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'''Diagnosis and Management of Skin diseases in Integrative medicine'''

'''Diagnosis and Management of Skin diseases in Integrative medicine'''

This article is based on a lecture delivered by Dr S R Narahari, MD (dermatology in biomedicine), Director, Institute of Applied Dermatology, Kasaragod, Kerala, India, in Prof.M.S.Baghel Memorial Lecture Series on Aug 09, 2021.

This article is based on a lecture delivered by Dr. S. R. Narahari, MD (dermatology in biomedicine), Director, Institute of Applied Dermatology, Kasaragod, Kerala, India, in Prof.M.S.Baghel Memorial Lecture Series on Aug 09, 2021.

 

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|title =  Contributors

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|data8 = Under process

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==Integrative Medicine==

==Integrative Medicine==

   

   

===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.   

 

[[File:Fig_1-_Guttate_Psoriasis.jpg|500px|'''Fig 1: Guttate Psoriasis (Mandala kushtha)'''|thumb]]

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.  

   

[[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: Guttate Psoriasis (Mandala Kushtha)  

|-

|-

! Symptom  !! Relative terms in Ayurveda

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

|-

|-

| | Annular ||  Mandala

| | Annular ||  Mandala

   

   

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.

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.

[[File:Fig_2-_Lichen_Planus.jpg|500px|'''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: General dermatological features of Lichen Planus

|-

|-

! Symptom  !! Relative terms in Ayurveda

! Symptom  !! Relative 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 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>  

[[File:Fig_3-Lymphedema.jpg|500px|'''Fig 3:  Lymphedema'''|thumb]]

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

{| class="wikitable"

{| class="wikitable"

|+ 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 terms !! Relative terms in [[Ayurveda]]

|-

|-

| | Dependent oedema of foot|| Bahushopha  pada  

| | Dependent oedema of foot|| Bahushopha  pada  

|}

|}

[[File:Fig_4-_Vitiligo.jpg|500px|'''Fig 4:  Vitiligo'''|thumb]]

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

{| class="wikitable"

{| class="wikitable"

|+ Table 4: Vitiligo (Swithra)  

|+ Table 4: Vitiligo (Swithra)  

|-

|-

! Symptom !! Comparable terms in Ayurveda

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

|-

|-

| |Absence of hair on lesional 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

|-

|-

| | Color of lotus petal|| Padmapatraprateekasha

| | Color of lotus petal|| Padmapatraprateekasha

The above examples show that the final diagnosis could be similar even though the nomenclatures are different in two different medical systems. In an integrated system, both systems learn from each other.

The above examples show that the final diagnosis could be similar even though the nomenclatures are different in two different medical systems. In an integrated system, both systems learn from each other.

===Local pathology (sthaneeyavikruti)===

=== 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 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>  

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

| |Krishna  ||Black pigmentation  ||Samsrava  ||Discharge  ||Bahukantakai parivrtam ||With nodules/ warty growth

| |Krishna  ||Black pigmentation  ||Samsrava  ||Discharge  ||Bahukantakai parivrtam ||With nodules/ warty growth

|-

|-

| | Teevrathoda/ arthi/ animittarujam|| Pain ||Mrudu  ||Soft ||Sthoola  ||Huge in size

| | Teevra toda/ arthi/ animittarujam|| Pain ||Mrudu  ||Soft ||Sthoola  ||Huge in size

|-

|-

| |Bahushajwara ||History of fever  ||Gurutwa  ||Heaviness  ||Gurutwamanisham  ||The feeling of heaviness (continuous)

| |Bahushajwara ||History of fever  ||Gurutwa  ||Heaviness  ||Gurutwamanisham  ||The feeling of heaviness (continuous)

|}

|}

[[File:Fig_5-_Vata_Dominance_Vitiligo.jpg|500px|'''Fig 5: Vata Dominance Vitiligo''|thumb]]

[[File:Fig_5-_Vata_Dominance_Vitiligo.jpg|350px|'''Fig 5: Vata Dominance Vitiligo''|thumb]]

{| class="wikitable"

{| class="wikitable"

|+ Table 6: Vata dosha specific features in vitiligo

|+ Table 6: [[Vata dosha]] specific features in vitiligo

|-

|-

! Symptoms  !! Allopathic terms

! Symptoms  !! Allopathic terms

| |Paridhwamsi  ||Galloping lesions with repigmentation or exploded

| |Paridhwamsi  ||Galloping lesions with repigmentation or exploded

|-

|-

| |Krishna || Dark repigmentation within the lesional skin when examined for the first time

| |Krishna || Dark repigmentation within the lesioned skin when examined for the first time

|-

|-

|}

|}

==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 (dashavidapariksha; 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 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.

