Correspondence Address:
R Adil
Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat
India

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Introduction: Avascular necrosis (AVN), also known as osteonecrosis, bone infarction, aseptic necrosis and ischemic bone necrosis is cellular death of bone components due to interruption of blood supply, because of which the bone tissue dies and the bone collapses.^[1],[2],[3] If AVN affects the bones of a joint, it often leads to destruction of the articular surfaces. It primarily affects epiphysis of long bones such as the femur and also involves shoulder, knee and hip joints etc. Other common sites include the humerus, shoulders, knees, ankles and the jaw.^[4] Many people have no symptoms in the early stages of avascular necrosis. As the condition worsens, the affected joint may hurt under stress.

Pain can be mild or severe, localized and develops gradually. Pain may be limited to groin, thigh or buttock if AVN affects hip. Pain location tends to be most specific in anterior hip and lower pelvis. Can be acute in onset (acute infarct phenomenon), which can mimic an acute injury. Range of motion will be reduced affecting the gait. No satisfactory therapy is available in conventional system of medicine, while the available procedures are not affordable by all. Prognosis of all such approaches are not convincing.^[5]

This condition can be correlated to Asthi majja gata vata and / or Asthi dhatu kshaya manifesting symptoms like Bhedo asthi parvanam (breaking type of pain in bones and joints), Sandhi shula (joint pain), Mamsakshaya (muscular wasting), Balakshaya (weakness), Aswapna santataruk (disturbed sleep due to continuous pain) and Sandhi shaithilyam (afflicted joints) with Shiryanti iva cha asthini durbalani (destruction of bony tissue causing generalized weakness), Pratata vata rogini (other aggravated features of vata) etc.^[6] Wide range of treatment modalities have been mentioned in Ayurveda that are effective in such manifestations.

Case report: A 35 years male patient visited Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar with chief complaints of pain at bilateral hip joints with restricted movements, difficulty in walking, unable to stand-up from sitting position and difficulty in forward bending since four months.

Patient noticed a jerk on sudden lifting of weight of about 40-45 kg followed by pain at both hip joints and left gluteal region four months back. Pain aggravated on next day, restricting movements of hip joint without radiating to any parts. A brief warm-up of five minutes was providing mild relief, but the improvement was time limited. No history of tingling sensation or numbness of lower limbs was reported.

Initially patient was managed with homeopathic medicines with which mild relief in pain was noticed. But, restricted movements were persisting with increased morning stiffness. Patient had a history of facial palsy about one and a half years back for which he was prescribed with corticosteroids and got significant relief.

The Shareera prakriti of the patient was Kaphavataja, had Krura koshtha (on the basis of bowel habits), Madhyama bala (optimum physical strength) with good Satva (psychological strength). He had mild Agnimandya (decreased digestion and appetite) and habit of occasional drinking alcohol.

Dosha dushya lakshana: Predominant Dosha in the disease is Vata in association with Pitta and Kapha. Since, there was a history of sudden jerk that may be responsible for local inflammation, vitiating Pitta. Besides, Avarana of Kapha and Meda over Vata may also be considered to play an important role in the manifestation of symptoms like stiffness and restricted movements of hip joint in the patient.

Assessment Criteria: Pain, stiffness and difficulty in walking [Table 1], Visual Analogue Scale (VAS) and improvement in the movements of flexion, extension and abduction were assessed at various stages of treatment.{Table 1}

Investigations: MRI of Hip joint was conducted before and after the treatment. MRI Findings were suggestive of AVN of bilateral femur with minimal joint effusion (AVN Stage II). The lesions involved from 9 to 4^O clock on sagittal images. No evident sub-chondral collapse or secondary degenerative osteoarthritis was found.

Management of the condition: The patient was admitted in the Panchakarma IPD and treatment was planned considering involved Dosha and Dushya. Tikta ksheera vasti was planned for eight days that was preceded by Rukshana therapy comprising of Udwartana (dry powdered massage), followed by Virechana karma [Table 2]. Udwartana was done for five days with mixture of 200 g of Yava churna and 50 g of Triphala churna that was made warm and rubbed firmly over the bilateral hip region for 25 to 30 minutes for five days. Internally, patient was advised to take Siddha jala [water processed one part of drug and 16 parts potable water] of Dhanyaka (Coriandrum sativum), Shunthi (Zingiber officinale) and Shatapushpa (Anethum sowa) for Deepana and Pachana for five days.{Table 2}

After assessment of Agni; Snehapana with Go-ghrita was planned that was given to the patient before 6.30 AM and continued till the appearance of Samyak snigdha lakshana. It took five days to observe these features. Dose of Go-ghrita was increased daily observing the digestive capacity of the patient. Go-ghrita was administered at a dose of 30 ml, 70 ml, 110 ml, 140 ml and 170 ml on 1^st, 2^nd, 3^rd, 4^th and 5^th day respectively. This was followed by Abhyanga and Swedana (sudation in a steam chamber) for three days. Patient was advised to take diet like Mudgayusha and fruit juice like orange or pomegranate twice a day for three days. At the end of this, drugs for Virechana were administered and Madhyama shuddhi was obtained.

