In Ayurveda, there are three primary doshas: Vata, Pitta, and Kapha, based on one’s body type. Vata is composed of space and air, which is the energy of movement; Pitta is composed of fire and water, which is the principle of digestion and metabolism; and Kapha is composed of water and earth, which is the dosha of structure and lubrication. 

Today we will discuss the importance of keeping these three doshas balanced.

Let's take a look at what causes dosha imbalances and how they can be corrected.

Supplements Recommended - Dashamoola, Rasna, Balaswagandhadi Thailam, Mahanarayana Thailam, Kottamchukkadi oil, Sahacharadi oil, Ajwain, Nirgundi, Ashwagandha, Flax milk, Sallaki, Turmeric, Bala, Rasnasaptakam kashayam

Vaidya - Namaste and welcome to another episode of the Athreya Herbs practitioner podcast. We are here to support our Ayurvedic community and practitioners by discussing compelling cases from our community. Our practitioners bring these cases to us, we discuss them, and we grow our knowledge. Tadvidya Sambhasha in Ayurveda is a concept that means you discuss and learn from a group of people who want to help and improve your clinical skills.

 

October 20, 2021 |  39 minutes.
By Vaidya. Jay Parla. 

 

Vaidya - That's the motivation of the Athreya Herbs practitioner podcast. We want to see our practitioners thrive in their practice. It is a greater good for Ayurveda, and that's the purpose of this podcast series. Today, we are back with Cheri. Welcome back and Namaste to you.

Cheri -  Namaste, Dr. Jay, Thank you so much for having me back.

Vaidya - For those who have not been familiar with our podcast, my name is Vaidya Jay. Everyone calls me Dr. Jay, but I like to go with the original name of Vaidya Jay. I bring in different practitioners from our community and discuss their cases. Today we have Cheri with us. She had a critical case a few weeks ago, and we have another strong case we learn with these cases. It's a real learning experience; your critical thinking, clinical skills, and herbal knowledge will improve. Thank you, Cheri, for coming and presenting here today. As usual, we will do the chanting, and then you can present your case. 

Cheri - Ok.

Vaidya - Om Namami Dhanwantrayam Aadi Devam, Surasura Vanditham Pada Padmam, Loke Jara Rugbhay Mrityu Nashakam, Datharam Eesham Vividhaushadhinam.Om Shanti Shanti Shanti Hari Om. May the Dhanvantray guide us in this clinical discussion. Thank you, Cheri. Go ahead and present your case to us. 

Cheri - Thank you, Vaidya Jay. This is an interesting case of a 60-year-old female. She came to me first with chronic hip pain. I started treating her using Ayurvedic treatments and Abhyanga massage with some herbal oils, and it helped her a lot. She came with the left upper hip pain, a torn labrum, and complained of right shoulder pain and rotator repair in 2012. She said that the surgery did not go well, and she had a hard time recovering from that shoulder surgery. She has traveling pain from the wrist to the shoulder and the hip. We kind of had to joke that it's traveling Arthur as you start to get arthritis in the body like travels around, so we had a little laugh about that and traveling Arthur goes from the wrist to the shoulder to the hip. Her digestion is all over the place, Vishamagni. Sometimes good, sometimes not. She does experience gas and bloating frequently and was diagnosed with osteopenia. She had an injury in the hip about ten years ago. By accident, she fell and then went over the handlebars and landed on the hip. She did say that overdoing tends to aggravate the hips, such as walking too long or hiking long distances. Her history of illness and surgeries, she had a cholecystectomy which is gallbladder removal. Hopefully, I'm saying that right.

Vaidya - Cholecystectomy.

