Rheumatoid Arthritis - Aravindh Herbal



Rheumatoid ArthritisArthritisArthritisHistoryWhile evidence of primary ankle (kaki) osteoarthritis has been discovered in dinosaurs, the first known traces of human arthritis date back as far as 4500 BC. In early reports, arthritis was frequently referred to as the most common ailment of prehistoric peoples. It was noted in skeletal remains of Native Americans found in Tennessee and parts of what is now Olathe, Kansas. Evidence of arthritis has been found throughout history, from ?tzi, a mummy (circa 3000 BC) found along the border of modern Italy and Austria, to the Egyptian mummies circa 2590 BCIn 1715 William Musgrave published the second edition of his most important medical work De arthritide symptomatica which concerned arthritis and its effects. DefinitionArthritis (from Greek arthro-, joint + -itis, inflammation; plural: arthritides) is a form of joint disorder that involves inflammation of one or more joints. There are over 100 different forms of arthritis. The most common forms are: osteoarthritis, rheumatoid arthritis, psoriatic arthritis, Septic arthritis The major complaint by individuals who have arthritis is joint pain. Pain is often a constant and may be localized to the joint affected. The pain from arthritis is due to : inflammation that occurs around the joint, damage to the joint from disease, daily wear and tear of joint, muscle strains caused by forceful movements against stiff, painful joints and fatigue.ClassificationThere are several diseases where joint pain is primary, and is considered the main feature. Generally when a person has "arthritis" it means that they have one of these diseases, which include:Ankylosing spondylitisGout and pseudo-goutJuvenile idiopathic arthritisOsteoarthritisRheumatoid arthritisSeptic arthritisStill's diseaseJoint pain can also be a symptom of other diseases. In this case, the arthritis is considered to be secondary to the main disease; these include:Ehlers-Danlos SyndromeFamilial Mediterranean feverHaemochromatosisHenoch-Sch?nlein purpuraHepatitisHyperimmunoglobulinemia D with recurrent feverInflammatory bowel disease (Including Crohn's Disease and Ulcerative Colitis)Lyme diseasePsoriasis (Psoriatic arthritis)Reactive arthritisSarcoidosisTNF receptor associated periodic syndromeWegener's granulomatosis (and many other vasculitis syndromes)An undifferentiated arthritis is an arthritis that does not fit into well-known clinical disease categories, possibly being an early stage of a definite rheumatic disease. Signs and symptomsRegardless of the type of arthritis, the common symptoms for all arthritis disorders include varied levels of pain, swelling, joint stiffness, and sometimes a constant ache around the joint(s). Arthritic disorders like lupus and rheumatoid can also affect other organs in the body with a variety of symptoms. Inability to use the hand or walkMalaise and a feeling of tirednessFeverWeight lossPoor sleepMuscle aches and painsTendernessDifficulty moving the jointIt is common in advanced arthritis for significant secondary changes to occur. For example, in someone who has limited their physical activity:Muscle weaknessLoss of flexibilityDecreased aerobic fitnessThese changes can also impact on life and social roles, such as community involvement.Extra-articular features of joint diseaseCutaneous nodulesCutaneous vasculitis lesionsLymphadenopathyOedemaOcular inflammationUrethritisTenosynovitis (tendon sheath effusions)Bursitis (swollen bursa)DiarrheaOrogenital ulcerationDisabilityArthritis is the most common cause of disability in the USA. More than 20 million individuals with arthritis have severe limitations in function on a daily basis.Absenteeism and frequent visits to the physician are common in individuals who have arthritis. Arthritis makes it very difficult for individuals to be physically active and many become home bound. It is estimated that the total cost of arthritis cases is close to $100 billion of which nearly 50% is from lost earnings. Each year, arthritis results in nearly 1 million hospitalizations and close to 45 million outpatient visits to health care centers. Arthritis can make it very difficult for an individual to remain physically active, contributing to an increased risk of obesity, high cholesterol or vulnerability to heart disease. Individuals with arthritis are also at increased risk of depression, which may be related to fear of worsening symptoms.DiagnosisDiagnosis is made by clinical examination from an appropriate health professional, and may be supported by other tests such as radiology and blood tests, depending on the type of suspected arthritis.All arthritis potentially feature pain. Pain patterns may differ depending on the arthritis and the location. Rheumatoid arthritis is generally worse in the morning and associated with stiffness; in the early stages, patients often have no symptoms after a morning shower. Osteoarthritis, on the other hand, tends to be worse after exercise. In the aged and children, pain might not be the main presenting feature; the aged patient simply moves less, the infantile patient refuses to use the affected limb.Elements of the history of the disorder guide diagnosis: Important features are speed and time of onset, pattern of joint involvement, symmetry of symptoms, early morning stiffness, tenderness, gelling or locking with inactivity, aggravating and relieving factors, other systemic symptoms. Physical examination may confirm the diagnosis, or may indicate systemic disease. Radiographs are often used to follow progression or help assess severity.Blood tests and X-rays of the affected joints often are performed to make the diagnosis. Screening blood tests are indicated if certain arthritis are suspected. These might include: rheumatoid factor, antinuclear factor (ANF), extractable nuclear antigen, specific antibodies.EpidemiologyArthritis is predominantly a disease of the elderly, but children can also be affected by the disease. More than 70% of individuals in India affected by arthritis are over the age of 65. Arthritis is more common in women than men at all ages and affects all races, ethnic groups and cultures. In survey based on data from 2007–2009 showed 22.2% (49.9 million) of adults aged ≥18 years had self-reported doctor-diagnosed arthritis, and 9.4% (21.1 million or 42.4% of those with arthritis) had arthritis-attributable activity limitation (AAAL). With an aging population this number is expected to increase. OsteoarthritisOsteoarthritis is the most common form of arthritis. It can affect both the larger and the smaller joints of the body, including the hands, feet, back, hip, and knee. Cause:The disease is essentially one acquired from daily wear and tear of the joint; however, osteoarthritis can also occur as a result of injury. Symptoms:Osteoarthritis begins in the cartilage and eventually causes the two opposing bones to erode into each other. Initially, the condition starts with minor pain while walking, but soon the pain can be continuous and even occur at night. The pain can be debilitating and prevent one from doing some activities. Osteoarthritis typically affects the weight-bearing joints, such as the back, spine, and pelvis. Unlike rheumatoid arthritis, osteoarthritis is most commonly a disease of the elderly. More than 30 percent of females have some degree of osteoarthritis by age 65. Risk factors for osteoarthritis: joint trauma, obesity, sedentary lifestyle.Management Osteoarthritis, like rheumatoid arthritis, cannot be cured, but one can prevent the condition from worsening. Physical therapy to strengthen muscles and joints is very helpful. Pain medications are widely required by individuals with osteoarthritis. For some patients, weight loss can reduce the stress on the joints. When the disease is far advanced and the pain is continuous, surgery may be an option. Unlike rheumatoid arthritis, joint replacement does help many individuals with osteoarthritis. Rheumatoid arthritisRheumatoid arthritis is a disorder in which the body's own immune system starts to attack body tissues. The attack is not only directed at the joint but to many other parts of the body. In rheumatoid arthritis, most damage occurs to the joint lining and cartilage which eventually results in erosion of two opposing bones. Rheumatoid arthritis often affects joints in the fingers, wrists, knees and elbows. The disease is symmetrical (appears on both sides of the body) and can lead to severe deformity in a few years if not treated. Rheumatoid arthritis occurs mostly in people aged 20 and above. In children, the disorder can present with a skin rash, fever, pain, disability, and limitations in daily activities. Often, it is not clear why the rheumatoid arthritis occurred. With earlier diagnosis and aggressive treatment, many individuals can lead a decent quality of life. The drugs to treat rheumatoid arthritis range from corticosteroids to monoclonal antibodies given intravenously. LupusThis is a common collagen vascular disorder that can be present with severe arthritis. Other features of lupus include a skin rash, extreme photosensitivity, hair loss, kidney problems, lung fibrosis and constant joint pain. GoutGout is caused by deposition of uric acid crystals in the joint, causing inflammation. There is also an uncommon form of gouty arthritis caused by the formation of rhomboid crystals of calcium pyrophosphate known as pseudogout. In the early stages, the gouty arthritis usually occurs in one joint, but with time, it can occur in many joints and be quite crippling. The joints in gout can often become swollen and lose function. Gouty arthritis can become particularly painful and potentially debilitating when gout cannot successfully be treated. When uric acid levels and gout symptoms cannot be controlled with standard gout medicines that decrease the production of uric acid (e.g., allopurinol, febuxostat) or increase uric acid elimination from the body through the kidneys (e.g., probenecid), this can be referred to as refractory chronic gout or RCG. Comparison of some major forms of arthritisOsteoarthritisRheumatoid arthritisGouty arthritisSpeed of onsetMonthsWeeks-monthsHours for an attackMain locationsWeight-bearing joints (such as knees, hips, vertebral column) and handsHands (proximal interphalangeal and metacarpophalangeal joint) wrists, ankles and kneesGreat toe, ankles, knees and elbowsInflammationMay occur, though often mild compared to inflammation in rheumatoid arthritisYesYesRadiologic changesNarrowed joint spaceOsteophytesLocal osteosclerosisSubchondral cystsNarrowed joint spaceBone erosions"Punched out" bone erosionsLaboratory findingsNoneAnemia and elevated ESR, rheumatoid factor and C-Reactive Protein (CRP)Crystal in jointsOther featuresNo systemic signsBouchard's and Heberden's nodesExtra-articular features are commonUlnar deviation, swan neck- and Boutonniere deformity of the handTophiNephrolithiasisOtherInfectious arthritis is another severe form of arthritis. It presents with sudden onset of chills, fever and joint pain. The condition is caused by bacteria elsewhere in the body. Infectious arthritis must be rapidly diagnosed and treated promptly to prevent irreversible and permanent joint damage. Psoriasis can develop into psoriatic arthritis. With psoriatic arthritis, most individuals develop the skin problem first and then the arthritis. The typical features are of continuous joint pains, stiffness and swelling. The disease does reoccur with periods of remission but there is no cure for the disorder. A small percentage develop a severe painful and destructive form of arthritis which destroys the small joints in the hands and can lead to permanent disability and loss of hand function. TreatmentThere is no cure for either rheumatoid or osteoarthritis. Treatment options vary depending on the type of arthritis and include physical therapy, lifestyle changes (including exercise and weight control), orthopedic bracing, medications. Joint replacement surgery may be required in eroding forms of arthritis. Medications can help reduce inflammation in the joint which decreases pain. Moreover, by decreasing inflammation, the joint damage may be slowed. Physical and Occupational TherapyIn general, studies have shown that physical exercise of the affected joint can have noticeable improvement in terms of long-term pain relief. Furthermore, exercise of the arthritic joint is encouraged to maintain the health of the particular joint and the overall body of the person. Individuals with arthritis can benefit from both physical and occupational therapy. In arthritis the joints become stiff and the range of movement can be limited. Physical therapy has been shown to significantly improve function, decrease pain, and delay need for surgical intervention in advanced cases. Exercise prescribed by a physical therapist has been shown to be more effective than medications in treating osteoarthritis of the knee. Exercise often focuses on improving muscle strength, endurance and flexibility. In some cases, exercises may be designed to train balance. Occupational therapy can provide assistance with activities as well as equipment.MedicationsThere are several types of medications that are used for the treatment of arthritis. Treatment typically begins with medications that have the fewest side effects with further medications being added if insufficiently effective. Rheumatoid arthritisThe name is based on the term "rheumatic fever", an illness which includes joint pain and is derived from the Greek word ("flow, current"). The suffix -oid ("resembling") gives the translation as joint inflammation that resembles rheumatic fever. The first recognized description of rheumatoid arthritis was made in 1800 by (1772–1840) of Paris. HistoryThe first known traces of arthritis date back at least as far as 4500 BC. A text dated 123 AD first describes symptoms very similar to rheumatoid arthritis. It was noted in skeletal remains of Native Americans found in Tennessee. In the Old World the disease is vanishingly rare before the 1600s. and on this basis investigators believe it spread across the Atlantic during the Age of Exploration. In 1859 the disease acquired its current name.An anomaly has been noticed from investigation of Precolumbian bones. The bones from the Tennessee site show no signs of tuberculosis even though it was prevalent at the time throughout the Americas. Jim Mobley, at Pfizer, has discovered a historical pattern of epidemics of tuberculosis followed by a surge in the number of rheumatoid arthritis cases a few generations later. Mobley attributes the spikes in arthritis to selective pressure caused by tuberculosis. A hypervigilant immune system is protective against tuberculosis at the cost of an increased risk of autoimmune disease.The art of Peter Paul Rubens may possibly depict the effects of rheumatoid arthritis. In his later paintings, his rendered hands show, in the opinion of some physicians, increasing deformity consistent with the symptoms of the disease. Rheumatoid arthritis appears to some to have been depicted in 16th century paintings. However, it is generally recognised in art historical circles that the