Many women will celebrate their 80^th birthday. This means women will spend at least one third of their life time after menopause. Menopause, also known as the climacteric, is thus defined as the time following one year of complete cessation of menstrual bleeding. The average age for menopause is 51.4 years.1

Knee problems occur in mid thirties and the risk increases with age and more commonly develops in women over 40 who are five times more likely to have this problem than men. OA is the most common and characteristic arthritis of the elderly. It is also the most common cause of disability amongst them. The prevalence of OA which is less than 1% below the age of 30 years, increases to 10-20% between 65-74 years of age and to 30% and above in those above 75 years of age.

Females are more commonly affected. In the Indian context, OA of knee and cervical and lumbar spine is most common. Dr Ashok Rajgopal, a well known knee replacement surgeon of India observed that most of the osteo-arthritis patients in India who seek knee replacement are in the advanced stage of the disease, with a high degree of deformity but treating such cases has its own research related advantage and the effect of the treatment is dramatic, which changes the complete lifestyle of the patient.

Here a question may be raised whether the numbers of cases requiring joint replacement can be reduced are not... certainly the incidences as well as the deformity may be minimised through the Ayurvedic line of treatment.

The aetiology and origin of osteoarthritis is not known to modern science but Ayurveda can infer the constitution of the individuals who are prone to this disease. And also the life style which can become a caused for the disease. In my practice more than 3 decades the study has shown that the women belonging to Vata prakrti are more prone to this sandhivata. Secondly those who have totally sedentary life (Ayoga) and over doing (athiyoga).

Being too overly conscious about the weight and avoiding Ghee or such beneficial fats in the diet, and consuming too much of katu spicy foods which are dry. Those who do house hold work with over exposure to cold water. And stand continuously for many hours, are the common victims for this sandhivata.

Women have an additional phase proudhavastha which starts with the slow changes in Arthavavaha srotas and ends up with Rajonivruththi ( Menopause). Normally active lady may have silent menopause without any suffering. But the awareness about the changes itself has become cause for many women to suffer during this phase of life.

As an young girl passes through the phase of puberty and adjusts to the change occurring in the body and various systems. The body also tries to adapt itself to the changing internal environment. Women slowly enters in to a phase predominated by Vata dosha. As per the interrelation ship of the doshas and dhatus asthi dhatu (bone tissue) is the ashraya (abode) for Vata dosha.

As per the general rule whenever there is increase of the doshas the corresponding dhatus should also increase. But this rule is not applicable to the combination of Asthi and Vayu. Thus the aggravation of Vata always plays a major role in diminution of Asthi dhatu. Arthava (the menstrual blood and also the factor responsible for conception) is the by-product of the first Dhatu i.e. rasadhatu.

Vata increase or aggravation also caused depletion in Rasa dhatu, the function of which is to nourish every cell in the body. These are important internal environmental changes, which become the cause for increased incidence of sandhivata (osteoarthritis) in women. If these contributing factors are taken care of both the prevention and remission of Sandhivata in women can be achieved.

Symptoms

Osteoarthritis develops slowly over several years. The symptoms of osteoarthritis are mainly pain, swelling, and stiffening of the knee. The pain of osteoarthritis is usually worse after activity. Early in the course of the disease, one may notice that the knee does fairly well while walking, then after sitting for several minutes the knee becomes stiff and painful. As the condition progresses, pain can interfere with even simple daily activities.

A common complaint is difficulty in squatting and sitting cross-legged and climbing down stairs. In the late stages, the pain can be continuous and even affect sleep patterns.

The diagnosis of osteoarthritis can usually be made on the basis of the following-

• Initial history and examination.
• X-Rays are very helpful in the diagnosis and may be the only special test required in the majority of cases. In some cases of early osteoarthritis, the X-rays may not show changes typical of osteoarthritis
• MRI
• Arthroscopy

Ayurvedic approach of management of sandhivata-

As mentioned earlier, osteoarthritis is compared with sandhivata. sandhi meaning the joints and the Vata dosha gets localised in the joints thereby causes Rukshatha which results in increased friction and the asthidhatu kshaya results.

The lakshanas-Clinical features are-
Sandhi vedhana- Pain in the joints,
Vedanayuktha chesta (painful movements)
Sandhi sphurana- cripitations in the joints,
Sandhi sthabdhatha- inactiveness of the joints, etc...

Often associated with other Vata lakshanas.

The management includes the local and internal treatment-

• Internally the drugs with the therapeutic activities like shothagna (Anti inflammatory), dhatuvardhaka (growth promotion especially of asthi dhatu/bone tissue), Vatahara (Pacifying Vata dosha), rasayana (adaptogenic) and vedanashamaka (Analgesic).

Panchakarma

• Adaptation of matrabasti, Administration of medicated Ghee or oil per rectum which is an easy procedure and can be carried out as out patient basis. A course of seven days Mathrabasti with only medicated oil or ghee provides prolonged relief from pain and also prevents further damage to the bone tissue. Generally used Ghee Gugguluthikthaka Grutha.

Which has the Myrrh guggulu, five bitter plants, and the Ghee. Guggulu and also the bitter plant products have proven effect on inflammation and pain. These are also good digestants and help in proper digestion and thus prevent the formation of Ama or the toxins which can get accumulated and interfere in the bone formation. The lipid component of the preparation helps in providing lubrication to the joints and help in easy movement oft affected joints.

If this therapy is used in the initial stages there will be prolonged relief . the author has observed the relief in patients for more than 4-5 years. In few where the inflammation is very severe and the dieses is chronic the therapy need to be repeated once in three months or even earlier in some cases. In obese patients instead of Ghee medicated oils can be utilised.

