An Ayurvedic Approach to and Inflammation and Joint Pain
Malynn Utzinger, MA, MD
Assistant Clinical Professor
University of Wisconsin-Madison
Doctor Malynn
Email: malynnu@gmail.com
Background
Ayurveda, a Sanskrit word meaning “the science of life,” emerged in India over five thousand years ago and today is practiced around the world. In all of its forms, Ayurveda is as much a philosophy as an elegant medical system involving treatment with foods, herbs, meditation, yoga, cleansing routines, and specialized massages.
The overarching goal of Ayurveda is to harmonize our human rhythms of appetite, digestion, elimination, sleep, and thinking with the cycles of nature. A passage in the Chakara Samhita, an Ayurvedic text from the third century BC, translates loosely to, “a quack is a doctor who treats symptoms only and does not address the underlying cause of disease.” Ayurveda therefore emphasizes nourishing the body and cultivating a clear mind through meditation and yoga. In fact, the Sanskrit word for health, Swastha, translates to “established in the self,” or grounded in healthy self-awareness (Chopra 2000, Simon.)
Scope of Ayurvedic Applications
Research has shown that Ayurvedic protocols may be valuable in the treatment of chronic diseases, such as diabetes (Babu et al, 2007, Gray 1999, Hlebowicz 2007, Mang 2006) cardiovascular disease (Chitthra, 1997, Koscielny 1999, Shah, 1990), neurological conditions (Chauhan, 2007, Kim 2007), and cancer (Colic, 2002, Simon 2000, Kimura 2001). Costs and unwanted side effects are low with administration of Ayurvedic herbs (Herron 2002, Shankar 1980, Sharma 2006 Sharma 2007), and studies suggest that Ayurvedic cleansing can remove toxins from the body (Herron, 2002, Shankar 1980). Specific anti-rheumatic properties are discussed under herbal preparations below.
- An Ayurvedic Understanding of the Body
The early Ayurvedic scholars observed five Great Elements--Space, Air, Fire, Water, and Earth in nature and in humans. These elements pair up to form three constitutional types, or Doshas, describing body type, personality, and behavioral tendencies. The first Dosha is called Vata (Space and Air). The second is Pitta (Fire and Water), and the third is Kapha (Water and Earth).
The doshic blend we express at birth is known as Prakruti, or “basic nature”. Subsequently the stresses of life and environmental conditions lead to different disruptions in health called Vikruti, or “current imbalance.”
Doshas are more than mere metaphor. New research suggests genomic differences between the doshas. For example, a Kapha-dominant (Water and Earth) person, classically described as vulnerable to diabetes and heart disease, appears to express genes that may be in part responsible for this correlation (Prasher 2008). This study indicates that number of other significant differences may exist between people of different Doshic phenotypes: liver function, hemoglobin levels, regulation of cyclin dependent protein kinase, immune responses, regulation of blood coagulation, and even expression of disease-related hub and housekeeping genes. Future study may strengthen links between Ayurvedic phenotypes and metabolic, immunological, infectious, cardiovascular, and neuro-psychiatric disease and certain cancers (Prasher 2008).
- The Doshas
Vata Dosha (space and air) governs movement in the body and is cold, quick, vast, changeable, rough, dry, subtle and light. People dominant in these qualities are generally thin with fine bones, small muscles and fast metabolism. Their skin tends to be dry and rough and eyes are small and lively. By nature, Vatas are prone to irritable bowel syndrome and constipation and nervous system issues: tight muscles, spasms, tremors, unexplained pains, or other “ticks” that are bothersome and may defy medical diagnosis.
Vata-dominant people are spontaneous, changeable, and tend to think and speak quickly. The Vata mind is expansive, seeing the big picture over operational details. Vata prefers to initiate a new project than finish an old one. Finally, Vata-dominant people tend to be articulate communicators.
Functions of Vata Dosha—(Movement and Nervous System Function) The primary functions of Vata are related to movement, breath, circulation, speech, memory, and elimination—especially those aspects of each controlled by the nervous system.