Cheri - She had that in 1995 and had a discectomy in L4 and L5. I'm not sure when she was diagnosed with osteopenia, she had rotator surgery in 2012. She has allergies to codeine and compazine. She is currently taking Gabapentin which was prescribed to her for rheumatic issues and sleep. She takes multivitamins and glucosamine. She's postmenopausal; when she had her cycle, it was pretty standard. Nothing was interesting there, 4 to 5 days of moderate discomfort. Her mother is 80 years old, and the only medication she takes is for cholesterol; otherwise, she's healthy. Her father died in an accident when he was in his 30s; her brother is a couple of years younger and is healthy. She's from South Dakota and currently lives in Minnesota with her wife and in La Quinta, and they have a home a couple of minutes away from mine. She is a retired ER nurse, and she retired after 33 years. She typically wakes up in the morning around 7:30 and 8:30. She says she wakes up full of energy, ready to start the day. Her typical morning routine would be coffee and yogurt, and then she would walk or do chores—the specific diet regimen. The only thing that she's cautious of is including too much fat in her diet. She eliminated fat, garlic, jalapenos, and spicy stuff that she has an adverse reaction to, and she has breakfast from 8:30-9:00 AM. Her typical breakfast is yogurt with fruit and coffee. She has lunch between 12:00 and 1:00, and her typical lunch was salad, some carrots, and celery stuff that was leftover from the night before. Maybe some soup, crackers, ham, chicken, tuna, veggies, things like that grilled cheese, not the most important meal; it was more of like a snacky meal. She would have dinner around 5:30, and that was her biggest meal. Her typical dinner would be quite a bit of fish and sushi salads. Again, scallops, lentils, and sometimes pasta have red wine or white wine or beer every night with her dinner.  She always has one kind of alcoholic beverage with her meal. She doesn't smoke but exercises like walking, biking, yoga, and stretching every day. An interesting finding is that she gets up in the middle of the night and eats cereal, with 2% milk and cold cereal. Sometimes she'll have a small meal or some eggs or something. She seems to get up at that time, from maybe all the years of being an ER nurse, and her body's just kind of used to that time. Her Agnibala is Vishamagni. She does have a bowel movement every day, but every day it's different. Sometimes it's loose, sometimes it's drier with difficulty, sometimes she feels constipated, she does experience quite a bit of gas and bloating, as mentioned before, and it's crampy and painful. She does get up in the middle of the night to urinate. The amount of time is one to four times in the night. She does not sweat and has a difficult time breaking a sweat. She's a very active mind, so she does kind of struggle with the mind, and that's what she said the Gabapentin was also for her sleep. Other than that, she says she sleeps pretty well. She seems to have more Vata disturbances with difficulty falling asleep. When she's asleep, she wakes up at 3 in the morning like clockwork, and the Vata time is at 3 o’clock, but she doesn't have a problem going back to sleep. Her energy level and emotional balance are good. Her pulse was gripping; her left was a strong Pitta pulse. It was Pitta-Vata, but Pitta came through quite a bit. The right one was not strong at all, and it was tough to detect and was a little more Vata over Pitta. A distinct difference between the two from right to left. The color of the tongue was also fascinating. I didn't see any Ama to report. It was pretty red, redder than I would say is normal, and it was bulging on the right side. I know, I'm kind of fascinated with the tongues, Vaidya Jay. The right side had a slight bulge, and I looked up in the book to see what that represented. And that is where the gallbladder and liver are; I thought that was interesting. I don't know if it means anything at all, but it was interesting. She does have a slight purple patch in the lower center part. Red tip cracks towards the back and throughout the tongue were quite a bit of cracks. Her voice was good, pleasant, strong, and her touch was warm. Vision has no issues other than she does wear glasses. She's skinny and very lean. She did get a lot of relief, doing Snehana and Swedana with me. With the physical pain in her neck, shoulder, wrist, and hip, she reported that she felt quite a bit better after having a few treatments with me. So I was happy about that.

Vaidya - Wow. Okay. So, what I think, in this case, Cheri, for all our listeners, first of all, this patient is retired after 35 years of being an emergency room nurse. Emergencies are always Vata-provoking because you never know what to predict about its abnormal movement throughout your life. So you have to sometimes get up at this time, sleep at that time, somebody calls you in the middle, you have to be on your feet most of the time because you are on the move all the time. So, invariably, there is a systematic Vata increase. On top of that, what happens is this, because of their work schedule, they never get to eat in an orderly fashion. That’s why the food habits are irregular. You said it is Vishamagni, which makes sense because it's self-created, which Vishamagni is. In the beginning, it may not be, when she was growing up may not be, but as she entered into her job, her job made her have a Vishamagni that is ongoing. How are her bowel movements? You said her bowel movements are regular? 

Cheri - Yes, they are not regular. She said they were different all the time. Sometimes it's normal, and sometimes she has a hard time. So it just really depends on whether she never had any regularity with anything normal about it.

Vaidya - That is again we Vishamagni leading to probably Vishama type of gut function which leads to  Vishtabdhajirna the Ajirna that is not obvious, they will not complain of many digestive issues until like either the gallbladder stops functioning. The gallbladder patients usually have a lot of bodyweight, and they are heavy. They tend to be alcoholic or drink a lot of alcohol and eat tonnes of meat. If you look at her diet, it seems to be not so, and what are the height and weight approximately? What would you say, Cheri? 

Cheri - Yes, she's probably about 120 pounds.

