Grudhrasi kc005 udp

A CLINICAL STUDY ON THE MANAGEMENT OF GRIDHRASI

WITH GANDHARVAHASTHA TAILA AND VATARI GUGGULU By

DEEPTHI. M.S.

B.A.M.S.

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment

of the requirements for the degree of DOCTOR OF MEDICINE (AYU)

GUIDE

DR.U.N.PRASAD M.D. (AYU)

PRINCIPAL

S.D.M.College of Ayurveda, Udupi CO-GUIDE

DR.JONAH.S. M.D. (AYU)

ASSISTANT PROFESSOR

S.D.M.College of Ayurveda, Udupi

DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA

S.D.M.COLLEGE OF AYURVEDA, UDUPI – 574 118

2006

I

Ayurmitra

TAyComprehended

Rajiv Gandhi University of Health Sciences

Karnataka, Bangalore

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled ‘A Clinical

study on the management of Gridhrasi with Gandharvahastha Taila

and Vatari Guggulu’ is a bonafide and genuine research work carried

out by me under the guidance of Dr.U.N.Prasad M.D.(AYU) and Co-

guidance of Dr.Jonah.S. M.D.(AYU).

Date: DR.DEEPTHI.M.S.

Place: Udupi B.A.M.S.

II

Ayurmitra

TAyComprehended



CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled ‘A Clinical study

on the management of Gridhrasi with Gandharvahastha Taila and

Vatari Guggulu’ is a bonafide research work done by Dr.Deepthi.M.S

in partial fulfillment of the requirement for the degree of Doctor Of

Medicine (Ayu).

Signature of the Co-Guide Signature of the Guide DR.JONAH.S M.D.(AYU) DR.U.N.PRASAD M.D. (AYU)

ASSISTANT PROFESSOR PRINCIPAL

S.D.M.C.A., UDUPI S.D.M.C.A., UDUPI

Date: Date:

Place:Udupi Place:Udupi

III



ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION

This is to certify that this dissertation entitled ‘A Clinical

study on the management of Gridhrasi with Gandharvahastha Taila

and Vatari Guggulu’ is a bonafide research work done by

DR.DEEPTHI M.S. under the guidance of DR.U.N.PRASAD

M.D.(AYU) and Co-Guidance of DR.JONAH.S.M.D.(AYU).

Signature of the H.O.D. Signature of Principal

DR.G.SRINIVASA ACHARYA M.D (AYU) DR.U.N.PRASAD M.D. (AYU)

Professor& Head of the Department Principal

Dept.of P.G.Studies in KayaChikitsa S.D.M.C.A., Udupi

S.D.M.C.A., Udupi

Date: Date:

IV

Place: Place:

COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka, shall have the rights to preserve, use and

disseminate this dissertation/thesis in print or electronic format for

academic/ research purpose.

Date: Signature of the Candidate

Place: DR.DEEPTHI.M.S.

© Rajiv Gandhi University of Health Sciences, Karnataka

V

ACKNOWLEDGEMENT

I sincerely express my indebtedness and deep sense of gratitude to rendered

teacher and guide Dr.U.N.Prasad, Pricipal, S.D.M. College of Ayurveda, Udupi, for his

valuable guidance and helping me in completing this work successfully. I would like to

put on record the affection and care with which my esteemed Guide directed me during

the study.

I express my deep sense of gratitude to my teacher and Co-guide

Dr.Jonah.S., Assistant professor, Department of Kayachikitsa, S.D.M. College of

Ayurveda, Udupi, for his support and guidance throughout the study.

I am ever grateful to Dr.G.Srinivasa Acharya, Prof. and H.O.D. of

Kayachikitsa Department, S.D.M. College of Ayurveda, Udupi for his encouragement,

support and helpful suggestions.

I express my sincere thanks to S.D.M. Education Society Ujire, for giving me an

opportunity for my Post Graduation Education.

I am grateful to our faculties of Kaya Chikitsa Department Dr.V.K.Shridhar

Holla, Dr.Shrilatha Kamat, Dr.Veerakumar, Dr.Lavanya, S.D.M. College of Ayurveda,

Udupi for their encouragement and support throughout the study.

I express my truthful thanks to Dr.Y. N.Shetty, Superintendent, Dr.Deepak S.M.,

Deputy Superintendent and Dr.C.S.Hegde of the S.D.M. Ayurveda Hospital, Udupi.

I am grateful to Dr.Muralidhar.B, Dr.Mohanan, S.D.M. Ayurvedic pharmacy for

providing me the medicines for my study.

I am grateful to Mr. Harish Bhat, Librarian, for providing me with all the books I

needed.

I am very much thankful to my classmates Dr Kuldeep patil, Dr.Ranjith Patil,

Dr. Ramesh.N., Dr. Magan Singh Shekawath, Dr. Shobha R Itnal for their kind

co-operation and help throughout the work.

VI

I am very much grateful to my seniors for their timely help and support and juniors

and friends for their kind co-operation.

I remember and appreciate the immense support and encouragement given by my

parents, sister Dr.Deepa Kiran, her husband DR.Kiran and other family members for the

completion of this work.

My thanks to M/S Ananth Connections and Sampark for printing and binding of

this thesis.

I thank all those who have directly or indirectly contributed to the successful

completion of the thesis work.

DEEPTHI M.S.

VII

LIST OF ABBREVIATIONS

Ch.S - Charaka Samhita

Su.S - Sushruta Samhita

AH - Ashtanga Hrudaya

BP - Bhavaprakasha

MN - Madhava Nidana

YR - Yogaratnakara

SS - Sarangadhara Samhita

HS - Harita Samhita

VIII

ABSTRACT

Gridhrasi is a Vatavyadhi, commonly seen due to changing life style and nature

of work and is characterized by Low backache with radiating pain to the foot and

with restricted movements of the spine. Gridhrasi is correlated to Sciatica in Modern

Sciences. In the present day, man expects miraculous effects with treatments which

are easily available at less cost with more efficacy and with less restrictions in routine

work Taking these into account, this study was planned to explore safe and cost

effective treatment for the patients of Gridhrasi which can give better relief and better

rate of cure. Thus Gandharvahastha Taila and Vatari Guggulu were selected to

evaluate the therapeutic effect in the management of Gridhrasi.

This is a single blind clinical study with pre test and post test design

where in 20 patients suffering from Gridhrasi of either sex between the age group of

20 and 60 years were randomly selected and subjected to the trial. These patients

were treated with Gandharvahastha Taila 10ml bd and Vatari guggulu 1gm tid for 30

days. The signs and symptoms were recorded on the proforma designed for the study

and assessment was done on weekly intervals. Results obtained were analyzed for the

statistical significance by adapting paired‘t’ test.

The study revealed that Gandharvahastha Taila and Vatari Guggulu are

found to be effective in bringing symptomatic relief and improving functional ability

in the patients of Gridhrasi.

Key words: Gridhrasi; Sciatica; Gandharvahastha Taila; Vatari Guggulu

IX

CONTENTS Page No.

1. INTRODUCTION 1-5

2. OBJECTIVES OF THE STUDY 6

3. REVIEW OF LITERATURE 7-73

4. METHODOLOGY 74-84

5. OBSERVATION & RESULTS 85-115

6. DISCUSSION 116-125

7. CONCLUSION 126

8. SUMMARY 127-128

9. BIBLIOGRAPHY 129-141

10. ANNEXURE 142-147

X

LIST OF TABLES Sl. No Tables Page no.

1. Hetu of Vataprakopa and Vatavyadhi 16

2. Symptoms of Gridhrasi 29

3. Vyavachedaka nidana 36

4. Effects of root compression 55

5. Assessment of Pain 77

6. Assessment of Neurological deficit 79

7. Assessment of Functional ability 79

8. Criteria for overall assessment 84

9. Incidence of Age 85

10. Incidence of Sex 86

11. Incidence of Marital status 87

12. Incidence of Religion 88

13. Incidence of Habitat 89

14. Incidence of Socioeconomic status 90

15. Incidence of Educational status 91

16. Incidence of Occupation 92

17. Incidence of Nature of work 93

18. Incidence of Addictions 94

19. Incidence of Dietary habit 95

20. Incidence of Prakruti 96

21. Analysis of Sara 97

22. Analysis of Samhanana 98

23. Analysis of Satwa 99

24. Analysis of Satmya 100

25. Analysis of Abhyavaharana sakthi 101

XI

26. Analysis of Jarana sakthi 102

27. A nalysis of Vyayama sakthi 103

28. Effect on Stambha 104

29. Effect on Ruk 105

30. Effect on Toda 106

31. Effect on Spandana 107

32. Effect on Aruchi 108

33. Effect on Gaurava 109

34. Effect on Tandra 110

35. Effect on Pain 111

36. Effect on Pain during the course of treatment 111

37. Effect on Neurological deficit 112

38. Effect on Neurological deficit during the course of treatment 112

39. Effect on Functional ability 113

40. Effect on Functional ability during the course of treatment 113

41. Effect on Functional disability 114

42. Effect on Functional disability during the course of treatment 114

43. Overall effect of treatment 115

XII

LIST OF FIGURES

Sl.No Figures Page no

1. Incidence of age 85

2. Incidence of sex 86

3. Incidence of marital status 87

4. Incidence of religion 88

5. Incidence of habitat 89

6. Incidence of socioeconomic status 90

7. Incidence of educational status 91

8. Incidence of occupation 92

9. Incidence of nature of work 93

10. Incidence of addiction 94

11. Incidence of dietary habit 95

12. Incidence of prakruti 96

13. Analysis of sara 97

14. Analysis of samhanana 98

15. Analysis of satva 99

16. Analysis of satmya 100

17. Analysis of abhyavaharana sakti 101

18. Analysis of jarana sakti 102

19. Analysis of vyayama sakti 103

20. Effect on stambha 104

21. Effect on ruk 105

22. Effect on toda 106

23. Effect on spandana 107

24. Effect on aruchi 108

XIII

25. Effect on gaurava 109

26. Effect on tandra 110

27. Relief on pain during the course of treatment 111

28. Relief on pain 111

29. Effect on neurological deficit during the course of treatment 112

30. Effect on neurological deficit 112

31. Effect on functional ability during the course of treatment 113

32. Effect on functional ability 113

33. Effect on functional disability during the course of treatment 114

34. Effect on functional disability 114

35. Overall effect of treatment 115

XIV

Introduction

INTRODUCTION

Diverse activities at various part of the body are the indispensable expression of

life. Grahana and dharana are accomplished by the hands, analogous to this gamana or

locomotion is achieved by the legs. Even gamana shows distinctiveness from person to

person. Unsteadiness in walking is the characteristic feature of vata prakriti. Elegant walk

is the nature of pitta prakriti. Slowness of walking is characteristic of kapha praktiti. All

these are regarded as normal distinctiveness. When the lower limbs are ailing this gamana

activity may be blemished. The style of gamana may turn to anomalous form, Gridhrasi is

a Vatavyadhi in which the gamana is aberrant and it simulates the walking style of

gridhra.

Life style has a major role in the causation of plethora of illness, and the Gridhrasi

leads the list. Owing to the growing needs, everyday life of man has changed drastically

and there seems no end to this revolution. The modern era decisively demands speed and

accuracy in once aptitude as well as activity for mere survival. To cope up with the

situation each and every person in the population at large ought to face hectic competitive

stressful life. Consequently, no surprise if one ignores the mandatory routine healthcare,

and hence, it is impossible to expect hale and health amongst people in such weird state

of affairs. Irregular food habits, suppression of natural urges, lack of proper sleep and less

time for relaxation are the enforced part of present life and also these are the factors

favoring ill health. Somewhere with in the core of this lifestyle prevails the unique cause

of Gridhrasi, which is also known by the name Sciatica in the realm of medicine.

Low backache is a prevalent Universal health problem and the Gridhrasi is

realized to be a major cause of this pain. Survey by one way or the other way is the

1

Introduction

indicator of future happenings. Epidemiology reveal progressive incidence of low back

and Sciatica. Low backpain is one of the top 10 reasons of patients seeking care from a

family physician. Acute low backpain is the fifth most common reason for all physician

visits. Low backache is second only to the common cold as a cause for visits to

physicians. 50 percent of persons in the working population have backpain every year. In

the United States, approximately 90 percent of adults experience back pain at some time

in life. In epidemiologic studies of different populations, the prevalence of low back pain

has varied from 7.6 to 37 percent. Peak prevalence is in the group between 45 and 60

years of age, although back pain is also reported by adolescents and by adults of all ages.

Most of these patients of low backache had sciatica. It is established that Sciatica is one

among the major causes of work absence in adults, badly influences the national

productivity.

Gridhrasi is a condition where the patient experiences pain primarily in the sphik

pradesha which later radiates to kati and to leg through the posterior aspect of uru, janu,

jangha and pada where the patient finds difficulty in extending the leg. Atyadhva, ati

yana, vyayama, vyavaya, dhavana, pidana, plavana, bharavahana etc are some of the

causative factor for this disease. Identical to this, Sciatica is characterized by low back

ache radiating down to legs and anterolateral aspects of foot, hence is unerringly equated

to Gridhrasi.

In the practice of conventional medicine the treatment of Sciatica is limited to

analgesics, anti inflammatory drugs, physiotherapy as well as surgical intervention in

extreme cases. Matchless to the cost of these treatments the response is never complete.

In addition to this relapse of the illness greatly enhance the gravity of the problem. On the

2

Introduction

other hand, Gridhrasi is enlisted as one among the Vatavyadhi in Ayurveda. Various

treatment modalities like Snehana, Swedana, Virechana, Basti etc are said to be

efficacious. Even specific treatments like siravyadha, agnikarma, basti etc are also

emphasised. Many samana yoga are mentioned in our classics which are proved to be

efficacious. Taila is the best among the samana aushadies for vitiated vata. Among them

Eranda taila has the property of vata samana. In Vatavyadhi in most of the occasions the

use of eranda taila is mentioned for the purpose of snehana as well as Anulomana.

Charaka mentions that koshta that has attained mrudutva by the administration of sneha

will not pave the way for the aggravation of vata. The eranda taila is mentioned in many

contexts of Vatavyadhi chikitsa. So also many samana yogas indicated in Gridhrasi

contains eranda taila as a major ingredient. In this back ground it is ideal to look into the

previous clinical research works in this regard.

About the previous RCT

• A study was done in IPGT&RA, Jamnagar in 2002 to find the efficacy of Rasna

Guggulu along with Shodhana therapy by Virechana followed by Basti karma.

The study proved Shodhana along with samana aushadhi is efficacious in

Gridhrasi.1

• A comparative clinical study was conducted to find out the efficacy of Agnikarma

and Matrabasti in Gridhrasi.The study revealed that Agnikarma and Matrabasti

have got equal effect in Gridhrasi with 44% improvement.2

• A comparative clinical study was designed to evaluate the efficacy of

Navajeevana Rasa and Rasna Guggulu in patients of Gridhrasi. This study

3

Introduction

concluded with better remission of symptoms in patients treated with

Navajeevana Rasa.3

• A single blind clinical study was carried out with pretest and post test design;

where in 20 patients of Gridhrasi were subjected to Katibasti with Vajigandhadi

Taila for a period of 6 days. The result showed best remission of the symptoms in

majority of patients, though complete cure was recorded in none.4

• The therapeutic efficacy of eranada beeja araka in patients suffering from

Gridhrasi was studied in a single blind clinical study. The medicine was

administered in a dose of 3 tsp tid for 28 days. The study recorded best

improvement in 14.28 % of patients.5

From the foregoing it is clear that, clinical trials on Gridhrasi is mosty centrerd on

bahiparimarjana chikitsa like Kati basti, different combination of vasti and oral

administration of herbo-mineral formulations. Most of these treatment modalities require

hospitalization. Contrary to this, less is explored about the drug of choice, Eranda taila as

both vatahara and anulomana and this definitely needs more detailed study. With this

view in mind, Gandharvahastha Taila and Vatari Guggulu are selected in this study which

contains Eranda taila as the main ingredient. Hospitalization is not essential for this oral

medication and is conveniently continued as domiciliary treatment and is the additional

benefit.

The present study is entitled - A clinical study on the management of Gridhrasi

with Gandharvahastha Taila and Vatari Guggulu comprises of:

● Review of Literature● Methodology● Results● Discussion

• Summary ● Conclusion.

4

Introduction

The Review of Literature consists of Ayurvedic review of the disease

Gridhrasi comprising of Vyutpathi, Nirukti, Paryaya, Nidana, Samprapti, Poorvarupa,

Rupa, Sadhyasadhyata, Vyavachedakanidana, Chikitsa and Pathyapathya of Gridhrasi.

This is followed by Modern review and then Drug review which includes the properties

of the individual drugs used in the preparation.

Next is about the Methodology of the present work. This is followed by

the complete description of assessment criteria. The descriptive statistical analysis of the

sample taken for the study is methodically elaborated. The Observation, Results and their

statistical analysis are presented in order with tables and graphs in the succeeding

chapter.

The chapter entitled Discussion includes the critical analysis of the result

obtained in the present study. The chapter named Summary and Conclusion comprises

the conclusions drawn from the present clinical research work.

5

Objectives

OBJECTIVES OF THE STUDY

1. To make a comprehensive literary study of Gridhrasi.

2. To evaluate the therapeutic efficacy of Gandharvahastha Taila and Vatari

Guggulu in bringing symptomatic relief in patients of Gridhrasi.

3. To study the functional improvement with Gandharvahastha Taila and Vatari

Guggulu in the patients of Gridhrasi.

6

Historical review

HISTORICAL REVIEW

History is a part of description of any object. Before going into detail about Gridhrasi an

attempt is made to trace the references regarding Gridhrasi in particular and Vatavyadhi

in general from the time of Vedic period.

The hisotorical period can be divided into 4 sections.

1. Vedic period

2. Pauranic period

3. Samhitha period

4. Sangraha period

1. VEDIC PERIOD (2500 BC to 500 BC)

The Vedas are considered as the oldest recorded knowledge in our culture. Gridhrasi

as such is not mentioned in Vedas.

In Atharvaveda the word ‘vatikrita’ is mentioned which denotes vatavyadhi. In

this context, Pippali (Ath.6/109/3) and Vishanika (Ath.6/49/3) have been claimed as

vatikritasya bheshaja and vatikritanashini respectively.

2. PAURANIC PERIOD

In Garuda Purana, subjects related to Ayurveda are described in detail. In this

treatise a separate chapter is available as Vatavyadhi Nidana, where Gridhrasi is

described as an entity.

3. SAMHITA PERIOD

Description regarding Gridhrasi available in various samhitas.

7

Historical review

Charaka Samhita (1000 BC):

This is the first and foremost Ayurvedic source for the detailed description of Gridhrasi.

