A SCIENTIFIC LOOK AT ALTERNATIVE MEDICINE
Eastern Approaches
Part 4: Ayurvedic medicine, yoga, Siddha, and Unani
Thomas J. Wheeler, Ph.D.
Associate Professor (retired), Department of Biochemistry and Molecular Biology,
University of Louisville School of Medicine, Louisville KY
thomas.wheeler@louisville.edu
Revised 2019
This original version of this material was a handout for an elective course given to medical students at the University of Louisville.
Copyright 2019. Permission to copy for non-profit uses is granted as long as proper citation of the source is given.
DISCLAIMER: The material presented here is not medical advice. It represents the author's summary of scientific evidence concerning various topics. For medical advice, see your physician.
A pdf file containing all parts and references can be downloaded from ARTICLES or EASTERN.
CONTENTS OF PART 4
Ayurvedic medicine
Background
Principles
Practice and scope
Herbal remedies
Reviews
Scientific critique
Characteristics of pseudoscience
Other medical traditions of India
Yoga
Overview
Reviews
Scientific critique
Siddha
Unani
AYURVEDIC MEDICINE (AYURVEDA)
Background
Ayurveda is a healing tradition from India, going back thousands of years. The name comes from ayur (or ayu) (life, life-span), veda (knowledge, science). "Ayurveda not only is a WMS [whole medical system] but also incorporates eclectic philosophies of life that have helped to shape complex theories about health and disease over more than three millennia, including philosophical, epistemological, and spiritual dimensions. For example, Ayurveda postulates a paradigmatic harmony of physiological, psychological, social, and environmental factors of the human microcosm and the universal macrocosm" (Kessler et al. 2013. Evid Based Complement Alternat Med. 2013:952432).
"Vedic medicine developed as a combination of religious, magical, and empirical views and practices. The causes of disease include sin, violation of a norm, the unjust cursing of a fellow man, and the wrongs committed by one's parents or by 'oneself' in a previous incarnation. Disease is either punishment meted out by the gods directly or through demons, or the result of witchcraft. Remedies include prayer, sacrifice, magic, exorcism, and water as a 'purifier'" (Raso 1993. Mystical Diets).
"In India...Ayurveda is generally the only system of medicine available in villages and remote areas" (Sharma et al. 2007. J Altern Complement Med. 13(9):1011-9). However, "'today most people turn to Ayurveda literally as a last resort,' says Vaidya Balendu Prakash, director of the VCPC Research Foundation, an Ayurvedic treatment center..." (Bagla 2011. Science 334(6062):1491).
"In India and some neighboring countries, Ayurvedic medicine is officially and legally recognized as on par with conventional medicine...in India alone above 400,000 registered Ayurvedic physicians practice Ayurveda and there are more than 250 universities and colleges where Ayurvedic medicine is systematically taught as a 4–6-year university degree program...In addition to its key role in Asian health care systems, it is playing a growing role in Complementary and Alternative Medicine (CAM), especially in integrative settings in Europe and North America. For instance, in Germany, Austria, and Switzerland Ayurveda is one of the fastest growing CAM methods...Concerning Ayurveda, two main opposing positions can be observed: (a) supporters of 'scientific' Ayurveda state that it has always been an empirical medical system in which religious and spiritual speculations are mere interpolations, alien to the system, or (b) supporters of 'traditional' Ayurveda state that religious and spiritual elements have always been integral components of Ayurveda as a WMS" (Kessler et al. 2013. Op. cit.).
Ayurveda includes a pharmacopeia with thousands of plants and plant derivatives (see "Herbal remedies" below).
It has been promoted in the U.S. by Maharishi Mahesh Yogi's Transcendental Meditation organization as "Maharishi Ayur-Veda." Maharishi University of Management (Fairfield, IA) conducts research on ayurvedic medicine. However, Viswanathan and Raso (2000. Priorities (American Council on Science and Health) 12(2)) wrote, “What passes for Ayurveda in the Western Hemisphere may have little relation to Ayurveda of the traditional kind...While the trend in India is somewhat to technologize the practice of classical Ayurveda, the trend in developed countries of the West is to mysticalize and supernaturalize classical Ayurveda itself.”
Author Deepak Chopra, M.D. (Quantum Healing; Perfect Health; Ageless Body, Timeless Mind) became prominent with the Maharishi group, and then established his own center in California. " Chopra is the owner and supervisor of the Mind-Body Medical Group within the Chopra Center, which in addition to standard medical treatment offers personalized advice about nutrition, sleep-wake cycles and stress management, based on mainstream medicine and Ayurveda" (Wikipedia contributors 2019. Deepak Chopra).