When a Vata person is in balance, he or she is trim, full of energy and enthusiasm, flexible, expressive, and an initiator of change. Classically, Vata people are said to have a highly lucid or illuminated mind.
In poor balance, Vata qualities are exaggerated. A lively mind turns to racing thoughts, anxiety, and insomnia. Flexibility and spontaneity become ungroundedness and unpredictability in work or relationships. A love of new projects becomes an inability to follow-through. An effervescent nature becomes excessive chatter and difficulty listening. Most importantly, Vata may strenuously resist routine of all kinds. Yet, restoring routine is the primary prescription for balancing Vata.
It is possible that Rheumatologic problems may be generated in Vata through a vulnerability in the gut, such as IBS or leaky gut syndrome. A Vata’s anxious nature and difficulty sleeping can erode wellbeing and worsen symptoms (Chopra, 2000).
Pitta Dosha (fire and water) governs metabolism and is hot, intense, steamy, acidic, aggressive, and action-oriented. Good digestive fire is responsible for chemical and enzymatic transformation throughout the body, but especially in the stomach and small intestine. The Pitta-dominant person tends to have a moderate-sized frame and ability to gain or lose weight easily. They are versatile athletes with loose joints. Their skin appears moist, glowing, and freckled with a reddish or ruddy tone. Hair is red or warm-colored with a tendency for early graying or balding. The person with a predominance of Pitta has a strong appetite and may exhibit a fondness for hot foods, but excessive acid potentially leads to heartburn, reflux, diarrhea and gas.
The Pitta-dominant person uses keen vision to set and achieve goals. His or her warmth, charisma, and joie de vivre attract and inspire others. Pittas’ work ethic and abundant energy make for natural leaders whose uncompromising vision, love of beauty, and demand for perfection in themselves and others result in excellent work, albeit with a sometimes critical nature. Still, Pitta doesn’t dwell on past problems, but rather expresses emotion/anger and moves on. Pitta expects and appreciates this same honesty from others.
When Pitta is out of balance, good qualities can go sour. Keen vision can turn into unhealthy perfectionism and rage over perceived mistakes. Similarly a strong work ethic may lead to burnout. If the Pitta is ill, he or she may feel angry with the body for interrupting work or play. According to Ayurvedic physicians, when the Pitta does not leave time for proper rest and digestion, toxins* build up and create inflammation, which may become chronic. The prescription for Pitta is appreciation of beauty, life, and people. Music, nature, or art can all have a tremendously healing affect on Pitta.
*NB: The accumulation of toxins is referred to in Ayurveda as Ama, which western practitioners know as gallstones, LDL cholesterol, inflammation, and other forms of excess. Ama may aggravate any Dosha and even “spill over” into other Doshas causing widespread imbalance.
In the Pitta person, Rheumatologic dysfunction is hypothesized to be generated through inflammation. Failing to manage stress may be a key contributor, as demonstrated in host of studies over the years (Sharma, 2007, Zellweger 2009).
Kapha Dosha (water and earth) creates structure in the body and is responsible for lubrication of joints and mucosal membranes. It is cool, cohesive, smooth, slow, solid, stable, and enduring. People expressing Kapha tend to have a large, muscular build, with solid bones, stable joints, and broad shoulders and chest. Their vulnerability is in the chest (or sinuses) where they are more prone than others to develop respiratory congestion, asthma, or sinusitis.
Kapha is led by the tastebuds and loves sweet and sumptuous tastes and smells. However, Kapha people do not digest quickly and report feeling full longer than their Vata and Pitta counterparts. Kapha generally needs more strenuous exercise than the other types to keep excess weight off.
In their interactions, Kapha people tend to be reserved, preferring to listen. Their voices are smooth, deep, and sonorous. They are gentle, trustworthy, loyal and even-keeled. Methodical, they generally dislike having to change routines abruptly.
Key physiologic functions of Kapha are protection of the tissues and bodily cavities (chest, pelvis, brain) through strong bones and solid muscle mass. Kapha also lubricates and cushions through saliva and mucous membranes, CSF and synovial fluid.