The commonly used oils are Mahanarayan taila, and Dhanvantara taila. These can be effective as hormone replacement too. Though the hormone replacement therapy has helped in reducing the incidence of sandhivata it has its own adverse reactions which can cause a range of health problems from Carcinoma, to obesity.

But on the other hand the mathra basti is more safer, providing sustained relief, and promotes overall well being of hte patient which is the need of the hour.

• Adaptation of janu basti or the local sudation therapy through basti to the affected joints. A therapy in which the warm medicated oill is poured over the joint with round bridge prepared by the dough made out of Black gram floor. Retention of oil over the joint helps in improving the circulation, gets absorbed and reduces pain and inflammation, and also helped in resolving the ama localised in the joints.
• Application of warm medicated oils like Mahanarayan taila, Hinguthriguna taila, murivenna oil, caster oil to the affected joints with gentle massage, followed by tight wrap for at least 3-4 hours reduces pain remarkably. Warm water may be poured over the joints.
• As in women the pathogenesis of the disease is aimed at the changes occurring in arthavavaha Srotas (reproductive systems) and its impact on the other dhatus and the doshas. As a general rule the management of arthava vikara (abnormality related to menstruation) as well as yoni vyapadhas (gynaecological diseases) are with a primary focus to Vata shamana and then the rasadhatu, even the problems during menopause is also aimed at alleviating these factors.
• In acute conditions the pain management is the basic need. There are number of drugs proved to have this effect. Few among them are  Ginger-Nagara, Turmeric- haridhra, Boswellia-shallaki.
• The use of rasayana is very essential which also fits in to the framework of conventional approach with vitamins, minerals and hormones. Many drugs have been proven to possess smaller quantity of phytoestrogen that will full fill the requirement of the hormone to prevent the further damage. These phyto-estrogens are proven to have no side effect. As the whole drug is used
• Amalki (Emblica officinalis), shigru (Moring monosperma), agasthya (Sesbania grandiflora), kaidarya ( Curry leaves), shathavari ( Asperagus racemoses) etc are the drugs which can take care of women in maintaining the general heath thus providing quality of life. Though these plants have been proven for their vitamin and mineral content, as well as phyto-hormones, when the whole drug is used in the natural form the limitation and the adverse effects are counteracted or minimised. These plants are more than the chemical single constituent identified by the scientists. These medicines also have rejuvenating effect on all the tissues of the body.

Preventive measures:

As the exact cause is not known the prevention also appears to be difficult. But any joint is vulnerable, especially if it has been injured or overused.

Relieving stress on the joints is recommended.

• Losing excess weight,
• Avoiding repetitive motions, and
• Choosing low-impact sports (e.g. bicycling, swimming)
• Practice of Yogasanas under proper supervision.
• Over grueling, joint-punishing activities.
• Instead of avoiding movements which is major mistake many would do one need to build up stronger muscle which prevents further wearing of the bone tissue.
• Diet rich in bone marrow, cartilage, tendons, and raw root vegetables provides the silicon a micro mineral which is essential for the development of bones.
• Calcium is connected to osteoarthritis because easily fractured bones only add to the discomfort and pain of arthritis. Calcium is easily obtained with three or four daily servings of Milk and Yogurt. Dark-green leafy vegetables, Millets the poor-mans food in south India. Use of Kukkutandatvak bhasma ( Bhasma prepared with the egg shell), Pravala Bhasma ( Bhasma of the corals)
• Prompt management of any abnormality in relation to rajapravruththi (Menstruation) .
• Administration of Rasayana dravyas prior to the onset of peri-menopausal stage is much beneficial. This is the rule for administration of Rasayanas in the Ayurvedic classics. Instead of waiting for the disease to crop up or the old age signs to develop the rasayanas should be administered before the onset of menopause. This make the body to adapt to the changes easily with out any untoward results.
• Education regarding the use of nithya rasayanas like milk and ghee etc.. is beneficial, This needs to be motivated.
• Encouraging every day abhyanga with ashwagandha bala laxadhi taila, or Mahanarayan taila keeps muscle tone and the supporting structures of the joints, and improves the lubrication to the joints.
• Screening at community level during the 3^rd , 4^th, and 5^th decade and detecting well in advance makes the women to maintain at an early age and keep themselves fit.
• Educating the community through training camps.

Daily activities- Here are some helpful hints to use during the day to limit strain on knee joint.

• Avoid standing for greater than 10 minutes; instead use a high stool or take frequent rests.
• Limit stair climbing; take the elevator, escalator, or ramp.
• Avoid bending and squatting; keep items at waist level, or use a reacher.
• Park close to your destination.
• Avoid low beds, chairs, and toilets; elevate them when possible.
• Control pain and inflammation.
• Reduce shock by using a walking aid, wearing good shoes, choosing soft surfaces, and keeping the leg muscles conditioned for unexpected stresses.
• Exercise daily to maintain range of motion, strength, and cardiovascular fitness.
• Use a shoe orthotic with a heel wedge for better alignment.
• Take precautions with daily activities to avoid stressing the knee. There are also braces on the market now that can reduce the pressure on the side of the knee that is most involved. These braces have been designed mainly for the more common condition of early wear and tear in the medial compartment of the knee.

Since the women are susceptible to osteoarthritis need to be cared for prevention, early detection and timely treatment. As the science Ayurveda can identify the chances of susceptibility, and can prevent the occurrence of sandhivata both for prevention and relief one can depend on Ayurveda.

Exercises for Osteoarthritis

People with osteoarthritis should do different kinds of exercise for different benefits to the body. exercises can improve the body density and hence should be a part of the life style. Yogic postures along with synchronised breathing helps in building up of the tissues and certainly reduces the risk and suffering. but any type of exercises should be started after the proper consultation.