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\title{'Arthrox' an Advanced Ayurvedic Detox Programfor Knee Osteoarthritis-A Case Report}
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\begin{document}

             \author[1]{Smita  Naram}

             \author[2]{Deepak S.  Mahajan}

             \author[3]{Hemang  Parekh}

             \author[4]{Ronak  Naik}

             \affil[1]{  Ayushakti Ayurveda Pvt Ltd}

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\date{\small \em Received: 15 December 2019 Accepted: 2 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Reported case was a 68 years old Male with Earlystage Osteoarthritis of both knees (Sandhigata Vata), accompanied by reduced medial joint spaces bilaterally, marginal osteophytes. Initially, VAS scale rating was poor. Proven herbal formulations like Painmukti MJ, Painmukti Sandhical, Painmukti cream along with Advance Virechana (Arthrox), Knee Dhara, Yogbasti, and Matrabastitwice a week was given for 16months.Visual analog scale for knee pain and an Ayurveda clinical assessment criteria used to evaluate the effects of Treatment and Herbal remedies monthly basis. After a treatment of 30 days of Advance Virechana (Arthrox), Knee Dharaand Yogbasti, Pain, movement, and stability of the joint was improved at an excellent level. During follow up visit with the help of Matrabasti twice a week, Pain, movement of joint and stability, and even X-ray reading were change. In conclusion, this knee osteoarthritis patient?s quality of life improved by Advance Virechana (Arthrox).

