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Management of Hashimoto’s Thyroiditis through Ayurveda

Authors:
  • Dr. Seetha's Niramaya Ayurgramam

Abstract and Figures

Hashimoto’s Thyroiditis (HT) is the most common auto-immune thyroid disease and the commonest cause of hypothyroidism. In conventional medicine, treatment of choice for HT is replacement of thyroid hormone. A case of HT was managed at the OPD level by following Ayurveda principles and found to be effective. A treatment protocol was designed based on the signs and symptoms and assigned in this patient. Snehapana followed by Vamana and Virechana and at the end Shamana was done with Varunadi kwatha bhavita shilajatu for a period of three months with two months follow up. The treatment protocol was found to be effective in symptomatic and biochemical profles of the patient. Patients of HT should be able to have a choice against the lifelong hormone therapy. This can be achieved by adequate evaluation of the individual action of the therapies adapted here and replicating the same in a much larger group.
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An Official Peer Reviewed Publication of
All India Institute of Ayurveda
New Delhi
Journal of Ayurveda Case Reports (AyuCaRe) Vol. 1, Issue 1, July - September 2107
Journal of
Ayurveda Case Reports
Journal of
Ayurveda Case Reports
Vol. 1, Issue 1, July - September 2017
AyuCaRe
AyuCaRe
EDITORIAL
AyuCaRe - A New Journal for Ayurveda Case Reports
Abhimanyu Kumar
1-2
Research in Traditional Systems of Medicine
Sung Chol, Kim
3
GUEST EDITORIAL
All India Institute of Ayurveda Launching Quarterly Journal of Ayurveda Case Reports
Ram Harsh Singh
4-5
CASE REPORTS
1Management of Avascular Necrosis through Panchakarma
Adil R, Sangeeta RT, Karishma S, Anup BT
6-12
2Jalaukavacharana (Leech application) and adjuvant therapy in the management of infected
wound
Mahanta VD, Foram J, Dudhamal TS, Gupta SK
13-17
3Management of Hashimoto’s Thyroiditis through Ayurveda
Seetha C, Rajam R, Patgiri BJ, Prakash M
18-22
4Ayurvedic Management of Ankylosing Spondylitis
Mayur M, Mayur B, Chandrashekhar YJ, Kandarp D
23-27
5Management of Frozen Shoulder in Diabetics through Panchakarma
Sangeeta RT, Adil R, Anup BT
28-33
6Ecacy of Triphaladya guggulu and Punarnavadi kashaya in the management of Hypothyroidism
Karishma S, Anup BT, Prajapati PK
34-39
GENERAL INFORMATION ABOUT THE JOURNAL i-vi
TABLE OF CONTENTS
Journal of Ayurveda Case Reports
Patron Co-Patron Editor in Chief
Sh. Shripad Yesso Naik Vd Rajesh Kotecha Prof. Abhimanyu Kumar
Minister of State (Independent Charge), Special Secretary, Director,
Ministry of AYUSH Ministry of AYUSH All India Institute of Ayurveda
New Delhi New Delhi New Delhi
International Advisory Board
Dr. Jery D White Dr. Pirag Valdis Dr. Antanio Morandi Dr. Christian S Kessler
Director, Oce of Director, Centre of Director, School of Research Coordinator
Cancer Complementary Complementary Medicine, Ayurvedic Medicine, Charitie Medical University
and Alternative Medicine University of Latvia, Italy Berlin
National Cancer Institute Latvia
NIH, USA
Dr. Madan Thangavelu
Dr. Jeorge Berra Dr. Rajendra Badgaiyan Dr. Amala Guha
Research Director,
Director, Professor, President,
European Ayurveda
Foundation De Salud Boonshoft School of Medicine International Society
Association, Germany
Ayurveda Prema, Wright State University, of Ayurveda & Health,
Argentina USA USA
National Advisory Board
Dr. Manoj Nesari Dr. DC Katoch Prof. KS Dhiman Prof. RH Singh Prof. GG Gangadharan
Advisor (Ayurveda), Advisor (Ayurveda), Director General, Distinguished Director, Ramaiah
Ministry of AYUSH, Ministry of AYUSH, CCRAS, Professor, BHU, Indic Specialty
New Delhi New Delhi New Delhi Varanasi Ayurveda Restoration
Hospital, Bangalore
Prof. Ravi Mehrotra Prof. A Srivastava Prof. GK Rath Dr. Vasudevan Dr. Ram Manohar
Director, NICPR, Head, Dept of Surgery, National Cancer Institute, Nampoothiri MR Director, Amrita
ICMR, AIIMS, AIIMS, Principal, Amrita Centre for Advanced
New Delhi New Delhi New Delhi School of Ayurveda, Research in Ayurveda,
Kerala Kerala
Prof. LP Dei Prof. Sanjeev Sharma Prof. YB Tripathi Prof. PK Goswami Prof. YK Tyagi
Director, Director, Dean, Director, Voice Chancellor,
IPGT & RA, Jamnagar NIA, Jaipur IMS, BHU, Varanasi NEIAH, Shillong Delhi University
Editorial Review Board
Prof. MS Baghel, Ex-Ayurveda Chair, University of Debrecen Prof. PK Prajapati, Head, Dept of RS & BK
Prof. HM Chandola, Ex-Director, CBPACS, New Delhi Prof. SK Gupta, Head, Dept of Shalya Tantra
Dr. KR Kohli, Director, Directorate of Ayurveda, Mumbai Prof. Tanuja Nesari, Head, Dept of Dravya Guna
Dr. GS Badesha, Director, ISM, Raipur Prof. Manjusha R, Head, Dept of Shalakya Tantra
Prof. SN Gupta, JS Ayurveda College, Nadiad Prof. Sujata Kadam, Head, Dept of PT & SR
Prof. JS Tripathi, IMS, BHU, Varanasi Prof. Mahesh Vyas, Head, Dept of Maulika Siddhanta
Dr. BS Prasad, KLE Ayurveda College, Belgaum Dr. Santosh Bhaed, I/C Head, Dept of Panchakarma
Dr. Sanjeev Rastogi, Ayurveda Expert, Lucknow Dr. Mangalagowri Rao, I/C Head, Dept of Swasthavria
Dr. Pawan Godatwar, NIA, Jaipur Dr. RK Yadava, I/C Head, Dept of Kaya Chikitsa
Dr. Supriya Bhalerao, Bharati Vidyapeeth, Pune Dr. VG Huddar, I/C Head, Dept of Roga Nidana
Dr. Rajagopala S, Dept of Kaumarabhritya
Dr. Krishna Dalal, Research Advisor, AIIA
Executive Editor Associate Editor
Dr. Galib Dr. Mahapatra Arun Kumar
Associate Professor Assistant Professor
Dept of Rasa Shastra & Bhaishajya Kalpana Dept of Kaumarabhritya
All India Institute of Ayurveda, All India Institute of Ayurveda,
New Delhi New Delhi
EDITORIAL BOARD
1
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):1-2
EDITORIAL
AyuCaRe - A New Journal for Ayurveda Case Reports
The Indian systems of medicine have age old acceptance
in the communities in India and in most places they form
the rst line of treatment in case of common ailments. Of
these, Ayurveda is the most ancient medical system with
a time tested impressive record of safety and ecacy.
These systems were well known to Indian population
and their acceptability in population is already there as
they form the part of house hold remedy, life style and
dietetic management of the society.
Majority of the world's population in developing
countries still relies on herbal medicines to meet their
health needs. They are often used to provide rst-line and
basic health service to people living in remote and poor
areas. Even in areas where modern medicine is available,
the interest on traditional practices has been increasing
rapidly in recent years because of many reasons.
Contribution of traditional practices, in particular of
Ayurveda in global health care cannot be ignored by any
science for its qualitative strength and clues provided
in the eld of therapeutics. India enjoys the largest
traditional health care, which is fully functional with a
network of qualied registered practitioners, research
institutions and licensed pharmacies.
Ayurveda can play a major preventive, curative, and
promotive role in community health. The eectiveness
of Ayurveda in dierent disease conditions need to be
shown to the community, for which, we need to proceed
in a systematic manner.
Study design is an important issue. Ill-designed
studies are unlikely to add any value either to science
or to Ayurveda. A comprehensive custom to explore
evidences on eectiveness in Ayurveda is the need of
hour to generate databases regarding the usefulness of
Ayurveda approaches in global healthcare.
Well-established, randomized controlled clinical trials
are undisputed gold standards and can provide highest
level of evidence for ecacy facilitating acceptance
of medical practices. These conventional concepts of
clinical research design may be dicult to apply when
using practices of traditional medicine. Methods such
as randomization and use of a placebo etc. may not
always be possible in Ayurveda clinical trials as they
may involve many technical problems. In addition;
prevention, diagnosis, treatment etc. in Ayurveda are
based on specic needs of an individual patient. Hence,
approaches like Whole Body Systems, MOST, STROBE,
Case Reports etc. possibly may benet Ayurveda studies.
Initiatives are to be made to enrich AYUSH professionals
with these methodologies.
Case reports signicantly can contribute and
disseminate Ayurveda potentialities to the global
community. They have an advantage of being adaptable
to the clinical needs of the patient and the therapeutic
approach of the practitioner. It is observed that, many
Ayurveda physicians have success stories for clinical
conditions, where no satisfactory answers are available
in contemporary eld. Dissemination of such success
practices is a way of sharing knowledge that will help
in shaping the health care system. Case Reports help
practitioners to share their experiences with peers,
researchers, students and other interested. Ayurveda
currently need more and more evidence based success
stories.
A suitable platform is needed to communicate all
such experiences. Considering this acute need; All
India Institute of Ayurveda, New Delhi is creating an
unique platform Journal of Ayurveda Case Reports
How to cite: Abhimanyu K. AyuCaRe - A New Journal
for Ayurveda Case Reports. J AyuCaRe 2017;1(1):1-2.
Journal of Ayurveda Case Reports
2
Abhimanyu K: Editorial
(AyuCaRe) for all stakeholders of AYUSH to share
their experiences. AYUCaRe invites Case Reports and
provides opportunities for students, researchers and
faculty of AYUSH and allied medical sciences to share
their experiences. This initiative is expected to play a
pivotal role in researches, further generating evidence
base for the claims and principles of Ayurveda practices
in a systematic way.
I take this opportunity to invite all the stakeholders of
Ayurveda to use this platform and share Case Reports
in the benet of traditional practices. At AIIA, we are
commied to put Ancient wisdom of Ayurveda in
Evidence Based Practice.
Prof Abhimanyu Kumar
Editor-in-Chief
Journal of Ayurveda Case Reports (AyuCaRe)
All India Institute of Ayurveda,
Sarita Vihar, Gautam Puri,
Mathura Road, New Delhi
E-mail: ak_ayu@yahoo.co.in
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):1-2
3
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):3
I am very glad to see the rst issue of the case study
focused Ayurveda journal by All India Institute of
Ayurveda in India.
India has a rich heritage in traditional systems of
medicine which include Ayurveda, Unani, Siddha,
Yoga, Naturopathy, Homeopathy and others.
Traditional herbal medicines an important part of most
traditional systems of medicine including Ayurveda.
Many people in developing countries still rely on herbal
medicines to meet their health needs, particularly in
rural and remote areas. Even in areas where modern
medicine is available, the interest in herbal medicines
has been increasing rapidly in recent years because of
their potential contributions to health and well-being,
because lifestyle-related diseases are becoming more
common across the world.
Traditional herbal medicines are believed to have much
to oer in the health promotion, disease prevention and
management, particularly for lifestyle-related diseases,
through their holistic approach.
How to cite: Sung Chol K. Research in Traditional
Systems of Medicine. J AyuCaRe 2017;1(1):3.
Research in Traditional Systems of Medicine
The WHO Traditional Medicine strategy 2014-2023,
promotes safe and eective use of traditional medicines
and has one important strategic objective, that is to
build and strengthen the knowledge base on traditional
medicines through research. This need for an improved
knowledge base was reinforced at the regional
consultation on traditional medicine for the WHO
South-East Asia region in 2015.
This journal is, therefore, important to build and
strengthen evidence-based knowledge in Ayurveda
through case studies and their documentation in this
region.
I strongly believe that this journal can provide a
platform to discuss, share and exchange experiences and
knowledge among eminent experts and researchers. This
will contribute to promoting evidence-based practices in
traditional systems of medicine.
Dr Sung Chol, Kim
Regional Advisor in Traditional Medicine (TRM)
Department of Health Systems Development (HSD)
World Health Organization
Regional Oce for South-East Asia
(WHO-SEARO)
Journal of Ayurveda Case Reports
4 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):4-5
I am delighted to learn that All India Institute of
Ayurveda, New Delhi is launching a quarterly journal
of Ayurveda Case Reports (AyuCaRe). I wish this
new journal a grand success. The success of any such
periodical publication depends on the quality of its
contents and its uninterrupted production with realistic
peer reviewing and growth of its readership among the
educators, researchers and practitioners of Ayurveda.
Inspite of some progress in the area of research by
way of MD, Ph.D theses and few institutional research
project mode researches; the rate of quality publication
from AYUSH sector has remained disappointing. Some
recently launched journals such as J-AIM, AYU, ASL
and AAM have shown steady growth but have not
succeeded to earn any impact factor. Traditional Chinese
medicine and Yoga have shown beer performance
than Ayurveda, which is really a maer of concern. The
reason for this slow turnover of publications is due to
lack of quality research in this sector besides lack of core
competency and lack of skill for research writing. The
third important factor is the dearth of good journals
in this eld willing to consider Ayurvedic research
submissions.
I am really happy to notice the initiatives of AIIA to
launch a new journal. Rapid publication needs rapid
growth of quality research yielding publishable data. It is
hoped that Central Council for Researches in Ayurvedic
Sciences will pool its resources and expertise to promote
Ayurvedic research both in fundamental and applied
aspects specially clinical researches through appropriate
scientic research methodology. I have been closely
How to cite: Singh RH. All India Institute of Ayurveda
Launching Quarterly Journal of Ayurveda Case
Reports. J AyuCaRe 2017;1(1):4-5.
involved in teaching, research and practice of Ayurveda
for over 50 years. My experiences suggest that one of
the main barriers in AYUSH research is non-availability
of appropriate research methodology which may test
Ayurveda as it is in true sense. Most of the present day
researchers conduct small scratchy researches ignoring
the Ayurvedic approach and principles using hurriedly
borrowed conventional methodology resulting in
baseless data throwing no light on Ayurveda. As a
maer of fact, Ayurveda research is facing a serious
methodology crisis.
It cannot be overemphasized that Ayurveda has
greater strength in its unique principles, concepts and
approaches, not so much in its medications. But the
entire R&D eort is devoted in drug development
through conventional methods with lile outcome. The
methodology of clinical drug research too is standing on
the crossroads seeking right directions in the changing
scenario. The double blind placebo controlled clinical
trials which were considered the gold standards of drug
testing during mid-20th century are no more considered
gold standards as they are full of fallacies and aws
specially when applied to Ayurvedic research.
The reverse pharmacology approach with pragmatic
clinical trials and careful and critical clinical case
studies are now considered as more authentic methods
of clinical evaluation of the safety and ecacy of a drug
or a procedure. In view of this trend, it is in tness of
things that, AIIA is launching a quarterly journal of
Ayurveda Case Reports (AyuCaRe). But this enterprise
will be purposeful only if clinicians keep good records
and carry case reporting in a duly critical and intensive
manner and not in a casual way. Each case report
should be peer-reviewed by three reviewers without
Journal of Ayurveda Case Reports
GUEST EDITORIAL
All India Institute of Ayurveda Launching Quarterly Journal of Ayurveda Case
Reports
5
Singh RH: Quarterly Journal of Ayurveda Case Reports
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):4-5
any conict of interest. Clinical case reports need more
rigorous scrutiny than the reports of controlled clinical
trials.
Many Indian journals who claim that they are peer
reviewed, treat the peer reviewing process as a formality
and as an academic ritual serving no purpose. There
is also an acute shortage of willing and competent
reviewers. The important issues like conict of interest
and authenticity of investigational data are often ignored.
Most journals are starving of publishable submissions
and there is not much choice of selection of papers for
running the life-line of a journal. Most of the journals
appear quarterly and there is hardly a good monthly
journal in AYUSH sector. Hence there is a simultaneous
need of fast track promotion and enhancement of good
research in Ayurveda on one hand and similar activism
on quality publication. Research and publication have to
go hand in hand. The educational institutions need to be
vitalized to produce talented and skilled postgraduates
who may have work-culture and scientic temper with
willingness and passion to opt research and teaching as
a career.
The role of good practitioners in the professional eld,
public or private, is equally important. Our practitioners
could conduct good clinical research in practice seings
and could submit good clinical research reports for
publication in AIIA Journal. All India Institute of
Ayurveda should organize periodical workshops and
training program for postgraduate students and faculty
members to learn the skill of writing Ayurveda research
papers and proposals. This is absolutely essential
because the main reason why Ayurvedic academia is
trailing behind is the poor performance on research and
publication frontiers. AIIA being the apex institution of
higher studies in Ayurveda, its mandatory responsibility
is to play activism. There is need of Action Now, no
more tomorrows.