Principles
Ayurveda proposes that the body is composed of five elements: earth, air, fire, water, ether. Combinations of these produce three "humors" or doshas: pitta, kapha, and vata. "Vata relates to movement, circulation, nerve impulses and respiration. Kapha has to do with solidarity, muscularity and physical strengths, while pitta is associated with digestion and metabolism" (National Council Against Health Fraud. Ayurvedic medicine/TM).
"In Ayurveda, the three doshas are considered to be universal principles that function in all aspects of material creation, including the mineral, plant, and animal kingdoms, the time of day, the seasons of the year, even the planets and galaxies. In this way the human physiology is inexorably connected to the whole of existence. The doshas have been correlated with systems theory in the field of physics, providing a sound theoretical basis for this Ayurvedic concept" (Sharma et al. 2007. Op. cit.).
“Doshas are constantly being formed and reformed by food, activity, and bodily processes” (National Center for Complementary and Alternative Medicine 2005. What is Ayurvedic Medicine?). Individuals are classified into types characterized by a predominant dosha. The “constitution” of an individual is referred to as the prakriti. Excess or deficiency of a dosha results in disease (e.g., kapha imbalance predisposes one to atherosclerosis). Treatments aim to balance the doshas.
"The vata dosha is thought to be a combination of the elements space and air. It is considered the most powerful dosha because it controls very basic body processes such as cell division, the heart, breathing, and the mind. Vata can be thrown out of balance by, for example, staying up late at night, eating dry fruit, or eating before the previous meal is digested. People with vata as their main dosha are thought to be especially susceptible to skin, neurological, and mental diseases" (National Center for Complementary and Alternative Medicine 2005. Op. cit.).
"In the body there are also seven Dhatus, which are fundamental principles that support the various bodily tissues; these are Rasa (plasma), Rakta (blood), Masma (muscle), Meda (fat), Asthi (bone), Majja (bone marrow), and Shukra (sperm or ovum). There are three metabolic waste products known as Malas, which are Mutra (urine), Purisha (feces), and Swed (sweat)" (Sharma and Chandola. 2011. J Complement Altern Med. 17(5):549-52).
"Health in Ayurveda is known as Swastha (Swa = Self, Astha = established), meaning a healthy person is one who is established in the Self. The inner Self is characterized by the quality of bliss. Self represents totality and wholeness, and contact with the inner Self is achieved by the technique of meditation. In Ayurveda, health is not merely the absence of disease. According to Susruta Samhita, a healthy individual is one whose doshas are in balance, whose appetite is good, whose dhatus [tissue elements] are functioning normally, whose malas [excretory products] are in balance, and whose body, mind, and senses remain full of bliss" (Sharma et al. 2007. Op. cit.).
Researchers are attempting to correlate the predominant doshas with biochemical characteristics and genetic information ("Ayurvedic genomics"). Another area of interest attempts to relate Ayurvedic diagnoses to conventional medical ones.
Practice and scope
There is an emphasis on a healthy lifestyle. "Dinacharya is the section of Ayurveda that addresses daily routine. According to Ayurveda, the three pillars of health are diet and digestion, elimination, and sleep. One’s daily routine can have a profound effect in these areas. Different doshas are predominant during different hours of the day and night and this factors into the recommendations for daily routine" (Sharma et al. 2007. Op. cit.).
Pulse diagnosis is used to detect diseases and imbalances (even in latent stages). In addition to a general physical exam and pulse diagnosis, there is examination of the urine, feces, tongue, eyes, skin and ears.
"The goals of Ayurvedic treatment are to:
Eliminate impurities...
Reduce symptoms...
Reduce worry and increase harmony in one's life.
Help eliminate physical and psychological problems."
(National Center for Complementary and Alternative Medicine. Fall 2005/Winter 2006. CAM at the NIH. 12(4):1-2, 7)
Types of treatment:
Treatment of the mind: meditation (e.g., Transcendental Meditation), reduction of stress
Treatment of the body: "These approaches include the use of diet, exercise, herbs, sensory modalities, and panchakarma (purification procedures that consist of medicated oil massages, herbalized heat treatments, and elimination therapies)" (Sharma et al. 1991. JAMA. 265(20):2633-4, 2637). The latter include enemas to "flush the loosened doshas out through the intestinal tract" (Chopra, quoted by Raso 1993. Op. cit.).
