0 -2.0 -2.0
0.0
-2.0
-2.0
-2.0
IMPROVEMENT %ge----->
0%
-100%
-100%
-100%
Adverse Incident Report (Drug or Treatment): NIL

Attachments

Date At the start of Treatment During the Treatment Post treatment
Images/ Details of the site
Lab Reports

Conclusion

At the end of treatments, patient has got significant relief from her symptoms. Mild pain and swelling is persisting ankle joint. She is advised to undergo Yogabasti after 3 weeks. She is advised to continue all his internal and external medicines for 15 days and review thereafter.

Direction for Future Research

ASO titre and RA factor to be seen before and after treatment.

References

  1. Bhavaprakasha
  2. Bhaishajyaratnavali
  3. Chakradatta

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