1. A lesson by Dr. K. Shiva Rama Prasad (09633552646/09290566566) – technoayurveda@gmail.com 1
Lesson plan 001 for Paper KC-A Practical
Date: 05-02-2009 Time: 9 AM to 11 AM Prof/ Batch 3rd phase 2005
Name of the faculty: Dr. K. Shiva Rama Prasad
Instructional aids / Clinical appreciation
tools needed:
Topic: Identifying and managing “Manyasthambha” (Cervical spondylarthritis)
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Objectives: Clinical – instrumental and Biochemical diagnosis of Manyasthambha and
management
Subject points (include flow diagrams & tables):
• Manya is the back or the nape of the neck
(musculus cucullaris and trapezius)
• Manyagraha is spasm or contraction of
the neck
• Manyasthambha is stiffness or rigidity of
the neck (Monier William Sanskrit
dictionary)
Some opines that Manyaastambha is a
succession of Apataanaka. Or it may
manifest without Apataanaka. Due to nap in
day, staring crookedly, there may be
Manyaastambha, due to aggravated Vata,
associated by Kapha. This condition from contemporary system is dealt with –
• Spondylarthritis (sponcdil-ar-thrUctis) Inflammation of the intervertebral articulations.
• Spondylopathy (spon-di-lopc^-thT) Any disease of the vertebrae or spinal column. Syn: rachiopathy.
• Spondylolysis (spon-di-lolci-sis) Degeneration or deficient development of the articulating part of a
vertebra.
• Spondylitis (spon-di-lUctis) Inflammation of one or more of the vertebrae.
• Spondylolisthesis (sponcdi-lb-lis-thTcsis) Forward movement of the body of one of the lower lumbar
vertebrae on the vertebra below it, or upon the sacrum. Syn: sacrolisthesis, spondyloptosis.
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2. A lesson by Dr. K. Shiva Rama Prasad (09633552646/09290566566) – technoayurveda@gmail.com 2
Clinical diagnosis:
Most Common Causes of Neck Pain
Etiology Typical history Key physical Key lab findings
examination findings
Spondylosis Dull neck ache Tender to Radiograph (x-ray) shows
palpation midline degenerative changes that can
Older age-group Decreased active include narrowing of disc space,
Occipital headache and passive sclerosis of posterior elements, and
± radicular ROMs osteophytes
symptoms
Cervical disc Sharp neck pain Decreased active MRI shows disc protrusion or
herniation ROM extrusion into spinal canal
Burning or tingling Reduced deep
in upper extremities tendon reflexes
Pain with neck Decreased
motion strength in upper
extremities
Upper extremity Positive
weakness Spurling's test
Cervical Intermittent dull Normal ROM X-ray is normal or shows loss of
strain/sprain neck pain lordosis
± Occupational Loss of lordosis Consider computed tomography to
related (postural) rule out bony injury in trauma
± Trauma history Palpable
(motor vehicle tightness,
accident, fall) ropiness
Muscle spasm Occasional acute
edema
Muscle spasms
Fibromyalgia Diffuse axial Normal passive No laboratory test to confirm
skeletal pain ROM
Sleep disturbance Trigger points
Fatigue
Inflammatory Dull ache Decreased active RA: increased rheumatoid factor
arthritis such as and passive and erythrocyte sedimentation rate
RA or AS ROMs
Morning stiffness >1 Other joint AS: positive HLA B27
h inflammation
Other joint involvement
Referred pain Symptoms from Normal ROM of X-ray of other sites ECG, MRI
other sites (e.g., neck potentially helpful
chest pain, shoulder Physical examination findings at other sites (e.g.,
pain) shoulder strength loss, chest rales)
ROM, range of motion; MRI, magnetic resonance imaging; RA, rheumatoid arthritis; AS, ankylosing spondylitis.
