Osteoarthritis

Osteoarthritis

What is Osteoarthritis?

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease is a group of mechanical abnormalities involving degeneration of bigger or weight bearing joints. In Ayurveda this can be correlated with “Sandhivata” or “sandhigatavata”.

Osteoarthritis is one of the most common forms of arthritis, which is a degenerative joint disease, slowly progressive and chronic in nature and usually affects almost all the weight-bearing joints. It is characterized clinically by pain, stiffness and at times swelling of the joints. Pathologically it shows degenerative changes in the articulating bones, together with irregular hypertrophy of the bone and cartilages, giving rise to osteophytes.

From the modern standpoint, the disease osteoarthritis is identical to Sandhi Vata in its signs and symptoms according to Ayurveda.

OA is a common degenerative disease of the joint. The disease is characterized by focal areas of destruction of articular cartilage, sclerosis of the bone and hypertrophy of the soft tissues. OA most commonly affects the weight-bearing joints in particular the knee, hip and spine and the interphalangeal joints of the hand. The wrist, shoulder and ankle are less often involved.

Incidence:
20% of people are having Osteoarthritis (Huskisson & Dundley, 1978).

Age – The common age of onset being 40 years with a peak onset at 50 years of age. In women, it appears soon after menopause. In a radiographic survey of women less than 45 years old, only 2% had OA, between the ages of 45 – 64 years, the prevalence was 30% and for those older than 65 years it was 68%. In males, the figures were similar, but somewhat lower in the older age groups.

Sex – Recent studies suggest that men and women are affected equally.

Climate– People of damp and cold area complain more pain. Clinically OA is seen in temperate and sub temperate zones. Frequency becomes less in Polar regions & Tropics.

Obesity– The disease is twice as prevalent in the obese and mainly affects the weight-bearing joints.

Classification:

  1. Primary O.A: Here degeneration of cartilage occurs without an apparent cause. The deterioration of articular cartilage of the affected joint is a result of biological ageing.
  2. Secondary O.A: The degenerative joint changes occur here in response to local or systemic factor such as trauma, metabolic and endocrine disorders, inflammatory arthropathies etc.

Ayurvedic Classification:

It can be classified in different ways as there is no proper classification mentioned in Ayurvedic texts available.

  1. According to pathogenesis of Vata (Ayurveda stresses a balance of three elemental energies or humors: vata, pittha and kapha, for maintaining health) it can be classified as below:
    • Dhatukshayajanya: Depletion of Dhatus (Dhatus are basically the body tissues which are responsible for the functioning of the systems and organs and the structure of the body.) is the main cause of Vatavyadhi.
    • Avaranajanya: Due to Avarana(obstruction) of Srotas(channels carrying nutrition)
    • Both: Kshaya as well as Avaranajanya.
  2. According to Nija and Agantuja, it can be classified in two varieties.
    • i) Nija Sandhivata– OA due to internal causes.
    • ii) Agantuja Sandhivata– OA due to external causes.

Osteoarthritis: Causes

The exact cause of Osteoarthritis is unknown many theories have been postulated for it. Obesity increases the risk of getting OA. Injury to a joint or repeated over use of it damages the cartilage and results in OA. 

In modern medical science, to know the aetiopathology clearly, some theories are put forward. They are:

  • Aging
  • Trauma
  • Physiologic stress and strain
  • Heredity
  • Metabolic disorders
  • Endocrine dysfunction
  • Focal infection
  • Vascular disorders
  • Psychological aspects.

Causes According to Ayurveda:

Ayurvedic literature does not reveal any specific etiological factors for Sandhivata however, the aggravative factors for vata can be adopted for it, and so, its aggravative factors, which can produce Sandhivata, are as follows. 

  • Aharaja (Due to food) :- Intake of foods which are excessively Ruksha(dry), Laghu(light),Sheeta(cold), Asatmya(Incompatible foods), Katu(pungent), Tikta(bitter) in nature and Mithya Ahara (over eating) etc.
  • Viharaja (Due to activities ) :- Ati Vata  Atapa sevana(Excessive exposure to sun and wind), Vyayama(Exercising beyond ones capacity), Vegavidharana(suppressing natural urges like urine, sneezing etc.), Ratrijagarana( remaining awake at night), Divaswapna(sleeping during daytime), Marmaghata(Injury to pressure points within the body where important nerves form junctures with muscles fibers, veins, bones and joints), Abhighata(Injury, trauma) etc.
  • Manasaja (Mental causes) :- Excessive- Chinta(thinking), Krodha(anger), Shoka(sadness), Bhaya(fear) etc.
  • Kalaja (Period) :-During Abhra (cloudy season),  Aparatra(end of night), Sheetakala (winter), Varsha (rainy season) etc. there will be aggravation of vata.

