Traditional Methods of Treatment of Rheumatoid Arthritis

#### **Chapter 10**

## Traditional Treatment for Rheumatoid Arthritis

*Krushna Chandra Sahoo*

#### **Abstract**

The most prevalent musculoskeletal disorder is rheumatoid arthritis (RA). The main concern with RA is extreme fatigue, pain, and weakness. Patients having severe pain are compelled to take medications containing a variety of indigenous substances. These indigenous substances, on the other hand, exacerbated illnesses and delay in seeking appropriate healthcare. Treatment is delayed due to a number of reasons, including patients' lack of access to trained healthcare professionals, delays in referral to a rheumatologist, and patients' belief on traditional healing practices. The choice of inappropriate healthcare providers often causes a delay in referral to a rheumatologist. Self-medication and seeking treatment from traditional healers are often compelled the patient to engage in a variety of traditional practices. Cultural values have a significant influence on care-seeking behavior. Since healthcare promotion is dictated by community demands, the healthcare system should understand the contextual phenomena behind common practices for better health education. This chapter will address the beliefs and values that underpin traditional treatment, the sources of traditional learning pathways and ethical aspects of traditional practice.

**Keywords:** rheumatoid arthritis, musculoskeletal disorder, traditional healing, indigenous treatment practices, use of animal products, care-seeking pathways

#### **1. Introduction**

Rheumatoid arthritis (RA) is one of the most common inflammatory musculoskeletal disorders, causing chronic pain in patients [1–6]. It is also a chronic destructive inflammatory disease characterized by the presence and consistency of an inflammatory infiltrate, resulting in joint architecture destruction and impairment of function [1–6]. The fingers, wrist, feet, and ankles are the most commonly affected by RA, and the chronic inflammation causes permanent joint destruction and deformity [1–6]. The main concern with RA is the pain, and its persistence frequently has negative health consequences [5–8]. As a systemic disease, RA has extra-articular manifestations in systems such as the pulmonary, ocular, and vascular systems, as well as other organs or structures that may be affected by the inflammatory process. As a result, timely and rational rheumatoid arthritis treatment is critical [8–10]. Nonetheless, despite greater recognition of the benefits of timely treatment, there is always a delay in obtaining treatment from appropriate healthcare providers among patients [11]. The delays in diagnosis and referral to a tertiary health care facility or specialist, such as a rheumatologist, causes worsening disease conditions and complicating care-seeking pathways [12–18].

#### **2. Rheumatoid arthritis, and complementary and alternative medicines (CAM)**

Rheumatoid arthritis is one of the most painful diseases, and patients seek a variety of treatment options, including complementary and alternative medicines (CAMs) [19–26]. CAM has grown in popularity among RA patients worldwide; CAM use is widespread among RA patients and is projected to increase further [2, 9, 27, 28]. The use of CAMs by people living with RA in the United States has been reported to range between 28 and 90 percent [21, 22]. The lifetime prevalence of CAM use in RA patients is 38 percent [29]. CAMs include a wide range of traditional or indigenous practices as well as a variety of products. Herbal treatments, homoeopathy ingredients, and various animal products are among the products available. Massage therapies, acupressure, acupuncture, electro-acupuncture, electrical stimulation, laser therapy, and mind–body therapies are among the indigenous treatment methods [7, 14, 17, 24, 26, 30, 31]. Many different types of physical activity are generally used and encouraged. Homeopathy employs ingredients in high concentrations that are not typically found in conventional medicines or treatments [7].

The fundamental question is why CAMs are not fully integrated into mainstream medical care, even in countries like China and India, which are known to be the birthplace of these traditional CAMs [7, 24, 26, 31]. The reasons could be scientific, political, or economic [19]. However, the most common argument is that traditional complementary and alternative medicine or therapies often create a barrier to scientific scrutiny [19]. The effect of CAMs with slight alterations and combinations can be demonstrated to be similarly effective and can suggest better patents; thus, research does not garner much private funding. The majority of studies are underpowered or poorly designed. As a result, pharmacovigilance research should concentrate on issues such as drug interactions and CAM intervention [19]. However, the most significant barrier to CAM research is a lack of funding and qualified experts to research these products. Currently, these CAMs are being subjected to scientific scrutiny [19]. Whatever the reason behind the popularity of CAMs, it is critical to understand which type of CAM is safe and effective for patients with RA [21, 22]. Physicians should be well informed and at ease discussing common complementary and alternative therapies, particularly their effects, side effects, and potential interactions with conventional RA treatments. Many patients may not volunteer for their use of CAM, so physicians must conduct systematic inquiries during consultations. This should be given extra attention in elderly patients with comorbidities.

#### **3. Various indigenous healing practices**

Traditional RA treatment includes the use of plant products or herbal remedies [22, 32, 33], animals or animal products [14, 22, 32, 34–37], and the application of alternative therapies [2, 7, 22, 32, 38, 39]. Traditional approaches to RA treatments include herbs/juices, spiritual practices, topical applications, movement-based therapies, and practitioner-based modalities [32]. These traditional treatments are used as a home remedy and were primarily encouraged or suggested by family members, neighbours, or relatives. The majority of the time, however, these traditional treatments are prescribed by local traditional healers. Traditional medicines are used in a variety of ways, including eating, drinking, tying, anointing, banding, massaging, and fumigation. It was eaten often fresh. The other methods of preparation were cooking, burning, crushing, grinding, wrapping, powdering, or drying. **Table 1** shows a detailed list of the animals and animal products that are used in traditional RA care.

*Traditional Treatment for Rheumatoid Arthritis DOI: http://dx.doi.org/10.5772/intechopen.99258*



#### *Traditional Treatment for Rheumatoid Arthritis DOI: http://dx.doi.org/10.5772/intechopen.99258*



#### **Table 1.**

*Animal or animal products use for treatment of RA.*

Herbal medicines were mostly prescribed or used in powder form. In the majority of cases, patients used roots and tubers to reduce joint swelling. They took herbal remedies in the form of liquid and powdered plant products. Herbal medicines have been used as anti-inflammatory treatments for the treatment of RA [22]. The herbal remedies or plants used for treatment of RA are given in **Table 2**.

A multi-country study conducted in the United Kingdom, Germany, the United States, Australia, and Canada found that self-management of RA with pacing, heat, cold, and rest without medical advice reduced intense pain [4]. A study in the Dominican Republic looked into the religious and environmental theories of arthritis etiology. According to their participants, arthritis was caused by God's will and due to contact with contaminated water; they believe that by praying, and avoiding


**Table 2.** *Use of herbal remedies for treatment of RA.*

#### *Traditional Treatment for Rheumatoid Arthritis DOI: http://dx.doi.org/10.5772/intechopen.99258*


#### **Table 3.**

*Application of traditional alternative therapies for RA.*

contact with contaminated water, RA can be cured [40]. Patients used heat and physical therapies, supplementation, traditional medicines, and prayer to get relief from RA [27, 28]. It was also observed that patients would sometimes practice hot compression by applying mustard oil to the affected areas [14]. The various applications of traditional alternative therapies for RA are provided in **Table 3**. Traditional healers have given powders or ash to RA patients on occasion [14]. According to a study conducted in the United States of America, 70% of patients never mention traditional treatments to their physicians, which is regarded as an invisible mainstreaming of alternative care [21, 22].

#### **4. Key reasons for traditional healing practices and its consequences**

Patients with RA have a wide range of health-care options, including selfmedication with home remedies, traditional or indigenous healing practices,

traditional herbal treatment, and treatment from informal healthcare providers (untrained or unqualified providers), trained prescribers, and specialists [10, 13, 14, 23]. Patients' pain frequently prompted medication decisions, which were frequently purposeful and multifaceted [7, 15]. Because of their fatigue, pain, and disability, people with musculoskeletal disorders are among the highest selfreported users of CAMs, particularly traditional treatments [41]. The swelling and joint damage that characterize active RA are the end results of complex autoimmune and inflammatory processes involving components of both the innate and adaptive immune systems, which compel them to seek care from multiple providers, especially in LMICs. Furthermore, foot deformity is common (80%) among RA patients, leading to foot ulceration [39]. The traditional treatment used by RA patients to alleviate or recover from severe pain [11–15, 42–45].

