Ayurveda: General Principles and Treatment of Rheumatoid Arthritis

By Manorama Venkatraman, PhD, and Nassim Assefi, MD

Deepak Chopra has championed certain elements of Ayurvedic practices in the United States over the last few years, but in India, Ayurveda has been an officially recognized health system for centuries.

Ayurvedic treatment for rheumatoid arthritis (RA) is appealing for many reasons and 68-94% of RA patients have reported using a complementary therapy at least once.1 There is historical precedent for its use: Classical Ayurvedic texts dating as far back as 1500 BC describe rheumatic diseases as well as their pathogenesis and treatment, including "astonishingly elaborate descriptions of rheumatoid arthritis features."2

Philosophy

Translated from Sanskrit as "the knowledge of life and longevity," Ayurveda is a multifaceted system, including herbal medicine, diet modification, oil therapies, massage, yoga, and meditation. Its holistic approach to the prevention and treatment of illness include lifestyle modification and a system of therapies that aim to restore balance to body, mind, and spirit.

Current practice and knowledge of Ayurveda are based on three classic Sanskrit texts, the most important of which is Charaka Samhita (circa 1500 BC). This text’s classification of more than 200 diseases is remarkably consistent with World Health Organization (WHO) disease classification criteria.

Principles

Ayurveda has eight traditional branches: surgery; internal medicine; gynecology; pediatrics; ophthalmology and otolaryngology; psychiatry; toxicology; and geriatrics. According to Ayurveda, the human body is a microcosm of the universe, composed of five elements (space, fire, water, earth, and air). The body consists of seven dhatus or tissues (fluid, blood, muscle, fat, bone, marrow, and reproductive tissue); three malas or waste products (feces, urine, and sweat); and agni, the energy of metabolism. Fluids and life forces travel through numerous channels that connect tissues.

The functional and maintenance aspects of the body are governed by the three dynamic energies called doshas (vata, pitta, and kapha), the active forms of the five elements. Doshas reportedly are formed in the body from food and other physiologic processes, and regulate thousands of separate functions in the mind-body system. Dosha equilibrium (their quantity, quality, and function relative to each other) is thought to be essential for optimal health and prevention of disease. An individual’s constitution and personality is determined by a unique combination of these three doshas.

Ayurvedic Pathophysiology for RA

Ayurvedic "pathophysiology" links vata, pitta, and kapha to the process of joint motion, metabolic and secretory functions (synovial fluid), and lubrication and preservation (structure and homeostasis), respectively. Inappropriate food habits are thought to weaken digestion and metabolism, causing an accumulation of impurities, which build up in the blood. Circulating throughout the body, these impurities are blocked in the structural curvature of the joints and theorized to remain lodged there. Associating with the doshas, they then cause the symptoms and signs of RA.

Diagnostics

Ayurvedic diagnostics are similar in some respects to those of conventional allopathic medicine. They include a detailed history and physical (including highly specialized examination of the pulse, tongue, and urine). In addition, the patient’s constitution and personality are determined, as well as the nature of imbalance among the doshas.

Treatments

In Ayurvedic treatment, the selection and dosage of medicines are specific to the patient and will depend on which of the three doshas are out of balance. Ayurveda has a rich tradition of plant pharmacotherapy with a great variety of anti-arthritic plants believed to improve digestion, remove impurities, and balance the doshas.

The traditional treatment system to balance doshas involves five therapies: purgatives or laxatives, therapeutic vomiting, medicated enema, nasal administration of medicines, and blood purification. If the patient is not strong enough to tolerate these therapies, a gentler palliative treatment to strengthen the patient is given first. Medicated enemas are considered to be highly effective for purifying the system, normalizing metabolism, preventing relapse, and promoting rejuvenation.

