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Urustambha Chikitsa (view source)

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<big>'''Abstract </big>'''

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The chapter deals with the management of ''urustambha'' which literally means stiffness of thighs. Patients present with pain and inability to move pelvis and lower extremities. This is the only disease in which [[Panchakarma]] are contraindicated. It can be misdiagnosed as ''vata'' dominant disorder due to its clinical presentation, however, ''kapha'' and ''meda'' are main culprits in the pathogenesis. Etiological factors, pathogenesis, clinical presentation, prognosis and treatment of ''urustambha'' are described in this chapter.

+

The chapter deals with the management of ''urustambha'' which literally means stiffness of thighs. Patients present with pain and inability to move pelvis and lower extremities. This is the only disease in which [[Panchakarma]] are contraindicated. It can be misdiagnosed as [[vata]] dominant disorder due to its clinical presentation, however, [[kapha]] and [[meda dhatu]] are main culprits in the pathogenesis. Etiological factors, pathogenesis, clinical presentation, prognosis and treatment of ''urustambha'' are described in this chapter.

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'''Keywords''': ''Viruddha, ama-visha, tridosha dushti, Saama-tridosha, Asthigata kapha, medahkaphaavrita-vata, Sneha-Shaitya-Sthairya'' in ''Uru, Rukshana, Kapha-meda-~~vaatahara''~~ treatment.

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'''Keywords''': Viruddha, ama-visha, tridosha dushti, Saama-tridosha, Asthigata [[kapha]], medahkaphaavrita-[[vata]], Sneha-Shaitya-Sthairya in Uru, [[Rukshana]], [[Kapha]]-meda-[[vata]]hara treatment.

</div>

== Introduction ==

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''Urustambha'' is placed in a sequence after management of disorders of three ''marma'' and before management of ''vata'' disorders. The sequence indicates that it is as hazardous as ''trimarma'' disorder and resembles ''vata'' disorders. Though the clinical presentation of ''urustambha'' resembles ''vata'' dominant diseases, the management is focused on main culprits like ''kapha'' and ~~''medas'~~'. The two obstruct the vessels flowing downwards in the thigh region causing stiffness and immobility of thighs.

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''Urustambha'' is placed in a sequence after management of disorders of three ''marma'' and before management of [[vata]] disorders. The sequence indicates that it is as hazardous as ''trimarma'' disorder and resembles [[vata]] disorders. Though the clinical presentation of ''urustambha'' resembles [[vata]] dominant diseases, the management is focused on main culprits like [[kapha]] and [[meda dhatu]]'. The two obstruct the vessels flowing downwards in the thigh region causing stiffness and immobility of thighs.

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''Urustambha'' evokes ~~''tridosha''~~ response which tries to metabolize ''rasa'' by directing it to digestive organs, where it is regarded as improperly transformed substance called ''ama rasa-dhatu''. Disproportionate fat causes susceptibility by directing the ''sama-~~tridosha''~~ (united ~~''tridosha''~~ and ''ama rasa-dhatu'') to the lower limbs. Combined with fat, ''kapha dosha'' having similar qualities gets more strength and fills up the bones of lower limbs. Simultaneously ''vata'' gets obstructed by fat resulting in the development of cardinal feature like- excessive fatigue of calf muscles and thighs, constant pain with slight burning sensation. Pain in feet on stepping on the ground, cold to touch, loss of sensation, inability to stand because of lack of muscle strength, unable to move the upper and lower parts of the lower limbs due to the feeling as if they are fractured.

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''Urustambha'' evokes tri[[dosha]] response which tries to metabolize ''rasa'' by directing it to digestive organs, where it is regarded as improperly transformed substance called ama [[rasa dhatu]]. Disproportionate fat causes susceptibility by directing the sama-tri[[dosha]] (united tri[[dosha]] and ama [[rasa dhatu]]) to the lower limbs. Combined with fat, [[kapha]] [[dosha]] having similar qualities gets more strength and fills up the bones of lower limbs. Simultaneously [[vata]] gets obstructed by fat resulting in the development of cardinal feature like- excessive fatigue of calf muscles and thighs, constant pain with slight burning sensation. Pain in feet on stepping on the ground, cold to touch, loss of sensation, inability to stand because of lack of muscle strength, unable to move the upper and lower parts of the lower limbs due to the feeling as if they are fractured.

If the patient develops burning sensation, pricking pain and tremors, ''urusthambha'' is fatal. If such symptoms are absent and is of recent origin, then it is curable.

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The treatment principle of ''urusthambha'' is ''rukshana'' (facilitating consumption and absorption of liquid metabolites in circulation and tissues) and ''pachana'' (increasing metabolism) by neutralizing toxic metabolites along with alleviation of ''vata''. Medicines should be alkaline medicines, medicated alcoholic preparations, cow’s urine, diaphoresis and massage with paste of herbs to remove fat and other liquid metabolites. After ''rukshana-pachana,'' oleation for restoring ''vata''- could be done internally, which would subside ''kapha-~~medas~~-vata'' due to the peculiarity of medicated oils. Along with external ''rukshana'' the patient should be made to exercise according to his strength. This disease could be cured only with careful diligence as it is situated in deeper tissues like bones and all three ~~''doshas''~~ are involved simultaneously.