Traditional healers are preferred because of the lack of trained healthcare providers and patients' trust in indigenous healing approaches, as well as the ease of access to care and patients' faith in traditional healing [11, 23]. The patient's care-seeking behaviour and treatment preferences vary depending on their education, culture, and beliefs [13, 27, 28]. Self-medication and seeking care from traditional healers frequently force people to engage in various indigenous practices. The studies revealed that there are two key factors responsible for the gap between onset of symptoms, definite diagnosis and appropriate health care or treatment from the right providers. These factors include poor health literacy among the patients and inaccessibility to modern health care systems or unavailability of trained providers, which often happens in rural and remote areas, where more than one-third of the patients live. Furthermore, these factors frequently result in a delay in care pathways or a proper referral system, aggravating disease conditions [11]. The major underlying reasons for treatment delay were the influence of ethnicity, such as folk beliefs, family and friends, and dietary manipulation [43].

Depression is the most common comorbidity in RA, and it has a significant impact on the quality of life [1]. It has been documented that some patients used traditional CAM therapy in addition to other modern antidepressants to recover from RA-related psychiatric disorders, particularly depression and anxiety [1]. The satisfaction with support was associated with adaptive behaviour, whereas disappointment was associated with maladaptive behavior [5, 13, 14]. Furthermore, the primary motivators of indigenous practice were easy access to healers and no prescription fees; the primary demotivators were high prices and ineffective treatment. Furthermore, the RA causes productivity loss; one of the major concerns was RA-related work-disability – permanent disability and temporary job loss [18]. For example, a study in Lithuania found that RA patients were 24 percent less likely to be employed than the general population [18]. Some of the patients sought care through multiple health care providers, and even received traditional treatment in order to avoid disability and RA-related productivity loss [18].

Treatments are frequently influenced by the patients' perspective and experience with the illness, such as the likely duration of disease onset, symptomatology, severity, diagnosis, urgency of care, and available facilities [46]. A metaethnography study of RA patients revealed that many were unsure about the severity and duration of the disease [47]. Patients'seeking care in various care practices during the disease period has a significant impact on disease cure [13, 48]. There were few positive outcomes from indigenous treatment; in many cases, patients experienced negative outcomes such as disease severity, side effects from incorrect treatment, and frequent delays in receiving appropriate care [13, 14]. As a result, improving the quality of life of RA patients is critical. Community literacy and mass screening would both contribute to the early detection and management of RA. It is critical to understand patients' perspectives in order to develop a more effective health care delivery model.

#### **5. Empirical knowledge on traditional healing**

Cultural factors are regarded as vital components in the promotion of conventional therapies; the use of traditional RA management has been influenced by cultural factors [7, 27]. Traditional cultures recognized the importance of belief healing requirements and devised complex rituals to elicit expectancy and participation from healers, patients, and the local community. Traditional healing techniques have been an integral part of nearly all societies' healing rituals since the beginning of time [36]. The sources of empirical knowledge of traditional healing were based on either learning from or motivated by family, relatives or local community members or with the attraction and preference of local traditional healers [14, 15, 27]. This was mostly due to an article of faith on severe pain reduction, or to witnessing others being cured, or to societal pressure. The key knowledge pathway of indigenous RA treatment was ancient tales, customs, and belief or faith in religious or traditional healers.

Many countries around the world have deep roots in traditional healing practices. According to the World Health Organization (WHO), traditional medicine is used for primary health care by 3/4 of the world's population [49]. Indigenous cultures are often known for their oral tradition – healing and medicine knowledge transmitted orally from one generation to the next [49]. Moreover, there is great diversity in indigenous cultures worldwide. Specific healing practices are practiced by one community may not be accepted by another. The treatment practices are often difficult to generalize without scientific proof. Understanding people's beliefs about etiology, feelings, thinking, and the content of lay beliefs is critical in medical sociology [49]. However, it is difficult to verify indigenous knowledge by scientific or adequately evaluated assumptions underlying such treatment practice as a basis for its' typical criteria and philosophies [50]. The convictions of the patients about etiology were often based on faith [40, 42, 48]. However, misleading assumptions frequently result in a community's health being jeopardized.

#### **6. Health system responsibilities and preparedness**

The absences of adequate facilities in rural and remote areas, as well as a lack of patient awareness, were major motivators for indigenous approaches to RA treatment. When patients do not have adequate access to modern care, they rely on traditional healers for primary care [51]. There is compelling evidence that community members frequently prefer self-medication to traditional providers for many health issues [51]. As a result, there is a need for RA management at primary health care centres with a proper referral system [13]. Patient-centered care models are essential for effective treatment [52]. The primary need for RA patients is physician consultation through active listening and professionalism with chronic pain management [42]. Inadequate community literacy on RA is the major reason for proper treatment [36, 44]. Patients with RA must be well informed and educated on modern treatment, which is a critical component of care [10, 12]. Furthermore, public health practitioners' understanding of indigenous health concepts may be beneficial in reducing unnecessary treatment burden and care complexity [53].

In countries where much effort has been put into building a single uniform health service delivery system, the pluralistic health care system is ignored. In the meantime, understanding the pluralistic medical system is critical to improving community health. India has a pluralistic medical culture with a well-documented history and practice of alternative medicine – Ayurveda, Yoga, and Naturopathy (AYUSH) [54]. Furthermore, multidisciplinary holistic approaches that focus on context-specific health determinants are important for understanding the cultural influence on RA care seeking pathways [13, 55, 56].

### **7. Conclusions**

Patients with RA seek immediate care from multiple traditional providers with a wide range of products and services with no gatekeeping. The most significant concern expressed by practitioners, policymakers, and researchers is the safety and efficacy of traditional treatments, which can be addressed by conducting a thorough examination of the products in common use. Primary health centres are the entry point for retaining RA patients; the availability of RA-trained providers at primary health centres, along with a proper referral system, is critical for convalescing careseeking pathways. Furthermore, community education on early symptoms, diagnosis, and proper treatment is critical.

### **Acknowledgements**

The author acknowledges all the studies authors for their valuable contribution in the fields.

### **Conflict of interest**

The author declares there is no conflict of interest.

#### **Author details**

Krushna Chandra Sahoo ICMR-Regional Medical Research Centre, Bhubaneswar, Odisha, India

\*Address all correspondence to: sahookrushna@yahoo.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Traditional Treatment for Rheumatoid Arthritis DOI: http://dx.doi.org/10.5772/intechopen.99258*

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#### **Chapter 11**

## Action Mechanisms of Antirheumatic Herbal Medicines

*Nima Nakisa and Mahboobeh Ghasemzadeh Rahbardar*

#### **Abstract**

Rheumatoid arthritis (RA) is a chronic inflammatory and debilitating joint disorder that causes severe impairment and reduces the quality of life. The available synthetic medicines used as standard therapy for RA have numerous side effects that can compromise their therapeutic outcomes. Thus, the demand for alternative and complementary medicines is increasing. A search of English articles in PubMed, Scopus, Google Scholar, and Web of Science databases was carried out on probable mechanisms of action of herbs with the antirheumatic property. Herbal medicines stated in folk medicine face acceptance concerns by the medical community because of the lack of scientific documents regarding their physiopharmacological mechanisms. This chapter aims to review the possible antirheumatic effects of various herbs, including *Rosmarinus officinalis* L., *Curcuma longa*, and *Crocus sativus*, their related mechanisms, and preclinical applications, in order to recall the therapeutic properties of herbal medicine. However, more clinical trials are required to confirm the safety and efficacy of these antirheumatic herbal medicines.

**Keywords:** rheumatoid arthritis, antirheumatic, herbal medicine, folk medicine, complementary drugs, physio-pharmacological effects

#### **1. Introduction**

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disorder that can strike men and women at any age [1]. About 1% of the world's population has been affected by RA, which has resulted in progressive articular damage, permanent impairment, and even reduced life expectancy [2]. Genetic and environmental factors have important roles in the aetiopathogenesis of RA [3]. The pathophysiology of RA is complex and mainly focuses on autoimmune response and inflammation [4]. The reactive oxygen species (ROS) damage proteins such as collagen and denature immunoglobulins that both might become autoantigens in RA [5]. Autoantibodies against immunoglobulin G (IgG) (also called rheumatoid factors (RFs)) and autoantibodies against citrullinated peptides (ACPAs) are two types of autoantibodies that can cause complement activation in RA patients [6, 7]. It was suggested that increased circulating ACPAs can promote bone loss by activating macrophages, producing B cells, organizing immune complexes or binding membrane citrullinated vimentin [8–11] which consequently ease the shift from autoimmunity to inflammation. Inflammation of the synovial membrane in RA is made up of both innate and adaptive immune cells [12]. The majority of immune responses are regulated by cytokines and chemokines including interleukin-6 (IL-6) and

tumor necrosis factor (TNF) which can induct or intensify the inflammatory response of the synovial compartment [13].