{| class="wikitable"

{| class="wikitable"

|+ Table 7: Methods of clinical examination in Ayurveda  

|+ Table 7: Methods of clinical examination in [[Ayurveda]]

|-

|-

! Clinical methods in Ayurveda  !! Comparable biomedical terminologies

! Clinical methods in [[Ayurveda]] !! Comparable biomedical terminologies

|-

|-

| | Prakriti  ||Biological constitution of the body  

| | [[Prakriti]]   ||Biological constitution of the body  

|-

|-

| | Dosha  || Primary life force

| | [[Dosha]]   || Primary life force

|-

|-

| | Dushya  || Deranged basic body tissues and excretions

| | Dushya  || Deranged basic body tissues and excretions

| |  Vyayama shakti || Exercise capacity

| |  Vyayama shakti || Exercise capacity

|-

|-

| | Agni/Kostha and Ahara  ||Assessment of digestive process and dietary habits and disorders related to it   

| | [[Agni]]/Koshtha and Ahara  ||Assessment of digestive process and dietary habits and disorders related to it   

|-

|-

| | Sattva  || Behavior patterns  

| | [[Sattva]]   || Behavior patterns  

|-

|-

| |  Satmya || Compatible dietary habits  

| |  Satmya || Compatible dietary habits  

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

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

In [[Ayurveda]], seven major skin diseases (mahakushtha) and 11 minor skin diseases (kshudrakushtha) are explained. Mainly this classification is based on the [[dosha]] combination. The skin lesion is examined according to color, shape, appearance, sensation, spreading in the body, pain, and discharge. For example, the symptoms of Kapalakushtha and its attributes are given in Table 8.

In [[Ayurveda]], seven major skin diseases (maha kushtha) and 11 minor skin diseases (kshudra kushtha) are explained. Mainly this classification is based on the [[dosha]] combination. The skin lesion is examined according to color, shape, appearance, sensation, spreading in the body, pain, and discharge. For example, the symptoms of Kapala kushtha and its attributes are given in Table 8.

{| class="wikitable"

{| class="wikitable"

|+ Table 8: Clinical features of kapalakushtha

|+ Table 8: Clinical features of kapala kushtha

|-

|-

! Symptom  !! Biomedical description !! Attributes

! Symptom  !! Biomedical description !! Attributes

|}

|}

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 lesional 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 current diagnosis. Thus, the conditions are diagnosed and treated with an integrative approach.

==Stages of disease==

==Stages of disease==

[[File:Fig_6-_Stages_of_disease.jpg|500px|'''Fig 6: Stages of disease '''|thumb]]

[[File:Fig_6-_Stages_of_disease.jpg|350px|'''Fig 6: Stages of disease '''|thumb]]

[[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 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.

[[File:Fig_7-Lymphedema-_Differential_diagnosis_(vyavachedha_nidhana).jpg|500px|'''Fig 7: Lymphedema: Differential diagnosis (vyavachedhanidhana)'''|thumb]]

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

==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|500px|'''Fig 8: Importance of amapachanain 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 amapachana (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 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.

 

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

{| class="wikitable"

{| class="wikitable"

|+ Table 9: Integrated Ayurveda and yoga treatment for lymphology guidelines  

|+ Table 9: Integrated [[Ayurveda]] and yoga treatment for lymphology guidelines  

|-

|-

! International Society of Lymphology consensus requirements<ref>Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020;53:3-19. </ref>  !! IntegratedAyurveda elements   

! International Society of Lymphology consensus requirements<ref>Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020;53:3-19. </ref>  !! Integrated[[Ayurveda]] elements   

|-

|-

| | Skincare to improve the barrier function of the skin  ||Washing and soaking in hot infusion (phanta) to heal chronic wounds, care of bacterial entry lesions

| | Skincare to improve the barrier function of the skin  ||Washing and soaking in hot infusion (phanta) to heal chronic wounds, care of bacterial entry lesions

|-

|-

| | Lymph drainage  ||Udwarthana (Indian manual lymph drainage ) and Yoga

| | Lymph drainage  || Udwartana (Indian manual lymph drainage) and Yoga

|-

|-

| | Breathing  ||Yoga  

| | Breathing  ||Yoga  

|}

|}

The rotating ankle movements as a Yoga exercise (Gulphachakrasana) are practised for lymphoedema patients. An increase in radioisotope clearance from lymphatics of lower limbs with even small-amplitude ankle movements is reported by Prof Peter Mortimer.<ref>Mortimer PS, Simmons R, Rezvani M. The measurement of skin lymph flow by isotope clearance –reliability, reproducibility, injection dynamics and the effect of massage. J Invest Dermatol 1990; 95: 677–682.</ref>  Yoga and asana bring mobility,joint and muscle pump activation and dermal stretch. It is hypothesized that Yoga may induce drainage of lymph.<ref>Narahari SR, Ryan TJ, Aggithaya MG. How Does Yoga Work in Lymphedema? J Yoga Phys Ther 2013; 3:135. doi: 10.4172/2157-7595.1000135</ref>   

The rotating ankle movements as a Yoga exercise (Gulpha chakrasana) are practiced for lymphoedema patients. An increase in radioisotope clearance from lymphatics of lower limbs with even small-amplitude ankle movements is reported by Prof Peter Mortimer.<ref>Mortimer PS, Simmons R, Rezvani M. The measurement of skin lymph flow by isotope clearance –reliability, reproducibility, injection dynamics and the effect of massage. J Invest Dermatol 1990; 95: 677–682.</ref>  Yoga and asana bring mobility, joint and muscle pump activation and dermal stretch. It is hypothesized that Yoga may induce drainage of lymph.<ref>Narahari SR, Ryan TJ, Aggithaya MG. How Does Yoga Work in Lymphedema? J Yoga Phys Ther 2013; 3:135. doi: 10.4172/2157-7595.1000135</ref>   

 

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. 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>

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]] 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.  

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