A Case Report on Dandalasaka W.S.R. To Ankylosing Spondylitis

Ankylosing spondylitis is one among the spondyloarthropathies which comprise of a set of inflammatory diseases. Ankylosing spondylitis (AS) is characterised by a chronic inflammatory arthritis predominantly affecting the sacroiliac joints and spine, which can progress to bony fusion of the spine. The cardinal feature is low back pain and early morning stiffness with radiation to the buttocks or posterior thighs. 1 Symptoms are exacerbated by inactivity and relieved by movement. In Ayurveda, we can consider it as Dandalasaka, 2 which is an extension of alasaka where in the extremely vitiated doshas go in tiryaggati(obliquedirection) as the other passages are blocked by aggravated ama resulting in causing the body to become rigid like a wooden rod. We present a case of AS which was treated with Panchakarma procedures to relieve the symptoms and to reduce severity of the disease.


INTRODUCTION
Ankylosing spondylitis is an inflammatory disorder of unknown cause that primarily affects the axial skeleton; peripheral joints and the extraarticular structures are also frequently involved.The onset is typically between the ages of 20 and 30, with a male preponderance of about 5:1.The overall prevalence is less than 0.5% in most populations.Ankylosing spondylitis typically affects the structures of the spine and the entheses.In the spine, the areas involved include the sacroiliac joints, the vertebral bodies, and the zygapophyseal joints.There is inflammatory granulation tissue at the junction of annulus fibrosus and vertebral bone.The outer annular fibers are eroded and eventually replaced by bone, which eventually forms a bony syndesmophyte, which then grows, ossifies and bridges the adjacent vertebral bodies.Ascending progression of this process leads to the typical "bamboo spine" appearance.The similar type of appearance is seen in condition called Dandalasaka, where in the word Danda refers to a stiff rod.This samprapti occurs due to the Tiryakgati of the doshas as the other strotas are blocked by the dushta ama present in the body presenting with lakshanas like Shula, Anaha, Angamarda, Agnivaishamya, Parshwa-prishta-katigraha, siraakunchana and stambhana.

CASE STUDY
A 39year old male patient hailing from Bengaluru came to our OPD with the complaints of 1. Pain and restricted movement of the neck and lowback region.2. Stiffness of the jaw 3. Reduced strength in right thigh region along with pain and numbness.4. Pain in the flanks The history of present illness goes like patient was apparently asymptomatic 10 years ago later when he was working, he experienced pain in thigh region and difficulty in climbing stairs for which he consulted a nearby clinic and was prescribed with medications for 8 months where he found mild relief in the symptoms.Later he experienced pain in the flanks for which he consulted a rheumatologist where he was suggested to get an MRI done and prescribed with allopathic medicines and suggested to get an injection (details not known).The patient got infected with COVID-19 in the 2 nd wave and got treatment for the same, but there was a flare up of above-mentioned symptoms along with stiffness of jaw resulting in difficulty in opening the mouth and reduced strength in right thigh along with pain and numbness.Due to this, he was unable to perform his day-to-day activities like difficulty in driving, difficulty in climbing the stairs.The pain was insidius in onset which aggravated during night, early morning and cold seasons.Stiffness used to aggravate in rest and gradually improved with activity.

Past History
No H/O of Type-2 DM, HTN, TB Personal history His appetite had reduced since the onset of disease resulting in reduced food intake Typeof diet was mixed and history of eating only junk food(bread, burger, deep friedfoods) and more amount of curd for 1 year even in the night.Pt had a history of constipation from 14 years of age, and since the onset of these symptoms he experienced bleeding per rectum during defecation occasionally on intake of spicy food.Sleep was disturbed in the last 10 years due to stiffness and pain.

Occupational history
Patient works as a project engineer Duration of work is 12-16hrs/day Nature of work -physical stain in the form of travelling for approximately 60-70 kms/day in two-wheeler.

EXAMINATION
▪ Pulse was 80bpm, regular ▪ Blood Pressure -120/80mmhg ▪ Respiratory rate -18cycles/min ▪ Tongue -coated ▪ CNS, CVS, per abdomen examination did not show any significant abnormality.▪ Spine examination revealed kyphosis of cervical spine.▪ Movements of the whole spine was restricted with positive Schober's test.

