Rheumatoid Arthritis
Rheumatoid Arthritis
Arthritis
Arthritis
History
While 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 Ötzi, a mummy (circa
3000 BC) found along the border of modern Italy and Austria, to the Egyptian mummies circa
2590 BC
In 1715 William Musgrave published the second edition of his most important medical work
De arthritide symptomatica which concerned arthritis and its effects.
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Rheumatoid Arthritis
Definition
Arthritis (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.
Classification
There 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 spondylitis

Gout and pseudo-gout

Juvenile idiopathic arthritis
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Rheumatoid Arthritis




Osteoarthritis
Rheumatoid arthritis
Septic arthritis
Still's disease
Joint 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 Syndrome
Familial Mediterranean fever
Haemochromatosis
Henoch-Schönlein purpura
Hepatitis
Hyperimmunoglobulinemia D with recurrent fever
Inflammatory bowel disease (Including Crohn's Disease and Ulcerative Colitis)
Lyme disease
Psoriasis (Psoriatic arthritis)
Reactive arthritis
Sarcoidosis
TNF receptor associated periodic syndrome
Wegener'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 symptoms
Regardless 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.

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
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Inability to use the hand or walk
Malaise and a feeling of tiredness
Fever
Weight loss
Poor sleep
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Rheumatoid Arthritis


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Muscle aches and pains
Tenderness
Difficulty moving the joint
It is common in advanced arthritis for significant secondary changes to occur. For example, in
someone who has limited their physical activity:



Muscle weakness
Loss of flexibility
Decreased aerobic fitness
These changes can also impact on life and social roles, such as community involvement.
Extra-articular features of joint disease
Cutaneous nodules
Cutaneous vasculitis lesions
Lymphadenopathy
Oedema
Ocular inflammation
Urethritis
Tenosynovitis (tendon sheath effusions)
Bursitis (swollen bursa)
Diarrhea
Orogenital ulceration
Disability
Arthritis 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.
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Rheumatoid Arthritis
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.
Diagnosis
Diagnosis 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.
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Rheumatoid Arthritis
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.
Epidemiology
Arthritis 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.
Osteoarthritis
Osteoarthritis 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:
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Rheumatoid Arthritis
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.
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Rheumatoid Arthritis
Rheumatoid arthritis
Rheumatoid 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.
Lupus
This 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.
Gout
Gout 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 arthritis
Speed of
onset
Osteoarthritis
Rheumatoid arthritis
Gouty arthritis
Months
Weeks-months
Hours for an attack
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Rheumatoid Arthritis
Hands (proximal
Weight-bearing joints
interphalangeal and
(such as knees, hips,
Great toe, ankles, knees and
Main
metacarpophalangeal
elbows
locations vertebral column) and
joint) wrists, ankles
hands
and knees
May occur, though
often mild compared to
Yes
Yes
Inflammation
inflammation in
rheumatoid arthritis
 Narrowed joint
space
 Osteophytes
 Narrowed joint
 "Punched out" bone

Local
space
Radiologic
erosions
osteosclerosis
 Bone erosions
changes
 Subchondral
cysts
Laboratory
None
findings