Prof Ram Harsh Singh
Distinguished Professor,
Department of Kayachikitsa,
Institute of Medical Sciences,
Banaras Hindu University,
Varanasi, India
Email: rh_singh2001@yahoo.com
6 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
Management of Avascular Necrosis through Panchakarma
Adil R*, Sangeeta RT, Karishma S, Anup BT
Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar, Gujarat, India.
*Correspondence: Email: adil.rais13@gmail.com, Mobile: +917060272769
Introduction: Avascular necrosis (AVN), also known
as osteonecrosis, bone infarction, aseptic necrosis
and ischemic bone necrosis is cellular death of bone
components due to interruption of blood supply,
because of which the bone tissue dies and the bone
collapses.[1-3] If AVN aects the bones of a joint, it often
leads to destruction of the articular surfaces. It primarily
aects epiphysis of long bones such as the femur and
also involves shoulder, knee and hip joints etc. Other
common sites include the humerus, shoulders, knees,
ankles and the jaw.[4] Many people have no symptoms in
the early stages of avascular necrosis. As the condition
worsens, the aected joint may hurt under stress.
ABSTRACT
Avascular necrosis of hip joint has emerged as one of the most disabling conditions of
present era of Orthopedics. It poses a challenge in front of the medical fraternity due
to non-availability of accurate management for this condition. Surgery oers hip joint
replacement that is not so commonly available and expensive too. Ayurveda can provide
a suitable answer through appropriate Panchakarma modalities useful in Asthi dhatu kshaya.
A diagnosed case of Avascular necrosis with complaints of pain at bilateral hip joint
and restricted movements approached the out-patient division of the hospital and was
managed by Udwartana, Virechana and Tikta ksheera vasti by following classical principles
of Ayurveda. Signicant improvement was noticed after the treatment. Pain was reduced
signicantly and the patient was able to walk and climb stairs at the end of the treatment.
Results obtained were encouraging and restricted disease progression was observed.
Keywords:
Asthikshaya,
Avascular necrosis,
Case report,
Tikta ksheera vasti,
Virechana
How to cite this article: Adil R, Sangeeta RT, Karishma
S, Anup BT. Management of Avascular Necrosis
through Panchakarma. J AyuCaRe 2017;1(1):6-12 .
Pain can be mild or severe, localized and develops
gradually. Pain may be limited to groin, thigh or buock
if AVN aects hip. Pain location tends to be most specic
in anterior hip and lower pelvis. Can be acute in onset
(acute infarct phenomenon), which can mimic an acute
injury. Range of motion will be reduced aecting the
gait. No satisfactory therapy is available in conventional
system of medicine, while the available procedures are
not aordable by all. Prognosis of all such approaches
are not convincing.[5]
This condition can be correlated to Asthi majja gata vata
and / or Asthi dhatu kshaya manifesting symptoms like
Bhedo asthi parvanam (breaking type of pain in bones and
joints), Sandhi shula (joint pain), Mamsakshaya (muscular
wasting), Balakshaya (weakness), Aswapna santataruk
(disturbed sleep due to continuous pain) and Sandhi
shaithilyam (aicted joints) with Shiryanti iva cha asthini
durbalani (destruction of bony tissue causing generalized
Journal of Ayurveda Case Reports
Adil et al.: Ayurvedic Management of Avascular Necrosis 1(1) 2017: 6-12
7
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
weakness), Pratata vata rogini (other aggravated features
of vata) etc.[6] Wide range of treatment modalities have
been mentioned in Ayurveda that are eective in such
manifestations.
Case report: A 35 years male patient visited Department
of Panchakarma, Institute for Post Graduate Teaching
and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar with chief complaints of pain at bilateral hip
joints with restricted movements, diculty in walking,
unable to stand-up from siing position and diculty in
forward bending since four months.
Patient noticed a jerk on sudden lifting of weight of
about 40-45 kg followed by pain at both hip joints and
left gluteal region four months back. Pain aggravated
on next day, restricting movements of hip joint without
radiating to any parts. A brief warm-up of ve minutes
was providing mild relief, but the improvement was time
limited. No history of tingling sensation or numbness of
lower limbs was reported.
Initially patient was managed with homeopathic
medicines with which mild relief in pain was noticed.
But, restricted movements were persisting with
increased morning stiness. Patient had a history of
facial palsy about one and a half years back for which he
was prescribed with corticosteroids and got signicant
relief.
The Shareera prakriti of the patient was Kaphavataja, had
Krura koshtha (on the basis of bowel habits), Madhyama
bala (optimum physical strength) with good Satva
(psychological strength). He had mild Agnimandya
(decreased digestion and appetite) and habit of
occasional drinking alcohol.
Dosha dushya lakshana: Predominant Dosha in the
disease is Vata in association with Pia and Kapha. Since,
there was a history of sudden jerk that may be responsible
for local inammation, vitiating Pia. Besides, Avarana
of Kapha and Meda over Vata may also be considered to
play an important role in the manifestation of symptoms
like stiness and restricted movements of hip joint in the
patient.
Assessment Criteria: Pain, stiness and diculty in
walking (Table 1), Visual Analogue Scale (VAS) and
improvement in the movements of exion, extension and
abduction were assessed at various stages of treatment.
Table 1: Grading of pain and other symptoms
Pain
No Pain 0
Mild pain with no diculty in walking 1
Moderate pain with slight diculty in walking 2
Severe pain with severe diculty in walking 3
Visual Analogue Scale
No Pain (0) 0
Mild (1-3) 1
Moderate (4-6) 2
Severe (7-10) 3
Stiness
No Stiness 0
Stiness of mild grade, need no intervention 1
Stiness relieved by topical medicaments 2
Stiness relieved by oral medication 3
Stiness not responded by medicine 4
Diculty in walking
No pain, normal movements 0
Mild pain with mild restriction of movements
Moderate pain with restriction of movement 2
Severe pain with restricting movements 3
Complete restriction of movements 4
Investigations: MRI of Hip joint was conducted before
and after the treatment. MRI Findings were suggestive
of AVN of bilateral femur with minimal joint eusion
(AVN Stage II). The lesions involved from 9 to 4O clock
on sagial images. No evident sub-chondral collapse or
secondary degenerative osteoarthritis was found.
Management of the condition: The patient was
admied in the Panchakarma IPD and treatment was
planned considering involved Dosha and Dushya.
Tikta ksheera vasti was planned for eight days that was
preceded by Rukshana therapy comprising of Udwartana
(dry powdered massage), followed by Virechana karma
Adil et al.: Ayurvedic Management of Avascular Necrosis 1(1) 2017: 6-12
8 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
(Table 2). Udwartana was done for ve days with mixture
of 200 g of Yava churna and 50 g of Triphala churna that
was made warm and rubbed rmly over the bilateral
hip region for 25 to 30 minutes for ve days. Internally,
patient was advised to take Siddha jala [water processed
one part of drug and 16 parts potable water] of Dhanyaka
(Coriandrum sativum), Shunthi (Zingiber ocinale) and
Shatapushpa (Anethum sowa) for Deepana and Pachana for
ve days.
Table 2: Plan of treatment
Procedure Duration Drugs used
Ruksha
udwartana
5 days Triphala and Yava churna
Snehapana 5 days Goghrita
Virechana Nimbaamritadi Eranda
taila and Triphala kwatha
Vasti 8 days Tikta ksheera vasti
After assessment of Agni; Snehapana with Go-ghrita was
planned that was given to the patient before 6.30 AM
and continued till the appearance of Samyak snigdha
lakshana. It took ve days to observe these features. Dose
of Go-ghrita was increased daily observing the digestive
capacity of the patient. Go-ghrita was administered at a
dose of 30 ml, 70 ml, 110 ml, 140 ml and 170 ml on 1st,
2nd, 3rd, 4th and 5th day respectively. This was followed
by Abhyanga and Swedana (sudation in a steam chamber)
for three days. Patient was advised to take diet like
Mudgayusha and fruit juice like orange or pomegranate
twice a day for three days. At the end of this, drugs for
Virechana were administered and Madhyama shuddhi was
obtained.
After completion of Sansarjana krama (specic diet
regimen after Shodhana) for Madhyama shuddhi (for ve
days), patient was advised a gap of three days that
was followed by Tikta ksheera vasti made-up of 50 ml of
Madhu (honey), 5 g of Saindhava lavana (rock salt), 100
ml of Go-ghrita (ghee), 25 g of Kalka (paste) prepared out
of powders of Guduchi (Tinospora cordifolia Miers.) and
Yashtimadhu (Glycyrrhiza glabra Linn.), and around 450 ml
Kwatha (decoction) of Guduchi and Erandamoola (roots of
Ricinus communis Linn.). The plan of Vasti is presented at
Table 3.
Observations and Results: Mild improvement was
reported in pain, stiness and range of movements
after Udwartana with a feeling of lightness in the
aected area. During Snehapana for Virechana, it took
around 6-8 hours to feel hunger by the patient on 1st
Table 3: Plan of Vasti
Day Dose
(ml)
Time of
administration
Time of Vasti
pratyagamana
Observations Complications
if any
1500 11 AM 15 min Feeling of lightness in body, Two bowel
evacuations
None
2500 11.15 AM 20 min A bowel evacuation, Lightness present in
body, Mild relief in pain and stiness
3600 11 AM 10 min A bowel evacuation, No other specic
observations
4600 11.30 AM 15 min
A bowel evacuation, Improvement in range of
hip joint movements
5600 10.30 AM 20 min
6600 10.45 AM 15 min
7600 11 AM 20 min A bowel evacuation with feeling of lightness
in body, Signicant relief in pain and stiness
8500 11 AM 30 min A bowel evacuation with signicant relief in
pain, stiness and improvement in hip joint
movements
Adil et al.: Ayurvedic Management of Avascular Necrosis 1(1) 2017: 6-12
9
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
and 2nd day of Snehepana, while it was increased to 10
hours on 3rd and 4th day and 13 hours on the 5th day.
Unctuousness in stools, downward movement of atus
and greasiness of skin were observed from 4th day
onwards. An average retention time of Vasti was around
18 minutes. No untoward eects were noticed during
Vasti regimen (Table 9). Mild relief was reported in
pain, stiness and range of movements after Udwartana
with a feeling of lightness in the aected area. After
Virechana, marked improvement was observed in pain,
stiness, improvement in range of movements at hip
joint region. After completion of Vasti, there was further
improvement in the movements due to decreased pain
and stiness.
Pain, stiness and diculty in walking responded
with Virechana and Tikta ksheera vasti (Table 4). Patient
was able to walk and climb stairs without any external
support. Body weight was reduced from 90 kg to 83 kg
after classical procedures of Udwartana, Virechana and
Vasti. Observations of Visual Analogue Scale (VAS) came
down from 4 to 1 by the end of treatment. Improvement
was also found in the range of movements of hip joint
(Table 5).
Discussion: Prakriti of the patient was Kaphavataja
and weight was 90 kg. Main symptoms present were
pain, stiness and decreased range of movements that
is an indication of Vata as the main Dosha leading to
Asthikshaya. Considering Vata as main dosha, Vasti was
planned in the management. Since Asthi was the main
involved Dhatu; Tikta dravya siddha vasti was selected.
[7] Erandamoola (roots of Ricinus communis) was used
considering its Vata shamaka properties.[8] Milk was
added in Vasti that nourishes Dhatus and specically
Asthi dhatu. Powders of Guduchi (Tinospora cordifolia
Willd.) and Yashtimadhu (Glycyrrhiza glabra Linn.) used
in the formulation may help in rebuilding the bone
tissue.[9]
AVN of hip joint develops basically due to obstruction of
small blood vessels supplying to femoral head leading
to gradual development of necrosis due to reduced
vascular supply. Thus, Rakta vaha sroto rodha becomes
prime cause leading to Asthi dhatu kshaya in the hip
joint. To counter this Rakta dushti; Virechana was planned
before proceeding to Vasti.[10] Virechana also helps in
Dhatu vishodhana.[11]
Patient suered from facial palsy about one and a half
years ago and there was a history of steroid drug intake
for the same, for six months, until recovery. Patients
having a history of oral steroid usage are more prone
to develop AVN.[12] Glucocorticoid-induced AVN
causes signicant morbidity and accounts for around
10% of all cases of total hip replacement in the United
States.[13] The prevalence of gluco-corticoid induced
AVN is between 3% and 38%, depending on the
underlying diseases, gluco-corticoid dosage and route of
administration.[14] Patient had a history of having alcohol
occasionally, which is also one of the causes making
more proneness for developing AVN.[15] Virechana was
selected as a therapy to be used here for Shodhana to
produce detoxifying eects since there was a history
of steroid and alcohol intake. Virechana also provides
stability to Dhatu countering dhatu sthairya,[16] that is
needed especially in conditions like AVN. Besides this,
there are chances for beer absorption of Vastidravya
after Shodhana, thus chances of beer results.
In this trial, Nimbaamritadi eranda taila was used for
Virechana.[17] The purpose was to perform Snigdha
virechana considering Vata predominant nature of
disease and involvement of Asthi dhatu that have Ruksha
and kharaguna. Besides, Eranda taila is said to act on
Vatadosha and when it is processed along with Tikta rasa
dravyas like Nimba and Guduchi; act on Asthi dhatu and
help as Rakta prasadaka too.
Before Virechana; Udwartana was planned for external
Rukshana as the patient was of Kapha vataja prakriti
with body weight of 90 kg. Rukshana would be the
procedure of choice to remove any Avarana caused
by Kapha and Meda before commencing with the
main treatment for beer action and bio availability
of subsequent therapies. About 200 g of Yavachurna
and 50 g of Triphala churna were used in Udwartana.
Reduction in stiness, weight loss and lightness in body
were observed after completion of this process. But,
severity of pain was persisting during walking and on
aempt to climb stairs. Reduction of stiness could be
due to the Rukshaguna of Yava cause neutralization of
Kapha, Pia, Meda and produce required
Lekhana eect.[18] Triphala churna also helps in removing
excessive Kapha, Meda and Twakgata kleda.[19] Once the
Avarana of Kapha and Meda is resolved; platform for
Adil et al.: Ayurvedic Management of Avascular Necrosis 1(1) 2017: 6-12
10 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
beer action of Virechana and Vasti is expected on Vayu.
This could also be the reason for loss of weight and the
relative lightness in patient. Internal Deepana, Pachana
with Dhanyaka and Shatapushpa also lead to increased
appetite and proper bowel evacuation on daily basis.
Most of the subjective and objective parameters showed
marked improvement after the Virechana karma.
Eighteen Virechana vegas with Shleshma pravrii in last two
vegas indicating optimum procedure (Samyak shuddhi) of
Virechana. No weakness was reported by patient on the
day of Virechana or subsequent days of Samsarjana krama.
Considerable improvement in pain and stiness in hip
joints probably owing to Vata shamaka and Ama nirharana
properties of Eranda taila.[20] Snigdha virechana was
planned owing to counteract the Ruksha eect created by
Vataprakopa. Tikta drugs present in it like Nimba, Amrita,
Patola, Kantakari, etc. nourish Asthi dhatu too. After
Virechana karma, Tikta ksheera vasti was administered.
Improvement in range of hip joint movements owes to
the signicant reduction in stiness and pain produced
after Virechana. Marked improvement was observed in
abduction, exion and extension of hip joint.
Honey is the rst component of Vasti, the base in which
the emulsion for other ingredients are prepared. It is also
said to possess Asthi sandhaniya properties that helps in
rebuilding damaged Asthi.[21] Vasti with Tikta dravya, Ghrita
and milk is indicated in Asthi kshaya janya roga. Guduchi is
said to be an excellent Rasayana drug, known to prevent
ageing and degeneration of the tissues, especially Asthi
dhatu.[22-23] Guduchi is grouped under Asthi sandhaniya maha
kashaya.[24] It also has a role in enhancing Rakta dhatu,[8]
thus may have a role in providing nourishment to hip
joint by re-channelizing blood vessels supplying to it.
Erandamoola is the other Dravya used in Vasti kwatha,
which is said to have Vata shamaka properties, thus
producing signicant relief in pain. It is also said to help
as Ama dosha nirharana that is responsible for production
of stiness and thus bringing about a considerable
improvement in the range of movements at hip joint.
Table 4: Changes observed in pain, stiness and walking after treatment
Features
BT After Udwartana After Virechana After Vasti
Right Left Right Left Right Left Right Left
Pain at hip joint 33331111
Stiness 44221111
Diculty in walking 44331111
Table 5: Changes observed in range of Hip Joint Movements
RIGHT LEFT
BT After Virechana After Vasti BT After
Virechana
After Vasti
Flexion 44o59o79o34o56o66o
Extension 29 o 32o34o29o32o30o
Abduction 31o35o36o27o32o32o
Adil et al.: Ayurvedic Management of Avascular Necrosis 1(1) 2017: 6-12
11
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
Before Treatment After Vasti
FlexionExtensionAbduction
Fig 1: Changes observed in range of
Hip Joint Movements
After completion of treatment, patient was prescribed
with Shamana drugs for a month to nourish Asthi dhatu
and thus preserving the eects produced by Panchakarma.