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The treatment principle of ''urusthambha'' is [[rukshana]](facilitating consumption and absorption of liquid metabolites in circulation and tissues) and [[pachana]] (increasing metabolism) by neutralizing toxic metabolites along with alleviation of [[vata]]. Medicines should be alkaline medicines, medicated alcoholic preparations, cow’s urine, diaphoresis and massage with paste of herbs to remove fat and other liquid metabolites. After [[rukshana]]-[[pachana]], oleation for restoring [[vata]]- could be done internally, which would subside [[kapha]]-[[meda dhatu]]-[[vata]] due to the peculiarity of medicated oils. Along with external [[rukshana]] the patient should be made to exercise according to his strength. This disease could be cured only with careful diligence as it is situated in deeper tissues like bones and all three [[dosha]] are involved simultaneously.

''Urusthambha'' is a disease, not well understood and researched. It requires further study and scientific exploration.

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Once Agnivesha asked about a doubt to the mentor Lord Punarvasu, who was having infallible intellect of true knowledge and penance, who was like the Sumeru mountain with unblemished like sun and moon and was abode of wisdom, self realization, memory, glory and patience.

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“Oh Lord, all the five therapies ([[Panchakarma]]) are explained together as well as separately as therapeutic measure for all the diseases. Is there any curable disease caused by ~~''doshas''~~ for the cure of which these five therapies are contraindicated?” [3-6]

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“Oh Lord, all the five therapies ([[Panchakarma]]) are explained together as well as separately as therapeutic measure for all the diseases. Is there any curable disease caused by [[dosha]] for the cure of which these five therapies are contraindicated?” [3-6]

=== Atreya’s reply ===

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*Over exertion, continuous fear, suppression of urges

*Due to excess unctuousness, accumulation of ''ama'' in ''koshtha'' takes place.

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*Due to above mentioned causes and due to ''ama'', vitiation of ~~''tridosha''~~ takes place.

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*Due to above mentioned causes and due to ''ama'', vitiation of tri[[dosha]] takes place.

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*''Ama'' with deranged ''medas'' obstructs ''prakupita ~~tridosha''~~ and due to heaviness, they move downward through ''siras'' to reach lower limbs. ~~''Doshas''~~, get accentuated by the strength of the ~~''medas''~~ to fill calves and thighs of the lower limbs causing involuntary movements and immobility.

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*''Ama'' with deranged ''medas'' obstructs ''prakupita tri[[dosha]] and due to heaviness, they move downward through ''siras'' to reach lower limbs. [[Dosha]], get accentuated by the strength of the[[meda dhatu]] to fill calves and thighs of the lower limbs causing involuntary movements and immobility.

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The ''kapha'' filled lower limbs become like a lake which is large, deep and fully filled with water which remains, still, stable and undisturbed.

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The [[kapha]] filled lower limbs become like a lake which is large, deep and fully filled with water which remains, still, stable and undisturbed.

This disease when gets associated with heaviness, strain, contracture, burning sensation, pain, numbness, tremor, splitting, twitching and pricking types of pain, then it becomes lethal.

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''Kapha'' with its ''sthira''(stable) and ''sheeta'' (cold) properties associated with ~~''medas''~~ subdues ''vata'' and ''pitta'' and causes immobility of ''uru'' (thighs). Hence the disease is termed as ''urusthambha''. [8-14]

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[[Kapha]] with its ''sthira''(stable) and ''sheeta'' (cold) properties associated with [[meda dhatu]]subdues [[vata]] and [[pitta]] and causes immobility of ''uru'' (thighs). Hence the disease is termed as ''urusthambha''. [8-14]

=== Prodromal symptoms ===

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Thinking or concentrating on something, excessive sleep, indolence (decreased emotion), anorexia, fever, horripilation, vomiting and reduced movements of calves and thighs (due to loss of strength) are the prodromal symptoms of ''urusthambha''.[15]

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=== Contraindication of ''snehana'' (oleation therapy)===

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=== Contraindication of [[snehana]] (oleation therapy)===

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</div></div>

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If oleation therapy is administered due to misunderstanding, that this disease as ''vata'' disorder or due to ignorance, it results in loss of strength in legs, loss of sensation in the legs and difficulty in raising the legs.[16]

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If oleation therapy is administered due to misunderstanding, that this disease as [[vata]] disorder or due to ignorance, it results in loss of strength in legs, loss of sensation in the legs and difficulty in raising the legs.[16]

=== Clinical features ===

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The reason for which oleation, enema, purgation and emesis are contraindicated in ''urusthambha'' is being explained for your understanding.

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Oleation and enema therapies always aggravate ''kapha''. Purgation is ineffective to remove ''kapha'' localized there (in the thighs). ''Kapha'' reaching its own place (''amashaya'') and ''pitta'' can be easily removed by emesis. Both these ~~''doshas''~~ lodged in ''amashaya'' can be eliminated by purgation. When lodged in ''pakvashaya'', all the three ~~''doshas''~~ could be fully removed by enema therapy. But in ''urusthambha'' since pathognomonic ''doshas'' are stagnant due to ''amatva'' (metabolic defect) and obstructed by fat, since ''kapha'' is lodged in the abode of ''vata'', which is of ''sheeta guna'' and since ''vata'' and ''kapha'' are immobile, it is not easy to remove them just as it is difficult to remove stagnant water from a ditch.[20-24]

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Oleation and enema therapies always aggravate [[kapha]]. Purgation is ineffective to remove [[kapha]] localized there (in the thighs). [[Kapha]] reaching its own place (''amashaya'') and [[pitta]] can be easily removed by emesis. Both these [[dosha]] lodged in ''amashaya'' can be eliminated by purgation. When lodged in ''pakvashaya'', all the three [[dosha]] could be fully removed by enema therapy. But in ''urusthambha'' since pathognomonic [[doshas]] are stagnant due to ''amatva'' (metabolic defect) and obstructed by fat, since [[kapha]] is lodged in the abode of [[vata]], which is of ''sheeta guna'' and since [[vata]] and [[kapha]] are immobile, it is not easy to remove them just as it is difficult to remove stagnant water from a ditch.[20-24]

=== Principles of management ===

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</div></div>

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Since ''kapha'' and ''ama'' are conspicuous in the pathogenesis of ''urustambha'', the physician should constantly judiciously administer therapies for their ''samshamana'' (pacification), ''kshapana'' (reduction) and ''shoshana''(drying up by absorption).