Vaidya - So usually, you don't find a typical gallbladder patient to be Kapha-oriented with a lot of Ama. She's not but what happened is this Vishamagni, bodyweight whose work propelled lifestyle and diet made the Vishamagni have Vishtabdhajirna. The Vishtabdhajirna gradually causes constriction of Kapha. It started removing or extracting the Kapha from different parts of the body. That's what happened first, and the gut dried out. From the gut, the Vata that escaped from there became a typical Sandhi Vata. The Vata was constantly being fed because of her lifestyle if you look at the Labrum tear in the shoulder rotator cuff or even the joint capsule issue that was surgically corrected but never went well.

Cheri - Yes

Vaidya - Then, the labrum of the hip acetabulum is also damaged. So, what is happening is Vata is consuming Kapha because of its opposite qualities. The quality of Vata that you're looking for is Ruksha, so the quality is increasing. Ruksha quality is diffused into the asthi; also, that's why osteopenia, so the bone is gradually progressing. The Vata is going deeper and deeper. Now, after all of this, we think about what is happening to the Pitta and Kapha. The Kapha is reduced because of opposite qualities. So the Pitta, along with Vata, will move because Vata will displace the Pitta from its position. So she will not feel hungry at lunchtime; she will feel hungry at the Vata time. So Pitta time will not be hungry, when Vata time comes in, which is like, late in the afternoon and you're saying right, she's eating a lot of food because her Pitta and Vata are working together. They are depleting the cover, so that's what is happening in terms of her tissues. Why I say the Pitta and Vata are depleted. The aggravated Vata first went from Amashaya to the Pittashaya. Pittashaya is the gallbladder, so it dried out the gallbladder; probably she had like Gall sludge. When they say Gall sludge, it's not gallstones; it’s fine gravelly like almost dry dried out secretion. That's what is a Gall sludge. If you ask her when she comes back, what was the reason? She will say my gallbladder had sludge; that is nothing but Vata drying out the secreted Ranjaka Pitta from there and then drying and then making it congested. They both simultaneously, but primarily Vata, increased and moved towards the Kapha sthana. Where do Vata and Kapha meet? Vata and Kapha meet in the joints because Vata is in the asthi, and Kapha is in the Sandhi, so they meet in that region. That became the battlefield where Vata and Kapha would fight each other, and mostly Vata would win because it kicked Kapha out. Whatever arms or shoulder or knee or elbow that she was overusing were overused because of the ruksha quality of Vata, to laghu quality of Vata to Chala quality of the Vata movement because of continuous moving, standing. There is also an abnormal movement because of her trauma when she fell and got injured. So, as long as Vata was favorable or favorable to Vata, it kept on increasing in the joints and driving the Kapha out. What are the other joints? I just wanted to ask you about that. 

Cheri - Yes, it was her left hip, but it went to her right shoulder, right wrist, and right side of her neck.

Vaidya -  She worked as an ER nurse, and in that, you need to make a lot of notes because doctors depend on your notes. She might be right-handed; moving the mouse and moving these things would keep on increasing the Vata in these areas because movement is favoring the Vata to come and settle into these joints and dry the Kapha out.  She's not taking anything else. She's only just taking gabapentin. So because gabapentin, as all our listeners know, is a painkiller, like, a powerful painkiller. That's what gabapentin is. So she's taking it daily to reduce the pain and to feel functional. Otherwise, she cannot move around if she doesn't take it because of Vata's pain quality. The gabapentin kind of masks the pain, so Vata can still move around without hurting. So that's what the gabapentin is doing. If she were not taking this medication, she would not be able to move around or carry out the daily things. Another thing that you observed is that she wakes up precisely at three o'clock and then eats cold cereal.

Cheri - She'll do that at 11 or midnight. She gets up at 3 am always like clockwork, and I think she has a snack sometimes, or she gets up and goes to the bathroom. But she always wakes up at three o'clock. 

Vaidya - Eating the cereal, which is dry, light, cold, and then milk. The Vata and Kapha combine, at the time when they are coming to a tug of war again. That's what is happening even when she is making those choices. That's what she is making, feeding the two Doshas that are interlocking, primarily Vata dosha that's what she is doing. That is the main thing. Now, you were saying, why is her pulse so Pitta in nature, the tongue is so red, what is that to do with the pathology she's having? Vata is displacing the Pitta from its original position? As it moves upwards, she will also have neck pain, she may notice that her neck is hurting, or she may develop headaches because the Vata and Pitta are moving in that upward direction. That's why you're feeling the pulse because both of them are coming in outward and upper fashion, the movement of Dosha gati we call is outward and upward (urdhva). These two show the pulse as very Vata and Pitta in nature, so you might not feel Kapha. It may be very faint or almost non-existent. That's because Pitta and Vata have taken their position, and there is no room for Vata to exist. That's why when you did a little bit of Sneha sweda, the oil's Snigdha quality reduced the Vata, and she felt so much better. She will go, oh my gosh, this helps so much. She came back to you again and again because gabapentin helps, but it doesn't improve the range of movement as the dry quality of Vata restricted the movement; when you did Sneha and sweda her range of motion improved, and she felt more at ease in her joints. That's why she appreciated what you did for her.