A balanced Kapha has a strong body and unusually good health compounded by high tolerance for discomfort. (Contrast this with the Vata, who has a “twitchier” nervous system that worries about unusual sensations, and the Pitta, who may have pain but chooses to “work through it”.) Kapha has excellent endurance, sound sleep, smooth digestion and elimination, and relaxed enjoyment of sensual pleasures.
In contrast, the unbalanced Kapha may have developed a sedentary lifestyle, which can lead to exhaustion and sluggishness. When stressed, the Kaphic person seeks sweet foods, leading to weight gain or edema. Classically, Kapha tends to form cysts, tumors, and enclosed pockets of disease, all reflecting Kapha’s inward tendencies. All of these processes worsen rheumatologic conditions or help to usher in co-morbid conditions.
Emotionally, an out-of-balance Kapha person can become rigid, sullen, withdrawn. In relationships, a Kapha’s gentle, loyal ways may turn to jealousy or clinginess. At work, a reliable Kapha may become resistant to any change. When it comes to disease management, the Kapha’s tendancy to withdraw or feel guilty may bring on isolation, which has been shown to worsen outcomes in a number of diseases (Afsar, 2009, Scherrer, 2009, Zellweger 2004).
How to Determine the Dosha or Doshas of Your Patients
According to Ayurvedic wisdom, all of us contain all three Doshas, although most people are thought to have one or two dominant Doshas. Approximately five percent of all people are tridoshic, with a relatively equal balance of all three Doshas (Chopra, 2000). A person is said to be in balance when he or she is expressing his or her particular doshic constitution (Prakruti) in a healthy manner. Excellent self-guided questionnaires are available to determine Prakruti, basic nature, and Vikruti, the imbalances to be corrected. See Resources.
Ayurvedic Diagnosis and Treatment
The Ayurvedic practitioner takes a detailed history, focusing on current symptoms, sleep, appetite, diet, digestion, elimination, allergies, menstrual cycles, relationships, sexuality, and engagement in life. The exam includes a careful Ayurvedic analysis of the pulses, tongue, fingernails, and eyes as well as standard elements of the western exam.
Diseases are seen as being uniquely expressed in people according to their Prakruti and Vikruti. While rheumatoid arthritis has primarily Pitta and Kapha components (inflammation and edema), autoimmune diseases in general can be described by an overly vigilant (Vata) immune system inappropriately attacking (Pitta) or protecting (Kapha) the self from self. Once disease is advanced, it is likely that all Doshas are affected.
When every Dosha is out of balance, Vata-calming therapies can be a wise place to start. Vata is considered the leader of all the Doshas--when Vata is healthy, the rest of the Doshas are pulled toward health. Therapies that calm the mind, relax tense muscles, and create good sympathetic-parasympathetic tone will tend to have beneficial effects throughout the body-mind.
Universal Ayurvedic Guidelines
No matter what the condition, Ayurveda recommends an ideal daily routine to help reset the system. Following even one or two of these steps may provide some physical relief and a sense of pride in achieving a goal.
Ayurveda and the Ideal Daily and Seasonal Routines
Ideally, early morning, from 2-6am, is quiet, fresh, undisturbed, and full of potential, just like the qualities of the healthy Vata mind. Ayurvedic texts recommend early am meditation, before or near sunrise, when the mind has stirred out of deep sleep into dreaming (REM) and liminal states.
Kapha time (6 am to 10 am) is a heavier period in which the body, if not already wide awake, might not be so ready to rise and shine. Indeed, oversleeping sometimes makes it harder, not easier to arise. For those people who experience mid-morning sluggishness, morning exercise or a stretch break may help.
From 10 am to 2 pm is Pitta time, the hottest time of day when the body’s digestive fires are said to be strongest. In Ayurveda, it is suggested to eat the biggest meal between 10 am and 2 pm and then to allow for a brief period of stillness followed by a gentle walk to aid digestion.
From 2 pm to 6 pm is again Vata time. Although ideally a time of mental clarity, many experience fatigue, possibly driven by poor nutrition, post-caffeine crash, or an overfull schedule. To remedy this, Ayurveda suggests a brief period of meditation in the late afternoon, just before dinner.