Two tablets of Abha guggulu (each 500 mg) twice a day
with 60 ml Rasna saptaka kwatha, a blend of Guduchi
churna (2 g), Ashwagandha churna (2 g) and Godanti
bhasma (250 mg) were advised. Patient was advised to
consume warm water and easily digestible food items.
Exposure to cold air, maintaining one particular posture
for a longer duration, frequent jerky movements and
lifting weights were asked to be avoided.
Patient was advised to re-visit the hospital after a month
to re-evaluate the features. No further deterioration
in the symptoms was noticed after a month. Pain was
present in hip joints but only during walking and
climbing stairs. Range of movements like exion,
extension and abduction at hip joints were restricted but
showed no signicant deterioration as compared to the
observations made just after completion of therapies.
MRI scans of the hip joint after the follow up period
showed no further deterioration in the gradation (Grade
II) of Avascular necrosis, which suggests that the disease
progression was stopped. He was advised to revisit
hospital after one month for next treatment regimen.
Conclusion: AVN is an orthopedic condition that poses
a challenge in front of whole medical fraternity owing to
the impeding of routine activities produced. The adopted
therapy in the current case provided marked relief from
pain, tenderness, general debility and improvement
in the gait. The grade of AVN did not worsen and was
maintained. This was a pilot study to evaluate the ecacy
of Udwartana, Virechana and Vasti in the management
of AVN and the results produced were encouraging
enough not only on the subjective and objective scales
but also provided a check in disease progression. It is
advisable to conduct this particular study on a larger
number of samples for a greater span of time to draw
more concrete conclusions. More awareness among
general public should be created towards management
of AVN using Ayurveda to promote earlier diagnosis
that might lead to beer prognosis.
Source of support: Institute for Post Graduate Teaching
and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar - 361008, Gujarat, India.
Conicts of interest: None declared.
References:
1. https://en.wikipedia.org/wiki/Avascular_
necrosis#cite_note-nawazkhan-1 last accessed on
Dec 1, 2016 at 13.01.
2. Digiovanni CW, Patel A, Calfee R, Nickisch F.
Osteonecrosis in the foot. The Journal of the
Adil et al.: Ayurvedic Management of Avascular Necrosis 1(1) 2017: 6-12
12 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):6-12
American Academy of Orthopaedic Surgeons
2007; 15(4): 208-17.
3. http://emedicine.medscape.com/article/333364-
overview last accessed on Dec 1, 2016 at 13.15.
4. Chapman C, Maern C, Levine WN.
Arthroscopically assisted core decompression
of the proximal humerus for avascular necrosis.
Arthroscopy 2004; 20(9): 1003-1006.
5. Kadlimai SM, Subbanagouda PG, Sanakal AI,
Milind D. Ayurvedic Management of Avascular
Necrosis of the Femoral Head - A Preliminary
Study. AYU 2008; 29(3): 154-160.
6. Kashinatha shastri, editor. Charaka samhita of
Agnivesha, Chikitsa sthana, Vatavyadhi Chikitsa,
chapter 28, verse 33, Chaukhambha Sanskrit
Sansthan; Varanasi: reprint 2007. p. 196.
7. Kashinatha shastri, editor. Charaka samhita of
Agnivesha, Sutra sthana, Vividhashita pitiya
adhyaya, chapter 28, verse 27, Chaukhambha
Sanskrit Sansthan; Varanasi: reprint 2007. p. 432.
8. Kashinatha shastri, editor. Charaka samhita of
Agnivesha, Sutra sthana, Yajjapurushiyam, chapter
25, verse 40, Chaukhambha Sanskrit Sansthan;
Varanasi: reprint 2007. p. 438.
9. Kashinatha shastri, editor. Charaka samhita of
Agnivesha, Sutra sthana, Shad virechana shata
shritiyam, chapter 4, verse 9, Chaukhambha
Sanskrit Sansthan; Varanasi: reprint 2007. p. 60.
10. Kashinatha shastri, editor. Charaka samhita
of Agnivesha, Sutra sthana, Vidhi shonitiyam,
chapter 24, verse 18, Chaukhambha Sanskrit
Sansthan; Varanasi: reprint 2007. p. 302.
11. Satyapal bhishag, editor. Kashyapa samhita of
Vriddha jivaka, Siddhi sthana, Tri lakshana siddhi,
Chaukhambha Sanskrit Sansthan, Varanasi: 2012.
p. 150.
12. David TF, Jennifer JA. Across section study and
evaluation of association between steroid dose and
bolus dose and avascular necrosis of bone. The
Lancet 1987; 329(8538): 902-906.
13. Mankin HJ. Non traumatic necrosis of bone
(osteonecrosis). N Engl J Med. 1992;326(22):1473-
1479.
14. Assouline DY, Chang C, Adam G, Yehuda S, et al.
Pathogenesis and natural history of osteonecrosis.
Seminars in Arthritis & Rheumatism. 2002; 32(2):
94-124.
15. Matsuo K, Hirohata, Tomio, Sugioka, et al.
Inuence of Alcohol Intake, Cigaree Smoking, and
Occupational Status on Idiopathic Osteonecrosis
of the Femoral Head, Clinical orthopedics and
related research. 1988, (234): 115-23.
16. Shailja S, editor, (4th ed.) Sharangadhara samhita
of Sharangadhara, Uara khanda, Virechanavidhi
adhyaya, chapter 4, verse 18, Chaukhambha
Orientalia, Varanasi: 2005. p. 347.
17. Atrideva gupta, editor, Ashtanga hridayam of
Vagbhata, Chikitsa sthana, Vatavyadhi Chikitsa,
chapter 21, verse 58-61, Chaukhambha Sanskrit
Sansthan; Varanasi: 2005. p. 420.
18. Brahmashankara misra, editor, Bhava prakasha of
Bhava misra, Madhyama khanda, Navamo dhanya
varga, chapter 21, verse 29-30, Chaukhambha
Sanskrit Sansthan; Varanasi: 2012. p. 640.
19. Atrideva gupta, editor, Ashtanga hr idayam of
Vagbhata, Sutra sthana, Anna swaroopa vigyaniya,
chapter 6, verse 159, Chaukhambha Sanskrit
Sansthan; Varanasi: 2005. p. 65.
20. Brahmashankara misra, editor, Bhava prakasha of
Bhava misra, Madhya khanda, Amavata Chikitsa,
chapter 26, verse 50, Chaukhambha Sanskrit
Sansthan; Varanasi: 2000. p. 286.
21. Kashinatha shastri, editor, Charaka samhita of
Agnivesha, Sutra sthana, Shad virechana shata
shritiyam, chapter 4, verse 5, Chaukhambha
Sanskrit Sansthan; Varanasi: reprint 2007. p. 60.
22. Shailja S, editor, (4th ed.) Sharangadhara samhita
of Sharangadhara, Poorva khanda, Deepana
pachanadi kathanam, chapter 4, verse 14,
Chaukhambha Orientalia; Varanasi: 2005. p. 33.
23. Yadavji trikamji, editor, Charaka samhita of
Agnivesa, Chikitsa sthana, Rasayana, chapter 1,
verse 7, Chaukhambha Surabharati Prakashan;
Varanasi: 2006. p. 376.
24. Kashinatha shastri, editor. Charaka samhita of
Agnivesha, Sutra sthana, Shad virechana shata
shritiyam, chapter 4, verse 5, Chaukhambha
Sanskrit Sansthan; Varanasi: reprint 2007. p. 60.
13
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):13-17
Jalaukavacharana (Leech application) and adjuvant therapy in the management
of infected wound
Mahanta VD*, Foram J1, Dudhamal TS2, Gupta SK
Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi, 1JS Ayurveda College, Nadiad, 2Institute for Post
Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India.
*Corresponding Author: Email: drvyasayu@yahoo.in, Mobile: +917838957972
Introduction: Ayurveda explains a wide range of factors
in the manifestation of Vrana like Abhighata (physical
trauma), exposure to Amla dravya (chemical), Kita damsa
(insect bite) etc.[1]
Keywords:
Case report,
Dusta vrana,
Insect bite,
Jalaukavacharana,
Katupila,
Leech application,
Panchavalkala,
Wound
ABSTRACT
Infected wounds are manifested as a complication of trauma or due to various pathological
conditions and are dicult to manage because of their non-healing nature. In Ayurveda,
infected wounds can be compared with Dusta vrana. Besides other modalities of treatment;
leech application has been emphasized in the management of such manifestations.
A male patient of 45 years age having Vata kaphaja prakriti visited OPD of Shalya tantra
with complaints of severe pain, swelling with ulceration over the dorsum of right foot
and intermient fever with history of unknown insect bite for the past two weeks. Local
examination revealed an ulcer covered with necrotic tissue with progressive inammatory
changes. Based upon the history and clinical ndings; the case was diagnosed as Dusta
vrana due to Kita dansha. Leech application was done by following classical guidelines of
Ayurveda. Simultaneously, cleaning of wound with Panchavalkala Kwatha and dressing
with powder of Katupila (Securinega leucopyrus) mixed with Tila Taila (sesame oil) was
done daily. Changes in size, shape, oor, and margin of the ulcer were recorded at regular
interval. Pain, discharge were completely subsided after three consecutive siings of
leech application. The ulcer was completely healed within two months with minimal scar
formation. Leech application along with local application of Katupila has signicant role in
controlling inammation and promoting healing of infected wounds without any adverse
eect.
How to cite this article: Mahanta VD, Foram J,
Dudhamal TS, Gupta SK. Jalaukavacharana (Leech
application) and adjuvant therapy in the management
of infected wound. J AyuCaRe 2017;1(1):13-17.
13
On accidental exposure, Kitas (insects) emit poisonous
substances into the blood through saliva and cause
formation of Vrana (ulcer) and Sopha (inammation)
at the site of bite. If appropriate interventions are not
taken at right time; other generalized reactions like Toda
(burning pain), Paka (suppuration), Shotha (swelling),
Vaivarnya (discoloured skin), Vrana kledana (foul
discharge from ulcer), Ruja (pain), Jwara (pyrexia) etc.
will manifest.[2]
Journal of Ayurveda Case Reports
14 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):13-17
Mahanta VD et al.: Management of infected wound through Jalaukaavacharana 1(1) 2017:13-17
Insect bite and sting cases are commonly seen in rural
clinical practice. Venom is composed of proteins and
other substances, which is responsible in developing
allergic reactions of various stages depending upon
the nature of the venom as well as patient’s resistance
power. Initially burning pain and redness appears
followed by gradual localized swelling. There may
be presence of visible sting or a small puncture at the
site of bite. The bites may cause manifestations like
acute generalized exanthematous pustulosis (AGEP)
or toxic pustuloderma, anaphylactic reaction etc.[3]
In routine; rest to the aected part, application of ice
packs, compression and elevation of the aected part
etc. are advised to reduce inammation and pain. In
addition, other medications like anti-allergic drugs,
anti-inammatory drugs, antibiotics etc are also
recommended to combat symptoms.
Exclusive description of wound and its management
can be observed in the texts of Ayurveda. Specically,
Rakta mokshana (blood-leing) through Jalauka (Leech)
is emphasized in the management of Savisaja vrana
(poisonous wound).[1] Various clinical studies have
reported rapid, eective and long-lasting potential of
leech application in managing painful conditions.[4]
Case report: A 45 years old male auto driver of Vata
kaphaja prakriti visited OPD of Shalya tantra, Institute
for Post Graduate Teaching and Research in Ayurveda,
Gujarat Ayurved University, Jamnagar with complaints
of severe pain, swelling with ulceration over the dorsum
of right foot and intermient fever for the past two
weeks. History revealed an unknown insect bite during
sleep. Burning pain was noticed immediately after the
bite that was increased gradually. On 2nd day, aected
foot was swollen with symptoms of cellulitis. Patient
had taken antibiotics, analgesics and anti-allergic
drugs for ten days from a private hospital. He did not
get relief and the severity of pain, size of ulcerative
lesion was increased. Routine laboratory investigations
were normal except slight variation on percentage of
neutrophil and lymphocyte count.
On local examination, a progressive ulcer at dorsum
of left foot just above the meta-tarso-phallangeal joint,
about 5x7 cm in size, with irregular, inamed margins
was found. Floor was covered with necrotic tissue
with foul smell and purulent discharge (Figure 1).
On palpation, local temperature was raised and the
surrounding area was tender (+++). Distal neurovascular
status was normal. Radiological examination of foot
revealed no bony abnormality. Based upon the signs
and symptoms; case was diagnosed as Dushta vrana due
to insect bite and planned for Jalaukaavacharana (leech
application).
Before application of Jalauka, necrotic tissue was removed
surgically and surrounding skin of the ulcer was cleaned
with Panchavalkala kwatha [decoction of barks of ve
trees i.e. Vata (Ficus bangalensis Linn.), Udumbara (Ficus
glomerata Roxb.), Ashwaha (Ficus religiosa Linn.), Parisha
(Thespesia populnea Solan ex Correa), and Plaksha (Ficus
lacor Buch-Ham.)].
Jalaukas were applied over the oor and at the border
of the ulcer (Figure 2). Jalaukaavacharana was started
with four Jalauka on rst day and three Jalauka on 3rd
and 5th day of admission (Figure 3-4). This was followed
by cleaning of the area with Panchavalkala kwatha and
dressing with paste of Katupila (Securinega leucopyrus
[Willd.] Muell) and Tila taila (sesame oil) regularly till
complete healing. All the Jalaukas used on 1st day were
died after 15 minutes of blood-leing, while Jalaukas
used on 3rd and 5th day were died after an hour.
Fig 1: Wound covered with necrotic tissue with
inamed margins (On the day of admission)
Observations: Swelling and pain were reduced
remarkably on 5th day of leech application. On 15th
day of regular dressing; necrotic tissue disappeared
completely and wound became clean with exposed
tendons (Figure 5). After 30 days, healthy granulation
tissue was observed and exposed tendons were covered
with healthy granulation tissue (Figure 6). Gradually,
15
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):13-17
Mahanta VD et al.: Management of infected wound through Jalaukaavacharana 1(1) 2017:13-17
the ulcer size was reduced with remarkable wound
contraction. After 45 days, the wound became small and
wound was healed completely by the end of two months
(Figure 7-10) without any internal medication.
Fig 2: Application of leeches Fig 3: On 3rd day (after debridement
and application of Jalauka)
Fig 4: On 5th day (after debridement
and application of Jalauka)
Fig 5: On 15th day (granulation
tissues developed)
Fig 6: On 30th day (contracted wound
with healthy granulation tissue)
Fig 7: On 35th day (covered surface
with healthy granulation tissue with
contracted margin)
Fig 8: On 42nd day Fig 9: On 49th day Fig 10: On 56th day (healed wound
with minimum scar)
Discussion: About 67 varieties of Kitas (insects) are
mentioned in the classics of Ayurveda. The group of
Tikshna Kita produces severe cutaneous reactions in form
of Sopha (inammatory lesions), Granthi (swellings),
Pidakas (vesicles) and other systemic manifestations
like Jwara (fever), Daha (burning pain), Angamarda
(bodyache), Murchchha (anaphylactic reactions) etc. by
virtue of their Ushna (hot), Tikshna (sharp), Shukshma
(penetrating into minute channels of the body), Vyavayi
(rapidly permeating into the whole body), Avipaki
(disturbing the tissue metabolism) etc. characters.[5] Due
to Ushna guna; Kita visha vitiates Rakta and Pia dosha
and produces Daha, Sopha at the local site. Being dry in
nature, it causes pain by vitiating the Vata. Shukshma
guna probably takes the poisons to the deeper tissues
and by spreading it causes cellulites.
16 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):13-17
Mahanta VD et al.: Management of infected wound through Jalaukaavacharana 1(1) 2017:13-17
In modern dermatology, these reactions are found when
body comes in contact with oended arthropods that
produce injury to the skin in a variety of mechanisms.[6]
Mites are also considered as aetiological factors in the
manifestation of dermatological reactions. Contact may
cause erythematous papules, pruritus and formation of
vesicles etc.[7]
Raktamokshana is being practiced in India since long in the
management of Dusta vrana (infected wounds), Granthi
(cystic lesions), Arbuda (Neo Plasm) etc. Jalaukaavacharana
is one type of Raktamokshana that counters vitiated
Rakta and Pia. After piercing the skin, leech sucks the
blood and injects number of biological substances into
the blood stream. A medium size leech sucks 5-15ml of
blood in one siing.[8] In this study, approximately 7-8
cm size leeches were used and they consumed 10-15 ml
of blood in each siing. As, leeches sucked vitiated Rakta
dosa (blood with toxins and unwanted metabolites) from
the site of ulcer; reduction in pain and inammatory
signs were noticed.