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Since [[kapha]] and ''ama'' are conspicuous in the pathogenesis of ''urustambha'', the physician should constantly judiciously administer therapies for their ''samshamana'' (pacification), ''kshapana'' (reduction) and ''shoshana''(drying up by absorption).

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The patient of ''urustambha'' should be constantly given ''rukshana'' (drying up therapies to facilitate absorption of liquid metabolites from circulation and tissues) with ''yava'' (barley), ''shyamaka'' (millet), and ''kodrava'' along with vegetables cooked with water and oil, but without adding salt. Leaves of ''sunishannaka, nimba, arka, vetra, aragwadha, vaayasi, vaastuka'' and bitter vegetables like ''kulaka'' (''karavellaka'') aid ''rukshana''.

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The patient of ''urustambha'' should be constantly given [[rukshana]] (drying up therapies to facilitate absorption of liquid metabolites from circulation and tissues) with ''yava'' (barley), ''shyamaka'' (millet), and ''kodrava'' along with vegetables cooked with water and oil, but without adding salt. Leaves of ''sunishannaka, nimba, arka, vetra, aragwadha, vaayasi, vaastuka'' and bitter vegetables like ''kulaka'' (''karavellaka'') aid [[rukshana]].

Administration of alkali (''kshaara'') preparations, ''arishta'' (medicated wines), ''haritaki'', water added with honey and ''pippali'' cures ''urustambha'' (immobility of thighs). [25-28]

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If the disease ''urusthambha'' is caused by ''apatarpana'', then the patient should be appropriately given ''santarpana'' therapy consisting of the meat of animals inhabiting in ''jangala desha'' (The land with shrubs and small trees) and old shali rice.

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If because (of excessive use) of ''rukshana'' therapies, ''vata'' gets aggravated causing insomnia and pain, then the patient should be given oleation and fomentation therapies for the alleviation of the ailments caused by ''vata''. [39 ½ - 41 ½]

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If because (of excessive use) of [[rukshana]] therapies, [[vata]] gets aggravated causing insomnia and pain, then the patient should be given oleation and fomentation therapies for the alleviation of the ailments caused by [[vata]]. [39 ½ - 41 ½]

=== ''Piluparnyadi taila'' ===

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</div></div>

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Mustard oil should be cooked by adding ''kushtha, shreeveshtaka, udichya, sarala, devadaru, kesara, ajagandha'' and ''ashwagandha''. The patient suffering from ''urusthambha'' should take this medicated oil in appropriate quantity by adding honey. This recipe makes the patient free from ''rukshana'' (''kevala-vata prakopaja'' symptoms) leading to the cure of ''urusthambha''. [43-44]

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Mustard oil should be cooked by adding ''kushtha, shreeveshtaka, udichya, sarala, devadaru, kesara, ajagandha'' and ''ashwagandha''. The patient suffering from ''urusthambha'' should take this medicated oil in appropriate quantity by adding honey. This recipe makes the patient free from [[rukshana]] (''kevala-vata prakopaja'' symptoms) leading to the cure of ''urusthambha''. [43-44]

=== ''Saindhavadi taila'' ===

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</div></div>

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One ''prastha'' (768 grams) of oil should be cooked by adding two ''palas'' (one ''pala'' = 48 grams) of ''saindhava'', five ''palas'' of ''shunthi'', two ''palas'' of ''granthika'', two ''palas'' of ''chitraka'', 20 fruits of ''bhallahaka'' and two ''adhakas'' of ''aranala''. Intake of this medicated oil helps in the conception of the offspring. It cures ''gridhrasi, urugraha, arshas,'' pain and all types of diseases caused by the aggravated vata. [45-46]

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One ''prastha'' (768 grams) of oil should be cooked by adding two ''palas'' (one ''pala'' = 48 grams) of ''saindhava'', five ''palas'' of ''shunthi'', two ''palas'' of ''granthika'', two ''palas'' of ''chitraka'', 20 fruits of ''bhallahaka'' and two ''adhakas'' of ''aranala''. Intake of this medicated oil helps in the conception of the offspring. It cures ''gridhrasi, urugraha, arshas,'' pain and all types of diseases caused by the aggravated [[vata]]. [45-46]

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In the above mentioned verses (no.s 25-47), the recipes to be used internally for the cure of ''urusthambha'' are briefly described.

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Hereafter recipes to be administered externally for the diminution of ''kapha'' will be described which you may hear.

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Hereafter recipes to be administered externally for the diminution of [[kapha]]' will be described which you may hear.

*The mud of ant-hill, the root, fruits and barks of ''karanja'' and bricks should be made to a powder. This should be used for ''utsaadana'' (therapeutic massage with mixture of powder and unctuous substance) frequently.

*Alternatively, the physician should administer this ''utsaadana'' therapy with the help of the root of ''ashwagandha, arka, pichumarda'' or ''devadaru''. Any one of these drugs may be mixed with honey, ''sarshapa'' and mud of ant-hill before being used as thick ''utsaadana'' or ''pralepana''.