Gridhrasi is included in the 80 types of nanatmaja Vatavyadhi in 20th chapter of

Sutrasthana termed as Maharogadhyaya.6

Description of two types of Gridhrasi as vataja and vatakaphaja has been

mentioned in 19th chapter of Sutrasthana.7

While mentioning about the indications of taila application in pada, Gridhrasi is

mentioned as one among them in Sutrasthana 5th chapter.8 The detailed symptomatology

and treatment of Gridhrasi is mentioned in the 28th chapter of Chikitsasthana named as

Vatavyadhi Chikitsitam.9,10

Sushruta Samhita (600BC – 400 BC):

The symptomatology and pathology of Gridhrasi is described in the first chapter of

Nidanasthana called as Vatavyadhi Nidana.11

Siravedha chikitsa is mentioned for Gridhrasi in Sushruta Samhita

Chikitsasthana- Mahavatavyadhi Chikitsitam12 and in 8th chapter of Sarirasthana.13

Ashtanga Samgraha (5th Century):

Gridhrasi is included under 80 types of vatavikara in Ashtanga Samgraha

Sutrasthana 20th chapter.14

The pathogenesis and symptomatology of Gridhrasi mentioned in Ashtanga

Samgraha Nidanasthana 15th chapter.15

Siravedha chikitsa in Gridhrasi is mentioned in 36th chapter of Sutrasthana.16

8

Historical review

Ashtanga Hridaya (5th Century):

The symptomatology and pathogenesis of Gridhrasi is described in the 15th

chapter of Nidanasthana.17

Site of Siravyadha in Gridhrasi is mentioned in the 27th chapter of Sutrasthana.18

Kashyapa Samhita:

Gridhrasi is included under the 80 types of vatavikara, but no other details are

available in 27th chapter of Suthrasthana of Kashyapa Samhita.19

Bhela Samhita (7th Century):

The treatment for Gridhrasi as vasti and raktamokshana is mentioned in the

26th chapter.20

4. SANGRAHA PERIOD

Madhava Nidana ( 7th Century):

In Vatavyadhi Nidana specific symptoms of the two types of Gridhrasi mentioned

as dehasya pravakrata in vataja type and mukhapraseka and bakthadwesha in vatakaphaja

type.21

Kalyanakaraka ( 8th Century):

The pathology and symptomatology of Gridhrasi is mentioned in the 8th chapter

named Vatarogadikara. The treatment is mentioned in the12th chapter named Vataroga

chikitsa.

9

Historical review

Chakradutta (12th Century):

Deals with the treatment aspects of Gridhrasi where shamana, snehana, basti and

sastra karma are mentioned under the heading of Vatavyadhi chikitsa.22

Arunadutta ( 12th Century):

Arunadutta, while commenting on Ashtanga Hridaya in Sarvangasundari has

mentioned about Gridhrasi which is caused due to the vitiation of vatadosha affecting the

kandara produces pain on extension of leg.23

Harita Samhita ( 12th Century):

In the 25th chapter of Tritiyasthana symptomatology and treatment of Gridhrasi

is mentioned.24

Gadanigraha ( 12th Century):

The treatment of Gridhrasi is mentioned in two contexts. One in the prayoga

khanda 4th chapter termed as Gutikadhikara,25 another in Kayachikitsa khanda 19th

chapter, Vatarogadhikara where vasti chikitsa26 is mentioned along with agnikarma and

raktamokshana.

Dalhana ( 12th Century)

The term used as synonym for Gridhrasi by Dalhana is ‘Randhrinee’27 where in

there will be severe pain.

Vangasena ( 12th Century):

Line of treatment of Gridhrasi mentioned as deepana, pachana, vamana,

virechana, vasti and siravedha.28

10

Historical review

Indu (13th Century):

The commentator of Ashtanga Samgraha, Indu in his Sashilekha commentary has

described the symptoms of Gridhrasi as similar to Vishwachi. If restricted movements

and pain occurs in upper limb, the disease is called as Vishwachi, and that occurs in

lower limb is termed as Gridhrasi.

Sarangadhara Samhita (13th Century):

Gridhrasi is included in the 80 types of Nanatmaja Vatavyadhi in the 7th chapter

of Purvakhanda.29 The treatment of Gridhrasi is mentioned in the 2nd and 5th chapter of

Madhyama khanda.30,31

Rasaratna Samuchaya (13th Century):

In the 30th chapter of Rasaratna Samuchaya the treatment of Gridhrasi is

mentioned.32

Bhavaprakasha (16th Century):

Gridhrasi has been mentioned in Vatavyadhinidana.33

Yogaratnakara (17th Century):

The symptomatology and classification of Gridhrasi is mentioned under

Vatavyadhi nidana along with few preparations useful in Gridhrasi.34

Bhaishajya Ratnavali (18th Century):

Treatments beneficial for Gridhrasi like snehana, vasthi and sastra karma are

mentioned in this text.

Basavarajeeyam and Sahasrayogam also mention different preparations for Gridhrasi.

11

Ayurvedic review

AYURVEDIC REVIEW

Vyutpatti

Gridhra + so – atonupasargitcha – Adding ‘kah’ pratya leads to Gridhra + so + ka by lopa

of ‘o’ and ‘k’, ‘s’ is replaced by ‘sa’ by rule ‘Dhatvadeh’ ‘sah sah’ ‘Gridhrasi’ derived.

Gridhasi word is derived from ‘gridhna’ dhatu, meaning to desire, to strive after

greedily or to be eager for. By the rule of ‘Susudhangridhangridhi bhyaha kran’ (Unadi

2/24) by adding ‘karana’ pratyaya ie. ‘gridh + kran’ by lope ‘k’ and ‘n’ the word ‘gridh +

ra’ the word ‘gridhra’ is derived.

Nirukti of Gridhrasi:

“Gridhram Api Syati So Antakarmani Atonupasargakah,

Cancva Gridhra Iva Syati Peedayati, Gridhra Syati Bhakshati”(sabda kalpa druma)

It means just as the bird vulture gives severe pain while eating its prey, in

the same way Gridhrasi also gives severe pain to the patient.

“Gridhraamiva Syaati Gacchati”.

As the gait has the resemblance with that of vultures gait, it is termed as Gridhrasi.

This is because the patient tilts to one side due to severe pain. Vulture walks with limping

a leg without lifting it up. The bird is fond of meat and it eats flesh of an animal in such a

fashion that it deeply pierce its beak in the flesh then draws it out forcefully; exactly such

type of pain occurs in Gridhrasi and hence the name.

Paribhaasha of Gridhrasi: Gridhrasi is a Vatavyadhi characterized by Stambha, Ruk,

Toda, Grahana and Spandana .This primarily starts from the region of Sphik pradesha

and radiates down wards through the Prushtabaga of Kati, Uru, Janu, Jangha, and Pada.35

12

Ayurvedic review

According to Sushruta, the kandara gets afflicted by the vitiated vata dosha

produces Gridhrasi, where in the patient finds difficulty in extending the leg. The two

kandaras according to Sushruta are one extending distally from the Paarshni to the toes,

and other extending above from the Paarshni to the Vitapa.36

Paryaaya of Gridhrasi:

The term Gridhrasi is used in almost all the Samhitas except in some occasions

where the term Gridhrasivata is used.

The synonyms of Gridhrasi are as follows:-

1. Ringhini 2. Randhrinee 3. Radhina

1. Ringhini - This term is used by Vacaspatimisra to denote Gridhrasi. The meaning of

which is Skhalana according to the Sabdakalpadruma; which means displacement of

particularly a Pichila material.37

2. Randhrinee - This word is used by Dalhana to denote Gridhrasi. The meaning of which

is a weak point or rupture of a material.38

3. Radhina39- This word is used by Kasirama & Aadamalla in their Gudartha Deepika and

Deepika commentary on Sarangadhara Samhita. The meaning of which is pressing,

compressing or destroying. In this context the meaning of which is compression of sciatic

nerve root leading to radicular pain. These were the terms commonly used to denote

Gridhrasi in olden days.

NIDANA

Nidana means the causative factor or etiology of a disease. Nidanas are divided

into two: Samanya nidana and Vishesha nidana.

13

Ayurvedic review

Gridhrasi is one among the Vataja nanatmaja vikaras.Gridhrasi is also mentioned

as one among the Vatavyadhies. For the disease Gridhrasi no specific /vishesha nidana,

as such, is mentioned in Ayurvedic classics.So the samanya Vata prakopakara nidanas

and Vatavyadhi samanya nidana can be considered as the nidana for Gridhrasi.

Charaka40 and Bhavaprakasha41 clearly mention the causative factors of

vatavyadhi while a detailed description about the nidana for vataprakopa is not

mentioned. However a detailed description about the nidana for vataprakopa is mentioned

in Sushruta Samhita42, Ashtanga Sangraha43 and Ashtanga Hrudaya.44Since Gridhrasi is

considered as one among the eighty Nanatmaja vatavikaras, the causative factors for vata

prakopa is to be considered as the nidana of Gridhrasi.

All the etiological factors mentioned for Vatavyadhi or vataprakopa can be

classified into the following headings:-

1. Aharaja (Dietetic factors)

2. Viharaja (Behavioural factors)

3. Agantuja (External factors)

4. Manasika (Mental factors)

5. Kalaja (Seasonal factors)

6. Anya hetuja (Other causes)

1. Aharaja (dietetic factors)

Excessive intake of food substances which are having rasa predominantly of tikta,

katu, kashaya and gunas which are predominantly of ruksha, laghu and seeta

causes the vitiation of vata. Aharas like kalaya, chanaka, mudga, adaki, and

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Ayurvedic review

pramana like alpa bhojana, hina bhojana and kala factors like anasana,

vishamasana also results in the provocation of vata dosha.

2. Viharaja (habits and regimen)

Vega dharana and udeerna, ratrijagarana, uchairbhashya (speaking loudly),

atyadhva (excessive walking), atiyana (excessive traveling) etc are considered as

the viharaja factors for vataprakopa. Also excessive indulgence in vyayama, vyavaya,

dhavana, pidana, plavana, bharavahana (lifting heavy weight) etc also result in the

provocation of vata.

3. Agantuja factors (External factors)

Agantuja factors like patana, pidana, abhighata, marmaghata, seeghrayana are

considered as external causative factors for the provocation of vata.

4. Manasika factors (Mental factors)

Factors like chinta, soka, bhaya result in vataprakopa.

5. Kalaja (Seasonal factors)

Varsha ritu, last part of day, night and in the last part of process of digestion vata get

increased.

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Hetu of Vataprakopa/Vatavyadhi

Table No: 1 Hetu (Etiological factors) of Vata Prakopa and Vata vyadhi

CAUSES Ch.S. Su.S A.S. A.H. B.P.

(A) AHARATAH (Dietetic causes)

Dravyatah

Adhaki (Cajanus cajan) - + - - -

Bisa (Nelumbuo nucifera) - + + - -

Chanaka (Cicer arietinum) - - + - -

Chirbhata (Cuccumus melo) - - + - -

Harenu (Pisum sativum) - + - - -

Jambava (Eugenia jambolena) - - + - -

Kalaya (Lathyrus sativus) - + + - -

Kalinga (Holarrhena antidysenterica) - - + - -

Kariya (Capparis decidua) - - + - -

Koradusha (Paspalum scrobiculatum) - + - - -

Masura (Lens culinaris) - + - - -

Mudga (Phaseolus mungo) - + - - -

Nishpava (Dolichos lablab) - + - - -

Neevara (Hygroryza aristata) - + - - -

Shaluka (Nelumbium speciosum) - - + - -

Shushkashaka (Dry vegetable) + - - -

Shyamaka (Setaria italica) - + - - -

Tinduka (Diospyros tomentosa) - - + - -

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Ayurvedic review

Trunadhanya (Grassy grain) - - + - -

Tumba (Lagenaria valgaris) - - + - -

Uddalaka (A variety of paspalum

Scrobiculatum) - + - - -

Varaka (Carthamus tinctorius) - + - - -

Virudhaka (Germinated Seed) - - + - -

Gunatah

Rukshanna (ununctous diet) + + + + +

Laghvannna (light diet) - + + - +

Gurvanna (heavy diet) - - + + -

Sheetanna (cold diet) + - + - -

Rasatah

Kashyanna (astringent taste) - + + + +

Katvanna (acrid taste) - + + + +

Tiktanna (Bitter taste) - + + + +

Karmatah

Vishtambhi (constipative diet) - - + - -

Veeryatah

Sheeta (cold) - - - - -

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Ayurvedic review

CAUSES Ch.S Su.S A.S. A.H. B.P

Matratah

Abhojana (fasting) + + - - +

Alpasna (dieting) + - + + -

Vishmashana (Taking unequal food) - + - - -

Kalatah

Adhyashana (eating before diges-

tion of previous meal - + - - -

Jirnanta (last part of digestion) - + + + +

Pramitashana (Taking food in impro-

per time) - - + + +

(B) VIHARATAH (Regimen)

I. Karmatah

1. Mithyayogatah

Ashmabhramana (whirling stone) - - + - -

Ashmachalana (Shaking of stone) - - + - -

Ashmaviksehpa (Throwing of stone) - - + - -

Ashmotkshepa (pulling down stone) - - + - -

Balavat vigraha (Wrestling with - + + - -

Superior healthy one

Damyagaja nigraha (subduing untam-

eable elephant)cow & horse. - - + - -

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Ayurvedic review

Divasvapna (day sleep) + + - - -

Dukhasana (uncomfortable sitting) + - - - -

Dukhashayya (uncomfortable sleeping) + - - - -

Ghadhotsadana (strong rubbing) - - + - -

Kashtabhramana (whirling of wood) - - + - -

Kashtachalana (shaking of wood) - - + - -

Kashta vikshepa (throwing of wood) - - + - -

Kashtotkshepa (pulling down wood) - - + - -

Lohabhramana (whirling of metal) - - + - -

Lohachalana (Shaking of metal) - - + - -

Lohavikshepa (Throwing of metal) - - + - -

Lohotkshepa (Pulling down metal) - - + - -

Paragatana (Strike with others) - - + - -

Shilabhramana (Whirling of rock) - - + - -

Shilachalana (Shaking of rock) - - + - -

Shilavikshepa (Throwing of rock) - - + - -

Shilotkshepa (Pulling down rock) - - + - -

Bharaharana (Head loading) - + + - -

Vegadharana (Voluntary suppression + + + + +

of natural urges)

Vegadeerana (forceful drive of natural-

urges) - - + + -

Vishamopchara (Abnormal gestures) + - - - -

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Ayurvedic review


2. Atiyogatah

Atigamana (excessive walking) + - + - -

Atihasya (Loud laughing) - + + + -

Atijrimbha (Loud yawning) - + - - -

Atikharachapakarshana (Violent-

stretching of the bow) - - + + -

Atilanghana + + + - -

Atiplavana (Excessive bounding) + + - - -

Atiprabhashana (Continuous talking) - - + + -

Atipradhavana (Excessive running) + + - - -

Atiprajagarana (Excessive awakening) + + + + +

Atiprapatana (Leaping from height) - + - - -

Atiprapidanam (Violent pressing blow) - + - - -

Atipratarana (Excessive swimming) - + + - -

Atiraktamokshana (Excessive

Blood letting) - - - - +

Atisrama (over exertion) - - - - +

Atisthana (standing for a long period) - + - - -

Ativyayama (Violent exercise) + + + + +

Ativyavaya (excessive sexual inter

course) + + + + +

Atiadhyayana (excessive study) - + + - -

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Ayurvedic review

Atyasana (sitting for a long period) - + - - -

Atyuchchabhashana (speaking loudly) - - - + -

Gajaticharya (excessive riding on

Elephant) - - + + -

Kriyatiyoga (excessive purification

therapy) - - + + +

Padaticharya (walking long distances) - + - - -

Rathaticharya (excessive riding on

chariot) - + - - -

Turangaticharya (excessive riding on

Horse) - + - - -

(B) Manah

Bhaya (fear) + - + + +

Chinta (worry) + - + - -

Krodha (Anger) + - - - -

Mada (Intoxication) - - - - +

Shoka (Grief) + - + + +

Utkantha (Anxiety) - - + - -

II. Kalatah

Abhra (cloudy season) - + - - -

Aparahna (evenning) - + + + +

Apararatra (the end of the night) - - + + -

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Ayurvedic review


Grishma (summer season) - - + + -

Pravata (windy day) - + + - -

Shishira (winter) - - - - +

Sheetakala (early winter) - + - - +

Varsha (rainy season) - + + - +

C. AGANTUJATAH

Abhighata (trauma) + - - - -

Gaja, Ustra, Ashvasighrayanapatamsana

(Falling from speedy, running elephant,

camel and horse) + - - - -

D. ANYAHETUTAH

Ama (undigested article) + - - - +

Asrukshaya (loss of blood) + + + - -

Dhatukshaya (loss of body elements) + - - - -

Doshakshaya (loss of excretor) + - - - -

Rogatikarshana (emaciation due to

disease) + - - - -

Gadakruta mamsakshaya (wasting due to

Disease) - - - - +

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Ayurvedic review

SAMPRAPTI

To treat a disease, the complete knowledge of its pathogenesis is a must. The word

‘Samprapti’ means ‘Samyak prapti of Roga’ that is the proper understanding of the

disease process.

The process of manifestation of the disease by the morbid doshas which are

circulating all over the body is known as samprapti, jati or agati.45 According to

Acharya Sushruta ‘Doshadushya sammurchana janitovyadhi’ . The disease process starts

right from the hetu sevana vitiating doshas. The actual manifestation of the disease occurs

when the circulating vitiated doshas get accumulated where khavaigunya is already

present.

For the disease Gridhrasi, the detailed samprapti has naot been mentioned in

Ayurvedic classics. Since Gridhrasi is a Nanatmaja Vatavyadhi, the general samprapti of

Vatavyadhi along with specific description available are considered here for the

explanation of samprapti.

There are two main reasons by which vata get vitiated. They are dhatu kshaya and

margavarodha.46 Because of the samprapti visesha; the same nidanas produce different

Vatavyadhies.47 This is because the presentation of the disease changes to the sthana

where dosha dooshya sammurchana takes place. Khavaigunya plays an important role in

the disease process. In Gridhrasi, exposure to mild but continous trauma to kati, sphik

region because of improper posture, travelling in jerky vehicles, carrying heavy loads,

digging etc or sometimes spinal cord injury, improperly treated pelvic diseases are

responsible for producing sthana vaigunya at kati, sphik, prishta etc. They may not be

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able to produce the disease at the instance, but after acquiring some vyanjaka hetu, the

disease may be produced. Here the samprapti takes place either by apatarpana, santarpana

or agantuja causes.

In the state of apatarpana, all the dhatus viz. rasa, rakta, mamsa etc are subjected

to kshaya. This dhatu kshaya results in to the aggravation of vata and this vitiated vata

fills up the empty srotases ultimately causing Vatavyadhi.48 Due to rookshadi aharas,

initially the rasa dhatu kshaya takes place and it leads to further dhatukshaya, involving

mamsa, meda, asthi, majja etc.

The second type of samprapti takes place by santarpana causing margaavarodha.

Here kapha is found as anubandhi dosha along with vata. Atibhojana, divaswapna etc are

the factors responsible for this kind of samprapti. Derranged jataragni, leads to formation

of Ama. Ama produces obstruction to the normal gati of vata. To overcome the

resistance, Vata attempts to function hyperdynamically. This leads to vata prakopa. Also

when ama samsrishta vayu resides at kati, prishta etc Gridhrasi may be produced.

Lakshanas like tandra, gaurava, agnimandhya etc are observed due to involvement of

Kapha and Ama. Impaired dhatvagni may lead to the production of athyasthi, arbuda,

granthi etc ie. Apachita dhatus. If they cause avarodha in the vata vaha nadi of the lower

limb, Gridhrasi may be produced.

