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Comparative Study of Clinical Effect of Kshara-Basti and Virechana-Karma in the Management of Amavata with Special Reference to Rheumatoid Arthritis

Rahul Dalavi , Pushpinder Singh, Anil Pardeshi, Md. Hanif Shaikh, Shubhangi Narwade, Pallavi Pardeshi
American Journal of Pharmacological Sciences. 2022, 10(1), 12-19. DOI: 10.12691/ajps-10-1-3
Received May 22, 2022; Revised June 27, 2022; Accepted July 07, 2022

Abstract

Background: Kshara Basti and Virechana Karma as therapy for Amavata are indicated in Ayurveda. Ayurveda is having a crucial role in the management of Amavata with special reference to rheumatoid arthritis (RA) as a crippling disease. Amavata is having clinical appearance as comparable with RA. The line of treatment as mentioned by Chakradatta is to bring Agni to normal state for digestion of Ama, eventually to eliminate vitiated Vata and Ama. Thus, here Kshara Basti and Virechana Karma are selected for the present study as Samshodhana process which corrects all the above captions. Objective: To evaluate and compare clinical efficacy of Kshara Basti and Virechana Karma as tharapy in Amavata. Methods: This was a randomized open-label, comparative clinical study. Total 35 randomly selected patients of Amavata were registered and screened and out of them 30 (15 patients in Group-A i.e. Kshara Basti and 15 patients in Group-B i.e. Virechan-Karma) were completed the treatment. Kshara Basti in the format of Kala Basti (as mentioned by Chakradatta) was given to the patients of Basti group and Virechana Karma as per Chakradatta was given to the patients of Virechana karma group. The effects of therapy in both groups were assessed by a specially prepared proforma. Results: The results of the study showed that both the groups showed significant relief in symptoms; however, compared to Virechana karma group, Basti group showed better result in the management of Amavata. Statistically significant improvement was found in ESR, RA factor (quantitative) and highly significant results were found in symptoms of Amavata (Kshara Basti results significant as compared to Virechana karma). Moderate improvement was seen in 80% of patients of Basti group (66.6% Virechana karma group), 6.6% patients got marked improvement in Basti group (no marked improvement in Virechana group), while mild improvement was found in 13.3% of patients of Basti group (33.3% for Virechana karma group). Conclusion: Kshara Basti and Virechana Karma have significant comparative activity in Amavata.

1. Background

Amavata is the prime disease which makes the person crippled and unfit for an independent life. Amavata word is composed of two words Ama and Vata, the condition which is caused by accumulation of Ama and Vata is called Amavata. In terms of medicine Ama refers to the events that follow and the factors that arise because of impaired functioning of ‘Agni’ whereas in literal terms the word Ama means unripe, immature and undigested.

This ‘Ama’ is then carried by ‘Vayu’ and travels throughout the body and accumulates in the joints, at the weaker sites (Khavaigunya) and Amavata occurs 1. It has similarities to clinical features associated with Rheumatoid Arthritis (RA). Rheumatoid Arthritis is a joint disorder which affects multiple joints at various sites. RA is a chronic systemic inflammatory disease 2.

In India, the prevalence of RA is estimated to be 0.8 %. The prevalence rate of this disease is about 3% with a male to female ratio of 1:3 3.

The principles of treatment of Amavata are Langhana and Swedana; and drugs having Tikta, Katu Rasa, Deepana, Virechana, Snehapana and Basti properties 4. In this present study an attempt is made to evaluate the effect of Panchkarma procedures i.e. Kshara Basti and Virechana in the management of Amavata.

Basti is very important therapy to manage Vata-Dosha and is called as Ardha Chikitsa. Vata is very important Dosha to be managed during treatment of any disease as other Doshas are handicapped without Vata- Dosha. Virechanakarma as a Shodhana-therapy is described as the effective management of Amavata. As it is the therapy for the Sthanika Pitta Dosha, it is responsible for Agnivardhana and evacuation of Ama, which is the main etiological factor of this disease 5. So, in the present study, Kshara Basti & Virechana karma has been selected as Shodhana Chikitsa which is mentioned in Chikitsa Sutra described by Chakradatta.

Thus, a clinical study was planned to assess the clinical effectiveness of Kshara basti and Virechana karma and to compare the effect of these two therapies in the treatment of Amavata.