Osteoarthritis: Diagnosis

The diagnosis of Osteoarthritis is based on clinical findings and radiographic features. 

Diagnosis is made with reasonable certainty based on history and clinical examination. In early stages of the disease, radiographic findings may be normal, but joint space narrowing becomes evident as articular cartilage is lost. Other characteristic radiographic finding includes subchondral bone sclerosis, subchondral cyst and osteophytosis. MRI can demonstrate early cartilage changes.

More than 90% of persons over the age of 40 years have some radiographic changes of Osteoarthritis in weight bearing joints but only 30% of these persons are symptomatic.

None of the laboratory studies are diagnostic for Osteoarthritis, but specific laboratory testing may help in identifying one of the underlying causes of secondary Osteoarthritis.

Diagnosis of Sandhivata:

No specific diagnostic examination methods for Sandhivata are given in Ayurvedic texts.

So diagnosis is made by clinical examinations like:

  • Darshana Pariksha (Inspection): In this examination, physician inspects the affected joint for any swelling, muscular wasting, gait, attitude of the patient etc.
  • Sparshana Pariksha (Palpation): The physician palpates the joint and perceives local temperature with the back of palm, looks for tenderness, crepitus during passive movements etc.
  • Prashna Pariksha (History Taking): History of common symptoms like pain, mode of onset, chronicity, joint involvement, stiffness, mechanical disorders etc. can be obtained from the patient through detailed history taking.

Osteoarthritis: Treatment

Lifestyle modification (such as weight loss and exercise) and analgesics is the mainstay of treatment. In Ayurveda Shamana (pacification) and Shodana (purification) type of treatments are done.

Treatment:

Treatment by nonsurgical measures is aimed at retarding progression, alleviating pain and stiffness, preventing deformity and improving motion and stability.

Conservative:

  • Rest
  • Traction
  • Physical Therapy
  • Graduate Exercises
  • Local/Tropical Application
  • Intra-articular Injections
  • Drug Therapy

Surgery:

In exceptional situations in which diseases is advanced within an individual joint and function is severely compromised by pain, restricted motion, deformity and internal degeneration of the joints surgical treatment may become necessary.

Diet:

People with OA should aim to eat a balanced diet that is rich in vitamins C and D.

Some individuals may benefit from dietary advice given by a dietician – particularly those with special dietary needs, e.g. weight reduction. Nutraceuticals like avocado, soybean etc.

Ayurvedic Treatment:

The aim of treatment is to remove causative factor as well as restoration of the equilibrium of three doshas. The elimination of the disease can be achieved by Shodhana(Purification /elimination therapy) and Shamana(Pacification therapy).

Shodhana comprises of Antaha Parimarjana (internal purification) and Bahir Parimarjana(External purification).

Bahira Parimarjana is achieved by Snehana (Oleation), Swedana(Fomentation theraphy), Mardana(Massage), Lepana(local application of herbal pastes etc.)

Shamana type of Chikitsa cures Disease without eliminating Doshas.

In the management of Sandhivata, the following are some of the measures done: 

Snehana : Snehana(oleation) besides being the chief Purvakarma(pre preparatory) procedure for the Panchakarma therapy, happens to be one of the most significant treatments for OA. Snehana therapy is administered to persons in two different ways as follows.

1) External application (Abhyanga-oil massage)
2) Internal application (Snehapana-oral administration of medicated ghee,oiletc)

Both external and internal Snehana are very effective in Sandhivata.

Sneha (medicated oils/Ghee) alleviates Vata because the properties of Sneha are exactly antagonistic to that of Vata. Snehana helps in the promotion and regulation of the proper functioning of Vayu and  it replenishes the joints and strengthens it. 

Upanaha : Upanaha is one of the four types of Swedana(Fomentation therapy). This procedure relieves stiffness, heaviness, coldness and induces sweating. Here a paste of the roots of Vayu subsiding drugs are prepared and mixed with medicated oil which are selected according to the condition of the patient, the mixture is then heated gently and is then applied on the affected joints. After applying the paste, the joint is covered with leaves and is then bandaged with cotton and leather or cloth. The duration of the bandage is about 12 hours. The application of heat and the herbs applied causes relaxation of the muscles and tendon and improves the blood supply.

Agnikarma : Agnikarma(thermal cauterization) on the affected joint relieves pain.This treatment method is not widely practiced. 

Bandhana : Bandhana means bandaging tightly. It is done to stabilize the joint thereby controlling excessive movement and thus prevents injury of neighboring structures, swelling and displacement of the joint.

Unmardana : This is a type of massage in which pressure is exerted on diseased joint. It relieves swelling and enhances blood circulation.