The agantuja factors chiefly bahya abhighata etc are responsible for the ‘achaya

poorvaka prakopa’ of doshas. Abhighata leads to dhatu kshaya directly and vata

provocation is liable to occur. The vitited vata may directly intermingle with asthi, majja

dhatu to produce Gridhrasi. Here the intermediate steps of samprapti ie. Chaya, Prakopa,

Prasara etc are absent. Also abhighata may lead to khavaigunya at the site.

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Vata is the main culprit in Gridhrasi. Obviously, pakvasaya is the udbhavasthana

of the disease. Among the five types of vata, apana and vyana vayu are mainly involved.

Apana resides in the lower part of the body especially kati, vasti etc. Because of the

various hetus apana is vitiated. In Gridhrasi Sakthiutkshepanigrahana is the main sign ie.

upward lifting of the lower limb is affected. This clearly explains the involvement of

vyana vayu in the samprapti as these movements are governed by vyana vayu.Also

sometimes kapha is the anubandhi dosha producing Vatakaphaja Gridhrasi.

Asthi dhatu and vata dosha have asraya-asrayi sambandha.49 Asthikshaya

produces vataprakopa. Also vata prakopa aharasevana is the main cause of asthivaha

srotodushti. Viharatmaka hetus like ativyayama etc may cause asthivaha sroto dushti.

Majja is the deep seated sneha in the asthi dhatu. Rookshadi ahara causes

shoshana of majja dhatu . Virudha ahara, abhighata etc are the causes of majjavaha

srotodushti which are commonly observed in the patients of Gridhrasi.

Mamsa and medodhatu are snigdha , guru dhatu. Rookshadi aharas hampers the

process of their poshana leading to mamsa and meda kshaya. Also sphik is mamsa

pradhana avayava. Sphik sushkata is mentioned in mamsakshaya lakshana. Rookshata at

mamsa dhatu produces sthambha in the muscles of lower limb restricting its movement.

Kati sandhi may be involved in Gridhrasi. Sandhis are responsible for the movement of

the limbs. In severe vata prakopa, Sandhi chyuti ie bhramsa of sandhi specifically in the

vertebral column may be seen. This can be correlated to the prolapse of the intervertebral

disc.

In the kshaya lakshanas of asthi, meda and mamsa, sandhi soonyata, sandhi

saithilyata and in kshaya of asthi and majja, asthi saushirya, asthi daurbalya and laghuta

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are described. All these dhatu kshaya lakshanas can be correlated to degenerative changes

specifically in bone eg Osteomalacia, osteoporosis, spondylosis, tuberculosis etc.

Acharya Sushruta clearly mentioned the involvement of kandara in Gridhrasi.

Dalhana explain kandara as Mahasnayu. According to Vaidyak Shabdasindhu, snayus are

the nadis that conduct vayu. According to Sushruta, vayu in its normal state, while

coursing through its specific siras helps the unobstructed performance of its specific

functions viz. prasarana and akunchana and produces clearness and non-illusiveness of

buddhi and the sense organs. When vitiated vayu enters the siras, it causes variety of

diseases.50 Sushruta has quoted special variety of siras called as Vatavaha siras, which are

the channels of movement of vata, in the senses.

Charaka explains kandaras as the upadhatu of rakta Dhatu. Chakrapani mentions

that kandara may also be considered as sthula snayu. Snayu is the upadhatu of meda and

mulasthana of mamsa dhatu. Also Charaka has mentioned stambha, supti, sphurana etc.

which are the symptoms of Gridhrasi under the diseases produced due to dushti of snayu,

sira and kandara.

Thus, from the above description involvement of rasa, rakta, mamsa, meda and

mainly asthi, majja dhatus, kandaras, siras and snayus in the disease Gridhrasi is obvious.

Samprapti Ghataka

Nidhan : Vataprakopaka nidana

Dosha : Vata – Apana and Vyana vayu, Kapha.

Dushya : Kandara, asthi, majja, rasa, rakta, mamsa, sira, snayu.

Agni : Jatharagni

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Ayurvedic review

Ama : Jatharagnimandyajanita

Udbhavasthana : Pakwashaya

Sancharasthana : Rasayani

Adhisthana : Prishtha,kati, sphik

Srotas : Asthi, majja, rasa, rakta, mamsa, meda

Srotodushti : Sanga

Rogamarga : Madhyama

Vyakti : Sphik, kati, prishtha, uru, janu, jangha, pada.

Bheda : Vataja and Vatakaphaja

Swabhava : Chirakari

POORVARUPA

Poorvarupa or prodromal symptoms occur prior to the complete manifestation of

the disease that indicates forthcoming disease.

Poorvarupa appears in the fourth stage of kriyakala ie in the sthanasamsraya

stage. Doshas in the prasaravastha spread all over the body and tend to accumulate at

certain places where already Kha vaigunya is present. Here dosha dooshya sammurchana

takes place resulting in sthanasamsraya where poorvarupa of the disease is exhibited. It is

important to diagnose and treat the disease at this stage, so that the further progression of

the disease can be prevented.

As Gridhrasi is a Vatavyadhi and as separate poorvarupa are not mentioned for

Gridhrasi, Vatavyadhi poorvarupa can be considered for Gridhrasi also. As the

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Ayurvedic review

poorvarupa mentioned for Vatavyadhi is avyakta and alpatva51 of lakshana, the symptom

of Gridhrasi exhibited in mild form and with lesser intensity can be considered as the

poorvarupa of Gridhrasi.

RUPA

Rupa appears in the vyaktavastha ie in the fifth kriyakala of the disease. In this

stage there will be manifestation of the disease by exhibiting its characteristic signs and

symptoms.

According to Charaka in Gridhrasi the pain is experienced first in the region of

sphik pradesha which extends either upwards to the prishta bhaga or to the leg in a

radiating pattern through the prishta bhaga of kati, uru, janu, jangha and pada. One

experiences ruk (pain), toda (pricking sensation), stambha (stiffness), grahana (restricted

movements) and spandana (altered sensations) in these regions. These are the cardinal

symptoms of Vataja Gridhrasi. In Vata kaphaja type of Gridhrasi in addition to the above

symptoms tantra (stupour), gaurava (heaviness) and arochaka (loss of appetite) will be

present.52

Sushruta and Vagbhata have mentioned ‘Saktanakshepam nigrahniyat’53 ie one

finds restriction in extending the leg due to severe pain.

Madhavakara has mentioned the same symptoms as mentioned by Charaka. In

addition to this, in Madhavanidana, he had mentioned symptoms of Vata and

Kaphanubandhavataja Gridhrasi. In Vataja Gridhrasi there will be toda and dehasya

vakrata (deformity in the body postures) along with sphurana (altered sensation) and

stambhana (stiffness) in janu, kati and uru sandhi. This deformity in the body posture

may be due to the lateral or forward bending of the body adopted due to the pain. The

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Ayurvedic review

lakshanas mentioned for kaphanubandhavataja Gridhrasi are similar to that of Vataja

Gridhrasi with additional symptoms like tandra (stupour), mukhapraseka (excessive

salivation), bhaktadwesha (aversion to food) associated with agnimandhya (loss of

appetite).54

Table No: 2 Symptoms of Gridhrasi

Symptoms Ch.S Su.S AH AS BP MN YR SS HS

General

Sphika Purva Kati, Pristha,

Uru, Janu, Jangha, Pada

Kramat Vedana

+ - - - + + + - -

Ruk + - - - + + + + -

Toda + - - - + + + + -

Stambha + - - - + + + + -

Muhuspandana + - - - + + - + -

Sakthikshepanigraha - + - - - - - - -

Sakthiutkshepanigraha - - + + - - - - -

Janu Madhya Vedana - - - - - - - - +

Uru Madhya Vedana - - - - - - - - +

Kati Madhya Vedana - - - - - - - - +

Vataja

Dehasyapravakrata - - - - + + + - -

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Ayurvedic review

Janusandhispurana - - - - + + + - -

Urusandhispurana - - - - + - - - -

Katisandhispurana - - - - + + + - -

Janghaspurana - - - - - + - - -

Suptata - - - - + - + - -

Vata-kaphaja

Tandra + - - - + + + + -

Gaurava + - - - + - + + -

Arochaka + - - - - - + + -

Vahni Mardava - - - - + + + - -

Mukhapraseka - - - - + + + - -

Bhaktadwesha - - - - + + + - -

Staimitya - - - - - - - - +

Details about some of the important symptoms of Gridhrasi are described below:-

1. Ruk (Pain)

As Gridhrasi is a shoola predominant disease, Ruk is considered as the main

symptom of Gridhrasi. The pain starts first in the sphik pradesha radiates to the

prishta bhaga of kati, uru, janu, jangha, and pada respectively. Obviously this is the

radicular pain present along the area distributed by Sciatic nerve.

2. Toda (Pricking sensation)

This symptom is mentioned by Charaka and Madhavakara. This is a pricking type of pain

or feeling of tingling sensation experienced in the leg.

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3. Stambha(Stiffness)

Charaka mentions that the patient of Gridhrasi experiences stambha in the

affected part. This is the feeling of stiffness or rigidity throughout the leg. This is due

to the rigidity of the paraspinal muscles that the free movements are restricted so as to

prevent further worsening of pain.

4. Grahana (Restricted movements)

This is a feeling of restriction in the movements of the leg which is manifested in the

form of difficulty in walking.

5. Spandana (Alterd sensations)

This is a feeling of altered sensation which is experienced in the distribution of

Gridhrasi nadi. In Modern science it is referred to the twitchings which is present in

the course of Sciatic nerve due to motor weakness. According to the level of disc

lesion, numbness can be seen in the thigh, knee and foot.

6. Saktanakshepa nigrahana

This symptom is mentioned by Sushruta. Commenting upon this Dalhana opines

that the vitiated vayu afflicting the kandara produces restriction in the movement of

the leg. The word Kshepa refers to prasarana ie. the patient experiences pain on

extention of the leg.

Acharya Vagbhata has used the term utkshepana55 in the place of kshepa which

means that the patient finds difficulty in lifting the leg. Commenting on this Arunadatta

has defined this term as ‘pada uddarana asakti’ which means that the patient is unable to

elevate or lift the leg.

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Ayurvedic review

This can be very well related to the Straight Leg Raising test done in the case of

Sciatica.

7. Dehasya vakrata (Deformity in body postures)

This symptom is mentioned by Madhavakara and in Bhavaprakasha which means

change in bodily posture which is adopted by the patient of Gridhrasi either by lateral or

forward bending on account of pain. The patient tries to put his body weight on the

unaffected leg causing a typical posture. This symptom can be related to the sciatic

scoliosis mentioned in Modern science.

8. Tandra (Stupour)

This is one of the symptoms of Vatakaphaja Gridhrasi mentioned in Charaka,

Madhava Nidana and Bhavaprakasa. This may be present in the case of acute disc

prolapse.

9. Gaurava (Heaviness)

This symptom is mentioned only by Charaka. This is a feeling of heaviness of the

body which is experienced whenever there is association of kapha dosha.

10. Arochaka (Loss of appetite)

Charaka, Madhavakara and Bhavamishra have mentioned this symptom in Vatakaphaja

Gridhrasi. The patient experiences loss of appetite.So when there is anubandha of vitiated

kapha this symptom is experienced.

11. Agnimandya

When there is vitiation of kapha it produces agnimandya.

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12. Mukha praseka

This is mentioned by Madhavakara and Bhavamishra. There will be excessive

salivation caused due to the vitiation of kapha. These symptoms are exhibited in the case

of Gridhrasi were there is anubandha of kapha.

13. Bhaktadwesha

This symptom is mentioned in Madhava Nidana and Bhavaprakasha where the

patient experiences aversion towards food which is produced due to the involvement of

vitiated kapha and ama.

14. Sthaimitya

Sthaimitya is the feeling of wet cloth wrapped around the body part. This is due to

the vitiation of kapha. This is compared with cold or clamp hand and feet due to

vasomotor instability. Only Harita has described this symptom.

SADHYASADHYATA

Sadhyasadhyata of any disease depends upon the severity of the conditions, the

causative factors, chronicity, doshas and other factors in the samprapti of the disease.

Sadhyasadhyata gives the clear picture about the prognosis of the disease ie., whether the

disease is easily curable, difficult to cure or incurable. A physician who can distinguish

between curable and incurable disease and initiate treatment in time with the full

knowledge can certainly accomplish his object.

In Gridhrasi, though the prognosis is not separately considered it can be assessed

like that of Vatavyadhi. Sushruta has included Vatavyadhi among the Ashtamahagadas

indicating its duschikitsya nature. Gridhrasi in which the vitiated vata is reaching the

majja and asthi dhatu or if Gridhrasi is assossiated with pangutva, angasosha, khudavata

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Ayurvedic review

and stambha may or may not be cured even after cautious treatment. But if this condition

occurs in a strong person and is of recent in origin and not associated with any

complication is curable.56 According to Sushruta, if Vatavyadhi is accompanied by sotha,

suptatvacha, bhagna, kampa, adhmana and deep seated pain then it is fatal.

VYAVACHEDAKA NIDANA

Every disease has its own cardinal signs and symptoms. But certain diseases have

resemblance in their clinical signs and symptoms. For the correct line of treatment it is

very important to make the accurate diagnosis of a particular disease and differentiate

from other similar disorders. Hence it is essential for a physician to make differential

diagnosis of the disease.

Gridhrasi also presents with a clear picture of shifting pain in lower limbs

radiating from sphik, kati, prishtha and affecting uru, janu, jangha and pada in order.

‘Sakthiutkshepanigraha’ is mentioned as a cardinal sign by Sushruta and Vagbhata. But

certain other symptoms such as stambha, toda, sphurana, ruk etc. are also found in some

other disease. Diseases like urustambha, khalli, kalayakhanja, vatakantaka can make

confusion with Gridhrasi.

Urustambha57 is a disease affecting one or both the legs. In this disease the leg

becomes cold and painful. Symptoms like toda, sphurana, stabdhata etc. are also found in

urustambha. But chardi, jwara etc are found in urustambha which are absent in Gridhrasi.

The typical radiating type of pain is found in Gridhrasi only. Also, a patient of Gridhrasi

will never have such a strange feeling that the leg doesn’t belong to him, which is

common in urustambha.

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Ayurvedic review

In Khalli, pain is at the root of pada, jangha, uru and hasta. Charaka has specified

the type of pain as avamotana i.e. mardanavat.58 Harita believes that Gridhrasi and

Vishwachi when found together is called Khalli, while Vagbhata gives importance to the

severity of pain. But Khalli can be differentiated from Gridhrasi by the nature of the pain

ie. originating from sphik, kati and then radiating to the leg.

Vitiated vayu while staying at kati affects the kandara of one leg, then it is khanja

and when it affects both the legs it is pangu.59 In Gridhrasi also, the kandara of leg is

affected. But in khanja there is no pain instead there is wasting in leg. Kalayakhanja is

caused due to ingestion of certain kind of peas (kalaya). In this disease there is difficulty

in walking and trembling gait.60In Gridhrasi kampana or sphurana is present but not

specially related to walking. Also, sandhi saithilya is seen in kalayakhanja but absent in

Gridhrasi.

Vatakantaka is a disease affecting gulpha sandhi and localised pain is the main

symptom. In Gridhrasi, pain may be present at gulpha sandhi but the whole leg is affected

which is not seen in vatakantaka.

In padaharsha, vitiated vayu along with kapha produces tingling and numbness in

the leg. But the radiating pain seen in Gridhrasi is absent here.

Vitiated vata when resides at guda, produces obstruction in excretion of vata,

mala, mutra. This is named as gudagata vata.61 Here also pain at jangha, uru, and trika

prishtha is found but the typical pattern seen in Gridhrasi is absent.

In the poorvarupas of Vatarakta, toda, sphurana, supti at janu, jangha, uru, kati are

mentioned.62 But these symptoms may be found in hands and are accompanied by other

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symptoms such as excessive sweating or complete loss of sweating, itching,

discolouration etc. which are not found in Gridhrasi.

In severe stages of Amavata, pain at gulpha, trika, janu, uru is found, but again, it

can be in hands and other joints of the body. It is associated with shotha and other

amajanita symptoms which are absent in Gridhrasi.

Table No.3 Table showing Vyavachedaka Nidana

Lakshanas Gridhr

asi

Uru-

stamb

ha

Kalay

-

khanj

a

Vata

–

kanta

ka

Khal

li

Pada

-

harsh

a

Vatarakta

(poorvaru

pa)

Am

avat

a

1 Sphik poorva

kati kramat

vedana

+ - - - - - - -

2 Stambha + + - - - - - -

3 Ruk + + - + + - - +

4 Toda + + - + - - + -

5 Muhu spandana + - - - - - + -

6 Sakthiutkshepa

nigraha

+ - - - - - - -

7 Janu sphuran + - + - - - + -

8 Dehasyapravak

rata

+ - + - - - - -

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9 Kati sandhi

sphurana

+ - + - - - - -

10 Stabdhata + + - - - - - -

11 Parshni vedana + - - + - - - -

12 Difficulty in

walking

+ - - + - - - -

13 Sandhi mukta - - + - - - - -

14 Supti + - - - - + + -

CHIKITSA

Chikitsa is the process of breaking down the pathogenesis of a disease. Diseases are

caused due to vitited doshas involving dhatus etc. The process which establishes

equilibrium in these body elements is Chikitsa.

While treating any disease, the first and foremost principle to be followed is to

avoid nidanas. For Gridhrasi, all the vata prokopa hetus including external factors such as

excessive walking, riding etc should be avoided. Gridhrasi, being a Vatavyadhi, the

general line of treatment of Vatavyadhi can be applied to it.

Charaka has advised dravyas having madhura, amla, lavana, snigdha, ushna

properties and upakramas like snehana, swedana, asthapana and anuvasana vasti, nasya,

abhyanga, utsadana, parisheka etc. Among these, asthapana and anuvasana vasti are

praised as the best treatment for vata.63

Vagbhata has stated that, sneha,sweda, mrudusamshodhana along with madhura ,

amla and lavana dravyas, veshtana, trasana, madhya, sneha siddha with deepana and

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pachana drugs, mamsa rasa and anuvasana vasti pacify the vata.64 In Ashtanga samgraha

hemanatha ritucharya is indicated in Vatavyadhi. Similarly Sushruta has advised

sirovasti, sirosneha, snaihika dhoomapana, sukhoshna gandusha for the treatment of

Vatavyadhi.65

All the above upakramas have their own qualities. Also when they are done in

proper sequence, the therapy as a whole also has its benefits.These karmas specifically in

relation to Gridhrasi is mentioned below:

Snehana:

Snehana should be done only in nirupasthambhita vata66. By the word snehana,

both external and internal snehana are included. For internal sneha pana, chaturvidha

maha sneha are indicated. But taila is praised in Vatavyadhi as it is having exactly

opposite qualities as that of vata. Sneha pacifies vata, brings out softness in the body and

removes mala sanga.

External snehana is done by abhyanga, parisheka, avagaha, etc. It acts on

sparshanendriya which is the seat of vayu. While mentioning the kala of abhyanga,

Sushruta has stated that after 900 matras the sneha can reach majja dhatu. It signifies the

action of sneha on asthi, majja dhatus which are involved in Gridhrasi.