Disease-modifying anti-rheumatic drugs (DMARDs), glucocorticoids, and nonsteroidal anti-inflammatory drugs (NSAIDs) are currently available drugs for RA [14]. Antirheumatic medications that are currently available for RA treatment target the inflammation and tissue swelling resulting from the disease. However, the majority of patients still experience extreme pain and physical impairment. These drugs are ineffective in preventing cartilage degradation and joint damage [15]. It was also reported that taking two or more biologic DMARDs at the same time, or a biologic DMARD with a nonbiologic DMARD, increases the risk of severe infections or cancer [16]. Other investigations have also illustrated the cardiovascular [17] and ocular [18] adverse effects of antirheumatic drugs. Therefore, the development of safe, fast-acting antirheumatic medicines is required.

Complementary and alternative medicine methods are now thought to provide adjuvant therapies to improve the chances of full remission of RA [19, 20]. Several herbal medicines have displayed pre-clinical and clinical antirheumatic properties including *Curcuma longa* L., *Rosmarinus officinalis* L., and *Crocus sativus* through their antioxidant, anti-inflammatory, anti-proliferative, and antinociceptive properties (**Figure 1**).

**Figure 1.** *Some herbal medicines with antirheumatic property.*

Thus, searching for herbal medicines with antirheumatic properties could be an advantageous method to find effective antirheumatic medicines with fewer side effects. The detailed information about medicinal herbs and their physio-pharmacological mechanisms of action is summarized in this chapter.

#### **2. Methods**

The present chapter mainly emphasizes the published original articles implicating the therapeutic and beneficial effects of herbs on rheumatoid arthritis. The data (Google Scholar, PubMed, and Scopus) search has been carried out by searching related keywords, including "rheumatoid arthritis", "rosemary", "*Rosmarinus officinalis* L.", "turmeric", "*Curcuma longa* L.", "*Crocus sativus* L.", "saffron", "*Zingiber officinale*", "ginger", "*Nigella sativa*", "black seed", "black cumin", "*Camellia sinensis*", and "green tea". No time limitation was considered.

#### **2.1 Herbal antirheumatic medicines**

In folk medicine, numerous plants have been used because of their antirheumatic properties. Researchers are currently focusing on evaluating and characterization of different plants and their components to treat RA. The aim of this section of the chapter is to review the mechanism of action of a number of medicinal plants that have antirheumatic properties.

#### **2.2** *Rosmarinus officinalis* **L. (rosemary)**

A former study indicated that administration of water-soluble compounds of rosemary reduced oxidative stress (by enhancing the glutathione (GSH) level and the GSH/glutathione disulfide (GSSG) ratio) and inflammation (paw edema, number of leukocytes in the femorotibial joint cavities, secondary lesions score, adrenal glands, inguinal lymph nodes, and popliteus lymph nodes weights) in rats with adjuvantinduced arthritis [21]. Carnosic acid, a major phenolic compound isolated from rosemary (5 mg/kg, 2 weeks, i.p.), administration to collagen-induced arthritis rats inhibited inflammation response and joint destruction by decreasing the amounts of TNF-ɑ, IL-1β, IL-6, IL-8, IL-17, matrix metalloproteinase-3 (MMP-3), and receptor activator of nuclear factor kappa-Β ligand (RANKL) [22] (**Table 1**). Moreover, it was observed that a methyl ester derivative of rosmarinic acid, a constituent of rosemary (50 mg/kg/day, 15 days, i.p.), has a potent anti-arthritic property in collagen-induced arthritis mice via its anti-inflammatory and immunosuppressive effects [34].

Another study has reported that rosmarinic acid triggers apoptosis via mitochondrial pathway in activated T cells taken from rheumatoid arthritis patients [35].

#### **2.3** *Curcuma longa* **L. (turmeric)**

A clinical trial was carried out on 45 patients with RA to investigate the antirheumatic effect of curcumin at the dose of 500mg for 8 weeks. Curcumin improved disease activity and the American college of rheumatology scores [36]. Another clinical trial reported that curcumin in a turmeric matrix (250mg, twice daily, 90 days) was an advantageous agent in managing RA by its analgesic and anti-inflammatory properties. Curcumin improved erythrocyte sedimentation rate, C-reactive protein, visual analog scale, rheumatoid factor, and American College of Rheumatology responses in comparison with the control group [37]. It was also seen that administration of CuroWhite™, a novel hydrogenated curcuminoid


*Bax: BCL2-associated X; Bcl-2: B-cell lymphoma-2; COX: cyclooxygenase; GSH: glutathione; GR: glutathione reductase; GSSG: glutathione disulfide; interferon gamma (IFN*γ*), IL: interleukin; MAPK: mitogen-activated protein kinase; MDA: malondialdehyde, MMP: matrix metalloproteinase; NFATC1: Nuclear Factor of Activated T Cells 1; NF-κB: nuclear factor kappa B; PGE2: Prostaglandin E2; RANKL: receptor activator of nuclear factor kappa-B ligand, SOD: superoxide dismutase; TNF: tumor necrosis factor.*

#### **Table 1.**

*Antirheumatic mechanisms of action of* R. officinalis *L.,* Curcuma longa *L., and* Crocus sativus *L.*

formulation, at the dose of 250 mg and 500 mg for 3 months ameliorated RA by its anti-inflammatory and antinociceptive effects which was confirmed by improving erythrocyte sedimentation rate, rheumatoid factor, visual analog scale, and C-reactive protein [25]. A recent clinical study reported that administration of curcumin (200–1000 mg) to patients with RA decreased pain, fatigue, stiffness, and swelling [26]. The results of a clinical trial indicated that the prescription of BioSOLVE Curcumin™ (250 mg, 12 weeks) to patients with RA improved the American college of rheumatology-20, Western Ontario and McMaster universities osteoarthritis index and visual analogue scale score [28].

A turmeric extract devoid of essential oils was given to Wistar female rats in an animal model of streptococcal cell wall-induced RA. Injections of an extract containing 4 mg/kg/day total curcuminoids intraperitoneally for four days prior to arthritis induction significantly reduced joint inflammation in both the acute (75%) and chronic (68%) phases [38]. A previous investigation stated that the administration of *C. longa* extract (30, 60, and 110 mg/ml/kg, 4 weeks) prevented degenerative alterations in the joints and bones of collagen-induced arthritic rats [30]. It was also observed that turmeric (200 mg/kg, 28 days, p.o.) significantly reduced the incidence and severity of arthritis by increasing the production of antiinflammatory agents and decreasing the amount of pro-inflammatory cytokines, as well as stimulating the anti-oxidant defense system [31]. Furthermore, turmeric

#### *Action Mechanisms of Antirheumatic Herbal Medicines DOI: http://dx.doi.org/10.5772/intechopen.99133*

(containing 60% v/v alcohol) mother tinctures decreased hind paw swelling in carrageenan-treated rats [32].

The findings of an *in vitro* study indicated that curcumin inhibited the production of prostaglandin E2 (PGE2) and induced apoptosis in synovial fibroblasts of patients with RA by reducing the level of B-cell lymphoma-2 (Bcl-2), an anti-apoptotic protein, upregulated the amount of BCL2-associated X (Bax), a pro-apoptotic protein, and activated caspase-3 and caspase-9. Besides, curcumin attenuated the cyclooxygenase (COX)-2 mRNA expression level [23]. The findings of another research confirmed that curcumin could inhibit the osteoclastogenic potential of peripheral blood mononuclear cells from patients with RA by suppressing the mitogen-activated protein kinase/Receptor activator of nuclear factor-kappa B/c-Fos/Nuclear Factor of Activated T Cells 1 (MAPK/RANK/c-Fos/NFATC1) signaling pathways, and it was suggested that curcumin might be an effective therapeutic agent for treating bone deterioration in inflammatory diseases including RA [24]. In another investigation, human fibroblast-like synoviocytes isolated from RA patients were treated with the IC50 of the curcumin. Curcumin downregulated the expression of the inflammatory response gene. Moreover, the authors suggested that prescribing curcumin along with the usual therapies could increase the quality of life in RA patients [39].