Basti : Basti (Medicated enema) is the treatment of choice for a wide number of diseases arising due to vata. In Sandhivata, Sneha Basti (Administering medicated oil as enema) is one of the most significant treatments for OA.

Yogasana: helps to a greater extent in preventing and curing of Sandhivata. The regular practice of Yogasanas improves the symptoms in different ways like decreasing overweight, decreasing laxity (Bhole – 1982). Posture will also be improved by Yogasana (Yogendraji – 1984), which is also an important predisposing factor in Sandhivata.

Apart from these some local procedures which are highly effective are listed below:

Nadi swedam: Here fomentation is done with the vapors generated out of medicated decoction that is then applied to the affected area with the help of a rubber tube. Proper oleation of the affected part is done prior to Nadi Sweda.

Janu basti: In this therapy, a receptacle is made out of dough over the affected knee and medicated oil is poured in it after heating it gently and allowed to remain inside for 30 minutes and the treatment is repeated for 7 to 14 days. It is very effective in controlling pain & stiffness in OA knee & degenerative disorders of the knees.

Kati vasti: Is an Ayurvedic procedure of retaining warm medicated oil over the lower back bordered with dough. The therapy can last for 45 to 60 minutes. It is a general cure for almost all types of spinal problems and back pains, OA hip etc.,

Greeva Vasti: Is an Ayurvedic procedure of retaining warm medicated oil over the nape of the neck bordered with dough. The therapy can last for 45 to 60 minutes. It is a general cure for almost all types of cervical spinal problems and neck pains & stiffness, OA neck, cervical spondylosis etc.


Diet and regimen:

Diet to be taken:

Generally foods, which are sour, salty and sweet in taste, are considered good for alleviating vata. Wheat, Meat, Red rice, Cow & Goats milk, Ghee, Grapes, Gooseberry, Hot water, Wine, rice porridge etc. can be consumed.

Foods to be avoided:

Generally foods which are pungent, bitter , astringent in taste vitiates vata so they are to be avoided. Apart from that Barley, chenna, Kalai Dal, cold water, dry meat, dry fish, and excessive alcohol intake are to be avoided.

Regimen:

Patient should bath only in hot water and avoid contact with cold water, should not lift heavy weight, should not do strenuous work, should not remain awake at night and sleep during day time, should not suppress natural urges, should not think excessively etc. and should try to remain as calm as possible.

Osteoarthritis: Clinical Features

The main symptom is pain-causing loss of ability, restricted movement and stiffness. OA can cause a crackling noise called crepitus when the affected joint is moved, the joints may also be filled with fluid.

Clinical Features: 

  • Pain: Pain is the cardinal symptom of degenerative joint disease which occurs on use (friction effect) and is relieved by rest. Later as the disease progresses, pain occurs even at rest. The severity various from a slight dull ache to a severe sharp pain. 
  • Swelling: Swelling may occur which usually feels hard. Distention of a joint is due to thickened synovial membrane. Joints may show localized tenderness. 
  • Stiffness: Stiffness is felt after resting or when first getting out of bed (Typically known as Morning stiffness). 
  • Crepitus: Crepitus may be felt or even heard. It can be detected by feeling the joint with one hand while it is moved passively with the other. 
  • Restricted Movements: Movement in the affected joints becomes increasingly limited, which is initially due to the pain and muscular spasm, but later because of capsular fibrosis, osteophyte formation and remodeling of bone. 
  • Deformity: Considerable deformity may result from the weakness of the muscles and ligaments and from the degeneration of the ends of bones, so that displacement and even shortening occurs. 
  • Heberden’s Nodes: This is a cartilaginous and bony enlargement of the terminal interphalangeal joint of the fingers. It is characterized by presence of small, hard nodular swelling in the vicinity of affected joints. Particularly on their dorso lateral surface. Similar nodes on the proximal interphalangeal joints are often called “Bouchard’s nodes”. Heberden’s nodes may be single, particularly following trauma, but usually are multiple. Generally they affect several of the fingers but are more commonly found in the index and middle fingers. Women are affected much more than men. They are usually painless, but may be painful and produce numbness and tingling in the fingers. 

Involvement of Specific joints:

Incidence – Knee (75%), Hands (60%), Lumbar Spine (30%), Hip joint (25%),

Cervical spine (20%), Ankle (20%), Shoulder (15%) are the commonest sites.

Rarely elbow and wrists are also involved.

Clinical Features of sandhivata:

The cardinal features of Sandhiavata according to various Ayurveda treatises can be summed up as

  • Sandhisula – Pain in the joints
  • Sandhisotha – Swelling in the joints
  • Stambha – Immobility /restricted movements of the joints
  • Sandhisputana – Crepitus in the joints
  • Akuncana Prasaranayoh Vedana – Pain during flexion and extension of the joints.