Changes

===Diagnosis through Integrative Medicine===

===Diagnosis through Integrative Medicine===

In integrative medicine, a disease is diagnosed by contemporary medical science parameters and its comparable condition in alternative medicine.  For example, in Psoriasis, annular, erythematous, xerosis lesions with an uneven surface are diagnosed as guttae psoriasis. The relative terms as explained in Ayurvedic classics in the context of [[Kushtha]] are listed in table 1. It shows that guttae psoriasis resembles mandala kushtha.  

In integrative medicine, a disease is diagnosed in contemporary medical science and its comparable condition in [[ayurveda]] following the patient examination together.  The patient examination is done by the multisystem doctors’ team separately based on their health system’s guidelines. This approach allows a clinician to understand the patient’s condition and helps identify the requirements, which is essential in the treatment using drugs from more than one system of medicine simultaneously. The findings of all the systems are documented to compare clinical features, prognosis, method of drug selection, and possible action of the drug in a specific disease condition. This process follows each therapeutic system’s guidelines strictly.  After examining multiple patients, a sthaneeya vikruti table was developed by collating all patients’ information. The information that contradicts the certain well-known facts of allopathy was excluded through mutual discussion. For example, the coppery red colour (thamra varna) of pitta dominant shwitra was excluded since it is a classical feature of lepromatous leprosy. The international experts reviewed the integrative medicine protocol and upgraded it whenever the multisystem doctor’s team needed improvement . For example, in Psoriasis, annular, erythematous, xerosis lesions with an uneven surface are diagnosed as guttae psoriasis. The sthaneeya vikruti table lists the comparable clinical terms as explained in Ayurvedic classics in the context of [[Kushtha]] are listed in table 1. It shows that guttae psoriasis resembles mandala kushtha.  

   

   

[[File:Fig_1-_Guttate_Psoriasis.jpg|350px|'''Fig 1: Guttate Psoriasis (Mandala kushtha)'''|thumb]]

[[File:Fig_1-_Guttate_Psoriasis.jpg|350px|'''Fig 1: Guttate Psoriasis (Mandala kushtha)'''|thumb]]

{| class="wikitable"

{| class="wikitable"

|+ Table 1: Guttate Psoriasis (Mandala Kushtha)  

|+ Table 1: Sthaneeya Vikruti of Guttate Psoriasis (Mandala Kushtha)  

|-

|-

! Symptom  !! Relative terms in [[Ayurveda]]

! Biomedical description !! comparable terms in [[Ayurveda]]

|-

|-

| | Annular ||  Mandala

| | Annular ||  Mandala

|-

|-

| | Erythematous ||  Rakta varna

| | Erythematous / Hypopigmented ||  Rakta / Shweta varna

|-

|-

| | Xerosis ||  Ruksha/Parusha

| | Coalescing lesions||  Anyonya samsaktham

|-

|-

| | Uneven surface ||  Khara

| | Uneven surface ||  Khara

Clinical examination in integrative medicine gives a mutual orientation with different medical systems.

Clinical examination in integrative medicine gives a mutual orientation with different medical systems.

   

   

Some general dermatological features and their Ayurvedic correlations in Lichen Planus<ref>Narahari SR, Prasanna KS, Sushma KV. Evidence based integrative dermatology. Indian J Dermatol 2013;58:127- 31.</ref> are given in table 2.

Dermatological features and their Ayurvedic correlations in Lichen Planus<ref>Narahari SR, Prasanna KS, Sushma KV. Evidence based integrative dermatology. Indian J Dermatol 2013;58:127- 31.</ref> are given in table 2.

[[File:Fig_2-_Lichen_Planus.jpg|350px|'''Fig 2: Lichen Planus'''|thumb]]

[[File:Fig_2-_Lichen_Planus.jpg|350px|'''Fig 2: Lichen Planus'''|thumb]]

{| class="wikitable"

{| class="wikitable"

|+ Table 2: General dermatological features of Lichen Planus

|+ Table 2: Dermatological clinical features of Lichen Planus

|-

|-

! Symptom !! Relative terms in [[Ayurveda]]

! Biomedical description !! Comparable terms in [[Ayurveda]]

|-

|-

| | Violaceous ||  Shyava/ Asita

| | Violaceous ||  Shyava/ Asita

Specific nomenclature resembling lichen planus is not observed in [[Ayurveda]] classics. However, in such cases, [[Ayurveda]] describes them based on pathophysiological features and still recommends treatments.