Cheri - I'm sorry to interrupt you, but I wanted to mention while you were on the Pitta being misplaced because I ended up giving her some warming herbs. I know that because I saw so much Vata, so I gave her some warming herbs for her joints like dashamoola and rasna. But then she came back and said she had Amlapitta, and that explains the Vata's going upwards.

Vaidya - That makes sense and brings us to what we should do in this case? We understand that the Vata and Pitta have gone up, especially long-term lifestyle-infused Vata, which is also very deep into dhatu, asthi, mamsa, and sandhi. What should we do? How would we work with this case? What you did is correct Cheri, the first thing you did is you gave her external treatments. That would be the best approach for this case, maybe every week, just the local Pinda sweda you can do on the shoulders, hip, elbow, and wrist with a specific oil such as Bala ashwagandhadi thailam. Mahanarayana thailam can be used as well, but you want to focus on the pain rather than nourishing it so that you can think of Kottamchukkadi thailam. A classical Kerala oil-Kottamchukkadi has kushta and ginger as main ingredients. Sometimes I would prefer Sahacharadi thailam made from Sahachara, which is Barleria prionitis. These oils have somewhat Ushna, Snigdha, and a little bit of Manda quality and can be used. Those oils can be heated on a pan, and then we can make a dry potali, potli; in a sense, most of our practitioners will know what a potli is, but I'm trying to explain you take the powders or the seeds as well so you can take the dill, you can take the horse gram (Kulatha). Dill, Kulatha, and add a few mustard seeds into it. You can use ajwain seeds and a bit of hing or something like that, and you blend it all, tie them into boluses, and heat them in either kottamchukkadi oil or Sahacharadi oil. You dip it in and then use that for fermenting, which is Sneha sweda for the joints. What happens with this when Vata increases in sankocha (constrict). So Vata is coming in. It drives the Kapha out, especially shleshaka Kapha, and constricts all the tendons, ligaments, and even the joint capsule, the synovial joint capsule, everything becomes constricted (sankocha). And using this heat, and then the herbs will make them dilate or become looser, more open. So that's what you do. Maybe for 30 minutes, you asked her to come back every week, for 30 minutes of this treatment, just focus on the shoulder elbow, a bit about the pain is the leading four or five joints that she has to work. That's what you do until you get this patient’s confidence, like, Oh wow, this helps really, it's making a difference. So that's one part. And then you also give her to take home with her some thailam. Either you can do the same Kottamchukkadi or Sahacharadi, or you can do Mahanarayana during the week that she applies on herself and then takes a massage, gives herself a self-massage, and then do some hot water, like steam or even hot water shower after this application. So you're constantly going through the external method of Sneha sweda with the oils on then that potali. Now, what should we do internally, the Herbs that you want to choose? You were thinking, let me get onto that Vata quickly. Your approach was correct, but we did not know that there was also an underlying Pitta there. Remember that she's been taking this gabapentin for a long time. Gabapentin makes your stomach very sensitive. Also, you wanted to think about that. The first thing you did was Dashmoola and Rasna, or something like that.

Cheri - I did with Ajwain and Nirgundi.

Vaidya - The best choice will be, in this case, will be something milder than Ajwain. Your choice of Rasna was okay, but Ajwain and Rasna maybe were a little more aggravating for her. So, you're right on track as far as the Vata is concerned, but remember, the Ruksha quality of Vata has increased. For Ruksha, you need to do Snigdha dravya. The Snigdha dravya we can just think about is as simple as practical as using the herb of ashwagandha. Ashwagandha will be snigdha, guru and also brimhana. We would do the ashwagandha in the milk, two times a day, once in the morning and once at night. Use flax milk instead of any other milk, warm up two cups and a half of this flax milk, add a teaspoon and a half of ashwagandha powder, mix it and then give it to her to drink once in the morning, once at night. As all our practitioners will agree, not many people like the smell and taste of ashwagandha. If they don't like it, then take three capsules in the morning and three capsules at night. That will start handling the ruksha quality. Is she hypertensive? 

