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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 33  |  Issue : 1  |  Page : 45-48

An approach to avascular necrosis by Saghṛta kṣīrabasti


Department of Panchakarma, KLEU's Shri BMK Ayurveda Mahavidyalaya, Belgaum, Karnataka, India

Date of Web Publication18-Jun-2014

Correspondence Address:
Suma S. S Joshi
Department of Panchakarma, Shri J.G. Co.Society's Ayurvedic Medical College and Hospital, Ghataprabha, Belgaum (Dist.) Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0257-7941.134602

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  Abstract 

A 62-year-old, male patient radiologically diagnosed as a case of avascular necrosis of femur head with grade 4, presented the following chief complaints. Pain in the left hip joint radiating to thigh (anterior part), of grade '9' on “visual analog scale (VAS)” associated with swelling in bilateral feet and decreased range of movements in the hip joint. This presentation was correlated with Asthi-majjagata vāta (musculo-skeletal disorder) and treated accordingly. Initially, patient had been administered dīpana and pācana followed by nityavirecana (therapeutic purgation). Further Saghrita kīrabasti (medicated enema prepared with milk and ghee) was administered in kalābasti schedule (16 in number). This resulted with relief of pain to grade “3” on “VAS” and complete resolution of pedal edema and improvement in range of movement of hip joint.

Keywords: Asthi-majjagata vata, avascular necrosis of head of femur, Saghrita ksheerabasti


How to cite this article:
Chaganti S, Sanipeti RV, Joshi SS. An approach to avascular necrosis by Saghṛta kṣīrabasti. Ancient Sci Life 2013;33:45-8

How to cite this URL:
Chaganti S, Sanipeti RV, Joshi SS. An approach to avascular necrosis by Saghṛta kṣīrabasti. Ancient Sci Life [serial online] 2013 [cited 2019 Oct 22];33:45-8. Available from: http://www.ancientscienceoflife.org/text.asp?2013/33/1/45/134602


  Introduction Top


Avascular necrosis (AVN) is a progressive disorder with surgical intervention as the prime choice. A patient presented to us had grade 4 presentation and advised for surgery. In this acute stage, the case was well managed and relieved significantly by Saghta kīrabasti. Going by the results presented here, it can be safely con cludedthat, AVN can be treated effectively with ayurveda approach which is non-invasive in nature.

AVN is a condition affecting different bones as a result of transient/permanent loss of blood supply to the bones. Eventual collapse of the bone tissue and its death is the resultant of the ischemia along with its overlying joint surface.[1] Necrosis is caused due to the arterial occlusion[2] and femoral head is the most commonly affected area. Most of the patients presenting this diagnosis are in their third or fourth decade of life with increased ratio in females.[3] Symptoms of AVN of femoral head are presented by groin or hip pain radiating to buttocks, anteromedial thigh or knee that is aggravated by weight-bearing and sometimes by coughing. Progressive increase of the pain worsens with time and use, patient experiences pain on rest which may be worse during night and may have association with morning stiffness.[2]

Asthi-majjagata vāta, vātavyādhi, occurs due to the vitiated vāta doa residing in asthi (bones) and majjā (marrow).[4] It presents with the clinical features as bhedo-asthiparvaā (breaking type of pain in bones), sandhishūla (joint pain), satata ruk (continuous in nature), sabalakaya (loss of strength and muscles weakness) and asvapna (disturbed sleep), which correlates with symptoms of AVN. Administration of snehana (oleation therapy) both external and internal form is the best treatment modality. External administration is performed by abhyaga (massage) with medicated oils, internally it is administered in the form of pāna (internal oleation through oral route) and basti (oleation through rectal route).[5] Therapeutic enemas in painful diseased conditions of basti-vakaa-pārshwa-uru-parwa-asthi (anatomical land marks indicating lower part of the body) is the precise approach, which are administered in the form of Saghta kīrabasti (milk infusions processed with ghee).[6]


  Case report Top


This is the case report of a 62-year-old, non-diabetic and non-hypertensive who presented with pain since one year in the left hip radiating to left anterior thigh. The pain was continuous in nature and used to aggravate during walking and night hours, with rest as relieving factor. Transient relief was found in conventional treatments with recurrence with intensified pain, weakness in left lower limb and swelling in the feet after few days. His condition gradually worsened and he developed inability to walk without support. Surgical intervention was advised, which the patient refused and approached Ayurvedic treatment for the condition.

Personal history revealed mixed diet, reduced appetite, irregular and constipated bowel and disturbed sleep (due to pain). He has habit of chewing tobacco and drinking since 40 years.

Systemic examination

Locomotor system findings were unable to be elicited because of complete arrest of range of movements and severe pain in the hip joints. Inspection revealed non-pitting type of pedal edema associated with blackish discoloration and local rise of temperature. Patient had normal muscle bulk and tone. Cardiovascular and respiratory systems were in normal limits.