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*The above mentioned drugs may be made into a paste by triturating them with cow’s urine and applied externally for the cure of ''urusthambha'' .[48-57]

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=== Beneficial diet and lifestyle in ''kapha'' vitiation ===

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=== Beneficial diet and lifestyle in [[kapha]] vitiation ===

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</div></div>

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*To alleviate ''kapha'', the able-bodied patients should be engaged in physical exercise and they should be made to walk over the ground covered with gravels and sand in the morning.

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*To alleviate [[kapha]], the able-bodied patients should be engaged in physical exercise and they should be made to walk over the ground covered with gravels and sand in the morning.

*The patient should be made to swim often against the current of river with cold water but harmless. He may also be advised swimming frequently in a pond having clean, cold and stable water.[58-60]

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</div></div>

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All the therapeutic measures which alleviate ''kapha'' but do not aggravate ''vata'' should always be employed for the treatment of ''urustambha''. These therapeutic measures should be administered while protecting the subject’s physical strength and power of metabolism.[60-61]

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All the therapeutic measures which alleviate [[kapha]] but do not aggravate [[vata]] should always be employed for the treatment of ''urustambha''. These therapeutic measures should be administered while protecting the subject’s physical strength and power of metabolism.[60-61]

=== Summary ===

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*''Urustambha'' occurs due to consumption of diet and lifestyle having mutual contradictory properties like hot and cold, unctuous and dry etc.

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*Inadequate digestion leading to vitiation of all ''dosha'' causes the basic pathogenesis.

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*Inadequate digestion leading to vitiation of all [[dosha]] causes the basic pathogenesis.

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*[[''Kapha'']] is the main dosha and ''meda'' is ''dushya''. ''Avarodha'' (blockage) by excess fat and lipids in the vessels going downwards in thigh region is the type of pathogenesis.

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*[[Kapha]] is the main [[dosha]] and [[meda dhatu]] is ''dushya''. ''Avarodha'' (blockage) by excess fat and lipids in the vessels going downwards in thigh region is the type of pathogenesis.

*Oleation and [[Panchakarma]] therapy is contraindicated in ''urustambha''.

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*Constant administration of therapies for ''samshamana'' (pacification), ''kshapana'' (reduction) and ''shoshana'' (drying up by absorption) of [[''kapha'']] and ''ama'' are indicated in ''urustambha''.

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*Constant administration of therapies for ''samshamana'' (pacification), ''kshapana'' (reduction) and ''shoshana'' (drying up by absorption) of [[kapha]] and ''ama'' are indicated in ''urustambha''.

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*''Rukshana'' (drying up) therapies with diet, lifestyle and medicinesis administered to absorb morbid ''dosha'' causing obstruction.

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*[[Rukshana]] (drying up) therapies with diet, lifestyle and medicinesis administered to absorb morbid [[dosha]] causing obstruction.

*The treatment includes internal administration of ''kshara, arishta'' and ''haritaki'' as well as the drugs having abovementioned actions. External application in the form of ''utsadana''( massage with mixture of powder and unctuous substance) is prescribed.

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*The strong patients shall be advised exercise which can reduce [[''kapha'']] and [[''meda'']] like walking on sand or swimming against the stream. The objective of exercise it to remove blockage from circulation.

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*The strong patients shall be advised exercise which can reduce [[kapha]] and [[meda dhatu]] like walking on sand or swimming against the stream. The objective of exercise it to remove blockage from circulation.

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*All the therapeutic measures which alleviate [[''kapha'']] but do not aggravate[[ vata]] should always be employed for the treatment of ''urustambha''. These therapeutic measures should be administered while protecting the subject’s physical strength and power of metabolism.

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*All the therapeutic measures which alleviate [[kapha]] but do not aggravate [[vata]] should always be employed for the treatment of ''urustambha''. These therapeutic measures should be administered while protecting the subject’s physical strength and power of metabolism.

== Vidhi Vimarsha (Applied Inferences ) ==

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''Urustambha'' resembles [[''vata'']] disorder because of clinical picture of painful weakness of pelvic girdle and lower extremities muscles. However, it should not be treated as ''vatic'' disorder as basically it is caused by vitiation of [[''kapha''] and ''ama'' formation leading to obstruction of [[''vata'']].

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''Urustambha'' resembles [[vata]] disorder because of clinical picture of painful weakness of pelvic girdle and lower extremities muscles. However, it should not be treated as ''vatic'' disorder as basically it is caused by vitiation of [[kapha]] and ''ama'' formation leading to obstruction of [[vata]].

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It is caused by poor lifestyle and diet with excess fat and inadequate digestion leading to ''ama'' and vitiation of three ''dosha'' of which ''kapha'' is predominant. ''Ama'', vitiated three ''dosha'' and deranged ''meda'' (fat) get deposited in the muscles of lower extremities and strangulate them.

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It is caused by poor lifestyle and diet with excess fat and inadequate digestion leading to ''ama'' and vitiation of three [[dosha]] of which [[kapha]] is predominant. ''Ama'', vitiated three [[dosha]] and deranged [[meda dhatu]] (fat) get deposited in the muscles of lower extremities and strangulate them.

Since it is ''tridoshic'' disorder with increased ama, [[Panchakarma]] is contraindicated.

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Specific treatment is internal and external ''rukshana'' (consumption therapies) consisting of:

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Specific treatment is internal and external [[rukshana]] (consumption therapies) consisting of:

*Consumption of the ''amadosha'',

*Releasing the ''medas'' which is strangulating/ deposited / adhered with the muscles

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*First pacify only ''kapha'' by consumption

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*First pacify only [[kapha]] by consumption

*Swimming against the flow of water.