\end{abstract}


\keywords{osteoarthritis, arthrox, sandhigatvata, virechana.}

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\let\tabcellsep& 	 	 		 \par
an Advanced Ayurvedic Detox Program for Knee Osteoarthritis-A Case Report I. 
\section[{Background}]{Background}\par
ain have been regarded as a symptom of an underlying condition.  {\ref 1} Pain is the main causative factor that forces a person to visit a doctor immediately. The most common symptom as joint pain and stiffness is a diseased condition called Osteoarthritis. Initially, symptoms may occur only following exercise, but over time may become constant. Other symptoms may include joint swelling, decreased range of motion \hyperref[b1]{2} .Osteoarthritis is also erroneously called degenerative joint disease, which mostly affects cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over each other, absorb the shock of movement. In osteoarthritis, the top layer of cartilage breaks down and wears away. This breakdown of cartilage allows bones under the cartilage to rub together. The rubbing causes pain, swelling, and loss of motion of the joint. \hyperref[b2]{3} The management of Osteoarthritis includes Lifestyle management, Physiotherapy, and Medication. The effectiveness of NSAIDs varies substantially. Paracetamol is clinically in effective in symptomatic the treatment of Osteoarthritis, nsaids such as naproxen, while more effective in severe cases, are associated with greater side effects, such as gastrointestinal bleeding. \hyperref[b3]{4} Another class of NSAIDs, COX-2 selective inhibitors (such as celecoxib) are equally effective, and have lower rates of adverse gastrointestinal effects, but higher rates of cardiovascular disease such as myocardial infarction \hyperref[b4]{5} Because oral medication often does not lead to an adequate clinical response in OA, non-pharmacological therapies such as exercise, weight reduction, and physical therapies play role in the long-term management of osteoarthritis and are recommended. In addition, complementary and alternative medicine (CAM) treatments such as acupuncture or herbal medicines are used frequently by OA patients.\par
Acharya Charaka mentioned Sandhigatavata, which can be compare with Osteoarthritis. Shula (pain) is the cardinal feature of the disease associated with Sandhishotha (joint inflammation), Vatapurna-dratisparsha (edema palpable as air-filled sac), Prasara?aakuncanasavedana (painful movement of the joints), and in the later stage Hantisandhi (restricted joint movements). \hyperref[b6]{6} II. 
\section[{Case Report}]{Case Report} 
\section[{P}]{P}\par
Reported case was a 68 years old Male with Early-stage Osteoarthritis of both knees (Sandhigata Vata), accompanied by reduced medial joint spaces bilaterally, marginal osteophytes, Tibia spiking,and Patellar breaking. When the patient was 65 years old, they developed pain in the right knee, at the age of 65.6 years in the left knee. At the age of around 66 years, he had an X-ray with a diagnosis early-stage osteoarthritis. Therefore the patient took NSAIDs and received conservative treatment and Physiotherapy. However, knee pain increases progressively along with weight; on the other hand, his daily living activities stared decreasing with age. At the age of 68 years, this patient visited Ayushakti Ayurveda Pvt Ltd outdoor unit in Thane, Mumbai, Maharashtra, India branch with a complaint of both knee pain while walking and climbing. The patient got his self-reported visual analog scale (VAS) pain score in-between 8 and 9. On clinical examination, both knees showed mild detectable effusion. As per clinical symptoms and X-ray reporting patient diagnosed as having Osteoarthritis of both knee joints. The patient was convinced to undergo Advance Virechana (Arthrox),Knee Dhara, Yogbasti, and Herbal formulations for 20 days, followed by matrabasti(60 ml oil enema) twice a week for 12 months along with Herbal formulations. All the test drugs ( table-01)Pain Mukti MJ 400 mg twice a day after food, Pain MuktiSandhical 720 Abstract-Reported case was a 68 years old Male with Earlystage Osteoarthritis of both knees (Sandhigata Vata), accompanied by reduced medial joint spaces bilaterally, marginal osteophytes. Initially, VAS scale rating was poor. Proven herbal formulations like Painmukti MJ, Painmukti Sandhical, Painmukti cream along with Advance Virechana (Arthrox), Knee Dhara, Yogbasti, and Matrabastitwice a week was given for 16months.Visual analog scale for knee pain and an Ayurveda clinical assessment criteria used to evaluate the effects of Treatment and Herbal remedies monthly basis. After a treatment of 30 days of Advance Virechana (Arthrox), Knee Dharaand Yogbasti, Pain, movement, and stability of the joint was improved at an excellent level. During follow up visit with the help of Matrabasti twice a week, Pain, movement of joint and stability, and even X-ray reading were change. In conclusion, this knee osteoarthritis patient's quality of life improved by Advance Virechana (Arthrox). The first regimen of Advance Virechana (Arthrox) was started for the patient after his informed written consent for the procedure, all the do's and don'ts, all the possible complications during Advance Virechana (Arthrox) procedure explained thoroughly. 
\section[{III. Treatment Plan Advance Virechana (Arthrox)}]{III. Treatment Plan Advance Virechana (Arthrox)}\par
The procedure of Advance Virechana (Arthrox) performed in three steps. The assessment of Advance Virechana (Arthrox)based on various parameters termed asShuddhi (cleansing) criteria like Vaigiki(number of bouts of stool passed), Maniki (quantitative measurements of stool), Laingiki (Symptoms), and Antyaki (assessment based on end points of purgation).This particular patient had Madhyamshudhhi. In the second regimen, the Advance Virechana (Arthrox) procedure was followed by Yogbastikrama (8 enemas) and Knee Dhara (pouring of oil on knee anterior and posterior aspect) with Mahanarayan oil for eight days. All the test drugs Pain Mukti MJ 400 mg twice a day after food, Pain MuktiSandhical 720 mg twice a day after food, Pain Mukti Cream for local Application was kept continue after that for 16 months. Matrabastitotal of 60 ml (Mahanarayan oil-20 ml, Balada oil-20 ml, Jivanyaghrut-20 ml) twice a week advised for 16 months.    
\section[{Results}]{Results}\par