The data of an *in silico* study disclosed that herbal compounds present in turmeric have strong inhibitory properties against the pro-inflammatory cytokines including TNF-α and IL-1. It was also proposed that turmeric has therapeutic potentials to be used for treating RA [40].

#### **2.4** *Crocus sativus* **L. (saffron)**

A clinical trial was carried on 66 women with RA to assess the effect of saffron (100 mg/day, 12 weeks) supplementation on their metabolic profiles and clinical outcomes. According to the obtained data, saffron considerably reduced the number of swollen and tender joints, pain intensity, and disease activity score compared to baseline values. Moreover, erythrocyte sedimentation rate was significantly improved and high-sensitivity C-reactive protein, TNF-α, interferon-gamma (IFNγ), and MDA levels reduced [41].

In an *in vivo* study, the efficiency of saffron was assessed on adjuvant-induced arthritic mice. As the results showed the daily administration of the saffron extract (25, 50, and 100 mg/kg, 47 days, p.o.) decreased the amount of lipid peroxides level and increased the activity of catalase and glutathione peroxidase [42]. The effect of saffron ethanolic extract (25–600 mg, 12 days, every other day, i.p.) was studied in an adjuvant-induced arthritis rat model. The results revealed that saffron ethanolic extract chiefly at the higher concentrations meaningfully attenuated tibiotarsal joint and paw diameters in comparison to the control group. It has also been suggested that saffron ethanolic extract could be potentially used as an anti-arthritic agent in managing inflammation in RA [43]. An investigation examined the effect of saffron extract (50, 100 mg/kg, 47 days, p.o.) on adjuvant-induced arthritis in mice. It was observed that saffron could remarkably reduce TNF-α and IL-1β levels. It also increased superoxide dismutase (SOD) and glutathione reductase (GR) activity [44]. Another *in vivo* study was planned to determine the effect of crocin, a carotenoid constituent of saffron, on the rat RA model. It was seen that intradermal prescription of crocin (6.25, 12.5, and 25 mg/kg, 28 days) pointedly alleviated the paw swelling, decreased arthritis score, the thymus index, the inducible nitric oxide synthase (iNOS) production, and the serum amount of TNF-α, IL-1β, and IL-6 [27]. Moreover, it was reported that crocin (40mg/kg, 36 days, p.o.) shows therapeutic potential for RA, by mitigating the symptoms and preventing the expression of

pro-inflammatory factors including TNF-α, IL-17, IL-6, and IL-8 in ankle tissues and serum of collagen-induced arthritic rats [29]. It was also illustrated that crocin treatment (50 mg/kg, a week, i.p.) significantly decreased the amounts of TNF-α, IL-1β, and IL-6 in collagen-induced arthritic mice through blocking nuclear factor kappa B (NF-κB) signal activation by its interaction with IκB kinase (IKK) [33] (**Table 1**).

#### **2.5** *Zingiber officinale* **(ginger)**

A former clinical trial was carried out on 6 patients with RA who took ginger powder (0.5–1 g/day, 3 months). It was found that all six patients reported pain relief, improved joint mobility, decreased swelling, and morning stiffness after three months of continuous ginger intake. There were no side effects recorded by any of the participants, and they all seemed to be happier and more engaged in their daily lives [45]. Another study investigated the effect of ginger on 56 RA patients. The findings revealed that after taking ginger (50 g/day raw/fresh, 3 months-2.5 years) more than three-quarters of participants reported pain and swelling relief to varying degrees. Also, all the subjects with muscular discomfort experienced pain relief. The authors suggested that at least one of the mechanisms by which ginger exerts its beneficial effects is thought to be linked to inhibition of prostaglandin and leukotriene biosynthesis, implying that it acts as a dual eicosanoid biosynthesis inhibitor [46]. The results of another study demonstrated that ginger powder (1500 mg, 12 weeks) administration ameliorated RA by reducing disease manifestations through controlling immunity factors, for instance enhancing the gene expression of forkhead box P3 (FoxP3), as well as attenuating RARrelated orphan receptor gamma (RORγt), and T-bet genes expression [47].

Prescription of *Z. officinale* (> 50 mg/kg/day, 26 days, i.p.) amended the disease incidence, clinical scores, cartilage destruction, swelling and temperature of the joint in rat collagen-induced arthritis. It also reduced serum levels of IL-1β, IL-2, IL-6, TNF-α, and anti-collagen type II (CII) antibodies [48]. The anti-inflammatory property of the essential oil of ginger was assessed in an experimental model of RA in female rats and it was observed that ginger essential oil (28 mg/kg, 28 days, i.p.) ameliorated chronic joint inflammation. These findings indicate that the anti-inflammatory properties of ginger are due to a combination of secondary metabolites, pungent-tasting gingerols, and aromatic essential oils, rather than only the phenolic compounds that have been studied previously [49]. A recent document explained that oral administration of zingerone, an active constituent of ginger (25 mg/kg, 3 weeks), to adjuvant-induced RA rats considerably decreased the amounts of NF-κB, transforming growth factor-beta (TGF-β), TNF-α, IL-1β, IL-6, and high-sensitivity C-reactive protein (hs-CRP), and significantly enhanced IL-10 levels. Moreover, zingerone restored the amounts of antioxidant enzymes [50]. Cedrol, a ginger active component, has been shown to improves RA by decreasing inflammation and preventing Janus kinase 3 (JAK3) phosphorylation [51].

Ginger extract was found to be an advantageous anti-inflammatory agent in an *in vitro* model on cultured fibroblast-like synoviocytes from RA patients by inhibiting the production of cytokines [52].

#### **2.6** *Nigella sativa* **(black seed, black cumin)**

The efficiency of *N. sativa* oil was studied in the management of RA. The subjects of the treatment group took *N. sativa* oil capsules (500mg, twice a day, 1 month). The results disclosed that the disease activity score, the number of swollen joints, and the duration of morning stiffness remarkably reduced compared with the

#### *Action Mechanisms of Antirheumatic Herbal Medicines DOI: http://dx.doi.org/10.5772/intechopen.99133*

placebo group [53]. Assessing the effects of *N. sativa* oil extract (500mg, twice a day, 8 weeks) on oxidative stress status and inflammatory cytokine response in patients with RA indicated that the serum amount of IL-10 augmented in the *N. sativa* group, besides serum malondialdehyde (MDA) and nitric oxide (NO) levels decreased compared with the baseline [54]. Another clinical trial reported that administration of *N. sativa* oil (1 g/day, in two divided doses, 2 months) to 43 female patients with mild to moderate RA led to a significant decrease of the serum hs-CRP amount and the number of swollen joints. A moderately similar T helper cells (CD4+ T cell) percentage was detected in the *N. sativa* oil and placebo groups. *N. sativa* also decreased CD8+, and amplified CD4+CD25+ T cell percentage and the CD4+/CD8+ ratio in comparison with the baseline and placebo group [55] (**Table 2**).

Evaluating the effects of thymoquinone, the volatile oil of black cumin (2.5, 5 mg/kg, 14 days, p.o.), on RA model in rats disclosed that signs of inflammation on the claw and the amounts of TNF-α, as well as IL-1β decreased in treatment groups


*CD4+ T cell: T helper cells, CII: collagen type II, COX: cyclooxygenase; FoxP3: forkhead box P3; GSH: glutathione; hs-CRP: high-sensitivity C-reactive protein; IFN-c: Interferon-c; IL: interleukinJAK3: Janus kinase 3; JNK: c-Jun N-terminal kinases, MDA: malondialdehyde, MPO: myeloperoxidase; NF-κB: nuclear factor kappa B; NO: nitric oxide, PGE2: Prostaglandin E2; ROR*γ*t: RAR-related orphan receptor gamma; SOD: superoxide dismutase; TGF-*β*: transforming growth factor-beta, TLR: toll like receptor; TNF: tumor necrosis factor.*

#### **Table 2.**

*Antirheumatic mechanisms of action of* Zingiber officinale*,* Nigella sativa*, and* Camellia sinensis*.*

[56]. Thymoquinone (5 mg/kg, 21 days, p.o.) treatment in the collagen-induced arthritis in Wistar rats could considerably reduce the amounts of pro-inflammatory mediators including PGE2, TNF-a, IL-1b, IL-6, Interferon-c (IFN-c), and increased IL-10 level. Thymoquinone also decreased arthritis scoring and improved bone histology [57]. Administration of the aqueous methanolic extract of black seed (400, 500 mg/kg, 20 days, p.o.) to arthritic rats decreased myeloperoxidase (MPO), elastase activity, lipid peroxidation, articular nitrite content, and increased GSH and SOD amounts [64]. In another rat model of RA, *N. sativa* oil (0.91, 1.82 mL/ kg (798, 1596 mg/kg, respectively), 25 days, p.o.) was administered to animals. *N. sativa* oil exhibited anti-inflammatory, anti-nociceptive, and anti-arthritic properties that were significant in comparison with the untreated arthritic rats [59]. The results of an *in vivo* study demonstrated that thymoquinone (10 mg/kg, 28 days, i.p.) administration arthritic rats attenuated the macroscopic arthritic score, pannus formation, synovial inflammation, bone erosion and CRP amount. Moreover, mRNA levels of IL-1, TNF-α, NFκB, TLR2, and TLR4 were reduced [60].

