Rheumatoid Arthritis is an auto immune disorder which is of an unknown cause which has affected 1/8th of Indian population. As per 2021 news report from Times of India, 1.3 crore people in India suffer from RA. It is an auto immune and inflammatory disease which attacks healthy cells in your body, causing inflammation (painful swelling) in the affected parts of the body. Joint inflammation causes swelling, stiffness, and limited motion, especially in the small joints of the hands and wrists. But inflammation in rheumatoid arthritis isn't limited to the joints it is present throughout the body like skin nodules, eye inflammation, and lung scarring are well-recognized features of rheumatoid arthritis, all related to unchecked inflammation [1, 2].

Both in modern and ayurvedic system of medicine have accepted that it is an incurable disorder or very difficult to cure the disorder. Rheumatoid factors are proteins made by your immune system that can attack healthy tissue in the body. High levels of rheumatoid factor in the blood are most often related to autoimmune diseases, such as rheumatoid arthritis and Sjogren syndrome (an immune system disorder characterized by eyes and dry mouth, where the body’s immune system attacks its own healthy cells that produce saliva and tears, this occurs with other disorders like RA and lupus – an inflammatory disease). But rheumatoid factor may be detected in some healthy people [3].   

Traditional pharmacologic approaches have relied on combinations of non-steroidal anti-inflammatory drugs (NSAIDs; eg, aspirin, ibuprofen), analgesics, glucocorticoids (eg, prednisone, methylprednisone), and disease-modifying anti-rheumatic drugs (DMARDs) NSAIDs and glucocorticoids act rapidly to suppress inflammation, thereby reducing pain and swelling. Studies have mentioned about the biological agents provide very effective relief of inflammation and pain within days and weeks [4, 5]. TNF blockers such as etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab are proteins that selectively inhibit the tumor necrotic factor and stop the inflammatory process [6, 7, 8].

 Long pepper is the universe is gifted with several medicinal herbs. These medicinal herbs are associated with various phytochemical constituents that help in drug development to treat a variety of diseases. A slender aromatic climber having flowers in solitary spikes forming small red berries sunken in solid fleshy spike. Indian long pepper (Piper longum) is a plant found in Southern Asia. Its fruit and root are used in Ayurvedic medicine and as a spice in foods. Indian long pepper fruit and root contain chemicals that might help kill certain parasites and reduce swelling. One of these chemicals is called piperine [9, 10].

Dr Raghuram Y S in his article has mentioned about the steroids, especially corticosteroids are indiscriminately prescribed so as to hasten the recovery from diseases, quick recovery, including Rhematoid Arthritis, allergies, bronchial asthma and other respiratory disorders, gastro intestinal diseases, inflammatory and auto immune disorder, lupus, rashes and many other serious disorders. Indiscriminate and prolonged use of steroids can lead to serious consequences and ill effects on health. He has given the Comparison of action of pippali with corticosteroid, and says that vardhamana pippali action is like the steroid.

 A study reported that P. longum was first written by Hippocrates who defines this plant as a medicine rather than a spice. The most utilized parts of this plant are mainly fruits and roots. Long pepper was considered one of the major Indian exporters for nearly 2400 years. Theophrastus categorized pepper in two divisions i.e. round one and another one which is long. This plant is mainly utilized as a spice and as a drug in Europe during the medieval period and in the 19th century. It is the source of the drugs Pippali and Pippalimulam. The fruit of P. longum has been used as a flavor since ancient times and is used as a preservative in pickles, food items, medicine and traditional drinks [10].

It can be inferred that pippali could have been the first ever known medicine with action and effects resembling steroidal effect. Pippali has a multi-dimensional role on various systems of the body and cures many diseases effectively, in quick time, just as the steroids does. Steroids have anabolic effect, similarly being a rasayana pippali, and being in loading doses, vardamana pippali too have an anabolic effect (rasayana has anabolic effect). It is said that the corticosteroids should not be used for a longer duration or in excessive doses.

Medicinally, the plant is reported as a good remedy to cure menstrual pain, gonorrhea, sleeping problems, tuberculosis, respiratory tract infections, arthritic conditions and chronic gut-related pain.

To evaluate the efficacy of long pepper/piper longum in the management and treatment of rheumatoid arthritis based on the severity of diseases.

Aim of the Study

The aim of this study is

• To provide a safe, economical and effective remedy to the patients of RA
• To analyze the improvement of the conditions for a period of 3 to 4 months.

A set of 30 clinically diagnosed based on mild, moderate and severity patients of Rheumatoid arthritis were selected from OPD, IPD and special camp at Ayurdhama ayurvedic panchakarma center and Paripoorna Ayurvedalaya, Bangalore – 560040. The study population was diagnosed on the basis of clinical features for R-A-factor, C-Reactive-Protein and ESR. All the symptoms were given score to assess the effect of the treatment objectively. Erythrocyte sedimentation rate (ESR), R-A-factor and C-Reactive protein was recorded before and after the treatment.