2. Methods

This clinical study was conducted at Department of Panchakarma, Rajiv Gandhi Government Post-graduate Ayurveda College, Paprola, Himachal Pradesh (India) to determine the the clinical effectiveness of Kshara basti and Virechana karma in Amavata.

2.1. Ethical Consideration

The study was approved by the Institutional Ethics Committee of Rajiv Gandhi Government Post-graduate Ayurveda College, Paprola (IEC/2013/372). Patients were enrolled in the study only after voluntary written informed consent.

2.2. Quality Testing of Ayurvedic Medicines from Drug Testing laboratory, Joginder-Nagar, Mandi

The Ayurvedic Medicines were tested in the laboratory for Quality and whether comply with the API (Active Pharmaceutical Ingredient) standards (Ref. DTL.P/15/13-848/3).

2.3. Selection of ‘Amavata’ Patient

After ethical approval from Institutional Ethics Committee; 35 IPD patients were selected for screening and 30 IPD were randomized and enrolled in 2 groups (after taking voluntary informed consent from patients) from the Department of Kayachikitsa. For this, patients fulfilling the criteria for the diagnosis of the disease were registered for the present study according to their age (between 18 to 70 years) but irrespective of their sex, religion, occupation and other parameters. Both acute and chronic phases of Amavata patients were taken for the study, following the ACR criteria of the diagnosis of RA in modern medicine and the clinical features of Amavata described in Madhava Nidana 6.

2.4. Study Design

Single centered, open-label randomized study.

2.5. Inclusion Criteria

The patients between the age group of 18–70 years of either sex presenting with the clinical features of Amavata like pain, stiffness and swelling in multiple joints along with features of Ama like loss of appetite, indigestion and fever. Patient diagnosed for RA on the basis ACR criteria.

2.6. Exclusion Criteria

Pregnant women and lactating mother;

Patients suffering from paralysis, neurological disorder, gout, cardiac disease, diabetes mellitus, hypertension, chronic kidney diseases, osteomyelitis;

Patients contraindicated for Basti and Virechana as mentioned in Samhitas. Patients having the classical features of Amavata like Angamarda, Aruchi, Trishna, Alasya, Jwara, Sandhishula, Sandhishotha 7, and modern parameters of Rheumatoid arthritis (RA) like morning stiffness, pain, tenderness, swelling, fever, raised E.S.R. etc. were included for the present study 8.

The criteria for diagnosing RA [as lay down by American Rheumatism Association (A.R.A.)] in 1987 was also taken into consideration 9. Both seropositive and seronegative RA factor cases RA. Chronicity for more than 10 years, having severe crippling deformity, cardiac disease, pulmonary- tuberculosis and diabetes mellitus patients were excluded.

A detailed research Proforma was prepared incorporating all the signs and symptoms seen in the disease.

2.7. Randomization

Patients were screened and randomized on first cum first served basis. The simple randomization table was generated through computer based standard software program.

2.8. Investigations

The routine haematological and biochemical investigation, RA factor and C-reactive protein (C.R.P.) test were done before and after treatment. Routine stool and urine examination were conducted during the study to see for any changes in the biological system.

2.9. Grouping

A total of 30 clinically diagnosed and registered patients of Amavata were divided randomly by lottery method into two groups. Each group had 15 patients.

Group I: Kshara-Basti Group

Amount of all dravyas as mentioned in the text was taken in its half quantity keeping in the mind the body strength (Rogibala) of the patients.

Group II: Virechana-Karma Group

Amount of all dravyas as mentioned in the text was taken in its half quantity keeping in the mind the body strength (Rogibala) of the patients.

2.10. Criteria for Assessment

The results of the therapy were assessed based on clinical signs and symptoms mentioned in the Ayurvedic classics. The improvements in the condition of patients were assessed based on Roga Bala, Agni Bala, Deha Bala, Chetasa Bala and as well as by American Rheumatism Association (ARA 1987) criteria for degree of disease severity 10.

A. Clinical assessment

The changes observed in the signs and symptoms were assessed by adopting suitable scoring method and by using appropriate clinical tools. The details of scoring pattern adopted for assessment of clinical sign and symptoms are given below:

B. Degree of disease activity

In the above criteria the maximum score can be calculated, which represents an average of grade 3 (severely active). The grade of disease is denoted by figures 0 – 3.