From 6pm to 10 pm is Kapha time, when daily rhythms slow down. A light dinner is recommended and, whenever possible, it is suggested to make one’s last media intake or conversations light, humorous, or inspiring. Journaling before bed can help cultivate deep sleep.
From 10 pm to 2 am is Pitta time, when, according to Ayurveda, the body wants to be in deep sleep in order to complete its digestive functions, separating out and removing wastes.
It is important to note that life simply does not allow perfect adherence to these “rules” all of the time. However, even small shifts may be worthwhile. It is up to our patients to do the experiments and decide which changes are helpful.
There are also seasonal recommendations for each Dosha, but a detailed listing is beyond the scope of this chapter. A simple summary is to pay attention to temperature and seek appropriate clothing and food for the day. On cold, dry, windy days, seek warm clothing, humidified air, and warm soups or teas. On cool, soggy days sitting in a warm, dry sauna, taking a dessert vacation, or eating warm, astringent foods may help alleviate symptoms. As simple as these remedies are, they are profound in their ability to increase quality of life through regular attention to the body’s signals.
Exercise and Ayurveda
Exercise guidelines must be flexibly applied due individual patients’ conditioning or injuries.
In general, Vata people have quick bursts of energy and are prone to tiring quickly. Thus, gentle exercise, such as Hatha yoga, light walking, or T’ai Chi may be best, especially in conditions such as fibromyalgia, in which strenuous exercise can be depleting and painful. As a practitioner I have found, however, it is best not to try to talk a runner, for example, out of running if he or she feels enriched by it. Far better to be doing something regularly and joyfully than to stop completely or over-analyze. At most, encourage the substitution of a day a week of yoga and let your patient evaluate the difference.
The Pitta person is often a versatile competitive athlete who need no more than a reminder to modify intensity. Pittas who do not exercise may respond to a direct statement that lack of exercise will quite possibly harm their capacity to perform in other ways. If overuse injuries occur, moderately intense yoga or cross-training may help.
Kapha, with its potential build up of weight, fluid, and “ama”, needs to sweat, burn calories, and release toxins through vigorous exercise, unless badly deconditioned. Once cleared, the most important thing for Kapha is to be invigorated and in touch, once again, with inner vitality.
Healing Foods and Aromas:
In Ayurveda, there are no “low carb” or “high protein” diets. Rather there are six “tastes,” that should be included at every meal.
Sweet—most carbohydrates, breads, grains, oils and fats, unprepared meats, and sugar/sweeteners. Most of our calories are derived from “sweet” foods, as they are energy rich and necessary for life. Seek complex carbohydrates when possible, and minimize simple, refined sugars. High quality oils are best, such as first cold pressed extra virgin olive oil or flaxseed oil with lignans. These should always be taken over hydrogenated oils and trans fats.
Salty—salt and salty fish, soy sauce, seaweed.
Sour—lemons, citrus fruits, cheese, chutney, yogurt, relish, pickles.
Pungent—hot foods and spices, such as cayenne peppers. Most herbs and spices have some element of pungent: e.g. cinnamon, cloves, oregano, thyme, parsley.
Bitter—dark, leafy greens such as chard, kale, arugula
Astringent—tannic tastes that make your mouth feel dry, such as granny smith apples, teas or pomegranates, or foods that soak up water when cooking, such as lentils and other beans.
When weight loss is desired, it is best to emphasize the pungent, bitter, and astringent foods, which are higher in nutrients and lower in calories. Still, all diets must include “sweet” as a source of energy.
The goal is for meals to contain all six of these in the proper proportion. Some foods have multiple tastes, such as oranges, which are sweet and sour, or dark chocolate, which is sweet, bitter, and astringent. For detailed instructions on doshic balance, it is helpful to consult a trained Ayurvedic practitioner. Basic guidelines follow:
Vata people are best balanced by sweet, salty, and sour tastes, which are heavier, warming, lubricating, and grounding. In situations of extreme Vata imbalance, vegetables are better eaten sautéed/cooked as raw vegetables are poorly digested.