An *in vitro* study explained that thymoquinone inhibited TNF-α-induced phospho-p38 and phospho-c-Jun N-terminal kinases (JNK) expression in RA synovial fibroblast [57].

#### **2.7** *Camellia sinensis* **(green tea)**

Evaluating the therapeutic effects of green tea (0.5, 1.0 g/kg, 24 days, p.o.) on articular/extra-articular difficulties in rat adjuvant-induced arthritis revealed that the arthritis severity and complications besides oxidative stress ratio in synovial fluid were significantly reduced [61]. In another *in vivo* study, adjuvant-induced arthritic rats received green tea aqueous extracts (0.5 and 1.0 g/kg, p.o.) for 28 or 14 consecutive days starting from day 0 or 14 of arthritis induction, respectively). It was observed that the high dose of green tea amended synovial joint inflammation, reduced blood leukocytosis and erythrocyte sedimentation rate, and changes in weight/cellularity of lymphoid organs. It also decreased the systemic production of pro-inflammatory cytokines and the expression of chemokine receptor-5 in synovial tissues [65]. Aqua-alcoholic extract of green tea (50, 100, 200, 400 mg/kg, 14 days, p.o.) was prescribed to collagen-induced arthritic rats. The findings showed that green tea was useful in reducing the ratio of oxidative stress by controlling the amounts of antioxidants, decreasing free radical levels, and restoring normal hematopoietic cascade [58]. The therapeutic potential of green tea was evaluated in an experimental model of RA in Lewis rats. The data showed that green tea reduced paw edema, bone erosion, and inflammatory responses in joints of treated rats. It also reduced telomerase activity in comparison with the control group [62].

In an *in vitro* study, crude aqueous *C. sinensis* (50, 100, 200, 400 μg/ml) infusion and decoction revealed anti-arthritic properties in protein denaturation and membrane stability methods [66]. It was also found that catechins derived from *C. sinensis* (epigallocatechin-3-gallate, epigallocatechin, and epicatechin) inhibit the IL-1β signaling pathway and consequently decrease the amounts of pro-inflammatory mediators such as IL-6 and IL-8, as well as COX-2 in primary human RA synovial fibroblasts [63] (**Table 2**).

#### **3. Conclusion**

Herbs are spread in different geographical and ecological throughout the world. Since the olden days several traditional herbs have been utilized for treating plenty of ailments. The number of medicinal plants that have antirheumatic properties is

*Action Mechanisms of Antirheumatic Herbal Medicines DOI: http://dx.doi.org/10.5772/intechopen.99133*

comparable to potent synthetic antidepressants. The antirheumatic effects of plants have been linked to their antioxidant, anti-inflammatory, analgesic properties. Furthermore, polyherbal formulations might be more effective due to their possible additive and/or synergistic effects and could be employed for ameliorating mild to moderate RA. As a result, it is possible to conclude that medicinal plants are at the center of nature and that more research is required to determine their therapeutic value.

#### **Abbreviations**


*Rheumatoid Arthritis*

#### **Author details**

Nima Nakisa1 and Mahboobeh Ghasemzadeh Rahbardar2 \*

1 Faculty of Physical Education and Sport Sciences, Kish International Campus, University of Tehran, Kish Island, Iran

2 Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran

\*Address all correspondence to: ghasemzadeh\_mahboobeh@yahoo.com; ghasemzadehrm962@mums.ac.ir

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[53] Gheita TA, Kenawy SA. Effectiveness of *Nigella sativa* oil in the management of rheumatoid arthritis patients: a placebo controlled study. Phytotherapy research. 2012;26(8):1246-8.

[54] Hadi V, Kheirouri S, Alizadeh M, Khabbazi A, Hosseini H. Effects of *Nigella sativa* oil extract on inflammatory cytokine response and oxidative stress status in patients with rheumatoid arthritis: a randomized, double-blind, placebo-controlled clinical trial. Avicenna journal of phytomedicine. 2016;6(1):34-43.

[55] Kheirouri S, Hadi V, Alizadeh M. Immunomodulatory effect of *Nigella sativa* oil on T lymphocytes in patients with rheumatoid arthritis. Immunological investigations. 2016;45(4):271-83.

[56] Tekeoglu I, Dogan A, Ediz L, Budancamanak M, Demirel A. Effects *Action Mechanisms of Antirheumatic Herbal Medicines DOI: http://dx.doi.org/10.5772/intechopen.99133*

of thymoquinone (volatile oil of black cumin) on rheumatoid arthritis in rat models. Phytotherapy Research: An International Journal Devoted to Pharmacological and Toxicological Evaluation of Natural Product Derivatives. 2007;21(9):895-7.

[57] Umar S, Zargan J, Umar K, Ahmad S, Katiyar CK, Khan HA. Modulation of the oxidative stress and inflammatory cytokine response by thymoquinone in the collagen induced arthritis in Wistar rats. Chemicobiological interactions. 2012;197(1):40-6.

[58] Tanwar A, Chawla R, Ansari MM, Thakur P, Chakotiya AS, Goel R, et al. *In vivo* anti-arthritic efficacy of *Camellia sinensis* (L.) in collagen induced arthritis model. Biomedicine & Pharmacotherapy. 2017;87:92-101.

[59] Nasuti C, Fedeli D, Bordoni L, Piangerelli M, Servili M, Selvaggini R, et al. Anti-inflammatory, anti-arthritic and anti-nociceptive activities of *Nigella sativa* oil in a rat model of arthritis. Antioxidants. 2019;8(9):342.

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[64] Sajad M, Asif M, Umar S, Zargan J, Rizwan M, Ansari S, et al. Amelioration of inflammation induced oxidative stress and tissue damage by aqueous methanolic extract of *Nigella sativa* Linn. in arthritic rats. Journal of Complementary and Integrative Medicine. 2010;7(1).

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#### **Chapter 12**

## Ayurveda Concepts of Joint Diseases

*Ayagama Pitadeniyage Anoma Jayasiri*

#### **Abstract**

Prevalence of bone related diseases are very high in the world today, among them arthritis is very common form of disease suffers millions of people, problematic for individually and economically to the society due to the long term disability. If not properly manage leads to joint replacement surgical procedures which are very common and high in cost. Aim of this chapter to make attention in application of Ayurveda medicine for betterment of the world population. Ayurveda explain theories in origin of these diseases, causative factors, eteopathogenesis and management steps mostly using herbal drug products mentioned in eight divisions of Ayurveda. Main common two diseases sandhigatha vatha correlated with osteoarthritis and amavatha correlated to rheumatoid arthritis well described with proper management procedures with many other bone and joint diseases. Different theories were discussed with the aid of philosophical backgrounds which facilitate these medical theories. These are five element or panchabhutha theory, three dosha concept or theory of three governing energies of the body, saptha dhathu concept or body bearing tissues, concept of agni or metabolic power. Different treatment plans were described as treatment options for cure and prevention of human being as a complete medical system.