Specific nomenclature resembling lichen planus is not observed in [[Ayurveda]] classics. However, in such cases, [[Ayurveda]] describes them based on pathophysiological features and still recommends treatments.

   

   

In table 3, symptoms of lymphedema and its relative biomedical terms are explained. Lymphoedema is known as Shleepada in [[Ayurveda]]<ref>Narahari, S. R., Ryan, T. J.,Prasanna, K. S. and Aggithaya, G. M., Integrating modern dermatology and [[Ayurveda]] in the treatment of Vitiligo and lymphedema in India. International Journal of Dermatology, 2011;50: 310–334</ref>.  The table contains essential clinical features of the disease.<ref>Narahari S. Treating lymphodema patients in Indian villages. J Lymphodema, 2011;6:87-90</ref>  

In table 3, symptoms of lymphedema and its relative biomedical terms in ayurveda and biomedicine are listed. For example, lymphedema is known as Shleepada in [[Ayurveda]].<ref>Narahari SR, Ryan TJ. Mainstreaming of an Integrative Medicine Protocol for Morbidity Management and Disability Prevention of Lymphatic Filariasis: An opportunity for establishing AYUSH based National Health Programme. Annals of Ayurvedic Medicine, 2020; 9: 108-115.</ref>.  The table contains essential clinical features of the disease.<ref>Narahari S. Treating lymphodema patients in Indian villages. J Lymphodema, 2011;6:87-90</ref>  

[[File:Fig_3-Lymphedema.jpg|350px|'''Fig 3:  Lymphedema'''|thumb]]

[[File:Fig_3-Lymphedema.jpg|350px|'''Fig 3:  Lymphedema'''|thumb]]

|+ Table 3: Features of lymphedema (known as Shleepada in [[Ayurveda]])

|+ Table 3: Features of lymphedema (known as Shleepada in [[Ayurveda]])

|-

|-

! Biomedical terms !! Relative terms in [[Ayurveda]]

! Biomedical description !! Comparable terms in [[Ayurveda]]

|-

|-

| | Dependent oedema of foot|| Bahushopha  pada  

| | Dependent oedema of foot^a|| Bahushopha  pada  

|-

|-

| |Black pigmentation ||Krishna

| |Black pigmentation^a ||Krishna

|-

|-

| |Pricking pain or pain without any cause ||Theevra Thoda or Arthi or Animitta rujam

| |Pricking pain or pain without any cause^a ||Theevra Thoda or Arthi or Animitta rujam

|-

|-

| | History of fever||Bahusho jwara

| | History of fever^a||Bahusho jwara

|-

|-

| | Discharge||Samsrava

| | Discharge^b||Samsrava

|-

|-

| |Soft ||Mrudu

| |Soft^b ||Mrudu

|-

|-

| |Heaviness ||Gurutwa

| |Heaviness^b ||Gurutwa

|-

|-

| | Largely oedematous||Adhika shopha

| | Largely oedematous^b||Adhika shopha

|-

|-

| | The  warmth of the limb/ fever||Jwara yukta

| | The  warmth of the limb/fever^b||Jwara yukta

|-

|-

| | Oily/shiny||Snigdha/Snigdha varna

| | Oily/shiny^c|| Snigdha/Snigdha varna

|-

|-

| |With Nodules/ warty growth ||Bahukantakai parivrtam

| |With Nodules/ warty growth^c ||Bahukantakai parivrtam

|-

|-

| | Huge in size||Sthoola

| | Huge in size^c||Sthoola

|-

|-

| |The feeling of heaviness[continuous] ||Guru Gurutwamanisham

| |The feeling of heaviness[continuous]^c ||Guru Gurutwamanisham

|-

|-

|}

|}

[[File:Fig_4-_Vitiligo.jpg|350px|'''Fig 4:  Vitiligo'''|thumb]]