Treatment of behavior: keeping of daily and seasonal routines related to health
Another classification of treatments (Ministry of AYUSH 2016. Ayurveda. Types of treatment):
Shodhana therapy (Purification Treatment)
Shamana therapy (Palliative Treatment)
Pathya Vyavastha (Prescription of diet and activity)
Nidan Parivarjan (Avoidance of disease causing and aggravating factors)
Satvavajaya (Psychotherapy)
Rasayana therapy (use of immunomodulators and rejuvenation medicines)
"Ayurveda recommends purification therapy at the change of seasons to rid the body of toxins and prevent the onset of disease. This therapy is known as Panchakarma. Various modifications of this procedure are in vogue today. Traditionally, Panchakarma involves two preliminary practices to initiate the toxin removal process, five main techniques to complete toxin removal from the body, and follow-up practices for rejuvenation and maintenance of the benefits Panchakarma provides. The two preliminary practices are Snehana and Swedana. Snehana involves internal and external oleation of the body, and Swedana is heat therapy. The five main techniques are Vamana (therapeutic emesis), Virechana (purgation), Basti (herbal and oil enemas), Nasya (nasal administration of medicated oils and powders), and Raktamokshana (therapeutic bloodletting). Vamana expels excess mucus and toxins from the stomach and respiratory system. Virechana expels bile and Pitta toxins from the small intestine and liver. Basti purifies and nourishes the large intestine. Nasya strengthens the cranial region, and Raktamokshana cleanses the bloodstream and stimulates the production of healthy new blood. Other therapies are available, depending on the patient’s individual needs" (Sharma et al. 2007. Op. cit.).
"According to Ayurveda, if Rasayanas are administered early in life, genetic predispositions for certain diseases can be avoided. When diseases do occur, the intensity of the disease is decreased by improving the resistance of the body" (Sharma et al. 2007. Op. cit.).
“Vital points therapy and/or massage may be used to reduce pain, lessen fatigue, or improve circulation. Ayurveda proposes that there are 107 ‘vital points’ in the body where life energy is stored, and that these points may be massaged to improve health” (National Center for Complementary and Alternative Medicine 2005. What is Ayurvedic Medicine?).
Foods are classified by their effects on doshas. " If the system is out of balance, foods can be used in a therapeutic manner to restore balance to the doshas. For example, sweet, bitter, and astringent foods reduce or pacify Pitta. Foods that are pungent, salty, and sour increase Pitta...foods that pacify Vata are recommended during winter, those that pacify Pitta are recommended during summer, and those that pacify Kapha are recommended during spring" (Sharma et al. 2007. Op. cit.). There is an emphasis on fresh fruits and vegetables, grains, nuts, high-fiber foods.
"Based on the material of origin, Ayurvedic medicines are divided into three classes, namely herbal, mineral and animal" (Parasuraman et al. 2014. Pharmacogn Rev. 8(16):73-80).
Oil dripping (often with sesame oil) is a component of Panchakarma.
Oil pulling "typically involves swirling oil in the mouth for a period of 15 minutes, before spitting it out. Advocates of this method believe that harmful bacteria are removed from the mouth resulting in improved gum and dental health, and additionally may confer some systemic benefits, such as reduced risk of heart disease" (Gbinigie et al. 2016. Complement Ther Med. 26(1):47-54). Olive, coconut, and sunflower oils are used.
Vedic sound therapy consists of “...listening to traditional recitations of selected portions of the classical Veda and Vedic literature, which have been suggested to correspond to specific areas of the human physiology and to promote homeostatic self-repair processes in those respective areas” (Nader et al. 2000. Behav Med. 26(1): 34–46).
"Beyond pure somatic healthcare services, adherents of Ayurveda expect the therapist to also function as a spiritual/psychological caregiver. As a result of training and patient expectations, the Ayurvedic therapist also frequently engages in functions (within an Ayurvedic treatment) that are also characterized by religious and spiritual elements, for example, mantra recitation, performing rituals, meditation, prayers, and so forth" (Kessler et al. 2013. Op. cit.).
Herbal remedies
As with traditional Chinese herbal medicine, herbal remedies often contain multiple ingredients to provide synergistic effects and to counteract side effects.