Swedana:

Sneha poorvaka swedana is indicated in nirama Vatavyadhi, while only swedana

is indicated in sama Vatavyadhi. Nadi, prasthara, sankara etc are the various types of

sweda.67

Swedana liquifies the doshas and expands the srotases, helping the doshas to

travel towards theirown sthana. Swedana activates Agni, creates komlata, ruchi, clears

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Ayurvedic review

srotases, and diminishes tandra. Sneha poorvaka swedana relieves the symptoms such as

harsha, toda, ruk, sotha, stambha, graha etc. It produces mruduta in the body. Charaka

says that proper snehana and swedana can make even dry wood flexible.

In Gridhrasi, stambha, ruk, toda etc are the main symptoms. Snehana and swedana

by virtue of their vata samaka and dhatu poshaka properties are useful in relieving the

symptoms. Here ekanga sweda on the affected side can be done.

Mrudu samshodhana:

The doshas which are not passified by snehana and swedana should be removed

from the body. Hence mrudu virechana68 is advised for this purpose. Snigdha virechana is

advised for Vatavyadhi.

By snehana and swedana vitiated doshas are brought to koshta.Then mrudu

virechana when administered brings out the malas from the body, increases the strength,

eliminates the disease and improves the quality of life.This is achieved by administering

drugs like eranda taila.

Vatanulomana is necessary for the vayu obstructed by malas lodged in strotases. It is to

be done by snigdha, amla, lavana, ushna drugs.

Vasti:

Vasti is the treatment for vata. In patients who are weak or are avirechya, niruha

vasti is advised for removal of doshas by Acharya Charaka.69

Vasti is considered as the best for vatahara purpose, because it makes the vata

move in its natural channels. Also it has systemic effect in eliminating doshas from the

body gradually by pakwasaya sodhana. Asthapana basti is srotovishodhana and

malapahara, while anuvasana performs the function of mala sodhana and vata samana.

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Ayurvedic review

Vasti increases bala, agni, medha, varna etc. It strengthens the body prolongs life

removes doshas from all over the body and thus pacifies all the ailments and is said to be

sarvarthakari.70

While explaining the importance of vasti, Charaka says that there is no

therapeutic procedure comparable to that of vasti, in as much as it possesses rapid and

useful properties of cleansing, in addition to its being a quick agent of impletion and

depletion and is unattented with danger. Thus vasti is rightly considered as

Chikitsardha.71

Specific treatment of Gridhrasi:

While describing the specific treatment for Gridhrasi, Acharyas have given

importance to karmas but at the same time different samana yogas are also mentioned in

the texts.

Charaka mentions Siravyadha between the kandara and gulpha pradesha, vasti

and agnikarma as the line of treatment of Gridhrasi.72

Sushruta as a master of Shalya tantra has advised only siravyadha at

janu.Siravyadha four angula above or below janu is mentioned for Gridhrasi in both

Ashtanga Samgraha and Ashtanga Hrudaya.

Chakradutta has described the treatment of Gridhrasi more precisely. He has

described the importance of agnideepana, pachana and urdhvashodhana before

administration of vasti for a patient of Gridhrasi. Before attainment of urdhvashodhana if

vasti is administered it becomes useless.73 A number of combinations are described in the

text for the samana chikitsa of Gridhrasi. Other formulations include decoction of

shephalika, decoction of panchamoola, trivrut ghrita, rasna guggulu, trayodashanga

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Ayurvedic review

guggulu, chagalyadi ghrita, saindhavadya taila. Also recipies like eranda phala payas and

vartaka prayoga are advised. While treating Vatakaphaja Gridhrasi, pippalichoorna along

with eranda taila and gomutra is advocated. Chakradutta has mentioned a small operation

with prior snehana and svedana to remove granthi in Gridhrasi and also siravyadha 4

angula below Indrabasti marma. If not relieved by this treatment then Agni karma at

kanishtika anguli of pada has been suggested.

Bhavaprakasha also states that basti should be given to patients of

Gridhrasi only after doing vamana and virechana karma and in diptagni and in

niramavastha. Eranda taila along with gomutra when administered for one month

especially in the morning hours relieves Gridhrasi. Also taila, ghrita, matulunga and

ardraka svarasa taken with chukra and guda are useful in shoola of kati, uru, prishta, trika

and in Gulma, Gridhrasi, Udavartra. He has advised decoction of eranda moola, bilva,

vibhihati and kantakari for chronic Gridhrasi. The decoction of simhasya, danthi,

krutamalaka along with eranda taila is advised for the Gridhrasi patients who have

difficulty in walking. The sara of brihatnimba is also useful in asadhya Gridhrasi. Also

rasnaguggulu, pathyadi guggulu are advised in Gridhrasi.

Yogaratnakara has advocated the use of lasuna along with hingu, jeeraka

etc in the morning for the patients of Gridhrasi. Also use of panchamooli kashaya,

vajigandhadi oil for vasti or oral use and saindhavadya taila is described. Yoga ratnakara

advises siravyadha in the area of 4 angula around basti. If this fails agni karma in the little

finger of the leg is advised. Gridhrasi is one among the indications of yogas like

maharasnadi kwatha, abhadi choorna, trayodashanga guggulu, mahavishagarbha taila etc.

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Ayurvedic review

Sarangadhara has described decoction of dashamoola or nirgundi with pushkara

moola and hingu, decoction of rasnasaptaka, mahanimba, and prasarani,mashadi and

narayana taila.

Harita while describing the treatment of Gridhrasi states that in this

disease bloodletting should be performed followed by sweda. Abhyanga should be done

with vata nasaka oil. Phanta of drugs like satavari, bala, atibala, pippali and

pushkaramoola if taken with eranda taila cures Gridhrasi. However if the disease doesnot

respond to this treatment, agnikarma with a an iron rod is advised. Agnikarma must be

done 4 fingures above the gulpha.Pathya mentioned in Vatavyadhi should be followed in

Gridhrasi also.

Bhela mentioned raktamokshana as the best treatment for Gridhrasi. Also bala

taila, moolaka taila and sahacharadi taila are advised for external application. Sneha vasti

and sneha unmardana are also advised.

Vangasena has repeated the necessity of urdhva sodhana before vasti.

Bhaishajyaratnavali has given same treatment for Gridhrasi as described by Chakradutta.

PATHYA – APATHYA

According to Ayurveda, various diseases are caused by the sanchaya, prakopa etc.

of the tridoshas. In person who indulges in pathyakara ahara and vihara, the dosha

sanchaya doesnot occur to such an extent as to cause dreadful diseases. The importance

of pathya is praised by various Acharyas. Some of them believe that diseases can be

treated only with pathya. This doesnot mean that the importance of drugs in the treatment

of disease is denied. If a person follows the rule of pathya for particular disease, there is

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Ayurvedic review

very little significance of drug treatment, and when a person exposed to apathya then

drug treatment is of no value.

Gridhrasi, being a Vatavyadhi, the pathyapathya mentioned for Vatavyadhi

should be followed. The pathya can be considered as to the ahara, aushadhi and vihara.

Ahara, vihara and aushadhi having properties opposite to vata and have vataghna effects

should be taken as pathya for vatavyadhi.

Pathya Ahara:

Ahara dravyas having Madhura, Amla and Lavana rasa, Snigdha, Ushna guna and

Brimhana property should be consumed by the patient.74 Chakradatta, Bhaishajya

ratnavali and Yogaratnakara have the description of pathyapathya in detail. It can be

presented as :

• Anna varga : Rakta shali, purana shashtika shali, kulatha, masha,

godhuma,lavana.

• Dugdha varga : Dugdha, ghrita, dadhi, matsyandika, dadhikurchika.

• Shaka varga : Patola, shigru, vartaka, lashuna, tambula

• Phala varga : Dadima, parushaka, badara, draksha, jambira

• Mamsa varga : Gramya, anupa, audaka mamsa, chataka, kukkuta, barhi,

tittira, nakra mamsa.

• Drava Varga : Taila, vasa, majja, yusha, mamsarasa, sura, naladambu

• Aushadha : Prasarini, gokshura, nimba, kshirkakoli.

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Ayurvedic review

• Pathya Vihara :

Snigdha swedana, abhyanga, vasti, sirobasti, sirahsneha, snaihika dhuma, sneha

nasya, sneha gandusha, sukhoshna parisheka, samvahana are the upakramas to be

followed .

Also patient should reside at a place where direct wind is avoided and sunlight is

present. Patient should use soft beds and should avoid abnormal postures.

Apathya Ahara:

Chanaka, kalaya, shyamaka, nivara, kangu, mudga, rajamashaka, all trina

dhanyas, nishpavabija, bimbi, kasheruka etc. should be avoided. Also tadaga, tatini jala,

sheetambu, viruddhanna should be avoided. Dravyas having kashaya, katu, tikta rasa

should not be consumed by a patient having Vatavyadhi.

Apathya Vihara:

Indulgence in sex, excessive riding on vehicles, excessive walking, sleeping on hard beds

should be avoided. Chinta, ratrijagarana, vegavidharana, shrama and upavasa should be

avoided.

Thus external as well as internal factors which cause vata prakopa should be

avoided by a patient of Gridhrasi.

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Modern review

MODERN REVIEW

The disease ‘Sciatica’ is named because of the involvement of sciatic nerve. The sciatic

nerve derives its name from its relationship to ischium, having been abbreviated from

‘ischiatic’ to ‘sciatic’

which means

• Affecting the hip or the sciatic nerve

• Belonging to the ischium or hip

From the modern point of view, sciatica is neuralgia of the sciatic nerve; the condition

was described by Cotugno in 1770. Neuralgia is modern term for somewhat indefinite

pain in the area supplied by one nerve, the cause of which is not immediately apparent

but which is popularly associated with the nerve. The term seems to have come into use

about the beginning of the 19th Century, entering English from the French. (Henary Alana

Skinner, 1949).

‘Sciatica’ is a term which has been used for centuries to describe a well known

clinical affliction. The association of low backache or lumbago with sciatica had been

known for some time. Lasegue (1816 – 1833); a Paris neurologist, drew attention to the

importance of the straight leg raising sign in sciatica. The characteristic posture of the

patient with sciatica was appreciated and a sciatic scoliosis was described by Charcot in

1888.

Until 30 years ago interstitial neuritis (sciatic neuritis) was considered as an

independent disease, but it is now thought that it is not an entity. Most of its symptoms

are the result of irritation of one of the root of the great sciatic nerve by displaced tissue;

commonly a prolapsed intervertebral disc, other changes in the disc and the surrounding

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Modern review

bone, osteophytes or secondary fibrosis and neuroma formations. Some are due to

primary and secondary tumours but some to injury. It is probable that the prime causes in

instance are mechanical (Ronald Bodly Scott., 1973).

DEFINITION OF SCIATICA

• The terms Sciatica has come to be applied to a benign syndrome characterized

especially by pain beginning in the lumbar region and spreading down the back of

one lower limb to the ankle75

• Pain radiating from a lumbosacral nerve root into the leg is sciatica. Irritation of the

fourth and fifth lumbar and first sacral roots, which form the sciatic nerve, causes

pain that extends mainly down the postero and anterolateral aspects of leg and into

the foot termed sciatica.76

Sciatica refers to pain that begins in the hip and buttocks and continues all the way down

the leg. This condition is often accompanied by low back pain, which can be more or less

severe than the leg pain. The term "sciatica" indicates that the sciatic nerve, which travels

from the lower back through the buttocks and into the leg, is thought to be the cause of

the pain in this condition. True sciatica is a condition that occurs when a herniated lumbar

disc compresses one of the contributing roots of the sciatic nerve. This type of low back

pain is less common than other causes and conditions that produce back pain. For

instance, sporting activities, recreational activities, and heavy labour can cause back and

leg pain, which is commonly misdiagnosed as sciatica. The challenge for a physician is to

distinguish between radicular pain, which is caused by an inflammed nerve root, and

referred pain, which is a result of a musculoskeletal sprain or strain.

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Modern review

Sciatic nerve anatomy

The sciatic nerve is the largest and longest single nerve in the human body, about as big

around as a thumb at its largest point. The nerve originates in the lower spine as nerve

roots exit the spinal cord (through the bones in the spine), and extends all the way down

the back of the leg to the toes.

The sciatic nerve is actually a combination of nerves. It is formed on the right and left

hand side of the lower spine by the combination of the fourth and fifth lumbar nerves and

the first three nerves in the sacral spine. Each nerve exits the spine between two vertebral

segments and is named for the segment above it.

• The nerve that exits between lumbar segment 4 and lumbar segment 5 (L4 and

L5) is called the L4 nerve root, and the nerve that exits between the L5 and Sacral

segment 1 is called the L5.

• The nerves that emerge from the sacral foramen are called the S1, S2 and S3

nerves.

The five nerves group together on the front surface of the piriformis muscle (in the

rear) and become one large nerve - the sciatic nerve. This nerve travels then down the

back of each leg, branching out to innervate specific regions of the leg and foot.

In the lower thigh/above the back of the knee, the sciatic nerve divides into two

nerves, the tibial and peroneal nerves, which innervate different parts of the lower

leg: The peroneal nerves travel laterally (sideways) along the outer aspect of the knee

to the upper foot.

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Modern review

• The tibial nerves continue to travel downward towards the feet and innervate the

heel and sole of the foot.

The sciatic nerve supplies sensation and strength to the leg as well as the reflexes

of the leg. It connects the spinal cord with the outside of the thigh, the hamstring

muscles in the back of the thighs, and muscles in the lower leg and feet. As such,

when the sciatic nerve is impaired it can lead to muscle weakness in the leg and/or,

numbness or tingling.

Causes of sciatica

Sciatica is charecterised by pain in the course of sciatic nerve. Any condition

resulting in sciatic nerve root irritation can result in the pain along the distribution of

sciatic nerve. In majority of the cases, this is caused due to prolapse of lumbar disc.

The etiology can be broadly classified into two headings.

1. Compressive causes of sciatica

2. Non compressive causes of sciatica

I. Compressive causes

1. Traumatic causes

Any external injury to the lumbar spine or in the near by structures can precipitate

pain. Injury may be caused due to various causes- either fall from height, lifting

heavy weight, blow or injury to the lumbar spine, travelling in uneven roads with

jerky movements, unexpected postures, twisting of trunk etc. These injuries can result

in strain, sprain, ligamentous or muscular injuries, fractures, dislocations etc.

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Modern review

2. Congenital defects

Defects in the vertebre and soft tissue allies as in the case of spina bifida, sacralisation of

the 5th vertebra, scoliosis, spondylosis, spondylolisthesis etc.

3. Inter vertebral disc pathology

Either due to increased turgidity or herniation of the nucleus pulposus, the intervertebral

disc can become a potent cause for sciatica. The disc, especially between fourth and fifth

lumbar vertebre and fifth lumbar and sacrum are subjected to great forces and

degenerative changes. As degenerative changes progress with disc material protruding

posteriorly into the neural canal it exerts pressure on the sciatic nerve roots. The amount

of nerve pressure varies depending on the size of the protrusion, local inflammation and

odema.

Other conditions which may result in nerve root irritation are:

• Lumbar spondylosis-Degenerative changes in lumbar region

• Spondylosis- Weakness in pars interarticularis

• Spondylolisthesis- Slipping of the vertebre along with the spinal

column above, over the vertebra below.

• Lumbar spinal stenosis- Degenerative spinal disorder

• Ankylosing spondylitis or Rheumatiod spondylitis

• Rheumatoid arthritis

• Lumbar spondylitis

• Osteo arthritis of lumbar spine

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Modern review

• Tuberculosis of vertebral column and spine

• Neoplastic conditions- Metastatic carcinoma (primary in lungs,

breasts, prostate, thyroid, kidney, GI Tract etc)

• Several metabolic diseases such as osteomalacia, osteoporosis etc

result in vertebral body weakness which is easily prone to fractures,

protrusion, herniation etc.

1) Non compressive causes

• True sciatic neuritis- Ischaemic necrosis in diabetis mellitus and

polyarthritis nodosa, leprosy neurofibromas, direct nerve injuries due to

penetrating wounds, claudication of sciatic nerve, compressive injury to

sciatic nerve due to emaciation or fetal head during delivery.

• Referred pain from visceral diseases-Caused due to abdominal, visceral or

pelvic pathologies. Upper abdominal conditions can cause pain in the

dorsolumbar region, lower abdominal conditions in the lumbar region,

genito urinary pathologies in the lumbosacral, sacral and sacroiliac

regions.

• Leucorrhoea, pelvic inflammatory diseases, repeated pregnancy, uterine

disorders, contraceptive device

• Postural back pain- Due to prolonged uneven postures

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Modern review

• Malingerer’s-With lack of any organic pathology and confirmed by their

bizarre manifestations and watching the patients activities at home and in

society.

• In females during pregnancy

• Occupational stress and strain can precipitate in sciatica.

Pathology of sciatica

In its totality, the behavior of the spine is that of a flexible rod. Its function is to

absorb loads and permit movement while protecting the spinal cord and emerging

nerve roots. The vertebrae are separated from each other by intervertebral discs,

designed to allow absorption of load and synovial apophysial joints which are angled

so that the appropriate movement is facilitated – flexion / extension, side flexion and

rotation in the cervical spine, predominantly rotation in the dorsal spine and

predominantly flexion / extension and side flexion in the lumbar region. The normal

spinal posture is vertical, with cervical and lumbar lordosis and a mild thoracic

kyphosis, this alignment facilitating absorption of impact loads during walking and

running.

The discs in the lumbar spine are the soft tissue structures that lie between the vertebrae.

A disc consists of an outer casing or annulus, and an inner jelly-like substance or nucleus.

The healthy disc has a jelly-like nucleus, but as discs age it subject to damage and/or

prolapse. A disc herniation occurs when the wall of the disc or annulus develops a tear or

weakness and disc material comprising nucleus and annulus is pushed out through the

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Modern review

weakening in the outer annulus. This may be associated with local back pain related to

the damage to the annulus.

When the disc herniates or ruptures it frequently puts pressure on the nerve root

that passes in close to the disc in the spinal canal. This is where the symptoms of sciatica

may occur. Most discs that rupture develop changes in the disc material consistent with

degeneration or wear and tear. It is not entirely clear whether this occurs before the disc

ruptures or after it. It seems likely that a variety of possibilities exist. The disc annulus

may weaken and develop tears with age, but it also seems likely that injury may have a

role.

When the nerve passing the disc is exposed to a rupture, the nerve can either be

affected by direct pressure of the prolapse or by chemical inflammation caused by the

tissue from the disc. Direct pressure occurs when the nerve is trapped by a prolapse

within the nerve canal. This probably accounts for changes in nerve conduction which the

patient feels as altered feeling or muscle weakness. The other effect that the disc prolapse

can have is to inflame the nerve. There is now good evidence that the chemicals from the

nucleus can leak out of the prolapse onto the nerve root resulting in inflammation of the

nerve, pain within its distribution (sciatica) and also changes of nerve function (again

manifest by numbness, pins and needles or weakness).