Study Protocol

• Informed consent will be taken from the patients before commencement of the study
• The study was conducted using questionnaire form for detailing the personal history food history, clinical signs and symptoms, physical examination and biochemical tests.
• Anthropomorphic measurements Height, weight, and BMI

Intervention

Process of Vardamana Pippali rasayan, it is given in the form of course powder of pippali or the Pippali fruit as a whole as it is easy and convenient for the patients to consume till the period of 1 month. 1st day the procedure starts with taking 1 pinch of pippali powder in 100 ml of milk, boil and reduce it to 50 ml and consume it in warm state, 2nd day 2 pinch with 100 ml of milk reduced it to 50 ml, so as on till 10th day, after 10th day from 11th day onwards 10 pinch is continued till 21st day then reduced to 9, 8, 7, 6, 5, 4, 3, 2, 1 pinch.

• 1st day to 10th day-1,2,3,4,5,6,7,8,9,10 pinch
• 11th day to 20th day -10,10,10,10,10,10,10,10,10,10 pinch
• 21st day to 30th day-10,9,8,7,6,5,4,3,2,1 pinch
• 1 pinch of pippali powder maybe equal to may be somewhere around 1mg.

A total number of 30 members were selected based on the severity from the camp conducted for arthritis diagnosis and treatment, irrespective of age, gender, height, weight etc. Among 30 study participants, 12 members were male and remaining 18 members were female. Based on severity of rheumatoid arthritis the study population was further divided into mild, moderate and severe group. Based on the severity-mild, moderate, and severe, 10 members were selected for each group based on the features given below in Figure 1.

Figure 1: Number of patients based on the severity.

Among 30 study population, 10 members had mild signs and symptoms of rheumatoid arthritis, 10 members with moderate signs and symptoms and other 10 members had severe signs and symptoms of rheumatoid arthritis.

Figure 2: BMI classification of total number of patients.

Body mass index of study population was computed and the results (Figure 2) obtained projected that among 30 participants 3 comes under normal category, 3 were overweight, 12 members each were obese garde-1 and obese grade-2 category. This indicates that overweight and obesity may further damage to the bone joints, indicating the patients to maintain their body weight. Here majority of female participants have been seen with obesity as they are sedentary worker with minimal activities and unhealthy food habits.

Among 30 study groups majority are with mixed diet total number of 21 members are having the mixed diet and other 7 members are having vegetarian diet and other 2 members are having the ova-vegetarian diet.

Figure 3: Distribution of sleep pattern among total number of participants.

In rheumatoid arthritis sleep is disturbed as the patients are undergoing both physical and mental pain, majority members from the study group are undergoing disturbed sleep a total number of 21 members among 30 members were experiencing disturbed sleep, 3 members had normal sleep pattern and remaining 6 members experienced both normal and disturbed sleep (Figure 3), so disturbed sleep is a major health concern Sleep pattern were found to be different among male and female participants normal sleep pattern was observed by 2 female and 1 male participants respectively.  9 male participants and 12 female participants expressed disturbed sleep pattern, while 2 male participants and 4 are from female participants said to have mixed sleep pattern.

To perform the day to day activities by the patients suffering from rheumatoid arthritis is quite difficult by majority of the patients due the stiffness in joint, pain around the joints, swelling in joints. Among the 30 participants 5 members perform their activity normally, other 15 members activity performance was at moderate range, 7 members performed their daily activities with difficulty, and remaining 3 members were disabled they needed the support from others their each and every chores ( Figure 4) Table 1.

Figure 4: Distribution of activity based on day to day activities.

Table 1: Pain score assessments of study participants.

Pain score was assessed using pain assessment chart, among 30 study participants 9 members score 1, 18 members score 2, and 3 members score 3 Table 2.

Table 2: Bowel type among study participants.

Majority of the participants have encountered constipation or hard stool or difficult in defecation, among the total number of participants 5 had normal bowel, 4 had irregular bowel, 19 members had constipation and 2 members had loose stool.

Constipation is very much common in rheumatoid arthritis patients as common as loose stool; it is less noticed in the modern aspect as they say that it is due to the medication used by the patients like pain killers and steroids. So the type of bowel has also been noted among the study participants.

After the Pippali Vardamana Rasayana treatment, an improvement was seen among the study participants, constipation has been gradually decreased, participants with irregular bowel has noticed normal bowel, participants with loose stools has now been normal.

Figure 5: Appetite type among study participants.