Patient was reported reduction in pain suggesting
poisonous substances might have been removed through
the blood by leeches. The inborn quality of Jalauka i.e.
Shita (cold) and Madhura (sweet) are opposite to Pia
dosa and these qualities might help in pacifying vitiated
Pia.[9] Hirudin, Hyaluronidase, Kallikrein, Histamine,
Collagenase, Bdellins, Eglins present in saliva of leech
possesses activity of wound healing. Hirudin is capable
to increase surface perfusion due to its anti-coagulation
eect. Presence of Histamine, a vasodilator constituent
improves blood circulation by dilating capillary bed in
that area and might help in ushing out of the unwanted
substances from the ulcer. Thus, possibly cellulites
was controlled. Other substances like hyaluronidase,
bdellins, eglins possesses anti-inammatory and anti-
biotic properties. All these in combination, possibly
played a great role in controlling inammation and
helped in wound healing.[10-12]
Panchavalkala kashaya helps in wound healing by the
virtue of its Kashaya rasa (astringent taste),[13] that brings
back the Vrana to Shudhha avastha (clean stage) besides
checking excessive discharge.[14] Paste of Katupila with
Tila taila is traditionally in use for dressing wounds and
its wound healing ecacy is reported.[15] Snigdha guna
of Tila taila helps in facilitating the process of overall
wound healing.
It is observed that the progressive phase of ulcer was
managed successfully by three siings of Jalaukavacharana
and regular dressing with paste of Katupila and Tila
taila. No other medicines were used during the course
of treatment.
Conclusion: Jalaukavacharana along with local application
of paste of Katupila mixed with Tila taila is an eective
and safe treatment modality for the management of
Dusta vrana caused by insect bite. This modality may
even be benecial in other types of infective and non-
healing ulcers. However, such usefulness needs to be
evaluated through well-dened clinical trials.
Source of support: Institute for Post Graduate Teaching
and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar - 361008, Gujarat, India.
Conicts of interest: None declared.
References:
1. Singhal GD. editor. (2nd ed) Sushruta samhita of
Sushruta, Chikitsa sthana, Dwivraniya Chikitsa,
chapter 1, verse 6, Chaukhambha Sanskrit
Sansthan; New Delhi: 2007. p. 140.
2. Shastri KN, Pandey GS. editor. Charaka samhita
of Agnivesha, Chikitsa sthana, Visha Chikitsa,
chapter 23, verse 178, Chaukhambha Sanskrit
Sansthan; Varanasi: reprint 2007. p. 577.
3. Bhat YJ, Hassan I, Sajad P, Atiya Y, Wani R. Acute
Generalized Exanthematous Pustulosis due to
Insect Bites? Indian Journal of Dermatology 2015;
60(4): 422.
4. Detlev K, Biebertaler BGH, Michael A, Thomas
R. Medicinal leech therapy in pain syndromes: a
narrative review. Wiener Medizinische Wochen
schrift 2014; 164(5): 95-102.
5. Singhal GD. editor. (2nd ed) Sushruta samhita of
Sushruta, Kalpa sthana, Kita Kalpa, chapter 8,
verse 5-18, Chaukhambha Sanskrit Pratishthan;
New Delhi: 2007. p. 630-631.
6. Kar S, Dongre A, Krishnan A, Godse S, Singh N.
Epidemiological Study of Insect Bite Reactions
from Central India. Indian Journal of Dermatology
2013; 58(5): 337-341.
17
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):13-17
Mahanta VD et al.: Management of infected wound through Jalaukaavacharana 1(1) 2017:13-17
7. Krinsky WL. Dermatoses associated with the
bites of mites and ticks (Arthropoda:Acari).
International Journal of Dermatology 1983; 22(2):
75-91.
8. Abdullah S, Latief MD, Rashid A, Tewari A.
Hirudotherapy / Leech therapy: Applications
and Indications in Surgery. Archieves of
Clinical and Experimental Surgery 2012;
1(3): 172-180.
9. Singhal GD. editor. (2nd ed) Sushruta samhita of
Sushruta, Sutra sthana, Kita Kalpa, chapter 13,
verse 6, Chaukhambha Sanskrit Pratishthan; New
Delhi: 2007. p. 87.
10. Porshinsky BS, Saha S, Grossman MD, Beery II PR,
Stawicki SP. Clinical uses of the medicinal leech: A
practical review. Journal of Postgraduate Medicine
2011; 57(1): 65–71.
11. Shankar KMP, Rao SD, Umar SN, KV. A clinical
trial for evaluation of leech application in the
management of Vicarcika (Eczema). Ancient
Science of Life 2014; 33(4): 236-241.
12. Abdualkader AM, Ghawi AM, Alaama M, Awang
M, Merzouk A. Leech Therapeutic Applications.
Indian Journal of Pharmaceutical Sciences. 2013;
75(2): 127-137.
13. Acharya YT, editor. Charaka samhita of Agnivesha,
Sutra sthana, Atreya bhadrakaapyeeya, chapter 26,
verse 43, Rashtriya Sanskrit Sansthan; New Delhi:
reprint 2002. p. 145.
14. Ajmeer AS, Dudhamal TS, Gupta SK, Mahanta
VD. Katupila Securinega leucopyrus as a potential
option for diabetic wound management. Journal
of Ayurved and Integrative Medicine. 2014; 5(1):
60-63.
15. Ajmeer AS, Dudhamal TS, Gupta SK. Management
of Madhumehajanya Vrana (diabetic wound) with
Katupila (Securinega leucopyrus [Willd] Muell.)
Kalka. AYU 2015; 36 (3): 353-55.
18 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):18-22
Management of Hashimoto’s Thyroiditis through Ayurveda
Seetha Chandran*, Rajam R1, Patgiri BJ, Prakash Mangalasseri2
Dept. of Rasa shastra and Bhaishajya kalpana, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved
University, Jamnagar, Gujarat,
1
Govt. Ayurveda College, Thiruvananthapuram,
2
Dept. of Kaya chikitsa, Vaidyaratnam PS Varier
Ayurveda College, Koakal, Kerala, India.
*Correspondence: E-mail: seethaac@gmail.com, Mobile: +91 9496830565
Introduction: Hashimoto’s Thyroiditis (HT), is the most
common auto-immune thyroid disease, with uctuating
thyroid function and the commonest cause of
hypothyroidism in iodine sucient areas of the world.
[1,2] It is primarily a disease of women, with a sex ratio
of approximately 7:1 and can also occur in children.[2] In
an epidemiological study conducted in India, prevalence
of >20% was recorded.[3] Incidence rate of HT is 0.54% in
India. The cause of HT is thought to be a combination of
genetic susceptibility and environmental factors.
It is characterized clinically by gradual thyroid failure,
ABSTRACT
Hashimoto’s Thyroiditis (HT) is the most common auto-immune thyroid disease and the
commonest cause of hypothyroidism. In conventional medicine, treatment of choice for HT
is replacement of thyroid hormone. A case of HT was managed at the OPD level by following
Ayurveda principles and found to be eective. A treatment protocol was designed based
on the signs and symptoms and assigned in this patient. Snehapana followed by Vamana
and Virechana and at the end Shamana was done with Varunadi kwatha bhavita shilajatu for a
period of three months with two months follow up. The treatment protocol was found to
be eective in symptomatic and biochemical proles of the patient. Patients of HT should
be able to have a choice against the lifelong hormone therapy. This can be achieved by
adequate evaluation of the individual action of the therapies adapted here and replicating
the same in a much larger group.
Keywords:
Case report,
Hypothyroidism,
Thyroiditis
How to cite this article: Seetha C, Rajam R, Patgiri BJ,
Prakash M. Management of Hashimoto’s Thyroiditis
through Ayurveda. J AyuCaRe 2017;1(1):18-22
with or without goitre formation, due to auto-immune-
mediated destruction of the thyroid gland involving
apoptosis of thyroid epithelial cells.[4] Graves' disease and
HT are closely related patho-physiologically.[2] HT has
many serious complications like infertility, suppurative
thyroiditis, recurrent miscarriages, preterm birth, heart
failure etc. Diagnosis of HT is made clinically and
biochemically. 90 per cent of HT patients have high anti-
thyroid peroxidase (TPO) and anti-thyroglobulin (Tg)
antibody which conrms the autoimmune pathology.[5]
The treatment of choice for HT is replacement of thyroid
hormone. The drug of choice is individually tailored
and titrated levothyroxine sodium administered orally.
[6] But, a long term hormonal therapy is not always free
from complications as well as side eects. Moreover, it
Journal of Ayurveda Case Reports
19
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):18-22
Seetha et al.: Ayurvedic Management of Hashimoto's Thyroiditis 1(1) 2017: 18-22
is unfeasible to revert the antibody blood parameters in
HT with modern medicine.
Currently, hypothyroid patients are opting for Ayurvedic
management due to dissatisfaction in modern regime.
A case of HT was managed through treatment protocol
based on the clinical features and managed by following
Ayurveda guidelines.
Case report: A 48 year old male patient, painter by
profession, who was apparently well fourteen years back,
developed progressive fatigue and drowsiness initially.
Then after two years (2005), he gradually developed
mild neck swelling that became diuse, painless and
slowly increased in size. These symptoms were followed
by sleeplessness, weight loss and palpitation. He was
diagnosed as Hyperthyroidism and was put on Tab.
Methimazole 20 mg/day (anti-thyroid medication) for
two years (2007 - 2009). Then he was on irregular follow
up for one year. In 2011, he developed new complaints
like constipation, nocturnal itching associated with mild
eruptions, cold intolerance, depression, hoarseness of
voice, dry hair and skin. Blood investigations at this stage
revealed Hypothyroidism. Radio iodine uptake and Fine
needle aspiration cytology (FNAC) were advised in 2011
to rule out malignancy. Radio iodine study detected
enlarged thyroids with high uptake, no cold area and
retrosternal extension suggestive of multi nodular goiter
(MND) and Thyrotoxicosis. Aspirate of FNAC showed
occasional groups of follicular cells and few collection
of lymphocytes and histocytes in a background of
blood and colloid, suggestive of Thyroiditis and he
was administered Tab. Levothyroxine. He was kept on
varying doses of drug (50 mg - 100 mg) based on his
hormone level. But he didn’t get much relief from any of
the above symptoms. As, Thyroid Stimulating Hormone
(TSH) levels were not coming into physiological range,
he stopped the medication against medical advice four
months before his rst visit to OPD of Govt. Ayurveda
College, Thiruvananthapuram in July 2012. Symptoms
like severe sleeplessness due to nocturnal itching,
weight loss, excessive appetite, constipation and cold
intolerance were the chief complaints during his visit
to the OPD. On examination there was mild swelling of
thyroid gland, dryness of skin and palpitation.
Patient was provisionally diagnosed as Kapha avrita vata
(vata obstructed by Kapha) with Piaanubandha (associated
with Pia) based on the presenting complaints like Sheeta
asahishnuta (cold intolerance), Swara graha (hoarseness
of voice), Dourbalya (tiredness).[7] Avarana (obstruction)
is the encompassing of metabolic pathways by vitiated
body humors. Symptoms like Galapaka (inammation
of thyroid gland), Atyagni (excessive appetite) can be
aributed to Pianubandhatwa.
The treatment was started with internal and external
Rookshana (desiccating) therapy. The treatment protocol
assigned for this patient was Rookshana and Snehapana
(internal administration of medicated ghee) followed by
Vamana (therapeutic emesis) and Virechana (therapeutic
purgation) followed by Shamana (pacication) with
Varunadi kwatha bhavita shilajatu gutika. Treatment
schedule followed is enlisted at Table 1.
Observations: Clinical features, Serum Thyroid fuction
test (TFT) values, TPO and Tg Antibody titre and
Thyroid gland sonography were assessed before and
after the treatment [Table 2]. Patient reported increased
appetite and normal bowel movements after Deepana
and Pachana. But, mild constipation and dryness of
skin was observed during Udwartana. By Achapana,
complaints like itching, constipation, sleeplessness and
dryness of skin were alleviated. Itching was completely
subsided after Vamana and palpitations after Virechana.
Enhanced complexion was also noticed after Virechana.
After administration of Shamana drug; relief in
depressive symptoms were observed. Blood parameters
were improved approaching towards normal value after
Shamana chikitsa. Both thyroid lobes were normal in
size, hypoechoic and showed coarsened parenchymal
echotexture with increased vascularity before trial. But
after the trial, normal size of the lobes was maintained
with changed texture to hyperechoic, showing a good
prognosis.
After two months follow up, TSH level came down to 10.3
mIU/L and with in the next month, it became 6 mIU/L.
No recurrence of previous symptoms were observed till
date. The treatment made a pleasing improvement in his
quality of life.
20 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):18-22
Seetha et al.: Ayurvedic Management of Hashimoto's Thyroiditis 1(1) 2017: 18-22
Table No 1: Treatment Schedule
Treatment Drug of Choice Duration
Deepana
and Pachana
(correction of
digestion and
metabolism)
Guduchyadi kwatha (90
ml) and Panchakola
choorna (5 g) in Buer
milk (200 ml)
8 days
Udwartana
(herbal powder
massage)
Kola kulathadi choorna 3 days
Snehapana Tiktaka ghrita[8] (started
with a dose of 50 ml
and increased to 250
ml)
7 days
Swedana
(Fomentation)
Abyanga (external
oleation) with
Dhanwantaram taila[9]
followed by Ushma
sweda (fomentation
therapy)
1 day
Vamana Madana pippali (seeds
of Randia dumetorum
Re.) and Yashtimadhu
phanta (hot infusion
of Glycyrrhiza glabra
Linn.)
1 day
Peyadi
sansarjana
krama (Dietary
prescriptions)
3 days
Mridu
virechana (mild
therapeutic
purgation)
Avipaikara choorna[10]
(20 gm)
One day
Peyadi
sansarjana
krama (Dietary
prescriptions)
One day
Shamana
chikitsa
Varunadi kwatha
bhavitha shilajatu (1g
twice a day with cold
water)
Three
months
Table 2: Eect on TFT & Thyroid Antibody
parameters
Parameters Normal
Values
Before
Trial
After
Trial
TSH (mIU/ mL) 0.4 - 4.2 46 16
T3 (ng/dl) 80 - 200 110 119
T4 (µg/dl) 4.6 - 10.5 7.3 7.2
Anti TPO
(IU/ML)
<34 208.7 32
Anti Tg (U/ML) <60 1270 56
Discussion: Autoimmunity is the main culprit in
Hashimotos Thyroiditis, impairing cellular metabolism.
Use of immuno-modulatory, anti-inammatory drugs
and other molecules that clears the nutrition pathway
through correction of digestion and metabolism will
help in breaking the pathology.
On analysis of signs and symptoms, the patient was
found to have Vata kapha pradhaana sannipatika doshadushti
(vitiation of all three body humors). An apt drug in this
condition should cause Sroto shodhana (removes blocks
in metabolic pathways) by elimination of vitiated kapha
pia and Anulomana of Vata. Patient was responding
positively to Deepana and Pachana (corrects digestion
and metabolism through augmenting the digestive
re), Rookshana (desiccating), Ushna (hot), and Vamana
treatment procedures.
Thus, the patient was treated on the line of mitigation
of Kapha and pacifying Vata (vata anulomana). As the
patient was having vitiation of Pia too; Pia hara drugs
and therapies were also included in the protocol. Agni
deepana (kindle digestive re) was done initially to
correct the digestion and metabolism.
So, Guduchyadi kashaya[11] and Panchakola
choorna [12] in Takra was advised in the initial stage to
achieve Ama pachana, Agni deepana and to subside vitiated
Kapha and Pia. Rookshana was induced by means of
Panchakola choorna internally and Udwartana with Kola
kulathadi choorna.[13] This was followed by Sneha pana as
Poorva karma of Shodhana. Both Vamana and Virechana are
21
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):18-22
Seetha et al.: Ayurvedic Management of Hashimoto's Thyroiditis 1(1) 2017: 18-22
adopted as Shodhana procedures in this case. Vamana
helps in eliminating vitiated Kapha dosha, while Virechana
helps in eliminating vitiated Pia dosha. Shamana drug
prepared by doing seven Bhavana of Shilajatu in Varunadi
Kwatha. Both the drugs have Katu vipaka and Ushna virya
in general. They also possess Agni deepana, Medohara
and Lekhana properties. Shilajatu is Tridosha shamaka
and Varunadi gana is Kapha vata prashamaka. Thus these
qualities of drug intensely suit the disease condition.
Micro-level Dosha correction will be ensured by the
Varunadi kwatha bhavita shilajatu and the reach of the
drug up to Medo dathu level explains the rationale behind
the success of the treatment protocol.[14,15] Moreover the
drug Shilajatu opted here is a Rasayana with multifaceted
action.