Prolapse of the intervertebral disc occurs when the nucleus pulposus is no

longer contained within the annulus but bulges through it. Because of the increased

curvature of the posterolateral border of the vertebra, prolapse takes place

preferentially at this site, which is adjacent to the, emerging nerve roots. The force

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Modern review

distribution throughout the spine is such that the L5-S1, discs are by for the most

commonly affected, although prolapse can occur at any level. Root pressure as these

sites gives rise to pain and neurological signs in the ipsilateral leg, usually refered as

Sciatica. The second commonest site of prolapse is at the posterior margin of the disc

where the extruded nucleus presses on the tightly bound posterior spinal ligament. This

causes pain without lateralizing signs and, if large, may result in cord or more usually,

cauda equina compression leading to interference with bladder function and anal

sphincter compentence. More chronic disc protrusion associated with degeneration can

lead to the condition of spinal stenosis. This causes symptoms of cord claudicatiton

with pain in the legs on exertion. The canal diameter is increased by flexion, which

produces the characteristic symptom that cycling is easier than walking, or that the

patients bend forward in order to hurry.

The apophyseal joints may be involved as a part of any inflammatory

polyarthritis, and are particularly prone to osteoarthritis, especially when loading is

abnormal as a result of degeneration and narrowing of the adjacent disc, or in a more

widespread fashion from alignment abnormalities such as scoliosis. Spondylosis is the

association of the degeneration and narrowing of the disc space with the development

of osteophytic lipping at the adjacent vertebral margin. There is often secondary

osteoarthritis in the associated apophyseal joints.

The integrity of the bony spinal cord may be interrupted at the pars

interarticularis, either because of a congenital defect or trauma. The resultant forward

slippage of the verterbra is called spondylolisthesis.

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Sciatica symptoms

The sciatica symptoms one feels (sciatic nerve pain, numbness, tingling,

weakness) tend to be different depending on where the pressure on the nerve occurs.

The patient’s pain and sciatica symptoms can usually be traced to where the

injured/irritated nerve originates in the lower back.

Different types of sciatica pain:

Sciatica from L4 nerve root (usually the L3-L4 level)

The patient may have reduced knee-jerk reflex. Symptoms of sciatica stemming from this

level of the lower back may include: pain and/or numbness to the medial lower leg and

foot; weakness may include the inability to bring the foot upwards (heel walk).

Sciatica from L5 nerve root (usually the L4-L5 level)

The patient may have weakness in extension of the big toe and potentially in the ankle

(called foot drop). Symptoms of sciatica originating at this level of the lower back may

include: pain and/or numbness to the top of the foot, particularly in the web between the

great toe (big toe) and the second toe.

Sciatica from S1 nerve root (the L5-S1 level)

The patient may have reduced ankle-jerk reflex. Symptoms of sciatica originating at this

level of the spine may include: pain and/or numbness to the lateral or outer foot;

weakness that results in difficulty raising the heel off the ground or walking on the

tiptoes.

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Pressure on the sacral nerve roots from sacroiliac joint dysfunction

Symptoms may include: a sciatica-like pain or numbness that is often described as a deep

ache, inside the leg more so than a linear, well-defined geographic area of pain/numbness

found in true sciatica.

Pressure on the sciatic nerve from the piriformis muscle

This pressure on the sciatic nerve can tighten and irritate the sciatic nerve called

Piriformis syndrome. Symptoms of piriformis syndrome may include: a sciatica-like pain

and/or numbness in the leg, usually more intense above the knee, which usually starts in

the rear rather than the low back, often sparing the low back of symptoms or signs.

Piriformis syndrome can mimic the signs and symptoms of sciatica pain from a disc

herniation and is part of the differential diagnosis of possible causes of sciatica.

Table No: 4 Effects of Root compression

Root

compression

Pain

refered

Motor

weakness

Reflex

changes

Sensory

changes

Muscle

wasting

L2

Upper

anterior

thigh

Flexion

and

adduction

of hip

None or

reduced

knee

reflex

None or

upper lateral

and anterior

thigh

None

L3

Anterior

thigh knee

Knee

extension

hip

flexion

and

adduction

Reduced

or absent

knee

reflex

None or

lower anterior

& medial

Thigh

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L4

Lateral

thigh,

medial calf

Foot

inversion

&

dorsiflexi

on, knee

extension

Reduced

or absent

knee

reflex

Antero

medial calf

Thigh

L5

Buttock,

back side

thigh,

lower leg

Extension

and

adductor

of hip.

Flexion of

knee,

dorsiflexi

on of foot

and toes

eversion

Reduced

ancle

reflex

Lateral calf

dorsal &

medial food

expecialy

hallux

Calf

S1

Buttock,

back of

thigh and

calf to heel

Flexion

knee, foot

eversion

and

plantor

flexion

Reduced

or absent

ankle

reflex

Lateral foot

ankle and

lower calf

back of heel

and sole of

foot

Calf

EVALUATION OF SCIATICA

When a patient sees the doctor for symptoms of sciatica, detailed evaluation is required.

This normally consists of a detailed history of symptoms and events that led to the onset

of them. It should also include a systemic questioning to exclude other potential causes of

problems.

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History is then followed by an examination which aims to exclude other causes of leg

pain and document any evidence of tension on the nerve, tenderness to the spine and

neurological change in the sciatic nerve distribution.

This will include a neurological examination of the legs checking for sensation, strength

and any change in reflexes. It is very common for the doctor to ask about symptoms

relating to abnormal function of the bladder or bowel.

This inquiry relates to symptoms of loss of control of the bladder or bowel rather than

change in regularity. If there are symptoms related to loss of bladder or bowel control the

doctor may have to perform a rectal examination where the back passage is checked for

any loss of sensation or anal muscle strength.

It is not uncommon for patients who have pain or who are taking pain relieving

medication to become constipated or find that they are inhibited from straining on the

toilet. It is also not uncommon for patients with back pain to go to the toilet more

frequently. The doctor asks about symptoms of control loss because there are very rare

cases where large disc herniations put pressure on the nerves supplying the bladder and

bowel. If this should happen and there were permanent damage to these nerves, it might

result in permanent loss of control of bladder and bowel function. This has very

important social as well as medical consequences.

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CLINICAL DIAGNOSIS:

History:

A thorough history and physical examination is an important part of the diagnosis of

sciatica. Nerve root tension tests can be used to confirm the presence of sciatica by

attempting to reproduce the discomfort with certain motions and body positions. These

tests are performed by a doctor and involve moving the legs in certain ways that

slightly stretch the sciatic nerve. If the patient experiences pain during these tests, an

irritated sciatic nerve is likely to be a source of the pain.

A detailed history regarding the nature, character of pain, its distribution, mode of onset,

chronicity, aggravating factors etc. should be taken. Also history of trauma, infectious

diseases, personal history, past medical history, any associated diseases and also family

history, obstetric history and occupational history should be inquired.

EXAMINATION

General examination

Any clues for systemic diseases should be looked for eg. fever etc. They help for

differential diagnosis as well as treatment decisions.

Musculoskeletal Examination

Gait: The patient of sciatica has a very typical limping gait while walking referred to as

Antalgic gait.

Posture: The shape of the lumber spine is altered and the mobility is restricted. The

spinal mobility is checked by the ability to bend forwards. There may be loss of normal

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lordosis. The muscular spasm produces list to one or other side on standing, known as

sciatic scoliosis.

Tenderness: Local tenderness and presence of trigger points in the back and limb should

be identified.

The following signs are helpful to confirm the diagnosis of sciatica.77

Straight leg raising test (SLR)

There is no universal agreement about the correct way to perform the straight leg

raising test. One method is that when the patient is in the horizontal position, on a

counch or on the floor, asks him to do straight leg raising. Another method is to

support the heel in the cupped hand of the examiner and having explained the

method to the patient, gently lift the heel from the counch with the knee still

extended. Normally the leg can be raised upto 80o -90o without any pain.

The opposite hand rests on the pelvis to limit pelvic rotation. The elevation is stopped

when the patient complains of pain which is due to stretching of the affected root and

the angle is assessed using goniometer. The patient is asked about the site of that

pain. However, although a little uncomfortable for the patient, better repeatability is

obtained by lifting the leg to the maximum permitted level.

This test is most useful diagnostically to assess the severity of the pain and

prognostically to assess the results of treatment. Crossed leg pain is pathognomic of a

disc herniation and suggests a poor prognosis.

• Lasegue test: It elicits pain in the leg or back, when at the limit of straight leg raising

the knee is slightly flexed, the hip further flexed and the knee then extended.

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• Bragaad’s test: At maximum straight leg raising, the foot is dorsiflexed to see if

tension on the posterior tibial nerve increases the sensation of pain. In the same

position, the limb is extremely rotated, relaxing the sacral plexus and then internally

rotated; increasing root tension, the experience of pain is recorded.

• Bow-string test: At the limit of straight leg raising, the knee is first flexed and then

extended and the tibial nerve compressed at the popliteal fossa with the examining

fingers of one hand, the ‘bow string test’.

• Flip test: Patients is asked to sit on the edge of couch with hip and knee flexed at 900

to examine the ankle jerk. In the presense of root irritation this test makes the patient

to ‘flip’ backwards to relieve the sudden increase of tension on nerve root.

• Schober’s test: A mark is made on the skin in the midline at the levels of Dimples of

Venus. Two marks are made, one 5 cm below and second 10 cm above the first mark.

A measuring tape is placed over the lower mark and the patient is asked to bend

forwards. Movement is recorded of the upper mark. On flexion the upper mark should

normally move upwards at least by 5 cms.

All the above mentioned tension signs are generally present when a lower lumbar or

sacral root is involved in the pathological process of pain. They are marked with acute

root involvement from a disc protrusion, but mild or absent with nerve root irritation

from long standing degenerative change. Also pelvic rotation and testing of sacroiliac

joints by pressure on two anterior superior iliac spines should be done.

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Neurological Examination

• The knee, ankle and plantar reflexes should be examined and they should be

symmetrical on both the sides.

• The motor power of selected muscles i.e. extensor hallucis longus (L5 or S1), peronei

(S1), quadriceps (L4 and 5) should be recorded.

• Wasting of muscles of the leg especially quadriceps should be measured.

• The sensation should be recorded by using a sharp pin. Areas of numbness,

hypoasthesias should be marked.

Others

• The dorsalis pedis and anterior tibial arteries should be palpated because claudication

pain can be confused with the radicular pain.

• Palpation of the abdomen is also mandatory, as an abdominal mass may explain the

cause of pain.

• Rectal examination should be carried out and in women vaginal examination also.

All the above signs have got some clinical value but it is not always that one or more of

them may be present and the diagnosis has to be confirmed by other measures.

Investigations

Laboratory investigations

• Urine examination for sugar etc.

• Complete blood count (C.B.C.), Erythrocyte sedimentation rate (E.S.R.) These are

especially helpful in screening for infection or myeloma.

• Rheumatoid factor for rheumatoid arthritis, serum calcium, phosphorus, uric acid,

alkaline phosphatase in suspected hyperparathyroidism, malignancy, osteoporosis,

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Paget’s disease and acid phosphate in suspected case of metastatic carcinoma of

prostate.

• Cerebrospinal fluid examination for the diagnosis of disease of the central nervous

system and spinal cord.

Other Diagnostic Techniques

• Plain radiographs: No assessment of spine is complete without radiographs. Many

causes of sciatic pain are associated with bony changes visible in radiographs

Roentgenograms of lumber spine (L4,L5,S1) in anteroposterior, lateral and oblique

planes gives differential diagnosis of narrowing of disc space, spondylolisthesis,

sclerosis of vertebral bodies, disc herniations, prolapse etc.

• Myelography: Myelography is radiography after injection of an opaque substance

into the lumbar spinal subarachnoid space, usually at the L2-L3 level. The purpose is

to outline the spinal cord and nerve root in order to demonstrate pathological lesions

such as lesions or fissuring of annulus, cyst on sacral nerve roots etc. It is obviously

contraindicated if lumbar puncture is contraindicated Epidurography can be done for

the diagnosis of intraspinal lesions not visualized by conventional myelography.

Discography may be done by injecting contrast medium directly into the

intervertebral disc but it is pain-provocating, carrying risk of damage and infection.

Also it is difficult to interprete.

• C.T. Scan: An important advance in radiological investigation of post fossa and

spinal lesions, from syringomyelia to lesions of the lumbosacral nerve roots and

cauda equina, has been the combination of CT scan with myelography using a non-

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Modern review

ionic water soluble medium such as iohexol. Reconstruction techniques can be used

to outline the spinal cord and nerve roots with a precision hitherto impossible.

• MRI: MRI has several advantages over CT scanning in the assessment of cervical

and lumbosacral spines. No ionising radiations involved and intradural soft tissue

lesions can be visualized without the need for intrathecal contrast.

• Procaine Injection Test: Disappearance of the pain following local injection of

procaine or lidocaine into the tender spot is both diagnostic and therapeutic of

fibrositic pain.

• EMG: Electromyographic studies help to confirm the presence of impaired nerve

functions. Selective muscle degeneration can be identified and can suggest the nerve

root responsible.

• Nerve conduction tests support a diagnosis of peripheral nerve entrapment of the

common peroneal nerve at the neck of the fibula and of the post tibial nerve in tarsal

tunnel syndrome.

• Radionuclide Bone Scanning: Bone scanning is currently used to investigate a wide

range of spinal disorders, both benign and malignant. It is a highly sensitive method

for demonstrating bone disease, often providing an earlier diagnosis and

demonstrating more lesions than are found on X-ray.

• Aortic arteriography, intravenous pyelography and barium enema may be necessary

to find out aortic aneurysm or pelvic or rectal pathology.

Differential Diagnosis of Conditions Causing Sciatica

1. Disc Lesion:Recurrent bouts of lower back pain (lumbago) followed by unilateral

sciatica, or pain first in calf or thigh or both without any lumbar symptoms,

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Straight leg rising limited, neurological signs absent if small protrusion present, if

large displacement compressing the root severely pain occurs. A huge herniation

may squeeze the root so hard that it becomes anaesthetic from ischemia and the

pain ceases; straight leg raising becomes once again of full range at the same time

as cutaneous analgesia and loss of power and reflexes supervene.

2. Spondylolisthesis: Signs of disc lesion together with lumbar deformity.

When spondylolisthesis causes intrinsic symptoms, there is backache after

prolonged standing, or bilateral sciatica. X-ray taken with the patient standing is

diagnostic.

3. Attrition of disc:Full approximation of the vertebral bodies following attrition of

disc allows posterior longitudinal ligament to be unduly long. Sciatica caused by

standing due to compression posterior bulge of the disintegrated disc which

pushed back into position when posterior longitudinal ligament is toughened by

lying down. X-ray shows markedly diminished joint space with marked anterior

beaking at the affected level.

4. Sacro-iliac Arthritis: Alteration of pain is significant ie. pain comes in one

buttock and posterior thigh, and then it transfers itself to the other side. Signs of

involvement of 1st and 2nd sacral segments. No lumbar signs. Pressure on

anterior iliac spines provokes pain in the buttock. SLR usually remains normal.

5. Secondary deposits in spine: Gradually central backache, tendency to radiate to

lower limb, soon to both. Marked limitation of involvements at lumbar spine.

SLR of full range, though painful at the extreme. Multiradicular signs in lower

limbs. Muscle weakness bilateral, unequal and marked.

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6. Benign Spinal Tumor:Progressive increase in symptoms. Neurological signs more

severe and progressive than in disc lesion. If radiograph shows erosion of bone

and induction of epidural anaesthesia does not cause disappearance of pain for the

time being, a tumor is very probably present.

7. Major Lesions in the Buttock:Such as acute osteomyelitis of ilium or upper

femur, ischio-rectal abscess pointing into buttock, septic gluteal bursitis. Straight

leg raising and hip flexion both very painful. (In sciatica due to disc lesion hip

flexion is not limited).

8. Arthritis of the Hip:Hip movements restricted and pain provoked by passives

movements. Radiograph of pelvis is diagnostic.

9. Intermittent Claudication: When internal iliac artery is affected alone,

claudication in gluteus maximus on walking may be the only symptom.

Diagnostic signs – patient lies prone and his hip is extended passively; this causes

no pain. He is then asked to keep the leg extended for a minute. This brings on

the claudication. Spinal claudication is to be suspected when the patient gets pins

and needles type of pain in both lower limbs on walking a certain distance.

Examination shows all arteries of the lower limbs to be patent. The cause is

intraspinal ischesmia of the nerve roots compressed by a disc lesion or involved

in arachnoiditis.

10. Dissecting Aneurysm: A rare cause of sciatica is a slowly expanding aneurysm at

the bifurcation of aorta compressing 3rd and 4th lumbar nerves and causing local

pain and accompanied by paraesthesia and weakness in left lower limb. Patient

complains of severe backache. Aortograpy should be done.

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Prognosis of Sciatica

In most cases of sciatica spontaneous recovery occurs rather slowly with some liability

to recurrence. In mild cases the stage of severe pain losts in only two to three weeks

and a patient recovers in a month or two but may from time to time experience aching

along the course of the nerve and stooping may still excite some pain in the affected

leg.

In more severe cases there may be slight improvement after several weeks, but

the condition then becomes stationary and the patient continues to suffer from

considerable pain which is fluctuating in severity and sustains for months or years

together. Finally the recovery occurs in most cases but some symptoms remain as

residue. Though there is symptomatic relief but relapses are very common as

underlying pathology i.e. disc protrusion, osteophytes, spurs etc. hardly change without

surgical interventions. In some cases relapse occurs at frequent intervals and in some,

second attack may be devloped ten or more years after the first.

Management of Sciatica

Type of treatment in any disease differs according the onset, severity, duration

and most important is the cause of the disease, the minor disc prolapse is usually self

limited, responding to simple conservative measures.

Most patients desire relief from pain when they have severe sciatica. This can be

achieved using a number of medications. Simple pain killers and anti-inflammatory

medications are most commonly prescribed. These can be used together. Anti-

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inflammatories can be very useful although care must be taken if there is a history of

peptic ulcer disease or other gastrointestinal upset, or any history of poor kidney function.

Stronger pain relievers, some with an opioid base, may be used for more severe and

persistent pain. Patients with intense neuralgic or nerve type pain may also respond to

medications that specifically act to reduce the sensitivity of the nerves. These include

low-dose antidepressants (tricyclics) and other drugs of a sedative nature. During the very

severe phase of sciatica rest may be necessary. There is a growing trend to avoid

prolonged periods of rest unless absolutely essential. Many find that it is the only way

that the very severest of symptoms can be controlled.

Physiotherapy may have a role, although with severe sciatica it can sometimes upset

symptoms.

Surgical options for Sciatica:

If sciatica has been present for a prolonged period of time (over six weeks) and has failed

to respond to conservative care, surgical treatment may have a role. It is imperative that

in this situation the patient is investigated with a CT or MRI scan to demonstrate the disc

herniation. At this point surgical treatment may be offered. The commonest and most

effective treatment is partial excision of the disc and is normally referred to as

"discectomy". This should only be considered for prolonged pain (greater than six

weeks), pain within a sciatic distribution below the knee, pain associated with some form

of neurological symptom and pain that is exacerbated by stretching the nerve. In these

situations pain can most often be relieved with partial discectomy.