After completion of Sansarjana krama (specific diet regimen after Shodhana) for Madhyama shuddhi (for five days), patient was advised a gap of three days that was followed by Tikta ksheera vasti made-up of 50 ml of Madhu (honey), 5 g of Saindhava lavana (rock salt), 100 ml of Go-ghrita (ghee), 25 g of Kalka (paste) prepared out of powders of Guduchi (Tinospora cordifolia Miers.) and Yashtimadhu (Glycyrrhiza glabra Linn.), and around 450 ml Kwatha (decoction) of Guduchi and Erandamoola (roots of Ricinus communis Linn.). The plan of Vasti is presented at [Table 3].{Table 3}

Observations and Results: Mild improvement was reported in pain, stiffness and range of movements after Udwartana with a feeling of lightness in the affected area. During Snehapana for Virechana, it took around 6-8 hours to feel hunger by the patient on 1^st and 2^nd day of Snehepana, while it was increased to 10 hours on 3^rd and 4^th day and 13 hours on the 5^th day. Unctuousness in stools, downward movement of flatus and greasiness of skin were observed from 4^th day onwards. An average retention time of Vasti was around 18 minutes. No untoward effects were noticed during Vasti regimen [Table 9]. Mild relief was reported in pain, stiffness and range of movements after Udwartana with a feeling of lightness in the affected area. After Virechana, marked improvement was observed in pain, stiffness, improvement in range of movements at hip joint region. After completion of Vasti, there was further improvement in the movements due to decreased pain and stiffness.

Pain, stiffness and difficulty in walking responded with Virechana and Tikta ksheera vasti [Table 4]. Patient was able to walk and climb stairs without any external support. Body weight was reduced from 90 kg to 83 kg after classical procedures of Udwartana, Virechana and Vasti. Observations of Visual Analogue Scale (VAS) came down from 4 to 1 by the end of treatment. Improvement was also found in the range of movements of hip joint [Table 5].{Table 4}{Table 5}

Discussion: Prakriti of the patient was Kaphavataja and weight was 90 kg. Main symptoms present were pain, stiffness and decreased range of movements that is an indication of Vata as the main Dosha leading to Asthikshaya. Considering Vata as main dosha, Vasti was planned in the management. Since Asthi was the main involved Dhatu; Tikta dravya siddha vasti was selected. ^[7] Erandamoola (roots of Ricinus communis) was used considering its Vata shamaka properties.^[8] Milk was added in Vasti that nourishes Dhatus and specifically Asthi dhatu. Powders of Guduchi (Tinospora cordifolia Willd.) and Yashtimadhu (Glycyrrhiza glabra Linn.) used in the formulation may help in rebuilding the bone tissue.^[9]

AVN of hip joint develops basically due to obstruction of small blood vessels supplying to femoral head leading to gradual development of necrosis due to reduced vascular supply. Thus, Rakta vaha sroto rodha becomes prime cause leading to Asthi dhatu kshaya in the hip joint. To counter this Rakta dushti; Virechana was planned before proceeding to Vasti.^[10] Virechana also helps in Dhatu vishodhana.^[11]

Patient suffered from facial palsy about one and a half years ago and there was a history of steroid drug intake for the same, for six months, until recovery. Patients having a history of oral steroid usage are more prone to develop AVN.^[12] Glucocorticoid-induced AVN causes significant morbidity and accounts for around 10% of all cases of total hip replacement in the United States.^[13] The prevalence of gluco-corticoid induced AVN is between 3% and 38%, depending on the underlying diseases, gluco-corticoid dosage and route of administration.^[14] Patient had a history of having alcohol occasionally, which is also one of the causes making more proneness for developing AVN.^[15] Virechana was selected as a therapy to be used here for Shodhana to produce detoxifying effects since there was a history of steroid and alcohol intake. Virechana also provides stability to Dhatu countering dhatu sthairya,^[16] that is needed especially in conditions like AVN. Besides this, there are chances for better absorption of Vastidravya after Shodhana, thus chances of better results.

In this trial, Nimbaamritadi eranda taila was used for Virechana.^[17] The purpose was to perform Snigdha virechana considering Vata predominant nature of disease and involvement of Asthi dhatu that have Ruksha and kharaguna. Besides, Eranda taila is said to act on Vatadosha and when it is processed along with Tikta rasa dravyas like Nimba and Guduchi; act on Asthi dhatu and help as Rakta prasadaka too.

