A Clinical Study Based on Ayurvedic Intervention in the Management of Ankylosing Spondylitis: A Case Report

Introduction

Ankylosing Spondylitis is characterized by inflammatory back pain that is typically subacute in onset and starts before the age of 45 years. Ankylosing Spondylitis is an autoimmune disease that mainly involves spine joints, sacroiliac joints and their adjacent soft tissue, such as tendon and ligaments. Inflammation at these sites results in new bone formation leading to the typical AS features of bridging and fusion of joints and ankylosis of the spine. Radiographic changes characteristically affect the sacroiliac joints and may involve variable levels of the spine [1]. As the disease progressed resulting in fibrosis and calcification of bone patients have symptoms like loss of flexibility and fusion of spine there is a name given to this type of symptoms resembling called “Bamboo” i.e like an immobile position.

AS is a slowly progressive disease, and x-ray changes often do not appear until a decade after onset of symptoms [2]. In some people who have a clinical history consistent with AS but lack the characteristic x-ray changes, MRI can identify early inflammatory bony changes not seen on plain x-ray [3]. The prevalence of AS has a clear correlation with the human leukocyte antigen (HLA)-B27 positive rate in specific populations. Studies have revealed that in HLA-B27-positive populations, the prevalence rate of AS is ~5%-6% [4].

In contemporary medical science the disease is usually managed with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), corticosteroids and various Disease Modifying Anti Rheumatic Drugs (DMARDs), but there are limited benefits and numerous side effects associated with these drugs when given systemically for over a longer period of time. So, it is the need of the hour to look for a better mode of management for the disease in other medical sciences. Ankylosing Spondylosis in Ayurveda- The Ankylosing Spondylitis patients treated on the line of management of Amavata (Rhematoid Arthritis) in initial stage and in later stage it is treated on the basis of Asthimajja Gata Vata (disorder of bone and bone marrow).

Asthi-majja gata vata of Ayurveda is similar with AS. Asthi-majja gata vata is characterized by vitiated vata affecting Asthi dhatu (bones). Asthi-majja gata vata is characterized by the signs and symptoms like, Asthibheda (pain in bones), parva bheda (pain in inter-phalangeal joints), sandhi shoola (joint pains), mamsa kshaya (atrophy of muscles), bala kshaya (loss of strength/weakness), aswapna (lack of sleep/disturbed sleep) and satata ruk (continuous pain). Adhyasthi (fusion/ankylosis/osteophyte formation) is the manifestation of Asthi pradoshaja vikara (diseases of bones) and vinamata (deformity such as kyphosis) is the manifestation of Majjavrita vata. Snehana (oleation), swedana (sudation) and Panchakarma procedures like enema with bitter ghee are indicated in bone pathology [5]. The present case was diagnosed and treated according to Asthi-majja gata vata.

Case Presentation

In December 2023 a 42-year-old male patient presented with complain of Low back pain, cervical pain and bilateral Knee joint pain since, 1 year, associated with morning stiffness that lasted more than 1 hours, which improved with activity. Symptoms gradually intensified over the last 15 days. For these complaints initially he consulted an allopathic physician where he got temporary relief by NSAIDs and corticosteroids but the patient did not get satisfactory result and the complaints reoccurred after sometime. Then the patient switched towards Ayurvedic mode of management for further treatment.

Past medical history: included HLA-B27-positive, ankylosing spondylitis (diagnosed in October, 2023), hypertension, type 2 diabetes mellitus. Abdomen and Pelvis Ultrasound suggest Mild Hepatomegaly with fatty infiltration. No H/O any trauma, surgery or other severe illness.

On Examination: Pulse was 82/min and regular, BP - 122/84 mm of Hg, Respiratory rate - 18/min.

Systemic Examination: Physical examination revealed limited lumbar spine mobility and tenderness over the sacroiliac joints. Schober’s test was positive(<5cm), indicating restricted forward flexion. The patient exhibited decreased chest expansion. Laboratory tests showed an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). HLA-B27 testing was positive.

Investigations

i. MRI of Cervical Spine reveals Intervertebral Disc degeneration and small posterior osteophytes disc complex at C2-3, C3-4, C4-5 and C5-6.

ii. MRI of Lumbosacral Spine and Pelvic bone reveals Squaring of anterior vertebral body in lumbar and lower thoracic spine. Anterior longitudinal ligament ossification from D11 level downwards. Visible Lumbar and lower thoracic spine progresses to osseous fusion at D12-L1, L1-2, and L2-3 levels. No disc herniation or neural compression. It shows reparative fatty marrow changes of left>>right sacroiliac joint with cortical irregularity.

HLA-B27 Test: Positive

Assesement criteria: The scoring of ‘Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is adopted for assessment. To give equal weighting, the average of the two scores relating to morning stiffness is taken. The resulting 0 to 50 score is divided by 5 to give a final 0 to 10 BASDAI Score (Table 1).