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When sciatica has resolved, whether or not surgery has been required, the patient should

maintain optimum conditions for their spine. The fact that the spine has had a prolapse,

and is not normal, does not preclude a relatively normal lifestyle.

General recommendations include avoidance of smoking (which is associated with

increased back pain and poorer outcomes from spinal surgery), and avoidance of obesity

(which is associated with greater loads across the spine and other joints).

An exercise programme to maintain aerobic fitness is to be encouraged. This may include

regular brisk walking, swimming or cycling. Specific exercises to maintain flexibility and

strengthen the abdominal and spinal muscles are important.

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Drug review

DRUG REVIEW

In the present clinical trial Gandharvahastha Taila78 mentioned in Ashtanga Samgraha

Chikitsa 15th chapter and Vatari Guggulu79 mentioned in Bhaishajya ratnavali 29th

chapter are administered for the patients of Gridhrasi.The details of the ingredients of

these medicinal combinations are detailed below.

Gandharvahastha Taila:

Eranda moola: 4.800Kg

Yava: 3.072Kg

Nagara: 96gm

Water: 24.576 L

Reduced to 6.144 L

Ksheera: 1.536

Eranda taila: 768gm

Eranda moola: 192gm

Sunthi: 48gm

Method of preparation:

Kwatha prepared with Eranda moola, yava and shunti and is reduced to 1/4th. This is

filtered and to this dugdha and eranda taila is added along Eranda moola and shunti as

kalka dravya and taila is prepared in mandagni.

Therapeutic uses: Mahavataroga, Vidradhi, pleeha, Gulma, Udavarta, Sopha, Udara

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Drug review

Vatari Guggulu:

Vatari Taila: 1 part

Suddha Gandhaka: 1 part

Suddha Guggulu: 1 part

Haritaki: 1 part

Vibhitaki: 1 part

Amalaki: 1 part

Method of preparation :

Suddha Guggulu is made soft by adding Eranda taila. Powders of other drugs are added

and mixed well. This is made into tablet form of 500mg.

Therapeutic Uses: Amavata, Katishula, Gridhrasi, Khanja, Pangu, Vatarakta,

Kroshtukasheersha

Eranda

Botanical name: Ricinus communis Linn

Family:Euphorbiaceae

Rasa: Madhura, Kashaya

Anurasa:Katu

Guna: Snigdha, Tikshna, Sukshma

Veerya: Ushna

Vipaka: Madhura

Doshakarma: Kaphavata samana

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Drug review

Yava

Botanical name: Hordeum vulgare Linn

Family: Gramineae

Rasa: Kashaya, Madhura

Guna: Ruksha, Laghu

Veerya: Seetha

Vipaka: Katu

Doshakarma: Vatakara, Sleshmapittahara

Nagara

Botanical name: Zingiber officinale

Family: Zingiberaceae

Rasa: Katu

Guna: Laghu, Snigdha, Ruksha

Veerya: Ushna

Vipaka: Madhura

Doshakarma: Kaphavata samaka, Dipana, Bhedana

Gandhaka

English : Sulphur

Rasa: Madhura, Tikta, Katu, Kashaya

Guna: Ushna, snigdha, sara

Vipaka: Katu

Veerya: Ushna

Karma: Garavishahara, amapachana, deepana, kandughna

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Drug review

Doshakarma: Vatakapha nasaka

Guggulu

Botanical name: Commiphora mukul

Family:Burseraceae

Rasa: Tikta, Katu

Guna: Laghu, Ruksha,Tikshna, Visada,Sukshma, Sara

Veerya: Ushna

Vipaka: Katu

Doshakarma: Vatahara, kaphahara

Haritaki

Botanical name: Terminalia chebula Retz

Family: Combretaceae

Rasa: Pancharasa, lavanavarjita, Kaphapradhana

Guna: Laghu, Ruksha

Veerya: Ushna

Vipaka: Madhura

Prabhava: Tridoshahara

Doshakarma: Vatapittakaphahara, viseshataha vatasaamaka

Vibhitaki

Botanical name: Terminalia bellirica Roxb

Family: Combretaceae

Rasa: Kashaya

Guna: Ruksha, Laghu

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Drug review

Veerya: Ushna

Vipaka: Madhura

Doshakarma: Tridoshahara,Viseshataha Kaphahara

Amalaki

Botanical name: Emblica officinalis Gaertn

Family: Euphorbiaceae

Rasa: Pancharasa, lavanarahita, amlapradhana

Guna: Guru, Rooksha, Seeta

Veerya: Seeta

Vipaka: Madhura

Doshakarma: Tridoshahara, viseshataha pittasaamaka

73

Methodology

MATERIALS AND METHODS

Aim

This study entiltled ‘A Clinical study on the management of Gridhrasi with

Gandharvahastha Taila and Vatari Guggulu is aimed to fulfill the following criteria.

1. To make a comprehensive literary study of Gridhrasi.

2. To evaluate the therapeutic efficacy of Gandharvahastha taila and Vatari guggulu

in bringing symptomatic relief in patients of Gridhrasi.

3. To study the functional improvement with Gandharvahastha Taila and Vatari

Guggulu in the patients of Gridhrasi.

Source of data

The patients who attented the OPD of S.D.M.Ayurveda Hospital, Udupi having the

complaints of Low backache radiating to leg were screened. Among them 20 patients

fulfilling the inclusion criteria of the present study were taken. A detailed history taking

and physical examinations were carried out in these patients. Relevant data along with the

elaborate assessment of Pain, Neurological deficit, Functional ability & Functional

disability was registered in the designed case proforma.

Inclusion Criteria

The patients were taken for the present study as per the following inclusion criteria.

1. Patients with pratyatma lakshana of Gridhrasi.

2. Patients between the age group of 20 to 60 years.

3. Patients having positive physical signs of radicular pain/ Sciatica

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Methodology

Exclusion Criteria

The patients suffering from Gridhrasi caused due to the following were excluded from

the study.

1. Neoplastic conditions of spine.

2. Trauma of spine

3. Infections of spine.

Investigations

Routine haematological investigations along with radiological investigations were carried

out when ever found necessary.

Design

It is a single blind clinical study with pre test and post test design were in 20 patients

diagnosed to have Gridhrasi fulfilling all the criteria for the study were selected randomly

and was placed in a single group.

Intervention

The patients were treated with oral administration of Gandharvahastha Taila 10ml Bd

with warm water and Vatari guggulu 1gm tid with warm water for duration of 30 days.

Assessment criteria

Assessment was done initially before intervention of medicine and there after weekly for

a period of 30 days. In the follow up period of 1 month, the patients were assessed once

in 15 days. Assessment was done by using the below mentioned scoring method.

1. Stambha (Stiffness):

i. No stiffness - 0

ii. Mild stiffness - 1

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Methodology

iii. Moderate stiffness - 2

iv. Severe stiffness - 3

2. Ruk (Pain):

i. No pain - 0

ii. Painful, walks without limping - 1

iii. Painful, walks with limping but without support - 2

iv. Painful, can walk only with support - 3

v. Painful, unable to walk - 4

3. Toda (Pricking Sensation):

i. No pricking sensation - 0

ii. Mild pricking sensation - 1

iii. Moderate pricking sensation - 2

iv. Severe pricking sensation - 3

4. Spandana (Twitchings):

i. No twitching - 0

ii. Mild twitching - 1

iii. Moderate twitching - 2

iv. Severe twitching - 3

5. Aruci (Anorexia):

i. No anorexia - 0

ii. Mild anorexia - 1

iii. Moderate anorexia - 2

iv. Severe anorexia - 3

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Methodology

6. Tandra (Stupor):

i. No stupor - 0

ii. Mild stupor - 1

iii. Moderate stupor - 2

iv. Severe stupor - 3

7. Gaurava (Heaviness):

i. No heaviness - 0

ii. Mild heaviness - 1

iii. Moderate heaviness - 2

iv. Severe heaviness - 3

Table No: 5 Assessment of Pain – Greenough and Fraser scoring method:

Question Answer Points

Never 6

Occasionally 4

Almost every day 2

How often do you have to take pain killers for

your pain?

several times every day 0

Never 6

Rarely 4

1-2 times per month 2

How often do you have consultation with a

doctor?

1-2 times per week 0

full time at regular job 9

full time at a lighter job 6

part time 3 At present, are you working?

not working 0

not at all 6 So you need to rest during the day because of

pain? a little 4

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Methodology

half the day 2

Over half the day 0

Normally 9

as many as usual, but slowly 6

A few, not as many as usual 3

At present, can you undertake household chores

or additional jobs?

not at all 0

as much as usual 9

almost as much as usual 6

Some, much less than usual 3

At present, can you undertake sports or active

pursuits, such as dancing?

not at all 0

no effect 3

mildly or moderately affected 2

Difficult 1

How much does back pain affect your ability to

dress?

not possible 0

no effect 3


Difficult 1


sit?

not possible 0

no effect 3


Difficult 1


walk?

not possible 0

no effect 3


Difficult 1


sleep?

not possible 0

no effect 3


Difficult 1


travel?

not possible 0

78

Methodology

no effect 6


Difficult 2 How much does back pain affect your sex life?

not possible 0

• The higher the score, the better the performance status.

Table No.6 Assessment of Neurological Deficit

Parameter Finding Points

Normal 0

reflex asymmetry, age > 50 or previous surgery 0

reflex asymmetry, age <= 50 years of age 5

motor weakness 10

sensory deficit 10

Neurological

signs

motor and sensory deficits 25

list-flexed knee stance 10

femoral nerve stretch positive 10

unilateral straight leg raising > 75° 0

unilateral straight leg raising 60-75° 10

unilateral straight leg raising < 60° 20

Root tension

signs

crossed straight-leg response 20

Table No.7 Assessment of Functinal Ability

Sugarbaker and Barofsky Clinical Mobility scale:

Mobility Parameter Finding Rating

Does not stand 0

stands only with personal assistance 1

stands with the assistance of a hand-held appliance (crutch,

cane, walker) 2

upright posture (how

patient functions with

or without prosthesis)

stands without assistance 3

walking (how patient does not walk 0

79

Methodology

walks only with personal assistance 1

walks with the assistance of a hand-held appliance (crutch,

cane, walker) 2

functions with or

without prosthesis)

walks without assistance 3

walks slowly or not at all 0

walks at a moderately slow pace 1

walks briskly 2

gait (how patient

functions with or

without prosthesis) can jog or run 3

sits only for short periods of time and prefers to lie down 0

sits without discomfort for short periods of time (1 hr) 1

sits without discomfort for longer periods of time (over 1

hr) 2

sitting (how patient

functions with or

without prosthesis)

sits without discomfort 3

cannot climb stairs 0

climbs stairs with assistance of another person 1

climbs stairs with assistance of hand rail and/or crutches 2

stair climbing (how

patient functions with

or without prosthesis) climbs stairs unassisted 3

cannot use crutches or cane 0

Must use crutches 1

uses single crutch or cane or two crutches intermittently 2

hand-held appliances

(crutches and canes)

uses no hand-held appliance 3

moves with the aid of wheelchair most of time 0

moves with the aid of wheelchair only for long distances 1

occasionally uses wheelchair 2 Wheelchair

Never uses wheelchair 3

Spends most day in bed or on couch at home 0

spends most of day in chair at home 1

spends most of day ambulatory but confined to the house 2 time usage

spends most of day ambulatory 3

80

Methodology

Functional Disability

Oswestry Disability assessment Questinnaire:

Questionnaire description: 10 sections describing the pain and its impact with each

section scored from 0-5, with higher values indicating more severe impact.

Section 1: Pain Intensity

• I can tolerate the pain I have without having to use pain killers. [0 points]

• The pain is bad but I manage without taking pain killers. [1 point]

• Pain killers give complete relief from pain. [2 points]

• Pain killers give moderate relief from pain. [3 points]

• Pain killers give very little relief from pain. [4 points]

• Pain killers have no effect on the pain and I do not use them. [5 points]

Section 2: Personal Care

• I can look after myself normally without causing extra pain. [0 points]

• I can look after myself normally but it causes extra pain. [1 point]

• It is painful to look after myself and I am slow and careful. [2 points]

• I need some help but manage most of my personal care. [3 points]

• I need help every day in most aspects of self care. [4 points]

• I do not get dressed, wash with difficulty and stay in bed. [5 points]

Section 3: Lifting

• I can lift heavy weights without extra pain. [0 points]

• I can lift heavy weights but it gives extra pain. [1 point]

• Pain prevents me from lifting heavy weights off the floor, but I can manage if

they are conveniently positioned, for example, on a table. [2 points]

81

Methodology

• Pain prevents me from lifting heavy weights but I can manage light to medium

weights if they are conveniently positioned. [3 points]

• I can lift only very light weights. [4 points]

• I cannot lift or carry anything at all. [5 points]

Section 4: Walking

• Pain does not prevent me walking any distance. [0 points]

• Pain prevents me walking more than 1 mile. [1 point]

• Pain prevents me walking more than 0.5 miles. [2 points]

• Pain prevents me walking more than 0.25 miles. [3 points]

• I can only walk using a stick or crutches. [4 points]

• I am in bed most of the time and have to crawl to the toilet. [5 points]

Section 5: Sitting

• I can sit in any chair as long as I like. [0 points]

• I can only sit in my favourite chair as long as I like. [1 point]

• Pain prevents me sitting more than 1 hour. [2 points]

• Pain prevents me from sitting more than 0.5 hours. [3 points]

• Pain prevents me from sitting more than 10 minutes. [4 points]

• Pain prevents me from sitting at all. [5 points]

Section 6: Standing

• I can stand as long as I want without extra pain. [0 points]

• I can stand as long as I want but it gives me extra pain. [1 point]

• Pain prevents me from standing for more than 1 hour. [2 points]

• Pain prevents me from standing for more than 30 minutes. [3 points]

82

Methodology

• Pain prevents me from standing for more than 10 minutes. [4 points]

• Pain prevents me from standing at all. [5 points]

Section 7: Sleeping

• Pain does not prevent me from sleeping well. [0 points]

• I can sleep well only by using tablets. [1 point]

• Even when I take tablets I have less than 6 hours sleep. [2 points]

• Even when I take tablets I have less than 4 hours sleep. [3 points]

• Even when I take tablets I have less than 2 hours of sleep. [4 points]

• Pain prevents me from sleeping at all. [5 points]

Section 8: Sex Life

• My sex life is normal and causes no extra pain. [0 points]

• My sex life is normal but causes some extra pain. [1 point]

• My sex life is nearly normal but is very painful. [2 points]

• My sex life is severely restricted by pain. [3 points]

• My sex life is nearly absent because of pain. [4 points]

• Pain prevents any sex life at all. [5 points]

Section 9: Social Life

• My social life is normal and gives me no extra pain. [0 points]

• My social life is normal but increases the degree of pain. [1 point]

• Pain has no significant effect on my social life apart from limiting my more

energetic interests such as dancing. [2 points]

• Pain has restricted my social life and I do not go out as often. [3 points]

• Pain has restricted my social life to my home. [4 points]

83

Methodology

• I have no social life because of pain. [5 points]

Section 10: Traveling

• I can travel anywhere without extra pain. [0 points]

• I can travel anywhere but it gives me extra pain. [1 point]

• Pain is bad but I manage journeys over 2 hours. [2 points]

• Pain restricts me to journeys of less than 1 hour. [3 points]

• Pain restricts me to short necessary journeys under 30 minutes. [4 points]

• Pain prevents me from travelling except to the doctor or hospital. [5 points]

Statistical Analysis:

Mean, percentage, S.D., S.E,‘t’ and ‘p’ value were calculated. Paired‘t’ test and

unpaired‘t’ test was used for calculating the‘t’ value in the data by using “Sigma stat”

statistical software.

The total effect of the therapy has been assessed as below: -

Table No.8 Criteria for overall assessment:

1. Cured 100% relief in sign and symptoms

2. Best Improvement >75% and <100% relief in sign and symptoms

3. Moderate Improvement >50% and <75% relief in sign and symptoms

4. Mild improvement >25% and <50% relief in sign and symptoms

5. Unchanged < 25% relief in signs and symptoms

84

Observations and results

OBSERVATIONS

The details of the descriptive statistical analysis in regards to age, marital status,

place, dietary habit etc of 20 patients suffering from Gridhrasi is elaborated in the

following paragraphs.

Distribution of patients according to Age:

Among the 20 patients included in this study maximum number of patients belonged to

the age group of 41 to 50 years ie. 30%. As shown in the Table No:9, 25% each of the

patients belonged to the age group of 31 to 40 years and 51 to 60 years. A minimum of

20 % patients represented the age group 21 to 30 years.

Table No:9 Incidence of Age

Age in years No. of patients %

21-30 4 20

31-40 5 25

41-50 6 30

51-60 5 25

Figure No.1 Incidence of Age:

20

2530

25

21-3031-4041-5051-60

85


Distribution of patients according to Sex:

In this study 55% of females were registered in comparison to 45% of males.

The following table no.10 shows the details.

Table No:10 Incidence of Sex

Sex No. of patients %

Male 9 45

Female 11 55

Figure No:2 Incidence of Sex:

45

55

MaleFemale

86


Distribution of patients according to Marital status:

The married patient ratio was more compared to the unmarried patient ratio. The

following table shows the details.

Table No:11 Incidence of Marital status

Marital status No. of patients %

Married 18 90

Unmarried 2 10

Figure No:3 Incidence of Marital status

90

10

MarriedUnmarried

87


Distribution of patients according to religion

Most of the patients are Hindus in the present study. The sample includes 85%

of Hindus, while Muslims and Christians were only15% and 0% respectively.

Table No: 12 Incidence of Religion

Religion No. of patients %

Hindu 17 85

Muslim 3 15

Christian 0 0

Figure No:4 Incidence of Religion

85

15 0

HinduMuslimChristian

88


Distribution of patients according to the Habitat

45% of patients were from urban area and 55% of patients from rural area.

Table No:13 Incidence of Habitat

Habitat No. of patients %

Urban 9 45

Rural 11 55

Figure No:5 Incidence of Habitat

45

55

UrbanRural

89


Distribution of patients according to Socio-economic status:

65% of patients were from low Socio economic status, 25% from middle class and

10% from Upper middle class.

Table No:14 Incidence of socio economic status

Socio economic

status

No. of patients %

Low 13 65

Middle 5 25

Upper 2 10

Figure No:6 Incidence of socio-economic status

65

25

10

LowMiddleUpper

90


Distribution of Educational status:

60% of patients had High school education. 20% were graduates. The incidence of

Educational status is shown in the table below.

Table No: 15 Incidence of Educational status

Educational Status No. of patients %

Illiterate 0 0

Primary 1 5

High school 3 15

Secondary 12 60

Graduate 4 20

Figure No:7 Incidence of Educational status

0 515

60

20IlleteratePrimaryHigh schoolSecondaryGraduate

91


Distribution of patients according to occupation

Majority of patients were House Wives with 40%. 25% and 20% of patients were Office

going and Laborers respectively.

Table No:16 Incidence of occupation

Occupation No. of patients %

Laborers 4 20

Office 5 25

House wife 8 40

Agriculture 2 10

Others 1 5

Figure No:8 Incidence of occupation

20

2540

10 5

LaborersOfficeHousewifeAgricultureOthers

92


Distribution of Nature of work:

30% of patients selected for the study were having moderate Nature of work.

