Rheumatoid Arthritis : Types, Symptoms, and  Ayurvedic Treatments

Introduction :

➢   An autoimmune disease in which the joint lining (synovial membrane) becomes inflamed as part of the body’s immune system activity.

➢   Most common inflammatory arthritis (chronic multisystem disease) in women.

 ➢   Typical clinical phenotype of RA is a symmetrical, deforming, small and large joint polyarthritis, often associated with systemic disturbance and extra articular disease. 

➢ Clinical course is usually life long, with  intermittent exacerbations and remissions and highly variable severity.

Aetiology 

• Autoimmune disease – immunogenitically predisposed individual to the effect of microbial agents as trigger antigen.

Pathogenesis

• Persistent cellular activation, autoimmunity and the presence of immune complexes at sites of articular and extra articular lesions.
• Chronic inflammation, granuloma formation and joint destruction.
• Swelling and congestion of the synovial membrane and the underlying connective tissues, which    become   infiltrated with lymphocytes(especially CD4 T Cells), plasma cells and macrophages.
• Effusion of synovial fluid into the joint space.
• Hypertrophy of synovial membrane occurs with the formation of lymphoid follicles.
• Inflammatory damage to synovium, small vessels and collagen.
• Destruction of cartilage, bone, fibrosis, ankylosis – joint deformities.

Clinical features

• Persistent synovitis.
• Onset of articular signs of inflammation is usually insidious, with prodromal symptoms of malaise, weight loss, and vague periarticular pain or stiffness.

Diagnosis

Criteria for Diagnosis of RA – diagnosis is made with four or more of the following:

5. Morning stiffness (> 1 hour)
6. Arthritis of three or more joint areas.
7. Arthritis of hand joints
8. Rheumatoid nodules- located over the extensor surfaces of the elbows, occiput, sacrum and fingers in subcutaneous tissue over pressure points.
9. Rheumatoid factor (A circulating antibody)
10. Radiological changes
11. Duration of 6 weeks or more

Patterns of presentation 

• Gradual onset of symmetrical arthralgia and synovitis of small joints of the hands, feets and wrists.
• Dramatic acute onset, sometimes over just a few days, with florid morning stiffness, polyarthritis 11  and pitting oedema, occurs more commonly in the elderly.
• Involvement of other synovial structures (tenosynovium, bursae) is common.

  

Extra articular features

• Anorexia, weight loss and fatigue are common since RA is a systemic disease.
• Generalised osteoporosis and muscle wasting (sarcopenia) result from systemic   inflammation
• Nonspecific inflammatory changes are seen in the blood vessels (acute vasculitis), lungs,pleura, pericardium, myocardium, lymph nodes, peripheral nerves and eyes and formation of subcutaneous nodules.

Complications.

       ➢Bony erosion

       ➢ Cartilage loss

       ➢ Inflamed synovium

       > Swollen capsule    

Complications- Chronic RA

• Ulnar deviation
• Muscular atrophy
• Swan neck deformity 

  Investigations 

• Acute Phase Reactants — ESR and CRP
• RA factor
• ACCP
• Arthroscopy
• Imagiology

Radiographic findings – juxta-articular osteoporosis,joint erosions, and narrowing of the joint spaces.

Variants of RA 

1. Chronic Juvenile polyarthritis(inch; Still’s disease)found in adolescent patients under 16 years of age is characterised by acute onset of fever, rash, lymphadenopathy and splenomegaly along with uveitis and keratopathy and predominant involvement of knees and ankles

2. Felty’s syndrome – Consists of polyarticular RA associated with splenomegaly and hypersplenism and consequent haematologic derangements.
3. Palindromic rheumatism -Repeated attacks of joint pains, redness and swelling. Attacks occur suddenly within hours and may affect one joint usually with signs of inflammation. Usually lasts for a few days and subside without any residual lesion.

 

ESSENTIALS OF DIAGNOSIS 

• Prodromal systemic symptoms of malaise, fever, weight loss and morning stiffness.
• Onset usually insidious and in small joints: progression is centripetal and symmetric: deformities are common.
• Radiographic findings – Juxtaarticular osteoporosis, joint erosions, and narrowing of the joint spaces. 
• Rheumatoid factor usually present

RA —Reading through Ayurveda 

 Rheumatoid Arthritis is basically a multifocal joint disease with deep dhatugatha pathologies. The lesions start from the twak and gradually spread upto Asthi and Majja dhatus resulting in permanent irreversible deformities. Autoimmune nature of RA is mainly due to Raktadushti and Dhatupaka. Dhatupaka leads to destruction of joint structures. Clinically RA is similar to Vata and Kapha dominant Vatarakta. Presence Ama is seen in most of the cases.   