**Keywords:** Herbal products, rejuanation, prevention, amavatha, arthritis

#### **1. Introduction**

Millions of people around the world suffer many kinds of bone and joint diseases. It was reported that five million people suffer from osteoarthritis and 12000 of children were from juvenile arthritis. In modern medicine described disorders of connective tissues, joints and bones that cause musculoskeletal pain and stiffness are predominant features [1]. Same as in modern medical field Ayurveda medical system also identified the commonest form of joint disease known as sandigatha vatha that correlated to osteoarthritis manifested with pain.

This information described well in history of the Ayurveda medicine included in literature which goes thousands of years back. Ayurveda, define as the science of life coming from ancient to this era as a system of natural way of healing to the world population. This medical system old at least 5000 years which come from time of (1500–1000 BC) but address the health problems appears today and benefited to promote good health and longevity while cure the diseases. When study about the historical background until 700 BC, this science has been orally discussed between sages and physicians [2]. There after two main texts were assembled to discuss medicine part by Charaka called Charaka Samhitha [3] and surgery concepts

were discussed by Susrutha in his text Susrutha Samhitha [4] later some texts were written and they were included to separate time periods until come to present stage, as pracheena kala (ancient period), madya kala (medieval period) and nuthana kala (modern period). Two Ayurveda authentic texts were available known as Charaka Samhitha which described etiology, symptomatology, pathology, prognosis and management of diseases written by physician Charaka and Susrutha Samhitha deals with surgical instruments and procedures written by surgeon Susrutha.

Ayurveda medical system mainly divided into main 08 branches known as Ashtanga Ayurvea (sub divisions). These divisions correlated to modern medical stream named as shalya thantra (surgary), shalakya thantra (ENT), kayachikithsa (general medicine), bhutha vidya (holistic medicine), agada thantra (toxicology), rasayana thantra (geriatrics), vageekarana therapy (aphrodisiac procedures) [5]. All these fields deals with every aspect of theories related to Ayurveda medicine on causative factors of diseases, treatment lines, preventive measures, prognosis, deformities and rehabilitation procedures. Except to these many literature were contributed to the field by ancient Ayurveda scholars including large amount of drugs as sauces from plant kingdom, mineral and animal kingdom among them Bhava Prakasha is one important text which was written in adhunika kala (modern period) [6]. Most of these literature described various facts relevant to joint diseases with treatment options in Ayurveda, this chapter also designed to give a view about joint diseases as Ayurveda approach.

#### **2. Ayurveda concept of health**

There are main two objectives of Ayurveda as medical system well explained par with the definition to a healthy person explained by the World Health Organization. Two objectives comprised preventive and curative aspects of living human beings. Ayurveda deals not only with body but also with the mind and spirit as well. In Ayurveda medicine well described the features of a healthy person. Firstly he or she must have three main energies (*tridosha*) that governing the body in balance state the term which implies *samadosha* (balanced three *doshas*) which act as main three pillars to stable the body in healthy state, by involve in body functions. *Agni* or metabolic power of the body is another factor that needs to be in balance state of a body. *Dhathu* or tissues seven in number are the components that bare the body of a person as per the Ayurveda view that need to be in balance state to give healthy life. Waste products of the body (*mala*) also need to be in balance state to appear a person in healthy manner. Except to these physical structures clear mental state as well as balance mind good spiritual soul need in a person to spend a healthy life as described in Ayurveda system of medicine. With these three energies maintain metabolic activities by the *agni* (metabolic power) help the interactions are processed inside the body constituents based on the theory of *panchabhutha* (five element theory of Ayurveda). *Panchamahabhuthas* are the material basis of the universe so as for the living body. The gross body of a living being consist of this five elements and life processes due to consciousness. Par with the philosophical explanations five *mahabhuthas* (*Panchabhutha* i.e. *Pruthvi, Ap, Thejas, Vayu, and Akasha* which correlated to atomic levels of structure that constitute the vegetable, animal and mineral kingdoms) along with consciousness called six *dhathus* (components) that a human being is comprise [5, 6]. This is the scientific background that implies in definition of healthy person related to the mind. On combination with consciousness, five elements, out of their some portions, constitute three *doshas* in order to perform and regulate the physiological process of the body [5, 6]. The changes in physiological functions can be given rise due these reasons as mal practices of food

patterns, behavioral nature of a person environmental, seasonal changes as well as traumatic conditions can be affect to change this balance state of a person and create diseases in the body that make individual mentality unstable.

#### **2.1 Ayurveda approach in origin of diseases**

According to Ayurveda, most diseases connected with the psychophysiological and pathologic changes in the body are caused by imbalance states in three *doshas* (ie, *vata, pitha and kapha*) these three energies which governs the body by maintaining the balance of body constituents and help in homeostasis in internal environment [7]. Each energy is responsible for certain type of body functions such as *Vatha* (Air/motile force) energy of movements, functions of nucleus, neurological activities, and natural urges stool/urine or gases etc. *Pitha dosha* (Fire/Agni) is responsible the functions of energy of metabolism, digestion with transformation, functions of mitrochondria, hormonal and enzymatic activities. Third category of energy is the *kapha* (Water/fluid component) that involves body functions of energy of lubrication structure, functions of protoplasm, secretory activities, and functions of the fluid contents of the body. These three energies govern the body bearing structures as well as functions of those structures. Another factor is tissues (*dhatus*) that bare the body, that seven in number correlated to the physical structures of the body such as rasa (plasma), *raktha* (blood), *mansa* (muscles), *medas* (fat tissues), *asthi* (bones), *majja* (bone marrow) and *shukra* (sperms/ovum). Three waste excretory products of the body known as *mala* (stools), *mutra* (urine) and *sweda* (sweat). Mainly *agni* (metabolic/fire) is an important concept describe in Ayurveda which mainly involve as causative factor for diseases, if it is in imbalance or mal function state known as *ama* (i.e. undigested state of foods in digestive tract which causes diseases/formation due to dearranged *agni*) which is mainly involved in certain type of joint diseases also. Important 13 agnis are activating in tissues, organs and systems of at different places of the body. Main type is *jataragni* (digestive power) activate in the digestive tract that correlated to enzymetic actions of gastrointestinal tract. Twelve other *agnis* (metabolic fire/power) are established in different places of the body and functionally contributed to internal homeostasis. Each tissue levels composed their owned metabolic powers namely dhatwagni 07 in number as *rasa dhathvagni*, *raktha dhathwagni*, *mansa dhathvagni*, *medas dhthvagni*, *asthi dhathvagni*, *majja dhathvagni*, *shukra dhathvagni* those involves in process of tissue metabolism. There is another important category of metabolic power is activated in micro channels and cellular level of the body named based on five element theory of Ayurveda as *panchabhuthagni* [8]. When these micro metabolic powers are not properly activated at cellular levels micro channels of the body *(srothas)* will not function properly, they blocked *(avarodha)* channels and tissues as well as organs then cause diseases. Main other concept of this medical system identified which cause the root for diseases produced *ama* within the body that can get mixed with *doshas* and formed complexes named as *sama vatha, sama pitha and sama kapha* which give rise symptoms of diseases [9]. Accoring to Ayurveda concepts *ama* means unripe substance produced under the weakened state of Agni (digestive power). Features of this *ama* state are *visha* (toxic), slimy in nature, has unpleasant odors, heavy in nature and has/represent various colors [9–11].

As per the view of this system of medicine development stages of a disease is describes based on five element theory, *saptha dhatu* and concept of *agni* described early paragraph. As the body composition and functioning energetic three doshas and the body tissues (*dhathus*) comprises from similar physical properties, there is relationship between doshas and tissues (*dhathus* synonym as *dushya*) in origin of a disease identified as combination these two components and named as *dosha dushya*  *sammurchana* (combination of vitiated dosha with tissues) according to this combinations demonstrate the symptoms of each disease in process of eatiopathogenesis [12]. Categoriztion of idiseses done according to this relationship between these *doshas* and *dhathus* (tissues seven in number) known as *dosha-dushya* complex that can be seen as symptoms in a patient.

Treating the diseases there are different conceptual theoretical background is established in this medical system. Mainly it described remove the causative factors of diseases such as diet, seasonal changes, correction of generating *ama* are some steps can be practically apply to breaking down the stages of etiopathogenesis and remove the *ama* by applying relevant medicaments. As an example rheumatoid arthritis which involve not only the joints but also certain other systems also in angle of Ayurveda view that cause when *samavata* mixed with rasa dhathu then causes Amavatha (rheumatoid arthritis), combination of *samapitta* and *raktha dhathu* produces *vatarakta* disease. *Ama* is a substance having a toxic nature and this toxic substances reacts with joint and bone elements causing the diseases. If *Ama* is not produced, there will be no bone joint disease either, this is the theory behind this medical science, that implies it has been mentioned that synonym given for diseases the word *ama*.