Distribution of Nature of work is elaborately shown in the table below.

Table No: 17 Incidence of Nature of Work

Nature of work No. of patients %

Sedentary 4 20

Moderate 6 30

Strenuous 10 50

Figure No:9 Incidence of Nature of work

20

30

50

SedentaryModerateStrenous

93


Distribution of patients according to Addictions:

Most of the patients had no addictions. The following table gives the details.

Table No:18 Incidence of Addictions

Addictions No. of patients %

Smoking 4 20

Betel chewing 3 15

Alcohol 3 15

None 10 50

Figure No:10 Incidence of Addictions

20

15

15

50

SmokingBetal chewingAlcoholNone

94


Distribution of patients according to Dietary habits

Among the 20 patients,60% were of mixed diet and remaining 40% were vegetarians.

Table No:19 Incidence of Dietary habits

Dietary habit No. of patients %

Vegetarian 8 40

Mixed 12 60

Figure No:11 Incidence of Dietary habits

40

60

VegetarianMixed

95


Distribution of patients according to Prakruti:

Majority of patients were of Vatapitta Prakruti with 70%. Vata Kapha Prakriti were

20% and Pittakapha prakruti patients constituted 10%.Ekadoshaja and tridoshaja patients

were not recorded for the study.

Table No:20 Incidence of Prakriti

Prakruthi No.of patients %

Vatapitta 14 70

Vatakapha 4 20

Pittakapha 2 10

Figure No:12 Incidence of Prakruti

70

20

10

VatapittaVatakaphaPittakapha

96


Distribution of patients according to Sara

All the patients taken for the study comes under Madhyamasara. The details given

in the following table.

Table No:21 Analysis of Sara

Sara No. of patients %

Pravara 0 0

Madhyama 20 100

Avara 0 0

Figure No:13 Analysis of Sara

0

100

0

PravaraMadhyamaAvara

97


Distribution of patients according to Samhanana:

In the present study, patients of Madhyama Samhanana were 95% while5% of

patients had Pravara Samhanana. The same is further detailed in the table.

Table No:22 Analysis of Samhanana

Samhanana No. of patients. %

Pravara 1 5

Madhyama 19 95

Avara 0 0

Figure No:14 Analysis of Samhanana

5

95

0


98


Distribution of patients according to Satwa:

In 80% of the patient showed Madhyama satwa, where as Pravara and

Avara satwa are 10%each.

Table No:23 Analysis of Satwa

Satwa No.of patients. %

Pravara 2 10

Madhyama 16 80

Avara 2 10

Figure No:15 Analysis of Satwa

10

80

10

Pravara MadhyamaAvara

99


Distribution of patients according to Satmya:

In 90% of the patients Madhyama Rasa Satmya was observed. Pravara

Satmya was recorded in just 5% of patients. Remaining patients

revealed Avara Satmya.

Table No:24 Analysis of Satmya

Satmya No. of patients. %

Pravara 1 5

Madhyama 18 90

Avara 1 5

Figure No:16 Analysis of Satmya

5

90

5


100


Distribution of patients according to Abhyavaharana Sakthi:

Madhyama Abhyavaharana sakti patients were 50%. Pravara and Avara Abhyavaharana

sakthi patients were 30% and 20% respectively.

Table No: 25 Analysis on Abhyavaharana sakthi

Abhyavaharana sakthi No. of patients. %

Pravara 6 30

Madhyama 10 50

Avara 4 20

Figure No: 17 Analysis on Abhyavaharana sakthi

30

50

20


101


Distribution of patients according to Jarana sakthi:

40% patients were of Madhyama Jarana Shakti and 30%each of Pravara and Avara

Jarana Shakti.

Table No: 26 Analysis on Jarana sakthi

Jarana shakti No. of patients. %

Pravara 6 30

Madhyama 8 40

Avara 6 30

Figure No: 18 Analysis on Jarana sakthi

30

40

30


102


Distribution of patients according toVyayama Sakthi:

Majority of patients ie.60% were having Avara Vyayama sakthi and remaining 40% were

of Madhyama Vyayama sakthi.

Table No: 27 Analysis on Vyayama Sakthi

Vyayama Shakti No. of patients %

Pravara 0 0

Madhyama 8 40

Avara 12 60

Figure No:19 Analysis on Vyayama sakthi

0

40

60


103


RESULTS

Effect on Stambha:

Effect of Gandharvahastha taila and Vatari Guggulu on Stambha before and after

the treatment in 20 patients of Gridhrasi are given below:

The statistical analysis revealed that the mean Stambha score of Gridhrasi which was

1.550 before the treatment was reduced to 0.550 after the treatment and this change is

statistically significant (p=<0.001). Further details with standard deviation, Standard

error of mean, ‘t’ value and ‘p’ value are given below in table no:

Table No: 28 Effect on Stambha

Mean Paired ‘t’ test

BT AT

DIFFERENCE

IN MEANS SD SEM t P

1.550 0.550 1.000 0.858 0.192 5.210 <0.001

Figure No: 20 Effect on Stambha

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT AT

104


Effect on Ruk:

The effect of Gandharvahastha taila and Vatari Guggulu proved to be efficacious in

reducing the symptom Ruk in Gridhrasi. The initial mean score of Ruk was 1.550. This

came down to 0.500 following the treatment, thus recording an improvement by 1.050 in

the mean score. The statistical analysis by adapting the paired t test also showed highly

significant improvement with p<0.001.

Table No 29 Effect on Ruk


BT AT

DIFFERENCE

IN MEANS SD SEM t P

1.550 0.550 1.050 0.686 0.153 6.842 <0.001

Figure No: 21 Effect on Ruk

1.55

0.5

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT AT

BTAT

105


Effect on Toda:

The study shows marked reduction in Toda after the treatment. Before the treatment the

mean score of Toda was 1.400 and was brought down to 0.500 after the treatment with an

improvement by 0.900 in the mean score which is statistically significant with p<0.001.

Table No: 30 Effect on Toda


BT AT

DIFFERENCE

IN MEANS SD SEM t P

1.400 0.500 0.900 0.641 0.143 6.282 <0.001

Figure No: 22 Effect on Toda

1.4

0.5

0

0.2

0.4

0.6

0.8

1

1.2

1.4

BT AT

BTAT

106


Effect on Spandana:

The study shows reduction in Spandana after the treatment. Before treatment the mean

score of Spandana was 0.500 and was brought down to 0.150 after the treatment with an

improvement by 0.350 in the mean score which is statistically significant with p=0.015

Table No: 31 Effect on Spandana


BT AT

DIFFERENCE

IN MEANS SD SEM t P

0.500 0.150 0.350 0.587 0.131 2.666 0.015

Figure No: 23 Effect on Spandana

0.5

0.15

00.050.1

0.150.2

0.250.3

0.350.4

0.450.5

BT AT

BTAT

107


Effect on Aruchi:

Before the administration of medicine the mean score of Aruchi was 0.800. Following

the medication this came down to 0.1000 recording an improvement by 0.700 in the mean

score. By the method of paired t test it was proved that the improvement observed was

statistically significant at 95% confidence level (p<0.001). Details of this statistical

analysis are as follows:

Table No: 32 Effect on Aruchi


BT AT

DIFFERENCE

IN MEANS SD SEM t P

0.800 0.1000 0.700 0.801 0.179 3.907 <0.001

Figure No: 24 Effect on Aruchi

0.8

0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

BT AT

BTAT

108


Effect on Gaurava:

The study shows reduction in Gaurava after the treatment. Before the treatment the mean

score of Gaurava was 0.800 and was brought down to 0.150 after the treatment with an

improvement by 0.650 in the mean score which is statistically significant (p=<0.001)

Table No: 33 Effect on Gaurava


BT AT

DIFFERENCE

IN MEANS SD SEM t P

0.800 0.150 0.650 0.671 0.150 4.333 <0.001

Figure No: 25 Effect on Gaurava

0.8

0.15

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

BT AT

BTAT

109


Effect on Tandra:

The analysis of the mean score of the symptom Tandra before and after the intervention

showed marked reduction. Before the treatment the mean score of Gaurava was 0.550.

After the treatment it came down to 0.200. The improvement after the treatment was

analysed by paired t test which showed statistically significant change at p= 0.031.

Table No: 34 Effect on Tandra


BT AT

DIFFERENCE

IN MEANS SD SEM t P

0.550 0.200 0.350 0.671 0.150 2.333 0.031

Fig No: 26 Effect on Tandra

0.55

0.2

0

0.1

0.2

0.3

0.4

0.5

0.6

BT AT

BTAT

110


Effect on Pain:

The statistical analysis revealed that the mean pain score of Gridhrasi which was 31.900

before the treatment was increased to 45.150 with a difference in mean of 13.250 which

was statistically highly significant with a P value of <0.001.

The assessment was done with Greenough and Fraser scoring method scoring method

where higher the score better is the improvement or relief in pain.

Table No: 35 Effect on Pain


BT AT

DIFFERENCE

IN MEANS SD SEM t P

31.900 45.150 13.250 8.328 1.862 7.115 <0.001

Table No: 36 Effect on Pain during the course of treatment

MEAN SCORE

DURING THE COURSE OF TREATMENT BT

7TH DAY 14TH DAY 21ST DAY 28TH DAY

31.900 34.400 39.550 44.550 45.15

Figure No: 27 Relief on Pain during Figure No: 28 Relief on Pain. the course of treatment

31.9

45.15

05

101520253035404550

BT AT

BTAT

45.1544.5539.55

34.431.9

05

101520253035404550

BT 7D 14D 21D 28D

Relief of Pain

111


Effect on Neurological deficit

The statistical analysis revealed that the mean score of Neurological deficit which was

29.750 before the treatment was reduced to 15.500 after the treatment with a difference in

mean of 14.250 which is statistically highly significant with a P value <0.001.

Table No: 37 Effect on Neurological deficit


BT AT

DIFFERENCE

IN MEANS SD SEM t P

29.750 15.500 14.250 10.915 2.441 5.838 <0.001

Table No: 38 Effect on Neurological deficit during the course of treatment

MEAN SCORE



29.750 29.500 23.500 16.250 15.500

Figure No: 29 Effect on Neurological Fig No: 30 Effect on Neurological deficit

deficit during the course of treatment

15.516.25

23.5

29.529.75

0

5

10

15

20

25

30

35

BT 7D 14D 21D 28D

NEUROLOGICAL DEFICIT

29.75

15.5

0

5

10

15

20

25

30

BT AT

BTAT

112


Effect on Functional ability:

The effect of treatment on Functional ability shown highly significant change in

statistical analysis. The improvement was from 16.500 to 19.850 with a difference in

mean of 3.350 and P value <0.001

Table No: 39 Effect on Functional ability


BT AT

DIFFERENCE

IN MEANS SD SEM t P

16.500 19.850 3.350 3.297 0.737 4.544 <0.001

Table No: 40 Effect on Functional ability during the course of treatment

MEAN SCORE



16.500 17.000 18.250 19.450 19.850

Figure No: 31 Effect on Functional ability Figure No:32Effect on Functional ability

during the course of treatment

19.8519.4518.251716.5

0

5

10

15

20

25

BT 7D 14D 21D 28D

FUNCTIONAL ABILITY

16.5

19.85

02468

101214161820

BT AT

BTAT

113


Effect on Functional disability:

The statistical analysis revealed that the mean score of Functional disability before

treatment which was 23.450 was reduced to 14.400 after the treatment with a mean score

of 9.050.

Table No: 41 Effect on Functional disability


BT AT

DIFFERENCE

IN MEANS SD SEM t P

23.450 14.400 9.050 7.891 1.764 5.129 <0.001

Table No: 42 Effect on Functional disability during the course of treatment

MEAN SCORE



23.450 21.800 18.000 15.100 14.400

Figure No: 33Effect on Functional disability Fig No:34Effect on Functional disability

during the course of treatment

14.415.118

21.823.45

0

5

10

15

20

25

BT 7D 14D 21D 28D

FUNCTIONAL DISABILITY

23.45

14.4

0

5

10

15

20

25

BT AT

BTAT

114


Over all effect of treatment:

Table No: 43 Overall effect of treatment

Effect No. of patients %

Cured 5 25

Best improvement 4 20

Moderateimprovement 9 45

Mild improvement 2 10

Figure No: 35 Overall effect of treatment

25

20

45

10

0

5

10

15

20

25

30

35

40

45

Cured Moderate

Overall effect

CuredBestModerateMild

115

Discussion

DISCUSSION

Gridhrasi is a condition which is caused by the vitiated vata afflicting the snayu and

kandra resulting in difficulty in walking and also restricted movements of the spine.

Gridhrasi can be related to Sciatica in contemporary sciences where the patient

experiences pain in the lumbosacral region and also in the course of Sciatic nerve. This

may be associated with tingling sensation or numbness in the leg. Gridhrasi is one among

the aseeti nanatmaja vatavikara and it is included in vatavyadhi also. No specific

etiological factors and poorvaroopa are mentioned for Gridhrasi as such. So the

etiological factors of vata prakopa and the etiological factors of vatavyadhi can be

considered as the nidana for Gridhrasi. In clinical practice also we can very well relate

the nidana of Gridhrasi similar to that of vatavyadhi nidana. Apart from the aharaja

factors like intake of rooksha , seta alpa bhojana etc ,Viharaja factors like langhana,

plavana (excessive swimming) atadhva (excessive walking) ativyayama(excessive

physical exercise) improper cheshtas like sitting in abnormal postures for prolonged

period of time are some of the major nidanas for Gridhrasi. Many of these nidanas can

produce peeda to kati pradesha due to the provocation of vata. This can be considered as

the precipitating factors for the production of Gridhrasi. If the nidanas are continued for a

prolonged period or with an addition of other nidanas like bhara vahana (lifting heavy

weights) etc can result in Gridhrasi. Here the pain primarily stars above the region of

sphik pradesha and in the prishta bhaga of kati which can be related to the lumbosacral

region where exactly the sciatic nerve root starts. The pain in later course radiates

through the posterior aspect of uru, janu and jangha. In contemporary sciences also in

Sciatica, pain in the course of Sciatic nerve is mentioned which is nothing but through the

116

Discussion

posterior aspect of the leg. Any cause which can result in sciatic nerve root irritation or

compression can result in pain in the course of sciatic nerve. It may be due to various

factors

1. Bharavahana resulting in disc prolapse

2. Sandhichyuti caused due to abhighata, patana, peedana etc resulting in

spondylolisthesis

3. Bhagna due to the same causes producing fracture of lumbar spine

4. Sandhivata pertaining to kati pradesha producing osteophytic lippings due to

degenerative changes

5. Arbuda or space occupying lesions or Neoplastic conditions of the spine

6. Any congenital abnormalities of the spine may be the cause

Another major causative factor may be due to Marmabhighata, particularly to

Kukundara marma and nitamba marma. Even abhighata occurring near to the marma

pradesha can also cause the same seriousness as that of marmabhighata.

In the present day, for the survival in this competitive world man has to

sacrifice his health to such an extent that it is seriously injured or affected with various

disorders. Incidence shows that lowback pain is a common disorder. Every individual in

his life might have suffered from low backpain at one or the other time due to various

reasons. This has nao exception to any stratum of society, sex or race. About 80% of

people with low back pain in later part of their life experience with pain radiating to leg.

This is a serious condition as it can produce serious disability which can make the patient

even bedridden.

117

Discussion

Vata is the prime dosha involved in the causation of this disease as one of the

sthana of vata is kati. Among the five subtypes of vata vyana and apanavata has got

major ro.le in the causation of this disorder. The vata is vitiated due to the above said

nidanas, get localized in the kati pradesha and affecting the snayu and kandara.In

some occasions there will be anubandha of kapha producing Kaphanubandha

Gridhrasi.The srotas of mamsa and asthi are also involved which results in the

production of the disease Gridhrasi. Snayugata vata, gudagata vata are some of the

conditions were the pain is appreciated even in the kati prishta pradesha.

Various treatment modalities like snehana, swedana, virechana, vasti etc are

mentioned for vata vyadhi in general and in specific treatments like vasti, siravyadha and

agnikarma are mentioned for Gridhrasi. Even many herbal and herbomineral preparations

as samana yogas are also mentioned for Gridhrasi the effects of which are to be explored.

In this new era, man expects miraculous effects with treatment which are easiliy available

at less cost with more efficacy and with less restriction in routine work. He desires to take

the medications at OPD level unless he is seriously bedridden. Considering all these

facts, present study was proposed with an idea of benefiting the patient at the OPD level.

Various researches are carried out in various parts of the country in the management

of Gridhrasi and are climed to be effective.In Ayurvedic classics, various herbal and

herbomineral preparations are explained which need to be studied for their efficacy by

the method of randomized clinical trials. Hence there is an intense need in exploring a

safe cost effective medicine for Gridhrasi considering the high incidence of the disease.

Keeping these factors in view, the present study is planned to know the clinical effect of

Gandharvahastha taila and Vatari Guggulu in the management of Gridhrasi.

118

Discussion

Description about this disease is present even from the time of vedic period in

the form of vatavyadhi. The etiological factors are similar to that opf vata prakopa karana

and vata vyadhi nidana. The specific lashanas mentioned are stambha, ruk, toda, grahana

and spandana of the leg. In case of Kaphanubandhata feature like aruchi, tandra and

gaurava may be present in addition.

Many drugs are mentioned in our classics for Gridhrasi. Among them

Eranda is having more importance as it has the properties of vata and kapha samana and

Anulomana property. So the present study was undertaken with Gandharvahastha taila

and Vatari Guggulu which are having Eranda as the main ingredient.

Plan of the study

It is a single blind clinical study with pretest and post test design where in 20 patients

diagnosed to have Gridhrasi fulfilling all the criterias were selected and Gandharvahastha

Taila and Vatari Guggulu were administered in a dose of 10ml Bd and 1gm tid

respectively. During the course of treatment weekly assessment were done for the

criterias like pain, Neurological deficit, Functional ability and Functional disability. The

patients were assessed at fortnightly intervals for a period of 1 month after the course of

treatment.

General description of the patient

Age: Among the 20 patients included in this study maximum number of patients

belonged to the age group of 41 to 50 years ie. 30%. This is followed by 25% each of

the patients belonged to the age group of 31 to 40 years and 51 to 60 years.The data

signifies the more working age may be more prone to lumbosacral strain.

119

Discussion

Sex: The illness does not show any predilection for sex, in the present sample taken for

the study 55% of the patients were females. This only indicates a sampling variation due

to the small size of the sample.

Marital status: 90%of the patients recorded in this study were married. It may be

possible that the responsibility of running family was one of the causes for patients which

may cause more stress. However it is not possible to draw a definite conclusion that

married persons are prone to develop Gridhrasi.

Religion: 85% of the patients in this sample were Hindus. The predominance of Hindu

caste in and around Udupi is reflected in this sample. The high incidence of illness in

Hindus in this study does not seem to have any significant relationship with the disease

Gridhrasi because it is the demographic area which plays major role in it.

Habitat incidence: The present study shows higher incidence about 55% in rural people.

This only reflects predominance of rural population in and around Udupi.

Socio economic status: 65%of patients belonged to low class and another 25% of middle

class. About socio-economic status of patients, maximum numbers of patients were of

lower and middle class. Maximum strain and inadequate health care may be contributory

in the causation of illness.

