The Gerson Institute of Ayurvedic Medicine

Scott Gerson, M.D., Ph.D. (Ayurveda) Medical Director, Jupiter Medical Center Dept. of Integrative Medicine Division of Education and Research

Jupiter Medical Center at The Calcagnini Center for Mindfulness
1210 S. Old Dixie Highway, Jupiter, Florida 33458, Suite M-117.2

 

Lake Mary Clinic and Panchakarma Facility: at 635 Primera Blvd. Lake Mary, Florida 32746

 

 Telephone: (561) 263-MIND (6463); option #2 or (561) 510-3833

 

The Ayurvedic Approach to Amavāta (Rheumatoid Arthritis)

Rheumatoid arthritis (RA) is a chronic, disabling autoimmune disease which may affect multiple tissues and organs but principally affects movable synovial joints. The world prevalence of RA is estimated to be 0.5–1.0% and the disease is found in all populations that have been studied, with the possible exception of rural African areas. Women are affected 3x’s more often than men. The autoimmune disease process invokes inflammation usually beginning in the synovial membrane and extending to the articular cartilage and bone.

Figure 1. Normal Synovial Joint

Ayurvedic texts describe a number of diseases characterized by pain and swelling of joints i.e. arthritides. According to Ayurveda arthritides are fundamentally of three types with distinctly different etiopathology, clinical presentation and line of treatment. These three are (1) Amavāta, (2) Sandhivāta (3) Vātarakta. Note that all these designations share the common term “Vāta”. Amavāta corre­lates quite closely with rheumatoid arthritis as known in Western medicine while Sandhivāta is a pure vatika disease most closely corresponding to osteoarthritis. Vātarakta most closely correlates to gouty arthritis.

 

Among these amavāta is a chronic, often progressive, and sometimes disfiguring disease. Amavāta is classified as a difficult to cure (Krichhrasadhya) disease in Ayurveda. It is character­ized by pain and swelling of multiple joints. As the name denotes this disease is caused due to lowering of agni and accumulation of systemic ama which because of its physical similarity with kapha has an affinity for the seats of kapha (kaphasthana) principally the joints (sandhi) and conjoining with vitiated Vāta precipitates a condition of painful swelling of all joints. Because of its antigenic nature, ama acts like an autoantigen and creates autoimmune disease of the joints.

 

All the diseases affecting the locomotor system are grouped under the single name Vātarakta in Charaka, Sushruta (where it is conspicuously not even mentioned) and Vagbhata Samhita (the “Brihatrayi” or “three major writings”). Specific details regarding amavāta are sparse in all of these ancient treatises. However an elaborate description of the presentation and treatment of amavāta is found in later works including Sarangadhara Samhita, Chakradatta and Madhava Nidana.

 

The concept of ama is fundamental in understanding the Ayurvedic perspective on the pathology of rheumatoid arthritis. Ama is a toxic substance which accumulates in the body and cannot be properly digested, metabolized, or utilized. There are three types of ama:

 

1. Rasama – formed from the gastrointestinal tract from incompletely digested foods

2. Malama – formed in any of the seven dhatus from accumulated metabolic wastes

3. Doshama – formed due to a sudden disturbance of the doshas from an external cause

 

Whatever the type, ama always has certain common properties. It is apakwam (not cooked) and asiddhi (not achieved its final form). In general, ama means an unripe, uncooked, immature, and indigestible substance.

 

Amavāta

Amavāta occurs in both madhyama roga marga (intermediate path) and abhiyantara roga marga (internal path). The clinical manifestations of the disease appear in the joints, periarticular tissues, and other tissues belonging to the madhyama roga marga, including the lungs, pleura, heart, pericardium, skin, and sclerae. However the initiation of the disease occurs in annavaha srota (kostha or gastrointestinal tract), belonging to abhiyantara roga marga. Specifically the production of ama, the vitiation of Samana Vāta dosha, the manifestation of mandagni, and Vātadosha sammurchana all take place in amashaya (stomach) and pakwashaya (small intestines).

Thus interestingly amavāta which manifests peripherally in joints essentially has its origin in the gut in the form of mandagni and ama formation. Simultaneously, there is a corruption of Samana Vāta subdosha, also located in the gut.  Accordingly the principal line of treatment, particularly during early stages of the disease, is to treat the agni by langhana, dipana, pacana, and appropriate herbs and spices in order to promote the agni and exhaust ama. Thus Ayurveda makes a unique approach to the management of rheumatoid arthritis, the main target being the gut not the joints.. Fasting (langhana) and vegetarian light hot diet are useful in the early stages. In the context of chronic amavāta when ama is no longer actively forming and accumulating but the disease is persisting in the form of morbid continuum and residual permanent joint destruction, the line of management is different. In such cases, in addition to ama pacana one has to prescribe specific antiarthritic, anti-inflammatory and analgesic remedies along with physiotherapeutic and rehabilitative therapies.