Special Physical Examination Tests of Cervical Spine
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3. A lesson by Dr. K. Shiva Rama Prasad (09633552646/09290566566) – technoayurveda@gmail.com 3
Test Evaluation for How performed Positive test
Spurling's Nerve root Head in mild extension and flexion Pain in dermatomal
test compression (disc toward side of radicular symptoms pattern on affected
herniation) side
Distraction Nerve root Head lifted axially with one hand Pain relief with
test compression (disc under chin and other hand around lifting head
herniation) occiput
Adson's Thoracic outlet Extend patient's symptomatic Loss of pulse in
maneuvers syndrome shoulder while patient rotates neck affected extremity
toward affected side. Pulse is
checked during deep inspiration
Lhermitte's Spinal canal Patient sitting with legs extended; Shock like sensation
sign narrowing (spinal ask patient to flex neck forward into lower back
stenosis), multiple and/or extremities
sclerosis
Differential Diagnosis of Neck Pain
Musculoskeletal Neurologic Infectious Neoplastic Referred
Cervical strain or sprain Thoracic outlet Diskitis Spinal cord Rotator cuff
syndrome tumor tendinopathy
Disc herniation Peripheral Osteomyelitis Primary neck Myocardial
neuropathy neoplasm ischemia
Degenerative disc disease Myelopathy Meningitis Malignant Pneumonia
neoplasm
Inflammatory arthritis Radiculopathy Cervical lymphadenitis
(rheumatoid, ankylosing
spondylitis)
Cervical fracture Whiplash
Cervical instability Diffuse idiopathic skeletal hyperostosis
Cervical stenosis Torticollis
Fibromyalgia
• Taylor's 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter,
2nded
ICD-9CM CODES
722.4 Degenerative intervertebral cervical disk
722.71 Degenerative cervical disk with myelopathy
Instrumental diagnosis -
Computed tomography of body (Spine), Diagnostic
Magnetic resonance imaging, Diagnostic
Radiography (Cervical disks of spine), Diagnostic
Bio-chemical Diagnosis –
Creatine is synthesized in the liver, taken up by muscle cells to store energy as creatine phosphate.
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4. A lesson by Dr. K. Shiva Rama Prasad (09633552646/09290566566) – technoayurveda@gmail.com 4
Creatinine is formed by hydrolysis of creatine and phosphocreatine in muscle and by ingestion of
meat. When ever the only muscular involvement noted with the variances in S. Creatine and
creatinine.
Bone formation markers of osteoblast activity:
Bone-specific alkaline phosphatase, osteocalcin, procollagen type I
Bone resorption markers of osteoclast activity:
Tartrate-resistant acid phosphatase (TRAP), hydroxyproline, pyridinoline, deoxypyridinoline,
N-telopeptide, C-telopeptide, urine calcium -
Because of diurnal rhythm, specimens should be collected at same time of day (preferably AM)
Acid Phosphatase, Tartrate-Resistant (TRAP), Serum
Synthesized by osteoclasts in contrast to prostatic acid phosphatase that is tartrate sensitive; also found
in Kupfer cells and macrophages, thus much of males with BPH are susceptible for C.S.
Use: Marker of bone resorption
Alkaline Phosphatase (ALP), Bone-Specific (TRAP), Serum
Synthesized by osteoblasts; is involved in calcification of bone matrix. Only ~80% of total ALP is destroyed
by heating along with some nonbone-specific ALP.
Use: Marker of bone formation
Increased In: Paget disease; may be more sensitive than total ALP, especially when activity is low
Primary hyperparathyroidism, Osteomalacia, Osteoporosis and Pregnancy
• Serum Calcium, Osteocalcin (Cytosolic calcium-binding protein), etc are also bone specific chemical
tests required according to situation.
(Jacques Wallach M.D., Interpretation of Diagnostic Tests, 8th Edition, Lippincott, New York, P.349)
• In Ayurveda it is told by Chakradatta as the condition of stiffened back at four levels as – Vaksha
(thoracic) – Trika (lumbo-sacral)– Skandha (low cervical) – Manaya (high cervical); a four level
vertebral diseases referred to Spondylolysis as nosology of cervical pathology. He further hints to have
Kapha association and treat in conceptual with Vamana and Nasya discriminatively used by the
physician. If Vamana is administered in Manyasthambha, the exertion may not be allowed by the
patient and may the pain aggravate. The Vamana is administered when the physician observes the
symptoms such as – sthaimitya, Sheeta, supta, sopha (inflammatory edema), gourava and
snehakathinya (soft lumps).
• Where in Susruta, Vata Kapha hara Dravya Nasya is administered for the Dosha elimination and
externally Rooksha Sweda is offered. It looks as the Nasya (Mahamashadi Taila – Avartita) –
administered to regulate the neural involved pathology of spinal level, as said lÉÉxÉÉÌWû ÍzÉUxÉÉå ²ÉUqÉç.