Conclusion: The treatment protocol containing
Rookshana, Snehana, Vamana and Virechana followed
by Shamana drug Varunadi kwatha bhavita shilajatu is
followed in this case of HT. This protocol is found to
be eective in clinical, biochemical and sonological
aspects. Though no drugs were given during the follow-
up period, symptomatic relief was maintained. Patients
of HT should be able to have a choice against the lifelong
hormone therapy. This can be achieved by adequate
evaluation of the individual action of the therapies
adapted here and replicating the same in a much larger
group.
Source of support: Nil.
Conicts of interest: None declared.
References:
1. Jaume JC. Endocrine autoimmunity. In : Gardner
DG, Shoback DM, editors. Greenspan’s basic &
clinical endocrinology. New York: McGraw-Hill
Medical; 2007. p. 59-79.
2. hp://www.uptodate.com/contents/pathogenesis-
of-hashimotos-thyroiditis-chronic-autoimmune-
thyroiditis last accessed on Aug 1, 2016 at 16.47.
3. Ambika GU, Sanjay K, Rakesh KS, Ganapathi B,
et al. Prevalence of hypothyroidism in adults:
An epidemiological study in eight cities of India.
Indian journal of Endocrinology and Metabolism
2013; 17(4): 647-652.
4. George JK, Tanja D, Jennifer G, Michael K, et
al. Thyroid Stimulating Antibodies Are Highly
Prevalent in Hashimoto’s Thyroiditis and
Associated Orbito pathy. J Clin Endocrinol Metab
2016; 101(5): 1998-2004.
5. Debmalya S. Spectrum of Hashimoto’s thyroiditis:
Clinical, biochemical & cytomorphologic prole,
Indian J Med Res. 2014; 140(6): 710-712.
6. https://misc.medscape.com/pi/iphone/
medscapeapp/html/A120937-business.html last
accessed on Aug 15th 2016 at 11.34.
7. Acharya YT, editor. Commentary Ayurveda
Dipika of Chakrapanidaa on Charaka Samhita
of Agnivesha, Chikitsa Sthana; Vata vyadhi
Chikitsa: chapter 28, verse 221-230. Chaukhamba
Krishnadass Academy; Varanasi: Reprint 2011. p.
626.
8. Harishastri P, editor. (9th ed.) Commentary
Sarvangasundara of Arunadaa on Ashtanga
Hridayam of Vagbhata, Chikitsa Sthana; chapter
19, verse 7-10. Chowkhambha Orientalia; Varanasi:
2005. p. 711.
9. Harishastri P, editor. (9th ed.) Commentary
Sarvangasundara of Arunadaa on Ashtanga
Hridayam of Vagbhata, Shareera Sthana; chapter 2,
verse 47-52. Chowkhambha Orientalia; Varanasi:
2005. p. 372.
10. Harishastri P, editor. (9th ed.) Commentary
Sarvangasundara of Arunadaa on Ashtanga
Hridayam of Vagbhata, Kalpa Sthana; chapter 2,
verse 21-23. Chowkhambha Orientalia; Varanasi:
2005. p. 743.
11. Acharya YT, editor. (9th ed.) Sushruta Samhita
of Sushruta, Sutra Sthana; chapter 38, verse 51.
Choukambha Orientalia; Varanasi: Reprint 2009.
p. 167.
12. Pandey GS, editor. (7th ed.) Commentary of
Chunekar KC on Bhavaprakasha Nigantu of
Bhavamishra, Hareetakyadi varga; chapter 1, verse
72-73. Choukambha Bharati Academy; Varanasi:
2010. p. 25.
13. Shivaprasad S, editor. Ashtanga Sangraha of
Vagbhata, Chikitsa Sthana; chapter 23, verse 2.
Chowkhambha Sanskrit Series; Varanasi: 2008. p.
564.
22 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):18-22
Seetha et al.: Ayurvedic Management of Hashimoto's Thyroiditis 1(1) 2017: 18-22
14. Kashinatha Shastri, editor. Rasa Tarangini of
Sadananda Sharma, chapter 22, verse 84-87.
Motilal Banarasi Das; Varanasi: 2004. p. 586.
15. Harishastri P, editor. Ashtanga Hridayam of
Vagbhata, Sutra Sthana; chapter 15, verse 21.
Chowkhambha Orientalia; Varanasi: 2005. p. 236.
23
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):23-27
Ayurvedic Management of Ankylosing Spondylitis
Mayur Mashru*, Mayur Barve1, Chandrashekhar Y Jagtap2, Kandarp Desai3
Superintendent, Smt. MAH Government Ayurved Hospital, Popatpura, Godhra, Panchamahal, Gujarat, 1Assistant Professor,
Department of Rasa Shastra and Bhaishajya Kalpana, Shri Saptashrungi Ayurved Mahavidyalaya and Hospital, Nashik,
Maharashtra, 2Research Ocer (Ayurveda), Regional Ayurveda Research Institute, Jhansi, Uar Pradesh, 3Director, Indian
System of Medicine & Homeopathy, Gandhinagar, Gujarat, India.
*Correspondence: Email: ayubeat.mayur@gmail.com, Mobile: +919904617086
Introduction: The only system of holistic health
management that existed since the dawn of man’s
history is the Indian system of Ayurveda. There is now
enough evidence to say that this was the mother of all
other systems of medicine.
ABSTRACT
Ayurveda serves best in many disease conditions where conventional system face several
limitations. Ankylosing spondylitis is one such condition, whose eective management
is becoming a challenge. It is a systemic auto-immune rheumatic disease, which shows a
strong association with genetic factor HLA-B27. Early stages of disease show inammation
of spine and other symmetrical small joints and other soft tissues, whereas chronic stage
presents with axial deformity and pain. NSAIDs and steroids are generally prescribed in
conventional systems, but are not a complete remedy. The signs and symptoms of this
disorder are not mentioned in Ayurveda, but, based upon the clinical picture, treatment
can be planned. A male 24 years patient diagnosed with axial and peripheral Ankylosing
spondylitis having HLA-B27 positive case was managed with Panchakarma procedures
followed by suitable Ayurvedic medicines. After completion of the treatment, pain in the
sacro-illiac region, morning stiness of joints were signicantly reduced with reduced ESR
and CRP. As the signs and symptoms of this disease are not mentioned in Ayurveda classics;
specic treatment protocol and formulations cannot be given. Selection of drugs may dier
from case to case. The treatment plan followed in this study may be adopted in future cases
changing the selection of drugs based upon the necessity to obtain good results.
Keywords:
Ankylosing
spondylitis,
Case Report,
HLA-B27,
Kaishora guggulu,
Sanshamani vati,
Panchakarma
How to cite this article: Mayur M, Mayur B,
Chandrashekhar YJ, Kandarp D. Ayurvedic
Management of Ankylosing Spondylitis. J AyuCaRe
2017;1(1):23-27.
But in-spite of the greatness of this science, Ayurveda
has to satisfy itself in the seat of alternative medicine,
although it was the chief system of medicine till the
emergence of modern allopathic medicine. But credit
should be denitely given to allopathic system of
medicine because it has made the life of human being
more comfortable with the help of various researches
and advancement in treatment modalities. But in
certain disease conditions like auto immune diseases;
allopathic system of medicine has still not found any
successful remedies. Ankylosing spondylitis is one such
Journal of Ayurveda Case Reports
24 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):23-27
Mayur et al.: Ayurvedic Management of Ankylosing Spondylitis 1(1) 2017: 23-27
auto-immune rheumatic disease that shows a strong
association with genetic factor HLA-B27.[1]
In early stages of disease, there is inammation of
spine with symmetrical small joints and other soft
tissues. Chronic stage is characterized by marked axial
immobility or permanent deformity and pain. It usually
starts in late teens and early twenties and can lead to
progressive bony fusion of sacro-iliac joints and the
vertebral column. Extra-articular manifestations may
also manifest in a few patients.[2] In allopathic system of
medicine, NSAIDs and steroids are generally prescribed
along with physiotherapy. But still it remains as a
symptomatic approach. If Ayurvedic approaches are
intervened appropriately, further progression of the
disease can be prevented. In this aempt, a case of
Ankylosing spondylitis has been successfully managed
with Ayurvedic treatment approaches.
Case report: A 24 year-old male patient visited the
OPD with complains of early morning stiness with
asymmetrical inammation of left knee, right ankle
and inter-phalangeal joints of hands since one year. He
was diagnosed with axial and peripheral Ankylosing
spondylitis having HLA-B27 positive.
Pulse was 84/min, regular; Blood Pressure - 120/80 mm
of Hg, Temperature - 99.6 0F, Respiratory rate - 18/min.
Respiratory, Cardiovascular and Central nervous system
did not show any specic abnormality. Per abdomen
examination was normal. Tenderness was present over
bilateral sacroiliac joints. Morning stiness of joints with
oedema over left knee and right ankle joint was present.
Achilles tendinitis was present in right leg causing pain
in lower part of leg. Hemoglobin levels were below 9.5%
for past one year whereas ESR was 100mm and CRP
level 76 mg/l.
Past treatment history: The patient was under the
supervision of a rheumatologist for eight months, where
combinations of dierent drugs have been prescribed
(Table 1).
No improvement was observed with these medicines,
subsequently all these medicines were withdrawn. The
patient was advised to continue Voveran (Diclofenac
sodium) tablet as an analgesic agent to relieve pain.
Patient lost 16 kg weight within the six months time and
developed other symptoms like hyperacidity and loss of
appetite.
Table 1: Conventional drugs prescribed to the patient
1Tab. Saaz DS (Sulphasalazine) 1000 mg twice a day
2Tab. Folitrax (Methotraxate) 15 mg once a week
3Tab. Etoshine (Etorecoxib) 120 mg twice a day
4Tab. Medrol (Methyl predenisolone) 8 mg once /
day
5Tab. Voveran SR (Diclofenac Sodium) 75 mg twice
/ day
6Tab. Folvite (Folic acid) 5mg once a day
7Tab. Ultracet (Tramadol Hydrochloride 37.5 mg &
Acetaminophen 325 mg) twice a day
The above drugs were used for three months by the
patient under the supervision of the rheumatologist.
As the response was very minimal, the prescription
was changed and the below drugs were prescribed.
1Inj. Depo-medrol (Methyl predenisolone Acetate)
120 mg once daily
2Inj. Folitrax (Methotrexate) 15 mg once a week
3Tab. Myospaz (Chlorezoxazone 250 mg +
Paracetamol 500 mg) twice a day
4Tab. Lefunomide 10mg once a day
Ayurveda perspective: Ankylosing spondylitis cannot
be mirrored with any particular disease condition
directly that is elaborated in Ayurveda classics. It can
be compared to some extent with Ama vata, or Gambhira
vatarakta, or Asthi-majjagata vata.[3-5] Taking this into
consideration, the patient was evaluated according
to Ayurvedic perspective. Prakriti of the patient was
Vata pia. Agnimandya was noticed in the patient
and presented with Ama lakshanas in Mala and Jihva.
Though, Vata and Pia were the dominating doshas in
this manifestation; involvement of Kapha dosha was also
noticed. All the three vitiated Doshas aected Rasa, Rakta,
Mamsa, Asthi, Majja dhatus. Considering the condition of
25
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):23-27
Mayur et al.: Ayurvedic Management of Ankylosing Spondylitis 1(1) 2017: 23-27
the patient; Panchakarma procedures were planned that
were followed by internal medications for 45 days (Table
2).
Besides these procedures; Kaishora guggulu (500 mg
thrice), Sanshamani vati (250 mg twice), Punarnavadi
kwatha (15 ml twice) and a blend of Amalaki, Musta,
Guduchi powders (1 g each with warm water) were
administered during the rst two weeks of the
management.
This was followed by Kaishora guggulu (500 mg thrice),
Sanshamani vati (250 mg twice), Rasna erandadi kashayam
(15 ml twice), powder of Ashwaha twak (1 g twice
with honey) and Lepa guti for external application over
swollen, inamed parts.
Table 2: Ayurvedic treatment plan
Panchakarma Treatment Duration
Dipana pachana (Amruotara kashayam) 5 days
Snehapana (Indukantam ghritam) 5 days
Abhyanga (Tila taila) 2 days
Swedana (Fomentation) 2 days
Virechana (Trivrutadi avaleha) 1 day
Samasarjana krama (Dietary regime) 7 days
Karma vasti 15 days
Anuvasana vasti (Sahacharadi taila)
Yapana vasti (Mustadi yapana)
Shastishali pinda swedana 15 days
Saravanga swedana [with Nirgundi (Vitex
negundo Linn.) and Shigru patra (leaves of
Moringa oleifera Lam.)]
15 days
Upanaha swedana 10 days
Jalaukacharana (Leech therapy) At right
ankle and left knee joint
3 days
Observations: All the allopathic medicines were
gradually withdrawn by 21st day of commencement
of Ayurvedic treatment. After withdrawing NSAIDs;
both pain and swelling were aggravated, but they were
tolerable. After completion of Panchakarma therapy,
sacro-illiac joint pain was completely reduced, while
morning stiness was reduced signicantly. Mild
swelling was observed over left knee and right ankle
joints especially in the morning hours, which was
reduced with physiotherapy. After one month of follow
up, only mild tolerable swelling over right ankle was
complained. This swelling was further reduced with
continuous physiotherapy. Hematological prole of the
patient was signicantly improved. Good improvement
in heamoglobin percentage was seen. ESR and CRP
were also reduced suggesting reduction in inammation
(Table 3). Patient gained 8 kg weight within two
months after completion of the treatment. By the end of
treatment, no need of conventional analgesics or anti-
inammatory drugs was needed by the patient.
Discussion: Patient was analysed by following
Ayurvedic principles. On examination; it was observed
that patient had symptoms of Ama, so Ampachana was
suggested with Amrutoaram kashayam[6] that is generally
used in vitiation of Tridoshas and is also indicated in
Jwara. Ama pachana is a crucial step that is done before
Snehapana followed by Virechana. Considering severity
of the disease and Samata of Mala, as well as dominancy
of Vata and Pia; Virechana was planned. Snehapana
with Indukantam ghritam[7] was planned, as it plays an
important role in Rasa pradoshaja diseases. Virechana
was given with Trivrutadi avaleha[8] considering vitiation
of Pia and Kapha. Trivrit helps in eliminating Pia
followed by Kapha and is also well tolerated by the
patient. After Virechana, patient was given Karma vasti
with alternate Anuvasana and Yapana vasti. Anuvasana
vasti was given with Sahacharadi taila[9] that acts very well
on lower part of the body. Mustadi yapana vasti[10] was
given considering Madhyama bala of the patient as well
as its ecacy on Vaata dosha. Mustadi yapana is good in
the involvement of Asthi and Majja. Shastika shaali pinda
sweda[11] and Upanaha sweda[12] were given for the relief
of pain and swelling, Sarvanga sweda with Nirgundi and
Shigru was also given for relief of pain and removing
Stambha. Internal medicine such as Kaishora guggulu[13]
and Sanshamani vati[14] were selected considering their
26 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):23-27
Mayur et al.: Ayurvedic Management of Ankylosing Spondylitis 1(1) 2017: 23-27
action on Vata, Pia, Kapha, Rasa, Rakta and Mamsa.
Amalaki, Guduchi and Musta in a combination is known
for its role in Asthi majja gata jwara pachana.[15]
Table 3: Changes in Hemotological prole
Investi-
gations
Before
treatment
Imme-
diately after
Pancha
karma
After 45
days of
Pancha
karma
Hb (gm%) 9.5 9.3 12.7
RBC (million
/ cmm)
3.95 3.8 4.84
ESR 106 76 32
CRP (mg/L) NA 27 14.30
Platelets (per
c. mm)
5,96,000 3,72,000 4,53,000
Punarnavadi kwatha[16] also shows action on Rasa, Rakta,
Mamsa and possess Shothahara property. Rasna erandadi
kashayam[17] added to the list of medicines in further
stages of treatment, as it pacies pain due to Vata mainly
in lower limbs and back. It also reduces Shotha due to
Vata. Ashwaha churna[18] was administered as it controls
vitiated Vata and Rakta. Jalaukacharana[19] (Leech therapy)
was done over right knee and left ankle to reduce the pain
and inammation occurring due to Achilles tendinitis.
Lepa guti[20] was added in follow up treatment to control
Vedana and Shopha (analgesic and anti-inammatory)
action locally. Physiotherapy with stretching exercises
were advised to relieve stiness of muscles as well as
joints.
Conclusion: Concept of pill for every ill is becoming
an outdated concept in the Modern era. The present
patient was examined and treated following to
Ayurvedic principles. For auto immune diseases, such
as Ankylosing spondilitis, where there is no satisfactory
proven treatment in conventional medical systems;
Ayurveda can be used eectively. Though single case
report cannot prove treatment for all such auto immune
manifestations; well designed clinical trials may be
planned in order to validate actual potency of treatment
paerns and principles applied in this case.
Source of support: Nil.