Cheri - No, she's not.

Vaidya - You can use something like sallaki. Sallaki is Frankincense, also called Boswellia. You can mix it, but the quantity will be less. You will use sallaki, a quarter teaspoon, along with turmeric. Sallaki and Turmeric are great. Many companies nowadays sell Boswellia and turmeric together, not an extract; don’t go for extract; just take it plain. You will get it from many Ayurvedic pharmacies. Athreya also sells sallaki and turmeric. Add that to the flax milk, add a quarter teaspoon of sallaki and a quarter teaspoon of turmeric into it. She has to drink this flax milk two times. She has these two Herbes in it, so you have Snigdha, Ushna quality, and manda quality that comes from sallaki, and ashwagandha is also manda. These two Herbs are perfect for her to take. I'm giving her milk because if there is any Pitta aggravation, the milk will make it calmer, and flax milk is great for bowel movements. It makes things go downwards. It has a little bit of anulomana effect, which can be beneficial for her. The first set of herbs is in the form of a milk mix. Some people don't like to drink a lot of this type of milk. You can even reduce the one and a half cups or one cup to half a cup. It is enough into which you mix these powders and then give. Now at the same time, you want to think about a Guggulu preparation for her.

Cheri -  Yograj? 

Vaidya -  Absolutely Yograj Guggulu will be good. Start from 111, 1 pill in the morning, one pill in the noon, and one pill at night. If her stomach agrees, you can change to 2 in the morning and two at night. Along with this, you can use a combination of Bala, rasna, ashwagandha but in capsule form. We at Athreya have a combination called vital joints, it’s a great blend when you do the treatment, and you do Dosha pratyanika chikitsa and Vyadhi pratyanika chikitsa. Dosha pratyanika is focused on the Vata, Kapha, and Pitta Doshas. You're tackling that, and then you look at the diseases as a whole that involves the specific dhatus, malas, srotas, then you choose the type of treatment. Yogaraj Guggulu is Vyadhi pratyanika (Disease-specific). The vital joint that I'm recommending is to be taken 2 in the morning and two at night. It doesn't irritate the gut and doesn't have a Pitta aggravating quality. Two of the Vital Joints in the morning and at night Yogaraj Guggulu 111 begin with, and then again 2 in the morning, two at night, can be continued after meals. These will be the combination of Herbs that we want to use. When she comes back every week for her treatments, keep asking about her progress. How is the progress? How is this joint feeling? If she's feeling better, you don't have to add anything, and if not, you need to change the internal Herbs to a little stronger ones. You can take rasnasaptakam kashayam. Seven other ingredients, including ginger, are used. That can be given provided Pitta is not that aggravated. Rasnasaptakam one and a half teaspoons in the morning, one and a half teaspoons at night can be given. Then at the end, after she comes back to you, I would recommend ten sittings of these oil treatments that we are doing. After that, you will give her something to improve the Asthi dhatu. A herb called Asthi sanghar is a bone generator, fuser, and strength-increasing herb. You can give asthi sanghar as one of the long-term herbal protocols to help her with the osteopenia she has not progressed into osteoporosis. In this case, we first use Vata, Pitta, shamaka herbs, and protocols. Kapha building bruhmana type of protocols for bulking, improving tissue strength, and tissue nourishment will be the next course of treatment. When she comes back after two to two and a half months of this treatment, switch to bruhmana type of treatment at that time. Does what I am explaining make sense?

Cheri -  It does. 

Vaidya -  We will love to get your feedback on how this patient responded or not. Make sure that you continue to give her at least ten external treatments; that’s the secret for this case.

Cheri - It's working for her, and she loves it. Thank you.

Vaidya - I think our listeners will see such cases, and we look forward to having you again with some instances from the Desert Ayurveda center. We love to discuss topics like this. It's incredible to interact with chronic cases, which are Ayurvedic strengths.

Cheri -  I appreciate the opportunity to learn from these people. It's humbling to come and present these cases to get help so that we can effectively help these people, and it is a gift. I am grateful, and it's wonderful that you're offering this.

Vaidya -  This is a blessing; otherwise, the Ayurveda world will be bottled up, and we don't want that. We want everybody to know Ayurveda, practice Ayurveda and spread the knowledge of Ayurveda for the greater good; that’s the purpose of these podcasts. Thank you so much, Cheri, for coming to our podcast and presenting to us. We look forward to having you again—Namaste, to you and all our listeners.

Cheri -  Namaste.