Investigations

Magnetic resonance imaging revealed - AVN of both hip joints, grade 4 of the left hip joint.

Treatment schedule

Dīpana ~carminative and pācana ~digestive treatment was adapted by administration of hingvaṣṭka cūra[7] (half teaspoon thrice a day) and śuṇṭhi kaāya[8] (40 ml twice a day) for 2 days in order to relieve āma (a state where metabolism is hampered) symptoms such as jihvāliptatā (coated tongue), aruci (lack of appetite and lack of interest in food), agagauravatā (heaviness in the body) and malabaddhatā (irregular and constipated bowel habits). The treatment was aimed at āmapacana (digestion of āma) and vātānuolamana (downward movement of vāta dos.a) effect.

Pādaśotha (pedal edema) confirmed the increased kledagua (increased fluidity) and kapha in the body causing srotorodha (obstruction of channels). Hence nityavirecana (regular therapeutic purgation) was planned with harītakī cūra (powder of Terminalia chebula 5 g) + gomūtra (cow's urine) (50 ml) for clearing srotorodha which resulted in relief of pedal edema.

Jihvā aliptatā (tongue not being coated) dehalāghavatā (lightness in the body), agnidīpti (increased appetite), vātānulomana and relief in pedal edema suggests nirāmāvasthā (corrected state of metabolism).

Later Saghta kīrabasti (therapeutic enema) was planned from 5th day in the following [Table 1] and [Table 2] pattern:
Table 1: Basti

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Table 2: Basti pattern (therapeutic schedule pattern)

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After Basti pain intensity reduced, improvement in strength and range of movements was observed.

Outcome and follow-up

Pain, pedal edema and range of movements were assessed. Pain is assessed by using visual analog scale (VAS), where “0” is no pain and “10” is severe pain. Circumference of the feet in inches was measured before and after the treatment to assess the swelling. Range of movements assessed subjectively.

Pain

On the day of admission, pain graded as “9” on VAS. After administration of carminatives and regular therapeutic purgative, pain reduced to grade 8. During the course of basti treatment assessment of pain grading is depicted in the graph every day [Graph 1]. [Additional file 1]

Swelling

On the 1st day, circumference feet, was around 27 in. After nityavirechana swelling was reduced and circumference measured about 23.5 in.

Range of movements

Initially, the patient was moving on wheel chair. At the time of discharge, he started walking with support which signifies improvement in strength and range of movements.

Advice on discharge

Amtottara kaāaya,[10] 15 ml 3 times a day with equal amount of warm water, does āmapacana (digests the āma) and vātānulomana. Kaiśor guggulu[11] one tablet thrice daily, possesses śothahara property (capacity to reduce edema) and rasāyana (rejuvenator) effect and advised with anupāna of Mahāmañjiṣṭhādi kaāya.[12] Mahāmañjiṣṭhādi kaāya is recommended for rakta prasādana (improveing circulation and favoring regeneration of tissue) and relieves prasupti (tingling sensation). Sahacaarādi kaāyam[13] is the medicine that is prescribed in conditions like siragata vāta (vāta doa taking shelter in vessels) and administered one tablet thrice daily. Guggulutiktaka ghta[14] mainly indicated in asthi (bony tissue), sandhi (joints), majjāgata vikāras (diseases of bone marrow). It also contains tiktarasapradhānadravya (drugs predominant in bitter taste), possesses Pthvī mahābhuta (earth element) which helps in bone formation and nourishment hence administered 20 ml twice daily with milk before food as śamana sneha (palliative oleation).

Follow-up after 15 days

During the follow-up, patient presented with a significant improvement by subjective assessment and second course of Saghta kīrabasti (therapeutic enema) with above same medicines was administered.


  Discussion Top


AVN is a pathologic condition that results from temporary or permanent loss of blood supply to the particular part, frequently affecting the femoral head. Though pathophysiology of AVN of the femoral head has been poorly understood, following mechanisms can theorized as the causes: [15]

  • Vascular occlusion: Due to direct trauma (e.g. fracture and dislocation), non-traumatic stress and stress fracture, there will be an interruption of the extra osseous blood supply
  • Altered lipid metabolism: Lipid-level-lowering drugs in animals showed reversal of lipid deposition in the femoral head
  • Intravascular coagulation: Coagulative disorders have been implicated in the pathogenesis of AVN
  • Healing process: Repair process triggered by necrotic bone which includes osteoclasts, osteoblasts, histiocytes and vascular elements. There will be new bone formation over the dead bone and forms a thick layer on the dead bone which prevents revascularization of the dead/necrotic bone
  • Mechanical stress: Animal studies have shown an association between increased weight bearing and an increased incidence of AVN of the femoral head.[15]


Whatever may be the reason, prime pathology involves the reduction in blood supply to the femoral head. Which can be inferred in Ayurvedic pathogenesis as follows: Rakta dhātu (blood tissue) supply to the femoral head is decreased. It leads to decreased nutrition supply to that part and reduction in its density (asthidhātukāya). As majjā (bone marrow) resides in asthidhātu, it may further result in majjādhātukaya.