Samprapti of Amavāta

As previously stated, the initiating condition of amavāta is the arising of mandagni (low agni) which leads to disrupted and incomplete digestion of food (ama). Coupled with this, there is a vitiation of Samana Vāta in the stomach and small intestines. Both of these initial conditions are the result of unhealthy dietary practices. The low and poorly functioning agni results in the formation of ama in the kostha (digestive tract). Ama then enters the blood circulation and is mobilized and carried to Kapha tissues (i.e. joints, synovial linings, heart) due to its similarity and affinity for its own gunas (snigda, guru, picchila). At these Kapha sites ama is further vitiated by Vāta dosha, becomes even more viscous and sticky, and re-enters the circulation where it now obstructs the srotas (channels) bringing nutrients to and wastes away from the joints and other affect tissues. This subsequently vitiates all three doshas and results in the condition known as amavāta. Unfortunately, mandagni produces ama and ama produces mandagni, which promotes the continuation of the disease if left untreated.

 

Flowchart: Mandagni + Samana Vāta vitiation

˅

Ajeerna (poor digestion)

˅

Formation of Ama

˅

Ama enters the Blood Stream (Amarasa)

˅

Ama relocates in Kapha Sthana (sites of Kapha, i.e. joints, synovia, heart)

˅

Sroto avarodha (blockage of rasa vaha srota, i.e. capillaries to/from joints)

˅

AMAVĀTA

 

 

Samprapti Ghatakas (Features of Pathology)

 

Dosha                          -           Vāta, Kapha

Dushya                        -           Rasa dhatu

Adhisthanam               -           Sandhi, Kapha tissues

Srotas                          -           Rasa vaha srotas

Srotodushti                 -           Sanga

Agni sthana                 -           Jatharagni, Dhatwagni, Bhutagni

Sanchara sthana          -           All sandis (joints) especially hands and larger joints

Rogamarga                  -           Madhyama and Abhiyantara rogamarga

 

 

Samanya Lakshana (Symptoms Common to All People Regardless of Constitution)

 

· Angamarda (pain in specific areas of the body)

· Aruchi (loss of appetite)

· Trishna (increased thirst)

· Alasya (loss of zest or enthusiasm for life)

· Jwara (increased body temperature)

· Apaka (low agni)

· Sandhi Stabdata, Sandhi Shoota, Sandhi Shopha (stiffness, inflammation and swelling of the joints)

 

 

In addition to these symptoms, amavāta can have many others in specific individuals including frequent urination, reduction of perspiration, hyper salivation, nausea and vomiting, constipation, flatulence. Although Vāta is the preeminent dosha involved in this condition, on the basis of doshanubandha lakshanas (signs connected to specific dosha), amavāta can be classified into three types:

 

· Vāta – will manifest with sharp, cutting pain and more digestive symptoms

· Pitta – will manifest with daha (burning sensation) throughout the body and in the joints with more intense redness

· Kapha–will manifest with more heaviness, rigidity and perhaps itching

 

 

Treatment of Amavāta (Rheumatoid Arthritis)

 

 

The treatment of amavāta consists of ten principle approaches:

 

 

1. Langhana                                6.   Snehana-Virechan

2. Swedana                                 7.   Niruha Vasti

3. Tikta-Katu Ahara                    8.   Upanaha swedana (local)

4. Deepana                                  9.   Aushadis (Medicines)

5. Pachana                                   10. Additional treatments according to predominant dosha of the disease

 

 

Generally, medicines are not given in the very acute stage because mandagni is already present and will not be able to digest food, amarasa, doshas, and medicine simultaneously. Instead, fasting (Langhana) is advised which alleviates the burden on agni by removing the food load. Fasting will also help agni regenerate and begin to digest ama and it will also relieve gurutwam (heaviness). Langhana can also be part of therapy in the non-acute stages of the condition. As amavāta is caused by both ama and Vāta, it must not be used beyond the point of ama pachana or it will cause further Vāta prakopa (aggravation).

 

 

Fomentation therapy (Swedana) is useful to pacify Vāta and Kapha doshas and lessen srotovarodha (blockage of the channels). In addition it relieves pain and swelling of the joints, heaviness of the body, and stiffness. If appropriate, swedana, virechana, and vastis are administered in the context of a complete Panchakarma regimen.

 

Use of Tikta-Katu Ahara and Aushadis (Bitter and Pungent foods and medicines) are agni-promoting, srotoshodana (channel purifying), appetite-promoting, Kapha-reducing, and creates lightness.

 

Deepana (agni-increasing) and Pachana (cooking) medicines and spices will both prevent further ama from being created and digest the existing ama in koshta, respectively.