"Ayurvedic formulations are often complex, containing several herb and mineral ingredients determined by the traditional principles of preparation, compatibility, and administration. Ayurvedic medicines are divided into two major types: those containing herbs only and 'rasa shastra' (combination of herbs with minerals and/or metals). By use of an oxidation process, raw metals and minerals are converted into ashes, known as 'bhasmas,' with presumed medicinal properties. These are regarded as non-toxic while retaining healing properties. One such commonly used preparation is the Guggul preparation that can contains ashes ('bhasma') of minerals such as gold (known as suvarna bhasma), silver, copper, iron, mica, mercury, sulfur, zinc, and lead" (Basnyat and Kolasinksi 2014. Curr Rheumatol Rep. 16(8):435).
Herbal compounds called rasayanas said to increase longevity and resistance to disease.
"Triphala (Sanskrit; tri=three and phala=fruits) is a well-recognized and revered polyherbal medicine consisting of dried fruits of the three plant species Emblica officinalis (Family Euphorbiaceae), Terminalia bellerica (Family Combretaceae), and Terminalia chebula (Family Combretaceae) that are native to the Indian subcontinent. It is classified as a tridoshic rasayana in Ayurvedic medicine as it promotes longevity and rejuvenation in patients of all constitutions and ages...Ayurvedic medicine uses Triphala as a pillar of gastrointestinal treatment; however, the complexity of the three rasayanas, or rejuvenative herbs, in the formulation allows for many applications...The major constituents of the formula are the tannins, gallic acid, ellagic acid, and chebulinic acid, which are potent antioxidants that may account, at least in part, for the observed immunomodulatory activity of the formula" (Peterson et al 2017. J Altern Complement Med 23(8):607-14).
"Each herb has five categories known as rasa, veerya, vipaka, prabhava and karma.
Rasa (taste or sensation that the tongue experiences when in contact with the herbals)...
Veerya (energy a herb releases when ingested)...
Vipaka (Post-digestive effect)...
Prabhava (special and unique power of a herb that has variable action)...
Karma (therapeutic action)...
Other than that, the doses, time of intake and Anupana (the carrier which the herbal medicines are prescribed with such as hot water, milk, honey, etc.) are also emphasized in the study of herbals under Ayurveda. In general, there are two types of Ayurvedic herbal formulations: Kasthoushadhies (pure herbal preparations) and Rasaushadhies (herbo-bio-mineral metallic preparation), in which the latter contains minerals added for their therapeutic effect" (Parasuraman et al. 2014. Op. cit.).
Guggul is used for obesity and high cholesterol, triphala for constipation, and turmeric for various conditions.
Spices such as turmeric, coriander, cumin, ginger, garlic, and cinnamon are employed for their therapeutic effects.
Reviews
Multiple Ayurvedic approaches
Arthritis - Kessler et al. 2015. Rheumatol Int. 35(2):211-32. Only Rumalaya can be seen as safe and effective; limited evidence in support of Shunti-Guduchi. "Other Ayurvedic interventions cannot currently be recommended."
Diabetes - Sridharan et al. 2011. Cochrane Database Syst Rev. CD008288. "Although there were significant glucose-lowering effects with the use of some herbal mixtures, due to methodological deficiencies and small sample sizes we are unable to draw any definite conclusions regarding their efficacy."
Epilepsy - Sriranjini et al. 2015. Epilepsy Behav. 52(Pt B):290-6. "There are very limited studies...rigorous clinical studies are lacking."
Multiple herbal remedies
Arthritis - Basnyat and Kolasinski. 2014. Op. cit. "...little in the scientific literature currently supports the use of Ayurveda for RA [rheumatoid arthritis]."
Hyperlipidemia - Singh et al. 2007. Altern Ther Health Med. 13(4):22-8. "There are herbals that have shown positive results...Ayurvedic herbs reviewed here should be considered by physicians..."
Specific herbal remedies
Ashwagandha (Withania somnifera) for anxiety - Pratte et al. 2014. J Altern Complement Med 20(12):901-8. Positive results, but "Current evidence should be received with caution..."
Triphala for cancer - Baliga. 2010. J Altern Complement Med. 16(12):1301-8. "Studies in the recent past indicate the immense potential of Triphala in cancer prevention and treatment. However, gaps in the studies conducted are apparent..." Most research has been with experimental animals.
Other therapies
Oil pulling for dental hygiene - Gbinigie et al. 2016. Op. cit. Limited evidence suggests beneficial effects.
Scientific critique
The Ayurvedic system is based on pre-scientific ideas that have little relationship to a modern understanding of the body and diseases. Doshas do not correspond to known physiological entities.
