Six progressive stages of disease for treatment interventions
The diagnosis and therapeutics in Ayurveda are based on clinical observation and assessment. Diagnosis at an early stage of disease, when abnormalities in body – mind functions are vague and non-specific is emphasized. In current times, diseases are diagnosed, when pathological, biochemical manifestations are surfaced,. However, at this stage, many times it is difficult to reverse the pathogenesis and restore health. Clinical diagnosis at an early stage can provide great input to manage a disease and prevent it from being untreatable.
More than 30 centuries ago, Sushruta – the father of Surgery in his compendium Sushruta Samhita has given the concept of Shatkriyakala (six stages of disease evolution). In this treatise after careful study of inflammatory process in open wounds (Vrana), conceptualized the natural history of disease evolution. The concept of Kriyakala (treatment strategy) describes the mode and stages of the development of disease.
There are six distinct formative patterns or stages of manifestation of diseases. A good understanding of each stage is very essential which has its own characteristic symptom to enable the treating physician to recognize the disturbance at early formative stage of disease for early diagnosis, prognosis and for adopting preventive and curative measures. Ayurveda advocates that if the deranged Doshas are checked or subdued in their primitive evolutionary phase (Chayavastha) may not be able to proceed with subsequent evolving changes (Su.Su. 21/37). However if left unresolved, they may gain the strength and intensity in course of their further developments.
A good knowledge of the concept of kriyakala (treatment strategy) is stated to be very necessary for the recognition of the disease process at very early inceptive stage, viz- the stage of commutation of effects – the accumulation (chayavastha) to arrest further developments.
The term Shatkriyakala is derived from three words as follows:
- Shat – Six
- Kriya– Action – for management (Treatment strategy)
- Kala– Time or stages of Disease manifestation
The six identified stages are as below:
|No.||Stage||Ayurvedic Term||State of Pathogenesis|
|1.||Accumulation of dosha at own site||Sanchaya||Sub clinical Observations|
|2.||Vitiation at own site||Prakopa||Sub clinical Observations|
|3.||Spread out through body channels||Prasara||Pre clinical Observations|
|4.||Localization at different sites||Sthansamshraya||Pre monitory features|
General clinical Manifestations
There are 3 natural dimensions of disease evolution, they are to be understood before going into the clinical manifestation
- Environmental influence on humans in form of seasonal effects
- Diurnal/nocturnal influence is consequence of transient fluctuations of Dosha (circadian rhythm)
- Physiologic variations of the body and at the level of defense mechanism
Natural Cumulative factors for Dosha fluctuations:
There are three basic physiological factor which run the body in physiological status and responsible for pathological manifestations. Tridosha (three bio-energies) are independent and responsible for all the physiological functioning of the body. The natural cumulative process of intrinsic factors like Tridosha are having a natural remission too, therefore they do not participate in evolutionary process of diseases condition. In Ayurveda effect of biological clock /circadian rhythm is described well and the formation of various ingredients of body physiology are influenced by following factors:
|Food||At the end of digestion process||During Digestion||Just after ingestion|
|Day time||Evening||Mid Day||Morning|
|Night Time||Late night||Mid Night||Early Night|
|Emotions||Grief, Lust, Fear||Anger, Envy||Satiety, Inertia|
|Tastes||Bitter, pungent and Astringents||Pungent, sourand salty||Sweet, Salty, and Sour|
|Foods||Bread, dried and preserved foods||Hot, Acidic and spicy foods||Sweets and heavy unctuous foods|
s.cy. c p/kop. c p/sr. S4ans.&ym\|
VyiKt wed. c yo vei% do8a`a. s wved\ iw8g\||su&ut sU5 21/36
The concept of kriyakala describes the mode and stages of the development of diseases. A good understanding of these are very essential for early diagnosis, prognosis and for adopting preventive and curative measures.
Charak and Vagbhata both from the medical school of Atreya described only three stages of natural processes of Tridosha pathophysiology.
- Chaya (Accumulation stage) – three Doshas (bio-energies) increase at their own seats from their individual threshold, may be due to circadian rhythm or seasonal variations or pre pathological condition.
- Prakopa – pathological or prepathological further accumulation where bio-energies are ready to flow out of their natural abode/seat. According to Charaka this state may be responsible for all pathological states if remission is not achieved.