Snehana-Virechana is widely utilized for expulsion of excessive Pitta dosha but in amavāta there is another purpose. Amavāta is the result of ama stagnated in the annavahasrota (digestive tract). Virechana karma is thebest way to evacuate the ama situated in the small intestines out of the body. This prevents further absorption of ama into the body. Eranda tailam is specified as the virechana dravya in the texts.

 

Since prakopa of Vāta dosha is part of the cause of amavāta, vasti karma is strongly advocated. Only niruha (decoction-based) and not anuvasana (oil-based) vastis are advised. The aim is to simultaneously reduce and remove both Vāta and ama. Many herbal medicines are used for the niruha vastis, with dashmoola and guduchi being common.

 

Local application of heat through pinda sweda (local application of hot boluses of milk, cooked rice and herbs) and other forms of lepa (poultice) application can be very helpful in opening srotasmi serving affected joints, relieving pain, improving circulation, and reducing swelling.

 

Which brings us to medicinal preparations. There are several mercury, mineral and metal-containing preparations which although are safe and effective when properly manufactured and administered, are illegal in the United States so will not be included here.

 

 

Some of the more common preparations are combinations of guggulu gum resin (Commiphora mukul) with other herbs. They are generally taken in tablet form in dosages of 2-3 grams 3x’s/day:

 

Ø Yogaraj Guggulu

Ø Kaishore Guggulu

Ø Simhanad Guggulu

Ø Rasna Guggulu

 

 

Other preparations are taken as kwaths (decoctions) made by boiling 3-4 grams of powdered herb in 240 ml. of water:

 

Ø Panchakola kwath

Ø Maharasnadi kwath

Ø Dashmoola kwath

Ø Guduchyadi kwath

Ø Panchtikta kwath

 

Powdered herbs are another dosage form for select plant medicines:

 

Ø Rasna

Ø Bhallataka

Ø Gaurakha (Dalbergia lanceolaria)

Ø Ashwagandha

Ø Yastimadhu

Ø Copacini (Smilax china)

Ø Pippali

Ø Eranda brista Haritaki (Haritaki powder cooked in eranda tailam)

Ø Vatsanabhi (Aconitum ferox)

Ø Maricha (Piper nigrum; black pepper)

Ø Haritaki (Terminalia chebula)

Ø Trivrit

Ø Shallaki (Boswellia serrata)

 

 

External Lepas (Poultices)

 

Ø Datura lepa

Ø Eranda lepa

Ø Arka lepa

Ø Mustard Seed lepa

 

 

Pathyapathya in Amavāta (Foods to Favor and Reduce)

 

The notion that food can modify the course of rheumatoid arthritis has long been rejected by Western medicine as foolish and even quackery. However, Ayurvedic physicians have known for generations that foods definitely affect inflammation—the critical process in amavāta.

 

Although it is not possible to develop a standard “amavāta diet” for all individuals due to constitutional differences and idiosyncratic features of the disease in each person, the foods which help or provoke symptoms in the greatest percentage of people can be identified.

 

 

Foods to Favor (Pathya)

 

• Bitter gourd                                        • Coconut water

• Loki (a type of vegetable)                  • Coconut milk

• Barley                                                 • Carrot juice

• Amaranth                                            • Beetroot juice

• Old rice                                               • Squash (all species)

• Buttermilk                                          • Zucchini

• Ginger                                                 • Pumpkin

• Cinnamon                                           • Leafy green salad

• Cardamom                                          • Kichadi

• Turmeric                                             • Garlic

 

Foods to Reduce (Apathya)

 

• Yogurt              • Cauliflower        • Black gram         • Okra                  • Cold Beverages

• Beef                  • Broccoli             • White potato       • Cola drinks       • Tea

• Poultry              • Cabbage             • Ice cream            • Caffeine            • Dried Fruits

• White sugar      • Spinach              • Chocolate           • Alcohol             • Bacon/Pork

 

 

Conclusion

The fundamental perception of amavāta/rheumatoid arthritis is very different in Ayurveda versus Western medicine. From the Ayurvedic perspective, until ama can be removed, agni restored and Vāta dosha normalized, no treatment method—conventional or holistic—will be effective.

The modern, conventional treatment for rheumatoid arthritis includes some combination of steroids (usually prednisone), antimetabolites (usually methotrexate), Tissue Necrosis Factor agents (e.g. Humera, Embrel) and sometimes a non-steroidal anti-inflammatory drug (to relieve pain) and an accompanying antacid (to treat the gastric side effects of all four of these). Although this treatment can often relieve joint pain and inflammation and slow or halt the disease process, they all have significant side effects.

Although the dietary, herbal, and purification approaches of Ayurveda may not be sufficient to stop all Western anti-inflammatory and immunosuppressant medicines in all cases, these treatments will in many cases improve the well-being and function of people experiencing amavāta symptoms and may allow for the reduction of dosages of the conventional medicines. Continuing research on this condition is revealing new aspects of therapies, building upon the ancient textual prescriptions, which are encouraging.