Conicts of interest: None declared.
References:
1. Zochling J, Van der Heijde D, Burgos-Vargas R,
Collantes E, et al. ASAS / EULAR recommendations
for the management of ankylosing spondylitis.
Annals of Rheumatic Diseases 2006; 65: 442-452.
2. Khan MA. Clinical features of ankylosing
spondylitis. In: Hochberg MC, Silman AJ,
Smolen JS, Weinbla ME, Weisman MH, editors.
Rheumatology, 3rd ed., London, 2003; 1161-1181.
3. Lakshmipati shastri, editor. Yogaratnakara,
Amavata Nidana, Chaukhambha Sanskrit
Sansthan, Varanasi: 2009. p. 564.
4. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Chikitsa sthana, Vata shonita chikitsa,
chapter 29, verse 21, Chaukhambha Surabharti
Prakashan, Varanasi: 2005. p. 986.
5. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Chikitsa sthana, Vata vyadhi chikitsa,
chapter 28, verse 33, Chaukhambha Surabharti
Prakashan, Varanasi: 2005. p. 942.
6. Sharma RN, Sharma S, editors. Sahasrayogam,
Kashaya prakaranam, Chaukhamba Sanskrit
Pratishthan, Delhi: 2007. p. 4.
7. Sharma RN, Sharma S, editors. Sahasrayogam,
Ghrita Prakaranam, Chaukhamba Sanskrit
Pratishthan, Delhi: 2007. p. 42.
8. Sharma RN, Sharma S, editors. Sahasrayogam,
Leha Prakaranam, Chaukhamba Sanskrit
Pratishthan, Delhi:2007. p. 204.
9. Sharma RN, Sharma S, editors. Sahasrayogam,
Taila Prakaranam, Chaukhamba Sanskrit
Pratishthan, Delhi: 2007. p. 90.
10. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Siddhi sthana, Uara vasti siddhi,
chapter 12, verse 15, Chaukhambha Surabharti
Prakashan, Varanasi: 2005. p. 1324.
11. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Sutra sthana, Swedadhyayam, chapter
14, verse 41, Chaukhambha Surabharti Prakashan,
Varanasi: 2005. p. 295.
12. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Sutra sthana, Swedadhyayam, chapter
27
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):23-27
Mayur et al.: Ayurvedic Management of Ankylosing Spondylitis 1(1) 2017: 23-27
14, verse 37, Chaukhambha Surabharti Prakashan,
Varanasi: 2005. p. 294.
13. Shastri V, editor. (1st ed) Sharangadhara Samhita
of Sharangadhara, Madhyama khanda, Gutika
prakarana, chapter 7, verse 70, Chaukhamba
Orientalia, Varanasi: 2006. p. 203.
14. Anonymous. (1st ed) Ayurveda Pharmacopoeia
compiled by Gujarat State Bheshaja Samiti, Health
Department, Gujarat state. 1966. p. 521.
15. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Chikitsa sthana, Jwara Chikitsa,
chapter 3, verse 202, Chaukhambha Surabharti
Prakashan, Varanasi: 2005. p. 186.
16. Shastri V, editor. (1st ed) Sharangadhara Samhita
of Sharangadhara, Madhyama khanda, Kwatha
kalpana, chapter 2, verse 118, Chaukhamba
Orientalia, Varanasi: 2006. p. 159.
17. Sharma RN, Sharma S, editors. Sahasrayogam,
Kashaya Prakaranam, Chaukhamba Sanskrit
Pratishthan, Delhi:2007. p. 33.
18. Tripathi B, editor. (1st ed) Charaka samhita of
Agnivesha, Chikitsa sthana, Vata shonita chikitsa,
chapter 29, verse 158, Chaukhambha Surabharti
Prakashan, Varanasi: 2005. p. 1007.
19. Sharma A, editor. Sushruta samhita of Sushruta,
Sutra sthana, Jalaukavacharaneeyam, chapter 13,
verse 19, Chaukhambha Surabharti Prakashan,
Varanasi: 2004. p. 97.
20. Gokhale B, Chikitsa Pradeepa, Dhanvantari
Pratishthan, Pune: 1989. p. 137.
28 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):28-33
Management of Frozen Shoulder in Diabetics through Panchakarma
Sangeeta RT*, Adil R, Anup BT
Dept. of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar,
Gujarat, India
*Correspondence: E-mail: dr.tanwarsangeeta04@gmail.com, Mobile: +91 9624188940
ABSTRACT
Diabetes is having a steep rise in prevalence and is on the way to take shape of a global
epidemic, mostly associated with improper diet and lifestyle. Musculoskeletal problems
are common in diabetics but are not so well- known as compared to other complications
of the disease. Frozen Shoulder, one such musculoskeletal problem, is estimated to aect
diabetic patients ve times more as compared to non-diabetics, resulting in pain and limited
range of movement and is compared to Apabahuka in Ayurveda. Conventional treatment
modalities like analgesics, NSAIDs, steroids and surgery etc have certain limitations.
Hence, alternatives are being searched from other systems of medicines. A 64 years old
female patient, presented with pain and restricted movements of left shoulder joint; was
treated with Udvartana followed by local Swedana with Jambeera pinda and Panchatikta
panchaprasritika vasti for ve ve days. After completion of therapy, pain was subsided
and satisfactory improvement was found in the shoulder joint movements. Panchakarma in
the form of Basti regimen and external therapies is surely a result oriented therapy in the
management of Diabetes and such complications like Frozen shoulder. Panchakarma in the
form of external therapies and Vasti regimen is a result oriented therapy in the management
of Frozen Shoulder and also eective in Diabetes.
Keywords:
Apabahuka,
Case report,
Diabetes,
Frozen shoulder,
Panchakarma,
Udvartana,
Vasti
How to cite this article: Sangeeta RT, Adil R, Anup BT.
Management of Frozen Shoulder in Diabetics through
Panchakarma. J AyuCaRe 2017;1(1):28-33.
Introduction: Diabetes has emerged as one of the most
common non-communicable diseases globally and it is
threatening to be the most challenging health problem
of this century. Complications from diabetes, such
as coronary artery disease and peripheral vascular
disease, diabetic neuropathy, diabetic nephropathy
etc are resulting in increasing disability, reduced life
expectancy and enormous health cost for every society.
Among them muscle cramps, muscle infarction,
neuropathic joints, carpel tunnel syndrome,
tenosynovitis, diuse idiopathic skeletal hyperostosis,
dupuytren’s contracture and adhesive capsulitis are
commonly seen. Among these, Adhesive Capsulitis of
Shoulder also known as Frozen Shoulder is the most
common manifestation, that aects diabetic patients ve
times more as compared to non-diabetics.[1] Hence, high
blood sugar is a big risk factor for the development of
Journal of Ayurveda Case Reports
29
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):28-33
Sangeeta et al.: Ayurvedic Management of Frozen Shoulder 1(1) 2017: 28-33
frozen shoulder. Studies reported increased prevalence
of frozen shoulder in diabetic patients (26.25%),
comparatively more in non dominant shoulders of
females with type II DM.[2]
Primary pathology in frozen shoulder is within the
glenohumeral joint capsule which becomes adherent
to the humerus head, resulting in pain and limited
range of movements. Pain mostly worsens at night and
there is progressive loss of passive range of movement
(PROM) and active range of movement (AROM). It
predominantly occurs unilaterally but both shoulders
may get aected in about 10-20% of cases.[3] Other Risk
factors include female sex, older age, shoulder trauma,
surgery, parkinsons disease,[4] increased body mass
index, cardiovascular and thyroid disorders etc.[5-9]
Clinically, frozen shoulder develops in three symptom-
related phases; rst one is freezing or painful phase
characterized by insidious onset of pain, which gradually
increases in intensity with gradual PROM & AROM. It
lasts for few weeks to nine months followed by frozen or
adhesive phase of about four to nine months and nally
thawing or recovery phase in which resolution starts
with the gradual returning of shoulder joint to almost
normalcy in six to twenty four or more months.
Sign and symptoms of frozen shoulder have resemblance
with Apabahuka described in Ayurveda, which is a
condition of deranged Vata and Kapha.[10] Hence Vata
kapha pacifying management was planned in the present
case study.
Though it is a self limiting condition, but recovery
process is quite slow, which hampers daily routine of
patients leading to frustration at times. Modern science
uses treatment options like Analgesics, Non Steroidal
Anti-inammatory Drugs, Steroids, Physiotherapy &
Surgery etc in the management which are not satisfactory
and are known to develop adverse eects too. Hence,
alternatives are being searched from other systems
of medicines. In this aempt, a patient presenting
with symptoms of frozen shoulder was managed with
Ayurveda principles.
Case report: A 64 years aged female patient, visited OPD
of Panchakarma, Institute for Post Graduate Teaching
and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar with complaints of pain, stiness and restricted
movements at left shoulder joint since 8 months. The
pain was dull initially, gradually increased in severity,
specially exacerbating at night (around 2 or 3 am). Pain
usually was aggravating with movements of shoulder
and was being relieved after intake of analgesics or with
hot fomentation. Gradually the condition was worsened
and the majority of shoulder joint movements were
restricted. Routine activities including combing hair,
bathing etc badly aected.
Patient had regular bowel and bladder habits. Appetite
was slightly reduced and sleep was altered due to
shoulder pain and stiness. Detailed examination
following Ashta vidha and Dasha vidha pareeksha was
done.[11-12]
The patient was a known diabetic, hypertensive and
was on anti-hypertensive drugs (Amlodipine 5 mg +
Atenolol 50 mg once daily, Losartan 50 mg twice daily),
hypoglycemic drugs (Glimepiride twice daily) and
analgesics (Tramadol SOS). Besides medicines, patient
also aended physiotherapy sessions for six months.
Blood pressure (138/86 mm of Hg), pulse (80/min) and
respiratory rate (22/min) were within the physiological
limits. Respiratory system examination revealed
bilateral adequate air entry with no added sounds.
Cardio vascular system revealed normal audible S1, S2.
Abdomen was soft with no tenderness, no organomegaly
or no lump. All the movements at left shoulder joint
were limited both actively and passively.
Investigations: Routine haematological, urine and
biochemical investigations were carried out to exclude
other pathology and to know the underlying cause,
which were within normal limits except blood sugar
level i.e. fasting & post prandial blood sugar levels were
232 mg/dl and 189 mg/dl respectively. Radiograph of
left shoulder joint (AP view) showed normal study.
Treatment protocol: After assessing the Dosha (Vata-
kapha), Aushadha (Tikta, Ushna, Teekshana), Desha (Jangala),
Kala (Sheeta), Satmya (Madhyama), Satva (Madhyama),
Agni (Manda), Vaya (old age) and Bala (Madhyama),[13]
local Udvartana was done for ve days, which was
followed by Jambeera Pinda Sweda along with Panchatikta
30 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):28-33
Sangeeta et al.: Ayurvedic Management of Frozen Shoulder 1(1) 2017: 28-33
panchaprasritika vasti for the next ve days.[14] Patient was
advised to take lukewarm water during the procedure.
Total duration of the study was 10 days. No oral drugs
were administered during this study period, while
conventional anti-hypertensive and anti-diabetic drugs
taking earlier were continued. Brief details of drugs
used in the treatment are mentioned at Table 1.
Table 1: Treatment Protocol
Procedure Ingredients Duration
Udvartana Yava choorna (powder of Hordeum vulgare Linn.) - 100 g Triphala
choorna - 20 g
First to Fifth Day
Jambeera pinda sweda Four Jambeera (Citrus medica Linn.) of medium size
Haridra choorna (powder of Curcuma longa Linn.) - 5 g
Saindhava lavana (Rock salt powder) - 10 g
Panchatikta pancha
prasritika vasti
Kwatha dravya: 400 ml of Patola (Trichoxanthes dioica Roxb.),
Nimba (Azadirachta indica A. Juss.) Bhunimba (Andrographis
paniculata Nees.), Rasna (Pluchea lanceolata Oliver & Hiern.),
Saptaparna (Alstonia scholaris (Linn.) R. Br.)
Kalka Dravya: 20 g of Sarshapa (Brassica campestris Linn.)
Sneha: 100 ml of Go-ghrita
Sixth to Tenth Day
Assessment criteria: Visual Analogue Scale (VAS),
Stiness, Range of movements using Goniometer and
Blood sugar were assessed before and after treatment
(Fig 1 and Table 2).
Figure 1: Visual Analogue Scale
Table 2: Gradation of Stiness
Stiness
0 No Stiness
1Stiness; no medication
2Stiness, relieved by external application
3Stiness, relieved by oral medication
4Stiness, not responded by medicine
Observations and Results: Satisfactory improvement in
overall functional status after ten days treatment was
observed. No analgesics were needed by the patient
during the treatment period and one month of follow
up. No untoward eects were noticed during the whole
procedure. Pain and stiness were relieved completely
by the end of treatment (Table 3) with signicant
improvement in the range of shoulder movements
(Figure 1 and Table 4). FBS and PPBS came down to
168 mg/dl and 93 mg/dl from 232 mg/dl and 189 mg/
dl respectively. No aggravation in pain or stiness was
reported by the patient during follow up period of about
one month after completion of therapy.
Table 3: Eect of therapy on VAS, Stiness and
Weight
Before
treatment
After
treatment
After
Follow up
VAS 60 0
Stiness 30 0
Weight 55 kg 54 kg 54 kg
31
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):28-33
Sangeeta et al.: Ayurvedic Management of Frozen Shoulder 1(1) 2017: 28-33
Table 4: Eect of Therapy on Range of Movement
F E Ab IR ER
Left
BT 55o30o55o50o30o
AT 110o50o115o90o60o
Right
BT 135o45o110o90o65o
AT 135o45o110o90o65o
F=Flexion, E=Extension, Ab=Abduction, ER=External Rotation
Discussion: Most of the complications of DM usually
intervene with various functions of visceral organs. But,
excess sugar in the blood stream seems to cause other
problems also like musculoskeletal complications, out
of which Frozen Shoulder is most common. Glucose
molecules can adhere to collagen and make it sticky.
Collagen is a major building block in the ligaments
that holds the bones together in a joint. In Diabetics,
this adhesion due to extra sugar molecules in blood
stream can contribute to abnormal deposits of collagen
in the cartilage and tendons of the shoulder, which
causes stiness of the aected shoulder and restricts its
movements.[15]
In addition, poor perfusion leads to abnormal collagen
repair and degenerative changes. The theory is that
platelet derived growth factor is released from abnormal
or ischemic blood vessels, which will then act as a
stimulus to local myobroblast proliferation.[16]
The pathology of frozen shoulder includes a chronic
inammatory response with broblastic proliferation,
which may be immuno-modulated. Characteristically,
pain precedes stiness in frozen shoulder, which
suggests an evolution from inammation to brosis.
These clinical and macroscopic features support the
pathological ndings of both inammation and brosis.
[17] That is why Udvartana was planned to reduce
inammation followed by Jambeera pinda sweda to act
on brosis owing to its Snigdha, Amla and Ushna guna.
Moreover, Swedana enhances local microcirculation,
by increasing the blood circulation rate of peripheral
arterioles, delivering higher level of oxygen and
nutrients to the injured cells.
Prameha has been mentioned as Santarpanoha vyadhi
and Virukshana kriya, Udvartana has been indicated in its
management.[18-19] So due to Rukshana kriya, excess Kleda
in Pramehi may get absorbed due to opposite Guna. This
may also cause reduction in viscosity due to increased
sugar molecules aached to collagen. Thus, this could
be helpful in reducing pain, stiness and improving the
range of shoulder movements.
Apabahuka is having Vata kapha dosha dominancy,[20] after
mobilization of dried Kapha and Shoshana of Kleda by
Udvartana; dominancy of Vata dosha remains to be dealt
with. Besides this, chronicity of the disease also leads to
Vata prakopa up to some extent, for which Jambeera pinda
sweda was applied, which is supposed to pacify Vata
dosha due to its Amla, Lavana, Snigdha and Ushna guna.
Though Vasti is not a choice of treatment for Prameha;
Before Treatment After Treatment
Flexion at Left
Shoulder Joint
Extension at
Left Shoulder
Joint
Abduction at
Left Shoulder
Joint
Figure 1: Improvement of the shoulder movements
before and after therapy
32 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):28-33
Sangeeta et al.: Ayurvedic Management of Frozen Shoulder 1(1) 2017: 28-33
Asthapana vasti can be administered.[21] However,
Panchatikta pancha prasritika vasti nds a special mention
for Prameha.[22]
The Rasa panchaka of the ingredients of Vasti possess
mainly Snigdha, Ushna guna, Ushna virya and Kapha
vataghna eects,[23] which would be helpful in pacifying
the Vata kapha dosha involved in the Samprapti of
Apabahuka. Besides this, Tikta rasa is supposed to have
direct eect on Asthi dhatu.[24]
Pharmacological properties of Vasti drugs exhibit
Hypoglycaemic, Hypotensive, Anti-inammatory,
Analgesic, Diuretic, Immuno-stimulant and Anti-
oxidative eects (Table 5). Hence, the hypoglycemic
eect found after Vasti regimen in the biochemical
reports and the analgesic eect may be aributed to
these properties of drugs.