Before Virechana; Udwartana was planned for external Rukshana as the patient was of Kapha vataja prakriti with body weight of 90 kg. Rukshana would be the procedure of choice to remove any Avarana caused by Kapha and Meda before commencing with the main treatment for better action and bio availability of subsequent therapies. About 200 g of Yavachurna and 50 g of Triphala churna were used in Udwartana. Reduction in stiffness, weight loss and lightness in body were observed after completion of this process. But, severity of pain was persisting during walking and on attempt to climb stairs. Reduction of stiffness could be due to the Rukshaguna of Yava cause neutralization of Kapha, Pitta, Meda and produce required Lekhana effect.^[18] Triphala churna also helps in removing excessive Kapha, Meda and Twakgata kleda.^[19] Once the Avarana of Kapha and Meda is resolved; platform for better action of Virechana and Vasti is expected on Vayu. This could also be the reason for loss of weight and the relative lightness in patient. Internal Deepana, Pachana with Dhanyaka and Shatapushpa also lead to increased appetite and proper bowel evacuation on daily basis. Most of the subjective and objective parameters showed marked improvement after the Virechana karma.

Eighteen Virechana vegas with Shleshma pravritti in last two vegas indicating optimum procedure (Samyak shuddhi) of Virechana. No weakness was reported by patient on the day of Virechana or subsequent days of Samsarjana krama. Considerable improvement in pain and stiffness in hip joints probably owing to Vata shamaka and Ama nirharana properties of Eranda taila.^[20] Snigdha virechana was planned owing to counteract the Ruksha effect created by Vataprakopa. Tikta drugs present in it like Nimba, Amrita, Patola, Kantakari, etc. nourish Asthi dhatu too. After Virechana karma, Tikta ksheera vasti was administered. Improvement in range of hip joint movements owes to the significant reduction in stiffness and pain produced after Virechana. Marked improvement was observed in abduction, flexion and extension of hip joint.

Honey is the first component of Vasti, the base in which the emulsion for other ingredients are prepared. It is also said to possess Asthi sandhaniya properties that helps in rebuilding damaged Asthi.^[21] Vasti with Tikta dravya, Ghrita and milk is indicated in Asthi kshaya janya roga. Guduchi is said to be an excellent Rasayana drug, known to prevent ageing and degeneration of the tissues, especially Asthi dhatu. ^[22],[23] Guduchi is grouped under Asthi sandhaniya maha kashaya. ^[24] It also has a role in enhancing Rakta dhatu,^[8] thus may have a role in providing nourishment to hip joint by re-channelizing blood vessels supplying to it.

Erandamoola is the other Dravya used in Vasti kwatha, which is said to have Vata shamaka properties, thus producing significant relief in pain. It is also said to help as Ama dosha nirharana that is responsible for production of stiffness and thus bringing about a considerable improvement in the range of movements at hip joint.

After completion of treatment, patient was prescribed with Shamana drugs for a month to nourish Asthi dhatu and thus preserving the effects produced by Panchakarma. Two tablets of Abha guggulu (each 500 mg) twice a day with 60 ml Rasna saptaka kwatha, a blend of Guduchi churna (2 g), Ashwagandha churna (2 g) and Godanti bhasma (250 mg) were advised. Patient was advised to consume warm water and easily digestible food items. Exposure to cold air, maintaining one particular posture for a longer duration, frequent jerky movements and lifting weights were asked to be avoided.{Figure 1}

Patient was advised to re-visit the hospital after a month to re-evaluate the features. No further deterioration in the symptoms was noticed after a month. Pain was present in hip joints but only during walking and climbing stairs. Range of movements like flexion, extension and abduction at hip joints were restricted but showed no significant deterioration as compared to the observations made just after completion of therapies. MRI scans of the hip joint after the follow up period showed no further deterioration in the gradation (Grade II) of Avascular necrosis, which suggests that the disease progression was stopped. He was advised to revisit hospital after one month for next treatment regimen.

Conclusion: AVN is an orthopedic condition that poses a challenge in front of whole medical fraternity owing to the impeding of routine activities produced. The adopted therapy in the current case provided marked relief from pain, tenderness, general debility and improvement in the gait. The grade of AVN did not worsen and was maintained. This was a pilot study to evaluate the efficacy of Udwartana, Virechana and Vasti in the management of AVN and the results produced were encouraging enough not only on the subjective and objective scales but also provided a check in disease progression. It is advisable to conduct this particular study on a larger number of samples for a greater span of time to draw more concrete conclusions. More awareness among general public should be created towards management of AVN using Ayurveda to promote earlier diagnosis that might lead to better prognosis.

Source of support: Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar - 361008, Gujarat, India.

Conflicts of interest: None declared.

References