TREATMENT
The patient was given with Shodhana karma first in the form of Virechana karma followed by Erandamooladi Basti in Karma Basti pattern.Phase -1:Virechana karma Purva karma Sarvangaudwartana with Triphalachurna and Kolakulattadichurna SarvanagaParisheka with Dashamoolakwatha Orally Gandharvahastadierandataila -20ml with milk (in empty stomach) Snehapana with PanchatiktaGhrita till the attainment of Samyak snighdalakshanas, followed by vishrama kala for 3 days where Sarvanga abhyanga with Brihat saindhavaditaila and Bashpasweda was done.Pradhana karma Virechana with Trivrutavalehya -70 grams was given.The total number of vegas observed was 10 with Samyak virechanalakshanas.Paschat karma Samsarjana krama was advised to the patient.Phase 2:Basti Karma Poorva Karma: SarvangaAbhyanaga with Brihat Saindhavaditaila followed by SarvanagaParisheka with DashamoolaKwatha.Pradhana Karma: Erandamooladi Basti given in karma basti pattern by using the following ingredients.

OBSERVATIONS
After the completion of Phase-1, the patient felt 1. Lightness in the body 2. Reduction of pain in the low back region.After phase-2, 1. Restricted movements and pain in the neck region reduced.

Discussion on disease
As Acharya Vagbhata states "RogahaSarvepiMandagnou", improper digestive capacity is the routecause for the manifestation of all the diseases. 3Mandagni further results in the formation of improper digestive material called Ama which gets circulated in the body by various channels.When in excess, it causes various conditions like Alasaka and Visuchika where in stagnation of the excessive ama dosha is called Alasaka and the forceful excretion of doshas from Urdhwa and Adhomarga is called as Visuchika. 4The excessive ama dosha if not eliminated from the body, gets into the vitiated and obstructed channels being unable to move inside them, begin to move in other unnatural channels to occupy the whole body making it stiff like a log of wood which is called by the term Dandalasaka.This is considered as Asadhya (incurable) because of the acuteness and also because of the contradiction involved in the treatment pertaining to Ama and Visha.And the main reason behind this is Viruddhaaharasevana, Adhyashana and Ajirna. 5iscussion on treatment Eventhough the condition is said to be Asadhya, with the help of Utkrushta Upaya mentioned in Sadhyaasadhya explained by Acharya Charaka, treatment was given after the assessment of degree of vitiation of doshas in the patient. 6he diseases caused due to Ama dosha is to be treated with Apatarpana. 7Since this is a Bahu dosha avastha, Doshavasechana has been adopted in the form of Virechana Karma. 8Also the reason behind adopting udwartana before virechana is to remove the sama condition, if ignored would result in the destruction of the body. 9fter assessing the removal of ama dosha, asthapana and anuvasana can be adopted as per the chikistasiddhanta of ama visha. 10ccording-lyBrihat saindhavaditailaanuvasana and erandamooladiasthapana was adopted here.Karma basti pattern was selected in this case as the person was able to withstand the treatment for longer duration, Vata Pradhanata, presence of deeply situated doshas. 11he total quantity of basti is 760ml which approximates to the Madhyama matra of bastidravya according to Sharangadhara Samhitha. 12Erandamooladibasti Madhu along with rukshaguna and ushnaviryahas Yogavahitva and Sukshma margaanusaritva property. 13aindhava lavana due to its Sukshma property reaches the minute channels and due to teekshna property breaks down the morbid malas and clears the channels. 14Brihat saindhavaditaila explained in Chakradatta,is considered Shreshta in all the vatavyadhis and improves Agni. 15Triphalakalkaprovides Tridoshahara, amapachaka action. 16Erandamooladikwatha which is used in more quantity has the property of Deepana and Lekhana required in this condition. 17Gomutrahas ruksha, tekshnoshnaguna with Deepana pachana property. 18

CONCLUSION
The Ayurvedic diagnosis of "Dandalasaka" is given for Ankylosing Spondylitis in the present case based on the clinical features.There was marked improvement in the signs and symptoms in the patient after Panchakarma.So in diseases with Bahudosha Avastha where the main nidana is viruddhaharasevana, Shodhana along with Nidana parivarjana helps in providing promising results.

2 .
Sleep was improved.3. Improvement seen in the appetite of the patient.4. Weakness in the left thighs reduced.5. Stiffness of the jaw reduced.