Table 5: Pharmacological properties of ingredients of
Panchatikta Panchaprasritika Vasti
Ingredient Properties
Patola Hypoglycaemic[25]
Nimba Hypoglycaemic, Hypotensive,
Analgesic, Sedative, Anti-
inammatory, Diuretic[26]
Bhunimba Anti-hyperglycaemic, Anti-
inammatory, Immuno-stimulant,
Hypotensive, Analgesic, Antioxidant[27]
Rasna Analgesic, Anti-inammatory[28]
Saptaparna Hypotensive[29]
Sarshapa Anti-inammatory, Anti-oxidant[30]
Conclusion: Though, Frozen Shoulder is a self limiting
disease, Ayurvedic treatment modalities can shorten
the recovery time. Rukshana kriya like Udvartana
followed by Jambeera pinda sweda can be helpful in
reducing pain, stiness and improving the range of
shoulder movement in frozen shoulder. Panchatikta
panchaprasritika vasti is eective in reducing the blood
sugar level and improving the quality of life of diabetics.
Thus, Udvartana followed by Jambeera pinda sweda along
with Panchatikta panchaprasritika vasti is found eective
in the management of frozen shoulder associated with
diabetes. To further establish this treatment protocol in
frozen shoulder, a study involving larger sample size is
needed.
Source of support: Institute for Post Graduate Teaching
and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar - 361008, Gujarat, India
Conicts of interest: None declared
References:
1. Zreik NH, Malik RA, Charalambos CP. Adhesive
capsulitis of the shoulder and diabetes: a meta-
analysis of prevalence. Muscle, Ligaments and
Tendons Journal. 2016; 6(1): 26–34.
2. Pooja DP, Deshpande P, Ranade P. Prevalence
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3. Pandey S, Pandey AK. Clinical orthopaedics
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Frozen shoulder and other shoulder disturbances
in Parkinson's disease. Journal of Neurology,
Neurosurgery & Psychiatry, 1989; 52(1): 63-66.
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30(8): 936-939.
7. Bowman C, Jecoate WJ, Parick M, Doherty
M. Bilateral adhesive capsulitis, oligoarthritis
and proximal myopathy as presentation of
hypothyroidism. British Journal of Rheumatology
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frozen-shoulder/basics/risk-factors/con-20022510
last accessed on Mar 10, 2015 at 15.25.
10. Acharya YT, editor. Sushruta Samhita of Sushruta,
33
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):28-33
Sangeeta et al.: Ayurvedic Management of Frozen Shoulder 1(1) 2017: 28-33
Nidana sthana, Jwara Chikitsa, chapter 1, verse 82,
Chaukhambha Orientalia; Varanasi: reprint 2014.
p. 269.
11. Tripathi I, Tripathi DS, editors. (3nd ed)
Yogaratnakara, Roginam ashtasthana pariksha,
verse 1, Chaukhambha Krishnadas Academy;
Varanasi: 2011. p. 4.
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Vimana sthana, Roga bhishagjitiya, chapter 8,
verse 94, Chaukhambha Orientalia; Varanasi:
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Siddhi sthana, Bastisutriyam, chapter 3, verse 6,
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15. hp://www.healthline.com/diabetesmine/the-411-
on-diabetes-frozen-shoulder last accessed on Dec
7, 2011 at 15.45.
16. Ronald Grisanti. Frozen Shoulder: The Diabetic
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17. Hand GC, Athanasou NA, Mahews T, Carr AJ.
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18. Acharya YT, editor. Charaka samhita of Agnivesha,
Sutra sthana, Santarpaniyam, chapter 23, verse 5,
Chaukhambha Orientalia; Varanasi: reprint 2011.
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50, Chaukhambha Orientalia; Varanasi: reprint
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1, verse 82. Choukambha Orientalia; Varanasi:
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pravibhagam, chapter 35, verse 22, Chaukhambha
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Siddhi sthana, Prasrita yogiyam, chapter 8, verse 8,
Chaukhambha Orientalia; Varanasi: reprint 2011.
p. 713.
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Chaukhambha Bharati Academy; Varanasi: reprint
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Sutra sthana, Vividhashita pitiyam, chapter 28,
verse 27, Chaukhambha Orientalia; Varanasi:
reprint 2011. p. 180.
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Ministry of health & Family welfare, Government
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Ministry of health & Family welfare, Government
of India. 2000. p. 289.
27. Anonymous. Database on medicinal plants used
in Ayurveda, Vol 4, Central Council for Research
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Ministry of health & Family welfare, Government
of India. 2002. p. 34.
28. Anonymous. Database on medicinal plants used
in Ayurveda, Vol 7, Central Council for Research
in Ayurveda and Siddha, Department of ISM & H,
Ministry of health & Family welfare, Government
of India. 2005. p. 375.
29. Anonymous. Database on medicinal plants used
in Ayurveda, Vol 1, Central Council for Research
in Ayurveda and Siddha, Department of ISM & H,
Ministry of health & Family welfare, Government
of India. 2000. p. 384.
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in Ayurveda, Vol 8, Central Council for Research
in Ayurveda and Siddha, Department of ISM & H,
Ministry of health & Family welfare, Government
of India. 2007. p. 309.
34 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):34-39
Ecacy of Triphaladya guggulu and Punarnavadi kashaya in the management
of Hypothyroidism
Karishma S*, Anup BT, Prajapati PK1
Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar, Gujarat, 1Department of Rasa Shastra and Bhaishajya Kalpana, All India Institute of Ayurveda, New Delhi, India.
*Correspondence: Email: dr.tejas01@gmail.com, Mobile: +919978827350
Introduction: Hypothyroidism is one of the most
common and challenging disease conditions in today’s
era. The prevalence of hypothyroidism in India is
around 11%.[1] Hypothyroidism is a condition in which
the thyroid gland does not produce enough Thyroxine
(T4) and Tri-iodothyronine (T3).
ABSTRACT
Changed life style of current scenario has provoked several disharmonies in the biological
system. Hypothyroidism is one such manifestation, which is believed to be a common
health issue in India. The pathogenesis of Hypothyroidism according to Ayurveda is
basically due to the abnormal functioning of Agni, which in turn aects Dhatwagni,
eventually brings out pathological sequence and ultimately the disease condition
develops. This condition can be managed by Ayurveda principles. A diagnosed case
of Hypothyroidism presenting with puness of face and eyelids, weakness, lethargy,
fatigue, prolonged intermenstrual period, dry and coarse skin, was managed with
Triphaladya guggulu (1000 mg twice a day) and Punarnavadi kashaya (50 ml twice a day) for
a period of 45 days. Thyroxine (100 mcg) that was being used by the patient since one year
was withdrawn one week before starting the treatment. Serum TSH levels were reduced
from 93.250 µIU/ml to 53.701 µIU/ml by the end of treatment. Triphaladya guggulu and
Punarnavadi kashaya are benecial countering signs and symptoms and bringing down
the TSH levels. As the observations were drawn from a single case; can be revalidated
through well designed clinical trials.
Keywords
Case report,
Hormone replacement
therapy,
Hypothyroidism,
Punarnavadi kashaya,
Triphladya guggulu
How to cite this article: Karishma S, Anup BT, Prajapati
PK. Ecacy of Triphaladya guggulu and Punarnavadi
kashaya in the management of Hypothyroidism. J
AyuCaRe 2017;1(1):34-39.
Iodine deciency and auto-immunity are the main
causes of Hypothyroidism, out of which auto-immunity
is common in the areas of iodine replete. There is
no promising cure in contemporary systems for
Hypothyroidism. The only available treatment is lifelong
use of synthetic thyroxine that invites complications in
the long run.
Concept of Agni (digestive re) and Ama (unwanted by
product of improper digestion) are the central dogma
of Ayurvedic therapeutics in general and in particular
in the management of auto-immune pathologies. Agni,
when becomes Manda (weak), is unable to metabolize
Journal of Ayurveda Case Reports
35
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):34-39
Karishma et al.: Ayurvedic Management of Hypothyroidism 1(1) 2017: 34-39
leading to accumulation of intermediate metabolic by-
products in the body at dierent levels. Such unwanted
by-products (sometimes may act as free radicals)
becomes toxic and may initiate pathologies of auto-
immunity.
As most body cells have receptors for thyroid hormones;
T3 and T4 exert their eects throughout the body.[2] These
hormones stimulate diverse metabolic activities in most
tissues, leading to an increase in basal metabolic rate.
Without thyroid hormones, almost all the chemical
reactions of the body would become sluggish. These
hormones can be considered as a part of Kayagni on
which the entire metabolic activities depends.[3] Hence,
impaired metabolism can be compared with vitiation
of Agni according to Ayurveda. Thus, principles that
correct the functioning of Agni will be benecial in
treating various pathologies. Following these guidelines,
a case of Hypothyroidism was managed.
Case report: A 30 years old female suering with
Hypothyroidism aended Panchakarma OPD, Institute
for Post Graduate Teaching and Research in Ayurveda,
Gujarat Ayurved University, Jamnagar with the
complaints of puness of face and eyelids, weakness,
lethargy, fatigue, prolonged inter menstrual period, dry
and coarse skin since one year with elevated levels of
Serum TSH (Thyroid Stimulating Hormone). She was
under Hormone replacement therapy (Tab Thyroxine
100 mcg OD) since one year. No positive family history
was noticed.
The Prakriti was found to be Vata pia. Despite of
continuous consumption of Thyroxine for one year; she
could not get satisfactory relief in the signs and symptoms
and approached Ayurveda for beer management.
As malfunctioning of Agni is considered in the
pathogenesis; Triphaladya guggulu (1000 mg twice a day)
along with Punarnavadi kashaya (50 ml twice a day) were
chosen in the current case and were administered for a
period of 45 days.[4-5] Composition formulation of these
two formulations has been placed at Table 1-2.
Triphaladya guggulu was prepared by dissolving Triphala
shodhita guggulu in Kanchanara twak kwatha until it
aained a sticky consistency, followed by addition of
powders of Trikatu and Triphala along with quantity
sucient honey for making pills of 500 mg size. It was
administered in a dose of two pills (1000 mg) twice a day
with luke warm water after meal for a period of 45 days.
Table 1: Composition of Triphaladya guggulu
Drug Botanical Name Part used Quantity
Shunthi Zingiber ocinale
Roxb.
Rhizome 1 Part
Pippali Piper longum
Linn.
Fruit 1 Part
Maricha Piper nigrum
Linn.
Fruit 1 Part
Amalaki Emblica ocinale
Gaertn.
Pericarp
1 Part
Haritaki Terminalia chebula
Re.
Pericarp
Bibhitaki Terminalia belerica
Roxb.
Pericarp
Kanchanara Bauhinia variegata
Linn.
Stem
bark
6 Parts
Guggulu Commiphora
mukul (Hook ex
Stocks) Engl.
Resin 10 Parts
Madhu Honey -Q.S
Table 2: Composition of Punarnavadi kashaya
Drug Botanical Name Part used Quantity
Punarnava Boerhavia diusa
Linn.
Root 1 part
Devadaru Cedrus deodara
(Roxb.) Loud.
Stem 1 part
Shunthi Zingiber ocinale
Roxb.
Rhizome 1 part
Guggulu Commiphora
mukul (Hook ex
Stocks) Engl.
Resin 1/30th
part
36 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):34-39
Karishma et al.: Ayurvedic Management of Hypothyroidism 1(1) 2017: 34-39
For preparation of Punarnavadi kashaya; patients were
advised to add 400 ml potable water to 25 g of coarse
powder of the ingredients and reduce to 50 ml and
consume on empty stomach twice daily for a period of
45 days.
Along with the oral medication, Pathya and Apathya
ahara and Vihara (wholesome and unwholesome diet
and lifestyle) were also advised to the patient. She was
asked to consume luke warm water in place of normal
/ cold water during the treatment period. In addition,
was advised to avoid consuming diet that is dicult
to digest; consuming diet before complete digestion of
earlier diet; frequent and excessive intake of curd and
day sleep. Thyroxine (100 mcg) that was being used by
the patient was withdrawn one week before starting the
treatment. Tests for thyroid proles were conducted and
the patient was assessed on subjective parameters before
starting the treatment and after 45 days of treatment.
Assessment criteria: Improvement was assessed on the
basis of percentage relief observed in the presenting
complaints. Grading criterion being followed in the
institute was adopted to assess the eectiveness of the
therapy.[6] (Table 3).
Table 3: Grading criteria
a) Puness
Absent 0
Occasional 1
Peri-orbital edema in the morning, relieved later 2
Persistent 3
b) Weakness
Able to exercise without diculty 0
Able to do mild exercise 1
Able to do only mild work 2
Able to do mild work with diculty 3
Not able to do even mild work 4
Unable to do even day to day routine work 5
c) Lethargy
Doing work satisfactorily with proper vigor in
time
0
Doing work without desire but in time 1
Doing work without desire, unsatisfactorily,
with lot of mental pressure & not in time
2
Not starting any work in his/her own
responsibility, doing lile work very slow
3
Does not have any initiation & not want to work
even after pressure
4
d) Fatigue
Normal 0
Patient likes to stand in comparison to walk 1
Patient likes sit in comparison to stand 2
Patient likes to lie down in comparison with
siing
3
Patient likes to sleep in comparison with lying
down
4
e) Muscle ache
No 0
Relieved by rest 1
Not relieved by rest. Relieved by external
application
2
Requires external application and internal
medication
3
Present consistently 4
f) Dry and coarse skin
No dryness 0
Dryness after bath only 1
Dryness over all body but relieved by oil
application
2
Dryness not even relieved by oil application 3
g) Interval between two cycles
25-29 days 0
35-39 days 1
40-45 days 2
>45 days 3
h) Constipation
Frequency Consistency Straining
Once a day - 0 Shithila - 0 No - 0
Once in two days - 1 Madhyama - 1 Occasionally
Bearable - 1,
Once in three days
- 2
Kathina - 2 Frequently,
Severe - 2
Once in more than
three days - 3
Granthil - 3
37
Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):34-39
Karishma et al.: Ayurvedic Management of Hypothyroidism 1(1) 2017: 34-39
Observations and Results: Considerable improvement
was noticed in complaints as placed at Table 4.
Discussion: Thyroid hormones stimulate diverse
metabolic activities in most tissues, leading to an
increase in basal metabolic rate, may be playing the role
of Kayagni, which possess its Amshas (components) and
inuence all over the body.[7] A role of the gut bacteria
is to assist in converting inactive T4 into the active form
of thyroid hormone T3. About 20% of T4 is converted to
T3 in the gastrointestinal tract, in the form of T3 sulfate
(T3S) and tri-iodoacetic acid (T3AC). The conversion of
T3S and T3AC into active T3 requires an enzyme called
Intestinal sulfatase. This intestinal sulfatase is released
from healthy gut bacteria. Intestinal dysbiosis, an
imbalance between pathogenic and benecial bacteria
in the gut, signicantly reduces the conversion of T3S
and T3AC toT3.[8] All of these connections make it clear
that one can’t have a healthy thyroid without a healthy
gut and vice versa. Fixing the gut is the foremost step to
achieve a healthy thyroid.
Table 4: Eect of therapy on chief complaints
Complaints Before
Treatment
After
Treatment
Weight (kg) 60 56
Puness of face and
eyelids
30
Weakness 3 1
Lethargy 30
Fatigue 20
Constipation 20
Muscle ache 10
Dry and coarse skin 10
Interval between
menstrual cycles
30
Ingredients of Punarnavadi kashaya exert diverse
activities. Punarnava (Boerhaavia diusa Linn.) owing to
its Shothahara property is an excellent remedy for treating
generalized oedematous condition and its roots are
reputed to be diuretic and laxative.
[9-10]
Devadaru is Kapha
vata shamaka and acts as Deepana pachana in addition to its
immunomodulatory and anti-inammatory activity.
[11-12]
Shunthi has Agni deepana property.
[13]
Triphladya guggulu is especially indicated for the
management of Gandamala. Acharya Sushruta has
indicated Guggulu in Shotha[14] that is one of the most
commonly observed clinical manifestation in cases of
hypothyroidism. It acts on Medo vaha srotas and does
Lekhana karma (desiccation), thus might be helpful in
managing obesity which is a common presentation
of hypothyroidism.
It also possess anti-inammatory
property.
[15]
Animal studies have reported a ketosteroid
isolated from oleoresin of Guggulu showed a strong
thyroid stimulatory action.[16] It is also found to have anti-
oxidant eect because of Gugglusterone that counters
oxygen free radicals.[17] Kanchanara possesses anti-
oxidant, anti-inammatory, and immuno-modulatory
activities.[18]
Agnimandya (impaired digestive functions) is the
causative factor as well as one of the consequences of
Hypothyroidism. It leads to the formation of Ama, which
initiates auto-immune responses in the body. Trikatu
through its Deepana properties,[19] help in maintaining
Agni, thus preventing further formation of Ama.