painting of hands in the sixteenth and seventeenth century followed certain stylised conventions, most clearly seen in the Mannerist movement. It was conventional, for instance to show the upheld right hand of Christ in what now appears a deformed posture. These conventions are easily misinterpreted as portrayals of disease. They are much too widespread for this to be plausible.The first recognized description of rheumatoid arthritis was in 1800 by the French physician Dr Augustin Jacob Landré-Beauvais (1772–1840) who was based in the famed Salpêtrière Hospital in Paris. The name "rheumatoid arthritis" itself was coined in 1859 by British rheumatologist Dr Alfred Baring Garrod. DefinitionRheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks flexible (synovial) joints. The process involves an inflammatory response of the capsule around the joints (synovium) secondary to swelling (hyperplasia) of synovial cells, excess synovial fluid, and the development of fibrous tissue (pannus) in the synovium.PathologyThe pathology of the disease process often leads to the destruction of articular cartilage and ankylosis (fusion) of the joints. Rheumatoid arthritis can also produce : diffuse inflammation in the lungs, membrane around the heart (pericardium), the membranes of the lung (pleura), white of the eye (sclera), nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pre vital role in both its chronicity and progression, and RA is considered a systemic autoimmune disease.About 1% of the world's population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. In addition, individuals with the HLA-DR1 or HLA-DR4 serotypes have an increased risk for developing the disorder. It can be a disabling and painful condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is a clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) and labs, although the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) publish classification criteria for the purpose of research. Diagnosis and long-term management are typically performed by a rheumatologist, an expert in joint, muscle and bone diseases. Various treatments are available. Non-pharmacological treatment includes physical therapy, orthoses, occupational therapy and nutritional therapy but these do not stop the progression of joint destruction. Clinical trials have shown that consumption of fish oil reduces the number of swollen joints for people with rheumatoid arthritis provides a beneficial anti-inflammatory effect, and provides a protective effect for occlusive cardiovascular disease, for which people with RA are at risk. Pathophysiology and causesRheumatoid arthritis is a form of autoimmunity, the causes of which are still incompletely known. It is a systemic (whole body) disorder principally affecting synovial tissues.The key pieces of evidence relating to pathogenesis are:A genetic link with HLA-DR4 and related allotypes of MHC Class II and the T cell-associated protein PTPN22.An undeniable link to the pathogenesis of vascular disease of many types, including the possibility of a strong causal connection to rheumatoid vasculitis, a typical feature of this condition. A remarkable deceleration of disease progression in many cases by blockade of the cytokine TNF (alpha).A similar dramatic response in many cases to depletion of B lymphocytes, but no comparable response to depletion of T lymphocytes.A more or less random pattern of whether and when predisposed individuals are affected.The presence of autoantibodies to IgGFc, known as rheumatoid factors (RF), and antibodies to citrullinated peptides (ACPA).These data suggest that the disease involves abnormal B cell–T cell interaction, with presentation of antigens by B cells to T cells via HLA-DR eliciting T cell help and consequent production of RF and ACPA. Inflammation is then driven either by B cell or T cell products stimulating release of TNF and other cytokines. The process may be facilitated by an effect of smoking on citrullination but the stochastic (random) epidemiology suggests that the rate limiting step in genesis of disease in predisposed individuals may be an inherent stochastic process within the immune response such as immunoglobulin or T cell receptor gene recombination and mutation. If TNF release is stimulated by B cell products in the form of RF or ACPA -containing immune complexes, through activation of immunoglobulin Fc receptors, then RA can be seen as a form of Type III hypersensitivity. If TNF release is stimulated by T cell products such as interleukin-17 it might be considered closer to type IV hypersensitivity although this terminology may be getting somewhat dated and unhelpful. The debate on the relative roles of immune complexes and T cell products in inflammation in RA has continued for 30 years. There is little doubt that both B and T cells are essential to the disease. However, there is good evidence for neither cell being necessary at the site of inflammation. This tends to favour immune complexes (based on antibody synthesised elsewhere) as the initiators, even if not the sole perpetuators of inflammation. Moreover, work by Thurlings and others in Paul-Peter Tak's group and also by Arthur Kavanagh's group suggest that if any immune cells are relevant locally they are the plasma cells, which derive from B cells and produce in bulk the antibodies selected at the B cell stage.Although TNF appears to be the dominant, other cytokines (chemical mediators) are likely to be involved in inflammation in RA. Blockade of TNF does not benefit all patients or all tissues (lung disease and nodules may get worse). Blockade of IL-1, IL-15 and IL-6 also have beneficial effects and IL-17 may be important. Constitutional symptoms such as fever, malaise, loss of appetite and weight loss are also caused by cytokines released in to the blood stream.As with most autoimmune diseases, it is important to distinguish between the cause that trigger the process, and those that may permit it to persist and progress.Possible infectious triggersIt has long been suspected that certain infections could be triggers for this disease. The "mistaken identity" theory suggests that an infection triggers an immune response, leaving behind antibodies that should be specific to that organism. The antibodies are not sufficiently specific, though, and set off an immune attack against part of the host. Because the normal host molecule "looks like" a molecule on the offending organism that triggered the initial immune reaction—this phenomenon is called molecular mimicry. Some infectious organisms suspected of triggering rheumatoid arthritis include Mycoplasma, Erysipelothrix, parvovirus B19 and rubellaEpidemiological studies have confirmed a potential association between RA and two herpesvirus infections: Epstein-Barr virus (EBV) Human Herpes Virus 6 (HHV-6). Individuals with RA are more likely to exhibit an abnormal immune response to the Epstein-Barr virus. The allele HLA-DRB1*0404 is associated with low frequencies of T cells specific for the EBV glycoprotein 110 and predisposes one to develop RA. Psychological factorsThere is no evidence that physical and emotional effects or stress could be a trigger for the disease. The many negative findings suggest that either the trigger varies, or that it might in fact be a chance event inherent with the immune response, as suggested by Edwards et al. Continued abnormal immune responseThe factors that allow an abnormal immune response, once initiated, to become permanent and chronic, are becoming more clearly understood. The genetic association with HLA-DR4, as well as the newly discovered associations with the gene and with two additional genes, all implicate altered thresholds in regulation of the adaptive immune response. It has also become clear from recent studies that these genetic factors may interact with the most clearly defined environmental risk factor for rheumatoid arthritis, namely cigarette smoking Other environmental factors also appear to modulate the risk of acquiring RA, and hormonal factors in the individual may explain some features of the disease, such as the higher occurrence in women, the not-infrequent onset after child-birth, and the (slight) modulation of disease risk by hormonal medications. Exactly how altered regulatory thresholds allow the triggering of a specific autoimmune response remains uncertain. However, one possibility is that negative feedback mechanisms that normally maintain tolerance of self are overtaken by aberrant positive feedback mechanisms for certain antigens such as IgG Fc (bound by RF) and citrullinated fibrinogen (bound by ACPA) Once the abnormal immune response has become established (which may take several years before any symptoms occur), plasma cells derived from B lymphocytes produce rheumatoid factors and ACPA of the IgG and IgM classes in large quantities. These are not deposited in the way that they are in systemic lupus. Rather, they appear to activate macrophages through Fc receptor and perhaps complement binding. This can contribute to inflammation of the synovium, in terms of edema, vasodilation and infiltration by activated T-cells (mainly CD4 in nodular aggregates and CD8 in diffuse infiltrates). Synovial macrophages and dendritic cells further function as antigen presenting cells by expressing MHC class II molecules, leading to an established local immune reaction in the tissue. The disease progresses in concert with formation of granulation tissue at the edges of the synovial lining (pannus) with extensive angiogenesis and production of enzymes that cause tissue damage. Modern pharmacological treatments of RA target these mediators. Once the inflammatory reaction is established, the synovium thickens, the cartilage and the underlying bone begins to disintegrate and evidence of joint destruction accrues.Role of vitamin DThe discovery of the vitamin D receptor (VDR) in the cells of the immune system and the fact that activated dendritic cells produce the vitamin D hormone suggested that vitamin D could have immunoregulatory properties. VDR, a member of the nuclear hormone receptor superfamily, was identified in mononuclear cells, dendritic cells, antigen-presenting cells, and activated T-B lymphocytes. In synthesis, the most evident effects of the D-hormone on the immune system seem to be in the downregulation of the Th1-driven autoimmunity. Low serum levels of vitamin D3 might be partially related, among other factors, to prolonged daily darkness (reduced activation of the pre vitamin D by the ultra violet B sunlight), different genetic background (i.e. vitamin D receptor polymorphism) and nutritional factors, and explain the latitude-related prevalence of autoimmune diseases such as rheumatoid arthritis (RA), by considering the potential immunosuppressive roles of vitamin D. 25(OH)D3 plasma levels have been found inversely correlated at least with the RA disease activity showing a circannual rhythm (more severe in winter). Recently, greater intake of vitamin D was associated with a lower risk of RA, as well as a significant clinical improvement was strongly correlated with the immunomodulating potential in vitamin D-treated RA patients. In patients with rheumatoid arthritis measuring vitamin D levels seems particularly pertinent as deficiency is highly prevalent in the group. Vitamin D is already known to be important in preventing osteoporosis and fracture falls, which are also common in RA. It is too early to tell whether administering vitamin D directly affects disease activity. Signs and symptomsRA is a chronic (long-term) disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most often. Inflammation sometimes can affect organs as well, for instance, the eyes or lungs.While rheumatoid arthritis primarily affects joints, problems involving other organs of the body are known to occur. Extra-articular ("outside the joints") manifestations other than anemia (which is very common) are clinically evident in about 15–25% of individuals with rheumatoid arthritis. It can be difficult to determine whether disease manifestations are directly caused by the rheumatoid process itself, or from side effects of the medications commonly used to treat it – for example, lung fibrosis from methotrexate or osteoporosis from corticosteroids.JointsA diagram showing how rheumatoid arthritis affects a jointThe arthritis of joints known as synovitis is inflammation of the synovial membrane that lines joints and tendon sheaths. Joints become swollen, tender and warm, and stiffness limits their movement. With time RA nearly always affects multiple joints (it is a polyarthritis), most commonly small joints of the hands, feet and cervical spine, but larger joints like the shoulder and knee can also be involved. Synovitis can lead to tethering of tissue with loss of movement and erosion of the joint surface causing deformity and loss of function. Rheumatoid arthritis typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Gentle movements may relieve symptoms in early stages of the disease. These signs help distinguish rheumatoid from non-inflammatory problems of the joints, often referred to as osteoarthritis or "wear-and-tear" arthritis. In arthritis of non-inflammatory causes, signs of inflammation and early morning stiffness are less prominent with stiffness typically less than 1 hour, and movements induce pain caused by mechanical arthritis. In RA, the joints are often affected in a fairly symmetrical fashion, although this is not specific, and the initial presentation may be asymmetrical.Other signs and symptoms that can occur in RA include:Loss of energyLow feversLoss of appetiteDry eyes and mouth from a related health problem, Sjogren's syndromeFirm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and handsDeformitisAs the pathology progresses the inflammatory activity leads to tendon tethering and erosion and destruction of the joint surface, which impairs range of movement and leads to deformity. The fingers may suffer from almost any deformity depending on which joints are most involved. Medical students are taught to learn names for specific deformities, such as: Swan neck deformity : Flexion of distal interphalangeal joint and hyperextension of proximal interphalangeal joint.Button hole deformity : Flexion of PIP and hyperextension of DIPulnar deviation of fingers.Z Deformity of thumbSubcutanious nodules in Extenor aspects of limbs.Attrition of Extensor tendon at wrist causing dropped fingers"Z-thumb" or "Z-deformity" consists of hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint and gives a "Z" appearance to the thumb.SkinThe rheumatoid nodule, which is sometimes cutaneous, is the feature most characteristic of rheumatoid arthritis. It is a type of inflammatory reaction known to pathologists as a "necrotizing granuloma". PathologyThe initial pathologic process in nodule formation is unknown but may be essentially the same as the synovitis, since similar structural features occur in both. The nodule has a central area of fibrinoid necrosis that may be fissured and which corresponds to the fibrin-rich necrotic material found in and around an affected synovial space. Surrounding the necrosis is a layer of palisading