During the treatment of the first 30 days, patient experienced gradual improvement. All the symptoms were around 50 \% reduced except climbing in first 30 days only (table-8). After the successful completion of all the arthrox treatment patient experienced 100 \% relief in all the symptoms. His VAS scale reading was improved significantly. When the patient had his both knee X-ray after 13 months, it showed no abnormality except mildly reduced joint space in medial compartments of both knees (image-1 and image-2).  
\section[{Discussion}]{Discussion}\par
Osteoarthritis (Sandhigatvata) is commonly known as wear and tear arthritis. In this natural cushion between the joints, cartilages wears away \hyperref[b7]{7} . There may be inflammation in the joint spaces, which causes symptoms like Pain initially,later Swelling. Due to lack of this cushion and absorption material, inflammation, in Sandhigatvatathe mobility of joints is restricted at the initial stage, and later it is aggravated by anatomical changes in the articular surfaces and joint capsule and the ligamnets \hyperref[b8]{8}  in his regular daily activities, he experiences the pain, which may cause wincing of the face. All the signs and symptoms noted for the patient, and the assessment was done. The symptoms assessed before starting treatment, after one month, three months, six months and final visit were after twelve months.\par
The two main events in any degenerative disease described by our Achary as are Asthidhatukshyaya and Vataprakopa, and according to Samhitas, Vata and Asthi have Ashrayaashrayisambandh(connection) in which the herbs are causing Kshaya of Vata are responsible for Asthidhatuvriddhi and vice versa \hyperref[b9]{9} .Bastichikitsa is the best panchakarma treatment for vitiated Vata \hyperref[b10]{10} . According to Acharya CharakPanchakarma procedure of Basti is called Ardhchikitsa (Half treatment) for Vata \hyperref[b12]{11} . Virechana increases the absorption of basti to achieve a target of pain relief in a short period. Virechana evacuates all morbid Doshas from all micro to macro Dhatu channels and regulates Vata, thus decreasing all symptoms of on Srotasa level \hyperref[b14]{12} .Painmukti MJ and Painmukti Sandhical are moderately effective and safe herb in chronic arthritic conditions along with painmukti cream for local application and used as an alternative to NSAID's without side effect \hyperref[b15]{13} . Cissusquadrangularis present in Painmukti Sandhicalcan stimulate osteoblastogenesis 14 . Boswelliaserrata blocks an enzyme 5-lipooxygenase that plays a role in the formation of leukotrienes, which stimulates inflammation 15 . 
\section[{VI.}]{VI.} 
\section[{Conclusion}]{Conclusion}\par
Arthrox plan can be used successfully in knee osteoarthritis for the long term; it can give better relief in Symptoms of Osteoarthritis as well as can reverse the early degenerative changes in X-ray readings.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_1}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.24527925531914893\textwidth}P{0.03956117021276596\textwidth}P{0.20232712765957447\textwidth}P{0.045212765957446804\textwidth}P{0.2690159574468085\textwidth}P{0.04860372340425532\textwidth}}
Pain Mukti MJ\tabcellsep \tabcellsep Pain MuktiSandhical\tabcellsep \tabcellsep Pain Mukti Cream\tabcellsep \\
Ingredients\tabcellsep Quantity\tabcellsep Ingredients\tabcellsep Quantity\tabcellsep Ingredients\tabcellsep Quantity\\
NirgundhiGhan (Vitexnirgundo)\tabcellsep 50 mg\tabcellsep Guggul(Commiphoramukul)\tabcellsep 150mg\tabcellsep Mahanarayan oil\tabcellsep 10\%\\
Rasna Ghan (Pluchealanceolata)\tabcellsep 100mg\tabcellsep Asthishrunkhlaghan (Cissusquadrangularis)\tabcellsep 100 mg\tabcellsep Lavang oil (Eugenia aromatica oil)\tabcellsep 0.5 \%\\
ShallakiGhan (Boswelliaserrata)\tabcellsep 100mg\tabcellsep Lajjalughana (Mimosa Pudica)\tabcellsep 30 mg\tabcellsep Twak oil (Cinnamomum Zeylanicum oil)\tabcellsep 0.5 \%\\
RaktaPunarnavaGhan (Boerhaviadiffusa)\tabcellsep 40mg\tabcellsep Lakha (Lacciferalacca)\tabcellsep 20 mg\tabcellsep Pudinaphool (Menthaspicata)\tabcellsep 5 \%\\
Shunthi powder (Zinziberofficinalae)\tabcellsep 25mg\tabcellsep Aswagandha (Withaniasominfera)\tabcellsep 20 mg\tabcellsep ShuddhaGuggul (Balsamodendronmukul)\tabcellsep 1 \%\\
Musta powder (Cyprus rotandus)\tabcellsep 75mg\tabcellsep Mukta\tabcellsep 400 mg\tabcellsep Marich ark (Capsicum extract)\tabcellsep 0.1 \%\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep Gandhapurapo oil (Winter green oil)\tabcellsep 10 \%\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.23073136427566804\textwidth}P{0.1661744022503516\textwidth}P{0.15661040787623065\textwidth}P{0.24746835443037973\textwidth}P{0.0490154711673699\textwidth}}
Days\tabcellsep Treatment\tabcellsep \tabcellsep Drug\tabcellsep Duration\\
1-5 days\tabcellsep Dry pindsweda\tabcellsep \multicolumn{2}{l}{Shunthi powder (Zinziberofficinalae), Ajwain powder Trachispermumammi}\tabcellsep 20 mins\\
6-10 days\tabcellsep Internal and external snehana (Oleation), Swedana (Steam)\tabcellsep \tabcellsep Internal-Mahatiktaghruta External-Mahanarayan oil\tabcellsep 20 mins\\
12 th day\tabcellsep Virechana (Detox)\tabcellsep \tabcellsep Special virechana tablet\\
13-15 days\tabcellsep Sansarjankrama\tabcellsep \tabcellsep Mand, Peya, Vilepee\\
13-20 days\tabcellsep Yogbasti Knee dhara\tabcellsep \tabcellsep Knee dhara-Mahanarayan oil\tabcellsep 20 mins\\
Onwards\tabcellsep Matrabasti\tabcellsep \multicolumn{2}{l}{(Mahanarayan oil-20 ml, Balada oil-20 ml, Jivanyaghrut -20 ml)}\tabcellsep Twice a week\\
\multicolumn{3}{l}{The overall improvement observed with}\tabcellsep \multicolumn{2}{l}{Walking (table-6) and difficulty in climbing (table-7) and}\\
\multicolumn{3}{l}{symptoms like Pain (table-3), Swelling (table-4),}\tabcellsep were grades like following-\\
\multicolumn{3}{l}{Akunchana Prasarane Vedana (table-5) difficulty in}\tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.8231578947368421\textwidth}P{0.026842105263157896\textwidth}}
Symptom\tabcellsep Grade\\
No Pain\tabcellsep 0\\
Mild pain of bearable nature, comes occasionally\tabcellsep 1\\
Moderate pain-Slight difficulty in joint\tabcellsep \\
movements due to pain , requires medication and may remain throughout\tabcellsep 2\\
the day\tabcellsep \\
Severe Pain-More difficulty in moving the\tabcellsep \\
joints and disturbing sleep and requires\tabcellsep 3\\
strong analgesics\tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.7810810810810811\textwidth}P{0.06891891891891892\textwidth}}
Symptom\tabcellsep Grade\\
No Swelling\tabcellsep 0\\
Minimal edema only in joint Capsule\tabcellsep 1\\
Edema in dependant parts\tabcellsep 2\\
Massive edema in the limb\tabcellsep 3\end{longtable} \par
 