Pitta people are balanced by sweet, bitter, and astringent and aggravated by salty, sour, and pungent foods eaten in excess.
Kapha people are balanced by pungent, bitter, and astringent foods and should lower proportions of sweet, salty, and sour or gravitate to their lighter forms.
Lists of foods and their primary and secondary (and even tertiary qualities) in Ayurveda are vast. The goal of this chapter is not to provide a complete list but rather an initial sense of direction. As always, high quality, fresh foods, as free as possible from pesticides and other synthetic chemicals are desired. Raw foods in general are minimized in Ayurveda, especially for Vata, but when cooking vegetables, a light steaming or sautéing is fine. You want to leave life in the food. Raw fruits are fine, especially in season and in keeping with your body’s preferences, e.g. a Pitta person might pass by the sour grapefruit in favor of the sweeter mango or peach. With your intuition, common sense, and these short guidelines, you can make good food choices without turning shopping and eating into a stressful event, which would be counterproductive.
Panchakarma and Herbal Remedies
Thusfar, recommendations in this chapter have been designed to be used readily by the reader/practitioner without special training. Panchakarma, on the other hand, is a specialized system of cleansing that requires specific Ayurvedic training. Inpatient and outpatient programs exist, lasting from days to months. The purpose is a profound, yet gentle cleansing of metabolic wastes and habits that are not nourishing. Controlled studies are rare, but simple pre/post design studies suggest improvements in multiple chronic conditions (Herron 2002). Key steps are as follows:
Oleation (snehana)—ingestion of sesame seeds and clarified butter (ghee) to quiet the digestive fires, soften wastes, and prepare for deeper cleansing.
Laxative (virechana) to clear the lower digestive track. (May be eliminated for some patients.)
Oil Massage (abhyanga) with Dosha-specific oils in patterns that direct wastes to the body’s organs of elimination. An oil massage in which warm oil is dripped on the forehead (Shirodhara) may be added to balance Vata.
Sweat treatments (swedana) is used to promote release of toxins through the skin.
Enemas (basti) with medical herbs are administered to those without health contraindications to help clear the intestines and nourish mucosa.
Neti Pot/Medicated Nasal Lavage is used to clear sinus passages of excess Kaphic mucus. This is followed by an oil infused with aromatic herbs to protect and open the nasal passageways.
Vamana (emesis) is used to clear excess phlegm and toxins from the upper GI system. It is prescribed rarely in the west in this time of disturbingly high incidence of eating disorders.
Although the practices stretch our modern understanding, patients often express renewed energy by the end of the procedure, not to mention significantly less pain and physical limitation. One study suggests panchakarma results in overall reduction in toxicity load, specifically 46% less dichlorodiphenyldichloroethylene (DDE) and 58% less polychlorinated biphenyls (PCBs), both of which appear to contribute to hormone disruption, immune dysregulation, reproductive disorders, several types of cancer and other diseases (Herron, 2002).
Ayurvedic Herbal Remedies
The last section of this chapter covers Ayurvedic herbs. While there are literally hundreds of herbs used in Ayurveda, made even harder to study given their often combined nature, a few single herbs stand out as being commonly used and more frequently studied in a modern, western lab or clinic:
Key Ingredients in Ayurvedic Remedies for Inflammation and Rheumatic Conditions
Turmeric (Curcumin longa) appears to modulate inflammation via downregulation of NF-κB and subsequent suppression of the expression of COX-2, 5-LOX, TNF-α, IL-1β, IL-6, IL-8, MMPs (matrix metalloproteinase’s) and,AM (adhesion molecules) (Khanna 2007). In a small study, it compared favorably to ibuprofen and phenylbutazone for morning stiffness, joint swelling, and walking distance, but was not rated higher in terms of overall effectiveness (Deodhar, 1980). Animal studies show curcumin administered before injury can reduce inflammation (Funk 2006). Finally a cross-over RTC showed curcumin combined with ashwagandha, boswellia, and zinc to effect significant reduction in pain and disability (Kulkharni, 1991). The lack of negative side effects, especially gastric distress, make it attractive as a therapeutic choice. (Khanna, 2007, Shankar 1980).