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*''Pachana,'' digestion regularization for the ''pitta dosha''.

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*[[Pachana]], digestion regularization for the [[pitta]] [[dosha]].

*Aggressive physiotherapy.

*All the myopathies should be treated as per line of treatment mentioned in ''urustambha''.

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*Differential diagnosis between ''urustambha, mamsa-medogata vata'' (disorder due to vitiated ''vata'' located in ''mamsa'' and ''meda''), ~~''pittavrita~~ vyana'' (''vyana'' covered by vitiated ''pitta'') and ''kapha avrita vyana'' (''vyana'' covered by vitiated ''kapha'') is necessary. These sets of disorders refer to genetic and acquired muscular disorders (inflammatory and degenerative disorders).

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*Differential diagnosis between urustambha, mamsa-medogata [[vata]] (disorder due to vitiated [[vata]] located in [[mamsa dhatu]] and [[meda dhatu]]), [[pitta]]vrita vyana (''vyana'' covered by vitiated [[pitta]]) and [[kapha]] avrita vyana ([[vyana]] covered by vitiated [[kapha]]) is necessary. These sets of disorders refer to genetic and acquired muscular disorders (inflammatory and degenerative disorders).

=== Etiological factors ===

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~~''Tridosha~~ prakopa nidana'' mentioned by Vagbhata comprises of ''sankirna, ajirna, vishama, viruddha, adhyashana, vyapanna-madya, putishushkakrishaamisha'' etc. <ref>Vagbhata. Nidana Sthana, Cha.1 Sarvaroga Nidana Adhyaya verse 19,20. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref>. Consuming foods having different ~~''gunas''~~ altogether (''sankirna''), practice of food and regimen which are antagonistic to the body’s state and stage (''viruddha''), consuming food before the previous one gets digested (''adhyashana'') and repeated development of indigestion (''ajirna'') explained in the aetiology are direct causes for ~~''tridosha~~ prakopa''. Regular habituation of ''viruddha, adhyashana'' and ''ajirna'' causes accumulation of toxic metabolites in ''rasa dhatu''. These toxic metabolites avert proper utilization of ~~''rasadhatu''~~ and elicit ~~''tridosha~~ prakopa'', which carry untransformed ~~''rasadhatu''~~ to ''amashaya''. This ~~''rasadhatu''~~, which is having attributes of ''kapha'' is taken to ''amashaya'' to get metabolized (digested) by ~~''kaphagni''~~ present there. Thus ''ama ~~rasadhatu''~~ is a condition of ''koshtha''. If ''amarasadhatu'' fails to get digested, it interacts and combines with elicited ~~''tridosha''~~ to become one which is designated as ''saama(tri)dosha''. Thus ~~''tridosha~~ prakopa'' occurs indirectly also by the toxic metabolites developing due to incompatible practices. As fat predominant circumstance paves for the initiation of pathogenesis of this disease, kapha gains more strength than the other two ~~doshas~~. Kapha or ~~saamakapha~~ subdues pitta.<ref>Vagbhata. Nidana Sthana, Cha.15, Vatavyadhi Nidana Adhyaya verse 48. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref> In medodushtija conditions all the channels will be obstructed by medas. <ref>Sushruta. Sutra Sthana, Cha.15 Doshadhatumalakshayavruddhivijnaneeyam Adhyaya verse 32. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.</ref>. If the subject happens to indulge in overexertion, jerks, day-time sleep or awakening in night, the pathogenic factor (saama-kapha-vata) along with medas from koshdha (rasa-dhatu) moves to lower limbs and affects sakthi (lower limbs). Causes for the movement of ~~doshas~~ from koshdha to other rogamargas include overexertion, uncontrolled digestive or metabolic activity, unwholesome practice or vyana hyperactivity. Aavarana (obstruction of the movement of vata) pathogenesis also takes place at the siras supplying lowerlimbs. Prakupita dosha (dosha which gets aggravated by extrinsic causes and are not innately present in the body) is regarded as vata and innate intrinsic dosha is regarded as vayu (prana-udana-vyana-samana-apana) in Classics. Though both vata and vayu can get avarana, here medasaavrita vata (obstruction to vata which got aggravated by extrinsic causes by vitiated medas) takes place. Hence urusthambha has a synonym aadhyavata<ref>Vagbhata.Nidana Sthana, Cha.15 Vatavyadhi Nidanam In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref>, which actually is a synonym of medasaavrita-vata (aadhyavata iti jneyassa kricchro medasaavrite – Madhav Nidan). The movement of vata as well as the active movement of lower limbs (performed by vyana vayu) will be obstructed by the medas and also made motionlessness (mudha-vata) by saamata. Hence the disease got the name by the samsthaana (sign), immobility of uru (urusthambha) caused by medas and ama.