macrophages and fibroblasts, corresponding to the intimal layer in synovium and a cuff of connective tissue containing clusters of lymphocytes and plasma cells, corresponding to the subintimal zone in synovitis. The typical rheumatoid nodule may be a few millimetres to a few centimetres in diameter and is usually found over bony prominences, such as the olecranon, the calcaneal tuberosity, the metacarpophalangeal joint, or other areas that sustain repeated mechanical stress. Nodules are associated with a positive RF (rheumatoid factor) titer and severe erosive arthritis. Rarely, these can occur in internal organs or at diverse sites on the body.Several forms of vasculitis occur in rheumatoid arthritis. A benign form occurs as microinfarcts around the nailfolds. More severe forms include livedo reticularis, which is a network (reticulum) of erythematous to purplish discoloration of the skin caused by the presence of an obliterative cutaneous capillaropathy.Other, rather rare, skin associated symptoms include:pyoderma gangrenosum, a necrotizing, ulcerative, noninfectious neutrophilic dermatosis.Sweet's syndrome, a neutrophilic dermatosis usually associated with myeloproliferative disordersdrug reactionserythema nodosumlobular panniculitisatrophy of digital skinpalmar erythemadiffuse thinning (rice paper skin), and skin fragility (often worsened by corticosteroid use).LungsFibrosis of the lungs is a recognized response to rheumatoid disease. It is also a rare but well recognized consequence of therapy (for example with methotrexate and leflunomide). Caplan's syndrome describes lung nodules in individuals with rheumatoid arthritis and additional exposure to .Pleural effusions are also associated with rheumatoid arthritis. Another complication of RA is Rheumatoid Lung Disease. It is estimated that about one quarter of Americans with RA develop Rheumatoid Lung Disease. KidneysRenal amyloidosis can occur as a consequence of chronic inflammation. Rheumatoid arthritis may affect the kidney glomerulus directly through a vasculopathy or a mesangial infiltrate but this is less well documented (though this is not surprising, considering immune complex-mediated hypersensitivities are known for pathogenic deposition of immune complexes in organs where blood is filtered at high pressure to form other fluids, such as urine and synovial fluid) Heart and blood vesselsPeople with rheumatoid arthritis are more prone to atherosclerosis, and risk of myocardial infarction (heart attack) and stroke is markedly increased. Other possible complications that may arise include: pericarditis, endocarditis, left ventricular failure, valvulitis fibrosis. Many people with rheumatoid arthritis do not experience the same chest pain that others feel when they have angina or myocardial infarction. To reduce cardiovascular risk, it is crucial to maintain optimal control of the inflammation caused by rheumatoid arthritis (which may be involved in causing the cardiovascular risk), and to use exercise and medications appropriately to reduce other cardiovascular risk factors such as blood lipids and blood pressure. OtherOcularThe eye is directly affected in the form of episcleritis which when severe can very rarely progress to perforating scleromalacia. Rather more common is the indirect effect of keratoconjunctivitis sicca, which is a dryness of eyes and mouth caused by lymphocyte infiltration of lacrimal and salivary glands. When severe, dryness of the cornea can lead to keratitis and loss of vision. Preventive treatment of severe dryness with measures such as nasolacrimal duct occlusion is important.HepaticCytokine production in joints and/or hepatic Kupffer cells leads to increased activity of hepatocytes with increased production of acute-phase proteins, such as C-reactive protein, and increased release of enzymes such as alkaline phosphatase into the blood. In Felty's syndrome, Kupffer cell activation is so marked that the resulting increase in hepatocyte activity is associated with nodular hyperplasia of the liver, which may be palpably enlarged. Although Kupffer cells are within the hepatic parenchyma, they are separate from hepatocytes. As a result there is little or no microscopic evidence of hepatitis (immune-mediated destruction of hepatocytes). Hepatic involvement in RA is essentially asymptomatic.HematologicalAnemia is by far the most common abnormality of the blood cells. Rheumatoid arthritis may cause a warm autoimmune hemolytic anemia. The red cells are of normal size and colour (normocytic and normochromic). A low white blood cell count (neutropenia) usually only occurs in patients with Felty's syndrome with an enlarged liver and spleen. The mechanism of neutropenia is complex. An increased platelet count (thrombocytosis) occurs when inflammation is uncontrolled, as does the anemia.NeurologicalPeripheral neuropathy and mononeuritis multiplex may occur. The most common problem is carpal tunnel syndrome caused by compression of the median nerve by swelling around the wrist. Atlanto-axial subluxation can occur, owing to erosion of the odontoid process and or/transverse ligaments in the cervical spine's connection to the skull. Such an erosion (>3mm) can give rise to vertebrae slipping over one another and compressing the spinal cord. Clumsiness is initially experienced, but without due care this can progress to quadriplegia.Constitutional symptomsConstitutional symptoms including fatigue, low grade fever, malaise, morning stiffness, loss of appetite and loss of weight are common systemic manifestations seen in patients with active rheumatoid arthritis.OsteoporosisLocal osteoporosis occurs in RA around inflamed joints. It is postulated to be partially caused by inflammatory cytokines. More general osteoporosis is probably contributed to by immobility, systemic cytokine effects, local cytokine release in bone marrow and corticosteroid therapy.LymphomaThe incidence of lymphoma is increased in RA, although it is still uncommon. DiagnosisDiagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints. Some blood tests also can help confirm RA. There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and X-rays.Telltale signs include:Anemia (a low red blood cell count)Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis)Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70% of patients with RA)Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)X RAYX-rays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first X-rays may be useful later to show if the disease is progressing. X-rays of the hands and feet are generally performed in people with a polyarthritis. In rheumatoid arthritis, there may be no changes in the early stages of the disease, or the x-ray may demonstrate juxta-articular osteopenia, soft tissue swelling and loss of joint space. As the disease advances, there may be bony erosions and subluxation. X-rays of other joints may be taken if symptoms of pain or swelling occur in those joints.Appearance of synovial fluid from a joint with inflammatory arthritis.MRI and ultrasound scanning are done to help judge the severity of RA. Details of the above USG: Signs of destruction and inflammation on ultrasonography and magnetic resonance imaging in the second metacarpophalangeal joint in established rheumatoid arthritis. Thin arrows indicate an erosive change; thick arrows indicate synovitis. Ultrasonography (left side of image) in the (a) longitudinal and (b) the transverse planes shows both signs of destruction and inflammation. Axial T1-weighted magnetic resonance images were obtained (c) before and (d) after contrast administration, also demonstrating synovitis. Additionally, a coronal T1-weighted magnetic resonance image (e) before contrast administration visualizes the same bone erosion as shown in panels c and d.Other medical imaging techniques such as magnetic resonance imaging (MRI) and ultrasound are also used in rheumatoid arthritis.There have been technical advances in ultrasonography. High-frequency transducers (10?MHz or higher) have improved the spatial resolution of ultrasound images; these images can depict 20% more erosions than conventional radiography. Also, color Doppler and power Doppler ultrasound, which show vascular signals of active synovitis depending on the degree of inflammation, are useful in assessing synovial inflammation. This is important, since in the early stages of rheumatoid arthritis, the synovium is primarily affected, and synovitis seems to be the best predictive marker of future joint damage. Blood testsWhen RA is clinically suspected, immunological studies are required, such as testing for the presence of rheumatoid factor (RF, a non-specific antibody). A negative RF does not rule out RA; rather, the arthritis is called seronegative. This is the case in about 15% of patients. During the first year of illness, rheumatoid factor is more likely to be negative with some individuals converting to seropositive status over time. RF is also seen in other illnesses, for example Sj?gren's syndrome, Hepatitis C, chronic infections and in approximately 10% of the healthy population, therefore the test is not very specific.Because of this low specificity, new serological tests have been developed, which test for the presence of the anti-citrullinated protein antibodies (ACPAs) or anti-CCP. Like RF, these tests are positive in only a proportion (67%) of all RA cases, but are rarely positive if RA is not present, giving it a specificity of around 95%.As with RF, there is evidence for ACPAs being present in many cases even before onset of clinical disease.The most common tests for ACPAs are the anti-CCP (cyclic citrullinated peptide) test and the Anti-MCV assay (antibodies against mutated citrullinated Vimentin). Recently a serological point-of-care test (POCT) for the early detection of RA has been developed. This assay combines the detection of rheumatoid factor and anti-MCV for diagnosis of rheumatoid arthritis and shows a sensitivity of 72% and specificity of 99.7%.Also, several other blood tests are usually done to allow for other causes of arthritis, such as lupus erythematosus.The erythrocyte sedimentation rate (ESR), C-reactive protein, full blood count, renal function, liver enzymes and other immunological tests (e.g., antinuclear antibody/ANA) are all performed at this stage.Elevated ferritin levels can reveal hemochromatosis, a mimic RA, or be a sign of Still's disease?a seronegative, usually juvenile, variant of rheumatoid.CriteriaIn 2010 the 2010 ACR / EULAR Rheumatoid Arthritis Classification Criteria were introduced. These new classification criteria overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis. The "new" classification criteria, Against Rheumatism establish a point value between 0 and 10.Every patient with a point total of 6 or higher is unequivocally classified as an RA patient, provided he has synovitis in at least one joint and given that there is no other diagnosis better explaining the synovitis. Four areas are covered in the diagnosis:joint involvement, designating the metacarpophalangeal joints, proximal interphalangeal joints, the interphalangeal joint of the thumb, second through fifth metatarsophalangeal joint and wrist as small joints, and shoulders, elbows, hip joints, knees, and ankles as large joints: Involvement of 1 large joint gives 0 pointsInvolvement of 2-10 large joints gives 1 pointInvolvement of 1-3 small joints (with or without involvement of large joints) gives 2 pointsInvolvement of 4-10 small joints (with or without involvement of large joints) gives 3 pointsInvolvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 pointsserological parameters – including the rheumatoid factor as well as ACPA – "ACPA" stands for "anti-citrullinated protein antibody": Negative RF and negative ACPA gives 0 pointsLow-positive RF or low-positive ACPA gives 2 pointsHigh-positive RF or high-positive ACPA gives 3 pointsacute phase reactants: 1 point for elevated erythrocyte sedimentation rate, ESR, or elevated CRP value (c-reactive protein)duration of arthritis: 1 point for symptoms lasting six weeks or longerThe new criteria accommodate to the growing understanding of rheumatoid arthritis and the improvements in diagnosing RA and disease treatment. In the "new" criteria serology and autoimmune diagnostics carries major weight, as ACPA detection is appropriate to diagnose the disease in an early state, before joints destructions occur. Destruction of the joints viewed in radiological images was a significant point of the ACR criteria from 1987. The criteria are not intended for the diagnosis for routine clinical care; they were primarily intended to categorize research . In clinical practice, the following criteria apply:two or more swollen jointsmorning stiffness lasting more than one hour for at least six weeksthe detection of rheumatoid factors or autoantibodies against ACPA such as autoantibodies to mutated citrullinated vimentin can confirm the suspicion of rheumatoid arthritis. A negative autoantibody result does not exclude a diagnosis of RA.Differential diagnosesSeveral other medical conditions can resemble RA, and usually need to be distinguished from it at the time of diagnosis: Crystal induced arthritis (gout, and pseudogout) – usually involves particular joints (knee, MTP1, heels) and can be distinguished with aspiration of joint fluid if in doubt. Redness (RA doesn't have redness at the joints), asymmetric distribution of affected joints, pain occurs at night and the starting pain is less than an hour with gout.Osteoarthritis – distinguished with X-rays of the affected joints and blood tests, age (mostly older patients), starting pain less than an hour, a-symmetric distribution of affected joints and pain worsens when using joint for longer periods.Systemic lupus erythematosus (SLE) – distinguished by specific clinical symptoms and blood tests (antibodies against double-stranded DNA)One of the several types of psoriatic arthritis resembles RA – nail changes and skin symptoms distinguish between themLyme disease causes erosive arthritis and may closely resemble RA – it may be distinguished by blood test in endemic areasReactive arthritis (previously Reiter's disease) – asymmetrically involves heel, sacroiliac joints, and large joints of the leg. It is usually associated with urethritis, conjunctivitis, iritis, painless buccal ulcers, and keratoderma blennorrhagica.Ankylosing spondylitis – this involves the spine, although a RA-like symmetrical small-joint polyarthritis may occur in the context of this condition.Hepatitis C – RA-like symmetrical small-joint polyarthritis may occur in the context of this condition. Hepatitis C may also induce Rheumatoid Factor auto-antibodiesRarer causes that usually behave differently but may cause joint pains: Sarcoidosis, amyloidosis, and Whipple's disease can also resemble RA.Hemochromatosis may cause hand joint arthritis.Acute rheumatic fever can be differentiated from RA by a migratory pattern of joint involvement and evidence of antecedent streptococcal infection. Bacterial arthritis (such as streptococcus) is usually asymmetric, while RA usually involves both sides of the body symmetrically.Gonococcal