  • Table 5. Comparative effects of Test-Therapies Kshar-Basti in Group-A and Virechana-Karma in Group-B on overall improvement in cardinal symptoms of Amavata in the trial (By paired t-test)

From above table, the comparative effects of therapies i.e. Kshar-basti and Virechana karma have significant improvement in Sandhi-shula, sandhi-shotha, sparsha-asahyata, sandhi-graha in both group-A and group-B.

3. Statistical Analysis

The available data was analyzed for demographic parameters, cardinal signs and symptoms of Amavata and results in both groups. Total allocation of 30 patients was planned and was randomized in two groups using SPSS software (version16). Demographic data and baseline information was analyzed by descriptive method and is presented with summary statistics (n, mean, standard deviation, range) for continuous variables, whereas counts and percentages for categorical variables. These summaries are presented as per these two treatment groups.

3.1. Consort Flow Diagram

4. Results

In this study majority of patients, i.e. 71.87% belonged to the age group of 31-50 years and 71.87% were female.

The 90.62% patients were Hindu, 81.25% were married, 53.12% patients were housewives, 61.24% were from low income group and 24.99% had history of smoking or alcohol while 56.30% of the patients were history of consuming analgesic and steroids.

Majority of the patients had Vata-Kapha Prakriti (53.12%) and 40.62% had Vata-Pitta Prakriti. The percentage of patients in other groups considered was as follows: Mandagni (93.75%). 21.87% of the patients had positive family history of RA, 53.12% of patients had insidious onset and 78.13% had chronicity of more than 2 years.

In this study, RA factor was found positive in 62.50% of patients and raised E.S.R found in 73.35% of the patients. Most of the patients of this series i.e. 59.37% were having Madhyam Abhyavarana Shakti while 53.12% were having Avara Jarana Shakti. The etiological factors of Amavata found were Viruddhahara (84.94%), Atiguru (27.35%), Bhojanattora Vyayama (81.10%), Divaswap (62.44%), Vishamashana (83.22%), and Snigdha Ahara (27.33%).

The chief complaints like Angmarda, Aruchi, Alasya, Shoonatam cha anganam were found in 94.56% patients while Trishna was found in 93.75%, Jwara and Apaka were found in 93.87% patients and Gauravata was found in 90.62%.

With respect to cardinal symptoms, Sandhi-shula and Sparsha-Asahyata were observed in all the patients, i.e., 100%, followed by Sandhishotha in 92.33% of patients. Maximum patients experienced Vid-Vibaddhata (98.02%), 96.87% experienced Agni-daurbalya and Nidraviparyaya followed by 90.62% for Hritgraha and Jadya.

It was observed that wrist joint was involved in 93.75% of the patients. 84.37% had proximal Interphalangeal Joint (P.I.P) and knee joints, 81.25% elbow and ankle joint involvement. 78.12% were reported with Distal Inter Pharyngeal joint involvement, 65.62% of patients were reported with Metacarpal joints involvement, 62.5% of patients had Neck joint involvement, 59.37% of patients had Shoulder joint and Metatarsal joint involvement, 50% patients had Hip joint involvements.

5. Discussion

Agnimandya (mandya=Low functioning of Agni) is an important main factor responsible for the formation of Ama.

The etiological factors like Guru Ahara, Viruddhahara, Viruddha Cheshta, Mandagni, Snigdhabhuktavata Vyayama are responsible for Amavata 11. Sedentary lifestyle and changes in daily-routine and dietary patterns are responsible factors for the manifestation of disease.

The effects of both Basti and Virechana-karma therapy was mentioned in above Table 8. In most of the patients, moderate improvement found in both therapies (73.33%). 80% of the Group-A patients and 66.66% of the Group-B patients had moderate improvement.

The overall effects of therapy are mentioned as below

The overall effects of therapy indicate that 73.33% of the patients (n=22/30) has moderate improvement while 23.33 % of the total study population (n=07/30) has mild improvement. Only 1 patient has marked improvement.

2016: Sasane P & et al had done the comparative clinical evaluation efficacy study Alambushadi Ghana Vati (Group-A) and Vaitarana Basti (Group-B) in the management of Amavata in Jaipur and found that intergroup comparison showed that there was no major difference in efficacy of trial drug of both groups. However, Angmarda (p < 0.05) which there was statistically significant difference that Group-A provided better result than Group-B. In Group-A, excellent relief was found in 6.66% of patients, while significant relief in 46.66%, moderate relief in 33.33%, whereas mild relief in 13.33% of the patients, while in Group-B – excellent relief was found in 20% of patients, while significant relief in 60%, moderate relief in 13.33%, whereas mild relief in 6.66% of the patients 11.