+

Tri[[dosha]] prakopa nidana mentioned by Vagbhata comprises of ''sankirna, ajirna, vishama, viruddha, adhyashana, vyapanna-madya, putishushkakrishaamisha'' etc. <ref>Vagbhata. Nidana Sthana, Cha.1 Sarvaroga Nidana Adhyaya verse 19,20. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref>. Consuming foods having different [[guna]] altogether (''sankirna''), practice of food and regimen which are antagonistic to the body’s state and stage (''viruddha''), consuming food before the previous one gets digested (''adhyashana'') and repeated development of indigestion (''ajirna'') explained in the aetiology are direct causes for tri[[dosha]] prakopa. Regular habituation of ''viruddha, adhyashana'' and ''ajirna'' causes accumulation of toxic metabolites in [[rasa dhatu]]. These toxic metabolites avert proper utilization of [[rasa dhatu]] and elicit tri[[dosha]] prakopa, which carry untransformed [[rasa dhatu]] to ''amashaya''. This [[rasa dhatu]], which is having attributes of [[kapha]] is taken to ''amashaya'' to get metabolized (digested) by [[kapha]]gni present there. Thus ama [[rasa dhatu]] is a condition of ''koshtha''. If ''amarasadhatu'' fails to get digested, it interacts and combines with elicited tri[[dosha]] to become one which is designated as saama(tri)[[dosha]]. Thus tri[[dosha]] prakopa occurs indirectly also by the toxic metabolites developing due to incompatible practices. As fat predominant circumstance paves for the initiation of pathogenesis of this disease, [[kapha]] gains more strength than the other two [[dosha]]. [[Kapha]] or saama[[kapha]] subdues [[pitta]].<ref>Vagbhata. Nidana Sthana, Cha.15, Vatavyadhi Nidana Adhyaya verse 48. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref> In medodushtija conditions all the channels will be obstructed by medas . <ref>Sushruta. Sutra Sthana, Cha.15 Doshadhatumalakshayavruddhivijnaneeyam Adhyaya verse 32. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.</ref>. If the subject happens to indulge in overexertion, jerks, day-time sleep or awakening in night, the pathogenic factor (saama-[[kapha]]-[[vata]]) along with medas from koshdha ([[rasa dhatu]]) moves to lower limbs and affects sakthi (lower limbs). Causes for the movement of [[dosha]] from koshdha to other rogamargas include overexertion, uncontrolled digestive or metabolic activity, unwholesome practice or vyana hyperactivity. Aavarana (obstruction of the movement of [[vata]]) pathogenesis also takes place at the siras supplying lowerlimbs. Prakupita [[dosha]] ([[dosha]] which gets aggravated by extrinsic causes and are not innately present in the body) is regarded as [[vata]] and innate intrinsic [[dosha]] is regarded as [[vayu]] (prana-udana-vyana-samana-apana) in Classics. Though both [[vata]] and vayu can get avarana, here medasaavrita [[vata ]](obstruction to [[vata]] which got aggravated by extrinsic causes by vitiated medas) takes place. Hence urusthambha has a synonym aadhyavata<ref>Vagbhata.Nidana Sthana, Cha.15 Vatavyadhi Nidanam In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref>, which actually is a synonym of medasaavrita-vata (aadhyavata iti jneyassa kricchro medasaavrite – Madhav Nidan). The movement of [[vata]] as well as the active movement of lower limbs (performed by vyana vayu) will be obstructed by the medas and also made motionlessness (mudha-[[vata]]) by saamata. Hence the disease got the name by the samsthaana (sign), immobility of uru (urusthambha) caused by medas and ama.

'''Table 1: Pathological factors involved in urustambha'''

{| class="wikitable"

|-

−

! Vitiated dosha !! Dushya Dhatu !! Srotas !! Prakriti (Sthanik dosha) !! Desha (Rogamarga) !! Kaala (stage of the disease)

+

! Vitiated [[dosha]] !! Dushya [[Dhatu]] !! Srotas !! [[Prakriti]] (Sthanik [[dosha]]) !! Desha (Rogamarga) !! Kaala (stage of the disease)

|-

−

| Vitiated Kapha (Gourava,Sthairya, Shaitya, Snigdha) - Vata (Laaghava & Vaishadya) || Rasa(+), Asthi (+) ||Rasavaha-srotas (+) Majjavaha-srotas (+) || Avalambaka Kapha (+),Paachaka pitta (-),Samaana (+), Vyaana (+) || Antar-roga maarga (+), Madhyama roga maarga (+) ||Saama kapha (+), Avrita-vata, Acute (+)

+

| Vitiated [[Kapha]] (Gourava,Sthairya, Shaitya, Snigdha) - [[Vata]] (Laaghava & Vaishadya) || [[Rasa dhatu]](+), [[Asthi dhatu]](+) ||Rasavaha-srotas (+) Majjavaha-srotas (+) || Avalambaka [[Kapha]] (+),Paachaka [[pitta]] (-),Samaana (+), Vyaana (+) || Antar-roga maarga (+), Madhyama roga maarga (+) ||Saama [[kapha]] (+), Avrita-[[vata]], Acute (+)

|-

|}

−

Note: (+)=Identical with vitiated dosha,(-)= not identical with vitiated dosha, Samprapti Bala: 11/12 (Pravara)

+

Note: (+)=Identical with vitiated [[dosha]],(-)= not identical with vitiated [[dosha]], Samprapti Bala: 11/12 (Pravara)

=== Reason of limitation of panchakarma in management ===

−

The reason why pancakarma therapies are ineffective in urusthambha is due to four reasons. The ~~tridosha~~ which is getting vitiated due to visharupa ama (toxic metabolites in [[rasadhatu]]) become ~~saamadosha~~ on interaction with ama ~~rasadhatu~~. This saamadosha will be directed to lower limbs by fat. So the two reasons being the adherence (paicchilyam) produced by ama and obstruction by medas. Due to these causes, the ~~doshas~~ are unable to move out of uru. The third reason is asthi is site of vata which is inherently shita (cold leading to stiffness) predominant. Kapha has cold properties leading to obstruction and stiffness. The fourth reason is mudha-vatata (vata in asthi is devoid of movement) due to ama and avarana and hence movement of kapha outwards is not facilitated. Moreover kapha is immobile.