Ayurvedic treatment for RA includes herbal medicines, medicated oils, and analgesic pastes. Oil therapies reportedly increase the mobility of the joints, relieve muscular spasm, and push accumulated toxins into the large intestine. These toxins are expelled from the body by medicated enemas.3 A light vegetarian diet is recommended, with avoidance of foods known to trigger painful disease activity (e.g., the "nightshade" vegetables such as potato and eggplant). Rest during the active disease phase, meditation, and yoga are advocated.

Clinical Research

A controlled trial of the whole system of Ayurvedic treatment for RA has not yet been reported in the literature, but the World Health Organization (WHO) studied Ayurveda for RA in its first-ever study of a traditional medical system at the Ayurvedic Trust in Coimbatore, India, enrolling 240 subjects from 1977 to1984.4 In this open, unblinded study, Ayurvedic physicians administered the treatment; the collaborating allopathic panel from the Indian Council for Medical Research evaluated the effects of the treatment, using American Rheumatism Association criteria (grip strength, walking time, number of swollen and painful joints, sedimentation rate [ESR], rheumatoid factor). Treatment was individualized according to the degree of imbalance of the doshas, and included internal herbal medicines, external application of analgesic pastes and medicated oils, specialized oil therapies, medicated enema, yoga, and dietary and lifestyle modification. The subjects were prohibited from taking allopathic medicines. The average length of treatment was four months. Tests done at six-week intervals showed no evidence of renal, liver, or blood abnormalities as a result of the Ayurvedic medicines.

The allopathic panel outcome evaluation indicated that there was significant improvement in the subjects’ conditions. Statistically significant results were noted in all parameters from baseline to end of treatment: Grip strength increased from 82 mm Hg to 111 mm Hg (P < 0.001); walking time decreased from 7.5 seconds to 4.8 seconds (P < 0.001); swollen joints decreased from 6.6 to 4.3 (P < 0.001); painful joints decreased from 7.8 to 3.6 (P < 0.001); mean joint count decreased from 74 to 30 (P < 0.001); mean ESR decreased from 59 mm to 37 mm (P < 0.001). Whereas 60% were classified as belonging to functional class III or IV at admission (American College of Rheumatology), only 12% were classified as such at the time of discharge: 33% improved by one class, 12% improved by two classes, and 6% improved by three classes. Subjects evaluated their condition at discharge more favorably than did the allopathic physicians. Follow-up data on 47 patients at six months after discharge showed that improvement in walking time and joint circumference were maintained and that mean ESR dropped to 25 mm (P < 0.01).

There are three reported clinical trials of isolated Ayurvedic herbal formulations for RA, two of them using the gum resin of Boswellia serrata, which traditionally has been used in Ayurvedic medicine to treat chronic inflammatory diseases like RA, asthma, and ulcerative colitis. Boswellic acids inhibit the leukotriene biosynthesis in neutrophilic granulocytes by a non-redox, noncompetitive inhibition of 5-lipoxygenase.5 Boswellia serrata extract (three 400 mg tablets two or three times a day) was effective in reducing symptoms of RA in 50-60% of 260 patients in a double-blinded, placebo-controlled clinical trial.6 Compared to the placebo group, there was a statistically significant reduction in swelling and pain.

A 16-week randomized double-blind, placebo-controlled trial of a standardized drug of Ayurvedic origin, RA-1 (Withania somnifera, Boswellia serrata, Curcuma longa, and zinc ash) was conducted in 182 patients with active RA.7 Concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying anti-rheumatic drugs were not allowed, but 76 patients on a fixed daily dose of prednisone (mean dose of 5.1 mg) were enrolled. Tenderness, pain, swelling, and several other efficacy measures were assessed.8 An intention-to-treat analysis showed improvement in the active group compared to baseline values, but the results were not significantly superior to the strong placebo response, except for improvement in joint swelling.