\caption{\label{tab_4}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.7856060606060605\textwidth}P{0.06439393939393939\textwidth}}
Symptom\tabcellsep Grade\\
No Pain\tabcellsep 0\\
Pain without wincing of face\tabcellsep 1\\
Pain with wincing of face\tabcellsep 2\\
Prevent complete flexion\tabcellsep 3\\
Does not allow passive movement\tabcellsep 4\end{longtable} \par
 
\caption{\label{tab_5}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.8103626943005181\textwidth}P{0.039637305699481866\textwidth}}
Symptom\tabcellsep Grade\\
No Effect\tabcellsep 0\\
Needs Minimal Assistance / Can Stand or walk for 1 Hour\tabcellsep 1\\
Needs Maximum Assistance / Can Stand or Work for less than 30 Minutes\tabcellsep 2\\
Almost Not Standing or Walking or Bed Ridden\tabcellsep 3\end{longtable} \par
 
\caption{\label{tab_6}Table 6 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7} \par 
\begin{longtable}{P{0.78625\textwidth}P{0.06375\textwidth}}
Symptom\tabcellsep Grade\\
No Effect On Climbing\tabcellsep 0\\
Needs Minimal Assistance\tabcellsep 1\\
Needs Maximum Assistance\tabcellsep 2\\
Almost No Climbing or Bed Ridden\tabcellsep 3\\
IV.\tabcellsep \end{longtable} \par
 
\caption{\label{tab_7}Table 7 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{8} \par 
\begin{longtable}{P{0.5587412587412587\textwidth}P{0.13076923076923078\textwidth}P{0.02972027972027972\textwidth}P{0.13076923076923078\textwidth}}
Symptom\tabcellsep \multicolumn{3}{l}{BT AT Relief in \%}\\
Pain scale\tabcellsep 3\tabcellsep 2\tabcellsep 33.33333\\
Swelling\tabcellsep 2\tabcellsep 0\tabcellsep 100\\
\multicolumn{2}{l}{AkunchanaPrasaraneVedana 3}\tabcellsep 1\tabcellsep 66.66667\\
Difficulty in Walking\tabcellsep 2\tabcellsep 1\tabcellsep 50\\
Difficulty in climbing\tabcellsep 2\tabcellsep 2\tabcellsep 0\end{longtable} \par
 
\caption{\label{tab_8}Table 8 :}\end{figure}
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