 Raktadushti will definitely be manifested as inflammation. Vatakopa will affect the normal chalaguna of Vata. Presence of Ama can again cause swelling and stiffness to joints. Hence it is better to consider all these three factors together in RA. There will be different proportions of these factors in different stages of RA. In other words the vikalpa samprapii will vary in different progressive stages of RA.

As RA progresses the features similar to Gambheera vatarakta are seen in the patient. Gradual involvement of the dhatus leads to multidimensional articular and non articular features in the patient. Sandhivakratha mentioned in gambheera vatarakta is similar to various deformities of RA. Circulatory disturbances are also seen in RA when there is severe mutual avarana to both vata and rakta. The features suggestive of vasculitis seen in RA are quite similar to raktavrutha vata in vatarakta.

Disease Profile

• Dosha — Vata mainly. Kapha is seen as anubandha in some cases.
• Dooshya — Twak and Mamsa in the first phase. In later stages, asthi and deep dhatus.
• Status of Agni — Ama is involved in early stages
• Samprapti Swabhava — Raktadushti,vatakopa,dhatupaka and dhatukshaya
• Rogamarga – Madhyama

Treatment principle

Basic protocol is the treatment of vata and kapha dominant vatarakta with amapachana principles of Amavata. In practice, the judicious combination of vatarakta and amavata chikitsas gives encouraging results.

In the initial phase there should be the administration of amapachana drugs to remove the ama if any. After amapachana, drugs which will control the inflammation are to be selected from the vatarakta pool. Once the severity of inflammation is controlled the next treatment is mainly vatahara. Ojokara rasayanas are given at the en’ to enhance the immune system and prevent the recurrence. Rasayana drugs will minimize the extra particular impact of RA.

Panchakarma Chikitsa

Since there is raktadushti, virechana is the main sodhana in the first phase of RA. Eranda based preparations are generally administered, as vata is the main dosha.

Virechana Drugs

1. Gandarva erandam — 25 ml with milk after 8am
2. Eranda sukumaram — 25m1 with milk
3. Erandathailam – 20 ml with Nirgundi Swarasa  20m1
4. Gandarvahasthadi Avanekkenna — 25m1 with milk

   Since there are deep dhatugatha stages with strong vatakopa, Vasthi is also important in RA. Ksheeravasthi is ideal here as it pacifies both raktadushti and vatakopa.Moreover Ksheeravasthi has excellent action in koshta, pakwasaya and sakha.

   Major Vasthi kalpanas in RA

1. Madhuthailika Vasthi
2. Erandamooladi Vasthi
3. Ksheera Vasthi with Panchathiktha kshecra and Ghritha

The acute phase of RA where the raktadushti is so severe. Jaloukaavacharana can be done frequently without causing vatakopa. To prevent the vatakopa due to raktakshaya, proper snehas, mainly ghrithas are periodically administered.

Basic indication of Jaloukaavacharana in RA

1. Ruk
2. Raga
3. Thoda
4. Daha in affected joints

Special Diet in RA – Peya made out of hraswa Panchamoola, badra and laja is given after Panchakarma. It is found effective in reducing the vata related symptoms.

External applications

External applications are done in the acute phase — Uthana stage of the disease. First start with ruksha kalpanas like lepana and after getting relief to sopha, switch over to snigda kalpanas like abhyanga and snehaseka.

Lepanas

• Nagaradi lepa with kanchika
• Kottam chukkadi lepa with chincha swarasa
• Jadamyadi lepa with kanchika
• Ellumnisadi lepa
• Grihadhoomadi lepa

 Thailas

1. Balathaila
2. Dhanwantharam thai la
3. Narayana thaila
4. Chinchadi thaita
5. Sathahwadi thaila
6. Kottamchnkkadi thaila
7. Karpasa.sthyadi thaila
8. Pindathaila
9. Aranaladi thaila
10. Ksheerabala thaila

Parishekas

• Dhara with ksheera, dadhi, kanchika, cold madya and tender coconut water in the acute phase of RA.

• Dhanyamladhara
• Dhara with Dasamoolasritha ksheera
• Dhara with kokilaksha kashaya
• Dhara with Karaskara Ghritha
• Dhara with Mahasneha in second phase of RA

Upanahas

1. Upanaha with Nagaradi lepa chooma, Saindava,  Dhanyamla and Dhanwantharam Thaila for seven days — Vata dominat cases with more pain and less stiffness.
2. Upanaha with Kottamelitikkadi lepa choorna,Saindava, Dhanyamla and karpasasthiyadi thaila for seven days. — Kapha dominant cases with more swelling and stiffness of the joints.

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