Other
features

Anemia and elevated
ESR, rheumatoid
Crystal in joints
factor and C-Reactive
Protein (CRP)
 Extra-articular
features are
No systemic
common
signs
 Ulnar
 Tophi
Bouchard's and
deviation, swan
 Nephrolithiasis
Heberden's
neck- and
nodes
Boutonniere
deformity of
the hand
Other
Infectious 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.
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Rheumatoid Arthritis
Treatment
There 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 Therapy
In 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.
Medications
There 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.
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Rheumatoid Arthritis
Rheumatoid arthritis
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Rheumatoid Arthritis
The 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.
History
The 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.
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Rheumatoid Arthritis
Definition
Rheumatoid 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.
Pathology
The 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.
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Rheumatoid Arthritis
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 causes
Rheumatoid 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:
1. A genetic link with HLA-DR4 and related allotypes of MHC Class II and the T cellassociated protein PTPN22.
2. 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.
3. A remarkable deceleration of disease progression in many cases by blockade of the
cytokine TNF (alpha).
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4. A similar dramatic response in many cases to depletion of B lymphocytes, but no
comparable response to depletion of T lymphocytes.
5. A more or less random pattern of whether and when predisposed individuals are
affected.
6. 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.
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Rheumatoid Arthritis
Possible infectious triggers
It 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 rubella
Epidemiological 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 EpsteinBarr 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 factors
There 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 response
The factors that allow an abnormal immune response, once initiated, to become permanent and
chronic, are becoming more clearly understood.
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Rheumatoid Arthritis
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 D
The 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.
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Rheumatoid Arthritis
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 symptoms
RA 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.
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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.
Joints
A diagram showing how rheumatoid arthritis affects a joint
The 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.
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Rheumatoid Arthritis
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 energy
Low fevers
Loss of appetite
Dry eyes and mouth from a related health problem, Sjogren's syndrome
Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such
as the elbow and hands
Deformitis
As 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:
1. Swan neck deformity : Flexion of distal interphalangeal joint and hyperextension of
proximal interphalangeal joint.
2. Button hole deformity : Flexion of PIP and hyperextension of DIP
3. ulnar deviation of fingers.
4. Z Deformity of thumb
5. Subcutanious nodules in Extenor aspects of limbs.
6. Attrition of Extensor tendon at wrist causing dropped fingers
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"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.
Skin
The 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".
Pathology
The 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:
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pyoderma gangrenosum, a necrotizing, ulcerative, noninfectious neutrophilic
dermatosis.
Sweet's syndrome, a neutrophilic dermatosis usually associated with myeloproliferative
disorders
drug reactions
erythema nodosum
lobular panniculitis
atrophy of digital skin
palmar erythema
diffuse thinning (rice paper skin), and skin fragility (often worsened by corticosteroid
use).
Lungs
Fibrosis 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.
Kidneys
Renal 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 vessels
People 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
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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.
Other
Ocular
The 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.
Hepatic
Cytokine 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 (immunemediated destruction of hepatocytes). Hepatic involvement in RA is essentially
asymptomatic.
Hematological
Anemia 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.
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The mechanism of neutropenia is complex. An increased platelet count
(thrombocytosis) occurs when inflammation is uncontrolled, as does the anemia.
Neurological
Peripheral 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 symptoms
Constitutional 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.
Osteoporosis
Local 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.
Lymphoma
The incidence of lymphoma is increased in RA, although it is still uncommon.
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Diagnosis
Diagnosis 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:
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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 RAY
X-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.
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Appearance of synovial fluid from a joint with inflammatory arthritis.
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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 tests
When 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.
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RF is also seen in other illnesses, for example Sjögren'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.
Criteria
In 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.
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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:
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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:
o Involvement of 1 large joint gives 0 points
o Involvement of 2-10 large joints gives 1 point
o Involvement of 1-3 small joints (with or without involvement of large joints)
gives 2 points
o Involvement of 4-10 small joints (with or without involvement of large joints)
gives 3 points
o Involvement of more than 10 joints (with involvement of at least 1 small joint)
gives 5 points
serological parameters – including the rheumatoid factor as well as ACPA – "ACPA"
stands for "anti-citrullinated protein antibody":
o Negative RF and negative ACPA gives 0 points
o Low-positive RF or low-positive ACPA gives 2 points
o High-positive RF or high-positive ACPA gives 3 points
acute 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 longer
The 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:
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two or more swollen joints
morning stiffness lasting more than one hour for at least six weeks
the 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 diagnoses
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Several other medical conditions can resemble RA, and usually need to be distinguished from it
at the time of diagnosis:
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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 them
Lyme disease causes erosive arthritis and may closely resemble RA – it may be
distinguished by blood test in endemic areas
Reactive 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-antibodies
Rarer causes that usually behave differently but may cause joint pains:
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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 progression
The 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).
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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:
DAS28 decrease from initial value
≤ 0.6
> 1.2
> 0.6 but ≤ 1.2
Inactive
Good improvement
Moderate improvement No improvement
≤ 3.2
> 3.2 but ≤ 5.1 Moderate Moderate improvement Moderate improvement No improvement
> 5.1
Very active Moderate improvement No improvement
No improvement
Current
DAS28
Treatment
There 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 therapies
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Regular 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
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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 THERAPY
Range-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.
Prognosis
The 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 factors
Poor prognostic factors include :
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persistent synovitis,
early erosive disease,
extra-articular findings (including subcutaneous rheumatoid nodules),
positive serum RF findings,
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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 Complications
Rheumatoid arthritis can affect nearly every part of the body. Complications may include:
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Damage to the lung tissue (rheumatoid lung)
Increased risk of hardening of the arteries
Spinal injury when the neck bones become damaged
Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin,
nerve, heart, and brain problems
Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart
muscle (myocarditis), which can lead to congestive heart failure
The 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.
Mortality
RA 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.
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Epidemiology
Disability-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 140
The 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%.
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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.
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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 Professional
Call your health care provider if you think you have symptoms of rheumatoid arthritis.
Prevention
There is no known prevention. Proper early treatment can help prevent further joint damage.
Rheumatoid Arthritis and Exercise
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:
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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.
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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 Arthritis
Are 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:
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Jogging, especially on paved roads
Heavy weight lifting
That'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.
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NUTRITION
Some 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 Avoid
Certain 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
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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.
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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.
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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 diet
At 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 allergies
Food 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
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
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 Herbals
Name equivalence in siddha system
Rheumatoid arthritis is compared to vali azhal keelvayu in siddha system of medicine
Definition of keelvayu
Vatha 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:
1. Vali keelvayu: Rheumatic arthritis
2. Azhal keelvayu: Oesteo arthritis
3. Iya keelvayu: Tubercular arthritis
4. Vali azhal keelvayu: Rheumatoid arthritis
5. Vali iya keelvayu}:
6. Iya vali keelvayu }: Gonococcal arthritis
7. Azhal vali keelvayu: Poly arthritis
8. Azhal iya keelvayu: Syphilitic arthritis
9. Iya azhal keelvayu: Haemophilic arthritis
10. Mukkutra keelvayu: Pyogenic arthritis
Definition 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.
Causes
This results due to :
 improper dietery habits like increased consumption of Red Meat, Eggs, Fishes, Alcohol.
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