3(a). Prasama (Remission) – at this stage the excessive accumulation of bio-energies are controlled by natural procedures or by dietetic modifications hence no further pathologies are produced.
- This happens physiologically in all bio energies (Tridosha), return to their natural threshold and abodes due to the compliance of good life style, seasonal regimen etc.
- In case if some a person gets involved in use of hot and spicy things (unsuitable food), excessive exercise then Dosha may transgress from original seat/abode (Koshtha) to peripheral tissues (Shakha) (C.Su. 28/31), and may proceed to further stage of evolution of disease which is called as stage of Prasara (Transmission/Spread).
- Thus, ifremission (Prasama) fails then it turns in to spread(Prasara) of Tridosha from their limiting threshold into healthy tissues through Srotas (micro channels)
3(b). Prasara – in this stage the bio-energies when cross their threshold limits at their abode tend to flow out in the peripheral microchannels.At this stage Vata gets rhythmic acceleration causing transmission of morbid (Doshik) materials in Channels.(C.Su. 28/31)
4. Sthan Samshraya –This stage of development of disease is known as localization due to the local deficiency/damage by many reasons defined in text to the tissue (Khavaigunya).
5. Vyakti – The stage of manifestation disease
6.Bheda–The stage of differentiation/ Complication/ termination / rehabilitation of symptomatology
Pathological stages of a disease:
- Stage of accumulation (sanchaya):
This is the inceptive phase of a disease, when doshaaccumulate and stagnate within their natural site of predominance. Vague and non-specific features are diagnosable with minute observations.
- Dullness or fullness of abdomen due to sluggish digestion is observed due to accumulation of vata dosha
- Dullness of color and complexion due to accumulation of pitta dosha
- Lower energy and subnormal temperature due to accumulation of kapha dosha
- An aversion of similar qualities of Dosha and attraction towards opposites
Principle of management in this stage:
Avoid “similar” diet and lifestyle, Using “opposites” diet and lifestyle
Fatigue, distended abdomen, loss of appetite occurs at the very early stage of most of viral fevers even during incubation period of infections. The patients and physicians both often ignore early features. Hence first opportunity
of the treatment is lost. The disease progression can be prevented or the less symptom disease will occurIf this stage is observed and proper interventions done.
2.Stage of vitiation (prakopa):
- Previously accumulated and stagnated dosha within their own site are further aggravated and get ready to spread all over the body with following symptoms:
- Variable pains – by vitiated Vata
- Burning & sucking sensation – by vitiated Pitta
iii. Retention of fluids – by vitiated Kapha
ManagementSuggested– is pacification of aggravated dosha, by use of dissimilar things or act.
This is the second opportunity of management if diagnosed at this level. These signs may appear due the micro inflammatory process in the tissues, which forms the backbone for the disease process.
3.Stage of spread or Prasara –At this stage there are two possibilities:
In this stage Dosha may return back to normalcy and at their normal sites, and stop further progression, if they are vitiated in first two stages. Doshas return to normalcy may be either Natural (Swabhavik) or due to the employment of appropriate therapeutic measures. Thus, leading to the absence of Vikaras or disturbances (A.Hr.Su. 12/24).
(a) Remission (prashama)
- The doshamay return back to normalcy and to their normal sites, and stop further progression, if they are vitiated in first two dimensions.
Supportive factors for remission:
- Wholesome& beneficial food (hita ahara)
- Daily & seasonal regimen of lifestyle (hita vihara)
- Sensible suitable use of senses (satmya indriyartha)
- Intact intelligence, patience & memory (pragya)
- The empowered state of body mind and digestion (Deha bala, chetas bala & agni bala)
- Followings expert’s advice (aptopsevi)
- Charity & Truthfulness (data & satyaparata) etc.
(b) Spread or prasara :
- If above said precautions are neglected, following factors lead to spread of vitiated dosha through the blood circulation.
- Spicy, excessive & incompatible diet
- Strength of body, mind and digestive capacity is less
iii. Misused senses, and intelligence
- Disease agents (nidana) not avoided
- In case of above said advises are neglected and following factors are used then the Doshas may move out of their abode to the circulation
- Spicy, excessive & incompatible diet
- Body, mind and weak digestive power
- Misused sensorias, and Intelligence
- Disease producing agents ( Nidana) are not avoided
- Remission /spread of Dosha to flow out into circulation and spread over the body
- Thus, this third stage of disease manifestation (3rd kriyakala) is a turning point for next phase of disease evolution.