#### **2.2 Involvement of Dosha in born and joint diseases in Ayurveda**

Born and joint diseases in Ayurveda mentioned with related concepts texts written in ancient to modern period. These information were stated by modern Ayurveda scholars after further study well they mentioned that three main joint manifestations were identified and treated. They are *Sandigatha Vatha* (osteo arthritis), *Amavatha* (rheumatoid arthritis) and *kostukashirsha* (pain with swelling of knee joint) [9] symptoms of these conditions can correlate to structural changes of modern clinical cases. Two of them are *polyarthritic* clinical entities having a range from acute to chronic. *Sandhigata vatha* is the commonest form of articular disorder. It is a type of disease which mainly occurs in oild age people due to the dryness of the tissues which limits daily activities such as walking, dressing, bathing making patient disabled. Because this is a type of *vatha* category of disease can be lead to dangerous if located in a vital point, same situation occurs in an old person difficult in cure. Therefore in identifying prognosis by detect early symptoms is very important because this is very common type of disease. As it is *vatha* type of disease *shula* (pain) is the cardinal feature of the disease associated with *sandhishotha* (swelling), lack of movements of the joints or painful movement of the joints, sometimes loss of function and dislocations are possible. *Vatha raktha* is a condition give rise symptoms of pain, fasciculations, swelling, dryness of the affected part with discoloration, itching, contraction are seen, predominantly in larger joints, but begins from the smaller joints both the *vatha* (motile force) and *raktha* (blood) are in predominant positions. This condition influenced by *ama* combined with *pitha dosha* that known as *sama pitha* and manifest the symptoms accordingly. *Kostukashirsha* is the other common form of disease naming according to its appearance of the knee joint after affected knee joint of the person known jackals head due to the swelling and same time person feels sever pain.

Modern period literature described the relationship between *ama* and joint disease to give a better diagnostic outlook. Rheumatoid arthritis which is a whole multitude of joint manifestations that given rise to joint malfunctioning disease correlated to *Amavata* decribed in Ayurveda [13]. Ayurveda diagnosis can be done only study the *dosha* involvement, causative factors, symptoms,malfunctioning of the affected part and finally can be treat using herbal drugs use in the field with the help of Ayurveda pharmacodynamic properties with the aid of drug actions [14].

#### *Ayurveda Concepts of Joint Diseases DOI: http://dx.doi.org/10.5772/intechopen.99384*

When considering structure–function relationship and *dosha* involvement need to mention the five verities of three *doshas vatha*, *pitha* and *kapha* is very important. There are 5 varities of three *doshas* which were located at specific places of the body and give its contribution to the proper functions of that area of the body [15, 16] were well described in Ayurveda texts and that types are tabulated in **Table 1**.

Each and every type of *dosha* located at its own site facilitate its action to that relevant body parts. These types of each *dosha* is well responsible to cover all the functions of the body, when consider the structure and functions of the joints *(sandhi) Shleshaka kapha* component is the main part that give the actions related to its structure in the locomotive system [15, 16].

*Sandi samslesha* (bindings of joint) is described as one of the functions of *kapha* that described in Ayurveda view. Susrutha postulates similar views and while describing the functions of *kapha*, mentions of Sandisamshleshanam (lubrication of the joint), *snehana* (promotion of uncouthness), *purana* (storage or filling), *stayikrit* (stability) which are directly connected properties pertaining to *sandhis* (joints). The text written in *pracheena kala Ashtangahrida samhitha* mentioned that among other functions shleshma promotes, sthirathwa (sturdily), *snighdhatwa* (viscosity) as well as hates (binding) actions that are specifically applied to joints. Keeping various components of it in firm unity that makes it possible to function as a single unit, further *shleshaka kapha* protects it's articulation and opposes any force that might cause it's separation and disunion. According to the literature it becomes clear that *Shleshaka kapha* is predominant in joints and keeps them well lubricated and nourished. These explanations correlated with structure (including synovial fluid) and functions to integrate as medical systems were mentioned in this paragraph.

In the disease state of *sandhis* (joints) one or more above functions seen to be deviate it's normal in functioning due to the pathological changes and give person abnormal feeling. The bone ends are covered by hyaline cartilage, avascular tissue which provides a smooth, low friction surface allowing joint movement. Normal articular cartilage is a smooth bluish translucent material which is composed of chondrocytes, proteoglycans, collagens and water that correlated to structure and functions of *Shleshaka kapha* variety explain in Ayurveda. It is very important to identify the bone and joint related diseases with proper classification of these in Ayurveda by integrating its application for treatment options due to high prevalence of these disease conditions. Disorders of the joints are among the most disabling of conditions. They cause serious morbidity to the affected individual same way major economic importance to both the patients and society [15–18].

#### **2.3 Types of bone and joint diseases in Ayurveda**

In this chapter mainly discuss about the joint diseases, Ayurveda literature mostly discuss about three joint related diseases such as *Vatha raktha, Sandigatha vatha* and


**Table 1.** *Categories of three Doshas.* *Kostukashirsha* but except to these in different texts written from ancient time to modern period discussed other bone related diseases and joint diseases. They have named according to the structural manifestation, *dosha* involvement, place that symptoms, structural changes can be seen, relevant to its tissues that mainly affected.

They are *Sandigatha vatha* (it is a *vatha dosha* category of condition that pain is the main feature of this, which mainly occurs in old age due to *dhatukshaya* or dryness of the tissues, which limits everyday activities such as walking, dressing, bathing making patient disabled*), Vata raktha* (swelling, dryness of the affected part with discoloration, itching, contraction are seen, predominantly in larger joints), *Kostuka shirsha* (pain and swelling in the knee joint), *Avabahuka* (pain with restriction in movements of the upper arm), *Vatakantaka* (pain at calcanium area), *Grudrasi* (pain along the hip joint and thigh that causes difficulty in walking, pain is the main symptom), *Khalli* (loss of function and paralysis, specifically affecting the leg), *Urustambha* (severe pain, loss of function and loss of temperature sense in the affected limb), *Hanusthamba* (mainly due to trauma, dislocation of tempero mandibular joints, loss of movement is seen), *Asthimajjagata vatha* (severe crushing pain in bones and joints, discolorations are possible, loss of muscular power and strength with gradual thining of the affected limb), *Visvachee* (loss of function of the hand due to the dryness of structures at wrist joint which cause pain that radiates from the proximal to distal hand), *Amavatha* (mainly affects bigger joints, appears symptoms of anorexis, vomiting, malaise, indigestion), *Raktha vatha*(cause due to vitiation of rakta dhatu, slightly similar to Vata rakta in its clinical presentation), *Visha vatha* (cause due to infections), *Jara vatha* (cause due to old age, this included to natural bony degeneration due to senility), *Jirna vatha* (manifest due to degenerative processes), *Pada bransha* (characterized by loss of function of the affected foot among the eighty types of *vatha rogas*), *Vatha khuddatha* (one among the eighty types of *vata rogas*), *Gulpha graha* (stiffness in the ankle joint is the predominant feature), *Uru sara* (severe pain, loss of function and loss of temperature sense in the affected limb), *Janubheda (*type of pain localized in the knee joint), *Pangulya* (person felt to limp a sign due to any causes, such as trauma, dosha), *Thrika graha* (stiffness at the macro iliac joints), *Prushta graha* (stiffness in the spine), *Bahu shosha* (wasting is the predominant sign in this condition, at the shoulder), *Griva sthambha* (Stiffness in the neck), *Asthyavrutha vatha* (Obstruction of *vatha* due to *asthi dhatu* causes penetrating pain, stabbing pain and lassitude), *Kaphavrutha vatha* (*Vyana vatha* is being obstructed by kapha dosha, pain felt at the small joints and the patient feels heaviness in the body) [17, 19, 20].