Appetite plays an important role in nutrition among 30 number of total participants 19 members showed normal appetite, 8 members showed no appetite or loss of appetite, other 3 members showed irregular appetite some times normal and sometimes no appetite. Those who were suffering from irregular and normal appetite may undergo malnutrition or malnourishment, which has to be taken care of (Figure 5).  After the treatment, among the no appetite group and irregular group an improvement have been noticed, all 11 participants have seen or noticed some changes in their appetite and still need to improve their condition. Usually long pepper increases the appetite most of the time [10, 11].

Figure 6: Results of ESR, RA-Factor and CRP of the study participants pre-treatment.

 Before treatment, study participants were subjected to ESR, CRP and RA-factor examination and noted down based on the severity of the patients and mean value has been calculated. (Figure 6) represents the distribution of study participants with mild, moderate and severe and their ESR, CRP and RA-factor examination results. The ESR, RA-Factor and CRP levels are comparatively low in patients with mild signs and symptoms.

Figure 7: ESR, RA-Factor and CRP of the study participants post-treatment.

Before treatment, among mild, moderate and severe the ESR, RA-Factor and CRP levels are comparatively low in patients with mild signs and symptoms (Figure 7). And after the treatment a great improvement have been noticed among mild and moderate group. In participants with severe signs and symptoms improvements is seen but not up to expectation or very minimum positive results [10].

Table 3:  Comparison of ESR, RA-Factor, CRP before and after the treatment.

*** Highly significant

From the above Table-3 it is evident that there was significant difference with ESR, RA factor and CRP results among the study population before and after treatment with Vardhamana Pippali Rasayana on Rheumatoid Arthritis. Hence, the study reported that the long pepper treatment had a positive impact in bring down the intensity of signs and symptoms of Rheumatoid Arthritis from moderate and mild to normal. Similar results were reported in a study, as The use of Vardhamana Pippali Rasayana in 73 registered cases of Amavata caused 50.56% relief from the symptom of pain in joints, 48.7% relief from the symptom of stiffness in the joints, 53.25% relief from the swelling in joints and 46.20% relief from restriction of movements. All these results were found to be statistically highly significant (P < 0.001). A remarkable reduction (17.76%) in ESR was also noticed in the patients registered for the current clinical study and this result is also statistically highly significant (P < 0.001) [11, 12].

Figure 8: Percent effect of Vardhamana Pippali Rasayana on symptoms of Rheumatoid Arthritis.

Figure 8 represents percentage effectiveness of the treatment accordingly 63.3% participants had positive results and 36.6% had minimum result or no effect. , though pippali vardamana rasayana has given the positive results among majority group still it is not sufficient with severe group. Among the male study group, 3 members among severe group have met the positive results, 7 members among moderate group have met the positive results, and 9 members among the mild group have met the positive results.  Among 18 number of female study group 13.

females have met the positive results and among 12 male study group 6 male have met the positive results. It is noteworthy that all participants with mild signs and symptoms showed positive result with under normal values of ESR, CRP and RA Factor; similar observation was seen among participants with moderate signs and symptoms. However participants with severe signs and symptoms showed no improvement. This refers to that the treatment may have to be continued for another 2 months. The result obtained was supported by other studies [13,14,15].

Rheumatoid arthritis is an auto immune, chronic inflammatory disorder which affect the joints. In later stages it may develop deformity and disability, in modern science its causes are unknown and treatment has its own limitation, steroids, painkiller and NSAIDS has bas effect upon the internal organs.

Long pepper having the properties of anti- inflammatory, analgesic and immuno- modulatory effect on rheumatoid arthritis had a positive impact on the participants suffering from mild and moderate symptoms. This was observed from the results of ESR, RA- Factor and CRP before and after the intervention with Pippali Vardamana Rasayana.

After the Pippali Vardamana Rasayana treatment, an improvement was seen among the study participants. Constipation had been gradually decreased, participants with irregular bowel noticed normal bowel movement and participants with loose stools have changed to normal.  Those who were suffering from irregular and normal appetite after the treatment noticed improvement in their appetite.

Observation revealed 63.3% member showed positive results and remaining 36.6% have seen the minimum result or no effect, though pippali vardamana rasayana have given the positive results among majority group still it is not sufficient with severe group, here the treatment has to be continued for another 2 months to get even more better results. Pippali alleviates toxins, the factor responsible for development of autoimmune disorders in the body, resulting in the correction in immune system activities. Pippali has medicinal and immunomodulator actions. Thus, because of all these actions together, it plays an important role in the breaking the disease process, bringing the pathogenesis to a halt, making it weak enough to progress towards the formation of disease of the i.e. rheumatoid arthritis. Further, the drug is very much economical and the therapy is very cost-effective also.

Long pepper with its positive effect in managing and treating Rheumatoid arthritis is a safe with no side effects, economical and effective remedy.

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