[[File:Fig_4-_Vitiligo.jpg|350px|'''Fig 4:  Vitiligo'''|thumb]]

{| class="wikitable"

{| class="wikitable"

|+ Table 4: Vitiligo (Swithra)  

|+ Table 4: Clinical features of pitta dominant Vitiligo (Swithra)  

|-

|-

! Symptom !! Comparable terms in [[Ayurveda]]

! Biomedical description !! Comparable terms in [[Ayurveda]]

|-

|-

| |Absence of hair on lesioned skin in hairy areas (differentiate it from Leprosy) || Roma vidhwamsa

| |Absence of hair on lesioned skin in hairy areas (differentiate it from Leprosy) || Roma vidhwamsa

=== Local pathology (sthaneeya vikruti)===

=== Local pathology (sthaneeya vikruti)===

   

   

While examining a patient through [[Ayurveda]], the vitiated doshas must be carefully examined and understood. [[Ayurveda]] selects an appropriate drug for a chosen patient, whereas modern medicine selects a patient for a chosen drug. The examination of the status of dosha in skin diseases can be done based on clinical features, as shown in the example (table 5).<ref>Narahari S.R, Ryan TJ, Aggithaya GM,Prasanna KS. Evidence based approaches for Ayurvedic traditional herbal formulations: Toward an Ayurvedic CONSORT model. Journal of Alternative and complementary medicine 2008;14: 769–776.</ref>  

While examining a patient in [[Ayurveda]], the vitiated [[dosha]] must be carefully elicited through clinical examination. [[Ayurveda]] selects an appropriate drug for a chosen patient, whereas modern medicine selects a patient for a chosen drug. The examination of the status of [[dosha]] in skin diseases can be done based on clinical features, as shown in the example (table 5).<ref>Narahari S.R, Ryan TJ, Aggithaya GM,Prasanna KS. Evidence based approaches for Ayurvedic traditional herbal formulations: Toward an Ayurvedic CONSORT model. Journal of Alternative and complementary medicine 2008;14: 769–776.</ref>  

{| class="wikitable"

{| class="wikitable"

|+ Table 5: Local pathologies and dosha specific clinical features in lymphoedema   

|+ Table 5: Local pathologies and [[dosha]] specific clinical features in lymphoedema   

|-

|-

! [[Vata dosha]] !! !! [[Pitta dosha]]!! !! [[Kapha dosha]] !!

! [[Vata dosha]] !! !! [[Pitta dosha]]!! !! [[Kapha dosha]] !!

|-

|-

| | Ayurvedic terms|| Relative biomedical terminologies||Ayurvedic terms ||Relative biomedical terminologies ||Ayurvedic terms ||Relative biomedical terminologies

| | Ayurvedic terms|| Comparable biomedical terminologies||Ayurvedic terms ||Comparable biomedical terminologies ||Ayurvedic terms ||Comparable biomedical terminologies

|-

|-

| |Ruksha  ||Xerosis ||Daha  ||Burning sensation ||Snigdha/snigdha varna ||Oily/ shiny  

| |Ruksha  ||Xerosis ||Daha  ||Burning sensation || Snigdha/snigdha varna ||Oily/ shiny  

|-

|-

| |Bahushopha pada ||Dependent edema of foot||Raktavarna ||Erythema/ redness||Shwetabha ||Whitish  

| |Bahushopha pada ||Dependent edema of foot||Raktavarna ||Erythema/ redness||Shwetabha ||Whitish  

==Clinical methods in [[Ayurveda]]==

==Clinical methods in [[Ayurveda]]==

The core concept of integrative medicine is ‘adhere to the basics of each system of medicine being integrated. If another system cannot explain certain concepts of one medical system, it should not be rejected. Instead, it should be accepted and included. ‘Amsha-amsha kalpana’ of [[Ayurveda]] is similar to the system by system examination of biomedicine. Researchers have shown that ayurvedic clinical examination goes beyond the ten types of clinical examination (dashavidha pariksha; the classical [[Ayurveda]] teaching).<ref>Narahari SR, Aggithaya MG. Morrow SE and Ryan TJ.  Developing an integrative medicine patient care protocol from the existing practice of [[Ayurveda]] dermatology. Current Science 2016:111:302-317.</ref>  Clinical methods in [[Ayurveda]] can be categorized as shown in table 7.