In this our study, moderate improvement was seen in 80% of patients of Kshara Basti group (66.6% Virechana karma group), 6.6% patients got marked improvement in Basti group (no marked improvement in Virechana karma group), while mild improvement was found in 13.3% of patients of Basti group (33.3% for Virechana karma group).

2012: Thanki K & et al, done the study effect of Kshara Basti along with Nirgundi Ghana Vati on Amavata and found that moderate improvement was seen in 40% of patients, 35.56% patients got marked improvement, while mild improvement was found in 24.44% of patients. Effect of therapy on chief complaints such as Sandhi-shula, Sandhishotha, Sandhistabdhata and Sandhisparsa-Asahyata was found to be statistically highly significant (P<0.001) 12. And, the study done by Pandey S & et al in 2012 was on clinical efficacy of Shiva Guggulu and Simhanada Guggulu in Amavata. On analysis of the results, it was found that Simhanada Guggulu provided better results as compared to Shiva Guggulu in the management of Amavata 13.

In this our study, intergroup comparison of effects of test-therapies Kshara Basti in Group-A and Virechana Karma in Group-B on overall improvement in cardinal symptoms of Amavata like Sandhishula, Sandhishotha, Sandhistabdhata and Sandhisparsa-Asahyata was studied and found no significant difference between these two therapies.

2010: The study done by Khagram R & et al, observed the clinical effect of Matra Basti (Group-A) and Vatari Guggulu (Group-B) in the management of Amavata in Jamnagar. After assessing the overall effect of therapy, it was seen that marked improvement and moderate improvement was more in group-A by 52% and 42% respectively while in group-B marked improvement was only 11.32% and moderate improvement was 28.30% respectively 14.

In our study, the moderate improvement seen more in group-A by 80% and in group-B by 66.66% while 13.33% mild improvement in group-A and 33.33% mild improvement in group-B. Marked improvement was found only in group-A as 6.66%.

6. Conclusion

Madhava-Nidana guides that Ama and Vata being contradictory in nature make it difficult to plan the line of treatment in Amavata. In this study, although the improvement was statistically highly significant in both the groups, the Kshara Basti group (group A) showed comparatively better relief than the Virechana-Karma group (group B). Thus, Basti can be thought of as an ultimate solution for the eradication of Vata Dosha, Virechanakarma as a therapy for the Sthanika Pitta Dosha, it is responsible for Agnivardhana and evacuation of Ama, which is the main etiological factor of this disease. On comparing the effect of two therapies it can be concluded that Kshara-Basti provides significantly better relief than Virechana-Karma in most of the signs and symptoms of the disease.

Acknowledgements

We thank Rajiv Gandhi Government Post-graduate Ayurveda College, Paprola (Himachal Pradesh) for allowing us to do this study.

References

[1]  Shastri K, Chaturvedi GN, Ed. Dridhabala, Charak Samhita of Agnivesh, Siddhi Sthana. Reprint edition. Ch. 1, Ver. 38-40. Varanasi: Chaukhabha Bharati Academy; p. 1169, (2003).
In article      
 
[2]  Harrison TR, Dennis L. Casper, Anthony, Bn Dan L Longo, Eugene Braunwald, Stephen L. Hauser, J. Larry Jameson, et al. Harrison’s Principles of Internal Medicine. Braunwald, editor. 15th ed, Vol. 2, Part 12. New York: McGraw Hill organization; p. 1928, (2001).
In article      
 
[3]  Malaviya AN, Kapoor SK, Singh RR, Kumar A, Pande I, (1993). Prevalence of rheumatoid arthritis in the adult Indian population. Rheumatol Int; 13(4).
In article      View Article  PubMed
 
[4]  Dr. Indradeva Tripathi, editor. Acharya Ramanatha Dwevedi. Chakrapani Dutta, Chakradutta-Vaidya Prabha Hindi commentary with explanation, 4th ed. Chakradutta 25/1. Varanasi: Chowkhambha Sanskrit Sansthana; p.166, (2002).
In article      
 