arthritis (another bacterial arthritis) is also initially migratory and can involve tendons around the wrists and ankles.Monitoring progressionThe progression of rheumatoid arthritis can be followed using scores such as Disease Activity Score of 28 joints (DAS28). It is widely used as an indicator of RA disease activity and response to treatment, but is not always a reliable indicator of treatment effect. The joints included in DAS28 are (bilaterally): proximal interphalangeal joints (10 joints), metacarpophalangeal joints (10), wrists (2), elbows (2), shoulders (2) and knees (2). When looking at these joints, both the number of joints with tenderness upon touching (TEN28) and swelling (SW28) are counted. In addition, the erythrocyte sedimentation rate (ESR) is measured. Also, the patient makes a subjective assessment (SA) of disease activity during the preceding 7 days on a scale between 0 and 100, where 0 is "no activity" and 100 is "highest activity possible". With these parameters, DAS28 is calculated as: From this, the disease activity of the patient can be classified as follows: CurrentDAS28DAS28 decrease from initial value> 1.2> 0.6 but ≤ 1.2≤ 0.6≤ 3.2InactiveGood improvementModerate improvementNo improvement> 3.2 but ≤ 5.1ModerateModerate improvementModerate improvementNo improvement> 5.1Very activeModerate improvementNo improvementNo improvementTreatmentThere is no known cure for rheumatoid arthritis, but many different types of treatment can alleviate symptoms and/or modify the disease process. The goals of treatment include minimizing clinical symptoms such as pain and swelling, as well as preventing bone deformity and radiographic damage (for example, bone erosions visible in X-rays), and maintaining the quality of life in terms of day-to-day activities. Pharmacological treatment of RA can be divided into: disease-modifying antirheumatic drugs (DMARDs), anti-inflammatory agents analgesics. Treatment also includes rest and physical activity.Other therapiesRegular exercise is important for maintaining joint mobility and making the joint muscles stronger. A Cochrane Review of studies determined that exercise programs designed to improve strength and stamina were safe and led to moderate benefits for RA sufferers. Other therapies are weight loss, orthoses, occupational therapy, podiatry, physiotherapy, immunoadsorption therapy, joint injections, special tools to improve hand movements (e.g., special tin-openers).The effectiveness of treating RA with acupuncture is inconclusive, and "more rigorous research seems to be warranted" according to one study. PHYSICAL THERAPYRange-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function and help keep muscles strong.Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint movement.Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.PrognosisThe course of the disease varies greatly. Some people have mild short-term symptoms, but in most the disease is progressive for life. Around 20%–30% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis.Prognostic factorsPoor prognostic factors include :persistent synovitis,early erosive disease,extra-articular findings (including subcutaneous rheumatoid nodules), positive serum RF findings, positive serum anti-CCP autoantibodies, carriership of HLA-DR4 "Shared Epitope" alleles, family history of RA, poor functional status, socioeconomic factors, elevated acute phase response (erythrocyte sedimentation rate [ESR],C-reactive protein [CRP]), increased clinical severity.Possible ComplicationsRheumatoid arthritis can affect nearly every part of the body. Complications may include:Damage to the lung tissue (rheumatoid lung)Increased risk of hardening of the arteriesSpinal injury when the neck bones become damagedInflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problemsSwelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failureThe treatments for RA can also cause serious side effects. Talk to your doctor about the possible side effects of treatment and what to do if they occur.MortalityRA is known to reduce the lifespan of patients by anywhere from three to 12 years. A new line of research does, however, show that the use of new biologic drug therapies extend the lifespan of patients with RA and reduce the risk and progression of atherosclerosis. According to the UK's National Rheumatoid Arthritis Society, "Young age at onset, long disease duration, the concurrent presence of other health problems (called co-morbidity), and characteristics of severe RA—such as poor functional ability or overall health status, a lot of joint damage on x-rays, the need for hospitalisation or involvement of organs other than the joints—have been shown to associate with higher mortality". Positive responses to treatment may indicate a better prognosis. A 2005 study by the Mayo Clinic noted that RA sufferers suffer a doubled risk of heart disease, independent of other risk factors such as diabetes, alcohol abuse, and elevated cholesterol, blood pressure and body mass index. The mechanism by which RA causes this increased risk remains unknown; the presence of chronic inflammation has been proposed as a contributing factor. EpidemiologyDisability-adjusted life year for rheumatoid arthritis per 100,000?inhabitants in 2004. ??no data??less than 40??40–50??50–60??60–70??70–80??80–90??90–100??100–110??110–120??120–130??130–140??more than 140The incidence of RA is in the region of 3 cases per 10,000 population per annum. Onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80. The prevalence rate is 1%, with women affected three to five times as often as men. It is up to three times more common in smokers than non-smokers, particularly in men, heavy smokers, and those who are rheumatoid factor positive. A study in 2010 found that those who drank modest amounts of alcohol regularly were four times less likely to get rheumatoid arthritis than those who never drank. First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%.It is strongly associated with the inherited tissue type Major histocompatibility complex (MHC) antigen HLA-DR4 (most specifically DR0401 and 0404)—hence family history is an important risk factor.The risk of first developing the disease (the disease incidence) appears to be greatest for women between 40 and 50 years of age, and for men somewhat later. RA is a chronic disease, and although rarely, a spontaneous remission may occur, the natural course is almost invariably one of persistent symptoms, waxing and waning in intensity, and a progressive deterioration of joint structures leading to deformations and disability.The normal joint structure appears on the left. On the right is the joint with rheumatoid arthritis. What is the broader health impact of rheumatoid arthritis? Research shows that people with RA, mainly those whose disease is not well controlled, have a higher risk for heart disease and stroke. Talk with your doctor about these risks and ways to lower them.The rheumatologist's role in the treatment of rheumatoid arthritis RA is a complex disease, but many advances in treatment have occurred recently. Rheumatologists are doctors who are experts in diagnosing and treating arthritis and other diseases of the joints, muscles and bones. Thus, they are best qualified to make a proper diagnosis of RA. They can also advise patients about the best treatment options.Living with rheumatoid arthritis It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible. When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.Finding that you have a chronic illness is a life-changing event. It can cause worry and sometimes feelings of isolation or depression. Thanks to greatly improved treatments, these feelings tend to decrease with time as energy improves, and pain and stiffness decrease. Discuss these normal feelings with your health care providers. They can provide helpful information and resources.Rheumatoid arthritis affects the wrist and the small joints of the hand, including the knuckles and the middle joints of the fingers. When to Contact a Medical ProfessionalCall your health care provider if you think you have symptoms of rheumatoid arthritis. PreventionThere is no known prevention. Proper early treatment can help prevent further joint damage.Rheumatoid Arthritis and ExerciseWhy do I need to register or sign in for WebMD to save?We will provide you with a dropdown of all your saved articles when you are registered and signed in.Learn about the importance of exercise for rheumatoid arthritis. Arthritis exercises can safely provide pain relief and build muscle strength.When joints are stiff and painful, exercise might be the last thing on your mind. Yet when you have rheumatoid arthritis, exercising regularly is one of the best things you can do to take care of yourself and your joints. Here is why exercise is so important:People who exercise live longer, with or without rheumatoid arthritis.Regular exercise can actually reduce overall pain from rheumatoid arthritis.Exercise can keep your bones strong. Thinning of the bones can be a problem with rheumatoid arthritis, especially if you need to take steroids. Exercise helps bones keep their strength.Exercise maintains muscle strength.Regular exercise improves functional ability and lets you do more for yourself.People with rheumatoid arthritis who exercise feel better about themselves and are better able to cope.Is Exercise Safe If You Have Rheumatoid Arthritis?Is exercise safe? Yes -- certain kinds of exercise are proven to be safe for people with rheumatoid arthritis. There are three types you can do: stretching, strengthening, and conditioning.Stretching exercises are the simplest and easiest. They consist of stretching and holding different joint and muscle groups for 10 to 30 seconds each. Stretching improves flexibility, and daily stretching is the basis for any exercise program.Strength exercises involve working the muscle against resistance. This can be either with or without weights. Resistance training strengthens the muscle and increases the amount of activity you can do pain-free.Conditioning exercise, also called aerobic exercise, improves cardiovascular fitness. There are countless benefits to aerobic exercise! Among them, it makes your heart and blood vessels healthier, prevents disability, and improves mood and well-being. Good conditioning exercises for people with rheumatoid arthritis include low-impact activities like walking, swimming, bicycling, or using an elliptical machine. Any of these will get your heart pumping.After being cleared by your doctor, you should try to do 20 to 30 minutes of low-impact conditioning exercise on as many days as you feel you can. More is better, but any amount is better than none at all!Exercises to Avoid if You Have Rheumatoid ArthritisAre there any kinds of exercise you should avoid if you have rheumatoid arthritis? In general, you should be careful about activities that put a lot of stress on a joint, or are "high-impact," such as:Jogging, especially on paved roadsHeavy weight liftingThat's not to say that these activities are totally off-limits. If you're interested in trying them, talk to your doctor first.Your rheumatologist can help you create an exercise program that is right for you. This may also involve meeting with a physical therapist. Physical therapists can identify what areas you need to work on, choose the right exercises for you, and tell you how vigorously you should exercise.There are also community exercise programs designed just for people with arthritis. People with Arthritis Can Exercise (PACE) and the Arthritis Self Help Course (ASHC) are offered by the Arthritis Foundation.You should work with your treatment team to design the right plan before starting to exercise, especially if you have other medical problems.As you start to exercise regularly, you'll realize the benefits, and you'll know you've taken control of your rheumatoid arthritis. Soon, not only will your joints feel better -- you'll feel better too.NUTRITIONSome people with RA may have intolerance or allergies to certain foods. A balanced nutritious diet is recommended. It?may be helpful to eating foods rich in fish oils (omega-3 fatty acids).Arthritis Diet and Food: Foods to AvoidCertain foodstuffs are believed to either aggravate or reduce the symptoms of arthritis. The arthritis diet which is recommended for people to repress symptoms of arthritis is given:Diet can alleviate or even worsen the symptoms of arthritis. People suffering from arthritis observe that the symptoms of arthritis are aggravated on consuming certain foodstuff. Such foodstuffs should be avoided. Let us take a look at the list of foods to be consumed and those to be avoided in the diet for arthritis. However, note that it is recommended to consult your doctor before following this diet or making drastic changes in your daily diet.Foods to Avoid with Arthritis You must avoid fats and cholesterol containing foodstuffs like red meat and poultry. Dairy products like whole milk, cheese, and butter also contain high cholesterol and phosphorous, and hence, should be excluded from the arthritis diet.It is advisable to avoid refined wheat and wheat products like wheat bread. It contains phosphorous and can aggravate arthritis. Corn should also be avoided.Avoid having tomatoes, bell pepper, and eggplant, as some people have reported reduced joint pain after avoiding these foods completely.Other foods that you need to avoid as a diet for arthritis pain relief are excess sugar and salt-containing foods. Abstain from having soft drinks with a lot of sugar, cookies, sodas; salt-containing foods like fries, etc. You must also avoid having too much coffee as it contains caffeine. Excess alcohol can aggravate gout. Citrus fruits like orange or lemon must be completely avoided.On the other hand, when eating out, it is essential to know the ingredients of foods and avoid consuming foods containing the above mentioned ingredients. Foods Good for Arthritis On the other hand, some foods are believed to reduce the symptoms of arthritis. Following is a list of foods that can be safely consumed when suffering from arthritis.Arthritis diet is a pure vegetarian diet. Therefore, try to reduce the intake of meat or avoid it completely.Foods that contain high polyunsaturated fatty acids, especially the omega-3 fatty acid, are very essential to reduce joint pain and other symptoms of arthritis. Fish like tuna, herring, mackerel and salmon are rich in omega-3 fatty acids. Similarly, walnuts, avocado and soybeans also contain omega-3 fatty acids.Having fresh fruits (like apples, kiwi, mango, peach, strawberries, etc.) and vegetables (like Broccoli, collard, spinach, sweet potatoes, etc) helps in relieving symptoms of arthritis. They contain many beneficial nutrients that are required by the body. They help improve the overall health of a person.You must have vegetable soups, juices and herbal teas. Try to eat fresh and healthy foodstuffs, avoiding processed and fried foods.The effectiveness of the foods in reducing or aggravating arthritis differ from person to person. For e.g., a certain foodstuff may cause aggravation of joint pain in a person, while may not affect the other person. Therefore, it is essential to consult the doctor and chalk out a proper diet plan. Along with this diet plan, it is also essential to maintain a healthy body weight. Proper body weight will put less strain on the joints and reduce pain.As the diet is found to have a considerable effect on arthritis, it is essential to follow a proper diet in order to gain quick relief. Lastly, it should be noted that this article is meant for information purposes only, and should not be substituted for proper medical advice. Take care! ?Consider a vegetarian dietAt least one study found that people who ate a vegetarian or vegan diet reported an improvement in RA symptoms, including pain score, morning stiffness, and grip strength compared to those who didn’t. However, because these diets are restrictive, many of the participants were unable to maintain them for the yearlong study period. If you can’t give up meat, then at least try to get a few more greens on your plate. The antioxidants, such as those found in green peas, bell peppers, and broccoli, may protect against tissue damage around the joints caused by free radicals.Find out about allergiesFood allergies, especially to dairy and shrimp, may aggravate rheumatoid arthritis. Some people try elimination diets, which involves removing all potential allergens from the diet and slowly adding these foods back to see if they trigger symptoms. Studies have tested whether exposing patients to foods that had previously upset their RA consistently worsened their symptoms. “You get a smidgen of a hint that food aggravates symptoms,” says Dr. Hadler. But he explains that there’s tremendous variation within any individual’s symptoms in a given time period, making it difficult to study the effects of elimination diets.Points to remember Newer treatments are effective. RA drugs have greatly improved outcomes for patients. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.Seek an expert in arthritis: a rheumatologist. Expertise is vital to make an early diagnosis of RA and to rule out diseases that mimic RA, thus avoiding unneeded tests and treatments. A doctor who is an expert in RA also can design a customized treatment plan that is best suited for you. Therefore, the rheumatologist, working with the primary care physician and other health care providers, should supervise the treatment of the patient with RA.Start treatment early. Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.Siddha Medicine Treatment for Rheumatoid Arthritis In Aravindh HerbalsName equivalence in siddha systemRheumatoid arthritis is compared to vali azhal keelvayu in siddha system of medicineDefinition of keelvayuVatha rises in its normal level and get vitiated in the joints(keelkal) and causes the disease keelvayu(arthritis). Types of keelvayu There are 10 types of keelvayu. They are:Vali keelvayu: Rheumatic arthritisAzhal keelvayu: Oesteo arthritisIya keelvayu: Tubercular arthritisVali azhal keelvayu: Rheumatoid arthritisVali iya keelvayu}: Iya vali keelvayu }: Gonococcal arthritisAzhal vali keelvayu: Poly arthritisAzhal iya keelvayu: Syphilitic arthritisIya azhal keelvayu: Haemophilic arthritisMukkutra keelvayu: Pyogenic arthritisDefinition of vali azhal keelvayu(rheumatoid arthritis)Vali Azhal Keelvayu is caused due to increase of Vali and Azhal kutram from their normalcy. Disease is usually associated with complaints like pain, swelling,redness,rise of temperature in that area and difficulty to flex or extend particularly the wrist joint,ankle joint,inter phalangeal and inter tarsal joint accompanying other symptoms like fever, indigestion etc along with it. CausesThis results due to :improper dietery habits like increased consumption of Red Meat, Eggs, Fishes, Alcohol. Sedentery life style .over exposure to hot and cold weather, psychic factors etc.Genetic and Environmental factors are precipitating ones.SymptomsInitially indigestion symptoms are seen like frequent constipation, obesity, abdominal discomfort etc.Then the joints of wrist, ankle, shoulders and fingers are involved with pain, redness and stiffness later major joints are also affected. The patient complaints of morning stiffness for more than one hour. This is a multi-system involving disease more common in females than in males. Excessive sweating in palm and sole, low grade fever, loss of weight, anaemiaSide effects of morden medicine :NSAID produces adverse effects in GIT (Peptic ulcer, Small bowel ulceration/perforation, Colitis, Stomatitis, Oesophagitis),Renal (Acute renal failure, Interstitial nephritis, Hyponatraemia, Hyperkalaemia, Transient rise in serum creatinine)Cardiovascular (Interference with actions of anti-hypertensive and anti-cardiac failure drugs)Hepatic (Cholestasis, hepatic failure)CNS (Headache, Tinnitus, Insomnia, Abnormal behaviour)Skin (Rashes, Erythema), Haematological (Bone marrow suppression, Anaemia secondary to GI blood loss, Thrombocytopenia.The adverse effects of DMART includes Renalfailure, Bone marrow suppression, Stomatitis etc.The symptoms may subside with administration of medicines but it mayreoccur with more severity as the disease becomes chronic finally leading to permanent debility.Siddha line of treatmentIn aravindh herbals the line of treatment followed is :First day Purgation is given by advicing the patient to take suga bedi oil:20 to 30 ml or adviced to take natural enema. This is done because of the siddhars saying “viraesanathal vatham thalum”Second day onwards cap rheumatigo 1 is adviced for three times a day and thylams like rheumatigo thylam,kayathirumeni thylam,ulundhu thylam,vathakesari thylam are adviced for external application on the joints.Ingrediends of Rheumatigo capsuleEach 450mg capsule contains:Pavonia zeylanica(sida acuta)Withania somniferaPlumbago zeylanicaPiper nigrumPiper longamZingiber officinale(Dry ginger)Vitex negundoKantha chenduramThe on coming paragraphs will give as detailed information about the proved pharmacological actions of each ingriedents of the capsule Sida acuta (Sittramutti)Kingdom:PlantaeClass:AngiospermsOrder:MalvalesFamily:MalvaceaeSubfamily:MalvoideaeGenus:SidaSpecies:acutaDistributionCommon Wireweed (Sida acuta) is a species of flowering plant in the mallow family, Malvaceae. It is believed to have originated in Central America, but today has a pantropical distribution and is considered a weed in some areas. They are found throughout the tropical and sub-tropical plains all over India and SrilankaIt grows in the wild in different types of habitats like overgrazed lands, roadsides; along the sides of walls of old plant etc. It has a number of species many of which are native to India, America and other countries of the world. Sida cordifolia, S.rhombifolia, S.acuta etc. are some of its popularly known species.MorphologySida is a shrubby plant.The herb is an annual and grows up to 30cms. The plant though seasonal, is available throughout the year, and is especially luxuriant during the months of October to December.The leaves are heart shaped, one at each node. The flowers are produced at the growing regions and are yellow in color. Actions : aphrodisiac, analgesic, anti-inflammatory tonic.Anti-rheumatic, Cardiac tonic, Febrifuge.Chemical constituents of the sida extractRoots and stems of the plant contain ephedrine, an important alkaloid. Besides this, traces of sitosterol and palmic, stearic etc. have also been isolated from this plant. According to a report, main alkaloid present in sida is asparagin. Besides this fatty oil, phytosterol, mucin, potassium nitrate, resins and acids are also known to be found in the plant extract.It is also reported that sida does not contain any tannin or glycoside.According to recent analysis, ephedrine and y-ephedrine are major alkaloids found in the aerial parts of the plant. Besides these two, some other chemical compounds that have been isolated from the aerial parts of sida are – 6-phenyl ethyl amine, carboxylated tryptomines, qunazoline, hypaphorine, vasicinol etc. Different species of this plant have been reported to contain cryptolepine also.Chemical analysis of the extract of sida plant reveals that it contains appreciable amounts of nutrients, the details of which are mentioned below –Proteins 74,000ppm to 347,000ppmCarbohydrate 94,000ppm to 475,000ppmFiber 33,000ppm to 167,000ppmFat 14,000ppm to 71,000ppmAsh 16,000ppm to 81,000ppmBesides the above, it has also been reported that roots of sida plant contain450ppm alkaloids including ephedrine, saponine, choline, pseudoephedrine, betaphenethylamine, vaccine, hipaphorine and related indole alkaloides.Siddha Medicinal Uses :The decoction prepared by root or samoolam is given in the dose of 30 to 60 ml twice a day daily for all vatham or arthritis, piles etc.The samoolam of this plant along with samoolam of notchi, garlic, chukku, thippili, seethil, milagu are taken and prepared as decoction for vatha suram, vatham and Ama vatham.The decoction of the plant is advised in the second trimester of pregnancy as a preventive measure for complaints like joint pain, indigestion, arthritis etc.The oil prepared from the paste of samoolam of this plant and gingelly oil is very effective external application for all painful conditions like arthritis.This plant is one of the main ingredient in the preparation of effective Siddha medicines like kayathirumeni thylam etc.The leaves and roots are used in kizhi or fomentation in arthritic ailments.The decoction prepared by the roots are effective in curing athisuram. Injhi or ginger can be used along with kurunthotti and prepared as decoction and given for feverSida cardifolia growing in the wildSida plant is widely used in Indian alternative medicine philosophy since the time immemorial. physicians prescribed the decoction of sida roots with ginger in intermittent fever. It is also administered in fever accompanied with rigour. The powdered root bark is administered with milk and sugar as treatment for urinary urgency and leucorrhoea. Seeds are also used to treat urinary infections. They have been reported to be aphrodisiac also. The plant is reported to be well tolerated in routine doses.A portion of Sida cardifolia showing flower and fruitsFresh extract of leaves of sida is used in dropsy and chronic renal failure in a dose of 20ml, two to three times a day. Roots boiled in milk are used in a single daily dose for maintaining health. Paste of roots is used topically for treating inflammation.It affects the central nervous system and provides relief from anxiety. Its extract is consumed to reduce body weight. It tones the blood pressure and improves the cardiac irregularity. It is also useful in fever, fits, Ophthalmia, rheumatism, colic and nervous disorders.The extract of the whole plant is used in spermatorrhoea. Some scholars have reported that bark of the plant is effective in curing facial paralysis and sciatica. It has also been reported to improve sexual strength. Sida oils are used topically to the sore muscles and sore joints in rheumatism and arthritis. It is diaphoretic in nature and increases perspiration and helps in lowering fever.Powdering and boiling the whole material and giving to the patient for relieving muscular pain. Bala taila is used for the treatment of complaints of nervous system, stomach problems and as a cardiac tonic. Crushed leaves of the plant are used as astringent for the treatment and dressing of wounds or skin injuries.Reports from surveys conducted in different regions reveal that sida acuta had many traditional usages that varied from regions to regions. The most popular use of sida acuta is made in the treatment of fever, headache, and infectious diseases. The powdered leaves of sida rhombifolia are used to relive swelling. Its fruits are used to cure headache, the mucilage of the plant is used as an emollient and the roots are used to treat rheumatism. Sida is traditionally used to treat diarrhea in Australia. The plant is traditionally being used as an astringent, antidote for scorpion stings and snake bites. Some traditional societies use this plant for the treatment of tuberculosis, chronic dysentery, nervous, urinary and cardiac diseases etc. Prooved Pharmacological ActionsSida has been reported to contain aphrodisiac, analgesic and anti-inflammatory properties. Its extract is reported to be a tonic in nature. It affects central nervous system and provides relief from anxiety. It is also used to reduce the body weight.The intake of the extract of sida leaves is reported to lower the blood pressure and to improve the cardiac irregularity. However, contradictory reports have also been there. It is useful in fevers, fits, Ophthalmia, rheumatism, leucorrhoea, micturition, gonorrhea, colic, nervous disorders, and general debility.The extract of roots of sida plant is useful in healing wounds. The extract of the whole plant is reported to be beneficial in spermatorrhoea. The bark of the stem is effective in sciatica and facial paralysis. The consumption of the juice of sida is reported to improve sexual strength.The oil extracted from sida is used topically to sore muscles, sore joints, in arthritis and rheumatism. It is reported to be a diaphoretic in nature and to increase perspiration and thus it reduces fever. According to a study, leaves of sida can be used as infusion in treating fevers and delirium. The roots of the plant are astringent and diuretic. Its infusion is useful in cystitis, haematuria, bleeding piles, chronic dysentery etc. Withania somniferaKingdom:PlantaeClass:AngiospermsOrder:SolanalesFamily:SolanaceaeGenus:WithaniaSpecies:somniferaBotanical name:Withania somniferaWithania somnifera, also known as ashwagandha, Indian ginseng, or winter cherry, is a plant in the Solanaceae or nightshade family. Several other species in the genus Withania are morphologically similar. It is used as a herb in siddha medicine.Ashwagandha in Sanskrit means "horse's smell" (ashwa- horse, gandha- smell), probably originating from the odour of its root which resembles that of a sweaty horse.The species name somnifera means "sleep-inducing" in Latin. Other names of Withania Somnifera: Ashwagandha, Indian Winter Cherry, Indian Ginseng, Ashvagandha, Ajagandha, Kanaje, AmukkaraDistributionWithania somnifera is grown as late rainy-season (kharif) crop. Semitropical areas receiving 500 to 750?mm rainfall are suitable for its cultivation as a rainfed crop. If one or two winter rains are received, then root development improves.The crop requires a relatively dry season during its growing period. It can tolerate a temperature range of 20 to 38°C and as low a temperature as 10°C. The plant grows from sea level to an altitude of 1500 metersWithania somnifera is cultivated in many of the drier regions of India, such as Mandsaur District of Madhya Pradesh, Punjab, Sindh, and Rajasthan. It is also found in Nepal.Withania Somnifera grows abundantly in India (especially Madhya Pradesh), Pakistan, Bangla Desh, Sri Lanka and parts of northern Africa.MorphologyIt grows as a short shrub with a central stem from which branches extend radially in a star pattern (stellate) and covered with a dense matte of wooly hairs (tomentose). Height: usually 30-60 cm but can grow up to 170 cm. Leaves: alternate and ovate, up to 10 cm long and up to 5 cm wide. Flowers: yellow petals on the inside but with a green outer-covering layer. Fruit: red berries in papery protective covering (calyx). Roots: long,brown, fleshy tubers.Chemical constitutionsThe principle constituents of its root are compounds known as withanolides,they are believed to account for the multiple medicinal applications of ashwagandha.These molecules are steroidal lactones with erggostane, which include tropine and cuscohygrine withanone, withaferin, withanolides, withasomidienone, withanolide C and alkanoids and bear a resemblance, both in their action and appearance, to the active constituents of Asian ginseng (Panax ginseng) known as ginsenosides.The leaves contain the steroidal lactones, withanolides, notably withaferin A, which was the first withanolide to be isolated from W. somnifera.It also contains withanine, somniferine, alkaloids, diethyl ether, anhydrine, ethanol, hexane and many more.Medicinal useIn siddha, the berries and leaves of W. somnifera are locally applied to tumors, tubercular glands, carbuncles, and ulcers. It has wide ranging properties to elevate health,mental and physical both in both the genders.Withania Somnifera has wide range of uses, it is used to pacify humors Vata and Kapha. It is used to relieve stress related disorders, calms anxiety and treats insomnia very well. Since it is capable to pacify Vata in the body it is useful in treating pains and facilitates movements of the body smoothly. It has anti-inflammatory properties which make it usable as topical application for relieving inflammations and swellings. It has aphrodisiac properties and is used as excellent health rejuvenator due to its powerful properties to boost up immunity and work as health supplement. Ashwagandha is very beneficial for treating disorders related to female reproductive system, it is very good supplement for aged people in maintaining proper health.Ashwagandha herb is also used to improve vision and is also given to children for upbeat mental health. It has anti-inflammatory properties which make it usable as topical application for relieving inflammations and swellings.Withania Somnifera is highly beneficial herb not only in curing and treating disorders and diseases but also for gaining or maintaining sound mental and physical health. It affects both genders equally well and is mild and free of side effects which make it beneficial even for children and aged people. Withania Somnifera is given to people suffering from Arthritis, hyper tension, debility and general weakness due to its capabilities to cure stress related disorders.Withania Somnifera is very beneficial for males and females suffering with disorders or problems related to reproductive system. This herb has shown very positive effects in curing problems like ED, spermatorrhea, low libido and lack of strength in males. Ashwagandha also treats very well problems like leucorrhea, pain in female intimate part due to infections, in curing infections and treating sterility in females. It is supplemented with other herbs to provide treatments to various other problems in females like lack of milk production, cure inflammation of uterus etc.Withania Somnifera is an excellent nutritional supplement for men, women, old people and children. It cures general debility, helps in gaining lean muscle mass, increases stamina, improves strength, improves vision, strengthens nervous system, cures fatigue, calms stress and very helpful in relieving rheumatic symptoms. Ashwagandha herb is very beneficial natural aid to promote sound mental health by increasing activity of brain and improving memory, this makes it an excellent herb for children for promoting all round development.Ashwagandha or Withania Somnifera is also given to people having trouble in breathing as it inhibits excessive cough formation and helps the body in removing it out of the system to cure persistent cough, bronchitis and allergies of lungs. It is also used topically for relieving inflammations, swellings and calming pain in the case of injuries and rheumatic pains.Ashwagandha has been found to have important healing effects on solid tissues, skin support, connective tissue, lymph tissues, blood vessels, and mucous membranes. Ashwagandha has found its most successful applications in treatment of conditions involving venous insufficiency, tissue inflammation and infection, and post-surgical healing. Ashwagandha is used to treat a number of disorders that affect human health including central nervous system (CNS) disorders, particularly in epilepsy, stress and neurodegenerative diseases such as Parkinson's and Alzheimer's disorders, tardive dyskinesia, cerebral ischemia, and even in the management of drug addictionTaken together, these actions support the traditional reputation of Ashwagandha as a tonic or adaptogen. It counteracts the effects of stress, headaches and generally promotes wellness.Prooved pharmacological actionsThe effect of a semipurified root extract of W. somnifera containing mostly withanolides was investigated using a transgenic mouse model of Alzheimer's disease. The transgenic mice showed reversal of behavioral deficits and plaque load after treatment with the extract for 30 days. Several studies have reported that withaferin A has anti-metastatic activity in mice.Roots of the plant show antitumor and radiosensitizing effects in animal model.Total alkaloid fraction of the root extract exhibit hypotensive bradycardic and respiratory stimulant activities in dogs. It shows relaxant and antispasmodic effects against several plasmogens on intenstinal, uterine, bronchial, tracheal and blood vascular muscles. Withanolides possess remarkable antibacterial, antitumor, antiarthritic and immunosuppressive.The herbal root extract has been traditionally used as a tonic and as a sedative but recent research shows that the leaf extract contains Withanolides which have been found to have regenerative properties on brain-cell synapses in mice and in human cell lines in laboratory studiesWithanolide A, withanoside IV, and withanoside VI have shown significant effects on the re-growth of brain-cell synapses in mice and in human cell lines in the laboratory. Further research is under way in Japan to test withanolide type molecules before testing them clinically. more on Withanolide Ashwagandha herb and root extract health benefit and use for stress reduction, anxiety treatment and relaxation, Withania somnifera plant research studies proves its action.Human studiesDepression treatmentAssessing depression following two ancient Indian interventions: effects of yoga and siddha on older adults in a residential home.The effects of yoga and siddha on geriatric depression were evaluated in 69 persons older than 60 who were living in a residential home. Participants were stratified by age and gender and randomly allocated to three groups: Yoga,siddha , or Wait-list Control. The 15-item Geriatric Depression Scale was used to assess depressive symptoms prior to the intervention, and after 3 months and 6 months post-intervention. Participation in one of the three groups lasted 24 weeks. The yoga program (7 hours 30 minutes per week) included physical postures, relaxation techniques, regulated breathing, devotional songs, and lectures. The siddha Group received an herbal preparation twice daily for the whole period. The depression symptom scores of the Yoga Group at both 3 and 6 months decreased significantly, from a group average baseline of 10 to 8 and 6, respectively. The other groups showed no change. Hence, an integrated approach of yoga including the mental and philosophical aspects in addition to the physical practices was useful for institutionalized older persons.Animal studiesDiabetes and metforminAmelioration of metformin-induced hypothyroidism by Withania somnifera and Bauhinia purpurea extracts in Type 2 diabetic mice.An investigation was carried out to reveal the possible ameliorative role of two plant extracts on an antidiabetic drug-induced hypothyroidism in Type 2 diabetic animals. Oral administration with either Withania somnifera or Bauhinia purpurea extract along with dexamethasone and metformin elevated the concentrations of circulating T(3) and T(4) to euthyroid level. The plant extracts also corrected RR ratio and serum concentration of lipids. Our findings reveal that the evaluated plant extracts have a potential to ameliorate metformin-induced hypothyroidism in Type 2 diabetic subjects.Kidney disease Effect of extract of Withania Somnifera on dehydration-induced oxidative stress-related uremia in male rats.Dehydration or water deprivation in the body decreases urinary excretion and allows urea and other protein waste products to accumulate in the blood. The aim of the present study is to evaluate the association of uremia and oxidative stress by applying the herbal plant Withania somnifera. The study was performed on male Wister strain rats in which, dehydration was achieved by water withdrawal. Dehydration-induced oxidative stress was established in our study by noting the low activities of super-oxide dismutase and catalase, both important antioxidant enzymes, in Group-2 animals; both enzymes were stabilized in animals of Groups-3 and 1. In conclusion, it is hypothesized that there is an antioxidative role of W. somnifera resulting in reducing the extent of renal injury as a result of oxidative stress. Plumbago zeylanicaKingdom:PlantaeClass:AngiospermsOrder:CaryophyllalesFamily:PlumbaginaceaeGenus:PlumbagoSpecies:zeylanicaBotanical namePlumbago zeylanicaPlumbago zeylanica, commonly known as Ceylon Leadwort or Doctorbush, is a species of plumbago with a pantropical distribution. Carl Linnaeus described the paleotropical P. zeylanica and neotropical P. scandens as separate species, but they are currently considered synonymous. DistributionPlumbago zeylanica native South Eastern Asia and India medicinal ornament evergreen shrub. This ornamental plant is one of ten to twenty species of Plumbago flowering plants.Plumbago zeylanica grows health in full to partial shade, intermediate warm temperatures, slightly acidic soil (no lime added), and recommended two parts peat moss to one part loam to two parts sand.Citraka plant grows throughout India, especially in Bengal, Uttar Pradesh, South India and Sri Lanka, in moist places.The red flowered variety of citraka grows abundantly of Khasi hills. MorphologyCeylon Leadwort is a herbaceous plant with glabrous stems that are climbing, prostrate, or erect. The leaves are petiolate or sessile and have ovate, lance-elliptic, or spatulate to oblanceolate blades that measure 5-9 × 2.5-4 cm in length. Bases are attenuate while apexes are acute, acuminate, or obtuse. Inflorescences are 3-15 cm in length and have glandular, viscid rachises. Bracts are lanceolate and 3-7 × 1-2 mm long. The heterostylous flowers have white corollas 17-33 mm in diameter and tubes 12.5-28 mm in length and appear all year long. Capsules are 7.5-8 mm long and contain are reddish brown to dark brown seeds. The fruits are like small cocklebur with glue on the soft spines and they will stick to anything. Seeds of the White Leadwort provide the best source to produce new plants (germinate in 21 to 3 days of 70 degrees Fahrenheit).The roots are stout, cylindrical, friable, blackish red in colour, with a pungent odour. The flowering occurs from Semptember to November .PropertiesCitraka is pungent and bitter in taste , pungent in the post digestive effect and has a very got potency . It alleviates kapha and vata dosas but aggravates pitta dosa. It possesses very sharp , light and dry attributes. Chemical constituentsTo investigate the chemical constituents from the aerial parts of Plumbago zeylanica L. The chemical constituents were isolated by various column chromatographic methods and the structures were elucidated by various spectroscopic methods, especially 2D NMR spectra. A new triterpenoid, 1β,3β,11α-trihydroxy-urs-12-ene, together with six known compounds, They are:(1)androsta-1,4-diene-3,17- dione (2), isoshinznolone(3), neoechinulin A (4) Harman(5) ergostadiene-3β,5α,6β-triol (6) and N-(N'-benzoyl-S-phenylalaninyl)-Sphenylalaninol (7) were isolated from the aerial parts of P. zeylanica. Compound 1 was a new compound, and compounds 2, 4-7 were obtained from this genus for the first timeMedicinal usesPlumbago zeylanica Roots, bark and seed are used for variety of medicinal treatments. The roots of the evergreen increase the digestion and promote appetite, and small doses stimulate central nervous system. The root of the plant is made into a paste and applied to the skin to treat abscesses, and other skin diseases including ulcers and scabies. The powder (Chitrak) may be added to bath teas for acne prone skin or for those suffering from chicken pox. In Africa, a cold infusion of the root is used for influenza and black water fever.In Zimbabwe Plumbago zeylanica root is cooked with meat in soup as an aphrodisiac. Bark of the Plumbargo zeylanica used to stop bleeding, cure baldness, and treat diarrheas. In Ethiopia powdered bark, root or leaves are used to treat gonorrhoea, syphilis, tuberculosis, rheumatic pain, swellings and wounds. Root-bark is useful to treat obesity. Also, Chitrak is used to correct menstrual disorders, and viral warts. Large doses of the White Leadwort roots is not recommend, cause death from respiratory failure and powerful poison. Also, the root (and leaves) of the plant is not recommend for use during a pregnancy cause an abortion, however known to be taken deliberately cause abortion in Malaysia and Africa . Plumago zeylanica recommend not be used to treat any symptoms unless under the supervision of a physician or qualified herbalist because of the potent ingredient of the plant may prove hazardous to those who have liver and kidney disease besides causing paralysis that can lead to death. Evidence has shown when Plumago zeylanica is administered orally inhibit tumor growth in laboratory rats. Second leading cause of cancer related deaths, prostate cancer maybe potentially inhibited by medicinal plant Plumago zeylanica. The skin of its roots is used for the medicinal purpose. Before use, the roots of citraka are purified in lime water. The roots are commonly used internally but seldom externally. In the form of an external paste, it is used in filariasis, depigmentation of the skin and anasarca generalized swelling all over the body. On applying its paste, boils appear on the skin and they burst open giving out the impurities. In rheumatic joints, its paste applied is beneficial. Orally or internally, citraka is used in a vast range of diseases. One must use citraka in small doses with caution, as it is very hot and sharp in its properties. It is indeed, a divine herb, in umpteen digestive disorders like loss of appetite, indigestion, piles, worms, colitis, ascites and liver diseases. A mixture of the powder of roots of citraka, rhzome of mustak and the fruits of vidanga in equal proportion, is taken 2-3 gms, with honey. It augments the appetite, improves digeston, relieves constipation and alleviates the urticaria – the allergic skin rashes. One gram