The core concept of integrative medicine is ‘adhere to the basics of each system of medicine being integrated. If another system cannot explain certain concepts of one medical system, it should not be rejected. Instead, it should be accepted and included. ‘Amsha-amsha kalpana’ of [[Ayurveda]] is comparable to the system by system examination of biomedicine. Researchers have shown that ayurvedic clinical examination goes beyond the ten types of clinical examination (dashavidha pariksha; the classical [[Ayurveda]] teaching).<ref>Narahari SR, Aggithaya MG. Morrow SE and Ryan TJ.  Developing an integrative medicine patient care protocol from the existing practice of [[Ayurveda]] dermatology. Current Science 2016:111:302-317.</ref>  Clinical methods in [[Ayurveda]] can be categorized as shown in table 7.

{| class="wikitable"

{| class="wikitable"

The above details of patient information contribute to the Ayurvedic diagnosis and drug selection.  

The above details of patient information contribute to the Ayurvedic diagnosis and drug selection.  

   

   

[[Dosha]] theories and personalized medicine are essential concepts of [[Ayurveda]], meaning clinical presentation and its pathophysiology are of prime importance. In biomedicine, clinical presentations, diagnosis, and co-morbidities are also given prime importance. In addition, clinical methods and differential diagnosis are in greater detail than in [[Ayurveda]].

[[Dosha]] theories and individualized medicine are essential concepts of [[Ayurveda]], meaning clinical presentation and its pathophysiology are of prime importance. In biomedicine, clinical presentations, diagnosis, and co-morbidities are also given prime importance. In addition, clinical methods and differential diagnosis are in greater detail than in [[Ayurveda]].

==Skin diseases in [[Ayurveda]]==

==Skin diseases in [[Ayurveda]]==

|+ Table 8: Clinical features of kapala kushtha

|+ Table 8: Clinical features of kapala kushtha

|-

|-

! Symptom  !! Biomedical description !! Attributes

! Ayurvedic term !! Biomedical description !! Attributes

|-

|-

| | Krishna ||Hyperpigmented  || Color  

| | Krishna ||Hyperpigmented  || Color  

|-

|-

| | Kapalabha  ||Dusky red  || Color  

| | Kapalabha  ||Dusky red and concave in shape like mud pot   || Color and shape 

|-

|-

| | Ruksha  ||Concave in shape like mud pot ||Shape 

| | Ruksha  ||Xerosis on inspection || Appearance

|-

|-

| | Parusha  || Dry on inspection  || Appearance  

| | Parusha  || Dry on inspection  || Appearance  

| | Toda bahula ||Severe pricking pain  ||Pain   

| | Toda bahula ||Severe pricking pain  ||Pain   

|-

|-

| | Vishama || Poor prognosis || Prognosis

| | Vishama visruthani || irregularly shaped || Appearance

|-

|-

|}

|}

In modern dermatology, skin lesions are also categorized based on history, morphology, pattern of distribution, and others.  Rather than disease, those 11 minor skin diseases need to be considered as lesioned skin morphology. In the Institute of Applied Dermatology, Kasargod, Kerala, [[Ayurveda]] doctors are asked to determine [[dosha]] vitiation of specific skin lesions. Dermatologists also examine the same patients to confirm the current diagnosis. Thus, the conditions are diagnosed and treated with an integrative approach.

In modern dermatology, skin lesions are also categorized based on history, morphology, pattern of distribution, and others.  Rather than disease, those 11 minor skin diseases need to be considered as lesioned skin morphology. In the Institute of Applied Dermatology, Kasargod, Kerala, [[Ayurveda]] doctors are asked to determine [[dosha]] vitiation of specific skin lesions. Dermatologists also examine the same patients to confirm the biomedical diagnosis. Thus, the conditions are diagnosed and treated with an integrative approach.