Secondly external mediated management through – Rooksha Sweda offers the local blood supply
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5. A lesson by Dr. K. Shiva Rama Prasad (09633552646/09290566566) – technoayurveda@gmail.com 5
improvement and relieves the neural conductive blocks. The dilation of bone regulates inter vertebral
disk space and places to normal with soft regulative spinal massage.
• Prescription of the medicaments also on the same grounds – as Kapha Vata shamaka – and vedana
sthapaka. To relieve pain we commonly consider the Dashamoola, Rasna etc in Kashaya form along
with guggulu enhances the effect. Abha, Nirgundi, Eranda are the single drugs used here.
• Yogaraja gugulu or Trayodashanga guggulu with Maharasnadi kwatha or Rasnaspataka kwatha daily
morning at Vata – Kapha sandhikala
• Vatagajankusha ras tab 250 to 500mg daily twice with Dashamoolarista after meals
• Mridu Abhyaga with Prabhanjana vimardana Taila / kuzumpu or Dhanwantaram Taila followed by
salvana Upanaha
Experimental / Practice examining cervical area for the tests told and routine
Practice module Practice how to prepare “Salvana Upanaha”
Assignment: Look for the combination of Vatagajankush ras and Trayodashanga guggulu for its
applicability in Manyasthambha
Essay
• Define Manyasthambha and discuss the Nidana and Chikitsa in detail
Short
• Write a brief note on Manyasthambha with its management
Model questions
Mini
• Manyasthambha Chikitsa sutra
• Name the Panchakarma in Manyasthambha
Fill in the
• Dosha predominance in Manyasthambha is –
blanks
• The Sweda done in Manyasthambha is –
• Multiple choice
• A 55-year-old man is evaluated for weakness. Over the past few months he has noted slowly progressive
weakness and cramping of his left leg. Lately he has also had some trouble swallowing food. He is awake
and alert. Findings on the neurologic examination are normal except for marked atrophy with fasciculations
in the muscles of both legs, hyperactive reflexes in the upper and lower extremities, a diminished gag reflex,
and a positive extensor plantar response. Which of the following represents the most likely diagnosis?
(A) Cervical spondylosis
(B) Guillain-Barre´ syndrome
(C) Lambert-Eaton syndrome
(D) Vitamin B deficiency 12
(E) Amyotrophic lateral sclerosis
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6. A lesson by Dr. K. Shiva Rama Prasad (09633552646/09290566566) – technoayurveda@gmail.com 6
The answer is E. Amyotrophic lateral sclerosis (ALS) is an untreatable disease that results in the progressive
loss of upper and lower motor neuron function. Other components of the nervous system remain intact,
including the neurons required for ocular motility. Limb weakness and cramping is the first symptom, followed
by muscular atrophy, fasciculations, and loss of function of the cranial nerve musculature. Early in the disease,
upper-tract signs may predominate, resulting in spasticity. Pneumonia resulting from failure of clearance of
secretions is usually the terminal event. Treatable causes of motor neuron diseases such as cervical
spondylosis (no bulbar involvement) and lead poisoning should be excluded whenever the diagnosis of ALS is
considered. Guillain-Barre´ syndrome produces an ascending, rapidly developing paralysis. Vitamin B
deficiency should lead to abnormalities in posterior column function. Lambert-Eaton syndrome is a
paraneoplastic neuromuscular disorder that does not feature upper-tract signs.
• Chronically progressive spinal cord disease with sensory and motor signs evolving over years may be due
to
(A) Kennedy’s disease
(B) multiple sclerosis
(C) Tay-Sach’s disease
(D) lumbar disk disease
(E) amyotrophic lateral sclerosis
The answer is B. Several disorders produce chronic progressive spinal cord disease with sensory and motor
involvement. Syndromes of spinocerebellar degeneration may involve the motor and sensory spinal cord
systems in addition to causing ataxia. Multiple sclerosis usually causes a relapsing illness but can cause a
progressive, usually cervical myelopathy in elderly women. Cervical spondylosis, or bony compression of the
cervical cord by osteophytic bars, is another common cause of myelopathy in the elderly. Lumbar disk
compression of the cauda equina, which is made up of peripheral nerves, does not cause spinal cord signs.
Amyotrophic lateral sclerosis is a disease of spinal cord motor neurons and corticospinal tracts but has no
sensory signs. Kennedy’s disease is an x-linked spinobulbar muscular atrophy in which there is progressive
weakness and wasting of the limb and bulbar muscles. Adult Tay-Sach’s disease is a very slowly progressive
disarthria with radiographically evident cerebullar atrophy.
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