The BASDAI or Bath Ankylosing Spondylitis Disease Activity Index is >4 suggest high disease activity.

Management

Prishta Basti with Murivenna Taila and Mahavishgarbh Taila and Erandmooladi Niruha Basti and Matra Basti with Dhanvantarm Taila in Karma Basti manner along with Shamana Chikitsa were given for the duration of 30 days (Tables 2 & 3).

Result

Before starting Ayurveda treatment BASDAI baseline score was 4.7 and after completion of treatment the score was reduced to 1.1 (Table 4).

Discussion

The condition was approached with classical line of treatment of Asthi Majjagat Vataas the characteristics were clearly reflecting in the symptoms mentioned by the patient.

Effect of Panchakarma Procedures

i. Prishta Basti: Prisht Basti (process of retaining a specific amount of lukewarm medicated oil on a specific area) was prescribed because it is an external local oleation and sudation. Thus, locally at Prisht Pradeshit causes Doshvilayan, Kledandue to taila application and Srotovishodhana, Swedpravartan due to its warm temperature [6]. Murivenna's ability to promote microcirculation due to its constituent composition may aid to reduce inflammation. When the qualities of each element in Murivenna were examined, it was found that the majority of them were predominantly Tikta, Katuand Madhura Rasaas well as Kapha Pitta Shamana. Animal study demonstrated neovascularization, fibroblast proliferation, pepsin-soluble collagen synthesis, and collagen turnover in wounds [7]. Mahavishgarbh Tailais very beneficial in chronic Rheumatic diseases, swelling of joints, rheumatic pain [8].

ii. Karma Basti: Erandmooladi Niruha Basti is Deepana and Lekhana in nature which helps in pacifying Kapha and reduces symptoms like heaviness and stiffness. Eranda (Ricinus communis Linn.) which is the main content of Erandmooladi Niruha Basti possess anti-inflammatory, antioxidant, analgesic and bone regeneration properties. This Basti contains 34 drugs in which most of the drugs are having Ushna Veerya and are Vatakaphahara in nature. Drugs are also possessing Ushna, Teekshna and SukshmaGuna which helps in the elimination of obstruction of Srotas which further helps in the formation of Prakrita Dhatu. It is also indicated in Kaphavrita condition, by which it played major role in pacifying the Kapha Dosha and reducing the symptoms like Stambha and Gaurava. Most of the drugs are Agni Deepaka which helped to improve the Agni of the patient, thereby increase in appetite was observed [9]. As patient was given Matra Basti of Dhanvantara Taila which is going to act as a Vatakaphahara, helping in Vatanulomana. It is said to be Sarvavatvikarhara and Bruhana in action [10].

Individual effect of Shaman drugs

i. Tryodashang Gugglu: Trayodashang guggulu act with its properties of Vedanastapana, Shoolhara and Rasayana, Madhur Vipaka, Ushna Virya. By the Ushna Virya,Snigdha guna of Madhur Vipaka it suppresses the symptoms of Stambha, Toda and reduces pain which is mentioned in Bhavprakash Samhita. Triyodashanga Guggulu is useful in Snayugatavata, Asthigatavata, Majjagatavata, Khanjavata, and various Vata disorders [11].

ii. Rasnasaptak kwath: Rasna Saptak Kwath is a formulation, which contains eight medicinal plants viz. Pluchea lanceolata, Tribulus terristris, Tinospora cardifolia, Boerrihia diffusa, Ricinus communis, Cedrus deodara, Cassia fistula and Zingiber officinalis. These herbs have the potential to treat symptoms like inflammation and pain other than that it also treats arthritis at immune and free radical level. These herbs are known for their immunosuppressive action (e.g. Pluchea lanceolata), anti-inflammatory action (e.g. Tribulus terristris,), analgesic action (ex. Ricinus communis,), and antioxidant (e.g. Tinospora cardifolia) [12].

iii. Agnitundi vati: All contents of Agnitundi Vatiare Deepan, Pachan, Vata Shamakand Shulaghna in properties due to its Ushna veerya it normalizes the function of Apana and Vyana vayu [13].

iv. Chandraprabha vati: Chandraprabha Vati is Rasayana, Balya, Tridosha Shamaka properties and also acts as catalyst [14].

Conclusion

This study demonstrates how Ankylosing Spondylitis can be treated using Ayurvedic medicine. The Shaman medications act on the vitiated Aam and Vata, while the Panchakarma treatments ease stiffness and discomfort by stimulating blood circulation and balancing Mraduta. Even though there is no known treatment for ankylosing spondylitis, Ayurveda can effectively control the disease's symptoms and progression, preventing harmful drug interactions and eventually improving the patient's quality of life.

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