==Stages of disease==

==Stages of disease==

[[Ayurveda]] describes different stages of the disease by different names. For example, fig 6 can be discussed below.  

[[Ayurveda]] describes different stages of the disease by different names. For example, fig 6 can be discussed below.  

Fig 6 (a) is Lichen rubour planus. Since it is erythematous (raga), annular (mandala) and papular (pidaka), this is considered as dadru as per [[Ayurveda]]. Fig 6(b) &6(c) are hypertrophic lichen planus. There is hypopigmentation observed in the middle, surrounded by violaceous color. The lesions are thickened (ghana), elevated (utseda) with rough edges (rukshambahi). All represent [[Kapha]] [[vata]] [[dosha]] dominance. It is essential to know the stage of disease (roga avastha) to guide specific and selective treatment options.

 

Fig 6 (a) is Lichen rubour planus. Since it is erythematous (raga), annular (mandala) and papular (pidaka), this is considered as dadru in [[Ayurveda]]. Fig 6(b) &6(c) are hypertrophic lichen planus. There is hypopigmentation observed in the middle, surrounded by violaceous color. The lesions are thickened (ghana), elevated (utseda) with rough edges (rukshambahi). All represent [[Kapha]] [[vata]] [[dosha]] dominance. It is essential to know the stage of disease (roga avastha) to guide specific and selective treatment options.

 

[[File:Fig_7-Lymphedema-_Differential_diagnosis_(vyavachedha_nidhana).jpg|350px|'''Fig 7: Lymphedema: Differential diagnosis (vyavachedhanidhana)'''|thumb]]

[[File:Fig_7-Lymphedema-_Differential_diagnosis_(vyavachedha_nidhana).jpg|350px|'''Fig 7: Lymphedema: Differential diagnosis (vyavachedhanidhana)'''|thumb]]

In both these conditions, erythema (rakta varna), discharge (srava) and papular lesions are present. Therefore, it is considered as [[pitta]] predominant condition. However, the same treatment fails in one patient but improves the condition in another. One patient developed more pain, which is considered as aggravation of [[vata]]. Biopsy of the patient in (b)revealed that the condition was lymphangiosarcoma arising from lymphoedema, while the patient who got relief by treatment is lymphoedema with lymphangiectasia and lymphorrhoea (a).

In Fig 7, both limbs exhibit erythema (rakta varna), discharge (srava) and papular lesions. Therefore, it is considered as pitta predominant condition. However, the same treatment fails in one patient (7B) but improves the condition in another (7A). The 7B patient developed more pain, which is considered as aggravation of vata. Biopsy of the patient in (Fig 7B)revealed that the condition was lymphangiosarcoma arising from lymphoedema, while the patient who got relief by treatment is lymphoedema with lymphangiectasia and lymphorrhoea (Fig 7A).

==Treatment of skin disorders==

==Treatment of skin disorders==

===Importance of [[agni]], [[ama]] ===

===Importance of [[agni]], [[ama]] ===

[[File:Fig_8-_Importance_of_amapachana_in__vitiligo.jpg|350px|'''Fig 8: Importance of [[ama]] [[pachana]] in  vitiligo'''|thumb]]

[[File:Fig_8-_Importance_of_amapachana_in__vitiligo.jpg|350px|'''Fig 8: Importance of [[ama]] [[pachana]] in  vitiligo'''|thumb]]

The assessment of [[agni]] (digestion and metabolism) and [[ama]] (accumulated undigested biological waste in the digestive tract) is vital for treating a skin disorder. The importance of treating [[ama]] is shown in figure 7. The [[ama]] aggravates by the treatment for vitiligo without [[ama]] [[pachana]] (digestion of [[ama]]). When [[ama]] is treated, the vitiligo also decreases. So if [[ama]] is present, treatment to remove it should be given at the beginning.