Educational status: Maximum number of patients registered were of secondary

education (60%) as well as graduated group (20%). However pattern of education with

Gridhrasi has no relation at all.

Occupation: Physically strenuous work in the form of labour (20%), housewives (40%)

score in the incidence study owing to the fact that physical strain is much more and it is

corresponding to the etiology of Gridhrasi..

120

Discussion

Addiction of the patients: Maximum number of patients (50%) had no addiction and the

others had addiction of smoking, alcohol and betel chewing. The above said factors are

said to induce Vata Prakopa and hence they are responsible for this disease.

Nature of work: 50% of patients taken for the study were having strenuous nature of

work while 30% had moderate nature of work. Physical strain is much more in such

occasions corresponding to the etiology of Gridhrasi..

Dietary habits: 60% of patients registered for the study were having mixed dietary

habits. But no definite conclusion may be drawn in this sample size on the nature of diet

in relation to this disease.

Prakruti: Maximum of 70% patients belonged to Vaatapitta Prakruti and 20% of

patients belonged to Vatakapha prakruti. This observation supports the tendency of

Vataja disorders like Gridhrasi in persons having dosha Prakruti where Vata is involved.

According to general principles, the patients of Vata Prakruti will have an increased risk

of suffering from Vatavyadhi.. From this small number of sample taken for the study, it is

not possible either to justify or deny this principle.

Sara,Samhanana: All the patients were belongings to madhyama sara, 95 % of the

patients had Madhyama samhanana. Probably the co-relation between disease &

influence of these factors cannot be proved scientifically.

Satwa,Satmya: Madhyama satwa was observed in 80% of patients, preponderance of

madhyama satmya with incidence in 90% of patients was observed. Physical and

emotional stress is known precipitating factors for causation of the disease.

Koshta: In the present study the sample showed that 60% of patients had krura koshta,

30% and 10% of patients were belonging to mrudu and madhyama koshta respectively

121

Discussion

Aahara abhyavaharana and Jarana sakthi: This revealed 50% of patients having

madyama abhyaraharana sakthi and 40% in and madyama aahara Jarana Sakti.

Vyayamasakthi: 60% of patients registered for the study were having avara Vyayama

sakthi and 40% of patients were having madhyama vyayama sakthi.

Type of Gridhrasi : Maximum no.of patients were having vatakaphaja Gridhrasi (65%)

followed by vataja Gridhrasi 35%.

Symptomatology: The different symptomatology observed depicts that the Ruk present

in 100% of patients, Toda was present in 90% of the patients with different severity,

whereas Stambha in 75%, Sakthnaaha Kshepam Nigraha in all, Spandana in 30%, Aruci

50%, Tandra in 50% and Gaurava in 40% of patients. This reveals the pain dominant

nature of the disease along with related symptoms like Stambha, Toda, Sakthnaha

Kshepam Nigrahana. Aruci Gaurava and Tandra of Kapha Lakshanas were observed in

Kaphanubandha Vataja Gridhrasi.

Therapeutic effect of medication

The assessments of results were made by adapting the standard methods of scoring

questionnaires and the signs and symptoms of Gridhrasi. It included the assessment of

Pain, Neurological deficits, Functional ability and Functional disability along with signs

and symptoms as per Ayurvedic classics such as Stambha, Ruk, Toda, Spandana, Aruchi,

Gaurava, Tandra.

Effect on Stambha: The severity of Stambha was decreased by 64.51% and the results

were statistically highly significant (P<0.001). This means Gandharvahastha Taila and

Vatari Guggulu are very effective in reducing the severity of Stambha in patients of

122

Discussion

Gridhrasi. As observed, a reduction in the mean severity score reduced by 1.000 which is

significant.

Effect on severity of Ruk: The mean score of severity of Ruk showed a reduction by

67.74%which is statistically highly significant as assessed by the paired ‘t’ test. This

observation proves that Gandharvahastha Taila and Vatari Guggulu is effective in

relieving Ruk.

Effect on magnitude of Toda: The mean score of Toda reduced by 0.900 which is

statistically significant. The magnitude of Toda showed an improvement by 64.29%. This

decrease in the magnitude of Toda after the treatment is suggestive of the efficacy of

Gandharvahastha Taila and Vatari Guggulu in bringing about the Vedana shamaka effect.

Effect on Spandana: The mean severity of Spandana after the treatment with

Gandharvahastha Taila and Vatari Guggulu was 0.350. Data showed that patients had

reduction in severity of Spandana by 70%. This shows that Gandharvahastha Taila and

Vatari Guggulu is effective in reducing Spandana.

Effect on Aruci: A favourable response was observed with the symptom Aruci by

87.5%. This symptom suggests the association of Kapha Dosha in the pathogenesis of

Gridhrasi and is best treated with the ingredients present in the combination like Nagara

and Gandhaka which has the property of Amapachana . As per statistics, the difference in

mean score before and after the treatment was 0.700 which is statistically significant.

Effect on Tandra: Accordingly to statistics, the effect on Tandra was better by 63.64%.

The difference in mean score of Tandra before and after the treatment was 0.350 which is

statistically significant. As it is a symptom suggestive of Kapha Dosha dominance and is

corrected by Vata and Kaphahara drugs.

123

Discussion

Effect on Gaurava: Reduction in Gaurava was observed by 81.25%. There was a

reduction mean severity score by 0.650 which is statistically significant. This effect is

due to the Vata Kaphaghna effect of Gandharvahastha Taila and Vatari Guggulu.

Effect on Pain: The mean score difference observed was 13.250 on the severity of pain.

It is worth to mention here that Gandharvahastha Taila and Vatari Guggulu showed

41.54% reduction in the magnitude of Pain. This proves the efficacy of drugs like Eranda

and Guggulu in pacifying the pain.

Effect on Neurological Deficits: The mean score difference observed in Neurological

deficits was14.250. This showed 47.90% improvement in neurological deficits proving

the efficacy of drugs.

Effect on Functional Ability: The effects of Gandharvahastha Taila and Vatari Guggulu

are claimed to be useful in improving the functional ability by 20.30%, rectifying the

morbidity of Vaata Dosha. The results showed a difference of mean score of 3.350.

Effect on Functional Disability: According to statistics, the decline of functional

disability from before to after the treatment with Gandharvahastha Taila and Vatari

Guggulu was 38.60%. The mean score difference 9.050 of functional disability is proved

to be statistically highly significant proving the effect of the drug in eliminating morbid

Vaata Dosha.

Probable mode of action:

Due to the Snigdha guna and Ushna veerya of Eranda it pacifies vata and by deepana and

amapachana property of drugs like nagara and gandhaka it is able to rectify the amatva,

ther by giving relief like symptoms like aruchi, tandra and gaurava.Guggulu is also

having kaphavata samana and anti inflammatory property by its ushna veerya and is

124

Discussion

proved to be vedana samaka. Eventhoug Eranda is having virecana property by the action

of other drugs likew yava, nagara and Guggulu which are having laghu, Ruksha guna the

virechana effect is minimized and Anulomana effect is achieved thereby serving the

purpose. As taila is best for vata samana and due to the property of Snigdha guna of

Eranda it produces koshta snigdhata there by prevents the vitiation of vata.In toto, the

drugs present in these combination produce mainly vata kapha samana thereby reducing

the symptoms of Gridhrasi which is vata predominant and sometimes associated with

anubandha of kapha.

The overall effect of Gandharvahastha Taila and Vatari guggulu revealed that

25% of the patients got complete cure, 20% got best improvement, 45% got moderate

improvement and 10% of patients got mild improvement in the symptoms like stambha,

ruk, toda, spandana, gaurava and tandra of Gridhrasi.

Among the 20 patients taken for the study, 8 patients ie.40% reported to have

loose stools during the course of treatment. These were observed in mrudu koshta

patients particularly. So the present study reveals that the koshta has to be assessed

necessarily before administering Gandharvahastha Taila and Vatari Guggulu and the dose

has to be fixed accordingly.

As the present study is carried out with the administration of Gandharvahastha

Taila and Vatari Guggulu together, the effect of each medicine could not be identified

separately. Therefore further studies are required to find out the individual effect of these

medicines in Gridhrasi.

After thorough analysis it is found from this study that, the administration of

Gandharvahastha Taila and Vatari Guggulu is effective in Gridhrasi.

125

Conclusion

CONCLUSION

• Gridhrasi is a Vatavyadhi and is characterized by pain primarily in the sphik

pradesha which extends upto the leg through the prishta bhaga of uru, janu,

jangha and pada. The symptoms present are stambha, ruk, toda and spandana in

Vataja Gridhrasi. In association with the above symptoms additional features

like aruchi, tandra and gaurava are seen in Kaphanubandha Vataja Gridhrasi.

• This condition can be correlated to Sciatica in contemporary sciences.

• Gandharvahastha Taila and Vatari Guggulu contains the main ingredients like

Eranda and Guggulu and so is selected for the present study as Gridhrasi is a

vata and shoola predominant vikara.

• The study revealed that Gandharvahastha Taila and Vatari Guggulu had

significantly reduced the symptoms of Gridhrasi and are found to be effective

in improving functional ability in the patients of Gridhrasi.

• The results obtained from the present study is by the combined effect of

Gandharvahastha Taila and Vatari Guggulu. Further studies can be planned in

this horizon to prove the efficacy of the individual medicines in the

management of Gridhrasi.

• Out of 20 patients, in 12 patients mild recurrence of symptoms were observed

during the follow up period due to the repeated indulgence in Nidanas. So

Nidanaparivarjana has a major role in treatment of this disease.

126

Summary

SUMMARY

The present dissertation entitled “A Clinical Study on the management of

Gridhrasi with Gandharvahastha Taila and Vatari Guggulu” is planned with the

following aims and objectives.

• To make a comprehensive literary study of Gridhrasi.

• To evaluate the therapeutic efficacy of Gandharvahastha Taila and

Vatari Guggulu in bringing symptomatic relief in patients of Gridhrasi.

• To study the functional improvement with Gandharvahastha Taila and

Vatari Guggulu in the patients of Gridhrasi.

The whole topic is elaborated in four parts:

The first section termed as Conceptual Study at the outset deals with the

Historical review of Gridhrasi followed by its Etymology. There after an attempt has

been made in regard to postulate the Nidana, Poorvarupa, Rupa, Samprapti, Sapeksha

Nidana, Sadhyata-Asadhyata and Chikitsa Sutra, Pathyapathya of Gridhrasi.

The Ayurvedic knowledge has been supplemented with Modern Medical

Literature, available regarding the disease Sciatica. The anatomy of Sciatic nerve has

been discussed. There after a detailed description regarding the disease with various

aspects like Causative factors, Symptomatology, Pathology, Differential diagnosis,

Prognosis and Management with Investigations have been incorporated in this section.

This is followed by drug review in which the details of the drugs present in the

formulations are mentioned along with its method of preparation.

The next section is about the methodology of the study: 20 patients fulfilling all

the criteria were randomly selected for the study. It was designed as a single blind clinical

127

Summary

study with pre test and post test design. The patients were administered with

Gandharvahastha Taila 10ml Bd and Vatari Guggulu 1gm tid for a period of one month.

The assessment of the result of the treatment were analysed stastistically using

paired ‘t’ test. A brief description about the Observation and Results of the study are also

included.

This is followed by Discussion were the disease Gridhrasi, observations and

results of the study are analyzed and interpreted along with the probable mode of action.

The running next section is named as Summary and dealing with summary of entire

work..

The last section is termed as Conclusion and in this section entire work has been

concluded.

128

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Chapter, Sloka No. 152, Chaukhambha Sanskrit Sansthan, Varanasi, Pp 891, Page no.443

141

DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA S.D.M. COLLEGE OF AYURVEDA & HOSPITAL, UDUPI

---------------------------------------------------------------- PROFORMA OF CASESHEET FOR A CLINICAL STUDY ON THE

MANAGEMENT OF GRIDHRASI WITH GANDHARVAHASTATAILA AND VATARI GUGGULU

Guide : DR. U.N.PRASAD MD (AYU) Scholar : DR.DEEPTHI M.S. Co - Guide : DR. JONAH S. MD (AYU) ________________________________________________________________________________ Name: Sl. No : Age: Date : Sex: Female/Male OPD No : Religion : M/Ch/others IPD No : Education: ILL/P/M/HS/GR/PG Bed No : Marital Status:M/UM/W/D DOA : Social Status: VP/P/LM/M/UM/R DOD : Desha: Jn /An/ Sad Occupation: Place of birth: U/R Postal address: Pradhaana Vedana: Pain Rt. Leg Lt. leg Duration Lumbar region Gluteal region Post thigh Post knee Post ankle Foot Toes Anubandha vedana Symptoms Rt. Leg Lt. Leg Duration Stamba. Ruk. Toda. Grahana Spandana Aruci Tandra Gaurava History of present illness: Onset : Sudden / Gradual Course : Progressive / Intermittent / Continuous Character : Dull aching / Deep pain / Pricking / Shooting / Excruciating Aggravating Factor : Travel / Exposure to hot or cold / emotional / Physical activities /Sneezing / Coughing / Straining for defecation /Any others.

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Relieving Factor : Application of heat/cold/Change of position/ Standing/Sitting/Lying/Bending. Poorva Vyadhi Vrittaanta: Kula Vrittaanta: Saamajika Vrittantha: Chikitsa Vrittaanta: Artava Vrittaanta: Menstrual cycle:Regular / Irregular. Bleeding days: Menarche: Menopause: Menorrhagia/Metrorrhagia/Dysmenorrhoea/Leucorrhoea Prasooti Vrittaanta : No. of deliveries: Normal- Surgical intervention- Abortions- Last delivery. Vayaktika Vrittaanta: A. Habits Habits Duration/continued Occasional /Regular Stopped/reduced Smoking Alcohol Tobacco Snuff Others B. Ahara : a) Type: Veg / Mixed. b) Quantity: Alpa / Pramitha / Sama / Atipramana. c) Dominant rasa: M / A / L / KA / T / K d) Guna: Ruksha / Snigdha / Usna / Sita / Guru /Laghu. e) Dietic habit: Samashana/Vishamasana Adhyasana/Anasana. C. Nature of work: Manual /Sedentary / Labour/ Traveling / Walking /Standing / Sitting / Day / Night D. Vishrama : Hours /.Proper / Less / Excessive E. Vyayama : No / Less / Proper / Excessive / Regular / Irregular F. Nidra : Sound / Disturbed /Ratri jagarana / hrs G. Mutra Pravrutti: Frequency / Color / Quantity / Discomfort H. Mala Pravrutti : Frequency / Colour / Quantity / Discomfort I. Agni :Vishama/Teekshna/Mandha/Sama J: Koshta :Krura/Madhyama/Mrudu General Examination: 1. Built: Well / Moderate / Poor 2. Nourishment : Well / Moderate / Poor 3. Height: …………cms. 4. Weight: ………….kgs. 5. Temperature: ………….F 6. Pulse: …………/min R / Irre / RIR / Full / Bounding / Feeble 7. Blood pressure: …………/mm of Hg

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8. Respiratory rate: ……..…/min 9. Lymphnodes: Palpable / Non palpable 10. Conjunctiva: Pink/Pallor/Bluish. 11. Nails: Cyanosis: Present / Absent Clubbing: Present / Absent Dashavidha Pareeksha: Asta Sthana Pareeksha: Prakrititah: Nadi: Saratah: Mala: Samhananatah: Mootra: Satmyatah: Jihwa: Satwatah: Sabda: Pramanatah: Sparsa: Ahara shaktitah: Drik: a)Abhyavarana: Akruti: b)Jarana: Vyayama Shaktitah: Vayatah: Sroto Praeeksha: 1. Pranavaha: 8. Asthivaha: 2. Udakavaha: 9. Majjavaha: 3. Annavaha: 10. Sukravaha: 4. Rasavaha: 11. Artavavaha: 5. Raktavaha: 12. Swedavaha: 6. Mamsavaha: 13. Mutravaha: 7. Medovaha: 14. Purishavah Systemic Examination: 1. C.V.S: 2. R.S: 3. C.N.S: 4. P/A: 5.Muskuloskeletal system:

Examination of spine: Inspection : Scoliosis/ Kyphosis/ Lordosis/

Loss of curvature of spine/ Swelling/ Redness/ Scars. Palpation :Tenderness – Present/Absent. Area- Temperature- Present/Absent Swelling- Soft/Hard/Cystic. Movement: Flexion to right- Painful/Restricted/Normal Flexion to left.- Painful/Restricted/Normal. Hyper extension of lumbar spine- Painful/Restricted/Normal.

Motor System: Rt. Leg Lt. Leg Strength of muscle:

Bulk of muscle: Tone of muscle: Reflex:

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Gait: Involuntary movements: Confirmatory Tests:

Rt. Leg Lt. Leg 1. SLR . Test : Active : Passive : 2. Bragaard test : 3. Lasegue’s sign : 4. Bowstring test : 5. Femoral nerve test : 6. Flip test : 7. Sitting test :

8. Schober’s test: Investigations: 1) Hematological : Hb% : TC : DC : ESR : RBS :

2) Urine- Routine . 3) X ray : Lumbosacral AP& Lateral view if necessary

4) Any other investigations if necessary. Samprapti ghataka: Dosha: Dooshya: Srotas: Srotodusti: Agni: Ama: Roga marga: Udbhava sthana: Sanchara sthana: Vyakta sthana: Adhishtana:

ASSESSMENT CRITERIA PAIN: Parameters BT 7D 14D 21D 28D 15AT 30AT Pain killers Consultations Work Rest Household job Sports/dancing Dress wearing Sitting Walking Sleep Travel Sexual life

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NEUROLOGICAL DEFICIT: Parameters BT 7D 14D 21D 28D 15AT 30AT Neurological Signs

Root tension signs

FUNCTIONAL ABILITY:

FUNTIONAL DISABILITY:

Parameters BT 7D 14D 21D 28D 15AT 30AT Upright Posture

Walking Gait Sitting Stair climbing Hand held appliances

Wheel chair

Time usage

Parameters BT 7D 14D 21D 28D 15AT 30AT Pain intensity Personal care Lifting Walking Sitting Standing Sleeping Sex life Social life Travelling

SUBJECTIVE: Symptoms BT 7D 14D 21D 28D 15AT 30AT Stambha Ruk Toda Spandana Aruci Gaurava Tandra

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Parameters BT 7D 14D 21D 28D 15AT 30AT Pain Neurological deficit

Functional ability

Functional disability

DURING TREATMENT AT CONFIRMATORY TESTS

BT 7 14 21 28 15 30

Lt/Rt Lt/Rt Lt/Rt Lt/Rt Lt/Rt Lt/Rt Lt/Rt SLR Test Active : Passive :

Bragaard test : Lasegue’s sign : Bowstring test : Femoral nerve test : Flip test : Sitting test :

Schober’s test:

BT 7D 14D 21D 28D 15AT 30AT

TTiimmee ttaakkeenn ttoo wwaallkk 3300 ffeeeett

TTiimmee ttaakkeenn ffoorr 1100 ssiitt--uuppss Time taken to climb 10 steps

Dis bet floor& finger tip in forward flexion

Signature Of The Guide Signature Of The Scholar

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