When observe these different types of bone joint diseases discussed in Ayurveda texts it shows some are appear as *vatha* category of diseases, some are causes due to traumatic conditions and involve the bones or joints. Therefore some scholars who were searched for these in modern period looked into that and categorized into certain classifications. They mentioned three disease conditions namely *Sandigatha Vatha, Vatha raktha* and *Kostukashirsha* were the mostly discussed disease conditions in literature, also these conditions common in clinical practice [21], therefore clearly mentioned involvement of *dosha*, causative factors, prognosis and deformities prominent diseases, then classification explained accordingly as mentioned here.

Rheumatoid arthritis is a critical disease condition which the person is highly disabled if it is not properly managed. In Ayurveda system of medicine this disease well described in modern period texts that correlated to name as Amavatha which is a disease that systemic involvement as well as local involvement can be seen in large joints. It mainly affect bigger joints, presenting symptoms of anorexia, vomiting, malaise, indigestion etc. causative factor is due to the malfunction of digestive power. In the patients it presenting swelling with predominant pain as the symptoms with many other complaints. In ancient literature term 'Ama' the word

#### *Ayurveda Concepts of Joint Diseases DOI: http://dx.doi.org/10.5772/intechopen.99384*

comprises Amavatha used to denote a state of illness cause 'visha' padartha (toxic matter) which produces due to malfunction of digestive power. Also malfunction of the metabolism of the body benefited this disease process. Texts and the scholars of modern period of Ayurveda history described views about arthritis or joint diseases by indicating variety of clinical presentations. They stipulated the possibility of occurs several interrelated entities with possibly different etiologies related to joint diseases as mention here. They are Rasa Vata (a synonym for Amavatha), Raktha Vatha (a similar condition to Vatha raktha in ancient texts), Visha vatha (a condition similar to acute infective arthritis in modern medicine), Jirna vatha a condition with sandhi jadya or ankylosis due to old age, Jara vatha similar to degenerative arthrosis, Sandhika jwara to rheumatic fever. Same manner Amawatha correlated with its symptoms to Rheumatoid arthritis and according to the causative factors and disease involvement different treatment measures were prescribed such as to correct the digestive power and digest the ama and facilitate to absorb to the system, and then avoid the manifest in the locomotive system. Different treatment measures were described for this to manage the disease process help of drug actions such as deeepana (appetizer), pachana (digestive) drugs, local treatments according to the involvement of joints external drug preparations are applied to relieve pain and swelling with improve the joint movements.

#### **2.4 Classification of bone and joint diseases**

Based on the clinical features these diseases classified according to the causative factors, involving places, and symptoms by compairing structurural and functioning features in modern medicine [1, 17, 19], manifest in diseased person which is important in treating and management of bone and joint diseases, par with Ayurveda treatment plans, here it has been mentioned according to the based on or predominance of each factor.

#### *2.4.1 According to causative factors*

#### 1.Based on names.

*Sandigatha Vatha, Kostukashirsha, Avabahuka, Vatha kantaka, Grudrasi, Khalli, Asthi majjagata Vatha, Hanu bramsa, Visvachee.*

2.Traumatic

*Vatha kantaka, Hanu bramsa, Grudrasi, Avabahuka.*

3.Based on dosha involovement

*Sandigatha vatha, Khalli, Visvachee, Gudegatha Vatha, Asthi majjagata vatha, Ama vatha.*

4.Based on origin of *Ama*

*Amavatha, Vatha raktha, Urusthambha,, Raktha vatha.*

5.Based on toxic factor

*Visha vatha.*

6.Based on time factor

*Jara vatha, Jirna vatha.*

	- 1.Based on Pain.

*Sandigatha vatha, Asthi majjagata vatha, Vatha kantaka, Amavatha, Urusthambha.*

2.Based on swelling

*Kostukashirsha.*

3.Based on inflammation

*Amavatha, Vatha raktha, Urusthambha.*

4.Base on malfunction

*Avabahuka, Khalli, Visvachee, Grudrasi, Hanu bransha.*

	- 1.Joint predominancy.

*Hanu bransha, Sandigatha vatha, Grudrasi, Amavatha, Vatha raktha, Avabahuka, Vatha kantaka, Khalli, Visvachee.*

2.Bone predominancy

*Asthi majjagata vatha, Urusthambha.*

3.Muscle with joint predominance

*Amavatha, Kostukashirsha, Avabahuka, Grudrasi, Vatha kantaka, Khalli, Visvachee.*

4.Ligaments & joint predominance

*Vatha raktha, Khalli.*

#### **2.5 Ayurveda treatment options for bone and joint diseases**

To manage these diseases different therapeutic measures are used according to the Ayurveda system of medicine. In clinical practice medicinal materials in form of single drugs as well as poly-herbal formula are used. Body has been buildup of dietetic materials, the drug materials giving to manage the diseases also constituted same physical properties identified by Ayurveda influence of philosophical literature, also the aid of these theoretical concepts drugs are prescribed based on their actions. Body treatment is correlated to management process of a disease in Ayurveda defined as *chikithsa* which has a broad meaning related with the body. Literary meaning of body, described based on philosophical backgrounds that stated body derives and develop from nutrient materials and it is a collection of nutrients. To maintain its balance status there should be equilibrium in metabolic functions. These functions are governing by the three energy flows (*vatha, pitha,* 

#### *Ayurveda Concepts of Joint Diseases DOI: http://dx.doi.org/10.5772/intechopen.99384*

*kapha*) with the help of different *agnis* (metabolic power) in the body. These processes activate in the body and responsible to maintain the internal environment in balance state by avoiding cause any imbalance which originated a disease. Therefore treatment defined as *chikithsa* that implies collection of suitable procedures which can be normalizing the imbalance state of internal environment of the body.

Collectively these procedures lead to promoting and preservation of health in healthy person and curing disease in the sick person which highlights curative, preservative, rehabilitative and preventive aspects to manage diseases which in same manner applied to the joint diseases. Based on theoretical aspects different treatment lines are applied to manage joint diseases. They are avoiding causative factors such as dietary mal practices, mal practices in behavior, correct expose to seasonal changes. Pacifying visited *doshas* mainly *vatha samana* using drugs pertain drug action of *vedana stapana* to relieve pain with other medicaments for correct rearranged body functions according to the causative factors [14, 21, 22]. Excretion of disease causative factor known as *ama* by digestion of *ama* into the system using suitable drugs. Cleansing the obstructed channels (*srothas*) by five bio purificatory process known as *Panchakarma* using suitable drugs [23]. Facilitate diseased person if the condition caused due to the aging process by *rasayana* (rejuanation) therapy which is a main branch of Ayurveda. Whether person needs the rehabilitation yoga therapy or meditation can be advice to the patient. Finally all these treatment options can be apply as local or systemic therapeutic applications according to the patient condition as well as the nature of the disease.

#### **3. Conclusions**

Three energies governing the body functions to maintain the balance state of internal body environment. *Vatha dosha* as motile force and neurological activities. *Pitha dosha* responsible for metabolic, enzymatic and hormonal actions. *Kapha dosha* represents fluid component and its actions. Common form of joint diseases are osteo arthritis and rheumatoid arthritis respectively correlated to sandhigatha vatha and amavatha, for management these conditions herbal products, body purificatory processes, rejuanation procedures with yoga exercises can be used as therapeutic options.

#### **Conflict of interest**

Not relevant.

#### **Notes/thanks/other declarations**

Not relevant.

*Rheumatoid Arthritis*

#### **Author details**

Ayagama Pitadeniyage Anoma Jayasiri Institute of Indigenous Medicine, University of Colombo, Rjagiriya, Sri Lanka

\*Address all correspondence to: anomajayasiri1010@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Ayurveda Concepts of Joint Diseases DOI: http://dx.doi.org/10.5772/intechopen.99384*

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### *Edited by Hechmi Toumi*

Rheumatoid arthritis (RA) is a chronic autoimmune disease generating joint pain and damage in which inflammation plays a major role. RA joints are inflamed and stiff. Symptoms include joint swelling and warmth causing fatigue affecting life's health-related quality. Still, there are many other medical conditions that can also be associated with your symptoms and signs. This book is not a substitute for a diagnosis from a healthcare provider. Yet, understanding your symptoms and signs and educating yourself about health conditions is important and can contribute to having the healthiest possible life. Herein, Professor Hechmi Toumi offers an edited volume with detailed new information on RA pathogenesis and explains both approaches and treatment options: recent clinical research and traditional methods.

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Rheumatoid Arthritis

Rheumatoid Arthritis

*Edited by Hechmi Toumi*