+

The reason why [[pancakarma]] therapies are ineffective in urusthambha is due to four reasons. The tri[[dosha]] which is getting vitiated due to visharupa ama (toxic metabolites in [[rasadhatu]]) become saama[[dosha]] on interaction with ama [[rasa dhatu]]. This saamadosha will be directed to lower limbs by fat. So the two reasons being the adherence (paicchilyam) produced by ama and obstruction by medas. Due to these causes, the [[dosha]] are unable to move out of uru. The third reason is asthi is site of vata which is inherently shita (cold leading to stiffness) predominant. [[Kapha]] has cold properties leading to obstruction and stiffness. The fourth reason is mudha-vatata ([[vata]] in [[asthi dhatu]] is devoid of movement) due to ama and avarana and hence movement of [[kapha]] outwards is not facilitated. Moreover [[kapha]] is immobile.

−

Panchakarma therapy is prescribed only when ~~doshas~~ are in a state of getting expelled out from nearest external orifices. In urusthambha due to adhering nature of ~~doshas~~, obstruction by fat, decreased metabolic activity in asthi and also due to immobile kapha-vata, srotashodhana (clearing channels), abhishyandana (flowing nature of doshas) or paaka (proper metabolic activity) do not take place. This shows the inadequacy to facilitate mobility and koshdha gati (movement of dosha towards GIT) of ~~doshas~~. Hence panchakarma therapy is not advisable in this circumstance.

+

Panchakarma therapy is prescribed only when [[dosha]] are in a state of getting expelled out from nearest external orifices. In urusthambha due to adhering nature of [[dosha]], obstruction by fat, decreased metabolic activity in [[asthi dhatu]] and also due to immobile [[kapha]]-[[vata]], srotashodhana (clearing channels), abhishyandana (flowing nature of doshas) or paaka (proper metabolic activity) do not take place. This shows the inadequacy to facilitate mobility and koshdha gati (movement of dosha towards GIT) of [[dosha]]. Hence panchakarma therapy is not advisable in this circumstance.

=== Importance of rukshana ===

−

The biological functions performed by ruksha guna are those opposite to sneha guna. Snehaguna imparts softness, unctuousness, increases strength and improves the complexion. Ruksha removes kleda (water elementary principle) from cells or tissues and causes hardening and eventually roughening takes place. Fat predominance in structures makes them soft while protein in excess makes them hard. Sneha-kleda vriddhi in excess in tissues makes them flaccid and soft. As the sneha-kleda vriddhi cannot be expelled from asthi and brought to koshdha, the treatment principle which is to be applied is either increasing the mobility of kleda and make it move outwards or drying up of kleda by absorption. Rukshana is performed not only by ruksha guna, but also by many gunas which directly or indirectly augment the absorption of kleda. Kashaya-katu-tikta tastes are successively more powerful rukshana rasas.

+

The biological functions performed by ruksha guna are those opposite to sneha guna. Snehaguna imparts softness, unctuousness, increases strength and improves the complexion. Ruksha removes kleda (water elementary principle) from cells or tissues and causes hardening and eventually roughening takes place. Fat predominance in structures makes them soft while protein in excess makes them hard. Sneha-kleda vriddhi in excess in tissues makes them flaccid and soft. As the sneha-kleda vriddhi cannot be expelled from [[asthi dhatu]] and brought to koshdha, the treatment principle which is to be applied is either increasing the mobility of kleda and make it move outwards or drying up of kleda by absorption. [[Rukshana]] is performed not only by ruksha guna, but also by many gunas which directly or indirectly augment the absorption of kleda. Kashaya-katu-tikta tastes are successively more powerful rukshana rasas.

−

Vyadhiviparita treatment encompasses reinstalling the functions of samana vayu, vyana vayu and avalambaka kapha. Hetuviparita treatment is ~~Saamadosha~~ management and ~~kaphaavrita~~ vata treatment.

+

Vyadhiviparita treatment encompasses reinstalling the functions of samana [[vayu]], vyana [[vayu]] and avalambaka [[kapha]]. Hetuviparita treatment is Saama[[dosha]] management and [[kapha]]avrita [[vata]] treatment.

=== Beneficial diet ===

−

Congenial (pathya or roga-saatmya) food should be changed to shyaamaaka, kodrava, uddaala and shaali which are puraana (stored for a long period like one year or more). Shaali though is madhura, puraana will subside kapha and medas. Yusha of shushka moolaka or patola, Jaangala maamsa and other vegetables without ghee and salt <ref> Sushruta. Chikitsa Sthana, Cha.5 Mahavatavyadhi Chikitsitam verse 38. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1. </ref>

+

Congenial (pathya or roga-saatmya) food should be changed to shyaamaaka, kodrava, uddaala and shaali which are puraana (stored for a long period like one year or more). Shaali though is madhura, puraana will subside [[kapha]] and medas. Yusha of shushka moolaka or patola, Jaangala maamsa and other vegetables without ghee and salt <ref> Sushruta. Chikitsa Sthana, Cha.5 Mahavatavyadhi Chikitsitam verse 38. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1. </ref>

=== Medicines ===

The best drug of choice is guggulu <ref>Sushruta. Chikitsa Sthana, Cha.5 Mhavatavyadhi Chikitsitam Adhyaya verse 40-45. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.</ref>. With its (guggulu’s) prabhaava (special attribute), it does rukshana (vaishadyakara) as well as vata-anulomana (ushna-virya) simultaneously.