Claims concerning ability to diagnose metabolic diseases through pulse are dubious. "Ayurvedic practitioners utilize methods similar to those of fortune tellers relying upon 'cold reading,' ...multiple choice fishing expeditions to elicit information..." (National Council Against Health Fraud. Ayurvedic Medicine/TM).
Some favorable research is of poor quality. “Most clinical trials of Ayurvedic approaches have been small, had problems with research designs, lack appropriate control groups, or had other issues that affected how meaningful the results were” (National Center for Complementary and Alternative Medicine 2005. What is Ayurvedic Medicine).
Herbal treatments may have dangerous side effects. Some have carcinogenic or toxic components; contamination by heavy metals is widespread. In some cases, heavy metals are used intentionally. Saper et al. (2008. JAMA. 300(8):915-23) examined Ayurvedic medicines offered for sale on the Internet. About 20% contained lead, mercury, or arsenic at higher than acceptable levels. Earlier the same group had found similar results for Ayurvedic medicines sold in stores in Boston. A more recent investigation (Mikulski et al. 2017. Int J Occup Environ Health. 23(3):187-92) found even higher frequencies (lead, mercury, and arsenic in 65%, 38%, and 32%, respectively, of samples), and "concentrations of those metals per pill that exceeded, up to several thousand times, the recommended daily intake values for pharmaceutical impurities."
"Drug experts have estimated that approximately 6000 medicines in the 'Ayurvedic Formulary' which intentionally contain at least one metal, with mercury and lead the most widely used. These toxic elements are known to be potent nephrotoxic, hepatotoxic, neurotoxic and hematotoxic agents...Although these toxicity cases are now in alarming level, the attitude of the Ayurvedic practitioners towards this problem is nevertheless passive. At the global level, the number of adverse reactions reported or recorded through pharmacovigilance programs is still negligible, primarily due to the false belief that Ayurvedic PHFs are always safe. Despite the facts that toxicity cases have occurred, the toxic effect of heavy metals added are still claimed to be removed by Shodhana, a process involved in Rasashastra to purify and detoxify toxic materials" (Parasuraman et al. 2014. Op. cit.). Related to this point, Saper et al. (2009. JAMA. 301(3):271-2) wrote: "the suggestion that nontoxic forms of lead can be created conflicts with the vast body of scientific knowledge regarding lead. No form or amount of lead is known to be safe. The purported changed form of lead has never been characterized. Numerous lead poisoning cases associated with Ayurvedic metal-based medicines provide further evidence of their toxicity."
A trial of guggulipid found that it did not reduce cholesterol and may actually increase LDL (Szapary et al. 2003. JAMA 290(6):765-72). It may also induce cytochrome P450, reducing the effectiveness of other drugs.
"Only a handful of medical studies have been done on the benefits of oil pulling; all of them are from India and none of them seem to show a consistent benefit for any particular condition" (Radford 2014. Skeptical Inquirer 38(6):26-27). Ernst (2018 Sep 8. Edzard Ernst blog) wrote: "To me, the evidence looks promising as far as oral health is concerned. For all other indications, oil pulling is neither plausible nor evidence-based."
In a discussion of "Ayurvedic genomics," Gorski (2011 Nov 21. Science-Based Medicine blog) wrote: "However, just because body types based on a system of classification that is more or less based on an Indian form of vitalism...might coincidentally have something to do with discoveries found later does not mean that the basis of the system upon which these body types are based has any external scientific validity...so what if Mukerji found differences in gene expression based on Ayurvedic body types. They’re different body types, and we already know that people with different body habitus can be prone to different kinds of diseases. Ayurveda adds nothing new to this knowledge, much less suggests a rationale upon which to base a new 'omics' discipline."
Characteristics of pseudoscience
Ayurveda involves nonscientific, unmeasurable concepts (motion, flow, imbalances, etc.). Also, it contains religious and metaphysical concepts. "Since Ayurveda attributes many diseases to demons and astrological influences, it is not surprising that incantations, amulets, spells, and mantras are commonly used as remedies" (Butler 1992. A consumer's guide to "alternative medicine"). “Ayurveda is considered to have divine origin...” (indianmedicine.nic.in).
There is an astrological component: “The Vedic approach to the patient considers that the individual is in a dynamic state of equilibrium with the entire environment, extending to the universe as a whole, including the influences of the cycles and rhythms of the sun, moon, stars, and planets” (Nader et al. 2000. Op. cit.).
It is claimed that Ayurvedic approaches are beneficial because they have been used for thousands of years, which is not a valid conclusion.