Higvaṣṭaka cūra and śuṇṭhi kaśāya were administered to increase the appetite as they contain ingredients such as higu (Ferula northax), trikau (pippali - Piper longum, marīca - Piper nigrum, śuṇṭhi-Zingiber officinale), ajamoda (Apium graveolens), saindhava, jīraka (Cumium cymium), kṛṣṇa jīraka (Carum carvi) - which predominate in kau rasa (pungent taste), usha vīrya (hot in potency). These qualities increase jaharāgni (digestive power) and help to regulate apāna vāyu (a type of vāta doa) in downward direction. Involvement of rasadhātu duṣṭ (1st body tissue) and kleda (increased fluidity) was evident by pādaśotha (pedal edema). Hence nityavirecana was planned with harītakī cūr (powder of Terminalia chebula) and gomūtra (cow's urine). Harītakī is kaāya pradhāna (predominant in astringent taste) pañcarasa, uṣṇa vīrya, rūka ga pradhāna (predominant in drying property) and anulomaka (facilitates downward movement). Gomūtra is kau, tikta (bitter taste), kaāya rasa (astringent taste), uṣṇa vīrya (hot in potency) and lekhana (scraping action). After nityavirecana, pādśotha and constipation were relieved.

Tiktaka kīrabasti was planned for strengthening of asthi dhātu. Tikta rasa is predominance of Vāyu and Ākāśa Mahābhūta. Hence, it has got affinity toward the body elements like Asthi which has same mahābhautika tattva (subtle constituents of matter). Most ingredients of Guggulutiktaka ghta that is administered for anuvāsana basti (retention enema) have tikta rasa, uṣṇa vīrya and madhura (sweet) and kau vipāka favors normal functioning of dhātvagni (metabolic stage), facilitating increased nutrition of the asthi dhātu (bony tissue). As a result, degeneration of asthi and majjā dhātu reduced helping its regeneration. Ghta (ghee) is vāta-pittashāmaka (reduces vāta and pitta doa), balya (increases body strength), agnivardhaka (increases appetite as well as metabolism), madhura, śīta vīrya (cold in potency). Thus, it pacifies vāta; improves the dhātu upacaya (metabolism of the tissues) and acts as a rejuvenator of the body. Ghta has the properties of saskarāsya anuvartana (that which inherits the properties of other drugs without altering itself) precipitating bio-availability of other drugs. Ghta also contains vitamin D which plays an important role to utilize calcium and phosphorous from blood and helps in bone formation.[16] Thus, helps in the samprāpti vighaana (breaking down of pathology) of the ashti-majjāgata vāta. Niruha basti (a type of enema evacuation enema) containing kīra (milk) as the main ingredient is called as kīrrabasti. Kīra has madhura and snigdha (having oleation property) properties which help to control vāta doa and acts as bhmaa (nourishing). Research studies on kīrabasti proved to be efficacious in asthi-kshaya (osteoporosis) conditions.[17] The kalka dravya manjista possess madhura (sweet), tikta (bitter) and kaāya (astringent). The uṣṇa quality allows the herb to penetrate into the cellular level of the tissues and helps in blood purification and cleansing of the lymphatic system. Mañjiṣṭ maintains normal blood pressure and favors smooth blood flow.[18] The other kalka dravya arjuna is kaāya rasa (astringent), śīta vīrya (cooling). It pacifies kapha and pitta. The kaāya rasa is sandhānakara (improves the compactness) in nature. Its usage with milk has been mentioned by the Ācāryas as asthi-sandhānakara. The bark of the Arjuna tree contains nutrients such as calcium helps bone regeneration. It enhances the elimination of cholesterol by accelerating the turnover of low density lipoprotein-cholesterol in the liver and lowers beta-lipoprotein lipids and the recovery of high density lipoprotein components in hyperlipidemia.[19] Thus, it prevents the deposition of lipids in the femoral head which increase the patency of vessels for increased circulation. It helps in reversing the hardening of the blood vessels. Thus the whole formation acts at different levels.

At the end of treatment, patient had complete relief of pedal edema, increased strength and range of movements, walking witnessed with support. Pain intensity reduced and graded as “3” on VAS.


  Take home message Top


It can be concluded that AVN can be well managed by Saghta kīrabasti as results show in the present study.