The assessment of [[agni]] (digestion and metabolism) and [[ama]] (accumulated undigested biological waste in the digestive tract) is vital for treating a skin disorder. The importance of treating [[ama]] is shown in figure 8. The [[ama]] aggravates by the treatment for vitiligo without [[ama]] [[pachana]] (digestion of [[ama]]). When [[ama]] is treated, the vitiligo also decreases. So if [[ama]] is present, treatment to remove it should be given at the beginning.

Integrative therapies should not compromise biomedical pathology, neither the principles of [[Ayurveda]].  Table 9 shows that mutual dialogue between the systems of medicine leads to the integrated treatment protocol

Integrative therapies should not compromise biomedical pathology, neither the principles of [[Ayurveda]].  Table 9 shows that mutual dialogue between the systems of medicine leads to the integrated treatment protocol

[[File:Fig_9-The_patient_arrived_for_treatment.jpg|350px|'''Fig 9: The patient arrived for treatment on June 2 2017 (left), and returned for follow up on January 21 2018 (right)'''|thumb]]

[[File:Fig_9-The_patient_arrived_for_treatment.jpg|350px|'''Fig 9: The patient arrived for treatment on June 2 2017 (left), and returned for follow up on January 21 2018 (right)'''|thumb]]

The above approach to chronic disease care leads to better treatment not provided by a single system alone. Figure 9 below shows the response of Lymphatic Filariasis (lymphoedema) following integrative medicine treatment. A clinic to lab research-based developed from such studies might provide new treatments for chronic disease.<ref>Karayi AK, Basavaraj V, Narahari SR, Aggithaya MG, Ryan TJ, Pilankatta R. Human skin fibrosis: up-regulation of collagen type III gene transcription in the fibrotic skin nodules of lower limb lymphoedema. Trop Med Int Health. 2020;25:319-327. doi:10.1111/tmi.13359</ref>

The above approach to chronic disease care leads to better treatment not provided by a single system alone. For example, figure 9 below shows the response of Lymphatic Filariasis (lymphoedema) following integrative medicine treatment. A clinic to lab research-based developed from such studies might provide new treatments for chronic disease.<ref>Karayi AK, Basavaraj V, Narahari SR, Aggithaya MG, Ryan TJ, Pilankatta R. Human skin fibrosis: up-regulation of collagen type III gene transcription in the fibrotic skin nodules of lower limb lymphoedema. Trop Med Int Health. 2020;25:319-327. doi:10.1111/tmi.13359</ref>

==Conclusion==

==Conclusion==

   

   

Integrative medicine bridges the gap between biomedicine and [[Ayurveda]]. It allows the re-purposing of drugs within [[Ayurveda]]. Integrative medicine helps [[Ayurveda]] stage the disease; by adopting modern investigations, effectiveness of treatment can be improved. At the same time, intersectoral collaboration helps modern medicine to use evidence-based traditional medicines. [[Prakriti]] based studies will add more knowledge to pharmacodynamics. Especially in chronic conditions, integrating [[Ayurveda]] and Yoga could be an example for WHOs innovative care for chronic conditions.<ref>Innovative Care for Chronic Conditions accessed from the WHO website https://www.who.int/chp/knowledge/publications/icccglobalreport.pdf on the 18th September 2019</ref> In order to develop a treatment protocol of integrative medicine, a sound knowledge of applied and translational science is required.  

Integrative medicine bridges the gap between biomedicine and [[Ayurveda]]. It allows the re-purposing of drugs within [[Ayurveda]]. Integrative medicine helps [[Ayurveda]] to stage the disease; by adopting modern investigations, effectiveness of treatment can be improved. At the same time, intersectoral collaboration helps modern medicine to use evidence-based traditional medicines. [[Prakriti]] based studies will add more knowledge to pharmacodynamics. Especially in chronic conditions, integrating [[Ayurveda]] and Yoga could be an example for WHOs innovative care for chronic conditions.<ref>Innovative Care for Chronic Conditions accessed from the WHO website https://www.who.int/chp/knowledge/publications/icccglobalreport.pdf on the 18th September 2019</ref> In order to develop a treatment protocol of integrative medicine, a sound knowledge of applied and translational science is required.  

</div>

</div>