Sedentery life style .
over exposure to hot and cold weather,
psychic factors etc.
Genetic and Environmental factors are precipitating ones.
Symptoms
Initially 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,
anaemia
Side 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 may
reoccur with more severity as the disease becomes chronic finally leading to permanent
debility.
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Siddha line of treatment
In 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 capsule
Each 450mg capsule contains:
Pavonia zeylanica(sida acuta)
Withania somnifera
Plumbago zeylanica
Piper nigrum
Piper longam
Zingiber officinale(Dry ginger)
Vitex negundo
Kantha chenduram
The on coming paragraphs will give as detailed information about the proved
pharmacological actions of each ingriedents of the capsule
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Sida acuta (Sittramutti)
Kingdom:
Plantae
Class:
Angiosperms
Order:
Malvales
Family:
Malvaceae
Subfamily:
Malvoideae
Genus:
Sida
Species:
acuta
Distribution
Common 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 Srilanka
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It 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.
Morphology
Sida 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 extract
Roots 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.
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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 347,000ppm
Carbohydrate 94,000ppm to 475,000ppm
Fiber
33,000ppm to 167,000ppm
Fat
14,000ppm to 71,000ppm
Ash
16,000ppm to 81,000ppm
Besides 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.
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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 fever
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Sida cardifolia growing in the wild
Sida 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.
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A portion of Sida cardifolia showing flower and fruits
Fresh 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.
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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 Actions
Sida 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.
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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.
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Withania somnifera
Kingdom:
Plantae
Class:
Angiosperms
Order:
Solanales
Family:
Solanaceae
Genus:
Withania
Species:
somnifera
Botanical name:
Withania somnifera
Withania 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, Amukkara
Distribution
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Withania 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 meters
Withania 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.
Morphology
It 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 constitutions
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The 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 use
In 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.
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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.
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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 addiction
Taken 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 actions
The 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
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regenerative properties on brain-cell synapses in mice and in human cell lines in laboratory
studies
Withanolide A, withanoside IV, and withanoside VI have shown significant effects on the regrowth 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 studies
Depression treatment
Assessing 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.
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Animal studies
Diabetes and metformin
Amelioration 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 metformininduced 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.
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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.
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Plumbago zeylanica
Kingdom:
Plantae
Class:
Angiosperms
Order:
Caryophyllales
Family:
Plumbaginaceae
Genus:
Plumbago
Species:
zeylanica
Botanical name
Plumbago zeylanica
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Plumbago 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.
Distribution
Plumbago 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.
Morphology
Ceylon 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.
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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 .
Properties
Citraka 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 constituents
To 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
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(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 time
Medicinal uses
Plumbago 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.
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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.
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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.
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The combination – citraka, vaca, sunthi and kutaja is a very comprehensive medicament for
diarrhea, associated with abdominal pain and chronic colitis.
Proved pharmacological actions
Plant 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.
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Piper nigrum
Kingdom:
Plantae
Class:
Angiosperms
Order:
Piperales
Family:
Piperaceae
Genus:
Piper
Species:
nigrum
Botanical name
Piper nigrum
Black 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.
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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 Peppercorns
Distribution
Pepper 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.
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Varieties
The 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 pepper
Black 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.
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White pepper
White 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 pepper
Green 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 freezedrying.
Pickled peppercorns, also green, are unripe drupes preserved in brine or vinegar.
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Their flavour has been described as piquant and fresh, with a bright aroma. They decay quickly if
not dried or preserved.
Morphology
The 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.
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Chemical constitutions
Pepper 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; athujone, a-pinene, camphene, sabinene, b-pinene, a-phellandrene, myrcene, limonene,
caryophyllene, b-farnesene, b-bisabolene, linalool and terpinen-4-ol.
Medicinal uses
Like 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.
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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.
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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 actions
The 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 anticarcinogenic 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 longum
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Kingdom:
Plantae
Class:
Angiosperms
Order:
Piperales
Family:
Piperaceae
Genus:
Piper
Species:
longum
Botanical name
Piper longum
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Long 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.
Distribution
It is found throughout India especially in the warmer places. It is also found in Malaysia, Indonesia,
Singapore, Sri Lanka and south Asian regions.
Morphology
It 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 ½ 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.
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Varities
According to ayurveda it has 4 varieties
Pippali
Gaja pippali
Saheli
Vana pippli
Chemical constitutions
It 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.
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Uses
Today, 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
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It is used against the following indications
Inflammation
Pain
Nervine weakness
Tastelessness
Indigestion
Loss of appetite
Constipation
Pain abdomen
Piles
Liver related problems
Anemia
Heart related problems
Blood disorders
Cough
Asthma
Hiccups
General body weakness
Tuberculosis
Decreased sperm count
Menstrual disturbances
Skin related disorders
Worms
Other uses
Oil and pasteIt 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
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occurring the body. It also helps in toning up of urinary tract. It provides strength to the body.
Other uses