of its root powder, with a glassful of buttermilk is recommended in the treatment of non-bleeding piles . The same is extremely helpful in colitis, when consumed for 4-6 months. Citraka alleviates oedema, hence effectively used in the enlarged liver and spleen. It relieves the obstructed phlegm in chronic colds and cough. It is used as a rejuenative (rasayana) in the diseases originated from the loss of appetite . It along with non-bleeding piles, works well in ano-rectal swellings. The medicated ghrta of citraka is very salutary in hepato splenomegaly and fever. The cough due to kapha dosa, is well controlled with Citrakadi curna a mixture of citraka, pippali, pippali mula and gaja pippali. Vagbhata and Sasruta have praised citraka as a bitter tonic and recommended as a rejuvenator . The tumours of vata origin are treated with Citraka ghrta whereas tumours of kapha origin are treated with the decoction of citraka with sunthi, pippali and eranda mula. Citraka digests the ama, augments the appetite and reduces the swelling , hence, is the potent drug for non-bleeding piles of vata and kapha types. Because of its extreme hot and sharp attributes, it irritates the uterus, enhances its contractions, hence is useful in cleansing it. It causes abortion, hence should be used with caution. It is absolutely contraindicated in preganacy . The decocotion of citraka works well in skin diseases, associated with pain and itching. The combination – citraka, vaca, sunthi and kutaja is a very comprehensive medicament for diarrhea, associated with abdominal pain and chronic colitis. Proved pharmacological actionsPlant extracts have shown potent mosquito larvicidal activity against the larvae of Aedes aegypti while showing no toxicity to fish Hexane extracts of Plumbago zeylanica have shown activity against canine distemper virus. Evidence has shown when Plumago zeylanica is administered orally inhibit tumor growth in laboratory rats. Second leading cause of cancer related deaths, prostate cancer maybe potentially inhibited by medicinal plant Plumago zeylanica. ???????????????????????????????????? Piper nigrum Kingdom:PlantaeClass:AngiospermsOrder:PiperalesFamily:PiperaceaeGenus:PiperSpecies:nigrumBotanical namePiper nigrumBlack pepper (Piper nigrum) is a flowering vine in the family Piperaceae, cultivated for its fruit, which is usually dried and used as a spice and seasoning. The word "pepper" is ultimately derived from the Dravidian word for long pepper, pippali. Ancient Greek and Latin turned pippali into the Latin piper which was used by the Romans to refer both to black pepper and long pepper, as the Romans erroneously believed that both of these spices were derived from the same plant. The English word for pepper is derived from the Old English pipor. The Latin word is also the source of Italian pepe, Dutch peper, German Pfeffer, French poivre, and other similar forms. In the 16th century, pepper started referring to the unrelated New World chili pepper as well. "Pepper" was used in a figurative sense to mean "spirit" or "energy" at least as far back as the 1840s; in the early 20th century, this was shortened to pep. Part Used : Dried Unripe Fruits, Usually Known As PeppercornsDistributionPepper is native to South East Asia and can be grown in soil that is neither too dry nor susceptible to flooding, moist, well-drained and rich in organic matter (the vines do not do too well over an altitude of 3000?ft above sea level).Black pepper is native to south India, and is extensively cultivated there and elsewhere in tropical regions. Currently Vietnam is the world's largest producer and exporter of pepper, producing 34% of the world's Piper nigrum crop as of 2008.Dried ground pepper has been used since antiquity for both its flavour and as a medicine. Black pepper is the world's most traded spice. It is one of the most common spices added to European cuisine and its descendants. The spiciness of black pepper is due to the chemical piperine. It is ubiquitous in the industrialized world, often paired with table salt.VarietiesThe fruit, known as a peppercorn when dried, is approximately 5 millimetres (0.20?in) in diameter, dark red when fully mature, and, like all drupes, contains a single seed. Peppercorns, and the powdered pepper derived from grinding them, may be described simply as pepper.The different varieties are: black pepper (cooked and dried unripe fruit), green pepper (dried unripe fruit) white pepper (dried ripe seeds).Black pepperBlack pepper is produced from the still-green unripe drupes of the pepper plant. The drupes are cooked briefly in hot water, both to clean them and to prepare them for drying. The heat ruptures cell walls in the pepper, speeding the work of browning enzymes during drying. The drupes are dried in the sun or by machine for several days, during which the pepper around the seed shrinks and darkens into a thin, wrinkled black layer. Once dried, the spice is called black peppercorn. On some estates, the berries are separated from the stem by hand and then sun dried without the boiling process.Once the peppercorns are dried, pepper spirit & oil can be extracted from the berries by crushing them. Pepper spirit is used in famous beverages like Coca-Cola and many medicinal and beauty products. Pepper oil is also used as a siddha massage oil and used in certain beauty and herbal treatments.White pepperWhite pepper consists of the seed of the pepper plant alone, with the darker coloured skin of the pepper fruit removed. This is usually accomplished by a process known as retting, where fully ripe red pepper berries are soaked in water for about a week, during which the flesh of the pepper softens and decomposes. Rubbing then removes what remains of the fruit, and the naked seed is dried. Sometimes alternative processes are used for removing the outer pepper from the seed, including removing the outer layer through mechanical, chemical or biological methods. White pepper has a slightly different flavour from black pepper due to the lack of certain compounds which are present in the outer fruit layer of the drupe but are not found in the seed.Green pepperGreen pepper, like black, is made from the unripe drupes. Dried green peppercorns are treated in a way that retains the green color, such as treatment with sulfur dioxide, canning or freeze-drying. Pickled peppercorns, also green, are unripe drupes preserved in brine or vinegar. Their flavour has been described as piquant and fresh, with a bright aroma. They decay quickly if not dried or preserved. MorphologyThe pepper plant is a perennial woody vine growing up to 4 metres (13?ft) in height on supporting trees, poles, or trellises. It is a spreading vine, rooting readily where trailing stems touch the ground. The leaves are alternate, entire, 5 to 10?cm long and 3 to 6?cm across. The flowers are small, produced on pendulous spikes 4 to 8?cm long at the leaf nodes, the spikes lengthening up to 7 to 15?cm as the fruit matures. The fruit of the black pepper is called a drupe and when dried it is a peppercorn.A single stem will bear 20 to 30 fruiting spikes. The harvest begins as soon as one or two fruits at the base of the spikes begin to turn red, and before the fruit is fully mature, and still hard; if allowed to ripen completely, the fruit lose pungency, and ultimately fall off and are lost. The spikes are collected and spread out to dry in the sun, then the peppercorns are stripped off the spikes. Chemical constitutionsPepper gets its spicy heat mostly from the piperine compound, which is found both in the outer fruit and in the seed. Black pepper contains between 4.6% and 9.7% piperine by mass, and white pepper slightly more than that.The outer fruit layer, left on black pepper, also contains important odour-contributing terpenes including pinene, sabinene, limonene, caryophyllene, and linalool, which give citrusy, woody, and floral notes. These scents are mostly missing in white pepper, which is stripped of the fruit layer. White pepper can gain some different odours (including musty notes) from its longer fermentation stage.The unripe, sun-dried peppercorns (fruit) are used for the extraction of the oil, using steam distillation which produces a yield of nearly 2%.The essential oil is composed of various chemical constituents and includes the following; a-thujone, a-pinene, camphene, sabinene, b-pinene, a-phellandrene, myrcene, limonene, caryophyllene, b-farnesene, b-bisabolene, linalool and terpinen-4-ol.Medicinal usesLike many eastern spices, pepper was historically both a seasoning and a medicine. Long pepper, being stronger, was often the preferred medication, but both were used.Black Pepper (or perhaps long pepper) was believed to cure illness such as constipation, diarrhea, earache, gangrene, heart disease, hernia, hoarseness, indigestion, insect bites, insomnia, joint pain, liver problems, lung disease, oral abscesses, sunburn, tooth decay, and toothaches. Various sources from the 5th century onward also recommend pepper to treat eye problems, often by applying salves or poultices made with pepper directly to the eye. There is no current medical evidence that any of these treatments has any benefit; pepper applied directly to the eye would be quite uncomfortable and possibly damaging. Nevertheless, Black pepper, either powdered or its decoction, is widely used in traditional Indian medicine and as a home remedy for relief from sore throat, throat congestion, cough etc.This warm and spicy essential oil helps to increase warmth of the body and mind, relieving sore muscles and joints, boost the immune and digestive system, stimulate the kidneys and disperse bruising by increasing circulation to the skin.Oil is a strong and sharp spicy smelling oil and is faintly reminiscent of clove oil, yet more refined. It can range in color from light amber to yellow-green and has a watery viscosity.This warm and spicy essential oil helps to increase warmth of the body and mind, relieving sore muscles and joints, boost the immune and digestive system, stimulate the kidneys and disperse bruising by increasing circulation to the skin.The therapeutic properties of black pepper oil include analgesic, antiseptic, antispasmodic, antitoxic, aphrodisiac, diaphoretic, digestive, diuretic, febrifuge, laxative, rubefacient and tonic (especially of the spleen).Black pepper oil can be used to help in the treatment of pain relief, rheumatism, chills, flu, colds, increase circulation, exhaustion, muscular aches, physical and emotional coldness, nerve tonic and fevers. It furthermore increases the flow of saliva, stimulates appetite, encourages peristalsis, tones the colon muscles and is a general digestive tonic.Sometimes it is used in place of cubebs for gonorrhoea. As a gargle it is valued for relaxed uvula, paralysis of the tongue. On account of its stimulant action it aids digestion and is especially useful in atonic dyspepsia and turbid condition of the stomach. It will correct flatulence and nausea. It has also been used in vertigo, paralytic and arthritic disorders.It has also been advised in diarrhoea, cholera, scarlatina and in solution for a wash for tinea capititis. Externally it is used for its rubefacient properties and as a local application for relaxed sore throat and some skin diseases. Its oleoresin has bacteriostatic and fungistatic properties.??Proved pharmacological actionsThe spiciness of black pepper is due to the chemical piperine. It is ubiquitous in the industrialized world, often paired with table salt.It has been shown that piperine can dramatically increase absorption of selenium, vitamin B, beta-carotene and curcumin as well as other nutrients. However, extracts from black pepper have been found to have antioxidant propertiesand anti-carcinogenic effects, especially when compared to chili. Piperine present in black pepper acts as a thermogenic compound. Piperine enhances the thermogenesis of lipid and accelerates energy metabolism in the body and also increases the serotonin and beta-endorphin production in the brain.Piperine and other components from black pepper may also be helpful in treating vitiligo, although when combined with UV radiation should be staggered due to the effect of light on the compound. Piperin also reduces the inflammation in rheumatic arthritis by increasing the serotonin secreation which has analgesic action. Piper longumKingdom:PlantaeClass:AngiospermsOrder:PiperalesFamily:PiperaceaeGenus:PiperSpecies:longumBotanical name Piper longumLong pepper (Piper longum), (Pippali), sometimes called Indian long pepper, is a flowering vine in the family Piperaceae, cultivated for its fruit, which is usually dried and used as a spice and seasoning. Long pepper has a similar, but hotter, taste to its close relative Piper nigrum. The word pepper itself is derived from the Tamil/Malayalam word for long pepper, pippali. The fruit of the pepper consists of many minuscule fruits — each about the size of a poppy seed — embedded in the surface of a flower spike that closely resembles a hazel tree catkin. Like piper nigrum, the fruits contain the alkaloid piperine, which contributes to their pungency. Another species of long pepper, Piper retrofractum, is native to Java, Indonesia.Long pepper is known to contain Piperlongumine, a compound believed to have an anti-tumor effect. DistributionIt is found throughout India especially in the warmer places. It is also found in Malaysia, Indonesia, Singapore, Sri Lanka and south Asian regions.MorphologyIt is a creeper that spreads on the ground or may take support of other trees. Leaves are 2 to 3 inch long. The older leaves are dentate, dark in color and heart shaped. The younger leaf is ovate in shape and contains 5 veins on them. Flowers are monoceous and male and female flowers are borne on different plants. Male flower stalk is about 1 to 3 inch long and female flower stalk is ? to 1 inch long. Fruit is long. When it ripes it attains red color and when it dries it attains black color. It is one inch in diameter. The fruit of the pepper consists of many minuscule fruits — each about the size of a poppy seed — embedded in the surface of a flower spike that closely resembles a hazel tree catkin.The plant flowers in rains and fruits in early winters. VaritiesAccording to ayurveda it has 4 varietiesPippaliGaja pippaliSaheliVana pippliChemical constitutionsIt contains aromatic oil that is about 0.7 %, piperine 4 to 5 % and an alkaloid and pipalartine. Besides this it contains sesamin and piplasterol. The root contains pipperin 0.15 to 0.18 %, pippalartin (0.13 to 0.20 %), pipperleguminin, sterols and glycosides.Long pepper is known to contain Piperlongumine, a compound believed to have an anti-tumor effect. It contains volatile oil, resin, piperine, piperlongumine, piplasterol, pipperin, pippalartin, piplartine, sylvatin, sesamin, diaeudesmin, piperlonguminine, piperlingumine, pipermonaline, piperundecalidine, brachyamide A, brachyamide B, brachystine, sterols, glycosides. UsesToday, long pepper is an extremely rare ingredient in European cuisines, but it can still be found in Indian vegetable pickles, some North African spice mixtures, and in Indonesian and Malaysian cooking. It is readily