[5]  Shastri BS, editor. Yogaratnakara of unknown author, Amavata Chikitsa. 6th ed., vol. Varanasi: Chaukhamba Sanskrit Sansthan; p. 566-73, (1997).
In article      
 
[6]  Shastri Sudarshana, Ed. Madhava Nidana of Madhavakara. 29th ed. Ch. 25, ver. 6. Varanasi: Chaukhambha Sanskrit Samsthan; p. 511, (1999).
In article      
 
[7]  Shri Sudarshana Shastri revised and edited by Prof. Yadunandan Upadhayay. Madhava Nidana of Shri Madhavakara with the Madhukosha Sanskrit commentary by Srivijayarakshita and Srikanthadatta with the Vidyotani Hindi commentary and notes by. 27th ed. Varanasi: Chaukhambha Sanskrit Samsthana; Amavata Nidana 25/6-11, P. 462-3, (1998).
In article      
 
[8]  Christopher Haslett, Edwin R Chilvers, Nicholas A Boon and Nicki R Colledge, Davidson’s Principle and Practice of Medicine. 19th edition Philladelphia, Churchill livingstone, p 1002-1007, (2002).
In article      
 
[9]  Bralulnwalad, Fauci, Kasper, Hauser, Longo and Jameson, Harrison`s principles of Internal medicine, Table 312-1, 15th International edition volume 2, New York, McGraw-Hill medical publication, p 1934, (2001).
In article      
 
[10]  Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, & et al, (1988). The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum; 31: 315-24.
In article      View Article  PubMed
 
[11]  Sasane P, Saroj UR, Joshi RK, 2016.Clinical evaluation of efficacy of Alambushadi Ghana Vati and Vaitarana Basti in the management of Amavata with special reference to rheumatoid arthritis. AYU; 37: 105-112.
In article      View Article  PubMed
 
[12]  Thanki K, Bhatt N & Shukla VD, (2012). Effect of Kshara Basti and Nirgundi Ghana Vati on Amavata (Rheumatoid Arthritis). AYU; 33:50-53.
In article      View Article  PubMed
 
[13]  Pandey SA, Joshi NP & Pandya DM, 2012.Clinical efficacy of Shiva Guggulu and Simhanada Guggulu in Amavata (Rheumatoid Arthritis). AYU; 33: 247-254.
In article      View Article  PubMed
 
[14]  Khagram R, Mehta CS, Shukla VD, Dave AR, (2010). Clinical effect of Matra Basti and Vatari Guggulu in the management of Amavata (rheumatoid arthritis). AYU; 31: 343-350.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2022 Rahul Dalavi, Pushpinder Singh, Anil Pardeshi, Md. Hanif Shaikh, Shubhangi Narwade and Pallavi Pardeshi

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Normal Style
Rahul Dalavi, Pushpinder Singh, Anil Pardeshi, Md. Hanif Shaikh, Shubhangi Narwade, Pallavi Pardeshi. Comparative Study of Clinical Effect of Kshara-Basti and Virechana-Karma in the Management of Amavata with Special Reference to Rheumatoid Arthritis. American Journal of Pharmacological Sciences. Vol. 10, No. 1, 2022, pp 12-19. http://pubs.sciepub.com/ajps/10/1/3
MLA Style
Dalavi, Rahul, et al. "Comparative Study of Clinical Effect of Kshara-Basti and Virechana-Karma in the Management of Amavata with Special Reference to Rheumatoid Arthritis." American Journal of Pharmacological Sciences 10.1 (2022): 12-19.
APA Style
Dalavi, R. , Singh, P. , Pardeshi, A. , Shaikh, M. H. , Narwade, S. , & Pardeshi, P. (2022). Comparative Study of Clinical Effect of Kshara-Basti and Virechana-Karma in the Management of Amavata with Special Reference to Rheumatoid Arthritis. American Journal of Pharmacological Sciences, 10(1), 12-19.
Chicago Style
Dalavi, Rahul, Pushpinder Singh, Anil Pardeshi, Md. Hanif Shaikh, Shubhangi Narwade, and Pallavi Pardeshi. "Comparative Study of Clinical Effect of Kshara-Basti and Virechana-Karma in the Management of Amavata with Special Reference to Rheumatoid Arthritis." American Journal of Pharmacological Sciences 10, no. 1 (2022): 12-19.
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  • Table 5. Comparative effects of Test-Therapies Kshar-Basti in Group-A and Virechana-Karma in Group-B on overall improvement in cardinal symptoms of Amavata in the trial (By paired t-test)
  • Table 6. Comparative effects on General symptoms of Amavata by Test-Therapies Kshar-Basti in Group-A and Virechana-Karma in Group-B
  • Table 7. Comparative effects on Associated symptoms of Amavata by Test-Therapies Kshar-Basti in Group-A and Virechana-Karma in Group-B
  • Table 8. The comparative effects of both therapies on Amavata on 30 IPD-patients belonging to Group-A and Group-B
[1]  Shastri K, Chaturvedi GN, Ed. Dridhabala, Charak Samhita of Agnivesh, Siddhi Sthana. Reprint edition. Ch. 1, Ver. 38-40. Varanasi: Chaukhabha Bharati Academy; p. 1169, (2003).
In article      
 