Long 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 action
An 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 (3000µg ml-1)
and M. tuberculosis (39 µg ml-1).
It also shows very significant activity against other bacterial strains like E.coli (152 µg ml-1),
Staphylococcus aureus (14 µg ml-1), Salmonella typhi (180 µg ml-1), Enterococcus faecalis (15
µg ml-1), and Pseudomonas aeruginosa (52 µg ml-1).
This fraction of ethyl acetate was then purified and characterized as piperine [5-(1, 3benzodioxol-5-yl)-1-piperidin-1-ylpenta-2,4-dien-1-one], a well known alkaloid from this plant.
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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 negundo
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Kingdom:
Plantae
Class:
Angiosperms
Order:
Lamiales
Family:
Lamiaceae
Genus:
Vitex
Species:
negundo
Botanical name
Vitex negundo
Distribution
Vitex negundo, commonly known as the five-leaved chaste tree. It is widely used in folk
medicine, particularly in South and Southeast Asia.
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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.
Morphology
Vitex 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.
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Varieties
Three 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 constitutions
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The 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, phydrobenzoic 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 leaves
The 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 uses
Nigundi 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.
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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.
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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 action
Leaves 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-3,4dihydro-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 20.00inhibit 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 assayinhibition at concentration of 18.2 with g/ml.
The antioxidant98.20% inhibition at concentration of 100 evaluation using DPPH radical
scavenging assay showed that luteolin and 6-hydroxy-4-(4- hydroxy-3-methoxyphenyl)3hydroxymethyl-7-methoxy-3,4-dihydro-2- g/ml exhibited significantnaphthaldehyde 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.
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In vitro and animal studies have shown that the plant has potential
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anti-inflammatory,
antibacterial,
antifungal
Analgesic activities.
Therapeutic action of the capsule rheumatigo
Pavonia 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.
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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.
Conclusion
Siddha 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.
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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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