- Rakta or Blood is the vehicle to carry or spread over Dosha into the whole body from their normal sites. At this stage, stimulated Dosha, circulating in blood, enter into the tissues/organs/ systems of the body (Dhatu).
- The pathway of disseminated Dosha is Srotasor micro channels
Features: The features in srotas or micro channels are manifested as:
- Painful distension of abdomen accompanied by rumbling noise & shifting pains – By Vata
- Hot flashes, regurgitations and sucking sensations – By Pitta
iii. Nausea and excess salivation – By Kapha
Treatment and precautions in this stage:
- Avoid antagonistic Diet (viruddhahar)
- Avoid suppression of natural urges (vegavarodha)
iii. Avoid exhaustive activities, stress, sex
- Avoid adulterants and intoxicants
- Practice daily and seasonal purification
- Localization stage at other site (stansamshraya )
- This is a Prodromal stage and symptoms of disease start to appear but these may be specific or non-specific,
- Provoked and circulating Dosha may getlocalized in specific micro channels/organs/tissues (Dosha-dushya sammurcchana).
- These Doshas interact with defense mechanism of body- Dhatu
- During invasive interactions of morbid factors, further features of disease may start to appear
- Doshaas morbid disease producing factors
- Dhatuas vital defense organisms of body interact at transporting and transforming micro channels.
- By the time of this stage now diseases are localized and can be named like – Diarrhea and skin disorders (atisara &kushtha)
- Khavaigunya– Structural and functional impairments cause loss of patency in these channels is termed as Khavaigunya Which is caused by:
- Specific causes of vitiation of all 13 micro channels
- Genetic predisposition
- Personalized body constitution
- Personalized Mental constitution
- Organ damaging factors previous diseases occurred at same sights but not cured properly
- 4 groups of defects of channels
Treatment at this stage:
- Practice for avoidance of impairing factors listed iv. Specifically for the 13 major involved channels
- Rejuvenation and protection of the vital organs
5. Manifestation – or Vyakti stage
The stage of full manifested disease as a result of invasive interaction of morbid factors into defensive healthy tissues (Dosha-dushya sammurcchana)with its characteristic symptomatology. At this stage the disease can be named properly.
This stage is comprised of:
- Weakened Digestion – Agni
- Vitiated morbid factors – Dosha
- Impaired micro channels – Srotas
- Debilitating defense mechanism – Dhatu
- Resulting pathologies in organs – Avayava
Treatment suggested at this stage
- Restoration of normalcy or – Vikriti vighata
- Improve Digestion
- Restore Dosha
- Repair the micro channels and organs
- Refresh the blood
- Rehabilitation of body tissues
- Non recurrence of disease
- Complication – or Bheda –
The stage of differentiation/ termination/ rehabilitation of symptomatology. In this stage disease become sub acute, chronic or incurable. When disease further progresses, it may produce complications becoming incurable or severe complications leading to death or may cause Temporary/ Permanent disability. Otherwise in self-limiting disorders disease may cured itself by body and rehabilitation will be required. This is the last opportunity of the management where all the possible management are to be applied.
- In this last phase of disease might be restored without disability.
- The importance of recognizing this stage is important for prognosis
- Recognition of this stage is also important to know the predisposition for further new disease (Nidanarthkaratva)
Suggested as Rehabilitative therapies orPrakriti Sthapan
- Prevent / limit the complications
- Prevent genetic transmissions to off springs
iii. Rehabilitation of disabilities
iv.Rejuvenation for non occurrence/recurrence of the diseases
- In this last stage, disease may lead to temporary/ permanent disability.
- It may advance to incurability/ complications / death on account of neglect of treatment suggested in earlier stages.
- With strong therapeutic interventions, the health might be restored without disability.
Six Stages of Disease Evolution and Management opportunities
|Pre Monitoring||Clinical Manifestation||Restoration Complication|
Sushruta Sutra Sthana. 21/36 Conceived By Prof C Dwarikanath in 1958 Revised by Prof Shrikrishna Khandel 2015- 20
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