−

The best formulation of choice is shaddharana churna which metabolises saama kapha and also medas along with vata-anulomana. Other chief drugs that could be used according to the status are triphala, trikatu, shilajit, karanjaphala, sarshapa etc. Choice of medicine is to be done according to the state and stage of the disease and diseased.

+

The best formulation of choice is shaddharana churna which metabolises saama [[kapha]] and also medas along with [[vata]]-anulomana. Other chief drugs that could be used according to the status are triphala, trikatu, shilajit, karanjaphala, sarshapa etc. Choice of medicine is to be done according to the state and stage of the disease and diseased.

−

Nourishment in vitiation of vata:If Urusthambha develops in emaciated (Apatarpanotha), santarpana of rasa dhatu has to be done with jaangala maamsa, puraana shaali etc. All the foresaid measures could be done in niraama stage only. The food, regimen and medicine should always be kapha-~~vatahara~~.

+

Nourishment in vitiation of [[vata]]:If Urusthambha develops in emaciated (Apatarpanotha), santarpana of [[rasa dhatu]] has to be done with jaangala maamsa, puraana shaali etc. All the foresaid measures could be done in niraama stage only. The food, regimen and medicine should always be [[kapha]]-[[vata]]hara.

−

The treatment should be always ~~kaphahara~~ (rukshana) along with ~~vatahara~~ (anulomana for laghu, vishada ~~gunas~~). Laaghava (decline of anulomana, effortless execution of activities) Aatma-rupa of vata causes symptoms in vyakti stage. Roukshya (degenerative changes) Aatma-rupa of vata causes symptoms of insomnia and pain (alarm to prevent necrosis) as upadrava due to careless application of rukshana.

+

The treatment should be always [[kapha]]hara ([[rukshana]]) along with [[vata]]hara (anulomana for laghu, vishada [[guna]]). [[Laaghava]] (decline of anulomana, effortless execution of activities) Aatma-rupa of [[vata]] causes symptoms in vyakti stage. Roukshya (degenerative changes) Aatma-rupa of [[vata]] causes symptoms of insomnia and pain (alarm to prevent necrosis) as upadrava due to careless application of [[rukshana]].

=== Medicated oils ===

−

Medicated oils are to be applied only in niraama-dosha as well as kapha and medas have decreased (aavarana lakshanas disappear) considerably. Medicated oils can alleviate roukshya, vaishadya and laghava without affecting or along with the decline of kapha and ~~medas~~.

+

Medicated oils are to be applied only in niraama-[[dosha]] as well as [[kapha]] and medas have decreased (aavarana lakshanas disappear) considerably. Medicated oils can alleviate roukshya, vaishadya and laghava without affecting or along with the decline of [[kapha]] and [[meda dhatu]].

−

=== Management of ama dosha ===

+

=== Management of ama [[dosha]] ===

−

All these therapeutics are to be administered after metabolizing saama dosha. As ama is of toxic nature, treatment principle of ama-vata (~~Langhanam swedanam~~ tikto ~~deepanaani~~ katuni ca) has to be applied initially. Then rukshana treatment principle without aggravating vata is explained. The foresaid food, recipes (medicine) and regimen help to achieve rukshana. Katu, tikta and kashaya rasaas are antagonistic to kapha, but aggravates vata. Dravyas which differ from the above principle are shunthi, pippali, rasona (katu dravyaas), guduchi, patola (tikta dravyas) and haritaki (kashaya dravya) will not aggravate vata. The patient should be made to walk on irregular surface will cause strain to lower limbs which is a treatment principle of kapha<ref>Vagbhata. Sutra Sthana, Cha.13 Doshopakramaneeya Adhyaya verse 12. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4. </ref>. Swimming in cool water would increase the internal temperature which counters the shita guna of kapha which is strongly embedded in shita asthi-dhatu. This would favour kapha kshapana from asthi and its mitigation.

+

All these therapeutics are to be administered after metabolizing saama [[dosha]]. As ama is of toxic nature, treatment principle of ama-[[vata]] ([[Langhana]]m [[swedana]]m tikto [[deepana]]ani katuni ca) has to be applied initially. Then [[rukshana]] treatment principle without aggravating [[vata]] is explained. The foresaid food, recipes (medicine) and regimen help to achieve [[rukshana]]. Katu, tikta and kashaya rasaas are antagonistic to [[kapha]], but aggravates [[vata]]. Dravyas which differ from the above principle are shunthi, pippali, rasona (katu dravyaas), guduchi, patola (tikta dravyas) and haritaki (kashaya dravya) will not aggravate vata. The patient should be made to walk on irregular surface will cause strain to lower limbs which is a treatment principle of [[kapha]]<ref>Vagbhata. Sutra Sthana, Cha.13 Doshopakramaneeya Adhyaya verse 12. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4. </ref>. Swimming in cool water would increase the internal temperature which counters the shita guna of [[kapha]] which is strongly embedded in shita [[asthi-dhatu]]. This would favour [[kapha]] kshapana from [[asthi]] and its mitigation.

=== Current clinical practices ===

Line 942: Line 942:

==== Principles of management ====

−

#Kshapana of kapha and meda ( reduction of kapha and meda)

+

#Kshapana of [[kapha]] and [[meda dhatu]] ( reduction of [[kapha]] and [[meda dhatu]])

−

#Rukshana and shoshana (drying and absorbing excess fat and lipids)

+

#[[Rukshana]] and shoshana (drying and absorbing excess fat and lipids)

#External application 4. Exercise in the form of swimming against the flow

==== Important medicines ====

Anaghas

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