U.S. Practices

Ayurveda is not yet recognized as a legitimate health care practice in the United States. Ayurvedic physicians have an educational and training requirement similar to allopathic physicians in India: approximately 10 years of study and supervised practice. However, Ayurvedic physicians in the United States must obtain a doctoral degree in one of the licensable professions (e.g., MD, DO, ND, DC) to diagnose and recommend Ayurvedic treatment.9 Even then, they are only able to incorporate particular aspects, and not the whole system of Ayurveda into their practice. Although a limited selection of symptom-specific Ayurvedic herbal products are marketed as food supplements, the majority of Ayurvedic medicines are prohibited due to Food and Drug Administration restrictions.

Conclusion

Ayurveda offers a holistic, historically rooted, reportedly safe, alternative treatment for RA patients, but no well-designed studies have evaluated the comprehensive Ayurvedic system on RA compared to the natural history of disease or conventional therapies. Two randomized, double-blinded, placebo-controlled studies of Ayurvedic herbs for RA containing Boswellia serrata show promising results. The Table summarizes the challenges of designing a high-quality trial of Ayurveda.

Findings from such studies enhance understanding of how various herbs work and fit the notion of herbs as medicines, but they represent only part of the multi-faceted Ayurvedic system of treatment. Ideally, Ayurveda’s various components should be included together in a trial; however, blinded studies of an entirely different health system are challenging to perform and may not be feasible.

Table
Methodological challenges of studying Ayurveda
  • Individualized diagnoses and subcategories of diagnosis within biomedically recognized diseases
  • Individualized treatment regimens consisting of multiple different interventions (herbal medicines, oils, massage, yoga, meditation, etc.)
  • Difficulty constructing a useful control group given the multiple types of interventions
  • Blinding of patients and independent physician assessors (blinding of Ayurvedic practitioners is virtually impossible)
  • Limited scope of Ayurvedic practice outside of India
  • Adequate sample sizes/power to detect a difference
  • Valid subjective and objective outcome measures
  • Duration of follow-up

Recommendation

Until there is better quality evidence for the effectiveness and safety of Ayurvedic treatment for RA, such therapies should be reserved for patients who fail all conventional therapies (either because they are ineffective or cause unbearable toxicities). If used, Ayurvedic treatments are most likely to be effective if they represent the holistic practice, and not just an element of Ayurveda in isolation. Nevertheless, the Ayurvedic herb, Boswellia serrata, warrants further study. 

Dr. Venkatraman is Research Assistant Professor, School of Nursing, and Dr. Assefi is Attending (Clinician-Teacher), Departments of Medicine and Obstetrics/ Gynecology, Complementary and Alternative Medicine Liaison, School of Medicine, University of Washington in Seattle.

References

1. Visser GJ, et al. Rheumatologists and their patients who seek alternative care: An agreement to disagree. Br J Rheumatol 1992;31:485-490.

2. Ulrich-Merzenich G, et al. Rheumatic diseases in Ayurveda: A historical perspective. Arthritis Rheum 1999;42:1553-1555.

3. Varier KS. Rheumatoid Arthritis: The Ayurvedic Approach. Coimbatore, India: The Ayurvedic Trust; 1994.

4. Ayurvedic Trust. World Health Organization/Indian Council for Medical Research Collaborative Study on the Efficacy of Ayurvedic Treatment in Rheumatoid Arthritis. Coimbatore, India: The Ayurvedic Trust; 1984.

5. Ammon, HP. Lehrstuhl Pharmakologie fur Naturwissenschaftler. Wien Med Wochenschr 2002;152:373-378.

6. Etzel R. Special extract of Boswellia serrata (H15) in the treatment of rheumatoid arthritis. Phytomedicine 1996;3:91-94.

7. Chopra A, et al. Randomized double-blind trial of an ayurvedic plant derived formulation for treatment of rheumatoid arthritis. J Rheumatol 2000;27:1365-1372.

8. Felson DT, et al. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. Arthritis Rheum 1993;36:729-740.

9. Lad DV. Ayurvedic Medicine. In: Jonas WB, Levin JS, eds. Essentials of Complementary and Alternative Medicine. Philadelphia, PA: Lippincott, Williams, and Wilkins; 1999:200-215.