[2]  Harrison TR, Dennis L. Casper, Anthony, Bn Dan L Longo, Eugene Braunwald, Stephen L. Hauser, J. Larry Jameson, et al. Harrison’s Principles of Internal Medicine. Braunwald, editor. 15th ed, Vol. 2, Part 12. New York: McGraw Hill organization; p. 1928, (2001).
In article      
 
[3]  Malaviya AN, Kapoor SK, Singh RR, Kumar A, Pande I, (1993). Prevalence of rheumatoid arthritis in the adult Indian population. Rheumatol Int; 13(4).
In article      View Article  PubMed
 
[4]  Dr. Indradeva Tripathi, editor. Acharya Ramanatha Dwevedi. Chakrapani Dutta, Chakradutta-Vaidya Prabha Hindi commentary with explanation, 4th ed. Chakradutta 25/1. Varanasi: Chowkhambha Sanskrit Sansthana; p.166, (2002).
In article      
 
[5]  Shastri BS, editor. Yogaratnakara of unknown author, Amavata Chikitsa. 6th ed., vol. Varanasi: Chaukhamba Sanskrit Sansthan; p. 566-73, (1997).
In article      
 
[6]  Shastri Sudarshana, Ed. Madhava Nidana of Madhavakara. 29th ed. Ch. 25, ver. 6. Varanasi: Chaukhambha Sanskrit Samsthan; p. 511, (1999).
In article      
 
[7]  Shri Sudarshana Shastri revised and edited by Prof. Yadunandan Upadhayay. Madhava Nidana of Shri Madhavakara with the Madhukosha Sanskrit commentary by Srivijayarakshita and Srikanthadatta with the Vidyotani Hindi commentary and notes by. 27th ed. Varanasi: Chaukhambha Sanskrit Samsthana; Amavata Nidana 25/6-11, P. 462-3, (1998).
In article      
 
[8]  Christopher Haslett, Edwin R Chilvers, Nicholas A Boon and Nicki R Colledge, Davidson’s Principle and Practice of Medicine. 19th edition Philladelphia, Churchill livingstone, p 1002-1007, (2002).
In article      
 
[9]  Bralulnwalad, Fauci, Kasper, Hauser, Longo and Jameson, Harrison`s principles of Internal medicine, Table 312-1, 15th International edition volume 2, New York, McGraw-Hill medical publication, p 1934, (2001).
In article      
 
[10]  Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, & et al, (1988). The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum; 31: 315-24.
In article      View Article  PubMed
 
[11]  Sasane P, Saroj UR, Joshi RK, 2016.Clinical evaluation of efficacy of Alambushadi Ghana Vati and Vaitarana Basti in the management of Amavata with special reference to rheumatoid arthritis. AYU; 37: 105-112.
In article      View Article  PubMed
 
[12]  Thanki K, Bhatt N & Shukla VD, (2012). Effect of Kshara Basti and Nirgundi Ghana Vati on Amavata (Rheumatoid Arthritis). AYU; 33:50-53.
In article      View Article  PubMed
 
[13]  Pandey SA, Joshi NP & Pandya DM, 2012.Clinical efficacy of Shiva Guggulu and Simhanada Guggulu in Amavata (Rheumatoid Arthritis). AYU; 33: 247-254.
In article      View Article  PubMed
 
[14]  Khagram R, Mehta CS, Shukla VD, Dave AR, (2010). Clinical effect of Matra Basti and Vatari Guggulu in the management of Amavata (rheumatoid arthritis). AYU; 31: 343-350.
In article      View Article  PubMed