 
  References Top

1.Schoenstadt A. Avascular necrosis. Available from: http://www.bones.emedtv.com/avascularnecrosis/avascular-necrosis.html. [Last updated/reviewed on 2008 Nov 05].  Back to cited text no. 1
    
2.Aiello MR. Avascular necrosis of the femoral head. Available from: http://www.emedicine.medscape.com/article/386808. [Last accessed on 2008 Aug 01].  Back to cited text no. 2
    
3.Aldridge JM 3 rd , Urbaniak JR. Avascular necrosis of the femoral head: Etiology, pathophysiology, classification, and current treatment guidelines. Am J Orthop (Belle Mead NJ) 2004;33:327-32.  Back to cited text no. 3
    
4.Trikramji AJ, editor. Charaka Samhita. 28 th Adhyaya 33 rd shloka Chikitsasthana. 5 th ed. Varanasi: Chaukhambha Sanskri Sansthan; 2006. p. 617.  Back to cited text no. 4
    
5.Trikramji AJ, editor. Charaka Samhita. 28 th Adhyaya 93 rd shloka Chikitsasthana. 5 th ed. Varanasi: Chaukhambha Sanskri Sansthan; 2006. p. 621.  Back to cited text no. 5
    
6.Trikramji AJ, editor. Charaka Samhita. 29 th Adhyaya 88 and 89 th shloka Chikitsasthana. 5 th ed. Varanasi: Chaukhambha Sanskri Sansthan; 2006. p. 631.  Back to cited text no. 6
    
7.Shastri SA, commentator. "10 th Adhyaya 59 th shloka". Bhaishajya Ratnavali. Hindi translation. Varanasi: Chaukhambha Sanskrit Samsthana. p. 242.  Back to cited text no. 7
    
8.Gopinath GB. In: Rasavaidya Nageendas Chaganlal Shah, editor. Bharat Bhaishajya Ratnakara. 1 st ed. Part 5. Yoga No. 7232. New Delhi: Motilal Banarasidas; 1928-37. p. 13.  Back to cited text no. 8
    
9.Vagbhata's Astanga Hradayam, Text with English Translation, Translated by Prof. KR Srikantha Murthy. 2 nd ed., Vol. II. 19 th Ch. 2 nd to 7 th shloka. Chikitsasthana. Varanasi: Krishnadas Academy; 1995. p. 472.  Back to cited text no. 9
    
10.Nishteshwar K, Vidyanath R, editors. "Kashaya Prakarana". Sahasrayoga. English translation. Varanasi: Chaukhambha Krishnadas Academy. p. 4.  Back to cited text no. 10
    
11.Chandra Murthy HP, editor. 7 th Adhyaya Madhyama Khanda 70-81 shloka. Sharangadhara Samhita. English commentary. Varanasi: Chaukhambha Sanskrit Series Office. p. 187-8.  Back to cited text no. 11
    
12.Chandra Murthy HP, editor. 2 nd Adhyaya Madhyama Khanda 137-42 shloka. Sharangadhara Samhita. English commentary. Varanasi: Chaukhambha Sanskrit Series Office. p. 135-6.  Back to cited text no. 12
    
13.Kunte AM, Navre Shastri KR, Vaidya HP, editors. 21 st Adhyaya Chikitsasthana 56 th shloka. Astanga Hradaya. Sanskrit commentary. Varanasi: Krishnadas Academy. p. 726.  Back to cited text no. 13
    
14.Kunte AM, Navre Shastri KR, Vaidya HP, editors. 21 st Adhyaya Chikitsasthana 58-61 shloka. Astanga Hradaya. Sanskrit commentary. Varanasi: Krishnadas Academy. p. 726-7.  Back to cited text no. 14
    
15.Tofferi JK. Avascular necrosis. Available from: http://www.emedicine.medscape.com/article/333364-overview#a0104. [Last accessed on 2012 Jan 19].  Back to cited text no. 15
    
16.Akhtar B, Mahto RR, Dave AR, Shukla VD. Clinical study on Sandhigata Vata w.s.r. to Osteoarthritis and its management by Panchatikta Ghrita Guggulu. Ayu 2010;31:53-7.  Back to cited text no. 16
    
17.Sanjaya K, Subbanagouda PG. Clinical evaluation of the role of Tikta ksheera basti and Ajasthi Bhasma in the management of Astgi-Kshaya vis-à-vis osteoporosis. Ayu 2009;30:131-41.  Back to cited text no. 17
    
18.Himalya Manjistha/Manjistha. Available from: http://www.favorfinesse.com/manjishtha.shtml. [Last accessed on 2013 Apr 25].  Back to cited text no. 18
    
19.Arjuna Herb-Benefits and side effects. Available from: http://www.sweetadditions.net/health/arjuna-herb-benefits-side-effects. [Last posted on 2010 Sep 09, 06:30 am by admin, 2013 Apr 25].  Back to cited text no. 19
    



 
 
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