Ayurveda employs primitive folk remedies involving blood, urine, feces, and body parts from animals. For example, cow urine and dung are components of panchagavya.
There have been false claims that Maharishi Ayur-Veda is supported by quantum physics. Deepak Chopra also has made invalid statements related to physics, as well as other pseudoscientific claims. "The pernicious tactic that he uses for this purpose is to decorate his speeches and writings with the names of famous physicists such as Einstein, Planck, Schrödinger, and Heisenberg and to attribute his own ideas about mind and matter to them" (Hassani 2016. Skeptical Inquirer 40(1):55-8).
OTHER MEDICAL TRADITIONS OF INDIA
In addition to Ayurveda, other forms of medicine in India include yoga, Siddha and Unani; all of these have official government recognition (along with homeopathy and naturopathy).
YOGA
Overview
While yoga is commonly thought (in the U.S.) to be a merely a program of exercise, in the Indian tradition it is an entire philosophy. It is thought to provide various benefits, such as relaxation, reduction of hypertension, improved balance, reduction of stress, improved athletic performance, and improved academic performance. Some claimed benefits for yoga are, however, incredible.
"As with other forms of exercise, practicing strenuous yoga releases endorphins, which are thought to create not only temporary forms of euphoria but also can help mask pain. Like exercise generally, practicing yoga can lower cortisol, a hormone correlated with stress, depression, and anxiety. By regulating cortisol levels, yoga may also help practitioners produce more melatonin, which can improve sleep and thereby overall mood...Recent studies point to a second possible way that the effects of yoga may differ from conventional exercise. Yoga appears to uniquely boost levels of gamma-amino butyric acid (GABA)" (Nisbet 2019. Skeptical Inquirer. 43(2):40-42).
Louie (2014. Issues Ment Health Nurs. 35(4):265-7) wrote that "musculoskeletal problems, mental health conditions, and asthma are the most common medical conditions for which yoga practitioners seek help through yoga."
"In the last hundred years numerous yoga schools or ways of teaching have emerged. Some are named after yoga masters, such as Iyenger yoga after B.K.S. Iyenger, and Bikram Yoga, after Bikram Choudhary. The names of other schools are based on the method or practices involved, for example, Kriya yoga, popularized by Paramahamsa Yogananda, and Hatha yoga, used to describe any method that places an emphasis on physical practices" (Telles and Singh 2013. Psychiatr Clin N Am 36(1):93-108).
Therapeutic yoga “incorporates poses (asanas), breathing (“pranayama”) and meditation techniques to improve quality of life and manage symptoms of various diseases, chronic conditions and illnesses - including asthma, back pain, fibromyalgia, depression and cancer” (Stein 2004. Los Angeles Times). “Unlike hatha and ashtanga, more mainstream yoga practices, kundalini doesn’t focus on holding static poses. Movement is dynamic, constant and often paired with a shallow, quick breath called ‘breath of fire.’...The theory is, there’s a coil of energy at the base of the spine that can be moved and freed through kundalini exercises...The ‘breath of fire’ supposedly helps balance the body’s systems and detoxify the internal organs.” (Ikenberg 2004. Louisville Courier-Journal).
A review comparing different styles of yoga (Cramer et al. 2016. Complement Ther Med 25:178-87) concluded that "RCTs [randomized controlled trials] with different yoga styles do not differ in their odds of reaching positive conclusions. Given that most RCTs were positive, the choice of an individual yoga style can be based on personal preferences and availability."
"Breath regulation is given this importance in yoga because it is believed to influence the mental state and hence the overall functioning. According to one of the Upanishads, this has been described more clearly. This description states that there are 5 levels of existence: (1) the physical level, (2) the level of subtle energy (called prana in Sanskrit), (3) the instinctual mental level, (4) the intellectual mental level, and (5) a state of optimal health and homeostasis. Imbalances are believed to occur at the mental level when there is conflict between the instinct and the intellect. The first obvious sign of this imbalance is at the level of subtle energy, which results in irregular breathing...It is believed, but not proven, that if a person realizes at this stage that something is wrong, they may be able to make the necessary physical and mental changes to prevent disease" (Telles and Singh 2013. Op. cit.).