Ginger (Zingebar officinalis) contains 6-shogaol, which appears to be one of the multiple chemicals responsible for its anti-inflammatory effect (Levy, 2006). Ginger has also demonstrated reduction in pain and improvement in mobility in humans, likely through the inhibition of the formation of cytokines. In a small study of patients with RA, cooked, fresh, and powdered forms led to pain relief, better joint mobility, and decreased swelling and morning stiffness (Srivastava, 1989). In a follow up observational study, seventy five percent of patients with OA/RA had improvement in pain or swelling while taking ginger, up to 4000 mg (Srivastava, 1992). A recent review found moderate evidence for the anti-inflammatory properties of ginger in OA and low back pain (Chrubasik, 2007). For practical uses, one gram powdered root is equivalent to approximately 10 grams or 1/3 oz fresh ginger root (¼ inch slice). Ayurvedic remedies use ginger in teas, soups, sauces, and topical poltices.
Guggul (Commiphora mukul) use correlates with significant reduction of pain, stiffness, and improved function without side effects in subjective and objective measures for older people with osteoarthritis (Singh, 2003). Guggul is used alone and in Ayurvedic formulations for pain and cleansing, but does not have common culinary uses. The main side effect is reduced platelet stickiness.
Ashwagandha (Withania somnifera) is known in classical Ayurveda as a powerful rejuvenative to slow aging and treat a broad range of conditions from cancer to depression (Kulkarni 2008). Recently, studies have shown its withanolides in combination with other herbs are effective against inflammation in OA, low back pain, limitations in walking, and high body mass index (Singh 2001, Singh 2003, Srivastava 1989, Srivastava 1992), and in vitro studies show a novel chondroprotective effect that may explain its anti-rheumatic properties (Sumantran, 2007). One case study reported reversible thyrotoxicosis in a pregnant woman (Van der Hooft, 2005). Overall, its safety profile is excellent. Typical doses are 500-1000 mg daily to bid. For insomnia, prescribe it 30 minutes before bed.
A host of other Ayurvedic herbs, including cloves, cinnamon, cumin, coriander, cayenne, thyme, oregano, licorice, black pepper, shatavari, amla, harataki, bibhitaki, guduchi have all been studied and found to have at least initial, encouraging evidence that they may help to treat or sooth inflammation and diseases such as obesity, high cholesterol, heart disease, insomnia, anxiety, depression, and infections, that complicate rheumatic conditions (Sharma, 2007).
Recent data on the purity of Ayurvedic herbs were published in a JAMA article in August 2008. Twenty percent of the samples from the US and India contained arsenic, lead, or mercury at levels exceeding at least one standard for human safety (Saper et al, 2008). In response, coalitions from the USA, UK, and Germany reanalyzed the data (www.ayurveda-nama.org), and concluded a five percent contamination level if supplements which were meant to contain these metals were excluded. Still, they recommended no more prescribing overtly heavy-metal-containing formulations until science can better elucidate the health effects. Organic and vertically integrated growers/sellers may offer better standards.
Based on thousands of years of observation and 50 years of modern research, a picture of Ayurveda is emerging as an important approach to worldwide health, including the prevention and treatment of chronic disease. Ayurveda’s principles may engage patients in reframing their illness and western practitioners can look to their Ayurvedically trained colleagues to oversee particular nutritional and herbal preparations and panchakarma.
Several excellent resources can be found at the following sites:
www.chopra.com Books, products, Ayurvedic consults, conferences and residential retreats in California and around the world
www.kripalu.com. Products, workshops, training in Ayurveda, Ayurvedic consults, and residential retreats in Massachussetts
www.banyanbotanicals.com. Products, certified organic
www.ayurveda-nama.org. Research, conferences, networking with professionals
www.ayurveda.com. Training in Ayurveda, consults, in-patient programs
www.vediccity.net. Comprehensive services and training programs. Residential options.
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