Triphala supports healthy digestion and absorption.
[20] It is a powerful antioxidant, protect cells from the
damage of free radicals.[20] Constipation, a symptom
in Hypothyroidism, can impair hormone clearance
and can elevate oestrogen levels, which in turn raises
thyroid binding globulin levels and decrease the levels
of thyroid hormones in the body.[8] Triphala can prove
to be benecial in avoiding constipation, thus help in
maintaining physiological levels of thyroid hormones.
Vitamin-C is an active component of Devadaru
and Amalaki.[21-22] Studies have shown that natural
antioxidants such as vitamin-C can reverse thyroid
damage by optimizing functions of thyroid.[23] Thyroid
gland need Vitamin-C to keep it healthy.[24] Eect of
therapy on Thyroid prole also validates the role of Agni
and vitamin-C (Table 5).
38 Journal of Ayurveda Case Reports, July-Sept 2017; 1(1):34-39
Karishma et al.: Ayurvedic Management of Hypothyroidism 1(1) 2017: 34-39
Table 5: Eect of therapy on Thyroid Prole
Investigations Before
Treatment
After
Treatment
Thyroid
prole
TSH 93.250 µIU/ml 53.701 µIU/ml
T30.68 ng/ml 0.49 ng/ml
T42.550 ng/dl 1.868 ng/dl
As Hypothyroidism is caused due to the malfunctioning
of Agni and Ama; and the ingredients of trial drugs
helps in repairing them; Samata (association with Ama)
and Strotorodha (obstruction in channels) might have got
cleared that pacied symptoms of Hypothyroidism by
maintaining physiological thyroid proles.
Improved Agni might have helped in optimizing the
function of thyroid gland thus yielding positive results
not only in the subjective parameters, but also on the
objective parameters of Hypothyroidism.
Conclusion: This was a single case study that validated
the ecacy of Triphaladya guggulu and Punarnavadi
kashaya in the management of Hypothyroidism. Though
Thyroxine was discontinued, the symptoms were under
control with the current trail drugs. As the observations
are encouraging, there is a need to evaluate actual
impact of the trial drugs in larger number of patients and
draw more concrete conclusions. Awareness regarding
Ayurveda is to be drawn among the masses so that a
maximum number of suerers can utilize the services
and have the benet of an enhanced quality of life.
Source of support: Institute for Post Graduate Teaching
and Research in Ayurveda, Gujarat Ayurved University,
Jamnagar - 361008, Gujarat, India.
Conicts of interest: None declared.
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vitamins.html last accessed on Dec 12, 2016 at 4.15
PM.
TYPES OF CASE REPORTS:
Case Reports from the below areas will be considered
by the journal.
1. Disease and Diagnosis:
Case reporting on exclusive Ayurvedic
diagnosis.
Unknown / Known etiology of a disease in
Ayurvedic parlance.
Understanding a disease on Ayurvedic
principles.
Presentation of Rare disease / Features/
Arishta (Bad Prognostic Signs) as mentioned in
Ayurvedic literature.
Dierential diagnosis of an Ayurvedic disease.
Case reporting - Nidanarthakara Roga and
Vyadhisankara (Unusual Association of
Diseases).
Fault in Ayurvedic diagnosis of a disease.
Any other cases that supplement the existing
knowledge of Ayurveda and principles of
diagnosis.
2. Treatment:
Cases where Ayurvedic medicines/ therapies /
procedures provide demonstrable relief.
Cases giving new insight in Ayurvedic
management of chronic or rare diseases.
Cases providing signicant clinical outcome.
Case reports demonstrating practical
application of any of the Ayurvedic treatment
principles. (eg. Guru apatarpana in Sthaulya)
Cases worthy of discussion particularly around
aspects of dierential diagnosis, decision
making, management, clinical guidelines and
pathology.
GENERAL INFORMATION
Cases exploring myth and truth regarding
extent of Ayurvedic treatment utility in
the management of rare and auto-immune
diseases.
Unusual or unexpected eect of a therapy /
treatment including adverse drug reactions.
Cases depicting common errors of
management (related to xing doses/ timing
of drug / choosing vehicle etc.) with their
possible outcome with remedy.
Referral cases from other system of medicines
to Ayurveda.
Failure of Ayurvedic therapy / management.
Management of emergency care only by
Ayurvedic modality.
Innovative protocol for management of disease
conditions following classical Ayurvedic
guidelines.
3. Complications & Accidents:
Diagnostic / therapeutic accidents (eg. during
Panchakarma therapy)
Patient complaints / malpractices etc.
4. Adverse outcomes of Therapies:
Drug reactions during pharmaceutical
processing or during ingestion of Ayurvedic
drugs.
Adverse events of Ayurvedic drug or therapy.
Adverse Drug Reactions / Side Eects of an
Ayurvedic drug reported by a physician of
any AYUSH system of medicines.
5. Miscellaneous / Others:
Educational purpose (only if useful for
systematic review or synthesis).
Clinical situation that cannot be reproduced
for ethical reasons.
Instructions – AyuCaRe
i
Journal of Ayurveda Case Reports
WHO CAN SUBMIT:
Faculty from any stream, Research scholars, General
Practitioners of AYUSH & other systems of medicine.
PREPARATION OF MANUSCRIPT:
General Guidelines for Submission in AyuCaRe: Text
should preferably be on an A-4 size word document,
wrien in Times New Roman font with line spacing of
1.5 and font size 12 point. Margins: 2.5 cm (1 inch) at top,
boom, right, and left.
The manuscript should include:
1. Title Page with the following information:
Full names and aliations of all authors,
Name of the department and institution in which
the work was done,
Full title of the manuscript,
Running (short) title of the manuscript,
Complete address including telephone number
and e-mail of the corresponding author,
Source(s) of nancial support in the form of grants
etc., if any.
2. Article File: Don’t reveal identity of authors in
article le.
Abstract not exceeding 200 words with
Background, Brief Case Report and Conclusion.
Keywords (3 to 6).
Text Pages: The text of the article should not be
more than 2500 words. It should cover:
a. Introduction should contain scientic
rationale and reason for publishing the Case
Report.
b. Case Report should include:
i. Patient information: age, gender, ethnicity
(age at the time of diagnosis of related
medical problem if dierent from the
patient’s age)
ii. Ethical considerations, if any.
iii. Information about substance abuse
(tobacco smoking, alcohol, any other), if
applicable.
iv. Objectives for reporting the case
v. Main medical problem, co-existing
diseases
vi. Dashavidha Pariksha / Ashtavidha Pariksha /
Sroto Pariksha (as applicable)
vii. Related medication, diagnostic and
therapeutic procedures. Details of drugs
and line of therapy should precisely be
mentioned including classical references,
dose and route of administration etc.
viii. Clinical solution of the described problem.
ix. Treatment of complications, if any.
c. Discussion: Discussion should deal only with
new and / or important aspects of the study. Do
not repeat in detail the data or other material
from the sections of Background or Case
Report. Include the implications of the ndings
and their limitations, including the application
in future research. Discussion should confront
the results of other investigations especially
those quoted in the text. All the ideas expressed
in discussion should be supported by classical
reasoning and aptly referenced.
d. Conclusions: State new hypotheses when
warranted. Include recommendations when
appropriate. Unqualied statements and
conclusions not completely supported by the
obtained data should be avoided.
e. Acknowledgment: Acknowledge all
contributors who do not meet the criteria
for authorship, such as technical assistants,
writing assistants or head of the department/
institute who provided only general support.
Financial and other material support (if any)
should be disclosed and acknowledged.
f. Conicts of Interest: Should be disclosed, if
any.
g. Images: Submit good quality colour images
(as applicable) of high resolution in any
format; but JPEG is most acceptable.
h. References: To the best possible extent,
references should be from authentic sources.
Avoid abstracts or review papers as references.
Unpublished observations and personal
communications cannot be used as references.
If essential, such material may be incorporated
in the appropriate place in the text.
Up-to-date referencing consecutively as they are to be
cited in text. References rst cited must be numbered
Instructions – AyuCaRe ii
so that they will be in a sequence with references cited
in the text. List all authors when there are six or fewer;
when there are seven or more, list the rst three, then
“et al”.
The following are a few examples:
Standard journal article: Silman A., Kay A.,
Brennan P. Timing of pregnancy in relation to the
onset of rheumatoid arthritis. Arthritis Rheum.
1992;35(2):152–155.
Book(s), as Author: Valiathan MS. The Legacy of
Caraka. 1st ed. Chennai: Orient Longman; 2003.
Book(s), Editors / Compilers as authors: Acharya
Y.T., editor. Charaka Samhita of Agnivesha,
Chikitsa Sthana; Vatashonita Chikitsa: chapter 29,
verse 19-23. Chaukhamba Surbharati Prakashan;
Varanasi: 2011. p. 628. reprint 2011.
If the reference is quoted from a commentary of
original text: Acharya Y.T., editor. Commentary
Ayurveda Dipika of Chakrapanidaa on
Charaka Samhita of Agnivesha, Chikitsa Sthana;
Vatashonita Chikitsa: chapter 29, verse 19-23.
Chaukhamba Surbharati Prakashan; Varanasi:
2011. p. 628. reprint 2011.
Chapter in a book: Phillips SJ, Whisnant JP.
Hypertension and stroke. In: Laragh JH, Brenner
BM, editors. Hypertension: pathophysiology,
diagnosis, and management. 2nd ed. New York:
Raven Press; 1995. p. 465-78.
Conference proceedings: Kimura J, Shibasaki
H, editors. Recent advances in clinical
neurophysiology. Proceedings of the 10th
International Congress of EMG and Clinical
Neurophysiology; 1995 Oct 15-19; Kyoto, Japan.
Amsterdam: Elsevier; 1996.
Conference paper: Bengtsson S, Solheim BG.
Enforcement of data protection, privacy and
security in medical informatics. In: Lun KC,
Degoulet P, Piemme TE, Rienho O, editors.
MEDINFO 92. Proceedings of the 7th World
Congress on Medical Informatics; 1992 Sep 6-10;
Geneva, Swierland.
Web references: The full URL should be given
along with the date and time when the reference
was last accessed.
Other general instructions to be followed while
preparing the manuscript:
All Ayurvedic, Sanskrit, Regional language terms
should be italicized.
Plant names are also to be in italics with rst leer
capitalized.
Precise nearby translation of Ayurveda terms into
English words is not always possible. Some terms
would require short description as parenthesis
or footnote for beer understanding of readers
of non-Ayurvedic background. Authors are
suggested to use common medical terminology for
obvious terms. Authors can use ‘Tilde’ (~) sign for
use of approximately nearer terms. For example,
Vamana Karma (~Therapeutic Emesis). The sign (~)
indicate that, though the ‘Vamana Karma’ is nearer
to ‘Emesis’ it sparingly / cautiously diers from the
laer and the term used in the bracket is just for
the understanding of readers. Please use standard
spelling while transliterating Sanskrit words. (eg.
Vijyana)
Tables:
Tables should be self-explanatory and should not
duplicate textual material.
Tables with more than 10 columns or 25 rows are
not acceptable.
Number the tables in Hindu-Arabic numerals (1,
2, 3,.......) consecutively in the order of their rst
citation in the text and supply a brief legend for
each.
Explanatory maer should be placed in the
footnotes and not in the heading of the table.
All non-standard abbreviations used in tables
should be explained in footnotes.
Permission for all fully borrowed, adapted, and
modied tables should be obtained and credit
should be given for each in the footnotes.
For footnotes use small English alphabets (a, b,
c,……).
Tables with their legends should be placed after
the references in ‘Article File’.
Mark the point of insertion of Tables in the text.
e.g. [Table 1]
Instructions – AyuCaRe
iii
Illustrations (Figures):
Please do not include images in ‘First Page’ or
Article’ les. These should be submied separately
as an aachment to e-mail. Captions for gures are
to be included in the last page of the manuscript.
Mark the point of insertion of images in the text.
e.g. [Figure 1]
The uploaded le size should not be more than 3
MB.
High resolution images should be uploaded
preferably in JPEG format.
Please ensure that the digital image has minimum
resolution of 300 dpi or 1024 x 780 pixels.
Figures should be numbered consecutively in the
order that they have been rst cited in the text.
Labels, numbers, and symbols in the images
should be clear and of uniform size.
Leering in gures should be large enough to be
legible after reduction to t journal printed column
width.
Symbols, arrows or leers used in photomicrographs
should contrast with the background and should
be marked neatly.
Detailed explanations for illustrations should be in
the legends and not on the illustrations themselves.
When graphs, scaer-grams or histograms are
submied, the numerical data on which they are
based should also be supplied if asked for.
Photographs and gures should be trimmed to
remove all unwanted areas.
If photographs of individuals are used, they must
be accompanied by wrien permission to use the
photograph. If photographs of face are required, it
should be masked so as to conceal the identity of
the patient.
If a gure has been published elsewhere, the
original source should be acknowledged and
wrien permission from the copyright holder to
reproduce the material should be submied to the
journal. A credit line should appear in the legend
for such gures.
The Journal reserves the right to crop, rotate,
reduce, or enlarge photographs to an acceptable
size.
Soft copies of sharp, glossy, un-mounted, color
photographs should be uploaded at the time
of submiing manuscripts. Print outs of digital
photographs are not acceptable.
Legends for illustrations: Legends (maximum 30 words,
excluding the credit line) for illustrations should be
typed out or printed using double spacing, with Arabic
numerals corresponding to the illustrations. When
symbols, arrows, numbers, or leers are used to identify
parts of the illustrations, each should be identied and
explained in the legend. The internal scale (magnication)
and methods of staining in photomicrographs should be
mentioned.
REVIEW PROCESS:
Manuscripts will be evaluated on the basis that they
present new insights to the investigated topic, are likely
to contribute to a research progress or change in clinical
practice or in thinking about a disease. It is understood
that all authors listed on a manuscript have agreed to
its submission. The corresponding author by checking in
all legal notices during the submission process signies
that these conditions have been fullled.
The received manuscripts will be examined rst at
the AyuCaRe oce for its suitability to be published.
Manuscripts with insucient priority for publication
will be rejected promptly. Incomplete submissions
or manuscripts not prepared in the structure will not
be sent for peer review until the correct and complete
submission has been provided.
Authors will be notied with a reference number upon
receiving a manuscript at the Editorial Oce. Such
manuscripts will be blinded and sent to independent
experts for scientic evaluation. Comments and
suggestions received from the reviewers will be
conveyed to the corresponding author. Corresponding
author(s) should provide point by point response to
the reviewer’s comments in a reply template when
submiing revised versions of their manuscript. This
process will be repeated till reviewers and editors
are satised. Based upon the revisions; status of the
manuscript (accepted or rejected) will be communicated
to the corresponding author(s).
The papers accepted in this review process will be
considered for publication. Authors should return a
Instructions – AyuCaRe iv
corrected paper within 1 to 6 weeks. The rst round peer
review process will usually take about 6 to 8 weeks.
Publication Charges: No processing / publication
fee will be charged by the journal.
Publication format:
Journal of Ayurveda Case Reports (AyuCaRe) will
be published quarterly (4 issues per year) in hard
copy. e-version can be accessed on www.aiia.co.in
Complementary copies will be provided to all
the authors and co-authors whose articles are
published in the journal.
PATIENT CONSENT:
Properly signed informed consent from patients
(or relatives / guardians as applicable) must for
submiing Case Reports to the journal. Please
anonymize the patient’s details as much as
possible. If the patient is deceased, the authors
must seek permission from the next of kin. If it is
not possible to get signed consent from the next
of kin, the head of the medical team / hospital or
legal team must take responsibility that exhaustive
aempts have been made to contact the family and
that the paper has been suciently anonymized
not to cause harm to the family. This is required to
upload a signed document for this eect.
PUBLICATION ETHICS:
Journal takes publication ethics very seriously
and abides by the best practice guidance of
the Commiee on Publication Ethics. The
Corresponding Author has the right to assign on
behalf of all authors and does assign on behalf
of all authors, a full assignment of all intellectual
property rights for all content within the submied
case report in any media known now or created
in the future, and permits this case report (if
accepted) to be published in AyuCaRe and to be
fully exploited within the remit of the assignment
as set out in the assignment which has been read.
Every article will be screened on submission and
the ones that are deemed to overlap more than
trivially with other publications will be rejected
with no right of appeal.
SUBMISSION OF NEW MANUSCRIPT:
Sending the manuscript to the AyuCaRe: Editors of
AyuCaRe currently accept only electronic submissions
via e-mail. Manuscripts can be submied by sending the
copies as an aachment to the Editor, AIIA Journal of
Ayurveda Case Reports, New Delhi through an email at
aiiaayucare@gmail.com
SUBMISSION OF REVISED MANUSCRIPT:
The revised version of a manuscript should be
subm