available at Indian grocery stores, where it is usually labeled pippali.The Ayurvedic texts list pippali as one of the most powerful Rasayana herbs, meaning it believed to be a longevity enhancer and is a remedy for throat irritation. Pippali is one of the most widely used Ayurvedic herbs.It has a strong erge to suppress any kind of infection occurring in the body due to its pungent taste.It helps in en expelling out the mucus that gets accumulated in the respiratory tract and also the sinuses present in face due to its sharp properties. It also strengthens the nervous system. It is a good digestive agent and helps in improving the gastrointestinal condition and also normalizes the peristaltic movements. It has a great effect on the respiratory tract???It is used against the following indications?InflammationPainNervine weaknessTastelessnessIndigestionLoss of appetiteConstipationPain abdomenPilesLiver related problemsAnemiaHeart related problemsBlood disordersCoughAsthmaHiccupsGeneral body weaknessTuberculosisDecreased sperm countMenstrual disturbancesSkin related disordersWormsOther uses??Oil and paste- It is used in applying on wounds and skin related ailments. It suppresses pain and also reduces inflammation.Powder – It maintains the normalcy of digestive tract and also helps in maintaining the proper peristaltic movement in the body. It tones up the respiratory tract and also cubs any kind of infection occurring the body. It also helps in toning up of urinary tract. It provides strength to the body. Other usesLong pepper helps in expelling out the mucus accumulated in the respiratory tract. It strengthens the nervous system, improves the gastrointestinal condition and normalizes the peristaltic movements. The herb serves as a good digestive agent. Its oil and paste is applied on wounds and skin-related ailments. Long pepper helps in suppressing pain and reducing inflammation. The herb helps maintain the normalcy of the digestive tract and tones up the urinary tract. Its fruits are used for respiratory tract diseases like cough, bronchitis and asthma. It benefits in anorexia, indigestion, flatulence, abdominal pain, hyperacidity, piles, paralysis of the tongue, diarrhea, cholera, chronic malaria, viral hepatitis, diseases of the spleen and tumors.It is given with amalaki, to treat anemia. The decoction of the plant is used in sciatica and hemiplegia. The herb is mixed with honey to control hiccups. Long pepper is used as an aphrodisiac, since it boosts the reproductive system. It is used as a sedative in insomnia and epilepsy. The infusion of the herb’s root is used after childbirth, to induce the expulsion of the placenta. Proved Pharmacological actionAn attempt was made to isolate some novel natural bioactive compounds with potential activity against multidrug resistant (MDR) Mycobacterium. A bioassay guided fractionation of Pippali was performed in five different organic solvents and their activities were monitored against different pathogenic bacteria including MDR Mycobacterium. Different fractions were screened for the bioactivity against Mycobacterium, and the structure of bioactive compound was characterized with H1 and C13 NMR. An ethyl acetate fraction of Pippali extract was found active against M. smegmatis (3000?g ml-1) and M. tuberculosis (39 ?g ml-1). It also shows very significant activity against other bacterial strains like E.coli (152 ?g ml-1), Staphylococcus aureus (14 ?g ml-1), Salmonella typhi (180 ?g ml-1), Enterococcus faecalis (15 ?g ml-1), and Pseudomonas aeruginosa (52 ?g ml-1). This fraction of ethyl acetate was then purified and characterized as piperine [5-(1, 3-benzodioxol-5-yl)-1-piperidin-1-ylpenta-2,4-dien-1-one], a well known alkaloid from this plant. Bioactivity guided fractionation concludes that Piperine is the only active ingredients in various fractions of fruit extract evaluated for antibacterial activity. Fraction having piperine has significant activity against multi drug resistant strains of Mycobacterium spp. than other purified fractions of fruit extract. The current finding encourages us to develop new alternative medicine that includes piperine alone and/or in combination with other drugs to fight against the drug resistance among Mycobacterial strains. ? Vitex negundoKingdom: Plantae Class:Angiosperms Order: Lamiales Family: Lamiaceae Genus: Vitex Species: negundo Botanical nameVitex negundoDistributionVitex negundo, commonly known as the five-leaved chaste tree. It is widely used in folk medicine, particularly in South and Southeast Asia. Vitex negundo is native to tropical Eastern and Southern Africa and Asia. It is widely cultivated and naturalized elsewhere. Countries it is indigenous to include Afghanistan, Bangladesh, Bhutan, Cambodia, China, India, Indonesia, Japan, Kenya, Madagascar, Malaysia, Mozambique, Myanmar, Nepal, Pakistan, the Philippines, Sri Lanka, Taiwan, Tanzania, Thailand, and Vietnam.[1] Vitex negundo are commonly found near bodies of water, recently disturbed land, grasslands, and mixed open forests. MorphologyVitex negundo is an erect shrub or small tree growing from 2 to 8 m (6.6 to 26 ft) in height. The bark is reddish-brown. It leaves are digitate, with five lanceolate leaflets, sometimes three. Each leaflet is around 4 to 10 cm (1.6 to 3.9 in) in length, with the central leaflet being the largest and possessing a stalk. The leaf edges are toothed or serrated and the bottom surface is covered in hair. The numerous flowers are borne in panicles 10 to 20 cm (3.9 to 7.9 in) in length. Each is around 6 to 7 cm (2.4 to 2.8 in) long and are white to blue in color. The petals are of different lengths, with the middle lower lobe being the longest. Both the corolla and calyx are covered in dense hairs. The fruit is a succulent drupe, 4?mm (0.16?in) in diameter, rounded to egg-shaped. It is black or purple when ripe. VarietiesThree varieties are currently recognized: Vitex negundo L. var. cannabifolia (Siebold & Zucc.) Hand.-Mazz. - found in China (including Hong Kong), India, Nepal, and Thailand. Vitex negundo L. var. incisa (Lam.) C. B. Clarke - found in China, India, Indonesia, and the Philippines. Vitex negundo L. var. negundo - Found in China, Japan, Taiwan and Nallamalas (India). Chemical constitutionsThe leaves contain fragrant, volatile oil and resins. The fruits contain resine, astringent organic acids, alkaloids and a pigment. The plant also contains alkaloids, glycosides, flavonoids, reducing sugars, sterols, resin and tannins. From seeds-n-triacontane, n-hentriacontane, n-pentatriacontane, n-nonacosane, sitosterol, p-hydrobenzoic acid and 5- oxyisophthalic acid isolated. 3, 4- dihydroxybenzoec acid is isolated from seeds. Vanillic acid, p-hydroxybenzoic acid and luteolin are isolated from bark.From essential oil pinene, limonene, camphene, phellandrene, methylheptanone, cumene, linalool, camphor, 4-terpineol, citral, caryophylline oxide, caryophyllene, terpinyl acetate, benzal – dehyde & cinnamaldehyde identified. Nishinaside and regundiside isolated from leaves identified. Nishinaside and regundiside isolated from leavesThe principal constituents the leaf juice are casticin, isoorientin, chrysophenol D, luteolin, p–hydroxybenzoic acid and D-fructose.The main constituents of the oil are sabinene, linalool, terpinen-4-ol, β-caryophyllene, α-guaiene and globulol constituting 61.8% of the oil. In vitro and animal studies have shown that the plant has potential anti-inflammatory, antibacterial, antifungaland analgesicactivities. Medicinal usesNigundi is pungent, bitter and astringent in taste, pungent in the post digestive effect and has hot potency. It alleviates vata and kapha doshas, but aggravates the pitta dosha. It possesses light and dry attributes. It has antipyretic, anti-arthritic and anti-inflammatory properties and is used in diseases like fever, worms, dermatoses, adenitis and splenic diseases etc The roots, fruits, flowers, leaves and bark of nirgundi have great medicinal value and are used for medicinal purpose externally as well as internally. Externally, nirgundi decoction is used for steam bath for arthritis, joint pains and sciatica. Particularly, nirgundi is very effective in alleviating the low back pain. The dried leaves when smoked are said to relieve catarrh and headache. Oil prepared with the juice is applied to sinuses and scrofulous sores. Oil is used also as bathing oil for rubbing on the head and in cervical lymphadenitis. The oil is also found to be salutary for sloughing wounds and ulcers. In premature graying of hair and scalp infections like pediculosis and lice, the oil is applied with great benefit. Decoction of nirgundi leaves is an effective gargle in stomatitis and sore throat. The poultice of hot leaves applied on swollen and painful joints, effectively mitigates the pains. Medicated oil is beneficial in suppurative otitis. The tub-bath of the decoction of its leaves is rewarding in sciatica, epididymo-orchitis and uterine inflammations. Internally, nirgundi is salubrious in vast range of diseases. It is used in vitiated conditions of vata like sciatica, arthritis, headache, spondylosis as a pain killer. The leaves juice is given along with cow’s urine, as a panacea for splenic pathology, associated with ascites. Nirgundi is extremely beneficial in cough, asthma, bronchitis and inflammatory conditions of pleura. Being diuretic, it is valusble in strangury to facilitate the micturition. The skin affections associated with pruritus are effectively ameliorated with nirgundi. The juice of leaves combined with honey, alleviates fever. Nirgundi is an influencial herb in vitiated conditions of vata, like hysteria, epilepsy, insomnia, vertigo etc. and works well as a brain tonic as well. It is a good rejuvenating plant in general debility. Proved pharmacological actionLeaves and stem of Vitex negundo were examined for phytochemicals using various techniques such as normal column chromatography, gel filtration on Sephadex LH-20 and radial chromatography. From the leaves, seven compounds were isolated and identified, by the use of various spectroscopic methods, to be mixture of the flavonoids luteolin, luteolin-3’-O-glucuronide, and isoorientin, the iridoid glycosides 2’-p-hydroxybenzoylmussaenosidic acid and agnuside, and phydroxyl benzoic acid as well as stigmasterol and β-sitosterol. Meanwhile, the stem yielded four lignans which were isolated for the first time from the plant, identified as 6-hydroxy-4-(4-hydroxy-3-methoxyphenyl)3-hydroxymethyl-7- methoxy-3,4-dihydro-2-naphthaldehyde, vitedoin A, vitrofolal E and detetrahydroconidendrin.Nitric oxide (NO) inhibitory assay using RAW 264.7 murine macrophage and soybean lipoxygenase inhibitory assay were carried out in the screening for antiinflamatory properties of the crude methanolic extract, the hexane, dichloromethane and ethyl acetate soluble fractions of the plant. From the leaves, both the hexane and dichloromethane fractions were shown to strongly g/ml and 20.00inhibit nitric oxide production with an IC50 of 14.00 g/ml respectively. Meanwhile, inhibition of soybean lipoxygenase activity was shown by the ethyl acetate fractions from both plant parts with IC50 of 56.38 g/ml and g/ml respectively.63.94 Further anti-inflammatory investigation on some of the isolated compounds showed that luteolin was significantly inhibited NO production with an IC50 of M), and inhibited formation of (9Z, 11E)-(13S)-13-g/ml (145.10 41.50 M).g/ml (5.42 hydroxyoctadeca-9,11-dienoate with an IC50 of 1.55 Luteolin also exhibited high activity in PAF receptor binding assay with 70.20% g/ml and xanthine oxidase assayinhibition at concentration of 18.2 with g/ml. The antioxidant98.20% inhibition at concentration of 100 evaluation using DPPH radical scavenging assay showed that luteolin and 6-hydroxy-4-(4- hydroxy-3-methoxyphenyl)3-hydroxymethyl-7-methoxy-3,4-dihydro-2- g/ml exhibited significantnaphthaldehyde at a concentration of 250 inhibition at 96.2% and 94.7% respectively. The results indicated that luteolin may play a key factor in the plant’s ability to reduce inflammation.In vitro and animal studies have shown that the plant has potential anti-inflammatory, antibacterial, antifungal Analgesic activities. Therapeutic action of the capsule rheumatigoPavonia zeylanica and plumago zeylanica both have anti inflammatory and analgesic action and there by reduces the inflammatory changes occurring in the minor joints of the body.Withania somnifera by its deobstruent action reduces the swelling,by its hypnotic action gives relief from the pain and by being general tonic strengthens the connective tissues and the affected parts of the body and also by being soporific gives relief from the mental stress.Piper nigrum,Piper longum,zingiber officinale being the mukkutramakatri normalises the increased vatha ,pitha and kapha kutrams and there by repairs the joints where the kutrams getvitiated and causes the damage to the cells,these three prevent the damage and also rejuvenate the joint cells.Vitex negundo by its anti pyretic ,anti inflammatory and anti spasmodic relives the stiffness present in the joints particularly by early morning and also lowers the temperature of the joints and also the body temperature.Kantha chenduram increases the hb level which will be certainly very low in rheumatoid patients,thereby reduces the general anasarca occurring in the body generally. Also gandham reduces inflammation and temperature and also redness, stiffness which are mainly seen in the rheumatoid patient.Withania somnifera,Kantha chendurum being anti vatha drug reduces vatham and plumbago zeylanica being a heat inducing drug acts on the kapha accumulated in the joints and relieves the stiffnesss and facilitates the movements in the joints.Zingiber officinale by its anti pitha action lowers the increased azhal kutram and hence reduces the redness and heat present in the joints and lowers the tenderness in the joints.Piper nigrum and piper longum being carminatives removes the loss of appetite.flatulens and induces the normal appetite and hence regains the losed body’s strength.In final result it reduces the inflammation of the joints and strengthens the immune system by which means the rheumatoid arthritis reduces its repeated episodes after this treatment.ConclusionSiddha System of medicine stresses on the correct selection of medicines according to the age, disease progession, symptoms, mental state of the patient etc. If diagnosed in the earliest stage, Siddha treatment is successful. Anxious and depressed patients should be well counseled. After the administration of Siddha drugs when the pain and inflammation subsides, patient should be encouraged to do mild yoga & pranayama. A regulation in diet should be made right from the beginning of the treatment throughout the life of the patient. Patients should avoid Cold food items, tapioca, sour food items like tamarind, excessive use of salt, curd, excess of non- vegetarian diet, smoking, tobacco, alcohol, fermented rice, etc should be strictly avoided. Prayers and Meditation should be a part of life always. ------------------------------------------------ ................
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