"The focus on the breath is one reason studies consistently indicate that yoga in comparison to conventional exercise is more effective at managing feelings of stress, depression, and anxiety. Almost all forms of yoga emphasize Ujjayi pranayama, a style of slow breathing. When we breathe quickly, which often occurs when we experience stress or anxiety, carbon dioxide levels in our bloodstream decrease while oxygen levels stay the same. The imbalance produced by faster than normal breathing boosts the excitability of our nerves and muscles, producing muscle spasms and tingling in our extremities, which can trigger greater feelings of anxiety. In contrast, the slow breathing emphasized in yoga practice increases carbon dioxide levels. In response, blood vessels in the brain dilate, sending more oxygen to the brain. By enabling our brains to absorb more oxygen, the slow breathing of yoga increases calmness and alertness..." (Nisbet 2019. Op. cit.)
"By cycling through the fast and slow parts of our nervous system, a yoga practice gives our metabolism and nervous system a healthy workout. A typical hour-long yoga practice will cycle through braking the sympathetic system and boosting the parasympathetic system. Fast flowing poses stimulate our sympathetic system. More static poses that we hold for a longer period of time or in positions of relaxation put the brake on the 'fight or flight' system and promote the 'rest and digest' parasympathetic system" (Ibid.).
"In the last several decades, the millions of practitioners and the rise of yoga studios have popularized yoga in the West as a holistic wellness approach. A recent report by the U.S. Department of Health and Human Services indicates a doubling of yoga use among adults between 2002 and 2012" (Jeter et al. 2015. J Altern Complement Med 21(10):586-92).
Reviews
* = review by Edzard Ernst and colleagues
Anxiety - Cramer et al. 2018. Depress Anxiety. 35(9):830-43. "... yoga might be an effective and safe intervention for individuals with elevated levels of anxiety. There was inconclusive evidence for effects of yoga in anxiety disorders."
Asthma - Cramer et al. 2014. Ann Allergy Asthma Immunol. 112(6):503-10. "Yoga cannot be considered a routine intervention for asthmatic patients at this point. It can be considered an ancillary intervention or an alternative to breathing exercises for asthma patients interested in complementary interventions."
Back pain - Goode et al. 2016. Complement Ther Med. 25:170-7. "Evidence suggests benefit of yoga in midlife adults with non-specific cLBP [chronic low back pain] for short- and long-term pain and back-specific disability, but the effects of yoga for health-related quality of life, well- being and acute LBP are uncertain."
Breast cancer - Cramer et al. 2017. Cochrane Database Syst Rev. CD010802. "Moderate-quality evidence supports the recommendation of yoga as a supportive intervention for improving health-related quality of life and reducing fatigue and sleep disturbances when compared with no therapy, as well as for reducing depression, anxiety and fatigue, when compared with psychosocial/educational interventions."
Depression - Louie 2014. Op. cit. "Although the significant positive findings are promising, the studies had methodological limitations..."
Diabetes
Kumar et al. 2016. Complement Ther Med. 25:104-12. "Beneficial effects of yoga as an add-on intervention" were observed, "But risk of bias was overall high for included studies."
Vizcaino and Stover. 2016. Complement Ther Med. 28:57-66. "Yoga practice may be considered a complementary therapy in the treatment of T2DM because of its positive impact on short-term glycemic control, and possible improvement in lipid profile." However, more rigorous trials are needed.
Epilepsy - Panebianco et al. 2015. Cochrane Database Syst Rev. CD001524. "No reliable conclusions can be drawn at present...evidence to inform outcomes is limited and of low quality."
Heart disease (prevention)
Cramer et al. 2014. Int J Cardiol. 173(2):170-83. "This meta-analysis revealed evidence for clinically important effects of yoga on most biological cardiovascular disease risk factors. Despite methodological drawbacks of the included studies, yoga can be considered as an ancillary intervention for the general population and for patients with increased risk of cardiovascular disease."
*Hartley et al. 2014. Cochrane Database Syst Rev. CD010072. "The limited evidence comes from small, short-term, low-quality studies. There is some evidence that yoga has favourable effects on diastolic blood pressure, HDL cholesterol and triglycerides, and uncertain effects on LDL cholesterol."
Heart disease (treatment) - Cramer et al. 2014. Eur J Prev Cardiol. 22(3):284-95. "...weak recommendations can be made for the ancillary use of yoga for patients with coronary heart disease, heart failure, and cardiac dysrhythmia at this point."
Hypertension
Cramer et al. 2014. Am J Hypertens. 27(9):1146-51. "Larger studies are required to confirm the emerging but low-quality evidence that yoga may be a useful adjunct intervention..."
*Posadzki et al. 2014. Complement Ther Med. 22(3):511-22. Evidence "is encouraging but inconclusive."
Park and Han 2017. J Altern Complement Med. 23(9):685-95. "While acknowledging the limitations of this research due to differences in BP [blood pressure] and participants' ages, meditation and yoga are demonstrated to be effective alternatives to pharmacotherapy."
Mental health - Hendriks et al. 2017. J Altern Complement Med. 23(7):505-17. "Yoga was found to contribute to a significant increase in psychological well-being when compared to no intervention but not compared to physical activity. For life satisfaction (emotional well-being), social relationships (social well-being), and mindfulness no significant effects for yoga were found over active or non-active controls. Due to the limited amount of studies, the heterogeneity of the intervention, and perhaps the way PMH is being measured, any definite conclusions on the effects of yoga on PMH [positive mental health] cannot be drawn."
Multiple sclerosis
Cramer et al. 2014. PLoS One. 9(11):e112414. "... since no methodological sound evidence was found, no recommendation can be made regarding yoga as a routine intervention for patients with multiple sclerosis."
Rogers and MacDonald. 2015. J Altern Complement Med 21(11):655-9. "Overall, the findings from this paper suggest that yoga may be a safe and effective means of managing the symptoms of MS."
Pain - *Posadzki et al. 2011. Complement Ther Med 19(5):281-7. "It is concluded that yoga has the potential for alleviating pain. However, definitive judgments are not possible."
Scientific critique
A critique of yoga studies by Palmer (2014 Mar 7. Slate) pointed out that "The yoga studies, however, contain myriad methodological problems...medical researchers have to agree on the elements essential to yoga practice before they can test it as a therapy. Is deep breathing or stretching the source of therapeutic benefit? Or maybe it’s simple exercise, which wouldn’t exactly be news...How much yoga do you need to do, and for how long, to achieve a benefit? There’s also significant individual variation at play. Some people breathe more deeply, hold poses for longer, and meditate 'better' (I assume) than others. That’s going to muddy the statistics. Control and blinding are also problematic. When you test a pill for heart disease, you give some people the pill and others a placebo (or an existing medication)...It’s not easy to convince someone that they’ve been doing yoga for six weeks when they haven’t, so the placebo effect is always a problem. And in a surprising number of yoga studies, the researchers aren’t blinded, either, raising the risk of a second form of bias. Take a look at systematic review articles and meta-analyses—studies that aggregate other studies—and you’ll see where the miraculous yoga cure really stands. The majority of such compilations both criticize the methodology of yoga research and find that yoga has little or no effect on serious illness...Why haven’t you already heard about all of these anti-yoga studies? They have no constituency, and therefore don’t interest the media much."
"Does yoga actually have benefits for wellness? The NCCIH [National Center for Complementary and Integrated Health] tells us: 'Only a small amount of research has looked at this topic. Not all of the studies have been of high quality, and findings have not been completely consistent. Nevertheless, some preliminary research results suggest that practicing yoga may help people manage stress, improve balance, improve positive aspects of mental health, and adopt healthy eating and physical activity habits.' 'May help' does not mean 'it does help.' And whilst TLC is always lovely, and virtually all interventions 'may help relieve stress and improve positive aspects of mental health,' the jury is out as to whether yoga actually does have such benefits" (Rawlins 2019 Mar 6. Edzard Ernst blog).
SIDDHA
The Siddha system “developed within the Dravidian culture, which is of the pre-vedic period...Like Ayurveda, this system believes that all objects in the universe including human body are composed of five basic elements namely, earth, water, fire, air and sky...As in Ayurveda, this system also considers the human body as a conglomeration of three humours, seven basic tissues and the waste products of the body...This system also deals with the concept of salvation in life...” (indianmedicine.nic). Among the drugs there is an emphasis on metals and minerals (including mercury), with roots in alchemy.
UNANI
Rather than being indigenous, Unani is based on ancient Greek ideas that were brought to India by the Arabs in the 1300's. “Unani Medicine is based on the Greece philosophy. According to Basic Principals of Unani the body is made up of the four Basic elements i.e. Earth, Air, Water, Fire...The body have the Simple and Compound Organs which got their nourishment through four Humours i.e. Blood, Phlegm, Yellow Bile, Black Bile...Diseases are mainly diagnosed with the help of Pulse (Nabz), physical examination of the Urine and Stool” (indianmedicine.nic). Treatments include regimenal therapy (e.g., exercise, massage, Turkish bath, douches); diet therapy; pharmacotherapy (mostly with herbal medicine); and surgery..
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